Endovascular treatment for vaccine-induced cerebral venous sinus thrombosis and thrombocytopenia following ChAdOx1 nCoV-19 vaccination: a report of three cases.

BACKGROUND: Vaccine-induced thrombosis and thrombocytopenia (VITT) is a rare complication following ChAdOx1 nCoV-19 vaccination. Cerebral venous sinus thrombosis (CVST) is overrepresented in VITT and is often associated with multifocal venous thromboses, concomitant hemorrhage and poor outcomes. Hitherto, endovascular treatments have not been reviewed in VITT-related CVST. METHODS: Patient records from a tertiary neurosciences center were reviewed to identify patients who had endovascular treatment for CVST in VITT. RESULTS: Patient records from 1 January 2021 to 20 July 2021 identified three patients who underwent endovascular treatment for CVST in the context of VITT. All were female and the median age was 52 years. The location of the CVST was highly variable. Two-thirds of the patients had multifocal dural sinus thromboses (sigmoid, transverse, straight and superior sagittal) as well as internal jugular vein thromboses. Intracerebral hemorrhage occurred in all patients; subarachnoid blood was noted in two of them, and intraparenchymal hemorrhage occurred in all. There was one periprocedural parenchymal extravasation which abated on temporary cessation of anticoagulation. Outcome data revealed a 90-day modified Rankin Scale (mRS) score of 2 in all cases. CONCLUSIONS: We demonstrate that endovascular treatment for VITT-associated CVST is feasible and can be safe in cases that deteriorate despite medical therapy. Extensive clot burden, concomitant hemorrhage, rapid clinical progression and persistent rises in intracranial pressure should initiate multidisciplinary team discussion for endovascular treatment in appropriate cases.

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients.

BACKGROUND: Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia. METHODS: A prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups. RESULTS: Of 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation). Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation. CONCLUSION: Apnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

Beta-Blockade in Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-Analysis.

BACKGROUND/OBJECTIVE: Sympathetic nervous system activation after aneurysmal subarachnoid hemorrhage (aSAH) is associated with complications and poor outcome. In this systematic review and meta-analysis, we investigate the effect of beta-blockers on outcome after aSAH. METHODS: The review was prospectively registered with PROSPERO (CRD42019111784). We performed a systematic literature search of MEDLINE, EMBASE, the Cochrane Library, published conference proceedings, and abstracts. Eligible studies included both randomized controlled trials and observational studies up to October 2018, reporting the effect of beta-blocker therapy on the following outcomes in aSAH: mortality, vasospasm, delayed cerebral ischemia, infarction or stroke, cardiac dysfunction, and functional outcomes. Studies involving traumatic SAH were excluded. Citations were reviewed, and data extracted independently by two investigators using a standardized proforma. RESULTS: We identified 819 records with 16 studies (four were randomized controlled trials) including 6702 patients selected for analysis. Exposure to beta-blockade either before or after aSAH was associated with a significant reduction in unadjusted mortality (RR 0.63, 95% CI 0.42-0.93, p = 0.02). A significant reduction in unadjusted mortality was also seen in prospective trials of post-event beta-blockade (RR 0.51, 95% CI 0.28-0.93, p = 0.03). Statistically significant differences were not seen for other outcomes investigated. CONCLUSIONS: In adult patients with aSAH, beta-blocker therapy is associated with a mortality benefit. Studies are generally of a low quality with considerable clinical heterogeneity. Prospective large interventional trials with patient centered outcomes are required to validate this finding.

Cardiac troponin T is associated with mortality in patients admitted to critical care in a UK major trauma centre: a retrospective database analysis.

