Sandbox/AL: Difference between revisions
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: ❑ [[Hypertension]] | : ❑ [[Hypertension]] | ||
: ❑ [[Marfan syndrome]]</div> | E06=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[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> ❑ Pain last > 10 min <br> | : ❑ [[Marfan syndrome]]</div> | E06=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[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> ❑ Pain last > 10 min <br> | ||
'''[[Stable angina]]''' <br> ❑ Pain usually lasts < 10 min <br> ❑ Improved by rest or [[nitroglycerin]] </div> |E07=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Esophageal rupture]]''' <br> ❑ </div>}} | '''[[Stable angina]]''' <br> ❑ Pain usually lasts < 10 min <br> ❑ Improved by rest or [[nitroglycerin]] </div> |E07=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''[[Esophageal rupture]]''' <br> | ||
❑ Vomiting <br> ❑ Lower chest pain <br> ❑ Cervical subcutaneous emphysema <br> ❑ Overindulgence in alcohol <br> ❑ Overindulgence in food <br> ❑ [[CXR]]: Air in the mediastium or peritoneum </div>}} | |||
{{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | |}} | {{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E01= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]''' <br>[[STEMI resident survival guide|Click here for the detailed management]]</div>| E02=[[Pericarditis resident survival guide|Click here for the detailed management]] |E03= [[Pulmonary embolism resident survival guide|Click here for the detailed management]] | {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E01= <div style="float: left; text-align: left; width: 14em; padding:1em;"> '''Administer:'''<br> ❑ [[Aspirin|<span style="color:white;">Aspirin</span>]] 162-325 mg <br> ❑ [[Oxygen therapy|<span style="color:white;">Oxygen </span>]](2-4 L/min) if satO2 <90% <br> ❑ [[Beta blockers|<span style="color:white;">Beta blockers</span>]] (unless contraindicated) <br> ❑ Sublingual [[nitroglycerin|<span style="color:white;">nitroglycerin</span>]] 0.4 mg every 5 min for a total of 3 doses <br> '''Do not delay [[primary angioplasty|<span style="color:white;">primary angioplasty</span>]] or [[fibrinolysis|<span style="color:white;">fibrinolysis</span>]]''' <br>[[STEMI resident survival guide|Click here for the detailed management]]</div>| E02=[[Pericarditis resident survival guide|Click here for the detailed management]] |E03= [[Pulmonary embolism resident survival guide|Click here for the detailed management]] |
Revision as of 19:13, 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) | Consider additional tests to rule out life-threatening conditions ❑ ABG ❑ Chest X-ray ❑ D-dimer | ||||||||||||||||||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
STEMI LBBB
| 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 | Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer | Pneumothorax ❑ Dyspnea ❑ Hypoxia ❑ Tracheal deviation towards the unaffected side ❑ Hyperresonance on the affected side | Aortic dissection ❑ Acute onset of heart failure ❑ Low pitched early diastolic murmur best heard at the 2nd right ICS ❑ Widened mediastinum on chest X-ray ❑ History of: | 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 ❑ Pain last > 10 min Stable angina ❑ Pain usually lasts < 10 min ❑ Improved by rest or nitroglycerin | Esophageal rupture ❑ Vomiting ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol ❑ Overindulgence in food ❑ CXR: Air in the mediastium or peritoneum | |||||||||||||||||||||||||||||||||||||||||||||||
Administer: ❑ Aspirin 162-325 mg ❑ Oxygen (2-4 L/min) if satO2 <90% ❑ Beta blockers (unless contraindicated) ❑ Sublingual nitroglycerin 0.4 mg every 5 min for a total of 3 doses Do not delay primary angioplasty or fibrinolysis Click here for the detailed management | Click here for the detailed management | 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
| 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 | ||||||||||||||||||||||||||||||||||||
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 | Consider the following:
❑ Sharp pain associated with inspiration and expiration | Consider the following: Pancreatitis ❑ RUQ pain associated with meals ❑ Positive Murphy sign ❑ Nausea and vomiting | Consider the following: GERD
❑ Alleviated by antacids ❑ Epigastric ± back pain ❑ History of vomiting ❑ Hematemesis | Consider the following: Musculoskeletal pain ❑ Anxiety ❑ Hypochondriasis ❑ Panic attack | |||||||||||||||||||||||||||||||||||
Treatment
The management of chest pain will depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of chest pain. Abbreviations:
CARDIAC | PULMONARY | GASTROINTESTINAL | OTHER |
---|---|---|---|
❑ STEMI/LBBB ❑ NSTEMI/Unstable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis |
❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pneumonia ❑ Pleuritis |
❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome |
❑ Musculoskeletal pain: |