What are the guidelines for managing a patient with sudden onset severe chest pain?

Management Guidelines for Sudden Onset Severe Chest Pain

Patients with sudden onset severe chest pain should be instructed to call 9-1-1 immediately for emergency medical services (EMS) transport to the nearest emergency department (ED) for prompt evaluation and treatment. 1

Initial Assessment and Triage

• Call 9-1-1 for EMS transport rather than using personal transportation, as EMS can provide critical pre-hospital care including ECG acquisition, treatment for pain/arrhythmias, and defibrillation if needed 1
• An ECG should be obtained and reviewed within 10 minutes of arrival to any medical facility to identify STEMI or other life-threatening conditions 1
• If an ECG cannot be obtained in an office setting, the patient should be transferred immediately to an ED 1
• Cardiac troponin should be measured as soon as possible after presentation to the ED in patients with suspected ACS 1
• Delayed transfer to the ED for troponin testing or other diagnostic workup should be avoided due to potential harm 1

Focused Physical Examination

• A focused cardiovascular examination should be performed initially to aid in diagnosis of potentially serious causes of chest pain 1
• Key physical findings to assess include 1:
  • Vital signs: tachycardia, tachypnea, hypotension
  • Cardiovascular: presence of S3, murmurs, pulse differentials between extremities
  • Respiratory: crackles, unilateral decreased breath sounds
  • Skin: diaphoresis, pallor

Life-Threatening Causes to Consider

• Acute Coronary Syndrome (ACS) 1

  • Characterized by pressure-like chest discomfort, often with radiation to arm/jaw
  • May be accompanied by diaphoresis, nausea, dyspnea
  • ECG may show ST-segment elevation (STEMI) or depression/T-wave changes (NSTE-ACS)

• Aortic Dissection 1, 2

  • Presents with sudden, severe "ripping" pain, often radiating to the back
  • May have pulse differentials between extremities (30% of cases)
  • Risk factors include hypertension, connective tissue disorders, and Marfan syndrome

• Pulmonary Embolism (PE) 1

  • Typically presents with dyspnea and pleuritic chest pain
  • Tachycardia present in >90% of patients
  • Pain often worsens with inspiration

• Esophageal Rupture 1, 3

  • Often preceded by forceful vomiting
  • May present with subcutaneous emphysema, pneumothorax
  • Carries high mortality if diagnosis is delayed

Special Considerations for Different Patient Populations

• Women may present with atypical symptoms including nausea, vomiting, dyspnea, or back/neck/jaw pain 4
• Elderly patients (≥75 years) may present with shortness of breath, syncope, confusion, or unexplained falls rather than classic chest pain 4
• Diabetic patients may have atypical presentations due to autonomic dysfunction 4

Management Algorithm

1. Immediate Actions:

   • Activate EMS by calling 9-1-1 1
   • If available, administer aspirin (unless contraindicated) 1
   • Transport to nearest appropriate ED; patients with known STEMI or cardiogenic shock should be sent directly to hospitals with interventional capabilities 1

2. Upon ED Arrival:

   • Obtain ECG within 10 minutes of arrival 1
   • Draw cardiac biomarkers 1
   • Perform focused physical examination 1
   • Obtain appropriate imaging based on clinical suspicion:
     • CT angiography for suspected aortic dissection or PE 2
     • Echocardiography for suspected valvular or pericardial disease 2

3. Treatment Pathway Based on Diagnosis:

   • STEMI: Immediate reperfusion therapy (primary PCI preferred if available within 120 minutes, otherwise fibrinolysis) 1, 5
   • NSTE-ACS: Anti-ischemic therapy, antiplatelet/anticoagulant medications, and risk stratification for timing of invasive management 5
   • Aortic dissection: Blood pressure control, surgical consultation 2
   • PE: Anticoagulation, consideration of thrombolysis for massive PE 1

Common Pitfalls to Avoid

• Dismissing chest pain in women or elderly patients who may present atypically 4
• Relying solely on pain intensity to determine seriousness of condition 4
• Delaying ECG acquisition beyond 10 minutes of arrival 1
• Attempting to evaluate chest pain solely via telephone 1
• Sending patients with suspected ACS to the ED by personal vehicle rather than EMS 1

Red Flags Requiring Immediate Action

• Chest pain described as "worst ever" or "ripping" with radiation to back 2, 4
• Presence of diaphoresis, tachypnea, tachycardia, or hypotension 1
• New-onset left bundle branch block or ST-segment changes on ECG 4
• Pain associated with syncope, severe dyspnea, or hemodynamic instability 4

Remember that time is critical in the management of acute chest pain, particularly for conditions like STEMI where early reperfusion significantly improves outcomes 1.