Chapters Transcript Video Chest Pain So, um, the topic today is that chest pain in children, um, a topic that can often result in a lot of um stress and anxiety. Um, however, hopefully with um some of the information we'll review, uh, hopefully we'll be able to provide some uh good reassurance to the, to our patients and families that uh things are OK and um do a very reasonable evaluation in terms of providing that reassurance. Uh, I have no disclosures, although I'm always welcome to have any um potential reasons for biases. Uh, the objective there just to review what are the potential chest causes of chest pain and probably more specific, what are the dangerous cardiac related causes of chest pain to which we need to evaluate, um, what are the relative prevalences and specifically what types of past medical history, patient populations in which to be most concerned about. Hopefully, I'll be able to provide some key pieces of information from both the historical and physical exam vantage point that can be helpful in that assessment. Um, there can be many different limiting age groups, so specifically referring to how to tailor our assessments um based on some uh a person's background and their age in terms of uh what would be most effective and what to really look out for. And lastly, I hope to impress upon what is potentially useful, how to maximize the information with the different testing modalities and hopefully impress upon everyone here what is most helpful in that assessment. So, the first few slides, Amelia, a little bit um boring, but just to have a general kind of um landscape in which to, to talk about these things. In terms of non-cardiac ideologies, which tend to be the vast majority of them, the list of what they are are all kind of here. Some of them have very specific names, so for example, precordial catch syndrome has a specific name, although generally speaking, when we say musculoskeletal, we're usually talking somewhere whether we can identify specifically a specific cartilage or a specific muscular area, especially we're talking about outside of the thorax, outside the chest cavity. Then the other ideologies to be to consider, um, particularly given how common it is for uh nowadays for kids to have either asthma or asthma like type of symptomatology, what are the pulmonary kind of causes which tend to be far more common than the uh cardiac causes of chest pain. The reason we worry about as much, and I think one of the reasons why a lot of my colleagues and I are involved is because the cardiac ideologies, although rare, are ones that can be very very concerning, potentially even deadly. Um, these are the ones that are Most concerning, so pericarditis or inflammation of the pericardium or lining around the heart, myocarditis, which in terms of the most concerning and severe form of fullin myocarditis can be very, very, very dangerous. Um, hopefully none of us will ever see a case of aortic dissection in someone under 20 years of age, but it's something to consider and to be thoughtful of. Um, one of the things we probably should also stay very, very mindful of is a tachycardia, tachycardiac arrhythmia, and I'll go over to why that's the case in the latter slides. And then lastly, and probably because it's very, very rare, uh, is to also consider myocardial ischemia and specifically which age or which patient populations to be most uh. Uh, cognizant of are going to be patients who have had a history of Kawasaki syndrome, who have, uh, Williams syndrome, or the one, if they're identified beforehand is whether or not someone has anonymous coronary, uh, with an intraarterial course. To give a bit of a historical background, I think kind of shapes how we should think about this going forward. So, for a very, very long time, and this is just one of the earliest papers I could kind of poll, uh, we've known the vast majority of chest pain in children are Or we either term idiopathic or nonlife threatening, so either they're idiopathic as we can't find etiology, functional anxiety, muscle cell to in terms of how often, even back in the 1980s, where we would find a life threatening or cardiac cause chest pain is really, really quite, quite small. That didn't change too much in the 1990s, so this is a publication for the late 1990s, where the percentages roughly haven't changed much at all, and a lot of the same ideologies are listed here, although just depicted with this um diagram from, from, from this paper. In terms of how frequently we see cardiac causes a chest pain in um in, in the cardiology clinic. Well, we certainly do see quite a few assessments for it, but in terms of how much pathology we see overall. There's 7 pages devoted to this in the um broad textbook for, for pediatric congenital cardiology. That textbook set is 1400 pages. So in terms of how frequently we actually see the pathology, this is how much the editors and authors devoted um for that um consideration. As time progressed from the 80s and 90s, um there was an effort to, an effort to really provide more data and support this to, to support the Gestalt that many of the clinicians had developed over the years. So this study called the SAM study was commissioned by the Children's Hospital in Boston in the 2000s and Really quite a thorough study here and I often refer to this paper when I speak with patients about um a cardiac cause of chest pain, and you can see here what the authors have observed um in their study. So out of over 3000, almost 4, 43,500 and it is kind of quite interesting is, as many of us kind of know the Life's not that straightforward. So, just having chest pain doesn't automatically mean you have one of these conditions. And likewise, having these conditions, whether we're talking about cardiomyopathy or even something as serious as as myocarditis and pulmon embolisms, it doesn't necessarily always cause chest pain. And that's what I thought was pretty interesting about this study here. They actually looked at in the reverse of what the scam study was looking at it like, well, we know these sort of cardiac causes of chest pain. How often do they actually have chest pain, uh, or have patients presenting with chest pain? Um, and one of the take home messages from this slide I thought was really backwardsly reassuring was one of the more common causes of, of, um, or a potential cause of chest pain is pericarditis, and it happens to be one of the ones that's most likely to cause chest pain, which makes sense because the entire pericardium is inflamed, but it's also one of the ones for which I would just automatically start treating patients with anti-inflammatories like a non-steroidal anti-inflammatory. So I found this to be some reassuring as a starting point and then thereafter being able to kind of assess and think through the process about these other ideologies in in that assessment. Uh, next slide. And um just for kind of to bring that slide up, the pericarditis I found to be quite um prevalent. And what was interesting is, and, and I find it interesting, um, mostly just being very specific as a cardiologist because I have so many colleagues who pontificate, worry and keep thinking about coronary abnormalities so often. And yet, It's the minority of them, minority of those patients who present or have chest pain when their coronary artery abnormalities are found. Uh, so next slide. So this was a very interesting study that was done in a Turkish out of a Turkish emergency department and I found it to be very helpful because they had a very methodical approach for looking into patients with chest pain. And, you know, granted, this is a very um biased patient population. And bias, I think in a good way. I mean, this is an emergency department uh uh based study, you know, all these patients came to the emergency department before coming to the pediatricians. So, um, if, uh, if you go to the next slide, it'll, uh, it will, um, Um, emphasize what we've done. So every single patient with 380 patients in the study. So they all got a lot of different tests. So they all got blood work, CBCs, EKGs, chest X-ray, echocardiograms. And so to me it was pretty thorough screenings and in addition to the study, the, a lot of these patients had further assessments with, with the tests that's listed in the paragraph. So the next slide will show us the interesting things, results of the study. So granted, a lot of data here. And what I wanted to bring your attention to is actually the first parts. When we click on that part next, it'll highlight what's really interesting. And that is out of all that information, what I really want you to focus on is 1 out of 380 patients. had a cardiac explanation for chest pain. It was for pericarditis. So, to me, that was really quite, quite reassuring saying, Well this is what we've been telling patients for Decades It is fairly accurate. Your chances of having a cardiac cause of chest pain is quite, quite rare. So next slide will give us a little bit of an explanation. So oftentimes, unfortunately, I do apologize if it's ever me who kind of looks like um Arnold from Kindergarten Cop. Now, the, the famous uh uh uh line from here it's not a tumor, but I think a lot of my colleagues may say it's not the heart. But then one thing I would caution when we click next. when we come to that conclusion, we should be providing that um reassurance that no, we're not missing a case of myocarditis or myoccursche or pulmonary embolism. And the reason we should be doing that is because those things can be potentially deadly and very, very, have very serious uh uh ramifications. Next slide, the next few slides tell us. How we come to that conclusion, when should we be worried about it? Well, in the cases of myocardial ischemia, the patient population I'd be most concerned about will be patients who had Kawasakis, more specifically, Kawasaki with persistent known coronary involvement or perhaps a patient who has a little unusual facial features and you're concerned about Williams syndrome. Those patients can develop coronary stenosis. Uh, the other one to, to