Managing Chest Pain in the Emergency Department: A Summary from the St. Emlyn's Podcast
Welcome to the St. Emlyn's podcast, hosted by Iain Beardsell and Simon Carley. In this episode, we discuss the management of chest pain, a common and challenging presentation in the emergency department (ED). Our primary focus is on identifying and ruling out life-threatening conditions, which is crucial for both new and experienced emergency physicians.
Common Causes of Chest Pain
Chest pain can stem from various conditions, some benign and others potentially fatal. The key is to rapidly identify or exclude serious causes. The top five conditions we focus on are:
- Acute Coronary Syndrome (ACS): Includes myocardial infarction (MI) and unstable angina.
- Pulmonary Embolus (PE): Blood clots in the lungs.
- Pneumothorax: Collapsed lung.
- Pneumonia: Infection of the lungs.
- Aortic Dissection: Tear in the aorta.
Initial Assessment and Prioritization
When a patient presents with chest pain, the first step is a rapid, systematic assessment to identify any immediate life-threatening conditions.
Initial Steps:
- History and Physical Examination: Focus on the character, location, and duration of pain, associated symptoms, and risk factors.
- Vital Signs: Look for abnormalities such as tachycardia, hypotension, or hypoxia.
- Electrocardiogram (ECG): Perform within 10 minutes of arrival to identify ischemic changes, arrhythmias, or other abnormalities.
- Chest X-ray: Useful for identifying pneumothorax, pneumonia, and other thoracic conditions.
Diagnostic Strategies for Common Conditions
Acute Coronary Syndrome (ACS)
Diagnosis:
- ECG: Look for ST-segment elevation or depression, T-wave inversion, or new left bundle branch block.
- Troponin Levels: High-sensitivity troponin assays are crucial for diagnosing myocardial infarction.
Management:
- Antiplatelet Therapy: Administer aspirin and a P2Y12 inhibitor.
- Anticoagulation: Use heparin or low molecular weight heparin.
- Reperfusion Therapy: For STEMI, immediate PCI or thrombolysis is essential. For NSTEMI, risk stratification guides further management.
- Symptom Relief: Use nitrates and morphine cautiously to relieve pain.
Pulmonary Embolus (PE)
Diagnosis:
- Clinical Assessment: Utilize the Wells score to stratify risk.
- D-dimer: Useful in low-risk patients to rule out PE.
- Imaging: CT pulmonary angiography (CTPA) is the gold standard for diagnosis. V/Q scan is an alternative in specific scenarios.
Management:
- Anticoagulation: Initiate treatment with low molecular weight heparin or direct oral anticoagulants (DOACs).
- Supportive Care: Oxygen therapy and fluids for hypotension.
- Thrombolysis: Consider in massive PE with hemodynamic instability.
Pneumothorax
Diagnosis:
- Clinical Presentation: Sudden onset of pleuritic chest pain and dyspnea.
- Imaging: Chest x-ray or bedside ultrasound for confirmation.
Management:
- Observation: Small, asymptomatic pneumothoraxes may be observed with repeat imaging.
- Intervention: Needle aspiration or chest tube insertion for larger or symptomatic pneumothoraxes.
Pneumonia
Diagnosis:
- Clinical Features: Fever, cough, sputum production, and pleuritic chest pain.
- Imaging: Chest x-ray showing infiltrates.
Management:
- Antibiotics: Empiric therapy based on community-acquired or hospital-acquired pneumonia guidelines.
- Supportive Care: Oxygen therapy, fluids, and symptom management.
Aortic Dissection
Diagnosis:
- Clinical Suspicion: Severe, tearing chest pain radiating to the back with possible differential blood pressures.
- Imaging: CT aortography is the gold standard for diagnosis.
Management:
- Blood Pressure Control: Aggressive management with IV beta-blockers and vasodilators to target systolic BP <120 mmHg.
- Surgical Consultation: Immediate for type A dissections; consider for type B depending on complications.
Risk Stratification and Decision-Making
Effective risk stratification is key to managing chest pain efficiently. Tools like the HEART score for ACS and the Wells score for PE aid in decision-making. Incorporate these tools with clinical judgment to determine the need for further testing or intervention.
HEART Score for ACS
- History: Highly suspicious, moderately suspicious, slightly suspicious.
- ECG: Significant ST-depression, non-specific repolarization disturbance, normal.
- Age: ≥65, 45–64, <45.
- Risk Factors: ≥3 risk factors or history of CAD, 1-2 risk factors, no risk factors.
- Troponin: >3x normal limit, 1-3x normal limit, ≤normal limit.
Wells Score for PE
- Clinical signs and symptoms of DVT: 3 points.
- Alternative diagnosis less likely than PE: 3 points.
- Heart rate >100 bpm: 1.5 points.
- Immobilization or surgery in the past four weeks: 1.5 points.
- Previous DVT/PE: 1.5 points.
- Hemoptysis: 1 point.
- Malignancy: 1 point.
Special Considerations in Chest Pain Management
Non-Cardiac Causes
Not all chest pain is cardiac. Consider gastrointestinal causes like gastroesophageal reflux disease (GERD) or musculoskeletal causes such as costochondritis. A thorough history and physical exam often reveal the underlying cause.
Pediatric and Geriatric Populations
Chest pain presentations in children and the elderly require special consideration. In children, consider congenital heart defects, respiratory conditions, or anxiety. In the elderly, multiple comorbidities can complicate diagnosis and management.
High-Risk and Atypical Presentations
High-risk patients with diabetes, chronic kidney disease, or those on immunosuppressive therapy may present atypically. Always maintain a high index of suspicion and consider more aggressive diagnostic approaches.
Patient Communication and Follow-Up
Clear communication with patients about their condition, treatment plan, and follow-up is essential. Ensure they understand when to return if symptoms worsen or new symptoms develop. Providing written instructions can improve comprehension and compliance.
Explaining Diagnoses and Next Steps
Be honest and clear when explaining to patients. If life-threatening conditions are ruled out, reassure them but emphasize the importance of follow-up. For non-specific chest pain, discuss potential diagnoses like musculoskeletal pain or GERD and provide appropriate management strategies.
Encouraging Follow-Up
Encourage patients to follow up with their primary care physician or specialist as needed. Ensure they understand the importance of follow-up, especially if their symptoms persist or worsen.
Conclusion
Chest pain is a common but challenging presentation in the emergency department. A systematic approach to assessment, risk stratification, and management is essential for identifying serious conditions and providing appropriate care. Always keep the patient's well-being at the forefront, and remember to communicate clearly and compassionately.
By following the strategies outlined in this guide, you'll be well-equipped to handle chest pain presentations effectively, ensuring that you provide the best possible care for your patients. Stay tuned for more insights and updates from the St. Emlyn's podcast.