Archives: BETs

A 40 year old alcohol dependent male is admitted to the short stay ward from the emergency department. Whilst recovering from his head injury he starts to withdraw from alcohol. You treat this with a chlordiazepoxide regime, and at the end of this he states he wants to stay off the booze. He has failed to do this previously. You recommend he engages with alcohol support services. You also wonder whether he'll benefit from acamprosate treatment.

A 33 year old female with morbid obesity presents to the emergency department with a 2 hour history of severe sharp pleuritic chest pain. She smokes and is on birth control pills. Her vital signs suggest mild hypoxia and tachycardia. With pulmonary emboli at or near the top of your differential, the patient requires a peripheral IV for contrast material during a CT scan of the thorax. The nurse, and colleagues have made multiple attempts at IV access and return to tell you an IV could not be obtained. You contemplate the efficacy of ultrasound to obtain peripheral intravenous access under these circumstances.

A 4-month-old boy presents with a fever of 38.9°C and no focus on clinical examination. He does not appear septic and clean catch urine is normal. There are no respiratory symptoms and no clinical signs of meningitis. You think he has a low risk of a serious bacterial illness. You wonder if procalcitonin can help you exclude serious bacterial illness that may need antibiotics?

A 7 month old boy is undergoing primary repair of his cleft lip. Before the operation the parents were concerned about the cosmetic result from using sutures (cross hatching) and also the discomfort of removing them. You wonder whether the use of wound glue would be an acceptable alternative, given the high mobility of the area and need for accurate approximation of the wound.

A 26 week gestation premature neonate is born with a birthweight of 650g. He is intubated and ventilated from birth. Both arterial and venous umbillical catheters are inserted. He is at risk of sepsis from maternal chorioamnionitis and prolonged rupture of membranes and is therefore commenced on broad spectrum antibiotics. Invasive candidiasis is an increasingly recognised problem in such infants. Would intravenous antifungals be effective and safe at preventing this?

A footballer presents to the ED having sustained a foot injury in a blatant and unnecessary foul on the edge of the opponents penalty box. The X-ray confirms a fracture of the 4th meta-tarsal which you decide can be treated conservatively. The patient mentions to you that he has heard of certain footballers with similar injuries having 'oxygen therapy' to speed up their recovery. You wonder if there is any evidence to support this form of treatment.

A 60 year old male presents to the emergency department with substernal chest pain. He is a smoker, has hypertension and has never been diagnosed with coronary artery disease. EKG does not show an acute myocardial infarction and initial cardiac enzymes are negative. Aspirin and sublingual nitroglycerin have relieved his pain.

A patient presents with headache and transient visual loss. He is diagnosed with pseudotumor cerebri. Conservative therapy fails. Could sinus stenting be an alternative treatment?

A 65 year old woman is brought into the emergency department following a 3 day history of nausea and vomiting, abdominal distension, and absolute constipation. Her vital signs are stable, and his abdomen is distended but not tender. A lower midline laparotomy scar from a previous hysterectomy is noted. A plain abdominal radiograph shows distended loops of small bowel with a paucity of air in the colon. A clinical diagnosis of ASBO is made. You wonder whether a water soluble contrast small bowel follow through (SBFT) study would be useful in the management of a patient with presumptive ASBO.

An 18 month old child attends the department with a limp. You question the mother of the child who explains that the child has fallen down three stairs at home. X-ray reveals a transverse tibial fracture. Further inquiry is unrewarding, and you wonder whether the prescence of the fracture alone is sufficient to support a diagnosis of non-accidental injury.

A 65 year old male patient is brought in to your department. He is severely short of breath, sweaty and has sats of 91% on a non rebreather. He is an ex smoker and known to have IHD and suffers from LVF. The standard teaching is that Diamorphine (morphine) should be given to these patients as it is an effective treatment for the condition. You wander if that is true and if there is any evidence for this statement.

A 78 year old male is brought to the Emergency Department having had a syncopal episode at home witnessed by his wife. He collapsed to the floor whilst standing, losing consciousness for 30 seconds and fully recovering within 5 minutes. He did not report chest pain or breathlessness. His presenting ECG shows no evidence of ischemia and he has no abnormalities on physical examination. Should this gentleman have delayed cardiac markers measured in order to rule-out an acute myocardial infarction?

You are anaesthetising a high risk CABG patient. Before coming off bypass, the surgeon requests that you give some thyroxine. You have never heard of this strategy before and thus while you give the thyroxine, you decide to review the literature to see if there is any evidence to back up this strategy.

You have been performing CABG surgery. The anaesthetist has used the Hepcon HMS Plus Hemostasis Management System (Medtronic, Minneapolis, MN) to monitor heparin concentration and calculate protamine dose to reverse anticoagulation. He claims that heparin and protamine dose optimisation decreases coagulation system activation, postoperative bleeding and allogeneic blood and blood component transfusion requirement. You wonder what evidence is available to justify this claim.

You are seeing a 60 year old patient 5 days after a left lower lobectomy for a 4cm squamous cell carcinoma. There were no obvious nodular involvement at operation. He is diabetic and an ex-smoker but otherwise relatively well and ready to go home. You tell him that he is ready to go, but that he will probably need chemotherapy in a few weeks time. He is alarmed at this and worried that the operation has therefore not been a success, and you enter into a long discussion about chemotherapy, the operation , and his likely prognosis. After this lengthy discussion you wonder whether it is really worth referring these early stage patients for chemotherapy and thus resolve to look up the evidence.

You are on your ward round and you see a fit 51 year old gentleman 3 days post right upper lobectomy. He has an air leak. He asks why he is not allowed to go to the toilet or go for a walk with the physiotherapist like everyone else on the ward. You tell him that the only way to resolve the air leak is to use suction. He mumbles that it is probably making it worse. You resolve to search the literature to see if he is right.

You are a chest registrar seeing a 55-year-old patient in a rapid access out-patient clinic who has recently presented with cough and hemopytsis. He is a smoker and had these symptoms for just a few weeks before being sent for a chest X-ray. It shows a large lesion in the right upper zone. The patient suspects he has lung cancer, which he probably does. He wants to know why he could not have had a chest X-ray before he was sick to pick up his lung cancer.

You are about to perform a Coronary arterial bypass graft on a 75-year-old gentleman with good LV function. You have recently been asking your perfusionist to use a centrifugal pump for all your high risk cases, and the perfusionist asks you if you want one for this case. You say 'yes' but you are unsure if there is evidence for benefit for these lower risk patients and, therefore, resolve to search for papers on the subject after the case.

A 75 y/o gentleman presents at 5am with a 2h history of sudden onset of shortness of breath. It is difficult to obtain a clear history as the patient is too breathless to speak. He is tachypnoeic, tachycardic, cold, clammy and is sweating profusely. Chest auscultation and CXR are consistent with pulmonary oedema and you start treatment for this, giving high flow oxygen, diuretics and a GTN infusion. The patient improves vastly over the next 30 minutes. You have heard of a new treatment for heart failure called nesiritide and wonder if it would have been useful in this situation.