Chest pain Flashcards
What are your differentials for chest pain?
Muscle strain
costochondritis
contusion
- Most common cause of chest pain (15-76%)
Muscle strain
CH ?: MUSCLE STRAIN
- Most common cause of chest pain (15-76%)
- Precordial catch syndrome (intercostal muscle
cramping): irritation of the parietal pleura that
produces a stabbing pain along the left sternal border
- Most often related to muscle overuse or trauma
involving the pectoral, upper back, or shoulder muscles
clinical manifestations of muscle strain
CM
1. Sharp (acute) or dull (chronic) chest pain
2. Swelling, muscle spasms, difficulty moving the affected area, pain while breathing, bruising
Diagnosis of muscle strain
Dx
- Primary clinical. Labs to r/o other diseases
1. CXR, MRI
2. ECG
management of muscle strain
Mgt
1. Rest. Light activity x 2 d after injury
2. Ice/cold pack x 20 min on affected area TID
3. Compression – if with inflammation using elastic bandage
4. Keep chest elevated while sleeping
5. NSAIDs
What is the other term for costochondritis?
- Tietze’s syndrome
CH ?: COSTOCHONDRITIS
- Tietze’s syndrome
- Inflammation of the costochondral junctions
- Isolated swelling of the upper costochondral area
- Most are idiopathic; others due to direct trauma,
aggressive exercise, prior URTI with cough
- Benign and self-limited
Clinical manifestations of costochondritis
CM
1. Sharp and stabbing Localized tenderness and pain of the anterior chest wall, usually unilateral and ICS 2-5
- Typically insidious (days to weeks), some acute
- May radiate to chest, back, upper abdomen
- Exacerbated by cough, sneezing, deep inspirations, movt of upper torso and upper extremities
- Relieved by rest, ice or heat
- Tenderness over the costochondral junction –diagnostic; localized and MC at sternocostal cartilage
at ICS 2-5. Palpation should reproduce tenderness. - N PE
Diagnostics for costochondritis
Dx
- Mainly clinical
1. CXR, CT, MRI – to r/o other causes
Management of costochondritis
Mgt
1. Reassurance
2. NSAIDs
3. Cough suppressants – if cough is an aggravating factor
4. Stretching exercises
5. Ice x 20 min
6. Rest of UE and avoidance of exacerbating activities
What is contusion?
CH ?: CONTUSION
- Chest wall bruise due to blunt trauma (car accident, fall)
CM
1. Chest pain, tenderness, bruising and swelling
2. May have broken ribs and injured muscles
3. Serious dyspnea
Dx
1. CXR, CT, MRI – r/o other dx, broken ribs
Mgt
1. Rest
2. Ice pack x 20 min q1-2h on D1, then TID for next days. WThen warm compress after 1-2d.
3. Pillow over affected area can ease pain
4. NSAIDs
What is pleural effusion?
