bestBETs

A 25 year old man presents to the emergency department after inversion injury to his ankle. He has sustained an unstable closed ankle fracture, which requires open reduction and internal fixation. An orthopaedic consultant has told you previously that the patient should have a pneumatic foot pump incorporated into the cast, as this will speed the patient''s time to surgery by facilitating the resolution of traumatic oedema. You wonder what the evidence there is to support this.

A patient presents to the Emergency department with significant dyspnoea. A chest x-ray reveals a pleural effusion. Should the chest drain be aimed apically or basally to drain efficiently?

You are the senior house officer on duty in the emergency department and a 79 year old male is brought in by his son who states that the patient collapsed at home after having sudden onset central abdominal pain radiating through to the back. He is cold and clammy with a pulse rate of 126/ min and his blood pressure reading is 74/46 mm Hg. You commence active resuscitation and the nurse provides you with a blood glucose reading of 1.2 mmol/l. The test was done with a glucometer on a capillary finger prick sample. You commence IV glucose after sending a venous lab sample. The lab result comes back as 23 mmol/l. You dont understand the reason for the difference between the lab result and the glucometer reading. Meanwhile your consultant has also arrived and she says that she has read somewhere in one of the journals that in cases of impaired peripheral perfusion, the glucometer result on a venous sample is more accurate than the capillary sample for assessment of blood glucose. You decide to do a literature search to find the evidence.

While working a busy nightshift in A&E, you see a patient with an acute exacerbation of COPD. They require bronchodilators & the nurse asks you if you want 2.5mg or 5mg of nebulised salbutamol. You usually administer 5mg however wondered if 2.5mg salbutamol would have the same effect?

A 40 year old man attends the emergency department having sustained facial injuries following an alledged assault. Examination of the oropharynx reveals a missing tooth. The patient has no clear memory of what happened to his tooth. You wonder whether a chest x-ray would aid diagnosis.

A 47 year old man arrives to the emergency department with severe chest pain. His chest pain significantly improves with sublingual nitroglycerin. You wonder if the relief of patient’s chest pain with nitroglycerin has any prognostic value in the diagnosis of cardiac chest pain.

A 36 year-old man presents to the Emergency Department with a painful, deformed left shoulder after falling from his bike on the way to work. Your clinical examination is suggestive of an anterior shoulder dislocation and shoulder X-rays confirm your suspicions. There is no associated fracture or neurovascular deficit. You are aware that there has been much debate about the best method of reduction of anterior shoulder dislocations and have recently been taught how to perform the FARES method. You wonder whether this method or the more traditional Kocher’s method would be the most effective and least painful.

A 26 year old male presents to the ED with an acute onset severe unilateral frontal headache and photophobia, similar to previous attacks of migraine but unresponsive to paracetamol, ibuprofen and codeine. You have heard anecdotally that aspirin is effective for migraine and decide to consult the available evidence.

A 35 year old right hand dominant carpenter presented to the emergency department after sustaining an injury with his saw to his right wrist. On examination, there was a transverse incision across the palmar crease with an completely transacted Palmaris longus tendon. He had limited range of motion in his wrist due to the swelling. X-ray revealed no fractures or foreign bodies. You wonder if it should be repaired or treated conservatively to give best clinical outcome.

A 35 year old man presents to A+E having been involved in high speed car accident. He is brought in haemodynamically stable with a CT negative closed head injury- GCS 6/15 and bilateral tibial shaft fractures. You wonder if compartment pressure monitoring of his lower limbs is indicated.

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.