bestBETs

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 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 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 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 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.

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.

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?

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 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.

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.

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.

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.