PHEM Evidence Rundown — September 2026

PHEM EVIDENCE RUNDOWN — ISSUE 8 — SEPTEMBER 2026

PHEM Evidence Rundown

Pre-hospital emergency medicine evidence for UK clinicians — monthly — emevidence.org

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

JRCALC CHANGE TONIGHT: Naloxone is no longer indicated in opioid-related cardiac arrest — JRCALC Clinical Update 2:26 (12 August 2026) removes it from the ALS algorithm based on ILCOR/ERC review. Update drug boxes, cognitive aids, and team protocols now. Safety Alerts (x2): MHRA NPSA for ResMed Astral 100/150 transport ventilators (17 Aug) — check your service's devices immediately. MHRA DSI/2026/009: NGPod pH device withdrawn from UK market — quarantine and dispose of all devices now. Airway triple: BEST Trial (SJTREM RCT) — bougie outperforms stylet in difficult airway trauma. 11-year HEMS RSI registry (n=2,431): 95.7% success with structured corrective manoeuvres; suction and BURP are the highest-yield first steps. Videolaryngoscopy is now “must always be available” for prehospital RSI per updated DAS guidance. Post-ROSC / OHCA: LOGICAL Trial (NEJM, n=1,840): conservative O2 post-ROSC does not improve 180-day outcome vs liberal O2. Target SpO2 94–98% and avoid extreme positions in either direction. Prehospital ETI associated with ROSC (OR 7.61) in new cohort data — association only, not a causal survival benefit. Core Revision: Tension Pneumothorax — prehospital decompression techniques and decision-making. DipIMC/FIMC exam focus.

BOTTOM LINE UP FRONT

ACT ON THIS NOW

CHANGE TONIGHT JRCALC Update 2:26 (12 Aug 2026): Naloxone removed from opioid-related cardiac arrest algorithm. Naloxone remains for peri-arrest opioid toxicity with respiratory depression — but once arrest is confirmed, standard ALS only. Update drug boxes and cognitive aids.

SAFETY ALERT MHRA NPSA — ResMed Astral 100/150 ventilators (17 Aug): National Patient Safety Alert for transport ventilators used by HEMS and critical care retrieval teams. Check MHRA guidance and implement required actions immediately.

SAFETY ALERT MHRA DSI/2026/009 — NGPod pH device (24 Aug): Manufacturer has ceased trading. All NGPod devices must be quarantined and disposed of. Transition to pH strips or aspiration-based NG confirmation now.

CHANGE THIS MONTH 1 in 4 patients after prehospital neuromuscular blockade-assisted airway management experience an adverse event (national EMS series). Rigorous pre-RSI checklist and continuous post-intubation monitoring are non-negotiable.

CHANGE THIS MONTH UK HEMS for non-traumatic brain pathology: NTBP is routine in UK HEMS but triage decisions are heterogeneous, without formal pathways. Review your service's NTBP dispatch criteria.

KNOW FOR NEXT TIME

INFORMING PRACTICE BEST Trial (SJTREM RCT): Bougie-guided ETI outperforms stylet in critically injured patients with difficult airway characteristics. Supports current DAS prehospital bougie-first recommendation. Ensure simulation training.

INFORMING PRACTICE LOGICAL Trial (NEJM, n=1,840): Conservative O2 post-ROSC (SpO2 90–95%) does not improve 180-day survival vs liberal O2. Target SpO2 94–98% is safe and pragmatic — avoid hyperoxia and hypoxia without being excessively restrictive.

INFORMING PRACTICE Advanced HEMS interventions add 41% to scene time each (SJTREM registry, n=1,357). Factor this into stay-and-play vs scoop-and-run decisions for each individual intervention.

INFORMING PRACTICE RCUK position statement (3 Aug): Insufficient evidence to recommend suction anti-choking devices (e.g. LifeVac). Standard FBAO management remains the evidence-based approach.

PAEDS PHEM Paediatric OHCA pathway selection beyond witness status: Asphyxial mechanism, rhythm, and CPR quality all matter more than witnessed/unwitnessed alone. For paediatric asphyxial arrest, early oxygenation is the priority.

INFORMING PRACTICE Core revision this issue: Tension pneumothorax — recognition, NDC, finger thoracostomy, bilateral decompression in traumatic arrest.

This month's pipeline is dominated by practice-changing signals from official UK sources. JRCALC has quietly removed naloxone from the opioid-arrest algorithm, and two MHRA alerts demand immediate action on kit used by prehospital teams. Alongside these, the airway evidence continues to mature: the BEST trial gives us the first RCT evidence for bougie-first in difficult airway trauma, and an 11-year HEMS RSI registry (n=2,431) confirms that structured corrective manoeuvres resolve difficult laryngoscopy in 95.7% of cases — with suction and BURP as the highest-yield first steps. The LOGICAL trial (NEJM) is the largest oxygen trial in post-ROSC care and provides reassurance that a pragmatic SpO2 94–98% target is clinically safe. The prehospital blood product section is expanded this month with evidence on non-traumatic haemorrhage and a scene-time cost analysis for advanced interventions. Three paediatric PHEM items are included, and the core revision covers tension pneumothorax decompression in full.

WHAT'S INSIDE

• JRCALC Update 2:26 — Naloxone in arrest removed
• MHRA NPSA: ResMed Astral 100/150 ventilators
• MHRA: NGPod pH device withdrawn
• BEST Trial: bougie vs stylet in difficult airway (RCT)
• Capnometry in prehospital intubation — outcomes data
• HEMS RSI 11-year registry: corrective manoeuvres 95.7%
• Safer PHEA — VL now mandatory per DAS guidance
• 1 in 4 adverse events after prehospital NMBA-AM
• LOGICAL Trial (NEJM) — O2 post-ROSC n=1,840
• Advanced HEMS interventions: 41% scene time increase each
• ECPR eligibility model assumptions — SJTREM
• UK HEMS for non-traumatic brain pathology
• HEMS socioeconomic equity — equal 30-day mortality
• Prehospital blood transfusion for medical haemorrhage
• Paeds: OHCA beyond witness status | weight documentation | drone AED
• Quick Hits: TOR in FBAO / O2 fire risk / signs of life / REBOA SR
• RCUK: anti-choking suction devices position statement
• Air Ambulances UK: 24/7 hospital helipad report

• Core Revision: Tension Pneumothorax (DipIMC/FIMC)

CHANGE TONIGHT Act immediately CHANGE THIS MONTH Adjust practice SAFETY ALERT Device/drug safety GUIDELINE Formal

guidance INFORMING PRACTICE Background evidence PAEDS PHEM

UK

FOAMED

DIPIMC/FIMC

Contents: 1. Safety Alerts & Guideline Changes — 2. Airway — 3. Resuscitation & Post-ROSC — 4. HEMS Operations & Governance — 5. Haemorrhage & Trauma — 6. Paediatric PHEM — 7. Quick Hits — 8. UK Policy & FOAMed — 9. Core Revision: Tension Pneumothorax — 10. Action Points

1 — SAFETY ALERTS & GUIDELINE CHANGES

CHANGE TONIGHT UK DIPIMC/FIMC

JRCALC Clinical Update 2:26 — Naloxone No Longer Indicated in Cardiac Arrest

JRCALC / jrcalc.org.uk — Available from 12 August 2026 — jrcalc.org.uk/announcements

JRCALC Clinical Update 2:26 removes naloxone from the algorithm for cardiac arrest with suspected opioid aetiology. An ILCOR and ERC systematic evidence review concluded there is insufficient evidence to recommend naloxone in opioid-related cardiac arrest. The ALS guideline has been simultaneously updated. Additional changes include an updated naloxone guideline covering pregnancy/breastfeeding and monitoring requirements, a new Falls Risk Stratification Table for older adults, and headache SNOOP10 criteria revisions.

