Chest Pain

ABCs

  • Assess airway, breathing, circulation
  • Check full vitals and attach cardiac monitor
  • Measure BP in both arms

HPI & Examination

  • Past history: IHD, asthma, lung disease, regurgitation
  • Pain characteristics:
    • Heaviness vs. stabbing
    • Exertional vs. pleuritic
    • Radiation: arm, jaw, back
  • Associated symptoms:
    • Diaphoresis, palpitations, N/V
    • Dyspnea, orthopnea, PND
    • Peripheral edema, fever, cough
    • Any symptoms of DVT

Red flags in history:

  • Sudden onset, exertional
  • Substernal or left-sided
  • Radiation to arm/jaw/back
  • Crushing, tearing, or ripping pain
  • SOB, diaphoresis, nausea/vomiting

Examination

  • Cardiopulmonary exam
  • Lower limb exam

Red flags on exam:

  • Hypoxia, hypotension
  • Pulsus paradoxus (>10 mmHg drop in SBP with inspiration)
  • BP difference >20 mmHg between arms
  • New murmur
  • Chest wall crepitus
  • Distant heart sounds

Management

  • ECG + HsTrop → If typical pain or abnormal findings -> contact cardiology
  • CXR

THEN based on your suspicion

  1. pneumothorax
    • urgent CXR
    • call for assistance and surgical consultation 
  2. lung collapse
    • if unequal/absent breath sounds
    • urgent CXR
    • call for assistance and respiratory consultation 
  3. pneumonia/HAP
    • Viral swabs
    • Inflammatory markers
    • ETT/Sputum CS if available
    • consider empirical antibiotics after consulting with your senior
  4. pulmonary embolism
    • CTPA if stable for shifting after signing consent, reviewing renal function and contacting radiology and your senior
    • anticoagulation if CTPA could not be done or delayed
    • Bedside echo if unstable
  5. stable aortic dissection call for assistance
    • CTA after signing consent, reviewing renal function and contacting radiology and your senior
    • control hypertension and heart rate: target SBP 100–120 mmHg and HR ≤ 60 
    • Start beta blocker (use nondihydropyridine CCB if β-blocker contraindicated)
    • Evaluate end-organ damage: send troponin, RFT and lactate
  6. unstable aortic dissection → call for assistance
    • Urgent bedside imaging: TEE (preferred), portable CXR, TTE or POCUS
    • Consult cardiothoracic surgeon
    • If low BP → hemodynamic support to target MAP ∼ 70 mm Hg 
    • If high BP → SBP 100-120 mmHg and HR ≤ 60 
    • Evaluate end-organ damage: send troponin, RFT and lactate 
    • +/- preoperative labs: CBC, type and screen, RFT and coagulation profile
  7. cardiac tamponade
    • call of assistance to contact cardiology urgently
    • suspect if beck triad
      • hypotension
      • muffled heart sounds
      • distended neck veins 
  8. MSK pain
    • Paracetamol 1g IV & reassess
    • Rule out emergencies first!

Life-threatening causes of chest pain

  • ACS i.e., STEMI, NSTEMI
  • pulmonary embolism
  • aortic dissection
  • tension pneumothorax
  • cardiac tamponade
  • esophageal rupture
MOC