Archives: BETs

A pregnant female presents to the emergency department with repeated episodes of vomiting. She has not used any medications at home for relief. She has been unable to tolerate fluids. While a nurse prepares to place a peripheral IV, you begin to wonder if ondansetron or metoclopramide would be more beneficial for a pregnant woman with vomiting.

Very few environments rival the complexity, unpredictability, acuity, time pressures and decision density of the Emergency Department (ED)1,2. Unsurprisingly it has been described as a natural laboratory for human error3. Despite the skills of the Emergency Physician in making decisions, an unacceptable number of decisions made in the process of medical diagnoses are wrong with error or diagnostic failure rate estimated to occur in 10-15% of decisions in the ED4. Expert opinions within Emergency Medicine have highlighted the role of cognitive debiasing strategies5 and cognitive forcing strategies6 to decrease the error attributable to cognition. The need to take all available steps to prevent error and harm from occurring has been highlighted as a moral and professional obligation in order to honour the ethical principles of beneficence, non-maleficence, fairness and justice7.

A 30-year-old male attends the Emergency Department with a dislocated shoulder, confirmed by plain film x-rays. This requires manipulayion and reduction under conscious sedation. You prepare your drugs, drawing up propofol. The patient however mentions that he had experienced some severe pain on the injection site during a previous sedation with a propofol. You remember one of your colleagues mentioning lidocaine use to prevent pain on propofol injection and wonder if there is any evidence for its use. 

A female patient presents at the emergency department, following the apparent ingestion of ecstasy in a night club. She appears confused and severely agitated, with tachycardia and a temperature of 40°C. The patient begins seizing, which is controlled with benzodiazepines, but as her temperature continues to rise, you consider which method may be best for cooling the patient.

A 30 year old male is brought to the emergency department following the ingestion of MDMA on a night out. He presents with a temperature of 40°C, rigidity and aggression. Following chemical restraint by diazepam, he is diagnosed with serotonin syndrome. As a your team attempt to manage his hyperkalaemic state, his temperature continues to rise and you consider whether or not administering cyproheptadine would reduce the risk of patient mortality.

A 30 year old male is brought to the emergency department following the ingestion of multiple ecstasy pills on a night out. He initially presents with a temperature of 40°C, impaired consciousness and muscle rigidity. He is diagnosed with serotonin syndrome, sedated with benzodiazepines and treated with ice packs. However, his temperature continues to rise. You consider whether olanzapine or chlorpromazine would be beneficial for the patient.

A 30 year old male is brought to the emergency department following the ingestion of MDMA on a night out. He presents with a temperature of 41 degrees C, rigidity and severe agitation. He is diagnosed with serotonin syndrome and sedated with diazepam. Ice packing is used to attempt patient cooling, however his temperature continues to rise. You consider whether or not dantrolene would reduce the likelihood of patient mortality.

The Trust introduced a new blood collection system that stated the tourniquet should be removed prior to blood collection during routine venepuncture. You conducted a quick survey of staff that revealed all clinicians (apart from one nurse who had recently attended her venepuncture training) leave tourniquets in place throughout the blood collection phase. You checked the current Trust policy, which also states that tourniquets should be removed prior to blood sampling. No rationale for this instruction is given and you wonder why tourniquet removal is recommended in the Trust policy. You carried out a quick Internet search that seemed to indicate serum electrolytes (potassium in particular) can be affected if the tourniquet is left on during blood collection.

75 year-old-gentleman from the old age residential home presented with acute breathlessness since 2 hours ago. He has a background of COPD, IHD, HT and CVA. The patient was too symptomatic to volunteer any history. Only very limited information was obtained from the carer from the residential home. ABG showed type 2 respiratory failure. The portable CXR machine was still on its way. You wonder if any further useful information can be obtained from bedside lung ultrasound assessment to help you quickly decide the treatment plan in the high dependency unit.

While working the evening shift, a 45 year-old man presents to the emergency department with a progressive erythematous and swelling area on his leg. He is afebrile with unremarkable vital signs. The physical exam is suspicious for underlying abscess, as there is a fluctuant and localized pain. Before you proceed to drainage, you wonder if a bedside ultrasound of the soft tissue might help you to better assess the presence or absence of abscess to avoid unnecessary procedure.

A 56 yo homeless man with a history of alcoholism and stroke is brought to the ED after he was seen sleeping on a park bench in the snow without shoes. He is rousable but 34 F [not sure about this - reads more like Celsius] and is clearly intoxicated with a blood EtOH of 0.22 mg/dL. After giving the patient initial re-warming treatment with warmed blankets, you notice his toes appear severely frostbitten. You know tPA therapy is absolutely contraindicated in this man, but wonder if something else will decrease the likelihood of this man’s toes being amputated.

A 4 year old girl is brought to the Emergency Department with a rash that is obviously chicken pox and she is very distressed. The triage nurse comes to ask what analgesia can be given as paracetamol was given at home 30 minutes ago and they have heard that ibuprofen is contra-indicated in chicken pox.

In the ED this intervention is usually required in the critically unwell patients who may well be hypotensive, tachycardic and distressed. Such physiology often results in poor peripheral perfusion and, in conjunction with an often pressured environment, can only increase the level of difficulty associated with an already challenging procedure. Dr Ian Sexton-Examining The Role of Ultrasound in The Placement of Radial Artery Catheters 5 Ultrasound (US) is becoming increasingly entwined in the delivery of critical care in the ED and has been incorporated in EM training for a number of years. The use of US in establishing central venous access is established best practice in the UK, improving both performance and safety. Perhaps the same applies to US in the placement of arterial catheters?

You are working in the Emergency Department and it is 0200h on Sunday morning. You review a 65 year old gentleman with severe atraumatic foot pain, particularly over the 1st metatarsophalangeal joint. He is overweight, with a history of hypertension and ischaemic heart disease, and you diagnose gout. Medical school knowledge tells you he needs colchicine, although a quick look at the British National Formulary suggests it can be toxic in higher doses (plus how will he get hold of this before Monday?). You review international guidelines which recommend non-steroidal anti-inflammatory drugs (NSAIDs) as first line treatment, but his co-morbidities may preclude their use. You see that systemic steroids are also recommended, but you wonder if they will work…

An 86 year old man is admitted to the respiratory ward with his third pneumonia in 6 months. A bedside swallow exam is abnormal however; no overt signs of aspiration / penetration are evident. The next available date for videofluoroscopy is in a week. We wonder if there is a sensitive predictor of silent aspiration that could be used at bedside. We have heard of cough reflex testing but wonder about its evidence base.

A 49-year-old female is brought to the emergency department via ambulance with left-sided facial droop, right tongue deviation, reduced sensation on her left side with pronator drift. Her symptoms were first noted shortly after waking; Can DWI/FLAIR mismatch MRI be used to identify the time of stroke onset for potential tPA treatment?

A 39-year-old female with acute behavioural disturbance was brought to the emergency department by police. She was intoxicated with alcohol, agitated, very abusive, spitting on others, and presented a physical threat to other patients and hospital personnel. Her relevant medical history was not known and it was not possible to take vital signs. She was physically restrained by five hospital security guards. You are concerned about the patient’s airway because of physical restraint, the possibility of cardiovascular instability and metabolic derangements, and about the safety of the emergency department environment. You wonder whether ketamine is an appropriate first drug of choice in this setting.