Chest Pain Differential for EMS: Beyond the Heart
Six life threats that present as chest pain, the findings that separate them, and how to avoid tunnel vision on ACS.
December 9, 2026 · 8 min read
Not every chest pain is a heart attack, and the exam loves the patient whose presentation does not fit ACS.
The six that kill
- Acute coronary syndrome: exertional, pressure-like, radiating, diaphoresis
- Pulmonary embolism: sudden dyspnea, clear lungs, tachycardia, risk factors
- Aortic dissection: tearing pain to the back, unequal pulses or blood pressures
- Tension pneumothorax: absent breath sounds, tracheal shift, hypotension
- Pericarditis with tamponade: positional pain, muffled tones, JVD
- Esophageal rupture: severe pain after vomiting, subcutaneous air
History does the heavy lifting
Use OPQRST plus risk factors. Sudden onset points vascular. Pain worse lying flat suggests pericarditis. Pain reproducible with palpation lowers ACS probability but never rules it out.
Nitroglycerin cautions
Hold for systolic under 100, recent PDE-5 inhibitor use, or suspected right ventricular infarction with inferior ST elevation.
Exam pattern
When the stem gives you unequal blood pressures, think dissection and avoid anticoagulants. When it gives you clear lungs with hypoxia, think PE. When it gives you sudden unilateral silence, decompress.
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