0:00

I wanna provide a framework for thinking about chest pain. So as you're

0:05

looking at images, it's helpful to think about what are the common causes

0:09

of chest pain, and these include, and they're not limited to,

0:12

myocardial infarction, pulmonary embolism, aortic dissection, pericarditis,

0:18

costochondritis, pneumonia, or there may be other things. But as you begin

0:21

to think about things that could cause chest pain, it may direct your

0:26

pattern for questions to answer. As you think about

0:31

imaging, here are some things that are listed. Now, not all of these

0:34

are indicated in every single instance, and some of these may not be

0:38

helpful in all instances. But generally speaking, PA and lateral chest radiographs

0:43

are very good screening tools. They're very common in the ED.

0:47

You will get comfortable because you'll be exposed to lots and lots and

0:51

lots of PA and lateral chest radiographs. The CTPA or the chest CT

0:56

for PE, or chest CTs with contrast, we're using those interchangeably.

1:02

And those, again, will give you information not just about whether or not

1:05

there is embolism, but depending on the protocol,

1:09

you can get information around aortic dissection, you'll be able to look

1:12

at the pericardium, you'll be able to look at the bones,

1:15

look at the lung parenchyma, things of that nature, and you may be

1:19

able to see enhancement of the myocardial tissue in cases where there's

1:22

acute infarc. So, lots of things that can be shown there.

1:26

Again, CTA of the coronary arteries is very focused looking at the coronary

1:31

arteries, when there's a question of myocardial infarction or myocardial

1:36

ischemia. This is something that can be done in the ER.

1:39

There are many other tests that may preclude this exam, so you may

1:42

not see this very frequently. EKGs and myocardial perfusion are, again,

1:46

imaging that gets done. Generally, for patients who are coming through the

1:50

ED, it may not necessarily be done in the acute time period,

1:54

but you may begin to see patients who have this as follow up.

1:57

In terms of some Pearls, think about... Again, the Wells criteria is an

2:01

excellent tool for determining which patients need to actually be imaged

2:05

if you're suspecting PE, but not all patients who have chest pain or

2:09

who shortness of breath will have PE or should have the Wells criteria

2:12

applied to them. So really, you need to have a high suspicion of

2:16

veno occlusive disease and a history of physical examination that would

2:20

suggest that this is a high likelihood and that those patients should undergo

2:24

the Wells criteria, and then be determined to go into

2:27

chest CT for PE. Now, I will say that for many patients who

2:31

come down the chest CT for PE category, what we began to see

2:36

is there are many alternative reasons for patients with shortness of breath.

2:39

So the cases of pneumonia that we don't see on X ray certainly

2:43

does happen. So there may be other diagnoses that while providers are saying,

2:48

"Does this patient have a PE?" they're actually asking for other types of

2:52

diagnoses that are listed here, so things like pneumonia, things like pericarditis,

2:56

things like dissection. So keep that in mind to be very broad in

3:00

your differential and to be inclusive.