bestBETs

A 30-year-old male presents to the emergency department with cough, fever, and an infiltrate on chest x-ray. He is subsequently diagnosed with community-acquired pneumonia. You would typically prescribe him amoxicillin-clavulin as an outpatient but he is reporting a vague history of penicillin allergy. You wonder whether this is a true allergy.

You are present in resus when a 35 year old arrives as a standby, with a low GCS. The anaesthetic team is in attendance. This history is of recent overdose of sedative and antidepressant medication, but there is also a history of recent respiratory illness. Blood gas analysis reveals a mixed acidosis and a decision is taken early to sedate and ventilate for airway protection and predicted clinical course. You don PPE, discuss roles during the team brief and agree to be the primary intubator, with anaesthesia administering induction drugs and providing team leadership. During the checklist you suggest an airway plan that starts with direct laryngoscopy (DL). The anaesthetic team recommend use of videolaryngoscopy (VL), stating that not only will this allow them to see a bit more of what is happening but also now has an evidence base suggesting better first pass success rates. They also suggest it is recommended for intubation of COVID-19 patients in several international guidelines. You did not know this and resolve to have a look at the evidence. Right after you’ve intubated this patient….

A 60-year old gentleman travels by ambulance to ED Majors. A varicose vein on the dorsum of his foot was caught on his sock while dressing. A puddle of blood quickly appeared. Despite direct pressure by the person and the ambulance service, the varicosity is still bleeding. You elevate the foot above the person's heart. You apply a compression dressing up to the level of their knee. You consider applying tranexamic acid as a topical haemostatic agent to reduce blood loss.

A young patient has been stabbed in the right lower abdomen and is in PEA cardaic arrest. You wonder whether emergency thoracotomy would improve his chances of survival?

A 55 year old with a background of hypertension is brought to the emergency department with a 7 day history of fever, cough, and shortness of breath. His oxygen saturations are 93% on 6 litres of oxygen via facemask and arterial blood gas results suggest type 1 respiratory failure. You suspect COVID-19 and refer to the medical team for conservative management and inpatient care. Having made the referral, you remember listening to a podcast about prone positioning and wonder if this would improve his oxygenation or reduce the likelihood of clinical deterioration?

A 22 year old female attends the emergency department after falling on her outstretched hand. On examination she has tenderness over the scaphoid, scaphoid tubercle with pain on axial loading of the thumb as well. Initial plain radiographs are normal. You have recently completed a musculoskeletal ultrasound course and wonder if ultrasound as a modality is useful in the diagnosis of occult scaphoid fractures.

A 28-year-old male football player has a blunt trauma to his quadriceps sustained 5 days previously. He now has painful, localised focal swelling over the lateral aspect of the mid-thigh and limited painful knee flexion. You suspect he may be developing Myositis Ossificans Circumscripta (MOC) within the Vastus Lateralis muscle. You decide that he would benefit from further investigation in the form of imaging. You have access to immediate point-of-care access to diagnostic ultrasound (US), but you wish to know if US will give you an accurate diagnosis comparable to that of the gold standard, computerised tomography (CT).

A young male was self-presented to the ED with sudden onset left-sided pleuritic chest pain. His physiological observations were within normal limits with an unremarkable physical examination, ECG and chest x-ray. The calculated two-level PE Well’s score was ‘0’ and the D-Dimer was reported as above the 99th percentile. He was clinically risk-stratified by sPESI scoring as low-risk mortality PE presentation. A CTPA could not be done until the following day and he wished to go home. The BTS guidelines 2018 recommends that patients with suspected PE who are deemed as low-risk are eligible for OP care with an alternative strategy of anticoagulation. Hence, can this patient with suspected PE be treated as OP safely pending radiological investigation?

A 40-year-old male with a history of hypertension and tobacco abuse presents to the emergency department (ED) complaining of chest pain. Workup is completed including a metabolic profile which is remarkable for a blood glucose of 294. He has no history of diabetes or hyperglycemia. The remainder of the workup reveals no abnormalities and undetectable troponin. The patient’s pain resolves after a dose of antacid in the ED. As you prepare discharge instructions, you wonder if you need to correct his hyperglycemia prior to sending him home.

A 28-year-old male with a history of IV drug use presents to the emergency department for injuries sustained during a motor vehicle collision. The patient was non-ambulatory at the scene with multiple injuries to his extremities including an obvious right-sided femur fracture. Upon arrival, the patient is hypotensive with weak distal pulses. Nurses are unable to obtain IV access but you successfully place an intraosseous (IO) line in the left proximal tibia. You consider whether administering tranexamic acid (TXA) via IO will have the same efficacy as IV or intramuscular (IM) administration.

A middle aged otherwise fit and well gentleman presents to your emergency department with symptoms highly suggestive of COVID-19 infection. He is streamed to be seen by you in the Amber area. He has been isolating at home for the last three days after developing myalgia and a fever. His oxygen saturations are 95% at rest on air and his respiration rate is 22 He is normally fit and well. Would a Computed Tomography (CT) scan help you to risk stratify him and decide whether admission is required?

One month after social distancing measures were introduced in the UK, a 35 year-old man attends with shortness of breath and is streamed to be seen by you in your COVID-19 assessment area. He has been isolating at home for the last three days after developing myalgia and a fever. He is normally fit and well and has not been tested for COVID-19. His oxygen saturations are 93% at rest on air and his respiratory rate is 22 breaths per minute. You know the NHS England guidance advises you to consider conducting a 40 step test to see if the patient desaturates on exertion. You wonder if this advice is evidence-based.

One month after social distancing measures were introduced in the UK, a 35 year-old man attends with shortness of breath and is streamed to be seen by you in your COVID-19 assessment area. He has been isolating at home for the last three days after developing myalgia and a fever. He is normally fit and well and has not been tested for COVID-19. His oxygen saturations are 93% at rest on air and his respiratory rate is 22 breaths per minute. You consult the NHS England guidance which advises that the decision to admit or discharge should be based on a senior clinical assessment. You wonder if a model is available to guide this decision.

A 70 year old man presents in PEA cardiac arrest. An ED echocardiogram shows cardiac activity but no pulse is palpable. Pseudo-PEA is diagnosed. You wonder whether CPR timed to systole may improve his chances of survival.

A patient develops flu-like symptoms 3 days after taking Holy Communion at church. You wonder whether in the current climate of coronavirus (Covid-19) risk does the sharing of a communion cup practiced by millions of Christains around the world put it's participants at risk of infection?

A 67-year-old female with a history of diabetes and hypertension, on metformin and an ACE-inhibitor, presents to the emergency department (ED) following an episode of syncope while walking into her bathroom. She had preceding lightheadedness, but no other symptoms. She has a blood pressure of 158/87 with a heart rate of 78, unremarkable ECG, and her blood glucose is 84 mg/dL. As part of her diagnostic evaluation, you consider whether orthostatic vital signs will help to rule out any life-threatening causes of her syncope?

25-year-old presents to the emergency department after sustaining a laceration to his ankle after cutting his leg on a piece of metal. The wound is hemostatic on presentation. There does not appear to be any gross contamination and a simple closure is adequate with nonabsorbable sutures. After closure the patient is given routine discharge instructions when he questions you about removing his sutures at home.