Archives: BETs

A 33 year school teacher arrives in the Emergency Department following a trip to the local botanical gardens. She has breathing difficulty with extensive expiratory wheeze and a florrid urticarial rash. She was given salbutamol by nebulizer in the ambulance. She continued to wheeze in the Emergency Department and was given intra-muscular adrenaline. You wonder whether nebulised adrenaline would have worked for her wheeze as this was an acute allergic reaction/anaphylaxis and not asthma.

Following a recent request from a parent to write a letter of support for her son with cerebral palsy to have "dolphin therapy", we thought we would look at the evidence base behind this. The mother was applying to a charity for funding to take her son to Florida to swim with dolphins.

A 13 year old girl attends outpatients with frequent migraines. She has tried pizotifen and propranolol for migraine prophylaxis but was unable to tolerate the side effects. You have heard about topirmate for this indication and wonder whether it may help.

In the Intensive care unit, a bronchoscopy guided percutaneous dilational tracheostomy (PDT) was performed. There were no clinical signs to suggest immediate post-operative complications like pneumothorax, pneumomediastinum or malposition of tracheostomy tube. You wonder whether a chest X-ray is appropriate to rule out the above mentioned complications.

A 30-year-old woman presents with a 7-day history of patellar tendonitis. You think of treating her with oral NSAIDs. However, you have seen some information about NSAIDs in a gel form. This seems an appealing alternative and you wonder if there is any evidence of its efficacy.

A 65 year old lady has had a total knee replacement for osteoarthritis. She has had an uneventful post op recovery and, as per protocol, has an appointment for outpatient physiotherapy. With the pressure on appointments you wonder whether a home exercise programme will be just as effective as outpatient programme at improving function and knee flexion range of movement.

A 29 year old male presents to AED with an acute ankle inversion injury sustained 3 hours previously. His ankle is swollen and he is capable though reluctant to take full weight. X-Rays reveal no bony injury. You want to encourage him to weight bear and decrease his pain and swelling so you decide to apply double Tubigrip™ bandage (DTG). But as supplies are getting very low, you wonder if there is just as much benefit from using single Tubigrip™ (STG) and decide to investigate further.

An eighteen year-old lady has ingested 20 of her 75mg amitriptyline tablets and presented to the Emergency Department. Her blood pressure is 80/40. You consult TOXBASE, which suggests administering intravenous fluids for the hypotension. You wonder if there is any evidence that intravenous fluids are helpful in this situation and whether there is any evidence that colloid is superior to crystalloid.

A 49 y/o women is brought to the emergency department by ambulance. She was having lunch with friends when she suddenly collapsed at the table. On arrival, she is aphasic and has a marked weakness of her right side. Her partner attends and informs you of her medical history which consists of treated hypertension and nil else of note. You arrange for an urgent CT scan and contact the on-call stroke physician. The patient has attended within 1h of onset of symptoms and you wonder if she would be a candidate for thrombolysis. You mention this possibility to the patient's partner and he bombards you with a series of specific and highly appropriate questions regarding the risks and benefits of thrombolysis in patients with stroke. You point out that the diagnosis needs to be confirmed by CT scan before this treatment can even be considered and then cunningly deflect his questions towards the stroke physician who has just arrived in the department. You are aware that thrombolysis for acute ischaemic stroke is considered beneficial for a certain group of patients within strict inclusion and exclusion criteria, but feel that you should know more about the outcomes of a treatment that is usually administered in your department.

You are clerking a patient who has been admitted for elective coronary artery bypass grafting (CABG) the next day. The responsible consultant asks you to omit the morning dose of ACE inhibitor for this patient. When you ask him ‘why?’ he replies that patients who get a morning dose of ACE inhibitor before surgery need more vasoconstrictors and inotropes postoperatively. Although you omit the morning dose of ACE inhibitor for this patient, however, you are confused as none of the other consultants in the unit practice this strategy. To resolve this issue you decide to carry out a literature search.