BACKGROUND: Elevated levels of cardiac troponin T are associated with poor outcome in critically ill patients and have been proposed as a prognostic marker in major trauma. This study investigated the relationship between cardiac troponin T levels on admission to intensive care unit (ICU) and all-cause mortality in major trauma patients. METHODS: A retrospective database analysis of cardiac troponin T levels on admission to the ICU in major trauma patients between 1 August 2015 and 31 December 2016 at a UK Major Trauma Centre was performed. RESULTS: Of the 243 patients, 69 (28.4%) died. Cardiac troponin T levels were significantly higher in patients who died compared to survivors: 42 vs. 13 ng/L, respectively (p < 0.0001); the odds of all-cause mortality increased significantly as troponin increased, independent of age or Acute Physiology and Chronic Health Evaluation score. DISCUSSION: This confirms cardiac troponin T at ICU admission as a marker of mortality in major trauma. Elevated cardiac troponin T may be seen in patients without evidence of direct cardiac trauma.

Best practice advice on pre-hospital emergency anaesthesia & advanced airway management.

BACKGROUND: Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management. METHOD: This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online. RESULTS: This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice. CONCLUSION: PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists.

INTRODUCTION: Prehospital emergency anaesthesia (PHEA or 'prehospital rapid sequence intubation') is a high-risk procedure. Standard operating procedures (SOPs) and checklists within healthcare systems have been demonstrated to reduce human error and improve patient safety. We aimed to describe the current practice of PHEA in the UK, determine the use of checklists for PHEA and describe the content, format and layout of any such checklists currently used in the UK. METHOD: A survey of UK prehospital teams was conducted to establish the incidence and conduct of PHEA practice. Results were grouped into systems delivering a high volume of PHEA per year (>50 PHEAs) and low volume (≤50 PHEAs per annum). Standard and 'crash' (immediate) induction checklists were reviewed for length, content and layout. RESULTS: 59 UK physician-led prehospital services were identified of which 43 (74%) participated. Thirty services (70%) provide PHEA and perform approximately 1629 PHEAs annually. Ten 'high volume' services deliver 84% of PHEAs per year with PHEA being performed on a median of 11% of active missions. The most common indication for PHEA was trauma. 25 of the 30 services (83%) used a PHEA checklist prior to induction of anaesthesia and 24 (80%) had an SOP for the procedure. 19 (76%) of the 'standard' checklists and 5 (50%) of the 'crash' induction checklists used were analysed. On average, standard checklists contained 169 (range: 52-286) words and 41 (range: 28-70) individual checks. The style and language complexity varied significantly between different checklists. CONCLUSION: PHEA is now performed commonly in the UK. The use of checklists for PHEA is relatively common among prehospital systems delivering this intervention. Care must be taken to limit checklist length and to use simple, unambiguous language in order to maximise the safety of this high-risk intervention.

Traumatic cardiac arrest: who are the survivors?

STUDY OBJECTIVE: Survival from traumatic cardiac arrest is poor, and some consider resuscitation of this patient group futile. This study identified survival rates and characteristics of the survivors in a physician-led out-of-hospital trauma service. The results are discussed in relation to recent resuscitation guidelines. METHODS: A 10-year retrospective database review was conducted to identify trauma patients receiving out-of-hospital cardiopulmonary resuscitation. The primary outcome measure was survival to hospital discharge. RESULTS: Nine hundred nine patients had out-of-hospital cardiopulmonary resuscitation. Sixty-eight (7.5% [95% confidence interval 5.8% to 9.2%]) patients survived to hospital discharge. Six patients had isolated head injuries and 6 had cervical spine trauma. Eight underwent on-scene thoracotomy for penetrating chest trauma. Six patients recovered after decompression of tension pneumothorax. Thirty patients sustained asphyxial or hypoxic insults. Eleven patients appeared to have had "medical" cardiac arrests that occurred before and was usually the cause of their trauma. One patient survived hypovolemic cardiac arrest. Thirteen survivors breached recently published guidelines. CONCLUSION: The survival rates described are poor but comparable with (or better than) published survival rates for out-of-hospital cardiac arrest of any cause. Patients who arrest after hypoxic insults and those who undergo out-of-hospital thoracotomy after penetrating trauma have a higher chance of survival. Patients with hypovolemia as the primary cause of arrest rarely survive. Adherence to recently published guidelines may result in withholding resuscitation in a small number of patients who have a chance of survival.