bestBETs

A 30 year old male elctrician attends the emergency department having suffered an electrical shock while servicing a washing machine. There was no water involved.

A 35 year old man presents with acute onset of difficulty walking which came on while paying sport. He describes sudden onset of pain at the back of the ankle. Clinical examination reveals complete rupture of the achilles tendon. You wonder whether operative treatment is better than conservative management in this case.

A 55 year old man presents to the emergency department with chest pain. An ECG shows changes consistent with acute myocardial infarction. He is given aspirin and oxygen. His thrombolytic therapy is commenced and in the meantime you wonder whether his pain would be best alleviated by either morphine or diamorphine.

An 8 year old boy attends the emergency department following a fall at school. Clinically he has a displaced fracture of the right radius and ulna. He is in a lot of pain and so needs analgesia before X-ray. You have heard of the use of nasal diamorphine for pain relief but wonder whether there is evidence to show whether it is as effective as injected morphine.

An ambulance is called to a patient suffering from acute chest pain, which is diagnosed as cardiac in origin.The pt has taken a spray of their own GTN with little effect, and you wonder whether a buccal GTN preparation would be more effective at relieving the pain?

An 18-month-old boy is admitted with his first febrile convulsion. At discharge his parents ask if there is there anything that can be done to prevent another one?

A twenty year-old lady presents to the Emergency Department claiming to have taken 100 co-codamol tablets two hours ago. The guidelines suggest that activated charcoal is of no benefit at this stage. However, you are aware that opioids encourage gastric stasis and wonder if there is any evidence that activated charcoal is still of benefit to this patient.

A 28 year old diabetic arrives in the department with a blood sugar of 1.4. After 50mls 50% dextrose she is briefly alert enough to tell you she has taken an overdose of 2ml insulatard into her left thigh. There is a raised area of skin suggestive of an injection site. You wonder whether surgical excision will reduce the availability of insulin and so aid her recovery.

A man attends the emergency department having deliberately taken 150 ml of "antifreeze". The can of antifreeze has conveniently been brought along and you find it consists of a mixture of methanol and ethylene glycol. The Poisons Centre is contacted. In addition to treatment with ethanol it is suggested that intravenous Leucovorin (calcium folinate) is given. You wonder if there is any evidence to support this recommendation.

An adult is brought into the emergency department following an out of hospital ventricular fibrillatory arrest. Ventricular fibrillation persists despite repeated shocks. You remember reading about biphasic defibrillation and wonder if it offers any advantages.

A 3 year old child comes into casualty and you need to assess their pain. Would it be better to use the Oucher scale, a self report measure, or CHEOPS, a behavioural pain measure, as at this age using either seems equally valid.

A 22 year old man has been cleaning out an old chemical drum. He attends the emergency department with severe burning in his eyes. He says the drum was marked as NaOH 20%. You arrange for copious irrigation and oral pain relief. You contact the duty opthamologist who asks to start mydriatics, antibiotic ointement and ascorbate drops. You do not have the ascorbate drops and wonder whether there is any evidence for their use.

You have been called to the resuscitation room to see a 67 year old woman who has walked out in front of a bus while shopping in town. She has an obvious closed fracture of her left arm and she is complaining of abdominal pain and central neck pain. You elicit from her husband that she has had two heart attacks in the past and the drugs in her handbag are bendrofluazide, frumil, and lisinopril. Her blood pressure is 90/52 and her pulse is 105. You are concerned that she may be hypovolaemic, but you are aware of the dangers of giving too much fluid to a patient with probable heart failure. You elect to insert a central line for central venous pressure monitoring but she has a neck collar on and so you wonder if placing this via the femoral vein would affect your readings.

Ambulance is called to an RTA involving a motor cyclist who has sustained upper and lower leg fractures on the same limb. You wonder whether his leg be immobilised using a traction splint.

Following a 999 call to their home, an adult insulin-dependent diabetic patient is successfully treated with IM glucagon for hypoglycaemia by the attending ambulance crew. The patient is now fully recovered, they feel fine and their blood glucose level is above 5mmol/l. The patient does not want to go to hospital so is it safe to leave them at home?

A 26 week infant is about to be delivered by emergency caesarean section to a mother with placental abruption and fetal distress. No antenatal steroids have been administered to the mother. You are called to attend the delivery. You are setting up the equipment when the respiratory therapist suggests that we should use high frequency oscillatory ventilation (HFOV) as primary mode of ventilation. He also cites few articles suggesting benefit of high volume strategy HFOV over conventional ventilation (CV). You wonder if there is enough evidence to support the intervention.

You are an intensive care registrar who has taken over the care of a three week old baby boy diagnosed as having clinical bronchiolitis (now found to be RSV +). He was initially admitted and ventilated because of increasing respiratory distress and apnoeas. His ventilatory requirements are increasing and gas exchange is getting worse. You have just finished your stint on neonates and recall hearing that surfactant has been used on infants with bronchiolitis in trials. You wonder if it may help this child.

You are a paediatric SHO, on a night shift. You are called to the ward to see a 6 year old girl, who cannot get to sleep because her eczema is too itchy. The nurses want you to prescribe an anti-histamine, but you doubt the efficacy of this treatment. As it is a surprisingly quiet shift, you go off to do a literature search.

A 17 year old male presents to the Emergency Department after a road traffic accident. His GCS was 8 on arrival but an immediate CT scan showed no focal abnormality. His GCS returned to 14 after 4 hours. You are talking to his mother who is reassured that he does not need urgent neurosurgery, but she asks whether he will suffer any long term consequences from this injury. You tell her that it is difficult to predict, but you have recently head that S-100 protein measurement is available in your hospital for research purposes. You wonder whether S-100 could help predict his long term prognosis.

You have seen a 26 year old right hand dominant man with 5 days old suspected fracture of Scaphoid in A&E, he is still tender around his Scaphoid area, and asking for early return to work. You have heard about advances in Ultrasonographic (US) diagnosis of upper and lower limbs pathologies, and wondering if US is a sensitive and specific test for early detection of suspected Scaphoid fractures.