PHEM Evidence — Q2 2026 State of the Science

PHEM EVIDENCE — QUARTERLY REVIEW

Q2

2026

PHEM Evidence Rundown

State of the Science — April–June 2026

Pre-Hospital Emergency Medicine — UK Edition

Jake Turner | Emergency Medicine Registrar · West Midlands Deanery

Curated with the assistance of AI (Perplexity). All content editorially reviewed. 74 primary evidence items · 4 issues published · emevidence.org

PHEM EVIDENCE RUNDOWN — Q2 2026

Table of Contents

APPENDIX

Trials to Watch — Q3 2026 and Beyond

ICS SOA26, PRINCESS3, BACHb, EVIS UK, RCUK PLS implementation

5 trials

CHAPTER 1 — Q2 2026

Quarter in Review

Executive Summary · April–June 2026 · Pre-Hospital Emergency Medicine UK

The second quarter of 2026 has been the most consequential period for UK prehospital emergency medicine since the CRASH-2 publication. Four major themes dominated: the full operational embedding of RCUK 2025 guidelines from 1 April, a set of landmark resuscitation science findings that refined pad position and brain cooling strategy, a trio of haemorrhage control studies that between them processed nearly 36,000 patients, and an airway evidence cluster that places videolaryngoscopy unambiguously as the first-line tool for prehospital RSI. The JRCALC April 2026 clinical update brought immediate changes to termination of resuscitation thresholds and paediatric defibrillation dose escalation that required protocol revision across all UK ambulance services.

Resuscitation science entered Q2 with the RCUK 2025 guidelines finally reaching full implementation on 1 April 2026, bringing confirmation that targeted temperature management at 33°C offers no advantage over 36°C, that post-ROSC coronary angiography is not mandated in the absence of STEMI, and that dispatcher-assisted CPR guidance has been restructured around high-quality CPR metrics. Within weeks, the DOSE-VF anteroposterior pad substudy (Resuscitation 2026, PMID 41856454) reported that AP pad position was independently associated with ROSC with an aOR approaching 2.0, translating this pre-existing recommendation into sharper clinical emphasis. Simultaneously, the PRINCESS2 pilot (n=100, Crit Care 2026) demonstrated that on-scene intranasal brain cooling is safe and feasible with 92% protocol adherence, laying the groundwork for the phase 3 PRINCESS3 trial. The CCO CPR meta-analysis (232,655 cases, Am J Cardiol) delivered a reassurance: continuous chest compression CPR produces outcomes equivalent to standard 30:2, supporting existing guidelines. The EXECT-CPR trial (JAMA Intern Med) delivered its own finding, showing TEE-guided CPR during resuscitation does not improve ROSC rates.

The haemorrhage and trauma evidence base underwent simultaneous restructuring on three fronts. The TOWAR trial (NEJM 2026, PMID 42150044), a UK HEMS-based RCT comparing prehospital Type O whole blood to component therapy, returned a null result: whole blood was not superior to FFP plus packed red blood cells. This mirrors the concurrent SWiFT trial result, and together they confirm that UK HEMS component therapy remains the NHSBT standard. Against this backdrop, a prehospital TXA meta-analysis pooling 12,682 patients (Frontiers in Medicine 2025, PMID 40160319) demonstrated a 28% reduction in 24-hour mortality with prehospital TXA administration within one hour of injury (OR 0.72, 95%CI 0.62–0.84), while a linked IPD safety analysis from PATCH, STAAMP, and ROC (PMID 42023936) confirmed that TXA is not associated with increased thromboembolic events (OR 0.97, 95%CI 0.73–1.29). The ACS-TQIP data set (n=23,362, PMID 42023940) provided a third message: high FFP:RBC ratios of 1:1.5 or better are independently associated with lower mortality in TBI patients with concomitant haemorrhage, reinforcing early balanced transfusion as the standard of care.

The airway chapter of Q2 was anchored by two high-impact publications. The Intub-8 registry analysis (Lancet Respiratory Medicine), the most attention-commanding PHEM publication of the quarter, quantified that prehospital RSI by HEMS saves approximately 170 additional lives per year in the UK compared to a counterfactual of no prehospital intubation, after case-mix adjustment in a prospective HEMS registry. The updated Association of Anaesthetists PHEA guidelines (Anaesthesia, March 2026) formalised videolaryngoscopy as first-line for prehospital RSI, endorsed push-dose vasopressors, and codified a post-intubation care bundle. A JAMA Network Open study then quantified the post-intubation hypotension risk in TBI, demonstrating that SBP below 100 within 60 minutes of prehospital intubation is independently associated with worse neurological outcomes, raising the vasopressor threshold from 90 to 100 mmHg in this specific group. For PHEM clinicians, Q2 2026 demanded both protocol updates and individual practice refinements across nearly every domain of the specialty.

Practice Change Summary — Q2 2026

CHAPTER 2 — 18 ITEMS

Resuscitation Science & Cardiac Arrest

DOSE-VF · PRINCESS2 · JRCALC April 2026 · ECPR · CCO CPR · April–June 2026

Q2 2026 delivered the most significant cluster of out-of-hospital cardiac arrest evidence in several years, anchored by a pad-position finding from the DOSE-VF trial, the first human feasibility data for on-scene brain cooling, and concurrent JRCALC protocol updates that changed both termination thresholds and paediatric defibrillation dosing. The ongoing OnScene ECPR trial completed enrolment at n=220 with results expected Q3 2026.

RESUSCITATION 2026 · PMID 41856454 · MONTHLY ISSUE 3 — MAY 2026

DOSE-VF Anteroposterior Pad Position Substudy — AP Independently Associated with ROSC

CHANGE THIS MONTH DIPIMC / FIMC

The DOSE-VF trial (NEJM 2023) randomised defibrillation strategies in refractory VF; this Q2 2026 substudy extracted data on defibrillator pad position and tested it as an independent predictor of ROSC after case-mix adjustment. Anteroposterior pad placement was independently associated with ROSC (aOR approximately 2.01, compared with anterolateral position). This is not a standalone RCT — it is a secondary analysis of an existing trial dataset — and should not be interpreted as definitive evidence for a mandated position change in non-refractory VF.

aOR ~2.01 — AP vs anterolateral pad position for ROSC

Clinical interpretation: Anteroposterior placement should be preferred when clinically feasible, particularly in prolonged refractory VF. The result aligns with physiological plausibility (greater transthoracic current vector through the myocardium). Standard anterolateral placement remains acceptable as default given speed-of-placement considerations in OHCA.

Limitations: Substudy of a single RCT. Case-mix adjusted but observational within the trial. Pad position was not the randomised variable. Replicate trials needed before guideline-level mandate.

For DipIMC/FIMC candidates: understand this as hypothesis-generating data that informs practice without mandating change, and be able to critique it as a secondary analysis. The DOSE-VF trial primary result (vector-change defibrillation superior) was a Q1 2026 PHEM item.

CRITICAL CARE 2026 · PRINCESS2 PILOT · MONTHLY ISSUE 3 — MAY 2026

PRINCESS2 Pilot (n=100) — On-Scene Intranasal Brain Cooling Safe and Feasible; Phase 3 Planned

CHANGE THIS MONTH DIPIMC / FIMC

The PRINCESS2 pilot enrolled 100 patients with OHCA across multiple HEMS systems, testing on-scene delivery of intranasal evaporative brain cooling as a bridge to hospital-based neuroprotection. Protocol adherence was 92%, supporting feasibility. No significant device-related complications were recorded. The hypothesis is that rapid on-scene brain cooling initiated within minutes of ROSC reduces the duration of cerebral thermal loading before ICU-level TTM can commence.

92% protocol adherence · n=100 · feasibility pilot

Not yet practice-changing. This is a feasibility pilot, not a powered efficacy trial. The PRINCESS2 pilot does not demonstrate neurological outcome benefit. The phase 3 PRINCESS3 trial is now planned; results are several years away.

Contextual background: Previous attempts at prehospital brain cooling (including the RhinoChill system in PRINCESS1) failed to show benefit in phase 3. PRINCESS2's intranasal route aims at earlier and more reliable cooling initiation. The bridge-to-neuroprotection concept remains mechanistically sound even as earlier iterations failed. UK HEMS teams should be aware this technology may appear in their systems as part of research protocols.

DipIMC/FIMC: Able to articulate why earlier cooling attempts failed and what PRINCESS2 pilot data does and does not prove. Understand the distinction between feasibility and efficacy trials.

JRCALC CLINICAL UPDATE · APRIL 2026 · MONTHLY ISSUE 3 — MAY 2026

JRCALC Resuscitation Update April 2026 — ToR 45 Min Minimum, 8 J/kg Paediatric VF Escalation, Post-ROSC Targets, AMIST Handover

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The April 2026 JRCALC clinical update delivered several operationally significant changes aligned with RCUK 2025 full implementation. The most immediately impactful change for PHEM and advanced paramedics is the revised termination of resuscitation guidance: a minimum resuscitation time of 45 minutes (extended from the prior 30 minute recommendation) is now required before ToR is considered in unwitnessed arrests, unless specific exclusion criteria are met (clear signs of death, valid DNACPR, witnessed arrest with no shockable rhythm and no bystander CPR). The JRCALC Q2 update (as noted in Issues 1 and 3) also extends the minimum to 45 min in specific circumstances, consistent with overall strengthened resuscitation emphasis.

Minimum ToR consideration: 45 minutes in unwitnessed OHCA (absent specific exclusions)

Paediatric VF dose escalation: 8 J/kg after 5th shock (new April 2026)

Paediatric defibrillation now includes a dose escalation pathway: after the 5th shock in refractory paediatric VF, 8 J/kg per shock is now supported by the updated JRCALC guidance. Post-ROSC SBP targets are formalised, and the AMIST handover framework (Age, Mechanism, Injuries, Signs, Treatment) is reaffirmed as the standard prehospital-to-hospital handover format. RCUK ReSPECT guidance is embedded, instructing paramedics to attempt to access existing ReSPECT forms before commencing resuscitation in attended arrests where delay permits.

Immediate protocol action: All UK ambulance services and HEMS platforms must update ToR and VoD documentation to reflect the 45-minute threshold. Paediatric resuscitation aide memoires require updating for the 8 J/kg 5th-shock escalation. This is not discretionary — JRCALC guidance underpins Clinical Practice Guidelines for all UK ambulance services.

RCUK 2026 · RESPECT POLICY BRIEFING · MONTHLY ISSUE 2 — MAY 2026

RCUK ReSPECT Policy Briefing 2026 Update — OOH ReSPECT Access Reaffirmed

INFORMING PRACTICE DIPIMC / FIMC

The RCUK 2026 ReSPECT Policy Briefing reaffirms guidance on out-of-hospital use of the Recommended Summary Plan for Emergency Care and Treatment. Paramedics and HEMS clinicians are directed to make a reasonable attempt to access any existing ReSPECT form before commencing resuscitation in an attended cardiac arrest where the brief delay is clinically safe. This guidance does not mandate delay in commencing resuscitation — it confirms that where forms exist and can be rapidly located (e.g. displayed in the patient's home), they should be honoured.

PHEM relevance: HEMS physicians attending secondary calls or bypassed scenes need to be conversant with ReSPECT form validity, completion standards, and how they interact with ToR decision-making. A valid ReSPECT form documenting CPR not appropriate overrides the default resuscitation response. Crews acting in good faith on a completed ReSPECT form are legally protected under the guidance of the British Medical Association and RCUK.

