Chest pain: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
===Workup of emergent chest pain=== | ===Workup of emergent chest pain=== | ||
{{seealso|Acute coronary syndrome}}" | {{seealso|Acute coronary syndrome}} | ||
Patients with all of the following findings have sufficiently low risk that even an [[electrocardiogram]] is not needed:<ref name="pmid3970650">{{cite journal| author=Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L| title=Acute chest pain in the emergency room. Identification and examination of low-risk patients. | journal=Arch Intern Med | year= 1985 | volume= 145 | issue= 1 | pages= 65-9 | pmid=3970650 | doi= | pmc= | url= }} </ref> | |||
* "sharp or stabbing pain" | |||
* "no history of angina or myocardial infarction" | |||
* "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall" | |||
In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". <ref name="pmid22221842">{{cite journal| author=Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al.| title=Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. | journal=Ann Emerg Med | year= 2012 | volume= 59 | issue= 4 | pages= 256-264.e3 | pmid=22221842 | doi=10.1016/j.annemergmed.2011.10.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22221842 }} </ref> | In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". <ref name="pmid22221842">{{cite journal| author=Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al.| title=Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. | journal=Ann Emerg Med | year= 2012 | volume= 59 | issue= 4 | pages= 256-264.e3 | pmid=22221842 | doi=10.1016/j.annemergmed.2011.10.016 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22221842 }} </ref> | ||
Revision as of 07:24, 11 May 2012
In medicine, chest pain is "pressure, burning, or numbness in the chest."[1] Chest pain can be caused by an extremely wide range of conditions, including some, such as myocardial infarction, which, if untreated, could lead to death within minutes or hours. Other causes may be less urgent, while others can indicate self-limiting disease. There are idiopathic chest pain syndromes that have no apparent cause.
Diagnosis
Workup of emergent chest pain
- See also: Acute coronary syndrome
Patients with all of the following findings have sufficiently low risk that even an electrocardiogram is not needed:[2]
- "sharp or stabbing pain"
- "no history of angina or myocardial infarction"
- "pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall"
In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.". [3]
Since many causes of acute chest pain can be immediately life-threatening, general supportive measures are begun when a more specific workup continues. Algorithms are adapted from [4]
First categorization
- If there is a history of chest trauma, go to chest trauma. Note that chest trauma can still have major physiologic effects on the heart and lungs
- If the patient is hypotensive orin shock begin emergency hypotension protocol, unless the patient is also in acute distress from pain or dyspnea; if so, begin immediate acute cardiac syndrome care
- Consider:
- Aortic dissection
- Leaking aortic aneurysm
- Myocardial infarction with vagotonia
- If the patient also exhibits central venous hypervolemia (e.g., jugular venous distention), consider:
- If central venous hypervolemia is not present, consider:
- Consider:
Non-emergent chest pain
- chostochondritis
- anxiety
- gout and pseudogout
- Abdominal injury or disease with referred pain
- Herpes zoster
- Acromioclavicular injury
- Anxiety
- Lung cancer
- Sternoclavicular joint injury
Treatment
Strong analgesics such as morphine are usually indicated in sudden, severe chest pain, with care to avoid depressing respiration. If the etiology is cardiac, morphine may improve survival as well as relieve pain.
Since chest pain is a symptom rather than a disease, diagnosis and treatment need to focus on the underlying disease(s).
Idiopathic chest pain
Among patients who have chest pain without any identifiable cause, antidepressants, either tricyclic antidepressants[5] or second-generation antidepressants[6] may reduce pain.
References
- ↑ Anonymous (2024), Chest pain (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients.". Arch Intern Med 145 (1): 65-9. PMID 3970650. [e]
- ↑ Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E et al. (2012). "Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.". Ann Emerg Med 59 (4): 256-264.e3. DOI:10.1016/j.annemergmed.2011.10.016. PMID 22221842. Research Blogging.
- ↑ Chansky ME, Nyce A, Friedman J (2004), Chapter 12, Chest Pain, in Barbarella SR, Dennis WR Jr., Current Emergency Diagnosis and Treatment (Fifth Edition ed.), Lange Medical Books, McGraw-Hill, Figure 12-1, p. 241
- ↑ Cannon RO, Quyyumi AA, Mincemoyer R, Stine AM, Gracely RH, Smith WB et al. (1994). "Imipramine in patients with chest pain despite normal coronary angiograms.". N Engl J Med 330 (20): 1411-7. PMID 8159194.
- ↑ Lee H, Kim JH, Min BH, Lee JH, Son HJ, Kim JJ et al. (2010). "Efficacy of venlafaxine for symptomatic relief in young adult patients with functional chest pain: a randomized, double-blind, placebo-controlled, crossover trial.". Am J Gastroenterol 105 (7): 1504-12. DOI:10.1038/ajg.2010.82. PMID 20332772. Research Blogging.