Chapter 14. Chest Pain

See Figure 14–1.

Initial Management

Airway, Breathing, Circulation

Begin Supplemental Oxygen

Give oxygen by nasal cannula or face mask, pending further evaluation.

Begin Continuous Cardiac Monitoring

Begin cardiac monitoring with pulse oximetry and treat life-threatening arrhythmias (Chapters 9 and 34).

Look for Markedly Abnormal Hemodynamics

Clinical Findings

Look for signs of shock. Altered sensorium, pale clammy skin, oliguria, and respiratory distress may result from arterial hypotension and poor peripheral perfusion.

Management of the Patient with Chest Pain and Abnormal Hemodynamics

Treatment and Disposition

Immediate Measures

Insert two large-bore (≥16-gauge) intravenous catheters. Intraosseous (IO) access is acceptable and compatible with all resuscitation infusions including thrombolytics. Obtain blood for a complete blood count (CBC), markers of cardiac injury, and basic metabolic panel (electrolytes, glucose, renal function). Begin administration of intravenous fluids based on estimate of intravascular fluid volume.

Hypovolemic Shock

Infuse 250–500 mL of intravenous crystalloid solutions (normal saline or lactated Ringer's). Monitor the response (blood pressure, urine output, sensorium).

Central Venous Hypervolemia (with or Without Shock or Hypotension)

Pending more precise diagnosis, infuse normal saline to keep the intravenous catheter patent or place a saline lock IV.

Briefly examine the pulmonary and cardiovascular systems, and palpate the abdomen for presence of a pulsatile mass. Obtain a 12-lead electrocardiogram (ECG). Obtain arterial blood for blood gas and pH determinations. Avoid unnecessary arterial punctures if the patient is a candidate for thrombolytic therapy for acute myocardial infarction. Obtain a portable chest radiograph. Insert a urinary catheter.

Hypotension or Shock Present

Central Venous Hypovolemia

Hypovolemia is manifested by collapsed neck veins, clear lung fields on physical examination or chest X-ray, and absence of peripheral edema. Table 14–1 lists the differentiating features of the three most important conditions causing chest pain with hypotension with central venous hypovolemia.

If the diagnosis is uncertain, treatment should be oriented primarily toward aortic dissection (Chapter 40). Type and crossmatch for 6–10 units of packed red blood cells. Expand intravascular volume with administration of intravenous crystalloid solution. Consider inserting a central venous catheter. For severe hypovolemia with shock, up to 3 L of crystalloid solution may be given rapidly (over 30–60 minutes) to restore normal hemodynamics until crossmatched blood is available. If there is no response to crystalloid solution, type-specific or universal donor blood (O negative, low antibody titer, or erythrocyte antigens) may be used pending the availability of crossmatched blood. Maintain blood pressure with continued infusion of blood and crystalloid solution. Obtain emergency vascular or thoracic surgical consultation.

Pulse deficits, an abdominal mass, or occult hematuria indicate aortic aneurysm or dissection. Obtain a portable chest X-ray and if the patient is stable consider computed tomography (CT) scan of the chest or abdomen and pelvis if indicated. Bedside ultrasound, if available, can be of great assistance in the diagnosis and management of these patients.

Management of thoracic aortic dissection consists of β-blockade (esmolol) to maintain heart rate less than 60–80 beats/min and vasodilators (nitroprusside) to maintain a systolic blood pressure less than 120 mm Hg, establishing the β-blockade first. Dissections involving the ascending aorta are managed surgically, while those not involving the ascending aorta are generally managed medically. For medical management, hospitalize the patient in an intensive care setting immediately for further evaluation and treatment.

Central Venous Hypervolemia

Superficial veins (especially neck veins) are distended; pulmonary and peripheral edema may be present. See Table 14–2 for guidelines to differential diagnosis.

Tension Pneumothorax

(See Chapter 24) Consider tension pneumothorax immediately because this condition may be quickly and reliably differentiated from the others and is easy to treat. Look for marked respiratory distress, tracheal deviation away from the affected side, and a hyperresonant hemithorax with markedly decreased or absent breath sounds on the affected side. Chest X-ray confirms the diagnosis, but treatment should not be delayed to obtain a chest X-ray. Treatment consists of the insertion of a thoracostomy tube if one is readily available (Chapter 7). Otherwise, a 14-gauge needle inserted in the second intercostal space at the midclavicular line or in the fourth intercostal space at the anterior axillary line relieves tension in the chest until a thoracostomy tube can be inserted. Hospitalize the patient for further care.

Cardiac Tamponade

(See Chapter 24) Cardiac tamponade should also be diagnosed early because treatment is reasonably effective but differs markedly from that for cardiogenic shock, heart failure, or pulmonary embolism. Look for hypotension, jugular venous distension, and muffled heart sounds (Beck triad). Electrocardiographic manifestations may include low voltage on all leads, electrical alternans, or diffuse ST-segment elevation typical of pericarditis. A narrow pulse pressure and pulsus paradoxus may also be present. Pulmonary edema is rare. Because acute tamponade does not cause cardiomegaly, chest X-ray is not helpful. Definitive diagnosis by noninvasive methods is best done by bedside emergency ultrasound or formal echocardiography. Attempt volume expansion with intravenous administration of 500–1000 mL of crystalloid solution over 20–30 minutes if the diagnosis is confirmed (this therapy is disastrous for cardiogenic shock). If the initial trial succeeds in elevating the blood pressure, volume expansion may be repeated once in a patient whose systolic blood pressure subsequently drops to less than 90 mm Hg.

Obtain emergency cardiothoracic consultation for therapeutic pericardiocentesis, which should be performed in the operating room or under echocardiographic or fluoroscopic guidance. If rapid, progressive hypotension develops and the patient fails to respond to volume expansion perform immediate pericardiocentesis (under ultrasound guidance if available) (Chapter 6). Hospitalize the patient at once in an intensive care unit.

Cardiogenic Shock (Arrhythmogenic)

See Chapter 35 for further details on the diagnosis and treatment of cardiac arrhythmias.

Give atropine, 0.5 mg intravenously; if necessary, repeat every 5–10 minutes up to a total dose of 0.04 mg/kg. An external transcutaneous pacemaker (Chapter 7) may be applied to increase the heart rate until a percutaneous transvenous pacemaker can be inserted, if indicated. Epinephrine infusion can be used for patients that do not respond to atropine. Begin an infusion at 2–10 μg/min and titrate to patient response. Assess intravascular volume and support as needed. Dopamine can be used to support blood pressure and increase myocardial contractility. Infuse at a rate of 10–20 μg/kg/min by continuous intravenous infusion. It may be administered with epinephrine or administered alone. Titrate the dose to patient response. Consider IV glucagon, 3 mg initially, followed by infusion at 3 mg/hour for patients with hypotension and bradycardia from either B-blocker or calcium channel blocker overdose.

Immediate cardioversion is the treatment of choice for tachydysrhythmia-induced shock. Deliver 50–100 J of synchronized direct current counter shock initially, and increase the shock by 50–100 J increments if there is no response. (If the patient is STABLE ie, no alteration in mental status, no chest pain, no shock or hypotension see Chapter 34).

Cardiogenic Shock (Myocardial Infarction)

(See also Chapter 34) In patients with no evidence of pulmonary edema, ensure adequate intravascular volume; give intravenous crystalloid solution, 250–500 mL over 30 minutes. If blood pressure improves, maintain the infusion at a rate of 100–200 mL/h. Avoid unnecessary arterial punctures in patients who may be candidates for thrombolytic therapy.

Give dobutamine 5–20 mcg/kg/min IV continuous infusion, dopamine 5–20 mcg/kg/min IV continuous infusion; increase by 1–4 mcg/kg/min q10–q30 minutes to optimal response, or a combination of both if no change in blood pressure occurs or if severe shock or pulmonary edema is present initially. Dobutamine is the drug of choice for treatment of cardiogenic shock due to pump failure. Caution: Observe for signs of dysrhythmia.

Give morphine, 2–4 mg intravenously every 5–20 minutes, until pain and dyspnea are controlled. If hypotension is a concern, then fentanyl may be used for pain. Carefully monitor the patient's respiratory status.

Nitroglycerin should generally be avoided in patients in cardiogenic shock or blood pressure less than 90 mm Hg systolic.

Consider aspirin 325 mg orally if aortic dissection is unlikely. In patients with aspirin allergy or expected deferred catheterization clopidogrel may be used.

Obtain cardiology consultation immediately if an acute infarction pattern is evident on the 12-lead ECG. Emergency reperfusion therapy with thrombolytic agents or percutaneous coronary intervention has been shown to be of benefit in decreasing the mortality rate and the size of the infarct. If thrombolytic therapy is to be used (Chapter 35), it should be initiated in the emergency department by the emergency physician, avoiding the delay necessitated by obtaining cardiologic consultation or transporting the patient to the coronary care unit. Hospitalize the patient immediately in a coronary care or intensive care unit.

Massive Pulmonary Embolism

(See Chapter 33) Because massive pulmonary embolism is a difficult diagnosis to confirm rapidly, every attempt should be made to exclude other causes of chest pain with shock. Consider an emergency echocardiogram if available. Findings consistent with massive pulmonary embolism include right ventricular hypokinesis and dilation. Right ventricular dysfunction from pulmonary embolism predicts increased mortality and the need for thrombolytic therapy.

Administer 250–500 mL of normal saline over 20–30 minutes in an effort to elevate systolic blood pressure. The dose may be repeated if the trial is successful and if heart failure does not develop. In the rare patient with hypotension without central venous hypervolemia, a fluid challenge should also be given, but a larger dose (500–1000 mL of normal saline instead of 300–500 mL) may be administered.

Give dopamine (see above). If clinical signs strongly suggest pulmonary embolism and thoracic dissection has been ruled out (computerized tomography may be useful in definitively establishing either of these diagnoses), begin heparin (unfractionated or a low-molecular-weight heparin) (see Pulmonary Embolism, below, and Chapters 33 and 34). Obtain pulmonary consultation, and consider thrombolytic therapy.

Hypotension or Shock Not Present

Central Venous Hypervolemia

Superficial veins (especially neck veins) are distended. Pulmonary and peripheral edema is common. Blood pressure is normal or (more commonly) elevated.

Acute exacerbation of congestive heart failure is the most common cause. It occasionally results from acute myocardial infarction (acute cardiogenic pulmonary edema), and less commonly from acute myocarditis or pericardial effusion.

Nitroglycerin

Nitroglycerin may be quickly administered either sublingually (0.4 mg) or transdermally (nitroglycerin ointment 1.25–2.5 cm) (½–1 inch). An intravenous nitroglycerin infusion may be started in the emergency department. Monitor the blood pressure closely, and if hypotension develops, place the patient in the Trendelenburg position and decrease the infusion rate. Avoid nitrates in patients taking any selective phosphodiesterase 5 inhibitor (sildenafil [Viagra], tadalafil [Cialis], or vardenafil [Levitra]).

Furosemide

Give furosemide, 0.5–1.0 mg/kg, by bolus intravenous injection. The initial effect of rapid preload reduction is of immediate benefit; diuresis occurs later.

Morphine

Give morphine, 2–4 mg intravenous, and repeat every 5–10 minutes until pain and dyspnea are relieved.

Aspirin

Give aspirin, 160–325 mg chewed, if not contraindicated. If the patient has an allergy to aspirin, use clopidogrel, 75 mg orally.

Angiotensin-Converting Enzyme (ACE) Inhibitors

Captopril and enalapril are associated with reduced admission rates to the intensive care unit and decreased endotracheal intubation rates. Acutely, reduction in preload and afterload has been reported. For oral or sublingual captopril, a one-time dose of 12.5 or 25 mg is given; enalapril is given as a 1.25 mg intravenous infusion over 5 minutes. Avoid using ACE inhibitors in patients who are hypotensive, pregnant, hyperkalemic, or have renal insuffiency.

Positive Pressure Ventilation

If the patient continues to deteriorate, consider early noninvasive positive pressure ventilation (BiPAP or CPAP); this approach may even prevent the need for endotracheal intubation.

