This case involves a middle aged female with no past medical history. She was taken by EHS to an Emergency Room in the state of Nevada, with chest pain/chest burning, diaphoresis, and shortness of breath after riding her bike to work. These symptoms persisted with minimal exertion. The emergency room physician interviewed and examined the patient. The physician conducted an echocardiogram and found no abnormalities. The physician’s final diagnosis was “atypical chest pain” and the patient was discharged home. The patient’s symptoms continued, and she presented to her family medicine physician. The PCP told the patient to immediately go to the Emergency Room where she was again worked up for chest pain. The patient was sent for a cardiac stress test. During the early stages of the test, the patient began to have weak pulses, abnormal rhythm, and agonal breathing. Shortly thereafter, she went into ventricular fibrillation and collapsed. ACLS protocols were initiated, however, the patient expired a short time later.
Question(s) For Expert Witness
- 1. What is the proper workup for chest pain in the ED?
- 2. Is an echocardiogram adequate to rule out unstable angina?
- 3. Was it possible the initial presentation could have been a missed MI?
Expert Witness Response E-000615
It seems hard to believe that someone would come to the Emergency Room with excruciating chest pain, shortness of breath and sweating and receive only an echocardiogram. The appropriate workup for such a patient would be to place the patient on a telemetry monitor, gain IV access, start oxygen, obtain an electrocardiogram, order a complete blood count, metabolic panel, cardiac enzymes, in particular troponin I, and a portable chest x-ray. If the first round of tests are negative and the patient is asymptomatic, then the next step is to order a second set of cardiac enzymes and electrocardiogram 2-6 hours later. If the patient is still symptomatic, she requires cardiac consultation and/or admission. An echocardiogram is not part of the standard of care workup for chest pain unless certain conditions are suspected, such as a pericardial effusion, constrictive paricarditis, ruptured valve, or other less common conditions. Usually, an echocardiogram is ordered after admission.
Expert Witness Response E-001278
When someone comes into the Emergency Room with chest pain usually we get EKG, Chest Xray, CBC, Metabolic panel, CK-MB, troponin, PT, PTT, INR, D-Dimer, BNP and admit for observation for serial cardiac emzymes. An echocardiogram would likely not be the best choice to rule out and unstable angina. An echocardiogram would be an unusual choice as well because it primarily measures the ejection fraction and ventricular wall motions. It is possible that the initial presentation could have been a missed MI, but I don’t know if the patient had any cardiac enzymes ordered and reviewed.