BACKGROUND:Snowmobile accidents occur in areas that may be difficult to reach by ground Emergency Medical Services (GEMS) vehicles. Helicopter EMS (HEMS) can potentially be useful in these situations, but there are few available data assessing HEMS-associated survival improvement in patients injured in snowmobile accidents. This study evaluates the national trauma database (NTDB) to identify snowmobile-related injury cases to determine if HEMS transport was associated with improved outcome, and whether any improvement in outcome is associated with worse functional status as indicated by disposition destination. METHODS:Using the American College of Surgeons National Trauma Data Bank (NTDB) for the years 2017-2022, snowmobile-related injury cases that were transported from the scene and in which transport mode (HEMS or GEMS) and survival status was known were assessed. Multivariable logistic regression (including use of Mahalanobis metrics within propensity-score calipers) was used to evaluate the primary endpoint of survival, with effect estimates reported as adjusted odds ratio (OR) with 95% confidence interval (CI). A secondary endpoint "unfavorable disposition destination" was assessed in survivors, to determine whether any HEMS-associated survival improvement came at the cost of a worse functional outcome. RESULTS:The study assessed 10,541 cases in which there were 521 (4.9%) deaths. Classical logistic regression incorporating demographics, vital signs, and receiving hospital characteristics indicated HEMS-associated improvement in survival (OR 1.9, 95% CI 1.4-2.7), which was confirmed in propensity-scored modeling indicating absolute risk difference of 2.7% (number needed to transport by HEMS to save one additional life: 37 with 95% CI 24-83). Secondary endpoint analysis did not suggest that improved HEMS survival came at cost of functional outcome; HEMS cases were slightly less likely to have unfavorable disposition destinations but the difference was not significant (OR 0.9, 95% CI 0.7-1.2, p = .461). CONCLUSION:In a group of cases injured using snowmobiles, HEMS transport is associated with significantly improved mortality without any indication that improved survival comes at a cost of worse functional outcome.

OBJECTIVE:Geriatric trauma patients are at increased risk of death or disability, and some have proposed trauma team activations based on advanced age alone. We sought to determine if there is a specific age at which a different approach to the trauma patient should be taken, based on their age-related risk for death, disability, or for needing acute resuscitative care. METHODS:We conducted a retrospective review of one year of data (2022) abstracted from the National Trauma Data Bank, including 984,335 adult trauma patients. The primary outcome was in-hospital mortality. Secondary outcomes were non-functional status at discharge, and a composite outcome created to capture the need for acute trauma interventions that included death in the ED, admission to the ICU, or need for emergent surgery, intubation, angioembolization, blood transfusions or procedures. RESULTS:Analyses adjusted for covariates showed the risk of receiving any acute intervention, including transfusions, surgeries, intubations and bedside procedures, all fell steadily with advancing age, as did risk of immediate death in the emergency department. Risk of death later during hospitalization, or of discharge to a non-functional status, rose steadily with advancing age. CONCLUSION:Trauma patients have rising mortality with advancing age, and a rise in likelihood of being sent to the ICU for care, but a falling rate of immediate, up-front death in the trauma bay, and a falling rate of receiving the acute, life-saving interventions associated with a trauma team activation. Further investigation is needed to determine the extent to which these findings illustrate differences in injury mechanism and severity, or age-related bias and differences in care.

Introduction:Opioid use is common for emergency department (ED) patients presenting with undifferentiated abdominal pain (AbdPain). Whether the potential analgesic benefits of opioids are offset by prolonged ED length of stay (LOS)-possibly due to extended evaluations or increased diagnostic testing-remains unclear. The primary objective was to determine whether administration of an opioid, compared to a nonopioid drug, as initial analgesia in AbdPain patients is associated with longer ED LOS after adjusting for demographics and pain severity. Secondary objectives evaluated whether initial opioid use was associated with higher adjusted likelihood of ordering abdominal CT (CTabd) or white blood cell count (WBC) testing. Methods:This retrospective observational study analyzed 4 months of electronic health record data from a single UK health system, including consecutive adult ED patients presenting with AbdPain who received analgesia and had a documented pain score. Variables included demographic factors, initial pain level, and analgesic administered. ED workup variables included diagnostic testing (CTabd, WBC), LOS, and disposition. Categorical data were summarized as proportions with binomial exact 95% confidence intervals (CIs); continuous data were summarized with medians and interquartile ranges (IQRs). Univariable analyses used Wilcoxon rank-sum or Pearson's χ 2 tests. Multivariable analyses employed quantile median regression for LOS and logistic regression for secondary outcomes. Results:During the study period, there were 884 patients meeting eligibility criteria. The median ED LOS was 7.7 h (IQR 5.0 to 11.9). CTabd and WBC were ordered in 362 (41.0%) and 797 (90.2%) of cases. Univariable analysis showed no association between initial opioid use and ED LOS (p = 0.255), CTabd ordering (p = 0.404), or WBC testing (p = 0.820). Multivariable modeling adjusting for operational factors, demographics, and pain score confirmed no significant association between initial opioid use and ED LOS (coefficient 0.18, 95% CI: -0.71-1.08, p = 0.684), CTabd (OR 1.12, 95% CI: 0.84-1.50, p = 0.430), or WBC testing (OR 0.91, 95% CI: 0.58-1.43, p = 0.698). Conclusions:Among ED patients with abdominal pain, initial opioid administration was not associated with longer LOS or increased use of diagnostic testing.

Introduction:In the emergency department (ED), commonly used analgesics for pain management are nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and opioids. The aim of this clinical trial was to evaluate the effectiveness of intravenous (IV) or oral (PO) paracetamol, combined with intramuscular (IM) diclofenac, in patients with acute limb injuries. Methods:This study utilized a double-blind, randomized controlled design to evaluate three different treatment groups. The trial included healthy adult males aged 18-65 years, who arrived at the ED with acute limb injuries, and an initial pain score of at least 5 on the Numerical Rating Scale (NRS). Participants were randomly assigned in equal numbers to one of three groups: one group received IM diclofenac (75 mg/3 mL), along with oral paracetamol (1000 mg); the second group was given IM diclofenac plus IV paracetamol (1000 mg in 100 mL); and the third group received IM diclofenac (75 mg/3 mL), accompanied by a placebo. The main goal of the study was to compare the average pain reduction among the three groups at 30 min after treatment (t30). Results:A total of 162 participants were recruited between October 2022 and February 2023. Pain levels were assessed at baseline (t0) and continued to be monitored up to 90 min after medication was administered (t90). The average reduction in pain scores for each group was as follows: diclofenac plus oral paracetamol resulted in a mean decrease of 2.5 ± 0.03, diclofenac plus IV paracetamol had a mean reduction of 2.6 ± 0.03, and diclofenac with placebo showed a mean decrease of 2.2 ± 0.04. These results indicate there was no statistically significant difference in pain relief among the three groups. Additionally, none of the groups required rescue pain medication, and no adverse events were reported in any group. Conclusion:The results demonstrate that the three treatment groups achieved similar levels of pain relief within the observed timeframe, offering no significant advantage in terms of speed or extent of pain reduction. Nonetheless, additional studies are warranted to explore the potential synergistic effects of combining paracetamol with NSAIDs via various administration routes, as well as to assess possible adverse events, and the necessity for supplemental analgesia. Trial Registration: ClinicalTrials.gov identifier: NCT04199572.

Prehospital transfusion of whole blood (WB) is being adopted in civilian Emergency Medical Services (EMS) systems, but the characteristics of patients receiving WB may differ by region. We aimed to compare prehospital WB transfusion programs in Sweden and in the Northeastern United States, focusing on patient demographics and transfusion details. We conducted a retrospective observational study of EMS-initiated WB transfusions in three regions in Sweden (2020–2024) and in multiple EMS programs in the Northeastern United States (2024). We compared patient age, sex (with female patients categorized as of childbearing potential (FCP) if ≤ 50 years), indication for transfusion (trauma vs. non-trauma), and prehospital WB transfusion practice (number of units initiated/completed and RhD type). A total of 196 patients received prehospital WB (85 in Sweden, 111 in U.S.). Sweden’s WB recipients were younger (median age 41 vs. 59 years) and more often trauma patients (90.6

