6. Chest pain

Question 1

What are the immediately life-threatening causes of chest pain?

Answer 1

• AMI,
• pulmonary embolism,
• aortic dissection,
• tension pneumothorax,
• cardiac tamponade,
• esophageal rupture.

Question 2

What is tension pneumothorax?

Answer 2

It is a life-threatening variant of pneumothorax caused by the continuous entrance and entrapment of air into the pleural space, thereby compressing the lungs, heart, blood vessels, and other structures.

Question 3

What are some red flags in chest pain?

Answer 3

• Sudden onset,
• exertional chest pain,
• substernal or left-sided pain,
• radiation to the left arm, jaw, neck, and/or back.
• quality of the pain : crushing , pressure, tearing
• associated symptoms : dyspnea, nausea, sweating

Question 4

What are the signs of critical causes of chest pain?

Answer 4

• 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.

Question 5

What is the ABCDE approach for chest pain?

Answer 5

Airway, breathing, circulation, disability, exposure.

Question 6

What diagnostic studies should be performed for all patients with chest pain?

Answer 6

12-lead ECG (ST elevations or no ST elevations), routine diagnostic studies (e.g. troponin, CXR).

Question 7

What should be done if red flags for chest pain are present?

Answer 7

• Perform point of care US (e.g. eFAST in trauma patients),
• begin time-sensitive management (e.g. activate cath lab for STEMI),
• obtain definitive imaging (e.g. CTA chest for TAA).

Question 8

What should be done if red flags for chest pain are absent?

Answer 8

• Use risk stratification tools, e.g. HEART score, Wells score
• consider further diagnostic testing based on risk stratification results.

Question 9

What is the HEART score used for?

Answer 9

It is used for MACE risk stratification.

Question 10

What is the Wells score used for?

Answer 10

It is used for PE risk stratification.

Question 11

What are the 8 clinical features of pulmonary embolism?

Answer 11

• Pleuritic chest pain,
• acute onset dyspnea,
• hypoxemia,
• cough,
• hemoptysis,
• unilateral leg swelling or history of DVT,
• hypotension,
• shock (if massive PE).

Question 12

What are the diagnostic findings of pulmonary embolism?

Answer 12

• Elevated D-dimer, troponin, BNP,
• pulmonary artery filling defect on CT angiography,
• perfusion-ventilation mismatch on V/Q scintigraphy.
• Wells score

Question 13

What are the clinical features of tension pneumothorax?

Answer 13

• Severe, sharp chest pain,
• dyspnea,
• hypoxemia,
• history of trauma,
• hyperresonance on percussion, decreased breath sounds,
• tracheal deviation,
• tachycardia,
• hypotension.

Question 14

What are the clinical features of spontaneous pneumothorax?

Answer 14

• Sudden, sharp unilateral chest pain,
• acute dyspnea,
• hypoxemia,
• hyperresonance on percussion,
• decreased breath sounds
• crepitus
• history of lung disease / trauma

Question 15

What are the clinical features of COPD exacerbation?

Answer 15

• Dyspnea,
• cough, purulent sputum,
• tachycardia,
• tachypnea, hypoxemia,
• diffuse wheezing,
• decreased breath sounds,
• signs of imminent respiratory arrest: confusion, absent breath sounds, bradycardia.

Question 16

What are the clinical features of pleural effusion?

Answer 16

• Unilateral, pleuritic chest pain,
• dyspnea,
• dry, nonproductive cough,
• dullness to percussion,
• decreased breath sounds,
• decreased tactile fremitus,
• pleural friction rub.

Question 17

What are the diagnostic findings of pleural effusion?

Answer 17

• CXR: homogenous opacity with blunting of the costophrenic angle,
• POCUS: hypoechoic space between the parietal and visceral pleura.

Question 18

What are the diagnostic findings of COPD exacerbation?

Answer 18

• Lab : increased CRP, increased procalcitonin
• ABG : respiratory acidosis