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Acute Chest Pain: Detailed Management

Acute Chest Pain: Detailed Management

Step 1: History Taking

  1. Acute Myocardial Infarction (MI):

  • Typical pain: Central chest tightness, radiating to the jaw, shoulders, or arms (left or both sides). Worsens with exertion. History of similar episodes or risk factors (coronary disease, hypertension, diabetes, dyslipidemia, chronic kidney disease).

  1. Aortic Dissection:

  • Pain: Sudden, severe, tearing or ripping sensation, often radiating to the back.

  1. Pneumothorax/Pulmonary Embolism (PE):

  • Presentation: Sudden onset dyspnea and sharp chest pain, worsening with deep breaths.

Other Causes:

  • GERD: Deep burning chest pain, lasting 5-60 minutes, worse in lying position, improves with antacids.

  • Esophageal Spasm: Deep chest pain, lasting 5-60 minutes, unrelated to exertion, improves with nitroglycerin.

  • Peptic Ulcer: Epigastric pain lasting hours, improves with food or antacids, EKG usually normal.

  • Biliary Disease: Epigastric pain lasting hours, radiating to the back, worsens postprandially.

  • Musculoskeletal Pain: Localized pain, varies with movement or position, can be specifically located and reproduced by palpation.

  • Hyperventilation: Chest pain lasting 2-3 minutes, deep or tight, associated with rapid breathing and stress.

  • Thyroiditis: Persistent pain, worsens with swallowing, localized to the neck.

Step 2: Physical Examination

  1. Vital Signs: Check blood pressure, pulse, respiratory rate, and oxygen saturation.

  2. Cardiovascular Examination: Listen to heart sounds, palpate pulses, and measure blood pressure in all limbs. Look for signs of pericarditis or aortic dissection.

  3. Respiratory Examination: Observe for accessory muscle use, chest expansion, palpate for crepitus, and listen to lung sounds. Consider pneumothorax or pneumomediastinum.

  4. Abdominal Examination: Focus on epigastric and right upper quadrant for cholecystitis, liver abscess, pancreatitis.

Step 3: Investigations

  1. EKG: Perform a 12-lead EKG on all patients. It's critical for diagnosing MI and can aid in diagnosing pulmonary embolism. Remember, a normal EKG does not exclude a cardiac cause.

  2. Chest X-Ray: Indicated if a pulmonary cause is suspected.

Specific Disease Evaluation and Initial Management

  1. Acute Coronary Syndrome:

  • STEMI: ST-Elevation (more than 1 mm except in V2, V3) in 2+ contiguous leads.

  • NSTE-ACS:

  • NSTEMI: Cardiac enzymes rising.

  • Unstable Angina: Cardiac enzymes not rising.

  • Initial Management:

  • Oxygen to keep SpO2 ≥ 90%.

  • Aspirin 325 mg PO chew stat.

  • Clopidogrel 300-600 mg oral stat or Ticagrelor 180 mg oral.

  • Anticoagulants: Unfractionated Heparin (UFH), Low Molecular Weight Heparin (LMWH).

  • Blood pressure control as per hypertensive emergency guidelines.

  1. Aortic Dissection: BP control, pain management, CTA, and surgical consultation.

  2. Pulmonary Embolism:

  • Unstable Vital Signs: Resuscitate following ABCD protocol, echocardiogram or CTA PE protocol, start Unfractionated Heparin 80 unit/kg IV bolus then 18 unit/kg/min drip after confirming PE.

  • Stable Vital Signs: Oxygen supplementation, IV fluids, CTA PE protocol.

In managing acute chest pain, precise history taking, specific physical examination findings, and targeted investigations are essential for accurate diagnosis and appropriate management.


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