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Background and Objectives: This study sought to identify predictors for peripartum patients admitted to non-intensive care wards who later upgraded to the Intensive Care Unit (ICU). Materials and Methods: This was a retrospective observational study of patients admitted to the Maternal Fetal Ward between 01/2017 and 12/2022, who later upgraded to the ICU. Upgraded patients were 1:1 propensity score matched with those who remained on the Maternal Fetal Ward (control). The Classification And Regression Tree, a machine learning algorithm, was used to identify significant predictors of ICU upgrade. Multivariable ordinal regression analysis was used to assess the time interval to upgrade. Results: From 1855 peripartum patients, we analyzed 37 control and 34 upgrade patients. Mean maternal age (±Standard Deviation) and gestational age for the group was 29.5 (±5.8) years and 31.5 (±7.5) weeks, respectively. The Median Sequential Organ Failure Assessment Score [Interquartile] at ward admission for the controls was 0 [0–1] versus 2 [0–3.3, p = 0.001] for upgrade patients. The Sequential Organ Failure Assessment score at Maternal Fetal Ward admission was most predictive, followed by the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and lactate dehydrogenase levels. The APACHE II score was also associated with ICU upgrade within 12 h of hospital admission (OR 1.4, 95% CI 1.08–1.91, p = 0.01). Conclusions: Compared to control patients, peripartum patients upgraded to the ICU are associated with higher physiologic scores at Maternal Fetal Ward admission. Until further studies are performed to confirm our observation, clinicians should pay attention to these physiologic scores, since they may be associated with higher-risk patients. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolisms constitute a major cause of morbidity and mortality with 60,000 to 100,000 deaths attributed to pulmonary embolism in the US annually. Both clinical presentations and treatment strategies can vary greatly, and the selection of an appropriate therapeutic strategy is often provider specific. A pulmonary embolism response team (PERT) offers a multidisciplinary approach to clinical decision making and the management of high-risk pulmonary emboli. There is insufficient data on the effect of PERT programs on clinical outcomes. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane to identify PERT studies through March 2024. The primary outcome was all-cause mortality, and the secondary outcomes included the rates of surgical thrombectomy, catheter directed thrombolysis, hospital length of stay (HLOS), and ICU length of stay (ICULOS). We used the Newcastle−Ottawa Scale tool to assess studies' quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. Results: We included 13 observational studies, which comprised a total of 12,586 patients, 7512 (60%) patients were from the pre-PERT period and 5065 (40%) patients were from the PERT period. Twelve studies reported the rate of all-cause mortality for their patient population. Patients in the PERT period were associated with similar odds of all-cause mortality as patients in the pre-PERT period (OR: 1.52; 95% CI: 0.80–2.89; p = 0.20). In the random-effects meta-analysis, there was no significant difference in ICULOS between PERT and pre-PERT patients (difference in means: 0.08; 95% CI: −0.32 to 0.49; p = 0.68). There was no statistically significant difference in HLOS between the two groups (difference in means: −0.82; 95% CI: −2.86 to 1.23; p = 0.43). Conclusions: This meta-analysis demonstrates no significant difference in all studied measures in the pre- and post-PERT time periods, which notably included patient mortality and length of stay. Further study into the details of the PERT system at institutions reporting mortality benefits may reveal practice differences that explain the outcome discrepancy and could help optimize PERT implementation at other institutions. [ABSTRACT FROM AUTHOR]

Epinephrine is the most common medication used in cardiac arrest. Although the medication has been a mainstay of treatment over the last century, the utility and efficacy of epinephrine has been re-evaluated in recent years. This study aims to evaluate the literature describing the efficacy, timing, and dosing of epinephrine use in cardiac arrest. We utilized an extensive PubMed and SCOPUS search that included randomized control trials, prospective observational studies, and secondary analysis of observational data. These articles evaluated the administration of epinephrine in cardiac arrest and reported patient outcomes, including survival rates, neurological function, and return of spontaneous circulation. Dosing of epinephrine has been standardized at 1 mg per administration in adults and studies show that higher doses may not have better outcomes and can potentially be harmful. Research on the optimal timing of epinephrine has shown that earlier administration of epinephrine in cardiac arrest is more likely to have improved outcomes compared to later administration and longer intervals, although there are still conflicting results on the improvement of neurological outcomes. Intravenous is the preferred route of administration for epinephrine, but new research suggests intramuscular administration may be beneficial. While epinephrine has been shown to improve the rates of return of spontaneous circulation and even survival to hospital discharge in several studies, epinephrine use may not provide patients who survive cardiac arrest with a meaningful neurological recovery. [ABSTRACT FROM AUTHOR]

