Sandbox/AL: Difference between revisions
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{{familytree | | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''Is the ST elevation specific to an anatomic area'''<br> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) <br></div> | C02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Does the [[TTE]] shows valve or aortic abnormalities?''' </div> }} | {{familytree | | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 14em; padding:1em;">'''Is the ST elevation specific to an anatomic area'''<br> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) <br></div> | C02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Does the [[TTE]] shows valve or aortic abnormalities?''' </div> }} | ||
{{familytree | |,|-|^|-|.| | | | | |,|-|^|-|.| | |}} | {{familytree | |,|-|^|-|.| | | | | |,|-|^|-|.| | |}} | ||
{{familytree | D01 | | D02 | | | | D03 | | D04 | | |D01=<div style="float: left; text-align: center; width: | {{familytree | D01 | | D02 | | | | D03 | | D04 | | |D01=<div style="float: left; text-align: center; width: 16em; padding:1em;">'''YES''' </div> | D02= <div style="float: left; text-align: center; width: 16em; padding:1em;">'''NO''' </div>| D03=<div style="float: left; text-align: center; width: 16em; padding:1em;">'''YES''' </div> | D04= <div style="float: left; text-align: center; width: 16em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | |!| | | |!| | | | | |!| | | |!|| |}} | {{familytree | |!| | | |!| | | | | |!| | | |!|| |}} | ||
{{familytree | E01 | | E02 | | | | E03 | | E04 | |E01=<div style="float: left; text-align: left; width: | {{familytree | E01 | | E02 | | | | E03 | | E04 | |E01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br> | ||
'''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ CK-MB and Troponin elevation <br> ❑ PR depression is absent <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> | '''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ CK-MB and Troponin elevation <br> ❑ PR depression is absent <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> | ||
'''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | '''[[LBBB]]''' <br> ❑ EKG evidence of LBBB | ||
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: ❑ QS or rS in V1 | : ❑ QS or rS in V1 | ||
: ❑ Monophasic R in I, aVL and V6 | : ❑ Monophasic R in I, aVL and V6 | ||
❑ Chest pain with same characteristic as STEMI <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> </div> | E02= <div style="float: left; text-align: left; width: | ❑ Chest pain with same characteristic as STEMI <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br> </div> | E02= <div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br> '''[[Pericarditis]]''' <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression is present <br> ❑ PR elevation in lead aVR is present <br> ❑ <br> ❑ <br> [[Pericarditis resident survival guide|Click here for detailed management]]<br><br> </div>| E03=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br> | ||
'''[[Aortic stenosis]]''' <br> ❑ Systolic ejection [[murmur]] with ejection click | '''[[Aortic stenosis]]''' <br> ❑ Systolic ejection [[murmur]] with ejection click | ||
: ❑ Best heard at the upper right sternal border | : ❑ Best heard at the upper right sternal border | ||
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: ❑ Intimal tear | : ❑ Intimal tear | ||
: ❑ [[Aortic regurgitation]] | : ❑ [[Aortic regurgitation]] | ||
❑ History of: | |||
: ❑ [[Hypertension]] | : ❑ [[Hypertension]] | ||
: ❑ [[Marfan syndrome]] | : ❑ [[Marfan syndrome]] | ||
[[Aortic dissection resident survival guide|Click here for detailed management]]<br><br></div> |E04=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br>'''[[Unstable angina]]/[[NSTEMI]]'''<br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ Not alleviated by rest or medications <br> ❑ Elevated [[cardiac enzymes]] <br> ❑ Pain last > 10 min <br> ❑ <br> [[NSTEMI angina resident survival guide|Click here for detailed management]]<br><br> | |||
'''[[Stable angina]]''' <br> ❑ Normal [[cardiac enzymes]] <br> ❑ Pain usually lasts < 10 min <br> ❑ Improved by rest or [[nitroglycerin]] <br> [[Chronic stable angina treatment|Click here for detailed management]]<br><br></div>}} | '''[[Stable angina]]''' <br> ❑ Normal [[cardiac enzymes]] <br> ❑ Pain usually lasts < 10 min <br> ❑ Improved by rest or [[nitroglycerin]] <br> [[Chronic stable angina treatment|Click here for detailed management]]<br><br></div>}} | ||
Revision as of 19:07, 29 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 ❑ 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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: ❑ Substernal chest discomfort that starts with a low intensity and slowly increases | 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 ❑ Onset (sudden or gradual) | |||||||||||||||||||||||||||||||||
Characterize the symptoms Non-specific symptoms
❑ Dyspnea
❑ Not related to exercise | |||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Previous episodes of chest pain
❑ Recent medical procedures
❑ Pulmonary disease ❑ Neurological diseases
| |||||||||||||||||||||||||||||||||
Identify possible triggers or risk factors: ❑ ❑ | |||||||||||||||||||||||||||||||||
Examine the patient:
Vitals ❑ Blood pressure
❑ Tachypnea (non-specific) Neck Cardiovascular examination Abdominal examination Neurological examination | |||||||||||||||||||||||||||||||||
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
Click here for detailed management | Consider the following: 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
❑ TTE findings of AS
❑ History of: Click here for detailed management | Consider the following: 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 ❑ Acute shortness of breath ❑ Wheezing ❑ History of asthma Click here for detailed management | Consider the following:
❑ ❑ ❑ Click here for detailed management | Consider the following: Pancreatitis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Nausea and vomiting ❑ Click here for detailed management | Consider the following: GERD
❑ Alleviated by antacids ❑ ❑ ❑ 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: