1. Algie CM, Mahar RK, Tan HB et al. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev. 2015 Nov 18;11:CD011656. [Epub ahead of print]
CONCLUSIONS: There is currently no information available from published RCTs on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI in the context of endotracheal intubation. On the basis of the findings of non-RCT literature, however, cricoid pressure may not be necessary to undertake RSI safely, and therefore well-designed and conducted RCTs
should nonetheless be encouraged to properly assess the safety and effectiveness of cricoid pressure. PMID: 26578526
Comments: Cricoid pressure was a standard part of RSI until recently, when mounting evidence has suggested it is not beneficial and may be harmful. This systematic review demonstrates that there is no RCT evidence to support cricoid pressure for RSI. Past observational studies have shown that it frequently does not occlude the esophagus anatomically and degrades laryngoscopic view.
2. Estcourt LJ, Stanworth SJ, Doree C et al. Comparison of different platelet count thresholds to guide administration of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation. Cochrane Database Syst Rev. 2015 Nov 18;11:CD010983. [Epub ahead of print]
CONCLUSIONS: In people with haematological disorders who are thrombocytopenic due to myelosuppressive chemotherapy or HSCT, we found low-quality evidence that a standard trigger level (10 x 10(9)/L) is associated with no increase in the risk of bleeding when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L). There was low-quality evidence that a standard trigger level is associated with a decreased number of transfusion episodes when compared to a higher trigger level (20 x 10(9)/L or 30 x 10(9)/L). Findings from this review were based on three studies and 499 participants. Without further evidence, it is reasonable to continue with the current practice of administering prophylactic platelet transfusions using the standard trigger level (10 x 10(9)/L) in the absence of other risk factors for bleeding. PMID: 26576687
Comments: The transfusion trigger for thrombocytopenia is unclear. This review clarifies that in patients with chemo or stem cell transplant, the trigger is 10,000.
3. Hao Q, Dong BR, Yue J et al. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2015 Sep 30;9:CD004437. doi: 10.1002/14651858.CD004437.pub4.
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. PMID: 26419832
Comments: Lytics for massive PE is well established. Submassive is up for debate. I think younger patients may benefit more than older, have ability to exercise (no pulmonary hypertension), and have a lower bleeding risk than their older counterparts.
4. Becker LA, Hom J, Villasis-Keever M et al. Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis. Cochrane Database Syst Rev. 2015 Sep 3;9:CD001726. doi: 10.1002/14651858.CD001726.pub5.
CONCLUSIONS: There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow restriction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow restriction. However, this potential benefit is not well supported by the available data and must be weighed against the adverse effects associated with their use. PMID: 26333656
Comments: This benefits people with any degree of airflow obstruction more than those with none. But if I have a young patient who is insistent something be done about their cough, I would rather give an albuterol inhaler than antibiotics.
5. Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. Cochrane Database Syst Rev. 2015 Sep 28;9:CD010106. doi: 10.1002/14651858.CD010106.pub2.
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. PMID: 26411330
Comments: Antiemetics are less effective than I thought. Pick whichever agent you want. None are better than the others and all work about as well as placebo. Fluids are probably as helpful as anything. Strange that trials of PO ondansetron in kids show such a benefit...
6. Stengel D, Rademacher G, Ekkernkamp A et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev. 2015 Sep 14;9:CD004446. doi: 10.1002/14651858.CD004446.pub4.
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%. PMID:26368505
Comments: I personally can't see FAST replacing CT in the evaluation of blunt trauma. The sensitivity is just not high enough.
7. Brouwer MC, McIntyre P, Prasad K et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;9:CD004405. [Epub ahead of print]
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. PMID: 26362566
Comments: Pre-antibiotic dexamethasone is a good practice in patients with suspicion for acute bacterial meningitis.
8. Tran DT, Newton EK, Mount VA et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015 Oct 29;10:CD002788. doi: 10.1002/14651858.CD002788.pub3.
CONCLUSIONS: Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions. PMID: 26512948
Comments: I use both routinely. Our Pediatric ED uses rocuronium and the adult ED uses succinylcholine. I definitely notice the longer time of onset for Roc when waiting while the patient is apneic for the jaw to loosen.
9. Batterink J(1), Cessford TA, Taylor RA. Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database Syst Rev. 2015 Oct 27;10:CD010344. doi: 10.1002/14651858.CD010344.pub2.