Patho
- Pleural fluid comes from the capillaries of the parietal pleura and is absorbed from the pleural space via pleural stomas and lymphatics
- Only 4-12ml of fluid is present in the pleural space and if formation exceeds clearance, fluid will accumulate as pleural effusion
- Transudative = renal, cardiac etiology
- Exudative = TB, infection, CA, empyema, SLE, etc
Differentiate Dry vs serofibrinous/serosanguineous vs empyema or purulent effusion
Differentiate Dry vs serofibrinous/serosanguineous vs empyema or purulent effusion
B. Pleural Fluid Analysis
- culture for bacterial, fungal, mycobacterial, gram stain
- protein, LDH, glu (<60 mg/dL in CA, TB, rheumatoid ds)
- amylase
- specific gravity and pH
- Total cell count and differential, cytologic examination (to reveal
malignant cells)
Differentiate Exudates vs transudate
Exudates (vs. Transudate) have >1 of the ff:
1. Protein >3 g/dL
2. pH <7.20
3. Pleural fluid:serum protein ratio >0.5*
4. Pleural fluid:serum LDH ratio >0.6*
5. Pleural fluid LDH level >200 IU/L or pleural fluid LDH
>2/3 serum LDH upper limit of normal*
*=Light’s criteria
C. Pleural fluid analysis in empyema
C. Pleural fluid analysis in empyema
1. Bacteria is present on gram stain
2. pH is <7.20
3. >100,000 neutrophils/uL
4. Pneumococcal empyema: culture is (+) in 58%
5. If negative culture for pneumococcus: do
pneumococcal PCR analysis
Transudate vs exudate
—–Transudate—–
clear
cell count <1000 (lympho, monocytes)
LDH <200 U/L
Pleural/serum LDH ratio: <0.6
Protein >3g: unusual
Pleural/serum CHON ratio: <0.5
GLUCOSE: normal
PH: Normal (7.4-7.6)
—–Exudate—–
cloudy
cell count >1000 (PMNs)
LDH >2000 U/L
Pleural/serum LDH ratio: >0.6
Protein >3g: COMMON
Pleural/serum CHON ratio: >0.5
GLUCOSE: low
PH: 7.2-7.4
—–Complicated emphysema—–
purulent
cell count >5000 PMNs
LDH >1000 U/L
Pleural/serum LDH ratio: >0.6
Protein >3g: COMMON
Pleural/serum CHON ratio: >0.5
GLUCOSE: very low
PH: <7.2, chest tube placement required
*****Decreased glucose or LDH seen in malignant effusion, TB, esophageal rupture, SLE
Diagnosis of Dry or Plastic Effusion
CXR: diffuse haziness at the pleural surface; dense, sharply demarcated shadow
Chest UTZ: if radiographs are negative, UTZ or CT scan of the chest may be done
Diagnosis of Serofibrinous or Serosanguineous Effusion
CXR: homogenous density obliterating the normal lung markings;
If small effusion: obliterated costophrenic or cardiophrenic angles or widening of the interlobar septa;
Examine the patient in both supine and upright positions to demonstrate a shift of effusion
Chest UTZ: helpful guide to the thoracentesis if effusion is loculated
Diagnosis of Empyema or Purulent effusion
CXR: similar findings with any pleural effusion; the absence of fluid shift with change in position indicates a loculated empyema
Chest UTZ: helpful guide to the thoracentesis if effusion is loculated
Management of Dry or plastic effusion
Tx directed at the underlying disorder
patients with pleurisy and pneumonia should always be screened for TB
analgesia with NSAIDS will be helpful
Management of serofibrinous or serosanguineous effusion
Tx directed at the underlying disorder
*therapeutic thoracentesis unless small effusion only
*rapid removal of ≥1L of pleural fluid may be associated with re-expansion pulmonary edema
*If underlying problem is adequately treated, further drainage is usually unnecessary
*Tube drainage is done for:
1. fluid re-accumulation leading to respiratory compromise
2. Older children with parapneumonic effusion, and the pleural fluid pH is ,7.20 or pleural fluid glucose level is <50mg/dL
Management of empyema or purulent effusion
Antibiotics: choice of antibiotics is based on in vitro sensitivities of the responsible organism
Clinical response is slow even with antibiotics (may have little improvement for as long as 2 weeks)
For staphylococcal infections: treatment for 3-4 weeks
Chest tube drainage: controlled by underwater seal and continuous suction; usually continued for 5-7 days; fibrinolytic agents are instilled to promote drainage, decrease fever, lessen need for surgical intervention and shorten hospitalization
Surgery:
If px remains febrile and dyspneic for >72 hours after systemic antibiotics and chest tube drainage –surgical decortication via VATS
If VATS is ineffective, open decortication is performed
CTT - >50-75% pleural eff, loculated, pH<7
Abx (NAGCOM):
- Complete HiB vax: Penicillin G 200000 U/kg/d q6 /
Ampicillin 200mkd q6 - Incomplete/no HiB: Ampicillin-Sulbactam 100mkd q6
or Cefuroxime 100mkd q8 or Ceftriaxone 100mkd q12
