MedMalMonthly: Chest Pain Pearls & Pitfalls
The EKG: 25-40% of malpractice and ACS misdiagnosis in the ED involves EKG interpretation.
- Over-reliance on computer interpretation; the machine will read 0.999 of ST elevation or depression as "non-specific EKG changes".
- Get an old EKG for comparison.
- One EKG begets another EKG - 10% of STEMI's are diagnosed on the second or third EKG.
Misdiagnosis of GERD: Single most common misdiagnosis in cardiac malpractice lawsuits involving missed MI/ACS.
- 20% used the word burning or indigestion to describe their MI.
- Maalox is the most dangerous drug in the Emergency Department - 15% with improvement after Maalox.
Atypical Presentations are Typical Med-Mal Cases:
- Elderly, Females, Diabetics.
- Women tend to present with more symptoms than men and often get an influenza-like illness diagnosis, especially in the winter time.
- Women are more likely to have a false negtive stress test than men, possibly because more likely to have single vessel disease.
- Anginal equivalents: Shortness of breath, neck pain, shoulder pain, jaw pain, arm pain or numbness.
- Know the elements that increase liklihood ratio of ACS:
- Chest pain radiating to bilateral arms or right arm
- Chest pain with exertion
- Chest pain with diaphoresis.
- Chest pain with vomiting.
- Atypical Risk Factors: CKD + HIV + Connective Tissue Disease like RA or Lupus
- Young Patients: Teenagers and young adults can true atherosclerotic myocardial infarctions with the increase in obesity.
- Upper Abdominal Pain: The diaphragm is not a concrete barrier and anything in the upper abdomen can cause chest pain and anything in the chest can cause upper abdominal pain. Have a low threshold to perform an EKG.
Failure to Emergently Consult a Cardiologist or Active the CATH lab for NSTEMI Condtions:
- ACC/AHA Guidelines:
- NSTEMI with intractable ischemic pain not resolving with medications within the first two hours.
- NSTEMI with ischemic EKG who develops acute heart failure.
- NSTEMI with persistent symptoms who develop ventricular arrhythmia.
- Make sure to document consultant's name + time of conversation + conversation + if the consultant will see the patient.
- Validated scoring systems (HEART, ADAPT) have been used to successfully defend med-mal cases.
- Document shared decision making - the patient needs to be aware that there risk is not 0.
- Give the patient time and action specific instructions.