not miss, like gosh should not miss is someone who looks like Abraham Lincoln and you're concerned about the possibly Marfin syndrome, erect dissection. So, other context historical attacks that can be helpful is, well, what is the chest pain in relation to exercise? Is it always or reliably provoked by exercise? Well then, OK, that may be a patient I'd be a little bit more concerned about the possibility of an abnormal coronary. If it's something where deep breaths seem to make it a bit worse, then I, or, or, or the pain is worse when they're breathing, then I might be more concerned about either um a pulmonary condition or uh infection or perhaps just chest wall manipulations that happen. Uh, certainly, if, if we palpate and to me, when I say palpation is always, this is one of those. Uh, devils in the details is how we go back to palpation. Sometimes patients are very clear with it. They say anytime I touch here, it hurts, but usually not coming to see us. But then sometimes we have to help them in that assessment and be very precise with our physical exam. Uh, other things that can be either helpful or can help point us in certain directions if particularly younger patients, let's say, uh, an early elementary school patient says, I have a chest pain, but then you ask a little bit further, it's like, no, my heart rate's going kind of fast when this happens, then palpitations may make us more concerned about the possibility of something like SVT. It just mark your shortness of breath with this, then that sometimes can help us identify those patients, um. Sometimes the symptoms are completely opposite. It makes us think like an upper respirator infection, um, and it was like, oh yeah, well, you're coughing a lot of things that makes sense why you would have some chest pain here and there. Uh, the reason I had this next, uh, part there saying family history is sometimes, uh, another family member like a grandparent or otherwise is dealing with their heart issues and that oftentimes raises the anxiety level within the family. Oftentimes in terms of social context. The stressed out I got to be a type A personality. I have to make straight A's. This, this, the, the self-motivator kind of uh person uh or a child oftentimes has non-cardiac chest pain, but sometimes it's helpful to kind of elicit that um uh a history to determine that. So next, I think we'll talk about the physical history of findings. And what I find to be very helpful with patients, particularly if from the get-go I have a high suspicion, this is just musculoskeletal, is really helping provide that reassurance and localize where that pain is. So I go very point by point with fingertip. Precision and go point by point till I find that one spot. And often you'd be surprised how often a patient, it's everywhere in the chest and you go point by point with a fingertip and you can really localize it and say, yeah, this is, you have costochondritis. It's right here on this one spot and oftentimes patients will give you a kind of wincing sign even if they're not actively having the pain. Um, certainly standard, um, uh, other components of physical exam with the, uh, the pulmonary exam, looking for any kind of chest wall deformities. I have facial dysmorphism there just on the possibility of Williams syndrome. You'd be surprised how often sometimes people are coming to the office and we're making the first diagnosis of Williams syndrome. Um, some other things are helpful, are just routine vitals, uh, give us a little bit of a sense of what the background is. Next slides will show us a little bit of what uh we can figure out. Um, so in terms of milk, which should be kind of pretty worrisome, one of the nice things I think about the assessment of chest pain is to stay cognizant that these really, really dangerous potential causes of cardiac chest pain. are usually not in isolation. So if you particularly focus on the right part of the slide, you'll see all the other documented or typically documented findings when someone presents with myocarditis. So, particularly if it's just chest pain and nothing else. It's almost like you were breathing a sigh of relief. So the next slide will tell us about uh pulmonary emboli. So pulmonary embolism like myocarditis, typically it's not just one thing. So these are the patients, they're coming and they're short, hopefully not coming into the outpatient office, but if they're coming into the emergency department, these are the patients who have chest pain and can't catch my right, it hurts so much the type of issue. Uh, if you click next. The other thing I found to be reassuring is looking in terms of risk factors for having a pulmonary embolism. And it's not typically, it's not just out of nowhere. It typically um it's a patient who's a bit heavyset, so it has a very significant BMI or someone who's on oral contraceptive. The other thing that's uh that helps point us in terms of the right direction or to have a higher indexes of suspicion. are going to be either someone who comes in telling