 Good afternoon, everyone. Welcome to this webinar. Myself Dr. Sushant Chabra. I'm the head of Emergency Medicine Department, Manipal Hospital, New Delhi. I, along with me, I have Dr. Colonel Amal Vera, who is the head of the radiology department. Today, we both are here. First of all, we would like to apologize for being late. It was some technical error, but we really want to apologize. Today's topic for webinar would be approach towards acute chest pain patient who presents you an emergency department. What are the pitfalls and what is a diagnostic dilemma? So we'll be covering this seminar into two parts. First part, I'll be talking about clinical aspects. That is, what patient, what are the complaints with a patient might come in? How would, what are the differential diagnosis or the red flag diagnosis, which you need to think of, of a patient coming to the ER with acute chest pain. And Dr. Vera will be talking about the diagnostic part of chest pain. So starting, I'll go ahead. So just quickly, the epidemiology. Yeah, so approximately seven to eight million visits annually in the ED patients come in with chest pain. So you can see that this is one of the most common complaints a patient comes in with ER. It is also, you can say, one of the most challenging strain on the healthcare delivery system. And more than one half of the huge number of the patient, patient presenting with chest pain discomfort have noncardia cost. So what for an emergency physician, it becomes a dilemma that whether you can discharge this chest pain patient safely to the home or you need to admit. And also there are, there are studies which have shown that there is a miss in the diagnosis. And you might discharge thinking that the patient is a low risk chest pain. And it turns out to be having a major cause of chest pain, which could be life threatening. So in another 15 minutes, I'll make you go through that when you are in an emergency in an emergency physician, what are the red diagnosis of the red flag diagnostic or the life threat diagnosis, which you should always keep in your mind. And that you should rule out first, other than thinking of the non urgent causes or non-emergent causes. Challenges faced as an emergency physician, chest pain being one of the highest risk chief complaints you will see in emergency department setting. Accurate diagnosing the etiology of acute chest pain emergency response is very difficult because neither the quality nor the intensity of the pain is specific to any organ or diagnosis. Chief complaints may vary from abdominal pain or the patient might have a back pain or a shoulder pain. Furthermore, presentation varies significantly even amongst the most common life threatening diseases. Failure to accurately diagnose these patients may have significant ramifications because patients with acute myocardial infarction, mistakenly we discharge from the ED, have almost double the risk of mortality compared to those who are hospitalized. And also when you are evaluating such chest pain patient, the patient might be there with you for more than four hours. So our goal standard in my hospital, which I follow is that within four hours we discharge or admit the patient. So it could be that the patient might be there for more than four hours and it could lead to ED over-crowding. So these are the normal challenges as an emergency physician I face when I approach a chest pain patient. Objective of this entire webinar, which I told you initially that described the initial actions which you need to take when you have a chest pain patient, important critical diagnosis which you need to rule out first and the approach you should have towards such when a patient you have many or thinking of these particular diagnosis. Recognize that classic symptoms may or may not be present and that serial biomarkers with prolonged observation may be required. And use the clinical decision rules to diagnose and to eliminate the life threatening diagnosis. So these are the common seven life-threatening diagnosis which I always keep in my mind whenever I approach a chest pain patient. Acute coronary symptom syndrome which includes ST elevation MI, non-ST elevation MI, unstable angina, aortic dissection, cardiac tympanart, esophageal rupture, pulmonary embolism, pneumonia and hemothorax. Because if I see if I rule out these seven life-threatening causes keeping in mind whenever I approach a chest pain patient the likelihood of patient having any further or a life-threatening cause completely gets ruled out. So this is the thing you should always keep in mind and always try to rule these out one by one whenever you approach. This could be ruled out through some through basic history taking, clinical examination and the diagnostic techniques which I'll be discussing in the coming slides. Initial actions and primary survey describe the initial actions taken from higher patient with chest pain, less critical diagnosis to recognize a classic symptom which I already told you. So initial actions and primary survey, so whenever I approach a chest pain patient I think always that chest pain is a team sport. So it's not just unknown the physician who can take care of patient presenting, it's also the nursing team or it could be another colleague who's there because a patient might come up in an odd hour in the night where your clinical discharge goes down because obviously it's the odd hour of the night. There a colleague might help you out. So it's always a team sport. So whatever the simple approach what I do is follow an ABC approach. Whenever a chest pain patient comes to me I first straight away I follow a simple thing, IV O2 and monitor. So I ask my staff to put an IV