Evidence current · 2024–2025
Faster Clinical
Decisions in the
Emergency Department
Evidence-based clinical decision support for general practitioners in the ED. Rapid triage, validated risk stratification, and first-line management — optimised for high-pressure, time-limited settings across Indonesia.
8
Pathways
77
References
14
Scores
5
Tiers
JKN
BPJS
Evidence Base77 sources
ESC Guidelines — Acute Coronary Syndromes2023
ESC Guidelines — Heart Failure2021
SCAI Cardiogenic Shock Classification2022
Surviving Sepsis Campaign2021
ESC/ESH Hypertension Guidelines2023
PERKI — Panduan SKA Indonesia2018
IDAI — Panduan Praktik Klinis2021
Kemenkes RI — Formularium Nasional2023
GINA Global Asthma Strategy2023
GOLD — Global Strategy for COPD2024
For clinical decision support only. Recommendations do not replace physician clinical judgement or specialist consultation where indicated. Drug doses must be verified against current local formulary before administration.
Evaluate this platform
Help us improve · 2 minutes · Google Form
Quick vitalsClear
Clinical Pathways
Critical
Chest Pain / ACS
~3 min
Critical
Sepsis
~4 min
Critical
Acute Heart Failure and Shock
~4 min
High
Paediatric Fever
~3 min
High
Dyspnoea
~5 min
High
Altered Mental Status
~4 min
Moderate
Syncope
~2 min
Moderate
Headache + Hypertension
~2 min
Clinical Tools
Drug Calculator
Weight-based · Fornas 2023
Score Library
14 validated tools
SBAR Generator
Auto-fill · JKN/BPJS ready
References
77 sources · 2024–2025
Evidence current · 2024–2025
Tier 2 · RS Tipe CChest Pain / ACS
RiskWorkupManagementDisposition
1
Risk Stratification
HEART Score — in progress
Immediate safety screen passed — no hard-stop criteria met. Proceed with structured assessment below.
H — History Clinician judgment
Slightly suspicious
Non-specific, atypical
Moderately suspicious
Classic features present
Highly suspicious
Typical ACS presentation
E — ECG Interpret 12-lead within 10 min
Normal
No significant changes
Non-specific repolarisation
LBBB, LVH, early repol
Significant ST deviation
ST elevation/depression, Wellens pattern
A — Age
Under 45
45 – 64
65 or older
R — Risk Factors
No known risk factors
1–2 risk factors
HTN, DM, dyslipidaemia, obesity, smoking
≥3 factors or known atherosclerosis
Prior MI, PCI, CABG, stroke, PAD
T — Troponin Lab result
≤ Normal limit
1–3× normal
>3× normal
HEART Score
—
Complete all 5 components
Six AJ et al. Eur J Emerg Med 2008 · AUC 0.83 for 30-day MACE · Validated for undifferentiated ED chest pain
2
Targeted Workup
Unlocks after risk stratification
Required Investigations
12-lead ECG within 10 minutes
Timestamp mandatory. Check for STEMI, Wellens, De Winter patterns.
High-sensitivity Troponin (0h)
hs-cTn: ESC 0h/1h algorithm · Conventional: 0h/3h protocol
IV access × 2 + bloods
FBC, BMP, coagulation, lipids
Chest X-ray
Widened mediastinum (dissection?), pulmonary oedema
ECG Red Flag Screen
ST elevation ≥1mm ≥2 contiguous leads
→ Activate STEMI protocol immediately — D2B target <90 min
New LBBB
→ STEMI equivalent — treat accordingly
Wellens pattern V2–V3
→ Critical LAD stenosis. Do NOT stress test.
QTc >500ms
→ Check medications — antibiotics, antipsychotics, antiemetics
Resource-limited (Tier 0–1): If troponin unavailable, use clinical + ECG (HEART E, R, A components). Transfer if HEART ≥4 or any high-risk feature.
3
Initial Management
Unlocks after workup
Management will appear here. Complete ECG in Block 1 and Troponin in Block 2.
4
Disposition Decision
Unlocks after management
Select disposition based on HEART score + clinical picture
Discharge with safety netting
HEART 0–3 + negative troponin + normal ECG
Observe ≥6 hours
HEART 4–6 or borderline troponin
Admit to monitored bed
HEART 7–10 or positive troponin
STEMI — Activate cath lab
D2B target <90 min · Transfer if no PCI capability
Sepsis
RecognitionSourceBundlesDisposition
1
Rapid Recognition
qSOFA bedside screen
qSOFA Score Bedside — no labs required
Respiratory rate >22/min
Altered mentation (new confusion)
Systolic BP <100 mmHg
qSOFA Score
0
Low concern — continue monitoring
qSOFA ≥2 = Sepsis likely. Seymour et al. JAMA 2016. Low qSOFA does NOT exclude sepsis — clinical gestalt overrides. Sepsis-3: SOFA ↑≥2 + suspected infection.
Severity Classification
Sepsis — organ dysfunction
SOFA ≥2 + suspected infection + MAP ≥65 without vasopressors
Septic Shock
Vasopressor needed for MAP ≥65 + lactate >2 despite adequate fluids
2
Source Identification
Drives antibiotic selection
Identify most likely infection source
Respiratory
Cough, sputum, tachypnoea, crackles → Pneumonia
Urinary
Dysuria, flank pain, cloudy urine → Urosepsis
Abdominal
Pain, guarding, rigidity → Peritonitis, cholangitis
Skin / soft tissue
Cellulitis, wound, IV site infection
CNS
Headache, neck stiffness, photophobia → Meningitis
Unknown source
No obvious focus — broad-spectrum coverage required
Indonesia endemic alert: Consider dengue (NS1/IgM, thrombocytopenia), malaria (thick film + RDT if endemic area), TB (chronic cough + weight loss + HIV), leptospirosis (rainy season), typhoid (relative bradycardia + rose spots).
3
Hour-1 Bundle
Target: all actions within 60 min
Hour-1 Bundle — All actions within 60 minutes
Surviving Sepsis Campaign 2021. Start the clock from time of recognition.
Blood cultures ×2 before antibiotics
Do NOT delay antibiotics >45 min to obtain cultures
Lactate level
If >2 mmol/L → septic shock · repeat at 2h to assess response
IV antibiotics within 1 hour of recognition
See source-specific selection below
IV fluid resuscitation — 30ml/kg crystalloid
Give if hypotension OR lactate ≥4 · complete within 3 hours
Apply vasopressor if MAP <65 after fluids
See vasopressor section below — only if septic shock
Empirical Antibiotic Selection
Antibiotic selection will appear after you identify the infection source in Block 2.
Vasopressors — Septic Shock Only
NorepinephrineStart 0.05 mcg/kg/min · titrate to MAP ≥65
First-line vasopressor in septic shock · Fornas ✓
SOAP II trial: NE superior to dopamine. Tier 0–1 alternative: Dopamine 5–20 mcg/kg/min if NE unavailable.
Vasopressin (adjunct)0.03 units/min IV — fixed dose
Add to NE if MAP not achieved at NE >0.25 mcg/kg/min
Do not titrate above 0.04 U/min. Spares norepinephrine requirement.
Consider Hydrocortisone 200mg/day IV (50mg every 6h) if MAP not achieved despite adequate fluids + NE >0.25 mcg/kg/min · Fornas ✓
4
Disposition
Unlocks after bundles
Admit — HDU / High-dependency
Sepsis responding · No vasopressor requirement
Admit — ICU
Septic shock · Vasopressor requirement · Mechanical ventilation
Transfer to higher facility
ICU not available locally · Stabilise first · SBAR letter essential
Acute Heart Failure and Shock
ClassificationWorkupTreatmentDisposition
1
Classification
Forrester + SCAI staging
Forrester Haemodynamic Profile
Warm + Wet
Most common · Congested, adequate perfusion → Diurese ± vasodilate
Cold + Wet
Congested + poor perfusion → Cardiogenic shock pathway
Cold + Dry
Poor perfusion, not congested → Cautious fluid ± inotrope
Warm + Dry
Compensated, haemodynamically stable
SCAI Shock Stage (if cardiogenic shock)
Stage C — Overt Shock
Hypotension + hypoperfusion despite volume · Lactate >2
Stage D — Deteriorating / Refractory
Failing to respond · Escalating vasopressor requirements
Stage E — Extremis / Arrest
Cardiac arrest or near-arrest · Maximum support needed
SCAI staging: Baran DA et al. Catheter Cardiovasc Interv 2019 · Updated: Naidu SS et al. JACC 2022 · Reassess every 30–60 min · Killip classification: Killip T & Kimball JT. Am J Cardiol 1967.
2
Targeted Workup
Unlocks after classification
12-lead ECG
ACS precipitant? Arrhythmia? LVH? Rate control needed?
CXR
Cardiomegaly, Kerley B lines, bat-wing opacification, pleural effusion
BMP: Na, K, creatinine, urea, glucose
K+ replace if <3.5 mmol/L
Troponin (ACS precipitant?)
Serial if any suspicion of ischaemic trigger
BNP / NT-proBNP (if available)
BNP >100: HF likely · >400: very likely · <35: HF unlikely · McDonagh ESC 2021
Bedside echo / POCUS (if available)
LV function, IVC collapsibility, pericardial effusion, RV strain
3
Pharmacological Treatment
Based on Forrester profile + SCAI stage
Treatment protocol will appear here based on your Forrester profile and SCAI stage selection in Block 1.
4
Disposition
Unlocks after treatment
Admit — HDU / ward
Warm+Wet responding · Killip II · No shock
Admit — ICU
Cardiogenic shock · Vasopressor requirement · SCAI C responding
Urgent transfer — SCAI D/E
MCS required · Stabilise and transfer immediately
Paediatric Fever
Age TriageRisk ScreenManagementDisposition
1
Age-Based Triage
Age determines entire pathway
Purpuric/non-blanching rash + fever = Meningococcal sepsis until proven otherwise
→ Ceftriaxone 80mg/kg IV/IM IMMEDIATELY before anything else. Do not wait for workup.
Patient age group
0 – 28 days (Neonate)
Fever ≥38.0°C rectal = EMERGENCY — no stratification tool applies
29 – 90 days (Young infant)
High risk — Step-by-Step algorithm applies
3 months – 36 months (Infant/Toddler)
Yale OBS + UTI screen + vaccination status
>36 months (Older child)
Source identification — more like adult logic
2
Risk Stratification
Step-by-Step + PECARN tools
Neonate (0–28 days): No Stratification Tool
All neonates with fever = ADMIT ALL. Full sepsis workup: Blood culture + CBC + CRP + UA (catheter) + LP (unless contraindicated). Empirical: Ampicillin 50mg/kg IV every 6 hours + Gentamicin 4–5mg/kg IV once daily. If HSV suspected: Acyclovir 20mg/kg IV · infuse slowly · max 1g/dose every 8 hours.
Young Infant (29–90 days): Step-by-Step Algorithm
Step 1: Ill-appearing? (clinician gestalt)
YES → HIGH RISK immediately
Step 2: Age <21 days?
YES → Treat as neonatal protocol
Step 3: Procalcitonin ≥0.5 ng/mL (or CRP ≥20 mg/L if PCT unavailable)?
YES → HIGH RISK
Step 4: Urinalysis positive? (LE/nitrites/pyuria — catheter specimen)
YES → HIGH RISK (UTI most common SBI in this age group)
Step 5: CRP ≥20 mg/L?
YES → HIGH RISK · All steps negative → LOW RISK (sensitivity ~98%) · Mintegi S et al. Pediatrics 2016
Infant/Toddler (3–36 months): Mandatory UTI Screen
Urinalysis mandatory in ALL 3–36 month fever without source. Catheter specimen preferred. Bag specimen unreliable for culture. Yale OBS ≥16/30 = High risk SBI (>25%). McCarthy PL et al. Pediatrics 1982.
