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.

Out-of-Hospital Perimortem Cesarean Section as Resuscitative Hysterotomy in Maternal Posttraumatic Cardiac Arrest.

The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early "separation" between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). This strategy is in contrast with the traditional treatment of cardiac arrest characterized by the maintenance of cardiopulmonary resuscitation (CPR) maneuvers without any emergent surgical intervention. We report the case of a prehospital perimortem delivery by Caesarean (C) section of a foetus at 36 weeks of gestation after the mother's traumatic cardiac arrest. Despite the negative outcome of the mother, the choice of performing a RH seems to represent up to date the most appropriate intervention to improve the outcome in both mother and foetus.

Successful Prolonged Mechanical CPR in a Severely Poisoned Hypothermic Patient: A Case Report.

Mechanical cardiopulmonary resuscitation (m-CPR) devices are an alternative to manual CPR, but their efficacy has been subject to debate. We present a case of a patient with full-neurologic recovery after prolonged m-CPR. The patient presented with severe hypothermia (internal temperature 24°C) and poisoning (sedatives/hypnotics). Hepatic perfusion and metabolism are considered keys to restore spontaneous circulation. During this period no problems related to the device or patient positioning were encountered. Delivery of high-quality CPR and prolonged resuscitation were achieved. We confirm that ventilations asynchronous with chest compressions can be a problem. Reduction in chest measurements can hamper lung ventilation. A synchronous mode of manual ventilation (30 : 2) seems to be the best solution. The patient had an initial period of manual CPR. No damage to any organ or structure was noted. This case is of further interest because our EMS helicopters can fly 24 hours a day and m-CPR devices could play an important role as a "bridge" in patients when active rewarming by cardiopulmonary bypass is indicated (CPB).

Stroke management in northern Lombardy: organization of an emergency-urgency network and development of a connection between prehospital and in-hospital settings.

Stroke is the leading cause of disability in adulthood, and the principal aim of care in cerebrovascular disease is the reduction of this negative outcome and mortality. Several studies demonstrated the efficacy of thrombolytic therapy in ischemic stroke, but up to 80% of cases could not be treated because the diagnostic workup exceeds the time limit. In this article, we described the design of a study conducted in the northern Lombardy, within the district of Sondrio, Lecco, Como, and Varese. The awaited results of this study are reduction of avoidable delay, organization of an operative stroke emergency network, and identification of highly specialized structures. The study schedules education and data registration with implementation and training of acute stroke management algorithms. The use of standardized protocols during prehospital and in-hospital phase can optimize acute stroke pathways. The results of this study could contribute to the assessment of an effective and homogeneous health system to manage acute stroke.