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==FIRE: Focused Initial Rapid Evaluation==
===Symptoms Related to Tumor Growth in the Thorax===
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598 }} </ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first = | title = Part 7.3: Management of Symptomatic Bradycardia and Tachycardia | url = http://circ.ahajournals.org/content/112/24_suppl/IV-67.full | publisher = | date = | accessdate = 2 March 2014 }}</ref>
* [[Cough]] (most common symptom)<ref name="pmid21565397">{{cite journal| author=van Meerbeeck JP, Fennell DA, De Ruysscher DK| title=Small-cell lung cancer. | journal=Lancet | year= 2011 | volume= 378 | issue= 9804 | pages= 1741-55 | pmid=21565397 | doi=10.1016/S0140-6736(11)60165-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21565397  }} </ref><ref name="pmid12527569">{{cite journal| author=Beckles MA, Spiro SG, Colice GL, Rudd RM| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes. | journal=Chest | year= 2003 | volume= 123 | issue= 1 Suppl | pages= 97S-104S | pmid=12527569 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12527569 }} </ref>
* [[Wheezing]]<ref name="pmid21565397">{{cite journal| author=van Meerbeeck JP, Fennell DA, De Ruysscher DK| title=Small-cell lung cancer. | journal=Lancet | year= 2011 | volume= 378 | issue= 9804 | pages= 1741-55 | pmid=21565397 | doi=10.1016/S0140-6736(11)60165-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21565397  }} </ref>
* [[Dyspnea]]<ref name="pmid21565397">{{cite journal| author=van Meerbeeck JP, Fennell DA, De Ruysscher DK| title=Small-cell lung cancer. | journal=Lancet | year= 2011 | volume= 378 | issue= 9804 | pages= 1741-55 | pmid=21565397 | doi=10.1016/S0140-6736(11)60165-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21565397 }} </ref>
* [[Hemoptysis]]<ref name="pmid21565397">{{cite journal| author=van Meerbeeck JP, Fennell DA, De Ruysscher DK| title=Small-cell lung cancer. | journal=Lancet | year= 2011 | volume= 378 | issue= 9804 | pages= 1741-55 | pmid=21565397 | doi=10.1016/S0140-6736(11)60165-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21565397  }} </ref>
* [[Chest pain]]<ref name="pmid21565397">{{cite journal| author=van Meerbeeck JP, Fennell DA, De Ruysscher DK| title=Small-cell lung cancer. | journal=Lancet | year= 2011 | volume= 378 | issue= 9804 | pages= 1741-55 | pmid=21565397 | doi=10.1016/S0140-6736(11)60165-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21565397  }} </ref>


<span style="font-size:85%">Boxes in salmon color signify that an urgent management is needed.</span>
===Constitutional Symptoms===
* [[Fatigue]]
* [[Anorexia]]
* [[Weight loss]]


