Archives: BETs

A 34 year old woman presents with a 2 day history of pleuritic chest pain. There are no abnormal physical signs and her only risk factor is that she is taking the oral contraceptive pill long term. You wonder if a combination of clinical examination and the available d-dimer test (SimpliRED) would be suitable to rule out pulmonary embolism.

A 38 year old man presents with moderate to severe left sided renal colic. He is known to suffer from renal stones. Examination reveals mild loin tenderness and there is blood in the urine. Oral analgesia seems unlikely to control his pain. You speak to a colleague who suggests that you use buscopan (hyoscine butylbromide) - an antispasmodic. You wonder if there is any evidence that this works.

A 38 year old man presents with moderate to severe non-specific abdominal pain that is colicy in nature. He has no significant past history. Examination reveals mild tenderness but no signs of peritonism. Oral analgesia seems unlikely to control his pain. You speak to a colleague who suggests that you use buscopan (hyoscine butylbromide) - an antispasmodic. You wonder if there is any evidence that this works.

A 20 year old man presents to the emergency department in status epilepticus. Initial therapy with benzodiazepines and phenytoin is unsuccessful. He is intubated and ventilated using thiopentone and suxamethonium. 10 minutes later he starts to fit again. The anaesthetist suggests that propofol may help but you have heard that propofol can increase EEG activity. You wonder whether this is an appropriate drug to use.

A mother brings her 2 year old daughter to your clinic. She is concerned about her speech which she feels is poor for her age. Her daughter has failed two consecutive audiograms. On otoscopy she has signs of bilateral otitis media with effusion (OME) which you have confirmed on a previous occasion two months ago. Should you refer for insertion of grommets?

Tearful nineteen year old university student accidentally walked into IVDA 6 hours ago at a party and has puncture wound to hand from needle projecting from user's pocket. Needle and user not available.

A 23 year old man attends the emergency department having been assaulted outside a nightclub with a hammer. He has sustained an isolated head injury with no loss of consciousness and is fully alert and oriented. He has a compound depressed left parietal skull fracture (confirm and defined by CT scan). No surgical intervention is considered. You wounder whether the adminstration of antibiotics will reduce the chance of meningitis developing.

A healthy 22-year old lady attends the emergency department, complaining of a painful, red finger, which she says has come on over a couple of days. Examination reveals erythema to the side of her fingernail with a suggestion of a slight yellow centre. You diagnose an acute paronychia, but wonder whether to prescribe her a course of oral antibiotics or formally incise and drain the suspected collection.

A 2 year old child presents to the emergency department with a limp. The child is mildly pyrexial and has some limitation of movement. You decide to take blood as part of your diagnostic strategy to exclude septic arthritis. The parents are keen to get on with the tests and are disappointed that the EMLA cream you intend to use takes so long to work. The paediatric emergency nurse suggests using tape to "clean" the skin prior to application in order to get the EMLA to work faster. You have no idea what she is talking about but wonder whether there is any evidence to show that she is right.

A friendly, coryzal 5 year old girl with acute lymphocytic leukemia attends with another episode of febrile neutropenia. According to departmental protocol, her admission includes a chest x-ray. You wonder as to the value of this routine irradiation.

You are the doctor on-scence of a road accident attending a 30 year old male who has sustained blunt trauma to the abdomen. Systolic BP is 70 mm Hg despite resuscitation. Someone suggests using the pneumatic antishock garment (PASG). You cannot remember from your recent ALSG course whether this can be used to support blood pressure in hypotensive patients. You wonder if PASG use has been shown to have any effect on mortality.

A 32 year old un-helmeted cycle courier is brought to the ED after a collision with a car. He has an isolated severe head injury (GCS=7) and is intubated before transfer to the CT scanner. You wonder if the severity of his injury, or his outcome, would be improved had he been wearing a helmet.

A thirty year old man presents to the emergency department with a spontaneous onset of atraumatic pleuritic chest pain. He is in a low risk group clinically. The medical registrar suggests that the fact that the ECG is normal makes the diagnosis of pulmonary embolus much less likely. You wonder whether his assertion that a normal ECG will help to exclude a pulmonary embolus is safe.

A 3-year-old child attended A&E with high fever for 24 hrs. Examination showed congested throat, runny nose and red tympanic membranes. You make a clinical diagnosis of URTI ? viral. You prescribed antipyretic medicine but a fan was on near by child's bed. So you wonder whether any evidence that fanning will be of additional benefit to antipyretic therapy.

A paramedic crew brings a 27 year old patient with a suspected cervical spine injury to the emergency department following an RTA. At the scene of the accident the patient had full spinal immobilization, which consisted of a long spinal board, a correctly sized cervical collar, and head blocks with straps to secure the head to the board. In the emergency department the patient is becoming increasingly distressed by the presence of the neck collar and requests that it is removed. You wonder whether the cervical collar provides any additional benefit in terms of immobilizing the spine.

A 4 month old infant attends the emergency department in the late morning with bronchiolitis. It is the first episode of wheeze. Clinically, there is moderate indrawing and recession, tachypnoea (RR=50), reasonable air movement on auscultation, and the oxygen saturation is 94% in air. You want to admit the infant, but the mother is breast-feeding and keen to get home by 3pm, when her other children get home from school. You have heard that in North America, nebulised adrenaline has been used in some cases and admission has been avoided.

A 4 year old boy presents to the emergency department with a 4cm laceration to the thigh. This requires cleaning and layered suture closure. You decide to sedate him using Ketamine IM. You are successful and close the wound. However, while he is recovering he appears to be experiencing unpleasant hallucinations. You wonder whether a small dose of midazolam given with the ketamine would have prevented this.

A 75 year old man presents to the emergency department with a wrist injury. X-ray reveals a Colles' fracture with dorsal angulation requiring manipulation. The patient has had lunch one hour before presentation. Your colleague tells you that you should manipulate the fracture before your shift ends in a hours time, but a passing anaesthetist says that you should wait at least 5 hours (6 hours after food) before you do anything. The departmental manager points out that this means the patient should be admitted since they will "breach" the target time of 4 hours if you wait. If they are admitted the next available trauma list is in 36 hours. You wonder whether the patient should be fasted for 4-6 hours or if it is safe to reduce this fracture under Bier's block without any period of fasting.

A 76 year old male is brought in to A&E in a collapsed state. He has a history of ischaemic heart disease. He is agitated, tachypnoeic and sweating profusely. His neck veins are distended and there are widespread coarse crepitations in his chest. He has a diminshed oxygen saturation. You make a clinical diagnosis of acute cardiogenic pulmonary oedema. In addition to vasodilator treatment and opiates, you wonder whether you should administer non-invasive positive pressure ventilation (NIPPV).

A 25 year old man is brought to the Emergency Department after collapsing in a club. His friends report ingestion of Gammahydroxybutyrate (GHB) and alcohol. His Glasgow Coma Scale score is 3 on arrival and he is intermittently apnoeic. When you attempt to intubate him he seems to rouse but quickly becomes unresponsive again once you stop. You ask for anaesthetic help. The anaesthetic registrar has a similar experience on attempting intubation. You are sure you have read that physostigmine can be used to avoid intubation in this situation. You wonder if you have remembered correctly.