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.
