Which facial views for facial trauma?

A short cut review was carried out to establish whether a reduced number of facial radiographs had acceptable clinical utility at detecting facial fractures after trauma. Altogether 614 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.


Comment(s)
There is evidence that LMWHs are a safe and effective treatment for DVT. The drug is a recognised alternative to warfarin in certain patient groups such as pregnant women. Supervision of the INR with warfarin allows clinicians to monitor the effectiveness of the anticoagulant. With LMWHs there is no way of knowing if the patient is taking the drug, and as IDUs are traditionally seen as a chaotic patient group, then this would be a concern. There are no RCTs comparing LMWHs with coumarins in the management of intravenous drug users. Thus there is currently very limited evidence on the best ways to manage this patient group.
c CLINICAL BOTTOM LINE Low molecular weight heparin seems to be a safe method of anticoagulation and may be considered as an alternative to warfarin in the anticoagulation of IDUs because it does not require ongoing monitoring. However, the evidence is very limited. Local guidelines should be followed. Abstract A short cut review was carried out to establish whether the two thumb technique was superior to the two finger

Clinical scenario
You are put on standby by the paramedic emergency service for a cardiac arrest in an 8 week old baby. While you are assembling your equipment in the emergency department, you recall that APLS suggests a two thumb, hand encircling technique may be better when more than one rescuer is present, but rarely do you see this being used. You wonder whether current evidence supports this or not.

Search outcome
Altogether 175 papers found of which four helped to answer the question posed. These are summarised in table 3.

Comment(s)
In addition to these papers, the International Consensus on Science published revised guidelines in 2000, which, among other things advocated the use of two thumb technique where possible. Whether this leads to improvement in overall survival rates needs further evaluation. Abstract A short cut review was carried out to establish whether nonsteroidal anti-inflammatory agents cause exacerbations of asthma in children. Altogether 301 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Clinical scenario
A 7 year old asthmatic boy presents to the emergency department with a history of fever that has not settled despite paracetamol. You consider prescribing ibuprofen but the staff nurse is concerned that this will cause an exacerbation of his asthma. You wonder whether there is any evidence for this.

Comment(s)
Non-steroidal anti-inflammatory medications (NSAIDs) are often withheld from asthmatic children for fear that they may cause an exacerbation of the condition. Although aspirin induced bronchospasm has been described in the literature, there are no case reports relating to NSAID induced bronchospasm in children. The two clinical trials that have investigated this problem have not established any link. The paper by Lesko et al actually showed a statistically significant reduction in outpatient consultations for asthma in the ibuprofen treated group. This may have been a chance result. Alternatively, it may be that either paracetamol can induce bronchospasm or that NSAIDs lead to an improvement in bronchial tone, perhaps as a result of their anti-inflammatory action. A third paper, by Lesko and Mitchell, investigated the safety of ibuprofen and paracetamol in children under two years of age. Although the paper did not answer the three part question directly, they randomised a total of 27 065 febrile children to receive either paracetamol, ibuprofen 5 mg/kg, or ibuprofen 10 mg/kg. There was no increase in the incidence of hospitalisation with asthma or anaphylaxis in the ibuprofen treated group. From the available evidence, it would seem that NSAIDs are safe to use in asthmatic children.

c CLINICAL BOTTOM LINE
There is no evidence that NSAIDs lead to exacerbation of asthma in children.  Abstract A short cut review was carried out to establish whether the insertion of a femoral central venous pressure line causes more thrombotic complications than insertion of a jugular line. Altogether 90 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant

Clinical scenario
You are in the emergency department attending to a 68 year old man who was found in his car that had left the road and hit a tree. On arrival his GCS was 6 and he had two fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema over the past few days. There is nothing acute on his ECG and only cerebral oedema is seen on the head computed tomography. You can see that his fluid balance will be very difficult to manage over the next few days. You elect to insert a femoral central line but wonder if there will be any additional risks to placing this into the femoral vein rather than the currently inaccessible cervical region.  Abstract A short cut review was carried out to establish whether the risk of suicide and parasuicide increases at Christmas. Fifteen papers were found using the reported search, of which six presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Clinical scenario
You are planning for winter pressures in your emergency department. You wonder if you will need additional psychiatric support over the Christmas period to cope with a perceived increase in the number of suicide attempts. When you bring this up at a senior team meeting a colleague suggests that in fact the number of suicides decreases over the Christmas period. You wonder if this is true.

Search outcome
Altogether 15 papers were found of which six were relevant to the clinical question. These papers are shown in table 6.

Comment(s)
Although the papers presented show a mix of suicide and parasuicide statistics it is apparent that there is a general trend for such events to reduce in December and in particular around the days preceding Christmas day. As with all studies in this area there may be difficulties in gauging the true incidence as a result of under reporting. This is unlikely to be significantly different at Christmas so overall trends should be valid. The perception of many is that rates go up around Christmas. This has resulted in a greater awareness and access to services at this time. It is an interesting question to ponder whether the reductions seen here are attributable to an overall reduction in need, or the effectiveness of available help services.