EM Reflections – February 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 



Top tips from this month’s rounds:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed



Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)


Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain



  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel



Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine


The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com


Another differential to consider is:


Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.


  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.





Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis


Posterior Nasal Packing – video




  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices





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