Chest Pain – Critically Unwell

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Introduction

• A rare event
•  The  patient presents with chest pain and critically unwell with significant hypoxia, respiratory distress and/or hypotension.
• Most are due to acute complications, some are the result of a delayed complications
• There are only a handful of situations where this occurs
  

  Condition	Suspicious features	Suspicious findings	Ancillary tests	Definitive investigation
  Complications of Myocardial infarction	Anterior wall STEMI Delayed presentation.  Pre-existing cardiac damage.	Signs of acute heart failure or shock	ECG – Anterior wall STEMI ↑ Troponin	Echocardiogram
  Complications of aortic dissection	Abrupt onset of sudden tearing chest pain radiating to interscapular region	Hypertensive Unequal BP in arms (subclavian extension) Stroke like symptoms (carotid extension) Bilateral neurological symptoms (spinal artery extension) Lower limb ischaemia (descending aorta extension) Aortic regurgitation (aortic valve extension) Shock (pericardial extension)	CXR – wide medistinum	CT angiogram chest and abdomen Transoesophageal echocardiography
  Massive pulmonary embolism	Unexplained hypoxia i.e. chest examination normal and normal CXR Wells > 0 or PERC positive	Hypoxia Shock	Elevated d-dimer ECG – right strain pattern
  Oesophageal Rupture with Sepsis (delayed)	History of violent retching or vomiting. Abrupt onset of chest pain	Abdomen may be non tender	CXR = pneumomediastinum	CT chest

  Tension Pneumothorax

  HIstory of obstructive lung disease or trauma

  Hypoxia Tachypnoea Shock Unequal AE and hyper-resonance

  CXR = tension pneumothorax