3. Systematic approach to cardiovascular symptoms

#### 3.1. Approach to chest pain in the emergency department

Chest pain is one of the most common symptoms which patients present with in the emergency department. The wide range of differentials and the severity of the consequences of missing serious causes of chest pain and fear of litigation put pressure on physicians to request a wide range of investigations to discharge the patient safely. The lack of confidence in decision-making and unnecessary referrals to other subspecialties are the reasons for delayed disposition, thus adding to the length of stay in the emergency department. In this section we will discuss in detail the common differentials of chest pain in the emergency department and how to investigate and dispose each patient timely and appropriately.

#### 3.1.1. Differential diagnosis of atraumatic chest pain

Chest pain is a symptom which could be due to a very serious underlying condition that may be life threatening, or it may be due to very benign condition [2, 3]. Here is the list of conditions which needs to be considered in patients presenting with chest pain [2] Table 1.

#### 3.1.2. History taking

c. Mitral regurgitation:

196 Essentials of Accident and Emergency Medicine

1. Dyspnea 2. Fatigue

3. Orthopnea

3. Pulmonary embolism

7. Dissociated abscesses

3. Systematic approach to cardiovascular symptoms

Chest pain is one of the most common symptoms which patients present with in the emergency department. The wide range of differentials and the severity of the consequences of missing serious causes of chest pain and fear of litigation put pressure on physicians to request a wide range of investigations to discharge the patient safely. The lack of confidence in decision-making and unnecessary referrals to other subspecialties are the reasons for delayed disposition, thus adding to the length of stay in the emergency department. In this section we will discuss in detail the common differentials of chest pain in the emergency department and how to investigate and dispose each patient timely and

3.1. Approach to chest pain in the emergency department

4. Cor pulmonale 5. Kidney damage 6. Enlarged spleen

8. Tender spleen 9. Janeway lesions

10. Petechiae

appropriately.

11. Osler nodes 12. Hematuria

1. Seizures 2. Stroke

4. Pulmonary edema

d. Infective endocarditis: signs and symptoms of infective endocarditis

E. Signs related to complications of cardiovascular diseases (infective endocarditis)

The most important key to diagnose serious medical conditions in the emergency department is the accurate history and examination. While taking history, all the important question


Table 1. Differential diagnosis of atraumatic chest pain.

should be asked which may help in ruling in or out the important differentials. The important questions to be asked while taking history are:

Musculoskeletal and pulmonary causes of chest pain aggravate with breathing and chest

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9. Risk factors: Patients with risk factors like diabetes mellitus, hypertension, smoking, hyperlipidemia, a strong family history of ischemic heart disease, ethnicity and age above 40 years, but patients with no risk factors are not immune to ischemic cardiac disease. The presence of risk factors is the indicator to be more vigilant and careful in discharging

10. Young patients with ischemic character of chest pain: Young patients when having ischemic type of chest pain present a clue to look at the conditions like vasculitis and connective

Detailed physical examination can give some clue to diagnose the underlying cause. Examination includes general physical examination, abnormalities in vital signs and presence of other signs which may be related to cardiac pathology or complication of ischemic heart disease or an underlying medical condition which is the reason to present as ischemic heart disease. These signs help in the diagnosis of underlying cardiac or other problems. Following are some important findings which must be looked at to diagnose the cause of chest

1. Tachycardia: Presence of tachycardia indicates serious underlying medical conditions.

2. Bradycardia: Bradycardia is a complication of ischemic cardiac problems and is related to

Acute MI Coronary ischemia Unstable angina

3. Hypertension: Hypertension may be seen as a stress response to acute cardiac ischemia or it may be the reason to present as acute heart failure or chest pain. Hypertension is seen in

Acute MI Coronary ischemia Aortic dissection

4. Hypotension: Hypotension may be seen as a complication of cardiovascular emergencies. Patient may also present with low BP in conditionwhich mimic cardiovascular emergencies

Cholecystitis Diabetic ketoacidosis Pulmonary embolism Esophageal rupture Mallory Weiss

tissue disorders and substance and drug abuse like cocaine.

Following are the conditions which cause tachycardia:

movements.

patients.

3.1.3. Examination

MI or coronary ischemia Myocarditis/pericarditis Aortic dissection Tension pneumothorax

conditions like

heart blocks. It may be seen in

pain.


Musculoskeletal and pulmonary causes of chest pain aggravate with breathing and chest movements.


#### 3.1.3. Examination

should be asked which may help in ruling in or out the important differentials. The important

1. Onset of pain: Sudden onset of severe chest pain may indicate conditions like pneumothorax or aortic dissection. Pain associated with meals may indicate gastrointestinal cause. Cardiac chest pain may occur with exertion or even at rest without any physical activity.

2. Character of pain: The character of pain may give some clue about the underlying condition although a large number of patients with ischemic cause may have non-specific chest pain which may mimic other conditions like dyspepsia. Patients with burning type of chest pain or indigestion may give the impression of gastrointestinal cause but it may be due to cardiac ischemia explaining visceral etiology of pain. Patients with ischemic cardiac disease may have crushing or squeezing chest pain or pressure-like symptoms. Aortic dissection may induce tearing chest pain which migrate from front to back or back to front. Sharp stabbing pain which may increase with breathing may be due to either

3. Severity of pain: The severity of pain may not be linked to severity of underlying diagnosis. Sometimes, peptic ulcer disease may present with a severe type of chest pain mimicking cardiac pain. Patients with ischemic heart disease may present with very vague or mild symptoms. Patients with dissection of aorta may present with severe tearing chest pain. 4. Duration of pain: Pain which is for few days with no change in character is unlikely to be due to cardiac ischemia. Anginal pain is usually less than 30 min in duration whereas pain of myocardial infarction (MI) stays more than 30 min. Pain which stays from few seconds

5. Associated symptoms: Cardiac chest pain may have associated symptoms like breathlessness, cough, palpitation, sweating and loss of energy and asthenia. Pulmonary embolism or pneumothorax may also present with chest pain, breathlessness and sweating, thus mimicking ischemic cardiac pain. Patients may have a fainting episode or syncope and near syncope before the onset of symptoms. Patients may present with some secondary conditions like road traffic accident or altered sensorium due to the underlying cardiac insult. Nausea and

vomiting may be seen with cardiovascular and gastrointestinal causes of chest pain.

