bestBETs

An 86 year old man is admitted to the respiratory ward with his third pneumonia in 6 months. A bedside swallow exam is abnormal however; no overt signs of aspiration / penetration are evident. The next available date for videofluoroscopy is in a week. We wonder if there is a sensitive predictor of silent aspiration that could be used at bedside. We have heard of cough reflex testing but wonder about its evidence base.

The Trust introduced a new blood collection system that stated the tourniquet should be removed prior to blood collection during routine venepuncture. You conducted a quick survey of staff that revealed all clinicians (apart from one nurse who had recently attended her venepuncture training) leave tourniquets in place throughout the blood collection phase. You checked the current Trust policy, which also states that tourniquets should be removed prior to blood sampling. No rationale for this instruction is given and you wonder why tourniquet removal is recommended in the Trust policy. You carried out a quick Internet search that seemed to indicate serum electrolytes (potassium in particular) can be affected if the tourniquet is left on during blood collection.

A 56 yo homeless man with a history of alcoholism and stroke is brought to the ED after he was seen sleeping on a park bench in the snow without shoes. He is rousable but 34 F [not sure about this - reads more like Celsius] and is clearly intoxicated with a blood EtOH of 0.22 mg/dL. After giving the patient initial re-warming treatment with warmed blankets, you notice his toes appear severely frostbitten. You know tPA therapy is absolutely contraindicated in this man, but wonder if something else will decrease the likelihood of this man’s toes being amputated.

Very few environments rival the complexity, unpredictability, acuity, time pressures and decision density of the Emergency Department (ED)1,2. Unsurprisingly it has been described as a natural laboratory for human error3. Despite the skills of the Emergency Physician in making decisions, an unacceptable number of decisions made in the process of medical diagnoses are wrong with error or diagnostic failure rate estimated to occur in 10-15% of decisions in the ED4. Expert opinions within Emergency Medicine have highlighted the role of cognitive debiasing strategies5 and cognitive forcing strategies6 to decrease the error attributable to cognition. The need to take all available steps to prevent error and harm from occurring has been highlighted as a moral and professional obligation in order to honour the ethical principles of beneficence, non-maleficence, fairness and justice7.

A 30-year-old male attends the Emergency Department with a dislocated shoulder, confirmed by plain film x-rays. This requires manipulayion and reduction under conscious sedation. You prepare your drugs, drawing up propofol. The patient however mentions that he had experienced some severe pain on the injection site during a previous sedation with a propofol. You remember one of your colleagues mentioning lidocaine use to prevent pain on propofol injection and wonder if there is any evidence for its use. 

A 4 year old boy comes in to the ED with 3 days of vomiting and diarrhea. Given the history and exam, you determine this child has gastroenteritis with signs of dehydration. His fingerstick blood glucose is 80 mg/dL (4.44 mmol/L). As the treating physician, you order a rapid infusion of intravenous saline with 5% dextrose. You wonder if the dextrose is really necessary.

A 30 year old male is brought to the emergency department following the ingestion of MDMA on a night out. He presents with a temperature of 41 degrees C, rigidity and severe agitation. He is diagnosed with serotonin syndrome and sedated with diazepam. Ice packing is used to attempt patient cooling, however his temperature continues to rise. You consider whether or not dantrolene would reduce the likelihood of patient mortality.

A 30 year old male is brought to the emergency department following the ingestion of multiple ecstasy pills on a night out. He initially presents with a temperature of 40°C, impaired consciousness and muscle rigidity. He is diagnosed with serotonin syndrome, sedated with benzodiazepines and treated with ice packs. However, his temperature continues to rise. You consider whether olanzapine or chlorpromazine would be beneficial for the patient.

A 30 year old male is brought to the emergency department following the ingestion of MDMA on a night out. He presents with a temperature of 40°C, rigidity and aggression. Following chemical restraint by diazepam, he is diagnosed with serotonin syndrome. As a your team attempt to manage his hyperkalaemic state, his temperature continues to rise and you consider whether or not administering cyproheptadine would reduce the risk of patient mortality.

A female patient presents at the emergency department, following the apparent ingestion of ecstasy in a night club. She appears confused and severely agitated, with tachycardia and a temperature of 40°C. The patient begins seizing, which is controlled with benzodiazepines, but as her temperature continues to rise, you consider which method may be best for cooling the patient.

A 66 year old man presents to emergency department with cough, shortness of breath and pedal oedema. Clinical examination reveals bilateral fine basal crepitations. You wonder if he has got pneumonia or cardiac failure. He has a background history of cardiovascular risk factors.

A 23 year old man went on a skitrip in an extreme cold and windy environment. He protected his face against cold injuries by applying of a protecting emollient, but he got frostbite in the face anyway. When arriving at the emergency department, he asks you whether the use of emollients isn’t a good protection against frostbites.

75 year-old-gentleman from the old age residential home presented with acute breathlessness since 2 hours ago. He has a background of COPD, IHD, HT and CVA. The patient was too symptomatic to volunteer any history. Only very limited information was obtained from the carer from the residential home. ABG showed type 2 respiratory failure. The portable CXR machine was still on its way. You wonder if any further useful information can be obtained from bedside lung ultrasound assessment to help you quickly decide the treatment plan in the high dependency unit.

A 55 year old female presents to the ED with the complaint of fever, chills, weakness. Upon presentation she appears pale Vitals are Temp 39, HR 105, RR 22 and WBC count 13,000. Given this patient meets SIRS criteria, will a procalcitonin level accurately diagnose serious bacterial infection?

A 69 year old man presents to the emergency department with epigastric pain that radiates to the back. He has been vomiting and has a fever. You suspect acute pancreatitis and wish to predict disease severity in order to start appropriate treatment.

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

An 18-year-old man presents to the Emergency Department having been bitten by his neighbour's dog three hours previously. He has a simple but ragged wound without signs of infection or inflammation. He is normally fit and healthy with no regular medications or allergies and has been immunised in accordance with the National Immunisation Programme (including five doses of tetanus immunisation). You wonder whether you should use simple wound care and irrigation alone or whether he should be discharged with prophylactic antibiotics, in conjunction with safety netting advice.

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?

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?