Archives: BETs

Whilst on duty in the ED, a young man is brought into the resuscitation room with a stab wound to his abdomen. A trauma call is put out and resuscitative measures started. Primary survey includes a positive FAST scan. The bleeding is severe and the Trauma Lead initiates the massive transfusion protocol. Packed red cells, platelets and FFP are transfused in a 1:1:1 ratio, as per protocol. The patient is taken to theatre to control the bleeding. As he is leaving, the Trauma Lead asks you to take a further clotting sample to measure PT, APTT and INR so that 'we’ll know how many more products to give him’. You follow up this patient and find that he survived and is currently on ITU. The Intensivist tells you he is suffering from ARDS, likely to be a Transfusion Associated Lung Injury (TRALI). The Intensivist believes the patient received far too many blood products during his resuscitation and in theatre. You wonder if there is a way of guiding blood product replacement in trauma situations which may supersede rigid transfusion protocols. You are aware that TEG machines are used to guide blood product replacement for open cardiac surgery patients and wonder if the same technique could be used to guide transfusion for trauma patients.

A two year old boy - 'Lance' - presents to the emergency department after falling off his bike. He sustained a head injury and is currently drowsy. After recently completing the ATLS course, you try to apply the ABCDE mnemonic to Lance. You remember GCS forms parts of 'D for Disability' but struggle to assess speech in a this child. You wonder if best motor response is sufficient in children?

A 10-year-old boy with well controlled epilepsy on sodium valproate attends your clinic. On a previous clinic visit his mother complained that he was hyperactive, impulsive and could not concentrate. This was affecting his school work. You sent Conners' Questionnaires to his parents and the school, and asked the attention deficit hyperactivity disorder (ADHD) nurse to observe him in school. The results of these investigations are strongly suggestive of a diagnosis of ADHD. You would like to treat him with methylphenidate (MPH) because you know this works well in other children. However, you remember reading some National Institute for Health and Clinical Excellence (NICE) guidance that suggests caution when treating children with epilepsy with psychostimulants. What should you do?

A 22-year-old woman, who is currently 12 weeks pregnant, presents to the emergency department complaining of a four week history of severe nausea and vomiting. She appears to be clinically dehydrated and urinalysis confirms she is ketotic. Immediate management includes intravenous fluids and standard anti-emetics. Unfortunately she gets minimal relief and continues to vomit. You recall from your recent oncology placement, the beneficial effect of steroid therapy on chemotherapy induced vomiting, and wonder if a trial of steroids might be useful to control the symptoms of severe hyperemesis gravidarum (HG)

A 67 year old female attends the Emergency department after a fall onto outstretched hand. X-rays identify a Colles fracture with dorsal angulation and shortening of the distal radius which requires manipulation. With experience of reducing Colles fractures you wonder if bupivacaine will give better analgesia improving patient comfort during and after the procedure than lignocaine.

A 20 year old patient presents to the Emergency Department after swimming off a sunny coastal area of Queensland, Australia. He has been stung by a jellyfish. He has severe pain at the site of the sting. He is very restless with back pain, muscle cramps, nausea and vomiting. He is tachycardic and hypertensive. You diagnose Irukandji syndrome and begin treatment with intravenous opiates before attempting to control his adrenergic storm. He tells you that as a first aid measure he washed the leg at the vinegar station on the beach. You wonder whether a tap water wash would have been as effective, if indeed it has made any differnce.

Adult trauma patient presenting with hemorrhage or at significant risk of hemorrhage. Can early administration of a 1 g loading dose of Tranexamic acid infused over 10 minutes followed by a transfusion of 1 g over 8 hours decrease rates of adverse events including further hemorrhage, blood transfusion and death?

70 yo male presents to ED with SOB and hypotension 75/40 with HR of 160. Pt found to be in afib. Pt does have h/o afib but usually rate controlled with dig. Pt is unsure how long he has been in afib. Pt is given 10mg of dilt after 1L IV NS bolus and pressure drops to 70/35. No change in HR. Would the addition of IV magnesium help with rate control of this patient?

A 40 year old man attends the emergency department having sustained facial injuries following an alledged assault. Examination of the oropharynx reveals a missing tooth. The patient has no clear memory of what happened to his tooth. You wonder whether a chest x-ray would aid diagnosis.

A 47 year old man arrives to the emergency department with severe chest pain. His chest pain significantly improves with sublingual nitroglycerin. You wonder if the relief of patient’s chest pain with nitroglycerin has any prognostic value in the diagnosis of cardiac chest pain.

A 35 year old right hand dominant carpenter presented to the emergency department after sustaining an injury with his saw to his right wrist. On examination, there was a transverse incision across the palmar crease with an completely transacted Palmaris longus tendon. He had limited range of motion in his wrist due to the swelling. X-ray revealed no fractures or foreign bodies. You wonder if it should be repaired or treated conservatively to give best clinical outcome.

The SHO on the post-natal ward is performing routine newborn examinations and notices a baby who is being monitored using a neonatal abstinence score chart due to a history of maternal illicit drug use. Urine toxicology results are positive for amphetamines, but negative for opioids. The SHO has seen the effects of opioid withdrawal on babies before, but asks the SCBU registrar whether babies act in a similar manner when withdrawing from stimulatory drugs such as cocaine and amphetamines.