Is helmet CPAP first line pre-hospital treatment of presumed severe acute pulmonary edema?

PURPOSE: Non-invasive continuous positive airway pressure (CPAP) is effective in reducing intubation rate and mortality of patient with acute cardiogenic pulmonary edema (ACPE). We report our experience on pre-hospital application of CPAP by helmet as an adjunct to medical therapy or as a stand alone procedure in patient with presumed ACPE. METHODS: In pre-hospital treatment of 62 patients with presumed ACPE, CPAP was added to standard medical treatment while in another 59 patients, CPAP was used as a sole therapy. RESULTS: Helmet CPAP was feasible in all patients. No patient required pre-hospital intubation. In both groups, CPAP significantly improved oxygenation (SpO(2) went from 79 +/- 12 to 97 +/- 3% and from 81 +/- 13 to 98 +/- 3%), reduced respiratory rate (from 26 +/- 4 to 21 +/- 3 bpm and from 30 +/- 9 to 22 +/- 8 bpm) and improved hemodynamics, with a more pronounced decrease in blood pressure in the group with medical treatment than in the one without it. In the two cohorts, four and five patients were, respectively, intubated in Emergency Department and 11 and 9 eventually died. CONCLUSIONS: Helmet CPAP is feasible, efficient and safe in pre-hospital treatment of presumed ACPE. A significant improvement of physiological variables was observed also in the group treated with CPAP in the absence of a drug therapy. We propose helmet CPAP as first line pre-hospital treatment of presumed severe ACPE.

Prospective performance evaluation of emergency medical services for cardiac arrest in Lombardia: is something moving forward?

BACKGROUND: Limited data are available in our region on out-of-hospital treatment of cardiac arrest. The aim of this study is to evaluate whether the changes implemented in the emergency system (i.e. an increased number of basic life support and advance life support crews that were dispatched) produced the expected outcome improvements. METHODS: (a) EXPERIMENTAL DESIGN: data were prospectively collected on patients with sudden out-of-hospital cardiac arrest in three emergency dispatch centers for 3 months during two study periods, year 2000 and year 2003, differentiated only by the increase of qualified crews. Outcomes and survival were evaluated at 24 h and 1 month after the event. (b) SETTING: out-of-hospital treatment. (c) PATIENTS: 352 (174 in the second study period) patients suffering cardiac arrest. (d) INTERVENTIONS: the study was observational. RESULTS: We could document, between the two study periods, stable 24 h (12.6 vs 9.1%) and 1 month survival (3.4 vs 5.8%, NS). Nevertheless, arrival time on site was significantly higher in the second period (from 8.3+/-3.3 to 10.1+/-5.4 min, P<0.05). CONCLUSIONS: The strengthening of only one link of the chain-of-survival did not improve 1 month survival.