( PE, ABG, pulse ox, CXR, ECG, CBC, CVP, PCWP, V/Q scan, sputum)

1. CHF CHF, Acuta Pulmonary Edema - CVP, JVD, bibasilar rales, ?wheezes, dependent edema, CXR -(cor, hilar congestion, Kerley B lines, pleural effusions), history of MI, ?fluid overload, ?recent transfusion; Rx - O2, IV-D5W-at KVO, MS 2-4 mg IVP q 10 min prn, NTP 1-2" q 4 hrs, Lasix 40-80 mg IVP and increase prn, Digoxin with tachyarrhythmias and/or S3.
2. MI - chest pain, diaphoresis, nausea, ?radiation, agitation, ECG changes; Rx - Suplemental 02 à95% 02 sat. (pulse oximeter); Sitting up; Nitroglycerin (Subling. NTG 0.3 or 0.4 mg or NTG spray 0.4 mg q 3-5 min x 3, then IV NTG -start 5-10 ug/min, titrate to pain relief and keep sys BP > 100 mmHg); ?Heparin, IV MS 2-4 mg q 5-10 min prn pain; IV NS 250 cc for NTG/MS induced hypotension; Lasix 20-40 mg IVP prn and an afterload reducing agent prn for symptoms and/or CXR findings of CHF; ASA 160-325 mg po QD (not with allergy or active GI bleed), Thrombolytic agents (Alteplase-tPA [give IV Heparin], Streptokinase, Reteplase, APSAC), Beta Blockers (Atenolol, Metoprolol, Propranolol), or ACE inhibitors (Captopril, Lisinopril); Magnesium Sulfate prn; ICU transfer with continuous ECG monitoring
3. Pulmonary Embolus - dyspnea, chest pain, tachypnea; ? lower extr. DVT; CXR (WNL, atelectasis, infiltrate, hemidiaphragm, effusion); ECG (sinus tc, RV strain, RAD, RBBB, tachyarrhythmias); ABG (elevated A-a gradient, PaO2 < 80 mmHg - room air, respiratory alkalosis); high probability V/Q scan; with low or intermediate probability V/Q scan -may need pulmonary angiogram; Rx O2, Heparin (if no contraindications) - 5000 -7500 units IVP, maintenance -25,000 units/500 cc D5W at 20 cc/hr (1000 units/hr); Check PTT in 4-6 hrs and titrate Heparin to 1.5-2 x control. platelet count (Heparin can cause thrombocytopenia). Consider thrombolytic agents (for massive PE), IVC filter (Greenfield…)
4. Pneumonia WBC, fevers, aspiration, sputum production, sputum gram stain - WBCs and bacteria, CXR -discrete infiltrate, which may increase with hydration; Rx - antibiotics (obtain sputum sample first).
5. Asthma - wheeze, + history; Rx -1. B2 Agonists -Alupent nebulizer -(0.3 cc in 3cc NS q 4 hrs or less), or Albuterol (Ventolin. Proventil) nebulizer; Consider continuous nebulizer if without clinical improvement or toxicity. 2. Aminophylline- (loading dose - 5.7 mg/kg IV bolus; maintenance - 0.6 mg/kg/hr for normal, 0.3 mg/kg/hr for CHF - liver disease - elderly, 0.9 mg/kg/hr for smokers); 3. Solucortef 2 mg/kg IVPB q 4-6 hrs, or Solumedrol 60-80 mg IVPB q 6-8 hrs; 4. Intubation may be needed if PaCO2 > 40 mmHg or work of breathing evident (use of accessory muscles). Follow ABG's and serial peak flow levels. ?MgSO4 ?HeO2.

Others - COPD,.htmiration, post-op atelectasis, tension PTX, pleural effusions, cardiac tamponade, fevers, arrhythmias, sepsis, abdominal distension, anxiety -hyperventilation