Inotropic Agents

Short-term inotropic therapy can improve hemodynamic parameters. These agents may be beneficial for patients who are unable to receive conventional therapy. Milrinone or dobutamine are reasonable choices.

Nesiritide

Has been shown by meta-analysis to actually increase mortality but can be considered in patients who cannot tolerate nitroglyerin. It is costly and has no additive benefit to nitroglycerin.

Hospitalization

Hospitalize the patient immediately in an intensive care setting.

Management of the Patient with Severe Chest Pain and Normal Hemodynamics

Clinical Findings

The patient is in acute distress because of chest pain but is neither hypotensive nor in shock.

Differential Diagnosis by Location and Quality of Pain

Evaluation of patients who complain of chest pain but are not in severe distress should proceed in a systematic fashion. The single most useful means of evaluation is the carefully elicited history supplemented by examination of the heart, lungs, abdomen, and peripheral vessels in conjunction with electrocardiography and chest X-ray. Consider most of the diagnostic possibilities at least briefly in every patient who presents with chest pain (Table 14–3).

Retrosternal Discomfort

Retrosternal discomfort, especially if it is a tightness, pressure, or “squeezing” pain, should suggest serious underlying disease, for example, myocardial infarction, unstable angina due to atherosclerosis or valvular heart disease, pericarditis, dissection of the aorta, or pulmonary embolism. When the abovementioned diagnoses are excluded, esophageal disease (eg, spasm, esophagitis) is the most common cause of retrosternal distress (see below). Because esophageal disease is relatively benign and rarely requires hospitalization, the more serious causes of retrosternal discomfort must be excluded with a high degree of certainty before concluding that the pain is of esophageal origin.

Pleuritic Pain

Pain that is markedly worse on inspiration should suggest pleurisy associated with pneumonia, pulmonary embolism, or isolated pleuritis. The pain of pneumothorax, pneumomediastinum, ruptured esophagus, and pericarditis frequently has a pleuritic component. The fleeting pain of a “stitch in the side” is often pleuritic in nature as well. Chest pain due to myocardial infarction may have a pleuritic component.

One of the most serious causes of pleuritic chest pain, pulmonary embolism, is also one of the most difficult to diagnose given the widely varied presentations of the disease with nonspecific history and physical examination findings. Because of the increased mortality associated with misdiagnosis, consider pulmonary embolism in all patients presenting with pleuritic chest pain (Chapters 33 and 35).

Back or Abdominal Pain with Chest Pain

Abdominal pain that is inferior to the xiphoid process and associated with chest pain should suggest intra-abdominal disease, dissecting aortic aneurysm, or possibly myocardial ischemia. In stable patients, CT scan of the chest and abdomen with intravenous contrast can reliably exclude the diagnosis of dissecting or ruptured aortic aneurysm. Even after aortic catastrophes are excluded, patients with chest pain often require hospitalization or admission to an observation unit to rule out myocardial ischemia.

Musculoskeletal Discomfort

Musculoskeletal disease with chest pain (Tietze's syndrome, rib fracture) is usually associated with marked tenderness localized over the affected site. Patients with chest pain referred from intrathoracic structures may also have some associated tenderness of superficial structures. Most patients with chest pain from musculoskeletal disorders can receive treatment in the emergency department and be discharged for outpatient follow-up care.

Chest Pain Unit

An emerging method of evaluation of chest pain in the Emergency Department is the Chest Pain Unit. Various structures can be utilized, but most are protocol-driven observation units intending to screen low risk patients for cardiac origin of chest pain. Often located in the ED proper, the Chest Pain Unit is a virtual observation unit holding patients in preparation for some form of noninvasive stress testing.

The protocols usually include serial electrocardiograms, serial markers of cardiac injury, telemetry, and risk stratification. Certain exclusion criteria typically apply: existing coronary artery disease, diabetes mellitus, stimulant induced chest pain, and sometimes female patients. These populations are thought to have higher likelihood of silent ischemia, reduced exercise tolerance, or increased risk of adverse events when undergoing stress testing.

