Sandbox/AL

❑ Immediately order a 12-lead ECG

Does the ECG has ST elevation?

YES

NO

STEMI ❑ Pain described as a heaviness or crushing sensation ❑ Radiates to the left arm, neck and/or jaw ❑ Not alleviated by rest or medications ❑ PR depression is absent

New LBBB ❑ ECG evidence of LBBB ❑ QRS ≥ 120 ms ❑ QS or rS in V1 ❑ Monophasic R in I, aVL and V6 ❑ Chest pain with same characteristics as STEMI

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 Suspect cardiac tamponade when the following finding are present: ❑ Hypotension ❑ JVD ❑ Muffled heart sounds

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

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 intercostal space ❑ Asymmetric blood pressure in the upper extremities ❑ Widened mediastinum on chest X-ray ❑ History of: ❑ Hypertension ❑ Marfan syndrome

Pulmonary embolism ❑ Sudden onset of chest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer

Esophageal rupture ❑ Vomiting ❑ Lower chest pain ❑ Cervical subcutaneous emphysema ❑ Overindulgence in alcohol or food ❑ chest X-ray ❑ pleural effusion ❑ pneumothorax ❑ air in the mediastinum or peritoneum

Key points for management 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

Key points for management ❑ For unstable patients, transfer to ICU ❑ In patients with cardiac tamponade perform pericardiocentesis Click here for the detailed management

Key points for management 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

Key points for management ❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax Click here for the detailed management

Key points for management ❑ Immediately order a TEE to confirm diagnosis ❑ Transfer to a cardio-thoracic unit for surgical management Click here for the detailed management

Key points for management ❑ If the patient is stable, order a CT pulmonary angiography to confirm diagnosis Click here for the detailed management

Key points for management ❑ Immediately start antibiotic therapy to prevent mediastinitis and sepsis ❑ Surgical repair of the perforation Click here for the detailed management

If none of the above conditions is found, proceed to the complete diagnostic approach below