We will review select aspects of clinical presentation, epidemiology, initial diagnostic testing, prophylaxis and treatment of important fungal infections. Both superficial and invasive mycoses will be discussed. Multiple new diagnostic tests for fungal infections, including serology-based, molecular-based, and next generation sequencing tools, are emerging. Novel treatments include both testing new molecules and repurposing old pharmaceuticals for antifungal activity. Awareness is increasing of the importance of timely diagnosis and aggressive treatment of fungal ocular disease. Recent papers highlight the association between severe viral diseases, including COVID-19, and invasive fungal infections and the potential for sexual spread of certain kinds of dermatophytoses. The growing burden of fungal infections, along with the emergence of novel pathogens and resistance to existing antifungal agents, make it important for clinicians to stay informed of new approaches in prophylaxis, diagnosis and management of fungal disease.
To review the current evidence and examine the evolving landscape of the diagnosis and management of nonconvulsive status epilepticus (NCSE). Nonconvulsive status epilepticus (NCSE) is a state of ongoing seizure activity without prominent motor convulsions. It is one of the most challenging and rapidly evolving areas in emergency medicine and critical care. Once considered a rare and largely academic diagnosis, NCSE is now recognized as a common cause of mental status changes in critically ill patients and accounts for a substantial proportion of status epilepticus presentations in emergency departments and intensive care units. Compared to convulsive status epilepticus, NCSE presents in clinically subtle ways which often makes it challenging to diagnose and manage.The widespread adoption of continuous electroencephalogram (cEEG) monitoring has changed our understanding of seizure activity in critically ill patients, in that, clinicians are able to identify electrographic seizures without overt clinical manifestations. This has raised important questions regarding identification, clinical significance, and management of NCSE. Rapid short term EEG systems now allow for bedside assessment within minutes to hours, reducing delays that historically limited timely diagnosis. Similarly, artificial intelligence (AI) assisted EEG interpretation is emerging as an efficient tool for diagnosing seizures in clinical settings where resources are limited. These innovations have led to not only increased access to EEG monitoring but to clinicians making earlier identification and treatment decisions. This chapter reviews the evolving concepts surrounding NCSE emphasizing advances in EEG technology, contemporary diagnostic criteria, seizure burden assessment, and emerging therapeutic strategies. We aim to provide emergency physicians with a practical framework for recognizing, interpreting, and managing this subtle but impactful neurological emergency.
Unregulated opioids often contain various adulterants, such as alpha-2 agonists, benzodiazepines, and stimulants. Medetomidine, an alpha-2 agonist, has emerged in the United States and has been linked to significant toxicity and severe withdrawal symptoms. This narrative review reviews medetomidine toxicity and withdrawal with a focus on management in the acute care setting. There is significant regional variation in the prevalence of secondarily added adulterants, and regions of the Northeast United States are experiencing high prevalence of medetomidine adulteration. Medetomidine exposure is associated with hypotension, bradycardia, and profound sedation. Naloxone will only reverse respiratory depression from concomitant opioid use without affecting the toxicity of medetomidine, making management largely supportive. Chronic exposure to medetomidine can lead to withdrawal with discontinued use. Patients with medetomidine withdrawal can be critically ill due to a catecholamine surge and sympathetic hyperactivity. Signs and symptoms begin within 6–24 h of last use, often before opioid withdrawal develops, typically with hypertension, tachycardia, anxiety, tremor, diaphoresis, nausea, vomiting, and hypoactive delirium. Treatment for medetomidine withdrawal includes alpha-2 agonists such as clonidine, guanfacine, tizanidine, or dexmedetomidine and antiemetics. Patients with opioid use disorder may be exposed to medetomidine as an adulterant which can cause severe illness in overdose and withdrawal. Patients in withdrawal should be treated with alpha-2 agonists and may require hospital admission, including to a critical care setting for severe withdrawal, and concomitant opioid withdrawal may be treated with agents such as buprenorphine or methadone.
