Sandbox/AL: Difference between revisions
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===Non-Cardiac Chest Pain=== | ===Non-Cardiac Chest Pain=== | ||
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{{familytree | | | | | | A01 | | | | A01=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Determine the non-cardiac etiology based on the physical examination and tests findings''' </div> }} | |||
{{familytree | | |,|-|-|-|^|-|-|-|.| |}} | |||
{{familytree | | K03 | | K04 | | K05 | | | K03= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Pulmonary''' </div> | K04= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Gastrointestinal''' </div>| K05= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Other''' </div>}} | |||
{{familytree | | |!| | | |!| | | |!| | |}} | |||
{{familytree | | L03 | | L04 | | L05 | | L03=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | |||
'''[[Pulmonary embolism]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pulmonary embolism resident survival guide|Click here for detailed management]] <br><br> | |||
'''[[Spontaneous pneumothorax]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Spontaneous pneumothorax resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Tension pneumothorax]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Tension pneumothorax resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Pulmonary hypertension]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pulmonary hypertension resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Pneumonia]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pneumonia resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Pleuritis]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pleuritis resident survival guide|Click here for detailed management]]<br><br></div> | |||
| L04= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | |||
'''[[GERD]]''' <br> ❑ Burning sensation from the epigastrium towards the throat <br> ❑ <br> ❑ <br> [[GERD resident survival guide|Click here for detailed management]] <br><br> | |||
'''[[Peptic ulcer]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Peptic ulcer resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Pancreatitis]]''' <br> ❑ Epigastric pain radiating to the back <br> ❑ <br> ❑ <br> [[Pancreatits resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Cholelithiasis]]''' <br> ❑ RUQ pain associated with meals <br> ❑ Positive [[Murphy sign]] <br> ❑ <br> [[Cholelithiasis resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Esophageal spasm]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Mallory-Weiss]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm resident survival guide|Click here for detailed management]]<br><br></div> | |||
| L05= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | |||
'''[[Musculoskeletal pain]]''' <br> ❑ Pain on palpation of costochondral joints <br> ❑ Exacerbated by chest wall movements <br> ❑ <br> [[Click here for detailed management]] <br><br> | |||
'''[[Herpes zoster]]''' <br> ❑ Burning pain localized in a dermatome <br> ❑ Unilateral vesicular rash <br> ❑ <br> [[Click here for detailed management]] <br><br> | |||
'''[[Psychiatric conditions]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Click here for detailed management]]<br><br></div>}} | |||
{{familytree/end}} | |||
==Treatment== | ==Treatment== |
Revision as of 18:29, 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 ❑ Sudden onset ❑ ❑ ❑ Related physical exertion | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ Onset (sudden or gradual) | |||||||||||||||||||||||||||||||||||||||||
Characterize the symptoms Non-specific symptoms
❑ ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ ❑ ❑ ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes
❑ Recent medical procedures
❑ Pulmonary disease
❑ Neurological diseases | |||||||||||||||||||||||||||||||||||||||||
Identify possible triggers: ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Examine the patient:
Vitals Cardiovascular examination Abdominal examination Neurological examination | |||||||||||||||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||||||||||
Consider the following: STEMI
❑ Chest pain with same characteristic as STEMI ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management | Consider the following: Aortic stenosis ❑ ❑ ❑ Click here for detailed management | Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management | Consider the following: GERD ❑ ❑ ❑ Click here for detailed management | Consider the following: Musculoskeletal pain ❑ ❑ ❑ Click here for detailed management | |||||||||||||||||||||||||||||||||||||
Cardiac Chest Pain
Does the EKG has ST elevation? | |||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||
Is the ST elevation specific to an anatomic area ❑ V1-V2 (Septal) ❑ V3-V4 (Anterior) ❑ V5-V6 (Apical) ❑ I, aVL (Lateral) ❑ II, III, aVF (Inferior) | NO | ||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||
Consider the following: STEMI
Click here for detailed management | Pericarditis ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management | ||||||||||||||||||||||||||||||
Non-Cardiac Chest Pain
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: