quick reference
PERC Rule for Pulmonary Embolism / Wells’ Criteria for DVT
HEART Score for Major Cardiac Events
If high index of suspicion for ACS, skip to ACS workup
History
location & radiation
- Location:
- Migration over time suggests aortic dissection.
- Very focal pain suggests chest wall or pleural source (rather than visceral pain). (Griffin 2022)
- Dermatomal distribution may suggest Herpes zoster.
- Radiation:
- Ischemia: may radiate to arms, neck, jaw, teeth, lower face, or epigastrium
- Dissection: often radiates to the back
- Pericarditis: may radiate to neck, back, trapezius ridge
- Musculoskeletal pain shouldn’t radiate
timing & patterning
- Rapid onset of pain?
- Ischemia: often takes a few minutes to reach maximal severity
- Sudden/instantaneous onset:
- Aortic dissection
- Pneumothorax and/or pneumomediastinum
- PE (pain may reflect distension of the pulmonary artery). (Braunwald 12e)
- Duration of pain?
- Fleeting chest pain (lasting seconds) is rarely ischemic
- Angina may last 2-10 minutes
- Acute myocardial infarction usually lasts >30 minutes
- Recurrent episodes of chest pain may suggest:
- Myocardial ischemia (anginal episodes)
- Gastroesophageal reflux disease
- Esophageal spasm
palliating or provoking factors?
- Palliating factors?
- Sitting and leaning forward may alleviate pericarditis or GERD.
- Nitroglycerine seems to improve pain:
- Caution: Diagnostic performance is poor.
- May suggest the following possibilities:
- Myocardial ischemia.
- Esophageal spasm.
- Random chance; placebo effect.
- Provoking factors?
- Exertional: suggests ischemia.
- Swallowing triggers pain: esophageal pathology (including esophageal perforation).
- Inspiration (pleuritic chest pain is worse with inspiration, but not general movement/palpation). Causes include:
- Pneumothorax.
- PE.
- Pericarditis.
- Pleuritis, pleuropericarditis.
- Mediastinitis, pneumomediastinum.
- Pneumonia.
- Esophageal disease.
- Musculoskeletal (e.g., costochondritis).
associated symptoms
- Diaphoresis? (worrisome in general, including ischemia)
- Nausea/vomiting?
- Nausea/vomiting simultaneous with pain concerning for ischemia
- Retching with subsequent pain suggests esophageal rupture (Boerhaave syndrome)
- Dyspnea? (MI, PE, pulmonary pathology, pneumothorax)
- Neurologic symptoms? (may suggest aortic dissection)
- Leg pain/swelling? (may suggest pulmonary embolism)
- Viral prodrome? (pericarditis, myocarditis, pneumonia, costochondritis, MI)
workup
Initial:
- ECG, vitals, telemetry, 2x 18g IV access
Diagnostics:
- CBC
- BMP
- CBG
- Chest X-ray
- Troponin
- PT-INR + PTT, Type & Screen
diagnosis
treatment
| Diagnosis | ED treatment | Definitive treatment |
|---|---|---|
| ACS/ STEMI | Nitroglycerin, aspirin, heparin, Dual antiplatelet therapy (ex. Tigrelacor, clopidogrel) | PCI w/ stenting or lytic therapy |
| PE | Heparin/Lovenox/DOACs/ TPA | Anticoagulation, thrombolysis, embolectomy |
| Aortic Dissection | Pain control, BP control (labetalol ivp or esmolol drip) | Surgery for Type A versus medical management for Type B |
| Tension Pneumothorax | Needle Decompression / Chest tube | Chest tube management, Pleurodesis |
| Esophageal Rupture | ABC’s, broad spectrum antibiotics | Surgical intervention/ICU care |
| Pericarditis/Tamponade | ABC’s IVF and pericardiocentesis | Cath lab for drain placement versus pericardial window |
more info
Don’t Miss Dx
MI
- Risk factors include:
- Personal history of atherosclerotic disease (e.g., prior MI, peripheral artery disease).
- Age.
- Smoking.
- Diabetes, hypertension.
- Radiation therapy.
- Sympathomimetic use (cocaine/methamphetamine).
- Vasculitis.
- Likelihood ratio for pain attributes: (16304077)
- Radiation to arm(s) or shoulder(s): LR ~4.
- Worse with exertion: LR ~2.5
- Associated with diaphoresis: LR ~2.
- Sharp: LR ~0.3
- Positional: LR ~0.3
- Reproducible with palpation: LR ~0.3
- Pleuritic: LR ~0.2
- Caution: chest pain may be atypical in women, elderly, or patients with diabetes.
Pulmonary Embolism
- Risk factors:
- Recent surgical procedures (especially orthopedic).
- Recent hospitalization for heart failure or MI.
- Prior venous thromboembolic disease.
- Malignancy (especially metastatic).
- Postpartum (especially after C-section).
- Estrogen-containing oral contraceptives, hormone replacement therapy, in vitro fertilization.
- Older age.
- Immobility.
- Thrombophilia (including autoimmune diseases, inflammatory bowel disease, infection).
- Approach to PE diagnosis: (https://emcrit.org/ibcc/pulmonary-embolism/#approach_to_PE_diagnosis)
aortic dissection
- Risk factors:
- Hypertension.
- Older age.
- Connective tissue disorder (e.g., Marfan syndrome).
- Known aortic pathology (e.g., bicuspid valve, coarctation).
- Sympathomimetic use (cocaine, methamphetamine).
- A recent procedure involving the aorta.
- Pregnancy (especially 3rd trimester).
esophageal rupture
- Risk factors:
- Severe retching/vomiting followed by chest pain.
- History of prior esophageal disease.
- History of recent esophageal procedures (e.g., nasogastric tube, Blakemore tube, endoscopy).
Pulmonary Embolism
Perimyocarditis / Pericardial Effusion
Differential
cardiac
- Myocardial ischemia (including unstable angina).
- Aortic dissection (or other acute aortic syndromes).
- Pericarditis.
- Myocarditis.
- Takotsubo cardiomyopathy.
pulmonary
- PE
- Pneumothorax
- Pneumonia
- Pleuritis (e.g., connective tissue disease, viral infection, uremic)
- Pulmonary hypertension (may cause anginal-quality pain with exertion)
- Lung cancer
gastrointestinal
- GERD (gastroesophageal reflux disorder)
- Esophageal spasm
- Esophagitis
- Esophageal rupture with mediastinitis
- Cholecystitis
- Peptic ulcer disease
- Pancreatitis
neurologic
- Herpes zoster
- Cervical root compression
- Thoracic outlet syndrome
musculoskeletal & rheumatologic
- Costochondritis
- Rib fracture or other trauma
- Intercostal muscle strain
- Sternoclavicular arthritis
psychiatric
- Anxiety
- Somatization/functional disorders