us, I've had a PE before, or someone who's come in and said, you know, I've been really, really sick in the past, or my child's been really, really sick of the past, you know, so sick to the fact that, you know, they had a revic, they had a central line, uh, a place, you know, because, uh, for their treatments. So to me, this is pretty helpful to say, OK, when do I have this index of suspicion to kind of work up a PE? Uh, the next slide will tell us about the, uh, risk factors that are associated with it. So it's usually not just one risk factor. Usually there are multiple risk factors that can be involved. But the other thing that can be helpful, particularly in emergency department setting would be to obtain a D dimer. Um, so this is one of those kind of scenarios where if it's positive, yes, this kind of uh uh prompt want to do more of an evaluation and such. However, If one does obtain one and the D-dimer is totally normal, then it kind of gives you a little bit more of a, a brief, uh, a sigh of relief. So the next slide will tell us about the differentiating symptoms. Now granted, this was a slide, a paper from circulation, um, that was more directed towards adults, but just trying to give a little bit of a sense for everyone in terms of what are the differentiating potential symptoms. So in terms of milk car ischemia. It's typically not a dramatic type of thing. And in fact, the more dramatic the chest pain is, the less concerned I am about the cardiac ideology. Uh, case in point, oftentimes the symptoms patients have, or at least adults when they have, or oftentimes when they do have, uh, myocardial ischemia is nausea. It isn't necessarily chest pain. Uh, contrast that to at least what I would consider less concerning thing like paradise, which can be quite painful, which uh can be quite traumatic, um. That, that, that those two different types of pains are very, very different typically. Uh, palmol shares a lot more of the quality of the characters of periss, but the big, big, big deal is differences in the EKGs which are listed on the bottom part of the slide, versus a pulmonary embolism, we have more specific abnormalities and I'll show you a few EKGs here in a little bit where the, uh, Significant finding is abnormalities in terms of the um leads related to the right heart. Pycard, it affects the entire heart, so the entire EKG is abnormal, contrast that to myocard myocardial ischemia. Well, typically it's just either one branch or one portion of the coronary artery. So it's a very, very specific, uh, EKG changes that we will see. So next slide What are the testings that can be helpful? So, Um, this is, is a fairly old old study, but I think a lot of it is bears true even to today. Um, this, these were things done before like the scamp, a Children's Boston study was kind of done and kind of showed what the utility of these are. But the vast majority of times when we do do this assessment. We're not gonna find anything abnormal. For the next slide, it's a little more details in the ensuing slides. Um, troponin levels sometimes can be helpful, particularly if you're very, very suspicious about pericarditis, uh, and, and, uh, uh, pericardial myocarditis, um, but it's also really, really helpful, uh, as you can see from the first part of this, uh, slide here, when it's normal, it's very, very reassuring like, no, we're not concerned about myoitis, we're not concerned about pericarditis and can move on. And then other testing we can do on the next slide. As an EKG. Now, I'm a big fan of doing EKGs. I will fully admit my biases as an electrophysiologist. I like EKGs, I like EKG tracings. That said, one of the things I really, really appreciate with you Gina we'll come back to this later on. Interpreted and used in the, in the correct context and with a reasonably accurate interpretation can give you a lot of information. I'll show you examples of this in the next few slides, but these are the general findings of myocarditis, pericarditis, and tardia rhythms. So myocarditis, we're usually seeing really low amplitudes, oftentimes depending on how severe the cases we are seeing T wave abnormalities. Pericarditis instead of seeing low amplitudes unless we're seeing the case of a pericardial effusion, we're usually seeing diffused SC segment elevations everywhere. Hackards are pretty straightforward in terms of what that EKG will look like. And in terms of myocard scheme we're seeing very localized depending upon which coronary artery is being affected, uh, very localized SC second elevations versus depressions depending upon which specific areas were located at. So the next slide will show us an example of myocarditis. So here you can see that QRS amplitudes are so incredibly low. In fact, they're almost as low as the P waves here, and it's only really the right side of the heart with the right precordial leads V1, B2, B3, where we see any significant uh QRS amplitudes. Next slide will show us an example, another example of someone with myocarditis. So this is a patient I encountered a