The Cochrane Reviews in this Evidence Aid Special Collection are freely available; please click on the links below to access the reviews.
A selection of Cochrane Reviews and their conclusions for healthcare topics that have been identified as important in the aftermath of a major earthquake. These are signposts to systematic reviews that might be helpful to decision-makers.
Topics covered: diarrhoea prevention and treatment; wound management; fracture management; physical trauma (excluding fractures); anaesthesia; renal; chest infections; neonatal health; child health and nutrition and human resources for health
Translations: a Japanese translation is maintained by Kyoto University School of Public Health. All countries in Latin America and the Caribbean can access The Cochrane Library in English, Spanish or Portuguese via the Virtual Health Library BIREME interface.
The World Health Organization (WHO) has published guidelines for drug donations following disasters (in English and Russian) and details an interagency emergency health kit (in English, French, and Spanish).
There is no evidence that using tap water to cleanse acute wounds in adults increases infection, and there is some evidence that it reduces infection. However, there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.
Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use. The objective of this review was to assess the effects of water compared with other solutions for wound cleansing. [Resumen en español]
Evidence for the effectiveness of negative pressure wound therapy (NPWT) for complete healing of acute wounds remains unclear, as does the effect of NPWT on time to complete healing. Rates of graft loss may lower when NPWT is used, but hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established.
Indications for the use of NPWT are broadening, with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. This review assessed the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention.
There is currently an absence of high-quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds.
Aloe vera is a cactus-like perennial succulent belonging to the Liliaceae family, commonly grown in tropical climates. Animal studies have suggested that Aloe vera may help accelerate the wound healing process. There is currently insufficient clinical trial evidence available regarding the effects of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds. This is primarily due to the lack of high-quality trials with adequate methodology.
There is evidence to support the use of sutures over tissue adhesives for minimising dehiscence.
Sutures, staples and adhesive tapes are often used in wound closure however; each method has some advantages and disadvantages. The aim of the review was to determine the relative effects of tissue adhesives and conventional skin closure techniques on the healing of surgical wounds.
There is insufficient evidence on the efficacy of various methods of debridement on wound healing and the rate of debridement to guide clinical practice. There are very few large high quality trials evaluating the efficacy of various methods of debridement that have been conducted after 1990. Studies recently conducted by manufacturers of new and existing wound debridement products have used controlled trials methods, retrospective analysis of patient case notes and case studies as evidence of effectiveness therefore more high quality randomised controlled trials are needed.
There is a common belief that debridement of infected surgical wounds helps to increase wound healing. However, there is no consensus on the best method for debridement. The aim of the review was to assess the effectiveness of various methods of debridement on wound healing and rate of debridement.
Evidence on the effectiveness of early dressing removal compared with dressing surgical wounds beyond 48 hours post-surgery is based on very low quality evidence from only three randomised controlled trials.
There is contradictory evidence on the importance of dressing surgical wounds beyond 48 hours post-surgery. The aim of the review was to evaluate the effectiveness of removing a dressing covering a closed surgical incision site within 48 hours permanently or beyond 48 hours of surgery permanently with interim dressing changes allowed on surgical site infection.
Bone scaffolding may improve anatomical outcome compared with plaster cast alone but there is insufficient evidence to conclude on functional outcome and safety; or for other comparisons.
Surgical treatment of fractures of the distal radius can involve the implantation of bone scaffolding materials (bone grafts and substitutes) into bony defects that frequently arise after fracture reduction. This review assesses the evidence from randomised controlled trials evaluating the implanting of bone scaffolding materials for treating distal radial fractures in adults. [Resumen en español]
From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Given the continued lack of evidence for the use of pre-operative traction, the onus should now be on clinicians who persist in using pre-operative traction to either stop using it or to use it only in the context of a well-designed randomised controlled trial.
Following a hip fracture, traction may be applied to the injured limb before surgery. This review evaluates the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.
There is some evidence to support the use of percutaneous pinning, its precise role and methods are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.
A key method of surgical fixation for distal radial fractures is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. This review evaluates the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults. [Resumen en español]
Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long-term outcomes. There is insufficient evidence to establish what is the best method of surgical treatment or when to start mobilisation after either surgical fixation or hemiarthroplasty.
Shoulder fractures are common in older people. The management (including surgery) of fractures of the proximal humerus fractures varies widely. This review assessed the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.
Overall, there is insufficient evidence to determine which method of treatment (randomised trials assessed four treatment options) is the most appropriate for the treatment of isolated fractures of the ulnar shaft in adults. However, there is weak evidence (all trials were methodologically flawed and potentially biased) that in people with minimally displaced isolated fracture of the ulna, cast immobilisation of the elbow may offer no short-term advantage in respect of pain relief or fracture union, and may be associated with longer delay in return to work, when compared with the use of a cast or brace that immobilises only the forearm. This summary does not imply that practitioners should use cast immobilisation of the elbow.
Isolated fractures of the shaft of the ulna are often sustained when the forearm is raised to shield against a blow. This review assesses the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults.
There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.
Fracture of the distal radius ('broken wrist') can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation. This review evaluates the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults. [Resumen en español]
Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common.
Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest. This review compares conservative with operative treatment for fractures of the proximal femur (hip) in adults. [Resumen en español]
There remains insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Patient preferences and circumstances, and the risk of complications should also be considered.
Fracture of the distal radius is a common clinical problem particularly in elderly white women with osteoporosis. This review aims to determine the most appropriate conservative treatment for fractures of the distal radius in adults [Resumen en español]
Antibiotic prophylaxis for closed fracture surgery is an effective intervention. Single dose intravenous prophylaxis is effective if the agent used provides tissue levels exceeding the minimum inhibitory concentration over a 12-hour period. If the antibiotic chosen has a short half-life which may not allow minimum inhibitory concentrations to be exceeded throughout the period from incision to wound closure, the use of multiple dose regimens using a 12-hour dosage schedule is a satisfactory alternative.
Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections. The aim of this review is to determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.
There are a variety of intramedullary nails and associated techniques available and widely used, but it is not clear which is the best method since there is insufficient evidence to draw definitive conclusions.
Fractures of the tibial shaft (breaks in the bone situated in the long middle section of the tibia or shin bone) are mostly caused by high-energy trauma. These fractures are major injuries and can result in severe permanent disability. Other serious complications include infection and compartment syndrome, where a dangerous build-up of pressure from internal bleeding restricts or cuts off the blood supply to the surrounding tissues. Intramedullary nailing is commonly used for treating these types of fractures. This review assesses the effects (benefits and harms) of different methods and types of intramedullary nailing for treating tibial shaft fractures in adults.
There is no evidence available from randomised controlled trials to ascertain whether surgical intervention of humeral shaft fractures gives a better or worse outcome than no surgery.
Fractures of the shaft of the humerus account for 1% to 3% of all fractures in adults. The management of these fractures, including surgical and non-surgical interventions, varies widely. This review assesses and compare the effects of surgical versus non-surgical intervention for non-pathological fractures of the humeral shaft in adults.
This review highlights the limitations of the available evidence on therapeutic ultrasound for acute fractures in adults. Currently, the best assessment of the clinical effectiveness of low intensity ultrasound (LIPUS) for complete or stress fractures in adults does not support the routine use of this intervention in clinical practice.
The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a patient's recovery after a fracture. This review assesses the effects of LIPUS, high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults. The studies included in the review generally assessed upper limb fractures (the tibia being the most investigated bone).
There is insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults.
Ankle fractures usually affect young men and older women and the question of whether surgery or conservative treatment should be used for ankle fractures remains controversial. This review assessed the effects of surgical versus conservative interventions for treating ankle fractures in adults.
There is insufficient high quality evidence to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal (heel bone) fracture.
Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures, and are mostly caused by a fall from a height, and common in younger adults. Treatment can be surgical or non-surgical. However, there is clinical uncertainty over optimal management. This review assessed the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults.
There is insufficient evidence to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures.
Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve. This review assessed the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults.
There is a lack of evidence to inform on the timing of mobilisation, and specifically on the use of early mobilisation, after non-surgical or surgical treatment for adults with elbow fractures.
Falling on the outstretched arm can result in an elbow fracture. Loss of elbow function is a common problem with these fractures and can have major implications for functional capabilities. This review assessed the effects (benefits and harms) of early mobilisation versus delayed mobilisation of the elbow after elbow fractures in adults.
The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate. Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw.
Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants. This review assessed condylocephalic nails (e.g. Ender and Harris nails) compared to extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults.
Limited low quality and weak evidence from randomised controlled trials to support the use of advanced haemodynamic monitoring compared to protocol using standard measures such as CVP for perioperative fluid volume optimisation for patients with proximal femoral fracture exists. Research findings to this point are insufficient to show how one can best optimize fluid levels in the large number of people around the world suffering from hip fracture.
Proximal femoral fracture (PFF) is often managed by early surgical fixation with the main aim of reducing associated complications. The aim of the review was to assess the safety and effectiveness of various methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture.
Intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There is not enough evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.
Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. This review compared compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults.
Sliding Hip Screws (SHS) appear to be preferable for fixation of hip fractures in adults, given the markedly increased fixation failure rate of fixed nail plates.
Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This review compared different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults.
There were no major differences in patient survival or complications related to the operation, using different implants for internal fixation of intracapsular hip fractures, from the available evidence within randomised trials.
Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular (close to the hip joint) hip fractures. Implants are used to stabilise the bone during healing thereby reducing the chance of the bones slipping out of line. They consist of either screws or pins and may have an additional side plate attached, which is fixed to the bone. This review aimed to determine which implant is superior for the internal fixation of intracapsular proximal femoral fractures.
