bestBETs

A three year old child is brought to the emergency department with pyrexia and dehydration, requiring cannulation. Routinely topical anaesthetic Ametop would be applied prior to this procedure. However a paediatrician has come to see the patient and requested giving the child sucrose. When questioned, the paediatric doctor explains it provides comfort and settles children during procedures such as cannulation. Despite years of Accident and Emergency experience using this technique for comfort in neonates you wonder whether this will be of similar effective use in older children.

in patients wirh acute severe asthma, does NIV improve outcome?

A 45 years old female teacher presents to the Emergency Department with severe hoarseness and a mild cough for three days. She hasn’t been able to work since then. Her vital signs and physical examination reveal nothing particular except an important dysphonia. You tell her that she has an acute laryngitis, a self-limited condition that will resolve with voice rest. You wonder if a brief course of corticosteroids can reduce her dysphonia and speed her recovery.

A 23-year old man presents to the emergency department because of pain and swelling of the left knee after a motorcycle accident that occurred the day before. Clnical examination suggested the presence of joint effusion in the suprapatellar pouch with sever pain in the affected knee. A radiograph of the knee showed no signs of fracture. Computed tomography (CT) of the left knee revealed an oblique fracture of the tibial plateau. As the treating clinician, you question the sensitivity of plain x-rays to identify fractures in the knee.

During a night shift, you receive in your resuscitation room your classical 6am pulmonary oedema patient. You start nitrates, furosemide and you initiate positive pressure ventilation, but you are asking yourself if you should still use the M of your LMNOP treatment mnemonic.

A 22-year-old female patient arrives to your emergency department with severe left-sided non-pulsating headache that began 3 days ago. She had been discharged from your ED a few hours earlier with a diagnosis of new onset migraines after partial resolution of her symptoms with analgesia and rest. She complains of progressive unilateral headache and mild nausea, which appears to be different from the occasional headaches she experienced in the past. She is healthy and takes only an oral contraceptive pill without any previous thromboembolic complications. Her neurological exam is once again unremarkable and you decide to order a non-contrast head CT which is completely normal. Once again, her symptoms partially resolve and you consider migraine headache to be the most likely diagnosis. However, the persistence and severity of her symptoms makes you wonder if cerebral venous thrombosis could be the cause of her headaches. Instead of repeating an imaging exam with venous contrast (magnetic resonance or computed tomography), you wonder if D-dimers, a laboratory assay frequently used in the exclusion of venous thromboembolism, could safely exclude cerebral venous thrombosis in this case.

An 8 year-old known asthmatic patient presents to the Emergency Department with a typical exacerbation of asthma. He is partially improved after one bronchodilator treatment and oral steroids. You wonder if inhaled corticosteroids (ICS) would benefit the systemic steroids you are already prescribing.

You work in a resource poor country and cooling of infants with Hypoxic Ischaemic Encephalopathy (HIE) is not available. A term baby is born with low Apgar scores and admitted to the neonatal unit, where you confirm moderate to severe HIE. As cooling is not available you wonder if starting phenobarbital (PB) would reduce mortality or disability.

10 month old girl seen in PICU, approx 12 hours after developing toxic shock syndrome secondary to a thigh myositis. Had been resusitated agressively in resus before transfer to PICU with fluids, antibiotics and commenced on inotropes. It was decided to give her IVIG. throughout the day the patient improved clinically, I noticed her ABG had dramatically improved, and she required less inotropic support. I wondered whether her dramatic improvement could have been sooner if we had administered IVIG in resus.

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?