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Objectives Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation. Methods Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE). Patients were categorized by largest occluded artery and aggregated into: ‘Require anti-coagulation’ (main, lobar, and segmental PE), ‘Does not require anti-coagulation’ (sub-segmental and No PE), ‘High risk of deterioration’ (main and lobar PE), and ‘Not high risk of deterioration’ (segmental, sub-segmental, and No PE) groups. Wilcoxon rank-sum test was used for 2 sample comparisons of median D-dimer concentrations. Receiver operating characteristic (ROC) curve analysis was utilized to determine a D-dimer cut-off that could differentiate ‘Require anti-coagulation’ from ‘Does not require anti-coagulation’ and ‘High risk of deterioration’ from ‘Low risk of deterioration’ groups. Results The ‘Require anti-coagulation’ group had a maximum area under the curve (AUC) of 0.92 at an age-adjusted D-dimer cut-off of 1540 with a specificity of 86% (95% CI, 81–91%), and sensitivity of 84% (79–90%). The ‘High risk of deterioration’ group had a maximum AUC of 0.93 at an age-adjusted D-dimer cut-off of 2500 with a specificity of 90% (85–93%) and sensitivity of 83% (77–90%). Conclusions An age-adjusted D-dimer cut-off of 1540 ng/mL differentiates suspected PE patients requiring anti-coagulation from those not requiring anti-coagulation. A cut-off of 2500 differentiates those with high risk of clinical deterioration from those not at high risk of deterioration. When correlated with clinical outcomes, these cut-offs can provide an objective method for clinical decision making when imaging is unavailable., Highlights • ED providers are faced with risks and benefits when empirically administering anti-coagulation for suspected PE patients. • We show that D-dimer concentration can be used as a clinical decision making tool to minimize these risks. • A D-dimer cut-off of 1540 ng/mL can be used to minimize unnecessary anti-coagulation exposure in patients who do not need it. • A D-dimer cut-off of 2500 ng/mL can be used to minimize risk of withholding treatment for patients at risk of clinical deterioration. • Together these cut-offs provide an objective measure that can be combined with clinical gestalt to weight the risks and benefits of empiric anti-coagulation.

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. 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 experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? (2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (3) In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? Evidence was graded and recommendations were made based on the strength of the available data.

Painful procedures are common. Patients prefer analgesia for painful procedures. Studies indicate that use of a topical refrigerant spray (TRS) prior to needlestick procedures decreases needlestick pain. TRS is easy to apply, inexpensive, has fast onset, and avoids needlestick pain and anxiety, and needlestick injury risk. Patient and health care provider (HCP) acceptance of any technique is essential before it is adopted. This study evaluated the decrease in pain with TRS and the patient and HCP satisfaction and acceptance of TRS for peripheral intravenous (PIV) placement. Adults (N = 300) randomized to placebo or TRS and HCPs (N = 300) placing PIVs answered questionnaires. Patients had significantly less pain than with prior PIVs, and were satisfied with and would use TRS in the future (P < 0.001). HCP felt that patients had significantly (P < 0.001) less pain with TRS than the placebo, and were satisfied with the TRS, and would use TRS in the future. Registered at Clinicaltrials.gov NCT01670487

Painful medical procedures are common. Topical anesthetics are easily applied, rapid onset, inexpensive, and avoid injection pain and needlestick injury. The aims of this study, using patient and health care provider questionnaires, were to answer the following questions: (1) Does vapocoolant spray decrease venipuncture pain? (2) Would patients be satisfied with and use a vapocoolant spray in the future? (3) Would providers be satisfied with and use a vapocoolant spray in the future?Adults (18-80 years) in a hospital emergency department (ED) were randomly assigned to sterile water placebo spray (S) (N = 50) or vapocoolant spray (V) (N = 50) before venipuncture. Questionnaires were completed by patients undergoing venipuncture (N = 100) and the health care providers (N = 100) who performed the venipuncture (total questionnaires = 200) as part of a prospective, double-blind, randomized controlled trial comparing the efficacy and safety of vapocoolant spray compared with placebo spray in patients undergoing venipuncture in the ED.Patient and venipuncture variables were not significantly different for the two groups (S vs. V). Responses to the questionnaires were significantly different for the S versus V groups for both the patients and the health care providers. Patient questionnaires: Did you have less pain with spray? S 14%, V 76% (p .001). Compared with previous blood draws, the spray was much more painful/more painful: S 10%, V 6%; same: S 76%, V 16%; less painful/much less painful: S 14%, V 78% (p .001). How satisfied were you with the spray? Satisfied/very satisfied: S 20%, V 74% (p .001). Would you use this spray in future? Yes S 20%, V 80% (p .001). Provider results: The patient had less pain with the use of the spray: S 14%, V 78% (p .001). How satisfied were you with the use of the spray? Satisfied/very satisfied: S 12%, V 82% (p .001). Would you use this spray in the future? Yes S 24%, V 84% (p .001).The use of a vapocoolant spray in adult ED patients undergoing venipuncture significantly decreased venipuncture pain, was associated with high patient and provider satisfaction, and both patients and providers would use a vapocoolant spray in the future for venipuncture and other painful procedures.

In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.

From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: Thomas W. Lukens, MD, PhD, (Chair) Stephen J. Wolf, MD Jonathan A. Edlow, MD Samina Shahabuddin, MD Michael H. Allen, MD, (American Association for Emergency Psychiatry) Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry) Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

Children have rights, as enumerated in the Declaration of the Rights of the Child, and need protection from violence, exploitation, and abuse. Global threats to child safety exist. These threats include lack of basic needs (food, clean water, sanitation), maltreatment, abandonment, child labor, child marriage, female genital mutilation, child trafficking, disasters, and armed conflicts/wars. Recent disasters and armed conflicts have led to a record number of displaced people especially children and their families. Strategies and specific programs can be developed and implemented for eliminating threats to the safety of children.

BACKGROUND D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents. METHODS PE-positive patients

Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.

Individuals with special healthcare needs have some of the highest morbidity and mortality rates during disasters. Efforts to triage, transport, shelter, or treat vulnerable populations often fail to take into consideration disabilities and social situations, including caregiver availability. Communication, medical care, independence, supervision, and transportation needs should be considered in emergency preparedness planning. Inconsistencies with the definitions and scope of individuals with special healthcare needs exist. The problems and complexity of vulnerable populations, as well as potential solutions are considered to assist planners and disaster responders in the preplanning, mitigation, treatment, and recovery of these individuals.

This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are: Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy. Recommendations are provided on the basis of the strength of evidence of the literature. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies that are based on preliminary, inconclusive, or conflicting evidence, or based on committee consensus. This clinical policy is intended for physicians working in hospital-based EDs.

Introduction:Between 2000 to 2017, there were over 150 hospital evacuations in the United States. Data received from approximately 35 states were primarily concentrated in California, Florida, and Texas. This analysis will provide disaster planners and administrators statistics on hazards that cause disruptions to hospital facilities.Aim:The aim of this study is to investigate US hospital evacuations by compiling the data into external, internal, and man-made disasters thus creating a risk assessment for disaster planning.Methods:Hospital reports were retrieved from LexisNexis, Google, and PubMed databases and categorized according to evacuees, duration, location, and type. These incidents were grouped into three classifications: external, internal, and man-made. Both partial and full evacuations were included in the study design.Results:There were a total of 154 reported evacuations in the United States. 110 (71%) were due to external threats, followed by 24 (16%) man-made threats, and 20 (13%) internal threats. Assessing the external causes, 60 (55%) were attributed to hurricanes, 21 (19%) to wildfires, and 8 (7%) to storms. From the internal threats, 8 (40%) were attributed to hospital fires and 4 (20%) chemical fumes. From the man-made threats, 6 (40%) were attributed to bomb threats and 4 (27%) gunmen. From the 20 total reported durations of evacuations, 9 (45%) lasted between 2 to 11:59 hours, 6 (30%) lasted over 24 hours, and 5 (25%) lasted up to 1:59 hours.Discussion:Over 70% of hospital evacuations in the US were due to natural disasters. Compared to 1971-1999, there was an increase in internal and man-made threats. Exact statistics on evacuees, durations, injuries, and mortality rates were unascertainable due to a lack of reporting. It is critical to implement a national registry to report specifics on incidences of evacuations to further assist with disaster and infrastructure planning.