AMERICAN JOURNAL OF CARDIOLOGY · MONTHLY ISSUE 2 — MAY 2026

Continuous Chest Compression (CCO) CPR vs Standard 30:2 — Equivalent Outcomes in 232,655 Cases

CHANGE THIS MONTH DIPIMC / FIMC

This large meta-analysis (n=232,655 OHCA cases) found no significant difference in outcomes between continuous chest compression (CCO, also termed hands-only or compression-only CPR) and standard 30:2 CPR. Survival to discharge and neurological outcomes were equivalent across the pooled dataset. The study supports existing guidelines that permit CCO by untrained bystanders, and contextualises the dispatcher-assisted CPR emphasis in RCUK 2025.

n=232,655 · no significant outcome difference CCO vs 30:2

Operational implication: For untrained bystanders receiving DA-CPR instructions, continuous compressions are as effective as 30:2. For trained responders with a protected airway, 30:2 continues to be supported. Do not delay compressions to achieve ventilation in the initial phases of OHCA.

JAMA INTERNAL MEDICINE · EXECT-CPR TRIAL · MONTHLY ISSUE 2 — MAY 2026

EXECT-CPR RCT — TEE-Guided CPR Does Not Improve ROSC Rates

CHANGE THIS MONTH DIPIMC / FIMC

The EXECT-CPR RCT tested whether real-time transesophageal echocardiography guidance during CPR (to optimise compression depth, rate, and position) improved ROSC rates compared to standard CPR. The result was negative: TEE-guided CPR did not improve ROSC rates. This is clinically important context for PHEM and critical care teams considering echocardiographic guidance as a quality measure during resuscitation.

No improvement in ROSC with TEE-guided CPR (RCT)

Context: TOE in OHCA may still have a role for diagnosis of reversible causes (e.g. cardiac tamponade, tension pneumothorax, pulmonary embolus) but should not be used as a CPR quality feedback tool in routine resuscitation. In PHEM, where TOE/TEE capability is limited to specialist HEMS platforms, the priority remains uninterrupted high-quality compressions with capnography-guided feedback.

RESUSCITATION 2026 · MONTHLY ISSUE 2 — MAY 2026

Asystolic OHCA Survival Falling Despite Rising Bystander CPR Rates (2003–2022)

INFORMING PRACTICE DIPIMC / FIMC

A 19-year longitudinal analysis of OHCA outcomes in a large registry found that while bystander CPR rates have increased substantially, survival from asystolic OHCA has paradoxically fallen. Shockable rhythm OHCA survival has improved in parallel with bystander CPR and early defibrillation. The divergence suggests that bystander CPR and improved chain of survival interventions primarily benefit shockable rhythms, and that asystolic OHCA — which carries an inherently different pathophysiology — requires a different research and intervention focus. ECPR, prehospital ECMO, and targeted pharmacological strategies remain the primary research areas for non-shockable OHCA.

PHEM implication: ToR decisions in asystolic OHCA are supported by this outcome data. Physician-attended HEMS should be reserved for cases with realistic ROSC potential; asystolic non-traumatic OHCA with prolonged downtime and no reversible cause has near-zero survival regardless of intervention level.

EMERGENCY MEDICINE JOURNAL · MONTHLY ISSUE 2 — MAY 2026

Bystander Sex and CPR Provision in OHCA — Dispatcher-Assisted CPR Reduces Gender Disparity

INFORMING PRACTICE

This EMJ study examined whether the known disparity in bystander CPR rates by patient sex persists when dispatcher-assisted CPR (DA-CPR) is provided. Female patients with OHCA receive bystander CPR at a lower rate than male patients in studies not using DA-CPR. The analysis found that DA-CPR substantially reduces this gender disparity, suggesting that the provision of dispatcher guidance equalises the likelihood of bystander CPR initiation regardless of patient sex. This reinforces the emphasis on high-quality DA-CPR in both JRCALC and RCUK 2025 updates.

CRITICAL CARE MEDICINE · MONTHLY ISSUE 2 — MAY 2026

International Paediatric OHCA Incidence — SR/MA: 5.56 per 100,000 (Crit Care Med)

INFORMING PRACTICE DIPIMC / FIMC

This systematic review and meta-analysis pooled international data on paediatric OHCA incidence, establishing a baseline rate of approximately 5.56 per 100,000 population. Survival to discharge was consistently below 10% across included studies. The data contextualise UK paediatric PHEM resource allocation and HEMS dispatch criteria for paediatric OHCA, and support the continued emphasis on rapid BLS initiation by first responders as the primary determinant of outcome.

MONTHLY ISSUE 3 — MAY 2026 · NETHERLANDS HEMS ECPR

OnScene ECPR Trial — Enrolment Complete (n=220); Results Expected Q3 2026

CHANGE THIS MONTH DIPIMC / FIMC

The OnScene trial, a Netherlands-based nationwide HEMS ECPR RCT, completed enrolment at n=220 patients in Q2 2026. This is the largest prehospital ECPR randomised trial to date. The trial tests whether prehospital ECPR initiation by HEMS for refractory OHCA (prolonged VF) improves neurologically intact survival compared to standard advanced resuscitation and in-hospital ECPR. Results are anticipated in Q3 2026 and will be the defining data set for UK prehospital ECPR protocols. The Sub30 London prehospital ECPR programme has separately published data showing comparable survival to in-hospital ECPR in selected cases.

Watch this space: OnScene results will likely drive major changes to UK HEMS ECPR selection criteria and dispatch protocols. All PHEM clinicians should be familiar with current ECPR candidacy criteria (witnessed VF, shockable rhythm, <5 min no-flow time, refractory to standard ALS) ahead of the trial publication.

CRITICAL CARE 2026 · PMID 41484784 · MONTHLY ISSUE 3 — MAY 2026

PHTEE-OHCA RCT — Prehospital Transesophageal Echocardiography Feasible Without CPR Compromise

CHANGE THIS MONTH DIPIMC / FIMC

The PHTEE-OHCA RCT (Crit Care 2026, PMID 41484784) demonstrated that prehospital transesophageal echocardiography (TOE) insertion during CPR is feasible on HEMS platforms without compromising CPR quality metrics (compression fraction, interruption time). This procedural feasibility finding is important context for ECPR-capable HEMS platforms where TOE is used to assess cardiac activity and confirm ECPR candidacy. The EXECT-CPR negative trial (see above) should temper enthusiasm for routine TOE guidance; prehospital TOE utility lies primarily in diagnosis rather than CPR optimisation.

MONTHLY ISSUE 3 — MAY 2026 · SINGER ET AL. LAA/LAS

Sub30 London Prehospital ECPR — Comparable Survival to In-Hospital ECPR in Selected Cases

INFORMING PRACTICE DIPIMC / FIMC

Data from the Sub30 prehospital ECPR programme delivered by London's Air Ambulance and London Ambulance Service showed that in carefully selected cases (witnessed VF, shockable rhythm, <5 min no-flow, refractory to 3 shocks), prehospital ECPR survival rates are comparable to in-hospital ECPR. The name "Sub30" refers to the target of achieving ECPR initiation within 30 minutes of cardiac arrest. This data supports the feasibility of UK prehospital ECPR and informs candidate selection for the OnScene trial's UK applicability.

PMID 41819339 · MONTHLY ISSUE 3 — MAY 2026

Paediatric Drowning Airway — ETI Not Superior to BVM in Prehospital OHCA

INFORMING PRACTICE DIPIMC / FIMC

This study (PMID 41819339, published March 2026) examined airway management in paediatric drowning-related OHCA and found that endotracheal intubation was not superior to BVM ventilation for survival outcomes. This aligns with the broader body of evidence suggesting that in paediatric OHCA, ETI does not confer survival advantage over effective BVM ventilation, and that prehospital ETI attempts may delay compressions or cause complications. For HEMS clinicians, paediatric RSI in drowning remains a judgement call based on individual airway assessment; the default should be BVM with early SGA consideration rather than mandatory ETI.

MONTHLY ISSUE 1 — APRIL 2026

Epinephrine in Prehospital Traumatic Cardiac Arrest — No Survival Benefit, Possible Harm

INFORMING PRACTICE DIPIMC / FIMC

Evidence from Q2 2026 adds to the growing literature questioning adrenaline use in traumatic cardiac arrest (TCA). Unlike medical OHCA (where PARAMEDIC2 supports adrenaline for ROSC, if not neurological benefit), TCA has a different pathophysiology dominated by hypovolaemia, tension pneumothorax, and cardiac tamponade. Adrenaline's vasopressor effects may be harmful by increasing afterload in an empty, unloaded heart and masking the physiological need for volume. Current FPHC and JRCALC guidance prioritises reversal of reversible causes (4 Hs and 4 Ts) over pharmacology in TCA. Adrenaline should not be given as a routine drug in prehospital TCA.

MONTHLY ISSUE 1 — APRIL 2026

IV vs IO Vascular Access in OHCA — IV First Reinforced by Registry Data

INFORMING PRACTICE DIPIMC / FIMC

Registry-based evidence from Q2 2026 reinforces the IV-first approach to vascular access in OHCA. Drug delivery via IO access (while faster to achieve) is associated with lower plasma drug concentrations and potentially inferior pharmacodynamic effect compared to IV. RCUK 2025 retained IV access as first-line with IO as the contingency when IV access cannot be rapidly achieved. In PHEM, IO should remain the second-line route when IV is not achievable within two attempts or is taking excessive time during active resuscitation. This should not delay drug administration — IO access within 2 attempts if IV fails.

MONTHLY ISSUE 1 — APRIL 2026

Airway Device Order in OHCA — SGA First-Pass Success Exceeds ETI in Non-Physician Providers

INFORMING PRACTICE DIPIMC / FIMC

Comparative data on airway device success rates in OHCA continues to support supraglottic airway devices (SGA, principally i-gel in UK practice) as having higher first-pass success than endotracheal intubation when placed by non-physician providers (paramedics, EMTs). ETI first-pass success in OHCA by non-physician providers consistently runs 60–75% in registry data, while i-gel placement rates exceed 88%. This reinforces JRCALC guidance positioning SGA as the preferred advanced airway in OHCA for paramedics, with ETI reserved for systems where competency is maintained through adequate clinical volume. In HEMS physician-paramedic teams, RSI by the physician with SGA as rescue remains the standard.

MONTHLY ISSUE 2 — MAY 2026

Resuscitative Hysterotomy in OHCA — Neonatal Survival 45% in Systematic Review

INFORMING PRACTICE DIPIMC / FIMC

A systematic review of resuscitative hysterotomy (perimortem Caesarean section) in maternal cardiac arrest found neonatal survival approaching 45% when the procedure was performed within 5 minutes of maternal arrest. Maternal ROSC was also facilitated in a proportion of cases through aortocaval decompression. This is a rare but critical PHEM skill for physician-attended HEMS. The procedure requires ≥24 weeks gestation and should be initiated without delay — within 4 minutes of arrest onset, targeting delivery by 5 minutes. Prehospital resuscitative hysterotomy has been documented in UK HEMS case series and is supported by FPHC and RCOG guidance. A scalpel is the only required instrument; no specialist equipment is needed.

Neonatal survival ~45% when delivered within 5 min of maternal arrest

MONTHLY ISSUE 5 — JUNE 2026

EMT vs Paramedic SGA Placement in OHCA — PMID 41812979

INFORMING PRACTICE

This study (PMID 41812979) compared SGA first-attempt success rates between EMTs and paramedics in OHCA, finding that outcomes were broadly comparable when i-gel type devices were used. The data support the policy of extending advanced airway privileges to EMTs for SGA placement in OHCA, and have relevance to UK ambulance service workforce planning where EMT scope of practice is under review. In PHEM, the clinical implication is that airway device selection should be guided by the device most reliably placed by the attending clinician rather than by arbitrary hierarchy.

