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RESEARCH showing out-of-hospital cardiac arrest patients in the US treated with basic life support have better survival rates and neurological outcomes than patients treated with advanced life support has divided Australian experts.
An observational cohort study, published in JAMA Internal Medicine, considered survival to hospital discharge and to 90 days of 31 292 patients attended by an advanced life support (ALS) ambulance for out-of-hospital cardiac arrest, and 1643 attended by a basic life support (BLS) ambulance. (1)
The researchers found that survival to hospital discharge was greater in those receiving BLS (13.1% v 9.2% for ALS), as was survival to 90 days (8.0% v 5.4% for ALS). BLS was also associated with better neurological functioning among hospitalised patients.
They described BLS as including rapid transport and basic interventions such as effective chest compressions, bag valve mask ventilation and automated external defibrillation. ALS providers were described as paramedics trained to use sophisticated, invasive interventions to treat cardiac arrest, including endotracheal intubation, intravenous fluid and drug delivery, and semiautomatic defibrillation.
While the researchers noted several limitations — including the likelihood that ALS would be provided for higher-risk patients — they concluded that their results called into question the “widespread assumption” that ALS resulted in better patient outcomes than BLS.
Associate Professor Paul Middleton, clinical associate professor of emergency medicine at the University of Sydney, told MJA InSight the findings were “massively applicable” in Australia.
“They have shown such a marked difference in outcomes that I think it’s absolutely applicable here and it really does reinforce a lot of the prior research that has been done”, said Professor Middleton, who also heads the newly formed organisation Take Heart Australia, which aims to boost cardiac arrest survival by strategies including community engagement.
“What we are talking about here is basic life support, which [includes] very simple interventions centring on high-quality continuous chest compressions, started immediately and with minimal interruptions, as well as early defibrillation”, he said.
These interventions had been accepted for a long time as being the most important aspects of cardiac arrest treatment, and previous evidence suggested ALS interventions had no benefit, Professor Middleton said. (2)
However, Professor Vivienne Tippett, head of discipline for paramedicine at the Queensland University of Technology, said the study, while robust, should be interpreted with caution.
She told MJA InSight that in Australia the basic educational requirement for most paramedics was a bachelor’s degree, with intensive care paramedics requiring at least 2 years’ practice and postgraduate qualifications. In contrast, training requirements for US paramedics were variable and often delivered by college or vocational education programs that were much shorter than Australian programs.
“We might be comparing apples with oranges if we blindly absorb these sorts of studies from some overseas countries without paying careful attention as to whether or not the educational standards and the practice arrangements are the same”, Professor Tippett told MJA InSight.
However, Professor Middleton disagreed. “There is undoubtedly more education that goes into paramedic training on a higher level than there used to be, however, that doesn’t alter the fact that paramedics are trained to the same protocols”, he said, adding that he was not criticising paramedics.
“They do great work in 99% of the job they do. NSW ambulance receives 1.1 million triple zero calls per year and … there are probably about 5000 cardiac arrests a year. You can see this is [a small percentage] of a paramedic’s job [and] one I believe they don’t do well.”
Professor Middleton said this was not paramedics’ fault, as training in ALS interventions had been prioritised worldwide when consistent training in BLS would probably lead to better outcomes.
An accompanying commentary in JAMA Internal Medicine backed the call for further evaluation of ALS versus BLS, saying most ALS interventions “are ‘advanced’ chiefly in our expectations, not in evidence-based efficacy”. (3)
Professor Middleton agreed on the need to go “back to basics”, saying this was the aim of Take Heart Australia, which wants to increase recognition of cardiac arrest and promote cardiopulmonary resuscitation training in the community, and agitate for the widespread distribution of easily accessible defibrillators.
Professor Tippett said the major challenge with cardiac arrest was lifting the low survival rates.
“What we do know with some confidence is that early compression at the appropriate rate and depth is one of the strongest predictors of survival”, Professor Tippett said, noting that this was promoted in the Australian Resuscitation Guidelines.
1. JAMA Intern Med 2014; Online 24 November
2. N Engl J Med 2004; 351: 647-656
3. JAMA Intern Med 2014; Online 24 November
(Photo: Lisa S / Shutterstock)
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Tricky, and may i deed be comparing apples with oranges.
As medicos, we tend to get excited about drugs, about procedures such as intubation and cool technologies such as prehospital ECMO
But of course all this is moot if no effective BLS. This is why I think apps such as the free GoodSAM app (or the paid subscription based PulsePoint) are useful – crowdsourcing BLS from nearby trained providers to deliver compressions before the ambos arrive. Then defib, LMA, ongoing compressions (mechCPR anyone), perhaps adrenaline (not convinced) and transport to hospital
Check out the free GoodSAM app http://goodsamapp.org avail in Oz
This study is about the intervention, not who delivers it. Effective CPR and early defibrillation improve patient orientated outcomes in cardiac arrest. This has not been demonstrated for intubation or drugs in clinical trials. While the findings are not necessarily surprising, it is important not to over-interpret this observational study. Only well designed randomised trials such as the PARAMEDIC 2 trial of adrenalin in out of hosital cardiac arrest in the UK will resolve these questions. As the professionals who manage the vast majority of OHCA, paramedics are playing a major role in this work. In the meantime the Take Heart Australia campaign is correct in its priorities.
BLS is a must and get the patient to hospital ASAP. Pharmacotherapy and intubation are best performed in emergency, as evidenced by results and my albeit irregular teaching of keen paramedics.
A full hospital team beats two paramedics in difficult conditions every time and it is well known that effective chest compression is the gold standard. It also makes the paramedic’s job more effective and saves many hours per year when other sick patients can be attended.
I agree with this finding. I previously assisted an OHCS case where the paramedic tried for an hour and still failed to intubate the patient. The hospital was only 10 mins away and a bag-and-mask with cricoid pressure would have been a more effective use of the time. The ALS paramedic also refused the help of two doctors (one an anaesthetist another an emergency doctor).
As a witness to a close family member’s out-of-hospital arrest and treatment by an “intensive care” paramedic team, I would back calls to go back to basics.
I would go one step further and take the controversial plea not to continue rescusitation for too long. The neurological consequences of prolonged arrest are devastating, and as a community we need to accept that there is a point where we need to step back and admit that there are very few who survive out-of-hospital arrests and that the statistics demonstrate that prolonged resuscitation rarely results in positive outcomes. We need to see the documentation not just on who leaves hospital breathing, but who leaves hospital and can continue a normal life.
The paramedics are efficient and experianced to learn and apply advanced cardiac support. Why can they not learn and make it useful?