bestBETs

An 11-year-old boy is struck by a car and sustains an acquired brain injury (ABI). He is admitted with a Glasgow Coma Scale score of 6/15. Cranial imaging reveals evidence of diffuse injury. Approximately 12 months later following discharge, the patient is seen for a planned review. The patient and his family report poor attention with hyperactive and impulsive behaviours. The school has reported to parents that there has been a change in his ability to concentrate at school and he is being disruptive in class. This represents a clear departure from the patient's preinjury behaviour. Parental and school management of this concerning conduct is structured and consistent. You have heard that stimulant medication may be of benefit in managing difficulties with attention, hyperactivity and impulsivity (attention deficit hyperactivity disorder (ADHD) type behaviours) following an ABI.

A 2-year-old child is acutely admitted at night to a district general hospital following a prolonged focal seizure. A CT scan of the head without sedation fails as the child is too active and distressed, and as the on-call paediatric registrar, you are requested by the radiographer to prescribe a sedative. The NICE guideline for sedation in children and young people advises that midazolam or chloral hydrate can be used to sedate for painless procedures. You wonder which of these drugs is the most effective and safe and which has the least side effects.

As a paediatric registrar you are presented with a 4-month-old baby in paediatric outpatients. His mum describes him as having large vomits up to 30 min after most feeds, and recently he has seemed reluctant to feed. He is exclusively breast fed, and is gaining weight appropriately and otherwise thriving. He has previously been investigated for his vomiting and you conclude that he has gastr­oeosphageal reflux without complications (GOR). In the first instance, positioning and thickened, small frequent feeds would be advised. The latter suggestion is not without difficulty for mothers exclusively breast feeding. As the mother is describing vomiting at least six times per day, but no signs suggestive of pain at present, could a pro-kinetic alone such as domperidone improve these symptoms?

A 28 year old man with Hodgkin’s lymphoma presents to the Emergency Department with increasing pain, swelling and erythema of the forearm following intravenous administration of doxorubicin a few hours ago at your local specialist cancer treatment centre. The pain was described as severe and constant with localised swelling, erythema, warmth and limited movement of the wrist. You suspect extravasation of anthracycline from the cannula site and as you initiate local measures of limb elevation and cooling, you wonder if emergency intravenous administration of dexrazoxane may be beneficial in reducing the risk of soft tissue necrosis and subsequent debridement.

A 30 year old patient attends your department 2 weeks following a lateral malleolar ankle fracture. They complain of increased pain and cramping up the calf. The toes are swollen but there are no clinical signs of compartment syndrome. You are concerned about the possibility of DVT and arrange an ultrasound scan to investigate further. A junior doctor asks you what the incidence /pretest probability of venous thromboembolism is within this cohort of immobilised ambulatory patients. You tell them that is an excellent question. And that you will give them one week to find out the answer for you.

A 40-year-old man who is having a haematemesis is brought into the emergency department. He has not attended the department before but admits to chronic alcohol dependency. It is not known if he has liver disease or varices. You resuscitate him and arrange an endoscopy. Being aware of the use of tranexamic acid in trauma patients you wonder if using it would reduce this man's bleeding and improve his chance of survival?

An adult patient attends the ED with a simple traumatic laceration to the pinna after fighting. You have heard that we should give prophylactic antibiotics to these patients after suturing the wound as they have a high risk of developing perichondritis. You wonder whether there is any evidence for this.

You are a paediatric registrar carrying out your shift in paediatric Accident and Emergency. You see a 12 year old girl presenting with an acute onset of right sided stroke. She was admitted to the Children’s ward and on further investigation she was found to have an ischemic stroke involving the left middle cerebral artery territory. Her cardiac evaluation was normal. The Paediatric Neurologist advised commencing her on Aspirin. The family are anxious about the efficacy and safety of Aspirin. You have heard that Aspirin has been proven to be beneficial in strokes in adults with arterial ischemic infarcts. However, you are not sure if there is enough evidence to justify its use in paediatric age group. You decide to find out the evidence

A 35 year old male patient attends the emergency department with acute onset pain in left flank that is constant and radiating anteriorly. You speak to the radiologist to request a non-contrast CT scan to identify the cause of his pain, but the request is declined on grounds that the radiation dose is high and not justified and other imaging is advised. You wonder whether the dose reduction is possible and propose a bet to methodically examine the literature.

A 12 year old female post motor vehicle collision is admitted to the pediatric ICU with a grade 3 liver laceration, pelvic bone fractures, and a humerus fracture. She has a central line that was started for treatment of hypotension. Your institution typically does not provide deep vein thrombosis (DVT) prophylaxis in children, but you wonder what the incidence and risk factors of venous thromboembolism (VTE) are in children who are critically ill after trauma.

A 31-year-old man was working in a local chemical factory when he splashed himself with hydrofluoric acid to the eye. He attends the emergency department and you arrange for copious water irrigation and oral pain relief. You have the heard about the Hexafluorine antidote solution and wonder whether there is any evidence for its use.

A 9 month old infant is brought to the Emergency Department by his mother with a 3 day history of coryzal symptoms and increasing difficulty breathing. Ausculation reveals widespread wheeze and crepitations, and you make a clinical diagnosis of bronchiolitis. You wonder whether a chest xray is indicated to confirm this diagnosis and assess its severity.

A 5 year old boy presented after being struck by a car while riding his bicycle without a helmet. He had a GCS of 5, and was found to have a right frontal skull fracture and a left sided subdural hematoma on CT imaging studies. He was intubated while in the emergency department and admitted to the Pediatric Intensive Care Unit. Does treatment with hypothermia have improved clinical outcomes?

You are seeing a 3yr old girl in the ED. She has fever, red tongue and conjunctivitis. Her mother mentions her BCG scar looks more red than usual. You wonder if this is significant.

A 42-year-old man presented to the emergency department with unilateral parasternal chest pain of recent onset. Examination revealed reproducible tenderness overlying the 2nd to 4th right sided costochondral junctions. Significant differentials were excluded subsequent to clinical examination and normal investigations, and a diagnosis of costochondritis was made. You prescribe ibuprofen, however he states he is intolerant to all non-steroidal anti-inflammatory drugs and asks whether there are any alternative treatments. Your registrar suggests giving either a local corticosteroid injection or oral soluble format prednisolone. You wonder what evidence exists to support this.