6. Radiation of pain: Pain in the chest which radiates to the back may indicate aortic dissection or gastrointestinal causes like perforation, pancreatitis and posterior peptic ulcer.

7. Location of pain: Pain which is localized and involves a small area is unlikely related to any visceral cause and is due to somatic nerves. Pain involving periphery of the chest is usually due to a pulmonary cause whereas cardiac chest pain is usually in the lower chest or upper abdomen. Gastrointestinal conditions may have the similar area of distribution as cardiac. Cardiac chest pain though is usually in the left precordial area but may also be in

8. Aggravating or relieving factors: Pain at exertion indicates ischemic coronary syndrome whereas pain at rest indicates conditions like dyspepsia and neuropathic pain.

questions to be asked while taking history are:

198 Essentials of Accident and Emergency Medicine

musculoskeletal cause or pulmonary cause.

to minutes is unlikely to be cardiac in origin.

Cardiac chest pain may radiate to the neck, jaw and arm.

right-sided chest.

Detailed physical examination can give some clue to diagnose the underlying cause. Examination includes general physical examination, abnormalities in vital signs and presence of other signs which may be related to cardiac pathology or complication of ischemic heart disease or an underlying medical condition which is the reason to present as ischemic heart disease. These signs help in the diagnosis of underlying cardiac or other problems. Following are some important findings which must be looked at to diagnose the cause of chest pain.

1. Tachycardia: Presence of tachycardia indicates serious underlying medical conditions. Following are the conditions which cause tachycardia:


2. Bradycardia: Bradycardia is a complication of ischemic cardiac problems and is related to heart blocks. It may be seen in


3. Hypertension: Hypertension may be seen as a stress response to acute cardiac ischemia or it may be the reason to present as acute heart failure or chest pain. Hypertension is seen in conditions like


4. Hypotension: Hypotension may be seen as a complication of cardiovascular emergencies. Patient may also present with low BP in conditionwhich mimic cardiovascular emergencies


c. Heart failure/pulmonary edema

kept in mind when examining CVS.

New murmur: Seen in

b. Coronary ischemia c. Aortic dissection

b. Coronary ischemia

b. Coronary ischemia

d. Tension pneumothorax

ogies mimicking cardiovascular emergencies. Unilateral decreased or absent breath sounds:

• Tension pneumothorax/pneumothorax

Pleural rub: Pulmonary embolism.

Pericardial rub: Pericarditis.

a. Acute MI

Gallop (S3/S4) a. Acute MI

Raised JVP: a. Acute MI

c. Pericarditis

e. PE

d. Tension pneumothorax/simple pneumothorax

Narrow pulse pressure: Pericarditis with effusion.

BP difference in upper and lower extremity: Aortic dissection.

9. Cardiovascular system (CVS) examination: When examining CVS, all the differential diagnosis must be kept in mind to elaborate the findings related to these conditions. Each condition may have specific findings which help in reaching diagnosis. The following cardiovascular conditions or conditions which mimic cardiovascular problems must be

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10. Respiratory examination: Respiratory system examination is one of the most important examinations in the cardiovascular emergencies as many pulmonary pathologies mimic serious cardiovascular problems, and sometimes differentiating them from cardiac problems is not that easy and needs sophisticated investigations like CT scan in contrast with V/ Q scans. Following are the important pulmonary signs which indicate respiratory pathol-

5. Hypoxemia: Hypoxemia may be seen in acute cardiovascular emergencies or conditions mimicking cardiac emergencies


6. Fever: Presence of fever with other serious symptoms like chest pain or breathlessness usually indicates medical emergencies related to other systems. Following are the conditions where fever may be present with other complaints


	- Acute MI
	- Aortic dissection
	- Coronary ischemia
	- Unstable angina
	- PE
	- Cholecystitis
	- Peptic ulcer
	- Esophageal rupture
	- a. Acute MI
	- b. PE

BP difference in upper and lower extremity: Aortic dissection.

Narrow pulse pressure: Pericarditis with effusion.

New murmur: Seen in

a. Acute MI

Severe massive MI Heart failure Aortic dissection Myocarditis/pericarditis

Pneumothorax

mimicking cardiac emergencies

200 Essentials of Accident and Emergency Medicine

Heart failure/pulmonary edema

Myocarditis/pericarditis

breathlessness. • Acute MI

• Aortic dissection • Coronary ischemia

• Unstable angina

• Cholecystitis • Peptic ulcer

a. Acute MI

b. PE

• Esophageal rupture

conditions which present with respiratory distress.

• PE

Mediastinitis PE

Coronary ischemia Tension pneumothorax

Esophageal rupture

PE

5. Hypoxemia: Hypoxemia may be seen in acute cardiovascular emergencies or conditions

Massive effusion

Cholecystitis Esophageal rupture

6. Fever: Presence of fever with other serious symptoms like chest pain or breathlessness usually indicates medical emergencies related to other systems. Following are the condi-

7. Sweating or diaphoresis: Sweating is an autonomic response to many medical emergencies. It is non-specific symptom or sign but may indicate seriousness of the underlying problem so it must be given importance when present. Following are the differentials which must be considered in a patient presenting with diaphoresis with chest pain or

8. Respiratory distress: Respiratory distress is one of the indications of serious underlying medical problems. Patients who are tachypneic or distressed at presentation in the emergency department should be prioritized and treated. Following are the serious underlying

PE

tions where fever may be present with other complaints


#### Gallop (S3/S4)


#### Pericardial rub: Pericarditis.

#### Raised JVP:


Unilateral decreased or absent breath sounds:

• Tension pneumothorax/pneumothorax

Pleural rub: Pulmonary embolism.

