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

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) ❑ PR depression is absent

❑ 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) ❑ PR Depression is present ❑ PR elevation in lead aVR is present

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 ❑ 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: ❑ 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: ❑ Substernal chest discomfort that starts with a low intensity and slowly increases ❑ Usually last < 10 min ❑ It is relieved by rest or nitrates ❑ Related to exertion or emotional stress

Look for supportive signs and symptoms: ❑ Back pain ❑ 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: ❑ Shortness of breath ❑ Chest pain ❑ Dyspnea ❑ Anxiety ❑ Pleuritic chest pain

Look for supportive signs and symptoms: ❑ Sudden shortness of breath ❑ Cyanosis ❑ Penetrating chest wound ❑ Flopping sound ❑ Following a medical procedure ❑ Patient on mechanical ventilation

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

{{{ }}}

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

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 (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 PE) ❑ Chills (suggestive of pneumonia) ❑ Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ Associated with meals ❑ Relieved by antacids ❑ ❑ ❑ ❑

Inquire about past medical history: ❑ Previous episodes of chest pain ❑ Cardiovascular disease ❑ Previous MI ❑ DVT ❑ Hypertension ❑ Recent medical procedures ❑ ❑ ❑ Pulmonary disease ❑ Previous PE ❑ ❑ Neurological diseases ❑ Malignancy ❑ Recent trauma ❑ Alcohol intake ❑ Recent surgery (<3 months)

Identify possible triggers or risk factors: ❑ ❑

Examine the patient: Vitals ❑ Temperature: Fever (suggestive ofpericarditis, pleuritis or infection) ❑ Heart rate ❑ Asymmetric blood pressure in extremities (suggestive of aortic dissection) ❑ Tachypnea (non-specific) Neck ❑ Elevated jugular venous pulse Cardiovascular examination Auscultation ❑ Third and fourth heart sound ❑ Carotid bruit ❑ Pericardial rub (pericarditis) ❑ Murmur (systolic murmur in hypertrophic cardiomyopathy, aortic stenosis) Respiratory examination ❑ Palpation - shift in trachea from midline (tension pneumothorax) ❑ Auscultation - decreased breath sound (pulmonary edema), pleural rub (pleuritis, pneumonia) Abdominal examination ❑ Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain ❑ Rectal examination - occult bleeding (peptic ulcers) 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

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 ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ 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 Pericarditis ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management

Consider the following: Aortic stenosis ❑ ❑ ❑ Click here for detailed management Aortic dissection ❑ ❑ ❑ Click here for detailed management Unstable angina/NSTEMI ❑ ❑ ❑ Click here for detailed management Stable angina ❑ ❑ ❑ Click here for detailed management

Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management Spontaneous pneumothorax ❑ ❑ ❑ Click here for detailed management Tension pneumothorax ❑ ❑ ❑ Click here for detailed management Pulmonary hypertension ❑ ❑ ❑ Click here for detailed management Pneumonia ❑ ❑ ❑ Click here for detailed management Pleuritis ❑ ❑ ❑ Click here for detailed management

Consider the following: GERD ❑ Burning sensation from the epigastrium towards the throat ❑ ❑ Click here for detailed management Peptic ulcer ❑ ❑ ❑ Click here for detailed management Pancreatitis ❑ Epigastric pain radiating to the back ❑ ❑ Click here for detailed management Cholelithiasis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Click here for detailed management Esophageal spasm ❑ ❑ ❑ Click here for detailed management Mallory-Weiss ❑ ❑ ❑ Click here for detailed management

Consider the following: Musculoskeletal pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ Click here for detailed management Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ Click here for detailed management Psychiatric conditions ❑ ❑ ❑ Click here for detailed management

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 ❑ 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

Pericarditis ❑ Diffuse, non-specific ST elevation ❑ PR depression is present ❑ PR elevation in lead aVR is present ❑ ❑ Click here for detailed management

Consider the following: Aortic stenosis ❑ ❑ ❑ Click here for detailed management Aortic dissection ❑ ❑ ❑ Click here for detailed management

Unstable angina/NSTEMI ❑ Elevated cardiac enzymes ❑ ❑ Click here for detailed management Stable angina ❑ Normal cardiac enzymes ❑ ❑ 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

Consider the following: Pulmonary embolism ❑ ❑ ❑ Click here for detailed management Spontaneous pneumothorax ❑ ❑ ❑ Click here for detailed management Tension pneumothorax ❑ ❑ ❑ Click here for detailed management Pulmonary hypertension ❑ ❑ ❑ Click here for detailed management Pneumonia ❑ ❑ ❑ Click here for detailed management Pleuritis ❑ ❑ ❑ Click here for detailed management

Consider the following: GERD ❑ Burning sensation from the epigastrium towards the throat ❑ ❑ Click here for detailed management Peptic ulcer ❑ ❑ ❑ Click here for detailed management Pancreatitis ❑ Epigastric pain radiating to the back ❑ ❑ Click here for detailed management Cholelithiasis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Click here for detailed management Esophageal spasm ❑ ❑ ❑ Click here for detailed management Mallory-Weiss ❑ ❑ ❑ Click here for detailed management

Consider the following: Musculoskeletal pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ Click here for detailed management Herpes zoster ❑ Burning pain localized in a dermatome ❑ Unilateral vesicular rash ❑ Click here for detailed management Psychiatric conditions ❑ ❑ ❑ Click here for detailed management

Treatment

Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the

Abbreviations:

• 
  

References

Template:WikiDoc Sources