Chapter 14. Chest Pain

See Figure 14–1.

Initial Management

Airway, Breathing, Circulation

Begin Supplemental Oxygen

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

Begin Continuous Cardiac Monitoring

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

Look for Markedly Abnormal Hemodynamics

Clinical Findings

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

Management of the Patient with Chest Pain and Abnormal Hemodynamics

Treatment and Disposition

Immediate Measures

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.

Hypovolemic Shock

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

Central Venous Hypervolemia (with or Without Shock or Hypotension)

Pending more precise diagnosis, infuse normal saline to keep the intravenous catheter patent or place a saline lock IV.

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.

Hypotension or Shock Present

Central Venous Hypovolemia

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.