Crepitation:


Subcutaneous emphysema:


Wheezes


• Aortic dissection • Coronary spasm

3.1.4. Investigations

ECG

• Acute MI

• PE

• Coronary ischemia

• Pericarditis/myocarditis

• Coronary spasm • Aortic dissection

• Arrhythmia

• Pneumothorax

• Tension pneumothorax

• Cardiomegaly (CCF, pericardial effusion)

13. Findings of DVT in extremity: PE

Patients presenting with chest pain should be investigated for serious underlying medical causes as delay in diagnosis may be catastrophic in many conditions. Following are the

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ECG: ECG is the most important bed-side investigations which should be ordered for any patient who comes to the emergency department with chest pain and pain involving lower chest, upper abdomen, neck, arm and jaw in a risky age group. It should be done in the earliest possible (within 10 min of arrival to the emergency department). Delaying in getting ECG done will delay the diagnosis which may result in serious consequences in conditions like acute MI.

CXR: Chest X-Ray is one of the simplest diagnostic modalities which may give important clues to patients with chest pain and or breathlessness. It may give information about heart, lungs and mediastinum and abdominal and diaphragmatic problems. It is easily available in hospitals and one should have a low threshold in requesting for them if the cause of chest pain and breathlessness is not clear or justified. Following are the conditions which can be seen on CXR.

important tests needed to diagnose important medical emergencies.

Following are the conditions which may have findings on ECG

• Pleural effusion (lung and heart pathologies, esophageal rupture)

• Pneumomediastinum (esophageal rupture, mediastinitis)

Positive cardiac markers: They give information about myocardial infarction.

#### Epigastric tenderness:


Left upper-quadrant tenderness: Pancreatitis.

Right upper-quadrant tenderness: Cholecystitis.

12. Neurologic examination: Cardiovascular emergencies may have a very atypical presentation when it's a true diagnostic dilemma in the emergency department. Following are the atypical neurological presentations of underlying serious cardiovascular emergencies

Focal neurological findings: Aortic dissection.

#### Stroke:


#### 13. Findings of DVT in extremity: PE

#### 3.1.4. Investigations

Patients presenting with chest pain should be investigated for serious underlying medical causes as delay in diagnosis may be catastrophic in many conditions. Following are the important tests needed to diagnose important medical emergencies.

Positive cardiac markers: They give information about myocardial infarction.

#### ECG

Crepitation:

a. Acute myocardial infarction

b. Coronary ischemia

202 Essentials of Accident and Emergency Medicine

Subcutaneous emphysema: a. Tension pneumothorax b. Simple pneumothorax

c. Esophageal rupture

d. Mediastinitis

• Cardiac asthma

Epigastric tenderness: • Esophageal rupture

• Cholecystitis • Pancreatitis

Stroke:

• Acute MI

• Coronary ischemia

• Mallory Weiss syndrome

Left upper-quadrant tenderness: Pancreatitis.

Right upper-quadrant tenderness: Cholecystitis.

Focal neurological findings: Aortic dissection.

11. Abdominal examination: Many abdominal conditions may mimic cardiovascular emergencies. Sometimes it is difficult to exclude them on the basis of history and examination alone. When examining the abdomen, following signs need to be looked at which indicate

12. Neurologic examination: Cardiovascular emergencies may have a very atypical presentation when it's a true diagnostic dilemma in the emergency department. Following are the atypical neurological presentations of underlying serious cardiovascular emergencies

abdominal conditions mimicking cardiovascular emergencies.

Wheezes

• Asthma

c. Unstable angina

d. Pneumonia

ECG: ECG is the most important bed-side investigations which should be ordered for any patient who comes to the emergency department with chest pain and pain involving lower chest, upper abdomen, neck, arm and jaw in a risky age group. It should be done in the earliest possible (within 10 min of arrival to the emergency department). Delaying in getting ECG done will delay the diagnosis which may result in serious consequences in conditions like acute MI.

Following are the conditions which may have findings on ECG


CXR: Chest X-Ray is one of the simplest diagnostic modalities which may give important clues to patients with chest pain and or breathlessness. It may give information about heart, lungs and mediastinum and abdominal and diaphragmatic problems. It is easily available in hospitals and one should have a low threshold in requesting for them if the cause of chest pain and breathlessness is not clear or justified. Following are the conditions which can be seen on CXR.


ABG: Arterial blood gases help in diagnosing the cardiac and lung pathologies indirectly by indicating the CO, oxygen, HCO3 levels, PH and A-a gradient. Hypoxemia and A-a gradient may indicate PE. ABG gives information about type 1 and type 2 respiratory failure as well.

thus can take timely decisions. Following information can be taken by using bed-side ultra-

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After taking proper history and doing a detailed examination, the differential diagnosis will be narrowed down. Use of appropriate investigation will help the emergency physician to reach to some conclusion. Serious conditions like tension pneumothorax, pulmonary embolism and acute coronary syndrome need quick attention and referrals to subspecialty for timely management. Each condition has its own management plan which will be discussed later in this

Timely patient disposition is the key to success. Patients presenting with acute coronary syndrome (ACS) and acute myocardial infarction should have timely referral to cardiology for possible early PCI. Patients with moderate to high risk of acute coronary syndrome should be admitted to cardiology care even if the initial labs are normal. Patients with low risk can be discharged with early follow up in the cardiology department. Normal ECG or absence of positive cardiac enzymes is not the criteria to discharge any patient with chest pain who falls in

Breathlessness is also one of the symptoms which has serious differential diagnosis, which, if not diagnosed and managed timely, can lead to grave consequences. Chest pain and breathlessness are the two serious symptoms which may be due to benign conditions and may be due to serious underlying problems which can lead to death from minutes to hours. Good medical knowledge, anticipation of problems, art of taking good medical history and doing detailed physical examination, choosing the right and appropriate investigation and timely

Breathlessness is one of the serious symptoms and should be given due care before we find out the reason for this symptom. Timely patients triaging and intervention is needed to deal with

sound.

• Pleural effusion and pericardial effusion

• Inferior vena cava and hydration status

• Cholelithiasis, cholecystitis and common bile duct

• Congestive hepatomegaly

• Pneumothorax

• Pneumonias

3.1.5. Management

chapter.

3.1.6. Disposition

the category of moderate or high risk.

and appropriate disposition help in saving life.

3.2.1. Differential diagnosis of breathlessness

3.2. Approach to breathlessness in the emergency department

Echocardiography: Echocardiography is one of the quickest and easily available modalities in many tertiary care centers where even the ER physicians are experts in using this modality and can get information about patient's conditions [4]. Echocardiography is now one of the most important diagnostic tools in modern emergency medicine practice. Following important information can be taken by using bed-side echo.


V/Q scan: V/Q scans are helpful in places where CT scans are not widely available or where due to some reasons CT scans cannot be done or are harmful. V/Q scans help in diagnosing PE.

Spiral CT: Spiral CT helps in diagnosing pulmonary embolism but also gives information about other pulmonary conditions and pathologies which may be the reason for these symptoms.

CT angiography: Computed tomography angiography (CTA) uses an injection of iodine-rich contrast material and CT scan to help diagnose and evaluate blood vessel diseases or related conditions, such as aneurysms or blockage.

Ultrasonography: Ultrasound is a rapidly available important diagnostic tool in many tertiary care centers and is getting more popular in emergency medicine practice. Emergency medicine physicians can use this tool to get important information about many medical conditions and thus can take timely decisions. Following information can be taken by using bed-side ultrasound.


• Widening of mediastinum (aortic dissection)

• Diaphragmatic problems (paralysis, hernia)

information can be taken by using bed-side echo.

• Hypertrophied ventricles and septum

• Left ventricular outflow tract obstruction

conditions, such as aneurysms or blockage.

• Cardiac masses and thrombi

ABG: Arterial blood gases help in diagnosing the cardiac and lung pathologies indirectly by indicating the CO, oxygen, HCO3 levels, PH and A-a gradient. Hypoxemia and A-a gradient may indicate PE. ABG gives information about type 1 and type 2 respiratory failure as well. Echocardiography: Echocardiography is one of the quickest and easily available modalities in many tertiary care centers where even the ER physicians are experts in using this modality and can get information about patient's conditions [4]. Echocardiography is now one of the most important diagnostic tools in modern emergency medicine practice. Following important

V/Q scan: V/Q scans are helpful in places where CT scans are not widely available or where due to some reasons CT scans cannot be done or are harmful. V/Q scans help in diagnosing PE. Spiral CT: Spiral CT helps in diagnosing pulmonary embolism but also gives information about other pulmonary conditions and pathologies which may be the reason for these symp-

CT angiography: Computed tomography angiography (CTA) uses an injection of iodine-rich contrast material and CT scan to help diagnose and evaluate blood vessel diseases or related

Ultrasonography: Ultrasound is a rapidly available important diagnostic tool in many tertiary care centers and is getting more popular in emergency medicine practice. Emergency medicine physicians can use this tool to get important information about many medical conditions and

• Lung masses (malignancies)

204 Essentials of Accident and Emergency Medicine

• Pericardial effusion

• RV strain

• Wall-motion abnormality

• Dilated right ventricle

• Ejection fraction

• Septal abnormality

• Valvular problems

• Aortic problems

• IVC

toms.

• Cholelithiasis, cholecystitis and common bile duct

#### 3.1.5. Management

After taking proper history and doing a detailed examination, the differential diagnosis will be narrowed down. Use of appropriate investigation will help the emergency physician to reach to some conclusion. Serious conditions like tension pneumothorax, pulmonary embolism and acute coronary syndrome need quick attention and referrals to subspecialty for timely management. Each condition has its own management plan which will be discussed later in this chapter.

#### 3.1.6. Disposition

Timely patient disposition is the key to success. Patients presenting with acute coronary syndrome (ACS) and acute myocardial infarction should have timely referral to cardiology for possible early PCI. Patients with moderate to high risk of acute coronary syndrome should be admitted to cardiology care even if the initial labs are normal. Patients with low risk can be discharged with early follow up in the cardiology department. Normal ECG or absence of positive cardiac enzymes is not the criteria to discharge any patient with chest pain who falls in the category of moderate or high risk.

#### 3.2. Approach to breathlessness in the emergency department

Breathlessness is also one of the symptoms which has serious differential diagnosis, which, if not diagnosed and managed timely, can lead to grave consequences. Chest pain and breathlessness are the two serious symptoms which may be due to benign conditions and may be due to serious underlying problems which can lead to death from minutes to hours. Good medical knowledge, anticipation of problems, art of taking good medical history and doing detailed physical examination, choosing the right and appropriate investigation and timely and appropriate disposition help in saving life.

#### 3.2.1. Differential diagnosis of breathlessness

Breathlessness is one of the serious symptoms and should be given due care before we find out the reason for this symptom. Timely patients triaging and intervention is needed to deal with this symptom. Breathlessness may be due to simple problems like anxiety and pregnancy, and it may be related to severe life-threatening conditions like tension pneumothorax. Here we will discuss important differential diagnosis of breathlessness based on the severity of underlying pathology (Table 2).

asked which may help in ruling in or out the important differentials. The onset of breathlessness and duration and severity of breathlessness give a clue about the nature of the underlying disorder and urgency to treat them. The important questions to be asked while taking the

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1. Onset of breathlessness: Breathlessness of sudden onset is usually serious and must be addressed immediately. Among the differentials of acute sudden onset breathlessness are pneumothorax and pulmonary embolism. Chocking with foreign bodies should be considered in the extreme of ages as well. Dyspnea which is slowly progressive and becomes serious in few hours to days may be due to conditions like asthma, COPD exacerbation, pneumonia, congestive heart failure, malignancies, recurrent small emboli, pleural effu-

