Major Trauma Evidence Rundown — Issue 1 (July 2026)

MAJOR TRAUMA EVIDENCE RUNDOWN

Major Trauma Evidence Rundown

Surgery & Critical Care · Issue 1 · July 2026 · UK Edition

Jake Turner

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

Full archive and PDF downloads at emevidence.org

LEAD TOWAR (NEJM, n=1,141): Type O whole blood vs components in prehospital

trauma — null result. Point estimate favours components. UK whole blood programmes should continue evidence review.

CHANGE TONIGHT: MHRA — Intersurgical BVM resuscitators recalled (trauma resus); ChloraPrep sterility breach; Guedel airways FSN. Check theatre and trauma bay stock immediately. | CHANGE THIS MONTH: BOA BOAST arterial injuries (June 2026): revascularisation now NCEPOD 1 within 1h, two-consultant amputation decision, concurrent CTA with WBCT. NICE NG24 TXA: no blood-loss threshold for in-theatre surgery.

BOTTOM LINE UP FRONT — ISSUE 1 · JULY 2026

ACT ON THIS NOW

TONIGHT MHRA — BVM recall: Intersurgical BVM resuscitators (affected batches) recalled. Check trauma bay and theatre stock. Replace before next shift.

TONIGHT MHRA — ChloraPrep: BD ChloraPrep 2% applicators — potential sterility breach (Class 2 recall). Check all trauma surgical prep stock.

TONIGHT MHRA — Flucloxacillin 500mg: Flamingo Pharma capsules recalled (wrong PIL). Flucloxacillin IV unaffected but check oral stock — critical for open fracture prophylaxis.

THIS MONTH BOA BOAST Arterial Injuries: NCEPOD 1 (within 1h); CTA concurrent with WBCT; two consultants for amputation; fasciotomy consideration mandatory. Audit pathway now.

THIS MONTH NICE NG24 TXA: Offer to all adults in theatre with any bleeding risk. 500ml threshold abolished. 1g IV before knife-to-skin. Update theatre checklists.

THIS MONTH Rib fractures: Serratus anterior plane block — SR/MA confirms NRS -2.1, opioid -28mg at 24h. Add to trauma analgesia pathways.

THIS MONTH Trauma intubation: Video laryngoscopy outperforms direct laryngoscopy in multicentre RCT. Should be default approach in trauma resus.

KNOW FOR NEXT TIME

GUIDELINE TOWAR (NEJM): Prehospital whole blood null vs components (n=1,141). Point estimate favours components. UK whole blood supply chain decisions require re-evaluation.

GUIDELINE NHSBT EPRR revised: Updated mass casualty blood product planning incorporating Synnovis cyber-attack lessons. Review your MHP gap analysis.

GUIDELINE NHS England EPRR 2026/27: Annual assurance cycle launched. MTCs must self-assess against Core Standards by December 2026.

INFORMING HEMS survival data (EMJ): 5 extra survivors per 100 major trauma patients. Prehospital emergency anaesthesia independently associated with survival improvement.

INFORMING Calcium in whole blood resus: 1g calcium chloride per 2 units whole blood associated with reduced early mortality (J Trauma Acute Care Surg).

INFORMING Oxygen targets post-trauma: RCT confirms restrictive (SpO2 94%) vs liberal O2 — no mortality difference. Avoid hyperoxia; target normoxia.

INFORMING Paeds TBI: Early specialist neurosurgical centre transfer improves outcomes in isolated severe paediatric TBI (JTACS 2026).

The inaugural issue of the Major Trauma Evidence Rundown covers a month of high-impact publications and urgent safety alerts. The TOWAR trial from NEJM — the largest prehospital whole blood RCT conducted (n=1,141) — delivers an uncomfortable null result, with a point estimate actually favouring standard component therapy. Alongside this, two landmark UK guideline documents have landed simultaneously: the BOA BOAST on arterial injuries (mandatory NCEPOD-1 revascularisation within one hour) and the NICE NG24 TXA update (threshold abolished for all in-theatre surgery). Three MHRA alerts require immediate stock checks across every trauma bay and theatre in the UK. And on outcomes data, a well-powered UK causal analysis shows that HEMS attendance saves five additional lives per 100 major trauma patients — the strongest UK evidence yet for advanced prehospital capability.

WHAT'S INSIDE — ISSUE 1

01 Key Trials & Research · 7 items incl. LEAD · TOWAR, HEMS survival, VICTORY burns, CRYOSTAT-2, SWiFT, prehospital anaesthesia, oxygen targets 02 Guidelines & UK Updates · 6 items · BOA BOAST Arterial Injuries, NICE NG24 TXA, NHSBT EPRR, JESIP review, NHS England EPRR, MHRA safety alerts 03 Haemorrhage & Resuscitation · 3 items · UK-REBOA, pelvic haemorrhage AE vs PPP, calcium in whole blood 04 Orthopaedic & Musculoskeletal Trauma · 2 items · Video laryngoscopy trauma RSI, serratus anterior block rib fractures 05 Paediatric & Special Populations · 2 items · Paeds TBI neurosurgical care, restrictive oxygen RCT 06 Quick Hits · 4 items 07 Core Revision: UK Major Haemorrhage Protocol · 08 Action Points · 09 Trials to Watch

TAG LEGEND

CHANGE TONIGHT CHANGE THIS MONTH CHANGE WHEN GUIDELINE UPDATES

INFORMING PRACTICE FRCS (T&O) / FRCS (GEN) PAEDS UK DATA NHSBT MCI

01 — KEY TRIALS & RESEARCH

NEW ENGLAND JOURNAL OF MEDICINE · CLUSTER-RANDOMISED TRIAL · PMID: 42150044 · 18 MAY 2026

TOWAR: Prehospital Type O Whole Blood vs Component Therapy in Trauma — Null Result With a Troubling Point Estimate

LEAD CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN) UK DATA

• 48.7% vs 47.7% DEATH OR MASSIVE TRANSFUSION AT 24H
• Null POINT FAVOURS COMPONENTS
• Cluster RCT US/UK AIR MEDICAL SERVICES
• n=1,141 HAEMORRHAGIC SHOCK, HEMS

TOWAR (Type O Whole Blood and Assessment of Age during Prehospital Resuscitation) is the largest and most methodologically rigorous prehospital whole blood trial conducted to date. It enrolled 1,141 adults (aged 18–90) with haemorrhagic shock — defined as SBP ≤90 mmHg with HR ≥108, or SBP ≤70 mmHg — transported by air medical services from across multiple US sites and included UK-equivalent HEMS programme data. Patients were cluster-randomised to receive up to 2 units of low-titre type O whole blood (anti-A and anti-B titre <256) or up to 2 units each of standard component therapy (packed red cells and/or plasma).

The primary outcome — death or massive transfusion (adults ≥10 units blood components) within 24 hours — was 48.7% in the whole blood group vs 47.7% in the component group. Not only did whole blood fail to demonstrate superiority, the point estimate sits on the wrong side of unity, suggesting the direction of effect — if any — favours standard components. The result remained consistent across all pre-specified subgroups including injury mechanism, severity, and time-to-hospital.

CRITICAL APPRAISAL

This is a definitive null trial. The point estimate (favouring components) combined with the cluster-randomised design and large sample size means that whole blood's advantage — if real — is either smaller than previously believed or depends on factors not captured here. Important caveats: (1) participants received at most 2 units of whole blood or 2 units of components before hospital arrival — this may underrepresent the full haemostatic benefit of whole blood in prolonged extrications; (2) the comparator was not no product but standard component therapy (which already includes plasma in many services); (3) the UK's SWiFT trial (NEJM, n=616, covered separately) reached the same null conclusion in a UK-specific HEMS population. Together, TOWAR and SWiFT represent a compelling body of evidence against routine whole blood adoption.

WHY IT MATTERS FOR UK MTC PRACTICE

UK HEMS services (London HEMS, DSAA, GNAAS et al.) have invested significantly in whole blood logistics — cold chain, type O supply, expiry management. TOWAR provides the highest-quality evidence that this logistical investment does not improve patient outcomes. For UK MTCs: (1) the MHP and in-hospital resuscitation practice using component therapy remains evidence-supported; (2) for services contemplating transitioning to whole blood delivery, TOWAR and SWiFT should prompt a formal review of the evidence base before further investment; (3) whole blood may still have a role in isolated prehospital environments or resource-constrained settings where component separation is impossible — but routine substitution for components cannot be endorsed on current evidence.

TELL YOUR MAJOR TRAUMA NETWORK

Two NEJM trials (TOWAR n=1,141 and SWiFT n=616) both show no benefit of prehospital whole blood over standard component therapy for survival or massive transfusion endpoints. UK HEMS blood product strategy should be reviewed at regional trauma network level against this evidence before further whole blood programme expansion.

Source: Sperry JL et al (TOWAR Study Group), NEJM 2026 May 18. doi: 10.1056/NEJMoa2602167 | SWiFT context: NEJM 2026 (UK data). PMID: 42150044

EMERGENCY MEDICINE JOURNAL · UK CAUSAL ANALYSIS · SE ENGLAND HEMS REGISTRY · FEBRUARY 2026 (PUBLISHED)/JUNE 2026 (WIDELY CITED)

HEMS Attendance Independently Associated with 5 Extra Survivors per 100 Major Trauma Patients — UK Causal Analysis

INFORMING PRACTICE UK DATA FRCS (T&O) / FRCS (GEN)

• 85% vs 81% ACTUAL VS PREDICTED 30-DAY SURVIVAL
• +5 per 100 EXTRA SURVIVORS (ARD VS PREDICTION)
• ~115/yr ESTIMATED ADDITIONAL LIVES/YEAR SAVED
• n=2,500 SE ENGLAND HEMS PATIENTS

Using a regional HEMS registry from South East England (n=2,500 patients; 2,125 survived to 30 days), Griggs et al. applied derivation and internal validation of prediction models to assess the survival benefit attributable to HEMS attendance. The observed 30-day survival was 85% vs an 81% predicted rate — equivalent to five extra survivors per 100 severely injured patients, or approximately 115 additional lives per year based on service caseload. The effect was greatest in patients with moderate predicted survival probability (25–45% predicted), where 35% of patients survived who were not expected to. Two factors were independently associated with unexpectedly high survival: younger age and higher initial GCS — but critically, prehospital emergency anaesthesia (PHEA) was identified as an independent survival predictor.

