Essential Guide for First-Year Family Medicine Residents in the Emergency Department

Most Common ED Presentations You Will Encounter

As a first-year family medicine resident, you will primarily manage psychiatric emergencies, stroke presentations, trauma (especially falls in elderly patients), respiratory emergencies, and acute behavioral crises. 1

1. Psychiatric and Behavioral Emergencies (≈6% of all ED visits)

Initial Assessment Approach

For alert, cooperative psychiatric patients with normal vital signs and non-contributory history/physical exam, routine laboratory testing is NOT necessary and should be avoided. 1

Medical clearance labs are low-yield: Only 1.2% of routine testing in psychiatric patients yields clinically significant findings that change management 1
Order labs ONLY when history or physical exam suggests medical cause: altered mental status, abnormal vital signs, new-onset psychiatric symptoms, or specific clinical suspicion 1
Urine drug screens rarely change ED management: Multiple studies show no significant difference in disposition between positive and negative screens 1

Critical Medical Mimics to Rule Out

Before accepting a psychiatric diagnosis, actively exclude these conditions through targeted history and exam 1:

Metabolic/Endocrine:

Hypoglycemia, hyperglycemia, hyponatremia, hypocalcemia
Thyroid disease (hyperthyroidism, thyroid storm, hypothyroidism)
Uremia, hyperammonemia

Neurologic:

Seizures, stroke, intracranial hemorrhage
Encephalitis, meningitis
Brain tumors (rare but can present with psychiatric symptoms)

Toxicologic:

Drug withdrawal: alcohol, benzodiazepines, barbiturates
Drug intoxication: cocaine, amphetamines, PCP, bath salts, synthetic cannabinoids
Medication effects: steroids, anticholinergics, psychiatric medications

Other:

Hypoxia, hypercarbia
Carbon monoxide poisoning
Infections (especially in young children and elderly)

Suicidal Ideation/Attempt Management

Suicide is the 3rd leading cause of death in ages 10-24 years, accounting for >4000 deaths annually; females attempt more but males complete suicide 5× more often due to more lethal means. 1

High-risk factors requiring psychiatric consultation: 1

Previous psychiatric disorder or recent hospitalization
Substance abuse
Family history of suicide
History of sexual/physical abuse
Homeless/runaway status
LGBTQ+ identification
Recent psychosocial stressors (family conflict, relationship breakup, bullying, legal troubles)

Immediate safety measures: 1

Personal and belongings search
Change into hospital attire
Place in safe room without access to medical equipment
Close staff supervision
Interview patient and caregivers separately
Obtain collateral information (patients often minimize severity)

Acute Agitation Management

For the acutely agitated patient, pharmacologic treatment is indicated when verbal de-escalation fails. 1

First-line options (choose based on clinical scenario):

Haloperidol 5 mg IM (typical antipsychotic)
Olanzapine 10 mg IM (atypical antipsychotic, less extrapyramidal symptoms)
Lorazepam 2 mg IM (benzodiazepine, useful if alcohol withdrawal suspected)
Combination: Haloperidol 5 mg + Lorazepam 2 mg IM (synergistic effect)

Critical pitfall: Avoid diphenhydramine in geriatric patients—it's a high-risk medication in this population 1

2. Acute Stroke (Time-Critical Emergency)

Immediate Actions (First 10 Minutes)

Your primary goal is door-to-needle time ≤60 minutes for thrombolysis candidates; every minute of delay worsens outcomes. 2, 3

Simultaneous initial steps: 2

Stabilize ABCs: Supplemental O₂ if SpO₂ <94%
Establish IV access immediately
Obtain blood samples: CBC, coagulation studies (PT/INR/PTT), platelets, electrolytes, renal function, glucose, cardiac troponin
Labs must be available within 20 minutes for thrombolysis candidates
Order non-contrast head CT STAT (target: completion within 30 minutes of arrival)
Check blood glucose at bedside (hypoglycemia mimics stroke)
Assess with NIHSS (National Institutes of Health Stroke Scale)

Blood Pressure Management (Critical for Thrombolysis Eligibility)

BP must be <185/110 mmHg BEFORE tPA and maintained <180/105 mmHg during and for 24 hours after treatment. 2, 3

For BP >185/110 mmHg in thrombolysis candidates: 2

Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, OR
Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr)

For non-thrombolysis candidates: 3

Do NOT treat BP unless systolic >220 mmHg or diastolic >120 mmHg
Exception: Intracerebral hemorrhage with hypertension history—keep MAP <130 mmHg

Thrombolytic Therapy

Alteplase (tPA) 0.9 mg/kg IV (maximum 90 mg total dose) is indicated for eligible patients within 4.5 hours of symptom onset. 2, 3

Dosing:

10% as IV bolus over 1 minute
Remaining 90% as IV infusion over 60 minutes

Absolute contraindications:

Intracranial hemorrhage on CT
BP >185/110 mmHg despite treatment
Recent surgery/trauma
Active bleeding
Platelets <100,000

Continuous Monitoring Post-Stroke

All stroke patients require: 2

Continuous automated monitoring: SpO₂, BP, cardiac rhythm, temperature
Cardiac monitoring ×24 hours minimum (detect atrial fibrillation)
Temperature checks every 4 hours ×48 hours
Frequent NIHSS assessments to detect complications

