Medicine and Pharmacology

Abstract: Management of prehospital hemorrhagic shock and traumatic cardiac arrest remains a critical capability gap in trauma resuscitation. Hybrid endovascular and extracorporeal technologies and techniques are evolving to meet the challenges of noncompressible hemorrhage, tissue perfusion, gas exchange, and metabolic derangement correction in the setting of complex traumatic injuries and aim to improve patient outcomes by augmenting the capabilities of interdisciplinary trauma/critical care resuscitation teams. The clinical value of these emerging technological advancements depends upon matching the intervention(s) to the dominant physiological failure modes while assisting in damage control surgery and definitive surgical repair. This narrative review discusses advancements in resuscitative endovascular balloon occlusion of the aorta (REBOA) and inferior vena cava (REBOVC), selective regional perfusion, and extracorporeal membrane oxygenation (ECMO), and the technical and logistical barriers facing their clinical implementation. An escalating care pathway and conceptual framework to manage noncompressible hemorrhage and hemorrhage-induced traumatic cardiac arrest utilizing an integrated endovascular and extracorporeal approach is proposed based on prior literature and recent developments in selective abdominopelvic perfusion. Market dynamics remain an important consideration for fielding new technologies; development of specialized medical devices would benefit from versatile, multi-use capabilities to serve broader patient populations to enable economically sustainable employment within healthcare systems.

Abstract: Background/Objectives: The transport of patients with high-consequence infectious diseases (HCIDs) links biosafety science and emergency medicine. The 2026 Bundibugyo virus disease epidemic and the multinational Andes virus outbreak associated with an expedition cruise ship have renewed attention on how such patients are moved safely between the community, hospitals and high-level isolation units. This narrative review synthesises the international literature on biocontainment transport and integrates it into an operational framework for emergency medical systems. Methods: A structured search of PubMed/MEDLINE and Scopus (to 10 October 2026), complemented by guidance from the World Health Organization, the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention and national authorities, was conducted and reported according to the SANRA scale. Evidence was organised across seven operational domains and combined with the operational experience of the Italian Red Cross biocontainment transport service. Results: Of 2432 records identified, 1485 unique records were screened. The literature is dominated by aeromedical case reports, technical evaluations and expert consensus, with few comparative studies. Recurrent findings concern device integrity and air quality within transport isolators, the risk of self-contamination during doffing, heat strain and communication limits imposed by personal protective equipment, decontamination of vehicles and isolators, the maintenance of team readiness during periods of low activity, and the psychological burden on patients and staff. These findings are integrated into a framework comprising a four-link containment chain, a seven-phase operational workflow, a three-tier complexity classification and a role-based responsibility matrix. Conclusions: Biocontainment transport is better understood as an integrated emergency system than as a device-centred intervention. The proposed framework is a structured, consensus-based reference for planning, training and quality assurance; its components require prospective evaluation.

Abstract: Background: Pain management in wilderness and austere care must balance humane, effective analgesia against limited monitoring, environmental exposure, restricted drug inventories, and evacuation delays that may last hours. This review evaluates practical analgesic strategies for prolonged wilderness evacuation and quantitatively synthesizes directly comparable prehospital ketamine-versus-morphine trials. Methods: A focused systematic search of PubMed/MEDLINE-indexed literature and backward citation chaining was conducted through September 5, 2026. Human prehospital, wilderness, remote, austere, and prolonged-field-care studies evaluating acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, ketamine, or regional anesthesia were prioritized. Guidelines and systematic reviews were used to contextualize operational feasibility. A random-effects meta-analysis pooled studies reporting directly comparable changes in 0-10 pain intensity for ketamine versus morphine. Results: Direct evidence specific to prolonged civilian wilderness evacuation was sparse. Across the broader prehospital literature, acetaminophen and NSAIDs provided useful low-complexity analgesia for mild-to-moderate pain and as components of multimodal therapy. Opioids remained effective for severe pain but impose respiratory, hemodynamic, nausea, sedation, and monitoring burdens. Ketamine produced analgesia broadly comparable with morphine in contemporary randomized trials, with faster onset in some studies and a different adverse-effect profile characterized by more emergence phenomena but less opioid-associated nausea, hypotension, or respiratory compromise in some datasets. Two directly comparable trials (n=559) yielded a pooled mean difference in pain-score change of -0.27 points favoring ketamine (95% CI, -0.70 to 0.17; I2=13%), indicating no clinically important difference in analgesic efficacy. Regional techniques, particularly fascia iliaca compartment block for proximal femur injury, showed substantial opioid-sparing potential when performed by trained clinicians. Conclusions: No single agent is optimal for prolonged wilderness evacuation. The most defensible strategy is staged multimodal analgesia matched to pain severity, physiology, evacuation duration, provider skill, and monitoring capacity. Oral acetaminophen and/or an NSAID form a practical foundation when not contraindicated; severe pain may justify titrated ketamine or an opioid, while regional anesthesia can be valuable for selected injuries. The major evidence gap is not short-term analgesic efficacy but safety, redosing, monitoring, and functional outcomes during evacuations lasting many hours.

