bestBETs

A child with suspected benign raised intracranial pressure requires a lumbar puncture and opening pressure readings. As you prepare for the procedure the consultant on call asks you to make sure the child’s legs are straightened out before you measure the opening pressure. You wonder whether measuring CSF pressure with the lower limbs in the flexed position truly does falsely elevates the reading, and whether you should take the reading with the lower limbs in the extended position?

A 4 year old child is brought to the Emergency Department by her parents. She presents with protracted seizures. It proves difficult to gain intravenous access for administration of IV Lorazepam, which is the standard of care. You wonder whether intranasal administration of Lorazepam may be an acceptable alternative.

A 65 year old male presents having returned from a two week holiday. Whilst on holiday he experienced a tearing pain between his shoulder blades, which has been slow to resolve. Examination reveals no abnormal findings. However, his blood pressure in both arms is measured at 135/80. An x-ray reveals a slightly enlarged mediastinal shadow; a CT aorta is performed which confirms the diagnosis of an uncomplicated type B aortic dissection.

A 56-year-old female presents to the emergency department complaining of intermittent nausea, she is now also experiencing angina, dyspnea, and diaphoresis. EKG shows signs concerning for myocardial ischemia. Interventional cardiology prepares to take the patient to the cardiac suite for coronary angiography.

A 45 year old man is brought to the ED in respiratory distress. He is HIV positive and has defaulted on both his anti retrovirals and follow up. From his chest X ray you suspect Pneumocystis jerovii pneumonia (PJP). After intubation he becomes increasingly difficult to ventilate and oxygenate. The team from Critical Care are talking about getting him onto the ICU to ventilate him in the prone position. Although this may improve his oxygenation you wonder whether it will affect his survival?

A 65 year old male has an out of hospital cardiac arrest that is witnessed by bystanders. EMS arrives and the patient needs an advanced airway. The airway kit has endotracheal tubes as well as supraglottic airways. The EMS responder must decide which airway will provide the best outcome for the patient.

13 years old boy attends clinic with uncontrolled epilepsy-Idiopathic generalized epilepsy- on lamotrigine having failed to respond to sodium valproate in adequate dosages. Prior to onset of epilepsy from primary school he had sustained elements of hyperactivity and impulsivity which on observations and connors questionares were thought to be ADHD. These have escalated and now need treatment with stimulants in their own right. Question is whether stimulants are safe in the presence of especially uncontrolled epilepsy.

A young child attends the emergency department with her concerned parents. She has been complaining of right sided lower abdominal pain for 2 days, with several associated episodes of vomiting. There is no fever, the child looks well and urinalysis is normal. On further questioning, several members of the family have had a recent viral illness. On examination the child has some generalised discomfort around the umbilical and right iliac regions, but no localised peritonism. Observations are within normal limits. After you have finished your examination, the father declares himself to be a barrister with a medicolegal firm. He mentions appendicitis and is very insistent that further tests be done to refute the diagnosis. You have recently read a research article about a new biomarker for acute appendicitis and wonder whether the test would go some way towards reassuring you and/or the family. You resolve to consult the literature.

A 25-year-old healthy man presented to a semi-urban trauma unit with a minor head injury (MHI). After thorough assessment and following UK National Institute for Health and Clinical Excellence (NICE) guidelines, you ascertain that the patient does not require CT brain scan and can be safely discharged home. A neurosurgical colleague, having recently returned from a European conference, had adopted protein S100B sampling as a neuroimaging triage tool for the department. He suggests this is a more accurate measurement of the extent of brain injury. On following his departmental policy serum S100B sampling yielded a positive result, but subsequent neuroimaging reveals no intracranial pathology. You wonder what the clinical utility of protein S100B actually is in MHI and also whether integration of this blood test within clinical guidelines might provide improved, more cost-effective care?

A bomb explodes in a busy downtown building. When emergency medical care arrives there are 70 casualties on the ground and 50 standing or sitting. The prehospital team knows the START triage system and classifies seven patients as black, 12 as red and 51 as yellow or delayed. The 12 casualties classified as red are transported to the hospital with all the vehicles that were available. You wonder whether using focused abdominal ultrasound would help in further prioritising the transportation of the remainder patients.

A 34 years old female presents to your emergency department with acute migraine refractory to acetaminophen, NSAID and triptans. Your colleague talk to you about the use of propofol in migraine and you wonder if propofol would improve the chance of a complete resolution of her headache.

A 34-year-old woman is discovered hanging from a noose around her neck. When a family member discovers her, she is in respiratory arrest and comatose. The paramedics provide artificial ventilation. After several minutes, the patient\'s breathing returns but she remains unconscious. On arrival at the emergency department, she is haemodynamically stable, normothermic and unresponsive. You are aware of the evidence for therapeutic hypothermia following return of spontaneous circulation for a cardiac arrest associated with a shockable rhythm. Given the potential neuroprotective effect of therapeutic hypothermia, you wonder whether a superior neurological outcome can also be obtained in comatose patients following asphyxia.

A 37-year-old woman presents at the emergency department with a left-sided headache. She has a past history positive for migraines and she describes the current episode as identical to her migraines. Your resident wants to prescribe prochlorperazine to treat her migraine, but you usually prescribe metoclopramide for patients with acute migraine. You wonder which of these dopamine antagonists is better for the treatment of a patient with acute migraine.

A 47 year old female patient is brought to your ED. She admits to regular alcohol consumption, is tachycardic with extremities tremor and ataxia. She asks you for something to help her with her symptoms. She has not drunk any alcohol for two days. You wonder if any biological marker would allow you to predict if she is really at risk of developing an alcohol withdrawal syndrome.

A patient is bought to the Emergency department with pelvic trauma. One of the members of the trauma team mentions that the new T-pod pelvic binder is better than the traditional wrapped sheet. You wonder if there is any evidence to support this

A young, independently mobile female attends the Emergency Department following a fall. X-ray reveals a Weber A fracture of the lateral malleolus. She is reluctant to have a plaster cast and you wonder if a removable functional brace would be as effective

You are leading the team resuscitation of a cyclist who was hit by a car. From the injury pattern you suspect she may have an open book pelvic fracture, and decide to apply a pelvic binder. One of your colleagues suggests there is no point unless the injury is shown on x-ray, and another thinks they are entirely pointless. You get the binder applied, but resolve to check the evidence before next time.

Having been unable to obtain intravenous access you have just placed an intraosseous needle in a 30-year-old intravenous drug user who has attended the emergency department with a Glasgow coma scale score of 6, pinpoint pupils and respiratory rate of 3 following an opiate overdose. You are about to inject lidocaine to reduce the pain of the infusion when a passing colleague suggests that it is a waste of time as it will not be effective (as the pain is caused by pressure effects distant to the injection site). You wonder if there is any evidence to support your practice?