bestBETs

A 9 year old girl attends the Emergency Department following a fall from her horse on her right (dominant)side. Examination and x-rays confirm an isolated, uncomplicated fracture of the clavicle. Overlying skin is not in jeopardy and there is no neurovascular impairment. You wonder whether broad arm sling, adequate analgesia and parental advice sheet would be enough or would the orthopaedic follow up improve the outcome.

A 3 month old books in to the Emergency Department with a 4 day history of a coryzal illness followed by breathing difficulties and decreased oral intake. It is December. Inwardly you sigh heavily, berating the fact that bronchiolitis season is upon you and all you really have to offer is supplemental oxygen, nasogastric feeding and paediatric admission. Just then, one of your colleagues mentions perusing the Cochrane Database recently and seeing something about the use of nebulised hypertonic saline in bronchiolitis. The paediatricians in the department are sceptical. A spark of hope alights in you that there may be an evidence-based treatment out there after all. You quickly decide to find out for yourself one way or the other.....

A 35 year-old man presents to the Emergency Department (ED) 15 minutes after having experienced 30 minutes of central chest pain that resolved spontaneously. He has no previous medical history. Physical examination is unremarkable and the ECG is normal. You know that current rapid rule out protocols have limited sensitivity and are not recommended by the European Society of Cardiology or the International Liaison Committee for Resuscitation. You wonder whether heart fatty acid binding protein (H-FABP), an intracellular constituent of cardiac myocytes that appears in plasma soon after the onset of acute myocardial infarction (AMI), could be used to facilitate rapid exclusion of AMI in the ED.

A mother brings her 4 year old son to the emergency department with a cough, runny nose, and sore throat for the last 3 days. She requests medicine for the cough which has been keeping them up at night. You wonder if there is sufficient evidence to support the use of honey for the treatment of cough in children with URTIs.

An 8-week-old baby is admitted with bronchiolitis. His parents mention that he has always cried a lot and that he is having a course of cranio-sacral therapy to try and improve things. You wonder whether there is any evidence for this.

You are the specialist registrar in paediatrics in a district general hospital which provides shared care for paediatric oncology patients. A girl on cyclical maintenance chemotherapy for acute lymphoblastic leukaemia was admitted 10 days ago with neutropenic sepsis. Blood culture from her Hickman line at admission had grown Staphylococcus epidermidis. She was treated according to the sensitivity pattern of the organism. She is now free of signs of systemic infection. However, the most recent blood culture from her Hickman line continues to grow S epidermidis. Concurrent peripheral venous blood cultures are sterile. At this point, you are keen to remove the central line. However, her parents want to avoid line removal as venous access has always been extremely difficult for her. You consult the oncologist at her referral centre, who suggests a trial of antibiotic lock of the Hickman line. The microbiologist at your hospital is not in favour of this approach and wants the colonised line to be removed immediately. You are unsure about the best therapy in this situation. You decide to do a literature search on the benefits and risks of antibiotic line lock technique (ALLT) and critically appraise the evidence.

On a routine neonatal check on the postnatal ward you come across a neonate whose mother developed chickenpox 3 days before delivery. You are aware that according to UK guidelines a baby should be given prophylactic varicella-zoster immunoglobulin (VZIG) if its mother develops chickenpox during the period that spans 7 days prior to delivery to 7 days after (and that the US Red Book recommends VZIG for neonates born to mothers with onset of chickenpox 5 days prior to delivery to 2 days after). The mother, who is keen for her baby to have this preventive treatment, asks you how likely it is that this measure will prevent the disease. You are unsure and consult the Department of Health (UK) publication Immunisation against Infectious Diseases (the Green Book), which provides limited information on this aspect, citing one reference only. The British National Formulary for Children (2007) offers even fewer details, and refers you to the former publication. Therefore, you wonder what evidence exists for the effectiveness of VZIG in preventing or modifying chickenpox in this setting.

A 6 year-old boy presents to the emergency department with vomiting and diarrhea for 4 days. He is able to hold down liquids but appears dehydrated. After adequate fluid administration orally, the patient appears well enough to be discharged home. Is the BRAT (bananas, rice, applesauce, and toast) diet going to improve the patients overall outcome?

An 18 year old female presents to the emergency department with lower abdominal pain, vaginal discharge. She is currently 8 weeks pregnant by dates and ultrasound confirms a viable intrauterine gestation. You wonder if this patient could have pelvic inflammatory disease even though she is pregnant.

A 52 yr old man presents with painful swollen right leg. On examination, he has moderate risk on wells score for DVT. Blood tests show a Raised D-Dimer. You wonder if compression Ultrasound has suffiently accurate in ruling in or ruling out the diagnosis of deep vein thrombosis.

A patient attends the Emergency Department after a hyper abduction injury of his thumb. On examination there is laxity of his ulnar collateral ligament (UCL). You wonder whether conservative treatment is adequate or will the patient require surgery. Would ultrasonography be helpful in assessing UCL ruptures which are going to require surgical input?

A 27 year old woman attends the emergency department with a 4 day history of pain to her upper jaw (made worse by leaning forwards) and a green disharge from her nose. A diagnosis of acute maxillary sinusitis is made. She informs you that she is due to go on holiday in 2 weeks and would like some antibiotics to "make sure she is better" by then. You wonder whether antibiotics would be of benefit in this situation.

You are treating a middle-aged man with severe pancreatitis. It is apparent that he is hypoxic, deteriorating, and will need to be ventilated. A chest X ray shows bilateral shadowing. There is no clinical indication to suggest either infection or pulmonary oedema. Your colleague from Intensive Care decides that the patient has Adult Respiratory Distress Syndrome and should be given high dose steroids. You wonder what evidence there is to support this treatment.

A 21 year old lady present to your Emergency Department with a laceration of the upper lip after accidentally being hit the by the tennis racket of het co-player. You wonder what kind of sutures provides the best result but nobody in your department really knows for sure, and the plastic surgeon can not be contacted.

You are a resident at the Emergency Department of a hospital in the Netherlands, when a 53 year old male presents with acute abdominal pain, diarrhea and a mild fever. He has a history of diverticulitis. After thorough evaluation of your patient, including labs and abdominal CT scan, you want to discharge him with the diagnosis 'acute, uncomplicated diverticulitis, since there was no evidence for an intra-abdominal abcess or bowel perforation. You are about to reassure your patient and give him some supportive therapy, when your supervisor, an Emergency Physician trained in the USA, suggest that you give the man a prescription for oral antibiotics. You wonder if there is any evidence for this treatment...

A 3yr old girl is brought to emergency department by mother with a wound on the left knee.Child was playing and fell on glass peice.There is a visible laceration of 3cm length and moderate depth.xray didn't show foreign body.You decide to go forward and suture the laceration under Ketamine Sedation.In the previuos hospital you worked sedation was always given IV route but in the current hospital you are working ketamine sedation is done IM route .You go through the hospital protocol for ketamine sedation and finish the procedure.Next while discussing this case with one your seniors they suggest the reason for using ketamine IM is that it is assocaiated with less complications and longer duartion of sedation.You wonder what is the evidence.

A 22 year-old female presents with lacerations on her hands after slipping and breaking a window with both hands. The wounds appear superficial on inspection. You wonder if these wounds can be adequately treated without the use of x-rays to rule out retained foreign bodies.

A known diabetic child presented to ED with abdo. pain vomiting and high blood glucose, you suspected DKA,you canulated the child and took blood samples including a sample for venous gases but your FY2 wondered (without chalenging your autharity) whether a venous sample is good enough to reflect the degree of acidodsis as compared to an arterial sample? you thought the answer was yes but wasn't sure about the evidence.

A 45 year old man presents with pain in the neck, wanting to know if he should be referred for Manual therapy (delivered by physiotherapists).