bestBETs

A 27 year-old man sustains punches to the face and ear during a drunken brawl. He attends the Emergency Department the next day complaining of unilateral deafness and otalgia. Examination reveals an intact tympanic membrane but blood in the middle ear cleft. The SHO on-call for ENT suggests he needs a myringotomy to drain the blood. You wonder whether there is any evidence that this could relieve symptoms and improve outcome.

A 65 year old woman is brought into the emergency department following a 3 day history of nausea and vomiting, abdominal distension, and absolute constipation. Her vital signs are stable, and his abdomen is distended but not tender. A lower midline laparotomy scar from a previous hysterectomy is noted. A plain abdominal radiograph shows distended loops of small bowel with a paucity of air in the colon. A clinical diagnosis of ASBO is made. You wonder whether a water soluble contrast small bowel follow through (SBFT) study would be useful in the management of a patient with presumptive ASBO.

A 67 year-old man with a history of angina presents with a sudden onset of left sided weakness in the early evening. You know that the patient will not receive a CT scan until the following day and that if he is having a cerebral infarction he may receive some benefit from administration of aspirin. You wonder if the potential benefit out-weighs a possible increase in the risk of worsening any intracranial haemorrhage.

A 55-year-old man presents to the emergency department with a sudden onset of abdominal and flank pain associated with hypotension. Our concern is that he may have an AAA, but at this time the patient is too unstable to leave the emergency department for formal imaging. The vascular surgeons suggest a bedside ultrasound study. We perform one scan and see no AAA. Can you be confident that an ultrasound scan performed by an emergency physician can accurately rule in or out an AAA?

An unwell infant presents with high intermittent fever and irritability. She has had no previous illnesses. A urine sample showed >100 white blood cells and >100,000 E.coli/ml, confirming a diagnosis of urinary tract infection (UTI). The mother asks whether she could be treated with just one dose of antibiotic as she herself was treated this way for a recent urinary tract infection, instead of the standard 5-7 days of antibiotics currently recommended.

A twelve year old boy presents for a routine asthma follow up appointment during the autumn. He takes 200mcg per day of inhaled budesonide and uses his salbutamol 3-4 times per week. His mother asks if the flu vaccine will make it less likely that he will have an asthma exacerbation over the winter.

A 12 year old boy with Osgood-Schlatter's disease presents to the ED with knee pain unresponsive to regular paracetamol and ibuprofen. You wonder if immobilising his leg would improve his pain, and if so, the best method for this.

A 35 year old accountant with recurrent shoulder dislocation presented to Emergency department with yet another episode of dislocation that happened this time while lifting a heavy load in his garage. The department is busy and he is in severe pain and considering his history you would like to reduce the shoulder without taking a pre-reduction shoulder X-ray but you are obliged by departmental policy to do the x-ray. You wonder if the pre reduction x-ray in this case would change your management.

A twenty year-old asthmatic lady presents to the Emergency Department with acute-onset of dyspnoea following a row with her boyfriend. She has a respiratory rate of 40/min, a pCO2 of 2.5, is tearful, extremely anxious and panicky but has an audible wheeze. You try in vain to reassure her and realise that the panic is not helping her bronchospasm. You know that benzodiazepines are to be avoided in acute severe asthma and do not prescribe them. Having stabilised her condition with nebulised salbutamol, intravenous magnesium and oral prednisolone you wonder whether there is any evidence within the literature of the harmful effect of benzodiazepines in this situation.

You just finish a busy call night and want to go home to get some sleep, you run into your colleage who is just returned from having a few beers at the bar. He challenges you that he could perform better in his intoxicated state, that you, in your sleep deprived state.

You are seeing a 60 year old patient 5 days after a left lower lobectomy for a 4cm squamous cell carcinoma. There were no obvious nodular involvement at operation. He is diabetic and an ex-smoker but otherwise relatively well and ready to go home. You tell him that he is ready to go, but that he will probably need chemotherapy in a few weeks time. He is alarmed at this and worried that the operation has therefore not been a success, and you enter into a long discussion about chemotherapy, the operation , and his likely prognosis. After this lengthy discussion you wonder whether it is really worth referring these early stage patients for chemotherapy and thus resolve to look up the evidence.

You have been performing CABG surgery. The anaesthetist has used the Hepcon HMS Plus Hemostasis Management System (Medtronic, Minneapolis, MN) to monitor heparin concentration and calculate protamine dose to reverse anticoagulation. He claims that heparin and protamine dose optimisation decreases coagulation system activation, postoperative bleeding and allogeneic blood and blood component transfusion requirement. You wonder what evidence is available to justify this claim.

A 5 year old girl presents to the Emergency Department with a one week history of polydipsia, polyphagia, polyuria, and nocturia. She has also had one day of non-localized abdominal pain and low grade fever (T 99ºF). Labs at the urgent care center one day prior show a non-fasting blood glucose of 284; labs at the PCP's office the day of the ED visit include a non-fasting CBG of 190 and HbA1c of 7.3. You wonder if the elevated glycosylated hemoglobin is acceptable for diagnosing diabetes or if she needs further testing with an oral glucose load.

A 29-year-old white woman with no background history of cardio-pulmonary or rheumatic disease was admitted with rather abrupt onset of exert ional dyspnoea, dry cough and recurrent syncopal episodes in absence of chest pain or haemoptysis. Clinical examination revealed evidence of right heart failure. There was no clinical or echcardiographic evidence of valvular heart disease, cardiac constriction or restriction. A subsequent V-Q scan was reported to be low probability for pulmonary thrombo-embolism. Cardiac catheterization showed elevated pulmonary arterial pressure (measured 113/57 mm Hg) and normal pulmonary arterial wedge pressure (excluding left sided heart disease). Apparently the patient was commenced on oral contraceptive pills five years prior to the admission. One wonders if the sudden onset of primary pulmonary hypertension without any overt pulmonary thromboembolism, in a previously healthy woman with no positive family history could be associated with oral contraceptive pills.

An ambulance arrives at the emergency department with a 35 year old male known heroin abuser who has overdosed. The patient dies despite naloxone administration and full attempts to resuscitate him. You treated him for a non fatal overdose 8 months ago and wonder if this could have been a factor in predicting fatal overdose on this occasion.

A 70 year old gentleman presents to the emergency department in acute urinary retention. You decide to catheterise him. Your SHO tells you that when he was doing Urology it was standard practice to give systemic antibiotics to any patient catheterised post operatively. You wonder whether the patient in front of you needs them?

A 27 year old male presents to the emergency department with a severe headache. A subarchnoid haemorrhage is suspected, the diagnosis is confirmed by CT. His GCS on admission is 8, you wonder if this will have any implication on his overall outcome.

A 65 year old patient with Alzheimer's disease presents to the accident and emergency department following a fall. Abdominal injury is suspected. The patient's BP systolic is 96mmHg, pulse rate 110. Is CT scanning more efficacious at diagnosing abdominal injury that diagnostic peritoneal lavage (DPL)?

It is 5pm on a Sunday afternoon. Your patient is a gentleman in his mid 20s who tells you that he had unprotected receptive anal sex on Thursday night with a man he now knows to be HIV positive, The patient is aware of PEP through literature he has seen in the GUM clinic, and requests a prescription. You calculate that 69 hours have passed between the exposure and now, and wonder if giving PEP at this time will reduce the risk of seroconversion. When giving the patient details of the PEP prescription, he is surprised to learn that it is a 28-day course. You wonder if a 28-day course has proven to be more efficacious in reducing the rate of seroconversion compared to a shorter course.

It is 7am on a Saturday morning and you are seeing a 19 year-old female university student who is dishevelled and still wearing the clothes she wore to a club the night before. She smells faintly of alcohol. She tells you she had unprotected sex while drunk, and requests the morning-after pill and postexposure prophylaxis for HIV. When you question her as to her need for PEP, she tells you that her partner of the night before was a student from South Africa, and she was aware of the high prevalence of HIV infection there. While giving you her medical history, she tells you that she has had the morning-after pill four times in the past eight months, all purchased over-the-counter in the large city-centre pharmacy, to avoid, she says, 'sanctimonious proselytising' from her GP. As you give her her prescription, you wonder if there are any behavioural interventions that might help reduce her risk-taking behaviour.