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C'est le temps de changer nos protocoles R�ellement pas compliqu� Une fin de semaine et c'est fait ! Chiche ! Charles Brault EMT-P J Trauma. 2000 Oct;49(4):584-99. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. Liberman M, Mulder D, Sampalis J. Department of Surgery, McGill University, Montreal, Quebec, Canada. BACKGROUND: The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy METHODS: A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems. RESULTS: Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92. CONCLUSION: The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach. Et les autres �tudes : Ann Surg. 2003 Feb;237(2):153-60. Comment in: Ann Surg. 2003 Feb;237(2):161-2. Multicenter Canadian study of prehospital trauma care. Liberman M, Mulder D, Lavoie A, Denis R, Sampalis JS. McGill University, Montreal, Quebec, Montreal General Hospital, Department of Surgery, Canada. OBJECTIVE: To evaluate whether the type of on-site care a trauma patient receives affects outcome. SUMMARY BACKGROUND DATA: The controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. METHODS: This prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. RESULTS: The overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. CONCLUSIONS: In urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients. J Trauma. 2000 Apr;48(4):643-8. Effect of prehospital advanced life support on outcomes of major trauma patients. Eckstein M, Chan L, Schneir A, Palmer R. University of Southern California School of Medicine, Los Angeles, USA. [EMAIL PROTECTED] 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. Acad Emerg Med. 1998 Jun;5(6):592-8. Advanced life support vs basic life support field care: an outcome study. Eisen JS, Dubinsky I. Queen's University Faculty of Medicine, Kingston, Ontario, Canada. OBJECTIVE: To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. METHODS: A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS. RESULTS: The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. CONCLUSIONS: There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center. J Trauma. 1997 Aug;43(2):288-95; discussion 295-6. Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. Sampalis JS, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Montreal General Hospital, Quebec, Canada. BACKGROUND: The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals. METHODS: The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly. RESULTS: The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001). CONCLUSION: The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential. Prehospital Disaster Med. 1996 Apr-Jun;11(2):101-4. Does the level of prehospital care influence the outcome of patients with altered levels of consciousness? Adams J, Aldag G, Wolford R. University of Illinois College of Medicine at Peoria, USA. HYPOTHESIS: Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers. METHODS: Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included; trauma, intoxication, drowning, shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records. RESULTS: Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the "alert, verbal, painful, unresponsive" scale (ALS vs BLS) were: "verbal" (40% vs 51%), "painful" (23% vs 23%), and "unresponsive" (37% vs 25%). The mean value for some time was 15 +/- 6 minutes for ALS versus 10 +/- 4 minutes for BLS (p < 0.001). On arrival in the emergency department, the LOC of 72 (64%) ALS patients and 58 (64%) BLS patients had improved to "alert." The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principal final diagnoses were seizure (27% ALS vs 38% BLS), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS providers had significantly shorter emergency department treatment times than did those transported by BLS providers (160 +/- 62 minutes ALS vs 229 +/- 67 minutes BLS [p < 0.005]). CONCLUSION: Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients. Prehospital Disaster Med. 1994 Jul-Sep;9(3):178-88; discussion 189. Determinants of on-scene time in injured patients treated by physicians at the site. Sampalis JS, Lavoie A, Salas M, Nikolis A, Williams JI. Department of Surgery, McGill University, Montreal, Quebec, Canada. INTRODUCTION: The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care. In Montreal, Quebec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene. HYPOTHESIS: The use of on-site ALS by physicians is associated with a significant increase in scene time. METHODS: A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data. RESULTS: Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009). CONCLUSION: This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries. J Trauma. 1993 Sep;35(3):460-6; discussion 466-7. Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more. Cayten CG, Murphy JG, Stahl WM. Institute for Trauma and Emergency Care, New York Medical College, Valhalla. To study the value of advanced life support (ALS) compared with basic life support (BLS) for penetrating and motor vehicle crash (MVC) patients, data were collected from eight hospitals over 24 months on 781 consecutive patients with Injury Severity Scores > or = 10 as well as on a subset of 219 hypotensive patients. Initial prehospital Revised Trauma Scores (RTSs) were compared with initial emergency department RTSs. Scene times, total prehospital times, and the use of a pneumatic antishock garment (PASG), intravenous fluids, and endotracheal intubation were also documented. A modified TRISS method was used to compare mortality rates. The MVC ALS patients showed improvement in mean RTSs between prehospital and the emergency department while MVC BLS patients did not. Mean changes in blood pressure (BP) and the percentage of patients with improved BP were significantly higher among patients who received ALS; ALS was associated with increased use of PASGs and IV fluids. There were no differences between groups with respect to observed versus predicted mortality. Similar results were found in the hypotensive subset of patients. No benefit from the use of ALS for trauma patients with total prehospital times of less than 35 minutes was documented. J Trauma. 1992 Dec;33(6):850-5. The association of advanced life support training and decreased per capita trauma death rates: an analysis of 12,417 trauma deaths. Messick WJ, Rutledge R, Meyer AA. Department of Surgery, UNC School of Medicine, Chapel Hill. This study identified a number of significant predictors of per capita county trauma mortality rates: rurality, percentage nonwhite population, percentage unemployment, and Advanced Life Support (ALS) versus Basic Life Support (BLS) status. Of these, ALS versus BLS status is not only the most significant independent predictor, it is the only predictor readily amenable to change. The aspects of ALS clearly associated with decreased trauma death rates should be identified and, if possible, undergo widespread implementation. J Trauma. 1988 May;28(5):563-70. Is advanced life support appropriate for victims of motor vehicle accidents: the South Carolina Highway Trauma Project. Reines HD, Bartlett RL, Chudy NE, Kiragu KR, McKnew MA. Department of Surgery, Medical University of South Carolina, Charleston 29425. There is continuing controversy over the use of Advanced Life Support (ALS) in the treatment of multisystem injury. In this study, performed to define the role of ALS in the management of motor vehicle accidents (MVA), 538 ambulance run reports (ARR) and hospital records of patients involved in MVA in South Carolina for 1983 were examined. Of these, 248 were reviewed in depth by a trauma review committee (TRC). Paramedics were present in 81% (93% urban, 80% rural) of cases. ALS crews averaged 24.8 minutes on the scene compared to 18.1 minutes for Basic Life Support (BLS). It took 6 minutes longer to transport rural patients than urban patients (15.7 vs. 9.6 min). Total EMS time (response, on scene, transport) was 46 +/- 20 minutes. Extrication increased on-scene time from 20.5 to 31.1 minutes. Endotracheal intubation attempts were 67% successful and IV's were placed in 88% of attempts. Thirty-two per cent of ALS patients demonstrated an increased blood pressure en route compared to 12% of BLS patients. The TRC felt prehospital care was beneficial in 85% of cases, while 11.7% had inappropriate or inadequate care. Resuscitation and ALS in MVA appears to be beneficial in the treatment of multisystem trauma in a rural state. : J Trauma. 1984 Jan;24(1):8-13. Prehospital advanced life support: benefits in trauma. Jacobs LM, Sinclair A, Beiser A, D'Agostino RB. The Boston Emergency Medical Service system was studied to determine the effects of Advanced Life Support (ALS) prehospital trauma care compared to Basic Life Support (BLS) treatment. The severity of injury and clinical status of patients was defined and monitored using the Trauma Score (TS) described by Champion. The TS on arrival at the hospital increased significantly more for patients receiving field ALS care than for patients transported by BLS ambulances (p = 0.01). ALS resuscitation had most influence on patients with TS 4-13 and did not delay transport time. Furthermore, a positive change in prehospital TS was significantly related to an increased chance of long-term survival for any given severity of injury (p = 0.0002). >From these data we conclude that the TS is useful for prehospital triage and that appropriate field ALS resuscitation results in more favorable outcomes following major trauma. __________________________________ Do you Yahoo!? SBC Yahoo! 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