Prehospital Advanced Life Support for Major Trauma: Critical Need for Clinical Trials,☆☆,

https://doi.org/10.1016/S0196-0644(98)70178-7Get rights and content

Abstract

We compared and contrasted the literature that currently exists on this topic. We examined methodologies, results, and conclusions for each article. We also stress the need for critical clinical evaluations in this arena. [Spaite DW, Criss EA, Valenzuela TD, Meislin HW: Prehospital Advanced Life Support for major trauma: Critical need for clinical trials. Ann Emerg Med October 1998;32:480-489.]

Section snippets

INTRODUCTION

Since the inception of prehospital care there has been an ongoing debate over the use of Advanced Life Support (ALS) measures in the out-of-hospital management of trauma victims. The debate centers around the assumption that the benefit of the various procedures available to the ALS provider (ie, intravenous access and intubation) must be weighed against the delay to definitive care that would result from a prolonged on-scene interval (OSI). There is no doubt that trauma system development has

THE ARGUMENT AGAINST ON-SCENE ALS IN TRAUMA CARE

Most authors who oppose the use of ALS for trauma care at the scene use the rationale that it wastes precious time that could be used in rapidly moving the patient to “definitive care.” A review of these publications reveals many of them are little more than editorials based on indirect data, theoretical arguments, and literature reviews from other editorials (Table 1).

. Comparison of articles arguing against ALS for prehospital care of trauma patients.

AuthorProspectiveControlsRandomizedEmpty Cell

THE ARGUMENT FOR PREHOSPITAL ALS IN TRAUMA CARE

Some experts believe that a significant number of trauma patients deteriorate or die en route to the hospital from physiologic abnormalities that could potentially be improved by prehospital ALS. They believe that, by adding prehospital ALS, the victims have an improved likelihood of prehospital survival so that they have a chance to benefit from “definitive care.” Numerous investigations seem to support this concept (Table 2).

. Comparison of articles arguing for ALS for prehospital care of

TIME INTERVAL FROM INJURY TO DEFINITIVE CARE

There is no objective proof that the primary determinant of outcome for the trauma patient is the time interval from injury to the operating room. The “studies” that support this relationship are flawed and nearly all are retrospective.

A series of studies by Bickell et al20, 21, 22 randomly assigned trauma patients into groups that would, or would not, receive the pneumatic antishock garment. Numerous aspects of the data were analyzed including time intervals. No association was found between

THE IMPACT OF ON-SCENE INTERVAL ON TRAUMA OUTCOME

Clearly, no association between the total prehospital interval and outcome has been established. Thus it is puzzling that there has been such a tremendous “brouhaha” in the literature regarding the “impact” of the OSI…since it is merely a portion of the total prehospital interval. This is especially surprising since OSI represents only a small percentage of time elapsed from injury to the operating room. The actual time sequence that exists for the trauma patient includes 911 notification,

THE EFFECT OF ALS ON PREHOSPITAL TIME INTERVALS

One of the most consistent historical arguments against the use of on-scene ALS care (especially establishing intravenous access) has been the belief that on-scene intravenous access attempts “take a long time” and will, necessarily, cause a significant delay in evacuation to definitive care. A classic example of this was revealed in a study by Smith et al.26 They retrospectively reviewed 52 consecutive trauma patients with blood pressures less than 100 mm Hg at the scene or on arrival at the

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    From the Arizona Emergency Medicine Research Center, Health Services Research Program, Section of Emergency Medicine, Department of Surgery, University of Arizona, Tucson, AZ.

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    Reprint no. 47/1/93131

    Reprints not available from the authors.

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