bestBETs

Following the diagnosis of acute pancreatitis, a 50 year old man awaits treatment in the emergency department. As the right course of action is determined by severity, it is uncertain whether if Matrix Metalloproteinase/Metallopeptidase-9 (MMP-9) can be used to assess the degree of severity in the early stages acute pancreatitis.

Your Trust launches an updated Acute Pain Policy which states that IV morphine should be given by a Doctor as a 2mg bolus at 5 minute intervals. Your ED has been using 1-10mg titrated for over 10 years without significant incident but the Trust Risk Management Committee require evidence that what you do is safe and effective. You wonder what the evidence is for your pratice.

You receive an emergency call to a 47 year old male with a fractured right ankle from playing football. On arrival you can identify a possible closed fracture of the distal tibia and proximal fibular. Your patient is in a great deal of pain causing him to move his leg and irritate his injuries. On closer inspection you find a strong pedal pulse with good perfusion distal to the injury. There are no other injuries. You turn your attention to pain relief. On taking a history you find your patient has not been SCUBA diving or ever had any pulmonary problems, you patient has also never been exposed to opiate based drugs. You wonder whether you should give Morphine or Entonox? Which one is more effective and safer?

A 27 year old lady presents to A&E with a one week history of worsening whole right upper limb swelling. She admits to lots of heavy lifting days prior to the swelling commencing. No acute injury can be found and she has no previous medical history. You are concerned she may have an UEDVT. Given she has no risk factors, you consider carrying out a d-dimer to exclude the diagnosis.

An 80 year old lady is referred to the Hospital and Community for community rehabilitation following her hospital admission. She has a diagnosis of dementia. She lives with her husband and he reports that she is struggling with activities of her daily living (ADLs). The Occupational Therapists wonder whether there is evidence that a cognitive rehabilitation programme will improve this lady's ability with her ADLs.

A 67-year-old woman presents to the Emergency Department (ED) with a 3-day history of a dysuria, nausea, vomiting and fever with rigours. She is confused and looks pale. Her respiratory rate is 40/min, heart rate is 120/min, blood pressure is 80/40 mm Hg and temperature is 38.9°C. You diagnose severe sepsis secondary to a urinary tract infection. You wonder whether crystalloids or colloids are best in the initial fluid resuscitation to improve her survival.

A 65 year old patient attends the Emergency Department with a fever and symptoms suggestive of urinary sepsis. He has a T 39.1 and HR 120-140 irregularly irregular. ECG confirms new-onset atrial fibrillation. You decide to rate control this patient with bisoprolol. Whilst doing this, you consider the need to anticoagulate the patient to prevent stroke.

A patient comes in to the accident and emergency department complaining of foreign body sensation after eating fish for dinner. The fish bone is not visible on soft tissue plain radiograph of the neck. Does knowing the species of the fish consumed help the clinician make a decision on referral for endoscopy?

An adult patient presents to the emergency department unwell with a temperature but no specific signs of a focus of infection. You wonder how useful a measurement of C Reactive Protein (CRP) will be in making a diagnosis of severe bacterial sepsis.

You see a 27 year old male who has ruptured his achilles tendon whilst playing football and you decide to treat him in an equinus cast. You are aware of a recent case in which a patient died from a pulmonary embolism after receiving similar treatment, as well as recent evidence noting a high (39%) proportion of venous thromboembolism in this particular ambulatory cohort [Nilsson-Helander]. You wonder if the evidence supports treatment with prophylactic LMWH.

A 34 year old female presents to the emergency department following an inversion injury to her ankle. An x-ray reveals a fracture, suitable for conservative management in a below-knee plaster cast. You are aware of an ongoing medico-legal case at your trust regarding a patient recently admitted with a pulmonary embolism, which was attributed to plaster cast immobilisation. You wonder if thromboembolic prophylaxis will significantly reduce the risk of subsequent VTE in your patient.

A 9 year old presents to the ED with acute abdominal pain; is pain on hopping/jumping indicative of appendicitis?

A 30 year old Nurse presents to the ED with two day history of a hot, swollen joint. She reports no prior knee swelling and no recent trauma or knee surgery, illegal drug use, rash, uvetis or risky sexual behavior. On examination, she is afebrile and has a left knee effusion. Her WBC, ESR and CRP are all raised. The joint aspirate reports a negative gram stain. You wonder if negative gram stain is enough to rule out septic arthritis?

A 49 year old gentleman presents with weakness of the entire right side of his face. He has no other neurological features to suggest a stroke. You diagnose idiopathic facial paralysis (Bell’s palsy). Should he be treated with prednisolone or a combination of prednisolone and an antiviral agent?

You are providing on site medical cover at a large music festival. There has been an incident and a 26 year old man is brought to the medical tent after being stabbed. He has a sucking chest wound. Should you use the fancy chest seal device in the medical box or make your own three sided dressing while you wait for the ambulance to arrive?

Working on Trauma orthopaedics you routinely use cryocuff to reduce swelling before operations. A nurse asks you how to use the cryocuff and if keeping it on longer than 20 minutes would be more effective in reducing swelling. Your unsure of this and therefore decide to check the evidence.