bestBETs

A 75 year old man presents to the emergency department with a wrist injury. X-ray reveals a Colles' fracture with dorsal angulation requiring manipulation. The patient has had lunch one hour before presentation. Your colleague tells you that you should manipulate the fracture before your shift ends in a hours time, but a passing anaesthetist says that you should wait at least 5 hours (6 hours after food) before you do anything. The departmental manager points out that this means the patient should be admitted since they will "breach" the target time of 4 hours if you wait. If they are admitted the next available trauma list is in 36 hours. You wonder whether the patient should be fasted for 4-6 hours or if it is safe to reduce this fracture under Bier's block without any period of fasting.

A young woman comes into casualty having just been stung by an unknown type of jellyfish while swimming in the sea at the local beach in the UK. There are large, painful weals on her leg and arm which she has wrapped in an ice pack. The nursing staff have suggested a wide variety of treatments to you, but you wonder which will be helpful in bringing rapid relief to your patient.

A 41 year old car driver was involved in a major road traffic accident, sustaining injuries to his head, a fracture of his right femur and multiple bruises on his chest. On scene he had altered sensorium and his GCS was estimated to be 5. He was intubated by the paramedics and brought to the Emergency Department. You wonder about the evidence in favour of endotracheal intubation as compared to bag and mask ventilation in trauma patients.

A 35 year old man presents to the emergency department with acute low back pain. he is normally fit and well, but developed lower back pain the previous day after lifting a heavy box. 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 tell him that the prognosis is favourable. 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 35 year old man presents to the emergency department with acute back pain sustained whilst lifting a heavy box. He complains of low lumbar spine pain. There are no neurological symptoms or signs and no "red flags" to indicate a potentially serious cause of his back pain. You diagnose a simple acute low back strain and advise analgesia and mobilisation. He tells you that he knows a local acupuncturist who could see him for acupuncture but wonders if it is worth spending the money. He asks if you are aware of any evidence for it's effectiveness.

A 24 year old man presents to the emergency department with severe lower back pain. He developed back pain after twisting awkwardly whilst lifting a box. There are no neurological signs on examination and he has no "red flag" signs or symptoms. You make a diagnosis of low risk musculoskeletal back pain, reassure him and prescribe analgesia. He was brought to the emergency department by ambulance and initially treated with NSAIDS, paracetmol and Codeine. You review him later and he tells you that the pain killers were worthless and that the last time this happened his GP gave him a presciprition of oramorph. He asks that you do the same.

A 42 year old woman presents to the emergency department with gradually progressive worsening of headache over 48hours refractory to analgesics.She is known to suffer from migraines and says that she has had increasing frequency of episodes recently and her pain is similar to her migrainous episodes.She has had CT scans lately which haven't shown any abnormality.You diagnose her to be suffering from severe migraine and treat her with parenteral Imigran (sumatriptan) and metocloparamide which makes her pain better.You have heard somewhere that using dexamethasone reduces the frequency of migraine episodes.You wish to know the evidence for it.

A 52 yr old known epileptic is brought in fitting for short time period to the Emergency Department (ED). She has received an appropriate dose of PR Diazepam pre-hospital and the seizure continues despite further IV lorazepam. You wonder whether there is any evidence to suggest a benefit of IV Fosphenytoin over IV Phenytoin as second line treatment of status epilepticus.

A 35 year old man presents with a dislocated shoulder. You are about to undertake the reduction under sedation in the emergency department and wonder whether the use of a propofol infusion rather than boluses of midazolam would give effective sedation with shorter recovery time without compromising safety.

A 14-year-old boy attends your general clinic suffering from weekly headaches for the last 6 months. The description of the headaches are typical for migraine headaches, neurological examination is normal. There is a strong family history of migraines in the mother and a sister. He already has made adjustments to his lifestyle by avoiding trigger foods and a regular sleep pattern with limited improvement. He is reluctant to take regular prophylactic medication but his parents are concerned about the amount of analgesia he takes. As his mother uses sumatriptan with good effect she wants to know if this would be an option for him.

A 32 year old female is receiving physiotherapy 2 weeks after her grade 2 ankle sprain. She asks if she still has to wear the Tubigrip™ bandage she was supplied with as she still has swelling but has heard from her sister that her ankle will be weaker as a result of wearing it long term. You wonder if there are any adverse long term effects of wearing Tubigrip™.

A patient attends the emergency department with pain in keeping with a fractured scaphoid. The standard scaphoid views failed to identify a fracture. Should magnetic resonance imaging be conducted or is it too expensive.

A 52 year old man presents to the primary care emergency centre with a 5 month history of back pain. He is dissatisfied with the care given by his usual GP. His GP has performed an X-ray which "Just showed a bit of wear and tear" and he has blood tests (FBC, UE, LFT, ESR, CRP) which have all been normal. He has no neurological signs or "red flag" type symptoms. A diagnosis of musculoskeletal back pain is confirmed. The patient is keen to try one of "those electrical thingies" as his daughter had one during labour and she said it marvellous. You wonder if there is any evidence to support the use of TENS in patients like this.

A 30 year old male presents to the Emergency Department with multiple stab wounds to soft tissues of chest/ abdomen and limbs. You wonder whether cleaning and allowing to heal by secondary intention is better than wound closure to prevent wound infection.

An otherwise well 3 week old infant born at 28 weeks gestation has a haemoglobin level of 68 g/l and is prescribed a blood transfusion. The departmental protocol states feeds should be withheld during the transfusion to decrease the risk of development of necrotising enterocolitis (NEC). What is the evidence that blood transfusion increases the risk of NEC?

You are a senior house officer in a paediatric assessment unit and commonly see children with acute otitis media who are febrile but otherwise well. You are not sure about the role of antibiotics in this condition and note that various existing guidelines have different recommendations about use of antibiotics. You wonder if measurement of C-reactive protein can be used as a screening test to differentiate between viral and bacterial otitis media and to decide which group of children require antibiotic therapy. You decide to find out more.

A 70-year-old male is admitted to the intensive care unit with a severe biliary sepsis. He is develops multi-organ failure, is placed on a ventilator and receives inotropic and vasopressor support. He becomes anuric over the next two days, despite adequate fluid resuscitation. He is commenced on renal replacement therapy when he develops fluid overload. You wonder if you could have preserved his renal function and reduced his chances of requiring renal replacement therapy by the use of a loop diuretic.

You are assessing a toddler who has presented with paroxysmal cough with a whoop and post tussive vomiting. A clinical diagnosis of 'whooping cough' is made and this is duly confirmed on pernasal swab cultures that reveal the growth of Bordetella pertussis (B. pertussis). From history, you note that he is allergic to Penicillin and has been given Erythromycin for a previous episode of tonsillo– pharyngitis. His mother recalls that he suffered severe abdominal pain when taking it and did not complete the course. You wonder whether newer macrolides such as Azithromycin or Clarithromycin could be effective alternatives to Erythromycin for the treatment of Pertussis in this setting.

A 2-week-old infant, born at 36 weeks gestation was admitted to the paediatric ward in November with a 24h history of runny nose, cough and episodes of shallow breathing and apnoeas. This was thought to be due to bronchiolitis, and the consultant paediatrician suggested starting the baby on caffeine (theophylline derivative with less side effects). As the resident middle grade doctor, I knew that caffeine has been used widely in neonatal units for apnoea of prematurity, but I wondered if there was any evidence for its use in this clinical situation.

A 46 year old man is brought to hospital after a road traffic accident, involving a rear end shunt, to "get checked out". He is fully alert and co-operative. You are aware that many people advise x-rays in all patients to exclude cervical spine injury. You wonder whether it is really necessary.