long, long time ago who had uh a lupus. They, as sometimes adolescents will do is decided, but I don't want to take my meds, and this person stopped taking meds, you see. The incredibly abnormal T wave, we see T wave for is pretty much everywhere. It does, it's almost everywhere is opposite where that QRS complex or or that access is. The next slide should be an example of uh uh pericarditis. And here you can appreciate, uh, diffusely all the different leads here, so not just localized to the uh right recorded leads, but every single lead we're seeing ST segment elevations. The next slide is another, I think another example of pericarditis, and you can see that while we can have reciprocal PR depressions per se, uh, the finding we typically see is uh SC segment elevations everywhere. The next slide should be an unfortunate example, oh, not the pericardis, uh, patient, so you can see a real, real world, real life example of it as well. The next slide should be an example of SVT. You can see this is a narrow complex tachycardia, um, very, very fast. Hopefully, we're suspicious of the possibility before the EKG but and just using it as a confirmation. The next thing should be hopefully something we'll never ever see or or oh sorry, that's the slide after this. So with, um, sometimes the, the, the event is already over. So like I have a little bit of chest soreness. And my heart was beating really, really fast before, but everything's OK now. But then if you do the EKGs every so often, you'll pick up on a patient who has well park and we can say, aha, you probably had SVT and OK, let's, uh, let's get you work, uh, worked up and get you on the right treatment uh for uh for your condition. Next slide, please. So hopefully if they do go to uh have a procedure, this doesn't happen. So this is a patient, uh it it's out of a textbook, so um. Uh, who underwent, uh, uh. Uh, catheter ablation and unfortunately whoever was doing the procedure at the time, uh, uh wound up damaging this person's uh left coronary artery as they were doing the, the ablation. You can see the ST segment elevations in the right, uh the left procorial leads and then you see the really high elevations in the inferior leads and uh accompanied by the ST depression reflectively in the right procorial leads. Next slide. And I think this is an example of someone who uh was born with an anomalous coronary artery. So, The reason I have this here is because these patients typically aren't. Actively having chest pain when they come see us. I mean this is this, this patient's resting uh EKG. You can see there's no IC segment elevations, no T wave inversion, no sign of kind of past heart attack. But for whatever reason is we had this uh suspicion of it and we subjected this patient to an exercise test and the next slide will show us what happens when this patient is uh their cardiac output goes up. And you can see that we have marked changes in the T waves. They invert in the uh left infrarolateral uh pattern accompanied by an elevation in the ST segments in the right cories and by my recollection, this is a patient who had an anomalous right coronary uh that went in between their aura and pulmonary artery. So they had, um, reversible ischemia is I think is what I'm trying to emphasize to everyone, um, listening. Next slide Uh These next few slides, I hope I will impress upon you what is the utility in which context and what the expectations are in terms of doing an echocardium. So this, uh, again, is going back to that Children's house in Boston study, that the SAM study. And the authors had a very methodical manner in which they, uh, uh, trained everyone, OK, this is how we're going to assess for chest pain. These are the conditions, the situations in which we're going to do ABC tests, and this is what they specifically did for echocardiography. And if we click, we'll see kind of what I, I think are, you know, going for the indication to do an echocardiogram. So that should be, if you click, it should say uh highlight chest pain in exercise and peak exercise and exertional synco. So these, these three symptoms in particular would concern me for the possibility of an anomalous coronary. Next slide will show us why While we do need to assess for it, thankfully in clicking will highlight frequency in which we see the abnormalities. Um, so while the offices were very forefront, it showed reported every single finding they had on these echocardiograms. if you click on that one more time, uh, we'll see that it is exceedingly rare. It is in 0.5% of the time where they, where they found an abnormality on the echocardio that explained the cardiac cause of chest pain, even in the context of someone who had classic, unquote classic symptoms for uh myocardial ischemia in terms of exertional chest pain. In fact, One, you can look at the numbers and just do a quick math in your head, you're 15 times more likely to find an incidental abnormality rather than finding an explanation for the patient's chest pain. Next slide will give us some additional data that uh supports us. So there was a publication in the Journal of American Cardiology in terms of what is the appropriate use of uh echocardiography for, for children. And one of the sections that the address was chest pain, and we clicked on, uh, again, we'll highlight what I um what I found very interesting about this paper is that they uh themselves also saw a very similar percentage in terms of the possibility of finding a uh explanation for uh chest pain using an echocardiogram. In fact, the percentage is remarkably very, very similar. Next slide. So the other really wonderful thing from that big study that the, the, those authors produced. is that they followed these patients. Over about 5 years after they were entered into the study. And what was very, very interesting about it, and they included the patients who had cardiac abnormalities that they incidentally found that 1% of the time. And clicking on the next slide will show us something very interesting, is that none of the patients That they checked in afterwards and remember this was Almost 3500 patients. So fairly big study, fairly well done study in terms of numbers. They did not observe any patients in their series who died from any kind of cardiac evaluate uh cardiac condition, whether identified with their routine screens or otherwise. Next slide please. Well, one of the things that can be helpful is an exercise test because we're certainly putting a patient in that context under the most stressful increasing the cardiac output, putting the most demand upon those coronary arteries and upon the heart in those contexts. And oftentimes I will refer patients for exercise testing even if it's just for the reason of like building that confidence among those um patients and family. You're doing OK. Your heart's under the most stressful situation. You're being monitored, as you can see with these pictures here. You've been continuously monitored by two different individuals. You're having continuous EKG monitoring during this time, and thereafter can give them more confidence and, look, I'm not picking up on any types of Ischemia or any abnormalities during this context. And the other reason I think this is a potentially very useful to us is one of the few tests that we can do that's dynamic. So in other words, we see what the response is to uh to exercise and increasing the cardiac output as opposed to some of these other testings, for example, uh, an X-ray or just a rest EKG. We only see that information for that small, small period of time. The next slide. will show, hopefully I'll impress upon you. Now, this process, I will admit, uh, this may be a little outdated. So I recently pulled this information about 10 years ago. And if anything, things are worse. And What's interesting is how much it costs, what are the implications of of the decisions we make. No, an EKG. 80 is still one of the cheapest tests we do, it's still, it's still $85. But some of these other things that we may or may not. Um, choose to do in that assessment and, you know, given the other information and data with those other prior slides, hopefully we'll think twice about utility of doing these different tests and particularly if it's not particularly helpful because We could really go down the rabbit hole quite easily and really, really raise the hospital bill or the, the medical care bill for these patients. And I think we need to ask ourselves, well, to what end and really how, you know, what are we achieving here? So next slide please. To me, the most important thing, knowing all this information, knowing how Concerning how dangerous, how potentially, um, or even potentially lethal chest pain can be and how unlikely percentage that it is, to me, a large part of our goals with assessing chest pain is really providing that reassurance. How do we go about doing that? A lot of it is just details, details, uh, history, detailed physical. Sometimes, uh, it's very helpful depending upon the patients you have, uh, particularly a type A, type of a student or patient. Going through, hey, this is published. We have been looking into this. This is what is the chance of having an abnormality. This is the, you know, actually 99% of the times it's going to be totally fine and totally OK. If, uh, in terms of utility of testing, what I think is high yield to me in terms of a screen, I think an EKG is very reasonable. I think we can get a lot of very good information, particularly um screenings for very dangerous forms or causes of chest pain. Depending upon the frequency, uh, sometimes inventory rhythm monitoring because we get more information besides just the 6 seconds of that EKG. I think exercise testing can be helpful, particularly among the athletes who may have some concerns about their safelines to, uh, to re-engage and participate in their sport. Um, and the reason I have this plus minus and I put, uh, multiple negative signs out, well, I don't think there's, I don't think, um, imaging is never ever indicated. I think it should be very, very rare