Abstract: Rabies virus, transmitted mainly through animal bites and scratches, causes an almost invariably fatal disease. Guangxi is among the regions of China with a high rabies burden, yet large clinical datasets on exposure patterns and post-exposure prophylaxis (PEP) remain limited. We retrospectively analyzed the records of 19,239 patients with mammal-related injuries treated at the animal injury clinic of the International Zhuang Medicine Hospital Affiliated to Guangxi University of Chinese Medicine from 2020 to 2024. Cats (53.94%) and dogs (39.38%), predominantly owned animals, caused most injuries, and the proportion of cat-related injuries increased from 44.12% in 2020 to 56.66% in 2024 (p for trend < 0.001). Category III exposures accounted for 68.02% of cases, and repeat exposure rose from 7.81% to 18.47% (p for trend < 0.001). Overall, 32.98% of patients presented more than 24 h after injury. Standardized wound management was provided to 71.36% of patients; all patients received rabies vaccination, whereas human rabies immunoglobulin was administered in 44.86% of category III exposures and remained below 47% in every year. Delayed presentation and persistently incomplete passive immunization suggest gaps in PEP delivery. Targeted health education, animal vaccination and management, and standardized wound care and passive immunization may strengthen rabies prevention.

Abstract: Background: Portable topical hemostats are needed across a spectrum that extends from superficial household cuts to compressible traumatic bleeding in austere environments. A patented polyethylene oxide formulation comprising liquid PEO-400, solid PEO-1500 and PEO-4000, and aqueous zinc and copper salts can be cast as a cylindrical stick. Existing records describe wound contraction, scab formation, antimicrobial activity, and lower semi-quantitative wound bleeding, but do not establish time to hemostasis or efficacy in severe hemorrhage. Methods: We performed a translational design analysis of the patent record and two prior publications, reconciled claims against the available endpoints, and converted the evidence into two target product profiles: a same-user multi-use household stick for minor external wounds and a single-casualty field applicator for repeated application during one care episode. Product architecture, failure modes, performance gates, and a staged verification programme were defined using current trauma guidance, device-risk principles, and benchmark hemostatic models. Results: The source formulation is compatible with twist-up or push-up dispensing and rapidly forms a hydrophilic film, but its hemostatic mechanism remains a testable hypothesis based on fluid sequestration, surface pressure, and barrier formation. Prior rat data showed differences between PEO-metal treatment (n=7) and untreated controls (n=11) on days 4, 5, and 7 and reported bleeding scores of + versus ++, respectively; these outcomes support continued development but cannot be interpreted as validated hemorrhage control. The principal reuse hazards are cross-contamination, dose variability, tip deformation, water uptake, and transfer of debris into the wound. A controlled advance mechanism, sacrificial tip removal, tamper-evident cap, and explicit single-user or single-casualty labelling are therefore essential. Conclusions: A solid PEO balm is a plausible delivery platform for minor superficial bleeding and subsequent wound protection. Claims for moderate, severe, junctional, or arterial bleeding require blood-contact testing and standardized large-animal hemorrhage studies against gauze-based comparators. The proposed validation pathway prevents premature field claims while preserving a practical route to a compact first-aid product.