CONCLUSIONS: Evidence for the acute pharmacological management of hyperkalaemia is limited, with no clinical studies demonstrating a reduction in adverse patient outcomes. Of the studied agents, salbutamol via any route and IV insulin-dextrose appear to be most effective at reducing serum potassium. There is limited evidence to support the use of other interventions, such as IV sodium
bicarbonate or aminophylline. The effectiveness of potassium binding resins and IV calcium salts has not been tested in RCTs and requires further study before firm recommendations for clinical practice can be made. PMID: 26506077
Comment: The best evidence for lowering potassium is for albuterol and insulin/glucose. It doesn't mean you can't use other agents though. Although, the evidence for sodium polystyrene sulfate is very sketchy.
10. Gagyor I, Madhok VB, Daly F et al. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2015 Nov 9;11:CD001869. [Epub ahead of print]
CONCLUSIONS: Low-quality evidence from randomised controlled trials showed a benefit from the combination of antivirals with corticosteroids compared to corticosteroids alone for the treatment of Bell's palsy of various degrees of severity. Low-quality evidence showed a benefit of combination therapy compared with corticosteroids alone in severe Bell's palsy. Corticosteroids alone were
more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no benefit from antivirals alone over placebo.Moderate-quality evidence indicated that the combination of antivirals and corticosteroids reduced sequelae of Bell's palsy compared with corticosteroids alone. We found no significant increase in adverse events from the use of antivirals compared with either placebo or corticosteroids, based on low-quality evidence. PMID: 26559436
Comments: Unless a patient has obvious vesicles in the ear canal, antivirals can be left out. Steroids are the thing.
11. Oyo-Ita A, Chinnock P, Ikpeme IA. Surgical versus non-surgical management of abdominal injury. Cochrane Database Syst Rev. 2015 Nov 13;11:CD007383. [Epub ahead of print]
CONCLUSIONS: Based on the findings of 2 studies involving a total of 114 people, there is no evidence to support the use of surgery over an observation protocol for people with penetrating abdominal trauma who have no signs of peritonitis and are stable. PMID: 26568111
Comments: I am going to leave this decision to the trauma surgeons, but just in case you see them admit and observe someone you thought would go to the OR, this may be why.
12. Widmer M, Lopez I, Gülmezoglu AM et al. Duration of treatment for asymptomatic bacteriuria during pregnancy. Cochrane Database Syst Rev. 2015 Nov 11;11:CD000491. [Epub ahead of print]
CONCLUSIONS: A single-dose regimen of antibiotics may be less effective than a short-course (four- to seven-day) regimen, but more evidence is needed from large trials measuring important outcomes, such as cure rate. Women with asymptomatic bacteriuria in pregnancy should be treated by the standard regimen of antibiotics until more data become available testing seven-day treatment
compared with shorter courses of three- or five-day regimens. PMID: 26560337
Comments: I think I will give antibiotics for a week. Antibiotic courses should be readily recognizable football scores (American football, of course): 3, 7, 10, 14, 21...
13. Ker K, Roberts I, Shakur H et al. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2015 May 9;5:CD004896. doi: 10.1002/14651858.CD004896.pub4.
CONCLUSIONS: TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining
uncertainties. PMID: 25956410
Comments: Still not sure why we have not embraced this in our institution. It may be because the time to definitive care is very short.
14. Prabhakar H, Rath S, Kalaivani M et al. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015 Mar 19;3:CD010645. doi: 10.1002/14651858.CD010645.pub2.
CONCLUSIONS: From the limited data available, evidence is insufficient to recommend use or avoidance of adrenaline in digital nerve blocks. The evidence provided in this review indicates that addition of adrenaline to lidocaine may prolong the duration of anaesthesia and reduce the risk of bleeding during surgery, although the quality of the evidence is low. We have identified the need for researchers to conduct large trials that focus on other important outcomes such as adverse events, cost analysis and duration of postoperative pain relief. PMID: 25790261
Comments: It is perfectly acceptable to use lidocaine with epinephrine for a digital block or not. It is your choice. Their finger will not fall off if you do.
15. Venekamp RP, Sanders SL, Glasziou PP et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015 Jun 23;6:CD000219. doi: 10.1002/14651858.CD000219.pub4.
