Chest pain

Medical Emergency - Chest pain is a common presentation in A&E. Whilst not always serious, there are several causes that need prompt management.

Definition

Pain, in the chestal region. Pleuritic chest pain is, very specifically a sharp, inspiratory pain. If it's no sharp, it ain't pleuritic. If it's not inspiratory, it ain't pleuritic. So there.

Epidemiology

Pretty common, since half the country has heart disease.

Pathophysiology

The commonest cause of chest pain is probably reflux, or ischaemic heart disease. The cause of the pain in these situations is very different. In the former, irritation of the bottom of the oesophagus causes pain, in the latter, ischaemia of muscles causes a deep sensation of pain.

Clinical and Associated Features

Worrying symptoms

• Huge amounts of pain
  • That radiates down arms or neck.
  • A deep dull pain, like someone sitting on your chest.
  • A terrifically sharp, tearing pain.
• Shortness of breath
• Palpitations
• Nausea and vomiting.

Less worrying symptoms

• Mild pain
• Sore throat
• Relieved by antacids
• Pain originally brought on by an abnormal muscle movement, or made worse on physical movement.

Differential Diagnosis

The following 6 causes can be fatal, so you should probably know how to diagnose them!

• Acute coronary syndrome - ie. angina, unstable angina, myocardial infarction
• Pulmonary embolism
• Tension pneumothorax
• Pericarditis
• Trauma
• Aortic dissection

Urgent but not emergency

• Ischaemic heart disease
• Pleurisy (pleural infection) from pneumonia, or pulmonary infarction.
• Neuromuscular - nerve root pain, fibromyalgia.

Not even urgent

• Herpes zoster
• Reflux
• Costocondritis - pain and inflammation of the costal joints.

Investigations and Management

If it is obviously something non serious, you obviously deal with the underlying problem.

However, if you have been admitted to A&E, the first thing they will do is ABC. If you are seriously short of breath, they will put you on high flow oxygen, setting up vitals statistics for blood pressure and heart rate.

Then the next step is an ECG, a Chest Xray and some blood tests in the realm of an FBC, U+Es, TFTs, Cardiac markers and an ABG.

That should give you enough to narrow it down to one of acute coronary syndrome, pulmonary embolism, tension pneumothorax, pericarditis or aortic dissection. Go to those pages for management of those.