Chest pain

Initial approach

Several life-threatening conditions can cause chest pain in the critically ill, and the initial approach should focus on prompt evaluation and resuscitation of the airway, breathing, and circulation. Assess the patient’s level of consciousness, palpate the pulse, and listen to the breath sounds and heart. Obtain vital signs, including oxygen saturation by pulse oximetry, and ensure that the patient is attached to a cardiac monitor and has adequate intravenous (IV) access. Such measures will help ensure that critical abnormalities such as hypoxemia, hypotension, and unstable dysrhythmias are quickly identified and treated. These conditions, as well as the life-threatening causes of chest pain discussed here, are covered in greater detail in other chapters in this textbook.

History

After initial evaluation and stabilization, obtain a more detailed history. If the patient can communicate, start with an open-ended question like “What’s going on, Mr. Jones?” Physicians often neglect to ask basic questions about the quality of chest pain, as was shown in a study of patients with aortic dissection (AD), and this omission is associated with a delay in diagnosis. The use of a history-taking mnemonic can help avoid this mistake (see online supplemental table for further detail: eTable 28.1 ). Ask the bedside nurse about recent changes in the patient’s condition. As an important subsequent step, a quick “chart dissection” should be performed, focusing on the findings at presentation, reason for intensive care unit (ICU) admission, past history, and progress notes. Attention should be given to recent procedures, previous diagnostic imaging such as chest computed tomography (CT), coronary angiography, or echocardiogram, in addition to electrocardiograms (ECGs). Much of the chest pain literature focuses on management in the emergency department (ED), and although the principles provided apply in both ED and ICU areas, there are also differences. Most notably, ICU patients are already admitted to the hospital and identified as critically ill, whereas ED patients are not. Key differences between assessment of chest pain in the ICU and ED are enumerated in Table 28.1 .

Physical examination

Inspect the chest for asymmetric excursions, rashes, or obvious sources of pain, such as chest tubes. Palpate the chest and neck for crepitus, which can result from a pneumothorax or pneumomediastinum. Check for pulsus paradoxus and jugular venous distention (JVD). Assess for asymmetry in the carotid, femoral, or radial pulses, which can be a sign of AD. If breath sounds are asymmetric, hyperresonance to percussion may confirm a pneumothorax. Cardiac auscultation may reveal a friction rub from pericarditis, “crunching” sounds from mediastinal emphysema (Hamman sign), a systolic murmur of aortic stenosis (AS), or an aortic insufficiency murmur from a proximal AD. A focused examination should include the abdomen to avoid missing an abdominal catastrophe masquerading as chest pain. Evaluate for evidence of shock, as demonstrated by coolness or mottling of the lower extremities, decreased urine output, or encephalopathy.

Diagnostic adjuncts

In the absence of an obvious cause of chest pain (e.g., shingles), a portable chest x-ray (CXR) and ECG should be obtained. Serial cardiac enzymes (particularly high-sensitivity troponin) should be considered to exclude a myocardial infarction (MI). The ECG is often nonspecific but occasionally shows evidence suggestive of acute coronary syndrome (ACS), pericarditis, or pulmonary embolism (PE). The CXR is a useful screening tool for life-threatening causes of chest pain, such as pneumothorax or esophageal rupture. Both the ECG and CXR should be compared with those performed before the onset of pain.

IV contrast-enhanced CT can help diagnose a number of causes of chest pain, including PE, AD, esophageal rupture, pneumothorax, and pneumonia. The benefits of CT scanning, however, must be weighed against the risks of transporting a critically ill patient out of the ICU. Ultrasound (including echocardiography) can be rapidly performed at the bedside with minimal risk to the patient, and in the hands of a highly skilled clinician, can provide dynamic functional imaging and serve as a substitute for the CXR. Pericarditis with associated effusion, wall motion abnormality from MI, AS, AD, pneumothorax, or pleural effusions are all within the diagnostic scope of ultrasound. Ultrasound has the added benefit of providing information about cardiac function. Further discussion of the utility and implementation of bedside ultrasound can be found in greater detail in other chapters in this textbook. Diagnostic adjuncts should be used to augment pre-test probability for a particular diagnosis following a focused history and physical examination, as opposed to a “shotgun” approach to testing.

Differential diagnoses

• 1.

  Do not assume the admission diagnosis is correct or all-inclusive. Premature closure, that is, failing to consider alternative possibilities after a diagnosis has come to mind, is a common cause of medical error. Premature closure likely contributes to the delay in diagnosis described in hospitalized patients with AD.

• 2.

  Do not be biased by the type of ICU to which the patient is admitted. AD can present as a stroke, prompting admission to a neurologic ICU, or an acute abdomen can develop in a medical ICU patient.

Potentially life-threatening causes of chest pain