Role of a prehospital medical system in reducing heroin-related deaths.

OBJECTIVE: The mortality rate from heroin overdose in Italy between 1977 and 1987 increased significantly. However, in the same period, a significant increase was not observed in Tuscany, an administrative region in Italy. This study was performed to determine if the prehospital emergency medical system of Florence, the capital of Tuscany (the only one operating in Italy during the study period), affected this lower mortality rate. DESIGN: Retrospective study. SETTING: The Florence system consists of 17 mobile ICUs, each of which is staffed by a physician and three paramedics. These units are able to carry out advanced cardiopulmonary resuscitation with equipment transported to the scene of an emergency. PATIENTS: A total of 126 consecutive patients with heroin overdose, assisted by four mobile ICUs from January 1, 1984 through December 31, 1987. INTERVENTIONS: Common therapeutic protocol in the treatment of heroin overdose and of cardiac arrest. RESULTS: Fifty-two (41.3%) patients were in respiratory arrest, and seven (5.6%) patients were in cardiorespiratory arrest. The prehospital mortality rate was 1.6%, the inhospital mortality rate was 0.8%, and the overall mortality rate was 2.4%. During the period considered, the number of heroin overdose-related interventions increased significantly, as did the number of heroin overdoses complicated by respiratory arrest or by cardiorespiratory arrest, but the mortality rate remained low. CONCLUSION: We suggest that an emergency medical system can play an important role in reducing the mortality rate from heroin overdose.

Neuropsychological outcome of survivors of out-of-hospital cardiac arrest.

Thirty patients resuscitated from out-of-hospital cardiac arrest (15 with and 15 without postanoxic coma on admission) underwent a clinical examination and neuropsychological testing. In order to assess quality of life, they were compared to two matched control groups; 15 patients with previous myocardial infarction and 15 healthy subjects. None of the survivors showed severe neurologic impairment, and all had returned to self-sufficient physical activity. However, the behavior rating scale scores were significantly worse in patients with postanoxic coma. The processing ability linked to memory was significantly worse in the postanoxic coma group. Mood disorders were also observed in this group, but they did not have pathological significance. The remarkably low incidence of neurologic and psychological sequelae in these resuscitated patients, particularly in those with early clinical evidence of severe cerebral damage, is an encouraging result that supports the therapeutic systems development and efforts in the management of out-of-hospital cardiac arrest.

[Methodologic and therapeutic approach to patients in shock]. / Approccio metodologico e terapeutico al malato in shock.

The authors extensively review pathophysiology and clinical aspects of the several forms of shock. Then they report a statistical evaluation of the incidence of the different shocks in the Campania area and an analysis of the therapeutic protocols used in several medical centers. From January 1983 to May 1986, 212 patients in shock have been followed: 90 patients with hypovolemic shock; 81 patients with cardiac shock; 24 patients with shock caused by abnormal peripheral distribution; 17 patients with obstructive shock; Furthermore, from January to May 1986, in a multicenter cooperative study (69 medical centers evenly distributed all over Italy) operational factors that could be considered prognostic factors have been investigated utilizing a questionnaire. Finally the authors extensively discuss the therapeutic management of shock proposing new therapeutic protocols based on recent knowledge concerning the pathophysiology of the several clinical features investigated.

Prognostic significance of early clinical manifestations in postanoxic coma: a retrospective study of 58 patients resuscitated after prehospital cardiac arrest.

The neurologic progress for 58 patients resuscitated after prehospital cardiac arrest was analyzed in order to evaluate their prognostic significance. Twenty-four patients were conscious on admission; their inhospital mortality rate was 4%. Thirty-four patients showed alterations of their state of consciousness; their inhospital mortality rate was 53%. On admission, only the absence of spontaneous breathing was significantly predictive of an unfavorable outcome. The failure of response to painful stimulation and pupillary light reflex became significantly predictive of an unfavorable outcome only in the late inhospital course. The time delay before onset of CPR was significantly longer in unconscious patients, but in this group no difference was observed between survivors and nonsurvivors. At discharge, no patient was in a comatose or vegetative state; three patients showed severe neurologic impairment. These data indicate that, in patients with postanoxic coma, early clinical evidence of severe neurologic dysfunction is predictive of neither inhospital death nor neurologic sequelae.