Emergency Medicine

Head injuries in children and adults are common presentations to the emergency department. Minor head injury is characterized by: Glasgow Coma Scale (GCS) 13– 15, an event that is associated with either witnessed loss of consciousness, definite amnesia, or witnessed disorientation. Most adults and children with minor head injuries do not suffer from serious brain injuries that require hospitalization or surgery. CT head scans performed on patients who lack high-risk features can expose patients to unnecessary ionizing radiation that has the potential to increase patients’ lifetime risk of cancer. They also increase length of stay and increase the detection of false-positives (incidental, non-clinically relevant findings). There is strong evidence that physicians should not order CT head scans for patients with minor head injury unless validated clinical decision rules are used to make imaging decisions (i.e., Canadian CT head rule for adults, and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) and/or PECARN rules for children). However, CATCH has been shown to be less sensitive than PECARN at detecting any brain injury on CT. While we recommend the use of clinical decision rules (CDRs) for head injuries, these rules are meant to assist and not replace, clinical judgment.

Respiratory distress from bronchospasm/wheezing is a common presentation in both children (i.e., bronchiolitis) and adults (i.e., bronchitis/asthma) seen in the emergency department. Most patients with symptoms do not have bacterial infections that require antibiotic treatment or influence outcomes (i.e., hospitalization). Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash, diarrhea and other side-effects) and has the potential to increase patients’ risk of antibiotic induced diarrhea, including infections with C. Difficile. These prescriptions also increase overall antibiotic resistance in the community, and limit the effectiveness of standard antibiotics in the treatment of legitimate bacterial infections. There is strong applied research evidence to recommend that physicians should not prescribe antibiotics in children (i.e., bronchiolitis) and adults (i.e., bronchitis and asthma) with wheezing presentations.

Adults with non-specific lumbosacral (low back) pain, in the absence of significant trauma (i.e., car crash, acute axial loading, acute hyperflexion, etc.), commonly present to the emergency department. The evaluation of patients presenting with non-traumatic low back pain should include a complete focused history and physical examination to identify “red flags” that may indicate significant pathology. These may include, but are not limited to:  features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, patients with first episode of low back pain over 50 years of age and especially if over 65, abnormal reflexes, loss of motor strength or loss of sensation in the legs. In the absence of red flags, physicians should not order radiological images for patients presenting with non-specific low back pain. Imaging of the lower spine for symptomatic low back pain does not improve outcomes, exposes the patient to unnecessary ionizing radiation and contributes to flow delays without providing additional value.

Neck pain resulting from trauma (such as a fall or car crash) is a common reason for people to present to the emergency department. Very few patients have a cervical spinal injury that can be detected on radiographs (“X-rays”). History, physical examination and the application of clinical decision rules (i.e., the Canadian C-spine rule) can identify alert and stable trauma patients who do not have cervical spinal injuries and therefore do not need radiography. The Canadian C-spine rule has been validated and implemented successfully in Canadian centres, and physicians should not order imaging unless this rule suggests otherwise. Unnecessary radiography delays care, may cause increased pain and adverse outcomes (from prolonged spinal board immobilization), and exposes the patient to ionizing radiation without any possible benefit. This strategy will reduce the proportion of alert patients who require imaging.

Abscesses are walled off collections of pus in soft tissue, with Staphylococcus aureus (both sensitive and resistant to methicillin) being the microbe most frequently involved. Most uncomplicated abscesses should undergo incision in an acute care setting such as the emergency department, using local anesthesia or procedural sedation, with complete drainage and appropriate follow-up. Antibiotics may be considered when patients are immunocompromised, systemically ill, or exhibit extensive surrounding cellulitis or lymphangitis. In populations with a high [methicillin-resistant S. aureus] MRSA prevalence, there is some evidence to suggest that antibiotics in addition to incision and drainage of uncomplicated abscesses may confer some benefit. However, we encourage physicians to discuss the use of antibiotics in uncomplicated abscesses with patients as the benefits conferred by antibiotics may not outweigh the risks associated with their use (i.e. nausea, diarrhea, and allergic reactions), and the possible benefit to a small percentage of patients may not balance the significant public health and societal effects of antibiotic overuse.

