bestBETs

A fit and well 48 year old woman attends your department with pleuritic chest pain and new shortness of breath on exertion. Her heart rate is 105. Several family members have had a recent viral infection. There are no clinical features suggestive of pneumonia. You are keen to exclude pulmonary embolism, so calculate the Wells score as 1.5 (low risk) and subsequently order a D-dimer. This comes back at 505ng/mL FEU. Your lab threshold for a positive test is 500ng/mL FEU. It always makes you cross for some reason when the D-dimer is so close to being ‘negative’. You are complaining about this at the workstation when a colleague overhears, and asks if you have considered applying a clinical probability adjusted (CPA) threshold to the D-dimer test. Your colleague explains that this approach allows you to adjust the D-dimer threshold according to pre-test probability as defined by the Wells score – accepting <1000ng/mL FEU as a negative result in patients at low risk. This is the first you have heard of this approach – you resolve to look it up immediately and see if it could help you safely avoid further imaging and interim anticoagulation.

You attend a cardiac arrest in a 48 year old female patient. The patient is in VF, and you follow the ALS algorithm but unfortunately you are unable to defibrillate the patient. You only have one defibrillator and so dual sequence defibrillation is not an option. Sadly, the patient never comes of VF, fading into asystole and then dies. At the debrief a colleague tells you that applying pressure to the pads reduces thoracic impedance and might be a way of improving the success of defibrillation. You wonder if this is true.

A 5 year old child presents to ED 5 days after tonsillectomy with bleeding from the tonsilar bed. You wonder if nebulised TXA plays an evidence based role in his management to minimise his bleeding and particularly his need for other intervention.

A 32 year old woman presents to the Emergency Department with epistaxis which she cannot stop herself. First aid measures in triage cause haemostasis. She is haemodynamically stable, her observations are within normal limits and she is not taking any anti-coagulation or anti-platelet medications. This is her first episode of epistaxis. The Ear, Nose and Throat specialist advises you to prescribe anti-septic nasal cream for one week “to prevent recurrence or complications.” You are unsure whether this treatment will reduce the risk of recurrent epistaxis or infective complications.

A 60 year old man presented to the A&E with a ~4cm dog bite laceration on the posterior thigh. He has already received all 3 doses of tetanus vaccine. It has been confirmed that the dog is up to date on rabies vaccination. The laceration is deep and requires sutures. Should you do primary closure of the wound?

A 46-year-old female patient presents to the emergency department with a warm to touch, painful, and erythematous rash on their right leg. No previous methicillin-resistant staphylococcus aureus colonization documented in the past. You are considering which outpatient oral antibiotic strategy would be most appropriate for this patient for suspected cellulitis.

A 25-year-old athlete suffers a first-time anterior shoulder dislocation. After reduction in the emergency department, you wonder whether immobilizing the shoulder in external rotation instead of internal rotation could better prevent recurrent dislocations.

A 40-year-old patient presents to the ED with epistaxis. They are otherwise fit and well with no signs of bleeding elsewhere. You wonder if a nasal clip will deliver more effective first aid than manual compression.

A 25 y/o male has sustained a femur fracture and is attended by Paramedics. I know IV Morphine will reduce pain and distress to facilitate the application of a Kendrick Traction Device, but will analgesic doses of IV Ketamine achieve this quicker?