bestBETs

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 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 59-year-old male is admitted to our ICU because of fever, low level of consciousness, decreased SPO2,he has a past medical history of diabetes mellitus. Chest radiography (CXR) was performed, which reported patchy air space opacity in the right upper lobe suspicious for pneumonia . Lung HRCT revealed bilateral ground-glass opacities (GGOs). LAB data shows leukocytosis and elevated CRP and ESR levels

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 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.

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?

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 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 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 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.

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 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 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.