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Common Medical Emergencies

Acute Chest Pain

Not yet clinically reviewed

This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.

Important Causes

  1. Musculoskeletal pain
  2. Esophagitis and Esophageal spasm
  3. Angina and Myocardial Infarction
  4. Pleurisy
  5. Pneumothorax
  6. Fracture rib
  7. Pericarditis
  8. Pancreatitis
  9. Cholecystitis
  10. Radicular pain
  11. Dissecting aneurysm of aorta
  12. Esophageal rupture, Mediastinitis
  13. Mediastinal emphysema
  14. Costochondritis/Intercostal myalgia
  15. Non-organic chest pain - Fibromyalgia

Approach to a Patient with Chest Pain

  • Decide whether the patient is very sick or not, Reassure the patient
  • Check vital signs (pulse, BP, respiratory rate and temperature)
  • Short history to differentiate between various causes of chest pain, decide whether the pain is due to IHD or not If pain is very severe, give parenteral analgesics preferably morphine or pethidine or pentazocine (opioid drugs are contraindicated in Bronchial asthma)
  • If cardiac pain is suspected get ECG done. In the periphery, primary management for IHD can be done on clinical suspicion alone, even if ECG is not available (like giving sedative—analgesic/sublingual nitrate/aspirin). Detailed history can be taken after the initial management.

Differentiating Features of Cardiac Pain from Non-cardiac Chest Pain

Cardiac Pain

  • Does the individual belong to the high-risk group, for IHD? (e.g.: above forty years, male, postmenopausal state, smoking, diabetes, hypertension, obese, sedentary life). Chances of having IHD is very high if it is an elderly male, chronic smoker, who is diabetic and hypertensive.
  • Physical Findings that Favor Diagnosis of IHD
  • Apprehensive look with a sense of impending doom with pale face, sweating and cold skin, hypotension or shock
  • Tachycardia/Bradycardia, Arrhythmias
  • Wide or narrow pulse pressure
  • Dyskinetic apical impulse, cardiomegaly
  • S3/S4/Apical systolic murmur (Papillary muscle dysfunction)
  • Pericardial rub, features of pulmonary edema.

Management of Acute Chest Pain

For severe chest pain of any etiology parenteral analgesics like morphine, pethidine and pentazocine can be given. These drugs can precipitate bronchospasm in patients with bronchial asthma, in whom diazepam may be used for sedation, but it lacks analgesic effect.

  • Pentazocine may be avoided in hypertensives. Investigations like ECG must be done only after giving sedative/analgesic drugs and reassuring the patient. Institute treatment for specific conditions without delay.
  • Never send the patient walking for ECG, when Acute MI or unstable angina is suspected, arrange for bedside ECG or at least send in wheel chair/trolley.

Specific Treatment

  1. Ischemic heart disease (refer chapter on IHD)
  2. Costochondritis and intercostal myalgia—Analgesic, anti-inflammatory drugs, local heat
  3. Pleurisy—Analgesics, treat the primary cause
  4. Pneumothorax (See under respiratory medicine)
  5. Esophagitis: A liquid antacid with local anesthetic action in acute phase. Treat the acid peptic disease and prevent reflux esophagitis using prokinetic agents like domperidone and other conservative measures. If candida esophagitis is suspected give Tab Nystatin in glycerin three times daily for a week, or Tab Fluderm (fluconazole) 150 mg daily for 5 days.
  6. Fracture rib: Rest, analgesics and treatment of complications, if any.
  7. Pericarditis: Analgesics/anti-inflammatory drugs or steroids when indicated. Treat the cause (infection, uremia, rheumatic fever)