CRITICAL APPRAISAL

This is a registry-based causal analysis, not a randomised trial. The survival benefit attributed to HEMS may partly reflect patient selection (HEMS dispatched to higher-acuity patients whose injuries, while severe, are survivable with rapid advanced intervention). The internal validation is reassuring but external validation to other UK HEMS regions would strengthen the finding. PHEA being independently associated with survival is consistent with the Lancet Respiratory Medicine causal inference study (separate analysis using machine learning, ~10% absolute survival improvement in airway-predicted patients). Together, these provide the strongest UK-specific evidence for advanced prehospital capability.

MTC NETWORK IMPLICATION

This UK data supports continued investment in HEMS and advanced prehospital capability. For major trauma network planning: PHEA capability (requiring physician or critical care paramedic with airway competence) is independently associated with survival, not just patient retrieval speed. This should inform HEMS crew composition decisions, regional dispatch criteria, and commissioning arguments at ICB level.

Source: Griggs J et al, Emergency Medicine Journal 2026; emermed-2025-215451 | doi: 10.1136/emermed-2025-215451

JAMA · RCT · N=238 · JUNE 2026

VICTORY: High-Dose IV Vitamin C in Severe Burns — Mortality Higher, Not Lower (RCT, n=238)

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN)

15.0% vs 7.6%

MORTALITY — VIT C VS PLACEBO

RR 1.96

NNH 14 — AVOID VIT C

Stopped early

FOR HARM SIGNAL

n=238

SEVERE BURNS (TBSA ≥20%)

High-dose IV vitamin C (ascorbic acid) has been used in severe burns resuscitation for years, based on observational data suggesting reduced fluid requirements and pulmonary oedema. VICTORY randomised 238 adults with burns ≥20% TBSA to 66 mg/kg/h IV vitamin C for 24 hours vs placebo. The trial was stopped early by the DSMB for a significant harm signal: 30-day mortality 15.0% in the vitamin C group vs 7.6% in placebo (RR 1.96, NNH 14). Organ dysfunction and ICU length of stay were also worse in the vitamin C group. The mechanism of harm is not fully established but may relate to oxalate nephropathy (high-dose vitamin C is metabolised to oxalate, causing AKI) or pro-oxidant effects at supraphysiological concentrations.

IMMEDIATE ACTION

High-dose IV vitamin C should no longer be used as part of burns resuscitation protocols. If your burns unit or MTC currently incorporates vitamin C infusions in burns pathways (following the Kahn et al. 2011 observational data), remove this recommendation immediately. Standard Parkland or modified Brooke formula fluid resuscitation remains the evidence base for burns resuscitation. Alert your burns network lead and update local protocols.

Source: VICTORY Investigators, JAMA 2026. JAMA 2026

JAMA · RCT · UK MULTICENTRE · N=1,604 · 2026

CRYOSTAT-2: Early Empirical Cryoprecipitate in Major Traumatic Haemorrhage — Null on 28-Day Mortality

INFORMING PRACTICE FRCS (T&O) / FRCS (GEN) NHSBT

• 23% vs 26% 28-DAY MORTALITY (NS)
• Fibrinogen HIGHER AT 2H — PHYSIOLOGICAL SIGNAL
• VISEP CONCURRENT ROTEM/TEG MAY SELECT RESPONDERS
• n=1,604 UK MTCS, MULTICENTRE

CRYOSTAT-2, a UK multicentre RCT at major trauma centres, randomised 1,604 adults with major traumatic haemorrhage (predicted to need MHP activation) to early empirical cryoprecipitate (3 pools, given in the first 45 minutes) or standard care (cryoprecipitate only if fibrinogen <2g/L or ROTEM/TEG indicated). The primary outcome — 28-day mortality — was 23% vs 26% (p=0.10), narrowly missing significance. Fibrinogen was higher in the intervention arm at 2 hours, confirming the product is delivered and working physiologically. However, this did not translate to a mortality benefit in the broad population.

CRITICAL APPRAISAL

CRYOSTAT-2 is almost certainly underpowered for the observed effect size, and the direction is consistently positive. The key question is not "does fibrinogen matter" (it clearly does) but "does empirical early cryoprecipitate in an unselected MHP population improve outcomes." The answer appears to be: probably not in an unselected population, but possibly in patients with demonstrable hypofibrinogenaemia. The FEISTY trial and viscoelastic-guided protocols (ROTEM/TEG-guided cryoprecipitate) may identify the responder subgroup. Current UK practice: give cryoprecipitate when fibrinogen <2g/L or ROTEM/TEG indicates hypofibrinogenaemia — do not give empirically to all MHP activations unless ROTEM/TEG confirms deficiency.

Source: CRYOSTAT-2 Investigators, JAMA 2026. JAMA

NEW ENGLAND JOURNAL OF MEDICINE · PRAGMATIC RCT · UK HEMS (10 AIR AMBULANCE SERVICES)

• N=616 · 2026

SWiFT: Prehospital Whole Blood vs Component Therapy in UK HEMS — No Survival Benefit (NEJM, n=616)

INFORMING PRACTICE FRCS (T&O) / FRCS (GEN) NHSBT UK DATA

• Null DEATH OR MASSIVE TRANSFUSION AT 24H
• Point estimate FAVOURS COMPONENTS (CONSISTENT WITH TOWAR)
• n=616 10 UK AIR AMBULANCE SERVICES

SWiFT (Stored Whole Blood in Field Trauma) is the UK-specific prehospital whole blood trial, conducted across 10 air ambulance services, and published in NEJM 2026. Patients with haemorrhagic shock received up to 2 units of leukodepleted platelet-rich whole blood (Type O) or up to 2 units each of packed red cells and plasma in the intervention and control arms respectively. The primary composite outcome (death or massive transfusion at 24 hours) was not significantly different. Consistent with TOWAR, the point estimate favoured component therapy. Together, SWiFT and TOWAR represent definitive evidence against whole blood superiority in unselected prehospital haemorrhagic shock.

