bestBETs

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.

A 56 year old female presents to the emergency department after waking up with left sided weakness. She was normal when she woke up to use the bathroom in the middle of the night 4 hours ago. You wonder if she could benefit from air transport (about 30 minutes) to a stroke center which uses the Penumbra System for mechanical clot extraction.

You have just reviewed an 87 year old lady who has presented to the emergency department with a minor laceration after striking her head on a shelf at home. She lives independently in the community, and thinks she may have tripped on a loose carpet. You note that she appears to be quite frail and you wonder if there is an appropriate tool to use, to assess her risk of falling before her discharge.

A 42-year-old man presents to the emergency department following an injury to his right index finger. Whilst at work approximately 2 hours ago, he sustained a significant crush injury to his right index finger. Examination reveals a swollen, bruised and erythematous distal phalanx with a deep laceration proximal to the nail fold. Radiographs confirm the diagnosis of an open fracture of the distal phalanx. You wonder whether prescribing a course of oral antibiotics, in addition to thorough wound toilet, will reduce the likelihood of infection developing.

A septic hypotensive patient required an arterial line for early goal directed therapy but bilateral radial pulses were weak and multiple attempts were unsuccessful. A radial artery catheter was eventually secured under ultrasound guidance.

A twenty year old male dials 999 for an ambulance complaining of acute onset shortness of breath and severe chest pain. The plain is pleuritic in nature, being worse on inspiration and limiting his ability to take a deep breath. His pain score is seven out of ten. He has no past medical history, but smokes ten cigarettes per day. On examination, his observations are normal, including an oxygen saturation of 97%. He has slightly decreased chest expansion on the left. There are no signs of mediastinal shift. There is hyper-resonance to percussion along the left chest. Breath sounds are decreased on the left with decreased air entry. The paramedic makes a provisional diagnosis of primary spontaneous pneumothorax and wonders whether a nitrous oxide and oxygen gas combination would be a safe analgesic choice in this patient.

A 55 year old male with no cardiac history presents for chest pressure with onset of about 2 hrs ago, now resolved. You question if new sensitive troponin assays will be able to more accurately rule in or rule out an acute myocardial infarction when compared with standard troponin assays.

A 24 year old man presents to the ED complaining of having injured his knee earlier that evening in a football match. He is in a significant amount of pain so you prescribe him diclofenac. A medical student asks why you prescribed diclofenac rather than ibuprofen, given its higher risk of gastro-intestinal complications. You inform the student that diclofenac is a better analgesic than ibuprofen but wonder if there is any evidence to support this.

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 undergo another investigation, such as an MRI, there and then?

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 undergo another investigation such as a CT scan there and then?

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 undergo another investigation, such as an MRI, there and then?

A 3-month-old child is seen in clinic because of a rapidly enlarging birthmark on his back. On examination it is seen to be a strawberry naevus measuring 45×25 mm. The parents want to know how much further it will enlarge and when it is likely to settle. A straw poll of staff at grand round reveals that it is reckoned that maximum size should be achieved by 13 months (median) and resolution should have occurred in half the cases at 5 years (median).

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 undergo another investigation, such as an MRI, there and then?