First Impression
-- Mental Status, acute distress
-- Tachypnea increased WOB (flaring, retraction, tripod, cyanosis) - protecting airway? 
-- Current oxygenation, what are they currently hooked up to, are they getting better? Do you need to intubate? Risk of coding? 

Initial Stabilization
-- If non-responsive (GCS<8), check pulse, intubate
‍-- If hypoxic - NRB at Fio2 100% --> HFNC (PaO2 <60 despite NRB, get on HFNC) --> NIPPV if COPD (BIPAP), or CHF (CPAP) --> intubate
-- If hypercarbic - PaCO2 >45, put on BIPAP
-- If acidosis pH <7.25, will likely tire out trying to blow off CO2
-- If trach or intubated - airway rapid if dislodged, suction to remove plugs
-- If Hemoptysis - if minimal (<30mL) observe; if massive, life-threatening, suction and lie patient down on side of suspected bleed, if not protecting airway, intubate immediately, transfuse, stabilize, correct coagulopathy, call iPulm if unstable to temporize with balloon, electrocautery, call IR if stable for embolization, consider CTA to localize; you don’t die from exsanguination if its a pulm source, you die from asphyxiation (varices is different)

Intake and Summary
-- Acute complaint, baseline, and acuity of change
-- Reason in the hospital
-- Relevant comorbidities
-- Day events and changes (procedures, new meds, aspiration)
-- Current Access
-- Code Status (intubations) and Decision-makers

Exam
‍-- Vitals - Hemodynamic, O2, RR
-- Wheezing, crackles, absent air sounds, signs of overload (JVP, edema)
-- POCUS - b-lines (edema), lung-sliding (PTX), RV strain (PE, pHTN), plump IVC (overload)
-- Red Flags for early intubation - AMS, pooling secretions, hemoptysis, respiratory distress

Workup
-- ABG/VBG - PaO2 <60 despite NRB - get in HFNC and to ICU; PaCO2 >45, put on BIPAP and to ICU; pH <7.25 consider intubation
-- STAT CXR - infilatrate (PNA, aspiration), edema (CHF, flash), lobar collapse and atelectasis (plugging), PTX
-- "Rainbow Labs" - CBC, CMP, lactate; consider troponin and NT-proBNP
-- EKG if chest pain or no other revealing etiology
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‍‍
Differential
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Hypoxia
PaO2 <60, caused poor oxygenation
-- Pneumonia or Aspiration - get antibiotics started
-- Pulmonary Edema from CHF or flash - CPAP, diuresis
-- Plugging, obstruction, lobar collapse - chest physiotherapy, mucolytics, consider iPulm for bronch
-- PTX - needle decompression if unstable; STAT page to thoracic surgery for chest tube placement
-- Pleural Effusion - diuresis, thoracentesis when stabilized
-- PE - will need to confirm with STAT CTPE, consider starting lovenox if no contraindications and high suspicion; can do POCUS to check for RV strain
-- Pulmonary Hypertension - if known patient, call pHTN team, gentle fluid, echo

Hypercarbia
‍PaCo2 >60, caused by poor ventilation
-- COPD/Asthma - BIPAP, nebs, steroids, abx
-- Opioids - narcan q2minutes based on response
-- AMS/Stroke - call stroke alert, head CT
-- Acidosis (sepsis, DKA, etc.) and Resp Muscle Fatigue - consider bicarb and intubation, treat presumed etiology
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Other
-- MI/ACS - load ASA 325mg, atorva 80mg, SL nitrate, heparin drip, BB if not in shock
-- Anaphylaxis - epi 1:1000 IM q5-15 minutes PRN; IV benadryl, albuterol, methylpred
-- Panic Attack/Psych - benzos PRN
-- Hemoptysis - if minimal (<30mL) observe; if massive, life-threatening, suction and lie patient down on side of suspected bleed, if not protecting airway, intubate immediately, transfuse, stabilize, correct coagulopathy, call iPulm if unstable to temporize with balloon, electrocautery, call IR if stable for embolization, consider CTA to localize; you don’t die from exsanguination if pulm source, you die from asphyxiation (varices is different)