There is insufficient evidence on the effectiveness of osteotomy for internal fixation of trochanteric hip fractures. Additionally, there was inadequate evidence on the use of compression of the fracture, reaming of the femur, cement augmentation and hydroxyapatite coating of the lag screw.
Many different technical aspects of surgical fixation exist. In addition, substances have been used, either inserted at the fracture site or coated on the implant, to enhance the fixation of the fracture. The review aimed to investigate the effectiveness of new and existing interventions used for internal fixation of extracapsular hip fractures in adults.
There is still a lack of evidence on the effectiveness of replacement arthroplasty compared to internal fixation for extracapsular hip fractures in adults.
Internal fixation of extracapsular fractures, using extramedullary or intramedullary devices, has been developed over the last 50 years. Internal fixation may fail, particularly in unstable fractures. This has led some surgeons to try replacing the proximal femur with an arthroplasty in the treatment of an extracapsular femoral fracture. This review aimed to compare the relative effects (benefits and harms) of replacement arthroplasty versus internal fixation for the treatment of extracapsular hip fractures in adults.
Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures
There is little data from RCTs on the relative efficacy of open versus closed reduction of intracapsular fractures. Additionally, there was insufficient evidence on the efficacy of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.
Various surgical tactics, implants and ancillary manoeuvres are used in the fixation of intracapsular hip fractures to reduce the frequency of non-union and aseptic necrosis of the femoral head. This review aimed to compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures in adults.
There is insufficient evidence from RCTs on the type of surgery most effective in treating fractures of the radius and ulna in children. Also, there is lack of evidence on when surgery is a prerequisite.
Diaphyseal fractures of the radius and ulna are common in children particularly, from falls. The treatment modalities include surgical and non-surgical. This review aimed to assess the clinical effectiveness of surgical versus non-surgical interventions in addition to the different surgical interventions for the fixation of diaphyseal fractures of the radius and ulna in children.
Closed reduction methods for treating distal radial fractures in adults
There was insufficient evidence to establish the relative effectiveness of different methods of closed reduction used in the treatment of displaced fractures of the distal radius in adults. The three included randomised controlled trials did not assess functional outcome and only one reported on complications.
Fracture of the distal radius is a common injury in adults. Displaced fractures are usually reduced using closed reduction methods, which are non-surgical and generally comprise traction and manipulation. The resulting position is then stabilised, typically by plaster cast immobilisation. This review assessed the evidence for the relative effectiveness of different methods of closed reduction for displaced fractures of the distal radius in adults.
Different methods of external fixation for treating distal radial fractures in adults
There was insufficient evidence to determine the relative effects of different methods of external fixation for treating distal radial fractures in adults.
Fracture of the distal radius is a common injury. A surgical treatment is external fixation, where metal pins inserted into bone on either side of the fracture are then fixed to an external frame. The external component holds the bony fragments in position while the bone heals. Most of the differences between methods of external fixation are in the characteristics and design of the external component and in the placement of pins. This review assessed randomised controlled trials comparing different methods of external fixation for distal radial fractures in adults.
Surgical versus conservative interventions for treating fractures of the middle third of the clavicle
There is insufficient evidence on the effectiveness of surgical versus conservative treatments for acute middle third clavicle fractures. Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.
The majority of clavicle fractures are treated with non-surgical interventions, however, displaced clavicle fractures maybe considered for surgical therapy. The aim of the systematic review was to assess the effectiveness (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures.
There is evidence that antibiotics reduce the incidence of early infections in open fractures of the limbs.
Antibiotics are routinely used in clinical practice as an adjunct to other treatment and management interventions in the prevention of infections resulting from open limb fractures. The aim of the review was to identify any evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limb.
There is no evidence from randomised trials that resuscitation with colloids reduces the risk of death, compared with resuscitation with crystalloids, in patients with trauma or burns, or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of randomised trials.
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. This review assesses the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. [Resumen en español]
Tranexamic acid safely reduces mortality in bleeding trauma patients without increasing the risk of adverse events. Tranexamic acid should be given as early as possible and within three hours of injury, as treatment later than this is unlikely to be effective.
Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. This review quantified the effects of antifibrinolytic drugs on mortality, vascular occlusive events, surgical intervention and receipt of blood transfusion after acute traumatic injury. [Listen to podcast]
Primary (immediate) closure versus delayed closure for non-bite traumatic wounds within 24 hours post injury
There is no randomised controlled trial evidence to suggest the best timing for closure of traumatic wounds within clinical practice.
Traumatic wounds presenting within six hours of injury and considered 'clean' by the attending surgeon have traditionally undergone primary closure (closure soon after patient arrives at health facilities) with the rest undergoing delayed closure as a means of controlling potential infection. This review assessed the impact of time to wound healing and adverse effects of primary versus delayed closure in acute non-bite traumatic wounds presenting within 24 hours post injury.
Tissue adhesives for traumatic lacerations in children and adults
There is evidence to suggest that tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. Additionally, the tissue adhesives are helpful in terms of reducing pain, ease of use, and procedure time.
The use of tissue adhesives to close simple lacerations has been widespread as an alternative to standard wound closure procedures. This review aimed to identify the best available evidence on the effectiveness of tissue adhesives on the healing of traumatic lacerations in children and adults.
Methylprednisolone has been shown to enhance sustained neurologic recovery in a phase III randomised trial; findings replicated in a second trial. Therapy must be started within 8 hours of injury using an initial bolus of 30 mg/kg by IV for 15 minutes followed 45 minutes later by a continuous infusion of 5.4 mg/kg/hour for 24 hours. Further improvement in motor function recovery has been shown to occur when the maintenance therapy is extended for 48 hours. This is particularly evident when the initial bolus dose could only be administered 3 to 8 hours after injury.
Steroid treatment in the early hours after acute spinal cord injury (SCI) is aimed at reducing the extent of permanent paralysis during the rest of the patient's life. This review assessed randomised trials of steroids for human acute SCI.
The evidence available does not support the use of ganglioside treatment to reduce the death rate in spinal cord injury (SCI) patients. No evidence has yet emerged that ganglioside treatment improves recovery or quality of life in survivors.
SCI results in loss of feeling and movement. Care for people with SCI has improved, leading to an increase in survival rates. Attempts to improve patients' feeling and movement have involved the use of a wide range of treatments. Laboratory studies have suggested that gangliosides may have protective effects on nerves and even help them to re-grow. Clinical trials have taken place using gangliosides (usually GM1 ganglioside) for a number of neurological conditions. The aim of this review is to quantify the evidence for the effectiveness and safety of gangliosides when used to treat acute SCI.
Spinal fixation surgery for acute traumatic spinal cord injury
There is insufficient evidence to assess the benefits and harms associated with spinal fixation surgery in patients with traumatic spinal cord injuries.
Spinal fixation surgery is aimed at preventing re-injury by ensuring the spinal cord is fixed in a vertical position. If the spine is unstable following traumatic spinal cord injury (SCI), surgical fusion and bracing may be necessary to obtain vertical stability and prevent re-injury of the spinal cord from repeated movement of the unstable bony elements. This review assessed the differences in functional outcome and other commonly measured outcomes between people who have a spinal cord injury and have had spinal fixation surgery and those who have not.
Spinal immobilisation for trauma patients
There is no evidence from randomised controlled trials (RCTs) on the effectiveness of spinal mobilisations on neurological injury, spinal stability, mortality and adverse effects in trauma patients.
Spinal immobilisation encompasses the use of various devices and strategies aimed at stabilising the spinal cord following trauma with the aim of preventing damage to the spinal cord. This review assessed the effectiveness of various spinal cord immobilisations (including no immobilisation as a comparator) on patient outcomes such as neurological injury, spinal stability, mortality and adverse effects.
Spinal injuries centres (SICs) for acute traumatic spinal cord injury
There is insufficient evidence on the benefits or disadvantages of immediate referral versus late referral to spinal injuries centres in patients with acute traumatic spinal cord injury.
The majority of acute traumatic spinal cord injuries related complications occur within the first 24 hours and, therefore, spinal injuries centres (SICs) are thought to impact on the pre-transfer care of patients with spinal cord injuries. However, the majority of patients do not have access to such specialist centres. This review assessed whether immediate referral to an SIC results in better patient outcomes compared to delayed referral.
Mannitol therapy for raised intracranial pressure (ICP) may have a beneficial effect on mortality when compared with pentobarbital treatment, but it may have a detrimental effect on mortality compared with hypertonic saline. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators.
Mannitol is sometimes effective in reversing acute brain swelling, but its effectiveness in the ongoing management of severe head injury remains unclear. There is evidence that, in prolonged dosage, mannitol may pass from the blood into the brain, where it might cause increased ICP. This review assesses the effects of different mannitol therapy regimens, of mannitol compared with other ICP-lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury. [Resumen en español]
There is no evidence that hypothermia is beneficial in the treatment of head injury. Hypothermia should not be used except in the context of a high-quality randomised controlled trial with good allocation concealment.
Hypothermia has been used in the treatment of head injury for many years. This review assesses the effect of mild hypothermia for traumatic head injury on mortality and long-term functional outcome complications. [Resumen en español]
The increase in mortality with steroids in one trial suggest that steroids should no longer be routinely used in people with traumatic head injury (TBI).
TBI is a leading cause of death and disability. Corticosteroids have been widely used in treating people with TBI. This review quantifies the effectiveness and safety of corticosteroids in the treatment of acute TBI.
