Treating Trauma - @

Treating Trauma




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

Innovation & Advancement

This is the seventh year of the EMS 10 Innovators in EMS program, jointly sponsored by Physio-Control and JEMS.
More >

Multimedia Thumb

Wesleyan Students Hospitalized for Overdose

11 students transported to local hospitals.
Watch It >

Multimedia Thumb

Denver Medic's Family Says Job Stress Contributed to Suicide

Veteran of over 25 years took her own life after a call.
Watch It >

Multimedia Thumb

Denver First Responders Join to Remember Paramedic

Veteran medic took her own life after fatal accident.
Watch It >

Multimedia Thumb

Rigs Going in Service from EMS Today 2015

Snap shots of some of the vehicles at EMS Today that will be on the streets soon
More >

Multimedia Thumb

Florida Hospital Fire

Fire halts construction project at Tampa cancer center.
More >

Multimedia Thumb

LMA MAD Nasal™

Needle-free intranasal drug delivery.
Watch It >

Multimedia Thumb

Braun Ambulances' EZ Door Forward

Helps to create a safer ambulance module.
Watch It >

Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

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

Multimedia Thumb

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

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

More Product Videos >