• Chest pain?
• A breast lump?
• Postmenopausal bleeding?
• Fatigue/weight loss?
• Joint pain?
• Something else?

50-Year-Old Obese Female: Epigastric Pain + Collapse in ER - A Red Flag Scenario

The Core Problem: Why This Case is Dangerous

"One-third of women older than 65 years with acute myocardial infarction present with abdominal pain alone. As a result, the diagnosis of ACS may be delayed..."

• Rosen's Emergency Medicine

STEP 1: The Dangerous Differentials You Must Rule Out FIRST (Prioritized)

1. NSTEMI / ACS (Most Likely - Rule Out First)

• Why missed: Women, obese patients, and elderly patients present atypically - epigastric/abdominal pain, nausea, diaphoresis, fatigue INSTEAD of chest pain
• Why ECG is unreliable: NSTEMI by definition may have a normal or near-normal ECG. A single "unremarkable" ECG does NOT exclude ACS
• Why she collapsed: Either cardiogenic shock, acute heart failure, or a lethal arrhythmia from an evolving MI
• Risk factors present: Female, age ~50, obese - likely also has hypertension, dyslipidemia, pre-diabetes

2. Aortic Dissection (Type A or B)

• Epigastric/back pain, collapse, shock - classic
• USG will be non-diagnostic for proximal dissection
• ECG may be completely normal
• Can be fatal within minutes if missed

3. Massive / Submassive Pulmonary Embolism

• Epigastric pain + collapse + shock
• ECG may be normal or show only sinus tachycardia
• USG of abdomen: unremarkable
• Risk: obesity, older female (especially if on any hormones)

4. Ruptured/Leaking Abdominal Aortic Aneurysm (AAA)

• Epigastric pain radiating to back + collapse
• Standard USG may miss a leaking retroperitoneal AAA
• Obese patients are harder to scan accurately

5. Severe Pancreatitis with Systemic Complications

• Can cause collapse via vasodilation, third spacing, SIRS
• But this is a diagnosis of exclusion once cardiac/vascular causes are out

6. Mesenteric Ischemia

• Severe epigastric pain "out of proportion to exam"
• Can cause shock and collapse
• USG often unremarkable

STEP 2: Immediate Actions in ER (The "No Time to Waste" Protocol)

SIMULTANEOUS Actions - Do All at Once:

STEP 3: What NOT to Do / Common Errors That Waste Time

STEP 4: The Diagnostic Pathway (Time-Sensitive)

ARRIVAL
   |
   |--- [0-10 min] 12-lead ECG (including V4R, V7-V9 posterior leads)
   |--- [0-10 min] IV access, bloods (hsTroponin T0, Lipase, Lactate, D-dimer)
   |--- [0-10 min] POCUS (cardiac + aorta + IVC)
   |
   |-- If BP asymmetry / tearing pain / wide mediastinum on CXR:
   |       --> CT Aortogram (STAT) = rule out dissection / AAA
   |
   |-- If POCUS shows RV dilation + D-dimer elevated:
   |       --> CT Pulmonary Angiogram (CTPA) = rule out PE
   |
   |-- Troponin at 1 hour (hsTroponin):
   |       Rise >5 ng/L = NSTEMI highly likely
   |       Very low at 0h AND 1h = rule out MI
   |
   |-- If Lipase >3x normal + troponins negative:
   |       --> Confirm pancreatitis, assess severity (APACHE/BISAP score)
   |       --> CT Abdomen with contrast if organ failure signs
   |
   |-- If lactate >2.0 mmol/L + epigastric pain + collapse:
   |       --> CT Mesenteric angiography = mesenteric ischemia

STEP 5: Treatment Once ACS is Confirmed (or Strongly Suspected)

Immediate ACS Protocol:

• Aspirin 300 mg loading dose PO immediately
• Ticagrelor 180 mg (preferred) OR Clopidogrel 600 mg loading
• Anticoagulation: Fondaparinux 2.5 mg SC (preferred for NSTEMI) OR UFH IV
• High-intensity statin: Atorvastatin 80 mg
• Nitrates: GTN sublingual or IV if systolic BP > 100 mmHg (AVOID if RV infarct or hypotension)
• Supplemental O2 only if SpO2 < 94%
• Morphine: Use cautiously - it delays antiplatelet absorption
• Beta-blockers: Only after stabilization, NOT in shock or acute decompensated HF

If She Collapses in ER (as described):

• Immediate POCUS - is it VF? Tamponade? Massive PE? Cardiogenic shock?
• Call cardiology NOW - she needs urgent cath lab activation (primary PCI or rescue PCI)
• If cardiogenic shock: Dopamine/noradrenaline to maintain MAP >65; consider IABP if PCI capable center

If Aortic Dissection Confirmed:

• Immediate surgical/vascular surgery consultation
• IV Labetalol - target heart rate <60, systolic 100-120 mmHg
• NO anticoagulation, NO thrombolytics
• Type A = emergency surgery; Type B = medical management initially

If Massive PE Confirmed:

• Thrombolysis (Alteplase 100 mg IV over 2h) if hemodynamically unstable and no contraindications
• Anticoagulation: UFH IV bolus

STEP 6: The "Triple Rule-Out" Mindset

"Acute chest/abdominal pain (MI, pulmonary thromboembolism, and aortic dissection) should be front of mind, and the so-called 'triple rule-out' CT scan and echocardiographic imaging should be employed judiciously for diagnosis."

Summary: The Key Clinical Pearl

1. Accepting a single normal ECG as cardiac clearance
2. Not doing serial high-sensitivity troponins
3. Not doing bedside cardiac echo (POCUS)
4. Not checking bilateral blood pressures
5. Not measuring serum lactate
6. Diagnosing empirically by exclusion rather than by investigation

In any obese, middle-aged woman with epigastric pain that does not rapidly improve with GI treatment - treat as ACS and investigate accordingly until proven otherwise.