Major Trauma Evidence Rundown — Issue 2 (August 2026)

MAJOR TRAUMA EVIDENCE RUNDOWN — ISSUE 2 — AUGUST 2026 — UK EDITION

Major Trauma Evidence Rundown

Monthly evidence for major trauma surgeons, intensivists, HEMS physicians, and trauma network leads — emevidence.org

Jake Turner

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

Lead: SHOT 2025 Annual Report published 10 July 2026 — the single most important UK transfusion safety document of the year. 5,147 reports submitted, 54 transfusion-related deaths, and 83% attributable to preventable errors. TACO remains the leading cause of mortality. Mandatory implementation of Transfusion Safety Standards by all NHS trusts. Mass Casualty: NHS England "Concept of Operations for Managing Mass Casualties" published 21 July 2026 — new national operational framework replacing earlier guidance. JESIP Interoperability Leadership Training launched 27 July 2026. Evidence: Children's MTCs have lower 30-day adolescent trauma mortality than adult MTCs (2.5% vs 4.9%, adjusted OR 2.41) — TARN-based EMJ data with UK implications. Restrictive damage control resuscitation in severe chest trauma: 28-day survival 95% vs 82% (propensity-matched cohort). Biomarkers (base deficit, serum lactate) significantly outperform ATLS vital signs for triage in haemorrhagic shock (BJS SR/MA).

BOTTOM LINE UP FRONT — AUGUST 2026

ACT ON THIS NOW

SAFETY SHOT 2025: 83% of reports preventable. TACO leading cause of death. Implement SHOT Transfusion Safety Standards and haemovigilance system — required across all NHS trusts. Audit against your MTP and blood transfusion safety framework.

MASS CASUALTY NHS England ConOps: New UK mass casualty concept of operations published 21 Jul 2026. Major Trauma Network leads and EPRR leads must read and update local mass casualty plans.

CHANGE THIS MONTH JESIP Leadership: JESIP Interoperability Leadership Training now available (27 Jul 2026). Nominate major incident leads for this training.

CHANGE THIS MONTH Restrictive DCR in chest trauma: Propensity-matched cohort (n=200) — DCR strategy (permissive hypotension, early blood products, restricted crystalloid) vs conventional: 28-day survival 95% vs 82%. Review your MTP activation and fluid strategy for severe chest trauma.

CHANGE THIS MONTH RhD-negative females: ACS-COT consensus (July 2026) — do not withhold RhD+ blood products from RhD-negative females of childbearing potential when clinically indicated. Implement a structured anti-D and antibody follow-up pathway.

KNOW FOR NEXT TIME

INFORMING PRACTICE Children's MTC vs adult: TARN data (n=21,033) — children's MTCs have lower crude and adjusted 30-day adolescent trauma mortality (2.5% vs 4.9%; adj OR 2.41). Adolescents to children's MTCs where possible — consistent with NHS England guidance.

INFORMING PRACTICE Biomarkers in shock: BJS SR/MA — BD and serum lactate significantly outperform ATLS-based vital sign classification for triage and outcome prediction in haemorrhagic shock. BD <-6 or lactate ≥2.5 mmol/L = prioritise for aggressive resuscitation.

INFORMING PRACTICE START triage re-analysis: Higher START red criteria count at ED arrival independently associated with increased 28-day mortality in CRASH-2 data (Sci Rep, 10 Jul). START red: ventilations >30/min, no radial pulse, GCS <2 — each additional criterion compounds risk.

FRCS/FRCA TEG-6s in trauma: Updated guidance on use of thromboelastography 6s for viscoelastic haemostatic assay-guided resuscitation in major trauma. Core knowledge for trauma surgery and trauma anaesthesia.

INFORMING PRACTICE St Emlyn's TTL Tip 18: "Dead Team Leader" — structured approach to managing the sudden incapacitation of the trauma team leader mid-resus. Pre-brief role transfer before the scenario requires it.

INFORMING PRACTICE JESIP ConOps update: JESIP Doctrine v4 call for evidence closed 5 July 2026; updated doctrine expected 2027. Doctrine v3.1 remains current. Review your joint decision log and METHANE/IIMARCH familiarity.

Three this month sit above the rest. The SHOT 2025 Annual Report — published 10 July, five days after the report's 30th anniversary — is the most important haemovigilance document the UK produces. Eighty-three percent of reported incidents are preventable. Fifty-four patients died from transfusion-related causes in 2025. TACO killed more patients than all other causes combined. The data is clear; the implementation is the problem. The NHS England Concept of Operations for Managing Mass Casualties, published 21 July 2026, replaces the previous framework with a much more granular operational structure — this is not optional reading for major trauma network leads, major incident coordinators, or EPRR leads. It is the policy document you will be asked about at your next major incident exercise. And the TARN-based EMJ study comparing children's and adult major trauma centres for adolescent outcomes has a finding that should trouble every trauma network in England that routes adolescents to adult centres by default: the adjusted odds of mortality in adult MTCs is 2.41 times higher than in children's MTCs. For the 14-to-17 age group specifically, the mortality differential is largest and most consistent. These are not abstract statistics — they are a case for urgent pathway review.

WHAT'S INSIDE — ISSUE 2, AUGUST 2026

• LEAD: SHOT 2025 Annual Report — 83% preventable, 54 deaths
• NHS England: Mass Casualty ConOps (21 Jul 2026)
• JESIP: Interoperability Leadership Training launch
• TARN-EMJ: Children's MTC vs adult MTC mortality
• Restrictive DCR: 95% vs 82% 28-day survival (chest trauma)
• ACS-COT: RhD-negative females + type-O whole blood
• BJS SR/MA: BD + lactate outperform ATLS vital signs
• START triage re-analysis (CRASH-2 data, Sci Rep)
• TEG-6s in trauma — updated guidance
• St Emlyn's TTL Tip 18: Dead Team Leader
• JTACS: Trauma centre survival, flail chest anaesthesia
• Quick Hits: ACS spinal injury guidance, WHO burns MCI

• Trials to Watch + Core Revision: Major Haemorrhage Protocol

CHANGE TONIGHT CHANGE THIS MONTH GUIDELINE INFORMING PRACTICE SAFETY FRCS/FRCA

MASS CASUALTY UK SPECIFIC PAEDS TRAUMA

S1 UK Governance & Safety | S2 Mass Casualty & EPRR | S3 Haemorrhage & Resuscitation | S4 Triage & Assessment | S5 FOAMed & NTS | S6 Quick Hits | Core Revision: Major Haemorrhage Protocol

SECTION 1 — UK GOVERNANCE & TRANSFUSION SAFETY

LEAD SAFETY UK SPECIFIC MANDATORY

SHOT 2025 Annual Report Published 10 July 2026 — 5,147 Reports, 54 Deaths, 83% Preventable: Implement Transfusion Safety Standards Now

Serious Hazards of Transfusion (SHOT). Published 10 July 2026. shotuk.org | AABB news 15 July 2026: aabb.org

The 2025 Annual SHOT Report is the definitive document for UK transfusion safety. Published at the SHOT Symposium on 10 July 2026, the report marks 30 years of SHOT haemovigilance and introduces important new elements including a Blood Service Errors chapter, country-level reporting, and a fully HTML-accessible format.

SHOT 2025 — KEY STATISTICS

• 5,147 TOTAL REPORTS
• 54 TRANSFUSION-RELATED DEATHS
• 83% PREVENTABLE ERRORS
• 2.16M COMPONENTS ISSUED IN 2025

Leading cause of death: Transfusion-Associated Circulatory Overload (TACO) and delayed transfusions remain the leading causes of mortality. Risk of transfusion-related death: ~1 in 40,000 blood components issued. Risk of serious harm: ~1 in 13,500 components.

Key patterns: Near misses (33.9% of all reports) provide opportunities to identify system weaknesses. ABO-incompatible transfusions: 8 events (5 red cells, 3 plasma). No confirmed transfusion-transmitted infections in 2025. Contributing factors: staffing, training gaps, IT issues, suboptimal safety culture. New chapter: Blood Service Errors chapter added. SHOT now available in HTML format at shotuk.org.

