Doctor, I am feeling Chest Pain

Updated: Jun 30, 2019

“Doctor, I am feeling chest pain”


This is one line that many of us hope to not hear from our patient at our clinic.


But what if a patient says this exact line to you during an ongoing dental procedure?


First thing you need to do is to find out if the pain is because of Ischemic Heart Disease or some other reason.


Common causes of acute (sudden) chest pain include Trauma, Gastritis and Ischemic Heart Disease

Common causes of acute (sudden) chest pain include Trauma, Gastritis and Ischemic Heart Disease.


I highly doubt that such a trauma to chest would occur in your presence and you won't notice it.


In a patient with chest pain due to gastritis, he would have a prior history of gastritis.


In both, chest pain due to trauma and gastritis, the pain exacerbates even on slight movement like changing position whereas angina pain does not aggravate or relieve on changing position.


Nature of pain in both these conditions is of sharp stabbing nature.


In Angina or Myocardial Infarction, patient describes the pain as crushing or squeezing or pressing or heaviness or “as though something very heavy has been put on my chest”.


Patient describes the pain as something very heavy has been put on my chest

In both these conditions (trauma and gastritis) the pain is localized whereas in Ischemic Heart Disease the pain radiates to left arm, shoulder and mandible.


Angina Pain radiates to Left arm (Ulnar nerve distribution), Left Shoulder, Mandible and Rarely right arm

Keep an eye on patient's vitals such as Blood Pressure, Heart Rate and Respiratory Rate.


Patient’s vitals do not change during chest pain because of gastritis. In case of chest pain because of trauma, there may be hypotension in cases where there is haemorrhage because of trauma.


Patient’s vitals change during chest pain because of Angina and Myocardial Infarction.

Heart rate is high in angina & low in MI, high respiratory rate is seen in both cases.


The classical sign to see in case of Anginal pain is Levine Sign. Levine's sign is a clenched fist held over the chest.


Levine sign is a clenched fist held over the chest


In the past, I have talked about Ischemic Heart Diseases and their effect on dental treatments.


Now that you have differentiated Ischemic Heart Disease from the other causes of Acute chest pain, let us talk about management of chest pain because of Ischemic Heart Disease.


Management

The most important thing for you to do is to stay calm in such situations.


First, remove all the stress-inducing factors (Stop dental treatment).


Then start administration of oxygen via the nasal cannula or oxygen mask at the rate of 4-5 Litre/Minute.


Also, Administer Oral sublingual 0.4 mg Nitroglycerin Tablet to the patient. Alternatively, you can use Nitroglycerin Spray sublingually (one spray delivers 0.4 mg Nitroglycerin).


Nitroglycerin spray & Tablets

Wait for 5 minutes.


If the pain is not relieved then administer another dose of 0.4 mg Nitroglycerin.


Wait for another 5 minutes.


If the pain is still not relieved then administer one more dose of 0.4 mg Nitroglycerin.


Wait for another 5 minutes.


If the pain does not subside even after the third dose, then suspect the pain to be of Unstable Angina or Myocardial Infarction and call for medical assistance as soon as possible.

Or better, accompany the patient to the medical hospital.


A dental surgeon should be well versed with emergency procedures like BLS and CPR.


If you have a question that why we administer oxygen and Nitroglycerin for Angina pain then keep reading.


Angina pain is because the Myocardium is under a heavy workload and is deficient in oxygen supply. Read about it in detail.


Nitroglycerin causes generalized vasodilation leading to reduces venous return and less blood pressure. This reduces the workload on the myocardium.


As there is oxygen deficiency, by delivering oxygen at 4-5 Litre/Minute we aim to increase the oxygen saturation of blood so even at reduced blood supply we can achieve an increase in oxygen supply.


Prevention


Follow stress reduction protocol.


Reduce stress (psychological and physical) factors as much as possible.


Prescribe Tab. Diazepam 5 mg a night before and 1 hour before the appointment.


In patients with a prior history of anginal pain, ask them to bring the Nitroglycerin spray prescribed by their physician.


Start a dental procedure with a preop dose of 0.4 mg sublingual Nitroglycerin .


Use Local Anesthesia with adrenaline.


Keep the duration of the appointment as short as possible, preferably half an hour.


With this, I conclude my article series on Ischemic Heart Disease.


I hope this answers your queries and helps you in managing such patients and emergencies much more confidently.


You can post any other queries regarding this topic or any other topic in the comment section.


Do let me know what topics would you want me to write about next. The topics can be from local anesthesia, Oral & Maxillofacial Surgery or Medical emergencies.


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