Archives: BETs

8-year-old boy, previously healthy presents to your emergency department with cellulitis of the right forearm. He is otherwise systemically well. You decide to prescribe flucloxacillin. His mother reports an allergy to penicillin. Allergy history reveals a maculopapular rash on day 3 of amoxicillin therapy for otitis media at 2 years of age. He has never had any penicillin antibiotic since then. A colleague suggests clindamycin. You wonder if he could tolerate flucloxacillin given the nature of the reported reaction whilst concerned about the adverse event profile of clindamycin.

A 66-year-old man presents to the Emergency Department (ED) acutely short of breath, on a background of 10 days of fever, cough and pleuritic chest pain. He tells you that he had a positive COVID-19 swab in the community 5 days ago. His oxygen saturations are initially 85% on 10L oxygen by face mask and he looks tired. He is rapidly intubated and stabilised in the department, but his oxygen requirements remain at 60% despite optimised ventilation. You are unsure whether he has a concurrent pulmonary embolism (PE). A colleague says that looking at the difference between the arterial partial pressure of carbon dioxide (PaCO2) and end-tidal carbon dioxide (ETCO2) can sometimes be helpful. They suggest that an increased alveolar dead space fraction (AVDSf), calculated by PaCO2-ETCO2/PaCO2, can increase the likelihood of PE. You resolve to consult the literature to see if there is anything in this recommendation.

30 years old male presents to emergency department with SOB and known past medical history of asthma. Recently he was not using his daily puffers as prescribed by his family physician. You start managing him as acute asthma exacerbation, you wonder if there test that will guide your management and assess the patient response to medications given.

A 38- year-old woman presents to the Emergency Department (ED) in her third trimester of pregnancy. She complains of right sided chest pain and shortness of breath. There are no clinical signs of deep vein thrombosis (DVT) and she does not report haemoptysis. This is her second pregnancy and she has no personal or familial risk factors for PE. Her oxygen saturators are 98% with respiratory rate of 21 and a regular heart rate of 109 at rest. Her blood pressure is normal and she is afebrile. A junior doctor has already assessed the patient. He tells you that all the blood tests are normal except for a D-dimer which is raised at 625ng/mL. A chest X-ray (CXR) is clear and electrocardiograph (ECG) shows sinus rhythm. The junior doctor is unsure what to do next. He does not want to misdiagnose PE but is also worried about requesting CTPA.

A 70-year-old patient is brought to the Emergency Department (ED) with a fracture dislocation of her ankle. Despite standard analgesic treatment (SAT) including 10mg of Morphine intravenously (IV), 1gr of Paracetamol (IV) and nitrous oxide, the patient is still in moderate pain. There is significant delay in organising reduction and cast application under sedation. The patient is asking for more analgesia and the paramedics state that they have heard Methoxyflurane can provide effective pain relief for patients with similar injuries in out of hospital settings. Methoxyflurane is currently not adopted or available as part of SAT in the ED.

A 78 years old female, a 87 years old male, a 64 years old male and a 53 years old female, all had falls and confirmed fracture neck of femur. All had received IV Morphine for pain by the ambulance crew. They received fascia iliaca block (FIB) with 0.25% levobupivacaine adjusted to their estimated weight by the emergency physicians. Their pain scale varied between moderate to severe. We were expecting drastic improvement in pain within the first 30-60 minutes after instilling the blocks. Instead all had no pain relief even after 1-2 hours and required additional analgesics to reduce the pain in the emergency department.

ED Presentations- 78 years old female, 87 years old male, 64 years old male, 53 years old female, all had falls and confirmed fracture neck of femur. All had received IV Morphine for pain by the ambulance crew. They received fascia iliaca block (FIB) with 0.25% levobupivacaine adjusted to their estimated weight by the emergency physicians. Their pain scale varied between moderate to severe. We were expecting drastic improvement in pain within the first 30-60 minutes after instilling the blocks. Instead all had no pain relief even after 1-2 hours and required additional analgesics to reduce the pain in the emergency department.

You are the EM Specialist Trainee covering the resus room for respiratory patients. The 'red phone' rings to pre-alert the department about a 52 year old woman who tested positive for COVID-19 3 days ago. She is breathless with oxygen saturations of 74% on room air and will arrive in 5 minutes. During a recent conversation with a rheumatologist about a different patient, colchicine was mentioned as being currently under investigation for treatment of COVID-19 due to its well-known anti-inflammatory properties. You wonder if there is any evidence to suggest this potential treatment would be beneficial for your impending arrival...

A 25 year old non-smoker presents with a right sided spontaneous pneumothorax. He is breathless at rest with normal oxygen saturations on air and does not want to come into hospital for treatment.

A forty-year-old patient is brought to the Emergency Department (ED) by paramedics with suspected drug intoxication. They have a Glasgow-Coma-Scale score of 3 and the decision is made to perform a Rapid-Sequence-Induction (RSI) to enable control of the airway, neuroprotective anaesthesia and facilitate transfer to the radiology department. Immediately following administration of Alfentanil, Propofol and Rocuronium, they develop profound cardiovascular instability thought likely to be Rocuronium-induced anaphylaxis. Following initial treatment (with adrenaline, steroids and antihistamines), the Anaesthetic Consultant in attendance suggests giving Sugammadex to encapsulate the Rocuronium. You wonder if Sugammadex can really improve cardiovascular instability in established anaphylaxis?

A 50 year old man is brought into the emergency department with signs of an acute gastointestinal bleed. An urgent endoscopy is arranged. As you resuscitate him and prepare for this you remember that tranexamic acid has proven useful in major haemorrhage and wonder if it will aid haemostasis in this man and increase his chance of survival.