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 ❑

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 ❑ Secure wide bore IV access ❑ Perform ECG monitor ❑ Monitor vitals continuously ❑ Immediately order an 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: ❑ ❑ ❑ ❑

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: Non-specific symptoms ❑ Altered mental status ❑ Shortness of breath ❑ Nausea and vomiting ❑ Dizziness Symptoms suggestive of cardiac etiology ❑ Heaviness or crushing sensation (suggestive of myocardial isquemia) ❑ 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 ❑ ❑ ❑ ❑ ❑ ❑ Symptoms suggestive of gastrointestinal etiology ❑ Burning sensation (suggestive of GERD) ❑ Colicky (suggestive of cholelithiasis) ❑ Epigastric pain ❑ ❑ ❑ ❑ ❑ ❑

Inquire about past medical history: ❑ Previous episodes ❑ Cardiovascular disease ❑ ❑ ❑ Recent medical procedures ❑ ❑ ❑ Pulmonary disease ❑ ❑ ❑ Neurological diseases ❑ Recent trauma ❑ Alcohol intake

Identify possible triggers: ❑ ❑

Examine the patient: Vitals ❑ Temperature (pericarditis, pleuritis, fever can precipitate ischemic attacks) ❑ Absent or decreased pulses in limbs (aortic dissection all four limbs), tachycardia (pulmonary embolism) ❑ Blood pressure in both the arms (aortic dissection) 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) ❑ Electrolytes ❑ Glucose (rule out hypoglycemia) ❑ ABG

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 ❑ ❑ ❑ Click here for detailed management LBBB ❑ ❑ ❑ Click here for detailed management Pericarditis ❑ ❑ ❑ 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 Pleuritis ❑ ❑ ❑ Click here for detailed management

Consider the following: GERD ❑ ❑ ❑ Click here for detailed management Peptic ulcer ❑ ❑ ❑ Click here for detailed management Esophageal spasm ❑ ❑ ❑ Click here for detailed management Cholelithiasis ❑ ❑ ❑ Click here for detailed management

Consider the following: Musculoskeletal pain ❑ ❑ ❑ 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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