PHEM EVIDENCE RUNDOWN — ISSUE 7 — AUGUST 2026 — UK EDITION
Pre-Hospital Emergency Medicine — UK Edition
Monthly evidence for HEMS physicians, critical care paramedics, and PHEM trainees — emevidence.org
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.
Lead: Bystander CPR quality matters as much as CPR initiation — Faddy (Resuscitation 2026, n=17,715): good quality bystander CPR was associated with aOR 2.62 for 30-day survival. This paper directly challenges whether UK public CPR training programmes are adequately quality-focused. Safety / Act Now: MHRA FSNs: WEINMANN MEDUMAT Standard² prehospital ventilator, ResMed Astral 100/150 portable ventilators — check with clinical engineering immediately. Rescue breathing is superior to compression-only CPR in suffocation/asphyxia OHCA (n=76,000). C-spine clearance SR/MA clarifies when CT, MRI, and x-ray are needed. HEMS reduces thrombectomy delays in LVO stroke — data to support commissioning arguments.
BOTTOM LINE UP FRONT — AUGUST 2026
ACT ON THIS NOW
CHANGE TONIGHT Bystander CPR quality: aOR 2.62 for 30-day survival with good quality CPR (n=17,715). Advocate for quality-focused public training, not just initiation rates.
CHANGE TONIGHT Suffocation OHCA: Rescue breathing associated with significantly better outcomes in asphyxia/suffocation OHCA (n=76,000). Compression-only is inadequate — change your ventilation approach for non-shockable arrest in drowning, strangulation, foreign body.
SAFETY MHRA FSNs: WEINMANN MEDUMAT Standard² and ResMed Astral 100/150 portable ventilators — FSNs issued. Check clinical engineering for affected serial numbers. Löwenstein elisa and Maquet Flow-i also affected.
CHANGE THIS MONTH HEMS/LVO stroke: SJTREM registry simulation shows HEMS reduces thrombectomy delays by median 28 min, improves clinical outcomes at 90 days, and is cost-effective at societal level. Use this data locally.
CHANGE THIS MONTH C-spine clearance: SR/MA (PMID:41955954) confirms: NEXUS/Canadian rules in adults; PECARN in children. CT for high risk; MRI for persisting symptoms with normal CT. Avoid prolonged collar use.
KNOW FOR NEXT TIME
INFORMING PRACTICE Tracheostomy/laryngectomy airway: Resus Room episode (15 Jul) — key distinction: tracheostomy patients may have patent upper airway (BVM from above still works); laryngectomy patients do not (neck breather only). Use NTSP green/red algorithms at scene.
INFORMING PRACTICE OHCA geography: SJTREM analysis shows significant geographic mismatch between prehospital critical care service deployment and OHCA population need — most underserved areas are rural with lowest HEMS density.
INFORMING PRACTICE Prehospital analgesia: SJTREM consensus: early non-IV analgesia (intranasal, IM, inhaled) is underutilised in prehospital trauma care. Ketamine IN and Entonox should be first-line before IV access.
INFORMING PRACTICE Paeds POCUS skull fracture: SR/MA of 9 studies — Sn 0.90, Sp 0.98 for POCUS detection of paediatric skull fracture. Strong rule-in at high pre-test probability; use to avoid CT in low-intermediate risk head trauma.
OPERATIONAL Ebola medevac UK: UKHSA confirmed precautionary medical evacuation of Ebola-exposed healthcare worker from DRC to UK — serves as trigger to review HICS and CBRN/HazMat activation protocols at your service.
DIPIMC/FIMC AnaesthEasier TXA: Comprehensive review — mechanism, CRASH-2/3 data, HALT-IT implications, timing rules (within 3 hours for trauma, 1 hour ideal). Core DipIMC pharmacology.
Two papers this month converge on the same operational conclusion through very different routes. Faddy et al. (Resuscitation 2026, n=17,715) shows that quality of bystander CPR — not just its initiation — is the key survival driver, with aOR 2.62 for good-quality compressions. Okada et al. (Resuscitation 2026, n=76,000+) shows that in suffocation-related cardiac arrest, rescue breathing provides substantially better outcomes than compression-only CPR — and that no CPR at all may paradoxically outperform compression-only in asphyxia. Together, these papers demand a nuanced public message: "call and do CPR" is no longer sufficient — the quality and technique must match the mechanism. From SJTREM this month, a registry simulation study quantifies what HEMS physicians have always argued: HEMS reduces median time to thrombectomy in large vessel occlusion stroke by 28 minutes, significantly improving 90-day functional outcomes. This is the commissioning argument in data form. The Resus Room's July episode on laryngectomy and tracheostomy emergencies should be required listening for every PHEM trainee before their next shift — the anatomy-based framework for distinguishing a tracheostomy patient (who may still have an upper airway) from a laryngectomy patient (who does not) is the difference between a patent airway and a catastrophic ventilation failure at scene.