Background: Nearly 30 years since its inception, the early warning scores (EWSs) remain pivotal, yet variations have emerged for hospital and prehospital use. Aggregated scores, reflecting multiple physiological parameters, outperform single‐parameter systems in assessing acute illness severity, though consensus on optimal approaches is lacking. Resource‐limited countries, including Angola, lack adapted EWSs, emphasizing the need for cost‐effective and adaptable solutions to enhance patient care. Objective: To explore the perspectives of Angolan experts to identify physiological parameters suitable for incorporation into existing EWSs, allowing the development of a new tool adjusted to the healthcare context in Angola. Methods: We conducted a three‐round Delphi survey, engaging a national expert panel comprising twenty‐five physicians and nurses with expertise in internal medicine, surgery, emergency rooms, intensive care units, and/or teachers at universities or at teaching courses in these fields. Participants were asked to rate items using a five‐point Likert scale. Consensus was achieved if the items received a rating ≥ 80% from the panel. Results: Consensus was evident for the inclusion of standard physiological parameters, such as systolic blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, neurological status, and the presence or absence of supplemental oxygen. Furthermore, there was consensus for the consideration of specific items, namely, seizures, jaundice, cyanosis, capillary refill time, and pain—typically not included in the current EWSs. Consensus was reached regarding the exclusion of both oxygen saturation and temperature measurements in healthcare settings where oximeters and thermometers might not be readily available. Conclusion: Angolan experts were able to identify the physiological parameters suitable for incorporation into the basic EWSs. Further study must be conducted to test and validate the impact of the newly suggested vital parameters on the discriminant and predictive capability of a new aggregated model specifically adjusted to the Angolan healthcare setting. [ABSTRACT FROM AUTHOR]

Background. Previous research suggests that patients from rural areas who are critically ill with complex medical needs or require time‐sensitive subspecialty interventions face worse healthcare outcomes and delays in care when compared to those from urban areas. The critical care resuscitation unit (CCRU) at our quaternary care center was established to expedite the transfer of critically ill patients or those who need time‐sensitive intervention. This study investigates if disparities exist in treatments and outcomes among patients transferred to the CCRU from rural versus urban hospitals. Methods. This is a retrospective study of adult, nontrauma patients admitted to the CCRU via interhospital transfer from outside facilities from January 1 to December 31, 2018. Patients transferred from within our institution or with missing clinical data were excluded. Multivariable logistic regressions were performed to measure the association between patients' demographic and clinical factors with in‐hospital mortality. Results. We analyzed 1381 nontrauma patients, and 484 (35%) were from rural areas. Median age was 59 [47–69], and 629 (46%) were female. Median sequential organ failure assessment was 3 ([1–6], p = 0.062) for both patients transferred from urban and rural hospitals. There was no significant difference between groups with respect to most demographic and clinical factors, as well as types of interventions after CCRU arrival, including emergent surgical interventions within 12 hours of arrival at the CCRU. Rural patients were more likely to be transferred for care by the acute care emergency surgery service than were patients from urban areas and were transferred over a significantly greater distance (difference of 53 kilometers (km), 95% CI: –58.9–51.7 km, P < 0.001). Transfer from rural areas was not associated with increased odds of in‐hospital mortality (OR: 0.90, 95% CI: 0.60, 1.36; P = 0.63). Conclusion. Thirty‐five percent of patients transferred to the CCRU came from rural areas, which house 25% of the state population of Maryland. Patients transferred from rural counties to the CCRU faced greater transport distances, but they received the same level of care upon arrival at the CCRU and had the same odds of in‐hospital mortality as patients transferred from urban hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Standard of care for patients with acute ischemic stroke from large vessel occlusion (AISLVO) includes prompt evaluation for urgent mechanical thrombectomy (MT) at a comprehensive stroke center (CSC). During the start of the coronavirus 2019 pandemic (COVID-19), there were reports about disruption to emergency department (ED) operations and delays in management of patients with AIS-LVO. In this study we investigate the outcome and operations for patients who were transferred from different EDs to an academic CSC’s critical care resuscitation unit (CCRU), which specializes in expeditious transfer of time-sensitive disease. Methods: This was a pre-post retrospective study using prospectively collected clinical data from our CSC’s stroke registry. Adult patients who were transferred from any ED to the CCRU and underwent MT were eligible. We compared time intervals in the pre-pandemic (PP) period between January 2018- February 2020, such as ED in-out and CCRU arrival-angiography, to those during the pandemic (DP) between March 2020-May 31, 2021. We used classification and regression tree (CART) analysis to identify which time intervals, besides clinical factors, were associated with good neurological outcome (90-day modified Rankin scale 0-2). Results: We analyzed 203 patients: 135 (66.5%) in the PP group and 68 (33.5%) in the DP group. Time from ED triage to computed tomography (difference 7 minutes, 95% confidence interval [CI]-12 to-1, P < 0.01) for the DP group was statistically longer, but ED in-out was similar for both groups. Time from CCRU arrival to angiography (difference 9 minutes, 95% CI 4-13, P < 0.01) for the DP group was shorter. Forty-nine percent of the DP group achieved mRS ≤ 2 vs 32% for the PP group (difference-17%, 95% CI-0.32 to-0.03, P < 0.01). The CART identified initial National Institutes of Health Stroke Scale, age, ED inand-out time, and CCRU arrival-to-angiography time as important predictors of good outcome. Conclusion: Overall, the care process in EDs and at this single CSC for patients requiring MT were not heavily affected by the pandemic, as certain time metrics during the pandemic were statistically shorter than pre-pandemic intervals. Time intervals such as ED in-and-out and CCRU arrival-to-angiography were important factors in achieving good neurologic outcomes. Further study is necessary to confirm our observation and improve operational efficiency in the future. [ABSTRACT FROM AUTHOR]

Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients. This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group. This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/− SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4–6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54). This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group. [ABSTRACT FROM AUTHOR]

Introduction: Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study's objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods: This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010–2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests. Results: We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9–3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications. Conclusion: Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO. [ABSTRACT FROM AUTHOR]

The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention. PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity. The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28–0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12–11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03–26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%. This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Medical complications in peripartum patients are uncommon. Often, these patients are transferred to tertiary care centers, but their conditions and outcomes are not well understood. Our study examined peripartum patients transferred to an intensive care unit (ICU) at an academic quaternary center. Methods: We reviewed charts of adult, non-trauma, interhospital transfer (IHT) peripartum patients sent to an academic quaternary ICU between January 2017 and December 2021. We conducted a descriptive analysis and used multivariable ordinal regression to examine associations of demographic and clinical factors with ICU length of stay (LOS) and hospital length of stay (HLOS). Results: Of 1,794 IHT peripartum patients, 60 (3.2%) were directly transferred to an ICU. The average was 32 years, with a median Sequential Organ Failure Assessment (SOFA) score of 3 (1-4.25) and Acute Physiology and Chronic Health Evaluation (APACHE) II score of 8 (7-12). Respiratory failure was most common (32%), followed by postpartum hemorrhage (15%) and sepsis (14%). Intubation was required for 24 (41%), and 4 (7%) needed extracorporeal membrane oxygenation. Only 1 (1.7%) died, while 45 (76.3%) were discharged. Median ICU LOS and HLOS were 5 days (2-12) and 8 days (5-17). High SOFA score was linked to longer HLOS, as was APACHE II. Conclusions: Transfers of critically ill peripartum patients between hospitals were rare but involved severe medical conditions. Despite this, their outcomes were generally positive. Larger studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

BACKGROUND: Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS: We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS: A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION: TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes. [ABSTRACT FROM AUTHOR]

Mobile integrated health-community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. The PubMed, Embase, CINAHL, and Scopus databases were searched for peer-reviewed literature related to MIH-CP programs. We included all full-length studies whose programs met the National Association of Emergency Medical Technicians definition, had MIH-CP–related interventions, and measured outcomes. We excluded all non-English papers, abstract-only, and incomplete studies. Our initial literature review identified 6434 titles. We screened 178 full-text studies to assess for eligibility and identified 33 studies to include in this review. These 33 include four randomized controlled trials, 17 cohort studies, eight 8 case series, and four 4 cross-sectional studies. Of the 29 non-randomized trials, five used matched controls, 13 used pre-post, and 11 used no controls. Outcomes measured were hospital usage (24 studies), ED visits (15), EMS usage (23), patient satisfaction (8), health-related outcomes (8), and cost (9). Studies that evaluated hospital usage reported one of several outcome measures: hospital admissions (11), ED length of stay (3), and hospital readmission rate (2). EMS usage was measured by ambulance transports (12) and EMS calls (10). Cost outcomes observed were ambulance transport savings (7), ED visit savings (4), hospital admission savings (3), and cost per quality-adjusted life year (2). Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs. [ABSTRACT FROM AUTHOR]

Novel medical technologies are designed to aid in cardiopulmonary resuscitation both in and out of the hospital. Out-of-hospital innovations utilize the skills of paramedics, bystanders, and other prehospital personnel, while in-hospital innovations traditionally aid in physician intervention. Our review of current literature aims to describe the benefits and limitations of six main technologic advancements with wide adoption for their practicality and functionality. The six key technologies include: extracorporeal membrane oxygenation (ECMO), real-time feedback devices, smart devices, video review, point-of-care ultrasound, and unmanned aerial vehicle (drone) automated external defibrillator (AED) delivery. The benefits and limitations of each technology were independently reviewed and expounded upon. Newer technologies like drone AED delivery, paramedic ultrasound use, and smart devices have been demonstrated to be safe and feasible, however, further studies are needed to compellingly demonstrate improved patient outcomes. In-hospital use of ECMO and ultrasound is well established by current literature to aid in cardiopulmonary resuscitation and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Nearly 565,000 patients will suffer from prehospital and inpatient cardiac arrest in the United States per annum. Cardiopulmonary resuscitation and all associated interventions used to achieve it remain an essential focus of emergency medicine. Current ACLS guidelines give clear instructions regarding mainstay medications such as epinephrine and antiarrhythmics; however, the literature remains somewhat controversial regarding the application of adjunctive therapeutics such as calcium, magnesium, sodium bicarbonate, and corticosteroids. The available data acquired in this field over the past three decades offer mixed pictures for each of these medications on the effects of core metrics of cardiopulmonary resuscitation (e.g., rate of return of spontaneous circulation, survival-to-hospitalization and discharge, 24 h and 30 d mortality, neurological outcome), as well as case-specific applications for each of these interventions (e.g., polymorphic ventricular tachycardia, electrolyte derangements, acidosis, post-arrest shock). This narrative literature review provides a comprehensive summary of current guidelines and published data available for these four agents and their use in clinical practice. [ABSTRACT FROM AUTHOR]

Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management. [ABSTRACT FROM AUTHOR]

Background: Every year, approximately 200,000 patients will experience in-hospital cardiac arrest (IHCA) in the United States. Survival has been shown to be greatest with the prompt initiation of CPR and early interventions, leading to the development of time-based quality measures. It is uncertain how documentation practices affect reports of compliance with time-based quality measures in IHCA. Methods: A retrospective review of all cases of IHCA that occurred in the Cardiac Intensive Care Unit (CICU) at an academic quaternary hospital was conducted. For each case, a member of the code team (observer) documented performance measures as part of a prospective cardiac arrest quality improvement database. We compared those data to those abstracted in the retrospective review of "real-time" documentation in a Resuscitation Narrator module within electronic health records (EHRs) to investigate for discrepancies. Results: We identified 52 cases of IHCA, all of which were witnessed events. In total, 47 (90%) cases were reviewed by observers as receiving epinephrine within 5 min, but only 42 (81%) were documented as such in the EHR review (p = 0.04), meaning that the interrater agreement for this metric was low (Kappa = 0.27, 95% CI 0.16–0.36). Four (27%) eligible patients were reported as having defibrillation within 2 min by observers, compared to five (33%) reported by the EHR review (p = 0.90), and with substantial agreement (Kappa = 0.73, 95% CI 0.66–0.79). There was almost perfect agreement (Kappa = 0.82, 95% CI 0.76–0.88) for the initial rhythm of cardiac arrest (25% shockable rhythm by observers vs. 29% for EHR review, p = 0.31). Conclusion: There was a discrepancy between prospective observers' documentation of meeting quality standards and that of the retrospective review of "real-time" EHR documentation. A further study is required to understand the cause of discrepancy and its consequences. [ABSTRACT FROM AUTHOR]

