Sandbox/AL: Difference between revisions
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{{familytree | {{familytree | | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 15em"> '''Identify cardinal findings that increase the pretest probability of life-threatening chest pain'''</div> <br> <div style="text-align: left; width: 15em"> ❑ Sudden onset <br> ❑ <br> ❑ <br> ❑ Related physical exertion <br> </div>}} | ||
{{familytree | {{familytree | | | | | | | | | | |!| | | | | | | | | | }} | ||
{{familytree | {{familytree | | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br> | ||
❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}} | ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}} | ||
{{familytree | {{familytree | | | | | | | | |,|-|^|-|-|-|. | | |}} | ||
{{familytree | {{familytree | | | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}} | ||
{{familytree | {{familytree | | | | | | | | |!| | | | | |!| | | | }} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen if SatO2 ≤95% <br> ❑ Secure wide bore IV access <br> ❑ Monitor vitals continuously <br> ❑ Immediately order a 12-lead [[ECG|<span style="color:white;">ECG</span>]]</div>}} | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen if SatO2 ≤95% <br> ❑ Secure wide bore IV access <br> ❑ Monitor vitals continuously <br> ❑ Immediately order a 12-lead [[ECG|<span style="color:white;">ECG</span>]]</div>}} | ||
{{familytree | {{familytree | | | | | | | | |!| | | | | C02 | | | | | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}} | ||
{{familytree | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | | | A01 | | | | | | A01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the [[ECG|<span style="color:white;">ECG</span>]] has [[ST elevation|<span style="color:white;">ST elevation</span>]]?''' </div>}} | ||
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}} | |||
{{familytree | {{familytree | | | B01 | | | | | | | | B02 | | | | B01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | B02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}} | ||
{{familytree | {{familytree | | | |!| | | | | | | | | |!| | | | | |}} | ||
{{familytree | {{familytree | | | C01 | | | | | | | | C02 | | | | |C01=<div style="float: left; text-align: center; width: 16em; padding:1em;">'''Is the ST elevation specific to an anatomic area?'''</div><div style="text-align: left"> ❑ V1-V2 (Septal) <br> ❑ V3-V4 (Anterior) <br> ❑ V5-V6 (Apical) <br> ❑ I, aVL (Lateral) <br> ❑ II, III, aVF (Inferior) </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: 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 | 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><br> | ||
| | '''[[LBBB]]''' <br> ❑ 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 <br> <br> </div> | E02= <div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br> '''[[Pericarditis]]''' <br> ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression <br> ❑ PR elevation in lead aVR <br> ❑ <br> ❑ <br> <br> </div>| E03=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Consider the following:'''<br> | |||
{{familytree | | '''[[Aortic stenosis]]''' <br> ❑ Systolic ejection [[murmur]] with ejection click | ||
: ❑ Best heard at the upper right sternal border | |||
: ❑ Bilateral radiation to the [[carotid arteries]] | |||
❑ [[aortic stenosis echocardiography|TTE findings of AS]] <br> ❑ Exertional [[dyspnea]]<br> ❑ [[Syncope]] <br><br> | |||
❑ | '''[[Aortic dissection]]''' <br> ❑ Acute onset of [[heart failure]] <br> ❑ Low pitched early diastolic murmur best heard at the 2nd right [[ICS]] <br> ❑ [[Widened mediastinum]] on [[chest X-ray]] <br> ❑ [[TTE]] findings of: | ||
❑ | : ❑ Intimal tear | ||
: ❑ [[Aortic regurgitation]] | |||
❑ History of: | |||
: ❑ [[Hypertension]] | |||
: ❑ [[Marfan syndrome]] | |||
<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><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>}} | ||
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{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }} | ||
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Angina]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E07= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E08= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}} | {{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Angina]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E07= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E08= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}} |
Revision as of 14:00, 30 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Does the ECG 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
| Consider the following: Pericarditis ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR ❑ ❑ | Consider the following: Aortic stenosis
❑ TTE findings of AS
❑ History of: | 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 ❑ Stable angina ❑ Normal cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Improved by rest or nitroglycerin Click here for detailed management | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ Sharp and pleuritic pain that is improved by sitting up and leaning forward ❑ Diffuse, non-specific ST elevation ❑ PR depression ❑ PR elevation in lead aVR ❑ ❑ 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:
❑ Sharp pain associated with inspiration and expiration ❑ ❑ 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 ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis Click here for detailed management | Consider the following: Musculoskeletal pain ❑ Depresion ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack Click here for detailed management | |||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
Abbreviations: