Sandbox Rim

❑ Assess the ECG ❑ Order troponins ❑ Perform a bedside echocardiogrpahy (if available)

Does the patient fulfill the criteria of myocardial infarction? ❑ Rise and/or fall of cardiac biomarker (preferably troponin) PLUS at least of the following ❑ Symptoms of ischemia ❑ New ST-T wave changes or new LBBB ❑ New Q wave ❑ New regional wall abnormality or new myocardial loss

Yes

No

Activate cath lab team Treat as STEMI or NSTEMI STEMI changes: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI), OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery), OR ❑ New LBBB

Does the patient have ECG changes/pericarditis? ❑ Diffuse ST elevation, AND/OR ❑ PR depression, AND/OR ❑ PR elevation in lead aVR

Yes

No

Rule out the following life-threatening conditions

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for signs and symptoms suggestive of Pericarditis: ❑ Pleuritic pain ❑ Chest pain that is positional ❑ Viral syndromes ❑ Fever ❑ Cough ❑ Pericardial rub

Look for supportive signs and symptoms: ❑ Pleuritic chest pain ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive signs and symptoms: ❑ Pleuritic chest pain ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive signs and symptoms: ❑ Sudden Shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Recent medical procedure ❑ Patient on mechanical ventilation ❑ Tracheal deviation towards the unaffected side ❑ Absent heart sound on the affected side ❑ Hyperresonance on the affected side

Look for supportive signs and symptoms: ❑ Vomiting ❑ Lower chest pain ❑ Hematemesis ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

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Click here for the detailed management

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