bestBETs

A 37 year old man presents to the emergency department with a cough and feeling generally unwell. He has signs of sepsis with a high; temperature, pulse, lactate and respiratory rate. He is assessed in triage and taken to the resuscitation room. He has a history of alcohol excess and known cirrhosis of the liver. He has some diffuse crackles at his left base but no clinical changes on his chest x-ray. He has a soft but distended abdomen, with known ascites, which he feels has increased in the last 48 hours. He is treated for sepsis of unknown origin and transferred to the acute medical assessment area. Within 24 hours he has deteriorated, he is not accepted for intensive care due to his high child-Pugh score and after 12 hours of fluids and antibiotics he has a cardiac arrest and dies. The post-mortem report concludes spontaneous bacterium peritonitis as the cause of death.

A 14 year old girl is admitted to the Macmillan Cancer Centre for a cycle of MAP chemotherapy. She has recently undergone limb salvage surgery for a distal femoral tumour and is now undergoing rehabilitation and struggling with being unable to do activities which she found easy before, this in turn is impacting on her mood and quality of life. You wonder if there is evidence to support the use of cycling to aid return to function and improve quality of life after surgery

A 75 year old man has a right fem-pop bypass to improve critical limb ischaemia, should he be referred to an exercise programme to reduce the risk of needing further surgery and improve his function?

Whilst working in an Emergency Department an adult patients attends and is assessed at triage as having sepsis. The patient receives prompt appropriate treatment. Does the initial triage affect their outcome?

You are working in A&E and review a patient with suspected poisoning or overdose, you are unclear of the identity of the substance so can not yet confidently consult the local toxicology database but are aware of the occasional need for intubation in such patients to maintain a safe airway and oxygenation. You wonder if there are any other clinical risk factors or predictors indicative of need for endotracheal intubation in poisoned patients which you could use to support your decision to intubate or not.

A 65-year-old man is found by passers by on a riverside path. He is unresponsive and not breathing. The bystanders ring 999 but do not attempt CPR. The patient has persistent asystole, no return of spontaneous circulation, and is declared dead. Would DA-CPR, or coaching from another trained third party have increased the odds of a favourable outcome?

A 22-year-old football player presents with a soft tissue injury to the ankle sustained earlier that same day while training. You suspect he has injured the anterior talofibular ligament (ATFL), but the acute clinical picture is confusing because of pain and swelling. You have access to diagnostic ultrasound (USS) to assess the integrity of the lateral ligament complex and want to know if this will give you an accurate diagnosis comparable to that of MRI.

While working the evening shift, a 45 year-old man presents to the emergency department with a progressive erythematous and swelling area on his leg. He is afebrile with unremarkable vital signs. The physical exam is suspicious for underlying abscess, as there is a fluctuant and localized pain. Before you proceed to drainage, you wonder if a bedside ultrasound of the soft tissue might help you to better assess the presence or absence of abscess to avoid unnecessary procedure.

A 13-year-old girl with a shoulder dislocation presents to your ED. You plan to reduce it using ketamine sedation but know that ketamine can cause emergence phenomenon in this age group. You wonder if you should use prophylactic midazolam to reduce the risk of this side effect.

A 50-year-old male presents to the Emergency Department with suspected carbon monoxide (CO) poisoning following an attempted suicide. He is haemodynamically stable; but is noted to have mild confusion and you are unsure if he requires admission for further monitoring or hyperbaric oxygen (HBO) therapy.

A two day old term neonate with meconium aspiration syndrome is on mechanical ventilation in a level III neonatal unit. He is diagnosed to have PPHN with a possibility to remain on the ventilator at least for another 24 hours. We know that dexmedetomidine is used in the paediatric intensive care units for sedation. But, can it be used in neonates? Is it more effective and safe compared to standard sedatives?

A 25 year old male presents to the emergency department in the late evening with symptoms of persistent nausea, vomiting and abdominal pain. He denies any diarrhea, fever, anorexia, sick contacts, or travel history. He reports daily use of 1-2g of THC/marijuana for the last 2 years, having started smoking in his early teens. He has had previous similar episodes in the last year lasting a few hours at a time. He typically takes 2-3 hot showers a day to improve his general symptoms of mild nausea and abdominal pain on a regular basis. He had a previous presentation and admission to hospital for two days with similar symptoms resolved with fluids and anti-emetics. This time, the symptoms have been persisting now for two days with no improvement. Clinically, he appears diaphoretic, and uncomfortable in pain. Vital signs are within normal limits. He appears clinically dehydrated with generalized abdominal tenderness but no acute peritonitis. History, physical exam, and investigations have ruled out emergent non-functional causes for his abdominal pain and vomiting. The clinical presentation is felt to be in keeping with cannabinoid hyperemesis syndrome (CHS). He received fluids, anti-emetics and pain control, all of which did not resolve his symptoms. You have heard that a single dose of haloperidol can improve symptoms of hyperemesis cannabinoid syndrome in the emergency department and avoid admission to hospital.

You arrive at a crash call on the ward. CPR is in progress and you are asked to manage the airway, but you are not trained in placing endotracheal tubes. You have been told that i-gels are easy to place but are unsure whether an LMA may be a more reliable way of securing the patient's airway. Which supraglottic airway device should you reach for?

You are seeing a 2 year old boy who has been non-weightbearing since sustaining a twisting injury whilst running. X-ray has revealed a toddler fracture of his left tibia (non-displaced spiral fracture). You are planning to place him in an above knee backslab but when you explain this to his mother she becomes upset because she feels this will be very distressing to him. You wonder if there are any other treatment options.

40 year old gentleman presents to your emergency department complaining of chest pain. After a full work up, there is no evidence of cardiac pathology, but the patient remains very anxious and distressed. Looking through the notes, you see that this is the third time this month he has visited your ED for chest pain, despite having had angiography some months ago which was reported as normal. You wonder if you can offer anything to this patient to help him understand his symptoms.