Approach to the Patient With Chest Pain

Eric J Milie D.O.

Objectives

Establish a differential diagnosis for the patient with chest pain

Recognize clues in the history and physical exam to rule in or rule out various etiologies of chest pain

Outline a basic treatment strategy for the treatment of a patient’s chest pain

General

Rule out most medically critical causes of chest pain first

General appearance of the patient Look through the chart Good history

Differential

Ischemia or infarction PE Pneumothorax Pericarditis Tamponade Pneumonia Aortic Dissection GERD Shingles Musculoskeletal

Myocardial Infarction/ Ischemia: History Pressure type pain (elephant on chest) Central to left sided pain, radiation to jaw Worse with activity, relieved with rest Relief with nitro Nausea, diaphoresis, syncope, SOB Enquire about risk factors: HTN, hyperlipid,

diabetes, previous cardiac history, smoker, family history, etc

“Pain within six feet of the chest in a diabetic is an MI until proven otherwise.”

Physical

Appearance: Does the patient look ill? Levine’s sign Hypotension: cardiogenic shock Bradycardia: high grade block Tachycardia: sichemia related

tachyarrhythmia Increased JVD, palpable liver, peripheral

edema: Right sided heart failure Crackles, S3: left sided failure

Levine’s Sign

80% sensitive, but only 51% specific

Investigations

EKG: Should be knee jerk response to any chest pain, SOB, etc

CXR: Rule out heart failure, anatomical cause for pain

Cardiac enzymes: Not always initially positive. CKMB will begin to rise within 6 hours, elevated for 48 hours, troponin rises within 12 hours, elevated for two weeks

Treatment

Morphine Oxygen Nitro Aspirin Lasix (if failure) Inotropes (if shock) Streptokinase, TPA, Retaplase, or Integrillin if

EKG criteria met (discuss with attending) Anticoagulate (heparin)

Pulmonary Embolus

Sudden onset of sharp chest pain Worse with inspiration Anxious patient, sense of “impending doom” Risk factors: immobilization, venous

insufficiency, trauma, known DVT, pregnancy, malignancy, clotting disorder

PE: Physical

Anxious Tachycardia, tachypnea, hypoxia Hypotension and syncope possible Look for unilateral calf swelling

Investigations

ABG: ↓PaO2 and PaCO2 CXR: Frequently normal EKG: nonspecific ST/T changes or sinus

tachycardia most common (“classic” S1Q3T3 seen in less than 11% of known PE’s)

D-Dimer: Sensitive but not specific; lag time of up to 24 hours here

Spiral CT of the chest: quick, easy with good sensitivity and specificity

Management

Anticoagulate with wt based heparin, TPA only if hemodynamically unstable from large saddle embolus

Supportive treatment with fluids, oxygen Intubate if unable to maintain oxygenation or

patient fatiguing

Pneumothorax: History

Acute pleuritic chest pain or dyspnea Primary pneumo in young, healthy, tall, thin

white males Secondary: procedures (CVP), ruptured bleb

in COPD patient, barotrauma (bagging during code, improper vent settings), or necrotic neumonia/empyema

Physical

Decreased expansion of the chest Hyperresonnant percussion If tension pneumo, may see deviation of

traches and progressive hypotension, decreased cardiac output- emergency

Investigation

Chest x-ray

Management

Watchful waiting for small, asymptomatic pneumo

Chest tube for large, hemodynamically unstable

Emergent: large bore needle to the 2nd intercostal space, midclavicular line