Investigation and management of patients with pleuritic chest pain presenting to the accident and emergency department.

The assessment of a patient with pleuritic chest pain calls for a high degree of clinical acumen and a high degree of suspicion that the diagnosis might be pulmonary embolism. This area is one of the most difficult in A&E medicine (and indeed chest medicine). One error is to "think the best" when considering the diagnosis in such patients but experience soon teaches to "think PE" and diagnose less serious conditions only when pulmonary embolism has been excluded. A key consideration is the presence of risk factors. Because the diagnosis is difficult, there should be no hesitation in requesting a senior opinion or referring to the inpatient medical team. We have produced an algorithm (fig 1) for the investigation and management of pleuritic chest pain as discussed in this article. Three questions relating to this article are: (1) Can pulmonary embolism be the diagnosis in a patient with pleuritic chest pain but a normal chest radiograph, ECG, and arterial blood gases? (2) What is the chest radiograph abnormality which is most likely to alert you to the possibility of pulmonary embolism? (3) What percentage of patients with a low clinical suspicion of pulmonary embolism but a high probability V/Q scan will have pulmonary embolism demonstrated on pulmonary angiography? The three key references are The PIOPED Investigators, Dalen, and Fennerty.     

Assessment of the patient with chest pain in the accident and emergency department

This article will review measures enabling emergency staff to identify patients with chest pain who are likely to need admission to a cardiac care unit, in particular those with manifestations of acute ischaemic heart disease - acute myocardial infarction and unstable angina. Other non-cardiac causes of chest pain will also be discussed.     

An audit of doctor's management of patients with chest pain in the accident and emergency department

In a series of 604 patients attending an accident and emergency department with chest pain, the decisions made by casualty officers about admission to the coronary care unit were compared with the retrospective opinions of experienced clinical assessors who knew the results of any subsequent investigations. Of the 119 patients whom the assessors judged should have been admitted to the coronary care unit, 14 (11.8 per cent) were judged to have been discharged in error. Of the 485 patients whom the assessors judged should not have been admitted to the coronary care unit, 32 (16 per cent) were judged to have been advised admission unnecessarily. Misinterpretation of the electrocardiographic results was apparently the reason for five of the 14 false negative errors and four of the 32 false positive errors. The median time that patients who were eventually admitted to the coronary care unit spent in the accident and emergency department was 78 min.     

Lung ultrasound in the evaluation of patients with pleuritic pain in the emergency department

The evaluation of pleuritic pain in the emergency setting is a diagnostic challenge. Most patients are discharged from the Emergency Department (ED) with a diagnosis of chest wall pain not otherwise specified. It is important to rule out possible sources of acute pleuritic pain, like pulmonary embolism, pneumonia, lung cancer, and pneumothorax. Clinical examination, plain film radiography of the chest, and other routine investigations may be inadequate to make the correct diagnosis. In this setting, another bedside test to aid diagnosis would be useful. ED bedside lung ultrasound is a novel technique for the diagnosis of lung diseases. We report on 5 patients who presented to our ED complaining of pleuritic pain, few other symptoms, and negative routine investigations, in whom bedside lung ultrasound aided in making the diagnosis.     

Women attending an accident and emergency department after assaults.

Assaults on women are a distressing aspect of A&E work. In a combined prospective and retrospective study, covering a 6-month period, 282 female victims were identified (0.75% of attendances). Although most of the injuries were relatively minor the recording of historical and social factors was poor. Attempted follow up for counselling and support proved ineffective. Better education of the doctors regarding the documentation for such patients, assessment of the social dimensions of their needs and requirement for improving both their immediate care and long term follow-up are discussed.     

Blood alcohol concentrations of patients attending an accident and emergency department

The prevalence of detectable blood alcohol in all new adult patients attending an accident and emergency department was 10.3%. The mean concentration was 20.9 mmol/1 (96 mg/dl). There were significantly more patients with detectable alcohol in the following groups: male patients; patients aged under 35 years; patients attending on Saturdays; patients attending between 21.00 and 08.59 hours; patients involved in road traffic accidents; patients presenting because of drug overdosage, and head injuries. Those with detectable blood alcohol were more likely to be admitted, probably because of their associated reason for attendance. Patients referred by their general practitioner were less likely to have detectable blood alcohol.     

Audit of patients with chest pain presenting to an accident and emergency department over a 6-month period.

The results of a 6-month retrospective audit of patients presenting with chest pain to an accident and emergency (A&E) department to which 46,000 new patients per year present are discussed. The computer diagnostic code assigned to the patients by the A&E doctor, referral rates for second opinion and disposal after assessment in the A&E department are examined, with particular reference to patients who may have had serious cardiac pathology, such as acute myocardial infarction (AMI) or unstable angina. Audit showed that overall 61% of patients with chest pain of all causes were assessed and discharged home by A&E doctors without recourse to second opinion. Of patients thought by the A&E doctors to have chest pain of cardiac origin, who were referred to the duty medical registrar or cardiologist, 88% were admitted. As a result of these findings a policy of more open referral for second opinion was instituted to reduce the likelihood of discharging patients home with serious cardiac pathology. In addition, the clinical problems of AMI and unstable angina are emphasized to all senior house officers early in their educational programme after joining A&E. Published literature on the diagnosis and misdiagnosis of AMI and unstable angina in the A&E department is reviewed. These studies are almost exclusively from North America, and a need for similar work in the U.K. is discussed.     

Chest pain in the accident and emergency department: is chest radiography worthwhile?

Four per cent of patients attend the Accident and Emergency Department (A&E) present with chest pain. In this prospective study of 297 patients the value of chest radiography is assessed. Overall, 23% of chest X-rays (CXRs) had an abnormality which influenced management of the patient, rising to 40% in those patients admitted to Coronary Care. Twenty-nine per cent of CXRs were misinterpreted by Casualty Officers but resulted in the mismanagement of only six patients (3.3%). Potentially serious errors were averted by early CXR audit by a Radiologist.     

Pain in young children attending an accident and emergency department

OBJECTIVES: To assess pain in young children presenting to an accident and emergency (A&E) department. To evaluate the use of the toddler-preschooler postoperative pain scale (TPPPS) and the use of analgesia in these children. METHODS: 100 children aged 1-5 years presenting to an A&E department were assessed for pain. Pain assessments were carried out using a modified form of the TPPPS; a visual analogue scale by parents and a numerical scale by nursing staff. RESULTS: The majority of children were assessed as having pain: 60 by the TPPPS, 58 by the nurses and 63 by parents. Only 30 children, however, received analgesia. Children with the highest pain scores as assessed by nursing staff or using the TPPPS all received analgesia. CONCLUSIONS: The pain scale appears suitable for use in young children in A&E departments. The subsequent management of pain in young children could be improved.     

Pain in young children attending an accident and emergency department

Objectives—To assess pain in young children presenting to an accident and emergency (A&E) department. To evaluate the use of the toddler-preschooler postoperative pain scale (TPPPS) and the use of analgesia in these children.     

The Patient's Charter: views of patients attending an inner-city accident and emergency department.

We conducted a prospective study of patient's understanding of the Patient's Charter. Every patient attending the Accident and Emergency (A&E) Department of St Bartholomew's Hospital over a 7-day period was questioned by an interviewer. Those not interviewed by this process were sent a postal questionnaire. A total of 584 patients attended during the study period, from whom 451 data sets were collected, a response rate of 77%. Only 51 patients were aware of The Patient's Charter guarantee of 'immediate assessment'. When asked what they understood by 'immediate', 67% of respondents considered this to mean 15 min or longer. Fifty-four per cent of respondents felt that this assessment should be performed by a nurse. A follow-up study conducted over a 48-h period in January 1994 showed no significant difference in the responses to the same questions. We conclude that the vast majority of patients in this study exhibited a very low level of awareness regarding the guarantees of The Patient's Charter. We also note that their interpretation of the term 'initial assessment' is at variance with that expressed by the NHS Chief Executive in a widely circulated document.     

Prevalence of human immunodeficiency virus risk factors in patients attending an accident and emergency department.

The prevalence of human immunodeficiency virus (HIV) risk factors was evaluated by questionnaire survey in 1565 consecutive patients who attended an adult A&E department in Brisbane over a 2-month period. The survey revealed that a total of 144 (9.2%) patients could be considered at risk of HIV infection (high-risk group) because of known seropositivity, admission to HIV high-risk factors or engaging in high-risk activities. The remaining 1421 patients who did not acknowledge any high-risk behaviour were classified as an 'unknown-risk' group. More than 70% of the HIV high-risk patient group were under the age of 30 years. A total of 275 (17.6%) patients presented with open wounds and/or needed hospitalization (23 [1.5%] high-risk patients). Of the 490 respondents who engaged in short term sexual relationships, 310 (63.3%) practised unprotected coitus, 32 of these including four seropositives were classified in the high-risk group. The patients were asked if they were in favour of an HIV testing service at their local A&E department; 1324 (86.6%) were in agreement 121 of whom were in the high-risk group. There was no significant difference (chi 2 = 0.093: P greater than 0.7) in opinion between the 'unknown risk' and high-risk patient groups on this matter.     

急诊胸痛患者心理状态及临床特征研究

目的：评估急诊胸痛患者的心理状态并分析其临床特征。方法：收集2012-06-2013-06我院主诉急性胸痛的患者301人病例,采用汉密顿焦虑量表（Hamilton Anxiety Rating Scale,HAMA）和汉密顿抑郁量表（Hamilton Depression Rating Scale-17,HAMD-17）评估患者心理状态,比较心源性胸痛（cardiac chest pain,CCP）与非心源性胸痛（non cardiac chest pain,NCCP）的临床特点及胸痛病因。结果：301例入选患者中,155例为CCP（51.5%）,146例为NCCP（48.5%）,并普遍表现为焦虑抑郁,其中CCP组中有肯定焦虑（HAMA〉14分）和肯定抑郁症（HAM D-17〉7分）的发生率分别是NCCP组的1.87倍和2.53倍。结论：CCP患者焦虑及抑郁发生率高,应及时给予心理支持,必要时再给予抗焦虑抑郁的药物干预,对降低心血管事件的发病率和病死率或有重要临床意义。     

Intravenous drug abusers attending an inner city accident and emergency department.

In a 3-month prospective study, intravenous drug abusers represented 1.14% of all new attendances at Glasgow Royal Infirmary. They generated a significant workload and were often difficult to identify. A very high proportion required surgery or other invasive procedures. The clinical and epidemiological characteristics of the patients were often unexpected. The risks to staff and other implications for the A&E department are discussed.