ALS or BLS: Questioning What We Thought Was Obvious

Cardiac arrests often occur at home. The American Heart Association estimated that roughly one million Americans suffer heart attacks annually; 88% occur at home, and patients have a 50-50 chance of reaching the hospital alive.

When the ambulance arrives and the technicians initiate care, does advanced life support (ALS—support that include medication and sometime, intubation) offer an advantage over basic life support (BLS—non-invasive support)?

Researchers from Harvard University recently looked at cardiac arrest patients supported with BLS and ALS, and reported that BLS patients may have better outcomes.

These researchers used an observational cohort study that included traditional Medicare beneficiaries from non-rural counties who experienced out-of-hospital cardiac arrest. They looked for Medicare billings for ALS or BLS ambulance services between January 1, 2009, and October 2, 2011. From the data, they extracted 31,292 ALS cases and 1643 BLS cases.

Mortality rates were high regardless of the intervention used. Patients treated with BLS were more likely to survive to hospital discharge than those treated with ALS. (13.1% vs 9.2% respectively). Ninety-day survival was also better in the BLS-supported group, with 8% alive at 90 days compared to 5.4% in the ALS group. These findings are in keeping with American Heart Association statistics indicating that overall, fewer than 8% of people who suffer cardiac arrest outside the hospital survive.

The researchers estimate that annually, providing BLS instead of ALS would allow 1,479 additional Medicare beneficiaries who have an out-of-hospital cardiac arrest to live to 90 days. Cost in the first year would also fall. Heart attack victims who received BLS incurred $154,333 in costs in the first year. Those who received ALS incurred average costs of $206,775.

Additionally, research found that BLS-supported patients were less likely to experience poor neurological functioning.

The researchers noted that ALS was often assumed to improve clinical outcomes. The opposite may be true because it createf risks associated with endotracheal intubation, including poor tube placement. In addition, ALS had been associated with aspiration, aggravation of existing injuries, and interference with effective chest compressions, and can also delay prompt transport to the hospital.

This study, published in JAMA Internal Medicine, prompted organized medicine to re-evaluate advanced pre-hospital care and determine whether, in the case of cardiac arrest, advanced care offered any real advantage over basic care.