A Direct Assessment of Noninvasive Continuous Blood Pressure Monitoring in the Emergency Department and Intensive Care Unit.

INTRODUCTION: Noninvasive continuous blood pressure monitoring has the potential to improve patient treatment in the hospital setting. Such noninvasive devices can be applied earlier in the treatment process to empower nurses and clinicians to react more quickly to patient deterioration with the added benefit of eliminating the risks associated with invasive monitoring. However, emerging technologies must be capable of reproducing current clinical measures for medical decision making. METHODS: This study aimed to determine the usability and willingness of nurses to implement a noninvasive continuous blood pressure monitoring device. The secondary aim directly compared the systolic blood pressure, diastolic blood pressure, and mean arterial pressure values recorded by the device (VitalStream; CareTaker Medical LLC, Charlottesville, VA) with the "gold standard" brachial cuff and arterial line measures recorded in the emergency department and intensive care unit settings. RESULTS: VitalStream was similarly received by nurses in the emergency department and intensive care setting, but ultimately had greater promotion from emergency nurses. Despite some statistical similarity between measurement methodologies, all direct comparisons were found to not meet the Association for the Advancement of Medical Instrumentation 2008 and Association for the Advancement of Medical Instrumentation / European Society of Hypertension / International Organization for Standardization 2019 consensus statement criteria for acceptable blood pressure measure differences between the VitalStream and "gold standard" clinical measures. In all instances, the standard deviation of the Bland-Altman bias exceeded 8 mm Hg with less than 85% of paired differences falling within 10 mm Hg of the "gold standard." DISCUSSION: Taken together, the tested device requires additional postprocessing for medical decision making in trauma or emergent care.

Pre-hospital guidelines for CPR-Induced Consciousness (CPRIC): A scoping review.

Background: CPR-Induced Consciousness is an emerging phenomenon with a paucity of consensus guidelines from peak resuscitative bodies. Local prehospital services have had to implement their own CPR-Induced Consciousness guidelines. This scoping review aims to identify prehospital CPR-Induced Consciousness guidelines and compare or contrast their management options. Objective: The purpose of this scoping review is to identify and compare as many prehospital CPR-Induced Consciousness guidelines as feasible, highlight common management trends, and discuss the factors that might impact CPR-Induced Consciousness guidelines and the management trends identified. Design: To search for prehospital CPR-Induced Consciousness guidelines, a bibliographical search of five databases was undertaken (MEDLINE, EMBASE, Cochrane, Scopus, and CINAHL plus). Also included was a grey literature search arm, comprised of four search strategies: 1. Customised Google search, 2. Hand searching of targeted websites, 3. Grey literature databases, 4. Consultation with subject experts. Results: Our search extracted 23 prehospital CPR-Induced Consciousness guidelines and one good practise statement from the International Liaison Committee on Resuscitation. Of the 23 prehospital guidelines available, we identified 20 different ways of treating CPR-Induced Consciousness. Midazolam was the most frequently used drug to treat CPR-Induced Consciousness (14/23, 61%), followed by Ketamine (11/23, 48%) and Fentanyl (9/23, 39%). Conclusion: Prehospital CPR-Induced Consciousness guidelines are both exceptionally uncommon and vary substantially from each other. This has a flow-on effect towards data collection and only serves to continue CPR-Induced Consciousness's relatively unknown status surrounding both knowledge of, and the effect CPR-Induced Consciousness treatment has on cardiac arrest outcomes.

Correlation between 25-hydroxyvitamin D/D3 Deficiency and COVID-19 Disease Severity in Adults from Northern Colorado.

