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Background: Acute aortic syndromes (AAS), encompassing aortic dissection, intramural hematoma, and penetrating aortic ulcers, are life-threatening emergencies requiring swift diagnosis and management in the emergency room (ER). This review provides a practical, evidence-based framework for managing suspected AAS in emergency settings.Methods: A narrative review was conducted, searching PubMed, Embase, Cochrane Library, and Web of Science from January 2000 to December 2024, using terms such as “aortic dissection,” “intramural hematoma,” “penetrating aortic ulcer,” “emergency aortic repair,” “EVAR,” and “TEVAR.” Clinical trials, cohort studies, and guidelines for adults (≥18 years) with AAS were included, adhering to PRISMA principles. Data were synthesized narratively to guide clinical decision-making.Results: Suspected AAS requires rapid triage, with CT angiography (CTA, 98% sensitivity) as the gold standard. Type A dissection mandates urgent open repair (15–25% 30-day mortality), while complicated type B dissection benefits from thoracic endovascular aortic repair (TEVAR, 5–10% mortality). Ruptured abdominal aortic aneurysms (rAAA) favor endovascular aortic repair (EVAR, 15–20% mortality) when feasible. Intramural hematoma and penetrating ulcers may require TEVAR for progression. Special populations (e.g., Marfan syndrome, elderly, women) and resource-limited settings necessitate tailored approaches.Conclusions: Clinicians should prioritize rapid imaging, hemodynamic stabilization, and multidisciplinary consultation. Open repair is critical for type A dissection, TEVAR/EVAR for type B and rAAA, and medical management for uncomplicated cases. Training and transfer protocols improve outcomes.