There is some evidence for the effectiveness of cognitive behavioural therapy (CBT) for treating acute stress disorder following mild traumatic brain injury (TBI) and of CBT combined with neurorehabilitation for targeting general anxiety symptomatology in people with mild-to-moderate TBI.
Psychological treatments are commonly used in the management of anxiety. Certain types of psychological treatments are well suited to needs of people with TBI. This review assesses the effects of psychological treatments for anxiety in people with TBI. [Resumen en español]
Psychosocial interventions for the prevention of disability following traumatic physical injury
There is no convincing evidence from RCTs for the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury. More RCTs with large sample sizes are needed.
The impact of traumatic physical injury is associated with various disabilities including physical, social functioning and mental health issues. The review assessed the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury.
Overall, there is a lack of evidence to inform clinical decisions for treating acute simple elbow dislocations in adults. Nonetheless, it should be noted that, while weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment did not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improved long-term function.
Dislocation of the elbow joint is a relatively uncommon injury and this review assessed the effects of various forms of treatment for acute simple elbow dislocations in adults.
Limited evidence supports primary surgery for young people engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine which treatment is better for other patient groups.
Acute anterior shoulder dislocation occurs where the top end of the humerus (the upper arm bone) is pushed out of the joint socket in a forward direction, usually as a result of an accident such as a fall and it is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to redislocation, especially in active young adults. This review compared surgical versus non-surgical treatment for acute anterior dislocation of the shoulder.
Evidence that supports the efficacy of damage control surgery (DCS) with respect to traditional laparotomy in patients with major abdominal trauma is limited and its benefit cannot be established. Patients with major trauma are usually unstable and are at risk of complications including bleeding, acidosis, hypothermia, and coagulopathy.
Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, DCS avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. This review assessed the effects of DCS compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma.
An accurate composite estimate of the benefit of helicopter emergency medical services (HEMS) could not be determined using the evidence identified in this review. The question of which elements of HEMS are most beneficial for patients has not been fully answered, and any HEMS-associated benefit could be the result of some combination of crew expertise, decreased prehospital time, and the fact that HEMS are an integral part of organized trauma systems in many developed countries. HEMS-associated benefits may include physician adjudicated launching criteria based on severity injury and mechanism, centrally coordinated launching algorithms with selected HEMS deployment, trauma volumes at receiving trauma centres, and the ability of the helicopter to transport patients in areas inaccessible by ground vehicles or prohibitively distant from trauma centres. This review stresses the importance of triage criteria since the benefits of HEMS may be greatest for patients with serious but potentially survivable injuries. Ideal dispatch criteria and triage guidelines to ensure the efficient use of helicopters remain elusive.
Although helicopter emergency medical services (HEMS) transport are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit. This review assessed whether helicopter emergency medical services transport (HEMS) was associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma.
There is evidence that tranexamic acid reduces blood transfusion in patients undergoing emergency or urgent surgery.
Emergency or urgent surgery, which can be defined as surgery which must be done promptly to save life, limb, or functional capacity, is associated with a high risk of bleeding and death. Antifibrinolytic agents, such as tranexamic acid, inhibit blood clot breakdown (fibrinolysis) and can reduce perioperative bleeding. Tranexamic acid has been shown to reduce the need for a blood transfusion in adult patients undergoing elective surgery but its effects in patients undergoing emergency or urgent surgery is unclear. This review assesses the effects of tranexamic acid on mortality, blood transfusion and thromboembolic events in adults undergoing emergency or urgent surgery.
There is a lack of evidence from randomised controlled trials (RCTs) for the use of surgical over non-surgical interventions such as observation for the management of people with abdominal trauma.
There is uncertainty about the best management approach (surgical and non-surgical) for abdominal injuries. The aim of the review was to assess the effects of surgical and non-surgical interventions in the management of abdominal trauma.
There is no evidence from randomised controlled trials on the benefits and harms for the use of antibiotics for abdominal trauma. Due to the lack of randomised controlled trials on the effectiveness of antibiotics for abdominal injuries, future research should focus on designing a randomised controlled trial to assess the relative effectiveness.
The use of antibiotics for penetrating abdominal trauma is based on expert opinion rather than evidence from randomised controlled trials. Studies with 33% to 57% infection rate with intra-operative antibiotic administration and 30% to 70% infection rate with only post-operative antibiotic administration have been reported. The aim of the review was to assess the effectiveness (benefits and harms) of prophylactic antibiotics for penetrating abdominal injuries.
There was insufficient evidence available from trials comparing regional versus general anaesthesia for surgical repair of hip fractures in adults to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.
The majority of people with hip fracture are elderly and are treated surgically, requiring anaesthesia. The most common types of anaesthesia are 'general' and 'spinal'. This review assessed different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.
There was insufficient evidence to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than intravenous regional anaesthesia (IVRA), and can compromise reduction.
Fracture of the distal radius (wrist) is a common clinical problem, particularly in women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment. This review asssessed the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults.
