bestBETs

A 20 year old female presents to casualty with complaints of recurrent pain and swelling in the perianal region. She has had similiar symptoms in the past and a perianal abscess was drained in the past but never really healed. On examination she has a small abscess with a fistulous track palpable. A diagnosis of recurrent perianal abscess is with an underlying fistula in ano. What is the evidence for the best available investigation to map the fistulous tracks.

A 55-year-old man with cardiac-sounding chest pain presents to the emergency department. The first ECG is normal. Just before you discharge him you stop to wonder what the sensitivity of the initial 12 lead ECG is in predicting acute myocardial infarction.

A friendly, coryzal 5 year old girl with acute lymphocytic leukemia attends with another episode of febrile neutropenia. According to departmental protocol, her admission includes a chest x-ray. You wonder as to the value of this routine irradiation.

A 8 year old child has a 3cm wound requiring local anaesthesia prior to wound closure. While preparing a measured amount of lignocaine, you wonder if buffering with sodium bicarbonate will reduce the pain of administration.

Different Emergency Departments have different protocols/preferences in the way children with mild or minor head injury are investigated. Some prefer observation plus or minus plain skull X-ray, others use head scan as the first choice modality. The department you are currently working in uses plain radiology. You are concerned that in children with mild head injury with no abnormal neurology and no fracture seen on plain skull films there is a tendency to be falsely reassured that intra-cranial injury (ICI) is unlikely.

A 60 year old man attends the emergency department with chest pain. He also gives a history of belching since the onset of the pain. His initial ECG is normal. You wonder if the symptom of belching has any prognostic value in the diagnosis of cardiac chest pain, or is more suggestive of a gastrointestinal cause.

A 35 year old male presents to A&E with acute renal colic proven on urine dipstick analysis and urgent IVU. His pain is severe and you would like to give him IM diclofenac as he is vomiting and it is your current practice. He tells you he developed a sterile abscess last time he was given IM diclofenac. You wonder if an alternative NSAID, piroxicam, given by the IM route would be as effective as the diclofenac you are reluctant to give.

You have just seen a patient with presumed renal colic. You have prescribed a dose of IM diclofenac as per departmental policy but wonder if a newer fast dissolving oral piroxicam agent would be as effective as the usual parenteral diclofenac agent.

A 32 year-old woman with asthma presents to the Emergency Department with a 20-minute history of palpitations. On examination she is cardiovascularly stable, there is no bronchospasm and the ECG shows a supraventricular tachycardia (SVT) that fails to respond to vagal manoeuvres. You would like to use IV adenosine but you are aware that asthma is a contraindication treatment. You wonder what evidence there is that IV adenosine will cause bronchospasm.

You have just finished an unsuccessful cardiac resuscitation with an initial presenting rhythm of ventricular fibrillation. You wonder if one of the new Biphasic defibrillators would have increased the possibility of successful defibrillation when compared to your old monophasic device.

A 45 year old female epileptic presents after sustaining a grand mal convulsion at home. She starts fitting again on arrival in the emergency department; the fit does not stop spontaneously after 5 minutes. The paramedics have secured intravenous access prior to arrival but have not given any anti-convulsants. You wonder whether lorazepam is more effective than diazepam as a first choice drug to safely terminate this convulsion.

An 8 year old boy is taken to the Emergency Department after falling out of a tree. He has no signs of injury apart from abrasions and tenderness across his upper abdomen; he is haemodynamically stable. He undergoes an abdominal ultrasound that is normal but you wonder how accurate this is at identifying intra-abdominal injury compared with the current gold-standard, abdominal CT.

A 45 year old female attends the emergency department with a 4-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 urinary trypsinogen can be used as a diagnostic marker to rule out pancreatitis in this patient.

An eighteen-year old presents to the emergency department with a two-day history of redness and swelling in their left arm after a scratch. They are systemically well, and apyrexial. A diagnosis of cellulitis is made and you feel you can discharge the patient on oral antibiotics with outpatient follow up. You wonder whether flucloxacillin or azithromycin would be better at improving outcome.

A 55 year old female is brought to the emergency department following an overdose of alcohol and tricyclic antidepressants. She has a tachycardia (110) and a systolic blood pressure of 105mmHg. The GCS is 5 (extends to pain). You decide to do an RSI using etomidate and suxamethonium. You are only able to visualise the epiglottis at laryngoscopy (Cormack grade 3 view), and struggle to intubate the patient on the third attempt (having intubated the oesophagus twice). You wonder if it would have been easier if you had used a gum-elastic bougie.

A 67 year old man attends with increasing shortness of breath. He is known to have obstructive airways disease. You want to perform arterial puncture for blood gases. He tells you that last time it was very painful.You wonder if an injection of local anaesthetic would help?

A patient is brought in after attempting suicide by inhaling exhaust fumes from their car. He/she has a GCS of 3 and has required intubation but is otherwise stable. He/she has a carboxyhaemoglobin level of 40%. They have been receiving high flow oxygen, but you wonder if transfer for hyperbaric oxygen therapy is indicated.

A 27 year old female with a 2 day history of headache attends the A&E department. Clinical assessment of this patient comforms with a diagnosis of tension headaches. She was given Kapake for pain relief and discharged.

A 3 year old boy is brought into the Emergency Department by his mother. She says that he swallowed a coin 2 hours earlier. The boy is asymptomatic. You know it is important to rule out oesophageal impaction and wonder whether a metal detector can accurately show whether the coin is above or below the diaphragm.

A child presents to the emergency department with a nosebleed that came on spontaneously and which has not responded to simple first aid measures. The bleed appears to be from the front of the nose and the patient has no underlying disease. You wonder whether silver nitrate cautery or application of nasal antiseptic cream is the best method of obtaining haemostasis.