bestBETs

A 45 year old labourer presents to the Emergency Department with a one day history of pain and swelling over his right elbow. Examination reveals a generally well, apyrexial man with a swollen, warm right olecranon bursa with overlying redness. You wonder whether it is necessary to aspirate and analyse bursal fluid to diagnose an treat this patient.

An insulin dependent diabetic adult is brought into the Emergency Department uncooperative and acutely confused. A blood glucose stick test confirms hypoglycaemia. You wonder whether parenteral glucose or glucagon is the drug of first choice.

A 4 year old girl presents to the Emergency Department with an urticarial rash. Her general practitioner has prescribed an oral antihistamine but the rash has persisted. You wonder if there is a role for oral steroids in this otherwise well child.

A 67 year old man has been brought into the emergency department by paramedic ambulance. He was initially in ventricular fibrillation, but now has pulseless electrical activity. He collapsed 15 minutes ago and received immediate bystander basic life support. You wonder whether intravenous vasopressin would be better than adrenaline in this situation.

You are resuscitating a 30 year old male with a severe closed head injury. His GCS was 3 on admission. He is intubated and ventilated and a CT scan is being organised. His blood pressure is only 90/40mmHg. You want to improve cerebral perfusion by giving IV fluid but are aware that too much fluid might worsen cerebral oedema. You wonder whether there would be any advantage in giving hypertonic saline.

A 60-year-old man presents to the Emergency Department with acute severe crushing chest pain. ECG shows changes consistent with acute myocardial infarction. You prescribe aspirin, thrombolysis, nitroglycerin, beta-blockers and high-flow oxygen. You know that oxygen therapy is traditionally held to be beneficial in this situation, but wonder if there is any evidence that it reduces mortality.

You are asked to see a 19 year old man who has presented to the Emergency Department with paraphymosis. He states that he fell asleep after sex the night before and woke up with swelling. Simple traction has failed to cure the problem (but has brought tears to his eyes). A surgeon, a specialist registrar in emergency medicine and a urologist are already in attendance. The first says that multiple punctures should be made with a needle, the second that an iced glove should be used and the third that sugar should be applied. You wonder whether any of the suggested methods are evidence-based.

A 20-year-old male is brought to the Emergency Department in acute respiratory distress with asthma. He has a history of poor compliance with unstable asthma and several hospital admissions in the past. His old notes are available and you notice whenever IV treatment has been commenced he has been given aminophylline. You feel that the best drug is a beta-2 agonist and that if it is not getting to the receptors via the airways then IV is the next best route. There is some dismay among the nursing staff when you formulate an IV regime. They say they have never given it before. You wonder whether your approach is evidence-based.

A 32 years old male presented to the A & E Department with bloody stools, fever after his return from holiday abroad. He had moderate signs of dehydration & was given IV Fluids. The next question was whether to start him on antibiotics or not

You have seen a 2 year old boy with croup, using parameters based on his clinical features you work out his Westely score is less than 7. He can be discharged with oral steroids. Do you advise his parents to treat with humidified air?

A six-month-old boy was admitted to the Paediatric ward with history of fever, non-blanching petechial rash, shrill cry and poor capillary refill. He required 20 ml/kg of fluid bolus. After a full sepsis screening including a lumbar puncture, he was started on IV Cefotaxime for a presumed diagnosis of meningococcal meningitis. Next day on the ward round the Specialist Registrar wondered if a short course of dexamethasone should have been started with the first dose of antibiotic to improve neurological outcome in this child.

A 5 year old boy, suffering from hyperinsulinemic hypoglycaemia and arterial hypertension secondary to polycystic kidney disease, was given nifedipine (0,3 mg/kg/TDS) to treat his high blood pressure. Normotension was restored and secondly, his blood sugar levels normalised. We wondered whether nifedipine could be used safely as long term treatment to counter hypoglycaemia in persistent hyperinsulemic hypoglycaemia of infancy (PHHI)?

You are ready to discharge a 57-year-old gentleman who has undergone CABG 8 days ago. It is your consultant's policy to discharge all people without contraindications on low dose aspirin, but you have recently attended a structured critical appraisal journal club and wonder whether a higher dose of aspirin may confer a survival advantage to your patient.

You are called to see a patient who is 1 hour post CABG. The patient has bled 300mls since theatre and the nurse performed an ACT which was prolonged at 150 seconds. You know that the heparin had been reversed in theatre using 1.3mg of protamine to every 1mg of Heparin, and that an additional 25mg was also given after checking the ACT. You are keen to give another dose of Protamine but you have heard that high doses of protamine can cause increased bleeding. You wonder whether this is true.

You are performing a difficult aortic valve replacement in an 80-year-old patient that also requires three coronary grafts and has an ejection fraction of only 35%. You know that the bypass time is going to be long. The perfusionist informs you that in the last institution he worked at, every patient was prophylactically haemofiltered if bypass was used and that this reduced inflammatory mediators and improved outcome. You decide to use a haemofilter in this high risk case but resolve to look up the evidence for this after the case.

You are asked to review a 65-year-old patient who had a coronary artery bypass grafting (CABG) 6 hours ago. Preoperatively he had triple vessel disease and good ventricular function. 600mls has been recorded in the drain bottles and 40mls drained in the last hour. The nurse asks you if the first dose of aspirin should be omitted. You are tempted to omit this first dose of aspirin but you wonder what implication this may have on the long-term patency of this man's grafts.

You are about to perform a coronary arterial bypass graft on a 70 year old lady who has left main stem disease and an ejection fraction of 30% on echocardiography. She was an urgent referral from the cardiologists after being admitted 3 weeks ago with unstable angina, but has been stable since admission. You realise that she is a high risk case and you wonder whether preoperatively inserting an intra-aortic ballon pump would be of benefit to her?

You are a registrar performing the sternotomy on a 65 year-old patient who is undergoing an aortic valve replacement, supervised by your consultant. You open the chest and start liberally applying bone wax to the sternal edges. Your Consultant is greatly alarmed and tells you that bone wax is 'poison' and should only be used for friable, bleeding sternums. You heed his advice but wonder what evidence exists for his strongly held views.

A six year old girl comes to your outpatient pediatric clinic with a two-month history of cough and shortness of breath, requiring, nearly three times a week, administration of beta 2 agonists by jet-nebulizer. She has often been noticed to wheeze at school during the gymnastic class and when she's laughing or crying; almost once a week she awakes during the night complaining of cough and respiratory difficulties. Your diagnosis is persistent asthma (1) and after a short course of nebulized salbutamol (albuterol) and oral steroids you decide to start, twice a day, a prophylaxis with inhaled steroids, via a spacer device. As her mother is working outside home till late afternoon, she asks you if a once-daily administration would have the same efficacy.

A 45 year old man presents to A&E with a 2/7 history of painful left elbow. He admits to undertaking a lot of gardening in the previous 3 weeks. Clinical examination reveals tenderness over the lateral humeral epicondyle and pain on resisted extension of the wrist. A clinical diagnosis of lateral epicondylitis is made. The patient is anxious to return to work and has heard that an injection can cure him.