Archives: BETs

A 55 year old man attends his GP with ongoing simple low back pain. He has no red flag symptoms and has tried analgesics in the past. You assess him and he tells you that he is very concerned about his pain and is very worried that he is doing more damage by continuing to work. You try and reassure him but wonder if some formal behaviour therapy might benefit him.

An anxious forty year-old lady with a family history of ischaemic heart disease presents with tight central chest pain of one hour's duration. The pain eases with reassurance in the ambulance and the ECG at presentation is normal. You don't believe this lady is having an acute coronary syndrome but are unwilling to risk missing the diagnosis and refer for troponin testing at 12 hours. Having explained that you need to rule out a clot in the coronary artery, the lady states that her husband recently had a blood test to rule out a clot in the leg and wonders why you can't do the same test. You therefore wonder if plasma D-dimer would enable accurate exclusion of acute coronary syndrome.

A forty-five year-old businessman presents to the Emergency Department with vague central chest pain for the past 2 hours. ECG is normal and you refer for troponin testing. He is very dissatisfied at having to be admitted and considers taking his own discharge. You wonder if there is a better way to exclude an acute coronary syndrome without having to admit for over 12 hours. Knowing that platelet activation is key to the pathogenesis of acute coronary syndromes and, having heard that thrombospondin may be a marker of this, you wonder if measurement of thrombospondin would allow earlier exclusion of acute coronary syndrome.

A fifty year-old lady with a severe needle phobia presents to the Emergency Department with a three-hour history of central tight chest pain. Baseline observations, chest radiograph and initial ECG are normal. You feel that you ought to exclude acute coronary syndrome before discharging her. Particularly in view of her needle phobia, you would like to be able to exclude the diagnosis using her admission blood samples but you are aware that troponin will be insufficiently sensitive at this time. Serial CK-MBmass would necessitate serial venepuncture. You wonder if there is an early marker you could use. As e-selectin as been proposed as such an early marker, you wonder if its measurement would help in this situation.

A 43 year old man attends his general practitioner with a 6 month history of simple low back pain. He is tolerating simple analgesics and manageing to stay at work but he is struggling and has had to take days off sick due to his symptoms. There is nothing to suggest a sinister underlying cause and clinical examination does not suggest a radiculopathy. He is keen to try physio or chiropractic. You wonder if with er have been shown to make a difference.

A 45 year-old man presents to the Emergency Department with a 48-hour history of palpitations, postural light-headedness and exertional dyspnoea. ECG demonstrates atrial fibrillation (AF) at a rate of 130 beats/minute. There are no apparent reversible causes following history, examination, chest radiography, urinalysis and haematological and biochemical screening. You feel that pharmacologic or electrical cardioversion to sinus rhythm rather than rate control would be most beneficial to the patient, but as you are aware of the possibility of atrial thrombus and systemic embolism you opt for rate control and refer for anticoagulation. You wonder if measuring D-dimer, a product of clot breakdown, would have allowed accurate exclusion of atrial thrombus, thus enabling the safe acute administration of flecainide.

A 56 year old female with a diagnosis of rheumatoid arthritis has benefited from a course of 6 hydrotherapy sessions. She asks if she should have some more. You wonder if there is any evidence to support the number of sessions provided.

A fifty year-old man presents to the Emergency Department with a two-hour history of dull central chest pain. Past history includes a coronary artery bypass graft six years ago following MI but no subsequent angina. He had a peptic ulcer two years ago. ECG shows some non-specific T wave flattening in the lateral leads. Judging him to be high risk, you follow your department protocol, refer for troponin testing at 12 hours and administer aspirin, clopidogrel, dalteparin, atenolol and pravastatin. You wonder if there is any evidence that measurement of P-selectin, a promising cardiac marker you have heard about, would aid your triage decision, perhaps enabling early discharge without the need for potentially unnecessary and risky treatment.

A 42 yr old radio presenter presented to emergency department with sudden onset occipital headache followed by expressive dysphasia. Examination revealed GCS 12/15 (E4 V2 M6). The symptoms reported are classical of SAH and it will take at least 2-3 hrs for CT scan for diagnosis. Should nimodipine be given while awaiting CT scan to give its benefits of reducing cerebral vasospasm and secondary ischaemic damage?

A 54 year old man with a history of chronic alcohol excess presents with generalised seizure activity. You wonder if treatment with phenytoin would be of benefit in preventing recurrence of seizures in the A&E department.

An adult is brought into the Accident and Emergency Department with vomiting, diarrhoea. They are diagnosed with gastroenteritis. Will IV or oral fluids be faster at rehydrating this patient to a point where discharge will be possible?

A young man is brought into your emergency department by ambulance with a suspected opiate overdose. His respiratory rate was initially adequate but has now dropped to 7/min, and his GCS is 6. His peripheral veins all seem obliterated and, recognising him from previous attendances, you remember him to be HCV positive. You have heard that naloxone is now given intranasally by a number of ambulance services in the US and wonder whether this might be worth trying.

A 25 year old male is brought into A&E by ambulance with a history of respiratory arrest following a suspected Opioid overdose. One of the paramedics describes struggling and failing to achieve peripheral venous access, sustaining a needle stick injury in the process. The paramedic describes proceeding to administer a total of 800mcg of Naloxone intramuscularly to which the patient's response has been slow. You wonder whether the administration of Naloxone intranasally, would have been effective in both reversing the effects of the overdose and eliminating the need to use needles in the pre-hospital environment in a patient at high risk of having both limited peripheral venous access and potentially contractible blood-borne viruses.

A 12-month-old boy with acute diarrhea is brought to the emergency department by his parents. He tolerates oral rehydration solution well but his parents still worry very much about his frequent loose stools. You wonder if the use of smectite would provide any additional benefit.

Parents bring their 10 month old, previously healthy infant to the ED after two days of fever, rhinorrhea, cough, and poor feeding. Today the infant is wheezing and has labored breathing. You wonder if administering corticosteroids will improve symptoms enough to allow discharge from the ED and outpatient management.

Recognising the limitations of troponin testing in suspected acute coronary syndromes you investigate possible alternatives within the literature. Having reviewed the evidence for brain natriuretic peptide (BNP), you discover that N-terminal-pro-BNP may be superior. You wonder if there is any evidence for its effectiveness.

A previously healthy sixty year-old lady presents with a thirty-minute history of left-sided chest discomfort, also felt in the left arm. Examination and initial ECG are normal. You refer her for troponin testing at 12 hours but recognise that this strategy has three major limitations: (1) The patient may be unnecessarily alarmed or receive inappropriate treatment for what turns out to be an erroneous diagnosis; (2) The patient's condition has not been diagnosed in the initial 12-hour period, when intensive guided therapy may have been most beneficial; (3) troponins merely mark myocardial necrosis and cannot inform you as to whether the patient has an unstable coronary atheromatous plaque. Having heard a rumour about brain natriuretic peptide (BNP) as an early cardiac marker, you wonder if it would help to avoid such disadvantages in this clinical situation.

A 25 year old man presents to your Emergency Department with a right shoulder injury following a rugby tackle. Clinical examination and a series of shoulder X rays reveal an anterior shoulder dislocation with no associated neuro-vascular deficit nor fracture. You wonder whether Kocher's or Milch's Technique would be most successful in reducing the dislocation without complication.

A fifty year-old man presents having experienced 2 hours of central crushing chest pain. He is diaphoretic and the ECG shows 4mm ST elevation in the anterior leads with reciprocal inferior ST depression. You prescribe aspirin, oxygen, clopidogrel, morphine, thrombolysis and buccal glyceryl trinitrate (GTN). Unfortunately his pain is not relieved. As you start to write "GTN; IV" on the drug kardex you wonder whether there is any evidence that nicorandil, a potassium channel opener with nitrate-like activity, will have a beneficial effect in this acute situation.

A forty-five year-old man presents with classical ischaemic chest pain occurring with increasing frequency over the past 48 hours, with intermittent rest pain for 4 hours. ECG shows deep, downsloping lateral ST depression without left ventricular hypertrophy. You diagnose unstable angina and prescribe aspirin, clopidogrel, low-molecular weight heparin, beta-blockers, statins and buccal nitrates. His pain is refractory to nitrates. Knowing that nicorandil is a useful adjunct in the treatment of poorly-controlled stable angina, you wonder if there is any evidence for its benefit in the acute situation.