Initial Triage - Red Alert Response
Rapid assessment: Airway, Breathing, Circulation, Disability, Exposure. Prioritize immediate life-threats and stabilize.
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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)
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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
| Category | Condition | Key Features |
|---|---|---|
| Cardiac: Ischemic | Acute Coronary Syndrome (ACS) | Substernal pressure, radiates arm/jaw, exertional, ECG changes, ↑enzymes. |
| Stable Angina | Predictable with exertion, relieved by rest/nitrates. | |
| Cardiac: Non-Ischemic | Pericarditis | Sharp, pleuritic, better leaning forward; friction rub. Diffuse ST elevation. |
| Aortic Dissection | Sudden, severe tearing pain to back; unequal BP/pulses. Widened mediastinum. | |
| Myocarditis | Viral prodrome, fever; heart failure signs. | |
| Pulmonary | Pulmonary Embolism (PE) | Sudden dyspnea, pleuritic pain, tachypnea, hemoptysis; 📌 PERC/Wells. |
| Pneumothorax | Sudden, sharp pleuritic pain, dyspnea; ↓breath sounds. | |
| Pneumonia/Pleuritis | Pleuritic pain, cough, fever; consolidation. | |
| Gastrointestinal | GERD | Burning, retrosternal, postprandial; antacid relief. |
| Esophageal Spasm | Substernal, mimics angina; dysphagia. | |
| Musculoskeletal | Costochondritis | Localized tenderness, worse with movement/palpation. |
| Neuropathic/Psych. | Herpes Zoster | Dermatomal burning pain; vesicular rash. |
| Panic Disorder | Chest tightness, palpitations, dyspnea; situational. | |
| Others | Mediastinitis | Severe pain, fever; post-op/perforation. |
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.
- 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).
- ECG: Ischemia (ST ↑/↓, T inversion), PE signs (S1Q3T3).
- 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.
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