A 24 year old male is brought to the emergency department after falling whilst sat on the window of a moving car. His only apparent injury is to the head where there is a laceration to the occiput. He is brought in tolerating a guedel airway. He responds to pain with abnormal flexion and opens his eyes to pain, there is no vocal response (GCS 7). You decide to intubate the patient using an RSI technique. As a cervical injury cannot be excluded you attempt intubation in the neutral position with manual C-spine control and the hard collar removed. At laryngoscopy using a size 4 Macintosh blade you are unable to visualise the cords (Grade 3 view) but manage to intubate the patient using a gum elastic bougie. Later, when discussing the case with an anaesthetic colleague they ask why you did not use a McCoy laryngoscope as they claim that these are better when patients are intubated in the neutral position. You wonder is there is any evidence to back this up before you go and buy some more equipment for the emergency department.
Archives: BETs
An unresponsive young adult is brough to the emergency department. No history is available. Neurological examination reveals no focal abnormality and pupils are mid-size and reactive. Blood glucose is normal. You suspect an overdose and wonder whether flumazenil should be given to ascertain whether benzodiazepines are involved.
Hand held metal detectors are sensitive enough to rule out oesophageal coins
A 3 year old boy is brought into the Emergency Department by his mother. She says that he swallowed a coin 2 hours earlier. The boy is asymptomatic. You know it is important to rule out oesophageal impaction and wonder whether a metal detector can accurately show whether the coin is above or below the diaphragm.
A 24 year old man presents to the Emergency Department with a history and examination consistent with appendicitis. On referral, the duty surgeon requests a full blood count. You wonder whether it will aid the diagnosis.
A 6 year old individual presents to the Emergency Department with a history and examination consistent of appendicitis. On referral, the duty surgeon requests a full blood count. You wonder whether it will aid the diagnosis.
Regional anaesthesia worked well for children with femoral shaft fractures
A 6 year old child presents to the Emergency department with an undisplaced fracture of the mid femur. You have used femoral nerve blocks in adult patients with similar fractures and wonder whether this block is useful in children.
A 50-year-old presents with Bells' Palsy. You have heard that physiotherapy is an effective treatment but wonder whether facial exercises produce a better outcome than treatment with electrical stimulation.
A 2 year old is brought to the emergency department with a first presentation of fitting secondary to febrile illness. She has been fitting for >30 minutes. You obtain intravenous access and wonder if lorazepam or diazepam would be best at terminating the fit safely.
A 2 year old child is brought into the emergency department by her parents. They tell you that she has not used her left arm since tripping over while holding her older sisters' hand. The child is holding her left arm flexed at the elbow and semi-prone. The diagnosis is clearly a pulled elbow. You have heard various colleagues arguing vehemently for pronation and supination manoeuvres, and wonder which is actually the best method for reduction?
GII/IIIB inhibitors in addition to LMWH unproven in unstable angina
A 45 year old man attends the Emergency department with 30 minutes of chest pain. An ECG shows ST segment depression in the inferior leads. You wonder whether he should be treated with low molecular weight heparin or a glycoprotein IIa/IIIb complex inhibitor.
A 29 year old man attends the emergency department having ingested an unknown quantity of car anti-freeze liquid. His airway, breathing and circulation are satisfactory. He is normoglycaemic. He appears intoxicated, has a depressed level of consciousness with no evidence of injury. You have heard that there is a new treatment available and wonder whether this (methylpyrazole) is better than the standard approach of ethanol and/or haemodialysis.
A 32 year-old woman with asthma presents to the Emergency Department with a 20-minute history of palpitations. On examination she is cardiovascularly stable, there is no bronchospasm and the ECG shows a supraventricular tachycardia (SVT) that fails to respond to vagal manoeuvres. You would like to use IV adenosine but you are aware that asthma is a contraindication treatment. You wonder what evidence there is that IV adenosine will cause bronchospasm.
Abdominal ultrasound in the diagnosis of childhood appendicitis
An 8 year old patient presents to the emergency department with a six hour history of right iliac fossa pain; examination is suggestive of acute appendicitis. You wonder whether an ultrasound scan would be helpful for diagnosis.
Ultrasound is better than x-ray at detecting hip effusions in the limping child
A 3 year old child presents to the Emergency Department with recent onset of left-sided limp and no history of trauma. He is apyrexial, systemically well with a normal white cell count and ESR. You diagnose irritable hip and wonder whether x-ray or ultrasonography is better at detecting a joint effusion.
A 24 year old man presents to the Emergency Department on Saturday night with injuries to his lower jaw. He has been involved in a fight. On examination there is extensive bruising to the left side of the face and chin. The patient is unable to open his mouth or talk due to pain and trismus. You suspect a mandibular fracture and decide to x-ray the mandible. You wonder whether a standard mandibular series or a panoramic view is the best technique for accurately detecting any fracture.
Reimplantation of the nail root in fingertip crush injuries in children
A 2 year old child presents to A&E with a crush injury to the left index finger tip. The fingernail has been avulsed from the proximal nail fold. You wonder if surgical re-implantation of the nail root into the proximal fold will produce a better cosmetic result.
Phenytoin or paraldehyde as the second drug for convulsions in children
A fitting three year old child presents to the emergency department. The child has received an appropriate dose of rectal diazepam from the prehospital team. Following administration of a dose of intravenous lorazepam the child continues to fit. You wonder whether there is any evidence to suggest whether paraldehyde or phenytoin should be given next.
A 25-year-old man attends the emergency department with a one-day-old wrist injury caused by falling onto his outstretched hand. He is tender in his anatomical snuff box and also on longitudinal thumb compression, but he is in very little pain on normal everyday movements. You send him for a scaphoid series of x-rays which reveal no fracture. You arrange for him to return to the department in two weeks time for a repeat radiological and clinical examination. You wonder whether his wrist should be immobilised in a plaster cast or whether a simple elastic support bandage will suffice.
Diagnostic needle aspiration in olecranon bursitis may be indicated to define the underlying cause.
A 45 year old labourer presents to the Emergency Department with a one day history of pain and swelling over his right elbow. Examination reveals a generally well, apyrexial man with a swollen, warm right olecranon bursa with overlying redness. You wonder whether it is necessary to aspirate and analyse bursal fluid to diagnose an treat this patient.
A patient attends the emergency department having sustained a crush injury to the tip of their right index finger. This has resulted in a painful subungual haematoma but no other significant fingertip injury.