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Basic Life Support (BLS) is basically CPR, and when bystanders are trained to help people suffering cardiac arrest with BLS and automated defibrillators, outcomes improve. Advanced Life Support (ALS) is a whole other story. We've got the research on it.



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It sometimes feels like there's not much we can do to save people's lives. But that is so not true. If you see someone in the midst of a cardiac arrest, you can make a huge difference by performing basic life support. And if basic life support is great, then advanced life support must be even better, right? Yeah, not so much. BLS and ALS are the topic of this week's Healthcare Triage.

Two very recent studies published in JAMA looked at how bystander interventions, those that regular people can administer, affect outcomes for those who have cardiac arrest. And those studies are really compelling.

The first is Association of Bystander Interventions With Neurologically Intact Survival Among Patients With Bystander-Witnessed Out-of-Hospital Cardiac Arrest in Japan. This study looked at how chest compressions and automatic defibrillators, components of BLS, were associated with outcomes when people have cardiac arrests in public. Chest compressions are CPR. Automatic defibrillators allow people without training to administer electrical shocks to the heart through those paddles you see on TV and in the movies. From 2005 to 2012, the number of bystander witnessed cardiac arrests went up in Japan from 14 per 100,000 persons to 18.7 per 100,000 persons. Neurologically intact survival went up too, from 3.3 percent of cases to 8.2 percent. At the same time, bystander chest compressions increased from 39 percent to 51 percent of cases, and bystander-only defibrillation increased from basically none to more than two percent.

After controlling for other factors, bystander chest compressions increased neurologically intact survival significantly, from 4.1 percent without to 8.4 percent with. So did bystander-only defibrillation over no defibrillation, increasing neurologically intact survival from two percent to 41 percent.

The second article is entitled Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013. This study examined how bystander and first responder resuscitation efforts changed following state-wide initiatives to improve bystander and first responder efforts in North Carolina from 2010 to 2013. It also looked at the association between those efforts and survival and neurological outcomes. And here's the take-home message from this study: survival following EMS-initiated CPR and defibrillation was 15.2 percent, but survival from bystander-initiated CPR and defibrillation was higher, at 33.6 percent. But OK, if doing a little for people in the field is a good idea, then doing more should be better, right? And that's where advanced life support comes in.

ALS requires a trained provider like a paramedic, and involves much more than BLS. ALS providers may put in endotracheal breathing tubes, start intravenous lines, deliver sophisticated cardiac drugs, and defibrillate patients manually. We've assumed for the most part that advanced life support is better than basic life support. So much so, that in most areas where both options are available, advanced life support is almost always used.

But a recent study in JAMA Internal Medicine brought this assumption in to question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived a hospital discharge and then months later. What they found was that about 13 percent of patients who received basic life support survived and were discharged versus nine percent of patients who received advanced life support. More patients who received BLS lived for 90 days after discharge too; eight percent versus five percent. Basic life support patients also had better neurological outcomes.

Now of course this isn't a randomised controlled trial, and it's possible that sicker patients received advanced life support and the people who didn't appear as sick received basic life support. But the authors called all of the state agencies and they reported that that really can't happen. After all, a 911 dispatcher can't tell if it's a mild or severe heart attack from a panicked third party on the phone with no medical training. Dispatchers send out advanced life support if it's available and basic life support if ALS is not.

It's also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren't corroborated in many other studies. In 2004, results from The Ontario Prehospital Advanced Life Support study were published in the New England Journal of Medicine. It was a multicenter controlled trial in 17 cities in Canada comparing ALS with BLS. They found that if an incidence of cardiac arrest was witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of BLS. The addition of ALS however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of ALS have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods; putting in an airway tube rather than using a bag mask, was associated with decreased survival compared with basic life support methods. As did a 2013 study in Japan. A 2012 JAMA study found the use of epinephrine was associated with worse outcomes. And a 2008 New England Journal of Medicine study found that adding vasopressin; another drug that like epinephrine constricts blood vessels to raise blood pressure, didn't improve things. A randomised controlled trial of these drugs published in 2009 in JAMA found that their use didn't improve survival either.

The evidence is compelling. ALS doesn't seem to provide any benefits in the randomised controlled trials, and it's often associated with worse outcomes in the cohort studies. How can this be so? Some theorize the things that work have already been incorporated into basic life support. All that the ALS may be doing is slowing things down in the field, distracting people from the useful BLS measures, and delaying the time until a patient can get to the hospital.

Regardless, learning BLS can save a life. We should all consider taking a class. ALS, on the other hand, doesn't seem to be doing much good. It might be time to question why we are letting it be used so widely.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation. Your support makes this show bigger and better. We'd especially like to thank our research associate Joe Sevits, give a special shout-out to Johnathan Dunn, and thank our surgeon admiral Sam. Thanks Joe and John! Thanks Sam! More information can be found at patreon.com/healthcaretriage.