Source: SWiFT Investigators, NEJM 2026. nejm.org | For logistical implications, see NHSBT EPRR guidance (Section 02).

LANCET RESPIRATORY MEDICINE · CAUSAL INFERENCE ANALYSIS · UK & INTERNATIONAL DATA · JUNE 2026

Prehospital Emergency Anaesthesia in Major Trauma — ~10% Absolute Survival Improvement in Airway-Predicted Patients (Causal Inference)

INFORMING PRACTICE UK DATA

A causal modelling study using machine learning and counterfactual analysis in a major trauma registry (including UK HEMS data) estimated that, in patients predicted to require early airway intervention, prehospital emergency anaesthesia (PHEA) with intubation was associated with an approximately 10% absolute improvement in 30-day survival. This is consistent with the EMJ survival analysis (5 per 100 overall, larger effect in airway-indicated patients) and provides the strongest UK-context evidence yet that physician-performed or advanced paramedic PHEA saves lives in a specific high-risk subgroup.

CRITICAL APPRAISAL

Causal inference studies are methodologically sophisticated but cannot replace RCT evidence. The 10% benefit estimate should be interpreted with appropriate caution — residual confounding (HEMS dispatched to more salvageable patients) may inflate the apparent benefit. The contrast with the matched registry cohort study (prehospital ETI not independently associated with survival after matching; Eur J Trauma Emerg Surg 2026) highlights the difficulty of isolating PHEA benefit from HEMS attendance benefit. Nonetheless, across multiple UK-specific analyses, the consistent direction of effect supports PHEA capability in trauma networks.

Source: Lancet Respiratory Medicine 2026. St Emlyn's review: stemlynsblog.org | Also: EMJ Griggs et al (HEMS survival, Item 2)

RCT · UMEM TRAUMA REVIEW · JUNE 2026

Restrictive vs Liberal Oxygen After Traumatic Injury — No Mortality Difference: RCT Confirms Avoid Hyperoxia

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN)

• Null MORTALITY AT 30 DAYS
• SpO2 94% TARGET: NORMOXIA, NOT HYPEROXIA
• RCT 8H POST-INJURY COMPARISON

This RCT randomised trauma patients to restrictive oxygen (SpO2 94%) vs liberal oxygen (12–15 L/min, SpO2 >99%) for 8 hours post-injury. No difference in 30-day mortality or major respiratory complications. This confirms the existing consensus that hyperoxia is at best unhelpful in trauma — and the consistent signal from critical care data (including ICU-ROXY trial context) suggests potential harm from pulmonary oxygen toxicity and increased absorption atelectasis. For trauma anaesthesia and ICU care: target SpO2 94–98%, not 100%. Reduce FiO2 after securing the airway and achieving haemostasis.

TRAUMA ANAESTHESIA PRACTICE POINT

In the trauma theatre and trauma ICU: titrate FiO2 to SpO2 94–98% once haemorrhage is controlled and oxygenation is stable. There is no benefit to maintaining SpO2 >99%, and evidence suggests potential harm. This applies post-intubation in both HEMS and in-hospital settings. Adjust ventilator settings accordingly rather than leaving FiO2 at 1.0 throughout the case.

Source: RCT via UMEM Trauma Pearls, June 2026. umem.org/educational_pearls

02 — GUIDELINES & UK UPDATES

BRITISH ORTHOPAEDIC ASSOCIATION · BOAST · JUNE 2026 (REPLACES PREVIOUS EDITION)

NEW BOA BOAST — Arterial Injuries Associated with Musculoskeletal Trauma: 18 Mandatory Standards Including NCEPOD-1 Revascularisation Within 1 Hour

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN) UK DATA

The BOA, BAPRAS, and Vascular Society of Great Britain and Ireland have jointly published a new BOAST on arterial injuries associated with musculoskeletal trauma, replacing the previous edition. This is a mandatory standards document — MTCs and trauma networks must have clear pathways that comply with all 18 standards.

MTC ACTION

Review your MTC's arterial injury pathway against all 18 BOAST standards. Key audit triggers: (1) Is CTA ordered concurrently with WBCT, not as a second scan? (2) Are two consultants from different specialties documented for all amputation decisions? (3) Is fasciotomy consideration documented (whether performed or not) for every revascularisation case? (4) Is time-to-revascularisation audited against the 1-hour NCEPOD-1 target? Distribute to trauma coordinators, orthopaedic and vascular leads, and theatre teams.

Source: BOA BOAST — Arterial Injuries (June 2026)

NICE · NG24 BLOOD TRANSFUSION · UPDATED 26 FEBRUARY 2026

NICE NG24 — TXA Now Recommended for ALL In-Theatre Surgery With Any Bleeding Risk: 500ml Threshold Abolished

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN) UK DATA

NICE updated NG24 in February 2026 with a pivotal change to perioperative TXA recommendations. The prior guidance limited TXA to procedures expected to involve >500ml blood loss. The new recommendation: "Offer TXA to adults having surgery in an operating theatre if the procedure breaches skin or mucous membranes and there is any risk of bleeding — give before surgery, typically 1g IV slow injection."

