Table 2 Summary of findings in the articles presenting effectiveness of advanced vs. basic life support.

12

Shuster et al. 1995

Canada

prospective chart review.

acute cardiac disease.

ALS n = 1821

BLS n = 1245.

ALS-PARAMEDIC, GA.

BLS-EMT, GA.

an urban setting with short transportation times (less than 10 minutes)

mortality ALS 16,5%

BLS 19,5%

risk of death

ALS OR = 1

BLS OR 1,12 (0,78-1,61)

no difference between the groups

13

Boissel 1995

France

multicentre study in 16 countries, PHT compared with thrombolysis in a hospital.

ALS (immediate PTH) n = 2750.

BLS (hospital throbolysis) n = 2719.

ALS-MD, GA.

BLS-MD, GA.

both groups treated by a physician.

30-day mortality ALS 9,7%, BLS 11,1%

adjusted p = 0,08

trend to favour PHT (ALS).

14

Alldredge et al., California, U.S.A.,

1995

retrospective chart review.

children with status epilepticus,

ALS n = 19 (treatment on site)

BLS n = 26 (treatment in a hospital)

ALS-PARAMEDIC, GA

BLS-EMT, GA

prehospital diazepam therapy (given rectally or intravenously)

duration of status epilepticus ALS 32 min, BLS 60 min (p = 0,007)

repeated cramps ALS 56%, BLS 85% (p = 0,045), mortality 0%

favours ALS.

15

Adams et al.1996

Illinois, U.S.A.

retrospective study.

declined level of (epilepsy, hypoglycaemia, stroke).

ALS n = 113, BLS n = 90

ALS-paramedic, GA

BLS-EMT, GA

mortality ALS 6%, n = 7

BLS 2%, n = 2

no difference between the groups

16

Demetriades et al. 1996

California, U.S.A.

retrospective, all traumas

ALS or BLS n = 4856

private transport n = 926

ALS-PARAMEDIC ori BLS-EMT compared with patients transported by a private vehicle

mortality: ALS or BLS 9,3%

private transport 4,0%

adjusted RR 1.60 (P = .002).

better survival and less permanently disabled in privately transported patients

17

Silfvast and Ekstrand

1996

Finland

before-after-design, prehospital cardiac arrest before (Period I, retrospective) and after (Period II, prospective) reorganisation of the EMS system.

Phase I: ALS-PHYSICIAN experienced physicians, n = 444

Phase II: ALS-PHYSICIAN junior physicians, n = 395

two ALS-systems. physicians experienced (Phase I) and less experienced (Phase II), both operated with a GA

total mortality:

Phase I 90.8%

Phase II 91,6% (NS)

survival of patients with ventricular fibrillation

phase I: 41 (34%)

phase II: 33 (25%) p = 0,05

no difference between groups in total mortality.

among patients with ventricular fibrillation better results in phase I

18

Nguyen-Van-Tam et al. 1997

England

retrospective cohort

cardiac arrest

ALS n = 285

BLS n = 144

dual response n = 79

ALS-PARAMEDIC, BLS-EMT

dual response: both ALs and BLS in the scene. GA in all groups.

mortality: ALS 91,9%, dual 98,7%, BLS 93,8%, p = 0,63)

ALS adjusted survival RR 1,21 (0,50-2,91)

no difference between ALS, BLS and dual response groups

19

Rainer et al. 1997a

England

prospective

trauma patients

ALS n = 247

BLS n = 843

ALS-PARAMEDIC, ALS-EMT

ALS GA

BLS GA

mortality: ALS 4%, BLS 3% (NS)

TRISS: unexpected deaths:

ALS n = 5, BLS n = 18

unexpected survivals:

ALS n = 6, BLS n = 9, (NS)

no difference between ALS and BLS groups

20

Rainer et al. 1997b England

prospective

cardiac arrest

ALS n = 111

BLS n = 110

ALS-PARAMEDIC, BLS-EMT

ALS GA

BLS GA

mortality ALS 93%, BLS 94%

p = 0,59. resuscitation by a bystander and early defibrillation associated with better survival

no difference between ALS and BLS groups

21

Suominen et al. 1998

Finland

retrospective

pediatric trauma, ALS n = 49

BLS n = 72, total material n = 288

ALS-PHYSICIAN, BLS-EMT

ALS helicopter and GA, BLS GA

ALS 22,4%

BLS 31,9% (NS)

no difference between groups, a subgroup ISS 25-49 ALS better (p = 0,04)

