Clinical Decisions | Diagnostic & Treatment Decision-Making Guide

Ventilator Initial Settings

Mode	AC/VC or PC
Tidal Volume	6-8 mL/kg IBW
RR	12-20 /min
FiO₂	Start 100% → wean
PEEP	5-8 cmH₂O
I:E Ratio	1:2
Plateau P	<30 cmH₂O

ARDS: TV 4-6 mL/kg, PEEP per ARDSNet table, Pplat ≤30

Vasopressors & Inotropes

Norepinephrine	0.01-3 µg/kg/min
Vasopressin	0.03-0.04 U/min
Epinephrine	0.01-0.5 µg/kg/min
Dobutamine	2.5-20 µg/kg/min
Dopamine	2-20 µg/kg/min
Phenylephrine	0.5-9 µg/kg/min

1st line septic shock: Norepinephrine. Add Vasopressin at NE >0.25 µg/kg/min

Sedation & Analgesia

Propofol	5-80 µg/kg/min
Dexmedetomidine	0.2-1.5 µg/kg/hr
Midazolam	0.02-0.1 mg/kg/hr
Fentanyl	25-200 µg/hr
Morphine	2-30 mg/hr

Target RASS: -2 to 0. Analgesia first (A1) strategy. Daily SAT+SBT.

Electrolyte Correction

K⁺ <3.5: 10 mEq KCl raises K⁺ by ~0.1. Max 20 mEq/hr peripheral, 40 mEq/hr central.

Mg²⁺ <1.6: 2g MgSO₄ IV over 1hr. Correct Mg before K.

Na⁺ correction: Max 8 mEq/L per 24hrs (risk ODS). 3% NaCl for severe (<120).

PO₄³⁻ <2.0: K-Phos or Na-Phos 15-30 mmol IV over 4-6hrs.

Ca²⁺ <7.0: 1-2g Ca gluconate IV over 10-20 min. Monitor QTc.

ABG Quick Interpretation

pH7.35 - 7.45

PaCO₂35 - 45 mmHg

HCO₃⁻22 - 26 mEq/L

PaO₂80 - 100 mmHg

AG8 - 12 mEq/L

Steps: 1) Acidemia/Alkalemia? 2) Respiratory or Metabolic? 3) Compensation? 4) AG? 5) Delta-Delta

RSI Checklist

PPreparation (equipment, team, plan A/B/C)

PPreoxygenation (3 min NRB / HFNC 60L / NIV)

PPretreatment (Fentanyl 1-3µg/kg if ↑ICP)

PParalysis + Induction (Ketamine 1-2mg/kg + Roc 1.2mg/kg)

PPlacement (confirm EtCO₂ waveform)

PPost-intubation (CXR, set vent, sedation)

Cardiac Arrest (ACLS)

Confirm Cardiac Arrest

Unresponsive + No pulse (10 sec max check)

Start CPR + Attach Defibrillator

30:2 or continuous if advanced airway. Rate 100-120/min, depth 5-6cm

Shockable? (VF/pVT)

YES → Shock 200J biphasic → CPR 2min

Non-Shockable? (PEA/Asystole)

Epinephrine 1mg IV q3-5min immediately. Identify reversible cause (Hs & Ts)

After 2nd Shock (if VF/pVT)

Epinephrine 1mg + Amiodarone 300mg IV push

ROSC?

12-lead ECG, targeted temp management 32-36°C, PCI if STEMI

Hs: Hypovolemia, Hypoxia, H⁺, Hypo/Hyperkalemia, Hypothermia
Ts: Tension pneumo, Tamponade, Toxins, Thrombosis (PE/MI)

Anaphylaxis

Recognize

Urticaria + Hypotension + Bronchospasm + Angioedema (any 2 systems)

Epinephrine IM (Anterolateral Thigh)

Adult: 0.3-0.5 mg (1:1000) IM. Repeat q5-15min

Position + Access

Supine with legs elevated. 2 large bore IVs. NS bolus 1-2L

Adjuncts

Albuterol nebulizer, Diphenhydramine 50mg IV, Methylpred 125mg IV

Refractory?

Epinephrine IV infusion 0.1-1 µg/kg/min. Glucagon if on β-blockers (1-5mg IV)

Sepsis / Septic Shock (Hour-1 Bundle)

qSOFA ≥2 or Suspected Infection

RR ≥22, Altered mentation, SBP ≤100

Measure Lactate

If >2 mmol/L → remeasure within 2-4 hrs

Blood Cultures × 2 Before Antibiotics

Do NOT delay antibiotics >1 hour for cultures

Broad-Spectrum Antibiotics Within 1 Hour

Cover gram +/-, consider MRSA, pseudomonas, fungal per risk

30 mL/kg Crystalloid for Hypotension or Lactate ≥4

Reassess volume status with dynamic parameters (PLR, PPV)

Vasopressors if MAP <65 Despite Fluids

Norepinephrine 1st line. Target MAP ≥65. Add Vasopressin 2nd.

