This study aims to analyze and describe terrorism-related attacks in East Asia from 1970 to 2020. This descriptive analysis of terrorist attacks in East Asia will help first responders, emergency medical services (EMS), hospital-based medical providers, and policymakers establish a more refined hazard vulnerability assessment framework and develop a counter-terrorism medicine (CTM) mitigation, preparedness, response, and recovery plan.

This descriptive observational study draws data from the Global Terrorism Database (GTD) from January 1, 1970, to December 31, 2020. Epidemiology outcomes included primary weapon type, primary target type, the country where the incident occurred, and the number of total deaths and injuries collected. Data from 2021 was not yet available at the time of this study. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

There were 779 terrorism-related events in East Asia from 1970 to 2020. In total, the attacks resulted in 1,123 deaths and 9,061 persons injured. The greatest number of attacks (371; 47.63%) occurred in Japan and the second most occurred in China (268; 34.4%). Explosives were the most used primary weapon type (308; 39.54%) in the region, followed by incendiary devices (260; 33.38%). Terrorist attacks drastically diminished from their peak of 92 in 1990, but there were additional peaks of 88 in 1996, 18 in 2000, 20 in 2008, and 36 attacks in 2014.

A total of 779 terrorist attacks occurred from 1970 to 2020 in East Asia, resulting in 1,123 deaths and 9,061 injuries. Of those, 82.03% of attacks occurred in Japan and China. Terrorist attacks drastically diminished since their peak in 1996, but there is an overall uptrend in attacks since 1999.

Decreasing symptom-to-door (S2D) delay is of vital importance for reducing morbidity and mortality in patients with ST-segment elevation myocardial infarction (STEMI). The factors associated with S2D delay in STEMI patients have not been well-characterized.

The aim of this study was to identify factors associated with S2D delay in patients with STEMI.

The PubMed, CINAHL, and Embase databases were searched for data. References from the selected articles and relevant background papers were also manually searched to identify additional eligible studies. The included articles were reviewed and assessed for risk of bias. The level of evidence for each identified factor was evaluated using a semiquantitative synthesis.

Twelve (12) papers were included in the review. Factors associated with S2D delay were complex and could be divided into sociodemographic, clinical history, and onset characteristics. The level of evidence regarding female sex and diabetes was strong, and the evidence was moderate regarding older age, smoking, history of hypertension, self-transport, or referral.

Female sex, older age, previous diabetes, previous hypertension, smoking, and self-transport are all strong or moderate risk factors for S2D time delay in patients with ST-segment myocardial infarction. More efforts should be made to educate at-risk populations concerning symptoms of STEMI and the importance of seeking early medical assistance.

Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.

The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.

The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.

In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.

The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.

Outdoor activities have accelerated in the past several years. The authors were tasked with providing medical care for the Union Cycliste International (UCI) mountain biking World Cup in Snowshoe, West Virginia (USA) in September 2021. The Hartman and Arbon models were designed to predict patient presentation and hospital transport rates as well as needed medical resources at urban mass-gathering events. However, there is a lack of standardized methods to predict injury, illness, and insult severity at rural mass gatherings.

This study aimed to determine whether the Arbon model would predict, within 10%, the number of patient presentations to be expected and to determine if the event classification provided by the Hartman model would adequately predict resources needed during the event.

Race data were collected from UCI event officials and injury data were collected from participants at time of presentation for medical care. Predicted presentation and transport rates were calculated using the Arbon model, which was then compared to the actual observed presentation rates. Furthermore, the event classification provided by the Hartman model was compared to the resources utilized during the event.

During the event, 34 patients presented for medical care and eight patients required some level of transport to a medical facility. The Arbon predictive model for the 2021 event yielded 30.3 expected patient presentations. There were 34 total patient presentations during the 2021 race, approximately 11% more than predicted. The Hartman model yielded a score of four. Based on this score, this race would be classified as an “intermediate” event, requiring multiple Advanced Life Support (ALS) and Basic Life Support (BLS) personnel and transport units.

The Arbon model provided a predicted patient presentation rate within reasonable error to allow for effective pre-event planning and resource allocation with only a four patient presentation difference from the actual data. While the Arbon model under-predicted patient presentations, the Hartman model under-estimated resources needed due to the high-risk nature of downhill cycling. The events staffed required physician skills and air medical services to safely care for patients. Further evaluation of rural events will be needed to determine if there is a generalized need for physician presence at smaller events with inherently risky activities, or if this recurring cycling event is an outlier.

Despite Spanish experience in counterterrorism, jihadism means new modus operandi, based on active mass casualty incidents, involving new injury patterns as mass bleeding ones. Therefore, the environment is completely different to first responders' structure. This change forced the revision of the tactical response model, led by the Spanish Association for Emergency Medicine's Tactical Care Secretary, who provides a discussion forum to its members, reaching a joint framework document, IBERO, adapted to Spanish tactical emergency capabilities.

Methodology was based on three parameters:

1. 1) Literature revision, selecting three sources: Books and academic papers, TCCC and TECC guidelines, and Hartford Consensus, and AARs from the main active incidents with similarities to jihadist ones.

2. 2) Formation of discussion groups: Threat definition, tactile response, and prehospital care, triage and evacuation systems.

3. 3) A final group formed by representatives of each discussion group wrote the final document.

The protocol defines a staged plan of action, adapted to Spanish legislation and institutions, following the acronym IBERO:

1. 1) Information: threat intelligence and information transmitted to responders from the incident location and dispatchers.

2. 2) Block the threat by perimeter, zonification and suppression of the threat.

3. 3) Escalation of resources. Definition of areas of action according to direct threat, indirect threat and safe areas of action.

4. 4) Response and Rescue. Extrication to safe areas, including different stages of triage and protection against secondary attacks.

5. 5) Order and evacuation. Access to other emergency services, and psychological first aid.

The document proves the need for a coordinating framework of the Spanish emergency system to be fully adapted to these new threats. The discussion groups have identified the need for regular training on threat identification, zonification setting, mass bleeding control, extrication, and evacuation techniques during hostile situations. To achieve this goal, realistic training is mandatory.

The on-going Russo-Ukrainian war has resulted in a renewed global interest in the safety and security of nuclear installations and the possibility of nuclear disasters caused by warfare and terrorism.

The objective of this study was to identify and characterize all documented terrorist attacks against nuclear transport, nuclear facilities, and nuclear scientists as reported to the Global Terrorism Database (GTD) over a 50-year period.

The GTD was searched for all terrorist attacks against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets in the period from 1970-2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss.

Ninety-one incidents that occurred from 1970 through 2020 were included. Incidents took place in 25 countries and nine world regions, with most (42; 46.1%) occurring in Western Europe.

During these 50 years, 91 incidents resulted in 19 fatalities and 117 injuries. One perpetrator was killed during an incident and one other assailant was injured.

Bombings and explosions were the most frequently identified attack type (n = 40; 44.0%), followed by facility/infrastructure damage (n = 24; 26.4%) and armed assaults and assassinations (both n = 7; 7.7%).

Nuclear power plants and reactors under construction were targeted in 13 (14.3%) and eight (8.8%) incidents, respectively. Most of the attacks took place on other nuclear industry-related sites.

Terrorist attacks carried out by non-state perpetrators against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets are rare, with only 91 incidents in a 50-year period. None of the attacks resulted in radioactive fallout or environmental contamination. Most of the attacks took place outside a nuclear power plant.

The ever-growing penetration of internet and mobile technologies into society suggests that people will increasingly use web searches to seek health-related information, including advice on first aid in medical emergencies. When a bystander is incompetent in first aid and has no immediate support from Emergency Medical Services (EMS), as it happens in low-resource settings or in disasters, instructions found online could be the sole driver for administering first aid before arrival of professional help.