Background. The critical care resuscitation unit (CCRU) facilitates interhospital transfer (IHT) of critically ill patients for immediate interventions. Due to these patients' acuity, it is uncommon for patients to be directly discharged home from this unit, but it does happen on occasion. Since there is no literature regarding outcomes of patients being discharged from a resuscitation unit, our study investigated these patients' outcome at greater than 12 months after being discharged directly from the CCRU. Methods. We performed a retrospective cohort study of all adult patients directly discharged from the CCRU between January 01, 2017, and December 31, 2020. The primary outcome was number of ED visits or hospitalizations within 6 months. Secondary outcomes were number of ED visits or hospitalizations within 6, 12, and >12 months from CCRU discharge. Results. We analyzed 145 patients' records. Mean age was 56 (standard deviation [SD] ± 19), with a majority being male (72%) and Caucasian (58%). The most common discharge destination was home (139 patients, 96% of total subjects) versus hospice (2%) or nursing facilities (2%). Most patients (55%) did not have any hospital revisits within the first 6 months of discharge, while 31% had 1-2 revisits, and 14% had ≥3 revisits. The most common discharge diagnoses were soft tissue infection (16.5%), aortic dissection (14%), and stroke (11%). Factors which were associated with a greater likelihood of any return hospital visit within 6 months receiving mechanical ventilation during CCRU stay (coefficient −2.23, 95% CI 0.01–0.87, P = 0.036), while high hemoglobin on CCRU discharge was associated with no ED revisit (coeff. 0.42, 95% CI 1.15–2.06, P = 0.004). Conclusions. Most patients who were discharged from the CCRU did not require any hospital revisits in the first 6 months. Requiring mechanical ventilation and having soft tissue infection were associated with high unplanned hospital revisits following discharge. Further research is needed to validate these findings. [ABSTRACT FROM AUTHOR]

BACKGROUND: Monkeypox (mpox) is a viral infection that is primarily endemic to countries in Africa, but large outbreaks outside of Africa have been historically rare. In June 2022, mpox began to spread across Europe and North America, causing the World Health Organization (WHO) to declare mpox a public health emergency of international concern. This article aims to review clinical presentation, diagnosis, and prevention and treatment strategies on mpox, providing the basic knowledge for prevention and control for emergency providers. METHODS: We conducted a review of the literature using PubMed and SCOPUS databases from their beginnings to the end of July 2023. The inclusion criteria were studies on adult patients focusing on emerging infections that described an approach to a public health emergency of international concern, systematic reviews, clinical guidelines, and retrospective studies. Studies that were not published in English were excluded. RESULTS: We included 50 studies in this review. The initial symptoms of mpox are non-specific: fever, malaise, myalgias, and sore throat. Rash, a common presentation of mpox, usually occurs 2-4 weeks after the prodrome, but the presence of lymphadenopathy may distinguish mpox from other infections from the Poxviridae family. Life-threatening complications such as pneumonia, sepsis, encephalitis, myocarditis, and death can occur. There are documented co-occurrences of human immunodeficiency virus (HIV) and other sexually transmitted infections that can worsen morbidity. CONCLUSION: The initial presentation of mpox is non-specific. The preferred treatment included tecovirimat in patients with severe illness or at high risk of developing severe disease and vaccination with two doses of JYNNEOS. However, careful history and physical examination can raise the clinicians' suspicion and point toward a prompt diagnosis. There are different modalities to prevent and treat mpox infection. [ABSTRACT FROM AUTHOR]

Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25–37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33–49%) than the Emergency Department (ED; 17%, 95% CI 12–24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5–19%) of intubations were complicated by hypoxia, 2% (95% CI 1–3.5%) by cardiac arrest, and 18% (95% CI 13–23%) by cardiovascular collapse. Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients. [ABSTRACT FROM AUTHOR]

