Emergency Medicine Practice

Hypotension can be a sign of significant underlying pathology, and if it is not rapidly identified and addressed, it can contribute to organ injury. Treatment of hypotension is best targeted at the underlying etiology, although this can be difficult to discern early in a patient's disease course. Expedited bedside evaluation with rapid initiation of treatment based on the most likely underlying etiology is paramount, followed by serial reassessment of the patient's condition. This review synthesizes the key aspects of the presentation and evaluation of a patient with hypotension, including salient historical features, physical examination findings, and diagnostic tests that can help guide treatment...

Management of patients who are acutely intoxicated with methamphetamine (a member of the substituted amphetamine class of drugs) can be resource-intensive for most emergency departments. Clinical presentations of the methamphetamine sympathomimetic toxidrome range from mild agitation to rhabdomyolysis, acute kidney injury, seizures, and intracranial hemorrhage. High-quality evidence on how to best manage these patients is lacking, and most research focuses on symptomatic interventions to control patients' agitation and hemodynamics...

Ocular injuries are common in the emergency department, and they are the most frequent cause of noncongenital monocular blindness in children and adults. Systematic evaluation and management of ocular trauma patients will ensure these patients have the best chance for a favorable final visual outcome. This review provides evidence-based recommendations for the diagnosis, treatment, and disposition of patients with traumatic ocular injuries, including retrobulbar hemorrhage, traumatic hyphema, open globe injuries, ocular chemical burns, and corneal abrasions...

Headache is the fifth most common presenting chief complaint in emergency departments, and it is vital to quickly rule out life-threatening secondary causes. Though there are many medications, new and old, that can be used to treat primary headache, the evidence for their effectiveness can be conflicting. This review describes the pathology, workup, and treatment for migraine and other primary headaches based on the best available evidence, including novel medications, nerve blocks, and strategies for preventing postdrome recurrence...

Rectal bleeding accounts for approximately 1 out of every 1000 United States emergency department visits annually. The causes of rectal bleeding are broad, and can range from the benign to the life-threating. This review provides foundational knowledge on rectal bleeding as well as evidence-based recommendations for its evaluation and initial management in the emergency department. Anatomic considerations are discussed, and the differential diagnosis based on risk factors such as age and comorbid conditions is presented...

Patients with pulmonary emboli present both diagnostic and therapeutic challenges to the emergency clinician, because initial symptoms can be variable and overlap with other medical conditions. This issue reviews treatment options for patients with pulmonary emboli based on risk stratification scores of low, intermediate-low, intermediate-high, and high risk classifications. The evidence on laboratory testing and imaging is presented, as well as treatment strategies that include anticoagulation, thrombolytics, and mechanical or surgical thrombectomy...

Acute intracerebral hemorrhage accounts for only a small portion of all stroke presentations, but often leads to a high rate of morbidity and mortality. The presentation of patients with ICH is often similar to other stroke patients and requires rapid recognition, imaging, and evaluation. Treatment begins in the emergency department and focuses on correction of abnormal coagulopathies, blood pressure reduction, emergent treatment of intracranial hypertension, and recognition of those in need of urgent surgical decompression...

Pericarditis and myocarditis represent a challenging set of diseases to diagnose and treat. These diseases typically present with chest pain and dyspnea in previously healthy young people, often in the weeks following a viral illness, including COVID-19. Nonetheless, the etiologies can be very diverse, including infectious, noninfectious, drug-induced, and autoimmune causes. This review focuses on the evaluation, diagnosis, and management of emergency department patients presenting with pericarditis and myocarditis and summarizes current guidelines and best-practice medical management strategies in order to avoid potential life-threatening cardiac complications...

Due to a variety of demographic and public health factors, the number of emergency department visits related to hypertensive emergencies has increased dramatically in recent decades, making it imperative that clinicians clearly understand the current treatment guidelines and definitions for the spectrum of hypertensive disease. This issue reviews current evidence on identifying and managing hypertensive emergencies and the differences between expert opinions on diagnosing and managing these emergencies. Clear protocols differentiating patients with hypertension from patients with hypertensive emergencies are needed to appropriately manage this patient population...

There are over 150,000 reports to American Poison Centers every year due to foreign body ingestions, and many patients will be directed to emergency departments for evaluation and management. This comprehensive review evaluates the current literature related to gastrointestinal foreign body diagnosis and management. A discussion of the utility of various imaging modalities is presented, along with a description of high-risk ingestions and the evidence behind society guidelines and management strategies. Finally, controversies in the management of esophageal impactions are reviewed, including the use of glucagon...

Intimate partner violence (IPV) and emergency medicine intersect when individuals experiencing IPV present to emergency departments for medical care, either on their own or when brought in by law enforcement authorities for medical evaluation and social services. Coordination of care is required, with particular attention paid to the sensitive nature of the patient's presentation and with an emphasis on trauma-informed care. Emergent medical needs must be balanced with concerns for the patient's emotional well-being and the need for advocacy and social services...

Education regarding ballistic injuries in the emergency department is sparse and may rarely be encountered if not training or practicing in a trauma center or a military wartime setting. This article provides a comprehensive review on the management of ballistic injuries in the emergency department, including how to assess and manage gunshot wounds, how to recognize when further imaging or evaluation is needed, and how to recognize when transfer to another facility is required. Algorithms are proposed for the management of gunshot wounds based on body part: head, neck, chest and abdomen, and extremities/soft tissue...

Stroke in patients with endocarditis is a unique, highly morbid condition requiring a high index of suspicion for diagnosis. This issue reviews the historical and physical examination factors that can provide clues to the etiology. The workup of these patients, involving both infection-focused and stroke-focused laboratory testing and neuroimaging, is discussed. The mainstay of treatment is empiric antibiotics, as thrombolytics are contraindicated. Recent evidence regarding the use of mechanical thrombectomy in largevessel occlusion strokes is discussed, as well as surgical options and consultation strategies with stroke, neurocritical care, infectious disease, and neurosurgery teams...

Managing patients with blast injuries can challenge emergency department operations, as patients can present in multiple waves, with occult or delayed injuries, and by personal transport, without standard prehospital care. Rapid and effective triage and evaluation includes approximation of blast proximity, determination of the category of blast - primary to quinary - and assessment of the body systems that are most likely to be injured from the type, location, and mechanism of the blast. This issue reviews the physics of the various types of explosions, how this affects the types of injuries that may be seen, and recommended treatments...

Approximately one-quarter of emergency department patients who are injured or experience medical emergencies will develop clinically significant posttraumatic stress disorder (PTSD) symptoms, which can evolve into PTSD. Emergency clinicians and rapid response teams (eg, trauma, cardiac, stroke) can play a critical role in recognizing symptoms of posttraumatic stress and providing early distress management techniques, screening, and referral to services that may mitigate the development of PTSD. This review summarizes the existing literature on psychological distress related to events that trigger the need for emergency care and synthesizes cutting-edge approaches that may impact patient outcomes...

Pelvic inflammatory disease is associated with complications that include infertility, chronic pelvic pain, ruptured tubo-ovarian abscess, and ectopic pregnancy. The diagnosis may be delayed when the presentation has nonspecific signs and symptoms. Even when properly diagnosed, pelvic inflammatory disease is often treated suboptimally. This review provides evidence-based recommendations for the diagnosis, treatment, disposition, and follow-up of patients with pelvic inflammatory disease. Arranging follow-up of patients within 48 to 72 hours and providing clear patient education are fundamental to ensuring good patient outcomes...

Emergency clinicians are often responsible for the acute management of complications pertaining to both the acute difficult airway and the chronic surgical airway; however, clinical knowledge and/or experience may be lacking. This review provides an overview of surgical airway complications, which can be a result of mechanical, infectious, or hematologic causes, and provides best-practice recommendations. Current consensus guidelines for the management of the difficult airway and indications for a surgical airway are discussed...

Angioedema is a histamine- or bradykinin-mediated response that can be acquired, hereditary, or idiopathic. Manifestations include nonpitting edema of the subcutaneous layer of the skin or submucosal layers of the respiratory or gastrointestinal tracts. While acute presentations are typically transient and localized, angioedema can result in acute airway compromise, requiring immediate stabilization. It can also result in abdominal pain that is commonly misdiagnosed, resulting in unnecessary and potentially harmful procedures...

Cardiogenic shock, cardiac arrest, and circulatory failure are life-threatening, and recognizing the underlying etiology and initiating treatment to promote perfusion are key to managing these patients and improving outcomes. This issue reviews the current evidence on diagnosis and management of cardiogenic shock, including oxygen supplementation, red blood cell transfusion, vasopressors, and inotropes. A summary of the various mechanical circulatory support options, including inclusion/exclusion criteria and admission and inter-facility transfer guidance, is included...

Valvular heart disease is becoming more prevalent as the United States' population ages, with aortic and mitral valves most commonly affected. Complications, including syncope, heart failure, dyspnea, and chest pain, can arise from slow progression of stenosis and regurgitation, though acute regurgitation from an ischemic or traumatic event can be life-threatening. Patients with valvular disease may present with cardiogenic shock, and vasoactive agent treatment will depend on determination of the valvular etiology...