In acute ischemic stroke (AIS), treatment delays can significantly affect the prognosis. Patients with large vessel occlusion (LVO) may benefit from endovascular treatment (EVT). However, this treatment is available only at comprehensive stroke centers (CSC). Therefore, identifying factors that can reduce logistical delays in patient transport is essential. We analyzed time metrics related to patient transportation and clinical outcomes among AIS patients treated with EVT at Kuopio University Hospital between 2015 and 2016. The study catchment area covers 78 268 km2 with a population of 813 487 (2016). We used a simulation model to estimate the potential time benefit that could have been achieved if patients had been transported directly to the CSC rather than first to a primary stroke center (PSC) before subsequent transfer to the CSC. We simulated two alternative transport pathways for each patient: (1) direct ground ambulance transport from the scene to the CSC and (2) direct helicopter transport to the CSC. Among 122 patients, the median time from emergency medical service (EMS) activation to arrival at the CSC was 119 min (interquartile range (IQR) 71–217). In the CSC group it was 76,5 min (IQR 52–109) and in the PSC group 252 min (IQR 205—281) (p < 0,001). In the simulation model, the estimated median time would have been 106 min (IQR 71–131) by ground ambulance and 83 min (IQR 57–100) by helicopter. Direct transport to the CSC would have resulted in time savings exceeding two hours for 17 patients transported by ambulance and 25 patients transported by helicopter. There were no significant differences in three months modified Rankin Scale (mRS) or mortality between the two groups (OR 1.57, 95
Pre-hospital Emergency Medical Services (EMS) are essential for the timely management of traumatic injuries and acute medical emergencies. This study evaluated temporal trends, epidemiological characteristics, and utilization patterns of pre-hospital EMS missions in Yasuj, Southwest Iran, from 2020 to 2023. This registry-based cross-sectional study included all eligible EMS missions recorded in the Asayar pre-hospital EMS registry between January 2020 and December 2023. Data on patient age, mission date, season, hour of occurrence, chief complaint, mission outcome, and ambulance operational code were analyzed. Mission characteristics were summarized using descriptive statistics, and effect sizes were considered alongside statistical significance for categorical analyses. Temporal trends were evaluated using 48 monthly observations in a time-series regression model of log-transformed monthly mission counts, accounting for calendar-month seasonality and first-order autoregressive [AR(1)] errors. A total of 159,073 EMS missions were analyzed. Annual mission volume increased from 28,312 in 2020 to 58,287 in 2023, corresponding to an approximate compound annual growth rate of 27.2
Public health emergencies, ranging from infectious disease outbreaks to climate-driven and humanitarian crises, generate communication demands that conventional health messaging often fails to meet. Risk communication is increasingly recognized as a determinant of population behavior, healthcare system burden, and ultimately morbidity and mortality during crises. The COVID-19 pandemic exposed substantial limitations in existing approaches, particularly regarding transparency, equity, and the management of information overload, and major retrospective assessments have characterized the global response as a systemic failure across multiple coordinated domains, of which communication is one. This narrative review synthesizes evidence on risk communication during public health emergencies, based on an iterative search of MEDLINE/PubMed, Embase, Google Scholar, and grey literature from major public health agencies covering 2018 to 2026. The synthesis is organized around three axes. Established frameworks are compared, including Crisis and Emergency Risk Communication, the World Health Organization guidance on emergency risk communication, and emerging community-centered and equity-focused models, with attention to how they complement, overlap with, and diverge from one another. Lessons are then drawn from recent crises, including the pre-vaccine phase of the COVID-19 pandemic, the 2022 and 2024 mpox outbreaks, and the 2026 Bundibugyo Ebola outbreak in the Democratic Republic of the Congo and Uganda. Persistent challenges are examined last, encompassing the infodemic, erosion of institutional trust, inequities in message reach, the dual role of digital, social, and traditional media, and the behavioral responses mediating the effects of messaging. Risk communication cannot be evaluated in isolation from the coordinated emergency response of which it forms a part, and is better understood as a transversal function serving every component of that response. Frameworks remain heavily centered on high-income contexts, transparency about uncertainty is often sacrificed for the appearance of authority, and systematic evaluation of intervention effectiveness is scarce. Emergency departments represent one important operational interface among several coordinated levels of the response rather than the sole communication setting. Future work should prioritize community-engaged interventions in low- and middle-income settings, cross-fertilization with behavioral epidemiology and public health ethics, and metrics capturing both the equity and the quality of communication outcomes.
