Emergency and Urgent Care
First minutes
Airway, breathing, circulation, then targeted history and exam. Anaphylaxis: intramuscular epinephrine 0.3–0.5 mg of 1:1000 into the lateral thigh immediately; antihistamines and steroids are adjuncts and never the first drug.
Can't-miss diagnoses
- Sepsis: obtain lactate as a severity marker; give broad-spectrum antibiotics within 1 hour for septic shock and within 3 hours for possible sepsis without shock, after cultures.
- ACS: ECG within 10 minutes; aspirin, nitroglycerin, and timely catheterization. A single normal ECG is not reassuring.
- Stroke: activate the stroke pathway; IV thrombolysis within 4.5 hours of last known well, thrombectomy up to 24 hours in selected patients.
- Asthma exacerbation: repeated albuterol, ipratropium, systemic steroids; magnesium for severe cases.
- Croup: dexamethasone, with nebulized epinephrine for stridor at rest. Epiglottitis: drooling with tripod positioning - do not examine the throat.
Traps
- Ordering imaging before giving epinephrine.
- Missing ectopic pregnancy in a reproductive-age patient with abdominal pain (get a pregnancy test).
- Discharging a febrile neonate.
- Resuscitating against a patient's documented goals - check code status.
Rule of thumb
If the treatment is safe and the diagnosis is lethal, treat while you test.
Worked example: a child with a barking cough, inspiratory stridor at rest, and retractions after a coryzal illness has croup with severe features. Give dexamethasone and nebulized epinephrine, and observe at least 3–4 hours before considering discharge.