Literature Review: Advanced Life Support for Major Trauma Patients

     Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS major trauma study: Impact of advanced life support on survival and morbidity. CMAJ 178(9):1,141–52, Apr 22, 2008.

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 controlled systemwide before/after clinical trial conducted in 17 cities. [Authors] enrolled adult patients who had experienced major trauma in a basic life support phase and subsequent advanced life support phase, during which paramedics could perform endotracheal intubation and administer fluids and drugs intravenously. The primary outcome was survival to hospital discharge.

     Results—Among the 2,867 patients enrolled in the basic life support (n=1,373) and advanced life support (n=1,494) phases, characteristics were similar, including mean age, frequency of blunt injury, median injury severity score and percentage with Glasgow Coma Scale scores less than 9. Survival did not differ overall (81% among patients in the ALS phase vs. 82% among those in the BLS phase). Among patients with GCS scores less than 9, survival was lower among those in the advanced life support phase (51% vs. 60%).

     Interpretation—The OPALS study showed that systemwide implementation of full advanced life support programs did not decrease mortality or morbidity for major trauma patients. [Authors] also found that during the advanced life support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. [They] believe that emergency medical services should carefully reevaluate the indications for and application of prehospital advanced life support measures for patients who have experienced major trauma.

Comment
     The OPALS group of studies represents the largest multicenter prehospital clinical trial ever done. Throughout the Canadian province of Ontario, researchers compared the outcomes of patients for three years in BLS systems and then for three years after introducing paramedics in ALS systems. Previous reports found that patients with respiratory distress or chest pain had better outcomes if treated by paramedics. This study looked at whether endotracheal intubation and intravenous drugs and fluids increased the likelihood that patients survived and if survivors had less disability.

     The authors conclude that, in an optimized BLS system with hospitals prepared to adequately treat trauma patients, adding these ALS procedures did not improve patient outcomes. Despite better short-term appearances—twice as many ALS patients were judged to have improved en route—long-term outcomes were unchanged. For patients with more severe brain injuries, intubation was actually associated with a nearly threefold increase in mortality.

     The practice of medicine evolves as we gain knowledge, and sometimes that means our procedures may not ultimately help our patients. In hospital surgical care we have learned that repairing amputated fingertips is no better and often worse than letting the finger heal itself. More recently we have learned that many ruptured spleens and livers don't need to be removed or repaired, and with close observation these patients will never need an operation. Despite short-term improvements (a repaired fingertip looks better than a bloody stump; once a spleen is removed, the bleeding stops), patients are better off in the long term without these procedures.

     There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility.

     EMS systems should carefully examine their treatment and transportation protocols for critical trauma patients and consider BLS measures with BVM ventilation and rapid transport to be the cornerstone of care.

Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies, and chair of the California Commission on EMS.