Pyogenic Liver Abscess (PLA) due to a foreign body (ingestion of fish bone) migration is very rare in occurrence. The diagnosis is usually delayed because the patient has difficulty remembering the history of foreign body ingestion. 44 year old male with immunocompetence presenting with a history of pain in the right upper quadrant, nausea and vomiting for three weeks, had an initial empirical antibiotic course which prevented the classical presentation of fever. His lab tests revealed leucocytosis, neutrophilia, raised inflammatory parameters, as well as abnormal liver enzymes. Contrast-enhanced CT scan showed a linear hyperdense object extending from the first portion of the duodenum to the right hepatic lobe, along with the development of a multiloculated abscess in liver segments VI, VII, and VIII. Laparotomy, fish bone extraction, abscess drainage guided by intra-operative ultrasound with cavity irrigation and drainage were done in the same setting. Culture of pus showed Klebsiella oxytoca, while blood culture came negative. PLA arising from fish bone foreign body reaction should be kept in mind for patients with cryptogenic liver abscess, especially if there is an unusual liver lesion on imaging. Contrast CT scan is the gold standard for diagnosis. Surgical intervention in terms of removal with source control is a good treatment option and gives excellent results. Not applicable.
Emergency departments (EDs) operate under time pressure, diagnostic uncertainty, and cognitive overload. Artificial intelligence (AI)–driven clinical decision support systems (CDSS) promise to enhance diagnostic accuracy, risk stratification, and workflow efficiency. However, translation from algorithmic performance to bedside integration remains inconsistent. This narrative review synthesizes current evidence on AI-based CDSS in emergency medicine, focusing on diagnostic performance, clinical impact, and implementation barriers. Literature published between 2015 to December 2025 was reviewed across PubMed, Scopus, and Embase. Applications include AI-assisted triage, sepsis prediction, stroke identification, ECG interpretation, imaging analysis, and ED operational forecasting. Many systems demonstrate strong retrospective performance (AUROC 0.85–0.95) and earlier identification of high-risk patients compared with conventional scoring tools. However, prospective multicenter validation demonstrating mortality reduction or sustained length-of-stay improvement remains limited. Performance degradation across institutions, algorithmic bias, data governance challenges, workflow disruption, alert fatigue, medico-legal ambiguity, and lack of explainability are persistent barriers to adoption. Evidence suggests AI is most effective when deployed as decision augmentation rather than autonomous replacement. AI-CDSS in emergency medicine demonstrates promising diagnostic capability but limited real-world outcome validation. Future development must prioritize prospective implementation trials, transparent model reporting, clinician engagement, and equitable performance across diverse populations to ensure safe and effective integration into emergency care systems.
Agriculture is a high-risk industry in the United Kingdom, with disproportionate rates of fatal and serious traumatic injury. Farm workers face hazards from machinery, livestock, chemicals, and transport incidents, often in remote settings where emergency care is delayed. Existing first aid training is usually generic and does not reflect the specific risks of agriculture. To describe the development of Farmers, Forestry and First Aid (F3A), a trauma-focused first aid training programme for agricultural workers, and to evaluate participant reactions to the course. F3A was developed by clinicians and farming professionals using experiential learning principles and scenario-based training. The course covers basic life support, cardiopulmonary resuscitation, automated external defibrillator use, and immediate management of severe trauma. Anonymous post-course feedback was collected from participants across 32 courses using a training evaluation form with Likert-scale and free-text responses. Feedback was received from 344 participants. Overall satisfaction was very high, with median scores at the top of the scale for all Likert items and 97
Nitrobenzene poisoning causes severe methemoglobinemia and multi-organ injury; lipophilicity allows accumulation in adipose tissue, which may trigger delayed lung damage. Existing literature only contains isolated single-case reports, lacking paired patients with identical chemical exposure but different dermal decontamination strategies to verify the correlation between skin contamination duration and toxic organ complications. This paired occupational poisoning case generates testable clinical and toxicological hypotheses for emergency critical care management. Two male workers simultaneously splashed by >99
