Algorithms

Presentation Diagnosed urinary tract infection with fever and unresponsive to 72 hour course of outpatient antibiotic
Evidence of gross hematuria
Altered mental status
Comorbidities Immunocompromised [AIDS, sickle cell, post splenectomy, transplant patient, cancer undergoing chemotherapy/ radiation or neutropenia with ANC <500]
Pregnancy
Single kidney or known polycystic kidney disease
Suprapubic catheter, ureteral stent or nephrostomy tube in place
History of multi drug resistant bacterial UTI
Examination Hemodynamic instability
Severe pain requiring 3 or more analgesic doses
Workup Meet sepsis criteria
Reduced urinary output < 0.5ml/kg/hr. with BUN > 45 or creatinine >3.0
Positive urine culture and sensitivity noted unresponsive to outpatient therapy
Positive blood culture
Diabetic ketoacidosis or blood sugar > 350
Obstructive uropathy [not previously diagnosed]
Pyelonephritis
Emphysematous pyelonephritis
Hydronephrosis
Management Persistent inadequate oral intake requiring IV fluids
Acute kidney injury or sodium <120 or > 160 or potassium > 6.0 mEq/L requiring fluids/ diuresis/ dialysis with close monitoring
Obstructive uropathy requiring intervention
Respiratory failure requiring respiratory support
Vasoactive / inotrope support
Presentation Persistent/worsening Dyspnea/ orthopnea/ fever
Failed/ non compliant outpatient antibiotic treatment
Unable to tolerate oral regimen
Comorbidities Immunocompromised [AIDS, sickle cell, post splenectomy, transplant patient, cancer undergoing chemotherapy/ radiation or neutropenia with ANC <500]
Pregnant
Examination Persistent or worsening Respiratory symptoms
Evidence of systemic illness ( SIRS/ Sepsis, Altered mental status, Acute renal insufficiency etc.)
Hemodynamic instability with or without arterial or venous pH > 7.50
pH <7.25 (Arterial or venous) with mental status changes
PSI score >70 points
Workup Chest x-ray findings of Multilobar pneumonia, lung abscess, empyema or necrotizing pneumonia
Suspected drug-resistant organism
Suspected tuberculosis
Management Persistent requirement of supplemental oxygen above baseline with documented hypoxia
Pleural effusion requiring tube thoracostomy or drainage
Complications requiring IV antiarrhythmic / anti-hypertensive / beta-blocker/ calcium channel blocker / diuretic / insulin/ vasoactive/ inotrope with monitoring and / or titration
Presentation DVT/PE with active bleeding
Bilateral DVT
Comorbidities History of coagulopathy
Liver disease with prolonged PTT or INR
Major surgery or trauma within last month
Malignancy with active cancer treatment
Stroke in last 3 months/history of intracranial hemorrhage
History of cancer with metastasis to brain
Recent overt bleeding within 2 weeks
Heparin induced thrombocytopenia
Thrombocytopenia with platelet count of <75,000/cu.mm
Pregnant
Previous DVT [at least 2 episodes/episode within last 3 Months/recurrent despite adequate anti coagulant therapy]
Subtherapeutic INR, Patient/ caregiver unable to administer anticoagulant and outpatient services unavailable
Examination Persistent Hemodynamic instability
Documented hypoxia requiring supplemental oxygen above baseline
Hemodynamic instability
Workup Documented extensive thrombosis (clot in vena cava or above iliofemoral bifurcation)
Limb threatening thrombosis
Management Emergent IVC filter placement
Catheter directed thrombolysis
Titrated vasoactive drips
Presentation Abdominal pain unresponsive to 2 doses of parenteral analgesic over six hours
Altered mental status
Comorbidities Pregnancy> 20 weeks gestation with renal colic/pyelonephritis (refer UTI algorithm)
Immunocompromised [AIDS, sickle cell, post splenectomy, transplant patient, cancer undergoing chemotherapy/ radiation or neutropenia with ANC <500]
Examination Rebound and/or guarding
Inability to tolerate oral intake
Persistent hemodynamic instability
Coma/ Stupor/Obtundation
Hemodynamic instability
Workup Acute Liver or Renal failure/ Hepatorenal syndrome with Cr>1.5mg/dl and requiring albumin/midodrine/octreotide
Complicated : Perforated/ Abscess
Acute Pancreatitis with enzymes 3 X normal
Acute diverticulitis
Ileus
Pyelonephritis with obstructive uropathy
Acute renal failure with renal colic
Renal colic with bilateral obstruction or single kidney with obstruction
Ascites initial episode requiring paracentesis or albumin or diuretic or salt and fluid restriction
Jaundice with Bilirubin >2.5mg/dl ± Albumin <2.0g/dl or BUN > 45 mg/dl or Cr > 3.0 mg/dl or increasing hepatomegaly or coagulopathy or fever or persistent vomiting or persistent IV fluids requiring anti infective/ anti emetic/ Serotonin agonist/ ERCP/ MRCP/ FFP/ Percutaneous transhepatic biliary drainage
Disseminated intravascular coagulation and blood product transfusion
Tubo ovarian abscess
Management NPO with IV fluids for 2 days
Uncontrolled pain requiring increasing pain medication, dose or frequency
Open surgical procedure
Nephrostomy tube placement for renal colic
IV medications [antiarrhythmic/ anticonvulsant/ antihypertensive/ calcium channel blocker/ beta-blocker/ diuretic/ insulin/ vasoactive medication/ inotrope] along with continuous monitoring or monitoring with titration
Presentation Persistent or worsening Neurological deficit or Unstable deficit (waxing/waning)
Persistent vomiting
Recurrent neurologic deficit in preceding days and especially if increasing
Non focal symptoms- confusion/ weakness/ seizures/ transient global amnesia
Severe Headache or concern for cranial arteritis
Disabling Stroke (new gait disturbance, unable to perform ADLs, NIHSS >3, fails dysphagia screen)
Comorbidities Known possible embolic source: Atrial fibrillation (esp. if not on anticoagulation), Cardiomyopathy, Artificial cardiac valve, Endocarditis, Known mural thrombus, Patent Foramen ovale or Recent myocardial infarction
Prior large stroke making serial neurological examination problematic
Pregnancy
Examination Hypertensive or metabolic encephalopathy
Hemodynamic instability
Coma/Stupor/ Obtundation
Continuous/ intractable seizure
GCS≤8 or decrease ≥2
Increased intracranial pressure
Workup Definitive imaging finding of CVA
Imaging results requiring further evaluation/management (carotid stenosis or abnormal echocardiogram)
Management Titrated vasoactive drip
Treatment of Embolic source (heparin/coumadin) e.g. mural thrombus, atrial fibrillation
Treatment for Encephalitis (e.g. IV Acyclovir)
Persistent hypertension requiring medication adjustment or addition
Presentation Intractable or incapacitating
Focal neurologic signs
Hypertensive emergency with symptoms
Comorbidities Prior large stroke making serial neurological examination problematic
Pregnancy
Examination Hemodynamic instability
Meningismus
Suspected giant cell arteritis (also called temporal arteritis)
Workup Abnormal brain imaging (e.g. cerebral bleeding, hydrocephalus or vasospasm)
Central nervous system infection
Increased intracranial pressure, or cerebral edema or papilledema
Blocked VP shunt
Antepartum/postpartum spinal headache requiring epidural blood patch or IV caffeine and fluid
Management Titrated vasoactive drip
Treatment of Embolic source (heparin/coumadin) e.g. mural thrombus, atrial fibrillation
Treatment for Encephalitis
Persistent hypertension requiring medication adjustment or addition
Presentation Persistent/Worsening Dyspnea, wheezing or facial swelling despite therapy
Intolerance/ inability to take oral intake
Comorbidities Severe COPD
Examination Altered mental status
Stridor or evidence of impending airway compromise
Hemodynamic instability
Workup
Management Anaphylaxis requiring repeat dosing of Epinephrine
Transfusion reaction
Persistent requirement of supplemental oxygen
Presentation Failure of 48 hrs. outpatient antibiotic treatment
Animal or Human bite to face or hand
Inability to tolerate or worsening despite oral antibiotics
Comorbidities Immunocompromised [AIDS, sickle cell, post splenectomy, transplant patient, cancer undergoing chemotherapy/radiation or neutropenia with ANC <500]
Cancer currently undergoing chemotherapy/radiation therapy or neutropenia
Poorly controlled Diabetes
Examination No improvement or worsening cellulitis-increase in girth of involved extremity or development of lymphangitis, purpura or petechiae
Weeping wound with increased exudates or foul smelling discharge
Site: Orbital or peri orbital cellulitis or located over prosthesis or implanted device or of upper lip/nose/neck, involving >9% total BSA
Extensive tissue sloughing
Hemodynamic instability
Workup Meets Sepsis criteria
Infected implanted hardware
Osteomyelitis
Joint effusion requiring drainage
Positive Blood cultures with suspected organism
Management Wound requiring debridement/ re-exploration
Need for operative intervention: necrotizing infection or osteomyelitis
Frequent Complex wound care
Presentation Persistent chest pain/ unstable angina,
AICD [automated implantable cardioverter defibrillator] with repetitive shocks ( > 2-3 shocks in 24 hrs.)
