What is the initial workup for a patient presenting to the emergency room (ER) with chest tightness after mold exposure?

Initial Workup for Chest Tightness After Mold Exposure in the Emergency Room

The initial workup for a patient presenting to the emergency room with chest tightness after mold exposure should include a 12-lead ECG within 10 minutes of arrival, cardiac troponin measurement, vital signs monitoring, and chest radiography to rule out both cardiac and pulmonary causes of symptoms.1, 2

Immediate Assessment (First 10 Minutes)

• Obtain a 12-lead ECG immediately and review within 10 minutes of arrival to identify potential STEMI or other acute coronary syndromes 1, 2
• Monitor vital signs including heart rate, respiratory rate, blood pressure, and oxygen saturation 1, 2
• Place patient on cardiac monitor with emergency resuscitation equipment nearby 2
• Measure cardiac troponin as soon as possible to evaluate for acute myocardial injury 1
• Assess airway, breathing, and circulation; be prepared to provide CPR and defibrillation if needed 1

Focused History

• Determine characteristics of chest tightness: onset, duration, quality, location, radiation, aggravating/alleviating factors 2
• Document timing and extent of mold exposure (home, workplace, duration of exposure) 3, 4
• Assess for associated symptoms:
  • Respiratory: shortness of breath, cough, wheezing 5, 6
  • Systemic: fever, fatigue, headache 6
  • Allergic: rhinitis, eye irritation 5, 4
• Inquire about pre-existing conditions, particularly asthma, COPD, or other respiratory disorders 3, 4

Physical Examination

• Perform thorough cardiopulmonary examination 1, 2
• Assess for:
  • Signs of respiratory distress: tachypnea, accessory muscle use, decreased breath sounds 1
  • Cardiac abnormalities: irregular rhythm, murmurs, S3 gallop 1
  • Upper airway findings: pale nasal mucosa, rhinorrhea, pharyngeal cobblestoning (suggesting allergic response) 6

Initial Diagnostic Testing

• Chest radiography to evaluate for pulmonary infiltrates, pneumothorax, pulmonary edema, or other thoracic pathology 1, 2
• If initial ECG is nondiagnostic but clinical suspicion for ACS remains high, perform serial ECGs 2
• Consider supplemental ECG leads V7-V9 to rule out posterior myocardial infarction if initial ECG is nondiagnostic 2
• Laboratory tests:
  • Complete blood count with differential to assess for eosinophilia (suggesting allergic response) 5, 6
  • Basic metabolic panel 1
  • Arterial blood gas if respiratory distress is present 1
  • Consider specific IgE to mold mixture (mx1) as a useful diagnostic marker for mold-associated respiratory symptoms 4

Differential Diagnosis Considerations

• Cardiac causes:
  • Acute coronary syndrome 1
  • Myocarditis 1
  • Pericarditis 1
• Pulmonary causes:
  • Hypersensitivity pneumonitis (especially with history of mold exposure) 3, 4
  • Asthma exacerbation 5, 6
  • Pneumothorax 1
  • Pulmonary embolism 1
• Other causes:
  • Allergic response to mold 5, 6, 4
  • Anxiety-related chest tightness 1

Initial Management

• Administer oxygen if oxygen saturation is <94% 1
• If signs of allergic reaction are present, consider antihistamines 6
• For suspected ACS, administer aspirin 160-325 mg if not contraindicated 1, 2
• If bronchospasm is present, consider bronchodilator therapy 5, 6

Additional Considerations for Mold Exposure

• Document details of mold exposure for potential environmental intervention 3
• Consider consultation with allergy/immunology if strong suspicion of mold-related hypersensitivity 5, 6, 4
• Be aware that mold exposure can cause both IgE-mediated allergic responses and non-IgE-mediated inflammatory reactions 5, 6, 4

Disposition Decision-Making

• Patients with evidence of ACS, significant respiratory compromise, or other life-threatening conditions require admission 1, 2
• For patients with mild symptoms and normal initial workup, consider observation in a chest pain unit with serial cardiac markers and ECGs 1
• Patients with clear non-cardiac, non-life-threatening causes may be discharged with appropriate follow-up 1, 2