Approach to the Patient With Chest Pain

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Approach to the Patient With Chest Pain

• Eric J Milie D.O.

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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 patients chest pain

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General

• Rule out most medically critical causes of chest
  pain first
• General appearance of the patient
• Look through the chart
• Good history

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Differential

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

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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.

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Physical

• Appearance Does the patient look ill?
• Levines 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

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Levines Sign
80 sensitive, but only 51 specific
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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

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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)

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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

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PE Physical

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

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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 PEs)
• 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

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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

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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

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Physical

• Decreased expansion of the chest
• Hyperresonnant percussion
• If tension pneumo, may see deviation of traches
  and progressive hypotension, decreased cardiac
  output- emergency

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Investigation

• Chest x-ray

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Management

• Watchful waiting for small, asymptomatic pneumo
• Chest tube for large, hemodynamically unstable
• Emergent large bore needle to the 2nd
  intercostal space, midclavicular line

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