bestBETs

A 61 year old female with MS is about to start a programme of rehab. She has pain in her right hip, stiffness throughout her right lower limb. She finds it difficult to mobilise independently and to climb stairs. Should the rehab programme be land based in rehab gym or a course of hydrotherapy?

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 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.

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.

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 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?

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.