Which patients in the ER with chest pain need a triple rule out CT?

Not every one, according to Robert D. Glatter, MD in a Medscape Ask the Experts piece:

Although this triple-rule out technique may exclude deadly causes of chest pain from 3 different anatomic vascular locations, the higher radiation dose delivered with current techniques is a valid clinical concern. Therefore, the triple rule-out protocol should be limited to selected patients in which there is "weighted" support for the diagnosis of either PE or AD, as well as suspicion for ACS.

Clinical assessment and simple initial testing usually narrows it down to one or two of the “big three.” Yet, there are those occasional patients with severe, undifferentiated and unrelenting pain who may benefit from the triple rule out protocol.