The aim of this study was to evaluate quality of advice on first aid generated by a web search engine’s question-answering system (QAS) in response to search queries concerning provision of help in common health emergencies.

In December 2022-January 2023, an English-language search was carried out in Google with ten queries based on the keyword combinations (what to do OR how to help) AND (bleeding OR chest pain OR choking OR not breathing OR seizure). The search engine’s QAS responses (up to 11 per search query) were evaluated for compliance with the International Federation of Red Cross First Aid Guidelines 2020 using the pre-developed checklists.

Out of 98 QAS items generated by Google, 67.3% (n = 66) were excluded, mainly because the QAS answers did not address original queries. Eligible unique QAS responses (n = 27) showed poor coverage of the guideline-compliant instructions on first aid. Mean percentage of QAS responses providing a first aid instruction with complete adherence to the guidelines varied from 0.0 for choking to 19.5 for seizure. Only three (11.1%) QAS responses contained an explicit instruction to access EMS, while 66.7% (n = 18) included directions either contradictory to the guidelines and potentially harmful (eg, use of home remedies in chest pain) or inapplicable for an untrained person (eg, use of tourniquet in bleeding).

Although the search engine’s QAS responds to user’s inquiries concerning assistance in health emergencies, the QAS-generated answers, as a rule, omit potentially life-saving evidence-based instructions on first aid and oftentimes give advices noncompliant with current guidelines or inadequate for untrained people, and thus create risks for causing harm to a victim.

Events, specifically those where excessive alcohol consumption is common, pose a risk to increase alcohol-related presentations to emergency departments (EDs). Limited evidence exists that synthesizes the impact from events on alcohol-related presentations to EDs.

This integrative review aimed to synthesize the literature regarding the impact events have on alcohol-related presentations to EDs.

An integrative literature review methodology was guided by the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) Guidelines for data collection, and Whittemore and Knafl’s framework for data analysis. Information sources used to identify studies were MEDLINE, CINAHL, and EMBASE, last searched May 26, 2021.

In total, 23 articles describing 46 events met criteria for inclusion. There was a noted increase in alcohol-related presentations to EDs from 27 events, decrease from eight events, and no change from 25 events. Public holidays, music festivals, and sporting events resulted in the majority of increased alcohol-related presentations to EDs. Few articles focused on ED length-of-stay (LOS), treatment, and disposition.

An increase in the consumption of alcohol from holiday, social, and sporting events pose the risk for an influx of presentations to EDs and as a result may negatively impact departmental flow. Further research examining health service outcomes is required that considers the impact of events from a local, national, and global perspective.

Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden.

The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden.

Descriptive comparative study of Sweden’s prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs.

A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff’s knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient.

The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.

An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs.

This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle–Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies.

The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.

The coronavirus disease 2019 (COVID-19) pandemic had detrimental impacts across multiple sectors of the Mexican health care system. The prehospital care system, however, remains largely under-studied. The first objective of this study was to calculate the monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the early pandemic period (January 1 through June 30, 2020), while the second objective was to conduct these calculations at the borough-level for the same outcomes and time period. The third objective was to compare monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the pre-pandemic (January 1 through June 30, 2019), early pandemic (January 1 through June 30, 2020), and later pandemic periods (January 1 through June 30, 2021).

A retrospective analysis was conducted to examine injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) and borough-levels. Monthly per capita rates were calculated using four datasets, including Mexico City’s Public Release 9-1-1 Emergency Calls, National Institute of Statistics and Geography’s (INEGI) Traffic Accidents Micro-Dataset, Mexico City’s Attorney General’s Office Crime Dataset, and Projections of the Population of the Municipalities of Mexico, 2015 to 2030. All statistical analyses were conducted using STATA 17.0.

