Medical Emergencies: Until Proven Otherwise

Critical conditions that must be ruled out before considering alternative diagnoses. These are time-sensitive emergencies requiring immediate evaluation and intervention.

Clinical Pearl: The "Until Proven Otherwise" Principle

In emergency medicine, certain clinical presentations are considered life-threatening emergencies until proven otherwise. This approach prioritizes patient safety and ensures that critical conditions are not missed. Always consider the worst-case scenario first, then work to rule it out.

Critical Emergencies

Immediate life-threatening conditions requiring urgent intervention within minutes to hours.

Urgent Emergencies

Serious conditions requiring prompt evaluation and treatment within hours.

Emergency Conditions

Conditions requiring emergency evaluation but may allow for more thorough workup.

Critical Emergencies (Immediate Action Required)

Critical Emergency Immediate

Headache in OCP Users

🔴 Consider Until Proven Otherwise:

  • • Cerebral Venous Sinus Thrombosis (CVST)
  • • Subarachnoid hemorrhage
  • • Intracerebral hemorrhage
  • • Meningitis/encephalitis

Any new, severe, or unusual headache in women taking oral contraceptives requires immediate neuroimaging to rule out CVST, which has a high mortality rate if missed.

Key Workup:

CT head → MRI/MRV if negative, D-dimer, coagulation studies

Critical Emergency Immediate

Acute Chest Pain

🔴 Consider Until Proven Otherwise:

  • • Acute Coronary Syndrome (ACS)
  • • Aortic dissection
  • • Pulmonary embolism
  • • Tension pneumothorax
  • • Esophageal rupture

All chest pain is cardiac until proven otherwise. Time is myocardium - immediate ECG and cardiac biomarkers are essential.

Key Workup:

ECG, troponins, CXR, consider CT angiography

Critical Emergency Immediate

Acute Dyspnea

🔴 Consider Until Proven Otherwise:

  • • Pulmonary embolism
  • • Acute coronary syndrome
  • • Tension pneumothorax
  • • Acute pulmonary edema
  • • Anaphylaxis

Sudden onset dyspnea requires immediate evaluation for life-threatening causes, especially in patients with risk factors.

Key Workup:

CXR, ECG, D-dimer, CT pulmonary angiogram if high suspicion

Critical Emergency Immediate

Acute Abdominal Pain

🔴 Consider Until Proven Otherwise:

  • • Ruptured abdominal aortic aneurysm
  • • Mesenteric ischemia
  • • Perforated viscus
  • • Ectopic pregnancy (reproductive age)
  • • Acute appendicitis

Sudden, severe abdominal pain requires immediate evaluation for surgical emergencies, especially in elderly patients.

Key Workup:

CT abdomen/pelvis, pregnancy test, CBC, lactate

Critical Emergency Immediate

Altered Mental Status

🔴 Consider Until Proven Otherwise:

  • • Hypoglycemia
  • • Meningitis/encephalitis
  • • Intracranial hemorrhage
  • • Sepsis
  • • Drug overdose

Any acute change in mental status requires immediate evaluation for reversible causes, starting with bedside glucose.

Key Workup:

Glucose, CT head, CBC, electrolytes, toxicology screen

Critical Emergency Immediate

Syncope

🔴 Consider Until Proven Otherwise:

  • • Cardiac syncope (arrhythmia, structural)
  • • Pulmonary embolism
  • • Subarachnoid hemorrhage
  • • Aortic dissection
  • • Severe anemia

Syncope with cardiac symptoms, family history of sudden death, or structural heart disease requires immediate cardiac evaluation.

Key Workup:

ECG, troponins, echocardiogram, Holter monitor

Urgent Emergencies (Prompt Evaluation Required)

Urgent Emergency Hours

Fever with Rash

🟡 Consider Until Proven Otherwise:

  • • Meningococcal disease
  • • Toxic shock syndrome
  • • Stevens-Johnson syndrome
  • • Rocky Mountain spotted fever

Fever with petechial or purpuric rash requires immediate evaluation for meningococcal disease, especially in children and young adults.

Key Workup:

Blood cultures, LP if no contraindications, antibiotics

Urgent Emergency Hours

Acute Back Pain

🟡 Consider Until Proven Otherwise:

  • • Cauda equina syndrome
  • • Spinal cord compression
  • • Aortic dissection
  • • Epidural abscess

Back pain with neurological symptoms, bowel/bladder dysfunction, or severe pain requires immediate imaging to rule out cord compression.

Key Workup:

MRI spine, CT if MRI unavailable, neurological exam

Urgent Emergency Hours

Acute Vision Changes

🟡 Consider Until Proven Otherwise:

  • • Central retinal artery occlusion
  • • Acute angle-closure glaucoma
  • • Giant cell arteritis
  • • Optic neuritis

Sudden vision loss is an ophthalmologic emergency requiring immediate evaluation to preserve vision.

Key Workup:

Ophthalmologic exam, ESR/CRP, consider temporal artery biopsy

Urgent Emergency Hours

Acute Testicular Pain

🟡 Consider Until Proven Otherwise:

  • • Testicular torsion
  • • Epididymo-orchitis
  • • Incarcerated hernia
  • • Testicular trauma

Acute testicular pain requires immediate evaluation for torsion, which can lead to testicular loss within 6 hours.

Key Workup:

Doppler ultrasound, urinalysis, surgical consultation

Emergency Conditions (Require Evaluation)

Emergency Condition Same Day

Dizziness/Vertigo

🔵 Consider Until Proven Otherwise:

  • • Posterior circulation stroke
  • • Benign paroxysmal positional vertigo
  • • Ménière's disease
  • • Vestibular neuritis

Dizziness with neurological symptoms requires evaluation for posterior circulation stroke, especially in elderly patients.

Key Workup:

Neurological exam, Dix-Hallpike test, MRI if concerning

Emergency Condition Same Day

Palpitations

🔵 Consider Until Proven Otherwise:

  • • Atrial fibrillation/flutter
  • • Ventricular tachycardia
  • • Supraventricular tachycardia
  • • Anxiety/panic disorder

Palpitations with syncope, chest pain, or structural heart disease require immediate cardiac evaluation.

Key Workup:

ECG, Holter monitor, echocardiogram, electrolytes

Clinical Decision Making Framework

Red Flags Requiring Immediate Action:

  • Severe, sudden-onset symptoms
  • Associated neurological deficits
  • Vital sign abnormalities
  • High-risk patient populations
  • Family history of sudden death

When to Escalate Care:

  • Uncertainty about diagnosis
  • Rapidly deteriorating condition
  • Multiple risk factors present
  • Inadequate resources for management
  • Patient request for second opinion

Key Takeaways

Remember:

  • • Always consider the worst-case scenario first
  • • Time is critical in many emergencies
  • • When in doubt, err on the side of caution
  • • Document your clinical reasoning
  • • Follow up on all patients

Clinical Pearls:

  • • "Common things are common, but don't miss the uncommon"
  • • "If you hear hoofbeats, think horses, but don't forget zebras"
  • • "The patient is the best historian"
  • • "Trust your instincts, but verify with evidence"
  • • "When you're not sure, get help"