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ALL YOU NEED TO KNOW ABOUT CHEST PAIN Mohammed Binyameen Nidhi Rege Here’s whatwedo: ■ Weekly tutorialsopento all! ■ Focussed oncore presentationsand teaching diagnostictechnique If you’re new here… ■ By medical students, for medical students Welcome to ■ Reviewed by doctorsto ensure accuracy Teaching ■ We’ll keepyouupdatedabout our Things! upcoming events viaemail and groupchats!CHEST PAIN Mohammed BinyameenPoll - How confident is everyone at differentiating between different causes of chest pain?Can you name somecausesof chest pain?Chest pain =/= MIChest pain =/= MIWhat we’ll be covering today Me: Nidhi: - Myocardial infarction - Pneumothorax - Pericarditis - Pulmonary embolism - Aorticdissection - Boerhaave’s - Anxiety - Other causes to considerA62-year-old manpresentsto theemergency department with central chest painthat started 30minutesagowhilehewas watchingtelevision. Hedescribes thepainasa heavy,crushingsensationthat radiates to his left armandjaw. He feelsnauseated and sweaty.Hehas ahistory of hypertension and hypercholesterolaemia. On examination,heis clammy,hispulseis 90bpm, andhis blood pressureis 140/85mmHg.AnECG showsST-segment elevationinleadsII,III,and aVF. A) Aorticdissection B)Anxiety C)Myocardial infarction D) Pericarditis E)Pulmonary embolismA 62-year-old man presents to the emergency department with central chest pain that started 30 minutes ago while he was watching television.He describes the pain as a heavy, crushing sensation that radiatesto his left arm and jaw. He feels nauseated and sweaty. He has a history of hypertension and hypercholesterolaemia. On examination,he is clammy, his pulse is 90 bpm,and his blood pressure is 140/85 mmHg. An ECG shows ST-segment elevation in leadsII, III,andaVF. What is the most likely diagnosis? A)Aortic dissection B)Anxiety C) Myocardial infarction D) Pericarditis E) Pulmonary embolism Answer:C) Myocardial infarctionPathophysiology of an MI MI =Reductionin blood flowleadingto necrosisof cardiac tissuedueto atheroscleroticplaque rupture Angina(Stablevs Unstable) STEMI Vs NSTEMIVs Unstable angina: - ECGchanges - TroponinRisk factors Modifiablevs non-modifiable Modifiable Non-modifiable - Smoking - Age - Hypertension - Malesex - Diabetes - Familyhistory - Hyperlipidemia - Obesity - Sedentary lifestyle.Whereis theblockage?Whereistheblockage? Answer -Anterior STEMI (Blockagein theLAD) HowtointerpretECGsfrombasics as Whereistheblockage? wellas basic physiology andanatomy oftheheart Answer - Anterior STEMI (Blockage intheLAD)Clinical presentation + Diagnosis Presentation: Diagnosis: - Central/Left sidedchest pain - ECGand Troponinaremost - Radiationto thejaw/left arm important investigations - Heavy/Squeezing pain - Shortnessof breath - N+V STEMI - Raisedtroponin+ST - Sweating/Clammy elevation onECG Diabetics/Elderly - Silent MI(could NSTEMI - Raisedtroponin+ST bedescribed as ‘heartburn’) depression/Twaveinversion Unstableangina- Normal troponin + Normal ECG (may havesomeT (Usually observationsnormal - waveinversion) UnlessHBor peri-arrest)Immediatemanagement Immediatemanagement: - Ato E(inc. ECG+ Trop) - ThinkMOAN - Morphine(if inpain) - Oxygen(if sats lessthan94%) - Aspirin300mg - Nitrates(avoid if hypotensive) If GP= Call anambulance Further management dependson the typeof MI (STEMI VsNSTEMI)Immediatemanagement Immediatemanagement: - Ato E(inc. ECG+ Trop) - ThinkMOAN - Morphine(if inpain) - Oxygen(if sats lessthan94%) - Aspirin300mg - Nitrates(avoid if hypotensive) If GP=Callan ambulance Further managementdependson thetypeofMI (STEMI Vs NSTEMI)STEMI management in hospitalSTEMI management in