bestBETs

A 10 year old female with DKA is being resuscitated with fluids in the Emergency Department. After a thorough assessment of hydration status and calculation of her maintenance requirements, you decide to calculate the hourly fluid rate for her treatment. However, you are aware that you gave the patient fluids as soon as she was admitted in order to quickly resuscitate the patient and correct peripheral circulation. The paediatric registrar arrives and tells you that you need to subtract your resuscitation bolus from the maintenance and deficit requirements. You wonder if there is any evidence for this if the risk of cerebral oedema would increase without the subtraction of the fluid bolus.

A 29 year old man presents to the emergency department with a first-time, left anterior shoulder dislocation. A detailed history and exmaination post-reduction does not suggest a fracture, but you are not clinically certain the joint is relocated. You wonder if ultrasound technology could be used, as an alternative to plain film X-ray, to determine if reduction was successful.

A 59 year old man presents to the emergency department with a four hour history of worsening central abdominal pain. He has a history of vascular disease and you suspect an Abdominal Aortic Aneurysm. His vital signs remain stable and you wonder if ultrasound scan or CT would best confirm your diagnosis.

A 30 year old man attends the emergency department who has suspected Influenza A(H1N1). You cannot decide which antiviral drug is more effective, oseltamivir (tamiflu) or zanamivir (relenza). You also want to consider adverse effects and bacterial complications rates associated. The intention is for treatment and not prophylaxis.

A 30 year old man attends the emergency department who has suspected Influenza A(H1N1). You know that the m2 ion channel blocking antiviral drugs amantadine and rimantadine are cheaper than the neuraminidase inhibitors. You want to know if they have similar or greater efficacy and need to take into account possible adverse effects. The intention is for treatment and not for prophylaxis.

A 30 year old man presents in the emergency department with an influenza-like illness. You wonder whether or not antibiotic prophylaxis would be of overall benefit to them with regard to duration of illness and incidence of bacterial complications.

You are involved in close contact management with a patient with possible influenza A(H1N1) and are advised to wear personal protective equipment. This involves wearing the FFP3 filtering facemask. You wonder how effective it is at protecting the wearer.

A 50 year old woman is referred to physiotherapy with a diagnosis of frozen shoulder. There is a history of minor trauma. The pain is severe, & sleep disturbed. There is marked, global loss of range of movement actively & passively, especially external rotation.Serious pathgology has been excluded.Debate ensues as to the most effective way of improving pain & function in this patient group.

You are the registrar on duty in the Children’s Emergency Department. A registered children’s nurse asks you about an 18-month-old child who came in with his parents. He has been vomiting for the last 24 hours and has today developed loose watery diarrhoea. His mother is concerned that his oral intake is poor and his nappies are not as wet as normal. The GP prescribed some Oral Rehydration Solution (ORS) yesterday but the child is refusing to drink it. A neighbour told the mother that allowing the child to drink “flat” cola was a good way to prevent him from getting dehydrated. The nurse asks you if this is a safe and acceptable treatment to recommend for children. You have heard it mentioned by parents of children with gastroenteritis before but feel unsure whether any evidence supports it.

An elderly gentleman is brought in with a reduced GCS following an unfortunate high speed accident involving several reindeer and a sleigh. You decide that he requires intubation in order to protect his airway. A colleague suggests that the presence of his full, white beard suggests that he will be difficult to intubate. You wonder if there is any truth in this statement.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder which factors of this patient’s situation in the ED might be prognostically predictive.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder if the patient’s serum procalcitonin might be a useful indicator of disease severity.

A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5°C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder if rectal thermometry is the most accurate available method for recording the patient’s core body temperature.

A patient over the age of forty five presents to the accident and emergency derpartment with new onset atrial fibrillation. This has been going on for less than 48 hours.

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.....

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.