2. Duration of breathlessness: Breathlessness of short duration includes acute conditions like asthma exacerbation, infections, allergies, foreign bodies, cardiac dysfunctions and arrhythmias, pulmonary embolism, psychogenic and inhalation of irritants. Chronic and progressive conditions include chronic lung diseases like interstitial lung diseases, chronic heart failure, chronic pleural effusion and chronic cardiac and pulmonary disorders. 3. Related to trauma: Breathlessness related to trauma points to some of the most serious conditions which may be life threatening if not managed early. These include pneumothorax, tension pneumothorax, pulmonary contusion, hemothorax, flail chest, diaphragmatic

4. Positional changes and aggravating and relieving factors: Patients complaining of orthopnea may be suffering from left-sided heart failure, COPD and asthma exacerbation and neuromuscular disorders affecting the diaphragm which lead to splinting. Paroxysmal nocturnal dyspnea may be due to left-sided heart failure and COPD. Exertional dyspnea may be due to left-sided heart failure, COPD and restrictive and obstructive heart and lung diseases and conditions with abdominal loading. Conditions with abdominal

5. Breathlessness with other associated symptoms: Other symptoms like fever, cough, chest pain, palpitation, sweating, weakness and paresthesia, swelling of feet and abdominal distension must be looked for. It helps in differentiating it from underlying cardiac prob-

After a detailed history, thorough physical examination helps in finding the underlying cause of breathlessness. The examination includes vital signs, general appearance and detailed physical examination including systemic examinations like CVS, central nervous system

1. Tachypnea: Presence of tachypnea may indicate serious underlying medical conditions.

rupture, cardiac tamponade, pericardial effusion and neurologic injury.

loading include ascites, obesity and pregnancy.

3.2.3. Examination

lems or infective pathologies or neuromuscular disorders.

(CNS), peripheral nervous system and respiratory system.

Following are the conditions which cause tachypnea:

history of breathlessness are:

sion and neuromuscular disorders.

#### 3.2.2. History taking

The most important key to diagnose serious medical conditions in the emergency department is proper history and examination. While taking history, all the important questions should be


Table 2. Differential diagnosis of breathlessness.

asked which may help in ruling in or out the important differentials. The onset of breathlessness and duration and severity of breathlessness give a clue about the nature of the underlying disorder and urgency to treat them. The important questions to be asked while taking the history of breathlessness are:


#### 3.2.3. Examination

this symptom. Breathlessness may be due to simple problems like anxiety and pregnancy, and it may be related to severe life-threatening conditions like tension pneumothorax. Here we will discuss important differential diagnosis of breathlessness based on the severity of underlying

The most important key to diagnose serious medical conditions in the emergency department is proper history and examination. While taking history, all the important questions should be

CVS:

1. Pericarditis 2. Myocarditis Respiratory: 1. Pneumothorax 2. Hemothorax 3. Asthma 4. Pneumonia 5. Aspiration 6. Cor Pulmonale Neuromuscular: 1. Multiple Sclerosis 2. Guillian Barre 3. Myasthenia Gravis 4. Tick Paralysis Increased Respiratory Effort: 1. Mechanical Interference

2. Hypotension 3. Bowel Obstruction 4. Renal Failure

8. Anemia

5. Electrolyte Abnormalities 6. Metabolic Acidosis 7. Diaphragmatic Rupture

Critical diagnosis Emergent diagnosis

pathology (Table 2).

206 Essentials of Accident and Emergency Medicine

3.2.2. History taking

CVS: 1. Acute MI 2. Pulmonary Edema 3. Cardiac Tamponade

Respiratory:

6. PE 7. Flail Chest Metabolic/Endocrine: 1. Toxic Ingestion 2. DKA Neuromuscular: 1. CVA

2. Epiglottitis 3. Anaphylaxis 4. Ventilatory Failure 5. Airway Obstruction

1. Tension Pneumothorax

2. Intracranial Insult 3. Organophosphate Poisoning

Non-emergent diagnosis: Cardiac: Metabolic/Endocrine:

1. Congenital Heart Disease 1. Thyroid 2. Cardiomyopathy 2. Fever 3. Valvular Heart Disease Pulmonary: Neuromuscular: 1. Pleural Effusion 1. ALS 2. COPD 2. Polymyositis

4. Hyperventilation Syndrome 8. Somatization Disorders

Table 2. Differential diagnosis of breathlessness.

Miscellaneous: 1. CO Poisoning 2. Acute Chest Syndrome

3. Pneumonia 4. Malignancies

Related to Respiratory Effort: 1. Pregnancy 5. Rib Fracture 2. Ascites 6. Panic attack 3. Obesity 7. Pneumonia

After a detailed history, thorough physical examination helps in finding the underlying cause of breathlessness. The examination includes vital signs, general appearance and detailed physical examination including systemic examinations like CVS, central nervous system (CNS), peripheral nervous system and respiratory system.

1. Tachypnea: Presence of tachypnea may indicate serious underlying medical conditions. Following are the conditions which cause tachypnea:


5. Fever

• Myocarditis • Malignancies 6. General appearance

• Pregnancy: PE

• Barrel chest: COPD

7. Skin, nails and hands

hypoxia

• Rub: Pleurisy

8. Neck

9. Respiratory

• Sniffing position: epiglottitis

• Infective conditions like pneumonia

• Obesity: Hypoventilation, PE, sleep apnea

• Tripod positioning: Severe COPD/asthma

hemopneumothorax, lung contusion

• Tobacco stain: COPD, malignancy, infection

drome, COPD/asthma exacerbation, PE

• Wheeze: CHF, anaphylaxis, bronchospasm

• Cheyne-stokes breathing: Intracranial insult

• Rales: heart failure, pneumonia, PE

• Wasting of hands: Pancoast tumor

• Tremors: CO2 retention

• Cachexia, weight loss: malignancy, chronic diseases like HIV

• Bruises/crepitation/subcutaneous emphysema on chest: Flail chest, rib fracture,

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• Clubbing: Malignancy, shunts (intracardiac), pulmonary vascular anomalies, chronic

• Stridor: Upper airway edema/infection, foreign body, traumatic injury, anaphylaxis

