01Approach to the Critical Patient/attcp50

Immediate priorities

›Stabilization and safety

›If abnormal vital signs

›If hypotension

›Escalate resuscitation bay

›If hypoxemia

›Supplemental oxygen to target SpO2 94% to 98%

›If fever with pleuritic pain or cough

›Infectious cardiopulmonary evaluation pathway

›If chest pain with high risk features

›Immediate ECG

›Cardiac monitor

›High sensitivity troponin pathway

›Rapid exclusion of time critical mimics

›Acute coronary syndrome concern

›Ischemic symptoms

›Radiation to arm jaw back

›Diaphoresis

›Exertional component

›Syncope or near syncope

›Pulmonary embolism concern

›Pleuritic pain

›Hemoptysis

›Unilateral leg swelling

›Recent surgery or immobilization

›Prior VTE

›Aortic catastrophe concern

›Sudden maximal onset

02History/hx51

Symptom characterization

›Pain phenotype

›Anterior chest pain

›Parasternal location

›Multiple adjacent costochondral joints

›Quality

›Sharp

›Achy

›Pressure like

›Triggers

›Deep inspiration

›Coughing

›Twisting

›Upper extremity movement

›Reproducibility history

›Pain with pressing on chest wall

›Pain with certain positions

Time course and precipitating factors

›Onset pattern

›Acute after strain

›Heavy lifting

›New exercise

›Repetitive overhead activity

›Subacute after infection

›Recent upper respiratory infection

›Prolonged coughing

›Duration

›Hours to days

03Physical Exam/exam35

Chest wall and musculoskeletal exam

›Costochondral exam

›Focal parasternal tenderness

›Reproducible pain with palpation

›Multiple adjacent joints common

›Swelling assessment

›Swelling suggests Tietze syndrome

›Erythema warmth suggests alternative diagnosis

›Pain with movement

›Pain with trunk rotation

›Pain with shoulder range of motion

›Adjacent structures

›Sternoclavicular tenderness

›Rib tenderness

›Pectoral muscle tenderness

Cardiopulmonary exam

›Vital signs

›Tachycardia

›Hypotension

›Hypoxemia

›Fever

›Cardiac exam

›New murmur

›Pericardial friction rub

›Signs of heart failure

›Respiratory exam

›Work of breathing

›Focal crackles

04Differential Diagnosis/ddx26

Life threatening and must not miss

›Critical chest pain diagnoses

›Acute coronary syndrome ICD-10 I20.0 I21

›Pulmonary embolism ICD-10 I26

›Aortic dissection ICD-10 I71.0

›Tension pneumothorax ICD-10 J93.0

›Pericardial tamponade ICD-10 I31.4

›Esophageal rupture ICD-10 K22.3

›Pneumonia with pleurisy ICD-10 J18

›Myocarditis ICD-10 I40

Common mimics and related entities

›Musculoskeletal

›Costochondritis ICD-10 M94.0

›SNOMED CT costochondritis concept

›Tietze syndrome ICD-10 M94.0

›Muscle strain ICD-10 T14.8

›Rib fracture ICD-10 S22.3

›Dermatologic and neurologic

›Herpes zoster ICD-10 B02

›Intercostal neuralgia ICD-10 G58.8

›Gastroesophageal

›GERD ICD-10 K21

›Esophageal spasm ICD-10 K22.4

›Inflammatory and infectious

›Rheumatoid arthritis chest wall involvement ICD-10 M06.9

›Ankylosing spondylitis ICD-10 M45

›Sternoclavicular septic arthritis ICD-10 M00.8

›Osteomyelitis sternum ICD-10 M86.9

05Laboratory Tests/lt22

Cardiac and systemic screening

›Risk based labs

›High sensitivity troponin for ACS concern

›Serial testing per local 0 and 1 hour or 0 and 2 hour pathway

›ACEP clinical policy supports low risk pathways using hs troponin for low 30 day MACE risk Level C

›CBC for infection anemia concern

›Leukocytosis supports infectious alternative

›Anemia increases ischemia risk context

›CRP or ESR for suspected inflammatory cause

›Elevated values support inflammatory arthritis or infection

›Targeted labs by alternate diagnosis

›D dimer for PE rule out context

›Use only in low pretest probability strategy

›Age adjusted threshold consideration in adults

›Pregnancy test for reproductive age

›Imaging and medication selection implications

›Basic metabolic panel for NSAID safety

›Creatinine for renal risk

PITFALLS

›Troponin interpretation limitations

›Chronic elevation in CKD

›Myocardial injury vs myocardial infarction distinction

›D dimer limitations

›Poor specificity in pregnancy inflammation malignancy postoperative state

06Diagnostic Tests/dt51

Scoring Systems

›Risk tools for chest pain and PE

›HEART score for suspected ACS

›History component

›ECG component

›Age component

›Risk factors component

›Troponin component

›Low risk category HEART 0 to 3 with negative troponins supports low 30 day MACE rates per ACEP Level C policy

›EDACS for chest pain risk stratification

›Symptom and risk factor based calculation

›Low risk group supports early discharge pathways

›Wells score for PE

›Low probability plus negative D dimer excludes PE in appropriate strategy

›PERC rule for PE

›PERC negative in very low risk supports no D dimer strategy

›Aortic dissection detection risk score

›High risk features guide imaging selection

MRI

›Role limited in typical costochondritis

›Persistent atypical chest wall pain

›Suspected inflammatory arthropathy

›Suspected neoplasm

›Suspected osteomyelitis or septic arthritis extension

›Contrast enhanced protocol consideration

›Contraindications

›Non MRI compatible implants

›Severe claustrophobia

07Disposition/dispo23

Level of care decisions

›Discharge appropriate after exclusion of serious causes

›Clinically stable

›Normal or acceptable vital signs

›No respiratory distress

›Low risk cardiac evaluation when performed

›Non ischemic ECG

›Negative troponin pathway

›Low risk score pathway alignment

›AHA ACC chest pain guideline supports discharge without urgent testing in low risk patients

