Chest Pain

Basics

Description

  • One of the most frequent chief complaints in the ED
  • Often the presenting symptom of a high-risk etiology:
    • Acute coronary syndrome
    • Pulmonary embolism
    • Aortic dissection
  • Assume life threatening until proven otherwise
  • Categorization may suggest the underlying etiology, but the presentation of chest pain can be extremely variable and vague
  • Thoracic pain:
    • May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagus
    • Pain is deep, visceral, and poorly localized
    • Characteristics vary from severe and crushing to mild, burning, or indigestion
  • Epigastric pain:
    • May involve the descending aorta, diaphragmatic muscles, gallbladder, pancreas, duodenum, and stomach
    • Pain is generally referred to the xiphoid region and in the back
  • Pleuritic pain:
    • Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface
    • Pain increased by breathing, laughing, coughing, sneezing
    • Tenderness to palpation may be present
    • Diaphragmatic pleurisy:
      • Sharp shooting pains in the epigastrium, lower retrosternal area, or shoulder intensified by thoracic movement
  • Chest wall pain:
    • Inflammation of skin and SC structures of the chest wall
    • Pain is reproduced by:
      • Palpation
      • Horizontal flexion of the arms
      • Extension of the neck
      • Vertical pressure on the head

Etiology

  • Thoracic:
    • Acute coronary syndrome
    • Pericarditis
    • Myocarditis
    • Stress-induced cardiomyopathy
    • Microvascular ischemia
    • Stimulant use
    • Thoracic aortic dissection
    • Esophagitis
    • Esophageal spasm
    • GERD
    • Esophageal hyperalgesia
    • Abnormal motility patterns and achalasia
    • Esophageal rupture and mediastinitis
  • Epigastric:
    • Dissection of the descending aorta
    • Peptic ulcer disease
    • Pancreatitis
    • Cholecystitis
    • Splenic rupture
    • Hepatic injury
    • Subdiaphragmatic abscess
  • Pleuritic pain:
    • Pulmonary embolism
    • Pneumothorax
    • Pneumonia
    • Costochondritis
  • Diaphragmatic pleurisy:
    • Splenic rupture
    • Hepatic injury
    • Subdiaphragmatic abscess
  • Esophageal rupture
  • Intercostal myositis
  • Intercostal neuralgia
  • Pectoralis minor strain
  • Pericarditis
  • Pleuritis
  • Pneumonitis
  • Rib fractures
  • Acute chest syndrome of sickle cell
  • Chest wall twinge syndrome:
    • Brief episodes of sharp anterior chest pain lasting 30 s–3 min, aggravated by deep breathing and relieved by shallow respirations
  • Chest wall pain:
    • Chest wall hematoma
    • Chest wall laceration
    • Herpes zoster
    • Thrombophlebitis of the thoracoepigastric vein
    • Xiphisternal arthritis
    • Adiposis dolorosa
    • Breast abscess, fibroadenosis, carcinoma

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