SCOPE OF THE PROBLEM

Chest pain is an extremely common complaint in the emergency department (ED), accounting for 5% of ED visits in the United States, or about 5 million visits annually. Pain in the chest may be caused by a wide variety of disease processes involving the cardiovascular, pulmonary, musculoskeletal, gastrointestinal, psychiatric, neurologic, and dermatologic systems (Table 16-1).

The differential diagnosis in the patient presenting with chest pain is broad and includes both acute, life-threatening illnesses and benign conditions. An accurate diagnosis and effective therapeutic strategy may be achieved by using a thorough knowledge of functional anatomy and physiology of the thorax in conjunction with a proper history and physical examination. The emergency physician's choice of analgesic should be based upon the known or suspected diagnosis.

One of the fundamental challenges in diagnosing and treating chest pain lies in the fact that neither the quality nor the intensity of the pain is specific for any single organ system. As an example, esophageal spasm and cardiac ischemia can present with nearly identical pain syndromes. A second challenge to treatment of this patient population is the fact that neither the location nor the radiation pattern reliably identifies the specific organ system. As a result, the clinician is frequently required to pursue a parallel course of both identification of the etiology of the pain and simultaneously treating the patient's pain syndrome. Once a definitive diagnosis is made, the analgesic regimen can be tailored to the individual pathologic process (Table 16-2).