Emergency Medicine

CARDIAC ARRHYTHMIAS

60 General Medical Emergencies

(a) admit the patient to rule out ACS with serial ECGs and

troponins, if there is any doubt at all about the diagnosis.

(iii) Otherwise give an antacid or proton-pump inhibitor orally.

2 Oesophageal rupture. See page 236.

3 Acute cholecystitis, pancreatitis and peptic ulceration may cause chest pain,

but other diagnostic features should be present.

Musculoskeletal and chest wall pain

DIAGNOSIS AND MANAGEMENT

1 Musculoskeletal disorders cause pain that is worse with movement and

breathing. There may have been preceding strenuous exercise, a bout of

coughing, or a history of minor trauma.

2 Pain is localized on palpation and the ECG is normal. A CXR may show a

fractured rib but is otherwise normal.

3 Give the patient a non-steroidal anti-inf lammatory analgesic such as ibupro-

fen 200–400 mg orally t.d.s., or naproxen 250 mg orally t.d.s. Refer back to

the GP.

4 Tw o s p e c i f i c c a u s e s a r e :

(i) Shingles

This causes pain localized to a dermatome, unaffected by breathing,

associated with an area of hyperaesthesia preceding the characteristic

blistering rash

(a) give the patient (usually elderly) with severe pain a narcotic

analgesic and aciclovir 800 mg orally five times a day for 7

days, or famciclovir 250 mg orally t.d.s. for 7 days, if seen

within 72 h of vesicle eruption

(b) admit to a suitable isolation area if unable to be nursed at home.

(ii) Costochondritis (Tietze’s syndrome)

This causes localized pain, swelling and tenderness typically around the

second costochondral junction, related to physical strain or minor injury.

(a) prescribe ibuprofen 200–400 mg orally t.d.s., or naproxen

250 mg orally t.d.s. Refer the patient back to the GP.

CARDIAC ARRHYTHMIAS

DIAGNOSIS

1 Cardiac rhythm disturbances include atrial, nodal and ventricular tachy-

cardias, atrial f lutter and fibrillation, the bradycardias and the various

degrees of heart block.