Sandbox/AL: Difference between revisions
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{{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Characterize the symptoms'''<br> | {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Characterize the symptoms'''<br> | ||
'''Non-specific symptoms'''<br> | '''Non-specific symptoms'''<br> | ||
❑ Altered mental status<br> | ❑ [[Altered mental status]]<br> | ||
❑ Shortness of breath <br> | ❑ [[Shortness of breath]] <br> | ||
❑ Nausea and vomiting <br> | ❑ [[Nausea]] and [[vomiting]] <br> | ||
❑ Dizziness <br> | ❑ [[Dizziness]] <br> | ||
<br> | ❑ [[Syncope]]<br> | ||
❑ [[Fatigue]] <br> | |||
❑ [[Lethargy]]<br> | |||
'''Symptoms suggestive of cardiac etiology'''<br> | '''Symptoms suggestive of cardiac etiology'''<br> | ||
❑ Heaviness or crushing sensation (suggestive of [[myocardial isquemia]]) <br> | ❑ Heaviness or crushing sensation (suggestive of [[myocardial isquemia]]) <br> | ||
❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) <br> | ❑ Radiating to left arm, neck and/or jaw (suggestive of [[myocardial ischemia]]) <br> | ||
❑ Interscapular (suggestive of [[aortic dissection]] <br> | ❑ Interscapular (suggestive of [[aortic dissection]] <br> | ||
❑ Epigastric pain (suggestive of inferior MI)<br> | ❑ [[Epigastric pain]] (suggestive of [[inferior MI]])<br> | ||
❑ Sweating <br> | ❑ [[Sweating]] <br> | ||
❑ Palpitations <br> | ❑ [[Palpitations]] <br> | ||
❑ Pain with exertion <br><br> | ❑ Pain with exertion <br><br> | ||
'''Symptoms suggestive of pulmonary etiology'''<br> | '''Symptoms suggestive of pulmonary etiology'''<br> | ||
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: ❑ Sharp or knife-like | : ❑ Sharp or knife-like | ||
: ❑ Increases with [[respiratory movements]] | : ❑ Increases with [[respiratory movements]] | ||
❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> | ❑ [[Dyspnea]] <br> ❑ [[Cough]] <br> ❑ [[Hemoptysis]] <br> ❑ Pain and swelling of lower extremities (suggestive of [[PE]] <br> ❑ Chills (suggestive of [[pneumonia]]) <br> ❑ <br> | ||
'''Symptoms suggestive of gastrointestinal etiology'''<br> | '''Symptoms suggestive of gastrointestinal etiology'''<br> | ||
❑ Burning sensation (suggestive of GERD) <br> ❑ Colicky (suggestive of [[cholelithiasis]]) <br> ❑ Epigastric pain <br>❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br></div>}} | ❑ Burning sensation (suggestive of GERD) <br> ❑ Colicky (suggestive of [[cholelithiasis]]) <br> ❑ Epigastric pain <br>❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br></div>}} | ||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Inquire about past medical history:'''<br> | {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Inquire about past medical history:'''<br> | ||
❑ Previous episodes<br> | ❑ Previous episodes of chest pain<br> | ||
❑ Cardiovascular disease | ❑ Cardiovascular disease | ||
: ❑ <br> | : ❑ Previous [[MI]] <br> | ||
: ❑ <br> | : ❑ [[DVT]] <br> | ||
: ❑ Hypertension <br> | |||
❑ Recent medical procedures <br> | ❑ Recent medical procedures <br> | ||
: ❑ <br> | : ❑ <br> | ||
: ❑ <br> | : ❑ <br> | ||
❑ Pulmonary disease<br> | ❑ Pulmonary disease<br> | ||
: ❑ <br> | : ❑ Previous [[PE]] <br> | ||
: ❑ <br> | : ❑ <br> | ||
❑ Neurological diseases<br> | ❑ Neurological diseases<br> | ||
❑ Malignancy | |||
❑ Recent [[trauma]]<br> | ❑ Recent [[trauma]]<br> | ||
❑ Alcohol intake </div> }} | ❑ Alcohol intake <br> | ||
❑ Recent surgery (<3 months)<br> </div> }} | |||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Identify possible triggers:''' <br> | {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Identify possible triggers or risk factors:''' <br> | ||
❑ <br> ❑ <br> </div>}} | ❑ <br> ❑ <br> </div>}} | ||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' | {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' |
Revision as of 13:23, 28 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 if SatO2 ≤95% ❑ Secure wide bore IV access ❑ Monitor vitals continuously ❑ Immediately order a 12-lead 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: ❑ Substernal chest discomfort that starts with a low intensity and slowly increases | 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
❑ Dyspnea ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ ❑ ❑ ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Identify possible triggers or risk factors: ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
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) | Does the TTE shows valve or aortic abnormalities? | ||||||||||||||||||||||||||||||||||||||
YES | 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 | Consider the following: Aortic stenosis ❑ ❑ ❑ 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: