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
• 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.

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 HTN (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 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.

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)

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• 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

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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 ECG
• 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 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)
    • 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.