bestBETs

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 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 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 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 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.

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?

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.

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 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.

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 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 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 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 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.

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.