Resident Readiness General Surgery 1st Ed.

A Patient Who Is Postoperative Day 2 With New-onset Chest Pain

Alden H. Harken, MD and Brian C. George, MD

You are in the middle of running the labs for all of your patients when you get a page. It says: Mr. Roberts is complaining of chest pain.—Pat MacDonald RN, phone 5-1234.

You remember that Mr. Roberts is on the exact other side of the hospital from where you are now. You pull out your cell phone and return the page as you are walking to the elevator. While you are on hold, you look at your list and see that Mr. Roberts is a vasculopath who is postoperative day 2 from a right below-the-knee amputation.

You get the nurse on the phone as you push the button for the elevator.

1. What is your first question to the nurse?

2. What diagnostic tests should you order over the phone?

3. Name 6 causes of chest pain that you must not miss.

CHEST PAIN

With disconcerting frequency you are going to be called to the emergency department, the recovery room (PACU), or the floor to see a patient who claims to have new-onset “chest pain.” Frequently this will be “nothing.” Sometimes it will be “something” and, occasionally, it will be “a really big deal.”

Answers

1. “What are the vital signs?”

This question determines your next response. Based on those vital signs you should initiate any needed supportive measures. Standard supportive measures include giving oxygen and pain control (both of which are protective if the patient is having an MI). If the patient is hypotensive, you should tell the nurse to call a code.

2. As you are going to see the patient, you can get a couple of things going so they will be available as soon as possible. An EKG is mandatory. Unless you are confident that the cause of the chest pain can be explained by some other benign process, you should also order a CXR.

3. In evaluating patients with chest pain, it is useful to relate the likely epidemiological frequency of the problem to (most importantly) How Big A Deal If You

Miss It (HBADIYMI) (see Table 27-1). Note that there are 6 diagnoses with HBADIYMIs of 3+ or higher.

Table 27-1. Causes of Chest Pain

Image

Acute myocardial infarction: In a 60-year-old cigar-chomping male, not only this happens, but also, in the perioperative period, the 30-day mortality increases by an order of magnitude (7% nonsurgical to 70% intraoperative in the Mayo Clinic series). Give an aspirin while obtaining a 12-lead ECG and cardiac enzymes.

Pulmonary embolism: In a 60-year-old patient soon following a pelvic operation for cancer, this is a frequent problem. If the patient is hypotensive, call for help. If the patient is stable, obtain a spiral CT. These studies are now so sensitive that they often pick up tiny PEs that are clinically irrelevant (but this decision is above your pay grade). It is OK to give 5000 U of heparin to a patient more than 48 hours, and lytic agents more than 8 days, following thoracoabdominal surgery.

Aortic dissection: The textbooks state that this presents as intrascapular back pain, but it can present as anterior chest/shoulder pain. The key is that it really hurts. Typically these patients are hypertensive, and urgent therapy includes aggressive blood pressure control. It is important to distinguish between ascending dissections (requires surgical intervention with a pump) and descending dissections (can be tucked away in your ICU with a rightradial arterial line and intravenous antihypertensive drugs). This distinction can usually be made with a TTE or CT angiogram.

Reflux esophagitis: This is surprisingly common in the perioperative period, but it’s OK if you miss it. Give an antacid.

Leaking triple A: This can be tricky because the stakes are high. Traditionally, when a previously hypertensive, elderly male presents with acute low back pain, the diagnosis is a “leaking triple A.” If this patient is hypotensive, he should be taken directly to the operating room. A rapid ultrasound of the abdomen can be very reassuring.

Do obtain a 12-lead ECG. If this patient is really having an acute MI, a midline abdominal incision will likely prove lethal.

Costochondritis: A diagnosis of exclusion, and it’s OK if you miss it. Give antiinflammatory Rx.

Acute cholecystitis: It seems unfair that this can masquerade as chest pain. In a fair/fat/fortyish female, it is more likely than myocardial ischemia. Obtain a RUQ ultrasound.

Pneumonia: This typically doesn’t hurt unless the inflammation extends out to the exquisitely sensitive pleura—then it can hurt a lot. A chest x-ray should confirm the diagnosis.

Tension pneumothorax: This also usually doesn’t hurt and presents as hypotension and tachycardia because the increased intrathoracic pressure decreases venous return—paradoxically, it is a volume problem (not respiratory). Do not wait for a chest x-ray. Obtain vital signs and listen to both sides.

Pneumothorax: Perhaps surprisingly, this can be completely painless. Unless this patient is hemodynamically unstable, there is no urgency. Confirm diagnosis with a chest x-ray.

Cardiac tamponade: This is a very rare cause of acute chest pain. The diagnostic and therapeutic urgency depends entirely on the hemodynamic status of the patient.

TIPS TO REMEMBER

Image You can avoid unnecessary delay by initiating both treatment and the diagnostic workup prior to arriving at the bedside.

Image Acute MI is both common and serious, but you must also not miss PE, aortic dissection, leaking AAA, tension pneumothorax, and cardiac tamponade.

COMPREHENSION QUESTION

1. Which of the following should not be ordered over the phone, before you have seen the patient?

A. Sublingual nitroglycerin

B. EKG

C. CXR

D. Oxygen

Answer

1. A. While nitroglycerin is indicated if there is evidence of myocardial ischemia, you don’t yet know the diagnosis. In that case, nitroglycerin can actually make things worse—for example, in a patient with a tension pneumothorax.