bestBETs

A 7-year-old boy presents to the accident and emergency department with cough, a high temperature and signs of respiratory distress. An x-ray shows pneumonia. Does this child require intravenous antibiotics, or would oral antibiotics be sufficient?

Recently, Drug Safety Update (a monthly newsletter from the Medicines and Healthcare products Regulatory Agency (MHRA) and the UK Commission on Human Medicines) issued an alert on the antiepileptic drug (AED) phenytoin (PHT) regarding an increased risk of Steven–Johnson syndrome (SJS) associated with the presence of the HLA-B*1502 genetic variant in patients of Asian origin. Likewise, the US Federal Drug Agency (FDA) recommended genotyping for the allele in all Asian patients before starting carbamazepine (CBZ). We wanted to explore the implications of this for our clinical practice.

PONV is a common problem after general anesthetic and has the possibility to cause delays from the recovery room. What is the incidence of post-operative nausea and vomiting (PONV) in fast-track patients after cardiac surgery?

A sixty-five year old man attends the Emergency Department with a twelve hour history of palpitations. An ECG confirms that he is in atrial fibrillation with a ventricular rate of 130 beats per minute. He has no cardiovascular compromise. You have heard that intravenous magnesium may be an effective and safe way of converting him back to sinus rhythm and wish to review the relevant literature.

70 yo male presents to ED with SOB and hypotension 75/40 with HR of 160. Pt found to be in afib. Pt does have h/o afib but usually rate controlled with dig. Pt is unsure how long he has been in afib. Pt is given 10mg of dilt after 1L IV NS bolus and pressure drops to 70/35. No change in HR. Would the addition of IV magnesium help with rate control of this patient?

A 28 week preterm boy required intubation after vaginal delivery. He received a dose of surfactant and was mechanically ventilated for less than 24 hours. He was subsequently weaned off continuous positive airway pressure (CPAP) support. Serial cranial ultrasounds showed a persistence of periventricular flares. The parents want to know whether this finding is significant in regards to their child’s development.

Scenario: A 6 week old boy has been investigated for failure to thrive. After further work up with sweat chloride testing he was diagnosed with cystic fibrosis. He is currently being seen at a paediatric out-patients clinic for follow up. As it is the beginning of RSV season the medical student asks the consultant whether Palivizumab prophylaxis would be beneficial.

A 20 year-old female is brought into the emergency department in respiratory failure from severe asthma. Her symptoms do not respond to beta agonist, steroids, magnesium and she requires intubation. Despite intubation, paralysis and sedation she becomes increasingly hypercapnic, difficult to bag with elevated peak inspiratory pressures and poor air-exchange. You have heard of external chest compressions to improve ventilation and wonder if this will help the patient.

A child presents that requires rapid IO access after failed IV access. The paramedics want to use their bone gun to achieve access but the department only has the EZ-IO. You want to know which is most likely to achieve a successful and quick result.

A 50yr old male is 'blue-lighted" into your ED resus in status epilepticus. Despite IV lorazepam and phenytoin, the patient continues to fit and a decision is made to intubate and sedate him, to control his seizures. As the team is preparing to intubate him, you wonder if there is any evidence to support giving him a prophylactic dose of an IV anti-emetic as you are concerned about the potential risks of aspiration and related complications during an RSI?

A 72-year-old woman presents to the emergency department with severe back pain after a mechanical fall. Plain radiographs of her thoracic spine show osteopenic vertebrae with a wedge compression fracture of the body of T8. Her pain is controlled acutely with paracetamol, ibuprofen and oral morphine sulphate. She is mobilised and arrangements are made for her to have physiotherapy in the community. You are keen to discharge this patient but want to maintain pain control and, given the potential side effects, would prefer to avoid opiates and non-steroidals. You have heard that some bisphosphonates relieve the pain of pathological fractures and wonder whether they do so in vertebral compression fractures.

A patient attends the emergency department (ED) with atraumatic pleuritic chest pain. She is 12 weeks pregnant with no other medical history. A junior doctor has dutifully followed the ED guideline, noted that the patient is at ‘low clinical risk’ of pulmonary embolism (PE) and requested a D-dimer level, which has returned within normal limits. The junior doctor is now keen to discharge the patient, who has remained well in the ED, but wants to ‘run it by you’ first. You are surprised by the normal D-dimer level in pregnancy but wonder whether the sensitivity and negative predictive values are as high in pregnant patients as they are in low risk non-pregnant patients.

A 45-year-old male presents to the emergency department with active epistaxis. It is determined he will require nasal packing. You have a choice of using a moistened, gel-coated, balloon inflated nasal tampon or a dry hydrophilic nasal tampon, and wonder which is less painful on insertion and removal?

A 32-year-old woman with no significant medical history presents to the emergency department with chest pain and dyspnoea. A pericardial friction rub is heard on examination. The ECG shows PR depression and widespread saddle shaped ST elevation. You diagnose acute pericarditis and prescribe a course of non-steroidal anti-inflammatory drugs (NSAIDs). However, recalling that colchicine may be useful for recurrent pericarditis, you wonder whether it is effective for a first episode of acute pericarditis.

You are a Paediatric SpR in a busy DGH and a previously well 6yr old girl is brought into Paediatric resus by ambulance with blood sugar of 32 and a significant acidosis. You make a diagnosis of DKA and commence treatment in accordance with your local Paediatric DKA guideline. However, you notice that the rate of insulin infusion it instructs you to use is 0.1units/kg/hour, which is double that suggested by the South Thames Retrieval Service guideline(1) you had used in your previous hospital. You wonder what the evidence is for the possible benefits of using a lower rate and which is the more appropriate rate to use.

It is mid-winter and a 4 month old boy has been admitted to the last bed in our acute admissions ward. He has typical signs and symptoms of moderate bronchiolitis and you wonder if there is a role for oral montelukast in his management.