Introduction: Despite the standard guidelines stating that giving epinephrine for patients with cardiac arrest is recommended, the clinical benefits of epinephrine for patients with traumatic out-of-hospital cardiac arrest (OHCA) are still limited. This study aims to evaluate the benefits of epinephrine administration in traumatic OHCA patients. Methods: We searched four electronic databases up to June 30, 2020, without any language restriction in research sources. Studies comparing epinephrine administration for traumatic OHCA patients were included. Two independent authors performed the selection of relevant studies, data extraction, and assessment of the risk of bias. The primary outcome was inhospital survival rate. Secondary outcomes included prehospital return of spontaneous circulation (ROSC), short-term survival, and favorable neurological outcome. We calculated the odds ratios (ORs) of those outcomes using the Mantel–Haenszel model and assessed the heterogeneity using the I² statistic. Results: Four studies were included. The risk of bias of the included studies was low, except for one study in which the risk of bias was fair. All included studies reported the inhospital survival rate. Epinephrine administration during traumatic OHCA might not demonstrate a benefit for inhospital survival (OR: 0.61, 95% confidence interval [CI]: 0.11–3.37). Epinephrine showed no significant improvement in prehospital ROSC (OR: 4.67, 95% CI: 0.66–32.81). In addition, epinephrine might not increase the chance of short-term survival (OR: 1.41, 95% CI: 0.53–3.79). Conclusion: The use of epinephrine for traumatic OHCA may not improve either inhospital survival or prehospital ROSC and short-term survival. Epinephrine administration as indicated in standard advanced life support algorithms might not be routinely used in traumatic OHCA.

Introduction: West Virginia has the highest incidence of obesity, smoking, and diabetes within the United States, placing its population at higher risk of stroke. In addition to these endemic risk factors, Appalachia faces various socioeconomic and health care access challenges that could negatively impact stroke incidence and outcomes. At present, there are limited data regarding geographic variables on stroke outcomes in rural Appalachia. We set out to quantify Appalachian geographic patterns of stroke incidence and outcomes. Methods: This is a retrospective analysis of all patients hospitalized with a diagnosis of stroke in West Virginia's largest tertiary hospital. During the study (2000–2018), 14,488 patients were analyzed, with an emphasis on those who died from stroke (n = 1022). We first used institutional ICD-9/10 data alongside demographics information and chart reviews to evaluate disease patterns while also exploring emerging hot spot pattern changes over time; we then exploited an emerging time series analysis using temporal trends to assess differing instances of stroke occurrence regionally with hot spots defined as higher than expected incidences of stroke and stroke death. Results: Data analysis revealed several hot spots of increasing stroke and mortality rates, many of which achieved statistically significant variance compared to expected norms (P = 0.001). Moreover, this study revealed high-risk zones in rural West Virginia wherein the incidence and mortality rates of stroke are suggestively higher and less resistance to economic change than urban centers. Conclusions: Stroke incidence and mortality were found to be higher than expected in many areas of rural West Virginia. The higher stroke risk populations correlate with area that may be impacted by socioeconomic factors and limited access to primary care. These high-risk areas may therefore benefit from investments in infrastructure, patient education, and unrestricted primary care.

Introduction: There has been a trend toward the use of alternative treatments to opioids for adequate pain management. This has paralleled a growing interest in the utilization of bedside point-of-care ultrasonography to guide placement of regional anesthesia in the emergency department. The purpose of this study was to establish the number of supervised examinations required for an emergency medicine resident to gain proficiency in accurately locating and identifying the nerves of the brachial plexus at the level of the interscalene space. Methods: Proficiency was defined as the number of attempts a resident required to accurately locate and identify the nerves of the brachial plexus on 10 separate, consecutive examinations. Didactic education was provided prior to the study and residents also participated in two instructional hands-on ultrasound examinations prior to the commencement of initial data collection. Count data are summarized using medians, means, and ranges. Random effects negative binomial regression was used for modeling panel count data where negative coefficients indicate increase in proficiency. Results: A total of 24 emergency medicine residents were enrolled in the study. Fourteen males and ten females participated. There were nine PGY-1 residents (37.5%), nine PGY-2 residents (37.5%), and six PGY-3 residents (25%). The median number of required supervised attempts and range for correctly performing both steps in the identification of the nerves of the brachial plexus was 2 (range 2–12). The median starting confidence level was 2 (range 1–4), and the median ending confidence level was 4 (range 1–5). Increases in confidence from start to finish were found to be statistically significant (P < 0.001). Conclusion: Emergency medicine residents are easily adept in the identification of the nerves of the brachial plexus at the level of the interscalene space following two supervised examinations. Residents made steady gains in confidence and proficiency throughout the study; statistical analysis found a significant association between the two.

Introduction: The fluid therapy is crucial in the treatment of critically ill children. Inadequate or excessive fluid resuscitation leads to increased mortality and morbidity, thus necessitating an accurate parameter for predicting fluid responsiveness when conducting fluid resuscitation. The inferior vena cava/abdominal aorta (IVC/Ao) ratio is suggested as a good guide for fluid resuscitation. However, the cutoff value for predicting fluid responsiveness in children has not been established. Is IVC/Ao ratio can be used to predict fluid responsiveness? Methods: The objective was to determine the accuracy and a cutoff value of IVC/Ao in predicting fluid responsiveness. A prospective cross-sectional study was conducted in the emergency room and the pediatric intensive care unit of the tertiary hospital from March to August 2017. We consecutively enrolled all critically ill children aged 1 month to 18 years' old who were hemodynamically unstable (shock). Measurements of IVC/Ao with ultrasound and stroke volume with ultrasound cardiac output monitor were obtained before and after fluid challenge. Results: Of 167 subjects enrolled in this study, only 58 subjects were included, most of whom were male (58.6%) and ranging in age from 1 to 11 months (32.8%). The mean IVC/Ao ratio before the fluid challenge in the fluid responsive group was 0.70 ± 0.053. The best cutoff of the IVC/Ao ratio is 0.675 with area under the curve 70.8% (95% confidence interval of 54.6%–87%), 75.7% sensitivity, and 61.9% specificity for predicting significant fluid responsiveness. Conclusion: The measurement of IVC/Ao is an accurate, sensitive, and specific parameter to predict fluid responsiveness. The best cut-off for the IVC/Ao ratio is 0.675.

Introduction: Pregnant trauma patients are an underdescribed cohort in the medical literature. Noting injury patterns and contributors to mortality may lead to improved care. Methods: Female patients between 14 and 49 years of age were identified among entries in the 2017 National Trauma Data Bank. Data points were compared using Chi-square test, Fisher's exact test, Student's t-test, Mann–Whitney rank-sum, or multiple logistic regression as appropriate. P < 0.05 was used to determine the findings of significance. Results: There were 569 pregnant trauma patients identified, which was 0.54% of the 105,507 women identified. Overall, mortality was low among all women and not different between groups (1.2% for pregnant women vs. 2.2% for nonpregnant, P = 0.12). Pregnant women with head injuries had a higher mortality rate than pregnant women without (4.2% vs. 0.47%, P < 0.01). Head injuries (Abbreviated Injury Severity Score [AIS] head >1) were associated with an increased risk for mortality (odds ratio: 3.33, 95% confidence interval: 3.0–3.7, P < 0.01). Conclusion: There was no increase in mortality for trauma patients who are pregnant when controlling for covariates. Factors such as head injuries, the need for blood, and comorbid diseases appear to have a more significant contribution to mortality. We also report the prevalence of head, cervical spine, and extremity injuries in pregnant trauma patients. Multidisciplinary simulation, jointly crafted protocols, and expanding training in regional anesthesia may be the next steps to improving care for pregnant trauma patients.

Growth plate (physeal) fractures are defined as a disruption in the cartilaginous physis of bone with or without the involvement of epiphysis or metaphysis. These represent around 15-18% of all pediatric fractures. It is important to diagnose physeal injury as early as possible, as misdiagnosis or delay in diagnosis may result in long term complications. Physeal injuries may not be initially obvious in children who present with periarticular trauma, and a high index of suspicion is important for diagnosis. Differential diagnosis for a Salter-Harris fracture includes a ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture. Salter-Harris I & Salter-Harris II growth plate fractures commonly are commonly managed by closed manipulation, reduction & immobilization. These are relatively stable injuries and can be retained by adequate plaster. Salter-Harris III & Salter-Harris IV fractures require anatomical reduction with the maintenance of congruity of joint. Physeal fractures can have many complications such as malunion, bar formation, acceleration of growth of physis, posttraumatic arthritis, ligament laxity and shortening of the bone. The key to well-healing fractures is successful anatomic reduction and patients must have regular follow-up for these injuries.

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the “group” definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Technology-driven educational modalities are increasingly utilized today in a variety of forms. Different combinations of the spectrum of simulation-based learning, the use of virtual reality, augmented reality, mixed reality, and serious gaming continue to gain traction on various educational platforms. In this paper, we share the formation of our project team to plan and execute a serious game on starting infusions and the use of infusion pump for nursing and health-care staff. The incorporation of element of assessment is also discussed. The various phases we went through included:

1. Learning needs assessment and conceptualization
2. Assembly of project team
3. Transfer of medical concepts
4. Storyboard and content production
5. Learners' experiential mapping
6. Testing of the prototype
7. Beta testing and release of the final product

The collaborative work and coordination between the subject-matter experts together with the technical production team is critical. Issues such as assessment and debriefing in serious gaming were also addressed, not forgetting the need to ensure that, above all, learning must take place.

Carotid artery dissection begins as a tear in one of the carotid arteries of the neck, which allows blood under arterial pressure to enter the wall of the artery and split its layers. The result is either an intramural hematoma or an aneurysmal dilatation. It is a significant cause of neurological signs and symptoms in all age groups. The common carotid artery dissection is the least affected and reported in the literature. There are multiple conditions that can cause the common carotid artery dissection including, trauma, procedures, and rarely spontaneous. Herein, we report a very unique and rare case of a female who presented with spontaneous and isolated common carotid artery dissection with no neurological signs and symptoms.

Traumatic dislocation of testis (TDT) is an uncommon event. During trauma, the cremasteric reflex can forcefully retract the testis out of the scrotal sac saving the testis from the injury. However, associated injuries in the form of skin degloving, penile avulsion, and amputation can be present. Early surgical intervention to locate and deposit the displaced testis to the scrotal sac is essential. We present a case of a 33-year-old man with bilateral congenital cryptorchidism who suffered blunt trauma to his genitalia following a road traffic injury. On presentation, based on a well-developed scrotum, it looked like a case of TDT. However, good history along with detailed physical and radiological evaluation helped us reach the correct diagnosis. TDT must be suspected in a case of blunt trauma to the genitalia when the scrotal sac (well-developed) is empty. This case report highlights the importance of detailed clinical and radiological evaluation in such cases.

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, “the alpha-bent” and “tunneling” for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications.