Archives: BETs

A 42-year-old man is brought to the ED with a single stab wound to the left lateral aspect of his chest and a systolic blood pressure of 85 mmHg. He is alert, well perfused and anxious but talking to you. Appropriate management is underway to stabilise his condition; should this include early restrictive intravenous fluid resuscitation prior to definitive surgical intervention?

A 17 year old man presents to the emergency department having been pulled from a local river. He fell whilst intoxicated and was submerged for a short period of time. He has clearly aspirated some water as evidenced by his cough and sputum production. You wonder if prophylactic antibiotics are indicated to prevent lower respiratory tract infection.

A patient has suffered a crush injury of his thigh and calf. You are concerned that he may go on to develop acute renal failure. You ask you Consultant if a urinary myoglobin assay might be useful in predicting this.

A 57 year old woman attends the Emergency Department with palpitations of uncertain duration. A diagnosis of recent onset atrial fibrillation with a ventricular rate of 160bpm is made. You decide to treat her by ventricular rate limitation and wonder whether you should use digoxin or a calcium channel blocker.

A 27 year old woman attends the emergency department with a 4 day history of pain to her upper jaw (made worse by leaning forwards) and a green disharge from her nose. A diagnosis of acute maxillary sinusitis is made. She informs you that she is due to go on holiday in 2 weeks and would like some antibiotics to "make sure she is better" by then. You wonder whether antibiotics would be of benefit in this situation.

You are a first year radiology registrar who performs a carotid-artery duplex ultrasound on a symptomatic patient that reveals an 80% unilateral stenosis. The patient has heard about endovascular carotid angioplasty with stenting (CAS) as an alternative to carotid endarterectomy (CEA) and is keen to have a minimally invasive procedure. However, you are unsure whether there is any evidence to suggest that CAS is equivalent to the traditional gold standard of CEA.

You see a patient on the coronary care unit referred for urgent CABG following angiographically demonstrated triple vessel disease including a significant left main stem lesion. On examination he is found to have a right sided carotid bruit. He is asymptomatic, having had no cerebrovascular accidents (CVAs) or transient ischaemic accidents (TIAs) in the past. He is on an anti-platelet agent. On carotid Doppler examination he is found to have a 70% stenosis of the internal carotid artery on the right side. You wonder whether he would benefit from synchronous or staged CEA at the same time as CABG but you decide to search for the evidence for this prior to consulting a vascular surgeon.

A seven year old girl presents having fallen onto her out-stretched hand. X-ray shows a typical buckle fracture of the distal radius, minimally displaced. The department protocol stipulates immobilisation in a full below-elbow cast for 4 weeks with regular fracture clinic follow-up but you remember that in your last job the orthopaedic surgeons preferred removable splints and symptomatic treatment, with no follow-up. You wonder if your current department is behind the times, or if your previous department was recklessly negligent!

A 6-year-old boy presented with ear ache and mild fever. The assessing registrar confidently made the assertion that the diagnosis could not be otitis media as he has read that the presence of wax excludes this. You wonder if this is true.

A patient presents to the Emergency department with significant dyspnoea. A chest x-ray reveals a pleural effusion. Should the chest drain be aimed apically or basally to drain efficiently?

A 7 year old girl presents to the emergency department complaining of pain in her left elbow, having fallen onto her outstretched hand. On examination she can fully extend the elbow on the affected side. You have heard that full elbow extension can be used as a 'rule-out' tool for significant injury and you wonder whether there is any value in obtaining an x-ray.

A 35 year old man presents to the emergency department complaining of pain in his left elbow, having fallen onto his outstretched hand. On examination he can fully extend the elbow on the affected side. You have heard that full elbow extension can be used as a 'rule-out' tool for significant injury and you wonder whether there is any value in obtaining an x-ray.

A 75 year old woman attends the emergency department having fallen at home. She has pain around her left upper arm, and is reluctant to move it. Examination reveals a probable fracture of the humerus and an x-ray confirms this. There are no neurovascular complications or displacement. The Orthopaedic team give differing advice about how you should immobilise her arm and what advice you can give her about when she can start to move it. You wonder if there are any studies that address this.

A 20-year-old man presents to the emergency department in extremis. He is known to have asthma. He is treated according to British Thoracic Society guidelines and has a rapid sequence induction with subsequent intubation. He is difficult to ventilate, due to high airway pressures (pneumothorax has been excluded). You wonder if he would benefit from endotracheal epinephrine?

You are on duty in the Emergency Department when you see a 20 year old woman who has perforated her left tympanic membrane with a cotton bud. You wonder if the ENT SHO is right when he suggests prophylactic antibiotics.

A patient/relative/member of staff has a mobile phone switched on in the Emergency Department. Is there any evidence to suggest that it may affect the Departments Medical Monitoring Equipment.

A young, independently mobile female attends the Emergency Department following a fall. X-ray reveals a Weber A fracture of the lateral malleolus. She is reluctant to have a plaster cast and you wonder if a removable functional brace would be as effective

A 3-month-old boy is admitted to the paediatric ward with bronchiolitis. He is initially managed with oxygen, nursing care and intravenous fluids. However, his respiratory distress worsens a few hours after admission. The senior house officer measures a capillary blood gas which shows a PCO2 of 8.7 kPa. You, the on-call registrar, review the patient and discuss the situation with the consultant. The consultant suggests that the child should be commenced on nasal continuous positive airway pressure (nCPAP). You wonder whether nCPAP in an infant with bronchiolitis would improve his clinical status and/or avoid intubation?