What are the initial treatments for emergency department cases beyond asthma, such as acute coronary syndrome, severe sepsis or septic shock, and acute ischemic stroke?

Initial Emergency Department Treatments Beyond Asthma

Acute Coronary Syndrome (ACS)

For patients with suspected ACS, immediately administer non-enteric aspirin 160-325 mg orally unless contraindicated by aspirin allergy or active gastrointestinal bleeding. 1

Immediate Assessment and Initial Therapy

• Obtain a 12-lead ECG within 10 minutes of presentation to distinguish between STEMI (ST-segment elevation myocardial infarction) and non-ST-segment elevation ACS 2
• Administer oxygen if the patient is dyspneic, hypoxemic, or has signs of heart failure, titrating to maintain oxygen saturation ≥94% 1
• Give sublingual or intravenous nitroglycerin for ongoing chest pain, unless contraindicated by hypotension (systolic blood pressure <90 mmHg), right ventricular infarction, or recent phosphodiesterase inhibitor use 1
• Administer morphine sulfate (2-4 mg IV with increments of 2-8 mg repeated at 5-15 minute intervals) for chest discomfort unresponsive to nitrates in STEMI; use with caution in unstable angina/NSTEMI due to association with increased mortality 1

Antiplatelet and Anticoagulation Therapy

• Add a second antiplatelet agent (clopidogrel 300-600 mg loading dose, ticagrelor, or prasugrel) for dual antiplatelet therapy in patients with moderate-to-high-risk non-ST-segment elevation ACS and STEMI 1, 3
• Initiate parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin (enoxaparin preferred over UFH for NSTEMI), bivalirudin, or fondaparinux 1, 3
• For NSTEMI managed with initial conservative approach, enoxaparin or fondaparinux are reasonable alternatives to unfractionated heparin 1

Beta-Blocker Administration

• Do NOT routinely administer IV beta-blockers in the prehospital setting or during initial ED assessment, as there is no evidence supporting routine use and increased risk of cardiogenic shock 1
• IV beta-blocker therapy may be considered only in specific situations such as severe hypertension or tachyarrhythmias in patients without contraindications (moderate-to-severe LV failure, pulmonary edema, bradycardia <60 bpm, hypotension with SBP <100 mmHg, signs of poor peripheral perfusion, second- or third-degree heart block, or reactive airway disease) 1
• Initiate oral beta-blockers within the first 24 hours in patients with suspected ACS who lack contraindications 1

Reperfusion Strategy Based on ECG Findings

For STEMI patients:

• Perform primary percutaneous coronary intervention (PCI) within 120 minutes of presentation, which reduces mortality from 9% to 7% 2
• If PCI cannot be achieved within 120 minutes, administer fibrinolytic therapy (alteplase, reteplase, or tenecteplase at full dose for patients <75 years; half dose for patients ≥75 years) followed by transfer for PCI within 24 hours 2
• Administer clopidogrel 300 mg orally to patients up to 75 years of age with STEMI who receive aspirin, heparin, and fibrinolysis 1

For NSTE-ACS patients:

• Perform risk stratification using clinical, electrocardiographic, and biochemical data (particularly troponin levels) 1
• High-risk patients (recurrent ischemia, elevated troponin, hemodynamic instability, major arrhythmias, diabetes mellitus) should undergo coronary angiography as soon as possible 1
• Invasive coronary angiography within 24-48 hours for high-risk NSTE-ACS patients reduces mortality from 6.5% to 4.9% 2

Common Pitfalls to Avoid

• Do not use NSAIDs (except aspirin) during hospitalization for STEMI due to increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture 1
• Avoid routine IV beta-blocker administration in the early phase, as this increases cardiogenic shock risk without clear mortality benefit 1

---

Severe Sepsis and Septic Shock

Initiate early goal-directed therapy immediately upon recognition of severe sepsis or septic shock, as early aggressive management is integral to improving outcomes. 4

Immediate Resuscitation (First Hour)

• Obtain blood cultures before antibiotic administration, but do not delay antibiotics beyond 45 minutes 4
• Administer broad-spectrum intravenous antimicrobials within the first hour of recognizing severe sepsis or septic shock, as each hour of delay increases mortality 4
• Begin aggressive fluid resuscitation with crystalloids (30 mL/kg bolus) targeting specific hemodynamic endpoints 4

Early Goal-Directed Therapy Targets

• Central venous pressure: 8-12 mmHg (12-15 mmHg if mechanically ventilated) 4
• Mean arterial pressure ≥65 mmHg 4
• Urine output ≥0.5 mL/kg/hour 4
• Central venous oxygen saturation ≥70% or mixed venous oxygen saturation ≥65% 4

Additional Therapies

• Initiate vasopressor therapy (norepinephrine preferred as first-line agent) if hypotension persists despite adequate fluid resuscitation 4
• Administer recombinant human activated protein C in selected high-risk patients with severe sepsis and low bleeding risk 4
• Consider low-dose corticosteroids (hydrocortisone 200-300 mg/day in divided doses or continuous infusion) for patients with septic shock requiring vasopressors despite adequate fluid resuscitation 4
• Achieve source control (drainage of abscesses, removal of infected devices, debridement of infected tissue) as soon as medically and logistically practical 4

Mechanical Ventilation Strategy

• Use low tidal volume ventilation (6 mL/kg predicted body weight) for patients with acute lung injury or acute respiratory distress syndrome to reduce mortality 4

---

Acute Ischemic Stroke

Time is brain—immediate assessment and treatment within the therapeutic window is critical for optimal outcomes in acute ischemic stroke.

Immediate Assessment

• Perform rapid neurological assessment using validated stroke scales (NIHSS) to quantify deficit severity
• Obtain non-contrast CT scan immediately to exclude hemorrhagic stroke before considering thrombolytic therapy
• Establish time of symptom onset precisely, as this determines eligibility for reperfusion therapies

Initial Supportive Care

• Maintain oxygen saturation >94% with supplemental oxygen if needed
• Avoid aggressive blood pressure lowering unless systolic BP >220 mmHg or diastolic BP >120 mmHg, or if thrombolytic therapy is planned (then target BP <185/110 mmHg)
• Maintain normoglycemia, treating hyperglycemia cautiously to avoid hypoglycemia
• Keep patient NPO until swallow evaluation completed to prevent aspiration

Reperfusion Therapy

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset for eligible patients without contraindications
• Consider mechanical thrombectomy for large vessel occlusions within 6-24 hours of symptom onset in selected patients based on imaging criteria
• Administer aspirin 160-325 mg within 24-48 hours after stroke onset (but not within 24 hours of thrombolytic therapy)