An 84 year old man presents to your Emergency Department with septic shock. He has a long list of medications, but you learn from his medical notes that he is normally independent at home. You need to decide what level of intervention is in this patient’s best interests. What factors should you consider in order to institute an appropriate ceiling of treatment for this patient?
A 78 year old male patient was undergoing an urgent cardiopulmonary bypass operation after a coronary angiogram revealed severe triple vessel disease. He also suffers from multiple co-morbidities and his ECHO revealed an ejection fraction of 25%. The cardiothoracic registrar suggests using a levosimendan infusion instead of an intra-aortic balloon pump. You wonder whether there is any evidence for this treatment.
You note that international guidelines recommend the use of chewable aspirin for patients with acute coronary syndromes (1). This conflicts with your personal experience of using soluble aspirin. You wonder if there is any evidence to suggest that chewable aspirin leads to faster inhibition of platelet function than soluble aspirin.
Laser therapy in the treatment of acute hamstring muscle injuries.
A 23 year old patient presents with a two day history of an acute grade 2 hamstring tear which occurred toward the end of the first half of a football match. The patient has been using the standard protection, rest, ice, compression, elevation (PRICE) acute injury management regime and referred for physiotherapy. You plan to begin an active exercise based rehabilitation programme following day 5 post injury. You have heard from a colleague who works in sports medicine that application of localised laser therapy can help improve pain, function and the quality of the repair site, and therefore wonder if it should form part of your treatment plan.
Antithrombotic treatment for isolated distal deep vein thrombosis
A 45-year-old woman attends the emergency department with a painful and swollen right calf. Her Wells score is low risk, but a d-dimer returns over the cut point for your local assay. Whole leg ultrasound examination later that day confirms a thrombosis of the posterior tibial and peroneal veins. She has no other medical history but you cannot identify a clear provoking factor for the thrombus. She is worried and symptomatic. A colleague reports to you that he does not treat any below knee DVT’s, as the NICE guidance supports above leg scanning only and he believes that the sensitivity and specificity of whole leg ultrasound are too low to be of clinical value. You are concerned about the idea of leaving an unprovoked isolated distal deep vein thrombosis (IDDVT) untreated in a patient who is symptomatic. However, you also worry about anticoagulation related bleeding. You decide to consult the literature to guide your decision-making.
A 16 year old male is brought to the emergency department with altered mental status, dry skin, dilated pupils, tachycardia and a core temperature of 40,2ºC. He is mildly agitated. His mother found him lying on the floor of the basement. Although she isn’t aware of him taking any drugs, a small bag of Datura stramonium seeds was found next to him. His EKG shows sinus tachycardia without QRS widening. You suspect an anticholinergic poisoning, and wonder if giving physostigmine would be beneficial for the patient.
Utility of ultrasound in the diagnosis of shoulder dislocation
A 30-year-old man with a history of remote shoulder dislocation presents with left shoulder pain and decreased range of movement after quickly reaching for the telephone. There was no direct trauma and the clinician is wondering if a shoulder radiograph is necessary.
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 42-year-old female with a diagnosis of fibromyalgia is assessed by a physiotherapist in an out-patient department. The patient is presenting with widespread pain, which is impairing her function. You wonder whether acupuncture is an effective treatment to use with your patient to decrease pain.
A 72-year-old man who is otherwise fit and well and on no regular medications presents to the emergency department (ED) with epistaxis that is ongoing despite appropriate first aid measures. No visible bleeding points can be seen on examination to allow cautery. After explaining treatment options to the patient, he states that he is very reluctant to have nasal packing because he once had it before and it was very uncomfortable and he then had to be admitted overnight, which he does not want. He is also concerned that after that admission he went home only to start bleeding again two days later. He wants to know whether there are any alternatives. You have heard of people using tranexamic acid to stop epistaxis but you are not sure whether this was topical, oral or intravenous and you do not know whether there is any evidence to support this …
A confused patient presents to the ED. Is the abbreviated mental test score the best method to screen for delirium/acute confusional state?
Low-dose Ketamine for Acute Pain in the Emergency Department
A man aged 25 years presents to the ED with a closed fracture of the right humeral head. He has severe pain around the shoulder and is allergic to opioids. He is given intravenous ketorolac and midazolam. Unfortunately, the patient's pain does not improve. A colleague recommends the use of subdissociative dose of ketamine for intractable pain and you wonder whether this is supported by the evidence.
A 24 year old male presents to the emergency department with sudden onset of right flank pain radiating to the groin. A clinical diagnosis of renal colic is made. However, the patient is allergic to opioids. You recall a recent study describing treatment with parenteral lidocaine for intractable renal colic.
Trimethoprim–Sulfamethoxazole for Uncomplicated Skin Abscess n
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.
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…
Tadalafil Medical Expulsive Therapy in Ureteral Calculi: A New Kid on the Block?
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.
Bedside lung ultrasound for the diagnosis of pneumonia in children
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.
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 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.
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.