Chest pain resident survival guide

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

Definition

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

Causes

Immediate Life-Threatening Causes

Immediate life-threatening causes are conditions which result in immediate death or disability if left untreated.

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

Other Common Causes

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

Management

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

Check vital signs Stabilize the patient Order an EKG Concise history and physical exam

Assess EKG

EKG consistent with ACS

EKG not consistent with ACS

Order a CXR

STEMI Revascularization

NSTEMI Risk stratification

Pneumothorax

Aortic dissection

No significant findings on CXR

Control BP Obtain a CT scan Emergent surgery consult

Assess the pretest probability for pulmonary embolism

Do's and Don'ts

• If suspecting dissection, transfer to ICU to reduce BP and inotropy with ß–blocker. Arrange for emergent CT scan or echo and call vascular surgery. ECG may show evidence of ischemia in RCA distribution if dissection is proximal.

• If pneumothorax suspected, get CXR and call surgery for chest tube placement. If tension pneumothorax, don’t wait for the CXR! Insert a 14 gauge angiocath into the 2nd intercostal space at the midclavicular line on the side of the pneumothorax.

• If high suspicion for pulmonary embolism, get chest CT with PE protocol or V/Q scan if available. Begin anticoagulation (if there are no contraindications) while you are waiting for the results.

• Be sure to obtain post-pain ECG and document the event.

References

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