Acute ED Emergencies — CritCare.in

The ED Approach Framework — For Every Patient

In the ED, assessment and treatment happen simultaneously. The following framework applies to every acute medical presentation.

🔴 Step 1 — Is the Patient SICK or NOT SICK? (30 seconds)

Look across the room: Mental status (awake vs altered), Work of breathing (laboured vs normal), Colour (pale, cyanotic, mottled). If sick → immediate intervention, don't wait for history.

🟠 Step 2 — Primary Survey: ABCDE (1–2 minutes)

A — Airway: patent? Stridor? Secretions? → If GCS ≤8: intubate
B — Breathing: RR, SpO₂, work of breathing, breath sounds → O₂, bronchodilators, CPAP/NIV if needed
C — Circulation: HR, BP, cap refill, pulses → IV access, fluid challenge or vasopressors, ECG
D — Disability: GCS, pupils, glucose (MUST check glucose in all altered consciousness) → dextrose if hypoglycaemic
E — Exposure: full examination, temperature, signs of injury, skin changes, rash, petechiae

🟡 Step 3 — Targeted History: AMPLE

Allergies | Medications | Past medical history | Last meal | Events leading to presentation

🟢 Step 4 — Investigations (based on differential diagnosis)

🔵 Step 5 — Disposition Decision

Acute Dyspnoea — Structured Approach

🫁 Acute Dyspnoea

Immediate: Sit up, O₂ to target SpO₂ ≥94% (88–92% if COPD), IV access, ECG, SpO₂ monitoring
Differentials to consider:
Acute pulmonary oedema / acute heart failure → Furosemide 40–80 mg IV + GTN if SBP >110 + CPAP
Acute severe asthma → Salbutamol nebuliser + ipratropium + steroids + O₂ 92–95% (GINA 2026)
COPD exacerbation → SABA + ipratropium + steroids + controlled O₂ (Venturi mask 24–28%) + NIV if pH <7.35
Tension pneumothorax → Tracheal deviation, absent breath sounds, ↑JVP, hypotension → Needle decompression 2nd ICS MCL IMMEDIATELY, then chest drain
Massive PE → Raised JVP, hypoxia, tachycardia, haemodynamic compromise → Anticoagulate + thrombolysis if massive PE + haemodynamic compromise
Cardiac tamponade → Beck's triad (↑JVP + muffled heart sounds + hypotension) + pulsus paradoxus >10 mmHg → ECHO + urgent pericardiocentesis
Key bedside test: POCUS — assess LV function, IVC, pleural/pericardial fluid, lung B-lines (cardiogenic oedema) vs A-lines (pneumothorax)

Acute Chest Pain — Structured Approach

❤️ Acute Chest Pain — Time-Critical Diagnoses

Immediate ECG within 10 minutes — if STEMI: activate cath lab NOW (don't wait for troponin)
5 life-threatening diagnoses to exclude:
1. STEMI: ST elevation ≥1mm in ≥2 contiguous limb leads or ≥2mm in precordial → primary PCI (door-to-balloon <90 min) or fibrinolysis (door-to-needle <30 min if PCI unavailable)
2. Aortic dissection: Tearing/ripping pain, radiates to back, BP difference >20 mmHg between arms, widened mediastinum on CXR, new aortic regurgitation → CT aortogram, NO anticoagulants, urgent surgical consult for Type A
3. Massive PE: Pleuritic pain + dyspnoea + haemodynamic compromise + risk factors (immobility, cancer, prior DVT) → CT-PA + anticoagulation + thrombolysis if massive
4. Tension Pneumothorax: Trauma/positive pressure ventilation context + above signs → treat immediately without waiting for CXR if haemodynamically compromised
5. Cardiac Tamponade: Beck's triad + electrical alternans on ECG + low voltage → Echo + pericardiocentesis
NSTEMI/UA: ST depression or T-wave changes + positive troponin → Antiplatelet + anticoagulation + early invasive strategy
Pericarditis: Sharp pleuritic pain, relieved sitting forward, friction rub → Aspirin 750 mg TDS + Colchicine 0.5 mg BD × 3 months

