title: Invasive and surgical procedures in pre-hospital care: what is the need?
abstract: BACKGROUND
  On occasion, advanced invasive procedures in pre-hospital care can be life saving. This study aimed to identify the contemporary use of these procedures on a regional doctor-led air ambulance unit, and to define the need, skill set and training requirements for a regional pre-hospital team in the UK.
  
  
  METHODS
  Mission data were recorded prospectively and the database reviewed to identify invasive procedures over a 76-month period. These cases were reviewed with indications, mechanism of injury, presence of cardiac arrest at any time point (±return of spontaneous circulation) and procedural failure or morbidity.
  
  
  RESULTS
  Two hundred and thirty-five procedures were performed: 16 for injuries affecting the airway, 111 for breathing and 108 for circulation. Almost a third of patients in cardiac arrest regained spontaneous circulation. Procedures performed increased fivefold from 2003 to 2009, with a marked increase in the use of thoracostomy and intra-osseous access. Procedural failure or inadequacy was high with needle cricothyroidotomy, needle chest decompression and early intra-osseous access experience.
  
  
  CONCLUSIONS
  A steady increase in the number of procedures was observed over time. Less invasive methods of airway and breathing support were frequently inadequate, though definitive surgical airway or chest decompression was effective each time it was performed. Thoracotomy was performed infrequently. There are implications for the training of pre-hospital doctors who work in the majority of the UK.
authors.affiliation: University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK. i.m.shapey@doctors.org.uk.
authors.forename: I M
authors.initials: IM
authors.lastname: Shapey
authors.affiliation: University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK.|Warwickshire and Northamptonshire Air Ambulance (WNAA), Princethorpe, Warwickshire, UK.
authors.forename: D S
authors.initials: DS
authors.lastname: Kumar
authors.affiliation: University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK.|Warwickshire and Northamptonshire Air Ambulance (WNAA), Princethorpe, Warwickshire, UK.
authors.forename: K
authors.initials: K
authors.lastname: Roberts
keywords: Air ambulance; Pre-hospital; Surgical procedures; Training
references.citation: Emerg Med J. 2008 Jul;25(7):444-9
references.pmid: 18573968
references.citation: CMAJ. 2008 Apr 22;178(9):1141-52
references.pmid: 18427089
references.citation: Emerg Med J. 2002 Jul;19(4):341-4
references.pmid: 12101155
references.citation: Anaesth Intensive Care. 2009 Nov;37(6):961-7
references.pmid: 20014603
references.citation: Emerg Med J. 2009 Oct;26(10):738-40
references.pmid: 19773501
references.citation: Prehosp Emerg Care. 2010 Jan-Mar;14(1):6-13
references.pmid: 19947861
references.citation: Injury. 2009 Nov;40 Suppl 4:S23-6
references.pmid: 19895949
references.citation: Resuscitation. 2007 Dec;75(3):394-5
references.pmid: 17706858
references.citation: Emerg Med J. 2009 Jun;26(6):438-41
references.pmid: 19465621
references.citation: N Engl J Med. 2004 Aug 12;351(7):647-56
references.pmid: 15306666
references.citation: Scand J Trauma Resusc Emerg Med. 2010 Oct 07;18:52
references.pmid: 20929544
references.citation: Anaesthesia. 2008 Nov;63(11):1204-8
references.pmid: 19032254
references.citation: Anaesthesia. 2006 Oct;61(10):962-74
references.pmid: 16978312
references.citation: J Trauma. 2011 May;70(5):E75-8
references.pmid: 21131854
references.citation: Br J Anaesth. 2009 Dec;103(6):891-5
references.pmid: 19797248
references.citation: Resuscitation. 2007 Nov;75(2):276-85
references.pmid: 17574721
references.citation: Br J Surg. 2009 Nov;96(11):1365-70
references.pmid: 19847879
references.citation: Emerg Med J. 2011 May;28(5):428-31
references.pmid: 20660897
references.citation: Crit Care. 2011;15(6):R276
references.pmid: 22108048