What are the recommended management steps for common emergency department diagnoses in the Philippines, including acute coronary syndrome, acute ischemic stroke, severe asthma exacerbation, community‑acquired pneumonia, dengue fever with warning signs, sepsis, trauma, and obstetric emergencies such as eclampsia?

Management of Common Emergency Department Diagnoses in the Philippines

Acute Coronary Syndrome (ACS)

Immediate Assessment and Triage

Perform a 12-lead ECG within 10 minutes of arrival to distinguish STEMI from non-ST-elevation ACS (NSTE-ACS), as this determines the entire treatment pathway. 1, 2

• Measure high-sensitivity cardiac troponin immediately at presentation (0 hours) with results available within 60 minutes, then repeat at 3-6 hours after symptom onset to identify rising or falling patterns 1, 3
• STEMI accounts for approximately 30% of ACS cases and is caused by complete coronary artery occlusion, while NSTE-ACS represents 70% and results from partial or intermittent occlusion 2

STEMI Management

Primary percutaneous coronary intervention (PCI) within 120 minutes of presentation reduces mortality from 9% to 7% and is the definitive treatment. 2

• If timely PCI cannot be achieved within 120 minutes (accounting for potential 60-minute delays due to system constraints), administer fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose for patients younger than 75 years, or half dose for patients ≥75 years 1, 2
• For patients arriving by ambulance, transport directly to hospitals with 24/7 catheterization laboratory facilities 1
• If the dedicated cathlab is unavailable upon arrival, proceed with fibrinolysis rather than waiting 1
• Perform left ventriculography during catheterization to assess for mechanical complications 1

NSTE-ACS Risk Stratification and Management

Calculate the TIMI risk score (0-7 points based on: age ≥65 years, ≥3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation, ≥2 anginal events in 24 hours, aspirin use in prior 7 days, elevated cardiac biomarkers) to guide invasive strategy timing. 1

Very high-risk patients (cardiogenic shock, recurrent refractory chest pain, acute heart failure, hemodynamic instability) should be managed identically to STEMI with immediate invasive strategy. 1

• High-risk patients (established NSTEMI with dynamic ST changes, LVEF <40%, or congestive heart failure) require early invasive coronary angiography within 24 hours 1
• Intermediate-risk patients (diabetes, renal dysfunction with eGFR <60 mL/min/1.73 m²) should receive medical stabilization and can be evaluated non-invasively with coronary CT angiography if available 1
• Low-risk patients should undergo conservative management with non-invasive stress testing 1

Immediate Medical Therapy

Start dual antiplatelet therapy immediately: aspirin 150-300 mg oral loading dose plus a P2Y12 inhibitor (ticagrelor or prasugrel). 3

• Administer sublingual nitroglycerin 0.3-0.4 mg every 5 minutes for up to 3 doses for ongoing ischemic pain 3
• Avoid clopidogrel and ticagrelor if lopinavir/ritonavir or other CYP3A4 inhibitors are being used (relevant in COVID-19 or HIV contexts) 1

Troponin Interpretation Pitfalls

Mild troponin elevations (<2-3 times upper limit of normal) in older patients with pre-existing cardiac disease do not require workup for type 1 MI unless accompanied by anginal chest pain or ECG changes. 1

• Marked elevations (>5 times upper limit of normal) warrant consideration of myocarditis, Takotsubo syndrome, spontaneous coronary dissection, or type 1 MI, and should prompt echocardiography if ECG is non-diagnostic 1

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Acute Ischemic Stroke

Time-Critical Assessment

Treat stroke patients with the same urgency as acute myocardial infarction or severe trauma, regardless of deficit severity, as outcomes are time-dependent. 4

• Establish the exact time of symptom onset (when patient was last at baseline) as the single most critical piece of information, since this determines thrombolysis eligibility 4
• Perform immediate non-contrast head CT to differentiate ischemic stroke from intracerebral hemorrhage before any specific treatment 4
• Obtain 12-lead ECG, complete blood count, electrolytes, coagulation studies (aPTT, INR), renal function, glucose, and troponin without delay 4

Thrombolysis Protocol

Administer intravenous rt-PA (alteplase) for patients presenting within 3 hours of symptom onset who meet eligibility criteria, as this is highly effective in improving outcomes. 4

• Maintain blood pressure below 180/105 mmHg during and for at least 24 hours after thrombolysis to prevent hemorrhagic transformation 4
• Delay aspirin administration until 24 hours after thrombolysis 4

Antiplatelet Therapy for Non-Thrombolysis Candidates

Administer aspirin 160-300 mg/day within 48 hours of ischemic stroke onset for patients not receiving thrombolysis. 4

Transient Ischemic Attack (TIA) Management

Admit patients with high-risk TIA (ABCD2 score >4) to a stroke unit or evaluate within 24-48 hours, as stroke risk reaches 13% in the first 90 days. 4

• Low-risk TIA patients (ABCD2 score ≤4) can be managed as outpatients with evaluation within 7-10 days 4
• The ABCD2 score includes: Age ≥60 years (1 point), Blood pressure ≥140/90 mmHg (1 point), Clinical features of unilateral weakness (2 points) or speech disturbance without weakness (1 point), Duration ≥60 minutes (2 points) or 10-59 minutes (1 point), Diabetes (1 point) 4

Supportive Care

Monitor temperature and treat fever (>38°C) aggressively, as hyperthermia worsens neurological outcomes. 4

• Initiate early gradual mobilization 4
• Provide continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation and other arrhythmias 4
• Reserve anticonvulsants only for documented seizures 4

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Severe Asthma Exacerbation

Immediate Triage and Assessment

Measure FEV1 or peak expiratory flow (PEF) immediately to classify severity: severe exacerbations show FEV1 or PEF <40% predicted, moderate exacerbations 40-69% predicted. 1

• Assess for life-threatening features: inability to speak in full sentences, respiratory rate >30/min, heart rate >120/min, oxygen saturation <90%, silent chest, altered mental status, or paradoxical thoracoabdominal movement 1

Primary Treatment Protocol

Administer oxygen to maintain SpO2 ≥90%, inhaled short-acting beta-2 agonists (albuterol/salbutamol) via nebulizer or MDI with spacer every 20 minutes for the first hour, and systemic corticosteroids (prednisone 40-60 mg PO or methylprednisolone 40-80 mg IV) within the first hour. 1

• Continuous nebulized albuterol is appropriate for severe exacerbations 1
• Add ipratropium bromide (0.5 mg nebulized every 20 minutes for 3 doses, then as needed) for severe exacerbations 1

Reassessment and Disposition

Repeat FEV1 or PEF measurement after 1 hour of treatment to guide disposition: discharge if ≥70% predicted with minimal symptoms, admit if <50% predicted or incomplete response with risk factors for asthma-related death. 1

• Patients with FEV1 or PEF 50-69% predicted require individualized assessment considering risk factors; extended observation in a holding unit may be appropriate 1

Discharge Planning

Prescribe systemic corticosteroids for 3-10 days after discharge to reduce relapse risk. 1

• Consider intramuscular depot corticosteroid injection for patients at high risk of non-adherence 1
• Continue inhaled corticosteroids during systemic corticosteroid therapy 1
• Consider initiating inhaled corticosteroids at discharge for patients not already receiving them 1
• Provide written discharge plan with instructions for medication use, symptom monitoring, and when to seek care 1
• Schedule follow-up appointment before discharge to increase adherence 1

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Acute Heart Failure

Immediate Severity Assessment

Classify patients as high-severity requiring immediate resuscitation bay or ICU/CCU transfer if they exhibit respiratory distress (respiratory rate >25/min, SpO2 <90% on supplemental oxygen, increased work of breathing) or hemodynamic instability (systolic BP <90 mmHg, severe arrhythmia, heart rate <40 or >130 bpm). 5

Simultaneous Monitoring and Treatment

Initiate continuous pulse oximetry, arterial blood pressure monitoring, respiratory rate assessment, and 12-lead ECG immediately upon arrival while beginning treatment. 5

• Monitor dyspnea, heart rhythm, urine output, and peripheral perfusion continuously 5
• Obtain cardiac troponin to exclude acute coronary syndrome as precipitant 5
• Measure BNP or NT-proBNP to confirm diagnosis and assess severity 5

Diuretic Therapy Protocol

Administer IV furosemide 40-80 mg bolus if diuretic-naïve, or at least equal to the patient's chronic oral daily dose if already on diuretics, within 60 minutes of presentation. 5

• Target urine output ≥100-150 mL/hour within 6 hours and urinary sodium ≥50-70 mmol/L within 2 hours 5
• Keep total furosemide dose <100 mg in first 6 hours and <240 mg in first 24 hours to avoid excessive diuresis and renal dysfunction 5

Treatment Goals

Maintain systolic blood pressure >90 mmHg with adequate peripheral perfusion, SpO2 >90%, and symptom improvement. 5

Disposition After Initial Stabilization

After approximately 2 hours of ED management, admit hemodynamically and respiratorily stable patients to general cardiology or internal medicine wards; transfer patients with persistent instability (need for intubation, cardiogenic shock, ongoing severe respiratory distress) to ICU/CCU; observe rapidly improving patients in ED observation unit for ≤24 hours. 5

• Schedule cardiology follow-up within 1-2 weeks for discharged patients 5

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Dengue Fever with Warning Signs

Recognition of Warning Signs

Identify warning signs that predict progression to severe dengue: abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation (ascites, pleural effusion), mucosal bleeding, lethargy or restlessness, liver enlargement >2 cm, or rising hematocrit with rapid platelet decline. [General Medicine Knowledge]

Fluid Management

Administer isotonic crystalloid solutions (normal saline or Ringer's lactate) at maintenance rates initially, increasing to 5-7 mL/kg/hour for 1-2 hours if warning signs develop, then reduce gradually based on clinical response. [General Medicine Knowledge]

• Monitor hematocrit every 4-6 hours during critical phase (days 3-7 of illness) [General Medicine Knowledge]
• Avoid excessive fluid administration, which can precipitate pulmonary edema and pleural effusion [General Medicine Knowledge]

Monitoring and Admission Criteria

Admit all patients with warning signs for close monitoring with serial hematocrit, platelet count, vital signs, and urine output assessment. [General Medicine Knowledge]

• Discharge only when: afebrile for 24 hours without antipyretics, improving clinical status, adequate oral intake, stable hematocrit, platelet count >50,000/μL and rising, and no respiratory distress [General Medicine Knowledge]

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Sepsis

Early Recognition and Resuscitation

Initiate the "sepsis bundle" within 1 hour of recognition: obtain blood cultures before antibiotics, administer broad-spectrum antibiotics, measure lactate, and begin fluid resuscitation with 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. [General Medicine Knowledge]

Antibiotic Selection for Philippines Context

Choose empiric antibiotics based on suspected source: ceftriaxone 2 g IV plus metronidazole 500 mg IV for intra-abdominal sources; ceftriaxone 2 g IV for community-acquired pneumonia; piperacillin-tazobactam 4.5 g IV for healthcare-associated infections or immunocompromised patients. [General Medicine Knowledge]

• Consider local resistance patterns; carbapenem-resistant organisms are increasingly prevalent in Philippine hospitals [General Medicine Knowledge]

Hemodynamic Support

Administer norepinephrine as first-line vasopressor if mean arterial pressure remains <65 mmHg after initial fluid resuscitation. [General Medicine Knowledge]

• Target mean arterial pressure ≥65 mmHg and lactate clearance [General Medicine Knowledge]

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Trauma

Primary Survey: CAB Approach

Prioritize "Circulation, Airway, Breathing" (CAB) assessment in trauma, as life-threatening hemorrhage is the leading cause of preventable trauma death. 6

Hemorrhage Control

Apply tourniquets immediately for life-threatening extremity hemorrhage, use direct wound packing for junctional and truncal bleeding, and implement permissive hypotension (target systolic BP 80-90 mmHg) until definitive hemorrhage control is achieved. 6

• Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of injury, followed by 1 g IV over 8 hours 6
• Establish intraosseous vascular access if peripheral IV access fails 6

Transfusion Strategy

Implement balanced transfusion with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets for patients requiring massive transfusion. 6

• Avoid over-resuscitation with crystalloids, which exacerbates coagulopathy 6

Airway Management

Assess airway patency immediately; common causes of airway compromise include head injury, alcohol intoxication, and decreased level of consciousness. 7

• Maintain cervical spine immobilization during airway management in trauma patients 7

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Obstetric Emergencies: Eclampsia

Immediate Seizure Management

Administer magnesium sulfate 4-6 g IV loading dose over 15-20 minutes, followed by 1-2 g/hour continuous infusion, as this is superior to other anticonvulsants for eclamptic seizures. [General Medicine Knowledge]

• Monitor for magnesium toxicity: check deep tendon reflexes hourly, maintain urine output >25 mL/hour, and monitor respiratory rate [General Medicine Knowledge]
• Have calcium gluconate 1 g (10 mL of 10% solution) IV available as antidote for magnesium toxicity [General Medicine Knowledge]

Blood Pressure Control

Treat severe hypertension (systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg) with IV labetalol 20 mg initial dose, doubling every 10 minutes (maximum 80 mg per dose) or IV hydralazine 5 mg, repeating every 20 minutes as needed. [General Medicine Knowledge]

• Target blood pressure <160/110 mmHg but avoid precipitous drops that compromise uteroplacental perfusion [General Medicine Knowledge]

Definitive Management

Arrange urgent delivery regardless of gestational age once maternal condition is stabilized, as delivery is the only definitive treatment for eclampsia. [General Medicine Knowledge]

• Continue magnesium sulfate for 24 hours postpartum to prevent recurrent seizures [General Medicine Knowledge]