bestBETs

A previously well 60-year-old gentleman attends your Emergency Department in acute urinary retention (AUR) for the past 10 hours. On closer questioning he reveals a history of preceding lower urinary tract symptoms. Following the uneventful passage of a urethral catheter, the production of a residual volume <1000ml and the finding of normal renal function, you wonder whether starting a short course of an alpha-blocker prior to discharge from the Emergency Department may increase his chance of an early trial without catheter (TWOC).

A 40 year old female attends the emergency department as a standby call. Her partner gives you a history of acute headache followed by collapse and reduced conscious level. She is rapidly intubated and taken for brain CT, which confirms your suspected diagnosis of acute subarachnoid haemorrhage. The case is discussed with the neurosurgical team on call and transfer is arranged. You are keen to provide prophylaxis against future vasospasm and further brain injury. However, no oral nimodipine is available to go down the NG just inserted. By the time it is sourced the patient will likely have left the department. You are sure you have recently heard about the use of IV magnesium as a further preventative measure for vasospasm in SAH. Serum magnesium is 0.9mmol/L. While you wait for the anaesthetist to facilitate transfer, you resolve to find out for yourself....

A 20 years old gentleman presents with a swollen ankle after an inversion injury. Clinically you suspect a fracture of lower one third of fibula. Radiograph confirms a Weber A fracture which is treated conservatively in a below knee back slab and crutches. You refer him to fracture clinic and very well know that operative fixation is highly unlikely and he will be changed into a full plaster soon. You wonder if giving him low molecular weight heparin might prevent development of deep vein thrombosis.

A 70 year-old lady presents to the emergency department(ED) with 2 days of fever, shortness of breath, and cough productive of green sputum. CXR confirms right basal pneumonia. She requires oxygen therapy and admission. It is busy in the ED. This patient has been waiting for 3.5 hours. Her bed is ready in the ward. You wonder if giving her the antibiotics now would affect her clinical outcome in terms of time to clinical stability, length of hospital stay, and mortality.

A 55-year-old male patient came to the emergency department with the symptoms of acute onset of severe chest pain with radiation to the back, cold sweating, and nausea. He had mild shortness of breath and his pain was most severe at onset. Physical examination revealed blood pressure: 210/120mmHg, heart rate: 101/min, respiratory rate: 20/min (SpO2 97% at room air), irregular heart beat without murmur, and clear breathing sound over the bilateral lung fields. The electrocardiogram (ECG) revealed atrial fibrillation with rapid ventricular response. Chest computed tomography showed a dissecting aortic aneurysm, from the descending thoracic aorta to the left common and external iliac artery. Therefore, a clinical diagnosis of aortic dissection, Stanford B was made. We wondered whether nicardipine was suitable to control his blood pressure and improve the outcome.

A 54 year old female pedestrian has been hit by a bus. She is brought into the ED by ambulance. Her GCS is 13 on arrival and examination reveals an isolated head injury with a haematoma over the left occiput. CT confirms a right frontal contusion with subdural and subarachnoid haemorrhage and a fracture of the left temporal and occipital bones. There is midline shift to the left. On return to the ED, her right pupil appears dilated and her GCS is now 10 (E2M4V4). The neurosurgical registrar is in theatre for the next 20 minutes. You intubate and ventilate the patient and wonder whether hypertonic saline would be better than mannitol at controlling the patient's ICP acutely.

An agitated 24-year-old patient with a history of schizophrenia enters the emergency department, and becomes aggressive and hostile towards staff and patients. De-escalation techniques fail, and the patient will not take oral medication or allow intravenous cannulation. You wonder whether intramuscular (IM) haloperidol or olanzapine is the best drug to rapidly, safely and effectively calm the patient.

A 50 yrs old man presents to the emergency department with central crushing chest pain, sweating and pain radiating to the left shoulder. ECG shows ST elevation in anterior leads. Your hospital is on take for PCI. You have referred him to the cardiology registrar informing that you have initiated the treatment with Aspirin, Clopidogrel and Fragmin. He tells you that he is taking this patient to the angiography suite in the next hour. He enquires if the department has Prasugrel, a new drug and tells you that Prasugrel is better than Clopidogrel for PCI with stent insertion. You wonder what this drug is and how this fares in comparison with Clopidogrel.

An adult male presents to the ED with flashes and floaters, and a curtain falling across the eye. Following standard ocular examination, there is a suspicion of RD, PVD or VH. Could ocular ultrasound performed by an ED physician help in confirming the diagnosis and accelerate his further management?

A 25 year old man is brought into the emergency deparment by his brother who found him unconscious at home. He is pinpoint pupils, a respiratory rate of 6. ABGs show a pH of 7.05 and a pCO2 of 14kPA. In light of the suspected opiate overdose you administer naloxone, but wonder if it would have been beneficial to treat the respiratory acidosis first.

A patient presents with a good clinical history and examination of ureteric colic. To provide good symptomatic relief and also treatment, is the use of nifedipine indicated?

A 54 year old man with a history of chronic alcohol excess presents with generalised seizure activity. You wonder if treatment with phenytoin would be of benefit in preventing recurrence of seizures in the A&E department.

After seeing a 50 year old man with coffee ground vomiting secondary to NSAID use you refer him to the RMO. You know the SIGN guidelines don't advocate pre-endoscopic proton pump inhibitors in non-variceal upper gastrointestinal haemorrhage, but ,yet again, the RMO requests an IV PPI. You wonder whether the medical SHO cohort know something that you and SIGN do not, so decide to evaluate the evidence yourself.

A 30 year old man presents to the ED with a 3 days history of right sided chest pain that increases in intensity with breathing, lying on the right side and application of local pressure. His BP is 130/70mm Hg, heart rate 90 beats per minute, respiratory rate 23/min, and temperature 37.3°. He denies any history of trauma. Pulmonary embolism is one of the differential diagnoses, but you question whether the presence of the chest wall tenderness is enough to rule out pulmonary embolism before carrying out further tests.