Sandbox/AL
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 ❑ Severe shortness of breath ❑ ❑ Related to physical exertion | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Identify cardinal risk factors 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 if SatO2 ≤95% ❑ Secure wide bore IV access ❑ Monitor vitals continuously > ❑ Immediately order a 12-lead ECG ❑ Order cardiac enzymes: Troponin, CK-MB | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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 New 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 | 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 ICS ❑ Widened mediastinum on chest X-ray ❑ History of: | Pulmonary embolism ❑ Suddenchest pain ❑ Severe dyspnea ❑ History of DVT, surgery, malignancy, immobility ❑ Elevated D-dimer | 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 | ❑ Immediately transfer the patient to ICU ❑ Perform pericardial fluid drainage Click here for the detailed 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 | ❑ 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 | ❑ Immediately order a TEE to confirm diagnosis ❑ Transfer to a cardio-thoracic unit for surgical management Click here for the detailed management | Click here for the detailed management | ❑ Immediately start antibiotic therapy to prevent mediastinitis and sepsis ❑ Surgical repair of the perforation Click here for the detailed management | |||||||||||||||||||||||||||||||||||||||||||||||
Stable angina
❑ Pain usually lasts < 10 min
❑ Improved by rest or nitroglycerin
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
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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 stenosis
❑ 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 ❑ Pain described as a heaviness or crushing sensation ❑ Normal value of cardiac enzymes ❑ Pain usually lasts < 10 min ❑ Provoked by exertion or stress ❑ Improves with 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 ❑ Shallow breathing ❑ Look for underlying cause | 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: |