bestBETs

You recently admitted an 82-year-old arteriopath who has had an 8-month history of critical leg ischaemia and who has debilitating pain at rest. Lower limb arteriogram confirms three-vessel disease not amenable to revascularisation. A below knee amputation was discussed with the patient. The patient asks you if anything could be done rather than an amputation. You have heard of sympathectomy, but wanted to confirm from the literature that this may be a viable option.

You are in the resuscitation room and are faced with a combative head injury requiring a CT scan. He needs to be intubated via a rapid sequence induction and you wonder whether you should do this, as you have previous anaeasthetic training or call the anaesthetists down to do it for you.

A 50 year old man attends the emergency department with a plethoric, swollen left calf. Ultrasound examination reveals a posterior tibial vein thrombosis. You are unsure what the risk of a pulmonary embolus is, or whether he should be anticoagulated.

A sixty year-old lady presents to the Emergency Department with a thirty minute history of intermittent resting central chest pain that seems likely to be ischaemic. Examination, baseline obserations and ECG are normal. You follow your department's rapid rule-out protocol, with serial CK-MBmass estimations and continuous ST segment monitoring for 6 hours. The lady completes the protocol and tests negative. You feel rather uneasy about sending her home. As CK-MBmass is a marker of myocardial necrosis, you realise that you have excluded infarction but not necessarily unstable angina. You wonder if there are any novel markers that would help to identify the vulnerable patient, who is at high risk for adverse cardiac events in the near future. Hearing that VCAM-1 has such potential, you wonder if the evidence suggests that it is suitable for clinical implementation.

An eighty year-old man presents to the Emergency Department with central chest pain. He had a myocardial infarction five years ago and can't remember if the pain is similar. His ECG shows left bundle branch block, which is known to be old and has no ischaemic features. You therefore prescribe aspirin, nitrates and clopidogrel and refer for troponin testing at 12 hours. Having heard about the potential of novel biomarkers to enable early exclusion of acute coronary syndromes (ACS), you wonder if there is any evidence that measuring ICAM-1, a cell adhesion molecule, will enable early exclusion of ACS and accurate risk stratification.

A 52 year old man presents to the emergency department with a history suggestive of myocardial ischaemia. He requires intravenous opioids for pain and is feeling nauseous so you decide to give him an intravenous antiemetic. However, your consultant tells you not to use cyclizine as it can increase the heart rate, and thus myocardial oxygen demand, in already ischaemic muscle. You wonder whether this is true, or just more evidence of his eccentricity?

A 7 year old child, previously healthy attends Emergency Department following first generalised tonic clonic seizure. There is no history of drug and alcohol ingestion or other provoking factors. Clinically the child is afebrile and you wonder whether serum biochemistry is nessecary for the diagnosis and management of this patient

A fifty year-old lady with a severe needle phobia presents to the Emergency Department with a three-hour history of central tight chest pain. Baseline observations, chest radiograph and initial ECG are normal. You feel that you ought to exclude acute coronary syndrome before discharging her. Particularly in view of her needle phobia, you would like to be able to exclude the diagnosis using her admission blood samples but you are aware that troponin will be insufficiently sensitive at this time. Serial CK-MBmass would necessitate serial venepuncture. You wonder if there is an early marker you could use. As e-selectin as been proposed as such an early marker, you wonder if its measurement would help in this situation.

A 42 year old man presents to the emergency department complaining of a 6 hour history of painful right eye after it was scratched by a twig during gardening. The clinician presecribes topical antibiotics, advises the patient to use lubricants and arranges a review in 48 hours. You wonder whether there's any evidence to support this decision.

67 year old life long smoker, known COPD, on long term home oxygen and home nebuliser therapy, was brought into the emergency department by ambulance. He received 100% oxygen in the ambulance and was put on 4 litre/min oxygen by triage nurse in A&E. On assessment by the emergency doctor the patient was found to be in decompensated type 2 respiratory failure. You wonder whether it was appropriate for this patient to receive 100% oxygen in the ambulance and whether this would affect his outcome.

