bestBETs

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.

A 67 year old female attends the Emergency department after a fall onto outstretched hand. X-rays identify a Colles fracture with dorsal angulation and shortening of the distal radius which requires manipulation. With experience of reducing Colles fractures you wonder if bupivacaine will give better analgesia improving patient comfort during and after the procedure than lignocaine.

You are called to the emergency department to see a 35 years old man who presented with severe left loin to groin pain and vomitting. On examination you find him rolling in the bed, tachycardic and has a left renal angle tenderness. You control his pain and decide to run a urine test to confirm the diagnosis of renal colic. The urine dipstick comes back as normal, and leaves you with this question: How sensitive is the lack of hematuria in rule out the diagnosis of acute renal colic?

Whilst on duty in the ED, a young man is brought into the resuscitation room with a stab wound to his abdomen. A trauma call is put out and resuscitative measures started. Primary survey includes a positive FAST scan. The bleeding is severe and the Trauma Lead initiates the massive transfusion protocol. Packed red cells, platelets and FFP are transfused in a 1:1:1 ratio, as per protocol. The patient is taken to theatre to control the bleeding. As he is leaving, the Trauma Lead asks you to take a further clotting sample to measure PT, APTT and INR so that 'we’ll know how many more products to give him’. You follow up this patient and find that he survived and is currently on ITU. The Intensivist tells you he is suffering from ARDS, likely to be a Transfusion Associated Lung Injury (TRALI). The Intensivist believes the patient received far too many blood products during his resuscitation and in theatre. You wonder if there is a way of guiding blood product replacement in trauma situations which may supersede rigid transfusion protocols. You are aware that TEG machines are used to guide blood product replacement for open cardiac surgery patients and wonder if the same technique could be used to guide transfusion for trauma patients.