Evidence Update (October 2015)

Evidence Update (October 2015)

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NICE Guidance


New and Updated Cochrane Systematic Reviews

Authors' conclusions: In an ED population, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo. Participants receiving placebo often reported clinically significant improvement in nausea, implying general supportive treatment such as intravenous fluids may be sufficient for the majority of people. If a drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost. The review was limited by the paucity of clinical trials in this setting. Future research should include the use of placebo and consider focusing on specific diagnostic groups and controlling for factors such as intravenous fluid administered.

Authors' conclusions: The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.

Authors' conclusions: Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

Authors' conclusions: There is low quality evidence that thrombolytics reduce death following acute pulmonary embolism compared with heparin. Furthermore, thrombolytic therapies included in the review were heterogeneous. Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events and stroke. More high quality double blind RCTs assessing safety and cost-effectiveness are required.

Authors' conclusions: There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.

We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.


Cardiac troponin testing

  • Updated 2015 Oct 05 07:13:00 AM: high-sensitivity cardiac troponin I measured twice 1 hour apart rules out and helps diagnose myocardial infarction in most patients presenting with chest pain and no ST elevation (Am J Med 2015 Aug)

Blood products administration

  • Updated 2015 Oct 05 07:04:00 AM: storage times < 21 days associated with similar mortality compared to storage times ≥ 21 days in patients having packed red blood cell transfusion (Cochrane Database Syst Rev 2015 Jul 14)

Decision rules for computed tomography in head injury in children

  • Updated 2015 Oct 05 06:58:00 AM: 2-factor decision rule may help rule out skull fracture without radiologic evaluation in children < 2 years old presenting to emergency department with low-risk minor head trauma (CMAJ 2015 Sep 8 early online)

Post-traumatic stress disorder (PTSD)

Post-dural puncture headache

  • Updated 2015 Oct 05 06:34:00 AM: caffeine (oral or IV) might improve pain in patients with post-dural puncture headache (Cochrane Database Syst Rev 2015 Jul 15)


  • Updated 2015 Oct 05 06:29:00 AM: propofol may have similar or lower risk of adverse events compared to alternative interventions for procedural sedation in emergency department (Cochrane Database Syst Rev 2015 Jul 29)

Inhaled corticosteroids for asthma

  • Updated 2015 Oct 05 06:27:00 AM: intermittent inhaled corticosteroid therapy may reduce exacerbations requiring oral corticosteroid therapy and might reduce risk of serious adverse events in preschool children with mild persistent asthma (Cochrane Database Syst Rev 2015 Jul 22)

Pulmonary embolism (PE)

  • Updated 2015 Sep 23 12:00:00 AM: European Society of Cardiology/European Respiratory Society (ESC/ERS) guideline on diagnosis and treatment of pulmonary hypertension (Eur Heart J 2015 Aug 29 early online)

UpToDate® Practice Changing Updates

Contrast regimens for children requiring abdominal and pelvic computed tomography after blunt trauma

In a multicenter, prospective observational study of over 5000 children with blunt trauma undergoing abdominal and pelvic computed tomography (CT) with intravenous (IV) contrast, of whom 1010 also received oral contrast, the sensitivity for identifying intra-abdominal injury was not significantly different with or without oral contrast (99 versus 98 percent, respectively) [3]. Patients who received oral contrast had a significantly longer delay in undergoing CT (median 12 minutes) compared with children who received IV contrast alone. Thus, oral contrast does not improve detection of intra-abdominal injury in children but delays time to imaging. We suggest that hemodynamically stable children undergoing CT of the abdomen and pelvis after blunt trauma receive IV contrast alone rather than IV and oral contrast.

See 'Overview of blunt abdominal trauma in children', section on 'Use of contrast'You will need to login with your UpToDate® or Athens Login information to read this article.

3. Ellison AM, Quayle KS, Bonsu B, et al. Use of Oral Contrast for Abdominal Computed Tomography in Children With Blunt Torso Trauma. Ann Emerg Med 2015; 66:107.

Reports and statistics

A&E delays

Monitor has published A&E delays: why did patients wait longer last winter? This report presents findings of research into increased waiting times in A&E for October-December 2014/15.  It shows that the target 4-hour emergency care indicator is a measure of the performance of the whole health and care system, not just emergency care departments.  The findings show that across England the rest of the hospital struggled to cope with the increase in admissions because of very high occupancy rates.   The supporting documents include: the findings at a glance; conclusions from 10 tested hypotheses; an econometric analysis and next steps.

Consultation on closer working between the emergency services

A joint open consultation has been launched by the Department of Health, Home and the Department of Communities and local Government to examine proposals to increase joint working between emergency services, in order to improve effectiveness and deliver savings for the public. The consultation closes on the 23 October 2015.

New video on the role of pharmacists in A&E

The Royal Pharmaceutical Society has released a new video filmed at the Birmingham Children’s Hospital, highlighting how pharmacists can improve patient care in Accident and Emergency Departments.  It shows what a specially-trained pharmacist can achieve in A&E and the impact the role has had on other health professionals in the department.

Impact of out-of-hours GP services on A&E attendance rates

The National Audit Office (NAO) has published as part of Audit insights papers series: Investigating the impact of out-of-hours GP services on A&E attendance rates: multilevel regression analysis. This report sets out how the NAO used an analytical technique called multilevel regression modelling to investigate the factors affecting levels of attendance at accident and emergency (A&E) departments by patients registered at a GP practice.  Such analysis is conducted under statutory authority to examine and report to Parliament on the economy, efficiency and effectiveness with which government departments and other bodies have used their resources

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