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 ❑  Cool 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 ❑  Intubation with mechanical ventilation ❑  ± IV bolus normal saline 100–200 mL ❑  ± Norepinephrine 0.1–2.0 μg/kg/min ❑  ± Control pain and/or anxiety ❑  Morphine sulphate ❑  Fentanyl ❑  Cardiology consultation

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

Immediate goals ❑  SaO2 >90%–92% ❑  CVP 8–12 mm Hg ❑  MAP >60 mm Hg ❑  PCWP 14–18 mm Hg ❑  CI >2.2 L/min/m2 ❑  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

Proceed to complete diagnostic approach below