BET 1: In paracetamol overdose, is oral N-acetylcysteine as effective as intravenous N-acetylcysteine?

A short-cut review was carried out to establish whether oral N-acetylcysteine is as effective as intravenous N-acetylcysteine in the management of paracetamol overdose. Seven studies were directly relevant to the question. The author, year and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that oral N-acetylcysteine is a safe alternative in patients for whom the intravenous route is not an option.

BET 2: CT versus MRI for occult hip fractures.

A short-cut review was carried out to establish whether CT or MRI is better at detecting an occult hip fracture. Six studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that CT is a valid first-line investigation for a suspected plain X-ray occult hip fracture. If clinical suspicion remains after a negative CT scan, then MRI should be used.

Qualitative research in critical care: Has its time finally come?

As clinicians, we are well acquainted with using randomised controlled trials, case-control studies and cohort studies together with p-values, odds ratios and confidence intervals to understand and improve the way in which we care for our patients. We have a degree of familiarity, trust and confidence with well-performed scientific quantitative studies in critical care and we make a judgment about our practice based on their recommendations. The same cannot be said of qualitative research, and its use accounts for only a small proportion of published studies in critical care. There are many research questions in our environment that lend themselves to a qualitative research design. Our positivistic education as doctors potentially incites distrust towards such studies and, as such, they are seldom undertaken in our units. We aim to describe and discuss the differences between quantitative and qualitative research with focus being given to common misunderstandings and misconceptions. An overview of the methods of data collection and analysis is provided with references towards published qualitative studies in critical care. Finally, we provide pragmatic and practical instruction and guidance for those wishing to undertake their own qualitative study in critical care.

BET 2: role of vinegar in Irukandji syndrome.

A shortcut review was carried out to establish whether dousing areas of contact with vinegar could relieve the symptoms of Irukandji syndrome. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is there is a lack of evidence for effectiveness and the latest local guidelines should be followed.

Best evidence topic reports. BET 2: does a normal CT scan within 6†h rule out subarachnoid haemorrhage?

A short cut review was carried out to establish whether a normal CT scan within 6 h of onset of a severe, sudden onset headache can be used to rule out a subarachnoid haemorrhage. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that a CT scan performed on a third generation scanner with thin slices, reported by a radiologist experienced in reporting CT brain scans, within 6 h of onset of the headache can be used to rule out a subarachnoid haemorrhage.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: role of vinegar in Irukandji syndrome.

A shortcut review was carried out to establish whether dousing areas of contact with vinegar could relieve the symptoms of Irukandji syndrome. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is there is a lack of evidence for effectiveness and the latest local guidelines should be followed.

Not all suffering is pain: sources of patients' suffering in the emergency department call for improvements in communication from practitioners.

BACKGROUND: Provision of prompt, effective analgesia is rightly considered as a standard of care in the emergency department (ED). However, much suffering is not 'painful' and may be under-recognised. We sought to describe the burden of suffering in the ED and explore how this may be best addressed from a patient centred perspective. METHODS: In a prospective cohort study, we included undifferentiated patients presenting to the ED. We undertook two face to face questionnaires with the first immediately following triage. We asked patients: (a) if they were 'suffering'; (b) how they were suffering; and (c) what they hoped would be done to ease this. Prior to leaving the ED, we asked patients what had been done to ease their suffering. Data were analysed thematically. RESULTS: Of 125 patients included, 77 (61.6%) reported suffering on direct questioning and 92 (73.6%) listed at least one way in which they were suffering. 90 (72.0%) patients had a pain score >0/10 but only 37 (29.6%) reported that pain was causing suffering. Patients reported suffering from both physical symptoms (especially pain, nausea, vomiting and dizziness) and emotional distress (notably anxiety). Treatment (to ease physical and emotional symptoms), information (particularly diagnosis, reassurance and explanation), care (notably friendly staff) and closure (being seen, resolving the problem and going home) were the key themes identified as important for relief of suffering. CONCLUSIONS: In seeking to ease suffering in the ED, clinicians must focus not only on providing analgesia but on treating Emotional distress, Physical symptoms, providing Information, Care and Closure (EPICC).

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: D-dimer levels during normal menstrual cycle.

A short cut review was carried out to establish whether d-dimer concentrations are increased during normal menstruation-. - studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there is little evidence on the question, but what there is suggests that d-dimer concentrations are not raised during normal menstruation.

BET 2: in children, do steroids prevent biphasic anaphylactic reactions?

A shortcut review was carried out to establish whether steroids prevent biphasic anaphylactic reactions in children. Seven papers were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there are no trials to show that steroids prevent biphasic reactions. However, there are other grounds for using them in anaphylactic reactions and they are still recommended in guidelines.

Hypoxia, haemorrhage and hypotension: the interface between emergency medicine and intensive care medicine.

This subjective review is based on a presentation made at the College of Emergency Medicine Scientific Conference in September 2013. My theme was that there are certain features of the critically ill which cause understandable anxiety, namely hypoxia, haemorrhage and hypotension. So, I have selected papers relevant to the management of these frightening situations.

Optimising well-being: is it the pain or the hurt that matters?

In recent years there has been a commendable focus on patient-centred medicine, with increasing attention being paid to the timely assessment and management of acute pain. 78% of patients who attend the emergency department report pain, the severity of which is often used to determine clinical priority at triage. Clinical guidelines are increasingly including the timely provision of appropriate analgesia as a clinical standard. Pain scoring has been widely adopted, causing pain to be considered as the 'fifth vital sign' by some. Interestingly, there remains little evidence to support the benefit of this approach for patients. The aim of this review is to explore some of the assumptions that made in defining and addressing 'pain', and to explore whether it is truly 'nociception' or 'suffering' that ought to be addressed. Through two thought experiments, it is demonstrated that the current approach to pain relies heavily on addressing 'nociception' but does little to address the 'suffering' that is undoubtedly they key determinant of well-being in patients. It is demonstrated that the current naturalistic approach risks neglecting many 'non-nociceptive' sources of suffering, including physical (eg, nausea, vertigo, dyspnoea, pruritus) and mental (anxiety, depression, fear, anger) symptoms. In the humane quest to relieve suffering, there is a clear need to examine current practice. Indeed, the philosophical enquiry presented even questions whether our culture risks overemphasising the importance of pharmacological analgesia and calls for emergency physicians to take a more holistic approach to meeting patient needs.