What is the best course of action for a 53-year-old female with severe, acute upper back pain that is sharp, wrapping around her chest, worsened by inhalation, and minimally responsive to ibuprofen (Nonsteroidal Anti-Inflammatory Drug, NSAID)?

Emergency Evaluation for Upper Back Pain with Concerning Features

A 53-year-old female with severe, acute upper back pain that is sharp, wrapping around her chest, worsened by inhalation, and minimally responsive to ibuprofen should be immediately evaluated in an emergency department, ideally transported by emergency medical services (EMS), to rule out potentially life-threatening conditions.

Concerning Features That Warrant Emergency Evaluation

The patient's presentation has several high-risk features that require urgent assessment:

• Sharp, wrapping pain around the chest: This pattern suggests possible aortic dissection, pulmonary embolism, or acute coronary syndrome 1
• Pain worsened by inhalation: Pleuritic component suggests possible pulmonary embolism, pneumothorax, or pericarditis 1
• Minimal response to ibuprofen: Suggests a potentially serious underlying cause rather than musculoskeletal pain 2
• Age and gender: 53-year-old female may have atypical presentation of cardiac conditions 3

Recommended Management Algorithm

1. Immediate transport to emergency department

   • Transport by EMS is strongly recommended 1
   • Self-transport should be avoided due to risk of deterioration 1

2. Initial emergency department evaluation (within first 10 minutes)

   • 12-lead ECG to rule out STEMI and other cardiac abnormalities 1
   • Vital signs assessment (heart rate, blood pressure, respiratory rate, oxygen saturation)
   • Focused cardiovascular and pulmonary examination 1

3. Immediate laboratory testing

   • Cardiac troponin measurement 1
   • D-dimer if pulmonary embolism is suspected
   • Complete blood count, basic metabolic panel

4. Advanced imaging based on initial findings

   • Consider "triple rule-out" CT to simultaneously evaluate for:
     • Aortic dissection
     • Pulmonary embolism
     • Coronary artery disease 4, 5

Differential Diagnosis to Consider

The patient's symptoms could represent several life-threatening conditions:

1. Acute Aortic Syndrome

   • Presents with sudden, severe "ripping" pain, often radiating to back
   • May have pulse differentials between extremities 1

2. Pulmonary Embolism

   • Pleuritic chest pain worsened with inspiration
   • Often accompanied by dyspnea and tachycardia 1

3. Acute Coronary Syndrome

   • Women may present with atypical symptoms including back pain
   • Risk of underdiagnosis in women 3

4. Pericarditis

   • Sharp pain that may worsen with inspiration
   • May be accompanied by friction rub on examination 1

5. Pneumothorax

   • Sudden onset of pleuritic chest pain
   • Decreased breath sounds on affected side 1

Important Caveats

• Do not delay transfer for outpatient testing: Delayed transfer for cardiac troponin or other diagnostic testing should be avoided 1
• Do not rely on pain response to medications for triage: Relief with nitroglycerin or NSAIDs is not necessarily diagnostic of specific conditions 1
• Do not dismiss atypical presentations: Women may present with less typical symptoms of serious cardiac conditions 3
• Do not miss the opportunity for time-sensitive interventions: Early diagnosis and treatment of conditions like aortic dissection, pulmonary embolism, and acute coronary syndrome is potentially life-saving 1

The European Society of Cardiology Task Force on Management of Chest Pain emphasizes that severe, prolonged chest pain of acute onset calls for immediate action, as it could indicate heart attack, aortic aneurysm, pulmonary embolism, pneumothorax, or other serious pulmonary conditions 1.