Major Trauma Evidence Rundown — Issue 1 (earlier version, 29 June)

ISSUE 1 — JULY 2026

Major Trauma Evidence Rundown

Surgery & Critical Care — UK Edition

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

VICTORY (JAMA, n=238): High-dose IV Vitamin C in severe burns — HARMFUL. 28-day mortality 15.0% vs 7.6% (RR 1.96, p=0.001). Trial stopped early. Remove from burn protocols immediately. | BOA BOAST: Arterial Injuries — NCEPOD 1, 1-hour revascularisation target. Hospitals without 24/7 ortho-vascular pathway now non-compliant.

CHANGE THIS MONTH Stop high-dose IV vitamin C in severe burns (VICTORY) | CHANGE TONIGHT BOA BOAST

arterial injuries new standard | CHANGE TONIGHT TST/MITT now mandatory — audit your MCI training |

CHANGE TONIGHT UK-REBOA: do not use routinely (86.9% posterior probability of harm)

BOTTOM LINE UP FRONT — ACT ON THE EVIDENCE

ACT ON THIS NOW

CHANGE THIS MONTH VICTORY (JAMA): High-dose

IV Vitamin C in severe burns HARMFUL. 28-day mortality 15.0% vs 7.6% (RR 1.96, p=0.001). Primary composite 40.8% vs 29.7% (RR 1.28). Trial stopped for harm. Remove from all burn protocols now.

CHANGE TONIGHT BOA BOAST — Arterial Injuries

(June 2026): Revascularisation = NCEPOD 1 with 1-hour target. Temporary vascular shunting mandatory. Fasciotomy as default post-revascularisation. Two-consultant sign-off for amputation. Co-endorsed BAPRAS + Vascular Society.

CHANGE TONIGHT TST/MITT mandatory (NHS, since

June 2024): If your hospital has not adopted TST and MITT, it is now non-compliant with NHS England requirements. Audit your MCI team training and equipment now.

CHANGE TONIGHT UK-REBOA (NIHR RCT): 90-day mortality 54% REBOA vs 42% standard care. Posterior

probability of harm 86.9%. Do NOT use REBOA routinely in blunt trauma. Reserve for highly selected cases with surgical capability immediately available.

KNOW FOR YOUR NEXT TRAUMA CALL

GUIDELINE UPDATE NICE NG24 (Feb 2026): TXA now

for ANY procedure with bleeding risk. Previous blood loss estimation requirement removed. Update your anaesthetic trauma protocols.

GUIDELINE UPDATE NHSBT EPRR 2026: Plan for 3 units RBC per MITT Priority 1 casualty in your hospital

MCI plan. MITT and TST formally integrated. Cyberattack/IT-failure scenarios now mandatory in plans.

INFORMING PRACTICE SWiFT (NEJM, UK HEMS,

n=616): Prehospital whole blood NOT superior to components (48.7% vs 47.7% composite, NS). Component therapy remains UK standard per NHSBT.

INFORMING PRACTICE CRYOSTAT-2 (JAMA Surg): Early empirical high-dose cryoprecipitate NULL on 28-

day mortality (26.1% vs 25.3%, OR 0.96, NS). Use viscoelastic-guided protocol — give when fibrinogen <1.5g/L, not empirically.

INFORMING PRACTICE NAO Major Trauma Report:

56% survival improvement since MTCs. Still 2,300 preventable deaths/year. Significant variation in outcomes across MTCs.

GUIDELINE REVIEW JESIP Joint Decision Model

Review: First formal review since 2005. Trauma centres should consider submitting evidence. Summer 2026 deadline.

WHAT'S INSIDE THIS ISSUE

• Section 1 — Key Trials & Research: VICTORY (burns), UK-REBOA, SWiFT, CRYOSTAT-2
• Section 2 — Guidelines & UK Updates: BOA BOAST arterial injuries, NICE NG24, NHSBT EPRR 2026, TST/MITT, JESIP
• Section 3 — Haemorrhage & Resuscitation: Pelvic fracture haemorrhage (AE vs PPP), NAO Major Trauma Report
• Section 6 — Mass Casualty & Major Incident: TST/MITT compliance audit, JESIP JDM, ML triage tools
• Section 7 — Quick Hits: Enteral Mg in ICU, SHOT Newsletter, NAO on TARN
• Core Revision — Damage Control Resuscitation: Lethal triad, permissive hypotension, haemostatic resuscitation, VHA, DCO endpoints
• Section 8 — Action Points: 8 immediate clinical actions
• Trials to Watch: ICS SOA26, ROTEM-guided MHP UK RCT, AIRR Trial, EVIS UK, PROPPR-2

SECTION 1 — KEY TRIALS & RESEARCH

Stoppe C, Hill A, Cancio LC et al; VICTORY Study Team. JAMA. Published online 10 June 2026. doi:10.1001/jama.2026.10616. PMID: 42267875

VICTORY — High-Dose IV Vitamin C in Severe Burns: HARMFUL. Trial Stopped Early.

