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Journal of Trauma-Injury Infection & Critical Care:
Article Titles

Effect of Prehospital Advanced Life Support on Outcomes of Major Trauma Patients

Eckstein, Marc MD; Chan, Linda PhD; Schneir, Aaron BS; Palmer, Roger BS

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Abstract

Objective: Determine whether prehospital advanced life support (ALS) improves the survival of major trauma patients and whether it is associated with longer on-scene times.

Methods: A 36-month retrospective study of all major trauma patients who received either prehospital bag-valve-mask (BVM) or endotracheal intubation (ETI) and were transported by paramedics to our Level I trauma center. Logistic regression analysis determined the association of prehospital ALS with patient survival.

Results: Of 9,451 major trauma patients, 496 (5.3%) had either BVM or ETI. Eighty-one percent received BVM, with a mean Injury Severity Score of 29 and a mortality rate of 67%; 93 patients (19%) underwent successful ETI, with a mean Injury Severity Score of 35 and a mortality rate of 93%. Adjusted survival for patients who had BVM was 5.3 times more likely than for patients who had ETI (95% confidence interval, 2.3–14.2, p = 0.00). Survival among patients who received intravenous fluids was 3.9 times more likely than those who did not (p = not significant). Average on-scene times for patients who had ETI or intravenous fluids were not significantly longer than those who had BVM or no intravenous fluids.

Conclusion: ALS procedures can be performed by paramedics on major trauma patients without prolonging on-scene time, but they do not seem to improve survival.

The role of prehospital Advanced Life Support (ALS) for major trauma patients remains a highly controversial issue. Although several studies have concluded that prehospital intravenous fluid (IVF) administration provides no benefit in an urban system 1–4 and may even be harmful, 5,6 the effect of prehospital airway intervention is less clear.

Paramedics are capable of assisting respirations through bag-valve-mask ventilation (BVM), endotracheal intubation (ETI), or with other airway adjuncts such as an esophageal obturator airway or an esophageal tracheal combination tube, with high degrees of success and few complications. 7–9 Each of these modalities offer different benefits, but all are measured against ETI as the “gold standard.” One of the concerns of prehospital ETI for trauma patients is the additional time that may be required to perform this procedure, which may delay definitive surgical care. 10 Prehospital ETI poses several challenges that may not exist in the more controlled setting of an emergency department or an operating room, including inadequate suction, combative patients, poor lighting, a hostile environment, inability to use induction agents, and often a lack of tools to confirm correct tube placement. In addition, concern over potential cervical injury often necessitates additional personnel to assist with ETI or warrants the use of medications to facilitate the procedure.

There is a paucity of literature that has examined the role of ETI on major trauma patients. 11–13 The purpose of this study was to determine the impact of prehospital ETI versus BVM on the outcomes of major trauma patients. In addition, the effect of other ALS procedures on patient survival and paramedic on-scene times was examined.

© 2000 Lippincott Williams & Wilkins, Inc.

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