ACEP clinical policies

Guidelines for ACEP Clinical Policy

• Level A: Generally accepted principles for patient management that reflect high degree of clinical certainty.
• Level B: Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty.
• Level C: Other strategies for patient management based on Class III studies, or in absence of any adequate, published literature and based on panel consensus.

• Inclusion:
• Exclusion:
• Level A:
• Level B:
• Level C:
• Source:

== Procedural sedation (2013)

• Inclusion: Patients of all age with emergent/urgent condition that require pain +/or anxiety management to accomplish interventional or diagnostic procedure and for high-risk patients (cardiopulm d/o, multiple/head trauma, CNS depressant) w understanding that these patients are at increased risk of complications from procedural sedation and analgesia.
• Exclusion: Patients receiving inhalational anesthetics, analgesia for pain control without sedatives, sedation solely for anxiolysis and behavioral emergencies, or intubated patients,
• Level A:
  • Ketamine safe for children. Propofol safe for children and adults for sedation in analgesia in ED.
• Level B:
  • Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in risk of emesis or aspiration
  • Capnography may be used as adjunct to pulse ox and clinical assessment to detect hypoventilation and apnea earlier than pulse ox +/or clinical assessment alone
  • Etomidate safe to adults. Combination of propofol and ketamine safe for children and adults.
• Level C:
  • During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring, in addition to the provider performing procedure. Physicians who are working or consulting in ED should coordinate procedures.
  • Ketamine safe for adults. Alfentanil safe for adults. Etomidate safe for children.
• Source: Clinical policy: Procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63:247-258.

tPA for Acute Ischemic Stroke (2012)

• Inclusion: Adult patients presenting to ED with acute ischemic stroke
• Exclusion: Children < 18 years
• Level A:
  • Offer IV tPA to acute ischemic stroke patients who meet NINDS inclusion/exclusion criteria and can be treated within 3 hours after symptom onset.
• Level B:
  • To consider IV tPA to acute ischemic stroke patients who meet ECASS III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.
• Source: Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke int he emergency department. Ann Emerg Med. 2013;61:225-243.

Neuroimaging and decision making in TBI (2008)

• Inclusion:
  • Nonpenetrating trauma to the head
  • Presentation to ED within 24 hours of injury
  • GCS 14 or 15 on initial evaluation in ED
  • Age ≥ 16
• Exclusion:
  • Penetrating trauma
  • Patients with multi-system trauma
  • GCS < 14 on initial evaluation in the ED
  • Age < 16
• Level A:
  • A noncontrast head CT indicate in head trauma patients with LOC or posttraumatic amnesia only if ≥ 1 of following is present:
    • Headache
    • Vomiting
    • Age> 60
    • Drug or alcohol intoxication
    • Deficits in short-term memory
    • Physical evidence of trauma above the clavicle
    • Posttraumatic seizure
    • GCS < 15
    • Focal neurological deficit
    • Coagulopathy
• Level B:
  • A noncontrast head CT should be considered in head trauma patients with no LOC or porttraumatic amnesia if there is:
    • Focal neurological deficit
    • Vomiting
    • Severe headache
    • Age ≥ 65
    • Physical signs of basilar skull fracture
    • GCS < 15
    • Coagulopathy
    • Dangerous mechanism of injury
  • Patients with an isolated TBI who have a negative head CT scan result are at a minimal risk for developing an intracranial lesion and therefore may be safely discharged from the ED.
  • Skull film radiographs are not recommended in mild TBI. Although presence of skull fracture increases the likelihood of intracranial lesion, its sensitivity is not sufficient to be a useful screening test. Negative findings on skull films may mislead clinicians.
• Level C:
  • In mild TBI patient with significant extracranial injuries and a serum S-100B level less than 0.5ℳg/L measured within 4 hours if injury, consideration can be given to not performing a CT.
  • Mild TBI patients discharged from the E should be informed abut postconcussive symptoms.
• No specific recommendation for use of head MRI in patient with mild TBI
• Source: Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52:714-748.

Syncope (2007)

• Inclusion: Adult
• Exclusion: Children or for patients whom episode of syncope is thought to be secondary to another disease process
• Level A:
  • Hx and PE c/w heart failure help identify patients at high risk for an adverse outcome.
  • Standard 12-lead EKG
• Level B:
  • High risk of AE: Older age, structural heart disease, h/o CAD
  • Low risk of AE: younger, nonexertional, w/o h/o or signs of CVD or family hx of sudden death and w/o comorbidities
  • Admit patients with syncope and evidence of heart failure or structural heart disease
  • Admit patients with syncope and other factors that lead to stratification as high-risk for adverse outcomes.
    • Older age and associated comorbidities
    • Abnormal EKG (Acute ischemia, dysrhythmia, or significant conduction abnormalities)
    • Hct < 30 (if obtained)
    • Hx or presence of heart failure, CAD< or structural heart disease
• Level C:
  • Lab testing and advanced investigative testing such as echo or cranial CT need not be routinely performed unless guided by specific findings in the Hx and PE. 2
• Source: Clinical Policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49:431-444.