Chest Pain

Episode 2 – An inevitable call for a junior doctor on-call. Whether it’s a STEMI or a panic attack, a solid foundation will set the patient up for the best outcome.

1st step (pending severity) – History

1. Observe patient during history (Is there; localized pain, pain on inspiration/expiration, tachypnoea, Levine’s sign)
2. Is there a history of ACS (+ the patient’s risk factors for the same)
3. SOCRATES (especially character, severity, and time onset)

2nd step – Your ABC’s

ABC MOVE – a fantastic tool that you should approach any ’emergency’ with.

1. Airway
2. Breathing
3. Circulation
4. Monitoring (SpO2 monitoring, SIBP, etc)
5. Oxygen (nasal prongs to start)
6. Venous access
7. ECG

Even if this is all you do – you save the Medical Reg or other senior help a lot of work and provide them with a strong platform for further treatment.

Step 3 – Examination

1. GCS (a rough estimate) – can they talk to you or not
2. Pulses
3. JVP
4. Chest – is there clinical correlation with the ECG
5. Chest – Lungs (multiple pathologies can be picked up with your steth!)
6. Legs (?DVT, what is their Well’s score?)

Step 4 – Investigations

1. Bloods
   1. Troponin
   2. Coag
   3. FBC
   4. Mg
   5. Renal/Liver/Bone profile
   6. D-dimer (if indicated)
2. Chest X-Ray
3. ABG
4. ECG (if not done already) – NB: ALWAYS compare with a previous one

Breathe! We have done a lot so far, but all very straight forward. If the chest pain is severe enough and/or the ECG has shown ischemic changes the Med Reg (or the Arrest team) is on the way, all investigations have been sent or processed.

Next question – what could it be?

1. ACS/AMI
2. Aortic dissection
3. PE
4. Pericarditis
5. GORD/PUD/Pancreatitis
6. Pneumothorax
7. Costochondritis (Tietze’s syndrome)
8. Anxiety

So let’s say it is an NSTEMI – 10 mins of you being the only doctor

1. ABC MOVE*
   1. Oxygen – Nasal cannula or Non-rebreather O2 (if hypoxia < 95%)
2. Call for senior help
3. Investigations above, including troponin and ECG
4. MONA is good from here
5. Discuss starting a heparin drip, you should be involving senior help at this point!

 

Chest pain is a broad term as you can see with the differentials above. If it is as severe as a STEMI you won’t be alone for long, but for the less acute the above foundation should serve as a definitive starting point to treating it.