bestBETs

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.

A 3 day old neonate female was seen by the neonatologist and noted to have a large congenital melanocytic/nevocellular naevus. The neonate had no focal neurology and was otherwise well in herself following a normal vaginal delivery. There was no family history of note.

Blood gas analysers are typically preset to assume a patient’s temperature is normothermic at 37 degrees centigrade. In clinical practice the temperature of the patient is infrequently taken at the time of sample or entered into the analyser. With emergency departments exposed to patients presenting with temperature extremes, you wonder whether the temperature entered into the gas analyser has a significant effect on results and subsequent clinical management.

A previously health 25 years old man present to the A&E department with a chief complain of vomiting a small amount of fresh blood. You consider doing a risk assessment for outpatient treatment in him, but wonder whether the use of Glasgow-Blatchford risk scoring system is sensitive in recognition the need for admission?

The SHO on the post-natal ward is performing routine newborn examinations and notices a baby who is being monitored using a neonatal abstinence score chart due to a history of maternal illicit drug use. Urine toxicology results are positive for amphetamines, but negative for opioids. The SHO has seen the effects of opioid withdrawal on babies before, but asks the SCBU registrar whether babies act in a similar manner when withdrawing from stimulatory drugs such as cocaine and amphetamines.

A 24 year old man presents to the A&E minors department referred by the dental emergency unit. He is complaining of a dull and constant pain localised to the lower right 4th, 5th and 6th. Although he is systemically well you can feel a submandibular swelling just below the affected teeth.

An adult patient arrives in the emergency department via ambulance and is unconscious and hypotensive following a car accident in which the patient was wearing a seat-belt. CT with contrast shows a transcection of their thoracic aorta which needs intervention.

A 32 year old man presents to the Emergency Department having landed on his knee whilst playing football. His x-ray reveals a closed vertical fracture of his patella. You wonder if a cricket pad splint is as good as a plaster cylinder for immobilisation.

A 34-year-old patient presents to the Emergency Department with altered level of consciousness from a suspected intracranial bleed. The decision is made to intubate him. You predict a difficult airway. As you gather your equipment, you wonder whether use of a new GlideScope device will help achieve better success at intubation as opposed to traditional direct laryngoscopy.

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.