cannula, connect the patient to oxygen if he is hypoxic on initial vital sign and also connect the patient to monitor. This is the basic things which I follow and the ABC approach that is airway breathing and circulation, this helps me quickly address the problems and also help could help me getting me a diagnosis at a very initial stage. So also if a patient is extreme chest pain I always prefer attaching the patient's chest with the cardioversion pads thinking that he might require a synchronized cardioversion or he might require a defibrillation if he crashes in front of me. Also ABC approach I'll come in the next slide that what exactly airway patient might have a impending threatening airway or he might have a patent airway. So simple way to assess is you can just have a quick award with the patient. If he's able to talk that means his airway is patent, his cerebral perforation is intact and that's why he will talk or the simple airway manoeuvres which you can do bedside you can just do a jaw thrust or a chin lift. You can put a nasopharyngeal airway if a patient is unconscious, you can sorry semi-conscious you can put up an oral airway or you can put up a lma or a retriculum inhibition. So this is a step by step things which we look into. By breathing what we need to do is we can quickly check the patients you can see the obviously see if a patient is breathing heavily. First thing as I said earlier IVO2 and monitor you can connect him to the oxygen by face mask then you can just use your stethoscope to to ascultate his chest which could definitely tell you a lot many things he might have visas he might have a crepitation he might be in heart failure or you can putting a chest stethoscope anterior you can ascultate his heart sounds you can get some kind of murmur a plural rub or you can always hear a S3 or a sound which would be S3 gallop which would be there in heart failure patients. So breathing you can address by putting the patient on simple oxygen devices like a face mask nasal canola if that doesn't help you can go into a non breathing mask and if that still doesn't help you can put the big bypass operation on bypass you can either do directly on bypass that's entirely on a clinical distribution what you see if bypass order doesn't help then back mass ventilation and followed by endotracheal intubation and mechanical ventilation. Circulation quickly assessed by blood pressure pulse you can do you can see his peripheries if it is cold then it indicates towards the patient having going into failure quick if the if you I will discuss the quick bedside use of point of care ultrasound you can see if his heart's pumping action is okay you can give him some 20 30 ml per kg of crystallite obviously you have to be very be very sure that his heart function is okay his kidney from he doesn't have a chronic kidney disease before pushing in such a big bolus of fluid if the patient throw secrecy or monitor if he is having a VT with a pulse you can give a meander on diagnosing or you can do a cardio version depending upon whether it's a stable VT or a stable depending upon whether it's an unstable tachycardia or deep evolution if he's in a cardiac arrest so that's a this ABC approach helps me quickly address the issues then and there then coming on to the presentation in patients with high risk chief company the worst diagnosis should be considered first which I told you always uh what uh once then whenever I'm talking to the patient I take a quick history from the patient and specifically I go into details of the history when I'm approaching an elderly patient with chest pain because elderly patients important thing is that they might be they might not have a classic book presentation they might come with some weird complaints of lethargy or they might come come with some weird complaints of this being couple of episodes of vomiting or some stomach pain so specifically when you are approaching with elderly patients you have to think all you have to go into details of the history what drugs they are on what past medical history they have did they have any uh preceding illnesses or any uh uh issues in last two three days or in couple of months they have they are they being disneyed uh whenever you are taking history simultaneously you can ask your nursing staff to get a 12 dcd summit if you will that's quickly simultaneously will be able to uh uh come to a diagnosis history I told you onset duration progression aggravating and relieving factors nature the addition of the pain is very important because if you are thinking of dissection it could be radiating towards black or the patient might present with inter scapular pain also or I have a dissection patients we have seen that the patient presents with flank pain so radiation of pain is also very important severity of pain and limitation of usual activity so the acs patient generally what what the book say represent with chest pain or weakness nausea and fatigue and clinical examination finding he might say that he had along with chest pain he might be sitting in a room with air conditioner on he had uh excessive sweating so that's one of the important things which would always catch he might be looking ill or sick to you or on auscultation he might have rails of repetitions pulmonary embolism it's always one of the diagnosis of exclusion which you should always think of a chest pain because such patients might crash within minutes if they have a massive pulmonary embolism typically they give you a history of periodic type chest pain that is chest pain or more on inspiration then you can always use the the perk rule or the wealth criteria to rule out pulmonary embolism so that criteria I'll be