Archives: BETs

in patients wirh acute severe asthma, does NIV improve outcome?

We routinely use EQ-5D as a patient experience based outcome for our stroke and neuro service but is it a valid measure for our service? Neurology was considered to be too wide an area and therefore we narrowed the question to stroke. We did not restrict the question to community dwelling patients as it was felt this would restrict the search.

An 8 year-old known asthmatic patient presents to the Emergency Department with a typical exacerbation of asthma. He is partially improved after one bronchodilator treatment and oral steroids. You wonder if inhaled corticosteroids (ICS) would benefit the systemic steroids you are already prescribing.

A three year old child is brought to the emergency department with pyrexia and dehydration, requiring cannulation. Routinely topical anaesthetic Ametop would be applied prior to this procedure. However a paediatrician has come to see the patient and requested giving the child sucrose. When questioned, the paediatric doctor explains it provides comfort and settles children during procedures such as cannulation. Despite years of Accident and Emergency experience using this technique for comfort in neonates you wonder whether this will be of similar effective use in older children.

You work in a resource poor country and cooling of infants with Hypoxic Ischaemic Encephalopathy (HIE) is not available. A term baby is born with low Apgar scores and admitted to the neonatal unit, where you confirm moderate to severe HIE. As cooling is not available you wonder if starting phenobarbital (PB) would reduce mortality or disability.

10 month old girl seen in PICU, approx 12 hours after developing toxic shock syndrome secondary to a thigh myositis. Had been resusitated agressively in resus before transfer to PICU with fluids, antibiotics and commenced on inotropes. It was decided to give her IVIG. throughout the day the patient improved clinically, I noticed her ABG had dramatically improved, and she required less inotropic support. I wondered whether her dramatic improvement could have been sooner if we had administered IVIG in resus.

Over the years there has been increasing evidence to support the benefit of effective chest compressions in the management of patients in cardiac arrest. In some areas, mechanical chest compression devices have been used in order to facilitate this. I want to explore the evidence surrounding these devices and their use / introduction in the Adult Emergency Department.

A 60-year-old man presents to the emergency department with typical cardiac chest pain but is now pain free. His ECG is not diagnostic of ST elevation myocardial infarction (STEMI) but shows 1.5 mm ST segment elevation in lead aVR. Having visited a number of educational websites, you recognise that this finding may signify left main coronary artery (LMCA) occlusion. Concerned about the potential risks associated with both failure to recognise such an important and potentially life-threatening diagnosis and with those associated with over-diagnosis, over-investigation and over-treatment, you wonder whether the presence of ST elevation in aVR is a specific marker of that diagnosis.

Your trauma patient rolls through the door. The blood pressure looks good and there does not appear to be any chest injuries. Disappointed, you put your new thoracotomy shears back in your pocket. You brighten up when you realise the patient has sustained a serious head injury and will need intubating. As you brandish your prefilled syringes of ketamine and rocuronium towards the patient the anaesthetist on the trauma team starts reading from the rapid sequence induction (RSI) checklist. Rolling your eyes, you point out that this is major trauma, not a Friday morning elective cholecystectomy and demand that they proceed with the intubation immediately. Anyway, you have already given the ‘ROCKET’ induction while you have been talking, so they better start doing something fast… Later, while pulling on your lycra shorts and downing a seventh can of Monster energy drink, you reflect on the case. Initially, you are clear that the SpO2 of 65% for a few minutes was unavoidable. Then you remember that the suction was found not to be working initially, the first laryngoscope failed and your plan B consisting of ‘get out of my way and let me do it’ seemed a surprise to everyone. You experience an unfamiliar twinge of self-doubt, and decide to read up on this checklist business after crossfit later…

A 72-year-old man who is otherwise fit and well and on no regular medications presents to the emergency department (ED) with epistaxis that is ongoing despite appropriate first aid measures. No visible bleeding points can be seen on examination to allow cautery. After explaining treatment options to the patient, he states that he is very reluctant to have nasal packing because he once had it before and it was very uncomfortable and he then had to be admitted overnight, which he does not want. He is also concerned that after that admission he went home only to start bleeding again two days later. He wants to know whether there are any alternatives. You have heard of people using tranexamic acid to stop epistaxis but you are not sure whether this was topical, oral or intravenous and you do not know whether there is any evidence to support this …

67yo female with past a medical history of chronic kidney failure presents with chest pain and fatigue. EKG shows wide QRS complex and peaked T waves. iStat shows potassium of 8.3mEq/L. While starting hyperkalemia treatment with Calcium Gluconate, Insulin + Dextrose, nebulized Salbutamol, and Kayexalate, you question whether nebulization or intravenous administration of Salbutamol is more effective in decreasing plasma potassium levels.

13 year old, previously healthy male presents with non-specific chest pain for last 3 hours. After a thorough history and physical, no abnormalities are found and diagnostic testing is debated. Knowing that adult patients with similar symptoms cause concern for ACS, you question whether pediatric patients have similar concerns with ACS and whether a full cardiac workup is warranted.

You are a senior doctor working in the Emergency department when a patient presents with a red painful eye. You suspect orbital compartment syndrome and know the patient could lose their sight if you don't act. You know how to do a lateral canthotomy as well as the risks but wonder if it is reasonable to do this within the emergency department?

A 4 year-old child presents to your local ED with respiratory symptoms and fever. In order to confirm your suspicion of pneumonia, you plan to order a chest radiograph, but a quick look into the child's medical record shows he has already undergone several X-rays in the last few years for the evaluation of upper respiratory tract infections. Being aware of the potential long-term effects of radiation on your patient, you wonder if bedside lung ultrasound could be used to diagnose pneumonia.

A 45 years old female teacher presents to the Emergency Department with severe hoarseness and a mild cough for three days. She hasn’t been able to work since then. Her vital signs and physical examination reveal nothing particular except an important dysphonia. You tell her that she has an acute laryngitis, a self-limited condition that will resolve with voice rest. You wonder if a brief course of corticosteroids can reduce her dysphonia and speed her recovery.

A 50 years old man with good past health presents to A&E with a 10/7 history of paroxysmal palpitation. His hear rate is around 80 bpm, and 12 leads ECG shows one PVC over 10 seconds with symptom. Repeat long lead ECG showed no PVC over 60 seconds at time of symptom free. TnI and CBC LRFT are normal. Private echocardiogram and Holter were performed a few days ago for previous episodes, and revealed pvc but no structural abnormalities. Blood tests including TFT in private were all within normal range. A clinical diagnosis of PVC is made. The patient is asking whether there is any drug to reduce his symptom.