 Welcome to the approach to chest pain in the emergency department. You're working in the emergency department and your next patient is complaining of chest pain. What should you do? Like with all emergency department patients, we start with ABC. We need to ensure the patient's airways patent. We want to support their breathing and give them oxygen if they're hypoxic. We want to give fluids if the patient has low blood pressure. We also want to put the patient onto a cardiac monitor. While we talk to the patient about their history, we want to get an ECG as soon as possible. A chest x-ray should also be ordered. And if the patient is unstable, the patient can have a portable chest x-ray. You'll want to review the ECG with your staff as soon as possible. Once you've made sure the patient is stable and the ECG looks normal, then you want to talk to them about the history to find out more about the chest pain. There are many diagnosis that can give patient chest pain. In the emergency department, we're really interested in ruling out the ticking time bombs or the deadly diagnoses. What are they? They include acute coronary syndrome, pulmonary embolism, aortic dissection, pericarditis and pericardiofusion, pneumothorax and esophageal rupture. These are the six deadly diagnoses we must keep in mind when seeing patients with chest pain in the emergency department. You want to take a thorough history. In the next section, we'll talk about what the typical history for each of the deadly diagnosis is. Also keep in mind that the patient may not say the word pain. They may instead describe their feeling as a discomfort, a pressure and ache, particularly in the elderly and the diabetics. For the history in patients with potential ACS, the pain or the discomfort can be retrosternal, epigastric, and the left side of the right side of the chest. It can radiate to the shoulders, down the arms or up to the jaw. The pain can be worse with activity or it can be decreased by rest. The patient can describe the pain as sharp, pressure, crushing, or it can be very vague. Associated symptoms can include diaphoresis, shortness of breath and nausea. For pulmonary embolism, the pain is usually on one side of the chest and typically does not radiate. The pain will increase with inspiration. Associated symptoms can include shortness of breath and syncope. The pain for aortic dissection is sharp and tearing. The pain can be mid-scapular between the two shoulder blades in the back. Associated symptoms can include neurological symptoms such as limb weakness. For pericardial fusion and pericarditis, the pain is sharp, pleuritic, and changes with position. The pain is usually in the anterior chest, either central or the left side. It can be associated with drawn as a breath and syncope. The pain for pneumothorax is sharp, pleuritic, and on either side of the chest. Associated symptoms will include shortness of breath based on the size of the pneumothorax. The pain for the esophageal rupture tends to be in the middle of the chest. Associated symptoms can include fever. You'll want to take a history that includes the risk factors for each of these six deadly diagnosis. We'll go through them quickly here. For ACS, the risk factors include diabetes, hypertension, high cholesterol, family history of coronary artery disease, and smoking. For PE, it includes immobilization, previous history of venous thromboembolism, and medications such as hormones. Active malignancy also increases the risk of pulmonary embolism. Risk factors for aortic dissection include connective tissue disease and hypertension. Pericarditis is usually triggered by an upper respiratory tract infection. Pericardial fusion can be associated with malignancy. Risk factors for pneumothorax include trauma and previous history of pneumothorax. Esophageal rupture can happen after repeated forceful vomiting or post endoscopic procedure. What are we looking for on physical examination? For the cardiac exam, you want to listen for S1S2. Decreased heart sounds can happen in patients with pericardial fusion. You might hear a pericardial rub in patients with pericarditis. For the lungs, we might hear decreased breath sounds in patients with pneumothorax. Once after you've done a history in physical, you should have a better idea of which deadly diagnosis you're most worried about. From that point on, you can then decide on the specific investigation and management. In summary, we talk about the six deadly diagnosis in patients with chest pain in the emergency department. Remember that we need to first rule these out before we can go further. They include ACS, PE, aortic dissection, pericarditis and pericardial fusion, pneumothorax and esophageal rupture. Please refer to the specific topic for a more detailed description. Thank you for watching.