Chest pain may be the first sign of a medical emergency and needs immediate attention. Always evaluate in person and immediately.
When called about a patient complaining of chest pain ask the following:
Severity, onset, nature, location, quality, and duration of the pain.
Vital signs.
History of cardiovascular disease (myocardial infarction [MI], angina, hypertension [HTN]) and if the pain is similar to past anginal episodes.
Age.
Admitting diagnosis, including toxicology screen results.
Order a stat EKG and vital signs, including blood pressures in both arms.
Differential Diagnosis of Chest Pain | |
|---|---|
Cardiovascular | Angina |
Pulmonary | Pleuritis |
Gastrointestinal | Biliary disease |
Musculoskeletal | Cervical disc disease |
Psychiatric | Anxiety |
Note: Italics indicate potentially life-threatening conditions. | |
Management and Differentiation of Various Causes of Chest Pain | ||||
|---|---|---|---|---|
Differential | Symptoms | Signs | Workup While Awaiting | Initial Managment |
Myocardial ischemia The earlier thrombolytic therapy is started, the better the outcome. Therefore, transfer to a cardiac care unit ASAP is critical. | Radiates to the neck or arms, palpitations, diaphoresis, shortness of breath, nausea/vomiting. | EKG may reveal T wave inversion, ST elevation/depression and Q waves. Compare with an old EKG. Examine for heart failure, hypotension (ominous), new S4 or murmurs. | Vital signs, O2 saturations Q15. CPK-MB and troponin stat., then serially by cardiac care team. CBC, CHEM 7, Ca, Mg, PO4. | Page medicine stat. and prepare to transfer patient. Aspirin (ASA) 325 mg chewed × 1 stat O2 2 L by nasal cannula. Continuous cardiac monitoring. Ensure IV access and rule out hypotension before nitroglycerin (NTG) administration. NTG 0.4 mg SL q5min × 3 prn continued chest pain, hold for systolic BP <100. Consider beta-blocker therapy/ACE inhibitor therapy. |
Aortic dissection | Tearing pain in the chest or upper back radiating to the neck and jaw, abdomen. Lacks squeezing quality or pressure of myocardial ischemia. | Diminished or unequal peripheral pulses and blood pressures. Syncope, hypotension. Neurologic deficits such as hemiplegia or lower extremity paralysis. EKG may be normal or reveal acute ischemic changes, left ventricular hypertrophy (LVH). | Vital signs, O2 saturations q15min. Type and cross match blood for possible surgery and/or rupture. Immediate workup may entail stat thoracic and/or abdominal CT/MRI scanning or transesophageal echocardiogram. | Page medicine and surgery stat. and prepare to transfer patient. Emergent medical treatment entails beta-blockade followed by vasodilation. Control pain with MSO42− Prn. |
Pericarditis Pericardial tamponade, requiring urgent intervention, presents with distant heart sounds, jugular venous distension, and hypotension. | Usually pleuritic pain (exacerbated by inhalation, coughing, sneezing), often relieved by sitting and/or leaning forward. Radiates to the back, neck, and/or shoulder. Fever. | Pericardial friction rub. Distant heart sounds if pericardial effusion present. EKG may reveal ST elevation, PR depression, T wave inversion. | Vital signs, O2 saturations q15min. CBC, CHEM 7. Chest x-ray. Transthoracic echocardiogram. Further workup may entail pericardiocentesis or biopsy for microbiologic and cytologic studies, as well as evaluation for infectious and noninfectious etiologies. | Page medicine stat. Ibuprofen 800 mg PO q6h with food. Avoid anticoagulants. Further management as determined by etiology and medicine recommendations. |
Pulmonary embolism (PE) | Pleuritic chest pain, shortness of breath, fever, hemoptysis. | Hypoxemia, pleural rub, new right-sided heart failure, and tachycardia. Signs and symptoms of deep venous thrombosis (DVT) increase risk of PE. | Vital signs, O2 saturations q15min. CBC and coagulation studies. Chest x-ray. EKG. Arterial blood gases. D-dimer. Further workup may entail venous duplex scan, V/Q scan, spiral chest CT and/or pulmonary angiogram. | Page medicine stat. Further management as per medicine. |
Pneumothorax Tension pneumothorax, requiring urgent intervention, presents with hypotension, respiratory distress, and history of mechanical ventilation and/or procedure involving piercing of the thorax. | Usually abrupt onset of shortness of breath, pleuritic chest pain, cough. | Involved hemithorax may be larger and relatively immobile during respiration. Accessory muscle usage. Pursed lip breathing. On lung exam, decreased breath sounds, decreased vocal fremitus, more resonant percussion note. | Vital signs, O2 saturations q15min. Arterial blood gases. Chest x-ray. EKG may be misinterpreted as acute myocardial infarction. | Page medicine stat. O2 2 L by nasal cannula. Large, progressive, or tension pneumothorax may require emergent thoracentesis with subsequent chest tube placement. |
Gastritis and peptic ulcer disease Ulcer perforation, requiring urgent intervention, presents with “coffee ground” emesis, hematemesis, melena or hematochezia, epigastric pain, syncope. | Epigastric pain described as burning, gnawing, “hunger-like.” Anorexia, nausea, vomiting. History of NSAIDs, alcohol, severe stress, burn injuries. | Mild, localized epigastric tenderness to deep palpation may be present. Hematemesis, melena. | CBC. Guiaic stools ×3. Esophagogastro-. duodenoscopy. Testing for Helicobacter pylori. | Discontinue NSAIDs, smoking, heavy alcohol, caffeine. Further treatment with H2 blockers/proton pump inhibitors/antacids as recommended. Potential pharmacotherapy may include famotidine 40 mg p.o. qhs, ranitidine 300 mg p.o. qhs, esomeprazole 40 mg p.o. QD, lansoprazole 30 mg po QD, pantoprazole 40 mg p.o. QD and/or H. pylori eradication treatment. |
Acute pancreatitis | Severe, constant, boring midepigastric or lower chest pain, radiating to the back. Nausea, vomiting. Fever. | Abdominal tenderness, distension, and guarding. Fever, tachycardia, hypotension. Mild jaundice. +/− palpable abdominal mass. | Amylase. Lipase. CBC. CHEM 7, Ca, Mg, PO4. Hepatic function. Further workup may include abdominal CT and/or abdominal-pelvic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP). | Page medicine and surgery stat. Keep NPO (nothing by mouth). Treatment necessitates inpatient admission and may involve fluid resuscitation, pain management, and electrolyte repletion. |
Musculoskeletal | Usually reproducible. Common causes include costochondritis, cervical disc disease, osteoarthritis, rib fractures, herpes zoster. | Unremarkable vital signs, chest x-ray, EKG. | Vital signs. Chest x-ray. EKG. | NSAIDs. |
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