There is evidence that multiple injection techniques using nerve stimulation for axillary plexus block produce more effective anaesthesia than either double or single injection techniques. There is insufficient evidence for a significant difference in other outcomes, including safety.
Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. Successful blocking of the nerves produces a numb and limp arm that enables pain-free surgery. This review compared the relative effects of single, double or multiple injections for axillary block of the brachial plexus for distal upper limb surgery.
There is still insufficient evidence from RCTs on the efficacy and safety of topical anaesthetics for repair of dermal laceration. Topical anaesthetics are, however, possibly an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations.
Topical local anaesthetics are used in providing effective analgesia in several superficial surgeries such as repair of dermal lacerations. The aim of this review was to compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for the repair of dermal lacerations. Additionally, to assess the efficacy and safety of several single or multi-component topical anaesthetics to identify cocaine-free topically applied anaesthetics that may provide equivalent analgesia to those containing cocaine.
There is evidence to support use of pulse oximetry for detecting hypoxaemia and other related events. However, there is no evidence to suggest that oximetry affects patient related outcomes.
The use of pulse oximetry in perioperative monitoring is very common in routine clinical practice. The aim of the review was to assess the effects of perioperative monitoring with pulse oximetry and to identify the adverse outcomes that might be prevented or improved by the use of pulse oximetry.
Single dose oral analgesics for acute postoperative pain in adults
There is a large amount of evidence available from thirty-five reviews on the efficacy of single dose oral analgesics for acute postoperative pain in adults. Additionally, this overview of reviews found a wealth of information on drugs that had no data, inadequate data or unreliable results as a result of publication bias.
Oral analgesics are used for acute pain relief in adults following surgery. The aim of this overview of Cochrane Reviews was to summarise all available data (from existing reviews) on the efficacy (including benefits and harms) of single dose oral analgesics in acute postoperative pain.
Nebulised or inhaled salbutamol, or IV insulin-and-glucose are the first-line therapies for the management of emergency hyperkalaemia that are best supported by the evidence. Their combination may be more effective than either alone, and should be considered when hyperkalaemia is severe. When arrhythmias are present, a wealth of anecdotal and animal data suggests that IV calcium is effective in treating arrhythmia.
Hyperkalaemia occurs in outpatients and in between 1% and 10% of hospitalised patients. When severe, consequences include arrhythmia and death. This review evaluates evidence from randomised trials informing the emergency management of hyperkalaemia. [Resumen en español]
There is insufficient evidence to determine whether tidal peritoneal dialysis is superior to any other mode of peritoneal dialysis for the treatment of patients with acute kidney injury.
Acute kidney injury is associated with substantial morbidity and mortality. Recent studies have shown that dialysis dose was a major factor associated with patient survival. Unresolved questions persist about which mode of peritoneal dialysis should be used for most patients with acute kidney injury. The one RCT identified by this review evaluated tidal peritoneal dialysis for the treatment of patients with acute kidney injury and was not designed to enable assessment of clinical outcome measures of efficacy.
There is inconclusive evidence for benefits or increased harm on the use of various interventions (including dopamine and analogues, diuretics, ACE inhibitors, erythropoietin, intravenous fluid and atrial natriuretic peptide) for protecting renal function in the perioperative period for patients undergoing surgery. Also, many criteria used to diagnose acute renal damage suffered from low methodological quality.
There are various interventions used for protection of kidney function in persons undergoing surgery. The aim of the review was to determine the effectiveness of various interventions for protection of kidney function during the perioperative phase.
Xpert used as an initial diagnostic test for TB detection and rifampicin resistance detection in patients suspected of having TB, MDR-TB, or HIV-associated TB is sensitive and specific. Xpert may also be valuable as an add-on test following microscopy for patients who have previously been found to be smear-negative. An Xpert result that is positive for rifampicin resistance should be carefully interpreted and take into consideration the risk of MDR-TB in a given patient and the expected prevalence of MDR-TB in a given setting.
Accurate and rapid detection of tuberculosis (TB) and drug resistance are critical for improving patient care and decreasing the spread of TB. Xpert® MTB/RIF assay (Xpert) is a rapid, automated test that can detect both TB and rifampicin resistance, within two hours after starting the test, with minimal hands-on technical time, but is more expensive than conventional sputum microscopy. This review assessed the diagnostic accuracy of Xpert for pulmonary TB (TB detection), both where Xpert was used as an initial test replacing microscopy, and where Xpert was used as an add-on test following a negative smear microscopy result. It also assessed the diagnostic accuracy of Xpert for rifampicin resistance detection where Xpert was used as the initial test, replacing conventional culture-based drug susceptibility testing. The assessment was made in the adult population suspected of having pulmonary TB or multidrug-resistant TB (MDR-TB), with or without HIV infection. Most studies were performed in high TB burden countries.
There is insufficient evidence from randomised controlled trials (RCTs) on the efficacy of various antibiotic treatments in patients who are older than 12 years of age with a diagnosis of community acquired pneumonia (CAP).
CAP is associated with very high mortality and morbidity rates, particularly in the elderly population. Antibiotic treatment is one of the most common methods of treatment for CAP although it is often associated with increased antibacterial resistance and adverse effects. The aim of this review was to summarise all available evidence from RCTs on the efficacy of various antibacterial treatments for CAP in participants older than 12 years.
The evidence from RCTs on the effectiveness of various antibiotics for community-acquired pneumonia (CAP) in children varies. For the treatment of patients with CAP in ambulatory setting, amoxycillin can be used as an alternative to co-trimoxazole. The limited data available on other antibiotics suggest that co-amoxyclavulanic acid and cefpodoxime may be used as alternatives in second-line therapy. Children with severe pneumonia but without hypoxaemia may be treated with oral amoxycillin in ambulatory settings. Additionally, children hospitalised with severe or very severe pneumonia may be given penicillin/ampicillin plus gentamycin as the preferred choice to chloramphenicol. Other alternative antibiotics for severe and very severe pneumonia are co-amoxyclavulanic acid and cefuroxime that may be used as second-line therapies.
Pneumonia in children is associated with high mortality rates, particularly in low income settings or countries. Early administration of antibiotics is associated with improved health outcomes. The aim of this review was to identify effective antibiotic drug therapies for community acquired pneumonia (CAP) of varying severity in children through a comparison of various antibiotics.
There is still insufficient evidence on efficacy and safety of corticosteroids in patients with pneumonia. The current available evidence suggests that corticosteroids in patients with pneumonia are usually helpful in accelerating the time to symptom resolution.
The use of corticosteroids is associated with improved immune regulation, stress response, electrolyte balance, carbohydrate and protein catabolism, however, their benefit in patients with pneumonia is still unclear. The aim of this review was to assess the efficacy and safety of corticosteroids in the treatment of pneumonia.
There is insufficient evidence from randomised controlled trials (RCTs) to support the use of zinc as an adjunct to antibiotics in the treatment of pneumonia in children aged between 2 and 59 months.
Acute respiratory infections particularly pneumonia, are responsible for high mortality in low income countries among children aged between 2 and 59 months. The evidence for the use of zinc as an adjunct to antibiotics in the treatment of pneumonia is rather varied. The aim of the systematic review was to evaluate zinc supplementation as an adjunct to antibiotics in the treatment of (clinical recovery) pneumonia in children aged between 2 and 59 months.
There is some evidence to suggest that some low cost and simple interventions such as hand washing would be useful in helping to reduce the transmission of epidemic respiratory viruses. Implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. However, the long term implementation of these interventions poses a challenge where no threat of epidemic is detected.
Viral pandemics and epidemics of acute respiratory infections like influenza or severe acute respiratory syndrome are a global threat. The use of vaccinations and antiviral medications may not necessarily stop the transmission of viruses. The aim of the review was to examine the effectiveness (harms and benefits) of physical interventions to interrupt and reduce the spread of respiratory viruses.
There is insufficient evidence on the effect of nasal versus oral replacement of enteral feeding tubes on growth and development, food tolerance, or incidence of adverse events in low birth weight or preterm babies. One small trial found no evidence of an effect on the time taken to establish enteral feeding or the time taken to regain birth weight, however the trial may have been too small to detect modest effect sizes. Another small trial found no statistically significant effects on incidence of apnoea, desaturation, and bradycardia during the study period.
In preterm or low birth weight infants, enteral feeding is a preferred method of nutrition. The enteral tubes can either be used orally (mouth) or inserted in to the nose. However, both methods of placement are associated with adverse events. For example, nasal placement is associated with restrictions in respiration whereas, oral tubes are associated with vagal stimulation, localised irritation and are often prone to displacement. The aim of this review was to determine the effect of nasal versus oral placement of enteral feeding tubes on food tolerance, growth and development and the incidence of adverse events in preterm or low birth weight infants.
There is evidence from randomised controlled trials (RCTs) suggesting that delayed introduction of progressive feeding beyond four days after birth is not associated with increased risk of developing necrotising enterocolitis in very preterm, very low birth weight infants and growth restricted infants. However, delaying the introduction of progressive enteral feeds results in the delay of establishing full enteral feeds although the clinical importance of this is still uncertain.
The introduction of enteral feeds for very preterm (< 32 weeks) or very low birth weight (< 1500 g) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis. However, delayed enteral feeding may be associated with diminished gastrointestinal functional adaptation thus increasing the need for prolonged parenteral feeding with its health associated problems. The aim of this review was to determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very preterm or very low birth weight infants.
