bestBETs

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.

A paramedic ambulance is dispatched to a 24-year-old male who has been ejected through the windscreen of his car. On arrival at the scene the patient is found to have major maxillofacial injuries a seriously compromised airway. Airway control cannot be achieved by manual techniques and endotracheal intubation is not possible. You decide to attempt cricothyroidotomy and wonder whether the surgical technique is more preferable to the percutaneous dilatation technique.

You have seen a toddler in clinic, and as a "by the way" on leaving the mother tells you that the child has a very red bottom and cries on defaecation although she is not constipated. On examination you see the classic signs of perianal dermatitis. You prescribe penicillin, and subsequent culture confirms streptococcal A infection. After clinic the staff grade doctor, who works with you and has expertise in child protection informs you that you should be considering sexual abuse as an issue. You decide to find out if there is an association between perianal dermatitis and child sexual abuse

A patient presents to the emergency department following a road traffic accident. He is found to have loin pain and tenderness and microscopic haematuria on dipstick testing. He is not hypotensive and has no other major injuries. You wonder whether radiological imaging is necessary to exclude significant injury to the renal tract?

A 35-year-old man alleges that he has been assaulted. He claims that he was hit on the head with a hammer. He is only complaining of pain around the site of the injury. On examination there is haematoma present, but no laceration. Standard skull views reveal no bony injury. You suspect a depressed skull fracture and wonder whether a tangential x-ray of the site of the injury, or a CT scan would be better able to detect it.

An elderly lady is admitted to the emergency department after collapsing in the street. She has a 3cm laceration in the left parietal area. Neurological examination and skull X-ray are normal. You have examined and cleaned the wound, but wonder if staples would be a better option than sutures for wound closure.

A 30 year old male who is a known opioid-addict is brought to the emergency department after an overdose of methadone. He had a GCS of 3, a respiratory rate of 4 breaths per minute, and pinpoint pupils. You are aware that the action of naloxone is shorter than that of methadone and wonder if naloxone infusion is less likely to precipitate acute withdrawal symptoms than repeated bolus doses.

A 3-year-old child attended A&E with high fever for 24 hrs. Examination showed congested throat, runny nose and red tympanic membranes. You make a clinical diagnosis of URTI ? viral. You prescribed antipyretic medicine but a fan was on near by child's bed. So you wonder whether any evidence that fanning will be of additional benefit to antipyretic therapy.

A 2 year old child presents to A&E with a crush injury to the left index finger tip. The fingernail has been avulsed from the proximal nail fold. You wonder if surgical re-implantation of the nail root into the proximal fold will produce a better cosmetic result.

A 20 year old man presents to the emergency department in status epilepticus. Initial therapy with benzodiazepines and phenytoin is unsuccessful. He is intubated and ventilated using thiopentone and suxamethonium. 10 minutes later he starts to fit again. The anaesthetist suggests that propofol may help but you have heard that propofol can increase EEG activity. You wonder whether this is an appropriate drug to use.

A 73 year old lady, who is usually fit and well, is brought to the emergency department following a fall. She is complaining of severe pain in her left groin. Examination shows that her left leg is shortened and externally rotated. You make a clinical diagnosis of fractured neck of femur (which is later confirmed radiologically). You wonder whether regional nerve block is better than intravenous analgesia for pain relief.

A 24 year old known asthmatic is brought into the emergency department by friends. She has been in a smokey bar and has become very wheezy. You assess her asthma as severe. You wonder whether a nebuliser is necessary, or whether a spacer device will suffice.

A 26 year old man attends the emergency department having been bitten on his right hand 30 minutes previously by his pet – a non-venomous snake. Examination reveals localised swelling and oedema of his right hand and forearm, he is systemically well, has no relevant previous medical history and is fully anti – tetanus immunised. You know there is the potential for infection from the snakes fangs and oropharynx, as well as contamination from the victim's skin and clothing. You thoroughly clean the wound with local wound toilet, and are happy that there is no fang left in situ. You wonder if prophylactic antibiotics are indicated to reduce the risk of infection.

A 25 year old male sustains an inversion ankle injury while playing football. Clinical examination and radiographic studies confirm an acute ligament rupture. You wonder whether this patient should be treated conservatively or admitted for surgical repair.

You are a neonatal junior doctor looking after the special care nursery. You process a capillary blood sample taken on the morning blood round by someone who has now gone home, and find the haematocrit to be high at 69%. You go back to the baby and find the child to be term, of low birthweight, and admitted to the special care nursery because of low Apgars the previous day. He has not been feeding too well, but the neonatal nurses are not otherwise concerned. He is normal on examination, and his venous haematocrit comes back at 68%. Does this baby need a partial plasma exchange transfusion (PPET)?

A young woman presents to the emergency department having taken an overdose of her iron tablets. She is in an emotionally distressed state but is cardiovascularly stable and requests treatment. It has been less than 2 hours since she took the tablets and you prescribe activated charcoal. You wonder whether this will actually do her any good.

A 40 year old man presents to the emergency department one day after suffering an injury to his knee. There is no evidence of bony injury on x-ray and a diagnosis of a traumatic haemarthrosis is made. You are unsure whether aspiration of the tense haemarthrosis will benefit him symptomatically.

A 32 year old man presents with a pedal puncture wound, which was sustained 4 hours prior to attending the emergency department. You wonder whether antibiotics should be prescribed to reduce infective complications.

A 26 year old man attends the emergency department having been bitten on his right hand 30 minutes previously by his pet a venomous snake. Examination reveals extensive swelling of his forearm with lymphangitis, hypotension and gingival bleeding. He has no relevant previous medical history and is fully anti – tetanus immunised. You know there is the potential for infection from the snakes fangs and oropharynx, as well as contamination from the victim's skin and clothing. You thoroughly clean the wound with local wound toilet, and are happy that there is no fang left in situ. You wonder if prophylactic antibiotics are indicated to reduce the risk of infection.

A 70 year old women presents to the A&E department with fracture of the distal radius, which requires manipulation. During the administration of Biers' block you failed to cannulate a vein distal to the fracture site. You wonder whether cannulation of vein at antecubital fossa is safe and effective.