bestBETs

You are performing an aortic valve replacement in a 78-year-old lady, with poor lung function, and who was smoking up until the day of the operation. You are keen to keep the pleura intact for this operation to optimise her post-operative recovery. During the sternotomy you ask the anaesthetist to deflate the lungs and you perform the sternotomy from the sternal notch to the xiphisternum. You are disappointed to find that despite these manoeuvres, you have widely opened the right pleura with the saw. The anaesthetist comments that deflating the lungs makes no difference and that you should have gone the other way with the saw as a colleague does this and 'never' has this problem. You resolve to search for the evidence for these comments.

You are at a clinical research meeting when you hear presentations comparing the use of magnetic resonance imaging (MRI), plethysmography and Doppler ultrasound techniques to assess adequacy of ulnar collateral flow in patients scheduled for radial artery graft conduit harvesting for CABG surgery. You decide to review the literature to identify just how good these techniques are and to find out whether they offer any advantage in identifying satisfactory collateral flow in the forearm over the Allen's test which you currently use in your own practice.

You are about to perform a coronary artery bypass graft (CABG) on an obese 65-year-old man who has triple-vessel disease involving the left anterior descending (LAD) artery, the first obtuse marginal (OM) branch, and the posterior descending artery (PDA), and an akinetic inferior wall with an estimated ejection fraction of 40%. You wonder whether you should use the saphenous vein (SV) or the radial artery (RA) to graft a heavily diseased PDA or OM to achieve long-term patency.

You are updating a protocol for the prophylaxis of atrial fibrillation after cardiac surgery for your department. For many years the protocol has been to continue the patient's own beta-blockers during the perioperative period, restarting them the day after surgery. A new surgeon in your group suggests that Sotalol, with type III antiarrhythmic properties in addition to Beta-Blockers is superior to this protocol, but other colleagues state that changing the patient's usual medications the day before surgery in this way will lead to a host of complications including bradycardia and hypotension. You resolve to search the literature to see whether it really is worth changing your departmental policy.

A 55 year-old man has had twenty minutes of central chest pain. ECG shows acute anterior myocardial infarction. Having read about the so-called 'pleiotropic effects' of statins, you wonder if there is any evidence that their immediate use in acute coronary syndromes confers any mortality benefit.

A 55 year-old man has had an anterior myocardial infarction. His symptoms started twelve hours ago. He has already been given aspirin, thrombolysis, nitrates, opiates, beta-blockers and clopidogrel. You know he ought to start statin therapy. Having read about the 'pleotropic effects' of statins, you wonder if there is any benefit in starting this therapy within the first 24 hours.

Chronic constipation is a frequently encountered problem in the paediatric wards and clinics. Your usual line of management has been to prescribe adequate doses of regular lactulose and use sodium picosulphate as a second line laxative or as add on treatment. Recently, you have become aware of a new drug—polyethylene glycol (PEG). As you have not prescribed this drug earlier, you want to appraise the evidence before using it in your clinical practice.

An 18 month old female is brought to the emergency department by her mother. She has been suffering from repeated vomiting and diarrhoea for the past 24 hours. Over the past eight hours she has vomited approximately 12 times. The vomitus has not contained any bile or blood. The little girl appears mildly dehydrated. Her stool tests positive for rotavirus. You wonder whether administration of an antiemetic may lessen her symptoms and increase the likelihood that oral rehydration therapy will be successful.

During a busy shift in the Emergency Department, you see a 50 year-old man with dull central chest pain and feel that, although he is clinically stable and the initial ECG is normal, myocardial ischaemia ought to be ruled out. He is very keen to get back to work, doesn't like hospitals and doesn't want to spend the day awaiting blood tests. On examination you elicit chest wall tenderness. You wonder if this sign is sufficiently reliable to allow the exclusion of an acute coronary syndrome.

A 55 year old male presents with massive haematemesis. He has known oesophageal varices. He is tachycardic, peripherally shut down and continues to actively vomit fresh blood. You wonder if pharmacological treatment with terlipressin or somatostatin will be effective in reducing the bleeding.

A 28 year old woman presents with acute suspected pulmonary embolus (PE). You wonder whether normal arterial blood gases are sufficient to rule out pulmonary embolus.

Your are an emergency medicine resident in a busy downtown tertiary care facility. Your 14th patient of the night is a 23-year-old male with a clinically obvious anterior shoulder dislocation. The dislocation was spontaneous and is his third this year. As a matter of routine a pre-reduction x-ray is ordered. ED beds are scarce and the the nurse asks if this is really necessary. Is it?

You performed a difficult Aortic Valve replacement and triple-coronary arterial-bypass-graft on a 77-year-old man, with a 30-year history of smoking. The operation proceeded uneventfully, but in the Intensive care it was not possible to extubate him on the first night due to basal collapse, and over the next few days he develops a ventilator-associated-pneumonia (VAP). You search the internet for manoeuvres that may avoid this frustrating complication and find that continuous subglottic suction would avoid pooling of secretions around the endotracheal tube and thus perhaps reduce VAP. Thus you resolve to search for evidence for this simple intervention.

You are a first year cardiothoracic registrar who is starting to work for a consultant surgeon who always prefers the pleura to remain intact whilst harvesting the internal mammary artery (IMA). The surgeon avoids pleurotomy to reduce pulmonary complications after cardiac surgery, but you wonder whether there is any evidence in the literature to support this practice

A 69 year old woman has slipped and caught her leg on a chair. She attends your A&E department with a large flap laceration to the anterior aspect of her right leg. She has no other injuries, no other significant past medical history and has good social support. you want her wound to heal quickly so that she may get back to her normal activities as soon as possible. You wonder whether a primary split skin graft or a simpler procedure using the existing flap would be best to achieve this.

You have been trained to leave the pericardium open after a routine cardiac surgery procedure because in the early postoperative period the patient's haemodynamic performance is better and there is less incidence of graft failure. In addition there is also said to be a reduced incidence of cardiac tamponade. You begin to question this teaching, especially in view of the benefit of a closed pericardium when it comes to re-do surgery. You decide to scrutinise the published literature with regard to the pitfalls of closing the pericardium.

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.