Sandbox/AL: Difference between revisions
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{{familytree | | | | | B01 | | | | | | | | | | | | B02 |B01='''Presence of ST elevation'''|B02='''Absence of ST elevation'''}} | {{familytree | | | | | B01 | | | | | | | | | | | | B02 |B01='''Presence of ST elevation'''|B02='''Absence of ST elevation'''}} | ||
{{familytree | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|. | {{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|v|-|-|-|.| }} | ||
{{familytree | C01 | | C02 | | C03 | | |!| | | |!| | | |!| | | |!| | C01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the patient have both of the following:'''<br> | {{familytree | C01 | | C02 | | C03 | | |!| | | |!| | | |!| | | |!| | | |!|C01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the patient have both of the following:'''<br> | ||
❑ 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)<br> | ❑ 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)<br> | ||
❑ PR depression is absent </div> | ❑ PR depression is absent </div> | ||
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❑ PR Depression is present <br> | ❑ PR Depression is present <br> | ||
❑ PR elevation in lead aVR is present </div>}} | ❑ PR elevation in lead aVR is present </div>}} | ||
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }} | {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | ||
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04= '''[[Aortic dissection]]'''| | {{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | | C08 | |C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04='''[[Angina]]'''|C05= '''[[Aortic dissection]]'''| C06= '''[[Pulmonary embolism]]'''| C07= '''[[Tension pneumothorax]]'''| C08= '''[[Esophageal rupture]]'''}} | ||
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }} | {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | ||
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D07 | {{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D07 | | D08 | | | ||
| D01= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | | D01= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | ||
❑ The pain is described as a heaviness or crushing sensation <br> | ❑ The pain is described as a heaviness or crushing sensation <br> | ||
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❑ Presence of tamponade </div> | ❑ Presence of tamponade </div> | ||
| D04= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | | D04= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | ||
❑ <br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br></div> | |||
| D05= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |||
❑ Back pain <br> | ❑ Back pain <br> | ||
❑ Diminution or absence of pulse <br> | ❑ Diminution or absence of pulse <br> | ||
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:❑ Lower extremity ischemia <br> | :❑ Lower extremity ischemia <br> | ||
:❑ Focal neurologic deficits </div> | :❑ Focal neurologic deficits </div> | ||
| | | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | ||
❑ Shortness of breath <br> | ❑ Shortness of breath <br> | ||
❑ Chest pain <br> | ❑ Chest pain <br> | ||
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❑ Anxiety <br> | ❑ Anxiety <br> | ||
❑ Pleuritic chest pain </div> | ❑ Pleuritic chest pain </div> | ||
| | | D07= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | ||
❑ Sudden shortness of breath <br> | ❑ Sudden shortness of breath <br> | ||
❑ Cyanosis <br> | ❑ Cyanosis <br> | ||
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❑ Following a medical procedure <br> | ❑ Following a medical procedure <br> | ||
❑ Patient on mechanical ventilation </div> | ❑ Patient on mechanical ventilation </div> | ||
| | | D08=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | ||
❑ Vomiting <br> | ❑ Vomiting <br> | ||
❑ Lower chest pain <br> | ❑ Lower chest pain <br> | ||
❑ Cervical subcutaneous emphysema <br> | ❑ Cervical subcutaneous emphysema <br> | ||
❑ Overindulgence in alcohol <br> | ❑ Overindulgence in alcohol <br> | ||
❑ Overindulgence in food </div>}} | ❑ Overindulgence in food </div> }} | ||
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | ||
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Aortic dissection resident survival guide|Click here for the detailed management]]| | {{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Angina]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E07= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E08= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Complete Diagnostic Approach== | ==Complete Diagnostic Approach== |
Revision as of 12:55, 25 April 2014
Overview
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 red 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 ❑ Altered mental status ❑ Severe dyspnea ❑ Oliguria ❑ Cold extremities | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initiate resuscitation measures: ❑ Secure airway ❑ Administer oxygen ❑ Secure wide bore IV access ❑ Perform ECG monitor ❑ Monitor vitals continuously ❑ Immediately order an ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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) | ❑ 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) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
STEMI | LBBB | Pericarditis | Angina | Aortic dissection | Pulmonary embolism | Tension pneumothorax | Esophageal rupture | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation | Look for supportive signs and symptoms: ❑ The pain is described as a heaviness or crushing sensation | Look for supportive signs and symptoms: ❑ Pleuritic pain | Look for supportive signs and symptoms: ❑ | Look for supportive signs and symptoms: ❑ Back pain
| Look for supportive signs and symptoms: ❑ Shortness of breath | Look for supportive signs and symptoms: ❑ Sudden shortness of breath | Look for supportive signs and symptoms: ❑ Vomiting | {{{ }}} | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | Angina | 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)
❑ | |||||||||||||||||||||||||||||||||||||||||
Characterize the associated symptoms: ❑ Altered mental status ❑ ❑ ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes | |||||||||||||||||||||||||||||||||||||||||
Identify possible triggers: | |||||||||||||||||||||||||||||||||||||||||
Examine the patient:
Vitals
| |||||||||||||||||||||||||||||||||||||||||
Order labs and tests: ❑ EKG (most important initial test) ❑ Electrolytes
❑ Glucose (rule out hypoglycemia) | |||||||||||||||||||||||||||||||||||||||||
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? | Determine the non-cardiac etiology based on the physical examination and tests findings | ||||||||||||||||||||||||||||||||||||||||
YES | NO | Pulmonary | Gastrointestinal | Other | |||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: