bestBETs

A 55-year-old female presents to the emergency department with an infective exacerbation of chronic obstructive pulmonary disease. The patient requires intravenous (IV) fluids and IV antibiotics whilst on non-invasive ventilation. The patient does not require ionotropic support. You and your fellow colleagues have failed at siting a peripheral cannula using traditional methods to administer IV medication. Does the use of US help obtain PIV and reduce the need for a CVC in this clinical scenario?

A 32 year old woman presents to the emergency department complaining of lower abdominal pain associated with bleeding. She has a history of bad period pain for which she takes medication. She has taken all her normal oral medication and is still in pain. You are familiar with salbutamol and it’s action on smooth muscle and know that it is used for tocolysis; you wonder if they may help her pain.

A 42-year old woman presents to the emergency department (ED) with an intentional paracetamol overdose. She is a known frequent ED attender due to paracetamol or insulin overdoses, but would often refuse the appropriate treatment. She has emotionally unstable personality disorder, with high levels of anxiety and distress when she comes into the department. You wonder if implementation of case management can reduce her number of ED visits due to overdoses.

A forty years old male attends the emergency department, with abdominal pain, nausea, heartburn, dyspepsia, reflux and bloating. Physical examination with stable vital signs, abdominal pain without peritoneal irritation. Contrast studies and upper endoscopy reveals a large hiatal hernia. We decided a laparoscopic repair, it has be with mesh or simple suture.

A 45 year old cyclist is brought up into resus after being knocked off his bicycle by a lorry. He is in traumatic cardiac arrest. ATLS is in progress you wonder whether IV adrenaline would improve his chances of survival?

A 7 year old boy is brought to the emergency department (ED) after falling onto the corner of a table. On examination he is noted to have a large laceration across his right cheek that needs suturing. The young boy is afraid of needles and will not allow you to place a cannula or give an IM injection. As the ED physician, you consider using intranasal dexmedetomidine for sedation in this patient.

A 22 year old woman with a history of hypoparathyroidism presents to the emergency department with recurrent grand mal seizures. Her ionized calcium level is 0.7 mmol/L (2.8 mg/dL). You prefer to administer intravenous calcium gluconate over calcium chloride because it causes less tissue necrosis if extravasated. Also, calcium gluconate is better tolerated through a peripheral IV. However, you recall that calcium gluconate might possess a slower onset of action because it requires hepatic metabolism to release the elemental and active form of calcium.

A 61-year-old lady presents to the ED with redness and swelling around a varicose vein that extends from the lateral aspect of the left knee to the mid-portion of the lateral aspect of the left leg. She has a 25-year history of asymptomatic lower extremity varicosities which appeared after the birth of her first child. A duplex ultrasound confirms your clinical diagnosis of "superficial thrombophlebitis". You begin treatment with a nonsteroidal anti-inflammatory drug (NSAID), compression stockings and arrange follow-up in 2-3 days. Although she has no risk factors for hypercoagulability or deep venous thrombosis, you wonder if anticoagulants might reduce complications.

A 12 year old girl with autism was admitted for elective orthopaedic surgery, requiring a 4 week inpatient stay for post-op physiotherapy. She required significant dietetic and psychiatric input, and had lost weight at successive outpatient appointments prior to hospital admission. She was diagnosed with anorexia during her admission. This case, is one of many, that highlighted the need for dietetic and psychiatric input intervention early in children with autism. Patient group: Children aged 5-15 years old with Autism Intervention: Eating Disorders (Anorexia AND/ OR Bulimia) Control group: Children aged 5-15 years old without Autism Outcome: Data on the prevalence of Eating Disorders in children with Autism compared to children without Autism

A patient is brought into ED with airway difficulty and stridor and requires intubation. Rapid sequence induction for anaesthesia is performed. On laryngoscopy the view is Cormack Grade 2 and the anaesthetist says they don’t need a bougie to pass the endotracheal tube and intubate the patient. You wonder if the endotracheal tube will be passed first time.

A 35 yrs old girl comes to the Emergency department with acute shortness of breath for last 6 hrs. The working diagnosis of pulmonary embolism is made. The D dimer was sent but will take 2-3 hrs for the results to be available. You wonder if arterial blood gas analysis can be used to diagnose the PE.

A 55 year old man has presents to the emergency department with severe hypoxia secondary to an exacerbation of congestive heart failure. His initial saturation is 83% with a reservoir oxygen mask; he is tachypneic with a respiratory rate of 35. You decide to intubate this patient and want to optimize his oxygen saturation before induction. You place a standard reservoir face mask with a flow rate of oxygen set as high as possible. After 3 minutes the saturation has improved to 95%. One of your colleagues suggests using high-flow nasal cannula oxygen during the intubation procedure to reducing desaturation (apneic oxygenation).

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus.On examination, He had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control.As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%. The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice? In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is contraindicated in patients with abnormal liver function test. Generally, anticoagulant is contraindicated in inaccessible ulceration (esophageal carcinoma in this patient).

59 year old male, presented to the emergency room with dyspnea and angina at rest. His past history was significant for Esophageal cancer on chemo-radiation, Ischemic stroke (left ACA territory – month prior to current presentation), Chronic Kidney disease, hypertension and diabetes mellitus. On examination, he had a heart rate of 192/minute and not in shock; ECG showed Atrial Fibrillation. His Blood Urea was 68 g/dl and Serum Creatinine was 2.3 mg/dl. His Troponin I was positive. Metaprolol was given at out emergency room which brought the heart rate under control. As the heart rate improved, the ECG changes were suggestive of Non-ST Elevation Myocardial Infarction. ECHO showed severe LV dysfunction with Ejection Fraction of 33%. Issues The dilemma of administering an anticoagulant as the patient had stroke recently and what is the anticoagulant of choice? In this patient with abnormal renal function enoxaparin sodium is contraindicated. Warfarin is also risky as this patient had cerebrovascular disease, hypertension, Chronic Kidney disease and malignancy on active treatment. Generally, anticoagulant is contraindicated in inaccessible ulceration (in this case - esophageal carcinoma).

Jennifer, a healthy 25-year- old medical student, presents to your emergency department (ED) during your afternoon shift with a severe headache that she has had for the past 8 hours. She has had nausea with vomiting for 6 hours. She has a long history of migraine headaches that keep her from her clinical duties for 1 or 2 days if untreated. After ruling out any cause for secondary headache, you decide to give 1 liter of intravenous (IV) saline along with IV metoclopramide. You consider if administration of IV fluid bolus might be associated with short-term or sustained outcomes

A 64 year old male with Type 1 diabetes is experiencing symptoms of hypoglycaemia and his wife calls 999. An ambulance crew attend the patient who is drowsy and non-cooperative with blood sugar 1.8mmol/l. Following treatment with intramuscular glucagon and oral carbohydrate, he fully recovers and you follow guidelines that suggest the patient can be left at home with a referral to their GP, but you worry that without diabetes specialist input the patient will not have timely follow up resulting subsequent hypoglycaemic events with ambulance call out.