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Best Bets from the Manchester Royal Infirmary Edited by K Mackway-Jones

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Best Bets from the Manchester Royal Infirmary Edited by K Mackway-Jones 247 BEST EVIDENCE TOPIC REPORTS Emerg Med J: first published as 10.1136/emj.19.3.248 on 1 May 2002. Downloaded from Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary Edited by K Mackway-Jones Clinical scenario Best evidence topic reports (BETs) summarise the evidence A 23 year old woman attends an emergency department hav- pertaining to particular clinical questions. They are not ing taken sixty 500 mg paracetamol tablets. Her four hour systematic reviews, but rather contain the best (highest paracetamol levels are above the treatment line. She does not level) evidence that can be practically obtained by busy want to be treated with intravenous therapy. You wonder practising clinicians. The search strategies used to find the whether oral antidote is as effective. best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. The BETs published below were first reported at the Critical Three part question Appraisal Journal Club at the Manchester Royal Infirmary.1 In [patients who need an antidote for paracetamol overdose] Each BET has been constructed in the four stages that have is [intravenous therapy better than oral therapy] at [prevent- been described elsewhere.2 The BETs shown here together ing liver damage and death]? with those published previously and those currently under construction can be seen at http://www.bestbets.org.3 Six Search strategy BETs are included in this issue of the journal. Medline 1966 to 12/01 using the OVID interface. [exp acetyl- cysteine OR acetylcysteine.mp OR n-acetylcysteine.mp OR c Oral or intravenous antidote for paracetamol overdose exp methionine/ OR methionine.mp OR exp antidote OR anti- c Vomiting in paracetamol overdose dote.mp] AND [exp overdose/ OR overdos$.mp OR exp c Intravenous or intramuscular/subcutaneous naloxone in poisons OR poison$.mp OR acute intoxic$.mp OR acute opioid overdose toxic$.mp] AND [exp acetamoniphen OR acetaminophen.mp OR exp paracetamol OR paracetamol.mp OR (co-codamol OR c Intravenous bolus or infusion of naloxone in opioid over- co-dydramol OR co-proxamol).mp] LIMIT to human AND dose English language. c Discharge of patients who have taken an overdose of opioids Search outcome c Gastric lavage in iron overdose Altogether 330 papers were identified, of which two were http://emj.bmj.com/ K Mackway-Jones Department of Emergency Medicine, Manchester directly relevant to the question (table 1). Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; [email protected] Comment(s) 1 Carley SD, Mackway-Jones K, Jones A, et al. Moving towards evidence based emergency medicine: use of a structured critical appraisal journal Perry’s study used historical controls although the demo- club. J Accid Emerg Med 1998;15:220–2. graphic characteristics of the two groups were remarkably 2 Mackway-Jones K, Carley SD, Morton RJ, et al. The best evidence similar. It was not included in Buckley’s meta-analysis topic report: A modified CAT for summarising the available evidence in because the patients were not recruited sequentially and it emergency medicine. J Accid Emerg Med 1998;15:222–6. on September 25, 2021 by guest. Protected copyright. 3 Mackway-Jones K, Carley SD. bestbets.org: Odds on favourite for was unclear whether the patients were treated solely at the evidence in emergency medicine reaches the worldwide web. J Accid study centre (possible variations in other treatment modalities Emerg Med 2000;17:235–6. could act as confounding factors). There have been no RCTs in this area. A meta-analysis of observational studies has failed to show a difference in efficacy between the oral and intravenous routes. However, these studies do not address other factors that may influence the choice of route, which include: activated charcoal adsorbs antidote and therefore precludes its use; the IV regimen is Oral or intravenous antidote shorter than the oral (24 hours and 52 hours respectively); the for paracetamol overdose IV route is safer with patients with altered levels of conscious- ness (for example due to coingestants) who may subsequently Report by Simon Clarke, Specialist Registrar lose their airway protective reflexes. Checked by Katrina Herren, Research Fellow c CLINICAL BOTTOM LINE Abstract The IV route is the treatment of choice for paracetamol A short cut review was carried out to establish whether there poisoning, but the oral route has a similar efficacy and is a was any evidence to decide between oral or intravenous anti- suitable alternative if IV access is difficult (for example IV dote in paracetamol (acetaminophen) poisoning. Altogether drug abusers) or refused by the patient. 