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Best evidence topic reports (BETs) summarise the evidence Diamorphine or morphine for
pertaining to particular clinical questions. They are not
systematic reviews, but rather contain the best (highest
ischaemic cardiac chest pain
level) evidence that can be practically obtained by busy Report by Steve Halford, Specialist Registrar
practicing clinicians. The search strategies used to find the
best evidence are reported in detail in order to allow Checked by H Simpson, Consultant
clinicians to update searches whenever necessary. The Abstract
BETs published below were first reported at the Critical A short cut review was carried out to establish whether mor-
Appraisal Journal Club at the Manchester Royal Infirmary1 phine is better than diamorphine at allieviating chest pain
or placed on the BestBETs web site. Each BET has been after an acute myocardial infarction. Altogether 66 papers
constructed in the four stages that have been described were found using the reported search, of which one presented
elsewhere.2 The BETs shown here together with those pub- the best evidence to answer the clinical question. The author,
lished previously and those currently under construction can date and country of publication, patient group studied, study
be seen at http://www.bestbets.org.3 Six BETs are type, relevant outcomes, results, and study weaknesses of this
included in this issue of the journal. best paper are tabulated. A clinical bottom line is stated.
• Diamorphine or morphine for ischaemic cardiac chest
pain Clinical scenario
• Type of oral corticosteroid in mild to moderate croup A 55 year old man presents to the emergency department with
• Glucagon in tricyclic overdose chest pain. An ECG shows changes consistent with acute
• Colourimetric CO2 detector compared with myocardial infarction. He is given aspirin and oxygen. His
capnography for confirming endotracheal tube thrombolytic therapy is started and in the meantime you
placement wonder whether his pain would be best alleviated by either
• Glucagon for the treatment of symptomatic β blocker morphine or diamorphine.
overdose
• Buscopan (hyoscine butylbromide) in abdominal colic Three part question
K Mackway-Jones Department of Emergency Medicine, Manchester
In [patients with a myocardial infarction] is [morphine better
Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; than diamorphine] at [alleviating chest pain]?
kevin.mackway-jones@man.ac.uk
1 Carley SD, Mackway-Jones K, Jones A, et al. Moving towards evidence Search strategy
based emergency medicine: use of a structured critical appraisal journal
club. J Accid Emerg Med 1998;15:220–2.
Medline 1966–02/03 using the OVID interface. [(exp chest
2 Mackway-Jones K, Carley SD, Morton RJ, et al. The best evidence pain OR exp myocardial infarction OR myocard$.mp OR
topic report: A modified CAT for summarising the available evidence in infarct$.mp OR MI.mp) AND (exp morphine OR mor-
emergency medicine. J Accid Emerg Med 1998;15:222–6. phine.mp OR heroin.mp OR diamorphine.mp OR analg$.mp
3 Mackway-Jones K, Carley SD. bestbets.org: Odds on favourite for
evidence in emergency medicine reaches the worldwide web. J Accid OR exp analgesics, opioid) AND (exp clinical trials OR exp
Emerg Med 2000;17:235–6. randomized controlled trials OR randomized controlled
trial.mp)] LIMIT to human AND English.
Search outcome
Altogether 66 papers were identified of which only one was
relevant. Details of this paper are shown in table 1.
Table 1
Study type
Author, date and (level of
country Patient group evidence) Outcomes Key results Study weaknesses
Scott ME and Orr R, 118 patients aged 30–79 PRCT Complete pain relief at 10 min 47% v 32% Randomisation unclear
1969, UK yrs with moderate to severe (p<0.05)
chest pain Complete pain relief at 30 min NSD Confidence intervals not
stated
Diamorphine 5 mg v Complete pain relief at 60 min NSD
morphine 10 mg
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Table 2
Study type
Author, date (level of
and country Patient group evidence) Outcomes Key results Study weaknesses
Ruddy JM et al, 4 year old ingested about Case report Cardiac status Improved with 1 mg boluses Case report
1972, Australia 1000 mg imipramine, episode glucagon Patient also received
of PEA 1.5 hours duration pyridostigmine, sodium
bicarbonate, isoprenaline,
digoxin, lignocaine and mannitol
Sener EK et al, 25 year old woman. Plasma Case report Blood pressure No response to 1 mg bolus Multiple drugs ingested in
1995, UK toxicology - imipramine 3.0 glucagon. 40 mm Hg systolic overdose
mg/l, desipramine 0.18 mg/l, rise after glucagons Patient also received sodium
diazepam 2.9 mg/l, Cardiac rhythm No response to 1 mg bolus bicarbonate, phenytoin and
nordiazepam 2.2 mg/l, glucagon. Broad complex isoprenaline and fluid resuscitation
chlorpromazine 0.3 mg/l, reverted to sinus after 10 mg
temazepam 0.25 mg/l bolus
Sensky PR and 36 year old OD-admission Case report Blood pressure No response to 1 mg bolus Case report
Olczak SA, toxicology dothiepin 2.58 glucagon. 30 mm Hg systolic Multiple drugs ingested in
1999, UK mg/l, desmethyldothiepin 0.51 rise after glucagons overdose
mg/l, paracetamol 135 mg/l, Cardiac rhythm No response to 1 mg bolus Patient also received
diazepam 0.33 mg/l, glucagon. Broad complex n-acetylcysteine, adrenaline,
nordiazepam 0.12 mg/l reverted to sinus after 10 mg noradrenaline, ephedrine,
bolus dobutamine, and aminophylline
with fluid restriction
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somewhat and her blood pressure is still low at 80/40. You have c CLINICAL BOTTOM LINE
heard that tricyclic overdoses may respond to glucagon and There is not enough evidence currently available to support
wonder whether there is any evidence for this. the use of glucagon in tricyclic overdose.
Ruddy JM, Seymour JL, Anderson NG. Management of tricyclic
antidepressant ingestion in children with special reference to the use of
Three part question glucagon. Med J Aust 1972;1:630–3.
In [overdose with tricyclic antidepressants] does [the addition Sener EK, Gabe S, Henry JA. Response to glucagon in imipramine overdose.
of glucagon to standard treatments] improve [clinical J Toxicol Clin Toxicol 1995;33:51–3.
Sensky PR, Olczak SA. High dose intravenous glucagon in severe tricyclic
outcome]? poisoning. Postgrad Med J 1999;75:611–12.
Search strategy
Medline 1966–02/03 using the OVID interface. [(exp antide-
pressive agents OR exp antidepressive agents, tricyclic OR exp
desipramine OR exp amitriptyline OR tricyc$.af. OR am-
Colourimetric CO2 detector
itriptyline.af. OR amoxapine.af. OR clomipramine.af. OR dox- compared with capnography
epin.af. OR dothiepin.af. OR imipramine.af. OR lofe-
pramine.af. OR nortriptyline.af. OR trimipramine.af.) AND for confirming ET tube
(exp glucagon OR glucagon.af.)] LIMIT to human AND Eng-
lish.
placement
Search outcome Report by K Hogg, Clinical Research Fellow
Altogether 31 papers found, 28 failed to answer the three part Checked by S Teece, Clinical Research Fellow
question, the three relevant papers are case reports summa- Abstract
rised in table 2. A short cut review was carried out to establish whether
colourimetric carbon dioxide detectors are as reliable as
Comment(s) capnometry at verifying tracheal placement of endotracheal
Although all three patients received multiple treatments the tubes after emergency intubation. A total of 69 papers were
authors state the improvement in condition was immediately found using the reported search, of which four presented the
after high dose glucagon administration. No reports of failure best evidence to answer the clinical question. The author, date
to respond to glucagon are found in the literature. This is most and country of publication, patient group studied, study type,
probably attributable to reporting and publication bias. relevant outcomes, results, and study weaknesses of these best
Further research is required. papers are tabulated. A clinical bottom line is stated.
Table 3
Study type
Author, date and (level of
country Patient group evidence) Outcomes Key results Study weaknesses
Goldberg JS et al, 62 men aged 18–70 Prospective 3 separate observers All three methods confirmed Study only used
1990, UK years old, ASA I, II observational recorded time to correct positioning in 100% haemodynamically stable
and III. Simulated study recognition of tracheal (n=51) cases. Colourimeter patients
difficult intubation drill, and oesophageal and capnograph were faster
using laryngoscope to intubation, by observing IR than chest auscultation. All Observers were specialist
increase larynoscopy capnography, FEF oesophageal intubations anaesthetic staff as were
grade. end-tidal colourimeter, and (n=11) confirmed by all 3 those intubating
auscultaion respectively. methods. One oesophageal
intubation gave mild colour Observers not blinded to
change but correctly other detection methods
interpreted.
Anton WR et al, 60 emergency Prospective Observation of colour Positive signal of exhaled CO2 Doctors were presumably
1991, USA intubations, out with observational change in FEF produced within 6 breaths by anaesthetists
theatre – respiratory study colourimeter within 6 59 of 60 by FEF detector, and
failure n=29, CPR breaths post intubation. 58 of 60 by TRIMED.Of the 9 There were no oesophageal
n=9, self-extubation Observation of a positive CPR patients 5 showed a intubations
n=7, ET tube change signal from portable colour change that was
n=6, airway protection TRIMED IR CO2 detector “subtle”, into the brown
n=3. ? other 6 within 6 breaths post range.One patient receiving
intubation CPR took 20 breaths before a
positive signal was received
in either
Kelly JS et al, 1992, 20 children age 6 Prospective Colour change in Fenem Of total 400 breaths, 398 All patients
USA months to 8 years observational CO2 detector versus IR registered yellow colour in the haemodynamically stable,
undergoing elective study capnographer reading in FEF colourimeter with with optimal intubating
anaesthesia 1.spontaneous mask expiration. This correlated conditions
ventilation 2.post tracheal with capnography readings. There were no oesophageal
intubation10 breaths 2 breaths fell into brown intubations
during each point were range–both of these during
monitored mask ventilation, corrected by Participants were specialist
mask adjustment anaesthetists
Puntervoll SA et al, 14 female patients Experimental Detection of tracheal 100% in both devices Small numbers
2002, Norway undergoing general study placement
Not emergency intubation
anaesthesia Detection of oesophageal In 5 patients with expired air
All had both tracheal misplacement placed in the oesophagus the
and oesophageal colourimeter changed colour
tubes passed
CO2 v capnography
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Clinical scenario
A 30 year old man is brought to the emergency department
Glucagon for the treatment of
with a Glasgow Coma Scale score of 8 after falling down stone symptomatic β blocker
steps while drunk. Although he has not vomited, you are con-
cerned that he cannot protect his airway. You decide to do a overdose
rapid sequence induction. As you organise and check your
equipment, you ask the nurse to bring the departmental cap- Report by R Boyd, Consultant
nograph to the bedside. She tells you that it is still in ITU Checked by A Ghosh, Senior Clinical Fellow
where it was left after transferring the last intubated patient. Abstract
She does, however, suggest you use a disposable colourimetric A short cut review was carried out to establish whether the
CO2 detector found in the paediatric arrest trolley. You wonder intravenous glucagon can support blood pressure in β blocker
whether you should wait five minutes while the capnograph is overdose. A total of 51 papers were found using the reported
brought from ITU, or whether the colourimetric indicator will search, of which six presented the best evidence to answer the
be just as accurate? 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
Three part question clinical bottom line is stated.
In an [emergency intubation] is [a colourimetric carbon diox-
ide detector as reliable as capnography] at [verifying endotra- Clinical scenario
cheal tube placement]? A 25 year old patient presents to the emergency department
two hours after taking a significant overdose of propanolol.
