What is the step-wise approach for a patient arriving in the emergency room with chest pain?

Step-wise Approach for Chest Pain Patients in the Emergency Room

The immediate assessment of patients with chest pain is mandatory on arrival at the emergency department, with ECG recording and assessment within 5 minutes to determine the need for urgent care. 1

Initial Assessment (First 5-10 Minutes)

1. Immediate Triage and Vital Signs

   • Check vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
   • Assess for hemodynamic instability or respiratory distress
   • Determine if patient needs "fast track" urgent care 1

2. Immediate Interventions

   • Administer oxygen by nasal prongs
   • Obtain IV access
   • Administer sublingual nitroglycerin (unless systolic BP <90 mmHg or heart rate <50 or >100 bpm) 1, 2
   • Provide adequate analgesia (morphine sulfate)
   • Administer aspirin 160-325 mg (chewed) 1, 3

3. Obtain 12-lead ECG within 5 minutes 1, 3

   • Interpret immediately for ST-segment elevation or depression
   • Look for LBBB or other ischemic changes

Risk Stratification (10-20 Minutes)

1. Evaluate High-Risk Features 1, 3

   • History: Interruption of normal activity, cold sweat, nausea, vomiting, dyspnea
   • Central chest pain with radiation to arms, neck, jaw
   • Age >65 years, known cardiovascular disease
   • Diaphoresis, tachypnea, tachycardia

2. Assess for Differential Diagnoses 3

   Clinical Syndrome	Key Findings
   Acute Coronary Syndrome	Diaphoresis, tachypnea, tachycardia
   Aortic Dissection	Severe pain with abrupt onset, pulse differential
   Pulmonary Embolism	Tachycardia + dyspnea, pain with inspiration
   Pneumothorax	Unilateral decreased breath sounds, dyspnea
   Pericarditis	Fever, pleuritic pain worse supine, friction rub

3. Initial Laboratory Tests

   • Cardiac biomarkers (high-sensitivity troponin preferred) 3
   • Basic metabolic panel
   • Complete blood count
   • Chest radiography 1, 3

Management Based on Initial Assessment (20-30 Minutes)

1. ST-Segment Elevation or New LBBB

   • Activate STEMI protocol
   • Prepare for immediate reperfusion therapy (fibrinolysis or primary PCI) 1
   • Target door-to-needle time <30 minutes for thrombolysis 1
   • Target door-to-balloon time <90 minutes for PCI 3

2. High-Risk Non-ST Elevation ACS

   • Continue anti-ischemic therapy (aspirin, nitroglycerin, beta-blockers)
   • Add anticoagulation (heparin)
   • Admit to coronary care unit or intensive care unit 1
   • Consider early invasive strategy 3

3. Intermediate Risk

   • Continue monitoring in emergency department or chest pain unit
   • Serial ECGs and cardiac biomarkers (0,3,6 hours) 1, 4
   • Apply validated risk scores (HEART, TIMI, or GRACE) 3
   • Consider observation unit admission for stress testing or additional imaging 3, 5

4. Low Risk

   • Consider early exercise testing if appropriate 6
   • Serial cardiac biomarkers
   • Consider discharge if negative serial troponins, normal ECG, and alternative diagnosis established 3

Specific Management for Non-ACS Causes

1. Suspected Aortic Dissection

   • Withhold antithrombotic therapy
   • Control blood pressure (target SBP 100-120 mmHg)
   • Start beta-blockers before other antihypertensive drugs
   • Transfer to center with 24/7 aortic imaging and cardiac surgery 1

2. Suspected Pulmonary Embolism

   • Maintain continuous ECG and oxygen saturation monitoring
   • Use clinical prediction scores to determine likelihood
   • Transfer unstable patients to centers equipped for thrombectomy 1

3. Pericarditis/Tamponade

   • Consider pericarditis in patients being evaluated for STEMI
   • Assess for signs of tamponade (jugular venous distension, hypotension)
   • Consider echocardiography if available 1

Common Pitfalls to Avoid

• Relying solely on ECG to rule out ACS (normal ECG does not exclude ACS) 3
• Using nitroglycerin response as a diagnostic test 3
• Discharging patients with ongoing symptoms 3
• Underdiagnosing women and elderly patients with atypical presentations 3
• Failing to obtain serial ECGs when clinical suspicion remains high 3
• Forgetting about non-cardiac life-threatening causes of chest pain 3

Disposition Decision (Within 6-12 Hours)

1. Admit to Hospital if:

   • Positive cardiac biomarkers
   • Ischemic ECG changes
   • Hemodynamic instability
   • High-risk features for non-ACS diagnoses 3

2. Observation Unit if:

   • Intermediate risk with negative initial workup
   • Need for stress testing or additional imaging 3, 5

3. Discharge if:

   • Low-risk features
   • Negative serial troponins
   • Normal or unchanged ECG
   • Alternative diagnosis established
   • Resolved symptoms 3

A systematic diagnostic approach as outlined above is essential for managing patients with chest pain in the emergency room, achieving high diagnostic accuracy while optimizing the use of coronary care unit beds 4.