Chest pain

CHAPTER 7 Chest pain


The first task in the evaluation of a patient with chest pain is to determine whether the pain is a life-threatening condition, such as ischemic heart disease, aortic dissection, or pulmonary embolism (PE). Myocardial ischemia and myocardial infarction (MI) are life-threatening causes of chest pain and must be assessed rapidly so emergent treatment can be initiated. Aortic dissection is a rare but equally catastrophic cardiovascular cause of chest pain that also must be diagnosed quickly. PE, which is also a life-threatening cause of acute chest pain, is accompanied by the sudden onset of dyspnea.


If acute ischemic heart disease is an unlikely cause, other causes of acute chest pain should be considered, such as pulmonary, gastrointestinal (GI), psychological, musculoskeletal, or other conditions (such as pericarditis). A significant proportion of patients whose presenting symptoms include acute chest pain have esophageal spasm or gastroesophageal reflux disease (GERD); however, harmless conditions can mimic more serious disease. Pericarditis and valvular diseases, such as aortic stenosis and mitral valve prolapse, are less emergent causes of cardiac pain.


Clue: A quick diagnosis of acute MI greatly increases the patient’s chances of survival.


Pain in any organ or system can be the result of inflammation, obstruction/restriction, or distention/dilation. All pain arising from the GI, musculoskeletal, respiratory, cardiac, and pulmonary systems transmits to the same spinal cord segments—T1 through T5—and makes identification of the specific origin of discomfort difficult. Many causes of noncardiac chest pain relate to chest anatomy, specifically skin, muscles, ribs, cartilage, pleura, lungs, esophagus, mediastinum, and thoracic vertebrae.


In children, chest pain is rarely associated with serious organic disease. The most common causes of chest pain in children are costochondritis; trauma and muscle strain to the chest wall; and respiratory conditions associated with cough. Chest pain from cardiac disease is relatively rare in children. However, patients and families often associate chest pain with heart disease and can be anxious about the condition because of reports of sudden death in young athletes.



Diagnostic reasoning: focused history


The identification of potentially acute life-threatening situations must be made immediately. After you have determined that there is no immediate risk of severe oxygen deprivation to vital organs (e.g., MI, aortic dissection, and PE), proceed with a focused history (Table 7-1).


Table 7-1 Differentiating Ischemic from Nonischemic Chest Pain



















FACTORS ISCHEMIC ORIGIN NONISCHEMIC ORIGIN
Character of pain Constricting, squeezing, burning, heavy feeling Dull or sharp pain
Location of pain Substernal, midthoracic; radiates to arms, shoulders, neck, teeth, forearms, fingers; interscapular Left submammary and hemothorax areas
Precipitating factors With exercise, excitement, stress, after meals Pain after exercise; provoked by specific body movements or deep breaths

Modified from Selzer A: Principles and practices of clinical cardiology, ed 2, Philadelphia, 1983, Saunders.






Characteristics of pain


Typical anginal pain is described as substernal heaviness, pressure, or a squeezing sensation that is provoked by exertion and relieved with rest or nitroglycerin. The substernal pain or discomfort radiates to the left shoulder and down the left arm and can extend to the neck and lower jaw. An abrupt tearing pain, located in the anterior or posterior chest, characterizes aortic dissection. It can migrate to the arms, abdomen, back, or legs. Patients with Marfan syndrome are at risk for aortic dissection.


Pneumonia, PE, and pneumothorax present with chest pain. The patient with PE is able to point to the area of pain over the affected lung and usually describes a gripping, stabbing pain that is moderate to severe in intensity. The pain can radiate to the neck or shoulders. Patients experiencing a pneumothorax most frequently report mild to severe chest pain of sudden onset located in the lateral thorax and radiating to the ipsilateral shoulder. The quality of pain is described as sharp or tearing. Chest pain of pneumonia is located over the area of infiltration and does not radiate. It frequently has a burning or stabbing quality and is associated with cough (see Chapter 10).


Remember that chest pain is subjective and that prior experience, personal attitudes, and cultural values form the patient’s perception of pain. The severity of the chest pain is not an indication of the severity of the condition. Assessment of the severity of the pain is often made easier by the use of rating scales that use 1 to 10 or happy to sad faces (see Figure 2-1).



