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Approach to the Critical Patient
Immediate threats
Initial stabilization priorities
Airway risk features
Stridor
Drooling
Muffled voice
Tripod positioning
Inability to swallow secretions
Breathing risk features
SpO2 < 92% on room air or below baseline
Severe tachypnea
Accessory muscle use
Cyanosis
Circulation risk features
Hypotension
Altered mental status
Poor perfusion
Escalation triggers
Activate resuscitation team for impending airway compromise
If anaphylaxis concern, initiate anaphylaxis pathway
If sepsis concern, initiate sepsis pathway
Triage and isolation
Infection control
Respiratory source precautions
Masking for patient and staff per local policy
Eye protection for aerosol generating procedures
High contagion syndromes
Influenza like illness during community circulation
COVID like illness during community circulation
Pertussis like cough syndrome
Key decision points
Early decision nodes
Predominantly viral URI syndrome
Rhinorrhea
Nasal congestion
Sore throat
Cough
Low grade fever
Alternate diagnosis flags
Focal lung findings
Pleuritic chest pain
Persistent high fever
Severe unilateral throat pain
Neck swelling
Trismus
Severe headache with neurologic deficits
Testing necessity decision
Host risk factors for complications
Need for targeted therapy
Public health or isolation implications
History
Presenting syndrome
Symptom characterization
Onset timing
Duration in days
Abrupt onset versus gradual onset
Upper airway symptoms
Nasal congestion
Rhinorrhea
Sneezing
Sore throat
Hoarseness
Lower airway symptoms
Cough
Wheeze
Dyspnea
Chest pain
Systemic symptoms
Fever
Myalgias
Fatigue
Headache
GI symptoms
Nausea
Vomiting
Diarrhea
Exposure and risk context
Epidemiologic context
Sick contacts
Household exposure
School or daycare exposure
Recent travel
Crowd exposure
Known outbreaks
Occupational exposure
Healthcare setting
Long term care setting
Vaccination history
Influenza vaccine current season
COVID vaccine recent status
Pertussis containing vaccine status
Red flags and complication screen
High risk features
Persistent or worsening course
Symptoms > 10 days without improvement
New fever after initial improvement
Severe symptoms
Severe sore throat with unilateral pain
Difficulty swallowing
Neck stiffness
Facial swelling
Respiratory compromise
Dyspnea at rest
Hemoptysis
Dehydration
Poor oral intake
Oliguria
Immunocompromise
Transplant
Active chemotherapy
High dose steroids
Advanced HIV
Past history and meds
Baseline risk
Asthma
COPD
Bronchiectasis
Heart failure
Diabetes
CKD
Pregnancy
Medication history
ACE inhibitor use
Anticoagulants
Immunosuppressants
Allergy history
NSAID hypersensitivity
Decongestant intolerance
Physical Exam
Vitals and general
Physiologic severity
Temperature
Heart rate
Blood pressure
Respiratory rate
SpO2 at rest
General appearance
Toxic appearance
Work of breathing
Hydration status
HEENT and neck
Upper airway exam
Nasal mucosa edema
Nasal discharge character
Oropharyngeal erythema
Tonsillar exudates
Uvular deviation
Trismus
Voice quality
Ear exam
TM erythema
TM bulging
Otorrhea
Sinus exam
Facial tenderness
Periorbital edema
Neck exam
Cervical lymphadenopathy
Neck stiffness
Submandibular swelling
Chest and cardiopulmonary
Lung findings
Wheeze
Crackles
Decreased breath sounds
Focal consolidation signs
Cardiac exam
Tachycardia disproportionate to fever
Signs of heart failure
PITFALLS
Missed serious illness patterns
Epiglottitis pattern with minimal oropharyngeal findings
Drooling
Stridor
Toxic appearance
Peritonsillar abscess pattern
Trismus
Uvular deviation
Hot potato voice
Pneumonia pattern with normal upper airway exam
Tachypnea
Hypoxia
Focal crackles
Differential Diagnosis
Common and benign
Viral acute upper respiratory infection
ICD-10 J06.9
SNOMED CT Acute upper respiratory infection
Acute nasopharyngitis common cold
ICD-10 J00
Acute pharyngitis viral
ICD-10 J02.9
Targeted treatable infections
Influenza
ICD-10 J10.1
Clues
Abrupt onset
Fever
Myalgias
COVID-19
ICD-10 U07.1
Clues
Exposure history
Systemic symptoms
Group A streptococcal pharyngitis
ICD-10 J02.0
Clues
Fever
Tonsillar exudates
Tender anterior cervical nodes
Absence of cough
Acute bacterial sinusitis
ICD-10 J01.90
