bestBETs

A 32 year old gentleman is brought to the Emergency Department via an ambulance. On arrival he is immobilised with a long board, cervical collar and blocks. The paramedics tell you that he has been involved in an RTC. He was the driver of a car and was wearing a seatbelt. He was driving between 30-35 miles/hour, when a car pulled out of a junction suddenly. Although the patient braked he collided with the car as it pulled out. On paramedic assessment he had mid-line c-spine tenderness so the patient was immobilised at the scene. The patient is finding the collar too tight. You wonder if a collar is essential and whether adequate c-spine immobilisation could be achieved with the blocks alone.

A 45-year-old woman presents to the emergency department with a displaced Colles fracture two hours after slipping on ice. As you prepare for the reduction, you wonder whether a hematoma block would be adequate for analgesia versus conscious sedation.

A 25 year old male is brought into the emergency department by police profoundly agitated. You wonder whether ketamine will work faster than lorazepam or midazolam to treat the agitation.

A 60-year-old man is brought to the emergency department (ED) via Emergency Medical Services (EMS) after a fall with vital signs absent. EMS provided Cardiopulmonary Resuscitation (CPR) and was able to achieve return of spontaneous circulation (ROSC) on route, however the patient became pulseless again. In the ED the patient was assessed, CPR was initiated and he was intubated; ROSC is achieved once more. Shortly thereafter the patient is found to be pulseless and CPR is restarted. The ACLS algorithm has been followed and all standard resuscitation practices have been implemented. You wonder if the use of Esmolol could have helped you achieve sustained ROSC.

Since the outbreak of COVID-19, there is a worldwide shortage in protective masks such as surgical and filtering facepiece (FFP) masks. However, your local government advises the public to wear an alternative protective mask, such as a homemade made from household materials or cloth mask, to avoid virus transmission during the pandemic. You are faced with the question whether in non-healthcare settings cloth or homemade facemasks are effective at preventing virus transmission or illness caused by viruses?

A 60-year old man in the emergency department develops a shockable arrhythmia leading to cardiac arrest. As you prepare to deliver a rescue shock, you instructed everyone to clear away from the patient. Knowing that minimizing interruptions to chest compression has been shown to improve outcomes,(1,2) you wonder if there is a safe way to perform hands-on defibrillation and deliver rescue shocks without interrupting chest compressions.

You are tasked to assess a 42-year-old solider who has developed sudden onset slurred speech and weakness in the right arm whilst on exercise. The National Institute for Health and Care Excellence (NICE) guidelines recommend the use of a validated stroke screening tool such as “FAST (Face Arm Speech Test)” in the pre-hospital setting, or “ROSIER (Recognition of Stroke in the Emergency Room)” in the hospital setting. Recognising different screening tools are recommended between settings, you wonder whether there is a difference in accuracy between the screening tools.

A young female adult attends the emergency department complaining of a severe headache associated with nausea and sensitivity to light. A diagnosis of acute migraine is made and her symptoms improve in the department following analgesia. She has frequent headaches and does not want to keep attending the emergency department. She does not wish to take prescription medications. She asks you which over the counter medications are most effective and work quickest.

You are a clinician working in a busy Emergency Department overnight. A 35 year-old woman presents feeling very nauseous, and requests medications to alleviate symptoms while awaiting results of her investigations. You prescribe an appropriate antiemetic, but note that the nurses are busy dealing with a number of other patients. You therefore anticipate a delay in administration of the antiemetic and wonder whether there is anything you can offer in the short term. You recall an anaesthetic colleague talking about how they ask patients to smell alcohol-containing wipes to treat post-operative nausea. You wonder whether there is any evidence to support similar practice in the Emergency Department.

A 23 year old woman attends your department having been kicked in the chest by her horse. On arrival, she is complaining of right sided chest pain. Her vital signs are normal and she has no respiratory distress. Your examination reveals an isolated chest injury. You arrange a portable chest x-ray which shows a small, right sided, apical pneumothorax. You wonder whether you can avoid inserting a chest drain, and manage this patient conservatively.

A 68-year-old man with a past medical history of COPD, hypertension, and diabetes who presents to the emergency department (ED) with a 3-day history of suprapubic pain. Initial vistal signs were T-37.6C, HR: 92, BP: 100/52, RR: 21, 02%: 94%. Patient was in no apparent distress and the abdominal exam was significant for tenderness in the suprapubic region, no evidence of pulsatile mass. Diagnostic workup showed no evidence of leukocytosis or urinary tract infection. He had a computerized tomography scan of the abdomen within two years that showed a normal abdominal aorta diameter. Patient received 1L of fluid, ketorolac, and ondansetron and on re-evaluation after negative workup, he was discharged. On discharge it was noted that his temperature was 38.1C. The patient returned 4 days later in septic shock secondary to a peri-nephric abscess.

A 71-year-old male with a history of tobacco abuse, sleep apnea, and obesity presents after awakening from sleep due to sudden onset, severe chest pain that radiates to the back between the shoulder blades. Exam reveals a diaphoretic and anxious appearing male. He is tachycardic and hypertensive with regular heart sounds. There is no pulse differential and no neurologic deficit. You suspect that the patient has an acute aortic dissection and you request that nursing perform bilateral upper extremity blood pressure (BP) readings. The right arm reads 191/92 mmHg and the left arm reads 168/90 mmHg. You wonder how reliable this finding is in determining whether the patient likely has an acute aortic dissection.

A 34-year-old male presents to the emergency department with a laceration to his left hand inflicted by a clean knife approximately 12 hours prior to arrival. The patient washed the wound thoroughly after the injury and then wrapped it in a pressure bandage. He comes to the ED this morning because he is concerned it needs stitches. You remember hearing of the “golden window” for wound closure and wonder if closing this patient’s wound would significantly increase his risk of developing an infection.

A 59 year old women has painful osteoarthritis of the 1st MTPJ (great toe). She has been told that a MTPJ fusion is the best surgical solution but has read on t'internet that there are now joint replacements for the big toe MTPJ. She asks for your advice but before imparting wisdom, you wonder if there has been any study comparing the two techniques.

You are asked by a junior colleague to help place a difficult peripheral cannula in a patient in ED using ultrasound guidance. You wonder if there is an increased risk infection from the ultrasound equipment.

A 65 year old man presented to the Emergency Department with hypoxia and confusion. Chest xray is consistent with severe COVID-19 pneumonia. COVID-19 was confirmed with PCR testing. A colleague mentions Azithromycin as a possible treatment. You wonder if Azithromycin would reduce mortality or length of stay. You also wonder if it is associated with increased adverse events.

A 52 year old presented to the Emergency Department with a 9 day history of coryzal symptoms including sore throat and fever, after 5 days developed a dry cough and shortness of breath on exertion. Shortness of breath had become more severe over the last 24 hours, now breathless at rest and complaining of right sided pleuritic chest pain. Chest X-Ray and blood result findings were highly suspicious of COVID-19 and this was confirmed on PCR testing. With ongoing research into novel therapies for COVID-19, you wonder if Lopinavir-Ritonavir would reduce mortality or length of hospital stay for this patient.

The ambulance service is called to a 33-year-old-gentleman who has been found unresponsive. The dwelling is dark and confined with poor hygiene. The patient is confirmed to have self-administered opiates intravenously and is also reported to be HIV positive. On examination the patients peripheral vasculature is delicate and bruised. The intranasal (IN) route, as opposed to intravenous (IV) or intramuscular (IM) routes, of administering Naloxone is considered.