Altered Consciousness / Coma — Structured Approach

🧠 Coma & Altered Consciousness — AEIOU TIPS Mnemonic

Immediate actions: Protect airway (intubate if GCS ≤8 or aspiration risk), IV access, check glucose (MUST), O₂, ECG, temperature
A — Alcohol/Drugs: Alcohol breath, needle marks, pinpoint pupils (opioids) → Naloxone 0.4–2 mg IV/IM if opioid suspected; Flumazenil 0.2 mg IV for benzodiazepine OD
E — Epilepsy: Post-ictal state vs ongoing SE (must rule out NCSE) → Levetiracetam if seizure suspected; EEG if prolonged coma
I — Insulin (hypoglycaemia): ALWAYS check finger-prick glucose → 25g Dextrose IV (50 ml of 50% dextrose); then 10% dextrose infusion
O — Overdose: History from bystanders, medication bottles → toxicology screen; activated charcoal if <1h and airway protected
U — Uraemia / Hepatic: Asterixis, ↑creatinine, jaundice, liver disease history → treat underlying cause; lactulose for hepatic encephalopathy
T — Trauma: Head injury; cervical spine protection; CT head urgently
I — Infection: Fever, neck stiffness, rash (meningococcal?) → LP if no raised ICP; Ceftriaxone 2g IV immediately + Dexamethasone 10 mg IV; DO NOT delay antibiotics for LP
P — Psychiatric/Psychogenic: Diagnosis of exclusion; eyes resist opening; normal pupil reflexes; normal motor exam
S — Stroke/Structural: Focal deficit, sudden onset → CT head (haemorrhage vs ischaemia); if ischaemic stroke <4.5h → consider tPA

Rule of 5s — Never Miss These in Coma

Glucose (always check first — hypoglycaemia is the most treatable cause)
Naloxone (if opioid toxidrome — pinpoint pupils, respiratory depression, miosis)
Thiamine (before glucose in alcoholics — prevents Wernicke's)
O₂ (hypoxia causes coma and worsens all other causes)
Temperature (hypothermia and hyperthermia both cause coma)

Undifferentiated Shock — Systematic Approach

💔 Undifferentiated Shock

Definition: SBP <90 OR MAP <65 OR SBP drop >40 from baseline + tissue hypoperfusion (altered mentation, oliguria, cold clammy skin, elevated lactate)
Simultaneous resuscitation + diagnosis: 2 large-bore IVs, O₂, monitoring (SpO₂, continuous ECG, NIBP q5 min, urine catheter)
RUSH Protocol (Rapid Ultrasound for Shock and Hypotension):
1. Heart (PLAX, apical 4-chamber): LV function, RV size, pericardial effusion → Cardiogenic or tamponade
2. IVC (subcostal): Flat + collapsing >50% = hypovolaemic/distributive (fluid responsive); Plethoric + no collapse = obstructive/cardiogenic
3. Lungs (bilateral anterior): B-lines = cardiogenic oedema; A-lines = normal or pneumothorax; unilateral absent sliding = pneumothorax
4. Abdomen: Free fluid (FAST) = haemoperitoneum/ectopic → surgical emergency
5. Aorta: AAA → surgical emergency; dissection → CT aortogram
Fluid challenge: 250–500 ml crystalloid bolus + PLR test to assess fluid responsiveness
If no response to fluids: Vasopressors (noradrenaline); AVOID waiting for central line — peripheral NE acceptable short-term

