bestBETs

An ambulance crew attends to a 46-year-old man who has presented in cardiac arrest. His presenting rhythm is VF and advanced life support (ALS) protocol is instigated. The patient remains in VF in spite of early defibrillation with escalated energy and intravenous amiodarone. Pad position is changed to anterior-posterior (AP) pads; and yet the patient remains in VF. He has now received 7 attempts at defibrillation and reversible causes have been optimised. Does escalation to double sequential defibrillation, initially though AP pads followed by anterior pads improve the chances of the patient regaining spontaneous circulation? Can this be extrapolated to in hospital atraumatic adult cardiac arrest?

At 22:40 the ambulance service operation centre receives a call for a 56-year-old patient complaining of chest pain and an ambulance unit is dispatched to the patient. On paramedic arrival, the woman is alert and orientated and shows no evidence of diaphoresis. She has no previous medical history. The chest pain had self-resolved 5 minutes ago. On examination, she has a clear airway, respiration is shallow, talking in complete sentences; lung sounds clear, skin warm and not clammy. The electrocardiogram (ECG) recorded on the scene shows benign early repolarization with no other abnormalities. There are no other pertinent findings. Her vital signs are: respiratory rate 20/minute, heart rate 65 beats per minute, oxygen saturation 96% in air, blood pressure 124/62. She stated that she suddenly could not catch her breath while stood up, then the chest pain started. She got dizzy, sat down, and called 999 but is now feeling back to normal. You are aware that the history, physical examination and ECG cannot be used to ‘rule out’ an acute coronary syndrome (ACS) alone. You wonder whether a point of care troponin test could help you to ‘rule out’ ACS without requiring transfer to hospital.

You are working in A&E and have just reviewed a patient with symptoms and clinical signs consistent with suspected acute appendicitis; you wonder whether there are any further clinical signs which may help your diagnosis and a referral to general surgery. You recall hearing of the speed bump sign from a colleague and wonder how useful this sign is in the diagnosis of acute appendicitis.

A 32 year old female with presents to the emergency department with an occipital headache and intermittent blurred vision for the past 3 weeks. D-dimer performed on admission is within normal range. Can you safely rule out cerebral venous sinus thrombosis?

A 66-years-old man is brought to the emergency department following a fall from his height. He has a score of 14 on the Glasgow Coma Scale and suffers from nausea. An initial Ct Scan is done showing a 4 mm subdural hematoma in the left frontal lobe. The emergency doctor decides to keep him in observation. The patient remains stable during the next eight hours but still complains about nausea. The doctor considers discharging the patient but is aware of case-reports about late clinical deteriorations. He wonders if a clinical decision rule exists to help him assessing the risk for his patient.

On a busy night shift, I was called to a cubicle because a patient had presented with epistaxis that had not responded to simple first aid measures. Visualisation of the bleeding point was difficult because of ongoing haemorrhage and that made cauterisation with silver nitrate impractical. I asked for a nasal pack and the nurse brought me a foam-based device, commonly known as “Merocel®”. The patient tolerated the insertion and expansion of this device extremely poorly, despite using 1% Xylocaine as anaesthetic. Although haemostasis was achieved, the patient required intravenous opioid medication after the procedure in order to alleviate their pain. I had previously used inflation devices known as Rapid Rhino® and I wanted to know if there was a significant difference in the two types of nasal packs in achieving haemostasis and which device is more comfortable for the patient.

A 28 week gestation baby is delivered by spontaneous vaginal delivery following prolonged preterm rupture of membranes of 6 weeks. He requires intubation and ventilation at delivery in view of respiratory distress and receives surfactant. He is transferred to the neonatal unit and is placed on volume guided ventilation, has a UVC and UAC inserted, receives antibiotics and is commenced on parental nutrition. His oxygen saturations are 80% in 100% oxygen. Despite increasing his tidal volume, changing to high frequency oscillation ventilation, repeating surfactant, and commencing inotropic support to maintain his blood pressure he still remains hypoxic. CXR shows the endotracheal tube, UAC and UVC in a good positions, the lungs look small and there is no pneumothorax. An echo shows pulmonary hypertension. Despite multiple inotropes and significant ventilator settings, he remains in hypoxic respiratory failure with an OI of 25. You wonder if inhaled nitric oxide would be of benefit.

Blood gas analysers are typically preset to assume a patient’s temperature is normothermic at 37 degrees centigrade. In clinical practice the temperature of the patient is infrequently taken at the time of sample or entered into the analyser. With emergency departments exposed to patients presenting with temperature extremes, you wonder whether the temperature entered into the gas analyser has a significant effect on results and subsequent clinical management.

A 45-year-old man presents to the emergency department with new onset abdominal pain, and the nurse asks you to quickly prescribe some paracetamol. You wonder if there is any difference in the analgesic effect by route of administration.

A 35-year-old male presents to the Emergency Department with an anterior abdominal stab wound (AASW). He is haemodynamically stable; you are unsure of the best method of investigation to detect significant intra-abdominal injury including hollow viscus perforation.

A child presents to the ED with distal fibular pain after a fall. The x-rays are negative for fracture, but the child still has significant pain despite analgesia. You suspect a Salter-Harris Type I fracture, but remember that your physical exam is not very specific for this injury; it could actually be a sprain. You do not want to immobilize this child without cause, so you wonder whether you can improve your diagnostic accuracy for a Salter-Harris Type I fracture with bedside ultrasound.

A 63-year-old gentleman with a history of hypertension comes to the Emergency Department complaining of sudden onset of right-sided weakness and slurring of speech 2 hours ago. You request an immediate non-contrast CT brain. However, you wonder if blood biomarkers could be used instead to diagnose a stroke, or more accurately, an ischaemic stroke.

A sixty year-old woman presents to the Emergency Department with a three-hour history of right sided hemiparesis. She has a past medical history of hypertension and myocardial infarction. Rapid evaluation and prompt initiation of thrombolytic therapy in acute ischemic stroke is extremely important for prognosis. Diagnosis of acute ischemic stroke usually relies on clinical grounds, after excluding hemorrhagic stroke by computed tomography. The availability of rapid and accurate diagnostic biomarkers to discriminate hemorrhagic from ischemic stroke would be helpful. Ideally, distinction should be made at pre-hospital triage, thereby directing patients to adequate centers for optimal care. We wonder if such biomarkers are present in the evaluation of acute stroke.

A 35-year-old male presents to the Emergency Department with an anterior abdominal stab wound (AASW). He is haemodynamically stable; you are unsure what the best method of investigation is to detect any significant intra-abdominal injury including hollow viscus perforation.

A 5 year-old boy presents to the emergency department with an acute exacerbation of asthma, with a tight chest and an oxygen requirement. He is followed up regularly in a paediatric respiratory clinic and is normally on a preventer inhaler. Along with back-to-back mixed nebulisers, you prescribe oral prednisolone, which he vomits 10 minutes later. The paediatric SHO says she has heard of a recent RCT that shows that a single dose of oral Dexamethasone is as good as 3 days of Prednisolone in the management of acute wheeze and you know from your own experience that oral Dexamethasone is usually well tolerated by kids presenting with croup. Given how often you see children vomit Prednisolone, you ask yourself whether the emergency department should switch to oral Dexamethasone instead for childhood wheeze?