A 56 year old woman arrives at A & E complaining of palpitations and lightheadedness. An ECG is performed and she is diagnosed with paroxysmal supraventricular tachycardia. She is haemodinamically stable but distressed with the palpitations. The physician attending this lady wonders which vagal manoeuvre to use before giving any drug intravenously.
A 48 year old female with a known history of recurrent paroxysmal supraventricular tachycardia arrives in A & E complaining of dizziness and palpitations. An ECG reveals a 160 bpm regular rhythm with visible p waves distorting the start of the QRS complex. Physical manoeuvres are attempted unsucessfully and an adenosine bolus is given. The tachycardia appears to be refractory to treatment and the lady goes into shock. A decision to electrically cardiovert is made. The physician on-call wonders which waveform would be more efficient at restoring sinus rhythm.
a 54 year old lady with a history of palpitations is refered to A & E by her GP, complaining of palpitations and lightheadedness. The attending registrar performs a 12 lead ECG revealing revealing a regular rhythm, an absent P wave and a narrow complex QRS with a ventricular response of >150 beats/min on the bedside monitor strip on leads II and V5. She is diagnosed with atriventricular nodal reentrant tachycardia and the valsava manoeuvre is attempted unsuccessfully. IV Adenosine is given which restores sinus rhythm but fails to maintain it as the lady relapses into the arrhthmia. A beta-blocker is then considered and the attending clinician debates which beta-blocker is more efficient at restoring and maintaining sinus rhythm.
Sotalol in the acute management of narrow complex tachycardia in haemodinamically stable patients
a 54 year old lady with a history of palpitations is refered to A & E by her GP, complaining of palpitations and lightheadedness. The attending registrar performs a 12 lead ECG revealing revealing a regular rhythm, an absent P wave and a narrow complex QRS with a ventricular response of >150 beats/min on the bedside monitor strip on leads II and V5. She is diagnosed with atriventricular nodal reentrant tachycardia and the valsava manoeuvre is attempted unsuccessfully. IV Adenosine is given which restores sinus rhythm but fails to maintain it as the lady relapses into the arrhthmia. A beta-blocker is then considered and the attending clinician debates which beta-blocker is more efficient at restoring and maintaining sinus rhythm.
A 42 year old female patient presents with moderate to severe right upper quadrant colicky pain radiating to the back with one episode of vomiting. She is apyrexial and examination reveals mild right subcostal tenderness with no guarding. You diagnose biliary colic and wonder is buscopan is effective in relieving pain.
Concomitant use of benzodiazepines in opiate overdose and the association with a poorer outcome.
A 27 year old man comes into the emergency department with a suspected opiate overdose. He exibits marked miosis and depressed mental status and had needle track marks on his arms. His mother, on questioning, shows you an empty temazepam bottle she found in his pocket. You wonder if he has had a polydrug overdose and if this will result in a poorer outcome.
A 28 year old diabetic attends having been found unrusable by friends. Initial examination shows her to be GCS 5/15 with a BM measurement of high. Blood gases show her to have a pH of 7.02 and a blood sugar comes back at 41mmol/l and her urine shows three plus ketones. You begin treatment with insulin and IV fluids and contact ITU for an opinion on airway management and ventilation. The ITU registrar asks you to start a bicarbonate infusion while he is on the way down. You are unsure if this is beneficial and decide to find evidence on who is right.
Myeloperoxidase: a novel cardiac marker with potential for future use in the Emergency Department
A fifty year-old man with no previous medical history presents to the Emergency Department with two hours of vague dull central chest pain. Initial ECG is normal. You arrange admission for troponin T testing at 12 hours but can't help thinking that there must be a better and quicker way to exclude acute coronary syndromes. A colleague tells you that myeloperoxidase (MPO) is set to make world headlines as a new definitive early cardiac marker.
A known asthmatic adult patient is brought into the emergency department with signs consistent with acute asthma. Little improvement is noted with nebulised beta agonist therapy. You wonder if adjunctive nebulised furosemide would provide any benefit.
Rectal or Intravenous non-steroidal anti-inflammatory drugs in acute renal colic
A 21 year old male presents to the emergency department with sudden onset of left lumbar pain radiating to the groin. A clinical diagnosis of renal colic is made. You wonder whether rectal NSAID's would be more effective than IV or IM NSAIDs?
A healthy 25-year-old man involved in an altercation with another man sustains a bite wound on the arm and presents to the Accident and Emergency Department. The wound is thoroughly cleaned and no signs of infection are present. You wonder whether prophylactic antibiotics are indicated to reduce the risk of wound infection in this patient.
Do non-steroidal anti-inflammatory drugs cause a delay in fracture healing?
A 21 year old man attends the emergency department having sustained an undisplaced, closed fracture of his distal radius. You wonder whether giving the patient a course of NSAIDs will delay fracture healing.
A 68yr old man, on warfarin for a mechanical aortic valve replacement, is brought into A&E after a minor head injury. He has a haematoma over the occipital region, however has no symptoms relating to his head injury. On examination, his GCS is 15/15 and there is no focal neurological deficit. You wonder if a CT scan of the head is indicated in this situation to safely rule out any significant intracranial injury.
Intraspinal opioids for the management of chronic low back pain
A 45 year old man is seen with a 4 year history of severe low back pain. He has undergone well conducted periods of rehabilitation under the care of chiropracters and physiotherapists with no success. Diagnostic imaging has revealed no isolated lesion as a cause of his back pain. He is depressed with his degree of disability and you are concerned for his mental and physical health. He was managing with NSAIDs, paracetamol and codeine but has recently had a severe GI bleed as a result of the NSAIDs and is very reluctant to take them again. You have read about long term epdural infusions of opitates and wonder if they might help your patient.
Use of local corticosteroid injections in supraspinatus tendinitis
A 56 year old lady present in Emergency Department with a history of severe pain in his right shoulder following a busy day working in his garden. She had pain on resisted abduction and tenderness over supraspinatus tendon.
Intradiscal electrothermy for the treatment of discogenic chronic low back pain
A 42 year man presents with a history of chronic back pain that has not resolved with good primary care management and active rehabilitation. MR and CT of the lumbar spine reveals a significant internal discdisruption at the L4/5 disc.You discuss surgical options of fusion but the evidence is not in favour. Reluctantly you suggest that conservative management is his best option. He returns 2 weeks later with information from the Internet on intradiscal electrothermal annuloplasty. The technique involves coiling a wire within the disc and then heating it to high temperature to seal any annular disruption. You wonder if this is another fad treatment or whether there is some evidence to support it's use.
A 35 year old man presents to his general practitioner department with a history of long term back pain. he is normally fit and well, but developed lower back pain 3 months previously following a skiing holiday. There are no red flag symptoms and he has a normal neurological examination. You advise that he tries to mobilise as best he can and give advice on lifting. You offer analgesics but he appears to be concerned that you suggest that he takes paracetamol AND ibuprofen. He asks how much additional benefit is he likely to get from the Ibuprofen as he is not keen on taking tablets.
A 32 year old man presents to the emergency department. He has a 5 day history of back pain that came on after a long bike ride. He has no red flag symptoms and there are no neurological signs on clinical examination. You advise him to take analgesia and stay active. He is keen to cycling as soon as possible and wonders if there are any specific exercises or program of exercises that he can do to get him back to cycling quicker.
A 45 year old patient presents with a 2 year history of low back pain. He has had to give up his job as a sign painter as a result of his problem which has resulted in siginificant financial problems for him and his family. He describes no red flag symptoms and has no specific neurological signs. He has been previously investigated with plain X-rays and MR scan which have revealed degenerative disease of the lumbar spine. He wants to know if surgery is an option for the relief of his pain.
A 35 year old woman presents to the emergency department with a 5 month history of lumbar back pain. The pain developed after a holiday skiing, but there was no specific injury and there is nothing in the history or examination to suggest a serious underlying cause. There are no red flag symptoms or signs. She has been on light duties at work for the last 3 months and is coming under pressure from her employer and family to get back to normal as soon as possible. She asks if there are any exercises she can do to help and you remember a physiotherapist telling you about an exercise program that can be used by back pain patients. You wonder if it is worth referring her for more advice and information.