Abstract: Background: Extremity tourniquets are established lifesaving interventions for severe traumatic hemorrhage, but much of the supporting evidence comes from systems in which evacuation and surgical care occur rapidly. Wilderness, rural, disaster, and contemporary battlefield environments may expose patients to substantially longer tourniquet times. This review examined duration-related outcomes of prolonged emergency tourniquet use and the implications for delayed evacuation. Methods: A rapid review was performed using PubMed/MEDLINE, Google Scholar, backward citation searching, and relevant wilderness and military guidance through Aug 6, 2026. Human trauma studies reporting tourniquet duration and clinical outcomes were eligible. Primary prolonged-use cohorts were included in an exploratory random-effects meta-analysis of amputation proportion. Prolonged use was defined as more than 120 minutes for the primary synthesis; a sensitivity analysis was restricted to cohorts with tourniquet duration greater than 4 hours. Results: Three primary prolonged-use cohorts provided extractable patient-level amputation data (105 patients). The pooled amputation proportion was 35.3% (95% CI, 26.8%-44.9%; I²=0%). Restriction to the two cohorts with tourniquet duration greater than 4 hours produced a similar estimate of 34.9% (95% CI, 25.8%-45.2%). Prolonged cohorts also reported substantial rates of nerve injury, infection, acute kidney injury, rhabdomyolysis, dialysis, and compartment syndrome. In contrast, military and civilian studies dominated by shorter application times reported low tourniquet-attributable morbidity and substantial hemorrhage-control benefit. Conclusions: Emergency tourniquets remain appropriate for life-threatening extremity hemorrhage, but the risk profile changes as evacuation time lengthens. The available evidence supports aggressive reassessment and, when trained personnel and appropriate conditions are present, timely conversion to another effective hemorrhage-control method before ischemic exposure becomes prolonged. Beyond approximately 6 hours, reperfusion and release become higher-risk decisions that should occur with advanced monitoring and resuscitative capability whenever possible. The certainty of evidence is low because prolonged-use studies are small, retrospective, and strongly confounded by injury severity.

Abstract: Background. The Naval Medical Research Center and Biopure Corporation developed the proposed Restore Effective SUrvival in Shock (RESUS) trauma trial of HBOC-201. A military research agreement, a planned field contingency, an investigational new drug application and permission to start a trial represent different steps. This review examines what the public record establishes about each step. Methods. We reviewed selected public records from 2003 to 2008: the RESUS agreement and amendment, a Department of Defense budget justification, an FDA advisory meeting notice and contemporaneous Biopure filings with the US Securities and Exchange Commission. We classified each action by actor, date and documented status. This is a focused historical review, not a systematic search or an evaluation of clinical efficacy. Results. The agreement assigned Navy and company roles and later included a conditional defense contingency provision for a possible request for 1,500 units. That provision did not itself authorize clinical use or establish delivery. NMRC submitted a RESUS investigational new drug application in June 2005, and FDA placed the proposed trial on clinical hold in July. An FDA advisory committee discussed the proposal in December 2006. Biopure reported an 11 to 8 vote, with one abstention, against proceeding with the design then proposed; the revised Phase 2 protocol remained on hold in 2007. A separate DoD budget line and subsequent preclinical supply arrangements document research activity, not battlefield deployment. Conclusion. The records trace RESUS from military research planning through IND submission, clinical hold, advisory review, revised protocol and preclinical product work. They do not establish that the proposed RESUS human trial began, that the contingency supply clause was executed, or that HBOC-201 received US authorization for operational military use.