Comorbidities
Examination Hemodynamic instability
Continued episodes of SVT or uncontrolled atrial fibrillation or atrial flutter on vasoactive drip
Workup Wide-complex tachycardia/ Atrial fibrillation/flutter, SVT, Non sustained ventricular tachycardia or symptomatic bradycardia requiring intervention and/or monitoring
Evidence of lethal ventricular arrhythmia
EKG findings of ischemia/infarction
Positive cardiac biomarkers
Management Titrated vasoactive drips requiring monitoring
Urgent electrical cardioversion
Temporary pacemaker
Defibrillation
Presentation Chest pain consistent with Acute coronary syndrome, unstable angina or NSTEMI
Shortness of breath
Comorbidities Acute exacerbation of COPD requiring Intervention
Uncontrolled Diabetes (BS >350mg/dl) requiring intervention
Acute renal failure requiring intervention
Bleeding requiring transfusion
Examination Pulmonary edema/ rales
Hemodynamic instability (Hypotension, Uncontrolled hypertension, Arrhythmia, Tachycardia, tachypnea etc.)
Workup Elevated / positive Troponin
EKG changes suggestive of Ischemia or Acute myocardial infarction
New onset or uncontrolled arrhythmia (requiring IV treatment/ pacemaker/defibrillation
Pericarditis requiring drainage or pain management
Management Acute coronary syndrome/ Unstable Angina/ Non STEMI/ STEMI requiring intervention ( IV Nitro drip, IV Heparin etc.)
Heart failure requiring intervention
Arrhythmia requiring intervention
Presentation Suicidal ingestion
History of delirium tremens or seizures
Comorbidities Head trauma
Examination Hemodynamic instability
Altered mental status
Combativeness
Hallucinations
CIWA score >15 or 8-14 with tachycardia
Workup Evidence of organ dysfunction due to ingestion
Management Frequent IV Medications requirement (e.g. IV Ativan)
Presentation New onset seizures and ≥2 within 24hrs
Known seizure disorder with ≥2 seizures within 24 hours and a change from baseline or change or progression of seizure type or increase in seizure duration
Ongoing seizures or postictal state
Seizures due to toxic exposure (e.g. theophylline or carbon monoxide toxicity) or hypoxemia
Recurrent seizures or status epilepticus
Comorbidities Pregnancy beyond first trimester / eclampsia
Examination Persistent focal neurological findings (e.g. Todd’s paralysis)
Clinical suspicion of meningitis or new CVA
Delirium of any etiology, including alcohol withdrawal syndrome / DTs
Hemodynamic instability
Workup New findings on head CT
New EKG changes or significant arrhythmias
Known seizure disorder with therapeutic drug level or patient compliant but drug level not measurable
Management Initiation of anti convulsant or titration : continuous with monitoring every 1-2 hrs. or Bolus every 1-2 hrs. with monitoring or titration every 1-2 hrs. with monitoring or titration >2hrs with monitoring <24hrs
Respiratory compromise requiring oxygen support
Presentation Decreased urination
Volume overload
Comorbidities Acute infection
Renal transplant
Immunocompromised status
Examination Hemodynamic instability
Workup Sodium < 120 mEq/L (120 mmol/L) and volume overload
Sodium > 160 mEq/L (160 mmol/L)
Potassium> 6.0 mEq/L (6.0 mmol/L) with Neuromuscular deficit or Widening QRS or peaked T waves requiring Calcium chloride/ calcium gluconate/ 50% glucose with insulin/kayexalate
Potassium<3.0mEq/L with PVCs requiring potassium administration
Urine output < 0.5 ML/KG/h or creatinine≥ 2 X ULN or baseline or GFR > 50% decrease from baseline
Management Diuretic continuous or bolus with frequent monitoring or titration
Dialysis initiation or Continuous renal replacement therapy
Presentation Persistent or worsening Neurological deficit
Persistent vomiting/ inability to take oral intake
Comorbidities Known possible infectious source
Pregnancy
Jaundice with bilirubin >2.5mg/dl
Hepatic Encephalopathy ≥ Grade II
Examination Neurologic assessment every 4 hours
Hemodynamic instability
Workup Hypertensive or metabolic encephalopathy
Definitive imaging finding e.g. CVA or Brain metastasis or cerebral edema
