bestBETs

You are a midwife looking after a low risk primigravida in labour. How do you support her in preventing perineal tears of any grade?

A 45 year old male patient was referred to community physiotherapy via his GP with a diagnosis of Grade 2 knee OA confirmed by x-ray. The patient is very fit and active and previously ran four times weekly. The patient is worried about worsening of his OA and asked whether continued running would cause disease progression of his OA.

A 14 year old boy was brought to the emergency department in cardiac arrest following a single stab wound to the chest. The team performed an emergency thoracotomy but unfortunately were unable to resuscitate the boy and he was declared dead in the department. Following this the large family who were present became very distressed and emotional scenes continued for many hours. Due to the nature of the event there were large numbers of staff present who found the event very traumatic and discussion around the clinical decisions made continued for many days after. Following this event it was noted that some staff requested to not be placed in the resuscitation area and there were concerns that it increased sickness in the department.

You are evaluating a pediatric patient in the emergency department in whom you are considering the diagnosis of acute community-acquired bacterial meningitis. You perform a lumbar puncture and when ordering CSF studies wonder if sending a CSF lactate would help distinguish acute bacterial meningitis (ABM) from acute viral meningitis (AVM).

A 37 year old man presents to the emergency department with a cough and feeling generally unwell. He has signs of sepsis with a high; temperature, pulse, lactate and respiratory rate. He is assessed in triage and taken to the resuscitation room. He has a history of alcohol excess and known cirrhosis of the liver. He has some diffuse crackles at his left base but no clinical changes on his chest x-ray. He has a soft but distended abdomen, with known ascites, which he feels has increased in the last 48 hours. He is treated for sepsis of unknown origin and transferred to the acute medical assessment area. Within 24 hours he has deteriorated, he is not accepted for intensive care due to his high child-Pugh score and after 12 hours of fluids and antibiotics he has a cardiac arrest and dies. The post-mortem report concludes spontaneous bacterium peritonitis as the cause of death.

A 14 year old girl is admitted to the Macmillan Cancer Centre for a cycle of MAP chemotherapy. She has recently undergone limb salvage surgery for a distal femoral tumour and is now undergoing rehabilitation and struggling with being unable to do activities which she found easy before, this in turn is impacting on her mood and quality of life. You wonder if there is evidence to support the use of cycling to aid return to function and improve quality of life after surgery

A 75 year old man has a right fem-pop bypass to improve critical limb ischaemia, should he be referred to an exercise programme to reduce the risk of needing further surgery and improve his function?

Whilst working in an Emergency Department an adult patients attends and is assessed at triage as having sepsis. The patient receives prompt appropriate treatment. Does the initial triage affect their outcome?

You are working in A&E and review a patient with suspected poisoning or overdose, you are unclear of the identity of the substance so can not yet confidently consult the local toxicology database but are aware of the occasional need for intubation in such patients to maintain a safe airway and oxygenation. You wonder if there are any other clinical risk factors or predictors indicative of need for endotracheal intubation in poisoned patients which you could use to support your decision to intubate or not.

While working the evening shift, a 45 year-old man presents to the emergency department with a progressive erythematous and swelling area on his leg. He is afebrile with unremarkable vital signs. The physical exam is suspicious for underlying abscess, as there is a fluctuant and localized pain. Before you proceed to drainage, you wonder if a bedside ultrasound of the soft tissue might help you to better assess the presence or absence of abscess to avoid unnecessary procedure.

A 22-year-old football player presents with a soft tissue injury to the ankle sustained earlier that same day while training. You suspect he has injured the anterior talofibular ligament (ATFL), but the acute clinical picture is confusing because of pain and swelling. You have access to diagnostic ultrasound (USS) to assess the integrity of the lateral ligament complex and want to know if this will give you an accurate diagnosis comparable to that of MRI.

A 65-year-old man is found by passers by on a riverside path. He is unresponsive and not breathing. The bystanders ring 999 but do not attempt CPR. The patient has persistent asystole, no return of spontaneous circulation, and is declared dead. Would DA-CPR, or coaching from another trained third party have increased the odds of a favourable outcome?

A 13-year-old girl with a shoulder dislocation presents to your ED. You plan to reduce it using ketamine sedation but know that ketamine can cause emergence phenomenon in this age group. You wonder if you should use prophylactic midazolam to reduce the risk of this side effect.

A 50-year-old male presents to the Emergency Department with suspected carbon monoxide (CO) poisoning following an attempted suicide. He is haemodynamically stable; but is noted to have mild confusion and you are unsure if he requires admission for further monitoring or hyperbaric oxygen (HBO) therapy.