What are the immediate steps to take for an adult with no known medical history experiencing severe and persistent chest pain, possibly indicative of a life-threatening cardiovascular condition?

Immediate Management of Severe Chest Pain

Call 9-1-1 immediately and activate emergency medical services (EMS) for any adult experiencing severe, persistent chest pain—this is the single most critical action that reduces mortality and treatment delays. 1

First Actions (Within First 5 Minutes)

Activate EMS Immediately

• Call 9-1-1 first, before any other intervention—EMS transportation reduces ischemic time and treatment delays compared to private vehicle transport, and approximately 1 in 300 patients with chest pain transported by private vehicle experiences cardiac arrest en route 1
• Do not delay calling EMS to self-medicate or wait to see if symptoms resolve 1
• Patients should remain seated or lying down to prevent falls from potential hypotension or syncope 2

Aspirin Administration While Awaiting EMS

• Encourage the patient to chew and swallow aspirin 162-325 mg (or 2-4 baby aspirin of 81 mg each) immediately while waiting for EMS arrival 1
• Aspirin reduces mortality in acute myocardial infarction, with early administration (median 1.6 hours from pain onset) showing higher survival than late administration 1
• Do NOT give aspirin if:
  • Known aspirin allergy 1
  • Recent bleeding or active bleeding disorder 1
  • Patient has been specifically advised by a physician not to take aspirin 1
  • Any uncertainty exists—wait for EMS arrival without aspirin 1

Nitroglycerin Considerations

• If the patient has been previously prescribed nitroglycerin, they may take ONE dose (sublingual tablet) immediately 1, 2
• If chest pain is unimproved or worsening 5 minutes after one nitroglycerin dose, this confirms the need for immediate EMS activation 1
• Do NOT give nitroglycerin if patient has taken erectile dysfunction medications (sildenafil, tadalafil, vardenafil) or has hypotension 2
• Critical pitfall: Do NOT use nitroglycerin response as a diagnostic tool—esophageal spasm and other non-cardiac conditions also respond to nitroglycerin 3, 4

Life-Threatening Conditions to Consider

The evaluation must focus on immediate identification of these conditions 1, 3:

Acute Coronary Syndrome (Most Common)

• Presentation: Retrosternal pressure, heaviness, squeezing, or tightness building gradually over minutes 1, 3
• Radiation: Left arm, jaw, neck, back, or upper abdomen 1
• Associated symptoms: Diaphoresis (cold sweats), dyspnea, nausea, vomiting, lightheadedness, or syncope 1, 3
• Key point: Pain may occur at rest or with minimal exertion in unstable angina or myocardial infarction 1, 3

Aortic Dissection

• Presentation: Sudden-onset "ripping" or "tearing" chest pain radiating to upper or lower back 1, 3
• Physical findings: Pulse differentials between extremities, blood pressure differences >20 mmHg between arms, new aortic regurgitation murmur 3, 4

Pulmonary Embolism

• Presentation: Acute dyspnea with pleuritic chest pain 3, 4
• Physical findings: Tachycardia (present in >90% of patients), tachypnea 3

Other Life-Threatening Causes

• Tension pneumothorax: Severe dyspnea with unilateral absence of breath sounds 3
• Esophageal rupture: Severe pain after vomiting or instrumentation 1

High-Risk Features Requiring Immediate EMS Transport

These patients require urgent ED transfer by EMS, NOT personal vehicle 1, 3:

• Age ≥75 years with accompanying dyspnea, syncope, acute delirium, or unexplained fall 1
• Hemodynamic instability (hypotension, shock) 1, 3
• Recent syncope or presyncope 1
• Chest pain at rest for >20 minutes 1
• Symptoms interrupting normal activity 1
• Associated cold sweats, nausea, vomiting, or lightheadedness 1, 4

Special Population Considerations

Women

• May present with atypical symptoms more frequently than men—nausea and shortness of breath are more common accompanying symptoms 1, 3
• Chest pain remains the dominant symptom in women with acute coronary syndrome, but accompanying symptoms should not be dismissed 1

Elderly Patients (≥75 years)

• Higher likelihood of atypical presentations including dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1
• Prevalence of myocardial infarction increases with age (≈1% in ages 18-44 vs 4% in ages ≥80) 1

Patients with Diabetes

• More likely to have atypical or minimal symptoms 1
• Should be considered high-risk even with less dramatic presentations 1

What NOT to Do

• Do NOT transport the patient yourself—use EMS 1
• Do NOT delay calling 9-1-1 to take aspirin or nitroglycerin—call first, then medicate 1
• Do NOT wait to see if symptoms resolve on their own—poor indicator of risk 1
• Do NOT dismiss "atypical" presentations, especially in women, elderly, or diabetic patients 1, 3
• Do NOT give oxygen unless the patient is hypoxic—not recommended for normoxic patients with acute coronary syndrome 1

Summary of Action Sequence

1. Call 9-1-1 immediately 1
2. Have patient sit or lie down 2
3. Give aspirin 162-325 mg (chewed) if no contraindications 1
4. If previously prescribed, patient may take one nitroglycerin 1, 2
5. Stay with patient until EMS arrives 1
6. Follow EMS dispatcher instructions 1