Background Geriatric patients who have fallen often call emergency medical services (EMS) for assistance back to their feet but then, once so assisted, refuse transport to the hospital. In this study, these incidents of geriatric fall with refusal of transport are referred to as a “lift-assist”. Methods A year’s worth of a single urban EMS service’s records was reviewed to identify cases where a patient refused transport after a fall and was at least 65 years old. Results More than 19,000 calls were reviewed, of which 7,329 were for patients at least 65 years old. Of these, 433 involved a fall with a refusal of transport. Of these, nearly a third (142, or 32.8%) involved a repeat EMS call within 30 days, which usually resulted in transport to the ED (71.1%) and often in a hospitalization (42.3%). Conclusion The literature, including our own recent review of the records of an urban EMS system in Massachusetts, suggests many of these patients need more than a helping hand to stand, and would benefit from immediate or near-term follow-up for medical and /or rehabilitation care.

BACKGROUND:Most emergency departments (EDs) don't have interpreter services bandwidth to translate written discharge instructions in a timely manner for patients with limited English proficiency (LEP). Prior studies evaluating the accuracy of Google Translate have been variable across languages. OBJECTIVES:We aimed to evaluate if translations of ED discharge (DC) instructions by Google Translate are acceptable to patients and if there are language characteristics that can predict accuracy. METHODS:We prepared DC instructions for three hypothetical ED visits. Reviewers with self-identified fluency in English and a non-English language were asked to indicate "Yes" or "No" to instruction-specific queries about translation accuracy. Accuracy was analyzed across different DC instruction domains and across different language categories. Comparisons between language groups were executed using nonparametric Kruskal-Wallis testing. RESULTS:We identified a 95% overall quantitative success rate for ED DC instruction translation by Google Translate across 26 languages. In 16 of 26 languages (61.5%, 95% CI 40.6-79.8%), at least one of the four DC instruction arenas scored 90 or less. The total score was less than 90% in 5 (Amharic, French, Oromo, Portuguese, and Yoruba) of 26 languages (19.2%, 95% CI 6.6-39.4%). There were no differences by DC instruction domain or across different language categories. CONCLUSION:Using Google Translate for DC instructions found an overall error rate of 5% across all languages. Specific languages for which Google Translate functions better are not easily identified. Further investigation into the safety of routine use of Google Translate in medical contexts with limited interpreter availability is warranted.

ImportanceTraumatic cardiac arrest (TCA) presents a critical challenge in trauma care, often occurring rapidly after injury before effective interventions are available.ObjectiveTo evaluate the association of prehospital resuscitative thoracotomy with survival outcomes for TCA.Design, Setting, and ParticipantsThis retrospective cohort study examined all cases of prehospital resuscitative thoracotomy for TCA in London from January 1999 to December 2019. Data were analyzed from July 2022 to July 2023.ExposurePrehospital resuscitative thoracotomy for TCA.Main Outcomes and MeasuresThe primary outcome was survival to hospital discharge. Secondary outcomes included survival to hospital admission and neurological status at discharge.ResultsPrehospital resuscitative thoracotomy was undertaken in 601 patients with out-of-hospital TCA. The median (IQR) age was 25 (20-37) years; 538 (89.5%) were male and 63 (10.5%) female. A total of 529 patients (88.0%) had a penetrating mechanism of injury. TCA occurred at a median (IQR) of 12 (6-22) minutes after the emergency call, with 491 arrests (81.7%) before the advanced trauma team’s arrival. TCA was the result of cardiac tamponade (105 patients, 17.5%), exsanguination (418 patients, 69.6%), and exsanguination combined with cardiac tamponade (72 patients, 12.0%). Thirty patients (5.0%) survived to hospital discharge, with a favorable neurological outcome observed in 23 survivors (76.6%). Survival varied significantly with the cause of TCA: 22 of 105 patients (21%) with cardiac tamponade, 8 of 418 patients (1.9%) with exsanguination, and none of the 72 patients with combined or other pathologies survived. There were no survivors beyond 15 minutes of TCA for cardiac tamponade and 5 minutes after exsanguination. Multivariable analysis revealed that the cause of TCA (adjusted odds ratio [aOR], 21.1; 95% CI, 8.1-54.7; P < .001), duration of TCA (aOR, 20.9; 95% CI, 4.4-100.6, P < .001), and absence of the need for internal cardiac massage (AOR, 0.2; 95% CI, 0.06-0.5; P = .001) were independently associated with survival.Conclusions and RelevanceTCA occurs soon after injury, with only a brief window available for effective intervention. This study found that resuscitative thoracotomy is feasible in a mature, physician-led, urban prehospital system and is associated with improved survival for patients with out-of-hospital TCA, particularly when caused by cardiac tamponade, in situations where other treatment options are limited.

