Downloaded from http://emj.bmj.com/ on June 17, 2017 - Published by group.bmj.com Best evidence topic reports 61 Three part question In [adults who have experienced severe blunt trauma who are fully conscious and asymptomatic] is [pelvic x ray] necessary to exclude [significant bony pelvic damage]? Search strategy Medline 1966 to 10/98 using the OVID interface. ({ [exp pelvis OR pelvi$.ti,ab,rw,sh] AND [exp x-rays OR x-ray$.ti,ab,rw,sh OR radiograph$.ti,ab,rw,sh] AND [exp "wounds and injuries" OR injur$.ti,ab,rw,sh OR trauma$.ti,ab,rw,sh] AND blunt$.ti,ab,rw,sh} LIMIT to human and english). symptoms and signs predict pelvic fracture with a sensitivity of 95.45% and a specificity of 95.53%. Furthermore the absence of clinical symptoms and signs has a negative predictive value of 99.6% in this group of patients. Clinical bottom line Adult trauma patients who are awake with normal sensation and who have no pelvic symptoms or signs do not need a pelvic x ray. Comment The studies above include 1699 awake patients. Aggregated figures show that clinical 1 Civil ID, Ross SE, Botehlo G, et al. Routine pelvic radiography in severe blunt trauma: is it necessary? Ann Emerg Med 1988;17:488-90. 2 Salvino CK, Esposito TJ, Smith D, et al. Routine pelvic x-ray studies in awake blunt trauma patients: a sensible policy? Jf Trauma 1992;33:413-16. 3 Yugeros P, Sarmiento JM, Garcia AF, et al. Unnecessary use of pelvic x-ray in blunt trauma. J7 Trauma 1995;39:722-5. 4 Ersoy G, Karcioglu 0, Enginbas Y, et al. Should all patients with blunt trauma undergo "routine" pelvic x-ray? European Journal of Emergency Medicine 1995;2:65-8. 5 Heath FR, Blum F, Rockwell S. Physical examination as a screening test for pelvic fractures in blunt trauma patients. W VMedJ 1997;93:267-9. The management of anterior epistaxis Report by Kevin Mackway-Jones, Consultant Search checked by Rosemary Morton, Consultant be from the front of the nose and the patient has no underlying disease. You wonder whether packing or cautery is the best method of obtaining haemostasis. Clinical scenario An adult patient presents to the emergency department with a nosebleed that came on spontaneously and which has not responded to simple first aid measures. The bleed appears to Three part question In [adult patients with spontaneous epistaxis and no underlying disease] is [cautery or packing] more effective at [stopping bleeding]? Search outcome Thirty two papers found of which 27 were irrelevant; the remaining papers are shown in table 1. Table 2 Study type (level of evidence) Author, date ,and country Patient group Toner and Walby, 1990, UK' 97 consecutive patients with anterior epistaxis attending the emergency department Randomised to either electrocautery or cautery with silver nitrate PRCT 30 consecutive patients with acute epistaxis in the control v 33 consecutive patients in the intervention group Intervention group had visualisation using the operating microscope and hot wire cautery Controlled clinical trial Nicolaides et al, 1991, UK2 McGlashan et al, 1992, UK' Outcomes Key results Study weaknesses Number having further epistaxis No statistical difference Low power study Complications No significant difference Complete control of bleeding by cautery 82% v 23% Need for subsequent packing 18% v 77% (p < 0.001) Need for admission for longer than 24 hours 27% v 76% Discomfort of insertion NS Rebleed rate NS Not randomised 40 consecutive adult (> 16 years) patients with significant epistaxis of at least 2 hours' duration Kalostat v xeroform packs PRCT Quine et al, 1994, UK4 100 consecutive adult (> 16y) patients with acute epistaxis All hot wire cauterised Observational Patients sent home immediately 80% Uncontrolled Pringle et al, 1996, UK5 83 patients packed with merocel out of 149 patients with epistaxis presenting over 1 year Observational Control of epistaxis 91.5% Uncontrolled Discomfort of insertion (n=34) Low VAS scores (median 3) PRCT=prospective randomised controlled trial; VAS=visual analogue scale. No power calculation Downloaded from http://emj.bmj.com/ on June 17, 2017 - Published by group.bmj.com Mackway-Jones 62 Search strategy Medline 1966 to 10/98 using the OVID interface. ([exp epistaxis OR epistaxis.ti,ab,rw,sh OR nose bleed$.ti,ab,rw,sh] OR { [exp hemorrhage OR hemorrhage$.ti,ab,rw,sh OR haemorrhage$.ti,ab,rw,sh OR bleed$.ti,ab,rw,sh] AND [exp nose OR exp nasal mucosa OR nose.ti,ab,rw,sh OR nasal.ti,ab,rw,sh OR nares.ti,ab,rw,sh] }) AND [pack$.ti,ab,rw,sh OR exp cautery OR cauter$.ti,ab,rw,sh] AND maximally sensitive RCT filter LIMIT to human and english language. scope requires skills unlikely to be found in the emergency department, while nasal packing is easier for the relatively unskilled to perform but is less comfortable for patients. Clinical bottom line Both cautery and packing can be effective. In the absence of better comparative studies the operator should use the technique with which they are most familiar. 