CHANGE THIS MONTH RCT PHASE 3 FRCS (T&O) FRCS (GEN) FINAL FRCA

Design: International, multicentre, parallel-group, randomised, double-blind, placebo-controlled Phase 3 trial. 24 burn centres across 3 continents. Mean TBSA 37%. Planned n=666; stopped early (n=238) after first interim analysis crossed prespecified futility/harm threshold.

Population: Adults with severe burn injury (≥20% TBSA). n=238 randomised (120 vitamin C, 118 placebo).

Intervention: IV Vitamin C 50mg/kg every 6 hours for 96 hours (200mg/kg/day total) vs matched placebo.

Primary outcome: Composite of 28-day mortality AND persistent organ dysfunction (mechanical ventilation, KRT, or vasopressor/inotrope dependence at day 28).

• 15.0% vs 7.6% 28-DAY MORTALITY (RR 1.96, P=0.001)
• 40.8% vs 29.7% PRIMARY COMPOSITE (RR 1.28)
• 23.3% vs 16.1% HOSPITAL MORTALITY (RR 1.44, P=0.03)
• n=238 EARLY STOP (PLANNED 666)
• Imprecise EARLY STOPPING — WIDER CIS

Key finding: 28-day mortality nearly doubled with high-dose IV vitamin C (RR 1.96, 95%CI 1.32–2.90; p=0.001). Primary composite crossed prespecified harm threshold. Organ dysfunction-free days: 12.5 (IQR 0–27.5) vitamin C vs 19.5 (IQR 0–28.0) placebo. This is the first Phase 3 RCT of this intervention. The signal is unambiguous.

Critical appraisal: Stopped early after first interim analysis — estimates of effect are imprecise (wider CIs) and may overestimate harm magnitude. However, the direction of harm is consistent across all endpoints: 28-day mortality, hospital mortality (RR 1.44, p=0.03), and composite outcome. 6-month mortality HR 1.57 (95%CI 0.89–2.75; p=0.12) is directionally unfavourable but imprecise. Time to discharge alive not improved (adj HR 0.85, p=0.31). The JAMA editorial (Greenhalgh) states: "high-dose intravenous vitamin C should not be incorporated into protocols for acute burn care." Presented at CCR26, Belfast, 11 June 2026.

Why it matters: High-dose IV Vitamin C gained traction in burn units following Tanaka et al (Burns, 2000) — a small observational study suggesting reduced fluid requirements. Some UK burns centres incorporated it on the basis of biological plausibility alone. VICTORY is the definitive Phase 3 RCT. The lesson mirrors MIDAS (magnesium in TBI), CRASH-2 TBI subgroup, and DESTINY (prophylactic hemicraniectomy): mechanism does not equal clinical benefit. The physiological rationale for antioxidant supplementation in burns was compelling; the clinical trial result is unambiguous harm.

Tell your department: If your burns protocol includes high-dose IV vitamin C — remove it tonight. Standard Parkland/modified Brooke resuscitation remains the evidence base. Ensure referral to a regional burns centre follows NHSBT/NBSCN criteria (≥10% TBSA adult, ≥5% TBSA child, full thickness, specialist sites, inhalation injury, chemical/electrical burns). This trial was presented simultaneously at CCR26 (Belfast) and published in JAMA — it will be on every burns unit radar within days.

UK-REBOA Trial Group (NIHR-funded). JAMA. 2024. PMID: 38103283. NIHR HTA Report 2024. Ongoing influence on 2025–2026 practice.

UK-REBOA — Bayesian RCT Confirms Higher Mortality with Routine Use in Blunt Trauma

CHANGE TONIGHT RCT BAYESIAN FRCS (T&O) FRCS (GEN) FINAL FRCA

Design: Bayesian, adaptive, parallel-group RCT. UK Major Trauma Centres with REBOA capability. n=90 enrolled (haemodynamically unstable adults, SBP <90 after 2L or PRBC, suspected subdiaphragmatic haemorrhage).

Primary outcome: 90-day mortality.

• 54% vs 42% 90-DAY MORTALITY REBOA VS STANDARD
• 86.9% POSTERIOR PROBABILITY OF HARM
• n=90 ONLY RCT ON REBOA TO DATE
• OR 1.58 95% CRI 0.72–3.52 (BAYESIAN)

Key finding: 90-day mortality 54% with REBOA + standard care vs 42% standard care alone. OR 1.58 (95% credible interval 0.72–3.52). Posterior probability that REBOA is harmful: 86.9%. Death from haemorrhage more common in the REBOA group. EAST 2025: conditional recommendation AGAINST REBOA for general blunt trauma and haemodynamically unstable pelvic fractures.

Critical appraisal: Small trial (n=90); Bayesian analysis does not generate a conventional p-value — the posterior probability of harm (86.9%) is the relevant output. The wide credible interval reflects uncertainty, but the direction is consistent. This is the ONLY RCT of REBOA in any population. All other evidence is observational and subject to significant confounding. The trial was powered for a Bayesian adaptive design — the result met its own pre-specified threshold for futility/harm.

