EM in 5: Approach to Chest Pain

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EMin5) // Edited by:Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

This week for our EM in 5 video by Dr. Anna Pickens we have some tips on the approach to chest pain:

Video 

One of the tricky things about patients who have chest pain is the huge differential that you have to consider.  And some of these are pretty benign, while others can be fatal!

But before you even consider the differential, you need to make sure the patient is stable.  Start with the following:

• EKG
• IV, O2, Monitor
• Primary survey

Then think about the Big 6 – the things that could kill the patient:

In order to start thinking about your differential, here are some suggested helpful questions (courtesy of JAMA 2005):

Now let’s go through the clinical features of our Big 6:

1.) Acute MI:

Exam:

Lungs: +/- crackles;  CV: tachy/arrhythmia/murmur/JVD;   Skin:  diaphoretic, pale, cool   Extr: +/- edema

2.) Aortic Dissection:

Exam:

VS: HTN, tachy;  CV: tachy, murmur;  ABD: pulsatile mass, bruising, distention;  Skin: diaphoretic, pale, cool;  Extr: unequal pulses, unilateral weakness

3.) Pulmonary Embolism:

Exam:

VS: HTN/hypotension, tachy, hypoxic;  Lungs: unequal/decreased BS;  CV: + JVD, tachy

4.) Myocarditis/Pericarditis/Pericardial effusion:

Exam:

VS: HTN, hypotension, tachy;  CV: tachy, rub, muffled, heart sounds, +/- JVD 

5.) Pneumothorax:

Exam:

VS: hypotension, tachy, hypoxia;  CV: tachy;  Skin: diaphoretic, pale, cool;   Extr: unilateral edema/ttp (DVT)  

6.) Esophageal Rupture:

Exam:

VS: hypotension, tachy;   Lungs: +/- ronchi/crepitus;   Abd: +/- epigatric ttp, peritoneal signs (free air), bloody emesis

Other diagnoses to consider that are less serious:

• Zoster (shingles)
• Musculoskeletal
• GERD

And as for your workup, here’s a few suggestions of imaging and labs that could be helpful to start with:

Suggested/Further Reading:

• Articles/Posts:
  • emDocs – Chest Pain Controversies Part 1
  • emDocs – Chest Pain Controversies Part 2
  • Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes
  • Rebel EM – Management and Disposition of Low Risk Chest Pain
  • JournalFeed – Heart Score vs EDACS for Chest Pain
  • Flipped Classroom
  • ALiEM – What is the Value of a Good History?