bestBETs

You have reviewed a 45 year old woman complaining of vertigo on head movement with no other concerning features. She has a positive Dix-Hallpike test and you diagnose BPPV. In teaching today you were shown the Semont manoeuvre, you wonder if this manoeuver or the Epley manoeuvre would be more effective in treating her.

A 28 year old male presents to the emergency department with a 2-week history of cough and progressive shortness of breath. An outside chest x-ray was non-diagnostic. Chest CT here demonstrates bilateral interstitial infiltrates, consistent with pneumonia. You wonder how often CT scan is necessary to diagnose a pneumonia after an equivocal chest x-ray.

A 40 year old pedestrian is stuck by a car travelling at 40mph. On primary survey she is shocked and hypotensive with signs of significant pelvic and intra-abdominal injury. FAST shows large volumes of peritoneal fluid and pelvic radiograph shows marked disruption of the pelvic ring. Despite four units of pRBCs and FFP you are unable to obtain a radial pulse. You wonder whether Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) might be helpful.

A 57-year-old man attends the Emergency Department with bilateral ptosis. You only have a short time in order to ascertain the cause of the ptosis and therefore refer appropriately. The ED SHO wonders if there is a simple bedside test to distinguish whether Myasthenia Gravis is the cause of this presentation.

In the middle of the night, a 48 years old male is brought to your emergency department after a car accident. His seatbelt was fastened and he complains of moderate to severe sternal pain. He is alert, has no shortness of breath, his vital signs are normal and your secondary survey is otherwise negative for any other injury. You suspect your patient has an isolated sternal fracture. After ordering an electrocardiogram, cardiac enzymes and administering medication to relieve your patient, you wonder if bedside ultrasound would perform better at diagnosing sternal fracture than standard chest and sternal x-rays.

A 74-year-old woman presents to the emergency department with significant primary epistaxis. She struggles to tolerate nasal packing. A passing orthopaedic registrar suggests that tranexamic acid may be beneficial since it works in other haemorrhage scenarios. You wonder if he is correct and whether there is any evidence for a role for intravenous tranexamic acid in the management of her epistaxis.

After an international conference on the management of patients in cardiac arrest and watching a lecture on this subject, I felt that this was a novel approach and wanted to explore the evidence surrounding this approach and the feasibility of this being introduced into our ED.

A 52 year old male presents to the orthopaedic knee service with gradual onset of knee pain and effusion. He finds walking is now limited to 2 hrs and he struggles to play a full round of golf. Knee X-ray findings confirm moderate signs of degenerative joint disease. He is not yet at the stage to consider a joint replacement. He has tried physiotherapy and relative rest but now is keen for an ‘injection’. Should he be offered a corticosteroid or hyaluronic acid injection?

A 17 year old male found intoxicated on the street brought in by ambulance unconscious. Smelled of ethanol. Alcohol specialist team advised to give high dose multivitamins. Made me wonder if high dose intravenous multivitamin actually improves clinical outcomes in intoxicated patients

A nine year old boy is brought into the emergency department by his parents. He is a known asthmatic and has become acutely short of breath. He is struggling to talk in full sentences and his PEFR is less than 50% predicted. You suspect acute severe asthma and begin the appropriate treatment in accordance with the BTS asthma guideline. You wonder if the addition of nebulised magnesium sulphate would improve his outcome.

A normally fit and well 26-year-old man presents to the emergency department with a sudden onset headache. It came on 2 h ago, and is the worst he has ever had. He has taken paracetamol without success. The headache made him feel very unwell, but he has no neurological symptoms. His Glasgow Coma Scale (GCS) is 15 and clinical examination is normal. You are concerned that he may have had a subarachnoid haemorrhage (SAH) and want to rule this out. He has a CT scan within 6 h of the onset of the headache. It is reported as normal. You wonder if this excludes a diagnosis of SAH.

A 52-year-old lady has presented to the Emergency Department with a suspected PE. This is confirmed by CT pulmonary angiography (CTPA). Consequently she requires anticoagulation. Hospital guidelines suggest the use of a low molecular weight heparin (LMWH) followed by 6 months of Warfarin therapy. You wonder whether Rivaroxaban, a novel oral anticoagulant (NOAC), would be a better treatment option for her and patients like her.

You see a middle age lady in the Emergency Department who has presented with nausea and vomiting. She continued vomiting despite ondansetron. One of the anaesthetists suggests that you try just intravenous fluids before giving further anti-emetics. You wonder if there is any evidence for this?