bestBETs

A 45 year old man (Mr X) sustained significant trauma in a road traffic accident (RTA). From clinical examination and a trauma series CT scan Mr X is diagnosed with grade 3 liver and splenic injuries. Mr X is haemodynamically stable and has no evidence of ongoing bleeding, initial plan is to manage the patient non-operatively. Mr X is in significant discomfort and is not mobilising from bed, you wonder about the safety of prescribing low molecular weight heparin (LMWH) venous thromboembolism (VTE) prophylaxis.

A 40-year old female known pulmonary aspergilloma in the left upper lobe is scheduled for surgical resection.The patient questions which is better,VATS or Thoracotomy?

A 41 year old male presented to the emergency department with a 48 hour history of increasing erythema, swelling, and pain over his left lateral thigh. On examination you note a 4 cm area of erythema with associated fluctuance and induration. The decision is made to perform an incision and drainage, and you wonder whether irrigation of the abscess cavity would improve patient’s outcome.

A 50-year old patient presenting to ED falls in the department and sustains fracture of the wrist. What steps could be taken to reduce the number of falls in patients presenting to the ED/CDU?

When faced with a trauma patient in a prehospital setting there has been numerous looks into the use of blood products. The practice of prehospital transfusions has been revitalised by recent military conflicts and has been shown to increase casualty survival leading to a resurrection of military prehospital blood product (PHBP) resuscitation. This has began to apply in a civilian setting with increasing focus on the use of blood and blood products during prehospital trauma. However, when faced with a pre-hospital trauma situation there any prospective and comparative data to support giving blood or blood products over the current standard practice of crystalloid fluid resuscitation?

A witnessed non traumatic out-of-hospital cardiac arrest occurs in your neighbourhood and the paramedics are rapidly called on scene. Basic Life Support (BLS) guidelines are applied and ventilation may be necessary at this point.

A pregnant female presents to the emergency department with repeated episodes of vomiting. She has not used any medications at home for relief. She has been unable to tolerate fluids. While a nurse prepares to place a peripheral IV, you begin to wonder if ondansetron or metoclopramide would be more beneficial for a pregnant woman with vomiting.

An 11 year old male presents to the emergency department after jumping for a rebound at basketball practice. He falls to the ground striking his head against the floor. He briefly loses consciousness and comes to emergency department with repetitive questioning, vomiting, and complaining of headache. You order a head CT which is unremarkable, symptoms improve during a brief observation period, and as you prepare for discharge the patient’s parents question about returning to physical and cognitive activities.

A 60 year old male suffering from low back pain and numbness in the posterior thighs, has been found to have a low grade spondylolisthesis at L5-S1. You wonder if a course on core staability exercises would help to improve pain and function.

A 41-year-old male with a past medical history of symptomatic paroxysmal atrial fibrillation (on metoprolol), hypertension, diabetes, morbid obesity, and chronic alcoholism was BIBA to the ED for palpitations and light-headedness that started one hour prior. Electrocardiogram and labs showed atrial fibrillation without RVR and ST changes, and a normal CK, troponin level, and chemistry panel. The patient claimed to be adherant with all medications and was on the maximum dose of metoprolol. He last ate a large meal one hour ago. The patient claims that flecainide, propafenone, amiodarone, and procainamide have been ineffective in the past for cardioversion and that he does not want to try any of them again. In an attempt to cardiovert this patient back to normal sinus rhthym, you wonder if ibutilide should be used.

A 28 year old patient with a past medical history of type II diabetes and irritable bowel syndrome currently taking a SGLT-2 inhibitor for his diabetes presents to the Emergency Department with the chief complaint of nausea and vomiting with associated fatigue. The patient is evaluated and treated for their nausea and vomiting. The patient continues to have intractable vomiting despite conventional therapy. On laboratory evaluation they are found to have a blood sugar of 162, pH of 7.2, elevated betahydroxybutyrate and large ketones in the urine.

-A 35 y/o male presents to the ER following a low speed MVA. Patient was a restrained driver hit on the front passenger side while turning into a parking lot. He had no LOC and was able to ambulate following the accident. He presents with chest pain on the right and pain with inspiration. Patient is GCS 15 on arrival with HR 88, BP 145/75, RR 18, O2 sat 97% RA, T 37.

A 75-year old man is referred to you for elective cardiac surgery. He has already been taking simvastatin for many years. You know that preoperative statin therapy improves post-operative outcomes in statin-naive surgical patients. You consider whether you should prescribe him additional preoperative statin doses in an attempt to recapture this benefit. To answer this question, you carry out a literature search for the evidence.

A 25 year old man comes to the ER with an injury to his right ring finger. It is a Monday and the waiting room is full, you wonder if there is a way to diagnosis nailbed injury without removing the finger nail.

You are part of an EMS crew dispatched to the scene where a construction worker has fallen from a rooftop onto the concrete below. He was initially reported as combative when a basic life support crew arrived, and they now report that he has just lost vital signs. You quickly think about your ATLS approach to the trauma patient and wonder if a finger thoracostomy would be effective and safe in this environment to rule out tension pneumothorax as a cause of his arrest.

It is Friday evening and a 2-year-old child presents to the ED with colicky abdominal pain. The ultrasound technician has left for the evening and no ultrasound imaging will be available over the weekend. You wonder whether you can use a fecal occult blood test to rule out intussusception in this patient.

A 68 year-old male is brought to the emergency department with tachypnea (32 breaths per minute), tachycardia and a core temperature of 39.2°C. He complains of a progressive back pain since 3 days and recently noticed hematuria. In the emergency department, his systemic arterial blood pressure is 80/56 mm Hg and his heart rate 136 beats per minute. You suspect a severe sepsis from an acute pyelonephritis. To restore the blood pressure, you administer a first bolus of intravenous crystalloid. To guide your fluid therapy, you wonder if bedside lung ultrasound will help you assess the interstitial fluid status of your patient to avoid over-hydration.