Archives: BETs

A patient presents with a fingertip injury that includes a laceration to the nail bed. The X-ray demonstrates a fracture of the distal phalanx. Should the patient receive antibiotics to prevent osteomyelitis, after appropriate wound toilet and closure?

An 83-year-old restrained female passenger involved in a head-on collision is brought to the ED via helicopter. The ED evaluation reveals an unidentified esophageal intubation. On questioning the helicopter paramedic crew, it is found that a carbon dioxide indicator was not used in the field.

A 70 year-old lady presents to the emergency department(ED) with 2 days of fever, shortness of breath, and cough productive of green sputum. CXR confirms right basal pneumonia. She requires oxygen therapy and admission. It is busy in the ED. This patient has been waiting for 3.5 hours. Her bed is ready in the ward. You wonder if giving her the antibiotics now would affect her clinical outcome in terms of time to clinical stability, length of hospital stay, and mortality.

A 38 year-old teacher presents to the ED with bilateral pneumonia. On arrival he is confused, SpO2 is 91% on air, RR is 38/min and BP is 105/59mmHg. You start treatment for severe CAP with a CURB-65 score of ≥3 and inform ITU. Would the addition of steroids to antibiotics improve this patient’s mortality and shorten his length of stay in hospital?

A 63 year old lady presents to the Accident and Emergency department with pain in her right wrist after a fall onto an outstretched hand. She is extremely tender over her distal radius and has poor range of movement. An x-ray of her wrist confirms a diagnosis of Colles fracture. Whilst in the plaster room, the question is raised of which position is best in order to immobilise her wrist in a plaster cast.

A 25 year old chap with a history of spontaneous pneumothorax presents to the ED with a further large pneumothorax. Unfortunately, attempted aspiration fails due to a permanent leak, and he requires an intercostal drain. He has had a chest drain inserted in the past and admits that it was very painful whilst the drain was in situ. You wonder whether administration of local anaesthetic down the tube would provide good analgesia, and decrease the need for oral/iv meds.

A 60 year old man attends the ED complaining that a fish bone has got stuck in his throat. Clinical examination rules out impaction within the pharynx so you are concerned that the bone has become impacted within the oesophagus. Prior experience tells you that oesophageal abrasions secondary to ingested bones can often mimic impaction, that rigid oesophgoscopy (the definitive investigation) carries a significant mortality and morbidity rate, and that the most readily available non-invasive investigations, lateral neck and chest x-rays, are often unreliable. You wonder whether a CT scan of the neck would be a more accurate non-invasive tool?

An obese, 12 year old girl comes for review in clinic. A year ago when you first saw her you gave comprehensive advice regarding dietary modification, and exercise. She has continued to gain weight with a BMI greater than the 99th centile. You arrange for an oral glucose tolerance test to be performed which shows her to be hyperinsulinaemic with fasting insulin of 20 mIU/l, and 120 min insulin of 200 mIU/l. She has normal fasting and 120 min blood glucose measurements. You wonder whether prescribing metformin may help her to lose weight.

John, a 4 year old boy, has been mechanically ventilated for three days during recovery from a blunt chest trauma. According to his level of ventilator support, he is considered to be ready to be extubated. The previous patient had to be reintubated as a result of postextubation laryngeal oedema. You wonder whether corticosteroids may reduce this risk of extubation failure.

An 8 month old baby girl, of Eastern European parents, presents with a week long history of coryzal symptoms for which she has been taking oral antibiotics. She is pyrexial, irritable, and unwell on examination. She is admitted with a clinical diagnosis of meningitis and commenced on intravenous cefotaxime. A lumbar puncture is performed and microscopy reveals an elevated number of white cells (majority lymphocytes), low glucose, and protein of 0.9 g/l. She does not respond to conventional therapy and nothing is growing on CSF or blood culture. There is no history of contact with tuberculosis and she was vaccinated with a single dose of BCG at birth. She was an intrauterine growth retarded baby but had no subsequent problems. The possibility of tuberculous meningitis is discussed and a colleague tells you that there is contradictory evidence about the efficacy of neonatal BCG vaccination against pulmonary tuberculosis. You question the efficacy of neonatal BCG vaccination against tuberculous meningitis.

A child attends the emergency department with an acute ankle injury. Clinically they are tender over the ankle and either partially or non weight bearing. A fracture is suspected but the xray appears normal. You wonder if the child could still have an occult fracture and wonder whether an USS would be of benefit for this child

A seventy-five year-old man with no significant previous medical history presents to the Emergency Department during the night with a two-hour history of typical cardiac chest pain. ECG demonstrates 2mm ST elevation in leads II, III and aVF with reciprocal ST depression in aVL. You diagnose acute inferior ST elevation myocardial infarction (STEMI). Primary angioplasty is currently unavailable and you obtain verbal consent for intravenous thrombolysis. You wonder whether the more fibrin-specific bolus thrombolytic, reteplase, confers any advantage over streptokinase, in terms of mortality and probability of reperfusion.

A 25 year old woman presents to the emergency department with acute headache. You wonder whether a C Reactive Protein (CRP) measurement will help in excluding the diagnosis of intracranial infection.

A 57 year old woman attends the Emergency Department with newly diagnosed atrial fibrillation of uncertain duration. You decide to treat her by ventricular rate limitation with a calcium channel blocker and wonder whether you should use diltiazem or verapamil.

A 50 years old man attends the Emergency Department with a 12 hours history of palpitations; he complains of slight shortness of breath on walking upstairs and on clinical examination is found to be in atrial fibrillation (rate 140/min.) with a normal BP, fine bilateral basal crepitations and an otherwise normal ECG. You wonder if amiodarone increases the chances of spontaneous cardioversion back to sinus rhythm.

A twelve year old boy presents for a routine asthma follow up appointment during the autumn. He takes 200mcg per day of inhaled budesonide and uses his salbutamol 3-4 times per week. His mother asks if the flu vaccine will make it less likely that he will have an asthma exacerbation over the winter.

A 4 year old boy in cardiac arrest is brought into the ED as a standby. CPR has been delivered by the ambulance crew en route. Whilst he is being intubated, cardiac compression is carrried out by one of the APLS trained paediatric nurses, but once she tires, it is continued by another staff nurse with no paediatric training. You wonder whether chest compression is more effective in children if delivered by an ATLS trained professional.

A twenty year-old asthmatic lady presents to the Emergency Department with acute-onset of dyspnoea following a row with her boyfriend. She has a respiratory rate of 40/min, a pCO2 of 2.5, is tearful, extremely anxious and panicky but has an audible wheeze. You try in vain to reassure her and realise that the panic is not helping her bronchospasm. You know that benzodiazepines are to be avoided in acute severe asthma and do not prescribe them. Having stabilised her condition with nebulised salbutamol, intravenous magnesium and oral prednisolone you wonder whether there is any evidence within the literature of the harmful effect of benzodiazepines in this situation.

A 45 year old male smoker attends the Emergency department with exacerbation of COPD. Repeated doses of nebulised Salbutamol and Ipratropium Bromide has been administered and Aminophyllin infusion has been commenced. You feel that the patient will require intubation and ventilation. You have got access to Heliox and you feel that it might improve the condition of the patient and might avoid intubation. Is there any evidence to support use of Heliox in such situation?