A 4-week-old term baby is brought into your DGH ED by his mother. He is crying inconsolably, and examination reveals a swollen and deformed right femur. Xrays confirm a midshaft fracture. You want to alleviate his pain and discuss strong analgesia. The ED nurses tell you that opiates are unsafe in his age group and state that paracetamol is the only option. You wonder about the evidence for this.
Archives: BETs
Does prone ventilation improve outcome in severe hypoxic respiratory failure?
A 45 year old man is brought to the ED in respiratory distress. He is HIV positive and has defaulted on both his anti retrovirals and follow up. From his chest X ray you suspect Pneumocystis jerovii pneumonia (PJP). After intubation he becomes increasingly difficult to ventilate and oxygenate. The team from Critical Care are talking about getting him onto the ICU to ventilate him in the prone position. Although this may improve his oxygenation you wonder whether it will affect his survival?
Permissive hypotension in penetrating trauma patients with hemorrhagic shock
A 25 year old man is brought to the Emergency department following a gunshot wound to the abdomen. His BP is 70/50mmHg. He is tachycardic with cool extremities. You wonder about recent studies on permissive hypotension in hemorrhagic shock management. You wonder whether you should aggressively resuscitate the patient with crystalloid or restrict the fluid resuscitation before the patient is taken to the operating room.
A 45yo male without significant medical problems presents to the Emergency Department complaining of acute onset of chest pain. His initial EKG and troponins are within normal limits. The department is over-crowded as usual, and you contemplate whether coronary CT angiography would be a reasonable safe way to exclude ACS and discharge the patient from the department.
A 65 year old male has an out of hospital cardiac arrest that is witnessed by bystanders. EMS arrives and the patient needs an advanced airway. The airway kit has endotracheal tubes as well as supraglottic airways. The EMS responder must decide which airway will provide the best outcome for the patient.
A 40 year old male with a negative cardiac stress test performed 1.5 years ago presents to the emergency depart with symptoms consistent with ACS.
Does Leg position alter CSF opening pressure during lumbar puncture? n
A child with suspected benign raised intracranial pressure requires a lumbar puncture and opening pressure readings. As you prepare for the procedure the consultant on call asks you to make sure the child’s legs are straightened out before you measure the opening pressure. You wonder whether measuring CSF pressure with the lower limbs in the flexed position truly does falsely elevates the reading, and whether you should take the reading with the lower limbs in the extended position?
A 42 year old man presents with severe constant upper abdominal pain with no nausea and vomiting preceded by two days of vague ‘heartburn’. He has been binge drinking over the weekend and is a smoker of 20 pack years. He had been diagnosed with peptic ulcer three years previously by his GP. He appears to be in obvious distress with a distended rigid abdomen, rebound tenderness, absent bowel sounds and is unwilling to sit up or be moved. His ECG is normal. You clinically suspect a perforated duodenal ulcer as your main differential diagnosis and as you resuscitate him you think if it is possible to detect free intra-peritoneal air using ultrasound.
You work in the emergency department as a consultant and your rota currently does not include night working. Nationally it has been recognised that there is a deficit of senior decision makers in emergency departments at night and inevitably it is suggested that care would be safer and more effective if (work-shy) senior emergency physicians stepped off the golf course and into the gap to work shifts. You have heard that this will increase your chances of a heart attack and shorten your life but wonder whether this is just union propaganda or hard actuarial fact.
Clinical Scenario Your musculoskeletal physiotherapy service is considering developing a supervised gym class for post-operative shoulder patients. Many patients experience post operative pain which impacts on their ability to perform exercises. Would the use of TENS machines during the class be beneficial in decreasing pain?
Evaluation of Intra-Aortic Balloon Support in cardiogenic shock.
A 67-year-old man is brought to the emergency department. He is cold, clammy and confused. He is also hypotensive and an ECG shows that he has had an AMI with ST elevation. While your colleagues prepare some vasopressors you speak to the cardiologist on call. He suggests getting the patient to the cardiac cath lab to put in an IABP. You wonder whether there is any evidence to support this course of action?
Is there value in testing troponin levels after ICD discharge?
A 50-year-old man presents to the emergency department having been woken from sleep by his implanted cardioverter-defibrillator (ICD) firing; it has fired twice more since that time. He is in sinus rhythm and has no acute signs or symptoms. A recent angiogram showed no significant coronary artery disease (CAD). You speak to the Cardiology Registrar who advises that troponin levels should be checked. You wonder if there is any evidence for this and, further, how you might interpret the result.
Long-term cognitive outcome following out-of-hospital cardiac arrest
A 48-year-old, well-trained, long-distance runner collapsed at the finish of a half marathon. Against his usual practice, the athlete tried to accelerate on the last hundred meters towards the finish line. Immediately after the collapse, cardiopulmonary resuscitation with defibrillation of ventricular fibrillation was successfully carried out. After ROSC, the patient was arousable but not fully alert. We sought to understand the long term neurological outcomes for patients with out of hospital cardiac arrest from ventricular fibrillation?