In the dynamic world of Emergency Medicine, staying up-to-date with the latest clinical guidelines is essential to providing the best possible care for our patients.
The American College of Emergency Physicians (ACEP) has recently released updated guidelines that directly impact our practice in the management of ischemic stroke care, suspected appendicitis, mild traumatic brain injury (mTBI) in adults, and acute heart failure syndromes.
With this update, ACEP is collating the results of recent articles, plus providing expert synopsis and commentary in an effort to drive good patient care forward on some really important topics. Let’s explore these updates and their implications for emergency providers.
Policy 1 - Ischemic Stroke Care:
Timely and efficient management of ischemic stroke is crucial. The updated guideline underscores several key points.
- ACEP recommends using a scoring tool such as Los Angeles Motor Scale (LAMS) or Rapid Arterial Occlusion Evaluation Scale (RACE) to determine if there's concern for large vessel occlusion in addition to the stroke scale.
- If there is concern for large vessel occlusion, particularly between 6 and 24 hours from symptom onset, ACEP supports CT perfusion or MR-based diffusion/perfusion imaging.
- TPA and tenecteplase (TNK) are equivalent medications for thrombolysis.
- Consider using a risk assessment tool, like the HINTS exam, for patients who have dizziness in the setting of possible stroke. Performing the HINTS exam requires proficiency to use it reliably.
Policy 2 -Suspected Appendicitis:
Appendicitis is a surgical emergency that requires early diagnosis to prevent complications. Notable updates pertaining to the management of suspected appendicitis are as follows:
- Regarding diagnostic imaging, the 2023 ACEP recommendations include a greater focus on ultrasound as a first-line imaging modality for evaluating suspected appendicitis, especially in pediatric patients and pregnant women, to minimize radiation exposure.
- For those with a BMI under 20, IV contrast during CT imaging is recommended when possible, although a non-contrasted CT can be used with minimal reduction in sensitivity. Conversely, for patients with a BMI over 20, non-contrasted and contrast-enhanced CTs are essentially equivalent in discerning diagnostic outcomes.
- The new guidelines also introduce clinical decision rules to help emergency providers more accurately identify patients at low risk for appendicitis, potentially mitigating the number of unnecessary CT scans. PAS and pARC score can be used to risk-stratify pediatric patients. However, clinical prediction scores, such as the Alvarado score, should not be used in adult patients.
Policy 3 - Mild Traumatic Brain Injury
Mild Traumatic Brain Injury (mTBI), commonly referred to as concussion, is a frequent ED presentation.
- For adult patients presenting with minor head trauma, the Canadian CT Head Rule is recommended. This rule demonstrates greater specificity compared to the Nexus Head CT decision instrument and the New Orleans Criteria (NOC).
- While both NEXUS and NOC can be applied for patients over 65 years of age, it's pertinent to note that none of these tools are suitable for patients on anticoagulants.
- There's no requirement for a repeated head CT in cases of minor head trauma if the initial CT findings are negative.
- Hospital admission or observation isn't generally recommended for mTBI patients, unless they fall into a high-risk category.
- It's crucial to inform patients about the symptoms of the rare entity of delayed hemorrhage after minor trauma.
- ACEP emphasizes the significance of providing patients with detailed, concussion-specific discharge instructions. Moreover, patients identified with a higher risk of developing post-concussive syndrome — such as females, those with a prior psychiatric history, a GCS score below 15, trauma resulting from an assault, acute intoxication, episodes of loss of consciousness, and a pre-existing psychological history like anxiety or depression — should be given appropriate referrals.
Policy 4 - Acute Heart Failure Syndromes:
The management of acute heart failure syndromes presents intricate challenges.
- The utilization of point-of-care ultrasound, when accessible and when the clinician is adept in its application, is recommended for the prompt diagnosis of acute heart failure.
- Patients with acute heart failure syndromes should receive diuretics before they leave the emergency department. This approach has been shown to reduce both hospital duration and associated mortality.
- High-dose nitroglycerin is a safe and effective therapeutic option when administered to patients with acute heart failure syndrome and elevated blood pressure.
- In the context of risk stratification tools, ACEP suggests these not be used to decide who can be discharged home. However, instruments such as the Ottawa Heart Failure Risk Scale (OHFRS), Emergency Heart Failure Mortality Risk Grade, or the STRATIFY decision tool can be instrumental in identifying patients at higher risk of adverse outcomes, suggesting a more cautious approach to discharge.
- Lastly, engage in shared decision-making, factoring in each patient's unique circumstances and resources, before making final determinations about disposition.
As emergency medicine providers, we must continuously adapt our practices to align with the most current clinical guidelines. The recent updates from the American College of Emergency Physicians regarding ischemic stroke care, suspected appendicitis, mild TBI in adults, and acute heart failure syndromes provide valuable insights for delivering the best possible care to our patients. By implementing these guidelines, we can enhance patient outcomes and improve the efficiency and safety of our emergency department practices. Stay informed, stay prepared, and, most importantly, keep saving lives.
