MONTHLY ISSUE · APRIL 2026
PHEM Evidence Rundown
Pre-Hospital Emergency Medicine & Critical Care Paramedic Edition
April 2026 opens with a landmark quarter for UK PHEM: the JRCALC resuscitation system overhaul goes live, the RCUK 2025 guidelines take formal effect, and a new FPHC crush injury standard replaces twenty-year-old doctrine. Internationally, epinephrine in traumatic cardiac arrest faces its most direct challenge yet, and the AHA delivers practice-changing stroke and PE frameworks that reshape prehospital destination decisions. Twenty-five items — curated, appraised, and ready to use at handover.
Key
CHANGE PRACTICE = operationally relevant change DipIMC/FIMC = exam-relevant topic 🔁 =
carry-over from tracking list
Contents
- Guidelines & Official Updates (8 items)
- Key Journal Articles & Trials (10 items)
- FOAMed & Critical Appraisal (5 items)
- Quick Hits / Also Notable (2 items)
- Action Points / This Month
1. Guidelines & Official Updates
1. JRCALC Resuscitation Update — April 2026 GUIDELINE CHANGE PRACTICE
Source: Joint Royal Colleges Ambulance Liaison Committee | Date: April 2026
Major overhaul of the UK termination of resuscitation (ToR) and verification of death (VoD) framework. The ROLE (Recognition Of Life Extinct) protocol is replaced by a new three-stage CUAD / ToR / VoD system. Minimum resuscitation time extends from 30 to 45 minutes before ToR can be considered. A mandatory 5-minute monitored asystole interval is required between ToR decision and VoD.
Paramedics gain increased clinical autonomy in decision-making for futile resuscitation scenarios.
Why it matters: Every UK paramedic and PHEM physician must be familiar with CUAD/ToR/VoD from April 2026. The extended minimum resus time will directly affect scene times for traumatic and medical OHCA — factor into HEMS tasking decisions and crew briefings.
Tell your department: "ROLE is gone from April 2026. CUAD replaces it with a new three-stage decision pathway — minimum 45 min resus, 5-min asystole monitoring before VoD. Brief your crews before the first cardiac arrest of the month."
2. RCUK 2025 Guidelines — Full Implementation 1 April 2026 GUIDELINE
Source: Resuscitation Council UK | Date: 1 April 2026 (implementation) | resus.org.uk
Formal implementation deadline for RCUK 2025 guidelines across all UK services. Key prehospital updates: jaw thrust is mandatory as first-line airway assessment step; airway management explicitly takes priority over spinal immobilisation; CPR on soft/uneven surfaces endorsed; paediatric 15:2 ratio reinforced for two-rescuer scenarios; POCUS integration for reversible causes in arrest.
Caution / Transition: Services still running 2021-era protocols are now non-compliant. Check your trust's implementation status. The jaw-thrust-first mandate changes initial airway assessment documentation requirements.
Tell your department: "Airway before spine — this is now the standard, not an exception. If your service hasn't formally adopted RCUK 2025, today is the deadline."
3. FPHC Crush Injury Consensus Statement (2025) — Replaces 2003 Document CONSENSUS
Source: Faculty of Pre-Hospital Care, RCSEd | Date: December 2025 | fphc.rcsed.ac.uk
New FPHC consensus statement on pre-hospital crush injury management replaces twenty-year-old guidance. Key changes: de-emphasis of aggressive fluid resuscitation prior to safe extrication; no routine prophylactic treatment of anticipated hyperkalaemia (calcium gluconate only if ECG changes or confirmed K+ elevation via POC monitoring); emphasis on early safe release of the compressing force as the primary intervention; individualised fluid strategy (guided by haemorrhage vs crush physiology); and rapid transfer to a Major Trauma Centre with capability for haemodialysis if rhabdomyolysis anticipated.
Why it matters: The 2003 protocol instructed aggressive IV resuscitation before extrication — a practice now known to accelerate reperfusion injury and worsen hyperkalaemia. This new standard directly changes the medical management of building collapses, industrial entrapment, and urban USAR incidents. POC potassium testing (iSTAT, Epoc) is now clinically indicated in prolonged entrapment.
