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Heart attack survival better with basic vs. advanced life support

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Evidence supports returning to basics in out-of-hospital care

Is it possible that basic life support – with automatic defibrillators, cardiopulmonary resuscitation, and airway management without intubation – could be as good or better [than advanced life support]? Sanghavi et al. have provided us with provocative data in answer to this question. The authors found that patients receiving advanced life support had 43% lower survival to hospital discharge, 51% had poorer neurologic function, and 30% had higher costs. The likelihood that their findings are true is strengthened by the study’s consistency with a growing body of research demonstrating the ineffectiveness of many advanced life support therapies.

How can outcomes of basic life support be equal or superior to “advanced” life support? For one, the handful of therapies with solid proof are all components of basic life support; most advanced life support interventions rely on tenuous evidence. Basic life support teams may take crucial basic skills more seriously and perform them better. Most importantly, advanced life support procedures are distracting, take extra time, and interrupt critical and effective basic life support measures. Unless advanced life support interventions were decisively proven to have major benefit (compared with “hail Mary” hopes), it would be inherently harmful to interrupt basic life support to perform them. In most EMS systems, many advanced life support providers have insufficient clinical experience to be truly adept at advanced procedures, many of which are done infrequently. Also, paramedics are not as well supervised or monitored as would be mandatory in a hospital environment.

How should we proceed now? The last 15 years have produced high-quality studies, all with similar conclusions. The most beneficial treatment changes in out-of-hospital cardiac arrest treatment have not involved new modalities, but instead the progressive removal of multiple unproven medications (e.g., antiarrhythmics) and interventions (pulse checks, precordial thumps) once mandated in protocols but now found to be ineffective or even harmful. We should complete the process of removing unproven and ineffective interventions from guidelines and practice until better interventions are backed up by evidence that meets contemporary standards. Using them where we know they will almost always fail is neither efficient nor ethical.

Dr. Michael Callaham is chair of emergency medicine at the University of California, San Francisco. These comments are excerpted from an editorial accompanying the study in the Nov. 24 online issue of JAMA Internal Medicine (doi:10.1001/jamainternmed.2014.6590). He reported no disclosures.


 

FROM JAMA INTERNAL MEDICINE

References

Patients who experience a heart attack outside of the hospital are more likely to survive and have better neurologic function when they receive basic rather than advanced life support, according to a recent study.

Emergency medical services respond to an estimated 380,000 cardiac arrests outside of the hospital each year, but 90% of these patients do not survive to hospital discharge, noted Prachi Sanghavi and her associates at Harvard University, Cambridge, Mass.

Basic life support trumps advanced care for out-of-hospital heart attacks. © Stockbyte/Thinkstock

Basic life support trumps advanced care for out-of-hospital heart attacks.

“Our study calls into question the widespread assumption that advanced prehospital care improves the outcomes of out-of-hospital cardiac arrest relative to the care following the principles of basic life support, including rapid transport and basic interventions such as effective chest compressions, bag valve mask ventilation, and automated external defibrillation,” the authors wrote (JAMA Intern. Med. 2014 Nov. 24 [doi:10.1001/jamainternmed.2014.5420]). Advanced life support involves use of interventions such as endotracheal intubation, intravenous fluid and drug delivery, and semiautomatic defibrillation.

From among more than 4 million emergency rides to the hospital billed under Medicare, the authors analyzed 31,292 involving cardiac arrest where advanced life support was provided and 1,643 cardiac arrests where basic life support was provided. All cases occurred in nonrural counties.

They found 13.1% of those receiving basic life support and 9.2% of those receiving advanced life support survived to hospital discharge. Similarly, 8% who received basic life support and 5.4% who received advanced life support survived to 90 days.

Neurological functioning was also superior in those receiving basic rather than advanced interventions: 21.8% who received basic life support had poor functioning, compared with 44.8% of those who received advanced life support.

“Mean medical spending was higher among beneficiaries receiving basic life support ($11,875 for BLS vs. $9,097 for ALS), in part because individuals who received basic life support survived longer and had more opportunity to receive medical care,” the authors reported.

The study was funded by the National Science Foundation, the Agency for Healthcare Research and Quality, and the National Institutes of Health. A coauthor, Joseph P. Newhouse, holds equity in and is a director at Aetna.

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