Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon in tricyclic overdose

Extracorporeal treatment for tricyclic antidepressant poisoning: recommendations from the EXTRIP Workgroup

The Extracorporeal Treatments In Poisoning (EXTRIP) workgroup was formed to provide recommendations on the use of extracorporeal treatments (ECTR) in poisoning. Here, the workgroup presents its results for tricyclic antidepressants (TCAs). After an extensive literature search, using a predefined methodology, the subgroup responsible for this poison reviewed the articles, extracted the data, summarized findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Blinded votes were compiled, returned, and discussed in person at a meeting. A second vote determined the final recommendations. Seventy-seven articles met inclusion criteria. Only case reports, case series, and one poor-quality observational study were identified yielding a very low quality of evidence for all recommendations. Data on 108 patients, including 12 fatalities, were abstracted. The workgroup concluded that TCAs are not dialyzable and made the following recommendation: ECTR is not recommended in severe TCA poisoning (1D). The workgroup considers that poisoned patients with TCAs are not likely to have a clinical benefit from extracorporeal removal and recommends it NOT to be used in TCA poisoning.

Tachyarrhythmias and defibrillation

Although cardiac arrhythmias less commonly cause hemodynamic compromise in children than in adults, prompt recognition and treatment of arrhythmias remain an important part of pediatric resuscitation because of the availability of specific, effective therapies. This article summarizes the 2005 American Heart Association Guidelines for Pediatric Advanced Life Support regarding tachyarrhythmias, including treatment with antiarrhythmics and direct current countershock therapy, and provides an update of recent literature since the guidelines were published.

New developments in antidotes

Although some antidotes are rarely used, they have an important, potentially life-saving role in the treatment of toxic exposures. The timely and judicious use of an antidote can prevent death and shorten hospitalization as well as reduce the patient's pain and suffering. Although their importance is recognized, sufficient stocking of antidotes remains a problem.