bestBETs

A 28 year old man presents to the emergency department with a punch injury to the left side of his face after a fracas. Clinical examination reveals no wound, but tenderness, bruising and swelling over the left infraorbital area. Radiological examination confirms the presence of fluid within the maxillary sinus, suggesting an undisplaced fracture of the orbital floor. You wonder whether you should prescribe him oral antibiotics to reduce the incidence of infection.

A 73 year old woman presents to the emergency department with chest pain. Her ECG shows left bundle branch block. She is on warfarin for recurrent pulmonary emboli. Her INR is 2.7. While you look for her old notes to see if LBBB is new or not, you try to find out at what INR thrombolysis is contraindicated. Everyone gives you an answer, but the answers are all different. You wonder if there is any evidence to support any of the recommendations.

A 44 year old man presents to the emergency department with a foreign body sensation in his right eye. Fluorescein examination reveals a piece of grit. After removal there is a small corneal abrasion with no evidence of perforation. The patient has had a primary course of tetanus antitoxin and thinks his last tetanus booster was less than ten years ago but is not sure. You wonder if the patient requires a tetanus booster to reduce any risk from the abrasion.

You are working as a pharmacist supporting a tertiary neonatal unit. A 36/40 gestation infant is transferred from another hospital. The infant had been born by normal vaginal delivery and collapsed on the postnatal ward at 3 hours of age. The child is hypoxic despite high pressures and 100% oxygen. The diagnosis of persistent pulmonary hypertension (PPH) is suggested; intravenous tolazaline had been tried without significant improvement. Nebulised tolazaline is mentioned, and you are asked to find out more.

2 yr old girl attends your department with a history of impetigo. In addition she has developed an erythematous rash with some bullous formation. She has a minimal pyrexia and seems otherwise quite well. You diagnose staphylococcal scalded skin syndrome. You wonder, as she is clinically well, whether you can treat her with oral rather than intravenous antibiotics.

A fitting three year old child presents to the emergency department. The child has received an appropriate dose of rectal diazepam from the prehospital team. Following administration of a dose of intravenous lorazepam the child continues to fit. You wonder whether there is any evidence to suggest whether paraldehyde or phenytoin should be given next.

A 7 year old boy presents to the Emergency Department having fallen in the playground, sustaining a laceration to his bottom lip which crosses the vermilion border. You know that the potential uses of tissue adhesive in the paediatric population are increasing, and wonder if it may be used in these circumstances instead of the traditional method of formal suturing.

A 62 year old male attends the department with central crushing chest pain, sweating and shortness of breath he has vomited twice.His chest is clear, he is hypotensive and has a raised JVP. ECG reveals bradycardia and ST elevation in aVR. Clinically convinced he has a right ventricular infarct you repeat the ECG using right sided chest leads which show ST elevation of 2mm in three leads. Happy that this man has an isolated right sided infarct you wonder whether there is any evidence supporting your plan to thrombolyse.

A 3 year old child attending the emergency department with moderately severe croup. I know that croup responds to steroid therapy, but I want to know whether oral dexamethasone is a better treatment than nebulised budesonide.

A 40 year old male is admitted into the resuscitation area of the Emergency Department following a high speed road traffic accident. He tells you he has not injured his head and has no pain in his pelvic area. He is alert orientated, he is not under the influence of any alcohol or drugs, and is neurologically intact. You cannot find any major injuries, his pulse is 94, and BP 145/90. He has no pain on flexing his pelvis. You wonder if it is necessary to perform a pelvic x-ray.

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 pharmacolgical treatment with terlipressin will be effective in reducing the bleeding.

You have just performed a manipulation under anaesthesia for a displaced supracondylar fracture in a child. Check X-rays reveal a satisfactory reduction. You wonder whether a simple collar and cuff is as effective as other means of holding reduction.

A 23 year old man attends the emergency department having been assaulted outside a nightclub with a hammer. He has sustained an isolated head injury with no loss of consciousness and is fully alert and oriented. He has a compound depressed left parietal skull fracture (confirm and defined by CT scan). No surgical intervention is considered. You wounder whether the adminstration of antibiotics will reduce the chance of meningitis developing.

A 68 year old gentleman attends the emergency department with two hours of ongoing central chest pain radiating into both arms. He is pale and sweaty, has vomited twice and has a history of angina. Examination shows him to have BP 90/55 and he has bibasal crepitations. 12 lead ECG is unremarkable but convinced clinically he is having a myocardial infarction you repeat the ECG using posterior leads which show ST elevation indicating a posterior MI. You have no access to angioplasty at this time and wonder whether he would benefit from thrombolysis.

A 2 year old child presents to the emergency department with a limp. The child is mildly pyrexial and has some limitation of movement. You decide to take blood as part of your diagnostic strategy to exclude septic arthritis. The parents are keen to get on with the tests and are disappointed that the EMLA cream you intend to use takes so long to work. The paediatric emergency nurse suggests using tape to "clean" the skin prior to application in order to get the EMLA to work faster. You have no idea what she is talking about but wonder whether there is any evidence to show that she is right.

An 18-month-old boy with cerebral palsy is brought to your office because of "spitting up" after feeds. It has been a problem for the past several months but is progressively worsening and now occurs after every meal and even at night. He was breast fed for 12 months and has slight developmental delay. Height and head circumference are between 25-50th percentile, but weight is below 5th percentile for age. A barium swallow reveals significant gastro-oesophageal reflux to the pharynx. A gastroscopic examination with biopsy reveals moderate esophagitis without eosinophilia. You wonder if a proton pump inhibitor will be an effective treatment.

An eight year old boy is brought to the emergency department by his parents, after tripping and hitting his head on the table edge. He has a 2cm laceration over the occipital region. You examine the wound and wonder whether staples might be an easier alternative to sutures.

A 30 year old opioid addict is brought to the emergency department having overdosed on heroin. He is successfully treated with a titrated bolus of naloxone. You wonder when it will be safe to discharge the patient.

A 27-year-old hiker attends with what appears to be a tick in the skin of his right leg. You seek the advice of your colleagues on the best method of removal, the registrar advises you to pull it straight out, another registrar suggests to pull out anticlockwise, the consultant denounces them as fools and says to pull clockwise. Sister suggests suffocating the tick with vaseline and a staff nurse thinks that nail varnish is better for this, a passing porter suggests burning it off with a lighted fag and the patient himself claims that his mother always recommended 70% isopropyl alcohol (for the removal of ticks). Confused you wonder whether there is any evidence for any of the suggested methods.

One evening after the emergency eye centre has closed you assess a patient and diagnose acute bacterial conjunctivitis. Your usual practice is to prescribe topical antibiotic therapy. Having recently attended a BestBETs course you wonder if this has been shown to reduce the time to clinical remission.