Action — all CCP and HEMS crews: Once cardiac arrest is confirmed, do not administer naloxone regardless of suspected opioid aetiology. High-quality CPR, rhythm identification, and adrenaline per algorithm are the priorities. Naloxone remains indicated in the peri-arrest patient with opioid toxicity causing respiratory depression or haemodynamic compromise — but the moment arrest is established, standard ALS applies. Remove naloxone from cardiac arrest drug packs at the point of arrest confirmation. Update cognitive aids and run a team debrief. Check the JRCALC app for the full revised guideline.

SAFETY ALERT UK DIPIMC/FIMC

MHRA National Patient Safety Alert: ResMed Astral 100 and 150 Transport Ventilators

MHRA / NHS England — 17 August 2026 — gov.uk/drug-device-alerts

A National Patient Safety Alert has been issued for the ResMed Astral 100 and 150 ventilators, used by critical care retrieval and HEMS transport teams for ventilated patient transfers. The alert details a risk of ventilator failure and specifies required immediate actions for all services using these devices.

Action: All PHEM services and critical care transport teams using ResMed Astral 100 or 150 ventilators must review the MHRA alert and implement required actions immediately. Contact your clinical governance lead and equipment lead today — do not wait for routine governance cycle.

SAFETY ALERT UK

MHRA DSI/2026/009: NGPod pH Device — Quarantine and Dispose of All Devices Immediately

MHRA — 24 August 2026 — gov.uk/drug-device-alerts

The NGPod handheld pH testing device — used to confirm nasogastric tube placement by pH testing in prehospital and critical care transfer settings — is being withdrawn from the UK market. The manufacturer has ceased trading. All remaining NGPod devices and sensor cartridges must be quarantined and disposed of immediately.

Action: Remove all NGPod devices from prehospital kits and clinical areas now. Transition to alternative pH testing strips or aspiration-based NG tube confirmation per your service guidance. Report any incidents involving NGPod to your clinical governance lead and via the MHRA Yellow Card scheme.

2 — AIRWAY

CHANGE THIS MONTH DIPIMC/FIMC

1 in 4 Patients Experience an Adverse Event After Prehospital Neuromuscular Blockade-Assisted Airway Management

Prehospital Emergency Care. PMID: 42546174 — National EMS Series

• 1 in 4 PATIENTS WITH ADVERSE EVENT AFTER PREHOSPITAL NMBA-AM
• Common events DESATURATION, HYPOTENSION, UNPLANNED EXTUBATION DURING TRANSPORT
• National LARGE NATIONAL EMS REGISTRY; OBSERVATIONAL
• Fix: Checklist PRE-RSI CHECKLIST + POST-INTUBATION MONITORING BUNDLE

Action: A 25% adverse event rate demands a systematic response. Pre-RSI checklists should be universal. Post-intubation monitoring — waveform EtCO2, SpO2, haemodynamic monitoring, tube position confirmation, sedation/analgesia — must be continuous and documented. Services should conduct case-level governance review of every prehospital adverse airway event. This data should feed directly into HEMS airway audit programmes.

INFORMING PRACTICE DIPIMC/FIMC

BEST Trial: Bougie vs Stylet for Intubation in Critically Injured Patients with Difficult Airway Characteristics — RCT

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM). August 2026. RCT

The BEST Trial (Bougie guided vs Endotracheal tube with Stylet guided intubation in critically injured patients with Difficult airway characteristics) is one of the first RCTs to compare these approaches directly in a trauma population with anticipated difficult airways. Bougie-guided intubation demonstrated superiority in first-pass success rates over stylet-guided ETI, consistent with the Difficult Airway Society (DAS) prehospital guidelines recommending a bougie-first approach.

UK practice: Bougie should be first-line for prehospital ETI in any case with anticipated or unexpected difficult airway features — this RCT now provides prospective data to support what the DAS already recommends. If your service uses stylet as default, this is the time to change. Bougie technique requires regular simulation — include it as a mandatory component of your prehospital airway training programme.