The Chest Pain Unit will likely grow in sophistication and see more widespread use in the future of emergency medicine. In centers with large indigent populations who may have difficulty obtaining outpatient follow up, emergency physicians will increasingly incorporate this observational method. As an alternative to hospital admission, this diagnostic modality offers a cost-effective means of observing and testing low-risk patients.

Cardiovascular Disorders

Acute Coronary Syndrome

See Chapter 35.

Myocardial Infarction

See Chapter 35.

Mitral Valve Prolapse

Essentials of Diagnosis

• Has late systolic click
• Palpitations are the most frequent complaint

Clinical Findings

Consider mitral valve prolapse in any patient with a mitral regurgitation murmur or clicks (without other known heart disease or other cause of chest pain) who presents with recurring atypical chest pains. The ECG may show nonspecific T-wave abnormalities. Echocardiography is required for definitive diagnosis.

Treatment

No specific emergency therapy is required. Although life-threatening arrhythmias may occur, they are rare. β-blocker therapy (eg, metoprolol, 50 mg orally twice daily) may be offered to patients who are uncomfortably symptomatic.

Disposition

Refer patients to a cardiologist or primary care physician for definitive evaluation and management.

Aortic Stenosis and Regurgitation

Essentials of Diagnosis

• Classic triad: angina, syncope, and heart failure
• Crescendo–decrescendo systolic murmur is classic finding in aortic stenosis, loudest at second right intercostal space
• Aortic regurgitation is a high-pitched, blowing decrescendo diastolic murmur

Clinical Findings

Aortic Stenosis and Regurgitation

Aortic stenosis may have a latent period of 10–20 years. Symptoms may develop gradually and eventually culminate in the classic triad of chest pain, heart failure, and syncope. Aortic regurgitation chest pain occurs less often than in patients with aortic stenosis. However, nocturnal angina, often accompanied by diaphoresis, may occur when the heart rate slows and arterial diastolic pressure falls to extremely low levels.

Chest pain in patients with severe aortic stenosis or regurgitation is clinically similar to that of angina and is probably the result of a similar mechanism, that is, relative myocardial ischemia secondary to diminished coronary blood flow.

Anginal pain in a patient with aortic valve disease may indicate that hemodynamically significant abnormalities of the valve are present, with a higher risk of impending sudden death. Murmurs of aortic stenosis or regurgitation are present on physical examination, often with adjunctive findings indicating severe valvular disease (eg, thrill over the carotid artery, wide pulse pressure; see Table 14–3).

Treatment

Provide symptomatic treatment pending further evaluation for definitive treatment. Begin oxygen, 4 L/min, by nasal cannula, and obtain an ECG. Insert an intravenous catheter (18–20 gauge) and begin an infusion of normal saline to keep the catheter open or insert a saline lock IV. Give nitroglycerin, 0.3–0.4 mg sublingually, for pain. Patients with aortic stenosis may be hemodynamically very sensitive to nitrates. If nitroglycerin is not effective, give morphine, 2–4 mg intravenously as tolerated. Monitor the patient closely and discontinue medication if any signs of decompensation develop.

Disposition

Hospitalization is warranted because of the imminent risk of decompensation or sudden death. Patients should be evaluated for cardiac catheterization or valve replacement with or without coronary bypass.

Pericarditis

See Chapter 35.

Aortic Dissection

See Chapter 40.

Pulmonary Disorders

Pleurisy and Pleurodynia

See also Chapter 33.

Essentials of Diagnosis

• Coxsackievirus b is the most common cause
• Sudden lancinating chest pain
• Associated with fever, malaise, and headaches

Clinical Findings

Patients with idiopathic pleurisy or pleurodynia are generally young, and the onset of illness is acute, with severe pleuritic chest pain. Apart from low-grade fever in some patients and possible friction rub, other findings on physical examination are usually normal. Chest X-ray may show a small pleural effusion, with or without a small pulmonary infiltrate. Viruses (especially enteroviruses) are the usual causative agents.

An accurate diagnosis of pleurisy is important because its symptoms are similar to those of pulmonary embolism. Pleurisy is often a diagnosis of exclusion.

