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LIST OF CONTRIBUTORS
ix
Jefferson G. Williams, MD, MPH
EMS Fellow and Clinical Instructor
University of North Carolina Department of
Emergency Medicine
Chapel Hill, North Carolina, USA
Carrie D Tibbles, MD
Associate Director, Graduate Medical Education
Beth Israel Deaconess Medical Center
Associate Residency Director Harvard Affi liated
Emergency Medicine Residency
Assistant Professor of Medicine
Harvard Medical School
Transcription editors
Colleen Birmingham,
MD
Fellow in Medical Toxicology
New York University Medical Center/
New York City Poison Center
New York, New York, USA
Jessica Klausmeier, MD
Division of Emergency Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
Ashleigh Hegedus, MD
Instructor in medicine
Harvard Medical School
Division of Emergency Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
Robin Naples, M.D.
Assistant Professor of Emergency Medicine
Temple University School of Medicine
Philadelphia, Pennsylvania, USA
David A. Peak, MD
Assistant Professor, Division of Emergency Medicine,
Harvard Medical School
Attending Physician and Assistant
Residency Director,
Department of Emergency Medicine,
Massachusetts General Hospital
Boston, Massachusetts, USA
David Plitt, MD
Department of Medicine
University of Virginia School of Medicine
Charlottesville, VA, USA
Kevin C. Reed, MD, FACEP, FAAEM
Assistant Professor of Clinical
Emergency Medicine
Georgetown University School of Medicine
Department of Emergency Medicine,
Washington, USA
Jeffrey Soderman, MD
Attending Physician
Department of Emergency Medicine
Beverly Hospital
Beverly, MA, USA
Shannon Straszewski, MD
Chief Resident
Harvard Affi liated Residency in Emergency Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
xi
Meaningful endeavors are seldom created in a vacuum.
The authors would like to acknowledge a number
of people who have enabled this book to come to
fruition. Firstly, I would like to thank my mentor
par excellence and chair, Dr Rich Wolfe, without
whose creativity, few of my dreams would have been
achieved. To Dr Peter Rosen, whose wisdom and
leadership is apparent in every page of this book, I am
forever indebted. To Maureen Blicker, your uncanny
organizational skill made 27 weekly case discussions
a reality. To my colleagues and residents in emergency
medicine at Beth Israel Deaconess Medical Center,
it is you who portray excellence in health care on a
daily basis and motivate this text. I thank my beloved
parents, Rabbi Rafael and Shirley Grossman, who
have taught me well the words of Herzl, “if you will
it, it shall not be a dream”. My remarkable children,
Naamah, Ezra, Atira, Meira, Tehila, Elianna and
Netanel, you continue to inspire and teach me new
ideas daily. To my wife Sharon, your partnership is
equal in all of life’s accomplishments; this book is a
product of your endeavors as much as mine, “. . .
and you have exceeded them all” (Proverbs 31:29).
Lastly, I thank G-d for all his wisdom and kindness
bestowed upon me. Ultimately, it is “the Lord who is
thy healer” (Exodus 15:26).
Shamai A. Grossman
To Drs. Tim Marshall and Wayne Pinto. Without your
expertise, I could not have worked on this book.
Peter Rosen
I would like to thank my wife, King, for everything
that she does; without her, none of this work would
be possible. I would also like to thank my children,
Lauren, Anne, Chip, and Katherine, for being both
wonderful and my inspiration. Lastly, I must also
thank my emergency medicine colleagues, both at the
University of Virginia and elsewhere, for their “most
excellent” care of the patient, at times under less than
optimal conditions in today’s healthcare world.
William J Brady
Dedicated to past, present, and future Harvard
Affi liated EM residents - thank you for inspiring me
every day.
David FM Brown
Thanks to my wife, Diana, and children, Lauren and
Taylor, for their love and support.
Theodore C. Chan
Thank you to my children, Quinn and Kelly, for con-
tinuing to open my eyes to what life is and what it
should be, and showing me how to make those two
things one.
Richard A. Harrigan
Dedicated to the “big rocks” in my life: my wife, Sejal,
and my children Nikhil, Eleena, and Kamran, for their
support and continued reminders of the priorities of
life; and to the students, residents, and faculty of the
Department of Emergency Medicine at the University
of Maryland School of Medicine for their commit-
ment to education.
Amal Mattu
To my parents, for their continuous support; to my
beautiful daughters Maya and Sienna, who brighten
and bring such joy to my day; to my wife Sonal, who
makes me a better person and doctor, and to the
patients who put their trust in me.
Edward Ullman
Acknowledgements
xiii
Preface
The hardest part of practicing medicine is knowing
what questions must be answered. In discussions about
our fi eld, it quickly becomes apparent that many of the
critical questions involve cardiac emergencies. We there-
fore decided to dedicate a monogram to the focused
discussion of cardiac problems. For many decades, the
right cardiac question was: “Is this patient having an
acute myocardial infarction?” Yet, as we have become
more sophisticated in being able to care for this disease
process, it has become apparent that this is no longer
the right question. Now we must struggle with: “Is this
patient having an acute ischemic coronary syndrome?”
As we all struggle to answer the correct question and
deal with it in an effi cient, safe and practical fashion,
we decided that it would be useful to query some of
our colleagues about which questions to ask, and how
they answer them.
With the emphasis today on making medical deci-
sions based upon evidence, we wished to not only
provide examples of that evidence at work, but to
show how it is expressed through the experience and
expertise of practicing Emergency Physicians.
We hope that this book will not only be of inter-
est, but of some utility for those young physicians who
are in the process of becoming fl uent in the language
of Emergency Medicine, as well as those students who
are considering the fi eld as a career. We also hope that
those physicians who are already practicing Emergency
Medicine will fi nd these discussions not only interest-
ing, but helpful to their daily management decisions
as well.
We also remembered that we ourselves learned best
from relevant clinical cases. We therefore decided to
have each topic introduced by a clinical case, chosen
from our actual practice, with a discussion of the case
by our editorial board, sometimes supplemented by
the chapter author.
Each chapter is divided into four sections: a relevant
case, a discussion, a concept section, and a manage-
ment section. Each chapter concludes with a manage-
ment section that summarizes care of each disease
in an algorithm or chart format. This fi nal section is
intended to serve as both a review and ultimately as an
easily used reference guide while caring for patients.
While the cases represent our own styles and
those of the institutions within which we practice,
we hope that these examples will help instruct those
who are struggling to formulate their own safe
approaches to clinical management and provide a
safe background upon which to build clinical con-
fi dence and expertise. Clearly these practices will
continue to evolve as we acquire more evidence to
solve some of the ongoing dilemmas that still exist
about management. Precisely for that reason, we
offer this book as a safe place from which to start,
to improvise and to modify, so as to achieve the best
outcomes for the patients with these complex and
critical problems.
Shamai A. Grossman
Peter Rosen
October 2011
SECTION ONE
Cardiac Ischemia
3
Cardiovascular Problems in Emergency Medicine: A discussion-based review, First Edition.
Edited by Shamai A. Grossman and Peter Rosen.
© 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
1
Chest pain
Michael Bohrn
1
, Amal Mattu
2
& Brian Browne
3
1
Clinical Associate Professor of Emergency Medicine, Penn State University College of
Medicine, Hershey, PA, USA
2
Professor and Residency Director, Department of Emergency Medicine, University
of Maryland School of Medicine, Baltimore, Maryland, USA
3
Professor and Chairman, Department of Emergency Medicine, University
of Maryland School of Medicine, Baltimore, Maryland, USA
Section I: Case presentation
A 46-year-old man presented to the emergency depart-
ment (ED) complaining of chest pain. The pain had
begun while he was carrying some heavy boxes at
home four hours prior, and had persisted since. He
described the pain as a severe ache in the midsternal
area, but there were superimposed sharp pains that
radiated to the left shoulder when he took a deep
breath. It did not appear to change with body or arm
position, with walking, or with swallowing. He felt
dyspneic and nauseated, and he also reported that
he was diaphoretic during the fi rst 20 minutes of the
pain. The pain did not improve with ibuprofen, so he
decided to come to the ED.
The past medical history was notable for HIV and hyper-
tension. The patient had stated that he had been non-
compliant with medications and primary care follow-up
during the prior year. The last CD4 count one year ago
was approximately 500. He had smoked one pack of
cigarettes per day for more than 20 years, and had used
crack cocaine regularly for 10 years, although he had not
used cocaine for a week. He was uncertain if there was a
family history of early cardiac disease or sudden death.
He had been admitted for chest pain approximately
six months earlier at a nearby hospital, and had a “nega-
tive” stress test at that time.
The vital signs were: temperature 37°C, pulse 90
beats/min, respirations 20 breaths/min, blood pressure
180/110 mmHg, pulse oximetry 98%. The cardiac
and pulmonary examinations were normal with the
exception of mild, sharp, left-sided chest pain with
deep inspiration. The chest wall was mildly tender.
The pulses and jugular venous pulsations were normal.
There was no peripheral edema. The rest of the physi-
cal examination was normal. An electrocardiogram
(EKG) was obtained, and demonstrated sinus rhythm
with voltage criteria for left ventricular hypertrophy
and diffuse T-wave fl attening across the precordium.
The chest X-ray study was normal.
Section II: Case discussion
Dr Peter Rosen: We are always taught that the most
important part of the evaluation of ischemic chest
pain is the history. Yet, for 30 years I have been try-
ing to fi nd a description of ischemic chest pain that
enables me to say, “this chest pain is ischemic, and
that is musculoskeletal, and that is gastrointestinal.”
Do you have any clues for us, or is that just one of the
legends of clinical medicine?
Dr David Brown: I don’t think there is an answer to
your question that is clinically useful. Each of us could
probably describe classic chest pain and classic fi nd-
ings for all of the conditions you just mentioned, but
there is considerable overlap between these disease
presentations such that I don’t think the emergency
CHAPTER 1
4
artery disease with protease inhibitors, and HIV patients
appear to be more likely to have traditional cardiac
risk factors then the general population.
1–9
All of this
requires one to truly think broadly when trying to sort
out a diagnosis in this patient.
PR: What is the utility of that CD4 count that’s a year
old?
Dr Ted Chan: It suggests that, a year ago, he was not
signifi cantly immunosuppressed, and not at risk for
many of the atypical infections associated with HIV.
It’s diffi cult to say what it might be now, particularly
if he has been non-compliant with his medications
over the past year.
PR: Would you say the same thing about his “negative”
stress test from six months earlier?
SG: The same suspicions that I had about this patient’s
report that he hadn’t used cocaine in a week would
make me skeptical about his report of a negative stress
test, and I wouldn’t accept this at face value. The value
of any stress test that is six months old is controversial,
although some studies suggest that there is utility in a
negative stress test anywhere from one and one-half to
three years later.
10–13
However, the utility of a stress test
is related to the pre- and post-test probability that this
patient’s symptoms are ischemic in etiology.
PR: This is the kind of patient who is going to be a
signifi cant management problem in the ED because no
cardiologist is going to be excited about working him
up, and he may be very hard to admit. We become
very cynical about these patients because of their social
circumstances, and they may have to prove to us that
they are experiencing something nefarious before we
will listen to their story. What should the extent of
his workup in the ED be before you would push for a
cardiology consult?
DB: Given an EKG that is nonspecifi c, a history that
is suggestive but nondiagnostic, and no cardiac mark-
ers, we have little compelling data to prompt a cardi-
ology consultation at this point. What he does need
now is a fi rst set of cardiac markers and a careful look
at his electrocardiogram, perhaps obtaining an old
EKG if one’s available. There are some data to sug-
gest that a rapid rule-out over 6 to 8 hours, including
two sets of negative markers followed by some sort of
provocative testing, is suffi cient to evaluate patients
with cocaine-related chest pain.
14
physician can use the history alone to reliably exclude
an acute coronary syndrome in a patient like this one.
PR: Do you think there is any benefi t to the patient
describing isometric exercise such as shoveling snow or,
as in this history, less isometric exercise in that he was
carrying boxes? Would a more isometric history, such as
if he had said that the pain came on while he was lifting
the boxes up onto a shelf, be more useful?
DB: If you have additional history from him regard-
ing whether or not any use of the muscles or move-
ment of his arm might have precipitated the pain, and
can fully reproduce it now while he is in the ED, this
may be useful. But I don’t think there is a lot of utility
in differentiating whether this exercise was isometric
because one could say that he was walking at the same
time, and that there was an aerobic component that
precipitated the pain.
PR: The drug abuse history in this case makes me far
less suspicious that this is ischemic pain. Once I get a
history of cocaine use in a patient who says he hasn’t
used it in the past week, although time is relative for
users, I fi nd it is more likely to be nonspecifi c chest
wall pain rather than ischemia. Is there any way you
can distinguish these patients from history alone, or
does it require a full workup?
Dr Shamai Grossman: Patients with cocaine chest
pain always worry me because I fi nd that they have
more atypical presentations. These patients seem to
present often, as this one has, with chest pain that can
be from multiple different etiologies. Once they tell
me that they use cocaine, I tend to not trust them to be
telling me the truth when they say they haven’t used
cocaine in the last week. I would simply assume that
the patient has actually used cocaine very recently,
likely within the last 24 hours. Once I assume this, I
also have to assume that the chest pain is cardiac in
etiology until it has been fully proven otherwise.
PR: This patient also has a past history of HIV. I’m
not aware of HIV causing ischemic cardiac disease. I
have seen cardiac ischemia with pulmonic, oncologic,
and gastrointestinal problems, but I don’t believe I’ve
ever seen a patient with HIV present with an ischemic
coronary syndrome. Is this true?
SG: HIV can cause a dilatated cardiomyopathy, although
not an ischemic cardiomyopathy. In addition, recent
data seem to suggest an increased incidence of coronary