(a)Aspiration pneumonia is an inflammation of lung parenchyma pre-
cipitated by foreign material entering the tracheobronchial tree. Alcoholics
are prone to aspiration pneumonia because of ethanol’s sedating effect. This
causes a decrease in the normal protective airway reflexes. Chest radi-
ograph findings are often delayed with atelectasis typically being the first
finding.(b)Alcoholics have a high incidence of pancreatitis and can
present with epigastric tenderness, however they usually don’t have medi-
astinal air on radiography. (c)The physical examination hallmark of acute
pericarditis is the friction rub. The rub may be caused by friction between
inflamed or scarred visceral and parietal pericardium or may result from
friction between the parietal pericardium and adjacent pleura. Aortic dis-
section(e)usually occurs in patients with chronic hypertension or con-
nective tissue disorders. They should not have Hamman sign.
7.The answer is c.(Rosen, pp 1171-1174.)The patient’s clinical picture of
chronic hypertension, acute onset tearing chest pain, diastolic murmur of aor-
tic insufficiency, and chest x-ray with a widened mediastinum is consistent
with an aortic dissection.The preferred study of choice is a transesophageal
echocardiogram (TEE),which is highly sensitive. It can be quickly per-
formed at the bedside and does not require radiation or contrast.
(a)ECG changes that are consistent with an aortic dissection are
ischemic changes, low voltage complexes, and electrical alternans. However,
this is suggestive but not diagnostic. (b)A TTE is limited in diagnosing aortic
dissections because wave transmission is hindered by the overlying sternum.
It can be useful to see pericardial fluid as a result of proximal dissection.
(d)A CT scan is an excellent study with sensitivities that approach TEEs. It is
the study of choice if a TEE is not readily available. However, it requires that
the patient leave the ED and receive IV contrast. (e)A magnetic resonance
image (MRI) has high sensitivity and specificity and has the benefit of identi-
fying an intimal tear. However, the study requires that the patient leave the ED
for an extended period of time. Currently, it is most useful for patients with
chronic dissections.
8.The answer is a.(Tintinalli, p 1077.)Patients with chest pain in the set-
ting of cocaine use should be evaluated for possible myocardial ischemia.
Patients suspected of ACS should be managed accordingly with oxygen,
nitrates, morphine, aspirin, and benzodiazepines; however, β-adrenergic
antagonisttherapy is absolutely contraindicated.Ifβ-adrenergic receptors
are antagonized, α-adrenergic receptors are left unopposed and available
Chest Pain and Cardiac Dysrhythmias Answers 27