bestBETs

Emergency physician clinical gestalt has been found to be overly optimistic regarding the incidence of PPCS; a recent study found while complete recovery was expected in over 90% of patients ~50% developed PPCS. A systematic review concluded that no available models adequately predict outcome after mTBI; many failing due to poor methodology. Subsequently, UPFRONT generated a prediction model which depends on psychological assessment at two weeks (the high number of patients precludes this in the NHS), and is not able to stratify patients on ED assessment. NICE Guidelines note there is an urgent need for a decision rule that risk stratifies patients at high-risk for PPCS early after presentation. There are a number of candidates to improve prediction – these include clinical features, premorbid factors and newer technologies including biomarkers and MRI. Current best models have found that clinical features ~2 weeks after injury are most predictive. However, there is some evidence that biomarkers within the ED visit and/or early MRI may help with earlier risk stratification. This search has focused on the key literature to show the current status of this area.

A patient has attended the Emergency Department following a head injury. They have had a normal CT head scan and are going to be discharged, however they still have a headache. You are concerned they are at risk for post concussion syndrome and wish to know if there are any interventions that may benefit them?

30 years old male presents to emergency department with SOB and known past medical history of asthma. Recently he was not using his daily puffers as prescribed by his family physician. You start managing him as acute asthma exacerbation, you wonder if there test that will guide your management and assess the patient response to medications given.

A 28 year old female is brought to the Emergency Department by ambulance after being in a road traffic accident. She is GCS 15 and on examination she is complaining of abdominal pain on palpation and has an abdominal seatbelt sign. You want to know how likely it is that a significant intra-abdominal injury (IAI) finding will be found on CT.

Your Head of Department is considering the implementation of psychological support for staff with poor resilience. He is wondering whether the COVID-19 pandemic worsens the level of resilience of frontline nurses during the COVID pandemic.

A 55-year-old woman presents with back pain and bilateral leg weakness. What would you do next?

A 55-year-old woman presents with shortness of breath, sinus tachycardia and low oxygen saturations. She is COVID-19 positive.

A 66y female presents to the ED. She has been unwell for 3 days with SOB, cough and lethargy. Her PMH includes hypertension, for which she is on Lisinopril. She looks unwell with a pulse of 112, RR 26/min, BP 106/45 and O2 sats of 92% on air. She has clinical and radiological signs of a left basal pneumonia. You begin treatment for a community acquired pneumonia, including oxygen and antibiotics. As well as routine haematology and biochemistry, you are aware that other blood tests may assist in prognostication and treatment planning, but are unsure which blood tests are best in this regard.

55 y/o women presents after taking 100 x 500mg paracetamol tablets. She has been found at home with the empty packets of tablets. On questioning she admits to taking the medication 10 hours ago. You immediately gain IV access and start NAC as per the SNAP protocol. Her paracetamol level comes back as >300mcg/ml. Given the high dose of paracetamol she has ingested you wonder if the standard dose of NAC will be enough and if there is any evidence to support increasing it?

A 68 year old patient, mechanically ventilated in the ICU has failed at multiple attempts at conventional weaning to a state of ventilator liberation, becoming dyspneic and desaturating. You wonder if there is a treatment adjunct you could use to increase her respiratory strength prior to further weaning attempts.

An 82 year old lady is brought in by ambulance after falling down a flight of stairs. He vital signs are unremarkable and she undergoes a whole body CT after the primary survey. This reveals a moderate right sided haemothorax. The trauma team are in agreement that drainage is indicted. Should a 28-38Fr open thoracostomy tube or a smaller (16Fr or less) seldinger drain be inserted?

A 35 year old man attends the emergency department having taking a staggered paracetamol overdose. He reports taking 72x500mg tablets over the past two days. He is suffering from persistent vomiting with increasing abdominal pain. His examination reveals right upper quadrant tenderness. He is acidotic on his blood gas. You start him on IV acetylcysteine as per the SNAP protocol immediately. Blood investigations are taken which reveal a raised ALT and INR. You are concerned that he is at risk of developing serious liver injury and wonder if there is any other treatment that could be initiated in addition to NAC to minimise this risk.

A 60 year old male presents to the Emergency Department with a minor head injury after tripping. He has no associated symptoms with the head injury but is on an anticoagulant. Should his management include a CT head?

A 25-year-old women attends the emergency department having taken a large paracetamol overdose. She reports taking 64x500mg tablets 7 hours ago. On questioning she describes nausea and vomiting with mild abdominal pain. Her examination reveals right upper quadrant tenderness. Blood investigations reveal a high paracetamol level. You start her on IV acetylcysteine as per the SNAP protocol. You are concerned that she is at risk of developing serious liver injury and wonder if there is any other treatment that could be initiated in addition to the NAC minimise this risk.

A 30-year-old, normally fit and well man presents with a headache, 36hrs after hitting his head when falling off his ladder. He did not lose consciousness at the time of injury, but now has a bad headache. He has a normal neurological exam. This fits the criteria for a mild head injury according the WHO head injury score. You know that current NICE guidance on imaging in head injuries has only been validated in populations of patients presenting within 24 hours. You wonder if you should request a CT head scan for this patient to look for possible traumatic intracranial pathology.

A fit and well 30-year-old male presents to the emergency department (ED) with central lower chest pain that came on at rest today and lasted 4 hours. He describes a “heavy ache” that radiated to his neck and made him feel sick, but denies vomiting or diaphoresis. He has had indigestion in the past but this felt higher and more severe than previous episodes. His observations, examination, and ECG are normal. He has no risk factors for coronary artery disease, but is worried about the possibility of a heart attack. You clinically suspect indigestion but feel a cardiac cause might be possible. He hasn’t had bloods sent and has been in the ED for 3 hours already. His HEAR score is 1 (due to a moderately suspicious history) and you wonder whether you really need to send a troponin in order to complete the HEART score and exclude an acute coronary syndrome (ACS).

A 31-year-old woman presents at the Emergency Department by ambulance following a heroin overdose. She requires naloxone for opioid-reversal. She has made a full recovery and is ready for discharge.

A 36 year old female presents to the emergency department (ED) with symptoms of acute migraine. She has a history of migraine. She is systemically well. You wonder whether this patient could get symptomatic relief from a sphenopalatine ganglion (SPG) block via administration of intranasal lidocaine.

A 46 year old female presents to the Emergency Department out of hours with left leg swelling. Wells score for DVT is +2. You suspect a lower limb DVT and wonder if you can use point-of-care ultrasound to make your diagnosis.