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EM Basic Chest Pain: Pet Mac P E T M A C
EM Basic Chest Pain: Pet Mac P E T M A C
EM Basic Chest Pain: Pet Mac P E T M A C
Chest pain
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