22

Nicholl et al. 1998

Sheffield, England

retrospective

trauma

ALS n = 882

BLS n = 331

ALS-PARAMEDIC, BLS-EMT

GA in both groups

6 months follow-up: mortality

ALS 6,0%, BLS 4,6%

OR 2,02 (1,05-3,89)

ALS: higher mortality in penetrating trauma and large fractures

higher mortality in ALS

23

Eisen and Dubinsky

1998, Canada

retrospective

all patient groups in prehospital care

BLS n = 1000

ALS n = 397

ALS-PARAMEDIC (level 2 and level 3, level 1 = BLS), BLS-EMT GA in both

mortality: ALS 5,8%, BLS 4,6% (NS), LOS. no difference between groups

no difference between groups

24

Abbott et al. 1998

California U.S.A.

prospective case-control

closed head injury

ALS-PHYSICIAN n = 196

ALS-PARAMEDIC n = 1090

HEMS manned by nurse or nurse/paramedic/physician

ALS-HEMS

ALS-PARAMEDIC

ALS-PHYSICIAN helicopter

ALS-PARAMEDIC GA

ALS-PHYSICIAN 20%

ALS-PARAMEDIC 31%

OR 1,75

1,21 - 2,53

subgroups: age, GCS had effect on mortality

ALS-HEMS better than ALS-PARAMEDIC

25

Owen et al. 1999

Texas, U.S.A.

retrospective TRISS

trauma patients, comparison between helicopter and GA,

ALS-PARAMEDIC (GA) n = 687

ALS-PARAMEDIC (helicopter) n = 105

ALS-PARAMEDIC (GA)

ALS-PARAMEDIC, ALS-N (helicopter)

ALS-PARAMEDIC (GA)

ALS-PARAMEDIC, ALS-N (helicopter)

mortality: 14,3%, 6,0%

TRISS: GA predicted 39 deaths, actually 41, helicopter: predicted 16 deaths, actually 15

no difference between groups

26

Mitchell et al. 2000 Scotlandi

before-after design

cardiac arrest,

period 1 n = 259

period 2 n = 294

ALS-PARAMEDIC, GA

period 1 94,2%

period 2 93,5%

no difference between groups

27

Eckstein et al. 2000

California, U.S.A.

retrospective

serious trauma

ALS n = 93

BLS n = 403

ALS-PARAMEDIC, BLS-EMT,

ALS GA, BLS GA

mortality ALS 93%, BLS 67%

adjusted 5,3 (2,3 -14,2)

higher mortality in ALS

28

Pitetti et al. 2001 Pennsylvania, U.S.A.

retrospective

pediatric cardiac arrest

ALS-PARAMEDIC n = 150

BLS-EMT n = 39

ALS-PARAMEDIC

BLS-EMT

ALS GA, BLS GA

ALS 96,7%

BLS 0% (NS)

no difference between ALS and BLS groups

29

Garner et al. 2001

Australia

retrospective comparison between two ALS-systems

blunt trauma in head

ALS-PARAMEDIC n = 250

ALS-PHYSICIAN n = 46

comparison of two levels of ALS

ALS-PARAMEDIC GA

ALS-PHYSICIAN helicopter (91%)

mortality: ALS-PHYSICIAN 20%

ALS-PARAMEDIC 31%

survival ALS-PARAMEDIC OR = 1, ALS-PHYSICIAN

OR = 2,70 (1,48-4,95)

ALS-PHYSICIAN better than ALS-PARAMEDIC

30

Di Bartolomeo et al. 2001

Italy

ALS patients compared with cases when ALS was requested but not obtained

Serious brain injury

ALS-PHYSICIAN n = 92

BLS-H n = 92

ALS-PHYSICIAN helicopter

BLS-H GA

mortality: ALS 30%, BLS 24%

adjusted no difference

no difference between groups

31

Kurola et al. 2002

Finland

expert panel

all prehospital patients, specialist appraisal, ALS-PHYSICIAN n = 206

ALS-PHYSICIAN

helicopter and GA

mortality 10,6%, no compatison, specialist appraisal

1,5% of patients benefit of ALS-treatment, 20.4% partial benefit

32

Bjerre et al. 2002

Danmark

chronic pulmonary disease

ALS n = 67, BLS n = 72

ALS-PHYSICIAN, BLS-EMT

ALS GA, BLS GA

mortality: ALS 15%, BLS 24%

ALS-PHYSICIAN better survival than BLS-EMT

33

Thomas et al. 2002

Massachusetts, U.S.A.

retrospective

blunt trauma, ALS-PARAMEDIC helicopter n = 2292

ALS-PARAMEDIC GA, n = 3245,

BLS-EMT GA n = 7723

3 groups: ALS-PARAMEDIC GA, ALS-PHYSICIAN helicopter, BLS-EMT GA

mortality: 9,4% (ALS helicopter or GA), BLS 3,0%; helicopter vs GA: OR 0,756 (0,59-0,98), BLS vs ALS 0,42 (0,32-0,56)

higher mortality in ALS than BLS

higher mortality in GA than helicopter

34

Lossius et al.

Norway 2002

expert panel

all prehospital patients, ALS n = 1062

appraisal by specialist group, BLS no comparison material

ALS-PHYSICIAN

40% helicopter transport, 60% GA

mortality 20,7%, specialist appraisal 7% (n = 74) benefit fromALS-care

ALS useful, no controls

35

Lee et al. 2002

Australia

retrospective

blunt trauma, head injury

ALS-PARAMEDIC n = 1167

ALS-PHYSICIAN n = 224

BLS level 3 n = 452

BLS level 4 n = 45

BLS other n = 96

ALS-PHYSICIAN

ALS-PARAMEDIC

BLS-EMT (2 different levels)

ALS GA, BLS GA

mortality:

ALS-PARAMEDIC 24,8%,

ALS-PHYSICIAN 19,6%

BLS level 3 12,2%, BLS level 4 13,3%, BLS other 21%

Adjusted: BLS OR = 1

ALS-PHYSICIAN OR = 4,27

ALS-PARAMEDIC OR = 2,18

higher mortality in ALS

higer mortality in ALS-PHYSICIAN than in ALS-PARAMEDIC

36

Cristenzen et al. 2003

Danmark

retrospective before-after -design

all prehospital patients

ALS-PHYSICIAN n = 795+35

BLS-EMT n = 4989.

before-after -study: in the second phase 28% of cases treated by ALS

ALS-PHYSICIAN

BLS-EMT

ALS GA

BLS GA

phase I mortality 10,0%

mortality in phase II = 10,5%

phase II mortality in ALS-group 14,7%, phase II mortality in BLS-group 8,9% (p < 0,001)

OR 1,06 (NS)

total mortality same in both periods

37

Osterwalder 2003

Switzerland

prospective TRISS

multiple trauma

ALS n = 196

BLS n = 71

ALS-PHYSICIAN,

BLS-P, BLS-EMT

EMT lower level education

ALS GA or helicopter, BLS GA

mortality in ALS 11,2%

BLS 14,1% (NS)

predicted mortality in ALS 23,3%, actual mortality 22%

predicted mortality in BLS 6,6%

actual mortality 10%

ALS trend to lower mortality than BLS

38

Bochiccio et al. 2003

Maryland, U.S.A.

prospective retrospective

brain injury:

blunt (92%), penetrating (8%),

comparison between patients intubated on site and those intubated in hospital

intubated on site n = 78

intubated in hospital n = 113

all ALS-PARAMEDIC

67% had helicopter transport, others with GA

mortality: intubated on site 23%

intubated in hospital 12,4% (p = 0,005)

higher mortality in patients intubated on site

39

Liberman et al. Canada, 2003

prospective epidemiological study

all traumas

Montreal ALS n = 801

Montreal BLS n = 4295

Toronto ALS n = 1000

Toronto BLS n = 1530

Quebec BLS n = 1779

Montreal ALS-PHYSICIAN

Montreal BLS-EMT

Toronto ALS-PARAMEDIC

Toronto EMT-BLS

Quebec BLS-EMT

ALS GA, BLS GA

ALS 29%

ISS 25-49 30%

ISS 50-76 79%

BLS 18%

ISS 25-49 26%

ISS 50-76 76%

ALS-PHYSICIAN vs BLS 1,36*

ALS-PARAMEDIC vs BLS 1,06**, ALS-PHYSICIAN vs ALS-PARAMEDIC 1,20**

ALS vs BLS 1,21*, *p = 0,01

**p = NS

higher mortality in ALS

40

Danchin et al. 2004

France

retrospective chart review

PHT n = 180

hospital trombolysis n = 365

CABG, PCI

n = 434

no reperfusion n = 943

96% of PHT-patients got treatment from"mobile intensive care unit"

all transported by GA

PHT 6% (1 year mortality)

hospital thrombolysis 11%

PCI 11%, no reperfusion treatment 21%, PHT mortality

RR 0,49 (0,24 - 1,00)

lowest mortality in PHT

Comparison between PHT and other reperfusion treatment

RR = 0,52 (p = 0,08)

41

Biewener et al. 2004

Germany

prospective TRISS

multiple trauma n = 403, 4 groups

1) HEMS-UNI n = 140

2) AMB-REG n = 102

3) AMB-UNI n = 70

4) INTER n = 91

all four goups ALS-PHYSICIAN

1) university hospital

2)regional hospital

3) university hospital

4) local hospital

1)transport by helicopter

2-4) transport by a GA

mortality rates:

1) 22,1%

2) 41,2%

3) 15,7%

4) 17,6%

adusted risk

1) OR = 1

2) OR = 1,06 NS

3) OR = 4,06, p < 0,05

4) OR = 1,28, NS

ALS-PHYSICIAN + helicopter transport to university hospital is better than transport by a GA to regional hospital

no difference in mortality between HEMS-UNI and AMB-UNI

42

Stiell et al. 2004

Canada

before-after -design

cardiac arrest

ALS n = 4247

BLS n = 1391

ALS-PARAMEDIC

BLS-EMT

ALS GA, BLS GA

mortality

ALS 95,0%

BLS 94,9% (p = 0,83)

no adjustment

No difference in QoL or cerebral performance

No difference in mortality.

43

Frankema et al. 2004

Netherlands

retrospective

all serious injuries

ALS n = 107

BLS n = 239

ALS-PHYSICIAN

BLS-EMT, ALS helicopter, BLS GA

mortality: ALS 34,5%, BLS 24,3%

adjustment: patients treated by ALS 2,4 fold probability to survive (p = 0,076).

Blunt trauma OR 2,8, p = 0,036, penetrating trauma 0,2 (NS)

ALS better survival

44

Wang et al.

2004

Pennsylvania, U.S.A.

retrospective epidemiological study

brain injury, comparison between patients intubated prehospitally with patients intubated in the hospital

intubation on-site n = 1797

intubated in a hospital n = 2301

on-site intubation by ALS-PARAMEDIC or by ALS-PHYSICIAN, transportation by helicopter or by a GA

mortality on-site intubaltion 48,5%, hospitla intubation

28,2%, adjusted OR 3,99 (3,21-4,93)

patients intubated on-site had 4-fold risk of dying;

patients intubated by using medication showed better survival.

45

Cameron et al. 2005

Australia

before-after-design

all prehospital patients

ALS-PHYSICIAN n = 211

ALS-PARAMEDIC BLS n = 163

ALS-PHYSICIAN, ALS-PARAMEDIC

no BLS-group.

ALS-PHYSICIAN helicopter

ALS-PARAMEDIC helicopter

30 days mortality

ALS-PHYSICIAN 2,8%

ALS-PARAMEDIC 2,5%, NS

no difference bewtween ALS-PHYSICIAN and ALS-PARAMEDIC -groups

46

Mellado Vergel et al. 2005

Spain

retrospective

cardiac infarct, PHT

PHT n = 152 (ALS), hospital trombolysis (BLS) n = 829

ALS-PARAMEDIC

BLS-EMT

ALS GA, BLS GA

30 days mortality

ALS 5,9%, BLS 26,6% (p = 0,066)

ALS (PHT) showed a trend to lower mortality

47

Di Bartolomeo et al. 2005

Italy

prospective

traumatic cardiac arrest

(blunt trauma)

ALS n = 56, BLS n = 73

ALS-PHYSICIAN

BLS-EMT+BLS-nurse

ALS helicopter, BLS GA

ALS 96,5%

only two patients survived

BLS 100%, NS

no difference between ALS and BLS groups.

prognosis still very poor

48

Davis et al. 2005

California, U.S.A.

retrospective epidemiological study

brain injury

ALS-helicopter n = 3017

ALS- GA n = 7295

Helicopter manned by paramedic, physician or nurse,

ambulances manned by paramedics

ALS helicopter, ALS GA

mortality: ALS helicopter 25,2%

ALS ground ambulance 25,3%

Adjusted OR 1,90 (1,60-2,25)

mortality of patients intubated on site: ALS-helicopter 42,5%

ALS-GA 43,1%, OR 1,42 (1,13-1,78)

ALS + helicopter + intubation on site better than ALS +GA + intubation in hospital

49

Björklund et al. Sweden, 2006

prospective

prehospital trombolysis

ALS n = 1690

BLS n = 3685

comparison between PHT entered in ambulance and thrombolysis in hospital

ALS-PARAMEDIC

BLS-EMT, GA in both groups

mortality: ALS 5,4%, BLS 8,3

p < 0,001. ALS 0,71 (0,55-0,92) (1 year mortality); ALS 0,79 (0,61-1,03) 30 day mortality

ALS showed lower mortality

50

Sukumaran et al. 2006

Scotland

prospective TRISS

all trauma patients

ALS n = 12339

BLS n = 9078

ALS-PARAMEDIC

BLS-EMT

ALS GA, BLS GA

mortality: ALS 5,3%, BLS 4,5%

p = 0,07; after adjustment no difference between groups

no difference between ALS and BLS groups

51

Iirola et al. 2006

Finland

retrospective before-after

multiple trauma

ALS n = 81, BLS n = 77

ALS-PHYSICIAN, BLS-EMT

ALS helicopter (60%) or GA (39%)

BLS GA

mortality: ALS 31%, BLS 18%

p = 0,065; TRISS: material does not fit with MTOS-material

QoL: no difference between groups

no difference between ALS and BLS groups,

trend to bigger mortality in ALS-group (p = 0,065)

52

Klemen and Grmec 2006

Slovenia

prospective, historical controls

multiple trauma, isolated head injury

ALS n = 64, BLS n = 60

ALS-PHYSICIAN, ALS-EMT

ALS GA, BLS GA

mortality ALS 40%, BLS 42% (NS). GOS level 4-5 achieved: ALS 53%, BLS 33%, p < 0,01

no difference in mortality

in ALS better QoL

53

Stiell et al. 2007

Canada

prospective before-after

dyspnoea, ALS n = 4218, BLS n = 3920

BLS-EMT, ALS-PARAMEDIC

ALS GA, BLS GA

ALS 11,3%

BLS 13,1% (p = 0,01)

lower mortality in ALS

54

Woodall et al. 2007

Australia

retrospective

cardiac arrest

ALS n = 1687

BLS n = 1288

ALS-PARAMEDIC

BLS-EMT

ALS GA, BLS GA

mortality: ALS 93,3%, BLS 95,3%; probablility for survival in all patients BLS = 1, ALS = 1,43 (1,02-1,99)

lower mortality ALS

55

Ma et al. 2007

Taiwan

prospective

cardiac arrest

ALS n = 386

BLS n = 1037

ALS-PARAMEDIC, BLS-EMT

ALS GA, BLS GA

mortality ALS 93%, BLS 95% (NS); survival in ALS adjusted OR 1,41 (0,85-2,32)

no difference between groups

56

Seamon et al. 2007

Pennsylvania, U.S.A.

retrospective

patients going to immediate thoracotomy comparison between ALS or BLS (n = 88)

and private transport by laymen n = 92

ALS-PARAMEDIC ori BLS-EMT,

compared to transportation by laymen.

mortality ALS,BLS 92%

private transport 82,6%

in multivariate analysis prehospital procedures were an independent predictor of mortality

better survival in persons transported by laymen

57

Stiell et al. 2008

Canada

Before-after -design.

92% blunt trauma, (ISS > 12), age ≥ 16 years

ALS n = 1494

BLS n = 1373

Only 72% of the patients were transferred directly to the trauma centers from the scene.

ALS-PARAMEDIC, GA.

BLS-PARAMEDIC, GA.

Endotracheal intubation (7%), iv fluid (12%) and drug administration during the latter period.

Mortality ALS 18,9%,

BLS 18,2% (p = 0,65)

In patients with GCS < 9

mortality ALS 49,1%,

BLS 40,0% (p = 0,02)

Implemantation of ALS did not decrease mortality or morbidity. In more severely injured patients (GCS < 9), mortality was lower in the BLS group.