Status Epilepticus

0-5 min: Stabilize

ABCs, O₂, glucose check, IV access, vitals

5-20 min: 1st Line Benzodiazepine

Lorazepam 0.1 mg/kg IV (max 4mg/dose) OR Midazolam 10mg IM

20-40 min: 2nd Line AED

Levetiracetam 60mg/kg (max 4500mg) IV OR Fosphenytoin 20mg PE/kg OR Valproate 40mg/kg

>40 min: Refractory → RSI + Infusion

Midazolam / Propofol / Pentobarbital infusion. Continuous EEG. ICU.

DKA Management Algorithm

Diagnosis: pH <7.3, HCO₃ <18, Glucose >250, Ketones +, AG >12

1. Fluids

NS 1-1.5 L/hr × 1hr → 250-500 mL/hr. Switch to D5½NS when glucose <200

2. Insulin

Regular insulin 0.1-0.14 U/kg/hr IV. Target glucose drop 50-70 mg/dL/hr

3. Potassium

K⁺ <3.3 → hold insulin, replace 20-40 mEq/hr. K⁺ 3.3-5.3 → add 20-30 mEq/L. K⁺ >5.3 → recheck q2h

4. Bicarb (only if pH <6.9)

NaHCO₃ 100 mEq in 400 mL over 2hrs

Resolution: AG <12, pH >7.3, HCO₃ ≥15, glucose <200. Overlap SC insulin 2hr before stopping drip.

STEMI Algorithm

STEMI Criteria: ≥1mm ST↑ in 2 contiguous leads (≥2mm in V1-V3 men, ≥1.5mm women) OR new LBBB

Immediate (MONA-B)

Morphine (if pain), O₂ (if SpO₂ <90%), Nitro SL (not in RV infarct), Aspirin 325mg, β-blocker (if no CI)

Anticoagulation

Heparin 60U/kg bolus (max 4000U) + 12U/kg/hr. P2Y12 inhibitor (Ticagrelor 180mg or Clopidogrel 600mg)

Reperfusion (Door-to-Balloon <90 min)

Primary PCI preferred. If >120 min to PCI → Fibrinolysis (tPA/TNK) within 30 min door-to-needle

Acute Ischemic Stroke

Time is Brain: Last known well time is KEY. CT head STAT to r/o hemorrhage.

IV tPA (Alteplase) — within 4.5 hrs

0.9 mg/kg (max 90mg). 10% bolus, 90% infusion over 60 min. BP <185/110 before, <180/105 after.

Thrombectomy — within 24 hrs (select patients)

LVO (ICA/M1/M2), NIHSS ≥6, ASPECTS ≥6, favorable perfusion mismatch

Exclusions for tPA

Active bleed, platelets <100K, INR >1.7, recent surgery <14d, BP uncontrolled

Upper GI Bleed Algorithm

Resuscitate

2 large bore IVs, crystalloid, type & crossmatch. Transfuse if Hb <7 (threshold 8 if cardiac). Correct coagulopathy.

Risk Stratify (Glasgow-Blatchford)

Score 0 = safe for outpatient. Score ≥6 = high risk → ICU.

Pharmacotherapy

PPI 80mg IV bolus + 8mg/hr infusion. Erythromycin 250mg IV (prokinetic pre-scope). Octreotide if variceal.

Endoscopy within 24 hrs (12 hrs if high risk)

Forrest Ia/Ib → dual therapy (epi + clip/thermal). Variceal → band ligation + Terlipressin/Octreotide.

Chest Pain Red Flags

Tearing/ripping pain radiating to back (Aortic Dissection)
New ST elevation or dynamic ECG changes
Hypotension + JVD + muffled heart sounds (Beck's Triad → Tamponade)
Unilateral absent breath sounds + tracheal deviation (Tension Pneumo)
Pleuritic pain + hemoptysis + recent immobilization (PE)
Subcutaneous emphysema (Boerhaave/Esophageal rupture)

Headache Red Flags (SNOOP)

Systemic symptoms (fever, weight loss, HIV, cancer)
Neurological signs (focal deficit, papilledema, seizure)
Onset sudden "thunderclap" (SAH until proven otherwise)
Older age new onset (>50 → GCA, malignancy)
Positional / Progressive / Precipitated by Valsalva
"Worst headache of my life" → CT head + LP

