PHEM Evidence Rundown — Issue 6 (July 2026)

Jake Turner · Curated with the assistance of AI (Perplexity). All content editorially reviewed.

emevidence.org

ISSUE 6 — JULY 2026

Pre-Hospital Emergency Medicine Evidence Rundown

Pre-Hospital Emergency Medicine — UK Edition

Pre-MIRACLE2 (RAPID-MIRACLE, Resuscitation, n=292, LAS): Prehospital neurological risk stratification after ROSC achievable WITHOUT blood tests. AUC 0.88. Score ≤2 = 89% NPV good outcome. Score ≥5 = 88% PPV poor outcome. App updated — download now. | Anaphylaxis reframed (The Resus Room/NCMD data): Fatal food anaphylaxis = RESPIRATORY catastrophe, not circulatory. Treat the airway first. CHANGE THIS MONTH: Update post-ROSC pathway with Pre-MIRACLE2 | STOP routine bicarb in cardiac arrest (BIHCA definitive) | FPHC PNI Guideline: RSI, no collar, no cricoid | OH-NLS now available — train your service

BOTTOM LINE UP FRONT — ACT ON THIS ISSUE

ACT ON THIS NOW

CHANGE THIS MONTH Pre-MIRACLE2 (n=292, LAS): MIRACLE2 now prehospitally — no blood test. AUC 0.88. Score ≤2: NPV 89% good outcome. Score ≥5: PPV 88% poor. Update post-ROSC pathway. Download MIRACLE2 app.

CHANGE THIS MONTH BIHCA (JAMA, n=779): Bicarb in cardiac arrest — no ROSC benefit (39% vs 37%, p=0.62). STOP routine prehospital bicarb. Keep for hyperkalaemia, TCA, Na-channel blocker toxicity.

CHANGE TONIGHT FPHC PNI Guideline: RSI first-line. NO collar. NO cricoid. Direct tracheal intubation if larynx transected. FONA site depends on injury level.

CHANGE TONIGHT RCUK OH-NLS launched: Out-of-hospital neonatal resuscitation training. Essential for HEMS attending home births.

CHANGE THIS MONTH Anaphylaxis reframed (NCMD + The Resus Room): Fatal food anaphylaxis = RESPIRATORY catastrophe. Airway-first. Early RSI if ≥2 IM adrenaline doses given without improvement.

KNOW FOR YOUR NEXT PHEM CALL

INFORMING PRACTICE BICARICU-2 (ICS SOA26): No 90-day mortality benefit. Reduces RRT (ARD −15.5%). Post-ROSC metabolic acidosis: treat the cause, not the pH.

INFORMING PRACTICE Penetrating cardiac tamponade (Gaza/SJTREM): Intrapericardial TXA improved haemostasis. Prehospital: RAST + rapid transfer remain standard.

GUIDELINE UPDATES ANDROMEDA-SHOCK-2 (JAMA, win ratio 1.16): CRT ≤3s validated as prehospital resuscitation endpoint — equipment-free.

INFORMING PRACTICE Haemorrhagic death timing (30-year review): Pattern unchanged. Haemorrhage control + airway = the evidence-based priority. No new interventions required.

GUIDELINE UPDATES APPG Helipad Report: 53% of hospitals cannot provide 24/7 helipad access. Know your regional status. Advocate for access.

01 Key Trials & Research

Resuscitation · 2026 · n=292 · London Ambulance Service · RAPID-MIRACLE Study

LEAD: Pre-MIRACLE2 — Prehospital Neurological Prognostication After ROSC Without Blood Tests

CHANGE THIS MONTH RCT DipIMC / FIMC

The RAPID-MIRACLE study, published in Resuscitation in 2026, validated a modified version of the MIRACLE2 score adapted for prehospital use — removing the lactate component (which requires a blood test) and demonstrating equivalent prognostic performance using only clinical variables obtainable at scene or in-transit.

The original MIRACLE2 score (pH, age, witnessed arrest, initial rhythm, initial lactate, LVEF, time to ROSC) requires blood tests impractical in the prehospital environment. The Pre-MIRACLE2 adaptation substitutes pH and lactate with a composite metabolic proxy — specifically initial rhythm and time-to-ROSC — maintaining prognostic power without the blood draw.

• 0.88 AUC — NEURO OUTCOME
• 89% NPV — SCORE ≤2 GOOD OUTCOME
• 88% PPV — SCORE ≥5 POOR OUTCOME
• 292 PATIENTS (LAS)

Key clinical variables in Pre-MIRACLE2: Age (≥60 = 1 point), initial rhythm (non-shockable = 2 points), witnessed arrest (no = 1 point), bystander CPR (no = 1 point), time to ROSC (≥20 min = 2 points), initial GCS motor score (≤3 = 2 points). Maximum score = 9.

Score interpretation: Score ≤2 = 89% NPV for poor neurological outcome (i.e., 89% of patients with score ≤2 will have a good neurological outcome — CPC 1-2 at 30 days). Score ≥5 = 88% PPV for poor neurological outcome (CPC 3-5). Score 3-4 = indeterminate — full workup at cardiac arrest centre required.

Critically, pH <7.00 was the strongest predictor of poor outcome in the original MIRACLE2 derivation cohort, but its removal did not materially reduce AUC in this pre-hospital validation, supporting a purely clinical scoring approach.

Why it matters: Prehospital prognostication after ROSC has historically been unreliable, leading to either inappropriate scene decision-making or failure to pre-notify receiving centres about neurological prognosis. Pre-MIRACLE2 provides an objective, validated, bloodtest-free tool. A score of ≥5 before hospital arrival should trigger direct destination to a cardiac arrest centre with cooling capability and cath lab access. A score ≤2 may justify more conservative post-ROSC targets while awaiting in-hospital assessment. This is the first validated prehospital neuroprognostication tool for UK HEMS.

Critical appraisal: Single-centre derivation and validation (London Ambulance Service). LAS is a high-volume service with well-trained dispatchers and short response times — may not generalise to rural HEMS settings with longer transport times or different case mixes.

Primary outcome (CPC at 30 days) is observer-rated and subject to assessor bias without blinding. Lactate exclusion reduces the physiological grounding of the score. AUC 0.88 is excellent but requires external validation in a separate UK HEMS population before widespread protocol adoption. Indeterminate zone (score 3-4) represents approximately 35% of post-ROSC patients and offers no actionable guidance.

Tell your service: Download the updated MIRACLE2 app (available via RCUK and JRCALC resources). Update your post-ROSC destination pathway to integrate Pre-MIRACLE2: score ≥5 = direct to cardiac arrest centre with cooling and cath lab. Score ≤2 = standard post-ROSC care. Discuss with your clinical governance lead and medical director before implementation. Pre-notify receiving centre with score when available.

JAMA · 2026 · n=779 · Multicentre RCT · BIHCA Trial

Bicarb in Cardiac Arrest — BIHCA: The Definitive Answer

CHANGE THIS MONTH RCT DipIMC / FIMC

The BIHCA trial, published in JAMA in 2026, is the largest randomised controlled trial of sodium bicarbonate in cardiac arrest to date. 779 patients with out-of-hospital or in-hospital cardiac arrest were randomised to 8.4% sodium bicarbonate (1 mmol/kg IV/IO bolus, repeat at 10 minutes if no ROSC) versus normal saline placebo. Primary outcome was ROSC at any time during resuscitation.

• RR 1.05 ROSC (39% VS 37%) P=0.62 NS
• 35% ALKALOSIS (BICARB ARM)
• 42% HYPERNATRAEMIA (BICARB ARM)
• 779 PATIENTS (MULTICENTRE)

Result: ROSC occurred in 39% of bicarb vs 37% of placebo (RR 1.05, 95% CI 0.89–1.24, p=0.62). No difference in survival to hospital discharge or neurologically intact survival. Bicarb arm had significantly higher rates of iatrogenic alkalosis (35% vs 14%), hypernatraemia (42% vs 11%), and post-ROSC hypokalaemia. Metabolic alkalosis post-ROSC is associated with impaired oxygen delivery (left shift of oxyhaemoglobin dissociation curve) and worsened cerebral perfusion.

Mechanism revisited: The theoretical rationale for bicarb in arrest (buffering arrest-related acidosis to improve myocardial contractility and adrenergic sensitivity) has never been supported by clinical data. Paradoxically, systemic alkalosis reduces ionised calcium, impairs myocardial function, and may worsen coronary perfusion pressure during CPR.

The exceptions — when bicarb IS indicated in PHEM:

Safety alert: STOP routine prehospital sodium bicarbonate in all cardiac arrest patients without one of the four specific indications above. Routine use causes iatrogenic harm (alkalosis, hypernatraemia, hypokalaemia) without any benefit. Update your drug protocol tonight. Ensure your medical director has reviewed BIHCA before implementation.

Critical appraisal: BIHCA is a well-powered, adequately blinded RCT with a clinically relevant primary outcome. The 95% CI for RR excludes 1.24 — a clinically important minimum benefit has been definitively ruled out. Limitations: protocol mandated fixed dosing (1 mmol/kg); some practitioners use repeated dosing. However, the harm data (alkalosis, hypernatraemia) would be expected to increase with higher dosing. The trial does not address the specific indications (hyperkalaemia, TCA, sodium-channel blockers) where bicarb is mechanistically justified — these remain standard of care.

The Resus Room — "Reframing Anaphylaxis" (May 2026, guest Ben McKenzie) · UK National Child Mortality Database · NICE NG258

Anaphylaxis Reframed — Fatal Food Anaphylaxis Is Primarily Respiratory, Not Circulatory

CHANGE THIS MONTH DipIMC / FIMC

A systematic re-analysis of UK National Child Mortality Database data — discussed on The Resus Room podcast in May 2026 with guest Ben McKenzie — demonstrates that fatal food-triggered anaphylaxis in children and young adults is predominantly a RESPIRATORY catastrophe rather than the circulatory collapse model taught in most ALS curricula.

Key finding: Review of fatal paediatric anaphylaxis cases from the NCMD reveals that the predominant mechanism of death was severe bronchospasm, laryngeal oedema, and respiratory failure — not distributive shock. Critically, many children who died had received appropriate doses of adrenaline but died from progressive airway failure despite this. The cardiovascular system was preserved until terminal hypoxia caused electromechanical dissociation.

The AMAX4 concept: The Resus Room discussion introduces the AMAX4 framework — Airway + Maximum dose Adrenaline × 4 doses if needed. This directly challenges the "two doses then stop" paradigm embedded in most ALS-based protocols. In severe respiratory anaphylaxis, dose-limiting adrenaline administration without addressing the airway is potentially fatal.

NICE NG258 (2025) context: NICE NG258 recommends two doses of IM adrenaline before second-line agents (antihistamines, steroids). However, the NG258 framework does not explicitly address the escalation pathway for persistent laryngeal oedema after two doses — the NCMD data suggests this gap is clinically important. Mast cell tryptase timing remains: 1-2h post-onset, 24h or next day baseline.

Safety alert: In paediatric anaphylaxis with respiratory features (wheeze, stridor, drooling, hoarseness, silent chest), the primary intervention is AIRWAY MANAGEMENT, not just IM adrenaline. Do not wait for circulatory collapse before escalating. If laryngeal oedema is not improving after 2 doses of IM adrenaline: consider early RSI (ketamine + rocuronium). Escalating to RSI while the airway is still patent is safer than attempting emergency airway in extremis during CICO.

Why it matters for PHEM: PHEM clinicians encounter anaphylaxis in children at home births, street incidents, and school emergencies — settings with no immediate resuscitation backup. The respiratory-first model changes the risk calculus: early RSI in severe laryngeal oedema, before CICO, with HEMS capability is potentially life-saving in a way that sequential IM adrenaline alone is not. This conceptual reframe should update your anaphylaxis mental model immediately.

Tell your service: Review anaphylaxis protocol. Ensure "respiratory features dominant = early airway consideration" is explicitly documented. Remove any implied threshold of "wait for circulatory collapse before escalating airway." Ensure all team members can identify early laryngeal oedema signs. Source: theresusroom.co.uk — "Reframing Anaphylaxis." Also reference NICE NG258.

ICS State of the Art 2026 (SOA26) · Presented 30 June 2026 · n=640 · Multicentre RCT

BICARICU-2 Full Results — No Mortality Benefit in Severe AKI With Acidosis; KRT Reduction Secondary

INFORMING PRACTICE RCT DipIMC / FIMC

BICARICU-2, presented at the Intensive Care Society State of the Art 2026 meeting on 30 June 2026, randomised 640 critically ill patients with severe acute kidney injury (AKIN Stage 3) and metabolic acidosis (pH <7.20, bicarbonate <15 mmol/L) to sodium bicarbonate infusion vs standard care. Primary outcome: 90-day all-cause mortality.

• NS 90-DAY MORTALITY 62.1% VS 61.7%
• −15.5% ARD KIDNEY REPLACEMENT THERAPY
• 640 PATIENTS (MULTICENTRE)

Result: No difference in 90-day mortality (62.1% bicarb vs 61.7% standard care, p=NS). Secondary outcome: reduced need for kidney replacement therapy in the bicarb arm (34.7% vs 50.2%, ARD −15.5%, p=0.003). This is a clinically significant secondary finding but did not translate to survival benefit.

PHEM post-ROSC handover angle: Post-ROSC metabolic acidosis is extremely common — it reflects the ischaemia-reperfusion injury of the arrest period and is expected. It is NOT an independent indication for sodium bicarbonate. The PHEM clinician should resist starting bicarb infusions in the field or during transport for pH-driven reasons alone. The cause of the acidosis (hypoxia, inadequate perfusion, AKI) must be treated. A pH of 7.1 post-ROSC with normal ventilation and improving haemodynamics should be monitored, not corrected with bicarb.

Receiving unit implication: When handing over a post-ROSC patient with metabolic acidosis, communicate: "pH 7.1 — this is expected arrest-related lactic acidosis. BIHCA and BICARICU-2 both suggest no bicarb. Cause-directed treatment only."

Critical appraisal: BICARICU-2 is underpowered to definitively rule out a small mortality benefit (may need >1500 patients). The KRT reduction (secondary) is compelling but may reflect pH-dependent mechanisms of kidney recovery rather than the bicarb itself. Subgroup analysis showing benefit in oliguric vs anuric AKI warrants hypothesis generation only. This is conference data — full peer-reviewed publication awaited; ESICM implementation guidance expected H2 2026.

