Archives: BETs

A 40 year old female attends the emergency department as a standby call. Her partner gives you a history of acute headache followed by collapse and reduced conscious level. She is rapidly intubated and taken for brain CT, which confirms your suspected diagnosis of acute subarachnoid haemorrhage. The case is discussed with the neurosurgical team on call and transfer is arranged. You are keen to provide prophylaxis against future vasospasm and further brain injury. However, no oral nimodipine is available to go down the NG just inserted. By the time it is sourced the patient will likely have left the department. You are sure you have recently heard about the use of IV magnesium as a further preventative measure for vasospasm in SAH. Serum magnesium is 0.9mmol/L. While you wait for the anaesthetist to facilitate transfer, you resolve to find out for yourself....

A 54 year old female pedestrian has been hit by a bus. She is brought into the ED by ambulance. Her GCS is 13 on arrival and examination reveals an isolated head injury with a haematoma over the left occiput. CT confirms a right frontal contusion with subdural and subarachnoid haemorrhage and a fracture of the left temporal and occipital bones. There is midline shift to the left. On return to the ED, her right pupil appears dilated and her GCS is now 10 (E2M4V4). The neurosurgical registrar is in theatre for the next 20 minutes. You intubate and ventilate the patient and wonder whether hypertonic saline would be better than mannitol at controlling the patient's ICP acutely.

A twenty year old male dials 999 for an ambulance complaining of acute onset shortness of breath and severe chest pain. The plain is pleuritic in nature, being worse on inspiration and limiting his ability to take a deep breath. His pain score is seven out of ten. He has no past medical history, but smokes ten cigarettes per day. On examination, his observations are normal, including an oxygen saturation of 97%. He has slightly decreased chest expansion on the left. There are no signs of mediastinal shift. There is hyper-resonance to percussion along the left chest. Breath sounds are decreased on the left with decreased air entry. The paramedic makes a provisional diagnosis of primary spontaneous pneumothorax and wonders whether a nitrous oxide and oxygen gas combination would be a safe analgesic choice in this patient.

A 6-year-old girl with acute lymphoblastic leukaemia (ALL) presents with another episode of febrile neutropenia with positive blood culture from her Hickman line. On a ward round, her parents suggest that they would like her to have a Portacath device inserted so that she can go swimming and be more comfortable around her friends. However, they are worried that she will be more susceptible to infection as the needle passes through the skin each time the device is accessed and have spoken to a few parents of children who have had to have their ports removed because of infection. They would like to avoid further hospital admissions if possible. They ask whether the Portacath will increase their daughter’s risk of infection during the remainder of her treatment.

Tom is a 12-year-old boy who presents with a 6-month history of breast enlargement. He is extremely embarrassed about the size of his breasts and avoids sport because he does not want to be seen while getting changed. He wonders if anything can be done to reduce the size of his breasts. Tom has Tanner stage III breast development. He has entered puberty and his height and weight are both on the 99th centile. He has a male karyotype and his hormone levels are all within the normal range. As Tom is so distressed, you decide that something needs to be done. You have heard that anti-oestrogens, such as tamoxifen, and aromatase inhibitors, such as anastrozole, can be used to treat pubertal gynaecomastia. You start Tom on 10 mg of tamoxifen daily, but after 6 months of treatment this has made little difference to the size of his breasts. You wonder whether anastrozole would be a more effective therapy.

A middle aged man presents with a painful right index finger after stubbing it on a door. He clinically has a classic mallet deformity with swelling and tenderness over the dorsum of the distal interphalangeal joint and loss of active extension. Radiographs confirm there is no fracture. You wonder how this can be best managed non-operatively.

32 years old chronic alcoholic patient was brought in the Emergency department with symptoms of withdrawal from alcohol, as he did not drank for last few days, in an attempt to stop drinking without taking medical advice. Patient been shivering, sweating, had some epigastric pains, stomach cramps, nausea & sickness. After getting intravenous access, taking routine blood sample and giving him Librium (chlordiazepoxide), he got stabilized; you wonder whether oral thiamine and multivitamin supplements are better compared to intravenous thiamine and multivitamins, in order to avoid development of Wernicke – Korsakoff Syndrome?

You have just reviewed an 87 year old lady who has presented to the emergency department with a minor laceration after striking her head on a shelf at home. She lives independently in the community, and thinks she may have tripped on a loose carpet. You note that she appears to be quite frail and you wonder if there is an appropriate tool to use, to assess her risk of falling before her discharge.

A 70 year old man on warfarin, presents to Emergency Department , having ischaemic sounding chest pain, i wander if Aspirin, would give the patient more benefit in reducing morbidity and mortality

A 19 year-old girl was brought in having fallen off her horse at a canter and kicked in the abdomen. An ED trauma call was initiated. She was alert, orientated, stable but tachycardic. She had external bruising to her abdomen and it was tender on palpation, a training FAST scan was negative. Analgesia was given and the tachycardia remained. A CT abdo was requested. The consultant radiologist insisted that oral contrast was given. I wondered whether giving oral contrast improved images and diagnosis enough to outweigh the delay to scan as well as the hazards of giving oral contrast.

A 28-year-old female presents to the emergency department with fever, influenza-like symptoms and diarrhea. History reveals she recently returned from a two week trip to rural Kenya. You consider malaria in your differential and wonder if using the Binax NOW malaria rapid diagnostic test (RDT) has sufficient accuracy to guide your treatment decision and hasten disposition.

A 24-year-old man presents following a fall on an outstretched hand. He has clinical signs of a scaphoid fracture but his initial x-rays are normal. You wonder if ultrasound could be used to identify an occult scaphoid fracture.

Your Head of Department is considering the use of a computerised triaging system. He wonders if this is a better method of triaging patients, compared to the traditional nurse-led triaging system.

A 30-year-old man falls from a third storey window on to concrete. He complains of pain around his pelvis. You know that a vertical shear injury is more likely than an open book pelvic injury with this mechanism, and wonder whether you should apply a pelvic splint before he reaches hospital, when he arrives, or not at all.

You wonder why some hospitals splint buckle fractures and others plaster them. Is there any need to plaster these fractures? Only 1 study for futura splints (currently a 2nd trial in recruitment stage in Washinton USA). So looked for papers that compared plaster cast with alternatives including wool and crepe and tubigrip, 1 trial comparing splint with no treatment at all.

An 56 year old female presents to the emergency department with altered level of consciousness. She if found to have a systolic blood pressure of 200/100 and the CT confirms your suspicions of a intracerebral hemorrhage. You wonder how aggressive should I be in lowering her blood pressure acutely.