You receive an emergency call to a 75 year old male in a nursing home who is terminally ill. On examination you find the patient is peri-arrest with an irregular pulse and hypotensive at 57/35 and the nursing home staff state that the patient has a DNAR order but they are unable to produce the relevant documentation. You commence oxygen therapy, gain iv access and start fluid resuscitation before rapidly transporting to hospital. Afterwards you wonder what you would have done had the patient gone into cardiac arrest in the absence of a written Advance Directive.
A 23 year old male presents to the emergency department with a knee injury sustained whilst playing football. You diagnose a probable anterior cruciate tear and decide to immobilise the patient in a cricket pad splint. He has a family history of deep vein thrombosis. He is partially weight bearing. You wonder whether the splint will increase his risk of a venous thromboembolic (VTE) event and in particular whether there is any potential benefit from the use of thromboprophylaxis.
A 65 year old lady with no history of DVT/PE presents with acute onset unilateral calf swelling/tenderness. There is no history of trauma, recent surgery, and no infective symptoms. She is investigated with a D-dimer blood test which comes back at 8000 ng FEU/ml and undergoes a doppler US which is negative. What is the evidence to suggest an underlying malignancy?
A 55-year-old patient with high BMI and known COPD is brought to the Emergency Department by paramedics, complaining of sudden onset of severe difficulty in breathing. The patient has decreased air entry on the right side, the trachea is deviated to left and hyper-resonance is noted on the right side. A clinical diagnosis of tension pneumothorax is made and immediate needle decompression is indicated. You wonder which approach is better for immediate needle decompression - the anterior approach (2nd intercostal space, mid-clavicular line) or the lateral approach (5th intercostal space, anterior or mid-axillary line).
A patient has suffered a crush injury of his thigh and calf. You are concerned that he may go on to develop acute renal failure. You ask you Consultant if a urinary myoglobin assay might be useful in predicting this.
You have seen a 34 year old female with a lateral malleolus fracture, which is suitable for immobilisation in a below knee plaster cast. She had a previous DVT several years ago when her other leg was in plaster following a fracture. She is anxious not to have another one. You are aware of recent evidence suggesting that heparin prophylaxis may be beneficial in this situation. When you discuss this with the patient she asks you to quantify the risks of bleeding. You are unsure, but resolve to find out immediately.
A patient presents to your emergency department following an acute knee injury. You exclude a fracture and any acute significant meniscal or ligamentous injury and diagnose a knee sprain. You provide the patient with analgesia and RICE advice and wonder whether the application of a tubigrip will also help reduce their pain and lead to a quicker recovery.
Is intranasal fentanyl better than parenteral morphine for managing acute pain in children?
A child presents to the paediatric emergency department in acute pain but you cannot give him intranasal diamorphine due to both a departmental and nationwide shortage. You are able to give them either IM or IV morphine but wonder whether you can use intranasal fentanyl instead
What is the efficacy of duct tape as a treatment for verruca vulgaris?
An 8-year-old girl attends a general paediatric outpatient clinic for medical review and it is noted that she has duct tape on her finger. When asked about it, her mother states that duct tape was recommended by a dermatologist for the treatment of verrucas on the girl's fingers and toes. You wonder what the evidence base is for this treatment.
The Pedi-Cap device (Covidien, Mansfield, Massachusetts, USA) is frequently used in neonatal resuscitation to check the position of the endotracheal (ET) tube in term and preterm neonates. As a paediatric trainee having worked in various regions of the UK you note a huge variability in this practice. Clinical assessment of chest expansion and air entry, with improvement in saturations, colour and heart rate have been used for decades and work well. Is the Pedi-Cap superior to clinical assessment for checking the position of the ET tube?
Is ketamine a viable induction agent for the trauma patient with potential brain injury.
A 26 year-old male is brought to the Emergency Department after being struck by a car. His Glasgow coma scale on arrival is 8/15 with obvious evidence of head injury and thoracoabdominal trauma. He has a profusely bleeding scalp wound and is tachycardic. You decide to undertake a rapid sequence intubation (RSI) and begin drawing up ketamine as an induction agent. Your colleagues raise a collective eyebrow and ask you to defend your choice of agent. You offer cardiovascular stability and familiarity as two main indications. They remain concerned about the risk of raising intracranial pressure (ICP) and insist that Ketamine is contraindicated in head injured patients. They are unable to cite any evidence to support this view. You propose a BET to methodically examine the literature.
What is the incidence of biotin deficiency in preschool children with global developmental delay?
A 3-year-old girl presents in clinic with mild to moderate general delay in all areas. There is no other relevant history, no family history and clinical examination is normal. The paediatric registrar decides to order some investigations, including the biotinidase activity level, to identify the possible aetiology of the global developmental delay (GDD).
Do wrist splints need to have a thumb extension when immobilising suspected scaphoid fractures?
A 23 year old man presents with a painful wrist following a fall on outstretched hand. On examination he has diffuse wrist pain and is tender in the anatomical snuffbox. His wrist and scaphoid views do not demonstrate a fracture. You organise a two week follow up appointment in the ED clinic and give advice regarding analgesia. You have decided to immobilise the wrist in a splint, but wonder if one with a thumb extension is better than a standard splint at immobilising suspected scaphoid fractures.
Prophylactic antibiotic use to prevent Weil’s Disease after immersion in water
A drainage engineer comes to the Emergency Department following a fall and total immersion in standing water. He is concerned about Weil's disease. You do not know whether prophylactic antibiotics are of any use in disease prevention.
A premature infant (30 weeks) weighing 1050g was recently admitted to the neonatal intensive care unit after an uncomplicated delivery. You have spoken to the mother regarding the benefits of expressed breast milk (EBM) compared to premature formula milk, including the decreased risk of necrotising enterocolitis (NEC), and this is being administered via a nasogastric tube. At the ward round the consultant suggests the addition of EBM fortifier to ensure the baby has an adequate intake of macronutrients and micronutrients and to maximise extra-uterine growth. You wonder if the addition of a cow's milk-based fortifier to EBM will confer an increased risk of NEC and decide to find out more.