What are the immediate management steps for a patient with sudden onset chest pain radiating to the back?

Immediate Management of Sudden Onset Chest Pain Radiating to the Back

Aortic dissection must be your primary concern in any patient presenting with sudden onset chest pain radiating to the back—immediately activate emergency medical services, withhold all antithrombotic therapy until dissection is excluded, and arrange urgent CT angiography of the chest. 1

Critical First Actions

Immediate Risk Stratification

• Apply the Aortic Dissection Detection (ADD) score immediately upon patient contact. 1 Award one point for any of the following:

  • High-risk conditions: Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, family history of aortic dissection, known aortic valve disease, recent aortic manipulation, or known thoracic aortic aneurysm 1
  • High-risk pain features: Abrupt/instantaneous onset, severe intensity, or ripping/tearing/stabbing/sharp quality 1
  • High-risk examination features: Pulse deficit, systolic blood pressure differential >20 mmHg between limbs, focal neurologic deficit, new murmur of aortic regurgitation, or hypotension/shock 1

• Any ADD score ≥1 indicates high risk for aortic dissection (91% sensitivity) and mandates immediate transport to a facility with advanced imaging and surgical capability. 1

Emergency Medical Services Activation

• Instruct the patient to call 9-1-1 immediately—do not attempt telephone evaluation or allow self-transport. 1, 2 Evaluation cannot be performed via telephone and requires physical examination, ECG, and cardiac biomarkers. 1, 2

• Direct EMS to transport suspected aortic dissection patients to centers with interventional cardiology, cardiac surgery, and advanced imaging capabilities. 1

On-Scene and Transport Management

Monitoring and Assessment

• Place patient on continuous cardiac monitoring with emergency resuscitation equipment immediately available. 2

• Obtain and interpret 12-lead ECG within 10 minutes of first medical contact. 2, 3 The ECG is usually normal in aortic dissection but is essential to exclude STEMI. 1

• Check bilateral arm blood pressures and pulses in all extremities—a systolic differential >20 mmHg or pulse deficit strongly suggests dissection. 1, 3

Critical Treatment Decisions Based on ADD Score

If ADD score ≥1 (suspected aortic dissection):

• DO NOT administer aspirin, P2Y12 inhibitors, or anticoagulation. 1 These agents are contraindicated until dissection is excluded.
• DO NOT give nitroglycerin if hypotension is present. 4 Nitroglycerin is contraindicated in hypotensive patients and may worsen outcomes in dissection.
• Target heart rate <60 bpm and systolic blood pressure 100-120 mmHg using intravenous beta-blockers as first-line therapy. 1 Beta-blockers must be started before other antihypertensives to prevent reflex tachycardia. 1
• Provide aggressive pain control with intravenous opioids. 1

If ADD score = 0 (low probability of dissection):

• Administer aspirin 250-500 mg (fast-acting formulation) immediately if not contraindicated. 2
• Consider nitroglycerin 0.4 mg sublingual every 5 minutes for up to 3 doses if systolic BP >90 mmHg. 4 Patients should sit during administration to prevent orthostatic hypotension. 4
• If chest pain persists after 3 nitroglycerin doses over 15 minutes, this constitutes a medical emergency requiring immediate hospital evaluation. 4
• Administer loading doses of ticagrelor or clopidogrel plus anticoagulation (enoxaparin or unfractionated heparin) if NSTE-ACS is suspected and early invasive strategy is planned. 1

Hospital Arrival Protocol

Immediate Diagnostic Workup

• Obtain cardiac troponin as soon as possible after ED arrival. 3

• Arrange CT angiography of the chest with IV contrast as the definitive test for aortic dissection. 3 This is the preferred initial imaging modality and can simultaneously evaluate for pulmonary embolism. 3, 5

• Consider focused cardiac ultrasound (FoCUS) in the pre-hospital or ED setting to support the diagnosis of aortic dissection, particularly when ECG shows ischemic changes. 1, 6

Differential Diagnosis Considerations

The sudden onset with back radiation pattern suggests three life-threatening conditions that require immediate differentiation:

1. Aortic dissection: Sudden, severe, "ripping" pain described as "worst pain ever" with back radiation 3, 7
2. Acute coronary syndrome: Particularly inferior wall MI may radiate to the back 3, 7
3. Pulmonary embolism: Typically presents with pleuritic pain, dyspnea, and tachycardia 3

Critical Pitfalls to Avoid

• Never dismiss symptoms over the telephone or delay emergency evaluation. 1, 2 Proper assessment requires physical examination, ECG, and laboratory testing.

• Never administer antithrombotic therapy before excluding aortic dissection in patients with ADD score ≥1. 1 This can be catastrophic if dissection is present.

• Never rely on pain severity alone to determine urgency—severity is a poor predictor of complications. 2

• Never use nitroglycerin in hypotensive patients or those taking PDE-5 inhibitors (sildenafil, tadalafil, vardenafil). 4 This combination can cause life-threatening hypotension.

• Do not delay definitive imaging while waiting for troponin results in patients with high ADD scores. 1, 3 Aortic dissection requires immediate surgical consultation regardless of biomarkers.

Special Population Considerations

• Elderly patients may present atypically with generalized weakness, stroke, syncope, or altered mental status rather than classic chest pain. 3

• Diabetic patients may have blunted pain perception due to autonomic dysfunction. 3

• Patients with hypertension, known aortic valve disease, or connective tissue disorders have substantially elevated risk for aortic dissection. 1, 3