Chest Pain

Rule out the six killers first — then risk-stratify the rest.

Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

ECG within 10 minutes; repeat if symptoms evolve or the first tracing is nondiagnostic.
Exclude the six killers: ACS/OMI, dissection, PE, tension pneumothorax, Boerhaave, tamponade.
Run an assay-specific hs-cTn 0/1h or 0/2h pathway (HEART/EDACS if using contemporary troponin).

Hypotension, syncope or pre-syncope
ST elevation, hyperacute T waves, De Winter, Wellens, or posterior STE (isolated ST depression V1–V3)
Sgarbossa / Smith-modified criteria in LBBB or paced rhythm
Pain radiating to the back with pulse/BP asymmetry
New murmur or pulsus paradoxus
Unilateral absent breath sounds or tracheal deviation

12-lead ECG within 10 minutes; repeat at 15–30 min if symptoms evolve or the first tracing is nondiagnostic
Posterior (V7–V9) and right-sided leads when inferior or isolated anterior ST depression
POCUS: pericardial effusion, lung sliding, RV strain

Acute Coronary Syndrome (STEMI / NSTEMI / UA / OMI)
Serial ECG + hs-troponin algorithm — not a single snapshot. Occlusion MI can exist without classic STE.
Aortic dissection
Tearing pain to the back, pulse/BP differential, wide mediastinum. Anticoagulating this as ACS can be lethal.
Pulmonary embolism
Very-low gestalt → PERC; otherwise a validated Wells/age-adjusted or YEARS probability-adapted D-dimer pathway. Normal sats do not exclude it.
Tension pneumothorax
A clinical diagnosis — hypotension + unilateral absent breath sounds = decompress, don’t image first.
Esophageal rupture (Boerhaave)
Post-emesis chest pain, subcutaneous emphysema, mediastinal air on CT.

Admit (observation / telemetry)

Observe-zone troponin kinetics, HEART 4–6, new AF, ongoing atypical symptoms, or incomplete rule-out.

ICU / cath lab activation

STEMI or occlusion-MI pattern, hemodynamic instability, suspected dissection/tamponade, refractory ischemic symptoms, arrhythmia.