Determine the Cause

Must be done rapidly and systematically, prioritizing life-threatening conditions while simultaneously resuscitating.

Before diagnostic workup, stabilize the patient:

A. Airway

  • Ensure airway patency. (How?)

  • Provide supplemental O₂ if hypoxic (SpO₂ < 90%).

  • Prepare for intubation if there is respiratory failure.

B. Breathing

  • Assess respiratory effort, rate, and oxygen saturation.

  • Listen for breath sounds (asymmetry suggests pneumothorax).

  • Look for signs of distress (cyanosis, accessory muscle use).

C. Circulation

  • Check pulse, blood pressure, perfusion, capillary refill.

  • Attach cardiac monitor and obtain 12-lead ECG immediately.

  • Establish IV access × 2 large-bore lines.

  • Draw blood for troponin, CBC, electrolytes, coagulation panel, etc.

  • Begin IV fluids if hypotensive; start vasopressors if unresponsive.

⚠️ 2. Rapid Identification of Life-Threatening Causes

Focus on the “Big Five” deadly causes of chest pain:

Condition Key Features Bedside Diagnostic Clues Immediate Management
Acute Coronary Syndrome (MI) Pressure-like pain radiating to arm/jaw, diaphoresis ECG: ST elevation/depression, Troponin ↑ Aspirin, nitroglycerin (if not hypotensive), morphine, reperfusion (PCI)
Pulmonary Embolism Sudden dyspnea, pleuritic pain, tachycardia, hypoxia D-dimer (if stable), bedside echo (RV strain), CT-PA (if stable) Oxygen, anticoagulation, thrombolysis if massive
Aortic Dissection Tearing chest/back pain, unequal BP in arms CXR: widened mediastinum, bedside echo or CTA BP control (β-blocker, nitroprusside), surgical consult
Tension Pneumothorax Sudden pleuritic pain, dyspnea, tracheal deviation, absent breath sounds Clinical diagnosis—don’t wait for X-ray Immediate needle decompression → chest tube
Cardiac Tamponade Dyspnea, muffled heart sounds, JVD, hypotension (Beck’s triad) Bedside echo: pericardial effusion, RV collapse Pericardiocentesis

🔍 3. Focused Bedside Investigations

While stabilizing:

  • 12-lead ECG — within 10 minutes.

  • Portable chest X-ray — for pneumothorax, dissection clues, CHF.

  • Bedside echocardiogram (POCUS) — for tamponade, dissection, PE, LV function.

  • Cardiac enzymes (troponin, CK-MB) — for ischemia.

  • ABG and lactate — to assess hypoxia, perfusion.

💉 4. Initial Empiric Interventions (as indicated)

  • Aspirin (if not contraindicated)

  • Oxygen (if hypoxic)

  • IV access, monitor, ECG

  • Nitroglycerin (if not hypotensive or RV infarct)

  • Morphine (for pain and anxiety)

  • Prepare for advanced support — vasopressors, defibrillator, possible intubation.

🧭 5. Secondary Evaluation After Stabilization

Once the patient is more stable:

  • Detailed history (onset, character, radiation, associated symptoms).

  • Comprehensive physical exam (murmurs, friction rubs, crepitus, asymmetry).

  • Serial ECGs and troponins to confirm or rule out MI.

  • Imaging (CT angiography for dissection or PE, if stable enough).

🧩 Mnemonic for Rapid Differential:

“My Patient Has Terrible Chest Pain”

  • M — MI (ACS)

  • P — PE

  • H — Hypotension from tamponade

  • T — Tension pneumothorax

  • C — Contained rupture (aortic dissection)

  • P — Pneumonia/pericarditis (less acute but relevant)

Would you like me to show this as a clinical decision algorithm or flowchart (like an emergency chest pain decision tree)? It can be visualized step-by-step for rapid bedside use.