{{Family tree/start}}
===Symptoms Related to Paraneoplastic Syndrome===
{{familytree | | | | | | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of wide complex tachycardia''' <br>❑ [[Palpitations]] <br> ❑ [[QRS complex]] > 120 ms <br>❑ [[Heart rate]] > 150 beats/min </div> <br> }}
{{familytree | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | B01 | | |B01=<div style="float: left; text-align: left; width: 13em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Cold extremities]]
:❑ [[Cyanosis|Peripheral cyanosis]]
:❑ [[Mottling]]
:❑ [[Altered mental status]]
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Heart failure|Decompensated heart failure]]</div>}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | |B01=<div style="float: left; text-align: central; background: #FA8072; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| '''Yes'''}} </div>|B02='''No'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | C02 | | | | |C02=<div style="float: left; text-align: left; width: 13em; padding:1em;">  ❑ '''[[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | | | C03 | | | | | | | | | | | | | | | |C03=<div style="float: left; text-align: left; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| '''Proceed with immediate cardioversion''' <br>  Perform the following without delaying cardioversion'''<br>  ❑ Maintain patent airway; assist breathing as necessary<br> ❑ Adminster [[oxygen|<span style="color:white;">oxygen</span>]] (if the patient is hypoxemic)<br> ❑ Cardiac monitor to identify rhythm; monitor [[blood pressure|<span style="color:white;">blood pressure</span>]] and [[oximetry|<span style="color:white;">oximetry</span>]] <br> ❑ Give IV sedation if the patient is conscious<br> ❑ Don't delay [[cardioversion|<span style="color:white;">cardioversion</span>]] to sedate the patient <br> ❑ Consider expert consultation }} </div>}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | | | A01 | | | | | | | | | | | | | |A01=<div style=" width: 13em; text-align: center; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''Can you determine the type of [[arrhythmia|<span style="color:white;">arrhythmia</span>]]?'''}} </div> </div>}}
{{familytree | | | | | | |,|-|-|-|(| | | | | | | | | | | | | | | | |}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | K02 | | K03 | | | | | | | | | | | | | | | |K02=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''''If you can't determine the type of [[arrhythmia|<span style="color:white;">arrhythmia</span>]] or you aren't sure, go for immediate unsynchronized [[cardioversion|<span style="color:white;">cardioversion</span>]]'''''}} </div> </div>|K03=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''''If you can determine the type of [[arrhythmia|<span style="color:white;">arrhythmia</span>]]'''''}} </div> </div>}}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | |}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF;  | A01 | | A02 | | A03 | | A04 | | A05 | | | | | | |A01=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[VT|<span style="color:white;">VT</span>]]/[[VF|<span style="color:white;">VF</span>]] presenting as [[cardiac arrest|<span style="color:white;">cardiac arrest</span>]]'''}} </div> </div>|A02=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Polymorphic [[VT|<span style="color:white;">VT</span>]]'''}}</div> </div>|A03=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[Atrial fibrillation|<span style="color:white;">Atrial fibrillation</span>]] with aberrancy'''}}</div> </div>|A04=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[Atrial flutter|<span style="color:white;">Atrial flutter</span>]] and other [[SVTs|<span style="color:white;">SVTs</span>]] with aberrancy''' }}</div> </div>|A05=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Monomorphic [[VT|<span style="color:white;">VT</span>]] (regular form and rate)''' }} </div> </div>}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | |}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | B01 | | B02 | | B03 | | B04 | | B05 | | | | | | |B01=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[Cardiac arrest resident survival guide|<span style="color:white;">Click here for cardiac arrest resident survival guide</span>]]''' }} </div> </div>|B02=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Unsynchronized [[cardioversion|<span style="color:white;">cardioversion</span>]]'''<br>
❑ Immediately deliver high-energy unsynchronized shocks <br>
❑ Provide an initial shock of 200 Joules<br>
❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J) }}</div> </div>|B03=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Synchronized [[cardioversion|<span style="color:white;">cardioversion</span>]]''' <br>
❑ Provide an initial dose of biphasic [[cardioversion|<span style="color:white;">cardioversion</span>]] of 120-200 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIa, level of evidence A</span>]])<br>
❑ If the initial shock fails, increase the dose in a stepwise fashion }} </div> </div> |B04=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Synchronized [[cardioversion|<span style="color:white;">cardioversion</span>]]''' <br>
❑ Provide an initial dose of biphasic [[cardioversion|<span style="color:white;">cardioversion</span>]] of 50-100 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIa, level of evidence B</span>]]) <br>
❑ If the initial shock fails, increase the dose in a stepwise fashion<br>
❑ If monophasic wave form is used, begin at 200 Joules and increase in stepwise fashion if not successful}} </div> </div>|B05=<div style=" width: 13em; text-align: left; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Synchronized [[cardioversion|<span style="color:white;">cardioversion</span>]]''' <br>
❑ Provide an initial dose of biphasic [[cardioversion|<span style="color:white;">cardioversion</span>]] of 100 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIb, level of evidence C</span>]])
❑ If the initial shock fails, increase the dose in a stepwise fashion }} </div> </div> }}
{{familytree | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|'| | | | | | | | |}}
{{familytree | | | | | | | | | D01 | | |D01= <div style="float: left; text-align: left; width: 13em; padding:1em;">❑ '''[[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|After the stabilization of the patient, continue with the complete diagnostic approach below]]''' </div>}}
{{Family tree/end}}


===Symptoms Related to the Distant Spread of the Tumor===
* [[Hoarseness]] (involvement of the [[recurrent laryngeal nerve]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Dyspnea]] (one of the causes is the involvement of the [[phrenic nerve]] and subsequent elevation of the hemi-[[diaphragm]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Pain]], [[muscle wasting]], or change in the skin temperature in areas corresponding to C8, T2 to T4 (involvement of the [[brachial plexus]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Chest pain]] (one of the causes is the involvement of the chest wall)<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Pleuritic chest pain]]<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Horner syndrome]] manifested by unilateral [[miosis]], [[ptosis]] and anhydrosis (involvement of the sympathetic trunk)<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Arrhythmia]] (involvement of the [[pericardium]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Cardiac tamponade]] manifested by chest pain, [[altered mental status]], [[cold extremities]], peripheral [[cyanosis]] (involvement of the [[pericardium]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Dysphagia]] (compression of the [[esophagus]])<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>
* [[Superior vena cava syndrome]] manifested by [[dyspnea]], [[headache]], and [[swelling]] of the face, neck, trunk, and arms<ref name="pmid17873166">{{cite journal| author=Spiro SG, Gould MK, Colice GL, American College of Chest Physicians| title=Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). | journal=Chest | year= 2007 | volume= 132 | issue= 3 Suppl | pages= 149S-160S | pmid=17873166 | doi=10.1378/chest.07-1358 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17873166  }} </ref>


 
===Uncommon Symptoms===
 
* [[Abdominal discomfort]] due to bilateral adrenal mass<ref name="pmid23825789">{{cite journal| author=Singh N, Madan K, Aggarwal AN, Das A| title=Symptomatic large bilateral adrenal metastases at presentation in small-cell lung cancer: a case report and review of the literature. | journal=J Thorac Dis | year= 2013 | volume= 5 | issue= 3 | pages= E83-6 | pmid=23825789 | doi=10.3978/j.issn.2072-1439.2011.09.05 | pmc=PMC3698258 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23825789  }} </ref>
{{Family tree/start}}
* [[Facial nerve palsy]] due to [[metastasis]] to the [[facial nerve]]<ref name="pmid21526004">{{cite journal| author=Yildiz O, Buyuktas D, Ekiz E, Selcukbiricik F, Papila I, Papila C| title=Facial nerve palsy: an unusual presenting feature of small cell lung cancer. | journal=Case Rep Oncol | year= 2011 | volume= 4 | issue= 1 | pages= 35-8 | pmid=21526004 | doi=10.1159/000324182 | pmc=PMC3082487 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21526004 }} </ref>
{{familytree | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01= [[Wide complex tachycardia]] <br> QRS ≥ 120ms}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | A02 | | | | | | | | | | | | | | | |A02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Begin initial management''' <br> ❑ Assess and support CAB as needed <br>
❑ Give [[oxygen]] <br>
❑ Monitor [[ECG]], [[blood pressure]], oxymetry <br>
❑ Establish IV access <br>
❑ Identify and treat reversible causes </div> }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | A03 | | | | | | | | | | | | | | | |A03=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Determine if the patient has any unstable sign or symptom''' <br> ❑ [[Chest pain]] <br>
❑ [[Congestive heart failure]] <br>
❑ [[Hypotension]] <br>
❑ [[Loss of consciousness]] <br>
❑ [[Seizures]] </div>}}
{{familytree | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | |}}
{{familytree | | | | B01 | | | | | | | | B02 | | | | | | | | | | |B01= '''Yes'''|B02= '''No'''}}
{{familytree | | | | |!| | | | | | | | | |!| | | | | | | | | | | |}}
{{familytree | | | | C01 | | | | | | | | C02 | | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 13em; padding:1em;"> '''[[Wide complex tachycardia resident survival guide#FIRE: Focused Initial Rapid Evaluation|Continue with the FIRE algorithm above]]''' </div> |C02= '''Determine the regularity of the rhythm''' }}
{{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|.| | | | | | | |}}
{{familytree | | | | | | | D01 | | | | | | | | | D02 | | | | | | |D01= '''Irregular rhythm''' |D02= '''Regular rhythm''' }}
{{familytree | | | | | | | |!| | | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | |,|-|-|-|v|-|^|-|v|-|-|-|.| | E05 | | E06 | | | | |E05=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[VT]] or uncertain rhythm''' <br> ❑ Give [[amiodarone]] 150 mg IV over 10 min <br>
❑ Repeat [[amiodarone]] as needed for a maximal dose of 2.2g/24h <br>
❑ Prepare for elective synchronized [[cardioversion]] <br> </div> |E06=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[SVT]] with aberrancy''' <br> ❑ Attempt vagal maneuvers<br>
❑ Give [[adenosine]] 6 mg rapid IV push <br>
❑ If no conversion give 12 mg IV push <br>
❑ May repeat 12 mg dose once </div>}}
{{familytree | E01 | | E02 | | E03 | | E04 | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Afib]] with aberrancy''' <br> ❑ Consider expert consultation <br>
❑ Control rate e.g [[diltiazem]] or [[beta blockers]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Pre-excited Afib ([[Afib]] + [[WPW]])''' <br>❑ Consider expert consultation <br>
❑ Avoid AV nodal blocking agents e.g [[adenosine]], [[digoxin]], [[diltiazem]] and [[verapamil]] <br>
❑ Consider [[amiodarone]] 150 mg IV over 10 min </div>|E03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Recurrent polymorphic [[VT]]''' <br>❑ Consider expert consultation </div>|E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Torsade de pointes]]''' <br> ❑ Load with [[magnesium]] 1-2 g over 5-60 min, then infusion </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
 
