Annals audio for July: POSTED!

July’s audio/podcast for Annals of EM is now posted here. Highlights:

-Early vs late rhythm analysis in OOHCA
-Ground based EMS transports and complications
-When do sepsis patients become septic? Usually NOT on arrival. Time to change the metric?
-Botulism outbreak
-Diethylene glycol outbreak
-Much, much more!

Enjoy, and email with any comments or questions any time,
D&A

ACEP Clinical Policies Committee to Develop Independent tPA Policy

The ACEP Board Directors accepted a recommendation last week from its Clinical Policies Committee to begin working on a tPA policy exclusive to ACEP instead of a joint project with the American Academy of Neurology.

The 2013 Council had asked that ACEP reconsider its current “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department,” which had been developed with the AAN and published in February 2013.

After an open 60-day comment period in early 2014 and a subcommittee review of the comments and literature findings, the Clinical Policies Committee recommended to pursue an independent policy, which will include updated evidence and grading criteria. The Board unanimously approved this recommendation.

Once the draft is developed, it will be available for members to review and comment for 60 days prior to the Committee’s presentation to the Board. An estimated timeline was not available.

Additionally, the Board confirmed its commitment to the clinical policy development process and agreed to add three methodologists to the committee, additional meetings, and another staff person to ensure a robust review process.

ACEP Clarifies Campaign Rules

By James M. Cusick, MD, FACEP
Chair, Candidate Forum Subcommittee of the ACEP Council

ACEP is a member-driven organization with a representative body of our peers – the ACEP Council – chosen through component bodies, including our chapters (1 representative per 100 members), our Sections of Membership, and other aligned organizations.

Each year, this body democratically votes to establish ACEP policy and elect leadership positions. Candidates present themselves to the Council through written statements, scheduled speeches, and unrehearsed Question and Answer sessions during the Candidate Forum, which is open to all members. Elections must be fair, follow guidelines applicable to all, and be free of undue influence or pressure on candidates.

The ACEP Council’s Candidate Forum Subcommittee recently performed its annual review of the campaign rules to ensure a fair campaign and elections process for all Board of Directors and President-elect candidates. The changes were approved by the Council Steering Committee.

This year, restrictions on the use of social media were substantially relaxed to allow forms of communication most of us use on a daily basis.

In addition, protections were incorporated into the rules to keep candidate interviews in ACEP publications. Our goal is to avoid candidates being put in the position of commenting on College policy without adequate preparation and to ensure that the campaign process is fair and equal for all candidates.

Certain candidates may unfairly benefit from coverage in non-ACEP publications, while some may be disadvantaged. In order to ensure a fair election, campaign questions and the vetting of candidates is the responsibility of ACEP, its Council and its Council Committees.

If there are specific questions you would like asked of the candidates prior to the election, please send them to communications@acep.org. The Candidate Forum Subcommittee will consider them, the selected questions will be posed to candidates and their responses will be made public.

Elections will occur during the Council meeting on Oct. 26 in Chicago. The Nominating Committee has selected the final slate of candidates for 2014:

President-Elect Candidates
Jay Kaplan, MD, FACEP
Robert O’Connor, MD, FACEP
Rebecca Parker, MD, FACEP

Board of Directors Candidates (4 positions to be filled)
Stephen Anderson, MD, FACEP (WA)
Jon Mark Hirshon, MD, FACEP (MD)
Hans House, MD, FACEP (incumbent – IA)
Mark Mackey, MD, FACEP (incumbent – IL)
John Rogers, MD, FACEP (incumbent – GA)
Mark Rosenberg, DO, FACEP (NJ)

 

June audio is up!

The Annals of EM June audio is posted and available. Highlights:

-How important is isolated vomiting in children as a predictor of TBI?
-The yield of ‘clearance’ laboratory testing for pediatric psych patients
-Confirming femoral lines with a saline flush—it works
-Should hydromorphone dosing be weight-based?
-Intranasal fentanyl for EMS
-Transgender populations in the ED: the experience
-Incidence of delayed anaphylaxis in the ED

And much much more…

Email any time at annalsaudio@acep.org.

D&A

Annals Clinical Case: Female With Lower Abdominal Pain and Bleeding

AnnalsMay 2014, Annals of Emergency Medicine

By Justin McNamee, DO; Nilesh Patel, DO; and Joseph Affortunato, DO

Department of Emergency Medicine
St. Joseph’s Regional Medical Center, Paterson, New Jersey

A 26-year-old woman presented to the emergency department, complaining of a 3-day history of lower abdominal pain and vaginal bleeding. She reported positive home pregnancy test results and that her last menstrual period was 17 weeks ago. On examination, the patient appeared comfortable and was afebrile, with a blood pressure of 131/67 mm Hg, pulse rate of 100 beats/min, and respiratory rate of 16 breaths/min.

Click here to read the full case, see the images and get the diagnosis.

ACEP Clinical Policy Review: Seizures

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

By J. Stephen Huff, MD, FACEP

In the April 2014 issue of the Annals of Emergency Medicine, the American College of Emergency Physicians (ACEP) published a clinical policy focusing on seizures. This is a revision of a 2004 clinical policy with the same name.

This clinical policy can also be found on ACEP’s website www.acep.

Dr. J. Stephen Huff

Dr. J. Stephen Huff

org and was accepted for abstraction on the National Guideline Clearinghouse website, www.guidelines.gov.

This clinical policy takes an evidence-based approach to answering four frequently encountered questions with regards to decision making associated with seizures in the emergency department. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:

Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; Level C recommendations represent other patient management strategies based on Class III studies, or in the absence of any adequate published literature, based on consensus of the members of the Clinical Policies Committee.

During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, neurologists, and individual members of the American Epilepsy Society, the American Academy of Neurology, the Epilepsy Foundation of America, the National Association of Epilepsy Centers, and ACEP’s Quality and Performance Committee. The draft was also open to further comments through various ACEP communication pieces. All responses were used to further refine and enhance this policy; however, their responses did not imply endorsement of this clinical policy.

This revision of the clinical policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department focused on selected critical questions. Key to this policy revision was employing updated nomenclature for classification of seizures. Seizures can be thought of as provoked or unprovoked. Provoked seizures are secondary to electrolyte disturbances, toxins, infections, central nervous system mass lesions, withdrawal syndromes, or other etiologies. These provoked seizures, also known as acute symptomatic seizures, by definition occur at the time of or within seven days of acute neurologic, systemic, metabolic, or toxic processes. Unprovoked seizures occur in the absence of acute precipitating factors. Seizures from such processes as stroke, brain injury, and other CNS insults that occurred more than seven days in the past are also classified as unprovoked seizures. Epilepsy is defined by recurrent unprovoked seizures.

The question of initiating treatment with antiepileptic drugs for the adult patient presenting to the ED following a first generalized seizure who has returned to baseline clinical status was one critical question. The short-term recurrence risk of this group of patients is unknown but thought to be low. After literature review and grading the evidence, level C recommendations were developed for subgroups of patients. Appropriate clinical assessment by emergency physicians of patients is important since presumptive assignment of the seizure as provoked or unprovoked drives the treatment recommendation. However, it is unclear if seizures can be precisely identified as provoked or unprovoked using information available during an emergency department evaluation. Additionally, patient safety should remain a paramount concern for the practicing physician. Though the evidence supports discharging an adult patient who has returned to baseline status following a first unprovoked seizure, supporting articles assumed a safe support system for the discharged patient. Consideration of social issues or other factors may prompt consideration for admission.

Another critical question addressed treatment of ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine. There are remarkably few randomized prospective studies on this problem and none that consider the causes of status epilepticus. Large prospective studies are in the planning stages. Until these studies are completed, recommendations for specific drugs must reflect current lower levels of evidence. Many different medications are recommended and no medication or class of medications is clearly superior.

Designation of a seizure as provoked or unprovoked at some level is arbitrary and may change with the clinical course or as additional studies are performed. Emergency physicians play a critical role in determining whether a seizure is provoked or unprovoked. If there is an underlying medical condition, identification and treatment of that process is the primary consideration. It is hoped that future studies will focus on seizure recurrence of patients presenting to the ED with seizures, and study outcomes over days or another time frame relevant to emergency medicine.

Critical Questions and Recommendations

Question 1:  In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?

Level C recommendations.

(1) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
(2) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
(3) Emergency physicians may initiate antiepileptic medication* in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.

* Antiepileptic medication in this document refers to medications prescribed for seizure prevention.

Question 2: In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events

Level C recommendations. Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.

Question 3: In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?

Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.

Question 4: In ED 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?

Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.

Dr. Huff is Professor of Emergency Medicine and Neurology, University of Virginia, Charlottesville, Virginia