There are three catastrophic blood clots that everybody needs to know. It doesn’t matter what field of medicine you’re in. You need to know these three blood clots like the back of your hand.
What are these clots?
- Heart Attack
- Pulmonary Embolism
Let’s compare and contrast for a second. First and foremost, two of them are emboli and one is a thrombus. Why is this important? Emboli come on quickly. Typically, MI pain doesn’t come on like that; it comes on crescendo-like.
Two are arterial; one is venous. The risk factors for arterial disease are almost completely exclusive from venous disease. There’s a very slight overlap because smoking is a risk factor for both, but overall arterial risk factors are very different than venous risk factors.
Big and Small Clots
There are three catastrophic blood clots: heart attack, stroke and pulmonary embolism. In each category, there are big ones and small ones. If you have a big heart attack, we call it a stemi. If you have a small heart attack, we call it a non-stemi. Big strokes are called CVA and little strokes are TIA.
This is the most important point I have to share with you: there are also two kinds of PEs, big ones and little ones. People miss this, and it’s one way you get burned. I do medical malpractice defense work defending PAs who are being sued. I’m sick of people contacting me, saying, “We have another missed PE. Do you want to look at it?”
There are two different PEs, big ones and small ones. I don’t think we understand the concept. It’s kind of like thoracic dissections. Everyone is pretty comfortable with AAA because they’re more common than a thoracic aneurysm. You might think the pain pattern from a thoracic dissection should be the same as an AAA. It’s not and if you don’t know that, you’re going to get burned. AAA and thoracic aneurysms look different and behave differently. It’s the same thing with big and small PEs.
Nobody misses a big PE. It hits the central circulation and knocks out their pulmonary drive, so they’re really short of breath and their vital signs are drastically off. There aren’t any pain receptors in the lung, so they’re really short of breath, but there’s no pain. Acute onset of shortness of breath with abnormal vital signs is a PE until proven otherwise. Nobody misses these.
We miss small PEs all the time. Why? Because the clot, typically from a DVT, goes in through the heart and hits the lung. With a small PE, vital signs are typically relatively normal because only 2-3% of pulmonary function is in jeopardy. A lot of times, small PEs aren’t tachycardic, hypoxic or even tachypneic.
Pleuritic Chest Pain
When you have someone with Hampton’s hump, they have a wedge-shaped plural density because they have a small inflamed area within their lung. It doesn’t hurt, because the lung has no nerve tissue. But the chest wall is a hotbed of nerves. When the patient takes a shallow breath, there’s no pain at all. But if the patient takes a deep breath, it’s like someone jabbed them with a fork. That’s pleuritic chest pain.
Hold on a second; there’s a caveat here. If I went outside and someone fractured my ribs with a baseball bat, my ribs are going to hurt regardless of breathing. I have broken ribs, so my chest pain is a 5/10, whether I’m breathing or not. It will be worse when I take a breath, no question.
When someone says they have chest pain, you need to listen to what they’re saying. There’s an infinite difference between “It’s worse when I breathe” and “It only hurts when I breathe.” If it’s pleuritic chest pain, something is in the lung touching the pleura every time they breathe. It’s either pneumonia or PE. It’s important to document pleuritic chest pain on your charts. Purely pleuritic chest pain demands you to think about PE. If not, you’ll get burned. I’m sick of getting those medical malpractice cases, because they don’t do well if you don’t pick it up early.
Who’s Your PAPPA?
Anybody who comes in with chest pain, I want you to say, “Who’s Your PAPPA?” This is a pivotal mnemonic that, if you apply it, will save lives. If you precept students, I want you to teach them this.
Here are the five causes of chest pain:
- Acute Coronary Syndrome
- Pulmonary Embolism
- Aorta, or a Thoracic Dissection
You can’t miss these. With every single chest pain you see, these five causes have to be ruled out.
I want to share something that I see people get burned by: the term acute onset. Say I ask a patient, “Was your headache gradual or acute?” They say “It was acute onset.” You have to ask them to clarify, “What do you mean acute?” The patient responds, “It came on over an hour.” That’s not acute; that’s a gradual onset over an hour. If you document an acute headache, you’re asking to be indefensible by a subarachnoid. Acute onset comes on instantaneously. Anything else is gradual onset.
There’s only one acute onset of a headache. That’s a subarachnoid. Tensions, migraines and sinusitis are all gradual. Your first objective with every single headache is asking, “Acute or gradual?” If you write acute headache, you better scan them and do the LP if the scan is negative, or you’re indefensible.
What causes acute onset pain? I understand mnemonics aren’t for everyone, but I’m a mnemonics-driven guy. I used the mnemonic BEST for the four causes of acute onset pain.
- Burst: Something pops, such as a subarachnoid, aneurysm (like an AAA or thoracic dissection) or ovarian cyst.
- Emboli: An ischemic limb because AFib flicked off a clot or a mesenteric ischemia that causes acute onset belly pain. PEs also go here, but keep in mind that small PEs can appear gradually.
- Stone: Kidney stones come on rapidly.
- Torsions: Torsions also come on rapidly.
I need you to be very sensitive about the term pleuritic chest pain. If someone says, “It hurts when I breathe,” you shouldn’t write, “Patient says it hurts when they breathe.” You need to ask for more clarification because if you write down acute, you’re looking at one of these causes of pain. Proceed with caution.
This mnemonic for pulmonary symptoms will also save lives. If anyone has pulmonary symptoms (cough, wheezing, dyspnea exertion, shortness of breath), you do not want to make a HORID mistake. There is no exception to this.
- Heart: Is it cardiac? Could it be CHF? If anybody has a cough, it could be CHF.
- Obstruction: It could be an obstructive phenomenon, some kind of tumor, foreign body, crux or epiglottitis.
- Reactive Airway Disease: That’s asthma and COPD.
- Infectious Disease: Consider pneumonia and bronchitis.
- Death: Death from a PE or pneumothorax.
Between these two mnemonics, PAPPA and HORID, what are the common denominators? Cardiac and PE.