First Impression: 

-- Mental Status, acute distress, general appearance

-- Tachypnea increased WOB (flaring, retraction, tripod) - protecting airway?

-- Current oxygenation, what are they currently hooked up to, are they getting better? Do you need to intubate?

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Initial Stabilization:‍

-- If non-responsive (GCS<8), check pulse (ACLS if none), intubate

-- Unstable (hypotension, AMS, chest pain, SOB/edema, new acute HF) - get pads and cardiovert ***; if you need to sedate for shcoks, push 50mcg fentanyl and 1-2mg midazolam

-- If in respiratroy distress or hypoxic - NRB 100% --> HFNC --> NIPPV if COPD (BIPAP), or CHF (CPAP) --> intubate; PaO2 <60 despite NRB, get on HFNC; PaCO2 >45, put on BIPAP; pH <7.25, will likely tire out trying to blow off CO2

-- Hypotension with c/f Infection - give LR, send basic and infectious workup, start antibiotics, pressor if needed

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Intake and Summary:‍

-- Reason in the hospital

-- Relevant comorbidities - MI/CAD, Heart Failure, prolonged QTc

-- Day Events

-- Recent meds - QT-prolonging meds

-- Current Access

-- Code Status and Decision-makers

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Exam and Workup

‍-- Vitals - Hemodynamic, O2, RR

-- Red Flags for early intubation - pooling secretions, hemoptysis, respiratory distress

-- Cardiopulm Exam: crackles, murmurs, perfusion, cold/warm

-- First Pass Workup: EKG, BMP, Mg, lactate, troponin if c/f ischemia, NT-proBNP

Management:

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Narrow and Regular

-- DDx: sinus tachycardia, atrial flutter, atrial tachycardia, AVNRT/AVRT

-- DDx for Sinus Tachycardia - pain, anxiety, hypovolemia, fever/infection, heart failure, ACS, PE, hypoxia, EtOH withdrawal, hyperthyroid, caffeine, other meds

-- Vagal maneuvers - steady pressure to carotid sinus (below angle of mandible at level of thyroid cartilage), blow into syringe for 10-15 seconds, passive leg raise to 45 degrees for 15 seconds

-- Meds - adenosine 6/6/12mg push (3/3/6mg is central line) --> metoprolol 5mg IV or amiodarone 150mg IV bolus followed by drip

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Narrow and Irregular

-- DDx: Afib with RVR, multifocal atrial tachycardia, Aflutter with variable block, sinus tachycardia with frequent PVCs

-- Meds - IV metoprolol 5mg --> amiodarone 150mg IV followed by drip (1mg/min for 6 hours followed by 0.5mg/min for 18 hours followed by PO)

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Wide and Regular

-- DDx: monomorphic VTach, SVT with aberrancy, preexcitation (WPW)

-- Meds - amiodarone (good for VT or SVT) 150mg IV bolus followd by drip as above OR lidocaine 1-1.5mg/kg IV bolus (100mg common dose, max 3mg/kg of boluses) followed by drip 1-4mg/min

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Wide and Irregular

-- DDx: polymorphic VTach, Torsades, Afib with aberrancy

-- Meds: magnesium 2-4mg over 15 minutes, lidocaine as above (ok for torsades and other PMVT), amiodarone if lower c/f torsades; increase HR with isoproterenol; overdrive pacing; if c/f WPW - procainamide

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