Sandbox/00008

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the salmon color signify that an urgent management is needed.

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; MVO2, mixed venous oxygen saturation; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; ScvO2, central venous oxygen saturation; SMA-7, sequential multiple analysis-7.

Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock? ❑  Evidence of hypoperfusion ❑  Altered mental status ❑  Cold extremities ❑  Cyanosis ❑  Oliguria ❑  Sustained hypotension ❑  SBP <90 mm Hg for ≥30 min or ❑  MAP ↓ >30 mm Hg below baseline for ≥30 min ❑  Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion

YES

NO

Cardiogenic shock suspected

Proceed to shock resident survival guide to identify and correct the cause

Immediate management (click for details) ❑  Intubation with mechanical ventilation ❑  ± Norepinephrine IV infusion 0.1–2.0 μg/kg/min

Immediate Workup ❑  ECG monitor ❑  Pulse oximeter ❑  Arterial blood gas ❑  Central venous catheter ❑  Pulmonary artery catheter ❑  CBC/DC/SMA-7/LFT/PT/PTT/INR ❑  Troponin, CK-MB ❑  Lactate ❑  Chest radiograph ❑  Echocardiography ❑  Foley catheter ❑  ICU admission ❑  Cardiology consultation ❑  Hold antihypertensive medications

Hemodynamic optimization: preload ❑  Goal: PCWP 14–18 mm Hg ❑  ↑ PCWP by normal saline IV bolus 100–200 mL ❑  ↓ PCWP by furosemide slow IV injection (over 1–2 min) ❑  ± Correct pulmonary congestion (click for details) ❑  ± Morphine 2–4 mg slow IV injection (over 1–5 min)

Hemodynamic optimization: afterload ❑  Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5 ❑  If ↑ MAP & ↑ SVR: wean vasopressors ± vasodilators ❑  If ↓ MAP & ↑ SVR: vasopressors + inotropes ❑  If ↓ MAP & ↓ SVR: vasopressors ± vasopressin

Hemodynamic optimization: cardiac index ❑  Goal: CI >2.2 L/min/m2 ❑  ± Dobutamine ❑  ± Milrinone ❑  ± IABP, VAD, or ECMO if refractory

Immediate goals ❑  SaO2 >90%–92% ❑  CVP 8–12 mm Hg ❑  MVO2 >60% ❑  ScvO2 >70% ❑  Hemoglobin >7–9 g/dL ❑  Lactate <2.2 mM/L ❑  Urine output >0.5 mL/kg/h ❑  ± Correct arrhythmia ❑  ± Correct electrolyte disturbance

ACS likely? (click for details) ❑  Positive cardiac biomarkers (cTnT, cTnI, or CK-MB) ❑  Symptoms of myocaridal ischemia ❑  New significant ECG findings of myocardial ischemia

YES, then manage as UA/STEMI and proceed to acute ischemia pathway

No, then proceed to complete diagnostic approach

Acute Ischemia Pathway

References