hospital To summarise: - If presenting within 12 hoursand PCIcanbedelivered within120mins= PCI w/stent - If otherwise= Fibrinolysis.DoECGafter 90minsandifST-elevation persists, mayrequirePCI Antiplatelets: - Aspirin(giventoeveryone) - Clopidogrel (if onanticoagulant), Ticagrelor (if fibrinolysis), Prasugrel (ifPCI) Other stuff: - Antithrombinwithfibrinolysis - Unfractionatedheparin with PCINSTEMI management in hospitalNSTEMI management in hospital To summarise: ECG+serialtroponins to calculateGRACEscore(6month probability of repeatMI/deathafter NSTEMI) - If unstable=PCI immediately (+antiplatelets+ heparin) - If morethan3%= PCIwithin72 hours(+antiplatelets+ heparin) - If lessthan3%= Conservativemanagement. Aspirin +clopidogrel (if on anticoagulants)or aspirin +ticagrelor otherwiseNSTEMI management in hospital To summarise: ECG+serial troponinsto calculateGRACE score(6monthmortality/CVevents) - Ifunstable= PCIimmediately (+antiplatelets +heparin) - Ifmorethan3%= PCIwithin72 hours(+antiplatelets+ heparin) - Ifless than 3% = Conservativemanagement.Aspirin+ clopidogrel (ifon anticoagulants)or aspirin +ticagrelor otherwisePost-hospital managementPost-hospital management To summarise: - Lifestyleadvice - Healthy weight + varied diet - Smoking and alcohol cessation - Exercise program - Medications - DAPT =Aspirin+ clopi/ticag/prasu - Beta-blocker = Bisoprolol - ACE inhibitor =Ramipril - Statin= 80mg atorvastatinComplications ThinkDARTHVADER: - D – Death(Within24 hours) - A– Arrhythmia(Within24 hours) - R– Rupture(3–7 days– Papillary muscle) - T– Tamponade(3–7 days– Dueto ventricularfreewall rupture) - H – Heart failure(Within 24 hours) - V– Valvedisease(3–7 days– Mitral regurgitationfrompapillary muscle rupture) - A– Aneurysm of the ventricle(Weeks–Months– Persistent ST elevation, risk of thrombus) - D – Dressler’s syndrome (2–6weeks– Autoimmunepericarditis) - E– Embolism (3–7 days– Mural thrombus →Stroke/systemicembolism) - R– Reinfarction(Weeks–Months)A35-year-old manpresentswithpleuriticchest painthat hasbeenworsening over thepast threedays.The painissharp, retrosternal,andimproveswhenhe leansforward.Hehad arecent viral upper respiratory tract infection. On examination,his temperatureis 37.8°C,heart rateis88bpm,and blood pressureis 125/80mmHg. Apericardial frictionrubisheardon auscultation. ECGshows widespreadconcaveST elevationand PRdepression. What is themost likely diagnosis? A) Acute coronarysyndrome B)Aorticdissection C)Myocardial infarction D) Pericarditis E)PneumothoraxA 35-year-old man presents with pleuritic chest pain that has been worsening over the past three days. The pain is sharp, retrosternal, and improves when he leans forward. He had a recent viral upper respiratory tract infection. On examination,his temperature is 37.8°C, heart rate is 88 bpm, and blood pressure is 125/80 mmHg. A pericardialfriction rub is heard on auscultation. ECG shows widespread concave ST elevation andPRdepression. What is the most likely diagnosis? A)Acute coronary syndrome B)Aortic dissection C) Myocardial infarction D) Pericarditis E) Pneumothorax Answer:D) PericarditisPericarditis Pathophysiology: - Inflammation of the pericardium - Usually preceded by viral infection or post-MI (in SBA land), but other causes include TB,uraemia, RA and malignancy Clinical presentation: - Sharp pleuritic chest pain often relieved by sitting forwards - May alsoexperience fever and shortness of breath Diagnosis: - ECG changes - Raised inflammatory markers (ESR, CRP) - Could be a slight raise in troponinPericarditis Management: - Treat underlyingcause(viral = conservativemanagement) - Avoid strenuous physical activityfor3 months - NSAIDs+ Colchicine - Usually resolveswithina few weeks Complications: - Constrictivepericarditis - CancauseHF/dyspnoea - Recurrent pericarditisA55-year-old manwithahistory of hypertensionpresentswithsudden-onset severechest painthat radiates to his back.Hedescribesit asa "tearing" sensation.Heisdiaphoreticand distressed. On examination,his blood pressureis190/110mmHg intheright arm and 160/100mmHg intheleft arm. Hispulse is100bpm,andthereis anew early diastolicmurmur.HisECGshows no significant ST changes,andhistroponins arenormal. What is themost likely diagnosis? A) Acute coronarysyndrome B)Aorticdissection C)Myocarditis D) Pericarditis E)Pulmonary embolismA 55-year-old man with a history of hypertension presents with sudden-onset severe chest pain that radiates to his back. He describes it as a "tearing" sensation. He is diaphoretic and distressed. On examination,his blood pressure is 190/110 mmHg in the right arm and 160/100 mmHg in the left arm. His pulse is 100 bpm,and there is a new earlydiastolic murmur. His ECG shows no significant ST changes, and his troponins are normal. What is the most likely diagnosis? A)Acute coronary syndrome B)Aortic dissection C) Myocarditis D) Pericarditis E) Pulmonary embolism Answer:B) Aortic dissectionAortic dissection - Pathophysiology Tear inintima layer = False lumen Canrupture,leadtoischaemiaor cause deathAortic dissection Presentation: - Severe‘tearing’chest pain - Sometimes radiates to the back - Patientscanbehypo/hypertensive - Asymmetrical blood pressures (occlusionof artery supplying arm) - Neurological deficits (stroke) - Aorticregurgitationmurmur Classification(typeAvstypeB): - Type Ainvolvestheascendingaorta and canaffect theaortic valveleading to aorticregurgitation - Type Binvolvesthedescendingaortaand hasa better prognosisAortic dissection Diagnosis: - CXR - Widenedmediastinum - TOE- If unstable - CT angiography- Gold standard- Falselumen Management-Dependson type ofAD: - Type A=Surgical management +/- BPcontrol withIVLabetalol - Type B=Bedrest +IVlabetalol Complications : - Aorticregurgitation - Inferior MI - RCAsinus involvement - StrokeA28-year-old womanpresentswithepisodes ofchest painthat comeon suddenlyandlast for several minutes.Thepainisassociated withpalpitations, shortness of breath,dizziness,and afeelingof impending doom.Sheis otherwisewell withno past medical history.Examination,ECG,andtroponin levels arenormal. What is themost likely diagnosis? A) Acute coronarysyndrome B)Aorticdissection C)Anxiety D) Pericarditis E)PneumothoraxA28-year-old womanpresentswithepisodes ofchest painthat comeon suddenlyandlast for several minutes.Thepainisassociated withpalpitations, shortness of breath,dizziness,and afeelingof impending doom.Sheis otherwisewell withnopastmedicalhistory.Examination,ECG,andtroponin levels arenormal. What is themost likely diagnosis? A) Acute coronarysyndrome B)Aorticdissection C)Anxiety D) Pericarditis E)Pneumothorax Answer: C) Anxiety Which ABG belongs to thewoman? 1) 2)Anxiety Thisisa5thyear topic,but hereis abrief overview causing significant distressor functional impairment.ortionto theactual threat,Anxiety Thisisa5thyear topichereisa brief overview Definition- Excessivefear or worry that isout of proportionto theactual threat, causing significant distressor functional impairment. Types ofanxiety: - GAD - OCD - Panicdisorder - PTSD - Social anxietydisorder - SpecificphobiasAnxiety Thisisa5thyear topichereisa brief overview Definition- Excessivefear or worry that isout of proportionto theactual threat, causing significant distressor functional impairment. Typesof anxiety: Clinical presentation: - GAD - Chest pain/discomfort - OCD - Feeling onedge - Panicdisorder - Autonomic - Palpitations,sweating, - PTSD dizziness - Social anxietydisorder - Respiratory- Shortnessof breath, - Specificphobias hyperventilationAnxiety Diagnosis - Rule out other causes - Medications,hyperthyroidism + other causesof chest pain(PE) - DSM-5 Management - Lifestyle- Reducecaffeine+ medicationreview +avoid triggers - CBT - SSRIs(sertraline,fluoxetine)CHEST PAIN Nidhi RegePoll - How confident is everyone at differentiating between different causes of chest pain?A45-year-old womanpresentstotheEmergency Department withsudden-onset shortness of breathandpleuriticchest pain.She recently returned from along-haul flight from New Zealand. Her observationsareasfollows: ● Heart rate:110bpm ● Blood pressure:95/60mmHg ● Respiratory rate:22 breaths/min ● Oxygensaturation:92%onroom air On examination,shehasmild tenderness inher right calf.Her chest X-ray isclear, and her ECG showssinus tachycardia. What is thenext stepinmanagement? A) D-Dimer B) CTPA C) Coagulation D) Proximal LegUltrasound E) Coronary AngiogramA45-year-old womanpresentstotheEmergency Department withsudden-onset shortness of breathandpleuriticchest pain.She recently returned from along-haul flight from New Zealand. Her observationsareasfollows: ● Heart rate:110bpm ● Blood pressure:95/60mmHg ● Respiratory rate:22 breaths/min ● Oxygensaturation:92%onroom air On examination,shehasmild tenderness inher right calf.Her chest X-ray isclear, and her ECG showssinus tachycardia. What is thenext stepinmanagement? A) D-Dimer B) CTPA C) Coagulation D) Proximal LegUltrasound E) Coronary AngiogramPulmonary Embolism - MEDICAL EMERGENCY - Possible A-Estation APE iscaused by theobstructionof at least onepulmonary artery, from a thrombusthat most likely originatedfroma deepvein. Theobstructionmeansthat blood cannot flow distally.Presentation? Thetextbooktriadis: - Pleuriticchest pain - Dyspnoea - HaemoptysisPresentation? Thetextbooktriadis: This is quiterare! - Pleuriticchest pain - Dyspnoea - HaemoptysisPresentation - Pleuriticchest pain - Dyspnoea - Tachycardia - Calftenderness - Haemoptysis - Myocardial - Tachypnoea ischaemia with - Crackles central chest - Pleural rub pain - Raised JVPPresentation - Pleuriticchest pain - Dyspnoea - Tachycardia - Calftenderness - Haemoptysis - Myocardial - Tachypnoea ischaemia with At least one-third of - Crackles patients presenting - Pleural rub central chest with DVT have pain clinically silent - Raised JVP pulmonary emboli Risk Factors Stasis related Factors Hypercoagulability Surgery Cancer Bed Rest Surgery Plaster Cast Immbolisation Pregnancy Pregnancy Administration of Oestrogens in contraception and HRT Long - Haul Travel Heritable ThrombophilliasPulmonary Embolism Rule Out Criteria - Thisisdoneif yoususpect alow pre-test probability of PE,and want more reassurancethat it isn’t the diagnosis - All haveto benegativeto ruleout PE - If your suspicionof PE isgreaterthan 15%,MOVESTRAIGHT TOWELLSA45-year-old womanpresentstotheEmergency Department with sudden-onset shortness of breathandpleuriticchest pain. Sherecently returned from a long-haul flight from New Zealand. Her observationsareasfollows: ● Heart rate:110bpm ● Blood pressure:95/60mmHg ● Respiratory rate: 22 breaths/min ● Oxygensaturation:92%onroom air On examination,shehas mild tenderness inher right calf. Her chest X-ray isclear, and her ECG showssinus tachycardia. PERCor Wells? 