discussing in the coming slides clinical examination he might have tachycardia he might be clear to auscultation he might have unilateral leg swelling which might indicate a dvd so whenever you examine a patient you should do a head to toe examination that is why it is important and for p quickly what you can do is you can do a blood gas bedside to the patient which might indicate hypoxia also ecg the classical s1 q3 d3 is not always seen in the ecg sinus tachycardia is what normally see aortic dissection another important diagnosis which is life threatening and which might kill the patient within minutes might be he might be dissecting in past few hours before presenting to five so a patient a couple of months back and dr berah helped me out diagnosing but because we had shifted so that patient had presented he was a hypertensive he had severe ripping pain in one of his legs and he had paracetia and weakness not able to move in left leg so initially we thought of because his pulses were not palpable on peripheral neuro vascular examination of the lower limbs so we initially thought that he might have any acute thrombus which is there he was a chronic spoker so though we got the patient shifted for a CT peripheral angiogram and when the die went up we could diagnose the aortic dissection so again as I said a peripheral pain a flank pain patient suddenly having panacea or paralysis which he was normal absolute normal couple of hours back you should always think of aortic dissection best clinical way to examine you can see will see unequal blood pressure so whenever you are thinking of dissection make sure you check blood pressure in both the arms you will always see you always check all the pulse in both the arms and also in the lower limbs and plus you might have neurological deficit which we had in that patient tension hemothorax the patient commonly has a history that he might have a history of COPD he might be a chronic spoker and this time his acute excisceration might not be the way it used to be so there would be a rupture of Goulet which has led to tension hemothorax so always oscillate the chest and clinically a hypoxic patient will be always irritable so whenever you are suspecting hemothorax and the patient is hypotensive you should do a quick bedside point of their ultrasound you can look for the status we are saying and that could help you diagnose it and the bedside treatment you can do a needle for epitomy and followed by a chest tube insertion key examination features a patient would be hypotensive unequal bed sounds and they would be a critical deviation so always look for that esophageal rupture this is a very rare diagnosis but a patient typically gives a history that after violent vomiting he started to develop severe chest pain in this you have to early involve the surgical specialty if you are thinking of that because again this leads to a quick crashing of the patient crashes quickly and he will not give you much time and this patient needs to be taken to the OR immediately for the repair so whenever you are suspecting this diagnosis a quick bedside x-ray but will tell you media stenitis whitening media stenum and also involve your GI surgeon as soon as possible pericarditis, tympanart, backstriad what we normally follow, muffled heart sound, distended neck veins, patient being hypotensive so again quick point of their ultrasound putting and looking for pericardial effusion and tympanart resulting from that could help you do a bedside pericardial synthesis and could help to save the patient so ECG is a basic and you should always do irrespective even for an abdominal patient so this is a golden rule that follow even in young patients who have who have a history of smoking a pain abdomen patient, epigastric pain patient I always ask my team members to do a ECG it's simply non-invasive it's very cheap investigation but it can help you get you a quick diagnosis so stemmy is all the ACSH we are which we are commonly looking for but other things could also be diagnosed for ECG and make sure it is done within 5 to 10 minutes of patient arriving in your ER whenever you have a chest pain patient you should be triaged to the red area of the ER unless it just proves that that chest pain is because of the non-emergent cost so in this ECG you can see ST elevation and then again other ECG which is ventricular tachycardia so this would be definitely a patient presenting with palpitations or chest pain and he would be conscious that's why we were able to capture this again the not a single ECG is always diagnostic patient might be in initial phases of his ACS so he might have a normal ECG and if you have a high suspicion you can you should always ask for serial ECGs that is after every 15 minutes or 30 minutes so this is the the progress the how the ECG starts this is a normal then you have hyperacute T waves then followed by ST elevation then you have appearance of Q waves then the ST elevation improves and this is the T wave which normalizes so Stanley you diagnosed by ST elevation in two or more contingencies pericarditis diffuse ST elevation PR depressions and I'll show you the ECG in the next slide cardiac temponade diminished QRS complexes electric alternates cardiac temponade or pericardial effusion you have very low voltage complexes so it's very classical whenever you see a low voltage complex is an ECG always think of pericardial effusion pulmonary embolism the book says classical book picture is S1 Q33 but I have seen in very one or two patients in my last 10 to 12 years of ER experience so sinus cardiac cardiac is most commonly seen and also right heart string pattern again this is the ECG indicating different leads which