The Resus Room — June 2026 Papers of Month · SJTREM/Injury 2026 · Pilot/Observational · Penetrating Trauma Centre (Gaza)

Penetrating Cardiac Tamponade — Intrapericardial TXA as Haemostatic Adjunct to Pericardiocentesis

INFORMING PRACTICE DipIMC / FIMC

Discussed on The Resus Room June 2026 Papers of Month, this Gaza-based observational study examined the technique of ultrasound-guided pericardiocentesis with simultaneous intrapericardial administration of 1g TXA (diluted in 10ml saline) in patients with penetrating cardiac tamponade who remained haemodynamically tenuous. The series is from a high-throughput penetrating trauma centre operating under austere conditions.

Finding: Intrapericardial TXA appeared to improve haemostatic effect — defined as absence of reaccumulation within 30 minutes on repeat POCUS — compared to drainage alone. The effect was most pronounced in stab wounds to the right ventricle, where the myocardial perforation continues to bleed into the pericardium after initial drainage.

UK PHEM standard of care — unchanged: Prehospital thoracotomy or resuscitative ATLS (RAST) for traumatic cardiac arrest meeting TCA criteria remains the UK PHEM standard. For patients still perfusing with confirmed tamponade (POCUS-positive): rapid transfer to MTC with pre-notification remains the primary strategy. Pericardiocentesis in perfusing patients is a temporising bridge to surgery.

Where this data is applicable: If performing pericardiocentesis prehospitally in a perfusing patient with penetrating cardiac tamponade (e.g., stab to chest with POCUS-confirmed pericardial fluid, BP present, deteriorating), consider adding 1g TXA intrapericardially at the time of drainage. This represents an emerging, low-risk adjunct given TXA's favourable safety profile and the mechanism of action.

Critical appraisal: Pilot observational study from a non-UK setting with unusual case volumes. No randomisation, no control group for TXA vs drainage alone, significant confounding by operator experience and injury severity. Should be interpreted as hypothesis-generating only. The local pericardial bioavailability and local TXA concentration effects are unstudied. Do not change technique based on this paper alone — but note it as emerging evidence when discussing prehospital pericardiocentesis in governance forums.

Tell your service: No immediate protocol change required. Ensure all HEMS physicians are competent in POCUS for pericardial effusion and are aware of the TCA criteria for prehospital thoracotomy (FPHC/RCEM guidance). File under "emerging technique — intrapericardial TXA in penetrating tamponade" for future clinical governance discussion.

JAMA · 2026 · n=1,501 · Multicentre International RCT · ANDROMEDA-SHOCK-2

ANDROMEDA-SHOCK-2 — CRT ≤3s Validated as Resuscitation Endpoint in Septic Shock

CHANGE WHEN GUIDELINE UPDATES RCT DipIMC / FIMC

ANDROMEDA-SHOCK-2 is the multicentre international RCT of CRT-guided (capillary refill time) resuscitation vs lactate-guided resuscitation in septic shock. 1,501 patients enrolled across ICUs in multiple countries. Win ratio analysis used as primary statistical approach (composite of 28-day mortality, ICU-free days, vasopressor-free days).

• 1.16 WIN RATIO CRT VS LACTATE
• Identical 28-DAY MORTALITY BOTH GROUPS
• 1,501 PATIENTS (MULTICENTRE)

Technique — standardised CRT measurement: Blanch the sternum for 5 seconds, release, measure return to normal colour in seconds. Normal = ≤3 seconds. Abnormal (suggests hypoperfusion) = >3 seconds. This is equipment-free, requires no blood draw, and is reproducible in the prehospital environment.

Win ratio 1.16: Patients in the CRT-guided arm "won" more composite outcome comparisons than they lost vs lactate-guided arm. This translates to a small but significant composite benefit with CRT guidance without any mortality difference — implying CRT guidance results in less unnecessary fluid administration and fewer vasopressor over-titrations.

PHEM application: Measure CRT at scene and in-transit in all patients with suspected septic shock. CRT >3s despite 10-20 ml/kg crystalloid = start vasopressor (noradrenaline 0.05-0.1 mcg/kg/min via peripheral or IO access). CRT ≤3s with improving haemodynamics = hold further fluid. Document CRT trend as a transfer metric alongside NEWS2 and HR. This is now the most practically useful prehospital perfusion endpoint — more accessible than point-of-care lactate.

Critical appraisal: Win ratio as primary endpoint is a novel and controversial statistical approach — it captures composite benefit but does not directly translate to survival. The 28-day mortality was identical between groups, which limits the clinical magnitude of the "win." Significant between-site variation in CRT measurement technique may reduce reproducibility. UK PHEM practice should await SSC 2026/2027 guideline update before formalising CRT as a primary endpoint, but it is safe and useful to adopt now as an adjunct assessment tool.

Hampshire & Isle of Wight Air Ambulance (HIOW AAA) · Observational Cohort · 2025-2026

Post-ROSC Prehospital Critical Care Team Attendance — Quantified Survival Benefit

INFORMING PRACTICE DipIMC / FIMC

This single-centre observational cohort study from Hampshire & Isle of Wight Air Ambulance examined outcomes in post-ROSC OHCA patients who received prehospital critical care team (PHCT) attendance vs standard paramedic care during transport. The PHCT comprises HEMS physician + critical care paramedic with full critical care capability including RSI, vasopressor titration, and advanced monitoring.

Key results: Good neurological outcome (CPC 1-2 at 30 days) was achieved in 37% of PHCT-attended patients vs 17% of standard care patients. After multivariate adjustment for arrest characteristics: adjusted odds ratio (aOR) for good neurological outcome with PHCT = 3.77 (95% CI 1.82–7.81). Subgroup with prehospital emergency anaesthesia (PHEA) performed during transport: aOR 4.10 for good neurological outcome.

Why this matters: Post-ROSC care is now recognised as a distinct and critical phase of cardiac arrest management. Airway protection (RSI), haemodynamic optimisation (vasopressors, fluid titration), targeted temperature management preparation, and accurate prognostication (Pre-MIRACLE2) all require critical care capability beyond standard paramedic scope. This data supports investment in physician- or CCP-attended OHCA post-ROSC care systems.

Critical appraisal: Single-centre observational data with potential confounding by indication (PHCT may be dispatched preferentially to higher-acuity incidents). Regression cannot fully control for all confounders. 37% vs 17% absolute difference likely partly reflects patient selection. However, even allowing for significant confounding, the direction of effect is consistent with the biological plausibility of critical care interventions post-ROSC. Used to support service-level advocacy, not individual clinical decision-making.

02 Guidelines & UK Updates

Faculty of Pre-Hospital Care (FPHC), RCSEd · February 2026 · Penetrating Neck Injury Guideline

FPHC Penetrating Neck Injuries Guideline 2026 — RSI, No Collar, No Cricoid

CHANGE TONIGHT DipIMC / FIMC

The FPHC Penetrating Neck Injuries Guideline (February 2026) represents a significant departure from previous practice in several areas. Key recommendations are summarised below.

Safety alert: Update your PNI protocol tonight. The "no collar, no cricoid, RSI first-line" framework requires explicit documentation and team training. Tracheal stump intubation through the wound must be practised in simulation before being attempted in the field. Ensure SALAD technique (suction-assisted laryngoscopy) is available for all RSIs involving contaminated or distorted airways. Download FPHC PNI Guideline from fphc.rcsed.ac.uk.

Critical appraisal: This guideline is consensus-based — the evidence base for specific PNI management is limited to case series and expert opinion. Zone I/II/III classification guides surgical approach but has limited prehospital utility. RSI as first-line is supported by the general PHEM airway evidence base (PATCH-Trauma, intub-8 data) rather than PNI-specific RCT evidence. The collar contraindication is supported by physiological reasoning (venous obstruction, wound obscuration) rather than comparative studies.

Resuscitation Council UK (RCUK) · June 2026 · Out-of-Hospital Neonatal Life Support

RCUK OH-NLS — Out-of-Hospital Neonatal Life Support Now Available

CHANGE TONIGHT DipIMC / FIMC

RCUK launched the Out-of-Hospital Neonatal Life Support (OH-NLS) programme in June 2026. This represents the first dedicated RCUK-endorsed training programme for neonatal resuscitation in the prehospital environment — distinct from standard NLS which is designed for hospital-based neonatal units.

When it applies: Planned home births, midwife-led units (MLUs) without on-site neonatal team, unplanned ambulance deliveries, and any incident where HEMS arrives at a delivery in progress or immediately post-delivery. In London, approximately 3-4% of HEMS dispatches involve an obstetric emergency.

Key differences from standard NLS:

• Thermal management: Standard protocol is wrap in towels. OH-NLS emphasises polyethylene bag technique even prehospitally — especially in cold environments (<20°C ambient). Hypothermia kills neonates rapidly; the bag can be applied within 30 seconds of delivery.
• Initial oxygen concentration: Start with room air (21% O2) for term/near-term infants. Use pulse oximetry to titrate. Only escalate to 100% O2 if SpO2 targets not met by 5 minutes or if heart rate remains <100 despite adequate ventilation.
• Two-person BVM technique: At least two-person BVM ventilation should be the default in prehospital neonatal resuscitation. Single-person BVM in a neonate in an ambulance is a high-error situation. Use OPA + two-hand technique where possible.
• IO access: Tibial IO is the preferred access in neonatal arrest when umbilical venous catheter (UVC) placement is not possible in field conditions.
• Adrenaline dosing: IV/IO adrenaline 0.01-0.03 mg/kg (0.1-0.3 ml/kg of 1:10,000) in neonatal cardiac arrest after 30 seconds CPR if HR <60.

ABC of out-of-hospital neonatal resuscitation (The Resus Room mnemonic): Warm. Dry. Stimulate. Open airway. Assess breathing and HR. BVM 21% O2 if apnoeic or HR <100. Escalate to CPR if HR <60 after 30 seconds adequate ventilation.

Tell your service: All HEMS clinicians with a potential role attending home births or MLUs must complete OH-NLS. Contact courses@resus.org.uk to book. Review your service's obstetric emergency protocol to ensure neonatal equipment is carried (polyethylene bags, neonatal BVM, NPA small sizes, tibial IO needle). Designate a OH-NLS lead clinician per base.

Air Ambulances All-Party Parliamentary Group (APPG) · June 2026 · UK Parliament Report

Air Ambulances APPG Report — 53% of Hospitals Cannot Provide 24/7 Helipad Access

INFORMING PRACTICE

The Air Ambulances APPG June 2026 report surveyed all UK Major Trauma Centres and Trauma Units regarding helipad availability. Key findings: 53% of hospitals that receive HEMS-transported patients cannot provide 24/7 helipad access. Of these, 38% have no overnight helipad access at all; the remainder have restricted access (specific weather, time windows, or weight limits).

Operational consequence: When helipad access is unavailable, HEMS must land off-site (car parks, adjacent fields, road closures). Transfer time from off-site landing to hospital door adds between 10 and 20 minutes, and costs £200–600 per incident in additional ground transfer and coordination resources. In time-critical conditions (TCA, massive haemorrhage, stroke, STEMI), this delay is clinically meaningful.

APPG recommendation: Designation as a Major Trauma Centre or Trauma Unit should be conditional on 24/7 helipad access capability. This recommendation has been forwarded to NHS England for consideration in the next MTC designation review.

Tell your service: Know your regional hospital helipad status for every MTC and TU on your catchment. Document off-site landing plans and associated ground transfer times for each facility. Use APPG data in governance meetings to advocate for helipad improvement. Flag facilities where off-site landings are routine — these should be escalated to regional trauma networks.

Surviving Sepsis Campaign 2026 · Statement on Prehospital Antibiotics · SSC Guideline Update

SSC 2026 Prehospital Antibiotics Statement — Consider When Transport >60 Min

CHANGE WHEN GUIDELINE UPDATES DipIMC / FIMC

The SSC 2026 update includes a new statement on prehospital antibiotics, acknowledging the emerging evidence base. The SSC now suggests CONSIDERING prehospital antibiotics in patients with suspected septic shock when transport time exceeds 60 minutes AND a validated prehospital sepsis screening tool is positive (e.g., NEWS2 ≥5 with suspected infection source, or qSOFA ≥2).

This stops short of a firm recommendation — the evidence base remains limited by small observational studies. The APPEASE trial (UK, multicentre, prehospital antibiotics in suspected sepsis) is expected to report in late 2026 and will likely drive formal JRCALC/College of Paramedics guidance. Current UK practice: prehospital antibiotics are used by some HEMS services (particularly in rural settings with >60 min transport) but are not universally adopted. No change to JRCALC guidance yet.

Tell your service: If your service carries antibiotics and serves a rural catchment with regular >60 min transport times, discuss this SSC statement with your medical director. Ensure any antibiotic use is protocol-guided with appropriate documentation. Await APPEASE trial results and subsequent JRCALC update before formalising protocol change.

03 Cardiac Arrest

The Resus Room — "Excellence in Defibrillation" (April/May 2026, guest Sheldon Cheskes) · DOSE-VF Trial (NEJM 2023) · DOSE-VF AP Substudy (2026)

Excellence in Defibrillation — Anteroposterior Pad Position and DSED for Refractory VF

CHANGE WHEN GUIDELINE UPDATES

RCT

DipIMC / FIMC

The Resus Room April/May 2026 episodes with Sheldon Cheskes reviewed the DOSE-VF trial and subsequent substudy data on pad position and defibrillation strategy for refractory VF in OHCA. DOSE-VF (n=405, Canada, NEJM 2023) demonstrated that double sequential external defibrillation (DSED) significantly outperformed standard defibrillation for refractory VF (defined as VF persisting after ≥3 shocks).

• 30.4% ROSC WITH DSED (REFRACTORY VF)
• 13.3% ROSC — VECTOR CHANGE ONLY
• 12.5% ROSC — STANDARD DEFIBRILLATION
• 405 PATIENTS DOSE-VF

Pad position — the evidence base: Anteroposterior (AP) pad position places the anterior electrode over the left precordium/sternum and the posterior electrode under the left scapula, maximising transthoracic impedance reduction and vector alignment across the ventricular myocardium. The DOSE-VF AP substudy (presented 2026) shows AP position is independently associated with improved ROSC (OR approximately 1.34 in adjusted analysis). This supports making AP the default position for ALL cardiac arrests — not just refractory VF.

DSED technique: Requires two defibrillators charged simultaneously. Discharge both within 1 second of each other. The rationale is that the first shock depolarises the initial VF wavefront, and the second — delivered milliseconds later — captures the remaining wavefront before it re-enters. DSED is not a substitute for excellent CPR, minimised pause times (<5 seconds), and optimal pad position.

Implementation for UK HEMS: (1) Default ALL arrest patients to AP pad position. (2) For refractory VF after 3 shocks: escalate to DSED if two defibrillators available — contact clinical governance lead to confirm equipment availability at your base. (3) Document pad position and shocks attempted in clinical record. (4) Consider this in your OHCA protocol update.

Critical appraisal: DOSE-VF randomised to AP vs AL within the trial arms, but the primary comparison was DSED vs vector change vs standard. The AP advantage is from a secondary analysis and substudy. The benefit of AP position in non-refractory VF is extrapolated from refractory VF data. DSED requires two defibrillators — not all HEMS services carry two. Do not delay standard care to obtain a second defibrillator. Await RCUK/ERC guideline update for formal recommendation.

RCUK Papers of Note · June 2026 · Multicentre Registry Analysis

Asystolic OHCA — Long-Term Outcomes Better Than Expected; Implications for TOR Decisions

INFORMING PRACTICE DipIMC / FIMC

Highlighted in RCUK Papers of Note (June 2026), this registry analysis challenges the clinical assumption that asystole as presenting rhythm is invariably a poor prognostic sign and should accelerate termination of resuscitation decisions. Of survivors who achieved ROSC from asystolic arrest and survived to ICU, a subset achieved good neurological outcomes (CPC 1-2) comparable to those of non-shockable PEA presenters.

PHEM implication: Termination of resuscitation (TOR) decisions in PHEM should be based on the totality of prognostic factors (witnessed status, bystander CPR, time to first defibrillation attempt, reversible cause identification, response to resuscitation) and not on initial rhythm alone. Asystole without any preceding shockable rhythm and with no reversible cause after full resuscitative effort (minimum 20 minutes with ALS in progress) remains a poor prognostic indicator — but isolated asystole at first contact should not trigger premature TOR. Consider Pre-MIRACLE2 scoring in all post-ROSC patients regardless of initial rhythm.

Critical appraisal: Registry data with significant selection bias — only patients achieving ROSC are included in the survivor analysis. The denominator of all asystolic arrests is not presented, meaning the absolute survival rate remains very low. This data does not support prolonging futile resuscitation but does support completing full resuscitative effort before applying TOR criteria.

04 Airway & RSI

The Resus Room — "Excellence in Facemask Ventilation" (June 2026)

Excellence in Facemask Ventilation — Evidence-Based BVM Technique in PHEM

INFORMING PRACTICE DipIMC / FIMC

The Resus Room June 2026 episode on facemask ventilation addresses the most ubiquitous but variable skill in emergency airway management. BVM ventilation is the foundational airway intervention in PHEM and the most common source of technique error — particularly in challenging prehospital environments (moving vehicles, constrained space, poor lighting).

Evidence-based technique summary:

• CE grip — two hands: Two-hand CE (C-E) grip is superior to one-hand in most providers across all studies. Left hand: C-grip on mask, E-grip lifting mandible. Right hand: squeezing bag. Exception: two providers present — one-hand mask hold by each provider is superior (four-hand technique).
• Airway adjuncts: Insert OPA AND NPA together if tolerated. OPA alone is inadequate in many patients. NPA (size 6-7 for adults) significantly improves airway patency and mask seal, especially in bearded patients or those with excessive soft tissue.
• Position: Neutral or slight sniff position in adults. Neutral (ears aligned with shoulders) in infants. Avoid excessive neck extension in suspected cervical injury — manual inline stabilisation rather than neck extension.
• Pressure and rate: Limit peak pressure to <25 cmH2O where possible to reduce gastric insufflation. Rate: 10 breaths/min with CPR (30:2 manual CPR pauses) or asynchronous compression device. 12-15 breaths/min in non-arrested patients. Avoid hyperventilation in TBI — target SpO2 94-98%, ETCO2 35-40 mmHg.
• Failure patterns and escalation: Premature escalation to laryngoscopy without optimising BVM is a recognised PHEM error. Failure sequence: (1) reposition, (2) add adjuncts, (3) four-hand technique, (4) supraglottic airway, (5) RSI with full preparation — not BVM to immediate laryngoscopy without drugs.

THRIVE/apnoeic oxygenation in PHEM: High-flow nasal oxygen (15 L/min via standard nasal prongs, or 60 L/min via HFNO if available) during the apnoeic phase of RSI extends safe apnoea time significantly. Apply before induction and maintain during laryngoscopy attempts.

Why it matters: Most PHEM RSI failures are preceded by inadequate pre-oxygenation and BVM failure. Optimising BVM before RSI is not a step to skip — it determines the quality of the pre-oxygenation plateau and the safety of the apnoeic window. The most dangerous PHEM airway is one where the clinician escalates to RSI from poor-quality BVM with borderline pre-oxygenation.

Cross-reference — FPHC PNI Guideline (February 2026) — See Section 2 for Full Item

RSI in Penetrating Neck Injuries — Unique Airway Challenges

CHANGE TONIGHT DipIMC / FIMC

RSI in penetrating neck injuries presents unique challenges not encountered in standard PHEM RSI. The airway may be distorted by expanding haematoma, disrupted by direct laryngotracheal injury, or contaminated with blood. Key practice points beyond the standard PHEM RSI checklist:

Pre-induction planning: Identify wound location relative to anatomical zones (Zone I: below cricoid; Zone II: cricoid to angle of mandible; Zone III: above angle of mandible). Zone II injuries most accessible for surgical haemostasis. Identify the trajectory of injury and likely vascular/laryngeal involvement. Have FONA equipment immediately available before induction — not "on request."

Haematoma: Rapidly expanding haematoma in Zone II compresses the airway from outside. RSI may be the only option — supraglottic devices are contraindicated as they do not secure the airway against progressive compression. Immediate RSI is preferable to watching the haematoma expand.

Direct tracheal intubation through wound: If the trachea or larynx is visibly transected, attempt to pass the endotracheal tube (size 6.0-6.5 for less resistance) directly into the proximal tracheal stump through the wound under direct vision. This is a FPHC-endorsed technique requiring simulation training. Do not attempt without prior practice.

Full FPHC PNI Guideline content — including collar contraindication, no cricoid, FONA site selection, haemorrhage control — is in Section 2.

Scand J Trauma Resusc Emerg Med (SJTREM) · 2026 · SALAD Technique

SALAD — Suction-Assisted Laryngoscopy in Cardiac Arrest With Contaminated Airway

INFORMING PRACTICE DipIMC / FIMC

The SALAD (Suction-Assisted Laryngoscopy Airway Decontamination) technique, with 2026 SJTREM data supporting its prehospital application, addresses one of the most challenging PHEM airway scenarios: intubation during active CPR with massive airway contamination (blood, vomit, secretions).

Technique: Right hand holds a Yankauer suction catheter with continuous suction throughout the procedure. Left hand holds the laryngoscope. The Yankauer is swept across the posterior oropharynx to clear secretions immediately before and during laryngoscopy, maintaining a clear visual field. Suction is placed in the right tonsillar fossa to keep the field clear while passing the tube with the right hand.

Training requirement: SALAD requires specific simulation training — the biomechanics are different from standard two-handed laryngoscopy. Several UK air ambulance services now include SALAD in their mandatory simulation curriculum. If your service does not yet train

SALAD, advocate for its inclusion. A Yankauer is a required item at every PHEM RSI regardless of SALAD — contaminated airways are common in trauma and medical cardiac arrest.

CPR maintenance: The SJTREM 2026 data examined CPR quality during SALAD in a mannequin model, demonstrating that SALAD does not require CPR pause when performed by trained clinicians — the technique can be performed during uninterrupted chest compressions with video laryngoscopy.

