# Cardiac chest pain vs. pleuritic chest pain



## MattCA (Dec 16, 2008)

What is the difference and how do you tell the difference?


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## Code 3 (Dec 16, 2008)

MattCA said:


> What is the difference and how do you tell the difference?



In quick and simple terms, cardiac chest pain stems from a lack of bloodflow and oxygen to the heart tissue, whereas pleuritic chest pains stems from inflammation and irritation of the pluera, which surrounds the lungs.

You can use textbooks and Google to find more detailed information on the differences if necessary.

I'm not sure if you can really tell the difference in a pre-hospital setting; however, your best bet would be to know the S/S of cardiac chest pain and go from there. Since pleuritic chest pain can be from respiratory infections (ie pneumonia), trauma to the rib cage, diseases, immune disorders, and certain drugs you can try and get a detailed history to help out.

I'm sure others will chime in


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## MattCA (Dec 16, 2008)

inflammation and irritation of the pluera is a good start. Thats pretty much what I understand also. Cardiac is lack of bloodflow such as a MI to the heart muscle and Plueritic is having to do with an infection in the lungs. I cant find anything in my textbook. Any idea of where to look? Google didnt really help to. It was more of webMD type stuff I guess you could say.


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## KEVD18 (Dec 16, 2008)

as somebody who has had a pleuritic infection, its hard to distinguish it from the patients point of view. 

one thing to look for is whether the pain changes with inspiration/expiration. cardiac c/p will remain fairly constant but pleuritic c/p will change when the lungs rub while expanding and contracting. if they cant take a deep breath because the pain get too bad, pleurisy is likely


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## Ridryder911 (Dec 16, 2008)

Usually pleuritic is described as a sharp, burning pain that only occurs with respiratory movement or associated with coughing, etc.. History is an important part of distinghing between the two. Such as productive cough, sometimes pain upon palpation of the chest wall as well. 

One has to be very careful not to assume one over the other. As an AMI may represent itself as pleuritic pain also. 

R/r 911


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## Code 3 (Dec 16, 2008)

MattCA said:


> I cant find anything in my textbook. Any idea of where to look? Google didnt really help to. It was more of webMD type stuff I guess you could say.



Try to Google the term "pleurisy" instead. You should get a lot of results such as this:

http://www.mayoclinic.com/health/pleurisy/DS00244


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## TomB (Dec 16, 2008)

If the patient is able to localize the pain (i.e., point to it with one or two fingers), it's sharp and worse with inspiration, and there are adventitious breath sounds auscultated over the exact spot, then you can pretty much bet that it's not cardiac. Remember, emergency physicians don't "diagnose" chest pain, they risk stratify chest pain! 

Tom


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## MSDeltaFlt (Dec 16, 2008)

Also, pleuritic chest pain is tender to palpation.  Cardiac usually isn't.  Poke on it.  If it hurts, odds are it's not cardiac.  Don't jab, but you get my point.


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## MattCA (Dec 16, 2008)

Thanks guys. Im guessing maybe he just wants the common difference as in cardiac is die muscle from lack of blood flow and plueritic is from a respirtory infection. Well see what happens! Also need to learn the trauma tree, dont know if hes expecting every injury or what h34r:


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## bled12345 (Dec 21, 2008)

how do you tell the difference?

Signs and symptoms eg: SOB, sweating, anxious, complains of significant chest pain, radiating pain, tachy pulse etc etc. 

+

Diagnostic 12 lead / 15 lead.  And even then, 12 leads have a margin of error,  so blood work  + or - trops, but even THEN trops take at least a little while to show up in the blood, and not many services I know of do bloodwork for trops in the field ( it can be done though )

SOOOOOOO..... best to always error on the side of caution, no paramedic ever got in trouble for transporting somebody to the hospital.  And when you start diagnosing between pleuritic pain / MI pain in the field, you are playing a very very dangerous game and you could potentially get burned REALLY bad one day.  Just saying ...


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## Melbourne MICA (Dec 22, 2008)

*What is what*

This is an important area of discussion particularly given 15% of AMI's present to the ED with atypical patterns of "chest pain" categorised as pleuritic.

It's never easy separating the two but the odds can be improved by widening assessment. 

A little background first. 

The characteristics of cardiac chest pain, especially where it is located, are derived from regions of nerve innervation called dermatomes. The heart happens to lie within the 4th thoracic dermatome T4, which amongst other things supplies the left arm and area across the anterior portion of the chest, hence the characteristic description of substernal central pain often radiating to the left arm. 

This applies to most people, however individual difference and various pathologies may alter, diminish or nullify these pathways. The most familiar is of course the diabetic where micro vascular damage implicates the nerves as well and these patients will often present with no pain we recognize as cardiac in nature. They are also, of course, a high risk cardiac patient.

The lungs themselves have no nerve innovation - so they cannot generate a pain response to injury. As other s have pointed out however, the pleura is innervated. So a chest wall injury, pleural effusion, pneumonia, friction rub etc will activate the pain receptors in the wall.

Pain is typically localised - that makes intuitive sense when you look at some of the pathologies I just mentioned, and may alter with movement palpation and inspiration when chest wall nerve fibres are disturbed or stretched.

But the key piece of understanding and the one that has got most of us into trouble is not to look at this information in isolation. There is also the factor that pain is individually subjective.

So when you ask a patient about pain listen very carefully and explore further. It is not enough to take a remark like, the pain changes when I breathe as a diagnostic statement. If it you it sounds pleuritic combine this remark with a chest auscultation that clearly reveals localised abnormal breath sounds like wheeze or course crackle, rhonchi or squeak. 

Also check the history for compelling signs of recent or emerging chest infection or injury such as use of prescribed antibiotics, coughs, runny noses, having a temperature, intermittent pain or did the pain start suddenly or gradually, a history of falls or strain from over exertion (if this is the case a secondary survey should be done as you would for any history of injury or falls)etc.

Pleuritic pain generally doesn't produce a lot of concurrent symptoms especially pallor and diaphoresis. Remember for the most part a septic patient will be hot and flushed not pale and cool, will be tachy and breathless with lots of breath sounds on auscultation etc.

Where SOB exists you can bet this will be occurring because of airway obstruction and adventitious breath sounds. Except for the LVF patient (whose crackles will always be bi-lateral by the way) an AMI pt for example will typically have a clear chest (except for failure in some instances).

Put the history in context with the sequence of events and know your risk factors for heart disease in particular.

In closing this classic example illustrates the point. 

42yo male of SriLankan decent, driving a car gets sudden onset crushing pain, breaks out in a sweat and begins panting. He feels decidedly unwell and goes to the doctor who calls an ambulance. The BLS crew arrives, correctly starts a cardiac assessment and gets to the question,"does the pain change when you breathe?" - yes says the patient - the pain is sharp in description. The ALS crew arrives and are told they were about to be cancelled because the pain was probably pleuritic. No auscultation done at this point.

So the key points.

* 42yo SriLankan male - 3 risk factors for AMI/IHD/ACS
* Sudden onset at rest
* Concurrent pallor, diaphoresis and SOB
* Central chest pain (going into left arm - not ascertained by BLS crew in history - T4 dermatome).
* No recent history over one or more days of illness, unwell, cough, febrile etc
* No adventitious lung sounds, no course localised crackles etc.
* No EKG reading done because they stopped at the pain changes with breathing point.
* The LMO has called an ambulance in the first place - an LMO can easily treat a chest infection with what she has there at the clinic.

Diagnosis? Inferior infarct - PTCA treatment with good outcome.

Pain as a point of history taking in isolation is a trap for the unwary. Do all your surveys and assessments before you jump to conclusions. Talk to the patient and ask about risk factors such as family history. If you commence cardiac treatment and new compelling information of pleuritic infection or injury emerges you can always stop your treatment.

A bit of a long description but I hope this helps a little.

MM


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## oneday (Oct 30, 2010)

this is gold.
i had a scenario, a 52 yr old male with diabetes and chest pain descibed as pluretic. Differential diagnosis of pulmonary embolis. i was wrong

tutor was very quick to tell me the man was having a silent AMI.

wont be forgeting to take into account diabetic pt complications any time in the near future


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## Melbourne MICA (Oct 31, 2010)

*Practice*

It's not gold, it's practice. There is only such much that can be learned from texts and lectures. At the end of the day ambulance practice is about dealing with real people and all the variations on a theme that go with this scenario. It's also about using logic, intuition, knowledge and above all problem solving. 

Most pt clinical events are are well covered within guidelines and learning packages as far as how we assess, plan, treat and reassess. There is even stuff about combining what you know with what you practice and how to adapt it to real situations. But even then you can only get so far with this material no matter whether its written or taught.

In the end "experience" is priceless as a learning and teaching tool - ("Experience" -  a term many young people mistakenly assume is "older" people bragging to compensate for their inadequacies and lack of youth).

A final note and caveat - always, *ALWAYS *, check for yourself when given pearls of wisdom based on experience. Never take anything for granted. Question everything and be satisfied within yourself before embracing information as definitive when passed on by others.

Remember, some of us are doomed to make the same mistakes over and over again and pass on the same errors to others.

Cheers and good luck with studies.

MM

PS Your next assignment is to check everything I wrote in the last post for errors (And I bet you there are some - I know I spotted at least one just re-reading now!!!).


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## JPINFV (Oct 31, 2010)

Since this was bumped, not all that is chest pain is an AMI (heck not all cardiac related chest pain is an AMI. What do you call chest pain with elevated ST segments in all leads but V1 and aVR?). Similarly, not all AMIs present with ST elevation or chest pain.


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## 8jimi8 (Oct 31, 2010)

JPINFV said:


> Since this was bumped, not all that is chest pain is an AMI (heck not all cardiac related chest pain is an AMI. What do you call chest pain with elevated ST segments in all leads but V1 and aVR?). Similarly, not all AMIs present with ST elevation or chest pain.



Epicarditis?
Stress induced cardiomyopathy?



Not everyone presents with the classic trifecta of

Nausea, Diaphoresis and pallor, but your secondary signs are often key.  Chest pain brought on by exertion? Sample hx...  Relieved by rest... Nitro?  Cardiac hx?  Family history?  Remember people don't usually preset with shock-like signs with pleuritic chest pain.  But just because they don't look shocky, doesnt mean it isn't cardiac!


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## Dutch-EMT (Nov 1, 2010)

MattCA said:


> What is the difference and how do you tell the difference?



pleuritic chestpain is related with the breathing, breathing in and out causes pain. Fever, pain while palpating, Painfull coughing.

I think it is difficult to make a good diagnosis in the field. 
Chestpain can be AMI, pulmonary embolis, Gastritis, oesophagitis, pneumonia, etc. A lot of options.


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