bestBETs

You are the A&E registrar on night shift. There has been a major incident involving a stadium collapse and your department has received 25 patients with various crush injuries. The level 3 patients have been moved to intensive care but you are to provide ongoing care to 5 patients overnight due to bed pressures. All the patients have a CK of > 5000 and you know they all are likely to have rhabdomyolysis. You wonder if alkaline diuresis (using sodium bicarbonate infusion fluid alongside a diuretic e.g mannitol or furosemide), will improve their chances of not developing acute renal failure, requiring haemodialysis or survival?

A 24 year old tree surgeon is brought into the emergency department after a tree she was felling landed on and trapped her arm. As she was working alone she was not found for several hours during which time the arm was trapped. You suspect she has sustained a crush injury to it. You consider what the best management strategy is with regard to the limb in improving her outcome.

A woman who is 9 weeks pregnant presents to the emergency department with debilitating early morning sickness. She is already taking several prescribed medications and would prefer to avoid adding another tablet if possible, asking whether any non-pharmacological options are available. A member of the emergency department team suggests inhalation of vapour from an isopropyl alcohol wipe, a technique occasionally used for nausea in other clinical settings. The clinician is uncertain whether there is evidence to support its use during pregnancy.

A 2-year-old child presents to the Emergency Department at 2 am with stridor at rest, mild-to-moderate intercostal recession, normal air entry on chest auscultation, normal oxygen saturations and a normal conscious level. You diagnose moderate croup. The parents report that the child's symptoms appeared to improve after being carried from the car park in the cool night air. You wonder whether there is evidence to support cold air exposure as a therapeutic intervention in children with croup.

A 34-year-old man presents to the emergency department with acute cocaine-associated toxicity, manifesting as agitation, hypertension, and persistent sinus tachycardia with a heart rate of 142 beats per minute. Despite appropriate first-line management with intravenous benzodiazepines, tachycardia persists. The treating clinician considers adding a beta-blocker to improve heart rate control but is concerned about the risk of adverse cardiovascular outcomes, including coronary vasospasm or hypertension due to unopposed alpha stimulation.

A 23-year-old male presents to the emergency department with symptoms and signs of anaphylaxis after being unable to self-administer adrenaline before arrival, he is administered intramuscular adrenaline. Once he has clinically improved he asks whether he could be discharged with intranasal adrenaline due to a reluctance to administer intramuscular adrenaline as he has a needle phobia. You wonder whether intranasal adrenaline is as clinically effective as intramuscular adrenaline.

A 72-year-old man presents to the Emergency Department with hypotension, tachycardia, and confusion. Clinical examination suggests shock, but the underlying cause remains unclear. Differential diagnoses include septic shock, cardiogenic shock, hypovolaemic shock, and obstructive shock. Rapid identification of the aetiology is essential to guide treatment. You wonder whether bedside POCUS can improve the accuracy and speed of diagnosis compared with standard assessment based on history, physical examination, ECG, laboratory investigations, and conventional imaging.

In progress

A 72-year-old man presents to the Emergency Department with hypotension, tachycardia, and confusion. Clinical examination suggests shock, but the underlying cause remains unclear. Differential diagnoses include septic shock, cardiogenic shock, hypovolaemic shock, and obstructive shock. Rapid identification of the aetiology is essential to guide treatment. You wonder whether bedside POCUS can improve the accuracy and speed of diagnosis compared with standard assessment based on history, physical examination, ECG, laboratory investigations, and conventional imaging.

A 34-year-old man presents to the emergency department with acute cocaine-associated toxicity, manifesting as agitation, hypertension, and persistent sinus tachycardia with a heart rate of 142 beats per minute. Despite appropriate first-line management with intravenous benzodiazepines, tachycardia persists. The treating clinician considers adding a beta-blocker to improve heart rate control but is concerned about the risk of adverse cardiovascular outcomes, including coronary vasospasm or hypertension due to unopposed alpha stimulation.

An 8-month-old infant is diagnosed with infantile epileptic spasms syndrome, confirmed by video EEG showing hypsarrhythmia. Following diagnosis, oral prednisolone and vigabatrin were prescribed as per UKISS guidelines. (1) However, parents are concerned regarding potential visual field constriction and retinal toxicity associated with vigabatrin use in young children.

A three-year old child presents with a two day history of cough and coryza. Their observations are normal, and they appear clinically well. Their parents are distressed by the cough and ask if there are any treatments that can be used to reduce its severity. They ask if the traditional treatment of honey is of any use; you wonder whether the evidence supports the use of honey to treat acute cough in children.

A 9 year old child presents to the ED after falling from a climbing frame, with a painful, swollen and visibly deformed forearm. X-rays confirm a displaced radial fracture requiring reduction. The department is busy and orthopaedic input may be delayed. Two emergency physicians trained in procedural sedation and fracture reduction are available. You consider whether ED led reduction and immobilisation provides comparable outcomes to orthopaedic led management in paediatric displaced upper limb fractures

While working at your local emergency department, you see an otherwise healthy 35-year-old who has sustained a simple laceration to his palm from working with an X-ACTO knife. He confides in you that he is a world-famous hand model and has an important show in Milan next week. He does not have time to return to have his sutures removed but is invested in the cosmesis of his wound. He asks whether absorbable sutures may be a convenient but safe option. You consult the relevant literature to find out.

You are working in a community emergency department on a night shift. A 19-year-old female presents to triage with severe lower abdominal pain and vomiting which has progressively worsened for the past 12 hours. She is previously healthy, other than an appendectomy when she was 12 and is currently on no medications other than her Mirena (intrauterine device). After you give her acetaminophen, ketorolac, some morphine and a dose of ondansetron she is more comfortable but still showing signs of discomfort. She has tenderness on palpation in the right lower quadrant and suprapubic region. You are concerned about possible ovarian torsion and would prefer to order a pelvic ultrasound on the patient to identify signs of decreased blood flow to the ovary. Your ultrasound technicians have gone home for the night and you’re wondering if you should call them back in. You know the time cut off for testicular torsion is roughly 6 hours before irreversible necrosis starts to set in, but is the ovary the same?

An 18-month-old with a two-day history of diarrhoea and vomiting is diagnosed with viral gastroenteritis. They are tolerating oral fluids and you feel they are safe to discharge. Their parents ask if probiotics could help with the diarrhoea. You wonder whether evidence supports probiotics in reducing diarrhoea duration in children with acute gastroenteritis managed in the paediatric emergency department (PED).

You attend a cardiac arrest in an 8-year-old child. As part of the resuscitation, you place a tibial intraosseous line (IO) and administer drugs including adrenaline. ROSC is achieved and you arrange for transfer to PICU. Before the patient is moved, however, the PICU consultant requests that the IO catheter be removed, due to the risk of complications. You wonder if there is evidence to support this concern and decide to find out more.

An obese 37-year-old patient is brought to the emergency department (ED) by ambulance after having been found unconscious outside a local nightclub. They are unresponsive on arrival and not protecting their airway. As your team prepares for intubation, you wonder whether the likelihood of first-pass success would be increased with non-supine positioning?

A 10-year-old child presents with with lump on head, loss of hair above the lump. The lump appears fluctuant and an US has been requested and the child started on intravenous flucloxacillin by a previous doctor. Was also started on antifungal medication for kerion. The mother would like the lump drained, but you are unsure if that is necessary.

Development of a blueprint for standardised care pathway for chronic MSK conditions such as GTPS in secondary care, to imrpove clinical outcomes for this cohort.