Chest Pain

Question 1

What are some of the causes of chest pain to consider in the acute setting?

Answer 1

Cardiac: ACS, pericarditis, aortic dissection, HF exacerbation

Respiratory: Pleural effusion, pneumonia, pneumothorax

Gastrointestinal: GORD, gastritis, PUD, perforation, biliary colic, pancreatitis, hepatits

Musculoskeletal: Costochondritis

Psychiatric: Generalised anxiety disorder, panic attack

Question 2

Outline the approach to chest pain in the acute inpatient setting

Answer 2

1. ABCDE survey
2. ECG
3. Gain IV access
4. Continuous telemetry + pulse oximetry
5. Supplemental oxygen, if evidence of hypoxaemia
6. Focussed hx and examination
7. Targeted diagnostics and Ix, as required
8. Tx underlying cause, if identified

Question 3

When evaluating an inpatient for reported chest pain, what are the RED FLAGS you must look out for?

Answer 3

History:

• Site: Substernal or left-sided chest pain
• Radiation: Radiation to the left arm, jaw +/ back
• Temporal: Sudden onset of pain
• Quality: Crushing, pressure, tearing, ripping
• Context: Exertional chest pain
• Associated features: Shortness of breath, diaphoresis, N +/ V

Examination:

• New murmur aortic dissection
• Chest wall crepitus subcutaneous emphysema ~ pneumothorax / oesophageal perforation
• Distant heart sounds cardiac tamponade ~ pericardial effusion
• Difference > 20 mmHg in SBP between arms aortic dissection
• Pulsus paradoxus cardiac tamponade
• Hypotension cardiac tamponade / AMI / PE / aortic dissection / tension pneumothorax
• Hypoxia AMI / PE / pneumothorax/ tamponade / dissection + more

Question 4

What are some of the immediately life threatening causes of chest pain to be aware of?

Answer 4

ACS: STEMI, NSTEMI, unstable angina

Pulmonary embolism

Aortic dissection

Tension pneumothorax

Cardiac tamponade

Oesophageal rupture

Question 5

What are some of the investigations that you should consider in the setting of acute inpatient chest pain?

Answer 5

Laboratory studies:

Troponin
> serial trops to evaluate for ACS
> trops elevated in other pathologies: PE
D-dimer
> evaluate for PE, if pre-test probability is low
FBE
> leucocytosis: could suggest inflammatory process
> anaemia: could suggest bleeding
ESR / CRP
> consider if concern re inflammatory process (ie. pericarditis)
UEC
> evaluate renal function and electrolytes
> uraemia can cause pericarditis
LFTs
> biliary colic can cause referred pain to the chest
Lipase / amylase
> evaluate for pancreatitis
BNP
> evaluate for heart failure
Blood type
> in case transfusion required
Coagulation studies
> in case transfusion or surgical mngt are required
Lactate
> elevated lactate should raise concern of ischaemia or shock
Cultures (blood, urine, sputum)
> if concern re infectious cause
Procalcitonin
> can help to differentiate b/w bacterial vs. non-bacterial infections
Toxicology screen
Respiratory virus panel
Hepatitis panel

Imaging:

ECG
> ST elevations: STEMI, NSTEMI, pericarditis
CXR
> look for infiltrate (pneumonia), pulmonary oedema, rib fracture, pneumothorax, dilated pulmonary vessels, widening of aorta (dissection)
FAST at bedside
Abdo X-ray (upright)
> look for pnuemoperitoneum (intestinal perforation)
CT chest w contrast
> can show pneumonia, pericardial effusion, dissection, pulmonary abscess
CTPA
> shows pulmonary vessels => pulmonary embolism
CT abdo pelvis w contrast
> liver, stomach, intestinal pathologies
RUQ U/S
> liver, biliary pathologies
Echo (TTE, TOE)
> if concern re HF or pericardial effusion
> TTE can identify proximal aortic dissection, but absence does not rule it out
Lung U/S
> look for consolidation (hyperechoic density)
V/Q scan
> if concerned re PE but CTPA is C/I (CKD)
Duplex U/S
> if concern re VTE