bestBETs

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.

A 32 year old woman with a 10 year history of rheumatoid arthritis (RA), treated with long-term, low dose oral prednisolone, presents to the emergency department with a 2-day history of a red, swollen left knee that is painful to touch. She reports no prior knee swelling, recent trauma, skin infection, knee surgery, illegal drug use or risky sexual behavior. On examination, she is afebrile, has an effusion and restricted movement in her left knee. You wonder if this is just another exacerbation of her RA? You order blood tests and deliberate whether the absence of fever is enough to rule out septic arthritis (SA)?

A 9-year-old boy presents with a 3 cm laceration to his left knee after falling off his bike. The wound requires closure by suturing but the patient tells you he is scared of needles. You explain that you can numb the area first using a special anaesthetic gel. You have lignocaine, epinephrine, tetracaine gel available in the department but your consultant has told you of another form of topical anaesthetic that she has used in the past containing tetracaine, epinephrine and cocaine. You wonder which topical anaesthetic is most effective.

A 5 year old boy presents to the Emergency Department with a 2 day history of limp and right hip pain he is afebrile. Is an ultrasound of the hip better at diagnosing septic arthritis than blood investigations (WBC, ESR, CRP)?

A 4 year old child present to the childrens area of the accident and emergency department with a painful tender hip joint. There is no history of trauma. His observations are normal and he has a temperature of 36.8C He has a normal xray and has has an ultrasound of the hip which shows a small effusion. He is awaiting blood tests. The mother feels blood tests are unnecessary. She asks you how necessary the blood tests are.

You are part of a HEMS crew tasked to a 50 year old farmer who has trapped his arm in a machine on his farm. The patient has sustained a traumatic amputation of the right arm at the level of the mid humerus and there is catastrophic blood loss. Bleeding has not been controlled with simple elevation, compression or a combat application tourniquet (C-A-T). You wounder which of the available haemostatic agents will best control this man's life threatening haemorrhage.

Mrs B. brings in her 8 month old son with a 3 day history of mild fever and nasal congestion. You diagnose an acute URTI and provide advise on supportive measures. Mum mentions that her neighbour was given saline drops by the GP for their child and asks if you can prescribe the same. You wonder if there is any evidence of saline drops helping babies with colds