1
Scene Size-Up & BSI ▼
- Gloves, eye protection — BSI before patient contact
- Scene safety: assess environment, hazards
- Determine # patients, request ALS/additional resources if needed
- Note MOI/NOI — cardiac vs other medical
↓
2
Initial Assessment — ABCs
- General impression — position of comfort, pallor, diaphoresis
- Airway: Open and patent?
- Breathing: Rate, depth, work of breathing, SpO2
- Circulation: Radial pulse — rate, rhythm, quality
- Skin: Color, temperature, moisture (diaphoresis = high concern)
↓
Immediate Life Threat?
Shock, apnea, unresponsive, SpO2 < 90%
Shock, apnea, unresponsive, SpO2 < 90%
YES
Rapid intervention: Position, O2 NRB 15L, ALS NOW, prepare for CPR/AED
NO
Continue systematic assessment below
3
SAMPLE History ▼
- Signs & Symptoms — onset, radiation, associated Sx
- Allergies — especially ASA, NSAIDs
- Medications — nitrates, antiplatelets, anticoagulants, Viagra/Cialis (⚠PDE5 inhibitors = nitro CI)
- Pertinent hx — prior MI, stents, CABG, cardiac hx, cocaine use
- Last oral intake
- Events — activity at onset, emotional stress, exertion
- ⚠ Females, elderly, diabetics: Atypical — jaw pain, nausea, fatigue, epigastric — no chest pain
↓
4
OPQRST Pain Assessment ▼
- Onset — sudden vs gradual; at rest vs exertion
- Provocation/Palliation — worse with movement, breathing, palpation?
- Quality — see table below
- Radiation — left arm, jaw, back, shoulder, epigastric
- Severity — 1–10 scale
- Time — duration; continuous vs intermittent
| Pain Quality | Suggests |
|---|---|
| Crushing / Pressure / Squeezing | ACS / Cardiac ischemia |
| Tearing / Ripping (worst ever) | Aortic Dissection ⚠ |
| Sharp, worse with breathing | Pleuritic — PE, Pneumonia, Pericarditis |
| Sharp, worse with palpation/movement | Musculoskeletal, Costochondritis |
| Burning, epigastric, worse lying flat | GERD / GI |
| Sudden severe unilateral | Tension Pneumothorax |
↓
5
Physical Assessment
- Vitals: BP both arms (discrepancy >20mmHg → dissection), HR, RR, SpO2, temp if febrile
- Lung sounds: Crackles (CHF/edema), wheeze, absent (pneumothorax)
- Neck: JVD (right heart failure, tamponade, tension PTX)
- Extremities: Pedal edema (CHF), calf tenderness (DVT/PE)
- Skin: Pale/cool/diaphoretic (poor perfusion), mottling
- Chest wall: Point tenderness (musculoskeletal), tracheal deviation
↓
📊 Step 6 — Interactive Differential
🧭 Build Your Differential
Pain Quality (select one)
Associated Symptoms (select all)
Select pain quality to see differential
🩺 Step 7 — Management
Position & Oxygenation
BLS Position: Sitting upright / position of comfort. Supine only if BP < 90 systolic or unresponsive.
BLS Oxygen: Titrate to SpO2 ≥ 94%. Avoid hyperoxia — do not apply O2 if SpO2 ≥ 94%. Use NC 2-4L → NRB 10-15L for severe hypoxia.
Aspirin Decision Tree
Aspirin indicated?
Give ASA 324mg
Suspected cardiac ischemia + no allergy + no active bleeding + not already taken today + not Aortic Dissection
Withhold ASA
Allergy to ASA, active GI bleed, suspected aortic dissection, already took ASA, no ischemia suspected
CONTRAINDICATED in suspected Aortic Dissection: ASA & Nitroglycerin — both worsen outcomes. DO NOT give.
🚨 ALS Intercept Criteria
🔴 ALS Request / Intercept — Any of the following:
- Suspected STEMI / ACS with hemodynamic instability
- Pulmonary edema / severe respiratory distress
- Suspected aortic dissection
- Tension pneumothorax (needle decompression needed)
- Cardiac tamponade
- SpO2 < 90% unresponsive to O2
- BP < 90 systolic
- Signs of shock (altered LOC, diaphoresis, poor perfusion)
- Arrhythmia on monitor (ALS only: 12-lead ECG, IV, medications)