bestBETs

A young poacher comes into the Emergency Department complaining of a sore thumb after a night pilaging the local squire's estate. He smells strongly of game birds and clinically he has a rupture of the ulnar collateral ligament of his thumb. You wonder whether to plaster him or place him in a functional splint in the first instance?

A 45 year old man presents to the emergency department with a one day history of left-side facial weakness. Physical examination confirms that the patient has an incomplete left-sided Bell's palsy. As prednisone has a limited role in improving the recovery of incomplete Bell's palsy and medical literature postulates a viral etiology in Bell's palsy, you wonder whether acyclovir would improve the outcome for this patient.

A 26 year old man attends the emergency department with a simple laceration requiring suturing. You wonder whether application of a topical antibiotic ointment may promote healing and reduce incidence of infection.

A 29 year old male is brought into resuscitation area having jumped out of a fourth floor window. He has abdominal and pelvic injuries but no chest, head or limb injuries. He is bleeding intractably and the orthopaedic team and surgical team cannot agree on a plan of management. You suggest that operative managment is required, they would like to perform a CT scan prior to theatre to determine who will lead the surgery. Exasperated you wonder whether factor VIIa would help to stabilise the patient and reduce his requirement for transfusion.

A 36 year old man is brought to the emergency department after a road traffic accident. He complains of neck pain. A 'pulled' lateral is taken, but fails to show the C7/T1 junction. You wonder whether a pair of supine oblique views or a swimmers view would be best to visualise this region.

A 25 year old man is stabbed in the chest during a pub brawl. He sustains an isolated chest injury that requires a tube thoracostomy. You wonder whether the administration of prophylactic antibiotics will reduce the incidence of intrathoracic infection in this patient.

A patient attends the emergency department having sustained a blunt head injury. On examination they have clinical signs of raised intracranial pressure and a Glasgow Coma Score of 5. You decide that the patient needs a rapid sequence intubation and contiuous mandatory ventilation in order to protect the airway and reduce intracranial pressure. You wonder whether the pretreatment with lignocaine will attenuate the rise in intracranial pressure from the rapid sequence intubation.

A 6 year old child presents to the Emergency department with an undisplaced fracture of the mid femur. You have used femoral nerve blocks in adult patients with similar fractures and wonder whether this block is useful in children.

In patients suffering with massive postpartum haemorrhage syntocinon is often used intravenously to control atonic uterine bleeding. Currently, clinical units have protocols for administering up to 10 units intravenously stat, repeated up to once, followed by an infusion of 40 units in 40 mls of diluent administered over 4 hours and repeated if required. There are variations of this protocol in use in different hospitals. There is a need to support the use of such doses of syntocinon / oxytocin with evidence from proper studies on the effectiveness of different uterotonics and reports of any adverse effects.

A 4 year old boy presents to the emergency department following a 1 metre fall onto a carpeted floor. The child has vomited 3 times in the last hour but is otherwise well. Clinical examination is unremarkable. You wonder how significant the vomiting is.

A four year old girl presents to the emergency department having pushed a bead up her right nostril. The foreign body is easily visible in the nasopharynx. You wonder which method of removal is most likely to meet with success.

A 3 year old child is brought into the emergency department with a crusty yellow rash on the forearm. She is systemically well and a diagnosis of impetigo is made. You wonder whether oral or topical antibiotics are better.

You have just completed a BET comparing Digoxin and Amiodarone for the treatment of AF as the consultants in your hospital have widely varying policies in this area. Unfortunately this BET only found 1 paper and therefore you decide to widen the search to compare rate-controlling drugs versus ant-arrhythmics.

You are a busy consultant doing a ward round before the first case gets into theatre. You come to a 75 year old lady 3 days post CABG who has gone into AF overnight with a rhythm of 160. Her BP is 100/60 and she has a good LV and was in sinus rhythm preoperatively. You congratulate the SHO for starting amiodarone at 2am but she then asks you why three of your consultant colleagues insist on digoxin whereas 2 of your colleagues always use amiodarone. As you have just set up a critical appraisal journal club, instead of answering her, you suggest that you both go away and attempt to retrieve the evidence by the end of the week.

Parents of a 6 year old with cerebral palsy want to know if hyperbaric oxygen will be an effective treatment for their child's gross motor problems

A very anxious mother brings her 4 year old daughter to the emergency department concerned about her persistent fever. Examination reveals that she does indeed have a temperature of 37.6ºC. She has no obvious signs of localised infection, so you decide that you need to test her urine to see whether she has got a UTI. After much coaxing she provides you with a sample but you now wonder if dipstick analysis is sufficient for diagnosis, or whether you ought to arrange for urgent microscopy.

A 50-year-old presents with Bells' Palsy. You have heard that physiotherapy is an effective treatment but wonder whether facial exercises produce a better outcome than treatment with electrical stimulation.

A 6 year old individual presents to the Emergency Department with a history and examination consistent of appendicitis. On referral, the duty surgeon requests a full blood count. You wonder whether it will aid the diagnosis.

A 45 year old female attends the emergency department with a four hour history of acute onset of epigastric pain. She has a history of alcohol usage. On examination you can elicit tenderness in the epigastrium but no peritonism. You are concerned that the patient may have pancreatitis. You wonder whether a serum lipase might be better than serum amylase as a diagnostic marker for pancreatitis in this patient.

A paramedic ambulance is dispatched to a 36-year-old female who has fallen from a horse. On arrival the rider is not wearing a helmet, is unconscious with a GCS of 3 and has laboured diaphragmatic breathing. A cervical spine injury is suspected and orotracheal intubation is indicated due to the reduced respiratory effort, possible head injury and the long transport time to the nearest emergency department. The patient has a grade 3 laryngoscopic view (Cormack and Lehane). You wonder whether intubation would be made easier if you had a gum elastic bougie or stylet.