Anaphylaxis

⚠️ Anaphylaxis — GINA 2026 / WAO Guidelines

Diagnosis: Acute onset (minutes to hours) + involvement of skin/mucosa (urticaria, flushing, angioedema) + ONE of: Respiratory compromise OR ↓BP or end-organ dysfunction
OR: Exposure to known allergen + ↓BP alone
FIRST ACTION — Adrenaline IM (GINA 2026 update):
Adults: Adrenaline 0.5 mg IM (0.5 ml of 1:1000 = 1 mg/ml) into anterolateral thigh
Children: 0.3 mg IM (6–12 years); 0.15 mg IM (<6 years)
If no response in 5–15 min: REPEAT IM adrenaline (no ceiling on dose if haemodynamically compromised)
If features of asthma + anaphylaxis: Adrenaline FIRST, then bronchodilators (GINA 2026)
Simultaneously: Position supine + legs raised | Remove trigger | Call for help | O₂ | IV access
Secondary (after adrenaline): IV crystalloid 1–2L rapid | Hydrocortisone 200 mg IV | Chlorpheniramine 10 mg IV slow | Salbutamol nebuliser if bronchospasm persists
IV Adrenaline ONLY in ICU/resuscitation room with monitoring: 50–100 mcg slow IV boluses or 0.05–0.5 mcg/kg/min infusion
Observe: Minimum 6 hours (24h if severe reaction) — biphasic anaphylaxis occurs in 5–20%
Discharge: EpiPen prescription, allergy referral, written action plan

Hypertensive Emergency

💊 Hypertensive Emergency — ESC/ACC-AHA Guidelines

Definition: Severely elevated BP (usually >180/120 mmHg) WITH acute end-organ damage
End-organ damage = Hypertensive Emergency (needs IV treatment):
Hypertensive encephalopathy: Confusion, headache, visual changes, seizures (BP usually >200/130)
Hypertensive stroke: Ischaemic stroke requiring tPA (careful BP management) or haemorrhagic stroke (>180/120 = treat)
Acute aortic dissection: BP >180 → target SBP <120 within 20 min (fastest BP lowering indication)
Acute pulmonary oedema with hypertension: GTN infusion + diuretics
Hypertensive emergency in pregnancy (eclampsia/HELLP): MgSO₄ seizure prophylaxis + Labetalol IV or Hydralazine IV
ACS with hypertension: GTN + beta-blocker (unless contraindicated)
WITHOUT end-organ damage = Hypertensive Urgency: Oral medication, gradual BP reduction over 24–48h, NO need for IV treatment
General target for hypertensive emergency: Reduce MAP by 10–20% in first hour (NOT to normal) → normalise over 24–48h. Exception: Aortic dissection (target SBP <120 fast) and Ischaemic stroke (specific targets)
IV Agents:
Labetalol 20–80 mg IV bolus q10–15 min OR 0.5–2 mg/min infusion (most versatile)
GTN (Nitroglycerin) 5–200 mcg/min infusion — preferred in ACS, LVF
Sodium Nitroprusside 0.3–10 mcg/kg/min — fastest onset; cyanide toxicity with prolonged use; use with arterial line
Hydralazine 5–10 mg IV slowly — useful in pregnancy; unpredictable response
Clevidipine 1–21 mg/hr infusion (IV Ca-channel blocker) — if available; rapid-onset, predictable
Avoid: Sublingual nifedipine (uncontrolled rapid BP fall → stroke, MI)

Acute Poisoning — Indian ED Context

☠️ Approach to Acute Poisoning

Most common in India: Organophosphate (pesticide), aluminium phosphide (ALP/celphos), paracetamol, snake bite, alcohol, TCA, opioids, sedative-hypnotics, rodenticides (superwarfarin)
ABCDE resuscitation first — treat airway/breathing/circulation before diagnosis
History: What (substance name, container), how much (dose), when (time of ingestion), route (oral/inhaled/IV/skin), any treatment given
Toxidrome Recognition:
Cholinergic (OP poisoning): SLUDGE (Salivation, Lacrimation, Urination, Defaecation, GI cramps, Emesis) + Bronchospasm + Bradycardia + Miosis → Atropine + Pralidoxime
Opioid: Miosis + RR ↓ + coma + ↓BP → Naloxone 0.4–2 mg IV/IM; repeat q2–3 min; infusion if long-acting opioid
Sympathomimetic (cocaine, amphetamine): Tachycardia + hypertension + hyperthermia + dilated pupils + agitation → Benzodiazepines; avoid beta-blockers (unopposed alpha)
Anticholinergic (antihistamines, antipsychotics, TCAs): "Hot as a hare, dry as a bone, red as a beet, mad as a hatter, blind as a bat" → Physostigmine (specialist use); supportive
Sedative-hypnotic: Coma + ↓RR + miosis (BZD) or fixed pupils (barbiturates) → Flumazenil for BZD; supportive for others
Decontamination: Activated charcoal 1 g/kg PO/NGT if <1h of ingestion + protected airway + not corrosive/hydrocarbon
Specific Antidotes (memorise):
OP → Atropine 2–4 mg IV q5 min till secretions dry + Pralidoxime 1–2g IV over 30 min
Opioid → Naloxone | BZD → Flumazenil | Paracetamol → N-Acetylcysteine | CO → 100% O₂ | Methanol → Fomepizole or ethanol + dialysis | Cyanide → Hydroxocobalamin | Iron → Deferoxamine | Digoxin → Fab fragments | Warfarin → Vitamin K + PCC
ALP (Aluminium Phosphide) Poisoning: No specific antidote; supportive only; 90%+ mortality; releases phosphine gas → multi-organ failure; magnesium sulphate and coconut oil anecdotally used in India
Call Poison Control: National helpline (India) 1800-11-6117

