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Addressing Social Risks and Needs in the Emergency Department
Contrary to popular beliefs, health outcomes are driven only to a small degree by healthcare, and driven far more by what are called the “social determinants of health” (SDOH). Emergency physicians (EPs) are perfectly situated to provide both local and national leadership to recognize and addre …
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Should Ketamine be Used to Treat Prehospital Agitation?
Ketamine is a medication that can be utilized in the emergency department and prehospital setting for the sedation of the severely agitated patient. After an incident involving the misuse of prehospital ketamine received attention in the lay press, the safety and appropriateness of the prehospital …
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Can Application of Artificial Intelligence Improve ED Triage Performance?
Emergency Department (ED) overcrowding and resulting delayed patient care is a rapidly growing worldwide problem leading to increased mortality and morbidity. (39,40,41) ED triage presents the first opportunity to promptly identify high-risk patients and efficiently allocate ED resources. Current E …
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Do Steroids Improve Clinically Relevant Outcomes in Patients with Septic Shock?
Sepsis is a dysregulated host response to infection that may progress to septic shock, a state of global hypoperfusion that often requires fluid resuscitation and vasopressors to support adequate oxygen delivery. Septic shock results in both macro- and microcirculatory failure, which ultimately pro …
Clinical Practice Statements, Other Issues
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ECMO in ED for Out of Hospital Cardiac Arrest
Statement reviewed and approved by AAEM Board of Directors. (4/23/2022)Executive SummaryEmergency departments (ED) and emergency medical services (EMS) are motivated to increase survival following sudden out of hospital cardiac arrest (OHCA).1 Extracorporeal cardiopulmonary resuscitation (ECPR) has …
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Interruptions in the Emergency Department
Statement reviewed and approved by the AAEM Board of Directors. (4/23/2022)Every day, we manage many complicated patients in the fast-paced environment of the Emergency Department (ED). This work includes making phone calls, answering questions (from physicians, students, patients, and families), c …
Clinical Practice Statements, Wellness
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Can Risk Stratification Tools be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?
Statement reviewed and approved by AAEM Board of Directors. (11/10/2021)Summary Recommendation: Febrile Neutropenia risk stratifications tools, such as the Multinational Association of Supportive Care inCancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, are suppor …
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Palliative Care in the Emergency Department: Recognizing and Meeting the Needs of Seriously Ill Patients
Statement reviewed and approved by AAEM Board of Directors. (9/16/2021)What is Palliative Care?The Center to Advance Palliative Care has provided the following definition: Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on pro …
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How Should Native Crotalid Envenomation Be Managed in the Emergency Department?
Statement reviewed and approved by AAEM Board of Directors. (9/14/2020)Updated 4/26/2021 and 8/16/2021. Recommendations: Address airway, breathing, circulation, then assess for local, hematologic, and/or systemic toxicity indicative of envenomation. Assess and determine the antivenom dosa …
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Do patients on Direct Oral Anticoagulants (DOACs) require repeat imaging and a period of observation after a head injury with an initial negative CT?
Statement reviewed and approved by AAEM Board of Directors. (4/8/2021)Summary Recommendation:There is substantial clinical uncertainty regarding the management of head injured patients taking DOACs for delayed intracranial hemorrhage (ICH) as there are no high-quality studies evaluating this questi …
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What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-inhibitor?
Statement reviewed and approved by AAEM Board of Directors. (11/12/2020)Recommendations: The primary focus of emergency treatment is airway evaluation and stabilization. A careful history and physical exam must be performed to differentiate ACE inhibitor-induced angioedema (ACE-I-AE) from …
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Does Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock?
IntroductionManagement of emergency department (ED) patients with severe sepsis and septic shock focuses on early identification, hemodynamic resuscitation, and appropriate antibiotic administration.[1] The 2012 Surviving Sepsis Campaign guidelines for the management of patients with severe sepsis …
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Triage Nurse-Ordered Testing in the Emergency Department Setting
Reviewed and approved by the AAEM Board of Directors. (June 5, 2020)Recommendations:1) Triage nurse-ordered testing reduces Emergency Department length of stay, though the overalldecrease in time is small. The decision to utilize triage nurse-ordered testing should weigh thepotential time saved ver …
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Telemetry Bed Usage for Patients with Low-Risk Chest Pain
Reviewed and approved by the AAEM Board of Directors. (4/19/2020)Recommendations: Insufficient data exist to support telemetry use in low-risk chest pain patients. (unchanged from 2011) The HEART score can identify patients at low-risk of short-term major adverse cardiovascular events. The …
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What Evaluations Are Needed in the Emergency Department Patients after a TASER Device Activation?
Reviewed and approved by the AAEM Board of Directors. (10/7/2019) Recommendations: The routine performance of EKGs, prolonged ED observation or hospitalization for ongoing cardiac monitoring is not indicated after CEW exposure in an otherwise asymptomatic awake and alert patient with a s …
Clinical Practice Statements, Other Issues
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Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?
Parenteral opioids are the most common analgesics used in the emergency department (ED) for relief of acute pain. Gastrointestinal side effects such as nausea and vomiting are common following opioid analgesia in long-term therapy for malignant and chronic pain and are considered a limiting factor …
Clinical Practice Statements, Other Issues
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What Is the Role of Intravenous and Intraoral Contrast in CT Evaluation of Acute Appendicitis?
Reviewed and approved by the AAEM Board of Directors. (6/7/2019) IntroductionPatients presenting to the emergency department (ED) with abdominal pain and concern for appendicitis typically require diagnostic imaging to confirm the diagnosis. Computer tomography (CT), magnetic resonance imaging ( …
Clinical Practice Statements, Other Issues
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The Use of qSOFA in the Emergency Department
Introduction:The concept of sepsis has recently been redefined by an International Task Force. The task force recommended the use of the qSOFA score instead of SIRS criteria to identify patients at high risk of mortality from sepsis outside of the ICU, including in Emergency Departments. However, t …
Clinical Practice Statements, Other Issues
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What is the Role of Thrombolysis in Intermediate Risk Pulmonary Embolism? with references
Reviewed and approved by the AAEM Board of Directors (11/28/2018) IntroductionPulmonary embolism (PE) remains a leading cause of cardiovascular mortality1 resulting in an estimated 150,000 deaths annually2 in the United States. With a 3-month mortality rate of 9-15%,3,4 PE presents an important …
Clinical Practice Statements, Other Issues
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Is Lactate Measurement in the Emergency Department Valuable as a Predictor of Poor Outcomes in Adult Patients with Sepsis?
Reviewed and approved by the AAEM Board of Directors (11/28/2018) Introduction Current emergency department (ED) management of sepsis includes serial measurements of serum lactate. Since the initial publication of the Surviving Sepsis Campaign Guidelines and the landmark study by Rivers and coll …
Clinical Practice Statements, Other Issues
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Options for Submitting a Board Approved CPC Paper for JEM Consideration
Submit the paper in initial format as written by the author(s) to Dr. Gary Vilke, our JEM "expediter.” He can send it to the appropriate editor for expedited review. (no sharing of authorship with this route and it is presumably not as involved as getting it published as an outsider sen …
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During the Emergency Department Evaluation of a Well Appearing Neonate with Fever, Should Empiric Acyclovir be Initiated?
Reviewed and approved by the AAEM Board of Directors (7/10/2017) IntroductionDuring the assessment of a febrile neonate, defined as less than 28 days of age, initiation of a full septic work-up including blood, urine and cerebrospinal fluid (CSF) analysis followed by administration of broad spec …
Clinical Practice Statements, Other Issues
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What is the Role of Reversal Agents in the Management of ED Patients with Dabigatran-Associated Hemorrhage?
Reviewed and approved by the AAEM Board of Directors (6/7/2017) IntroductionDabigatran was approved by the Food and Drug Administration (FDA) in 2010 and was the first nonwarfarin oral anticoagulant (NOAC) to be introduced to the U.S. market. Dabigatran is a direct thrombin inhibitor that inhibi …
Clinical Practice Statements, Other Issues
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Can an Age-Adjusted D-Dimer be Used to Safely Rule Out Pulmonary Embolism in Emergency Department Patients?
Reviewed and approved by the AAEM Board of Directors (3/20/2017) Introduction: Pulmonary embolism (PE) is a serious, potentially fatal condition, but is difficult to safely rule out using only clinical features. Studies have demonstrated that a combination of risk-stratification and D-dimer test …
Clinical Practice Statements, Other Issues
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Ultrasound for the Diagnosis and Management of Ureterolithiasis in the Emergency Department
Reviewed and approved by the AAEM Board of Directors (3/17/2017) IntroductionThe work-up of uncomplicated suspected ureterolithiasis has been shown to be expeditious when ultrasound is the diagnostic modality of choice. Classically, a non-contrast cat scan (CT) of the abdomen and pelvis has been …
Clinical Practice Statements, Other Issues
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What is the Preferred Resuscitation Fluid for Patients with Sepsis and Septic Shock?
Reviewed and approved by the AAEM Board of Directors (3/17/2017). Answer: Crystalloid solutions remain the resuscitative fluid of choice for patients with sepsis and septi shock. Balanced crystalloid solutions may improve patient-centered outcomes and should be considered as an alternative to 0. …
Clinical Practice Statements, Other Issues
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tPA and Ischemic Stroke: Focused Update of 2010 Clinical Practice Advisory from the AmericanAcademy of Emergency Medicine
Reviewed and approved by the AAEM Board of Directors (3/17/2017) Executive Summary:No new studies published between 2010 and 2016 meaningfully reduced uncertainty regarding our understanding of the benefits and harms of tPA for acute ischemic stroke. Discussions regarding benefit and harm should …
Clinical Practice Statements, Other Issues
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Does Early Goal-Directed Therapy Decrease Mortality Compared with Standard Care in Patients with Septic Shock?
Reviewed and approved by the AAEM Board of Directors (2/17/2016) Answer: No. However, standard care has significantly improved since the publication of the original EGDT trial. Early recognition of sepsis, prompt administration of appropriate antimicrobial therapy, urgent source control, intrave …
Clinical Practice Statements, Other Issues
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Is There a Role for Intravenous Sub-Dissociative-Dose Ketamine Administered as an Adjunct to Opioids or as a Single Agent for Acute Pain Management in the ED?
IntroductionSub-dissociative dose ketamine (low-dose ketamine) is useful and safe to use alone or in combination with opioid analgesics for the treatment of acute pain in the Emergency Department (ED) and in pre-hospital settings. Its use is associated with higher rates of minor but well tolerated …
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Intra-Arterial Thrombectomy (“Clot Retrieval”) for Selected Patients with Acute Ischemic Stroke
Executive SummaryAppropriate patients may be eligible for mechanical thrombectomy whether or not they have previously received intravenous t-PA, and whether or not they presented to a center capable of this specialized technique. Based on several recent randomized controlled trials, mechanical trea …
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Use of Intravenous Fat Emulsion in the Emergency Department for Cardiovascular Collapse in the Poisoned Patient
IntroductionThe successful use of intravenous fat emulsion (IFE) for the adverse effects associated with local anesthetics has led to its consideration as an effective antidote for multiple xenobiotics/substances (1, 2, 3, 4, 5, 6) . Similar to most toxicology research, the evidence is completely r …
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Timing of Acute Cholecystectomy in the Emergency Department Patient with Acute Cholecystitis
Position StatementCurrent evidence suggests that patients with acute cholecystitis who are under 70 years of age and without risk factors should undergo early cholecystectomy during their initial hospital stay, preferably within 24-48 hours after onset of symptoms. DiscussionAcute cholecystitis …
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The Pertinent ED Information Concerning the Vaccination Efficacy, Sensitivity of Diagnostic Testing, and Role for Antiviral Medications for Seasonal Influenza
IntroductionInfluenza is an acute respiratory virus that is responsible for both epidemic and pandemic outbreaks of disease. There are three types of Influenza (A, B, and C) that are further subtyped based on surface proteins. Currently, A (H1/N1) and A (H3/N2) are the subtypes circulating in human …
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CTA of the Brain Is a Reasonable Option to Consider to Help Rule out Subarachnoid Hemorrhage in Select Patients
Executive summaryComputed tomography angiography (CTA) of the brain is a reasonable test to consider when evaluating select patients for subarachnoid hemorrhage after a negative non-contrast computed tomography of the brain. The benefits and risks of CTA of the brain need to be considered by the tr …
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Ultrasound Should be Integrated into Undergraduate Medical EducationCurriculum
Policy StatementIt is the position of the American Academy of Emergency Medicine that ultrasound should be integrated into the core curriculum of undergraduate medical education. BackgroundMedical diagnostic ultrasound has been used by various specialties since the 1950s. Contemporary point of c …
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Emergency Department Opioid Prescribing Guidelines for the Treatment of Non-Cancer Related Pain
Executive summaryPain is one of the most common chief complaints among emergency department patients with a reported rate of over 50%.(1) There is great variability among emergency clinicians in the management of pain, especially with respect to the use of opioid medications.(2) Importantly, morbid …
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Ultrasound Should Be Strongly Considered as the Initial Imaging Modality in Acute Appendicitis in the Pediatric Patient
It is the position of the American Academy of Emergency Medicine that when appropriate expertise is available ultrasonography (US) should be strongly considered as the initial imaging modality when evaluating the pediatric patient with suspected acute appendicitis who requires imaging. Backgrou …
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Utility of Ultrasound in the Initial Evaluation of Adult Patients with Suspected Appendicitis
Clinical Policy StatementUtilization of ultrasound (US) as the initial imaging screening tool for appendicitis in adults can reduce the need for computer tomography (CT) and exposure to ionizing radiation. SummaryAcute appendicitis continues to be the most frequent cause of acute abdominal emerg …
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Safety of Droperidol Use in the Emergency Department
Droperidol (Inapsine®) is a butyrophenone used in emergency medicine practice for control of psychosis/agitation (1), as an antiemetic (2), for vertigo (3), as an adjunct analgesic (especially in opioid-tolerant patients) and as a treatment for benign headache (4). Initially produced in 1961, it h …
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Propofol and Other Sedating Agents Can Be Safely Used by Emergency Physicians without an Anesthesiologist Present
Clinical Policy StatementIt is the position of the American Academy of Emergency Medicine that emergency physicians must be permitted by hospital bylaws and credentialing procedures to utilize propofol (and other sedating agents) for the induction of procedural sedation, without an anesthesiologist …
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Mortality Related to Delay of ICU Patient Transfer from the Emergency Department
Critically ill emergency department (ED) patients that require admission to the intensive care unit (ICU) often utilize significant personnel, time, and equipment when compared to patients who do not require ICU level care. In many EDs, critical resources can quickly be depleted. This has the poten …
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AAEM Response to CMS 2009 Revision of Anesthesia Services Interpretive Guidelines
On December 11, 2009, the Centers for Medicare and Medicaid Services (CMS) published revised Hospital Anesthesia Services Interpretive Guidelines. These guidelines apply to the Conditions of Participation of hospitals in Medicare. The American Academy of Emergency Medicine (AAEM) Board of Directors …
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Radiology Interpretation in Emergency Department After 5:00PM
SummaryAccurate, timely interpretations of radiologic studies by board-certified radiologists are necessary to provide the best patient care and promote patient safety. This can only be accomplished if attending radiologists are interpreting studies while clinical care is being provided. Emergency …
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Telemetry Bed Usage for Patients with Low Risk Chest Pain
Every year, more than 8 million Americans present to the emergency department (ED) with chest pain, making it the 2nd most common complaint in the ED [1]. Although <5% of low-risk chest pain patients are found to have an acute myocardial infarction (MI) [2], many are admitted to the hospital for …
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What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-inhibitor?
Update to 2006 guideline reviewed and approved by the AAEM Board of Directors 4/11/2011. Angiotensin-converting-enzyme (ACE) inhibitors are one of the most commonly prescribed antihypertensive medications worldwide. A known adverse effect of ACE-inhibitors is angioedema, characterized by the abr …
Clinical Practice Statements, Other Issues
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Informed Consent for Procedures Performed by Other Physicians
It is the position of the American Academy of Emergency Medicine that emergency physicians should not obtain informed consent for any procedure they will not personally perform or supervise. DiscussionWith respect to patients who present to the Emergency Department with STEMI, the American Heart …
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Emergency Physicians Dual Coverage in Emergency Department and on Inpatient Floors
The American Academy of Emergency Medicine is aware that some emergency physicians (EPs) are being compelled to provide dual simultaneous coverage for both the ED and the inpatient hospitalist services. This dual-coverage requires EPs to leave the emergency department (ED) to manage routine and non …
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What Evaluations Are Needed in Emergency Department Patients After a TASER Device Activation?
Use of Conducted Energy Weapons (CEW) such as the TASER includes delivery of a series of brief electrical pulses, which result in pain and muscular contractions. The pulses may be delivered via a pair of sharp metal probes fired from the device, commonly referred to as “probe mode”, or by direc …
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Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?