MONTHLY ISSUE 5 — JUNE 2026

RCUK OH-ALS Course Launch + "Weakest Link" Report on OHCA Chain of Survival Gaps

INFORMING PRACTICE

RCUK launched the updated Out-of-Hospital Advanced Life Support (OH-ALS) course in June 2026, incorporating RCUK 2025 guideline changes including updated TTM, post-ROSC coronary angiography guidance, and ToR criteria. Concurrently, the RCUK "Weakest Link" report identified dispatcher recognition and DA-CPR instruction quality as the most impactful current gaps in the UK OHCA chain of survival. Response time improvements showed diminishing returns beyond 8 minutes, whereas improving DA-CPR instruction quality showed the largest modellable gain in survival. This has direct implications for ambulance control room training prioritisation and PHEM system design.

MONTHLY ISSUE 5 — JUNE 2026 · PMID 42218532

Paediatric PHEM EPA Competency Survey (PMID 42218532) — Training Gap in Neonatal and Paediatric PHEM

INFORMING PRACTICE DIPIMC / FIMC

A survey-based study of PHEM trainees and trainers (PMID 42218532) using entrustable professional activity (EPA) frameworks found significant self-reported and assessed gaps in paediatric and neonatal PHEM competencies, including neonatal resuscitation, paediatric RSI, and paediatric trauma. The findings support the case for structured paediatric PHEM simulation curricula and specific EPA-based assessments at HEMS and BASICS level. For DipIMC/FIMC candidates, paediatric PHEM scenarios including paediatric RSI, paediatric OHCA decision-making, and neonatal resuscitation are core examination domains.

CHAPTER 3 — 9 ITEMS

Airway & RSI

PHEA Guidelines · Intub-8 · Post-Intubation Hypotension · VL First-Line · April–June 2026

Q2 2026 delivered three publications that together constitute a landmark quarter for prehospital airway management: Intub-8 quantified the survival benefit of HEMS RSI at 170 lives per year UK-wide, the Association of Anaesthetists updated PHEA guidelines placed VL unambiguously as first-line, and a JAMA Network Open study raised the post-intubation SBP threshold in TBI from 90 to 100 mmHg. Together these items affect every HEMS physician and critical care paramedic performing prehospital RSI in the UK.

LANCET RESPIRATORY MEDICINE · INTUB-8 · MONTHLY ISSUE 2 / ISSUE 7 — APRIL–MAY 2026

Intub-8: Prehospital RSI by HEMS Saves Approximately 170 Additional Lives Per Year in UK

CHANGE TONIGHT DIPIMC / FIMC

The Intub-8 study, published in Lancet Respiratory Medicine, is the first large-scale quantification of the survival benefit attributable to prehospital RSI by HEMS in the UK. Using a prospective HEMS registry with case-mix adjustment, the analysis compared outcomes in patients receiving prehospital RSI by physician-paramedic HEMS teams with modelled counterfactual outcomes had those patients received standard (no prehospital intubation) prehospital care. The result: prehospital RSI by HEMS is associated with approximately 170 additional survivors per year across the UK compared to a world without prehospital intubation.

~170 additional lives saved per year in UK attributable to HEMS RSI (case-mix adjusted, prospective registry)

Methodology note: This is a registry analysis with case-mix adjustment, not an RCT. The comparator is modelled rather than directly observed. Case-mix adjustment attempts to control for the HEMS system selecting the sickest and most physiologically disrupted patients. The direction and magnitude of effect align with the physiological rationale for prehospital airway control in TBI, trauma, and medical OHCA.

Why this matters: Intub-8 provides the strongest evidence yet that physician-performed prehospital RSI is a life-saving intervention at population scale. It directly supports continued investment in UK HEMS physician-paramedic model, and should inform HEMS commissioning, base-positioning, and tasking criteria. For DipIMC/FIMC candidates this is the most cited new PHEM paper of Q2 2026 — know the number (170), the study design, and its limitations.

The result does not imply that all prehospital RSI is net beneficial — complications including peri-intubation hypoxia, post-intubation hypotension, and delayed scene departure carry real harms. The benefit is maximised when RSI is performed rapidly, safely, and with adequate post-intubation monitoring including ETCO2 and blood pressure management.

ANAESTHESIA 2026 · ASSOCIATION OF ANAESTHETISTS · MONTHLY ISSUE 2 — MAY 2026

Updated Association of Anaesthetists PHEA Guidelines (Anaesthesia, March 2026) — VL First-Line, Push-Dose Vasopressors, Post-Intubation Bundle Formalised

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The Association of Anaesthetists published updated Prehospital Emergency Anaesthesia (PHEA) guidelines in March 2026, replacing the previous 2017 iteration. The most impactful change is the formal designation of videolaryngoscopy (VL) as the recommended first-line technique for all prehospital RSI, superseding direct laryngoscopy as the standard. This aligns with evidence from the DAS 2025 difficult airway guidelines and the broader anaesthetic evidence base, where VL consistently improves first-pass success and reduces failed intubation rates regardless of grade of difficulty.

VL recommended as first-line for prehospital RSI (all cases) — PHEA 2026

Push-dose vasopressors are formally endorsed in the PHEA 2026 document for peri-intubation haemodynamic support. Agents include phenylephrine 100 micrograms IV bolus or epinephrine 10–20 micrograms IV bolus, to be used when SBP falls below 90 (or 100 in TBI) following induction. A post-intubation care bundle is formalised, comprising: continuous ETCO2 monitoring, chest auscultation/equivalent to CXR confirmation, cuff pressure measurement (<30 cmH2O), and gastric tube insertion in secured patients.

Immediate equipment implication: All HEMS platforms and PHEM-capable physician responses should carry and be trained in videolaryngoscopy. The BVM with direct laryngoscopy model is no longer the PHEA-supported standard. HEMS medical directors should audit platform compliance with VL availability.

DipIMC/FIMC: The full post-intubation care bundle (ETCO2, cuff pressure, gastric tube, CXR equivalent) is directly examinable. Know which patients require what and at what thresholds.

JAMA NETWORK OPEN · MONTHLY ISSUE 7 — APRIL–MAY 2026

Post-Intubation Hypotension in TBI — SBP <100 Within 60 Min Independently Associated with Worse Neurological Outcome

CHANGE TONIGHT DIPIMC / FIMC

This JAMA Network Open study examined post-intubation blood pressure management in traumatic brain injury patients receiving prehospital intubation. SBP below 100 mmHg within 60 minutes of prehospital intubation was independently associated with worse neurological outcomes at 30 days, after adjustment for injury severity, age, and GCS. Crucially, the threshold that emerged was SBP 100 mmHg — not the 90 mmHg threshold used in non-TBI trauma haemodynamic targets.

SBP <100 within 60 min of intubation independently associated with poor neurological outcome in TBI

Target SBP ≥100 mmHg post-intubation in TBI (not ≥90 as in non-TBI trauma)

Immediate practice change: For intubated TBI patients, the vasopressor trigger threshold should be SBP <100, not <90. Push-dose phenylephrine or metaraminol should be immediately available following RSI in TBI patients. This threshold distinction (100 vs 90) is directly examinable at DipIMC/FIMC level and must be correctly recalled in clinical decision-making.

Pathophysiological rationale: TBI impairs cerebrovascular autoregulation, making cerebral perfusion pressure (CPP = MAP − ICP) critically sensitive to MAP falls. Post-induction vasodilation (propofol/ketamine/opioid effect) in an already hyperaemic or impaired autoregulation TBI patient produces a disproportionate fall in CPP. Higher SBP target mitigates this.

MONTHLY ISSUE 1 — APRIL 2026 · NHTSA/AHRQ

NHTSA/AHRQ Evidence-Based Guideline for Prehospital Airway Management — 22 Recommendations

INFORMING PRACTICE DIPIMC / FIMC

The US NHTSA/AHRQ published a comprehensive evidence-based guideline for prehospital airway management comprising 22 recommendations. Key messages relevant to UK PHEM include: BVM with two-person technique as the baseline standard for all prehospital ventilation; SGA as first advanced airway in non-physician EMS systems; ETI with RSI for physician-available HEMS/critical care paramedicine systems; VL superior to DL for ETI in non-optimal prehospital environments. The guideline's recommendation structure maps closely onto existing UK DAS and PHEA guidance, reinforcing the international alignment of current evidence with UK practice.

EMERGENCY MEDICINE JOURNAL · MONTHLY ISSUE 2 — MAY 2026

Prehospital Severe Agitation SR — Ketamine IM 5 mg/kg Most Effective for Acute Behavioural Disturbance

INFORMING PRACTICE DIPIMC / FIMC

This EMJ systematic review of prehospital management of severe agitation and acute behavioural disturbance (ABD) found that intramuscular ketamine at 5 mg/kg was the most effective single agent for rapid sedation to permit clinical assessment and transport. Time to adequate sedation was shorter than with benzodiazepines or droperidol alone. Complication rates (laryngospasm, emergence phenomena) were low at the 5 mg/kg dose. The RCEM June 2026 ABD guideline update (Chapter 3) mirrors this, formally replacing "excited delirium" terminology and recommending IM ketamine as first-line.

IM ketamine 5 mg/kg — fastest time to adequate sedation in prehospital ABD

Airway consideration: Post-sedation monitoring for airway compromise is essential. IM ketamine at 5 mg/kg may produce partial airway obstruction in the obtunded patient; jaw thrust, positioning, and NPA insertion are priorities. Escalation to RSI may be required if airway is not maintained post-sedation.

NEUROLOGY 2025 / PMID AVAILABLE · MONTHLY ISSUE 3 — MAY 2026

Ketamine vs Morphine Prehospital Meta-Analysis (4 RCTs, n=757) — No Pain Advantage for Ketamine; Higher Adverse Events

CHANGE THIS MONTH DIPIMC / FIMC

A meta-analysis pooling 4 RCTs (n=757) comparing ketamine versus morphine for prehospital analgesia found no significant advantage for ketamine in pain reduction at 30 minutes, with higher rates of adverse events (dizziness, dysphoria, emergence phenomena) in the ketamine group. This contrasts with the broader sub-dissociative IV ketamine literature. The result applies to analgesic-dose ketamine (0.1–0.3 mg/kg IV), not sedative-dose ketamine (1–2 mg/kg IV or 4–5 mg/kg IM), and should not influence ABD sedation or RSI practice.

No pain-score advantage for ketamine vs morphine at analgesic doses in 4 RCTs (n=757)

Practical implication: Morphine or fentanyl remain appropriate first-line analgesics for prehospital pain management. Ketamine's role is in patients where opioids are contraindicated (haemodynamic compromise, head injury with ICP concerns) or as an adjunct. Do not substitute ketamine for opioids based on perceived superiority — this evidence does not support it.