* Abbreviations: ASD — : autism spectrum disorder CI — : confidence interval CNS — : central nervous system DD — : developmental disorder ED — : emergency department FDA — : US Food and Drug Administration IV — : intravenous NIAAA — : National Institute of Alcohol Abuse and Alcoholism NMS — : neuroleptic malignant syndrome OT — : occupational therapy PNES — : psychogenic nonepileptic seizures SSRI — : selective serotonin reuptake inhibitor VCS — : visual communication system Part I of this clinical report (http://www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570) discusses the common clinical issues that may be encountered in caring for children and adolescents presenting to the emergency department (ED) or primary care setting with a mental health condition or emergency and includes the following: Part II discusses the challenges a pediatric clinician may face when evaluating patients with a mental health condition, which may be contributing to or a complicating factor for a medical or indeterminate clinical presentation. Topics covered include the following: The report is written primarily from the perspective of ED clinicians, but it is intended for all clinicians who care for children and adolescents with acute mental health and behavioral problems. An executive summary of this clinical report can be found at http://www.pediatrics.org/cgi/doi/10.1542/peds.2016-1574. ### Overview The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition recognizes 7 distinct somatic symptom and related disorders, including somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurologic symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder.1 Each disorder has specific diagnostic criteria, which apply to both adults and children and which are not adjusted for children. All these disorders refer to an individual’s subjective experience of physical symptoms. These diagnoses can also be applied to situations in which the level of distress or disability is thought to be disproportionate to what is typically associated …

Procedural sedation and analgesia, formerly conscious sedation, is the process of administering sedatives or dissociative agents concurrently with analgesics as indicated, in order to create an altered state of consciousness allowing the patient to undergo unpleasant and/or painful procedures while preserving cardiovascular function. Analgesia is pain relief without the intentional alteration of mental status. In addition to the many procedures that any individual may undergo that may require procedural sedation and analgesia, from fracture reduction to the insertion of tubes to wound care, patients with atrial fibrillation may also need to undergo cardioversion. Patients with atrial fibrillation range from the newborn with congenital heart disease to the essentially healthy individual with a structurally normal heart to the hemodynamically unstable geriatric patient with multiple comorbidities and end-stage heart failure. Providing procedural sedation and analgesia to patients with atrial fibrillation presents additional problems and adds another layer of complexity to the sedation. Patients with atrial fibrillation often have higher American Society of Anesthesia (ASA) physical status classification which puts them at much greater risk for complications during sedation. The cardiovascular effects of the various medications used during procedural sedation and analgesia need to be kept in mind when sedating patients with atrial fibrillation. This may limit the choices of medications used for the procedural sedation and analgesia.

BackgroundAlternative treatment of dehydration is needed when intravenous (IV) or oral rehydration therapy fails. Subcutaneous (SC) hydration facilitated by recombinant human hyaluronidase offers an alternative treatment for dehydration. This clinical trial is the first to compare recombinant human hyaluronidase-facilitated SC (rHFSC) rehydration with standard IV rehydration for use in dehydrated children.ObjectiveThis Phase IV noninferiority trial evaluated whether rHFSC fluid administration can be given safely and effectively, with volumes similar to those delivered intravenously, to children who have mild to moderate dehydration.MethodsThe study included mild to moderately dehydrated children (Gorelick dehydration score) aged 1 month to 10 years. They were randomized to receive 20 mL/kg of isotonic fluids using rHFSC or IV therapy over 1 hour and then as needed until clinically rehydrated. The primary outcome was total volume of fluid administered (emergency department [ED] plus inpatient hospitalization). Secondary outcomes included mean volume infused in the ED alone, postinfusion dehydration scores and weight changes, line placement success and time, safety, and provider and parent/guardian questionnaire.Results148 patients (mean age, 2.3 [1.91] years]; white, 53.4%; black, 31.8%) were enrolled in the intention-to-treat population (73 rHFSC; 75 IV). The primary outcome, mean total volume infused, was 365.0 (324.6) mL in the rHFSC group over 3.1 hours versus 455.8 (597.4) mL in the IV group over 6.6 hours (P = 0.51). The secondary outcome of mean volume infused in the ED alone was 334.3 (226.40) mL in the rHFSC group versus 299.6 (252.33) mL in the IV group (P = 0.03). Dehydration scores and weight changes postinfusion were similar. Successful line placement occurred in all 73 rHFSC-treated patients and 59 of 75 (78.7%) IV-treated patients (P < 0.0001). All IV failures occurred in patients aged

Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/ surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included.The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification.The third part deals with special patient populations: the special healthcare needs patient and mental health issues.

There are several central nervous system (CNS) infections (meningitis, encephalitis, and brain abscess), any of which may present with an altered level of consciousness. Because CNS infections can have a devastating outcome, it is important to recognize the presence of a CNS infection and begin treatment as soon as possible because early appropriate therapy may, in some cases, limit morbidity and mortality.

Infectious disease outbreaks, epidemics, and subsequent pandemics are not typical disasters in the sense that they often lack clearly delineated phases. As in any event that is biological in nature, its onset may be gradual with signs and symptoms that are so subtle that they go unrecognized, thus missing opportunities to invoke an early response and implement containment strategies. An infectious disease outbreak—whether caused by a novel virus, a particularly virulent influenza strain, or newly emerging or resistant bacteria with the capability of human-to-human transmission—can quickly degrade a community’s healthcare infrastructure in advance of coordinated mitigation, preparation, and response activities. The Transitional Medical Model (TMM) was developed to aid communities with these crucial phases of disaster response as well as to assist with the initial steps within the recovery phase. The TMM is a methodology that provides a crosswalk between the routine operations and activities of a community’s public health infrastructure with action steps associated with the mitigation, preparedness, response, and recovery phases of an infectious disease outbreak.

Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included. The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification. The third part deals with special patient populations: the special healthcare needs patient and mental health issues.

High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home. At times, the office of the pediatric primary care provider will serve as the entry site into the emergency care system, which comprises out-of-hospital emergency medical services personnel, emergency department nurses and physicians, and other emergency and critical care providers. Recognizing the important role of pediatric primary care providers in the emergency care system for children and understanding the capabilities and limitations of that system are essential if pediatric primary care providers are to offer the best chance at intact survival for every child who is brought to the office with an emergency. Optimizing pediatric primary care provider office readiness for emergencies requires consideration of the unique aspects of each office practice, the types of patients and emergencies that might be seen, the resources on site, and the resources of the larger emergency care system of which the pediatric primary care provider's office is a part. Parent education regarding prevention, recognition, and response to emergencies, patient triage, early recognition and stabilization of pediatric emergencies in the office, and timely transfer to an appropriate facility for definitive care are important responsibilities of every pediatric primary care provider. In addition, pediatric primary care providers can collaborate with out-of-hospital and hospital-based providers and advocate for the best-quality emergency care for their patients.

Background Compare the efficacy and safety of Plasma-Lyte A (PLA) versus 0.9 % sodium chloride (NaCl) intravenous (IV) fluid replacement in children with moderate to severe dehydration secondary to acute gastroenteritis (AGE). Methods Prospective, randomized, double-blind study conducted at eight pediatric emergency departments (EDs) in the US and Canada (NCT#01234883). The primary outcome measure was serum bicarbonate level at 4 h. Secondary outcomes included safety and tolerability. The hypothesis was that PLA would be superior to 0.9 % NaCl in improvement of 4-h bicarbonate. Patients (n = 100) aged ≥6 months to

The care of children is an integral aspect of emergency medicine. This article reviews the many important contributions that emergency physicians have made in advancing the acute care of children.

Emergency physicians have a duty to advance the care of pediatric patients in the emergency medical services (EMS) system. This policy resource and education paper, designed to support the American College of Emergency Physicians policy paper "The Role of the Emergency Physician in Emergency Medical Services for Children," describes the development of the federal EMS for Children Program, the importance of the integration of EMS for children into EMS systems, and the role of the emergency physician in EMS for children.

Febrile seizures are the most common seizures seen in children younger than 5 years old. Out-of-hospital and emergency department providers need to be familiar with the principles of the evaluation and management of this common disorder. Most febrile seizures are brief, do not require any specific treatment or extensive workup, and have a benign prognosis. Recognizing the pattern of a simple febrile seizure in young children is important to limit interventions and to reassure parents. Patients with febrile seizures are not at higher risk for serious bacterial illnesses than similarly aged febrile patients. Excluding meningitis and encephalitis are the primary clinical interventions through a thorough history and physical examination and, occasionally, a lumbar puncture. Reassuring parents of patients with febrile seizures and arranging primary care follow-up are important roles for the emergency physician.

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.

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.

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.

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 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.

Observing pediatric patients in an OU (whether a pediatric or combined or hybrid unit) has many advantages: better patient care, a decrease in missed diagnoses and acuity, better risk management, decreased malpractice liability, cost effectiveness, increased patient and family satisfaction, and psychosocial benefits. Key principles of observation medicine (purpose, time frame, general patient inclusion and exclusion criteria, administration, CQI, and so forth) are equivalent for pediatric and adult observation patients, but there are important differences. Unique characteristics of pediatric observation patients include specific diagnosis, decreased length of stay, less need for cardiac monitoring, a highly variable admission rate, and a decreased percentage or admission rate to the OU from the ED. Whereas the adult OU is primarily a cardiac-monitoring unit, the pediatric OU is a respiratory and infectious disease unit with a frequent need for an i.v. therapy and hydration. Types of pediatric patients commonly treated in an OU include respiratory illnesses (asthma, croup, bronchiolitis, pneumonia), gastrointestinal disorders (gastroenteritis, abdominal pain), dehydration, infections (fever, cellulitis, lymphangitis, pyelonephritis or UTI), overdoses or poisonings, and seizures.

Effects of lecithin-cholesterol acyltransferase deficiency include coronary artery disease, renal disease, and corneal opacity.

Emergency departments (EDs) are vital in the management of pediatric patients with mental health emergencies (MHE). Pediatric MHE are an increasing part of emergency medical practice because EDs have become the safety net for a fragmented mental health infrastructure which is experiencing critical shortages in services in all sectors. EDs must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses including those with mental retardation, autistic spectrum disorders, attention deficit hyperactivity disorder (ADHD), and those experiencing a behavioral crisis. EDs also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, post traumatic stress disorder, maltreatment, and those exposed to violence and unexpected deaths. EDs must address not only the physical but also the mental health needs of patients during and after mass casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support the following actions: advocacy for increased mental health resources, including improved pediatric mental health tools for the ED, increased mental health insurance coverage, adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home, and promotion of education and research for mental health emergencies. Language: en

In rural America, pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children (EMSC). Pediatricians may represent the only source of pediatric expertise for a large region and are a vital resource for rural physicians (eg, general and family practice, emergency medicine) and other rural health care professionals (physician assistants, nurse practitioners, and emergency medical technicians), providing education about management and prevention of pediatric illness and injury; appropriate equipment for the acutely ill or injured child; and acute, chronic, and rehabilitative care. In addition to providing clinical expertise, the pediatrician may be involved in quality assurance, clinical protocol development, and advocacy, and may serve as a liaison between emergency medical services and other entities working with children (eg, school nurses, child care centers, athletic programs, and programs for children with special health care needs).

Disasters affect all ages of patients from the newborn to the elderly. Disaster emergency management includes all phases of comprehensive emergency management from preparedness to response and recovery. Disaster planning and management has frequently overlooked the unique issues involved in dealing with the pediatric victims of a disaster. The following will be addressed: disaster planning and management as related to pediatric patients and the integration of pediatric disaster management as part of an all-hazard, comprehensive emergency management approach. Key recommendations for dealing with children, infants, and special needs patients in a disaster are delineated.

OBJECTIVES: The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age.METHODS: Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration.RESULTS: Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied.CONCLUSIONS: rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.