Archives: BETs

In a tertiary care Neonatal department, we came across a 4 day old 28+1 week preterm baby with suspected sepsis and low neutropil count. I wonder whether giving GM-CSF or G-CSF improves final outcome

A 38 year old female presents with a 4 month history of plantar fasciitis. You wonder whether ultrasound will be beneficial in the treatment of plantar fasciitis, but before deciding on treatment you check the evidence first.

A teenage girl has been at a party with her friends. She had been drinking vodka for the past few hours prior to admission. She is found collapsed on the bathroom floor and is brought to the emergency department by ambulance. On assessment she smells strongly of alcohol but there are no signs of trauma or suspicion of other drug ingestion. Her blood glucose is stable and she is not vomiting but would iv fluid therapy increase ethanol clearance and hasten her discharge?

42 year old lady presented with acute onset of migraine headache in the ED similar to her previous episodes but unresponsive to her usual triptan and amitryptiline medications; you have tried NSAIDs and metoclopramide after ruling out other etiology (like SAH) but hasn't made a lot of difference; your colleague mentions opioids but you are not very keen as you think it doesn't help much but you want to consider Haloperidol because you have read somewhere about its anti-migraine and anti-emesis effects; you look up the evidence

You are seeing a 60-year-old man who has been referred for multivessel coronary artery bypass grafting (CABG). He is an insulin-treated diabetic with a body mass index of 27 and no previous myocardial infarction. His father also died of a heart attack when he was 65 years old. You tell him that the grafts with the best long-term patency are the internal thoracic arteries. You would like to perform CABG using bilateral internal thoracic arteries (BITA) and a vein graft. You inform the patient that this configuration of the procedure carries higher risk for mediastinitis, which is associated with about 20% in-hospital mortality and higher long-term mortality [Toumpoulis]. He is not that keen on the idea and asks if there are any other configurations that could have the same long-term results without the risks of mediastinitis. You wonder whether BITA would be performed in diabetics with low risk of mediastinitis

You are seeing a 67-year-old diabetic patient who had coronary artery bypass grafting 15 years ago. He felt that his last operation had transformed his life but now he presents with aortic stenosis with a gradient of 130 mmHg. He had five grafts in total the last time and both long saphenous veins were harvested, as the left side was documented as having been 'too varicose to use in a young man'. Two vein grafts are patent but a graft to a large diagonal and the PDA are occluded with reasonable distal targets. Unfortunately the radials have no refill on Allen's testing and his diabetes makes you reluctant to use the right mammary artery. You wonder whether you could use the short saphenous vein to do the grafts for this operation.

You are seeing a 72-year-old with a 12-year old mechanical mitral valve replacement, presenting 'in-extremis' with breathlessness, dizziness and hypotension. Her family report that she has been confused recently and might not have taken her warfarin. An echocardiogram shows severely restricted movement of the prosthetic mitral valve leaflets with the appearance of thrombus in-situ. You wonder whether first-line treatment should be emergency surgery or thrombolytic therapy.

You are seeing a patient at lunch-time 4 days after his coronary artery bypass grafts. He is well and has been walking around the wards. You are aware that he only gave up smoking three weeks ago, when he was admitted with a non-ST myocardial infarction. He thanks you for doing his operation and asks if it is okay to have some salt on his chips for lunch. You tell him that you are sure that it's okay and that he has to have a few pleasures in life. On walking away from the patient, your nurse practitioner tells you off. She had just told him that high salt intake is bad for him and that he should cut down. You sheepishly promise your nurse practitioner that you will look up the evidence.

A 78-year-old patient has returned to your intensive care following a quadruple coronary arterial bypass graft. The operation note states that the targets were very small and there is some lateral ST segment elevation on the monitor. One hour post-surgery he suddenly goes into ventricular fibrillation. The nurses start to massage the patient. You place external pads on the patient and deliver a single 150 J biphasic shock which is unsuccessful. You start to charge for a second shock but the nurses who have just gone on a resuscitation update course recommence cardiac massage and tell you that he needs 2 min of massage. You are aware that a graft may be kinked or occluded or there may be a tamponade and, thus, do not want to delay reopening, but to not want to reopen after a single failed shock, and later resolve to look up how many shocks we should perform prior to reopening.