Paediatric Vital Sign Reference
HR normal: <3mo <180 · 3–12mo <160 · 1–5y <140 · 5–12y <130. Tachypnoea for age: <2y >50/min · 2–5y >40/min · >5y >30/min. Hypotension: <3mo SBP <60 · 3–12mo <70 · 1–5y <75 · 5–12y <80.
3
Management
Antipyretics + antibiotics if indicated
Antipyretics — Weight-based
Paracetamol15 mg/kg/dose PO/PR
q4–6h · Max 75mg/kg/day · All ages · Fornas ✓
Antipyretics do NOT reduce febrile seizure recurrence. Sullivan & Farrar. Pediatrics 2011.
Ibuprofen10 mg/kg/dose PO
q6–8h · Max 40mg/kg/day · ≥3 months only
Avoid if dehydrated or renal concerns. Do NOT use in neonates.
High-Risk Infection — Empirical Antibiotics
Ceftriaxone (Paediatric)50–80 mg/kg IV/IM OD
Max 4g/day · 80mg/kg for meningitis/bacteraemia · Fornas ✓
⚠️ Do NOT give to neonates <28d with hyperbilirubinaemia (displaces bilirubin). Age ≥29 days safe.
Febrile Seizure — Protocol
Simple (generalised, <15 min, single episode, full recovery): LP not routinely required if >18 months + vaccinated. No AED. Observe then discharge if well.
Complex (focal/>15min/multiple): Full workup + neurology consult + admit. AAP Subcommittee 2011.
Complex (focal/>15min/multiple): Full workup + neurology consult + admit. AAP Subcommittee 2011.
Midazolam (Active seizure)0.2 mg/kg IV/IM/buccal
Max 10mg · If seizure continues after 5 min: repeat same dose once · Fornas ✓
Phenobarbital 20mg/kg IV · infuse slowly · max 1g/dose if no response at 10 min. Transfer to PICU if status epilepticus.
4
Disposition
Unlocks after management
Admit ALL (0–28 days)
No exceptions. Transfer if NICU/PICU not available.
Admit — high risk (29–90 days)
Any Step-by-Step high-risk criterion. Observe only if ALL low-risk + reliable carer.
Observe 4–6 hours then reassess
Low-risk young infant · Well-appearing toddler · Source identified
Discharge with safety netting
Older child · Source identified + treating · Responding · Reliable carer + 48h follow-up
Dyspnoea
Pattern IDWorkupManagementDisposition
1
Clinical Pattern Identification
Match presentation to likely diagnosis
Never withhold oxygen from a hypoxic patient pending diagnosis
Target SpO₂ ≥94% (88–92% if known/suspected COPD). Oxygenate first — diagnose second.
Dominant clinical pattern — select best match
Acute Heart Failure
Orthopnoea, PND, bilateral crackles, elevated JVP, leg oedema, cardiac history
Asthma / COPD Exacerbation
Wheeze, prolonged expiration, known history, triggers, pursed lip breathing
Pneumonia
Fever, productive cough, unilateral crackles, pleuritic pain, ill appearance
Pulmonary Embolism
Sudden onset, pleuritic pain, tachycardia, risk factors, clear chest exam
Tension Pneumothorax
Unilateral absent sounds, tracheal deviation, haemodynamic collapse
Anaphylaxis
Urticaria + angioedema + wheeze + allergen exposure + rapid onset
2
Targeted Workup
Unlocks after pattern identification
CURB-65 — Pneumonia Severity Score
Confusion (new)
Urea >7 mmol/L
RR ≥30/min
BP <90 systolic or DBP ≤60
Age ≥65
CURB-65
0
0–1: Low · 2: Moderate · 3–5: High severity
Lim WS et al. Thorax 2003. Score 0–1: outpatient · 2: short admission · 3–5: admit, ICU if ≥4. Additional high-risk: SpO₂ <92%, multilobar, immunocompromised.
