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It is 7:45am and you are just winding down with a coffee before the end of a shift and the doors to the Emergency Department (ED) burst open. Lying on a stretcher is a young, obese lady who is screaming in agony. She has an obvious fracture dislocation of the ankle. Just when you thought things couldn't get any worse the paramedics inform you that she has no visible peripheral veins. While you evaluate your options of escape you ask yourself the question: "Would intranasal fentanyl be as efficacious as intravenous morphine in the reduction of pain from this broken ankle"?

A 78-year-old female with long standing heart failure (New York Heart Association grade 3) is brought to the Emergency Department (ED) with respiratory distress and reduced conscious level. Arterial blood gas analysis demonstrates that the patient has type 2 respiratory failure and she scores 5/15 on the Glasgow Coma Scale (GCS). An opinion is sought from the Intensive Care Unit (ICU) physicians regarding the prospect of invasive mechanical ventilation (IMV), but they decide that the patient is not suitable for IMV. You consider instituting non-invasive ventilation (NIV). However, a depressed level of consciousness is traditionally thought to be a contraindication to NIV. This makes you wonder whether it would be an appropriate management strategy in this situation.

A multisystem trauma victim arrives in the emergency department and the trauma team is activated. After initial resuscitation, you wonder if whole-body CT scan would benefit this patient by improving his chance of survival.

A 4 year old girl with a known history of asthma presents in the emergency department with a two-day history of increased wheezing. She has been using her albuterol inhaler more frequently but is still symptomatic. Her symptoms improve after two nebulizer treatments, and as you prepare for her discharge you wonder if an IM dose of dexamethasone before discharge would be as effective as an oral course of prednisone at home.

An 82 year old lady has been brought to ED complaining of hip pain having been found on the floor at her residential home. Clinical examination indicates likely fractured neck of femur. Plain AP and lateral radiographs of the hip demonstrate to obvious fracture. What is the most accurate investigation to rule out fracture?

Your Head of Department is considering the use of a computerised triaging system. He wonders if this is a better method of triaging patients, compared to the traditional nurse-led triaging system.

Whilst working as a registrar in the paediatric emergency department a 9 year old boy presents with a headache, low grade fever, photophobia and neck stiffness. He requires a diagnostic lumbar puncture to look for meningitis. You wonder if nitrous oxide might be an effective method of reducing the pain and distress associated with this procedure.

You are the paediatric registrar in a district general hospital. An 8 year old boy, who is known to have asthma, presents to the paediatric assessment unit acutely with severe exacerbation of asthma. He has received back to back nebulisers of salbutamol and ipratropium bromide with no improvement in his condition. You are inclined to give an intravenous bolus of salbutamol to the child. However, the paediatric nurse informs you that they are familiar only with the use of intravenous aminophylline. You perform a literature search to seek evidence for the comparative efficacy of intravenous salbutamol vs. aminophylline in the management of this child.

A 55 year old male presents on the ward with a history of chest pain in the last 12 hours and, as Acute Coronary Syndrome is suspected, a Troponin T Test is performed. The patient is now pain free and you are asked to help mobilise and walk the patient, but you wonder whether it is safe to do so if the result confirms a raised Troponin T.

A 7 year old boy is brought into your ED following a road traffic collision while on his push bike. He was not wearing a helmet. He has sustained a head injury and has been intubated and ventilated in preparation for transfer for imaging. You know that his c-spine collar is associated with decubitus ulcers and increased ICP. You wonder if there are any evidence based protocols for clearing his c-spine at the same time.

In patients suffering traumatic cardiac arrest does emergency department thoracotomy result in superior survival rates compared to pre-hospital thoracotomy?

A 5 year old boy is brought to the emergency department following riding his bike into a lamp-post. On examination he is noted to have a large laceration across his forehead that unfortunately needs suturing. The young boy is petrified by needles and will not allow you to place a cannula or give an IM injection. The question is asked whether intranasal ketamine is a safe and effective alternative for sedation in this patient.

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient have immobilization with POP or functional splinting while waiting for further investigation?

A 34 year old female presents to the ED and states that she is having a "migraine" headache that has been present for 30 hours. She describes the headache has a frontal bilateral pressure associated with photophobia and nausea. She is afebrile and states that she has had headaches like this in the past but does not currently have any migraine medications at home and that the headache has not responded to OTC analgesics. You decide to give the patient a dopaminergic agent such as prochlorperazine or metoclopramide but wonder if there is any other way to help her pain. Your ED pharmacist recently mentioned possibly adding 1g of magnesium to the "Headache Cocktail" order set in your electronic medical record. You wonder if the addition of magnesium to your normal treatment of migraine headaches is efficacious.

A 33 year-old male is brought into the emergency department with an episode of acute breathlessness following a syncopal episode. His left leg is in a cast and he tells us that he returned from Australia recently where he broke his lower limb during a trek. He is tachycardic, tachypnoic, hypotensive, sweaty and clammy: he is in a peri-arrest situation. You wonder if bedside transthoracic echocardiography could rapidly confirm or exclude your presumed diagnosis and support your decision-making process with regard to treatment.

A 9 year old boy with osteogenesis imperfecta is admitted having fallen out of bed and sustaining a left fractured femur. He is in considerable pain. He is given intranasal diamorphine and cannulated to be given systemic analgesia. You are aware that it is recommended that femoral nerve blocks should be performed with ultrasound guidance and that you are not competent to perform this procedure. You are competent to perform a fascia iliaca blocks and wonder if this would give adequate analgesia.

You start at a new hospital and find that there is a protocol in place to guide the treatment of patients with sepsis. It states that if the patient's blood glucose is found to be greater than 7.8 mmol/l then insulin should to be started to keep it tightly controlled . You wonder if some degree of hyperglycaemia is not such a bad thing, given that it is part of a natural physiological response to stress and glucose is required for brain metabolism. A quick review of the literature throws up contrasting results and so you decide that you should really examine the evidence in a more systematic manner.

A 7-year old girl is brought in the ED by her father who is concerned about a petechial rash over her face and neck only. She developed a dry cough the day before. Her observations and are normal and the child looks well. You have heard about petechiae developing in the distribution of the superior vena cava secondary to increased intrathoracic pressure and wonder if it is safe to discharge the patient without further investigations.

A 32 year old man was brought into A&E following a motorcycle accident. He was complaining of pain in his right lower leg. On examination his calf was minimally swollen, soft, neurovascularly in tact, however he was complaining of pain. We suspected a mid-shaft tibia fracture, and this was proven on X-ray. Given the high risk of compartment syndrome with mid-tibia fracture, compartment pressure monitors were used. The orthopaedic registrar mentioned that 30mmHg was an absolute value to treat compartment syndrome. You are wondering if there is any evidence to support or refute this.