Emergency Medicine Practice

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...

An acute allergic reaction is a rapid-onset, IgE-mediated hypersensitivity reaction. Although it is most commonly caused by food, insect stings, and medications, there are many additional causes. Symptoms can range from mild urticaria and swelling, to abdominal cramping, to respiratory collapse. Anaphylaxis and anaphylactic shock are the most severe, life-threatening forms of allergic reaction, with fast onset and decompensation, requiring urgent airway monitoring and support. This issue reviews the current evidence on managing allergy and anaphylaxis with epinephrine, and reviews the evidence on corticosteroids, antihistamines, and other adjunctive therapies...

Procedural sedation is a common procedure performed in the emergency department and is a fundamental skill for emergency clinicians. With a wide variety of procedures and patient populations, procedural sedation can be systematically tailored to individual patients' needs, in order to optimize safety and efficacy. This evidence-based review distinguishes the various levels of sedation, provides insight on which patients are appropriate for procedural sedation, lists adjuncts that should be used, and reviews considerations for special populations...

Cellulitis and other skin and soft-tissue infections (SSTIs) are common presentations in the emergency department. This review describes the varied etiologies and patient presentations of the more common SSTIs: cellulitis, abscesses, and necrotizing soft-tissue infections. A discussion of the common diagnoses masquerading as SSTIs is presented, as well as a stepwise approach to avoiding misdiagnosis. Diagnostic studies are also evaluated, including discussions on ultrasound, computed tomography, and clinical decision rules...

Pneumothorax, or air in the pleural space, is common in trauma, and has been found in up to 50% of severe polytrauma patients with chest injury. Findings associated with pneumothorax include dyspnea, chest pain, tachypnea, and absent breath sounds on lung auscultation. Although pneumothorax is traditionally diagnosed on plain film and confirmed with CT, the advent of portable ultrasonography has provided a way to rapidly diagnose pneumothorax, with a higher sensitivity than plain film. Patients with traumatic pneumothorax are typically treated with needle decompression or tube thoracostomy...

Infectious meningitis and encephalitis are often life-threatening illnesses, though prompt workup and targeted treatment can greatly reduce morbidity and mortality. Although presentation of central nervous system infection can sometimes be subtle, this issue focuses on evidence-based strategies for identifying combinations of signs and symptoms to narrow the diagnosis. Identifying meningitis versus encephalitis; bacterial versus viral, fungal, or iatrogenic causes; and providing prompt empiric antimicrobials and appropriate diagnostic testing are key to management...

Postpartum patients may present to the emergency department with complaints ranging from minor issues, requiring only patient education and reassurance, to severe, life-threatening complications that require prompt diagnosis and multidisciplinary consultation and management. At times, vague presentations or overlapping conditions can make it difficult for the emergency clinician to recognize an emergent condition and initiate proper treatment. This issue reviews the major common emergencies that present in postpartum patients, by chief complaint, including hemorrhage, infection, pre-eclampsia, eclampsia, headache, and cardiopulmonary conditions, and reviews the most recent evidence and guidelines...

Emergency clinicians must have a high index of suspicion and a judicious approach to evaluating the chief complaint (ie, headache) of patients with suspected subarachnoid hemorrhage, as accurate initial diagnosis and management are critical to optimizing outcomes. Aneurysmal subarachnoid hemorrhage accounts for a small percentage of strokes, but contributes significantly to the morbidity rate in stroke. The diagnosis is challenging and has devastating consequences if missed. This review evaluates the literature and current evidence, including controversies and recent guidelines, to support a best-practice approach to the diagnosis and treatment of patients with spontaneous subarachnoid hemorrhage...

Asthma is a disease of the airways characterized by inflammation, hyperresponsiveness, and bronchoconstriction. The diagnosis is primarily a clinical one, based on a focused history and physical examination, to differentiate from other entities such as heart failure, pneumonia, and pulmonary embolism. Radiographs, laboratory studies, and blood gases are not routinely recommended, except in atypical or refractory cases, or if there is diagnostic uncertainty. The cornerstone of acute asthma treatment includes short-acting beta agonists, anticholinergics, and systemic corticosteroids...