Intracranial hemorrhage following intravenous thrombolytic therapy most commonly occurs within 12 hours of administration. Because many patients remain in the emergency department during this period, a structured, time-sensitive approach to recognition and management is critical. This review summarizes current recommendations for the diagnostic workup, use of reversal agents, and escalation of care for postthrombolysis intracranial hemorrhage, with particular attention to guidelines addressing stroke and neurocritical care management. Contraindications to intravenous thrombolysis and risk factors for postthrombolysis intracranial hemorrhage are also discussed.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but potentially fatal mucocutaneous emergencies that exist on a spectrum and are most commonly caused by a medication reaction. Although data guiding diagnosis and management remain limited, early recognition, prompt identification and discontinuation of the causative agent, symptomatic management, and multidisciplinary involvement are essential to improving patient outcomes. Validated prognostic tools can further guide management decisions. This review provides an evidence-based approach to the recognition and management of SJS/TEN in the emergency department.
Heat-related illness encompasses a spectrum of conditions ranging from heat cramps and heat exhaustion to life-threatening heat stroke, all resulting from impaired thermoregulation under excessive environmental heat load. The incidence and severity of heat-related illnesses are increasing, underscoring the need for evidence-based emergency management strategies. Accurate diagnosis requires differentiating heat-related illness from conditions that may mimic hyperthermia. Timely recognition and rapid cooling are the cornerstones of management. This review summarizes current evidence on the diagnosis, treatment, and disposition of heat-related illness in the emergency department, with an emphasis on distinguishing heat stroke from conditions with overlapping clinical presentations and on optimizing cooling interventions.
Wide complex tachycardia encompasses a range of cardiac tachydysrhythmias, several of which can be life-threatening, difficult to distinguish, and require distinct treatment approaches. This review summarizes the etiologies and pathophysiology of wide complex tachycardia, outlines the differential diagnosis, and provides an evidence-based approach to distinguishing the various types using the history, physical examination, electrocardiography, and response to intravenous adenosine. Management strategies and disposition decisions are also reviewed, with attention to special clinical circumstances and selected areas of ongoing controversy, including emerging artificial intelligence tools.
Traumatic brain injury is a significant cause of long-term disability and death worldwide. Recent advances in the acute management of traumatic brain injury have improved outcomes across the full spectrum of disease, including severe injury. Early recognition, optimization of oxygenation and perfusion, and appropriate disposition are essential components of care for patients with severe traumatic brain injury. A systematic history and physical examination are critical to identifying life-threatening injuries and guiding timely interventions, including management of elevated intracranial pressure. This review summarizes current evidence-based recommendations for the emergency department evaluation and management of severe traumatic brain injury, highlights ongoing controversies, and identifies key areas for future research.
Acute coronary occlusion is a time-sensitive cardiac emergency that requires early, accurate diagnosis and prompt treatment to restore coronary perfusion, usually by percutaneous coronary intervention. Successful management of these patients demands a highly coordinated effort among emergency medical services, the emergency department, and cardiology. This issue highlights the importance of recognizing distinct electrocardiographic patterns that represent acute coronary occlusion, even in the absence of traditional STEMI criteria, and reviews evidence-based management recommendations.
Syphilis is a sexually transmitted infection known as the "great imitator" due to its large variety of presentations, depending on the stage of the disease. Because of its prevalence and the possibility of severe outcomes, emergency clinicians must remain vigilant when evaluating patients, especially those in high-risk groups. Clinicians should be familiar with the treatment recommendations for the various stages of syphilis, including alternative regimens, when national drug shortages limit the availability of first-line treatments. This review discusses the various presentations, diagnostic options, and potential complications for syphilis, as well as current and emerging treatment recommendations.
Early recognition of stroke in young adults is crucial for effective treatment and mitigation of long-term impact on quality of life. This issue of Emergency Medicine Practice: Stroke EXTRA! offers a comprehensive, evidence-based review of stroke in young adults, including its distinct etiologies, diagnostic complexities, and tailored management approaches. Select case presentations highlight key considerations in evaluating and managing stroke in young adults, emphasizing the importance of timely recognition, rapid intervention, and longterm management.
Despite current legal and medical controversies surrounding cannabinoids, it is a fact that emergency departments are seeing an increasing number of patients presenting with symptoms associated with the use of these drugs. This review outlines the pathophysiology of cannabinoids, the potential clinical findings associated with their use, and the current evidence for best practice management of patients who present with signs of acute intoxication and chronic use. Differences between natural and synthetic cannabinoids are discussed, along with evidence for diagnosing and managing patients presenting with the intractable vomiting of cannabinoid hyperemesis syndrome. Emerging treatments for cannabinoid hyperemesis syndrome are presented as well as an update on the legal status of medical cannabinoid substances.
Alcohol withdrawal syndrome is a constellation of symptoms and signs resulting from the abrupt decrease or cessation of heavy alcohol use. Complications of alcohol withdrawal syndrome present significant dangers for patient morbidity and mortality, as well as burdens on emergency department resources. This review presents an overview of the pathophysiology of alcohol withdrawal syndrome and a systematic approach for management in the emergency department. Current evidence on treatment regimens and adjunctive therapies is reviewed, and recommendations for management of patients with alcohol use disorders are discussed.
Cerebral venous sinus thrombosis is a rare cause of stroke with an overall good prognosis. It predominantly affects women of reproductive age and patients with prothrombotic conditions. It has a diverse presentation that includes headache, seizures, focal neurological deficits, and encephalopathy. A strong index of suspicion is required to make a prompt diagnosis and initiate early management. Despite aggressive care, death or functional dependence occurs in 10% to 15% of patients. This review provides an overview of the literature and recent guidelines on the emergency department approach and the therapeutic challenges in the management of patients with cerebral venous sinus thrombosis.
Adrenal insufficiency is a challenging condition to diagnose and manage in the emergency department, and adrenal crisis remains a significant cause of morbidity and potential mortality. Rapid recognition of adrenal insufficiency and adrenal crisis is essential to ensure that life-saving therapy is initiated without delay. This issue provides a review of the etiology and pathophysiology of adrenal insufficiency and focuses on emergency department evaluation and treatment of this condition. The current literature was reviewed to provide an up-to-date guide and the best practices related to management of these diagnoses, as well as strategies for patient education and prevention.
Status epilepticus is a neurological emergency requiring prompt intervention by emergency clinicians, as delays can lead to significant morbidity and mortality. Etiologies include acute causes such as electrolyte imbalance, infection, drugs, and acute strokes, as well as chronic causes such as remote brain injury, progressive epilepsies, and brain tumors. This issue presents evidence for an algorithmic approach to status epilepticus, from managing underlying causes and administering initial benzodiazepines, to second-line antiseizure agents, and escalating to intravenous anesthetics for refractory cases. Disposition for patients in status epilepticus includes inpatient care tailored to the patient's clinical needs, and appropriate follow-up.
Injuries of the hand and wrist are commonly encountered in the emergency department. Though they are rarely life-threatening, there is potential for significant patient pain, morbidity, and long-term functional loss if they are not treated appropriately. A thorough and focused examination and plain radiographs are sufficient to diagnose most hand injuries, with outpatient referral to a hand specialist when indicated. Clinicians must be able to identify the life- or limb-threatening hand injuries that can present, both in treating and facilitating urgent hand consultation. This review provides a best-practice update on the evaluation and treatment of common hand and wrist emergencies.
The American Society of Anesthesiologists and the British Difficult Airway Society have generated and revised guidelines over the past 30 years based on analyses of the causes of airway catastrophes. Guideline components include airway management algorithms, equipment standardization, and routine training. Algorithms utilize intubation, supraglottic airway insertion, fiberoptic intubation, awake intubation, and front of neck surgical access. This issue summarizes difficult airway management guidelines and discusses their application to trauma patients, including patients with physiologically difficult airways and patients with maxillofacial and laryngotracheal trauma.
Patients experiencing thyroid emergencies can present with a wide array of clinical presentations and comorbid conditions, so a systematic strategy to identify key historical and physical examination features can help guide the emergency clinician in recognizing these infrequent conditions. This issue review the most up-to-date evidence for diagnosing and managing decompensated hypothyroidism and thyroid storm in adult, pediatric, and pregnant patients.
This issue reviews 3 neurological conditions that can cause or complicate a patient's emergency department presentation: Parkinson disease, myasthenia gravis, and multiple sclerosis. Parkinson disease is a common comorbidity, and can be exacerbated in the ED if not managed expeditiously. Myasthenia gravis carries the potential for significant respiratory compromise and requires swift recognition and emergency care. Multiple sclerosis has many manifestaions, stages, and treatments that emergency clinicians need to understand to best manage flares. This review presents a summary of the presentations, the common pitfalls, and the roles of various therapeutics in managing patients with chronic neurologic disease.
Manifestation of sodium disorders will depend on the rapidity of development, the absolute level of sodium, and the patient's overall health. Acute symptomatic hypernatremia should be corrected rapidly, while chronic hypernatremia is generally corrected more slowly due to the risks for brain edema during treatment. Hyponatremia symptoms are vague, but acute severe symptomatic hyponatremia, whether self-induced, drug related, or hospital-acquired, is a medical emergency that demands immediate recognition and intervention. This issue reviews the evidence on the causes, diagnosis, and treatment of hypernatremia and hyponatremia in the emergency department, focusing on early recognition and best-practice management.
Knee pain is a common presenting complaint in the emergency department, and although the major etiologies are overuse and degenerative, inflammatory and infectious causes must be ruled out. This issue reviews the potential causes of knee pain from the history and physical examination, symptom location based differential, clinical clues, and special testing strategies. Evidence on the uses of x-ray and ultrasound for diagnostic imaging is reviewed. For suspected infectious causes, procedures for palpation-guided and ultrasound-guided arthrocentesis are outlined. Treatment strategies are summarized, with evidence on the effectiveness of weight loss, physical therapy, orthotics, medication therapies, joint injections, and nerve blocks considered.
With almost 2.9 million people in the United States seeking medical attention for head trauma each year,1 emergency clinicians face the critical task of efficiently and accurately identifying those with potentially life-threatening intracranial trauma. Due to the heterogeneity of patients, there is no one-size- fits-all approach to managing patients with suspected mild traumatic brain injury. This issue of Emergency Medicine Practice: Trauma EXTRA! reviews clinical guidelines, challenges in care for patients at extremes of ages, and strategies for managing patients with bleeding disorders or those taking anticoagulants or antiplatelet agents. Indications for imaging are also discussed, as well as which patients are at increased risk for intracranial injury and post-concussive syndrome. Management of patients with mild traumatic brain injury includes neurosurgery consultation, hospital admission for further observation, repeat imaging, or discharge home with careful discharge instructions.
