Sandbox/AL: Difference between revisions
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{{familytree | | | K03 | | | | | K04 | | | | K05 | | | K03= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Pulmonary''' </div> | K04= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Gastrointestinal''' </div>| K05= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Other''' </div>}} | {{familytree | | | K03 | | | | | K04 | | | | K05 | | | K03= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Pulmonary''' </div> | K04= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Gastrointestinal''' </div>| K05= <div style="float: left; text-align: center; width: 15em; padding:1em;">'''Other''' </div>}} | ||
{{familytree | | | |!| | | | | | |!| | | | | |!| | |}} | {{familytree | | | |!| | | | | | |!| | | | | |!| | |}} | ||
{{familytree | | | F01 | | | | | F02 | | | | |!| | | F01=<div style="float: left; text-align: left; width: 15em; padding:1em;">''' | {{familytree | | | F01 | | | | | F02 | | | | |!| | | F01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Is the onset sudden?''' </div> |F02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Is the onset sudden?''' </div> }} | ||
{{familytree | |,|-|^|-|.| | | |,|^|-|.| | | |!| | |}} | {{familytree | |,|-|^|-|.| | | |,|^|-|.| | | |!| | |}} | ||
{{familytree | A01 | | A02 | | A03| |A04 | |!| | | A01=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''YES''' </div> | A02=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''NO''' </div> | A03=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''YES''' </div>| A04=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''NO''' </div>}} | {{familytree | A01 | | A02 | | A03| |A04 | |!| | | A01=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''YES''' </div> | A02=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''NO''' </div> | A03=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''YES''' </div>| A04=<div style="float: left; text-align: center; width: 15em; padding:1em;">'''NO''' </div>}} | ||
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'''[[Pneumonia]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pneumonia 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> | '''[[Pleuritis]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pleuritis resident survival guide|Click here for detailed management]]<br><br></div> | ||
| L05=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Consider the following:''' <br> | |||
| | '''[[Pancreatitis]]''' <br> ❑ Severe epigastric pain radiating to the back <br> ❑ Nausea and vomiting <br> ❑ Increased levels of [[amilase]] or [[lipase]]<br> ❑ History of [[alcohol intake]] or [[gallstones]] <br> [[Pancreatits resident survival guide|Click here for detailed management]]<br><br> | ||
'''[[Acute cholecystitis]]''' <br> ❑ RUQ pain associated with meals <br> ❑ Positive [[Murphy sign]] <br> ❑ Nausea and vomiting <br> ❑ <br> [[Acute cholecystitis resident survival guide|Click here for detailed management]]<br><br></div> | |||
| L06= <div style="float: left; text-align: left; width: 15em; 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> | '''[[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> ❑ Epigastric pain: | '''[[Peptic ulcer]]''' <br> ❑ Epigastric pain: | ||
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'''[[Esophageal spasm]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm 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> | '''[[Mallory-Weiss]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm resident survival guide|Click here for detailed management]]<br><br></div> | ||
| L07= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Consider the following:'''<br> | | L07= <div style="float: left; text-align: left; width: 15em; 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> | '''[[Musculoskeletal pain]]''' <br> ❑ Pain on palpation of costochondral joints <br> ❑ Exacerbated by chest wall movements <br> ❑ <br> [[Click here for detailed management]] <br><br> |
Revision as of 17:18, 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
❑ Not related to exercise ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes of chest pain
❑ Recent medical procedures
❑ Pulmonary disease
❑ Neurological diseases | |||||||||||||||||||||||||||||||||
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 | ||||||||||||||||||||||||||||||||
Click here for the cardiac chest pain approach | Click here for the non-cardiac chest pain approach | ||||||||||||||||||||||||||||||||
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
❑ TTE findings of AS
| Unstable angina/NSTEMI ❑ Elevated cardiac enzymes ❑ ❑ Click here for detailed management Stable angina ❑ Normal cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Improved by rest or nitroglycerin Click here for detailed management | ||||||||||||||||||||||||||||||||||||
Non-Cardiac Chest Pain
Determine the non-cardiac etiology based on the physical examination and tests findings | |||||||||||||||||||||||||||||||||||||||
Pulmonary | Gastrointestinal | Other | |||||||||||||||||||||||||||||||||||||
Is the onset sudden? | Is the onset sudden? | ||||||||||||||||||||||||||||||||||||||
YES | NO | YES | NO | ||||||||||||||||||||||||||||||||||||
Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management Click here for detailed management | Consider the following:
❑ ❑ ❑ Click here for detailed management | Consider the following: Pancreatitis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Nausea and vomiting ❑ Click here for detailed management | Consider the following: GERD
❑ Alleviated by antacids ❑ ❑ ❑ Click here for detailed management | Consider the following: Musculoskeletal pain ❑ ❑ ❑ Click here for detailed management | |||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: