|
|
| Line 1: |
Line 1: |
| Please find below an algorithm that summarizes the approach to chest pain.
| | {{familytree/start |summary=PE diagnosis Algorithm.}} |
| {{familytree/start}} | | {{familytree | | | | | | | | GMa | GMa='''Assess the pretest probability of PE'''}} |
| {{familytree | | | | | | | | | A01 | | | | | |A01=Assess [[ECG]]}}
| | {{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }} |
| {{familytree | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| }}
| | {{familytree | | |JOE| | | | | | | |SIS| | | JOE='''Low pretest probability of PE'''|SIS='''High pretest probability of PE'''}} |
| {{familytree | | | B01 | | | | | | | | | | B02 |B01='''❑ Presence of ST elevation '''<br> OR <br> '''❑ ST depression in in at least two precordial leads V1-V4''' <br> OR <br> '''❑ New LBBB'''|B02='''❑ Absence of ST elevation'''}} | | {{familytree | | | |!| | | | | | | | | |!| }} |
| {{familytree | | | |!| | | | | | | | | | | |!| | | | | | | | }} | | {{familytree | | |MOM| | | | | | | | |!| |MOM='''Order [[D-dimer]]'''}} |
| {{familytree | | | |!| | | | | | | | | | | B03 | | | | | | | B03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> ❑ Rule out life threatening conditions </div>}}
| | {{familytree | |,|-|^|.| | | | | | | | |!| }} |
| {{familytree | |,|-|^|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| | }}
| | {{familytree |GPa| |JOE|~|~|~|~|~|MOM|GPa='''Normal D-dimer (<500 ng/ml)'''|JOE='''Elevated D-dimer (>500 ng/ml)'''|MOM='''Order [[Pulmonary embolism other imaging findings#Angiography|CT Pulmonary angiography]]'''}} |
| {{familytree | C01 | | C03 | | |!| | | |!| | | |!| | | |!| | C01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the patient have both of the following:'''<br> | | {{familytree | |!| | | | | | | | | |,|-|^|.| }} |
| ❑ 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<br>OR <br>
| | {{familytree |MOM| | | | | | |SIS| | |GMa|MOM='''PE is excluded'''|SIS=Negative|GMa=Positive}} |
| ❑ ST depression in at least two precordial leads V1-V4 (suggestive of posterior MI)<br>OR <br>
| | {{familytree | | | | | | | | | | |!| | | | |!| }} |
| ❑ ST depression in several leads plus ST elevation in lead aVR (suggestive of occlusion of the left main or proximal LAD artery)<br>OR <br>
| | {{familytree | | | | | | | | | |SIS| | |GMa|SIS='''PE is excluded'''|GMa='''PE is confirmed'''}} |
| ❑ New LBBB </div>
| |
| | C03=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Does the patient have any of the following:''' <br> | |
| ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse) <br>OR<br>
| |
| ❑ PR Depression is present <br>OR<br>
| |
| ❑ PR elevation in lead aVR is present<br><br>
| |
| '''Suspect cardiac tamponade when any of the following findings are present:''' | |
| ❑ [[Jugular venous distention]]<br>
| |
| ❑ [[Dyspnea]]<br>
| |
| ❑ [[Pulsus paradoxus]]<br>
| |
| ❑ [[Muffled heart sounds]]<br>
| |
| ❑ [[Hypotension]]</div>}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }} | |
| {{familytree | C01 | | C03 | | C04 | | C05 | | C06 | | C07 | C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04= '''[[Aortic dissection]]'''| C05= '''[[Pulmonary embolism]]'''| C06= '''[[Tension pneumothorax]]'''| C07= '''[[Esophageal rupture]]'''}} | |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }} | |
| {{familytree | D01 | | D03 | | D04 | | D05 | | D06 | | D07 | |
| | D01= <div style="float: left; text-align: left; width: 12em; padding:1em;"> ❑ '''Activate the cath lab team''' <br>❑ '''Look for supportive signs and symptoms while the cath lab team is mobilized:''' <br> | |
| :❑ The pain is described as a heaviness or crushing sensation <br>
| |
| :❑ Pain radiating to the left arm <br>
| |
| :❑ Elbow pain <br>
| |
| :❑ Shortness of breath or dyspnea <br>
| |
| :❑ Nausea and vomiting <br>
| |
| :❑ Diaphoresis <br>
| |
| :❑ An elevation of the CK MB enzyme <br>
| |
| :❑ An elevation of the troponin enzyme <br>
| |
| :❑ An elevation of the myoglobin </div>
| |
| | D03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ Pleuritic pain <br>
| |
| ❑ Chest pain that is positional <br>
| |
| ❑ A viral syndrome <br>
| |
| ❑ Fever <br>
| |
| ❑ Cough <br>
| |
| ❑ A pericardial rub <br>
| |
| ❑ Presence of tamponade </div>
| |
| | D04= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Sudden onset of chest pain radiated to the back or [[interscapular pain]] <br>
| |
| ❑ Acute onset of heart failure<br>
| |
| ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space<br>
| |
| ❑ Asymmetric blood pressure in the upper extremities <br>
| |
| ❑ Diminution or absence of pulse <br>
| |
| ❑ Coma <br>
| |
| ❑ Altered mental status <br>
| |
| ❑ CVA <br>
| |
| ❑ Vagal episode <br>
| |
| ❑ Evidence of ischemia <br>
| |
| :❑ Splanchnic ischemia <br>
| |
| :❑ Renal insufficiency <br>
| |
| :❑ Lower extremity ischemia <br>
| |
| :❑ Focal neurologic deficits </div>
| |
| | D05= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Pleuritic hest pain <br>
| |
| ❑ Shortness of breath <br>
| |
| ❑ Dyspnea <br>
| |
| ❑ Anxiety <br>
| |
| ❑ History of:
| |
| :❑ DVT
| |
| :❑ Recent surgery
| |
| :❑ Malignancy
| |
| :❑ Immobility</div>
| |
| | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ Sudden shortness of breath <br>
| |
| ❑ [[Tracheal deviation]] towards the unaffected side <br>
| |
| ❑ Absent [[heart sound]] on the affected side <br>
| |
| ❑ Hyperresonance on the affected side <br>
| |
| ❑ Cyanosis <br>
| |
| ❑ Penetrating chest wound <br>
| |
| ❑ Flopping sound <br>
| |
| ❑ Following a medical procedure <br>
| |
| ❑ Patient on mechanical ventilation </div>
| |
| | D07=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ Vomiting <br>
| |
| ❑ [[Hematemesis]] <br>
| |
| ❑ Lower chest pain <br>
| |
| ❑ Cervical subcutaneous emphysema <br>
| |
| ❑ Overindulgence in alcohol <br>
| |
| ❑ Overindulgence in food </div>}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | |
| {{familytree | E01 | | E03 | | E04 | | E05 | | E06 | | E07 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E05= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E06= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E07= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}} | |
| {{familytree | | | | | | | | | |`|-|-|-|^|-|v|-|^|-|-|-|'| }} | |
| {{familytree | | | | | | | | | | | | | | | F01 | | | | F01= <div style="text-align: center; padding: 5px;">'''If none of the above conditions is found, proceed to the [[Chest pain resident survival guide#Complete Diagnostic Approach| complete diagnostic approach]] below'''</div>}} | |
| {{familytree/end}} | | {{familytree/end}} |