Introduction: Blood pressure measurement is important for treating patients. It is known that there is a discrepancy between cuff blood pressure vs arterial blood pressure measurement. However few studies have explored the clinical significance of discrepancies between cuff (CPB) vs arterial blood pressure (ABP). Our study investigated whether differences in CBP and ABP led to change in management for patients with hypertensive emergencies and factors associated with this change. Methods: This prospective observational study included adult patients admitted between January 2019-May 2021 to a resuscitation unit with hypertensive emergencies. We defined clinical significance of discrepancies as a discrepancy between CBP and ABP that resulted in change of clinical management. We used stepwise multivariable logistic regression to measure associations between clinical factors and outcomes. Results: Of 212 patients we analyzed, 88 (42%) had change in management. Mean difference between CBP and ABP was 17 milligrams of mercury (SD 14). Increasing the existing rate of antihypertensive infusion occurred in 38 (44%) patients. Higher body mass index (odds ratio [OR] 1.04, 95% confidence Interval [CI] 1.0001-1.08, P-value <0.05) and history of peripheral arterial disease (OR 0.16, 95% CI 0.03-0.97, P-value <0.05) were factors associated with clinical significance of discrepancies. Conclusion: Approximately 40% of hypertensive emergencies had a clinical significance of discrepancy warranting management change when arterial blood pressure was initiated. Further studies are necessary to confirm our observations and to investigate the benefit-risk ratio of ABP monitoring. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies have demonstrated that rapid transfer to definitive care improves the outcomes for many time-sensitive conditions. The critical care resuscitation unit (CCRU) improves the operations of the University of Maryland Medical Center (UMMC) by expediting the transfers and resuscitations for critically ill patients who exceed the resources at other facilities. In this study we investigated CCRU transfer patterns to determine patient characteristics and logistical factors that influence bed assignments and transfer to the CCRU. We hypothesized that CCRU physicians prioritize transfer for critically ill patients. Therefore, those patients would be transferred faster. Methods: We performed a retrospective review of all non-traumatic adult patients transferred to the CCRU from other hospitals between January 1-December 31, 2018. The primary outcome was the interval from transfer request to CCRU bed assignment. The secondary outcome was the interval from transfer request to CCRU arrival. We used multivariate logistic regressions to determine associations with the outcomes of interest. Results: A total of 1,741 patients were admitted to the CCRU during the 2018 calendar year. Of those patients, 1,422 were transferred from other facilities and were included in the final analysis. Patients' mean age was 57 ± 17 years with a median Sequential Organ Failure Assessment (SOFA) score of 3 [interquartile range 1-6]. Median time from transfer request to CCRU bed assignment was 8 (0-70) minutes. A total of 776 (55%) patients underwent surgical intervention after arrival. Using the median transfer request to bed assignment time, we found that patients requiring stroke neurology (odds ratio [OR] 5.49, 95% confidence interval [CI] 2.85-10.86), having higher SOFA score (OR 1.04, 95% CI 1.001-1.07), and needing an immediate operation (OR 2.85, 95% CI 1.98-4.13) were associated with immediate bed assignment time (≤8 minutes). Patients who were operated on (OR 0.74, 95% CI 0.55-0.99) were significantly less likely to have an immediate bed assignment time. Conclusion: The CCRU expedited the transfer of critically ill patients who needed urgent interventions from outside facilities. Higher SOFA scores and the need for urgent neurological or surgical intervention were associated with near-immediate CCRU bed assignment. Other institutions with similar models to the CCRU should perform studies to confirm our observations. [ABSTRACT FROM AUTHOR]

Alcohol Withdrawal Syndrome (AWS) among patients with chronic and heavy alcohol consumption can range from mild to severe and is associated with high morbidity and mortality. Currently, treating AWS with benzodiazepines is the standard of care, but phenobarbital has also been hypothesized to be an effective first-line treatment due to its pharmacological properties and mechanism of action. We conducted a meta-analysis to review relevant literature and compare the clinical outcomes for patients diagnosed with AWS in ED and ICU settings. We performed a literature search in in the PubMed, Scopus, and Web of Science databases from inception to June 30, 2022. Randomized trials and observational (prospective or retrospective) studies were eligible if they included adult patients who presented in the ED and were treated in the ED and/or the intensive care unit (ICU) with a diagnosis of AWS. The primary outcome was the rate of intubation among patients who received phenobarbital, compared with benzodiazepines. Secondary outcomes such as rates of seizures, hospital, and ICU length of stay (LOS), also were included. The PROSPERO registration is CRD42022318862. We included twelve studies (1934 patients) in our analysis. Of the 1934 patients in these studies, 765 (41.7%) were treated with phenobarbital and 1169 (58.3%) were treated with other modalities for alcohol withdrawal. Treating AWS patients with phenobarbital did not affect their risk for intubation, as the risk for intubation was similar between the phenobarbital and the control group (RR 0.70, 95% CI 0.36–1.38, P = 0.31). In addition, patients who were treated with phenobarbital were found to have similar rates of seizures (RR 0.73, 95% CI 0.29–1.89) and length of stay in the hospital (Standardized Mean Difference −0.02, 95% CI −0.26, 0.21) or the ICU (SMD −0.02, 95% CI −0.21, 0.25) when compared with patients receiving benzodiazepines. Management of patients with AWS with phenobarbital is associated with similar rates of intubation, length of stay in the ICU, or length of stay in the hospital as treatment with benzodiazepines. However, due to the inclusion of mostly observational studies and a significant level of heterogeneity among the studies assessed in this review, additional trials with strong methodology are needed. [ABSTRACT FROM AUTHOR]