indicates a different arteries which might be involved lateral leads which includes one ABLB 5E6 if they have ST elevation at point toward LCS LCS lateral circumflex left circumflex artery blockage inferior leads 2 3 in alias it could be RCA or left circumflex depending upon which is dominant anterior or septal leads LED which is the most common artery which is involved this is the ECG of I was talking about this pericarditis diffuse ST elevation and PR depression always think of that again this is a very good tool which we normally use in our ER quickly diagnose the patients cardiac ultrasound would give you quickly give you the regional mall motion abnormality which points toward ACS or it could show us the pericardial effusion also the lung and truss on bedside can tell you about the nemothorax it's it's more sensitive than a chest x-ray and obviously in a busy ER it's very difficult to call the radiology department and get a bedside x-ray so this is a co-finding of one of our patients you can see a massive pericardial effusion the chest x-ray of tension nemothorax and also you can see a pneumomedia spinum so in this obviously this patient might not be this this was not from our setup side from the image gallery so this patient so always a tension nemothorax is a clinical diagnosis then you are in a dilemma you should always you can do a bedside ultrasound because that will quickly tell you and confirm your if you have any doubt and do the management accordingly this is one of the cases where you can see the media widening media spinum another important test which we do is the biomarkers and the de-dimer the cardiac enzymes which in an emergency setup which we use but the limitation with this enzymes is that they arise or that they level start rising after a particular time period so if the patient might come to you in a very early stage he might be scared he just have a history of half an hour of chest pain presence to you might send cardiac enzymes and still they come out to be negative and you might think that he doesn't have any acute he might not be having ACS so that's wrong so in the later part in coming slides I will be discussing about the heart store which we normally use in our patients to differentiate that what are the low risk patients or the high risk patients troponin i it's generally on set is 3 to 12 hours between 8 to 24 hours and it's normal or they are raised up to 10 days and ck total and mv again 3 to 12 hours 8 to 24 hours a peak and their maximum duration till the time they are in the blood their levels are high 78 to 48 hours so cpk mv and high sensitivity troponin i is what we do again as I said we'll be testing at the time 0 and 3 hours in use in clinical pathways such as heart score i'll be discussing in the coming slides this is a common rule pulmonary embolism rule out criteria this i use for my to rule out pulmonary embolism i'll not go into much into details of this this is a very important tool which is used worldwide and go globally in the er's that's called heart score that includes history ecg age of the patient risk factors and hl troponin you don't need to mug it up you have apps these days you can just open up and you can select the criteria accordingly and you can see what's the scoring of the patient so lowest patient with heart score 0 to 3 may be discharged with follow up with low probability of major cardiac event so basically this score helps you detect a probability of 30 days to a major cardiac event by that i mean that the patient having cardiac arrest or he's having a mi a high risk patient with heart score 3 to 5 should be admitted for provocative testing and observation in the hospital or in the observation unit or of a heights for patient has a heart score of more than five probably for more cardiology consultation admission to the hospital so generally in my set up in patient is having a heart score of 3 to 5 we call the cardiologist and get him admitted treatment i'll just quickly summarize because we will not be going into all the details acs patient or a semi patient you load the patient with anti platelets aspirin you can also give him a heparin preferred dual anti platelets at the time of presentation also give a statin definitive treatment you call announce supports tell me and you call the cardiologist and the patient is shifted for PCI primary PCI pulmonary embolism we have normalized one patient in our setup to the strong uvp normally use a place for thrombolysis aortic dissection there are two types of data would be discussing on the details the type a which requires a surgery for type a and for medical managers for type b for er what you can do is you should definitely control bp and bp control in this only patient use of target to be pure on 120 80 and never plow ivy or a small grip would be idle tension emotorax bedside needle decompression followed by chest tube insertion esophageal rupture quick addressing of the airway breathing and circulation broad spec antibiotics and quickly involving the surgical specialty the GI surgeons so that the patient would be shifted toward pericarditis temponad again address the airway breathing circulation ivy fluids and pericardial synthesis ultrasound guided if required and definitive treatment if your patient is stable you can shift him to cath lab for a fluoroscopic guided insertion of a pigtail catheter pulse and this is my last slide pulse and pitfall if the EKG is not diagnostic a secondary survey focus on key teachers of light setting chest pain movement needed keep a broad differential initially always don't keep a tunnel vision important again I repeat and I keep telling my team members also that think of the worst diagnosis for rule