Management of Chest Pain and Shortness of Breath

Primary topic:

Initial management of patient with chest pain and acute shortness of breath

Secondary topics:

Management of acute myocardial infarction according to type and local protocols
Management of acute left ventricular failure

Curriculum mapping

Foundation programme 7.1 (Core skills in relation to acute illness)


Common presenting symptoms and signs of acute illness
Causes of chest pain
Clinical interpretation of acutely abnormal physiology
Safe oxygen therapy
Safe use of analgesia


Promptly assesses the acutely ill or collapsed patient
Responds appropriately to abnormal physiology
Reassesses appropriately


Foundation programme 7.2 (Resuscitation)


Contents of advanced life support


Able to initiate resuscitation at advanced life support level


Foundation programme 7.3 (Management of the “take”)


Indications for urgent investigations and therapy
When to seek help and from whom


Able to prioritise
Interacts effectively with other health care professionals
Keeps patients and relatives informed
Receives and makes referrals appropriately
Delegates effectively and safely
Performs safe handover


Learning Objectives

At the end of this session the doctors should be able to:
In scenario role;
Confidently assess an acutely ill patient using the ABCDE approach
Recognise STEMI with LVF
Take a focused history
Initiate appropriate initial management
Apply STEMI protocol
Reassess after intervention
Appropriately handover to a colleague

In observation role;
Critique colleague performance

In debrief;
Discuss different approaches to the clinical problem

Discussion topics

Differentiation between NSTEMI and STEMI
Typical ECG appearances of NSTEMI / STEMI / LVF
Management of NSTEMI / STEMI / LVF according to local protocols
Use of tirofiban
Use of thrombolysis
Referral for angioplasty


66 year old female just arrived via ambulance to ED. Past medical history of breast cancer (treated 5yrs previously) and hypertension. Takes aspirin, ramipril and tamoxifen. Works as a carer, current smoker 20/d with 30 PYH and a family history of IHD – father died 67 of MI. Presents with sudden onset 2hrs ago of cardiac sounding chest pain which came on at rest with associated dizziness and SOB. She was given oxygen, GTN and aspirin in the ambulance and is feeling a little better but still has some pain.






Initial assessment



F2 arrives to see the patient in a very busy department.  A nurse is available but has not yet applied monitoring.


Patient is complaining of chest pain and is feeling short of breath.

Sats: 95% on 02

Pulse: 100

BP: 145/78

RR: 26

Temp: 37.4



Introduces self

Explains throughout to patient

Asks for monitoring

Takes focused but adequate history.


Airway: Assesses airway as patent


Breathing: Assesses respiratory rate and SaO2

Palpates, percusses and auscultates noting mild bilateral creps.

High flow oxygen

Sits up



Circulation: Notes observations. Asks for cap refill time.

Requests ECG.

Inserts cannula and takes bloods

Encourage to talk to patient and treat as would usually, if doesn’t take much history.




If they ask for observation but haven’t attached that monitoring prompt to do so.








If forgets bloods or ECG, nurse to ask “anything else?” but no other prompt – let scenario run.

Initial management

Patient is still complaining of chest pain and is feeling short of breath.







Patient is managed according to initial part of STEMI protocol and reaches the stage of consideration of primary angioplasty vs. thrombolysis at which point patient deteriorates. (Don’t let them thrombolyse before deterioration)

Sats 96% on high flow O2

Pulse 104

BP 130/85

RR 26

Temp 37.3


ECG shows anterior ischaemia with ST elevation


ABG on 02

P02 – 13.9

PC02 – 4.9

HC03 – 21

BE - -2

Hb 11

Lactate 1.8





Recognises that requiring high levels of 02 to maintain oxygenation.


Requests portable CXR.


Recognises STEMI from ECG and symptoms.  Suggests possible acute LVF also. 


Manages according to initial part of attached STEMI protocol.  Gives Frusemide in addition.


Assesses for primary angioplasty and makes clear referral to senior with all relevant information over phone.


Reassessment *

Patient more short of breath.


F2 could arrive at this point.

BP 125/70

P 110

Sa02 91% on high flow 02

RR 30

Temp 36.8



Recognises deterioration.

Assesses ABCDE


Airway – assesses as patent


Breathing – as previous

Asks for repeat CXR.


Asks for further ECG.


Calls for help.


Calls for resus trolley.

Nurse can prompt “She isn’t looking as well doctor.


If does not notice deterioration drop sats further.



If does nothing appropriate eventually patient arrests.

Management of deterioration

Patient remains more short of breath.

BP 125/70

P 110

Sa02 92% on high flow 02

RR 30

Temp 36.8


CXR shows worsening LVF.

Continues high flow oxygen.


Gives clear update of situation to seniors.


Considers treatment with nitrates and CPAP.


* At this stage depending upon progress the candidate could be encouraged to reassess even without patient deteriorating.