Although none of the editors of InsideSurgery are involved in his care, we are following news reports that radio personality Rush Limbaugh has been hospitalized with chest pains and is listed in serious condition.
Limbaugh, 58, was taken to Queen’s Medical Center in Honolulu by an ambulance crew. He has no previously reported hospitalizations for chest pain.
Chest pain in a 58 year old man can have multiple causes, some several potentially very serious such as myocardial infarction (MI or heart attack or aortic dissection or rupture).
Limbaugh, who has lost a significant amount of weight in the last year, would be at an increase risk of cardiovascular disease because of his age, morbid obesity, and known affinity for smoking cigars.
When a patient arrives to the emergency room with a complaint of chest pain, most emergency rooms activate protocols to rapidly diagnose and treat the causative condition.
Below is a description of what typically happens to a patient with this complaint after they get to the emergency room.
Patients who arrive via ambulance with chest pain are given a high priority for treatment and are usually triaged immediately to a bed where they can be seen and examined (that is, they generally do not have to wait in the waiting room.)
If they are awake and talking as Limbaugh reportedly was, immediately after admission they are assessed by a nurse who takes vital signs – a heart rate, blood pressure, and temperature.
Usually, supplemental oxygen is then applied through a nasal cannula (plastic prongs inserted into each nostril that is attached to an oxygen supply from a wall outlet.)
The patient is then fairly quickly placed on a heart monitor where a one-lead heart tracing can be seen second-to- second – usually the V2 lead. Generally, the one-lead electronic heart monitor tracing is used to detect irregular heart beats and not ischemic disease.
Most emergency rooms in large hospitals have heart monitors that can also produce a paper 12 lead electrocardiogram (ECG) that is the first test used to detect whether the patient might be having cardiac ischemia.
Typically the 12 lead ECG is obtained both before and after treatment for chest pain to assess whether the ECG changes with treatment.
The nurse will then take a history asking the patient if they have ever had chest pain before, when it started, the nature of the pain (stabbing, dull, crushing, whether it radiates to the chin or down either arm or towards the back.)
If the patient still is having pain, typically they are given nitroglycerin under the tongue to dilate the coronary arteries. Resolution of chest pain with administration of nitroglycerin most typically is suspicious for cardiac ischemia but can occur with conditions other than heart attack.
If the patient is still relatively stable, a blood draw for laboratory testing is then done. The specfic tests done depend on the patient’s medical history but should always include troponin level and “cardiac enzymes”.
Troponin is a substance that is released when muscle dies. There are three types of troponin that can be release and the blood test should always investigate for an increase level of fractionated troponin – most generally troponin T.
The term “cardiac enzymes” generally refers to a serum test for the enzyme CK-MB, which is the specific enzyme in that class released into the blood in heart attacks.
Limbaugh undoubtedly received both of these blood tests shortly after arrival in the emergency room.