What is the best course of treatment for an elderly female with severe back pain between the shoulder blades and vomiting?

Immediate Cardiac Evaluation is Mandatory

This elderly female with severe interscapular back pain and vomiting requires immediate evaluation for acute coronary syndrome (ACS), specifically unstable angina or non-ST elevation myocardial infarction (NSTEMI), before considering musculoskeletal causes. 1

Critical Red Flag Recognition

• Pain radiating to the back or between the shoulder blades is a recognized atypical presentation of ACS, particularly in elderly women who present more frequently with atypical symptoms than men 1
• Associated nausea and vomiting with back discomfort is specifically listed as requiring immediate ACS protocol initiation 1
• Elderly patients may present with atypical symptoms such as generalized weakness, syncope, or altered mental status rather than classic chest pain 1

Immediate Management Algorithm

First Actions (Within Minutes)

• Obtain stat 12-lead ECG immediately to evaluate for ST-segment depression, T-wave inversion, or ST-elevation 1
• Draw cardiac biomarkers (troponin I or T) immediately, with repeat sampling at least 6 hours apart to differentiate unstable angina from NSTEMI 1
• Initiate continuous cardiac monitoring and establish IV access 1

If Cardiac Workup is Negative

Only after excluding ACS with serial ECGs and troponins should musculoskeletal back pain management be considered:

Pharmacological Management:

• Administer acetaminophen 1000 mg IV every 6 hours on a scheduled basis as first-line therapy, providing superior pain control compared to PRN dosing in elderly patients 2, 3
• Apply topical lidocaine patches directly to the interscapular area for localized analgesia without systemic effects 2, 3
• Add NSAIDs only with extreme caution due to significant risks of gastrointestinal bleeding, renal dysfunction, and cardiovascular complications in elderly patients 2, 3
• Consider topical NSAIDs as a safer alternative to systemic NSAIDs for localized pain 2

Non-Pharmacological Interventions:

• Apply ice packs to the affected area in conjunction with pharmacological therapy 2
• Provide education on proper positioning and advise remaining active rather than prolonged bed rest 1, 2

Adjunctive Options for Severe Pain:

• Add gabapentin if neuropathic pain components develop (such as radiating pain) 2, 3
• Consider low-dose ketamine (0.3 mg/kg IV over 15 minutes) as an alternative to opioids, providing comparable analgesia with fewer cardiovascular side effects 2, 3
• Reserve opioids strictly for breakthrough pain when non-opioid strategies fail, using the shortest duration and lowest effective dose due to high risk of accumulation, over-sedation, respiratory depression, and delirium in elderly patients 2, 3, 4

Additional Life-Threatening Causes to Exclude

Beyond ACS, other emergent conditions presenting with interscapular pain and vomiting include:

• Aortic dissection - requires immediate imaging if clinical suspicion exists 5
• Ruptured abdominal aortic aneurysm - can present with back pain and hemodynamic instability 5
• Spinal epidural abscess - particularly if fever, focal neurologic deficits, or risk factors for infection present 5, 6, 7
• Vertebral compression fracture - especially in patients with osteoporosis or chronic steroid use 2

Reassessment Timeline

• Immediate reassessment is required if pain worsens, new neurologic symptoms develop, or hemodynamic instability occurs 2
• If symptoms persist after cardiac and other emergent causes are excluded, reevaluate after 1 month, as most acute back pain improves substantially within the first month 1, 2
• Earlier reassessment (within 1-2 weeks) is warranted for severe pain or significant functional deficits 2

Critical Pitfalls to Avoid

• Never dismiss interscapular pain with vomiting in an elderly female as simple musculoskeletal pain without cardiac evaluation - this is a classic atypical ACS presentation 1
• Avoid both inadequate analgesia and excessive opioid use, as both increase risk of delirium, delayed mobilization, and poorer outcomes 2, 3
• Do not routinely obtain imaging for nonspecific back pain without red flags, as it does not improve outcomes and may lead to unnecessary interventions 1, 2
• Never exceed maximum daily acetaminophen dose (4 g/24 hours), particularly when using combination products 2, 3