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Initial Assessment
Initial Assessment
ABCDE: Airway, Breathing, Circulation, Disability, Exposure
- Symptom relief: Pain, nausea, fever
- Access & Monitoring:
- Insert IV cannula
- Check random blood sugar (RBS)
- Attach monitor
Vital Signs to be recorded:
Blood Pressure
Pulse Rate
Respiratory Rate
Oxygen Saturation
Temperature
Consciousness Level (GCS)
Immediate Triage Decisions
- Crash Room Transfer If:
- Hypotensive, hypoxic, or GCS <14
- Tachycardia or tachypnea depending on clinical context (e.g., fever, pain, anxiety)
- If in shock, follow the ‘Shock’ Algorithm
ECG: Within 10 Minutes of Arrival
ECG: Within 10 Minutes of Arrival
Assess for:
- STEMI or STEMI equivalent
- Type of STEMI
- Discuss all ECGs with the senior on call
If STEMI
If STEMI
Call Cardiology
- Send Labs: CBC, Troponin, UCE, Ca, Mg, PT, APTT
- Cath Lab Preparation
If Inferior wall STEMI:
If Inferior wall STEMI:
Evaluate for aortic dissection risk factors:
- Marfan syndrome
- Known aortic valve disease
- Aortic surgery or aneurysm history
- Abrupt, tearing pain
- Focal neurological signs
- BP difference >20 mmHg between arms
- New murmur or shock
Medications
Medications
(If no contraindication)
(If no contraindication)
Aspirin 300 mg
Clopidogrel 300 mg
Atorvastatin 80 mg
Unfractionated Heparin 5000 units IV
Nitroglycerin (Sublingual 0.4 mg):
Up to 3 doses unless contraindicated (e.g., RV infarct, hypotension, PDE-5 inhibitors, HOCM, aortic stenosis)
IV Metoprolol (5 mg up to 15 mg):
Only if: VT, hypertension, persistent pain
Avoid if: bradycardia, heart block, cardiogenic shock, EF↓, HR >110, SBP <120, shock index >0.8
Pain Management:
Pain Management:
Prefer paracetamol, nitrates, beta-blockers
Avoid opioids unless post-angiography or other measures fail
Oxygen
Oxygen
only if SpO₂ <92%
only if SpO₂ <92%
If No STEMI
If No STEMI
Step 1: Clinical Assessment
Evaluate for other fatal causes of chest pain (see below)
Send Labs: CBC, Troponin, UCE, Ca, Mg, PT, APTT
Step 2: NSTEMI / Unstable Angina
Call Cardiology
If acute ischemic ECG changes
Give Aspirin 300 mg
Nitroglycerin if not contraindicated
If Troponin positive: add Clopidogrel 300 mg, Atorvastatin 80 mg
Step 3: No Ischemia on ECG + Troponin <5
If symptoms >3 hrs:
→ Calculate HEART Score
If symptoms <3 hrs:
→Troponin after 2 hrs
If positive: treat as NSTEMI
If delta <2: calculate HEART score
Otherwise: call cardiology
Other Causes of Chest Pain
Other Causes of Chest Pain
Aortic Dissection
<40 years: Consider only if Marfan, bicuspid valve, or prior surgery
>40 years: Sudden tearing/migrating pain, neuro signs, unequal pulses/BP
Discuss with senior immediately
Tension Pneumothorax:
Signs: Hypotension, hypoxia, tracheal deviation, unequal chest rise
Needle decompression: 16G in 6th ICS, midaxillary line
Spontaneous Pneumothorax:
Same signs without hypotension or tracheal shift
CXR or POCUS, inform senior
Cardiac Tamponade
Suspect if JVP ↑, muffled heart sounds, hypotension
Urgent senior review
Pericarditis / Myocarditis
Features: Fever, malignancy, sharp pleuritic or positional pain
ECG: PR depression + ST elevation
Echo if available
Esophageal Rupture
Signs: Hematemesis, persistent retching, crepitus, hypotension
Inform Senior and Surgery immediately
Herpes Zoster
Band-like pain preceding rash
Consider early if dermatomal pain is present
Pulmonary Embolism
Wells Score:
<2: Apply PERC rule
2–4: D-dimer
>4: CTPA (if non-pregnant) +LMWH 1 mg/kg SC if no contraindications
PERC Rule: PE ruled out only if all criteria are negative
References
References
EB Medicine – Chest Pain
2022 ACC Expert Consensus Pathway – Chest Pain in ED
Contributors
Contributors
Author: Dr Faysal Subhani
Editor: Dr Ayesha Saeed
Page updated
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