An 85 year old man presents to the emergency department with headache and sudden loss of vision. He has signs of an acute retinal arterial occlusion. He has a moderate headache and some mild tenderness along his scalp arteries. His ESR is 110 and his CRP is 150. You diagnose temporal arteritis and decide to give him steroids. The Ophthalmic nurse practitioner suggests Methylprednisolone, but your departmental handbook says that oral steroids will suffice. You wonder which to give.

You are the Emergency Department physician seeing a 35 year old woman who presents with extreme, short bursts of dizziness. Upon further questioning and physical exam, you find out that she is experiencing vertigo several seconds after moving her head, the vertigo resolves when her head is kept still and she has a positive Dix-Hallpike test. She did not experience any prodromal symptoms prior to the onset of her vertigo. You are confident that she has benign positional vertigo and recall the Epley Maneuver as a way to help treat her symptoms. Before performing the Epley Maneuver on the patient, you wonder if there has been any proof that the Epley Maneuver actually works in reducing the symptoms of acute benign positional vertigo.

A 42 year old man presents to the emergency department complaining of a 6 hour history of painful right eye after it was scratched by a twig during gardening. The clinician advises the patient to use lubricants as a prophylactic measure against Recurrent Corneal Erosion (RCE) syndrome. You wonder whether there's any evidence to support this decision.

An anxious forty year-old lady with a family history of ischaemic heart disease presents with tight central chest pain of one hour's duration. The pain eases with reassurance in the ambulance and the ECG at presentation is normal. You don't believe this lady is having an acute coronary syndrome but are unwilling to risk missing the diagnosis and refer for troponin testing at 12 hours. Having explained that you need to rule out a clot in the coronary artery, the lady states that her husband recently had a blood test to rule out a clot in the leg and wonders why you can't do the same test. You therefore wonder if plasma D-dimer would enable accurate exclusion of acute coronary syndrome.

A 43 year old man attends his general practitioner with a 6 month history of simple low back pain. He is tolerating simple analgesics and manageing to stay at work but he is struggling and has had to take days off sick due to his symptoms. There is nothing to suggest a sinister underlying cause and clinical examination does not suggest a radiculopathy. He is keen to try physio or chiropractic. You wonder if with er have been shown to make a difference.

A 55 year old man attends his GP with ongoing simple low back pain. He has no red flag symptoms and has tried analgesics in the past. You assess him and he tells you that he is very concerned about his pain and is very worried that he is doing more damage by continuing to work. You try and reassure him but wonder if some formal behaviour therapy might benefit him.

A forty-five year-old businessman presents to the Emergency Department with vague central chest pain for the past 2 hours. ECG is normal and you refer for troponin testing. He is very dissatisfied at having to be admitted and considers taking his own discharge. You wonder if there is a better way to exclude an acute coronary syndrome without having to admit for over 12 hours. Knowing that platelet activation is key to the pathogenesis of acute coronary syndromes and, having heard that thrombospondin may be a marker of this, you wonder if measurement of thrombospondin would allow earlier exclusion of acute coronary syndrome.

A fifty year-old man presents to the Emergency Department with a two-hour history of dull central chest pain. Past history includes a coronary artery bypass graft six years ago following MI but no subsequent angina. He had a peptic ulcer two years ago. ECG shows some non-specific T wave flattening in the lateral leads. Judging him to be high risk, you follow your department protocol, refer for troponin testing at 12 hours and administer aspirin, clopidogrel, dalteparin, atenolol and pravastatin. You wonder if there is any evidence that measurement of P-selectin, a promising cardiac marker you have heard about, would aid your triage decision, perhaps enabling early discharge without the need for potentially unnecessary and risky treatment.

A 42 yr old radio presenter presented to emergency department with sudden onset occipital headache followed by expressive dysphasia. Examination revealed GCS 12/15 (E4 V2 M6). The symptoms reported are classical of SAH and it will take at least 2-3 hrs for CT scan for diagnosis. Should nimodipine be given while awaiting CT scan to give its benefits of reducing cerebral vasospasm and secondary ischaemic damage?

A 25 year old man presents to the emergency department complaining of a 4 hour history of painful right eye after it was scratched by his 3 month old daughter. You recall being told that topical non-steroidal may be of help but wonder if they are any better than lubrication on its own. You also wonder if the non-steroidals may affect the eventual outcome and time to healing.