TRAUMA THEATRE IMPACT

For trauma surgery: TXA should be given to all patients undergoing emergency trauma surgery in theatre. If TXA was given prehospital (1g), a second dose (1g) should be given at the start of surgery if haemorrhage is ongoing (this was already recommended practice; NG24 makes it explicit). Key patient safety note: the new guidance includes mandatory labelling requirements to distinguish intrathecal TXA syringes from IV preparations — this is a high-risk error category and spinal TXA causes fatal complications. Ensure your theatre has a clear labelling and segregation protocol for all TXA preparations. Notify theatre pharmacy.

Source: NICE NG24 | CRASH-2 trial: Lancet 2010. doi: 10.1016/S0140-6736(10)60835-5

MHRA · MULTIPLE FIELD SAFETY NOTICES · JUNE 2026

MHRA June 2026 — Trauma-Critical Safety Alerts: BVM Resuscitators, ChloraPrep, Guedel Airways, Flucloxacillin, and Ventilators

CHANGE TONIGHT UK DATA

IMMEDIATE STOCK CHECK REQUIRED — ALL TRAUMA BAYS AND THEATRES INTERSURGICAL ONE-PIECE BVM RESUSCITATORS (FSN, 11 JUNE 2026): Specific batch recall.

BVMs are used in every trauma resuscitation. Identify affected batch numbers, remove from trauma bay equipment, replace immediately. Check emergency equipment trolleys, theatre, and ICU stores.

INTERSURGICAL ONE-PIECE GUEDEL AIRWAY (FSN, 18 JUNE 2026): Field safety notice. Check

batch numbers against MHRA alert. Remove affected stock from trauma airway trolleys.

CHLORAPREP 2% APPLICATORS (BECTON DICKINSON) — CLASS 2 RECALL, 2 JUNE 2026:

Potential sterility breach in surgical skin antisepsis applicators. Used in all trauma surgery. Remove affected stock from theatres; contact pharmacy for replacement Chlorhexidine prep solution.

FLUCLOXACILLIN 500MG CAPSULES (FLAMINGO PHARMA) — CLASS 3 RECALL: Wrong patient

information leaflet (Amoxicillin PIL). IV flucloxacillin unaffected but oral capsules used in open fracture discharge prescribing. Alert pharmacy and trauma coordinators.

GE HEALTHCARE CARESTATION 600/750 ANAESTHETIC WORKSTATIONS (FSN, 15–19 JUNE):

Alert relevant to trauma theatres using Carestation models. Notify anaesthetic department equipment lead and biomedical engineering.

LÖWENSTEIN ELISA ICU VENTILATORS + PHILIPS BIPAP A30/A40/A40PRO: ICU ventilator FSNs.

Alert trauma ICU and critical care leads. POLYNOVO NOVOSORB BTM (FSN, 26 MAY): Biodegradable temporising matrix used in complex soft tissue and burns wound coverage. Alert plastic surgery and burns team.

Sources: MHRA FSNs 8–12 June | 15–19 June | Safety Roundup June 2026

NHSBT / JESIP / NHS ENGLAND · MULTIPLE UK GOVERNANCE UPDATES · MAY–JUNE 2026

UK Major Incident Governance: NHSBT EPRR Revised Blood Product Planning, JESIP Doctrine Review Open for Evidence, NHS England EPRR Annual Assurance 2026/27

CHANGE WHEN GUIDELINE UPDATES MCI NHSBT UK DATA

NHSBT Revised EPRR Guidance for Hospital Transfusion Teams (28 May 2026): Updated mass casualty blood product planning guidance incorporating lessons from the 2023 Synnovis cyber attack (which disrupted blood group testing and transfusion services across multiple London trusts). Key changes: revised gap analysis tool for hospital transfusion teams; updated mass casualty blood product demand planning; specific guidance on maintaining group O negative/O positive inventory under cyber-attack or IT failure scenarios. All UK hospital transfusion services should complete the updated gap analysis. Download from hospital.blood.co.uk/the-update.

JESIP Doctrine Review — Call for Evidence (closes 5 July 2026): JESIP (Joint Emergency Services Interoperability Programme) is undertaking a formal review of the Joint Doctrine, which underpins all multi-agency major incident response in the UK (METHANE, Joint Decision Model, Guidance on Managing Information). UK MTCs, ambulance trusts, and police/fire collaboration teams are invited to submit evidence on what works and what requires revision. MTCs with major incident experience (particularly London Bridge 2017, Manchester Arena) are well-placed to contribute. jesip.org.uk

NHS England EPRR Annual Assurance 2026/27 (launched 26 June 2026): The annual NHS EPRR self-assessment cycle has launched. All MTCs and major trauma networks must assess compliance against NHS EPRR Core Standards by the regional deadline (December 2026). The new cycle includes specific emphasis on cyber resilience (post-Synnovis), CBRN decontamination readiness, and MTPAS (Mobile Telecommunications Privileged Access Scheme) awareness. Assign your trust's EPRR lead to coordinate the submission.

Sources: NHSBT The Update | JESIP newsletter June 2026 | NHS England EPRR 2026/27

03 — HAEMORRHAGE & RESUSCITATION

BAYESIAN RCT · UK MULTICENTRE · UK-REBOA COLLABORATIVE · 2026

UK-REBOA Trial — 90-Day Mortality Higher With REBOA: Strong Signal of Harm (86.9% Posterior Probability)

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN) UK DATA

• 86.9% POSTERIOR PROBABILITY REBOA CAUSES HARM
• No benefit ON ANY SECONDARY OUTCOME
• UK MTCs HAEMORRHAGIC SHOCK, BLUNT/PENETRATING

The UK-REBOA trial is a Bayesian adaptive RCT conducted across UK MTCs, randomising patients with haemorrhagic shock to in-hospital REBOA (zone III aortic balloon occlusion) plus standard care vs standard care alone. With an 86.9% posterior probability that REBOA is associated with higher 90-day mortality and no benefit on any secondary outcome (organ failure, blood product requirements, time-to-haemorrhage-control), this trial represents a significant challenge to routine REBOA use in UK trauma centres. The likely mechanism of harm: bowel, spinal cord, and lower limb ischaemia from zone III occlusion, combined with the haemodynamic effects of balloon deflation and reperfusion.

CLINICAL GUIDANCE — UK MTCS

In-hospital REBOA for blunt or penetrating haemorrhagic shock: the UK-REBOA trial data should prompt urgent reassessment of any institutional REBOA programme. At minimum, REBOA should only be considered in patients where immediate operative haemorrhage control cannot be achieved and where the limb/spinal cord ischaemia risk is explicitly weighed. Resuscitative thoracotomy (for penetrating cardiac or great vessel injury) and emergency operative haemorrhage control remain the primary interventions. REBOA should not be used as a bridge to delayed intervention. Discuss at your MTC governance meeting.

Source: UK-REBOA Trial Collaborative, 2026. PubMed search: UK-REBOA 2026

J TRAUMA ACUTE CARE SURG · REGISTRY-BASED ANALYSIS · 2026

Pelvic Fracture Haemorrhage — Angioembolisation Only Independent Predictor of Mortality Reduction; PPP Alone Insufficient

INFORMING PRACTICE FRCS (T&O) / FRCS (GEN)

A registry-based analysis examining outcomes in haemodynamically unstable pelvic fractures (the most challenging injury pattern in blunt trauma) compared three management strategies: pelvic packing only (PPP), angioembolisation only (AE), and combined PPP + AE. The key finding: angioembolisation was the only independent predictor of mortality reduction across all injury patterns. PPP alone did not independently predict reduced mortality. Combined PPP + AE was not superior to AE alone in most cases, suggesting that the sequence and specificity of intervention matter more than combining both.

CRITICAL APPRAISAL AND UK APPLICATION

This registry analysis does not change the fundamental principle that the source of pelvic haemorrhage (arterial vs venous vs bony bleeding) determines the most appropriate intervention — AE for arterial bleeding, PPP for venous/bony bleeding. However, it reinforces that if arterial bleeding is suspected (pelvic X-ray shows pattern high-risk for vascular injury; haemodynamic instability persists despite adequate resuscitation and PPP), the priority is getting the patient to angiography for AE — not persisting with pelvic packing alone. The UK standard (ATLS-based) of haemodynamic stability following PPP as a decision point for AE is validated by this data.

JOURNAL OF TRAUMA & ACUTE CARE SURGERY · RETROSPECTIVE COHORT · APRIL 2026 · PMID: 41995161

Calcium Chloride in Whole Blood Resuscitation — At Least 1g per 2 Units Reduces Early Mortality

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN) NHSBT

Hypocalcaemia is a component of the lethal triad in trauma, and whole blood resuscitation (which does not contain the citrate-chelated calcium of processed components in the same way) may paradoxically worsen ionised hypocalcaemia if supplemental calcium is not given. This retrospective cohort study found that calcium chloride administration at a ratio of at least 1g per 2 units of whole blood was independently associated with reduced early mortality in trauma patients receiving whole blood resuscitation. The finding reinforces existing guidance on ionised calcium monitoring during massive transfusion — and highlights that if whole blood is used (where it remains part of local HEMS protocols), calcium replacement is not optional.

TRAUMA RESUSCITATION PROTOCOL POINT

During massive transfusion (whole blood or components): monitor ionised calcium every 30 minutes. Give calcium chloride 1g IV (or calcium gluconate 3g IV) whenever ionised Ca<1.1 mmol/L, or empirically with every 4–6 units of blood. If your service uses whole blood, a minimum of 1g calcium chloride per 2 units whole blood should be given. This should be included in your major haemorrhage protocol calcium replacement guidance.

Source: PMID: 41995161, J Trauma Acute Care Surg 2026 Apr 17. doi: 10.1097/TA.0000000000005009

04 — ORTHOPAEDIC, AIRWAY & ANAESTHESIA

MULTICENTRE RCT · UMEM TRAUMA EVIDENCE SUMMARY · JUNE 2026

Video Laryngoscopy vs Direct Laryngoscopy for Trauma RSI — VL Outperforms DL on First-Pass Success

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN)

• Higher FPS FIRST-PASS SUCCESS — VL SUPERIOR
• Equal complications NO INCREASE IN ADVERSE EVENTS
• Multicentre RCT TRAUMA INTUBATION POPULATION

This multicentre RCT of direct vs video laryngoscopy for trauma intubation (RSI) in the emergency setting confirmed that video laryngoscopy (VL) achieves a significantly higher first-pass success rate compared with direct laryngoscopy (DL), with equal complication rates. This is consistent with the broader literature (McGRATH-ED trial, DAS guidelines). For UK major trauma centres: VL should be the default technique for trauma RSI. DL remains a competency for difficult airway rescue (e.g., blood/secretions obscuring video view), but the initial attempt should use VL. Review your trauma team RSI equipment — a video laryngoscope must be available in every trauma resus bay at all times.

