EM Basic

Chest pain

 Look at chart: age, vitals, EKG

 Is this STEMI?
 Reading an EKG:
o Look at 1 and avL  lateral
o 2,3, avF  inferior
o V1-V3  anteroseptal
o V4-V6  lateral
o Dubin’s method: Rate, rhythm, axis, interval  look for signs of ischemia
 Rate?
 Sinus or not?
o Look for flip T waves  ischemia
o Elevations  infarctions
o Depressions  ischemia or infarction opposition of that lead
 Ask for history: OPQRST
 Ask what they were doing at onset of pain
 Associated symptoms
 Recent Echo, stress test
 Focus on: BP meds, hyperlipidemia meds, anticoagulants
 Ddx: PET MAC
o Pulmonary Embolism
o Esophageal rupture
o Tension Pneumothorax
o MI
o Aortic dissection
o Cardiac tamponade
 PE
o Volume status?
 Important in CHF pts
 Listen to murmurs: aortic stenosis, if it radiates to carotids
o Press on chest wall to reproduce pain
 20% of MI pts have reproducible chest pain
o Palpate abdomen for AAA
o Check for DVT
o Check for edema? Pitting (compressible) or non-compressible
o Check pulses
 Symmetric
 Asymmetric may be aortic dissection
 Workup: everyone needs a EKG and CXR
o EKG – arrhythmia, CAD
o CXR – esophageal rupture, pneumothorax, aortic dissection
o Young – if syncope, different workup is required
o Evaluate for >/= 2mm ST elevations in >/= 2 contiguous leads
o New or presumed LBBB pattern = indication for immediate cath
o Sgarbossa criteria distinguishes LBBB from MI:
 ≥ 1 lead with ≥1 mm of concordant ST elevation
 ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
 ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive
discordant STE, as defined by ≥ 25% of the depth of the preceding S-
wave.

o Compare with old EKG

o CXR
 Young, thin smoker, asthmatic  pneumothorax
 Febrile  pneumonia
 60-70% sensitive for aortic dissection
 Esophageal rupture
 Boerhaave’s – free air in diaphragm
 Peritonitis on PE
 Recent endoscopy
 Alcoholic, bulimic, vomiting hx
 Aortic dissection
 Risk factors: HTN, pregnancy, CT disease (Marfan’s, ED)
 Don’t rely on unequal BPs (>20 mmHg b/w two arms) or
widened mediastinum
 pain radiating to back
 Chest pain + motor or nerve deficit
 Chest pain + unrelated complaint
 r/o with CTA with contrast
 if dye allergy or renal arteries are involved, do TEE or Cardiac
MRI
 Cardiac tamponade – Beck’s triad: muffled heart sounds, JVD,
hypotension
 Narrow pulse pressure due to incomplete emptying at diastole
 r/o with bedside U/S
o Female diabetics – fatigue, nausea, may not have chest pain symptoms
o General workup – EKG, labs: CBC, Chem 10, coag, cardiac enzymes
 CBC – check for anemia
 Chem 10 – electrolyte abnormalities
 Coag – if needing to anticoagulate
 Cardiac enzymes – Troponins (elevated 4-6 hrs, stays elecated 3-5
days) CK (elevated 6-8 hrs, down 1-2 days, CKMB, +/-myoglobin, BNP
o Management:
 325mg ASA unless taken one in past 24 hrs, even if on coumadin
 NTG 0.4mg sublingual q 5 min till chest pain resolves
 Contraindicated Viagra 24 hrs, Cialis 72 hrs
 Make sure IV is in place
  Make sure that you don’t see any sign of posterior MI, mirror
sign in V1
 If pain persists: IV 4 mg Morphine and 10mg Zofran
 Titrate morphine as needed
 If pain persists, get another EKG as it may be unstable angina
 Even if pain free, get a second EKG and compare
 Time to admit, talk to a cardiologist
 Age, risk factors, hx of CAD, EKG, CXR, cardiac enzymes, ASA,
NTG, repeat EKG
o PE – pleuritic chest pain, SOB, tachycardia, tachypnea, hypoxia
 Risk factors – OCP, pregnancy, recent surgery, DVT
 If on Coumadin with therapeutic INR – not less likely to get PE or DVT
 Workup: EKG, CXR, PA lateral, labs (CBC, chem 10, coag)
 Chem 10 – creatnine
 Coag – needing to anticoagulate
 D-dimers – don’t order D-dimers on everyone; D-dimers is very
sensitive, not very specific
 If medium or high risk  do CT scan
 If low risk  do PERC criteria to check need for CT scan
 PE Rule out Criteria(PERC): If any of 6 criteria
 BREATHS
 Blood in sputum
 Room O2 sat <95%
 Estrogen or OCP
 Age >50
 Thrombosis in past, PE, or DVT, or current concern for DVT
 HR>100, anytime during triage
 Surgery in past 4 weeks
 If they don’t have any of these, the risk for PE is 1.8%. Don’t need anti-
coagulation
 If PERC +, D-dimer -, don’t need CT
 Submassive PE management: 1mg/kg sc Lovanox with Heparin drip;
cardiac enzymes and BNP elevated or Echo shows RV strain, consult
for need thrombolytics
 Hemodynamically unstable (systolic <90)  need thrombolytics right
away

Abdominal pain

 First impressions:
o Open ended question
o OPQRST to assess pain
o ROS – N/V/D/ chest pain, SOB, urinary sx,
o Endoscopy/colonoscopy?
o Food intake
 o Meds?
 PE
o CVAT, point where it hurts the most with one finger
o Bend their knees as it relaxes abdominal muscles
o Check for rebound, guarding
o Peritoneal signs – shaking stretcher hurts
o Psoas sign – roll pt on left, take right leg and extend it all the way back.
Positive if increased pain on RLQ pain (positive in appendicitis)
o Obturator sign – pt flexes and externally rotates right leg, positive if pain in
RLQ pain (positive in appendicitis)
o Rovsings – pushing on LLQ reproduces RLQ pain (positive in appendicitis)
o Reverse Rovsing’s – positive in diverticulitis
o Murphy’s – take a deep breath in as you push in and it stops inspiration
midbreath (positive in cholecystitis)
o Ask about testicular pain and do a testicular exam (testicular torsion)
 DDx:
o Appendicitis
o Cholecystitis
o Pancreatitis
o Diverticulitis
o Bowel obstruction
o Bowel perforation
o Mesenteric Ischemia
o Kidney stones
o Gastroenteritis/ Gastritis
o AAA
 Workup:
o All females are pregnant unless proven otherwise
 UA, HCG in females
 Don’t automatically send for a culture unless doing a UTI
o CBC – surgeons want WBC
o Chem 10 – if you have hypokalemia
 can cause ileus
 low bicarb looks like acidosis in sicker pts
 Need creatnine to do contrast
o Coag – severe liver disease will show elevated coags before elevated LFTs
o LFTs – lipase to check for pancreatitis
o VBG with lactate – screen for mesenteric ischemia
 Give pain control before imaging – narcotics
o Better exam as it might give focal exam
o Give frequent titrated doses IV 0.1 mg/kg morphine or 4 mg morphine q 15
min x3 prn for pain; hold for somnolence, hypoxia, systolic <100
o Give 8mg Zofran IV for nausea
o Rash or itching – 12.5 - 25 mg Benadryl IV
 Imaging
 o LUQ – rarely requires imaging
o Epigastric – rarely requires imaging
 If pancreatitis, check for gallstones as cause
o RUQ – cholecystitis; U/S
o RLQ – appendicitis noncontrast CT of abd/pelvis, but hospitals prefer IV or
PO contrast
o Suprapubic – UTI
o LLQ – diverticulitis; CT with IV contrast
o Flank pain – CVAT, colicky pain; CT Abd w/o contrast (stone protocol, pt lays
on stomach); don’t let lack of hematuria dissuade you
o Gastritis, gastroenteritis
 Scenarios:
o Afib with intense abd pain worse with eating – no pain presently with
palpation
 Obstructive Mesenteric ischemia
 If sepsis and is on vasopressors  nonobstructive mesenteric
ischemia
o Multiple abdominal surgeries, vomiting, diffuse abd tenderness
 Bowel obstruction
 PO contrast helpful as it opacifies the bowel
 IV contrast CT abd/pelvis
o Perforation

