Basic Life Support in the Modern Era
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1 The ALS in BLS TheRoleof of Basic Life Support in the Modern Era Raymond L. Fowler, MD, FACEP Professor of Emergency Medicine, Surgery, and Allied Health The University of Texas Southwestern at Dallas
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4 What do we do in EMS? To provide care for all patients that is compassionate, competent, courteous, regardless of circumstances; to do no harm, and to treat others as we wish to be treated.
5 When Considering i Care What do we do CLINICALLY in the field that makes a difference in patient outcomes?
6 Literature and Research Review
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8 Traumatic Emergencies Shootings/Stabbings/Assaults? Conclusions: The benefits of ALS care vary with the illness or Very injury being little treated, regarding as well field as some treatment other variables, such as transport time and the severity of the pathology. Rapid transport p g Rapid transport need need to plug the leak BLS and ALS no difference in outcomes In trauma patients, no evidence that ALS care improves survival in patients with short transport times to Level-I trauma centers as well as for patients with penetrating trauma. Does Advanced Life Support Provide Benefits to Patients?: A Literature Review D. Isenberg, R. Bissell. Prehospital and ddi Disaster Medicine, July - August, 2005, pp
9 Ontario Prehospital Advanced Life Support Trauma Study 2008 The OPALS Major Trauma Study showed that systemwide implementation of full advanced life support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced d life-support measures for patients who have experienced major trauma. Journal of the Canadian Medical Association April 22, 2008, Pages
10 Cardiac Emergencies Timely defibrillation? Definitely What Works? Advanced Cardiac Life Support? Very little
11 Ontario Prehospital Advanced Life Cardiac Arrest Study 2004 Conclusions: The addition of advanced d life support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency medical services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapiddefibrillation responses a priority for the resources of emergency medical services systems. New England Journal of Medicine August 12, 2004 Pages
12 Respiratory Emergencies? Asthma/Allergic Reaction/Heart t Failure? Yes: Albuterol, Nitroglycerin, CPAP EMT s can perform these treatments
13 So in Respiratory Emergencies? Basic Airway management -assuring good oxygenation and ventilation? Yes! This is an EMT Skill Is CPAP an EMT Skill? Probably YES!!
14 Ontario Prehospital Advanced Life Respiratory Study 2007 Conclusion: The addition of a specific regimen of out-of-hospital advanced d life support interventions ti to an existing EMS system that provides basic life support was associated with a decrease in the rate of death of 1.9 percentage points among patients with respiratory distress. Study of 8138 patients in respiratory distress. Began with BLS only, and then they added drugs and endotracheal intubation. Very little difference found, and almost all ALS improvement was provided by the bronchodilator and nitroglycerin. New England Journal of Medicine May 24, 2007 Pages
15 Ontario Prehospital Advanced Life Respiratory Study 2007 The most substantial ti change in therapeutic ti intervention was the marked increase in the use of medications for symptom relief; this intervention is not a component of advanced life support Thus, the benefit of the intervention in this trial may have been primarily due not to the availability of advanced-life-support techniques but to the use of nebulized salbutamol and sublingual nitroglycerin. New England Journal of Medicine May 24, 2007 Pages
16 Fowler s Lawof Improved Work of Breathing A patient s work of breathing will appear to get better for one of two reasons: They re y getting g better They re getting WORSE!!!
17 Prehospital Intubation? The Paramedic/ALS Skill? Not so much Lets look at it
18 Literature and Research Prehospital intubation has not been shown to improve outcomes and may cause significant harm in the hands of inexperienced operators. Anything which delays transfer to definitive care in severe trauma is inappropriate. Academic Emergency Medicine February 16, 2006
19 EMS Literature and Research Concluding Thoughts If at all possible, endotracheal intubation is a procedure to avoid. If BLS adjuncts can maintain an open airway, promote good oxyhemoglobin saturations and adequately protect the patient from aspiration, then they areclearlythepreferredchoiceof choice of care. Howard Rodenberg, MD, MPH Journal of Emergency Medical Services
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21 Status of Current Protocols They are already designed for both BLS and ALS care EMT - staffed Ambulances are already in policy because medical directors often have already approved their use
22 Potential Ambulance Designs BLS ILS ALS MICU
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24 EMT Ambulance A Basic Life Support Ambulance Staffed with Emergency Medical Technicians (EMTs) Perform According to National Clinical Standards d of Care
25 National Standard Treatments t by EMT s Airway Adjuncts and Medication Oxygen Delivery Administration Bag-Valve-Mask CPAP Bleeding and Shock Management Cardiac Arrest Management/AED Bandaging/Splinting Bronchodilators Epinephrine i SQ / IM Nitroglycerin Aspirin Glucose Optional Airway: Dual Lumen Airway Insertion Endotracheal Intubation??
26 Suggested Policies Governing EMS Response / Levels We CANNOT be in a position of being unable to respond in a timely manner Basic EMT Trucks are a safe and timely answer We must stop responding to calls that we can prevent
27 Critical Element EMT Truck does NOT equal old Basic Life Support
28 From Dr. Ed Racht, 5/27/08 Chairman of the Texas Governor s EMS and Trauma Advisory Council We are stuck using antiquated nomenclature. BLS and ALS no longer accurately fit EMS. It is the clinical results that t matter.
29 Suggested Policies for Basic EMS Unit Implementation We can produce EMT-staffed ambulances more quickly than paramedic ambulances Trained by us, QA d byus Be on the street quickly A license to learn
30 Questions and Comments
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