Approach to the Patient With Chest Pain

1. Approach to the Patient With Chest Pain Eric J Milie D.O.

2. 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

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

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

5. 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.”

6. 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

7. Levine’s Sign 80% sensitive, but only 51% specific

8. 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

9. 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)

10. 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

11. PE: Physical • Anxious • Tachycardia, tachypnea, hypoxia • Hypotension and syncope possible • Look for unilateral calf swelling

12. 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

13. 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

14. 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

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

16. Investigation • Chest x-ray

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