bestBETs

A 45-year-old male presents to the Emergency Department with an Altered Mental State. He is acutely agitated and aggressive, and attempts at verbal de-escalation are unsuccessful. A decision to pharmacologically sedate is made. As benzodiazepines are commonly used first line to sedate acutely agitated patients, you wonder whether using them as a single agent, or in combination with an antipsychotic, will result in more effective (faster and minimal need for re-sedation) and safer (fewer adverse events) sedation.

A young man with type 1 diabetes presented to the emergency department (ED) with disorientation and was diagnosed with DKA. Despite his elevated baseline serum lactate, his condition improved relatively quickly. This makes you wonder whether high baseline serum lactate predicts outcomes in DKA patients.

A 50-year old obese man with a history of severe shellfish allergy is rushed into the resuscitation room for sudden onset of shortness of breath. On examination he had marked face and tongue swelling, stridor and his oxygen saturation remained ~75% despite given 15L/min oxygen via a face mask. You are the only trainee available at the moment and anaesthesia on call takes another 5-10 minutes to arrive. With the anticipation of difficult airway, you wonder if the use of a hyperangulated laryngoscopy blade would increase your first-attempt success rate of videolaryngoscopic intubation.

You receive a major trauma patient to your emergency department. The history is of a 42 year old male who has fallen 8 foot from a balcony. On arrival, there is obvious evidence of head injury and Glasgow Coma Score is 4 (E1, V1, M2). You conduct a primary survey and find evidence of airway obstruction, but no other immediately life-threatening conditions. You undertake a drug assisted endotracheal intubation, which is uneventful. The patient is sedated, ventilated and escorted to radiology for definitive imaging. A full body trauma CT is reported within the hour as showing severe Traumatic Brain Injury (TBI) and 2 displaced right sided rib fractures. The case is discussed with the neurosurgical team who recommend admission to critical care for placement of an intracranial pressure bolt and a period of monitoring. As you are preparing for transfer, a colleague mentions recent evidence reporting that prophylactic antibiotics given within 12h of intubation can prevent subsequent pneumonia in patients with TBI. You have not heard of this before and are reluctant to prescribe anything, given the importance of antimicrobial stewardship. You escort the patient to Intensive Care, get a coffee and sit down to review any evidence on the topic.

You are called to attend an adult male in cardiac arrest. When commencing CPR your colleague notices pronounced cyanosis of the upper torso and queries whether this may indicate a pulmonary embolism.

A 75 year old man presents to A&E with a closed blunt head injury after a trip and fall on ice. He takes regular clopidogrel following a stroke a few years prior. He remains well including no signs of skull fracture, GCS 15, no focal neurological deficit, and no loss of consciousness or amnesia experienced. As per NICE guidelines for adult head injury, you could deduce that no further imaging is required. However, this depends on which medications the clinician considers ‘anticoagulation’ and the department you work in treats clopidogrel (but not aspirin) as such for head injuries and therefore a CT head was performed. You wonder if there is an increased risk of acute ICH in patients who take clopidogrel as opposed to aspirin monotherapy.

You are in the emergency department when a pre-alert arrives for a 70-year-old man who has become unwell over the last 3 days with shortness of breath, on a background of interstitial lung disease. He is requiring 15L of oxygen via a non-rebreather mask to maintain saturations of 94%. A rapid COVID-19 swab is negative. Your colleague mentions high flow nasal oxygen is available, but you are unsure when it is appropriate to initiate.

A 26-year-old patient presents to ED with a facial laceration following a drunken fall. After clearing them from a head injury perspective, you close the wound with six stitches. As you prepare for discharge, you wonder whether advising the use of topical silicone gel could improve cosmetic and symptomatic outcomes of the laceration.

A 24-year-old female has presented to the Emergency Department (ED) with a distal radius fracture. She refuses cannulation due to a needle phobia but remains in severe acute pain despite the use of oral analgesics. You are aware of the increasing off-license use of intranasal (IN) ketamine for acute severe pain and wonder if it provides as effective pain relief as intravenous (IV) opiates for this patient.

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 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.

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.