Transcript Chest Pain Case Presentation at KAOM 1 x

CHEST PAIN: A CASE
PRESENTATION
By Drew Posey D.O.
PGY III Via Christi
My patient P.W. Kansan Farmer
Chief Complaint: Chest Pain
History of Present Illness
• 75 YO male with chest pain.
• Beginning 3 hours ago at nearly 1600hrs
• Left sub-sternal, intermittent, lasting <30sec to 1minute,
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radiated to back.
Character of pain – tightness and sharp with deep
inhalations.
Pain relieved with rest
Associated with dizziness, intermittent blurry vision, near
syncope, disorientation
EMS therapy – ASA and nitro x 3
History of Present Illness
• ED presentation
• P.W.’s chest pain had resolved except for intermittent episodes that
occurred when placed flat on back
• In the CT scanner his chest pain returned and his lips turned blue
according to the Radiology Tech
• Sitting upright on the ED bed he was largely symptom free
Past Medical History
• Hypertension
• chronic for multiple years and normally controlled with blood
pressure medicines
• Impaired Glucose Intolerance
• Trialing diet and exercise for effect at PCP’s recommendation
• Hyperlipidemia
• on anti-cholesterol medicine
• Gastric Ulcer
• 25 years ago, with hemorrhage, associated with syncope.
Required EGD and cautery to stabilize
• Hx Tobacco Smoking 1PPD > 50yrs
• Current Smoker
History
• Surgical History
• Appendectomy
• EGD with cautery of
gastric ulcer
• Family History
• Father
• HTN
• MI – cause of death at 82
• Mother
• HTN
• CVA – cause of death
History
• Medications
• HCTZ/Lisinopril 25/20mg PO daily
• Nitroglycerin 0.4mg PO PRN chest pain
• Terazosin 5mg PO daily
• Simvastatin 40mg PO daily
• Diltiazem 180mg PO daily
• Allergies
• None
Pertinent Review of Systems
• Constitutional:
• Weakness. Has felt weakness and fatigue over last month. No fever.
• Eyes:
• Recent vision problems, blurry vision associated with CP
• Cardio:
• No pain in neck/jaw/arms
• GI:
• No nausea/vomiting.
• Skin:
• No diaphoresis
• Neuro:
• No head ache, no numbness, no tingling
• Psych:
• No Anxiety
• All other review of systems not in HPI are negative
Physical Exam
• Vital Signs
• Weight 73Kg
• HR 96 BPM
• RR 20
• BP 115/61
• SpO2 94% on 2 LPM
oxygen NC
Physical Exam
• General: A&O, NAD
• Skin: warm, dry, pink
• Neck: supple, no carotid
bruit heard
• HEENT: PERRL, MMM
• CV: Tachycardia, no
murmur, normal
peripheral perfusion. No
edema.
• Respiratory: diminished
breath sounds on the
left. No retractions.
• Vascular: normal radial
pulses B/L
• Chest Wall: non-tender
• Back: normal ROM,
normal alignment
• MS: normal finger
lengths
• GI: S, NT, ND +BS
• Neuro: no deficits
• Psych: cooperative,
appropriate mood
DDX: First Thoughts
• GI:
• Esophageal Spasm, Gastritis, GERD, Mallory Weiss Tear, Pancreatitis
• Cardiac:
• Tapenade, Acute Coronary Syndrome, Pericarditis, Myocardial
Sarcoma, Endocarditis
• Pulmonary:
• Pulmonary Embolism, Pleurisy, Pneumonia, Influenza
• Musculoskeletal:
• Chostochondritis, Somatic Dysfunction T5 and/or Ribs
• Mediastinal:
• Aortic Aneurysm, Aortic Dissection, Mediastinal Tumor
ECG
• 19:22hrs – Sinus Rhythm at 92 BPM, so ST segment
changes. +RBBB
Laboratory
Na
139mmol/L
Troponin
<0.02 (normal)
K
3.6 mmol/L
Albumin
3.2g/dL
Cl
100 mmol/L
Glucose
178mg/dl
CO2
31 mmol/L
Ca
8.8mg/dL
BUN
17 mg/dL
WBC
21.4 x 10-3
Cr
1.1
Hgb
13.8 x 10-3
Total Bili
0.3 mg/dL
HCT
40.9%
Alk Phos
75 unit/L
PLT
235 x 10-3
AST
16 unit/L
Neut %
90%
ALT
20 unit/L
Bands
0%
Imaging
Imaging
Imaging
Imaging
Imaging
A/P:
Assessment
• 1. Thoracic Aortic
Aneurysm
Plan
• 1. Cardiac Monitoring
• 2. Transfer to Higher
• Slow leak
• 2. Left Hemothorax
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• 3. ACS
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• 4. Hx HTN
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• 5. Tobacco Use
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Level of Care
3. Blood Pressure control
4. Smoking cessation
5. Discuss DNR status
6. Supplemental Oxygen
Discussion with Patient and Family
• Discussed severity/risk of situation with patient and wife
• Gave R/B/I for various options of treatment
• Including:
• Transfer to Higher Level of Care – including Major Cardiothoracic Surgery
• DNR Status
• Need for Anti-hypertensive medicine
• Expectant Management
• Asked about DNR status/Living Will
• P.W. was ok to be DNR and not pursue treatment, but agreed to wife’s
wishes for full code status and opted for treatment.
Transfer Conversations: 5
From Rural Kansas to Somewhere Else
• 1. Called Dispatch at nearest Major Kansas Center 1
• No CT surgery on call at Center 1
• 2. Call transferred to other nearest Major Kansas Center 2
• 3. Was told to call Kansas Center 1 again
• no CT surgeon accepting these cases in Kansas. Rec to call a CT
surgeon in Houston, TX
• 4. Conversation with CT surgeon at Center 3 in Houston.
• Surgeon disability prevents acceptance of case
• Rec to call another group
• 5. Conversation with CT surgeon at Center 4 in Houston.
• Patient accepted.
Timing Day 1
• 18:55 hrs – Arrival to ED. Seen upon arrival by physician
• 19:15 – lab at bedside
• 19:20 – ECG obtained and tracing viewed by physician
• 19:43 – Radiology performed CXR
• 20:03 – Rad report received
• 20:45 – P.W. returned to RAD for CT chest
• 21:25 – CT report called to Physician, 2nd opinion
recommended
• 23:10 – 2nd opinion, radiologist D/W ED physician
• 23:22 – Options of care D/W family
• 23:30 – Kansas Center 1 transfer request called
• refused
Timing continued… Day 2
• 23:35hrs – Kansas Center 2 transfer request call
• refused
• 00:00hrs – CT surgery Center 3 (Houston, TX)
• no cover, surgeon disability
• 00:45 – CT surgery Center 4 (Houston, TX)
• accepted patient
• 00:50 – Eagle Med contacted for transfer arrangements
• Eagle med report approx 1-2hr ETA
• 01:42 – Report called to CVICU in Houston, TX
• 02:15 – Eagle Med / EMS staff arrive to ED
• 02:30 – P.W. departs with Eagle Med / EMS staff to airport
• Wife accompanies them to fixed wing
Subsequent Course of Events
• Day 2
• Early AM - P.W. transferred by fixed wing to Houston, TX
• PM – PCI of Heart discovers significant coronary disease
• CT surgery planned for Tuesday
• CABG and Thoracic Aortic Aneurysm repair
• Day 3
• Early PM – P.W. suffers Cardiopulmonary arrest and passes
• Day 4
• Wife travels to DFW where she has family
• 1 Week Later
• Follow up call to wife
Thoracic Aortic Aneurysm Epidemiology (3)
• Incidence 5.6 – 10.4 cases per 100,000
• Estimated prevalence: 4.2% of the general population
without HTN
Descending Thoracic Aneurysm
Normal Thoracoabdominal Aorta
Aneurysm Classification
Types of Aortic Dissection
TAA etiology (3)
• Degenerative Aneurysms
• Atherosclerotic
• Genetically Triggered Aneurysm Syndromes
• Marfan Syndrome
• Loeys-Dietz Syndrome
• Bicuspid Aortic Valve
• Turners Syndrome
• Familial non-syndromic TAA syndrome
• Aortitis
• Infectious
• Non infections/inflammatory
• Trauma
• Chronic Aortic Dissection
Typical Symptoms of TAA
• Symptoms can include: dysphagia, hoarseness, chest
pain, back pain, s/s aortic insufficiency (3)
• Location: (5)
• TAA ascending – pain located in sub-sternal pain
• TAA descending – pain located in intra-scapular
• Often asymptomatic (silent) until rupture (5)
• 15% of patients may have symptoms that preceded
rupture/dissection.
• Other symptoms not excluded
Diagnostics In The ED
• CT angiography and MRI approach 100% sensitivity and
specificity (5)
• CT has obvious advantages in the ED due to speed of testing
• Go ahead and order imaging of entire aorta if pathology present (3)
• CXR is a good initial test but not always sensitive (5)
• TEE has a place in TAA and aortic valve surveillance
• D-Dimer has nearly 100% sensitivity for aortic dissection
(5)
Management Decisions:
Surgery or Surveillance? (3)
• Incidental and Asymptomatic?
• Ascending or arch >5.5cm/ Descending > 6cm
• Congenital Ascending 4-5cm/ Descending >5.5cm
• Symptomatic?
• Any aortic abnormality associated with symptoms.
• Mortality Rate of 1-2% per hour in first 24hrs (5)
Things To Do During Decision Making (5)
• Blood Pressure Control
• Start with Systolic of 90-100mmHg unless patient unable to tolerate
• Afterload decrease with nitro drip or Nitroprusside
• Anti-Impulse therapy with titratable Beta blocker like Esmolol.
• Or consider a dual alpha/beta blockade like labetalol. Titrate to Heart
Rate affect (4).
• Anti-inflammatory Affect
• Doxycycline, Cox-2 inhibitor, statin and immunosuppressant
• These therapies are under study but not approved.
Safety of Thoracic Aortic Surgery (2)
• We need to give proper R/B/I for our patients
• Mortality risk 3%
• Risk of Stroke 3%
• For patients <55 years, survival rate
• 1year 84.7%
• 3 years 78.3%
• 5 years 72.5%
• And 98% freedom from permanent complication: death, stroke,
paraplegia
• 10 year survival rate 73% (4)
Follow Up Call
• Almost a week later the wife was called to ask about her
husband; how had he faired.
Resources
• 1. Old Farmer photo:
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http://www.flickr.com/photos/boston_public_library/5935074088/sizes/
o/in/photostream/
2. Achneck et al. Safety of Thoracic Aortic Surgery. Ann Thorac Surg
2007;84:1180-5
3. Booher and Eagle. Diagnosis and MGMT Issues in TAA. Am Heart
J 2011;162:38-46.e1
4. UpToDate
5. Elefteriades. TAA: Reading the Enemy’s Playbook. Curr Probl
Cardiol, May 2008;33:203-277
6. ECG photo: http://hqmeded-ecg.blogspot.com/2012/04/is-thissimple-right-bundle-branch.html
7. Ariel photo over Crater Lake and Old Lady: Taken by Drew Posey
2012
8. Aorta Images taken from:
• Safi, H et al. Thoracic Vasculature with Emphasis on the Thoracic Aorta.
SabistonTextbook of Surgery: The Biological Basis of Modern Surgical Practice
18th Edition © 2008 Ch 63. pg 1857-8