|
|
| (279 intermediate revisions by the same user not shown) |
| Line 1: |
Line 1: |
| | | {| style="border: 0px; font-size: 85%; margin: 3px; width:600px;" align=center |
| | | |valign=top| |
| ==Overview==
| | |+ |
| | | ! style="background: #4479BA; color:#FFF; width: 100px;" | |
| | | ! style="background: #4479BA; color:#FFF; width: 200px;" | |
| | | ! style="background: #4479BA; color:#FFF; width: 250px;" | |
| | | |- |
| ==FIRE: Focused Initial Rapid Evaluation==
| | | style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | |
| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
| | | style="padding: 5px 5px; background: #F5F5F5;" | |
| | | | style="padding: 5px 5px; background: #F5F5F5;" | |
| <span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span>
| | |} |
| | |
| <span style="font-size:85%">'''Abbreviations:''' </span>
| |
| | |
| {{Family tree/start}}
| |
| {{familytree | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 15em"> '''Identify cardinal findings that increase the pretest probability of life-threatening chest pain'''</div> <br> <div style="text-align: left; width: 15em"> ❑ </div>}}
| |
| {{familytree | | | | | | | | | |!| | | | | | | | | | }}
| |
| {{familytree | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br>
| |
| ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}}
| |
| {{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}}
| |
| {{familytree | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}}
| |
| {{familytree | | | | | | |!| | | | | |!| | | | }}
| |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen <br> ❑ Secure wide bore IV access <br> ❑ Perform ECG monitor <br> ❑ Monitor vitals continuously <br> ❑ Immediately order an [[ECG|<span style="color:white;">ECG</span>]]</div>}}
| |
| {{familytree | | | | | | |!| | | | | C02 | | | | | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}}
| |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | G01 | | | | | | | | | G01=<div style="text-align: center; width: 15em; padding:1em;">'''[[ECG|<span style="color:white;">ECG</span>]] findings'''</div>}}
| |
| | |
| {{familytree | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
| |
| {{familytree | | | | | B01 | | | | | | | | | | | | B02 |B01='''Presence of ST elevation'''|B02='''Absence of ST elevation'''}}
| |
| {{familytree | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | }}
| |
| {{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|v|-|-|-|.| }}
| |
| {{familytree | C01 | | C02 | | C03 | | |!| | | |!| | | |!| | | |!| | | |!|C01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the patient have both of the following:'''<br>
| |
| ❑ There is ST elevation in a limited number of leads that fits the anatomic distribution of a coronary artery (examples would include but are not limited to leads 2,3,F, or Leads v1-v4)<br>
| |
| ❑ PR depression is absent </div>
| |
| | C02= <div style="float: left; text-align: left; width: 12em; padding:1em;"> ❑ Evidence of [[LBBB]] </div>
| |
| | C03=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Does the patient have any of the following:''' <br>
| |
| ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse)<br>
| |
| ❑ PR Depression is present <br>
| |
| ❑ PR elevation in lead aVR is present </div>}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }}
| |
| {{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | | C08 | |C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04='''[[Angina]]'''|C05= '''[[Aortic dissection]]'''| C06= '''[[Pulmonary embolism]]'''| C07= '''[[Tension pneumothorax]]'''| C08= '''[[Esophageal rupture]]'''}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }}
| |
| {{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D07 | | D08 | |
| |
| | D01= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ The pain is described as a heaviness or crushing sensation <br>
| |
| ❑ Pain radiating to the left arm <br>
| |
| ❑ Elbow pain <br>
| |
| ❑ Shortness of breath or dyspnea <br>
| |
| ❑ Nausea and vomiting <br>
| |
| ❑ Diaphoresis <br>
| |
| ❑ An elevation of the CK MB enzyme <br>
| |
| ❑ An elevation of the troponin enzyme <br>
| |
| ❑ An elevation of the myoglobin </div>
| |
| | D02= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ The pain is described as a heaviness or crushing sensation <br>
| |
| ❑ Pain radiating to the left arm <br>
| |
| ❑ Elbow pain <br>
| |
| ❑ Shortness of breath or dyspnea <br>
| |
| ❑ Nausea and vomiting <br>
| |
| ❑ Diaphoresis <br>
| |
| ❑ An elevation of the CK MB enzyme <br>
| |
| ❑ An elevation of the troponin enzyme <br>
| |
| ❑ An elevation of the myoglobin </div>
| |
| | D03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Pleuritic pain <br>
| |
| ❑ Chest pain that is positional <br>
| |
| ❑ A viral syndrome <br>
| |
| ❑ Fever <br>
| |
| ❑ Cough <br>
| |
| ❑ A pericardial rub <br>
| |
| ❑ Presence of tamponade </div>
| |
| | D04= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ <br>
| |
| ❑ <br>
| |
| ❑ <br>
| |
| ❑ <br></div>
| |
| | D05= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Back pain <br>
| |
| ❑ Diminution or absence of pulse <br>
| |
| ❑ Coma <br>
| |
| ❑ Altered mental status <br>
| |
| ❑ CVA <br>
| |
| ❑ Vagal episode <br>
| |
| ❑ Evidence of ischemia <br>
| |
| :❑ Splanchnic ischemia <br>
| |
| :❑ Renal insufficiency <br>
| |
| :❑ Lower extremity ischemia <br>
| |
| :❑ Focal neurologic deficits </div>
| |
| | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Shortness of breath <br>
| |
| ❑ Chest pain <br>
| |
| ❑ Dyspnea <br>
| |
| ❑ Anxiety <br>
| |
| ❑ Pleuritic chest pain </div>
| |
| | D07= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Sudden shortness of breath <br>
| |
| ❑ Cyanosis <br>
| |
| ❑ Penetrating chest wound <br>
| |
| ❑ Flopping sound <br>
| |
| ❑ Following a medical procedure <br>
| |
| ❑ Patient on mechanical ventilation </div>
| |
| | D08=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Vomiting <br>
| |
| ❑ Lower chest pain <br>
| |
| ❑ Cervical subcutaneous emphysema <br>
| |
| ❑ Overindulgence in alcohol <br>
| |
| ❑ Overindulgence in food </div> }}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }}
| |
| {{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Angina]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E07= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E08= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}}
| |
| {{familytree/end}}
| |
| | |
| ==Complete Diagnostic Approach==
| |
| A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
| |
| | |
| <span style="font-size:85%"> '''Abbreviations:''' </span>
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the chest pain:'''<br>
| |
| ❑ Heaviness or crushing sensation (suggestive of myocardial isquemia) <br>
| |
| ❑ [[Pleuritic pain]]
| |
| : ❑ Sharp or knife-like
| |
| : ❑ Increases with [[respiratory movements]]
| |
| ❑ <br> ❑ <br>
| |
| '''Onset'''<br>
| |
| ❑ Sudden <br>
| |
| ❑ <br>
| |
| '''Location'''<br>
| |
| ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) <br>
| |
| ❑ Interscapular (suggestive of [[aortic dissection]] <br>
| |
| ❑ <br>
| |
| ❑ <br>
| |
| '''Activity prior''' <br>
| |
| ❑ </div>}}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the associated symptoms:'''<br>
| |
| ❑ Altered mental status<br>
| |
| ❑ Shortness of breath <br>
| |
| ❑ Nausea and vomiting <br>
| |
| ❑ Dizziness <br>
| |
| ❑ Palpitations <br>
| |
| '''Symptoms suggestive of cardiac etiology'''<br>
| |
| ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br>
| |
| '''Symptoms suggestive of pulmonary etiology'''<br>
| |
| ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br>
| |
| '''Symptoms suggestive of gastrointestinal etiology'''<br>
| |
| ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br></div>}}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Inquire about past medical history:'''<br>
| |
| ❑ Previous episodes<br>
| |
| ❑ Cardiovascular disease
| |
| ❑ Recent medical procedures
| |
| ❑ Neurological diseases
| |
| ❑ Recent [[trauma]]
| |
| ❑ Alcohol intake </div> }}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Identify possible triggers:''' <br>
| |
| | |
| </div>}}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''
| |
| '''Vitals'''<br>
| |
| ❑ [[Heart rate]]
| |
| | |
| ❑ [[Blood pressure]]<br>
| |
| | |
| ❑ [[Respiratory rate]]
| |
| | |
| | |
| '''Cardiovascular'''<br>
| |
| '''Respiratory''' <br>
| |
| ❑ [[Rales]] (suggestive of [[HF]]) <br>
| |
| '''Neurologic'''<br></div> }}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)''
| |
| ❑ [[Electrolytes]]
| |
| ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]]
| |
| </div> }}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ [[EKG]] <br> ❑ [[Chest X-ray]] <br> ❑ [[Echocardiography]] </div> }}
| |
| {{familytree | | | | | | | |!| | | }}
| |
| {{familytree | | | | | | | U01 | | U01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Does the chest pain has any of the following findings suggestive of cardiac etiology?''' <br> ❑ <br> ❑ <br> ❑ <br> </div> }}
| |
| {{familytree | | | |,|-|-|-|^|-|-|-|.| | | }}
| |
| {{familytree | | | I01 | | | | | | I02 | | | I01= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''YES''' </div> | I02= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''NO''' </div>}}
| |
| {{familytree | | | |!| | | | | | | |!| |}}
| |
| {{familytree | | | J01 | | | | | | J02 | | J01= <div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the EKG has ST elevation?''' </div> | J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Determine the non-cardiac etiology based on the physical examination and tests findings''' </div> }}
| |
| {{familytree | |,|-|^|-|.| | |,|-|-|^|v|-|-|-|.| | }}
| |
| {{familytree | K01 | |K02| | K03 | | K04 | | K05| | |K01= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''YES''' </div> | K02= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''NO''' </div>| K03= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''Pulmonary''' </div> | K04= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''Gastrointestinal''' </div>| K05= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''Other''' </div>}}
| |
| {{familytree | |!| | | |!| | |!| | | |!| | | |!| | |}}
| |
| {{familytree | L01 | |L02| | L03 | | L04 | | L05 | |L01= <div style="float: left; text-align: left; width: 12em; padding:1em;">'''Consider the following:'''<br>
| |
| '''[[STEMI]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[STEMI resident survival guide]]<br>
| |
| | |
| '''[[LBBB]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[STEMI resident survival guide]]<br>
| |
| | |
| '''[[Pericarditis]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Pericarditis resident survival guide]]<br></div>
| |
| | L02= <div style="float: left; text-align: left; width: 12em; padding:1em;">'''Consider the following:'''<br>
| |
| '''[[Aortic stenosis]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Aortic stenosis resident survival guide]] <br>
| |
| | |
| '''[[Aortic dissection]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Aortic dissection resident survival guide]]<br>
| |
| | |
| '''[[Stable angina]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Stable angina resident survival guide]]<br></div>
| |
| | L03=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Consider the following:'''<br> | |
| '''[[Pulmonary embolism]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Pulmonary embolism resident survival guide]] <br>
| |
| | |
| '''[[Spontaneous pneumothorax]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Spontaneous pneumothorax resident survival guide]]<br>
| |
| | |
| '''[[Pulmonary hypertension]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Pulmonary hypertension resident survival guide]]<br>
| |
| | |
| '''[[Pleuritis]]''' <br> ❑ <br> ❑ <br> ❑ <br> Click here for [[Pleuritis resident survival guide]]<br></div>
| |
| | L04= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''Gastrointestinal''' </div>| L05= <div style="float: left; text-align: center; width: 12em; padding:1em;">'''Other''' </div>}}
| |
| | |
| | |
| {{familytree/end}}
| |
| | |
| ==Treatment==
| |
| | |
| Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
| |
| | |
| <span style="font-size:85%">'''Abbreviations:''' </span>
| |
| | |
| ==Do's==
| |
| * <br>
| |
| *
| |
| | |
| ==Don'ts==
| |
| *
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
| | |
| [[Category:Cardiology]]
| |
| [[Category:Resident survival guide]]
| |
| [[Category:Up-To-Date]]
| |
| [[Category:Emergency]]
| |
| | |
| {{WikiDoc Help Menu}}
| |
| {{WikiDoc Sources}}
| |