Effectiveness of ambulance paramedics versus ambulance technicians in managing out of hospital cardiac arrest

Is advanced life support better than basic life support in prehospital care? A systematic review

BACKGROUND

Prehospital care is classified into ALS- (advanced life support) and BLS- (basic life support) levels according to the methods used. ALS-level prehospital care uses invasive methods, such as intravenous fluids, medications and intubation. However, the effectiveness of ALS care compared to BLS has been questionable.

AIM

The aim of this systematic review is to compare the effectiveness of ALS- and BLS-level prehospital care.

MATERIAL AND METHODS

In a systematic review, articles where ALS-level prehospital care was compared to BLS-level or any other treatment were included. The outcome variables were mortality or patient's health-related quality of life or patient's capacity to perform daily activities.

RESULTS

We identified 46 articles, mostly retrospective observational studies. The results on the effectiveness of ALS in unselected patient cohorts are contradictory. In cardiac arrest, early cardiopulmonary resuscitation and defibrillation are essential for survival, but prehospital ALS interventions have not improved survival. Prehospital thrombolytic treatment reduces mortality in patients having a myocardial infarction. The majority of research into trauma favours BLS in the case of penetrating trauma and also in cases of short distance to a hospital. In patients with severe head injuries, ALS provided by paramedics and intubation without anaesthesia can even be harmful. If the prehospital care is provided by an experienced physician and by a HEMS organisation (Helicopter Emergency Medical Service), ALS interventions may be beneficial for patients with multiple injuries and severe brain injuries. However, the results are contradictory.

CONCLUSIONS

ALS seems to improve survival in patients with myocardial infarction and BLS seems to be the proper level of care for patients with penetrating injuries. Some studies indicate a beneficial effect of ALS among patients with blunt head injuries or multiple injuries. There is also some evidence in favour of ALS among patients with epileptic seizures as well as those with a respiratory distress.

Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service

BACKGROUND

Prehospital research has found little evidence in support of advanced cardiac life support (ACLS) for out-of-hospital cardiac arrest. However, these studies generally examine city-based emergency medical services (EMS) systems. The training and experience of ACLS-skilled paramedics differs internationally, and this may also contribute to negative findings. Additionally, the frequency of negative outcome in out-of-hospital cardiac arrest suggests that it is difficult to establish sufficient numbers to detect an effect.

PURPOSE

To examine the effect of ACLS on cardiac arrest in Queensland, Australia. Queensland has a population of 3.8 million and an area of over 1.7 million km2, and is served by a statewide EMS system, which deploys resources using a two-tier model. Advanced treatments such as intubation and cardioactive drug administration are provided by extensively trained intensive care paramedics.

METHODS

An observational, retrospective design was used to examine all cases of cardiac arrest attended by the Queensland Ambulance Service from January 2000 to December 2002. Logistic regression was used to examine the effect of the presence of an intensive care paramedic on survival to hospital discharge, adjusting for age, sex, initial rhythm, the presence of a witness and bystander cardiopulmonary resuscitation.

RESULTS

The presence of an intensive care paramedic had a significant effect on survival (OR = 1.43, 95% CI = 1.02 to 1.99).

CONCLUSIONS

Highly trained ACLS-skilled paramedics provide added survival benefit in EMS systems not optimised for early defibrillation. The reasons for this benefit are multifactorial, but may be the result of greater skill level and more informed use of the full range of prehospital interventions.

Admissions to intensive care units from emergency departments: a descriptive study

OBJECTIVES

To describe the case mix, activity, and outcome for admissions to intensive care units (ICUs) from emergency departments (EDs).

DESIGN

An observational study using data from a high quality clinical database, the Case Mix Programme Database, of intensive care admissions, coordinated at the Intensive Care National Audit & Research Centre (ICNARC).

SETTING

91 adult ICUs in England, Wales, and Northern Ireland, 1996-99.

SUBJECTS

46,587 intensive care admissions.

MAIN OUTCOME MEASURES

Ultimate hospital mortality.

RESULTS

Admissions from EDs constituted 26% of total admissions to ICU, 77% of which were direct admissions to ICU from EDs. Direct admissions from EDs, indirect admissions from EDs, and non-ED admissions presented to ICU with different conditions and severity of illness. Indirect admissions from EDs presented in the ICU with the more severe case mix (older age, more acute severity of illness, more likely to have a chronic illness) compared with direct admissions to ICU from EDs. Compared with ICU admissions not originating in EDs, unit and hospital mortality were higher for admissions from EDs, with indirect admissions experiencing the highest hospital (46.4%) mortality. For ICU survivors, indirect admissions stayed longest in the ICU.

CONCLUSIONS

A large proportion of admissions to ICU (26%) originate in EDs, and differ from those not originating in EDs in terms of both case mix and outcome. Additionally, those admitted directly to ICU from EDs differ from those admitted indirectly via a ward. The observed differences in outcome between different admission routes require further investigation and explanation.

Nurse competence: advantageous in pre-hospital emergency care?

Aspects of the organization and function of pre-hospital emergency care services in western Sweden were assessed by interviewing physicians (n = 20) with administrative (n = 10) or/and active (n = 10) roles in the pre-hospital emergency care field. The data obtained indicate that although the present standard of care is acceptable, there is an obvious need for a more effective organization and the personnel involved should have a higher competence level. Ambulance personnel were not considered to have a high enough competence level. Therefore, a need for more nurses, preferably anaesthesia or intensive care nurses, was expressed. An awareness of the importance of research was noted among the physicians responsible for the services, and the research capability of nurses, along with their general competence in emergency medical service related problems, was considered an important argument for involving more nurses in pre-hospital emergency care. It was thought that by such an approach, a more scientific basis for assessing the efficacy of pre-hospital emergency care could be achieved.

'Out-of-hospital cardiac arrests' treated by the West Midlands Ambulance Service over a 2-year period

We aimed to determine whether our results were any better or worse than other published reports and to examine the efficacy of the West Midlands Ambulance Service (WMAS) policy of applying cardiopulmonary resuscitation (CPR) and manual ventilation to all unwitnessed cardiac arrests in preference to immediate defibrillation. All cardiac arrests were studied from October 1994 to September 1996. In all unwitnessed arrests, crews undertook CPR and manually ventilated the lungs via a mask or an endotracheal tube with a bag and valve or a mechanical resuscitator using an FIO2 of 1 or 0.21 for at least 2 min before defibrillation was attempted. There were 3403 diagnosed cardiac arrests but, in these, the diagnosis was not certain. CPR and advanced life support (ALS) were applied in 3380 patients and return of spontaneous circulation (ROSC) was obtained in 554, giving a success rate of 16.4%. A total of 364 patients were accepted into hospital, 90 patients died in A&E but 274 patients were admitted to ICU/CCU. Seventy died within 24 h, 69 died after 24 h and 135 were discharged alive and well without cerebral damage. The final success to discharge rate was 49.27%. Of those discharged, 69 had a circulatory arrest period of more than 4 min but in only 10 was a bystander available to start CPR. The European Resuscitation Council Guidelines recommending immediate defibrillation for unwitnessed arrests are not supported by these results. The apparent lack of cerebral damage and the percentage success suggests that resuscitation considerations should be as brain orientated as they are heart orientated. The elapsed time periods reported challenge several shibboleths.