1. Ask for vital signs on the phone immediately, including O2 sat. If the patient is unstable, go to the patient immediately; if stable, you can ask the nurse a little about the pain.
2. Take a look at your signout card. Is this at all worrisome for angina or MI? If so, or if the story sounds good (have a low threshold), ask the nurses to get an ECG or at least bring the ECG machine to the bedside during the time it takes you to arrive to see the patient.
3. Upon arriving in patient's room, look at ECG first (ask for prior ECG from chart) or start obtaining the ECG as you're asking history.
4. Directed history and physical. This will comprise the bulk of your diagnostic workup. You will need to rule out bad stuff rather than diagnose definitively. The major killers are:
- MI: typically - pressure/pain associated with shortness of breath, diaphoresis, radiation to left jaw/arm, nausea/vomiting, cardiac risk factors present; remember, MI can present atypically, and not only in women and diabetics.
- Aortic dissection: tearing pain, associated with HTN, smoking, radiation to back, unequal pulses.
- Pneumothorax: COPD, trauma, decreased breath sounds, hyperresonance, deviation of trachea away from side with pneumothorax, and hypoxia.
- PE: dyspnea, tachypnea, tachycardia, pleuritic chest pain, hypoxia, A-a O2 gradient, hemoptysis.
5. Other etiologies that are sometimes overlooked include pericarditis, pneumonia/pleurisy, GERD, PUD, esophageal spasm, esophageal rupture or tear (Mallory-Weiss), candidiasis, herpes zoster, costochondritis (Tietze?s syndrome), anxiety (a diagnosis of exclusion).
6. Treatment: If angina suspected, start O2 by NC and use sublingual nitroglycerin (NTG 0.4 mg SL q5 min x 3; hold for SBP <100). Remember, just because the chest pain responds to NTG does not automatically rule in angina. If ineffective, try other antianginals including:
- Morphine 2-4 mg IV (watch BP and for oversedation).
- Metoprolol 5 mg IV q5 min x 3 (avoid in COPD/asthma or CHF).
- Nitropaste (see Sliding Scales: Nitropaste).
- If patient is not already on aspirin and has no contraindications, have patient chew and swallow ASA 325 mg.
7. If suspecting dissection, transfer to ICU to reduce BP and inotropy with blocker. Arrange for emergent CT scan or echo and call vascular surgery. ECG may show evidence of ischemia in RCA distribution if dissection is proximal.
8. If pneumothorax suspected, get CXR and call surgery for chest tube placement. If tension pneumothorax, don't wait for the CXR! Insert a 14 gauge angiocath into the 2nd intercostal space at the midclavicular line on the side of the pneumothorax.
9. If high suspicion for pulmonary embolism, get chest CT with PE protocol or V/Q scan if available. Begin anticoagulation (if there are no contraindications) while you are waiting for the results.
10. Be sure to obtain post-pain ECG and document the event.
Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000; 342:1187-95.
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