Source: Multicentre RCT via UMEM Educational Pearls June 2026. umem.org

ACADEMIC EMERGENCY MEDICINE / MCMASTER EVIDENCEALERTS · SR/MA · MCMASTER SCORE 5/7 · JUNE 2026

Serratus Anterior Plane Block for Acute Rib Fractures in the ED — SR/MA Confirms Pain Reduction and Opioid Sparing

CHANGE THIS MONTH FRCS (T&O) / FRCS (GEN)

• NRS −2.1 PAIN REDUCTION (95% CI −3.0 TO −1.2)
• −28mg MORPHINE EQUIVALENT REDUCTION AT 24H
• SR/MA of RCTs MCMASTER 5/7

Multiple rib fractures are among the most painful and potentially morbid injuries seen in major trauma — inadequate analgesia leads to splinting, reduced cough, atelectasis, and pneumonia, significantly worsening outcomes in older and frail patients. This SR/MA of RCTs confirms that serratus anterior plane block (SAPB) reduces pain by a clinically meaningful 2.1 points on the NRS (minimum clinically important difference ~1.5) and reduces 24-hour opioid consumption by approximately 28mg oral morphine equivalent — sufficient to meaningfully reduce opioid-related sedation and respiratory depression.

TECHNIQUE: SERRATUS ANTERIOR PLANE BLOCK

SAPB is straightforward under ultrasound guidance. With the patient supine or lateral, identify the serratus anterior muscle on the lateral chest wall (at the level of the 5th rib, mid-axillary line). Inject 20–30 mL of 0.25% bupivacaine or 0.25–0.375% ropivacaine between the serratus anterior muscle and the external intercostals (superficial SAPB, targeting the long thoracic nerve) or deep to serratus anterior (deep SAPB). Provides lateral thoracic wall analgesia (T2–T9). Repeat dose or catheter placement can extend coverage. Can be performed by trained emergency physicians, anaesthetists, and in some services, advanced nurse practitioners. Add to your rib fracture analgesia pathway alongside the BTS rib fracture bundle.

Source: McMaster EvidenceAlerts 27 Jun 2026 (Score 5/7). Acad Emerg Med 2026. BTS rib fracture care bundle: brit-thoracic.org.uk

05 — PAEDIATRIC & SPECIAL POPULATIONS

JOURNAL OF TRAUMA & ACUTE CARE SURGERY · MULTICENTRE STUDY · US/UK CONTEXT · JULY 2026

Paediatric Isolated Severe TBI — Early Transfer to Specialist Neurosurgical Centres Independently Improves Outcomes

INFORMING PRACTICE

PAEDS

FRCS (T&O) / FRCS (GEN)

In children with isolated severe traumatic brain injury (GCS ≤8, no major extracranial injury), access to specialist neurosurgical care is the primary modifiable outcome determinant. This multicentre registry analysis from JTACS confirmed that early transfer to a specialist paediatric neurosurgical centre — rather than management at a non-specialist MTC — independently improved functional outcomes and survival. The key implication for UK practice: children with isolated severe TBI who present to an MTC without on-site paediatric neurosurgery should be rapidly transferred to a CATS (Children's Acute Transport Service) destination with paediatric neurosurgical capability. Do not delay transfer for normalization of non-cranial physiology unless haemorrhage is ongoing.

UK TRANSFER PROTOCOL POINT

For isolated severe paediatric TBI: contact CATS (London) or equivalent regional paediatric critical care transport service immediately after initial stabilisation. Neurosurgical consultation should occur concurrently — not after MTC management. Permissive hypotension targets should NOT be applied in isolated TBI (maintain SBP ≥110mmHg or MAP ≥70mmHg in children over 5 years). Avoid secondary insults during transfer: maintain normocapnia, normoglycaemia, normothermia.

Source: J Trauma Acute Care Surg, July 2026 (JournalFeed Surgery 2 July 2026). journals.lww.com/jtrauma

NICE · NG258 · 27 MAY 2026 (REPLACES CG134) · TRAUMA THEATRE APPLICATION

NICE NG258 Anaphylaxis — Three Tryptase Samples Now Required in Trauma Theatre: Update Your Post-Anaphylaxis Protocol

CHANGE WHEN GUIDELINE UPDATES

FRCS (T&O) / FRCS (GEN)

Trauma patients undergoing emergency surgery receive multiple agents simultaneously — antibiotics, anaesthetic induction agents, neuromuscular blocking drugs, blood products, colloids — creating a high-risk environment for perioperative anaphylaxis. NICE NG258 (replacing CG134) now requires three tryptase samples: at 30–120 minutes from event onset, at 3–4 hours, and a baseline at >24 hours or follow-up. All confirmed or suspected anaphylaxis events must be referred to allergy services before the patient leaves hospital. In trauma theatre, the event timing may be poorly documented: assign a team member specifically to record the exact time of any suspected anaphylaxis reaction so that the 30–120 minute sample window can be correctly identified. Update your trauma theatre post-anaphylaxis proforma.

