6. Chest pain

What are the differential diagnoses with chest pain

• Cardiac

  • (AMI, pericarditis, aortic dissection, cardiac tamponade, arrhythmias)

• Pulmonary

  • (PE, tension pneumothorax, pneumonia)

• GI

  • (GERD, peptic ulcer disease, hiatal hernia, achalasia)

• Chest wall

  • (costochondritis, herpes zoster, TB, rib contusion)

• Psychological

  • (panic attack, anxiety)

What are life threatening causes of chest pain

• AMI

• Pulmonary embolism

• Aortic dissection

• Tension pneumothorax

• Cardiac tamponade

• Esophageal rupture

When should you do a more narrow differential diagnosis

When life threatening causes are ruled out by- patient history, examination, rapid diagnosis

What are the symptoms of chest pain (red flags)

• Sudden onset

• Exertional chest pain

• Substernal or left-sided pain

• Radiation to the left arm, jaw, neck and/or back

What are the qualities of chest pain (red fllags)

• crushing

• pressure

• teating

• ripping

What are the associated symptoms (red flags)

• dyspnoea

• excessive sweating

• nausea

• vomiting

What are the signs accompanying chest pain (red flags)

• Vital sign abnormalities (e.g. hypoxia, hypotension)

• Pulsus paradoxus (decrease in systolic BP during inspiration)

• Difference of >20mmHg in systolic BP between arms

• Chest wall crepitus

• Distant heart sounds

How do you approach CP in all patients

• ABCDE approach

  • (airway, breathing, circulation, disability, exposure)

• 12-lead ECG

  • (ST elevations or no ST elevations)

• Routine diagnostic studies

  • (e.g. troponin, CXR)

• Identify and treat the underlying cause

How do you approach CP if red flags are present

in high risk of critical causes of chest pain

• Perform point of care US (e.g. eFAST)

• Begin time-sensitive management (e.g. activate cath lab for STEMI)

• Obtain definitive imaging (e.g. CTA chest for TAA)

How do you approach CP if red flags are absent

low risk of critical causes of chest pain

• Use risk stratification tools, e.g.:

  • HEART score for ACS risk stratification

  • Wells score for PE

What is the diagnostic process of chest pain

What are the pulmonary causes of chest pain

• PE

• tension PTX

• spontaneous PTX

• asthma exacerbation

• COPD exacerbation

• pleural effusion

Describe PE

Clinical features:

• Pleuritic chest pain

• Acute onset dyspnea, hypoxemia

• Cough, hemoptysis

• Unilateral leg swelling or history of DVT

• Hypotension, shock (if massive PE)

Diagnostic findings:

• Labs: elevated D-dimer, troponin, BNP

• ECG: normal sinus rhythm, sinus tachycardia, signs of RV strain

• CT angiography: pulmonary artery filling defect

• V/Q scintigraphy: perfusion-ventilation mismatch

• Clinical calculators: Wells score, PERC rule, PESI

Describe tension pneumothorax

Clinical features:

• Severe, sharp chest pain

• Dyspnea, hypoxemia

• History of trauma

• Hyperresonance on percussion, decreased breath sounds, tracheal deviation

• Tachycardia, hypotension

Diagnostic findings:

• Clinical diagnosis

• CXR: absent lung markings, tracheal deviation, pneumomediastinum

Describe sponteneous PTX

Clinical features:

• sudden, sharp unilateral chest pain

• Acute dyspnea, hypoxemia

• Hyperresonance on percussion, decreased breath sounds on the affected side

• Crepitus

• History of lung disease or trauma

Diagnostic findings:

• Inspiratory CXR: increased lucency, displaced lung markings, subcutaneous emphysema

• POCUS: absent lung sliding on eFAST

Describe pneumonia

Clinical features:

• Fever, chills

• Cough, dyspnea

• Hypoxemia, crackles

Diagnostic findings:

• Labs: leukocytosis, elevated ESR/CRP and procalcitonin

• Positive sputum culture

• CXR: consolidation, pleural effusion

• CT chest: hyperdense consolidation

Describe asthma exacerbation

Clinical features:

• Dyspnea, cough

• Tachycardia, tachypnea, hypoxemia

• Diffuse wheezing

• Decreased or absent breath sounds

• Increased work of breathing

Diagnostic findings:

• Peak expiratory flow: decreased from predicted or personal best

• ABG: ↓pH, ↑PaCO2, ↓PaO2 ( → respiratory acidosis)

Describe COPD exacerbation

Clinical features:

• Dyspnea, cough

• Purulent sputum#

• Tachycardia, tachypnea, hypoxemia

• Diffuse wheezing, decreased breath sounds

• Signs of imminent respiratory arrest: confusion, absent breath sounds, bradycardia

Diagnostic findings:

• ABG: ↓pH, ↑PaCO2, ↓PaO2 ( → respiratory acidosis)

• Labs: ↑CRP, ↑procalcitonin (if underlying bacterial infection)

• CXR: hyperinflated lungs: signs of pneumonia, pneumothorax and/or pleural effusion

Describe pleural effusion

Clinical features:

• Unilateral, pleuritic chest pain

• Dyspnea

• Dry, nonproductive cough

• Dullness to percussion, decreased breath sounds, decreased tactile fremitus

• Pleural friction rub

Diagnostic findings:

• CXR: homogenous opacity with blunting of the costophrenic angle

• POCUS: hypoechoic space between the parietal and visceral pleura

What are CV causes of chest pain

• STEMI

• NSTEMI

• aortiic dissection

• cardiac tamponade

• pericarditis

• HF exacerbation

What are the characteristics of N/STEMI

What are the characteristics of aortic dissection

What are the characteristics of cardiac tamponade

What are the characteristics of pericarditis

What are the characteristics of HF exacerbation

What are the GI causes of chest pain

• esophageal perforation

• GERD and erosive erophagitis

• Gastritis

• peptic ulcer disease

• acute pancreatitis 

• esophageal hypermotility

What are the characteristics of oesophageal perforation

What are the characteristics of GERD and erosive oesphagitis

What are the characteristics of gastritis

What are the characteristics of peptic ulcer disease

What are the characteristics of acute pancreatitis

What are the characteristics of oesophageal hypermotility disorders