Approach to chest pain management

Definition

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain of moderate or greater intensity is commonly accompanied by anxiety and an urge to escape or relieve the sensation.

Pain is a subjective and unique perceptual experience with multiple dimensions that may not be directly observed by others or measured using physiological tests. Therefore, pain assessment relies primarily on the patient's self-report.

Assessment of pain

Self-report is the cornerstone of pain assessment.

In non-verbal or pre-verbal children, facial expression is the most reliable indicator of pain. Use an appropriate faces pain scale to assess pain severity.

Assess the following:

• Duration

• Severity (e.g., whether the pain awakens the patient from sleep)

• Site

• Characteristics (e.g., stabbing, throbbing, crushing, or cramp-like)

• Pattern (persistent or intermittent)

• Relieving and aggravating factors

• Associated symptoms

• Distribution or radiation of pain

Pain assessment in children

In children, pain may also be assessed by observing:

• Crying

• Voice

• Posture

• Movement

• Skin colour

Clinical approach

The evaluation of non-traumatic chest pain requires early recognition of life-threatening conditions. Patients with life-threatening causes of chest pain may initially present with normal or stable vital signs.

Differential diagnosis

Consider the following causes of chest pain:

Cardiovascular causes

• Acute coronary syndrome

• Myocardial infarction

• Cardiac tamponade

• Pericarditis

• Myocarditis

• Aortic dissection

Respiratory causes

• Pulmonary embolism

• Tension pneumothorax

• Lung infection (pneumonia)

• Acute chest syndrome (in patients with sickle cell disease)

Gastrointestinal causes

• Esophageal perforation

• Reflux esophagitis

Musculoskeletal causes

• Musculoskeletal chest pain

Investigations

Investigations should be guided by the clinical presentation.

Recommended investigations include:

• Point-of-care ECG

• Bedside ultrasound (cardiac, lungs, pleural space, inferior vena cava, abdominal aorta, kidneys, and other relevant structures)

• Point-of-care troponin

• Serum electrolytes

• Blood gas analysis

• Serum creatinine and urea

• Urine pregnancy test, where indicated

• Chest X-ray

• CT scan of the chest, where indicated

Pharmacological treatment

Treat the underlying cause as described in the relevant disease-specific chapters.

The following analgesics may be used for pain relief.

Oral analgesia

Paracetamol (PO)

• 1 g every 6 hours for 24 hours.

OR

Ibuprofen (PO)

• 400 mg every 8 hours for 24 hours.

OR

Diclofenac (IM)

• 50–100 mg stat.

Analgesia for patients unable to take oral medication

Tramadol (IV)

• 50–100 mg stat.

OR

Morphine (IV)

• 0.1 mg/kg stat.

OR

Paracetamol (IV)

• 1 g stat.

Suspected myocardial ischemia

If myocardial ischemia is highly suspected, administer:

Acetylsalicylic acid (PO)

• 325 mg stat.

AND

Clopidogrel (PO)

• 300 mg stat.

Referral

Refer the patient to a higher-level facility with appropriate expertise if the cause of chest pain cannot be established.