Useless ECG?

Clinical Scenario

A 67 y/o man arrives to the ED by ambulance because of precordial pain since half an hour, during the transport, paramedics perform an ECG that shows a left bundle branch block (LBBB), that patient refers in his history.

They find it unuseful and so they do not transmit it to the cardiologist, is it correct?

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Atypical or typical, is this the question?

Clinical Scenarios

It is a busy day in your ED:

A 60 y/o female refers a retrosternal pain radiates to right arm that lasts more than 20 minutes. 

A 50 y/o male refers a pressure  in his chest, with tachycardia and sweating.

A 75 y/o female refers a sharp and stabbing pain exacerbates by forceful breathing.

In all cases the ECGs are nondiagnostic.

Do these clinical features help to predict an acute myocardial infarction (AMI)?

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Can we fight against Pulmonary Embolism using the LR’s arrows?

Clinical Scenario

A 80 y/o woman presented to the ED for dyspnoea.

She underwent a knee replacement 2 weeks ago, RR is 24, O2 saturation is 88%. HR is 90, the knee is edematous.

You are going to hunt a pulmonary embolism (PE)

While you phone the radiologist for a thorax CT scan you have an idea:

Can a compression ultrasonography (CUS) helps to avoid a CT?

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What does it hide behind a negative X-Ray?

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 

Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml.

Maybe is not a wall chest pain, but in which direction this test are carrying you?

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Pleuritic pain and radio-occult lesion

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain localized on the left in basal region. The pain is described as stabbing, well localised, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. Chest x ray is normal. 

Is it a wall chest pain or there migth be something else? 

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Chest X-Ray and aortic dissection

Clinical Scenario 

A 70 yo man come to the ED for restrosternal chest pain and shortness of breath during minimal activity in the last days. He is an ex smoker, with a history of hypertension. On physical examination the patient is not in distress, with a regular blood pressure and regular oximetry. ECG shows no evidence of ischemia. You first think about coronary artery disease, but you also want to exclude an aortic dissection. In Radiology the patient remaine seated and receive an anteroposterior (AP) chest Xray: maximal mediastinal width (MW) is 8,80 cm (the optimal cutoff level is 8,65 cm), no other signs. 

Shall you worry?

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How LR works. Why any test is unnecessary for a patient with very low-risk chest pain ?

A 40 yo truck driver, presented in ED with substernal chest pain. He is healthy, no family history of CAD. Held for observation, serial ECG have not modified, not elevated troponin.

Is an Exercise Treadmill Testing useful (ETT)? Or a Myocardial Perfusion Imaging (MPI) is better ?

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D-dimer and Aortic dissection

It’s 3.00 am when a 55 yo man is accompained to the ED by his wife because of sudden onset precordial pain, he has not clinical history, he does not smoke and he has an active life style, you find a normal blood pressure and clinical examination and a normal ECG, but the pain is severe and continuos. The patient start sweating, and you too. You give morfine and start thinking about….AORTA! you don’t find any pulse difference, but your feeling increases, how can you explain your feeling to the radiologist? 

Can something else help you to rule-out aortic dissection….

Conclusion The presence of pulse deficits or focal neurological deficits increases the likelihood of an acute thoracic aortic dissection in the appropriate clinical setting. Conversely, a completely normal chest radiograph result or the absence of pain of sudden onset lowers the likelihood. Overall, however, the clinical examination is insufficiently sensitive to rule out aortic dissection given the high morbidity of missed diagnosis. A negative D-dimer (<500) can rule-out an aortic dissection. Unfortunately a positive test does not give any additional chance to persuade radiologist… Bibliography Epidemiology of thoracic aortic dissection. LeMaire SA, Russell L. Nat Rev Cardiol. 2011 Feb;8(2):103-13. Epub 2010 Dec 21. Does this patient have an acute thoracic aortic dissection? Klompas M. JAMA. 2002 May 1;287(17):2262-72. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Shimony A, Filion KB, Mottillo S, Dourian T, Eisenberg MJ. Am J Cardiol. 2011 Apr 15;107(8):1227-34. Epub 2011 Feb 4. D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study. Eur Heart J. 2007 Dec;28(24):3067-75. Epub 2007 Nov 6. Sodeck G, Domanovits H, Schillinger M, Ehrlich MP, Endler G, Herkner H, Laggner A. D-dimer as the sole screening test for acute aortic dissection: a review of the literature. Sutherland A, Escano J, Coon TP. Ann Emerg Med. 2008 Oct;52(4):339-43. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Ohlmann P, Faure A, Morel O, Petit H, Kabbaj H, Meyer N, Cheneau E, Jesel L, Epailly E, Desprez D, Grunebaum L, Schneider F, Roul G, Mazzucotteli JP, Eisenmann B, Bareiss P. Crit Care Med. 2006 May;34(5):1358-64.  Ilenia Spallino

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