Transcript Approach to the Patient With Chest Pain

Approach to the Patient With
Chest Pain
Eric J Milie D.O.
Objectives
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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
General
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Rule out most medically critical causes of
chest pain first
General appearance of the patient
Look through the chart
Good history
Differential
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Ischemia or infarction
PE
Pneumothorax
Pericarditis
Tamponade
Pneumonia
Aortic Dissection
GERD
Shingles
Musculoskeletal
Myocardial Infarction/ Ischemia: History
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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.”
Physical
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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
Levine’s Sign
80% sensitive, but only 51% specific
Investigations
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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
Treatment
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Morphine
Oxygen
Nitro
Aspirin
Lasix (if failure)
Inotropes (if shock)
Streptokinase, TPA, Retaplase, or Integrillin if
EKG criteria met (discuss with attending)
Anticoagulate (heparin)
Pulmonary Embolus
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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
PE: Physical
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Anxious
Tachycardia, tachypnea, hypoxia
Hypotension and syncope possible
Look for unilateral calf swelling
Investigations
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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
Management
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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
Pneumothorax: History
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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
Physical
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Decreased expansion of the chest
Hyperresonnant percussion
If tension pneumo, may see deviation of
traches and progressive hypotension,
decreased cardiac output- emergency
Investigation
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Chest x-ray
Management
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Watchful waiting for small, asymptomatic
pneumo
Chest tube for large, hemodynamically
unstable
Emergent: large bore needle to the 2nd
intercostal space, midclavicular line