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 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 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 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?

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 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.

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.

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.

A 45 years old man came to emergency department with sever epigastric pain and vomiting, he was tachycardic and hypotensive, immediate fluid resuscitation stabilized his hemodynamic status. Labs revealed high lipase and amylase suggesting acute pancreatitis; he was kept NPO on intravenous fluid and was treated with analgesics and anti-emetics. The case was referred to gastroenterologist for admission who on further discussion, was enquiring why antibiotic was not started in ED for a better outcomes? This stimulated my thought, if starting prophylactic antibiotics in case of acute pancreatitis improve the outcome in term of morbidity and mortality.

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?

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 five year old girl presents with mild vincristine neuropathy (peripheral neuropathy of common peroneal nerve) affecting bilateral Tibialis Anterior muscles. She is able to actively dorsiflex but walks with an affected gait. You wonder whether kinesiotaping would be of benefit to facilitate these muscles and retrain gait.