How to manage patients with unexpected symptoms in the Emergency Department (ED)?

From the Guidelines

To effectively manage patients with unexpected symptoms in the Emergency Department (ED), it is crucial to prioritize a systematic approach that identifies life-threatening conditions, and for patients with symptoms consistent with Acute Coronary Syndrome (ACS) without objective evidence of myocardial ischemia, observation in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals is reasonable 1. When managing patients with unexpected symptoms, the initial step involves a rapid assessment using the ABC (Airway, Breathing, Circulation) protocol while obtaining vital signs. This approach is critical in identifying potential life-threatening conditions early on.

• The next steps include ordering diagnostic tests based on the presenting symptoms, such as complete blood count, basic metabolic panel, cardiac enzymes, urinalysis, chest X-ray, and ECG as indicated.
• Providing symptomatic relief with medications like acetaminophen for pain or fever, or ondansetron for nausea, is also essential while waiting for test results.
• For patients with possible ACS, it is reasonable to observe them in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals if they have nonischemic initial ECG and normal cardiac troponin 1.
• Additionally, for patients with possible ACS who have normal serial ECGs and cardiac troponins, treadmill ECG or stress myocardial perfusion imaging before discharge or within 72 hours after discharge is a reasonable approach 1.
• In patients with possible ACS and a normal ECG, normal cardiac troponins, and no history of CAD, coronary CT angiography to assess coronary artery anatomy is a reasonable initial step 1.
• Maintaining frequent reassessments, especially for patients with changing symptoms or abnormal vital signs, is vital.
• If the diagnosis remains unclear after the initial workup, considering observation status for 6-24 hours rather than immediate discharge, particularly for vulnerable populations, can help balance the need to identify serious conditions while avoiding unnecessary testing.

From the FDA Drug Label

If signs or symptoms of meningitis develop in a patient on ibuprofen tablets, the possibility of its being related to ibuprofen tablets should be considered. Patients should be informed of the warning signs and symptoms of hepatotoxicity (e. g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness and "flu-like" symptoms). Patients should be informed of the signs of an anaphylactoid reaction (e.g., difficulty breathing, swelling of the face or throat). Get emergency help right away if you get any of the following symptoms: shortness of breath or trouble breathing chest pain weakness in one part or side of your body slurred speech swelling of the face or throat

Managing patients with unexpected symptoms in the Emergency Department (ED) involves being alert for symptoms such as:

• Shortness of breath or trouble breathing
• Chest pain
• Weakness in one part or side of the body
• Slurred speech
• Swelling of the face or throat
• Signs of meningitis
• Signs of hepatotoxicity
• Signs of an anaphylactoid reaction

Patients should be instructed to seek immediate emergency help if they experience any of these symptoms. 2 2

From the Research

Managing Patients with Unexpected Symptoms in the ED

• Patients with unexpected symptoms in the Emergency Department (ED) require prompt and effective management to prevent adverse outcomes.
• Airway management is critical in the ED, particularly for patients with high-risk features such as severe metabolic acidosis, shock, and hypotension 3, 4.
• A systematic approach to managing patients with unknown poisoning includes initial stabilization, consideration of key history, possible toxidrome, and data from vital signs, physical examination, laboratory analysis, ECG, and imaging 5.
• For patients with recurrent, low-risk chest pain, guidelines suggest the use of high-sensitivity troponin testing, stress testing, and referral for expedited outpatient testing as warranted 6.
• Patients with cardiac chest pain should be given a high triage priority, receive adequate analgesia and aspirin, and be considered for fibrinolytic agents or inpatient care as needed 7.
• Key considerations in managing patients with unexpected symptoms in the ED include:
  • Rapid assessment and treatment
  • Airway management expertise
  • Systematic approach to unknown poisoning
  • Evidence-based guidelines for recurrent, low-risk chest pain
  • High triage priority for cardiac chest pain

High-Risk Airway Management

• Patients with high-risk features such as trauma, elevated intracranial pressure, and morbid obesity require airway expertise 4.
• Adverse events during emergent airway management are common, but many can be avoided with proper identification and understanding of underlying physiology, preparation, and postintubation management 3, 4.

Recurrent, Low-Risk Chest Pain

• Guidelines suggest the use of high-sensitivity troponin testing to reasonably exclude acute coronary syndrome (ACS) within 30 days 6.
• Referral for expedited outpatient testing is recommended for patients with non-obstructive coronary artery disease (CAD) or no occlusive CAD on prior angiography within 5 years 6.