Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3736_Библиотеки_им_академика_М_И_Перельмана

Chest radiograph is a quick, noninvasive test that should be performed with patient’s complaining of chest pain. Chest radiographs often do not change management in acute coronary syndrome but are benecial for evaluating other potential etiologies of chest pain. A pneumothorax can be readily identied on chest X-ray by a visible vis­ceral pleura edge seen as a thin, sharp white line without lung markings peripheral to this line. Mediastinal deviation from midline suggests ten­sion physiology and warrants urgent interven­tion. Subcutaneous emphysema may also be seen. A widened mediastinum may be seen in acute aortic dissection, although this lacks sensi­tivity and does not exclude the possibility of aor­tic dissection. Bacterial pneumonia may be seen as a focal opacity which may produce symptoms of chest pain. Other parenchymal lung diseases like malignancy may be identied.

the American College of Emergency Physicians and American Society of Echocardiography, the use of focused cardiac ultrasound (FOCUS) pro­vides great utility for the assessment of global car­diac systolic function, marked ventricular chamber enlargement, or the assessment for the presence of a pericardial effusion. In cases of uncertain volume status, FOCUS may be used to aid in the assess­ment of intravascular volume assessment. FOCUS should also be used for guidance during pericardio­centesis and conrmation of a transvenous pacing wire placement [19].

cardial infarction is one of the most considered conditions for troponin elevation, several other conditions include chronic kidney disease, con­gestive heart failure, pulmonary hypertension, skeletal myopathies, chemotherapeutic agents, hypertrophic cardiomyopathy, and inltrative processes such as cardiac amyloid, hemochro­matosis, or cardiac sarcoidosis which have been linked to elevated troponin levels [20]. Troponin assay is recommended in all patients who pres­ent to the emergency department for chest pain unless an obvious noncardiac etiology is present [7]. Newer high-sensitivity assays have replaced traditional troponin assays which have mark­edly improved the early diagnosis of acute myo­cardial infarction [21]. Troponins have tremendous negative predictive value to rule out AMI.The negative predictive value for myocar­dial infarction within 30 days in patients with undetectable high- sensitivity troponin and no ischemic ECG changes with 99.8% and the neg­ative predictive value for death was 100% [22]. Two consecutive high-sensitivity troponins below detection on high-sensitivity assays effectively exclude acute coronary syndrome. Patients who presented with chest pain with an initial high-sensitivity troponin that was unde­tectable had a less than 1% risk of MI at 30-day follow-up. High-sensitivity troponin has utility in noncoronary pathologies as well. Troponin can be elevated and acute pericarditis in up to 40% of cases. Elevated troponin may also be seen in the cases of acute aortic dissection and pulmonary embolism. In the case of a pulmo­nary embolism, troponin elevation is a sign of RV strain, myocardial injury, and increased dis­ease severity. Signicantly elevated troponin with a nondiagnostic EKG also warrants consid­eration for myocarditis.