bestBETs

23-year-old otherwise healthy male presents to the ED for an injury to the distal portion of his right 3rd digit. He was working at a construction site when his finger got crushed between two large cement barriers. This resulted in a traumatic amputation of the distal tip of the digit. The distal tip is not salvageable. There is some exposed bone and not enough tissue to create a flap to close the wound. The wound is also grossly contaminated. You will need to thoroughly irrigate the wound and remove the bone down prior to closing the wound with a skin flap. You consider the most effective method of local anesthesia.

A 77-year-old female with a history of type 2 diabetes, hypertension, and paroxysmal atrial flutter presents to the emergency department after syncope and collapse. She was walking in her home when she began to feel lightheaded and was unable to reach the counter before losing consciousness. She has not missed any medications, and the initial workup in the emergency department did not identify an apparent cause of syncope. The treating ED clinician arranges admission for cardiac monitoring and observation. He wonders if a specialist service might reduce hospital admissions as well as adverse events.

An adult male is involved in a high-speed frontal MVC, sustaining significant facial injuries. You are part of the trauma team receiving him in the resuscitation room. On arrival he is sedated, intubated and ventilated. On primary survey, despite your best efforts, you cannot fully examine his eyes or pupillary response due to significant facial deformation. He undergoes a CT trauma series from head to pelvis and is reported as having unilateral proptosis and retrobulbar haematoma which the radiologist reports as ‘suggestive of orbital compartment syndrome’. The receiving ICU team ask whether canthotomy and cantholysis should be performed before he is transferred for further management?

An 88-year-old man from a care home arrives at the Emergency Department with abnormal vital signs indicating septic shock. Assessment reveals pneumonia and new-onset atrial fibrillation (AF). The patient’s relatives are concerned about stroke risk from AF and ask if anticoagulation should be started immediately. The clinical team explains this is a complex decision in sepsis-induced new-onset AF due to uncertain evidence, and will review current literature to guide shared decision-making.

A 34-year-old comes to the ED with one day of abdominal pain with mild anorexia but no fevers. Pain is well controlled with IV medication in the ED and CT of the abdomen and pelvis shows possible developing appendicitis. The patient would like to go home since he is feeling better, and as you discuss return precautions and appropriate follow-up care. You wonder how best to provide discharge instructions to ensure the patient understands your advice.

A 23-year-old male with no significant past medical history presents to the emergency department due to concerns that he may have contracted a sexually transmitted infection (STI). The patient reports that he has been sexually active with multiple new partners which he met using a dating app. He denies any systemic or genitourinary symptoms, but states that he just felt like he should “get checked out”. He states that he uses condoms infrequently and has never been treated for an STI in the past. He is a student at the local university and does not have a primary care physician. As his physician, you wonder if this patient would benefit from prophylactic antibiotics given his high-risk sexual behavior.

A 42-year-old man with past medical history of Type II diabetes presents to the emergency department for nausea and vomiting. Despite first-line antiemetics, he continues to experience nausea and vomiting. Initial lab workup demonstrates an initial blood glucose of 325, pH of 7.15, bicarbonate of 14, elevated serum and urine ketones, and an anion gap of 18. You consider whether this patient’s condition could be treated with subcutaneous insulin rather than intravenous insulin infusion.

A 28-year-old male presents to the emergency department after blunt facial trauma. He works at a construction site and a heavy beam struck his face. Your workup demonstrates maxillary fractures, and plastic surgery recommends non-operative management of these fractures. You wonder if antibiotic administration would help prevent facial fracture associated infection.

Paramedics were called to the home of a woman found lying on the floor unresponsive. The patient's family stated that she may have used drugs. Her Glasgow Coma Score was 5. The patient's pupils were constricted and non-reactive. Glucose level was 84. An IV was established and the patient received a total of 5 mg of Narcan en route to the hospital. By the time the patient arrived at the hospital, she had become alert and responsive. The patient's vital signs were stable and her physical exam was normal. She told the ED nurse that she had smoked heroin. A urine drug screen was performed and was positive for both opiates and cocaine. As the treating physician you consider how long you should monitor the patient before discharge from the ED.

A 50-year-old female with stage 4 chronic kidney disease (CKD) presents to the emergency department with shortness of breath and chest pain. Workup shows an ECG with a normal sinus rhythm and non-specific ST-T wave changes. She is at low risk for aortic dissection (ADD-RS = 1), and her D-dimer was normal (400 ng/mL). Given her CKD, you wonder if there is a way to rule out an acute aortic dissection without having to give a contrast load for a computed tomography (CT) angiogram. Will a normal D-dimer and POCUS rule out acute aortic dissection with certainty?

A 42-year-old male with longstanding history of alcohol use disorder present to the ED with tremors, agitation and elevated CIWA score. You initiate symptom-triggered lorazepam (Ativan) per protocol but wonder whether phenobarbital could reduce the risk of ICU transfer, improve sedation control, and shorten the patient's ED stay.

A 72-year-old presents with a late dislocation of a primary total hip arthroplasty (THA) (≥1 year after index surgery). After closed reduction, the team is considering post-reduction bracing (hip abduction brace or immobilisation such as a knee immobiliser/cricket splint) to prevent recurrence.

A 74-year-old man at a district general hospital ED has sudden onset abdominal and back pain, hypotension, and a pulsatile abdominal mass. You perform a POCUS scan and identify an AAA. CT imaging is not working. You wonder if doing a FAST exam to look for free intraperitoneal fluid (an indicator of rupture) will increase confidence in the diagnosis of rupture and help expedite transfer to a vascular surgery center.

A 13-year-old child presents to the Emergency Department with an anterior shoulder dislocation. You must decide between intranasal fentanyl or inhaled methoxyflurane (Penthrox) for procedural analgesia. Which option provides better pain relief and overall patient experience?

A 68 year old man has been mechanically ventilated in the intensive care unit for six days following presentation with severe community acquired pneumonia. He is now established on a spontaneous ventilation mode and passed a spontaneous breathing trial this morning. The nursing team perform a cuff leak test (deflating his endotracheal tube cuff) which shows no air leak, suggesting a high risk of laryngeal oedema and potential extubation failure. On the ward round, the ICU consultant suggests delaying any trial of extubation to administer prophylactic corticosteroids. You have not seen this practice before. Although you understand that airway swelling can cause stridor and increase the risk of extubation failure, you are also aware that that corticosteroids carry risks (e.g. increased infection) and worry that delaying a trial of extubation may increase the risk of iatrogenic lung injury. The consultant is also not clear on the agent, dose, timing and duration of a steroid course for this indication. You decide to get a coffee after the ward round and review the literature.

A 45-year-old male presents to the Emergency Department with an Altered Mental State. He is acutely agitated and aggressive, and attempts at verbal de-escalation are unsuccessful. A decision to pharmacologically sedate is made. As benzodiazepines are commonly used first line to sedate acutely agitated patients, you wonder whether using them as a single agent, or in combination with an antipsychotic, will result in more effective (faster and minimal need for re-sedation) and safer (fewer adverse events) sedation.

A 42-year-old man presents with dysphagia, hemisensory loss and ispsilateral neck pain. CT angiography revealed an occlusive dissection of the left internal carotid artery.

A 68-year-old man presents to the emergency department after sustaining blunt trauma to his chest after a fall. Imaging confirms two rib fractures with no other associated injuries. He is discharged home with analgesia and written advice. You wonder whether the use of incentive spirometry (IS) after discharge could reduce the risk of subsequent pulmonary complications.