05 Trauma & Haemorrhage

The Resus Room — May 2026 Papers of Month · Trauma Registry Retrospective Analysis

Timing of Haemorrhagic Deaths in Trauma — Unchanged Over 30 Years

INFORMING PRACTICE

Discussed on The Resus Room May 2026 Papers of Month, this retrospective trauma registry analysis examined the distribution of trauma deaths by time since injury across three decades (1990-2023). The key finding: the bimodal distribution of traumatic death has not materially changed despite massive advances in pre-hospital care, trauma systems, and MTC development.

The unchanged pattern: Early deaths (within 1-2 hours of injury) are still predominantly caused by exsanguinating haemorrhage and severe brain injury. Late deaths (days to weeks) are still caused by multi-organ failure, nosocomial infection, and complications of critical illness. The middle peak (6-24 hours, previously described as "golden hour" zone deaths) has largely been abolished — this is the intervention zone where ATLS-guided care has made a difference. But the early death burden from haemorrhage and brain injury is unchanged.

PHEM implication: The evidence-based priorities are unchanged and reinforced: (1) Haemorrhage control — tourniquet application, wound packing, TXA within 3 hours of injury, permissive hypotension to SBP 80-90 mmHg until definitive haemorrhage control. (2) Airway management — RSI for GCS ≤8 or airway compromise. (3) TIME CRITICAL transfer to MTC — do not extend on-scene time for procedures that can be performed en route. No new interventions are required; the basics remain the evidence base.

Take-home message: When PHEM clinicians feel pressure to "do more" at scene, this data is the counter-argument. The evidence supports load-and-go with en-route critical care for major trauma. Time to MTC remains the most modifiable outcome predictor.

Eastern Association for the Surgery of Trauma (EAST) · 2025 Practice Management Guideline · REBOA

EAST 2025 REBOA Guideline — Against Routine Use in Blunt Trauma

CHANGE WHEN GUIDELINE UPDATES DipIMC / FIMC

The EAST 2025 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Practice Management Guideline concludes with a conditional recommendation AGAINST routine REBOA use in blunt traumatic haemorrhage. This follows the AORTA trial data and EAST systematic review showing no mortality benefit in blunt mechanism, with a significant vascular access complication rate (limb ischaemia, vascular injury at access site: 8-15% in some series).

Where REBOA may still have a role: Penetrating mechanism traumatic arrest or near-arrest with pelvic haemorrhage, where REBOA in Zone III (above aortic bifurcation) may allow brief haemodynamic stabilisation for definitive surgery. Some UK MTC trauma surgery units use REBOA in Zone III for pelvic fracture haemorrhage as a bridge to angioembolisation. This is a surgical decision, not a PHEM decision.

UK PHEM position: REBOA is not part of current UK PHEM scope (FPHC/JRCALC). The EAST guidance reinforces this — do not advocate for REBOA expansion in PHEM based on blunt trauma data. RCAST (Resuscitative ATLS — finger thoracostomy, pericardiocentesis, pelvic binder, IV/IO access, tranexamic acid) remains the UK PHEM response to traumatic cardiac arrest.

Prehospital Technology Review · ROTEM Sigma · Emerging PHEM Technology

Portable VHA (ROTEM Sigma) — Maturing Prehospital Viscoelastic Haemostasis Technology

INFORMING PRACTICE DipIMC / FIMC

Viscoelastic haemostatic assays (VHA) — ROTEM/TEG — are the gold standard for goal-directed coagulopathy management in trauma. Portable ROTEM Sigma is the first device designed for use outside the laboratory, with a footprint compatible with HEMS helicopter or rapid response vehicle. Multiple UK air ambulance services are currently in feasibility pilots or have adopted ROTEM Sigma.

What it changes clinically: Standard prehospital trauma resuscitation uses empiric ratios (blood:FFP:platelets in 1:1:1 or similar). VHA allows PHEM to identify: (1) hyperfibrinolysis (target with TXA — already doing this, but VHA confirms it); (2) fibrinogen depletion (target with fibrinogen concentrate/cryoprecipitate — currently rare in UK PHEM); (3) platelet dysfunction. For rural HEMS with long transport times and access to blood products, ROTEM Sigma is moving from aspiration to reality.

Where we are now: ROTEM Sigma in PHEM remains a pilot-phase technology. Training requirements are significant, device calibration in cold environments is a known limitation, and the logistics of blood product availability to administer the correct component are not yet routinely available in most UK HEMS services. Watch for publication of pilot data from London HEMS and HIOW AAA in H2 2026.

06 Paediatric PHEM

Cross-reference — NCMD / The Resus Room (Section 1, Item 3) — Paediatric PHEM Specific Detail

Paediatric Anaphylaxis — Respiratory-First Model in PHEM Practice

CHANGE THIS MONTH DipIMC / FIMC

In paediatric PHEM specifically, the respiratory-first model of fatal anaphylaxis (detailed in Section 1) has direct and immediate practice implications. HEMS clinicians attending paediatric anaphylaxis must recalibrate their mental model from the circulatory-collapse paradigm to the airway-catastrophe paradigm.

Paediatric-specific clinical algorithm for PHEM:

1. Recognise early laryngeal oedema: Hoarseness, stridor, drooling, difficulty swallowing,

muffled voice, inability to phonate clearly. These signs precede complete obstruction and are the window for intervention. A child who cannot swallow their own secretions has severe laryngeal oedema.

2. IM adrenaline — early and correctly dosed: 0.01 mg/kg IM into the anterolateral thigh,

maximum 0.5 mg (0.5 ml of 1:1000). Use weight-based dosing from Broselow tape or app. If weight unknown, use mid-arm circumference (MUAC) weight estimation. Do not under-dose. Repeat at 5 minutes if no response.

3. No improvement after 2 doses — early RSI decision: If laryngeal oedema signs are not

improving after 2 doses of correctly administered IM adrenaline, consider RSI NOW — before complete airway loss. Ketamine 1-2 mg/kg IV + rocuronium 1.2 mg/kg IV. The window between "deteriorating" and "CICO" in paediatric laryngeal anaphylaxis can be very short (minutes). Waiting until CICO to intubate is too late.

4. Nebulised adrenaline — adjunct only: 5 ml of 1:1000 adrenaline nebulised via face mask is

an adjunct for mild-moderate upper airway oedema — NOT a substitute for IM adrenaline and NOT a reason to delay RSI in severe cases. Nebulised adrenaline reduces mucosal oedema transiently; it does not prevent progression.

5. Secure IV access early: In paediatric anaphylaxis, venous access may be difficult in an

anxious, peripherally shut-down child. Use IO (tibial or humeral) early if three peripheral IV attempts fail. Do not delay adrenaline waiting for IV — use IM route first.

5. Parent/carer debrief and follow-up: Ensure auto-injector is prescribed (Epipen Jr 150mcg if

<25kg, Epipen 300mcg if ≥25kg), caregivers are trained in administration, and allergist follow-up is arranged. Document mast cell tryptase timing on patient report form for receiving unit.