Tell your department: "Crush syndrome: release first, targeted fluids second — not litre-bags before extrication. Pre-treat ECG changes, not anticipated hyperkalaemia."
4. FPHC Consensus Statement: Pre-Hospital Management of Injured Pregnant Patients 🔁 CONSENSUS
Source: Faculty of Pre-Hospital Care, RCSEd | Date: December 2025 | fphc.rcsed.ac.uk
UK-specific consensus covering the prehospital assessment and management of pregnant trauma patients. Key points: left lateral tilt from 20 weeks for haemodynamically compromised patients (manual uterine displacement preferred over wedging); permissive hypotension targets should be modified for pregnancy (SBP >90 mmHg minimum); TXA administration recommended as per standard haemorrhagic shock criteria; and resuscitative hysterotomy (perimortem caesarean section) should be considered at 20+ weeks gestation in maternal OHCA if standard resuscitation fails within 4 minutes. Fetal survival data: neonatal survival rates up to 45% are reported in literature when delivery occurs within the first few minutes of maternal arrest.
Why it matters: Pregnant trauma calls are uncommon but high stakes. This document provides the first formal UK PHEM consensus for managing this patient group — directly relevant to DipIMC/FIMC scenarios and operational protocols for HEMS and BASICS teams.
5. 2026 AHA/ACC Acute Pulmonary Embolism Guideline — New A–E Classification 🔁 GUIDELINE
Source: AHA/ACC/ACEP + 7 co-societies | Date: 19 Feb 2026 | Circulation 2026;153:e977–e1051 | doi.org/10.1161/CIR.0000000000001415 | PubMed
The first-ever dedicated AHA/ACC PE guideline, replacing the old low/intermediate/high-risk taxonomy with a new five-category (A–E) system based on clinical severity, biomarkers, RV dysfunction, and haemodynamic status. Categories C–E require hospitalisation with escalating advanced therapies. Category E (haemodynamic compromise) guides vasopressor selection: avoid deep sedation and mechanical ventilation where possible (RV-afterload effect); dobutamine for low-output RV failure. LMWH preferred over UFH for initial anticoagulation. PERT (PE Response Team) recommended. ACEP is a co-endorsing society — this governs emergency and prehospital care, not just cardiology.
Why it matters: HEMS and critical care retrieval teams now have a structured A–E framework to guide which patients need PERT consultation, ECMO centre direct conveyance, or aggressive in-flight resuscitation. Category E haemodynamic PE is a time-critical conveyance decision.
Counterpoint (PulmCrit): Josh Farkas identifies four flaws in the A–E system — see FOAMed section, Item 19. ESC 2019 stratification may still be preferable for prehospital risk triage.
6. 2026 AHA/ASA Acute Ischemic Stroke Guideline — MSU Class 1A, EVT Destination, Tenecteplase GUIDELINE
Source: American Heart Association / American Stroke Association | Date: 26 Jan 2026 | Stroke | doi.org/10.1161/STR.0000000000000513
Major update to the 2018 AIS guideline. Prehospital-specific changes: Mobile Stroke Units (MSU) receive Class 1, Level A recommendation where available — the first time any international guideline has issued its highest recommendation level for MSU (B-PROUD and BEST-MSU trials). EMS destination triage refined: direct bypass to EVT-capable centre endorsed where interhospital transfer is slow. Tenecteplase formally endorsed alongside alteplase within 4.5 h (single bolus = more practical in field/ED). EVT eligibility extended to 24 hours with advanced imaging. Validated prehospital stroke tools (FAST-ED, LAMS) encouraged for LVO identification.
Why it matters for UK PHEM: London's MSU is the largest in Europe — this guideline provides Class 1A backing for expansion nationally. For HEMS and critical care paramedics: LVO suspicion should now default to direct EVT centre unless transfer time considerations make thrombolysis-first logical. The tenecteplase endorsement aligns with NHS England pathway discussions.
Tell your department: "Suspected LVO: aim for the thrombectomy centre. Tenecteplase is now guideline-endorsed as a single bolus — operationally simpler than alteplase infusion."
7. Surviving Sepsis Campaign 2026 Adult Guidelines — 129 Statements, 46 New GUIDELINE
Source: Surviving Sepsis Campaign | Critical Care Medicine | doi.org/10.1097/CCM.0000000000007075 Paediatric version: Paediatric Critical Care Medicine
The 2026 SSC adult guidelines include 129 statements (46 new, 83 updated). Key prehospital-relevant changes: NEWS2 recommended over qSOFA for sepsis screening in prehospital and ED settings; MAP target of 60–65 mmHg in patients ≥65 years (less aggressive, reducing adverse events — from OVATION-65 trial); antibiotic deferral acceptable if source control not yet achieved and patient haemodynamically stable; 1–2 L crystalloid initial resus (not the old 30 mL/kg mandate); POCUS recommended for fluid responsiveness assessment. Paediatric
SSC 2026 introduces a revised paediatric sepsis definition and a conditional recommendation for POCUS in paediatric shock.
Why it matters: NEWS2 is already the UK standard — this SSC endorsement validates current NHS practice. The MAP 60–65 target in elderly patients is operationally relevant for critical care transport decision-making and vasopressor titration in septic patients ≥65 years.
Tell your department: "30 mL/kg blanket sepsis fluid protocol is gone from international guidelines — titrated 1–2 L with POCUS reassessment is the new framework."
8. MHRA Safety Alert: GLP-1 Agonists and Acute Pancreatitis (Feb 2026)
Source: Medicines and Healthcare products Regulatory Agency | Date: February 2026 | gov.uk/mhra
MHRA has strengthened warnings for acute pancreatitis with GLP-1 receptor agonists and dual GLP-1/GIP receptor agonists: dulaglutide, exenatide, liraglutide, semaglutide (Ozempic/Wegovy), and tirzepatide (Mounjaro). Risk appears higher in the first 6 months of treatment and with weight-loss doses. MHRA advises that any patient on a GLP-1 agonist presenting with acute abdominal pain should have pancreatitis actively excluded before attributing symptoms to other causes.
Safety point: GLP-1 usage has surged in the UK via NHS and private prescribing (Ozempic, Wegovy, Mounjaro). Prehospital clinicians will increasingly encounter these patients. Acute epigastric pain with vomiting in a GLP-1 user = pancreatitis until proven otherwise. Also note: GLP-1 users are at higher aspiration risk due to delayed gastric emptying — relevant for prehospital RSI.
2. Key Journal Articles & Trials
9. EAST Urban Penetrating Trauma Transport — Scoop and Run Evidence Base 🔁 SR/MA
Reference: J Trauma Acute Care Surg 2026;100:136–146 | DOI | PubMed | JEMS IPMI Review
EAST 12-member working group meta-analysed 13 studies comparing police/private vehicle vs EMS transport for adults with urban penetrating trauma. EMS did not improve survival to admission (OR 1.06, 95% CI 0.83–1.35) or to discharge. Private vehicle improved survival to admission over waiting for EMS (OR 0.31, 95% CI 0.11–0.85). Conditional recommendation: police or private vehicle transport over waiting for EMS in urban settings with short transport times. Traditional ALS interventions (IV access, fluids, intubation on scene) confer no benefit and may worsen outcome.
Why it matters: In London, Manchester, and Birmingham, police already occasionally transport penetrating trauma — this is the most robust evidence base yet for a formalised scoop-and-run protocol. It challenges the traditional HEMS value proposition for urban stab/gunshot wounds and has direct SOP implications.
Tell your department: "For urban penetrating trauma with a short transport window — minimal on-scene time beats comprehensive ALS on scene. Discuss whether your HEMS SOP reflects this."
10. EAST TXA Practice Management Guideline — 30-Study Meta-Analysis 🔁 SR/MA
Reference: J Trauma Acute Care Surg 2025;99:785–794 | DOI | PubMed
The most comprehensive TXA evidence synthesis yet: 19-member EAST group, 30 studies, 24 meta-analysable. Prehospital TXA associated with significant 24-hour mortality reduction (log RR −0.29, p=0.02) and 30-day mortality reduction (log RR −0.38, p=0.02). No increased VTE events. Conditional recommendation for routine prehospital TXA in patients at haemorrhagic risk (SBP ≤90 or HR ≥110 or clinical bleeding). TXA benefit maintained even in severe hypotension (SBP ≤75 mmHg). No strong recommendation for/against higher-dose bolus regimens.
Why it matters: This EAST PMG independently corroborates the NAEMSP/ACEP/ACS-COT TXA Position Statement (already covered in Q1). The 30-day survival signal is a meaningful advance. Together, two major bodies now issue concordant conditional recommendations — the case for universal prehospital TXA in UK HEMS/BASICS protocols is now very strong.
11. Epinephrine in Prehospital Traumatic Cardiac Arrest — No Survival Benefit, Possible Harm OBSERVATIONAL
Reference: Witt et al. Prehospital Emergency Care 2026;30:153–161 | PubMed 39889233 | JEMS IPMI April Review
Retrospective multi-centre analysis of 1,631 traumatic cardiac arrest patients across 7 trauma centres. Epinephrine was not associated with improved survival to discharge — in fact, survival was significantly lower in the epinephrine group (5% vs 16%, p<0.001). After propensity matching, no survival benefit was demonstrated. Causal inference limited by design (epinephrine given to sicker patients), but the signal is consistent with concerns that vasopressor-driven increase in afterload worsens haemorrhagic arrest physiology.
Safety point: Traumatic cardiac arrest has a distinct pathophysiology from medical arrest. In haemorrhagic arrest, epinephrine-driven vasoconstriction without volume repletion may worsen coronary and cerebral perfusion. UK JRCALC guidelines currently do not mandate adrenaline in traumatic CA — this data supports a trauma-focused algorithm (haemostasis, thoracostomy, volume) over the standard ALS drug protocol.
Tell your department: "In traumatic arrest: fix the cause (haemorrhage, tension, tamponade). Adrenaline should not be a reflex step — it is not associated with improved outcomes and may worsen them."
12. IV vs IO Vascular Access in OHCA — IV First Reinforced
Reference: Doa et al. Am J Emerg Med 2026;103:73–78
Large observational study comparing IO vs IV first-attempt vascular access in OHCA. IO group had significantly less ROSC (19.4% vs 26.7%). No significant difference in 30-day survival. Adds to the growing body of evidence that IO access — while faster to establish — may be associated with inferior drug delivery kinetics and haemodynamic outcomes in cardiac arrest. IV should remain the preferred first-attempt route where feasible; IO remains essential when IV is not achievable.
Caution: This is consistent with the PARAMEDIC-3 pilot RCT data (already published) suggesting IO may be inferior for drug delivery in arrest. IO remains standard for difficult access scenarios — but should not be the default first attempt when IV is achievable. Bolus flush technique matters: always use a 20 mL flush after IO drug administration.
13. Airway Device Order in OHCA — SGA First-Pass Success Exceeds ETI OBSERVATIONAL
Reference: Gage et al. JAMA Netw Open 2026;9(1):e2553413 | JEMS IPMI April Review
Large US registry analysis of airway device selection in OHCA. ETI was the most commonly used first-choice device (70.5% of cases) but SGA was associated with significantly higher first-pass success (93% vs 71%). No significant mortality difference between device types across the full cohort. Findings support a pragmatic approach: SGA (i-gel, LMA Supreme) as default first-choice in systems without high ETI proficiency or where RSI is not available; ETI appropriate in RSI-capable physician-led teams where first-pass success rates are maintained.
14. Paramedic i-gel Placement — 88% Positive Rate Confirmed
Reference: Wilhelm et al. Prehospital Emergency Care 2026;30:290–295 | JEMS IPMI April Review
Prospective analysis of paramedic i-gel placements in cardiac arrest. 88% positive placement rate (confirmed by waveform capnography). Supports i-gel as an effective, reliable SGA option in the UK JRCALC framework and corroborates existing evidence for i-gel as the SGA of choice in UK paramedic practice. Waveform capnography essential for confirmation — passive oxygenation without ETCO₂ should not be accepted as confirmed airway.
15. Low-Dose S-Ketamine for Prehospital Analgesia — Danish Paramedic Data 🔁 OBSERVATIONAL
Reference: Danish Medical Journal February 2026
Danish paramedic service analysis evaluating sub-dissociative S-ketamine (intranasal and IV) for acute prehospital pain management. Effective analgesia demonstrated with sub-dissociative IV S-ketamine 0.3 mg/kg — comparable to opioid regimens with fewer respiratory depression events. Adverse psychomimetic effects (emergence phenomenon) were uncommon at sub-dissociative doses and manageable in the prehospital environment. Relevant to UK services where S-ketamine is not routinely available (racemic ketamine is the UK standard) but growing interest in S-ketamine formularies for HEMS and critical care paramedic programmes.
Why it matters: With growing restrictions on prehospital opioid use and supply chain pressures, sub-dissociative ketamine has been proposed as a morphine adjunct or alternative. The Danish data provides a real-world safety and efficacy dataset applicable to UK critical care paramedic scope of practice discussions.
16. FiiRST-2 Trial: Factor Concentrates vs FFP in Trauma — Non-Inferiority Signal 🔁 RCT
Reference: da Luz LT et al. JAMA Netw Open 2025
RCT comparing early 4-factor prothrombin complex concentrate (4F-PCC) + fibrinogen concentrate to FFP-based resuscitation in traumatic haemorrhage. The factor concentrate strategy was non-inferior for 24-hour mortality. Secondary outcomes favoured factor concentrates for clot strength recovery (ROTEM/TEG parameters). Logistically, factor concentrates are faster to reconstitute, room-temperature stable, and require no blood group matching — significant advantages for prehospital use. Not yet approved as a standalone prehospital coagulopathy strategy in UK HEMS protocols, but provides platform for ongoing adoption of fibrinogen concentrate prehospitally.
Why it matters: Prehospital fibrinogen concentrate (RiaSTAP, Haemocomplettan) is already used by some UK HEMS. FiiRST-2 provides the strongest RCT evidence yet for factor concentrate-first haemostatic resuscitation — relevant to HEMS Trauma Cell formulary discussions and DipIMC exam scenarios on prehospital coagulopathy management.
17. Resuscitative Hysterotomy in OHCA — Neonatal Survival 45% in SR 🔁 SR/MA
Reference: Leech C et al. Resuscitation 2025
Systematic review of resuscitative hysterotomy (perimortem caesarean section, PMCS) performed in out-of-hospital cardiac arrest. Neonatal survival reported in 45% of cases where delivery was performed — significantly higher than in-hospital estimates for prolonged cardiac arrest scenarios. Maternal survival benefit less clear but mechanistically plausible (aortocaval decompression, improved CPR mechanics from ≥20 weeks gestation). Timing: current evidence supports initiation at 4 minutes of refractory arrest if ≥20 weeks gestation, consistent with RCUK 2025 guidance.
Why it matters: PMCS in the prehospital environment is a rare but potentially life-saving intervention. The 45% neonatal survival figure should inform team decision-making about hospital destination (obstetric/NICU capability) and physician-level procedure authorisation in HEMS operating procedures.
18. NHTSA/AHRQ Evidence-Based Guideline for Prehospital Airway Management — 22 Recommendations GUIDELINE
Reference: NHTSA/AHRQ, February 2026 | Full PDF (ABEM)
The first US national evidence-based guideline for prehospital airway management, 22 formal recommendations covering: airway assessment, BVM technique, SGA vs ETI selection, RSI criteria, and airway rescue. Notable positions: SGA recommended over ETI in systems without high ETI proficiency (consistent with UK data); RSI recommended in well-resourced/physician-led systems; BVM with PEEP valve should be considered as a pre-intubation oxygenation step; video laryngoscopy preferred over DL where available; ETCO₂ mandatory for ETI confirmation.
Context: Although US-focused, this guideline represents the most comprehensive recent synthesis of prehospital airway evidence. The SGA-over-ETI recommendation in lower-proficiency systems does not apply to UK HEMS (where RSI first-pass success is well documented), but the BVM optimisation and ETI confirmation standards are directly applicable to all UK paramedic and critical care practitioner airway training.
3. FOAMed & Critical Appraisal
19. PulmCrit: Four Fatal Flaws in the AHA/ACC PE Risk-Stratification (Farkas) REVIEW
Source: EMCrit / PulmCrit — Josh Farkas | 7 March 2026 | emcrit.org/pulmcrit/peguidelines/
Incisive critique of the new AHA/ACC A–E PE system. Farkas identifies: (1) the A–E categories do not map cleanly to treatment decisions; (2) thrombus burden (anatomy) is explicitly excluded from risk-stratification but drives many practical management decisions; (3) the guideline de-emphasises the proven ESC 2019 intermediate-high risk category in favour of an unvalidated A–E system; (4) vasopressor guidance for Category E patients may be inappropriate. Farkas concludes that the ESC 2019 low/intermediate/high system remains superior for prehospital and ED risk triage and that clinicians should be cautious before wholesale adopting the A–E framework.
Take-home: Read the guideline (Item 5 above) and the PulmCrit critique together. For UK PHEM: use the ESC 2019 framework as your primary prehospital PE risk tool; use the AHA A–E system to inform destination and PERT escalation conversations until the new system is validated in prospective cohorts.
20. St Emlyn's Podcast: DOSE VF and Double-Sequence Defibrillation (Cheskes, March 2026) REVIEW
Source: St Emlyn's Blog & Podcast | March 2026 | stemlynsblog.org
Sheldon Cheskes discusses the evidence behind double-sequence external defibrillation (DSED) for refractory ventricular fibrillation (defined as VF persisting after ≥3 defibrillation attempts). DOSE VF RCT (NEJM 2022) data revisited: DSED improved survival to discharge (30.4% vs 13.3%) and favourable neurological outcome vs standard defibrillation in refractory VF. Vector-change defibrillation also significantly better than standard. Cheskes clarifies implementation: two defibrillators required, simultaneous discharge in some protocols. Key question for UK PHEM: are your services equipped and trained for DSED in refractory VF?
Why it matters: Refractory VF is the "treatable" cardiac arrest rhythm where survival can be dramatically improved with an operational change (second defibrillator). DipIMC/FIMC candidates should know the DOSE VF data and DSED protocol in detail.
21. St Emlyn's: Pericardiocentesis for Traumatic Tamponade — Evidence Review (March 2026) REVIEW
Source: St Emlyn's Blog | 30 March 2026 | stemlynsblog.org
Review examining whether pericardiocentesis has a role in the prehospital management of traumatic pericardial tamponade — particularly in resource-limited settings or prolonged extrication scenarios where resuscitative thoracotomy is not immediately available. Concludes that POCUS-guided pericardiocentesis is technically feasible prehospitally and may serve as a temporising measure when definitive surgical intervention will be delayed. Current UK HEMS practice favours clamshell thoracotomy over pericardiocentesis for cardiac tamponade in traumatic arrest — this review does not challenge that but identifies a potential niche role in BASICS/wilderness/remote scenarios.
22. JEMS IPMI Literature Reviews — March & April 2026 REVIEW
Source: International Prehospital Medicine Institute / JEMS | March 2026 | April 2026
The IPMI bi-monthly literature reviews cover the key PHEM papers from the preceding period. The March 2026 issue flags the EAST Urban Penetrating Trauma PMG as "the most operationally significant trauma EMS paper" of the issue (see Item 9). The April 2026 issue covers: epinephrine in traumatic CA (Item 11), airway device order in OHCA (Item 13), i-gel paramedic placement (Item 14), and provides critical appraisal context for each. An efficient "catch-up" resource for UK practitioners wanting US perspective on the same evidence base.
23. ERC 2025 Avalanche Algorithm (AvaLife) + ICAR 60-Minute Burial Threshold Change GUIDELINE
Source: European Resuscitation Council / ICAR MEDCOM | ERC 2025 Guidelines | ICAR MEDCOM 2023 (Resuscitation DOI: 10.1016/j.resuscitation.2023.109708)
The ERC 2025 Special Circumstances chapter formally integrates the AvaLife algorithm for avalanche resuscitation, incorporating ICAR MEDCOM 2023 evidence. The critical operational change: burial threshold for distinguishing asphyxic from hypothermic cardiac arrest is now ≤60 minutes (previously ≤35 minutes). If burial ≤60 min with no vital signs: presume asphyxia, prioritise rescue breaths. If burial >60 min with cardiac arrest: manage as hypothermic arrest and consider ECLS-capable destination. The 150 cm burial depth threshold for multi-victim triage in mass casualty scenarios is also formally incorporated.
Why it matters: Scottish, Welsh, and northern England HEMS teams and mountain rescue MOs need to update their avalanche protocols. The 60-min threshold has doubled from the previously taught 35-min rule — this changes resuscitation decisions, airway priority, and ECLS referral criteria in avalanche arrest.
4. Quick Hits / Also Notable
- AHRQ Systematic Review: Prehospital Transfusion (ARC Bundle Signal) 🔁 SR/MA — AHRQ Feb 2026 update identifies early signal for benefit from the ARC Bundle (Albumin, RBC, Crystalloid) approach in prehospital haemorrhagic shock. Data immature; not yet practice-changing but worth monitoring. Relevant to UK HEMS blood product carriage protocols and ongoing PICO discussions around prehospital FFP vs packed red cells.
- Paediatric Medication Dosing Errors in EMS — System Factors Dominate 🔁 OBSERVATIONAL — Prehospital Emergency Care March 2026. Analysis of paediatric drug errors in EMS finds the majority of errors are weight-estimation related (Broselow tape not used or unavailable) and volume calculation errors at the point of draw-up, rather than agent selection errors. Direct implication for UK paediatric PHEM training: weight-based dosing apps (PaedDRug, ePaedDrug) and simulation should focus on administration errors, not just drug selection. Critical consideration for paediatric OHCA and major paediatric trauma — two high-stakes scenarios where dosing errors can be fatal.
5. Action Points / This Month
- Update your ToR/VoD knowledge now. CUAD replaces ROLE from April 2026. Ensure your team are briefed on the three-stage system, the 45-minute minimum resus rule, and the 5-minute asystole monitoring requirement before VoD.
- Check your service's RCUK 2025 implementation status. 1 April 2026 is the implementation deadline. Jaw thrust first, airway before spine — confirm these are reflected in your trust's SOPs and ClinQ documentation.
- Read the FPHC Crush Injury Consensus Statement at fphc.rcsed.ac.uk. Ensure your USAR/industrial entrapment protocol reflects individuallised fluid management and early POC potassium — not prophylactic alkali infusions.
- Review your stroke destination protocol against AHA/ASA 2026. Confirmed or high-probability LVO: does your service bypass to the nearest thrombectomy centre? Is tenecteplase on your HEMS formulary or in your pre-alert pathway for stroke?
- Consider your epinephrine policy for traumatic cardiac arrest. The evidence is now consistent: adrenaline does not improve outcomes in haemorrhagic arrest and may worsen them. Your team should default to a "cause-first" algorithm: haemostasis, thoracostomy, volume — not the standard ALS drug protocol.
- Ensure paediatric weight-estimation tools are accessible and used. Broselow tape or validated weight-estimation app should be reach-ready on every PHEM kit. Simulation scenarios should include draw-up and volume calculation steps.
- Pre-read PulmCrit PE critique before your next PE retrieval. The new AHA A–E system is the emerging standard but has documented weaknesses — know both frameworks before advising on PERT activation or ECMO centre conveyance.
Sources Checked This Issue
JRCALC · Resuscitation Council UK · Faculty of Pre-Hospital Care (RCSEd) · MHRA · NICE · AHA/ACC · AHA/ASA · Surviving Sepsis Campaign · EAST · ACS-COT · NHTSA/AHRQ · ICAR MEDCOM · ERC · NAEMSP · ILCOR · Prehospital Emergency Care · JAMA Netw Open · Circulation · Am J Emerg Med · J Trauma Acute Care Surg · Resuscitation · Danish Medical Journal
- EMCrit/PulmCrit · St Emlyn's · JEMS/IPMI · The Bottom Line
Next briefing: First week of May 2026
This newsletter is an educational summary for qualified prehospital and critical care practitioners. It does not constitute clinical guidance or replace local SOPs, drug protocols, or scope-of-practice frameworks. All clinical decisions should be made in the context of individual patient assessment and applicable trust or service protocols. Evidence is appraised to the best of the editor's ability; limitations of original studies apply.
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.