Archives: BETs

A 5 year old boy presented after being struck by a car while riding his bicycle without a helmet. He had a GCS of 5, and was found to have a right frontal skull fracture and a left sided subdural hematoma on CT imaging studies. He was intubated while in the emergency department and admitted to the Pediatric Intensive Care Unit. Does treatment with hypothermia have improved clinical outcomes?

Gaining vascular access in the prehospital environment is often challenging. In the circumstance where an intravenous (IV) insertion is delayed or unobtainable, intraosseous (IO) insertion should be attempted. The manual intraosseous infusion device and the semi-automatic intraosseous infusion device are both available, so you question which device offers the best rate of success, accuracy and user satisfaction in the prehospital setting.

A 49 year old gentleman presents with weakness of the entire right side of his face. He has no other neurological features to suggest a stroke. You diagnose idiopathic facial paralysis (Bell’s palsy). Should he be treated with prednisolone or a combination of prednisolone and an antiviral agent?

An emergency medicine trainee is called to a 66-year-old man in the Emergency Department (ED), who has just had a cardiac arrest. Advanced life support (ALS) has started. The trainee knows the guidelines have recently been updated, but is not familiar with the changes. The resuscitation attempt is unsuccessful and the patient dies. Later she wonders whether using a checklist (e.g. from her smart phone or on a poster) would have been useful during the arrest to ensure that current guidelines were followed and whether this would have improved the patients chances of survival.

Your patient in the Emergency Department is diagnosed with Community Acquired Pneumonia and requires antibiotic treatment. You are advised by the Medical team to give a stat dose of oral Clarithromycin as research shows oral Clarithromycin is as effective as an intravenous Clarithromycin for treatment of Community Acquired Pneumonia, and provides a cost effective treatment

A 26-year-old woman presents to the Emergency Department with pelvic pain and purulent vaginal discharge is diagnosed with pelvic inflammatory disease (PID). She had an intrauterine device (IUD) placed six months ago after the birth of her third child. She is afebrile, able to tolerate oral intake, and can be managed as an outpatient. As you discharge her with antibiotics, you wonder if you should have removed the IUD or arrange to have it removed by her gynecologist.

A patient presents to the Emergency Department with isolated Weber C ankle fracture. He is placed in a non weight bearing plaster cast. He has a previous history of DVT and is an active smoker. You are concerned about the risk of recurrent DVT and discuss the potential benefits of thromboprophylaxis with him. He is keen, but unfortunately claims to be needle phobic and is reluctant to take daily subcutaneous LMWH. You wonder if there is any evidence to support any type of oral thromboprophylaxis in this situation.

A sixty year-old woman presents to the Emergency Department with a three-hour history of right sided hemiparesis. She has a past medical history of hypertension and myocardial infarction. Rapid evaluation and prompt initiation of thrombolytic therapy in acute ischemic stroke is extremely important for prognosis. Diagnosis of acute ischemic stroke usually relies on clinical grounds, after excluding hemorrhagic stroke by computed tomography. The availability of rapid and accurate diagnostic biomarkers to discriminate hemorrhagic from ischemic stroke would be helpful. Ideally, distinction should be made at pre-hospital triage, thereby directing patients to adequate centers for optimal care. We wonder if such biomarkers are present in the evaluation of acute stroke.

A patient is referred for physiotherapy with greater trochanteric pain syndrome and you wonder if electrotherapy modalities will be beneficial in improving pain.

A 70-year-old male patient, weighing 80 Kg, with diabetes mellitus, coronary heart disease, congestive heart failure (NYHA III), essential Hypertension (stage 2) and renal dysfunction (serum urea: 80 mg/dL, serum creatinine: 1,6 mg/dL, creatinine clearance of 48,6 mL/min/1.73m²); His therapeutic regimen included isosorbide dinitrate 20 mg bid, furosemide 40 mg qd, enalapril 20 mg qd and metformin 1000 mg tid. He was admitted in the emergency department of our Hospital, complaining of fever, malaise, respiratory distress, myalgias, disorientation and abdominal discomfort with positive right Murphy’s sign. He was hemodynamically unstable with MAP (mean arterial pressure) of 50 mmHg and tachycardia (120 bpm). Laboratory evaluation revealed leukocytosis 28000/mm³, severe renal failure (serum urea: 210 mg/dL, serum creatinine: 6 mg/dL, creatinine clearance of 4,9 mL/min/1.73m²), high anion gap metabolic acidosis in arterial blood gas analysis (pH 6,9; AG 30 mEq/L), a plasma lactate of 10 mEq/L, no ketonuria or evidence of ingestion of a toxic substance (such as ethylene glycol, methanol). A renal ultrasound confirmed right acute pyelonephritis. According to the patient’s medical and drug history, clinical and laboratory analysis (although confirmatory laboratory metformin levels were not obtainable), we suspected of a case of Metformin associated lactic acidosis (MALA), complicating a septic shock in the context of acute pyelonephritis. The patient was transferred to our intensive care unit and managed aggressively in accordance with the Sepsis Surviving Campaign Guidelines (2008), with mechanical ventilation, fluids and vasopressor agents; despite intravenous sodium bicarbonate therapy, the clinical scenario was deteriorating and therefore immediately continuous venovenous hemodiafiltration (HDFVVC) was started and went on during 23 hours. Ultimately, he was stabilized and progressive restoration of acid-base balance and renal function was observed. Did hemodialysis, compared to supportive care, had a more positive effect on this patient’s outcome?

A 30-year-old man presents to the emergency department (ED) after twisting his knee. You suspect a soft tissue injury and are aware that the Ottawa knee rule could be used to help determine whether radiography is necessary. A colleague suggests that you should use the Pittsburgh rule instead. You wonder which rule has greater sensitivity (thus missing fewer fractures) and greater specificity (thus reducing the need for unnecessary radiography).

A 30 year old man presents to the ED with a painful knee due to a traumatic sporting injury. You suspect a soft tissue injury and wonder if he needs an x-ray?

A 30 year old man presents to the Emergency Department with a painful, swollen knee after sustaining a sports-related injury. You suspect a soft-tissue injury and wonder if he still requires an x-ray?

Patient is in alcohol withdrawal. You want to know which is the best benzodiazepine to prescribe.

Patient is experiencing symptoms of alcohol withdrawal. You want to know which is the best benzodiazepine to give.

Patient thought to be using alcohol hazardously or showing early signs of alcohol withdrawal. You want to know the best way to assess their risk of alcohol withdrawal syndrome.