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CDHB

Chest Pain

Initial assessment and resuscitation

• Airways, Breathing, Circulation: including cardiac monitoring and intravenous access in all but trivial cases.

Complete assessment

History, Examination, Investigations: directed according to the differential problem list.

Acute Coronary Syndrome will often present with atypical features and cannot always be excluded on history alone.

Investigations usually include CXR and ECG but may require pulse oximetry/arterial blood gases and markers of myocardial damage. Myocardial injury markers, including troponins, are the most useful screening tests for an acute myocardial infarction.

Remember, cardiac markers are slow to rise after myocardial damage and therefore normal cardiac markers soon after the onset of pain will not exclude myocardial damage.

If in doubt, keep the patient under observation and repeat myocardial injury markers at 8 - 12 hours from the onset of symptoms. Other investigations that may be required include a CTPA or ventilation/perfusion scan, abdominal ultrasound, aortography, echocardiography.

Definitive management

According to the cause or possible causes:

• Traumatic - chest wall, lung, heart, great vessels, diaphragm, oesophagus, spine.
• Non-traumatic:
  • Chest wall - (pleuritic pain, tenderness).
  • Lung - (pleuritic pain, focal signs), pneumothorax, infective, inflammatory, pulmonary embolism.
  • Heart - ischaemia, pericarditis.
  • Great vessels - dilatation, dissection (if there is chest pain and another area of pain outside the chest, think dissection, e.g., chest and abdomen, chest and limb, chest and head).
  • Oesophagus - inflammation, spasm, rupture
  • Abdominal - peptic ulceration, pancreatitis, cholecystitis etc.
  • Psychogenic.

Important to exclude

• Ischaemic heart disease
• Aortic dissection
• Pulmonary embolism
• Pneumothorax
• Pneumonia

Topic Code: 2280