bestBETs

8-year-old boy, previously healthy presents to your emergency department with cellulitis of the right forearm. He is otherwise systemically well. You decide to prescribe flucloxacillin. His mother reports an allergy to penicillin. Allergy history reveals a maculopapular rash on day 3 of amoxicillin therapy for otitis media at 2 years of age. He has never had any penicillin antibiotic since then. A colleague suggests clindamycin. You wonder if he could tolerate flucloxacillin given the nature of the reported reaction whilst concerned about the adverse event profile of clindamycin.

It is a warm humid evening in July and you are working a stretch of evening shifts in a busy emergency department. Given the humidity, you check the weather as you are coming in to work and see thunderstorms on the forecast for all day tomorrow. You go about your shift and when you check the trackboard to see who is in the waiting room, you notice that 11 of the 18 patients in the waiting room all have the same chief complaint, “shortness of breath”. Additionally, you notice that the age of these patients varies widely, with age range from as young as 7 to as old as 68. You wonder if the impending thunderstorm has anything to do with the influx of all these respiratory complaints.

A 32-year-old patient presents to the emergency department following a high-speed motor vehicle accident. He is hypotensive and has obvious ecchymosis on the abdomen with a “seatbelt sign.” Paramedics were unable to administer tranexamic acid (TXA) due to difficulty in establishing IV access. You wonder if IM would be effective alternative to an IV route for administering TXA in bleeding trauma patients.

The patient is a 52-year-old male with history of hypertension who presents to the emergency department (ED) with complaints of chest pain that started 1 hour prior to arrival. On arrival to the ED, he appears comfortable with stable vital signs, and has a normal physical exam. His pain is reported as mild, sharp and substernal, non-radiating, and worse with certain movements but not exertion. His pain resolves after 324 mg chewable aspirin and a lidocaine patch. His lab workup and elecrocardiogram are normal. The patient has a heart score of 2. You consider ordering a chest x-ray (CXR) prior to discharging the patient.

A Physiotherapist would like to know if the benefits of participation in early mobilisation with patients post SAH with EVD outweigh the risks of adverse events relating to EVD and mobilisation

A 22-year-old woman presents to the Emergency Department (ED) with suicidal ideation and ongoing Medically Unexplained Symptoms (MUS). This is her second attendance today, and her fourth this week. This patient is a known high-intensity user/Frequent Attender (FA) due to multiple previous episodes of Deliberate Self-Harm and intentional overdose. She has a background of emotionally unstable personality disorder, depression & anxiety, and a learning disability- all of which contribute to her distress while in the department, meaning she frequently leaves before being seen by a clinician. You wonder if there is an effective intervention that you could implement, to reduce her number of ED visits.

10 year girl present in A&E with 2 day history of fever, right sided back pain and dysuria. She had urine dip done which showed 3+ leucocytes, 1+ blood and nitrates positive. The registrar seeing the patient wants her to be immediately started on IV antibiotics for suspected pyelonephritis. The SHO questions why is IV required when the patient can tolerate oral?

A 49 year old man presents to your family medicine office with signs and symptoms of alcohol use disorder. He is willing to explore pharmaceutical support to reduce his drinking.

A forty-year-old patient is brought to the Emergency Department (ED) by paramedics with suspected drug intoxication. They have a Glasgow-Coma-Scale score of 3 and the decision is made to perform a Rapid-Sequence-Induction (RSI) to enable control of the airway, neuroprotective anaesthesia and facilitate transfer to the radiology department. Immediately following administration of Alfentanil, Propofol and Rocuronium, they develop profound cardiovascular instability thought likely to be Rocuronium-induced anaphylaxis. Following initial treatment (with adrenaline, steroids and antihistamines), the Anaesthetic Consultant in attendance suggests giving Sugammadex to encapsulate the Rocuronium. You wonder if Sugammadex can really improve cardiovascular instability in established anaphylaxis?

A 14-year-old male presents to the emergency department at 3 A.M. after awakening suddenly from sleep with severe right sided groin pain. A clinical exam of the genitourinary system, with chaperone, is grossly normal, however the cremaster reflex on the right side is equivocal. You recognize that testicular torsion is an emergent diagnosis on the differential of Acute Scrotum and speak with the Radiologist on Call to arrange a formal ultrasound. The Radiologist asks if you have performed a POCUS? As you hang-up the phone, you wonder 'what is the diagnostic accuracy of POCUS for testicular torsion?'

