Chapter 14: Chest Pain

IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

See Figure 14–1.

INITIAL MANAGEMENT

Airway, Breathing, Circulation

A. Primary Survey

This primary survey should be done in a parallel fashion noting airway, breathing, circulation, and disability. If the patient is pulseless and/or apneic, follow advanced cardiac life support (ACLS) pathway (Chapters 9 and 34).

B. Consider Supplemental Oxygen

In the spontaneously breathing patient, oxygen may initially be applied to ill-appearing patients during initial evaluation. If a patient is saturating well, decrease oxygen as needed. New studies on oxygen show that it can be harmful when given to patients with normal oxygen levels. Oxygen is a drug and can have toxicity. Only apply oxygen if the patient has hypoxemia and a need for oxygen.

C. Begin Continuous Cardiac Monitoring

Begin cardiac monitoring with blood pressure and pulse oximetry. Treat life-threatening arrhythmias (Chapters 9 and 34).

Look for Markedly Abnormal Hemodynamics

A. Clinical Findings

Look for signs of shock to include altered sensorium, pale clammy skin, oliguria, and respiratory distress from arterial hypotension and poor peripheral perfusion.

MANAGEMENT OF THE PATIENT WITH CHEST PAIN AND ABNORMAL HEMODYNAMICS

Treatment and Disposition

A. Immediate Measures

Insert two large-bore intravenous catheters. Intraosseous (IO) access is acceptable and compatible with all resuscitation infusions including blood, vasopressors, and even thrombolytics. The proximal humerus is preferred over tibia in adults due to its proximity of central circulation. Obtain blood for a complete blood count (CBC), markers of cardiac injury, and basic metabolic panel (electrolytes, glucose, renal function). Consider blood gas, serum lactate, blood type, and screen if transfusion is being considered. Obtain a pregnancy test on women of childbearing age. Begin administration of intravenous fluids based on estimate of intravascular fluid volume.

1. Hypovolemic shock

Infuse 500–1000 mL of intravenous crystalloid solutions (normal saline or lactated Ringer). Monitor the response (blood pressure, urine output, sensorium).

2. Central venous hypervolemia (with or without shock or hypotension)

Briefly examine the pulmonary and cardiovascular systems, and palpate the abdomen for presence of a surgical abdomen or pulsatile mass. Obtain a 12-lead electrocardiogram (ECG). Obtain a portable chest radiograph. Perform point-of-care bedside ultrasound (POCUS) to assist in diagnosis and management. Rapid ultrasound for shock and hypotension (RUSH) protocol is one method of systematically evaluating the hypotensive patient in shock. The examination includes scanning the heart, inferior vena cava (IVC), Morison pouch ...