Sandbox/AL

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

Continue with the complete diagnostic approach below

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 ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ PR depression is absent LBBB ❑ EKG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as STEMI

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: ❑ Hypertension ❑ Marfan syndrome

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 ❑ Pain last > 10 min Stable angina ❑ Pain usually lasts < 10 min ❑ Improved by rest or nitroglycerin

Esophageal rupture ❑

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) ❑ Location (retrosternal, epigastric, chest wall, diffuse) ❑ Type (sharp, pleuritic, heaviness, colicky) ❑ Radiation (shoulder, neck, back) ❑ Duration ❑ Worsen by (activities, position, drugs) ❑ Alleviated by (activities, position, drugs)

Characterize the symptoms Non-specific symptoms ❑ Altered mental status ❑ Shortness of breath ❑ Nausea and vomiting ❑ Dizziness ❑ Syncope ❑ Fatigue ❑ Lethargy Symptoms suggestive of cardiac etiology ❑ Heaviness or crushing sensation (suggestive of myocardial ischemia) ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) ❑ Interscapular pain (suggestive of aortic dissection) ❑ Epigastric pain (suggestive of inferior MI) ❑ Sweating ❑ Palpitations ❑ Pain with exertion Symptoms suggestive of pulmonary etiology ❑ Pleuritic pain ❑ Sharp or knife-like ❑ Increases with respiratory movements ❑ Dyspnea ❑ Cough ❑ Hemoptysis ❑ Pain and swelling of lower extremities (suggestive of DVT) ❑ Chills (suggestive of pneumonia) Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colic (suggestive of cholelithiasis) ❑ Epigastric pain ❑ Pain is associated with: ❑ Meals (suggestive of GERD or peptic ulcer) ❑ Medication intake ❑ Swallowing ❑ Changes in position ❑ Wakening during night (suggestive of GERD) ❑ Relieved by antacids ❑ Not related to exercise

Inquire about past medical history: ❑ Previous episodes of chest pain ❑ Cardiovascular disease ❑ Previous MI ❑ DVT ❑ Hypertension ❑ Recent medical procedures ❑ CVC (suggestive of pneumothorax) ❑ ❑ Pulmonary disease ❑ Previous PE ❑ COPD ❑ Asthma ❑ Neurological diseases ❑ Malignancy ❑ Recent trauma ❑ Alcohol intake ❑ Recent surgery (<3 months) ❑ Rheumatoic disorders ❑ SLE ❑ Rheumatoid arthritis

Identify possible triggers or risk factors: ❑ ❑

Examine the patient: Vitals ❑ Fever (suggestive ofpericarditis, pleuritis or infection) ❑ Heart rate ❑ Tachycardia ❑ Bradycardia ❑ Blood pressure ❑ ❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection) ❑ Tachypnea (non-specific) Neck ❑ Elevated jugular venous pulse Cardiovascular examination ❑ S3 ❑ S4 ❑ ❑ Pericardial rub (suggestive of pericarditis) ❑ Murmur (systolic murmur in hypertrophic cardiomyopathy, aortic stenosis) Respiratory examination ❑ Palpation - shift in trachea from midline (tension pneumothorax) ❑ Auscultation ❑ Absent breath sounds ❑ Rales ❑ Wheezing (suggestive of asthma or COPD) ❑ Pleural rub (pleuritis Abdominal examination ❑ Resonant percussion over the liver (suggestive of perforated peptic ulcer) ❑ Rectal examination that shows occult bleeding (peptic ulcer) Neurological examination ❑ Cerebrovascular accidents (aortic dissection) ❑ Paraplegia

Order labs and tests: ❑ EKG (most important initial test) ❑ Cardiac enzymes (Troponin, CK-MB ❑ CBC ❑ ABG ❑ D-dimer

Order imaging studies: ❑ Chest X-ray ❑ Echocardiography

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 ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ CK-MB and Troponin elevation ❑ PR depression is absent Click here for detailed management LBBB ❑ EKG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristic as 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 ❑ Systolic ejection murmur with ejection click ❑ Best heard at the upper right sternal border ❑ Bilateral radiation to the carotid arteries ❑ TTE findings of AS ❑ Exertional dyspnea ❑ Syncope Click here for detailed management 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 ❑ TTE findings of: ❑ Intimal tear ❑ Aortic regurgitation ❑ History of: ❑ Hypertension ❑ Marfan syndrome 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 ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer Click here for detailed management Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side Click here for detailed management Asthma exacerbation ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma Click here for detailed management

Consider the following: Pulmonary hypertension ❑ Dyspnea on exertion ❑ Increased P2 ❑ JVD ❑ Lower extremity edema ❑ History of gradual onset of shortness of breath Click here for detailed management Pneumonia ❑ Productive cough ❑ Fever ❑ Dyspnea ❑ New infiltrate on the CXR Click here for detailed management Pleuritis ❑ Sharp pain associated with inspiration and expiration ❑ ❑ Click here for detailed management

Consider the following: Pancreatitis ❑ Severe epigastric pain radiating to the back ❑ Nausea and vomiting ❑ Increased levels of amilase or lipase ❑ History of alcohol intake or gallstones Click here for detailed management Acute cholecystitis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Nausea and vomiting ❑ Click here for detailed management

Consider the following: GERD ❑ Burning sensation from the epigastrium towards the throat ❑ After meals ❑ Duration: minutes to hours Click here for detailed management Peptic ulcer ❑ Epigastric pain: ❑ Starts 5-15 min after a meal (suggestive of gastric ulcer) ❑ Alleviated by meals (suggestive of duodenal ulcer) ❑ Alleviated by antacids ❑ Click here for detailed management Esophageal spasm ❑ Vomiting ❑ Intermittent lower chest pain ❑ Cervical subcutaneous emphysema ❑ Alcohol excess ❑ Click here for detailed management Mallory-Weiss ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis Click here for detailed management

Consider the following: Musculoskeletal pain ❑ Localized pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ History of RA Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ History of immunodepresion or severe stress Click here for detailed management Psychiatric conditions ❑ Depresion ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack Click here for detailed management

Treatment

The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain. Abbreviations:

CARDIAC	PULMONARY	GASTROINTESTINAL	OTHER
❑ STEMI/LBBB ❑ NSTEMI/Unstable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis

• 
  

References

Template:WikiDoc Sources