 
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of wide complex tachycardia''' <br>❑ [[Palpitations]] <br> ❑ [[QRS complex]] > 120 ms <br>❑ [[Heart rate]] > 150 beats/min </div> <br> }}
{{familytree | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | B01 | | |B01=<div style="float: left; text-align: left; width: 13em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Cold extremities]]
:❑ [[Cyanosis|Peripheral cyanosis]]
:❑ [[Mottling]]
:❑ [[Altered mental status]]
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Heart failure|Decompensated heart failure]]</div>}}
{{familytree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | | B02 | | | | | | | | | | |B01=<div style="float: left; text-align: central; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ '''Yes'''}} </div>|B02=❑ '''No'''}}
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | C02 | | | | |C02=<div style="float: left; text-align: left; width: 13em; padding:1em;">  ❑ '''[[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree | | | | | | | | | C03 | | | | | | | | | | | | | | | |C03=<div style="float: left; text-align: left; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| '''Prepare the patient for immediate cardioversion and simultaneously do the following:'''<br>  ❑ Maintain patent airway; assist breathing as necessary<br> ❑ Adminster [[oxygen]] (if the patient is hypoxemic)<br> ❑ Cardiac monitor to identify rhythm; monitor [[blood pressure]] and oximetry <br> ❑ Give IV sedation if the patient is conscious (don't delay cardioversion to sedate the patient) <br> ❑ Consider expert consultation }} </div>}}
{{familytree | | | | |,|-|-|-|-|+|-|-|-|-|.| | | | | | | | | | | |}}
{{familytree | | | | A01 | | | A02 | | | A03 | | | | | | | | | | |A01=<div style=" width: 13em; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''[[VT]]/[[VF]] in the form of [[cardiac arrest]]'''<br> '''[[Cardiac arrest resident survival guide|<span style="color:white;">Click here for Cardiac arrest resident survival guide</span>]]''' }} </div> </div> |A02=<div style=" width: 13em; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Unsynchronized cardioversion'''<br> ❑ If a patient has polymorphic VT and is unstable, treat the rhythm as VF and deliver high-energy unsynchronized shocks <br>
:❑ Provide an initial shock of 200 Joules<br>
:❑ Increase the dose if no response to the first shock (eg, 300 J, 360 J, 360 J) }} </div> </div>|A03=<div style=" width: 13em; padding:1em;"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF| '''Synchronized cardioversion''' }} </div> </div>}}
{{familytree | | | | | | | | | | | |,|-|-|+|-|-|.| | | | | | | | }}
{{familytree | | | | | | | | | | D01 | | D02 | | D03 | | | | | | |D01=<div style="float: left; text-align: left; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| '''Atrial fibrillation with aberrancy'''
:❑ Provide an initial dose of biphasic cardioversion of 120-200 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIa, level of evidence A</span>]])
:❑ If the initial shock fails, increase the dose in a stepwise fashion }} </div>|D02=<div style="float: left; text-align: left; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| '''Arial flutter and other SVTs with aberrancy'''
:❑ Provide an initial dose of biphasic cardioversion of 50-100 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIa, level of evidence B</span>]])
:❑ If the initial shock fails, increase the dose in a stepwise fashion
:❑ If monophasic wave form is used, begin at 200 Joules and increase in stepwise fashion if not successful }} </div>|D03=<div style="float: left; text-align: left; background: #FA8072; width: 13em; padding:1em;"> {{fontcolor|#F8F8FF| '''Monomorphic VT (regular form and rate)'''
:❑ Provide an initial dose of biphasic cardioversion of 100 Joules ([[ACC AHA guidelines classification scheme|<span style="color:white;">Class IIb, level of evidence C</span>]])
:❑ If the initial shock fails, increase the dose in a stepwise fashion }} </div> }}
{{familytree | | | | | | | | | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | D01 | | |D01= <div style="float: left; text-align: left; width: 13em; padding:1em;">❑ '''[[Wide complex tachycardia resident survival guide#Complete Diagnostic Approach|After the stabilization of the patient, continue with the complete diagnostic approach below]]''' </div>}}
{{Family tree/end}}
 
<span style="font-size:85%">'''Abbreviations:''' '''ECG:''' electrocardiogram; '''VT:''' ventricular tachycardia; '''VF:''' ventricular fibrillation; '''ICD:''' implantable cardioverter-defibrillator; '''BPM:''' beat per minute </span>
 
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | | A01 | | A01=
<div style="float: left; text-align: left; width: 21em; padding:1em;"> '''Characterize the symptoms:'''<br>
❑ [[Palpitations]]<br> ❑ [[Lightheadedness]] <br> ❑ [[Dyspnea]] <br> ❑ [[Diaphoresis]] <br> ❑ [[Chest pain|Chest discomfort]] <br> ❑ [[Shock]]<br> ❑ [[Syncope]] <br> ❑ [[Seizures]] <br> ❑ [[Cardiac arrest]] <br>
'''Characterize the timing of the symptoms:'''<br>
❑ Onset <br>
:❑ First episode
:❑ Recurrent
❑ Duration <br>
❑ Frequency<br>
❑ Termination of the episode
:❑ Spontaneous
:❑ Medication use
:❑ Not terminated</div>}}
{{familytree | | | | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | | | | B01 | | | B01= <div style="float: left; text-align: left; width: 21em; padding:1em;"> '''Identify possible triggers:'''<br>
<table>
<tr class="v-firstrow"><td>❑ [[Infection]]</td><td>❑ [[Caffeine]]</td><td>❑ [[Alcohol]]</td></tr>
<tr><td>❑ [[Nicotine]] </td><td> ❑ [[Recreational drugs]]</td><td>❑ [[Hypovolemia]]</td></tr>
<tr><td>❑ [[Hyperthyroidism]]</td><td> ❑ [[Hypoxia]]</td><td> ❑ [[Acidosis]] </td></tr>
<tr><td>❑ [[Hypokalemia]]</td><td> ❑ [[Hyperkalemia]]</td><td> ❑ [[Hypoglycemia]] </td></tr>
<tr><td>❑ [[Hypothermia]]</td><td> ❑ [[Toxins]]</td><td>❑ [[Pulmonary embolism]] </tr>
<tr><td>❑ [[Coronary thrombosis]]</td><td> ❑ [[Cardiac tamponade]]</td><td> ❑ [[Trauma]] </td></tr></table>
</div>}}
{{familytree | | | | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | | | | C01 | | C01= <div style="float: left; text-align: left; width: 21em; padding:1em;">
'''Examine the patient:'''<br>
'''Vitals'''<br>
❑ Pulse
:❑ Rate  <br> 
::❑ [[Tachycardia]] (> 100 bpm)  <br> 
:❑ Rhythm  <br>
::❑ Regular <br>
::❑ Irregular  <br>
:❑ Strength  <br>
::❑ Weak  <br>
::❑ Alternating in strength (atrial fibrillation with aberrancy) <br> 
❑ [[Respiration]]<br>
: ❑ [[Tachypnea]]<br>
❑ [[Blood pressure]]<br>
:❑ [[Hypotension]] (in hemodynamically unstable patients)<br>
:❑ Marked fluctuation of [[blood pressure]] (suggestive of AV dissociation in [[VT]]) 
'''Neck'''<br>
:❑ Canon A waves on examining the [[jugular venous pressure]] of the neck (suggestive of AV dissociation in [[VT]])<br>
'''Cardiovascular examination'''<br>
❑ Auscultation <br>
:❑ [[Heart sounds]]
::❑ Rapid regular or irregular beats <br>
::❑ Murmurs (suggestive of valvular diseases)<br>
::❑ Variability in the occurrence and the intensity of heart sounds especially S1 (suggestive of AV dissociation in [[VT]])<br>
❑ Inspection <br>
:❑ Midsternal incision (sugestive of previous cardiothoracic surgery)<br>
❑ Palpation <br>
:❑ Pace maker or ICD are usually palpapable on the left pectoral area
</div>}}
{{familytree | | | | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 21em; padding:1em;">'''Order labs and tests:''' <br> ❑ Order and monitor the [[ECG]]<br>
<span style="color:red">Perform urgent cardioversion in unstable patients</span> <br>
❑ Chest x ray
:❑ Cardiomegaly (suggestive of heart disease)
:❑ Pace maker and ICD appear in the x ray
❑ Invasive electrophysiological studies <br>
❑ [[Electrolytes]]
: ❑ [[Hypomagnesemia]]
: ❑ [[Hypokalemia]]
❑ Plasma concentration of drugs (eg,[[digoxin]], [[quinidine]] or [[procainamide]]  <br>
</div> }}
{{familytree | | | | | | | | | | | | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | |A01='''Wide QRS complex tachycardia'''<br>(QRS duration greater than 120 ms)}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | B01 | | | | | |B01=Regular or irregular?}}
{{familytree | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | | | | | | | | C01 | | | | | | | | | | | | C02 |C01=Regular|C02=Irregular}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | |)|-| D01 | | | | | | | | | D02 |D01=Is QRS identical to that during SR?<br>If yes, consider:<br> '''- SVT and BBB<br> - Antidromic AVRT'''|D02='''Atrial fibrillation<br>Atrial flutter / AT with variable<br> conduction and:<br>a) BBB or<br>b) Antegrade conduction via AP'''}}
{{familytree | | | | | | E01 |-|(| | | | | | | | | | | | | |E01=Vagal maneuvers or<br>adenosine}}
{{familytree | | | | | | | | | |)|-| E02 | | | | | | | | | |E02=Previous myocardial infarction or structural heart disease? If yes, '''VT''' is likely.}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | F01 | | | | | | | | | | | | | |F01=1 to 1 AV relationship?}}
{{familytree | | | | |,|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | }}
{{familytree | | | | G01 | | | | | | | | | | | | G02 | | | | | G01= Yes or unknown| G02= No}}
{{familytree | | | | |!| | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | | |!| | | | | | | | | | | |,|-|^|-|.| | | | }}
{{familytree | | | | |!| | | | | | | | | | | H01 | | H02 | | |H01= V rate faster than A rate|H02=A rate faster than V rate}}
{{familytree | | | | |!| | | | | | | | | | | |!| | | |!| | | | }}
{{familytree | | | | I01 | | | | | | | | | | H03 | | H04 | | | I01=QRS morphology in precordial leads| H03='''VT'''|H04='''Atrial tachycardia'''<br>'''Atrial flutter'''}}
{{familytree |,|-|-|-|-|+|-|-|-|v|-|-|.| | | | | | | | | | | | }}
{{familytree |!| | | | |!| | | |!| | |!| | | | | | | | | | | | }}
{{familytree | J01 | | J02 | | J03 | | J04 | | | | | | | | | | | J01= Typical RBBB <br> or LBBB| J02=Precordial leads:<br>- Concordant<br>- No R/S pattern<br>- Onset of R to nadir longer than 100ms<br>| J03=RBBB pattern:<br>- qR, Rs or Rr' in V1<br>- Frontal plane axis range<br>from +90 degrees to -90 degrees<br>| J04=LBBB pattern:<br> - R in V1 longer than 30 ms<br>- R to nadir of S in V1 greater than 60 ms<br>- qR or qS in V6}}
{{familytree |!| | | | |!| | |!| | | | |!| | | | | | | | | | | }}
{{familytree | K01 | | K02 | | K03 | | K04 | | | | | | | | | | |K01= '''SVT'''|K02='''VT'''|K03='''VT'''|K04='''VT'''}}
{{Family tree/end}}
 
