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] Alejandro Lemor, M.D. [3]

Chest Pain Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnosis Cardiac Non-Cardiac
Treatment
Do's
Don'ts

Overview

Chest pain is define as a discomfort or pain felt anywhere along the front of the body between the neck and the upper abdomen. The main causes of chest pain include diseases of cardiac, pulmonary and gastrointestinal etiology, without underestimating other causes like psychiatric and musculoskeletal conditions. Chest pain is one of the most common complains in the ER and it is extremely important to rule out life-threatening conditions that need to be managed immediately; such as myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. It is important to do a complete description of the chest pain, including the location, intensity, quality, onset, radiation, the alleviating and aggravating factors and the associated symptoms. An EKG is the most important initial test to diagnose or rule out a myocardial infarction. The treatment for chest pain would depend on the etiology

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.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red signify that an urgent management is needed.

Abbreviations:

Identify cardinal findings that increase the pretest probability of life-threatening chest pain ❑ Sudden onset ❑ Severe shortness of breath ❑ Unstable patient ❑ Related to physical exertion

Identify cardinal risk factors of life-threatening chest pain ❑ Age > 45 years ❑ Hypertension ❑ Smoking ❑ History of CAD ❑ Diabetes mellitus ❑ Male gender

Does the patient has the following findings suggestive of acute coronary syndrome (ACS)? ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Associated with: ❑ Diaphoresis ❑ Dyspnea ❑ Nausea or vomiting

YES

NO

❑ Immediately order a 12-lead ECG ❑ Order cardiac enzymes: Troponin, CK-MB

Rule out other life-threatening conditions

Does the ECG has ST elevation?

YES

NO

STEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ PR depression is absent New LBBB ❑ ECG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as STEMI

Unstable angina/NSTEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ Pain last > 10 min

Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR

Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side

Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Widened mediastinum on chest X-ray ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Pulmonary embolism ❑ Sudden onset ofchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer

Esophageal rupture ❑ Vomiting ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food ❑ CXR: Air in the mediastinum or peritoneum

Administer: ❑ Aspirin 162-325 mg ❑ Oxygen (2-4 L/min) if satO2 <90% ❑ Beta blockers (unless contraindicated) ❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses Do not delay primary angioplasty or fibrinolysis Click here for the detailed management for STEMI Click here for the detailed management for NSTEMI

❑ Immediately transfer the patient to ICU ❑ Perform Pericardiocentesis Click here for the detailed management

❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax Click here for the detailed management

❑ Immediately order a TEE to confirm diagnosis ❑ Transfer to a cardio-thoracic unit for surgical management Click here for the detailed management

Click here for the detailed management

❑ Immediately start antibiotic therapy to prevent mediastinitis and sepsis ❑ Surgical repair of the perforation Click here for the detailed management

If none of the above conditions is found, proceed to the complete diagnostic approach below

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: MI: Myocardial infarction; DVT: Deep venous thrombosis; GERD: Gastroesophageal reflux disease; CHD: Coronary heart disease; PE: Pulmonary embolism; COPD: Chronic obstructive pulmonary disease; SLE: Systemic lupus erythematosus; LVH: Left ventricular hypertrophy; ECG: Electrocardiogram; P2: Second heart sound, pulmonary component; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography; HF: Heart failure; CBC: Complete blood count; ABG: Arterial blood gases; JVD: Jugular venous pressure; CXR: Chest X-ray; TB: Tuberculosis; LBBB: Left bundle branch block; STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction;

Characterize the chest pain ❑ Onset (sudden or gradual) ❑ Location (retrosternal, epigastric, chest wall, diffuse) ❑ Type (sharp, pleuritic, heaviness, colicky) ❑ Radiation (shoulder, neck, back) ❑ Duration ❑ Worsened by (activities, position, drugs) ❑ Alleviated by (activities, position, drugs)

