bestBETs

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 19 year old male who has been using crack cocaine for the past few days presents to the emergency room with chest pain and a wide complex tachycardia. He is quite agitated, hypertensive and uncooperative. You know that benzodiazepines are the recommended drugs for cocaine overdose, but what is the best medical treatment for cocaine induced arrhythmias.

A 42 year old man presents with severe constant upper abdominal pain with no nausea and vomiting preceded by two days of vague ‘heartburn’. He has been binge drinking over the weekend and is a smoker of 20 pack years. He had been diagnosed with peptic ulcer three years previously by his GP. He appears to be in obvious distress with a distended rigid abdomen, rebound tenderness, absent bowel sounds and is unwilling to sit up or be moved. His ECG is normal. You clinically suspect a perforated duodenal ulcer as your main differential diagnosis and as you resuscitate him you think if it is possible to detect free intra-peritoneal air using ultrasound.

An 30-year-old female is brought to your Emergency Department by ambulance with a chief complaint of drug overdose. The patient has intermittent tonic-clonic seizure activity and decreased responsiveness. In her pocket, you find several tablets later identified as party pills (or piperazine derivatives). As she is admitted to the hospital, you wonder what her prognosis will be.

A 52-year-old woman presents to your emergency department with a severe gastroenteritis. She is moderately dehydrated and is nauseated. While you prescribe intravenous rehydration and metoclopramide as antiemetic medication, one of your colleagues comes in and suggests that you add prophylactic diphenhydramine to prevent metoclopramide-induced akathisia. You wonder if this should be done routinely and perform a thorough search of the literature.

An infant under 3 months with Erb’s Palsy is referred to occupational therapy for hand splints. You wonder if splinting is a useful intervention to improve joint range of movement (ROM) for this client group.

A 3-year-old boy is brought to your ED after falling top to bottom of stairs at home. Parents witnessed his landing and he did not lose consciousness. The child is distressed, and only his mother is able to have a reasonable rapport with him. Would having Clinical Decision Rule (CDR) help in clearing C-spine clinically, to avoid imaging?

Clinical Scenario Your musculoskeletal physiotherapy service is considering developing a supervised gym class for post-operative shoulder patients. Many patients experience post operative pain which impacts on their ability to perform exercises. Would the use of TENS machines during the class be beneficial in decreasing pain?

Evidence for the effectiveness of circuit class therapy (CCT) in patients post stroke has concentrated on lower limb parameters, walking tasks and balance. There is some research emerging on the effects of participation in CCT on upper limb recovery post stroke. This BET will help to inform class structure and content.

You are at the scene of a car crash with a medical team. The driver is showing signs of hypovolaemic shock, and the limited access and poor light make vascular access difficult. You elect to insert an intraosseous needle, but while preparing the proximal tibial site a paramedic suggests that using the humerus will allow for faster fluid infusion. You wonder if there is any evidence for this?

A 49 year old man with acute lumbodynia for more than 2 weeks for which he received 2 non-steroidal anti-inflammatory drug tablets daily, but with no other health relating conditions, comes to the emergency department referring meleana dejections. In the laboratory tests haematocrit is discovered to be 27%, thus a transfusion is obligatory. You wonder whether the premedicasion transfusion could prevent the appearance of any allergic or febrile non-haemolytic transfusion reactions.

You are called to resus to see an adult with known epilepsy who has been brought in by ambulance in status epilepticus. The seizure is ongoing despite IM and IV midazolam boluses. A phenytoin infusion is the widely accepted second line treatment for benzodiazepine-resistant seizures, however you are aware of draft guidelines suggesting the use of newer anticonvulsants such as valproate or levetiracetam.