bestBETs

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 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

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.

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.

You are taking care of a 36 year-old female with confirmed pulmonary embolism (PE) on CT angiography. She complains of a moderate pleuretic chest pain and is slightly short of breath. Her vitals signs and her ECG are normal. She is hemodynamically stable since her arrival in the ED. You know that right ventricular strain in patients with PE is associated with significant mortality and morbidity and that high-sensitivity troponin and BNP could help identify these patients. While planning to potentially discharge the patient after appropriate PE treatment, you wonder if high sensitivity troponin would better perform than BNP to identify individuals with high-risk of complications or serious adverse events.

A 79 year old patient attends the ED for a minor medical problem. While taking the history it becomes apparent that this patient lives alone, with no relatives nearby and no social support. You wonder if this finding alone increases the risk of re-attendance and the length of stay for this patient.

You are asked to attend to an 82 year old foreign language speaking female patient presenting with a 3 hour history of chest pain. She has multiple comorbidities and is quite distressed at having been brought to the hospital. She speaks very limited English, making it almost impossible to take a detailed history. You wonder if this language barrier might influence her management and outcome.

A child suffers major trauma, resulting in cardiac arrest.

You are asked to see a patient in the ED who is not fluent in English and requires an interpreter. You find that the telephone translation service is a bit difficult and you wonder if video conferencing or translation services using novel technologies may lead to better outcomes than the telephone service.

You are a newly appointed Emergency Medicine Consultant at a large inner-city hospital, and you notice a high incidence of assault victims attending your department, and you wonder which interventions might be helpful in reducing this.