| Case 1: 72-year-old man with acute chest discomfort and associated intense diaphoresis; known hypertension and type 2 diabetes; no coronary artery disease |
Call 911 Measure vital signs, oxygen saturation, and glucose level Administer 160 mg of oral acetylsalicylic acid (should be chewed) For severe pain, administer 0.4 mg of sublingual nitroglycerin spray every 3 to 5 min (after systolic blood pressure is confirmed to be > 100 mm Hg before each dose); nitroglycerin might cause severe hypotension in the context of an inferior myocardial infarction Give oxygen if saturation is below 90%9,10
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Obtain an electrocardiogram Obtain IV access Administer 2.5 to 5 mg of IV morphine if you will accompany the patient or if the paramedics provide morphine and subsequent monitoring Administer an antiplatelet agent
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| Case 2: 18-year-old man with asthma that has been worse than normal for a few weeks; smokes 15 cigarettes per day and has been trying to quit; and has been very short of breath for 1 h. You are unable to hear breath sounds with auscultation of the left side of his chest. His trachea is shifted to the right side |
Call 911 Measure vital signs and oxygen saturation Check if trachea is in the midline position Auscultate for breath sounds bilaterally Perform needle thoracostomy in tracheal shift away from the side with no air entry with the largest gauge IV catheter available11 Administer 8 to 10 puffs of a 200-µg salbutamol metered-dose inhaler with aerochamber every 5 min
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| Case 3: 52-year-old woman feels weak when you administer a local anesthetic; develops an urticarial rash, wheezing, and a feeling of impending doom |
Call 911 Measure vital signs, glucose level, and oxygen saturation Administer 0.3 to 0.5 mL of intramuscular 1:1000 epinephrine12,13 and repeat after 5 min if there is no response Administer 8 to 10 puffs of a 200-µg salbutamol metered-dose inhaler with aerochamber every 5 min Administer oxygen if saturation is below 95%
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Obtain IV access and give a 1-L bolus of normal saline if the patient has hypotension If there is hypotension and vascular access, consider IO access and bolus of normal saline or Ringer solution Administer 50 mg of oral prednisone
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