out being an emergency condition rule them out first and then go on to the non-emergent causes try to formulate a systematic differential using a system that you uh such as part common atypical rare and don't miss the reassess ABC specifically as a patient status may change at any moment do not rely on a normal EKG and a normal component to rule out up to the correlation from they are not sensitive enough clinical decision rules can be helpful in to guide this position thank you this is one of the favorite quotes I use the good physician treats the disease that is great patient treats the patient who has a disease thank you this is my email id you can email me if you have any questions or you can tweet me and now I hand over the thing to dr berat who will be discussing about the diagnostic part thank you so some for your very very elaborative description and critical picture of this a good chest pain in the ID and their treatment part now I'll cover the imaging aspect of the uh good chest pain emergency particularly about some life-threatening conditions chest pain accounts for approximately 7.6 million annual visits to emergency department in united states making chest pain the second most common complaint most challenging strain on our in health care delivery system more than one half of the huge number of patients presenting with chest pains have known cardiac leak causes cardiac hospital cause may be present in up to 20 percent of patients presenting with chest pain but majority of these patients are up low risk only 5.5 percent of these patients have an acute life-threatening conditions failure to accurately diagnose these patients may have significant termifications any acute myocardial infarction percent mistakenly discharge from ED have almost double the risk of mortality compared to compared those who are hospitalized problem assessment of all patients who present to the emergency department with chest pain is costly and associated with ED overcrowding so need to have their uh quickly diagnosed and disposed of so the principal objective in evaluation of chest and presence in emergency department is rectified for accurate diagnosis and proper restructurization as per the international regulation more than two percent failure to diagnose is somehow not acceptable apart from the various causes we have to identify the most life-threatening causes they includes acute coronary syndrome where an unstable engineer non-strain over the strain in your mind next is acute erotics in rooms there were three components acute dissections acute intramural hematoma or ulcerating atherosclerosis of fear dangerous third is the pulmonary injury fourth is tension nematode 6 is cardiac tamponade and 7 is medial stanitis a spatial rupture or other organ infections so one by one i go through all different aspects how they can be diagnosed properly in the emergency for that i go i think about the usual care protocols and what is the mbct best protocol in usual care protocol diagnostic protocol what we do in the emergency standard chest x-ray blood enzymes components whatever they are ecg stress test stress scope electrocardiogram emp e nuclear provision imaging spec fb i diagnostic in your acceptance to reach a diagnosis about the biggest life-threatening conditions what is the mbct best protocols here we overcome all these things after the initial ecg those who are glorious patients are subject to mbct protocol of course those who are high risk they are on their um st leaders are subjected to catholic in mbct is gaining ground in the fast non-vegetable chest pain screening tool for hospital emergency rooms and chest pain centers quickly screen low and medium risk doesn't rule out coronary disease as well as other clinical condition that causes immediate threat to the life so what is the role of mbct in acute chest pain mbct is gaining ground with non-vegetable and effective chest pain screening tool mbct best screening protocol can help cut healthcare costs and cut using the real care protocol mbc is ideal at chest pain center of emergency department to quickly screen low and medium risk process to rule out coronary artery disease because it's at very high negative rate value of 99 to 100 percent as well as other clinical conditions that cause an immediate threat to the life mbct best protocol has proven to be cost effective with higher diagnostic yield compared to ideal care protocol in the ed in chest pain patients two recent randomized trials to support the effectiveness of mbct best protocols in the clinical chest pains so i vote these two there are a lot of other protocols and otherwise the trials but these two are very very initial trials and are quite supportive in favor of mbct best protocol the first one is acute chest trial acute CT trial this was compared with the conventional testing protocols but this is a coronary CT n diagram perfect for self discharge of patients with possible approved coronary syndrome part of the study demonstrated coronary CT n diagram in lower to intermediate risk process is safe with similar patient outcomes when compared to currently available standard of care strategy the conventional testing protocol so what are the results coronary CT has faster trials in ed compared to conventional plus in the term of higher rate of discharge here with the mbct best protocol we are able to discharge 49.6 percent patients compared to 22.7 percent with the easier protocol shorter stay so certain length of stay in the emergency here we have only 18 hours stay in the emergency department versus 24.8 hours in the conventional testing protocol higher rate of detection of coronary treated is here with 9 percent compared to 3.5 percent this