Background: Despite advances in trauma care, haemorrhagic shock continues to be one of the leading causes of preventable deaths after injury. Often, the difference between life and death comes down to how quickly the bleeding is recognized and treated especially in the emergency department. To address this, hospitals have developed Massive Transfusion Protocols (MTPs), which provide a structured, team-based approach to rapidly deliver the right balance of blood products. These protocols are designed to give critically bleeding patients the best possible chance of survival when every second counts. Objective: This narrative review synthesizes contemporary literature and international guidelines on the implementation and impact of MTPs in trauma care, highlighting evolving strategies, current challenges, and future directions. Methods: A narrative review was conducted using a systematic search of PubMed, Scopus, and Google Scholar databases. Boolean operators and relevant keywords were used to identify peer-reviewed articles, clinical guidelines, and consensus statements published... Continue Reading

Introduction:  Emergency Department(ED) job satisfaction is a critical determinant of ED healthcare workers' well-being, staff retention especially in the Low and Middle middle-income country(LMIC) excessive overcrowded and limited resources setting, where both “job satisfaction” and “gender-based issues” are less discussed. This comprehensive audit was initiated at  Accident and Emergency Department( A&E) of Colombo South Teaching Hospital(CSTH), Sri Lanka to identify specific domains of “gender disparity in job satisfaction” for an evidence-based, targeted departmental intervention for quality improvement. Methods: A single-centre, cross-sectional audit was conducted in early 2025 within CSTH A&E (average 400-500 patients per day). This audit included the permanent ED HCW, including physicians and nursing officers. Data was collected via an anonymous, voluntary, self-administered online/ printed questionnaire specified to LMIC ED context issues. Domains assessed included overall job satisfaction, gender bias, environment and work-life balance, burnout and compensation, workplace equity, unconscious bias, threats, expectations and support available.   Results: A robust... Continue Reading

Background:Drowning remains a major cause of accidental death worldwide, particularly in coastal and tourist regions. Previous studies have suggested that foreign nationals may be disproportionately affected by drowning incidents; however, analyses based on systematic prehospital emergency medical data are limited, and no such studies have been conducted in Japan. Methods:We retrospectively reviewed drowning-related helicopter emergency medical service (HEMS) dispatches in Okinawa Prefecture, Japan, between April 2016 and March 2025. Only completed dispatches were included. Patient characteristics included age, sex, nationality (Japanese or foreign national), and cardiopulmonary arrest (CPA) status. To evaluate the impact of international travel restrictions, cases were categorized into three periods: pre-COVID (April 2016–January 2020), COVID period (February 2020–May 2023), and post-COVID (June 2023–March 2025). Results:During the study period, 226 drowning-related HEMS dispatches were recorded, of which 170 were accepted and analyzed. The median patient age was 43 years (interquartile range 25–59), and 65.3% of patients presented with... Continue Reading

Introduction Arterial pH levels below 6.8 are traditionally considered incompatible with life due to irreversible cellular dysfunction and poor survival. Severe acidosis with concurrent hyperkalemia and critical anemia presents an exceptional resuscitation challenge. This case describes full recovery in a patient with a pH of 6.75 after traumatic hemorrhagic shock, highlighting how aggressive, multidisciplinary management can reverse physiology once deemed fatal. Aims / Objectives To report a trauma patient’s survival and full recovery from extreme acidosis, hyperkalemia, and anemia, underscoring the value of rapid correction and coordinated resuscitation in restoring physiological stability. Materials / Methods A multidisciplinary trauma, surgical, and critical care approach was employed using institutional massive transfusion and resuscitation protocols. Serial clinical, hemodynamic, and metabolic assessments guided real-time management, including fluid and blood replacement, electrolyte correction, and definitive surgical intervention. Case Description A 42-year-old male with no comorbidities presented 15 minutes after a high-speed motor vehicle collision with... Continue Reading

Background:Acute gastric volvulus is a rare but potentially life-threatening condition that requires promptrecognition and management. Its non-specific clinical presentation often poses diagnosticchallenges, particularly in patients with predisposing anatomical anomalies such as a hiatushernia. Case Presentation:We report the case of a 48-year-old female who presented with a 24-hour history of sudden-onset, continuous upper abdominal pain and vomiting. Her medical history included asthmaand gastritis secondary to a known hiatus hernia. Examination revealed upper abdominaltenderness and bi-basal crepitations, predominantly on the right side. Laboratoryinvestigations showed elevated inflammatory markers, including a white cell count of 19.5(neutrophils 16.9) and a CRP of 320.A contrast-enhanced CT scan confirmed a large hiatus hernia complicated by gastricvolvulus, along with a right lower lobe pneumonia suggestive of aspiration. The patient wasmanaged conservatively with nasogastric decompression, intravenous fluids, and antibiotics,and was referred for surgical evaluation. Conclusion:This case highlights the importance of maintaining a high index of suspicion for gastricvolvulus in... Continue Reading

