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A 6-year-old boy presents to the paediatric emergency department complaining of pruritus affecting his scalp. On examination you notice several nits attached to his hair as well as a few adult head lice. You are considering treatment with pediculocides, but his mother is rather reluctant to use "chemicals". You consult the BNF for children, which apart from listing three classes of pediculocides – carbaryl, malathion and pyrethroids (permethrin and phenothrin) – outlines the option of using wet combing as an alternative. You wonder whether there is good evidence to support the sole use of this intervention in head lice infestation.

An 8-month-old infant is admitted with fever and vomiting. Urinary tract infection (UTI) is diagnosed. You decide to commence IV treatment with gentamicin. In your paediatric ward, gentamicin is routinely administered in three times daily dose (TD) regimens but you look up gentamicin administration in the BNF for children and find that it can be given once daily (OD). This prompts debate amongst staff as to whether the same can be done on your ward. Everyone wonders whether there is any supportive evidence for efficacy and safety when OD gentamicin is used in the treatment of UTI.

You are the specialist registrar in paediatrics doing the ward rounds. There has been a recent outbreak of Escherichia coli (E coli) O157:H7 gastroenteritis in the community. A 5-year old girl was admitted 3 days ago with bloody diarrhoea, abdominal cramps and vomiting. Her stool has grown E coli O157:H7. She is now stable and her parents are keen to take her home but are understandably anxious and ask you about possible complications. You are aware of the risk for progression to haemolytic uraemic syndrome (HUS). However, you are not sure if all such patients should be closely monitored. You note that the patient now has a normal platelet count and renal function and wonder if there are any simple parameters to predict the risk of HUS, which may take up to 2 weeks to develop. You talk to the consultant in public health medicine, who kindly directs to you to the national guidelines by the Health Protection Agency (HPA) on the management of E coli O157:H7 infections. Unfortunately, the guidelines do not answer your question. Your consultant has come across anecdotal evidence that leukocytosis may be a predictor for HUS in such children. You decide to do a literature search and critically appraise the evidence.

A 59 year old lady with a 22 year history of Multiple Sclerosis where truncal ataxia is a major feature has become increasingly less able to carry out all activities of daily living. Lycra suits have been used in children with cerebral palsy where ataxia is a feature, to improve postural stability. Would the same benefit be gained in adults?

A 27 year old man presents to the ED after being bitten by a dog on his right palm. The wound is contaminated and needs a good clean before referral on to plastics for more formal repair. It is very painful and you elect to use a median nerve block to facilitate good wound toilet. You use a landmark technique and infiltrate a mixture of lignocaine and bupivicaine. However, you are dissapointed to find that it has not worked. You ask a colleague to help and they suggest getting the Ultrasound machine out to help localise the nerve more precisely. You are familiar with this technique for other nerve blocks but have not seen it done at the wrist before.

A 50 year old man presents to accident and emergency department after an assault and has injuries to his hand. On examination you are not sure if it needs plastic surgery, you try your best to relay the relevant information to plastic surgeon in the regional centre and transfer the patient to the centre. At the centre he is evaluated and it is found that he does not need plastic surgery. Could we have avoided this scenario by using teleconsultation.

A 36 month old child arrives in A and E looking well, the parent says she has had a temperature for the last 24 hours with no additional symptoms. You measure the temperature and it is 38°c you wonder whether this is a fever that we should be concerned about or can the child be sent home without any intervention.

A 24 year old woman presents to the ED with left sided renal colic. She is not septic and following initial fluid and analgesic administration, an unenhanced CT demonstrates the presence of a 4 mm calculus adjacent to the left vesico-ureteric junction. There is only mild hydronephrosis and by the time the patient returns from X-ray, her symptoms are under control. Before you discharge her with oral analgesics and fluid advice, you ring Urology to arrange an outpatient's appointment. To your surprise, the Urologist on-call asks you to prescribe Tamsulosin, a drug normally used by elderly men in benign prostatic hyperplasia, to your young, female patient with a urinary calculus. You wonder whether there is any evidence behind this?

