Chest Pain

Posted: November 7, 2010 by smarinz7 in A & E

Chest Pain

  • Usually we send this pt to RED ZONE

Etiology

a)      Life threatening

  • Thoracic aortic dissection
  • Esophageal rupture
  • Tension pneumothorax
  • ACS(e.g. MI,UA)
  • Pulmonary embolism

b)      Most common

  • GI: GERD,PUD
  • CVD
  • Pulmonary
  • Musculoskeletal
  • Psychological

Things to ask:

O – Onset: “When did the pain starts?”

P – Provocation: “during cough, stress, after food and RECENT SPORT that might lead to overuse of chest muscle.

Q – Quality: “describe your pain; dull, sharp”

R – Radiation: to the head, scapula, left hand.

S – Severity:“I give u the scale from 1-10,10 is the most painful…which number is your severity?”

  • PMH: HT, DM, cerebrovasc dss, PE.
  • Medications? – drugs can trigger coronary artery spasm(e.g. cocaine, NSAID)

*If possible, ask the pt to hand the drugs to you.

  • What position relieves the pain?
  • Palpate and check skin of chest – trauma, abrasion, bruises, subcutaneous emphysema(crackles sound when palpate)

Dx

*Main Aim: TRO Life threatening causes!!

  • Pulse oximetry
  • ECG within 10min
  • CXR
  • Look for cardiac markers: TRO ACS etiology(e.g. troponin,CK-MB)

*If STEMI à start PCI or thrombolytic therapy within 90 min standard.( refer STEMI)

Suspect PE if

  • Leg swell
  • HR > 100
  • >3days immobilization
  • History of surgery within the last 4 weeks
  • Hemoptysis

Thoracic Aortic Dissection

  • Blood penetrates the tunica intima and the pressure tears the tunica media of the blood vessels.
  • 2 type

1)      Type A – in ascending aorta (typically chest pain)

2)      Type B – in descending aorta (usually abdominal pain)

  • History of HT,blunt trauma to chest.
  • Dx: TEE(transesophageal echochardiography)and MRI-gold standard, CT scan.
  • Within 2 weeks(80% mortality).
  • Tx : surgery or HT tx

Cardiac tamponade

  • a minimum of 100ml fluid in pericardium is enough to cause this.
  • Beck’s triad:

1)      Low arterial BP – bcos low stroke volume.

2)      Jugular vein distension – in non-supine position due to diastolic filling of RV.

3)      Muffled heart sound (decrease heart sound)– effects of passing thru fluid in pericardium.

  • Etio: pericarditis,myocardial rupture, blunt trauma.
  • Dx: ECG – low voltage QRS complex
  • Signs n symptom of shock(tachycardia, apnea, decrease level of consciousness .
  • Tx: pericardiocentesis at 5th intercostals space.

Tension Pneumothorax

  • chest pain is sharp and pleuritic,dyspnoe,cyanosis,tracheal deviation,jugular venous distension
  • do CXR to confirm
  • Tx: insert largest cannula into the 2nd intercostal space in the midclavicular line at the site with the absent or reduced breath sounds.
  • If air rushes out,leave the cannula in place until a chest drain is inserted.

Tips:

Auscultation of abdominal aorta : at the back of the patient lower a bit from interscapular region,slightly left from the vertebra.

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