bestBETs

A 40 year old male has been diagnosed with an anterior shoulder dislocation following a fall. Is inhaled Methoxyflurane a safer, more practical and efficacious drug to use for pain control before and during the reduction when compared to nitrous oxide?

A 75 year old female patient presents by ambulance to the Emergency Department after a fall from standing on to her left hip. On clinical examination she is unable to straight leg raise and cannot weight bear. You suspect a fractured neck of femur. Plain radiographs of her pelvis and hip are inconclusive. You remain suspicious for a hip fracture. Is CT or MRI the next most appropriate imaging modality?

An 18 year old presents with partial thickness burns over the feet, with a self-reported pain score of 7/10 and a significant fear of needles. Adequate first aid has been provided already and burns covered in clingfilm. All of the cylinders of Entonox are currently being used by other patients in the Emergency Department. You've been told the ED has acquired 'the green whistle' device for inhaling methoxyflurane but haven't used it in clinical practice, and wonder how good it is in comparison to Entonox?

A 17 year old female has presented to the Emergency Department after taking forty 500mg tablets of paracetamol. Her 4 hour plasma paracetamol levels are above the treatment line. However, she is needle-phobic and refusing intravenous treatment. You want to treat her with an oral antidote and wonder if oral N-acetylcysteine is as effective as intravenous.

You are the emergency department duty doctor for resus, and an ambulance pre-alert is given for a patient with potential airway burns from a house fire. Whilst preparing for patient arrival, a non-rebreathe mask is set up, but a colleague suggests using high flow (>15lpm) humidified oxygen therapy which isn’t immediately available in your department. You consider whether this should be used as first line treatment?

You are the emergency department (ED) duty doctor for resus, and get a pre-alert from the ambulance service about a patient with massive haemorrhage from a groin gunshot wound whilst eating in a fast food shop, ETA 5 minutes. RR30, HR 55, NIBP 40/palp, GCS of 5 with E1 V2 M2, no other vital signs given. Having placed a trauma call and activated the major haemorrhage protocol, rapid sequence intubation drugs are being drawn up. You note the last time a patient similar to this attended in a peri-arrest state, they arrested at induction despite markedly reduced doses of ketamine, keeping with your concerns about a patient who has used up most of their endogenous catecholamine stores. Etomidate isn’t stocked, and you wonder if faced with the same situation, and if you can’t improve haemodynamics more, whether you would consider a suxamethonium-only (with the intent of induction and maintenance of anaesthesia after endotracheal tube secured) intubation?

You are the emergency department (ED) duty doctor for resus, and get a pre-alert from the ambulance service about a patient with a witnessed fall at home, who is anticoagulated with warfarin. Injuries suggest intra-abdominal bleeding and observations indicate haemorrhagic shock. Whilst preparing to receive the patient you consider whether use of PCC, which is established practice in your ED, could be brought forward safely to the patient in the pre-hospital phase of their care, and how much time could this bring PCC forward by?

An 18 year old male presents to the emergency department with unilateral testicular pain and swelling. You are unsure whether you can safely discharge or whether he requires further urological work up for testicular torsion.

A 67-year-old female presents with pain in a dermatomal distribution in an area of a healing rash. She was recently diagnosed and treated for Shingles. She would like to avoid oral narcotics and medications that make her “sleepy” and is wondering if there are any effective topical applications.

You are an Emergency Medicine (EM) Registrar seeing a patient with a sore throat and have a plan to discharge home without formal follow-up arranged. However, you wish to rule out supraglottitis as a differential. It’s changeover day and the current Ear, Nose and Throat (ENT) junior doctor hasn’t been trained in Flexible Nasal Endoscopy (FNE) and there is no senior support on site. FNE is not in your current or previous skillset. A new EM junior doctor, having just rotated from ENT, offers to assist in performing FNE. Whilst taking them up on the offer, you wonder if FNE should be part of the skill set of an EM Registrar?

The patient is a 40-year-old obese but otherwise healthy woman with history of recent knee surgery 1 week ago who presents to the ED with shortness of breath that began suddenly 4 hours ago. You suspect pulmonary embolus with her presentation but, due to her body habitus, intravenous access cannot be established. As you prepare to place a central line, a colleague suggests using an IO catheterization device for administration of iodinated contrast media.

A 48-year-old male presents to the emergency department (ED) with a left ankle injury. X-rays showed no acute fracture. The patient has a history of chronic alcohol abuse, hepatitis C, opioid abuse, and gastric ulcers. Therefore, he is unable to take acetaminophen, nonsteroidal anti-inflammatory drugs (NSAID), or narcotics.

A 24-year-old healthy male presents to the Emergency Department with a two-day history of sore throat. He does not complain of cough or other respiratory symptoms. On examination he is feverish (38°C), with exudate on his tonsils and tender cervical lymph nodes. His sister had been seen the day before (by a different doctor) with the same symptoms and was prescribed antibiotics immediately.

You are the emergency department duty doctor for resus, and a known epileptic with a BMI of 34 is now-post ictal and you have decided to place him in the recovery position. A colleague (who has recently been on an obstetric resuscitation course) asks which side you wish to roll him over on to, and whether the non-pregnant patient is at risk of supine hypotensive syndrome?

A 26-year-old multiparous female presents to a rural emergency department. She had a precipitous delivery on her way into the hospital. On arrival in emergency department, she is having a significant amount of vaginal bleeding and is beginning to become symptomatic, though her blood pressure is currently stable. You contact Obstetrics, obtain labs and blood type and cross, and begin uterotonics. You wonder if adding tranexamic acid will improve this patient’s outcome.

A 6 year old boy with an angulated forearm fracture presents to your ED. You feel he is a suitable candidate for procedural sedation. Your department’s policy for procedural sedation is IV ketamine 1-2mg/kg. You know that one of the recognised side-effects of ketamine is vomiting and you wonder whether giving prophylactic ondansetron would reduce his chance of vomiting.

A 25 year old female presents to the emergency department with a complaint of yellow vaginal discharge for the past week after having unprotected sex. She is afebrile with normal vital signs and has no history of sexually transmitted disease (STD) in the past. You tell her that vaginal swabs need to obtained to test for gonorrhea and chlamydia and she asks if a speculum exam is really necessary for this test.

A 55-year-old male presents to the Emergency Department following a fall down the stairs while intoxicated. He suffers immediate onset tetraplegia with a high sensory level to his upper chest. He remains alert and a CT confirms a fracture dislocation at the C5/C6 junction with retropulsed fragments into the spinal canal. You site an arterial line while he awaits spinal orthopaedic review, but at present there is no sign of neurogenic shock and his mean arterial pressure (MAP) sits at 60. A colleague asks if you are planning to start vasopressors and aim for a higher MAP target in order to reduce the ischaemic penumbra. You nod sagely, then sneak off to a computer to google the word penumbra which you have heard before but never remember exactly what it means. While at the computer, you wonder if there is any actual evidence to support the idea of induced hypertension to improve outcome in traumatic spinal cord injury.

A 30-year-old male presents to Emergency Medical Services with a Richmond Agitation-Sedation Scale of + 4 after reported use of intravenous amphetamines. A preliminary diagnosis of Excited Delirium Syndrome (ExDS) is made based on the history obtained and the decision is made to chemically sedate the patient. Whilst preparing for sedation, you wonder which pharmacological agent will produce the fastest and safest sedation in this patient population.

We routinely use EQ-5D as a patient experience based outcome for our stroke and neuro service but is it a valid measure for our service? Neurology was considered to be too wide an area and therefore we narrowed the question to stroke. We did not restrict the question to community dwelling patients as it was felt this would restrict the search.