At the Bedside

  • Assess severity first: Work of breathing, SpO₂, mental status, hydration, sepsis physiology, pregnancy status, comorbidities.
  • High-risk groups: Age <5 or >65, pregnancy/postpartum, chronic pulmonary/cardiac/renal/hepatic/metabolic disease, immunocompromise, neurologic disease, BMI ≥40, nursing home residents.
  • Typical findings: Abrupt fever, chills, myalgias, headache, cough, sore throat, malaise. GI symptoms can occur, especially in children.
  • Testing:
  • PCR/NAAT is preferred if available; rapid antigen tests have lower sensitivity.
  • Test if result will affect treatment, isolation, admission decisions, outbreak control, or high-risk exposures.
  • Do not delay antivirals in high-risk or severely ill patients while awaiting testing.
  • Evaluate complications when indicated:
  • CXR for hypoxia, focal lung findings, persistent fever, severe cough, concern for pneumonia.
  • Labs if ill appearing, septic, dehydrated, elderly, pregnant, or admitted: CBC, CMP, lactate, blood cultures if bacterial pneumonia/sepsis suspected.
  • ECG/troponin if chest pain, arrhythmia, syncope, myocarditis concern.
  • Initial ED management:
  • Droplet precautions.
  • Antipyretics, fluids, bronchodilators if wheezing, oxygen/ventilatory support as needed.
  • Start antivirals for severe disease, hospitalization, high-risk patients, pregnancy, or symptom onset ≤48h.
  • Treat suspected secondary bacterial pneumonia: especially if biphasic illness, focal infiltrate, purulent sputum, leukocytosis, shock.
  • Disposition:
  • Discharge if stable oxygenation, tolerating PO, reliable follow-up, no concerning comorbid decompensation.
  • Admit for hypoxia, pneumonia, sepsis, altered mental status, inability to hydrate, pregnancy with complications, high-risk patient with clinical instability.
  • ICU for respiratory failure, shock, severe myocarditis, encephalitis, or escalating oxygen needs.
A Classic Presentation
A 72-year-old man with COPD presents in January with 24 hours of fever, severe myalgias, dry cough, and worsening dyspnea. He is febrile, tachycardic, SpO₂ 89% RA, wheezing diffusely, and CXR shows no focal infiltrate. Influenza PCR is sent, but oseltamivir is started immediately due to high-risk status and hypoxia; he receives bronchodilators, steroids for COPD exacerbation if indicated, oxygen, and is admitted.

Study Directive

  • Memorize influenza high-risk categories and indications for antivirals beyond 48 hours.
  • Practice disposition decisions using 3 mock cases: healthy young adult, pregnant patient, elderly COPD patient.
  • Review local influenza testing and isolation policy.
  • Write out adult antiviral doses from memory, including oseltamivir, baloxavir, zanamivir, and peramivir.
  • Compare viral influenza pneumonia vs secondary bacterial pneumonia on timing, exam, and CXR findings.

Recent Literature