Sandbox/AL

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the salmon color signify that an urgent management is needed.

Abbreviations:

Identify cardinal findings that increase the pretest probability of life-threatening chest pain ❑

Does the patient have any of the findings that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Severe dyspnea ❑ ❑

Yes

No

Initiate resuscitation measures: ❑ Secure airway ❑ Administer oxygen ❑ Secure wide bore IV access ❑ Perform ECG monitor ❑ Monitor vitals continuously ❑ Immediately order an ECG

Continue with the complete diagnostic approach below

ECG findings

Presence of ST elevation

Absence of ST elevation

Does the patient have both of the following: ❑ 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) ❑ PR depression is absent

❑ Evidence of LBBB

Does the patient have any of the following: ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse) ❑ PR Depression is present ❑ PR elevation in lead aVR is present

STEMI

LBBB

Pericarditis

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation ❑ Pain radiating to the left arm ❑ Elbow pain ❑ Shortness of breath or dyspnea ❑ Nausea and vomiting ❑ Diaphoresis ❑ An elevation of the CK MB enzyme ❑ An elevation of the troponin enzyme ❑ An elevation of the myoglobin

Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation ❑ Pain radiating to the left arm ❑ Elbow pain ❑ Shortness of breath or dyspnea ❑ Nausea and vomiting ❑ Diaphoresis ❑ An elevation of the CK MB enzyme ❑ An elevation of the troponin enzyme ❑ An elevation of the myoglobin

Look for supportive signs and symptoms: ❑ Pleuritic pain ❑ Chest pain that is positional ❑ A viral syndrome ❑ Fever ❑ Cough ❑ A pericardial rub ❑ Presence of tamponade

Look for supportive signs and symptoms: ❑ Back pain ❑ Diminution or absence of pulse ❑ Coma ❑ Altered mental status ❑ CVA ❑ Vagal episode ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive signs and symptoms: ❑ Shortness of breath ❑ Chest pain ❑ Dyspnea ❑ Anxiety ❑ Pleuritic chest pain

Look for supportive signs and symptoms: ❑ Sudden shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Following a medical procedure ❑ Patient on mechanical ventilation

Look for supportive signs and symptoms: ❑ Vomiting ❑ Lower chest pain ❑ 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

Click here for the detailed management

Click here for the detailed management

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.

Abbreviations:

Characterize the chest pain: ❑ Heaviness or crushing sensation (suggestive of myocardial isquemia) ❑ Pleuritic pain ❑ Sharp or knife-like ❑ Increases with respiratory movements ❑ ❑ Onset ❑ Sudden ❑ Location ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) ❑ Interscapular (suggestive of aortic dissection ❑ ❑ Activity prior ❑

Characterize the associated symptoms: ❑ Altered mental status ❑ Shortness of breath ❑ Nausea and vomiting ❑ Dizziness ❑ Palpitations Symptoms suggestive of cardiac etiology ❑ ❑ ❑ ❑ ❑ ❑ Symptoms suggestive of pulmonary etiology ❑ ❑ ❑ ❑ ❑ ❑ Symptoms suggestive of gastrointestinal etiology ❑ ❑ ❑ ❑ ❑ ❑

Inquire about past medical history: ❑ Previous episodes ❑ Cardiovascular disease ❑ Recent medical procedures ❑ Neurological diseases ❑ Recent trauma ❑ Alcohol intake

Identify possible triggers:

Examine the patient: Vitals ❑ Heart rate ❑ Blood pressure ❑ Respiratory rate Cardiovascular Respiratory ❑ Rales (suggestive of HF) Neurologic

Order labs and tests: ❑ EKG (most important initial test) ❑ Electrolytes ❑ Glucose (rule out hypoglycemia) ❑ ABG

Order imaging studies: ❑ Echocardiography

Does the chest pain has any of the following findings suggestive of cardiac etiology? ❑ ❑ ❑

YES

NO

Does the EKG has ST elevation?

YES

NO

Treatment

Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the

Abbreviations:

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References

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