Search

Objectives: Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA., Data Sources: We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023., Study Selection: We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management., Data Extraction: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935)., Data Synthesis: We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty)., Conclusions: In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events., Competing Interests: Dr. Sharif holds a McMaster University Department of Medicine Internal Career Research Award. Dr. Nichol’s institution received funding from the National Institutes of Health, the Centers for Disease Control and Prevention, and Abiomed Inc.; he received funding from OLL Medical Corp., Vapotherm Inc., ZOLL Circulation Inc., CPR Therapeutics Inc., Heartbeam Inc., Invero Health LLC, Kestra Medical Technologies Inc., and Orixha Inc. Dr. Nolan disclosed he is Editor-in-Chief Resuscitation of Elsevier Journal. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

The optimal timing of coronary angiography remains unclear following out-of-hospital cardiac arrest (OHCA) without ST elevation on electrocardiogram. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of early angiography versus delayed angiography following OHCA without ST elevation., Data Sources: The databases MEDLINE, PubMed EMBASE, and CINHAL, as well as unpublished sources from inception to March 9, 2022., Study Selection: A systematic search was performed for randomized controlled trials of adult patients after OHCA without ST elevation who were randomized to early as compared to delayed angiography., Data Extraction: Reviewers screened and abstracted data independently and in duplicate. The certainty of evidence was assessed for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. The protocol was preregistered (CRD 42021292228)., Data Synthesis: Six trials were included ( n = 1,590 patients). Early angiography probably has no effect on mortality (relative risk [RR] 1.04; 95% CI 0.94-1.15; moderate certainty) and may have no effect on survival with good neurologic outcome (RR 0.97; 95% CI 0.87-1.07; low certainty) or ICU length of stay (LOS) (mean difference 0.41 days fewer; 95% CI -1.3 to 0.5 d; low certainty). Early angiography has an uncertain effect on adverse events., Conclusions: In OHCA patients without ST elevation, early angiography probably has no effect on mortality and may have no effect on survival with good neurologic outcome and ICU LOS. Early angiography has an uncertain effect on adverse events., Competing Interests: Drs. Sharif and Belley-Côté hold a McMaster University Department of Medicine Internal Career Research Award. Dr. Belley-Côté holds a National New Investigator award from the Heart and Stroke Foundation of Canada. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications., Case Summary: A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks., Conclusion: This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The diagnostic accuracy of ultrasound (US) for suspected lower extremity deep vein thrombosis (DVT) in nonpregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US, serial US is generally recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women., Methods: Two authors independently reviewed the following databases: MEDLINE, PubMed, and EMBASE from inception until February 2019. We assessed the risk of bias using the CLARITY group tool for prognostic studies and performed a random effects meta-analysis to report the pooled false negative rate of a single leg ultrasound., Results: Eight studies (seven prospective and one retrospective) were included. An overlap among study populations was identified in four of the manuscripts. Two authors performed data re-extraction from these hard copy research charts. Risk of bias was low for the included populations and method of measurement, and low or high for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, six were diagnosed with DVT during repeat serial testing (0.94%) and three developed DVT or PE during 3-month follow-up after serial ultrasonography (0.47%). The pooled false-negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42-2.56), I 2  = 27%., Conclusion: The false-negative rate is low with a single US for suspected DVT in pregnancy. Our results will help inform shared decision-making around planning repeat ultrasound scans in these patients., (© 2019 International Society on Thrombosis and Haemostasis.)

Subarachnoid and intraparenchymal haemorrhages due to cerebral mycotic aneurysms are rare and associated with high mortality. Streptococcus agalactiae , is a rare cause of endocarditis and there are no reported cases of cerebral mycotic aneurysms secondary to this organism. We report a rare case of streptococcus agalctiae induced intracranial mycotic aneurysm.

Background: Left bundle branch block (LBBB) and dominant R wave in lead V1 (RV1) post-biventricular pacing (BiVp) are associated with better clinical outcomes. However, some patients continue to deteriorate despite these favorable electrocardiographic changes., Objective: We tested the hypothesis that baseline LBBB and post-BiVp RV1 are associated with better cardiac function and clinical outcomes in patients with progressive deterioration in heart failure after BiVp ("clinical nonresponders") than in patients without these electrocardiographic criteria., Methods: Consecutive patients with advanced heart failure and BiVp were included. An increase in R-wave amplitude of over 4.5 times the baseline value was defined as RV1. Clinical outcome was survival free of heart transplantation and/or implantation of mechanical circulatory support., Results: A total of 179 (100 (56%) with LBBB; 79 (44%) with non-LBBB) patients with advanced heart failure and BiVp were included. Of the 100 patients with LBBB, 67 (67%) developed RV1 (group 1) but 33 (33%) patients did not develop RV1 (group 2). Of the 79 patients with non-LBBB, 49 (62%) developed RV1 (group 3) and the remaining 30 (38%) patients did not develop RV1 (group 4). Changes in left ventricular ejection fraction and left ventricular end-systolic volume index were not significant in group 1, but deteriorated in the other groups (P < .05). The change in left ventricular end-systolic volume index was associated with the change in QRS duration and absence of RV1 (P < .01). Clinical outcome was most favorable in group 1 (LBBB and RV1). Changes in left ventricular ejection fraction, tricuspid annular plane systolic excursion, and right atrial pressure were associated with clinical outcomes., Conclusion: Despite progressive deterioration in heart failure, patients with LBBB and RV1 post-BiVp demonstrate more stable cardiac function and more favorable clinical outcomes than did patients with non-LBBB with or without RV1 post-BiVp., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)