bestBETs

A 48-year-old man with a history of pulmonary embolism (PE) and antiphospholipid antibody syndrome taking rivaroxaban presents to the ED with shortness of breath, hemoptysis, and pleuritic chest pain. Chest CT demonstrated multiple PEs. You wonder what is the incidence of recurrent venous thromboembolism (VTE) despite anticoagulation.

A 26-year-old male athlete presents to emergency department with a knee injury during playing basketball 4 hours ago. According to history and physical examination, anterior cruciate ligment tear is suspected with knee instability. You wonder whether an ultrasound scan is helpful in the diagnosis of anterior cruciate ligment rupture.

An 8 year old girl is brought to your emergency department after falling in the local park and sustaining a laceration across her cheek. The wound needs to be cleaned and sutured. You feel that she will require sedation in order to fully comply during the procedure, and have heard about dexmedetomidine which is already being used safely and effectively in sedation for painless procedures. You wonder if this agent will provide you with effective procedural sedation without increasing her adverse event risk.

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 14-year-old boy presents to the Emergency Department with abdominal pain that started 3 days ago and yesterday became more intense and moved to the right lower quadrant. He has decreased appetite, two episodes of emesis today, and low-grade fever.

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 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.

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 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?

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 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 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 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.

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.

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?