bestBETs

A 71-year-old female presents to the ambulance service with exacerbation of COPD. She is short of breath and has a significant expiratory wheeze. You treat the patient with nebulised salbutamol, but only have the oxygen driven jet nebuliser available. Following advice from the British Thoracic Society, an oxygen driven nebuliser should be limited to 6 minutes in patients with COPD to limit the risk of hypercapnic respiratory failure. You wonder if the oxygen driven jet nebuliser can deliver the recommended 5mg dose of salbutamol within this 6-minute period.

A 72‑year‑old with known COPD (FEV₁ 45% predicted) presents to ED with three days of worsening dyspnoea and productive cough. After oxygen titrated to target saturations, back‑to‑back salbutamol/ipratropium nebulisers, and oral prednisolone, he remains breathless with SpO₂ 90–91% on 2 L/min. You consider IV magnesium sulfate (2 g) as an adjunct, recalling its bronchodilatory role in severe asthma, and wonder whether the evidence supports improved outcomes in AECOPD.

A 35 year-old woman attends the ED with a significant laceration to her face that requires closure with sutures. She is travelling at present with plans to fly to Asia in the next few days, has no registered GP and is uncertain of how she can be followed up over the next few weeks. You prepare to close her laceration with 6-0 non-absorbable interrupted sutures as you have been previously taught that this method provides optimal conditions for wound healing and reduces the risk of complications. As you are gathering equipment, your supervising consultant asks whether she could get a similar result from absorbable sutures, saving her the need for further downstream healthcare resource use. You ask the patient to wait for 5 minutes while you grab a coffee and consult the evidence supporting this option.

You are a doctor working with an enhanced pre-hospital care team, tasked to a severely injured patient. They are comatose with a head injury and require a pre-hospital emergency anaesthetic. You consider inserting an arterial line for invasive blood pressure monitoring to optimise your pre-hospital emergency anaesthesia (PHEA) and/or improve your haemodynamic monitoring. You are cognisant however of minimising time on scene and wonder whether this may delay their transport to definitive care.

A 58‑year‑old man suffers a witnessed out‑of‑hospital cardiac arrest. After initial defibrillation and high‑quality CPR, he is brought to the Emergency Department where an arterial line is rapidly inserted. Despite optimal guideline‑based chest compressions and standard epinephrine intervals, the arterial waveform shows very low diastolic pressures, suggesting inadequate coronary perfusion. Your team considers titrating CPR to haemodynamic targets—for example SBP ≈ 100 mmHg and/or CPP > 20 mmHg—as described in experimental models. You question whether goal‑directed intra‑arrest CPR is superior to fixed‑depth CPR. AHA/ILCOR education material acknowledges that BP‑guided CPR may be reasonable if an arterial line already exists, but provides no numeric recommended targets. Current ILCOR consensus states there is insufficient human evidence to recommend specific haemodynamic targets during CPR.

A 44-year-old woman present to ED with severe gastrointestinal bleeding. She is actively vomiting blood and has a reduced level of consciousness requiring urgent intubation. Standard airway assessments such as Mallampati scoring are impossible due to persistent vomiting and poor cooperation. You consider calling for early senior anaesthetic help and wonder if there is any evidence supporting the use of POCUS to perform an initial assessment of the patient’s airway.

You are seeing several adult patients with poor oral hygiene and periodontal disease. Some ask whether untreated gum disease could increase their risk of heart disease, including coronary artery disease and endocarditis. You want to know if scientific evidence supports a link between oral conditions and cardiovascular disease.

A 55-year-old patient in cardiac arrest has received 3 unsynchronised shocks but remains in ventricular fibrillation. You must decide whether to continue standard defibrillation at the same energy or attempt dual sequential defibrillation if the patient remains in VF at the next rhythm check.

A 7-year-old presents to the Emergency Department with 48 hours of sudden left-sided lower motor neuron facial weakness. The features are consistent with Bell’s palsy. You must decide whether to start oral prednisolone or only provide supportive care alone.

A 27-year-old patient is brought into the emergency department (ED) after being found unconscious by a passerby. On clinical examination, the patient has reduced consciousness, pinpoint pupils, evident track marks and a reduced work of breathing. The patient is known to misuse nitazenes, a highly potent synthetic opioid. You suspect a possible nitazene overdose. You are aware that naloxone is first-line at reversing the effects of synthetic opioid overdoses. Still, you are wondering whether you need to use a high dose of naloxone to treat this patient’s overdose due to the higher potency of nitazenes.

An adult patient presents to the emergency department with fever and myalgia 5 days after returning from a malaria-endemic region of Nigeria. They have no past medical history. A rapid diagnostic test for malaria is performed at triage and is negative. You wonder whether malaria can be excluded on this basis, or whether expert microscopy is still required.

An adult patient presents to the emergency department with a displaced distal radius fracture after a fall on an outstretched hand. The fracture requires manipulation, but the department is too busy to facilitate procedural sedation. You wonder what your likelihood of a successful reduction would be using a haematoma block and whether there is an increased risk of adverse events.

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.