Chest pain is a common and potentially serious symptom encountered in emergency medicine. It requires prompt evaluation to distinguish between life-threatening and benign causes. Here’s a detailed overview to assist you in managing chest pain effectively:
Common Causes of Chest Pain
Chest pain can originate from various systems, including cardiovascular, respiratory, gastrointestinal, musculoskeletal, and psychological. Here are some key causes:
Cardiovascular Causes
Acute Coronary Syndrome (ACS): Includes myocardial infarction (heart attack) and unstable angina. Characterized by chest pain that may radiate to the arm, neck, or jaw, often associated with sweating, nausea, or shortness of breath.
Pericarditis: Inflammation of the pericardium causing sharp, pleuritic chest pain that may improve when sitting forward.
Aortic Dissection: Sudden, severe chest or back pain described as tearing or ripping. It is a medical emergency.
Respiratory Causes
Pulmonary Embolism (PE): Sudden onset of pleuritic chest pain, often accompanied by dyspnea and tachycardia.
Pneumothorax: Sudden sharp chest pain and shortness of breath due to air in the pleural space.
Gastrointestinal Causes
Gastroesophageal Reflux Disease (GERD): Burning chest pain often related to meals and relieved by antacids.
Esophageal Spasm: Can mimic angina with intense retrosternal pain.
Musculoskeletal Causes
Costochondritis: Inflammation of the costal cartilage causing localized chest wall pain that is reproducible on palpation.
Psychological Causes
Panic Attacks: Can cause chest pain along with palpitations, sweating, and a sense of impending doom.
Evaluation and Diagnosis
History and Physical Examination
Obtain a detailed history focusing on the onset, character, duration, and location of the pain. Ask about associated symptoms like dyspnea, diaphoresis, or syncope.
Conduct a thorough physical examination to identify any abnormal heart or lung sounds, signs of heart failure, or reproducible chest wall tenderness.
Diagnostic Tests
Electrocardiogram (ECG): Essential for identifying ischemic changes indicative of ACS or other cardiac abnormalities.
Chest X-ray: Useful for detecting pneumothorax, pneumonia, or widened mediastinum suggestive of aortic dissection.
Blood Tests: Cardiac biomarkers (e.g., troponins) are crucial for diagnosing myocardial infarction. D-dimer tests can help rule out pulmonary embolism in low-risk patients.
Additional Imaging: CT angiography may be warranted for suspected PE or aortic dissection.
Management in the Emergency Department
Immediate Interventions
For suspected ACS, initiate treatment with aspirin, nitroglycerin (if not contraindicated), oxygen (if hypoxic), and consider anticoagulation.
Manage severe pain with appropriate analgesics while continuing diagnostic evaluation.
Risk Stratification
Use clinical judgment and risk scores (e.g., HEART score) to determine the need for admission versus outpatient follow-up.
Disposition
Patients with life-threatening conditions require urgent intervention and admission to appropriate care units.
Those with non-cardiac causes may be discharged with follow-up plans if stable and low-risk.
A systematic approach to evaluating chest pain ensures that critical conditions are identified promptly while providing appropriate care for less urgent cases.
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