bestBETs

A 35 year old gentleman presents to the Emergency department complaining of painful left eye with foreign body sensation. Slit lamp examination demonstrates a corneal abrasion. You apply topical anaesthesia and he feels instantly better. He then requests to take the drops home. Your consultant tells you that it is dangerous to give topical anaesthetics because patients will go on to develop corneal ulceration and impaired healing. You wonder if there is any evidence to support this.

You are working as the middle grade leading a trauma call. Your patient has multiple rib fractures as well as a flail chest and is clearly in pain and has somewhat laboured breathing. The anaesthetist is getting ready to induce and then intubate the patient to take him upto ICU for mechanical ventilation. You wonder if it is a good idea to be this aggressive and if more conservative management would result in a better outcome. You do not however have any evidence to hand to prove things one way or the other.

One Friday night you decide to leaf through the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. You note that the guidelines recommend chewable aspirin yet the majority of departments you have worked in use soluble aspirin. You wonder if there is any evidence to back the use of chewable aspirin?

A 48 year old man presents to the Emergency Department with an exertional dyspnoea for a few days. He has no risk factors for PE and no signs of DVT, but his D-dimer comes back positive. Your respiratory physician colleagues suggest that an acute PE diagnosis is more likely if his oxygen saturation would drop on exertion. You wonder if there is any evidence to support the use of exercise induced hypoxia as a risk stratification tool for acute pulmonary embolism.

69 year old male presents to the Emergency Department after having an asystolic arrest with spontaneous return of circulation following CPR. You wonder if therapeutic hypothermia would offer any benefit to this patient.

A healthy 3 year-old girl is brought into Emergency Department by her mother. She lifted her up on the couch by pulling on her left hand from this moment her daughter didn’t use her left arm. This little girl has a clear history of a ’’pulled elbow’’. You wonder whether supination-flexion or hyperpronation is the best technique for this reduction.

A 40 year-old male patient presents to your emergency department with a five days history of sudden onset low back pain irradiating to the posterior aspect of his left leg. You perform a straight leg raise test, confirming the diagnosis of sciatica without any classic back pain red flags. In addition to standard analgesia, you wonder if a single-dose systemic corticosteroids could help relieve his pain.

A six year old boy with an asystolic cardiac arrest is successfully resuscitated in the A&E department, but he remains comatose and on a ventilator. The paediatric retrieval team is on its way. The anaesthetic consultant asks you whether, as is the case in adult medicine, induced hypothermia should be initiated.

An adult, over 18 years of age, has a dislocated shoulder and you have been asked to manipulate the joint. It is a primary dislocation with no nerve damage or other associated trauma. While assessing the patient and considering the options for relocation you recall a recent discussion from an ultrasound course regarding the use of interscalene blocks to assist the procedure. You consider the question of "is an interscalene block better at reducing pain and facilitating joint reduction than procedural sedation" considering the time required to recover the patient from intravenous conscious sedation.

A 34 week baby has been delivered following a uterine rupture and is pale and floppy with no heart rate. Resuscitation is started and the baby quickly responds. Apgar scores are 11, 25 and 410. One hour later, the baby develops abnormal movements consistent with a seizure. Blood gas analysis at this time shows: pH 6.90, PCO2 6.5, PO2 8.2, BE -14, Lactate 11. Although by gestation this baby is one week below the 35 week limit suggested in the national guideline for therapeutic hypothermia, should this baby be considered for cooling?

You are the emergency physician in charge of a busy Emergency Department (ED) in a large hospital. The department is experiencing overcrowding and you are investigating possible solutions. You wonder whether placing a senior physician at triage will help to improve flow through the department and reduce patient length of stay (LOS) and ED crowding.

A 70yr old man is rushed into resus with a BP of 60/30. He has been passing blood and clots in the urine for the last 24 hours. As you commence fluid resuscitation you wonder whether tranexamic acid may have a role in his manageemnt

A 74 year old male patient with known COPD presents acutely breathless with widespread wheeze. He refuses an arterial blood gas (ABG) and complains that last time he was here it took a long time to get the sample and it was very painful. You have already obtained a venous blood gas which has a PaCO2 of 5.5kPa. You wonder if this is sufficient to rule out arterial hypercarbia, and therefore, is an ABG in this patient an unnecessary test?

A 60-year-old man presents to the emergency department with symptoms of lower oesophageal food bolus impaction. You have previously seen intravenous glucagon used in an attempt to relieve lower oesophageal impactions but wonder if there is any evidence for its use. You wonder if there is any evidence to support use of intravenous glucagon to treat lower oesophageal food bolus impaction.

A 54-year-old man has suffered an out-of-hospital cardiac arrest. The Paramedic Emergency Service have instituted ALS—administering a defibrillatory shock and managing his airway by insertion of a laryngeal mask airway device. Spontaneous circulation has returned but the patient still required airway and breathing support. The resuscitation team leader is just having a conversation with the anaesthetist about securing the airway with an endotracheal tube when the patient has what appears to be a fit. During the tonic phase of the fit, he clenches his teeth and occludes the laryngeal mask airway device. His airway is obstructed, and he subsequently develops pulmonary oedema. You wonder whether these complications could have been prevented with a bite guard.

A 20 year old patient presents to the Emergency Department after swimming off a sunny coastal area of Queensland, Australia. He has been stung by a jellyfish. He has severe pain at the site of the sting. He is very restless with back pain, muscle cramps, nausea and vomiting. He is tachycardic and hypertensive. You diagnose Irukandji syndrome and begin treatment with intravenous opiates before attempting to control his adrenergic storm. He tells you that as a first aid measure he washed the leg at the vinegar station on the beach. You wonder whether a tap water wash would have been as effective, if indeed it has made any differnce.

A patient presents to the emergency department (ED) with a suspected acute coronary syndrome. The ECG shows ST elevation, which almost meets the criteria for the diagnosis of ST elevation myocardial infarction (STEMI) when measured at the J point. If measured 60 ms after the J point, the ECG meets criteria for diagnosing STEMI. You wonder if there is any evidence to determine whether ST elevation should be measured at the J point, as stipulated in international guidance (Thygesen et al, 2012), or 60 ms after the J point)