Fever & Sepsis in the Indian ED

🦠 Fever in the Indian ED — Don't Miss These

Always consider tropical causes in addition to routine infection:
Malaria: Rapid antigen test (HRP2 for falciparum, pLDH for vivax) in ALL febrile patients in endemic areas; P. falciparum = medical emergency (cerebral malaria, blackwater fever, ARDS, renal failure) → Artesunate 2.4 mg/kg IV at 0, 12, 24h then daily
Dengue: NS1 antigen (days 1–5) + IgM ELISA (day 5+); Dengue shock syndrome (rapid deterioration, plasma leak, haematocrit rise) → IV crystalloid resuscitation (NOT colloids) carefully; platelet transfusion only if <10,000 or <20,000 + active bleeding
Scrub Typhus: Eschar (painless, black, crusted) at bite site + fever + lymphadenopathy + monsoon season; ELISA positive; → Doxycycline 200 mg loading then 100 mg BD for 7 days (drug of choice)
Leptospirosis (Weil's disease): Monsoon + fever + jaundice + AKI + conjunctival suffusion; Doxycycline 100 mg BD or Penicillin G IV for severe
Meningococcal disease: Petechial/purpuric rash + fever + meningism = meningococcal septicaemia → EMERGENCY: Ceftriaxone 2g IV IMMEDIATELY (before LP), Dexamethasone 10 mg IV; isolate patient
Typhoid: Relative bradycardia + rose spots + hepatosplenomegaly + step-ladder fever + positive Widal (though low specificity) → Blood culture (gold standard); Ceftriaxone 2g IV OD or Azithromycin 1g OD × 5 days
Sepsis Bundle (SSC 2026): Apply Hour-1 bundle — blood cultures → antibiotics → crystalloid → lactate → vasopressors if needed

Clinical Pearls for the Indian ED

💡 Pearl 1 — ECG in 10 Minutes for Every Chest Pain/Dyspnoea

The 10-minute ECG rule is an absolute standard. Every patient presenting with chest pain, dyspnoea, or syncope gets an ECG within 10 minutes. STEMI is an ECG diagnosis — don't wait for troponin. Every minute matters.

💡 Pearl 2 — Check Glucose in EVERY Altered Consciousness

Hypoglycaemia is the most common reversible cause of coma and it costs nothing to check. ALWAYS do a bedside glucose before anything else in altered consciousness. Give 25g dextrose if <60 mg/dL — immediate reversal is diagnostic.

💡 Pearl 3 — Adrenaline FIRST in Anaphylaxis (GINA 2026)

GINA 2026 explicitly states: if anaphylaxis + asthma features → Adrenaline FIRST, then bronchodilators. The combination of anaphylaxis + asthma is the highest-risk scenario for fatal outcome. Never delay adrenaline.

💡 Pearl 4 — Don't Lower BP to Normal in Hypertensive Emergency

Target: Reduce MAP by 10–20% in first hour. Chronic hypertension shifts cerebral autoregulation — too-rapid normalisation causes watershed infarction, stroke, or renal failure. Exception: Aortic dissection (target SBP <120 rapidly).

