PHEM Evidence Rundown — October 2026

PHEM EVIDENCE RUNDOWN — ISSUE 9 — OCTOBER 2026

PHEM Evidence Rundown

Pre-hospital emergency medicine evidence for UK clinicians — monthly — UK Edition

Jake Turner — Senior Registrar in Emergency Medicine, ST6 — Curated with the assistance of AI (Perplexity). All content editorially reviewed.

The full archive of every issue is available at emevidence.org — including audio summaries and PDF downloads.

Lead — vascular access in OHCA: IPD meta-analysis of the two large RCTs (n=7,561): no difference in 30-day survival between IO-first and IV-first (OR 1.01). The UK PARAMEDIC-3 Bayesian re-analysis puts an 81.6% probability on IO-first being worse, but any effect is probably small. Change this month: Emergency thoracotomy 2026 update (EMJ, UK prehospital authors) • London ECPR pathway reaches only 3% of eligible patients within 45 minutes • prehospital whole blood SR/MA shows no mortality benefit • paediatric prehospital transfusion consensus criteria. UK: HART paramedics delivering Lyoplas (Manchester Arena Inquiry recommendation) • APPiR: advanced paramedics paralysing post-ROSC patients under PGD • 129 laser attacks on air ambulances in 18 months. Core Revision: Traumatic cardiac arrest — HOTT priorities and the thoracotomy decision.

BOTTOM LINE UP FRONT — OCTOBER 2026

ACT ON THIS NOW

CHANGE THIS MONTH IO vs IV in adult OHCA (IPD MA, n=7,561): no survival difference; point estimate for sustained ROSC favours IV (OR 0.90, 95% CI 0.81–1.01). IV first where quick; IO is the fallback.

CHANGE THIS MONTH Emergency thoracotomy 2026 (EMJ): ERC threshold ≤15 min from loss of vital signs; crucifix positioning; pause ventilation for key steps; no Foley catheters in cardiac wounds; governance checklist for every service.

CHANGE THIS MONTH London ECPR access (n=776 eligible): only 3% reach an ECMO centre within 45 min during operating hours. Early recognition and early movement decide eligibility.

SAFETY Laser attacks on air ambulances: 129 incidents in the 18 months to June 2026 (CAA). Report every event.

KNOW FOR NEXT TIME

INFORMING Prehospital whole blood (SR/MA, n=4,040): no difference in 24-hour (RR 1.00) or 28/30-day mortality (RR 1.09).

INFORMING Minithoracostomy vs chest drain (HEMS cohort, n=94): no longer scene time and fewer recorded complications; hypothesis-generating.

INFORMING Arterial lines on scene (EMJ BET): all 4 studies associated insertion with longer scene times (4–34.4 min).

PAEDS PHEM Prehospital transfusion in children (Delphi): severe haemorrhage + shock after first-line haemorrhage control + clinical judgement.

PAEDS PHEM Paediatric dosing deviations (n=386 doses): 46.4% deviated ≥20% from protocol, mostly underdoses, especially intranasal.

October's issue is anchored by a question every UK crew answers at almost every cardiac arrest: needle in the vein or drill in the bone? Two papers from the PARAMEDIC-3 team and collaborators now give us the most complete answer we are likely to get for some years. Alongside them sits the 2026 rewrite of the emergency thoracotomy "how to" guide by a UK air ambulance team, a sobering London analysis of who can actually reach ECPR in time, and a run of UK service evaluations, from HART paramedics carrying freeze-dried plasma to advanced paramedics paralysing post-ROSC patients. Paediatric content this month covers transfusion criteria, dosing errors and surgical airway in injured children.

WHAT'S INSIDE

• Lead: IO vs IV access in OHCA — IPD meta-analysis and PARAMEDIC-3 Bayesian re-analysis
• Emergency thoracotomy: how to do it in 2026 (EMJ)
• ECPR pathway accessibility in London (Resusc Plus)
• Post-ROSC ECG: NST-OMI patterns (Resuscitation)
• CPR-induced consciousness: 16-year trends and a UK systematic review
• APPiR: paramedic neuromuscular blockade after ROSC (Br Paramed J)
• Prehospital whole blood — SR/MA (Injury)
• HART PLAsMa: Lyoplas delivery in hazardous areas (Br Paramed J)
• Prehospital vasopressor infusions in trauma — SR (Eur J Emerg Med)
• Minithoracostomy vs chest drain in HEMS (Prehosp Emerg Care)
• Prehospital arterial lines and scene time — BET (EMJ)
• Endovascular resuscitation and CFA access (EMJ reviews)
• Prehospital heparin in STEMI — SR/MA (Eur J Emerg Med)
• Inhaled methoxyflurane for trauma pain — SR/MA (J Emerg Med)
• Paeds: transfusion consensus; dosing deviations; eFONA in paediatric trauma; PEA vs asystole; teleconsultation
• Quick Hits: NRB plus nasal cannula preoxygenation; ventilation feedback; prehospital antibiotics; safety incidents reported by patients and witnesses; prehospital guideline quality
• UK Policy: laser attacks on air ambulances; GNAAS aircraft resilience
• Core Revision: Traumatic cardiac arrest (DipIMC/FIMC)

