Nurse Triage Algorithm for Chest Pain
Patients presenting with chest pain should be immediately assessed using a structured triage protocol to identify potential acute coronary syndrome (ACS) and other life-threatening conditions, with an ECG obtained and reviewed within 10 minutes of arrival. 1
Initial Assessment by Registration/Clerical Staff
Immediate Triage Required for Patients Presenting with:
- Chest pain, pressure, tightness, or heaviness
- Pain radiating to neck, jaw, shoulders, back, or one/both arms
- Indigestion or heartburn with associated chest discomfort
- Persistent shortness of breath
- Weakness, dizziness, lightheadedness, or loss of consciousness
Triage Nurse Assessment Protocol
Step 1: Identify High-Risk Symptoms
- Chest pain or severe epigastric pain with characteristics of myocardial ischemia:
- Central/substernal compression or crushing chest pain
- Pressure, tightness, heaviness, cramping, burning, or aching sensation
- Unexplained indigestion, belching, or epigastric pain
- Radiation to neck, jaw, shoulders, back, or arms
- Associated symptoms:
- Dyspnea
- Nausea/vomiting
- Diaphoresis
Step 2: Obtain Immediate 12-lead ECG
- Must be acquired and reviewed within 10 minutes of arrival 1
- If ECG shows ST-segment elevation or new LBBB, activate STEMI protocol immediately
Step 3: Targeted Medical History
- Current or past history of:
- Previous coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI)
- Known coronary artery disease (CAD), angina, or previous MI
- Nitroglycerin use to relieve chest discomfort
- Risk factors:
- Smoking
- Hyperlipidemia
- Hypertension
- Diabetes mellitus
- Family history of CAD
- Cocaine or methamphetamine use
- Current medications
Step 4: Physical Examination
- Vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
- Cardiovascular examination (heart sounds, murmurs, signs of heart failure)
- Pulmonary examination (breath sounds, crackles, wheezing)
- Check for pulse differentials (particularly with suspected aortic dissection)
Risk Stratification and Management
High Risk (Immediate Action Required):
- ECG with ST-segment elevation, new LBBB, or significant ST depression/T-wave inversion
- Hemodynamic instability (hypotension, tachycardia)
- Signs of heart failure (crackles, S3 gallop)
- Severe, ripping chest/back pain with pulse differential (suspect aortic dissection)
- Action: Immediate cardiac monitoring, IV access, cardiac biomarkers, and transfer to emergency department via EMS
Intermediate Risk:
- Typical anginal symptoms without ECG changes
- Multiple cardiovascular risk factors
- Known CAD with stable symptoms
- Action: Obtain ECG, cardiac biomarkers, and arrange urgent evaluation in emergency department
Low Risk:
- Atypical symptoms
- Normal ECG
- No history of CAD
- Young age
- Action: Consider non-cardiac causes but maintain vigilance
Special Considerations
- Women may present with more atypical symptoms than men 1
- Diabetic patients may have atypical presentations due to autonomic dysfunction
- Elderly patients may present with generalized weakness, stroke, syncope, or altered mental status rather than classic chest pain 1
Common Pitfalls to Avoid
- Delayed ECG acquisition - ECG must be obtained within 10 minutes of arrival
- Dismissing atypical presentations - Especially in women, elderly, and diabetic patients
- Relying solely on pain relief with nitroglycerin - Not diagnostic for cardiac ischemia
- Delaying transfer - Patients with suspected ACS should be transported immediately to the ED
- Incomplete assessment - Always consider other life-threatening causes of chest pain (pulmonary embolism, aortic dissection, pneumothorax)
Following this structured approach ensures rapid identification of patients with potentially life-threatening conditions while appropriately triaging those with lower-risk presentations, ultimately reducing morbidity and mortality in patients presenting with chest pain.