A heart attack is a pumping problem. It’s what happens when there is a blockage in one of the arteries that takes blood to the heart muscle. Cells around the blockage start to die off, which affects how the electrical signals pass through the heart, and consequently how well it can pump. It can lead to cardiac arrest, when the heart stops pumping normally, if it’s left untreated.

In most cases, someone having a heart attack will complain of chest pain - often described as heavy or crushing, or like someone/something sitting on their chest. This pain can radiate up into the neck, the jaw and back, and down the arm/s. Associated symptoms include dizziness, shortness of breath, nausea, vomiting, sweating and a feeling of ‘impending doom’. Alway seek medical help if you think someone is having a heart attack. 

Angina is chest pain that’s caused by a reduced flow of blood to the heart muscle. On its own, it’s not normally life threatening, but it is a warning sign that you could be at risk of a heart attack or a stroke. 

Angina pain tends to be described at tight, dull or heavy, and as for heart attacks, it may radiate. People can experience shortness of breath and nausea too. It’s normally triggered by exertion or stress (known as stable angina), but should resolve with a few minutes rest. If rest doesn’t resolve it, then the angina may be unstable and needs a review by a Doctor.

Once diagnosed, treatment may include lifestyle changes and GTN spray or tablets to reduce the risk of more serious problems. 

The GTN is administered under the tongue but be aware that due to its action of relaxing and dilating the blood vessels, it can cause the blood pressure to drop - resulting in a dizzy patient with the risk of fainting.. 

Blunt trauma is pretty self explanatory and involves a blunt force impacting with the chest. So, as you’d imagine, we would expect injury to skin, but also the underlying structures. Just picture what your chest looks like from the outside and then picture what’s inside and where.

If you’re assessing someone’s chest for injuries, remember to include the sides and the back - it’s all classed as ‘chest’! 

So, imagine a punch to the centre of the chest - it could cause pain, bruising to the skin, damage to the sternum and ribs, disrupt blood vessels and even impact on the lungs, heart and other organs underneath. It could lead to difficulty breathing.

Remember that the chest is one of the 4 body cavities that can collect a large quantity of internal bleeding, often with only subtle outward signs initially.

As for blunt trauma, the term ‘penetrating trauma’ is pretty self explanatory and involves something penetrating the chest wall. That could be something as small as a needle, or as big as a telegraph pole! For any penetrating trauma, you would expect to see pain, a wound, injury to the skin, and possibly the bones and underlying organs - the lungs, heart, blood vessels and maybe even the stomach, liver, kidneys, intestines and spleen, depending on the angle of entry.

The biggest concern is the penetration into the chest cavity, allowing air into the pleural space and causing even bigger problems - see Pneumothorax/haemothorax and Tension Pneumothorax below. 

It can also be tricky to work out how deep the injury actually is, especially if you didn’t witness it or don’t know what caused it. In that case, always err on the side of caution and plan for the worst.

Generally associated with chest trauma (blunt or penetrating) both pneumothorax and haemothorax are potentially life threatening. 

Pneumothorax is what happens when air enters the chest cavity. It can be open, with an external (sucking) wound, or internal. In both cases there is the risk of a partial or full lung collapse due to the change in pressure. For an open pneumothorax, we can use a chest seal to help stabilise the injury and try to reinflate the lung a little, administer oxygen and pain relief and monitor while a medevac is organised. For a closed pneumothorax, there’s little we can do other than oxygen, pain relief and monitoring before medevac. 

A haemothorax is what happens when the injury causes the chest cavity to fill with blood. This affects the lungs' ability to work, can cause a collapsed lung and also means we have a shock situation, where the circulating volume of blood isn’t where it’s supposed to be! Treatment would be oxygen, pain relief and monitoring before an urgent medevac. 

Signs and symptoms for all of these conditions would be pain, evidence of an injury (think about your mechanism of injury), reduced chest rise and fall and/or reduced breath sounds on the affected side, hyperresonance for pneumothorax and hyporesonance for haemothorax. Difficulty breathing, low oxygen saturations, increased work of breathing. 

Oh, and just to scare everyone, pneumothorax can actually happen spontaneously with no apparent cause - especially in tall young men! Winner!

A tension pneumothorax happens when a pneumothorax either isn’t identified and treated, or if it worsens. 

Put simply, the air trapped inside the chest cavity isn’t able to escape and it results in what’s called mediastinal shift (shifting from the middle). So we have a collapsed lung on one side, which causes pressure to build up on the heart, the other lung, the trachea and other structures. This pressure can actually cause a shift, squashing all the organs towards the uninjured side of the chest where they can’t work properly.

Symptoms are as for pneumothorax, plus you may be able to see the trachea sited to one side of central. 

The aorta is the hoooge artery that exits from the heart. It copes with blood pumping under the most pressure, so is extremely strong. It runs from the heart, down the body to the pelvis where it splits into the two femoral arteries. 

Sometimes the wall of the aorta weakens, causing an aneurysm which is like a bulge on the artery. If this ruptures it can cause sudden and extreme blood loss internally. 

In the case of aortic dissection, a weakened section of the aorta tears or splits, causing blood to leak between the layers that make up the aorta wall. It can happen suddenly or over time. Classic symptoms are a sudden, severe pain in the chest, or back, between the shoulder blades. Often described as tearing or ripping in nature. The pain can radiate, and be accompanied with feeling cold, clammy, faint and short of breath. 

A difference of 20mmHg when measuring the systolic blood pressure - with the left arm being higher than the right can suggest a dissected aorta but can’t be relied on to diagnose it.

A pulmonary embolism or PE is a blood clot in the lungs that blocks the blood flow to part of the lung tissues.

These blood clots most often start as a deep vein thrombosis (DVT) in the legs but can be caused by other conditions too. The clot travels through the bigger blood vessels until it gets to the lungs where the blood vessels narrow and they get stuck. 

Typical symptoms would be sudden shortness of breath, sharp chest pain - sometimes described as pinpoint pain, feeling faint and coughing. Symptoms can be accompanied by signs of a DVT which are calf pain, localised redness, swelling and heat in the calf. 

Treatment in hospital is needed so keep the casualty calm and monitor their condition while you wait for a medevac. You can give Oxygen if the saturations can’t be maintained at the right levels by breathing air.

No, it’s actually not a beautiful Mediterranean holiday location, it’s actually a very painful condition!

Costochondritis is inflammation of the joints where your ribs join the sternum in the middle of your chest. It causes a very sharp chest pain, especially when you’re breathing or moving around and it’s normally worse when you press on it. 

It can be caused by infection, repetitive movement, a chest injury, coughing or as a result of certain conditions. Normally it will resolve on its own with rest, but may need pain relief to help the casualty stay comfortable. 

Myocarditis is an inflammation of the heart muscle, the myocardium. If severe, the inflammation can reduce the heart's ability to pump blood. Typical symptoms would be chest pain, shortness of breath, and rapid or irregular heart rhythms (arrhythmias).

Myocarditis can be caused by a viral infection, a general inflammatory condition or sometimes a reaction to a drug. 

Treatment is normally via medication, or in severe cases, surgery may be required.

The pericardium is the protective sac surrounding your heart and pericarditis is what happens when it becomes inflamed. On its own, pericarditis isn’t normally serious, but it can happen alongside myocarditis, when it becomes a bit more worrying. 

Symptoms include a sharp chest pain, often to the left side which may be relieved a little when the casualty leanins forward. It can be worse on lying down and you might feel generally unwell too.

Pericarditis is generally treated with painkillers and anti inflammatories, though very occasionally requires surgery. 

We have two pleural layers around our lungs, one inside the other with a fluid filled space in between. The fluid lubricates the layers and helps them to glide past each other as your lungs expand and contract during breathing.

Pleurisy is an inflammation of this space and causes the tissues to swell and become inflamed. This means that the two layers rub against each other like sandpaper. It can be very painful and is worse on deep inspiration. If you’re able to listen with a stethoscope it sounds dry and scratchy. 

Treatment is through pain management and treating the cause of the inflammation, while monitoring in case it worsens or develops into a more serious condition.

Rib fractures can be due to blunt or penetrating trauma (see above). In the elderly, especially when they have osteoporosis, fractures can actually occur spontaneously or due to violent coughing or other movement.

Rib fracture pain is normally a sharp pain, localised over the injury site, which worsens on taking a deep breath. It can be associated with other injuries too. 

Unless the rib is displaced (or an open fracture), treatment is normally via pain relief and rest - ribs are no longer strapped up as the idea is to start moving as soon as the pain allows. The pain will be quite intense at first, making daily tasks difficult, but will suddenly improve after a couple of weeks. 