WHAT'S INSIDE — ISSUE 7, AUGUST 2026
- LEAD: Bystander CPR quality and OHCA survival (n=17,715)
- Rescue breathing in suffocation/asphyxia OHCA (n=76,000)
- SJTREM: HEMS impact on LVO stroke thrombectomy
- SJTREM: OHCA service geography and population need
- C-spine clearance SR/MA (adults + paeds)
- SJTREM: Prehospital analgesia — time to act
- MHRA FSNs: prehospital ventilators (Medumat, Astral)
- UKHSA: heat deaths 2026 + Ebola medevac UK
- AnaesthEasier: TXA + Ketamine (DipIMC/FIMC)
- Resus Room: Laryngectomy/tracheostomy emergencies
- SJTREM: Major incident cross-border response
- SJTREM: Helicopter hoist electrostatic discharge
- SJTREM: Family communication NTS in resuscitation
- Paeds PHEM: POCUS skull fracture SR/MA + SIPA index
- Quick Hits + Core Revision: RSI Rapid Sequence Intubation
S1 OHCA & Resuscitation | S2 Trauma & Airway | S3 UK Safety & Operational | S4 Paediatric PHEM | S5 FOAMed & DipIMC | S6 SJTREM Special & Quick Hits | Core Revision: RSI
SECTION 1 — OHCA & RESUSCITATION
Bystander CPR Quality — Not Just Initiation — Drives OHCA Survival: aOR 2.62 for Good-Quality CPR (n=17,715)
Faddy SC, Packham N, Heycott M, Davis KJ, Evens T. Resuscitation. 2026. PMID: 42361890. JournalFeed EM Speed Read, 31 July 2026. pubmed.ncbi.nlm.nih.gov/42361890
Why it matters: Most OHCA data focuses on CPR initiation rates as the public health metric. This large population-based registry study asks a different question: does the quality of bystander CPR matter once it has been started? The paramedic-assessed quality framework — scoring compression rate, depth, recoil, and interruptions — was applied retrospectively across 17,715 OHCA patients.
- 2.62 AOR 30-DAY SURVIVAL (GOOD CPR)
- Poor CPR REF (AOR = 1.0)
- n=17,715 POPULATION-BASED REGISTRY
- Paramedic ASSESSED CPR QUALITY
Key findings: Good quality bystander CPR (defined as compressions at guideline-consistent rate, depth, and recoil by paramedic assessment on arrival) was associated with aOR 2.62 (95% CI: 1.94–3.54) for 30-day survival compared with poor-quality CPR. The effect was independent of witness status, initial rhythm, and response time. Even bystander CPR that was initiated but poorly delivered conferred less survival benefit than no CPR assessment would predict — the "bystander CPR started: yes/no" binary fails to capture this difference.
Why it matters for PHEM: This data reframes the public health argument. The UK's Restart a Heart campaign and community CPR training schemes rightly focus on CPR initiation rates — but this paper suggests that quality training (feedback devices, compression rate targets, recoil cues) is not a luxury but a survival determinant. PHEM services should advocate for feedback-enabled public CPR training, community first responder quality assessment, and integration of CPR quality metrics into OHCA audit data. The aOR of 2.62 is a compelling number for a commissioning conversation.
Critical appraisal: Observational registry — paramedic CPR quality assessment was retrospective and may be subject to recall and classification bias. "Good quality" was paramedic-defined, not device-confirmed. Confounding by bystander demographics, OHCA location, and witness characteristics is possible despite adjustment. Direction and magnitude of effect are consistent with RCT-derived CPR quality data and the ILCOR 2020 meta-regression. Applies to the prehospital phase specifically — good-quality CPR matters most in the critical minutes before HEMS/EMS arrival.
Rescue Breathing Significantly Improves Outcomes in Suffocation-Related OHCA — Compression-Only Is Inadequate for Asphyxia (n=76,000)
Okada A et al. Resuscitation. 2026. PMID: 42361892. JournalFeed EM Speed Read, 31 July 2026. pubmed.ncbi.nlm.nih.gov/42361892
Study: Retrospective cohort of over 76,000 adults with witnessed suffocation-related out-of-hospital cardiac arrest from Japanese national OHCA registry, comparing: (1) no CPR; (2) compression-only CPR; (3) CPR with rescue breathing. Primary outcome: 30-day survival with favourable neurological outcome.
- Best CPR + RESCUE BREATHS
- Intermediate COMPRESSION-ONLY CPR
- n=76,000+ JAPANESE OHCA REGISTRY
Key finding: In suffocation-related OHCA, CPR with rescue breathing was associated with significantly better neurological outcomes than compression-only CPR. The gap was largest in asphyxia-predominant arrests. In contrast to undifferentiated OHCA (where compression-only is broadly non-inferior), the asphyxial mechanism requires oxygen delivery to be restored alongside circulation.
Prehospital implication — change now: This paper directly affects PHEM practice. The causes of asphyxial cardiac arrest encountered by HEMS and critical care paramedics include: drowning, strangulation, hanging, foreign body airway obstruction, epiglottitis, Ludwig's angina, and opioid-related arrest. In ALL of these, the mechanism is hypoxaemic — not primarily cardiac. Compression-only CPR for a drowning victim or strangulation victim significantly disadvantages them compared with ventilation-plus-compressions. JRCALC guidelines already recommend rescue breaths for drowning — this data extends the principle to all asphyxia mechanisms. Review your service protocols and bystander coaching scripts for these specific causes.
SECTION 2 — TRAUMA & AIRWAY
HEMS Impact on Thrombectomy Delays in LVO Stroke: Median 28-Minute Reduction, Improved 90-Day Outcomes, Cost-Effective (SJTREM)
SJTREM. Published 8 July 2026. DOI: 10.1186/s13049-026-01658-6
Study: Retrospective registry-based counterfactual simulation study comparing actual HEMS-assisted pathways for large vessel occlusion (LVO) stroke with simulated road ambulance pathways using matched controls from a national stroke registry. Primary outcomes: time to endovascular thrombectomy (EVT), 90-day functional outcome (mRS), and cost per QALY at societal level.
- 28 min MEDIAN EVT DELAY REDUCTION
- Improved 90-DAY MRS OUTCOMES
- Cost-eff. SOCIETAL COST PER QALY
- Registry SIMULATION STUDY DESIGN
Significance: Every 10-minute reduction in time-to-EVT in LVO stroke is associated with approximately 1 week of additional disability-free life. A 28-minute HEMS advantage is clinically meaningful and has been difficult to quantify definitively in previous work. The societal cost-effectiveness finding is particularly important for NHS commissioning arguments.
PHEM application: This paper provides the evidence base for HEMS dispatch for suspected LVO stroke at scene, particularly in areas where HEMS transport enables direct transfer to EVT-capable centres bypassing primary stroke units. UK HEMS services with acute stroke destination protocols should review and document their LVO activation criteria, destination agreements with neurovascular centres, and local time-to-EVT audit data. The EDEN dispatch model (SJTREM 1 Jul) provides a mathematical framework for optimising dispatch in parallel.
Modern C-Spine Clearance in Paediatric and Adult Trauma: SR/MA — NEXUS, Canadian, PECARN Rules, CT/MRI Thresholds
SR/MA: J Emerg Med. 2026 Jun;85:95-113. PMID: 41955954. JournalFeed AaD, 31 July 2026. pubmed.ncbi.nlm.nih.gov/41955954
Study: Systematic review and meta-analysis of c-spine clearance approaches in both adult and paediatric trauma patients. Covered: NEXUS criteria, Canadian C-Spine Rule (CCR), PECARN paediatric tool, CT vs plain x-ray vs MRI, and clinical clearance protocols. Primary focus: sensitivity and NPV for clinically significant c-spine injury.
Key conclusions: Adults: NEXUS and Canadian C-Spine Rule both have high sensitivity (>99%) for excluding significant injury in low-risk patients; CCR is slightly more specific. CT remains first-line for high-risk patients (mechanism, neurological deficit, midline tenderness). MRI is appropriate for persisting neurological symptoms with normal CT, or inability to clinically assess. Plain x-ray alone is no longer recommended as a primary tool. Children: PECARN paediatric decision rule identifies very low-risk children who do not require imaging. CT use in children should be minimised — MRI preferred when imaging is needed. Collar use: Prolonged rigid collar use is associated with pressure injury and raised ICP (in head-injured patients) — early removal in cleared patients is beneficial.
PHEM context: Prehospital c-spine management begins at scene. UK JRCALC guidance recommends manual inline stabilisation as the primary intervention, with rigid collar as a temporary adjunct only. This SR/MA reinforces the move away from prolonged collar use and supports clinical clearance protocols in awake, alert, neurologically intact patients. In HEMS operations: patients who are GCS 15, ambulatory at scene, have no midline tenderness, and have a low-mechanism injury can be considered for clinical clearance with documented NEXUS/CCR assessment before transport collar application. Document clinical decision-making explicitly.
Early Non-IV Analgesia in Prehospital Trauma — Time to Act: SJTREM Consensus
SJTREM. Published 16 July 2026. DOI: 10.1186/s13049-026-01663-9
This SJTREM commentary and evidence synthesis argues that early non-intravenous analgesia in prehospital trauma care is substantially underutilised, and that IV access delays frequently lead to undertreated pain — with significant consequences for patient outcomes (increased sympathetic response, coagulopathy, secondary injury). The authors advocate for protocol-level changes that allow first-contact analgesia before IV access is established.
