USMLE Step 3: Red Flag Emergency Orders
Life-Saving Interventions That Must Be Ordered Immediately
🚨 Critical Principle: On Step 3 CCS, if you delay stabilization while ordering labs, your score plummets — even with correct diagnosis.
First-Click Priority
100%
Oxygen
Nasal cannula, mask, or intubation if needed
📌 First response for any respiratory distress
Intubation / mechanical ventilation
Secure airway for compromised breathing
📌 AMS, severe hypoxemia, impending respiratory failure
ABG
Arterial blood gas analysis
📌 Any acute respiratory distress
Nebulized bronchodilators
Albuterol/ipratropium for bronchospasm
📌 Asthma/COPD exacerbation
Epinephrine IM
Immediate treatment for anaphylaxis
📌 Anaphylaxis with airway compromise
IV access ×2 large-bore
Secure adequate venous access
📌 Unstable patient, shock, trauma (or central line)
IV fluids bolus
NS or LR for volume resuscitation
📌 Hypotension, sepsis, DKA, trauma
Blood transfusion
Replace blood loss
📌 GI bleed, trauma with unstable vitals, Hgb <7 in ICU
Vasopressors
Norepinephrine for blood pressure support
📌 Septic/cardiogenic shock not responding to fluids
Defibrillation / cardioversion
Electrical therapy for arrhythmias
📌 Unstable arrhythmias (VT/VF, rapid afib with hypotension)
Aspirin + Heparin
Antiplatelet + anticoagulant therapy
📌 Suspected ACS (unless contraindicated)
Head CT (non-contrast STAT)
Immediate brain imaging
📌 Stroke, ICH, trauma with AMS
tPA or thrombectomy consult
Reperfusion therapy for ischemic stroke
📌 Ischemic stroke within treatment window
Mannitol / hypertonic saline
Osmotic therapy for increased ICP
📌 Increased ICP/herniation signs
Anticonvulsants
Lorazepam → phenytoin for seizure control
📌 Seizure/status epilepticus
Empiric IV antibiotics immediately
Broad-spectrum antibiotic therapy
📌 Sepsis, meningitis, neutropenic fever
Broad coverage first, culture second
Time-sensitive antibiotic administration
📌 Timing > precision for Step 3
Dexamethasone
Adjunctive steroid therapy
📌 Bacterial meningitis (with/just before antibiotics)
OB consult STAT
Immediate obstetric consultation
📌 Ectopic, preeclampsia/eclampsia, fetal distress
Magnesium sulfate
Seizure prophylaxis in preeclampsia
📌 Eclampsia, severe preeclampsia
Antihypertensives
Labetalol, hydralazine for severe hypertension
📌 Severe preeclampsia/HTN emergency
Type & cross / laparotomy
Prepare for surgical intervention
📌 Ruptured ectopic pregnancy
NPO, IVF, IV antibiotics, surgical consult
Preoperative preparation
📌 Acute abdomen, appendicitis, perforation
FAST exam / Trauma CT
Rapid trauma assessment
📌 Blunt trauma assessment
Cervical spine immobilization
Spinal protection
📌 Trauma patient with neck injury risk
Tetanus prophylaxis
Prevention of tetanus infection
📌 Wound management
Why This List Matters
First-Click Priority
These are the first orders in unstable scenarios. The exam engine rewards early, lifesaving action.
Score Impact
If you delay stabilization while ordering 20 labs, your score plummets — even if you eventually diagnose correctly.
Big Points
These "Red Flag Emergency Orders" are worth significant points because Step 3 wants to see if you stabilize the patient first.
Clinical Reasoning
The exam tests whether you recognize life-threatening situations that require immediate intervention before diagnostic workup.