Emergency Medicine

CHEST PAIN

58 General Medical Emergencies

4 Establish venous access with a large-bore (14- or 16-gauge) i.v. cannula, and

send blood for FBC, ELFTs, cardiac enzymes and group and cross-match.

Attach a cardiac monitor and pulse oximeter to the patient.

5 Perform an ECG, which may look remarkably normal despite the severity of

the pain, with left ventricular hypertrophy and non-specific changes.

6 Request a CXR that may show a widened mediastinum, blurred aortic knob

and a left pleural effusion, but can be normal.

MANAGEMENT

1 Give high-dose oxygen via a face mask. Aim for an oxygen saturation above

94%.

2 Relieve the pain with morphine 5–10 mg i.v. and give an antiemetic.

3 Reduce the systolic BP to below 110 mmHg using a labetalol infusion or

sodium nitroprusside plus propranolol i.v. in consultation with the senior ED

doctor or intensive care team, when dissection is diagnosed or highly likely.

4 Organize an urgent helical CT angiogram, transoesophageal echocardio-

gram or aortogram to conf irm t he diagnosis.

5 Contact the cardiothoracic surgeons and arrange transfer without delay.

Involve the intensive care team early.

Pericarditis

DIAGNOSIS

1 T h is may be post-v i r a l such a s C ox s ack ie or fol low a myoc a rd ia l i n fa rc t ion eit her

early within 24 h or later at 2–3 weeks (Dressler’s syndrome), pericardiotomy,

connective tissue disorder, uraemia, trauma, tuberculosis or a neoplasm.

2 The pain is sharp, pleuritic, retrosternal and positional, relieved by sitting

forward.

3 Listen for a pericardial friction rub, best heard along the left sternal edge

with the patient sitting forward, which may be transient or intermittent.

4 Send blood for FBC, ELFTs, cardiac biomarkers and viral serology. Attach a

cardiac monitor and pulse oximeter to the patient.

5 Perform an ECG that may show sinus tachycardia alone or AF, widespread

concave ST elevation, followed by T wave f lattening t hen inversion.

6 Request a CXR, which is usually normal, even if a pericardial effusion is present.

MANAGEMENT

1 Give high-dose oxygen via a face mask. Aim for an oxygen saturation above

94%.

2 Give the patient a non-steroidal anti-inf lammatory analgesic such as ibupro-

fen 200 –400 mg ora lly t.d.s. or naproxen 250 mg ora lly t.d.s.