bestBETs

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 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.

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.

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 24 year old woman in her first trimester of pregnancy presents to the Emergency Department with nausea and vomiting, with no other concerning features of alternative pathology. She provides a urine sample at triage and is found to have 4+ ketones present. On examination she is clinically dehydrated and you wish to start intravenous fluids. You wonder, would dextrose-containing solutions be better at switching off ketogenesis and providing symptomatic improvement than intravenous fluids without glucose?

A 37-year-old man is involved in a rear-end shunt road traffic collision (RTC). He is alert and is brought to hospital with no cervical spine immobilisation in place. You wonder whether efforts should have been made to immobilise his cervical spine to protect from potential spinal cord injury.

You are first on scene to a road traffic collision (RTC) involving a 32 year old male who has crashed his motorbike at 30mph. He is haemodynamically normal but complains of pain in his right chest and right hip and is unable to walk. You wonder whether the optimum management of this patient would be to bypass the nearby trauma unit for direct transfer to the closest major trauma centre.

An adult patient with a history of variceal bleeds presents to the Emergency Department with haematemesis associated with tachycardia and hypotension. Despite treatment with Terlipressin, Omeprazole, Tranexamic acid and blood transfusion, hypotension and tachycardia persist and the patient continues to experience haematemesis. There is approximately a thirty-minute delay before endoscopy can be undertaken. You wonder whether insertion of a Sengstaken-Blakemore tube may be beneficial in achieving haemostasis and improving haemodynamic stability.

Search and rescue services locate a missing adult male, who is found to have reduced consciousness and a core temperature of 32 degrees. Preparing for hospital transfer, the team insulate the casualty to prevent further heat loss.

A 72 year old gentleman is admitted to the Emergency Department Resuscitation suite. He is hypoxic, hypotensive with right ventricular strain on ECG and a CT scan performed showed a large saddle embolus. He is given thrombolytic therapy and you are asked to prescribe ongoing anticoagulation. You wonder if there is any evidence to support the use of a unfractionated heparin infusion as compared to a Low Molecular Weight Heparin to reduce adverse outcomes?

A child suffers major trauma resulting in cardiac arrest.

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.

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.

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.