rarely, um, done. Uh, in terms of medications, Oftentimes, whether we talk of muscular skull, chest pain, or you know, probably worst case is pericarditis, non-sterileal anti-inflammatory medications are going to be a very reasonable first line therapy and the way I would go about it is having patients take it routinely for about a week to kind of maximize that effect. So the next slide will tell us that in many respects, what we're trying to do is help our patients be like Homer Simpson and just being OK with being OK. The next slide, I think. And my conclusions are That It is usually very uh highly um anxiety provoking among um our, our patients and their family members. We had to be totally Uh, forthright with patients and they say sometimes we can't tell them very precisely, hey, this is what's going on. It's great when it, when it does happen when you can say this is costochondritis is this particular cartilage joint. Uh, one of the variations, hopefully I, I've been able to impress upon you is that the cardiac causes, while very dangerous. Are very, very rare. And one of the things I really want to press in and as a take home message is chest pain in children is just like everything else we do in medicine. It's usually not just one thing. It's usually multiple things, so it's putting all this information together and really looking at it holistically. Uh, mortality, thankfully either has that or extremely, extremely extremely extremely rarely ever been reported in this instance. Uh, in, in, in my opinion, I think that unfortunately, uh, despite a lot of reassuring information, reassuring publications in the past, Oh, a decade or decades, um, that we often are going overboard with, with the testing. And so, uh, to me, very old school methods. Good detailed history, very targeted uh physical exam, and I certainly think an EKG is, is appropriate as a screen. Depending on context, and this is where the devil's in the details. Depending on context, yes, some of these other tests can be helpful, but I would uh like to emphasize it in the context is really, really matters greatly, uh, and that we should be, um, targeted in terms of what we kind of go forth and suggest for our patients. With that, I think that's my last slide, so I um I'm happy to take any uh questions and concerns and again I apologize for the uh technical difficulties. um I don't know why my laptop doesn't like Zoom. That's OK. Looks like you have a question and we'll let people uh type other questions in. I'm gonna bring up the QR code for you all to scan um for the survey evaluation and Doctor Lee will take questions. So go ahead and and do that, and please read the question out loud. So the first question is, there is a patient that had sustained a trauma to the chest from a lacrosse ball um two days prior to the visit. And it was localized and it was pretty, pretty moderate pain that was localized to the sternum, just about to the 7th rib, but there's no crepi's no shortness of breath. So the question is whether or not an X-ray is absolutely needed. I think in that particular context, I don't think an X-ray is needed. Perhaps immediately, let's say this patient had the chest pain and there was continued to have shortness of breath and difficulties and we're presenting to the emergency department. I would certainly be very understanding of the emergency. A physician in that context getting one just to make sure they're not missing uh a pneumothorax or, or a pneumonitis as a potential cause. But two days afterwards, I, I think it's unlikely that it will be a uh a particular benefit. Again, it's most, uh, at most, um, from what I kind of wrote in the, uh, concluding uh slides. I think an EKG would be pretty reasonable to then provide that reassurance to the family say, look, we're not seeing any uh issues related to the heart afterwards. Perhaps the most concerning thing in that specific context of, of having taken a blow to the chest will be fairly instantaneous in terms of a specific heart issue will be rare to call commercial cortti, which is where, um, someone sustains a blow to the chest right over the myocardium, um. Right when the patient's uh myocardium is starting to repolarize, so it's like doing an ROT, which is how uh in the procedure when we place the fibrillator, we're trying to cause someone to go into ventricular fibrillation. Those are the kind of patients, you know, if it should happen, it's instantaneous. Within seconds, they're passed out, they have a VF and we're calling the paramedics and doing CPR. That specific for the specific case days afterwards doing the assessment, I don't think an X-ray is absolutely necessary. Great, thank you. We'll give it another minute. If anybody has any questions, please type them in. Um, as I said previously, please fill out the survey for Doctor Lee's talk today to get CME credit. Please do that by May 12th in the morning. Uh, you'll also get an email with the survey link. So if you miss scanning this or the web browser, you can fill it out that way too. Created by