o AAA
 Rapidly deadly
 Syncope, hematuria
 Back pain, abd pain
 Low threshold to U/S
 >2cm aorta, unstable  surgery schedule now
 2-5cm aorta, asx  outpt followup
 >5cm aorta, asx  surgery consult
o What is the mortality for STEMI?
 8%
o What is the mortality for abdominal pain?
 10%
 Have a low threshold to CT patients

Female abdominal pain

 Is the patient pregnant?
o Get a urine HCG
o If you’re getting an IV, just order a serum quant HCG
 Vaginal bleeding, discharge, fever, chills, back pain
 Gs and Ps
 Sexual history: married, relationship, single, monogamous, concern for STDs, ever
had sex? Lifetime partners? Assure confidentiality and privacy
 Is this abdominal or pelvic pain?
 DDx:
o Ectopic pregnancy
o Threatened abortion/ miscarriage
o Normal pregnancy
o STD
o PID
o Tubo-ovarian abscess
o Ovarian torsion
o Ovarian cyst
o Bacterial vaginosis
o Bacterial candiadisis
 Workup:
o UA; Urine/serum HCG
o May need abdominal labs: CBC, Chem 10, LFTs, lipase, coags
o G/C swab, wet prep, KOH prep
o Quantitative HCG if pregnant in first trimester
 PE:
o Look for discharge
o Cervical sample for G/C swab
o Wet prep/ KOH – vaginal wall swab
o Bimanual – check for open or closed cervix
o Check for CMT
o Check adnexal masses/tenderness
 Imaging
o Ectopic pregnancy or ovarian torsion – transvaginal U/S
 Fluid filled mass in uterus in intrauterine pregnancy
 Fetus in uterus if HCG>1500
 It’s possible to have an ectopic pregnancy in fallopian tube and have a
pseudosac in uterus; do serial HCG if HCG<1500, no fetal pole or HR (if
doubles, that is a positive sign for the pregnancy; if it doesn’t double,
concern increases for ectopic or miscarriage)
o Positive HCG + unstable or peritonitis
 Emergent OB consult
 OR right away
o Ruptured ectopic will be bradycardic (paradoxical bradycardia)
 Blood in peritoneum will cause a vagal response
 Ovarian torsion
o Time critical diagnosis
o Sharp, stabbing, sudden onset, lower abd pain with N/V
o +/- significant adnexal tenderness
o Imaging: a negative pelvic U/S does not rule out ovarian or testicular torsion
 Intermittent torsion may occur, so negative U/S is not always
confirmatory
 Most ovaries torse 2/2 large cyst >5cm in dm
  Torsion of ovaries have been reported after hysterectomy
 Ovarian cyst
o Transvaginal U/S can also be helpful to diagnose ovarian cyst.
 Pt with pain on side of cyst, with good flow through ovaries. Pain
controlled with pain meds. Good possibility of cyst
 STD/PID
o Treat pts with cervical discharge or CMT, or high suspicion with STD
o Treat both G and C
o Pure cervicitis (no CMT, positive swab) – 100 mg ceftriaxone IM
 If PCN allergy – 2gm azithromycin + Zofran (causes vomiting); same
dose every 30 minutes
o PID (CMT) – ceftriaxone 200mg IM + doxy 100mg for 14 days
o Toxic appearing, surgical abdomen, PO intolerant, pregnant – admit for
observation, no sex for 7 days after treatment
o Fitz Hugh Curtis – perihepatitis – RUQ abdominal pain, R shoulder pain,
elevated LFTs
 Treat underlying PID, consult OB/gyn
o Tubo-ovarian abscess – lower abdominal pain
 If suspecting ovarian torsion, suspect this
 If recurrent PID or suspect PID
 Transvaginal U/S