PE — Wells Score Assessment
Wells ≤4 + negative D-dimer (age-adjusted: age × 10 mcg/L if ≥50y) → PE excluded. Wells >4 → CT-PA directly (skip D-dimer). No CT-PA available + Wells >4 → treat empirically, transfer for imaging. Wells PS et al. Thromb Haemost 2000.
12-lead ECG
S1Q3T3 (PE), AF, ST changes (ACS), right heart strain
CXR
Consolidation (PNA), Kerley B (AHF), clear fields (PE/PTX)
ABG / VBG
pH, pCO₂, lactate · COPD: CO₂ retention screening essential
D-dimer (if Wells PE ≤4)
Age-adjusted threshold: age × 10 mcg/L if ≥50 years
Peak flow (asthma/COPD)
Compare to predicted and personal best
3
Initial Management
Pattern-specific treatment
Select the clinical pattern in Block 1 to see the appropriate management protocol.
4
Disposition
Unlocks after management
Discharge
Mild asthma responded · Low PESI PE · PNA CURB 0–1 · Full resolution
Admit — ward
PNA CURB 2 · AHF responding · PE moderate risk
Admit — ICU / HDU
Severe asthma · COPD type 2 failure · PNA CURB 3–5 · Massive PE
Transfer
Tension PTX needing chest surgery · Massive PE for thrombolysis/thrombectomy
Altered Mental Status
First 5 minDifferentialCT / WorkupDisposition
1
First 5 Minutes — Parallel Actions
Run simultaneously — do not sequence
DEFG — Do not Ever Forget Glucose
BGL within 2 minutes. BGL <3.3: 50mL 50% dextrose IV immediately. If alcohol history: Thiamine 100mg IV BEFORE glucose (prevents Wernicke's precipitation).
BGL (bedside glucometer) — within 2 minutes
Treat if <3.3 mmol/L before anything else
Airway assessment — GCS <8 = at risk
Recovery position · High-flow O₂ · Anaesthetics alert for intubation
Pupil examination (size, symmetry, reactivity)
Pinpoint: opioids → Naloxone now · Fixed dilated: herniation · Unequal: structural lesion
IV access × 2 + blood draw
FBC, BMP, LFTs, ammonia, calcium, TFTs, coagulation, toxicology, paracetamol level, VBG
Collateral history from family / EMS
Last seen normal, medications, alcohol/drugs, prior episodes — AMTLS framework
12-lead ECG
Arrhythmia, QTc prolongation (drug-induced AMS common), ischaemia
Pinpoint pupils + respiratory depression?
→ Naloxone 0.4–2mg IV/IM immediately · Repeat q2–3min · Max 10mg
2
AEIOU-TIPS Differential
Structured diagnostic framework
Most likely cause — AEIOU-TIPS framework
A — Alcohol / Toxic
Intoxication, withdrawal, Wernicke's, CO, organophosphate, methanol, jamu toxicity
E — Epilepsy / Endocrine
Post-ictal, NCSE, hypoglycaemia, DKA, HHS, thyroid storm, hyponatraemia
I — Infection
Bacterial meningitis, HSV encephalitis, TB meningitis, cerebral malaria, JE, septic encephalopathy
O — Organ Failure
Hypoxia, CO poisoning, hepatic encephalopathy, uraemic encephalopathy
T — Trauma / Structural
TBI, SDH (elderly + anticoagulants), ICH, SAH (worst headache), basilar artery occlusion
P — Psychiatric / Poisoning
NMS, serotonin syndrome, psychosis · ALWAYS diagnosis of exclusion
Indonesia endemic: Cerebral malaria (Papua/Maluku — IV Artesunate, avoid steroids), TB meningitis (subacute + weight loss + HIV), Japanese Encephalitis (Java/Bali/NTT), Organophosphate poisoning (agricultural Indonesia — SLUDGE syndrome → Atropine 2–4mg IV).
3
CT Decision + Specific Management
CT not always first — see logic
CT Head — Order Immediately When:
Sudden onset AMS + worst headache of life
SAH until proven otherwise — CT now
New focal neurological deficit
Unilateral weakness, aphasia, gaze deviation, facial asymmetry
New unilateral fixed dilated pupil
Uncal herniation until proven otherwise
Trauma + AMS or anticoagulated + any AMS
SDH even without trauma history in elderly on anticoagulants
Meningitis — Antibiotics Before CT if Unstable
Dexamethasone0.15 mg/kg IV every 6 hours × 4 days
Give WITH or BEFORE first antibiotic dose · de Gans & van de Beek NEJM 2002 · Fornas ✓
Ceftriaxone (Meningitis dose)2g IV every 12 hours
Do NOT delay for LP if unstable · Do NOT delay for CT if clearly septic · Fornas ✓
+ Ampicillin 2g IV every 4 hours if age >50/immunocompromised (Listeria). If HSV cannot be excluded: Acyclovir 10mg/kg IV every 8 hours.
Wernicke's Encephalopathy
Thiamine200–500mg IV three times daily · continue 3 days
IV preferred · Before glucose in at-risk patients · Fornas ✓
High-risk: alcohol, malnutrition, prolonged vomiting, post-bariatric surgery. Classic triad in <20% of cases. Day E et al. Cochrane 2013.
Toxidrome Quick Reference
Opioid: Pinpoint pupils + resp depression → Naloxone 0.4–2mg IV/IM · Organophosphate: SLUDGE + bradycardia → Atropine 2–4mg IV (repeat until secretions dry) · Serotonin: Clonus + hyperthermia + agitation → Cyproheptadine 8mg PO · NMS: Lead-pipe rigidity + hyperthermia + antipsychotic → Stop drug + Bromocriptine + Dantrolene if severe.
4
Disposition
Unlocks after workup
Discharge (very select cases only)
Cause fully identified + treated + complete recovery to baseline + reliable carer
Admit — ward
Improving but not at baseline · Delirium · Metabolic encephalopathy correcting
Admit — ICU / HDU
GCS ≤12 · Airway at risk · Haemodynamically unstable · Active meningitis treatment
Transfer — Neurosurgical emergency
ICH/SDH with mass effect · SAH · Stroke for thrombolysis/thrombectomy · No neurosurgery on site
Syncope
ClassificationECG + RiskManagementDisposition
1
Confirm True Syncope
Exclude mimics first
True syncope: Transient LOC + postural tone loss + rapid onset + short duration + spontaneous complete recovery. Exclude mimics: seizure (post-ictal confusion, lateral tongue bite), hypoglycaemia (gradual onset, slow recovery), drop attack (no LOC). ESC Guidelines 2018.
Syncope type — structured 3P history
Vasovagal (most likely)
Upright position, prodrome (nausea/sweating/warmth), emotional trigger/prolonged standing
Orthostatic hypotension
On standing, elderly, medications (antihypertensives, diuretics, α-blockers)
Possible cardiac syncope
During exertion, preceded by palpitations, lying down, no prodrome, known heart disease
Immediate Red Flags
Syncope DURING exertion (not after)
→ HOCM, arrhythmia, structural heart disease
Family history sudden cardiac death <50 years
→ Inherited channelopathy (Long QT, Brugada, ARVC, CPVT)
Haemodynamic instability post-syncope
→ GI bleed, ruptured AAA, ectopic pregnancy, aortic dissection
2
ECG + Canadian Syncope Risk Score
Mandatory ECG within 10 minutes
ECG Red Flags in Syncope — Mandatory ECG Within 10 Min
QTc >500ms
→ Long QT syndrome · Torsades de pointes risk · Check medications
Delta wave + short PR <120ms
→ WPW syndrome · Pre-excitation → AF → VF
Brugada pattern — coved ST elevation V1–V2
→ Brugada syndrome · VF risk · Antzelevitch C et al. Circulation 2005
Complete heart block / Mobitz II
→ High-degree AV block · Bradyarrhythmia
Epsilon waves + T-wave inversion V1–V3
→ ARVC · EP referral needed
Canadian Syncope Risk Score (CSRS)
Predisposing/precipitating factors for vasovagal
Heart disease history
SBP <90 or >180 mmHg in ED
Elevated troponin (>99th percentile)
QRS duration >130ms
QTc >480ms
ED diagnosis: cardiac syncope
ED diagnosis: vasovagal syncope
CSRS
0
≤0: Very low (0.4%) · 1–3: Medium (3–6%) · ≥4: High (>20%) 30-day SAE
Thiruganasambandamoorthy V et al. CMAJ 2016 + Validation Ann Emerg Med 2020. Also consider ROSE Rule: BNP ≥300, bradycardia ≤50, fecal occult blood +, Hb ≤90, chest pain, Q-wave, SpO₂ ≤94% → any = HIGH RISK. Reed MJ et al. Emerg Med J 2010.
