bestBETs

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.

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?