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Emerg Med J 21:226-232 doi:10.1136/emj.2003.013938
  • Prehospital care

The ABC of community emergency care

3 Chest pain

  1. C Laird1,
  2. P Driscoll2,
  3. J Wardrope3
  1. 1BASICS Scotland, Auchterarder, UK
  2. 2Accident and Emergency Department, Hope Hospital, Salford, UK
  3. 3Accident and Emergency Department, Northern General Hospital, Sheffield, UK
  1. Correspondence to:
 Mr C Laird
 BASICS Scotland, Collyhill Lodge, Auchterarder PH3 1ED, UK; clairdbasics-scotland.org.uk

    Chest pain is the commonest reason for 999 calls and accounts for 2.5% of out of hours calls. Of patients taken to hospital about 10% will have an acute myocardial infarction (AMI). Evidence suggests that up to 7.5% of these will be missed on first presentation. There are a number of other life threatening conditions, which can present as chest pain and must not be overlooked. The objectives of this article are therefore to provide a safe and comprehensive system of dealing with this presenting complaint (box 1).

    Box 1 Objectives of assessment of patients with chest pain

    • To undertake a primary survey of the patient and treat any immediately life threatening problems

    • To identify any patients who have a normal primary survey but have an obvious need for hospital admission

    • To undertake a secondary survey considering other systems of the body where dysfunction could present as chest pain

    • To consider a list of differential diagnoses

    • Discuss treatment based on the probable diagnosis(es) and whether home management or hospital admission is appropriate

    • Consider follow up if not admitted

    PRIMARY SURVEY

    ABC principles

    Primary survey—If any of the following present treat immediately and transfer to hospital

    • Airway obstruction

    • Respiratory rate <10 or >29 per minute

    • O2 sats <93%

    • Pulse <50 or >120

    • Systolic BP <90 mm Hg

    • Glasgow coma score <12

    PATIENTS WITH NORMAL PRIMARY SURVEY WITH OBVIOUS NEED FOR HOSPITAL ADMISSION

    There are four life threatening medical conditions that can present with chest pain. These are:

    • Acute coronary syndrome (ACS)

    • Massive pulmonary embolus

    • Dissection of the thoracic aorta

    • Tension pneumothorax

    The history and a brief examination may lead you to suspect that one of these is the probable diagnosis but often in the early stages, patients may not have significant abnormal physical signs. Nevertheless, urgent hospital admission must be arranged if you suspect any of the above or any other life threatening …


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