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Figure 14–1.
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Management of complaints of chest pain.

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Initial Management

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Airway, Breathing, Circulation

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Begin Supplemental Oxygen
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Give oxygen by nasal cannula or face mask, pending further evaluation.

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Begin Continuous Cardiac Monitoring
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Begin cardiac monitoring with pulse oximetry and treat life-threatening arrhythmias (Chapters 9 and 34).

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Look for Markedly Abnormal Hemodynamics

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Clinical Findings
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Look for signs of shock. Altered sensorium, pale clammy skin, oliguria, and respiratory distress may result from arterial hypotension and poor peripheral perfusion.

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Management of the Patient with Chest Pain and Abnormal Hemodynamics

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Treatment and Disposition

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Immediate Measures
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Insert two large-bore (≥16-gauge) intravenous catheters. Intraosseous (IO) access is acceptable and compatible with all resuscitation infusions including thrombolytics. Obtain blood for a complete blood count (CBC), markers of cardiac injury, and basic metabolic panel (electrolytes, glucose, renal function). Begin administration of intravenous fluids based on estimate of intravascular fluid volume.

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Hypovolemic Shock
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Infuse 250–500 mL of intravenous crystalloid solutions (normal saline or lactated Ringer's). Monitor the response (blood pressure, urine output, sensorium).

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Central Venous Hypervolemia (with or Without Shock or Hypotension)
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Pending more precise diagnosis, infuse normal saline to keep the intravenous catheter patent or place a saline lock IV.

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Briefly examine the pulmonary and cardiovascular systems, and palpate the abdomen for presence of a pulsatile mass. Obtain a 12-lead electrocardiogram (ECG). Obtain arterial blood for blood gas and pH determinations. Avoid unnecessary arterial punctures if the patient is a candidate for thrombolytic therapy for acute myocardial infarction. Obtain a portable chest radiograph. Insert a urinary catheter.

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Hypotension or Shock Present
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Central Venous Hypovolemia
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Hypovolemia is manifested by collapsed neck veins, clear lung fields on physical examination or chest X-ray, and absence of peripheral edema. Table 14–1 lists the differentiating features of the three most important conditions causing chest pain with hypotension with central venous hypovolemia.

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Table Graphic Jump Location
Table 14–1. Differentiating Features of Conditions Causing Chest Pain with Hypovolemia.

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