Underwent Emergency Angiography Research Articles

Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study.

This study aimed to elucidate whether immediate angiography within 30min is associated with lower in-hospital mortality compared with non-immediate angiography. We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30min after arrival (door-to-angio time ≤ 30min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time. Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100min after arrival. In trauma patients, immediate angiography ≤ 30min was associated with lower in-hospital mortality and fewer NOM failures. Level 3b, non randomized controlled cohort/follow up study.

Angioembolization performed by trauma surgeons for trauma patients: is it feasible in Korea? A retrospective study

Purpose: Recent advancements in interventional radiology have made angioembolization an invaluable modality in trauma care. Angioembolization is typically performed by interventional radiologists. In this study, we aimed to investigate the safety and efficacy of emergency angioembolization performed by trauma surgeons.Methods: We identified trauma patients who underwent emergency angiography due to significant trauma-related hemorrhage between January 2020 and June 2023 at our trauma center. Until May 2022, two dedicated interventional radiologists performed emergency angiography at our center. However, since June 2022, a trauma surgeon with a background and experience in vascular surgery has performed emergency angiography for trauma-related bleeding. The indications for trauma surgeon–performed angiography included significant hemorrhage from liver injury, pelvic injury, splenic injury, or kidney injury. We assessed the angiography results according to the operator of the initial angiographic procedure. The term “failure of the first angioembolization” was defined as rebleeding from any cause, encompassing patients who underwent either re-embolization due to rebleeding or surgery due to rebleeding.Results: No significant differences were found between the interventional radiologists and the trauma surgeon in terms of re-embolization due to rebleeding, surgery due to rebleeding, or the overall failure rate of the first angioembolization. Mortality and morbidity rates were also similar between the two groups. In a multivariable logistic regression analysis evaluating failure after the first angioembolization, pelvic embolization emerged as the sole significant risk factor (adjusted odds ratio, 3.29; 95% confidence interval, 1.05–10.33; P=0.041). Trauma surgeon–performed angioembolization was not deemed a significant risk factor in the multivariable logistic regression model.Conclusions: Trauma surgeons, when equipped with the necessary endovascular skills and experience, can safely perform angioembolization. To further improve quality control, an enhanced training curriculum for trauma surgeons is warranted.

Characteristics and outcomes of cardiac arrest patients with prolonged resuscitation

Background: There is lack of uniformity and consensus amongst the emergency physicians about an appropriate duration of cardiopulmonary resuscitation (CPR) and resuscitative efforts before deciding about termination of resuscitation (TOR) in patients with either out-of-hospital or in the emergency department (ED) non-traumatic cardiac arrests. An ideal duration of resuscitation for those with persistent cardiac arrest has not been determined yet. This study aims to evaluate the resuscitative interventions, patient factors and outcomes associated with prolonged duration of resuscitation in these patients. Methods: A retrospective study conducted in the Emergency Department (ED) of Changi General Hospital, Singapore and included 15 non-consecutive and randomly selected adult patients who either had an out-hospital cardiac arrest (OHCA) or suffered a witnessed cardiac arrest soon after arrival in the ED and were resuscitated further. Results: The median age was 58 years (IQR 51.5–70.5 years), and the median total CPR and resuscitation duration was 46 min (IQR 40–62.5 min). 12 patients sustained ROSC and one had transient ROSC. Ten (10) patients survived to hospital admission from ED and 5 of them underwent emergency angiography from ED. Three patients were discharged from hospital eventually with mRS scores of 0–1. Conclusion: Patients with sustained ROSC were older, had more prevalence of co-morbidities and lesser prevalence of shockable rhythms, received bystander CPR and pre-hospital adrenaline more frequently, had longer total duration of CPR and a larger proportion were administered intravenous calcium gluconate during ED resuscitation.

