Archives: BETs

You have seen a 34 year old female with a lateral malleolus fracture, which is suitable for immobilisation in a below knee plaster cast. She had a previous DVT several years ago when her other leg was in plaster following a fracture. She is anxious not to have another one. You are aware of recent evidence suggesting that heparin prophylaxis may be beneficial in this situation. When you discuss this with the patient she asks you to quantify the risks of bleeding. You are unsure, but resolve to find out immediately.

You see a 27 year old male who has ruptured his achilles tendon whilst playing football and you decide to treat him in an equinus cast. You are aware of a recent case in which a patient died from a pulmonary embolism after receiving similar treatment, as well as recent evidence noting a high (39%) proportion of venous thromboembolism in this particular ambulatory cohort [Nilsson-Helander]. You wonder if the evidence supports treatment with prophylactic LMWH.

A 78 year old man on warfarin for AF presents to the ED with a head injury following a mechanical fall. There was no LOC, nausea or vomiting, amnesia or visual disturbances and neurological examination was normal. He did however sustain a laceration to his occiput, which required suturing. Despite not fulfilling NICE criteria he underwent a CT head, which was unremarkable besides an old infarct. The gentleman was admitted for observation and 10hrs later dropped his GCS to 4/15. Repeat CT demonstrated a large subdural haematoma. He subsequently died 14hrs later. In hindsight, should his INR have been reversed regardless of its value to help prevent delayed bleeding?

A 43 year old female presents to the ED with symptoms and signs suggestive of DVT. According to local protocol she requires a Doppler ultrasound study to diagnose or exclude a DVT. Unfortunately there is no scan available from radiology for 2 days. One of the new ED registrars is trained in ultrasound to level 2, including peripheral vascular studies. You wonder if there is evidence that the scan performed by the EM trainee will be equivalent to that performed in the radiology department, thus avoiding delay in diagnosis and possible unnecessary treatment.

Patient attends the emergency department following an episode of collapse with no obvious cause. How should you assess the suitability for in/ out patient management? How successful is the San Francisco syncope rule at highlighting the patients that are at risk of significant future events. The San Francisco Syncope rule attempts to highlight those patients who are at risk of a serious outcome following an episode of syncope, by scoring the patients according to the outcomes of initial investigations. The mneumonic often used to remember these is "CHESS" history of Congestive heart failure, Hematocrit <30%, abnormal ECG, a patient complaint of Shortness of breath, and a systolic blood pressure <90 mm Hg.

You are asked to review a febrile 2-month-old infant who presented to the accident and emergency department. The urine analysis carried out before your arrival is suggestive of urinary tract infection (UTI) (urine dipstick: positive for nitrites and white blood cells (WBCs); microscopy: 220 WBCs per high powered field). On examination the infant appears well and has no signs suggestive of meningitis. However, you recall a senior colleague stating that young infants with UTI should always have a full septic workup to rule out co-existing bacterial meningitis. You wonder if there is any evidence to support routinely performing a lumbar puncture in this setting?

A 3 year old boy was brought to the ED because of a fever, sore throat and an inflamed and tender tonsils. A diagnosis of tonsillitis was made. What course of antibiotics should be prescribed to the child? Which is more effective, a short-course or long-course antibiotic?

A 65 year-old man is referred to the ED by his GP with a serum potassium concentration of 6.5mmol/L. Repeat tests confirm hyperkalaemia. You order an ECG which shows characteristic hyperkalaemic changes. You consider prescribing calcium gluconate, but wonder what effect this will achieve.

A 65 year-old man is referred to the ED by his GP with a serum potassium concentration of 6.5mmol/L. Repeat tests confirm hyperkalaemia. You order an ECG which shows characteristic hyperkalaemic changes. You wonder whether you should prescribe calcium chloride or calcium gluconate, as you're not sure which is more effective.

A 65 year-old man is referred to the ED by his GP with a serum potassium concentration of 6.5mmol/L. Repeat tests confirm hyperkalaemia. You order an ECG which shows characteristic hyperkalaemic changes. ............

A patient is showing signs of alcohol withdrawal. You want to know whether using the CIWA-Ar tool is better than using your own clinical judgement at assessing whether this patient is indeed in alcohol withdrawal and preventing symptoms.

A 14 year old restrained male was involved in a MVA. He has a fractured forearm but no other significant injuries. He is currently alert and oriented times three and does not complain of abdominal pain. Is physical exam combined with laboratory studies sufficient to exclude any significant intraabdominal injury (IAI) in this child?

A 2 year old girl is brought in to the ED by her mother who is worried about the fever she has been having for the past 5 days. The little girl was also noted to have an enlarged lymph node on her neck which was not tender. She didn't have any history of sore throat or a previous URTI. The doctor treating her suspects Kawasaki Disease. Will a CRP level help confirm this diagnosis?