bestBETs

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?

A well appearing 4-year-old child presents to the emergency department with a fever and a non-blanching rash. There have recently been several missed cases of meningococcaemia at your institution. As a result, local practice has been changed to include giving empiric antibiotics to all suspected cases. You wonder whether a procalcitonin level would help you identify those patients who do and those who do not need antibiotics?

A 20 year Arabian girl presents to emergency department having stung by a bee in her garden. She has urticaria and lip swelling. You offer her injection of adrenaline into her thigh, but she demands female doctor and adds that she will take injection only in her arm. You wonder whether there is any difference in the absorption and effect of adrenaline between the thigh and the deltoid.

You treat a 7 year old girl in paediatric A&E for anaphylactic shock after eating peanuts to which she is allergic. Her mother had used her Epipen before the ambulance arrived, however the symptoms did not improve. The child subsequently received more adrenaline, steroids and antihistamine in the department. You wonder if the child should have two Epipens with them which can be used in an emergency?

A 23 year old male is brought in to your emergency department after ingesting a handful of pills in an attempt to kill himself. His friends bring in an empty bottle of the only medication he took, the benzodiazepines he takes for intermittent anxiety. You wonder what symptoms he exhibits puts him at a high risk for complications from his ingestion.

A 14 girl presents to Paediatric A&E with her mother with a widespread urticarial rash and swollen lips after eating some egg to which she is allergic. You administer antihistamines and her symptoms improve. You prescribe antihistamines for discharge and wonder if they will prevent a biphasic reaction?

A 24 year old man has been admitted to the hospital after an anaphylactic reaction to shellfish, in accordance with NICE guidelines he should be discharged with an adrenaline autoinjector (eg Epipen), you wonder if using the training DVD will be better than the written information to train the patient how to use his device appropriately?

You care for a 8 year old patient in paediatric A&E who is recovering from an anaphylactic reaction after a bee-sting. In accordance with NICE guidelines he should be discharged with an adrenaline autoinjector (AAI). The correct dose for adrenaline is 0.1mg per kg although only two strengths of AAI are available - 0.15mg and 0.3mg He weighs 23kg. You wonder which is the most appropriate one to prescribe?

A 10 year old child presents to the paediatric emergency department after eating peanut butter to which he is allergic. His reaction is severe, he is struggling to breathe and his blood pressure is low. IM adrenaline, steroids and fluids are administered. You wonder if lying the child flat will help his symptoms.

A 29 year old male is brought to A&E in an ambulance after eating accidentally eating prawns at a restaurant. He is allergic to seafood and has had anaphylactic reactions in the past. His symptoms are severe, he is struggling to breathe and is hypotensive. Adrenaline is required, you wonder if a subcutaneous injection would be more effective than an intramuscular one.

A child attends the emergency department with an acute ankle injury. Clinically they are tender over the ankle and either partially or non weight bearing. A fracture is suspected but the xray appears normal. You wonder if the child could still have an occult fracture and wonder whether an USS would be of benefit for this child

A 45yo male without significant medical problems presents to the Emergency Department complaining of acute onset of chest pain. His initial EKG and troponins are within normal limits. The department is over-crowded as usual, and you contemplate whether coronary CT angiography would be a reasonable safe way to exclude ACS and discharge the patient from the department.

You are assessing a wound on the forearm of a 4 year old boy who fell whilst playing football. There does not appear to be any deeper structure involvement but you feel the wound is likely to require suturing. Your department does not currently perform paediatric sedation and therefore the vast majority of young children presenting with wounds requiring suturing are referred to specialty teams for general anaesthetic for wound closure. You have worked in a department where topical anaesthetic is applied to wounds in children to facilitate closure and wonder whether the use of this in your department would reduce the number of children referred for closure under general anaesthetic.

A 40 year old male with a negative cardiac stress test performed 1.5 years ago presents to the emergency depart with symptoms consistent with ACS.

A 47-year-old female presents to the emergency department with fever, shortness of breath, tachycardia and tachypnea. Her O2 saturation is 90% with an Fi02 of 50% and her blood pressure is 75/35 mmHg. Her x-ray reveals a large consolidation compatible with the diagnosis of community-acquired pneumonia. After adequate fluid resuscitation and early antibiotics, she remains hypotensive and poorly perfused. You have dopamine and norepinephrine at hand for vasopressor support, and you wonder which one is the best in septic shock.

A multidisciplinary supported discharge team (Physiotherapists, Occupational Therapist, Rehabilitation Assistants) notice an increase in referrals for patients in the early post-op phase (2-6 weeks) following CABG. The team provide short-term rehab (up to 6 weeks) to patients in their own homes. Team physiotherapists are unsure what form of intervention is most effective at improving exercise tolerance in this patient group.

A 38 year-old teacher presents to the ED with bilateral pneumonia. On arrival he is confused, SpO2 is 91% on air, RR is 38/min and BP is 105/59mmHg. You start treatment for severe CAP with a CURB-65 score of ≥3 and inform ITU. Would the addition of steroids to antibiotics improve this patient’s mortality and shorten his length of stay in hospital?

A 62 year old man is brought in to hospital with a 48 hour history of breathlessness, a productive cough and fever. He is tachypnoeic and hypoxaemic with SpO2 on air of 89%. His oxygen saturations correct to 98% with high flow oxygen via a facemask. However, he is confused and uncomfortable and repeatedly removes the facemask resulting in recurrent desaturations. You wonder whether there is an effective alternative to face mask oxygen that he is more likely to tolerate.