Snakebite envenomation remains a major neglected tropical disease worldwide and frequently results in substantial local tissue injury despite timely antivenom therapy. Effective adjunctive strategies for early local symptom control are still limited. We aimed to evaluate whether early local block therapy (LBT) is associated with improved pain and limb swelling outcomes in patients with Gloydius envenomation. We conducted a single-center retrospective cohort study including 203 adult patients with confirmed Gloydius envenomation between 2019 and 2024. Patients were categorized according to receipt of LBT (perilesional lidocaine, dexamethasone, and α-chymotrypsin) in addition to standard care. Primary outcomes were reduction in limb swelling (change in limb circumference from admission to Day 3) and pain relief (change in VAS score within 48 h). Secondary outcome was length of hospital stay (LOS). Multivariable linear regression and propensity score–based analyses were performed to adjust for potential confounders, including baseline wound infection. Baseline wound infection was more frequent in the LBT group than in controls (41.3
Blunt cardiac injury (BCI) is a rare but serious presentation in emergency departments (EDs) nationwide. These injuries arise in trauma and may be accompanied by confounding injuries that complicate the clinical picture. Timely recognition is crucial, as BCI may lead to complications such as pericarditis or life-threatening cardiac tamponade. Notably, there are no current guidelines on approaches in evaluating BCI.1 We describe a patient who presents one week after a motor vehicle accident (MVA) with delayed BCI manifesting as pericarditis. After an extensive literature search, we found only one similar case—highlighting limitations in the current discussion. Importantly, our case is unique because the patient was initially unable to provide a medical history, and point of care ultrasound (POCUS) was pivotal in the initial evaluation. BCI remains challenging due to variable presentation and potential for delayed symptoms, as seen in this case. This case underscores the importance of maintaining a high index of suspicion for BCI, particularly in patients with chest trauma who delay seeking care or present with limited history. Further, early intervention is critical in preventing life-threatening sequelae. Utilizing a combination of physical examination, imaging, and laboratory findings can guide clinicians in accurate diagnosis of BCI. Our report contributes to a limited body of literature by documenting a delayed pericardial complication one week post-MVA, highlighting the need for broader awareness and more structured diagnostic pathways for BCI.
Difficult laryngoscopy during prehospital rapid sequence intubation may lead to procedural failure and serious adverse outcomes. Evidence is limited regarding whether a structured correction bundle can convert an initial poor view into successful intubation before declaring failure. We evaluated the outcomes of a structured correction protocol used after a poor initial laryngoscopy view during physician-staffed helicopter emergency medical service rapid sequence intubation. We conducted a retrospective observational study using prospectively collected data from the Hungarian Air Ambulance airway registry. Patients older than 14 years with maintained circulation who underwent a tracheal intubation attempt between 2012 and 2022 were included. The primary endpoint was the proportion of successful tracheal intubations after at least one corrective maneuver among cases requiring corrective maneuvers. Secondary endpoints included the success rates of individual maneuvers and associations between corrective maneuvers and prespecified covariates. Among 2,431 included patients, 1,827 (75.2
Effective management of burn mass casualty incidents (BMCIs) requires coordinated systems that include early stabilization, definitive burn care, surge capacity, and rehabilitation, supported by adequate infrastructure and workforce capacity. Although different countries have national guidelines, the full synthesis of the components of the health system needed by BMCIs response remains limited. This study aimed to systematically identify and classify the key components of the response to BMCIs. A systematic literature review was conducted to identify and synthesize the key components required for effective response to BMCIs. A systematic review was conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD42024625737). This research was conducted through a systematic review and searches of the databases PubMed, Scopus, Web of Science, and Google Scholar. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used for systematic search, and a Mixed Methods Appraisal Tool (MMAT) was used for quality assessment of final extracted articles. From an initial set of 7,975 articles, 27 studies were included for analysis. The key components for responding to BMCIs were analyzed in 5 categories and 36 subcategories. The primary themes and related main categories included: (1) Preparedness and Prevention; (2) Command, Control, Coordination, and Communication; (3) Prehospital and Transport Management; (4) Hospital and Surge Capacity Management; and (5) Clinical and Supportive Care. This review provides a comprehensive, evidence-informed framework outlining essential health system components for effective BMCIs response. The identified domains may guide the development of national and regional response models, strengthen disaster preparedness, and enhance health system resilience to BMCIs scenarios.
Penetrating gallbladder injury is rare and usually occurs with associated intra-abdominal injury. In hemodynamically responsive trauma patients, distinguishing hemobilia from hollow viscus or other adjacent organ injury may be challenging, and multiphasic contrast-enhanced computed tomography (CT) can play an important role in clarifying the source of bleeding and guiding management. A 28-year-old male presented following a stab wound to the right upper quadrant with initial hemodynamic instability that resolved with resuscitation. CT demonstrated a segment IVb liver laceration extending into the gallbladder, with arterial-phase contrast extravasation into the gallbladder lumen and progressive venous-phase tracking through the biliary system into the duodenum. This phase-dependent pattern localized the bleeding source to the gallbladder and indicated hemobilia rather than hollow viscus injury. The patient underwent fully laparoscopic exploration, methylene blue instillation to exclude gastrointestinal perforation, and laparoscopic cholecystectomy. No additional injuries were identified. The key operative steps are illustrated in the accompanying video. Recovery was uneventful, and the patient was discharged on postoperative day 2. In selected hemodynamically stable patients with isolated penetrating hepatobiliary injury, multiphasic CT may help localize the bleeding source and support single-stage laparoscopic management when gallbladder-origin hemobilia is identified without additional injuries.
Lemierre’s syndrome (LS) is a rare but potentially fatal condition characterized by septic thrombophlebitis of the internal jugular vein (IJV) following oropharyngeal infection, with an estimated incidence of 3.6 cases per million population. It primarily affects healthy adolescents and young adults; pediatric presentations, particularly in children under ten, are exceedingly rare and frequently atypical, with a heightened risk of diagnostic delay and multisystem morbidity. Although orbital cellulitis and intracranial venous extension have each been individually described in pediatric LS, their combined occurrence together with culture-negative status and a prolonged, indolent clinical course remains sparsely documented in children under ten years of age. We report a case of a previously healthy 6-year-old Asian male who presented to a tertiary pediatric hospital after approximately one year of intermittent fever and progressive left-sided facial swelling. Over the preceding 15 days, his illness acutely worsened, with the development of necrotic periorbital and facial lesions and chest pain, prompting emergency referral. On admission, generalized edema, hypoalbuminemia, and nephrotic-range proteinuria raised an initial working diagnosis of nephrotic syndrome, which reflected a true concurrent glomerular process, a hypercoagulable cofactor, or an epiphenomenon of prolonged systemic inflammation that could not be definitively resolved, as the family left the hospital before a complete nephrological work-up could be completed. Contrast-enhanced MRI of the brain and orbits demonstrated preseptal, periorbital, and facial soft tissue inflammation with diffusion restriction, along with loss of flow-void signal in the left sigmoid sinus and left IJV, indicative of thrombosis. Subsequent contrast-enhanced CT of the neck and chest confirmed left IJV thrombosis with septic pulmonary embolization, fulfilling the imaging criteria for Lemierre’s syndrome with intracranial venous extension in the likely but not histologically or microbiologically confirmed setting of an oropharyngeal or dental portal of entry. Serial blood cultures yielded no bacterial growth, consistent with culture-negative LS in a child with probable prior antibiotic exposure, although the details of any treatment administered before referral could not be retrieved. The patient was managed with broad-spectrum intravenous antibiotics, subcutaneous enoxaparin, intravenous immunoglobulin, fresh frozen plasma, packed red cell transfusion, and albumin supplementation delivered through a multidisciplinary care pathway. Despite ongoing management, the family elected to leave against medical advice on day 19 of admission before a full antimicrobial and anticoagulation course could be completed. This case illustrates an unusually indolent, culture-negative pediatric presentation at the interface of Lemierre-spectrum disease and complicated sepsis, combining a one-year prodrome, nephrotic-range proteinuria of uncertain primary etiology, orbital/facial and intracranial venous thrombosis, and septic pulmonary embolization in a 6-year-old child. Because several features deviate from the classic acute, oropharyngeal-onset picture of LS, we present this as a diagnostically challenging, atypical case rather than a textbook example, and we highlight how a superimposed hypercoagulable state, whether inflammatory, septic, or renal in origin, can blur the boundary between ‘clean’ LS and complicated pediatric sepsis. Maintaining a high index of suspicion for LS-spectrum vascular and septic complications in children with atypical, protracted facial or orbital disease, along with early imaging, prompt broad-spectrum antibiotic therapy, and coordinated multidisciplinary management, remains essential, even when the presentation departs from classic teaching.