J CONTEMPORARY CLINICAL PRACTICE 2025 · MONTHLY ISSUE 3 — MAY 2026

Protocolised RSI SR/MA — RR 0.77 for Hypoxaemia; Improved First-Pass Success

INFORMING PRACTICE DIPIMC / FIMC

This SR/MA examined the impact of standardised RSI protocols (checklists, drug dose cards, pre-oxygenation mandates, post-intubation care bundles) on RSI safety outcomes in both prehospital and emergency department environments. Protocol-driven RSI was associated with a relative risk of 0.77 for peri-intubation hypoxaemia compared to non-protocolised RSI. First-pass success rates were significantly higher in protocolised systems. The mechanism is reduction in cognitive load at the point of procedure, ensuring pre-oxygenation adequacy, drug selection accuracy, and post-intubation assessment completion. This supports the PHEA 2026 post-intubation bundle as a structural intervention.

MONTHLY ISSUE 3 — MAY 2026 · THE RESUS ROOM / FOAMED

The Resus Room April 2026: SWiFT Trial + Updated PHEA Guidelines — Critical Appraisal

INFORMING PRACTICE

The Resus Room podcast and blog (theresusroom.co.uk) provided a combined critical appraisal of the SWiFT null result and the updated PHEA guidelines in April 2026, highlighting the integration challenge for HEMS teams: a new airway standard (VL first-line) coinciding with a confirmed haemostatic strategy (components over whole blood). The discussion noted that the PHEA 2026 VL recommendation is grade-agnostic — it applies to all prehospital RSI, not just predicted difficult airways — which is a clinically significant departure from previous "difficult airway" framing of VL use.

MONTHLY ISSUE 5 — JUNE 2026 · RCEM

RCEM ABD Guideline Updated — No "Excited Delirium" Terminology; IM Ketamine Confirmed First-Line

INFORMING PRACTICE DIPIMC / FIMC

The RCEM updated its Acute Behavioural Disturbance guideline in June 2026, explicitly removing "excited delirium" as a diagnostic category (following its removal by NAEMSP in 2023 and the broader medico-legal concerns around the term in positional asphyxia cases). Intramuscular ketamine is confirmed as the first-line prehospital pharmacological agent for ABD requiring chemical restraint, with droperidol as an alternative. The guideline emphasises monitoring for post-sedation respiratory depression and the importance of not conflating chemical restraint with therapeutic management of the underlying cause.

PHEM implication: HEMS clinicians must be familiar with this terminology change for documentation, medicolegal, and handover purposes. "Excited delirium" should not appear on HEMS clinical records as a diagnostic label. Use "acute behavioural disturbance", "severe agitation", or the suspected underlying diagnosis.

MONTHLY ISSUE 1 — APRIL 2026 · DANISH PARAMEDIC REGISTRY

Low-Dose S-Ketamine for Prehospital Analgesia — Danish Paramedic Registry Data

INFORMING PRACTICE DIPIMC / FIMC

Danish paramedic registry data published in Q2 2026 examined the use of low-dose S-ketamine (esketamine, 0.1–0.25 mg/kg IV) for prehospital pain management in traumatic and medical emergencies. S-ketamine, the active S-enantiomer of racemic ketamine, is approximately twice as potent and has a shorter duration of action. The registry analysis found adequate pain relief (NRS reduction ≥2 points) in 78% of patients, with a low adverse event profile (dysphoria 4%, emergence phenomena 2%, hypersalivation 5%). The analgesic performance was superior to racemic ketamine at equivalent doses in indirect comparison.

78% adequate analgesia with S-ketamine 0.1–0.25 mg/kg IV in prehospital setting

UK context: S-ketamine (esketamine) is not yet widely available in UK prehospital formularies; racemic ketamine remains the standard. This data supports a future licensing and formulary case for S-ketamine in UK HEMS and critical care paramedic practice. At sub-dissociative doses, the distinction from racemic ketamine is primarily pharmacokinetic; both produce analgesia via NMDA antagonism. DipIMC/FIMC candidates should understand the enantiomer pharmacology and the emerging data even if S-ketamine is not yet in UK protocols.

CHAPTER 4 — 12 ITEMS

Trauma & Haemorrhage Control

TOWAR · TXA Meta-Analysis · FFP:RBC in TBI · FPHC Crush Injury · REBOA · April–June 2026

Q2 2026 processed nearly 36,000 patients across three haemorrhage-related datasets and delivered a definitive answer on prehospital whole blood: it is not superior to component therapy in UK HEMS. Simultaneously, the TXA evidence base achieved new depth, with a 12,682-patient meta-analysis confirming a 28% mortality reduction and an IPD safety analysis definitively excluding thromboembolic harm. The FPHC Crush Injury Consensus Statement replaced a 23-year-old document with new early calcium gluconate guidance.

NEJM 2026 · PMID 42150044 · MONTHLY ISSUE 5 — JUNE 2026

TOWAR Trial — Prehospital Type O Whole Blood vs Component Therapy in UK HEMS: Null Result

CHANGE THIS MONTH DIPIMC / FIMC

The TOWAR trial (published NEJM 2026, PMID 42150044) was a UK-based prehospital RCT comparing Type O cold-stored whole blood to standard component therapy (FFP + packed red blood cells) in haemorrhagic trauma patients attended by HEMS. The primary outcome was 30-day mortality. The result was null: whole blood was not superior to component therapy. This mirrors the concurrent SWiFT trial, which reached the same conclusion in a slightly different service context (trauma ambulance versus HEMS).

Whole blood not superior to component therapy in UK HEMS — null result (TOWAR, NEJM 2026)

Operational conclusion: UK HEMS component therapy (FFP + pRBC) remains the NHSBT standard. Do not adopt Type O whole blood off-protocol in UK HEMS until a future trial demonstrates superiority. The US military data showing whole blood benefit may reflect different patient populations, different product quality, and different comparators (crystalloid rather than balanced components).

Why did TOWAR fail to show benefit? Leading hypotheses: UK component therapy is already high-quality and well-balanced (NHSBT standard leuco-depleted FFP and CMV-negative pRBC); whole blood advantage may only appear when the comparator is suboptimal component therapy; the platelet component of whole blood (absent in stored cold whole blood) may be the critical missing element; or whole blood's benefit in military/tactical settings reflects a different injury and logistics profile.

DipIMC/FIMC: Know both the TOWAR result and its limitations. Understand the difference between low-titre Type O whole blood (LTOWB) and standard stored whole blood. Be able to articulate why the US military experience does not directly translate to UK HEMS.

FRONTIERS IN MEDICINE 2025 · PMID 40160319 · MONTHLY ISSUE 3 — MAY 2026

Prehospital TXA Meta-Analysis (n=12,682) — 28% Reduction in 24-Hour Mortality; 34% Reduction in Haemorrhage Mortality

CHANGE THIS MONTH DIPIMC / FIMC

This systematic review and meta-analysis (Frontiers in Medicine 2025, PMID 40160319) pooled 12,682 patients from prehospital TXA trials and registries. Prehospital TXA administered within one hour of injury was associated with a 28% relative reduction in 24-hour mortality (OR 0.72, 95%CI 0.62–0.84). The relative reduction in mortality specifically attributable to haemorrhage was 34%. This is the largest prehospital TXA dataset yet assembled and the most precise quantification of the survival benefit in the prehospital window.

OR 0.72 (95%CI 0.62–0.84) — 28% relative reduction in 24h mortality with prehospital TXA within 1 hr

34% relative reduction in haemorrhage-specific mortality

Time-to-treatment message: The benefit is concentrated in TXA administered within 1 hour of injury and falls substantially at 1–3 hours. Administration at >3 hours is associated with harm in the CRASH-2 data. This reinforces the standard of TXA as a first-responder drug given in the prehospital phase, not deferred to the emergency department.

PHEM integration: Supports the NAEMSP/ACEP/ACS-COT joint TXA position statement (Q1 2026) and the EAST TXA Practice Management Guideline (Q2 Issue 1). TXA should be given by the first HEMS/BASICS/advanced paramedic team on scene for qualifying trauma patients. The administration should be documented with time of injury and time of administration.

PMID 42023936 · IPD META-ANALYSIS · MONTHLY ISSUE 5 — JUNE 2026

TXA Thromboembolism Safety Analysis — PATCH/STAAMP/ROC IPD: No Increased TE Risk (OR 0.97)

INFORMING PRACTICE DIPIMC / FIMC

An individual patient data (IPD) meta-analysis of three prehospital TXA RCTs — PATCH, STAAMP, and ROC (PMID 42023936) — examined the safety signal around thromboembolic events (DVT, PE, arterial thrombosis) with prehospital TXA. The pooled analysis found no increased risk of thromboembolic events with TXA versus placebo (OR 0.97, 95%CI 0.73–1.29). This is a definitively reassuring safety finding given prior theoretical concerns about TXA's antifibrinolytic mechanism promoting thrombosis.

OR 0.97 (95%CI 0.73–1.29) — TXA not associated with thromboembolic events (IPD, 3 RCTs)

Practice implication: Concerns about TXA-associated thromboembolism are not supported by this high-quality IPD analysis. There is no need to withhold TXA in qualifying trauma patients on grounds of TE risk. This should also inform post-TXA DVT prophylaxis decisions: standard risk-stratified prophylaxis rather than heightened TE surveillance is appropriate.

ACS-TQIP · PMID 42023940 · MONTHLY ISSUE 5 — JUNE 2026

FFP:RBC High Ratio in TBI — ACS-TQIP (n=23,362): aOR 0.81 for Mortality with ≥1:1.5 Ratio

INFORMING PRACTICE DIPIMC / FIMC

This ACS-TQIP registry analysis (n=23,362, PMID 42023940) examined FFP:RBC transfusion ratios in TBI patients with concomitant haemorrhage. A high FFP:RBC ratio (defined as ≥1:1.5, i.e. nearly 1:1 balanced) was independently associated with lower in-hospital mortality (aOR 0.81, 95%CI 0.74–0.90) compared to lower ratios. This represents the largest dataset specifically examining transfusion ratio in TBI-haemorrhage, an area where previous guidelines were extrapolated from non-TBI trauma populations.

aOR 0.81 (95%CI 0.74–0.90) — high FFP:RBC ratio (≥1:1.5) associated with lower mortality in TBI+haemorrhage

PHEM relevance: When initiating prehospital transfusion in TBI patients with haemorrhage (e.g. polytrauma with TBI), aim for balanced component therapy from the outset. In systems with FFP+pRBC, attempt 1:1 administration. Do not preferentially give pRBC without concurrent FFP in TBI patients with active bleeding. This data applies specifically to TBI with haemorrhage — isolated TBI without haemorrhage has different haemostatic considerations.

MONTHLY ISSUE 1 — APRIL 2026 · FPHC/RCSED 2025

FPHC Crush Injury Consensus Statement 2025 — Replaces 2003 Document; Early Calcium Gluconate, Fasciotomy Deferred

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The Faculty of Pre-Hospital Care (FPHC/RCSEd) 2025 Crush Injury Consensus Statement replaces the 2003 FPHC document that had guided UK PHEM practice for over two decades. The key new recommendations are clinically significant. Early intravenous calcium gluconate is now recommended for crush injuries where rhabdomyolysis or hyperkalaemia is suspected — this reflects the pathophysiology of reperfusion injury following prolonged entrapment, where hyperkalaemia-induced cardiac arrhythmia is the primary early-mortality risk. Fasciotomy decisions are formally deferred to the receiving hospital unless limb loss is clearly preventable by immediate field intervention (a very high threshold).

Key change: Early IV calcium gluconate for suspected rhabdomyolysis/hyperkalaemia in crush injury

Fasciotomy: deferred to receiving hospital in almost all circumstances

The consensus statement mandates clinical reassessment at 30-minute intervals for signs of reperfusion syndrome during extrication and transport. ECG monitoring is strongly recommended where available, with particular attention to peaked T waves and widened QRS as hyperkalaemia markers. Fluid resuscitation guidance recommends crystalloid at sufficient rate to maintain urine output >200 mL/hr once at hospital, but IV access and fluid initiation in the prehospital phase is appropriate.

Extrication context: The guidance on calcium gluconate applies primarily to prolonged entrapment scenarios (>1 hour) where rhabdomyolysis is anticipated. In brief crush injuries (<15 minutes) without clinical evidence of major muscle involvement, the risk is lower. Calcium gluconate administration in the absence of ECG-confirmed hyperkalaemia should be balanced against available resources and transport time.

DipIMC/FIMC: Crush injury with prolonged entrapment and subsequent reperfusion syndrome is a classic PHEM examination scenario. Know the mechanism (hyperkalaemia, myoglobinaemia), the pharmacological intervention (calcium gluconate, sodium bicarbonate, furosemide), and the complication sequence (ventricular arrhythmia, acute renal failure, ARDS).

J TRAUMA · MONTHLY ISSUE 2 — MAY 2026

REBOA vs Resuscitative Thoracotomy SR/MA — REBOA Favoured in Non-Compressible Haemorrhagic Shock

INFORMING PRACTICE DIPIMC / FIMC

A systematic review and meta-analysis (J Trauma) comparing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with resuscitative thoracotomy for haemorrhagic shock management in prehospital and trauma bay settings found REBOA was associated with better short-term survival outcomes in the non-traumatic cardiac arrest haemorrhagic shock population. REBOA avoids the perioperative risks of thoracotomy while achieving Zone III aortic occlusion for pelvic and sub-diaphragmatic haemorrhage. In UK HEMS, REBOA deployment is limited to specific programmes (London's Air Ambulance, KSS HEMS) but the evidence base continues to develop.

DipIMC/FIMC: Understand the three REBOA zones (Zone I — descending thoracic aorta; Zone III — infrarenal aorta; Zone II — avoided due to mesenteric vessels), the device components, and the indication thresholds. REBOA in prehospital practice remains a specialist intervention; know which UK HEMS programmes deploy it and the current evidence quality.

SJTREM · MONTHLY ISSUE 2 — MAY 2026

Prehospital Time and Hypotensive Trauma Mortality — 5.1% Increased Mortality Per 10 Min Delay

INFORMING PRACTICE DIPIMC / FIMC

This SJTREM analysis quantified the relationship between prehospital time and mortality in hypotensive trauma patients (SBP <90 on arrival). Each additional 10 minutes of prehospital time was associated with a 5.1% increase in mortality, after adjustment for mechanism and injury severity. This reinforces the "platinum 10 minutes" and "stay and play vs load and go" debate in PHEM: for haemorrhagic shock, transport time reduction should be prioritised and scene time minimised. HEMS tasking criteria that reduce transport time for haemorrhagic shock patients are directly justified by this analysis.

5.1% increased mortality per 10-min additional prehospital time in hypotensive trauma

MONTHLY ISSUE 2 — MAY 2026 · PLOS ONE

MATTS — Major Trauma Triage Tool Validation in England: 3.1% Prevalence

INFORMING PRACTICE

The MATTS triage tool validation study (PLoS ONE) assessed a clinical decision tool for prehospital identification of major trauma in England. The tool demonstrated acceptable sensitivity and specificity, but the major trauma prevalence in the validation dataset was only 3.1%, limiting positive predictive value. This has direct implications for HEMS tasking and trauma activation calls: low prevalence means many activations will be for non-major trauma patients, and triage tool performance must be interpreted in the context of local prevalence. Over-triage rates remain a system challenge across all UK trauma networks.

MONTHLY ISSUE 1 — APRIL 2026 · EAST

EAST Urban Penetrating Trauma Transport — Scoop and Run Evidence Base

INFORMING PRACTICE DIPIMC / FIMC

The Eastern Association for the Surgery of Trauma (EAST) published an evidence review on urban penetrating trauma transport strategy, finding that a scoop-and-run model with minimal scene intervention was associated with improved survival in urban penetrating trauma when transport time to a definitive surgical centre is short (<10 minutes). In the UK context, this translates to continued support for direct transport to a Major Trauma Centre in urban penetrating trauma, with haemorrhage control (direct pressure, tourniquet, wound packing) as the only mandatory prehospital intervention. Airway management should not delay transport in the haemodynamically unstable penetrating trauma patient.

MONTHLY ISSUE 1 — APRIL 2026 · EAST

EAST TXA Practice Management Guideline — 30-Study Meta-Analysis

CHANGE THIS MONTH DIPIMC / FIMC

The EAST TXA Practice Management Guideline, informed by a 30-study meta-analysis, issued a strong conditional recommendation for prehospital TXA in traumatic haemorrhage, emphasising the 1-hour window and CRASH-2 3-hour outer limit. The guideline explicitly recommends not withholding TXA due to concerns about thromboembolic risk (now addressed by the PATCH/STAAMP/ROC IPD analysis). In the UK, TXA is already standard in HEMS protocols; this guideline reinforces the evidence base for early administration and may support expansion to BASICS and advanced paramedic scope in regions where it remains limited.

MONTHLY ISSUE 1 — APRIL 2026 · FIIRST-2 TRIAL

FiiRST-2 Trial: Factor Concentrates vs FFP in Trauma — Non-Inferiority Signal for Fibrinogen Concentrate

CHANGE THIS MONTH DIPIMC / FIMC

The FiiRST-2 trial compared factor concentrate-based resuscitation (fibrinogen concentrate plus PCC) to fresh frozen plasma (FFP) in traumatic haemorrhage, finding a non-inferiority signal for factor concentrate resuscitation in terms of 28-day mortality and haemostatic efficacy. Factor concentrates offer logistical advantages in prehospital settings: they do not require ABO compatibility, have a longer shelf life at ambient temperature, require smaller volumes, and can be prepared more rapidly than FFP. The trial result is clinically important for UK HEMS services that currently carry FFP and pRBC but cannot carry full coagulation factor products due to cold chain constraints.

Factor concentrates non-inferior to FFP for haemostatic efficacy in trauma (FiiRST-2)

Current UK practice: NHSBT-standard FFP and pRBC remain the HEMS recommendation following TOWAR and SWiFT. FiiRST-2 opens a potential future pathway for fibrinogen concentrate as either a supplement or replacement for FFP in prehospital haemorrhage resuscitation. This has not yet translated to a protocol change but will be reviewed in future RCUK/FPHC haemorrhage guidance iterations. DipIMC/FIMC candidates should be able to discuss fibrinogen concentrate mechanism, dosing (3–4 g IV), and the haemostatic rationale in the context of trauma-induced coagulopathy.

MONTHLY ISSUE 1 — APRIL 2026 · FPHC/RCSED

FPHC Consensus Statement: Pre-Hospital Management of Injured Pregnant Patients

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The FPHC 2026 Consensus Statement on prehospital management of injured pregnant patients provides updated guidance on trauma management in pregnancy, addressing spinal immobilisation (left lateral tilt ≥15 degrees), TXA administration (not contraindicated in pregnancy; use standard dosing), resuscitative hysterotomy (mandatory consideration at ≥24 weeks gestation in maternal cardiac arrest), and HEMS tasking criteria (physician attendance strongly recommended for major trauma in pregnancy beyond 20 weeks). Placental abruption and uterine rupture are specifically highlighted as time-critical diagnoses requiring immediate MTC transfer without delay for imaging.

MONTHLY ISSUE 2 — MAY 2026 · NEJM (SWIFT)

SWiFT RCT: Whole Blood vs Component Therapy in UK HEMS — Not Superior (NEJM)

CHANGE THIS MONTH DIPIMC / FIMC

The SWiFT trial (NEJM), reported in the May 2026 PHEM issue, examined prehospital whole blood in UK trauma ambulance systems (as distinct from TOWAR's HEMS context). The SWiFT result was also null. Together, SWiFT and TOWAR constitute converging UK evidence that whole blood is not superior to FFP+pRBC in prehospital trauma resuscitation within the NHS context. Component therapy is the recommended NHSBT standard and should not be displaced by whole blood adoption outside research protocols. The question of whether a different whole blood product formulation (e.g. with platelet additive) might outperform current stored cold whole blood remains open.

SWiFT + TOWAR: both null — component therapy remains UK HEMS standard

CHAPTER 5 — 9 ITEMS

Guidelines & Governance

RCUK 2025 Full Implementation · JRCALC Update · PE & Stroke Guidelines · Avalanche Algorithm · April–June 2026

The first week of Q2 2026 delivered the most consequential guideline update in a decade for UK resuscitation practice: the full operational implementation of RCUK 2025 guidelines from 1 April. This chapter covers the PHEM-specific changes and the concurrent JRCALC update, alongside two major international guidelines (PE, stroke) with direct PHEM implications and an updated avalanche algorithm.

RESUSCITATION COUNCIL UK · FULL IMPLEMENTATION 1 APRIL 2026 · MONTHLY ISSUE 1

RCUK 2025 Guidelines — Full Implementation 1 April 2026: TTM 36°C Standard, No Mandatory Post-ROSC Angio, Updated DA-CPR

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The RCUK 2025 Resuscitation Guidelines reached full operational implementation across UK ambulance services and HEMS platforms on 1 April 2026. For PHEM clinicians, the most directly impactful changes are: targeted temperature management at 33°C is no longer recommended over 36°C (from the TTM and TTM2 trial evidence, already adopted in most ICUs but now embedded in RCUK guidelines); post-ROSC coronary angiography is not mandated in the absence of ST-elevation on ECG; and dispatcher-assisted CPR guidance has been restructured around optimising high-quality CPR metrics rather than specific rhythm-based instructions.

TTM 2026: 36°C standard — 33°C no longer recommended as superior by RCUK 2025

Post-ROSC cath lab activation: STEMI only — not mandatory for OHCA survivors without STEMI

Additional PHEM-relevant changes: greater emphasis on high-quality CPR metrics (target compression depth 5–6 cm, rate 100–120/min, fraction >60%); confirmation that defibrillation pad selection and placement should be guided by evidence (supporting the DOSE-VF AP pad substudy implication); and updated guidance on ECPR candidacy (witnessed VF, no-flow <5 min, refractory to 3 shocks, reversible aetiology).

Clinical governance action: HEMS platforms should have reviewed and updated clinical protocols, drug dose cards, and training materials to reflect RCUK 2025 by 1 April 2026. Post-ROSC management pathways must be updated: temperature target 36°C, cath lab activation criteria STEMI-driven only, AMIST handover with documented TTM plan.

DipIMC/FIMC: The TTM2 trial (2021) and RCUK 2025 guideline convergence on 36°C is a core examination topic. Understand the TTM and TTM2 trial designs, why they overturned earlier guidance, and the physiological rationale for active temperature control at 36°C even if active cooling to 33°C provides no additional benefit.

MONTHLY ISSUE 1 — APRIL 2026 · AHA/ACC

2026 AHA/ACC Acute Pulmonary Embolism Guideline — New A–E Risk Classification; PHEM Pre-Alert Implications

INFORMING PRACTICE DIPIMC / FIMC

The 2026 AHA/ACC Acute Pulmonary Embolism guideline introduced an A–E risk classification system replacing the older massive/submassive/low-risk framework. Class A (low risk) to Class E (cardiac arrest) stratify PE by haemodynamic severity and risk of deterioration. For PHEM, the Class D (high risk, haemodynamic instability, not in arrest) and Class E (cardiac arrest) categories are directly relevant. Class E PE with OHCA represents an ECPR candidacy group and requires immediate dispatch to an ECPR-capable centre where available.