Treatment

Pleurisy and pleurodynia are benign, self-limited diseases, and only symptomatic measures are necessary. Although aspirin is sufficient for most patients, indomethacin, 25–50 mg orally three times daily, is reported to be more effective.

Disposition

Hospitalization is rarely indicated (only for relief of severe pain). Refer patients to an outpatient clinic for tuberculin testing and repeat chest X-ray.

Spontaneous Pneumothorax

See Chapter 33.

Traumatic Pneumothorax

See Chapter 25.

Pneumomediastinum

See also Chapter 33

Essentials of Diagnosis

• “Crunch” of subcutaneous air is felt on examination
• Chest X-ray is diagnostic
• Retrosternal pain

Clinical Findings

Pneumomediastinum is frequently associated with pneumothorax. It is characterized by severe boring pain located retrosternally or in adjacent areas; the pain sometimes radiates to the back. Chills, fever, and shock may be present, especially if there is concurrent mediastinitis. A mediastinal “crunch” on auscultation or air in the mediastinum on chest X-ray is diagnostic.

Treatment

Give oxygen by nasal cannula or mask. Insert an intravenous catheter and keep it open with normal saline. Give morphine for pain.

Treat pneumothorax with tube thoracostomy as indicated. Evaluate the patient thoroughly to rule out serious underlying disease, ruptured bronchus, or a ruptured esophagus. Rupture of the esophagus is invariably associated with mediastinitis.

Disposition

Hospitalize patients for observation and examination to rule out serious precipitating factors such as rupture of the trachea, bronchus, or esophagus. Refer patients with chronic or recurrent pneumomediastinum for outpatient care.

Pulmonary Hypertension

See also Chapter 33

Essentials of Diagnosis

• Dyspnea, exertional syncope, and exertional chest pain
• Evidence of right ventricular failure almost always present
• Prominent P2 (pulmonic) heart sound
• Doppler echocardiography can help make diagnosis

Clinical Findings

Severe or sudden onset of significant pulmonary hypertension may cause an oppressive retrosternal sensation or frank angina associated with dyspnea on exertion. A history of easy fatigability, weakness, syncope on exertion, and hemoptysis may be elicited. A loud P2 and right ventricular lift on physical examination suggest pulmonary hypertension. The ECG may reveal strain in the right side of the heart or cor pulmonale (right axis deviation; depressed ST segment and inverted T waves in leads II, III, aVF, and V1–5; and tall, peaked P waves in leads II, III, and aVF). On chest X-ray a large right ventricle or large pulmonary vessels are diagnostic.

Treatment

No specific treatment is available for pulmonary hypertension. Administer oxygen for hypoxia and treat other abnormalities (bronchopulmonary infection, recurrent pulmonary emboli, heart failure) that may be exacerbating the pulmonary hypertension.

Disposition

Hospitalization is indicated for patients with severe pain, hypoxia, or severe heart failure. Refer patients to a cardiologist for complete evaluation to rule out repairable lesions and to evaluate patients for treatment with anticoagulants or other investigational treatments.

Pulmonary Embolism

See Chapter 33.

Pneumonia

See Chapter 42.

Gastrointestinal Disorders

Esophageal Disorders

Clinical Findings

Esophageal disorders such as esophagitis, spasm, motility disorders, and gastroesophageal reflux frequently cause retrosternal chest pain that can be difficult to differentiate from pain due to cardiac causes. When cardiac disease is excluded, esophageal disorder is the most common cause of chest pain. Characteristic features of chest pain of esophageal origin include pain that is burning in nature, often radiates along the sternum, is made worse by lying down and relieved by sitting, may be induced by swallowing, and often persists for hours after a shorter episode of more intense pain. Rest, sublingual nitroglycerin, “GI cocktails,” and calcium channel blockers can relieve pain of both cardiac and esophageal origin and should not be used as diagnostic aids. Because cardiac disease is more life threatening, cardiac causes of chest pain must be excluded with a high degree of certainty before attributing the symptoms to an esophageal disorder.