You are attending the thoracic multidisciplinary meeting. The case of a 44-year-old man with localised, resectable oesophageal carcinoma is discussed. One of the oncologists suggests neoadjuvant chemotherapy for this patient, however, the thoracic surgeon disagrees with his suggestion claiming that there is no benefit of this strategy and it would make surgery more difficult. You resolve to investigate this further.

You are at a national conference hearing about the benefits of a stentless aortic valve over a conventional stented valve. An eminent speaker from the floor then stands up and contends that there have been no definitively proven benefits for stentless valves. He continues to say that as the implantation time in these older patients is significantly higher with an associated increase in morbidity, that those who implant stentless valves outside of a clinical trial are similar to cardiologists who implant coronary stents outside of published national guidelines, and both practises should be discontinued. You resolve to check the literature yourself.

In [adults with displaced nasal fractures] does [ digital manipulation under local anaesthesia] produce [cosmetic appearance and airway patency comparable to manipulation under general anaesthesia, at acceptable pain levels for the patient

A 5 year old girl presents to your ED complaining of a 2 day history of painful lesions in her mouth, fever and difficulty in eating. You diagnose primary herpetic stomatitis and wonder if aciclovir will reduce the duration of her symptoms.

It is 7 pm on a busy weekend shift. A 5 year old boy is brought to the emergency department by his mother following an unobserved fall from a trampoline. He was found in a dazed state, it is not known if there was a period of unconsciousness. He has a moderate sized contusion to his occiput but no focal neurology. His GCS is 15 but appears to have little recollection of events leading up to his fall. There are no clinical signs of a skull fracture. You consider it appropriate to CT him on the basis of his scalp haematoma, apparent retrograde amnesia and the possibility of loss of consciousness. The on-call radiologist doesn't want to do the scan and thinks it more appropriate to admit for neurological observation. You are conflicted between the knowledge that a number of children who present in this way will have intra-cranial injury (ICI), some of whom will require neurosurgery versus the unnecessary admission of the majority of children who will not have ICI.

While on duty in the emergency department a 35 year old known idiopathic epileptic is brought in in status epilepticus. After 2 benzodiazepine doses and intravenous phenytoin the seizure activity continues. You wonder if intravenous magnesium may be helpful in terminating the siezure.

A 4 week old baby is brought by parents with inconsolable crying for more than 3 hours a day for the past 3-4 days.Child is passing a lot of flatus and from the history the child is having a typical colic behaviour. Parents are advised by someone to use Gripe Water which din't help the baby and they want to know if there is anything we can do in ED.You hear from your colleague that that Probiotiocs help the baby.Is there any evidence for probiotic use in Infantile colic?

A 25 year old man is brought into the emergency department after being hit by a car. He has a closed midshaft femur fracture with no neurovascular compromise and no other injuries. The orthopaedic registrar asks you to put him in a thomas splint. You are unsure how to apply the splint and wonder if an above knee back slab would be reasonable since he is likely to be operated on tomorrow.

A 98 year old woman is brought to the Emergency Department on an unseasonally chilly summer's morning. The paramedics had picked her up from home in a peri-arrest state with a respiratory rate of 3, bradycardic, hypotensive, hypoglycaemic and hypothermic. Despite some degree of ridicule from Sister, you decide to resuscitate her. Her initial lactate, on an arterial blood gas, is 12. 4 hours later, she is sat up chatting with a lactate of 6. You wonder whether her rapid rate of lactate clearance, rather than the initial absolute level, is a predictor of survival.

A 29-week gestation neonate is having frequent apnoeas while on continuous positive airway pressure, so you prescribe caffeine to help prevent apnoeas of prematurity. You notice another baby of the same gestation is not on caffeine but recall reading caffeine treatment may reduce future neurodevelopmental disability. You wonder how strong the evidence is and whether all neonates under 32 weeks gestation should be on caffeine treatment.

A 3 year old boy presents to paediatric A&E with refusal to weightbear for the last day and a temperature of 37.9 ° centigrade. The pain is located in his hip. What clinical or laboratory tests could help discriminate between septic arthritis and transient synovitis?