Clues
Persistent symptoms > 10 days
Severe symptoms with fever and purulent discharge
Worsening after initial improvement
Pertussis
ICD-10 A37.0
Clues
Paroxysmal cough
Posttussive vomiting
Prolonged cough > 2 weeks
Serious mimics and complications
Community acquired pneumonia
ICD-10 J18.9
Clues
Tachypnea
Focal auscultation findings
Hypoxia
Epiglottitis
ICD-10 J05.1
Peritonsillar abscess
ICD-10 J36
Retropharyngeal abscess
ICD-10 J39.0
Ludwig angina
ICD-10 K12.2
Asthma exacerbation triggered by URI
ICD-10 J45.901
COPD exacerbation triggered by URI
ICD-10 J44.1
Pulmonary embolism
ICD-10 I26.99
Clues
Pleuritic chest pain
Unexplained tachycardia
Disproportionate dyspnea
Laboratory Tests
Minimal testing strategy
Routine labs typically unnecessary in uncomplicated viral URI
Exceptions
Severe systemic illness
Immunocompromise
Suspected pneumonia or sepsis
Infectious testing
Viral pathogen tests when results change management
SARS-CoV-2 NAAT or rapid antigen per local performance and availability
Higher utility with high pretest probability or high risk host
Influenza A and B NAAT or rapid antigen in season
Higher utility within 48 hours for antiviral decisions
RSV testing in high risk adults or infants when it changes disposition
Streptococcal pharyngitis tests when bacterial pharyngitis suspected
Rapid antigen detection test
If negative in children and adolescents, confirm with throat culture or NAAT per local practice
Throat culture or NAAT
Higher sensitivity than RADT
Inflammatory and organ function labs when complications suspected
CBC with differential for severe illness
Leukocytosis not specific for bacterial infection
Neutrophil predominance supportive but non diagnostic
CRP or procalcitonin selective use
Limited role in routine URI
Consider in equivocal pneumonia decisions per local pathways
BMP for dehydration or high risk host
Sodium and creatinine for volume status and renal function
Venous blood gas when ventilatory failure risk
Hypercapnia concern in COPD or severe asthma
Diagnostic Tests
Scoring Systems
Pharyngitis decision support
Centor criteria adult
Tonsillar exudates
Tender anterior cervical lymphadenopathy
Fever history
Absence of cough
McIsaac modification
Age adjustment
Improves applicability across age groups
FeverPAIN optional tool in some settings
Fever
Purulence
Attend rapidly within 3 days
Inflamed tonsils
No cough or coryza
Pneumonia severity when pneumonia suspected
CRB-65 or CURB-65
Confusion
Respiratory rate elevated
Blood pressure low
Age 65 or older
Use for disposition support not as sole determinant
MRI
MRI indications uncommon in routine URI
Complicated sinusitis concern
Orbital cellulitis
Cavernous sinus thrombosis concern
Intracranial extension concern
Neck deep space infection with neurologic complication concern
MRI limitations
Access delays
Motion sensitivity
Sedation needs in pediatrics
CT
CT chest
Pneumonia complication concern
Empyema concern
Abscess concern
Alternative diagnosis concern
PE pathway imaging per standard protocols
CT neck with contrast
Deep neck space infection concern
Retropharyngeal abscess
Parapharyngeal abscess
Ludwig angina extent
CT sinus
Sinusitis complications concern
Orbital involvement
Neurologic symptoms
CT appropriateness
Avoid routine imaging in uncomplicated URI
Ultrasound
Lung ultrasound
Pneumonia support
Focal B lines
Subpleural consolidation
Pleural effusion
Peritonsillar abscess ultrasound
Intraoral or transcutaneous when available
Supports drainage decision and avoids blind needle aspiration
Soft tissue ultrasound
Cervical lymphadenitis abscess concern
Cellulitis versus abscess differentiation
Disposition
Discharge versus admission
Discharge criteria typical for uncomplicated URI
Stable vitals
SpO2 acceptable for age and baseline
No respiratory distress
Adequate oral intake or hydration plan
No red flags for deep space infection or pneumonia
Observation or admission indications
Hypoxia
Moderate to severe respiratory distress
Inability to maintain hydration
High risk host with worsening course
Suspected complications
Peritonsillar abscess requiring drainage and monitoring
Deep neck infection
Pneumonia requiring inpatient therapy
Transfer criteria
Airway compromise risk
Need for ENT or anesthesia not available
Pediatric ICU need
Follow-up planning
Primary care follow-up
Symptom persistence beyond expected course
High risk comorbidities
Specialty follow-up
ENT for abscess, recurrent severe tonsillitis, airway concerns
Pulmonology for recurrent wheeze or uncontrolled asthma
Treatment
Supportive care foundation
Nonpharmacologic measures
Hydration
Oral fluids goal based on thirst and urine output
Oral rehydration solution for vomiting or poor intake
Rest and sleep
Activity as tolerated
Humidified air
Nighttime symptom relief
Saline nasal irrigation
Isotonic sprays or rinses
Honey for cough if age older than 1 year
2.5 mL to 10 mL at bedtime based on age tolerance
Analgesic and antipyretic options
Acetaminophen
Adult dosing
650 mg PO every 4 to 6 hours as needed
Maximum 3000 mg per day typical outpatient limit
Pediatric dosing
15 mg per kg PO every 4 to 6 hours as needed
Maximum 75 mg per kg per day
Hepatic risk considerations
Lower maximum in chronic liver disease or heavy alcohol use
Ibuprofen
Adult dosing
400 mg PO every 6 to 8 hours as needed
Maximum 1200 mg per day OTC typical
Pediatric dosing
10 mg per kg PO every 6 to 8 hours as needed
Maximum 40 mg per kg per day
NSAID precautions
CKD
GI bleed risk
Dehydration
Nasal congestion and rhinorrhea
Intranasal corticosteroids for prominent rhinitis symptoms
Fluticasone
Adult dosing
1 to 2 sprays per nostril once daily
Adolescent dosing
1 spray per nostril once daily
Intranasal ipratropium for rhinorrhea
Ipratropium bromide nasal 0.03%
Adult dosing
2 sprays per nostril 2 to 3 times daily
Adverse effects
Nasal dryness
Epistaxis
Oral decongestants selective use
Pseudoephedrine
Adult dosing
60 mg PO every 4 to 6 hours as needed
Maximum 240 mg per day
Avoid or caution
Uncontrolled hypertension
Significant arrhythmia history
Severe anxiety or insomnia
Phenylephrine oral
Lower and inconsistent efficacy compared with pseudoephedrine in many settings
Topical decongestants short course only
Oxymetazoline nasal
Adult dosing
2 sprays per nostril every 12 hours as needed
Maximum 3 days to reduce rebound congestion risk
Cough symptom control
Dextromethorphan
Adult dosing
10 mg to 20 mg PO every 4 hours as needed
Maximum 120 mg per day
Drug interaction risk
Serotonergic medications
MAOI contraindication
Guaifenesin
Adult dosing
600 mg to 1200 mg PO every 12 hours as needed
Maximum 2400 mg per day
Hydration supportive role
Adequate fluid intake for expectoration
Benzonatate adult only
Adult dosing
100 mg to 200 mg PO three times daily as needed
Safety cautions
Avoid in children due to severe toxicity risk
Do not chew capsules
Bronchodilator trial when wheeze present
Salbutamol albuterol MDI
Adult dosing
2 puffs every 4 to 6 hours as needed
Spacer use
Improves delivery
Nebulized albuterol for moderate distress
Adult dosing
2.5 mg nebulized every 20 minutes up to 3 doses then reassess
Pediatric dosing
0.15 mg per kg per dose nebulized every 20 minutes up to 3 doses then reassess
Antibiotic stewardship and targeted therapy
Antibiotics not indicated for uncomplicated viral URI
Stewardship rationale
No benefit in viral syndromes
Adverse effects and resistance risk
Streptococcal pharyngitis treatment when confirmed or strongly suspected per local pathway
Penicillin V
Adult dosing
500 mg PO twice daily for 10 days
Amoxicillin
Adult dosing
500 mg PO twice daily for 10 days
Pediatric dosing
50 mg per kg per day PO once daily for 10 days
Maximum 1000 mg per day
Penicillin allergy non anaphylaxis
Cephalexin
Adult dosing
500 mg PO twice daily for 10 days
Pediatric dosing
20 mg per kg per dose PO twice daily for 10 days
Maximum 500 mg per dose
Penicillin allergy anaphylaxis
Azithromycin
Adult dosing
500 mg PO day 1 then 250 mg PO daily days 2 to 5
Pediatric dosing
12 mg per kg PO day 1 then 6 mg per kg PO daily days 2 to 5
Acute bacterial sinusitis antibiotics when criteria met
First line amoxicillin clavulanate adult
875 mg and 125 mg PO twice daily for 5 to 7 days
Pediatric dosing
45 mg per kg per day amoxicillin component divided twice daily
Alternative in beta lactam allergy
Doxycycline adult
100 mg PO twice daily for 5 to 7 days
Avoid doxycycline in pregnancy and in young children per local guidance
Antiviral therapy when indicated