›Clear musculoskeletal features

›Reproducible focal tenderness

›Pain tied to movement or palpation

›Observation or admission triggers

›Persistent concerning chest pain

›Abnormal ECG

›Positive or rising troponin

›Hypoxemia

›Hemodynamic instability

›Significant comorbidities limiting outpatient care

›Follow up planning

›Primary care follow up for symptom persistence

›Physical therapy referral for refractory pain

›Cardiology follow up if cardiac workup equivocal

08Treatment/t57

Analgesia and anti inflammatory strategy

›First line supportive care

›Activity modification

›Avoid provoking lifting twisting

›Gradual return as symptoms improve

›Local heat

›Heat packs several times daily

›Topical analgesics

›Diclofenac gel

›Typical adult application per product label

›Avoid on broken skin

›Lidocaine patch 4% or 5%

›Apply to maximal tenderness area

›Maximum wear time per product label

›Capsaicin topical

›Burning sensation counseling

›Oral analgesics

›Acetaminophen

›Adult 500 to 1000 mg PO every 6 to 8 hours as needed

›Maximum 3000 mg per day typical outpatient ceiling

›Lower maximum in chronic alcohol use or liver disease

›NSAIDs if no contraindication

›Ibuprofen

›Adult 400 mg PO every 6 to 8 hours as needed

›Maximum 2400 mg per day typical outpatient ceiling

›Naproxen

›Adult 250 to 500 mg PO every 12 hours as needed

›Maximum 1000 mg per day

09Special Populations/sp32

Pregnancy

›Pregnancy specific considerations

›Common mechanical contributors

›Increased rib cage strain in late pregnancy

›Postural changes

›Medication safety

›Acetaminophen preferred first line

›NSAIDs avoidance in third trimester

›Topical lidocaine limited systemic absorption

›Imaging strategy

›Avoid ionizing radiation unless alternate diagnosis concern

›Ultrasound and ECG preferred initial tests when indicated

Geriatric

›Higher risk alternate diagnoses

›ACS and aortic disease higher baseline risk

›Osteoporotic rib fracture after minor strain

›Medication cautions

›NSAID renal risk

›NSAID GI bleeding risk

›Polypharmacy interactions

›Disposition cautions

›Lower threshold for cardiac evaluation when risk factors present

Pediatrics

›Pediatric chest pain context

›Musculoskeletal causes common

›Cardiac causes rare but not zero

›Red flags

›Exertional syncope

10Background/b28

Epidemiology

›Frequency in chest pain presentations

›Musculoskeletal chest wall pain common in ambulatory and ED settings

›Typical age patterns

›Adults and adolescents common

›Tietze syndrome tends younger adults

›Risk associations

›Repetitive strain

›Cough related strain

Pathophysiology

›Mechanism

›Inflammation at costochondral or chondrosternal junctions

›Microtrauma and overuse contribution

›Cough induced strain contribution

›Tietze syndrome mechanism

›Inflammation with visible swelling of costal cartilage

›Usually upper ribs involvement

Therapeutic Considerations

›Rationale for supportive care

›Self limited inflammatory process

›Pain control enables normal breathing and mobility

›NSAID rationale

›Cyclooxygenase inhibition reduces inflammation and pain

›Topical agents rationale

›Local analgesia with reduced systemic risk

›Physical therapy rationale

›Reduces muscle guarding

›Improves posture and thoracic mobility

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Diagnosis explanation

›Chest wall inflammation at rib cartilage joints

›Not a heart attack once serious causes ruled out

›Expected course

›Improvement over days to weeks common

›Flare ups possible with strain or cough

›Home care

›Avoid heavy lifting and twisting until improved

›Heat packs to tender area

›Acetaminophen as directed on label

›NSAIDs as directed on label if safe for you

›Topical diclofenac or lidocaine patch if helpful

›Gentle chest wall stretches if tolerable

›Return to ED now

›New or worsening shortness of breath

›Fainting or near fainting

›Chest pain with exertion

›Chest pressure with sweating nausea or vomiting

›Pain radiating to arm jaw or back

›Coughing blood

›New leg swelling

›Fever or chills

›New rash with blistering

›Follow up

›Primary care visit if not improving within 1 to 2 weeks

›Earlier follow up if recurrent episodes

›Physical therapy referral if persistent pain limiting function

12References/r12

Clinical guidelines and evidence sources

›Evidence sources

›2021 AHA ACC multisociety guideline for evaluation and diagnosis of chest pain

›Low risk acute chest pain supports discharge without urgent diagnostic testing for CAD

›ACEP clinical policy for suspected non ST elevation ACS and hs troponin pathways

›Level C recommendation for hs troponin accelerated diagnostic pathways in low risk patients

›StatPearls Costochondritis updated 2024

›Supportive care with heat topical agents NSAIDs acetaminophen

›Mayo Clinic costochondritis diagnosis and treatment

›Stretching and TENS as therapy options

›Patient.info Costochondritis and Tietze syndrome updated 2025

›Tietze syndrome localized vs costochondritis more diffuse

›Project source file

Evidence & Review

Evidence & Review