is a study report so this gives a faster discharge shorter stay better diagnostic aid and at the same time ER costs are reduced because your stay in the ER has come down tremendously from 24 to 18 hours but does not apply to intermediate to high risk percent this has been trying to lower risk patients this is published in journal of where you do have 2012 you can see next is CT state trial this is mbct protocol higher compared to the spec MRI based MPI based protocol for the study demonstrated lower risk patients were randomized to treatment higher coronary CT and you were best protocol and spec MPI best protocol and followed up over a period of six months the result are CT based protocol where diagnosed 54 percent faster than spec MPI best protocol cost 38 percent less than the spec MPI best protocols no difference in major adverse cardiac treatments in each diagnostic strategy at 30 days is the landmark and lower radiation in coronary CT protocol protocols compared to mbct MPI best protocol here the 11.5 million cereals versus 12.5 million cereals in the MPI best protocol that the result is coronary CT angiogram based protocol is faster more accurate and less costly than spec MPI best protocol in the evaluation of acute lower risk chest pain in the emergency department this is also published in our medical college of cardiology so based on this various protocol I propose a simple protocol in the lower risk ECG without st elevation subject to the mbct protocol pathological isn't found admit if no reason so possibly they'll be normal so you can discharge and those who are st elevation should go to the catholic what is good to rule out protocol here you can see instead of giving a small focal area for the heart here we do a wide coverage about the entire chest the upper abdomen so that lung fields heart everything can be covered you adjust the injection time so that coronary vessels as your primary vessels are classified at the time of stairs so you can see the coronary vessels you can see the entire aorta you can see the pulmonary vessels at the same time you can see the lung fields for pneumothorax as well as the medicinal contents so this is a basic advantage we repeat test and we are regularly with the accident result so let's see the various conditions let's go to the acute coronary syndrome coronary vascular disease remains the leading killer of adults in level of countries SCAC is believed to be caused by atherosclerotic blood rupture this is a vulnerable play so cardiac risk factors are poor predictors of acute events in a symptomatic presence and absence of cardiac risk factor does not identify presence that can safely be discharged from the ID we have seen from very a person without having that identified factors what have got coronary disease management of acute coronary syndrome is determined largely by severe BCE and serum enzymes and dramatically increase the sensitivity for detecting SCS compared to only clinical assessment in SPMI patients MBC evaluation of coronary artery is helpful in early at dispossession of chest and presence with suspected non-SPMI SCS with negative serum enzymes they will talk only so this is coronary CT and you were on part one of the patient who had STMI, delievation, blood pressure, cath and you are not done due to COVID scenario so SCT and you what we see we have got the detailed I'll give one why is that a very short type one LED with almost distal LED completely blocked with black then we have got our D2 proximal D2 we have got this is the LED distal LED multiple soft black with luminal obliteration my ideal vision this is the D2 proximal D2 has got black almost clearly luminal and have a this is a left luminal vascular cordon so distal NCX has got some blacks and in the my ideal view you can see there is a transneural hypodensity on the back so this we can demonstrate in CT and after for the output MI this is a very very critical patient came to the ID with chest pain but somehow asked for the coronary CT and give the coronary CT and what we see there is a LED block there is a LCX block there yeah uh RCA block all three major vessels are mostly limited soft packing this is the globe view you can see the plaque in the LCX you can see the proximal LED the LCX you can see the plaque in the RAD all type of vessels so ultimately patient was sent to 44 for the management this is one of our colleague in the hospital she has utilized it quite active but non-medical very often for chest pain after exertion she was hypertensive on the management only she asked me what I want to do my coronary but I'm getting very frequent chest pain whenever I do for exertion what we could see there is a anomalous origin of RCA which between the aorta and pulmonary trunc and this is somehow compressed and possibly this is a part for exertional pain and tachycardia and pulpitations this is another one of the vessels uh not classical chest pain but having chest discomfort and tiredness after working for sometimes so we basically you can see no calcium in zero but there is a proximal LED almost moderate within a level with concentrated man so definitely CTE NGO is very good result of this presentation now let's go to the acute coronary erotic syndrome acute erotic syndrome comprises several life-threatening erotic conditions it includes erotic dissection, intramural hemorrhage and pancreatic atherosclerotic ulcer main number 40 years with hypertension and those younger than 40 years with morphine syndromes or barteris pediatrics are at higher risk characteristic symptoms include very tabra concept of chest pain usually described as shock, tearing or ripping pain may radiate neck, back or abdomen depending on location of the erotic