bestBETs

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 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 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 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.

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.

A confused patient presents to the ED. Is the abbreviated mental test score the best method to screen for delirium/acute confusional state?

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 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 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.

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…

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 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.

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 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 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 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.

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.

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.