Emergency Medicine

CHEST PAIN

General Medical Emergencies 59

3 Refer the patient to the medical team for bed rest and cardiac monitoring if
there are widespread ECG changes or raised cardiac enzymes.

4 Arrange urgent echocardiography and pericardiocentesis for signs of cardiac
tamponade such as tachycardia, hypotension, pulsus paradoxus and a raised
JVP that rises on inspiration, k nown as Kussmaul ’s sign (see p. 10).

Pleurisy

DIAGNOSIS

1 Pleurisy or pleuritic pain occurs in association with pneumonia, pulmonary
infarction from a PE, neoplasia, tuberculosis, connective tissue disorders,
uraemia, or following trauma.

2 It may also be due to viruses, especially enteroviruses, and may be mimicked
by a pneumothorax or epidemic myalgia (Bornholm’s disease).

3 The pain is sharp, knife-like, localized and exacerbated by moving, cough-
ing or breathing, which tends to be shallow. Radiation to the shoulder or
abdomen occurs with diaphragmatic involvement.

4 Listen for a pleural rub, although this may be inaudible if pain limits deep
breat hing, and disappears as an ef f usion develops.

5 Send ABGs if there are significant signs of pulmonary parenchymal disease.
Perform an ECG, which should be normal.

6 Request a CXR that may reveal the underlying cause or may be quite normal.

MANAGEMENT

1 Give the patient oxygen and a non-steroidal anti-inf lammatory analgesic
such as ibuprofen 200 –400 mg ora lly t.d.s. or naproxen 250 mg ora lly t.d.s.

2 Rule out a PE if there was sudden dyspnoea, tachypnoea and risk factors for
thromboembolism. A PE is possible even with a normal CXR and ECG (see
p. 51).

3 Refer the patient to the medical team for treatment of the underlying cause,
or discuss with the senior ED doctor before discharging.

Abdominal causes of chest pain

DIAGNOSIS AND MANAGEMENT

1 Oesophagitis
(i) This is suggested by burning retrosternal or epigastric pain,
worse on stooping or recumbency, exacerbated by hot drinks or
food, and relieved by antacids.
(ii) It may mimic cardiac pain and may even be relieved by
sublingual GTN, so consult the senior ED doctor