Treating Trauma - @ JEMS.com


Treating Trauma

ALS vs. BLS

 

 
 
 

Keith Wesley, MD, FACEP | | Saturday, August 9, 2008


Review of:Stiell IG, Nesbitt LP, Pickett W, et al: "The OPALS Major Trauma Study: Impact of advanced life-support on survival and morbidity." Canadian Medical Association Journal. 178(9):1141-1152, 2008.

The Science

The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before-and-after, system-wide controlled clinical trial conducted in 17 cities. The researchers enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase (during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

Among the 2,867 patients enrolled in the BLS (n = 1,373) and ALS (n = 1,494) phases, characteristics were similar. This included mean age (44.8 v. 47.5 years), frequency of blunt injury (92.0% v. 91.4%), median injury severity score (24 v. 22) and percentage of patients with Glasgow Coma Scale (GCS) score less than 9 (27.2% v. 22.1%). Survival didn't differ overall (81.1% among patients in the ALS phase v. 81.8% among those in the BLS phase; p = 0.65).

However, among patients with GCS score less than 9, survival was lower among those in the ALS phase (50.9% v. 60.0%; p = 0.02).

The OPALS Major Trauma Study showed that system-wide implementation of full ALS programs didn't decrease mortality or morbidity for major trauma patients. They also found that during the ALS phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. The authors concluded, "We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma."

The Street

This study will add fuel to the fire that continues to rage across the U.S. Is ALS better than BLS? Before we go on, remember that a Canadian EMT has many times the training hours of the U.S. EMT-Basic. With that being said, the OPALS study spent $15.8 million dollars in training and operational upgrades to implement ALS for trauma. During the ALS phase of this study, only 102 intubations were performed on 1,492 patients. That's $154,000 per intubation. OK, that's not fair. They also established 779 IVs, ran fluids 144 times and gave morphine 35 times. Let's just call it 1,060 ALS interventions. That's more reasonable -- $14,905 per intervention.

But it didn't make any difference!

More importantly, when they noted the subset of patients who were intubated were those with GCS less than 9 because they didn't have RSI. Not surprising, they had poorer outcomes similar to what has been documented in other studies with traumatic head injury and prehospital intubation.

Now, before you start sending me death threats: Do I think there is a role for ALS in trauma? Absolutely. But is the answer to simply train everyone and send them forth, like they did in Canada, and then hope for the best. No. We must learn from our brave northern brethren and examine our systems closely. Further, we must make risk-benefit analysis the cornerstone of any implementation. Bigger isn't always better. In many if not most systems, pre-planning and a tincture of accelerator may save more lives than the ET tube or salt water.




Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Extrication and Rescue, Head and Spinal Injuries, Research

 
What's Your Take? Comment Now ...

Buyer's Guide Featured Companies

Featured Careers & Jobs in EMS

Get JEMS in Your Inbox

 

Fire EMS Blogs


Blogger Browser

Today's Featured Posts

 

EMS Airway Clinic

Improving Survival from Cardiac Arrest Using ACD-CPR + ITD

Using active compression-decompression CPR with an ITD has been shown to improve 1-year survival from cardiac arrest by 33%.
More >

Multimedia Thumb

Over Half of Seattle Fire Stations Test Positive for MRSA

Surprisingly high results come from test kits based on earlier study.
Watch It >


Multimedia Thumb

AMR Crew Rescues Mississippi Driver from Fiery Crash

Rescue during crash in Jackson is caught on video.
Watch It >


Multimedia Thumb

Tempe’s Drug Dilemma

Dealing with overdoses.
Watch It >


Multimedia Thumb

I’m a Paramedic

Profile of a Northshore LIJ medic.
Watch It >


Multimedia Thumb

Nightwatch Series Premiere Party

JEMS Editor-in-Chief A.J. Heightman attends the series premiere of A&E's new reality show, "Nightwatch."
More >


Multimedia Thumb

Ottawa Chemical Investigation

Chemicals and suspicious package are probed at two locations
More >


Multimedia Thumb

Cincinnati Overpass Collapse

Fatal pancake collapse occurs during demolition.
More >


Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

Sneak peek of customizable run forms & more.
Watch It >


Multimedia Thumb

LMA MAD Nasal™

Needle-free intranasal drug delivery.
Watch It >


Multimedia Thumb

The AmbuBus®, Bus Stretcher Conversion Kit - EMS Today 2013

AmbuBus®, Bus Stretcher all-hazards preparedness & response tool
Watch It >


Multimedia Thumb

VividTrac offered by Vivid Medical - EMS Today 2013

VividTrac, affordable high performance video intubation device.
Watch It >


More Product Videos >