Newer generation CT angiography is the modality of

choice to diagnose pulmonary embolism and aortic dissection and may have an evolving role in the evaluation of

patients with potential coronary artery disease.

Transthoracic echo is often readily available and clinically useful to evaluate for possible pericardia! effusions

and tamponade physiology, ventricular hypokinesis in

patients with ACS, and right ventricular strain in patients

with massive PE. A bedside transesophageal echo is very

sensitive for diagnosing acute aortic dissection in patients

who are not candidates for CT angiography.

MEDICAL DECISION MAKING

A detailed history and physical exam in combination with

an ECG and/or chest radiograph may provide sufficient

evidence to exclude a myriad of emergent conditions.

CHAPTER 13

Patient presenting with

chest pain

Rapidly address ABC's, IV access,

supplemental 02 and cardiac mon itor

Immediate ECG and CXR

Absent breath

sounds with

shock

Pain radiates to

the back with wide

mediastinum on CXR

ECG with ischemia

or positive troponin

Pleuritic CP,

hypoxia, + CT

angiogram

History of vomiti ng,

mediastinal air on

CXR

Hypotension,

JVD, muffled

heart tones

.&. Figure 13-1. Chest pain diagnostic algorithm. BMP, basic metabolic panel; BP, blood pressure; CBC, complete blood

count; CP, chest pain; CT, computed tomography; CXR, chest x-ray; ECG, electrocardiogram; JVD, jugular venous distention.

When this is not adequate, a thoughtful use of laboratory

studies combined with the pretest probability of disease

will guide decision making (Figure 13-1).

TREATMENT

� Acute Coronary Syndrome

Provide supplemental 0 2, administer a loading dose aspirin

(162-365 mg), and begin sublingual nitroglycerin (0.4 mg

every 5 minutes) on all ACS patients without known contraindications (eg, allergy, hypotension). Further antithrombotic

(eg, clopidogrel) and anticoagulation (eg, low-molecularweight heparin) therapy will differ by institution and cardiologist. Of note, the preceding interventions are often only

temporizing measures, as early revascularization is definitive,

especially in those patients presenting with an ST -elevation MI.

� Aortic Dissection

Patients with an aortic dissection require an immediate

and aggressive reduction in both heart rate and blood pressure. The goal of treatment is to maintain a heart rate

<60 bpm and systolic blood pressure < 100 mmHg. There

are multiple medication options for this purpose, and

often concurrent infusions are required to meet the pre ­

ceding targets. When utilizing dual therapy, it is of utmost

importance to control the heart rate before dropping the

blood pressure to avoid a "reflex tachycardia" and conse ­

quent expansion of the underlying dissection.

� Pulmonary Embolism

Treatment will vary based on the hemodynamic impact of

the embolism. Anticoagulate stable patients with either

low-molecular-weight or unfractionated heparin. Hemo ­

dynamic instability may necessitate the use of thrombolytic

therapy.

..... Boerhaave Syndrome

Esophageal rupture is uncommon and classically presents

with the sudden onset of chest pain after vomiting. Initiate

broad-spectrum antibiotic coverage while arranging for

definitive surgical repair.

..... Pneumothorax

Place all patients with a pneumothorax on s upplemental 02

via a nonrebreather mask. Those with a tension pneumothorax require immediate needle decompression followed

by chest tube thoracostomy. Simple pneumothoraces can be

treated with tube thoracostomy or simple observation.

..... Pericardia! Tamponade

The recognition of tamponade is much easier in the age of

bedside ultrasonography. Perform immediate pericardio ­

centesis in unstable patients while arranging for an operative pericardia! window via cardiothoracic surgery.

DISPOSITION

...,_ Admission

Admit all patients with concerning presentations to a

monitored bed. The following chapters discuss the

CHEST PAIN

disposition of patients with specific conditions m

greater detail.

..... Discharge

Many patients with chest pain can be discharged with close

primary care follow-up and a list of strict indications for

reevaluation. Take care to exclude emergent causes and

discharge only those cases with a clear nonemergent etiology (eg, chest wall pain, zoster, dyspepsia). If clinical doubt

exists, it is certainly prudent to err on the side of caution