bestBETs

A 7 year old girl presents to the emergency department complaining of pain in her left elbow, having fallen onto her outstretched hand. On examination she can fully extend the elbow on the affected side. You have heard that full elbow extension can be used as a 'rule-out' tool for significant injury and you wonder whether there is any value in obtaining an x-ray.

A 3 year old child comes into the Emergency Department complaining of tummy ache. As part of the abdominal examination you listen for bowel sounds. You wonder whether this will aid the diagnosis.

A 28 year old male with known depression attends the Emergency Department (ED) six hours after a small overdose of benzodiazepines. He is threatening to leave the ED prior to mental health assessment. You wonder whether the SADPERSONS scale is useful in predicting his risk of further self harm or completed suicide.

A 41 year old female presents to the department hours after a FOOSH. She has pain on the radial side of the wrist and over the ASB. You wonder if she has had a fracture of the scaphoid and want to know the best clinical test to help the diagnosis

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?

Three-day-old twins are reported to have persistent bilious vomiting on the postnatal ward. You suspect midgut malrotation and it is suggested by a colleague that a Doppler ultrasound might be a better investigation than an upper gastrointestinal (UGI) contrast study, as it does not involve radiation and is non-invasive. You are uncertain which test is best.

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.

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 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.

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 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.