Approach to the critical patient
›First 5 minutes
›Continuous monitoring if instability or sepsis concern
›IV access criteria
›Two large bore IV for sepsis or major trauma
›One IV for stable analgesia and labs
›Oxygen criteria
›If oxygen saturation under 92 percent
›If respiratory distress
›Early tests time targets
›Blood cultures if febrile
›Lactate if sepsis concern
›Hip and pelvis radiographs if trauma or inability to bear weight
›Immediate consult triggers
›Ortho for suspected septic arthritis
›Ortho for fracture or dislocation
›Vascular for limb ischemia signs
Analgesia and symptom control
›Nonopioid analgesia examples
›Acetaminophen PO 1000 mg once
›Maximum 3000 mg per day in older adults or liver disease risk
›Ibuprofen PO 400 mg once
›Avoid in CKD or GI bleed risk
›Ketorolac IV 15 mg once
›Avoid in CKD or anticoagulation with bleeding risk
›Opioid analgesia examples
›Hydromorphone IV 0.2 mg
›Repeat every 10 to 15 minutes to effect
›Monitor for respiratory depression
›Regional anesthesia for hip fracture
›Fascia iliaca block local protocol dependent
›Reduces opioid requirement
›Contraindications include infection at site and anticoagulation risk assessment
Infection and inflammatory management
›Suspected septic arthritis
›Aspiration prior to antibiotics if stable
›Empiric antibiotics after cultures local protocol dependent
›Vancomycin IV weight based dosing local protocol dependent
›Add gram negative coverage if immunocompromised local protocol dependent
›Suspected necrotizing infection
›Broad spectrum antibiotics immediately
›Surgical consult emergent
›Inflammatory arthritis flare
›NSAID if safe
›Steroid decision individualized and infection excluded
›Trauma or inability to bear weight
›Radiographs pelvis and hip
›If negative but high suspicion, MRI for occult fracture
›Fever or toxic features
›CBC
›CRP and ESR
›Blood cultures
›Ultrasound for effusion
›Neuro symptoms or back pain red flags
›MRI spine if epidural abscess concern
›Urgent neurosurgery or spine consult if deficit
›Leg swelling or thromboembolism concern
›Wells probability assessment
›Compression ultrasound as indicated
›Scheduled reassessment
›Pain score after analgesia within 30 to 60 minutes
›Repeat neurovascular exam after reduction or splinting actions
›Change triggers
›Rising fever
›New inability to bear weight
›New neurologic deficit
›Worsening swelling or compartment concern