bestBETs

A patient present with a simple corneal abrasion detected using fluorescein and the slit lamp. They are symptomatic and you prescribe an antibiotic ointment and an ocular lubricant. You wonder whether there is any evidence to use both items and cost your trust more money

A 50- year old woman is referred to the Emergency Department by her GP with a serum potassium level of 6.4 mmol/L. A repeat blood test confirms hyperkalaemia, with a serum potassium of 6.8 mmol/L. After giving a cardiac membrane stabiliser you order an IV infusion of insulin and glucose, but wonder how effective this will be in lowering her serum potassium.

A 50- year old woman is referred to the Emergency Department by her GP with a serum potassium level of 6.4 mmol/L. A repeat blood test confirms hyperkalaemia, with a serum potassium of 6.8 mmol/L. After giving a cardiac membrane stabiliser and an IV infusion of insulin and glucose her serum potassium is still high. You consider prescribing nebulised salbutamol but wonder how effective this would be at this stage.

A 70-year-old male patient, weighing 80 Kg, with diabetes mellitus, coronary heart disease, congestive heart failure (NYHA III), essential Hypertension (stage 2) and renal dysfunction (serum urea: 80 mg/dL, serum creatinine: 1,6 mg/dL, creatinine clearance of 48,6 mL/min/1.73m²); His therapeutic regimen included isosorbide dinitrate 20 mg bid, furosemide 40 mg qd, enalapril 20 mg qd and metformin 1000 mg tid. He was admitted in the emergency department of our Hospital, complaining of fever, malaise, respiratory distress, myalgias, disorientation and abdominal discomfort with positive right Murphy’s sign. He was hemodynamically unstable with MAP (mean arterial pressure) of 50 mmHg and tachycardia (120 bpm). Laboratory evaluation revealed leukocytosis 28000/mm³, severe renal failure (serum urea: 210 mg/dL, serum creatinine: 6 mg/dL, creatinine clearance of 4,9 mL/min/1.73m²), high anion gap metabolic acidosis in arterial blood gas analysis (pH 6,9; AG 30 mEq/L), a plasma lactate of 10 mEq/L, no ketonuria or evidence of ingestion of a toxic substance (such as ethylene glycol, methanol). A renal ultrasound confirmed right acute pyelonephritis. According to the patient’s medical and drug history, clinical and laboratory analysis (although confirmatory laboratory metformin levels were not obtainable), we suspected of a case of Metformin associated lactic acidosis (MALA), complicating a septic shock in the context of acute pyelonephritis. The patient was transferred to our intensive care unit and managed aggressively in accordance with the Sepsis Surviving Campaign Guidelines (2008), with mechanical ventilation, fluids and vasopressor agents; despite intravenous sodium bicarbonate therapy, the clinical scenario was deteriorating and therefore immediately continuous venovenous hemodiafiltration (HDFVVC) was started and went on during 23 hours. Ultimately, he was stabilized and progressive restoration of acid-base balance and renal function was observed. Did hemodialysis, compared to supportive care, had a more positive effect on this patient’s outcome?

A 56 year-old male patient attends review clinic with recurrent olecranon bursitis. The bursitis was aspirated one week previously, and the resulting culture is negative. You wonder whether re-aspiration and bursal steroid injection will prevent recurrence.

A 50- year old woman is referred to the Emergency Department by her GP with a serum potassium level of 6.4 mmol/L. A repeat blood test confirms hyperkalaemia, with a serum potassium of 6.8 mmol/L. After giving a cardiac membrane stabiliser and IV insulin and glucose her serum potassium is still high. You are about to prescribe IV salbutamol, then remember someone telling you they always prescribe nebulised salbutamol in hyperkalaemic. You wonder which of the two is more effective.

