Thomas W. Lukens

Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: Thomas W. Lukens, MD, PhD, (Chair) Stephen J. Wolf, MD Jonathan A. Edlow, MD Samina Shahabuddin, MD Michael H. Allen, MD, (American Association for Emergency Psychiatry) Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry) Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

This clinical policy from the American College of Emergency Physicians is an update of a 2000 clinical policy on the evaluation and management of patients presenting with nontraumatic acute abdominal pain.1 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 decision making 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.

Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries

STUDY OBJECTIVE Two separate clinical decision rules, one developed in Ottawa and the other in Pittsburgh, for the use of radiography in acute knee injuries have been previously validated and published. In this study, the rules were prospectively validated and compared in a new set of patients. METHODS A prospective, blinded, multicenter trial was conducted in the emergency departments of three urban teaching hospitals. A convenience sample of 934 patients with knee pain requiring radiographs was enrolled. A standardized data form was completed for each patient, comprising the 10 clinical variables included in the two rules. Standard knee radiographs were then taken in each patient. The rules were interpreted by the primary investigator on the basis of the data sheet and the final radiologist radiograph reading. RESULTS In the 745 patients in whom the Pittsburgh rules could be applied there were 91 fractures (12.2%). The use of the Pittsburgh rule missed one fracture, yielding a sensitivity of 99% (95% confidence interval [CI], 94% to 100%); the specificity was 60% (95% CI, 56% to 64%). The Ottawa inclusion criteria were met by 750 patients, with 87 fractures (11.6%). The Ottawa rule missed three fractures, for a sensitivity of 97% (95% CI, 90% to 99%); specificity was 27% (95% CI, 23% to 30%). CONCLUSION Prospective validation and comparison found the Pittsburgh rule for knee radiographs to be more specific without loss of sensitivity compared with the Ottawa rule.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia

This clinical policy from the American College of Emergency Physicians focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED)with community-acquired pneumonia. It is an update of the 2001 clinical policy for the management and risk stratification of adult patients presenting to the ED with community-acquired pneumonia. A subcommittee reviewed the current literature to derive evidence-based recommendations to help answer the following questions: (1) Are routine blood cultures indicated in patients admitted with community-acquired pneumonia? (2) In adult patients with community-acquired pneumonia without severe sepsis, is there a benefit in mortality or morbidity from the administration of antibiotics within aspecific time course? The evidence was graded and recommendations were given based on the strength of evidence.

Clinical Policy for the Initial Approach to Patients Presenting With Penetrating Extremity Trauma

Abstract [American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Ann Emerg Med May 1999;33:612-636.]