CHANGE TONIGHT Act immediately CHANGE THIS MONTH Adjust practice SAFETY ALERT

GUIDELINE

INFORMING

PRACTICE PAEDS PHEM UK FOAMED DIPIMC/FIMC

Contents: 1. Key PHEM Articles & Trials — 2. Guidelines & UK Updates — 3. Paediatric PHEM — 4. FOAMed & Critical Appraisal — 5. Quick Hits — Core Revision — 6. Action Points — Trials to Watch

1 — KEY PHEM ARTICLES & TRIALS

CHANGE THIS MONTH

UK TRIAL DATA

DIPIMC/FIMC

Lead: IO-First vs IV-First Access in Adult OHCA — IPD Meta-analysis (n=7,561) and the PARAMEDIC-3 Bayesian Re-analysis

(1) Holmberg MJ, Couper K, Andersen LW, Lall R, Granfeldt A, Ji C, Perkins GD, Vallentin MF. Intravenous or intraosseous vascular access in cardiac arrest: an individual participant data meta-analysis. Resuscitation. 2026;228:111304. doi:10.1016/j.resuscitation.2026.111304. PMID: 42727699. (2) Couper K, Ji C, Deakin CD, et al. Intraosseous versus intravenous access in adult out-of-hospital cardiac arrest: a Bayesian secondary analysis of the Paramedic-3 randomised controlled trial. Resuscitation. 2026. doi:10.1016/j.resuscitation.2026.111335. ISRCTN14223494.

Design: (1) PRISMA-IPD systematic review and individual participant data meta-analysis of individually randomised trials of IO-first vs IV-first access in cardiac arrest (search to 18 March 2026), with adjusted logistic regression, prespecified Bayesian priors and GRADE. Two trials contributed, both OHCA. (2) Pre-planned Bayesian secondary analysis of PARAMEDIC-3, the UK multi-ambulance-service RCT (November 2021 to July 2024), using non-informative priors with sceptical and enthusiastic sensitivity priors.

Key results: (1) In 7,561 patients there was no difference in 30-day survival (OR 1.01, 95% CI 0.81–1.25; moderate certainty) or favourable neurological outcome (OR 1.08, 95% CI 0.83–1.41; low certainty); sustained ROSC favoured IV but was not statistically significant (OR 0.90, 95% CI 0.81–1.01; low certainty). Bayesian analyses found a high probability that any difference was small. (2) In PARAMEDIC-3 (n=6,082; IO 3,040, IV 3,042; 30-day survival 4.8% overall), the probability that IO-first was worse than IV-first was 81.6% for 30-day survival, 61.8% for favourable

neurological outcome and 98.0% for ROSC at handover; the probability of a moderate harm (OR <0.75) for survival was only 13.4%. Only 64.6% of the IV-first group actually received IV first; crossover 8.7%.

• 7,561 OHCA PATIENTS, 2 RCTS (IPD)
• OR 1.01 30-DAY SURVIVAL IO VS IV (0.81–1.25)
• OR 0.90 SUSTAINED ROSC IO VS IV (0.81–1.01)
• 98.0% PARAMEDIC-3: PROBABILITY IO-FIRST WORSE FOR ROSC

Critical appraisal: These are the two largest randomised datasets on the question and include a UK trial delivered by NHS ambulance services, so external validity for UK practice is unusually strong. The trials compared strategies rather than routes: in PARAMEDIC-3 a third of the IV-first arm did not get IV first, which biases towards no difference and may mask a real route effect. The IPD meta-analysis rests on only two trials, so between-trial heterogeneity cannot be meaningfully explored. The Bayesian re-analysis is sensitive to the prior: with enthusiastic priors favouring IO, the probability of IO benefit for 30-day survival rose to 78.0%. Absolute survival is low, so even the most plausible effect translates into small absolute differences. The ROSC signal is consistent across both papers, and ROSC is the pathway to every downstream outcome.

UK PHEM practice: Attempt IV access first in adult OHCA where it can be achieved promptly (for example within two attempts), with IO as the rescue route rather than the reflex. Do not delay early adrenaline in non-shockable rhythms to chase IV access. These data do not apply to children, in whom IO remains standard when IV access is difficult. Align with your ambulance trust's JRCALC-based protocol and RCUK guidance.

CHANGE THIS MONTH UK AUTHORS DIPIMC/FIMC

Emergency Thoracotomy: How To Do It in 2026 — The Prehospital Update of the 2005 Wise Guide

Chesters A, Hughes M, Ley E, O'Meara M, Davies G, Hormis A. Emergency thoracotomy: how to do it in 2026. Emerg Med J. 2026 (epub; accepted 2 August 2026). doi:10.1136/emermed-2026-216110. First author affiliated with Lincs & Notts Air Ambulance; UK authors. Covered in depth in EM Evidence Rundown Issue 32.

What it says: An expert practice review integrating ERC 2025, EAST and WTA guidance with UK prehospital experience. Recommended threshold: ERC ≤15 minutes from loss of vital signs, modified by signs of life and CPR duration. Prehospital data show tamponade patients are more likely to survive if thoracotomy is performed within 15 minutes of witnessed loss of signs of life, whereas exsanguinating patients rarely survive beyond 5 minutes; survival in exsanguination was 1.9% in a large London series, with no survivors when tamponade and exsanguination coexisted. Prehospital-specific points: crucifix arm positioning even in confined spaces; scene lighting and head torches; supraglottic airway with ventilation paused during incision, pericardiotomy and hilar control; a small bespoke instrument set agreed with a local hospital; senior remote advice to counter the team's emotional bias to continue; external defibrillation after partial closure of the clamshell (internal paddles are rarely feasible outside hospital); and transport planning, including reverse loading of the scoop in UK road ambulances to keep the left chest accessible, with the caveat that this may compromise standard restraint.

