bestBETs

A 77-year old woman presents to the Accident and Emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a "3-in-1" block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound (US) has been used as an alternative to nerve stimulators (NS) in this setting.

A 38 year old man presents with one week history of jaundice. He admits to drink alcohol excessively of about 10 units per day for the last 10 years. Clinical examination reveals jaundice, spider naevi over chest and tender, palpable hepatomegaly with no clinical signs of ascites. Hepatitis screen and septic screen are negative . A diagnosis of alcoholic hepatitis is made. You wonder whether early commencement of steroids would improve his short term survival.

Is Gabapentin effective as an adjuant in reducing postoperative pain and opioid requirement?

A previously healthy sixty year-old lady presents with a thirty-minute history of left-sided chest discomfort, also felt in the left arm. Examination and initial ECG are normal. You refer her for troponin testing at 12 hours but recognise that this strategy has three major limitations: (1) The patient may be unnecessarily alarmed or receive inappropriate treatment for what turns out to be an erroneous diagnosis; (2) The patient's condition has not been diagnosed in the initial 12-hour period, when intensive guided therapy may have been most beneficial; (3) troponins merely mark myocardial necrosis and cannot inform you as to whether the patient has an unstable coronary atheromatous plaque. Having heard a rumour about brain natriuretic peptide (BNP) as an early cardiac marker, you wonder if it would help to avoid such disadvantages in this clinical situation.

26 year old male presented to the Emergency department with a two days history of paraphimosis. Rather than using granulated sugar the local practice is to make the patient soak his in a paper cup containing 50 ml of 50% dextrose water for approximately 20 minutes. This appeared to be easy and straightforward with a successful outcome. You wonder therefore whether there is any evidence showing concentrated sugar solution being better than granulated sugar in reducing a paraphimosis.

A thirty year old man presents to the department with a swollen leg, admitting to a recent history of injecting drug use. You suspect he has a deep vein thrombosis but injecting drug use does not feature as a risk factor on the Wells criteria- the widely used model for assessing pre-test probability for this condition, and you wonder if this reflects the incidence rate for deep vein thrombosis in this patient group.

A 45 year old woman presents to the emergency department one hour after taking eight ibuprofen tablets. She denies co-ingestion. You are happy with her medical condition, but concerned about her mental state, and so request a psychiatric review. However, the psychiatric doctor refuses to see her until she is proven to need no treatment for paracetamol poisoning. As this will take another three hours, you wonder if a sample drawn now, would, if it contained no paracetamol, exclude a significant overdose, thus expediting referral.

A 65 year old male presents to the emergency department with a severe pneumonia. He is intubated and placed on a ventilator because of worsening hypoxia. He has no history of previous renal disease however he becomes increasingly oliguric over the next 2 hours despite adequate fluid resuscitation and vasopressor support. You wonder whether the administration of a loop diuretic in order to improve/maintain his urine output will improve his prognosis and reduce the need for continuous veno-venous haemofiltration (CVVH).

A 25 year old man with sickle cell disease presents with a two day history of pain in his arms and legs. His pain is consistent with his usual painful crisis symptoms. He is afebrile, has normal vital signs, and has no acute findings on physical exam. You promptly treat his pain. You order haematologic tests in these situations as a matter of routine. You wonder if the results of his complete blood count or reticulocyte count will alter your management.

You are going on a family holiday to Scandinavia during the summer. You wonder what evidence there is that oral antihistamines will reduce the symptoms of the inevitable insect bites.

You have been approached by a representative of a company who is promoting their harmonic scalpel. They tell you that their scalpel is quicker and safer than the diathermy technique and that it causes less arterial spasm. The representative gives you several brochures to back this up with some references in small type at the bottom of the page. You are keen to try this ultrasonic scalpel but you discover that it is more expensive than your usual technique so you decide to look up the clinical evidence for a benefit for harmonic scalpels before committing to a trial of this new device.

A 74y/o lady with a significant medical history of ischaemic heart disease and COPD presents to the Emergency Deparment with acute shortness of breath. You are unsure whether this represents an episode of acute heart failure or an exacerbation of her COPD. You request an urgent CXR in the hope that it makes the diagnosis clearer so that you are able to confidently prescribe the appropriate treatment.

A 35 year old male comes to A&E complaining of severe pain in his loin. After initial KUB and urinalysis, the registrar on duty questions which method; US or IVP, is better at detecting calculi.

A fine Irish male professional rugby union player is spear tackled by 2 nasty New Zealand players and sustains a totally undeserved dislocated shoulder. He undergoes operation to reduce the dislocation and repair the associated detached glenoid labrum. The surgeon wants to play safe in the post-operative phase whilst the physios are keen to get him back to playing as soon as possible but are worried about re-dislocation rate and permanent loss of function. Debate ensues about whether an accelerated rehabilitation programme or a more conservative approach should be adopted for him.

A 44 year old man presents to the Emergency Department with a six hour history of palpitations. His ECG confirms that he is in atrial fibrillation and a detailed history suggests that this is acute atrial fibrillation of less than 48 hours duration. It is decided that cardioversion is the treatment of choice, but which waveform is likely to be more effective? Monophasic or biphasic?

A 19 year olld presents to the ED with redness tracking up the left arm. A diagnosis of cellulitis is made. However, he is going on holiday in 3 days time and is keen not to miss the trip. The patient attends the ED regularly for the administration of iv antibiotics, over 3 days and is then discharged with a 5 day course of oral antibiotics.

You are called to see a middle aged man with an acute onset of severe, colicky, left-sided loin pain. Clinical examination rules out peritonitis while urinalysis reveals '+ + +' microscopic haematuria. You strongly suspect a diagnosis of ureteric stone disease. In such circumstances, impacted renal calculi trigger the production of prostaglandins which subsequently stimulate pain. While opiates can offer pain relief by subduing patients' awareness of these stimuli, NSAID's can actually treat the pathophysiological mechanisms that cause them in the first place. You wonder whether they would be more effective at providing analgesia?

A 25 year old male is brought into A&E by ambulance with a history of respiratory arrest following a suspected Opioid overdose. One of the paramedics describes struggling and failing to achieve peripheral venous access, sustaining a needle stick injury in the process. The paramedic describes proceeding to administer a total of 800mcg of Naloxone intramuscularly to which the patient's response has been slow. You wonder whether the administration of Naloxone intranasally, would have been effective in both reversing the effects of the overdose and eliminating the need to use needles in the pre-hospital environment in a patient at high risk of having both limited peripheral venous access and potentially contractible blood-borne viruses.

The patient is a 39 yo Afr-Am G3P0Ab2 with IUP at about 22 weeks with hyperemesis gravidarium and clinical Grave's disease. At 20 weeks, blood tests show that her serum TSH is suppressed at 0.02 mIU/ml (0.4-3.5), free T4 is 3.0 ng/dL (0.8-1.8) and free T3 is 2.6 ng/dL (0.2-0.6), her pulse is about 120. Ultrasound shows borderline normal fetal growth with a fetal heart rate of 170 (120-160). She is currently being treated with PTU (propylthiouracil) 200 mg TID. At about 22 weeks, targeted ultrasound reveals low normal fetal weight, a fetal anterior neck mass consistent with fetal goiter, normal amniotic fluid volume, and fetal heart rate of 150. How should the mother be treated?

A 40 year old man presents to the emergency department 30 minutes after drinking 500ml fenthion. He has a Glasgow Coma Scale score of 13/15, and has pinpoint pupils and excessive sweat. A rapid sequence induction and intubation is done. Given the recent onset and the undefinite efficacy of activated charcoal in organophosphate you wonder whether he is a candidate for gastric lavage.