Sandbox/AL: Difference between revisions
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{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Characterize the chest pain:'''<br> | {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Characterize the chest pain:'''<br> | ||
''' | '''Non-specific symptoms'''<br> | ||
❑ Altered mental status<br> | ❑ Altered mental status<br> | ||
❑ Shortness of breath <br> | ❑ Shortness of breath <br> | ||
❑ Nausea and vomiting <br> | ❑ Nausea and vomiting <br> | ||
❑ Dizziness <br> | ❑ Dizziness <br> | ||
<br> | |||
'''Symptoms suggestive of cardiac etiology'''<br> | |||
❑ Heaviness or crushing sensation (suggestive of [[myocardial isquemia]]) <br> | |||
❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) <br> | |||
❑ Interscapular (suggestive of [[aortic dissection]] <br> | |||
❑ Epigastric pain (suggestive of inferior MI) | |||
❑ Sweating <br> | |||
❑ Palpitations <br> | ❑ Palpitations <br> | ||
❑ Pain with exertion <br><br> | |||
'''Symptoms suggestive of pulmonary etiology'''<br> | '''Symptoms suggestive of pulmonary etiology'''<br> | ||
❑ [[Pleuritic pain]] | |||
: ❑ Sharp or knife-like | |||
: ❑ Increases with [[respiratory movements]] | |||
❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> | ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> | ||
'''Symptoms suggestive of gastrointestinal etiology'''<br> | '''Symptoms suggestive of gastrointestinal etiology'''<br> | ||
❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br></div>}} | ❑ Burning sensation (suggestive of GERD) <br> ❑ Colicky (suggestive of [[cholelithiasis]]) <br> ❑ Epigastric pain <br>❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br></div>}} | ||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Inquire about past medical history:'''<br> | {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Inquire about past medical history:'''<br> | ||
❑ Previous episodes<br> | ❑ Previous episodes<br> | ||
❑ Cardiovascular disease | ❑ Cardiovascular disease | ||
❑ Recent medical procedures | : ❑ <br> | ||
❑ Neurological diseases | : ❑ <br> | ||
❑ Recent [[trauma]] | ❑ Recent medical procedures <br> | ||
: ❑ <br> | |||
: ❑ <br> | |||
❑ Pulmonary disease<br> | |||
: ❑ <br> | |||
: ❑ <br> | |||
❑ Neurological diseases<br> | |||
❑ Recent [[trauma]]<br> | |||
❑ Alcohol intake </div> }} | ❑ Alcohol intake </div> }} | ||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Identify possible triggers:''' <br> | {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Identify possible triggers:''' <br> | ||
❑ <br> ❑ <br> </div>}} | |||
</div>}} | |||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' | {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' | ||
'''Vitals'''<br> | '''Vitals'''<br> | ||
❑ [[ | ❑ Temperature ([[pericarditis]], [[pleuritis]], [[fever]] can precipitate ischemic attacks)<br> | ||
❑ Absent or decreased pulses in limbs ([[aortic dissection]] all four limbs), [[tachycardia]] ([[pulmonary embolism]])<br> | |||
❑ [[Blood pressure]]<br> | ❑ Blood pressure in both the arms ([[aortic dissection]])<br> | ||
'''Neck'''<br> | |||
❑ Elevated [[jugular venous pulse]]<br> | |||
❑ [[Respiratory | '''Cardiovascular examination'''<br> | ||
''' Auscultation'''<br> | |||
❑ Third and fourth heart sound<br> | |||
❑ [[Carotid bruit]] <br> | |||
❑ [[Pericardial rub]] ([[pericarditis]])<br> | |||
❑ Murmur (systolic murmur in [[hypertrophic cardiomyopathy]], [[aortic stenosis]]) | |||
<br> | |||
'''Respiratory examination'''<br> | |||
❑ [[Palpation]] - shift in trachea from midline ([[tension pneumothorax]])<br> | |||
❑ [[Auscultation]] - decreased breath sound ([[pulmonary edema]]), pleural rub ([[pleuritis]], [[pneumonia]])<br> | |||
'''Abdominal examination'''<br> | |||
❑ Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain<br> | |||
❑ [[Rectal examination]] - occult bleeding ([[peptic ulcers]])<br> | |||
''' | '''Neurological examination'''<br> | ||
❑ [[Cerebrovascular accident]]s ([[aortic dissection]])<br> | |||
❑ [[ | ❑ [[Paraplegia]]</div> }} | ||
{{familytree | | | | | | | |!| | | }} | {{familytree | | | | | | | |!| | | }} | ||
{{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' <br> ❑ [[Electrolytes]] <br> ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]] | {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' <br> ❑ [[Electrolytes]] <br> ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]] |
Revision as of 15:52, 25 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 ❑ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ Secure wide bore IV access ❑ Perform ECG monitor ❑ Monitor vitals continuously ❑ Immediately order an 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: ❑ | 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: Non-specific symptoms
❑ ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ ❑ ❑ ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes
❑ Recent medical procedures
❑ Pulmonary disease
❑ Neurological diseases | |||||||||||||||||||||||||||||||||||||||||
Identify possible triggers: ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
Examine the patient:
Vitals Cardiovascular examination Abdominal examination Neurological examination | |||||||||||||||||||||||||||||||||||||||||
Order labs and tests: ❑ EKG (most important initial test) ❑ Electrolytes ❑ Glucose (rule out hypoglycemia) ❑ ABG | |||||||||||||||||||||||||||||||||||||||||
Does the chest pain has any of the following findings suggestive of cardiac etiology? ❑ ❑ ❑ | |||||||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||||||
Does the EKG has ST elevation? | Determine the non-cardiac etiology based on the physical examination and tests findings | ||||||||||||||||||||||||||||||||||||||||
YES | NO | Pulmonary | Gastrointestinal | Other | |||||||||||||||||||||||||||||||||||||
Consider the following: STEMI ❑ ❑ ❑ Click here for detailed management | Consider the following: Aortic stenosis ❑ ❑ ❑ Click here for detailed management | Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management | Consider the following: GERD ❑ ❑ ❑ 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: