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Chest Pain, Emergency Medicine

Basics

Description

- Pleuritic pain: - Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface - Pain increased by breathing, laughing, coughing, sneezing - Tenderness to palpation may be present. - Diaphragmatic pleurisy: - Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement

- Chest wall pain: - Inflammation of skin and SC structures of the chest wall - Pain is reproduced by: - Palpation - Horizontal flexion of the arms - Extension of the neck - Vertical pressure on the head

- Pleuritic pain: - Pulmonary embolism - Pneumothorax - Pneumonia - Costochondritis

- Diaphragmatic pleurisy: - Splenic rupture - Hepatic injury - Subdiaphragmatic abscess

- Aortic dissection: - Sudden onset of pain with maximal intensity early - Tearing pain - Radiation to back and/or flank - HTN - Diastolic murmur of aortic insufficiency - Difference in upper-extremity pulses - Syncope - Nausea - Vomiting - Associated neurologic changes (i.e., visual changes)

- Pneumothorax: - Pleuritic pain - Shortness of breath - Anxiety - Tachypnea - Decreased unilateral breath sounds - Can be spontaneous (young), or associated with very minor trauma (elderly)

- The history is the most important tool to distinguish between the various etiologies. - Have the patient define the key features: - Duration - Location: - Retrosternal - Subxiphoid - Diffuse

- Frequency: - Constant - Intermittent - Sudden vs. delayed onset

- Lab testing should be individualized to the patient and the presentation, based on the risk of potential life threats. - See "Cardiac Testing."Ł - d-Dimer: - Sensitive but poor specificity for physical exam - Indicated for low-risk patient if there is an indication to rule out pulmonary embolus - Controversial use as a screening test for aortic dissection

- CXR: - Pneumothorax - Pneumonia - CHF - Aortic dissection: - Widened mediastinum seen in ~55-62% of patients - A pleural effusion is found in ~20% of patients. - Apical capping - Aortic knob obliteration - A normal chest radiograph is found in 12-15% of patients.

- US: - Test of choice for pericardial and valvular disease - Transesophageal Echo can be used in diagnosis of aortic dissection, especially in unstable patients and those unable to tolerate contrast. - Right ventricular dilation and hypokinesia is suggestive for pulmonary embolus and can be used to guide therapy - Bedside transthoracic Echo can be used to quickly discover significant pericardial effusion, pneumothorax, and pleural effusion

- Therapeutic interventions should be guided by the patients presentation, risk factors, and past history. - If a cardiac life threat is suspected: - IV access - Cardiac monitoring - EKG - Oxygen - Baby aspirin/Full aspirin - Pain control:

  • One of the most frequent chief complaints in the ED
  • Often the presenting symptom of a high-risk etiology:Acute coronary syndromePulmonary embolismAortic dissection
  • Assume life threatening until proven otherwise.
  • Categorization may suggest the underlying etiology, but the presentation of chest pain can be extremely variable and vague.
  • Thoracic pain:May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagusPain is deep, visceral, and poorly localized.Characteristics vary from severe and crushing to mild, burning, or indigestion.
  • Epigastric pain:May involve the descending aorta, diaphragmatic muscles, gallbladder, pancreas, duodenum, and stomachPain is generally referred to the xiphoid region and in the back.
  • Pleuritic pain:Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surfacePain increased by breathing, laughing, coughing, sneezingTenderness to palpation may be present.Diaphragmatic pleurisy:Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement
  • Chest wall pain:Inflammation of skin and SC structures of the chest wallPain is reproduced by:PalpationHorizontal flexion of the armsExtension of the neckVertical pressure on the head

Etiology

  • Thoracic:Acute coronary syndromePericarditisMyocarditisStress-induced cardiomyopathyCardiac syndrome XStimulant useThoracic aortic dissectionEsophagitisEsophageal spasmGERDEsophageal hyperalgesiaAbnormal motility patterns and achalasiaEsophageal rupture and mediastinitis
  • Epigastric:Dissection of the descending aortaPeptic ulcer diseasePancreatitisCholecystitisSplenic ruptureHepatic injurySubdiaphragmatic abscess
  • Pleuritic pain:Pulmonary embolismPneumothoraxPneumoniaCostochondritis
  • Diaphragmatic pleurisy:Splenic ruptureHepatic injurySubdiaphragmatic abscess
  • Esophageal rupture
  • Intercostal myositis
  • Intercostal neuralgia
  • Pectoralis minor strain
  • Pericarditis
  • Pleuritis
  • Pneumonitis
  • Rib fractures
  • Acute chest syndrome of sickle cell
  • Chest wall twinge syndrome:Brief episodes of sharp anterior chest pain lasting 30 sec-3 min, aggravated by deep breathing and relieved by shallow respirations
  • Chest wall pain:Chest wall hematomaChest wall lacerationHerpes zosterThrombophlebitis of the thoracoepigastric veinXiphisternal arthritisAdiposis dolorosaBreast abscess, fibroadenosis, carcinoma

Diagnosis

Signs and Symptoms

  • Coronary artery disease:PressureSqueezing painRadiation to arm, jawShortness of breathDiaphoresisNauseaVomitingWeaknessFatigue especially in women or elderlySigns of CHFAnxiety
  • Aortic dissection:Sudden onset of pain with maximal intensity earlyTearing painRadiation to back and/or flankHTNDiastolic murmur of aortic insufficiencyDifference in upper-extremity pulsesSyncopeNauseaVomitingAssociated neurologic changes (i.e., visual changes)
  • Pulmonary embolism:Pleuritic painShortness of breathAnxietyDiaphoresisTachypneaTachycardiaLow-grade feverSyncopeLocalized ralesWheezing
  • Acute pericarditis:Substernal painVaries with respirationIncreased with recumbencyRelieved by leaning forwardAnxietyAnorexiaFeverPericardial friction rub
  • Pneumothorax:Pleuritic painShortness of breathAnxietyTachypneaDecreased unilateral breath soundsCan be spontaneous (young), or associated with very minor trauma (elderly)

History

  • The history is the most important tool to distinguish between the various etiologies.
  • Have the patient define the key features:DurationLocation:RetrosternalSubxiphoidDiffuseFrequency:ConstantIntermittentSudden vs. delayed onsetPrecipitating factors:ExertionStressFoodRespirationMovementTiming:Context of onset of pain (i.e., at rest, exertional)Duration of painQuality:BurningSqueezingDullSharpTearingHeavyAssociated symptoms:Shortness of breathDiaphoresisNauseaVomitingJaw painBack painRadiationPalpitationsSyncopeFeverWeakness: Generalized vs. focalFatigue

Physical Exam

  • Cardiac exam for murmurs, rub, decreased heart sounds, or extra heart sounds
  • Chest exam for decreased breath sounds, rales, wheezing
  • Extremity exam for decreased pulses, pulsus paradoxus
  • Skin exam for lesions of herpes zoster
  • Abdominal exam for tenderness, rebound, guarding

Diagnosis Tests & Interpretation

EKG: á

  • Inexpensive and available
  • Obtain and interpret within 10 min of arrival
  • Serial EKG can be useful in patients with high concern for ACS and a negative initial EKG.
  • See specific etiologies.

