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Original Investigation
June 20, 2018

Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions: Japanese Registry-Based Study

Author Affiliations
  • 1Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
  • 2Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 3Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  • 4Division of Acute Care Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 5Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
  • 6Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Surg. 2018;153(6):e180674. doi:10.1001/jamasurg.2018.0674
Key Points

Question  Is physician involvement in prehospital advanced life support (ALS) associated with increased chance of favorable outcomes after traumatic out-of-hospital cardiac arrest?

Findings  In this Japanese nationwide, population-based registry study, including 4382 patients with traumatic out-of-hospital cardiac arrest, ALS by physician was associated with increased chance of prehospital return of spontaneous circulation and 1-month survival compared with both ALS by emergency medical service personnel and basic life support. Advanced life support by physician was also associated with increased chance of neurologically favorable survival compared with ALS by emergency medical service personnel, although there was no difference between ALS by physician and basic life support.

Meaning  Physicians should probably be involved in prehospital ALS in traumatic out-of-hospital cardiac arrest cases; however, further well-designed studies are required to determine the optimal prehospital care for patients with traumatic out-of-hospital cardiac arrest.

Abstract

Importance  Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting.

Objective  To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it.

Design, Setting, and Participants  Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017.

Exposures  Advanced life support by physician, ALS by EMS personnel, or BLS only.

Main Outcomes and Measures  The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2.

Results  A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score–matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses.

Conclusions and Relevance  In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.

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