Chest pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Chest pain is discomfort or pain that is felt anywhere along the front of the body between the neck and the upper abdomen.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Aortic dissection
• Myocardial infarction
• Pericardial tamponade
• Pneumothorax
• Pulmonary embolism
• Unstable angina

Common Causes

• Biliary colic
• Costochondritis
• Cocaine induced coronary vasospasm
• Esophageal spasm
• GERD
• Myocardial infarction
• Panic attacks
• Pneumonia
• Stable angina

Click here for the complete list of causes.

Management

Please find below an algorithm that summarizes the approach to chest pain.

Assess EKG

Presence of ST elevation

Absence of ST elevation

❑ Rule out life threatening conditions

Does the patient have both of the following: ❑ There is ST elevation in a limited number of leads that fits the anatomic distribution of a coronary artery (examples would include but are not limited to leads 2,3,F, or Leads v1-v4) ❑ PR depression is absent

❑ Evidence of LBBB

Does the patient have any of the following: ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse) ❑ PR Depression is present ❑ PR elevation in lead aVR is present

STEMI

LBBB

Pericarditis

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation ❑ Pain radiating to the left arm ❑ Elbow pain ❑ Shortness of breath or dyspnea ❑ Nausea and vomiting ❑ Diaphoresis ❑ An elevation of the CK MB enzyme ❑ An elevation of the troponin enzyme ❑ An elevation of the myoglobin

Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation ❑ Pain radiating to the left arm ❑ Elbow pain ❑ Shortness of breath or dyspnea ❑ Nausea and vomiting ❑ Diaphoresis ❑ An elevation of the CK MB enzyme ❑ An elevation of the troponin enzyme ❑ An elevation of the myoglobin

Look for supportive signs and symptoms: ❑ Pleuritic pain ❑ Chest pain that is positional ❑ A viral syndrome ❑ Fever ❑ Cough ❑ A pericardial rub ❑ Presence of tamponade

Look for supportive signs and symptoms: ❑ Back pain ❑ Diminution or absence of pulse ❑ Coma ❑ Altered mental status ❑ CVA ❑ Vagal episode ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive signs and symptoms: ❑ Shortness of breath ❑ Chest pain ❑ Dyspnea ❑ Anxiety ❑ Pleuritic chest pain

Look for supportive signs and symptoms: ❑ Sudden shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Following a medical procedure ❑ Patient on mechanical ventilation

Look for supportive signs and symptoms: ❑ Vomiting ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

References

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