Recommended early non-IV routes (in priority order): (1) Intranasal: ketamine (1-2 mg/kg IN) or fentanyl (1.5-2 mcg/kg IN via MAD); fastest to administer, no injection required (2) Intramuscular: morphine, ketamine — appropriate where IN is not available or inadequate (3) Inhaled: methoxyflurane (Penthrox) — patient-controlled, effective for moderate pain, limited to 6 mL per use (4) Entonox (50% nitrous oxide) — effective for procedural pain and short painful extrications
UK service applicability: Critical care paramedics and BASICS doctors working at scene should default to IN ketamine or IN fentanyl as first-line for significant trauma pain when the situation requires speed (entrapment, multiple casualties). IV access is not a prerequisite for analgesia. JRCALC endorses IN fentanyl and morphine IM. Ketamine IN for prehospital analgesia is supported by Level 2 evidence. Review your service formulary and standard operating procedures — if IN ketamine is available, it should be first-line for trauma analgesia at scene.
SECTION 3 — UK SAFETY & OPERATIONAL
MHRA Field Safety Notices: WEINMANN MEDUMAT Standard², ResMed Astral 100/150 — Prehospital and Transport Ventilators Affected
MHRA, multiple FSNs — July 2026. gov.uk/drug-device-alerts
SAFETY ALERT — PREHOSPITAL VENTILATORS
WEINMANN MEDUMAT Standard² (with and without CO2 monitoring) MHRA ref 39886981 2026/005/006/601/037 | FSN issued 29 June – 3 July 2026 The MEDUMAT Standard² is a portable transport ventilator widely used by UK HEMS services, critical care paramedics, and hospital transport teams. This FSN relates to a device behaviour issue. Action: Check with clinical engineering for affected serial numbers. Do not use until cleared or substituted. Full FSN details at gov.uk/drug-device-alerts. ResMed Astral 100 / Astral 150 MHRA ref 40133174 2026/006/023/601/070 | FSN issued 6–10 July 2026 Portable electric ventilators used in critical care transport and home ventilation. Action: Check serial numbers against the FSN. Report immediately to clinical engineering. Obtain a replacement device for affected units before patient use. Also issued this month: Löwenstein elisa 300/500/600/800 (VIT) — critical care ventilators (MHRA ref 40266406, 20–24 July 2026) Maquet Critical Care Flow-i/Flow-c/Flow-e anaesthesia systems (MHRA ref 40080669 2026/007/002/601/073) Hamilton coaxial breathing circuit set (MHRA ref 40284619)
UKHSA: 2,877 Excess Heat Deaths in England 2026 — Amber Alerts Active — Ebola-Exposed HCW Medically Evacuated to UK
UKHSA, July 2026. gov.uk/ukhsa
UKHSA reported 2,877 excess heat deaths attributable to the May/June 2026 heatwaves — nearly double the 2025 total (1,504). Amber heat-health alerts were reissued across multiple English regions in July. NHS ambulance trusts reported record incident volumes (South Western Ambulance: busiest day ever, 25 June; national Cat 2 average 32m31s in July).
Separately: UKHSA confirmed a precautionary medical evacuation of a healthcare worker with potential Ebola exposure (while treating Ebola patients in the DRC) to a UK high consequence infectious disease (HCID) unit. This is a reminder that CBRN/HCID protocols must remain live for UK PHEM services, particularly for international patient repatriation and medevac scenarios.
PHEM operational actions: Heat stroke: core temperature >40°C with neurological dysfunction — immediate whole-body cooling, target <39°C within 30 min. Cold water immersion or evaporative cooling + fanning. IV fluid replacement. Monitor for rhabdomyolysis. Ebola/HCID medevac: review your service's HCID activation criteria, PPE stockpile, decontamination pathways, and receiving HCID unit contacts. The Ebola medevac triggers a requirement to audit HICS readiness — not because of UK community transmission risk (nil confirmed), but as an operational preparedness exercise.
SECTION 4 — PAEDIATRIC PHEM
POCUS for Paediatric Skull Fractures: SR/MA — Sensitivity 0.90, Specificity 0.98 — Strong Rule-In at High Pre-Test Probability
Wang X et al. J Int Med Res. 2026. PMID: 42339785. POCUS JournalFeed Speed Read, 31 July 2026. pubmed.ncbi.nlm.nih.gov/42339785
Design: Systematic review and meta-analysis of 9 studies examining the diagnostic accuracy of point-of-care ultrasound for the detection of skull fractures in children.
- 0.90 SENSITIVITY
- 0.98 SPECIFICITY
- 45 LR+ (EST.)
- 0.10 LR− (EST.)
- n=9 STUDIES SR/MA
CLINICAL SCENARIO
PRE-TEST PROB.
POST-TEST (POCUS+)
POST-TEST (POCUS−)
| Low risk mild head trauma — alert, no LOC, no scalp haematoma | 5% | 70% | 0.5% |
| Intermediate — scalp swelling, brief LOC, uncertain mechanism | 20% | 92% | 2.4% |
| High risk — palpable skull defect, GCS reduced, high-energy mechanism | 60% | 99% | 13% |
LR+ = Sn/(1-Sp) = 0.90/0.02 = 45. LR− = (1-Sn)/Sp = 0.10/0.98 ≈ 0.10. Bayesian calculations use standard odds method. These are SR/MA pooled estimates from 9 studies; individual study variability and operator skill are significant. Not validated specifically in prehospital settings.
PHEM application: POCUS skull fracture assessment is not currently standard in UK prehospital HEMS practice, but the data supports its use by trained operators as a triage aid in low-to-intermediate risk paediatric head trauma — potentially avoiding unnecessary transfer to a CT-capable centre for children with a negative POCUS at scene. A positive POCUS in a child at intermediate-to-high pre-test probability (post-test 92-99%) should prompt transfer to a paediatric neurosurgical centre regardless of GCS. Operator training and documentation of image quality are prerequisites. DipIMC/FIMC candidates should be familiar with this diagnostic accuracy data.
Paediatric Age-Adjusted Shock Index (SIPA) for Early Identification of Haemorrhagic Shock in Children — JournalFeed Thursday
JournalFeed EM Speed Read, Thursday 30 July 2026. J Trauma Acute Care Surg. 2026.
The shock index (HR/SBP) is validated in adults for early haemorrhage identification, but in children normal heart rate and blood pressure vary by age, making the standard shock index less reliable. The paediatric age-adjusted shock index (SIPA) adjusts the threshold by age group. This study examined the performance of SIPA vs standard shock index for early identification and management of haemorrhagic shock in paediatric trauma patients in a retrospective cohort.
Thresholds (SIPA — age-adjusted): <2 years: HR/SBP >1.2 = abnormal. 2–5 years: >1.0. 6–12 years: >0.9. 13–17 years: >0.8. These thresholds are not universally agreed upon across all evidence, but represent the most widely cited framework. Use in conjunction with clinical assessment, mechanism, and physiological trend rather than as a standalone decision rule. Standard shock index in children underestimates shock severity due to compensatory tachycardia and maintained systolic pressure until late decompensation.
SECTION 5 — FOAMED & DIPIMC EVIDENCE
The Resus Room: Laryngectomy and Tracheostomy Emergencies — Roadside to Resus (15 July 2026)
The Resus Room (London HEMS clinicians). Published 15 July 2026. theresusroom.co.uk | Also: EMCrit weekly digest, mid-July 2026.
A practical, anatomy-based framework for tracheostomy and laryngectomy airway emergencies at scene or en route. The critical clinical distinction — which determines whether upper airway ventilation via BVM is possible — is anatomical:
| FEATURE | TRACHEOSTOMY | LARYNGECTOMY |
|---|---|---|
| Upper airway patent? | Yes (usually) | No — never |
| BVM from mouth/nose | May work (if tracheostomy occluded/removed) | Will NOT work |
| Primary rescue airway | Tracheostomy tube; BVM via tube | Neck stoma only — BVM directly to stoma |
| NTSP algorithm | Green (upper airway breathing) | Red (neck breather only) |
| Key hazard | Misidentifying as laryngectomy | Applying BVM to face — no gas exchange |
Management approach at scene (NTSP algorithm): (1) Oxygen via face mask AND via tracheostomy tube or stoma simultaneously. (2) Remove tracheostomy tube attachments (speaking valve, inner cannula). (3) Suction the stoma if visible secretions. (4) Deflate cuff if tube in situ. (5) Remove non-functioning tube. (6) In laryngectomy: ALL ventilation via stoma — face mask ventilation is futile and may inflate the oesophagus.
This is a DipIMC/FIMC topic. The National Tracheostomy Safety Project (NTSP) green (tracheostomy) and red (laryngectomy) bedside emergency algorithms are available at tracheostomy.org.uk and should be referenced in every critical care paramedic and PHEM physician airway kit.
AnaesthEasier: Tranexamic Acid — Mechanism, Timing Rules, CRASH-2/3, HALT-IT Implications
AnaesthEasier. Published 20 July 2026. anaestheasier.com — specific article link from email notification.
Source note: This item is drawn from AnaesthEasier, a high-quality anaesthesia and critical care educational resource, included here due to its direct relevance to PHEM practice. Not a primary research source. Verify against primary evidence before practice change.
TXA mechanism: Tranexamic acid is a synthetic lysine analogue that competitively inhibits plasminogen activation, preventing fibrinolysis. It does not promote clot formation — it prevents established clots from being dissolved. This distinction matters: TXA is most effective when given early, before fibrinolysis is established.
CRASH-2 (Lancet 2010, n=20,211): TXA given within 3 hours of injury reduced all-cause mortality (RR 0.91, ARD 1.5%, NNT 67). Delayed administration (>3 hours) was associated with increased risk of death from bleeding. CRASH-3 (Lancet 2019, n=12,737): TXA within 3 hours of head injury in adults reduced head injury mortality in mild-moderate TBI (RR 0.89). No benefit beyond 3 hours. HALT-IT (Lancet 2020, n=12,009): TXA in gastrointestinal bleeding did not reduce mortality and increased venous thromboembolic events — TXA is NOT indicated for GI bleeding.
PHEM rules for TXA: (1) Give within 3 hours of injury — aim for within 1 hour at scene (every 15 minutes of delay reduces efficacy). (2) Dose: 1g IV over 10 minutes at scene; repeat 1g IV over 8 hours in hospital. (3) Indications: trauma with significant haemorrhage, TBI with significant mechanism. (4) NOT indicated: GI bleeding (HALT-IT), obstetric haemorrhage (separate evidence base — WOMAN trial), isolated head injury without torso haemorrhage (consider, but evidence is weaker). (5) Contraindications: active thromboembolic disease, known fibrinolysis inhibitor therapy. UK JRCALC guidance endorses prehospital TXA for major trauma.
AnaesthEasier: Top Tips for Using Ketamine — Prehospital and Critical Care Context
AnaesthEasier. Published 16 July 2026. anaestheasier.com.
Source note: This item is drawn from AnaesthEasier, a high-quality anaesthesia and critical care educational resource, included here due to its direct relevance to PHEM practice. Not a primary research source. Verify against primary evidence before practice change.
Ketamine's unique pharmacological profile makes it particularly suited to prehospital and HEMS use: bronchodilation, sympathomimetic cardiovascular effects (maintains MAP in haemodynamically compromised patients), analgesic and dissociative properties, and preservation of laryngeal reflexes (though not reliably — still intubate for airway protection). Key prehospital applications: RSI (1-2 mg/kg IV), procedural sedation (0.5-1 mg/kg IV or 1-2 mg/kg IN), prehospital analgesia sub-dissociative (0.1-0.3 mg/kg IV), and trapped patient/entrapment analgesia. The myth that ketamine is contraindicated in head injury is not supported by current evidence — it does not raise ICP clinically when ventilation is controlled. Use midazolam (2-5 mg IV) alongside ketamine if emergence phenomena are a concern.
SECTION 6 — SJTREM SPECIAL & QUICK HITS
SJTREM: Cross-Border EMS Response to Train Crash Major Incident
SJTREM. 11 July 2026. DOI: 10.1186/s13049-026-01661-x
Retrospective analysis of an international EMS major incident response to a train crash. Key lessons: cross-border interoperability requires pre-agreed communication protocols; patient tracking across national systems failed during the incident; medical command roles need explicit assignment at scene from the outset. UK JESIP principles (Joint Emergency Services Interoperability Principles) were partially applicable but not designed for international incidents — a gap in major incident doctrine.
SJTREM: Helicopter Hoist Operations — Electrostatic Discharge Hazard
SJTREM. 24 July 2026. DOI: 10.1186/s13049-026-01666-6
First systematic description of electrostatic discharge hazard during helicopter hoist operations — a phenomenon known to crews but absent from the literature. Electrostatic charge builds on the hoist cable and can be discharged through a rescuer or patient on contact. Mitigation: touch the hoist line to a grounded surface before making personal contact. This paper provides the evidence base for this being a formal safety teaching point in hoist operations training. Share with your flight ops team.
SJTREM: Non-Technical Skills — Family Communication in Resuscitation
SJTREM. 23 July 2026. DOI: 10.1186/s13049-026-01665-7
Expanding the NTS framework for resuscitation to include family communication — currently absent from most NTS toolkits. The paper argues that family presence during resuscitation and high-quality communication about goals of care are core competencies for prehospital resuscitation teams. UK evidence: family-witnessed resuscitation (FWR) is endorsed by Resuscitation Council UK and associated with lower family PTSD and better bereavement outcomes. DipIMC candidates should include this in NTS competency portfolios.
ROYAL COLLEGE OF PARAMEDICS — Rebrand Confirmed (Effective 1 January 2026)
College of Paramedics, effective 1 January 2026. collegeofparamedics.co.uk
The College of Paramedics formally became the Royal College of Paramedics on 1 January 2026, following an EGM vote with 97.24% approval. The rebrand reflects the profession's maturity, expansion of paramedic clinical scope, and alignment with other Royal Colleges. References in PHEM governance documents and scope of practice statements should be updated accordingly.
RCUK/HEART RESTART: 16 MILLION AT RISK DUE TO DEFIBRILLATOR GAPS IN ENGLAND AND WALES
The Guardian, 22 July 2026 — citing Heart Restart campaign analysis; RCUK Clinical Director Adam Benson Clarke quoted. Guardian article
Heart Restart campaign analysis identified over 16 million people in England and Wales living in areas where a defibrillator cannot be reached within the critical 3–5 minute window. RCUK Clinical Director emphasised the importance of public AED awareness and community defibrillator mapping. Awareness item for commissioning conversations and community CPR advocacy — PHEM services can signpost local defibrillator databases to the public.