With musculoskeletal back pain being one of the most common presentations in the emergency department, evidence-based management strategies are needed to address such complaints. Along with other medications, cyclobenzaprine is a muscle relaxant commonly prescribed for patients complaining of musculoskeletal pain, in particular, pain associated with muscle spasms. However, with recent literature questioning its efficacy, the role of cyclobenzaprine use in patients with musculoskeletal back pain remains unclear. The objective of the study is to investigate trends of cyclobenzaprine utilization among patients presenting to the emergency department (ED) in the United States. This is a retrospective cohort review of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2007 and 2019. We analyzed ED visits of patients 18 years and older. Visits during which cyclobenzaprine was administered in the ED or prescribed at discharge were identified. Trends were described using a time series analysis of patients' visits who received administration and prescriptions of cyclobenzaprine. Between 2007 and 2019, we identified an estimated 1.35 billion ED visits, 57.2% (772.6 million) were female. From that sample, 2.4% (32.7 million) of all visits received cyclobenzaprine prescription in the ED only, and 0.5% (6.6 million) of total visits were both given the drug in the ED and were prescribed the drug at discharge). Overall trend analysis shows a slight decrease in annual percentages of cyclobenzaprine administration and prescriptions during the study period. Visits of certain subgroups: 26–44 years, white showed relatively higher percentages of administration and prescription of cyclobenzaprine. Although there was a slight decrease, our study still shows significant cyclobenzaprine utilization in the ED, despite conflicting evidence demonstrating efficacy for patients with musculoskeletal complaints and the concern for adverse effects. Additional studies are needed to examine its overall effectiveness and risk-benefit analysis in treating patients with such conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Blood pressure (BP) monitoring is essential for patient care. Invasive arterial BP (IABP) is more accurate than non-invasive BP (NIBP), although the clinical significance of this difference is unknown. We hypothesized that IABP would result in a change of management (COM) among patients with non-hypertensive diseases in the acute phase of resuscitation. METHODS: This prospective study included adults admitted to the Critical Care Resuscitation Unit (CCRU) with non-hypertensive disease from February 1, 2019, to May 31, 2021. Management plans to maintain a mean arterial pressure >65 mmHg (1 mmHg=0.133 kPa) were recorded in real time for both NIBP and IABP measurements. A COM was defined as a discrepancy between IABP and NIBP that resulted in an increase/decrease or addition/discontinuation of a medication/infusion. Classification and regression tree analysis identified significant variables associated with a COM and assigned relative variable importance (RVI) values. RESULTS: Among the 206 patients analyzed, a COM occurred in 94 (45.6% [94/206]) patients. The most common COM was an increase in current infusion dosages (40 patients, 19.4%). Patients receiving norepinephrine at arterial cannulation were more likely to have a COM compared with those without (45 [47.9%] vs. 32 [28.6%], P=0.004). Receiving norepinephrine (relative variable importance [RVI] 100%) was the most significant factor associated with a COM. No complications were identified with IABP use. CONCLUSION: A COM occurred in 94 (45.6%) non-hypertensive patients in the CCRU. Receiving vasopressors was the greatest factor associated with COM. Clinicians should consider IABP monitoring more often in non-hypertensive patients requiring norepinephrine in the acute resuscitation phase. Further studies are necessary to confirm the risk-to-benefit ratios of IABP among these high-risk patients. [ABSTRACT FROM AUTHOR]