Severe electrolyte abnormalities as possible etiology requiring frequent monitoring and intervention
Acute heart failure with hypoxia and tachycardia
Management Anticonvulsant initiation
Presentation Persistent vomiting/diarrhea/inability to tolerate oral intake> 48hrs
Altered mental status
Comorbidities History of CHF preventing aggressive hydration
Neutropenic cancer patient
History of organ transplant
Pregnant patient
Examination Hemodynamic instability
Workup Meets criteria for sepsis
Evidence of ileus or bowel obstruction
Acute renal failure
Severe electrolyte abnormalities with EKG finding or requiring close monitoring
Diabetic ketoacidosis
Management NPO with IV fluids for 2 days
Nasogastric tube
TPN nutrition
Initiation of Corticosteroid/ immunosuppressant/Anti tumor necrosis factor / monoclonal antibody for Inflammatory Bowel Disease
Presentation Left heart failure with worsened symptoms
Right heart failure with worsened symptoms, > 3lbs weight gain and extremities’ edema
Comorbidities Chronic Obstructive Pulmonary Disease
Diabetes mellitus with uncontrolled blood sugar(>300)
Pneumonia
Mental Sickness or Substance Abuse
Examination Persistent tachycardia and /or Hypotension
Persistent Hypoxia or increased oxygen requirement from baseline
Altered mental status
Class III or IV Angina
Hemodynamic instability
Workup Worsening renal failure or ESRD requiring >1 dialysis run or poor diuresis
Unstable cardiac rhythm or new onset dysrhythmia (A.fib/flutter, SVT with rate >120, V. fib/ tach, wide complex tachycardia)
New onset Heart Failure
Cardiac ischemia
Management Continuous diuretic drip or increasing requirement of diuretic due to poor response
Titrated vasoactive/ inotropic drips
Pacemaker placement
Presentation New onset or newly diagnosed Diabetes Mellitus
Altered mental status
Comorbidities Infection / myocardial infarction/ surgery/ trauma
Hemodialysis patient
Examination Hemodynamic instability
Workup DKA as confirmed by Blood glucose > 250, pH < 7.30, HCO3≤18 mEq/L, positive serum or urine ketones
Hyperosmolar hyperglycemic state as noted with serum osmolarity >320 and Blood sugar >600
Acute renal failure or extreme oliguria
Cerebral edema
Management Blood glucose and electrolyte monitoring at least every 4 hours
IV Insulin
IV fluids requirement due to poor oral intake or hydration
Presentation Syncope during exertion or while supine
Associated symptoms [palpitations, shortness of breath]
Comorbidities Family history of sudden cardiac death
Known diastolic dysfunction or ejection fraction <35% or previous myocardial infarction
Examination Hemodynamic instability
New neurological deficit
Workup Abnormal EKG finding: Wolff Parkinson White syndrome, bradycardia without suspected drug toxicity, QRS duration more than or equal to 120ms, QT interval either prolonged [men > 440ms; women > 460ms] or short <340ms, right bundle branch block with ST elevation in leads V1, V2 and V3,
Pacemaker malfunction requiring temporary pacemaker
Arrhythmia as possible etiology
Severe electrolyte abnormalities requiring close monitoring
Aortic stenosis as possible etiology requiring further management
Management Continuous cardiac monitoring excluding Holter monitor
Initiation of antiarrhythmic medication
Pacemaker placement
Presentation Hematemesis or melena: significant amount or multiple episodes
Syncope/ dizziness / lethargy/ chest pain/ dyspnea
Altered mental status
Comorbidities End stage liver disease
Coagulopathy (PT ≥ 1.5X ULN or INR ≥ 2.0 or PTT ≥ 1.5 X ULN or on anti coagulants)
Portal hypertension
Esophageal varices
Pregnancy or postpartum
Examination Hemodynamic instability (Tachycardia and/or Tachypnea)
Orthostatic hypotension
Workup EKG changes concerning for ischemia or rhythm abnormalities
Management Blood transfusion
IV fluid resuscitation
IV Anti arrhythmic / anticonvulsant/ vasoactive/ inotrope/ octreotide or somatostatin
Endoscopy with procedure to control bleeding
Postpartum requiring return to OR to stop bleeding
Presentation Wheezing with persistent/worsening symptoms after outpatient treatment for at least 1 day