This review summarizes the current evidence supporting the use of point-of-care ultrasound (POCUS) in the evaluation of acute ocular emergencies encountered in acute care settings, with an emphasis on sonographic findings, diagnostic performance, and clinical applications. Recent evidence supports ocular POCUS as a rapid and reliable bedside tool for the assessment of several vision-threatening conditions, particularly retinal detachment, vitreous hemorrhage, lens dislocation, central retinal artery occlusion, elevated intracranial pressure, Studies demonstrate high diagnostic accuracy for retinal detachment and lens dislocation, acute angle closure glaucoma, central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), giant cell arteritis (GCA), endophthalmitis, and retrobulbar hematoma, while diagnostic performance for posterior vitreous detachment and globe rupture remains more inconsistent. Emerging developments in ultrasound use include AI-assisted image interpretation and automated optic nerve sheath analysis, which may improve diagnostic consistency and broaden its utility in resource-limited settings. Ocular POCUS has become an increasingly valuable adjunct in acute care settings, enabling rapid triage and earlier recognition of time-sensitive ophthalmologic emergencies when formal ophthalmologic evaluation and other imaging is delayed or unavailable. Although limitations including operator dependence and pathology-specific variability remain, continued advances in training and image analysis technology are likely to further expand its clinical role.
Seizure activity in pregnancy poses a unique challenge. Emergency clinicians must rapidly distinguish between pre-existing epilepsy, new-onset seizure disorders, and pregnancy-specific etiologies while simultaneously balancing maternal stabilization and fetal safety. This review summarizes the emergency evaluation and management of seizures in pregnant patients across all trimesters and the postpartum period. Key considerations include physiologic changes in pregnancy, fetal risks associated with antiseizure medications, and the importance of avoiding abrupt medication withdrawal. Diagnostic evaluation should focus on identifying reversible triggers, excluding life-threatening etiologies, and assessing for pregnancy-related complications. Neuroimaging, electroencephalography, laboratory testing, and fetal monitoring should be tailored to gestational age and clinical presentation. Management of acute seizure activity in pregnancy differs from standard care in several ways and often requires a multidisciplinary approach to optimize maternal stabilization, fetal outcomes, and long-term neurologic care.
This review will comprehensively assess the role and efficacy of deep-learning artificial intelligence (AI) models in assisting with the diagnosis and management of facial fractures in the emergency department (ED), with secondary emphasis on their implications for ED triage, disposition, and immediate management. Convolutional neural network– and transformer-based models now achieve near-expert diagnostic performance for mandibular, orbital, zygomatic, and nasal fractures across panoramic radiography, CT, and cone-beam CT, although performance is weaker for condylar/condylar-neck fractures and for occult or subtle injuries. Multi-reader, multi-case studies—drawn mostly from general skeletal rather than facial-specific trauma—show that AI assistance narrows the accuracy gap between emergency physicians and radiologists, roughly halving fracture miss rates and modestly shortening reading time, with a smaller body of evidence linking this to measurable ED outcomes such as reduced length of stay. Adjunctive technologies are maturing alongside diagnostic AI. Point-of-care ultrasound offers a radiation-free but operator-dependent triage option. Automated deep-learning segmentation has compressed virtual surgical planning and 3D-printing timelines from tens of minutes to as little as one to five minutes, supporting same-day operative readiness. Intraoperative navigation and augmented reality improve reduction accuracy and reduce operative time, and telemedicine networks reduce unnecessary inter-facility transfers and expedite specialist consultation. Early work also applies machine learning and large language models to predict surgical need and support management decisions. Across this literature, methodological limitations are prominent, as most studies are single-center and retrospective, external validation is uncommon, and no published study has yet measured the widespread effect of these tools on patient outcomes. AI and adjunctive technologies demonstrate strong and consistent diagnostic accuracy and workflow benefits for facial fracture care, but the evidence base remains largely proof-of-concept relative to real-world ED implementation. Prospective, multicenter studies directly measuring triage time, disposition accuracy, and patient outcomes, together with greater attention to generalizability and equitable access, are needed before these tools can be considered standard components of ED facial fracture management.
Emergency airway checklists are increasingly used in emergency medicine, critical care, anesthesiology, and prehospital systems to improve preparation, reduce omissions, and support team communication during airway management. Despite widespread adoption, there remains no broadly accepted framework defining optimal airway checklist structure, operational design, or bedside usability. The purpose of this review was to identify the core operational and human-factor characteristics associated with effective airway checklists and propose a generalized framework for future airway checklist development. A focused comparative review was conducted using a representative emergency department (ED) airway cart checklist alongside major published airway checklist models and guideline-supported frameworks, including those from the Difficult Airway Society (DAS), Society of Critical Care Medicine (SCCM), New South Wales/Agency for Clinical Innovation (NSW/ACI), and EmergencyCareBC. Across reviewed airway checklists, the most consistently high-yield elements included role allocation, oxygenation strategy, suction readiness, physiologic optimization, backup airway planning, escalation pathways, and post-intubation confirmation with waveform capnography. Operationally effective checklists emphasized brevity, visual clarity, and compatibility with verbal bedside workflow, whereas excessive medication dosing information, troubleshooting algorithms, and reference-style content frequently reduced usability during time-sensitive airway management. Airway checklist effectiveness appears to depend as much on usability and implementation as on content completeness. High-functioning checklists prioritize omission-prone tasks, communication structure, physiologic preparation, and deliberate escalation while minimizing unnecessary cognitive burden. This review proposes a generalized airway checklist design framework emphasizing concise read-aloud workflow, explicit backup planning, and post-intubation stabilization.
To provide physicians with a clear, evidence-based, and practical approach to transitioning from aggressive fluid loading to fluid restriction and early de-resuscitation in the management of sepsis and septic shock in the emergency department (ED) and inpatient settings. This review outlines a five-step clinical framework that integrates current landmark trial data, pathophysiological insights, and specific diagnostic tools to mitigate fluid accumulation syndrome. While initial fluid resuscitation remains a cornerstone of early sepsis care, emerging evidence highlights that cumulative positive fluid balance is independently associated with significant morbidity and elevated mortality. Recent multi-center randomized controlled trials (such as CLOVERS and CLASSIC) demonstrate that a restrictive fluid strategy utilizing early vasopressors is safe and prevents the destructive downstream effects of tissue edema and organ compartment syndromes. Fluid management is not a static triage checkbox in septic shock. Physicians must actively guide septic patients through the distinct phases of fluid resuscitation. A structured, five-step clinical framework can help emergency clinicians identify when further crystalloids are harmful, when to shift to early vasopressors, and how to execute early fluid stewardship and de-escalation directly from the frontline of care.
Cellulitis is a soft tissue infection commonly seen in the emergency department (ED). It is associated with a high rate of misdiagnosis, often leading to inappropriate interventions. This review examines both traditional and emerging imaging modalities used in the diagnosis of cellulitis in the acute care setting, evaluating their individual diagnostic utility and respective limitations. Many different imaging modalities have been studied for the diagnosis of cellulitis in the ED. Ultrasound remains the most clinically useful first-line tool, given its ability to regularly alter treatment plans and limit surgical interventions at the bedside. Emerging modalities, such as near-infrared spectroscopy and hyperspectral imaging, also show potential as adjunctive imaging techniques, although their indications for use in diagnosing cellulitis remain speculative. No single imaging modality appears poised to provide a definitive solution to the high rates of misdiagnosed cellulitis in the ED. In fact, emerging technologies will likely serve as adjuncts to traditional techniques, rather than replacing them entirely. Large prospective studies comparing various diagnostic imaging modalities in cellulitis populations are needed to develop more effective evidence-based imaging protocols.
Pediatric emergencies in general and community hospitals, where most children are seen, are infrequent and cognitively demanding, and deviation from resuscitation algorithms is common despite certification. This review treats that as a failure of execution under load rather than a knowledge deficit, and reads together two separately developed literatures: head-mounted augmented reality (AR) guidance, which externalizes the algorithm, and real-time physiological sensing, which estimates the clinician’s cognitive state. Controlled trials of head-mounted guidance report improved guideline adherence and fewer dosing errors in simulation, but effects are inconsistent across outcomes, samples are small, endpoints are process measures, and some interventions slow performance or raise workload. Cognitive-state classification is accurate within individuals but generalizes poorly across them, and the signals index arousal and effort rather than load. The adaptive combination has been proposed but never tested. Adaptive guidance needs controlled comparison against static guidance with cognitive load and performance as co-primary outcomes, models that generalize across clinicians, and patient-level rather than simulation-only endpoints.
This review explores the literature guiding blood pressure (BP) management across three domains: acute ischemic stroke (AIS), intracranial hemorrhage (ICH), and subarachnoid hemorrhage (SAH). It aims to reinforce important physiologic mechanisms following stroke, summarize current guideline recommendations, and highlight areas of continued uncertainty and discordance. Emerging evidence reinforces that BP management must be tailored to stroke type, treatment eligibility, and individual factors. In AIS, recent data show no clear benefit to early, aggressive BP control in patients who are not thrombolytic candidates. Strict thresholds are still crucial for patients undergoing thrombolysis and thrombectomy. For ICH, newer trials have proposed that early lowering to systolic blood pressure (SBP) 130–150 mmHg is safe and may improve functional outcomes, especially when conducted in bundled care pathways. Substantial BP variability and excessive BP lowering or “overshooting” (SBP < 120 mmHg) continue to be associated with harm. Randomized controlled trials (RCTs) in SAH remain limited, though gradual reduction to SBP 140–160 mmHg and avoidance of large BP fluctuations are recommended to balance both re-bleeding and ischemia risks. Optimal BP management in acute stroke necessitates an individualized, patient-centered approach that weighs both perfusion and risk of hemorrhage. Regardless of stroke type, preventing hypotension and large BP variability is essential. While research is ongoing to refine timing and methods of BP control, we propose adoption of bundled care pathways to standardize care and improve patient outcomes.
Gastrointestinal (GI) bleeding in children is a high-stakes emergency department presentation whose etiological spectrum differs fundamentally from that of adults, shifting markedly across the neonatal, infant, toddler, and adolescent age groups. This narrative review synthesizes current evidence on the evaluation and management of pediatric upper and lower GI hemorrhage, presenting an age-stratified etiological framework spanning necrotizing enterocolitis in neonates to inflammatory bowel disease in adolescents, while critically appraising the adequacy of adult-derived diagnostic and risk-stratification tools when extrapolated to children. Fewer than 20
Emergency department (ED) triage prioritizes patient care based upon a patient’s presenting medical condition at the time of arrival. However, variability and errors in human triage can lead to mistakes. This review focuses upon recent evidence for the use of artificial intelligence (AI) in ED patient triage, including both current use and potential future applications. Emergency departments are increasingly exploring the use of AI to facilitate improved triage success in areas such as patient wait time, patient satisfaction, and the speed of care transition from the ED. The use of AI algorithms is associated with higher triage accuracy when compared to triage by non-physician workers, particularly in the case of atypical patient presentations. Triage methods using this technology can help to decrease the time required to properly allocate patients to definitive care, further mitigating the effects of ED overcrowding. Although AI already shows great potential in this application, evidence remains limited.
Rib fractures are common in emergency care and are associated with substantial morbidity driven by pain-related hypoventilation and pulmonary complications. Contemporary management is shifting toward early, opioid-sparing multimodal strategies and broader use of ultrasound-guided regional analgesia. This review summarizes recent evidence relevant to clinicians treating rib fracture pain in the emergency department. Recent reviews and practice guidance emphasize that multimodal regimens can reduce opioid exposure while maintaining analgesic effectiveness. Ultrasound-guided thoracic nerve blocks, including erector spinae plane, serratus anterior plane, and intercostal approaches, are increasingly described as feasible in the emergency department with favorable safety profiles when performed with appropriate technique. In older adults with multiple rib fractures, regional techniques have been associated with clinically meaningful improvements in patient-centered outcomes such as delirium risk in observational data. Important evidence gaps remain, however, and standardized care pathways are still evolving. Rib fracture pain management is increasingly outcomes-driven and opioid-sparing. Early multimodal pharmacotherapy should be paired with consideration of ultrasound-guided regional analgesia for selected patients, particularly those at higher risk for opioid-related adverse effects or pulmonary decline. Protocolized, emergency department-based approaches may improve timeliness and consistency of care.
Pediatric MCIs across prehospital, field, and emergency department settings in resource-limited environments pose grave risks due to children’s physiological vulnerabilities compounded by systemic shortages of equipment, medications, and specialized staff. To evaluate evidence-based strategies for pediatric mass casualty management in resource-limited environments, encompassing triage protocols, crisis standards of care, field-adapted innovations, and psychosocial support. This synthesis integrates evidence from PubMed literature (2010–2025), WHO/ICRC guidelines, and field data from 17 disaster responses (Nepal earthquake, Syrian refugee crises, Gaza conflict). We evaluated: triage protocols (JumpSTART, ETAT+), CSC, improvised medical devices, psychosocial and family-centered interventions. JumpSTART triage reduced pediatric errors by 40
Pediatric resuscitation is a high-stakes, low-frequency clinical challenge disproportionately encountered in community emergency departments. This review evaluates Extended Reality (XR) - encompassing Virtual Reality (VR), Augmented Reality (AR), and Mixed Reality (MR) - as a scalable adjunct to traditional simulation-based training for supporting pediatric resuscitation readiness and mitigating the limitations of episodic training in low-volume emergency settings. Emerging evidence suggests VR supports cognitive rehearsal and algorithm fluency, with studies demonstrating acceptable performance on selected CPR metrics, high learner acceptability, and short-term knowledge retention. AR shows promise for anatomical visualization and procedural guidance in airway management training. However, the evidence base remains heterogeneous, predominantly involving laypersons, undergraduate learners, and adult CPR contexts, with limited pediatric emergency department-specific data. Fully immersive VR systems demonstrate insufficient haptic fidelity for psychomotor skill acquisition, and no established link to patient-level outcomes has yet been demonstrated. Extended reality represents a promising adjunct - not a replacement - in the landscape of pediatric resuscitation training. In low-volume emergency settings where traditional simulation is insufficient to maintain competency at the required frequency, VR and AR may complement existing approaches by supporting cognitive rehearsal, algorithm fluency, and procedural familiarity. Integration into clinical workflows, competency frameworks, and quality improvement systems warrants further structured evaluation. Future research should prioritize objective performance metrics, pediatric clinician populations, and patient-level outcomes to guide broader adoption.
Malnutrition is a significant and global threat in pediatric emergency departments (PEDs), associated with nearly half of all deaths in children under the age of 5. While low and middle-income countries (LMICs) face life-threatening severe acute malnutrition (SAM), high- income countries (HICs) increasingly deal with obesity related complications. This review describes the epidemiology and clinical profiles of nutritional emergencies (NEs) in PEDs, summarizes evidence-based management strategies, including the WHO 10- step protocol and discusses the systemic approaches to strengthen the global PED response. Globally, an estimated 13.6 million children under 5 suffer from SAM, with hospital case fatality rates ranging from 10 to 30
The intensive care unit (ICU) cares for some of the most medically complex and vulnerable patients in healthcare. These patients are particularly susceptible to developing surgical emergencies, ranging from intra-abdominal sepsis in the setting of malignancy-associated neutropenia to life-threatening gastrointestinal hemorrhage related to advanced liver disease and portal hypertension. In this review, we examine emerging artificial intelligence (AI) applications that may enhance decision-making in critically ill surgical patients, particularly in settings characterized by physiologic instability, diagnostic uncertainty, and fragmented data. AI represents a promising approach for synthesizing and interpreting the large volumes of multimodal data generated in the ICU, with the goal of producing more timely and accurate clinical insights for critically ill surgical patients. Early applications of AI have demonstrated potential across several domains, including risk prediction, diagnostic support, computer vision-enabled monitoring, and triage or resource allocation. Emerging advances in multimodal and continuously learning models may further enhance AI’s ability to capture the dynamic trajectory of critical illness and adapt to evolving practices and protocols among intensivists and surgeons. The translation of AI into critical care and emergency surgery settings will require more than technical innovation. These systems must be supported by rigorous evidence of clinical benefit, safely incorporated into high-acuity, high-stakes clinical workflows, and implemented in ways that preserve, and ultimately augment, high-quality clinician training, expertise, and judgment.
Traumatic peripheral nerve injuries (PNIs) are high-stakes presentations in the emergency department (ED). Missed deficits and delayed referral can lead to functional loss and chronic neuropathic pain. This review summarizes an ED-centered approach to evaluation, early risk stratification, and management pathways. Contemporary epidemiology suggests PNIs after extremity trauma occur at clinically meaningful rates. High-resolution ultrasound and neuromuscular ultrasound can visualize nerve continuity, focal enlargement, traumatic neuroma, and entrapment, though performance depends on operator skill and nerve depth. Magnetic resonance neurography complements ultrasound for deeper nerves, plexus-level injury, and muscle denervation patterns. Electrodiagnostic testing remains central for localization and prognosis but is usually most informative in the subacute period. ED care should integrate mechanism-based suspicion, nerve-specific examination with repeat post-reduction reassessment, selective imaging when it changes decisions, timely surgical consultation for suspected transection/entrapment/progression, and clear documentation with structured follow-up. We recommend an emergency department approach to traumatic peripheral nerve injury that prioritizes early recognition, identification of time-sensitive lesions, and a closed-loop follow-up plan when observation is appropriate. Every at-risk extremity trauma should receive a nerve-specific motor and sensory exam documented before and after reduction, splinting, or casting, because evolving deficits can reflect entrapment, hematoma expansion, ischemia, or compartment syndrome. When mechanism and exam raise concern for high-grade injury, particularly sharp lacerations with motor loss, open fractures with neurologic deficit, progressive weakness after immobilization, or deficits out of proportion to pain, urgent surgical consultation is warranted. High-resolution ultrasound adds the most value when it answers a focused question that changes acute decisions, specifically whether the nerve is in continuity, whether there is focal compression by hematoma or displaced fragments, and whether post-reduction positioning is producing dynamic impingement. In stable closed injuries with preserved continuity and no red flags, we favor functional splinting, multimodal analgesia, and early specialty follow-up with a planned timeline for electrodiagnostic testing in the subacute period to localize injury and guide prognosis. For suspected deep nerve or plexus involvement, equivocal ultrasound, or complex regional injury patterns, magnetic resonance neurography can complement ultrasound by defining lesion extent and demonstrating denervation patterns that influence urgency. Overall, ED success depends less on assigning a perfect injury grade at presentation and more on reliably detecting injuries unlikely to recover spontaneously, reassessing after interventions, and ensuring timely definitive nerve evaluation.
It is important for physicians to understand the late effects of chimeric antigen receptor T-cell (CAR T) therapy because more cancer survivors are presenting to the emergency department (ED) months to years after treatment, often with atypical or life-threatening complications. CAR T therapy, used for hematologic malignancies such as diffuse large b cell lymphoma, B cell acute lymphoblastic lymphoma, mantle cell lymphoma and multiple myeloma. As CAR T use expands, ED clinicians will increasingly encounter these patients, making familiarity with long-term complications an essential component of emergency care. One major concern is prolonged cytopenias and hypogammaglobulinemia, which increase the risk of severe or opportunistic infections. Physicians must recognize that fever in a patient who has previously received CAR T may represent overwhelming sepsis even in the absence of typical inflammatory responses. Early appropriate antibiotic administration and rapid evaluation are critical. CAR T therapy alters immune function in complex and sometimes prolonged ways, awareness of its late effects improves diagnostic accuracy, prevents delays in life-saving treatment, and reduces morbidity and mortality both in the ED and in the hospital. Chimeric antigen receptor CART -cell therapy has revolutionized the treatment of hematologic malignancies, achieving unprecedented response rates. However, the long-term effects of this powerful immunotherapy are increasingly recognized as a critical aspect of patient care. This review explores the late effects of CART -cell therapy, focusing on hypogammaglobulinemia, prolonged cytopenias, and late infections, encompassing bacterial, fungal, parasitic, and viral etiologies. Additionally, this review will discuss ways in which these conditions can be treated in an acute care setting.