Action required — all trauma and surgical departments: (1) Download and review the 2025 SHOT Annual Report and share with your transfusion team lead (shotuk.org). (2) Implement the SHOT Transfusion Safety Standards (published July 2025) — these are now expected at CQC inspection. (3) Review your massive transfusion protocol (MTP) against SHOT haemovigilance data — specifically TACO prevention: ensure MTP de-escalation criteria are explicit. (4) Ensure all staff involved in blood transfusion complete SHOT-endorsed training for identification and reporting of transfusion reactions. (5) Register your department with the SHOT database and ensure all reportable incidents are submitted.

Major trauma / MTP specific: The SHOT 2025 data on massive transfusion incidents should be reviewed alongside your trust MTP. Key risk points: sample labelling in the resus bay under time pressure, verbal communication of blood group to blood bank, delay in MTP activation. Conduct a tabletop exercise of your MTP pathway against the SHOT haemovigilance framework — SHOT recommends simulation as a mitigation strategy for repeat error patterns.

CHANGE THIS MONTH PAEDS TRAUMA UK SPECIFIC

Children's MTCs Have Lower 30-Day Adolescent Trauma Mortality vs Adult MTCs — TARN Data (n=21,033): Adjusted OR 2.41 for Adult MTC

Emerg Med J. 2021;38:488–494 (EMJ volume 38, July issue). Using TARN registry data. emj.bmj.com

Study: Retrospective cohort using TARN registry data from English major trauma centres (n=21,033 patients aged 10–24.99 years). Compared 30-day mortality across children's MTCs, adult MTCs, and mixed MTCs. Adjusted for injury severity (ISS), mechanism, physiological parameters, and hospital ID.

• 2.5% CHILDREN'S MTC 30D MORTALITY
• 4.9% ADULT MTC 30D MORTALITY
• 4.4% MIXED MTC 30D MORTALITY
• 2.41x ADJ ODDS ADULT VS CHILDREN'S

Key findings: After adjustment for injury severity and confounders, mortality odds in adult MTCs were 2.41 times higher (95% CI 1.31–4.43, p=0.005) and mixed MTCs 1.85 times higher (95% CI 1.03–3.35, p=0.041) than children's MTCs. The mortality differential was largest in the 14–17.99 age group. The association persisted across subgroup analyses including severe trauma (ISS >15).

UK system implication: This TARN-based evidence should be reviewed by all Major Trauma Networks in England. NHS England guidance recommends that paediatric major trauma patients (typically defined as <16 years) are triaged to a children's MTC — this data reinforces that recommendation and extends it to 17-year-olds. Trauma networks with mixed or adult MTCs as their designated paediatric centre should audit their outcome data against this benchmark. If an adolescent is taken to an adult or mixed MTC, ensure paediatric-specific protocols are immediately accessible: PERT (Paediatric Early Resuscitation for Trauma), paediatric RSI doses, appropriate blood product volumes, and paediatric trauma surgery on-call availability.

SECTION 2 — MASS CASUALTY & EPRR

MASS CASUALTY NHS ENGLAND UK SPECIFIC READ NOW

NHS England: Concept of Operations for Managing Mass Casualties — New National Framework Published 21 July 2026

NHS England. Published 21 July 2026. england.nhs.uk/publication/concept-of-operations-for-managing-mass-casualties

NHS ENGLAND MASS CASUALTY CONOPS — KEY POINTS

What it is: The "Concept of Operations for Managing Mass Casualties" is the national framework for how NHS England plans to respond to a mass casualty incident (MCI). It should be read alongside NHS England's national and regional incident response and mass casualty plans. Published 21 July 2026. Who this applies to: Major trauma network leads, hospital EPRR (Emergency Preparedness, Resilience and Response) leads, major incident co-ordinators, and all clinical staff with mass casualty or major incident roles. Key operational elements (to be verified against full document): Casualty reception, surge capacity activation, patient flow from scene to receiving hospital, NHS EPRR framework triggers, NHS111/999 surge, mortuary and forensic coordination, decontamination pathways for CBRN casualties, communications framework (including METHANE reporting), and NHS Command Cell structure. Replaces earlier guidance and aligns with JESIP Joint Working doctrine. Read in full at: england.nhs.uk

