Emergency Department · CCS Case Walkthrough

Chest Pain — Acute Coronary Syndrome

58-year-old male presents to the ED with sudden-onset crushing substernal chest pain radiating to the left arm, diaphoresis, and nausea for the past 45 minutes.

Step-by-Step Approach

1. Obtain 12-lead ECG within 10 minutes of arrival
2. Place on continuous cardiac monitor and pulse oximetry
3. Establish IV access and draw troponin, CBC, BMP, PT/INR, lipid panel
4. Administer aspirin 325 mg chewable, nitroglycerin SL, morphine if pain persists
5. Start heparin drip and consider clopidogrel or ticagrelor loading
6. Obtain chest X-ray to rule out alternative diagnoses
7. Consult cardiology for possible catheterization
8. Admit to CCU/telemetry, order serial troponins q6h

Common Orders Checklist

Common Pitfalls

• ⚠Forgetting to order ECG immediately — this is the #1 timed action
• ⚠Not giving aspirin early (should be within first 5 minutes)
• ⚠Ordering a stress test before ruling out STEMI
• ⚠Missing serial troponins — a single negative troponin does not rule out ACS
• ⚠Forgetting to advance the clock to check for ST changes or troponin rise

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