Initial Approach To The Patient

All chest pain patients, like trauma patients, should receive a high triage priority and be evaluated without delay. The patient care team—nurses, electrocardiography (ECG) technicians, and physicians—should be mobilized around the patient simultaneously. During this time, the patient should be placed on a cardiac monitor, have intravenous access established, oxygen administered, vital signs measured, and a 12-lead ECG obtained.

The initial moments with the patient must be considered similar to a primary survey for trauma, with the focus on identifying an immediate life threat. First, there is a rapid assessment of the patient's airway, breathing, and circulation, general appearance, and vital signs. The initial history should include only a few directed questions—e.g., as to the presence and character of any ongoing symptoms and the presence of significant underlying cardiovascular or pulmonary pathology, such as a history of pulmonary embolism, acute myocardial infarction (AMI), or coronary revascularization. A focused pulmonary and vascular exam is performed next.

If immediate life threats have not been detected or have already been addressed, a more extensive evaluation can then be performed. The secondary survey consists of a more comprehensive history and physical examination and appropriate laboratory and diagnostic testing. This evaluation should focus on those variables that will aid in establishing a tentative diagnosis.

Every patient in whom ACS is entertained, particularly those that present with CP, must have concurrent consideration of several entities that may have similar presentation. Missing any of these diagnoses carries the same order of risk of morbidity and even mortality as missed ACS. These include PE, pneumothorax, pericarditis, pneumonia, aortic dissection, perforated peptic ulcer, and under certain circumstances esophageal rupture. These represent a minimum differential diagnosis of consequence. Some authorities would add such entities as aortic stenosis (CP, syncope, DOE) and possibly acute cholecystitis and pancreatitis within the list of conditions to be simultaneously considered. It is important to emphasize that this differential must be pursued simultaneous, and the evaluation should be concerned with ruling in, or ruling out, each entity. While important history that may point to an ACS is detailed below, the history and physical exam should also include consideration of the above conditions (Iable.45-1). Fortunately, the evaluation of the patient with possible ACS readily includes ancillary investigations that also appropriately consider most of the above noted entities. For example, a chest x-ray and an EKG readily consider PE, pneumothorax, pericarditis, pneumonia, dissection, and even perforated viscus. Among these, PE requires more evaluation if other evidence suggests further investigation. Cholecystitis, pancreatitis, and aortic stenosis may require additional avenues of investigation, although routine chemistries may assist in establishing or refuting the diagnosis of the first two.

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