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Purpose of Review The goal of this review is to summarize the importance of identifying and treating a spinal epidural abscess. This review also delves into the intricacies of imaging modalities and the controversies regarding management options. Recent Findings Although magnetic resonance imaging (MRI) is a valuable diagnostic tool for evaluating SEA, focused attention to T2 imaging to the exclusion of other sequences can result in diagnostic errors and overlooking critical epidural abscesses. Summary Spinal epidural abscess is a rare disease; however, it has high morbidity and mortality if left untreated. Although rare, there is a slow progressive increase in the incidence of SEA. Imaging should be considered for any patient with red flags in their history or physical examination. MRI is the imaging test of choice to assure early diagnosis and treatment. Reliance on T2 imaging can result in an underappreciation of SEA. The characteristic space-occupying process, the essential comparison of T1 and T2 imaging, and the use of contrast characteristics are key ingredients for an accurate diagnosis.

Purpose of Review This review aims to provide a comprehensive overview of emergency department management of central retinal artery occlusion (CRAO). It examines common presentations, etiologies, workup, and various treatment options with their evidence. Recent Findings There is limited research on CRAO. Most treatment methods and guidelines are based on observational literature, case series, retrospective studies, and expert opinion. Many of the treatments available to the emergency provider have limited success. More advanced treatments with hyperbaric therapy or thrombolytics are becoming more established. Summary Workup for CRAO should focus on establishing the etiology of the event. There are many treatment options available to the emergency provider, including emergent hyperbaric oxygen therapy and thrombolytics. Emergency department care should occur in conjunction with ophthalmology and neurology. Much of the treatment is guided towards preventing future cardiovascular events.

Purpose of Review This review summarizes the current knowledge and evidence behind the diagnosis and management of adult status epilepticus (SE) in the Emergency Department (ED). It incorporates the most recent evidence-based diagnostic and management strategies, while reflecting them back onto the foundational aspects of SE care. Recent Findings Recent studies have re-emphasized the importance of early and appropriately dosed benzodiazepines as first-line therapy for SE. Second-line therapy has evolved from phenytoin to alternative anti-epileptics (AEDs) like levetiracetam. Additionally, cerebral perfusion-computed tomography (PCT) and electroencephalogram (EEG) are critical in the diagnosis of non-convulsive SE (NCSE) in the ED. Summary Early and aggressive medical management is crucial to curb the morbidity and mortality of adult SE in the ED starting with benzodiazepines and progressing to AEDs. Patients who remain altered after treatment may still have NCSE. Due to the clinical subtleties associated with NCSE, it is essential to utilize tools such as alternative EEG monitoring and PCT.

Purpose of Review This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework. Recent Findings Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers’ primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort. Summary Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.

Purpose of Review This review covers evaluation and Emergency Department (ED) management of patients with symptoms consistent with idiopathic intracranial hypertension (IIH), along with reviewing new proposed mechanisms and treatments for the disease. Recent Findings New imaging techniques can provide evidence to support the clinical diagnosis of IIH, including MRI and bedside ultrasound. Recent studies suggest novel metabolic mechanisms and possible treatments for IIH. Summary In the Emergency Department, clinicians should keep IIH on their differential in patients with headache and/or papilledema and work patients up to include or exclude other life threats as indicated. Treatment for IIH in the ED remains symptomatic, with most standard treatments unsupported by strong evidence. In patients with suspected or diagnosed IIH, knowing when to admit for consultation can improve patient outcomes and possibly spare their vision.

Purpose of Review This review summarizes the clinical manifestations, diagnosis, and treatment of Wernicke’s encephalopathy (WE) in the absence of alcohol use. Emergency physicians are well-acquainted with the disorder when associated with alcohol, but this reversible disease should be considered as part of the differential in numerous other patient populations. Recent Findings Treatment for WE has not changed significantly, and standard of care continues to be high-dose thiamine, although dosing and duration vary between different society guidelines. Radiographic evidence of disease continues to evolve. More recent literature focuses on at-risk groups more so than advances in treatment and includes numerous case reports of patients with non-alcoholic WE with etiologies such as gastric surgery, cancer, and HIV/AIDS. Summary Timely identification of WE in the emergency department leads to more rapid treatment with high-dose thiamine and reduced morbidity. Because there is evidence that WE may be under-diagnosed and treatment is both low risk and cost-effective, wider consideration of at-risk individuals and more research into treatment specifically among those with non-alcoholic WE are warranted.