• Hemoptysis: Malignancy, mitral stenosis, infection, CHF, bleeding disorders

• Subcutaneous emphysema: Pneumothorax, tracheobronchial disruption

• JVD: Tension pneumothorax, tamponade, CHF, volume overload, thoracic outlet syn-

	- PE
	- Drugs/toxins
	- Infections
	- Tension pneumothorax
	- Tamponade
	- Trauma
	- Lung contusion
	- Hypoxia-causing conditions
	- Acidosis and metabolic disorders
	- Myocarditis
	- Electrolyte and endocrine disorders
	- Tension pneumothorax
	- Cardiac tamponade

5. Fever

• Pulmonary edema

208 Essentials of Accident and Emergency Medicine

• Pneumonia

• Fever

• Ascites

• Toxins

3. Tachycardia: • PE

• Pneumothorax

• Psychogenic

• Endocrine disorders

• Infectious causes

• Intracranial insult • Drugs and toxins

• Drugs/toxins • Infections

• Tamponade

• Lung contusion

• Myocarditis

4. Hypotension

• Trauma

• Tension pneumothorax

• Hypoxia-causing conditions

• Tension pneumothorax • Cardiac tamponade

• Acidosis and metabolic disorders

• Electrolyte and endocrine disorders

• Metabolic causes like diabetic ketoacidosis

• Trauma leading to mechanical issues

• Obstructive and restrictive respiratory and cardiac causes

2. Hypopnea: It can be seen in respiratory depression due to neurologic causes or from toxins.

	- Pregnancy: PE
	- Obesity: Hypoventilation, PE, sleep apnea
	- Cachexia, weight loss: malignancy, chronic diseases like HIV
	- Barrel chest: COPD
	- Sniffing position: epiglottitis
	- Tripod positioning: Severe COPD/asthma
	- Bruises/crepitation/subcutaneous emphysema on chest: Flail chest, rib fracture, hemopneumothorax, lung contusion
	- Wasting of hands: Pancoast tumor
	- Tremors: CO2 retention
	- Tobacco stain: COPD, malignancy, infection
	- Clubbing: Malignancy, shunts (intracardiac), pulmonary vascular anomalies, chronic hypoxia
	- Stridor: Upper airway edema/infection, foreign body, traumatic injury, anaphylaxis
	- JVD: Tension pneumothorax, tamponade, CHF, volume overload, thoracic outlet syndrome, COPD/asthma exacerbation, PE
	- Wheeze: CHF, anaphylaxis, bronchospasm
	- Rales: heart failure, pneumonia, PE
	- Hemoptysis: Malignancy, mitral stenosis, infection, CHF, bleeding disorders
	- Rub: Pleurisy
	- Cheyne-stokes breathing: Intracranial insult
	- Subcutaneous emphysema: Pneumothorax, tracheobronchial disruption

#### 10. Cardiac


#### 11. Neurologic


Doppler: It is a modality to look for the source of PE. Sometimes, finding DVT gives indirect

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Ultrasound: Look for important Causes of breathlessness and differentiate it from cardiac causes. US may help in detecting or giving a clue about PE, pneumothorax, pleural effusion,

ECHO: It helps in identifying cardiac problems like ejection fraction, fluid overload, aortic dissection, IVC status, wall-motion abnormality, RV strain pattern, pericardial effusion, fea-

ECG: ECG is the most important investigation to diagnose the cardiac causes of breathless-

Serious cardiac emergencies presenting as breathlessness like pulmonary edema, MI, PE and cardiac tamponade should be diagnosed immediately for timely management. The manage-

All serious medical emergencies are admitted to the medical ward or in ICU depending on the severity of problem. The individual disposition of each medical diagnosis is discussed further

Cardiovascular emergencies may present with palpitation in the emergency department. Palpitation is a symptom which could be the manifestation of serious cardiovascular underlying problems. The underlying cause of palpitation may be either ischemic heart disease, metabolic and endocrine disorders, drugs, malignancies, inflammatory and infiltrative disorders, connective disuse disorders and environmental factors like electrocution. Any condition which affects conduction across myocardium may lead to irregular or abnormally fast or slow conduction manifesting as palpitation. On taking an ECG, one may find either very fast or slow rhythm which may be regular or irregular. The other abnormalities which may be seen on the ECG are short PR, prolonged QT, short QT, broad QRS, narrow QRS, abnormalities of P

ment of individual emergency is discussed further in the chapter.

3.3. Approach to palpitation in the emergency department

information about the cause of breathlessness.

tures of PE and features of CCF.

• MI/ACS leading to pulmonary edema • PE: dysrhythmias, right-heart strain • Pericarditis/myocarditis: heart failure

ness.

• Arrhythmias

3.2.5. Management

3.2.6. Disposition

in the chapter.

waves and blocks.

pericardial effusion, pneumonia and aortic dissection.


#### 12. Extremities


#### 3.2.4. Investigation

Patients presenting with chest pain should be investigated for serious underlying medical causes as delay in diagnosis may be catastrophic in many conditions. Following are the important tests needed to diagnose important medical emergencies.

CXR: Chest X-Ray is one of the simplest diagnostic modalities which may give important clues in patients with chest pain and or breathlessness. It may give information about heart, lungs and mediastinum and abdominal and diaphragmatic problems. It is easily available in hospitals and one should have a low threshold in requesting them if the cause of chest pain and breathlessness is not clear or justified. Following are the conditions which can be seen on CXR.

ABG: Look for A-a gradient for PE, hypoxia and hypercapnia.

Positive cardiac markers: Myocardial infarction leading to heart failure and presenting with breathlessness can be detected by positive cardiac markers.

VQ Scan: To differentiate PE from other causes.

CT Scan: It helps in identifying pulmonary and mediastinal and intra-abdominal causes and differentiating it from cardiac.

ProBNP: It helps in identifying congestive cardiac failure and complications of MI.

D-Dimer: It gives a clue about PE and negative D-Dimer helps in ruling out PE.

Doppler: It is a modality to look for the source of PE. Sometimes, finding DVT gives indirect information about the cause of breathlessness.

