The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

Abstract

Background:To date, the benefit of prehospital advanced life-support programs on trauma-related mortality and morbidity has not been established Methods:The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before-after systemwide controlled clinical trial conducted in 17 cities. We 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. Results:Among the 2867 patients enrolled in the basic lifesupport (n = 1373) and advanced life-support (n = 1494) phases, characteristics were similar, including 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 score less than 9 (27.2% v. 22.1%). Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65). Among patients with Glasgow Coma Scale score less than 9, survival was lower among those in the advanced life-support phase (50.9% v. 60.0%; p = 0.02). The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant (1.2, 95% confidence interval 0.9-1.7; p = 0.16). Interpretation:The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced lifesupport phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. 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.

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies

“…We did several sensitivity analyses (Appendixes 9 to 16 of the Supplement), none of which changed the direction or significance of our main findings. Our findings are consistent with other evidence for cardiac arrest (Appendix 17 of the Supplement) and trauma (4,5,7,(10)(11)(12)(13)(14)(15)(16)(17)(18). Little prior evidence, however, exists for patients with stroke, AMI, and respiratory failure.…”

“…Because these high-acuity conditions necessitate early optimization of care, one would have expected any advantage of ALS over BLS to manifest itself in these diagnoses. Although ALS may be expected to improve outcomes because of early treatment, the opposite may occur in practice if ALS is associated with delays in hospital management or iatrogenic injury (3,(5)(6)(7)31).…”

“…First, ALS may delay hospital care that would otherwise offer definitive clinical management (3,(5)(6)(7). Even when clinical guidelines recommend not delaying transport for prehospital interventions, delays may still result from the on-site provision of optional interventions that are intended to be done en route to the hospital (32).…”

“…Whereas ALS providers can use invasive interventions, such as endotracheal intubation for airway management and intravenous catheters for drug and fluid delivery, BLS providers use noninvasive interventions, such as bag valve masks for respiratory support. The ALS providers spend more time at the scene on average (3,(5)(6)(7) and receive higher reimbursement (8).…”

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis

“…Endotracheal intubation in prehospital settings has not been shown to reduce mortality and morbidity in patients with severe trauma; moreover, there are concerns that performing this difficult task under trying conditions might cause harm. [8][9][10][11] Endotracheal intubation by unskilled practitioners could result in adverse events and result in ineffective chest compressions with significant interruptions. 8 The value of prehospital intravenous fluid resuscitation has also been questioned.…”