Comorbidities Past history of sudden exacerbation, respiratory failure, and/or intubation
Examination Persistent tachypnea
Persistent documented hypoxia (O2 Sat< 90% or pO2 < 60mmHg or pCO2 >45 mmHg) requiring supplemental oxygen above baseline
Impending respiratory fatigue/ accessory muscle use/ stridor or worsening dyspnea after treatment
Decreased level of consciousness/ altered mental status
Hemodynamic instability
Workup PEF 26-39% predicted after bronchodilator (for asthma)( PEF <25% → ICU)
Imaging finding of Pulmonary edema/ pulmonary embolism/ pulmonary infiltrates/ pneumothorax / pleural effusion
Management Bronchodilator >6X/24h
Persistent supplemental oxygen requirement above baseline
Mechanical ventilation or NIPPV
Presentation Finding of acute end organ damage [acute renal failure, hypertensive encephalopathy, intracranial hemorrhage, papilledema, focal neurologic abnormalities, cerebrovascular accident, congestive heart failure, acute coronary syndromes, aortic dissection]
Comorbidities Pregnancy
Pheochromocytoma induced hypertension
Examination Altered mental status
Papilledema
Focal neurological abnormality
Unstable vital signs/ Hemodynamic instability
Acute EKG findings
Persistent or worsening symptoms
Workup
Management Initiation of antihypertensive requiring titration and/or monitoring beyond observation time
Initiation of antiarrhythmic requiring titration and/or monitoring
Presentation High risk for thromboembolism requiring anticoagulation therapy [check DVTs/PE algorithm]
Bleeding and blood product transfusion with chest pain or dyspnea or tachycardia and postural hypotension and/or INR > 2.0
Acute onset or worsening neurological impairment
Cardiac arrest and post resuscitation care
Intolerance to oral intake NPO with IV fluids
Post operative fever
Comorbidities Worsening of previous arrhythmia
COPD requiring bronchodilator(≥6/day) or steroid
NYHA Class III or IV
Sleep apnea
Requiring continuous cardiac monitoring due to known ventricular assist device
Examination Hypoxia with pulse oximetry <89% requiring supplemental oxygen above baseline
Compartment syndrome/ limb ischemia
Malignant hyperthermia
Hemodynamic instability
Workup Elevated cardiac biomarkers [see chest pain algorithm]
Hyperkalemia (potassium > 6.0) with EKG changes or neuromuscular deficit requiring  management with calcium chloride/ calcium gluconate/ glucose with insulin/ Kayexalate
Hypokalemia with potassium <3.0, PVCs >6 / min/ Bigeminal rhythm / Multifocal PVCs/ Torsades de pointes / Ventricular fibrillation / ventricular tachycardia and  potassium chloride ≥ 10 mEq/h or ≥ 120 mEq/24h
Hypercalcemia (calcium of 11.1-≥15.0 mg/ dl) requiring management with IV fluids / calcium lowering agent
Hypocalcemia (calcium level of <5.0 -7.4mg/ dl) requiring calcium administration
Hypermagnesemia (magnesium > 2.5) requiring calcium gluconate or diuretic
Hypomagnesemia (magnesium <1.0-1.4) with Torsade de pointes/ ventricular fibrillation/ ventricular tachycardia requiring magnesium administration
Hypernatremia with sodium > 150 mEq/ L requiring IV fluid and electrolyte monitoring
Hyponatremia with sodium of 120-129 requiring fluid restriction/ IV fluid and oral sodium supplement / medication administration (Conivaptan / Demeclocycline/ diuretic / lithium / tolvaptan)
Hypophosphatemia with serum phosphorus of < 1.0 requiring phosphate administration
Acute kidney injury criteria (check under AKI )
Disseminated intravascular coagulation
Management IV medications [antiarrhythmic/ anticonvulsant/ antihypertensive/ calcium channel blocker/ beta-blocker/ diuretic/ insulin/ vasoactive medication/ inotrope] along with continuous monitoring or monitoring with titration
Pain management requiring parenteral medication [3 times over 24 hours or change in medication, dose or frequency]
Cerebral edema requiring intracranial pressure monitoring / corticosteroid / osmotic diuresis
Chest tube with continuous suction or drainage >100ml / d or requiring repositioning < 24 hrs.