 

+++++++++++++++++++++++++

 

Pivotal Assessments (One after the other) Finding

EKG

 

ST Segment Elevation

Non ST Segment Elevation

Indeterminate

Left bundle branch block

Presence of Q waves

T-wave inversion

Ventricular Tachycardia

Ventricular Tachycardia

Ventricular Fibrillation

Normal

 

 
Portable Chest X-Ray

Pneumothorax

Pneumonia

Pleural Effusion

Aortic Dissection

  1. 1
    2
    .
  2. [ Intramural hematoma (IMH) - Bleeding within the aortic wall without an intimal tear
    1
    .
  3. Penetrating atherosclerotic ulcer (PAU) - An ulceration in an atherosclerotic plaque that penetrates the internal elastic lamina
    .

 

  
D-Dimer* Elevated, Greater than .05 < .05

* D-Dimer Reference

 

If the patient is stable, treat the underlying cause of poor circulation:

  • Myocardial infarction (MI):

    • Administer aspirin (chew 162–325 mg) immediately.

    • Give nitroglycerin (if not hypotensive and no RV infarct).

    • Prepare for reperfusion therapy (PCI or thrombolysis).

  • Cardiac arrhythmia:

    • Identify via ECG and manage per ACLS algorithm (e.g., bradycardia → atropine, tachyarrhythmia → synchronized cardioversion or antiarrhythmics).

  • Cardiogenic shock:

    • Support with inotropes (e.g., dobutamine) and consider mechanical support (IABP, Impella) if refractory.

🧠 5. Ongoing Monitoring

  • Reassess vital signs and perfusion frequently.

  • Continue cardiac monitoring for rhythm changes or deterioration.

  • Prepare for advanced cardiac life support if cardiac arrest occurs.

Would you like me to include a flowchart (algorithm) showing the steps for assessing and establishing circulation in chest pain (both with and without pulse)?

Here’s a clear algorithmic flowchart for establishing circulation in a patient with chest pain, covering both situations — with pulse and without pulse:

🫀 Circulation Algorithm in Chest Pain

START → Patient with Chest Pain                │                ▼       Check Responsiveness                │     ┌──────────┴──────────┐     │                     │  Unresponsive        Responsive     │                     │     ▼                     ▼  Check Pulse         Assess Circulation  (Carotid or Radial)  (Pulse, BP, Perfusion)     │                     │     ▼                     ▼  ┌────────────┐       ┌────────────────────┐  │Pulse Absent│       │Pulse Present       │  └──────┬─────┘       └────────┬───────────┘         │                      │         ▼                      ▼  🚨 Begin CPR           ✅ Establish IV Access     (30:2 ratio)           and Cardiac Monitoring     │                      │     ▼                      ▼  Attach AED/Monitor     Obtain 12-Lead ECG     │                      │     ▼                      ▼  Check Rhythm:          Assess BP, SpO₂, Skin,   VF/VT? → Shock         Capillary Refill   Asystole/PEA? → CPR    │     │                      ▼  Follow ACLS Protocol   ┌────────────────────────┐                         │Is SBP < 90 mmHg or     │                         │signs of poor perfusion?│                         └─────────┬──────────────┘                                   │                     ┌─────────────┴─────────────┐                     │                           │                   YES                          NO                     │                           │                     ▼                           ▼  Give IV Fluids (250–500 mL NS)      Continue Monitoring  If Pulmonary Congestion → Skip      and Manage Pain/Anxiety  Consider Vasopressor (NE)           │                     │                           │                     ▼                           ▼  Treat Underlying Cause         Treat Underlying Cause   (e.g., MI, arrhythmia, shock)   (ACS, anxiety, musculoskeletal)                     │                           │                     ▼                           ▼           **Stabilize Circulation** → Reassess Vital Signs                               │                               ▼                          Prepare for Definitive Care                  (PCI, Thrombolysis, Advanced Support)

🧩 Key Points:

  • Always secure IV access early (two large-bore lines).

  • Monitor ECG and SpO₂ continuously.

  • Avoid nitroglycerin if hypotensive or right ventricular infarction is suspected.

  • Reassess every few minutes — patient may deteriorate rapidly.

  • If cardiac arrest develops, immediately transition to ACLS.

 

Generated image

Management and Determining the Cause

Digital World Medical School
© 2025