Chest Pain Assessment and Plan

Pharmacology / Cardio & Renal / Heart Failure Drugs

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The chest pain assessment begins with a primary survey that evaluates the patient's airway, breathing, and circulation. ECG is crucial for detecting STEMI, and further tests such as chest x-ray, CBC, chemistry panel, and cardiac troponin should be conducted if ECG results are inconclusive. Administer aspirin and initiate PCI (coronary balloon angioplasty) in conjunction with heparin, nitrates, and opiates for improved outcomes. To rule out pulmonary embolism (PE), utilize a negative D-dimer test in low-probability patients and confirm with CTA or V/Q scan depending on risk. Direct oral anticoagulants are the standard PE treatment, with severe cases necessitating embolectomy or systemic thrombolysis.



To diagnose aortic dissection, start with a chest x-ray and follow up with a CTA. Manage aortic dissection using beta-blockers for blood pressure control and surgical correction as needed. Confirm cardiac tamponade with echocardiography and perform pericardiocentesis for immediate relief. Diagnose tension pneumothorax using a chest x-ray, and treat with needle decompression followed by chest tube placement. Suspect esophageal rupture in patients with pneumomediastinum on chest x-ray, and promptly refer for emergent surgical evaluation. In cases of ongoing ACS symptoms, perform serial ECGs and use the HEART score to assess the 6-week risk for a major cardiac event.

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1. Primary sentry + ABC checklist - Primary survey includes assessment of airway, breathing, and circulation
2. ECG barrier + elevated ST sign - ECG is the most important test for identifying STEMI
3. Skull crossbones flag + test tubes + T-bone steak - When ECG findings are not diagnostic, perform other tests (eg, chest x-ray, CBC and chemistry panel, cardiac troponin)
4. ASA umpire helmet - Aspirin should be given while activating the catheterization lab
5. Balloon tied to leg - PCI (coronary balloon angioplasty) is associated with greater mortality benefit than thrombolytic therapy
6. Hunting vest + box of nitro - Heparin, nitrates, and opiates should be used in conjunction with PCI
7. Bird’s nest in lung tree + dropping D-shaped dimes - Pulmonary embolism can be ruled out by a negative D-dimer test in patients with low probability for PE
8. Cat + Vive le republiQue - CTA is the gold standard for confirming PE, but a V/Q scan should be used when CTA is risky
9. Breaking up bird’s nest - Direct oral anticoagulants are the standard treatment of PE, but severe cases may ​​require embolectomy or systemic thrombolysis
10. Dissected lance + skull crossbones + cat - Chest x-ray is the best initial test for aortic dissection, but CTA is easiest to obtain and is most often used
11. Muted β-bugle + scalpel - Treatment of aortic dissection includes beta-blockers for blood pressure control and surgical correction
12. Hand squeezing heart + echoing bullhorn - Cardiac tamponade can be confirmed by echocardiography
13. Arrow into heart - Pericardiocentesis should be performed immediately in patients with tamponade
14. Skull crossbones flag + taut rope + collapsed lung sail - Tension pneumothorax can be confirmed by chest x-ray
15. Tube slide - Tension pneumothorax is treated with immediate needle decompression followed by chest tube ​​placement
16. Ruptured horn + holes in chest tunic - Patients with esophageal rupture may have a pneumomediastinum on chest x-ray
17. Scalpel - Emergent surgical evaluation is required for patients with esophageal rupture
18. Series of ECG waves - Serial ECGs should be performed in patients with ongoing ACS symptoms
19. Heart-shaped sun - HEART score helps determine 6-week risk for a major cardiac event

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