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.
Therapeutic hypothermia for cardiac arrest of asphyxial origin
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 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.
Can Protein S-100B integrate with current NICE guidelines in adult minor head injury?
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 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 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.
Is prehospital focused abdominal ultrasound useful during triage at mass casualty incidents? n
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.
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 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
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.
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 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 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
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.
Signs and symptoms associated with significant morbidity/mortality in benzodiazepine overdose
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.
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 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?
To lie or not to lie – the best position for patients in anaphylaxis?
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 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?