Abstract: Background: Fournier’s gangrene (FG) is a rapidly progressive necrotizing soft-tissue infection associated with substantial mortality despite modern surgical, antimicrobial, and critical-care management. Objective: To synthesize the evidence supporting clinical determinants, FG-specific severity scores, LRINEC, inflammatory biomarkers, general critical-care and comorbidity instruments, and emerging mortality indices in FG. Methods: PubMed/MEDLINE, Web of Science, Scopus, and Google Scholar were searched for publications from 1980 to 2026 using terms related to FG, necrotizing fasciitis, mortality prediction, FGSI, UFGSI, SFGSI, LRINEC, NLR, SOFA/qSOFA, NEWS2, APACHE, Charlson indices, Surgical Apgar Score, FGMI, and FGMI-2P. Original derivation studies, validation cohorts, comparative studies, systematic reviews, and meta-analyses were prioritized. Diagnostic instruments were considered separately from mortality-prediction tools, and retained quantitative claims were checked against their cited primary sources. Results: Large syntheses place FG mortality at approximately 16–20%, with one 25-year review reporting 19.8% mortality among 6,152 cases and no significant temporal improvement [8]. FGSI, UFGSI, and SFGSI remain the best-established FG-specific composite scores; a 40-study meta-analysis reported pooled AUCs of 0.90, 0.94, and 0.84, respectively [21]. LRINEC was developed for diagnosis of necrotizing fasciitis and performs less consistently for mortality prediction in FG [19,20,25,27]. NLR is associated with mortality at thresholds of ≥8 and ≥10 but is best regarded as an adjunct rather than a stand-alone score [73]. CCI/ACCI, SOFA/qSOFA, NEWS2, and APACHE II add information on comorbidity and systemic severity, whereas FGMI and FGMI-2P are promising newer indices requiring further external validation [20,27,28,49,54,60]. Conclusions: Prognostic assessment in FG is best approached as multidimensional. FG-specific scores should be interpreted together with organ dysfunction, comorbidity burden, and inflammatory/nutritional markers. No prognostic score should delay resuscitation, broad-spectrum antimicrobial therapy, or urgent surgical source control.

Abstract: Biopure Corporation’s emergency and military program was not initially conceived to develop another transfusion product. Over more than a decade, its development focused on a distinct operational challenge: how can oxygen-carrying support be made available early enough for severely bleeding casualties when conventional donor red blood cells cannot be obtained, arrive too late, are difficult to transport, or cannot be properly maintained near the point of injury? Surviving government, congressional, scientific, and corporate records trace a clear progression. It begins with military blood-logistics concerns in the late 1990s, followed by an explicit U.S. congressional requirement for room-temperature-stable hemoglobin oxygen carriers shortly before September 11, 2001. After the attacks, the work expanded into emergency-readiness deliberations and U.S. Army trauma research funding, culminating in a formal U.S. Navy clinical-development program named Restore Effective SUrvival in Shock - RESUS. These records matter because they reveal a shift away from blood-replacement logistics toward understanding the physiology and practical delivery of oxygen during hemorrhagic shock. By the program’s later stages, the research scope extended beyond oxygen-carrying capacity alone to include vasoactivity, nitric-oxide biology, formulation engineering, and multifunctional resuscitation.

Abstract: Background: Severe hemorrhage simultaneously compromises circulating volume, hemostasis, red-cell oxygen-carrying capacity, and tissue oxygen delivery. Fresh whole blood can restore several of these functions and remains the biological reference for hemorrhagic shock resuscitation when promptly available. Military medicine and emergency medical services (EMS), however, increasingly face scenarios in which these functions require support before appropriate blood products and surgical care can reach the patient. Objective: This Perspective examines the transition from unit-based blood replacement toward function-based resuscitation, with particular attention to prolonged casualty care, contested evacuation, drone-dominated warfare, strategic blood readiness, hemostatic technologies, oxygen-delivery therapeutics, and fieldable delivery systems. Evidence framework: Peer-reviewed military, trauma, transfusion, and oxygen-carrier literature was considered alongside Joint Trauma System guidance and official U.S. Department of Defense, U.S. Army, NATO, DARPA, FDA, Congressional, and Government Accountability Office documents. This is a narrative and translational Perspective, not a systematic review. Perspective: During the twentieth century, military trauma systems progressively compressed injury-to-surgical-care intervals from approximately 6-12 hours during World War II to 2-4 hours in Korea and approximately one hour during Vietnam [3]. During Afghanistan, implementation of the U.S. Department of Defense Golden Hour policy reduced median helicopter transport time in a large cohort from 90 to 43 minutes [6]. The operational assumption is now being challenged. Contemporary large-scale combat operation planning anticipates delayed or denied evacuation [10-17]. Ukrainian experience documents prolonged casualty care lasting 24 hours to multiple days, while drone saturation has displaced evacuation and surgical nodes farther from the contact line and increased the proportion of casualties arriving after prolonged intervals [10,11]. NATO has described the emerging transition from the “Golden Hour” toward a “Golden Day” in drone-contested environments [12]. U.S. requirements extend further: current Army planning discusses a 72-hour expectation, U.S. Marine Corps standards include capability beyond 96 hours for selected personnel, and USSOCOM research requirements seek far-forward solutions capable of supporting 3-5 patients for at least 5-7 days [13,16,17]. These changes redefine the engineering problem. The objective is no longer solely to move casualties rapidly toward advanced medical capability. Increasingly, therapeutic capability must move toward the casualty, remain available during prolonged holding and transport, and function with minimal infrastructure, personnel burden, weight, volume, and cold-chain dependence. Military medical research increasingly reflects this functional architecture. DARPA’s FSHARP program separated critical blood functions including oxygen delivery, hemostasis, and volume support [29]. Its 2026 RAPIID program explicitly advances “shelf-stable” oxygen carriers, platelet-derived products, and dried plasma toward clinical trials, regulatory authorization, scale manufacturing, and field deployment [31]. DARPA’s GOLDEVAC program independently explores automated prolonged resuscitation and oxygenation through a single intravascular interface extending from near the point of injury through evacuation [30]. Authors’ perspective: Next-generation far-forward oxygen therapeutics should be evaluated by both molecular oxygen-carrying performance and operational delivery architecture: shelf stability, compact form factor, minimal preparation, closed delivery, monitored administration, compatibility with clinically practical vascular access, flexibility during transport, and limited dependence on gravity-fed infusion systems. Within this framework, BHOC (Biological Hemoglobin Oxygen Carrier) is proposed as a candidate component of Precision Oxygen Therapeutics. Its intended function is oxygen transport and delivery under defined conditions, rather than replacement of the broader functions of whole blood. A proposed BHOC treatment protocol would pair a characterized biological oxygen carrier with a compact cartridge-based, controlled-delivery system. This concept requires independent physicochemical, engineering, preclinical, regulatory, and clinical validation. Conclusion: The central scientific question is changing from “How do we replace blood?” to “Which biological function is failing, how long must that function be supported, and how can it reach the point of casualty before appropriate definitive blood therapy becomes available?” This transition may define the next phase of military resuscitation, civilian EMS, and Precision Oxygen Therapeutics.

Abstract: Adenosine remains the first-line pharmacologic agent for terminating atrioventricular node-dependent supraventricular tachycardia (SVT), but it is still administered as a fixed 6 mg bolus, escalating to 12 mg, regardless of body weight or body mass index (BMI). Because the same absolute dose is given across a wide range of body sizes, effective milligram-per-kilogram exposure falls as body weight rises, raising the question of whether fixed dosing still delivers equivalent therapeutic exposure in an increasingly heavier patient population. This review examines whether elevated BMI reduces the efficacy of standard adenosine dosing in SVT and evaluates the evidence for alternative dosing strategies.Multiple retrospective cohorts show that increased body weight and lower mg/kg exposure are independently associated with reduced first-dose cardioversion success. These patients who convert consistently received higher relative doses (approximately 0.09–0.10 mg/kg) than those who failed. Emerging evidence further suggests that obesity blunts the electrophysiologic response itself: obese patients exhibit significantly shorter post-adenosine sinus pauses than non-obese patients at standard doses. Two strategies have been proposed to close this exposure gap — individualized weight-based dosing, which is pharmacologically ideal but lacks prospective validation, and higher initial fixed-dose administration, which improves first-dose success (particularly among severely obese patients) while preserving the simplicity of current protocols.Collectively, the available evidence — though predominantly observational — supports reframing adenosine dosing around achieving adequate therapeutic exposure rather than delivering a predetermined absolute dose. Prospective pharmacokinetic studies and randomized trials comparing dosing strategies are needed before guideline changes can be confidently recommended.

Abstract: Background/Objectives: The VA Emergency Medicine Addiction Hotline (VEMAH) is a real-time telehealth addiction consult service for Veterans Health Administration (VHA) providers in acute-care settings. VEMAH launched in May 2023 across eight Veterans Integrated Service Network 22 (VISN 22) facilities, expanding to 17 total VHA sites over 3 years. Results: Over 38 months (May 7, 2023 through July 23, 2026), the service completed 2,154 encounters, including real-time e-consults, direct patient tele-care, care coordination, proactive tele-outreach, and provider education. The most common indications for consultation were opioid- and alcohol-related concerns. Pain-related concerns accounted for about 11% of all encounters. VEMAH providers focused on proactive outreach, substance use disorder (SUD) pharmacotherapy interventions, and coordinating care with local SUD services for ongoing treatment. Conclusions: We describe the feasibility of implementing and scaling a real-time telehealth addiction consult service across VHA acute care settings. A descriptive comparison of ED OSI dashboard trends before and after VEMAH implementation showed positive concurrent trends in naloxone and buprenorphine prescribing within VISN 22, though these observations are hypothesis-generating rather than confirmatory. These findings support VEMAH as a scalable model for extending addiction care access across VHA acute-care settings.

