Archives: BETs

You are asked to see a 19 year old man who has presented to the Emergency Department with paraphymosis. He states that he fell asleep after sex the night before and woke up with swelling. Simple traction has failed to cure the problem (but has brought tears to his eyes). A surgeon, a specialist registrar in emergency medicine and a urologist are already in attendance. The first says that multiple punctures should be made with a needle, the second that an iced glove should be used and the third that sugar should be applied. You wonder whether any of the suggested methods are evidence-based.

You are a registrar performing the sternotomy on a 65 year-old patient who is undergoing an aortic valve replacement, supervised by your consultant. You open the chest and start liberally applying bone wax to the sternal edges. Your Consultant is greatly alarmed and tells you that bone wax is 'poison' and should only be used for friable, bleeding sternums. You heed his advice but wonder what evidence exists for his strongly held views.

You have reviewed a 48 year old man who presents with isolated pleuritic chest pain on the left side. His fingers are nicotine stained. He tells you he regularly coughs up yellow phlegm in the morning. His PaO2, PaCO2 are normal and D-dimers elevated. You would like to discharge him to the care of his GP if you are able to rule out pulmonary embolus. Would a CT pulmonary angiogram allow you to do this?

A 22 year old man has been cleaning out an old chemical drum. He attends the emergency department with severe burning in his eyes. He says the drum was marked as NaOH 20%. You arrange for copious irrigation and oral pain relief. You contact the duty opthamologist who asks to start mydriatics, antibiotic ointement and ascorbate drops. You do not have the ascorbate drops and wonder whether there is any evidence for their use.

2 yr old girl attends your department with a history of impetigo. In addition she has developed an erythematous rash with some bullous formation. She has a minimal pyrexia and seems otherwise quite well. You diagnose staphylococcal scalded skin syndrome. You wonder, as she is clinically well, whether you can treat her with oral rather than intravenous antibiotics.

You are about to perform a coronary arterial bypass graft on a 70 year old lady who has left main stem disease and an ejection fraction of 30% on echocardiography. She was an urgent referral from the cardiologists after being admitted 3 weeks ago with unstable angina, but has been stable since admission. You realise that she is a high risk case and you wonder whether preoperatively inserting an intra-aortic ballon pump would be of benefit to her?

A 25 week gestation infant aged 30 days has a continuous murmur and easily palpable pulses. He has already received a course of indomethacin for a "clinically diagnosed" patent ductus arteriosus (PDA). The baby is ventilator dependent. How good (or bad) is clinical examination at diagnosing a clinically important PDA?

You are working as a pharmacist supporting a tertiary neonatal unit. A 36/40 gestation infant is transferred from another hospital. The infant had been born by normal vaginal delivery and collapsed on the postnatal ward at 3 hours of age. The child is hypoxic despite high pressures and 100% oxygen. The diagnosis of persistent pulmonary hypertension (PPH) is suggested; intravenous tolazaline had been tried without significant improvement. Nebulised tolazaline is mentioned, and you are asked to find out more.

A 26 week infant is about to be delivered by emergency caesarean section to a mother with placental abruption and fetal distress. No antenatal steroids have been administered to the mother. You are called to attend the delivery. You are setting up the equipment when the respiratory therapist suggests that we should use high frequency oscillatory ventilation (HFOV) as primary mode of ventilation. He also cites few articles suggesting benefit of high volume strategy HFOV over conventional ventilation (CV). You wonder if there is enough evidence to support the intervention.

A 62 year old male attends the department with central crushing chest pain, sweating and shortness of breath he has vomited twice.His chest is clear, he is hypotensive and has a raised JVP. ECG reveals bradycardia and ST elevation in aVR. Clinically convinced he has a right ventricular infarct you repeat the ECG using right sided chest leads which show ST elevation of 2mm in three leads. Happy that this man has an isolated right sided infarct you wonder whether there is any evidence supporting your plan to thrombolyse.

A 68 year old attends the department with knee pain. The knee appears swollen and he tells you he has Christmas disease. He has considerable pain and has been told by a relative that acupuncture is wonderful. You wonder whether it is a good or bad thing in this condition.

You are asked to review a 65-year-old patient who had a coronary artery bypass grafting (CABG) 6 hours ago. Preoperatively he had triple vessel disease and good ventricular function. 600mls has been recorded in the drain bottles and 40mls drained in the last hour. The nurse asks you if the first dose of aspirin should be omitted. You are tempted to omit this first dose of aspirin but you wonder what implication this may have on the long-term patency of this man's grafts.

You are teaching a group of medical students basic life support when one of the group expresses concern about the risk of HIV on performing mouth to mouth on a complete stranger. After telling him it is unlikely you wonder whether this advice would sound better with some evidence behind it.

A 45 year old woman is admitted to the emergency department with a minor head injury after being involved in a road traffic accident. She had a GCS of 14 in the ambulance and had a witnessed loss of consciousness of around 10 minutes at the scene. However she now has a normal GCS, a mild headache but no other clinical symptoms or signs. All investigations are normal and you are about to send her home. However she is worried about her headache and tells you that she had a friend who was 'never right again' after a head injury 2 years ago. You wonder whether she should be followed up but you don't know which patients are at high risk of long term disabilities such as headache, dizziness, or symptoms classed as post-concussional syndrome.

A six year old child in bathing trunks and towel attends the emergency department, howling with anxious parents. He has just been swimming in the sea and has large weals on his arm and leg from a common jelly fish sting which are very sore. You wonder what is the most effective way to treat this pain.

A 3 year old boy arrives in the emergency department in the early hours of the morning. His mother reports that he has been unwell for 24 hours with a barking cough. On examination he is well and active but has stridor at rest. His temperature is normal, there is no indrawing and oxygen saturations are normal. You know that oral steroids reduce the length of illness and need for hospital admission but are unsure whether to use oral dexamethasone or oral prednisilone.

You are performing a difficult aortic valve replacement in an 80-year-old patient that also requires three coronary grafts and has an ejection fraction of only 35%. You know that the bypass time is going to be long. The perfusionist informs you that in the last institution he worked at, every patient was prophylactically haemofiltered if bypass was used and that this reduced inflammatory mediators and improved outcome. You decide to use a haemofilter in this high risk case but resolve to look up the evidence for this after the case.

On Christmas Eve you intend to circumnavigate the globe stopping at every household containing a child in the space of one night using a dozen reindeer as your means of propulsion. However it is a bit misty out and you feel this will make performing this task a little bit tricky and feel some sort of navigational aid would be helpful. You notice one of the reindeer has a very shiny red nose (you might even say it glows). All of the other reindeer are laughing and calling it names but you wonder whether this may be the answer to your navigational problems.

You have just read a recent important publication by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons who recommend that in the under 9 age group, children requiring radiological assessment of their Cervical Spine need only undergo an AP or lateral cervical spine view. It is your current practice to perform three view radiography but you realise that getting the odontoid peg view can be very difficult in non-compliant children. You wonder on what evidence this specific guideline was based.