bestBETs

A patient two hours after a double valve and grafts suddenly goes into ventricular fibrillation as you are passing by his bed in the intensive care unit. Three rapid attempts at defibrillation fail and the nurse who was looking after him said that he had been very unstable with a high CVP prior to the arrest. You elect to perform an emergency re-sternotomy, which relieves a tamponade and the heart spontaneously cardioverts into sinus rhythm. A vein proximal anastomosis was bleeding and you repair this and you are eventually happy to re-close the chest. The anaesthetist asks you if you want any more antibiotics and the scrub nurse asks you if you want a betadine washout. You do this as you are not sure how sterile one of your scrubbed colleagues were, but you are not sure if this is necessary.

A 26 years old man presents at the ED after a blunt trauma. His vital signs are normal except for a heart rate at 110. His labs are normal except for an abnormal base deficit. The doctor wonders if the abnormal base deficit means that this patient could be at risk of complications or death.

A 22 year old female presents to the emergency department with a positive home pregnancy test. She had been sexually active and her last menstrual perior only 2 weeks ago. She wants to know if her home test is correct.

A 20 year old university student presents to the ED with two day history of a hot, swollen joint. She reports no prior knee swelling and no recent trauma or knee surgery, illegal drug use, rash, uvetis or risky sexual behavior. On examination, she is afebrile and has a left knee effusion. Her WBC, ESR and CRP are all raised. The joint aspirate reports an elevated WBC and negative gram stain and culture. You wonder what value knowing the WBC and differential of the joint aspirate will give you in making a diagnosis and ruling out SA?

A 26-year-old man presents to the ED with a history of blunt trauma to the left trunk. Clinical signs are inconclusive and a supine chest x ray (CXR) demonstrates no pneumothorax. A subsequent CT scan demonstrates a left anterior pneumothorax. You have heard that focused thoracic ultrasound can detect pneumothorax and wonder whether this imaging modality is superior to plain x ray and whether there is any evidence to support this.

You suspect appendicitis when a 20 year old female, 25 weeks pregnant, presents with right lower quadrant abdominal pain, vomiting, and low grade fever. An abdominal ultrasound is performed, but the appendix was not visualized, and the study is read as inconclusive. Knowing that there is a 25-50% negative laparotomy rate for appendicitis in pregnant patients you are hesitant to recommend surgery. You wonder if an MRI would be helpful in clarifying the diagnosis.

You have always used blood cardioplegia but you start to work for a consultant who uses crystalloid cardioplegia. He evangelically states that crystalloid is cheaper, quicker and gives you a better view when performing distal coronary artery anastomoses. You have always been told that blood is superior as it is a more physiological buffer and has an important oxygen carrying capacity. You then realise that you have never actually read a single paper on the comparison between these two solutions even though you use it every day and resolve to look up the evidence.

A 25yr old pregnant woman is admitted to delivery suite in early labour and has a lumbar epidural sited for analgesia. Four hours later the CTG shows prolonged, late decelerations (fetal distress) and clinical examination demonstrates cervical dilatation of only 7cm. The woman is transferred to obstetric theatre for an emergency (Grade 2) caesarean section. The epidural has provided excellent pain relief in labour.

A patient presents with a simple transverse fracture of his second metatarsal, you wonder whether he could be safely discharged in a support bandage rather than a below knee backslab

A 62 year old female school teacher who lives alone presents with a headache. She has a history of atrial fibrillation and takes Coumadin daily. You order a MDCT (Multi-detector computerized tomography) head scan and find an intracerebral hemorrhage. During her time in the ED she becomes slightly confused. What is your management? Three Part Question: In [patients with AAICH (Anticoagulant Associated Intracerebral / Intracranial Hemorrhage) and elevated INR from VKA (Vitamin K Antagonist)], how useful are [Vitamin K, FFP (Fresh Frozen Plasma), PCC (Prothrombin Complex Concentrate) and rFVIIa (recombinant factor VIIa)] in [INR normalization, clinical outcome and hematoma reduction]?

A 4 y/o boy presents to an urgent care setting with a 1 cm laceration across the volar aspect of his index finger just distal to the dip joint? The attending physician is debating whether to numb the laceration locally versus employing a digital block

A pediatric patient presents to the Emergency Department with pyelonephritis. You would like to use a fluoroquinolone antibiotic, but are concerned about its safety in this patient population.

You are clerking a patient who has been admitted for elective coronary artery bypass grafting (CABG) the next day. The responsible consultant asks you to omit the morning dose of ACE inhibitor for this patient. When you ask him ‘why?’ he replies that patients who get a morning dose of ACE inhibitor before surgery need more vasoconstrictors and inotropes postoperatively. Although you omit the morning dose of ACE inhibitor for this patient, however, you are confused as none of the other consultants in the unit practice this strategy. To resolve this issue you decide to carry out a literature search.

A small child with a scalp laceration presents to the Emergency Department. You wonder whether the less painful technique of closing wounds with hair apposition will produce as good as a result as suturing.

A 73 year old patient with a history of COPD and diabetes, 2 days after a right upper lobectomy for lung cancer asks you why he has not got an incentive spirometer by his bed when the 2 patients opposite him both have them. You can’t answer him and when you look more deeply into this find that administration of spirometers on your ward is sporadic. We decide to check the literature and decide who should get them.

A 70-year-old woman presents to the Emergency Department with urosepsis and requires intubation. You consider using Etomidate as an RSI agent, but wonder if it will increase morbidity and mortality secondary to adrenal suppression.

A 3-month-old boy is admitted to the paediatric ward with bronchiolitis. He is initially managed with oxygen, nursing care and intravenous fluids. However, his respiratory distress worsens a few hours after admission. The senior house officer measures a capillary blood gas which shows a PCO2 of 8.7 kPa. You, the on-call registrar, review the patient and discuss the situation with the consultant. The consultant suggests that the child should be commenced on nasal continuous positive airway pressure (nCPAP). You wonder whether nCPAP in an infant with bronchiolitis would improve his clinical status and/or avoid intubation?