bestBETs

Recognising the limitations of troponin testing in suspected acute coronary syndromes you investigate possible alternatives within the literature. Having reviewed the evidence for brain natriuretic peptide (BNP), you discover that N-terminal-pro-BNP may be superior. You wonder if there is any evidence for its effectiveness.

An adult is brought into the Accident and Emergency Department with vomiting, diarrhoea. They are diagnosed with gastroenteritis. Will IV or oral fluids be faster at rehydrating this patient to a point where discharge will be possible?

You have just started working with a consultant in a new firm. The consultant you had previously worked with uses topical papaverine to prevent vasospasm of the left internal mammary artery. Your new consultant never does this. On the first theatre day in your new firm you have completed harvesting the internal mammary and noted the flow to be poor. You are contemplating using topical papavarine to improve the vasospasm of the mammary artery. However, your consultant stops you and asks you to show him the evidence that topical vasodilators significantly improve mammary arterial flow before using any vasodilators in his cases.

A fifty year-old man presents having experienced 2 hours of central crushing chest pain. He is diaphoretic and the ECG shows 4mm ST elevation in the anterior leads with reciprocal inferior ST depression. You prescribe aspirin, oxygen, clopidogrel, morphine, thrombolysis and buccal glyceryl trinitrate (GTN). Unfortunately his pain is not relieved. As you start to write "GTN; IV" on the drug kardex you wonder whether there is any evidence that nicorandil, a potassium channel opener with nitrate-like activity, will have a beneficial effect in this acute situation.

A forty-five year-old man presents with classical ischaemic chest pain occurring with increasing frequency over the past 48 hours, with intermittent rest pain for 4 hours. ECG shows deep, downsloping lateral ST depression without left ventricular hypertrophy. You diagnose unstable angina and prescribe aspirin, clopidogrel, low-molecular weight heparin, beta-blockers, statins and buccal nitrates. His pain is refractory to nitrates. Knowing that nicorandil is a useful adjunct in the treatment of poorly-controlled stable angina, you wonder if there is any evidence for its benefit in the acute situation.

You refer a fifty year-old man, with vague central chest pain but normal ECG, to the Medics for troponin testing at 12 hours. The medical registrar comments that one day this will be a thing of the past, as Emergency Departments will be able to test all patients with suspected cardiac chest pain for whole blood choline, thus referring only those with genuine acute coronary syndromes (ACS). You wonder if she is right.

A 43 year old re-presents to her GP with a 3 year history of intermittant back pain. She is rarely without any pain but has regular exacerbations. She is concerned that her sickness record is causing concern amongst her employers and if fearful that she might lose her job. She has heard that she can go to special classes to help her get better and wonder if you know if these "back schools" are any good. You endevour to find out.

A consultant physician informally comments about the high volume of patients with vague central chest pain that pass through the Medical Admissions Unit for exclusion of acute coronary syndromes by troponin testing at 12 hours. Wondering if there is a better way, you perform a quick literature search and find several articles investigating the utility of soluble CD40 ligand as a cardiac marker. You wonder if there is any evidence that it may be useful for exclusion of acute coronary syndromes in the Emergency Department.

A 35 year old man has been trapped in a burning building and suffered extensive burns over his chest and legs. He requires fluids and you start fluid therapy based on the Parkland formula. You wonder if this formula will provide sufficient fluids for resuscitation.

A 24 year old woman presents to the Emergency Department with a corneal foreign body. You wonder which topical anaesthetic agent will provide adequate anaesthesia for removal of the foreign body with the least amount of stinging on instillation.

A 45 year-old male has been trapped in a house fire. You are concerned that he may have an inhalational injury. You wonder which clinical features suggest significant inhalational injury.

A 55 year old woman has been trapped in a small room in a house fire. COHb levels confirm she has carbon monoxide poisoning. You wonder whether normobaric or hyperbaric oxygen will give her a better outcome.

A 65 year old female arrives to the emergency department following burns after falling asleep in front of a gas fire. She shows no signs suggestive of smoke inhalation, you wonder if it is necessary to measure her COHb levels.

A 29 year old man is brought into accident and emergency suffering massive burns after having been soaked in petrol and set alight. You need to assess the depth of his burns and wonder which clinical assessment will give the best accuracy of burn depth in the emergency setting.

A 30 year-old woman presents to A&E after having burnt her forearm on a gas stove whilst cooking dinner. She is complaining of a moderate amount of pain. You wonder whether cooling the burn will relieve some of her pain.

A fifty year-old man has presented to the Emergency Department with chest pain. ECG shows 4mm anterior ST elevation with reciprocal ST depression in the inferior leads. You discuss the case with the on-call cardiology registrar, who accepts the patient for primary angioplasty. He asks for the patient to be given 600mg clopidogrel. You wonder if there is any evidence that this is superior to a 300mg loading dose.

A healthy 22-year old lady attends the emergency department, complaining of a painful, red finger, which she says has come on over a couple of days. Examination reveals erythema to the side of her fingernail with a suggestion of a slight yellow centre. You diagnose an acute paronychia, but wonder whether to prescribe her a course of oral antibiotics or formally incise and drain the suspected collection.

You see a patient on the coronary care unit referred for urgent CABG following angiographically demonstrated triple vessel disease including a significant left main stem lesion. On examination he is found to have a right sided carotid bruit. He is asymptomatic, having had no cerebrovascular accidents (CVAs) or transient ischaemic accidents (TIAs) in the past. He is on an anti-platelet agent. On carotid Doppler examination he is found to have a 70% stenosis of the internal carotid artery on the right side. You wonder whether he would benefit from synchronous or staged CEA at the same time as CABG but you decide to search for the evidence for this prior to consulting a vascular surgeon.

A young healthy adult with known asthma presents to the emergency department with an acute severe asthma attack. Following the BTS guidlines, you use salbutamol and ipratropium nebulisers and IV hydrocortisone, and wonder if a single dose if IV magnesium sulphate would be beneficial.

A 26 year old woman presents to accident and emergency with vaginal bleeding. She has a positive pregnancy tes. You suspect she may have an ectopic pregnancy and wonder if any findings on examination are can help rule in/out this diagnosis?