Background: Aphasia without accompanying motor deficit is an uncommon neurological presentation that may lead to diagnostic delay in emergency settings. Global aphasia without hemiparesis presents a particular challenge, as it may mimic seizure, metabolic encephalopathy, or postictal states, especially when early neuroimaging is unrevealing. Case Presentation: An 84-year-old man with a background of asthma was brought to the emergency department following a witnessed episode of vacant staring with possible brief limb movements lasting approximately one minute. There was no loss of continence, tongue biting, prodromal symptoms, or aura. He had been well earlier that day, with no history of alcohol misuse, recent trauma, infection, or anticoagulant use. Following the episode, the patient demonstrated complete absence of meaningful speech despite preserved limb strength. This deficit was observed by paramedics and persisted on arrival to hospital one hour after symptom onset. He was hemodynamically stable with a regular cardiac rhythm. Neurological examination... Continue Reading

Background: Sternal fractures are most commonly associated with high-energy blunt thoracic trauma and are readily identified on computed tomography. In contrast, sternal insufficiency fractures are rare and may present insidiously, particularly in older adults with severe osteoporosis. Delayed symptom evolution and initially negative imaging can obscure diagnosis and delay appropriate management. Case: An 84-year-old woman with hypertrophic cardiomyopathy and severe osteoporosis treated with teriparatide presented to the Emergency Department after a low-impact forward fall while gardening. Initial examination revealed facial bruising and bilateral anterior chest wall tenderness. High-resolution CT of the chest, abdomen, and pelvis demonstrated no acute traumatic injury, showing only known vertebral insufficiency fractures. She was discharged with conservative advice. Three days later, she re-presented with new-onset focal sternal pain and visible anterior chest wall swelling. She denied any further trauma. Examination now demonstrated a clear sternal deformity with marked point tenderness, findings absent during the initial assessment.... Continue Reading

Background: Soft tissue swellings are a frequent presentation in the emergency department and are commonly attributed to abscesses or cellulitis. In patients with vascular risk factors or prior arterial interventions, however, vascular pathology such as pseudoaneurysm must be considered. Failure to recognize pseudoaneurysms may result in inappropriate intervention and life-threatening hemorrhage. Point-of-care ultrasound offers rapid bedside assessment to distinguish vascular from non-vascular soft tissue pathology. Case Series: We present two emergency department cases highlighting the diagnostic value of POCUS in evaluating undifferentiated soft tissue swellings.The first case involved a man in his early 30s with a history of intravenous drug use who presented with a painful, firm left groin swelling following femoral injections. Clinical assessment raised concern for a groin abscess. Given the high risk of vascular injury in this anatomical region, POCUS was performed prior to intervention. Ultrasound demonstrated a complex, loculated fluid collection clearly separate from the femoral... Continue Reading

Background:The establishment of Midland Metropolitan University Hospital (MMUH) in October 2024, following the merger of Sandwell and City Hospitals, created the newest acute care university hospital in the UK. This transition was associated with a marked rise in patient acuity and emergency department (ED) attendances, including the highest ambulance conveyance rate in the West Midlands. Junior doctors, including non-training grade clinicians, faced increased clinical complexity alongside reduced access to structured education. A rapid, sustainable educational intervention was therefore required. Methods:An ongoing Quality Improvement Project was implemented using a three-cycle Plan–Do–Study–Act (PDSA) framework over four months. Brief, 10-minute microteaching sessions were delivered Monday to Friday during ED handovers. Sessions were interactive, case-based, gamified, and mapped to the RCEM curriculum to ensure relevance while minimising disruption to clinical workflow. Content selection was guided by curriculum mapping, local incidents, and trainee feedback. Evaluation was conducted using post-session electronic surveys assessing engagement, relevance, confidence,... Continue Reading

Importance Asthma exacerbations are a leading cause of emergency department (ED) visits and hospitalizations in children. Optimizing acute management is essential to improve outcomes and reduce healthcare utilization. ObjectiveTo determine whether nebulized epinephrine, when added to standard salbutamol therapy, improves PRAM (Pediatric Respiratory Assessment Measure) scores in pediatric patients with moderate to severe asthma exacerbations. Design, Setting, and ParticipantsDouble-blind, randomized controlled trial at tertiary care centers. Children aged 3 to 12 years with moderate to severe asthma exacerbations were randomized to receive either nebulized epinephrine plus standard salbutamol therapy or standard salbutamol therapy alone. InterventionsNebulized epinephrine in addition to standard salbutamol therapy versus standard salbutamol therapy alone. Main Outcomes and Measures Primary outcome: Change in PRAM score at 60, 80, and 100 minutes post-intervention. Secondary outcomes: ED length of stay, hospital admission rates, ED revisit within 72 hours, and adverse events. ResultsThirty children were randomized (15 per group). The mean... Continue Reading

Background Pain is a subjective but critical clinical symptom and should be managed with the same urgency as other vital signs in the emergency department (ED). Delayed analgesia, particularly among patients triaged to lower-acuity areas, contributes to prolonged suffering and reduced patient satisfaction. This study evaluated the impact of a structured Quality Improvement (QI) initiative aimed at improving timeliness and effectiveness of pain management in the ED.   Objective To reduce door-to-analgesia time by at least 25% from baseline and improve time to 50% reduction of initial pain score among adult ED patients with moderate to minor injuries.   Methods A prospective QI study using Plan–Do–Study–Act (PDSA) cycles was conducted over 8 weeks in a tertiary care emergency department with a 3-tier triage system. Adults aged ≥18 years presenting with pain scores ≥1/10 were included. Baseline data were collected for 50 consecutive patients over 2 weeks. Interventions included staff education... Continue Reading

Background - The first hour of emergency care—the Golden Hour—is critical for patient survival, with the initial five minutes (“Golden Window”) playing a decisive role in identifying life-threatening conditions. Point-of-Care Ultrasound (POCUS) provides rapid, real-time physiological information and has become an essential adjunct to clinical examination. Despite its proven utility in shock, trauma, and acute dyspnea, POCUS is often underutilised or delayed beyond the initial assessment, potentially limiting its impact on early decision-making. Objective - To evaluate the effect of performing structured POCUS within the first five minutes of emergency assessment on diagnostic accuracy, time to life-saving intervention, and early clinical decision-making in patients with undifferentiated hypotension, trauma, or acute dyspnea. Methods - A prospective observational study was conducted over three months in a high-volume tertiary emergency department. A total of 150 consecutive adult patients presenting with undifferentiated hypotension, trauma, or acute dyspnea were included. Patients were divided into two... Continue Reading

Background: Right-sided diverticulitis, particularly cecal diverticulitis, is a rare condition that can mimic other causes of acute abdomen and pose a diagnostic challenge.Case Presentation: A 57 year old male presented with acute tearing epigastric pain followed by lower abdominal pain. Examination revealed bilateral iliac fossa tenderness with guarding in the right iliac fossa and positive psoas and obturator signs. Laboratory testing showed elevated C reactive protein (70 mg/L) with otherwise unremarkable results. Because the initial tearing epigastric pain raised concern for serious conditions, including acute coronary syndrome, pancreatitis, and aortic pathology, cardiac enzymes, ECG, serum lipase, and contrast‑enhanced CT were obtained, which excluded these diagnoses. Abdominal ultrasound demonstrated focal bowel wall thickening in the right lumbar region. Contrast‑enhanced CT identified a cecal diverticulum with surrounding pericolic fat stranding and localized inflammatory changes without abscess or perforation, consistent with Hinchey stage Ia cecal diverticulitis. The patient was managed conservatively with intravenous ceftriaxone... Continue Reading

Introduction: The history of traumatic injury treatment is a progression from crude ancient practices to modern trauma systems, marked by significant developments in military medicine, surgery, and understanding of physiology. Key milestones include early documentation in ancient Egypt, the extensive but primitive record-keeping of the American Civil War, the introduction of antisepsis, the development of trauma centers, and advancements in casualty evacuation and the treatment of shock. There is a direct link between military and civilian trauma care that starts during the Civil War and continues until the current conflict in Ukraine. The wars of the last two decades have changed the nature of injuries seen on the battlefield, leading to further trauma management innovation. Trauma is a global burden of disease that is responsible for 5 million deaths around the world annually. Lessons learned in these hostile environments have guided many developments in trauma care in high-income countries, resulting... Continue Reading

Introduction  Armed conflicts have been implicated in the development of antimicrobial resistance. Cases of antimicrobial-resistant microorganisms among people with war injuries were first documented during World War II and have been increasingly reported in more recent conflicts (Mende et al., 2022). As the survival of military personnel wounded in previous wars increased due to advancements in personal protective equipment and combat casualty care, there was a corresponding rise in trauma-related infections (Tribble et al, 2011). Combat trauma across the modern battlefields has revealed an alarming increase in multidrug–resistant organisms (MRDO). During these wars, the most common combat trauma–related infections were skin and soft–tissue (41%), pneumonia (13%), bloodstream infections (13%), osteomyelitis (6%), and sepsis (4%) (Tribble et al, 2016). Infection has been a complication of war wounds throughout history. Extremity wounds are the most prevalent injury pattern among combat casualties (Petfield et al, 2022). Wounds from blasts, gunfire, and shrapnel are... Continue Reading

