DVT complete diagnostic approach resident survival guide

Please find below an algorithm that summarizes the approach to chest pain.

Assess ECG

❑ Presence of ST elevation OR ❑ ST depression in in at least two precordial leads V1-V4 OR ❑ New LBBB

❑ Absence of ST elevation

❑ Rule out life threatening conditions

Does the patient have both of the following: ❑ ST elevation in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads OR ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI) OR ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery) OR ❑ New 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) OR ❑ PR Depression is present OR ❑ PR elevation in lead aVR is present Suspect cardiac tamponade when any of the following findings are present: ❑ Jugular venous distention ❑ Dyspnea ❑ Pulsus paradoxus ❑ Muffled heart sounds ❑ Hypotension

STEMI

Pericarditis

Aortic dissection

Pulmonary embolism

Tension pneumothorax

Esophageal rupture

❑ Activate the cath lab team ❑ Look for supportive signs and symptoms while the cath lab team is mobilized: ❑ The pain is described as a heaviness or crushing sensation ❑ Pain radiating to the left arm ❑ Elbow pain ❑ Shortness of breath or dyspnea ❑ Nausea and vomiting ❑ Diaphoresis ❑ An elevation of the CK MB enzyme ❑ An elevation of the troponin enzyme ❑ An elevation of the myoglobin

Look for supportive signs and symptoms: ❑ Pleuritic pain ❑ Chest pain that is positional ❑ A viral syndrome ❑ Fever ❑ Cough ❑ A pericardial rub ❑ Presence of tamponade

Look for supportive signs and symptoms: ❑ Sudden onset of chest pain radiated to the back or interscapular pain ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Diminution or absence of pulse ❑ Coma ❑ Altered mental status ❑ CVA ❑ Vagal episode ❑ Evidence of ischemia ❑ Splanchnic ischemia ❑ Renal insufficiency ❑ Lower extremity ischemia ❑ Focal neurologic deficits

Look for supportive signs and symptoms: ❑ Pleuritic hest pain ❑ Shortness of breath ❑ Dyspnea ❑ Anxiety ❑ History of: ❑ DVT ❑ Recent surgery ❑ Malignancy ❑ Immobility

Look for supportive signs and symptoms: ❑ Sudden shortness of breath ❑ Tracheal deviation towards the unaffected side ❑ Absent heart sound on the affected side ❑ Hyperresonance on the affected side ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Following a medical procedure ❑ Patient on mechanical ventilation

Look for supportive signs and symptoms: ❑ Vomiting ❑ Hematemesis ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food

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Click here for the detailed management

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If none of the above conditions is found, proceed to the complete diagnostic approach below