3
Management
Cause-specific treatment
Vasovagal: Reassurance + education + trigger avoidance. Physical counterpressure maneuvers (leg crossing + tensing, hand grip) — van Dijk N et al. JACC 2006 — evidence-based reduction in recurrence. No medications routinely needed in ED.
Orthostatic: Identify cause (dehydration, medications). Review antihypertensives, diuretics, α-blockers. IV/oral fluids if dehydrated. Slow positional changes advice. Compression stockings.
Symptomatic bradycardia (if present)Atropine 0.5mg IV
Repeat to max 3mg · Transcutaneous pacing if severe · Urgent cardiology referral · Fornas ✓
Safety Netting at Discharge
Return if: recurrence (especially lying down), palpitations before episode, chest pain/dyspnoea, neurological symptoms, significant injury. Do not drive until cleared by physician. Outpatient cardiac follow-up within 2 weeks if any uncertainty.
4
Disposition
Unlocks after management
Discharge safely
CSRS ≤0 · Clear vasovagal/orthostatic · Normal ECG · Safety netting given + follow-up
Observe 6–24 hours + monitoring
CSRS 1–3 · Uncertain diagnosis · Awaiting serial troponin · First episode elderly
Admit — monitored bed + cardiology
CSRS ≥4 · ECG red flag · Exertional syncope · Known structural heart disease
Headache + Hypertension
Red FlagsHTN ClassManagementDisposition
1
SNOOP4 — Secondary Headache Screen
Screen for dangerous causes first
Critical distinction: Hypertensive EMERGENCY = BP ≥180/120 + END-ORGAN DAMAGE → treat NOW. Hypertensive URGENCY = BP ≥180/120 WITHOUT end-organ damage → oral agents over hours–days. Rapid normalisation causes stroke, AKI, MI. van den Born BJ et al. Blood Press 2022.
SNOOP4 — Secondary Headache Red Flags
S — Systemic symptoms / risk factors
Fever + headache, weight loss, HIV, pregnancy/postpartum, malignancy
N — Neurological symptoms or signs
Focal deficit, diplopia, papilledema, altered consciousness, neck stiffness
O — Onset sudden / Thunderclap
Maximum intensity within 60 seconds → SAH until proven otherwise → CT immediately
O — Older age: new headache >50 years
Temporal artery tenderness/jaw claudication → GCA: ESR + CRP + Prednisolone 1mg/kg IMMEDIATELY (before biopsy)
P — Progressive (worse over days–weeks)
Worse lying down/Valsalva → raised ICP: tumour, abscess, hydrocephalus → CT with contrast
P — Prior headache change
Established migraineur with different headache → secondary cause workup required
P — Precipitated by exertion / Valsalva
Cough, sneeze, exercise headache → SAH, Chiari malformation
SAH Protocol — Thunderclap Headache
CT head WITHOUT contrast — STATSensitivity ~98% within 6h
If CT normal + onset <6h → LP mandatory (xanthochromia = blood breakdown). Perry JJ et al. BMJ 2018 (Ottawa SAH Rule).
CT normal does NOT exclude SAH. Xanthochromia detectable 12h–2 weeks after bleed. CT normal + >6h: CTA head + neck.
