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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
312
C. J. Rees et al.
Differential Diagnosis
• The initial differential diagnosis of chest pain must include all the serious and
potentially life-threatening diseases, such as acute coronary syndromes, aortic
dissection, pulmonary embolism, and pneumothorax.
• The differential diagnosis of musculoskeletal causes of chest pain is broad. It includes,
primarily, inammatory musculoskeletal pain syndromes such as costochondritis
(and others as below), and rheumatic musculoskeletal syndromes such as bromyalgia, rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
• Primary (inammatory) musculoskeletal chest pain syndromes include:
• Costochondritis. Costochondritis typically affects those over age 40, and usu-
ally involves pain to palpation over the costochondral junctions of the third,
fourth, and fth ribs. Costochondritis is diagnosed more often in women.
• Tietze’s Syndrome. In Tietze’s syndrome there is painful swelling of usually
one (but sometimes several), costochondral joints. It usually involves either the
second or third costochondral junctions. There must be obvious physical signs
of inammation, such as erythema, swelling, and warmth over the affected
joint, for the diagnosis to be considered. It is a rare disorder of unknown etiology. Tietze’s syndrome is more common in those under 40, and affects both
sexes equally.
20 Costochondritis
Inverted C-shape tracer uptake in chronic Tietze’s disease. A Anterior pinhole scan in
a 63-year-old man with tender swelling for 2 months in the left rst costochondral junction shows inverted C-shape tracer uptake (arrow). B Posteroanterior radiograph shows
nonspecic calcication (arrow). C Conventional X-ray tomograph shows inverted
C-shape ossication in the costochondral junction (arrow) [Bahk Y-W.Infective and
In ammatory Diseases of Bone. In: Combined Scintigraphic and Radiographic
Diagnosis of Bone and Joint Diseases [Internet]. Berlin, Heidelberg: Springer Berlin
Heidelberg; 2013 [cited 2016 Nov 7]. p.75–106. Available from:
com/10.1007/978-3-642-25144-3_6] Caption from original
• Xiphodynia/xiphalgia. Sharp, pleuritic chest pain that is reproduced by
light palpation of the xyphoid process.
• Precordial catch syndrome (sometimes called texidor twinge). Fleeting
(lasting seconds to minutes), lancinating episodes of chest pain, often precipitated by deep inspiration.
• Slipped rib syndrome. Pain and often a feeling of fullness usually along the
inferior margin of the anterior tenth rib. There is often point tenderness and
reproduction of the symptoms with pressure. Thought to be secondary to
hypermobility of the distal costal cartilage that occurs after lifting or twisting. More commonly diagnosed in women.
• Sternalis syndrome. Localized tenderness over the sternum thought sec-
ondary to inammation of the overlying sternalis muscle. Rare, more common in women, and often causes bilateral pain, especially with palpation.
• Sternoclavicular subluxation. Another rare diagnosis, marked by spontane-
ous or traumatic subluxation of a sternoclavicular joint. More commonly
noted on the side of the dominant hand, and worsens with pulling and lifting motions. Mostly seen in women 40– 60 years old, and associated with
moderately heavy repetitive tasks.
http://link.springer.
313
Pathophysiology andEtiology
• The pathophysiology of costochondritis is felt to primarily involve inammation of the costochondral junctions. The inammation may be spontaneous
and idiopathic, or may be related to injuries cause by trauma or overuse.
Presentation
Typical/“Classic”
• Chest pain that that is highly localized, and consistently reproducible by light
palpation over a small area.
• Usually described as sharp and pleuritic, and often worsens when changing
positions, coughing, and sneezing.
• Onset can be sudden, but is more often gradual and insidious.
314
C. J. Rees et al.
Atypical
• May present as dull, diffuse pain that is poorly localized.
Primary Differential Considerations
• Initial consideration to patients presenting with these symptoms should be
given to the following differential diagnoses:
• Acute coronary syndrome
• Pulmonary embolism
• Pericarditis
• Pleurisy
• GERD
• Herpes zoster (shingles)
History andPhysical Exam
Findings That Conrm Diagnosis
• It must be stressed that all the life-threatening causes of chest pain must
always be considered in patients presenting with a complaint of chest pain.
• It must also be stressed that reproducibility and chest wall tenderness are not
sensitive or specic signs, and they can also occur with acute coronary
syndromes.
• The diagnosis can usually be conrmed, after more serious causes of have
chest pain have been excluded (either by history and physical or testing),
when there is a discrete area of tenderness in which the pain is consistently
reproduced by light palpation.