Ultrasound: Look for important Causes of breathlessness and differentiate it from cardiac causes. US may help in detecting or giving a clue about PE, pneumothorax, pleural effusion, pericardial effusion, pneumonia and aortic dissection.

ECHO: It helps in identifying cardiac problems like ejection fraction, fluid overload, aortic dissection, IVC status, wall-motion abnormality, RV strain pattern, pericardial effusion, features of PE and features of CCF.

ECG: ECG is the most important investigation to diagnose the cardiac causes of breathlessness.


10. Cardiac

11. Neurologic

• ALS 12. Extremities • DVT

3.2.4. Investigation

• Murmur/S3, S4 Gallop, S2 Accentuation: PE

• Diffuse weakness: Metabolic/electrolyte abnormalities (Ca, Mg, PO4), anemia

Patients presenting with chest pain should be investigated for serious underlying medical causes as delay in diagnosis may be catastrophic in many conditions. Following are the

CXR: Chest X-Ray is one of the simplest diagnostic modalities which may give important clues in patients with chest pain and or breathlessness. It may give information about heart, lungs and mediastinum and abdominal and diaphragmatic problems. It is easily available in hospitals and one should have a low threshold in requesting them if the cause of chest pain and breathlessness is not clear or justified. Following are the conditions which can be seen on CXR.

Positive cardiac markers: Myocardial infarction leading to heart failure and presenting with

CT Scan: It helps in identifying pulmonary and mediastinal and intra-abdominal causes and

ProBNP: It helps in identifying congestive cardiac failure and complications of MI.

D-Dimer: It gives a clue about PE and negative D-Dimer helps in ruling out PE.

• Muffled heart sound: Tamponade

• Hyporeflexia: Hypermagnesemia

• Ascending weakness: Guillian Barre syndrome

important tests needed to diagnose important medical emergencies.

ABG: Look for A-a gradient for PE, hypoxia and hypercapnia.

breathlessness can be detected by positive cardiac markers.

VQ Scan: To differentiate PE from other causes.

differentiating it from cardiac.

• Focal deficit: Stroke, ICH • Neuromuscular disease

210 Essentials of Accident and Emergency Medicine

• Myasthenia Gravis

• Edema of legs due to CHF

#### 3.2.5. Management

Serious cardiac emergencies presenting as breathlessness like pulmonary edema, MI, PE and cardiac tamponade should be diagnosed immediately for timely management. The management of individual emergency is discussed further in the chapter.

#### 3.2.6. Disposition

All serious medical emergencies are admitted to the medical ward or in ICU depending on the severity of problem. The individual disposition of each medical diagnosis is discussed further in the chapter.

#### 3.3. Approach to palpitation in the emergency department

Cardiovascular emergencies may present with palpitation in the emergency department. Palpitation is a symptom which could be the manifestation of serious cardiovascular underlying problems. The underlying cause of palpitation may be either ischemic heart disease, metabolic and endocrine disorders, drugs, malignancies, inflammatory and infiltrative disorders, connective disuse disorders and environmental factors like electrocution. Any condition which affects conduction across myocardium may lead to irregular or abnormally fast or slow conduction manifesting as palpitation. On taking an ECG, one may find either very fast or slow rhythm which may be regular or irregular. The other abnormalities which may be seen on the ECG are short PR, prolonged QT, short QT, broad QRS, narrow QRS, abnormalities of P waves and blocks.

#### 3.3.1. Differential diagnosis of palpitation

• Narrow complex tachycardia (regular or irregular) AV node independent:

medication whereas hemodynamically unstable patients require synchronized cardioversion [5]. Patients should be taken to the monitored bed and the IV line is maintained and investiga-

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Cardiovascular emergencies may present as syncope, pre-syncope and fainting episode in the emergency department [4, 6]. Syncope is defined as a sudden transient loss of consciousness with a loss of postural tone. Any condition which affects cerebral perfusion (cardiac output, systemic vascular resistance, blood volume, regional vascular resistance) can lead to pre-syncope

Pre-syncope or syncope may be caused by cardiovascular or CNS conditions. Here are the

tions are sent to look for reversible causes which can be corrected.

or syncope.

1. MI

• Cardiovascular diseases:

2. Aortic dissection 3. Cardiomyopathy

1. Valvular stenosis

3. Atrial Myxoma

5. Pulmonary hypertension

7. Congenital heart disease

II. Ventricular tachycardia

V. Torsade de Pointes

6. Cardiac tamponade

• Reduced cardiac output:

1. Tachycardia

I. SVT

III. VF

IV. WPW

• Outflow obstruction:

2. HOCM

4. PE

3.4. Approach to syncope and fainting episode in the emergency department

differential diagnoses of cardiovascular emergencies presenting as syncope:

3.4.1. Differential diagnosis of cardiovascular causes of syncope


AV-node dependent:

	- 1. Ventricular tachycardia
	- 2. SVT with aberrant conduction
	- 1. Heart tissue damage related to aging
	- 2. Tissue damage due to ischemic heart disease
	- 3. Congenital heart diseases
	- 4. Myocarditis
	- 5. Heart surgery
	- 6. Malignancy
	- 7. Inflammatory and infiltratory diseases
	- 8. Metabolic and endocrine disorders
	- 9. Radiations
	- 10. Toxins, drugs and chemicals

#### 3.3.2. Approach to palpitation

Whenever a patient complains of palpitation, the priority is to look for if the patient is stable or unstable. Immediately, vital signs of patients need to be recorded and the general condition of the patient is looked for. Patients with abnormal vital signs need to be taken to the monitored bed for further management. Patients who are stable hemodynamically can be treated by medication whereas hemodynamically unstable patients require synchronized cardioversion [5]. Patients should be taken to the monitored bed and the IV line is maintained and investigations are sent to look for reversible causes which can be corrected.

