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.
Nontraumatic Thoracic Aortic Dissection (2014)
- Inclusion: Adult ≥ 18 with suspected acute nontraumatic thoracic aortic dissection
- Exclusion: Traumatic aortic dissection, pediatric, pregnant
- Level A: None
- Level B:
- CTA to exclude thoracic aortic dissection (accuracy similar to that of TEE and MRA).
- Do not rely on abnormal bedside TTE result to definitively establish diagnosis
- Level C:
- Do not use clinical decision rules alone to identify very low risk acute thoracic aortic dissection. Decision to pursue further work up discretion of EP.
- Do not rely on d-dimer alone to exclude the diagnosis of aortic dissection
- Immediate surgical consultation or transfer to higher level of care if TTE suggestive or dissection
- Decrease BP and pulse if elevated. No specific targets.
Seizures (2014)
- Inclusion: Adult ≥ 18 with generalized convulsive seizures
- Exclusion:
- Pediatrics
- Complex partial seizures
- Acute head trauma
- Multi-system trauma
- Brain mass or tumor
- Immunocompromised patients
- Eclampsia.
- Level A:
- Administer additional antiepileptic medication in refractory status epilepticus who have failed treatment with BZDs
- Level B:
- Administer IV phenytoin, fosphenytoin, or valproate in refractory status epilepticus who have failed BZD
- Level C:
- EP need not initiate antiepileptic medication in ED for 1st time provoked seizure. Identify and treat precipitating medical conditions.
- EP need not initiate antiepileptic medication in ED for 1st time unprovoked seizure w/o evidence of brain disease or injury.
- EP may initiate antiepileptic medication in ED or defer in coordination with other providers, for patients who experienced 1st unprovoked seizure w a remote h/o brain disease or injury.
- Do not need to admit patients with 1st unprovoked seizure who have returned to clinical baseline in Ed.
- When resuming antiepileptic medication in ED is deemed appropriate, EP may administer IV or oral medication at their discretion.
- Administer IV levitiracetam, propofol or barbiturates in refractory status epilepticus who failed BZD
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:
- Inhalational anesthetics
- Analgesia for pain control without sedatives
- Sedation solely for anxiolysis and behavioral emergencies
- 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.
Asymptomatic HTN (2013)
- Inclusion:
- Age ≥ 18
- Symptomatic elevated BP
- Lack signs of symptoms of acute target organ injury.
- Exclusion:
- Acute hypertensive emergencies (acute stroke, cardiac ischemia, pulmonary edema, encephalopathy, CHF)
- Pregnant
- ESRD
- Emergent conditions that are likely to cause elevated BP not directly related to acute target organ injury
- Acute presentation of serious medical conditions associated with HTN (stroke, MI, CHF)
- Level A: None
- Level B: None
- Level C:
- Routine screening for acute target organ injury (Cr, UA, EKG) not required
- In select patient population ( poor f/u), screening Cr may identify kidney injury that affects disposition.
- Routine ED medical intervention not required.
- May treat elevated BP in ED +/or initiate therapy for long term control in select patients.
- Refer for outpatient f/u.
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.
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
- A noncontrast head CT indicate in head trauma patients with LOC or posttraumatic amnesia only if ≥ 1 of following is present:
- 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.
- A noncontrast head CT should be considered in head trauma patients with no LOC or porttraumatic amnesia if there is:
- Level C:
- In mild TBI patient with significant extracranial injuries and a serum S-100B level ≤ 0.5ℳg/L measured w/in 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
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
Sources
- Clinical Policy: Critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection.
- Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63:437-447.
- Clinical Policy: Critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62:59-68.
- Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke int he emergency department. Ann Emerg Med. 2013;61:225-243.
- Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52:714-748.
- 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.
- Inclusion:
- Exclusion:
- Level A:
- Level B:
- Level C:
- Source: