Archives: BETs

A 40 year old male presents to the emergency department with a 4 day history of cellulitis of the lower extremity, fever and chills. How useful is an initial serum lactate concentration drawn in the ED as a predictor of mortality?

A 475g baby girl born at 24 weeks and 2 days gestation by emergency cesarean section following maternal pre-eclampsia, develops hypotension in the first 48 hours of life. She is given inotropic support with dopamine, dobutamine and adrenaline.

A 35 year-old non-pregnant female presents to the emergency departement with symptoms of dysuria and frequency. You suspect she has a UTI, however the urine dipstick is negative for both leukocyte esterase and nitrite. Will treating this patient with empiric antibiotics alleviate her symptoms?

A pleasant elderly gentleman presents to the emergency department following a recent return from the Indian subcontinent. He is nauseated, feels tired and is clearly jaundiced. His blood tests confirm a hepatitis, and further tests confirm that this is secondary to a viral hepatitis infection. There is NO evidence of paracetamol overdose. A few hours later, you are called to see him as he has become increasingly confused. He is encephalopathic, and repeat bloods show he is developing a coagulopathy. You diagnose acute liver failure, and institute supportive measures. Your colleague states that you should start him on N-acetylcysteine (Parvolex), but you tell him not to be silly, as there is no paracetamol involved. However, he insists that N-acetylcysteine will still be beneficial. You wonder if there is any evidence behind his words.

You are the RMO in A&E and are seeing a gentleman with suspected cardiac chest pain. He is still in significant pain despite taking his GTN spray and you decide to give him some morphine. Soon after, his blood pressure drop to 70/40, and you need to give naloxone to reverse the effect of the opiate. Fortunately, his blood pressure comes up again, but the episode has left you with concerns. You wonder if giving an opiate is the best thing to do for analgesia in these patients.

You are the neonatal registrar reviewing a newborn infant whose mother is infected with HCV (but not infected with human immunodeficiency virus (HIV)). She wishes to breast feed but is concerned about whether this would affect the risk of her infant acquiring HCV infection. You would like your decision to be based on sound evidence.

A 72-year-old man with a known history of ischaemic heart disease presents to the emergency department in the early hours of the morning with acute dyspnoea. He is diaphoretic and on examination has crepitations on both middle and lower zones of his chest. A chest radiograph shows cardiomegaly and increased shadowing consistent with pulmonary oedema. He remains unwell despite the administration of oxygen, nitrates, diuretics and opiates and, knowing that ACE inhibitors have proven benefit in chronic heart failure, you wonder if he would receive benefit from this drug in the acute setting.

A 32 year old woman with a 10 year history of rheumatoid arthritis (RA), treated with long-term, low dose oral prednisolone, presents to the emergency department with a 2-day history of a red, swollen left knee that is painful to touch. She reports no prior knee swelling, recent trauma, skin infection, knee surgery, illegal drug use or risky sexual behavior. On examination, she is afebrile, has an effusion and restricted movement in her left knee. You wonder if this is just another exacerbation of her RA? You order blood tests and deliberate whether the absence of fever is enough to rule out septic arthritis (SA)?

A healthy 14-year-old boy involved in an altercation with another boy sustains injury to his jaw and two of his incisor teeth are avulsed. He attends the Emergency Department with his teeth wrapped in tissue paper. The nurse at the triage asks whether we need to put the teeth in milk immediately. You wonder whether this is 'Nanny advice' or evidence-based?

A 38 year old man presents with one week history of jaundice. He admits to drink alcohol excessively of about 10 units per day for the last 10 years. Clinical examination reveals jaundice, spider naevi over chest and tender, palpable hepatomegaly with no clinical signs of ascites. Hepatitis screen and septic screen are negative . A diagnosis of alcoholic hepatitis is made. You wonder whether early commencement of steroids would improve his short term survival.

You review a 67 year old female and diagnose Community Acquired Pneumonia (CAP). A junior colleague had requested NT-proBNP levels as part of the work up, and the value was elevated at 1500pg/ml. The patient has no evidence of heart failure. Based on your previous reading of BNP, you wonder whether this may have prognostic significance.

A 65 year old man presents to the ED with a large, fresh upper GI bleed. He has a history of non-steroidal anti-inflammatory drug (NSAID) use and complains of increasing indigestion over the last few months. On examination, he has no stigmata of chronic liver disease and is unwell with a BP of 80 systolic and tachycardia of 140. In view of his history and lack of positive examination findings you feel that the most likely diagnosis is a bleeding peptic ulcer. You wonder if there is any evidence to support the use of vasoconstrictor therapy in non variceal upper GI bleeds.

A 65 year old man presents to the ED with a large, fresh upper GI bleed. He has a history of NSAID use and complains of increasing indigestion over the last few months. You think some of this may be due to the fact he drinks 35 units of alcohol a week. On examination, he has no stigmata of chronic liver disease and is unwell with a BP of 80 systolic and tachycardia of 140. In view of his history and lack of positive examination findings you feel that the most likely diagnosis is a bleeding peptic ulcer. You wonder if there is any evidence to support the use of iv terlipressin in non variceal upper GI bleeds.

Is Gabapentin effective as an adjuant in reducing postoperative pain and opioid requirement?

A 23 year old female has been referred to physiotherapy with a 6 month history of temporomandibular joint (TMJ) pain without disk displacement. Based on some published evidence, the referrers commonly request electrotherapy, but you want to investigate if other forms of physiotherapy may be more beneficial.

A 78-year old male presents to the Emergency Department in a coma two days after a minor head injury. You note he is taking clopidogrel for treatment of his ischaemic heart disease. CT scan shows a large sub-dural haematoma. You wonder whether the clopidogrel has contributed to the development of this haematoma?

You are in a multidisciplinary team meeting, discussing a 76 year old lifelong smoker who has a T2 right upper lobe adenocarcinoma. She has COPD and arthritis and is quite a frail lady and lung function testing showed that she would not tolerate a pneumonectomy. The CT scan shows a 5cm tumour that may be resectable by lobectomy and there are no obviously enlarged mediastinal nodes although the radiologist reports that there are a few nodes there that are 0.8cm in diameter. A consultant surgeon accepts her for lobectomy, but the anaesthetist suggests a mediastinoscopy first to reduce the likelihood of an 'open and close' thoracotomy. The chest physicians state that this would be contrary to current guidelines and thus you suggest that you could look up the evidence and present it at the next week's meeting.

A thirty year old man presents to the department with a swollen leg, admitting to a recent history of injecting drug use. You suspect he has a deep vein thrombosis but injecting drug use does not feature as a risk factor on the Wells criteria- the widely used model for assessing pre-test probability for this condition, and you wonder if this reflects the incidence rate for deep vein thrombosis in this patient group.

You have been approached by a representative of a company who is promoting their harmonic scalpel. They tell you that their scalpel is quicker and safer than the diathermy technique and that it causes less arterial spasm. The representative gives you several brochures to back this up with some references in small type at the bottom of the page. You are keen to try this ultrasonic scalpel but you discover that it is more expensive than your usual technique so you decide to look up the clinical evidence for a benefit for harmonic scalpels before committing to a trial of this new device.

A 45 year old woman presents to the emergency department one hour after taking eight ibuprofen tablets. She denies co-ingestion. You are happy with her medical condition, but concerned about her mental state, and so request a psychiatric review. However, the psychiatric doctor refuses to see her until she is proven to need no treatment for paracetamol poisoning. As this will take another three hours, you wonder if a sample drawn now, would, if it contained no paracetamol, exclude a significant overdose, thus expediting referral.