Diagnostic tests include barium swallow, endoscopy, manometry, and pH monitoring. Definitive emergency diagnosis of the esophageal disorder is seldom warranted.

Treatment

General symptomatic treatment can be offered to patients who are in discomfort because the specific esophageal disorder is not usually known at the time of the emergency visit. A trial of viscous lidocaine, 15 mL mixed with 15 mL of an antacid given orally, can be tried for acute relief. Clinicians are cautioned to avoid attributing chest pain symptoms to an esophageal cause based entirely on improvement in chest discomfort after a “GI cocktail.” Other measures include eating frequent small meals, using antacids, avoiding food before sleep, and using bed blocks (10–15 cm [4–6 in] high) under the head of the bed. If gastroesophageal reflux is suspected, H2-receptor blocker or proton pump inhibitor therapy may be tried.

Disposition

If an esophageal disorder is diagnosed as the cause of chest pain and cardiac disease or other life-threatening conditions can be excluded with confidence, refer the patient for outpatient care within 1–2 weeks.

Perforated Esophagus

See also Chapter 24

Essentials of Diagnosis

• Severe chest pain
• Pain increased with swallowing or breathing
• Chest X-ray may reveal air within the mediastinum, pleural cavity, pericardium, or subcutaneous tissue

Clinical Findings

Esophageal perforation is marked by agonizing retrosternal chest pain associated with pneumomediastinum, pneumothorax, pneumonia, or purulent pleural effusion. A recent history of severe retching, vomiting (Boerhaave's syndrome), or endoscopy is often present. The diagnosis is confirmed by an esophagogram using water-soluble contrast medium or esophagoscopy.

Treatment

See Chapter 24.

Disposition

Hospitalize the patient in a critical care unit for resuscitation, physiologic monitoring, limiting the extent of mediastinal contamination (NPO and nasogastric tube decompression), broad-spectrum antibiotics, and usually surgical treatment.

Perforated Stomach or Duodenum

See also Chapter 15

Essentials of Diagnosis

• Often a history of peptic ulcer disease
• Vomiting is common
• Acute distress
• Acute abdominal X-ray may reveal free air in the abdomen

Clinical Findings

Perforation distal to the esophagus is characterized by sudden onset of severe pain that is usually epigastric but may be retrosternal and may radiate to the back. A history of chronic epigastric pain or ulcer disease often is present. Epigastric tenderness and diminished or absent bowel sounds may be found. If peritonitis has supervened, rebound tenderness and a rigid abdomen are present. Air under the diaphragm may be seen on an X-ray. Serum amylase or lipase levels may be elevated as a result of posterior perforation into the pancreas. Leukocytosis with a shift to the left often is present.

Treatment

Insert a large-bore intravenous catheter, and give crystaloid solutions intravenously to support blood pressure. Give morphine for pain.

Insert a nasogastric tube and begin continuous suction. Obtain urgent surgical consultation and begin prophylactic intravenous antibiotics (see Table 15–1).

Disposition

Hospitalize the patient at once for emergency surgery.

Pancreatitis

See Chapter 15.

Cholecystitis

See Chapter 15.

Musculoskeletal Disorders

Costochondral Separation, Rib Fractures, and Intercostal Muscle Strain

See also Chapter 24.

Essentials of Diagnosis

• Pain associated with movement
• X-rays may reveal a fractured rib
• Often a history of trauma

Clinical Findings

In this group of musculoskeletal disorders, pain is usually worse with movement and breathing. A history of minor trauma, strenuous exercise, or severe coughing often is present. Pain is localized and elicited by palpation. Chest X-ray may be normal or may show rib fractures if they are present.

Treatment

Oral analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for analgesia. Local heat alone may provide relief. Narcotic analgesics may be required if respiratory effort is affected because of pain. Splinting is generally not recommended for rib fractures, because it may impair respiratory function and promote atelectasis or pneumonia. For patients with rib fractures, ensure that a pneumothorax is not present on X-ray.

Disposition

Refer the patient for outpatient follow-up if pain is severe or persistent.

