bestBETs

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.

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.

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.

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?

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?

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.

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.

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?

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.

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.

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.

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 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.

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.