Электрокардиографические изменения в раннем периоде после плановой реваскуляризации миокарда

INTRODUCTION: To date, highly effective methods of myocardial protection have been developed, which are widely used in cardiac surgery. At the same time, the problem of perioperative myocardial infarction still exists and is one of the causes of adverse cardiovascular events and mortality, both at the hospital stage of treatment and in the long-term period. A factor leading to such a complication may be acute dysfunction of the coronary bypass graft, the timely detection and elimination of which will reduce the negative consequences of myocardial damage. The relevance of the study results from investigation of the relationship between the angiographic data and the character of ischemic changes on the electrocardiogram of patients with and without proven acute dysfunction of coronary bypass graft. AIM: Identification of the most pathognomonic electrocardiographic signs of dysfunction of coronary bypass grafts in the early postoperative period after planned myocardial revascularization. MATERIALS AND METHODS: The study included 196 (1.86%) of 10,550 patients operated for coronary artery disease in Chelyabinsk Center of Cardiovascular Surgery from 2011 to 2020, who underwent emergency angiography after planned coronary artery bypass graft surgery due to the appearance of signs of myocardial damage in the early postoperative period. Depending on the type of angiographic findings and the chosen treatment tactics, patients were divided to 3 groups. Group I (n = 86) included patients in whom angiography revealed defects in the area of large bypassed coronary arteries, of them 60 patients underwent endovascular treatment, and 26 patients underwent repeated open surgery. Group II (n = 33) consisted of patients in whom bypass graft dysfunction was noted, but, however, due to the small diameter or pronounced diffuse lesion of the bypassed coronary arteries, all the patients underwent conservative therapy. Group III included 77 patients in whom hemodynamically significant defects in grafts and native arteries were not identified. RESULTS: When studying postoperative electrocardiographic data, it was found that significant differences between the groups were obtained only in the occurrence of ventricular arrhythmias (P1–2 = 0.027; P2–3 = 0.01). As for other pathological electrocardiographic signs and their combinations, no statistical differences were found. CONCLUSIONS: An isolated electrocardiographic study in the early postoperative period does not permit to identify patients with dysfunction of coronary bypass grafts. It is necessary to develop a diagnostic algorithm, including instrumental and laboratory methods, for accurate diagnosis of myocardial ischemia caused by impaired graft function or pathological deformation of the coronary bed due to surgical procedures.

Subcapsular renal haematoma after ureteroscopic lithotripsy: a single-centre, retrospective study in China

ObjectivesTo investigate the incidence, predisposing factors, diagnosis and management of subcapsular renal haematoma (SRH) after ureteroscopic lithotripsy (URSL).DesignRetrospective observational study.SettingShandong Provincial Hospital, a 4500-bed tertiary hospital in China.ParticipantsThe data from...

Emergency angiography for trauma patients and potential association with acute kidney injury

BackgroundAngiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not.MethodsA retrospective cohort study was conducted using a nationwide trauma database (2004–2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy.ResultsAmong 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57–2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses.ConclusionsEmergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

Effect of Respiratory Impairment on the Outcomes of Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction and Coronavirus Disease-2019 (COVID-19).

Coronavirus Disease-2019 (COVID-19) may impair outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The extent of this phenomenon and its mechanisms are unclear.Methods and Results:This study prospectively included 50 consecutive STEMI patients admitted to our center for primary percutaneous coronary intervention (PCI) at the peak of the Italian COVID-19 outbreak. At admission, a COVID-19 test was positive in 24 patients (48%), negative in 26 (52%). The primary endpoint was in-hospital all-cause mortality. Upon admission, COVID-19 subjects had lower PO2/FiO2 (169 [100-425] vs. 390 [302-477], P<0.01), more need for oxygen support (62.5% vs. 26.9%, P=0.02) and a higher rate of myocardial dysfunction (ejection fraction <30% in 45.8% vs. 19.2%, P=0.04). All patients underwent emergency angiography. In 12.5% of COVID-19 patients, no culprit lesions were detected, thus PCI was performed in 87.5% and 100% of COVID-19 positive and negative patients, respectively (P=0.10). Despite a higher rate of obstinate thrombosis in the COVID-19 group (47.6% vs. 11.5%, P<0.01), the PCI result was similar (TIMI 2-3 in 90.5% vs. 100%, P=0.19). In-hospital mortality was 41.7% and 3.8% in COVID-19 positive and negative patients, respectively (P<0.01). Respiratory failure was the leading cause of death (80%) in the COVID-19 group, frequently associated with severe myocardial dysfunction. In-hospital mortality of COVID-19 patients with STEMI remains high despite successful PCI, mainly due to coexisting severe respiratory failure. This may be a critical factor in patient management and treatment selection.

Contrast nephropathy incidence after coronary angiography among patients with acute renal dysfunction

Aim: Contrast-induced acute kidney injury (AKI) may be seen after contrast agent exposure which is known as nephrotoxic. It is fact that, patients with AKI have an increased risk after contrast exposure compared to patients with normal renal function values. However, the incidence of contrast nephropathy after contrast exposure with AKI is not clear. In this study, we planned to investigate the incidence of contrast nephropathy in patients undergoing coronary angiography with AKI and whether there is an increased risk compared to the control group. Materials and Methods: The study was planned as a retrospective study and we investigated the clinical outcome of patients who underwent isoosmolar contrast angiography in the arterial phase with acute kidney injury between January 2014 and December 2017. Results: The number of AKI patients included in the study was 280 and the control group consisted of 478 participants. There was no statistically significant difference between two groups. (3.2% (n: 9) of patients with AKI contrast nephropathy vs 6.5% (n: 31) of patients with normal kidney function and contrast nephropathy) (p> 0.05). On the other hand, there was statistically significant difference between two groups according to diabetes mellitus (patients with contrast nephropathy 26 (65%) had diabetes vs 14 (35%) participants had no diabetes). This difference was statistically significant (p <0.05). Conclusion: In this study, in patients who underwent emergency angiography with a preliminary diagnosis of acute coronary syndrome in the emergency department, we did not find an increased risk of acute renal injury and contrast-enhanced nephropathy compared to the patient population with normal kidney function.

Inflammatory markers of contrast-induced nephropathy in patients with acute coronary syndrome.

Contrast-induced nephropathy (CIN) is among the serious complications of invasive cardiovascular procedures that are performed with the administration of contrast agents. We investigated the role of the inflammatory markers in predicting CIN in acute coronary syndrome patients. This study included 232 consecutive patients with acute coronary syndrome who underwent emergency angiography at our center. There were 38 (19.1%) patients in the CIN group (mean age: 62.4 ± 10.2; 68.4% male), and 162 patients in the non-CIN group (mean age: 62.1 ± 11.5; 60.5% male). In the CIN positive group, serum gamma-glutamyl transferase (GGT) (P < 0.001), uric acid (P < 0.001), high sensitivity C-reactive protein (P < 0.001), the neutrophil-to-lymphocyte ratio (P = 0.02) were higher, whereas vitamin D (P < 0.001), hemoglobin (P < 0.001) and baseline glomerular filtration rate (P = 0.011) were lower compared with the CIN negative group. The receiver operating characteristic analysis showed that the cutoff point of GGT was 56 U/L for predicting CIN with a 84.2% sensitivity and a 72.2% specificity (area under the curve = 0.879, P < 0.001). The predictive value of GGT was the highest compared other inflammatory markers for CIN (area under the curve = 0.879). Our study showed that the levels of GGT, high sensitivity C-reactive protein, vitamin D, uric acid and neutrophil-to-lymphocyte ratio were the effective factors in development of CIN. The level of GGT was found as the most effective factor in prediction of the development of CIN.

Impact of oxygen therapy to ameliorate contrast-induced nephropathy in patients with acute coronary syndrome undergoing emergency angiography; a double-blinded clinical trial

Introduction: Contrast-induced nephropathy (CIN) is one of the major causes of acute kidney injury. Objectives: Regarding an increase in mortality and morbidity in patients with CIN, this study aimed to evaluate the effect of oxygen therapy in prevention of the CIN in individuals with acute coronary syndrome undergoing emergent angiography. Patients and Methods: This study was a double-blinded clinical trial with control group (parallel design), randomized, and with a sample size of 204 individuals conducted on male or female patients over 35 years old and suspected of coronary artery disease undergoing emergent angiography refereed to Rasoul Akram hospital in 2018. Participants were divided into 2 groups (supplementary oxygen and oxygen-free groups). The first group received two to three liters of oxygen per minute from 10 minutes before the start of the procedure until the end of the procedure, and the second group inhaled the oxygen in the room air. Arterial blood gas (ABG) was taken prior to receiving oxygen and at the end of the procedure. Serum creatinine level was tested for all individuals before and 48 hours after the procedure. Results: The mean age in intervention and control groups was 61.66 ± 14.64 years and 60.49 ± 11.59 years, respectively (P=0.54). Mean glomerular filtration rate (GFR) and serum creatinine before and after angiography was not significantly different (P&gt;0.05). There was a significant difference between the two genders regarding the development of CIN (P=0.002), which was higher in women from that of men. Female gender was a strong risk factor and approximately increased four times the risk of CIN (OR = 4.1; (P=0.001). History of chronic kidney disease (CKD) and hypertension (HTN) also produced such a situation (OR = 22.37; P=0.007). Conclusion: According to the results, oxygen therapy has no effect on the occurrence of CIN. It is also found that female gender, history of CKD and hypertension are risk factors for CIN.

