PERCENTAGE OF PT WITH CHEST PAIN

• 15% I.M.A.

• 30-35% Unstable Angina

• 55%: Non coronaropathy

PERCENTAGE OF MISSING IMA

• In patient with atypical symptoms

(4-13%)

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Medical Malpractice Alerts Volume IndexDr. John Limbert, MD

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Volume 1, Issue 3, May 2000Chest Pain

Pointers

?

Heart Attack Commonly Missed

Author Karcz A; Holbrook J; Burke MC; Doyle MJ; Erdos MS; Friedman M; Green ED; Iseke RJ; Josephson GW; Williams K Institution Department of Emergency Medicine, Metrowest Medical Center, Framingham, Massachusetts. Title Massachusetts emergency medicine closed malpractice claims: 1988-1990. Source Ann Emerg Med 1993 Mar;22(3): p553-9

CONCLUSION: Emergency physicians must have a particular awareness of their great risk exposure for missed myocardial infarction. Addition of dictation or voice-activated record generation systems, departmental protocols for radiograph follow-ups, and holding and re-evaluation of the intoxicated patient will help provide systems supports for reducing the liability of individual emergency physicians.

,

Author Murata GH Institution Ambulatory Care Service, Veterans Affairs Medical Center, Albuquerque, NM 87108.

Title Evaluating chest pain in the emergency department. Source West J Med 1993 Jul;159(1): p61-8

Chest pain is one of the most difficult diagnostic problems for physicians working in an emergency department. In this setting, more malpractice dollars are awarded for missed myocardial infarction than for any other physician error. This problem usually occurs when the patient has atypical symptoms, the physician is inexperienced, or the diagnosis is not considered.. .. feature of a patient's history excludes infarction with certainty, pain that is sharp, positional, pleuritic, or reproduced by palpation indicates a lower probability of acute ischemic heart disease. established the prognostic value of the initial electrocardiogram.. Emergency physicians must also consider other diseases for which coronary care might be beneficial.

ECG AND MALPRACTICE

• Failure to perform an ekg

• Misinterpretation

• Failure to record data from clinical evaluation

DOLORE TORACICO

• VISCERALE:

• SOMATICO

DOLORE TORACICO VISCERALE

• Cuore

• Pericardio

• Grossi Vasi

• Esofago

DOLORE TORACICO PARIETALE

• Pleura parietale

• Pleura diaframmatica

• Pleura Mediastinica

DOLORE TORACICO VISCERALE:CARATTERISTICHE

• Dolore retrosternale profondo• Diffuso,poco localizzabile• Caratterizzato da notevole irradiazione DESCRIZIONI(BEAN)• Compressione schiacciamento 44%• Costrittivo-oppressivo 29%• Soffocante 18%• Acuto,penetrante,a colpo di coltello 11%• Atroce,angoscioso 11%• Torturante7%• Urente 5%

DOLORE TORACICO VISCERALE:VIE NERVOSE

• Cuore:nervi cardiaci simpatici>gangli catena simpatico*>rami comunicanti>nervi spinali>radici posteriori**>tratto spino-talamico

*Alcune fibre del ganglio cerv superiore si connettono col ganglio del trigemino

** A questo livello giungono le informazioni somatiche dei dermatomeri contigui

I DUE RISCHI DIFFERENTI:

• A)Che rischio ha il dolore toracico di essere di natura coronarica?

• B)Scontato che il dolore sia di origine coronarica:che rischio ha il paziente?

GOLDMAN RISK

The Three Components of a Chest Pain Center

1)ATTACK PROGRAM: is that patients crashing with an acute myocardial infarction need to be quickly identified and given prompt opening therapy be it thrombolytic or PTCA

2) OBSERVATIONAL PROGRAM. Once acute myocardial infarction has been ruled out, this unit attempts to determine which patients with chest pain are more likely to have myocardial ischemia (moderate probability) and which are unlikely to have myocardial ischemia (low probability).

3) OUTREACH PROGRAM by, "providing for the success of a low probability ischemic pathway work up in which 80% of such patients can be sent home...." This third component of the Chest Pain Center focuses on prevention and community education

                                                           

     

Protocols for chest pain centers

• University of Cincinnati ‘’Heart ER’’

• Medical College of Virginia

• Mayo Clinic

• Manchester Royal Infirmary

Heart ER Strategy(Cincinnati)

• Low-moderate risk:chest pain and normal Ecg

• 9h protocol:using serial CK-MB ST monitoring

• Rest echo

• Stress test

• Results:14% required admission…

Medical College of Virginia

• Spect scanning immediately

• Serial biochemistry for eight hours

Mayo Clinic

• Low-intermediate risk

• 6 h observation

• St and byoochemistry monitoring

• .stress test

ROYAL INFIRMARY MANCHESTER

• Low-intermediate risk

• 6 h observation

• St and byoochemistry monitoring

• .stress test

BMJ 2001;323:372 [Full] ( 18 August )Papers

Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study

K R Herren, research fellow a, K Mackway-Jones, consultant a, C R Richards, research assistant a, C J Seneviratne, consultant clinical scientist b, M W France, consultant b, L Cotter, consultant c. 

a Department of Emergency Medicine, Manchester Royal Infirmary, Manchester M13 9WL, b Department of Clinical Biochemistry, Manchester Royal Infirmary, c Manchester Heart Centre, Manchester Royal Infirmary

Correspondence to: K Mackway-Jones kevin.mackway-jones@man.ac.uk

Dear Dr Rinciari

Thank you for your email. It will be possible for you to come and observe without any special documentation. A letter from your institution introducing you will suffice.

