CC: CP - the Approach
Is this a Levine sign???
If you have worked in the ER for one day, you have seen a patient with vague chest pain (CP). Unfortunately, they do not usually come in with a sign telling you what to do. Many times, the patient looks great, and you can predict that EKG and labs will be normal, but then there are times when I have been surprised when someone rules in for an NSTEMI or the EKG for the patient insisting it is just "heartburn" shows a STEMI.
And don’t forget the other dangerous causes of CP. I have seen a patient with a negative D-dimer almost get discharged home with a massive pneumothorax, and unfortunately, a patient code during a stress test due to an undiagnosed pericardial effusion with pericarditis, not CAD, the cause of his symptoms. Recently, with extremely long wait times and work-ups initiated from triage, I have found several pneumonias and PEs in patients waiting hours for serial troponins to “rule out” ACS.
For this reason, I argue for a scripted approach to all chest pain, and what better way to do that than with a CP template???
Your ED likely has protocols (i.e. scripts) to follow for acute MI getting to the cath lab in under 90 min and order sets for NSTEMI. Let's create a script we can follow to ensure we never miss a life threat, consider even rare diagnoses, and most importantly document a thorough chart that minimizes the risk of ever being successfully sued in a rare, atypical, or subtle case of CP.
To accomplish this, I suggest an order or a method to my madness that does not follow the typical order taught in school. Sure, we will get to the history of present illness (HPI) and review of systems (ROS), both of which we no longer need to document in excruciating detail for billing purposes, yet are still important. Instead, I propose a more realistic order as seen below. In every ER where I have worked, patients with CP get an EKG very early on in the visits, so I suggest that you look at this first.
Overview:
First, look at the ECG
Is it a STEMI?
An NSTEMI?
Other important ECG patterns to recognize
Next, what are possible Immediate life threats: Aortic dissection, Pulmonary embolism, Tension pneumothorax, Tamponade
What else to include in your Differential? Pericarditis and other non-emergent stuff.
Next, check the vital signs - What clues can you pick up (or miss) on VS?
Interviewing the patient? Yeah, the history still matters — What questions to ask.
Examining the patient - What are the key components of the exam to include on every CP pt?
Does the PE even matter?
BONUS: How to incorporate bedside ultrasound into every CP evaluation
Decision time: Medical Decision Making and tools.
Labs, tests, and other things to order (or not order).
HEART pathway for low-risk chest pain
Well’s, PERC, and others
Putting it all together: The full CP template
Bonus: How to not get (successfully) sued on a CP case!!!
Before we jump to my typical workflow, let’s review the “Don’t miss Diagnoses”.
