bestBETs

An eight-year-old female patient arrives at the Emergency Department with her mother after being struck by a car while riding her bicycle. Her respirations are strained and she has an obvious deformity of the right shoulder. She is evaluated immediately by the trauma service. Possible interventions include the placement of a chest tube. Should her mother be removed from the room?

A 6 month-old-female is brought to the emergency department by their parents after what they describe as a fall from a bed to the floor. The child has several bruises that appear to be in various stages of healing and the parents seem very tense. I suspect non-accidental injury. How likely am I to see occult fractures on a standard skeletal survey?

A 22-year-old woman, who is currently 12 weeks pregnant, presents to the emergency department complaining of a four week history of severe nausea and vomiting. She appears to be clinically dehydrated and urinalysis confirms she is ketotic. Immediate management includes intravenous fluids and standard anti-emetics. Unfortunately she gets minimal relief and continues to vomit. You recall from your recent oncology placement, the beneficial effect of steroid therapy on chemotherapy induced vomiting, and wonder if a trial of steroids might be useful to control the symptoms of severe hyperemesis gravidarum (HG)

A 28-year-old man is brought to the emergency department by ambulance. He was thrown out from a club following an argument with a bouncer. As he tried to escape from the bouncer he was sprayed in the eyes by another doorman. At the scene the paramedics tell you that the bouncer had a can of CS spray with him that had been confiscated by the police. He has watery and painful eyes with a foreign body sensation. You ask one of the senior nurses to perform an eye washout but she suggests that he would be better off standing in front of a fan and letting the air blow the CS particles off. You wonder how on earth they know this but remember that sister Milly Terry is a weekend warrior with the Territorial Army and that they use CS gas for Chemical, biological, radiological and nuclear (CBRN) training.

A 70-year-old woman presents to the emergency department (ED) with confusion and collapse. You find her serum creatinine is 180 μmol/l and wonder which classification system you should use to determine her renal function and prognosis.

A 40 year old man presents in the Emergency Department complaining of fever and increased abdominal size for the last two days. He is an alcoholic and the clinical exam shows a distended abdomen with dullness in the flanks. An abdominal ultrasound confirms ascitis. A diagnostic paracentesis is done and reveals a polymorphonuclear (PMN) cell count greater than 250/mm3.

A patient requires a thoracotomy for resection of a lobe of their lung is worried about pain relief post-operatively. You wonder whether it might be pertinent to provide them with an spinal block rather than prescribe IV analgesia for the immediate post-operative period.

A patient has undergone a video assisted thorascopic surgical procedure and is returned to the cardiac HDU unit. Following surgery the patient requires analgesia and there is the potential for IV or spinal/intrathecal delivery of the analgesia.

A 4 year old boy presenting to Emergency department with high pyrexia of 39.5C and on going generalised clonic tonic seizure. No IV access is immediately obtainable. You have identified that the child requires urgent first line treatment for initial seizure control.

An 8-year-old female is hit by a car while riding her bike. Upon arrival to the emergency department she is hypotensive and tachycardic. Multiple intravenous attempts were made en route to the hospital but have been unsuccessful. You question if a powered intraosseous insertion device would provide access as safe and effective as intravenous access?

A 6 year old attends the emergency department with a moderate exacerbation of his asthma.

A 65 years old male patient is admitted through your Emergency department with severe sepsis. Early Goal Directed Therapy (EGDT) was started within one hour of patient’s arrival. You are aware that sepsis has a very high mortality and you wonder is there anything else you can do to improve the chances of your patient surviving. ITU registrar mentions the possible role of statins in the management of septic patients. On your search you realized that 3-hydroxy-3-methylglutaryl coenzyme A (HMG-COA) reductase inhibitors (statins), possess a number of pleiotropic effects that are thought to have a beneficial effect in septic patients. Data from animal models has shown promising results in improving survival in mice with sepsis, and you wonder if statins could be the new breakthrough drug in the management of these patients.

A 47-year-old woman self-presents to the emergency department complaining of a sudden-onset headache associated with vomiting, which had developed suddenly. Her only medical history is migraine with aura diagnosed and treated by a neurology clinic; but this felt different. Triage notes show that she is apyrexial and routine observations are within normal parameters (GCS E4 V5 M6). No neurological signs are present but she appears incredibly uncomfortable, in the absence of true photophobia. A CT scan is done and no abnormality is identified. The patient feels reassured and is keen to get home, where her husband would be able to keep an eye on her. This seems reasonable. However, you wonder whether or not there is evidence for any circumstances where not progressing to lumbar puncture +/- admission would be supported, despite the current consensus opinion that it is required for the added confidence when combined with CT, in excluding sub-arachnoid haemorrhage (SAH). Your thought is based on the fact that in your experience LP procedures on non-ambulance arrivals have not yielded positive results.

A one year old girl presents to the Emergency Department with acute wheeze and suspected asthma. Her GP had given her salbutamol syrup which did not appear to help. You use salbutamol via a spacer and want to know if oral bronchodilators are effective at relieving asthma symptoms.

A 26-year-old woman presents to the Emergency Department with pelvic pain and purulent vaginal discharge is diagnosed with pelvic inflammatory disease (PID). She had an intrauterine device (IUD) placed six months ago after the birth of her third child. She is afebrile, able to tolerate oral intake, and can be managed as an outpatient. As you discharge her with antibiotics, you wonder if you should have removed the IUD or arrange to have it removed by her gynecologist.