bestBETs

A 3 year old girl presents to the emergency department after catching her face on the edge of a table. She has a 2.5 cm laceration to the cheek which requires closure. The wound is not suitable for steristrips. The parents are very worried abbout her having stitches and also about scarring. You wonder whether glue is the best option for this child.

A 16 year old male is brought to the emergency department following a drive by shooting. He has an isolated entry wound to the right temporal region consistent with a .22 calibre bullet. On arrival he is cardiovascularly stable but has GCS of 5 (extending to pain) with reactive pupils. You decide to intubate using an RSI technique but you are worried as the patient has a small mandible and may present difficulties in intubation. You wonder if it is safe to remove the C-spine collar, flex the neck and extend the head, but you are worried about a c-spine injury. You take a risk, remove the collar and intubate the patient. Later you wonder just how risky it was.

A 24 year old man presents to the Emergency Department on Saturday night with injuries to his lower jaw. He has been involved in a fight. On examination there is extensive bruising to the left side of the face and chin. The patient is unable to open his mouth or talk due to pain and trismus. You suspect a mandibular fracture and decide to x-ray the mandible. You wonder whether a standard mandibular series or a panoramic view is the best technique for accurately detecting any fracture.

A ten year old girl has presented on several occaisons since a recent head injury with a persistent headache. Clinical examination has previously been documented as normal. You wonder how significant the headache is with respect to the initial head injury.

A 24 year old man is brought to the emergency department by his friends having been shot in the leg. Examination of the thigh reveals a through and through wound with no bone, nerve or major vessel involvement. You wonder whether simple entry and exit wound cleaning with or without antibiotics or surgical debridement is the best treatment.

A 35 year old woman attends the Emergency Department with a swollen and painful left leg. A DVT is suspected and confirmed on ultrasound. You are aware of the possible risks of developing post-thrombotic syndrome and wonder whether this young woman would benefit from the use of compression stockings.

A 27 year old woman who is 14 weeks pregnant, presents to the emergency department with the symptoms and signs of appendicitis. You refer the case to the acute surgical team who ask you to obtain a white cell count. You wonder whether this test has any value in this situation.

A 24 year old male is brought to the emergency department after falling whilst sat on the window of a moving car. His only apparent injury is to the head where there is a laceration to the occiput. He is brought in tolerating a guedel airway. He responds to pain with abnormal flexion and opens his eyes to pain, there is no vocal response (GCS 7). You decide to intubate the patient using an RSI technique. As a cervical injury cannot be excluded you attempt intubation in the neutral position with manual C-spine control and the hard collar removed. At laryngoscopy using a size 4 Macintosh blade you are unable to visualise the cords (Grade 3 view) but manage to intubate the patient using a gum elastic bougie. Later, when discussing the case with an anaesthetic colleague they ask why you did not use a McCoy laryngoscope as they claim that these are better when patients are intubated in the neutral position. You wonder is there is any evidence to back this up before you go and buy some more equipment for the emergency department.

A 25 year old man presents at the Emergency Department with a 2 day history of a swollen and painful right leg. A DVT is suspected and an ultrasound confirms the presence of an extensive clot in the femoral vein. Otherwise he is fit and well. There are no beds in the hospital and you wonder whether the evidence exists to confirm that this patient can be treated safely as an outpatient using low molecular weight heparin.

A 45 year old female attends the emergency department with cellulitis. You decide to admit her for intravenous antibiotics. She becomes agitated, distressed and tearful when you explain this to her. On questioning she reveals that she is afraid of the pain of intravenous cannulation. You wonder whether a prior injection of local anaesthetic would lessen the pain of cannulation without affecting your chances of success.

A 19 year old man attends the Emergency Department having been assaulted in a night club. He has sustained an isolated head injury with no loss of consciousness and is fully alert and orienttated. He has CSF rhinorrhoea secondary to bbase of skull fracture. You wonder whether the administration of antibiotics will reduce the chances of meningitis developing.

A 35 year old man presents to the emergency department with a 1 day history of a right sided facial weakness. Examination reveals a complete right facial nerve palsy, without any evidence of herpes zoster, middle ear disease, trauma or further neurology. A diagnosis of idiopathic (Bell's) facial nerve palsy is made. You wonder whether early high dose steroids would improve his prognosis or speed of recovery.

A 25-year-old man presents to the A+E department following a crush injury to the middle finger. There is a laceration over the distal phalanx involving the nail bed. The nail bed is disrupted. The injury requires removal of the nail and repair of the underlying nail-bed laceration. You wish to perform this procedure under local anaesthesia and suggest using a digital nerve block for anaesthesia. Your colleague suggests that a metacarpal block would be a better method as it is less painful to perform.

A 12 year old girl presents to the emergency department with "tummy ache". The history and examination are suggestive of appendicitis. You call the surgical team but they are unable to attend for one hour as they are tied up in theatre. You wonder if giving analgesia will affect the accuracy of the surgical diagnosis.

You see a 50 year old man with a 2 hour history of cardiac chest pain and an ECG suggestive of acute myocardial infarction. You decide to thrombolyse. The cardiology registrar suggests that you also give IV Magnesium to reduce the incidence of ventricular fibrillation. You wonder whether there is any evidence to support this.

A 60 year old man presents to the Emergency Department with an acute exacerbation of COPD. Analysis of his blood gases is required. You wonder whether a capillary blood sample will be as accurate as an arterial blood sample.

A 70 year old woman presents to the Emergency Department with a pretibial flap laceration. The wound will need cleaning and then closing. You wonder whether adhesive strips or sutures should be used to achieve closure.

An adult patient 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 packing or cautery is the best method of obtaining haemostasis.

An 80-year old man is brought into the Emergency Department in the early hours of the morning with acute shortness of breath. He is pale, clammy and very distressed. You diagnose acute left ventricular failure. You have heard that frusemide may increase vascular resistance and wonder whether nitrates should be used instead.

A 56 year old immunocompetent man presents to the emergency department at 10pm on a Saturday night with acute shingles. You know acyclovir is effective but wonder how quickly it needs to be started.