Consult specialist early.  These patients are critically-ill with altered physiology and have very high mortality
First intervention should always be to check any medication pumps.  Resume medication immediately.  If malfunctioning or empty, most pumps/patients have card with hot-line to call if their pulmonologist is not available
Usually euvolemic or hypervolemic, rarely need IV fluids so diuretics can benefit and treat the RV failure
Furosemide 20-40mg IV
Furosemide drip at 5-20mg/hr
If suspect sepsis or hypovolemia, small (250-500cc) NS challenge to assess fluid responsiveness.  If not responsive to IVF challenge, start vasopressin or norepinephrine(MAP > 65 mmHg).
Furosemide 20-40mg IV
Furosemide drip at 5-20mg/hr
Once MAP >65 mmHg, start low dose dobutamine (5-10mcg/kg/min)
Improves inotropic support and theoretically decreases<unk>  vascular resistance
Avoid hypoxia, maintain O2 sat >90% (increases<unk>  vasoconstriction)
Avoid hypercapnia (increases<unk>  vascular resistance)
Avoid acidosis
SVT most common although may also become bradycardic (aflutter and afib occur equally)
Treatment of aflutter is often more successful than afib
Do not tolerate negative inotropy, deteriorate to RV failure
May require radiofrequency ablation
AVOID calcium channel blockers or β-blockers
noninvasive oxygenation: attempt nonrebreather mask or high flow nasal cannula to maximize oxygenation. Use NIPPV with caution as positive pressure decreases preload and increases right sided pressures.
Intubate as a last resort: RSI meds cause hypotension worsening RV ischemia. hypercapnea and hypoxia worsen<unk>  artery vasoconstriction. positive pressure ventilation decreases preload and increases right sided pressures.
Intubated patients should be optimized to increased O2 delivery and minimize hypercapnia, maintain low tidal volumes and low PEEP as tolerated
May require interventions not readily available in the ED:<unk>  arterial catheter
Inhaled<unk>  vasodilators
Mechanical support with right ventricular assist device or ECMO<unk>  arterial catheter
Inhaled<unk>  vasodilators
Mechanical support with right ventricular assist device or ECMO
Pulmonary hypertension 
Airway obstruction
Bronchopulmonary dysplasia
Anaphylaxis
Empyema
Angioedema
Pneumoconiosis
Aspirated foreign body