bestBETs

A 20-year-old man presents to the emergency department in extremis. He is known to have asthma. He is treated according to British Thoracic Society guidelines and has a rapid sequence induction with subsequent intubation. He is difficult to ventilate, due to high airway pressures (pneumothorax has been excluded). You wonder if he would benefit from endotracheal epinephrine?

A 75-year-old man presents to the emergency department at 06:00 hours sweaty, acutely short of breath and coughing pink frothy sputum. You diagnose acute left ventricular failure/acute pulmonary oedema. You know intravenous nitrates are part of first line therapy but wonder whether a high dose will provide increased benefit.

A 45-year-old man presented to the emergency department with a history of sudden onset left-sided loin pain radiating to the left groin. Urinalysis revealed 2+ blood and nil else. Plain abdominal x ray did not reveal any radio-opaque calculus. You wonder whether a spiral computed tomography (CT) scan or intravenous urography (IVU) will be more appropriate for the further evaluation of the patient.

An eight year old girl presents to the Emergency Department with a painful knee having fallen at gymnastics. She is not able to bend it to 90 degrees and says she cannot walk. The knee is not particularly swollen and there are no skin wounds present. You wonder whether the Ottawa Knee Rule would help you decide whether or not to x-ray her knee, which is what her mother wants.

A twenty-four year old man attends the emergency department with an anterior shoulder dislocation. You have heard of ketamine/propofol mixtures being used for sedation and wonder if you should consider using it for procedural sedation.

A 62-year-old man presents to the emergency department with a 45-minute history of chest pain that is beginning to abate after aspirin and buccal nitrates in the ambulance. As he has a 1 mm ST depression in his anterior leads you give him low molecular-weight heparin and refer him to the medical team. While waiting to be transferred to the ward his 12-h troponin level is reported as negative; the medical senior house officer feels he is therefore fit for discharge. You disagree saying he remains high risk and needs further investigation and/or intervention. During the ensuing discussion you wonder if there is any evidence to back up your assertions

A 13 year old boy attends the emergency department after a clash of heads on the rugby field. He has a mild head injury and is discharged home with a head injury advice sheet based on the NICE guidelines. He is not happy with the advice to abstain from sport for 3 weeks as he will miss the remainder of the season.

A 10-month-old child is brought to the emergency department in the middle of the night, with a short history of episodic inconsolable crying, pulling his legs up and non-bilious vomiting. You suspect intussusception is the diagnosis, and you wonder whether a plain abdominal X-ray will assist in the diagnosis.

A 25 year-old man presents to the Emergency Department with central sharp chest pain that is eased by sitting forward. ECG shows widespread saddle shaped ST elevation consistent with acute pericarditis. The patient is clinically stable with normal heart rate and blood pressure and no signs of left ventricular failure. You wonder whether it will be worthwhile sending blood for troponin to rule out significant myocardial damage in relation to myopericarditis. As such you wonder whether a normal troponin will reassure you that the patient is at low risk of complications and suitable for out-patient treatment. Similarly, you wonder whether a raised troponin would indicate the need for hospital admission.

You have been asked to evaluate a previously very fit 65 year old ex-mountaineer for aortic valve replacement(AVR). He first presented to the cardiologists in pulmonary oedema 2 weeks ago although he tells you that he has been getting gradually worse for 3 years. The transthoracic echo revealed an effective orifice area (EOA) of his aortic valve of 0.7cm2, left ventricular ejection fraction of 30%, and mean transaortic pressure difference of 25mmHg. The cardiologists performed a dobutamine stress echocardiography(DSE) that revealed a minimal rise in the systolic velocity integral (15%) and no increase in the EOA. The cardiologists feel that he is beyond the point at which an AVR would help him, but would value your opinion.

You are asked by the interventional cardiologist on-call to discuss a 73 year old gentleman still on the table in the angiography lab. He was admitted with a non-ST myocardial infarction with a small troponin rise, has had clopidogrel, aspirin and reopro and is currently stable. The coronary angiogram shows a tight proximal left main stem lesion of about 70%. The patient is mildly obese and diabetic with some varicosities of the left leg and has prostate carcinoma which is currently well controlled. The cardiologist would like to stent this lesion if you thought that he was not a good surgical candidate and asks for your opinion.

An otherwise fit 71-year old lady presents to your department having slipped on the ballroom floor during a tea dance. She is unable to weight bear and has pain in her left hip. X-ray reveals a dislocation of her hip prosthesis, and she tells you that it's not the first time. You wonder if it's reasonable to sedate her and manipulate it in the department, or refer her to orthopedics to join the rather long emergency list, to be manipulated later. Perhaps days later. She is starved, and you have suitable anaesthetic experience.

A pregnant woman of 32 weeks gestation is admitted to the ED after a fall. She has blunt abdominal trauma and is having what seem to be uterine contractions. You wonder whether you start tocolytic therapy to try to prevent or delay a premature delivery and so prevent some of the possible complications for both mother and baby.

A pregnant patient in her 3rd trimester is brought in by ambulance following an accident in a car where she was the driver. You wonder how effective ultrasound would be in detecting the presence of peritoneal fluid in such a late stage of pregnancy.