Patient is a previously healthy 8-year-old male who presents to your emergency department as a level II trauma activation after being involved in a motor-vehicle collision. The patient was a restrained back-seat passenger when their vehicle was T-boned at a suspected speed of 45 mph. There was no loss of consciousness on scene. EMS report his vital signs have been stable enroute. The child has some moderate abdominal tenderness, and you consider whether to order computed tomography (CT) or perform point of care ultrasound (POCUS) to evaluate his abdomen.

Patient is a 45-year-old with a history of alcohol abuse who presents to the emergency department intoxicated. On your initial assessment, the patient’s eyes are closed and only open to pain; he only moves when a painful stimulus is applied; he is not speaking. You give the patient a GCS of 8 and you question whether this patient would benefit from being intubated.

A 12-year-old Vietnamese speaking female with a complicated past medical history presents to the emergency department (ED) with complaints of dizziness. History and physical exam are obtained from the patient and her family using a professional interpreter. You wonder how using an interpreter impacts ED utilization (incidence and costs of diagnostic testing, admission rate, and length of ED visit).

Climate change is the biggest global health threat of the 21st century. According to the recent Intergovernmental Panel on Climate Change, the global mean temperature is projected to rise by 1.4 to 5.8 degrees by the end of the century. Extreme temperatures overwhelm the body's heat regulatory mechanism, and multi-system organ dysfunction results. In light of recent global heatwaves, it is imperative that emergency care clinicians appreciate the diversity of climate sensitive emergency health conditions and their impacts on emergency care systems.

A 5-year-old child with presented to the emergency department following an motor vehicle collision. He was a restrained passenger of a vehicle going approximately 30 mph when the collision occurred. Air bags deployed at the time of impact. His workup in the emergency department was significant for atlantooccipital dissociation and the patient was eventually pronounced dead on arrival. During your review of the case, you wonder whether airbag deployment contributed to his cervical spine injury.

Fascia iliaca blocks (FIB), first described by Dalens et al in 1989, have become a key method of managing pain in patients with fractured neck of femur. In your department FIB tend to be performed using a landmark (loss of resistance) technique. However, it has been noted that there have been a number of ineffective blocks recently, leaving patients still in need of opioids to manage their pain. At clinical governance one of the consultants, a point of care ultrasound enthusiast, suggests that the department should move to performing FIB under ultrasound guidance as he believes they are more likely to succeed. You leave the meeting wondering if he is right.

A 65-year-old male with a history of hypertension, hyperlipidemia, stage 4 chronic kidney disease (CKD) and daily smoking presents to the emergency department (ED) complaining of chest pain. Vitals show that he is hypertensive with a blood pressure (BP) of 170/95, with otherwise normal vitals. He has no neuro deficits. Workup completed shows an EKG with a normal sinus rhythm and non-specific ST-T wave changes but without evidence of acute ischemia. Troponins are normal. You wonder if he may have an aortic dissection, but he is well-appearing without neuro deficits and equal pulses. Given his CKD you wonder if there is a way to rule out an acute aortic syndrome without having to give a contrast load for a computed tomography (CT) angiogram. Will using the aortic detection risk score in conjunction with a d-dimer help either rule out or increase suspicion for acute aortic syndrome?

A 50-year-old male/female with a past medical history of rheumatoid arthritis attends pre-operative clinic prior to an elective right upper lobectomy. Amongst the regular medications is methotrexate. You wonder whether the patient should continue methotrexate to reduce risk of flare-up and problems with post-operative pain control or stop this medication prior to surgery due to concerns about immunosuppression and increased risk of post-operative complications; especially wound infections and air leaks. If you were to stop it, how long should it be discontinued for and when should it be re-started?

A 65 year old male presents to the ED with a 3 day history of cough and breathlessness. You are unsure of whether this is likely to be COVID-19 or something else. You worry that sending this gentleman into the hot zone of the department will expose him to COVID-19. You know that a nasopharyngeal swab will take a long time to come back, and wonder whether LUS will help you decide whether this gentleman is likely to have COVID-19 or not, in order to triage him safely.