bestBETs

An 83-year-old restrained female passenger involved in a head-on collision is brought to the ED via helicopter. The ED evaluation reveals an unidentified esophageal intubation. On questioning the helicopter paramedic crew, it is found that a carbon dioxide indicator was not used in the field.

A 17-year-old male presents to the Emergency Department with a unilateral loss of vision and orbital swelling a day after an altercation outside a community college with weapons-carrying students. The patient is not forthcoming with details. The pupils are equal and reactive to light. You want to establish the extent of orbital/ocular damage. There is a wait for a CT scan so you wonder if using the bedside ultrasound scanner (USS) for a focused ocular ultrasound would provide useful imaging for either safely reviewing the patient later or making an informed prioritisation for CT.

A 55-year-old man presented to the emergency department due to nausea, jaundice, and mild abdominal pain over the right-upper quadrant that had persisted for three days. Lab data showed hyperbilirubinemia and abdominal CT revealed multiple stones in the common bile duct (CBD). ERCP was performed for removal of CBD stones. Both amylase and lipase were elevated the day following ERCP and post-ERCP pancreatitis was diagnosed. As it is a feasible route for a patient treated without oral intake, you wonder if the use of rectal indomethacin would have lowered the occurrence of post-ERCP pancreatitis?

A 12 year old male involved in a motor vehicle crash is brought in by EMS. His vitals are within normal limits, however on exam you do note moderate left upper quadrant tenderness. Before sending the patient to the CT scanner you wonder if a negative read will be sensitive enough to rule out significant intra-abdominal injury (IAI).

A 29 year old female presents to the physiotherapy department for treatment of recurrent giving way of her right ankle, present since a severe ankle sprain in her late teens. The ankle gives way into the inversion direction when walking on uneven surfaces such as cobble stones; this occurs approximately twice per week. Any possible underlying structural cause for the instability has been ruled out by a Consultant Orthopaedic Foot and Ankle Surgeon assessment, X-rays and a MRI. A diagnosis of “Functional Instability” has been made and she has been referred to physiotherapy for rehabilitation.

A 7 yr old boy presents to the trauma bay in the emergency department after a high speed motor vehicle collision. He is alert, talking, and moving all extremities. During his secondary survey, you wonder if a digital rectal exam would be of any prognostic or diagnostic utility.

A 4-month-old girl with respiratory distress presents at the emergency room in January. On physical examination the child has a fever, nasal discharge and a dry wheezy cough with tachypnoea and dyspnoea. On auscultation you find inspiratory crackles and expiratory wheezing. You know that there is no evidence for the use of bronchodilators or corticosteroids in bronchiolitis, but you wonder whether the combination of dexamethasone and epinephrine could help your patient to recover more quickly.

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.