1) PERC 2) WELLSA45-year-old womanpresentstotheEmergency Department with sudden-onset shortness of breathandpleuriticchest pain. Sherecently returned from a long-haul flight from New Zealand. Her observationsareasfollows: ● Heart rate:110bpm ● Blood pressure:95/60mmHg ● Respiratory rate: 22 breaths/min ● Oxygensaturation:92%onroom air On examination,shehasmild tenderness inher right calf.Her chest X-ray isclear, and her ECG showssinus tachycardia. PERCor Wells? 1) PERC 2) WELLSWellsScore What score suggests PE likely?WellsScore What score suggests PE likely? >= 4A 45-year-old woman presents to the Emergency Department with sudden-onset shortness of breathand pleuritic chest pain. She recently returned from a long- haul flight from New Zealand. Her observations are as follows: ● Heart rate: 110 bpm ● Bloodpressure: 95/60 mmHg ● Respiratoryrate: 22 breaths/min ● Oxygen saturation: 92% on roomair Onexamination,shehas mildtenderness in her right calf. Her chest X-ray is clear,and her ECG shows sinus tachycardia.InvestigationsOther Investigations - ECG:classic textbook ECG of PE isS1Q3T3 - A large S wave in Lead I - A large Q wave in LeadIII - An invertedT wave in LeadIII - However this is only seen in about20 % of patients - May alsosee sinus tachycardia - ChestX-ray:doanywaytoexclude other pathologies - Can be normal in PE - V/Q:if renalimpairmentorcontrastcontraindicated(suchas allergies)Management Anticoagulation - Anti coagulation therapy forms the basis of management - 3 months at least , - An additional 3 months if cause was unprovoked Thrombolysis, eg alteplase - If haemodynamically unstable: - Obstructive Shock (SBP <90mmHg) - Persistent Hypotension (SBP <90 mmHg or drop in SBP 40mmHg or more) SBA 2 A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? 1) Dischargewithoutpatient follow upin2 weeks 2) Chest DrainInsertion 3) Aspiratewith16G Cannula 4) Highflow Oxygenwithnon-rebreathemask 5) Needledecompressioninthesecond intercostal space SBA 2 A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? 1) Dischargewithoutpatient follow upin2 weeks 2) Chest DrainInsertion 3) Aspiratewith 16 G Cannula 4) Highflow Oxygenwithnon-rebreathemask 5) Needledecompressioninthesecond intercostal spacePneumothorax An abnormal space of air in the pleural cavityPneumothorax An abnormal space of air in the pleural cavity How do weclassify?Pneumothorax - Classification Spontaneous Traumatic Primary Secondary Spontaneous SpontaneousPneumothorax - Classification Spontaneous Traumatic Iatrogenic Primary Secondary CVPlineinsertion Spontaneous Spontaneous Pleural aspiration/ biopsy Absence of When there is underlying trauma, lung disease Percutaneousliver biopsy - Asthma, COPD, CF Usually due to - Lung Cancer Positivepressure rupture of - Diseaseive Tissue ventilation subpleural bulla - Lung InfectionHow does a person with a pneumothorax present? - Asymptomatic if small - Sudden dyspnoea and/or pleuritic chest pain - If PMHx of Asthma or COPD, may suddenly deteriorateHow does a person with a pneumothorax present? - Asymptomatic if small - Sudden dyspnoea and/or pleuritic chest pain - If PMHx of Asthma or COPD, may suddenly deteriorate What do you do first ?Resp exam !! Youmayfind: Percussion - Reduced Expansion - Hyperresonancewhenpercussed Auscultation - Diminished breath sounds onaffected sides Whatifthetracheais deviated?Tension Pneumothorax! Mediastinal Displacement No route for escape for air in pleural space Pushing Mediastinum over Compressing the great veins Cardiorespiratory Arrest will occurTension Pneumothorax - the signs - Chest pain - Respiratory Distress - Tachycardia - Hypotension - Distended Neck Veins - Tracheal Deviation AWAYfrom the side of the pneumothorax - Increased percussion note - Reduced air entry/breath sounds on affected side Whydoes it matter?If you suspect a Tension Pneumothorax ….. DO NOT DO A CHEST X-RAYIf you suspect a Tension Pneumothorax ….. DO NOT DO A CHEST X-RAY Save time, save livesIf you suspect a Tension Pneumothorax ….. DO NOT DO A CHEST X-RAY Save time, save lives Doesour patient have a tension pneumothorax?SBA 2 A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper- resonance on percussion of the left side of the chest. Tension pneumothorax present? Yes or No?SBA 2 A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper- resonance on percussion of the left side of the chest. Tension pneumothorax present? No!Management - Oxygen if Hypoxic - Analgesiaif required (don’t forget pain) - Dependent on: - If high risk characteristics present - Pneumothorax size - Patient PrioritiesWhat are the high risk characteristics? - Haemodynamic Compromise (eg tension pneumothorax) - Significant Hypoxia - BilateralPneumothorax - Underlying Lung Disease - >=50 years with significant smoking history - HaemopneumothoraxSize The magic number of 2cm - If size >= 2cm, it’s safe to intervene - If less, it’s NOTPatient Preferences What does your patient want? - To avoid procedures? - Rapid Symptom Relief, in anambulatory setting? - Rapid Symptom Relief, in the form of short-term drainage?Management Types Patientwants toavoid procedures: Think aboutthetypeofpneumothorax Primary spontaneous : review every 2-4 days as an outpatient Secondary spontaneous: monitor as inpatient For both: if stable, follow upoutpatient in 2-4 weeksManagement Types Patient wants RapidSymptomRelief Ambulatory: Catheterlike devicesuch as theRocket Pleural Vent Short - term drainage: Needle Aspiration If fail, do chest drain If successful, follow up outpatient 2-4 weeksPut it altogether! BTS Pneumothorax 2024 Guidelines No tensionpneumothorax SBA 2 A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? No tensionpneumothorax No signsof SBA 2 haemodynamic instability A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? No tensionpneumothorax No signsof SBA 2 haemodynamic instability A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? Size,safetointervene No tensionpneumothorax No signsof SBA 2 haemodynamic instability A 20-year-old man presents to the emergency department with a 3 hour history of chest pain worse on inspiration. He also complains of shortness of breath. On examination, the trachea is central and there is hyper-resonance on percussion of the left side of the chest. Chest X-ray confirms the diagnosis of a 2 cm pneumothorax. He is keen for the symptoms to resolve as soon as possible and is open to interventional management. Which of the following is the most appropriate management of this patient? Size,safetointervene Patientwants symptom resolvingmanagementWhat wereour options? 1) Discharge with outpatient follow up in 2 weeks 2)Chest Drain Insertion 3)Aspirate with 16 G Cannula 4)High flow Oxygen with non-rebreathe mask 5)Needle decompression in the second intercostal spaceWhat wereour options? 1) Discharge with outpatient follow up in 2 weeks 2)Chest Drain Insertion 3)Aspirate with16 G Cannula 4)High flow Oxygen with non-rebreathe mask 5)Needle decompression in the second intercostal spaceWhat wereour options? 