symptom.chest_pain.ed_undifferentiated.v1PRODUCTION

symptom.chest_pain.ed_undifferentiated.v1

Undifferentiated chest pain (ED)

symptomacuteundifferentiatedadult

Hard-required inputs

0 / 20

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

ED chest-pain triage; pain quality + onset time + "worst-of-life" flag; hemodynamic state (AHA/ACC 2021)

Inputs

Actions

Advance rule

Set

Advance when

pain characterized + onset clock started

Severity triggers (8)

8 need judgement

informationallife_threateningstemi_pattern_ecg
ST-elevation ≥1 mm in 2 contiguous leads OR new LBBB with ACS symptoms on 12-lead ECG (AHA/ACC 2021 Class I)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningdissection_pattern
Tearing chest / interscapular pain + BP differential >20 mmHg between arms OR widened mediastinum on CXR OR neurologic deficit + chest pain (AHA 2022 Acute Aortic Disease)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningmassive_pe_pattern
Suspected PE + sustained hypotension (SBP <90 ×≥15 min) OR cardiac arrest with PEA / pulseless rhythm (ESC 2019 PE)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningtension_pneumothorax
Tracheal deviation + decreased breath sounds + hyperresonance + hemodynamic compromise — bedside diagnosis, do NOT delay for imaging (ATS/CHEST 2010)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningtamponade_physiology
Beck triad (hypotension + muffled heart sounds + JVD) + pericardial effusion on POCUS + pulsus paradoxus >10 mmHg (AHA 2021; ESC 2015 Pericardial Disease)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveredynamic_troponin_or_ecg
Hs-cTn dynamic rise/fall >20% over 1-3 h (Δ-positive) OR new ischemic ECG changes (ST-depression / T-inversion) during observation (Reichlin 2009; Thygesen 2018)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehemodynamic_instability
SBP <90 OR HR >120 OR SpO2 <90% on room air with ongoing chest pain (Gulati 2021)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterepeat_ecg_evolution
Ongoing chest pain with non-diagnostic initial ECG — repeat hs-cTn + ECG q15 min until evolution captured or pain resolves (AHA/ACC 2021)
Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives disposition

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Recommended regimen

ed playbook — drug actions (5)

1. oxygen
NC 2 L/min titrate to SpO2 ≥94% • inhaled • continuous
trigger: SpO2 <94%
AHA/ACC 2021 — supplemental O2 to maintain ≥94%; avoid hyperoxia (DETO2X-AMI 2017 showed harm of routine O2 in normoxic ACS)
2. aspirin
rxcui 1191
162-325 mg chewed • PO • single loading dose
trigger: ACS not clearly excluded AND no contraindication (active bleeding / true allergy)
AHA/ACC 2021 Class I — empiric ASA pending ACS rule-out; low harm + high benefit per ISIS-2 anchor
3. nitroglycerin
rxcui 4917
0.4 mg SL • sublingual • q5 min × 3 PRN
trigger: Suspected angina with SBP >100; not RV-infarct pattern; not suspected dissection until BP control established
AHA/ACC 2021 — symptomatic relief; CAUTION inferior MI with RV involvement (lead V4R), suspected dissection (use beta-blocker FIRST per AHA 2022)
4. IV fluid bolus
250-500 mL crystalloid • IV • titrate to MAP ≥65
trigger: Hypotension with chest pain (suspected massive PE / tamponade / RV-MI / dissection)
Cautious — RV-MI and tamponade need preload; LV-pump-failure is fluid-intolerant (Gulati 2021)
5. esmolol or labetalol
Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV • IV • titrate to HR <60 + SBP <120
trigger: Suspected dissection — IMPULSE control FIRST per AHA 2022; HR before BP
AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator to reduce dP/dt; nitroprusside ONLY after beta-blockade

Auto-drafted A&P note

Subjective

- Possible entry pathways: Acute chest pain presenting to ED (AHA/ACC 2021 Class I — ECG within 10 min); Chest pressure radiating to jaw / arm / back ± diaphoresis ± nausea (Gulati 2021); Tearing chest / interscapular pain — dissection suspicion (AHA 2022 Acute Aortic Disease).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Undifferentiated chest pain (ED)** (symptom.chest_pain.ed_undifferentiated.v1).
Phenotype framing: ACS (STEMI/NSTEMI ~10-15%) / PE (~5-7%) / dissection (~0.3%) / PTX (~0.5%) / pericarditis (~5%) / esophageal-GERD (~20-30%) / MSK (~20-30%) / anxiety (~5-10%) — pre-test priors per Goodacre 2002 PMID 11874776 and Bösner 2010 PMID 20603345
Scope: ED chest-pain triage; pain quality + onset time + "worst-of-life" flag; hemodynamic state (AHA/ACC 2021)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Triage + rule-in/rule-out ACS / PE / dissection / PTX / pericarditis; ECG within 10 min (AHA/ACC 2021 Class I); hs-cTn 0/1-h or 0/3-h pathway; disposition by HEART + TIMI/GRACE + Wells (Gulati 2021)
1. oxygen NC 2 L/min titrate to SpO2 ≥94% inhaled continuous — SpO2 <94% (AHA/ACC 2021 — supplemental O2 to maintain ≥94%; avoid hyperoxia (DETO2X-AMI 2017 showed harm of routine O2 in normoxic ACS))
2. aspirin 162-325 mg chewed PO single loading dose — ACS not clearly excluded AND no contraindication (active bleeding / true allergy) (AHA/ACC 2021 Class I — empiric ASA pending ACS rule-out; low harm + high benefit per ISIS-2 anchor)
3. nitroglycerin 0.4 mg SL sublingual q5 min × 3 PRN — Suspected angina with SBP >100; not RV-infarct pattern; not suspected dissection until BP control established (AHA/ACC 2021 — symptomatic relief; CAUTION inferior MI with RV involvement (lead V4R), suspected dissection (use beta-blocker FIRST per AHA 2022))
4. IV fluid bolus 250-500 mL crystalloid IV titrate to MAP ≥65 — Hypotension with chest pain (suspected massive PE / tamponade / RV-MI / dissection) (Cautious — RV-MI and tamponade need preload; LV-pump-failure is fluid-intolerant (Gulati 2021))
5. esmolol or labetalol Esmolol 500 mcg/kg bolus then 50 mcg/kg/min; labetalol 10-20 mg IV IV titrate to HR <60 + SBP <120 — Suspected dissection — IMPULSE control FIRST per AHA 2022; HR before BP (AHA 2022 Acute Aortic Disease — beta-blocker before vasodilator to reduce dP/dt; nitroprusside ONLY after beta-blockade)

Non-pharmacologic actions:
- Activate stroke alert / code STEMI if ST-elevation (AHA/ACC 2021 Class I)
- Two large-bore IVs; type & screen if dissection suspected (AHA 2022)
- NPO until disposition (potential cath lab / OR)
- Continuous telemetry monitoring (AHA/ACC 2021 Class I)
- POCUS cardiac + lung + IVC if available (Gulati 2021)
- Notify cath lab if STEMI; vascular surgery if dissection; CT scanner if PE/dissection workup
- Emergent needle decompression for tension PTX BEFORE imaging (ATS/CHEST 2010)

Monitoring

Setting (ed) monitoring:
- Continuous ECG telemetry (AHA/ACC 2021 Class I)
- BP q15 min × 1 h then q30 min; both arms if dissection suspicion (AHA 2022)
- SpO2 continuous (AHA/ACC 2021)
- Repeat ECG q15 min if dynamic changes or ongoing pain (AHA/ACC 2021)
- Serial hs-cTn per 0/1-h or 0/3-h algorithm (Reichlin 2009; Hoffmann 2017 PMID 22830462)
- Pain reassessment q30 min on documented 0-10 scale

Follow-up plan: If discharged low-risk: PCP / cardiology within 72 h; return precautions (chest pain recurrence, dyspnea, syncope, new neurology); ASCVD risk factor counseling; smoking cessation; outpatient lipid panel deferred (Gulati 2021; 2026 ACC/AHA Lipid; 2025 AHA/ACC HTN)
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Continuous telemetry until rule-out complete; serial hs-cTn per 0/1-h or 0/3-h pathway; repeat ECG q15 min if dynamic changes or ongoing pain; pain reassessment q30 min (Reichlin 2009; AHA/ACC 2021)

Disposition

Current setting: ed — Triage + rule-in/rule-out ACS / PE / dissection / PTX / pericarditis; ECG within 10 min (AHA/ACC 2021 Class I); hs-cTn 0/1-h or 0/3-h pathway; disposition by HEART + TIMI/GRACE + Wells (Gulati 2021)

Disposition criteria:
- Discharge: HEART 0-3 + negative serial hs-cTn + no dynamic ECG changes + reliable follow-up ≤72 h (Backus 2013; Gulati 2021)
- Observation unit: HEART 4-6 OR low-risk after PE workup pending stress/CCTA (Gulati 2021)
- Admit: HEART ≥7; positive hs-cTn; TIMI ≥3 OR GRACE >140; confirmed PE / dissection / pericarditis with effusion / pneumothorax requiring chest tube
- Cath lab direct: ST-elevation STEMI (AHA/ACC 2021 Class I — DTB ≤90 min)
- ICU: hemodynamic instability; intubation; post-arrest; massive PE on thrombolytics; dissection awaiting OR

Escalation triggers (move to higher acuity):
- ST-elevation → STEMI route (cardio.stemi.core.v1) — cath lab DTB ≤90 min (AHA/ACC 2021 Class I)
- Dynamic hs-cTn rise/fall >20% OR new ischemic ECG changes → NSTEMI route (cardio.nstemi.core.v1)
- BP differential >20 mmHg + widened mediastinum + tearing pain → dissection route (cardio.aortic-dissection.core.v1) — STAT CTA chest (AHA 2022)
- Wells >4 OR PERC-positive → CTPA → if positive route to pulm.pe.core.v1 (ESC 2019 PE)
- Tension pneumothorax physiology → immediate needle decompression then route to pulm.pneumothorax.core.v1 (ATS/CHEST 2010)
- Tamponade Beck triad + pericardial effusion → emergent pericardiocentesis; route to cardio.pericarditis.core.v1
- Persistent hemodynamic instability despite resuscitation → ICU admit + downstream engine route

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] ST-elevation ≥1 mm in 2 contiguous leads OR new LBBB with ACS symptoms on 12-lead ECG (AHA/ACC 2021 Class I)
- [LIFE_THREATENING] Tearing chest / interscapular pain + BP differential >20 mmHg between arms OR widened mediastinum on CXR OR neurologic deficit + chest pain (AHA 2022 Acute Aortic Disease)
- [LIFE_THREATENING] Suspected PE + sustained hypotension (SBP <90 ×≥15 min) OR cardiac arrest with PEA / pulseless rhythm (ESC 2019 PE)

Citations

- 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline (Gulati JACC 2021) + ESC 2020 NSTE-ACS + 2025 AHA/ACC HTN + 2026 ACC/AHA Lipid + ESC 2019 PE + AHA 2022 Acute Aortic Disease + ATS/CHEST 2010 Pneumothorax [PMID:11874776](https://pubmed.ncbi.nlm.nih.gov/11874776/)
- Cited evidence (PMID 20603345) [PMID:20603345](https://pubmed.ncbi.nlm.nih.gov/20603345/)
- Cited evidence (PMID 23465250) [PMID:23465250](https://pubmed.ncbi.nlm.nih.gov/23465250/)
- Cited evidence (PMID 22892889) [PMID:22892889](https://pubmed.ncbi.nlm.nih.gov/22892889/)
- Cited evidence (PMID 32860058) [PMID:32860058](https://pubmed.ncbi.nlm.nih.gov/32860058/)

Last reconciled with current guidelines: 2026-05-14.

References

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline (Gulati JACC 2021) + ESC 2020 NSTE-ACS + 2025 AHA/ACC HTN + 2026 ACC/AHA Lipid + ESC 2019 PE + AHA 2022 Acute Aortic Disease + ATS/CHEST 2010 Pneumothorax — PMID:11874776
Cited evidence (PMID 20603345) — PMID:20603345
Cited evidence (PMID 23465250) — PMID:23465250
Cited evidence (PMID 22892889) — PMID:22892889
Cited evidence (PMID 32860058) — PMID:32860058

Clinical Commander