Approach to Chest Pain,Levente Batizy, DO September 15, 2005,Chest Pain,5% of ED visits 5 million pts/yrAccurate diagnosis remains a challenge,Chest Pain,Visceral Often referred Aching, heaviness, discomfort Difficult to localize pain Somatic Sharp, easily localized,Chest Pain Definitions,Acute Chest Pain: Acute - sudden or recent onset (usually within minutes to hours), presenting typically 24 hrs Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch Pain noxious uncomfortable sensation Ache or discomfort,Initial Approach,Triage Chest pain Significant abnormal pulse Abnormal blood pressure Dyspnea These pts need IV, O2, Monitor, ECG,Initial Approach,Evaluation: Airway Breathing Circulation Vital Signs Focused exam Cardiac, pulmonary, vascular,Initial Approach,History: Character of pain Presence of associated symptoms Cardiopulmonary history Pain intensity, 0-10 pain,Initial Approach,Secondary exam: History Quality, radiation/migration, severity, onset, duration, frequency, progression and provoking or relieving factors of pain Risk factors Physical exam Review old records/ekgs,Categorizing Chest Pain,Chest Wall Pain Sharp, Precisely localized Reproducible: Palpation, movement Pleuritic or Respiratory CP Somatic pain, Sharp Worse with breathing/coughing Visceral CP Poorly localized, aching, heaviness,Causes Table 49-1,Chest wall Costosternal synd Costochrondritis Precordial catch synd Slipping Rib Synd Xiphodynia Radicular Synd Intercostal Nerve Fibromyalgia,Pleuritic Pulmonary Embolism Pneumonia Spontaneous pneumo Pericarditis Pleurisy,Causes Table 49-1,3. Visceral Pain: Typical Exertional Angina Atypical Angina Unstable Angina Acute Myocardial Infarction (AMI),Aortic Dissection Pericarditis Esophageal Reflux or spasm Esophageal Rupture Mitral Valve Prolapse,Categorizing Chest Pain Assessment of Risk Factors,CAD: Cigarette Smoking Diabetes Hypertension Hypercholesterolemia Family History,Categorizing Chest Pain Assessment of Risk Factors,Aortic Dissection: Middle Aged Male Hypertension Marfan Syndrome,Categorizing Chest Pain Assessment of Risk Factors,Pulmonary Embolism Hypercoagulable Diathesis Malignancy Recent Immobilization Recent Surgery,Chest pain incidentals ACS,AMI Rare under 30 y/oexcept with cocaine use GI cocktail may cause relief even in AMI Nitroglycerin can cause relief of esophagus spasm, biliary colic, and AMI NSAIDS can be analgesic for all types of pain,Atypical Chest Pain,Dyspnea at rest, DOE Discomfort: shoulder, jaw, arm Nausea, Epigastric pain Lightheadedness, Generalized weakness MS changes Diaphoresis Atypicals usually in DM, females, non-white, elderly, altered MS pts,Differential Dx Acute Coronary Syndrome (ACS),ACS = AMI or Unstable Angina Visceral chest pain pts AMI 15% UA 25-30%,Differential Dx Acute Coronary Syndrome (ACS),ECG is the most useful test Incidence Significant ST elevation = 80% are AMI ST depression/T wave inversion = 20% are AMI No change 20 min, severe Associated Sx: Dyspnea, Diaphoresis, Nausea May even be Reproducible,Differential Dx ACS,Exertional Angina: Episodic pain, 20 min High risk of AMI,Differential Dx ACS,Pulmonary Embolism: Atypical, presenting with any combination of: Chest Pain, Dyspnea, Syncope, Shock, Hypoxia Fever, cough, hemoptosis Pain is often pleural Reproducible with breathing, palpation Classic presentaion: Sharp pain, Dyspnea Tachypnea, tachycardia, hypoxemia,Differential Dx ACS,Aortic Dissection: Risk Factors Atherosclerosis, HTN (uncontrolled), Coarctation of Aorta, Bicuspid Aortic Valve, Aortic Stenosis, Marfan Syn, Ehlers-Danlos Syn, Pregnancy Pain midline Substernal CP, tearing, ripping, searing, radiating to interscapular area Pain Above AND Below Diaphragm Often assoc. with stroke, AMI, limb ischemia,Differential Dx ACS,Spontaneous Pneumothorax: Risks: Sudden Change in barometric pressure Smokers, COPD, Idiopathic Bleb DZ Pain: sudden, sharp, pleuritic chest pain, and dyspnea Dx: Absence of breath sounds ipsilaterally Hyper resonance to percussion CXR Dx simple pneumo,Differential Dx ACS,Esophageal Rupture (Boerhaave Syn): Life-threatening Substernal, sharp CP Sudden onset after forceful vomiting Dyspneic, diaphoretic, and ill-appearing CXR: Normal, SQ air, Pleural Effusions, Pneumothorax, pneumoperitoneum, pneumomediastinum Water Soluble Contrast Study,Differential Dx ACS,Acute Pericarditis: Acute, sharp, severe, constant, substernal CP Radiation to back, neck, shoulders Worse with lying down and inspiration Relief with leaning forward FRICTION RUB EKG: ST segment elev., T wave inversion, or PR depression,