Archives: BETs

A 42 year old male presents to the ED with opioid withdrawal symptoms of moderate severity. He is hoping to be prescribed opioid agonist therapy treatment with buprenorphine. He has no other complaints.

EMS brings in a 65-year-old female who was found weak and confused at home after being found on the ground by her spouse. You complete a general assessment and rule out any major injuries. Unfortunately, you find that the patient cannot give you a useful history due to her confusion and decide to call her spouse for more information. As you are calling her spouse, the patient's nurse alerts you that she suddenly lost her pulse. Chest compressions are on-going as you enter the room and find she has PEA at the next pulse and rhythm check. You perform POCUS and find there is evidence of cardiac activity. You wonder what the likelihood of obtaining ROSC will be.

You are discharging a 52-year-old man who tested positive for COVID-19 recently from the emergency department. He lives in a remote area and asks you if there’s anything else you can give him to help “stay away from the hospital”. You vaguely remember some reports on inhaled budesonide and wonder whether prescribing an inhaler would help.

A patient with a history of asthma presents to your Emergency Department with a severe exacerbation. Despite treatment with standard therapies, the patient continues to deteriorate, and you begin to prepare for intubation. You are aware of the reported potential bronchodilatory properties of ketamine and wonder if treatment with nebulized ketamine may avoid the need for intubation and mechanical ventilation.

A young man attends the emergency department having sustained an acute anterior shoulder dislocation in a rugby tackle. Peripheral venous access has not yet been obtained. You wonder if inhaled methoxyflurane (MF) could be as effective as procedural sedation and analgesia (PSA) in facilitating successful shoulder reduction whilst reducing length of departmental stay.

A 6 day old baby was seen in CEC with mild increase in WOB. The baby was saturating well and was feeding normally so parental education was given and they were advised to go home and return if things change. However, before discharge the parents mentioned they were worried about the yellow tinge to babys skin. The history revealed no risk factors for pathological jaundice, however, before discharge a serum bilirubin level (SBR) was done to ensure normal bilirubin levels and put the parents mind at ease. The results showed serum bilirubin was well below the treatment line (122umol/L). Was it necessary to bleed this baby or would a transcutaneous bilirubin measurement have been an effective method to rule out significant hyperbilirubinemia?

A 63 year old male, presents with a 4 month history of a painful adhesive capsulitis or frozen shoulder. He is non-diabetic. He has restriction in motion in the capsular pattern of the shoulder. He experiences, a deep throbbing ache/ pain in his mid-upper arm, which is worse at night, affecting his sleep hygiene. A referral to physiotherapy for management of his range and pain made by his GP. If offered an injection, is there a significance of the dosage of CS (triamcinolone acetonide) on his pain reduction?

25 year old Male presenting with a 2 day history of central abdominal pain associated with nausea, vomiting and poor appetite. On examination he is restless with pain, dehydrated and diffusely tender with guarding in his lower abdomen. CRP has not been done on admission bloods, and the specialty team want a CRP done before they will see him.

A 64-year-old woman is brought to your Emergency Department with acute onset isolated lip and tongue swelling. Despite having no other symptoms of anaphylaxis, she quickly receives intramuscular epinephrine and intravenous methylprednisolone without any effect. Her history reveals that she has been taking ramipril for two years to treat her hypertension. You suspect a bradykinin-mediated ACE-inhibitor angioedema and have heard that icatibant may help this patient, but you’re not sure if there is convincing evidence for its use.

Emergency physician clinical gestalt has been found to be overly optimistic regarding the incidence of PPCS; a recent study found while complete recovery was expected in over 90% of patients ~50% developed PPCS. A systematic review concluded that no available models adequately predict outcome after mTBI; many failing due to poor methodology. Subsequently, UPFRONT generated a prediction model which depends on psychological assessment at two weeks (the high number of patients precludes this in the NHS), and is not able to stratify patients on ED assessment. NICE Guidelines note there is an urgent need for a decision rule that risk stratifies patients at high-risk for PPCS early after presentation. There are a number of candidates to improve prediction – these include clinical features, premorbid factors and newer technologies including biomarkers and MRI. Current best models have found that clinical features ~2 weeks after injury are most predictive. However, there is some evidence that biomarkers within the ED visit and/or early MRI may help with earlier risk stratification. This search has focused on the key literature to show the current status of this area.

A patient has attended the Emergency Department following a head injury. They have had a normal CT head scan and are going to be discharged, however they still have a headache. You are concerned they are at risk for post concussion syndrome and wish to know if there are any interventions that may benefit them?

A 55-year-old woman presents with back pain and bilateral leg weakness. What would you do next?