Management of complaints of chest pain.
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
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
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.
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.
Table 14–1. Differentiating Features of Conditions Causing Chest Pain with Hypovolemia. ||Download (.pdf)
Table 14–1. Differentiating Features of Conditions Causing Chest Pain with Hypovolemia.
|Myocardial infarction with vagotonia||Crushing chest pain; nausea||Bradycardia; stable hypotension||Acute infarction pattern and bradycardia||Nonspecific|
|Aortic dissection||Tearing chest pain; back pain; often history of hypertension||Tachycardia; pulse deficits; progressive hypotension||Nonspecific or may show ischemia or infarction pattern, left ventricular hypertrophy||Widened mediastinum; pleural fluid. CT scan is ...|