This clinical policy from the American College of Emergency Physicians (ACEP) is the revision of a clinical policy approved in 2015 addressing a critical question regarding the use of thrombolytics for the management of acute ischemic stroke. A writing committee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical question: In adult stroke patients who are a candidate for mechanical thrombectomy, is the use of intravenous thrombolysis prior to mechanical thrombectomy (Bridge therapy) beneficial and safe versus mechanical thrombectomy alone? Evidence was graded, and recommendations were made based on the strength of the available data.

STUDY OBJECTIVE:Emergency medicine residents use podcasts as part of their learning process, often listening while driving. It is unclear how driving while listening to a podcast affects knowledge acquisition and retention. This study evaluated the knowledge gained from listening to podcasts while driving compared to that gained from undistracted listening.METHODS:This was a multicenter, randomized, crossover trial among postgraduate year (PGY) 1 to 4 emergency medicine residents at 4 institutions. Residents were randomized with stratification by site and PGY level to listen to podcasts while driving first or sitting undistracted in a room first. Within 30 minutes of listening, they completed a 20-question test. They subsequently crossed over to the alternate intervention, serving as their own controls, and listened to a different podcast before completing a second 20-question test. Each of the podcasts was professionally recorded and based on 5 emergency medicine-relevant journal articles that had not been covered in a journal club or curriculum at any of the institutions. One month later, participants completed a delayed recall test composed of 40 new questions based on both podcasts. Questions were derived and validity evidence was collected prior to use. Data were compared using a paired-sample t test and ANOVA.RESULTS:A total of 100 residents completed the initial recall tests, and 96 residents completed the delayed recall test. There was no statistically significant difference between the driving and undistracted cohorts on the initial recall (74.2% versus 73.3%) or delayed recall (52.2% versus 52.0%).CONCLUSION:Driving while listening to a podcast does not meaningfully affect knowledge acquisition or retention when compared with undistracted podcast listening among emergency medicine residents.

This Policy Resource and Education Paper (PREP) from the American College of Emergency Physicians (ACEP) discusses the use of high-sensitivity cardiac troponin (hs-cTn) in the emergency department setting. This brief review discusses types of hs-cTn assays as well as the interpretation of hs-cTn in the setting of various clinical factors such as renal dysfunction, sex, and the important distinction between myocardial injury versus myocardial infarction. In addition, the PREP provides one possible example of an algorithm for the use of a hs-cTn assay in patients in whom the treating clinician is concerned about potential acute coronary syndrome.

STUDY OBJECTIVE:Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS:In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS:All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION:Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.

This clinical policy from the American College of Emergency Physicians is a revision of the 2007 "Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is the diagnostic accuracy of point-of-care lung ultrasound sufficient to direct clinical management? (2) In adult patients presenting to the ED with suspected acute heart failure syndrome, is early administration of diuretics safe and effective? (3) In adult patients presenting to the ED with suspected acute heart failure syndrome, is vasodilator therapy with high-dose nitroglycerin administration safe and effective? (4) In adult patients presenting to the ED with symptomatic acute heart failure syndrome, is there a defined group that may be discharged directly home for outpatient follow-up? Evidence was graded, and recommendations were made on the basis of the strength of the available data.

Study objective: The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events. Methods: We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated. Results: From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events. Conclusion: ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.

Sport-related concussion refers to the subset of concussive injuries occurring duringsport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

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.

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.

This clinical policy from the American College of Emergency Physicians addresses key issues for well-appearing infants and children younger than 2 years presenting to the emergency department with fever. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (>= 38.0 degrees C [100.4 degrees F]), are there clinical predictors that identify patients at risk for urinary tract infection? (2) For well-appearing febrile infants and children aged 2 months to 2 years undergoing urine testing, which laboratory testing method(s) should be used to diagnose a urinary tract infection? (3) For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (>= 38.0 degrees C [100.4 degrees F]), are there clinical predictors that identify patients at risk for pneumonia for whom a chest radiograph should be obtained? (4) For well-appearing immunocompetent full-term infants aged 1 month to 3 months (29 days to 90 days) presenting with fever (>= 38.0 degrees C [100.4 degrees F]), are there predictors that identify patients at risk for meningitis from whom cerebrospinal fluid should be obtained? Evidence was graded and recommendations were made based on the strength of the available data.

A total of 957 unique citations were found, with 75 primary studies included in the systematic review. In the emergency department (ED)–based studies, 1 of 4 patients presenting with persistent wrist pain, suspicion for scaphoid fracture, and an initial negative radiograph result was ultimately found to have a scaphoid fracture, thus reflecting a 25% pretest probability. No historical factors were predictive of scaphoid fracture. According to the QUADAS-2 analysis, the study quality overall was low to moderate, mostly because 40 of the 75 primary studies did not clearly identify ED patients, automatically reducing those studies to low applicability.