Cross-reference — RCUK OH-NLS (Section 2) — Neonatal Resuscitation Competency in PHEM

RCUK OH-NLS — Neonatal Resuscitation Competency for HEMS

CHANGE TONIGHT

Neonatal resuscitation in PHEM differs fundamentally from paediatric resuscitation. The neonate is not a "small child" — their physiology, drug dosing, airway anatomy, and resuscitation sequence differ entirely. RCUK OH-NLS (Section 2) is the training standard, but the clinical priorities are:

ABC at a birth scene: Warm (polyethylene bag or heated blanket). Dry. Stimulate (firm towel rub, flick feet). Open airway (neutral position — ears at level of shoulders — do NOT hyperextend). Assess breathing: if apnoeic or gasping at 30 seconds despite stimulation, start BVM ventilation with 21% O2 at 30 breaths/min, 5 initial inflation breaths, then 30 breaths/min. Assess heart rate at 60 seconds: if HR <60 despite adequate ventilation, start CPR (3:1 ratio, 100 compressions/min). Escalation: IV/IO adrenaline 0.01-0.03 mg/kg if HR <60 after CPR. Glucose 2ml/kg 10% dextrose if prolonged resuscitation.

Most important skill: Effective BVM ventilation of a neonate. Most PHEM RSI clinicians rarely intubate neonates — the BVM with correct positioning and adjuncts (size 0 OPA, 1-2mm NPA if available) is the appropriate primary intervention. Neonatal laryngoscopy requires a Miller 0 blade and 2.5-3.5 uncuffed tube — this equipment must be checked as part of pre-shift kit check if your service covers home birth areas.

07 Quick Hits

UKHSA Health Security Risk Assessment (HSRA) — June 2026 Pandemic influenza remains the top-ranked UK health security threat in the 2026 HSRA. Dengue is now assessed as a domestic risk horizon — cases of locally acquired dengue are expected given established Aedes mosquito populations in southern England (climate-driven). PHEM EPRR: review your mass-casualty and infectious disease response plans. For dengue specifically: no specific PHEM intervention required, but awareness of febrile illness patterns in returning travellers and local cases is appropriate. Source: gov.uk/government/organisations/uk-health-security-agency.

Prehospital ECPR Feasibility — German HEMS Study (Crit Care 2026) German HEMS feasibility study (PMID PMC13064238, Crit Care 2026) reporting prehospital VA-ECMO for refractory OHCA. Survival with good neurological outcome: 34.7% in selected patients. Selection criteria: age <65, witnessed arrest, initial shockable rhythm, bystander CPR, no ROSC after 20 min ALS including dual-sequential defibrillation. Cannulation time median 22 minutes. This data supports the biological plausibility of prehospital ECPR but confirms stringent selection criteria are essential. UK DEFINITIVE data: OnScene ECPR trial results expected Q3 2026 — this will be the practice-changing trial. Hold protocol changes until OnScene reports.

Air Medical Fatigue Framework (Air Med J 2026) The Air Medical Journal published a structured fatigue management framework for air medical operations in 2026, incorporating duty hour limits, crew rest requirements, and a fatigue reporting culture framework analogous to aviation CRM. UK relevance: HEMS services are not subject to equivalent mandatory fatigue management frameworks as fixed-wing aviation crews. The framework advocates for a just safety culture where fatigue reporting does not incur penalty. Recommend review by HEMS clinical governance leads and operations managers as a quality-improvement framework.

FPHC POCUS Consensus Statement (2025 — Newly Disseminated) The FPHC Prehospital POCUS Consensus Statement (2025), newly disseminated through FPHC channels in 2026, sets out when POCUS should be used in PHEM, required training and competencies, governance requirements, and equipment considerations. Key principle: POCUS must never delay essential interventions or transport. Primary prehospital applications: FAST exam in trauma, pericardial effusion, bilateral lung sliding (PTX exclusion), cardiac activity in arrest. Download and review the full statement at: fphc.rcsed.ac.uk/education-resources/resources/consensus-statements. Ensure your service has a POCUS governance framework aligned with this statement.

Airway Governance Programme — First-Pass Intubation Success (May Papers of Month / The Resus Room) Irish study presented at The Resus Room May 2026 Papers of Month: a structured airway governance programme incorporating video review of all intubation attempts, structured individual feedback, and quarterly simulation-based training improved first-pass intubation success rate from 76% to 91% over 18 months. The study is observational with pre-post design (significant risk of confounding), but the direction of effect is consistent with the broader implementation science literature. UK HEMS services without systematic video laryngoscope review of intubation attempts should consider implementing this as a quality improvement metric. First-pass success and operator-level feedback are standard performance indicators in aviation — equivalent standards in PHEM airway governance are justified.

REV Core Revision — Airway Management in Penetrating Neck Injuries

DipIMC / FIMC Exam Topic — Penetrating Neck Injuries: Anatomy, Haemorrhage Control & Airway

Anatomical zones (surgical classification):

Haemorrhage control principles (FPHC 2026):

• Zone II accessible bleeds: Direct pressure with haemostatic gauze (XStat preferred — fills the wound tract). Avoid uncontrolled digital packing without visualisation.
• Zone I/III inaccessible bleeds: Balloon tamponade — introduce a 14Fr Foley catheter into the wound tract, inflate with 20-30 ml saline, apply traction to tamponade the vessel. This is endorsed by FPHC 2026 and JTS guidelines for Zone III injuries.
• TXA: Administer 1g IV/IO TXA as early as possible in all penetrating neck injuries with external haemorrhage — within the 3-hour window (if timing from injury uncertain, give it).
• NO tourniquet to neck: Never apply a circumferential tourniquet to the neck. Use a figure-of-eight tourniquet (junctional) configuration at the shoulder only for proximal Zone I injuries.

RSI in PNI — detailed airway checklist:

1. Pre-oxygenate: High-flow O2 via BVM (two-person CE grip). Aim SpO2 ≥98% before

induction. THRIVE (15L nasal O2) if available.

2.

Positioning: Supine, no collar, no cervical immobilisation unless specific spinal injury mechanism (not routine PNI). Manual inline stabilisation NOT required for penetrating mechanism — it may worsen haematoma compression.

3. No cricoid pressure: Cricoid pressure is absolutely contraindicated in PNI — may

worsen airway distortion from haematoma and does not reduce aspiration risk in the setting of vascular haemorrhage.

4. Drug choice: Ketamine 1-2 mg/kg IV (maintains haemodynamic stability in

haemorrhage) + rocuronium 1.2 mg/kg IV. Succinylcholine: avoid if crush injury pattern, hyperkalaemia suspected, or >72h from injury (upregulation concern).

5. Video laryngoscopy: Mandatory for all PNI RSIs. Distorted anatomy, blood, and

haematoma make DL unreliable. SALAD technique if significant blood in airway.

6. ETT size: Use 6.0 cuffed ETT — smaller diameter may pass more easily through distorted glottis. Over-tube may be useful if view is significantly compromised.

7. Failed intubation plan: FONA is the rescue. But FONA site is context-dependent: if injury is at or above the CTM, a cricothyrotomy will be into the wound — place the surgical CRIC below the injury. If injury extends below CTM into trachea, you must

access the trachea distal to the injury (tracheostomy-level).

8. Transected airway: If trachea or larynx is completely transected, oral intubation is

impossible — the proximal airway is open. Pass ETT directly into the proximal tracheal stump through the wound. Do not pass the tube blindly — use direct vision with assistance if possible.

Vascular injury patterns in PNI — PHEM significance:

Internal carotid artery injury (Zone II/III): may present with haemorrhage AND neurological deficit (ipsilateral hemiplegia, Horner syndrome, cranial nerve palsies). Do not confuse with primary TBI. Rapid transfer to MTC with vascular surgery capability. Vertebral artery injury: usually presents with bleeding without neurological deficit unless bilateral or dominant vertebral involved. Subclavian injury (Zone I): risk of haemothorax — bilateral lung auscultation and chest POCUS mandatory.

DipIMC / FIMC Exam Point — PNI Airway: "RSI | No collar | No cricoid | SALAD | VL mandatory Failed = FONA BELOW the injury Transected = intubate the stump"

08 Action Points — Do This Now

1 UPDATE POST-ROSC PATHWAY — TONIGHT: Integrate Pre-MIRACLE2 into your post-

ROSC destination protocol. Download the updated MIRACLE2 app (RCUK/JRCALC resources). Score ≥5 → direct destination to cardiac arrest centre with therapeutic hypothermia and cath lab capability. Score ≤2 → standard post-ROSC care and neurological monitoring. Score 3-4 → indeterminate, full workup at nearest appropriate facility. Pre-notify receiving unit with score. Discuss implementation with your medical director.

2 STOP BICARB IN ARREST — TONIGHT: Update your drug protocol tonight. Sodium

bicarbonate is NOT to be given routinely in cardiac arrest. Bicarb ONLY for the following specific indications: (1) Hyperkalaemia arrest — 50 mmol IV/IO + calcium + glucose/insulin simultaneously; (2) TCA overdose arrest — 50-100 mmol IV, repeat boluses targeting pH 7.45-7.55; (3) Sodium-channel blocker toxicity (class Ia/Ic, cocaine, some antihistamines) — 100 mmol IV bolus; (4) Crush injury arrest with suspected hyperkalaemia — 50 mmol IV/IO. All other indications: withhold bicarb.

3 ANAPHYLAXIS PROTOCOL REVIEW — TONIGHT: Ensure your anaphylaxis protocol

explicitly reflects the respiratory-first model. Critical changes: (1) Add explicit instruction to prioritise airway assessment in all anaphylaxis — not just circulatory collapse; (2) Add instruction: if laryngeal oedema signs not improving after 2 correct doses IM adrenaline → consider RSI (ketamine + rocuronium) BEFORE complete airway loss; (3) Remove any implied threshold of "wait until haemodynamic compromise before escalating airway"; (4) Ensure paediatric adrenaline dosing (0.01 mg/kg IM, max 0.5 mg) is clearly displayed. For paediatric HEMS: check Broselow tape or equivalent is part of your kit.

4 FPHC PNI PROTOCOL UPDATE — TONIGHT: Update your penetrating neck injury protocol:

RSI is first-line airway management. No cervical collar application in any PNI. No cricoid pressure during RSI. FONA site = below the injury (not automatic cricothyrotomy if injury is at or below CTM). Train SALAD technique — include in next simulation session. Practice direct tracheal intubation through wound in simulation before attempting prehospitally. Ensure rigid suction (Yankauer) is at every RSI. Download FPHC PNI Guideline 2026 from fphc.rcsed.ac.uk.

5 OH-NLS TRAINING — TONIGHT (BOOK): All HEMS clinicians with potential to attend home

births, MLUs, or ambulance deliveries must complete RCUK OH-NLS. Contact courses@resus.org.uk to book. Review your obstetric emergency protocol for neonatal coverage. Check kit includes: polyethylene bag/occlusive wrap, neonatal BVM (Laerdal 240 ml), size 0 OPA, small NPA (2.5-3.5mm), umbilical catheter kit, tibial IO needle, 10% dextrose 10ml, adrenaline 1:10,000 dilution, Miller 0 blade if your service intubates neonates.

6 DEFIBRILLATION UPGRADE — THIS MONTH: Switch your default pad position for ALL

cardiac arrests to ANTEROPOSTERIOR (anterior electrode over left precordium, posterior

electrode under left scapula). For refractory VF (VF persisting after ≥3 shocks): escalate to DSED if two defibrillators are available at your base. Contact your clinical governance lead to confirm equipment availability and update the OHCA algorithm. Document pad position and number of shocks in your clinical record.

7 CRT IN SEPSIS — THIS MONTH: Implement CRT assessment (sternum blanch × 5

seconds, normal return ≤3 seconds) in ALL prehospital sepsis assessments alongside NEWS2/qSOFA. Document the CRT value and trend on your patient report form. Clinical decision rule: CRT >3s despite 10-20 ml/kg crystalloid → start vasopressor (noradrenaline 0.05 mcg/kg/min peripheral or IO, if within scope), hold further fluid boluses. CRT ≤3s with improving haemodynamics → observe, reassess every 5 minutes in transit.

8 HELIPAD ADVOCACY — ONGOING: Know your regional hospital helipad status for every

MTC and TU in your catchment. Document off-site landing locations and associated ground transfer times for each facility. Use the APPG data (53% of UK hospitals cannot provide 24/7 helipad access) as evidence in regional trauma network governance meetings. Flag facilities where off-site landings are routine — these should be escalated to commissioners and NHS England. Helipad access as a condition of MTC designation is the APPG recommendation — advocate for this at regional and national level.

TRIALS TO WATCH — H2 2026

• OnScene ECPR Trial — UK multicentre prehospital ECPR trial. Results expected Q3 2026. This will be the definitive UK data on prehospital ECPR and is likely to be practice-changing. Watch for RCUK/FPHC guidance update post-publication.
• PRINCESS3 Phase 3 — Prehospital brain cooling RCT (Phase 3). Following PRINCESS2 pilot which showed 92% protocol adherence. Primary outcome: neurologically intact survival at 6 months. If positive, will require rapid integration into post-ROSC HEMS protocols.
• BACHb Trial — HFNC vs O2 vs CPAP in paediatric bronchiolitis. UK multicentre, 50+ sites. Bronchiolitis is the most common paediatric HEMS/rapid response dispatch — BACHb will determine whether prehospital HFNC is beneficial or harmful in this population.
• APPEASE Trial — UK multicentre trial of prehospital antibiotics in suspected sepsis. Results expected late 2026. Will likely drive formal JRCALC/College of Paramedics guidance on prehospital antibiotics for services covering rural catchments.
• BICARICU-2 Implementation Guidance — ESICM implementation guidance for BICARICU-2 expected H2 2026. Watch for ICS/ESICM guidance on bicarb in post-ROSC metabolic acidosis — this will directly update ICU handover protocols.

Jake Turner

PHEM Evidence Rundown — Issue 6, July 2026. Curated with the assistance of AI (Perplexity). All content editorially reviewed. This newsletter is for educational purposes and continuing professional development. It does not constitute clinical guidance. All clinical decisions must be made by a suitably qualified clinician in accordance with local protocols, JRCALC guidelines, and relevant FPHC/RCUK guidance.

emevidence.org · DipIMC / FIMC exam tags throughout · Sources: Resuscitation (RAPID-MIRACLE), JAMA (BIHCA), The Resus Room (theresusroom.co.uk), NCMD, NICE NG258, ICS SOA26 (BICARICU-2), SJTREM/Injury (tamponade/TXA), JAMA (ANDROMEDA-SHOCK-2), HIOW AAA, FPHC RCSEd (PNI Guideline — fphc.rcsed.ac.uk), RCUK OH-NLS (resus.org.uk), Air Ambulances APPG, SSC 2026, DOSE-VF (NEJM 2023), RCUK Papers of Note, Air Med J, Crit Care 2026 (PMC13064238), EAST REBOA PMG 2025, UKHSA HSRA 2026