Importance:Prehospital transfusion (PHT) of blood products by emergency medical services (EMS) has become common in civilian settings. However, variability exists in practices across the US. There are few large-scale data describing US civilian PHT with regard to blood products administered, potential exposure of females of childbearing potential to D-positive blood, or the proportion of PHT cases occurring in EMS transports of short duration. Objective:To evaluate nationwide PHT trends, regional differences, and potential risks, particularly for D-positive blood administration in females of childbearing potential. Design, Setting, and Participants:This cohort study, Characteristics, Regional Evaluation, and D-Antigen in Transfusions by EMS (CREDIT-EMS), assessed data collected from January 1, 2020, to October 31, 2024 (before hypothesis generation), in trauma and nontrauma patients of all ages treated in 48 states in the US. Exposure:Prehospital-initiated transfusion of blood products. Main Outcomes and Measures:Age, sex, blood product characteristics (including blood type), and transport time. Comparative analyses were conducted using Pearson χ2, Wilcoxon rank sum, and nonparametric trend tests. Proportions were reported with binomial exact 95% CIs. Results:The study analyzed 10 444 patients (median [IQR] age, 45 [29-63] years; 7302 of 10 439 [70.0%] male) who received 18 177 units of blood products. The proportion of transfused units that were whole blood (WB) increased from 10.0% in 2020 to 30.8% in 2024 (P < .001). Regional variations in PHT were identified, with the Northeast having the highest proportion of WB use (33.2% of PHT). A total of 1589 (15.2%; 95% CI, 14.5%-15.9%) of the study patients were females of childbearing potential (aged 12-50 years), with an increasing number receiving D-positive blood products over time (73 of 169 [43.2%] in 2020 to 372 of 497 [74.9%] in 2024) (P < .001). Prehospital times were 20 minutes or less in only 255 of 10 343 cases (2.5%; 95% CI, 2.2%-2.8%). Conclusions and Relevance:This cohort study of civilian PHT practices in the US found geographic and temporal variability. There was increasing adoption of WB and significant implications for females of childbearing potential who are increasingly likely to receive D-positive PHT. Cases of PHT uncommonly involved short prehospital duration. These findings highlight the need for standardized protocols and further evaluation of risk-benefit considerations.

Objectives Identifying whether there is a traumatic intracranial bleed (ICB+) on head CT is critical for clinical care and research. Free text CT reports are unstructured and therefore must undergo time-consuming manual review. Existing artificial intelligence classification schemes are not optimised for the emergency department endpoint of classification of ICB+ or ICB−. We sought to assess three methods for classifying CT reports: a text classification (TC) programme, a commercial natural language processing programme (Clinithink) and a generative pretrained transformer large language model (Digitalizing English-language CT Interpretation for Positive Haemorrhage Evaluation Reporting (DECIPHER)-LLM).Methods Primary objective: determine the diagnostic classification performance of the dichotomous categorisation of each of the three approaches.Secondary objective: determine whether the LLM could achieve a substantial reduction in CT report review workload while maintaining 100% sensitivity.Anonymised radiology reports of head CT scans performed for trauma were manually labelled as ICB+/−. Training and validation sets were randomly created to train the TC and natural language processing models. Prompts were written to train the LLM.Results 898 reports were manually labelled. Sensitivity and specificity (95% CI)) of TC, Clinithink and DECIPHER-LLM (with probability of ICB set at 10%) were respectively 87.9% (76.7% to 95.0%) and 98.2% (96.3% to 99.3%), 75.9% (62.8% to 86.1%) and 96.2% (93.8% to 97.8%) and 100% (93.8% to 100%) and 97.4% (95.3% to 98.8%).With DECIPHER-LLM probability of ICB+ threshold of 10% set to identify CT reports requiring manual evaluation, CT reports requiring manual classification reduced by an estimated 385/449 cases (85.7% (95% CI 82.1% to 88.9%)) while maintaining 100% sensitivity.Discussion and conclusion DECIPHER-LLM outperformed other tested free-text classification methods.