Action for trauma leads: (1) Share this document with your hospital EPRR lead and major incident medical coordinator immediately. (2) Audit your local major incident plan for alignment with the new ConOps. (3) All major trauma network medical leads should read and incorporate into their next major incident tabletop exercise. (4) Update your triage officer training to reflect current JESIP doctrine and this ConOps. (5) Ensure your Surgical Recovery Area (SRA), P3 holding area, and CBRN decontamination protocols are consistent with this framework.

JESIP UK SPECIFIC TRAINING

JESIP: Interoperability Leadership Training Programme Launched — 27 July 2026

JESIP. Published 27 July 2026. jesip.org.uk

JESIP (Joint Emergency Services Interoperability Principles) launched a new Interoperability Leadership Training course on 27 July 2026. This course is specifically designed for senior leaders from police, fire, ambulance, and healthcare services who have command and coordination responsibilities at multi-agency incidents — including major trauma and mass casualty events. The course covers the five JESIP principles (Co-locate, Communicate, Co-ordinate, Jointly understand risk, and Shared situational awareness) at a leadership and strategic decision-making level, building on existing JESIP foundation knowledge.

EPRR relevance: For UK major trauma networks and NHS EPRR leads, JESIP Leadership Training is increasingly expected as a standard for those with Gold/Silver command medical roles. Contact your NHS trust EPRR team or NHS England regional EPRR lead to identify eligibility and register. JESIP Doctrine v4 is currently under development (call for evidence closed 5 July 2026) — those completing leadership training now will be well-positioned when the updated doctrine is published in 2027. Current doctrine: JESIP Joint Doctrine v3.1 (2021).

SECTION 3 — HAEMORRHAGE & RESUSCITATION

CHANGE THIS MONTH FRCS/FRCA

Damage Control Resuscitation in Severe Chest Trauma: 28-Day Survival 95% vs 82% vs Conventional Resuscitation (Propensity-Matched Cohort, n=200)

Frontiers in Physiology. Published 15 July 2026. DOI: 10.3389/fphys.2026.1827424

Design: Propensity score-matched retrospective cohort study comparing DCR-like restrictive resuscitation strategy (limited crystalloid, permissive hypotension, early blood product use) versus conventional resuscitation in 200 patients with severe chest trauma and haemorrhagic shock.

• 95% DCR ARM 28-DAY SURVIVAL
• 82% CONVENTIONAL ARM 28-DAY SURVIVAL
• ↓ARDS 16% VS 34% ARDS RATE
• ↓DIC 7% VS 20% DIC RATE

Bottom line: DCR-like restrictive strategy (limited crystalloid + permissive hypotension until haemorrhage control + early blood products) was associated with: 28-day survival 95% vs 82% (p=0.003); ARDS 16% vs 34%; DIC 7% vs 20%; MODS 15% vs 36% (all p<0.01). The 2025 ESICM guideline recommends restrictive fluid strategy for blunt trauma haemorrhagic shock (moderate certainty).

Critical appraisal: Retrospective, propensity-matched, single-centre cohort — significant confounding is possible despite matching. Chinese study setting may not be directly transferable to UK trauma systems. However, the direction and magnitude of effect is consistent with PROPPR, MATTERS, and existing DCR literature. The key message is not new but is reinforced: avoid crystalloid loading in haemorrhagic shock — activate MTP early, use permissive hypotension (MAP 50–65 mmHg in penetrating until haemorrhage control, MAP 65–80 in TBI), and prioritise blood products. This is consistent with UK Major Haemorrhage Protocol (NICE NG39) and AAGBI/ESICM guidance.

