A controlled trial of prehospital advanced life support in trauma

doi:10.1016/S0196-0644(88)80397-4

Annals of Emergency Medicine

Volume 17, Issue 6, June 1988, Pages 582-588

https://doi.org/10.1016/S0196-0644(88)80397-4 Get rights and content

We compared the outcome of 472 trauma patients who required ambulance attention and who received prehospital advanced life support (ALS) with another similar 589 patients who received only basic life support (BLS). Nontrapped, critically injured ALS patients were treated for an average of 13 minutes at the scene of injury, compared with 17 minutes for BLS cases (P < .05). Seventeen of 37 ALS deaths (36%) occurred within 24 hours of injury, compared with 24 of 33 BLS fatalities (73%) (P < .05). However, the overall case fatality rate was similar in the two groups, and regression analyses did not demonstrate an impact of ALS care on mortality. ALS resuscitation did not reduce the duration of hospital or intensive care unit stay, or the incidence of disability after head injury. However, the incidence of respiratory failure in the critically injured patients was 5% (ALS) and 19% (BLS) (P < .025). ALS care appeared to influence patient outcome during the first 24 hours after injury, but had little impact on the later clinical course. Our sample size was too small to rule out any effect of ALS on in-hospital mortality. However, the improved 24-hour survival associated with ALS care suggests some benefit of prehospital resuscitation in major trauma.

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Cited by (73)

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Citation Excerpt :
The 113 articles which remained after the abstract selection were reviewed extensively and 96 articles were excluded (74 articles were not included comparison between ALS and BLS in the pre-hospital setting, 21 articles reporting non controlled trials and 4 articles were duplicated in the 4 different databases). After evaluating these citations and references therein we included 18 trials.21–38 The quality assessment of these studies, based on the recommendations of The Cochrane Collaboration, revealed that inadequate sequence generation provided the largest risk of bias followed by inadequate allocation concealment (Table 1).13
The scientific evidence of a beneficial effect of ALS in pre-hospital treatment in trauma patients or patients with any acute illness is scarce. The objective of this systematic review of controlled studies was to examine whether ALS, as opposed to BLS, increases patient survival in pre-hospital treatment and if so, to identify the patient groups that gain benefit.
A systematic review of studies published in the databases Medline (PubMed), EMBASE, Cochrane Library and Scopus up to July 31st, 2010. Controlled studies comparing survival after the pre-hospital ALS treatment versus BLS treatment in trauma patients or patients with cardiac arrest were included.
We identified 1081 studies of which 18 met our inclusion criteria. In nine of 18 studies including 16,857 trauma patients in the intervention group, ALS care did not increase survival compared to BLS treatment (pooled OR 0.892, 95% CI, 0.775–1.026). In nine of 18 studies including 7659 patients with cardiac arrest in the intervention group, ALS care increased survival compared to BLS treatment (OR 1.468, 95% CI, 1.257–1.715). Most subgroup analyses revealed no significant interactions, but data from six trials, where ALS was provided by physicians, increases the probability of survival at hospital discharge even more (OR 2.047, 95% CI 1.593–2.631).
Implementation of ALS care to non-traumatic cardiac arrest patients can increase survival and further research is unlikely to change our confidence in the estimate of the effect. On the contrary, in trauma patients our meta-analysis revealed that ALS care is not associated with increased survival. However, only few controlled studies of sufficient quality and strength examining survival with pre-hospital ALS treatment exist.
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Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene.
A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room.
Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route.
EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.
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Evidence from urban trauma centers questions the efficacy of pediatric field endotracheal intubations (ETIs). It is recognized that in the rural environment, discovery, transport delays, and a paucity of pediatric expertise contribute to higher pediatric trauma mortality rates compared with urban environments. The purpose of our study was to determine the effectiveness of field ETI in rural pediatric trauma patients.
ETI attempts (field, referring hospital, trauma center [TC]) in trauma patients less than 19 years old were included. Prehospital and TC charts, including demographics, injury mechanism, indication, location, person performing, number of attempts, Glascow Coma Scale (GCS), complications from ETI, and outcome, were assessed.
Between 1991 and 2000, 105 of 2,907 patients met study criteria. Paramedics, trauma flight nurses (field ETIs), emergency physicians, surgeons, and anesthesiologists performed the ETI. One hundred fiftyfive ETIs (1 to 6 per patient) were attempted in 105 children. Fifty-seven percent of the ETIs were attempted in the field, 22% in transferring hospital, and 21% at the TC. Successful intubation on first attempt was 67% (field), 69% (referring hospital), and 95% (TC). Subsequent ETI attempts had failure rates of 50% (field) and 0% (referring hospital, TC). Indication for ETI included fear of losing airway control (37%), closed head injury (36.1%), respiratory rate less than 10 or greater than 40 (11.2%), cardiopulmonary arrest (6.5%), respiratory arrest (4.6%), and airway obstruction 4.6%. Only 9.3% of children could not be oxygenated or ventilated by bag valve mask (BVM) before ETI. Twenty-three percent had complications directly related to ETI (eg, aspiration). The relative risk of an airway complication was 2.5× higher with more then one ETI attempt (P < .05). Four percent of the airway complications occurred in TC, 29% (transferring hospital) and 66% (field, P < .05), respectively. Airway complications and multiple ETIs were associated with transport delay, lower GCS, longer hospital stay, and lower discharge GCS (P < .001) but independent of injury severity score, sex, age, and survival (P > .05).
Multiple ETI attempts are associated with significant complications and may offer limited advantage over BVM and possibly may affect outcome. Indications for field intubations may require review especially in rural pediatric trauma.
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: This study was assisted by a Health Services Research and Development Grant awarded by the Australian Institute of Health.

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Original contributionA controlled trial of prehospital advanced life support in trauma

Lancet

Road Traffic Crashes in New South Wales

IS ALS necessary for prehospital trauma care?

J Trauma

An analysis of pre-hospital care of blunt trauma

J Trauma

Role of the intensive care ambulance in the transport of accident victims

Aust NZ J Surg

Prehospital advanced life support: Benefits in trauma

J Trauma

Pre-hospital stabilization of critically injured patients: A failed concept

J Trauma

Original contribution
A controlled trial of prehospital advanced life support in trauma