You are asked to review a febrile 2-month-old infant who presented to the accident and emergency department. The urine analysis carried out before your arrival is suggestive of urinary tract infection (UTI) (urine dipstick: positive for nitrites and white blood cells (WBCs); microscopy: 220 WBCs per high powered field). On examination the infant appears well and has no signs suggestive of meningitis. However, you recall a senior colleague stating that young infants with UTI should always have a full septic workup to rule out co-existing bacterial meningitis. You wonder if there is any evidence to support routinely performing a lumbar puncture in this setting?

A 65 year-old man is referred to the ED by his GP with a serum potassium concentration of 6.5mmol/L. Repeat tests confirm hyperkalaemia. You order an ECG which shows characteristic hyperkalaemic changes. You wonder whether you should prescribe calcium chloride or calcium gluconate, as you're not sure which is more effective.

A 65 year-old man is referred to the ED by his GP with a serum potassium concentration of 6.5mmol/L. Repeat tests confirm hyperkalaemia. You order an ECG which shows characteristic hyperkalaemic changes. You consider prescribing calcium gluconate, but wonder what effect this will achieve.

A 23-year-old female presents to your department following a fall and is diagnosed with a Weber B ankle fracture by one of your junior colleagues. They arrange plaster immobilisation and fracture clinic follow-up for 1 week later. Before discharge they approach you and raise the question of thromboprophylaxis. The patient is a smoker and on the combined oral contraceptive pill, but otherwise has no clear risk factors for venous thromboembolism (VTE). You wonder if there is any means of predicting the patient's risk for subsequent VTE in order to help make an evidence based decision regarding thromboprophylaxis.

In the primary care setting, sore throat is a very common cause for consultation. However, the cause of tonsillitis is not known in many cases. Relying on clinical presentation and history alone is unreliable in differentiating streptococcal from viral tonsillitis, creating the problem of unnecessary and ineffective use of antibiotic therapy in many situations. Microbiological culture is the best way to establish an aetiological diagnosis, but is time consuming. The question therefore arises whether inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white cell count (WCC) and procalcitonin (PCT) can differentiate streptococcal from viral tonsillitis.

An 18-year-old woman self-presents to the emergency department with a 12 h history of light headedness, nausea and vomiting, severe abdominal pain, tachycardia and hypotension. She has had previous similar episodes of abdominal pain associated with swellings of her hands and feet which have become more frequent of late. There is no urticaria or pruritus. She is on oral contraception medication started 4 months ago. She mentions her father has had similar episodes. As you secure intravenous access, you wonder if there is any value in administering a bradykinin receptor antagonist you've heard a lot about.

Gaining vascular access in the prehospital environment is often challenging. In the circumstance where an intravenous (IV) insertion is delayed or unobtainable, intraosseous (IO) insertion should be attempted. The manual intraosseous infusion device and the semi-automatic intraosseous infusion device are both available, so you question which device offers the best rate of success, accuracy and user satisfaction in the prehospital setting.

A 32 year old un-helmeted cycle courier is brought to the ED after a collision with a car. He has an isolated severe head injury (GCS=7) and is intubated before transfer to the CT scanner. You wonder if the severity of his injury, or his outcome, would be improved had he been wearing a helmet.

An emergency medicine trainee is called to a 66-year-old man in the Emergency Department (ED), who has just had a cardiac arrest. Advanced life support (ALS) has started. The trainee knows the guidelines have recently been updated, but is not familiar with the changes. The resuscitation attempt is unsuccessful and the patient dies. Later she wonders whether using a checklist (e.g. from her smart phone or on a poster) would have been useful during the arrest to ensure that current guidelines were followed and whether this would have improved the patients chances of survival.

A 32 year old male presents to the Emergency Department with a laceration on his right forearm. He accidentally cut his forearm with the sharp edge of a metal can 14 hours ago. The wound appears clean and there is no evidence of any foreign body. Neuro-vascular and tendon examination are normal. The wound is irrigated with saline and repaired with nylon sutures. You wonder whether this wound is at a higher risk for infection because of the time lapse from injury to repair.