Abdominal Pain Red Flags

Peritoneal signs (rigidity, guarding, rebound)
Hemodynamic instability with abdominal pain (ruptured AAA/ectopic)
Pain out of proportion to exam (Mesenteric ischemia)
Free air under diaphragm (Hollow viscus perforation)
Obstructive pattern + bilious vomiting + no flatus
Grey Turner/Cullen sign (retroperitoneal hemorrhage)

Back Pain Red Flags

Saddle anesthesia + urinary retention (Cauda Equina → MRI STAT)
Progressive bilateral leg weakness
History of cancer + new back pain (spinal mets)
Fever + IVDU + back pain (Epidural abscess)
Age >50 + new onset + unexplained weight loss
Pulsatile abdominal mass + back pain (AAA rupture)

Dyspnea Red Flags

Stridor (impending airway obstruction → prepare RSI)
Silent chest in asthma (near-fatal, exhausted patient)
SpO₂ <90% despite high-flow O₂
Tripod position + accessory muscle use + inability to speak
Acute onset + unilateral pleuritic pain + tachycardia (PE)
Frothy pink sputum (Flash pulmonary edema)

Altered Mental Status Red Flags

Unequal pupils + GCS drop (herniation → mannitol + neurosurg)
Fever + nuchal rigidity + AMS (Meningitis → empiric abx STAT)
Focal neuro deficit + acute AMS (Stroke → CT STAT)
Hypoglycemia (<60 mg/dL) → Dextrose 50% IV push
Pinpoint pupils + respiratory depression (Opioid OD → Naloxone)
GCS ≤8 → Secure airway (intubate)

Sepsis & Septic Shock

• Antibiotics within 1 hour
• Lactate q2-4h to guide therapy
• 30 mL/kg bolus early
• Norepinephrine as 1st vasopressor
• Daily assess for de-escalation
• Source control within 6-12 hrs

DON'T

• Delay antibiotics for cultures
• Use Dopamine 1st line (↑arrhythmia)
• Overshoot fluids (lung edema)
• Ignore lactate clearance
• Steroids unless refractory shock
• Forget to reassess volume status

Mechanical Ventilation

• Use IBW for tidal volume
• Keep Pplat ≤30 cmH₂O
• Head of bed 30-45°
• Daily SAT + SBT
• Lung-protective ventilation in ARDS
• Prone if P/F <150

DON'T

• Use actual BW for TV (obesity)
• Hyperventilate (↓cerebral perfusion)
• Allow auto-PEEP in COPD
• Deep sedation without reason
• Ignore ventilator asynchrony
• Forget cuff pressure check (20-30)

Airway Management

• Preoxygenate 3+ min (apneic oxygenation HFNC)
• Have Plan B/C ready
• Confirm placement by EtCO₂
• Ramped/sniffing position
• Post-intubation CXR
• Ketamine if hemodynamically unstable

DON'T

• Rush without equipment check
• Thiopental/Propofol in shock
• Forget post-intubation sedation
• Rely solely on auscultation
• Multiple attempts without rescue plan
• Succinylcholine in hyperkalemia/burns

IV Fluids & Resuscitation

• Balanced crystalloids (LR/Plasmalyte)
• Reassess after each bolus
• Use dynamic parameters (PLR, IVC, SVV)
• Blood products in hemorrhagic shock (1:1:1)
• Consider albumin in cirrhosis
• Stop fluids when no longer responsive

DON'T

• NS in large volumes (HCMA risk)
• Colloids (HES) → renal injury
• Fluids in cardiogenic shock
• Ignore fluid overload signs
• LR in hyperkalemia
• Rely on CVP alone for volume

Cardiac Arrest & CPR

• High-quality CPR (rate 100-120, depth 5-6cm)
• Minimize interruptions (<10 sec)
• Epi q3-5 min in non-shockable
• Defibrillate immediately when indicated
• EtCO₂ monitoring (quality marker)
• Targeted temperature management post-ROSC

DON'T

• Pause CPR for intubation >10 sec
• Lean on chest between compressions
• Shock asystole/PEA
• Skip reversible causes (Hs & Ts)
• Hyperventilate (↓venous return)
• Give Epi before 2nd shock in VF/pVT

ICU Medication Safety

• Renal-dose adjust (Vanc, Aminoglycosides)
• DVT prophylaxis daily
• Stress ulcer ppx if indicated
• Glycemic control (140-180 target)
• Review all infusions q shift
• Taper sedation before stopping

DON'T

• Push KCl undiluted (cardiac arrest)
• Mix insulin with other infusions
• Propofol >5 mg/kg/hr >48h (PRIS)
• Nephrotoxics without monitoring
• Forget to adjust for hepatic failure
• IV push phenytoin in dextrose (precipitates)