INITIAL MANAGEMENT :

PATIENT WITH CHEST

PAIN

Advanced Diploma in Emergency

Care
 DIAGNOSTIC APPROACH

Chest pain in ED can be triaged into traumatic and non

traumatic etiologies

The evaluation of non traumatic chest pain requires an

algorithmic approach that excludes acute myocardial
ischemia before working through the various
aetiologies of chest pain

Advanced Diploma in Emergency

Care
Medical & Surgical Emergencies
 DIAGNOSTIC APPROACH
Clinical presentation alone cannot be reliable to
determine ACS

Past medical history & specific cardiac risk factors

such as known cardiac disease, raised cholesterol,
hypertension, smoking and family history support a
cardiac cause

Physical examination give additional values to help in

making diagnosis
Advanced Diploma in Emergency
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Medical & Surgical Emergencies
 CLINICAL FEATURES
During initial assessment, the diagnosis of ACS should be considered in concert with
other life-threatening conditions:

Aortic dissection

Pulmonary embolism

Pneumothorax

Pericarditis

Pericardial tamponade

Pneumonia

Esophageal rupture

Advanced Diploma in Emergency

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 Life threatening Causes of Chest Pain: Classic
Symptoms Compared
Pain Associated
Disorder
Location Character Radiation Symptoms

Crushing,
R or L Dyspnea,
Retrosternal tightness,
Angina pectoris shoulder / arm/ diaphoresis,
or epigastric squeezing,
hand / jaw nausea
pressure
Dyspnea,
unstable vitals,
Heaviness,
Massive PE Whole chest None feeling of
tightness
impending
doom

Segmental PE Focal chest Pleuritic None Tachycardia

Secondary
Midline, Intra scapular
Aortic Dissection Ripping, tearing arterial branch
substernal area of back
occlusion
Pneumothorax Advanced Diploma in Emergency
Care
Medical & Surgical Emergencies
Life threatening Causes of Chest Pain:
Classic Symptoms Compared
Pain Associated
Disorder
Location Character Radiation Symptoms

Pneumothorax One side of Sudden, sharp, Shoulder, dyspnea

chest lancinating, back
pleuritic
Dyspnea,
Sudden, sharp,
Esophageal diaphoresis,
Substernal after forceful Back
rupture may see signs
vomiting
of sepsis
Sharp, constant or Back, neck, Fever,
Pericarditis Substernal
pleuritic shoulder pericardial rub
Faver, may
Pneumonia Focal chest Sharp, pleuritic None seen sign of
sepsis
Perforated Back, up into Acute distress,
Epigastric Severe, sharp
peptic ulcer chest diaphoresis
Advanced Diploma in Emergency
Care
Medical & Surgical Emergencies
 PAIN ASSESSMENT

Using any pain scale to quantify pain severity,

administer the appropriate type of analgesic agent (as
ordered by medical officer)

Patient may need repeated bolus of medication

Continuous vital signs monitoring and reassessment of

patients relief after given analgesic

Advanced Diploma in Emergency

Care
Medical & Surgical Emergencies
 ANCILLARY TESTING

Acute chest pain needs ECG, laboratory testing, and

imaging studies to distinguish a potential life
threatening condition

Advanced Diploma in Emergency

Care
Medical & Surgical Emergencies
 RISK ASSESSMENT
Risk assessment of a patient with chest pain is usually done by
the medical officer to determine if the patient actually belongs in
the possible ACS

Example

HEART Score it predicts 6 weeks risk of major cardiac

adverse event (MACE)

0-3 0.9 1.7 % risk for MACE

46 12 16.6% risk for MACE

7 10 50 65% risk for MACE

Advanced Diploma in Emergency
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Medical & Surgical Emergencies
 Evaluation process in ED
Secondary Evaluation
Primary Evaluation

Possible ACS
Observation unit or
History inpatient unit
Physical Examination Serial ECG
ECG Serial cardiac markers
First set of cardiac (excludes AMI)
biomarker Definite ACS
CXR Or High risk features

Admission to CCU or
Chest pain not from ACS revasculatization (if STEMI) Chest pain not from ACS

Treat alternative diagnosis Treat alternative diagnosis

Advanced Diploma in Emergency

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 Initial Management of ACS
Supplemental O2

Sublingual nitroglycerin

Antiplatelet / anticoagulant therapy (Aspirin /

Clopidogrel)

Analgesic

Low molecular weight heparin

Reperfusion strategy (thrombolysis vs PCI)

Advanced Diploma in Emergency

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Medical & Surgical Emergencies
Contraindication for thrombolysis

Advanced Diploma in Emergency

Care
Medical & Surgical Emergencies