(Hgb/Hct, pulse, CVP, U/O, WBC, ECG, CXR, 2D Cardiac ECHO, ABG, PE [^ JVD - CHF, cardiac tamponade, tension pneumothorax]) -Initiate ABC's (airway control, bilateral breath sounds, 02, good IV access, continuous ECG monitoring)

1. Hypovalemia ( low CVP, (dec)Hgb/Hct, (dec)CO/CI, U/O < 30 cc/hr, pre-renal, meta. acidosis)
   a. post-op - anesthesia, spinal, inadequate fluids, b. Bleeding - trauma (chest, abdomen, retroperitoneum, pelvic fx, femur fx), post-op, GI, ectopic pregnancy, ruptured ovarian cyst, thoracic/AAA; c. Third Spacing - peritonitis, pancreatitis, bowel obstruction, prolonged surgery
   Dehydration vomiting, diarrhea, polyuria, sweating, excess NG or other body tube drainage
   Rx - Trendelenburg, Fluid Challenges IVSS over 15-30 min. (NS 250-500-1000 cc +/- SPA 25 gms, Ringers Lactate, PRBC's, and blood products prn) - titrate volume status to CVP-10 mmHg (may not be useful), PCWP 10-18 mmHg, U/O > 0.5-1.0 ml/kg/hr for adult. Have 2 large bore IV sites available.
   
2. Cardiogenic ( ECG and PE [S3/S4, ?JVD, new rub or murmur, PMI...])
   a. Arrythmias - (DDx - AFib, AFlutter, SVT, VT, bradycardia); correct with meds, cardioversion, ?PM
   b. MI - acute ECG changes (T wave inversion [not Ill], ST segment elevation/ depression - > 1 mm in 2 or more contiguous leads, significant Q waves [not Ill], ? new BBB); Labs - CPK-MB, Myoglobin, Troponin, Lipid Profile; Rx - 02, ASA, Dobutamine, Dopamine, and/or Levophed; ?IV Nitroglycerin, IV Heparin, ?Thrombolytics, ?Intra-aortic balloon pump (IABP), ?PTCA, ?CABG; Complications S/P MI leading to hypotension - AFib, VTach, bradycardia, septal rupture, papillary muscle rupture (mitral regurgitation), cardiac tamponade
   c. Tension PTX - dyspnea, ipsilateral hyperresonance, contralateral tracheal shift; Rx- #14-16 gauge needle into 2nd midclavicular intercostal space, then insert chest tube; consider tension HTX with trauma; Don't wait for the CXR
   d. Cardiac Tamponade - elevated CVP, pulsus paradoxus > 10 mmHg, muffled heart sounds, distended neck veins; + 2D ECHO; Rx -pericardiocentesis, ?OR
   e. Massive PE: see SOB section
   f. Others - Unstable Angina (?Rx - ASA, Heparin, pressors, IAPB, Angiography [post cath complications - groin bleeding- dissection- fistula- pseudoaneurysm, distal emboli, retroperitoneal hematoma, AAF, aortic dissection, CVA-TIA], PTCA, CABG), Viral Myocarditis, Cardiomyopathy
   
3. Sepsis (WBC with left shift, fever, ^CO, (dec)SVA [early, hyperdynamic], infectious source - urine, abdomen, pneumonia, toxic shock syn., immunocompromised, endocarditis); may progress to ARDS; Rx - gram stains, and obtain cultures (blood, urine, wound, abscess, sputum...), IV fluid challenges, antibiotics, ? Dopamine, Dobutamine and/or Levophed
   
4. Medications - narcotics (Rx - Narcan 0.2-0.8 mg IV, and repeat prn), antihypertensives (B blockers, calcium channel blockers, Nitroglycerin), benzodiazepines (Rx -Flumazenil 0.2 mg IV, then 0.3 mg IV over 30 sec., then 0.5 mg IV over 30 sec. and repeat q 1 min. to a max of 3 mg), sedatives; Rx - D/C meds, fluid challenges
   
5. Anaphylaxis - (flushed face, pharyngeal or facial edema, wheezes, SOB, urticaria, (delta) MS); DDx - transfusion reaction, IV contrast, drugs, bee/ asp stings; Rx - NS wide open, Epinephrine O.3 mg IVP (3 mls of 1:10,000 soln), Benadryl 50 mg IVP, Solucortef 250 mg IVSS then 100 mg IVSS q 6 hrs, pressors prn
   
6. Adrenocortical Insufficiency - Addisonian Crisis: history of adrenal or kidney surgery or recent steroid use (asthma, COPD); Rx -Solucortef 2 mg/kg IVSS q 4-6 hours, fiuids
   
7. Neurogenic - loss of vascular autonomic tone via spinal cord injury or anesthesia