Chest pain radiating to the back

[suckstobeme]

Do you guys scan pretty much everyone with chest pain radiating to the back?

---

Members don't see this ad.

 

[Colbert]

As a blanket statement, no. Aortic dissection is an often looked for, rarely found diagnosis. It unfortunately has a huge morbidity. That said, the HPI is really important to me.

 

[dotcb]

Always consider it, rarely/occasionally do it.

 

[tkim]

Had a case last year. Tearing back pain, hypertensive. It was almost textbook.

 

[suckstobeme]

As a blanket statement, no. Aortic dissection is an often looked for, rarely found diagnosis. It unfortunately has a huge morbidity. That said, the HPI is really important to me.

What do you feel are the key points on the HPI that increase/decrease the risk of dissection? I mean I usually put in a sentence on my chest pain pt's that I think the risk of dissection is low because of atypical history, narrow mediastinum, normal pulses exam, yada yada... but none of that is any good at ruling in/out the disease.

I've only diagnosed 3 dissections. One had a decent story- tearing chest pain to the back- but the other 2 were "incidental" findings on CT r/o PE studies.

 

[Arcan57]

What do you feel are the key points on the HPI that increase/decrease the risk of dissection? I mean I usually put in a sentence on my chest pain pt's that I think the risk of dissection is low because of atypical history, narrow mediastinum, normal pulses exam, yada yada... but none of that is any good at ruling in/out the disease.

I've only diagnosed 3 dissections. One had a decent story- tearing chest pain to the back- but the other 2 were "incidental" findings on CT r/o PE studies.

I'm not sure the history is terribly helpful except in textbook cases (family hx, connective tissue disorders, pregnant, vocaine abuse). That bring said in my n=6 I've never seen a dissection that looked ok. They tend to look ill and something inside is screaming that there is something wrong with the patient. I'm about 50/50 on whether AD was on the top of the differential going into the scanner.

 

[ORL10]

The IRAD data base can give you some idea (although it is subject to spectrum bias because all of these people HAD aortic dissections) about complaints and findings that suggest aortic dissection.

I agree with Arcan having rotated through a busy CT surgery ICU as a regional referral center almost NONE of the type A's looked well. Type B's might have looked a little better, but still unrelenting pain was the common theme in all of them.

Had a 65 yo with left sided facial droop and slurred speech 1 hr prior to arrival, went to CT no hemorrhage, but we started a new protocol getting CTA's on many of our stroke codes (part of an ongoing study) and caught a massive dissection extending into the carotid. Had I not done the CTA he definitely would have gotten tPA.

In the end probably should be standard of care to miss these, rather than as a rule getting CTA's on all well appearing people with chest pain radiating to the back.

 

[Hair Police]

What do you feel are the key points on the HPI that increase/decrease the risk of dissection? I mean I usually put in a sentence on my chest pain pt's that I think the risk of dissection is low because of atypical history, narrow mediastinum, normal pulses exam, yada yada... but none of that is any good at ruling in/out the disease.

http://http://circ.ahajournals.org/content/121/13/e266.full.pdfI've only diagnosed 3 dissections. One had a decent story- tearing chest pain to the back- but the other 2 were "incidental" findings on CT r/o PE studies.

The AHA has a well-written guideline on when to pull the trigger on investigating a possible dissection, with low/med/high risk categories. Check page 46.

http://http://circ.ahajournals.org/content/121/13/e266.full.pdf

Also google "IRAD," there's a good review from the Lancet and the rational clinical exam series:

http://http://circ.ahajournals.org/content/121/13/e266.full.pdf

http://jama.jamanetwork.com/article.aspx?articleid=194885