During the early pandemic period, injury-related 9-1-1 emergency calls, traffic accidents, and crime experienced similar trends in monthly per capita rates at the state-level and borough-levels. While the monthly per capita rates remained constant from January to March 2020, starting in March, there was a precipitous decrease across all three outcomes, although decline rates varied across boroughs. The monthly per capita rates across the three outcomes were higher during the pre-pandemic period compared to the early pandemic period. As the COVID-19 pandemic progressed, the monthly per capita rates during the later pandemic period increased across the three outcomes compared to the early pandemic period, although they did not reach pre-pandemic levels during the study period.

The precipitous decline in injury-related 9-1-1 calls, traffic accidents, and crime in Mexico City occurred at the same time as the issuance of the first wave of public health orders in March 2020. The largest decrease across the three outcomes occurred one to two months post-issuance of the orders.

In recent years, unmanned aerial vehicles (UAVs) have been increasingly used for medical surveillance purposes in mass-gathering events. No studies have investigated the reliability of live video transmission from UAVs for accurate identification of distressed race participants in need of medical attention. The aim of this study was to determine the proportion of time during which live medical surveillance UAV video feed was successfully transmitted and considered of sufficient quality to identify acute illness in runners participating in the 2022 Montreal Marathon (Canada).

Four UAVs equipped with high-resolution cameras were deployed at two pre-defined high-risk areas for medical incidents located within the last 500 meters of the race. The video footage was transmitted in real-time during four consecutive hours to a remote viewing station where four research assistants monitored it on large screens. Interruptions in live feed transmission and moments with inadequate field of view (FOV) on runners were documented.

On September 25, 2022, a total of 6,916 athletes ran during the Montreal Marathon and Half Marathon. Out of the eight hours of video footage analyzed (four hours per high-risk area), 91.7% represented uninterrupted live video feed with an adequate view of the runners passing through the high-risk areas. There was a total of 18 live feed interruptions leading to a total interruption time of 22 minutes and 19 seconds (median interruption time of 32 seconds) and eight distinct moments with inadequate FOV on runners which accounted for 17 minutes and 33 seconds (median of 1 minute 47 seconds per moments with inadequate FOV). Active surveillance of drone-captured footage allowed early identification of two race participants in need of medical attention. Appropriate resources were dispatched, and UAV repositioning allowed for real-time viewing of the medical response.

Live video transmission from UAVs for medical surveillance of runners passing through higher risk segments of a marathon for four consecutive hours is feasible. Live feed interruptions and moments with inadequate FOV could be minimized through practice and additional equipment redundancy.

The aim of this study was to analyze congestive heart failure (CHF) discharges in Florida (USA) post tropical cyclones from 2007 through 2017.

This was a retrospective longitudinal time series analysis of hospital CHF quarterly discharges across Florida using the Healthcare Cost and Utilization Project (HCUP) database. The autoregressive integrated moving average (ARIMA) model was used with correlated seasonal regressor variables such as cyclone frequency, maximum cyclone wind speed, average temperature, and reports of influenza-like illness (ILI).

A total of 3,372,993 patients were identified, with average age in each quarter ranging 72.2 to 73.9 years and overall mortality ranging 4.3% to 6.4%. The CHF discharges within each year peaked from October through December and nadired from April through June with an increasing overall time trend. Significant correlation was found between CHF discharge and the average temperature (P <.001), with approximately 331.8 less CHF discharges (SE = 91.7) per degree of increase in temperature. However, no significant correlation was found between CHF discharges and frequency of cyclones, the maximum wind speed, and reported ILI.

This study suggests that with the current methods and the HCUP dataset, there is no significant increase in overall CHF discharges in Florida as a result of recent previous cyclone occurrences.

In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future.

A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results.

This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team’s perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute.

From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit’s shelf life prior to transfusion.

Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

This study aimed to determine the long-term mortality (one-year follow-up) associated with patients transferred by Emergency Medical Services (EMS), and to reveal the determinants (causes and risk factors).

