bestBETs

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.

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 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

You see a patient following rotator cuff repair. You wonder whether treating them in a gym rehabilitation class would be as efficacious as a course of 1:1 physiotherapy treatment at improving pain, range of movement and function.

A 52 year-old women presented to the emergency department with a history of sudden onset of hearing loss in her right ear, which came on over the preceding hour. She had no past medical history of note. Examination of the ear was unremarkable and Weber’s / Rinne’s tests suggested that her hearing loss was sensorineural in nature. A diagnosis of sudden onset idiopathic sensorineural hearing loss (SSHL) was made. The ENT surgeon on call was contacted and advised prescribing acyclovir. You wonder what the evidence is to support this strategy.

A patient presents to the Emergency Department with isolated Weber C ankle fracture. He is placed in a non weight bearing plaster cast. He has a previous history of DVT and is an active smoker. You are concerned about the risk of recurrent DVT and discuss the potential benefits of thromboprophylaxis with him. He is keen, but unfortunately claims to be needle phobic and is reluctant to take daily subcutaneous LMWH. You wonder if there is any evidence to support any type of oral thromboprophylaxis in this situation.

A 43 year old female presents to the ED with symptoms and signs suggestive of DVT. According to local protocol she requires a Doppler ultrasound study to diagnose or exclude a DVT. Unfortunately there is no scan available from radiology for 2 days. One of the new ED registrars is trained in ultrasound to level 2, including peripheral vascular studies. You wonder if there is evidence that the scan performed by the EM trainee will be equivalent to that performed in the radiology department, thus avoiding delay in diagnosis and possible unnecessary treatment.

You are the Subspecialty Paediatric Emergency Medicine Trainee working in the Paediatric Emergency Department review clinic. The next patient is a four-year-old girl who has been brought back for review of throat swab results, as prior to being seen in the PED last week she had been on amoxicillin from the GP for four days without clinical effect. Her mother tells you she has now had an additional week of Penicillin V without improvement. She has had intermittent fever for nine days, is miserable with red eyes and a cracked, sore mouth, a transient rash, and this morning her mother noticed that her hands and feet were sore with peeling skin. The throat swab is negative. You realise that Kawasaki disease is a significant possibility in this case, and wonder whether you should start aspirin prior to urgent paediatric cardiology review – and if so, at what dose?