Archives: BETs

An elderly woman attends your emergency department (ED) following a mechanical fall. She takes warfarin for atrial fibrillation and has a small occipital haematoma. Her Glasgow Coma Score (GCS) is 15; she has no amnesia and a normal neurological examination but did briefly lose consciousness. The International Normalised Ratio (INR) comes back within the therapeutic range at 2.9 and a CT scan is requested according to the National Institute of Health and Care Excellence (NICE) guidelines. The scan is reported as normal, and her social circumstances are adequate in that she lives with her husband who can keep an eye on her. You wonder, though, whether it is safe to discharge her or if there is a possibility of delayed intracranial haemorrhage (DICH) due to her coagulopathy, and therefore she should be admitted for a period of neurological observation so that it can be identified and acted upon at the earliest opportunity.

A young person with autism comes to hospital for an intervention and the procedure is cancelled as a result of the patient’s challenging behaviour and distress. You wonder if an individualised care plan would have reduced patient anxiety and improved cooperation with the intervention.

During a long resuscitation in the emergency department, you have to repeatedly remind the members of staff performing chest compressions to keep up a good rate. You recall that during previous cardiac arrests, the quality and rate of external cardiac compressions differs between operators. You wonder if a metronome could help providers by defining a set rate and so improve cardiopulmonary resuscitation (CPR) quality.

A 49 year old man with known alcoholic liver disease attended the ED, unwell. While in the ED he had a fit and bit his tongue. He only had a platelet count of 28 and so developed massive tongue swelling, which obstructed his airway. He had an emergency tracheostomy and has been sedated and ventilated. He will be transferred to ICU. The ENT surgeon asks for dexamethasone to be started to reduce tongue swelling. As the tongue swelling is caused by a large haematoma you wonder whether he would benfit more from the application of leeches (hirudotherapy)?

You heard from a colleague that "if there is a radial pulse, then the SBP is at least 80mmHg", you wonder if this is actually true in the trauma patient.

A 78 year old lady is admitted on a saturday follwing a fall at home and acopia. She is then admitted to the acute medical unit. Physiotherapy and Occupation Therapy assessments only occur Monday to Friday between 08:15am and 16:15pm. We wonder whether a seven day therapy service on the acute medical unit would decrease her length of stay.

69 year old male presents to the Emergency Department after having an asystolic arrest with spontaneous return of circulation following CPR. You wonder if therapeutic hypothermia would offer any benefit to this patient.

A 27-year-old man is brought to the emergency department (ED) with a chest injury following a road traffic accident. Initial assessment reveals a right-sided haemothorax. You elect to place a chest drain and ask for the equipment to be set up. You are asked if you want a large bore 36F chest drain or a small 14F seldinger chest drain. You remember that advanced trauma life support training recommended a large bore drain but wonder if the smaller drain might be just as good and/or risk fewer complications?

Having been unable to obtain intravenous access you have just placed an intraosseous needle in a 30-year-old intravenous drug user who has attended the emergency department with a Glasgow coma scale score of 6, pinpoint pupils and respiratory rate of 3 following an opiate overdose. You are about to inject lidocaine to reduce the pain of the infusion when a passing colleague suggests that it is a waste of time as it will not be effective (as the pain is caused by pressure effects distant to the injection site). You wonder if there is any evidence to support your practice?

A 10-year-old child is to be discharged from the paediatric emergency department after presenting in anaphylactic shock. In accordance with National Institute for Health and Clinical Excellence guidelines you prescribe an adrenaline autoinjector (AAI) and teach him and his mother the six-step technique for use using a training device. They both seem happy but you wonder if they will still remember the technique in the future or in an emergency situation?

You read through the latest edition of a medical journal and notice a case report of a doctor who accidentally injected their own thumb while trying to use an Epipen. When you subsequently try to practice using a training device you do the same thing, this makes you wonder how many doctors do know how to use AAI correctly?

A 29 year old male is brought to A&E in an ambulance after eating accidentally eating prawns at a restaurant. He is allergic to seafood and has had anaphylactic reactions in the past. His symptoms are severe, he is struggling to breathe and is hypotensive. Adrenaline is required, you wonder if a subcutaneous injection would be more effective than an intramuscular one.

A 6 year old boy has been brought into the paediatric emergency department after an anaphylactic reaction to granary bread. After appropriate treatment the child's symptoms resolve. You wonder whether discharging with steroids will prevent a biphasic reaction?

A 24 year old man has been admitted to the hospital after an anaphylactic reaction to shellfish, in accordance with NICE guidelines he should be discharged with an adrenaline autoinjector (eg Epipen), you wonder if using the training DVD will be better than the written information to train the patient how to use his device appropriately?

A 10 year old child presents to the paediatric emergency department after eating peanut butter to which he is allergic. His reaction is severe, he is struggling to breathe and his blood pressure is low. IM adrenaline, steroids and fluids are administered. You wonder if lying the child flat will help his symptoms.

You treat a 7 year old girl in paediatric A&E for anaphylactic shock after eating peanuts to which she is allergic. Her mother had used her Epipen before the ambulance arrived, however the symptoms did not improve. The child subsequently received more adrenaline, steroids and antihistamine in the department. You wonder if the child should have two Epipens with them which can be used in an emergency?

You care for a 8 year old patient in paediatric A&E who is recovering from an anaphylactic reaction after a bee-sting. In accordance with NICE guidelines he should be discharged with an adrenaline autoinjector (AAI). The correct dose for adrenaline is 0.1mg per kg although only two strengths of AAI are available - 0.15mg and 0.3mg He weighs 23kg. You wonder which is the most appropriate one to prescribe?

A 14 girl presents to Paediatric A&E with her mother with a widespread urticarial rash and swollen lips after eating some egg to which she is allergic. You administer antihistamines and her symptoms improve. You prescribe antihistamines for discharge and wonder if they will prevent a biphasic reaction?