D-dimer as a diagnostic tool for suspected cerebral venous thrombosis
A 22-year-old female patient arrives to your emergency department with severe left-sided non-pulsating headache that began 3 days ago. She had been discharged from your ED a few hours earlier with a diagnosis of new onset migraines after partial resolution of her symptoms with analgesia and rest. She complains of progressive unilateral headache and mild nausea, which appears to be different from the occasional headaches she experienced in the past. She is healthy and takes only an oral contraceptive pill without any previous thromboembolic complications. Her neurological exam is once again unremarkable and you decide to order a non-contrast head CT which is completely normal. Once again, her symptoms partially resolve and you consider migraine headache to be the most likely diagnosis. However, the persistence and severity of her symptoms makes you wonder if cerebral venous thrombosis could be the cause of her headaches. Instead of repeating an imaging exam with venous contrast (magnetic resonance or computed tomography), you wonder if D-dimers, a laboratory assay frequently used in the exclusion of venous thromboembolism, could safely exclude cerebral venous thrombosis in this case.
An 8 year-old known asthmatic patient presents to the Emergency Department with a typical exacerbation of asthma. He is partially improved after one bronchodilator treatment and oral steroids. You wonder if inhaled corticosteroids (ICS) would benefit the systemic steroids you are already prescribing.
You work in a resource poor country and cooling of infants with Hypoxic Ischaemic Encephalopathy (HIE) is not available. A term baby is born with low Apgar scores and admitted to the neonatal unit, where you confirm moderate to severe HIE. As cooling is not available you wonder if starting phenobarbital (PB) would reduce mortality or disability.
10 month old girl seen in PICU, approx 12 hours after developing toxic shock syndrome secondary to a thigh myositis. Had been resusitated agressively in resus before transfer to PICU with fluids, antibiotics and commenced on inotropes. It was decided to give her IVIG. throughout the day the patient improved clinically, I noticed her ABG had dramatically improved, and she required less inotropic support. I wondered whether her dramatic improvement could have been sooner if we had administered IVIG in resus.
Thromboelastography (TEG) Guided Transfusion in Trauma Patients
A 34-year-old male is brought by EMS as a trauma activation s/p MVC. He was an unrestrained driver with +LOC. En route, vitals deteriorated to the following: 80/45, 125, 28, 96%. He was intubated for airway protection. On arrival to the ED, GCS is 3T. As 2L crystalloid are being infused through 2 large bore IVs, ETT is confirmed to be in place, breath sounds are CTAB, carotid and femoral pulses are 1+ and thready bilateral. On exam, he has a seatbelt sign and initial FAST is positive. Trauma blood transfusion is initiated. Initial labs are drawn in the ED and he is taken straight to the OR by trauma surgery. You know that TEG is useful in transplant and cardiac surgery and wonder if a TEG-directed transfusion strategy will improve this patient’s clinical outcome.
The Use of Mechanical Chest Compression Devices in the Adult Emergency Department
Over the years there has been increasing evidence to support the benefit of effective chest compressions in the management of patients in cardiac arrest. In some areas, mechanical chest compression devices have been used in order to facilitate this. I want to explore the evidence surrounding these devices and their use / introduction in the Adult Emergency Department.
Is ST elevation in aVR a sure sign of left main coronary artery stenosis?
A 60-year-old man presents to the emergency department with typical cardiac chest pain but is now pain free. His ECG is not diagnostic of ST elevation myocardial infarction (STEMI) but shows 1.5 mm ST segment elevation in lead aVR. Having visited a number of educational websites, you recognise that this finding may signify left main coronary artery (LMCA) occlusion. Concerned about the potential risks associated with both failure to recognise such an important and potentially life-threatening diagnosis and with those associated with over-diagnosis, over-investigation and over-treatment, you wonder whether the presence of ST elevation in aVR is a specific marker of that diagnosis.
Silibinin in suspected amatoxin-containing mushroom poisoning
A 36-year-old woman presents to the emergency department after eating some unidentified wild mushrooms 12 h previously. She is complaining of abdominal pain and diarrhoea, which started 2 h before. The toxidrome leads you to suspect that the mushroom may have been Amanita phalloides. You are aware of the dire prognosis. You discuss the case with your consultant who suggests the use of silibinin. You wonder whether this would reduce her risk of death or need for liver transplant.
Core stability versus conventional exercise for treating non-specific low back pain.
A 24 year old male presents with chronic low back pain. Investigations have ruled out any serious disc, joint or bony pathology. Current opinion advocates core stability as the ‘go to’ treatment for this non-specific pain scenario. You wonder if it would be more effective than a conventional exercise programme?
A 62-year-old women is brought to the emergency department (ED) with sudden onset left sided hemiplegia. Computed tomography (CT) scan of her head shows an acute right basal thalamic intracerebral haemorrhage (ICH). Her blood pressure in the ED is 195/100. You wonder whether you should treat this patient’s hypertension in the ED?
Advantages of ultrasound assisted lumbar puncture : new evidences
While working the night shift, a patient is admitted for thunderclap headache 12 hours ago. After a negative head CT, you decide to do a lumbar puncture to rule out subarachnoid haemorrhage. You specifically need a non-traumatic LP and you wonder if localizing the right lumbar space with an ultrasound would reduce the rate of traumatic LP.
You are a senior doctor working in the Emergency department when a patient presents with a red painful eye. You suspect orbital compartment syndrome and know the patient could lose their sight if you don't act. You know how to do a lateral canthotomy as well as the risks but wonder if it is reasonable to do this within the emergency department?
Necessity for Troponin Levels in Pediatric Patients Presenting with Chest Pain
13 year old, previously healthy male presents with non-specific chest pain for last 3 hours. After a thorough history and physical, no abnormalities are found and diagnostic testing is debated. Knowing that adult patients with similar symptoms cause concern for ACS, you question whether pediatric patients have similar concerns with ACS and whether a full cardiac workup is warranted.
Intravenous versus Nebulized Salbutamol in Acute Treatment of Hyperkalemia
67yo female with past a medical history of chronic kidney failure presents with chest pain and fatigue. EKG shows wide QRS complex and peaked T waves. iStat shows potassium of 8.3mEq/L. While starting hyperkalemia treatment with Calcium Gluconate, Insulin + Dextrose, nebulized Salbutamol, and Kayexalate, you question whether nebulization or intravenous administration of Salbutamol is more effective in decreasing plasma potassium levels.
A 50 years old man with good past health presents to A&E with a 10/7 history of paroxysmal palpitation. His hear rate is around 80 bpm, and 12 leads ECG shows one PVC over 10 seconds with symptom. Repeat long lead ECG showed no PVC over 60 seconds at time of symptom free. TnI and CBC LRFT are normal. Private echocardiogram and Holter were performed a few days ago for previous episodes, and revealed pvc but no structural abnormalities. Blood tests including TFT in private were all within normal range. A clinical diagnosis of PVC is made. The patient is asking whether there is any drug to reduce his symptom.