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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
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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
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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
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