Onset of pain








Location and character of pain


Pain arising from the thoracic skin and other superficial tissues, such as that associated with furuncles, contusions, and abrasions, is sharply localized.


Irritation of the intercostal nerves can result in a neuritis that produces sudden onset of a stabbing, burning pain, and tenderness. The pain is easy to locate at the intercostal spaces and along inflamed nerves with three maximal pain points: adjacent to the vertebrae, in the axillary lines, and along the parasternal lines. Pain can be severe when the patient breathes deeply, coughs, or moves suddenly.


Dorsal root irritation associated with herpes zoster can present with intense burning or knifelike pain along the spine to the lateral thoracic wall and the anterior midline. This pain can restrict movement of the trunk and respirations. Generally this pain is continuous and increases in severity.


Nerve root pain is caused by mechanical irritation or edema of the nerve root. This pain can be felt at the point of irritation but is frequently referred to points along the peripheral course of the nerve. Thoracic spinal segment root pain is often referred to the lateral and anterior chest wall and is seen with spinal diseases and thoracic deformities.


Costal cartilage that loosens from the fibrous attachment most often causes localized dulling, aching pain and tenderness over the eighth, ninth, and tenth ribs on either side; however, the pain can be acute, paroxysmal, or stabbing.


Musculoskeletal pain is produced by irritation of tissues and transmitted through the sensory nerves. The stimulus travels through the nerve to the dorsal ganglion up the spinal afferent pathway to the central nervous system.


Bone pain results from irritation of sensory nerve endings in the periosteum and is intense and well localized. Chronic diseases affecting the bone marrow can cause a poorly localized pain of varying severity. Ribs are common sites for metastatic malignant deposits, probably because of their rich vascularity. When metastasis expands to the rib and involves the periosteum, pain results. Referred pain from a nerve dermatome is described as intense, aching, and boring.


When tumors involve the mediastinum, chronic aching or dull substernal chest pain is produced by pressure of the tumor against the spine or ribs.


Lung pain is caused by the involvement of adjacent structures. The trachea and large bronchus are innervated by the vagus nerve (cranial nerve X). The finer bronchi and lung parenchyma are free of pain innervation, and therefore extensive disease can occur in the periphery of the lungs without pain until the process extends to the parietal pleura. Pleural pain, or pleuritis, results from the loss of normal lubricating function and irritation of the serous membranes of the pleural surfaces. It is a constant, localized, cutting sensation that is accentuated with respiratory movement. Diaphragmatic pleural pain can be referred to the base of the neck or abdomen. Children often report chest pain from tachyarrhythmia because they are unable to differentiate between true pain and the unusual sensation of the arrhythmia. Cardiac causes of chest pain in children are usually associated with congenital anomalies or acquired diseases of the coronary artery, such as Kawasaki disease.











Food association


Differentiating between esophageal and cardiac origin of chest pain can present a challenge because the character and location of the pain can be very similar. Nitroglycerin can relieve both the pain of angina and the pain of esophagitis. In these instances, an electrocardiogram is indicated.


Esophagitis is the most frequent GI cause of chest pain. Patients describe this pain as “heartburn,” or a dull, burning sensation in the epigastric and retrosternal area. The esophagus is more pain sensitive in its proximal portion. Therefore chest pain that is temporally related to eating meals or particular foods should suggest esophagitis.


Sometimes associated symptoms of a sour taste in the mouth and mild nausea are associated with esophagitis. An esophageal tear or spasm causes more acute, severe chest pain, described as a “tearing” or “crushing” sensation. Frequently the patient experiencing pain of GI origin reports mild to moderate chest pain occurring intermittently over days to months.


Peptic ulcer and cholecystitis can cause chest pain intermittently. Hematemesis (blood in the emesis) or hematochezia (blood in the stool) frequently accompanies peptic ulceration. Cholecystitis is frequently reported as right anterior chest pain that radiates to the shoulder or upper back.


Acute pancreatitis should be considered if the chest pain is excruciating and constant and is reported in the left upper quadrant of the abdomen radiating to the chest, shoulder, and arm. Pancreatitis is often accompanied by hypotension. Physical examination and diagnostic tests are necessary to differentiate it from chest pain of cardiovascular origin.



Apr 10, 2017 | Posted by in NURSING | Comments Off on Chest pain

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