Aortic dissection (AD), with a prevalence of 5–30 cases per million people, is a rare but life-threatening condition that often relies on pattern recognition for diagnosis. Classical presentation involves acute presentation of severe chest pain; however, atypical symptoms can obscure timely recognition.  A 49-year-old man with a history of hypertension, ischemic heart disease, and previous lung empyema  presented with chronic symptoms of reduced effort tolerance and left lower limb numbness during ambulation. On examination, absent pulses were noted in the left femoral artery and distal pulses. Point-of-care ultrasound (POCUS) revealed a dilated aortic root with intimal flaps in both the thoracic and abdominal aorta. CT angiography confirmed the diagnosis of a Stanford A thoracoabdominal AD. Unfortunately, due to the complexity of the tear, the patient was managed conservatively. This case underscores the critical role of clinical acumen paired with POCUS in identifying atypical presentations of AD. In emergency settings, where rapid diagnosis can be life-saving, POCUS serves as a... Continue Reading

Breaking the Bad News ! Any news that drastically and negatively alters the patients view of their future.( Buckmann,1992) Despite the commitment to openness and right to information, the decision to whether to withhold or disclose that difficult information continues to trouble the healthcare professionals. Conveying bad news to the patient themselves or to their attendants is rather a process than an event, resulting in cognitive, behavioural or emotional deficit, and this lasts beyond the bad news encounter. These deficits have implications on how the person will think, behave and feel in their response to changes, resulting from the news in shorter and the longer term. For this reason, it is vital for a structured framework to deliver the bad news to be employed that not only dispense the required information, but also enables them to engage in decision making about their care when the choices become limited by allowing... Continue Reading

Background: Pain is a primary reason for emergency department (ED) visits and hospitalizations following injuries, and its inadequate management can lead to complications. Effective and safe pain control is crucial in traumatic patient management. While opioids like morphine are commonly used for acute pain due to their effectiveness and rapid action, ketamine, has recently been explored for pain management in various settings. This meta-analysis aimed to compare the efficacy and safety of morphine sulfate and ketamine in trauma patients experiencing musculoskeletal pain. Methods and materials: This meta-analysis was registered in PROSPERO (CRD420251001307) and followed PRISMA guidelines. An extensive search was conducted across PubMed, Web of Science, Scopus, and Embase databases in March 2025 to identify randomized controlled trials (RCTs) comparing ketamine and morphine for pain in trauma patients. Two independent reviewers screened and evaluated articles, resolving conflicts with a third reviewer. Inclusion criteria focused on English-language RCTs comparing intravenous (IV)... Continue Reading

Background: Endothelium-derived hyperpolarizing factor (EDHF) is a major mediator of endothelium-dependent vasorelaxation in small resistance arteries and is crucial for microcirculatory regulation. Sepsis causes endothelial injury and profound microcirculatory dysfunction, yet the time course of EDHF function during sepsis remains unclear. Methods: Male Wistar rats received intraperitoneal lipopolysaccharide (LPS) 5 mg/kg. Mesenteric and right gastroepiploic arteries were harvested at baseline (Control), 24 h (Day 1), and 72 h (Day 3). Vasorelaxation was assessed by acetylcholine (ACh)–induced relaxation in small arteries and by recording smooth muscle membrane potential (hyperpolarization). To examine nitric oxide (NO) contribution, experiments were repeated with the NO synthase inhibitor nitro-L-arginine (L-NNA). Results: ACh-induced vasorelaxation was markedly suppressed on Day 1 versus Control, accompanied by reduced endothelial hyperpolarization, indicating early impairment of EDHF-associated responses. By Day 3, vasorelaxation and hyperpolarization recovered toward baseline. However, under NO inhibition with L-NNA, the Day 3 recovery was abolished, suggesting compensatory NO-dependent... Continue Reading

Background: Gas-forming liver abscess caused by Clostridium perfringens is extremely rare but carries a high mortality rate. Early recognition of hemolysis and hepatic gas formation is critical for timely management. Case Presentation: An 80-year-old man with type 2 diabetes mellitus and a history of gastrectomy for gastric ulcer presented with fever, headache, abdominal discomfort, and nausea. He had undergone endoscopic retrograde cholangiopancreatography (ERCP) four times over the previous ten months, most recently three weeks before admission. On arrival, he was alert but appeared ill, with fever, tachypnea, jaundice, and an oxygen requirement of 2 L/min via nasal cannula. His abdomen was distended and tender. Laboratory tests showed leukocytosis, anemia, elevated liver enzymes, and severe hemolysis. A plain CT scan obtained at presentation revealed a 2.3-cm gas-forming lesion in hepatic segment 6. Two hours later, contrast-enhanced CT demonstrated enlargement to 4.6 cm. Empiric broad-spectrum antibiotics (sulbactam/ampicillin) were started, and percutaneous drainage... Continue Reading