APPROACH TO CHEST PAIN Investigation & Management

Mohd Hafis Zul Arif Bin Awang 01201005 0476

(BMSc), 4th Year MBBS IMS:MSU

Differential Diagnoses
CARDIOVASCULAR Angina Myocardial ischemia or infarction Aortic dissection Pericarditis Tamponade GASTROINTESTINAL Esophageal perforation Reflux esophagitis Gastritis, peptic ulcer disease Esophageal spasm Hiatus hernia Pancreatitis Biliary tract disease

Differential Diagnoses
PULMONARY Pneumonia Pulmonary embolism Pneumothorax Hemothorax Pleuritis/Serositis MUSCULOSKELETAL Chest wall injuries Costochondritis Secondary tumor of the rib Shingles (Herpes Zoster) Fibromyalgia

Differential Diagnoses
PSYCHOLOGICAL Depression Panic disorder Anxiety Depression Somatoform disorders

Investigations
General
Blood test Complete blood count Electrolytes and renal function (creatinine) Liver enzymes D-dimer Serum amylase Cardiac markers Troponin I or T Creatine kinase (CK-MB) Chest Xray ECG

Specific V/Q scan Pulmonary angiography CT aortography Upper GI endoscopy Esophageal manometry

 Myocardial Ischemia / Infarction Aortic Dissection Pulmonary Embolism Pneumothorax Others

Myocardial Ischemia/Infarction
Investigation
EKG CXR to look for signs of congestive heart failure Cardiac enzymes:
CK (will begin to rise 6 hours after infarct and remain elevated for 24-48 hours), Troponin (will begin to rise 12 hours after infarct and remain elevated for 2 weeks).

Exercise-stress test, dobutamine stress echo, myocardial perfusion scan: useful to look for inducible ischemia if unsure Coronary angiography: gold-standard

 12 Lead EKG - Look for ST segment elevation (at least 1mm in two contiguous leads) - Look for ST segment depression - Look for T wave inversions - Look for Q waves - Look for new LBBB - Always compare to old EKGs

Management
Morphine for pain Oxygen if hypoxic Nitro spray/drip for pain Aspirin Lasix if in congestive heart failure Inotropes if in cardiogenic shock Streptokinase (thrombolysis-TPA or TNK more commonly used) Anticoagulation
Also, think of beta-blockers (reduce heart rate and contractility but beware of worsening of CHF). Statins and ACE-inhibitors should be added as indicated. Primary angioplasty may be indicated.

Aortic Dissection
Investigation
CXR: Look for widened mediastinum CT Scan: Angiography TEE

Management
Antihypertensive therapy o Start with beta blockers (esmolol, labetalol) o Combined with vasodilators (nitroprusside) if further BP control is needed ONLY after have achieved HR control with beta blockers If ascending dissection: surgery If descending: may be able to medically manage

Pulmonary Embolism
Investigation ECG: - Sinus tachycardia most common - Often see nonspecific abnormalities - Look for S1Q3T3 (S wave in lead I, Q wave in lead III, inverted T wave in lead III)

Pulmonary Embolism
Chest X-ray Normal in 25% of cases Often nonspecific findings Hamptons hump: triangular pleural based density with apex pointed towards hilum. Sign of pulmonary infarction. - Westermarks sign: dilation of pulmonary vessels proximal to embolism and collapse distal. - Pallas sign: a prominent right descending pulmonary artery. -

Westermark Sign, is a sign that represents a focus of oligemia (vasoconstriction) seen distal to a pulmonary embolus. The sign results from a combination of: (1) the dilation of the pulmonary arteries proximal to the embolus and (2) the collapse of the distal vasculature creating the

Pulmonary Embolism
Other Investigation
ABG - Look for abnormal PaO2 ,PaCO2 Increased A-a gradient D-dimer - elevated in PE. Not specific Pulmonary angiography - Gold Standard V/Q Scan Echo - if large embolus, can see signs of right-sided compromise

Management
Anticoagulation - initiate Heparin followed by coumadin. Fibrinolytic / Thrombolysis Therapy. Supportive treatment with oxygen, and fluids.

Pneumothorax
Investigation
CXR: fine line of visceral pleural detached from parietal pleura seen on ipsilateral side o In large pneumoathoraces, mediastinal shift and contralateral compression of lung can be seen

Pneumothorax
Management
Watchful wait for small pneumothoraces repeat CXR Chest tube insertion for large, hemodynamically unstable pneumothoraces In emergent situation, insert large bore needle in 2nd ICS, midclavicular line, followed then by chest tube insertion. Give oxygen: Increases pleural air absorption

Others Management
Shingles Antivirals - reduce duration of symptoms. May also reduce incidence of postherpatic neuralgia. +/- corticosteroids may reduce inflammation Analgesia Musculoskeletal Pain Analgesia (NSAIDs)

Others Management
Esophageal Perforation

Diagnosis CXR: May see pleural effusion (usually on left). Also may see subcutaneous emphysema, pneumomediastinum, pneumothorax. CT chest Esophagram

Treatment Broad spectrum Antibiotics Immediate surgical consultation

Others Management
Psychological Diagnosis of exclusion Psychiatric evaluation

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