title: "Chest Pain: First Hour Triage (ACS + Can’t-Miss)"
Chest Pain: First Hour Triage (ACS + Can’t-Miss)
Aim: don't miss the killers, stabilise physiology, and hand over a coherent plan. You don't need the perfect diagnosis in minute 5.
This is for medical education. In real clinical settings, follow local pathways, senior guidance, and your hospital's protocols.
Chest Pain: Can't-Miss Diagnoses
Rule out the killers • Escalate early if unstable • Repeat ECG if ongoing pain
Pressure/heaviness ± diaphoresis
Dynamic ECG changes • CAD risks
Sudden severe pain • "ripping" to back
Pulse/BP differential • neuro deficit
Pleuritic pain + dyspnoea • tachycardia
Hypoxia • VTE risk factors
Severe dyspnoea • unilateral absent sounds
Hypotension • tracheal deviation late
Shock + raised JVP (may be subtle)
Muffled sounds/pulsus paradoxus
Post-vomiting chest pain • toxicity
Subcutaneous emphysema
0–10 minutes: stabilise + data
| Do | Why it matters |
|---|---|
| ABCDE + vitals + bedside impression | “Sick vs not sick” is a real skill |
| ECG early (and repeat if ongoing pain) | The first ECG can be normal early |
| IV access + bloods (incl. troponin as per pathway) | Lets you trend risk, not guess |
| Analgesia + antiemetic | Pain drives sympathetic chaos |
| CXR when appropriate | Pneumo / pneumonia / mediastinum clues |
| Escalate early if unstable | The best junior move is calling sooner |
A quick “can’t-miss” discriminator table
| Diagnosis | Clues that should spike your concern |
|---|---|
| ACS | Pressure/heaviness ± diaphoresis/nausea, exertional, CAD risks, dynamic ECG changes |
| Dissection | Sudden severe pain, “ripping” to back, neuro deficit/syncope, pulse/BP differential |
| PE | Pleuritic pain + dyspnoea, tachycardia, hypoxia, risk factors (recent surgery/immobility) |
| Tension PTX | Severe dyspnoea, unilateral absent breath sounds, hypotension, tracheal deviation late |
| Tamponade | Shock + raised JVP, muffled heart sounds (may be subtle), pulsus paradoxus |
| Oesophageal rupture | Post-vomiting chest pain, systemic toxicity, subcutaneous emphysema |
ECG: simple pattern buckets
| Pattern bucket | Think | Action tendency |
|---|---|---|
| STEMI pattern | Acute occlusion | Escalate for urgent reperfusion pathway |
| Ischaemia (non-STEMI/UA pattern) | Demand/supply mismatch | Serial ECG/troponin + risk stratification |
| Pericarditis-like | Pleuritic, positional pain | Check for pericardial features and troponin |
| Normal/unchanged ECG | Doesn’t exclude ACS | Trend biomarkers + reassess trajectory |
What to say when you call (make it easy to help you)
ISBAR one-line escalation for chest pain: identify, situation, background, assessment, request.
- Identify (I): "I'm ___ on ___, calling about ___ (age/sex)."
- Situation (S): "Chest pain with ___ (instability/ECG change/troponin pending)."
- Background (B): "Relevant risks / timing / key history."
- Assessment (A): "RR __, SpO2 __ on __, HR __, BP __, temp __."
- Request (R): "Can you review now / advise next test / start pathway?"