bestBETs

A 12 year old boy has sustained a head injury at a school rugby match. The coach takes him off the pitch, but the player is keen to finish the game. He is told he needs an assessment for traumatic head injury before he can continue to play. As the team doctor you perform the head injury assessment but wonder if it is useful for predicting outcome and guiding further management in mild traumatic brain injury (TBI).

A 48 year old male presents to the emergency department following a fall at work. He recalls grabbing a pole as he tried to slow his fall. He complains of right shoulder and elbow pain. Active elbow flexion and supination is painful and weak. Radiographs exclude fracture and/or dislocation at the shoulder and elbow. You suspect a distal bicep injury and recall there is a time urgency to manage such injuries. You perform the 'hook test' but are unsure of its reliability and accuracy in detecting Distal Biceps Tendon Rupture (DBTR). You consult the literature to support your discussion to expedite this case to the upper limb orthopaedic team.

A 25 year old non-smoker presents with a right sided spontaneous pneumothorax. He is breathless at rest with normal oxygen saturations on air and does not want to come into hospital for treatment.

A 42-year-old man presents to the Emergency Department (ED) with an acute anterior shoulder dislocation following a fall. He does not tolerate reduction with nitrous oxide and intravenous (IV) access is not possible. Your Consultant suggests using intra-articular lidocaine (IAL) to aid reduction. You wonder if IAL is a safe and effective alternative to intravenous analgesia with or without sedation.

A 13 year old adolescent presents to emergency department with one day history of unilateral headache associated with phonophobia and photophobia which gets better on lying down in a dark room after taking NSAIDs. There is a past history of recurrent headaches of similar nature and frequency has increased over past two months (4-5 episodes/month) and response to NSAIDS has also reduced. This affects his quality of life in terms of missed school days. After complete history and examination, a diagnosis of migraine is made. I wonder if migraine prophylaxis should be considered and if riboflavin is effective prophylactic medicine in reducing the frequency, duration or severity of migraine attacks.

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 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.

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 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.