PHEM EVIDENCE RUNDOWN — CORE REVISION — ISSUE 7 — AUGUST 2026
Rapid Sequence Intubation (RSI) in Prehospital Practice
Drugs, sequence, optimisation, and rescue airway — DipIMC/FIMC edition
Goal of RSI: Achieve intubating conditions within 60 seconds using induction + neuromuscular blockade, while maintaining oxygenation, haemodynamic stability, and minimising aspiration risk. In PHEM, every RSI carries additional constraints: unfamiliar environment, single operator, limited monitoring, limited rescue options. Fail to plan, plan to fail.
THE RSI SEQUENCE — 10 PS (PREHOSPITAL MODIFIED)
| PHASE | ACTION | PHEM-SPECIFIC NOTE |
|---|---|---|
| Plan | Indication, risk-benefit, backup plan, team briefing | Brief all team members — "Sterile cockpit" (no chat during laryngoscopy) |
| Prepare | Drugs drawn, equipment checked, positioning | Double-check: suction on, ETCO2 connected, BVM available, CICO plan ready |
| Preoxygenate | 15L/min via NRM x3 min; head-up 20-30° | Aim SpO2 >98% before induction; use high-flow nasal oxygen (THRIVE/HFNO) if available; manual positioning in trauma |
| Premedication | Ketamine (1-2 mg/kg) for analgesia pre-induction in trauma | Optional but reduces pain response to laryngoscopy in awake/semi-conscious patients |
| Paralysis + Induction | Induction + suxamethonium or rocuronium simultaneously | See drug table below — give TOGETHER, not sequentially |
| Positioning | Ramped/sniffing position; external laryngeal manipulation (ELM) | Trauma: maintain manual inline stabilisation — do NOT apply traction. In-line does not worsen view significantly. |
| Placement | Video laryngoscopy (VL) preferred; direct laryngoscopy (DL) as backup | VL first-line in prehospital; confirm with capnography — waveform ETCO2 is the gold standard. Do not rely on chest rise alone. |
| Post-intubation | Confirm ETCO2, CXR equivalent, sedation/analgesia infusion | Target ETCO2 35-40 mmHg. Avoid hypotension (MAP >65). Avoid hyperventilation. |
| Packaging | Secure tube, ventilator settings, monitoring, reassess | Tape + cervical collar for airway security in transport; suction immediately accessible |
| Prehospital plan B | Know your failed airway algorithm before you start | CICO: scalpel-bougie-tube (STT) cricothyrotomy. Kit must be within arm's reach. |
RSI DRUG SELECTION — PREHOSPITAL
| DRUG | DOSE | ONSET | DURATION | PHEM INDICATION | AVOID IF |
|---|---|---|---|---|---|
| Ketamine | 1.5–2 mg/kg IV | 45–60 s | 10–15 min | First-line induction. Maintains BP. Bronchodilator. Ideal for trauma, shock, bronchospasm | No absolute PHEM contraindications. Use with caution in hypertensive emergency. |
| Thiopental | 3–5 mg/kg IV | 15–30 s | 5–10 min | Rapid cerebral protection — neuroprotection in elevated ICP | Haemodynamic instability, shock — profound hypotension risk. Not widely carried. |
| Propofol | 1.5–2.5 mg/kg IV | 15–45 s | 5–10 min | Good intubating conditions; familiar in elective anaesthesia | Hypovolaemia, shock — causes profound hypotension. Avoid in trauma. |
| Suxamethonium | 1.5 mg/kg IV | 45–60 s | 8–10 min | Fastest neuromuscular blockade. Facilitates early reversal if needed. Traditional RSI agent. | Burns (>24h), massive crush injury, hyperkalaemia, personal/family hx of malignant hyperthermia, myopathies, neuromuscular disease. |
| Rocuronium | 1.2 mg/kg IV | 60–90 s | 30–60 min | Preferred where suxamethonium is contraindicated or sugammadex is available for reversal (high-dose: 16 mg/kg IV). Good intubating conditions at 1.2 mg/kg. | No reversal agent available if you need to rescue from CICO. Always have CICO plan. |
| Midazolam | 0.1–0.2 mg/kg IV | 60–90 s | 30–60 min | Post-intubation sedation/amnesia alongside analgesic infusion (ketamine/morphine/fentanyl). | Sole induction agent — insufficient for RSI alone. Haemodynamically unstable patients. |
CICO — CAN'T INTUBATE CAN'T OXYGENATE: PREHOSPITAL PROTOCOL
CICO at scene = scalpel-bougie-tube (STT) cricothyrotomy. This is the only reliable rescue.
