Sandbox Rim

❑ Assess the ECG ❑ Order troponins ❑ Perform a bedside echocardiography (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 STEMI ❑ 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) NSTEMI ❑ ST depression in at least 2 contiguous leads ❑ New Q wave ❑ New regional wall abnormality or new myocardial loss

Yes

No

Activate cath lab team Click here for STEMI resident survival guide Click here for NSTEMI resident survival guide

Rule out the following life-threatening conditions

Pericarditis

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive ECG changes: ❑ Diffuse ST elevation, AND/OR ❑ PR depression, AND/OR ❑ PR elevation in lead aVR Look for supportive signs and symptoms: ❑ Pleuritic pain ❑ Chest pain that is positional ❑ Viral syndromes ❑ Fever ❑ Cough ❑ Pericardial rub

Look for supportive signs and symptoms: ❑ Sudden onset of chest pain radiated to the back or interscapular pain ❑ Back pain ❑ Acute heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Coma ❑ Diminution or absence of pulse ❑ Altered mental status ❑ Vagal episode ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

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

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management

Click here for the detailed management