bestBETs

A 45 year old adult presents to the emergency department following a fall from a height. Neurological examination is normal, however, CT shows a burst fracture at L1. You wonder what the current method of management in these patients is.

A 45 year old male presents to the emergency department complaining of lower back pain following a 6 ft fall from a ladder. CT confirms your suspicion of a burst fracture at L1. Neurological examination is normal. You wonder if bed rest and TLSO bracing in these patients will produce a satisfactory functional outcome

A 45 year old male patient falls 12 ft from a ladder onto his back. He presents to the emergency department complaining of lower back pain. You wonder if CT is better than plain X-ray at diagnosing thoracolumbar fracture

Following a fall from a height a window cleaner aged 40 years arrives by ambulance to the emergency department. He complains that he can't feel his legs. Neurological examination shows both motor and sensory deficit in the lower limbs. You wonder if MRI would be better than CT as the primary radiological investigation

A 25 year old male adult falls 4 ft and lands on his back. He comes into the Emergency Department complaining of lower back pain. He denies any pain in the neck region. The pateint has been completely immobilised by paramedics. On neurological examination NAD. Plain X-ray shows a Type A thoracolumbar burst fracture at the T12-L1 junction. You wonder whether further spinal immobilization is necessary in this patient

A 25 year old haemodynamically stable patient presents to the emergency department following a high speed RTA with suspected intraabdominal injury. You wonder whether an FAST scan would be helpful for diagnosis.

A twenty month old girl is seen on the paediatric assessment unit with a 3 day history of diarrhoea, vomiting, and poor fluid intake. On examination she is miserable and lethargic and moderately dehydrated. A random bedside blood sugar measurement is 2.1 mmol/L. A metabolic screen is performed and results are not suggestive of an underlying metabolic disorder. Before discharge a controlled fast is carried out with no abnormality detected. Was all this investigation necessary?

A 40 year old male sustains a 2 cm laceration to his left forearm. There is no tendon/neurovascular damage. Would warmed local anaethetic or room-temperature local anaesthetic be less painful on infiltrating the wound prior to suturing?

A baby sustained extensive skin burns after the use of a skin preparation (alcoholic chlorhexidine). Following this event the hospital started using an aqueous preparation of chlorhexidine 0.05%. Was this the right choice and what is the evidence for the use of this or any other skin preparation in preterm infants?

Jack is a 2.5 year old boy. He has been referred for developmental assessment by his health visitor. His community paediatrician diagnoses speech and language delay. His mother reports he first sat independently at 9 months and walked at 17 months.

The orthopaedic department has listed several patients for total hip or knee arthroplasty which is putting demand on bed turnover. It is hypothesised that a pre-operative education session would reduce length of stay post-operatively as an in-patient.

A 23 year man was due to undergo a VATS procedure with talc insufflation for recurrent spontaneous pneumothorax. While preparing the patient for theatre he asks you about how the talc that will be insufflated in the operation works. After explaining how the talc causes an inflammatory reaction that causes the pleura to adhere together, he asks that since the talc causes a reaction, can it cause any long term problems.

You are referred a diabetic 78 yr old gentleman with left main stem disease and triple vessel disease. He has severe varicose veins in both his legs, but he has a large first diagonal artery and you would like to place 4 grafts. You would like to use the left internal mammary artery, and both radial arteries and you wonder whether you could also use a cephalic vein from his arm. You resolve to check the patency of these veins in the literature prior to proceeding.

You are performing an esophagectomy for a cT2N0M0 adenocarcinoma of the gastro esophageal junction. You have just mobilised the stomach and your surgical assistant asks whether you plan to perform to a pyloroplasty as he has heard it is associated with improved early post-operative recovery. You do not routinely do this but decide to check the literature after the operation.

A patient arrives in the Emergency Department after suffering thoracic trauma. A member of the team suggests using ultrasound to search for the presence of haemothorax, as an extension of the usual FAST assessment. You wonder how accurate the ultrasound would be compared to either the usual initial supine chest x-ray or to a computed tomography which could be performed later in the patients assessment.

A 59 year old man has a witnessed out of hospital cardiac arrest and immediate bystander cardiopulmonary resuscitation (CPR). When the paramedic ambulance crew arrive after 8 minutes the first recorded rhythm is asystole. Resuscitation continues according to current ALS guidelines. The patient is intubated, ventilated with high flow oxygen and receives 1mg of adrenaline and 3mg of atropine iv. He remains in asystole after a further cycle (2 minutes) of CPR. You have heard that other agents may be useful at this stage and wonder if there is any evidence that iv aminophylline is effective.

56-year-old man known to have non-insulin dependent diabetes mellitus presents to the Emergency Department after taken an overdose of his own oral hypoglycaemic - Glipizide. The initial blood sugar was very low; therefore he was given a 50 ml bolus of 50% dextrose. The patient recovered but despite a continuous intravenous infusion of 10% dextrose, hypoglycemia recurred. You know that intra-venous dextrose stimulates insulin release, and that sulfhonylurea compounds have a long half-life. You wonder about the use of the somatostatin analogue octreotide, which causes marked suppression of serum immunoreactive insulin and C-peptide concentration, and whether it is safe and effective under such circumstances.

In treating pediatric patients with diabetic ketoacidosis (DKA), minimizing the risk of cerebral edema is a mainstay of therapy. However, the pathophysiologic mechanism of cerebral edema in pediatric DKA is controversial. A literature search is performed to assess the evidence favoring the use of mannitol vs. hypertonic saline in the treatment of pediatric DKA.

A mother brings her five year old son to the Emergency Department (ED) with a deep scalp laceration having fallen onto the corner of a coffee table. The wound requires sutures. For various reasons the option for procedural sedation in this department is limited to midazolam. Due to your past experience, you are more comfortable using ketamine. Although there is a large amount of data in the Emergency literature to show efficacy and safety for both agents, you are not aware of direct comparisons to back your preference for ketamine in children in the ED setting.

A 24 year old male pateint presents to the emergency department after a high speed motor vehicle accident. Patient was intubated in the field has a GCS of 7T, multiple lacerations and obvious deformity of his RLE. While ordering diagnostic xrays, you wonder about the radiation exposure to the patient.