bestBETs

A 29-year-old pregnant lady at 26 weeks of gestation, attends to the Emergency Department with painful swollen leg. An ultrasound evaluation showed no evidence of deep vein thrombosis, she was subsequently discharged with analgesics. She returned 5 days later with severe respiratory distress and an evaluation by CT PE showed bilateral pulmonary embolism

A 49-year-old female is brought to the emergency department via ambulance with left-sided facial droop, right tongue deviation, reduced sensation on her left side with pronator drift. Her symptoms were first noted shortly after waking; Can DWI/FLAIR mismatch MRI be used to identify the time of stroke onset for potential tPA treatment?

In the ED this intervention is usually required in the critically unwell patients who may well be hypotensive, tachycardic and distressed. Such physiology often results in poor peripheral perfusion and, in conjunction with an often pressured environment, can only increase the level of difficulty associated with an already challenging procedure. Dr Ian Sexton-Examining The Role of Ultrasound in The Placement of Radial Artery Catheters 5 Ultrasound (US) is becoming increasingly entwined in the delivery of critical care in the ED and has been incorporated in EM training for a number of years. The use of US in establishing central venous access is established best practice in the UK, improving both performance and safety. Perhaps the same applies to US in the placement of arterial catheters?

You are working in the Emergency Department and it is 0200h on Sunday morning. You review a 65 year old gentleman with severe atraumatic foot pain, particularly over the 1st metatarsophalangeal joint. He is overweight, with a history of hypertension and ischaemic heart disease, and you diagnose gout. Medical school knowledge tells you he needs colchicine, although a quick look at the British National Formulary suggests it can be toxic in higher doses (plus how will he get hold of this before Monday?). You review international guidelines which recommend non-steroidal anti-inflammatory drugs (NSAIDs) as first line treatment, but his co-morbidities may preclude their use. You see that systemic steroids are also recommended, but you wonder if they will work…

A 65 year old male presents to the emergency department with new onset dyspnea. He has no prior history of congestive heart failure. Bedside lung ultrasound is preformed by the emergency physician and found B lines in multiple lung zones. The question is how accurate is bedside lung ultrasound in the diagnosis of acute heart failure?

A patient arrives in your resuscitation bay in respiratory distress with a background of chronic obstructive pulmonary disease. After administering standard medical therapy, and controlled oxygen the patient remains in respiratory acidosis. Non-invasive ventilation is instituted, but the patient continues to be acidotic and deteriorates. The patient is prepared for rapid sequence induction and mechanical ventilation, but you wonder if there is an alternative?

A 39-year-old female with acute behavioural disturbance was brought to the emergency department by police. She was intoxicated with alcohol, agitated, very abusive, spitting on others, and presented a physical threat to other patients and hospital personnel. Her relevant medical history was not known and it was not possible to take vital signs. She was physically restrained by five hospital security guards. You are concerned about the patient’s airway because of physical restraint, the possibility of cardiovascular instability and metabolic derangements, and about the safety of the emergency department environment. You wonder whether ketamine is an appropriate first drug of choice in this setting.

A mother of an 8-year-old child asks if there are glasses can help with her son’s shortsightedness progression.

You are a mountain medic as part of an expedition trekking the Annapurna Circuit in central Nepal and you have just delivered a speech on altitude sickness. One of the trekkers has been given Ginkgo Biloba extract and told that it is effective at reducing the risk of altitude sickness. You are asked if this is true and if it is effective as prophylaxis against acute mountain sickness.

A 48 year old male presents to the emergency department with a history of 45 minutes of palpitations. He is otherwise well and his only past medical history is of paroxysmal SVT. His ECG confirms SVT on this occasion. You are going to attempt the valsalva manoeuvre and wonder whether the patient should stay sitting or whether the trendelenburg position would be better.

A 60-year old gentleman is brought into the Emergency Department with an OOHCA. All monitoring is attached whilst ALS protocol is ongoing, including CO2 monitoring. You want to assess whether the patient is going to survive and thereby achieve a return of spontaneous circulation (ROSC) and you wonder whether the patient’s ETCO2 level can prognosticate this.

A previously fit and well 36 year old male returns from a holiday to Greece 48 hours ago and presents to the Emergency Department complaining of headache, malaise and feeling generally unwell. While waiting to be seen, the patient’s headache rapidly worsens, he spikes a high temperature of 38.9 ̊C, becomes increasingly agitated and starts vomiting. He is taken to a resuscitation cubicle and has a heart rate of 135 bpm and blood pressure 71/45 mmHg. Examination of the patient reveals several small non blanching petechiae. You manage the patient as suspected meningitis and commence appropriate sepsis management. After 3 litres IV fluid the patient remains with a systolic blood pressure less than 80mmHg. The intensive care doctor informs you that they are trying to make a space available in the ITU for this patient but are struggling to step anyone down and the patient must remain in the resuscitation department. The resuscitation nurse asks you to prescribe more fluid. You wonder whether a peripheral metaraminol infusion would be more effective at increasing arterial pressure and maintaining organ perfusion.

A 45 year-old women presents to your Emergency Department with right elbow pain after accidentally falling on her outstretched hand. Her elbow examination reveals a slightly limited flexion and extension and significant pain during pronation and supination. On palpation, the pain is limited to the radial head. The skin and neurovascular exam are normal. Given that the elbow x-ray does not show a fracture or frank effusion, you wonder if ultrasound can be used to confirm your suspicion of radial head or neck fracture.

A 4-year-old boy presents to your local ED with a 72-hour history of mild fever and cough. While you order a CXR to confirm your suspected diagnosis of pneumonia, you remember that the radiology department of your hospital has introduced a policy to limit children radiographs to a single frontal view. You wonder if the omission of the lateral view will risk missing an infiltrate on your patient's X-ray.

An 8-year-old girl presents to the paediatric ED with palpitations. She is not distressed, and has a normal BP, but her pulse is 200 beats per minute. An ECG reveals supraventricular tachycardia. If she were an adult, you would try the posturally modified Valsalva manoeuvre and then reach for the adenosine, but you wonder what evidence there is for this or other vagal manoeuvres in children and, indeed, what evidence there is for the use of adenosine.

A 5-year-old boy presents to the ED after falling off his skateboard, onto his left arm. He is complaining of forearm pain and is unable to move his left arm. He is very tender to palpation at the middle to distal aspect of his left forearm and edema is noted. You concerned about a radial or ulnar fracture and wonder if ultrasound can be used to exclude a fracture.

A 74-year-old woman presents to the emergency department following a fall. She can’t remember how she fell, but thinks she must have just tripped over. You want to perform the necessary initial investigations and predict her risk of subsequent falls before she is discharged.