bestBETs

A 76 year old man presents to the Emergency Department with multiple rib fractures after falling down stairs. His pain is difficult to manage, despite intravenous opioids. You speak to the acute pain team for advice on how to manage his pain. They suggest using 5% lignocaine patches over the site of maximal pain.

A 25-year-old man presents to the emergency department (ED) with a fracture dislocation of his ankle. His ankle needs reducing, and you intend to use conscious sedation to facilitate this. You wonder whether bispectral index monitoring (BIS) would help achieve an appropriate level of sedation, thereby reducing the risk of respiratory depression while maintaining comfort. .

An 89-year-old woman presents to your emergency department following a fall. She is complaining of severe pain in her right hip area. A plain radiograph shows a neck of femur fracture. A fascia iliaca nerve block with bupivacaine is the opioid sparing analgesia of choice in your department. You have heard that magnesium can prolong the duration of action and effectiveness of the local anaesthetic. You wonder if there is any evidence for this adjunct in fascia iliaca nerve blocks.

A 5 year old child attends the ED with an acute respiratory tract infection that requires admission. A colleague mentions zinc supplementation is used in many rural areas in Asia for the prevention of respiratory tract infections. But is there evidence that zinc as an adjunctive therapy has a therapeutic role in the management of acute respiratory tract infections?

As a new attending in a regional hospital, you constantly search for new indications to use your brand new ultrasound machine. You see a 23 years old man with facial trauma after a ski accident and suspect a nasal bone fracture. You ask yourself if an ultrasound would be as sensitive or even more than your standard CR to confirm a clinical diagnosis of nasal bone fracture in adults.

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 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 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