Chest Pain

History and examination

• Nature of the pain, radiation and associations
• rapid examination to exclude hypotension, note the presence of murmurs and to identify and treat acute pulmonary oedema

Secure iv access

12 lead ECG and continuous monitoring for dysrhythmias

Give

• Oxygen 100% (unless history of severe COAD)
• GTN spray 2 puffs SL
• Diamorphine 2.5-5 millegrammes IV PRN for pain relief
• Metoclopramide 10 millegrammes IV TDS for nausea

Take blood for

• FBC and U&E; supplement K to maintain at 4-5 mmol/L
• Glucose; may be increased acutely post myocardial infarction
• Cardiac enzymes; Changes start at 4 hours post myocardial infarction
• Troponin test; levels remain elevated up to 2 weeks post myocardial infarction, elevation is specific marker for myocardial infarction

CXR (portable)

to assess cardiac size and pulmonary oedema

Differential diagnosis

• Pericarditis
• Pulmonary embolism
• Esophageal reflux, spasm or rupture
• Biliary tract disease
• Pancreatitis
• Perforated peptic ulcer disease
• Dissecting aortic aneurysm
• Fracture ribs
• Costochondritis