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A retrospective review was conducted of 500 consecutive patients who underwent surgery for complete collateral ligament ruptures of their thumb metacarpophalangeal (MP) joints comprising 362 ulnar collateral and 138 radial collateral ligaments. Complete rupture was confirmed in all cases at surgery. When surgery was carried out within 3 weeks of the injury, reinsertion of the ligament was pos- sible in 98% of cases. When surgery was performed after 3 weeks, reinsertion of the ligament was possible in 45% of ulnar and 68% of radial injuries. Reconstruction utilizing a free tendon graft was required for the other cases. All patients who had surgery within 3 weeks of their injuries regained stable, pain free thumbs. Surgery was less suc- cessful in patients who had surgery after 3 weeks and the failure rate was 5%. Surgery within 3 weeks of the injury permitted re-insertion of the ligament in almost all cases. We propose that avulsions treated within that period be referred to as "acute" injuries and those treated later as "chronic." Treatment of acute injuries is preferred because they rarely require reconstruction, and the results were better than when surgery was performed for chronic injuries. Repair of thumb MP collateral ligaments is predictably possible within 3 weeks of injury but less likely if surgery is delayed after that time period.

This article presents the outcomes of repairs of flexor tendon lacerations within digital sheaths performed more than 2 weeks after injury.A retrospective review of 46 patients; 37 with finger lacerations involving a total of 54 severed tendons in 42 fingers and nine with thumb lacerations of the flexor pollicis longus (FPL). In those patients with finger lacera- tions, 30 lacerations were isolated to the flexor digitorum profundus (FDP; 17 in Zone I and 13 in Zone II), and 12 involved both FDP and flexor digitorum superficialis (FDS) for a total of 24 tendon lacerations.The delay in surgery for finger lacerations ranged from 2 to 96 weeks (average: 8.5 weeks) and for thumb lacerations, 2 to 17 weeks (average: 5.5 weeks). In Zone I finger lacerations, postoperative flexion of the distal interphalangeal (DIP) joint averaged 35° with 82% of patients regaining total active motion (TAM) in the good to excellent range. In Zone II injuries isolated to the FDP tendon, postoperative DIP joint flexion averaged 36.5° with 73% of patients regaining good to excellent TAM. In Zone II injuries involving both flexor tendons, final average DIP flexion was 37° with only 45% of patients regaining good to excellent TAM. All patients with FPL lacerations regained at least 30° (average: 46°) of active interphalangeal joint flexion.When certain conditions exist that are deter- mined at surgery, delayed repairs of isolated FDP lacera- tions in fingers and FPL lacerations in thumbs can restore satisfactory mobility. Results are less favorable when both flexor tendons in the finger are lacerated and only the FDP repaired.

The objective of this study was to determine the role of ad- junctive surgical procedures on the median nerve for carpal tunnel syndrome as measured by somatosensory evoked potentials (SEPs) on the nerve. Fifty-five median nerves in 47 patients were studied. In each patient, a base-line SEP was recorded in the operating room prior to incision and then intraoperatively following each of three sequential pro- cedures: division of the transverse carpal ligament, an epi- neurolysis of the nerve, and finally, either an epineurotomy or epineurectomy that we refer to as a "limited internal neu- rolysis" since it did not involve any intraneural dissection of fascicles. Comparison of the baseline mean SEP latency for the median nerve, referred to as N19 (negative polarity = 19 msec), showed a statistically significant improvement following each of the three procedures. The average reduc- tion of latency after ligament release alone was 1.52 msec, and the total improvement in latency from baseline through limited internal neurolysis was 4.72 msec. Our study showed that epineurolysis followed by a limited internal neurolysis using either an epineurotomy or epineurectomy produced a significant electrophysiologic improvement in the median nerve. There was no significant difference when comparing epineurotomy and epineurectomy.

Summary The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post‐1984 literature there are no published reports of aspiration‐associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus‐derived algorithm in which each patient is first risk‐stratified during their pre‐sedation assessment, using evidence‐based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

This article corrects the Guidelines by Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP on behalf of the International Committee for the Advancement of Procedural Sedation, ‘An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children’ [1]. The authors thank a careful reader who identified that a study from this table by Rajasekaran et al should have been excluded, as it included fewer than 5000 patients. The corrected table without this study is shown below, and this change does not alter our other findings and conclusions. An author and corresponding affiliation were omitted and is now revised as follows: 1 Table Literature estimates of aspiration risk during procedural sedation* (Table presented.) * To include just the largest studies we display those with 5,000 or more patients. We also exclude studies which report duplicate sub-sets of patients.

OBJECTIVES We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California. METHODS We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact. RESULTS We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. CONCLUSIONS In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task.We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment "patient does not follow commands" (ie, GCS motor score6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the "alert, voice, pain, unresponsive" scale.In this analysis of 47,973 trauma patients, we found that the binary assessment "patient does not follow commands" was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures.In this 2-center external validation, we confirmed that a simple binary assessment-"patient does not follow commands"-could effectively replace the more complicated GCS for field trauma triage.

Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for

Many hospitals, and medical and dental clinics and offices, routinely monitor their procedural-sedation practices—tracking adverse events, outcomes, and efficacy in order to optimize the sedation delivery and practice. Currently, there exist substantial differences between settings in the content, collection, definition, and interpretation of such sedation outcomes, with resulting widespread reporting variation. With the objective of reducing such disparities, the International Committee for the Advancement of Procedural Sedation has herein developed a multidisciplinary, consensus-based, standardized tool intended to be applicable for all types of sedation providers in all locations worldwide. This tool is amenable for inclusion in either a paper or an electronic medical record. An additional, parallel research tool is presented to promote consistency and standardized data collection for procedural-sedation investigations.

The incidence of peri-procedural amnesia following procedural sedation in children is unclear and difficult to determine. This study aimed to apply quantitative and qualitative approaches to better understand amnesia following dental sedation of children. After Institutional Review Board Approval, children scheduled for sedation for dental procedures with oral midazolam (OM), oral midazolam and ketamine (OMK), or intranasal midazolam and ketamine (IMK) were recruited for examination of peri-procedural amnesia. Amnesia during the dental session was assessed using a three-stage method, using identification of pictures and an animal toy. On the day following the sedation, primary caregivers answered two questions about their children’s memory. One week later, the children received a semi-structured interview. Behavior and level of sedation during the dental session were recorded. Quantitative data were analyzed using descriptive statistics and comparison tests. Qualitative data were analyzed using content analysis. Triangulation was used. Thirty-five children (age: 36 to 76 months) participated in the quantitative analysis. Most children showed amnesia for the dental procedure (82.9%, n = 29/35) and remembered receiving the sedation (82.1%, n = 23/28 for oral administration, 59.3%, n = 16/27 for intranasal administration). The occurrence of amnesia for the dental procedure was slightly higher in the oral midazolam group compared with the other groups (44.8%, n = 13/29 for OM, 13.8%, n = 4/29 for OMK, and 41.4%, n = 12/29 for IMK). Twenty-eight children participated in the qualitative approach. The major theme identified was that some children could remember their procedures in detail. We conclude that peri-procedural amnesia of the dental procedure was common following sedation.

Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

Eastern gray squirrels produce moans for aerial predators and quaas for terrestrial threats. One commonly-supported hypothesis for such predator-associated signals is that they elicit predator-specific escape responses in conspecifics. With simulated aerial predators, squirrels ran to the far side of tree trunks. In response to simulated terrestrial predators, squirrels frequently ran to where they could see the predator but could quickly flee to the far side of the tree trunk. Playbacks of quaas and moans elicited flight behaviour, but without association between escape location and alarm call type. Locations elicited by alarm calls differed from those elicited by simulated predators, with squirrels pausing on the side facing the call’s source. While grey squirrel alarms and escape strategies differ by predator type, the vocalizations do not function to elicit divergent escape strategies in conspecifics. This result stands in contrast to observed functions in other species with calls differing by predator type.

The basal joint is a collection of articulations at the base of thumb that serve an important function in the overall dexterity of the hand. The unique anatomy of the basal joint provided many evolutionary advantages to the human hand, but also made this joint susceptible to arthrosis and degenerative changes. Surgical treatment of basal joint arthritis has continued to evolve since it was first described in 1949, including excisional arthroplasty, tendon interposition, ligament reconstruction, implant arthroplasty, and arthroscopy. A review of the pathoanatomy, history, and surgical treatments are assessed including a critical review of the literature.

In the late 1980s, undertreated pain became a focus of many clinicians, investigators, and industry. We coined a term, oligoanalgesia, to embolden earlier, titrated opioids and other analgesic use. Regulators mandated pain assessments and actions as a part of health care facility credentialing, and the prescribing of opioids increased yearly from 1990 to 2010. We now sit amid another opioid epidemic with death and disability. Many know of the patterns of use and abuse near the turn of the 20th century when opium was a new agent; this triggered opioid regulations and control, notably, the US Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite regulation of opioids, swings upward in medical and nonmedical use exist in recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction crisis, reminding us that the cycles reappear often, with varying frequency, responses, and consequences. The current opioid upswing is rooted in prescribed and illicit use, the latter including heroin (or other “street” opioids) and diversion of another’s or factitious gain of a prescribed opioid. The widespread increase in opioid use correlates with increased overdose deaths and deaths in all segments, including more affluent and suburban or rural groups, not just in an inner-city or isolated population. Although the peak of the current wave crested in approximately 2010, we retain a large group with this affliction. This triggered calls for regulation and control in many facets of opioid deployment, including emergency care, despite few data suggesting a clear link between emergency department (ED) opioid use and later harm. Some seek governmental ED dose restrictions, and others call for “an opioid-free ED.” The goal of these calls to action is good: to avoid opioid harm, notably, death. At the

We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation.

Purpose A 2-part biomechanical study was constructed to test the hypothesis that coronal morphology of the thumb metacarpophalangeal joint impacts the assessment of instability in the context of radial collateral ligament (RCL) injury. Methods Fourteen cadaveric thumbs were disarticulated at the carpometacarpal joint. Four observers measured the radius of curvature of the metacarpal (MC) heads. In a custom jig, a micrometer was used to measure the RCL length as each thumb was put through a flexion and/or extension arc under a 200 g ulnar deviation load. Strain was calculated at maximal hyperextension, 0°, 15°, 30°, 45°, and maximal flexion. Radial instability was measured with a goniometer under 45 N stress. The RCL was then divided and measurements were repeated. Analysis of variance and Pearson correlation metrics were used. Results The RCL strain notably increased from 0° to 30° and 45° of flexion. With an intact RCL, the radial deviation was 15° at 0° of flexion, 18° at 15°, 17° at 30°, 16° at 45°, and 14° at maximal flexion. With a divided RCL, instability was greatest at 30° of flexion with 31° of deviation. The mean radius of curvature of the MC head was 19 ± 4 mm. Radial instability was inversely correlated with the radius of curvature to a considerable degree only in divided RCL specimens, and only at 0° and 15° of flexion. Conclusions The RCL contributes most to the radial stability of the joint at flexion positions greater than 30°. The results suggest that flatter MC heads contribute to stability when the RCL is ruptured and the joint is tested at 0° to 15° of metacarpophalangeal flexion. Clinical relevance The thumb MC joint should be examined for RCL instability in at least 30° of flexion.

A standard descent procedure with a fixed flight-path angle is proposed to improve trajectory predictability for arriving small jets in the transition airspace into congested terminal area. Three candidate strategies for selecting fuel-efficient and flyable descent flight-path angles are proposed. The three strategies vary in operational complexity and fuel-burn merits. To mitigate variation of wind among flights, the two simpler strategies are adapted to airport, directions of arrival, and time. Three major U.S. airports with different degrees of wind variation and disparate arrival traffic flows are analyzed. Results show that, when compared to the simple airport–static adaptation, the finest adaptation of the simpler strategies recover up to 50–75% of the extra fuel burn relative to the minimum-fuel strategy. Wind variation, descent altitude restrictions, arrival directions, and fleet composition all affect the fuel efficiency of the simple strategies. Tradeoffs between fuel burn and planned speed-brak...

Threat-specific vocalizations have been observed in primates and ground squirrels, but their contemporaneous usage with visible signals has not been experimentally analyzed for association with threat type. Here we examine the eastern gray squirrel, an arboreal squirrel that uses both vocal and tail signals as alarms. Squirrels were presented with cat and hawk models simulating natural terrestrial or aerial predator attacks and also with control objects that do not resemble predators but approach in a similar manner. Individuals responded with tail signals (twitches and flags) and vocalizations (kuks, quaas and moans), but only flags and moans are associated with predator type. Moans were elicited primarily by aerial stimuli and flags by terrestrial stimuli. Eastern gray squirrels use an alarm-signaling system in which signals in each modality potentially are associated with particular attributes of a threat or may be general alarms. Terrestrially-approaching stimuli yielded vocal and tail alarm signals regardless of whether the stimulus resembled a predator. With aerially-approaching stimuli, however, quaas were used more often when the stimulus resembled an aerial predator than when it did not. An approaching object’s physical appearance may therefore affect squirrels’ responses to aerial, but not terrestrial, objects. When the stimuli resembled real predators approaching in the natural manner (terrestrially or aerially), both tail flags and vocal moans were associated with predator type, so we also considered moans and flags together. The presence and absence of moans and flags in an alarm signaling bout yields a higher statistical index of predictive association as to whether the threat is aerial or terrestrial than does either component alone.

