Chest Pain Assessment for Paramedics
Learn to assess and manage chest pain confidently — from systematic history to ECG interpretation to STEMI recognition and prehospital ACS management.
Start Free TodayChest Pain: Always Take it Seriously
Chest pain is one of the most common and most consequential calls a paramedic attends. While the majority have non-life-threatening causes, the consequences of missing an ACS, aortic dissection, tension pneumothorax, or massive PE are potentially fatal.
A systematic, methodical approach every time — regardless of how benign the presentation initially appears — is the hallmark of safe paramedic practice.
Red Flag Features
Red flags that raise concern for a serious cause: tearing/ripping pain radiating to the back (dissection), syncope, haemodynamic instability, unequal blood pressures in both arms, oxygen saturation not improving with O2, and pleuritic pain with risk factors for PE.
Differential Diagnoses for Chest Pain
🔴 STEMI
Crushing central chest pain, ST elevation on ECG, diaphoresis. Immediate PPCI pathway.
🟠 NSTEMI/UA
Similar symptoms to STEMI but no ST elevation. ST depression or T wave changes may be present.
⚠️ Aortic Dissection
Tearing/ripping pain radiating to back. BP differential between arms. Immediate surgical emergency.
🩺 Pulmonary Embolism
Pleuritic pain, dyspnoea, tachycardia, hypoxia, risk factors (DVT, malignancy, immobility).
💨 Pneumothorax
Sudden onset pleuritic pain, reduced breath sounds, tracheal deviation if tension.
🫀 Pericarditis
Sharp pain, worse lying flat, relieved sitting forward. Saddle-shaped ST elevation on ECG.
The Chest Pain Assessment Approach
History (SOCRATES)
Site — central, left-sided, right-sided? Onset — sudden or gradual? At rest or on exertion? Character — crushing, sharp, tearing, burning, pressure? Radiation — jaw, left arm, back, shoulder? Associated symptoms — dyspnoea, nausea, diaphoresis, syncope, palpitations? Severity — 0 to 10?
Risk Factors
For ACS: hypertension, diabetes, smoking, hyperlipidaemia, family history, obesity, previous cardiac history. For PE: recent immobility, surgery, malignancy, previous DVT/PE, pregnancy, OCP use.
12-Lead ECG
A 12-lead ECG is mandatory in any patient with chest pain. Look for ST elevation (STEMI), ST depression or T wave changes (NSTEMI), and new LBBB. A normal ECG does not exclude ACS — up to 50% of NSTEMIs present with a normal initial ECG.
Serial ECGs
If your initial ECG is normal but clinical suspicion remains, repeat the ECG every 5–10 minutes on scene. Dynamic changes (evolving ST changes) are highly significant and may reveal an evolving MI not seen on the first recording.
Practise Chest Pain Scenarios
AI Patient Scenarios Pro
Work through realistic chest pain cases — from stable angina to STEMI — with AI-generated patients responding to your assessment.
ECG Practice Pro
Build confidence in ECG interpretation — a critical skill for chest pain assessment. Recognise STEMIs, LBBB, and other relevant changes.
Chat with Hollie Free
Ask Hollie to explain the pathophysiology of ACS, quiz you on red flag features, or walk through the differences between STEMI and NSTEMI management.
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Frequently Asked Questions
How do paramedics assess chest pain?
Paramedics use a structured approach: full ABCDE assessment, targeted SOCRATES history, 12-lead ECG interpretation, vital signs, and clinical examination. The priority is identifying or excluding time-critical diagnoses — STEMI, aortic dissection, tension pneumothorax, and PE — that require immediate intervention or bypass to specialist centres.
What are the main causes of chest pain a paramedic should know?
Key diagnoses include ACS (STEMI, NSTEMI, unstable angina), aortic dissection, PE, pneumothorax, pericarditis, myocarditis, and musculoskeletal/non-cardiac causes. Each has characteristic features — the history and ECG together guide your working impression.
What is the significance of serial ECGs in chest pain assessment?
A single normal ECG does not exclude ACS — up to 50% of NSTEMIs may present with a normal initial ECG. Repeating the ECG every 5–10 minutes on scene allows detection of dynamic changes that may reveal an evolving MI not seen on the first recording.