[Revised Edition] Surviving the Emergency Room! Red Flag Signs Summary ① Chest Pain

【Minhosu! (Let's become hospitalists together in a fun way!) Writing Team & Wordsmith Project】
※This note is a revised version of "Things I want to tell residents: Surviving the Emergency Room ① 'Red Flag Signs for Chest Pain and Abdominal Pain'" published on October 27, 2023.
⇩Click here for the old version

For residents, the emergency room is likely filled with many anxieties, such as "Will I be able to handle this properly?" or "What if I miss a dangerous disease?" However, being able to perform appropriate emergency management is directly linked to saving the patients in front of you whom you will encounter in the future. In a sense, it is the opportunity where you can grow the most as a doctor.

Therefore, I have completely revised the popular note series, "Surviving the Emergency Room, Red Flag Signs Summary." I have continued to focus the content on "the bare minimum for residents to survive the emergency room" and have adopted a simple structure, prioritizing at-a-glance readability so that it can be used immediately in the emergency room. Because of this, I have carefully selected only the most important points and condensed them. I am sure there will be comments like "This is missing!" or "That is missing!", but please understand that the concept is strictly defined as mentioned above. The theme of the first installment is "Red Flag Signs for Chest Pain."

Must rule out for chest pain patients

When facing a patient with chest pain, there are four conditions you must always rule out: the 4 killer chest pains.
① Acute Coronary Syndrome (ACS) ② Aortic Dissection ③ Pulmonary Embolism ④ Tension Pneumothorax. Especially for ① to ③, even if the initial symptoms are atypical, they are lethal, so the attitude of "if you suspect it, you must rule it out"

is important.

If you suspect ①, performing a 12-lead ECG is essential, so when you see a chest pain patient, please perform a 12-lead ECG on all cases, even if the symptoms seem mild
. Contrast-enhanced CT is necessary for the definitive diagnosis of ② and ③. ② and ③ both have diverse symptoms, and they cannot be ruled out by D-dimer values alone. If the risk is high in a chest pain patient,
do not hesitate to perform a contrast-enhanced CT. And, ② (if cardiac tamponade occurs), ③, and ④ can lead to obstructive shock. If there is obvious
jugular venous distension in addition to hypotension, consider obstructive shock and urgently evaluate with an X-ray or echocardiogram while stabilizing the circulatory dynamics.

Basic flow for handling chest pain patients

When facing a chest pain patient, "just listening to their story first" can be the most dangerous option. For handling chest pain patients in the emergency room, drill the flow for ruling out the 4 killer chest pains into your body! If there are abnormal vital signs suggesting instability in respiratory or circulatory dynamics, such as hypotension or low SpO2 in ①, report to your supervising doctor immediately. You must never try to handle it alone as a resident. Of course, once you hit ①, you need to perform ② through ⑤ in parallel. Secure plenty of help and proceed with medical care while cooperating.

🚩Collection of Red Flag Signs for Chest Pain🚩

The point of red flag signs is whether there is a likelihood of the 4 killer chest pains. When you first see the patient, and during the interview and physical examination, check for the following signs. Above all, the iron rule is that the interview and physical examination of a chest pain patient should be done while performing initial treatment.

In particular, aortic dissection and pulmonary embolism present with very diverse symptoms and arrive when you least expect them.
・I thought it was a cerebral infarction because there was hemiplegia, but it was actually an aortic dissection
・I thought it was orthostatic hypotension because there was syncope, but it was actually a pulmonary embolism
There are pitfalls like these (Reference: Kyoto ER Pocketbook 2nd Edition p.135-136). Also, there are patterns of ACS that do not present with chest pain, and I have seen ACS cases where the chief complaint was simply nausea or shortness of breath (Reference: Emergency Room Diagnosis in Progress! p.192). Therefore, I follow the teaching of our hospital's supervising doctor: "

For symptoms above the navel in middle-aged people or older, consider ACS at least once," and I try to lower the threshold for performing a 12-lead ECG.

Summary of points

・When a chest pain patient arrives, check vital signs and first perform a 12-lead ECG to rule out ACS! ・Given that aortic dissection and pulmonary embolism cause diverse symptoms, do not hesitate to perform a contrast-enhanced CT! ・If you observe obvious jugular venous distension in addition to hypotension, consider diseases that cause obstructive shock and promptly evaluate with an X-ray or echocardiogram while stabilizing circulatory dynamics!

To everyone who has read this far, thank you very much!!
If you don't mind, I would be very happy if you could press the "Like" button on the article (even non-note members can press it)!! It will be an encouragement for writing the next article.
Thank you very much 🤲

References
・Kyoto ER Pocketbook 2nd Edition "Chest Pain" p.129-137
・Cardiology Door "Acute Coronary Syndrome" p.1-8
・Internal Medicine Outpatient Manual for Generalists 3rd Edition "Chest Pain" p.128
・Emergency Room Diagnosis in Progress! "When you encounter a chest pain patient" p.180-194