Critical appraisal: Expert opinion grounded in observational series with survivorship and selection bias; the time windows are associations, not prospectively validated cut-offs. Moving from 10 to 15 minutes may increase procedures with very low survival probability unless mechanism (tamponade vs exsanguination) is weighed. The governance framework — three-part checklist aligned with NatSSIPs, SOP with authorisation criteria, mandatory debrief and audit, and an equipment agreement with sterile services — is the most immediately actionable part for services.

UK PHEM practice: Review your service's thoracotomy SOP against this paper: threshold, checklist, kit list, ventilation choreography, operator rotation for internal massage, and the vehicle loading plan for post-thoracotomy transfer. Every case should be debriefed and audited.

CHANGE THIS MONTH UK DIPIMC/FIMC

London's ECPR Pathway: Only 3% of 776 Eligible OHCA Patients Could Reach an ECMO Centre Within 45 Minutes

Sahay A, Sears C, Faulkner M, Fothergill R. Assessing accessibility to the extracorporeal cardiopulmonary resuscitation pathway for out-of-hospital cardiac arrests in London. Resusc Plus. 2026;31:101468. doi:10.1016/j.resplu.2026.101468. PMID: 42751014. London Ambulance Service.

Design and results: Retrospective analysis of five years of London Ambulance Service OHCA data with pathway modelling and geospatial analysis against the London ECPR pathway's 45-minute arrest-to-arrival target. Of 776 patients meeting eligibility criteria, only 23 (3%) were estimated to reach an ECMO-capable centre within 45 minutes and during operating hours; in many cases the threshold was exceeded before the patient was ready to move. Extending the interval to 60 minutes would add 50 patients (a 217% increase); extending operating hours +24 (104%); broadening activation criteria +12 (52%); adding receiving centres +7 (30%).

• 776 ECPR-ELIGIBLE OHCA OVER 5 YEARS
• 3% (23) REACH ECMO CENTRE ≤45 MIN IN OPERATING HOURS
• +217% ACCESS IF TARGET EXTENDED TO 60 MIN

Critical appraisal: A modelling study, not an outcome study: it estimates access, not survival, and relies on recorded timestamps and assumed transport times. Extending the time window would increase access but likely lower the probability of good neurological outcome per patient, a trade-off this paper cannot quantify. It nevertheless shows that, in many cases, the 45-minute window was exceeded before the patient was ready to move — on-scene time is a major constraint alongside geography and operating hours.

UK PHEM practice: Where an ECPR pathway exists, the decision must be made early — identify candidates (witnessed, bystander CPR, shockable or other pathway criteria) within the first minutes, apply mechanical CPR and package early, and pre-alert. Services designing pathways should model their own "ready to move" times before setting thresholds.

CHANGE THIS MONTH DIPIMC/FIMC

The Post-ROSC ECG: Half of Confirmed Occlusions Had No STEMI Pattern

Silwanis C, Groche M, Huss M, et al. The post-ROSC ECG: morphological spectrum of non-ST-elevation occlusion and prognostic markers after cardiac arrest. Resuscitation. 2026. doi:10.1016/j.resuscitation.2026.111334.

Retrospective single-centre study of 214 ICU-admitted post-ROSC patients with angiography as reference: 101 had confirmed OMI. NST-OMI patterns were more prevalent than STEMI patterns among confirmed OMI (48% vs 44%) yet went to angiography less often (78% vs 98%); 30-day mortality was 75% in NST-OMI patients without angiography. Commonest NST-OMI patterns: left main equivalent and modified Sgarbossa (8% each), Aslanger (5%), lateral OMI, shark-fin and hyperacute T waves (4% each). Appraisal: small, retrospective, survivor-selected and confounded (patients not taken to the cath lab were probably sicker), but the core message is robust.

UK PHEM practice: When choosing a destination or pre-alerting after ROSC, do not rely on STEMI criteria alone. Transmit the 12-lead and describe OMI-equivalent patterns to the receiving cardiology or ED team, and record a repeat ECG before handover where time allows.

INFORMING PRACTICE UK REVIEW DIPIMC/FIMC

CPR-Induced Consciousness: Rising Incidence, Better Survival — and Only Midazolam Data to Guide Sedation

(1) Howard J, Stub D, Kennett T, Humar M, Olaussen A, Nehme Z. Trends in the incidence and outcomes of CPR-induced consciousness in out-of-hospital cardiac arrest. Resuscitation. 2026;228:111287. doi:10.1016/j.resuscitation.2026.111287. PMID: 42697466. (2) Prokop N, Rice A, Durham M. Pharmacological interventions for CPR-induced consciousness in the prehospital setting: a systematic review. Br Paramed J. 2026;11(2):29–35. doi:10.29045/14784726.2026.9.11.2.29. PMID: 42683417.

