In those with significant chest pain as the main symptom there are 3 diagnoses that kill which you need to consider acutely and these are ACS/MI, PE and less commonly but should always be considered Aortic Dissection. In an in-hospital patient, PE is always the main worry. The most useful acute tests are ECG, Dimer, Troponin and CTPA/Aortogram
|Chest pain of recent onset
|If sounds like potential IHD or PE then en route ask staff to get IV access, Give Oxygen if hypoxic, Get ECG and arrive quickly. On arrival. Assess ABCDE severity. Check the NEWS score. Take a focused history and exam whilst doing ECG which is the key test. If breathless or hypoxia start 15 L/min oxygen unless COPD when starting 28% and monitor sats. Get IV access. Send blood for FBC, U&E, CRP, Troponin and Dimer. Get CXR: may show pneumonia, pulmonary oedema, oligaemia (PE) or rib fractures or wide mediastinum (Dissection)
|If ACS suspected consider S/L GTN 1-2 puff if SBP> 110 mmHg and treat as ACS. If no effect after 5 mins and pain till felt to be ACS and severe then consider Diamorphine 2.5-5 mg slow IV or Morphine 2.5-5 mg slow IV. Give Aspirin 300 mg PO (US ASA 325 mg) . If you give an opiate give Metoclopramide 10 mg IV as an antiemetic. Discuss with cardiology. Assess risk factors that support IHD - smoking, age, diabetes, HTN, cholesterol Follow ACS algorithm. If STEMI (ECG shows ST elevation or presumed new left bundle branch block ) then needs urgent revascularisation by PCI or thrombolysis. May need to give additional antiplatelets.
|If PE suspected (check Well's score) then get CTPA and consider for thrombolysis and if not start treatment dose LMWH or UFH. Follow PE algorithm. Assess risk factors - previous PE, DVT, post op, malignancy, immobility etc. Well's score
|If suspected Aortic dissection - if seriously considered needs urgent CTA chest and BP management and cardiothoracic referral. See topic. Follow dissection algorithm
|If suspected Chest infection then assess and treat as CAP/HAP
|If unsure what the cause is it can be that you treat as ACS and PE. Try to avoid antithrombotics or anticoagulants of aortic dissection
|If a de Novo patient presents with chest pain you need to have good evidence that it is not IHD or PE before you diagnose a non-lethal cause and discharge. If unsure get a senior review. Some with IHD and PE may not have classical presentations and ECG can be unreliable
|Acute Coronary Syndrome
|Classical central chest pain usually at rest and typical ECG changes. Not usually breathless unless LVF. If unclear then Troponin, Echo. If ECG changes and high risk treat as ACS. ST-elevation means urgent PPCI or thrombolysis. Give Aspirin 300 mg PO while assessing
| Severe interscapular or chest pain. Hypertensive history and hypertensive. EDM as aortic root affected with aortic regurgitation. CXR may show widening mediastinum and unfolding or aorta, Urgent CT, TOE|TEE if available. Reduce BP with IV Labetalol and move to cardiothoracic centre urgently. Avoid giving anticoagulants, thrombolysis
|Common in inpatients. Consider if significant risk factors, sudden SOB and CP. Breathlessness and chest pain both present. Normal CXR. Check D-Dimers or straight to CTPA if moderate to high risk. If in extremis and hypotensive consider echo and thrombolysis. All should be anticoagulated with LMWH while awaiting CTPA. Check Wells score.
| Sudden SOB, Diagnostic CXR. If tension then needle in 2nd space to relieve it. Otherwise aspiration and/or chest drain. Give 15 L/min Oxygen even if not hypoxic as long as no COPD. It helps resorb pneumothorax.
|Can be seen in any age and the younger the less likely is ACS. Sharp chest pain eased by sitting up and forwards. Maybe an audible friction rub at apex "like walking on snow". ECG diffuse ST elevation all but aVr. CXR may show pericardial effusion. Analgesia. Echo. ECG. If a myopericarditis then Troponin rises but this is not ACS.
|Maybe indigestion and heartburn but only make this diagnosis once you have reliable excluded PE and MI. May benefit from Antacids and starting a PPI.
| severe chest pain, dysphagia, fever, context of severe vomiting or trauma or post endoscopic procedure in oesophagus. Needs CXR and CT chest and ITU. Antibiotics. Cardiothoracics.
| Infective history with cough, sputum, fever, Systemically unwell. CXR may be deceptive initially. Give oxygen and antibiotics and respiratory support if severe. Pain relief for severe pleurisy.
|May be elderly, HIV or other form of immunocompromise, Dermatomal Rash. Consider antivirals and analgesia.
|Rib or Sternal fracture
| history, CXR, localised severe tenderness. May consider good analgesia even lidocaine patches can help
|History of some form of trauma and associated tenderness and other injuries may be present. Gte CXR to exclude any PTX or rib #
|Rib and bone primary or metastases
| see on CXR, Bone scan, raised ALP, cachexia. May also be Myeloma or Pagets. Consider CT CAP
|Bone pain - Sickle Crisis
|Usually a known sickler. Needs commencement on IV fluids, Oxygen if hypoxic and effective analgesia and referral to haematology
|CXR may show a lesion. Pain to shoulder tip. Identify cause and treat.