Archives: BETs

You are the paediatric registrar in a district general hospital. An 8 year old boy, who is known to have asthma, presents to the paediatric assessment unit acutely with severe exacerbation of asthma. He has received back to back nebulisers of salbutamol and ipratropium bromide with no improvement in his condition. You are inclined to give an intravenous bolus of salbutamol to the child. However, the paediatric nurse informs you that they are familiar only with the use of intravenous aminophylline. You perform a literature search to seek evidence for the comparative efficacy of intravenous salbutamol vs. aminophylline in the management of this child.

A 50yr old male is 'blue-lighted" into your ED resus in status epilepticus. Despite IV lorazepam and phenytoin, the patient continues to fit and a decision is made to intubate and sedate him, to control his seizures. As the team is preparing to intubate him, you wonder if there is any evidence to support giving him a prophylactic dose of an IV anti-emetic as you are concerned about the potential risks of aspiration and related complications during an RSI?

An otherwise healthy 25 year old woman presents to the ER with 3 days of runny nose, sneezing, and nonproductive cough. She reports it feels like a common cold and usually she recovers without intervention. She has never received relief from over the counter cold medications. She is seeking care because she has a job interview in two days and wants to know if there is anything she can take to recover faster. You have heard that some providers use second generation antihistamines for upper respiratory infections, and wonder if there is any evidence behind the practice.

A 55 year old male presents on the ward with a history of chest pain in the last 12 hours and, as Acute Coronary Syndrome is suspected, a Troponin T Test is performed. The patient is now pain free and you are asked to help mobilise and walk the patient, but you wonder whether it is safe to do so if the result confirms a raised Troponin T.

A 7 year old boy is brought into your ED following a road traffic collision while on his push bike. He was not wearing a helmet. He has sustained a head injury and has been intubated and ventilated in preparation for transfer for imaging. You know that his c-spine collar is associated with decubitus ulcers and increased ICP. You wonder if there are any evidence based protocols for clearing his c-spine at the same time.

A 5 year old boy is brought to the emergency department following riding his bike into a lamp-post. On examination he is noted to have a large laceration across his forehead that unfortunately needs suturing. The young boy is petrified by needles and will not allow you to place a cannula or give an IM injection. The question is asked whether intranasal ketamine is a safe and effective alternative for sedation in this patient.

In patients suffering traumatic cardiac arrest does emergency department thoracotomy result in superior survival rates compared to pre-hospital thoracotomy?

Both crystalloids and colloids are commonly used in both the emergency department and ICU in the fluid resuscitation of patients with sepsis. The use of hydroxyethyl starches is controversial, and improved hemodynamic parameters compared to crystalloids and other colloids must be balanced against growing evidence of nephrotoxicity. This appraisal suggests that hydroxyethyl starch, when used in the management of patients with sepsis, increases the risk of acute renal failure.

A 34 year old female presents to the ED and states that she is having a "migraine" headache that has been present for 30 hours. She describes the headache has a frontal bilateral pressure associated with photophobia and nausea. She is afebrile and states that she has had headaches like this in the past but does not currently have any migraine medications at home and that the headache has not responded to OTC analgesics. You decide to give the patient a dopaminergic agent such as prochlorperazine or metoclopramide but wonder if there is any other way to help her pain. Your ED pharmacist recently mentioned possibly adding 1g of magnesium to the "Headache Cocktail" order set in your electronic medical record. You wonder if the addition of magnesium to your normal treatment of migraine headaches is efficacious.

A 32 year old man was brought into A&E following a motorcycle accident. He was complaining of pain in his right lower leg. On examination his calf was minimally swollen, soft, neurovascularly in tact, however he was complaining of pain. We suspected a mid-shaft tibia fracture, and this was proven on X-ray. Given the high risk of compartment syndrome with mid-tibia fracture, compartment pressure monitors were used. The orthopaedic registrar mentioned that 30mmHg was an absolute value to treat compartment syndrome. You are wondering if there is any evidence to support or refute this.

A 29-year-old man presents to the emergency department after sustaining a mid-shaft spiral closed tibial fracture in a motorcycling crash. You know he is at high risk of developing compartment syndrome and requires compartment monitoring. You wonder whether the distance of the compartment monitoring device from the fracture site affects the pressure reading and therefore the accuracy of the diagnosis of compartment syndrome.

A 35 year old man presents to A+E having been involved in high speed car accident. He is brought in haemodynamically stable with a CT negative closed head injury- GCS 6/15 and bilateral tibial shaft fractures. You wonder if compartment pressure monitoring of his lower limbs is indicated.

You are called to the emergency department to see a 35 years old man who presented with severe left loin to groin pain and vomitting. On examination you find him rolling in the bed, tachycardic and has a left renal angle tenderness. You control his pain and decide to run a urine test to confirm the diagnosis of renal colic. The urine dipstick comes back as normal, and leaves you with this question: How sensitive is the lack of hematuria in rule out the diagnosis of acute renal colic?

A 24 year old man attends the Emergency Department having suffered an injury to his right shoulder whilst playing rugby. He has severely restricted movement. Plain x-ray shows no fracture. MR scan shows rotator cuff disruption. He is referred and subsequently undergoes operative repair. He is sent for rehabilitation post operatively. You wonder whether hydrotherapy will benefit him.

Whilst working as a registrar in the paediatric emergency department a 9 year old boy presents with a headache, low grade fever, photophobia and neck stiffness. He requires a diagnostic lumbar puncture to look for meningitis. You wonder if nitrous oxide might be an effective method of reducing the pain and distress associated with this procedure.

A 14 year old girl presents to the Paediatric Emergency Department with cough, chest pain and neck pain. Chest Radiograph demonstrates pneumomediastinum and surgical emphysema in the neck. She is booked onto a transatlantic flight for five days time. To aid resolution of the mediastinal air she is admitted for oxygen therapy.

A neutropenic 35-year-old man, who received chemotherapy five days ago for a Non-Hodgkin Lymphoma (NHL), presents to the emergency department with a febrile acute respiratory failure secondary to a pneumonia. The patient is hemodynamically stable, but shows a slow deterioration in his respiratory status. He now needs a FiO2 of 80% to keep his saturation over 92%. He should be transferred to the ICU in the next hour. The physician wonders whether NPPV might prevent intubation and therefore improve outcome in this immunocompromised host.

A sixty-five year old man attends the Emergency Department with a twelve hour history of palpitations. An ECG confirms that he is in atrial fibrillation with a ventricular rate of 130 beats per minute. He has no cardiovascular compromise. You have heard that intravenous magnesium may be an effective and safe way of converting him back to sinus rhythm and wish to review the relevant literature.