bestBETs

A 24 year old male presents to the ED in an acute sickle cell pain crisis. He is requiring increasing amounts of opioids to control his pain with little effect. You wonder if a subdissociative dose of ketamine may be effective to control his pain and reduce his overall opioid consumption.

A 47 year old female presents to the ED with a 6 cm superficial laceration on her forearm. She sustained the injury while cutting wood to build an outdoor patio set. She is very anxious and complaining of severe pain making it difficult to exam the entire wound or provide local anesthetic. You wonder how to proceed with irrigation and closure. Distraction methods are commonly used in paediatric emergency departments to ease anxiety and reduce pain perception in children undergoing painful procedures. Can distraction methods, specifically virtual reality, be effective in decreasing pain perception in adults undergoing painful procedures?

A 2 month old infant is admitted to hospital with 2 day history of fever, irritability and reduced feeding. A septic work-up including lumbar puncture is performed. CSF white cells are raised and culture confirms Neisseria meningitidis organism. The infant is appropriately started on antibiotic regime as per local anti-microbial guidelines. On day 2 of admission, the infant develops focal motor seizures. It is well established that infants with a diagnosis of meningitis are at risk of developing seizures. You wonder whether the infant should have been prophylactically started on an antiepileptic medication when the diagnosis of meningitis was confirmed.

Is anterior serratus nerve block a good analgesic choice for patients with rib fractures in Emergency Departments?

The Royal College of Obstetricians and Gynaecologists (1) reports that 11 pregnancies per 1000 are ectopic and that the maternal mortality rate from ectopic pregnancy is 0.2 per 1000. The Healthcare Safety Investigation Branch (2) found of the 12 maternal deaths in early pregnancy in the UK between 2009-14, 9 were related to ectopic pregnancy.

A 46 year old male presents with a 4 month history of 'tennis elbow'. He is wondering if there is any benefit from using of the elbow support?

A 22 year old man is brought into A&E having been stabbed. He has an isolated chest injury which requires a tube thoracostomy. There is a discussion as to whether administration of presumptive antibiotics will reduce the risk of intrathoracic infection in this patient.

A 23 year old woman attends your department having been kicked in the chest by her horse. On arrival, she is haemodynamically stable and complaining of right sided chest pain. Your examination reveals an isolated chest injury. You arrange a portable chest xray which shows a small, right sided, apical pneumothorax. Her observations are all normal and she has no respiratory distress. You wonder whether you can avoid inserting a chest drain, and manage this patient conservatively.

A 27 year old primigravida at 19 weeks gestation presents to the Emergency Department with shortness of breath and pleuritic chest pain. She is afebrile, has a respiratory rate of 28, a heart rate of 120 and oxygen saturation of 96% on room air. There is no evidence of leg pain or swelling. Her ECG is normal. Since imaging tests expose both mother and fetus to ionizing radiation, you wonder whether a clinical decision rule will allow you to safely rule out a pulmonary embolism.

You are part of a HEMS crew and are called to a 53-year-old motorcyclist who is reported to be not breathing after a collision with another vehicle. Ambulance crews are already on scene and have commenced advanced life support. An iGel is in situe and you consider upgrading this to an endotracheal tube. You note however that the patient has a cervical collar fitted and that his airway sounds contaminated. You wonder if using a video laryngoscope will aid in your intubation of this patient.

An 80 year-old male presents to the Emergency Department following a fall at home. The nurse reports that the patient is complaining of pain in his right leg, which appears shortened and externally rotated. You wonder whether you can use point of care ultrasound to establish whether he has a fractured neck of femur.

A 21 year-old man who has admitted with left dorsal hand injury with full thickness skin loss and exposed extensor tendons. It extended about half of the dorsum with dorsum of the whole index finger. 1-2.5 cm defect has noticed to the EDCs index and Middle finger. After through debridement one stage reconstruction has done using free ALT flap with fascia lata. Radial vessels were used as recipient vessels and dorsal hand cutaneous nerve was connected with lateral femoral nerve to neurotise the flap area at anatomical snuff box. Fascia lata has used to bridge the gap in extensor tendons. After two months of initial surgery a second operation was performed to debulk the flap as well as release of reconstructed extensor tendons. Post operative mobilization has started from the next day. After six month good extension of MCPJ and PIPJ noted to the reconstructed fingers with reduced sensation on flap territory compared to normal dorsal skin. (1)

33 year old male presented to the ED with pain around the Achilles tendon and decreased physical performance whilst training for a marathon. His symptoms had been gradually worsening as his training progressed, but now he was struggling to walk. He had seen a physiotherapist and was carrying out regular strengthening exercises. Furthermore, he had seen a podiatrist and now had specialised in-soles in his running trainers. You wonder if extra-corporeal shock-wave therapy (ESWT) conducted via referral is likely to improve his symptoms?

Headache is a common presenting complaint, but the incidence of subarachnoid hemorrhage is only about 9 per 100,000 patient-years. Is the Ottawa Subarachnoid Hemorrhage Rule a sensitive and specific clinical tool in predicting which patients merit further investigation with computed tomography?

A 6-year-old girl presents to the Emergency Department with two days of fever, mouth pain, and poor oral intake consistent with hand-foot-mouth disease. The parents ask you what they can do to maintain adequate oral intake while the patient is ill.

An 8 week old infant presents to the paediatric emergency department with a toe tourniquet formed from a hair thread. You struggle to unwind the thread but wish to avoid removing it via incision, and so consider the use of hair removal cream - but could it be effective?

A 15 year-old female presents to your emergency department after sustaining a scald burn from hot coffee. She has a mix of superficial partial thickness and deep partial thickness burns totaling approximately 15% total body surface area (TBSA). She was treated with cool water therapy (CWT) for 20 minutes in the field. You remember than CWT is recommended in first aid guidelines but also recall that not all experts are convinced of the value of the treatment. You decide to consult the literature to assess the benefits of CWT in acute burns.

You are part of the response team on route to a multi-vehicle road traffic collision. Initial reports state that one of the vehicles is an overturned minibus carrying 12 children, with all sustaining varying degrees of injury. Aware that you have limited clinical resources immediately available you consider whether a paediatric major incident triage tool would help to prioritise patients needing life-saving interventions.