Abstract: Background/Objectives: Frozen triage narratives may contain prognostic information not captured by urgency categories or vital signs. We evaluated their incremental value for hospital admission and subsequent critical outcomes among adults assigned Emergency Severity Index (ESI) levels 3-5. Methods: This single-center retrospective study used routine electronic records from 1 April 2025 to 30 June 2026. Models were developed using 51,735 visits (4852 admissions) in April-December 2025 and evaluated without refitting in 40,433 visits in January-June 2026. Hospital admission included accepted interhospital inpatient transfers. Separate models predicted index-hospital ICU transfer or death among completed, observable episodes, including 285 development events. ESI-only, structured, text-only and combined logistic models were compared using discrimination, calibration and patient-cluster bootstrap intervals. Grouped cross-validation and fixed model variants assessed overfitting and source-quality sensitivity. Results: Temporal evaluation included 3517 admissions (8.70%). Adding text increased admission AUROC from 0.763 to 0.835 (95% CI 0.828-0.841) and average precision from 0.246 to 0.340. The combined model had a calibration slope of 1.083 and observed-to-expected ratio of 0.982. Among 39,697 secondary-analysis visits, 177 had ICU transfer or death (0.446%); combined AUROC was 0.924 (95% CI 0.908-0.940) and average precision 0.076. Text gains persisted without the seven measured fields or their missingness indicators. Conclusions: Frozen triage text added predictive information in a later calendar period. Admission prediction estimates recorded disposition rather than medical necessity. Low critical-outcome precision, incomplete follow-up exclusions and single-center design preclude clinical deployment without further validation. No specific research funding or registration identifier was reported.

Abstract: Background: Acute pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. Right ventricular dysfunction (RVD) reflects the hemodynamic consequences of acute pulmonary arterial obstruction and is an important prognostic marker in patients with PE. However, data regarding the prevalence, clinical correlates, and prognostic significance of RVD remain limited in sub-Saharan Africa, particularly in Somalia, where diagnostic and critical care resources are constrained. Objective: To determine the prevalence and clinical correlates of RVD among adults with acute PE and to assess its association with in-hospital mortality at a tertiary referral hospital in Mogadishu, Somalia. Methods: This retrospective cohort study included adults aged ≥18 years with acute PE confirmed by computed tomography pulmonary angiography (CTPA) who were admitted to Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital between January 2020 and December 2023. RVD was defined as structural or functional right ventricular impairment documented on transthoracic echocardiography or CTPA. Demographic, clinical, comorbidity, imaging, treatment, and outcome data were extracted from medical records. Associations were assessed using chi-square or Fisher’s exact tests, as appropriate. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. Results: Among 293 patients, the mean age was 59.2 years, and 201 patients (68.6%) were female. RVD was identified in 110 patients (37.5%). Compared with patients without RVD, those with RVD had higher prevalences of hypertension (46.4% vs. 34.4%; p=0.042) and pre-existing heart failure (19.1% vs. 9.8%; p=0.024). Patients with RVD were more likely to require intensive care admission (92.7% vs. 59.0%; p<0.001) and to present with hypoxemia (91.8% vs. 58.5%; p<0.001) and syncope (12.7% vs. 1.6%; p<0.001). Active malignancy was more frequent among patients with RVD, although the difference was not statistically significant (12.7% vs. 6.6%; p=0.081). Overall, 51 patients (17.4%) died during hospitalization. Mortality was significantly higher among patients with RVD than among those without RVD (29.1% vs. 10.4%; p<0.001). After adjustment for age, sex, hypertension, diabetes mellitus, hypoxemia, and intensive care admission, RVD remained independently associated with in-hospital mortality (adjusted odds ratio [aOR], 2.55; 95% confidence interval [CI], 1.30–5.04; p=0.007). Conclusions: RVD was present in more than one-third of Somali adults hospitalized with acute PE and was independently associated with a more than two-fold increase in the odds of in-hospital mortality. Routine assessment of right ventricular function may improve early risk stratification and support prioritization of intensive care resources in resource-limited settings.