Factors That Suggest Diagnosis
• Chest pain that is sharp, localized, and consistently reproducible by light
palpation.
Factors That Exclude Diagnosis
• Chest wall pain syndromes can coexist with many other causes of chest pain,
and as such can only be excluded when there is no complaint of chest pain.
20 Costochondritis
Ancillary Studies
Laboratory
• Laboratory studies are inly useful in excluding other diagnoses. There are no
laboratory studies that help in the diagnosis of costochondritis or other chest
wall pain syndromes.
Imaging
• Imaging studies are only helpful in the exclusion of other diagnoses.
Special Populations
Age
• Costochondritis is more common above the age of 40, but can be diagnosed
in any adult age group.
• Costochondritis can affect children as well as adults.
• In some studies of musculoskeletal chest pain in children, costochondritis
accounted for nearly 15 percent of nal diagnoses.
315
Co-morbidities
• Costrochondritis can coexist with any other diagnosis. There are no comorbidities of signicance.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• It is critically important to rst consider the life-threatening causes of chest
pain.
Mimics
• Costochondritis can present similarly to other, more serious causes of chest
pain, such as pulmonary embolism and acute coronary syndrome.
316
C. J. Rees et al.
Time-Dependent Interventions
• There are no time-dependent interventions.
Overall Principles ofTreatment
• Costochondritis and the other musculoskeletal chest pain syndromes are usually self-limited conditions.
• Treatment is usually conservative, and starts with reassurance that no more
serious condition exists.
• Treatment is usually with simple analgesics such as acetaminophen. If acetaminophen is unsuccessful, a trial of NSAIDs may be appropriate.
• In situations where the precipitating event is felt to be trauma or overuse, a
short period of rest may be helpful.
• In situations where the pain is well localized, a trial of capsaicin cream,
NSAID creams or patches, or lidocaine patches may be helpful.
• In resistant cases, it may be necessary to refer to a pain center for local injections of a glucocorticoid/local anesthetic mixture.
Disease Course
• The course of costochondritis and the other chest wall pain syndromes is generally benign and self-limited and will resolve spontaneously within 2–3
weeks or a month.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Woodard PK, White RD, Abbara S, Araoz PA, Cury RC, Dorbala S, Earls JP, Hoffmann
U, Hsu JY, Jacobs JE, Javidan-Nejad C, Krishnamurthy R, Mammen L, Martin ET,
Ryan T, Shah AB, Steiner RM, Vogel-Claussen J, White CS.ACR Appropriateness
20 Costochondritis
Criteria chronic chest pain-low to intermediate probability of coronary artery disease. J Am Coll Radiol. 2013 May;10(5):329-34. https://doi.org/10.1016/j.
jacr.2013.01.018. PMID: 23542027. http://www.ncbi.nlm.nih.gov/pubmed/
23542027
**
317
Review
King JE, Magdic KS.Chest pain: a time for concern? AACN Adv Crit Care. 2014
Jul-Sep;25(3):279-83. https://doi.org/10.1097/NCI.0000000000000039. PMID:
25054533. http://www.ncbi.nlm.nih.gov/pubmed/25054533 **
Ayloo A, Cvengros T, Marella S.Evaluation and treatment of musculoskeletal chest
pain. Prim Care. 2013 Dec;40(4):863-87, viii.
08.007. PMID: 24209723. http://www.ncbi.nlm.nih.gov/pubmed/24209723 **
Proulx AM, Zryd TW.Costochondritis: diagnosis and treatment. Am Fam Physician.
2009 Sep 15;80(6):617-20. PMID: 19817327.
pubmed/19817327 **
https://doi.org/10.1016/j.pop.2013.
http://www.ncbi.nlm.nih.gov/
Cohort Study
Bösner S, Bönisch K, Haasenritter J, Schlegel P, Hüllermeier E, Donner-Banzhoff
N.Chest pain in primary care: is the localization of pain diagnostically helpful in
the critical evaluation of patients?--A cross sectional study. BMC Fam Pract.
2013 Oct 18;14:154. https://doi.org/10.1186/1471-2296-14-154. PMID:
24138299. http://www.ncbi.nlm.nih.gov/pubmed/24138299
Case Study
Cubuk R, Tasali N. Medical image. Tietze’s syndrome. N Z Med J. 2009 Feb
13;122(1289):87-8. PMID: 19305456. http://www.ncbi.nlm.nih.gov/pubmed/
19305456
Volterrani L, Mazzei MA, Giordano N, Nuti R, Galeazzi M, Fioravanti A.Magnetic
resonance imaging in Tietze’s syndrome. Clin Exp Rheumatol. 2008 SepOct;26(5):848-53. PMID: 19032818. http://www.ncbi.nlm.nih.gov/pubmed/
19032818 **
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Tietze’s Syndrome”[Mesh] OR “Costochondritis”
Chapter 21
Cyanide Poisoning
CharlesV.Pollack,Jr., MelissaPlatt, RichardM.Cantor,
andVictoriaG.Riese
Name andSynonyms
Cyanide Poisoning
Incidence/Epidemiology
• Rare occurrence
• Usually in association with smoke inhalation from a residential or industrial re
• Occasionally seen as suicidal ingestion
Differential Diagnosis
• Myocardial infarction
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
M. Platt
Department of Emergency Medicine, University of Louisville, Louisville, KY, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_21
319© Springer Nature Switzerland AG 2019
320
C. V. Pollack, Jr. et al.
• Meningitis and encephalitis
• Hemlock poisoning
• Pulmonary embolism
• Cardiogenic shock
• Ischemic stroke
• Carbon monoxide toxicity
• Hydrogen sulde toxicity
• Iron toxicity
• Isoniazid toxicity
• Nonsteroidal anti-inammatory drug toxicity
• Azide toxicity
• Methanol toxicity
• Strychnine toxicity
Pathophysiology andEtiology
• Mitochondrial toxicity by binding cyanide to ferric ion (Fe3+). Oxidative
phosphorylation ceases, leading to anaerobic metabolism.
• Rapidly absorbed through gastrointestinal tract and skin
• Rapidly lethal
• Exposure may be
• From smoke inhalation/re
• Formed when structures containing both carbon and nitrogen (such as
polyurethane) burn
• Industrial
• From metal extraction, electroplating
• Medical
• Use of some antineoplastic agents (such as amygdalin) and other infusions (such as nitroprusside) may result in accumulation of toxic levels
of cyanide.
• Diet
• Fruit pits and bitter almond contain cyanogenic glycosides
• Tobacco abuse
• At baseline, chronic smokers have signicantly higher blood levels of
cyanide than nonsmokers
21 Cyanide Poisoning
Presentation
Typical/“Classic”
• Symptoms depend on severity and route of poisoning.
• Central nervous system symptoms, including headache, anxiety, confusion,
vertigo, coma, and seizures, are most prominent.
• Also prominent are cardiovascular symptoms, including tachycardia,
hypertension then bradycardia and hypotension, atrioventricular block, and
ventricular dysrhythmias.
• Skin and lip ushing also may be seen.
Atypical
• Lower-level exposure may delay the onset of the aforementioned signs and
symptoms.
• Nausea and vomiting
• Muscular twitching
Primary Differential Considerations
321
• Because of the wide range of signs and symptoms, the differential is quite
large and includes exposure to tricyclic antidepressants, organophosphates,
methemoglobin, strychnine, carbon monoxide, or arsine.
History andPhysical Exam
Findings That Conrm Diagnosis
• There is no clinical conrmation of cyanide toxicity. This is a laboratory diagnosis in a challenging clinical setting in which early testing of arterial blood
gas and lactate levels is important.
Factors That Suggest Diagnosis
• Bright red venous blood
• Despite hypotension, apnea, or bradycardia, cyanosis usually is not present.
• After hydrogen cyanide inhalation:
322
C. V. Pollack, Jr. et al.
• Bitter almond odor
• Headache, anxiety, nausea, and metallic taste
• After cyanogen chloride inhalation:
• Eye and mucous membrane irritation, bronchorrhea, cough, and dyspnea
• After dermal exposure/ingestion:
• Delayed symptoms: minutes to hours
• After parental exposure:
• Confusion and combativeness initially may be mistaken as intensive care
unit (ICU) syndrome
• After ingestion
• Nausea and vomiting
• Large quantities of such foods may result in toxicity
The starchy roots of the cassava plant (Manihot esculenta) contain cyanide. The
roots are a staple in the diet of people living in the tropics, and inadequate processing of the roots can lead to cyanide poisoning [Lottermoser BG. Mine wastes
[Internet]. Berlin, Heidelberg: Springer; 2010. Chapter 5, Cyanidation wastes of
gold-silver ores; [cited 2015 Aug 13]; p. 243-262. Available from: http://link.
springer.com/10.1007/978-3-642-12419-8_5] Caption from original