CHANGE THIS MONTH DIPIMC/FIMC

Capnometry in Prehospital Intubation — Use and Association with Clinical Outcomes

Prehospital Emergency Care. PMID: 42615855 — Large observational cohort

This large prehospital cohort examined capnometry use following prehospital intubation. Services with routine waveform EtCO2 monitoring had lower rates of unrecognised oesophageal intubation and improved outcome metrics. The data provide the strongest observational support yet for the JRCALC mandate: waveform capnography for all prehospital intubations.

Action: JRCALC mandates waveform capnography for all prehospital intubations — if your service is not achieving 100% compliance, establish why and fix it. EtCO2 trending matters, not just the presence of waveform: a progressive fall may indicate oesophageal placement, cardiac arrest, or tension pneumothorax. Treat any EtCO2 loss immediately as presumptive oesophageal intubation until disproved.

INFORMING PRACTICE DIPIMC/FIMC

HEMS RSI — 11-Year Registry: 95.7% Success with Structured Corrective Manoeuvres in Difficult Laryngoscopy

SJTREM. DOI: 10.1186/s12245-026-01342-7 — 11 August 2026 — Registry n=2,431

• 95.7% SUCCESS WITH STRUCTURED CORRECTIVE MANOEUVRES IN DIFFICULT LARYNGOSCOPY
• 75.2% INTUBATED WITHOUT ANY CORRECTIVE MANOEUVRE
• Suction + BURP MOST EFFECTIVE SINGLE CORRECTIVE MANOEUVRES
• n=2,431 11-YEAR HEMS RSI REGISTRY; PHYSICIAN-LED

When first-pass laryngoscopy is difficult: Optimise positioning (ramping, HELP position for obesity/pregnancy), apply BURP, use suction for secretion clearance. These are the highest-yield corrective manoeuvres in HEMS RSI. A structured escalation plan — direct laryngoscopy, VL, bougie, SGA, surgical airway — should be pre-planned before every RSI, not improvised. The 95.7% success rate with structured correction confirms that systematic technique, not repeated unmodified attempts, is the key to rescue.

CHANGE THIS MONTH FOAMED DIPIMC/FIMC

How Can We Deliver Safer Prehospital Anaesthesia? — Guideline Evidence Review (August 2026)

Diarmaid McMenamin (Substack) — 9 August 2026 — diarmaidmcmenamin.substack.com — Updated DAS prehospital airway guidance review

An excellent synthesis of the current prehospital RSI and PHEA evidence base, including a review of updated DAS UK prehospital airway guidance. The key update: videolaryngoscopy has moved from “should be available” to “must always be available” for prehospital RSI. Well-governed HEMS programmes are now reporting first-pass intubation success rates equivalent to or better than receiving EDs when VL is used with a structured protocol.

Action: If your service does not yet have VL as standard issue for all prehospital RSI — this is the moment to escalate. The evidence base has shifted from optional to mandatory. Review your service's VL rollout and training standards, and ensure all HEMS physicians are proficient on your specific device under pressure.

3 — RESUSCITATION & POST-ROSC

KEY TRIAL INFORMING PRACTICE DIPIMC/FIMC

LOGICAL Trial (NEJM): Conservative vs Liberal O2 Post-ROSC — No Difference in 180-Day Neurological Outcome

New England Journal of Medicine. DOI: 10.1056/NEJMoa2513814 — Discussed The Resus Room, August 2026 — RCT n=1,840

38.2%

39.7%

No difference

n=1,840

180-DAY FAVOURABLE NEURO OUTCOME: CONSERVATIVE O2 (SPO2 90–95%)

180-DAY FAVOURABLE NEURO OUTCOME: LIBERAL O2 (SPO2 ≥96%)

ALL PRIMARY AND SECONDARY OUTCOMES INCLUDING MORTALITY

ICU POST-ROSC; LARGEST OXYGEN RCT IN THIS POPULATION

The LOGICAL trial randomised 1,840 ICU patients post-ROSC to conservative oxygen (SpO2 90–95%) vs liberal oxygen (SpO2 ≥96%). Neither strategy produced a significant difference in 180-day survival with favourable neurological outcome, in-hospital mortality, or secondary outcomes.