Managing penetrating renal trauma: experience from two major trauma centres in the UK.

To present our series of patients with penetrating renal trauma treated at two urban major trauma centres and to discuss the contemporary management of such injuries. We reviewed prospective urological trauma databases for all patients presenting with penetrating renal trauma between January 2005 and October 2016. Patient demographics, clinical characteristics, imaging, management and follow-up data were analysed. Over the 11-year period, 63 patients presented with penetrating renal injuries. The vast majority of patients were male (n = 61; 96.8%), with a mean (range) age of 27.4 (14-71) years. Injuries were equally common on either side (31 left, 32 right). The most common mechanism of injury was stabbing (n = 55; 87.3%), followed by gunshot (n = 7; 11.1%) and crossbow injuries (n = 1; 1.6%). All patients underwent contrast-enhanced computed tomography. Using the American Association for the Surgery of Trauma renal injury grading system, 11 (17.5%) had grade II, 26 (41.3%) had grade III and 26 (41.3%) had grade IV injury. The most common associated injuries were thoracic (n = 23; 36.5%), liver (n = 11; 17.5%), splenic (n = 10; 15.9%), gastrointestinal tract (n = 8; 12.7%) and musculoskeletal (n = 6; 9.5%). At presentation, 16 patients (25.4%) were haemodynamically unstable. The majority of patients did not require blood transfusion (n = 56; 88.9%), while transfusion of >5 units was rare (n = 4; 6.3%). Fifty-two patients (82.5%) were managed by observation alone, while 10 (15.9%) underwent emergency angiography and embolization. Patients with grade IV injury were more likely to require embolization than those with grade III injury; however, the difference was not significant (26.9% vs 15.4%; P = 0.29). One patient (1.6%) underwent retroperitoneal exploration of their renal injury and was managed conservatively. Eight patients underwent laparotomy for other visceral injuries while their renal injury was managed conservatively. Renal artery pseudoaneurysm developed in five patients (7.9%) and one patient (1.6%) developed renal arteriovenous malformation. No patients underwent nephrectomy and no mortality was reported. The vast majority of patients with penetrating renal injuries can be safely managed non-operatively in this setting. Selective renal artery embolization is an effective option for patients in an unstable condition, with excellent outcomes. Associated thoracic or visceral injuries requiring operative management are common in penetrating renal trauma, while urologists should limit or have a high threshold for surgical intervention.

PWE-147 The Use of Angiography with A View to Embolisation In Non Variceal Gastrointestinal Haemorrhage Uncontrolled with Endoscopic Therapy, A 10 Year Experience at A Teaching Hospital

