Archives: BETs

Joseph, a 4-year-old boy with septic shock, lactic acidosis and multi-organ failure has been admitted to the paediatric intensive care unit. Mechanical ventilation, vaso-active support and renal replacement therapy (CVVHD) are initiated. His haemoglobin level is 8.8 g/dl (5.5 mmol/l). The senior consultant decides to order a red cell transfusion in order to optimise oxygen delivery, but the junior fellow argues that there is no evidence that transfusion improves outcome and that it may potentially be harmful.

You are going on a family holiday to Scandinavia during the summer. You wonder what evidence there is that oral antihistamines will reduce the symptoms of the inevitable insect bites.

A 50 years old lady is 3 months post surgery to the wrist for Carpal Tunnel Syndrome. Although her previous symptoms related to CTS have resolved and her wound is well healed, her recovery has been hindered by a hypersensitive surgical scar. Consequently, she is referred to physiotherapy to help resolve these symptoms where there are mixed views about whether electrotherapy or a more manual form of therapy is the best technique for desensitising the scar.

A 28 years old man is referred to physiotherapy with a clinical and radiographic diagnosis of myositis ossificans 3 months after direct trauma to his right quadriceps muscle. He only has about 450 of right knee flexion and severe pain in the right thigh. You wonder whether an aggressive knee mobilisation regime rather than a more conservative approach might be beneficial to improve function quicker.

A 53years old man is referred to physiotherapy with a painful, intact Baker's cyst. His knee is painful and swollen posteriorly, though not warm to the touch and has limited RoM of flexion and extension. In the absence of any firm treatment guidelines, you wonder if there is any additional benefit from using ICE and cryotherapy to reduce the popliteal swelling.

A 62 year old man with a longstanding history of peripheral vascular disease and atrial fibrillation presents to the emergency department with a 2 hour history of severe pain in the left forefoot. Examination reveals a cool, pale, pulseless left foot. You wonder whether low molecular weight or unfractionated heparin is better in this patient.

A 30 year old known asthmatic presents with an acute severe attack of asthma. Despite administering continuous nebulised beta-agonists and intravenous corticosteroids, he fails to improve. You wonder whether adding an intravenous bolus of aminophylline followed by an infusion to his therapy would be beneficial.

A call comes over your urban emergency department dispatch radio about a 25 year old man involved in a high speed motor vehicle crash, multiple injuries, depressed mental status, and your estimated time from the scene is 6 minutes. The paramedics want to use RSI to intubate, and you say bag-valve-mask, we will intubate in the ED. They arrive with the patient using BVM, angry with you. You want to show them why BVM is better.

You recently admitted an 82-year-old arteriopath who has had an 8-month history of critical leg ischaemia and who has debilitating pain at rest. Lower limb arteriogram confirms three-vessel disease not amenable to revascularisation. A below knee amputation was discussed with the patient. The patient asks you if anything could be done rather than an amputation. You have heard of sympathectomy, but wanted to confirm from the literature that this may be a viable option.

You are about to perform four coronary arterial bypass grafts on a 78-year-old ex steel worker. He has a 60 pack per year history of smoking and his lung function tests are significantly abnormal with an FEV1 only 40% of his predicted values. His coronary arterial targets are small and you feel that an on-pump technique is the only option. You discuss the case with the anaesthetist and he asks whether he could keep ventilating while the patient is on bypass in order to improve his post-operative lung function. You have significant concerns that this may make the case even more difficult but rather than refusing this request you resolve to search the literature for evidence that this will improve post-operative lung function as your anaesthetist suggests.

You start work in a new unit which routinely uses thromboelastography to manage coagulopathy and guide treatment with blood component therapy following surgery. As you have no experience of the technique you decide to review the literature to identify whether the technique is actually beneficial in decreasing exposure to allogeneic blood and blood component therapy.

A fifty year-old man presents with tight central chest pain for thirty minutes. There are no abnormalities on physical examination and his initial ECG is normal. He asks, "Is it my heart, doctor?". You explain that you cannot be certain but will do a blood test to make sure he hasn't had a heart attack in twelve hours time. He looks confused. You wonder why the triage of cardiac chest pain is still so difficult in the 21st century. Surely there is a better way of excluding acute coronary syndromes. Having heard about placental growth factor as a promising cardiac biomarker, you wonder if there is any evidence that it would be useful in this situation.

A 39y old woman presents with a one day history of suprapubic pain, dysuria and urinary frequency. She is systemically well but dipstick testing confirms blood, protein and leucocytes in her urine sample. You send the sample to the microbiology department for culture and write a prescription for antibiotics. The patient states that she does not like to use conventional medicines and asks if cranberry juice is effective for the treatment of UTIs.

A 27 year old female presents to A&E, she is drowsy and complains of feeling thirsty and having diffuse abdominal pain. She is a known diabetic and has been vomiting for 2 days. She is tachycardic, clinically dehydrated and is breathing very deeply. Initial investigations confirm the presence of diabetic ketoacidosis. You start IV rehydration and an insulin infusion at 6 units per hour. A senior nurse states that another doctor usually gives a bolus of insulin prior to commencing the infusion. You wonder if this is necessary.

A sixty year-old lady presents to the Emergency Department with a thirty minute history of intermittent resting central chest pain that seems likely to be ischaemic. Examination, baseline obserations and ECG are normal. You follow your department's rapid rule-out protocol, with serial CK-MBmass estimations and continuous ST segment monitoring for 6 hours. The lady completes the protocol and tests negative. You feel rather uneasy about sending her home. As CK-MBmass is a marker of myocardial necrosis, you realise that you have excluded infarction but not necessarily unstable angina. You wonder if there are any novel markers that would help to identify the vulnerable patient, who is at high risk for adverse cardiac events in the near future. Hearing that VCAM-1 has such potential, you wonder if the evidence suggests that it is suitable for clinical implementation.

An eighty year-old man presents to the Emergency Department with central chest pain. He had a myocardial infarction five years ago and can't remember if the pain is similar. His ECG shows left bundle branch block, which is known to be old and has no ischaemic features. You therefore prescribe aspirin, nitrates and clopidogrel and refer for troponin testing at 12 hours. Having heard about the potential of novel biomarkers to enable early exclusion of acute coronary syndromes (ACS), you wonder if there is any evidence that measuring ICAM-1, a cell adhesion molecule, will enable early exclusion of ACS and accurate risk stratification.

67 year old life long smoker, known COPD, on long term home oxygen and home nebuliser therapy, was brought into the emergency department by ambulance. He received 100% oxygen in the ambulance and was put on 4 litre/min oxygen by triage nurse in A&E. On assessment by the emergency doctor the patient was found to be in decompensated type 2 respiratory failure. You wonder whether it was appropriate for this patient to receive 100% oxygen in the ambulance and whether this would affect his outcome.

A 42 year old man presents to the emergency department complaining of a 6 hour history of painful right eye after it was scratched by a twig during gardening. The clinician presecribes topical antibiotics, advises the patient to use lubricants and arranges a review in 48 hours. You wonder whether there's any evidence to support this decision.

A 52 year old man presents to the emergency department with a history suggestive of myocardial ischaemia. He requires intravenous opioids for pain and is feeling nauseous so you decide to give him an intravenous antiemetic. However, your consultant tells you not to use cyclizine as it can increase the heart rate, and thus myocardial oxygen demand, in already ischaemic muscle. You wonder whether this is true, or just more evidence of his eccentricity?

A 42 year old man presents to the emergency department complaining of a 6 hour history of painful right eye after it was scratched by a twig during gardening. The clinician advises the patient to use lubricants as a prophylactic measure against Recurrent Corneal Erosion (RCE) syndrome. You wonder whether there's any evidence to support this decision.