bestBETs

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-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.

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?

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 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 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 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 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 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.

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?

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 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?

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.