Annals of emergency medicine
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Randomized Controlled Trial Multicenter Study
Out-of-hospital continuous positive airway pressure ventilation versus usual care in acute respiratory failure: a randomized controlled trial.
Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care. ⋯ Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.
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Evidence-based medical literature is lacking about the best methods to train health care providers in disaster response. We systematically review the recent literature to report whether training interventions in disaster preparedness improve knowledge and skills in disaster response. ⋯ The available evidence is insufficient to determine whether training interventions for health care providers are effective in improving knowledge and skills in disaster response.
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Multicenter Study
Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
In an effort to improve neurologically normal survival of victims of cardiac arrest, a new out-of-hospital protocol was implemented by the emergency medical system medical directors in 2 south-central rural Wisconsin counties. The project was undertaken because the existing guidelines for care of such patients, despite their international scope and periodic updates, had not substantially improved survival rates for such patients during nearly 4 decades. ⋯ In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.
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WHAT IS ALREADY KNOWN ON THIS TOPIC: Application of continuous positive airway pressure (CPAP) for patients with acute respiratory distress reduces the need for tracheal intubation and mechanical ventilation. Case series have demonstrated CPAP's feasibility in out-of-hospital settings. ⋯ WHAT THIS STUDY ADDS TO OUR KNOWLEDGE: Within the CPAP group, the rate of intubation was 30% less than the usual care group, and mortality was 20% lower. HOW THIS MIGHT CHANGE CLINICAL PRACTICE: Emergency medical services systems and their medical directors should consider making CPAP available as part of the treatment for out-of-hospital severe respiratory distress patients, particularly in systems with long transport times.