Asma

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BEST EVIDENCE TOPIC REPORTS

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary
Edited by K Mackway-Jones
............................................................................................................................... Emerg Med J 2006;23:470–474. doi: 10.1136/emj.2006.037572

Best Evidence Topic reports (BETs) summarise theevidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with aclinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETsshown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org.3 Four BETs are included in this issue of the journal. c Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma c Delivery of bronchodilators in acute asthma in children c Lorazepam or diazepam in paediatric status epilepticus c Tibialfractures in very young children and child abuse
Carley SD, Mackway-Jones K, Jones A, et al. Moving towards evidence based emergency medicine: use of a structured critical appraisal journal club. J Accid Emerg Med 1998;15:220–222. Mackway-Jones K, Carley SD, Morton RJ, et al. The best evidence topic report: A modified CAT for summarising the available evidence in emergency medicine. J AccidEmerg Med 1998;15:222–226. Mackway-Jones K, Carley SD. bestbets.org: Odds on favourite for evidence in emergency medicine reaches the worldwide web. J Accid Emerg Med 2000;17:235–6.

studied, study type, relevant outcomes, results and study weaknesses of this best paper is tabulated. It is concluded that anti-cholinergics reduce time to recovery and discharge and may reduce admissions for moderateto severe groups. Clinical scenario A seven year old boy with moderately well controlled asthma since his last admission 10 months ago presents to the emergency department with an acute exacerbation. You ask the nurse to administer salbutamol and ipratropium 5 mg and 0.25 mg as a nebuliser. She questions the value of adding an anti-cholinergic, despite your theoretical knowledge that the mechanismof action of both drugs should be additive you are left wondering about the clinical evidence to support this. Three-part question In [children with acute asthma who present to the Emergency Department] is [salbutamol and ipratropium better than salbutamol alone] at [producing a clinical improvement and reducing hospital stay]? Search strategy OVID Medline 1966 to March Week 4 2006 [(exp asthma/ORasthma mp) AND (exp albutarol/OR salbutamol.mp.) AND (exp atropine derivatives/OR exp ipratropium/).OR [*‘‘Adrenergic beta-Agonists’’/AND *‘‘Cholinergic Antagonists’’/AND ‘‘Drug Therapy, Combination’’/] LIMIT to Humans and English Language and BestBETs paediatric filter. OVID Embase 1980 to 2006 Week 12 [(exp asthma/OR asthma mp) AND (exp Salbutamol/or albutarol.mp.) AND (exp atropinederivative/OR exp ipratropium bromide/) OR [exp Beta Adrenergic Receptor Stimulating Agent/AND exp Cholinergic Receptor Blocking Agent/AND exp Drug Combination/] AND (exp Emergency Ward/). LIMIT to Human and English Language AND (infant ,to one year. or child ,unspecified age. or preschool child ,1 to 6 years. or school child ,7 to 12 years. or adolescent ,13 to 17 years.). The Cochrane Library 2006 Issue...