bestBETs

Both crystalloids and colloids are commonly used in both the emergency department and ICU in the fluid resuscitation of patients with sepsis. The use of hydroxyethyl starches is controversial, and improved hemodynamic parameters compared to crystalloids and other colloids must be balanced against growing evidence of nephrotoxicity. This appraisal suggests that hydroxyethyl starch, when used in the management of patients with sepsis, increases the risk of acute renal failure.

A 14 year old girl presents to the Paediatric Emergency Department with cough, chest pain and neck pain. Chest Radiograph demonstrates pneumomediastinum and surgical emphysema in the neck. She is booked onto a transatlantic flight for five days time. To aid resolution of the mediastinal air she is admitted for oxygen therapy.

A 14-year-old boy sustains a brain injury and is admitted with a Glasgow Coma Scale score of 3/15. Imaging reveals evidence of diffuse injury. Approximately 12 months later, the patient is seen for a planned review in an outpatient clinic. Full reintegration into school has occurred and clear cognitive and physical improvements are evident. Despite this, the patient and his family explain that unprovoked episodes of agitation, aggression and emotional lability occur. These have not lessened in frequency and represent a clear departure from the patient's preinjury behaviour. Parental and school management of this concerning conduct is structured and consistent. You have heard that carbamazepine (CBZ) may be of value in managing post-injury agitation and aggression.

A forty year-old homeless man presents to the Emergency Department claiming to have taken ten of his dothiepin tablets two hours ago. His ECG shows normal QRS duration and normal QRS axis, his blood pressure is 130/85 and he is fully conscious. He therefore appears to be at low risk of complications but his heart rate is 110 beats per minute. You wonder if this is a useful predictor of complications.

You have just seen a 6 year old child who is complaining of a painful left elbow after falling off a trampoline, plain x-rays are inconclusive and you wonder if an ultrasound has any value in detecting a fracture of the elbow joint in young children.

A neutropenic 35-year-old man, who received chemotherapy five days ago for a Non-Hodgkin Lymphoma (NHL), presents to the emergency department with a febrile acute respiratory failure secondary to a pneumonia. The patient is hemodynamically stable, but shows a slow deterioration in his respiratory status. He now needs a FiO2 of 80% to keep his saturation over 92%. He should be transferred to the ICU in the next hour. The physician wonders whether NPPV might prevent intubation and therefore improve outcome in this immunocompromised host.

A premature baby born at 24 weeks gestational age is admitted to the neonatal unit having been born in poor condition and receiving cardio-pulmonary resuscitation (CPR) with adrenaline in the delivery room. Considering the available evidence, is the use of CPR at delivery of extremely premature infants associated with very poor outcomes such that CPR in these infants may be inappropriate? Does the administration of CPR provide these infants with a chance of survival free of disability?

A 35 year old man presents to the emergency department complaining of pain in his left elbow, having fallen onto his outstretched hand. On examination he 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 28 year old male with a gunshot wound to the leg presents to the emergency department in hypovolemic shock. Among other things, you place the patient in the Trendelenburg position, with the body tilted so that the feet is higher than the head. You wonder whether this position actually improves hemodynamics.

An elderly woman attends your Emergency Department following a mechanical fall. She takes warfarin for atrial fibrillation and has a small occipital haematoma. Her Glasgow Coma Score (GCS) is 15; she has no amnesia and a normal neurological examination but did briefly lose consciousness. The INR (International Normalised Ratio) comes back within the therapeutic range at 2.9 and a computed tomography (CT) scan is requested according to the National Institute of Health and Clinical Excellence (NICE) guidelines. The scan is reported as normal, and her social circumstances are adequate in that she lives with her husband who can keep an eye on her. You wonder, though, whether it is safe to discharge her or if there is a possibility of delayed intracranial haemorrhage due to her coagulopathy, and therefore she should be admitted for a period of neurological observation so that it can be identified and acted upon at the earliest opportunity.

A 24-year-old man presents following a fall on an outstretched hand. He has clinical signs of a scaphoid fracture but his initial x-rays are normal. You wonder if ultrasound could be used to identify an occult scaphoid fracture.

A 2.5 year old boy has presented in clinic with mild to moderate general delay in all areas. There is no other relevant history, no family history and clinical examination is normal. The paediatric registrar decided to order some investigations for identifying the possible aetiology of the global developmental delay including the biotinidase activity level. His consultant asked him to justify the test for biotinidase deficiency based on the prevalence of biotinidase deficiency in the population of pre-school children with developmental delay and the possible efficacy of treatment.

A two year old boy - 'Lance' - presents to the emergency department after falling off his bike. He sustained a head injury and is currently drowsy. After recently completing the ATLS course, you try to apply the ABCDE mnemonic to Lance. You remember GCS forms parts of 'D for Disability' but struggle to assess speech in a this child. You wonder if best motor response is sufficient in children?

A 10-year-old boy with well controlled epilepsy on sodium valproate attends your clinic. On a previous clinic visit his mother complained that he was hyperactive, impulsive and could not concentrate. This was affecting his school work. You sent Conners' Questionnaires to his parents and the school, and asked the attention deficit hyperactivity disorder (ADHD) nurse to observe him in school. The results of these investigations are strongly suggestive of a diagnosis of ADHD. You would like to treat him with methylphenidate (MPH) because you know this works well in other children. However, you remember reading some National Institute for Health and Clinical Excellence (NICE) guidance that suggests caution when treating children with epilepsy with psychostimulants. What should you do?