Yours

Kevin Mackway-JonesEmergency DepartmentManchester Royal InfirmaryOxford Road MANCHESTER M13 9WL

T +44(0)1612766781F +44(0)1612768538

Sacramento (Ca)

CHEST PAIN EVALUATION UNIT (CPEU) I

Initiated in 1993 as a joint program of the divisions of Emergency Medicine and Cardiovascular Medicine.

Close cooperation between the two Division has been an essential feature of the CPEU which is administered by the Division of Emergency Medicine with close consultation by the Division of Cardiovascular Medicine

The CPEU is staffed by 3 physicians who have completed residency in internal medicine with further training in exercise stress testing

The CPEU is covered daily by one of these Ph.

CHEST PAIN EVALUATION UNIT (CPEU) II

Consultation is available to these physicians at all times by the CCU attending cardiologist in selected cases as needed.

During the night (8p.m - 8a.m.),

these patients are managed by the Cardiology Inpatient Service (CIS), which can admit them to the CPEU for further evaluation and disposition

Patients presenting to the ED) who are identified as low risk by clinical criteria (< 7 % MI, < 15% unstable angina) for an ischemic event and its complications are triaged to the CPEU. If low risk is confirmed (clinically stable and resting ECG being normal or having only minor nonspecific repolarization abnormalities) and other serious causes of chest pain are absent on screening evaluation, the patient usually undergoes immediate exercise treadmill testing (IETT)

CHEST PAIN EVALUATION UNIT (CPEU) III

Accelerated Rule Out MI

•Continuous Telemetry Monitoring

•ECG's @ 0, 3, 6hrs and prn Chest Pain

•CPK-MB and Myoglobin @ 0, 3, 6, ± 12 hrs

•Troponin I if late presenter or CPK-MB Equivocal

Pennsylvania

Hamot's Chest Pain Center

Hamot's Chest Pain Center-based in the Emergency Department-is the point of entry for patients experiencing chest pain. There, emergency physicians immediately begin the process of evaluating and diagnosing the cause of the chest pain. From the initial evaluation in the Emergency Department, physicians work to determine if the patient has most likely already suffered a heart attack, is in danger of suffering a heart attack, or if the chest pain is not cardiac related. From that initial evaluation, the most appropriate next steps are determined.

The protocol monitors moderate- to low-risk patients over an 18- to 24-hour period

“It’s so important to make a diagnosis of coronary disease sooner, rather than later,” says Dr. Ted Szymanski, chair of Emergency Medicine, Mayo Clinic/St. Luke’s Hospital. “Now we are able to assess coronary risk by stratifying patients in the Emergency Department, which allows for quicker diagnosis and in many cases, keeps us from admitting patients who don’t need to be.”

More than 44,000 people seek Harrison's emergency care each year, making it one of the most visited ERs in Washington

Harrison's chest-pain clinic (also known as at the rule-out MI, for myocardial infarction, clinic), sees 300 people a year. A decade ago, these patients might have spent one week in the hospital before being diagnosed

…..

Billie Dunford, RN, Harrison's Critical Care Director, says the advantages of the chest-pain clinic aren't limited to quick assessment and patient convenience.

16-bed unit in the University Hospital's Emergency Department serves adult and pediatric patients who need additional follow-up after seeing U-M emergency physicians for chest pains, abdominal pain, dehydration, asthma attacks, and other conditions.

MEDPATH

University of Michigan Health System

Chest Pain Unit is adjacent to the existing Emergency Department and features five cardiac observation beds. Patients experiencing chest pain or other symptoms of a heart attack should enter the main EMERGENCY DEPARTMENT

After evaluation and testing in the Emergency Department, most patients complaining of chest pains can be treated in the Chest Pain Center

For many, the center is able to answer the question about the pain's cause in less than a day without being admitted to the hospital

The Paul Dudley White Coronary Care SystemSt. Agnes Health Care, Baltimore, Maryland

•components necessary for a Chest Pain Center in the Emergency Department

Full Certification as a Chest Pain Center in the Emergency Department

•Emergency Chest Pain Unit "Attack Program"

•Observation Program for tracking chest pain patients

•Functional unit design and monitoring equipment

•Appropriate staffing and proper opening

•Outreach program for the community (EHAC)

•TQM based management of Chest Pain Center