SAH confirmed → Nimodipine60mg by mouth every 4 hours · continue for 21 days
Vasospasm prevention · Neurosurgery immediately · Fornas ✓
Pickard JD et al. Lancet 1989. BP: maintain SBP <160 until aneurysm secured. Avoid hypotension.
2
Hypertension Classification
End-organ damage screen
Hypertension classification
Hypertensive Emergency
BP ≥180/120 + end-organ damage (PRES/encephalopathy, ICH, ACS, AHF, AKI, eclampsia)
Hypertensive Urgency
BP ≥180/120 WITHOUT end-organ damage · Oral agents only · Hours–days target
Ischaemic stroke + hypertension
Permissive HTN — do NOT lower unless >220/120 (or >185/110 if thrombolysis candidate)
Eclampsia / Severe pre-eclampsia
Pregnancy ≥20 weeks + BP ≥160/110 + proteinuria/seizure/symptoms
End-Organ Damage Screen
Neurological: confusion, visual change, seizure, papilledema
→ Hypertensive encephalopathy / PRES · Target: 20–25% MAP reduction over 1h NOT normalisation
Cardiac: chest pain, dyspnoea, pulmonary oedema
→ ACS, hypertensive AHF · See respective pathways
Renal: acute creatinine rise >30%, haematuria, oliguria
→ Hypertensive nephropathy · Nephrology consultation
Migraine / Primary Headache — ED Management
Prochlorperazine (Highly effective)12.5mg IV slow
+ IV fluid bolus 500mL NS (often dehydrated) · Dark quiet environment · Fornas ✓
Paracetamol + Metoclopramide1g PO + 10mg IV/PO
First-line mild–moderate migraine · Fornas ✓
3
Management
HTN treatment + headache management
Select hypertension classification in Block 2 to see the appropriate management protocol.
4
Disposition
Unlocks after management
Discharge
Primary headache identified + treated · Urgency → oral agents + follow-up · BP <180 at discharge
Observe 4–6 hours
BP titrating with oral agents · Thunderclap awaiting LP result · Unclear diagnosis
Admit
Hypertensive emergency + end-organ damage · SAH confirmed · PRES · Eclampsia · ICH
Transfer immediately
SAH → neurosurgery · ICH with mass effect → neurosurgery · Ischaemic stroke thrombolysis candidate · Eclampsia without obstetric service
—
/10
ASSESSMENT
Complete pathway first
Select disposition in final block
Immediate action protocol
Next steps
Evidence-based recommendation
Patient weight for dose calculation
kg
All
Resuscitation
Vasoactive
Antibiotics
Analgesics
Paediatric
Facility Configuration
Facility Tier
RS Tipe C — Tier 2
Region / Province
Jawa Timur · Dengue + Leptospirosis alerts active
Select Facility Tier
Tier 0
Puskesmas / Klinik
Primary care · no CT · no troponin
Tier 1
RS Tipe D
Basic labs · ECG · X-ray
Tier 2
RS Tipe C
CT scan · troponin · basic ICU
Tier 3
RS Tipe B
Full specialists · ICU · echo · cath lab
Tier 4
RS Tipe A / RSUP
Tertiary · PCI 24h · ECMO · cardiac surgery
Platform Features
Endemic Disease Alerts
Regional disease prompts in pathways
Offline Mode
Pathways cached for offline use
Fornas Drug Flags
Show availability by facility tier
Feedback & Evaluation
Evaluate CardioBoyo Emergency Assist
Share your feedback · Help us improve · Takes 2 minutes
Opens Google Form in your browser · Your responses help improve this platform
Access & Session
Sign Out
Clear session · Requires code to re-enter
About
CardioBoyo Emergency Assist
v1.0 · 2025 · Part of the CardioBoyo Platform ecosystem
Current
Evidence Base
77 references · Updated 2024–2025 · Next review 2026
Disclaimer
Clinical decision support only · Does not replace physician judgement · Verify drug doses against local formulary