bestBETs

A 74-year-old male with a history of diabetes and COPD presents via EMS in acute distress. EMS reports the patient was found somnolent and minimally responsive by a family member who came to check on him. He has a productive cough. Vital signs initially are significant for a rate of 122 BPM, a temperature of 39 degrees C, respiratory rate of 56, SpO2 of 89% and blood pressure 88/45. He has a GCS of 14. You suspect sepsis and begin your workup and treatment, including placing him on 6L nasal cannula. The patient is fluid resuscitated with 30 mL/kg of normal saline, cultures are drawn, and antibiotics are started. As the second liter is finishing, the patient becomes progressively less responsive and his SpO2 begins to drop. His blood pressure is now 82/38. As you prepare to intubate, you are concerned about his fluid-refractory hypotension in the peri-intubation period and consider a bloused dose of phenylephrine to bridge him to more definitive therapy.

A 23-year-old male presents with right shoulder pain after falling and catching himself. Physical exam demonstrates a squared off right shoulder with anterior fullness, with the patient holding his arm in slight abduction and external rotation. Anterior shoulder dislocation is suspected. The x-ray department is backed up, and you are wondering if point-of-care ultrasound is appropriate for diagnosing a shoulder dislocation.

25 year old male patient presenting to ED 3 days after a head injury where a heavy wooden door swung into his head. He presented with ongoing symptoms of nausea and headache

A 45 year-old female presents to the ED with a 3-day history of cough and breathlessness. You wonder whether this patient has COVID-19. You worry that sending this lady into the hot zone of the department may result in a potentially vulnerable patient being exposed to COVID-19. You know that a CT scan is the gold standard imaging choice for COVID-19 pneumonitis, but its practicality, cost, and irradiation cause you to wonder whether LUS would be an appropriate alternative to facilitate safe triage of this patient.

A 2 year old boy presents to the emergency department with a large laceration to his temple after he fell onto a corner of a coffee table. He will require procedural sedation to suture the laceration. You ask the bedside nurse to start an IV to administer ketamine. As the child squirms and cries getting the IV, you wonder, is there a better option?

You are referred a 55 year old woman for a mobility assessment. She was diagnosed with an acute calf DVT yesterday and started on anticoagulation therapy. Is it safe to complete a mobility assessment today?

A 5 year old girl presents to your paediatric ED with a one day history of abdominal pain and an acute episode of haematemesis. Her mother explains that she is unable to locate a button battery she left on the kitchen table. She is tachycardic (heart rate 150 beats per minute) but normotensive (blood pressure 105/55 mmHg). A chest x-ray identifies a button battery in the proximal oesophagus. You are worried about the potential for this child’s haematemesis to worsen and consider whether any novel strategies could be used to mitigate deterioration prior to endoscopic removal.

Mrs. Majorie Knowsbleed is a 75 year old woman, with history of avalvular atrial fibrillation, on Apixaban, presenting to the ED for 2 hours of atraumatic epistaxis. In your arsenal of epistaxis management, you consider the utility of topical tranexamic acid to stop the bleeding.

You are working in a busy emergency department and intubate a patient using a rapid sequence induction with rocuronium as your neuro-muscular blocking agent (NMBA) of choice, there is a delay in setting up a sedative infusion and shortly after intubation, your patient becomes tachycardic and hypertensive. You worry they are under-sedated and experiencing awareness so give a bolus dose of sedative as a temporising measure. You wonder whether your choice of a longer acting NMBA compared to the more traditionally used suxamethonium could have delayed your recognition of awareness and led to under-sedation.

A 66-year-old man presents to the Emergency Department (ED) acutely short of breath, on a background of 10 days of fever, cough and pleuritic chest pain. He tells you that he had a positive COVID-19 swab in the community 5 days ago. His oxygen saturations are initially 85% on 10L oxygen by face mask and he looks tired. He is rapidly intubated and stabilised in the department, but his oxygen requirements remain at 60% despite optimised ventilation. You are unsure whether he has a concurrent pulmonary embolism (PE). A colleague says that looking at the difference between the arterial partial pressure of carbon dioxide (PaCO2) and end-tidal carbon dioxide (ETCO2) can sometimes be helpful. They suggest that an increased alveolar dead space fraction (AVDSf), calculated by PaCO2-ETCO2/PaCO2, can increase the likelihood of PE. You resolve to consult the literature to see if there is anything in this recommendation.

74 year old man presents to emergency department with a 1 day history of dizziness, sensation of vertigo and imbalance. He has nystagmus on clinical exam. His head CT is negative for cerebellar infarct. Does he need an MRI to exclude cerebellar stroke?

A 44 year old woman with recurrent episodes of benign paroxysmal peripheral vertigo (BPPV) presents to the ED. You perform a successful Epley manoeuvre but are unsure if there is anything you can prescribe her for residual dizziness as an outpatient.

A 40 year old male attends the emergency department with a persistent dry cough and fever. He tested positive for COVID-19 infection five days ago and has been isolating ever since. On examination his heart rate is 120 beats per minute, respiratory rate is 20 and his oxygen saturations are 94% on room air. Would measuring his serum lactate help you to risk stratify this patient and determine his requirement for medical intervention?

You see a 32-year-old man in the rapid assessment zone of your emergency department with acute neck pain a few hours after helping his friends move to their new apartment. There was no direct trauma and he has no neurological deficits and no bony tenderness. He has tried acetaminophen and ibuprofen but he continues to have limited range of motion and significant pain on the left side of his neck.

A 70-year-old patient is brought to the Emergency Department (ED) with a fracture dislocation of her ankle. Despite standard analgesic treatment (SAT) including 10mg of Morphine intravenously (IV), 1gr of Paracetamol (IV) and nitrous oxide, the patient is still in moderate pain. There is significant delay in organising reduction and cast application under sedation. The patient is asking for more analgesia and the paramedics state that they have heard Methoxyflurane can provide effective pain relief for patients with similar injuries in out of hospital settings. Methoxyflurane is currently not adopted or available as part of SAT in the ED.

A 38- year-old woman presents to the Emergency Department (ED) in her third trimester of pregnancy. She complains of right sided chest pain and shortness of breath. There are no clinical signs of deep vein thrombosis (DVT) and she does not report haemoptysis. This is her second pregnancy and she has no personal or familial risk factors for PE. Her oxygen saturators are 98% with respiratory rate of 21 and a regular heart rate of 109 at rest. Her blood pressure is normal and she is afebrile. A junior doctor has already assessed the patient. He tells you that all the blood tests are normal except for a D-dimer which is raised at 625ng/mL. A chest X-ray (CXR) is clear and electrocardiograph (ECG) shows sinus rhythm. The junior doctor is unsure what to do next. He does not want to misdiagnose PE but is also worried about requesting CTPA.