bestBETs

A 20-Year-old female front seat passenger with the seat belt on sustained a neck injury from a frontal collision car Accident that left her with a fronto-parietal scalp laceration; presented to the Emergency Room with cervical spine precautions. Primary survey demonstrated a non-disabling local neck pain and tenderness. The neurologic examination was normal with no disabilities, and no cranial nerve involvement. Glasgow coma scale was 15/15. Past medical history is unremarkable with no previous incident. An X-Ray, Computed Tomography (CT) scan and MRI of the neck revealed only a Jefferson fracture with a 12 mm widening of the lateral mass of C1. The Anterior Atlanto-Dens Interval (ADI) was normal (2mm) and the Space Available for the Cord was 17mm.

A 35 year old male patient presents to ED feeling non-specifically unwell following subcutaneous administration of 'Melanotan II' for the purposes of tanning. He describes hyperpigmentation around the injection site, but otherwise no localising symptoms.

A 78 years old female, a 87 years old male, a 64 years old male and a 53 years old female, all had falls and confirmed fracture neck of femur. All had received IV Morphine for pain by the ambulance crew. They received fascia iliaca block (FIB) with 0.25% levobupivacaine adjusted to their estimated weight by the emergency physicians. Their pain scale varied between moderate to severe. We were expecting drastic improvement in pain within the first 30-60 minutes after instilling the blocks. Instead all had no pain relief even after 1-2 hours and required additional analgesics to reduce the pain in the emergency department.

An 11-month old boy is admitted with difficulty breathing, cough and poor feeding. On examination he has bilateral wheeze with fine inspiratory crepitations and moderate recession. His oxygen saturations are 88% on room air. Management with nasogastric feeds and supplementary oxygen is commenced in line with national guidelines. The Nurse in Charge suggests placing him in the prone position. You wonder what effect ‘proning’ may have on his clinical outcome and what the evidence for this is.

8-year-old boy, previously healthy presents to your emergency department with cellulitis of the right forearm. He is otherwise systemically well. You decide to prescribe flucloxacillin. His mother reports an allergy to penicillin. Allergy history reveals a maculopapular rash on day 3 of amoxicillin therapy for otitis media at 2 years of age. He has never had any penicillin antibiotic since then. A colleague suggests clindamycin. You wonder if he could tolerate flucloxacillin given the nature of the reported reaction whilst concerned about the adverse event profile of clindamycin.

It is a warm humid evening in July and you are working a stretch of evening shifts in a busy emergency department. Given the humidity, you check the weather as you are coming in to work and see thunderstorms on the forecast for all day tomorrow. You go about your shift and when you check the trackboard to see who is in the waiting room, you notice that 11 of the 18 patients in the waiting room all have the same chief complaint, “shortness of breath”. Additionally, you notice that the age of these patients varies widely, with age range from as young as 7 to as old as 68. You wonder if the impending thunderstorm has anything to do with the influx of all these respiratory complaints.

A 32-year-old patient presents to the emergency department following a high-speed motor vehicle accident. He is hypotensive and has obvious ecchymosis on the abdomen with a “seatbelt sign.” Paramedics were unable to administer tranexamic acid (TXA) due to difficulty in establishing IV access. You wonder if IM would be effective alternative to an IV route for administering TXA in bleeding trauma patients.

The patient is a 52-year-old male with history of hypertension who presents to the emergency department (ED) with complaints of chest pain that started 1 hour prior to arrival. On arrival to the ED, he appears comfortable with stable vital signs, and has a normal physical exam. His pain is reported as mild, sharp and substernal, non-radiating, and worse with certain movements but not exertion. His pain resolves after 324 mg chewable aspirin and a lidocaine patch. His lab workup and elecrocardiogram are normal. The patient has a heart score of 2. You consider ordering a chest x-ray (CXR) prior to discharging the patient.

A forty-year-old patient is brought to the Emergency Department (ED) by paramedics with suspected drug intoxication. They have a Glasgow-Coma-Scale score of 3 and the decision is made to perform a Rapid-Sequence-Induction (RSI) to enable control of the airway, neuroprotective anaesthesia and facilitate transfer to the radiology department. Immediately following administration of Alfentanil, Propofol and Rocuronium, they develop profound cardiovascular instability thought likely to be Rocuronium-induced anaphylaxis. Following initial treatment (with adrenaline, steroids and antihistamines), the Anaesthetic Consultant in attendance suggests giving Sugammadex to encapsulate the Rocuronium. You wonder if Sugammadex can really improve cardiovascular instability in established anaphylaxis?

A Physiotherapist would like to know if the benefits of participation in early mobilisation with patients post SAH with EVD outweigh the risks of adverse events relating to EVD and mobilisation

A 22-year-old woman presents to the Emergency Department (ED) with suicidal ideation and ongoing Medically Unexplained Symptoms (MUS). This is her second attendance today, and her fourth this week. This patient is a known high-intensity user/Frequent Attender (FA) due to multiple previous episodes of Deliberate Self-Harm and intentional overdose. She has a background of emotionally unstable personality disorder, depression & anxiety, and a learning disability- all of which contribute to her distress while in the department, meaning she frequently leaves before being seen by a clinician. You wonder if there is an effective intervention that you could implement, to reduce her number of ED visits.

10 year girl present in A&E with 2 day history of fever, right sided back pain and dysuria. She had urine dip done which showed 3+ leucocytes, 1+ blood and nitrates positive. The registrar seeing the patient wants her to be immediately started on IV antibiotics for suspected pyelonephritis. The SHO questions why is IV required when the patient can tolerate oral?