Archives: BETs

A 29 year old female presents to the physiotherapy department for treatment of recurrent giving way of her right ankle, present since a severe ankle sprain in her late teens. The ankle gives way into the inversion direction when walking on uneven surfaces such as cobble stones; this occurs approximately twice per week. Any possible underlying structural cause for the instability has been ruled out by a Consultant Orthopaedic Foot and Ankle Surgeon assessment, X-rays and a MRI. A diagnosis of “Functional Instability” has been made and she has been referred to physiotherapy for rehabilitation.

A 10-year-old girl presents to the emergency department (ED) with pain in her right lower quadrant. She states that the pain started 2 days ago when it was diffuse across her lower abdomen. She has had a decreased appetite but no nausea or vomiting. On examination, her abdomen is soft, non-distended, with no guarding and no rebound tenderness. Rovsing\'s sign is negative, but she has positive obturator and psoas signs. Murphy\'s sign is negative. Bowel sounds are heard throughout her abdomen. She is afebrile and her basic laboratory tests show a leucocytosis of 11 000 white blood cells/µl with a left shift. You wonder how likely it is that this patient has appendicitis and how best to manage this individual. You wonder if the Alvarado scoring system used for this purpose in adults is supported by evidence in paediatrics.

A 9-year-old boy presents with a 3 cm laceration to his left knee after falling off his bike. The wound requires closure by suturing but the patient tells you he is scared of needles. You explain that you can numb the area first using a special anaesthetic gel. You have lignocaine, epinephrine, tetracaine gel available in the department but your consultant has told you of another form of topical anaesthetic that she has used in the past containing tetracaine, epinephrine and cocaine. You wonder which topical anaesthetic is most effective.

A 7 year old presents to the emergency department following a minor head injury with repeated vomiting. He is GCS 15 on assessment with no focal neurological deficit. Cranial CT scan is normal. You would like to know if he can be safely discharged to a capable parent.

You are the Subspecialty Paediatric Emergency Medicine Trainee working in the Paediatric Emergency Department review clinic. The next patient is a four-year-old girl who has been brought back for review of throat swab results, as prior to being seen in the PED last week she had been on amoxicillin from the GP for four days without clinical effect. Her mother tells you she has now had an additional week of Penicillin V without improvement. She has had intermittent fever for nine days, is miserable with red eyes and a cracked, sore mouth, a transient rash, and this morning her mother noticed that her hands and feet were sore with peeling skin. The throat swab is negative. You realise that Kawasaki disease is a significant possibility in this case, and wonder whether you should start aspirin prior to urgent paediatric cardiology review – and if so, at what dose?

You are the middle grade doctor attending a patient with an isolated head injury in the Emergency Department. The GCS on arrival is now E2V2M4 (8/15). There is a history of vomiting en route to the hospital. The anaesthetist present agrees that the patient should be intubated following rapid sequence induction for CT scan; while you are pre-oxygenating another middle grade appears and helpfully reminds you that "suxamethonium will only increase this patient's intracranial pressure." You wonder whether the evidence is compelling enough to avoid suxamethonium altogether in patients with head injury.

A one year old girl presents to the Emergency Department with acute wheeze and suspected asthma. Her GP had given her salbutamol syrup which did not appear to help. You use salbutamol via a spacer and want to know if oral bronchodilators are effective at relieving asthma symptoms.

You are about to perform a rapid sequence intubation on a 26 year old man. You’ve heard rocuronium may provide similar intubating conditions to succinylcholine with fewer side effects, and wonder which should be your muscle relaxant of choice.

A 4-month-old girl with respiratory distress presents at the emergency room in January. On physical examination the child has a fever, nasal discharge and a dry wheezy cough with tachypnoea and dyspnoea. On auscultation you find inspiratory crackles and expiratory wheezing. You know that there is no evidence for the use of bronchodilators or corticosteroids in bronchiolitis, but you wonder whether the combination of dexamethasone and epinephrine could help your patient to recover more quickly.

A 6-year-old boy weighing 23 kg is repatriated to your unit from a Dutch hospital after appendectomy complicating a short holiday trip abroad. He is still on parenteral hydration. You notice that the prescribed intravenous solution of 1600 ml a day is hypotonic: dextrose 5%, NaCl 0.45% with 2 mmol potassium/kg/day added. His serum electrolytes and glucose are within the normal range. You wonder why your colleagues abroad did not prescribe isotonic maintenance solution so you decide to contact them. You are informed by the referral hospital that it is common practice to prescribe hypotonic fluids as maintenance solution, and you wonder whether your routine of prescribing isotonic fluids as maintenance is be preferred.

A 12 year old female post motor vehicle collision is admitted to the pediatric ICU with a grade 3 liver laceration, pelvic bone fractures, and a humerus fracture. She has a central line that was started for treatment of hypotension. Your institution typically does not provide deep vein thrombosis (DVT) prophylaxis in children, but you wonder what the incidence and risk factors of venous thromboembolism (VTE) are in children who are critically ill after trauma.

A 40 year old man presents in the Emergency Department complaining of fever and increased abdominal size for the last two days. He is an alcoholic and the clinical exam shows a distended abdomen with dullness in the flanks. An abdominal ultrasound confirms ascitis. A diagnostic paracentesis is done and reveals a polymorphonuclear (PMN) cell count greater than 250/mm3.

A 58-year-old man comes to the emergency department complaining of upper abdominal pain, nausea and vomiting during the past 8 h. He has a history of alcohol excess. He is sweaty and pale. His blood pressure is 85/45 mm Hg and blood sugar 250 mg/dl. The upper quadrants of the abdomen are very painful to the touch. Abdominal ultrasound and blood tests analysis confirms a heterogenous pancreas with raised serum amylase, lipase, lactate dehydrogenase and transaminases. His white blood count is 22 000/mm3. The patient is admitted with the diagnosis of severe acute pancreatitis and a nasogastric tube is placed in passive drainage. On admission to high dependency you suggest feeding via the enteral route, but the local protocol suggests total parenteral nutrition (TPN). You wonder whether TPN, with its known associated complications is really needed in this case.