Can’t Miss Diagnoses
- Acute Coronary Syndrome
- Aortic Dissection
- Pericardial tamponade
- Pulmonary Embolism
- Tension pneumothorax
- Esophageal rupture
Points to focus upon
- Risk factors for Coronary Artery Disease and Pulmonary Embolism
- Functional Status – Exercise Tolerance, Recent Decline?
- Use of Medications – Nitro Spray effective? Adherent to anticoagulant prescriptions?
- Habits to inquire about – Smoking, Recent or recurrent cocaine use
- Hemoptysis, Dyspnea (symptoms consistent with PE)
- Always check for signs of DVT on your physical exam.
- CBC, BUN, Cr, Lytes, Glucose,
- Serial Troponin (usually 2-3 hours apart)
- Serial ECGs (especially if recurrent chest pain)
- Chest x-ray where warranted
- Consider D-Dimer where appropriate (use PERC to rule out)
- ECG – Remember to compare an old ECG; Consider 15-lead ECG if pain refers to back
- Consider telemetry
Tips on Tests
hs-troponin T – the 2h delta to rule-out is <4ng/L and the delta to rule-in is >= 10ng/L. ( EM CASES)
CXR – looking for alternative diagnoses (Pneumothorax, pneumonia) or incidental findings (ground-glass opacities, suggestive of COVID-19)
Clinical Decision Tools of Relevance
Risk-stratify chest pain patients into low, moderate, and high-risk groups with the help of HEART SCORE for MACE .
May qualify for early discharge using HEART Pathway
Low-risk patients with a follow-up troponin (at 3 hours) can be considered for safe discharge home with appropriate follow-up.
Other Management Pearls
- Hypotensive patients with inferior wall ST changes
- May need 15 lead ECG
- Review right ventricular infarction
- Assess pts with focal neuro signs for aortic dissection
- <93% O2, consider oxygen supplementation and monitoring, Aspirin where warranted
- Remember, we usually do serial Troponins and ECG where warranted. Guidelines advise that these troponins should be at least 2 hours apart. Consult your institutional policy for specific guidance based on your troponin assay.
“One ECG begets another” – Dr. Amal Mattu
Recommended reading, videos, and podcasts
- First 5 min: Approach to: Chest pain
- CRACKCast E026 – Chest Pain
- EMCases: Low-Risk Chest Pain and High Sensitivity Troponin
- CRACKCast E085 – Aortic Dissection
- CRACKCast E076 – Pneumonia
The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.
This post was edited by Dr. Brent Thoma MD FRCPC. This post was copyedited and uploaded by Evan Formosa.