bestBETs

A 70-year-old man presents to the ED with acute chest pain. His ECG shows ventricular paced rhythm with left bundle branch block morphology. You are aware that the Sgarbossa criteria could be used to diagnose acute myocardial infarction (AMI) in this context1 and that the modification to those criteria proposed by Smith et al 2 could improve diagnostic accuracy. You wonder if the same criteria can be applied to diagnose AMI in patients with ventricular paced rhythm.

A man aged 21 years presents to the ED with a 3-day history of increasing redness, swelling and pain in his right thigh. On examination there is an area of fluctuance, approximately 3 cm in diameter, with associated tenderness, on the right anterior thigh. Erythema extends approximately 1 cm beyond the edges of the fluctuance. As the emergency physician, you incise and drain the abscess. You wonder whether a 7-day course of trimethoprim-sulfamethoxazole is really necessary in a healthy person, despite the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infections.

You are reviewing urine culture and sensitivity results in your ED. You come across a result growing a germ that is sensitive to ciprofloxacin only. You contact your patient to come and collect a prescription later in the day. Your colleague who has been listening to your phone conversation warns you of the increased risk of tendinopathy in patients taking fluoroquinolones. You wonder if this is just anecdotal. You decide to search and review the current literature to see if any evidence substantiates this risk at all.

A 27 year old professional footballer sustains a structural right hamstring injury during a match. A visiting club official says that in his country, PRP injections are used to bring a quicker return to field based activities (including match play) in addition to a traditional rehabilitation protocol. You decide to find evidence to support his view.

Your trauma patient rolls through the door. The blood pressure looks good and there does not appear to be any chest injuries. Disappointed, you put your new thoracotomy shears back in your pocket. You brighten up when you realise the patient has sustained a serious head injury and will need intubating. As you brandish your prefilled syringes of ketamine and rocuronium towards the patient the anaesthetist on the trauma team starts reading from the rapid sequence induction (RSI) checklist. Rolling your eyes, you point out that this is major trauma, not a Friday morning elective cholecystectomy and demand that they proceed with the intubation immediately. Anyway, you have already given the ‘ROCKET’ induction while you have been talking, so they better start doing something fast… Later, while pulling on your lycra shorts and downing a seventh can of Monster energy drink, you reflect on the case. Initially, you are clear that the SpO2 of 65% for a few minutes was unavoidable. Then you remember that the suction was found not to be working initially, the first laryngoscope failed and your plan B consisting of ‘get out of my way and let me do it’ seemed a surprise to everyone. You experience an unfamiliar twinge of self-doubt, and decide to read up on this checklist business after crossfit later…

You are put on standby by the paramedic emergency service for a cardiac arrest in a 2-year-old boy hit by a car. As you send for the ‘CPR step’, you wonder whether you really should give chest compressions as per ALS-teaching or whether they are ineffective in hypovolaemic or obstructive shock due to trauma (as recent opinion has suggested).

A 44-year-old diabetic male is diagnosed in the emergency department with acute pericarditis following a viral illness. He is allergic to nonsteroidal anti-inflammatory drugs. You wonder about the safety and efficacy of colchicine as stand-alone therapy for the prevention of recurrent pericarditis.

A patient in your ED requires endotracheal intubation due to respiratory failure, refractory to non-invasive ventilation. The patient is preoxygenated with non-invasive ventilation on 100% oxygen prior to anaesthetic induction and until apnoea. During the intubation attempt, the oxygen saturation falls significantly. This leads you to consider if additional strategies alongside optimised preoxygenation may have provided more time before desaturation during apnoea. You decide to search and appraise the currently available literature to see if the use of the so-called apnoeic oxygenation would delay critical desaturation.

A 72 year old male presents to the emergency department with pulseless ventricular tachycardia. You wonder if a precordial thump is effective in restoring the heart to a sinus rhythm?

A 33-year-old patient presents to ED with a 5 mm calculus in the right distal ureter. You heard about a new type of medical expulsion therapy, tadalafil, which supposedly has a high ureteral stone expulsion rate as well as significant pain control. You wonder how it might compare to α-receptor blockers, such as tamsulosin or silodosin.

A 30-year-old male involved in a high-speed motorcycle accident is attended to by a prehospital critical care team. On scene the patient is moribund and in a shocked state. As the reversible causes of shock are addressed you wonder if resuscitation with blood products rather than crystalloid would improve the patient's chances of survival. Major haemorrhage protocols are used in hospital and intuition would suggest potential benefit if these protocols were administered at the point of injury, in order to reduce the later incidence of coagulopathy.

A 74-year-old male presents to the emergency department with out-of-hospital cardiac arrest. Paramedics administered epinephrine prior to arrival to the hospital. The patient is unresponsive but has a faint pulse. You wonder about the long-term benefits of epinephrine which is still recommended by the American Heart Association.

A 4 year-old child presents to your local ED with respiratory symptoms and fever. In order to confirm your suspicion of pneumonia, you plan to order a chest radiograph, but a quick look into the child's medical record shows he has already undergone several X-rays in the last few years for the evaluation of upper respiratory tract infections. Being aware of the potential long-term effects of radiation on your patient, you wonder if bedside lung ultrasound could be used to diagnose pneumonia.

An 8 year boy with coeliac disease has eaten a biscuit at a friends birthday party. His mother has brought him to A+E because she has read on a coelaic disease support forum that charcoal can reduce the risk abdominal pains and diarrhoea.

A busy emergency department has a long list of patients in the waiting area and several patients have recently arrived on trolleys from the ambulance service. There is pressure to get patients seen and either discharged or admitted as soon as possible. You wonder if asking the triage nurses to determine whether they think each patient will need admitted will speed the process along by allowing earlier booking of inpatient beds.

An 8 year old child is brought the emergency department following a high speed road traffic collision. He was unrestrained in the vehicle and has evidence of head trauma. He arrested at the scene and on arrival has undergone 15 minutes of CPR, has fixed pupils with no pulse and asystole on the cardiac monitor. Is it appropriate to stop resuscitation?

You are the most senior doctor in the Emergency Department when you receive an alert call from the pre-hospital medical team. They are bringing an 8 year old boy who was a pedestrian struck by a bus. He is displaying signs of hypovolaemia due to suspected ongoing internal bleeding, with tachycardia and hypotension despite fluid resuscitation. You are concerned that he is at risk of cardiac arrest, but are unsure of the optimal method of identifying cardiac arrest in such patients to help you decide when to start your traumatic cardiac arrest protocol.