Vitamin D deficiency is common in the United States and leads to altered immune function, including T cell and macrophage activity that may impact responses to SARS-CoV-2 infection. This study investigated 131 adults with a history of a positive SARS-CoV-2 nasopharyngeal PCR and 18 adults with no COVID-19 diagnosis that were recruited from the community or hospital into the Northern Colorado Coronavirus Biorepository (NoCo-COBIO). Participants consented to enrollment for a period of 6 months and provided biospecimens at multiple visits for longitudinal analysis. Plasma 25-hydroxyvitamin D levels were quantified by LC-MS/MS at the initial visit (n = 149) and after 4 months (n = 89). Adults were classified as deficient (<30 nM or <12 ng/mL), insufficient (<30−50 nM or 12−20 ng/mL), or optimal (50−75 nM or >20 ng/mL) for 25-hydroxyvitamin D status. Fisher's exact test demonstrated an association between disease severity, gender, and body mass index (BMI) at baseline. Mixed model analyses with Tukey-Kramer were used for longitudinal analysis according to BMI. Sixty-nine percent (n = 103) of the entire cohort had optimal levels of total 25(OH)D, 22% (n = 32) had insufficient levels, and 9% (n = 14) had deficent levels. Participants with severe disease (n = 37) had significantly lower 25-hydroxyvitamin D (total 25(OH)D) when compared to adults with mild disease (p = 0.006) or no COVID-19 diagnosis (p = 0.007). There was 44% of the cohort with post-acute sequalae of COVID-19 (PASC) as defined by experiencing at least one of the following symptoms after 60 days' post-infection: fatigue, dyspnea, joint pain, chest pain, forgetfulness or absent-mindedness, confusion, or difficulty breathing. While significant differences were detected in 25-hydroxyvitamin D status by sex and BMI, there were no correlations between 25-hydroxyvitamin D for those without and without PASC. This longitudinal study of COVID-19 survivors demonstrates an important association between sex, BMI, and disease severity for 25-hydroxyvitamin D deficiency during acute stages of infection, yet it is not clear whether supplementation efforts would influence long term outcomes such as developing PASC.

Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services.

INTRODUCTION: The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) identifies patients with "severe sepsis" and mandates antibiotics within a specific time window. Rapid time to administration of antibiotics may improve patient outcomes. The goal of this investigation was to compare time to antibiotic administration when sepsis alerts are called in the emergency department (ED) with those called in the field by emergency medical services (EMS). METHODS: This was a multi-center, retrospective review of patients designated as sepsis alerts in ED or via EMS in the field, presenting to four community emergency departments over a six-month period. RESULTS: 507 patients were included, 419 in the ED alert group and 88 in the field alert group. Mean time to antibiotic administration was significantly faster in the field alert group when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs 44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates, fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic utilization rates were not found to be significantly different. CONCLUSIONS: Sepsis alerts called in the field via EMS may decrease time to antibiotics and increase the likelihood of antibiotic administration occurring within 60 min of arrival when compared to those called in the ED.

Recommendations on the Appropriate Level of Medical Support at Ultramarathons.

Participation in ultramarathons continues to grow, especially among older individuals and among younger runners who may have less running and wilderness experience than many past participants. While ultramarathons tend to have relatively few serious medical issues, adverse medical incidents do occur. These factors make it increasingly important that appropriate safety precautions and medical support are defined and implemented at these events to enhance the safety of participants, spectators, and volunteers. This document establishes the minimum recommended level of medical support that should be available at ultramarathons based on current knowledge and the experience of the authors. It offers a balance that is intended to avoid excessive stress on the local medical system while also precluding undue burden on events to provide medical support beyond that which is practical. We propose a three-level classification system to define the extent of medical services, personnel, systems, supplies, and equipment in place and recommend the level of medical support based on event size, distance/duration, remoteness, and environmental conditions that may be encountered during the event. This document also outlines the recommended education and training of medical providers and discusses other medical and logistical considerations related to the provision of medical support at ultramarathons. We suggest that ultramarathon organizers review and adopt these recommendations to enhance safety and reduce the risk of adverse events to participants.

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review.

OBJECTIVE: As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods. METHODS: This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported. RESULTS: The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support). CONCLUSIONS: While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Mass casualty triage: an evaluation of the data and development of a proposed national guideline.

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.