Archives: BETs

A 6 year old boy presents to the emergency department after falling out of a fast moving car. He is extremely distressed and appears to have sustained multiple injuries including a large laceration to his head, bruising and deformity to both forearms and his left lower leg. After initial assessment and stabilisation you decide to paralyse, intubate and ventilate him prior to performing a head CT. However you are also concerned about the possibility of an intra-abdominal injury. You wonder whether an ultrasound or CT would be better at identifying this.

A 60 year old man presents to the Emergency Department with an acute exacerbation of COPD. Analysis of his blood gases is required. You wonder whether a capillary blood sample will be as accurate as an arterial blood sample.

A 49-year-old man presents to the Emergency Department with a three-hour history of central crushing chest pain. An ECG reveals an acute inferior myocardial infarction. You know that the administration of aspirin reduces future morbidity and mortality but wonder if the administration of aspirin is as time critical as thrombolysis.

A ten year old girl has presented on several occaisons since a recent head injury with a persistent headache. Clinical examination has previously been documented as normal. You wonder how significant the headache is with respect to the initial head injury.

A 67 year old man attends with increasing shortness of breath. He is known to have obstructive airways disease. You want to perform arterial puncture for blood gases. He tells you that last time it was very painful.You wonder if an injection of local anaesthetic would help?

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 diminished 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 continuous positive airways pressure (CPAP).

A 3 year old child presents to the emergency department with a short history of limp, temperature and difficulty in weight bearing on the left leg. The pain is principally located at the hip joint and you fear this may be a septic arthritis. You wonder if an Erythrocyte Sedimentation Rate (ESR) will help in excluding the diagnosis of septic arthritis.

A 28 year old man presents to the emergency department with a punch injury to the left side of his face after a fracas. Clinical examination reveals no wound, but tenderness, bruising and swelling over the left infraorbital area. Radiological examination confirms the presence of fluid within the maxillary sinus, suggesting an undisplaced fracture of the orbital floor. You wonder whether you should prescribe him oral antibiotics to reduce the incidence of infection.

A 35 year old man presents to the emergency department with an 18 hour history of a right sided sudden hearing loss. Examination does not reveal a cause. A diagnosis of idiopathic sensorineural deafness is made. Your consultant suggests that a course of prednisolone might be of benefit. You discuss this with the registrar in audiological medicine who does not support this approach. You wonder who is right.

A 25 year old patient presents to the emergency department 2 hours after taking a significant overdose of propanolol. She is bradycardic and hypotensive despite initial resuscitation with oxygen and IV fluids. An ECG shows a sinus bradycardia of 50 bpm. You have heard of treatment with IV glucagon but wonder if it has been of any proven benefit.

You have just finished an unsuccessful cardiac resuscitation with an initial presenting rhythm of ventricular fibrillation. You wonder if one of the new Biphasic defibrillators would have increased the possibility of successful defibrillation when compared to your old monophasic device.

A 5-year-old boy attends the A&E department after sustaining a twisting injury to his left ankle. On examination there is swelling and tenderness over the lateral malleolus. You know that the Ottawa ankle rules are applicable in adult patients and you wonder whether they are applicable in children too.

A child presents to the emergency department with a nosebleed that came on spontaneously and which has not responded to simple first aid measures. The bleed appears to be from the front of the nose and the patient has no underlying disease. You wonder whether silver nitrate cautery or application of nasal antiseptic cream is the best method of obtaining haemostasis.

A 2 year old child is brought into the emergency department with a general malaise and irritability for the last 24 hours. Examination of the right ear reveals a diffusely red bulging ear drum. A diagnosis of acute otitis media is made. You wonder whether there is any evidence that oral antibiotics would decrease the time to recovery and prevent secondary complications.

A seven year old boy with moderately well controlled asthma since his last admission 10 months ago presents to the Emergency Department with an acute exacerbation. You ask the nurse to administer salbutamol and ipratropium 5mg and 0.25mg as a nebuliser. She questions the value of adding an anti-cholinergic, despite your theoretical knowledge that the mechanism of action of both drugs should be additive you are left wondering about the clinical evidence to support this.

A 26 year old man attends the emergency department having been bitten on his right hand 30 minutes previously by his pet a venomous snake. Examination reveals extensive swelling of his forearm with lymphangitis, hypotension and gingival bleeding. He has no relevant previous medical history and is fully anti – tetanus immunised. You know there is the potential for infection from the snakes fangs and oropharynx, as well as contamination from the victim's skin and clothing. You thoroughly clean the wound with local wound toilet, and are happy that there is no fang left in situ. You wonder if prophylactic antibiotics are indicated to reduce the risk of infection.

A 55 year old female is brought to the emergency department following an overdose of alcohol and tricyclic antidepressants. She has a tachycardia (110) and a systolic blood pressure of 105mmHg. The GCS is 5 (extends to pain). You decide to do an RSI using etomidate and suxamethonium. You are only able to visualise the epiglottis at laryngoscopy (Cormack grade 3 view), and struggle to intubate the patient on the third attempt (having intubated the oesophagus twice). You wonder if it would have been easier if you had used a gum-elastic bougie.

A 56 year old lady present in Emergency Department with a history of severe pain in his right shoulder following a busy day working in his garden. She had pain on resisted abduction and tenderness over supraspinatus tendon.

You see a 50 year old man with a 2 hour history of cardiac chest pain and an ECG suggestive of acute myocardial infarction. You decide to thrombolyse. The cardiology registrar suggests that you also give IV Magnesium to reduce the incidence of ventricular fibrillation. You wonder whether there is any evidence to support this.

A 35-year-old man with a severe head injury is brought to the emergency department. He has fallen from a ladder and is leaking CSF from the left ear suggesting a base of skull fracture. He has a GCS of 3 and dilated pupils. There are no other apparent injuries. You decide to intubate him using an RSI technique. Laryngoscopic view is poor despite the use of a McCoy laryngoscope and cricoid pressure. You eventually intubate using a gum-elastic bougie. Your assistant performing cricoid pressure asks during the procedure if you want a BURP. Other bodily functions come to mind! Later your colleague explains that BURP (backwards, upwards, to the right, with pressure) on the thyroid cartilage improves the view. You wonder if in fact it is any better than simple cricoid.