bestBETs

An 18-year-old male presents after having been stabbed with a 9inch screwdriver 1cm below the left nipple. On arrival he is tachycardic at 125 bpm with a blood pressure of 110/75. This settles with two litres of normal saline to a pulse rate of 85 bpm and a blood pressure of 129/82. He is fully alert. His chest X-ray reveals the presence of a pneumopericardium. He has no other injuries.

You are called to see a young adult male who is accompanied by two members of Her Majesty's Customs and Excise. They tell you that he is under suspicion of trying to smuggle drugs into the country and that he may have done this by ingesting packets of cocaine. Physical examination is unremarkable, but abdominal radiography does reveal multiple, oval foreign bodies in the bowel. You know that such 'body packers' might well develop intestinal obstruction and/or get potentially fatal cocaine toxicity from leakage of the contents of these packages in their bowels. You wonder whether to simply leave the patient as he is and observe him for signs of obstruction and/or pending cocaine toxicity, intervene conservatively and do the latter as well, or whether to do something more aggressive to remove the packages from the patient's intestines.

A 25 year old man who has been involved in an RTA is brought into your department by the paramedics. He has signs of cord transection and is complaining of low back pain. You wonder if a logroll to examine his back is appropriate.

A 25 year old male attends A&E after a fight in which he sustained a laceration to the eyelid. There are no signs of intra-occular injury. You clean and suture the wound and wonder whether you should cover the wound with prophylactic antibiotics as you have recently seen a case of peri-orbital cellulitis associated with an eyelid wound.

A 20 year old man is brought into the emergency department having been hit by a high-speed vehicle while crossing the road. He has a large haematoma to the head and is confused and combative. Plain radiographs of his cervical spine are normal, as are radiographs of his chest and pelvis. You request a CT brain scan and a CT of his upper cervical spine, as you have heard that plain radiographs can miss injuries in this area. The radiologist does not agree that this is indicated as the plain radiographs of the cervical spine appear normal. You wonder if there is any evidence to support your request.

A 6 year old boy presents to the emergency department after falling out of a fast moving car. He is extremely distressed and appears to have sustained multiple injuries including a large laceration to his head, bruising and deformity to both forearms and his left lower leg. After initial assessment and stabilisation you decide to paralyse, intubate and ventilate him prior to performing a head CT. However you are also concerned about the possibility of an intra-abdominal injury. You wonder whether an ultrasound or CT would be better at identifying this.

You are telephoned by your Cardiac Nurse Specialist who has visited a 65 year old gentleman who was discharged 2 days ago after CABG with LIMA grafting. She reports that he is still Short of Breath and Examination reveals Stony dull percussion notes and no Breath sounds on the Left side of the Chest. As you arrange readmisison, you wonder whether if you had inserted a pleural drain intraoperatively you could have avoided this annoying complication.

You receive a call from one of your adolescent patients, a 16-year-old boy with a longstanding history of seasonal allergic rhinitis (SAR). He is currently treating his mainly nasal symptoms with an oral histamine antagonist (OH1A). His symptoms are getting increasingly difficult to control. He is worried about the upcoming hay fever season and asks for other treatment options.

A mother brings her 7-year-old son with Down syndrome to clinic complaining of sleep difficulties. He won’t go to sleep alone, frequently wakes in the night and will not be settled unless transferred to his parents’ bed. His parents are exhausted, and his mother believes his lack of sleep is also disrupting his daytime behaviour. He has always been difficult to settle and seldom slept through the night without waking. The child is overweight, but not obese, and upon enquiry his mother tells you that he does not usually snore, or suffer from nocturnal enuresis (bedwetting), which makes obstructive sleep apnoea an unlikely cause. His mother tells you, “I’m sure he’s just waking up out of stubbornness and not because anything’s wrong, but we’re all worn out. I don’t know what to do.” You wonder if a behavioural treatment programme might be able to help in this situation.

You are attending to a 68 year old gentleman who was found in his car having left the road and hit a tree. On arrival his GCS was 6 and he had 2 fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema. There is nothing acute on his ECG and only mild cerebral oedema is seen on the head CT. You can see that his fluid balance will be very difficult to manage over the next few days and that the balance between hypovolaemia and pulmonary or cerebral oedema will be vital to management. You elect to insert a femoral central line but wonder if there will be any infective risks to placing this into the femoral vein rather than the currently inaccessible cervical region.