Parenteral opioids are the most common analgesics used in the Emergency Department for relief of acute pain. Gastrointestinal side effects such as nausea andvomiting are common following opioid analgesia in long-term therapy for malignant and chronic pain and are considered a limiting factor in …
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Is an Unenhanced CT Scan of the Abdomen and Pelvis Accurate in Diagnosing Acute Appendicitis in Adults?
With the advent of more sophisticated CT scanners, imaging without contrast (unenhanced) is increasingly utilized in the evaluation of adults with suspectedacute appendicitis. Oral contrast presents a significant delay to imaging. Intravenous contrast presents the small, but real risks of allergic …
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Does Early Goal Directed Therapy Decrease Mortality in Patients with Septic Shock?
Reviewed and approved by the AAEM Board of Directors 2/14/2010 Define the Issue and State the Question A. Topic Area: Sepsis B. General Issue: Early goal directed therapy C. Specific Question: Does early goal directed therapy decrease mortality in patients with septic shock? D. Execut …
Clinical Practice Statements, Other Issues
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Does the Urine Dipstick and/or the Urine Microanalysis Correlate with a Culture Positive UTI in Febrile Children?
Reviewed and approved by the AAEM Board of Directors 2/14/2010. Define the Issue and State the Question A. Topic Area: _______Pediatric fever_____________ B. General Issue: __Urinary tract infection ___________ C. Specific Question: _Does the urine dipstick and or the urine microana …
Clinical Practice Statements, Other Issues
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Do Steroids Administered in the Emergency Room Improve Mortality or Shock Reversal in Patients with Septic Shock?
Reviewed and approved by the AAEM Board of Directors 2/14/2010. Define the Issue and State the Question A. Topic Area: Sepsis B. General Issue: Steroid administration in septic shock C. Clinical Question: Do steroids administered in the emergency room improve mortality or shock reversa …
Clinical Practice Statements, Other Issues
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During the Emergency Department Evaluation of a Well Appearing Neonate (<30 days of age) with a Fever, Should Empiric Acyclovir be Initiated?
Reviewed and approved by the AAEM Board of Directors 1/11/2010. Define the Issue and State the Question A. Topic Area: PEDIATRIC FEVER: NEONATAL HERPES INFECTION B. General Issue: NEONATAL HERPES INFECTION C. Specific Question: DURING THE EMERGENCY DEPARTMENT EVALUATION OF A WELL A …
Clinical Practice Statements, Other Issues
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The Measurement of Time to Antibiotics for Admitted Patients with Community-Acquired Pneumonia (CAP) in the ED
Reviewed and approved by the AAEM Board of Directors 3/1/2009. Define the Issue and State the Question A. Topic Area: The measurement of time to antibiotics for admitted patients with community-acquired pneumonia (CAP) in the ED. B. General Issue: Unintended consequences of the implementati …
Clinical Practice Statements, Other Issues
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Emergency Care Psychiatric Clinical Framework
SUMMARY DEVELOPMENT OF EMERGENCY CARE PSYCHIATRIC CLINICAL FRAMEWORK By default, the emergency department (ED) has become the "portal to the community" and the entry point where most patients are introduced to the health care system. It is also a logical place to expedite needed reform t …
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Procedural Sedation Consensus Statement
The immediate availability of interventions including procedural sedation is critical to serving the needs of our patients. Preserving life, restoring health, and alleviating suffering have been fundamental to the practice of nursing and medicine for centuries. We are challenged as health care profe …
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Clinical Practice Guideline: Initial Evaluation and Management of Patients Presenting with Acute Urticaria or Angioedema
AAEM statements are not to be construed as dictating an exclusive course of action nor are they intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. AAE …
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Steroids in Acute Spinal Care Injury
On 2/23/03 the board of directors of AAEM voted to endorse the CAEP position statement on the use of steroids in spinal cord trauma. This statement declares that steroids are not the standard of care for spinal cord injury but a treatment option. CAEP did an excellent job in critically reviewing thi …
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AAEM Position Statement on tPA: The Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke
AAEM statements are not to be construed as dictating an exclusive course of action nor are they intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. AAE …
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Position Statement on the Use of Amiodarone in Refractory Pulseless VT/VF
AAEM statements are not to be construed as dictating an exclusive course of action nor are they intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. AAE …