What is the appropriate management for a patient presenting with chest pain, back pain, diaphoresis (excessive sweating), nausea, pallor (pale appearance), and urinary retention?

Immediate Management of Suspected Acute Coronary Syndrome

This patient requires immediate activation of emergency medical services (EMS) and transport to the emergency department for suspected acute myocardial infarction, as the constellation of chest pain, back pain, diaphoresis, nausea, and pallor represents classic signs of acute coronary syndrome (ACS). 1

Critical Initial Actions

Activate Emergency Response Immediately

• Call 9-1-1 immediately rather than attempting self-transport, as EMS transportation reduces ischemic time and treatment delays, and approximately 1 in 300 patients with chest pain transported by private vehicle experience cardiac arrest en route. 1
• The urinary retention is likely secondary to severe sympathetic activation from cardiac ischemia and should not delay cardiac evaluation. 1

Aspirin Administration While Awaiting EMS

• Administer aspirin 162-325 mg (chewed and swallowed) immediately while waiting for EMS arrival, unless the patient has a known aspirin allergy or has been advised by a healthcare provider not to take aspirin. 1
• Early aspirin administration (within first few hours) reduces mortality in acute myocardial infarction compared to delayed administration. 1
• If there is any uncertainty about aspirin contraindications, wait for EMS arrival without administering aspirin. 1

Why This Presentation Demands Urgent Evaluation

Classic ACS Symptom Complex

• The combination of chest pain with back pain, diaphoresis, nausea, and pallor represents the typical autonomic nervous system activation seen in acute myocardial infarction. 1
• These associated symptoms (nausea, vomiting, diaphoresis, pallor) point strongly toward a cardiac cause of chest pain and indicate high-risk features. 1
• Back pain radiation is a recognized pattern in acute coronary syndrome, particularly in women and certain patient populations. 1

High-Risk Features Present

• Pain with autonomic symptoms (sweating, pallor, nausea) represents a high-risk presentation requiring immediate fast-track evaluation. 1
• The inability to urinate likely reflects severe sympathetic activation and hemodynamic compromise rather than a primary urologic problem. 1

Emergency Department Management

Immediate Diagnostic Workup

• Obtain a 12-lead ECG within 10 minutes of arrival to identify ST-elevation myocardial infarction (STEMI), ST-segment depression, or T-wave inversions indicating acute ischemia. 1
• Measure cardiac troponin immediately upon arrival, though reperfusion therapy should not be delayed waiting for troponin results if ECG shows STEMI. 1, 2
• The ECG diagnosis alone is sufficient to activate the cardiac catheterization laboratory for STEMI patients. 2

Life-Threatening Differential Diagnoses to Exclude

While ACS is most likely, the emergency evaluation must also rapidly exclude:

• Aortic dissection: Sudden-onset "ripping" chest pain radiating to the back, pulse differential between extremities, or widened mediastinum on chest X-ray. 1
• Pulmonary embolism: Tachycardia, dyspnea, and pleuritic chest pain. 1
• These diagnoses require different management and must be considered given the back pain component. 1

Initial Treatment Measures

• Administer morphine titrated intravenously for pain relief and to reduce sympathetic activation. 2, 3
• Provide oxygen supplementation only if oxygen saturation is less than 90%; routine oxygen is not indicated. 1, 2
• Initiate continuous cardiac monitoring with defibrillation capability for potentially fatal arrhythmias. 2
• Administer dual antiplatelet therapy (aspirin plus P2Y12 inhibitor such as ticagrelor 180 mg or prasugrel 60 mg) if STEMI is confirmed. 2

Critical Pitfalls to Avoid

Do Not Delay for Troponin Results

• If the ECG shows ST-elevation with ischemic symptoms, proceed immediately to primary percutaneous coronary intervention (PCI) without waiting for troponin elevation. 2
• The goal door-to-balloon time is less than 90 minutes for STEMI patients. 2, 3

Do Not Attribute Symptoms to Urinary Retention

• The urinary retention is almost certainly a consequence of severe sympathetic activation from cardiac ischemia, not the primary problem. 1
• Focusing on the urinary retention while missing acute myocardial infarction would be a catastrophic error. 1

Do Not Use Nitroglycerin Response as Diagnostic

• Relief with nitroglycerin is not diagnostic of myocardial ischemia and should not be used as a diagnostic criterion. 1

Risk Stratification Considerations

• Age, duration of symptoms, and presence of autonomic symptoms all increase mortality risk substantially in ACS patients. 2
• Duration of several hours means ongoing myocardial necrosis with a time-dependent salvage window closing, emphasizing the critical need for prompt reperfusion therapy. 2

The bottom line: This symptom complex represents acute coronary syndrome until proven otherwise, and every minute of delay increases myocardial damage and mortality risk. 1, 2