This was a multicenter, prospective, observational, controlled, ambulance-based study of adult patients transferred by ambulance to emergency departments (EDs) from October 2019 through July 2021 for any cause. A total of six Advanced Life Support (ALS) units, 38 Basic Life Support (BLS) units, and five hospitals from Spain were included. Physiological, biochemical, demographic, and reasons for transfer variables were collected. A longitudinal analysis was performed to determine the factors associated to long-term mortality (any cause).

The final cohort included 1,406 patients. The one-year mortality rate was 21.6% (n = 304). Mortality over the first two days reached 5.2% of all the patients; between Day 2 and Day 30, reached 5.3%; and between Day 31 and Day 365, reached 11.1%. Low Glasgow values, elevated lactate levels, elevated blood urea nitrogen (BUN) levels, low oxygen saturation, high respiratory rate, as well as being old and suffering from circulatory diseases and neurological diseases were risk factors for long-term mortality.

The quick identification of patients at risk of long-term worsening could provide an opportunity to customize care through specific follow-up.

Targeted Automobile Ramming Mass Casualty attacks (TARMAC) have occurred worldwide since 2010. The dramatic increase in incidence warrants special attention to the unique pattern of injury associated with such attacks as they are unlike any other type of intentional trauma. This study characterizes the resulting injuries from the 2017 Charlottesville, Virginia TARMAC attack.

Patient records of victims were identified and analyzed for injuries, demographics, and surgical needs. The data were evaluated for patterns.

Nineteen TARMAC victims were treated in the UVAHS Emergency Department. Most were female (68%). Average age was 29.4 years (range 13 – 72 years). Data showed seven ICU admissions, four standard admissions, and seven discharges. There was one fatality and the specific injury data was unavailable. Most injuries were orthopedic: lower extremity fractures (n=7) [2 open], upper extremity fractures (n=7), axial skeleton fractures (n=6), and a facial fracture (n=1). Arterial injuries required interventional radiology (n=1) or observation (n=2). Organ injuries included a Grade 1 spleen laceration (n=1) and pneumomediastinum (n=1). six victims required one or more operative interventions during admission: emergent procedures (n=6) and delayed procedures (n=4). In the Emergency Department, two bony reductions were performed, five lacerations were repaired, and one thoracotomy was performed. Injury Severity Scores were calculated (mean=11.5; median 6; range 1-75).

Due to the mechanism of injury, TARMAC attacks inflict a unique wounding pattern. Intentional mass blunt trauma is previously unknown to emergency medicine. Vehicle variables including weight, speed, and bumper height affect the injury location and severity. This vehicle, a low-height sports car, inflicted primarily lower extremity injuries. Mortality rates have been higher in attacks involving taller, heavier vehicles, as seen in France, Germany, and Sweden. Analysis of victim data from TARMAC attacks will help emergency medicine physicians, surgeons, and disaster medicine specialists to prepare, train, and mitigate against this increasingly frequent tactic.

The use of telemedicine for the prehospital management of emergency conditions, especially stroke, is increasing day by day. Few studies have investigated the applications of telemedicine in Emergency Medical Services (EMS). A comprehensive study of the applications of this technology in stroke patients in ambulances can help to build a better understanding. Therefore, this systematic review was conducted to investigate the use of telemedicine in ambulances for stroke patients in 2023.

A systematic search was conducted in PubMed, Cochrane, Scopus, ProQuest, Science Direct, and Web of Science from 2013 through March 1, 2023. The authors selected the articles based on keywords and criteria and reviewed them in terms of title, abstract, and full text. Finally, the articles that were related to the study aim were evaluated.

The initial search resulted in the extraction of 2,795 articles. After review of the articles, and applying the inclusion and exclusion criteria, seven articles were selected for the final analysis. Three (42.85%) studies were on the feasibility and intervention types. Also, randomized trials, feasibility, feasibility and prospective-observational, and feasibility and retrospective-interventional studies were each one (14.28%). Six (85.71%) of the studies were conducted in the United States. The National Institutes of Health Stroke Scale (NIHSS) and RP-Xpress were the most commonly used tools for neurological evaluations and teleconsultations.