Introduction Gastrointestinal (GI) bleeding is a common medical emergency. The incidence is 1.33/1000 population, approximately 85,000 cases/year. The NCEPOD review of GI haemorrhage emphasised the role of embolisation in patients with GI bleeding who have failed endoscopic therapy. Transcatheter arterial embolisation (TAE) has been shown to be as effective as emergency surgery in the treatment of refractory acute non variceal upper GI bleeding (ANVGIB) with reduced 30 day mortality rates. The study aim was to review the utilisation and outcomes of patients undergoing emergency angiography (EA) with a view to embolisation in ANVGIB not amendable to, or controlled by, endoscopic therapy. Methods A retrospective analysis of patients undergoing EA for ANVGIB between January 2005 and February 2016 was performed. Patients were identified from endoscopy and radiology databases. Endoscopy reports and discharge letters were reviewed electronically. Successful embolisation was deemed when extravasation had stopped and/or no bleeding post embolisation. Results Over the study period, 22412 patients were diagnosed with GI bleeding. 57.9% (12967/22412) had an endoscopy. EA was performed in 107/12967 (0.83%) of patients undergoing endoscopy due to uncontrolled GI bleeding. Mean age was 69 years for males and 74 years for females (range 30–98); 74/107 were male. EA and embolization was performed in hours in 71% of cases and out of hours in 29%. Pre-angiography endoscopy report was available in 86/107 patients. The commonest endoscopic diagnosis was duodenal ulcer which was present in 25.6% (22/86) of the cases. A normal upper GI endoscopy was noted in 20.9% (18/86) of patients. Lower GI bleeding was the cause in 17.4% (15/86) of patients. Other causes included; unidentified bleeding point, dieulafoy lesion, gastric ulcer. Of those patients undergoing angiography 54/106 (50.9%) had TAE. TAE was deemed successful in 90.7% (49/54) of cases. Surgical intervention was necessary in 2/5 of the unsuccessful cases. The 30 day mortality for the patients undergoing angiography with or without intervention was 18/107 (16.8%). 57% (61/107) were alive at 1 year. Conclusion The results demonstrate that angiography and embolisation is a valuable tool in the management of GI bleeding not controlled by endoscopic therapy with a high success rate avoiding the need for surgery in the majority of cases. Our figures are comparable to published studies. The results support the need for 24/7 access to interventional radiology which is part of the recommendations from the NCEPOD review of the care received by patients who had a severe gastrointestinal haemorrhage. Disclosure of Interest None Declared

Angiographic result of index PCI determines the presence of right ventricular infarction in patients with acute inferior myocardial infarction.

It is still a matter of debate which patients with acute inferior myocardial infarction are at increased risk of developing right ventricular (RV) myocardial infarction (RVMI). Cardiac magnetic resonance imaging (CMRI) with late enchancement (LE) is regarded as the gold standard for RVMI assessment. We aimed to determine the impact of initial angiographic status and salutary effect of primary percutaneous coronary intervention (PCI) on the presence of RVMI. In 114 patients undergoing emergency angiography and primary PCI of right coronary artery, 3-5 days after index PCI, LE CMRI was performed for assessing the RVMI. Forty-eight patients (42%) demonstrated RVMI. Multivariate regression analysis identified TIMI flow <2 in at least one RV branch after PCI as an independent angiographic predictor of RVMI [odds ratio (OR) 143.00, 95% confidence interval (CI) 18.10-1130.05, p < 0.001]. ST-segment elevation ≥ 1 mm in V4R was present in 83 (73%). TIMI flow <3 in at least one RV branch before PCI (OR 4.07, 95% CI 1.24-13.33, p = 0.02) was independent angiographic predictor of ST-segment elevation ≥ 1 mm in V4R. The only predictor of RVMI was TIMI flow <2 in at least one RV branch after PCI. ST-segment elevation ≥ 1 mm in V4R is caused by TIMI <3 flow in at least one RV branch before index PCI.

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial

Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59). Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).

Abstract 18123: An Integrated Resuscitation Service, Combining a Specialist Pre-Hospital Physician Response Unit With Delivery to a Dedicated High-Volume Cardiac Arrest Centre, Optimises Survival Following Cardiac Arrest

Background: Despite advances in resuscitation medicine, survival rates to discharge following out-of-hospital cardiac arrest (OHCA) remain poor. Recent data support early critical care interventions including therapeutic hypothermia (TH) and immediate percutaneous coronary intervention (PCI). In London, a package of high quality physician-led critical care intervention on scene, with the capacity to transfer these patients direct to a PCI centre, is available through the deployment of London’s Air Ambulance specialist Physician Response Unit (PRU). Methods: Prospective data was gathered on OHCA treated by the PRU, which were transferred to a single PCI centre. Data included patient demographics, clinical characteristics, interventions and outcome. Results: Between April 2011 and April 2013, data was obtained on 20 patients, with a mean age of 59. Clinical characteristics - presenting rhythm: VF 65%, asystole 15%, PEA 15%, VT 5%. Return of spontaneous circulation (ROSC) was achieved at scene in 75%. PRU interventions: Advanced airway management 90%, rapid sequence induction 50%, early TH 45%, mechanical CPR (mCPR) during transfer 15%. Overall survival to ICU was 50%, with overall survival to discharge 45%. Of those patients who underwent emergency angiography, 71% survived to ICU, with 64% surviving to discharge. Of patients presenting in VF, 62% survived to discharge. Interestingly, 66% of patients who received TH survived to discharge, compared with 45% where TH was not used. All patients who underwent successful PCI survived to discharge with good neurological outcomes. 9 patients had a confirmed single vessel culprit lesion treated by PCI, one patient had complex mutlivessel disease complicated by cardiogenic shock and underwent mutivessel PCI, and 2 patients had an undiagnosed underlying cardiomyopathy. Conclusions: In selected cases, outcomes following OHCA can be optimized by integrating a PRU cardiac arrest service, enabling direct triage of patients to a cardiac arrest centre, with early application of neuroprotective strategies, mCPR, circulatory support and interventional cardiology techniques.

