bestBETs

A 74-year-old man at a district general hospital ED has sudden onset abdominal and back pain, hypotension, and a pulsatile abdominal mass. You perform a POCUS scan and identify an AAA. CT imaging is not working. You wonder if doing a FAST exam to look for free intraperitoneal fluid (an indicator of rupture) will increase confidence in the diagnosis of rupture and help expedite transfer to a vascular surgery center.

A 13-year-old child presents to the Emergency Department with an anterior shoulder dislocation. You must decide between intranasal fentanyl or inhaled methoxyflurane (Penthrox) for procedural analgesia. Which option provides better pain relief and overall patient experience?

A 68 year old man has been mechanically ventilated in the intensive care unit for six days following presentation with severe community acquired pneumonia. He is now established on a spontaneous ventilation mode and passed a spontaneous breathing trial this morning. The nursing team perform a cuff leak test (deflating his endotracheal tube cuff) which shows no air leak, suggesting a high risk of laryngeal oedema and potential extubation failure. On the ward round, the ICU consultant suggests delaying any trial of extubation to administer prophylactic corticosteroids. You have not seen this practice before. Although you understand that airway swelling can cause stridor and increase the risk of extubation failure, you are also aware that that corticosteroids carry risks (e.g. increased infection) and worry that delaying a trial of extubation may increase the risk of iatrogenic lung injury. The consultant is also not clear on the agent, dose, timing and duration of a steroid course for this indication. You decide to get a coffee after the ward round and review the literature.

A 45-year-old male presents to the Emergency Department with an Altered Mental State. He is acutely agitated and aggressive, and attempts at verbal de-escalation are unsuccessful. A decision to pharmacologically sedate is made. As benzodiazepines are commonly used first line to sedate acutely agitated patients, you wonder whether using them as a single agent, or in combination with an antipsychotic, will result in more effective (faster and minimal need for re-sedation) and safer (fewer adverse events) sedation.

A 42-year-old man presents with dysphagia, hemisensory loss and ispsilateral neck pain. CT angiography revealed an occlusive dissection of the left internal carotid artery.

A 68-year-old man presents to the emergency department after sustaining blunt trauma to his chest after a fall. Imaging confirms two rib fractures with no other associated injuries. He is discharged home with analgesia and written advice. You wonder whether the use of incentive spirometry (IS) after discharge could reduce the risk of subsequent pulmonary complications.

A 45-year-old male presents to the Emergency Department with an Altered Mental State. He is acutely agitated and aggressive, and attempts at verbal de-escalation are unsuccessful. A decision to pharmacologically sedate is made. As benzodiazepines are commonly used first line to sedate acutely agitated patients, you wonder whether using them as a single agent, or in combination with an antipsychotic, will result in more effective (faster and minimal need for re-sedation) and safer (fewer adverse events) sedation.

A young man with type 1 diabetes presented to the emergency department (ED) with disorientation and was diagnosed with DKA. Despite his elevated baseline serum lactate, his condition improved relatively quickly. This makes you wonder whether high baseline serum lactate predicts outcomes in DKA patients.

A 50-year old obese man with a history of severe shellfish allergy is rushed into the resuscitation room for sudden onset of shortness of breath. On examination he had marked face and tongue swelling, stridor and his oxygen saturation remained ~75% despite given 15L/min oxygen via a face mask. You are the only trainee available at the moment and anaesthesia on call takes another 5-10 minutes to arrive. With the anticipation of difficult airway, you wonder if the use of a hyperangulated laryngoscopy blade would increase your first-attempt success rate of videolaryngoscopic intubation.

You receive a major trauma patient to your emergency department. The history is of a 42 year old male who has fallen 8 foot from a balcony. On arrival, there is obvious evidence of head injury and Glasgow Coma Score is 4 (E1, V1, M2). You conduct a primary survey and find evidence of airway obstruction, but no other immediately life-threatening conditions. You undertake a drug assisted endotracheal intubation, which is uneventful. The patient is sedated, ventilated and escorted to radiology for definitive imaging. A full body trauma CT is reported within the hour as showing severe Traumatic Brain Injury (TBI) and 2 displaced right sided rib fractures. The case is discussed with the neurosurgical team who recommend admission to critical care for placement of an intracranial pressure bolt and a period of monitoring. As you are preparing for transfer, a colleague mentions recent evidence reporting that prophylactic antibiotics given within 12h of intubation can prevent subsequent pneumonia in patients with TBI. You have not heard of this before and are reluctant to prescribe anything, given the importance of antimicrobial stewardship. You escort the patient to Intensive Care, get a coffee and sit down to review any evidence on the topic.

You are called to attend an adult male in cardiac arrest. When commencing CPR your colleague notices pronounced cyanosis of the upper torso and queries whether this may indicate a pulmonary embolism.

A 75 year old man presents to A&E with a closed blunt head injury after a trip and fall on ice. He takes regular clopidogrel following a stroke a few years prior. He remains well including no signs of skull fracture, GCS 15, no focal neurological deficit, and no loss of consciousness or amnesia experienced. As per NICE guidelines for adult head injury, you could deduce that no further imaging is required. However, this depends on which medications the clinician considers ‘anticoagulation’ and the department you work in treats clopidogrel (but not aspirin) as such for head injuries and therefore a CT head was performed. You wonder if there is an increased risk of acute ICH in patients who take clopidogrel as opposed to aspirin monotherapy.

You are in the emergency department when a pre-alert arrives for a 70-year-old man who has become unwell over the last 3 days with shortness of breath, on a background of interstitial lung disease. He is requiring 15L of oxygen via a non-rebreather mask to maintain saturations of 94%. A rapid COVID-19 swab is negative. Your colleague mentions high flow nasal oxygen is available, but you are unsure when it is appropriate to initiate.

A 26-year-old patient presents to ED with a facial laceration following a drunken fall. After clearing them from a head injury perspective, you close the wound with six stitches. As you prepare for discharge, you wonder whether advising the use of topical silicone gel could improve cosmetic and symptomatic outcomes of the laceration.

A 24-year-old female has presented to the Emergency Department (ED) with a distal radius fracture. She refuses cannulation due to a needle phobia but remains in severe acute pain despite the use of oral analgesics. You are aware of the increasing off-license use of intranasal (IN) ketamine for acute severe pain and wonder if it provides as effective pain relief as intravenous (IV) opiates for this patient.