Archives: BETs

A 35-year-old man alleges that he has been assaulted. He claims that he was hit on the head with a hammer. He is only complaining of pain around the site of the injury. On examination there is haematoma present, but no laceration. Standard skull views reveal no bony injury. You suspect a depressed skull fracture and wonder whether a tangential x-ray of the site of the injury, or a CT scan would be better able to detect it.

Different Emergency Departments have different protocols/preferences in the way children with mild or minor head injury are investigated. Some prefer observation plus or minus plain skull X-ray, others use head scan as the first choice modality. The department you are currently working in uses plain radiology. You are concerned that in children with mild head injury with no abnormal neurology and no fracture seen on plain skull films there is a tendency to be falsely reassured that intra-cranial injury (ICI) is unlikely.

An 8 year old boy attends the emergency department following a fall at school. Clinically he has a displaced fracture of the right radius and ulna. He is in a lot of pain and so needs analgesia before X-ray. You have heard of the use of nasal diamorphine for pain relief but wonder whether there is evidence to show whether it is as effective as injected morphine.

A 35 year old pregnant woman is brought into the resuscitation room of the Emergency Department in established cardiac arrest of 3 minutes duration. Full basic life support has been present since arrest; initial application of advanced protocols has not re-established circulation. You wonder whether emergency caesarian section could be life saving for either foetus or mother.

You have just seen a patient with presumed renal colic. You have prescribed a dose of IM diclofenac as per departmental policy but wonder if a newer fast dissolving oral piroxicam agent would be as effective as the usual parenteral diclofenac agent.

A 59 year old man presents with an exacerbation of COPD. You wonder whether it is better to nebulise salbutamol or ipratropium bromide alone, or a combination of the two.

You are resuscitating a 30 year old male with a severe closed head injury. His GCS was 3 on admission. He is intubated and ventilated and a CT scan is being organised. His blood pressure is only 90/40mmHg. You want to improve cerebral perfusion by giving IV fluid but are aware that too much fluid might worsen cerebral oedema. You wonder whether there would be any advantage in giving hypertonic saline.

An 8 year old boy is taken to the Emergency Department after falling out of a tree. He has no signs of injury apart from abrasions and tenderness across his upper abdomen; he is haemodynamically stable. He undergoes an abdominal ultrasound that is normal but you wonder how accurate this is at identifying intra-abdominal injury compared with the current gold-standard, abdominal CT.

A 35 year old man presents with a dislocated shoulder. You are about to undertake the reduction under sedation in the emergency department and wonder whether the use of a propofol infusion rather than boluses of midazolam would give effective sedation with shorter recovery time without compromising safety.

A 55 year old male presents with massive haematemesis. He has known oesophageal varices. He is tachycardic, peripherally shut down and continues to actively vomit fresh blood. You wonder if pharmacolgical treatment with terlipressin will be effective in reducing the bleeding.

A 35 year old male presents to A&E with acute renal colic proven on urine dipstick analysis and urgent IVU. His pain is severe and you would like to give him IM diclofenac as he is vomiting and it is your current practice. He tells you he developed a sterile abscess last time he was given IM diclofenac. You wonder if an alternative NSAID, piroxicam, given by the IM route would be as effective as the diclofenac you are reluctant to give.

A 45 year old man presents to the emergency department with a one day history of left-side facial weakness. Physical examination confirms that the patient has an incomplete left-sided Bell's palsy. As prednisone has a limited role in improving the recovery of incomplete Bell's palsy and medical literature postulates a viral etiology in Bell's palsy, you wonder whether acyclovir would improve the outcome for this patient.

An eighteen-year old presents to the emergency department with a two-day history of redness and swelling in their left arm after a scratch. They are systemically well, and apyrexial. A diagnosis of cellulitis is made and you feel you can discharge the patient on oral antibiotics with outpatient follow up. You wonder whether flucloxacillin or azithromycin would be better at improving outcome.

A 5 year old shocked child is presented to the emergency department via ambulance. Intravenous access is not possible and you decide to place an intraosseous needle. You find that the trolley has been stocked with standard bone marrow aspiration needles rather than the special intraosseous (IO) needles that you are used to. You swear loudly and eventually gain access with great difficulty using a cutdown technique. You later wonder whether you could have used the standard bone marrow needle instead.

A middle aged man attends the emergency department having sustained an acute primary anterior shoulder dislocation during a fall. It is impossible to obtain peripheral venous access and you are not able to get him to breathe entonox. You are aware that shoulder dislocations can be reduced with intra-articular lidocaine (IAL). You wonder if IAL is as effective as intravenous analgesia and sedation (IVAS).

A 20-year-old male is brought to the Emergency Department in acute respiratory distress with asthma. He has a history of poor compliance with unstable asthma and several hospital admissions in the past. His old notes are available and you notice whenever IV treatment has been commenced he has been given aminophylline. You feel that the best drug is a beta-2 agonist and that if it is not getting to the receptors via the airways then IV is the next best route. There is some dismay among the nursing staff when you formulate an IV regime. They say they have never given it before. You wonder whether your approach is evidence-based.

A 37 year old female patient attends the emergency department with a 4 hour history of epigastric pain. The patient has been taking NSAIDs for backache for the last few months. On examination they have mild tenderness in the epigastric region but no peritonism. You wonder whether an erect chest Xray is sensitive enough to exclude a perforation of an abdominal viscus in this patient.

A man attends the emergency department having deliberately taken 150 ml of "antifreeze". The can of antifreeze has conveniently been brought along and you find it consists of a mixture of methanol and ethylene glycol. The Poisons Centre is contacted. In addition to treatment with ethanol it is suggested that intravenous Leucovorin (calcium folinate) is given. You wonder if there is any evidence to support this recommendation.

A patient attends the emergency department in status asthmaticus. On examination they have a sinus tachycardia at a rate of 150/min, an oxygen saturation of 92% on high flow oxygen and a pCO2 of 7.0kPa. Despite maximal medical treatment they are becoming exhausted. You decide that the patient needs a rapid sequence intubation and continuous mandatory ventilation. You wonder whether the pretreatment with lignocaine will attenuate the respiratory response (bronchospasm) to airway manipulation.