bestBETs

You are working in the Paediatric Emergency Department when a 7 year old child comes in who has fallen off a swing and has an obvious deformity to his forearm. Your department has recently introduced a protocol to give intranasal diamorphine for pain relief. However you have also read a paper from Australia advocating the use of intranasal fentanyl in this situation. You wonder if there is any evidence that one drug is more effective than the other.

A 7-year-old child with a history of cough and fever for 1 week, has bronchial breathing over her left lower zone on auscultation. A diagnosis of lobar pneumonia is made, confirmed on plain chest x ray, and she is treated with appropriate intravenous antibiotics. However, she continues to have a spiking fever and develops signs of a left sided pleural effusion. Repeat chest x ray shows a "white out" of the left chest with no mediastinal shift. She is referred to the regional thoracic centre for consideration of thoracotomy and drainage of a left sided parapneumonic effusion. Should she be referred to the surgeons and if so, what should they do?

A 7-year-old boy is admitted to the general paediatric ward with bacterial community acquired pneumonia affecting the right lower lobe. It is suggested on the ward round that we arrange chest physiotherapy to try to reduce the length of his hospital stay. We wonder if there is evidence to support the use of physiotherapy in this case.

You have noticed the appearance of numerous dispensers for alcohol based hand gel within your emergency department. This is accompanied by a poster campaign to make staff aware of the importance of hand hygiene. You wonder what evidence lies behind the campaign.

A seven year old girl presents having fallen onto her out-stretched hand. X-ray shows a typical buckle fracture of the distal radius, minimally displaced. The department protocol stipulates immobilisation in a full below-elbow cast for 4 weeks with regular fracture clinic follow-up but you remember that in your last job the orthopaedic surgeons preferred removable splints and symptomatic treatment, with no follow-up. You wonder if your current department is behind the times, or if your previous department was recklessly negligent!

A 6 year-old boy presents to the emergency department with a two day history of earache and fever. After examination, Acute Otitis Media was diagnosed and a prescription for analgesia and oral antibiotic course were given. You wonder if the administration of topical analgesia (ie eardrops) would be helpful in providing additional and fast relief of this child's pain symptoms.

A 60 year old woman presents with a closed, undisplaced, uncomplicated fracture of the shaft of the humerus. You seek advice on the best method to support / splint the arm and receive a range of different answers. You wonder whether there is any evidence to suggest that any one method is the best.

A 75 year old woman attends the emergency department having fallen at home. She has pain around her left upper arm, and is reluctant to move it. Examination reveals a probable fracture of the humerus and an x-ray confirms this. There are no neurovascular complications or displacement. The Orthopaedic team give differing advice about how you should immobilise her arm and what advice you can give her about when she can start to move it. You wonder if there are any studies that address this.

A 19-year-old girl attends the emergency department six hours after ingesting 80 paracetamol tablets. Her serum paracetamol level is above the treatment line and acetylcysteine is administered intravenously. She experiences nausea and vomiting. You have heard that ondansetron is more effective than other anti-emetics in this patient group and wonder whether this should be your first-line option.

An elderly lady presents to the emergency department following a fall onto an outstretched hand, sustaining a Colles' fracture. The fracture is manipulated and you need to apply a backslab. Many departments would use a dorsal backslab, but you have seen a radial backslab used for these fractures and were impressed. Believing that the radial backslab may hold the reduction more effectively, you search the literature for an answer.

You are seeing a 72-year-old with a 12-year old mechanical mitral valve replacement, presenting 'in-extremis' with breathlessness, dizziness and hypotension. Her family report that she has been confused recently and might not have taken her warfarin. An echocardiogram shows severely restricted movement of the prosthetic mitral valve leaflets with the appearance of thrombus in-situ. You wonder whether first-line treatment should be emergency surgery or thrombolytic therapy.

A 3 year old boy is admitted to your general paediatric ward with clinical features consistent with a diagnosis of Kawasaki disease. His parents agree for him to receive the current standard primary therapy of intravenous immunoglobulin (IVIG) and high dose aspirin. Given that the key pathological finding of Kawasaki disease is a vasculitis, you wonder whether treatment with steroids in addition to the IVIG can improve outcome, in particular reduce his risk of developing coronary artery aneurysms?

A 4 week old baby is brought by parents with inconsolable crying for more than 3 hours a day for the past 3-4 days.Child is passing a lot of flatus and from the history the child is having a typical colic behaviour. Parents are advised by someone to use Gripe Water which din't help the baby and they want to know if there is anything we can do in ED.You hear from your colleague that that Probiotiocs help the baby.Is there any evidence for probiotic use in Infantile colic?

A three year old girl with the first episode of a febrile unilateral otitis media with purulent discharge and otalgia is brought to Children's Emergency. As usual you would prescribe oral amoxicillin but the consultant who happens to stand next to you when filling out the prescription advises you to use antibiotic eardrops instead. They would just be better.

A teenage girl has been at a party with her friends. She had been drinking vodka for the past few hours prior to admission. She is found collapsed on the bathroom floor and is brought to the emergency department by ambulance. On assessment she smells strongly of alcohol but there are no signs of trauma or suspicion of other drug ingestion. Her blood glucose is stable and she is not vomiting but would iv fluid therapy increase ethanol clearance and hasten her discharge?

A 67 year-old presented to the emergency department following a head injury. He has no significant medical history apart from osteoarthritis for which he takes regular NSAIDs. He denies any intake of Aspirin. You wonder if the use of regular NSAIDs increases the risk of intracerebral bleeding post head injury.

A 30-year-old woman presents with a 7-day history of patellar tendonitis. You think of treating her with oral NSAIDs. However, you have seen some information about NSAIDs in a gel form. This seems an appealing alternative and you wonder if there is any evidence of its efficacy.