CHANGE THIS MONTH FRCS/FRCA UK APPLICABLE

ACS-COT Consensus: RhD-Negative Females of Childbearing Potential Who Receive RhD-Positive Type-O Blood During Trauma — Do Not Withhold; Implement Anti-D Pathway

Henry R et al.; ACS Committee on Trauma, PBTC, NAEMSP, THOR Network, Allo Hope Foundation. J Am Coll Surg. Published July 2026. facs.org

This multidisciplinary consensus statement addresses a practically important dilemma in trauma resuscitation: when type-O whole blood or red blood cells are given in an emergency without knowing the patient's blood group, what is the reproductive risk for RhD-negative females of childbearing potential (FCP), and what should be done about it?

Key modelling findings: Risk of perinatal death from anti-D-mediated HDFN: ~0.04%. Combined severe HDFN/perinatal death risk: ~0.24%. Risk of any HDFN-complicated future pregnancy: ~0.6–6.5%. These risks are modest, particularly compared with the mortality risk from withholding blood products in a haemodynamically unstable trauma patient.

Consensus recommendations: (1) Do NOT withhold RhD-positive blood products from RhD-negative FCPs when RhD-negative products are unavailable and transfusion is clinically indicated. Immediate survival takes precedence. (2) After transfusion, implement structured post-transfusion antibody surveillance and anti-D immunoglobulin prophylaxis where appropriate (low-volume exposure). (3) Provide patient counselling and multidisciplinary follow-up (obstetrics, haematology). (4) Develop institutional protocols for RhD-negative FCP management post-emergency transfusion. (5) UK application: NHSBT and your local blood transfusion team should be involved in implementing a pathway. Check your trust MTP and emergency blood release policy for RhD documentation and follow-up processes.

FRCS/FRCA INFORMING PRACTICE

Thromboelastography 6s (TEG-6s) in Major Trauma — Updated Guidance on Viscoelastic Haemostatic Assay-Guided Resuscitation

PubMed PMID: 42490321. Published August 2026. pubmed.ncbi.nlm.nih.gov/42490321

Updated guidance on the use of point-of-care thromboelastography 6s (TEG-6s, Haemonetics) for viscoelastic haemostatic assay (VHA)-guided resuscitation in major trauma. VHA-guided strategies have been shown in several studies to reduce blood product use and improve targeted resuscitation compared with conventional coagulation tests (PT/APTT) in trauma settings. The TEG-6s provides results in <15 minutes, enabling real-time adjustment of resuscitation strategy during active haemorrhage.

Clinical framework for TEG-6s in trauma: CFF (citrated functional fibrinogen): Low CFF MA = fibrinogen deficiency → cryoprecipitate/fibrinogen concentrate. CK (citrated kaolin): Long CK R-time = factor deficiency → FFP. Short CK R-time = hypercoagulable → anticoagulation consideration. CRT (citrated rapid thrombelastography): MA and LY30 for fibrinolysis assessment → TXA if LY30 >3%. RCF (rapid clotting function): Platelet contribution to clot strength. This guidance is directly tested in the FRCS(Tr&Orth) and Final FRCA — both exam pathways include VHA-guided resuscitation as a key perioperative/trauma competency.

SECTION 4 — TRIAGE & ASSESSMENT

CHANGE THIS MONTH FRCS/FRCA

Biomarkers (Base Deficit + Serum Lactate) Significantly Outperform ATLS-Based Vital Signs for Triage and Outcome Prediction in Haemorrhagic Shock — BJS SR/MA

Systematic review and meta-analysis. BJS (British Journal of Surgery) Supplement 6. Volume 113. Published 10 July 2026. DOI: 10.1093/bjs/znag063.682

Design: Systematic review of 7 observational studies comparing ATLS triage vital signs (HR, BP, GCS, respiratory rate, capillary refill) versus biomarkers (serum lactate (SL) and base deficit (BD)) for predicting morbidity and mortality in haemorrhagic shock.

Key findings: Both TVS and biomarkers correlated with morbidity and mortality. However, SL and BD consistently provided superior predictive value. Shock classification based on SL or BD offered clearer guidance for triage, resuscitation, and prognostication.

