What is the initial workup for a patient presenting to the emergency department after a front impact low-speed Motor Vehicle Collision (MVC) with complaints of chest pain and abdominal pain?

Initial Workup for Front Impact Low-Speed MVC with Chest and Abdominal Pain

For patients presenting to the emergency department after a front impact low-speed motor vehicle collision (MVC) with complaints of chest pain and abdominal pain, the initial workup should include a 12-lead ECG within 10 minutes of arrival, focused cardiovascular examination, and appropriate imaging based on clinical findings. 1, 2

Immediate Assessment

• Obtain and review a 12-lead ECG within 10 minutes of arrival to identify potential cardiac injury or STEMI 3, 1
• Measure cardiac troponin as soon as possible when ACS is suspected 3, 1
• Perform a focused cardiovascular examination to identify potential serious causes of chest pain (e.g., ACS, aortic dissection, pulmonary embolism) 3
• Place patient on cardiac monitor with emergency resuscitation equipment nearby 2
• Assess vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature 3, 2

Focused History and Physical Examination

• Evaluate chest pain characteristics: nature, onset/duration, location/radiation, severity, precipitating factors, relieving factors, and associated symptoms 3, 2
• Assess for high-risk features of chest pain: retrosternal location, pressure/heaviness/tightness, radiation to arms/jaw, diaphoresis, nausea/vomiting, dyspnea 3, 2
• Perform targeted abdominal examination to assess for tenderness, guarding, rigidity, or other signs of intra-abdominal injury 3
• Look for external signs of trauma: seat belt sign, steering wheel imprint, bruising 3
• Consider that older patients (≥75 years) may present with atypical symptoms such as shortness of breath, syncope, or acute delirium 3

Initial Imaging

• Obtain portable AP chest radiograph to screen for immediate life-threatening findings such as pneumothorax, hemothorax, widened mediastinum, and rib fractures 3
• Obtain portable AP pelvis radiograph to evaluate for pelvic fractures and hip dislocations 3
• Consider FAST (Focused Assessment with Sonography for Trauma) examination to evaluate for free fluid in the pericardium, pleural spaces, and abdomen 3

Advanced Imaging Based on Clinical Findings

• For patients with abnormal chest radiograph, concerning vital signs, or persistent symptoms, obtain contrast-enhanced CT of the chest, abdomen, and pelvis 3
• CT of the chest with IV contrast has greater sensitivity for detecting cardiac, vascular, and pulmonary injuries compared to non-contrast CT 3
• Consider CT angiography (CTA) of the chest if there is concern for aortic or major vessel injury 3
• For suspected cardiac injury (abnormal ECG, elevated troponin, hemodynamic instability), obtain echocardiography 3

Common Pitfalls and Caveats

• Do not rely on the absence of external signs of trauma to rule out internal injuries, as significant internal injuries can occur in low-speed collisions 3
• Do not use relief with nitroglycerin as a diagnostic criterion for myocardial ischemia, as other conditions may show comparable response 2
• Do not delay transfer to the ED for troponin testing if ACS is suspected in an outpatient setting 3, 2
• Chest radiographs have lower sensitivity for detecting pneumothorax, hemothorax, lung contusions, rib fractures, and cardiac/vascular injuries compared to CT 3
• Remember that women, elderly patients, and those with diabetes may present with atypical symptoms 2

Risk Stratification and Disposition

• Patients with STEMI or high-risk features should be treated according to ACS guidelines with consideration for immediate reperfusion therapy 2
• Patients with suspected significant traumatic injuries should be managed according to trauma protocols 3
• Consider observation unit admission for patients with low to moderate risk of cardiac events who require further evaluation 4, 5
• Patients with non-cardiac, non-traumatic causes of chest pain should be treated according to the specific diagnosis 2