| Summary: | Considerable variation exists in the type and quality of interventions carried out on victims of major trauma in the pre-hospital phase of care. One model of care consists of high level interventions delivered by a doctor-led team. Examining two controversial areas of treatment (traumatic cardiac arrest and advanced airway management), this thesis set out to determine the quality and potential shortfalls of current practice and how they might be improved. A systematic review of traumatic cardiac arrest survival confirmed that outcome was historically very poor. A study of the largest series of traumatic cardiac arrest reported to date then suggested that a doctor –led system was associated with survival rates which were greater, and which were compatible with those after medical cardiac arrest. A significant proportion of survivors were victims of penetrating trauma who had been treated with on-scene thoracotomy. I thus examined the use, success rate and place of this intervention through analysis of the only reported case series. Finally, I considered how new or established interventions might be best applied in the early phase of trauma care to improve outcome, proposing a treatment algorithm to guide current management. Advanced airway management is presented as a controversial subject with uncertainty about who should deliver it and how it should be performed. The data presented demonstrates that, in a UK system ambulance service, interventions fail to deliver adequate airway care to trauma victims. In terms of doctor-delivered care, a meta-analysis is presented which demonstrates that doctors have better intubation success rates than paramedics, even when drug assistance and high levels of training are provided. The largest series of physician-delivered intubation then confirms this position. Lastly, a pre-hospital airway consensus process is described which attempts to improve the quality of data to guide future service development and research.
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