Cardiac Emergencies: Getting to the Heart of the Problem

Abstract

n emergency medicine, counter to most other Isubspecialties, the focus of care is usually centered on management as opposed to diagnosis. The emergency department (ED) provider must ultimately decide on a course of action (treat or not treat; discharge home or admit to the hospital) regardless of whether a diagnosis is made. To help guide this decision-making process, the ED provider often considers 2 different groups of etiologies. First, what are the most common conditions that present with the patient's particular constellation of symptoms, considering a variety of factors including patient age, duration of symptoms, and time of year? At the same time, the ED provider must consider those conditions associated with high morbidity and mortality, even though they may be less common epidemiologically. In basic terms, what could this patient have that might kill him? For example, in the middle of the winter, a 5-yearold who presents with mild respiratory distress and wheezing on physical examination is likely to have asthma or pneumonitis. However, the ED provider should entertain the possibility that this child might have a less common but more serious etiology such as mediastinal mass, aspirated foreign body, or myocarditis. When considering these diagnoses, the provider focuses on critical aspects of the physical examination (eg, presence of asymmetric breath sounds, fever, gallop heart rhythm, hepatomegaly) aided, if necessary, by selected imaging studies and laboratory testing. This information, collected in a focused yet complete manner, allows the provider to weigh the relative risks of possible diagnoses and embark on the most reasonable treatment plan and disposition for the child. Generally, in the evaluation of many common presenting symptoms, the ED provider considers cardiac etiologies as those less common but highmorbidity diseases that should not be missed. In a study of sudden death from cardiac causes in children and young adults, prodromal symptoms were present in about 50% of patients. The most common symptoms were chest pain, syncope, and near syncope. Although these symptoms in children are generally caused by noncardiac disorders, the ED provider needs to know what associated symptoms, medical history, and family history should