What is the initial order for a patient presenting with severe chest pain of 9/10 severity?

Initial Management of Severe Chest Pain (9/10)

For a patient presenting with severe chest pain (9/10), an ECG should be acquired and reviewed within 10 minutes of arrival as the first diagnostic order. 1, 2

Immediate Assessment Algorithm

1. 12-lead ECG within 10 minutes

   • Must be reviewed immediately for STEMI or other life-threatening abnormalities
   • If initial ECG is nondiagnostic but clinical suspicion remains high, serial ECGs should be performed 1
   • Consider supplemental leads V7-V9 if posterior MI is suspected 1

2. Laboratory tests

   • High-sensitivity cardiac troponin (preferred biomarker) 1
   • Should be measured as soon as possible after presentation 1

3. Chest radiography

   • Useful to evaluate for cardiac, pulmonary, and thoracic causes of symptoms 1

4. Additional immediate measures

   • Establish IV access
   • Administer aspirin 160-325 mg (chewed) unless contraindicated 2
   • Provide supplemental oxygen if saturation <90% 2

Clinical Decision Points

The ECG findings will direct subsequent management:

• If STEMI or new LBBB: Immediate activation of STEMI protocol
• If ST depression or T-wave inversions: Treat according to non-ST-elevation ACS guidelines
• If normal or nondiagnostic: Continue evaluation with serial ECGs and troponin measurements

Important Considerations

• Age matters: In patients ≥75 years, ACS should be considered when accompanying symptoms like shortness of breath, syncope, or acute delirium are present 1

• Beware of normal ECGs: Up to 40% of patients with acute myocardial infarction may have a normal initial ECG 2

• Pain characteristics: Higher probability of ischemia is associated with central/left-sided, pressure/heaviness/tightness, and retrosternal chest pain 2

• Avoid delays: For patients initially evaluated in an office setting, delayed transfer to the ED for troponin testing should be avoided 1

Common Pitfalls

1. Delaying ECG acquisition beyond the recommended 10-minute window
2. Failing to repeat ECGs when symptoms persist or change
3. Relying on a single normal ECG to rule out ACS
4. Overlooking atypical presentations of ACS, especially in women, elderly, and diabetic patients
5. Focusing only on cardiac causes while missing other life-threatening conditions like aortic dissection, pulmonary embolism, or pneumothorax

The initial ECG is the cornerstone of chest pain evaluation, providing critical information that guides immediate management decisions and helps identify patients requiring urgent intervention. This should always be the first diagnostic order for a patient with severe chest pain.