Characterize the symptoms Non-specific symptoms ❑ Altered mental status ❑ Shortness of breath ❑ Nausea and vomiting ❑ Dizziness ❑ Syncope ❑ Fatigue ❑ Lethargy Symptoms suggestive of cardiac etiology ❑ Heaviness or crushing sensation (suggestive of myocardial ischemia) ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) ❑ Interscapular pain (suggestive of aortic dissection) ❑ Epigastric pain (suggestive of inferior MI) ❑ Sweating ❑ Palpitations ❑ Pain associated with exertion ❑ Loss of consciousness Symptoms suggestive of pulmonary etiology ❑ Pleuritic pain ❑ Sharp or knife-like ❑ Increases with respiratory movements ❑ Dyspnea ❑ Cough ❑ Hemoptysis ❑ Pain and swelling of lower extremities (suggestive of DVT) ❑ Chills (suggestive of pneumonia) Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colic (suggestive of cholelithiasis) ❑ Epigastric pain ❑ Pain is associated with: ❑ Meals (suggestive of GERD or peptic ulcer) ❑ Medication intake (eg: NSAIDs) ❑ Swallowing ❑ Changes in position ❑ Wakening during night (suggestive of GERD) ❑ Relieved by antacids ❑ Not related to exercise

Inquire about past medical history and risk factors ❑ Previous episodes of chest pain ❑ Cardiovascular disease ❑ Previous MI ❑ DVT ❑ Hypertension ❑ Family history of MI or CHD ❑ Recent medical procedures ❑ CVC (suggestive of pneumothorax) ❑ Bronchoscopy (suggestive of pneumothorax) ❑ Pleural biopsy (suggestive of pneumothorax) ❑ Pulmonary disease ❑ Previous PE ❑ COPD ❑ Asthma ❑ Malignancy ❑ Recent trauma ❑ Psychiatric disorders ❑ Alcohol intake ❑ Smoking ❑ Cocaine use ❑ Methamphetamine use ❑ Hyperlipidemia ❑ Recent surgery (<3 months) ❑ Rheumatoic disorders ❑ SLE ❑ Rheumatoid arthritis

Examine the patient: Vitals ❑ Fever (non-specific) ❑ Heart rate ❑ Tachycardia (non-specific) ❑ Bradycardia ❑ Blood pressure ❑ Narrow pulse pressure (suggestive of aortic stenosis) ❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection) ❑ Tachypnea (non-specific) General appearance ❑ Pale ❑ Diaphoresis ❑ Severe distress Neck ❑ Elevated jugular venous pulse (suggestive of pericarditis) ❑ Kussmaul sign (suggestive of pericarditis) Cardiovascular examination Palpation ❑ Pain on palpation of chest wall (suggestive of costochondritis) ❑ Apical impulse (suggestive of LVH in aortic stenosis) Pulses ❑ Pulsus parvus et tardus (suggestive of aortic stenosis) ❑ Pulsus paradoxus (suggestive of pericarditis) Auscultation ❑ Presence of S3 and/or S4 ❑ Paradoxical splitting of S2 (suggestive of aortic stenosis) ❑ Muffled heart sounds (suggestive of pericarditis) ❑ Pericardial friction rub (suggestive of pericarditis) ❑ Systolic murmur (suggestive of aortic stenosis or hypertrophic cardiomyopathy) ❑ Diastolic murmur (suggestive of aortic dissection Respiratory examination ❑ Shift of the trachea from midline (suggestive of tension pneumothorax) ❑ Hyperresonance over the affected side (suggestive of tension pneumothorax) Auscultation ❑ Absent breath sounds in one hemithorax (suggestive of pneumothorax) ❑ Rales (suggestive of HF or pneumonia) ❑ Wheezing (suggestive of asthma or COPD) ❑ Pleural rub (pleuritis Abdominal examination ❑ Positive Murphy sign (suggestive of acute cholecystitis) ❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer) ❑ Tenderness over the epigastrium (suggestive of gastrointestinal etiology) ❑ Rectal examination that shows occult bleeding (peptic ulcer) Neurological examination ❑ Focal abnormalities (suggestive of stroke due to aortic dissection) ❑ Hemiparesis ❑ Vision loss ❑ Aphasia ❑ Hypertonia Skin ❑ Unilateral vesicular rash located in one or two adjacent dermatomes (suggestive of herpes zoster) ❑ Jaundice (suggestive of acute cholecystitis) ❑ Xanthoma (suggestive of dyslipidemia)

Order labs and tests: ❑ EKG (most important initial test) ❑ Cardiac enzymes (Troponin, CK-MB) In high suspicion of MI, do not delay initial management ❑ CBC ❑ ABG ❑ D-dimer

Order imaging studies According to the suspected etiology ❑ Chest X-ray ❑ Echocardiography

Does the chest pain has any of the following findings suggestive of cardiac etiology? ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Associated with: ❑ Diaphoresis ❑ Dyspnea ❑ Nausea or vomiting

YES

NO

Click here for the cardiac chest pain approach

Click here for the non-cardiac chest pain approach

Cardiac Chest Pain

Click on each disease shown below to see a detail approach for every cause of chest pain.

Does the EKG has ST elevation?

YES

NO

Is the ST elevation specific to an anatomic area? ❑ V1-V2 (Septal) ❑ V3-V4 (Anterior) ❑ V5-V6 (Apical) ❑ I, aVL (Lateral) ❑ II, III, aVF (Inferior)

Does the TTE shows valve or aortic abnormalities?

YES

NO

YES

NO

Consider the following: STEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ CK-MB and Troponin elevation ❑ PR depression is absent New LBBB ❑ EKG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as STEMI

Consider the following: Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR

Consider the following: Aortic stenosis ❑ Systolic ejection murmur with ejection click ❑ Best heard at the upper right sternal border ❑ Bilateral radiation to the carotid arteries ❑ TTE findings of stenosis ❑ Exertional dyspnea ❑ Syncope Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Widened mediastinum on chest X-ray ❑ TEE findings of: ❑ Intimal tear ❑ Aortic regurgitation ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Consider the following: Unstable angina/NSTEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ Elevated cardiac enzymes ❑ Pain last > 10 min Stable angina ❑ Pain described as a heaviness or crushing sensation ❑ Normal value of cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Provoked by exertion or stress ❑ Improves with rest or nitroglycerin

Non-Cardiac Chest Pain

Determine the non-cardiac etiology based on the physical examination and tests findings

Pulmonary

Gastrointestinal

Other

Is the onset sudden?

YES

NO

Consider the following: Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side Asthma exacerbation ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma

Consider the following: Pulmonary hypertension ❑ Dyspnea on exertion ❑ Increased P2 ❑ JVD ❑ Lower extremity edema ❑ History of gradual onset of shortness of breath Bacterial pneumonia ❑ Productive cough ❑ Fever ❑ Dyspnea ❑ New infiltrate on the CXR Pulmonary TB ❑ Cough ❑ Hemoptysis ❑ Night sweats ❑ Weight loss ❑ Cavitary lesion on CXR Pleurisy ❑ Sharp pain associated with inspiration and expiration ❑ Shallow breathing ❑ Look for underlying cause

Consider the following: Pancreatitis ❑ Severe epigastric pain radiating to the back ❑ Nausea and vomiting ❑ Increased levels of amilase or lipase ❑ History of alcohol intake or gallstones Acute cholecystitis ❑ RUQ pain associated with meals ❑ Radiation to right shoulder ❑ Positive Murphy's sign ❑ Nausea and vomiting ❑ Jaundice GERD ❑ Burning sensation from the epigastrium towards the throat ❑ After meals ❑ Duration: minutes to hours Peptic ulcer ❑ Epigastric pain: ❑ Starts 5-15 min after a meal (suggestive of gastric ulcer) ❑ Alleviated by meals (suggestive of duodenal ulcer) ❑ Alleviated by antacids Esophageal spasm ❑ Vomiting ❑ Intermittent lower chest pain ❑ Cervical subcutaneous emphysema ❑ Alcohol excess Mallory-Weiss syndrome ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis

Consider the following: Musculoskeletal pain ❑ Localized pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ History of Rheumatoid arthritis Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ History of immunodepresion or severe stress Psychiatric conditions ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain.
Abbreviations: STEMI: ST elevation myocardial infarction; NSTEMI: Non-ST elevation myocardial infarction; GERD: Gastroesophageal reflux disease

CARDIAC	PULMONARY	GASTROINTESTINAL	OTHER
❑ STEMI/LBBB ❑ NSTEMI/Unstable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome	❑ Musculoskeletal pain: ❑ Costochondritis ❑ Rheumatoid arthritis ❑ Rib fracture ❑ Herpes zoster ❑ Anxiety ❑ Panic disorder

Do's

• 
  

Don'ts

References

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