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First look and triggers
High risk states
Respiratory failure
SpO2 < 90% on room air
Rising PaCO2 with fatigue
Shock
SBP < 90 mmHg
MAP < 65 mmHg
Lactate >= 2.0 mmol/l
Ischemia
Ongoing chest pain
New ischemic ECG changes
Malignant arrhythmia
Sustained VT
AF with RVR and instability
Altered mental status
Suspected hypercapnia
Hypoperfusion
Resuscitation priorities
Airway and breathing
Positioning
Upright
Legs dependent if severe congestion
Oxygen strategy
SpO2 target 92% to 96%
COPD or chronic hypercapnia target 88% to 92%
Noninvasive ventilation
CPAP 5 to 10 cmH2O
BiPAP IPAP 10 to 15 cmH2O
BiPAP EPAP 5 to 8 cmH2O
If worsening mental status, prepare intubation
Intubation risk reduction
Preoxygenation with NIV
Avoid large induction doses in shock
Post intubation hypotension plan
Circulation and perfusion
Monitoring
Continuous ECG
Noninvasive BP q 3 to 5 min
Arterial line if vasoactive infusions
Foley for hourly urine output if severe
IV access
Two large bore IV
Central access if vasopressors expected
Fluid strategy
Avoid empiric fluid bolus in pulmonary edema
If suspected RV infarct and underfilled, small bolus 250 ml with reassessment
Immediate reversible causes
ACS
If STEMI, activate cath lab
If NSTEMI with shock, urgent cardiology
Hypertensive emergency
Rapid symptom relief with vasodilator if no contraindication
Arrhythmia driven decompensation
If unstable, synchronized cardioversion
If stable, rate control based on LV function
Mechanical complication
Acute severe MR
VSD
Tamponade
PE
If shock and high suspicion, PE pathway
Infection
Sepsis triggers with lactate and cultures
Hemodynamic phenotypes
Profile classification
Warm and wet
Congestion with preserved perfusion
Primary strategy IV diuresis
Cold and wet
Congestion with hypoperfusion
Primary strategy inotrope plus diuresis
Warm and dry
Alternative diagnosis likely
Discharge pathway if safe
Cold and dry
Underfilled or advanced pump failure
Small fluid challenge only if underfilled evidence
Early bedside targets
Symptom targets
Dyspnea improvement within 30 to 60 min
Work of breathing reduction with NIV
Decongestion targets
Urine output >= 100 to 150 ml per hour early response
Net negative 1 to 2 l per 24 hours if tolerated
Safety targets
MAP >= 65 mmHg
Creatinine trend stable or expected mild rise
Potassium 3.5 to 5.0 mmol/l
Consultation and pathways
Early specialist triggers
Cardiogenic shock or inotrope requirement
ICU admission
Advanced HF or critical care consult
Refractory hypoxemia on NIV
ICU admission
Airway team
Suspected ACS
Cardiology consult
Cath lab activation criteria
Suspected mechanical cause
Emergent echocardiography
Cardiothoracic surgery notification if indicated
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.