Remote prehospital consultations, triage, and sending patient data before they go to the emergency department can be provided through telemedicine in ambulances. Neurological evaluations via telemedicine are reliable and accurate, and they are almost equal to in-person evaluations by a neurologist.

The COVID-19 pandemic inspired social changes that promote outdoor activities including eating at restaurants, which may linger in a world hyperfocused on disease transmission prevention, increasing the vulnerabilities to vehicle-based terrorism. Vehicle ramming attacks started to transition from a relatively rare method of attack to one of the most lethal forms of terrorism prior to the emergence of COVID-19.

This study aims to provide a historical analysis of the terrorism-based attacks using vehicles between 1970 and 2019 by retrospectively searching the Global Terrorism Database for terror events that used a vehicle as a means of attack–a methodology suggested by Tin et al.

257 recorded terror attacks involved some type of vehicle between 1970 and 2019. The attacks resulted in 808 fatalities and 1715 injuries when excluding the September 11 attacks. 76 events occurred in the West Bank and Gaza Strip, 25 in the USA, 16 in Israel, and 14 in the UK. Of the 257 terror incidents, 71% (183) occurred within the last 6-year span of inquiry.

By 2016, vehicle attacks were the most lethal form of attack comprising just over half of all terrorism-related deaths in that year. Large gatherings such as festivals, sporting events, and now outdoor seating at restaurants, leave a number of people highly vulnerable to vehicle ramming attacks depending on established countermeasures. The increased prevalence of outdoor activities and gatherings in a post-COVID-19 world will further expose large numbers of people to the potential vulnerabilities of vehicle-based terrorism. The scale of the casualties from a vehicle-based terror attack can overwhelm traditional resources and strain the abilities of the healthcare sector. Counterterrorism and disaster medicine specialists are crucial players in educating first responders and emergency medicine providers, allowing them to adequately prepare for an evolving threat in a world devastated by COVID-19.

Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury.

The purpose of this investigation was to evaluate the types of trauma associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion.

A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care.

Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage.

Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.

Sub-Saharan Africa (SSA) has become a hotspot for global terrorism, with nearly 50% of global terror-related deaths occurring in SSA in 2021. With a large population and complex geopolitical and social climate, terrorist activity further burdens an already strained medical system. This study provides a retrospective descriptive analysis of terrorist-related activity in SSA from 1970-2020.

A retrospective analysis of the Global Terrorism Database (GTD) was performed for the region of SSA from 1970-2020. Data were filtered using the internal database search function for all events in the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, the Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, People’s Republic of the Congo, Republic of the Congo, Rhodesia, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. Number of attacks, deaths, and injuries, as well as primary weapons types, country where attacks occurred, and primary target types, were collated and analyzed.

A total 19,320 attacks were recorded, resulting in 77,565 deaths and 52,986 injuries. Firearms were the most frequent weapons used (8,745), followed by explosives (6,031), unknown (2,615), and incendiary (1,246), with all others making up the remainder (683.) Private citizens and property were the most frequently targeted entities (8,031), followed by general government facilities (2,582), police (1,854), business (1,446), military (805), diplomatic government facilities (741), and religious figures/institution (678), with all other targets making up the remainder (3,183).

The majority of deaths from terrorism in SSA are the result of firearm attacks and explosions. Nigeria, Somalia, South Africa, The Democratic Republic of the Congo, and Sudan have had the largest number of attacks since 1970, and Nigeria has the largest number of people killed and injured. The health implications of terrorist attacks are often compounded by violence and pose unique challenges to governments, populations, and aid organizations. By understanding the impact and scope of terrorist activity in SSA, Counter-Terrorism Medicine (CTM) initiatives can be employed to improve health care outcomes.