💡 Pearl 5 — Petechiae + Fever = Meningococcal Until Proven Otherwise

Petechial/purpuric rash + fever = meningococcal septicaemia until proven otherwise. Give Ceftriaxone 2g IV immediately. Every hour of delay = worse outcome. Don't wait for LP result. Isolate the patient.

💡 Pearl 6 — RUSH POCUS Saves Lives in Undifferentiated Shock

RUSH (Rapid Ultrasound for Shock) in 2–3 minutes can distinguish cardiogenic from distributive from hypovolaemic from obstructive shock. This changes your treatment completely. Every ED physician should perform RUSH routinely.

💡 Pearl 7 — OP Poisoning: Atropine Target is DRY Secretions

In organophosphate poisoning, atropine is titrated to DRY secretions — NOT heart rate, NOT pupil size. Give 2–4 mg IV every 5 minutes until secretions dry. You may need 20–100+ mg total. Under-dosing atropine = preventable death.

💡 Pearl 8 — Sublingual Nifedipine is Dangerous

Sublingual nifedipine causes uncontrolled, unpredictable BP drops → stroke, MI, death. It is NOT appropriate for hypertensive urgency or emergency. Use IV labetalol, nitrates, or oral amlodipine. Remove it from your practice completely.

Exam Pearls (DrNB / PDCC / Emergency Medicine)

Q: Triad of cardiac tamponade? → Beck's triad: ↑JVP + Muffled heart sounds + Hypotension. Plus: Pulsus paradoxus >10 mmHg, Electrical alternans on ECG, Tachycardia. Confirm with echo → urgent pericardiocentesis.

Q: Antidote for organophosphate poisoning? → Atropine (to dry secretions — NOT for heart rate or pupils) + Pralidoxime (2-PAM) within 24–48h of exposure. Benzodiazepines for seizures. Avoid succinylcholine for intubation (pseudocholinesterase inhibition = prolonged paralysis).

Q: First-line treatment in anaphylaxis? → Adrenaline 0.5 mg IM (1:1000) into anterolateral thigh — immediately. Not antihistamines, not steroids, not beta-agonists. Adrenaline first, always.

Q: RUSH protocol — what does it assess? → Heart (LV function, pericardial effusion) + IVC (volume status) + Lungs (B-lines = cardiogenic oedema, A-lines ± absent sliding = pneumothorax) + Abdomen (FAST — free fluid) + Aorta (AAA, dissection).

Q: What is CURB-65 and its significance? → Pneumonia severity score: Confusion + Urea >7 mmol/L + RR ≥30 + BP (SBP <90 or DBP <60) + Age ≥65. Score ≥3: admit; 4–5: consider ICU. Used to guide disposition in CAP.

Q: Why is sublingual nifedipine dangerous in hypertensive emergency? → Causes uncontrolled, unpredictable, precipitous BP drop → watershed stroke, myocardial infarction, death. It cannot be titrated. Use IV labetalol or GTN infusion instead.

References

Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients with Acute Coronary Syndromes. J Am Coll Cardiol. 2025;85(9):e59–e161.
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Updated May 2026. Available from: www.ginasthma.org
Simons FER, Ardusso LR, Bilo MB, et al. (WAO). World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. J Allergy Clin Immunol. 2011;127(3):587–593.
Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026;54(4):725–812.
WHO. Guidelines for the Treatment of Malaria, 3rd Edition. World Health Organization; 2015.
National Vector Borne Disease Control Programme (NVBDCP), India. Guidelines for Diagnosis and Treatment of Malaria, Dengue, Scrub Typhus. Directorate General of Health Services, Ministry of Health & Family Welfare; Updated 2024.
Oh TE (ed). Oh's Intensive Care Manual, 8th edition. Section on Emergency Medicine. Elsevier; 2018.
Tintinalli JE, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw-Hill; 2020.
Washington Manual of Critical Care, 4th edition. Chapters 1–5: Critical Care Emergencies. Lippincott Williams & Wilkins; 2020.