What are the recommended next steps for a 60-year-old female patient with a history of chronic obstructive pulmonary disease (COPD), chronic pain syndrome, and other comorbidities, who was involved in a care collision and is experiencing chest pressure, after a radiology report showed no evidence of acute cardiopulmonary disease?

Management of Chest Pressure in a 60-Year-Old Female Post-Car Collision with COPD and Normal Chest Radiograph

For a 60-year-old female with COPD who experienced a car collision and is now having chest pressure with a normal chest radiograph, cardiac evaluation is recommended as the next step, focusing on potential cardiac causes while managing her chronic pain and COPD symptoms. 1

Initial Assessment and Considerations

• The patient's normal chest radiograph rules out acute cardiopulmonary disease, including pneumothorax, pleural effusion, infiltrates, and congestive heart failure 1
• Given the history of car collision and chest pressure, cardiac evaluation should be prioritized even with a normal chest radiograph, as chest pain/pressure following trauma may indicate cardiac contusion or other cardiac issues 1
• Chronic pain is highly prevalent in COPD patients (approximately 60% compared to 52% in other chronic diseases) and may be exacerbated by trauma 2, 3

Recommended Next Steps

1. Cardiac Evaluation

• Obtain ECG to evaluate for potential cardiac injury or ischemia 1
• Consider cardiac biomarkers (troponin) to rule out myocardial contusion or ischemia following trauma 1
• For intermediate-risk patients with acute chest pain and no known CAD, coronary computed tomography angiography (CCTA) is useful if initial cardiac evaluation is negative or inconclusive 1

2. Musculoskeletal Assessment

• Evaluate for chest wall injury, which may not be visible on standard chest radiograph but could cause chest pressure, especially in a patient with osteoarthritis 1
• Consider focused physical examination of the thoracic spine and ribs, as COPD patients have higher prevalence of chest and upper back pain 2

3. COPD Management

• Assess for COPD exacerbation that may have been triggered by the stress of the collision 1
• Monitor oxygen saturation and respiratory parameters, as COPD patients are at higher risk for respiratory compromise following trauma 1
• If COPD exacerbation is suspected despite normal chest radiograph, consider airway clearance techniques 1

4. Pain Management

• Address chronic pain syndrome, which affects 40-60% of COPD patients and may be exacerbated by trauma 2, 3
• Consider that chest pressure may represent a manifestation of chronic pain rather than acute cardiopulmonary pathology 4
• Evaluate for potential interaction between pain medications and COPD treatments 3

Follow-up Recommendations

• If chest pressure persists despite normal initial evaluation, consider follow-up chest imaging in 6-12 weeks to ensure no developing pathology 1
• For patients with COPD and chronic pain, regular follow-up is essential as pain is associated with higher dyspnea, depression, and lower physical activity levels 2

Special Considerations

• The patient's multiple comorbidities (COPD, chronic pain syndrome, osteoarthritis, Sjögren's syndrome, rheumatoid arthritis) increase the complexity of evaluation 1
• Be cautious about attributing symptoms solely to COPD exacerbation when trauma has occurred; maintain high suspicion for cardiac injury 1
• Consider that diaphragmatic dysfunction can occur in COPD and may be exacerbated by trauma, contributing to chest pressure 1

Common Pitfalls to Avoid

• Do not assume chest pressure after trauma in a COPD patient is solely due to COPD exacerbation 1
• Avoid dismissing normal chest radiographs in trauma patients, as they may not reveal all injuries 1
• Don't overlook the high prevalence of pain in COPD patients, which can manifest as chest pressure and be exacerbated by trauma 2, 4