07 Medical Emergencies

Recognize overlapping presentations

Medical emergencies can present with overlapping findings, including altered mental status, weakness, shortness of breath, vomiting, abnormal vital signs, or seizures. A single reassuring finding—such as normal blood glucose or no fever—does not rule out serious illness.

Use current state and local protocols for medication selection, doses, destination decisions, and scope of practice. National model guidelines do not replace local authorization.

Use a systematic assessment

Begin by considering hazards such as violence, hazardous materials, infectious exposure, heat or cold, and contaminated clothing or equipment. Do not enter an unsafe atmosphere without appropriate training and personal protective equipment.

Assess airway, breathing, circulation, disability, and exposure. Support oxygenation and ventilation as indicated, control immediate threats, and reassess after every intervention.

Obtain vital signs, mental status, a focused examination, and point-of-care glucose early when altered mental status, seizure, or stroke-like symptoms are unexplained. Consider hypoxia, hypoglycemia, stroke, seizure, infection, intoxication, trauma, and metabolic disease together.

Establish the timeline and context: ask about onset or last known well, medications and recent changes, allergies, medical history, exposures, substances, and witnessed events. When available, seek collateral history and review medication containers, medical identification, and scene clues.

Prioritize time-sensitive care and an appropriate destination. Provide an early, concise hospital notification and report trends, treatment response, key times, and relevant negative findings.

Manage neurologic emergencies

Suspect stroke with sudden facial droop, unilateral weakness or numbness, speech or language difficulty, vision loss, imbalance, or an unexplained acute neurologic change. Use a validated stroke screen and follow local stroke-routing criteria.

Record the exact last-known-well time, not merely when symptoms were discovered. Obtain information about anticoagulant use, baseline function, and witness contact details. Check glucose because hypoglycemia can mimic stroke, but do not let that check or another nonessential procedure delay transport. Support airway and ventilation, monitor, avoid oral intake, and notify the receiving stroke-capable facility early. Follow regional routing systems for acute ischemic stroke care and EMS triage.

Protect a patient having a seizure from injury, time the event, and do not restrain them or place objects in their mouth. After convulsions stop, reassess airway, ventilation, oxygenation, glucose, temperature, trauma, and return toward baseline.

A prolonged or recurrent seizure without recovery is time-critical. Provide airway support and administer anticonvulsant treatment only when authorized by protocol. Consider hypoglycemia, toxins or withdrawal, infection, pregnancy-related eclampsia, head injury, and missed antiseizure medication. Persistent altered mental status or a focal deficit requires evaluation for causes beyond a postictal state.

Recognize endocrine emergencies

Hypoglycemia may cause sweating, tremor, behavior change, confusion, focal-appearing deficits, seizure, or coma. Check glucose and determine whether the patient can swallow safely. Give oral glucose only when the patient has adequate consciousness and airway protection. If swallowing is unsafe or the patient is altered, use an authorized non-oral therapy and protect the airway.

Recheck glucose and mental status. Look for recurrence risks, including long-acting medication, poor intake, or exertion. If symptoms persist, evaluate for other causes.

Hyperglycemic crisis may present with dehydration, weakness, nausea, vomiting, abdominal pain, deep or rapid breathing, fruity breath, and altered mentation. Diabetic ketoacidosis can occur with glucose below the traditionally expected range, so a single glucose value does not exclude it. Provide supportive care, assess perfusion and hydration, monitor, and transport rather than delaying care for a presumed uncomplicated explanation.

Respond to toxicologic emergencies

Treat the patient, not just the suspected substance. If possible, identify the route, substance, amount, and time. Inspect the scene without unsafe handling, and contact a poison center or medical control for substance-specific guidance. For symptomatic or unstable patients, prioritize resuscitation and transport. Do not induce vomiting.

Prevent secondary contamination. Move away from inhaled hazards only when safe; remove contaminated clothing; and irrigate exposed skin or eyes according to product guidance and protocol.

Toxidromes can guide assessment but are not proof of a specific substance:

• Opioid pattern: Depressed consciousness, slow or inadequate breathing, and often pinpoint pupils. Ventilate first when needed. Give naloxone under protocol and, when feasible, titrate it to adequate ventilation rather than precipitating severe withdrawal.

• Sympathomimetic pattern: Agitation, diaphoresis, tachycardia, hypertension, hyperthermia, and possible seizures. Reduce stimulation, manage dangerous agitation or seizures according to protocol, cool the patient if hyperthermic, and monitor for cardiac complications.

• Anticholinergic pattern: Delirium, hot dry skin, dilated pupils, tachycardia, and urinary retention.

• Cholinergic pattern: Secretions, bronchospasm, bradycardia, vomiting or diarrhea, weakness, and sometimes fasciculations. Protect rescuers from contamination, decontaminate as appropriate, and use protocol-directed antidotes.

Mixed exposures are common. Bring packaging or exposure details when safe, and reassess for delayed or recurrent toxicity.

Treat allergic reactions and anaphylaxis

A mild, localized allergic reaction differs from anaphylaxis, which is a rapidly developing systemic reaction that may involve airway swelling, wheezing, respiratory distress, hypotension, collapse, or multiple organ systems. Skin findings can be absent.

Give intramuscular epinephrine promptly when anaphylaxis is suspected; it is first-line treatment. Support airway and ventilation, position the patient to support perfusion while avoiding sudden standing, and monitor closely. Repeat epinephrine or provide adjunctive treatment only as allowed by protocol. Antihistamines do not replace epinephrine for airway or circulatory compromise. Watch for deterioration or recurrence during transport.

Identify infectious emergencies

Suspect sepsis when infection is accompanied by evidence of organ dysfunction or poor perfusion, such as altered mentation, hypotension, abnormal skin signs, tachypnea, or weakness. Fever may be absent, particularly in older or immunocompromised patients. Obtain a focused infection history, follow vital-sign trends, check glucose when indicated, and perform protocol-directed monitoring. Support perfusion and oxygenation, transport promptly, and provide early sepsis notification. No single screening score or vital sign rules sepsis in or out.

Consider meningitis or another serious infection with fever or hypothermia, severe headache, neck stiffness, photophobia, rash, confusion, or seizure. Presentations vary, and classic signs may be absent. Use appropriate infection-control precautions, avoid delaying transport, and alert the receiving facility when a contagious illness is suspected.

Manage environmental emergencies

Heat exhaustion commonly causes weakness, dizziness, nausea, heavy sweating, and dehydration. Altered mental status, seizure, collapse, or marked hyperthermia suggests heat stroke, a life-threatening emergency. Move the patient from the heat, remove excess clothing, rapidly cool using the most effective safe method available, monitor airway and temperature, and transport. Do not delay active cooling while arranging transport, and do not give oral fluids to a patient with altered consciousness.

Suspect hypothermia after cold or wet exposure, including in cool conditions, especially when confusion, impaired coordination, slurred speech, drowsiness, or reduced vital signs are present. Handle the patient gently, prevent further heat loss, remove wet clothing when practical, insulate, and use protocol-directed rewarming. Assess for trauma, intoxication, and hypoglycemia. In severe hypothermia, signs of life may be difficult to detect; follow resuscitation and transport protocols.

For drowning or submersion, ensure scene safety and remove the patient from the water safely. Prioritize ventilation and oxygenation because hypoxia is central to the event. Manage suspected trauma, prevent heat loss, and transport patients with respiratory symptoms, altered mentation, or resuscitation needs. Respiratory deterioration can occur after rescue.

Reassess and adapt clinical judgment

An older adult with confusion, tachycardia, and weakness may have sepsis, hypoglycemia, stroke, medication toxicity, or several problems at once. A patient with suspected intoxication may instead have a stroke or head injury.

Reassess after treatment. Improvement after glucose supports hypoglycemia but does not prove it was the only problem; response to naloxone does not exclude other causes. If the presentation does not fit, the patient worsens, or the expected response does not occur, reopen the differential and escalate care.

Across emergencies, prioritize scene safety and airway, breathing, and circulation support. Use a structured assessment, check glucose early when neurologic or mental-status changes are present, establish accurate onset and exposure timelines, and treat immediately reversible threats. Recognize time-critical stroke, prolonged seizure, hypoglycemia, toxidromes, anaphylaxis, sepsis, heat stroke, and hypothermia. Reassess, transport to an appropriate destination, and communicate findings and trends that may change definitive care.

• Toxidrome