›Two large bore IV if hypotension bleeding severe vomiting
›Oxygen if SpO2 less than 90 percent
›Immediate ECG if any ACS concern
›Early bedside ultrasound if shock or AAA concern
Analgesia and symptom control
›Symptom treatment
›Acetaminophen PO or IV dosing per weight and liver risk
›Opioid analgesia for severe pain with reassessment
›Antiemetic selection with QT risk awareness
GI targeted therapy
›Acid suppression strategy when appropriate
›PPI therapy for suspected ulcer or gastritis pathway
›Avoid NSAIDs when ulcer concern
Fluids and electrolytes
›Resuscitation and correction
›Isotonic crystalloid for dehydration or pancreatitis
›Potassium replacement guided by ECG and labs
Diagnostic sequencing
›Test sequencing
›ECG and troponin pathway early for anginal equivalent
›Lipase and LFTs early for pancreatobiliary differential
›CTA if dissection AAA mesenteric ischemia concern
Consultation plan
›Consultation triggers
›Cardiology for ischemic ECG or dynamic troponin
›Surgery for perforation peritonitis bowel ischemia concern
›Gastroenterology for significant GI bleed or refractory symptoms
Reassessment loop
›Reassessment cadence
›Repeat vitals and pain score within 30 to 60 minutes after interventions
›Escalate if rising lactate worsening vitals new peritonitis or new ECG change
17Disposition/dispo19
ICU and high acuity criteria
›ICU criteria
›Vasopressor requirement
›Persistent hypoxemia or respiratory failure
›Severe pancreatitis with organ failure
›Massive GI bleed with instability
Inpatient admission criteria
›Admission criteria
›Suspected ACS or abnormal serial troponin or ischemic ECG
›Pancreatitis requiring IV fluids and ongoing pain control
›Inability to tolerate oral intake with dehydration
›Suspected perforation or peritonitis
Observation pathway criteria
›Observation considerations
›Low risk ACS pathway completion needed
›Symptom control and oral challenge after fluids and antiemetics
Discharge criteria
›Discharge requirements
›Hemodynamic stability
›Pain controlled with oral regimen
›Tolerating oral fluids
›No alarm features and reassuring evaluation for life threats
›Follow up plan reliable
18Discharge Instructions/di21
Copy discharge instructions
›Summary
›Seen for epigastric pain evaluation
›Testing today did not show an emergency cause requiring admission
›Medications
›Take prescribed acid suppression as directed if provided
›Avoid NSAIDs such as ibuprofen or naproxen unless instructed otherwise
›Avoid alcohol until symptoms resolved
›Diet and activity
›Start with clear fluids then advance to bland foods as tolerated
›Avoid large fatty meals for 24 to 48 hours
›Follow up
›Follow up with primary care within 2 to 7 days
›Earlier follow up within 24 to 72 hours if symptoms persist
›Return to ED now for
›Chest pain pressure or shortness of breath
›Fainting or severe weakness
›Vomiting blood or black stools
›Fever or shaking chills
›Worsening abdominal pain or new severe pain
›Inability to keep down fluids
›Yellow skin or eyes
19References/r6
Guidelines and key sources
›Evidence based sources
›ACC AHA guideline for the evaluation and diagnosis of chest pain 2021
›ACC AHA guideline for the diagnosis and management of aortic disease 2022
›ACG and CAG clinical guideline management of dyspepsia 2017
›ACG clinical guideline management of acute pancreatitis 2013
›ACG clinical guideline upper gastrointestinal and ulcer bleeding 2021
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.