Perforated peptic ulcer (PPU) is a critical surgical emergency associated with high morbidity and mortality. Traditional risk factors include Helicobacter pylori infection, nonsteroidal anti-inflammatory drug (NSAID) use, smoking, and severe physiological stress. Khat (Catha edulis) is a widely consumed plant stimulant in the Horn of Africa and the Arabian Peninsula that alters gastric physiology, delays gastric emptying, and reduces mucosal blood flow, yet its specific association with acute PPU remains underreported. A 40-year-old male driver with no prior medical history or baseline peptic ulcer symptoms presented with a 1-week history of progressive abdominal pain, persistent vomiting, and absolute constipation. Social history was notable for daily consumption of 30 g of khat for five years, alongside irregular meal patterns. Examination revealed tachycardia and generalized peritonitis with guarding. Laboratory workup demonstrated prominent leukocytosis. Contrast-enhanced abdominal computed tomography (CT) confirmed pneumoperitoneum secondary to acute perforation of a chronic anterior duodenal ulcer. The patient underwent emergency exploratory laparotomy and successful surgical repair using an omental (Graham) patch. Postoperative recovery was uneventful; he was discharged on day 7 on an 8-week oral proton-pump inhibitor regimen, tested negative for H. pylori, and was referred for behavioral khat-cessation support. This case highlights an acute perforation of a chronic peptic ulcer in a heavy khat user lacking conventional risk factors. It underscores the importance of obtaining a detailed regional substance use history and utilizing targeted contrast-enhanced CT imaging when clinical or plain radiological findings require definitive surgical localization. Further epidemiological studies are needed to evaluate khat habituation as an independent risk factor for peptic ulcer complications.
Acetone toxicity is typically associated with ingestion or inhalation, whereas clinically meaningful transdermal absorption is uncommon and may be overlooked, particularly in patients with impaired skin barriers. A 48-year-old man with C4 quadriplegia, a chronic sacral ulcer, and cranial cortical stimulation electrodes from the ReHAB trial presented with two weeks of poor oral intake and progressive encephalopathy culminating in respiratory failure. Initial testing showed high anion-gap metabolic acidosis with an elevated osmolar gap (pH 7.22; HCO₃ 6 mmol/L; anion gap 28 mmol/L; measured osmolality 453 mOsm/kg), beta-hydroxybutyrate 7.2 mmol/L, and serum acetone 29.8 mg/dL, with undetectable isopropanol and other toxic alcohols. Additional history revealed topical isopropyl alcohol application to scalp connector sites approximately 36 h before presentation. The patient improved with intravenous fluids and bicarbonate therapy, required brief mechanical ventilation, and returned to baseline mentation by hospital day 9. This case demonstrates two concurrent mechanisms: starvation ketoacidosis as the primary driver of anion-gap acidosis and transdermal isopropyl alcohol exposure with hepatic conversion to acetone as a plausible contributor to acetonemia and the elevated osmolar gap. Clinicians should consider noningestional exposures in unexplained dual-gap acidosis, especially in patients with neurodisability and device-adjacent or compromised skin. Not applicable
In future digital battlefields, the systematic collection of combat casualty care information is essential for improving trauma outcomes and guiding medical resource allocation. However, a significant methodological gap exists in determining which specific data points are most valuable to record when prospective wartime data are unavailable. Rather than constructing a physical information collection system, this study aims to develop a simulation-based screening framework that can identify and prioritize high-value examination and treatment information across the continuum of tactical combat casualty care. A Markov decision tree model was used to simulate the effects of different treatment techniques on injury-state transitions during casualty evacuation, spanning line-of-fire care, tactical medical care, and damage-control treatment at rescue institutions. Inspection and treatment techniques recorded in battlefield medical documents were screened and ranked based on expert-informed evaluation. Simulation outputs indicate that the on-site treatment phase exerts the most substantial impact on injury state evolution, with comparatively smaller changes observed during ground and air evacuation. The model differentiated the information value of various diagnostic and therapeutic techniques, yielding a prioritized list of essential data elements specific to each care echelon. These include immediate life-saving interventions (e.g., tourniquet application time, needle decompression status) and continuous monitoring parameters (e.g., pulse oximetry trends, serial Glasgow Coma Scale assessments) that should be captured in field medical documentation.
Methanol poisoning poses significant challenges due to its rapid progression and high mortality rate, necessitating timely and accurate ICU admission decisions. Explainable artificial intelligence (XAI) offers transparent insights into these decisions, enhancing trust and interpretability in predictive models. This study aims was to compare the effectiveness of deep learning and machine learning models in predicting ICU admissions for methanol poisoning patients using explainable AI techniques. This study analyzed a dataset of 897 patient records collected from Loghman Hakim Hospital in Tehran, Iran, involving confirmed cases of methanol poisoning. Among these patients, 202 required ICU admission, whereas 695 did not. To develop predictive models, eight established approaches were implemented, including machine learning methods (Support Vector Machine (SVM), Extreme Gradient Boosting (XGBoost), Decision Tree (DT), and Random Forest (RF)) as well as deep learning architectures (Deep Neural Network (DNN), Feedforward Neural Network (FNN), Long Short-Term Memory (LSTM), and Convolutional Neural Network (CNN)). To reduce the risk of overfitting, 10-fold cross-validation and systematic hyperparameter tuning were applied. Model interpretability was ensured using Shapley Additive Explanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME). The performance of all models was evaluated through multiple metrics, including accuracy, sensitivity, specificity, F1-score, and the area under the ROC curve (AUC). Among all DL and ML models, the XGBoost ML model outperformed the others, achieving an accuracy of 92.0
Emergency department (ED) crowding is increasingly recognized as a global public health issue, while evidences from South-East Europe remain limited. The aim of this study was to characterize daily, annual, weekly, and monthly patterns of ED crowding in a high-volume tertiary hospital. We conducted a retrospective observational study of ED crowding in the largest ED in Serbia over 360 consecutive days (8,640 one-hour intervals). Crowding was measured hourly using the National Emergency Department Overcrowding Score (NEDOCS), derived from routinely collected data from health information system and expressed on a 0–200 scale, later grouped into six standard categories. Descriptive analyses assessed annual distribution, circadian and weekly variation, seasonal trends, and patient age structure. Between-group differences in NEDOCS scores were assessed using the Kruskal–Wallis test. Effect sizes were estimated using eta-squared (η²). The majority of patients in ED (43.14
Tension pneumothorax is a life-threatening emergency requiring immediate decompression followed by definitive pleural drainage to prevent rapid cardiopulmonary collapse. Management becomes particularly challenging in resource-limited settings where standard intercostal chest drains are unavailable. A 21-year-old woman presented with recurrent tension pneumothorax at a rural clinic in Bhutan after initial needle decompression. Because a standard intercostal chest drain was unavailable and transfer to the nearest referral hospital required approximately four hours, an improvised chest drain using an 18-Fr nasogastric tube connected to an underwater seal was inserted. The patient improved clinically and radiographically, allowing safe transfer for definitive management. This case demonstrates that prompt clinical decision-making and the use of an improvised nasogastric tube connected to an underwater seal can provide an effective temporary bridge when standard pleural drainage equipment is unavailable in remote settings. Judicious use of readily available devices may provide a lifesaving bridge for recurrent tension pneumothorax when standard equipment is unavailable, allowing safe transfer for definitive management. Not applicable.
Early revisits to the emergency department (ED) are commonly used as a quality indicator and reflect challenges in discharge decision-making. Although the National Early Warning Score 2 (NEWS2) is widely used to detect clinical deterioration, its ability to predict early ED revisits after discharge remains unclear. We conducted a retrospective cohort study at a tertiary university hospital ED in Thailand from January 2019 to June 2022. Adult patients discharged from the ED were included. The primary outcome was an unplanned same-institution ED revisit within 48 h. Initial triage NEWS2 scores were analyzed, and predictive performance was assessed using overall area under the receiver operating characteristic curve (AUROC) and threshold-specific operating characteristics. Among 75,609 eligible index visits, 182 (0.24
