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| {{Family tree/start}} | | {| style="border: 0px; font-size: 85%; margin: 3px; width:600px;" align=center |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | | | | | Z01 | | | | | | | | | Z01=<div style="float: left; text-align: center; width: 15em; padding:1em;"> ❑ '''Immediately order a 12-lead [[ECG|<span style="color:white;">ECG</span>]]'''</div>}}
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| {{familytree | | | | | | | | | | | | |!| | | | | | | | | | }}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | | | | | X01 | | | | | | | | | X01=<div style="text-align: center; width: 15em">'''Does the [[ECG|<span style="color:white;">ECG</span>]] has [[ST elevation|<span style="color:white;">ST elevation</span>]]?''' </div>}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | B01 | | | | | | | | | | | | | B02 | | | | B01='''YES'''| B02= '''NO''' }}
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| {{familytree | | | | | |!| | | | | | | | | | | | | | |!| | | | | | }}
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| {{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|-|^|v|-|-|-|v|-|-|-|.|}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | E01=<div style="float: left; text-align: left; width: 12em; padding:1em;">
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| '''[[STEMI|<span style="color:white;">STEMI</span>]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ PR depression is absent </div>
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| | E02=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''New [[LBBB|<span style="color:white;">LBBB</span>]]''' <br> ❑ [[ECG|<span style="color:white;">ECG</span>]] evidence of [[LBBB|<span style="color:white;">LBBB</span>]]
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| : ❑ QRS ≥ 120 ms
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| : ❑ QS or rS in V1
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| : ❑ Monophasic R in I, aVL and V6
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| ❑ Chest pain with same characteristics as [[STEMI|<span style="color:white;">STEMI</span>]]</div>| E03= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''[[Pericarditis|<span style="color:white;">Pericarditis</span>]]''' <br> ❑ Sharp and [[pleuritic pain|<span style="color:white;">pleuritic pain</span>]] that is improved by sitting up and leaning forward <br> ❑ Diffuse, non-specific [[ST elevation|<span style="color:white;">ST elevation</span>]] <br> ❑ PR depression <br> ❑ PR elevation in lead aVR <br><br> '''Suspect [[cardiac tamponade|<span style="color:white;">cardiac tamponade</span>]] when the following finding are present:''' <br> ❑ [[Hypotension|<span style="color:white;">Hypotension</span>]] <br> ❑ [[JVD|<span style="color:white;">JVD</span>]]<br> ❑ [[Muffled heart sounds|<span style="color:white;">Muffled heart sounds</span>]]</div> |E04= <div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Unstable angina|<span style="color:white;">Unstable angina</span>]]/[[NSTEMI|<span style="color:white;">NSTEMI</span>]]'''<br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ Pain last > 10 min</div> | E05=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Pneumothorax|<span style="color:white;">Pneumothorax</span>]]''' <br> ❑ [[Dyspnea|<span style="color:white;">Dyspnea</span>]]<br> ❑ [[Hypoxia|<span style="color:white;">Hypoxia</span>]] <br> ❑ [[Tracheal deviation|<span style="color:white;">Tracheal deviation</span>]] towards the unaffected side<br> ❑ [[percussion|<span style="color:white;">Hyperresonance</span>]] on the affected side </div> |E06=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Aortic dissection|<span style="color:white;">Aortic dissection</span>]]''' <br> ❑ Acute onset of [[heart failure|<span style="color:white;">heart failure</span>]] <br> ❑ Low pitched early diastolic murmur best heard at the 2nd right [[intercostal space|<span style="color:white;">intercostal space</span>]] <br> ❑ Asymmetric blood pressure in the upper extremities <br> ❑ [[Widened mediastinum|<span style="color:white;">Widened mediastinum</span>]] on [[chest X-ray|<span style="color:white;">chest X-ray</span>]] <br>❑ History of:
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| : ❑ [[Hypertension|<span style="color:white;">Hypertension</span>]]
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| : ❑ [[Marfan syndrome|<span style="color:white;">Marfan syndrome</span>]]</div> | E07=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Pulmonary embolism|<span style="color:white;">Pulmonary embolism</span>]]''' <br> ❑ Sudden onset of [[chest pain|<span style="color:white;">chest pain </span>]] <br> ❑ Severe [[dyspnea|<span style="color:white;">dyspnea</span>]] <br> ❑ History of [[DVT|<span style="color:white;">DVT</span>]], [[surgery|<span style="color:white;">surgery</span>]], [[malignancy|<span style="color:white;">malignancy</span>]], immobility <br> ❑ Elevated [[D-dimer|<span style="color:white;">D-dimer</span>]]</div> |E08=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Esophageal rupture|<span style="color:white;">Esophageal rupture</span>]]''' <br>
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| ❑ Vomiting <br> ❑ Lower chest pain <br> ❑ Cervical [[subcutaneous emphysema|<span style="color:white;">subcutaneous emphysema</span>]] <br> ❑ Overindulgence in alcohol or food <br> ❑ [[chest X-ray|<span style="color:white;">chest X-ray</span>]]
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| : ❑ [[pleural effusion|<span style="color:white;">pleural effusion</span>]]
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| : ❑ [[pneumothorax|<span style="color:white;">pneumothorax</span>]]
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| : ❑ air in the [[mediastium|<span style="color:white;">mediastinum</span>]] or [[peritoneum|<span style="color:white;">peritoneum</span>]] </div>}}
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| {{familytree | |`|-|v|-|'| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | E01 | | | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | E01='''''Key points for management'''''<br> <div style="float: left; text-align: left; width: 18em; padding:1em;"> '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]''' <br><br>'''[[STEMI resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]'''</div>| E02='''''Key points for management'''''<br> <div style="float: left; text-align: left; padding:1em;"> ❑ For unstable patients, transfer to [[ICU|<span style="color:white;">ICU</span>]] <br> ❑ In patients with [[cardiac tamponade|<span style="color:white;">cardiac tamponade</span>]] perform [[Pericardiocentesis|<span style="color:white;">pericardiocentesis</span>]] <br><br>'''[[Pericarditis resident survival guide#Treatment of Acute Pericarditis|<span style="color:white;">Click here for the detailed management</span>]]'''</div>|E03 ='''''Key points for management'''''<br> <div style="float: left; text-align: left; width: 18em; padding:1em;"> '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]''' <br><br>'''[[NSTEMI resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]'''</div>| E04='''''Key points for management'''''<br> <div style="float: left; text-align: left; padding:1em">❑ Immediately [[Tension pneumothorax resident survival guide#Treatment|<span style="color:white;">insert a 14-16 Gauge needle </span>]] in the 2nd [[intercostal space|<span style="color:white;">intercostal space</span>]] at the [[midclavicular line|<span style="color:white;">midclavicular line</span>]] of the affected hemithorax <br><br>'''[[Tension pneumothorax resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]''' </div>|E05='''''Key points for management'''''<br> <div style="float: left; text-align: left; padding:1em">❑ Immediately order a [[TEE|<span style="color:white;">TEE</span>]] to confirm diagnosis<br> ❑ Transfer to a cardio-thoracic unit for surgical management<br><br> '''[[Aortic dissection resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]'''</div> | E06='''''Key points for management'''''<br> <div style="float: left; text-align: left; padding:1em">❑ If the patient is stable, order a [[Pulmonary embolism other imaging findings#Angiography|<span style="color:white;">CT pulmonary angiography</span>]] to confirm diagnosis <br><br> '''[[Pulmonary embolism resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]''' </div>| E07='''''Key points for management'''''<br> <div style="float: left; text-align: left; padding:1em"> ❑ Immediately start antibiotic therapy to prevent [[mediastinitis|<span style="color:white;">mediastinitis</span>]] and [[sepsis|<span style="color:white;">sepsis</span>]] <br> ❑ Surgical repair of the perforation <br><br> '''[[Esophageal rupture resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]'''</div> }}
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| {{familytree | | | | | | | | | | | | | | | A01 | | | | | A01=<div style="text-align: center; padding: 5px;">'''If none of the above conditions is found, proceed to the [[Chest pain resident survival guide#Complete Diagnostic Approach| complete diagnostic approach]] below'''</div>}}
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