Temporary or permanent pacemaker
Presentation Pre-term premature rupture of membranes  (PPROM) with 24-<32 weeks  requiring  corticosteroid administration or ≥ 32 weeks
Abdominal pain or trauma
Nausea/ vomiting
Spinal headache
Comorbidities Hypertension
Diabetes/ Pregestational Diabetes/ Gestational Diabetes
Thyroid Disorder
Substance Abuse
Mental Health Disorder
Examination Hemodynamic instability
Inadequate oral intake
Workup Persistent amniotic fluid leakage
Concern of chorioamnionitis
Preterm premature rupture of membranes with Amniotic fluid index < 5cm
Preterm premature rupture of membranes with oligohydramnios (Single deep amniotic fluid pocket ≤2cm)
Management IV medications [antiarrhythmic/anticonvulsant/ antihypertensive/calcium channel blocker/ beta-blocker/diuretic/insulin/ vasoactive medication/ inotrope] along with continuous monitoring or monitoring with titration
Presentation Graft dysfunction (Graft vs Host Disease/ rejection/failure) and on immunosuppressant requiring medication adjustment or with signs of toxicity
Bone Marrow or Stem Cell Transplant requiring fluids or awaiting engraftment
Liver Transplant complication
Acute vascular rejection
Comorbidities Post Transplant infection with ANC < 1000/cu.mm or WBC >12,0000 or Bands > 10%
Acute Leukemia or Lymphoma and induction chemotherapy
Radioactive implant ≤ 7d since insertion and isolation
Examination Hemodynamic instability
Hypoxia requiring supplemental oxygen
Persistent tachycardia/ development of rhythm abnormalities
Workup Acute kidney injury/ urinoma/ worsening proteinuria
Aplasia secondary to treatment (myeloablative therapy)
Tumor Lysis syndrome with Calcium <7.5mg/dl or K >5.5 mEq/L or PO4 ≥4.1mg/dl or Uric acid ≥ 7.5 mg/dl
Echocardiogram showing new findings of decreased ejection fraction or other abnormalities
AST/ALT/ Alkaline phosphatase > 4X upper limit of normal
Bilirubin >2X Upper limit of normal
Biloma/ Hematoma of Liver
Hepatic abscess
Hepatic artery thrombosis
Lymphocele causing compression of urinary bladder/ iliac vein or obstruction of ureter
Seroma requiring drainage
Management New immunosuppressant initiation or adjustment
Multiple transfusion dependency
Thrombolysis/ thrombectomy or anticoagulant initiation for hepatic/portal vein thrombosis
Presentation Altered mental status
Seizure
Impending respiratory failure
Comorbidities Acute Kidney injury
SIADH
Examination Hemodynamic instability
Workup Lumbar puncture findings indicative of infection
Cerebral edema
Sepsis
Brain Abscess
Lactic acidosis
Management Neurological assessment every 1-2 hours
Anti-infective (antibiotic/anti-fungal/ anti-viral)
IV Medication (Vasoactive/Inotrope/ antiarrhythmic/anti convulsant/ anti hypertensive/ beta blocker/ calcium channel blocker/ diuretic/ insulin/ neuromuscular blockade) administration with frequent monitoring
Disseminated intravascular coagulation and blood product transfusion
Presentation Altered mental status
Seizure
Impending respiratory failure
Comorbidities Acute Kidney injury
SIADH
Examination Hemodynamic instability
Workup Lumbar puncture findings indicative of infection
Cerebral edema
Sepsis
Brain Abscess
Lactic acidosis
Management Neurological assessment every 1-2 hours
Anti-infective (antibiotic/anti-fungal/ anti-viral)
IV Medication (Vasoactive/Inotrope/ antiarrhythmic/anti convulsant/ anti hypertensive/ beta blocker/ calcium channel blocker/ diuretic/ insulin/ neuromuscular blockade) administration with frequent monitoring
Disseminated intravascular coagulation and blood product transfusion