bestBETs

A 45 year old cyclist is brought up into resus after being knocked off his bicycle by a lorry. He is in traumatic cardiac arrest. ATLS is in progress you wonder whether IV adrenaline would improve his chances of survival?

A 7 year old boy is brought to the emergency department (ED) after falling onto the corner of a table. On examination he is noted to have a large laceration across his right cheek that needs suturing. The young boy is afraid of needles and will not allow you to place a cannula or give an IM injection. As the ED physician, you consider using intranasal dexmedetomidine for sedation in this patient.

A 22 year old woman with a history of hypoparathyroidism presents to the emergency department with recurrent grand mal seizures. Her ionized calcium level is 0.7 mmol/L (2.8 mg/dL). You prefer to administer intravenous calcium gluconate over calcium chloride because it causes less tissue necrosis if extravasated. Also, calcium gluconate is better tolerated through a peripheral IV. However, you recall that calcium gluconate might possess a slower onset of action because it requires hepatic metabolism to release the elemental and active form of calcium.

A 12 year old girl with autism was admitted for elective orthopaedic surgery, requiring a 4 week inpatient stay for post-op physiotherapy. She required significant dietetic and psychiatric input, and had lost weight at successive outpatient appointments prior to hospital admission. She was diagnosed with anorexia during her admission. This case, is one of many, that highlighted the need for dietetic and psychiatric input intervention early in children with autism. Patient group: Children aged 5-15 years old with Autism Intervention: Eating Disorders (Anorexia AND/ OR Bulimia) Control group: Children aged 5-15 years old without Autism Outcome: Data on the prevalence of Eating Disorders in children with Autism compared to children without Autism

A 35 yrs old girl comes to the Emergency department with acute shortness of breath for last 6 hrs. The working diagnosis of pulmonary embolism is made. The D dimer was sent but will take 2-3 hrs for the results to be available. You wonder if arterial blood gas analysis can be used to diagnose the PE.

A patient is brought into ED with airway difficulty and stridor and requires intubation. Rapid sequence induction for anaesthesia is performed. On laryngoscopy the view is Cormack Grade 2 and the anaesthetist says they don’t need a bougie to pass the endotracheal tube and intubate the patient. You wonder if the endotracheal tube will be passed first time.

A 55 year old man has presents to the emergency department with severe hypoxia secondary to an exacerbation of congestive heart failure. His initial saturation is 83% with a reservoir oxygen mask; he is tachypneic with a respiratory rate of 35. You decide to intubate this patient and want to optimize his oxygen saturation before induction. You place a standard reservoir face mask with a flow rate of oxygen set as high as possible. After 3 minutes the saturation has improved to 95%. One of your colleagues suggests using high-flow nasal cannula oxygen during the intubation procedure to reducing desaturation (apneic oxygenation).

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus.On examination, He had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control.As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%. The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice? In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is contraindicated in patients with abnormal liver function test. Generally, anticoagulant is contraindicated in inaccessible ulceration (esophageal carcinoma in this patient).

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus. On examination, he had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control. As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%. Issues The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice? In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is also risky as this patient had cerebrovascular disease, hypertension, Chronic Kidney disease and malignancy on active treatment. Generally, anticoagulant is contraindicated in inaccessible ulceration (in this case - esophageal carcinoma).

Jennifer, a healthy 25-year- old medical student, presents to your emergency department (ED) during your afternoon shift with a severe headache that she has had for the past 8 hours. She has had nausea with vomiting for 6 hours. She has a long history of migraine headaches that keep her from her clinical duties for 1 or 2 days if untreated. After ruling out any cause for secondary headache, you decide to give 1 liter of intravenous (IV) saline along with IV metoclopramide. You consider if administration of IV fluid bolus might be associated with short-term or sustained outcomes

A 64 year old male with Type 1 diabetes is experiencing symptoms of hypoglycaemia and his wife calls 999. An ambulance crew attend the patient who is drowsy and non-cooperative with blood sugar 1.8mmol/l. Following treatment with intramuscular glucagon and oral carbohydrate, he fully recovers and you follow guidelines that suggest the patient can be left at home with a referral to their GP, but you worry that without diabetes specialist input the patient will not have timely follow up resulting subsequent hypoglycaemic events with ambulance call out.

70 year old male presenting to the emergency department with a 2 day history of fever and rigors with dysuria and increased urinary frequency. Could a point-of-care capillary lactate measurement be used to predict illness severity and prognosis?

A 56-year-old man who presented to the ED with acute upper GI bleed was enlisted for urgent endoscopy after assessment by a senior registrar. You knew that patient would have better outcome if they receive early endoscopy but wonder if there was any difference in outcome between 12 hours and 24 hours.

A 40-year-old man came in to ED with suspected upper GI bleed. He was prescribed erythromycin before going for endoscopy. You wonder what was the role of erythromycin pre-endoscopy

You are asked to attend to an 87 year old female patient who fell at home. She has no acute injuries, but is quite distressed at having been brought to hospital. The ambulance crew state that she did not fulfill their criteria for home management. You wonder if all pre-hospital screening tools for frailty are equally effective at deciding which patients can be safely left at home.

An 80-year-old man presents to ED with a mechanical fall. He has sustained a minor head injury and complains of left hip pain. On further questioning, he had three recent falls in the past week. He mentions that he is not coping at home. Investigations reveal no evidence of intracranial injury or bony injury to the hip. You wonder if the service has met with his expectations, and dealt with the underlying problems he presented with.

A 42-year-old woman presents to the emergency department stating she has suicidal ideation. She denies any overdose or intoxication. She states in the past few days she has been planning to end her life.