DVT Prophylaxis (Start Immediately)

Apply intermittent pneumatic compression (IPC) devices to all immobilized patients immediately; continue until independently mobile or 30 days. 2

Pharmacologic prophylaxis for high-risk patients: 2

Enoxaparin (low-molecular-weight heparin) for most patients
Unfractionated heparin for renal failure patients

Critical pitfall: Never use anti-embolism stockings alone—they are ineffective without IPC or pharmacologic prophylaxis 2

3. Geriatric Emergencies (Falls, Polypharmacy, Delirium)

Medication Reconciliation (Mandatory for ALL Geriatric Patients)

Every geriatric patient requires immediate comprehensive medication reconciliation regardless of presenting complaint; 40% take 5-9 medications daily, 18% take >10 medications. 1, 4

Why this matters: 1

50-60% chance of drug-drug interaction with 5 medications
90% chance of drug-drug interaction with ≥10 medications
Adverse drug events are a major cause of ED visits and admissions

Obtain medication list from: 4

Patient
Caregivers/family
Skilled nursing facility staff
Electronic medical records

High-Risk Medications in Geriatrics (Screen Every Patient)

Patients with polypharmacy (>5 medications) or high-risk medications require pharmacist consultation before admission. 1, 4

Common high-risk medications to identify:

Diphenhydramine (Benadryl)—avoid in elderly 1
Benzodiazepines
Anticholinergics
NSAIDs
Opioids
Sliding-scale insulin

Trauma in Elderly (Even Minor Falls Are High-Risk)

Falls represent major traumatic mechanisms in geriatric patients and cause disproportionate morbidity/mortality compared to younger patients. 1

Lower threshold for imaging:

Head CT for any head strike (even without loss of consciousness)
C-spine imaging for neck pain or tenderness
Consider occult fractures (hip, pelvis, vertebral compression)

Why elderly are high-risk: 1

Anticoagulation use common
Osteoporosis
Polypharmacy affecting balance
Baseline frailty

4. Respiratory Emergencies

Initial Assessment and Treatment

Respiratory emergencies are among the most common office/ED emergencies requiring immediate intervention. 1, 5

Immediate actions:

Pulse oximetry
Supplemental O₂ to maintain SpO₂ >94%
Assess work of breathing, respiratory rate, accessory muscle use
Auscultate lungs

Common presentations:

Asthma exacerbation
COPD exacerbation
Pneumonia
Pulmonary embolism
Anaphylaxis

For asthma/COPD exacerbation:

Albuterol 2.5-5 mg nebulized (can repeat every 20 minutes ×3)
Ipratropium 0.5 mg nebulized (add to albuterol)
Prednisone 40-60 mg PO or methylprednisolone 125 mg IV
Consider magnesium sulfate 2 g IV over 20 minutes for severe exacerbations

5. Seizures

Acute Management

Clinical seizures require immediate antiseizure medication; patients with altered mental status and electrographic seizures on EEG also require treatment. 1

First-line treatment:

Lorazepam 0.1 mg/kg IV (usual adult dose 4 mg IV), may repeat once after 5-10 minutes, OR
Diazepam 0.15 mg/kg IV (usual adult dose 10 mg IV)

If IV access unavailable:

Midazolam 10 mg IM (for adults)

Second-line (if seizures continue):

Fosphenytoin 20 mg PE/kg IV at 100-150 mg PE/min
Levetiracetam 60 mg/kg IV (maximum 4500 mg)

Critical pitfall: Do NOT start long-term anticonvulsants for single self-limiting seizures 2

6. Chest Pain/Acute Coronary Syndrome

Immediate Workup

Every chest pain patient requires:

12-lead ECG within 10 minutes of arrival
Cardiac troponin (baseline and serial)
Aspirin 162-325 mg PO (chewed) unless contraindicated
IV access
Continuous cardiac monitoring
Supplemental O₂ if SpO₂ <94%

For STEMI:

Activate cath lab immediately
Aspirin 325 mg PO
Ticagrelor 180 mg PO or clopidogrel 600 mg PO
Heparin bolus 60 units/kg IV (max 4000 units), then infusion
Nitroglycerin 0.4 mg SL every 5 minutes ×3 for chest pain
Morphine 2-4 mg IV for persistent pain (use cautiously—associated with increased mortality in NSTEMI) 3

7. Hypoglycemia

Recognition and Treatment

Check blood glucose in ANY patient with altered mental status, confusion, or stroke-like symptoms—hypoglycemia mimics many conditions. 2, 3

Treatment for glucose <70 mg/dL with symptoms:

If conscious and able to swallow: 15-20 g oral glucose (juice, glucose tablets)
If altered or unable to swallow: Dextrose 50% 25 g (50 mL) IV push
If no IV access: Glucagon 1 mg IM

Recheck glucose in 15 minutes and repeat treatment if needed

8. Anaphylaxis

Immediate Treatment

Anaphylaxis is a clinical diagnosis requiring immediate epinephrine—do not delay for labs or testing. 1