You are teaching a group of medical students basic life support when one of the group expresses concern about the risk of HIV on performing mouth to mouth on a complete stranger. After telling him it is unlikely you wonder whether this advice would sound better with some evidence behind it.

While closing a 59 year old lady after elective mitral valve replacement, the theatre nurse hands you 500mg of vancomycin powder to apply to the sternotomy wound prior to closure. You have just completed a BET relating to resistant bacteria in surgical patients and you question whether there is any benefit to this method in addition to intravenous antibiotics.

A 25 week gestation infant aged 30 days has a continuous murmur and easily palpable pulses. He has already received a course of indomethacin for a "clinically diagnosed" patent ductus arteriosus (PDA). The baby is ventilator dependent. How good (or bad) is clinical examination at diagnosing a clinically important PDA?

A 35 year old pregnant woman is brought into the resuscitation room of the Emergency Department in established cardiac arrest of 3 minutes duration. Full basic life support has been present since arrest; initial application of advanced protocols has not re-established circulation. You wonder whether emergency caesarian section could be life saving for either foetus or mother.

A mother with her 11 month old daughter attends the surgery. The child has gastro-enteritis and is mildly dehydrated. Mum has been starving the child the last 24 h as "everything comes back up". She has read this and also to avoid milk feeds in her health manual at home. Having read a paper once on continueous milk feeding as opposed to gradual regrading of milk, I decide to look which approach would be better.

A 4 year-old boy with a cough and a fever is referred by his general practitioner. On auscultation of his chest there are focal signs suggestive of a lower respiratory tract infection; a chest X-ray confirms right lower lobe collapse and consolidation. He is started on oral antibiotics and discharged home within 24 hours. He is given a follow-up appointment in 4 weeks time in the "registrar clinic" to be reviewed after having a repeat chest X-ray as per your unit's protocol. At the follow-up appointment he is clinically well and has a normal radiograph. After discharging him you wonder whether the "routine" exposure to radiation outweighs the detection of persistent radiological changes.

An 18 year old student is brought to the Emergency Department having been found collapsed in her room. She had been seen by her friends earlier in the day, when she reported that she had a severe headache. On examination, she is found to have a temperature of 38.40C, a GCS of 12 (E3 M6 V3) and slight neck stiffness. She is noted to be more settled with the lights out. There is no papilloedema and no focal neurological signs. You make an initial diagnosis of bacterial meningitis, but in view of the depressed level of consciousness request a CT Brain before lumbar puncture is carried out. This will take at least one hour to be organised, and in the meantime, you decide to proceed with intravenous ceftriaxone. You are unsure whether she would benefit from the administration of dexamethasone prior to her antibiotics.

A 10 day old neonate (corrected gestation 29 weeks, birthweight 960g) has been slow to establish feeds. Intravenous access is difficult and he is receiving parenteral nutrition through a CVC. He develops temperature instability and hyperglycaemia. You decide to start empirical intravenous antibiotics but keep the CVC in situ as the infant is relatively stable. Peripherally taken blood cultures grow CoNS. Should the CVC be removed, knowing that a future replacement may be very difficult?

A 32 year old man presents to the emergency department with central chest pain suggestive of cardiac ischaemia. He has had pain for 50 minutes after nasal cocaine. He is an occasional cocaine user who has not had chest pain previously. He is previously well. His 12 lead ECG is normal and he is now pain free. You see him in the resuscitation room and prescribe oral aspirin 300mg. He is cardiovascularly stable. You admit him and do a 12 hour troponin T, which is normal. The next day a colleague suggests that there was no need to admit as he was well, had a normal ECG, had few risk factors and that as cocaine causes spasm rather than clots he could have gone home. You wonder whether this is good advice.

A 30 year old man presents to the emergency department after a road traffic accident. On initial assessment you identify a haemothorax/pneumothorax on the left side of his chest; there are no signs of tension. You elect to place a chest drain and discover that you have a seldinger 'over-the-wire' technique chest drain in front of you. You wonder whether this method of placement is be better than any other at achieving succesful management of the injury without complication.