If you get through a 12-hour emergency shift without tackling a “Chest Pain” patient, go straight to the bodega and buy yourself a lotto ticket. A miracle has happened. “Chest Pain,” along with “Abdominal Pain,” “Dizziness,” and “I Got Stabbed By My Friend When We Were Doing PCP Together At His Mom’s House” is one of our bread and butter chief complaints. It’s important to get comfortable with it, but it’s also a great chief complaint to get you started on thinking like an Emergency Physician.
The ED is unlike any other place in the hospital. We want to find out what’s causing our patient’s pain, we want to alleviate that pain, we want to have them on the right medications going forward, but most of all, we want to make sure they don’t die. Therefore, we’re often more interested in what the patient’s chest pain is not, than what it actually is. In other words, if the patient has chest pain and we can say with relative certainty that we’re not concerned about a life-threatening diagnosis, we will likely be comfortable creating a discharge plan for them and moving on to the next patient.
When approaching any patient, it’s important to take a step back and think, “What are the pathologies that could present with this chief complaint that could kill my patient?”
There are eight deadly causes of chest pain (CP):
- Acute Coronary Syndrome
- Aortic Dissection
- Pulmonary Embolism (PE)
- Tension Pneumothorax
- Cardiac Tamponade
- Esophageal Rupture
It’s critical to consider these 8 causes regardless of how well your patient appears. A patient with a PE can appear well and then go on to die that night. A patient with an aortic dissection can easily be mistaken for a patient with a myocardial infarction (MI). It is a central skill in Emergency Medicine to methodically consider each of these diagnoses not just for academic purposes but in order to catch the patient with the critical presentation. Remember, you can’t diagnose it if you don’t think about it.
Chest Pain Diagnostic Workup – Basics
- Obtain vital signs
- Start an IV
- Administer O2 (if hypoxic)
- Attach the patient to a cardiac monitor.
- 12-Lead EKG
With your vitals and EKG alone, you have your first two branching points (presented here in series, but in reality, these are acted on in parallel as a STEMI and unstable vital signs are both very concerning)
Final Thoughts: This is by no means an exhaustive review of the evaluation of chest pain. The above is just a glimpse into the EM mindset; consider the deadly diagnoses first and then broaden our thought process to address the most likely diagnosis. Keep in mind that this is simply a basic framework for every single one of your patients who mutters the words “chest pain.” Get used to this thought process — of ruling out and addressing the most deadly things first in your head — and apply it to all your other chief complaints.