The available evidence on the reduction in time taken for infants to attain an adequate energy intake as a result of use of dilute formula is based on three small low quality studies. No evidence was reported on outcomes such as gastrointestinal problems. Also, on the outcome of feeding intolerance, no evidence of important differences between the dilute and full strength formulae was found.
The aim of the review was to assess the effects of dilute versus full strength formulae on the incidence of necrotising enterocolitis, feeding intolerance, weight gain, length of stay and time to achieve full calorie intake in exclusively formula-fed preterm or low birth weight infants. Additionally, it aimed to assess the effects of different dilution strategies.
There is some evidence to support the use of alternating and combination therapy compared with monotherapy alone at reducing temperatures in children with a fever. However, on the outcome of child discomfort, the evidence still remains unsatisfactory. Furthermore, there is insufficient evidence to ascertain which combination or alternative therapy would be more useful at treating fevers in children.There were no serious adverse events reported that were directly attributed to the medications used.
There is inconsistent evidence on the effects of using monotherapy compared to combination therapies for the treatment of fever in children. The aim of the review was to assess the safety and effectiveness of combining paracetamol and ibuprofen or alternating them as consecutive treatments compared with monotherapy for treating fever in children.
Ready-to-use therapeutic food for home-based treatment of severe acute malnutrition in children from six months to five years of age
There is insufficient evidence from clinical trials on the effectiveness of home-based ready to use therapeutic food (RTUF) in comparison to the standard diet on clinical outcomes of recovery, relapse and mortality in children with severe acute malnutrition. Either RUTF or flour porridge can be used to treat children at home depending on availability, affordability and practicality. Pragmatic randomised controlled trials of HIV-uninfected and HIV-infected children with severe acute malnutrition are needed.
Malnutrition is associated with increased mortality rates and health associated illnesses. The aim of the systematic review was to assess the effectiveness (benefits and harms) of home-based ready to use therapeutic food (RTUF) on recovery, relapse and mortality in children with severe acute malnutrition.
Specially formulated foods for treating children with moderate malnutrition in low- and middle-income countries
There is moderate to high quality evidence on the effectiveness of lipid-based nutrient supplements and blended foods for treating children with moderate acute malnutrition. Although, lipid-based foods were associated with increased recovery rates compared with blended foods; lipid-based foods did not reduce mortality rates or the risk of progression to severe acute malnutrition. There is scarcity of data from Asia despite the high prevalence of moderate acute malnutrition.
Various treatment approaches for children with moderate malnutrition in low and middle income countries exist. However, there is no consensus on the most effective treatment approach. The aim of the systematic review was to assess the effectiveness (benefits and harms) of various specially formulated foods for children with moderate acute malnutrition in low and middle income settings, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective.
Intermittent iron supplementation for improving nutrition and development in children under 12 years of age
There is evidence to suggest that intermittent iron supplementation when compared to placebo or no intervention, is effective in reducing the risk of anaemia in children ≤12 years of age. However, daily supplementation is more effective than intermittent iron supplementation in preventing and controlling anaemia. Intermittent iron supplementation maybe used in settings where daily supplementation cannot be applied.
The use of daily iron supplements in children ≤12 years of age has been associated with several side effects. The use of intermittent supplementation has been proposed as an effective and safe alternative. The aim of the review was to assess the effects of intermittent supplementation alone or in combination with other vitamins and minerals on nutritional and developmental outcomes in children ≤12 years of age compared with placebo, no intervention or daily intervention.
Community-based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries
There is insufficient evidence to support the community-based supplementary feeding for promoting the growth of children under 5 years old in developing countries. This is because of the scarcity of available studies and their heterogeneity, which makes it difficult to reach any firm conclusions. Meanwhile, children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children.
The effectiveness of community supplementary feeding is still unclear due to the lack of evidence from large well conducted randomised controlled trials. The aim of the review was to evaluate the effectiveness of community based supplementary feeding for promoting the physical growth of children under five years of age in low- and middle-income countries (LMICs).
Lay health workers may provide benefits in promoting immunisation uptake and breastfeeding, improving tuberculosis cure rates, and child health when compared to usual care. There is insufficient evidence to draw any conclusions for other health issues.
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues, however, little is known about the effectiveness of LHW interventions. This review assesses the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases. The evidence had considerable diversity with regards to country, targeted health issue and aims.
Image credit: Will and Deni Mcintyre/Science Photo Library
Date published: 10 March 2010; updated 21 December 2010, 25 October 2011, 9 December 2011, 20 December 2012, 1 February 2013, 14 Februay 2013, 21 May 2013, 14 June 2013, 29 July 2013, 02 August 2013, 09 September 2013 and 06 November 2013. Last updated 03 January 2014 to include 5 new reviews and 2 updated reviews.
Contact: Cochrane Editorial Unit (firstname.lastname@example.org) for suggestions for additions or changes to this Special Collection or queries about the included Cochrane Reviews; and Evidence Aid (email@example.com) for information about this initiative.