(1) In the Victorian registry (43,402 adult OHCA, 2008–2024), 1,438 (3.3%) had CPR-induced consciousness (CPRIC); incidence rose each year (IRR 1.083) and was associated with mechanical CPR, among other factors. CPRIC was independently associated with survival to discharge (OR 2.71, 95% CI 2.38–3.09), for both interfering and non-interfering phenotypes. (2) The UK-authored systematic review found only two Australian retrospective cohorts (39,569 patients, 164 with CPRIC); patients managed with medication had lower survival, and the only drug with data was midazolam. Confidence was low and no meta-analysis was possible.

Appraisal: CPRIC is a marker of good-quality perfusion and favourable physiology, so the association with survival is expected. The lower survival with sedation is very likely confounded by indication — sedation is given to patients with interfering CPRIC during prolonged resuscitation — and should not be read as harm from sedation itself.

UK PHEM practice: Expect more CPRIC as mechanical CPR use grows. Agree a service approach — the only outcome data concern midazolam, although other agents are increasingly used and document CPRIC as a prognostic sign of life when making termination decisions.

INFORMING PRACTICE UK SERVICE DATA

APPiR: Advanced Paramedics Gave Neuromuscular Blockade to 99 Intubated Post-ROSC Patients Under PGD, With No Adverse Physiological Trends

Brown N, Edwards T, Hennessey L, Ballard D, Hymers C. Advanced Paramedic Paralysis in ROSC (APPiR) study. Br Paramed J. 2026;11(2):36–44. doi:10.29045/14784726.2026.9.11.2.36. PMID: 42683377.

One-year retrospective cohort (June 2024 to May 2025) in one UK ambulance service of every occasion an advanced paramedic practitioner in critical care gave neuromuscular blockade to an intubated post-ROSC patient with poor tube tolerance. 99 patients (85.9% male, mean age 57.6); median time to NMB 71 minutes from arrest, 40 minutes post-ROSC and 28 minutes before hospital arrival. All intubations were within two attempts and all met PGD criteria. There were no statistically significant adverse trends in SpO2, EtCO2, MAP or heart rate in the 10 minutes before vs after NMB.

Appraisal: Descriptive, single-service and retrospective with no comparator; 10-minute physiological windows will miss later harms such as unrecognised tube displacement or awareness, and patient-centred outcomes were not reported. It does show the model is deliverable within a PGD with high compliance.

UK PHEM practice: Services considering paramedic NMB after ROSC should require continuous waveform capnography, a sedation plan alongside paralysis to avoid awareness, and audit of every case against the PGD.

CHANGE THIS MONTH DIPIMC/FIMC

Prehospital Whole Blood in Traumatic Haemorrhagic Shock: No Mortality Benefit in a Meta-analysis Including Recent RCTs

Ribeiro Junior MAF, Possiedi RD, Pacheco LS, de Cesaro Schpchacki N, Vieira LF. Prehospital whole blood transfusion in traumatic hemorrhagic shock: a systematic review and meta-analysis. Injury. 2026;57(11):113732. doi:10.1016/j.injury.2026.113732. PMID: 42815248.

Design and results: Six studies (3 RCTs, 3 cohorts; searched to 22 May 2026), 4,040 adults (1,558 whole blood, 2,482 standard care). No difference in 24-hour mortality (RR 1.00; p=0.98) or 28/30-day mortality (RR 1.09; p=0.30), nor in 6-hour or in-hospital mortality. Whole blood reduced in-hospital red cell requirement in the first 24 hours (MD −0.97 units; p=0.03), but this lost significance in sensitivity analysis and was driven by observational cohorts at serious risk of bias. No significant differences in ARDS, stroke or thrombosis; certainty very low to moderate.

• 4,040 PATIENTS (3 RCTS, 3 COHORTS)
• RR 1.00 24-HOUR MORTALITY, WHOLE BLOOD VS STANDARD CARE
• RR 1.09 28/30-DAY MORTALITY (P=0.30)

Critical appraisal: Pooling three RCTs with three observational cohorts adds bias, and the abstract does not give separate RCT-only estimates or describe what "standard care" comprised in each study. The confidence intervals are not reported in the abstract, so a clinically important benefit or harm cannot be excluded.

UK PHEM practice: No change to current UK practice of early prehospital blood components for haemorrhagic shock. This review does not support switching to whole blood for mortality benefit; logistical arguments (one bag, fewer donor exposures) remain the main rationale, and UK services piloting whole blood should continue to collect outcome data.

INFORMING PRACTICE UK MAJOR INCIDENT

HART PLAsMa: Hazardous Area Response Team Paramedics Can Safely Deliver Lyophilised Plasma — a Manchester Arena Inquiry Recommendation in Practice

Wallace T, Metcalf M, Godfrey T, et al. Service evaluation of pre-hospital lyophilised plasma delivery by a hazardous area response team: the HART PLAsMa project. Br Paramed J. 2026;11(2):54–63. doi:10.29045/14784726.2026.9.11.2.54. PMID: 42683044.

Twelve-month prospective service evaluation (April 2023 to March 2024) in one UK ambulance service: 61 HART paramedics trained to give Lyoplas under a major haemorrhage protocol requiring critical care advisor authorisation. 20 activations, 18 authorised, Lyoplas given in 17 (HART-initiated in 11, supporting an enhanced/critical care team in 6), 30 units in total. Authorisation was sought in 100%, indications appropriate in 94%, dosing correct in 88%, calcium chloride compliance 81%. No transfusion reactions or safety incidents; wastage 3.1%.

Appraisal: Small numbers and no major incidents during the evaluation, so it demonstrates feasibility in routine practice, not effectiveness in the hazardous-area setting it was designed for. No patient outcomes were reported.

UK PHEM practice: A useful template for services addressing the Manchester Arena Inquiry gap. HEMS and critical care teams should know whether their local HART can start blood products in the warm zone, and plan handover and calcium dosing accordingly.

INFORMING PRACTICE DIPIMC/FIMC

Prehospital Vasopressor Infusions in Trauma: Very Low-Certainty Evidence, Some Signals of Harm

El-Menyar A, Spencer Netto F, Al-Hassani I, et al. Utility and outcomes of prehospital vasopressors infusion in trauma patients: a systematic review. Eur J Emerg Med. 2026 (epub 24 September). doi:10.1097/MEJ.0000000000001379. PMID: 42808211.

Five retrospective studies (31,849 patients; 1,443 received prehospital vasopressor infusions). Two found no adjusted association with mortality and two found a significant association; a military study showed lower adjusted survival (aOR 0.32, 95% CI 0.18–0.56). One study associated vasopressors with massive transfusion (aOR 4.97) and trauma-induced coagulopathy (aOR 3.05). Qualitative synthesis only; very low certainty.

Appraisal: Confounding by indication dominates: vasopressors are given to the sickest, most hypotensive patients. These data neither prove harm nor support routine use.

UK PHEM practice: In haemorrhagic shock, blood products and haemorrhage control come first. Reserve vasopressors for specific scenarios such as peri-induction hypotension or suspected spinal shock, ideally with invasive monitoring, and document the rationale.

INFORMING PRACTICE DIPIMC/FIMC

Minithoracostomy vs Prehospital Chest Drain in a Physician-Led HEMS: Not Slower, Fewer Recorded Complications

Tomasino S, Orso D, Grandesso M, et al. Prehospital minithoracostomy versus chest drainage for emergency pleural decompression in major trauma. Prehosp Emerg Care. 2026 (epub 24 September). doi:10.1080/10903127.2026.2739424. PMID: 42782255.

Retrospective Italian HEMS cohort (2018–2024), 94 adults (66 minithoracostomy, 28 chest drain), Bayesian analysis. Posterior median scene-time difference −5.9 minutes (95% CrI −13.8 to 1.7; 94.0% probability minithoracostomy shorter). Recorded complications 0/50 evaluable minithoracostomy vs 6/10 evaluable chest drain (risk difference −58.7 percentage points). Prehospital survival was lower with minithoracostomy, reflecting greater severity; no clear differences at 1, 30 or 90 days.

Appraisal: The authors themselves describe this as hypothesis-generating: allocation was by clinician choice, complication status was missing for 16 of 66 and 18 of 28 patients, and ascertainment differed between procedures.

UK PHEM practice: Supports existing UK HEMS practice of simple (finger) thoracostomy in the ventilated patient, with chest drain insertion deferred to hospital unless transfer is prolonged.

INFORMING PRACTICE UK BET

Prehospital Arterial Lines Are Associated With Longer Scene Times (4–34.4 Minutes) — Context Decides Whether It Matters

Lyon J, Garner S. Quantifying the impact of prehospital arterial line insertion on scene time. Best Evidence Topic reports. Emerg Med J. 2026;43(10):658–660. doi:10.1136/emermed-2026-215949. PMID: 42759966.

Focused systematic review (MEDLINE, EMBASE): 468 papers screened, 4 included; all four associated arterial line insertion with increased scene time (4 to 34.4 minutes). None measured insertion time directly or isolated its contribution. Two further studies reported a median of 2 minutes for cannulation plus 3 minutes for set-up, and a median of 12 minutes from opening the pack to first reading; one UK HEMS service inserted 39% of its arterial lines en route.

Appraisal: Retrospective comparisons of eligible patients with and without lines cannot separate the line from the sicker patient and the concurrent anaesthetic. The authors argue the trade-off differs by pathology — scene time matters most in haemorrhage, while accurate blood pressure control may matter more in TBI.

UK PHEM practice: Avoid routine arterial line insertion on scene in haemorrhaging patients; consider it where accurate blood pressure control matters most, such as TBI, or once moving if your service supports insertion en route.

INFORMING PRACTICE UK REVIEWS DIPIMC/FIMC

Endovascular Resuscitation and Common Femoral Artery Access: Two EMJ Practice Reviews for the Prehospital Clinician

Adams TD, et al. Endovascular resuscitation. Emerg Med J. 2026;43:626–633. doi:10.1136/emermed-2025-215376. Common femoral artery access in emergency medicine. Emerg Med J. 2026;43:572–576. doi:10.1136/emermed-2025-215295.

The EVR review covers REBOA, selective aortic arch perfusion and ECPR around OHCA and non-compressible haemorrhage scenarios. In the UK-REBOA trial (ED-initiated REBOA in UK major trauma centres), 90-day mortality was 54% (25/46) with REBOA vs 42% (18/43) with standard care (OR 1.58, 95% credible interval 0.72–3.52; posterior probability of harm 86.9%); the trial stopped early for harm. The UK ERICA-ARREST pilot of prehospital REBOA in OHCA (NCT06071910) is recruiting, and the Norwegian REBOARREST trial (NCT04596514) has completed recruitment. The CFA review argues ultrasound-guided CFA access should be deliberately trained, as the gateway to all endovascular techniques; RCEM curricula include arterial lines but not CFA access specifically.