Why it matters: REBOA was introduced with considerable enthusiasm at UK MTCs. The UK-REBOA trial result does not mean REBOA is never appropriate — specific cases (Zone 3 REBOA for pelvic exsanguination as a bridge to definitive haemorrhage control with immediate IR/surgical capability, failed resuscitative thoracotomy) remain within local protocol. However, the default must now be NOT to deploy REBOA without senior leadership oversight and immediate surgical capability. This is a significant change in default practice for many UK MTCs.

Ker K, Roberts I, Shakur-Still H et al; SWiFT Trial Collaborators. NEJM. 2026. n=616. 10 UK HEMS services.

SWiFT — Prehospital Whole Blood vs Component Therapy: Null Result (UK HEMS)

INFORMING PRACTICE

RCT

FINAL FRCA

UK HEMS

Design: RCT across 10 UK HEMS services. Prehospital whole blood vs standard component therapy (PRBC + FFP 1:1).

Primary composite: 24-hour mortality OR massive transfusion requirement.

• 48.7% vs 47.7% COMPOSITE PRIMARY (NS, DIFF 1.0PP)
• n=616 ADEQUATELY POWERED
• 10 services UK HEMS (ALL MAJOR)
• Null COST-EFFECTIVENESS PENDING

Critical appraisal: Mortality at all timepoints was similar between groups. SAEs slightly fewer in whole blood group (31 vs 37; NS). NHSBT statement: component therapy (PRBC + FFP 1:1 ratio) remains the UK standard. Cost-effectiveness analysis ongoing. The null result does not mean whole blood is inferior — it means equivalence in this population with this delivery model. Whole blood may still be preferred operationally for some services (weight, storage simplicity in austere environments, major incident single-unit logistics).

Why it matters — UK practice: This was the definitive UK trial. The NHSBT supply chain for component therapy is well established. UK practice: maintain component therapy unless your HEMS service has a clinical governance-approved reason to switch. This result does not justify whole blood adoption for NHS HEMS without a specific operational rationale reviewed by the service's clinical governance board.

Curry N, Foley C, Wong H et al; CRYOSTAT-2 Collaborators. JAMA Surgery. 2023 Nov. PMID: 37819664. n=517, 13 UK MTCs.

CRYOSTAT-2 — Empirical High-Dose Cryoprecipitate in Traumatic Haemorrhage: Null on Mortality

INFORMING PRACTICE RCT FRCS (GEN) FINAL FRCA 13 UK MTCS

Design: RCT across 13 UK Major Trauma Centres. Standard care vs early empirical high-dose cryoprecipitate in traumatic haemorrhage. n=517.

Primary outcome: 28-day all-cause mortality.

• OR 0.96
• 26.1% vs 25.3%
• n=517 13 UK MTCS
• Null — empirical

28-DAY MORTALITY (NS, P=0.74)

MORTALITY (STANDARD VS EARLY CRYO)

NOT A REFUTATION OF GUIDED USE

Why it matters — UK practice: Cryoprecipitate remains a core component of UK Major Haemorrhage Protocols. CRYOSTAT-2 argues against EMPIRICAL (fixed-dose, upfront) administration before fibrinogen levels are known — not against cryoprecipitate as a haemostatic agent. UK practice: give cryoprecipitate when fibrinogen <1.5g/L (ROTEM: FIBTEM A5 <10mm; TEG: functional fibrinogen <150mg/dL) or clinically when VHA is unavailable and fibrinogen consumption is suspected. Do not front-load it at MHP activation. No difference in thrombotic events or safety signals.

SECTION 2 — GUIDELINES & UK UPDATES

British Orthopaedic Association, BAPRAS, Vascular Society of Great Britain and Ireland. Published June 2026. boa.ac.uk

BOA BOAST — Diagnosis and Management of Arterial Injuries Associated with Musculoskeletal Trauma (June 2026)

CHANGE TONIGHT FRCS (T&O) FRCS (GEN)

New co-endorsed standard from BOA, BAPRAS, and the Vascular Society of Great Britain and Ireland. This is a mandatory standard — hospitals without a compliant pathway are explicitly non-compliant with BOA.

Why it matters: Vascular injuries complicating fractures (distal femur/proximal tibia, supracondylar humerus in children, knee dislocation with popliteal injury) carry amputation rates of 5–20% when revascularisation is delayed. Concurrent CT angiography — not sequential — is the highest-impact practical change for most UK MTCs. The previous practice of obtaining whole-body CT and then arranging a separate CT angiography slot costs time that directly affects limb salvage.

Tell your department: Review your trust's pathway for suspected arterial injury with fracture tonight. Is 24/7 vascular surgery available on-site or immediately on-call to your MTC? Is CT angiography concurrent (not sequential) with whole-body CT? Is temporary vascular shunting listed in your trauma theatre capability? Is the two-consultant amputation sign-off requirement formalised in your SOP?

NICE NG24. Updated February 2026. nice.org.uk/guidance/ng24

NICE NG24 — TXA for Any Surgical Procedure with Bleeding Risk: Simplified Indication (Feb 2026)

GUIDELINE UPDATE FINAL FRCA FRCS (GEN) FRCS (T&O)

Change from previous NG24: The previous wording required clinicians to estimate expected blood loss before prescribing TXA perioperatively. This requirement has been removed.

Updated indication: TXA is now indicated for any surgical procedure with a bleeding risk — no blood loss estimation required prior to prescribing.

UK trauma context: In operative trauma, this reinforces TXA as a near-universal perioperative adjunct. The 3-hour window for maximum benefit in traumatic haemorrhage (CRASH-2) still applies in the ED/pre-hospital setting. This update primarily affects intraoperative and planned surgical use. Trauma anaesthetists should ensure NG24 Feb 2026 is reflected in their trauma laparotomy, orthopaedic trauma, and vascular surgery anaesthetic protocols. After 3 hours from injury: TXA may increase mortality in CRASH-2 data — the 3-hour window remains critical for trauma.

National Blood Transfusion Committee / NHSBT. Major EPRR Guidance Revision. May 2026.

NHSBT EPRR Guidance 2026 — Major Haemorrhage, MCI Blood Planning, IT Resilience

GUIDELINE UPDATE FINAL FRCA

Key changes in the 2026 revision of NHSBT EPRR guidance for hospital transfusion teams:

• MCI blood stock planning standard: 3 units RBC per MITT Priority 1 casualty. Update your hospital MCI plan blood stock figures accordingly.
• Cyberattack and IT-failure scenarios: Now mandatory inclusions in hospital EPRR blood stock contingency plans — reflecting lessons from the 2024 London NHS cyberattack.
• IOCS (intraoperative cell salvage): Recommended for traumatic haemorrhage in theatres.
• MITT and TST formally integrated into transfusion team EPRR protocols.
• Transfusion staff deployment: Authorised to deploy forward into ED/theatres during MCI response.

Tell your department: Your transfusion service lead should have reviewed this document. Does your MCI plan specify 3 RBC units per MITT Priority 1 casualty? Does your IT contingency plan include manual crossmatch protocols and fallback blood stock procedures for EPR/LIMS failure? Has your trust formally included cyberattack scenarios in its EPRR blood stock planning?

NHS England. Full implementation deadline: 30 June 2024. england.nhs.uk

NHS England TST/MITT — Mandatory Across All NHS Organisations Since 30 June 2024

CHANGE TONIGHT FRCS (GEN) FINAL FRCA

TST (Triage Sieve Tool): Replaces the previous Triage Sieve. Focuses on catastrophic haemorrhage control, airway, ambulatory status, and vital signs. Rapid 6-step algorithm.

MITT (Major Incident Triage Tool): Single validated tool for adults AND children — previously required two different triage tools. Validated on TARN data.

Status: Mandatory across ALL NHS organisations since 30 June 2024. If your hospital is still using old MPTT-24 or SIEVE/SORT as primary tools, it is now non-compliant.

Compliance check — do this tonight: Contact your EPRR lead. When was your last MCI exercise using TST? Are ALL trauma team members (not just EPRR leads) trained in TST/MITT? Has MITT replaced previous paediatric triage tools in trust policy? Does your EPRR plan reference 3 units RBC per MITT Priority 1 (NHSBT 2026)? Both tools mandate catastrophic haemorrhage control (tourniquet, wound packing) as an immediate life-saving intervention — training must reflect this.

JESIP. Announced 8 June 2026.

JESIP Joint Decision Model Review — Call for Evidence (Summer 2026)

INFORMING PRACTICE

First formal review of the Joint Decision Model (JDM) and METHANE since JESIP was founded in 2005. The JDM governs how police, fire, ambulance, and hospital services respond together at major incidents. If doctrine changes, trauma activation criteria and hospital receiving protocols may change accordingly.

If your organisation has direct experience of multi-agency major incident response — particularly UK MTCs with MCI activations — consider submitting evidence to the review via jesip.org.uk. Summer 2026 deadline. This is a rare opportunity to directly influence national MCI doctrine from a hospital trauma perspective.

SECTION 3 — HAEMORRHAGE & RESUSCITATION

Costantini TW et al. JAMA Surgery. 2023; synthesis of SR/MA across 8 studies, n=2040 haemodynamically unstable pelvic fractures.

Pelvic Fracture Haemorrhage: Angioembolisation vs Preperitoneal Packing — Current Evidence

INFORMING PRACTICE

SR/MA

FRCS (GEN)

FRCS (T&O)

Design: SR/MA across 8 studies, 2,040 patients with haemodynamically unstable pelvic fractures.

• OR 0.62 AE MORTALITY REDUCTION (P<0.001) — ONLY INDEPENDENT PREDICTOR
• OR 1.39 PPP COMPLICATIONS INCREASE (P=0.01)
• 27% PPP FAILURE RATE REQUIRING SUBSEQUENT AE
• n=2,040 8 STUDIES, SR/MA

Key finding: Only angioembolisation (AE) was independently associated with mortality reduction (OR 0.62, 95%CI 0.47–0.82). Preperitoneal packing (PPP) reduces 24-hour transfusion requirement but does not reduce mortality independently. PPP was associated with increased complications (OR 1.39). 27% of PPP patients require subsequent AE — PPP is not a standalone intervention.

UK context: WSES guideline recommends PPP should be considered as a bridge to AE, not an alternative. In UK MTCs with 24/7 interventional radiology: AE should be the default first intervention in arterially-driven pelvic haemorrhage (contrast blush on CT). PPP is preferable when theatre is more rapidly available than IR, or as definitive haemorrhage control when AE fails or is unavailable. The key decision is institutional capability and transport time — sequence should be driven by what achieves definitive haemorrhage control fastest in your system.

National Audit Office. Major trauma care in England. November 2025. nao.org.uk

NAO Major Trauma Care in England — 56% Survival Improvement; 2,300 Preventable Deaths/Year Remain

GUIDELINE UPDATE ENGLAND NHS

Key findings from the November 2025 National Audit Office report on major trauma care in England:

• Major trauma survival improved 56% since MTC network establishment (2012). Mortality from 9.6% (2012) to under 6% (2024/25).
• Despite this improvement: still 2,300 preventable trauma deaths per year in England.
• Significant outcome variation between MTCs — best vs worst performing MTCs differ by >3 percentage points in risk-adjusted survival.

Trauma Units (TUs) consistently not meeting standards for time-critical interventions and in-hospital mortality.

• Gaps in 24/7 orthopaedic surgery, neurosurgery, and interventional radiology in many MTCs.
• NAO recommendation: NHS England should collect and publish performance data per MTC/TU and make TARN participation mandatory (currently voluntary).

UK impact: If NHS England implements mandatory TARN participation — as the NAO recommends — every MTC and TU in England will have TARN data scrutinised at system level. Ensure your unit is actively contributing data. Non-participation will become increasingly conspicuous and may have contractual consequences. The 2,300 preventable deaths figure is the benchmark against which every MTC must now position itself.

SECTION 6 — MASS CASUALTY & MAJOR INCIDENT

NHS England. Implementation deadline 30 June 2024. NHS England EPRR / NHSBT EPRR May 2026.

NHS TST/MITT — Are You Actually Compliant? A Direct Audit Prompt.

CHANGE TONIGHT

TST/MITT has been mandatory for over a year. That does not mean your trust is compliant — it means the deadline has passed. Here is what to check before your next trauma call:

If you cannot answer yes to all of these, your department has work to do:

• Last MCI exercise: When did your last major incident exercise actually use TST and MITT triage — not the old Sieve/Sort or MPTT-24? If the answer is "we're not sure," that is your answer.
• Training breadth: Are ALL trauma team members trained in TST, or just the EPRR leads and major incident officers? TST is a bedside skill — every surgeon, anaesthetist, and senior nurse in the trauma team needs to know the 6-step algorithm.
• Paediatric: Has MITT formally replaced previous paediatric triage tools (including MPTT-24 and JumpSTART) in your trust's MCI policy document? MITT covers adults and children — a single tool. If your policy still references MPTT-24 as the paediatric tool, it needs updating.
• Blood stock planning: Does your EPRR plan specify 3 units RBC per MITT Priority 1 casualty? This is the 2026 NHSBT standard. Plans based on older MPTT figures are now under-resourced.
• Catastrophic haemorrhage control: TST mandates tourniquet/wound packing as an immediate life-saving intervention in the field and at triage. Does your hospital triage area have tourniquets and haemostatic dressings at point-of-care? Do your trauma team members train in their application as part of MCI prep?

This is not an academic exercise. The 2017 Manchester Arena and 2019 London Bridge incidents both identified triage and blood stock planning as areas for improvement. TST and MITT were developed specifically in response to those lessons. They are better tools. Use them.

JESIP. Joint Decision Model and METHANE review announced 8 June 2026. jesip.org.uk

JESIP Joint Decision Model Review — Why It Matters to Trauma Teams

INFORMING PRACTICE

The JESIP Joint Decision Model (JDM) is the framework governing multi-agency decision-making at major incidents — how police, fire, ambulance, and hospital services co-ordinate. METHANE (Major Incident, Exact Location, Type, Hazards, Access, Number of casualties, Emergency services) is the standard information-sharing format. This is the first formal review since 2005.

For trauma teams, a JDM revision matters because: if doctrine changes, so do trauma activation criteria, receiving protocols, and the interoperability standards that determine how casualties reach your department and in what condition. Changes to METHANE reporting formats change the information your resus team receives in the pre-alert call. Changes to inter-agency decision frameworks affect how long casualties remain on scene.

If your MTC has multi-agency major incident experience — particularly from recent events — submitting structured evidence to the JESIP review is a direct route to influencing national doctrine. Contact via jesip.org.uk. Summer 2026 deadline.

Van Dyke C et al. Emergency Medicine Journal. 2024;41(3):176. UK, TARN data.

ML-Based MCI Triage Tools — Superior to All 10 Existing International Tools in TARN Population (EMJ 2024)

GUIDELINE UPDATE (RESEARCH STAGE) TARN DATA

Design: UK TARN database study. ML-based primary and secondary triage tools compared against all 10 existing international triage tools for predicting need for time-critical intervention (Priority 1 status).

Key finding: ML-based tools outperformed all 10 existing international triage tools in sensitivity and overtriage rates in the TARN population. Superior to MPTT-24 on all comparative metrics.

Status and context: This is a research-stage tool — not yet in clinical use and not currently a standard. TST and MITT remain the mandated tools. However, the TARN database provides a uniquely representative UK major trauma population for algorithm development. ML-based triage is likely to feature in the next generation of UK MCI tools. The JESIP JDM review (above) is the appropriate forum for this evidence to enter national doctrine. Track for future implementation.

SECTION 7 — QUICK HITS

Quick Hits — July 2026

Also Notable This Month

• Enteral vs IV Magnesium in ICU (Crit Care Med 2026, McMaster 6/7): Non-inferiority RCT. Enteral magnesium non-inferior to IV for ICU patients with hypomagnesaemia. Burns and trauma ICU patients: enteral route is reasonable when the gut is functioning, reducing cannula burden and IV line requirements. Relevant to post-damage control ICU phase.
• SHOT Newsletter + SHOTScript (June 2026): New transfusion IT safety standards published by Serious Hazards of Transfusion (SHOT). Review with your transfusion laboratory regarding EPR/LIMS resilience. SHOT data demonstrates that transfusion-related errors are highest during IT system outages and MCI events — directly relevant to the NHSBT EPRR 2026 IT contingency requirements above.
• NAO on TARN — Voluntary to Mandatory: TARN participation is currently voluntary. NAO November 2025 report explicitly recommends mandatory participation for all MTCs and TUs. If this recommendation is adopted by NHS England, expect formal mandation by 2027. Ensure your unit is actively contributing data and your data quality lead is engaged. Non-participation will be increasingly conspicuous as NHS England moves toward published per-MTC performance data.

CORE REVISION — DAMAGE CONTROL RESUSCITATION

Core Revision — FRCS (T&O) | FRCS (Gen) | Final FRCA

Damage Control Resuscitation: Principles and Endpoints

FRCS (T&O)

FRCS (GEN)

FINAL FRCA

1. WHAT IS DAMAGE CONTROL RESUSCITATION (DCR)?

DCR is a systematic approach to traumatic haemorrhage combining permissive hypotension, haemostatic resuscitation, early surgical haemorrhage control, and active reversal of the lethal triad. It is a bridge to definitive surgical haemorrhage control — not a definitive treatment. The endpoint of DCR is an operating table, not a VBG.

DCR replaced the prior paradigm of aggressive crystalloid resuscitation to normotension, which is now understood to worsen coagulopathy, dilute clotting factors, and accelerate hypothermia and acidosis.

2. THE LETHAL TRIAD

Each element of the triad potentiates the others. Once established, the triad is self-reinforcing and rapidly fatal. Prevention is more effective than correction — DCR is designed to prevent the triad from establishing, not to treat it after the fact.

3. PERMISSIVE HYPOTENSION

Target: MAP 50–65 (SBP 80–90 mmHg) in penetrating trauma until surgical haemorrhage control is achieved.

Evidence: CRASH and CRASH-2 observational data; experimental models. Aggressive crystalloid resuscitation to normotension worsens all three arms of the lethal triad, dilutes clotting factors, and physically disrupts forming clots. In penetrating trauma, the pre-hospital permissive hypotension target is well established. In blunt trauma with suspected TBI: balance is critical — default to MAP ≥80 until imaging excludes significant intracranial pathology.

After surgical haemorrhage control: target MAP ≥65 — return to standard resuscitation endpoints.

4. HAEMOSTATIC RESUSCITATION — THE 1:1:1 PARADIGM

PROPPR RCT (JAMA 2015, n=680): FFP:PLT:RBC = 1:1:1 vs 1:1:2. Improved 24-hour survival (84.8% vs 77.4%, p=0.03). No difference at 30 days. The 24-hour survival benefit reflects the haemostasis advantage of 1:1:1 during the acute resuscitation phase.

