bestBETs

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?

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.

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 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 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 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 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 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)

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 56yr old man with a chronic history of intermittent low back pain presents to your ED. It hasn’t been right since a motorcycle injury ten years ago and when his pain is exacerbated, as it has been this time for three weeks now, it affects his gait and daily functioning, with stiffness, difficulty standing from sitting, pain on movement, worse on rising. No red flags in history or exam. He is on co-codamol and difene as per his GP, and has tried agents for neuropathic pain previously but felt they were ineffective. No red flags in history or exam. Your consultant advises you to give him a prescription for a lidocaine patch and to get him out the door. You know that the patch is only licensed for post-herpetic neuralgia and wonder if you are just wasting the patient’s time and money with this measure.

You call the surgical SHO to refer a patient whom you suspect has acute appendicitis and he asks you what the patient's lactate is? You wonder the significance of a serum lactate in the diagnosis of acute appendicitis.

A 35 year old male is brought to the emergency department with severe pain due to a fractured humerus. Intravenous access is available, and you wonder whether the use of intravenous paracetamol would decrease the amount of morphine analgesia he will need and provide better pain relief with less potential adverse effects.

Phantom Limb Pain is the sensation that an amputated or missing limb is still present and attached to the body. Phantom limb pain or phantom sensations are usually painful and can be an extremley troublemsome phenomenon.

A 70 year old man presents with back pain and collapse. His pulse is 120 and BP 90/63. CT shows a ruptured abdominal aortic aneurysm. You wonder whether giving tranexamic acid would reduce his risk of death.

A nine year-old child presentes to the emergency department with a laceration to his nail bed following trapping his finger in a door.