bestBETs

55 y/o women presents after taking 100 x 500mg paracetamol tablets. She has been found at home with the empty packets of tablets. On questioning she admits to taking the medication 10 hours ago. You immediately gain IV access and start NAC as per the SNAP protocol. Her paracetamol level comes back as >300mcg/ml. Given the high dose of paracetamol she has ingested you wonder if the standard dose of NAC will be enough and if there is any evidence to support increasing it?

A 68 year old patient, mechanically ventilated in the ICU has failed at multiple attempts at conventional weaning to a state of ventilator liberation, becoming dyspneic and desaturating. You wonder if there is a treatment adjunct you could use to increase her respiratory strength prior to further weaning attempts.

An 82 year old lady is brought in by ambulance after falling down a flight of stairs. He vital signs are unremarkable and she undergoes a whole body CT after the primary survey. This reveals a moderate right sided haemothorax. The trauma team are in agreement that drainage is indicted. Should a 28-38Fr open thoracostomy tube or a smaller (16Fr or less) seldinger drain be inserted?

A 25-year-old women attends the emergency department having taken a large paracetamol overdose. She reports taking 64x500mg tablets 7 hours ago. On questioning she describes nausea and vomiting with mild abdominal pain. Her examination reveals right upper quadrant tenderness. Blood investigations reveal a high paracetamol level. You start her on IV acetylcysteine as per the SNAP protocol. You are concerned that she is at risk of developing serious liver injury and wonder if there is any other treatment that could be initiated in addition to the NAC minimise this risk.

A 35 year old man attends the emergency department having taking a staggered paracetamol overdose. He reports taking 72x500mg tablets over the past two days. He is suffering from persistent vomiting with increasing abdominal pain. His examination reveals right upper quadrant tenderness. He is acidotic on his blood gas. You start him on IV acetylcysteine as per the SNAP protocol immediately. Blood investigations are taken which reveal a raised ALT and INR. You are concerned that he is at risk of developing serious liver injury and wonder if there is any other treatment that could be initiated in addition to NAC to minimise this risk.

A 60 year old male presents to the Emergency Department with a minor head injury after tripping. He has no associated symptoms with the head injury but is on an anticoagulant. Should his management include a CT head?

A 30-year-old, normally fit and well man presents with a headache, 36hrs after hitting his head when falling off his ladder. He did not lose consciousness at the time of injury, but now has a bad headache. He has a normal neurological exam. This fits the criteria for a mild head injury according the WHO head injury score. You know that current NICE guidance on imaging in head injuries has only been validated in populations of patients presenting within 24 hours. You wonder if you should request a CT head scan for this patient to look for possible traumatic intracranial pathology.

A fit and well 30-year-old male presents to the emergency department (ED) with central lower chest pain that came on at rest today and lasted 4 hours. He describes a “heavy ache” that radiated to his neck and made him feel sick, but denies vomiting or diaphoresis. He has had indigestion in the past but this felt higher and more severe than previous episodes. His observations, examination, and ECG are normal. He has no risk factors for coronary artery disease, but is worried about the possibility of a heart attack. You clinically suspect indigestion but feel a cardiac cause might be possible. He hasn’t had bloods sent and has been in the ED for 3 hours already. His HEAR score is 1 (due to a moderately suspicious history) and you wonder whether you really need to send a troponin in order to complete the HEART score and exclude an acute coronary syndrome (ACS).

A 31-year-old woman presents at the Emergency Department by ambulance following a heroin overdose. She requires naloxone for opioid-reversal. She has made a full recovery and is ready for discharge.

A 36 year old female presents to the emergency department (ED) with symptoms of acute migraine. She has a history of migraine. She is systemically well. You wonder whether this patient could get symptomatic relief from a sphenopalatine ganglion (SPG) block via administration of intranasal lidocaine.

A 46 year old female presents to the Emergency Department out of hours with left leg swelling. Wells score for DVT is +2. You suspect a lower limb DVT and wonder if you can use point-of-care ultrasound to make your diagnosis.

A 37 year-old man attends the emergency department with cyanosis unresponsive to high flow oxygen. When blood is drawn it is a dark ‘chocolate’ colour and does not lighten when exposed to air. The patient reports he has recurrent methaemoglobinaemia of unknown origin and is currently under haematology who are attempting to illicit a cause. When is this man safe to be discharged?

A 70-year-old woman presented to the Emergency Department with hypoxia and confusion. Her chest X-ray findings are consistent with severe COVID-19 pneumonia. COVID-19 infection was confirmed with RT-PCR testing. A colleague mentions inhaled budesonide as a possible treatment. You wonder if inhaled budesonide would reduce mortality or time to recovery. You also wonder if it is associated with increased adverse events.

A 66-year-old man came to the emergency department by ambulance for cough and viral illness. His chest X-ray revealed bilateral infiltrates concerning for viral pneumonia. RT-PCR test confirmed the diagnosis of COVID-19 infection. You wonder if monoclonal antibody therapy would provide any benefits to mortality, length of stay, requirement for ventilation.