Resuscitation of patients who sustain a cardiac arrest as a result of trauma (traumatic cardiac arrest) has previously been described as 'futile'. Several published series have since contradicted this claim and reported survival-to-discharge data ranging from 0 to 35%. International resuscitation guidelines (European Resuscitation Council and American Heart Association) promote a consistent approach to cardiopulmonary resuscitation on the basis of up-to-date evidence and consensus opinions. This minimizes de-novo decision-making under high-stress situations, promotes a rational approach and reduces the burden on an individual clinician. This narrative review sets out to highlight the differences in aetiology of traumatic cardiac arrest as compared with medical cardiac arrest and the consequent priorities in resuscitation.

Background Pre-hospital Emergency Anaesthesia (PHEA) is regarded as one of the highest risk interventions that pre-hospital providers perform. AAGBI guidance from 2017 suggests the use of Key Performance Indicators (KPIs) to audit PHEA quality. The aim of this study was to develop KPIs for use in our service and evaluate their impact. Methods Using the AAGBI 2017 document as a guide we developed a list of ten auditable domains. Data for each case was extracted from the Electronic Patient Record (EPR) and a score assigned to each of the domains; one if the domain is achieved and zero if the domain is not achieved or if data is missing, giving a total score out of ten. This analysis is then presented as a colour-coded matrix alongside the score. Data were analysed monthly at our case review and governance meeting. The process was refined during the year and after 12 months a formal review of the KPI process occurred. Results Eighty-two cases were analysed. Domains with the highest percentage of achievement were: Indication 96%; Tube position confirmed 94% and Full AAGBI monitoring and Grade of view < 3 both 89%. The amount of missing data declined throughout the year. The results of the clinician survey showed that almost all respondents found the TVAA PHEA review process useful. Conclusion The KPI process has demonstrated areas of good quality practice and led to improvements in equipment, processes and documentation and therefore patient care. We offer suggestions to other organisations considering implementing KPIs for PHEA.

Pre-hospital medicine is developing rapidly. Increasingly, specialist pre-hospital medical practitioners are working in this environment and paramedics are advancing their skill base. Tools traditionally associated with hospital care are now used pre-hospital to improve diagnosis and intervention. In this paper, we assess the developing role of ultrasound in improving trauma care in the pre-hospital arena. Focused ultrasound is used to facilitate early diagnosis of pneumothorax and intraperitoneal/pericardial haemorrhage in trauma victims. Ultrasound may have a role in assessing the circulating blood volume, fracture diagnosis and triage in mass casualty scenarios. Information obtained using ultrasound may change diagnoses and consequently alter therapy, as well as patient disposition by highlighting injuries not identified on physical examination. Receiving hospitals can be alerted to injuries requiring intervention upon arrival. Ultrasound is also used to reduce complications and improve performance in numerous procedures such as obtaining vascular and intra-osseous access, paracentesis and tracheal tube placement. There is emerging evidence that ultrasound may be used safely pre-hospital without increasing on-scene times and with results comparable to use in hospital.

The first operational deployment of emergency medicine in the UK Defence Medical Services was in support of a 50-bed field hospital during OP AGRICOLA, Kosovo, from 25 June-26 August 1999. In preparation, new equipment scales were designed to extend the traditional surgical-based approach to the reception of patients. The organisation of the front end of a field hospital was modified to reflect the current UK peace-time practice of emergency medicine. Specialist emergency medicine trained doctors and nurses provided the core personnel. 1189 patients were treated in the 2-month deployment. 903 were KFOR troops (862 BRITFOR), 187 Kosovo-Albanian, 69 Serbian and 30 derived from United Nations or nongovernment organisations. There were 63 resuscitations, with 21 relating to KFOR troops. 42 patients met the criteria for a trauma team activation; age was 33.4 ± 18.7 years (mean ± SD). Mean Injury Severity Score (ISS) was 16.3 ± 18.6; mean New Injury Severity Score (NISS) was 22.5 ± 20.5. 14 of 42 were ‘major trauma’ characterised by ISS ≥16; 22 had a NISS ≥16. 36% of the major trauma by ISS was gunshot wound (GSW), 7% blast and fragmentation, and 57% blunt; age was 33.3 ± 20.4 years (mean ± SD for ISS ≥16 group). Standardised Mortality Ratio was 1.50. The Effectiveness E value for outcome was 0.85. NISS detected 3 further patients with GSW, 3 with blast/fragmentation, and 2 with blunt injury. A diverse range of medical emergencies was encountered. The extended role of the emergency physician was exploited to include coordination of major trauma audit and clinical feedback, local and national disaster planning, and co-ordination of humanitarian support to design, build and equip an emergency department at the University Hospital of Pristina. The operational value of emergency medicine within UK Defence Medical Services has been firmly established.