Patients commonly present to the emergency department with syncope. Syncope is a transient loss of consciousness followed by a spontaneous return to baseline neurologic function that does not require resuscitation. The evaluation of syncope should include a thorough history and physical exam to identify high-risk clinical predictors for CT head abnormalities. These high-risk predictors include, but are not limited to: trauma above the clavicles, headache, persistent neurologic deficit, age over 65, patients taking anticoagulants, or known malignancies. Many patients with syncope receive a CT scan of the head; however, in the absence of these predictors, a CT head is unlikely to aid in the management of syncope patients. CT scans can expose patients to unnecessary ionizing radiation that has the potential to increase patients’ lifetime risk of cancer. Unwarranted imaging also increases length of stay and misdiagnosis.

Many adults present to the emergency department with chest pain and/or shortness of breath. The majority of adult patients with these symptoms do not have a pulmonary embolism (PE) that requires investigation with a CT pulmonary angiogram (CTPA) or ventilation perfusion (VQ) lung scan. CTPAs or VQ scans expose patients to ionizing radiation that has the potential to increase patients’ lifetime risk of cancer.  CTPAs also place patients at risk for potential allergic reaction and acute kidney injury from the intravenous contrast required for the CTs. Imaging also increases length of stay and may contribute to misdiagnosis. Evidence demonstrate that physicians should not order CTPAs or VQ scans to diagnose PE until risk stratification with a clinical decision rule (Wells score, PERC rule) has been applied and d-dimer biomarker results are obtained for those patients where it is indicated. For high-risk populations in which the clinical decision rules have not been validated (i.e., pregnancy, hypercoagulability disorders), physicians are urged to exert their clinical judgment.

Adults and children frequently present to the emergency department with sore throats (pharyngitis). The vast majority of cases of pharyngitis are caused by self-limiting viral infections that do not respond to antibiotics. The benefit of antibiotics for the approximately 10% of cases in adults (25% in children), caused by bacteria (principally Group A Streptococcus [GAS]) is modest at best, although they are associated with fewer complications and a slightly shorter course of illness. Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash, and diarrhea) and increase overall antibiotic resistance in the community. Evidence suggests that antibiotics should only be used in patients with intermediate and high clinical prediction scores for GAS (CENTOR or FeverPAIN score) AND confirmatory testing (throat cultures or rapid testing) that is positive for GAS.

Foot and ankle injuries in children and adults are very common presentations to emergency departments. The Ottawa Ankle Rules (OAR) have been validated in both children (greater than 2 years old) and adult populations, and have been shown to reduce the number of X-rays performed without adversely affecting patient care. In alert, cooperative and sensate patients with blunt ankle and/or foot trauma within the previous ten days and who are not distracted by other injuries, only those who fulfill the OAR should undergo ankle and/or foot X-rays. Imaging of the ankle and/or foot in patients who are negative for the OAR does not improve outcomes, exposes the patient to unnecessary ionizing radiation and contributes to flow delays without providing additional value.

Both adults and children commonly present to the emergency department with symptoms of a middle ear infection, or acute otitis media (AOM). The symptoms of AOM include fever, earache, discharge from ear, and/or decreased hearing. Evidence suggests that adults and children with uncomplicated AOM do not need antibiotics. Treatment should focus on analgesia and the use of antibiotics should be limited to complicated or severe cases. A watch and wait approach (analgesia and observation for 48 to 72 hours) should be considered for healthy, non-toxic appearing children older than six months of age with no craniofacial abnormalities, mild disease (mild otalgia, temperature < 39°C without antipyretics), and who have reliable medical follow-up. Antibiotics should be considered if the child’s illness does not improve during the observation period, and for those children who are < 24 months of age with infection in both ears, and in those with AOM and ear discharge. Similarly, antibiotics should not be used for the initial treatment of uncomplicated AOM in adults. Delayed antibiotics are an effective alternative to immediate antibiotics to reduce antibiotic use. Inappropriate administration of antibiotics can expose patients to unnecessary risks (i.e., allergies, rash and diarrhea), and increase overall antibiotic resistance in the community.

Respiratory illnesses are among the most common reasons for pediatric emergency department (ED) visits, with wheezing being a frequently encountered clinical finding. For children presenting with first-time wheezing or with typical findings of asthma, bronchiolitis, or croup, radiographs rarely yield important positive findings and expose patients to radiation, increase cost of care, and prolonged ED length of stay. National and international guidelines emphasize the value of the history and physical examination in making an accurate diagnosis and excluding serious underlying pathology. Radiography performed in the absence of significant findings has been shown to be associated with overuse of antibiotics. Radiographs should not be routinely obtained in these situations unless findings such as significant hypoxia, focal abnormalities on lung exam, prolonged course of illness, or severe distress are present. If wheezing is occurring without a clear atopic etiology or without upper respiratory tract infection symptoms (eg, rhinorrhea, nasal congestion, and/or fever), appropriate diagnostic imaging should be considered on a case-by-case basis

The incidence of mental health problems in children has increased in the last two decades, with suicide surpassing homicide as the second leading cause of death in teenagers. Most children with acute mental health issues do not have underlying medical etiologies for these symptoms. A large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs. Any diagnostic testing should be based on a thorough history and physical examination. Universal requirements for routine testing should be abandoned.

Children presenting with unprovoked, generalized seizures or simple febrile seizures who return to their baseline mental status rarely have blood test or CT scan findings that change acute management.

Blood tests such as electrolyte panels should not be routinely ordered and are only indicated in specific circumstances based on history and clinical examination findings.

CT scans are associated with radiation-related risk of cancer, increased cost of care, and added risk if sedation is required to complete the scan. A head CT scan may be indicated in patients with a new focal seizure, new focal neurologic findings, or high-risk medical history (such as neoplasm, stroke, coagulopathy, sickle cell disease, age <6 months).

Functional constipation and nonspecific, generalized abdominal pain are common presenting complaints for children in emergency departments. Constipation is a clinical diagnosis and does not require testing, yet many of these children receive an abdominal radiograph. However, subjectivity and lack of standardization result in poor sensitivity and specificity of abdominal radiographs to diagnose constipation. Use of abdominal radiographs to diagnose constipation has been associated with increased diagnostic error. Clinical guidelines recommend against obtaining routine abdominal radiographs in patients with clinical diagnosis of functional constipation. The diagnosis of constipation or fecal impaction should be made primarily by history and physical examination, augmented by a digital rectal examination when indicated.

Viral infections occur frequently in children and are a common reason to seek medical care. The diagnosis of a viral illness is made clinically and usually does not require confirmatory testing. Additionally, there is a lack of consistent evidence to demonstrate the impact of comprehensive viral panel (i.e., panels simultaneously testing for 8-20+ viruses) results on clinical outcomes or management, especially in emergency department settings. Hence, most national and international clinical practice guidelines do not recommend their routine use. Additionally, some viral tests are quite expensive, and obtaining nasopharyngeal swab specimens can be uncomfortable for children. Comprehensive viral panel testing can be considered in high-risk patients (eg, immunocompromised) or in situations in which the results will directly influence treatment decisions such as the need for antibiotics, performance of additional tests, or hospitalization. Testing for specific viruses might be indicated if the results of the testing may alter treatment plans (e.g., antivirals for influenza) or public health recommendations (e.g., isolation for SARS-CoV-2). For more specific recommendations related to diagnosis and management of SARS-CoV-2, please see https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/).