PHEM implication: Class E PE (PEA or asystolic OHCA with suspected PE) should trigger ECPR consideration if local resources allow. Class D PE with prehospital haemodynamic instability should receive vasopressor support, oxygen, and high-priority transfer to a PE response team. Empirical prehospital thrombolysis for PE in arrest remains a HEMS physician decision based on clinical probability when no other reversible cause is identified.

MONTHLY ISSUE 1 — APRIL 2026 · ERC 2025

ERC 2025 Avalanche Algorithm (AvaLife) — ICAR 60-Minute Burial Threshold Change

CHANGE WHEN GUIDELINE UPDATES DIPIMC / FIMC

The European Resuscitation Council (ERC) 2025 AvaLife avalanche resuscitation algorithm, incorporating updated ICAR MEDCOM guidance, revises the burial duration threshold for resuscitation versus non-resuscitation decisions. The 60-minute burial threshold for non-resuscitation (when core temperature is <32°C and airway impaction is suspected) replaces the previous 35-minute threshold, reflecting evidence that survival is possible with longer burial times in patients with patent airways and no airway snow impaction. All UK mountain rescue teams and HEMS platforms responding to avalanche scenarios should update protocols accordingly.

New ICAR threshold: 60 minutes burial before considering non-resuscitation (with core temp <32°C, no airway impaction)

UK context: Avalanche OHCA is rare in UK practice but occurs in Scottish Highlands and Northern Wales. Mountain rescue team HEMS interface protocols should reflect the AvaLife algorithm update. ECMO/ECPR capability for rewarming in profound hypothermic arrest remains the definitive treatment; the updated threshold increases the window in which patients should be resuscitated and transported to ECMO-capable centres.

MONTHLY ISSUE 1 — APRIL 2026 · SURVIVING SEPSIS CAMPAIGN

Surviving Sepsis Campaign 2026 Adult Guidelines — 129 Statements, 46 New; PHEM Bundle Implications

INFORMING PRACTICE DIPIMC / FIMC

The SSC 2026 Adult Guidelines issued 129 statements across sepsis management, of which 46 are new or significantly revised. PHEM-relevant changes include: updated fluid resuscitation targets (30 mL/kg initial bolus remains but is now explicitly a starting point, not an endpoint); noradrenaline as first-line vasopressor, with vasopressin and adrenaline as adjuncts; and recognition that septic shock requiring vasopressor initiation should trigger higher-acuity transfer in the prehospital phase. The SSC 2026 does not endorse prehospital vasopressor initiation outside physician-attended systems but acknowledges its role in prolonged transport scenarios.

MONTHLY ISSUE 2 — MAY 2026 · RCUK

RCUK ReSPECT Policy Briefing 2026 — OOH ReSPECT Access; Paramedic Guidance Updated

INFORMING PRACTICE

See Chapter 2 for the full ReSPECT item. From a governance perspective, the 2026 RCUK Briefing notes that ReSPECT implementation across the UK is now approximately 70% complete in primary and community care settings. Paramedics acting in good faith on completed ReSPECT forms are protected from litigation under BMA/RCUK joint guidance. Key governance issue: HEMS crews should not delay resuscitation to search for a ReSPECT form, but should honour a clearly presented valid form in the patient's home or on their person. Copies held digitally in Summary Care Record are increasingly accessible via ambulance service portals.

MONTHLY ISSUE 3 — MAY 2026 · AAUK

AAUK National Policy Position Statement 2026 — Helipads, PRANA System, EGNOS-Equipped Approaches

INFORMING PRACTICE

Air Ambulances UK (AAUK) published its National Policy Position Statement 2026, covering helipad standards, the PRANA (Pre-hospital Resuscitation AAUK National Audit) outcomes data framework, and EGNOS-equipped precision instrument approaches for night and low-visibility operations. The PRANA framework is the first national UK HEMS outcomes audit, enabling cross-service benchmarking on key PHEM metrics including ROSC rates, HEMS RSI complication rates, trauma mortality, and time-to-critical-intervention. The EGNOS guidance reflects advances in GPS-augmented IFR approaches that are extending the operational envelope of UK HEMS particularly in winter and adverse weather.

MONTHLY ISSUE 3 — MAY 2026 · ROYAL COLLEGE OF PARAMEDICS

Royal College of Paramedics 25th Anniversary & Professional Strategy 2026–2036

CHANGE WHEN GUIDELINE UPDATES

The College of Paramedics was formally rebranded the Royal College of Paramedics in May 2026, marking the 25th anniversary of the college and the launch of the Professional Strategy 2026–2036. The strategy emphasises post-registration advanced practice pathways, PHEM as a distinct clinical specialty with College representation, and a commitment to research capacity building within the paramedic profession. For PHEM clinicians, this signals an increasingly formalised advanced paramedic and HEMS paramedic career structure with CPD requirements and competency frameworks that will intersect with DipIMC/FIMC training.

MONTHLY ISSUE 5 — JUNE 2026 · NICE

NICE NG258 Anaphylaxis Update — PHEM Handover and Adrenaline Auto-Injector Implications

INFORMING PRACTICE DIPIMC / FIMC

NICE NG258, the updated anaphylaxis guideline, introduces several PHEM-relevant changes. The repeat adrenaline dosing interval guidance has been revised to allow a second dose at 5 minutes (unchanged from previous) with clear criteria for HEMS physician escalation to adrenaline infusion if auto-injector doses are insufficient. The guideline strengthens prehospital-to-hospital handover requirements for anaphylaxis, specifying that the trigger, time of adrenaline, total dose administered, and haemodynamic response must be documented and handed over to the receiving team. Biphasic reaction risk is quantified at approximately 20% within 8 hours, and an extended observation period of at least 6 hours post-stabilisation is recommended.

Biphasic anaphylaxis risk ~20% within 8 hours — minimum 6h observation post-stabilisation

MONTHLY ISSUE 5 — JUNE 2026 · MHRA

MHRA DSI/2026/003 and DSI/2026/004 — Active Device Safety Investigations

INFORMING PRACTICE

MHRA Device Safety Investigations DSI/2026/003 and DSI/2026/004 remained active as of June 2026. UK HEMS clinicians and ambulance services should ensure their MHRA safety alert monitoring is current and that any affected devices have been identified and removed from service. All UK NHS organisations are required to respond to MHRA Device Safety Investigations within 72 hours. Details of the specific devices involved should be checked against current MHRA records at mhra.gov.uk.

CHAPTER 6 — 4 ITEMS

Stroke & Neurology

AHA/ASA 2026 · MSU Class 1A · ATLAS LVO Triage · EMS Routing · April–June 2026

The 2026 AHA/ASA Acute Ischaemic Stroke guideline delivered a Class 1A recommendation for Mobile Stroke Units (MSU), strengthening the evidence base for prehospital thrombolysis and destination decision-making. PHEM routing accuracy for large vessel occlusion (LVO) stroke remains a system challenge: 1 in 10 UK stroke patients are still transported to non-stroke-capable centres.

MONTHLY ISSUE 1 — APRIL 2026 · AHA/ASA 2026

2026 AHA/ASA Acute Ischaemic Stroke Guideline — MSU Class 1A Recommendation; EVT Destination; Tenecteplase

INFORMING PRACTICE DIPIMC / FIMC

The 2026 AHA/ASA Acute Ischaemic Stroke Guideline upgrades Mobile Stroke Units (MSU) to a Class 1A recommendation — the strongest level of evidence-based guideline recommendation — for prehospital thrombolysis. This follows the B_FAST, BEST-MSU, and PHANTOM-S trial data demonstrating earlier thrombolysis and improved functional outcomes. Endovascular therapy (EVT) destination decisions are specifically addressed, with the guideline recommending direct transport to an EVT-capable centre for suspected LVO stroke regardless of transfer implications for standard thrombolysis cases.

MSU: Class 1A recommendation for prehospital thrombolysis — AHA/ASA 2026

Tenecteplase replaces alteplase as the preferred thrombolytic agent in the 2026 guideline (already reflected in NICE TA962 for UK). Tenecteplase's single IV bolus administration is particularly suited to prehospital MSU delivery. The guideline also addresses extended-window thrombolysis (4.5–24 hours from onset with perfusion imaging selection), which reinforces the PHEM pre-alert requirement for documented last-known-well time.

UK relevance: MSUs currently operate in London (King's College Hospital programme) and are under evaluation in several regional networks. DipIMC/FIMC candidates should understand the MSU model, the evidence base, and the PHEM crew role in MSU-attended stroke calls. Know the current UK tenecteplase availability and NICE guidance alignment.

JAHA 2025 · PMC12826932 · MONTHLY ISSUE 3 — MAY 2026

EMS Stroke Routing Cross-Sectional — 1 in 10 to Non-Stroke-Capable Centre (JAHA 2025)

INFORMING PRACTICE DIPIMC / FIMC

This cross-sectional analysis (JAHA 2025, PMC12826932) found that approximately 1 in 10 EMS-transported stroke patients in the studied systems were taken to a non-stroke-capable facility, resulting in avoidable transfers and treatment delays. Misrouting was more common in rural and out-of-hours presentations, and in cases where stroke was not the primary working diagnosis at dispatch. In UK PHEM, this reflects the ongoing challenge of accurate FAST-negative stroke recognition and appropriate destination decision-making.

PHEM implication: HEMS and BASICS teams arriving on scene with a suspected stroke patient should confirm the receiving centre's acute stroke capability (thrombolysis and EVT) before departing. A primary transport to the nearest hospital that lacks EVT will cause a delay equivalent to a secondary transfer — always favour primary transfer to an EVT-capable centre where transport time differential is <30 minutes.

MONTHLY ISSUE 5 — JUNE 2026 · PMID 42107392

ATLAS IPD LVO Stroke — PHEM Triage Score Implications for Direct EVT Centre Transfer

INFORMING PRACTICE DIPIMC / FIMC

The ATLAS individual patient data study (PMID 42107392) on LVO stroke identification examined the performance of prehospital triage scores (including VAN, RACE, LAMS, BEFAST) for identifying large vessel occlusion requiring endovascular therapy. No single score achieved adequate sensitivity and specificity simultaneously. The study supports using a low-sensitivity, high-capture approach (favour over-triage to EVT centres over undertriage) when the differential transport time to an EVT-capable versus non-EVT-capable centre is less than 30–45 minutes. This has direct implications for UK HEMS and BASICS destination protocols.

SJTREM · MONTHLY ISSUE 2 — MAY 2026

Ten Second Triage Simulation Validation — 4x Faster Than MITT for MCI Initial Sort

INFORMING PRACTICE

Simulation-based validation of the Ten Second Triage (TST) tool found it to be approximately four times faster than the MITT (Major Incident Triage Tool) for initial casualty sorting at mass casualty incidents (MCI), with equivalent accuracy in categorisation of Priority 1 (immediate) casualties. Speed of primary sort is the key operational bottleneck at MCIs with large casualty numbers; TST's reduced cognitive and time burden may support its adoption in UK PHEM MCI protocols. Awareness of multiple triage systems and their performance characteristics is a DipIMC/FIMC examined domain.

CHAPTER 7 — 3 ITEMS

Medical PHEM

Surviving Sepsis 2026 · NICE NG258 Anaphylaxis · GLP-1 Agonist Alert · April–June 2026

Medical emergencies in the prehospital setting increasingly require awareness of guideline updates that affect destination decisions, pre-alert content, and the clinical context of hospital handover. Three items in Q2 2026 have direct PHEM clinical implications: updated sepsis guidelines, the NICE anaphylaxis update, and an MHRA safety alert on GLP-1 agonist complications.

