bestBETs

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.

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.