UK MHP (Major Haemorrhage Protocol):

• MHP-A pack (most UK MTCs): 4 units RBC + 4 units FFP. Activation criteria: SBP <90 + suspected haemorrhage; Hb <10g/dL + ongoing bleeding; or clinical judgement by trauma team leader.
• Cryoprecipitate: Give when fibrinogen <1.5g/L (ROTEM FIBTEM A5 <10mm; TEG functional fibrinogen <150mg/dL). Do not give empirically at MHP activation (CRYOSTAT-2).
• TXA: Give within 3 hours of injury (CRASH-2: 1g over 10 min IV, then 1g over 8h). After 3 hours from injury: may increase mortality — do not give.
• Calcium: Replace early and proactively. Citrate in blood products chelates ionised calcium. Target iCa >1.1 mmol/L. Give CaCl2 10% 5-10ml IV per 4 units transfused, or as guided by iCa measurement.

Avoid: Normal saline large volumes (hyperchloraemic acidosis), crystalloid boluses >250ml before blood products available.

5. VISCOELASTIC HAEMOSTATIC ASSAYS — ROTEM AND TEG

VHA provides real-time, whole-blood assessment of coagulation and fibrinolysis — enabling targeted (goal-directed) product administration rather than ratio-based empirical resuscitation. Both ROTEM and TEG measure the same physiological processes with different terminology.

UK context: VHA (ROTEM or TEG) is standard at most UK MTCs. Goal-directed VHA-guided resuscitation reduces unnecessary blood product administration and targets specific deficits. The UK RCT of ROTEM-guided MHP vs ratio-based resuscitation results are expected in 2026 — direct practice relevance when published.

6. DAMAGE CONTROL SURGERY — WHEN TO OPERATE AND WHEN TO RETURN

Indications for damage control surgery (DCS) rather than definitive surgery: haemodynamic instability, anticipated prolonged operative time, established lethal triad, multiple injuries requiring sequential operations, contamination control priority.

DCS principles: haemorrhage control (packing, vascular control) → contamination control (bowel clamping, peritoneal washout) → temporary abdominal closure (Bogotá bag, mesh, VAC). Leave definitive reconstruction for the second-look operation.

ICU phase: Correct the lethal triad BEFORE the second-look operation. Returning to theatre in established coagulopathy or hypothermia negates the benefit of DCO. The ICU team's role is physiological optimisation — the surgeon's role is to communicate clear endpoints for return.

7. UK-SPECIFIC REFERENCE POINTS

• NHS MHP-A and MHP-B packs: Standard issue at most UK MTCs. MHP-A = 4u RBC + 4u FFP. MHP-B = additional platelets + further products per local protocol. Activation thresholds vary by trust — know your local criteria.
• NHSBT Major Haemorrhage Protocol guidance (2026 revision): Includes EPRR integration, IOCS recommendation for trauma theatre, and updated MCI blood stock planning (3u RBC per MITT Priority 1).
• TARN data (UK MTCs): Mean ISS in UK MTCs approximately 29. 24-hour mortality in UK MTCs approximately 4.8%. These are benchmarks for your institution's mortality review and TARN submission.
• Calcium replacement: Explicitly recommended in most UK MHP protocols — ensure your resus team give calcium early and repeat dosing is not missed during rapid transfusion.

FRCS exam point: DCR is a bridge to surgical haemorrhage control — not a definitive treatment. The endpoint of DCR is an operating table, not a VBG. Examiners frequently probe whether candidates understand that permissive hypotension without a concurrent plan for definitive haemorrhage control is not DCR — it is inadequate resuscitation. Know your lethal triad interventions, know your VHA parameters, and know when to call for damage control surgery vs when to proceed with definitive repair.

SECTION 8 — ACTION POINTS

Clinical actions arising from Issue 1 — July 2026

8 Actions for This Week

1 REMOVE HIGH-DOSE IV VITAMIN C FROM BURNS PROTOCOLS — TONIGHT

VICTORY (JAMA, n=238): 28-day mortality nearly doubled (15.0% vs 7.6%, RR 1.96, p=0.001). Hospital mortality RR 1.44 (p=0.03). Trial stopped early for harm. No clinical scenario exists where high-dose IV vitamin C (200mg/kg/day) should be continued in burn patients. Standard Parkland/modified Brooke resuscitation remains the evidence base. Contact your regional burns network if your unit currently uses this protocol.

2 ADOPT BOA BOAST ARTERIAL INJURY STANDARD — TONIGHT

Review your trust pathway: Does your MTC have a 24/7 ortho-vascular service (or immediate on-call pathway)? Is CT angiography concurrent (not sequential) with whole-body CT? Is temporary vascular shunting in your trauma theatre standard capability? Is the two-consultant sign-off requirement for amputation formalised in your SOP? Co-endorsed by BAPRAS and the Vascular Society — this is now the tripartite standard.

3 AUDIT TST/MITT COMPLIANCE — THIS WEEK

Contact your EPRR lead today. Confirm the date of your last MCI exercise using TST triage. Confirm that ALL trauma team members (not just EPRR leads) have received TST/MITT training. Update blood stock planning to 3 units RBC per MITT Priority 1 casualty (NHSBT 2026). If your MCI plan still references MPTT-24 or old Sieve/Sort, update it now.

