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

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Angina

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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 (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

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 ❑ Systolic ejection murmur with ejection click ❑ Best heard at the upper right sternal border ❑ Bilateral radiation to the carotid arteries ❑ TTE findings of AS ❑ Click here for detailed management Aortic dissection ❑ Acute onset of heart failure ❑ Widened mediastinum on chest X-ray ❑ TTE findings of: ❑ Intimal tear ❑ Aortic regurgitation ❑ Click here for detailed management

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 Click here for detailed management Pneumothorax ❑ ❑ ❑ 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 ❑ ❑ ❑ Click here for detailed management Pleuritis ❑ ❑ ❑ 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 ❑ ❑ 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 ❑ ❑ ❑ Click here for detailed management

Consider the following: Musculoskeletal pain ❑ Pain on palpation of costochondral joints ❑ Exacerbated by chest wall movements ❑ 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:

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References

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