Primary Care in the ED

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Primary Care in the ED

Oct. 1, 2025

The emergency department offers critical access to health care in our broken system. An important skillset of the modern emergency physician is a set of low-risk, low-time commitment, high-benefit interventions for the management of chronic diseases. In this episode, Peter Lorenz, MD, and guest Bobby Ries, MD, discuss the diagnosis and management of hypertension, type 2 diabetes, asthma, alcohol use disorder, and tobacco use disorder from the emergency department.

Show Notes

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Host

Peter Lorenz, MD

Christiana Care
EM/IM Combined Residency Class of 2027
EMRA*Cast Episodes

Guest

Bobby Ries, MD

EM/FM Resident, ChristianaCare

As an Emergency Medicine / Family Medicine combined resident at Christiana, Bobby enjoys higher acuity clinical scenarios but also appreciates time to connect with patients on a long-term basis. In his free time, he loves to send it for hiking and snowboarding adventures. Like other Christiana residents, Bobby rescued one of the many Wilmington stray cats and is now father to a goofy orange cat named Dewey.

OVERVIEW

The emergency department offers critical access to health care in our broken system. An important skillset of the modern emergency medicine physician is a set of low-risk, low-time commitment, high-benefit interventions for the management of chronic diseases. In this episode, we discuss the diagnosis and management of hypertension, type 2 diabetes, asthma, alcohol use disorder, and tobacco use disorder from the emergency department.

Discussion

Is it a part of your practice to initiate or modify treatments for chronic conditions from the emergency department?

  • The patient population discussed comprises “outpatients” who are:
    • Stable for discharge
    • Issue is chronic
  • While evidence-based, interventions are our opinion only.
  • All patients need to be referred to primary care!

HYPERTENSION

Diagnosis in clinic

  • 2 ideal time separated measurements, multiple home measurements, ambulatory monitoring
    • Stage 1: 130-139/80-89
    • Stage 2: >140/>90

Diagnosis in the ED

  • No clear consensus, 160/100? 180/110?
    • Look for trends in previous documentation
    • Ensure pain or other stressors are managed first

Medication of choice: Amlodipine 5-10 mg PO once daily

  • No laboratory monitoring
  • 5-10 mmHg drop in SBP
  • Side effects: constipation, ankle edema

Lifestyle changes

  • Weight loss, reduce salt, increase potassium, DASH diet, physical activity
  • Discontinuation of chronic NSAIDs

Evidence/support

  • AHA, ACEP guidelines support initiation from ED

Future consideration

  • Guidelines also support titration of medications if BP is undertreated

TYPE 2 DIABETES

Diagnosis in clinic

  • A1c > 6.5, fasting Glc > 126, 2 hr 75 g glucose tolerance test >200, classic signs or symptoms of hyperglycemia with glucose >200

Diagnosis in the ED

  • Glucose >200 without PO intake in 2 hrs
  • Glucose >200 with signs or symptoms of hyperglycemia such as polyuria, polydipsia, blurry vision, etc.
  • Ensure not on steroids or experiencing significant physiologic stress
  • Exclude Type I Diabetes
    • UA: Look for ketones
    • Weight loss is concerning for type I diabetes/insulin deficiency
    • ADA; AABBCC approach
      • AA: Age <35, Autoimmunity (personal or family)
      • BB: BMI <25, Background: FHx T1DM
      • CC: Control: inability to achieve glycemic control on non-insulin therapy, Comorbidities: Checkpoint inhibitors can cause new-onset T1DM in older adults

Medication of choice: metformin

  • Prescription: 500 mg tablet of metformin ER, 2 tablets 2 times per day
  • Instructions: Start at 1 tablet once per day, once GI symptoms resolve increase to 1 tablet twice per day, once GI symptoms resolve continue increasing to a maximum of 2 tablets twice per day
  • Side effects
    • Diarrhea
    • Metformin-associated lactic acidosis
      • Life threatening
      • Occurs typically in setting of AKI on CKD
    • Contraindication: GFR <30

Lifestyle interventions

  • Discontinue sugary beverages!
  • Weight loss and Mediterranean diet
  • Physical activity

Future considerations

  • POC A1c machine in your ED
  • Protocol, in collaboration with OP offices, diabetes educators, for initiating insulin from the ED (have been well-described)

ALCOHOL USE DISORDER

Diagnosis in clinic

  • DSM 5 Criteria

Diagnosis in the ED

  • Gestalt typically sufficient

Medication of choice: Naltrexone 50 mg daily

  • NNT 12
  • Tends to be more effective in reducing binge drinking
  • Can be transitioned to long acting injectable
  • Side effects: fatigue, nausea
  • Contraindications
    • Opioid use
    • Advanced/decompensated liver disease (Child Pugh C)or transaminases 3x ULN
    • Can consider acamprosate in these patients. Contraindication to acamprosate is CKD

Guideline support

  • GRACE-4 guidelines from SAEM

Future considerations

  • Develop familiarity with acamprosate as well
  • Consider co-prescription of gabapentin which can reduce mild withdrawal symptoms
  • LAI naltrexone initiation in the ED has been described

ASTHMA

Diagnosis in clinic

  • PFTs and clinical history

Diagnosis in the ED

  • Thoughtful consideration
  • Up to ⅓ of patients with a clinical diagnosis of asthma do not have asthma
    • Despite this, if asthma is the most likely diagnosis, GINA guidelines still recommended ICS containing medication initiation
  • Peak flow meter with +20% expiratory flow after bronchodilation is strongly suggestive of asthma

Medication of choice

  • ICS + Formoterol
    • Symbicort: Budesonide - Formoterol
    • Dulera: Mometasone - Formoterol
    • Learn your state’s Medicaid formulary
    • If symptoms less than 4-5 days or 1 night per week, PRN use, if more frequent, BID + PRN
    • SABA only therapy - more ED visits, more asthma progression, higher mortality
  • Provide instruction on use

Lifestyle interventions

  • Smoking cessation
  • Trigger identification

Guideline support

  • GINA guidelines: After acute care visit for asthma, initiate ICS-Formoterol

Future considerations

  • Build familiarity with asthma action plans and peak flow meters
  • This can include a prescription for PO steroids for use only if prespecified criteria on asthma action plan are met

TOBACCO USE DISORDER

Diagnosis in clinic and in the ED

  • Any tobacco use

Preferred medication: Nicotine replacement therapy, started at highest doses

  • Patch: 21 mg
    • If trouble sleeping, remove at night, otherwise OK to leave on
  • Gum: 4 mg
    • Chew then lip like a dip. Can cause stomach upset if chewed too vigorously or swallowed
    • Use as soon as cravings begin
  • Typically covered by insurance

Lifestyle interventions

  • Good evidence for brief negotiated interview from the ED
  • Help identify triggers for smoking and identify ways to introduce barriers
  • Encourage smoking reduction if cessation is not realistic
  • Refer to your state’s quit smoking line

Future considerations

  • There is data for varenicline from the inpatient setting, can consider from ED

TAKE-HOME POINTS

  • There are low-timecommitment, high-impact pharmacologic and lifestyle interventions for hypertension, type 2 diabetes, alcohol use disorder, asthma, and tobacco use disorder that are feasible from the ED
  • These interventions are supported by guidelines and literature

References

EMRACast Social EM Clinical

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