Bruce M. Lo

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure

This clinical policy from the American College of Emergency Physicians is the revision of a 2006 policy on the evaluation and management of adult patients with asymptomatic elevated blood pressure in the emergency department.1 A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In emergency department patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes? (2) In patients with asymptomatic markedly elevated blood pressure, does emergency department medical intervention reduce rates of adverse outcomes? 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.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. 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.

Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

This clinical policy from the American College of Emergency Physicians addresses key issues for adults presenting to the emergency department with suspected transient ischemic attack. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected transient ischemic attack, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the emergency department? (2) In adult patients with suspected transient ischemic attack, what imaging can be safely delayed from the initial emergency department workup? (3) In adult patients with suspected transient ischemic attack, is carotid ultrasonography as accurate as neck computed tomography angiography or magnetic resonance angiography in identifying severe carotid stenosis? (4) In adult patients with suspected transient ischemic attack, can a rapid emergency department-based diagnostic protocol safely identify patients at short-term risk for stroke? Evidence was graded and recommendations were made based on the strength of the available data.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

&NA; This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non–ST‐elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence‐based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST‐elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30‐day major adverse cardiac events? (2) In adult patients with suspected acute non–ST‐elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30‐day major adverse cardiac events? (3) In adult patients with suspected non–ST‐elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30‐day major adverse cardiac events? (4) Should adult patients with acute non–ST‐elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30‐day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction

Ischemic heart disease is the leading cause of death in the world. More than half a million patients present to emergency departments across the United States each year with ST-segment elevation myocardial infarctions. Timely reperfusion is critical to saving myocardium at risk. Multiple studies have been conducted that demonstrate that improved care processes are linked to improved survival in patients having an acute myocardial infarction. This clinical policy from the American College of Emergency Physicians addresses key issues in reperfusion for patients with acute ST-segment elevation myocardial infarction. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients having an ST-segment elevation myocardial infarction, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events when percutaneous coronary intervention is delayed? (2) In adult patients having an ST-segment elevation myocardial infarction, does transfer to a percutaneous coronary intervention center decrease the incidence of major adverse cardiac events? (3) In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Correction: Correction to ‘Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department’ [Annals of Emergency Medicine 63 (2014) 247-258.e18]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to ‘Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures’ [Annals of Emergency Medicine 63 (2014) 437-447.e15]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to ‘Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department’ [Annals of Emergency Medicine 66 (2015) 322-333.e31]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to ‘Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department’ [Annals of Emergency Medicine 68 (2016) 354-370.e29]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Correction: Correction to ‘Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning’ [Annals of Emergency Medicine 69 (2017) 98-107.e6]

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.