Archives: BETs

A 10-month-old child is brought to the emergency department in the middle of the night, with a short history of episodic inconsolable crying, pulling his legs up and non-bilious vomiting. You suspect intussusception is the diagnosis, and you wonder whether a plain abdominal X-ray will assist in the diagnosis.

A 19 year old woman is brought to the emergency department 6 hours after paracetamol overdose. She is fully conscious and admits ingestion of 32 tablets of paracetamol. She is complaining of abdominal discomfort but no nausea or vomiting. Her examination is unremarkable. You arranged blood investigations. IV access and n-acetyl cysteine infusion started as per protocol. You wonder whether oral methionine would have been as effective as n-acetyl cysteine in her treatment.

A 27-year-old hiker attends with what appears to be a tick in the skin of his right leg. You seek the advice of your colleagues on the best method of removal, the registrar advises you to pull it straight out, another registrar suggests to pull out anticlockwise, the consultant denounces them as fools and says to pull clockwise. Sister suggests suffocating the tick with vaseline and a staff nurse thinks that nail varnish is better for this, a passing porter suggests burning it off with a lighted fag and the patient himself claims that his mother always recommended 70% isopropyl alcohol (for the removal of ticks). Confused you wonder whether there is any evidence for any of the suggested methods.

A 29 year old male is brought into resuscitation area having jumped out of a fourth floor window. He has abdominal and pelvic injuries but no chest, head or limb injuries. He is bleeding intractably and the orthopaedic team and surgical team cannot agree on a plan of management. You suggest that operative managment is required, they would like to perform a CT scan prior to theatre to determine who will lead the surgery. Exasperated you wonder whether factor VIIa would help to stabilise the patient and reduce his requirement for transfusion.

A 70 year old women presents to the A&E department with fracture of the distal radius, which requires manipulation. During the administration of Biers' block you failed to cannulate a vein distal to the fracture site. You wonder whether cannulation of vein at antecubital fossa is safe and effective.

A 70 year old gentleman presents to the emergency department in acute urinary retention. You decide to catheterise him. Your SHO tells you that when he was doing Urology it was standard practice to give systemic antibiotics to any patient catheterised post operatively. You wonder whether the patient in front of you needs them?

You are a junior doctor working in a neonatal intensive care unit. You are about to take blood from a baby born at 34 weeks gestation who is now 24 hours old and not being ventilated. The neonatal sister suggests you give the baby some oral sucrose before the procedure as analgesia. You have never used sucrose before and are uncertain whether there is any real evidence behind its efficacy.

A six year old girl comes to your outpatient pediatric clinic with a two-month history of cough and shortness of breath, requiring, nearly three times a week, administration of beta 2 agonists by jet-nebulizer. She has often been noticed to wheeze at school during the gymnastic class and when she's laughing or crying; almost once a week she awakes during the night complaining of cough and respiratory difficulties. Your diagnosis is persistent asthma (1) and after a short course of nebulized salbutamol (albuterol) and oral steroids you decide to start, twice a day, a prophylaxis with inhaled steroids, via a spacer device. As her mother is working outside home till late afternoon, she asks you if a once-daily administration would have the same efficacy.

A 20 year old female presents to casualty with complaints of recurrent pain and swelling in the perianal region. She has had similiar symptoms in the past and a perianal abscess was drained in the past but never really healed. On examination she has a small abscess with a fistulous track palpable. A diagnosis of recurrent perianal abscess is with an underlying fistula in ano. What is the evidence for the best available investigation to map the fistulous tracks.

A 2 year old child is seen in the out patients department with a history of breath holding spells for the last three months, occurring about 3-4 times per week. These are causing her mother a great deal of concern. You consider whether or not a course of iron would reduce the frequency of these attacks.

A gentleman attends the emergency department with a typically urticarial allergic reaction, which is not compromising either his airway, breathing, or circulation. You prescribe an H1 antihistamine and observe for resolution. At 2 hours he is no better. You wonder if you could have improved his chances of rapid relief with the use of an H2 antihistamine?

A 26 year old man attends the emergency department with a simple laceration requiring suturing. You wonder whether application of a topical antibiotic ointment may promote healing and reduce incidence of infection.

A 55 year old man presents to the emergency department with chest pain. An ECG shows changes consistent with acute myocardial infarction. He is given aspirin and oxygen. His thrombolytic therapy is commenced and in the meantime you wonder whether his pain would be best alleviated by either morphine or diamorphine.

A 10 day old neonate (corrected gestation 29 weeks, birthweight 960g) has been slow to establish feeds. Intravenous access is difficult and he is receiving parenteral nutrition through a CVC. He develops temperature instability and hyperglycaemia. You decide to start empirical intravenous antibiotics but keep the CVC in situ as the infant is relatively stable. Peripherally taken blood cultures grow CoNS. Should the CVC be removed, knowing that a future replacement may be very difficult?

A 30 year old man is brought to the emergency department with a GCS of 8 after falling down stone steps while drunk. Although he has not vomited, you are concerned that he cannot protect his airway. You decide to do a rapid sequence induction. As you organise and check your equipment, you ask the nurse to bring the departmental capnograph to the bedside. She tells you that it is still in ITU where it was left after transferring the last intubated patient. She does, however, suggest you use a disposable colourimetric CO2 detector found in the paediatric arrest trolley. Should you wait five minutes while the capnograph is brought from ITU, or would the colourimetric indicator be just as accurate?

A 30 year old male who is a known opioid addict is brought to the emergency department after an overdose of heroin, with a GCS of 3, a respiratory rate of 4 breaths per minute, and pinpoint pupils. You are aware that many addicts self-discharge on reversal of opioid intoxication (possibly due to precipitation of acute withdrawal symptoms), and that because naloxone has a shorter duration of action than most opioid agonists, there is a risk of harm to the patient if he becomes renarcotized away from the hospital. You wonder if use of the intramuscular or subcutaneous route reduces this risk by prolonging the duration of action of naloxone.

A 30 year old male who is a known opioid-addict is brought to the emergency department after an overdose of methadone. He had a GCS of 3, a respiratory rate of 4 breaths per minute, and pinpoint pupils. You are aware that the action of naloxone is shorter than that of methadone and wonder if naloxone infusion is less likely to precipitate acute withdrawal symptoms than repeated bolus doses.

A 30 year old opioid addict is brought to the emergency department having overdosed on heroin. He is successfully treated with a titrated bolus of naloxone. You wonder when it will be safe to discharge the patient.

A 25 week gestation baby, birth weight 695g is ventilated for respiratory distress syndrome. Invasive blood pressure monitoring at 2 hours of age showed a mean of 23-25 mmHg. The blood pressure did not improve over the next 24 hours, in spite of three intravenous boluses of 0.9% saline and concurrent infusions of dopamine and dobutamine at 15 ug/kg/min. A colleague suggests that dexamethasone might help to improve the baby's blood pressure.