Clinical thresholds: Patients with BD >-6 mmol/L or SL ≥2.5 mmol/L should be prioritised for higher-level care and aggressive resuscitation. These are the triage decision points with the strongest evidence base. ATLS vital signs classification (Class I-IV based on HR/BP/pulse pressure/capillary refill) is still useful for rapid initial assessment at scene — but BD and lactate should be obtained from the first arterial or venous blood gas in the resus bay and used to refine the resuscitation decision. This data supports the existing movement away from sole vital sign-based shock classification toward physiologically integrated assessment.

INFORMING PRACTICE TRIAGE FRCS/FRCA

START Triage Red Criteria Count at ED Arrival Independently Associated with 28-Day Mortality — CRASH-2 Data Reanalysis (Sci Rep, 10 July 2026)

Scientific Reports. Published 10 July 2026. nature.com/articles/s41598-026-62050-z

Study: Reanalysis of CRASH-2 trial patient data (20,211 adults with traumatic haemorrhage). Scored each patient for START triage red criteria at ED arrival: (1) respiration >30/min, (2) absent/weak radial pulse, (3) GCS <2. Number of START red criteria at presentation was the predictor; 28-day mortality was the outcome.

Finding: Higher START red-criteria count was independently associated with increased 28-day mortality. Each additional START red criterion compounds mortality risk — the relationship is dose-dependent. Patients with 3/3 criteria have the highest mortality.

Mass casualty application: START (Simple Triage And Rapid Treatment) is the standard primary mass casualty triage tool in the UK, used by first responders at scene. The "Red" (Immediate) category is triggered by: >30 respirations/min, no radial pulse (or capillary refill >2s in paediatric variant), or GCS <2 (unresponsive). This CRASH-2 reanalysis provides external validation that START red criteria at ED arrival have prognostic validity for 28-day mortality — supporting the rationale for START as a triage tool. FRCS/FRCA candidates should know the START algorithm, criteria, and evidence base. This paper does not change the tool — it reinforces its prognostic value.

SECTION 5 — FOAMED & NON-TECHNICAL SKILLS

ST EMLYN'S FRCS/FRCA NTS

St Emlyn's TTL Tip 18: "Dead Team Leader" — Managing Sudden Incapacitation of the Trauma Team Leader Mid-Resuscitation

Simon Carley, St Emlyn's. Published 2 August 2026. stemlynsblog.org

St Emlyn's TTL Tip 18 (published 2 August 2026, just within our window) addresses a scenario that is rarely trained but is a genuine operational risk: the sudden incapacitation of the trauma team leader during an active resuscitation — medical emergency, aggression, contamination, or incapacitation by the clinical scenario itself. The "dead team leader" framework involves: designating a named deputy before the patient arrives, briefing role transfer protocols in the pre-arrival team brief, and practising escalation to the deputy without loss of team situational awareness.

NTS application: This is an extension of crew resource management (CRM) principles applied to trauma resuscitation. Pre-designate a named deputy TTL in the pre-alert brief (not during the emergency). The deputy should know: who to escalate to, how to obtain additional help, and what the current resuscitation priorities are. This is a non-technical skills (NTS) competency relevant to FRCS(Tr&Orth), ATLS instruction, and ARCP portfolios. TTL Tip 17 (Sterile Cockpit, 29 Jul) was also published this month — covered in Issue 23 EM newsletter with the NTS application for resus bay communication.

JTACS JULY 2026 FRCS/FRCA

JTACS July 2026: Trauma Centre Level, Flail Chest Regional Anaesthesia, and HALO Procedure Framework

J Trauma Acute Care Surg. Volume 101, Issue 1. July 2026. journals.lww.com/jtrauma

Trauma centre level survival: Major JTACS study examining outcomes by trauma centre designation level — Level I/II vs Level III/IV. Level I trauma centres continue to show superior survival for penetrating and polytrauma cases. Level of trauma centre designation matters; UK Major Trauma Centres (equivalent to Level I) are justified by this evidence base.

Flail chest regional anaesthesia timing: Study examining whether earlier placement of thoracic epidural or paravertebral block improves outcomes in flail chest. Early regional anaesthesia (within 24 hours of admission) was associated with lower rates of respiratory failure, ICU admission duration, and mortality in the study cohort. This supports existing FICM/CPOC guidance on early regional anaesthesia for rib fractures and flail segments.

HALO procedure framework: Haemorrhage control At the Landing (HALO) — prehospital operative intervention for compressible and junctional haemorrhage at the air ambulance landing site. Proof-of-concept framework paper for hybrid prehospital/HEMS surgical capability. Not yet UK operational practice — watch for feasibility data from London HEMS/TAAS.

SECTION 6 — QUICK HITS

ACS-COT: PREHOSPITAL SPINAL CORD INJURY MANAGEMENT — PERSPECTIVES PAPER (PREHOSP EMERG CARE, 16 JULY 2026)

ACS Committee on Trauma. Prehosp Emerg Care. Published 16 July 2026. DOI: 10.1080/10903127.2026.2703176 — Note: c-spine clearance protocol (NEXUS/PECARN/MRI) was covered in PHEM Issue 7. This ACS-COT paper covers the broader prehospital spinal cord injury management framework — distinct topic.

The ACS Committee on Trauma published perspectives on prehospital management of suspected spinal cord injuries, including stabilisation, transport, and destination decisions. Key emphasis: immobilisation is indicated for at-risk patients but should not delay definitive haemorrhage control in polytrauma. UK JRCALC and BASICS guidelines are consistent — manual inline stabilisation with SMR as primary intervention; avoid prolonged rigid collar use.

WHO: REHABILITATION IN BURN MASS CASUALTY INCIDENTS — GUIDANCE BRIEF (8 JULY 2026)

World Health Organization. Published 8 July 2026.

WHO published a rehabilitation-focused guidance brief specifically for burn mass casualty incidents. Key messages: early rehabilitation in burn MCIs is associated with improved functional outcomes; rehabilitation teams should be included in mass casualty planning alongside surgical and critical care. For UK burns mass casualty planning: review your trust's burn MCI plan against WHO guidance. Burns surge capacity is a known gap in many UK MCI plans.

NHSBT ANNUAL REPORT 2025-26 PUBLISHED (14 JULY 2026)

NHS Blood and Transplant. Published 14 July 2026. gov.uk

NHSBT's 2025-26 Annual Report covers blood supply performance across England and the three devolved nations. Key to trauma: blood stock availability, walking blood bank programmes, and organ donation performance. 2.16 million blood components issued (as cited in SHOT 2025). Read in conjunction with the SHOT 2025 Annual Report for a complete picture of UK blood safety and supply performance.

TOURNIQUET QIP IN UPPER LIMB TRAUMA: AUDIT AGAINST BSSH/BOAST STANDARDS (BJS SUPPLEMENTS, 10 JULY 2026)

BJS Supplements Volume 113, Issue Supplement_6. DOI: 10.1093/bjs/znag063.224

Closed-loop audit of tourniquet use in a tertiary plastic surgery trauma centre against BSSH/BOAST guidance. Improvements after QIP intervention: pre-operative skin condition documentation 33% → 50%, post-operative assessment 0% → 50%, safe tourniquet pressure documentation 94% → 100%. No tourniquet burns in either cycle. Relevant for FRCS(Tr&Orth) portfolio: tourniquet safety is a core BOAST competency and regularly features in FRCS short cases.

MAJOR TRAUMA EVIDENCE RUNDOWN — CORE REVISION — ISSUE 2 — AUGUST 2026

Major Haemorrhage Protocol (MHP) and Damage Control Resuscitation

UK framework, blood product ratios, permissive hypotension, and reversal — FRCS(Tr&Orth) & Final FRCA edition

Goal: Stop bleeding, restore oxygen delivery, correct coagulopathy — in that order. MHP activates the system. DCR is the strategy. TEG guides the target. Resuscitate to haemostasis, not to normal vital signs.