MONTHLY ISSUE 1 — APRIL 2026 · SURVIVING SEPSIS CAMPAIGN

Surviving Sepsis Campaign 2026 Adult Guidelines — Vasopressor Timing, Fluid Targets, Pre-Alert Language

INFORMING PRACTICE DIPIMC / FIMC

From a PHEM perspective, the SSC 2026 key changes for pre-hospital practice relate to the recognition that "time to vasopressor" in septic shock is a less critical determinant of outcome than previously thought (supported by the Time to Vasopressor paper in the Space files), that early IV fluid administration (500 mL crystalloid initial bolus) is appropriate prehospital, and that the pre-alert for septic shock patients should include estimated NEWS2 score, time of symptom onset, and lactate if available. HEMS physicians attending patients in septic shock should initiate noradrenaline infusion rather than repeat crystalloid boluses if initial fluid responsiveness is absent.

EVIS UK Trial context (see Trials to Watch): The EVIS UK trial is examining peripheral vasopressor initiation in septic shock in the community. Results will directly inform whether peripheral noradrenaline in septic shock should be initiated prehospital by HEMS physicians outside ICU-level monitoring.

MONTHLY ISSUE 1 — APRIL 2026 · MHRA

MHRA Safety Alert: GLP-1 Agonists and Acute Pancreatitis — Prehospital Awareness (Feb 2026)

INFORMING PRACTICE

The MHRA February 2026 safety alert linking GLP-1 receptor agonists (semaglutide, dulaglutide, liraglutide) with an increased risk of acute pancreatitis is clinically relevant to prehospital acute abdominal pain assessment. With over 2 million UK patients now on GLP-1 agonists, the incidence of GLP-1-associated pancreatitis presenting to ambulance services is increasing. PHEM clinicians should be aware of this association when triaging acute upper abdominal pain with vomiting in patients taking these drugs. Serum lipase or amylase is not available prehospital; clinical suspicion and appropriate destination selection (with pre-alert to ED) is the intervention.

MONTHLY ISSUE 5 — JUNE 2026 · UKHSA

UKHSA Hantavirus MV Hondius — PHEM Responder Awareness Update

INFORMING PRACTICE

UKHSA issued a public health update regarding hantavirus exposure risk connected to the MV Hondius vessel, with potential implications for prehospital responders attending patients who may have occupational or recreational exposure history. Hantavirus presents as haemorrhagic fever with renal syndrome (HFRS) or hantavirus pulmonary syndrome (HPS); neither is directly transmissible person-to-person. Standard PPE is adequate for prehospital responders. The risk to HEMS and ambulance crews is low; awareness of the clinical presentation and appropriate referral for specialised infectious disease assessment is the required action.

CHAPTER 8 — 2 ITEMS

Paediatric PHEM

Neonatal Resuscitation EMS Data · Paediatric OHCA Drowning · April–June 2026

Paediatric and neonatal PHEM calls constitute a small proportion of HEMS tasking but carry disproportionate clinical complexity and emotional burden. Q2 2026 delivers two new datasets with direct relevance to HEMS and advanced paramedic competency frameworks: neonatal resuscitation in the out-of-hospital environment, and airway strategy in paediatric drowning. Both support the EPA competency framework findings that paediatric PHEM training gaps are wider than adult equivalents.

PMID 41875342 · MONTHLY ISSUE 5 — JUNE 2026

Prehospital Neonatal Resuscitation EMS Data (PMID 41875342) — Outcome Predictors and Competency Implications

INFORMING PRACTICE DIPIMC / FIMC

This EMS dataset analysis (PMID 41875342) examined outcomes in prehospital neonatal resuscitation, identifying predictors of survival to hospital discharge including gestation (≥28 weeks), initial APGAR equivalent on EMS arrival, response time, and whether a physician or advanced paramedic (vs standard paramedic) was on scene. Physician or advanced paramedic attendance was independently associated with improved outcomes, supporting HEMS dispatch criteria for unresponsive or severely compromised neonates. Competency maintenance for neonatal resuscitation in PHEM is a known gap; simulation-based training at 6-month intervals is recommended by multiple UK bodies for personnel whose primary role is not neonatal care.

DipIMC/FIMC: Neonatal resuscitation is a core PHEM examination domain. Know the Newborn Life Support algorithm (NLS), the difference between dry and stimulate vs active resuscitation triggers, neonatal intubation weight-based drug dosing, and the criteria for HEMS dispatch to a neonatal emergency.

PMID 41819339 · MONTHLY ISSUE 3 — MAY 2026 — ALSO CHAPTER 2

Paediatric Drowning Airway — ETI Not Superior to BVM (Paediatric-Specific Context)

INFORMING PRACTICE DIPIMC / FIMC

From a paediatric PHEM perspective, this study (PMID 41819339) reinforces that airway management strategy in paediatric drowning should not default to immediate ETI. Prehospital BVM ventilation delivers equivalent or superior outcomes to prehospital ETI in paediatric drowning-associated cardiac arrest. The pathophysiology of drowning OHCA (hypoxic arrest, often in otherwise healthy children) differs from adult OHCA: airway protection and oxygenation are paramount, and ETI attempts that interrupt compressions or cause laryngospasm are detrimental. RSI-facilitated intubation by a HEMS physician is appropriate where airway control is genuinely required; non-physician ETI attempts in paediatric drowning should be avoided unless SGA has failed.

PHEM protocol implication: Paediatric drowning algorithms in HEMS clinical protocols should specify BVM as primary airway, i-gel as secondary, and physician RSI as tertiary only when oxygenation cannot be achieved by BVM or SGA. Early thorough drying, rewarming during transport, and ETCO2 monitoring are priorities.

CHAPTER 9 — 19 ITEMS

Operational, Governance & Workforce

HEMS Equity · KSSAA Outcomes · Prehospital POCUS · Wellbeing · Quality Improvement · April–June 2026

Operational PHEM in Q2 2026 was dominated by four intersecting themes: geographic equity in access to physician-based HEMS, continued growth of prehospital POCUS and technology-assisted clinical decision-making, workforce wellbeing and the newly formalised Royal College of Paramedics, and quality and governance frameworks including PRANA data and the MATTS triage validation. These items collectively address the systems within which clinical evidence is delivered.

THEME A — HEMS ACCESS, EQUITY, AND OUTCOMES

OPERATIONAL REVIEW · MONTHLY ISSUE 2 / ISSUE 5 — 2026

Physician-Based HEMS Access Equity — UK Data: Geographic Inequity Identified; Rural Wait Longer

INFORMING PRACTICE DIPIMC / FIMC

UK data reported in Q2 2026 on physician-based HEMS access patterns identified a geographic inequity with a counterintuitive structure: patients in rural areas are actually more likely to receive a physician-attended HEMS response when one is dispatched (given the higher proportion of HEMS responses in rural settings relative to road ambulance coverage), but they wait longer for that response. Patients in peri-urban and suburban areas — served by a mix of road ambulance and occasional HEMS — had the most variable access. Inner-urban patients with rapid road ambulance access received HEMS physician attendance rarely but quickly. The policy implication is that HEMS base positioning decisions must account for this three-tier geographic access profile, and that HEMS tasking criteria should be optimised for the scenarios where physician attendance adds most value (prehospital RSI, REBOA, ECPR, complex medical PHEM).

Governance relevance: HEMS commissioning decisions must incorporate equity analysis as well as raw outcomes data. The PRANA framework (AAUK) is designed to capture the distributional dimension of HEMS benefit, not only average outcomes. This data will likely inform NHSE and integrated care board HEMS commissioning reviews in 2026–27.

EMJ 2026 · DOI 10.1136/EMERMED-2025-215451 · MONTHLY ISSUE 3 — MAY 2026

KSSAA HEMS Outcomes (EMJ 2026) — 5 Extra Survivors per 100 Major Trauma; TCA ROSC Improving 6%/yr

INFORMING PRACTICE DIPIMC / FIMC

Data from Kent, Surrey and Sussex Air Ambulance (KSSAA) published in Emergency Medicine Journal (DOI 10.1136/emermed-2025-215451) demonstrates approximately 5 additional survivors per 100 major trauma patients attended by HEMS compared to modelled road ambulance outcomes, consistent with the Intub-8 survival benefit quantification. Traumatic cardiac arrest ROSC rates have been improving at approximately 6% per year over the study period, attributable to protocol refinements, improved REBOA deployment, and RSI quality improvement. This is the most recent UK HEMS service-level outcomes publication and directly supports HEMS commissioning and DipIMC curriculum argument for physician-attended HEMS value.

5 extra survivors per 100 major trauma — KSSAA HEMS (EMJ 2026)

TCA ROSC improving 6%/year — KSSAA longitudinal data

PREHOSPITAL EMERGENCY CARE · MONTHLY ISSUE 2 — MAY 2026

Automated vs Manual Ventilation with i-gel in HEMS — 100% vs 33% Target Minute Volume Achieved

INFORMING PRACTICE DIPIMC / FIMC

A PEC study comparing automated transport ventilators to manual bag-valve ventilation through an i-gel in HEMS found that automated ventilation achieved target minute volume in 100% of patients, compared to only 33% with manual ventilation by the crewmember during transport. Manual ventilation is particularly compromised during flight (vibration, positional constraints, attention competition) and in non-sedated patients. This strongly supports the use of automated transport ventilators in all HEMS-transported intubated patients, and extends the argument to include SGA-secured airways. Tidal volume targets should be set at 6–8 mL/kg ideal body weight; ETCO2 monitoring is mandatory.

Automated ventilation: 100% target MV achieved vs 33% manual in HEMS transport

THEME B — QUALITY IMPROVEMENT, POCUS, AND TECHNOLOGY

SJTREM · MONTHLY ISSUE 2 — MAY 2026

Paramedic Prehospital POCUS — 87.9% Sensitivity, Changes 36% of Transport Decisions

INFORMING PRACTICE DIPIMC / FIMC

This SJTREM study examined paramedic-performed prehospital POCUS across a range of clinical presentations, finding 87.9% sensitivity for clinically important findings (cardiac standstill, pericardial effusion, pneumothorax, free fluid) and documenting that POCUS changed transport decision-making in 36% of cases. The latter finding is particularly significant: more than one in three patients had their destination or urgency of transport altered based on POCUS findings. This is a strong argument for expansion of POCUS training in the advanced paramedic and critical care paramedic scope of practice.

87.9% sensitivity for key POCUS findings · 36% transport decisions changed

PREHOSPITAL EMERGENCY CARE 2026 · DOI 10.1080/10903127.2026.2625227 · MONTHLY ISSUE 3

Rural Paramedic POCUS — Feasible in Rural Context; 18% Clinical Decision Impact

INFORMING PRACTICE

A complementary study (DOI 10.1080/10903127.2026.2625227) specifically examined POCUS feasibility and impact in a rural paramedic context, finding 18% clinical decision impact in a smaller cohort with longer transport times. The rural context is particularly relevant because longer transport times increase the window in which prehospital diagnosis affects management: a pneumothorax identified by POCUS 40 minutes from hospital changes the entire clinical trajectory in a way that identification at 5 minutes from hospital does not. Rural HEMS and BASICS teams should prioritise POCUS training for pneumothorax and haemothorax assessment.

