bestBETs

A 6-year-old child was brought to hospital as a major trauma having been hit by a reversing car. The actual incident was not witnessed but the tyre tracks across the child's chest and the petechiae on his face and neck give credence to the theory that the car rolled over him. The child has an obvious head injury with a history of a period of consciousness but is haemodynamically stable. After immediate assessment and initial resuscitation you discuss the appropriate imaging with the radiologist. The radiologist agrees to perform a CT of the child's head and neck but declines to do a CT of the child's thorax. He quotes the Royal College of Radiology guidelines that state that for children who have suffered major trauma, CT scans of the thorax are not indicated for the haemodynamically stable child with a normal CXR (https://www.rcr.ac.uk/sites/default/files/publication/BFCR%2814%298_paeds_trauma.pdf). The child subsequently has a normal looking CXR and so you admit him for a period of observation while wondering if a plain film has the sensitivity to rule out significant injury.

A 66 year-old man suffers a witnessed out of hospital cardiac arrest. He is given immediate bystander cardiopulmonary resuscitation (CPR) until a paramedic ambulance crew arrives. The first recorded cardiac rhythm shows ventricular fibrillation. The ambulance crew continues CPR in accordance with current Advanced Life Support guidelines. Initial resuscitation attempts including three defibrillation attempts fail. Each time the patient is defibrillated, there is a necessary interruption in chest compressions. As medical director, you question the safety of a rescuer remaining in contact with a patient being shocked with modern defibrillation equipment.

Patient seeking a relatively safe, non surgical cosmetic treatment to the upper eyelid.

A patient has bee diagnosed with a lower limb stress fracture following an MRI scan. You wonder if early mobilisation is better than non-weight bearing in managing this patient and reducing complications.

A patient presents with a lower limb stress fracture and you wonder what the best first initial investigations should be. You arrange an X-ray of the lower limb, but wonder what the sensitivity and specificity of this investigation is.

A 24 year old female presents to the emergency department with atraumatic bony pain in her left foot. She tells you that she is a keen runner and is in the process of training for a marathon. You wonder if her previous activity levels or current increase in activity are a greater risk factor for a stress fracture.

An 8-year-old boy presents to the emergency department with right lower quadrant abdominal pain with features suggestive of appendicitis. The surgeons are not immediately available and suggest imaging of the right iliac fossa. There is a delay before either ultrasonography or CT scanning can be carried out by the diagnostic radiology department. You wonder if point-of-care ultrasound (POC US) might result in a quicker decision and therefore a shorter length of stay (LOS) for the child.

A 24 year old professional football player presents with a hamstring strain grade 1-2 to the long head of biceps femoris. You have heard from a colleague who works in sports medicine that eccentric loading can be used as an alternative to lumbopelvic movement control retraining. Therefore, to try and improve function and reduce recovery time, you wonder if it should form part of your management plan.

A mother attends the Emergency Department with her breastfed 8-week-old baby girl who is crying inconsolably. History and examination point towards a diagnosis of infantile colic. You wonder whether you should suggest a proprietary over-the-counter remedy or whether you should just say that this is a self-limiting condition. A passing paediatrician notices your dilemma and suggests probiotic therapy to reduce the baby's distress. You wonder if there is any evidence to support her advice.

A 47-year-old man presents complaining of a painful gritty sensation within his left eye. He had been taking down a ceiling in his house and had not been wearing eye protection. You suspect a corneal foreign body. You are about to instil local anaesthetic drops when your registrar suggests that this is not necessary since, if there is a foreign body and it is subtarsal it could be removed without the need for the drops. She points out that installation of local anaesthetic drops is not without risk. You wonder if there is any evidence to support her pragmatic view.

Mrs. Jones is a 25 y/o F with reccurent shoulder dislocation who presents with anterior shoulder dislocation. After your second attempt using traction counter-traction under sedation with Propofol x-ray confirms failed reduction. You wonder should I have started with a different method.

A 4 month old infant presents to the ED with a 2 day history of coryza and cough. His mother reports he has become breathless over the last 24 hours and is no longer feeding as well as usual. You make a clinical diagnosis of bronchiolitis. You are aware that bronchodilators are not recommended in bronchiolitis but are keen to give some treatment. You wonder if hypertonic saline is effective.

A 72-year-old gentleman presents to ED with symptoms of a Stroke arisen within the last hour. His wife rushed him to ED. A middle cerebral artery infarction is confirmed on diffusion weighted MR scan. The Stroke Team Consultant is called to consider thrombolysis. On noting that the patient has a high blood pressure, he wants the patient started on a Labetalol infusion prior to administration of thrombolytic agent. Amongst other things the question of evidence on the best anti hypertensive drug to be used in such a situation arises

Whilst working at a local hospital ED, I was asked to review a 72-year-old lady by my F2. She had attended with chest pain and then had later collapsed. Her chest x-ray showed a widened mediastinum and a CT scan confirmed Thoracic Aortic Dissection. She was hypertensive with different blood pressure readings in either arm. On referring this patient to the on-call Cardio-Thoracic registrar, he asked for her to be started on a Labetalol infusion to control the blood pressure. Not being available in the ED immediately, it took a little while to get IV Labetalol from the hospital pharmacy. It just made me ask whether it is the best drug to be used.

A patient presents with a few days history of pleuritic chest pain. All clinical findings and investigations are normal except for a raised d-dimer. A high probability V/Q scan confirms the diagnosis of pulmonary embolism. The patient is very keen to be discharged. You are aware that right ventricular strain is associated with a poor outcome in pulmonary embolism and you also know that B natriuretic peptides are raised in the presence of ventricular strain. You wonder if a low B natriuretic peptide level could be used to confirm the absence of ventricular stain and low risk of death or serious complications, therefore suggesting suitability for outpatient management.

A 78 year old female presents to your emergency department reporting increased wheezing over the last 24 hours. She reports a mildly productive cough and denies fever. A chest x-ray reveals no clear evidence of pneumonia. In addition to therapy for what you believe is a COPD exacerbation, you consider the possibility of bacterial infection. A colleague mentions that they are using procalcitonin as a biomarker to guide antibiotic therapy for patients with potential respiratory infection on the intensive care unit. You wonder if there is any evidence assessing the utility of procalcitonin for this indication in the emergency department.