Annals of Emergency Medicine - In Press.Proof corrected by the author Available online since dimanche 21 decembre 2014

Clinical decision rules are everywhere in medicine today. These impressive-looking decision algorithms and scoring systems are widely promoted as tools to either improve diagnosis or decrease expensive testing. As clinicians, we find decision rules psychologically appealing because they would appear to create order out of disorder. Medicine is inherently subjective; however, decision rules strive to transform such murky complexity into structured and tangible tools. Certainly a scientific decision instrument statistically derived from 10,000 or more patients must be superior to the frailty and variability of clinician judgment, mustn’t it? Many would assume so. Despite their many strengths, decision rules can also have important limitations. Before adoption, I suggest that readers scrutinize each such rule on the following questions. Three high-quality articles in this issue of Annals will help illustrate the principles discussed—the first a derivation of a rule to decrease abdominal computed tomography (CT) in children with blunt torso trauma, the second a contrast of the relative accuracy of decision rules for pulmonary embolism risk stratification when compared with unstructured clinical judgment, and the third an attempted validation of the modified Alvarado score—a previously described decision rule for appendicitis.

Procedural sedation is an integral part of emergency medicine (EM) practice in the USA, Canada, Australia and New Zealand. These countries have produced a large, robust literature supporting the safe and efficacious use of ketamine, propofol and other ED sedation agents for managing procedural pain and anxiety.1–3 In the UK and Ireland, EM and paediatric EM practitioners are striving to similarly establish procedural sedation as a fundamental part of their practice. McCoy et al describe, through a structured interview session with a group of EM consultants, the current issues impacting procedural sedation in the UK and the barriers to its adoption. Many of these same challenges and impediments were encountered in North America and Australia/New Zealand, and the lessons learned may be applicable and helpful in the UK and Ireland.4 As veterans of these challenges, here is our perspective. The capability of paediatric emergency physicians to administer timely procedural sedation directly benefits patients and their families by providing a safe, effective and efficient outpatient way of managing procedural pain and anxiety. Emergency physicians from North America, Australia and New Zealand reading the McCoy et al report will be surprised by the acceptance of hospitalisation as standard practice for management of simple forearm fractures in children, especially in the UK where EM is an established specialty. Such an approach transforms a brief ED procedure and a 30–90 min recovery into an overnight bed, an admitting paediatrician, a theatre room and an anaesthetist. Instead of promptly returning to the comforts of home, …

Summary Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Intrinsic paralysis can be the manifestation of a variety of pathologic entities (stroke, cerebral palsy, Charcot-Marie-Tooth, muscular dystrophy, leprosy, trauma, cervical disease, and compressive and metabolic neuropathies). Patients present with a spectrum of clinical findings dependent on the cause and severity of the disease. The 3 main problems caused by intrinsic weakness of the fingers are clawing with loss of synchronistic finger flexion, inability to abduct/adduct the digits, and weakness of grip. Clawing is defined as hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. This article describes the clinical evaluation and surgical treatment options for claw hand.

It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound. Teasdale and Jennett devised the GCS in 1974 not for acute care, but rather for the “repeated bedside assessment” in a neurosurgical unit to detect “changing states” of consciousness and to measure the “duration of coma.” They never intended for its elements to be assigned numeric scores or for its 3 subscales to be merged or totaled. Yet, despite their objections both such dubious modifications subsequently proved irresistible to the medical community. The quantitative GCS subsequently has become the undisputed universal criterion standard for mental status assessment and is thus a fundamental part of the culture of emergency medicine, out-of-hospital care, trauma surgery, and neurosurgery. This scale is a core component of prominent trauma and life support courses, and in most of the developed world out-of-hospital care providers routinely assess the GCS for each patient with trauma or altered mental status. The original GCS article has been cited almost 6,000 times. This editorial outlines the potent limitations of the GCS and why it should now be considered obsolete within acute care medicine. This scale might be useful, however, for detecting subtle neurologic changes over time in an ICU (as originally envisaged). Curiously, though, it has never been validated for this separate role.

INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. Emergency physicians have a wellestablished track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians.