bestBETs

A 62 year old male emergency patient arrives in cardiac arrest. During resuscitation he is found to have pulseless electrical activity (PEA). Several rounds of ACLS are performed with no improvement in the patient's condition. You wonder if a rapid bedside cardiac ultrasound (echocardiography) would be of any prognostic or diagnostic utility.

A 30-year-old man attends your emergency department after a deliberate overdose of his father's atenolol tablets. He is bradycardic, hypotensive and has had seizures. Despite fluids, atropine and a glucagon infusion, he remains hypotensive and you start treatment with inotropes. He remains unresponsive to treatment and very hypotensive and you wonder if an intravenous lipid infusion would help.

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 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.

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 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 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 28-year-old woman experiencing dizziness, vertigo, nausea, and vomiting after riding a boat is brought to the emergency department. She has no systemic disease or diarrhea and denies being pregnant; her vital signs are normal. Her symptoms improve a lot after resting. She enquires about methods to prevent the motion sickness. You wonder whether natural ginger extracts could help prevent or reduce severity of motion sickness.

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

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.