Hippo ERcast September 2025

Guideline Update: HTN in the ED

Asymptomatic hypertension in the emergency department usually does not need emergent testing after a careful history and physical exam. The 2025 ACEP clinical policy supports considering antihypertensive initiation at ED discharge and emphasizes prompt outpatient follow-up. Asymptomatic Hypertension in the ED No emergent workup needed: A focused history and physical exam is the key screen for true asymptomatic elevated blood pressure; without symptoms or exam red flags, routine ED testing is generally not required. Discharge prescribing shift: The 2025 ACEP policy recommends clinicians consider starting an antihypertensive at discharge for selected adults with asymptomatic hypertension rather than deferring all treatment. Level C recommendation: This is a Level C ACEP recommendation, which makes the guidance usable but still dependent on bedside judgment, patient context, and reliability of follow-up. Rapid follow-up matters: Starting treatment is paired with quick outpatient follow-up, since the ED visit can open the door to longitudinal blood pressure control. We get into the practical handoff in the episode. Agent selection guidance: The policy offers general direction on which antihypertensive classes to consider at discharge, while leaving patient-specific drug choice and exceptions to clinical judgment.

Bronchoscopy in the ED

Emergency department bronchoscopy is uncommon but practical in selected airway emergencies. The highest-yield scenarios are suspected foreign body aspiration, complete hemithorax whiteout where mucus plugging is on the table, and unexplained hypoxemia or poor ventilation immediately after intubation. When ED Bronchoscopy Changes Management Foreign body aspiration clues: Foreign body aspiration is usually a history-plus-exam diagnosis; the classic cough, wheeze, and decreased breath sounds triad appears in less than 40% of cases, so a convincing story can matter more than the textbook pattern. Adult aspiration risk profile: In adults, aspiration usually follows impaired consciousness or swallowing rather than bad luck alone, and small organic objects like nuts or beans are the realistic targets for an ED flexible scope. Whiteout tracheal position: A complete hemithorax whiteout with a midline trachea should raise mucus plugging alongside consolidation and edema, whereas tracheal shift away points more toward pleural effusion than a problem bronchoscopy will fix. Post-intubation rescue role: When oxygenation or ventilation worsens right after intubation, bronchoscopy can rapidly confirm the tube is above the carina and identify aspirate or mucus plugging among the immediate can’t-miss causes. We walk through that bedside differential in the episode. Flexible scope limitations: ED bronchoscopes have smaller suction channels than rigid scopes, so patient selection matters; bulky or smooth obstructing objects may exceed what a flexible bronchoscope can safely retrieve. ED Bronchoscopy Setup And Pearls Respiratory therapist partnership: Your first call is respiratory therapy because scope diameter substantially narrows the endotracheal tube lumen, making ventilator adjustments and close coordination central to a safe procedure. Ventilator strategy changes: Pressure control is the preferred procedural mode, with FiO2 increased to 100% and baseline PEEP generally maintained; the practical reason is preserving ventilation despite the scope occupying tube space. Lidocaine through the scope: A headline move is endobronchial 1% lidocaine at the carina to blunt coughing and improve tolerance, paired with adequate analgesia and sedation before you start. Sampling every opportunity: Bronchoalveolar lavage should be sent whenever feasible because you are already in position to add microbiologic value, and the chapter gets into the practical collection sequence. Documentation that helps ICU: Procedure notes should specify what was seen, exactly where it was seen, secretion character and volume, lavage details, airway patency, bleeding, bilateral breath sounds, and the patient’s response afterward.

Lit Matters 1: ATLANTIC

Prehospital ticagrelor in STEMI did not improve pre-PCI reperfusion in ATLANTIC, despite a biologically plausible push to start P2Y12 inhibition earlier. The trial helped simplify prehospital and ED STEMI care while leaving a signal of possible early stent-thrombosis benefit. Prehospital Ticagrelor in STEMI Trial question and drug: ATLANTIC tested whether a 180 mg ticagrelor load given before hospital arrival could improve coronary reperfusion before PCI in ECG-confirmed STEMI. Hard primary endpoints: The co-primary endpoints were tough markers of early reperfusion: at least 70% ST-segment resolution before PCI and TIMI 3 flow on initial angiography. Negative main result: Earlier ticagrelor did not improve either pre-PCI reperfusion endpoint, so the central prehospital strategy failed despite strong physiologic rationale. Safety and thrombosis signal: Major adverse cardiac events were unchanged, but definite stent thrombosis was lower with prehospital dosing at 24 hours and again at 30 days, a nuance we get into in the episode. Timing as key limitation: The gap between field dosing and PCI was relatively short, which likely blunted any chance for ticagrelor to show a measurable pre-PCI effect. Practice-level implication: A negative, logistically difficult STEMI trial still mattered because it supported incremental simplification of prehospital and ED antiplatelet workflows.

Approach to the Agitated Patient

Agitation in the emergency department is a safety problem first and a diagnostic problem second. The key bedside split is agitation with versus without CNS dysfunction, because delirium, toxidromes, withdrawal, and primary psychiatric illness do not get managed the same way. ED Agitation Assessment and De-escalation Initial safety framing: Provider, staff, and patient safety come first, with the first clinical question being whether agitation reflects acute CNS dysfunction that demands rapid control for evaluation. Broad dangerous differential: Agitation can signal delirium, sympathomimetic or anticholinergic toxicity, serotonin syndrome, neuroleptic malignant syndrome, withdrawal, infection, or structural CNS disease. Bias-aware bedside mindset: Implicit bias can distort threat assessment, especially around the poorly defined label of excited delirium, which is not recognized in DSM-5 or ICD-10. Project BETA approach: Verbal de-escalation is the preferred first step, emphasizing personal space, concise communication, limit-setting, and offering choices before coercive measures. We walk through the bedside tone in the episode. Chemical Sedation and Restraint Pearls No proven best regimen: Current literature is low quality and does not support one universally superior chemical sedation strategy, so agent choice should follow likely etiology rather than habit. Benzodiazepine niche: Benzodiazepines fit withdrawal states and many toxidromes, with midazolam acting faster than lorazepam for acute agitation when speed matters. Antipsychotic options: Droperidol and olanzapine have strong practical roles in acute agitation, with olanzapine showing faster early sedation in some studies and droperidol comparing well throughout. Avoid the B-52: Diphenhydramine-haloperidol-lorazepam is not evidence-backed for routine agitation care, and diphenhydramine's anticholinergic effects can worsen confusion and agitation. Ketamine tradeoffs: Ketamine has a very fast onset, including IM use, but lower-than-dissociative dosing can worsen agitation and serious airway complications remain a real concern. Restraint as bridge only: Physical restraint should be a temporary bridge to medication, using a five-person team, avoiding neck or chest compression, and reassessing frequently. The practical setup is worth hearing in the chapter.

Unraveling GU Infections

Urinary tract infection is a clinical diagnosis: symptoms plus pyuria plus a positive culture. GU infection workups go wrong when colonization, pelvic floor disease, low-estrogen states, prostatitis, catheter urine, or an obstructing stone are mistaken for straightforward cystitis. UTI Diagnosis and Common Mimics Diagnostic triad for UTI: A true UTI requires symptoms, pyuria, and a positive culture; treating a vague story with a questionable urinalysis is how bladder cancer, vaginitis, and other mimics get missed. Red flag negative cultures: Persistently positive urinalysis with negative cultures is a red flag for alternate pathology, including bladder cancer, and should trigger further evaluation rather than repeat antibiotic courses. Low estrogen mimic state: Peri- and postmenopausal low-estrogen states drive both lower urinary tract symptoms and recurrent UTIs, and vaginal estrogen is a preventive option without increased thrombosis or malignancy risk. When diagnosis is unclear: If symptoms are nonspecific and the urinalysis is equivocal, hold antibiotics until culture clarification and reassess the broader differential. We get into the bedside decision-making in the episode. Age-Specific GU Infection Pitfalls Elderly symptom interpretation: Older adults often lack classic dysuria and frequency, while asymptomatic pyuria is common, so treatment decisions should hinge on actual urinary symptoms rather than a positive test alone. Altered mental status concern: Altered mental status in an older patient should keep UTI on the differential early, but the diagnosis still needs clinical context because colonization and false-positive studies are common. Preverbal pediatric clues: Young children may present with fussiness, irritability, or poor feeding instead of localizing urinary symptoms, making history from caregivers and overall illness behavior especially important. Constipation as pediatric mimic: Constipation can closely mimic pediatric UTI, and potty-trained children may withhold urine because dysuria hurts, creating frequency and irritability that point in the wrong direction. Prostatitis and Male Pelvic Pain Acute bacterial prostatitis pattern: Acute bacterial prostatitis is uncommon but typically makes patients look sick, often with a markedly positive urinalysis, and rectal exam may worsen pain or bacterial translocation. Chronic prostatitis relapse risk: Chronic bacterial prostatitis relapses because the prostate is a large bacterial reservoir with poor oral antibiotic penetration, so treatment usually means a prolonged course rather than a short cystitis regimen. Named oral antibiotic options: Fluoroquinolones, doxycycline, and trimethoprim-sulfamethoxazole are the headline oral agents for chronic bacterial prostatitis, with drug selection shaped by culture data and patient factors. Pelvic pain syndrome mimic: Noninfectious pelvic pain can cause perineal, scrotal, penile, or urinary symptoms with a negative urinalysis, and it is commonly mislabeled as prostatitis and overtreated with antibiotics. Noninfectious treatment direction: Alpha-1 blockade such as tamsulosin and referral for pelvic floor physical therapy are key moves for male pelvic pain syndromes, an underrecognized diagnosis we unpack further in the chapter.

Lit Matters 2: HEART score

The HEART score helped standardize emergency department chest pain risk stratification before high-sensitivity troponin pathways became dominant. It still offers a fast bedside estimate of short-term major adverse cardiac events, especially for low-risk patients, but its role is now more supportive than central in hs-troponin era ACS evaluation. HEART Score in Chest Pain Low-risk discharge signal: A HEART score of 0-3 identified a large low-risk group with about 98% freedom from 6-week MACE, making it useful for ED discharge and shared decision-making conversations. High-risk escalation group: Scores of 7-10 marked a cohort with roughly 50% 6-week MACE, a clear signal that chest pain patients need aggressive ACS evaluation rather than reassurance. Better than older scores: In low- and intermediate-risk patients, HEART outperformed TIMI and GRACE for short-term cardiac events, which is why it became such a practical ED tool. Single-troponin design era: This validation used only the first conventional troponin, not high-sensitivity assays, which explains why the score feels dated beside modern 2- to 3-hour hs-troponin pathways. Modern role shift: HEART remains easy to calculate and useful at the bedside, but hs-troponin algorithms now lead contemporary chest pain pathways. We get into where HEART still fits in the chapter.

Blocked and Bloated: Bowel Obstructions in the ED

Small bowel obstruction is common ED pathology, but the dangerous misses are ischemia, perforation, and closed-loop or colonic obstruction. Plain films still matter for free air and interval progression, while CT and selective oral contrast help define anatomy and guide operative planning. Small Bowel Obstruction Workup Plain film first pass: Acute abdominal radiographs can be enough in the ill-appearing patient with perforation, and serial KUBs remain useful for trending bowel dilation or interval improvement. CT with contrast nuance: CT is the main anatomic study for suspected SBO, but oral contrast still has a role by improving bowel visualization and sometimes helping a partial obstruction move along. Routine surgical involvement: Every ED patient with suspected SBO should have a surgical consult in the workup, even when the patient looks well and immediate operative intervention is unlikely. Partial obstruction priorities: Partial SBO is usually not a surgical emergency; initial management centers on symptom control, IV fluids, electrolyte correction, and searching for causes like Crohn disease or malignancy. We get into the disposition nuances in the episode. Emergency operative red flags: Peritonitis, free air, large abscess, bowel ischemia, perforation, and closed-loop obstruction are the findings that should push bowel obstruction toward urgent operative management. NG Tubes and Surgical Urgency Challenged NGT routine: Recent retrospective studies and a limited systematic review found no clear reduction in surgery, bowel resection, or mortality with routine nasogastric decompression for SBO. Why NGT still matters: Despite weaker outcome data, NG decompression reduces recurrent vomiting and decompresses the bowel before surgery, which may improve the chance of a laparoscopic approach. NGT contraindication groups: Nasogastric tubes deserve extra caution or avoidance in Roux-en-Y gastric bypass, closed-loop obstruction, and colonic obstruction, where anatomy or pathophysiology changes the risk. Colonic obstruction urgency: High-grade colonic obstruction behaves as a closed-loop obstruction and should be treated as a surgical emergency rather than a wait-and-see admission problem. Well-appearing high grade SBO: A high-grade SBO in a stable, well-appearing patient may still start with conservative care such as decompression and fluids, but the operative boundary lines are worth hearing in the chapter.

Lit Matters 3: NINDS: t-PA for acute ischemic stroke + Lit Matters 4: PECARN - Pediatric Head Injury Algorithm

Alteplase for acute ischemic stroke offers a modest functional benefit when given early, but that benefit is inseparable from a real intracranial hemorrhage risk. PECARN remains the benchmark pediatric head injury rule, identifying children at very low risk of clinically important traumatic brain injury and helping avoid unnecessary CT radiation. Alteplase for Acute Ischemic Stroke Landmark treatment window: NINDS established that IV alteplase can improve 3-month functional outcomes when used within 3 hours of clearly defined ischemic stroke onset, anchoring modern reperfusion care. Functional benefit signal: The clearest effect was a 12% absolute increase in minimal or no disability at 3 months, while the 24-hour neurologic endpoint was not convincingly different. Hemorrhage tradeoff: Symptomatic intracranial hemorrhage rose in the first 36 hours with alteplase, reinforcing that thrombolysis is a benefit-harm decision rather than an uncomplicated win. Trial fragility concern: The study was methodologically rigorous but carried a fragility index of 3, one reason alteplase split emergency medicine and neurology for years. We get into that controversy in the episode. Eligibility discipline: Baseline noncontrast head CT excluding hemorrhage, a measurable NIHSS deficit, and blood pressure below 185/110 were central gatekeepers for treatment in the original trial. PECARN Pediatric Head Injury Algorithm Clinically important TBI target: PECARN was built to predict clinically important traumatic brain injury, defined by outcomes that matter: neurosurgery, prolonged intubation, death, or a significant admission with CT findings. Age-specific decision rules: The rule uses separate predictor sets for children younger than 2 years and those 2 years or older, a key reason it performs better than one-size-fits-all head injury tools. Low-risk rule performance: In children under 2, the validated low-risk rule had 100% sensitivity and 100% negative predictive value for clinically important TBI, with no missed neurosurgical cases. Older child validation: For children 2 years and older, the low-risk rule reached 96.8% sensitivity and 99.95% negative predictive value; the rare misses did not require neurosurgery. CT reduction rationale: Only 0.9% of the cohort had clinically important TBI, yet more than a third underwent CT, making PECARN especially valuable for avoiding radiation in minor blunt head trauma. We walk through the bedside use of that distinction in the chapter.