Emergency Medicine/Chest pain

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[edit] Chest Pain

Multiple conditions may present as chest pain. These can range from simple causes such as indigestion, to extremely severe conditions, such as Myocardial Infarctions (heart attack). Potentially life threatening causes of non-traumatic chest pain include heart attacks, pulmonary embolus (clot in the lung), tension pneumothorax and aortic dissection.

[edit] Diagnosis

• The first step in the diagnosis of chest pain involves obtaining a history and performing a physical examination. This history and physical may provide important clues to the most likely diagnoses.
• The next step is to obtain an EKG (electrocardiogram).

This may show evidence of heart muscle (myocardial) injury or arrhythmias (irregular rhythm). The most important finding for heart muscle injury on the EKG is elevation or depression of the ST segment. Elevation of the ST segment with ongoing chest pain suggests acute myocardial infarction (ST elevation myocardial infarction or STEMI) and requires emergency therapy to open the culprit artery. Blood tests must be obtained to detect elevation of biochemical markers of heart damage('cardiac enzymes' like Troponin I or T, or CK-MB). Elevated troponin blood tests are more specific indicators of myocardial damage and suggest an increased risk of further cardiac events. It is important to note that no single test is capable of conclusively proving or disproving the diagnosis of myocadial infarction. A Chest X-ray may also be helpful. Newer diagnostic modalities in chest pain include using the new 64 slice CT (Computerized Tomography) Scanners, MRI (Magnetic resonance imaging), or Echocardiography. CT scans are being evaluated for a "triple rule out" strategy to image the coronary arteries (to assess for myocardial infarction), the aorta (for aortic dissection), and to rule out pulmonary embolism.

[edit] Treatment

Treatment of chest pain, is cause based.

• Myocardial infarction is traditionally treated with Morphine ( a strong pain killer), oxygen, nitrates and Aspirin (a blood thinner). Newer treatment may include angioplasty or cardiac bypass surgery.
• Heparin or Warfarin (other blood thinners)are used to thin the patient's blood and help treat blood clots in the lungs. Decompression is the only definitive treatment for a pneumothorax. Surgery may be the only definitive treatment for aortic dissection.