damage CTE angiography usually the diagnostic test of choice although PE or MRI can be used depending on present characteristics and facility capabilities dissection typically behaves with a tear in the inner layer of the erotone erotic valve, intima, aligned blood to track between the intima and media and property downwards the vestal erotone so there are two basically two types of you can say that different two classification one is stanford there is stanford A and stanford B second person is divaki stanford says once erotic root is involved this is stanford A stanford B is the star root if the dissection start the star root left subtly one after another but diva divaki has got three type one type two type three type one is starting from the erotic root and go up to the range of 40 rota or 116 whereas type two is only limited to the ascending erota and type three is distal dissection beyond the subtly range of tree this is the characteristic schematic example from type one starting from the erotic root going along the entire left subtly of this red part is the false woman this white one is the true woman so false woman is always larger in the true woman and in the meantime they can involve the neck vessels and compress they can replace the visceral vessels renal artery spleen category and even cause one of the ideal vessels compromise and completely partial defect is the type one with erotic erotic root can resume you can see involving the enumerator tree going to that and coming down to the some of the renal artery so this is also type one dissection is going to be the type two erotic vessels is involving the left common keratin artery as well as right side common earlier cut it down to the opposite because the false woman is almost possibly compressing and blocking the right side this is a type two distal to the left subtly renal artery and going down this is all of the case where we can see the type one dissection involving the enumerator tree and coming down and involving extending up to the common area of the artery but here celiac axis this is the small one the true woman false woman is larger one so celiac axis involved and here the renal left renal artery is coming from the false woman so these are the potential reasons for the perfusion to the kidney as a human this is a type two dissection very known followed up case of erotic arthritis you can see the common keratin left we are completely narrowed so suddenly one day came with a severe chest pain due to the angiogram you see the type two dissection extending up to the distal apica so this is the common cause of the common for this particular dissection but this is a case very very interesting case as in time to the ear there is severe chest pain the chest x-ray was done found where the moderate right urology done so had a thoracic surgeon encouraged to put a icd placed here but after icd placement they found only blood is coming out so they contracted us for a CTN diagram and CTN diagram what we see there is a type two dissection from the distal arc large also but there is a leaking and regime going to the right side pulmonary space not the left side that is very very uncommon maybe the erotic leaking erotic dissection go to the left left side but here the right side pulmonary space and this one and conservatively by placing a stand uh blocking the entry side see another patients again type two dissection and this is a case with intra pulmonary hematoma you see there is a hyper dense blood linear blood along the left posterior claspid and this is the intima which is calcified outside the intima so this is intra pulmonary they are causing a severe pain or here this white club with the decision bound but now the different entity is another same case with intra pulmonary hematoma very different you can see from the left posterior there is a hyper dense blood in angiogram this is outside the argument this is intra pulmonary put intra pulmonary hematoma this is again you see the ulcerating plaques a thermotas flux this is descending here at all the multi a thermotas changes will be as multiple a thermotas plaques ulcerating plaques and going to the sub pulmonary spaces that is a subset of locations so these are also very very painful they can rupture and cause here at rest of it uh this is a very very unusual case not fitting the requirement but worth mentioning this is a middle-aged lady had undergone a everything ball replacement mom mom pair suddenly developed chest pain and hemoptysis like outside deli but she was immediately limited from Lucknow to deli because she's lady has undergone ABR at deli hospitals i was there we did a city chest and they had a x-ray was done where they had said that paratracheal mass may be in carcinoma that was all right so i did a city scale but what to my heart it was nothing it was a pseudo on region large pseudo on region arising from the electric rent at the ABR site so this was life threatening so this percent was somehow managed very very early way i see how this was managed overnight by putting a emplacer device a sd block a device which was placed there you can see is the sd device and it was actually corrected by our endovascular cardiologist so nice case to learn about the incidence of permolubilism is estimated about one in one thousand patients and the mortality rates vary widely based upon formal good conscience and the size of the ambulance early diagnosis and treatment reduce modality for a large hemorrhagic and unstable pulmonary hemorrhage pulmonary hemorrhage occurs when a dislodged venous clot migrates through the right side of the heart and becomes lost at the branch point of the pulmonary artery that is not settled from us or