Severe chest pain and sweating in a 61-year-old: a live emergency case

Why acute chest pain with sweating matters

Acute chest pain is the presentation where minutes matter most. Several of its causes kill quickly and need opposite treatments, so the first ten minutes are about recognising which one you are dealing with, while keeping the patient safe.

What to ask in the history

• Onset: sudden or gradual, and what he was doing
• Character: crushing, tight, tearing, sharp; worse on breathing or moving
• Radiation: arm, jaw, back
• How long it has lasted
• Sweating, nausea, breathlessness, palpitations, fainting
• Risk factors: smoking, diabetes, high blood pressure, cholesterol, family history
• Previous heart disease, angina, stents
• Recent immobility or travel, leg swelling; drug use

Red flags

• Pain lasting more than 20 minutes, or ongoing
• Low blood pressure, cold clammy skin, confusion
• Breathlessness or crackles in the chest
• An irregular or very fast or slow pulse
• Tearing pain going through to the back, or unequal blood pressure in the two arms
• Low oxygen saturation

What to examine

• Airway, breathing, circulation: get the vital signs straight away
• Blood pressure in both arms; pulses
• Heart sounds, new murmurs, JVP
• Chest: crackles, air entry on each side
• Legs: swelling or tenderness

First investigations

• 12-lead ECG within 10 minutes of arrival, and repeated if the pain changes
• Cardiac troponin, repeated as per protocol
• Chest X-ray
• Full blood count, electrolytes, renal function, glucose, coagulation
• Further imaging (echo, CT) guided by what the ECG and examination show

Differential diagnosis of acute chest pain with sweating

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Waiting for a troponin result when the ECG already shows what to do.
• Giving blood thinners before considering aortic dissection.
• Being reassured by a normal first ECG or first troponin. Both can be normal early.