bestBETs

A 65 year old man suffered a witnessed out-of-hospital cardiac arrest. He received 20 minutes of basic and advances cardiac life support measures in the field. On arrival in the emergency department, the rhythm showed persistent ventricular fibrillation and he continued to be pulseless. You decide to continue another cycle of defibrillation and think of anti-arrhythmic drugs apart from correctable causes.You know that amiodarone is helpful. Your colleague mentions the use of magnesium as per ALS guidelines. Is Magnesium really helpful in return to spontaneous circulation in refractory ventricular tachyarrhythmias?

You are performing coronary artery bypass grafting on a 49-year-old diabetic with triple vessel disease and normal left ventricular function. He is overweight with a body mass index of 35. You would like to give him the best possible long-term results without causing increase in morbidity. Your colleague suggests the use of bilateral skeletonised internal mammary artery, thus giving long term results due to use of internal mammary artery. You decide to use a skeletonised LIMA and two vein grafts in this high-risk case but resolve to look up the evidence after the case.

There are a number of patients with poor left ventricular function being referred to the cardiac surgeon with angina who have had previous multiple revascularisation procedures and are on maximal medical therapy. They are clearly unsuitable for further surgical revascularisation either due to diffuse coronary artery disease with poor targets or have no useable conduits. Although some of these patients may be eligible for orthotopic heart transplantation, current waiting times for donor hearts and limitations in organ availability render this option unlikely to occur before the patient has become severely ill and reached status I priority level. Gene based modalities for ischaemic myocardium may eventually constitute a therapeutic option for these patients. You wish to find out what current evidence exists in this area of research.

One of your patients with borderline pulmonary function is still intubated following CABG 5 days ago. He is haemodynamically stable but his arterial blood gas shows that he is unlikely to be successfully extubated. The ITU staff ask you to site a tracheostomy surgically at the end of your list. In previous units your intensivists routinely inserted them percutaneously. The ITU staff are reluctant for a percutaneous procedure following problems with bleeding earlier that year. As you are unsure of the current evidence on which method is safer you decide to review the literature before returning to the ICU.

You performed a right lower lobectomy on a 67-year-old gentleman who had a 4-cm squamous cell carcinoma of the right lower lobe. He is a life long smoker and his tumour was staged as T2 N0 pre-operatively. You are now due to see him in your clinic but you discover that the histologist found a tumour involving the bronchial resection margin. You wonder whether to offer this patient completion pneumonectomy or whether to send him to an oncologist for post-operative radiotherapy and spare him this additional operation. Thus, you resolve to search the literature before seeing him that afternoon.

You are a first year radiology registrar who performs a carotid-artery duplex ultrasound on a symptomatic patient that reveals an 80% unilateral stenosis. The patient has heard about endovascular carotid angioplasty with stenting (CAS) as an alternative to carotid endarterectomy (CEA) and is keen to have a minimally invasive procedure. However, you are unsure whether there is any evidence to suggest that CAS is equivalent to the traditional gold standard of CEA.

A 65y/o gentleman presents to the Emergency Department complaining of acute onset of shortness of breath. You suspect on clinical grounds that this may be due to heart failure. His ECG shows sinus rhythm with a rate of 96bpm and no abnormalities that you can detect. You wonder if this suggests that there is another cause for his symptoms.

A 35-year-old female with sickle cell disease presents with pain in her arms and legs for twenty-four hours. Her pain is consistent with her usual pain crisis symptoms. She is afebrile, has normal vital signs, and no acute findings on physical exam. You promptly treat her pain. You wonder if a chest radiograph or urinalysis will detect an occult bacterial infection that may have precipitated the crisis.

A 55 year old man, known to have angina, presents to the Emergency Department with new-onset typical ischaemic rest pain that is not relieved by his nitrate spray at home. His ECG shows ST depression in V3-V6. He is haemodynamically stable. You treat him with oxygen, aspirin, nitrates, beta-blockers and heparin, after which he becomes pain free. You also give him clopidogrel 300 mg because you have heard that patients with unstable angina and non ST-elevation MI have a better cardiovascular outcome when treated with a combination of clopidogrel and aspirin versus aspirin alone. You wonder whether there is any evidence to support this.

An asymptomatic conscript walks into the Medical Centre and provides a urine sample for testing for glycosuria as part of a screening procedure for Diabetes Mellitus. How useful is a urine dipstick in screening for the condition.

A term baby is admitted to the neonatal unit with a history of grunting 1 hour after birth. You are the SHO on call and plan to start the baby on antibiotics-Benzylpenicillin and Gentamicin for suspected sepsis. One of the Neonatal Nurses asks you about once daily dosing and multiple dosing of Gentamicin and you wonder which of these regimens would be more safe and effective?

A 5-year-old boy attends the A&E department after sustaining a twisting injury to his left ankle. On examination there is swelling and tenderness over the lateral malleolus. You know that the Ottawa ankle rules are applicable in adult patients and you wonder whether they are applicable in children too.

A 76y old gentleman with a known history of ischaemic heart disease presents with a history of recent onset of severe dyspnoea. On questioning a history is revealed of mild exertional dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea. On arrival in the department the gentleman had been started on high-flow oxygen via a mask with a reservoir. You wonder if there is evidence to support the use of supplemental oxygen in patients with heart failure.

A 2 day old baby born at 28 weeks gestation is currently on ventilator. He is doing well on minimal respiratory support and you decide to extubate him. You decide to start caffeine prior to extubation.

You have a 4 year old girl with hemihyperplasia limited to the left leg in your clinic come for review. This child was originally referred to your clinic a few weeks back after her mother noticed leg length discrepancy when she bought a new pair of trousers. You notice asymmetry between the two legs, with the left leg larger and longer than the right. An orthopaedic surgeon was consulted, who ruled out a hip problem and suggested the possibility of hemihyperplasia of the left leg. There is an increased risk of cancer, especially of Wilm's tumour in these children, and hence a paediatric surgeon was consulted. Ultrasound scan of abdomen ruled out an intra-abdominal tumour. Her parents were trained to feel their daughter's abdomen weekly. You are unsure about the actual incidence of the risk of tumour (cancer) development and the best scheme for surveillance. Hence you decide to look at the evidence base for these answers so that the family can be counselled appropriately.

A 10 year old male presents after a suffering a laceration on his lower leg from a snow skiing accident. It cannot be closed using glue. You would like to save the child the pain and discomfort of suture removal. You wonder if absorbable sutures would increase the rate of complications or scarring.

Hannah is a 7 year old girl with Henoch-Schonlein purpura (HSP). She has a lot of abdominal pain which is not settling with simple analgesia. An ultrasound scan reveals that she does not have an intussusception. The SHO on-call tells you that her handbook of paediatrics says that such pain can be treated with steroids, but is there really any evidence to support this?

A 71 year old lady presents to the A+E department following a fall on the outstretched hand. X-rays reveal a Colles fracture with shortening and dorsal angulation requiring manipulation. Having worked in several different departments you have experience of reducing these fractures with either Biers block or a Haematoma block. The department is better and you think that it will be quicker to manipulate the fracture using a haematoma block but you wonder which is best for your patient.

A 3 year old boy is admitted to a paediatric intensive care unit with a history of fever, non-blanching petechial rash, decreased conscious level, and grunting; capillary refill is poor. After screening for sepsis, antibiotics are started. He is intubated, receives fluid resuscitation (total of 100 ml/kg), and a central catheter is placed, showing a central venous pressure of 12 mm Hg. Despite dopamine infusion the attending physician is unable to stabilise his blood pressure, and he requires noradrenaline infusion to achieve and maintain his haemodynamic state.

You are a paediatric registrar on the children's intensive care unit. You are about to intubate a 2 year old child with severe meningococcal septicaemia. Your recent experience in ventilating children with this condition is that they often develop acute respiratory distress syndrome, and require high pressures to maintain adequate oxygenation and ventilation. At these high pressures significant leaks occur around the endotracheal tube, impairing effective ventilation, and on occasion it is necessary to change to an endotracheal tube of greater diameter. Re-intubation under such circumstances carries a greater risk of hypoxia because of the inevitable loss of positive airway pressure during the procedure. You think it would be wise to insert a cuffed endotracheal tube, in which the cuff could be inflated if leak becomes a problem. It has been traditionally taught that only uncuffed endotracheal tubes should be used for intubation in children under the age of 8 years to decrease the risk of airway mucosal injury and post-extubation stridor. You wonder if there is any evidence to the above statement.