bestBETs

A 78 year old lady is admitted on a saturday follwing a fall at home and acopia. She is then admitted to the acute medical unit. Physiotherapy and Occupation Therapy assessments only occur Monday to Friday between 08:15am and 16:15pm. We wonder whether a seven day therapy service on the acute medical unit would decrease her length of stay.

A 48-year-old, well-trained, long-distance runner collapsed at the finish of a half marathon. Against his usual practice, the athlete tried to accelerate on the last hundred meters towards the finish line. Immediately after the collapse, cardiopulmonary resuscitation with defibrillation of ventricular fibrillation was successfully carried out. After ROSC, the patient was arousable but not fully alert. We sought to understand the long term neurological outcomes for patients with out of hospital cardiac arrest from ventricular fibrillation?

A 60 year old male, brought in by ambulance crew,with the complaint of sudden onset severe right flank pain. He is also known to have cardiac problems and is on several medications. On examination his systolic blood pressure is 100 mm of Hg and the pulse rate of 65 per minute. The immediate concern is a ruptured AAA. Can ultrasonography by emergency physicians detect accurately the presence or absence of an abdominal aortic aneurysm,AAA and affect the immediate management strategy in this patient?

In the physiotherapy department you see two 50-year-old female patients who have both sustained ankle fractures 12 weeks ago and are mobilising with crutches. One has been conservatively managed and the other has had an open reduction–internal fixation. You wonder whether hydrotherapy would be a viable treatment option for either patient. A literature search is required in order to ascertain whether hydrotherapy is an appropriate intervention for either patient.

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 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 37 year-old man, who is known to suffer from cluster headaches, presents to the Emergency Department with a severe unilateral headache associated with lacrimation, rhinorrhoea and restlessness. He has already taken his own triptan and has been put on oxygen therapy on arrival. You remember being told that intranasal lidocaine can help in cluster headaches and you wonder what the evidence is for this therapy.

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 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 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 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 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.