Acute Thoracic Pain

Douleur Thoracique Aigue

Acute Thoracic PainCLINICAL SIGNS:

* suspicious signs , apart from an obvious clinical picture:

– history of coronary heart disease.

– pains that last for several seconds at least.

– pain dependent on breathing.

– Pain not reproducible by palpation and mobilization of the rib cage.

– associated digestive symptoms.

– risk factors for thromboembolic disease.

* signs of gravity :

– sweating, nausea, dyspnea, fever, polypnea.

Hypotension, thrombophlebitis, aortic insufficiency murmur, right heart failure, blood pressure asymmetry and peripheral pulses, focal pulmonary signs, abdominal defense.


* benign causes :

– parietal pain exacerbated by palpation or mobilization of the thoracic cavity:

 intercostal neuralgia, herpes zoster, primary fibromyalgia.

Osteoarthritis or sternocostal sprain.

 contusion, fracture, osteoporotic fracture, Tietze syndrome, Cyriax, bone cancer.

– pain in young neurotic subject:

 pain of psychic origin: anxious state .

– chest pain and vertebral pain :

 disc conflict in the dorsal or cervical vertebrae.

 vertebral compression.

– gastro-oesophageal reflux, spastic colitis.

– esophageal spasm:

 in the elderly person.

 Retrosternal spastic or constrictive pain radiating in the back, sensitive trinitro, during the meal or after ingestion of cold water.

 dysphagia and gastroesophageal reflux sometimes associated.

 treatment: trinitrine, Spasfon.

* serious causes:

– trinitrino-sensitive pain:


– intense pain, lasting more than half an hour, sensitive or not to trinitrin:

 myocardial infarction.

– pain with dorsal or descending lumbar irradiation, peripheral pulse asymmetry and breath of aortic insufficiency:

 aortic dissection.

– pain aggravated by inspiration, respiro-dependent:

 acute pericarditis.


– pain with dyspnea and signs or risk factors for thromboembolic disease:

 pulmonary embolism.

– lateralized pain + fever + expectorant cough + dyspnea:

Acute acute lobar pneumonia .

– low chest pain + digestive disorders:

Acute pancreatitis, peptic ulcer, cholecystitis.

 infarction inferior.


* scope, SpO², temperature.

* ECG before and after trinitrin:

– except if certain non-cardiac origin.

– a normal ECG is not incompatible with unstable angina or even an IDM.

– to repeat regularly in case of doubt.

* chest x-ray, ASP.

* CPK, CPK-MB , troponin or myoglobin, to be redone in case of doubt.

* possibly, D-dimers.


* treatment of the cause .

* if suspicion of a coronary event:

– trinitrin in the absence of hypotension, effective in 2-3 minutes unless IDM.

* if suspected of esophageal colic:

– sublingual trinitrine which calms the pain in about ten minutes.

* analgesics:

– oral pain relievers.

– or Nubain: ½ or 1 ampoule SC, IV or Morphine: 1 mg / 10 kg to be diluted in 10 ml, to inject ml / ml IV, until sedation of the pain.

– do not do intramuscular .

* if doubt diagnosis, suspicious signs or signs of gravity:

– venous route, oxygen therapy mask.

– hospitalization.