Australasian College for Emergency Medicine
Recommendations from the Australasian College for Emergency Medicine on CT scans for head injury and renal colic, end-of-life care in emergency departments, cervical spine (neck) imaging and coagulation studies. ACEM is the not-for-profit organisation responsible for training emergency physicians and advancing professional standards in emergency medicine in Australia and New Zealand.
Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
Most head injuries presenting to emergency departments will be minor and do not require immediate neurosurgical intervention or inpatient care. Mild head injury patients can be risk stratified into ‘low’ or ‘high’ risk groups based on the presence or absence of identified clinical risk factors. Current validated clinical decision rules include the Canadian CT Head Rule (for adults) or the PECARN (Paediatric Emergency Care Applied Research Network) Tool (for children). These rules can safely identify patients who can be discharged home, without CT scanning.
This is a joint recommendation with The Royal Australian and New Zealand College of Radiologists (RANZCR).
- Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011;71(1):245-51.
- Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and economic evaluation. Health Technol Assess. 2011;15(27):1-202.
- Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, and Wells GA. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center. Acad Emerg Med. 2012;19:2–10.
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation*.
- 3 Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- 4 For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- 5 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.