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This is a medical emergency, and an immediate surgical consult is warranted. A contrast esophagram is the best confirmatory test. Ī left pleural effusion on a chest x-ray may suggest esophageal rupture. Start with beta-blocker therapy to prevent reflux tachycardia. Place two large-boar IVs and quickly lower the patient’s blood pressure to systolic between 100 mmHg to 130 mmHg. CT angiography is the best test to evaluate for dissection. Often immediate surgery is required consult cardiothoracic surgery early. Needle pericardiotomy or pericardial window to relieve pressure inside the pericardial sack. A fluid bolus may be used as a temporizing measure. īedside ultrasound is useful for establishing a diagnosis. Pneumothorax should be decompressed with a chest tube. Patients who are hemodynamically unstable should be started on thrombolytics stable patients should be started on anticoagulants. ĬT pulmonary angiogram (CTPA) is the best confirmatory test, a VQ scan can also be used, but this test is not as accurate in patients with chronic lung disease. In elderly patients and those with comorbidities, patients should be admitted for observation and further cardiac workup. Patients with stable angina may be appropriate for outpatient workup. Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for a cardiology consult and workup.

If PCI is not possible, thrombolytics should be initiated within 30 min. PCI is preferred and should be initiated within 90 minutes onsite or 120 minutes if transferred to an outside facility.

Patients with ST elevation on ECG patients should receive immediate reperfusion therapy, either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI). Nitroglycerin has shown a mortality benefit, aiming for a 10% mean arterial pressure (MAP) reduction in normotensive patients and a 30% MAP reduction in hypertensive patients avoid in hypotensive patients and those with inferior ST elevation. Place patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. Common descriptors of somatic pain are sharp, stabbing, and poking.Ī complete discussion of the management of ACS is beyond the scope of this paper however, initial steps should be performed in patients with a diagnosis of ACS. Somatic pain is also less likely to refer to other parts of the body. Somatic pain is more specific than visceral pain, and patients will usually be able to point to a specific spot. Diaphragmatic irritation may refer to the shoulders as well. Symptoms like nausea and vomiting may also be a sign of visceral pain. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw, or left arm. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Common descriptors of visceral pain are dull, deep, pressure, and squeezing.

When asking patients to point with one finger where they feel the pain, they will often move their hand around a larger area. Visceral pain usually presents with a vague distribution pattern meaning that the patient is unlikely to localize the pain to a specific spot. It sometimes is helpful to consider the different etiologies of pain.