bestBETs

A 17 year old male found intoxicated on the street brought in by ambulance unconscious. Smelled of ethanol. Alcohol specialist team advised to give high dose multivitamins. Made me wonder if high dose intravenous multivitamin actually improves clinical outcomes in intoxicated patients

A nine year old boy is brought into the emergency department by his parents. He is a known asthmatic and has become acutely short of breath. He is struggling to talk in full sentences and his PEFR is less than 50% predicted. You suspect acute severe asthma and begin the appropriate treatment in accordance with the BTS asthma guideline. You wonder if the addition of nebulised magnesium sulphate would improve his outcome.

A 52-year-old lady has presented to the Emergency Department with a suspected PE. This is confirmed by CT pulmonary angiography (CTPA). Consequently she requires anticoagulation. Hospital guidelines suggest the use of a low molecular weight heparin (LMWH) followed by 6 months of Warfarin therapy. You wonder whether Rivaroxaban, a novel oral anticoagulant (NOAC), would be a better treatment option for her and patients like her.

A normally fit and well 26-year-old man presents to the emergency department with a sudden onset headache. It came on 2 h ago, and is the worst he has ever had. He has taken paracetamol without success. The headache made him feel very unwell, but he has no neurological symptoms. His Glasgow Coma Scale (GCS) is 15 and clinical examination is normal. You are concerned that he may have had a subarachnoid haemorrhage (SAH) and want to rule this out. He has a CT scan within 6 h of the onset of the headache. It is reported as normal. You wonder if this excludes a diagnosis of SAH.

You see a middle age lady in the Emergency Department who has presented with nausea and vomiting. She continued vomiting despite ondansetron. One of the anaesthetists suggests that you try just intravenous fluids before giving further anti-emetics. You wonder if there is any evidence for this?

A 33 years-old itinerant comes to the emergency department after a long winter night outside. He has clear blisters on three of his right fingers. You diagnose moderate frostbite and you start a rewarming process. Then, you wonder what to give him to reduce the inflammatory cascade. Should you use aspirin or a non-steroidal-anti-inflammatory drug?

A 15 year old boy with type 1 DM is admittd to the ED unwell, with a BM of 29. O/E he is pale, sweaty and lethargic with a BP of 90/40 and pulse 120. Otherwise exam is unremarkable. You site an iv cannula and take a VBG which shows pH 7.1 and HCO3- 10. You give a 900ml 0.9% NaCl fluid bolus (20ml/kg) and are about to start a sliding scale when the paediatric SpR tells you that local policy is to hold off insulin for the first 2-3 hours as it may increase the risk of development of cerebral oedema. You wonder what the evidence shows.

A 15 year old boy with type 1 DM is admitted to the ED unwell, with a BM of 29. O/E he is pale, sweaty and lethargic with a BP of 90/40 and pulse 120. Otherwise exam is unremarkable. You site an IV cannula and take a VBG which shows pH 7.1 and HCO3- 10. You give a 900ml 0.9% NaCl fluid bolus (20ml/kg) and are about to start a sliding scale when the paediatric SpR tells you that local policy is to hold off insulin for the first 2-3 hours as it may increase the risk of development of cerebral oedema. You wonder what the evidence shows.

A 23-year-old woman presents to the emergency department after falling into the canal. She was resuscitated at the scene and is now fully recovered, apart from seeming a little short of breath. You wonder if a bronchodilator would help with her symptoms.

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 15-year-old male presents to the Emergency Department after falling into a canal. He was resuscitated at the scene and is currently asymptomatic. You wonder if performing a chest X-ray will help to provide diagnostic information.

A 10-year-old boy presents to A&E after falling into a river. He was rescued and resuscitated at the scene but now has a GCS of 7. There is no evidence of trauma. You wonder if a CT scan of his head will aid the management

A 23-year-old woman presents to the emergency department after falling into the canal. She was resuscitated at the scene but is now cold, pale and short of breath. You decide she needs fluids, but aren’t sure which would be best to give.

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.

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.

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.