Source: NICE NG258

06 — QUICK HITS

NAO Major Trauma Care in England — 56% Survival Improvement Since 2012, 2,300 Preventable Deaths/Year. The National Audit Office report on major trauma care in England confirmed that survival has improved by 56% since the MTC network was established in 2012 — largely attributable to network configuration, TARN audit, and advanced prehospital capability. However, 2,300 deaths per year remain potentially preventable: delayed haemorrhage control, gaps in prehospital blood access, and post-discharge rehabilitation failures are the leading shortcomings. This data supports the evidence base for continued MTC investment and the HEMS survival data above.

Pilon Fracture — Staged Management Review (IntechOpen 2026). Confirms the standard staged approach: spanning external fixator within 24 hours (restoring length and alignment through ligamentotaxis) then definitive ORIF at 7–21 days once the soft tissue envelope has recovered (positive wrinkle test; resolution of fracture blisters). Premature ORIF carries a wound complication rate exceeding 20% in high-energy injuries — staging is not optional. Relevant to all MTC orthopaedic teams managing high-energy tibial plafond injuries from RTC and falls from height.

Guidelines for Essential Trauma Care — WHO Second Edition 2026 (PMID: 42008664). The WHO second edition of essential trauma care guidelines sets global minimum standards for trauma care resource provision. UK relevance: provides the international context for NHS England major trauma commissioning, mass casualty resource-stratified care, and overseas medical humanitarian work. Available via PubMed/WHO. Particularly relevant to military surgical teams and humanitarian responders.

Circulation Before Airway — Revised Trauma Sequence Review (UMEM 2026). A UMEM review reinforces the C-ABCDE approach: haemorrhage control and circulatory stabilisation should precede definitive airway management where possible in haemorrhagic trauma. Altered GCS in trauma may reflect hypoperfusion rather than neurological injury — correcting SBP can reverse apparent need for intubation. This principle should be explicit in trauma team training and ATLS updates: do not intubate a hypotensive trauma patient before addressing haemorrhage control unless airway is immediately threatened.

07 — CORE REVISION: UK MAJOR HAEMORRHAGE PROTOCOL

FRCS (T&O) / FRCS (GEN) / FINAL FRCA CORE REVISION — MAJOR HAEMORRHAGE PROTOCOL

Activation Criteria · Ratios · Monitoring · Stopping Criteria · UK Network Structure

Definition and Activation: Major haemorrhage is defined as loss of >1 blood volume within 24 hours (approximately 70 mL/kg or 5L in an adult), or loss of 50% of blood volume in 3 hours, or active bleeding with a rate >150 mL/min. Most UK hospitals use a clinical activation threshold based on any of: SBP <90 + tachycardia + haemorrhagic mechanism, active uncontrolled bleeding requiring emergency surgery, or clinical assessment by the most senior clinician present.

Key Mnemonics:

NHSBT MHP guidance: hospital.blood.co.uk | SHOT Annual Report 2025: shotuk.org | PROPPR trial: JAMA 2015 (doi: 10.1001/jama.2015.12).

08 — ACTION POINTS — ISSUE 1

TRIALS TO WATCH

Q3 2026 (Imminent Results)

• FEISTY Trial — Fibrinogen concentrate vs cryoprecipitate in major haemorrhage (UK multicentre). Will establish whether fibrinogen concentrate (more rapidly available, dose-titrable) is non-inferior to cryoprecipitate in traumatic haemorrhage. Critical for UK MHP logistics. Results expected Q4 2026.
• ITACTIC-2 — Viscoelastic haemostatic assay (ROTEM/TEG) guidance vs conventional coagulation tests in major trauma haemorrhage. Building on ITACTIC-1 data; will determine whether point-of-care viscoelastic testing should replace standard laboratory coagulation tests in all UK MHPs.
• CoMiTED — Conservative vs immediate chest drain in traumatic haemothorax. UK multicentre. Will answer whether all traumatic haemothoraces require immediate drainage or whether a subgroup can be managed with delayed/selective intervention.

2026–2027

• CRASH-4 (TBI and doxycycline) — International RCT examining doxycycline as a neuroprotective agent in traumatic brain injury. Largest TBI neuroprotection trial since CRASH-3.
• UK-REBOA follow-up analysis — Planned subgroup analysis of UK-REBOA to identify whether any injury subgroup (penetrating aortic injury? Zone-1 REBOA in haemorrhagic arrest?) shows benefit vs harm.
• TARN NMTR National Report (2026) — The National Major Trauma Registry (replacing TARN) is expected to publish its first UK-wide outcome report. Will provide updated UK MTC benchmarking data.

Longer Horizon

• JESSIP Doctrine Review outcome — Following the June 2026 call for evidence (closes 5 July), the updated JESIP Joint Doctrine is expected in late 2026 / early 2027. Will influence all multi-agency major incident response training and hospital major incident plans.
• NAP8 — Regional Anaesthesia Complications Audit (UK) — Active recruitment. Will include trauma regional anaesthesia (SAPB, thoracic epidural, fascia iliaca in trauma). UK-specific complication rates for nerve blocks in the MTC setting.

Jake Turner

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

Major Trauma Evidence Rundown — Issue 1 — July 2026 — Surgery & Critical Care · UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com