PHEM post-ROSC oxygen strategy: Target SpO2 94–98%. Conservative targets (90–95%) are safe and do not worsen outcomes — but being excessively restrictive adds complexity without benefit. The harm is from uncorrected hypoxia and sustained extreme hyperoxia. Titrate supplemental O2 with pulse oximetry en route; avoid 100% O2 on high-flow in the post-ROSC patient. This remains a pragmatic, guideline-consistent approach.

INFORMING PRACTICE DIPIMC/FIMC

Prehospital ETI Associated with Higher ROSC in OHCA — Retrospective Cohort (OR 7.61)

BMC Emergency Medicine. DOI: 10.1186/s12873-026-01718-1 — Retrospective registry cohort

• OR 7.61 ETI VS BVM; 95%CI 6.07–9.53; P<0.001 — ROSC
• 21.1% vs 3.8% ROSC RATE ETI VS BVM ALONE; ARD 17.3%
• NOT causal RETROSPECTIVE; AIRWAY TIMING NOT CAPTURED; SURVIVAL TO DISCHARGE NOT PRIMARY OUTCOME

Critical appraisal: This retrospective registry association should not change practice in isolation. The apparent ROSC benefit almost certainly reflects selection bias — ETI is used in patients with more favourable cardiac arrest profiles. Airway timing relative to collapse was not captured, and survival to discharge did not differ. What matters in OHCA airway management: early high-quality CPR, minimal interruption, and first-pass airway success by the most experienced operator using whichever device achieves that. The AIRWAYS-2 and PART trials remain the primary evidence base.

INFORMING PRACTICE

Post-ROSC Quality Indicators for Prehospital Care — Significant Gaps Identified in Scoping Review

Prehospital Emergency Care. PMID: 42612190 — Scoping review

Despite well-established in-hospital post-resuscitation benchmarks (temperature management, ventilation targets, haemodynamic goals), specific quality indicators for the prehospital post-ROSC period are largely absent from the literature. This scoping review maps the gap and calls for standardised prehospital post-ROSC care bundles.

UK PHEM post-ROSC bundle principles: MAP 65–90 mmHg (vasopressors if needed); SpO2 94–98%; EtCO2 35–45 mmHg (target normocapnia); avoid pyrexia; TTM if your service has the capability; early pre-alert for PPCI/TTM centre. Your service should have a documented post-ROSC bundle — if it does not, this scoping review provides the mandate to create one.

4 — HEMS OPERATIONS & GOVERNANCE

INFORMING PRACTICE DIPIMC/FIMC

Advanced HEMS Interventions Add 41% to Scene Time per Intervention — Physician Air Ambulance Registry

SJTREM. DOI: 10.1186/s13049-026-01613-5 — Retrospective cohort n=1,357 — Discussed The Resus Room, August 2026

• +41% INCREASE IN SCENE TIME PER ADDITIONAL ADVANCED INTERVENTION (P<0.001)
• 24→29% PATIENTS RECEIVING ADVANCED INTERVENTIONS INCREASED OVER TIME
• Stable overall MEDIAN SCENE TIME UNCHANGED DUE TO SHIFT TOWARD PENETRATING TRAUMA

Operational decision-making: Every advanced intervention has a time cost. The question is always: will this intervention improve outcome sufficiently to justify the scene time it costs in this specific patient? Tourniquet, chest decompression, and RSI for airway compromise have outcome data supporting their scene time investment. Prehospital REBOA, CVP lines, and invasive monitoring at scene require robust governance justification against time-to-hospital benefit. Scoop-and-run vs stay-and-play is not binary — it is intervention-by-intervention.

CHANGE THIS MONTH UK DIPIMC/FIMC

UK HEMS for Non-Traumatic Brain Pathology — Heterogeneous Triage, No Formal Pathways

Air Medical Journal. PMID: 42608120 — Survey / Observational

Non-traumatic brain pathology (NTBP) — including ICH, hypoxic brain injury, seizures with airway compromise, and acute encephalopathy — is routinely attended by UK HEMS. However, this paper documents that triage decisions for NTBP are heterogeneous across services and infrequently supported by formal, audited clinical pathways. Trauma has well-established HEMS triage criteria; NTBP does not.

Action: Review whether your HEMS service has defined, audited criteria for NTBP dispatch. Seizures with airway risk, high-grade ICH with GCS decline, post-arrest hypoxic brain injury — all should trigger HEMS consideration. National standardisation via FPHC or NHS England guidance is urgently needed. If your service lacks NTBP criteria, use this paper to support a clinical governance proposal to develop them.

INFORMING PRACTICE UK

Socioeconomic Equity in UK HEMS — Equal 30-Day Mortality Across All Deprivation Quintiles

Emergency Medicine Journal. PMID: 42521477 — UK Retrospective Cohort

This UK cohort used Indices of Multiple Deprivation to examine whether socioeconomic status influenced 30-day mortality in HEMS-attended patients. Equitable outcomes were achieved across all deprivation quintiles, suggesting dispatch criteria within this service do not systematically disadvantage deprived communities. Geographical access remains a separate equity challenge.

UK context: Reassuring evidence that HEMS is reaching and benefiting patients equitably within the operational footprint studied. Other UK services should consider auditing and publishing equivalent equity data. The outstanding equity issue is geographic — rural and remote communities without nearby 24/7 HEMS coverage remain disproportionately underserved.

INFORMING PRACTICE DIPIMC/FIMC

Operational Assumptions Underlying ECPR Eligibility Models — Implications for HEMS Programmes

SJTREM. PMID: 42665814 — 28 August 2026

ECPR eligibility models make specific assumptions about prehospital response times, low-flow intervals, and patient selection that may not reflect the real-world operational context of HEMS services. This analysis documents discrepancies between model parameters and operational realities, with implications for how UK HEMS services design their ECPR programmes.

UK context: UK HEMS services running or developing ECPR programmes should audit eligibility criteria against this framework. Selecting patients within an operationally unrealistic low-flow window undermines programme validity. Evidence for ECPR in shockable OHCA continues to develop — the INCEPTION trial and UK-based programmes are the ones to watch.

5 — HAEMORRHAGE & TRAUMA

INFORMING PRACTICE DIPIMC/FIMC

Prehospital Blood Transfusion for Medical (Non-Traumatic) Haemorrhage — Case Series

Prehospital Emergency Care. PMID: 42664368 — Two-system observational study

Just under a third of prehospital blood transfusions in this two-system series were administered for non-traumatic causes: GI haemorrhage, ruptured AAA, obstetric haemorrhage, and other medical causes. This is higher than most HEMS services anticipate when designing blood product protocols focused on trauma.

Action: UK HEMS blood product protocols should explicitly address medical haemorrhage. A ruptured AAA or massive GI bleed carries the same haemorrhagic physiology as penetrating trauma. If your service protocol restricts blood products to trauma alone, review this. Ensure your crews can identify and activate blood product protocols for medical indications, including obstetric haemorrhage and non-traumatic abdominal catastrophe.

INFORMING PRACTICE

Thoracic Injuries in Elderly Trauma — More Severely Injured, Worse Outcomes than Younger Patients

SJTREM. PMID: 42629558 — 17 August 2026 — Registry cohort

Elderly patients (>65 years) with thoracic injuries were more severely injured, required more intensive in-hospital care, and had substantially worse outcomes than younger counterparts with similar mechanism of injury. ISS scores and complication rates were disproportionately high relative to clinical presentation at scene.

Prehospital approach: Do not underestimate thoracic trauma in the elderly. Bilateral rib fractures following a fall from standing in an 80-year-old may follow the trajectory of a high-energy mechanism in a younger patient. Early adequate analgesia (fentanyl + ketamine), optimise oxygenation, low threshold for HEMS dispatch, and early hospital pre-alert. Consider chest wall injury scoring and early respiratory compromise anticipation.

6 — PAEDIATRIC PHEM

Weight Documentation in Paediatric EMS Responses — 3 in 4 Compliant; 1 in 4 Still Not

Prehospital Emergency Care. PMID: 42636409 — Quality improvement

Three quarters of paediatric EMS responses were compliant with weight-based medication documentation. The 25% non-compliance gap represents a direct patient safety risk — weight-based drug errors in prehospital paediatric care are a recognised cause of harm, particularly with paralytic agents, adrenaline, and sedatives.

Action: Use a validated length-based estimation tool for every paediatric patient (Broselow tape or PAWPER XL-MAC). Document estimated weight on the clinical record before any drug administration. Prehospital RSI pre-checklists should include mandatory weight estimation. Ensure drug concentration references are paediatric-specific — most errors occur at the concentration/dose calculation step.

PAEDS PHEM INFORMING PRACTICE

Drone AED Delivery — Public Acceptance High; Self-Efficacy is the Barrier

Prehospital Emergency Care. PMID: 42646255 — National survey

Public acceptance and trust in drone-delivered AED is high in this national survey. The limiting factor is self-efficacy — whether bystanders feel confident to use the device when it arrives. Acceptance alone does not translate into action; community CPR and AED training must specifically address the confidence gap.

UK context: Drone AED deployment is being piloted in several UK regions. This data should inform how programmes communicate with the public — training for action, not just awareness. The cardiac arrest survival chain begins with bystander CPR and defibrillation; drone delivery is only useful if the bystander is confident to act.

7 — QUICK HITS

CHANGE THIS MONTH TOR Rules Perform Poorly in FBAO-Related OHCA — 2 Survivors Would Have Been

Terminated DIPIMC/FIMC

Prehospital Emergency Care. PMID: 42456096

BLS termination-of-resuscitation rules classified two patients with favourable neurological outcome as TOR-positive in this FBAO-related OHCA cohort. Standard TOR rules must not be applied in suspected foreign body airway obstruction arrests — clinical judgement must override algorithmic rules. In FBAO arrest, every reasonable attempt to clear the obstruction (direct laryngoscopy, Magill forceps, finger sweep) must precede any TOR consideration.

INFORMING PRACTICE Signs of Life During OHCA — 1 in 4 Patients; Do Not Use as Reason to Terminate

Prehospital Emergency Care. PMID: 42480096

One in four treated OHCA patients displayed at least one sign of life during resuscitation. Agonal breathing and spontaneous movement were associated with higher ROSC rates. Do not use agonal breathing or gasping as a futility indicator — these are signs of residual cardiac electrical activity. Termination-of-resuscitation decisions must not be made based on the presence of agonal breathing alone.

INFORMING PRACTICE Prehospital Low-Priority Patients with Physiologic Instability — Increased In-Hospital

Mortality DIPIMC/FIMC

Prehospital Emergency Care. PMID: 42384761

Prehospital physiological instability in patients initially categorised as low-priority was independently associated with in-hospital mortality. Reassessment of vital signs en route is essential — dispatch priority should not fix clinical reassessment. Continuous monitoring and early reclassification can identify patients whose trajectory is deteriorating before hospital arrival.

INFORMING PRACTICE Oxygen Enrichment During CPR — Fire Risk at Standard Flows Not Confirmed DIPIMC/

FIMC

SJTREM. PMID: 42596016 — Manikin study

Clinically relevant oxygen accumulation at defibrillation sites was not observed during simulated CPR at standard flow rates. While removing O2 delivery before defibrillation is common practice, evidence for fire risk at standard flows is limited. Defibrillation should not be delayed for oxygen removal — pause O2 delivery momentarily and shock promptly without compromising resuscitation quality.

INFORMING PRACTICE Prehospital REBOA — Evidence Remains Very Limited; Not for Routine Use Outside

Governed Programmes

Prehospital Emergency Care. PMID: 42530919 — Systematic review

Current evidence for prehospital REBOA is limited by small retrospective series and heterogeneous populations. No comparative RCT data exists in the prehospital setting. This SR does not support routine prehospital REBOA outside structured HEMS programmes with dedicated governance, training standards, and outcome tracking. Early TXA, blood products, and damage control principles remain the standard for haemorrhagic shock management.

UK RCUK: Insufficient Evidence for Suction Anti-Choking Devices (e.g. LifeVac)

Resuscitation Council UK — 3 August 2026 — resus.org.uk

RCUK has issued a formal position statement finding insufficient evidence to recommend anti-choking suction devices for routine clinical use. Standard FBAO management — back blows, abdominal thrusts, direct laryngoscopy and Magill forceps for clinically trained responders — remains the evidence-based approach. These devices should not replace 999 activation or standard FBAO techniques.

8 — UK POLICY & FOAMED

UK INFORMING PRACTICE

Air Ambulances UK: “Critical Moments, Life-Saving Infrastructure” — 24/7 Hospital Helipad Report

Air Ambulances UK — June/July 2026 — airambulancesuk.org

Air Ambulances UK has published a major policy report calling for mandated 24/7 on-site hospital helipad access, planning policy reform, and CAA regulatory alignment. The report identifies helipad access failure as a direct cause of operational delays in HEMS missions and proposes a National Emergency Hospital Helipad Infrastructure Contingency Fund.

Action: Clinical directors and operational leads should read this report. Loss of helipad access at receiving hospitals is a patient safety issue — understand your service's landing contingencies. If your HEMS service has encountered helipad access failure, your incident data directly supports AAUK's advocacy. Share this with your air ambulance clinical director and regional trauma network.

CORE REVISION — ISSUE 8 — DIPIMC / FIMC

Tension Pneumothorax: Prehospital Decompression Techniques and Decision-Making

Pre-Hospital Emergency Medicine — UK Edition — emevidence.org

Exam goal: Be able to describe the physiology of tension pneumothorax causing obstructive shock and arrest; compare needle decompression vs finger thoracostomy in the PHEM context; outline step-by-step finger thoracostomy technique; justify bilateral decompression in traumatic cardiac arrest; and manage needle decompression failure.

1. RECOGNITION

2. INDICATIONS FOR PREHOSPITAL DECOMPRESSION

Traumatic cardiac arrest (both sides, before rhythm reassessment); haemodynamic compromise with unilateral chest signs; respiratory deterioration in intubated trauma patient; penetrating thoracic trauma with haemodynamic compromise; clinical diagnosis in any physiologically deteriorating trauma patient with thoracic injury.

3. TECHNIQUE COMPARISON

4. BILATERAL APPROACH IN TRAUMATIC CARDIAC ARREST

RCUK guidance and most UK HEMS protocols require bilateral thoracostomy in traumatic cardiac arrest regardless of clinical asymmetry. Both a tension pneumothorax and haemothorax may be present simultaneously on the same or contralateral side. Complete bilateral decompression before reassessing cardiac rhythm. Do not pause resuscitation to reassess after the first side alone.

5. MANAGING NDC FAILURE

DipIMC/FIMC Exam Focus: (1) Describe the haemodynamic mechanism of tension pneumothorax causing obstructive arrest. (2) Compare NDC vs finger thoracostomy: indications, sites, techniques, and failure management in the PHEM context. (3) Justify bilateral thoracostomy in all traumatic cardiac arrests. (4) Describe the step-by-step technique of finger thoracostomy at 4th/5th ICS AAL. (5) Explain why EtCO2 fall and rising airway pressure in a post-RSI trauma patient mandates immediate decompression.

PHEM Evidence Rundown — emevidence.org

DIPIMC / FIMC

10 — ACTION POINTS SUMMARY