Cognitive Forcing Strategies


  • Killers (11): SAH, ICH, meningitis, ENT/facial infection, CO poisoning, temporal arteritis, venous sinus thrombosis, cervical artery dissection, glaucoma, IIH, preeclampsia
  • Tx sequence: ivf, metoclopramide + benadryl, toradol, decadron. Sphenopalatine block.

Chest Pain

  • Killers (6): ACS, PE, ao dissection, tamponade, PTX, PNA
  • STEMI equivalents: aVR elevation, deep inverted/biphasic Ts (Wellens), ant precordial STD (posterior MI), hyperacute ST slope (deWinter), modified Sgarbossa in LBBB, *isolated TWI or STD in aVL*
  • Tx tips: ASA immed, NTG ointment, morphine worsens outcomes
  • Tips: pain above & below diaphragm = dissection w/u,

Syncope Plus

  • Structural/electrical heart disease or FH: arrhythmia
  • Exertion: HOCM
  • Young woman with abdominal pain: ectopic pregnancy
  • Older male with abdominal/flank pain: AAA
  • Sudden severe HA: SAH
  • Malignancy, SOB: PE



Agitated patient

  • Sequence: Must be undressed. Needs met? Verbal de-escalation, show of force, offer “something for the nerves” po, chemical + physical restraints (need to document & remove asap)
  • give home meds if possible, haldol 2-5mg IM +/- ativan 1-2mg IM, quetiapine/seroquel, olanzapine/zyprexa (safest for QTc)
  • Tips: avoid bzd in elderly and autistic, avoid antipsychotics if suspect tox, avoid benadryl in elderly


Procedural sedation
midazolam 0.05mg/kg IV, or haloperidol 5mg IV pretreatment to prevent recovery agitation after ketamine

Sick patient

  • eval: iv x 2 (io), O2, monitor, A-B-C-Dextrose
  • shock: empty tank (hypovolemia/hemorrhage), leaky tank (anaphylaxis, sepsis), pump failure (cardiogenic, dissection), obstructive (PE, tamponade)
  • Hs (5) & Ts (6): H’s, hypo/hyperK, hypoxia, hypovol, hypothermia; TPTX, tamponade, thrombosis ACS, thrombosis PE, tox, trauma
  • post ROSC (3): BP, EKG, gas, pressor
  • calling codes: unwitnessed arrest, nonshockable rhythm, no ROSC, age >60, pH<7, unknown downtime, pocus echo. K>12 futile.



  • airway H&P (each with high LR+ for difficult airway): hx difficult tube, snoring, LEMON (Look externally [beard, retrognathia, obesity], Eval 3-3-2, Mallampati, Obstruction, Neck mobility), inability to exaggerate underbite (new!)
  • prep: SOAPME, position is ramped up, +/- push-dose pressor at hand (+bicarb if also severely acidotic), post-tube sedation +/- pressors hung, voice plan and backup to team

SCD patient

  • no O2 if not hypoxic!
  • no fluids if euvolemic (esp in AChS)! Only give D51/2NS, hypotonic fluids prevent further sickling. Bolus only for septic unstable patients.

Before discharge

  • have vitals normalized?
  • PO challenge? Road test?
  • review labs, imaging, & documentation – Does everything make sense? Any incidental findings?


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