330 papers were found using the reported search, of which two presented the best evidence to answer the clinical Perry HE, Shannon MW. Efficacy of oral versus intravenous N-acetylcysteine question. The author, date and country of publication, patient in acetaminophen overdose: results of an open-label, clinical trial. J Pediatr group studied, study type, relevant outcomes, results and 1998;132:149–52. Buckley NA, Whyte IM, O’Connell DL, et al. Oral or intravenous study weaknesses of these best papers are tabulated. A clinical N-acetylcysteine: which is the treatment of choice for acetaminophen bottom line is stated. (paracetamol) poisoning? J Toxicol Clin Toxicol 1999;37:759–67. www.emjonline.com 248 Best evidence topic reports Table 1 Emerg Med J: first published as 10.1136/emj.19.3.248 on 1 May 2002. Downloaded from Author, date and country Patient group Study type Outcomes Key results Study weaknesses Perry HE, et al, 25 patients (<16 years) attending an Observational Hepatotoxicity 8% IV; 6.9% oral; 0% Small non-randomised study 1998, USA emergency department less than 24 (transaminases either group when hours after a single, potentially toxic >1000 u/l) treated <10 hours after overdose of paracetamol, given IV ingestion N-acetylcysteine (NAC). Encephalopathy 0% IV; 3.4% oral 29 patients previously given oral Coagulopathy None noted NAC were used as historical controls. requiring FFP Buckley NA, 5 observational studies Meta-analysis Hepatotoxicity There was no significant Meta-analysis et al, 1999, difference in the IV data was pooled from 4 studies Australia hepatotoxicity rates (total of 341 patients) but oral data between IV and oral was taken from only one (1462 NAC. patients) of the 3 eligible studies (248 patients excluded) acetaminophen.mp OR exp paracetamol OR paracetamol.mp Vomiting in paracetamol OR (co-codamol OR co-dydramol OR co-proxamol).mp] AND [exp vomiting OR vomit$.mp OR nause$.mp OR emesis.mp] overdose LIMIT to human AND English. Report by Katrina Herren, Research Fellow Checked by Simon Clarke, Specialist Registrar Search outcome Altogether 48 papers of which two were relevant (table 2). Abstract A short cut review was carried out to establish whether vom- iting was a significant consequence of paracetamol (acetami- Comment(s) nophen) overdose. Altogether 48 papers were found using the Adams’ paper quoted two further estimates of vomiting: the reported search, of which two presented the best evidence to first (77%) referred to an anecdotal report in another paper 3; answer the clinical question. The author, date and country of the second (16%) was a value obtained from a prospective, publication, patient group studied, study type, relevant observational study of 132 patients with four hourly levels outcomes, results and study weaknesses of these best papers above the 22 mg/l level all treated with methionine, only 5% are tabulated. A clinical bottom line is stated. vomited after the antidote.4 The paper quotes two further sources that describe frequent vomiting. Clinical scenario No mention was made about any delay in starting antidote A 27 year old woman presents to the emergency department therapy in this group. Neither study addresses other factors http://emj.bmj.com/ having taken a paracetamol overdose; she is not vomiting. You such as adsorption of oral antidote by activated charcoal, nor have been told that people with a significant overdose of para- cetamol will vomit. You wonder whether this is true. the fact that oral therapy lasts longer than IV (72 and 24 hours respectively). Three part question In [patients who have taken an overdose of paracetamol] what c CLINICAL BOTTOM LINE [is the incidence] of [vomiting]? The incidence of vomiting after paracetamol is relatively low and is amenable to antiemetic therapy. on September 25, 2021 by guest. Protected copyright. Search strategy Medline 1966–12/01 using the OVID interface. [exp overdose Adams RA, Dallas V, Daniels RG, et al. Vomiting in paracetamol poisoning. BMJ 1980;280:560–1. OR overdos$.mp OR exp poisons OR poison$.mp OR acute Scharman EJ. Use of ondansetron and other antiemetics in the management intoxic$.mp OR toxic$.mp] AND [exp acetaminophen OR of toxic acetaminophen ingestions. J Toxicol Clin Toxicol 1998;36:19–25. Table 2 Author, date and country Patient group Study type Outcomes Key results Study weaknesses Adams RA, et 392 patients with paracetamol Observational Vomiting 11.7% vomited before Does not report the incidence of al, 1980, UK overdose of whom 120 took the onset of antidote vomiting in the paracetamol alone paracetamol alone therapy group Cannot exclude the confounding influence of co-ingestants (eg dextropropoxyphene in 112 patients) Scharman EJ, 1009 adult patients with a Observational Vomiting 12.5% vomited (61% No attempt to assess the proportion 1998, USA paracetamol ovedose, who were were in the toxic range of patients in the non-vomiting group reported to a poisons centre. and 41% had taken who had taken co-ingestants or who co-ingestants) were in the toxic range Antiemetic used 33% failed first line and its antiemetic therapy and effectiveness were given ondansetron: of these 16% failed (ie 4% required IV antidote) www.emjonline.com Best evidence topic reports 249 Table 3 Emerg Med J: first published as 10.1136/emj.19.3.248 on 1 May 2002.
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