Purpose of Review Vertebral or carotid artery dissections, collectively called cervical artery dissections (CeADs), are uncommon, regularly missed vascular injuries. They are associated with major trauma, but also occur spontaneously or with relatively minor trauma. Diagnosis hinges on imaging identification. Previously, catheter angiogram was the gold standard, but currently, there is no consensus on the initial imaging study. Recent Findings Computer tomography angiography (CTA) is the most common initial study for CeAD, but can fail to identify some dissections. MRI/MRA provides better images and is preferred in the pediatric population, but misses some pathology. Newer MRI/MRA techniques are improving diagnostic accuracy for CeADs. Ultrasound is increasingly used for screening and monitoring. Treatment focuses on preventing thromboembolic events with antiplatelet or anticoagulation medications, though neither appears superior based on the CADISS trial. Summary No imaging study is the best initial CeAD study. MRI/MRA is preferred for pediatric patients. Ultrasound has good specificity for CeAD identification with caveats.

Purpose of Review This review seeks to inform ED providers about best practices in the evaluation and treatment of new onset seizures in adults as well as those with established seizure diagnosis and breakthrough seizures. Recent Findings Current evidence suggests that early EEG has a higher rate of detecting epileptiform activity which is important as it can determine which patients need initiation of AED therapy. Early initiation of AEDs is important because although it does not have a mortality benefit or improve long-term remission it does improve quality of life and number of seizures. Summary Appropriate assessment and treatment of new onset and breakthrough seizures are crucial for this common presentation. Successfully ruling out other etiologies and ensuring timely follow-up and EEG/neuroimaging are key decisions ED providers must make in the care of these patients. Given the variability of neurology consultation and follow-up based on location, ED providers must understand and well utilize their available resources to advocate for best care for patients with seizures in their EDs.

Purpose of Review Emergency providers are well prepared for the rapid diagnosis and management of common etiologies of altered mental status. However, patients with persistently altered mental status of unclear etiology can present diagnostic and management challenges. Recent Findings Enhanced laboratory and imaging testing for patients in the emergency department has enabled the expanded workup and rapid diagnosis of life-threatening etiologies of altered mental status. Emergency physicians can improve patient care by reviewing updates in the current understanding of complex conditions causing altered mental status such as posterior reversible encephalopathy syndrome, vasculitis, and autoimmune disorders. Summary Herein, we provide a discussion of clinical cues and brief management pearls for some of the less common causes of altered mental status encountered in adults in the emergency department.

Purpose of Review This review describes the technologies and methods currently utilized to detect large vessel occlusion (LVO) ischemic stroke in the prehospital setting. A comparison of various LVO stroke scales, including their similarities and differences, is included. Emerging technology, novel stroke detection methods, and likely areas of future research are discussed. Recent Findings Many prehospital stroke detection scales have been described previously in the medical literature, characterized by varying degrees of efficacy. Despite their cost-effectiveness and ease of use, prehospital stroke scales do not reliably detect LVO. Current efforts in prehospital LVO stroke detection are aimed at improving upon the sensitivity and specificity of these scales, leveraging new screening technologies to streamline LVO triage and decrease time-to-intervention. Summary The prehospital stroke scales that we reviewed differ greatly in many respects, including their definition of LVO and the type and number of items tested. Despite the tremendous global effort made to rapidly triage and deliver LVO stroke patients to definitive treatment centers, no single scale has emerged with both a high positive predictive value (PPV) and negative predictive value (NPV). This has led to a lack of consensus, preventing widespread adoption of a single scale for prehospital LVO detection. Despite the ever-increasing number of stroke scales available to the prehospital clinician, LVO detection remains a challenge. Future advances in prehospital LVO stroke detection are expected to involve new and improved in-field diagnostic testing.