Are intravenous (IV) fluids administered to patients presenting with chest pain in the emergency department (ED)?

Intravenous Fluid Administration for Chest Pain in the Emergency Department

Intravenous fluids are not routinely administered to patients presenting with chest pain in the ED; instead, fluid administration is reserved for specific clinical scenarios such as hypotension, right ventricular infarction, or hemodynamic instability, while the primary focus remains on aspirin, nitroglycerin, antiplatelet agents, and anticoagulation. 1, 2

Initial Management Priorities

The cornerstone of chest pain management in the ED does not include routine IV fluid administration. Instead, the focus is on:

• Aspirin (162-325 mg chewed) should be administered immediately unless contraindicated 2, 1, 3
• Sublingual nitroglycerin for suspected ischemic chest pain, followed by IV nitroglycerin if symptoms persist 2, 1, 3
• Morphine sulfate IV when chest pain is not relieved by nitroglycerin or when acute pulmonary congestion is present 2, 3
• IV beta-blockers for ongoing chest pain without contraindications 2, 3

Specific Scenarios Requiring IV Fluids

Right Ventricular Infarction

IV fluids are specifically indicated for right ventricular infarction presenting with hypotension, as these patients are preload-dependent and require volume expansion rather than vasodilators. 2 Nitrates should be avoided in this population as they can precipitate profound hypotension. 3

Hypotension and Hemodynamic Instability

Fluids may be administered when:

• Systolic blood pressure falls below 90 mmHg or drops 30 mmHg below baseline 3
• Signs of inadequate perfusion are present (altered mental status, poor capillary refill, decreased urine output) 2
• Cardiogenic shock develops, though these patients require careful fluid management and often need inotropic support rather than aggressive fluid resuscitation 2

Important Contraindications and Cautions

Avoid aggressive fluid administration in patients with:

• Acute heart failure or pulmonary edema, where IV diuretics (typically furosemide) are indicated instead 2
• Suspected aortic dissection, where blood pressure control with IV beta-blockers is the priority, not fluid expansion 2
• Established acute coronary syndrome without hypotension, as excessive fluids can worsen pulmonary congestion 2

The target blood pressure in most chest pain patients should be maintained between 100-120 mmHg systolic, achieved through medications rather than fluids. 2

Clinical Pitfalls

A common error is administering IV fluids reflexively when establishing IV access in chest pain patients. This practice lacks evidence and may be harmful in patients with:

• Left ventricular dysfunction, where fluid overload can precipitate acute decompensation 2
• Ongoing myocardial ischemia, where increased preload may worsen myocardial oxygen demand 2

The primary therapeutic interventions remain pharmacological (aspirin, antiplatelet agents, anticoagulation, nitrates, beta-blockers) rather than volume expansion. 2, 1 IV access should be established for medication administration, not routine fluid infusion. 4