bestBETs

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 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.

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 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.

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.

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.

A busy emergency department has a long list of patients in the waiting area and several patients have recently arrived on trolleys from the ambulance service. There is pressure to get patients seen and either discharged or admitted as soon as possible. You wonder if asking the triage nurses to determine whether they think each patient will need admitted will speed the process along by allowing earlier booking of inpatient beds.

You are the most senior doctor in the Emergency Department when you receive an alert call from the pre-hospital medical team. They are bringing an 8 year old boy who was a pedestrian struck by a bus. He is displaying signs of hypovolaemia due to suspected ongoing internal bleeding, with tachycardia and hypotension despite fluid resuscitation. You are concerned that he is at risk of cardiac arrest, but are unsure of the optimal method of identifying cardiac arrest in such patients to help you decide when to start your traumatic cardiac arrest protocol.

An 8 year old child is brought the emergency department following a high speed road traffic collision. He was unrestrained in the vehicle and has evidence of head trauma. He arrested at the scene and on arrival has undergone 15 minutes of CPR, has fixed pupils with no pulse and asystole on the cardiac monitor. Is it appropriate to stop resuscitation?

A 67-year-old male presents to A&E with shortness of breath. He is found to be hypoxic, tachycardiac and tachypnoeic. Chest auscultation reveals bilateral wheeze and reduced air entry throughout. A clinical diagnosis of acute exacerbation of COPD is made. Patient is given Salbutamol and Ipratropium nebulisers followed by intravenous hydrocortisone. He is also given titrated supplemental oxygen. Since patient is already on theophylline and its serum levels is not available, intravenous aminophylline is not given. NIV is considered. You wonder if giving intravenous Magnesium Sulphate is of any benefit.

A 53 year old man attends the emergency department with a 2 hour history of chest pain that may be cardiac. You want to rule out possible acute aortic aneurysm dissection and wonder whether a D-Dimer level can help do this

a patient presenting to A&E with simple shoulder dislocation. Should they receive a USS guided interscalene block or a procedural sedation for the joint reduction

A 78 year old women with no cognitive impairment is brought to the ED with a story of an accidental fall from her height followed by right hip pain and inability to walk or bear any weight on her right leg. Initial evaluation followed by plain films denoted a stable right hip fracture. Initial pain management in the ED was limited. You are concern with the overuse of opiates and development of delirium in the ED and you wonder if the use of regional anesthesia using ultrasound guidance could beneficial for this patient in the ED.

A 32 otherwise fit and well man attends the ED two hours after running his hand along an old wooden broom. He sustained a penetrating wound from a large wood splinter which he thought he had removed. He now complains of ongoing sharp sensation in the ulnar border of his palm on palpation and movement. A radiograph by the triage nurse shows no foreign body but you know that wood is radiolucent 85-100% of the time. You consider whether ED ultrasound might be useful