Elsevier

Resuscitation

Volume 82, Issue 9, September 2011, Pages 1130-1137
Resuscitation

Mini-review
Advanced life support versus basic life support in the pre-hospital setting: A meta-analysis

https://doi.org/10.1016/j.resuscitation.2011.04.006Get rights and content

Abstract

Background

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.

Methods

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.

Results

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).

Conclusion

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.

Section snippets

Background

The impetus for the development of modern pre-hospital emergency medicine has come from a variety of concerns. Among the major forces has been the realization that traumatic injuries have often been neglected and that modern management of their care has been much better for wartime combatants than for civilians. Second, has been the recognition that cardiac arrest is capable of resuscitation, and need not be an automatic death sentence. Third has been the development of the specialty of

Materials & methods

The present review is based on a protocol which was peer reviewed by the Scientific Committee of the post-graduate program of Health Crisis Management of the University of Athens Medical School.

Study characteristics

Detailed results of the literature research are presented in Fig. 1. We initially identified 1081 potentially eligible citations by searching Medline (through PubMed, n = 276), EMBASE (n = 66), Cochrane Library (n = 376) and Scopus (n = 363). Two authors screened titles and abstracts for potential eligibility and 968 articles were excluded (689 articles were duplicated in the 4 different databases, 212 articles reported results of non comparative studies, 53 articles had other endpoints than survival

Discussion

In this systematic review, we have summarized the available evidence from controlled trials that compared ALS to BLS care in trauma and not trauma (cardiac arrest) patient survival to the pre-hospital setting. Information on the methodological quality was incomplete in a number of small-sized trials. In our study, trials that adequately reported methodological quality items were large trials, and dominate the pooled estimates of effect. Therefore, it is unlikely that pooled estimates are

Conclusions

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 regards trauma patients, our meta-analysis and review produced non-significant results. There is necessity for further research which should concentrate on the evaluation of trauma systems, taking into consideration, the type of the trauma, the trauma severity as well as the pre-hospital setting

Limitations

There are a number of limitations in the study. Only few controlled studies of sufficient quality and strength examining survival in trauma were published and the majority of the data produced from controlled before-and-after trials and other controlled trials, which were not truly randomized but the treatment allocations were made using other pseudo- or quasi-random processes. Differences in patient (both cardiac arrest and trauma) between ALS versus BLS populations may have confounded the

Conflict of interest statement

No conflicts of interest to declare.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.04.006.

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