Approach to Chest Pain in ED

Chest pain presentation

Acute chest pain

of recent onset, typically <24 hours, which causes the patient to seek prompt medical attention location on the anterior thorax a sensation distressing to the patient.

Triage
Visceral chest pain Abnormal vital signs Significant vascular disease risks ABC compromised

Immediate management
Cardiac monitor IV line Oxygen ECG Vitals at regular intervals

Life-threatening causes of acute chest pain

Important causes of acute chest pain

Investigations
Test ECG ACS ST and T-wave changes Cardiomegaly, pulmonary edema, widened mediastinum Aortic dissection ST and T-wave changes Widened mediastinum PE S1Q3T3 Pneumothorax QRS depression Pericarditis ST:T >0.25

CXR

Pleural effusion, enlarged pulmonary artery, peripheral opacity TTE/TOE D-dimer Troponin elevated

Visceral pleural line overlying radiolucent area without vascular or lung markings US

Normal or enlarged heart shadow

Others Troponin and CK-MB elevated

Troponin elevated CT

US

Further Management in ED
ACS PCI within 90 mins or fibrinolysis within 30 mins Aortic dissection Sodium nitroprusside and beta blocker PE LMWH Pneumothorax Needle thoracocentesis and chest tube insertion Pericarditis Ibuprofen Pericardioce ntesis if large pericardial effusion present