Emergency Medicine: Guidelines

A writing subcommittee reviewed the literature as part of the process to develop evidence-based recommendations to address 4 key critical questions: (1) In a hemodynamically unstable patient with blunt abdominal trauma is ultrasound the diagnostic modality of choice? (2) Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma? (3) In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result? (4) In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse events who do not need an abdominal CT?
Evidence was graded and recommendations were based on the available data in the medical literature related to the specific clinical question.

A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis? (2) In adult patients with suspected acute appendicitis who are undergoing a computed tomography scan, what is the role of contrast? (3) In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of computed tomography and ultrasound in diagnosing acute appendicitis? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

This guideline provides algorithms guiding the management of unstable patients, stable patients, and patients that might be eligible for cardioversion in the ED. There is also a separate algorithm guiding anticoagulation.
• This guideline discusses a wide breadth of treatment issues, including pharmacologic rate control, when to apply urgent DC cardioversion, when to consider a rhythm control strategy, what to do if patients spontaneously convert to sinus rhythm, when to consult Cardiology or Electrophysiology, and how to best
reduce risk of stroke.
• Some guideline highlights include:
• Recommendation to use the CHADS-VASC stroke risk assessment tool (instead of the CHADS tool).
• Recommendation to use the “novel anticoagulants” as first line agents in many patients.
• Recommendation to consult Electrophysiology on a larger number of atrial fibrillation patients in the
hospital.
• Recommendations for the management of postoperative AF, including special considerations for thoracic
surgery patients.

The critical questions addressed in this clinical policy are: (1) In the adult ED patient with noncancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse? (2) In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications? (3) In the adult ED patient for whom opioid prescription is considered appropriate for treatment of new-onset acute pain, are short-acting schedule II opioids more effective than short-acting schedule III opioids? (4) In the adult ED patient with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential harms?

A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk
of emesis or aspiration? (2) In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events? (3) In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications? (4) In
patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate,dexmedetomidine, alfentanil and remifentanil be safely administered? A literature search was performed, the evidence was graded, and recommendations were given based on the strength
of the available data in the medical literature.

A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures? (2) In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events? (3) In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures? (4) In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? A literature search
was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Answers four critical questions: (1) Is intravenous tissue plasminogen activator (tPA) safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset? (2) Is intravenous tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.