Archives: BETs

You have been trained to leave the pericardium open after a routine cardiac surgery procedure because in the early postoperative period the patient's haemodynamic performance is better and there is less incidence of graft failure. In addition there is also said to be a reduced incidence of cardiac tamponade. You begin to question this teaching, especially in view of the benefit of a closed pericardium when it comes to re-do surgery. You decide to scrutinise the published literature with regard to the pitfalls of closing the pericardium.

A 35 year old man presents to the emergency department with acute low back pain. he is normally fit and well, but developed lower back pain the previous day after lifting a heavy box. There are no red flag symptoms and he has a normal neurological examination. You advise that he tries to mobilise as best he can and tell him that the prognosis is favourable. You offer analgesics but he appears to be concerned that you suggest that he takes paracetamol AND ibuprofen. He asks how much additional benefit is he likely to get from the Ibuprofen as he is not keen on taking tablets.

A 24 year old man presents to the emergency department with severe lower back pain. He developed back pain after twisting awkwardly whilst lifting a box. There are no neurological signs on examination and he has no "red flag" signs or symptoms. You make a diagnosis of low risk musculoskeletal back pain, reassure him and prescribe analgesia. He was brought to the emergency department by ambulance and initially treated with NSAIDS, paracetmol and Codeine. You review him later and he tells you that the pain killers were worthless and that the last time this happened his GP gave him a presciprition of oramorph. He asks that you do the same.

A 42 year old woman presents to the emergency department with gradually progressive worsening of headache over 48hours refractory to analgesics.She is known to suffer from migraines and says that she has had increasing frequency of episodes recently and her pain is similar to her migrainous episodes.She has had CT scans lately which haven't shown any abnormality.You diagnose her to be suffering from severe migraine and treat her with parenteral Imigran (sumatriptan) and metocloparamide which makes her pain better.You have heard somewhere that using dexamethasone reduces the frequency of migraine episodes.You wish to know the evidence for it.

A 52 yr old known epileptic is brought in fitting for short time period to the Emergency Department (ED). She has received an appropriate dose of PR Diazepam pre-hospital and the seizure continues despite further IV lorazepam. You wonder whether there is any evidence to suggest a benefit of IV Fosphenytoin over IV Phenytoin as second line treatment of status epilepticus.

A 32 year old female is receiving physiotherapy 2 weeks after her grade 2 ankle sprain. She asks if she still has to wear the Tubigrip™ bandage she was supplied with as she still has swelling but has heard from her sister that her ankle will be weaker as a result of wearing it long term. You wonder if there are any adverse long term effects of wearing Tubigrip™.

A 30 year old man is brought into A&E following a bicycle accident. He is complaining of agonizing pain in his Right thigh. On examination his thigh is very swollen and any attempt to move it is extremely painful. You suspect a femoral shaft fracture and want to administer some strong analgesia and a splint and send him for x-ray. The orthopaedic registrar complains that a femoral block could potentially mask the symptoms of a compartment syndrome. You are wondering if there is any evidence to support this.

A young woman comes into casualty having just been stung by an unknown type of jellyfish while swimming in the sea at the local beach in the UK. There are large, painful weals on her leg and arm which she has wrapped in an ice pack. The nursing staff have suggested a wide variety of treatments to you, but you wonder which will be helpful in bringing rapid relief to your patient.

A 35 year old woman presents to the emergency department with acute lower back pain radiating to her right buttock. Neurological examination is normal and there are no "red flag" symptoms or signs to suggest that this is anything other than simple low back pain. You treat her with oral paracetamol and voltarol and return to review her later. She is still in pain and appears to get a lot of spasm when she tries to get up. You suggest a course of diazepam to act as a muscle relaxant but your registrar says that it is a waste of time and to get her going quick as it is 3 hours since she arrived in the department.

A patient attends the emergency department with pain in keeping with a fractured scaphoid. The standard scaphoid views failed to identify a fracture. Should magnetic resonance imaging be conducted or is it too expensive.

A 10 year old male presents after a suffering a laceration on his lower leg from a snow skiing accident. It cannot be closed using glue. You would like to save the child the pain and discomfort of suture removal. You wonder if absorbable sutures would increase the rate of complications or scarring.

A 52 year old man presents to the primary care emergency centre with a 5 month history of back pain. He is dissatisfied with the care given by his usual GP. His GP has performed an X-ray which "Just showed a bit of wear and tear" and he has blood tests (FBC, UE, LFT, ESR, CRP) which have all been normal. He has no neurological signs or "red flag" type symptoms. A diagnosis of musculoskeletal back pain is confirmed. The patient is keen to try one of "those electrical thingies" as his daughter had one during labour and she said it marvellous. You wonder if there is any evidence to support the use of TENS in patients like this.

A 28year old female presents with a 4 month history of 'tennis elbow' (lateral epicondylitis). She receives physiotherapy in the form of manual and electrotherapy and you wonder if there is any benefit from additional use of an epicondyle clasp.

A 30 year old male presents to the Emergency Department with multiple stab wounds to soft tissues of chest/ abdomen and limbs. You wonder whether cleaning and allowing to heal by secondary intention is better than wound closure to prevent wound infection.

An 8 month old child presents to the Emergency Department in status epilepticus and is given so much benzodiazepines during treatment that he can no longer protect his airway. His vital signs are all stable and a non-rebreather mask is helping him to maintain his oxygen saturations. As you prepare to intubate him using RSI, you wonder if atropine is really necessary or helpful in preventing the bradycardia reported during endotracheal intubation.

An otherwise well 3 week old infant born at 28 weeks gestation has a haemoglobin level of 68 g/l and is prescribed a blood transfusion. The departmental protocol states feeds should be withheld during the transfusion to decrease the risk of development of necrotising enterocolitis (NEC). What is the evidence that blood transfusion increases the risk of NEC?

You are a senior house officer in a paediatric assessment unit and commonly see children with acute otitis media who are febrile but otherwise well. You are not sure about the role of antibiotics in this condition and note that various existing guidelines have different recommendations about use of antibiotics. You wonder if measurement of C-reactive protein can be used as a screening test to differentiate between viral and bacterial otitis media and to decide which group of children require antibiotic therapy. You decide to find out more.

A 65 year old male presents to the emergency department with a severe pneumonia. He is intubated and placed on a ventilator because of worsening hypoxia. He has no history of previous renal disease however he becomes increasingly oliguric over the next 2 hours despite adequate fluid resuscitation and vasopressor support. You wonder whether the administration of a loop diuretic in order to improve/maintain his urine output will improve his prognosis and reduce the need for continuous veno-venous haemofiltration (CVVH).

A 70-year-old male is admitted to the intensive care unit with a severe biliary sepsis. He is develops multi-organ failure, is placed on a ventilator and receives inotropic and vasopressor support. He becomes anuric over the next two days, despite adequate fluid resuscitation. He is commenced on renal replacement therapy when he develops fluid overload. You wonder if you could have preserved his renal function and reduced his chances of requiring renal replacement therapy by the use of a loop diuretic.

During a busy shift in the Emergency Department, you see a 50 year-old man with dull central chest pain and feel that, although he is clinically stable and the initial ECG is normal, myocardial ischaemia ought to be ruled out. He is very keen to get back to work, doesn't like hospitals and doesn't want to spend the day awaiting blood tests. On examination you elicit chest wall tenderness. You wonder if this sign is sufficiently reliable to allow the exclusion of an acute coronary syndrome.