bestBETs

A 55-year-old man with a history of prior abdominal surgery presents to the emergency department with nausea, abdominal distension and absence of bowel movements for 2 days. He is not vomiting. An abdominal X-ray shows signs of small bowel obstruction. You know that there are considerable safety issues in passing and confirming the correct placement of nasogastric tubes (NGT). You wonder if there is any literature supporting these of NGT in such cases, or whether the risks outweigh the benefits.

A 67-year-old man is brought to the emergency department. He is cold, clammy and confused. He is also hypotensive and an ECG shows that he has had an AMI with ST elevation. While your colleagues prepare some vasopressors you speak to the cardiologist on call. He suggests getting the patient to the cardiac cath lab to put in an IABP. You wonder whether there is any evidence to support this course of action?

A seventeen-month-old boy attends the Emergency Department with his mother following a head injury after tripping over at home. He has an obvious large and "boggy" scalp haematoma. He appears very well and has no clinical signs to suggest intracranial injury. You are unsure if a CT scan is needed and would like to know how much emphasis you should put on this one clinical sign.

A 40-year-old patient attends the emergency department having fallen down some five stairs. During evaluation, he reports pain over his left chest and tenderness is found on palpating of his ribs in this area. You consider sending him for a chest x-ray to diagnose fractured ribs but are advised against this by a senior colleague who says it is insensitive. You wonder if ultrasound is more sensitive than x-ray in detecting rib fractures.

A 12-year-old boy presents to the emergency department with a history of limp and decreased range of movement at his right hip. You suspect that he may have a slipped capital femoral epiphysis. You wonder whether plain film radiograpy or ultrasound sonography would be a more sensitive diagnostic modality for slipped capital femoral epiphysis.

A 1-year-old child presents to the emergency department in cardiac arrest. His mother does not speak English; through an interpreter, you learn she gave an unknown cold medication, but she is not sure if she gave the correct amount because she did not understand the English instructions. You wonder whether the cause of the cardiac arrest is more likely to be the underlying condition or over the counter medication.

You read through the latest edition of a medical journal and notice a case report of a doctor who accidentally injected their own thumb while trying to use an Epipen. When you subsequently try to practice using a training device you do the same thing, this makes you wonder how many doctors do know how to use AAI correctly?

A 49 year old man with known alcoholic liver disease attended the ED, unwell. While in the ED he had a fit and bit his tongue. He only had a platelet count of 28 and so developed massive tongue swelling, which obstructed his airway. He had an emergency tracheostomy and has been sedated and ventilated. He will be transferred to ICU. The ENT surgeon asks for dexamethasone to be started to reduce tongue swelling. As the tongue swelling is caused by a large haematoma you wonder whether he would benfit more from the application of leeches (hirudotherapy)?

A 50-year-old man presents to the emergency department having been woken from sleep by his implanted cardioverter-defibrillator (ICD) firing; it has fired twice more since that time. He is in sinus rhythm and has no acute signs or symptoms. A recent angiogram showed no significant coronary artery disease (CAD). You speak to the Cardiology Registrar who advises that troponin levels should be checked. You wonder if there is any evidence for this and, further, how you might interpret the result.

A 27-year-old man is brought to the emergency department (ED) with a chest injury following a road traffic accident. Initial assessment reveals a right-sided haemothorax. You elect to place a chest drain and ask for the equipment to be set up. You are asked if you want a large bore 36F chest drain or a small 14F seldinger chest drain. You remember that advanced trauma life support training recommended a large bore drain but wonder if the smaller drain might be just as good and/or risk fewer complications?

A 72 year old man with a history of hypertension presents to the emergency department with acute onset of sharp chest pain. There are no acute ischemic ECG changes. Thoracic aortic dissection is certainly one of many diagnoses in the differential. You wonder if there is a clinical risk score than can be calculated to categorize the risk of having an aortic dissection.

A 10-year-old child is to be discharged from the paediatric emergency department after presenting in anaphylactic shock. In accordance with National Institute for Health and Clinical Excellence guidelines you prescribe an adrenaline autoinjector (AAI) and teach him and his mother the six-step technique for use using a training device. They both seem happy but you wonder if they will still remember the technique in the future or in an emergency situation?

A 41-year-old woman with a history of intravenous drug abuse and hepatitis C is brought to the emergency department with altered mental status. She is somnolent but opens her eyes to loud verbal stimuli and localises pain. She is breathing spontaneously with good effort. She has evidence of track marks along her upper extremities. The nursing staff are having difficulty obtaining intravenous access. The respiratory technician happens to be walking by the room and asks you if there is anything he can do to help—he has heard of patients having nebulised naloxone when in this state. You wonder if he is right.

You are working a shift in an Emergency Department (ED), and you receive a call from prehospital providers requesting advice in management of a violent and incoherent patient with strength far in excess of expected for his size. This seems consistent with reports you have read of Excited Delirium Syndrome (EXDS). You recall reports of sudden death in these patients and wonder if you can prevent this.

You work in the emergency department as a consultant and your rota currently does not include night working. Nationally it has been recognised that there is a deficit of senior decision makers in emergency departments at night and inevitably it is suggested that care would be safer and more effective if (work-shy) senior emergency physicians stepped off the golf course and into the gap to work shifts. You have heard that this will increase your chances of a heart attack and shorten your life but wonder whether this is just union propaganda or hard actuarial fact.

A 75-year-old man with a known history of chronic obstructive pulmonary disease and type 2 respiratory failure presents to the emergency department with a 2 day history of productive cough and shortness of breath. There are no signs of cardiovascular shock. He refuses radial arterial blood gas sampling due to pain and discomfort from previous attempts and asks whether an alternative site for sampling can be used. You ask a colleague who recommends the brachial artery—a vessel you have avoided in the past having been told that distal ischaemia can result. You wonder whether your worries are evidence based.

An 87 years old man presents to the Emergency Department with acute onset of central abdominal pain.. The pain is mild and was relieved by simple analgesia. you noticed that he had a temp of 37.8 and whit cell count of 13,000 with elevated neutrophil count. examination revealed no tenderness, guarding or rigidity and there was no masses but bowel sounds were sluggish. You wonder if this patient can go home or need to be admitted for observation and if so why?. The patient's medical history included hyperlipaedemia, hypertension, and that he is a smoking 10 cigarettes every day for the past 55 years..

A 56 years old male, who is a smoker and known case of hypertension not on any medication as well as known case of severe Gastro-eosophageal reflux disease attended emergency department with sever tearing pain retrosternally radiating to back. Examination did not reveal anything significant, and he remains heamodynamically stable through-out . Serial ECG and troponine are negative. Chest x-ray does not show any widening of mediastinum or any other evidence suggestive of Aortic dissection. Still the possibility of aortic dissection was considered due to the nature of the pain hence; D- dimer was send and the result was negative. I was wondering is it sensitive enough to rule out aortic dissection?