Lab

  • Lab testing should be individualized to the patient and the presentation, based on the risk of potential life threats.
  • See "Cardiac Testing."Ł
  • d-Dimer:Sensitive but poor specificity for physical examIndicated for low-risk patient if there is an indication to rule out pulmonary embolusControversial use as a screening test for aortic dissection

Imaging

  • CXR:PneumothoraxPneumoniaCHFAortic dissection:Widened mediastinum seen in ~55-62% of patientsA pleural effusion is found in ~20% of patients.Apical cappingAortic knob obliterationA normal chest radiograph is found in 12-15% of patients.Acute pericarditis:Usually normal unless massive effusion enlarges cardiac silhouetteEsophageal rupture:Usually will show mediastinal airMay have left pleural effusion
  • Helical CT scan:Pulmonary embolismSensitive for aortic dissection
  • Ventilation/perfusion scan:Useful in pulmonary embolusMust have normal CXR
  • Angiography:Pulmonary embolism; although rarely doneUseful in dissection, especially in stable patients
  • US:Test of choice for pericardial and valvular diseaseTransesophageal Echo can be used in diagnosis of aortic dissection, especially in unstable patients and those unable to tolerate contrast.Right ventricular dilation and hypokinesia is suggestive for pulmonary embolus and can be used to guide therapyBedside transthoracic Echo can be used to quickly discover significant pericardial effusion, pneumothorax, and pleural effusion

Differential Diagnosis

See "Etiology."Ł á

Treatment

Pre-Hospital

  • Therapeutic interventions should be guided by the patients presentation, risk factors, and past history.
  • If a cardiac life threat is suspected:IV accessCardiac monitoringEKGOxygenBaby aspirin/Full aspirinPain control:

Initial Stabilization/Therapy

As guided by the patients presentation: á

  • ABCs
  • IV
  • Oxygen
  • Cardiac monitoring

Ed Treatment/Procedures

  • IV, oxygen, and monitoring
  • EKG
  • Treatment varies based on suspected etiologies.

Medication

Dependant on etiology á

Follow-Up

Disposition

Admission Criteria

Dependent on the risk for life-threatening cardiopulmonary etiologies á

Discharge Criteria

Safe if patient is deemed to have low-risk etiology of chest pain á

Issues for Referral

Follow-up with primary care physician on low-risk chest pain for outpatient assessment á

Followup Recommendations

Patient should be instructed to return if: á

  • Chest discomfort lasts >5 min
  • Chest discomfort gets worse in any way
  • History of angina, and discomfort not relieved by usual medicines
  • Shortness of breath, sweats, dizziness, vomiting, or nausea with chest pain or chest discomfort
  • Chest discomfort moves into your arm, neck, back, jaw, or stomach

Pearls and Pitfalls

  • Caution in only ordering a single biomarker
  • Using response to medications as a diagnostic tool
  • Not using serial EKG in patients with suspected ACS or repeating EKGs when patients have recurrent chest pain

Additional Reading

  • Anderson áJL, Adams áCD, Antman áEM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(18): e426-e579.
  • Body áR, Carley áS, Wibberley áC, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010; 81(3):281-286.
  • Courtney áDM, Kline áJA, Kabrhel áC, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4): 307-315.
  • Hoffmann áU, Truong áQA, Schoenfeld áDA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Eng J Med. 2012;367(4):299-308.
  • Upadhye áS, Schiff áK. Acute aortic dissection in the emergency department: diagnostic challenges and evidence-based management. Emerg Med Clin North Am. 2012;30(2):307.

Codes

ICD9

  • 786.50 Chest pain, unspecified
  • 786.51 Precordial pain
  • 786.59 Other chest pain
  • 786.52 Painful respiration
  • 786.5 Chest pain

ICD10

  • R07.2 Precordial pain
  • R07.9 Chest pain, unspecified
  • R07.89 Other chest pain
  • R07.1 Chest pain on breathing
  • R07.81 Pleurodynia
  • R07.82 Intercostal pain
  • R07.8 Other chest pain

SNOMED

  • 29857009 Chest pain (finding)
  • 102587001 Acute chest pain
  • 426396005 cardiac chest pain (finding)
  • 274668005 non-cardiac chest pain (finding)
  • 281245003 Musculoskeletal chest pain (finding)
  • 3368006 Dull chest pain (finding)
  • 59139008 Crushing chest pain (finding)