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.

Use of IV tPA for Acute Ischemic Stroke (2013)

• 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 in acute setting (2002)

• Inclusion criteria:
  • 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 criteria:
  • 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, or 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.