 
''The above algorithm is adapted from the 2003 American College of Cardiology.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598 }} </ref>''

Latest revision as of 13:48, 19 June 2014

Symptoms Related to Tumor Growth in the Thorax

Constitutional Symptoms

Symptoms Related to Paraneoplastic Syndrome

Symptoms Related to the Distant Spread of the Tumor

Uncommon Symptoms

  1. ↑ 1.0 1.1 1.2 1.3 1.4 van Meerbeeck JP, Fennell DA, De Ruysscher DK (2011). "Small-cell lung cancer". Lancet. 378 (9804): 1741–55. doi:10.1016/S0140-6736(11)60165-7. PMID 21565397.
  2. ↑ Beckles MA, Spiro SG, Colice GL, Rudd RM (2003). "Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes". Chest. 123 (1 Suppl): 97S–104S. PMID 12527569.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Spiro SG, Gould MK, Colice GL, American College of Chest Physicians (2007). "Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition)". Chest. 132 (3 Suppl): 149S–160S. doi:10.1378/chest.07-1358. PMID 17873166.
  4. ↑ Singh N, Madan K, Aggarwal AN, Das A (2013). "Symptomatic large bilateral adrenal metastases at presentation in small-cell lung cancer: a case report and review of the literature". J Thorac Dis. 5 (3): E83–6. doi:10.3978/j.issn.2072-1439.2011.09.05. PMC 3698258. PMID 23825789.
  5. ↑ Yildiz O, Buyuktas D, Ekiz E, Selcukbiricik F, Papila I, Papila C (2011). "Facial nerve palsy: an unusual presenting feature of small cell lung cancer". Case Rep Oncol. 4 (1): 35–8. doi:10.1159/000324182. PMC 3082487. PMID 21526004.
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