#### 3.4. Approach to syncope and fainting episode in the emergency department

Cardiovascular emergencies may present as syncope, pre-syncope and fainting episode in the emergency department [4, 6]. Syncope is defined as a sudden transient loss of consciousness with a loss of postural tone. Any condition which affects cerebral perfusion (cardiac output, systemic vascular resistance, blood volume, regional vascular resistance) can lead to pre-syncope or syncope.

Pre-syncope or syncope may be caused by cardiovascular or CNS conditions. Here are the differential diagnoses of cardiovascular emergencies presenting as syncope:

#### 3.4.1. Differential diagnosis of cardiovascular causes of syncope

	- 1. MI

3.3.1. Differential diagnosis of palpitation

AV node independent: 1. Sinus tachycardia

212 Essentials of Accident and Emergency Medicine

3. Atrial fibrillation

AV-node dependent:

1. AV node re-entry tachycardia

2. AV re-entry tachycardia 3. Junctional tachycardia

1. Ventricular tachycardia

3. Congenital heart diseases

4. Myocarditis 5. Heart surgery 6. Malignancy

9. Radiations

3.3.2. Approach to palpitation

2. SVT with aberrant conduction

1. Heart tissue damage related to aging

7. Inflammatory and infiltratory diseases

Whenever a patient complains of palpitation, the priority is to look for if the patient is stable or unstable. Immediately, vital signs of patients need to be recorded and the general condition of the patient is looked for. Patients with abnormal vital signs need to be taken to the monitored bed for further management. Patients who are stable hemodynamically can be treated by

8. Metabolic and endocrine disorders

10. Toxins, drugs and chemicals

2. Tissue damage due to ischemic heart disease

• Broad complex tachycardia

• Bradycardia

4. Atrial flutter

• Narrow complex tachycardia (regular or irregular)

2. Atrial tachycardia (unifocal/multifocal)

	- 1. Valvular stenosis
	- 2. HOCM
	- 3. Atrial Myxoma
	- 4. PE
	- 5. Pulmonary hypertension
	- 6. Cardiac tamponade
	- 7. Congenital heart disease
	- 1. Tachycardia
		- I. SVT
		- II. Ventricular tachycardia
		- III. VF
		- IV. WPW
		- V. Torsade de Pointes
	- I. Sinus node disease
	- II. Heart block (second and third degree)
	- III. Prolonged QT
	- IV. Pace maker malfunction
	- V. ICD malfunction
	- I. MI
	- II. Aortic dissection
	- III. Cardiomyopathy

#### 3.4.2. History taking

History taking is the most important in diagnosing the patients presenting with syncope. There are wide differentials of syncope which range from very benign medical conditions like vasovagal attacks to most serious emergencies like aortic dissection or acute MI. History taking helps in narrowing down the differentials to a few in the list and then by detailed examination and suitable investigations physicians may reach to diagnosis or may be comfortable in discharging the patient to appropriate facilities for further management. The important information required in history taking include:

3.4.3. Examination

• CNS examination:

3.4.4. Investigation

3.4.5. Management

of cardiovascular symptoms.

1. Ischemic heart disease

2. Cardiomyopathies

3. Blocks

a. ECG

• Respiratory system examination:

• Cardiac enzymes: Myocardial infarction

diseases with complications.

Detailed physical examination is required to reach to diagnosis. The examination includes all

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The emergency physicians must choose important investigations to diagnoses serious underlying medical problems for timely management. Delay in the diagnosis of critical conditions may lead to serious consequences. Following are the important investigations needed in emergency department to diagnose cardiovascular emergencies presenting as syncope.

• Echocardiogram: Cardiac outflow obstruction, tamponade, aortic dissection, PE, valvular

Underlying cardiovascular problem needs to be treated once diagnosed. Management of

4. Quick simple diagnostic and bed-side modalities to rapidly differentiate

Patients presenting in the emergency department with chest pain, breathlessness, palpitation or sweating or with pre-syncope or syncope may have a wide range of differentials as a cause. Some of the conditions may be very serious and of grave outcomes if not managed immediately. Emergency physicians can use some important skills, tools and diagnostic tests to pick very serious underlying conditions which are the causes of these presentations. Timely management and disposition of these conditions may impact the overall outcome and prognosis. Here we will mention few tests and investigations which will help in differentiating the cause

the important systems which are included in the differential diagnosis of syncope.

• ECG: Arrhythmias, ischemic heart diseases, cardiomyopathies

individual emergencies is discussed further in the chapter.

serious underlying medical emergencies


#### 3.4.3. Examination

2. Bradycardia

214 Essentials of Accident and Emergency Medicine

I. MI

3.4.2. History taking

I. Sinus node disease

IV. Pace maker malfunction

III. Prolonged QT

V. ICD malfunction

II. Aortic dissection III. Cardiomyopathy

mation required in history taking include:

• Underlying medical conditions and comorbidities

• Associated symptoms like seizure, loss of consciousness, weakness

• Presence of chest pain

• Breathlessness

• Cough

• Palpitation

• Onset of symptom

• Use of medication • Straining factors

• Emotional instability

• Toxins and drugs

• Pre-syncope symptoms

• H/O previous such episodes

3. Other cardiovascular diseases

II. Heart block (second and third degree)

History taking is the most important in diagnosing the patients presenting with syncope. There are wide differentials of syncope which range from very benign medical conditions like vasovagal attacks to most serious emergencies like aortic dissection or acute MI. History taking helps in narrowing down the differentials to a few in the list and then by detailed examination and suitable investigations physicians may reach to diagnosis or may be comfortable in discharging the patient to appropriate facilities for further management. The important inforDetailed physical examination is required to reach to diagnosis. The examination includes all the important systems which are included in the differential diagnosis of syncope.


#### 3.4.4. Investigation

The emergency physicians must choose important investigations to diagnoses serious underlying medical problems for timely management. Delay in the diagnosis of critical conditions may lead to serious consequences. Following are the important investigations needed in emergency department to diagnose cardiovascular emergencies presenting as syncope.


#### 3.4.5. Management

Underlying cardiovascular problem needs to be treated once diagnosed. Management of individual emergencies is discussed further in the chapter.
