Management and Determining the Cause

Chief Complaint: Chest Pain

Identify Life-Threatening Symptoms

Crushing, pressure-like chest pain radiating to arm, jaw, back
Diaphoresis, dyspnea, nausea
Syncope or near-syncope
Tachycardic, bradycardic,
Increased respiratory rate, decreased respiratory rate,
Altered mental status
Hypotension or shock
Unequal pulses or BP in both arms
Sudden tearing pain radiating to back
Hemoptysis or acute dyspnea after immobilization

If any are present,

Establish Airway

Establish Breathing

Establish Circulation

Determine the Cause

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Monitor Patient

Oxygen saturation, pulse, BP, temperature, ECG monitoring and IV access

STEP 2. Determine Pain Characteristics

Parameter	Typical Findings	Possible Causes
Onset	Sudden	MI, PE, pneumothorax, aortic dissection
	Gradual	Angina, pericarditis, esophagitis
Character	Pressure, squeezing	Angina, MI
	Sharp, stabbing	Pericarditis, pleurisy, musculoskeletal
Location	Substernal	Cardiac, esophageal
	Lateral chest	Pulmonary, musculoskeletal
Radiation	Left arm, jaw	Cardiac
	Back	Aortic dissection, esophageal
Duration	<15 min	Angina
	>30 min	MI, dissection, PE
Relieved/Worsened by	Rest or nitroglycerin → angina; movement/palpation → musculoskeletal; leaning forward → pericarditis; swallowing → esophageal
Associated symptoms	Dyspnea (PE, MI), nausea (MI), cough/fever (pneumonia), palpitations (arrhythmia)

STEP 3. Initial Diagnostic Workup

ECG (12-lead)
- ST elevation/depression → MI or ischemia
- Diffuse ST elevation with PR depression → pericarditis
- Sinus tachycardia → nonspecific (PE, anxiety, etc.)
Cardiac enzymes (Troponin I/T, CK-MB)
- Elevated → myocardial infarction or myocarditis
Chest X-ray
- Pneumonia, pneumothorax, aortic dissection, cardiomegaly, mediastinal widening
Other tests as indicated
- D-dimer / CT pulmonary angiography → suspected PE
- Echocardiography → pericardial effusion, wall motion
- Esophagram / endoscopy → GI source
- Musculoskeletal exam → tenderness or reproduction of pain

STEP 4. Categorize Cause by System

Category	Common Diagnoses	Key Clues
Cardiac	Angina, MI, pericarditis, myocarditis	Pressure, radiation, ECG/troponin changes
Pulmonary	PE, pneumonia, pneumothorax, pleurisy	Dyspnea, pleuritic pain, abnormal CXR
Aortic	Aortic dissection	Sudden tearing pain, pulse deficit, widened mediastinum
GI	GERD, esophageal spasm, peptic ulcer	Burning pain, after meals, relieved by antacids
Musculoskeletal	Costochondritis, trauma	Reproducible with palpation or movement
Psychogenic	Anxiety, panic attack	Normal ECG/CXR, hyperventilation, tingling, sweating

STEP 5. Management Path

Findings	Action
ECG changes or elevated troponin	Admit → ACS protocol
Pleuritic pain with abnormal CXR or D-dimer	Work up for PE or pneumonia
Reproducible tenderness, normal ECG & CXR	Musculoskeletal pain → NSAIDs, rest
Heartburn-like pain, relieved by antacid	GERD → PPI/H2 blocker
Unclear diagnosis	Consider stress test, echo, or CT angiography

Mnemonic for Major Life-Threatening Causes

“PAMPE”

P: Pulmonary embolism
A: Acute coronary syndrome (MI/angina)
M: Myocarditis/pericarditis
P: Pneumothorax
E: Esophageal rupture (Boerhaave’s syndrome)
Aortic dissection (often added as “PAAMPED”)

Would you like me to generate a flowchart diagram (visual algorithm) for this chest pain workup? It can be used for teaching or clinical documentation.