Emergency Medicine and Chest Pain: Don’t make a lethal, critical mistake!

by John Bielinski Jr, MS, PA-C

Anyone who presents to an Emergency Department with chest symptoms, whether it is chest pain, pressure, shortness of breath, indigestion, cough, you have to ask, “Who is your PAPPA” to assist in finding the proper chest pain diagnosis.  You need to look at them, point to them and say, “Who’s your PAPPA?” PAPPA is a mnemonic for the high-risk, can’t-miss cause of chest pain, that if you miss and they go home, they could die. So, these are the high-risk, can’t-miss causes of chest pain.  If we play the odds, we are obligated to focus our attention toward the acute coronary syndrome.  But, there are other causes of chest pain that are equally as lethal and more elusive.

Trust me when I say that you do not want to come to work and have someone say to you, “Hey, remember that patient you saw the other day”…………because these conversations never end positively, it’s not that they sent you a thank you note. More commonly it is that the patient was admitted to another hospital with something bad, or came back with something bad, or died!

“PAPPA” stands for high-risk, can’t-miss causes of chest pain. The first two, “PA” of “PAPPA” have to do with the heart. The next two, “PP,” have to do with the lungs. And the last “A” is an aneurysm. P is Pericarditis, A is as Acute Coronary Syndrome (or acute myocardial infarction,) P is Pneumothorax, P is Pulmonary Embolism, and A is Aneurysm.

There are two main attack strategies to assess acute chest pain, one is a systematic evaluation, and the other is the emergency assessment by the assessment of cardiac enzymes, the EKG/ECG.  You have to be a master at 12 lead EKG/EKG interpretation.  What are the 6 causes of ST segment elevation?  I cannot stress this enough, and if you have been sleeping through this article, you need to wake up for these points: chest pain is a risky business.  You need a system, to apply 100% of the time in any patient that presents with chest symptoms.  It has to be reproducible and easy to apply.  Ask, “Who’s Your PAPPA”. This works, I swear by it.  Then, you have to be strong at evaluating the 12 lead EKG/ECG.  25% of missed acute myocardial infarctions are directly due to the misinterpretation of the EKG/ECG.  Sharpen you EKG/ECG skills!

See John Bielinski Jr, MS, PA-C cover this topic and more at the GAPA 2018 Summer Conference in Sandestin, FL. Click here for details.

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