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This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation 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 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) Inpatients 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.

This clinical policy from the American College of Emergency Physicians is the revision of the 2003 Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy.(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Should the emergency physician obtain a pelvic ultrasound in a clinically stable pregnant patient who presents to the emergency department (ED) with abdominal pain and/or vaginal bleeding and a beta human chorionic gonadotropin (β-hCG) level below a discriminatory threshold? (2) In patients who have an indeterminate transvaginal ultrasound, what is the diagnostic utility of β-hCG for predicting possible ectopic pregnancy? (3) In patients receiving methotrexate for confirmed or suspected ectopic pregnancy, what are the implications for ED management? Evidence was graded and recommendations were developed based on the strength of the available data in the medical literature. A literature search was also performed for a critical question from the 2003 clinical policy.(1) Is the administration of anti-D immunoglobulin indicated among Rh-negative women during the first trimester of pregnancy with threatened abortion, complete abortion, ectopic pregnancy, or minor abdominal trauma? Because no new, high-quality articles were found, the management recommendations from the previous policy are discussed in the introduction.

The death of a child in the emergency department (ED) is often overwhelming to the child's community, including the health care providers involved in that child's care. Sudden death, especially of a child, induces a strong emotional response in health care providers and in the families involved. Advanced preparation by emergency staff is vital to appropriately care for the patient, the grieving family, and the ED staff. The American College of Emergency Physicians and the American Academy of Pediatrics have jointly adopted a policy statement entitled "Death of a Child in the Emergency Department Joint Statement by the American Academy of Pediatrics and the American College of Emergency Physicians." The purpose of this article is to provide the emergency physician with information related to the management of children and their families who die in the ED. The following important issues will be discussed: a family and team-centered approach when a child dies, support for families and communities, communication within the child's medical home, identification of resources for use when a child dies, and critical incident stress management.

Injury is the number one cause of death and life-years lost for children. In children, injury mortality is greater than childhood mortality from all other causes combined. Modern injury prevention and control seeks to prevent and limit or control injuries through the 4 Es of injury prevention: engineering, enforcement, education, and economics. Emergency physicians are often placed in a critical role in the lives of individuals, are respected authorities on the health and safety of children and adults, and have daily exposure to high-risk populations. This gives emergency physicians a unique perspective and an opportunity to take an active role in injury control and prevention. Specific methods or strategies for promulgating injury prevention and control in our emergency medicine practices are suggested, ranging from education (for our patients and health professionals); screening and intervention for domestic violence, child maltreatment, drug-alcohol dependency and abuse; data collection; reporting unsafe products; research; legislation; serving in regulatory and governmental agencies; emergency medical services-community involvement; and violence prevention. Emergency physicians can play a significant role in decreasing pediatric injury and its concomitant morbidity and mortality.

Recognition of injuries to the cervical spine is of critical importance. Such injuries may be difficult to recognize in patients who have an altered level of consciousness or other significant injuries. We present the case of an alert ambulatory patient with no complaint of neck pain, no tenderness of the neck on physical examination, and no history of trauma who, while being evaluated for fever, was found to have an unstable cervical-spine fracture that was not present on radiographs done one year earlier.

There are many clinical situations in which IV access is unavailable, and the endotracheal route is a valuable alternative route for drug therapy. The optimal technique of endotracheal drug administration, however, has not been determined. Twenty-nine dogs were divided into five groups and given endotracheal lidocaine at two doses, 2 mg/kg and 4 mg/kg, by differing techniques: control, undiluted lidocaine in a syringe was given as a bolus; needle, the drug was given through a needle attached to the syringe; dilution, lidocaine was diluted approximately 1:1 with normal saline and the entire dilution was given as a bolus; normal saline (NS) followup, lidocaine in a syringe was given as a bolus, followed immediately by an equal bolus of normal saline; and catheter, the drug was given through a catheter that was placed inside and extended just beyond the endotracheal tube. Mean plasma lidocaine levels (microgram/mL) at five minutes were as follows (at a 2-mg/kg endotracheal lidocaine dose): control, 0.64; needle, 0.0; dilution, 3.1; and (at a 4-mg/kg endotracheal lidocaine dose) control, 1.0; needle, 0.6; dilution, 6.2; NS followup, 1.9; and catheter, 1.9. At all time periods with either dose of lidocaine (2 or 4 mg/kg), the highest plasma lidocaine levels occurred with dilution and the lowest with the needle method. These results were highly significant (P less than .001). The highest plasma lidocaine levels may be attained by diluting the drug with normal saline. Higher levels were achieved when the drug was given through a catheter or when the drug was followed with a bolus of normal saline.(ABSTRACT TRUNCATED AT 250 WORDS)

Four cases of acute laryngeal fracture that demonstrate the history and clinical findings characteristic of blunt laryngotracheal trauma are presented. Symptoms in these patients included shortness of breath, neck pain, dysphasia, dysphonia, and hemoptysis. Physical examination findings suggesting acute laryngeal injury included pain on palpation of neck, swelling or edema of the neck, subcutaneous emphysema, and loss of landmarks in the neck. All four patients were admitted to the surgical intensive care unit and had the diagnosis of laryngeal fracture confirmed at laryngoscopy. Airway obstruction is a potential complication in all patients sustaining blunt laryngotracheal trauma. Early diagnosis and management may lead to a good outcome, as with these four patients.

The recognition and appropriate initial management of the patient with an acute cervical spine injury in the ED is important because of the devastating and catastrophic effects of spinal cord injury. The use of computed tomography (CT) scan compared with initial plain radiographs in the detection of acute blunt traumatic cervical spine injury was evaluated in 20 patients. There was a disparity between the plain film and the CT scan as read by an attending radiologist in 12 patients (60%). In five patients (25%) the plain radiograph suggested a fracture or dislocation that was confirmed by CT scan. In eight patients (40%) the cervical spine film was read as a fracture, dislocation, or soft tissue widening between the cervical spine vertebrae. CT scan done later after admission was normal. In the remaining seven patients the plain film was read as "normal." CT scan, however, was normal in only three, and in four of these seven patients there was a discrepancy between the plain radiograph and the CT. Thus in four of 20 patients (20%) the plain film was read as "normal," while CT scan showed a fracture in our study. CT scan was superior to plain films in diagnosing cervical spine trauma, and it eliminated the false-positive (40%) and false-negative (20%) results obtained by relying on plain radiographs alone.

In the many emergency situations in which it is difficult or impossible to obtain venous access rapidly endotracheal drug therapy can be effective and life saving. Yet relatively little is known about endotracheal drug therapy. Plasma lidocaine levels were measured in 23 dogs after the administration of endotracheal lidocaine at a dose of 2 or 4 mg/kg. Endotracheal lidocaine was given either as a dilution with normal saline (1:1 dilution) or undiluted (Group 1, no dilution; Group 2, dilution). Significantly higher plasma lidocaine levels occurred with the dilution group in all the time periods and with either dose of lidocaine (2 or 4 mg/kg) (P less than .001). Mean plasma lidocaine levels (microgram/mL) at five minutes were: (at 2 mg/kg dose) Group 1, 0.64; Group 2, 3.4; and (at 4 mg/kg dose) Group 1, 1.9, Group 2, 4.7 (P less than .001). Arterial blood gases were not significantly different before or after endotracheal drug administration. This study suggests that higher plasma lidocaine levels are achieved and maintained longer when diluted with normal saline than when given undiluted; and higher plasma lidocaine levels can be obtained by dilution without any detrimental effect on respiratory function as measured by arterial blood gases.