E-017 Emergency Onyx embolization of avulsed basilar artery perforator following an endoscopic colloid cyst resection

IntroductionEndoscopic resection of a colloid cyst and third ventriculostomy is a well described neurosurgical procedure and is performed commonly. Inadvertent vascular injury can occur due to the limited peripheral field...

Field Triage Reduces the Incidence and Mortality of Ischaemic Cardiogenic Shock in Patients with Acute Myocardial Infarction

reduce door to balloon (DTB) time in STEMI. Shorter DTB times are associated with reduced mortality. The main barrier to implementing ED CCL activation is concern of inappropriate activation of the CCL. Aim:Tocompare falsepositive ratesof suspectedSTEMI patients undergoing emergency coronary angiography by cardiology verses senior ED activation of the CCL. Methods: All patients undergoing emergency cardiac catheterisation forSTEMI from2007 to2009wereanalysed. Falsepositive rateswere comparedbefore andafter implementing a protocol enabling independent ED activation of the CCL (2007–2008 vs. 2009). Some patient characteristics required ED to communicate with cardiology prior to CCL activation (elderly, borderline ECG changes, out of hospital arrest, LBBB, significant co-morbidities). Patient files, ECGs, coronary angiograms and left ventriculograms were reviewed in all patients undergoing emergency angiography without percutaneous coronary intervention to determine diagnosis, management and cause of the false positive cases. Results: Cardiology 2008–2009 (n= 150) ED 2009 (n= 84) Primary PCI 118 (79%) 70(83%) Medical management 11 (7%) 4 (5%) Surgery 3 (2%) 1 (1) False positive 18 (12%) 9 (11%) (NS) Causes of false positives: Chest pain of unclear cause with either early repolarisation of ST segments or LBBB (63%, 7/27). Takotsubo cardiomyopathy (22%, 6/27), myo/pericarditis (11%, 3/27) and pulmonary embolism (5%, 1/27). Conclusion: False positive rates in patients undergoing emergency angiography for suspected STEMI is not increasedwithacontrolledsystemofemergencyphysician activation of the cardiac catheterisation laboratory. doi:10.1016/j.hlc.2010.06.975

An Evaluation of the Accuracy of Emergency Physician Activation of the Cardiac Catheterization Laboratory for Patients With Suspected ST-Segment Elevation Myocardial Infarction

Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI. We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease. During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded. A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients.

Rescue percutaneous coronary intervention for failed thrombolysis in a patient with anomalous coronary arteries

Coronary artery anomalies (CAA) often render technically difficult the completion of coronary angiography and intervention. Their presence in patients undergoing emergency angiography for acute myocardial infarction (AMI) is particularly challenging for interventional cardiologists. In this article, we report, for the first time in the literature, a case of rescue percutaneous coronary intervention for failed thrombolysis in a patient with AMI due to occlusion of a left circumflex coronary artery with anomalous origin from right sinus of Valsalva (in an anomalous left coronary system also including an anomalous origin of the left anterior descending artery from the right sinus). In particular, the present clinical vignette emphasizes the importance of a thorough search for the culprit vessel during cardiac catheterization. Especially in the emergency setting, non-invasive methods of ischemia localization, such as ST-segment elevation at the ECG and wall motion abnormalities at echocardiography, are of pivotal usefulness to guide the interventional cardiologist in identifying and treating the diseased coronary vessel in a timely and effective fashion.

Rescue percutaneous coronary intervention for failed thrombolysis: results from a district general hospital

Objective: To assess the outcome of a policy of emergency percutaneous coronary intervention (PCI) in patients with acute myocardial infarction and electrocadiographic (ECG) evidence of failed reperfusion after thrombolysis. Design:...