Campbell, B. C.V. et al. (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.ABSTRACT Background: CT-perfusion (CTP) and MRI may assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of ischaemic core and penumbra volumes were associated with functional outcomes and treatment effect.

Campbell, B. C. V. et al. (2018) Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurology, 17(1), pp. 47-53. (doi:10.1016/S1474-4422(17)30407-6) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/149670/ variables. An alternative approach using propensity-score stratification was also used. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models. Bias was assessed using the Cochrane tool.Findings: Of 1764 patients in 7 trials, 871 were allocated to endovascular thrombectomy. After exclusion of 74 patients (72 who did not undergo the procedure and 2 with missing data on anaesthetic strategy), 236/797 (30%) of endovascular patients were treated under GA. At baseline, GA patients were younger and had shorter time to randomisation but similar pre-treatment clinical severity compared to non-GA. Endovascular thrombectomy improved functional outcome at 3 months versus standard care in both GA (adjusted common odds ratio (cOR) 1·52, 95%CI 1·09-2·11, p=0·014) and non-GA (adjusted cOR 2·33, 95%CI 1·75-3·10, p<0·001) patients. However, outcomes were significantly better for those treated under non-GA versus GA (covariate-adjusted cOR 1·53, 95%CI 1·14-2·04, p=0·004; propensitystratified cOR 1·44 95%CI 1·08-1·92, p=0·012). The risk of bias and variability among studies was assessed to be low.Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding:The HERMES collaboration was funded by an unrestricted grant from Medtronic to the University of Calgary. Research in contextEvidence before this study between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of general anaesthesia versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of general anaesthesia. Added value of this studyThese data from contemporary, high quality randomised trials form the largest study to date of the association between general anesthesia and the benefit of endovascular thrombectomy versus standard care. We used two different approaches to adjust for baseline imbalances (multivariable logistic regression and propensity-score stratification). We found that GA for endovascular thrombectomy, as practiced in contemporary clinical care across a wide range of expert centres during the rand...

Objectives: The objective was to determine if 9-1-1 paramedics trained in ultrasound (US) could adequately perform and interpret the Focused Assessment Sonography in Trauma (FAST) and the abdominal aortic (AA) exams in the prehospital care environment.Methods: Paramedics at two emergency medical services (EMS) agencies received a 6-hour training program in US with ongoing refresher education. Paramedics collected US in the field using a prospective convenience methodology. All US were performed in the ambulance without scene delay. US exams were reviewed in a blinded fashion by an emergency sonographer physician overreader (PO).Results: A total of 104 patients had an US performed between January 1, 2008, and January 1, 2009. Twenty AA exams were performed and all were interpreted as negative by the paramedics and the PO. Paramedics were unable to obtain adequate images in 7.7% (8 ⁄ 104) of the patients. Eighty-four patients had the FAST exam performed. Six exams (6 ⁄ 84, 7.1%) were read as positive for free intraperitoneal ⁄ pericardial fluid by both the paramedics and the PO. FAST and AA US exam interpretation by the paramedics had a 100% proportion of agreement with the PO.Conclusions: This pilot study shows that with close supervision, paramedics can adequately obtain and interpret prehospital FAST and AA US images under protocol. These results support a growing body of literature that indicates US may be feasible and useful in the prehospital setting. ACADEMIC EMERGENCY MEDICINE2010; 17:624-630 ª 2010 by the Society for Academic Emergency MedicineKeywords: prehospital ultrasound, paramedic ultrasound, trauma care, and ultrasound P oint-of-care (POC) ultrasound (US) has significantly increased in use over the past 20 years. [1][2][3] Multiple studies have shown the efficacy and efficiency of POC US. Some studies have demonstrated improved morbidity and mortality outcomes.3-5 The use of POC US in the prehospital setting is a relatively new application of this medical technology. Small studies have shown utility in military, ground, and helicopter emergency medical services (EMS) in both Europe and the United States. [5][6][7][8][9][10][11][12][13][14][15][16][17] These studies have largely concentrated on US use for trauma evaluation and involve the application of the Focused Assessment Sonography for Trauma (FAST) or an extended FAST examination. Prehospital US use has been more fully described in Germany, France, and Italy than in the United States.

Background-Treatment times for ST-elevation myocardial infarction (STEMI) patients presenting to percutaneous coronary intervention hospitals have improved dramatically over the past 10 years, particularly for patients using emergency medical services. Limited data exist regarding treatment times and outcomes for patients who develop STEMI after hospital admission.

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A 41-year-old male was stabbed in the left chest. When paramedics arrived at the scene, the patient was unconscious. The airway was managed with a nasal trumpet, and the patient was quickly moved to the ambulance. The systolic blood pressure was 85 mm Hg. In the ambulance, one paramedic performed a bedside, prehospital ultrasound (PUS) using a SonoSite MicroMaxx (Sonosite Inc., Bothell, WA) with a P17 probe using a subcostal cardiac view. A large pericardial effusion with hyperechoic and anechoic fluid in the pericardial sac was identified (Figure 1, Video Clip S1, available as supporting information in the online version of this paper). Based on this ultrasound finding, the decision was made to immediately transport the patient to the closest Level 1 trauma center, with intravenous fluids administered enroute. The total emergency medical systems (EMS) scene time was 9 minutes and transport time was 6 minutes. The PUS took less than 1 minute to obtain and did not impact transport times. The emergency department was alerted that a patient with a hypotensive stab wound to the heart with a positive sonographic pericardial effusion was enroute.The patient was quickly assessed in the emergency department. The emergency physicians and trauma surgeons reviewed the PUS video. The patient was taken directly to the operating room based on the PUS video, and a median sternotomy was performed with evacuation of a large mixed-density clot and repair of a right ventricular stab wound using a single 3.0 Prolene suture with pledget. The patient had an uneventful postoperative course and was discharged from the hospital 4 days later with complete neurologic recovery.Prehospital ultrasound has been used in our EMS system on a limited basis for the past 12 months. This case demonstrates that EMS personnel can be adequately trained to utilize this technology to shorten time to determining certain diagnoses and facilitate proper destination decisions, which can improve overall patient care. This case is part of a larger PUS study that was approved by our institutional review board. Supporting InformationThe following supporting information is available in the online version of this paper: Video Clip S1. Prehospital ultrasound showing a large mixed-density pericardial effusion with right ventricular collapse. This ultrasound was taken by paramedics enroute to the hospital. The video clip is an AVI file.Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. DYNAMIC EMERGENCY MEDICINE

Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

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