bestBETs

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.

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 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.

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.

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?

A 33 years-old itinerant comes to the emergency department after a long winter night outside. He has clear blisters on three of his right fingers. You diagnose moderate frostbite and you start a rewarming process. Then, you wonder what to give him to reduce the inflammatory cascade. Should you use aspirin or a non-steroidal-anti-inflammatory drug?

A 15 year old boy with type 1 DM is admitted to the ED unwell, with a BM of 29. O/E he is pale, sweaty and lethargic with a BP of 90/40 and pulse 120. Otherwise exam is unremarkable. You site an IV cannula and take a VBG which shows pH 7.1 and HCO3- 10. You give a 900ml 0.9% NaCl fluid bolus (20ml/kg) and are about to start a sliding scale when the paediatric SpR tells you that local policy is to hold off insulin for the first 2-3 hours as it may increase the risk of development of cerebral oedema. You wonder what the evidence shows.

A 15 year old boy with type 1 DM is admittd to the ED unwell, with a BM of 29. O/E he is pale, sweaty and lethargic with a BP of 90/40 and pulse 120. Otherwise exam is unremarkable. You site an iv cannula and take a VBG which shows pH 7.1 and HCO3- 10. You give a 900ml 0.9% NaCl fluid bolus (20ml/kg) and are about to start a sliding scale when the paediatric SpR tells you that local policy is to hold off insulin for the first 2-3 hours as it may increase the risk of development of cerebral oedema. You wonder what the evidence shows.

A 20 year old man presents to the Emergency Department after being pulled from the canal. He fell into the canal while intoxicated, and on arrival is unconscious. There are no clinical signs of serious injury. You wonder whether his cervical spine should be immobilised until imaging rules out trauma.

A 10-year-old boy presents to A&E after falling into a river. He was rescued and resuscitated at the scene but now has a GCS of 7. There is no evidence of trauma. You wonder if a CT scan of his head will aid the management

A 23-year-old woman presents to the emergency department after falling into the canal. She was resuscitated at the scene but is now cold, pale and short of breath. You decide she needs fluids, but aren’t sure which would be best to give.

A 20-year-old male is rushed to the Emergency Department after falling into a canal. He is unresponsive and suffers a cardiac arrest for which CPR is commenced. You wonder if therapeutic hypothermia may have a role in his management.