UK PHEM practice: REBOA is not standard UK prehospital care outside research or specific service models. Patients may, however, arrive with femoral sheaths in situ from services that use them; know how to secure, monitor and hand over these devices.

INFORMING PRACTICE

Prehospital Unfractionated Heparin in STEMI: Better Pre-PCI Patency, No Clear Mortality Effect

Wu YJ, Lin HJ, Lin YH, Hung CS. Prehospital versus in-hospital unfractionated heparin in STEMI undergoing primary PCI: a systematic review and meta-analysis. Eur J Emerg Med. 2026 (epub 2 September). doi:10.1097/MEJ.0000000000001371. PMID: 42684123.

Seven studies (2 RCTs, 5 observational), 10,954 patients. Prehospital UFH was associated with more pre-procedural TIMI 2–3 flow (OR 1.49, 95% CI 1.28–1.74), no significant reduction in 30-day mortality (OR 0.70, 95% CI 0.44–1.13; I²=60.9%), a reduction in the composite of 30-day or in-hospital mortality (OR 0.68, 95% CI 0.49–0.95), and no significant increase in major bleeding (OR 0.77, 95% CI 0.57–1.05). Appraisal: mostly observational with heterogeneity; the composite mortality signal should not be over-read.

UK PHEM practice: Follow your local primary PCI pathway; prehospital anticoagulation in the UK is usually directed by the receiving heart attack centre.

INFORMING PRACTICE

Inhaled Methoxyflurane for Trauma Pain: Faster Relief, Less Rescue Analgesia, More Dizziness

Husain AZ, Alsahli ASM, Alghamdi AMA, et al. Efficacy of inhaled methoxyflurane for acute trauma pain management: a systematic review and meta-analysis. J Emerg Med. 2026. doi:10.1016/j.jemermed.2026.09.008.

Seven RCTs (1,585 participants): time to first pain relief shortened by 5.93 minutes (95% CI −6.86 to −5.00), lower pain scores at 5–20 minutes, and less rescue analgesia (RR 0.40, 95% CI 0.18–0.90); dizziness and drowsiness more common (RR 6.64). Four of seven trials were at high risk of bias, several used placebo comparators, and only one predominantly enrolled children.

UK PHEM practice: Methoxyflurane remains a reasonable rapid bridge analgesic for extrication and splinting; plan the next analgesic step because the effect is short-lived, and follow SmPC limits.

2 — GUIDELINES & UK UPDATES

SAFETY UK

Laser Attacks on Air Ambulances: 129 Incidents in 18 Months

BBC News, 11 September 2026, citing Civil Aviation Authority data. bbc.com/news/articles/c20ven5kj6zo.

CAA statistics recorded 129 incidents of air ambulances being targeted with lasers in the 18 months to June 2026, described as a nationwide problem. Dorset and Somerset Air Ambulance's chief pilot warned that night-vision systems amplify laser light and that an incident could be catastrophic with up to six people on board. Shining a laser at an aircraft is illegal, with an unlimited fine and up to five years in prison.

UK PHEM practice: Report every laser event through your aviation and clinical incident systems; these reports underpin enforcement.

INFORMING PRACTICE UK

Great North Air Ambulance: 557 Missions in One Summer and a Two-Aircraft Resilience Gap

BBC News, 23 September 2026. bbc.co.uk/news/articles/cmg49w9dp9k5o.

GNAAS responded to 557 call-outs between 21 June and the third week of September 2026, most commonly cardiac arrests and road traffic collisions. It has funding for two new Airbus H145 D2 helicopters and is fundraising for a third; with only two aircraft, maintenance plus a fault can leave the region without a helicopter response. A reminder of how charity-funded UK HEMS capacity depends on aircraft availability.

GUIDELINE

How Good Are Prehospital Guidelines? 2026 Systematic Review of 71 New Evidence-Based Guidelines

Martin-Gill C, Patterson PD, Richards CT, et al. 2026 systematic review of evidence-based guidelines for prehospital care. Prehosp Emerg Care. 2026. doi:10.1080/10903127.2026.2731488. PMID: 42725780.

71 new prehospital evidence-based guidelines published 2023–2025; 52.1% met all adapted National Academy of Medicine criteria, most of them resuscitation, cardiovascular and trauma compilations; mean AGREE II overall score 70.9%. A useful map for services reviewing SOPs, although US-led and not focused on UK guidance such as JRCALC or FPHC consensus statements.

3 — PAEDIATRIC PHEM

CHANGE THIS MONTH PAEDS PHEM DIPIMC/FIMC

Prehospital Blood Transfusion in Children: Expert Consensus Criteria From a Modified Delphi

Magill CF, Heintz H, Finney J, et al.; Pediatric Prehospital Blood Transfusion Collaborative. Consensus guidelines for prehospital transfusion in children: a modified Delphi study. Prehosp Emerg Care. 2026 (epub 11 September). doi:10.1080/10903127.2026.2729895. PMID: 42725789.

Twenty experts in paediatric surgery, paediatric EM and EMS considered 208 candidate items over six rounds, accepting 35 recommendations (consensus ≥80%). Eligibility: (1) known or suspected severe haemorrhage or major blood loss, and (2) at least one shock indicator after first-line haemorrhage control (physiological compromise, haemodynamic instability, poor perfusion, low cardiac output or an abnormal validated paediatric shock index), and (3) clinical judgement that transfusion is needed. Contraindications: non-haemorrhagic shock and DNR orders prohibiting transfusion. No consensus on end-tidal CO2 as an indication.

Appraisal: Expert opinion from a US-led panel, not outcome data. The criteria are pragmatic and close to how UK HEMS services already approach children.

UK PHEM practice: Check that your service's paediatric major haemorrhage SOP has explicit triggers (including an age-adjusted shock index), weight-based volumes, and the requirement to apply haemorrhage control first.

CHANGE THIS MONTH PAEDS PHEM MEDICATION SAFETY

Nearly Half of Prehospital Paediatric Drug Doses Deviated by 20% or More From Protocol — Mostly Underdoses

Spigner MF, Butterbaugh MW, Genthe NA, et al. Deviations from recommended drug dosing in the prehospital treatment of pediatric patients. Prehosp Emerg Care. 2026 (epub 29 September). doi:10.1080/10903127.2026.2740143. PMID: 42809474.

386 administrations to 240 children across nine US EMS agencies: 46.4% deviated ≥20% from protocol dose, 79.9% of them underdoses. Deviations by drug: ondansetron 85.3%, midazolam 50.0%, fentanyl 45.5%, adrenaline 44.8%; intranasal route 69.7%. Ondansetron (aOR 36.9) and the intranasal route (aOR 7.3) were independently associated with deviation. Weight-estimation error was not associated; excluding fixed-dose formulations and full-vial doses reduced deviations (81.6% vs 42.5%).

Appraisal: A single US metropolitan system; many "deviations" reflect fixed-dose products and protocol design rather than clinician error, and clinical harm was not measured.

UK PHEM practice: Use JRCALC page-for-age dosing and service-approved paediatric dose aids; double-check intranasal doses and volumes aloud, and audit paediatric drug administration against protocol.

INFORMING PRACTICE PAEDS PHEM UK REGISTRY

Emergency Front of Neck Access in Paediatric Trauma: 27 Cases Across Two Registries in 22 Years

McDonald R, Coffey M, Lecky F, Mclellan S, Cameron P, Mullen S. Emergency front of neck access in the setting of paediatric trauma (letter). Emerg Med J. 2026;43:662–664. doi:10.1136/emermed-2025-215688.

TARN (UK and Ireland, 2000–2022) and the Victorian State Trauma Registry (2001–2022): 27 eFONA procedures within 24 hours of injury in children under 16 — 20 tracheostomies (15 TARN, 5 VSTR) and 7 cricothyroidotomies (all TARN, 2 of them prehospital). Two of the seven TARN cricothyroidotomy patients survived. Guidance differs: DAS recommends surgical cricothyroidotomy over 8 years; APLS UK suggests emergency surgical tracheostomy under 1 year and tracheostomy or surgical cricothyroidotomy at 1–5 years.

UK PHEM practice: No prehospital clinician will gain experience of paediatric eFONA. Your service needs an age-banded paediatric CICO algorithm, the right kit, and regular simulation.

INFORMING PRACTICE PAEDS PHEM

PEA vs Asystole in Children: Asystole Has Lower ROSC Odds, but No Survival Difference Beyond the Neonatal Period

Wong R, Lasa JJ, Topjian A, et al.; AHA GWTG-Resuscitation Investigators. Pulseless electrical activity versus asystole as initial pulseless rhythm in children. Resuscitation. 2026;227:111289. doi:10.1016/j.resuscitation.2026.111289. PMID: 42692184.

9,423 paediatric in-hospital arrests (57.5% PEA, 42.5% asystole). Asystole had lower odds of ROSC (aOR 0.70) and survival to discharge (aOR 0.89), but outside NICU there was no survival difference (36.1% vs 34.1%; aOR 0.99), and in older age groups survival did not differ. Appraisal: in-hospital US registry data, so prehospital generalisability is limited, but it argues against using asystole alone as a reason to stop paediatric resuscitation early.

INFORMING PRACTICE PAEDS PHEM

Video Teleconsultation With a Paediatric Emergency Physician During Simulated Critical Ambulance Transports: Feasible and Acceptable

Boyle TP, Chu D, Okafor IM, et al. Feasibility and acceptability of pediatric expert teleconsultation during critical ambulance transports: a pilot randomized controlled simulation trial. Resusc Plus. 2026;31:101448. doi:10.1016/j.resplu.2026.101448. PMID: 42699314.

24 paramedic–physician teams, 72 simulated paediatric transports: with video, paramedics attempted physician contact in 94% vs 47% with audio-only usual care; usability scores 5.6–5.8 out of 7. Paramedics reported less frustration; physicians reported higher workload. Simulation only — no patient outcomes.

4 — FOAMED & CRITICAL APPRAISAL

FOAMED

Journal Club: One Termination of Resuscitation Rule to Guide Them All?

Herrera-Castillo L, Alharthi MZ, Schauder S, Lauridsen KG. Young European Resuscitation Council journal club. Resusc Plus. 2026;31:101443. doi:10.1016/j.resplu.2026.101443. PMID: 42699599.

A Young ERC Masterclass appraisal of the external validation of the Universal TOR rule in the Pan-Asian Resuscitation Outcomes Study (Onoe et al., 2025), focusing on how system heterogeneity affects the transportability of clinical prediction rules. A good teaching piece for crews applying TOR rules derived in other systems: performance of a prediction rule can change when it is transported into a different EMS system.

5 — QUICK HITS

Preoxygenation: NRB plus nasal cannula is inferior to a flush-rate NRB. In 30 healthy volunteers, mean FeO2 was 85% with flush-rate NRB vs 68% (NRB + nasal cannula each at 15 L/min) and 75% (each at 25 L/min). Where only portable cylinders are available this matters; flush the NRB when you can. Prehosp Emerg Care. 2026. PMID 42784740.

Ventilation feedback devices: mandated, but used in 29%. In a French prehospital system, a device was used in only 48/166 (28.9%) OHCAs despite a protocol mandating it. Exploratory unadjusted outcomes favoured device use but with wide confidence intervals. An implementation lesson for any new kit. Resusc Plus. 2026. PMID 42733415.

Prehospital antibiotics for suspected sepsis (single-centre Thai cohort, n=364). 28-day mortality 25.9% with prehospital antibiotics vs 28.1% usual care; adjusted ARR 8.9% (95% CI 0.8–17.1); antibiotics given 124.6 minutes sooner at the cost of 8.5 minutes more scene time. Observational and small; In the UK, routine prehospital antibiotics for sepsis are not standard; JRCALC supports benzylpenicillin for suspected meningococcal disease. Prehosp Emerg Care. 2026. PMID 42742186.

Safety incidents reported by patients and witnesses after EMS care. Structured telephone follow-up of 3,156 episodes (1,756 patient and 1,400 witness respondents) across Andalusia identified a declared incident in 5.3%, about a third with reported harm; reporting rose to 26.3% among those who felt unsafe. Eur J Emerg Med. 2026. PMID 42804156.

Prehospital stroke trials consensus. Expert consensus (Stroke, 2026) on consent models, randomisation, end points and technology for prehospital stroke trials in conventional EMS settings — relevant to UK services taking part in prehospital stroke research. PMID 42804552.

CORE REVISION — ISSUE 9 — OCTOBER 2026 — DIPIMC / FIMC

Traumatic Cardiac Arrest: HOTT Priorities and the Thoracotomy Decision

Reversible causes first, compressions second — and when to open the chest

Exam goal: Explain why traumatic cardiac arrest (TCA) is managed differently from medical arrest; list and prioritise the reversible causes (HOTT); describe simultaneous interventions; state the indications and time thresholds for resuscitative thoracotomy; and know when to stop.

1. HOTT — TREAT REVERSIBLE CAUSES SIMULTANEOUSLY

2. THE THORACOTOMY DECISION (CHESTERS ET AL., EMJ 2026)

3. OPEN-CHEST SEQUENCE

4. WHEN TO STOP

Stop for injuries incompatible with life, or when there is no cardiac activity despite adequate volume replacement and aortic occlusion. End-tidal CO2 and direct assessment of cardiac filling help guide this decision. Use senior remote advice to counter the team's emotional momentum, and debrief every case.

DipIMC/FIMC Exam Focus: (1) TCA priorities are HOTT, delivered simultaneously, with haemorrhage control before compressions. (2) Bilateral thoracostomies in every ventilated TCA patient with suspected chest injury. (3) Thoracotomy threshold ≤15 minutes from loss of vital signs (ERC 2025), strongest case in penetrating tamponade. (4) Exsanguination has very poor survival; combined tamponade and exsanguination had none. (5) VF in trauma usually reflects poor coronary perfusion — fix the circulation first. (6) Governance: checklist, SOP, debrief and audit.

6 — ACTION POINTS

• Cardiac arrest access: IV first in adults where it can be achieved promptly; IO as rescue. Do not delay adrenaline in non-shockable rhythms.
• Thoracotomy SOP: Review threshold, checklist, kit, ventilation choreography and post-thoracotomy vehicle loading against the 2026 EMJ guide.
• ECPR: Identify candidates in the first minutes and move early; measure your "ready to move" interval.
• Post-ROSC ECG: Transmit and describe OMI-equivalent patterns, not just STEMI, when choosing a destination.
• Paeds haemorrhage: Check your paediatric major haemorrhage SOP has explicit shock triggers and weight-based volumes.
• Paeds drug safety: Read back intranasal doses and volumes; audit paediatric dosing against protocol.
• Preoxygenation: Flush-rate NRB in preference to NRB plus nasal cannula where oxygen supply allows.
• Aviation safety: Report every laser strike.

TRIALS TO WATCH

RECRUITING NOW

RESULTS EXPECTED

REBOARREST Norwegian phase 2 RCT of prehospital REBOA vs standard ALS in OHCA (NCT04596514); recruitment complete, primary endpoint ROSC.

RECENTLY REPORTED

PARAMEDIC-3

Bayesian re-analysis and IPD meta-analysis published September 2026 (this issue).

PHEM Evidence Rundown — Issue 9 — October 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine, ST6 | Curated with the assistance of AI (Perplexity). All content editorially reviewed. For DipIMC, FIMC, and prehospital emergency medicine clinicians in the UK. Feedback: Submit feedback emevidence.org | Contact: emevidence999@gmail.com | Unsubscribe via Loops This newsletter provides educational evidence summaries only. It does not replace clinical judgement, local protocols, JRCALC or service SOPs.