Emergency Medicine

CHEST PAIN

General Medical Emergencies 49

Gastrointestinal

causes

(see p. 59)

Burning, nocturnal

pain, gastrointestinal

symptoms

Abdominal

tenderness,

rebound or

guarding

Lipase, AXR,

ultrasound

Musculoskeletal

causes

(see p. 60)

Pain increased with

movement or

muscular activity

Chest-wall

tenderness to

palpation (may

occur in ACS!)

Normal

ACS, acute coronary syndrome; AXR, abdominal X-ray; BP, blood pressure; CT,
computerized tomography; CTPA, computerized tomography pulmonary angiogram;
CXR, chest X-ray; ECG, electrocardiograph; V/Q, ventilation perfusion; WCC, white
cell count.

(i) Unstable angina (UA) includes increasing severity or frequency

of angina, angina at rest and new-onset angina that markedly

limits physical activity or following a recent myocardial

infarction.

(ii) Older patients, females, diabetics and chronic renal failure

patients may present with atypical ACS pain.

3 Establish venous access with an i.v. cannula, and attach a cardiac monitor
and pulse oximeter to the patient.

4 Send blood for FBC, coagulation profile, ELFTs, cardiac biomarker assay
such as cardiac troponin I (cTnI) or troponin T (cTnT) and lipid profile,
exactly as for STEMI.

5 Perform an ECG within 10 min of patient arrival, with immediate review by
a senior ED doctor.
(i) This may show ST depression, T wave inversion or flattening,
non-specific or transient changes, or
(ii) The ECG may be normal.

MANAGEMENT

1 Give aspirin 150–300 mg orally unless contraindicated by known hypersen-
sitivity.
(i) Give clopidogrel 300 mg oral loading dose, then 75 mg once daily
if aspirin-intolerant, or in addition if this is local policy.

2 Give GTN 150–300 g sublingually, and add morphine 2.5–5 mg i.v. with an
antiemetic, e.g. metoclopramide 10 mg i.v., if pain persists.

3 Commence heparin for all patients with a suspected NSTEMI or UA, without
necessarily awaiting the first cardiac biomarker results particularly with
new ECG changes.
(i) Give LMW heparin such as enoxaparin 1 mg/kg s.c. or dalteparin
120 units/kg s.c. both 12-hourly, or