bestBETs

A 36 hour old well baby born at term is jaundiced at their baby check and the serum bilirubin is 270 millimoles/litre (above treatment line according to Canadian PaediatricSociety guidelines, 2007). The baby is put under phototherapy but how much under the treatment line should the bilirubin be before the phototherapy can be stopped to prevent the baby needing to be readmitted for phototherapy.

A 34 year old gentleman presents to the department with a cut to his right arm caused by a knife which slipped during a D.I.Y accident. The wound needs closure with sutures and you wonder if using an absorbable material would provide a more convenient and equally as safe option.

You are in the resuscitation room with a complex trauma case that has significant external bleeding. The wounds are dressed tightly with cotton gauze and bandages that are soaked through in spite of standard measures. You wonder if there are alternative dressings that will reduce the amount of blood lost before definitive management is organized.

A five year old child is rushed into the Emergency Department in cardiac arrest in the early hours of the morning. The circumstances leading to this are not clear. The paramedics have tried and failed to intubate the child. Two further unsuccessful attempts at intubation are made in the department. The paediatric anaesthetist has been called and is on her way but will not be there for some time. Reasonable chest expansion is possible using bag and mask ventilation although there appear to be a lot of secretions in the upper airway. You wonder if it is better to persist with bag and mask ventilation or if placement of a laryngeal mask would allow superior ventilation.

A child presents to your developmental clinic at 30 months old. His mother reports developmental regression of previously acquired developmental milestones. He has now lost his previously acquired language skills and only makes incomprehensible babbles. He is otherwise clinically well and does not have any clinical seizures. From his early history and current behaviour your clinical diagnosis is autism. You wonder whether an electroencephalogram (EEG) should be performed to rule out possible underlying subclinical epilepsy that may contribute to his developmental regression.

Following a recent request from a parent to write a letter of support for her son with cerebral palsy to have "dolphin therapy", we thought we would look at the evidence base behind this. The mother was applying to a charity for funding to take her son to Florida to swim with dolphins.

A 9 year old boy presents with severe right iliac fossa pain. You contact the surgical team who are currently in theatre and will not be able to attend for at least twenty minutes. You wonder if administering morphine to the boy will hinder or delay diagnosis.

A 55 year-old woman presents to the emergency department with fresh malaena. She is haemodynamically unstable. You wonder whether early use of intravenous omeprazole (prior to endoscopy) could reduce her rebleeding rate after emergency upper gastrointestinal endoscopy.

A pregnant patient who was the restrained passenger in a motor vehicle accident was brought in my ambulance 10 minutes ago unconscious, all of a sudden she goes into cardiac arrest. CPR is commenced and you wonder if the next thing to do would be a caesarean section but she is only 24 weeks pregnant.

A 35 year old man presents to the emergency department after falling off his bicycle while drunk. He has a large scalp laceration, some blood in his right ear canal and his GCS has dropped from 15 to 13 in the ambulance. He is now combative. His pupils are equal and reactive. Our concern is that his GCS is reducing because of a significant head injury with increasing intracranial pressure (ICP). How can you identify if the low GCS score is due to raised ICP, and initiate emergency treatment before the CT scan confirms the diagnosis.

A 48 year old with a presents with a one day history of red, swollen right knee. On examination she is febrile, has decreased range of movement and a left knee effusion. You order bloods and the CRP comes back within normal range. You wonder what benefit CRP gives in ruling out SA?

You are a paediatric registrar in a clinic. A mother comes in concerned about the shape of her 6-month-old infant’s head. She has previously been advised that counter-positioning and physiotherapy might help. She has heard from a friend about using helmets to correct the head shape. She wants to know if this therapy would benefit her child. You wonder if there is any evidence for the use of helmet therapy in correcting positional plagiocephaly.

An ambulance arrives at the Emergency Department with a patient who is said to have suffered a heroin overdose. On arrival the patient has a GCS of 14 with no signs indicative of opiate overdose. The friend that accompanied him in the ambulance claims to have injected him with some naloxone he obtained. You wonder if there is any convincing evidence that known addicts should be given naloxone to administer to other addicts in order to prevent deaths from overdose.

A 29 year old man presents to the Emergency Department with a cat bite wound on left his arm. He says he was bitten some 6 hours prior to attendance. The wound is cleaned and it is noted that there are no signs of infection. You wonder whether prophylactic antibiotics are required to reduce the risk of wound infection.

A 12 year old boy is brought in unconscious following an attempted hanging. CT of his brain and cervical spine are normal. There is no clinical evidence of a spinal cord injury. You wonder if giving steroids will improve his neurological outcome

A 50 year old man presents to the Emergency Department with epigastric pain. Acute pancreatitis was diagnosed by routine diagnostic tests. You wonder whether CRP level is better than lactate dehydrogenase level in predicting the severity of the pancreatitis.

It is midsummer''s day in a busy Emergency Department and it is sweltering outside. Your impervious, long-sleeved uniform (that the Trust insist you should wear for health and safety reasons) is moist with sweat. The temperature is 30 degrees centigrade and you are rushing around, like usual, trying to do three things at once. You decide to turn the electric fan on but the nurse in charge tells you that Infection Control have removed all of the fans because they spread infection. The air conditioning has been out of use for a long time because it, too, apparently spreads infection. You wonder whether there is actually any evidence that electric fans spread infection or whether it is more of a risk for the patients to be treated by an overheated, dehydrated, sweaty doctor.