MONTHLY ISSUE 5 — JUNE 2026 · PMID 42029153

Haemothorax 300 mL Volume Cutoff — Multi-Centre n=962: Drainage Threshold Validated

INFORMING PRACTICE DIPIMC / FIMC

This multi-centre study (n=962, PMID 42029153) validated a 300 mL volume threshold for haemothorax drainage decision-making, finding that haemothoraces below this threshold could be safely managed conservatively without immediate drainage in haemodynamically stable patients. This has PHEM implications for the decision to perform needle thoracostomy versus chest drain in suspected haemothorax: if the primary concern is pneumothorax rather than haemothorax, needle decompression is appropriate; if haemothorax is suspected with haemodynamic instability, prehospital chest drain is justified but requires physician-level competency. Prehospital sonographic haemothorax assessment (FAST) is relevant context.

MONTHLY ISSUE 5 — JUNE 2026 · PMID 41661170

Prehospital Resuscitation Network Meta-Analysis — 15 RCTs, n=7,504 (PMID 41661170)

CHANGE THIS MONTH DIPIMC / FIMC

This network meta-analysis (15 RCTs, n=7,504, PMID 41661170) assessed prehospital resuscitation interventions including fluid type, airway strategy, and drug administration order in haemorrhagic and medical OHCA. The analysis found that no single prehospital intervention dominated across all clinical scenarios, reinforcing the systems-based view of prehospital resuscitation. Bundled care (TXA + component blood + ETI with RSI) in trauma outperformed any single intervention. In medical OHCA, high-quality CPR with early defibrillation and vasopressor administration remained the combination with most consistent outcome benefit. The NMA design allows head-to-head comparisons between interventions not directly compared in individual trials.

THEME C — GOVERNANCE, FRAMEWORKS, AND SAFETY

MONTHLY ISSUE 2 — MAY 2026 · UKHSA

UKHSA: Legionnaires Disease Outbreak NW/SW London (HPR Vol 20 Issue 3)

INFORMING PRACTICE

UKHSA Health Protection Report Volume 20 Issue 3 documented a Legionnaires disease outbreak in NW and SW London in May 2026. For PHEM responders, awareness of cluster infectious disease outbreaks is important for clinical suspicion when managing severe respiratory presentations and for appropriate HEMS crew PPE decisions. Legionella pneumophila is not transmissible person-to-person; standard infectious precautions are adequate for prehospital attendance. Clinicians should include legionellosis in the differential for severe pneumonia presentations during the outbreak period.

MONTHLY ISSUE 2 — MAY 2026

College of Paramedics Rebranded as Royal College of Paramedics — Professional Governance Implications

CHANGE WHEN GUIDELINE UPDATES

See Chapter 5 for the full item. From a governance perspective, the Royal College of Paramedics rebranding confers enhanced professional standing for HEMS paramedics and critical care paramedics in multidisciplinary team governance structures. Advanced paramedics on HEMS platforms now operate within a college framework equivalent in professional standing to medical royal colleges and the College of Emergency Medicine. This has implications for professional indemnity, scope of practice governance, and the relationship between advanced paramedic practitioners and supervising physicians on HEMS platforms.

MONTHLY ISSUE 3 — MAY 2026 · AAUK

AAUK National Policy Position Statement 2026 — PRANA Outcomes Framework; EGNOS Night Operations

INFORMING PRACTICE

See Chapter 5 for context. The PRANA national audit framework introduced by AAUK in this document will for the first time enable standardised cross-service HEMS outcome benchmarking in the UK. Key metrics include: HEMS RSI first-pass success rate, post-intubation hypotension rate, OHCA TCA ROSC rate, major trauma undertriage/overtriage rate, and dispatch-to-scene time. PRANA data will be available to NHSE, ICBs, and HEMS commissioners from Q4 2026 onwards. All HEMS services are expected to participate in PRANA by April 2027.

MONTHLY ISSUE 3 — MAY 2026

OnScene Trial Conclusion — FOAMed Context and UK ECPR Protocol Review

CHANGE THIS MONTH

With the OnScene ECPR trial having completed enrolment, UK PHEM services were prompted to review existing ECPR protocols ahead of anticipated results. The Sub30 (London) and KSSAA prehospital ECPR programmes have published their early experience data, and the FOAMed community (EMCrit, The Resus Room, St Emlyns) produced a series of critical appraisals of prehospital ECPR selection criteria, circuit management, and logistics in Q2 2026. The consensus prior to OnScene publication is that prehospital ECPR for highly selected refractory VF OHCA is feasible and produces reasonable survival rates in specialist systems, but the resource implications for widespread adoption are significant.

THEME D — WELLBEING, WORKFORCE, AND EDUCATION

MONTHLY ISSUE 5 — JUNE 2026

UK HEMS Jet Fuel Cost Crisis — Operational Sustainability Implications

INFORMING PRACTICE

A fuel cost crisis affecting UK HEMS operations was reported in June 2026, with several charitable HEMS operators reporting significantly increased operating costs driven by jet fuel price increases and the expiry of legacy fuel supply contracts. The operational sustainability of charitable HEMS funding models, which account for the majority of UK HEMS services (outside MAGPAS, which is NHS-funded), is under review. For clinicians, awareness of HEMS operational constraints — including weather limitations, maintenance downtime, and now fuel cost pressures — is important context for service planning and individual call decisions about ground vs air dispatch.

MONTHLY ISSUE 5 — JUNE 2026 · JOURNALFEED / JEMS IPMI MAY 2026

JournalFeed PHEM Roundup + JEMS IPMI May 2026 — PHEM Literature Synthesis

INFORMING PRACTICE

JournalFeed's PHEM Roundup and the JEMS IPMI (International Prehospital Medicine and Innovation) May 2026 literature review provided synthesis across the high-volume PHEM publication output of Q2 2026. Key themes identified in these FOAMed sources included: the convergence of TXA evidence (meta-analysis + safety analysis); the null TOWAR/SWiFT findings and their implications for whole blood programme planning; and the growing HEMS outcomes dataset (Intub-8 + KSSAA) providing the strongest survival evidence base yet for UK physician-HEMS. JEMS IPMI specifically highlighted the Intub-8 result as the landmark PHEM publication of the year to date.

MONTHLY ISSUE 1 — APRIL 2026 · JEMS IPMI

JEMS IPMI Literature Reviews — March and April 2026 Prehospital Evidence Synthesis

INFORMING PRACTICE

The JEMS International Prehospital Medicine and Innovation literature reviews for March and April 2026 highlighted several items of relevance to UK PHEM: the prehospital TXA meta-analysis findings, the updated PHEA guidelines videolaryngoscopy recommendation, and the evolving evidence on prehospital POCUS utility. JEMS IPMI is one of the primary continuing education resources for PHEM practitioners internationally; UK HEMS clinicians should be aware of its monthly publications as a supplement to the PHEM Evidence Rundown.

MONTHLY ISSUE 1 — APRIL 2026

Paramedic i-gel Placement — 88% Positive Rate Confirmed in Registry Data

INFORMING PRACTICE

Registry data published in Q2 2026 confirmed i-gel first-attempt placement success rates of 88% by UK paramedics in OHCA. This benchmark is used in national training and competency frameworks and supports the JRCALC recommendation for i-gel as the advanced airway of choice for non-physician OHCA management. Services with first-attempt success rates below 85% are advised to review technique training and assess whether device sizing, head position, or pre-oxygenation adequacy are contributing factors. The 88% benchmark does not account for placement quality (seal, capnography waveform); functional placement rate may be lower.

MONTHLY ISSUE 5 — JUNE 2026 · MHRA

MHRA DSI/2026/003 + DSI/2026/004 — Ongoing Device Safety Investigations

INFORMING PRACTICE

See Chapter 5 (Guidelines) entry for MHRA DSI items. Both investigations remained active as of 29 June 2026 and require compliance from UK NHS organisations. HEMS clinical governance leads should ensure their medical director has reviewed both safety alerts and that any affected devices have been quarantined, reported, and replaced through MHRA-approved channels.

APPENDIX — Q3–Q4 2026

Trials to Watch

Forthcoming results with high PHEM impact expected Q3–Q4 2026

Anticipated High-Impact PHEM Results — Q3–Q4 2026

OnScene ECPR Trial — Results Q3 2026

Netherlands nationwide HEMS prehospital ECPR RCT. Enrolment complete n=220. Largest prehospital ECPR randomised trial to date. Primary outcome: neurologically intact survival. Will define UK HEMS ECPR selection criteria and protocol standards if positive. Watch: Resuscitation, Crit Care, NEJM for publication Q3 2026.

ICS State of the Art 2026 (SOA26) — 30 June–2 July, Birmingham

Intensive Care Society State of the Art 2026 conference (30 June–2 July 2026, Birmingham). Key anticipated presentations: ANDROMEDA-SHOCK-2 (peripheral perfusion-guided resuscitation in septic shock — post-ROSC sepsis management relevant to PHEM handover) and BICARICU-2 (bicarbonate in critically ill patients — relevant to post-ROSC metabolic acidosis management). Both trials have direct implications for HEMS-to-ICU handover content and post-ROSC targets.

PRINCESS3 Phase 3 — Prehospital Brain Cooling

Following the PRINCESS2 pilot (n=100, 92% adherence, feasible), the PRINCESS3 phase 3 trial is now planned. This will be a powered efficacy trial of on-scene intranasal evaporative brain cooling in OHCA. Recruitment timeline estimated 2027–2029. Will be the definitive test of whether prehospital neuroprotection via brain cooling can improve neurological outcomes. Not expected to influence practice before 2029 at earliest.

BACHb Trial — HFNC vs O2 vs CPAP in Paediatric Bronchiolitis

BACHb (Bronchiolitis Airway management in Children High-flow oxygen vs CPAP vs standard oxygen) is a UK paediatric respiratory support RCT with direct PHEM implications. Bronchiolitis with respiratory failure is a common prehospital paediatric HEMS call; CPAP and HFNC use in PHEM for this indication is increasing but evidence-free. BACHb results will guide PHEM respiratory support protocols for paediatric bronchiolitis, currently one of the most evidence-deficient areas of paediatric PHEM.

EVIS UK Trial — Peripheral Vasopressors in Septic Shock; PHEM Pre-Alert Implications

EVIS UK (Evidence for Vasopressors in Shock UK) is examining peripheral vasopressor administration in septic shock in community and pre-ICU settings. Results will directly inform whether HEMS physicians should initiate noradrenaline infusion via peripheral IV in septic shock patients with prolonged transport times, and what pre-alert language should accompany vasopressor-dependent patients handed over from HEMS to ED/ICU.

RCUK Paediatric Life Support 2025 Guidelines — Full Implementation Audit Due Q3 2026

The RCUK PLS 2025 guidelines included changes to paediatric defibrillation dosing (now reflected in JRCALC April 2026 update), post-cardiac arrest temperature management in children, and the approach to non-shockable paediatric OHCA. A national implementation audit is due Q3 2026, with results expected to identify training gaps and protocol compliance variability across UK ambulance services and HEMS platforms. PHEM clinicians should ensure their paediatric resuscitation competencies reflect PLS 2025 changes ahead of the audit.

Jake Turner

Emergency Medicine Registrar · West Midlands Deanery · PHEM Evidence Rundown PHEM Evidence Rundown · Q2 2026 State of the Science · 74 primary evidence items across 8 chapters

Curated with the assistance of AI (Perplexity). All content editorially reviewed. · © Q2 2026 EM Evidence · emevidence.org