Abstract: Although pressure bandage immobilisation (PBI) stopped systemic venom absorption in animal experiments, the real-world utility of PBI for snake bites in humans is incompletely defined. PBI is often applied for extended periods in rural Australia where snake bites are common. We describe a case of a man with taipan envenomation who required an above knee amputation after 12 hours of PBI. We hypothesise that this was the result of overzealous PBI application leading to a compartment syndrome and tissue ischaemia. The potential harms of PBI necessitate further research to define the incremental advantage of PBI in snakebites over immobilisation alone.

Abstract: Acute gastrointestinal bleeding is a serious emergency condition which without prompt and accurate diagnosis can lead to severe hemorrhagic shock and death. The initial diagnosis relies on a clinical assessment of the bleeding site. If symptoms such as hematemesis and melena are present, an esophagogastroduodenoscopy (EGD) is typically the first diagnostic procedure. In cases of massive rectal bleeding, a computed tomography scan with angiography (CTA) is often used to identify the source and cause of the bleeding. multiphasic CTA is the definitive first-line diagnostic standard, enabling prompt diagnosis and crucial pre-procedural planning for endovascular management in massive cystojejunal bleeding.

Abstract: Severe traumatic brain injury is a leading cause of death and disability worldwide. The optimal role of invasive intracranial pressure and cerebral perfusion pressure monitoring compared with non‑invasive clinical and imaging‑based management remains uncertain, particularly in low‑resource settings. The objective of this study was to design and evaluate new diagnostic and treatment algorithms for adult patients with severe TBI. A quasi‑experimental study was carried out between January 2010 and December 2024. Patients were assigned to two groups: Group I received continuous invasive ICP and CPP monitoring together with clinical and CT monitoring; Group II received only clinical and CT monitoring. The primary outcome was functional status at one-year post‑discharge according to the Glasgow Outcome Scale (GOS). A total of 250 patients were included: 145 (58%) in Group I and 105 (42%) in Group II. In Group I, the most frequent outcome was GOS V (good recovery), whereas in Group II, GOS I (death) predominated. Satisfactory recovery was achieved in 104/145 patients (71.72%) in Group I vs. 65/105 (61.90%) in Group II. Mortality was 39/145 (26.9%) in Group I vs. 44/105 (41.9%) in Group II (difference 15.0 percentage points; p ≤ 0.05). Continuous invasive ICP and CPP monitoring, was associated with significantly lower mortality and higher rates of satisfactory recovery compared with clinical and imaging‑based management alone. These findings support the use of invasive neuromonitoring where resources permit, while the non‑invasive algorithm may serve as an alternative in low‑resource settings.

Abstract: Background Prehospital invasive ventilation is used across a range of critically ill adult patients, yet reported practices, monitoring approaches, and clinical outcomes vary considerably be-tween systems. Existing literature has focused largely on airway management, and the overall landscape of evidence regarding invasive ventilation strategies in the prehospital setting remains unclear. This scoping review aimed to map the extent and nature of the literature on prehospital invasive ventilation in adults, describe the clinical contexts in which it is applied, and identify knowledge gaps. Methods This scoping review was conducted according to Joanna Briggs Institute methodology and PRISMA-ScR guidelines. MEDLINE (via PubMed), Embase, and the Cochrane Library were searched from inception to the date of search. Studies were eligible if they included adult patients (≥18 years) receiving invasive ventilation in a prehospital setting. Random-ized and non-randomized controlled trials and observational studies were included. Two reviewers independently screened studies, charted data, and summarized findings de-scriptively. Results A total of 3,461 records were identified, of which 25 studies met inclusion criteria. Nine studies evaluated out-of-hospital cardiac arrest, ten focused on trauma, one examined sep-tic shock, and five included mixed populations. Across clinical contexts, deviations from recommended ventilation targets—particularly hyperventilation and inconsistent appli-cation of lung-protective tidal volumes—were common. Mechanical ventilation generally improved physiological parameters compared with manual ventilation, but consistent benefits in survival or neurological outcomes were not demonstrated. Capnogra-phy-guided ventilation and real-time feedback systems improved adherence to ventilation targets. Evidence was predominantly observational and heterogeneous in design and re-porting. Conclusion Prehospital invasive ventilation in adults is characterized by substantial variability in practice and limited high-quality comparative evidence. Ventilation quality and monitor-ing may be more important than ventilation modality alone. Prospective controlled studies and standardized reporting of prehospital ventilation practices are needed to create evi-dence-based recommendations.

