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Emergency Medicine Practice
Clinical Pathways:
Evidence To Improve Patient Care
In Emergency Medicine
BROUGHT TO YOU EXCLUSIVELY BY THE PUBLISHER OF:
Emergency Medicine Practice
Pediatric Emergency Medicine Practice
EM Practice Gideine Udate
Te Lie ng Learning and Seement Stdy Gide
EM Critica Care
E Oercr ding S ti n
Table Of Contents
General Emergency Medicine
Clinical Pathway For Evaluation Of Patients With Suspected Acute Hepatic Injury ..........1
Clinical Pathway For Asymptomatic Hypertension ........................................................................ 2
Clinical Pathway For Symptomatic Hypertension ........................................................................... 3
Clinical Pathway For Treatment Of Skin And Soft Tissue Infections ........................................4
Clinical Pathway For The Management Of The Postpartum Patient With Headache .......5
Clinical Pathway For The Management Of The Postpartum Patient With Elevated
Blood Pressure (> 140 Systolic Or > 90 Diastolic) .......................................................................... 6
HEENT Emergencies
Clinical Pathway For Blunt Eye Trauma ............................................................................................... 7
Clinical Pathway For Penetrating Eye Trauma .................................................................................. 8
Clinical Pathway For Treatment Of Acute Otitis Media ................................................................ 9
Hematologic Emergencies
Clinical Pathway For Evaluation Of Suspected Malignant Epidural Spinal Cord
Compresion .................................................................................................................................................10
Clinical Pathway For The Management Of Hypercalcemia Of Malignancy ........................11
Clinical Pathway For Management Of Tumor Lysis Syndrome ................................................12
Clinical Pathway For The Initial Management Of Neutropenic Fever ...................................13
Toxicologic Emergencies
Clinical Pathway For Single APAP Ingestion ...................................................................................14
Clinical Pathway For Initial Evaluation Of Toxic Alcohol Poisoning .......................................15
Clinical Pathway For Management Of Methanol And Ethylene Glycol Poisoning ...........16
Clinical Pathway For Management Of Isopropanol Poisoning ................................................16
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Clinical Pathway For Evaluation Of Patients
With Suspected Acute Hepatic Injury
AST and/or ALT > 300 U/L?
YES NO
AST > 3000 U/L? AST > 2x ALT?
YES NO YES NO
Probable toxic or ischemic ALK < 3x Upper NI? History of ethanol abuse? Not acute hepatic injury
injury
YES NO YES NO
Acute hepatitis panel History of drug exposure? Alcoholic hepatitis
POSITIVE NEGATIVE YES
NO
IgM anti-HAV Probable drug injury HCV exposure? NO
POSITIVE NEGATIVE YES
Acute HAV IgM NEGATIVE Anti-HCV HCV RNA Consider obstruction,
anti-HBc other causes
POSITIVE POSITIVE
POSITIVE NEGATIVE
Acute HBV Previous neg?
YES NO
Acute HCV Possible
acute HCV
Abbreviations: ALK, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HAV, hepatitis A virus; HBc, hepatitis B
core antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; IgM, immunoglobulin M antibody; NI, normal.
CLINICAL CHEMISTRY. ONLINE by Dufour, Lott, Nolte, Gretch, Koff, Seef. Copyright 2000 by AMERICAN ASSOCIATION FOR CLINICAL CHEMIS-
TRY, INC. Reproduced with permission of AMERICAN ASSOCIATION FOR CLINICAL CHEMISTRY, INC in the format Journal via Copyright Clear-
ance Center.
Emergency Medicine Practice © 2010 10 EBMedicine.net • April 2010
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1
Clinical Pathway For Asymptomatic Hypertension
Vital signs show BP
elevation
Recheck BP BP normal now? YES Home; recheck BP
in 1 month (Class III)
NO
BP > 180/110 mm Hg? Home; recheck BP in
NO 1 week to 1 month
YES (Class III)
HYPERTENSIVE
URGENCY
Consider ancillary testing:
CBC
BMP
Chest x-ray
ECG
Signs of end-organ NO Contact primary care
damage? provider; follow up 1 day
to 1 week
YES Consider starting 2-drug
oral therapy, especially if
BP > 200/120 mm Hg
Go to the Clinical Pathway Do NOT attempt to nor-
For Symptomatic Hyper- malize BP in the ED
tension, next page (Class III)
Abbreviations: BMP, basic metabolic panel; BP, blood pressure; CBC, complete blood count; ECG, electrocardiogram; ED, emergency department.
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate tatives from the resuscitation
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research councils of ILCOR: How to De-
• Definitely useful • Probably useful • Possibly useful • No recommendations until velop Evidence-Based Guidelines
• Proven in both efficacy and Level of Evidence: • Considered optional or alterna- further research for Emergency Cardiac Care:
effectiveness • Generally higher levels of tive treatments Level of Evidence: Quality of Evidence and Classes
Level of Evidence: evidence Level of Evidence: • Evidence not available of Recommendations; also:
• One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress Anonymous. Guidelines for car-
studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- diopulmonary resuscitation and
exceptions) case control studies • Case series, animal studies, tory emergency cardiac care. Emer-
• High-quality meta-analyses • Less robust RCTs consensus panels • Results not compelling gency Cardiac Care Committee
• Study results consistently posi- • Results consistently positive • Occasionally positive results and Subcommittees, American
tive and compelling Significantly modified from: The Heart Association. Part IX. Ensur-
Emergency Cardiovascular Care ing effectiveness of community-
Committees of the American wide emergency cardiac care.
Heart Association and represen- JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2010 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC d.b.a. EB Medicine.
Emergency Medicine Practice © 2010 14 EBMedicine.net • June 2010
Full issue available free for subscribers or for purchase for non-subscribers on our website.
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