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Table 1 Studies of advanced life support systems and interventions

From: Pro/con debate: Is the scoop and run approach the best approach to trauma services organization?

Study Study design, environment, provider and population Intervention Major findings Major limitations
In support of ALS systems
Roudsari and colleagues [14] Multicenter, multinational, ecological study Countries with physician-provided ALS compared with countries with paramedic-provided ALS Lower early (24 hour) mortality with physician-provided ALS Heterogeneity in the types of prehospital and inhospital care across countries with apparent similar prehospital models of care precludes attributing improved outcomes to physician-provided ALS alone
  Physician and paramedic providers   Lower mortality to hospital discharge among those with ISS >25  
  Adult, major trauma    
Klemen and Grmec [16] Single-center, retrospective cohort study ALS with ETI by physicians compared with BLS by paramedics No difference in overall survival Possible measurement bias in recording GCS
  Urban/physician and paramedic providers   Improved early (1 hour, 24 hour) survival and functional outcomes with physician providers Crossover between groups
  Adult, moderate to severe head injury with ISS >15   Lower mortality among patients with GCS of 6 to 8 with physician providers  
Messick and colleagues [13] Multicenter, ecological study Counties with ALS programs compared with counties with BLS programs ALS program availability an independent predictor of lower per-capita county trauma death rates Significant residual confounding as BLS counties were significantly more rural
  Urban and rural/paramedic providers    
  Adult and pediatric, major trauma    
Honigman and colleagues [9] Single center, case series ALS (ETI, intravenous, PASG) Scene time did not adversely affect outcome No direct comparison of BLS with ALS
  Urban/paramedic providers   Scene time independent of field procedures performed and mortality Not generalizable to greater spectrum of trauma patients
  Adult, penetrating cardiac injuries    
Jacobs and colleagues [10] Single-center, prospective cohort study ALS-trained paramedics (ETI, intravenous, PASG) compared with BLS-trained paramedics Improvement in trauma score in prehospital setting with ALS ALS care assignment nonrandom
  Urban/paramedic providers   ALS not an independent predictor of survival  
  Adult and pediatric, major trauma    
Aprahamian and colleagues [11] Single center, before/after design New ALS program (ETI, intravenous, thoracentesis, pericardiocentesis) compared with police-provided ambulance service Lower mortality among patients with prehospital systolic blood pressure<60 mmHg Historical controls fail to take into consideration other changes in care
  Urban/paramedic providers    
  Adult, penetrating injuries    
Fortner and colleagues [12] Two centers, before/after design ALS program (ETI, intravenous) compared with BLS program Greater proportion of patients surviving to reach hospital and surviving to hospital discharge Historical controls
  Urban/paramedic providers    Specific interventions were not documented
  Adult, falls from significant height    
In support of ALS interventions
Bulger and colleagues [24] Single-center, retrospective cohort study Prehospital ETI with RSI compared with prehospital ETI without RSI Lower mortality with prehospital RSI Nonrandom selection
  Urban/paramedic and nurse providers   Lower mortality with prehospital RSI among patients with GCS <9 Possible confounding by indication; patients not receiving RSI probably agonal
  Adult, moderate to severe head injury   Improved functional outcomes with prehospital RSI among patients with GCS <9  
Bushby and colleagues [15] Single-center, retrospective, TRISS analysis Intubation, needle chest decompression Prehospital intubation, chest decompression associated with better than expected outcomes Historic controls (TRISS methodology)
  Urban and rural/paramedic providers    Long prehospital times among large proportion of patients limit generalizability
  Adult, blunt injuries causing moderate to severe thoracic injuries    
Arbabi and colleagues [17] Two centers, retrospective cohort study Prehospital ETI compared with emergency department ETI and nonintubated patients Higher mortality with emergency department ETI compared with prehospital ETI Nonrandom selection and potential for residual confounding
  Urban/paramedic providers   No difference in survival with prehospital ETI compared with no intubation  
  Adult, major trauma    
Winchell and Hoyt [18] Multicenter, retrospective cohort study Prehospital ETI compared with nonintubated patients Lower mortality among intubated patients Nonrandom selection
  Urban and rural/paramedics   Lower mortality among intubated patients with severe head injuries Residual confounding (no adjustment for age, ISS, shock)
  Adult, blunt injuries, GCS <9    
In support of BLS systems
Stiell and colleagues [32] Multicenter, before/after design New ALS program (ETI, intravenous, administration of medication) compared with BLS program No difference in survival Study conducted early after implementation of ALS – may not reflect mature prehospital system
  Urban/paramedic providers   Higher mortality among patients with GCS <9 after implementation of ALS program Relatively few patients received ALS interventions after implementation of ALS program
  Adult, major trauma    
Liberman and colleagues [31] Multicenter, retrospective cohort study ALS care (physician or paramedic provided) compared with BLS care (paramedic provided) Higher mortality with onscene treatment by physicians Nonrandom assignment of ALS care, likely confounding by indication
  Urban/physician and paramedic providers   Higher mortality with prehospital ALS  
  Adult, major trauma    
Di Bartolomeo and colleagues [29] Multicenter, prospective cohort study Prehospital ALS by physician (air transport) compared with BLS by paramedics (ground transport) No difference in mortality with prehospital ALS provided by physicians Prolonged transport times with frequent interfacility transfers limit generalizability
  Urban and rural/physician and paramedic providers    
  Adult and pediatric, severe head injury    
Eckstein and colleagues [20] Single-center, retrospective cohort study Prehospital ETI compared with prehospital BVM and emergency department ETI Higher mortality with prehospital ETI Nonrandomized with possible confounding by indication
  Urban/paramedic providers Prehospital intravenous fluids compared with no prehospital intravenous fluids   
  Adult and pediatric, major trauma    
Cayten and colleagues [27] Multicenter, retrospective, TRISS analysis ALS units (ETI, intravenous fluids, PASG) compared with BLS units Improved prehospital RTS with ALS Biased exclusion of patients due to missing data
  Urban/paramedic providers   No improvement in predicted mortality with ALS Variable expertise among providers
  Patients aged >12 years, major trauma   Higher than predicted mortality for patients with penetrating injuries receiving ALS care Historic controls (TRISS methodology)
Sampalis and colleagues [30] Multicenter, retrospective cohort study ALS care (physician provided) compared with BLS care (physician or paramedic provided) No difference in mortality Nonrandom assignment of ALS care, likely confounding by indication
  Urban/physician and paramedic providers    
  Adult and pediatric, major trauma    
Potter and colleagues [25] Multicenter, prospective cohort study ALS prehospital care compared with BLS prehospital care Lower rate of early deaths (24 hours) with prehospital ALS, yet no improvement in survival to hospital discharge Nonrandom assignment of ALS, likely confounding by indication
  Urban/paramedic providers    Ad hoc presence of physicians with BLS crew renders attribution of outcomes to ALS versus BLS crew difficult
  Adult, major trauma and burns    
Ivatury and colleagues [34] Single-center, retrospective cohort study Field stabilization (ETI, intravenous, PASG, drug administration) compared with direct transport Lower survival among patients with field stabilization attempts Wide range of ALS procedures, some with low success rates
  Urban/paramedic providers    Confounding by indication likely
  Patients with penetrating thoracic injuries, in extremis, requiring emergency department thoracotomy    
In support of BLS interventions
Davis and colleagues [19] Multicenter, retrospective cohort study Prehospital ETI compared with emergency department ETI Higher mortality with prehospital ETI Nonrandomized with possible confounding by indication
  Urban/paramedic providers   Higher mortality with prehospital ETI among patients with severe head injuries  
  Adult, moderate to severe head injury    
DiRusso and colleagues [39] Multicenter, retrospective cohort study Prehospital ETI compared with emergency department ETI and nonintubated patients Higher mortality with prehospital ETI No information about provider type
  Urban and rural/paramedic providers   Worse functional outcomes at discharge with prehospital ETI Nonrandomized with possible confounding by indication
  Pediatric, major trauma    
Stockinger and McSwain [21] Single-center, retrospective cohort study Prehospital ETI compared with prehospital BVM Higher mortality with ETI compared with BVM Nonrandomized with possible confounding by indication
  Urban/paramedic providers   Higher than predicted mortality with ETI among patients with penetrating injuries using the TRISS methodology  
  Adult, major trauma, receiving prehospital ETI or BVM   Mortality as predicted among patients with blunt injuries receiving ETI  
Wang and colleagues [37] Multicenter, retrospective cohort study Prehospital ETI compared with emergency department ETI Higher mortality with prehospital ETI Nonrandomized with possible confounding by indication
  Urban and rural/paramedic providers    
  Adult, moderate to severe head injury    
Davis and colleagues [42] Multicenter, retrospective matched cohort study Prehospital ETI attempted with RSI compared with matched nonintubated historical controls Higher mortality with prehospital RSI Nonrandomized with possible confounding by indication
  Urban/paramedic providers   Higher mortality related to hypocapnea on arrival  
  Adult, moderate to severe head injury    
Murray and colleagues [38] Multicenter, retrospective cohort study Prehospital ETI compared with attempted ETI or nonintubated patients Higher mortality with prehospital ETI compared with nonintubated patients Nonrandomized with possible confounding by indication
  Urban/paramedic providers   Higher mortality with prehospital ETI compared with attempted ETI  
  Adult and pediatric, severe head injury    
Sloane and colleagues [36] Single-center, retrospective cohort study Prehospital ETI compared with emergency department ETI No difference in mortality in subgroup analysis of patients with isolated head injuries Small sample size with potential for type II error
  Urban/aeromedical crews, physician, paramedic or nurse provider   Overall mortality effect not reported  
  Adult, major trauma    
Bickell and colleagues [33] Single-center, prospective, unblinded quasirandomized study (alternate-day assignment) Prehospital fluid resuscitation compared with delayed fluid resuscitation (once hemorrhage controlled) Lower mortality with delayed resuscitation Not generalizable to wider spectrum of trauma patients
  Urban/paramedic providers   Shorter length of stay with delayed resuscitation  
  Adult, penetrating torso injuries causing hypotension and operative intervention    
  1. ALS, advanced life support; BLS, basic life support; BVM, bag–valve–mask ventilation; ETI, endotracheal intubation; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; PASG, pneumatic anti-shock garment; RSI, rapid sequence intubation; TRISS, Trauma Related Injury Severity Score.