| STEP | ACTION | CUE |
|---|---|---|
| 1 | Call CICO — do not persist with repeated direct laryngoscopy (maximum 3 attempts total including VL) | SpO2 falling, repeated failed views — call it early |
| 2 | Two-person BVM + jaw thrust — maintain SpO2 while preparing cricket | Maximise oxygenation time |
| 3 | Landmark: midline, cricothyroid membrane (below thyroid cartilage notch, above cricoid ring) | Palpate or ultrasound if available |
| 4 | Scalpel — horizontal stab incision through skin + CTM, 1.5–2 cm | Control the scalpel depth — do not go too deep |
| 5 | Bougie — insert via incision, advance into trachea inferiorly (feel clicks) | Tracheal clicks = correct position |
| 6 | Tube — 6.0 cuffed ETT railroaded over bougie, inflate cuff, ventilate | Confirm ETCO2 waveform |
| 7 | Secure, ventilate, package, transport — do not delay | Tube is temporary — definitive surgical airway at receiving hospital |
DipIMC / FIMC Core Knowledge: The DipIMC OSCE regularly tests RSI sequence, drug choice in specific clinical scenarios (trauma + shock, bronchospasm, elevated ICP), and CICO management. Common exam traps: (1) Propofol in hypovolaemia — wrong answer for trauma RSI. (2) Rocuronium without stating sugammadex availability. (3) Suxamethonium in burns — know the timeline (>24 hours post-burn). (4) Forgetting post-intubation management (ETCO2, MAP, sedation). (5) Not having a named CICO plan before starting. Ketamine + rocuronium (1.2 mg/kg) is the current UK standard for prehospital RSI in the majority of cases, with suxamethonium reserved for when rapid offset is specifically required and there are no contraindications.
PHEM Evidence Rundown — Core Revision — Issue 7 · emevidence.org
Sources: Resuscitation Council UK ALS/PHEM guidelines 2025 · JRCALC Clinical Guidelines 2025 · EMCrit IBCC Airway · LITFL RSI · DAS Guidelines 2023
SECTION 7 — ACTION POINTS
- Bystander CPR quality advocacy: Share Faddy et al. (aOR 2.62, n=17,715) with your trust's community resuscitation team, cardiac arrest coordinators, and commissioning leads. Quality-focused training (feedback devices, rate/depth targets) is now supported by outcome data. Advocate for this shift in UK public training programmes and community first responder schemes.
- Suffocation/asphyxia OHCA protocols: Review your service protocol for drowning, strangulation, hanging, FBAO, and opioid arrests. In all asphyxial mechanisms, rescue breathing is an active clinical decision — not optional. Update coaching instructions for bystanders in these specific scenarios. Compression-only is not adequate.
- Prehospital ventilator safety check: If your service uses WEINMANN MEDUMAT Standard² or ResMed Astral 100/150, contact clinical engineering immediately to check serial numbers against the MHRA FSN. Do not use affected devices until cleared. Document the check in your service governance records.
- LVO stroke HEMS dispatch: Using SJTREM registry data (median 28 min EVT delay reduction, cost-effective), build or update the case for HEMS dispatch for suspected LVO stroke in your service. Review direct-to-EVT-centre agreements with your regional neurovascular centre. Document response time and destination data for audit.
- Scene analgesia protocol review: Ensure IN ketamine (1-2 mg/kg) and/or IN fentanyl (1.5-2 mcg/kg) are available and protocol-endorsed as first-line for significant trauma pain before IV access. IV access should never be a prerequisite for analgesia at scene. Review your service SOP and identify any barriers to non-IV analgesia deployment.
- CICO readiness: Every PHEM clinician must have a scalpel-bougie-tube set within arm's reach at every RSI — not in the bag, not in the vehicle, on the person or within immediate reach. Conduct a team simulation or moulage of the STT cricothyrotomy technique within the next 30 days if not done in the last 6 months.
- Laryngectomy/tracheostomy identification: Brief every crew member on the anatomical distinction between tracheostomy and laryngectomy emergencies. Carry printed NTSP green and red algorithms. In laryngectomy: no face mask ventilation, ever. All rescue ventilation via stoma.
- Hoist electrostatic discharge: Share the SJTREM paper on helicopter hoist electrostatic discharge with your flight operations team. Ensure the mitigation step (grounding the cable before personal contact) is included in hoist training materials and crew briefings.
TRIALS TO WATCH
NEAR-TERM (Q3/Q4 2026)
| PARAMEDIC-3 | UK OHCA — enhanced community resuscitation interventions vs standard. Results expected late 2026/2027. |
| ARREST-2 | Lidocaine vs amiodarone vs placebo for refractory VF in OHCA — follow-up publication expected Q3 2026. |
| UKHSA HCID Guidance | Ebola-exposure medevac (July 2026) likely to prompt updated HCID/special pathogen PHEM guidance from UKHSA. Watch for formal publication. |
2026–2027 HORIZON
| EDEN Dispatch | SJTREM mathematical dispatch optimisation model for stroke — watch for prospective validation in UK HEMS services. |
| NMTR Year 1 | NHS England National Major Trauma Registry (successor to TARN) — first annual report expected 2026/2027. |
| ECPR at scene | Multiple ongoing UK and European trials of prehospital ECPR for refractory OHCA. UK PHEM service ECPR capability audit expected 2027. |
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed. PHEM Evidence Rundown — Issue 7 — August 2026 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines and service protocols before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com
Previous issues are archived at emevidence.org. This newsletter is for educational purposes only and does not constitute clinical advice.