Abstract: Background: Large language models (LLMs) are seeing more use in clinical decision support and medical education, though how well they perform in arterial blood gas (ABG) interpretation is still not fully understood. Few studies have looked at whether model accuracy changes between English and non-English prompts. This study compared ABG interpretation performance of GPT-4o and Gemini 1.5 Pro in English and Turkish. Methods: We conducted a cross-sectional evaluation with 100 open ended questions covering ABG physiology, pathophysiology, and clinical application. Each question was presented to four configurations: GPT-4o and Gemini 1.5 Pro in English and Turkish. Two independent assessors scored responses using a 14-dimension rubric (0–2 points per dimension, maximum 28 points). We used Kruskal-Wallis and Friedman tests with Bonferroni correction for statistical comparisons, and Cohen’s kappa for inter-rater reliability. Hallucination rates and Winter formula accuracy served as secondary outcomes. Results: Mean total scores were: GPT-4o English 22.36 ± 2.11/28 (79.9%); GPT-4o Turkish 21.28 ± 2.54/28 (76.0%); Gemini 1.5 Pro English 19.81 ± 3.52/28 (70.7%); and Gemini 1.5 Pro Turkish 17.52 ± 3.26/28 (62.6%). Kruskal-Wallis H = 109.87, p < 0.001; all six pairwise comparisons remained significant after Bonferroni correction. All four models showed progressive score decline across parts (Friedman p < 0.001 each). English outperformed Turkish within both model families. Cohen’s kappa = 0.91. Hallucination rates were 4%, 7%, 18%, and 25%; Winter formula accuracy was 96%, 88%, 75%, and 63%, respectively. Conclusions: GPT-4o outperformed Gemini 1.5 Pro in both languages, and English prompts yielded higher scores than Turkish prompts. Performance deteriorated with increasing clinical complexity. These findings support continued human oversight for LLM use in ABG-related tasks, particularly in non-English settings and complex cases.

Abstract: Introduction Trauma remains a leading cause of morbidity and mortality in the United States and places a substantial economic burden on the healthcare system. Although simulation-based training has been associated with improved trauma team performance and patient outcomes, whether emergency medicine simulation fellowship programs are associated with differences in trauma mortality remains unknown. This study examined whether counties with emergency medicine simulation fellowship programs differ in trauma mortality rates compared with counties without such programs. Methods County-level trauma mortality data (2021–2023) were obtained from the CDC WONDER Multiple Cause of Death database. The database was queried by county, year, and external cause of death. Trauma-related deaths were identified using ICD-10 external cause-of-death codes corresponding to blunt and penetrating injuries, excluding suicide. Counties with emergency medicine simulation fellowship programs were identified through publicly-available fellowship directories and classified according to the presence or absence of a simulation fellowship program. Trauma mortality rates were calculated by dividing the total number of trauma-related deaths by the cumulative county population for counties with and without simulation fellowship programs. The two mortality rates were compared using the rate ratio, 95% confidence interval, and P value calculated with the MedCalc online statistical calculator. Results Trauma mortality was 8.0 per 100,000 population in counties with emergency medicine simulation fellowship programs compared with 3.3 per 100,000 population in counties without fellowship programs (rate ratio, 2.45; P<0.0001). Conclusion Contrary to our hypothesis, counties with emergency medicine simulation fellowship programs demonstrated higher trauma mortality rates. Because these programs are predominantly located in urban counties, these findings may reflect greater injury severity and higher emergency department volume rather than effects of the fellowship programs themselves. These factors should be considered when interpreting the association between emergency medicine simulation fellowship programs and trauma-related mortality.