Chest Pain Evaluation

Initial Triage - Red Alert Response

Rapid assessment: Airway, Breathing, Circulation, Disability, Exposure. Prioritize immediate life-threats and stabilize.

• Red Flags:

  • Hemodynamic instability (SBP < 90 mmHg, HR < 50 or > 120 bpm)
  • Respiratory distress ($SpO_2 < extbf{90}%$, tachypnea)
  • Altered mental status
  • Sudden, severe, tearing/ripping pain (suspect Aortic Dissection)
  • Asymmetrical breath sounds, tracheal deviation (suspect Tension Pneumothorax)
  • Muffled heart sounds, JVD, pulsus paradoxus > 10 mmHg (Beck's triad for Tamponade)

• Life-Threatening Causes (📌 PET MAC):

  • Pulmonary Embolism
  • Esophageal Rupture
  • Tension Pneumothorax
  • Myocardial Infarction (ACS)
  • Aortic Dissection
  • Cardiac Tamponade

⭐ For suspected ACS, administer Aspirin 300-325 mg (chewable) immediately, unless contraindicated.

Differential Diagnosis - Suspect Spectrum

Focused Evaluation - Clinical Clue Quest

• History: Crucial for diagnosis.
  • 📌 OPQRST/SOCRATES for pain: Onset, Provocation/Palliation, Quality, Radiation, Severity, Timing.
  • Key Symptoms: Dyspnea, syncope, palpitations (cardiac?); fever (infection?); cough, hemoptysis (pulmonary?).
  • Risk Factors:
    • Cardiac: HTN, DM, HLD, smoking, family Hx.
    • PE: Immobility, surgery, malignancy, DVT Hx.
• Physical Examination: Targeted search.
  • Vitals: BP (hypotension; >180/120 mmHg in dissection), HR, RR, Temp, SpO2.
  • General: Distress, diaphoresis.
    • Levine's sign.
  • Cardio: Murmurs, rubs, S3/S4; unequal pulses/BP (dissection).
  • Resp: Crackles (HF), wheeze, ↓ breath sounds (pneumothorax); pleural rub.
  • Abdo: Tenderness (GERD, referred).
  • MSK: Chest wall tenderness (costochondritis).

⭐ A normal physical exam does not rule out ACS; maintain high index of suspicion with suggestive history.

Diagnostic Workup - Test & Tell Toolkit

• Initial Tests:
  • ECG: Ischemia (ST ↑/↓, T inversion), PE signs (S1Q3T3).
  • Cardiac Biomarkers: Troponin T/I (serial, ↑ in MI), CK-MB.
  • CXR: Pneumothorax, pneumonia, widened mediastinum (aortic dissection).
  • D-dimer: If PE suspected (Wells/Geneva), >500 ng/mL (age-adjusted).
• Advanced Tests:
  • Echocardiography: Wall motion, valves, effusion.
  • CT: CTPA for PE, CT Aortogram for dissection.
  • Stress Test: Stable, low-intermediate CAD probability.

⭐ Troponin levels can rise 2-4 hours post-MI, peak at 12-24 hours, and remain elevated for 7-10 days.

High‑Yield Points - ⚡ Biggest Takeaways

• ECG within 10 minutes is crucial for all acute chest pain.
• Typical angina is substernal, exertional, and relieved by nitrates/rest.
• Suspect aortic dissection with sudden, tearing pain radiating to the back.
• Pulmonary embolism often presents with pleuritic pain and hypoxia.
• Cardiac troponins are the gold standard biomarkers for MI.
• TIMI/GRACE scores aid in ACS risk stratification and management.
• Always rule out life-threatening causes first: ACS, PE, dissection, tamponade, tension pneumothorax.