1. Montinee Sangtian, MD
Emergency Physician
BUMRUNGRAD INTERNATIONAL HOSPITAL

2. INTRODUCTION
 high-risk specialty
 not purely due to a lack of knowledge but
rather to simply “letting one’s guard down.”
 Did not use the evidence-based in clinical
decision.

3. COMMON PRESENTING SYMPTOMS IN ED
 Abdominal Pain
 Chest Pain
 Dyspnea, Shortness of Breath

4. CHEST PAIN
 5% of all ED visits
 Ranging from benigh to life-threatening.
 ACS is 20% of all deaths in US.
 Fear of being sued : increased hospital cost
and admit non-cardiac caused in IPD or CCU

5. IMMEDIATE LIFE THREATENING CAUSED OF
CHEST PAIN

6. FINAL DIAGNOSIS OF CHEST PAIN FROM ED
i*trACS registry data, Jun1, 1999- Aug1, 2001

7. BUT, MORE OVER…
 Missed Cardiac Ischemia 2-4%, with
mortality rate 10-25%
 It means : every 100 chest pain patients
- 4/100 : Missed Cardiac Ischemia
- 1/100 : dead from missed diagnosis.

8. Characteristics associated with inadvertent discharge
of a patient with missed cardiac ischemia
• Younger patient
• Atypical symptoms
• Women
• Nonwhite
• Physician inexperiences
• Lower-volume EDs
• Failure to detect ischemia on initial ECG
• Failure to obtain an ECG
(Ann. Emerg Med 1989;18(10):1029-34)

9. CLINICAL QUESTIONS
 How to rule out or rule in life-threatening
chest pain?
 Characteristics of pain, History, Risk factors,
Physical exam, ECG, Lab, CXR
 Outcome.

10. CHARACTERISTICS OF CHEST PAIN
 NRMI2 – 1/3 of MI – no chest pain
 20% of MI – with presenting symptoms other
than chest pain
Risk Factors % Without chest pain
Prior Heart Failure 51
Prior Stroke 47
Age > 75 yr 45
DM 38
Non-White 34
Woman 39

11. ATYPICAL CHEST PAIN
 7% of ACS : chest wall tenderness
 6% of costochondritis dx : enz - proven MI
( Arch. Intern Med 1994; 154(21):2466-9)
To define low-risk group : use combination of 3
1. sharping or stabbing pain
2. no history of angina
3. pain reproduced by palpation
Without these combination – 5% were MI.
( Arch. Intern Med 1985; 145(1):65-9)

12. HISTORY
 Burning, Indigestion complaints – as strong
as chest pressure (QJM 2003;96(12);893-9)
 Precipatating factors : physical activities
35%, eating 8.2%, emotional stress 6.8%
(Int. J. Cardiol.; 117(2):260-9)
 Relieving factor : GI cocktail, antacids, NTG –
not reliable. (Ann. Emerg Med 1996;26(6):687-90)

13. Features that increased the probability of an acute MI
Jama 1998;280:1256
• CLINICAL FEATURES Likelihood ratio (95% CI)
• Pain in chest or left arm 2.7
• Chest pain radiation : Rt shoulder 2.9(1.4-6.0)
• Chest pain radiation : Lt arm 2.3(1.7-3.1)
• Chest pain radiation : Both Lt and Rt arm 7.1(3.6-14.2)
• Nausea or vomiting 1.9(1.7-2.3)
• Diaphoreis 2.0(1.9-2.2)
• 3rd Heart sound on ausculation 3.2(1.6-6.5)
• Hypotension (SBP < 80 mmHg) 3.1(1.8-5.2)
Features that decreased the probability of an acute MI
• Pulmonary crackles 2.1(1.4-3.1)
• Pleuritic Chest Pain 0.2(0.2-0.3)
• Sharp or Stabbing Chest Pain 0.3(0.2-0.5)
• Positioning Chest Pain 0.3(0.2-0.4)
• Chest Pain reproduced by palpation 0.2

14. Classic or traditional Non-traditional
Risk Factors Risk Factors
• Advanced age • HIV
• Male • SLE
• Hypertension • ESRD
• DM • Cocaine
• Hypercholesterolemia • Type A Personality
• Premature CAD in • Genetic and Acquired
1st degree relatives thrombophilias
• Cigarette smoking

15. 4 RISK FACTOR :
DM, HT, HYPERCHOL, FAMILY HX OF CAD
Group No Risk Factors ≥ 4 Risk Factors
LR – LR +
Age < 40 yr 0.17 7.39
(95% CI 0.04-0.66) (95% CI 3.09-17.67)
40 – 65 yr 0.53 2.13
(95% CI 0.40-0.71) (95% CI 1.66-2.73)
65 yr 0.96 1.09
(95% CI 0.74-1.09) (95% CI 0.64-1.62)
i*trACS registry data analysis

16. RISK STRATIFICATION : TIMI, GRACE, ETC.
 Don’t be confuse !
 TIMI, GRACE, ESSENCE – for predicting outcome,
adverse events.
 Not for rule out Acute Coronary Syndrome.
 Can not use for discharge decision making.
 Even TIMI score = 0, rate of adverse events
in 30 days = 1.7% (95% CI 1-4%)

17. ECG AND CARDIAC BIOMARKERS
 Single initial normal EKG and Cardiac Enz can not
be used for rule out ACS.
 7.8% of MI : normal initial ECG
 35.3% of MI : non-specific finding on initial ECG
 Be careful in LBBB and Ventricular Pacing Rhythm
(VPR) ECG.

18. LBBB
• Widened QRS complex > 0.12s
• Monophasic notch R-wave in the lateral leads Lead I, V5
• Absent of Q-wave in Lateral leads.
• There is discordant between the major vector of QRS complex and
the major vector of ST-segment/ T-wave complex that follows

19. ACUTE MI IN THE PRESENCE OF LBBB
•There is concordant ST-segment elevation in lead I, aVL, V5, V6
•Concordant ST-segment depression in leads V1-V3

20. Scarbossa’s criteria for STEMI in the presence of LBBB
ST-segment elevation ≥ 1 mm concordant Score 5
with QRS complex
ST-segment elevation ≥ 1 mm Score 3
in lead V1, V2 or V3
ST-segment elevation ≥ 5 mm discordant to Score 2
QRS complex
Score ≥ 3 : likely to experience STEMI
Score < 3 : indetermined

21. VPR
•Small amplitude spikes before the widened QRS cpx
•Predominate negative QRS cpx (9/12), less opportunity for
Concordant ST-segment elevation

22. ACUTE MI IN THE PRESENCE OF VPR
Concordant ST-segment elevation in leads II, III, aVF and
Reciprocal ST-segment depression in leads I and aVL

23.  Only 1 useful to detect STEMI in VPR :
 ST-segment elevation ≥ 5 mm discordant to
QRS complex.
 The ECG in VPR is more likely to rule in the
diagnosis of acute MI than to rule it out.

24. PRIOR NEGATIVE CARDIAC WORKUP :
Stress test (Am J Cardiol 1997; 80(8): 1086-7)
• 3 yr Event rate for prior negative stress test is 5-15%.
• A Stress test can be considered to rule out coronary
disease during that visit only.
Cardiac Cath. (Arch Intern Med 2006; 166(13): 1391-5)
• 1 yr Event rates for prior negative C.Cath
• 3.3% : mild CAD (< 50% stenosis)
• 1.2% : serious event rate.
• Normal angiogram equals to no short-term risk of ACS

25. OTHERS CAUSES OF
ACUTE LIFE-THREATENING CHEST PAIN
 Aortic Dissection
 Pulmonary embolism
 Pericarditis with cardiac tamponade
 Tension pneumothorax
 Esophageal ruptured.

26. AORTIC DISSECTION OF THORACIC AORTA
 Chest pain (sensitivity 67%), Back Pain (32%),
Abd. Pain (23%), ANY PAIN (90%)
 Other symptoms : syncope (4-13%), stroke (6%),
other neuro deficit (17%)
 In AD patients : 62% Widening mediastinum , 50%
Abn. Aortic contour, 12% normal CXR

27. PERICARDITIS
 Failure to differentiate Pericarditis from other chest
syndrome
 Classic symptoms : progressive, central, pleuritic
shest pain that worse in supine
 PE : friction rub, heard best in sitting up and
leaning forward.
 ECG : diffuse ST elevation , PR depression
( except lead aVR)
 35-50% of Patients : elevated Troponin level
 Always look for Signs of Pericardial tamponade!

28. a. Acute Pericarditis : Concave ST segment Elevation
b. Acute MI : Convex ST segment Elevation

29. Ratio of the ST segment and T wave amplitudes, Lead V6
a. ratio ≥ 0.25 : Pericarditis
b. ratio < 0.25 : BER (Benign Early Repolarized)

30. BOERHAAVE’S SYNDROME
 Classic Triad: forceful emesis, chest pain,
subcutaneous emphysema.
 CXR abnormalities usual on the Left : 90% tear in
the left posterolateral wall of lower 1/3 esophagus
 pneumomediastinum, hydropneumothorax
 20% of case : no vomiting
 Other caused : swallowing sandwich, violent cough,
weight lifing, seizures, blunt abdomen.
 Diagnosis : CXR, CT, Esophagogram

31. SUMMARY : PITFALLS IN CHEST PAIN
 Over-reliance on the classic presence of chest
pain for the diagnosis of acute myocardial
infarction (MI)
 Exclusion of cardiac ischemia based on
reproducible chest wall tenderness
 Assumption that acute MI cannot be diagnosed
with a 12-lead ECG in the presence of pre-
existing left bundle branch block or ventricular
paced rhythm

32.  STEMI can be diagnosed on an ECG with LBBB …
the ECG is more useful in ruling in the diagnosis
than in excluding it.
 Use of a “GI cocktail” to distinguish between cardiac
versus non-cardiac chest pain
 Assumption that a normal ECG rules out cardiac
ischemia
 Single determinations of cardiac markers at the time
of presentation appear to be inadequate to exclude
the diagnosis of acute MI and provide no
information about the possibility of cardiac ischemia

33.  Over-reliance on a “classic” presentation.
 Use of the chest X-ray to exclude AD
 The use of ECG findings to rule in or rule out PE

34.  Failure to differentiate pericarditis from other chest
syndromes
 Assumption that the standard chest X-ray
completely rules out pneumothorax
 Excluding the diagnosis of Boerhaave’s syndrome
due to an absence of antecedent retching or
vomiting
 Failure to evaluate a patient with chest tenderness
for herpes zoster

36.  Frequent chief complaint in ED
 Common associated with hospital admission
 Subjective symptom
 Crucial for EPs to consider related underlying
disease.
 Delayed diagnosis and treatment can lead to
increase morbidity and mortality.

37.  Pericardial Effusion and Cardiac Tamponade
 Pneumothorax
 Pulmonary Embolism
 Asthma, COPD
 Anemia, etc.

38.  Ausculation in Hemothorax, Pneumothorax :
sensitivity 50-82%, PPV 97-98%
 Normal ausculatory exam : up to 800 cc of
hemothorax, 28% of pneumothorax
 Pneumonia : sensitivity 47-69%, specificity 58-75%

39.  Pulse oximetry : useful for detect hypoxia,
 Not for hypercarbia, hypoventilation
 Anxiety and depressive are common in
elderly and more likely with non-specific
symptoms.

40.  < 50% of Pt with cardiac tamponade have
the classic finding.
 Doppler Echocardiography : sensitivity 96%

41.  Classic symptoms: pleuritic chest pain and SOB
 20% asymptomatic or minor symptoms
 23% missed pneumothorax in standard CXR in ICU
patients. 26% missed in severe injured patients
 CXR Upright 80% sensitivity, Supine 50% Sens.
 Others options : expiratory CXR, lateral decubitus
film, US, Chest CT
 Bedside US : up to 98% sensitivities
 CXR and US cannot diff. Bullous and Pneumothorax

42.  Not including pulmonary embolism in the
differential diagnosis of the patient with dyspnea
 Use objective criteria to assess pretest probrobility.
 Over-reliance on the D-dimer, ABG, CXR, or EKG to
exclude PE
 CXR, EKG should not be used alone to exclude PE.
 A D-dimer test should not be used to exclude PE in
patients with moderate or high clinic pre-test
probability.

43.  Only 20% present with classic triad of chest pain,
dyspnea, hemoptysis
 In PE patients only 44% has pleuric chest pain
 80-92% of PE patients presented with dyspnea.
 67% of Pt : rapid onset of dyspnea over sec to min.
 Classic S1Q3T3 ECG only 12-50% of PE.
 Precordial T-wave inversion was the most common
finding in ECG of PE (68%)
 Sinus tachycardia : 8-69% of PE

45.  Low risk Wells score + Negative D-Dimer :
NPV 96-100% (Ann Intern Med 2001;135(2):98-107)
 PERC : can exclude PE in low pretest prob.
(Am J Emerg Med 2008;26(2):181-5)
 D-Dimer
 normal D-Dimer level (ELISA): 95% likelihood of
not having PE
 Poor PPV, Good NPV
 (Mayo Clin Proc 2003;78(11):1385-91)

46.  CXR : poor diagnostic tool for PE
(Chest 1991;100(3):598-03)
 ECG : neither sensitive nor specific for PE
(Emerg Med Clinic North Am 2006;24(1):133-43)
 CXR, EKG should not be used alone to exclude PE

47.  Bedside US : sensitivity 51-93%, specificity
82-90% ( Int J Cardiol 1998;65(1):101-9)
 V/Q Scan :
 normal, low, intermediate, high probability of PE
 High Probability : PPV 85-90%
 Normal and High Prob : powerful prognostic tool.

48. CONTRAST-ENHANCED HELICAL, SPIRAL, OR
ELECTRON-BEAM CT
 Pulmonary Computed Tomography
Angiography (PTCA) : Senstivity 53-70%
 PTCA + Scoring System: 83-96%
(N Engl J Med 2006;354(22):2317-27)

49.  Gold standard : Pulmonary angiography
 Disadvantage : Invasive

50.  Identifying asthmatics at risk
 Assessing asthma severity
 Clinical presentation : slow or fast onset
 Some Pt. have low perception of dyspnea

51.  Overly or underly aggressive oxygen administration in
patients with COPD
 Do not withhold oxygen from a hypoxic COPD patient;
however, be cautious with its use and follow PCO2 levels.
 Initial Goal : SaO2 > 90%, PaO2 60-70 mmHg
 Cutoff at Sao2 92%, detect hypoxia : sensitivity 100%,
specificity 86%
 Not considering non-invasive positive pressure ventilation;
that is, CPAP/BiPAP as an alternative to intubation in
selected patients
 Data support for using NPPV is strongest for COPD.
 Decreased Intubation Rate (RR 0.42, 95%CI 0.31-0.59)
 Decreased Mortality (RR 0.41, 95%CI 0.26-0.64)

53.  5-10% of all ED visits.
 18-25% admitted for investigation
 10% : operation
 Challenge for emergency physician (EP):
 About 1/3 have an atypical presentation.
 If misdiagnosis, mortality rate 2.5 times higher than
correct diagnosis in the elderly.
 Problematic : Women (child-bearing age), HIV, Elderly.

54.  A 65 yr Male, DM,HT with epigastric pain,
nausea, no fever
 A 43 yr Female, Lower abdominal pain,
vaginal bleeding
 A 25 yr Male: fever with RLQ pain
 A 78 yr Male, ESRD on HD : abdominal pain

55.  Who is the patient of acute abdomen?
 What are the probable diagnoses you have in
mind?
 Why do you consider such diagnosis?
 How do you prove it?
 When will you consult surgeon for operation?

56.  Common, lifetime risk 7%
 Only 20% of elderly pt have classic findings.
 MANTRELS (Alvarado) Score : less suited for
elderly, women
 Missed Appendicitis in score < 5 : age 60-80 yr
 High score in women has a lower PPV
 Score > 7 in women : 1/3 were normal appendix

58.  No lab test specific for appendicitis.
 Scoring system : MANTRELS, Ohmann score
: none of these are accurate enough to
predict appendicitis.

59.  CT : sensitivity 94%, specificity 94%
 CT : appendix > 6 mm, wall thickening, RLQ
inflammatory changes, appendicoliths.
 Contrast CT vs NonContrast CT : equal
 IV contrast : highlight inflammed tissue.
 Oral Contrast : better differentiate the
appendix from surrounding tissue.

60.  High sensitivity as CT in some studies
 Lower NPV than CT (specificity 83%)
 Finding : non-compressible lumen, diameter >
6mm, absence gas in lumen and appendicoliths
(some center use 7mm)
 Doppler US – increased flow in an inflammed
appendix, but limit in necrotic or ruptured
appendix.
 Limitations : Obese, Bowel gas, Operator
dependent
 US best use as an initial study in children,
women, pregnant patients.

61. A 43y Female, Lower abdominal Pain, no fever,
no nausea/vomiting
 Vaginalbleeding : spotting for 20 days
 Refused probability of pregnancy
 No contraception
• UPT +
• PV : OS closed, minimal bloody mucoid
• Treated as Threatened abortion, D/C

62. 3 DAYS LATER
 The patient came to ED, with abdominal pain
with spotting.
 V/S : BP 100/80, PR 110

64.  1:30000 pregnancies
 4 common signs
abdominal pain, adnexal mass, peritoneal irritation,
enlarged uterus (absent in 1st Tri.)
 Consider heterotropic pregnancies in women receiving ART :
1:100 Pregnancies

65.  8% of Unstable angina presented with
epigastric pain
 Painless ulcer was found 35% of Pt > 60 yr
 Elderly Pt with Acute cholecystitis
 50% has afebrile. 33% absent leukocytosis and
normal LFT
 Pancreatitis
 incident 200 folds in > 65y
 Higher risk of necrotizing pancreatitis in >80y
 Early CT in Elderly

66.  Low incidence (1/1000 Hospital admission)
 High Mortality (80%), with immediate
angiogram (mortality reduced to 54%)
 Severe Abdominal Pain (out of proportion to
exam)
 Risk Factors for mesenteric ischemia

67. Type of Mesenteric Risk Factors Special Notes
Ischemia
SMA Embolus Cardiac Disease 1/3 have Hx of Embolic
•AF and other arrhythmias event
•Valvular diasease
•Ventricular aneurysm
•Cardiomyopathy
SMA Thrombosis Vascular Disease Risks Acute event may be
•HT preceded by period of
•Hypercholesterolemia “intestinal angina” and
•DM prolonged period of
•Smoking significant weight loss
Mesenteric Venous Hypercoagulable State Women > Men
Thrombosis •Inherited ½ have personal or
•Acquired (Malignancy, Oral family Hx of DVT/PE
contrceptions) Subacute presentation
NOMI Low-flow state
(Non-Occlusive Mesenteric •Sepsis Heart Failure
Ischemia) •Volume depletion Hemodialysis
Drugs
•Digitalis Ergot derivatives
•Cocaine Norepinephrine

68.  Misdiagnosis of cardiac ischemia
 Over-reliance on “classic” presentations and
laboratory results of appendicitis
 Over-reliance on laboratory values and ancillary
testing in suspected mesenteric ischemia.
 Failure to consider heterotopic pregnancy in
women receiving reproductive assistance
 Failure to appreciate atypical signs and
symptoms in the elderly

69.  Do Not over-reliance on the classic signs,
symptoms, diagnostic tools.
 Know Limitations of Test and Scoring system
 Negative test does not mean no disease.
 Use Evidence-Based in decision making
 Do not “ Guard Down”