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

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

Reference no research, author, country, publication year. type on the study
illness or injury.
research population.
n(ALS), n (BLS).
severity of disease or injury
the implementer of the care.
ALS, BLS.
transport.
ALS, BLS.
treatments.
Outcome, mortality, other outcome variables, results conclusion
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.
  1. Abbreviations: ALS = advanced life support, BLS = basic life support, EMT = emergency medical technician, LOS = length of stay (in hospital), ISS = Injury severity scale/score, TRISS = Trauma Score - Injury Severity Score, HEMS = Helicopter emergency medical service, GA = ground ambulance. PHT = prehospital throbolysis, OR = odds ratio, RR = risk ratio, ALS-N = advanced life support - nurse, ISS = injury severity score. QoL = quality of life.