bestBETs

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 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.

A 66 year old female presents to the emergency department (ED) after a motor vehicle crash. Radiographs reveal an acute posterior dislocation of the right hip. Although her hip was successfully reduced in the ED, you sustain a lumbar muscle strain while applying the necessary force to the patient's hip to accomplish reduction. The following day during a hospital conference you hear about a new method for the easy and safe management of hip dislocation called the "Captain Morgan" technique.

During a morbidity and mortality conference at a local Emergency Medical Services (EMS) agency, a paramedic questioned the effectiveness of a new mechanical device used for chest compressions during cardiac arrest. As the EMS medical director, you recall at least one recent randomized clinical trial that addresses this question.

You attend a 60 year old male in cardiac arrest. A double crewed ambulance with a student observer and a rapid response vehicle are already on scene. The patient has ongoing CPR and with effective ALS you regain a pulse. At this point the decision is made to intubate the patient to secure their airway for transport. During the debrief intubation is discussed and the student asks about the training the paramedics at the scene received. There is considerable variation in the training received by the paramedics and the training the student paramedic is undergoing at present. This sets you thinking about how paramedics actually learn to intubate.

A 56 year-old man suffers a witnessed out of hospital cardiac arrest. He is given immediate bystander cardiopulmonary resuscitation (CPR). A paramedic ambulance crew arrives after 8 minutes. The first recorded cardiac rhythm shows ventricular fibrillation. The ambulance crew continue CPR in accordance with current Advanced Life Support guidelines. Initial resuscitation attempts including three defibrillation attempts fail. The paramedic team is equipped with and fully trained in the use of a mechanical CPR device and this is applied and the patient transferred to the nearest emergency department. You wonder whether mechanical CPR or manual CPR is more effective at achieving a restoration of spontaneous circulation and improving the patient's chances of leaving hospital alive.

A 62-year-old gentleman attends your Emergency Department with shortness of breath and chest pain. You suspect a pulmonary embolism (PE) and request a CT pulmonary angiogram. The radiologist reports an isolated subsegmental PE and you question whether this gentleman requires anticoagulation therapy given the size and location of his PE.

An elderly lady who is otherwise well presents at your Emergency Department (ED) with a swollen, red leg. You suspect deep vein thrombosis (DVT), assess her Wells’ score, which is found to be low, and request a D-dimer level. The D-dimer level is marginally raised using the standard diagnostic cut-off. Your current clinical protocol mandates ultrasound scanning in this situation but you have recently heard that there is a natural rise in D-dimer levels with age. The usual normal range may therefore give a high false positive rate in older people. You wonder whether the use of an age-adjusted D-dimer cut-off might allow you to safely rule out DVT without requesting a scan.

A 4-years-old boy with previous history of asthma presents to your Emergency Department with moderate asthma exacerbation. His condition improved with salbutamol and you are ready to discharge him. He already received one oral dose of dexamethasone. You wonder if there is enough evidence to discharge him without prescribing additional oral corticosteroid. You search the available literature.

A 35 year old man has been out drinking alcohol all night. He is brought in to the Emergency Department in the early hours of the morning after having fallen asleep in the back of a taxi and appears extremely intoxicated. Clinical examination is otherwise unremarkable and reveals no external evidence of a head injury. His observations are all within the normal range. You are asked to prescribe some intravenous fluids to “flush out the alcohol” but the nursing staff and wonder whether it will actually make any difference to his recovery and discharge.

A 2 year old child with history of prematurity with NICU stay presents with cough, runny nose and fever. She has not had an influenza vaccination this year. Parents have been using antipyretics without resolution of symptoms. The child has chest x-ray and laboratory studies performed. A nasal swab is positive for influenza A. The family is concerned about her prognosis given the past medical history.

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

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

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.

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.

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.

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.