CONCLUSIONS: This review reveals that antibiotics have no early effect on pain, a slight effect on pain in the days following and only a modest effect on the number of children with tympanic perforations, contralateral otitis episodes and abnormal tympanometry findings at two to four weeks and at six to eight weeks compared with placebo in children with AOM. In high-income countries, most cases of AOM spontaneously remit without complications. The benefits of antibiotics must be weighed against the possible harms: for every 14 children treated with antibiotics one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics were withheld. Therefore clinical management should emphasise advice about adequate analgesia and the limited role for antibiotics. Antibiotics are most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease in high-income countries, an expectant observational approach seems justified. PMID: 26099233
Comments: I think at least an informed discussion with parents is warranted about the expected benefits vs. risks. And yes, I am bitter that the FDA took away Auralgan. That was dumb. Don't they have anything better to do?
16. Bruder EA, Ball IM, Ridi S et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015 Jan 8;1:CD010225. doi: 10.1002/14651858.CD010225.pub2.
CONCLUSIONS: Although we have not found conclusive evidence that etomidate increases mortality or healthcare resource utilization in critically ill patients, it does seem to increase the risk of adrenal gland dysfunction and multi-organ system dysfunction by a small amount. The clinical significance of this finding is unknown. This evidence is judged to be of moderate quality, owing mainly to significant attrition bias in some of the smaller studies, and new research may influence the outcomes of our review. The applicability of these data may be limited by the fact that 42% of the patients in our review were intubated for "being comatose", a population less likely to benefit from the haemodynamic stability inherent in etomidate use, and less at risk from its potential negative downstream effects of adrenal suppression. PMID: 25568981
Comments: Use etomidate if you want. It's fine...really.
17. Tokmaji G, Vermeulen H, Müller MC et al. Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev. 2015 Aug 12;8:CD009201. doi: 10.1002/14651858.CD009201.pub2.
CONCLUSIONS: This review provides limited evidence that silver-coated ETT reduces the risk of VAP, especially during the first 10 days of mechanical ventilation. PMID: 26266942
Comments: I want my ETT gold-plated.
18. Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler MT et al. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev. 2015 Apr 8;4:CD009534. [Epub ahead of print]
CONCLUSIONS: No differences were observed between antibiotics versus no treatment of asymptomatic bacteriuria for the development of symptomatic UTI, complications or death. Antibiotics were superior to no treatment for the bacteriological cure but with significantly more adverse events. There was no clinical benefit from treating asymptomatic bacteriuria in the studies included in this review. PMID: 25851268
Comments: Unless pregnant, there is no benefit in treating asymptomatic bacteriuria.
19. Dumville JC, Coulthard P, Worthington HV et al. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2014 Nov 28;11:CD004287. doi: 10.1002/14651858.CD004287.pub4.
CONCLUSIONS: Sutures are significantly better than tissue adhesives for minimising dehiscence. In some cases tissue adhesives may be quicker to apply than sutures. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives with alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension. PMID: 25431843
Comments: Tissue adhesives are good only if they don't really need sutures anyway. Then it's great!
20. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8;12:CD003162. doi: 10.1002/14651858.CD003162.pub3.
CONCLUSIONS: There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises. PMID: 25485940
Comments: Don't try this at home without a bag to catch the vomit. Yes, I tried it on my wife when she has BPPV. Did it work? Like magic! But only after she almost vomited on our bed. Thank heavens a plastic shopping bag was there! By the way, I don't know what those other maneuvers are. I thought they were dance moves.
21. Oduwole O, Meremikwu MM, Oyo-Ita A et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2014 Dec 23;12:CD007094. doi: 10.1002/14651858.CD007094.pub4.
CONCLUSIONS: Honey may be better than 'no treatment', diphenhydramine and placebo for the symptomatic relief of cough, but it is not better than dextromethorphan. None of the included studies assessed the effect of honey on cough duration' because intervention and follow-up were for one night only. There is no strong evidence for or against the use of honey. PMID: 25536086
Comments: How disillusioning this is! I guess I shouldn't have bought stock in buckwheat honey...alas.
22. McNab S, Ware RS, Neville KA et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database Syst Rev. 2014 Dec 18;12:CD009457. doi: 10.1002/14651858.CD009457.pub2.
CONCLUSIONS: Isotonic intravenous maintenance fluids with sodium concentrations similar to that of plasma reduce the risk of hyponatraemia when compared with hypotonic intravenous fluids. These results apply for the first 24 hours of administration in a wide group of primarily surgical paediatric patients with varying severities of illness. PMID: 25519949
Comments: This is a game-changer. Use isotonic fluids for maintenance, not just for boluses.
Clinical Prediction Rules