Rapid Fire - ACEP Clinical Updates

Large-vessel occlusion stroke, appendicitis imaging, minor head trauma CT use, and acute heart failure diagnosis all saw meaningful ACEP policy updates. The practical themes are better bedside risk stratification, less unnecessary imaging, and more confident use of ultrasound and modern stroke imaging when timing and presentation fit.

Acute ischemic stroke updates

• Prehospital LVO screens: LAMS and RACE can be used to flag patients with higher likelihood of large-vessel occlusion, giving EMS and ED teams a practical way to prioritize stroke pathways.
• Late-window perfusion imaging: CT perfusion or MR diffusion-perfusion imaging is recommended when ischemic stroke is suspected in the 6-to-24-hour last-known-well window, a distinction we walk through in the episode.
• Thrombolytic agent choice: Both tenecteplase and alteplase remain acceptable thrombolytic options for suspected acute ischemic stroke, with TNK highlighted as a single-bolus alternative.
• Acute vertigo stroke risk: ABCD2, ocular motor examination, and HINTS can help risk stratify possible posterior circulation stroke, but HINTS is only as good as the examiner behind it.

Suspected appendicitis imaging

• Pediatric risk tools: PAS and pARC can help risk stratify children with possible appendicitis, but ACEP cautions against using a score alone to rule out advanced imaging.
• Ultrasound-first strategy: Right lower quadrant ultrasound is a reasonable first-line test in both children and adults, and a clearly visualized dilated appendix is highly actionable.
• Equivocal pediatric ultrasound: A nondiagnostic ultrasound in a child with persistent concern should not reassure you; MRI, CT, surgical input, or observation remain on the table.
• Adult noncontrast CT: Noncontrast CT has only a minimal drop in sensitivity for adult appendicitis, particularly when BMI is above 20, which matters when contrast is a problem.
• CT contrast choices: If CT is obtained, IV contrast is preferred when feasible, while oral and rectal contrast do not meaningfully improve accuracy. We get into the operational implications in the chapter.

Mild traumatic brain injury

• Preferred CT decision rule: The Canadian CT Head Rule is ACEP’s preferred tool for adults with minor head injury because it improves CT use better than lower-specificity alternatives.
• Lower-specificity alternatives: NEXUS Head CT and the New Orleans Criteria can be used, but their lower specificity means more scans without the same efficiency as CCHR.
• Anticoagulation caveat: Standard head CT decision instruments do not apply to patients taking anticoagulants or antiplatelet agents, an exclusion that changes bedside decision-making fast.
• Negative CT disposition: Patients with a normal initial head CT and baseline neurologic exam generally do not need routine repeat imaging, admission, or observation if no other red flags exist.
• Discharge risk counseling: Good discharge instructions should cover delayed hemorrhage symptoms and post-concussive syndrome, especially in higher-risk patients such as those with intoxication or assault-related injury.

References:

1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Ischemic Stroke, Lo BM, Carpenter CR, et al. Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke: Approved by the ACEP Board of Directors February 1, 2023. Ann Emerg Med. 2023;82(2):e17-e64. PMID: 37479410
2. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Appendicitis, Diercks DB, Adkins EJ, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med. 2023;81(6):e115-e152. PMID: 37210169
3. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Mild Traumatic Brain Injury, Valente JH, Anderson JD, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023). Ann Emerg Med. 2023;81(5):e63-e105. PMID: 37085214
4. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Heart Failure Syndromes. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022 [published correction appears in Ann Emerg Med. 2023 Mar;81(3):383]. Ann Emerg Med. 2022;80(4):e31-e59. PMID: 36153055