Disk Disease: Cervical and Thoracic

Essentials of Diagnosis

• Pain radiates from neck or back to arms
• Paresthesia in fingers
• Weakness in arm with decreased reflexes

Clinical Findings

Disk disease may cause paroxysmal pain radiating from the back of the neck into the arms and fingers. The pain is aggravated by coughing, sneezing, and straining. Neck movement is restricted by cervical muscle spasm. The patient may have paresthesias and pain in the fingers, weakness of hand and forearm muscles, and decreased biceps and triceps reflexes. Narrowing of the vertebral interspace may be seen on a plain film, and magnetic resonance imaging confirms the diagnosis.

Treatment

Treatment is symptomatic. Superficial heat may relax muscles and be of value. A soft cervical collar is recommended only for acute soft-tissue neck injuries and should not exceed 3–4 days of continuous use.

Disposition

Hospitalization is rarely required, even for patients with severe disk disease. Outpatient follow-up by a spinal surgeon is recommended. Mild cases can be treated on an outpatient basis.

Tietze's Syndrome: Costochondritis

Essentials of Diagnosis

• Remember that cardiac pain also can be reproducible by palpation
• Pain is localized to a specific point

Clinical Findings

Tietze's syndrome affects the costochondral or chondrosternal junctions with localized tenderness.

Treatment

Pain usually is relieved by NSAIDs or other oral analgesics.

Disposition

Refer the patient for outpatient follow-up if pain is severe or persistent.

Muscle Spasm: “Stitch”

Essentials of Diagnosis

• History of trauma or exercise

Clinical Findings

The patient complains of aching pain, usually in localized areas but sometimes more generalized. Pain often increases with movement and palpation. A history of minor trauma or strenuous exercise may be present. Chest radiograph is normal.

Treatment

Massage, heat, and other local treatments are effective. Aspirin or other NSAIDs are useful.

Disposition

Refer the patient for outpatient follow-up as needed. A search for more serious illnesses (eg, myositis, arthritis, Pancoast tumor) may be necessary in recurrent or persistent cases that have no obvious cause.

Miscellaneous Disorders

Intrathoracic Neoplasm

Essentials of Diagnosis

• History of fever, night sweats, and weight loss
• Cough or hemoptysis
• Chest X-ray may reveal a mass

Clinical Findings

Intrathoracic neoplasm is suggested by a mass seen on chest X-ray with no other explanation for the chest pain.

Treatment

Give analgesics and other supportive measures as required.

Disposition

Depending on their general condition, patients with intrathoracic neoplasms should be either hospitalized or referred for timely evaluation by a pulmonologist.

Varicella Zoster

See also Chapter 48.

Essentials of Diagnosis

• Vesicles in a dermatomal pattern
• Does not cross midline
• Pain may precede vesicles

Clinical Findings

In the pre-eruptive stage of zoster, pain felt on the skin surface in dermatomal distribution may occur several days before the characteristic skin lesions (clusters of clear, fluid-filled vesicles in a dermatomal distribution) appear. Pain is typically unilateral and does not cross the mid-line. Hypoesthesia in dermatomal distribution may also be present.

The appearance of the skin lesions confirms the diagnosis. Rarely, patients may present with pain as the only manifestation of the disease; in such patients, a rise in antibody titer is diagnostic.

Treatment

Give analgesics as necessary; narcotics may be required for relief. Acyclovir, 800 mg orally five times daily for 7–10 days, or famciclovir, 500 mg orally three times a day for 7 days, if given within 72 hours of onset, may alleviate symptoms, shorten the duration of illness, and reduce the incidence of postherpetic neuralgia, a special concern in elderly patients. Local nerve block with long-acting anesthetics (eg, bupivacaine [Marcaine, Sensorcaine]) is effective and obviates the need for narcotics and their associated side effects. It may also decrease the incidence and severity of postherpetic neuralgia. Prednisone, 60 mg orally daily (tapered over 2 weeks), may also decrease the incidence and severity of postherpetic neuralgia in elderly patients.

Disposition

Patients with severe cases (extensive localized disease, dissemination, immunosuppression) may require hospitalization for pain control and possible treatment with intravenous acyclovir. Other patients may be referred for outpatient evaluation and continued treatment (analgesia).