Helicopter EMS (HEMS) is an important component of prehospital trauma scene response care worldwide, including for traumatic brain injury (TBI), a major cause of mortality in injured patients. Our objective was to perform a meta-analysis (MA) of trauma HEMS scene responses to patients with severe head injury to determine whether air medical response is associated with improved survival. A broad and systematic search of the literature was conducted from the years 1970–2024. We included studies with the outcome of mortality in HEMS vs. the control of ground EMS (GEMS) in trauma scene transports (adult or pediatric) with severe TBI as defined by Glasgow Coma Score (GCS) < 9 or Head Abbreviated Injury Score (AISHead) ≥ 3. A random effects restricted maximum likelihood MA was conducted, with post-analysis evaluation for bias. Of 21 HEMS outcomes studies evaluating TBI, 15 were eligible for MA, and effect estimates were HEMS-favorable in 13 and statistically significant in 9. The null hypothesis of no HEMS association with TBI survival was rejected (p < .01) for both the GCS < 9 and the AISHead3+ groups. Heterogeneity measures supported generation of a pooled effect estimate for the GCS < 9 group: HEMS survival OR 1.37 (95

OBJECTIVE:Tranexamic acid (TXA) is a standard therapy for the early treatment of life-threatening traumatic hemorrhage. Multiple studies suggest a benefit to earlier TXA, and meta-analysis calculates that each 15-minute time savings achieved by prehospital TXA improves mortality 10%. In trauma patients for whom helicopter emergency medical services (HEMS) initiated prehospital TXA, this study's primary aim was to calculate the minutes' time savings achieved compared with hypothetical TXA initiation at trauma centers. A secondary study aim was to evaluate whether there was geographic variation in the degree to which HEMS-initiated TXA expedited the initiation of the TXA. METHODS:Four years of data (2021-2024) were queried using the medical records database of a nationwide HEMS organization. Eligible cases were injured patients who received TXA initiated by HEMS flight crews in the prehospital setting. Variables assessed included patient age, sex, transport year, state/US Census Bureau region, time of TXA initiation, and time of hospital arrival. RESULTS:The study assessed 7,188 prehospital HEMS TXA initiations and found that flight-crew commencement of TXA therapy saved a median of 22 minutes overall and 25 minutes for pediatric patients. In all 4 regions of the United States, HEMS initiation of TXA saved at least 15 minutes; inter-regional variation in the degree to which HEMS initiation of TXA saved time was largely explained by variations in overall prehospital time. CONCLUSION:In the study dataset, HEMS was associated with significantly faster time to TXA, and despite regional variation in the degree of time savings, HEMS initiation of TXA saved at least 15 minutes in all 4 major US regions. Application of the metric of 10% survival increment per 15-minute expedited TXA initiation resulted in an estimate of mortality improvement of 14.7% overall and 16.7% for pediatric patients.

Introduction Paediatric major trauma patients with more severe injuries and physiological or biochemical abnormalities as a result of the injury are more likely to require invasive management in the form of an operation/interventional radiology (IR). Adverse psychological outcomes, such as post-traumatic stress disorder, anxiety, depression and adjustment disorder, are frequently observed in paediatric patients with major trauma. Similarly, it is recognised that children and adolescents who have invasive management are also at an increased risk of adverse psychological outcomes. However, it is not known to what extent major trauma patients requiring invasive management are at risk of adverse psychological outcomes compared with those managed conservatively. This study aims to determine whether paediatric major trauma patients who require an operation/IR have increased odds of having an adverse psychological outcome compared with those who are managed conservatively.Methods and analysis The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. The databases Medline (via Ovid), Embase (via Ovid), PsycInfo (via Ebscohost) and Cinahl (via Ebscohost) will be searched from inception to February 2025. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. For randomised controlled trials, the Cochrane Risk of Bias Tool will be employed, while for non-randomised studies, the Newcastle-Ottawa Quality Assessment Scale will be used. We will assess bias using contoured funnel plots (with p set at 0.01, 0.05 and 0.10), non-parametric trim-fill analysis, leave-one-out analysis and Galbraith plotting. We will execute formal (Egger) testing for funnel plot asymmetry and also calculate prediction intervals if sufficient study N of 10 is accrued. Certainty and confidence in cumulative evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Ethics and dissemination Ethical review is not required as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences.PROSPERO registration number CRD42025643459.