more distally in lower segmental branches occlusion of pulmonary blood flow results in pulmonary hypertension wide ventricular dysfunction, poor gas exchange and ultimately very timely function pulmonary cp angiogram helps to lock eyes from us in the pulmonary artery and help assess the severity for appropriate treatment planning so cp angiogram is generally put in the management called pulmonary embolism this is the case of pulmonary angiogram revealed right side pulmonary tree almost okay but left side lower lower branch totally up to there this is a large sedent from us in the bi-colonial point next you see left side lower lower branch completely blocked and right side is also partially blocked so this is a this severe form of formal embolism this is another case also formal embolism right side lower lower branch totally up to there left side of the sedent partially seen so there is a infar a peripheral sub-colonial point sedentary opacity say pulmonary my pulmonary heart or this indicates a pulmonary infar this is also pulmonary embolism having settled from us bi-lateral blood loss opacity this can be also presented feature in pulmonary embolism and for nemothorax nemothorax can occur following promo or interventional procedures primary nemothorax and also occurs spontaneously present with underlying lung disease like CO2D 65 doses bronchiolasma PCP nemia step nemina ATC this is known as secondary nemothorax accumulation of air in the pulmonary space can lead to tension nemothorax with compression of medias tenom causing rapid clinical deterioration and death if undecognized so this is a serious condition tension nemothorax is considered as medical emergency and its early detection helps institution of elective life-saving thalapathy measures now CXR is capable of detecting tension nemothorax and this it is more effective to for diagnosis as you are identifying pathologicalism to assist in thalapathy planning so this is the x-ray of various form of nemothorax this is a careful nemothorax because the midline is straight to the left side the heart in normal position possibly the retrospective heart is from the lung this is another nemothorax completely collapsed right lung midline see we are left side there is a nemothorax for mild medial senile see and here there is a complete these are the x-ray of various form of nemothorax but how does cp help ct apart from the nemothorax they can see the lung condition whether they are partially collapsed or not collapsed and the location these are two different partially collapsed here they see down their partially collapsed or medial senile see to the right they are on the right side again right lung completely collapsed in medial senile see those various form of nemothorax and very well recognize the ct and as you already are seeing here that's the cardiac tamponade cardiac tamponade occurs when there is accumulation of pericardial fluid under pressure leading to embay our cardiac feeling tamponade may occur with a rotubi section atop for a siploma or age a consequence of acute pericarditis from infection, malignancy, urea or some other cause tamponade covers a spectrum of clinical severity ranging from mild compromise to severe compromise cardiac feeling producing a picture resembling cardiogenic shock cardiac tamponade requires immediate reduction in pericardial pressure by pericardial synthesis as light remeasure mdcp is an effective measuring tool for accurate assessment of pericardial diffusion slash cardiac tamponade as well as high-defying etopacillical factor these are the extremes of various severity of pericardial diffusion when tamponade is the model to see as a very severe pericardial decline classical class occurrence this is again ct you can see what there is a pericardial diffusion as well as there is a pericardial thickening possibly this is a factor which is not learned hard to expand out this is a model to see the amount of pericardial diffusion because of tamponade so we can see the severity in ct better than the access those is the demodestinal x-ray you can do steps for cardiac care for most of them but security benefits say here in the city apart from the pericardial or medistinal infeasema you can see the x-ray to the chest wall as well as the neck every extension so ct gives much better inner view compared to the x-ray medistinitis common cause of medicine include ontogenic infections, esophageal perforation and hydrogen complication of cardiac surgery for upper gastrointestinal and heroin procedures mortality for patients with medistinal case remains high 40 to 42 percent very high even when treated with operative development and antibiotics delaying diagnosis further increase mortality so this condition needs very early diagnosis for appropriate therapy mbc to provide excellent depictions of pathological processes related to medistinitis as well as health treatment planning so this is a and this is a very very useful ingredient in medistinitis this is the x-ray you see a super medistinal wardening is now a special appearance giving idea that there is something inside and here in the ct scan you see the end of super medistinal there is an abscess cavity this was second to third operation this is a you see the sorry we are ngt we are there is a large retrovestite collection with the upfield legal especially this is a abscess deleted to esophageal part this is a you see the pathogenization of trachea will can be as well as the genuomaniastana this is also ct you can see the extending to the oral spaces here again we have got a pericardial region thick enhancing pericardium so possibly this is a a high end conditions giving like to medistinitis so thank you everybody for listening