ACEP clinical policies

Recommendation Levels

• 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 with out 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 history of 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
• High-risk patients (cardiopulmonary 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.

Asymptomatic Hypertension (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 hypertension (stroke, MI, CHF)
• Level A: None
• Level B: None
• Level C:
  • Routine screening for acute target organ injury (Cr, UA, ECG) not required
  • In select patient population ( poor follow up), screening creatinine 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 follow up.

tPA for Acute Ischemic Stroke (2015)

• Inclusion: Adult patients presenting to ED with acute ischemic stroke
• Exclusion: Children < 18 years
• Level A:
  • None.
• Level B:
  • Offer IV tPA to acute ischemic stroke patients who meet NINDS inclusion/exclusion criteria and can be treated within 3 hours after symptom onset. Consider increased risk of symptomatic intracranial hemorrhage in decision to administer tPA. (May consider administration in carefully selected patients presenting within 3-4.5 hours of symptom onset.)

Prescribing Opioids (2012)

• Inclusion: Adult with acute non-cancer pain or acute exacerbation of chronic non-cancer pain
• Exclusion: Long term care of patients w cancer or chronic non-cancer pain
• Level A:
• Level B:
  • Short-acting opioids such as oxycodone or hydrocodone for short term relief of acute musculoskeletal pain
• 'Level C:
  • Use of state prescription monitoring program may help identify patients at high risk for prescription opioid diversion or doctor shopping.
  • For patient being discharge from ED w acute low back pain, EP should ascertain whether non-opioid analgesics and non-pharmacologic therapies will be adequate
  • Opioids reserved for more severe pain or pain refractory to other analgesics
  • Unknown benefit of short-acting schedule II over schedule III opioids.
  • If opioids indicated, prescription for lowest practical dose for limited duration <1 week), and should consider risk for misuse, abuse, or diversion.
  • Avoid prescribing outpatient opioids for a patient with an acute exacerbation of chronic non-cancer pain.
  • Honor existing patient-physician pain contracts/treatment agreements and consider past prescription patterns.

Neuroimaging and decision making in TBI (2008)

• Inclusion:
  • Non-penetrating 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 post-traumatic 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
    • Post-traumatic seizure
    • GCS < 15
    • Focal neurological deficit
    • Coagulopathy
• Level B:
  • A noncontrast head CT should be considered in head trauma patients with no LOC or post-traumatic 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.
• 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 post-concussive 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:
  • History and PE consistent with heart failure help identify patients at high risk for an adverse outcome.
  • Standard 12-lead ECG
• Level B:
  • High risk of AE: Older age, structural heart disease, history of CAD
  • Low risk of AE: younger, nonexertional, with out history of or signs of CVD or family history of sudden death and with out co-morbidities
  • 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 co-morbidities
    • Abnormal ECG (Acute ischemia, dysrhythmia, or significant conduction abnormalities)
    • HCT < 30 (if obtained)
    • History 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 History and PE.

References

Authors

Ami Yamamoto, Ross Donaldson, Yos Yachivev, Neil Young, Michael O'Brien, MD, Daniel Ostermayer, amit joshi, Michael Holtz