Chest Pain, Shortness of Breath, Cyanosis & Cough

“6% of patients presenting with acute chest pain are discharged from EDs with missed prognostically important myocardial damage.”
— Collinson et al, 2000

CAP 6 – Breathlessness

CAP 7 – Chest Pain

CAP 9 – Cough

CAP 10 – Cyanosis

EM Curriculum: (click to view)

Background

Acute chest pain is a common presenting complaint in patients attending general practice, Emergency Departments (EDs) and Medical Assessment Units (MAUs). It accounts for 6% of all new attendances at EDs in the UK (Goodacre et al, 2004). Ischaemic heart disease is responsible for 38% of all adult deaths in the UK (Allender et al, 2008). It is estimated that there are 96,000 new cases of angina and 146,000 new cases of myocardial infarction each year in the UK (Allender et al, 2008). Early management of ischaemic heart disease in the UK has been revolutionised by evidence based guidelines. Acute chest pain may be the only clue of a life-threatening condition and all such patients should be urgently assessed.

Patients presenting with acute chest pain are at risk of being inappropriately discharged home following inadequate assessment, with potentially catastrophic consequences: 6% of patients presenting with acute chest pain are discharged from EDs with missed prognostically important myocardial damage (Collinson et al, 2000). A careful history and examination will often suggest the cause in non-cardiac chest pain. Many causes of non-cardiac chest pain require immediate treatment to avoid serious sequelae. 

85% of all cases of dyspnoea are accounted for by asthma, cardiac failure, COPD, pneumonia, interstitial lung disease and psychogenic disorder. Don't forget pneumothorax and pulmonary embolism. Any patient with significant dyspnoea will require a rapid assessment of their vital signs followed by appropriate resuscitation (airway support, supplemental oxygen, ventilatory support, etc.).

Patients who do not require immediate resuscitation will have their management guided by a thorough clinical assessment commencing with a focussed history and examination. Certain examination findings upon respiratory system examination are diagnostic in the context of presentation with dyspnoea. Pulse oximetry provides a simple, accurate, non-invasive and continuous means of monitoring arterial oxygen saturation. A number of factors can affect the accuracy of pulse oximetry and it is important to be aware of its limitations. ABG analysis is the investigation of choice for assessment of a patient’s respiratory and acid-base status.

Remember: A high RR can also be caused by non-respiratory pathology, for example compensation for a metabolic acidosis.

LEARNING OUTCOMES FROM THE TASKS

  • Understand the role of Troponin in ruling out MI and where the evidence behind this comes from...

  • Identify STEMI on ECG.

  • Recognise and describe the management of Aortic Dissection.

  • Recall the limitations of D-dimer in ruling out PE.

  • Develop an approach to the breathless patient presenting to the ED.

LEARNING OUTCOMES FROM THE FACE-TO-FACE

  • Revise the presentations of chest pain to the ED.

  • Revise the causes of breathlessness in the ED.

  • Demonstrate how to manage a patient in respiratory arrest.

  • Demonstrate how to insert a chest drain.

  • Demonstrate how to set up CPAP and NIV machine in ED.

  • Form a differential diagnosis for Cyanosis and when to consider Methaemoglobinaemia.

Tasks

Complete the following before the face-to-face session:

Task 1: Effectiveness of TROPONIN

Duration: 6 mins

This short video summarises Dr. Body's Lecture from #RCEM15 (Manchester) and summarises nicely some the effectiveness of modern troponin assays at ruling out Myocardial Infarctions.

Our interview with Dr. Rick Body, Consultant in Emergency Medicine at Manchester Royal Infirmary, at the Royal College of Emergency Medicine's Annual Scientific Conference 2015 in Manchester.

Task 2: Can you spot a STEMI?

Duration: 20-25 mins

This 36 ECG quiz challenges you to spot ST Elevation MI's. Some of the changes can be very subtle - but the quiz will compare you to others who have taken it and a computer algorithm. It also gives you an idea of your sensitivity and specificity for identifying a STEMI.

Task 3: Acute aortic Dissection

Duration: 60 mins

This module will cover all you need to know about aortic dissection. This is important not to be missed in the ED and can difficult to diagnose.

Task 4: 'Adjust' PE study

Duration: 30 mins

This podcast from SGEM looks at the limitations of D-Dimers and on study in particular that looks at an age adjusted D-Dimer. It also briefly mentions the use of the PERC Score in conjunction with D-Dimer to rule out PE. As always the discussion is based around a short case example. (link via iTunes – if you don't have iTunes click on the image to the right)

Task 5: Breathlessness

Duration: 60 mins

This RCEM Learning module covers common causes, pathophysiology and management of patients presenting to the ED with breathlessness.

#EM3 Content

Lightning Learning:

SIMBLOG:

Mini Teaches:

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, but for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to chest pain and breathlessness.

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A 54-year-old white male presented to the Emergency Department with complaints of progressive dyspnea and chest pain that had started simultaneously with acute onset 8 hrs before arrival.”
“A 38 year old man has presented to the Emergency Department with a chronic history of shortness of breath.”

ADDITIONAL RESOURCES

Seldinger Chest Drain Insertion:

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: