bestBETs

A 13-year-old boy presents with an 8 month history of abdominal pain, diarrhoea and some weight loss. Investigations confirm Crohn’s disease (CD) of moderate severity. To induce remission you consider either a 6-12 week course of corticosteroids or exclusive enteral nutrition with a polymeric formula for 6 weeks. You plan to reserve the thiopurines (azathioprine [AZA] or 6-mercaptopurine [6-MP]) for second-line therapy. After an internet search, the parents are aware that relapse occurs frequently after initial treatment and that the disease often progresses. They are keen for their son to start a thiopurine straight away.

The trauma team including the cardiothoracic surgical department discusses at a grand round meeting the introduction of a new “adult thoracic trauma” management protocol after patients with thoracic trauma have been stabilised in the emergency department. This protocol involves the use of Video-Assisted Thoracoscopic Surgery (VATS). You are not sure whether VATS is a safe and effective technique for managing thoracic trauma so you decide to look up the evidence yourself.

You are the emergency department consultant who attends an adult who has been brought in by HEMS following a high speed RTC. He suffered loss of consciousness and was intubated at scene with a GCS 6. He has a sustained a severe closed head injury. You consider if there is any benefit for this patient in receiving combination progesterone and vitamin. D therapy for potential neuroprotection post- traumatic brain injury. Would this therapy improve clinical outcomes for the patient? You resolve to search the literature.

A ten year old girl is admitted with a widespread petechial rash and bleeding gums. A full blood count demonstrates a platelet count of 3,000/mm3 and a diagnosis of idiopathic thrombocytopenic purpura is made. You decide that she warrants medical treatment but have seen both steroids and intravenous immunoglobulins used previously by colleagues. You wonder which treatment is most effective.

A 69yrs female comes after a fall with right hip pain; x rays confirm the diagnosis of fracture neck of femur (NOF). She is very hard to cannulate and you have read an article about anaesthetists putting ultrasound guided fascia iliaca block for NOF fractures. We want to know how good it is in the hands of ED physicians.

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 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 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 56 year old is brought to the ED suffering from a STEMI. He is hypotensive and suffering from cardiogenic shock. He has been started on dobutamine but he has failed to respond to this initial treatment. The Cardiologist asks if the ED has levosimendan as he would like this started on the patient since there is already another patient in the Cath lab. You wonder whether there is any evidence for this treatment.

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 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 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 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 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?

During a long resuscitation in the emergency department, you have to repeatedly remind the members of staff performing chest compressions to keep up a good rate. You recall that during previous cardiac arrests, the quality and rate of external cardiac compressions differs between operators. You wonder if a metronome could help providers by defining a set rate and so improve cardiopulmonary resuscitation (CPR) quality.

A 25-year-old man presents to the ED complaining of pleuritic chest pain and shortness of breath. He is afebrile, has no other symptoms, takes no medications and has never had any surgery. You wonder whether a clinical decision rule such as the (PERC could help exclude PE without the need for D-dimer testing.