I report the use of oral sildenafil in a male preterm of 28 weeks gestation, born with congenital hydrops secondary to maternal parvovirus. He received maximal ventilatory and inotropic support. His neonatal course was complicated with pulmonary hypertension refractory to inhaled nitric oxide treatment. Sildenafil was administered via an orogastric tube to the neonate. Forty-eight hours after treatment commenced, echocardiography revealed that the contractility of both ventricles had improved and evidence of tricuspid incompetence had decreased, resulting in a marked reduction in pulmonary arterial pressure. Low dose oral sildenafil was initiated at 250 to 500 micrograms/kg/dose once a day to 3 times a day for 6 to 8 weeks until complete resolution of pulmonary hypertension. This helped the neonate wean from the ventilator and subsequently discharged home on low flow oxygen. There was no major adverse effect noted during the treatment period, except for a small drop in blood pressure post dose administration which was short lived. He had a normal cranial ultrasound. Had oral sildenafil contributed to the reduction in pulmonary vascular resistance and therefore successful extubation? Should it be considered as a second line treatment for severe pulmonary hypertension?

Your last evening shift in the emergency department was particularly busy. The charge nurse remarked, "There must be a full moon out tonight." You wonder if there is truly any link between ED census and the lunar phases, or is this belief simply a myth.

You have inserted a mechanical prosthetic mitral heart valve into a 60-year-old man. He subsequently has a GI bleed while on warfarin so you decide to review the literature to confirm optimal therapeutic INR which minimises long-term thromboembolic and haemorrhagic complications.

You are about to perform a coronary arterial bypass graft on a 47-year-old ex-smoker who has triple vessel disease requiring three grafts. You elect to use both mammary arteries, but he is a manual labourer with many scars and tattoos on both his arms, and Doppler ultrasound and Allen's testing of his radials show poor flow on both sides. You wonder whether selecting the gastroepiploic artery would give him better long-term patency then using a saphenous vein.

Another day as hotshot Clinical Director, another day of corporate meetings and complex decision-making: Is alcohol a significant contributor to ED presentations? Would I be able to justify the implementation of an Alcohol Health Service within the department? Is this really as big a priority as the Government makes out? Luckily, you have your resident Professor to hand, a man of many talents - he is able to conduct robust literature searches at the touch of a button. You decide to find out the prevalence of alcohol misuse across UK EDs as a first step in deciding whether to jump on the 'Preventive Emergency Medicine' band-wagon and offer brief intervention to eligible patients

A 33 year old male arrives at the ED having been involved in a road traffic accident whilst driving under the influence of alcohol. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. Having assessed and treated the patient, you wonder whether it is worthwhile referring him on to them...

A 12 year old child comes to the emergency department accompanied by her mother. The child complains of a severe throbbing headache which started an hour ago but is still present. She has also vomited once in the last 30 minutes. She has had this headache once before last week but did not attend the emergency department. After taking the history and doing the clinical examination you diagnose the child as having migraine. You wonder whether Prochlorperazine is useful in treating the childs migraine.

A 9 year old child comes to the emergency department accompanied by her mother. The child complains of a bilateral severe throbbing headache which started an hour ago but is still present. She has also vomited once. She complains that noise makes the headache worse. She has had this headache once before last week but did not attend the emergency department as it was relieved after sleeping. After taking the history and clinical examination your clinical impression is migraine. You wonder whether the ICHD is useful to support your diagnosis.

A 13 year old child presents with a bilateral severe throbbing headache to the emergency department with her mother. She came to the emergency department 2 months ago complaining of the same type of headache but of moderate intensity. At that time she explained that the headaches started a month before attending the emergency department. She was referred to the head specialist and was given a headache diary to fill in. You look at the headache diary and see that headaches last on average for one and a half hours, are associated with nausea and vomiting and are relieved by sleep. You wonder whether the headache diary is useful in making the diagnosis of migraine.

A 5 year old child comes to the emergency department accompanied by her mother. The child complains of a bilateral headache of moderate intensity which started 30 minutes ago and is still present. She has also vomited in the last 10 minutes. You wonder whether this patient has a migraine or a tension headache.

A 9 year old child comes to the emergency department accompanied by his mother. The child complains of recurrent headaches which started a month ago. The headaches awakens him from sleep and are worse in the morning. He has also had recurrent vomiting associated with his headaches. On questioning the childs mother she reports that her son tends to be confused during the headache episodes, and that there has been a recent change in her sons personality. You are worried that this child could have a brain tumor. You wonder whether a CT scan is better than an MRI scan to rule out the diagnosis of a brain tumor.

A 9 year old child comes to the emergency department accompanied by his mother. The child complains of recurrent headaches which started a month ago. The headaches awakens him from sleep and are worse in the morning. He has also had recurrent vomiting associated with his headaches. On questioning, the childs mother reports that her son tends to be confused during the headache episodes, and that there has been a recent change in her sons personality. You are worried that this child could have a brain tumor. You wonder whether you should refer the child to radiologists for MRI scan of the head.