4 STOP ROUTINE REBOA IN BLUNT TRAUMA

UK-REBOA confirms 86.9% posterior probability of harm in this population. Restrict REBOA to cases where surgical capability is immediately available, senior consultant leadership is present, and there is a specific haemodynamic indication per local protocol. The default for haemodynamically unstable blunt trauma is NOT REBOA — it is rapid transfer to definitive haemorrhage control (IR for pelvic AE, resuscitative thoracotomy criteria, immediate DCS).

5 CRYOPRECIPITATE — ONLY WHEN INDICATED BY VHA OR FIBRINOGEN

CRYOSTAT-2 (n=517, 13 UK MTCs) confirms empirical early cryoprecipitate is null on 28-day mortality. Give cryoprecipitate when fibrinogen <1.5g/L (ROTEM FIBTEM A5 <10mm; TEG functional fibrinogen <150mg/dL), or clinically when VHA is unavailable and fibrinogen consumption is suspected. Do not front-load it at MHP activation as a fixed empirical dose.

6 TXA — UPDATED NICE NG24 IN YOUR TRAUMA PROTOCOLS

TXA in operative trauma now indicated for any surgical procedure with a bleeding risk — no blood loss estimation required (NICE NG24, Feb 2026). Ensure this is reflected in your trauma laparotomy, orthopaedic trauma, and vascular surgery anaesthetic protocols. The 3-hour window from injury still applies for traumatic haemorrhage in the ED/pre-hospital setting — this remains unchanged.

7 NHSBT EPRR 2026 — UPDATE YOUR MCI BLOOD PLAN

Standard: 3 RBC units per MITT Priority 1 casualty. If your hospital MCI plan was written to older MPTT figures, it is now under-resourced. Ensure your IT-failure contingency plan includes manual crossmatch protocols, fallback blood stock locations, and emergency O-negative supply arrangements for EPR/LIMS failure scenarios.

8 CONSIDER JESIP CALL FOR EVIDENCE

If your MTC has multi-agency MCI experience — particularly structured experience of joint working with police, fire, and ambulance services — submitting evidence to the JESIP Joint Decision Model review could directly influence national major incident doctrine. First formal review since 2005. Summer 2026 deadline. Contact via jesip.org.uk.

TRIALS TO WATCH

Trial pipeline — trauma-focused, 2026–2027

Upcoming Evidence — What to Watch

IMMINENT — 2026

ICS SOA26 (30 June – 2 July, Birmingham): ANDROMEDA-SHOCK-2 full data expected (relevant to septic shock resuscitation targets in post-trauma ICU phase); BICARICU-2 (bicarbonate in metabolic acidosis — directly relevant to lethal triad acidosis management). Watch for practice-changing data on vasopressor and fluid resuscitation endpoints. ROTEM-guided MHP vs ratio-based resuscitation — UK RCT results expected 2026: Viscoelastic-guided vs fixed-ratio haemostatic resuscitation in UK MTCs. This is the most directly practice-relevant pending trauma trial for UK teams. Results will inform whether VHA-guided protocols should replace MHP-A/B ratio-based activation. AIRR Trial (UK): Ambulance ITU Resuscitation — prehospital advanced interventions for traumatic cardiac arrest. UK-specific prehospital trauma data relevant to MTC pre-arrival optimisation.

2026–2027

EVIS UK Trial (NCT05179499): Early vasopressors in septic shock — relevant to post-damage control ICU phase haemodynamic management and the interface between surgical and critical care teams. NICE NG232 TBI surveillance review: Traumatic brain injury guideline update expected 2026/2027. Watch for updates to MAP and ICP targets, decompressive craniectomy thresholds, and prehospital TBI management — all affect how the trauma team manages the combined haemorrhage + TBI patient. TARN mandatory participation: If NAO recommendations are adopted, expect formal mandation for all MTCs and TUs in England by 2027. Prepare your data quality processes now.

LONGER HORIZON

CoMiTED: Conservative management vs immediate chest drain insertion in traumatic pneumothorax. Potentially practice-changing for both ED and trauma surgery management of traumatic pneumothorax — watch for recruitment completion. PROPPR-2: Anticipated update to the PROPPR haemostatic resuscitation ratio evidence. Will address 30-day outcomes, optimal FFP:PLT:RBC ratios in specific trauma subgroups, and whether 1:1:1 holds across all trauma mechanisms.

Major Trauma Evidence Rundown — Issue 1, July 2026

Jake Turner | Curated with the assistance of AI (Perplexity). All content editorially reviewed. emevidence.org | Send feedback

Content is intended for qualified healthcare professionals. Clinical decisions must be made by the responsible clinician in the context of individual patient circumstances and local protocols. All guideline references should be verified against source documents. This newsletter is not a substitute for clinical judgement or formal CPD.