Archives: BETs

A mother brings her 7-year-old son with Down syndrome to clinic complaining of sleep difficulties. He won’t go to sleep alone, frequently wakes in the night and will not be settled unless transferred to his parents’ bed. His parents are exhausted, and his mother believes his lack of sleep is also disrupting his daytime behaviour. He has always been difficult to settle and seldom slept through the night without waking. The child is overweight, but not obese, and upon enquiry his mother tells you that he does not usually snore, or suffer from nocturnal enuresis (bedwetting), which makes obstructive sleep apnoea an unlikely cause. His mother tells you, “I’m sure he’s just waking up out of stubbornness and not because anything’s wrong, but we’re all worn out. I don’t know what to do.” You wonder if a behavioural treatment programme might be able to help in this situation.

A 68 year old gentleman attends the emergency department with two hours of ongoing central chest pain radiating into both arms. He is pale and sweaty, has vomited twice and has a history of angina. Examination shows him to have BP 90/55 and he has bibasal crepitations. 12 lead ECG is unremarkable but convinced clinically he is having a myocardial infarction you repeat the ECG using posterior leads which show ST elevation indicating a posterior MI. You have no access to angioplasty at this time and wonder whether he would benefit from thrombolysis.

An 11 year old boy is brought to the emergency department by paramedics after falling off his bicycle. They have immobilised his cervical spine with a hard collar. He has no visible external injury, is fully alert and co-operative and does not complain of any neck pain. You are aware of the “trend” for radiographic cervical spine imaging in virtually all blunt trauma patients, as unrecognised cervical spine injury can lead to disastrous neurological sequelae. However, you wonder whether imaging in this case is really necessary.

In patients suffering with massive postpartum haemorrhage syntocinon is often used intravenously to control atonic uterine bleeding. Currently, clinical units have protocols for administering up to 10 units intravenously stat, repeated up to once, followed by an infusion of 40 units in 40 mls of diluent administered over 4 hours and repeated if required. There are variations of this protocol in use in different hospitals. There is a need to support the use of such doses of syntocinon / oxytocin with evidence from proper studies on the effectiveness of different uterotonics and reports of any adverse effects.

A 4 year old girl presents to the Emergency Department with an urticarial rash. Her general practitioner has prescribed an oral antihistamine but the rash has persisted. You wonder if there is a role for oral steroids in this otherwise well child.

A 45 years old man with known history of peptic ulcer disease is admitted with haematemesis and malaena. The is no history or stigmata of chronic liver disease to suspect varices. You want to know whether giving proton pump inhibitors (PPI) as intermittent intravenous (IV) bolus dose is as effective as as a continuous IV infusion pre endoscopy.

You are working in an African hospital during the malaria season. A 10 year old boy is admitted in coma with a fever after having had a convulsion at home. A blood slide shows asexual forms of Plasmodium falciparum, his blood sugar has been checked to be normal, and he has been loaded with Intravenous quinine. Antibiotics have been given until meningitis can be excluded by a normal lumber puncture. Local experience suggests intravenous mannitol is of benefit in unconscious patients with cerebral malaria, its use however, is not recommended by the World Health Organisation (1).

You receive a call from one of your adolescent patients, a 16-year-old boy with a longstanding history of seasonal allergic rhinitis (SAR). He is currently treating his mainly nasal symptoms with an oral histamine antagonist (OH1A). His symptoms are getting increasingly difficult to control. He is worried about the upcoming hay fever season and asks for other treatment options.

A four year old girl presents to the emergency department having pushed a bead up her right nostril. The foreign body is easily visible in the nasopharynx. You wonder which method of removal is most likely to meet with success.

You are a busy consultant doing a ward round before the first case gets into theatre. You come to a 75 year old lady 3 days post CABG who has gone into AF overnight with a rhythm of 160. Her BP is 100/60 and she has a good LV and was in sinus rhythm preoperatively. You congratulate the SHO for starting amiodarone at 2am but she then asks you why three of your consultant colleagues insist on digoxin whereas 2 of your colleagues always use amiodarone. As you have just set up a critical appraisal journal club, instead of answering her, you suggest that you both go away and attempt to retrieve the evidence by the end of the week.

You have just completed a BET comparing Digoxin and Amiodarone for the treatment of AF as the consultants in your hospital have widely varying policies in this area. Unfortunately this BET only found 1 paper and therefore you decide to widen the search to compare rate-controlling drugs versus ant-arrhythmics.

You are telephoned by your Cardiac Nurse Specialist who has visited a 65 year old gentleman who was discharged 2 days ago after CABG with LIMA grafting. She reports that he is still Short of Breath and Examination reveals Stony dull percussion notes and no Breath sounds on the Left side of the Chest. As you arrange readmisison, you wonder whether if you had inserted a pleural drain intraoperatively you could have avoided this annoying complication.

You are ready to discharge a 57-year-old gentleman who has undergone CABG 8 days ago. It is your consultant's policy to discharge all people without contraindications on low dose aspirin, but you have recently attended a structured critical appraisal journal club and wonder whether a higher dose of aspirin may confer a survival advantage to your patient.

56-year-old man known to have non-insulin dependent diabetes mellitus presents to the Emergency Department after taken an overdose of his own oral hypoglycaemic - Glipizide. The initial blood sugar was very low; therefore he was given a 50 ml bolus of 50% dextrose. The patient recovered but despite a continuous intravenous infusion of 10% dextrose, hypoglycemia recurred. You know that intra-venous dextrose stimulates insulin release, and that sulfhonylurea compounds have a long half-life. You wonder about the use of the somatostatin analogue octreotide, which causes marked suppression of serum immunoreactive insulin and C-peptide concentration, and whether it is safe and effective under such circumstances.

A 7 year old boy presents to the Emergency Department having fallen in the playground, sustaining a laceration to his bottom lip which crosses the vermilion border. You know that the potential uses of tissue adhesive in the paediatric population are increasing, and wonder if it may be used in these circumstances instead of the traditional method of formal suturing.

You are updating a protocol for the prophylaxis of atrial fibrillation after cardiac surgery for your department. For many years the protocol has been to continue the patient's own beta-blockers during the perioperative period, restarting them the day after surgery. A new surgeon in your group suggests that Sotalol, with type III antiarrhythmic properties in addition to Beta-Blockers is superior to this protocol, but other colleagues state that changing the patient's usual medications the day before surgery in this way will lead to a host of complications including bradycardia and hypotension. You resolve to search the literature to see whether it really is worth changing your departmental policy.

You have been called to the resuscitation room to see a 67 year old woman who has walked out in front of a bus while shopping in town. She has an obvious closed fracture of her left arm and she is complaining of abdominal pain and central neck pain. You elicit from her husband that she has had two heart attacks in the past and the drugs in her handbag are bendrofluazide, frumil, and lisinopril. Her blood pressure is 90/52 and her pulse is 105. You are concerned that she may be hypovolaemic, but you are aware of the dangers of giving too much fluid to a patient with probable heart failure. You elect to insert a central line for central venous pressure monitoring but she has a neck collar on and so you wonder if placing this via the femoral vein would affect your readings.

You are attending to a 68 year old gentleman who was found in his car having left the road and hit a tree. On arrival his GCS was 6 and he had 2 fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema. There is nothing acute on his ECG and only mild cerebral oedema is seen on the head CT. You can see that his fluid balance will be very difficult to manage over the next few days and that the balance between hypovolaemia and pulmonary or cerebral oedema will be vital to management. You elect to insert a femoral central line but wonder if there will be any infective risks to placing this into the femoral vein rather than the currently inaccessible cervical region.

While closing a 59 year old lady after elective mitral valve replacement, the theatre nurse hands you 500mg of vancomycin powder to apply to the sternotomy wound prior to closure. You have just completed a BET relating to resistant bacteria in surgical patients and you question whether there is any benefit to this method in addition to intravenous antibiotics.

A 4 year-old boy with a cough and a fever is referred by his general practitioner. On auscultation of his chest there are focal signs suggestive of a lower respiratory tract infection; a chest X-ray confirms right lower lobe collapse and consolidation. He is started on oral antibiotics and discharged home within 24 hours. He is given a follow-up appointment in 4 weeks time in the "registrar clinic" to be reviewed after having a repeat chest X-ray as per your unit's protocol. At the follow-up appointment he is clinically well and has a normal radiograph. After discharging him you wonder whether the "routine" exposure to radiation outweighs the detection of persistent radiological changes.