1 Toner JG, Walby AP. Comparison of electro and chemical cautery in the treatment of anterior epistaxis. Jf Laryngol Otol 1990;104:617-18. 2 Nicolaides A, Gray R, Pfleiderer A. A new approach to the management of acute epistaxis. Clin Otolaryngol 1991;16: 59-61. 3 McGlashan JA, Walsh MB, Dauod A, et al. A comparative study of calcium sodium alginate (Kalostat) and bismuthtribromophenate (xeroform) packing in the management of epistaxis. JLaryngol Otol 1992;106:1067-71. 4 Quine S, Gray RF, Rudd M, et al. Microscope and hot wire cautery management of 100 consecutive patients with acute epistaxis-a superior method to traditional packing. J Laryngol Otol 1994;108:845-8. 5 Pringle MB, Beasley P, Brightwell AP. The use of Merocel nasal packs in the treatment of epistaxis. J Laryngol Otol 1 996;1 10:543-6. Search outcome Altogether 103 papers found of which 82 were irrelevant and 16 of insufficient quality for inclusion; the remaining papers are shown in table 2. Comment There is a paucity of good evidence in this area. No head to head trials have been carried out. Hot wire cautery using an operating micro- Topical analgesia in corneal abrasions Report by Simon Carley, Clinical Fellow Search checked by Bruce Martin, Clinical Fellow Clinical scenario A 25 year old man presents to the emergency department complaining of a four hour history of painful right eye after it was scratched by his 3 month old daughter. You recall being told that topical non-steroidal may be of help but wonder if they are any better than lubrication on its own. You also wonder if the nonsteroidals may affect the eventual outcome and time to healing. Three part question [In adults with acute corneal abrasions] are [non-steroidal eye drops better than simple lubrication] at [improving pain relief and improving time to healing]? Search strategy Medline 1966 to 10/98 using the OVID interface. ({ [exp cornea OR cornea.ti,ab,rw,sh] AND abrasion$.ti,ab,rw,sh} AND [exp analgesia OR analgesi$.ti,ab,rw,sh OR exp antiinflammatory agents, non-steroidal OR nonsteroidal.ti,ab,rw,sh]). Table 3 Author, date, and country Patient group Study type (level of evidence) Outcomes Brahma et al, 1996, UK' 401 patients with corneal abrasions in an eye emergency department PRCT Ocular pain 6 hourly PRCT Ocular pain Day 1 All patients received chloramphenicol ointment +/- study drops: polyvinyl alcohol alone, homatropine 2%, flubriprofen 0.03% or homatropine 2% + flubriprofen 0.03% Jayamanne et al, 1997, UK2 40 patients with unilateral traumatic corneal abrasions Day 2 All patients received chloramphenicol ointment +/- study drops: diclofenac sodium 0. 1% or normal saline Kaiser and Pineda, 1997, USA3 100 patients with traumatic or foreign body related corneal abrasions All patients received a cycloplegic and polymixin B +/- study drops: ketorolac tromethamine 0.5% or control vehicle drops PRCT=prospective randomides controlled trial. PRCT Ocular pain Key results Study weaknesses Both patient groups Very low response rate, receiving flubriprofen only 55.8% of patients had significantly less enrolled in the study pain completed it There was no added benefit when homatropine was given with flubriprofen Less in diclofenac group (p< 0.02) Less in diclofenac group (p< 0.001) Photophobia Less in ketorolac group from day 1 (p< 0.002) Less in ketorolac group from day 1 (p< 0.009) Foreign body sensation Healing time Complication rate Less in ketorolac group from day 1 (p< 0.003) No difference No difference Downloaded from http://emj.bmj.com/ on June 17, 2017 - Published by group.bmj.com Towards evidence based emergency medicine: best BETs from the Manchester Royal infirmary. The management of anterior epistaxis. K Mackway-Jones J Accid Emerg Med 1999 16: 61-62 doi: 10.1136/emj.16.1.61 Updated information and services can be found at: http://emj.bmj.com/content/16/1/61.citation These include: Email alerting service Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Notes To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
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