Search strategy She is bradycardic and hypotensive despite initial resuscita-
Medline 1966–02/03 using the OVID interface. [(exp Carbon tion with oxygen and intravenous fluids. An ECG shows a
Dioxide OR end-tidal.mp OR exp Capnography OR carbon sinus bradycardia of 50 bpm. You have heard of treatment with
dioxide.mp OR capnograph$.mp) AND (colorimetric.mp OR intravenous glucagon but wonder if it has been of any proved
benefit.
exp Colorimetry OR colourimetric.mp)] LIMIT to human AND
English language. Three part question
In [symptomatic significant beta-blocker overdose] is [intra-
Search outcome venous glucagon] effective at [reversing the induced hypoten-
Altogether 69 papers were found of which four were relevant sion]?
to the question. Details of these papers are shown in table 3.
Search strategy
Medline 1966–02/03 using the OVID interface. [exp glucagon
Comment(s) Or glucagon.mp] AND [{exp adrenergic beta antagonist}
There have been no studies investigating the use of these AND {exp poisoning OR exp overdose OR poisoning.mp OR
devices exclusively within the emergency department. intoxication.mp overdose.mp} OR {beta blocker overdose.mp
OR beta blocker poisoning.mp}]
c CLINICAL BOTTOM LINE
Search outcome
The colourimetric CO2 detector is as accurate as IR capnogra-
Altogether 51 papers were found of which six were deemed
phy at detecting tracheal intubation, but is potentially less
relevant. No clinical trials were identified and all the papers
accurate at detecting oesophageal intubation.
available were case reports. Details of these papers are shown
Goldberg JS, Rawle PR, Zehnder JL, et al. Colorimetric end-tidal carbon
dioxide monitoring for tracheal intubation. Anesth Analg 1990;70:191–4. in table 4.
Anton WR, Gordon RW, Jordon TM, et al. A disposable end-tidal CO2
detector to verify endotracheal intubation. Ann Emerg Med 1991;20:271–5. Comment(s)
Kelly JS, Wilhoit RD, Brown RE, et al. Efficacy of the FEF colourimetric No clinical trials or even case controlled studies have been
end-tidal carbon dioxide detector in children. Aneth Analg 1992;75:45–50.
Puntervoll SA, Soreide E, Jacewicz W, et al. Rapid detection of oesophageal
published. There is therefore only anecdotal evidence for the
intubation: take care when using colourimetric capnometry. Acta Anaethesiol use of glucagon. The doses of glucagon suggested are higher
Scand 2002;46:455–7. than the usual therapeutic doses given in hypoglycaemia and
Table 4
Study type
Author, date and (level of Study
country Patient group evidence) Outcomes Key results weaknesses
Peterson CD et al, 2 cases of mixed overdose including Case report Survival Bolus of 12 mg and 4 mg used to reverse Case report
1984, USA β blockers cardiogenic shock
Weinstein RS et al, 1 case of propanolol overdose Case report Survival 80 mg glucagon intravenous given over 18 Case report
1985, USA hours to reverse cardiogenic shock
Khan MI and Miller 1 case of propanolol overdose Case report Survival Use of 20 mg glucagon to reverse Case report
MT, 1985, South cardiogenic shock
Africa
Tai YT et al, 1990, Single case of metoprolol overdose Case report Survival 1 mg of glucagon is claimed to have Case report
Hong Kong reversed cardiogenic shock
O’Mahony D et al, One patient after oxprenolol overdose Case report Survival 30 mg bolus with 10 mg/h infusion of Case report
1990, Eire glucagon, successful resuscitation from beta
blocker induced cardiogenic shock
Mansell PI, 1990, Single mixed overdose including Case report Survival Bolus of 4 mg glucagon with an infusion of Case report
Australia propanolol 10 mg in 3 hours
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there is no evidence available to answer this question. Further There is no evidence supporting the use of buscopan in
research is needed. non-specific abdominal pain.
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These include:
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Notes