Chest Pain – Critically Unwell

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  • 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

    Complications of aortic dissection Abrupt onset of sudden tearing chest pain radiating to interscapular region  

    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


    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
    Unequal AE and hyper-resonance
    CXR = tension pneumothorax


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