EMERGENCY MEDICINE GUIDELINES
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Chest Pain Assessment in the ED

Resources

DDx
Serious/do not miss
Acute coronary syndrome (ACS)
Aortic dissection
Pulmonary embolus
 
Common
Pneumothorax
Pmeumonia
Pericarditis
Abdominal- oesophagitis, cholecsystitis
 
Unusual
Oesophageal rupture
 
Assessment
 
History- is very important in assessing chest pain, and is helpful in risk stratification of patients. RIsk stratification plays an important role in determining disposition of the patient.
 
High risk:
  • Repetitive or prolonged chest pain (>10 mins)
  • Elevated troponin
  • ECG changes
  • Haemodynamic compromise with SBP< 90, cool peripheries
  • Kilip class 1> heart failure
  • New onset mitral regurgitation
  • Ventricular tachycardia
  • Syncope
  • LVEF < 40%
  • PCI in the last 6 months
  • Diabetes and chronic renal failure eGFR < 60 ml/min with typical ACS symptoms

Intermediate risk
  • chest pain in last 48 hours that occurred at rest or was repetitive or prolonged, but now resolved
  • age > 65 years
  • prior AMI
  • 2 or more risk factors (hypertension/family history/smoker/hyperlipidemia)
  • Diabetes and chronic renal failure eGFR < 60 ml/min with atypical ACS symptoms
 
Low risk
  • Patients with chest pain without high risk or intermediate risk features.

High risk are likely to require CCU admission or admission with telemetry monitoring and therefore should be discussed early with the cardiology team.
Intermediate risk patients warrant a stress test (either a myocardial perfusion scan or exercise stress test prior to discharge); at TPCH this is done via CPAS or admission for cardiology for serial troponins.
 
​And the low risk patients are ones that you would probably discharge home following a negative troponin and no repeated symptoms with GP follow up. At TPCH, there is the pathway to organise this PRIOR to discharge via the Accelerated Diagnostic Protocol (ADP) pathway.
 
Examination
Examination in patients with chest pain can often be unremarkable, unless there are signs of heart failure.
 
Investigation
ECG- all patients with active chest pain need an ECG done within 10 mins, as serious causes of chest pain (ie STEMIs) are diagnosed only with ECG and these patients require urgent reperfusion therapy. Serial ECGs are essential for all patients with ongoing chest pain to identify any dynamic changes.
Emergency Medicine - Cadogan & Brown

Rosen's Emergency Medicine
Chest Pain Guideline TPCH
ADP request
Copyright © 2015
  • Home
  • Guidelines
    • Abdominal pain in adults
    • AAA Rupture
    • Acute Coronary Syndrome
    • Anaphylaxis
    • Aortic Dissection
    • Appendicitis
    • Asthma
    • Backpain
    • Bowel Obstruction
    • Bronchiectasis
    • Burns
    • Chest Pain >
      • ADP Chest Pain Pathway
    • Cholecystitis
    • Confusion
    • COPD
    • Diverticulitis
    • DKA
    • DVT
    • Eating Disorders
    • Febrile Neutropaenia
    • Fractures >
      • Bier's block procedure form
      • Fractured neck of Femur
    • Funnel Web Spider Bite
    • Headache
    • Influenza Like illness
    • Meningitis
    • Obstetrics >
      • QLD Clinical Guidelines
    • Pancreatitis
    • Paracetamol OD
    • Pathology Ordering
    • Peri-anal abscess
    • Pertussis
    • Pneumonia
    • Pneumothorax
    • Podiatry
    • Procedural Sedation >
      • Procedural Sedation
    • Pulmonary Embolus
    • PV Bleeding in Early pregnancy >
      • EPAU - Early Pregnancy Assessment Unit
    • Redback Spider Bite
    • Ring cutter use
    • Seizure
    • Septic Arthritis
    • Use of Restraints
    • Stroke / TIA
    • Sepsis
    • Smoking cessation
    • Snake Bite
    • Syncope >
      • Telemetry guideline
    • TIA
    • Tonometer use
    • Antidotes
    • Dagibatran reversal guidelines
    • Funnel Web Spider Bite
    • Redback Spider Bite
    • Paracetamol OD
    • Snake Bite
    • Warfarin Reversal Guidelines
    • Trauma >
      • C-spine injury
      • Head Injury
      • Imaging Guidelines
      • Trauma in pregnancy
      • Sutures
    • Abdominal Pain
    • Allergy / Anaphylaxis
    • Antimicrobial Guidelines
    • Asthma & Wheeze
    • Behavioural Disturbance
    • Boils - Staph decolonisation treatment
    • Bronchiolitis
    • Buckle fractures
    • Burns
    • Cervical Spine Guideline
    • Chest Pain (Paediatric)
    • Child Protection
    • Constipation
    • Croup
    • DKA
    • Drowning
    • Eating Disorders
    • Fever
    • Fluids in Kids
    • Foreign Bodies
    • Gastroenteritis
    • Headache
    • Head Injury
    • High Flow Nasal Cannula Oxygen
    • Hypoglycaemia
    • Jaundiced Neonate
    • Limping in children
    • Malaria
    • Meningitis
    • Oncology Emergencies
    • Otitis Externa
    • Otitis Media
    • Paediatric Fracture Clinic Referral
    • Paracetamol Poisoning
    • Petechial Rash
    • Pneumonia (CAP)
    • Seizures / Status Epilepticus
    • Sepsis Guideline
    • Tetanus Prophylaxis
    • Torticollis
    • UTI NICE Guideline
    • Trauma in children >
      • LCCH Paeds Trauma Guidelines
      • C Spine Injury LCCH Guideline
      • LCCH Massive Transfusion
    • RCH Melbourne Guidelines
  • Parent Handouts
    • Accidental Poisoning
    • Abdominal Pain
    • Ankle Sprain
    • Arrhythmia
    • Asthma
    • Bronchiolitis
    • Chest Infections
    • Cast Care
    • Cellulitis
    • Constipation
    • Croup
    • DKA
    • Epistaxis
    • Eye Foreign Body
    • Febrile Convulsion
    • Fever
    • Fracture- Buckle
    • Fracture- Clavicle
    • Fracture- Elbow
    • Fracture- Finger/Toe
    • Fracture- Foot
    • Gatroenteritis
    • Glue- Lacerations
    • Head Injury
    • Jaundice
    • Otitis Externa
    • Parechovirus
    • Periorbital and Orbital cellulitis
    • Pulled Elbow
    • Seizures
    • Tonsillitis
    • Urticaria
    • Viral Illness
    • Wound Care
  • ACE the ACEM
  • Blog