BACKGROUND:Ovarian and testicular torsion are fertility threatening surgical emergencies and represent relatively frequent emergency department (ED) presentations. OBJECTIVES:The current study aimed to evaluate for association between demographics and time-related endpoints related to evaluation and management of gonadal torsion in adults presenting to the ED. The primary endpoint was time from ED presentation to arrival in the operating room (tOR). Secondary endpoints included times from ED presentation to radiology-performed ultrasound (tUS) and to specialist consultation. METHODS:We assessed four years (2020-23) of adult (age > 18) gonadal torsion patients diagnosed in an urban academic center. Eligible cases were those with a primary diagnosis of gonadal torsion. RESULTS:Of 57 patients, 45 were female sex (79.0%). Race was most commonly White (35, 61.4%), with 9 patients (15.8%) each in categories of Hispanic or Black/African-American and remaining 4 patients (7.0%) were Asian. 48 (84.2%) of 57 torsion patients went directly from the ED to OR. Univariate analysis found that compared to males, tOR for females was prolonged by 156 min (95% CI: 79-239), and tUS was prolonged by 32 min (95% CI: 7-66). Multivariable QR confirmed longer tOR for females (128 min, 95% CI: 5-251, p = 0.042) and found prolonged tOR for Asians as compared to Whites (229 min, 95% CI: 49-409, p = 0.014) although with small subgroup numbers. CONCLUSIONS:Despite constituting a substantial majority of adult ED patients with gonadal torsion, time from presentation to ultrasound was prolonged by more than 30 min and operative intervention was prolonged by over 2 h for females as compared to males.

BACKGROUND:Older patients who fall may call Emergency Medical Services (EMS) for assistance, then refuse transport to the Emergency Department (ED). We sought to describe the characteristics of such patients, and to identify predictors of the need within 30 days for a repeat EMS call, ambulance transport and/or hospitalization. METHODS:The records of a single urban EMS service were reviewed for one year concluding in October 2024 to identify cases where a geriatric patient (age > 64) refused transport after a fall. Multivariable logistic regression was used to evaluate dichotomous endpoints of repeat EMS call and hospitalization. RESULTS:Of 19,694 overall calls, there were 7329 for geriatric patients, 931 of whom refused transport. Of these 931 geriatric refusals, 433 were refusals after a fall. 142 (32.8 %, 95 % CI 28.4-37.4 %) had at least one same-month repeat EMS call and 101 of those (71.1 %, 95 % CI 62.9-78.4 %) were transported, with 65.9 % of transports resulting in hospitalization. Multivariable analysis identified no patient factors predictive of repeat EMS call. Admission was predicted by advancing age (OR 1.08 for each year, with 95 % CI 1.01-1.14, p = .016). CONCLUSION:Nearly a third of falls with transport refusals are associated with a same-month repeat EMS call, a majority (71.1 %) of which result in transport to the ED, usually followed by hospital admission. We identified no predictors of repeat EMS call or hospitalization. Geriatric patients who refuse transport after a fall are at high risk for repeat EMS calls and hospitalizations, but predictors of such needs are elusive.

OBJECTIVE:This scoping review is an annual update of helicopter emergency medical services (HEMS) outcomes literature added to the HEMS outcomes assessment research database (HOARD). HOARD is maintained by the critical care transport collaborative outcomes research effort (CCT CORE) and is updated each year with the previous calendar year's studies assessing whether HEMS use alters patient-centered outcomes. METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) guidelines, we used multiple reviewers of records retrieved from multiple medical and gray literature sources: Medline (PubMed), EMBASE, Scopus, CINAHL, and Google Scholar. Eligible for review was HEMS vs. ground EMS outcomes studies either published or appearing in preprint databases during calendar year 2024. HOARD excludes case reports and review articles (unless they provide a new calculation of effect estimate). We assessed articles for subject matter (trauma vs non-trauma), journal impact factor (JIF), and geographic region of the study's correspondence author. Categorical analyses comparing 2024 studies with HOARD studies from 2023 were executed with Pearson's chi-square or Fisher's exact test, and we also calculated risk ratio with its 95% confidence interval. Non-normal JIF data were described using median and interquartile range and analyzed using rank sum testing. Nonparametric trend testing evaluated the last decade's evidence using Cochrane-Armitage (dichotomous) or Cuzick (JIF) testing. RESULTS:Of an initial records of N = 5,179 (74 of which were reviewed as full text), we identified 21 studies for addition to HOARD. Longitudinal analysis revealed a significant (P < .001) annual trend toward increasing proportions of studies focusing on non-trauma; 2024 was the first time in a decade that the more than half of the year's outcomes studies focused on non-trauma. There was no indication of trend involving the proportion of studies emanating from the USA (P = .821) or from the combined countries of USA and Europe (P = .566). The 2024 JIF had a median of 2.11 and interquartile range of 1.25 to 2.60. There was no suggestion (P = .919) of longitudinal JIF trend in the past decade. CONCLUSION:This scoping review provides information on 21 HEMS outcomes studies new to the evidence base in 2024. The HOARD database, freely available, has been updated with these studies.

Background Manipulation and reduction (M&R) of an injured limb is often required to reduce pain, bleeding and restore anatomical alignment, typically using procedural sedation and analgesia (PSA). Inhaled methoxyflurane (IMF) may be a suitable alternative that is simple to administer, does not require intravenous access, and has a favourable side effect profile. The objective of this systematic review and meta-analysis was to determine the effectiveness of IMF compared to PSA for M&R in acute traumatic limb injury. The primary outcome measure was procedural success rate. The secondary outcomes were to compare the length of stay, adverse events, patient satisfaction and cost-effectiveness. Methods This systematic review was planned, conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and is registered on PROSPERO CRD42024561087. A literature search was conducted and included studies from database inception to the search date (22 February 2024), using MEDLINE, EMBASE, Cochrane, CINAHL and PubMed platforms. All studies involving the use of IMF for M&R of acute traumatic limb injuries were included. Animal studies, case-reports, non-English language publications and opinion articles were excluded. The risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was undertaken for the primary outcome of procedural success. Narrative synthesis was undertaken for the themes of length of stay, adverse events, patient satisfaction and cost-effectiveness. Results Fifty one abstracts were screened through a database search, reference review, and search of the grey literature. Following full-text review and exclusions, a total of six studies were included, with two suitable for meta-analysis. No significant differences in performance were observed between IMF and PSA (RR 0.90, 95% confidence interval 0.77–1.04, p = 0.16). Patients receiving IMF had a shorter emergency department length of stay, a low incidence of adverse events, and overall positive patient satisfaction. There may be cost-savings associated with the use of IMF. Conclusion Inhaled methoxyflurane was observed to perform no differently to procedural sedation for the successful manipulation and reduction of acute traumatic limb injuries in the emergency department. The overall quality of the evidence is poor, and further higher-level evidence is required.

Outcomes in acute limb ischemia (ALI) depend on early recognition. Rapid evaluation methods in the emergency department (ED) include physical exam, hand-held Doppler (HH), or spectral Doppler (SD) using point-of-care ultrasound (POCUS). This study aims to estimate performance characteristics of HH versus emergency medicine (EM)-performed SD compared to angiography along with clinician confidence when evaluating for ALI. This was a prospective observational pilot study. A convenience sample of patients presenting to an urban, academic ED with concern for ALI who underwent angiography were eligible. The primary aim evaluated diagnostic performance of HH and SD in correctly classifying flow in posterior tibial (PT) and dorsalis pedis (DP) arteries in patients with 100

Background: Awake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research question: Does APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study design: Two center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring >= 5 liters/min oxygen to maintain saturations >= 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. Results: Between 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22-2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. Interpretation: In COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registration: NCT04853979 (clinicaltrials.gov).