bestBETs

A patient who has suffered a traumatic brain injury (TBI) is admitted to your rehabilitation hospital. Other therapists have used body weight supported treadmill training (BWSTT) with patients post stroke. What evidence supports the use of BWSTT in a TBI population?

A 28 year old male attends at 7.30am having dislocated his shoulder again, this time when making the bed that morning. He states he is awaiting an elective orthopaedic procedure planned later this year. This is his 3rd non traumatic dislocation in the last 2 months. The shoulder is clinically relocated with ease using morphine and entonox only. A pre-reduction x-ray was not taken as the diagnosis was clinically obvious. You are confident that the shoulder is relocated and wonder if a post reduction film is still required.

You are seeing a patient at lunch-time 4 days after his coronary artery bypass grafts. He is well and has been walking around the wards. You are aware that he only gave up smoking three weeks ago, when he was admitted with a non-ST myocardial infarction. He thanks you for doing his operation and asks if it is okay to have some salt on his chips for lunch. You tell him that you are sure that it's okay and that he has to have a few pleasures in life. On walking away from the patient, your nurse practitioner tells you off. She had just told him that high salt intake is bad for him and that he should cut down. You sheepishly promise your nurse practitioner that you will look up the evidence.

You are at a national conference hearing about the benefits of a stentless aortic valve over a conventional stented valve. An eminent speaker from the floor then stands up and contends that there have been no definitively proven benefits for stentless valves. He continues to say that as the implantation time in these older patients is significantly higher with an associated increase in morbidity, that those who implant stentless valves outside of a clinical trial are similar to cardiologists who implant coronary stents outside of published national guidelines, and both practises should be discontinued. You resolve to check the literature yourself.

You are seeing a 67-year-old diabetic patient who had coronary artery bypass grafting 15 years ago. He felt that his last operation had transformed his life but now he presents with aortic stenosis with a gradient of 130 mmHg. He had five grafts in total the last time and both long saphenous veins were harvested, as the left side was documented as having been 'too varicose to use in a young man'. Two vein grafts are patent but a graft to a large diagonal and the PDA are occluded with reasonable distal targets. Unfortunately the radials have no refill on Allen's testing and his diabetes makes you reluctant to use the right mammary artery. You wonder whether you could use the short saphenous vein to do the grafts for this operation.

A 60 year old patient with risk factors for ischaemic heart disease suffers a non traumatic out of hospital cardiac arrest. There is no return of cardiac output despite advance life support. You know that the majority of sudden cardiac arrests are thrombotic in origin and you wonder whether thrombolysis would be of benefit.

A five year-old boy is admitted with severe anaphylactic shock having inadvertently ingested peanuts at a birthday party. He had a previous reaction two years ago and was given an epinephrine auto-injector for use at home. His mother had used this when the reaction first started but to no avail. You administer intramuscular epinephrine while wondering whether there is any evidence for the effectiveness of epinephrine self-injection.

A 65 y.o. presents tachycardic, hypotensive and decreased LOC. ECG reveals ventricular tachycardia. As your staff places the pads for cardioeversion you discover he has been on digoxin for the past three years. You remember Digoxin Fab fragment, not cardioversion, is the treatment for digoxin induced ventricular dysrhythmias; however, you wonder if there are other therapies that maybe beneficial to your patient.

A 78-year-old patient has returned to your intensive care following a quadruple coronary arterial bypass graft. The operation note states that the targets were very small and there is some lateral ST segment elevation on the monitor. One hour post-surgery he suddenly goes into ventricular fibrillation. The nurses start to massage the patient. You place external pads on the patient and deliver a single 150 J biphasic shock which is unsuccessful. You start to charge for a second shock but the nurses who have just gone on a resuscitation update course recommence cardiac massage and tell you that he needs 2 min of massage. You are aware that a graft may be kinked or occluded or there may be a tamponade and, thus, do not want to delay reopening, but to not want to reopen after a single failed shock, and later resolve to look up how many shocks we should perform prior to reopening.

A 42 year old man attends the Emergency Department with an episode of renal colic. PR voltarol has not provided any relief. You wonder if a calcium channel blocker would facilitate passage of the stone and allow for earlier discharge from the Emergency Department.

In a tertiary care neonatal unit a 30 weeks preterm was admitted from delivery suite. There was no any maternal risk factor for sepsis. The neonate remained stable in the first week of life. A percutaneous long line was sited on day 4 and parenteral nutrition was started. On day 8 he started having frequent desaturations & bradycardias, which later needed ventilation. In the view of deterioration he had partial septic screen, the FBC, CRP and Blood culture. The initial & repeated CRP remained negative. He had bedside Procalcitonin checked 24 hours after his illness started which came back strongly positive. The Blood culture grew gram positive cocci. The PCT responded to antibiotic therapy. We wonder if PCT is a better marker of neonatal sepsis than C-reactive protein.

A 21-year old man attends the emergency department after a night out. He is intoxicated and has an occipital head injury. He apparently lost consciousness for 10 minutes and has vomited 4 times since arriving in the department. You decide to request a CT scan of his head. Local guidelines allow you to interpret this yourself. You wonder how robust this is compared to the old system of requesting the scan through the radiologist on call

It is 7 pm on a busy weekend shift. A 5 year old boy is brought to the emergency department by his mother following an unobserved fall from a trampoline. He was found in a dazed state, it is not known if there was a period of unconsciousness. He has a moderate sized contusion to his occiput but no focal neurology. His GCS is 15 but appears to have little recollection of events leading up to his fall. There are no clinical signs of a skull fracture. You consider it appropriate to CT him on the basis of his scalp haematoma, apparent retrograde amnesia and the possibility of loss of consciousness. The on-call radiologist doesn't want to do the scan and thinks it more appropriate to admit for neurological observation. You are conflicted between the knowledge that a number of children who present in this way will have intra-cranial injury (ICI), some of whom will require neurosurgery versus the unnecessary admission of the majority of children who will not have ICI.

A 720 g neonate in the intensive care unit develops severe hyperkalaemia with cardiac arrhythmia. The specialist registrar decides to give a calcium gluconate bolus and start an insulin and dextrose infusion. The new registrar queries why salbutamol and ion exchange resins were not considered as these therapies are frequently used in the management of hyperkalaemia in older children and adults.

A 35 year old woman presents to A&E with 3 hours of severe unilateral headache and photophobia. She has a history of migraines and has been given opiates and NSAIDS in the past with little success. You wonder whether you should try some IV metoclopramide for her headache.

A 41 year old man comes to the emergency department complaining of sudden onset of excruciating headache with photophobia and episodes of vomiting.He is afebrile and has a blood pressure of 180/110mmHg. You are worried he may have a subarachnoid haemorrhage and arrange an urgent CT scan.The radiologist kindly agrees to it and reports no haemorrhage seen on a non-contrast CT head scan. He is still symptomatic and gets admitted for a lumber puncture. You have heard about Computed Tomographic Angiography (CTA) as a primary diagnostic study for SAHs and wonder if this should have been the first step and if he should still go onto have a CTA instead of an LP?

A 22 year old female presents to physiotherapy with patello femoral symptoms present for the last six months.At this time, she had moved into a flat on the third floor, & noticed gradual onset of symptoms.You are aware that quadriceps strengthening is known to improve the outcome of conservative treatment.Debate ensues as to whether open or closed kinetic chain exercises will be most beneficial in improving pain & function.