COPD is an umbrella term used to describe a collection of chronic respiratory diseases such as chronic bronchitis, emphysema, chronic asthma, bronchiectasis, and a number of industrial respiratory conditions. 

Chest pain can be continual, or at times when the underlying condition ‘flares up’, such as when it’s exacerbated by a chest infection.

Infection, inflammation and swelling can obstruct the airways, causing pain and discomfort. Pain can be sharp or dull, and may be in a small or larger area. 

Treatment immediately would be the casualties own inhalers, plus oxygen if needed. Then, looking at the cause of the flare up may indicate antibiotics, steroids or other treatment.  

A common lung condition that causes occasional breathing difficulties. Asthma affects all age groups and there’s currently no cure, but it is normally well controlled with medication. 

Most adults with asthma will know they have it, will carry medication to deal with an asthma attack, know what to do when they have an attack and will know the triggers that set it off.

Symptoms include a distinctive expiratory wheeze, caused by narrow airways, a tight chest often described as feeling like a band around the chest, coughing and shortness of breath. 

Treatment would be to remove any trigger or remove the casualty from the trigger. Use the casualty’s own inhalers in the first instance and if there’s no improvement, an ambulance crew might use a nebuliser. Oxygen could be an option if the attack worsens. 

Any number of activities, especially on board a boat, can result in overstretching or spraining the muscles around the chest - including the intercostal muscles between the ribs. 

Any injury of this nature will cause pain in the area of the injury which may increase on deep inspiration and movement. 

Providing a fracture is ruled out, treatment would be pain management and monitoring. 

I’m sure we’ve all had a chest infection at some point in our lives, and let's be honest, it can make you feel very rough.

There are thousands of different chest infections doing the rounds every year and some are worse than others. Most will cause you to feel rubbish for a few days, but rest, drinking plenty of fluids and paracetamol based remedies will help to manage the symptoms. 

If you think the chest infection is a bit worse and it’s causing chest pain, you’re coughing up yellow, brown, green or blood stained sputum, and have difficulty breathing, or if you have any underlying respiratory problems, you may want to seek medical advice. 

In some cases, a course of antibiotics and steroids may be appropriate to help you to make a full recovery. 

So you might think this is a long shot to get to our 20 causes of chest pain! But, anyone who has had chickenpox as a child (so that’s most people who grew up in the UK!) is at risk because shingles is a reactivation of the varicella-zoster virus that causes chickenpox. 

Shingles starts as a tingling or painful sensation on an area of skin - often on the chest. There you go, another cause of chest pain! Though it can be anywhere on the body. You may also have a headache and feel generally unwell. After a few days, a blotchy rash forms on one side of the body. The rash develops to oozing blisters, then scabs over and disappears. It can last up to 4 weeks and be quite painful.

Treatment once shingles is diagnosed is paracetamol, keeping the rash clean, wearing loose clothing and using something to cool the rash a couple of times a day. 

Acid reflux (indigestion) happens when stomach acid leaks from the stomach into the oesophagus.

GORD is a chronic condition, diagnosed when acid reflux happens more than two times a week, or when it causes inflammation and damage in the oesophagus.

The result of the leakage is… chest pain!

Other symptoms are bloating, belching, bad breath, oesophagitis, feeling and being sick, pain and/or difficulty swallowing, sore throat, hoarseness, cough. 

Treatment is via lifestyle changes and medication to manage pain and the condition.

An incredibly common cause of 999 calls for an ambulance! 

Panic or anxiety attacks come with a host of symptoms including a racing heart, shortness of breath, difficulty breathing, chest pain or a tight chest, dizziness, nausea, vomiting, a stitch-like pain… the list goes on.

The best treatment is to coach the breathing - use square breathing -breathe in for 4 seconds, hold your breath for 4, breathe out for 4, hold for 4. There are also a number of Apps that can help too. A top tip is to make sure the shoulders are relaxed and dropped down so that the ribs can swing normally.

Panic attacks can make someone feel like they're dying - they struggle to breathe, so they breathe faster to compensate, then they feel even more like they can’t breathe… and so a vicious circle starts. 

Longer term, being able to recognise a panic attack and having a toolbox of tricks that are tried and tested is good advice. 

Our Paramedic Rachel told us about a little known cause of chest pain. When she was working as a frontline paramedic, there were regular calls to the local Police custody suite for a variety of reasons. 

But it seems that being arrested and finding out what you were being charged with often brought on some random bouts of non specific chest pain! Who knew?!