bestBETs

A six year old boy attends the Paediatric Emergency Department. He has area of broken eczematous skin that appears to be infected. He has been treated with Flucloxacillin but it appears to have made no difference. You wonder if other bacteria may be present or if there is antibiotic resistance and what antibiotic to use.

You are preparing to perform a lumbar puncture to exclude subarachnoid haemorrhage. The patient is concerned that he might develop a worse headache after the lumbar puncture as his father has experienced in the past. He asks you if there is anything you could do to ensure this does not happen. You are using the smallest available LP needle, and you wonder whether prophylactic caffeine could prevent post lumbar puncture headache.

A 65-year-old male, with past medical history of pulmonary tuberculosis, attends the Emergency Department with shortness of breath and central chest pain for 7 days. Physical examination reveals raised JVP and chest x-ray shows a globular-shaped heart. You wonder whether pericardial fluid adenosine deaminase level would assist in the diagnosis of tuberculous pericardial effusion.

A 3-year-old boy presents to Emergency Department having pushed a nut in to right nostril. The foreign body is easily visible in his nose but the child is very uncooperative for you to remove it. While you are about to refer the child to ENT, your colleague asks you to try parent’s kiss and you wonder whether it will work?

A seventy four year old female presents from a nursing home with altered mental status and recent diagnosis of pneumonia. She is febrile, tachypnoeic, tachycardic, anuric, and has a blood pressure of 72/35. Your attending physician suggests you start her on an infusion of norepinephrine, however epinephrine has more inotropic effect. You wonder what is the best vasopressor for your patient?

A 30-year-old woman suffers a witnessed out-of-hospital cardiac arrest. You lack experience with ETI and wonder what evidence supports routine use of LMA compared to ETI or bag mask ventilation for airway management in cardiac arrests.

An 8-year old child presents to the Emergency Department within six hours of an unclear incident at home which left nonspecific bruising and acute change in mental status. Fundoscopic exam reveals retinal haemorrhages, and a CT scan done later into the work-up demonstrates a small subdural haematoma. While you consult an ophthalmologist to verify your findings and concentrate on maintaining supportive care, you remember that brain injuries in adults, both hypoxic and traumatic, are increasingly treated with therapeutic hypothermia, and you wonder if this could result in a better outcome for your paediatric patient.

You performed an LP on a middle aged male patient and you were very pleased with the negative result. Forty-eight hours later the same patient returns with disabling headache associated with nausea and vomiting. After your clinical assessment it all fits into a post lumbar puncture headache (PLPH). You decide upon conservative management as a blood patch requires real expertise. You think you saw an anaesthetist using caffeine for a similar case and you wonder whether you should use it.

A 60 year old man is admitted to the stroke unit following a stroke. He has increased tone in the forearm flexors, causing malalignment of the wrist into flexion. You passively realign the wrist and facilitate activity during therapy sessions. You wonder if you should also provide a palmar resting splint to maintain the muscle length.

A 22 year old female presents to the emergency department with apparent acute confusion. You know thyroid dysfunction is a cause of delirium and wonder whether to check her thyroid levels or not.

A 55 year old male presents at the emergency department with apparent confusion. There are no obvious signs as to the cause. You wonder if it is due to infection.

A 82 year old female presents at the emergency department acutely confused, with no obvious signs as to the cause. You wonder whether to test her urine to aid to the diagnosis of her confusion.

A 46 year old male patient presents at the emergency department with signs of acute confusion. He is being disruptive in the waiting room and you worry he will hurt himself or others. You wonder which out of Haloperidol and Risperidone would be better to sedate him effectively and safely.

An aggressive and/or hostile patient in the Accident and Emergency department requires a dose of olanzapine as a sedative measure. You wonder whether administering the drug orally or intra-muscularly is the best option to bring about safe and effective sedation.

An agitated and/or hostile patient enters the emergency room. You wonder if there is an underlying non-organic cause to their heightened state of aggression and perform the Mini Mental State exam to identify or exclude these causes.

A 50 year old patient attends the Emergency Department with a fever, and symptoms suggestive of a urinary tract infection. He has a T 39.1, HR 110, RR 20. As you are making your assessment, the staff nurse appears at your elbow, anxious to administer 1g paracetamol for his pyrexia. You muse that as pyrexia in response to infection is a result of thousands of years of evolution, it may well serve a purpose. You wonder whether treating pyrexia has a positive or detrimental effect on the body’s response to infection.

A 75 years old man presents at the ED with a pneumonia and severe sepsis. The patient is also known for cardiac failure. After being intubated and having received few liters of fluids, the patient does not seem to get better. The physician wonders if the ultrasonography of the inferior vena cava would help him to know if the patient is fluid-responsive or not.

A child attends the Paediatric Emergency Department with an exacerbation of atopic eczema. You ask the mother about their current medications and usage. You find that the mother is confused as to what the diagnosis means and is struggling to comply with the emollient regimes. She has frequently been to the GP who alters the lotions and indicates that the instructions are labelled. You are very busy in the Emergency department and try to impart some knowledge with regards to the condition and the treatment regime before discharging them. You wonder if a educational session would help improve the situation.

A term neonate presents at 24 hours of age with tachyapnoea and a temperature of 37.8 °c following a low-risk normal vaginal delivery. There had been no prolonged rupture of membranes and a high vaginal swab was negative for any significant pathogens. You provisionally diagnose suspected bacterial neonatal sepsis, perform a septic screen, and start IV antibiotics according to local antibiotic protocol. His CRP is 42 and FBC reveals a leukocytosis with left shift on blood film examination. Blood, urine and CSF cultures are all negative. CXR shows no significant focal abnormality. His symptoms resolve over the next few days and you wonder how long antibiotics should be continued.

It is a busy shift in the A&E, and you receive a courtesy call from the paramedics of a 65 years old gentleman with chest pain. When you see the patient you find out that he had crushing central chest pain with radiation to his left arm, diaphoresis, and nausea for about one hour, but he is pain free now. On further questioning you find that he is receiving Warfarin anticoagulation for previous pulmonary Embolism. You think of treating him for ACS, and decide that he should receive the Aspirin, but not the LMWH. But you are puzzled whether giving Clopidogrel is of any proven benefit or not?