What is the appropriate emergency evaluation and management for a patient presenting with burning chest and back pain?

Emergency Evaluation of Burning Chest and Back Pain

Activate emergency medical services immediately and obtain a 12-lead ECG within 10 minutes, because burning chest pain radiating to the back represents acute aortic dissection until proven otherwise—a life-threatening emergency that requires urgent imaging and surgical consultation. 1, 2

Immediate Actions (First 10 Minutes)

• Obtain a 12-lead ECG within 10 minutes to detect ST-elevation myocardial infarction (≥1 mm in contiguous leads), ST-depression, T-wave inversions, or pericarditis patterns (diffuse ST-elevation with PR-depression). 1, 2, 3

• Draw high-sensitivity cardiac troponin immediately because it is the most sensitive and specific biomarker for myocardial injury, even though aortic dissection remains the primary concern with this presentation. 1, 2, 3

• Measure vital signs in both arms (heart rate, bilateral blood pressures, respiratory rate, oxygen saturation) to detect pulse or blood-pressure differentials—a systolic BP difference >20 mmHg between arms occurs in ~30% of aortic dissections. 1, 2

• Perform a focused cardiovascular examination for pulse differentials in all four extremities, new aortic regurgitation murmur (present in 40-75% of type A dissections), diaphoresis, tachypnea, crackles, S3 gallop, unilateral absent breath sounds, and jugular venous distension. 1, 2

• Withhold aspirin, heparin, and all antithrombotic therapy until aortic dissection is definitively excluded by imaging, because anticoagulation can be catastrophic in dissection. 2

Life-Threatening Diagnoses to Exclude First

Acute Aortic Dissection (Primary Concern)

• Sudden, severe "ripping" or "tearing" chest or back pain that is maximal at onset is the hallmark presentation; burning quality does not exclude dissection. 1, 2, 4

• Physical clues include: pulse differential between extremities (~30% of cases), systolic BP difference >20 mmHg between arms, new aortic regurgitation murmur (40-75% of type A dissections), and syncope (>10% of cases). 2

• When severe abrupt pain, pulse discrepancy, and widened mediastinum on chest X-ray coexist, the probability of dissection exceeds 80%. 2

• Immediate management: Transfer urgently to a center with 24/7 aortic imaging (CT angiography, MRI, or transesophageal echocardiography) and cardiac surgery capability; do not delay for troponin results. 2

Acute Coronary Syndrome

• Typical ACS presentation: Retrosternal pressure, squeezing, or heaviness that builds over minutes (not instantaneous), often radiating to the left arm, neck, or jaw—but burning quality occurs in some patients. 1, 2, 3

• Associated symptoms: Diaphoresis, dyspnea, nausea, vomiting, lightheadedness, presyncope, or syncope markedly increase ACS likelihood. 1, 2

• If STEMI is identified (ST-elevation ≥1 mm in contiguous leads): Activate STEMI protocol immediately with door-to-balloon time <90 minutes for primary PCI or door-to-needle time <30 minutes for fibrinolysis. 1, 2, 3

• If ST-depression, T-wave inversions, or elevated troponin without ST-elevation: Admit to coronary care unit, initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor) and anticoagulation, and plan urgent coronary angiography. 1, 2

Pulmonary Embolism

• Sudden dyspnea with pleuritic chest pain that worsens on inspiration is typical; tachycardia occurs in >90% of PE cases. 1, 2, 4

• Apply Wells criteria for risk stratification: Use age- and sex-adjusted D-dimer for low-to-intermediate probability, or proceed directly to CT pulmonary angiography if high probability. 2

Esophageal Rupture (Boerhaave Syndrome)

• Severe substernal pain after forceful vomiting with subcutaneous emphysema and concurrent pneumothorax in ~20% of cases. 2

• Diagnosis: Chest CT with oral contrast or contrast esophagography. 2

Serial Monitoring When Initial Tests Are Non-Diagnostic

• Repeat high-sensitivity troponin at 1-3 hours (or conventional troponin at 3-6 hours) because a single normal result does not exclude ACS. 2, 3

• Obtain serial ECGs every 15-30 minutes if clinical suspicion remains high to capture evolving ischemic changes. 2

• Add posterior leads V7-V9 when suspicion for ACS is intermediate-to-high and the standard ECG is nondiagnostic. 2, 3

Pre-Hospital Management

• Activate EMS immediately; do not transport by personal vehicle because 1.5% of chest pain patients develop cardiopulmonary arrest en route. 1, 3, 5

• Do NOT administer aspirin until aortic dissection is excluded by imaging. 2

• Provide intravenous morphine 4-8 mg (repeat 2 mg every 5 minutes as needed) for pain relief, recognizing that pain increases sympathetic drive and myocardial workload. 1

• Supply supplemental oxygen 2-4 L/min only if the patient is breathless, shows heart-failure features, or has low oxygen saturation; routine oxygen in normoxemic patients may be harmful. 1

Common Pitfalls to Avoid

• Do not assume burning chest pain is esophageal or musculoskeletal without first excluding aortic dissection and ACS; burning quality occurs in both cardiac and aortic emergencies. 2, 6, 4

• Do not administer aspirin, heparin, or thrombolytics until aortic dissection is definitively ruled out by imaging. 2

• Do not delay EMS transport for troponin testing when aortic dissection or ACS is suspected; immediate transfer is essential. 1, 2, 3

• A normal physical examination does not exclude life-threatening disease; early MI, PE, and even some dissections can present with entirely normal findings. 2

• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain; esophageal spasm and other conditions may also improve. 2

Imaging Algorithm After Initial Stabilization

• If pulse differential, BP differential >20 mmHg, or widened mediastinum on chest X-ray: Proceed immediately to CT angiography of the chest (aorta protocol) or transesophageal echocardiography. 2, 7

• If initial ECG and troponin are normal but clinical suspicion for ACS remains: Consider coronary CT angiography in low-to-intermediate risk patients to rapidly exclude obstructive coronary disease. 8, 7

• "Triple rule-out" CT protocol (simultaneous assessment of coronary arteries, aorta, and pulmonary arteries) may be appropriate in older patients with atypical chest pain and low-to-intermediate risk, but the increased radiation dose must be considered. 8, 7