12 months old boy tried to walk and fell over. He was unable to weight bear. Examination revealed mild tenderness over the distal tibia and xrays of tibia and fibula showed no fracture. You wonder whether you should treat him in above knee plaster for presumed toddler's fracture.

A thirty year-old lady with a history of depression is brought into the Resuscitation Room as a "Standby Call". She claims to have taken 50 of her amitriptyline tablets. Her ECG demonstrates ventricular tachycardia. You wonder whether magnesium sulphate will confer any advantage over stndard treatment (including correction of hypoxia and acidosis and bicarbonate infusion).

During a lull in the action over the Festive Season, an Academic ST trainee and a Specialist Registrar are discussing a case. The ST trainee cites a paper to back up his arguments. The Specialist Registrar ignores the ST trainee, claiming that his experience and "old school expertise" are obviously superior. You wonder whether evidence-based medicine is truly superior to expert opinion. Expert opinion holds that evidence-based medicine is superior. But what does the evidence say?

A 65 year old man was admitted to the ICU department with ARDS secondary to acute pancreatitis. He was found to have a raised Troponin on random blood testing. It was considered whether the raised troponin was a poor prognostic indicator for the patient.

A 60-year-old man comes to the emergency room with his right knee swollen and has experienced pain for two days. He has concomitant fever and history of gouty arthritis. Laboratory studies do not demonstrate specific findings except a slightly higher serum level of uric acid. You wonder whether or not serum procalcitonin could be helpful in the differentiation between septic and nonseptic arthritis.

A 5-week-old infant is admitted to a high dependency unit with paroxysmal cough associated with dusky episodes. The severity and frequency of cough paroxysm increases and 48 h later pernasal swab confirms the diagnosis of pertusis. You want to treat the infant with erythromycin. However, you have heard that erythromycin can cause hypertrophic pyloric stenosis in young infants. So you decide to find out more before starting the treatment.

A 4-year-old girl presents with low-grade pyrexia and dysuria. A urine dipstick test shows positive results for leucocytes and nitrite, suggesting urinary tract infection. On examination, you notice partial adherence of the vulval labia minora. Her mother reports that the girl has intermittently had discomfort in the genital area over the last year. While waiting for the results of the urine microscopy, you remember that one of your colleagues has mentioned treating labial adhesions with oestrogen creams in the past. You wonder whether there is good evidence to support their use in this condition.

An 8-month-old girl has been referred to the emergency department by her general practitioner with a 24-h history of drooling, intermittent screaming and low-grade fever (maximum 38.2°C). She is refusing solids and her fluid intake has decreased. Her parents report that her nappies are drier than normal but her stools are looser. She has had some relief from oral paracetamol syrup. Her parents suspect teething. On examination she is found to be miserable. She is not clinically dehydrated and has a diffusely hyperaemic right cheek. On examination of her mouth you notice a raw area on her upper gums where two teeth are erupting. No other abnormal clinical signs are noted. You agree that the infant may be teething, but wonder if there are any symptoms that would distinguish between teething and an alternative diagnosis.

"A 35 year old male presents to the physiotherapy department two weeks after an acute episode of low back pain with referred leg pain. You make a clinical diagnosis of acute lumbar disc prolpase. Evidence based national guidelines suggest it is effacious to give advice on back care education & the stay active concept, but you want to add in manual therapy as you feel this will further speed up his improvement.You decide to see if there is any evidence to support this."

A 38-year-old previously fit and well insulin-dependent diabetic presents to the emergency department with a fever, vomiting and reduced Glasgow Coma Score. He has obvious signs of meningism and is suspected to have acute bacterial meningitis. He is appropriately managed with antibiotics and is subsequently intubated and transferred to the intensive care unit. His initial CT brain scan is unremarkable, but the LP is turbid and subsequently grows Neisseria meningitidis C, as do his throat swabs. You have read about the use of steroids in meningitis but are unsure of the evidence in acute bacterial meningitis and decide to look it up.