bestBETs

A 57 year old man presents with a one hour history of central chest pain the character of which he cannot describe. There is no radiation but there is mild sweating and subjective shortness of breath. He has a history of smoking, hypertension, angina and a hiatus hernia; the pain came on after a curry. He has a normal ECG on admission and an unremarkable examination. You cannot decide whether this is cardiac or oesophageal in origin and wonder whether a single dose of antacid might relieve his pain and therefore clarify the diagnosis.

An 11 year old boy is brought to the emergency department by paramedics after falling off his bicycle. They have immobilised his cervical spine with a hard collar. He has no visible external injury, is fully alert and co-operative and does not complain of any neck pain. You are aware of the “trend” for radiographic cervical spine imaging in virtually all blunt trauma patients, as unrecognised cervical spine injury can lead to disastrous neurological sequelae. However, you wonder whether imaging in this case is really necessary.

You have just read a recent important publication by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons who recommend that in the under 9 age group, children requiring radiological assessment of their Cervical Spine need only undergo an AP or lateral cervical spine view. It is your current practice to perform three view radiography but you realise that getting the odontoid peg view can be very difficult in non-compliant children. You wonder on what evidence this specific guideline was based.

You are the child health lead in a primary care trust. The manager of the local Children's Fund comes to ask your advice about how best to meet the Children's Fund sub-objective of reducing inequalities in child health for children aged 5–13. A local child safety organisation has applied to the Children's Fund for a grant to arrange traffic safety education sessions in the local community, teaching children how to cross roads more safely. The manager wonders whether this is the best way to reduce inequalities in child traffic injuries. Meanwhile, the Children's Fund has done some preliminary work on one of its other objectives of involving the local community. In their consultations with workers, children and families, they have found that: Children say it is unfair that they don't have enough safe places to play. They don't like cars speeding through their neighbourhood. Parents feel under stress when the kids are in all the time but worry about sending them to the playground on the far side of a busy road. The Children's Fund is charged with delivering preventive services, listening to what children and families say they need, and reducing inequalities in child health. Traffic education might well help to address this. But will it actually reduce child traffic injuries and increase the local community's sense of safety on the streets? Is there something else—perhaps targeting the traffic rather than the children—that might be more effective, and more responsive to the local community?

The son of one of the authors came home from school with a letter explaining that prior to swimming each term, children would have their feet checked for verrucas. School policy stated that if a verruca was discovered a protective sock must be worn. Many public swimming pools have no restrictions on children swimming with verrucas, and in view of conflicting policies we wondered whether verrucas were transmitted during swimming and if wearing verruca socks was a necessary intervention.

You are the attending neonatal consultant. It is 6 pm on a Friday after a busy week on the unit. A rather flustered midwife appears from the postnatal ward with a baby and two anxious parents. The baby is full term and appropriately grown, following a normal vaginal delivery and just 8 hours old. Mum has been attempting to breast feed but the baby is reported to have been "not feeding well" and "jittery". There are no prenatal risk factors for sepsis. Your examination of the baby is normal—he is now not "jittery". A capillary heel prick blood test (Medisense) done on the postnatal ward has given a blood glucose reading of 2.6 mmol. Because this result is perceived to be abnormal (low), one of the neonatal trainees has suggested to the parents that he may need admission to the neonatal unit. As she has had three previous babies, the mother was hoping for an early (six hour) discharge from hospital. The midwife asks you to "sort out the situation". Some hours later, the laboratory plasma glucose result (taken at the same time as the Medisense capillary sample) is available. This result is 3.4 mmol/l. The mother agreed to stay overnight with the baby on the postnatal ward, received breast feeding support, and was discharged home next morning. No further blood samples were taken. A phone call to the mother on day 3 confirmed that the baby remained well and fully breast fed.

A 20 year old woman presents to the emergency department having suffered her first lateral patellar dislocation 1 hour before. She has managed to reduce it herself. You wonder whether surgery is superior to conservative management.

A 75 year old man presents to the Emergency department after collapsing at home with a sudden onset of back pain. On examination he is fully conscious, distressed with pain and has an expansile pulsating epigastric mass. His blood pressure is 80/40 mmHg. While you are waiting for the surgical consult you wonder whether it would be worthwhile administering a large I/V fluid bolus. This should raise his BP and may improve his tissue oxygen delivery. However, it may also increase bleeding from the aneurysm and will dilute clotting factors.

A 3 year old child presents to the Emergency Department with recent onset of left-sided limp and no history of trauma. He is apyrexial, systemically well with a normal white cell count and ESR. You diagnose irritable hip and wonder whether x-ray or ultrasonography is better at detecting a joint effusion.

A 40 year old man presents with acute suspected pulmonary embolus (PE). You wonder whether a negative SimpliRed d-dimer assay is sufficient to rule out the diagnosis of PE.

A middle aged man attends the emergency department having sustained an acute primary anterior shoulder dislocation during a fall. It is impossible to obtain peripheral venous access and you are not able to get him to breathe entonox. You are aware that shoulder dislocations can be reduced with intra-articular lidocaine (IAL). You wonder if IAL is as effective as intravenous analgesia and sedation (IVAS).

Tearful nineteen year old university student accidentally walked into IVDA 6 hours ago at a party and has puncture wound to hand from needle projecting from user's pocket. Needle and user not available.

A 5 month old boy attends the emergency department with a history of fever given by his mother. His temperature as taken with a tympanic thermometer is 37.5oC. His mother says he is hot to the touch. He has no focus for his fever on examination. The departmental protocol recommends a full septic screen in this age group if the temperature is above 38oC. You would like to know how accurate temperatures taken by this method are and whether you should check the temperature using another method.

A patient attends the emergency department having sustained a crush injury to the tip of their right index finger. This has resulted in a painful subungual haematoma but no other significant fingertip injury.

A 2 year old child is brought into the emergency department by her parents. They tell you that she has not used her left arm since tripping over while holding her older sisters' hand. The child is holding her left arm flexed at the elbow and semi-prone. The diagnosis is clearly a pulled elbow. You have heard various colleagues arguing vehemently for pronation and supination manoeuvres, and wonder which is actually the best method for reduction?

A 25 year old female attends the emergency department having been in a rear end shunt. She complains of pain in her neck. On examination she has right sternomastoid tenderness and restricted movement. You diagnose a neck sprain and advise physiotherapy, exercise and anti-inflammatory drugs. She asks you whether she should go and see an osteopath or a chiropractor. You wonder whether there is any evidence for these alternative treatments.

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.