bestBETs

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.

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.

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.

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 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.

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 patient is brought into the emergency department with a severe acute head injury. You remember that there was recent trial in the hospital on the use of progesterone in head injury and wondered if it would be in the patients best interests?

A child attends the emergency department with a life threatening exacerbation of asthma. Despite the use of standard therapies the patient continues to deteriorate. You are aware of the bronchodilatory properties of ketamine and consider whether it may be of use as an additional therapy.

You are a paramedic assessing a patient with difficulty in breathing. On auscultation you think you hear a third heart sound. You wonder how accurate paramedics are at identifying abnormal heart sounds.

A 25 year old man is brought to the Emergency department following a gunshot wound to the abdomen. His BP is 70/50mmHg. He is tachycardic with cool extremities. You wonder about recent studies on permissive hypotension in hemorrhagic shock management. You wonder whether you should aggressively resuscitate the patient with crystalloid or restrict the fluid resuscitation before the patient is taken to the operating room.

A 64 year old patient with a history of epistaxis presents to the emergency department with a 3 hours history of spontaneous epistaxis. Simple first aid measures have been ineffective, and nor has the application of ice. You wonder whether there is any evidence base behind the use of topical vasoconstrictors or decongestants in the management of adult patients with epistaxis.

A 25 year old football player patient presents with a 24 hour history of delayed onset muscle soreness affecting his gluteal and hamstring region following an intense gym weight training session which included loaded squats, deadlifts, stiff leg deadlift and lunge exercises. He is due to train today and tomorrow before a game in three days’ time, although he feels he is too sore and stiff to be able to participate in training. You have heard from a colleague who works in sports medicine that application of localised laser therapy can help improve pain, function and the reduce recovery time, and therefore wonder if it should form part of your management plan to enable the player to return to training as soon as possible.

A parent of a 9 year old male suffering from myopia came to the clinic wondering if using contact lenses would slow the progression of myopia in her child as she read in the Internet.

A young woman presents to the emergency department (ED) with a number of vague, non-specific complaints. The team suspect she may be suffering domestic abuse. Upon enquiry, the patient discloses a recent history of abuse by her current partner. What ED-based interventions will be most effective in improving the management of such a patient to reduce her risk of further abuse?