1) Discharge with outpatient follow up in 2 weeks - not stable 2)Chest Drain Insertion - haven’t tried other interventions 3)Aspirate with16 G Cannula 4)High flow Oxygen with non-rebreathe mask not hypoxic 5)Needle decompression in the second intercostal space - not tension pneumothoraxTension Pneumothorax Management Needle Decompression in the 2nd intercostal space on the side of the pneumothoraxUpon discharge… (for your OSCEs) Smoking: Avoid smokingto reducerisk offurther episodes Flying:If x-ray at follow upclear,can fly after 1week (after follow up) Scuba Diving: permanently avoidedunless the patient has had bilateral surgical pleurectomyandnormallungfunction and CT scan post-op SBA 3 A 45year old man presentstothe emergency department following an episode ofbinge drinking. He hassevere retrosternal chest pain, andis struggling tobreath, following some forceful vomiting. On examination he hasreducedbreath soundson hisleft side, andthere is crepitus on palpation of the chest wall.A CT ofhis chest revealsfree airin the mediastinum. What is the most likelydiagnosis? - GORD - Zenker’s Diverticulum - Mallory Weiss - Boerhaave - OesophagealVarices SBA 3 A 45year old man presentstothe emergency department following an episode ofbinge drinking. He hassevere retrosternal chest pain, andis struggling tobreath, following some forceful vomiting. On examination he hasreducedbreath soundson hisleft side, andthere is crepitus on palpation of the chest wall.A CT ofhis chest revealsfree airin the mediastinum. What is the most likelydiagnosis? - GORD - Zenker’s Diverticulum - Mallory Weiss - Boerhaave Syndrome - OesophagealVaricesBoerhaave Syndrome - Quite rare, but is a differential for chest pain - Full thickness rupture of the oseophagus (usually on left side) - This happens when there is a sudden rise of intraoesophageal pressure - Whichhappens afterrepeated episodesof forceful vomiting - Associated with Chronic AlcoholismBoerhaave Syndrome signs and symptoms - Severe chest pain thatgets worse on swallowing - Minimal or no blood in vomit (coffee ground vomit) - Signs of shock(tachycardia, hypotension, altered mental status) - Subcutaneous emphysema - Radiological Signs such as pneumomediastinum, pleural effusions, or pneumothorax on CXRBoerhaave Syndrome signs and symptoms See why - Severe chest pain thatgets worse on swallowing historiesare important? - Minimal or no blood in vomit (coffee ground vomit) - Signs of shock(tachycardia, hypotension, altered mental status) - Subcutaneous emphysema - Radiological Signs such as pneumomediastinum, pleural effusions, or pneumothorax on CXRA 45year old man presentstothe emergency department following an episode of binge drinking. He hassevere retrosternalchest pain, andis strugglingtobreath, following some forceful vomiting. On examination he hasreducedbreath soundson hisleft side, andthere iscrepitus on palpation of the chest wall.A CT of hischestreveals free airin the mediastinum.A 45year old man presentstothe emergency department following an episode of binge drinking. He hassevere retrosternalchest pain, andis strugglingtobreath, following some forceful vomiting. On examination he hasreducedbreath soundson hisleft side, andthere iscrepitus on palpation of the chest wall.A CT of hischestreveals free airin the mediastinum. The clinical picture fits Boerhaave !Investigations - Do CXR,ECGetcto ruleout other differentialswehavecovered - TheCXRmay alsoshow complicationsegpleural effusion, pneumothorax, pneumomediastinum - CT withwater solublecontrast swallowed to show siteof perforation - DONOT doOGD soyou don’texacerbateperforation.Management Act quick - delays of more than 24 hours are associated with a high mortality rate - Think A-E - IV fluids to manage shock - IV antibiotics - to cover for sepsis (massive complication of Boerhaave) - Surgeryto correct ruptureOther causes of chest pain that we haven't covered - GORD - MSK causes(costochondritis, rib fracture,muscle strain, sternoclavicular arthritis) - Myocarditis - Pneumoniaw/ pleurisy - Pleural effusion - Lung cancer w/ chest wall involvement - Shingles w/ pre-eruptivepain THANKS FOR WATCHING! on Medall and see you next week!