Sandbox/AL: Difference between revisions
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{{familytree | | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br> | {{familytree | | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br> | ||
❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}} | ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}} | ||
{{familytree | | | | | | | | |,|-|^|-|-|-|. | | |}} | {{familytree | | | | | | | | |,|-|^|-|-|-|. | | | }} | ||
{{familytree | | | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}} | {{familytree | | | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No''' }} | ||
{{familytree | | | | | | | | |!| | | | | |!| | | | }} | {{familytree | | | | | | | | | |!| | | | | |!| | | | }} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen if SatO2 ≤95% <br> ❑ Secure wide bore IV access <br> ❑ Monitor vitals continuously <br> ❑ Immediately order a 12-lead [[ECG|<span style="color:white;">ECG</span>]]</div>}} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen if SatO2 ≤95% <br> ❑ Secure wide bore IV access <br> ❑ Monitor vitals continuously <br> ❑ Immediately order a 12-lead [[ECG|<span style="color:white;">ECG</span>]]</div>}} | ||
{{familytree | | | | | | | | |!| | | | | C02 | | | | | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}} | {{familytree | | | | | | | | | |!| | | | | C02 | | | | | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the [[ECG|<span style="color:white;">ECG</span>]] has [[ST elevation|<span style="color:white;">ST elevation</span>]]?''' </div>}} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the [[ECG|<span style="color:white;">ECG</span>]] has [[ST elevation|<span style="color:white;">ST elevation</span>]]?''' </div>}} | ||
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}} | {{familytree | | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}} | ||
{{familytree | | | B01 | | | | | | | | B02 | | | | B01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | B02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | B01 | | | | | | | | B02 | | | | B01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | B02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | | | |!| | | | | | | | | |!| | | | | |}} | {{familytree | | | | |!| | | | | | | | | |!| | | | | |}} | ||
{{familytree | | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''Is the ST elevation specific to an anatomic area?'''</div><div style="text-align: left"> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) </div> | C02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Consider additional tests to rule out life-threatening conditions'''<br> ❑ ABG <br> ❑ Chest X-ray <br> ❑ D-dimer</div> }} | ||
{{familytree | |,|-|^|-|.| | | | | | | {{familytree | | |,|-|^|-|.| | |,|-|-|-|+|-|-|-|.| | |}} | ||
{{familytree | D01 | | D02 | | | | | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| D01 | | D02 | | |!| | | |!| | | |!| |D01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | D02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | |!| | | |! | {{familytree | | |!| | | |!| | |!| | | |!|| |}} | ||
{{familytree | E01 | | E02 | | | | | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em;"> | ||
'''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> | '''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ PR depression is absent <br> | ||
---- | |||
'''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | '''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | ||
: ❑ QRS ≥ 120 ms | : ❑ QRS ≥ 120 ms | ||
: ❑ QS or rS in V1 | : ❑ QS or rS in V1 | ||
: ❑ Monophasic R in I, aVL and V6 | : ❑ Monophasic R in I, aVL and V6 | ||
❑ Chest pain with same characteristic as STEMI | ❑ Chest pain with same characteristic as STEMI </div> | E02= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''[[Pericarditis]]''' <br> ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression <br> ❑ PR elevation in lead aVR </div>| E03=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''[[Pulmonary embolism]]''' <br> ❑ Sudden[[chest pain]] <br> ❑ Severe [[dyspnea]] <br> ❑ History of [[DVT]], [[surgery]], [[malignancy]], immobility <br> ❑ Elevated [[D-dimer]]</div>| E04=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''[[Pneumothorax]]''' <br> ❑ [[Dyspnea]]<br> ❑ [[Hypoxia]] <br> ❑ [[Tracheal deviation]] towards the unaffected side<br> ❑ [[percussion|Hyperresonance]] on the affected side </div> |E05=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''[[Aortic dissection]]''' <br> ❑ Acute onset of [[heart failure]] <br> ❑ Low pitched early diastolic murmur best heard at the 2nd right [[ICS]] <br> ❑ [[Widened mediastinum]] on [[chest X-ray]] <br>❑ History of: | ||
'''[[ | |||
❑ [[ | |||
'''[[Aortic dissection]]''' <br> ❑ Acute onset of [[heart failure]] <br> ❑ Low pitched early diastolic murmur best heard at the 2nd right [[ICS]] <br> ❑ [[Widened mediastinum]] on [[chest X-ray]] <br> | |||
❑ History of: | |||
: ❑ [[Hypertension]] | : ❑ [[Hypertension]] | ||
: ❑ [[Marfan syndrome]] | : ❑ [[Marfan syndrome]]</div> | E06=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''[[Unstable angina]]/[[NSTEMI]]'''<br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ Pain last > 10 min <br> | ||
'''[[Stable angina]]''' <br> ❑ Pain usually lasts < 10 min <br> ❑ Improved by rest or [[nitroglycerin]] </div>}} | |||
'''[[Stable angina]]''' | {{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E01= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]''' <br>[[STEMI resident survival guide|Click here for the detailed management]]</div>| E02=[[Pericarditis resident survival guide|Click here for the detailed management]] |E03= [[Pulmonary embolism resident survival guide|Click here for the detailed management]] | ||
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | | | E04=[[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 15:20, 30 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||
Does the ECG 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) | Consider additional tests to rule out life-threatening conditions ❑ ABG ❑ Chest X-ray ❑ D-dimer | ||||||||||||||||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||
STEMI LBBB
| Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR | Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer | Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side | Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Widened mediastinum on chest X-ray ❑ History of: | |||||||||||||||||||||||||||||||||||||||||||||||
Administer: ❑ Aspirin 162-325 mg ❑ Oxygen (2-4 L/min) if satO2 <90% ❑ Beta blockers (unless contraindicated) ❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses Do not delay primary angioplasty or fibrinolysis 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 ❑ 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 ❑ Blood pressure
❑ Tachypnea (non-specific) Neck 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 | Consider the following: Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR ❑ ❑ Click here for detailed management | Consider the following: Aortic stenosis
❑ TTE findings of AS
❑ History of: Click here for detailed management | Consider the following: Unstable angina/NSTEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ Elevated cardiac enzymes ❑ Pain last > 10 min ❑ 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 ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma Click here for detailed management | Consider the following:
❑ Sharp pain associated with inspiration and expiration ❑ ❑ 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 ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis Click here for detailed management | Consider the following: Musculoskeletal pain ❑ Depresion ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack Click here for detailed management | |||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: