Critical care paramedics: where is the evidence? A systematic review.

OBJECTIVES: Paramedic-delivered prehospital critical care is an established concept in a number of emergency medical services around the world and, more recently, has been introduced to the UK. This review identifies and describes the available evidence relating to paramedics who routinely provide prehospital critical care as primary scene response (critical care paramedics, or CCP).

METHODS: A systematic search of electronic databases was performed: CENTRAL, EMBASE, MEDLINE (through EMBASE and Web of Knowledge) and Web of Science (through Web of Knowledge).

RESULTS: The search identified 12 relevant publications, one of which was a randomised controlled trial. The remaining 11 were retrospective studies. Five studies compared CCPs with physician-led care. Three of these publications demonstrated improved outcomes with physician care, while two showed no difference. Four further publications examined CCPs versus non-physician-led care and found improved outcomes (two studies), mixed effects (one study) and no difference (one study) for CCPs. Finally, three publications addressed the addition of skills to CCP competencies. A randomised controlled trial of CCP rapid sequence induction (RSI) and tracheal intubation demonstrated improved neurologic outcomes. CCP tube thoracostomy was shown to have similar complication rates to the same procedure performed in the emergency department, while addition of a non-invasive ventilation protocol to CCP practice had no effect on long-term mortality.

CONCLUSIONS: There is limited evidence to support the concept of paramedic-delivered prehospital critical care. The best available evidence suggests a benefit from prehospital RSI carried out by CCPs in patients with severe traumatic brain injury, but the impact of CCPs remains unclear for many conditions. Further high-quality research in this area would be welcome.