MAJOR HAEMORRHAGE DEFINITION AND ACTIVATION

BLOOD PRODUCT RATIOS — UK MAJOR HAEMORRHAGE PROTOCOL (NICE NG39 + SHOT GUIDANCE)

PERMISSIVE HYPOTENSION TARGETS

FRCS(Tr&Orth) / Final FRCA Revision: Common exam questions: (1) Define massive haemorrhage and when to activate MTP. (2) What is the correct pRBC:FFP:platelet ratio and why? (3) When should TXA be given, and why must it not be given after 3 hours? (4) What are the three goals of damage control resuscitation? (Stop bleeding → Correct lethal triad: hypothermia + acidosis + coagulopathy → Restore oxygen delivery). (5) What is permissive hypotension and what are the exception conditions (TBI, pregnancy)? (6) Why is calcium given with MTP? (7) Describe VHA-guided resuscitation (TEG/ROTEM). Know that CRASH-2 all-cause mortality NNT = 67 with TXA within 3 hours. Know that FFP volume = 15 mL/kg for coagulation correction. Know the SHOT 2025 data — it is being increasingly assessed in surgical exams as a governance question.

Major Trauma Evidence Rundown — Core Revision — Issue 2 · emevidence.org

FRCS / FINAL FRCA

Sources: NICE NG39 (Major Trauma 2016/2020) · SHOT 2025 Annual Report · CRASH-2 Lancet 2010 · ESICM Guidelines 2025 (fluid strategy) · AAGBI/CPOC Major Haemorrhage Guidelines · NICE NG39

ACTION POINTS

• SHOT 2025 Annual Report: Read the executive summary and relevant chapters at shotuk.org. Specifically: TACO chapter, Near Miss chapter, Key Messages. Circulate to your transfusion practitioner, blood bank lead, and major trauma team. Identify one action from SHOT recommendations for your department within 30 days.
• MTP TACO prevention: TACO (transfusion-associated circulatory overload) is the leading cause of transfusion-related death in SHOT 2025. In major trauma resuscitation: apply MTP de-escalation criteria as soon as haemorrhage control is achieved — do not continue 1:1:1 indefinitely. Furosemide post-resuscitation, haemodynamic monitoring, and early discussion with ICU for fluid balance management.
• NHS England Mass Casualty ConOps: Hospital EPRR leads and major trauma leads should read the new document (england.nhs.uk) and update local mass casualty plans for alignment. Confirm your EPRR exercise schedule for autumn 2026 includes mass casualty scenarios aligned with the new ConOps.
• JESIP Leadership Training: Identify two named major incident medical leads in your trust/network for JESIP Interoperability Leadership Training (launched 27 Jul 2026, jesip.org.uk). Contact your NHS England regional EPRR lead for nomination pathway.
• Adolescent trauma routing: Review your trauma network's routing protocol for 14-17-year-olds. TARN data shows adjusted odds of 30-day mortality 2.41x higher in adult vs children's MTCs. Ensure protocols default to children's MTC for this age group within appropriate geography.
• RhD-negative protocol update: Check your trust MTP or emergency blood release policy for documentation and follow-up processes for RhD-negative females of childbearing potential who receive emergency type-O blood. If no pathway exists for anti-D prophylaxis and antibody follow-up — create one with your blood bank and obstetrics team.
• Biomarkers in shock triage: Ensure every trauma patient arriving at the resus bay has an early arterial blood gas documenting base deficit and serum lactate. BD <-6 or SL ≥2.5 mmol/L = aggressive resuscitation priority. Do not rely solely on ATLS vital sign classification — the BJS SR/MA confirms biomarkers are superior for risk stratification.
• NTS — dead team leader drill: Add "deputy team leader designation" as a mandatory item in your pre-trauma team brief. Before every trauma activation: state who the deputy TTL is. Practise role handover in a low-fidelity simulation within the next 3 months. Document in governance records.

TRIALS TO WATCH

NEAR-TERM (Q3–Q4 2026)

2026–2027 HORIZON

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. Major Trauma Evidence Rundown — Issue 2 — August 2026 — UK Edition Published by EM Evidence — emevidence.org For educational purposes only. Not clinical advice. Verify against local guidelines, trust protocols, and NICE guidance before implementing changes. All content editorially reviewed.

Previous issues archived at emevidence.org — emevidence999@gmail.com