Influenza antiviral therapy when likely or confirmed and within treatment window or high risk host
Oseltamivir
Adult dosing
75 mg PO twice daily for 5 days
Pediatric dosing
Weight based dosing per local formulary
COVID-19 outpatient antivirals for eligible high risk patients
Eligibility requires local guideline alignment and drug interaction review
Renal and hepatic function review before prescribing where required
Special Populations
Pregnancy
Pregnancy considerations
Maternal risk
Higher complication risk from influenza and COVID
Lower threshold for testing and treatment when indicated
Medication safety
Acetaminophen preferred for fever and pain
Avoid NSAIDs especially in later pregnancy
Decongestants caution in hypertension or preeclampsia risk
Escalation thresholds
Any hypoxia
Persistent high fever
Reduced fetal movement concerns
Geriatric
Older adult considerations
Atypical presentation
Blunted fever response
Delirium as primary symptom
Higher risk complications
Pneumonia
Dehydration
Medication adverse effects
Medication cautions
Anticholinergics worsening urinary retention or confusion
Decongestants worsening hypertension or arrhythmia
Pediatrics
Pediatric considerations
Airway size vulnerability
Higher risk of respiratory distress with congestion
Medication cautions
Avoid OTC cough and cold products in young children per local guidance
Avoid benzonatate in children
Honey contraindicated under 1 year
Dehydration risk
Poor intake with fever and tachypnea
Serious bacterial illness screen in infants
Age under 3 months with fever requires separate pathway
Background
Epidemiology
Epidemiology overview
Viral pathogens predominate
Rhinovirus common cause
Seasonal coronaviruses common cause
RSV and influenza seasonal contributions
Transmission patterns
Droplet and contact spread
High household secondary transmission
Pathophysiology
Pathophysiology overview
Upper airway mucosal inflammation
Nasal congestion from vascular engorgement
Rhinorrhea from secretions
Cough mechanisms
Postnasal drip
Airway hyperreactivity
Fever and myalgias mechanisms
Cytokine mediated systemic response
Therapeutic Considerations
Treatment principles
Symptom targeted therapy
Analgesic and antipyretic
Nasal symptom control
Cough control selective
Antibiotic stewardship
Avoid antibiotics without bacterial syndrome evidence
Use narrow spectrum when indicated
Return precautions emphasis
Worsening respiratory status
Dehydration
Complication signs
Patient Discharge Instructions
copy discharge instructions
Discharge instruction set
Expected course
Symptoms often peak by day 2 to 3
Cough may persist 2 to 3 weeks
Home care
Fluids and rest
Saline nasal spray or rinse
Humidified air
Acetaminophen or ibuprofen as directed for fever or pain
Infection prevention
Hand hygiene
Masking around high risk people while symptomatic
Avoid sharing drinks or utensils
Return to ED now
Trouble breathing
Blue lips or face
SpO2 low if home monitor available
Severe chest pain
Confusion or fainting
Inability to swallow saliva or drooling
Severe neck swelling or stiffness
Severe headache with weakness or vision changes
Call clinic within 24 to 48 hours
Fever lasting more than 3 days
Symptoms worsening after initial improvement
Severe ear pain or drainage
Sinus pain with fever and worsening congestion
Cough lasting more than 3 weeks
Medication cautions
Avoid decongestants if uncontrolled high blood pressure or significant heart rhythm history
Do not use honey under 1 year of age
Avoid OTC cough and cold combination products in young children per local guidance
References
Clinical guidelines and evidence sources
Primary guidance sources
CDC outpatient antibiotic stewardship for respiratory infections
IDSA guideline for group A streptococcal pharyngitis
IDSA guideline for acute bacterial rhinosinusitis
ATS and IDSA guideline for community acquired pneumonia
CDC influenza antiviral guidance
Diagnostic decision tools
Centor and McIsaac criteria for streptococcal pharyngitis risk stratification
CURB-65 or CRB-65 for pneumonia severity support
Safety references
Pediatric cough and cold medication safety advisories
Benzonatate pediatric toxicity warnings
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.