Archives: BETs

Therapists assess and treat patients following surgery for fractured neck of femur (NOF). Hip precautions (no hip flexion above 90 degrees, no adduction beyond midline and no rotation of the operated leg) are routinely adhered to in those having undergone hemiarthroplasty and total hip replacement. This has time and cost implication for example waiting for equipment delivery for discharge can increase length of stay. To ensure that following hip precautions is evidenced based practice, the orthopaedic therapy team wanted to conduct a BestBETs.

A 30 year-old male is brought in by paramedics with ongoing generalised tonic/clonic seizures that have been ongoing for 25 minutes. The paramedics have given 15mg of Midazalam IM with no effect, and couldn't gain IV access due to extensive track marks over the patient’s veins from extensive IV drug use. Vascular access is urgently needed to terminate this state of status epilepticus and to prevent further neurological sequelae. A central line would take too long to place, and would be extremely difficult in this patient. You decide to use an IO access kit to gain rapid access in this patient, so that benzodiazepines can be administered.

An adult patient presents to the emergency department with acute renal colic ('loin-to-groin' pain). You would like to give Tamsulosin 'off-label' to facilitate stone passage.

A nine year-old child presentes to the emergency department with a laceration to his nail bed following trapping his finger in a door.

A 44 year old male presents to the ED with primary epistaxis. It has spontaneously resolved. Should Naseptin cream be given on discharge to prevent recurrence?

An elderly lady who is otherwise well presents at your Emergency Department (ED) with a swollen, red leg. You suspect deep vein thrombosis (DVT), assess her Wells’ score, which is found to be low, and request a D-dimer level. The D-dimer level is marginally raised using the standard diagnostic cut-off. Your current clinical protocol mandates ultrasound scanning in this situation but you have recently heard that there is a natural rise in D-dimer levels with age. The usual normal range may therefore give a high false positive rate in older people. You wonder whether the use of an age-adjusted D-dimer cut-off might allow you to safely rule out DVT without requesting a scan.

A 78 year old female presents to your emergency department reporting increased wheezing over the last 24 hours. She reports a mildly productive cough and denies fever. A chest x-ray reveals no clear evidence of pneumonia. In addition to therapy for what you believe is a COPD exacerbation, you consider the possibility of bacterial infection. A colleague mentions that they are using procalcitonin as a biomarker to guide antibiotic therapy for patients with potential respiratory infection on the intensive care unit. You wonder if there is any evidence assessing the utility of procalcitonin for this indication in the emergency department.

A 70yr old man is rushed into resus with a BP of 60/30. He has been passing blood and clots in the urine for the last 24 hours. As you commence fluid resuscitation you wonder whether tranexamic acid may have a role in his manageemnt

A 72 year old male presents to the emergency department with pulseless ventricular tachycardia. You wonder if a precordial thump is effective in restoring the heart to a sinus rhythm?

You are the specialty emergency trainee doctor working in the emergency department. The next patient is a 42 years old female who is referred by her General practitioner with confirmed diagnosis of Carpal tunnel syndrome since last six months, for symptom management especially pain. She complained of pain, tingling and numbness in the left hand which gets worse at night. She mentioned about disturbed sleep due to aggravating symptoms. She was concerned because she was unable to return to work and look after her family. There was no significant past medical history. On examination there was sensory impairment in the first three digits, Phalen sign was positive. You discussed with the orthopedic Specialty registrar on call who requested to discharge the patient on oral analgesia and refer to the orthopaedic outpatient clinic for further evaluation for surgical intervention. You wonder whether non surgical intervention is better than surgical.

You are asked to see a 2-month-old boy who has been ill for 3 days. He has respiratory syncytial virus positive bronchiolitis and is needing 1.5 L/min oxygen by low flow. His capillary blood gas has pH 7.26 pCO2 9.9 kPa pO2 4.5 kPa and base excess −5.0. His respiratory rate is 60 and increasing. The family has been told he may need moving to 40 miles to the regional paediatric intensive care unit (PICU). They are worried and angry, not least because his sister is delivering a baby upstairs. You wonder whether starting continuous positive airway pressure (CPAP) will reduce the need for ventilation and help keep them together.

A 76 year old man presents to the Emergency Department with multiple rib fractures after falling down stairs. His pain is difficult to manage, despite intravenous opioids. You speak to the acute pain team for advice on how to manage his pain. They suggest using 5% lignocaine patches over the site of maximal pain.

A 9-year-old boy with a brain tumour attends my outpatient clinic for review. His current most disabling symptom is fatigue. His parents have done a Google search and found that methylphenidate can be used to treat fatigue in adults. They ask my opinion as to whether this would be an option for their son. What should I advise?

A 3-year-old boy was seen in the community paediatric clinic for follow up of his Duchenne muscular dystrophy (DMD). There have been recent discussions about starting him on steroids. His parents would like to know if treatment with glucocorticoid corticosteroids (GCs) has been shown to prolong ambulation and the best age to start steroids. They also want to know if steroids reduce the complications of DMD and if the side effects of long-term steroids are acceptable.

As the paediatric registrar in clinic, you see a child with cystic fibrosis (CF). Her mother mentions reading about newer treatments available to help improve lung function and mucus clearance. You have heard of inhaled mannitol being used in this context and wonder how effective it is and how it compares to the established treatments.

A 32 year old patient reports having a persistent headache during his most recent mountaineering trip to Colorado. He notes the headache occurred just prior to reaching the summit of Pikes Peak (14,115 ft)and persisted until his decent. He wants to know if there are any safe and effective medications he can take to help alleviate his symptoms during future high altitude climbs.

A 35 year old female known to suffer with severe depression and suicidal tendencies goes missing from her home address. Search teams are deployed and following a 3 day search the missing person is found alive but very cold and in a remote area of woodland inaccessible to other emergency services. Further medical support is requested to aid with rewarming the MISPER (missing person) and evacuate her to hospital.

You treat a cutaneous abscess in young adult male in the emergency department with incision and drainage. You wonder which method of wound closure will allow the wound to heal the quickest - primary suture straightaway or leaving it to heal by secondary intention

A 32 year old man attends casualty with a large abscess on his bottom, painful and ready to burst. You wonder whether you should pack the abscess after draining it. He is self-employed and needs to get back to work quickly.