Behavioral, Pediatric, and Obstetric/Gynecologic Emergencies
Core concepts
Behavioral emergencies: use verbal de-escalation first, exclude hypoglycemia, hypoxia, and head injury, then use rapid tranquilization with a butyrophenone or second-generation antipsychotic plus a benzodiazepine. Distinguish serotonin syndrome (clonus, hyperreflexia, rapid onset after serotonergic drugs) from neuroleptic malignant syndrome (lead-pipe rigidity, hyporeflexia, days of antipsychotic exposure) and from anticholinergic toxicity. Alcohol withdrawal is treated with symptom-triggered benzodiazepines and thiamine before glucose. Pediatrics: use the pediatric assessment triangle (appearance, work of breathing, circulation), weight-based dosing, and age-specific vitals. Febrile infants ≤28 days need full sepsis evaluation including lumbar puncture and admission; bronchiolitis is supportive; croup gets dexamethasone and nebulized epinephrine; suspected epiglottitis means no throat examination and controlled intubation. Consider abuse with patterned or implausible injuries, delayed presentation, and inconsistent history. Obstetrics: pregnancy test every reproductive-age woman with abdominal pain; unstable ectopic pregnancy goes to the operating room, while stable cases may qualify for methotrexate. Preeclampsia is hypertension after 20 weeks with proteinuria or organ dysfunction; eclampsia is treated with magnesium sulfate (4–6 g load, then infusion), with calcium gluconate as the antidote. Postpartum hemorrhage is uterine atony until proven otherwise - massage, oxytocin, tranexamic acid, and escalate early. In maternal arrest, apply left lateral tilt and perform perimortem cesarean within 4 minutes.
Traps
A "normal" blood pressure can still be preeclampsia in a chronically hypertensive patient. Never perform a digital vaginal examination with placenta previa. Avoid ACE inhibitors and NSAIDs in pregnancy. Attributing postpartum bleeding to normal lochia delays transfusion.
Rule of thumb
Any woman of childbearing age with abdominal pain, syncope, or shock gets a pregnancy test before anything else - the ectopic you miss is the one that kills.