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Background Endotracheal intubation is an important pre-hospital intervention in critically ill patients. However, it can be a challenging skill, and previous studies have highlighted varying success rates. The European Resuscitation Council (ERC) have set a clear target of a greater than 95% success rate within two attempts, for all clinicians who provide endotracheal intubation during cardiac arrest. This service evaluation looks to explore the impact of training and education on the intubation performance of critical care paramedics. Methods Retrospective data was collected from a single service over a six year period, from April 2019 to December 2024. During that time period, a number of educational or organisational interventions were introduced, with the aim of improving endotracheal intubation success rates. Data from all intubation attempts for patients in cardiac arrest by critical-care paramedics working with the Devon Air Ambulance Trust were recorded. The primary outcome was the rate of success of endotracheal intubation within two attempts. Secondary outcomes included the rate of first-pass success and the number of patients who had a failed first intubation attempt and did not receive a subsequent attempt. A Chi-squared statistical test was used to judge the significance of change between data from the years 2019 and 2024. Results 390 patients were included and reviewed. Between 2019 and 2024, success rates within two attempts improved by 7.9% points (χ 2  = 4.205, p  = 0.040), while first-pass success rates improved by 18.4% points (χ 2  = 7.125, p  = 0.0076). The success rate within two attempts at endotracheal intubation in 2024 was 97.7%. Over the whole time period, intubation was successful within two attempts in 94.6% ( n  = 369) of patients, while the first-pass success rate was 82.6% ( n  = 322). Of the 68 patients who had an unsuccessful first intubation attempt, 19.1% ( n  = 13) did not receive a second attempt. Conclusions Implementation of a training and education programme was associated with a significant improvement in endotracheal intubation success rates within the service. With dedicated training, critical care paramedics demonstrate safe and effective endotracheal intubation for patients in out-of-hospital cardiac arrest, meeting the ERC recommendations of a greater than 95% success rate within two attempts at intubation.

Background Physically trapped patients following motor vehicle collisions are at high risk of time-critical injuries and poor outcomes. Despite this, there is limited consensus on which injuries should be prioritised and which early interventions are both necessary and feasible in the prehospital setting. This study aims to develop expert consensus on injury categorisation and the delivery of early care interventions to guide clinical and operational decision-making at the scene. Methods A modified Delphi method was used to gather consensus from a multidisciplinary panel of subject matter experts, including clinicians, paramedics, and members of fire and rescue services. In Round 1, participants contributed to the development of draft statements relating to injury time sensitivity, intervention prioritisation, and responder roles. In Rounds 2 and 3, participants rated their level of agreement with these refined statements. A final face-to-face consensus meeting was held to discuss statements that had not yet reached consensus, explore areas of disagreement, and conduct further voting where appropriate. Consensus was defined as ≥ 70% agreement. Results Consensus was achieved on 45 statements across the domains of injury categorisation, time-critical interventions, and multi-agency responsibilities. Participants strongly endorsed the early delivery of analgesia, tranexamic acid, and protection from environmental stressors, regardless of provider background, provided that appropriate training and governance are in place. There was broad support for expanding the scope of practice of non-clinical responders to meet urgent patient needs. Conclusions This Delphi consensus provides a framework for prioritising early interventions in the care of trapped patients. It supports a patient-centred, capability-based approach to prehospital care, emphasising feasibility, urgency, and ethical responsibility. Findings should inform the development of standard operating procedures, triage tools, and training frameworks across emergency services, with further research needed to validate assessment heuristics and address barriers to implementation.

Background Motor vehicle collisions (MVCs) are a leading cause of injury and death worldwide. Up to 40% of casualties may become trapped and entrapment is associated with delayed care and worse outcomes. There is little national or international consensus guiding the care of physically trapped patients who cannot self-extricate. This study aimed to develop multidisciplinary consensus-based principles to optimise clinical and operational care for trapped patients following MVC. Methods A three-round Delphi study was conducted from January to March 2025, following the CREDES framework. A multi-professional steering group developed preliminary statements informed by literature review and expert consultation. Subject matter experts (SMEs) with operational experience in extrication, prehospital, and trauma care were recruited through stakeholder organisations. Statements were refined iteratively through SME feedback. Consensus was defined as ≥ 70% agreement or disagreement. Statements reaching consensus were removed from subsequent rounds; others were revised based on free-text feedback. Results Sixty-six SMEs participated, with high engagement across all three rounds. Consensus was achieved for 104 statements covering standardised extrication terminology, prioritisation of time-sensitive extrication for critically injured patients, minimisation of unnecessary on-scene interventions, emphasis on early psychological support for trapped casualties, and the importance of interdisciplinary communication and coordination. The consensus supports a paradigm shift towards rapid, patient-centred extrication, balancing clinical needs, operational realities, and psychological welfare. Conclusions This Delphi study establishes expert-endorsed principles for the care of physically trapped patients following MVCs. Adoption of these principles could reduce delays, strengthen multi-agency response and improve patient outcomes. Further work is required to validate the impact of these recommendations on clinical outcomes and to support their integration into practice through policy development, training, and evaluation.

BackgroundEighty five percent of strokes are due to an ischaemic event and approximately 10% of these can now be treated with mechanical thrombectomy retrieval (MTR). The benefit of MTR drops by 5.7% for every hour since onset. In Devon, MTR is currently only available at University Hospital Plymouth (UHP). The longest transfer time to UHP is undertaken by patients at North Devon District Hospital (NDDH); approximately 110 minutes by road. A quality improvement project was designed to reduce the transfer time for these patients and increase the number of patients eligible for MTR.MethodsA collaborative team of Devon Air Ambulance (DAATCL), NDDH and UHP designed a transfer protocol for MTR eligible patients to be airlifted to UHP, reducing the transport time of 110 minutes by land to approximately 20 minutes by air. DAATCL liaised with South Western Ambulance Service (SWASFT) HEMS dispatchers to provide a specific dispatch procedure for MTR transfers.ResultsThe pilot has now been running for 12 months and 16 patients have been transferred for MTR at UHP. The median transfer time was 25 minutes by air, giving a median time saving of 1 hour 25 minutes compared to a land transfer.ConclusionSixteen patients have benefited from this new service, and it is anticipated that numbers will increase as the MTR service expands. MTR is not yet a 24/7 service, however it is hoped this will be achieved within the next few years. MTR is an expensive procedure, however due to reduced hospital stay and social care needs, cost savings can be considerable; and the benefit to patients and their families can be even greater. There is also wider benefit to patients in the region with land resources available to respond to other 999 calls when they would have been otherwise unavailable during the transfer.

In a trial involving adults with out-of-hospital cardiac arrest, an intraosseous-first strategy for vascular access did not result in a higher incidence of 30-day survival than an intravenous-first strategy.

BackgroundPrehospital critical care is a rapidly evolving field. There is a paucity of evidence relating to its practice, with limited progress in answering those research questions identified over a decade ago. It is vital that evidence gaps are identified and addressed. This study aimed to define the current research priorities in UK prehospital critical care.MethodsThis modified national Delphi study was coordinated by the Pre-HOspital Trainee Operated research Network and conducted in four rounds between October 2021 and April 2022. Rounds 1 and 2 were conducted online with clinicians involved in prehospital critical care delivery and non-clinical prehospital researchers. Rounds 3 and 4 were completed online by a subject matter expert (SME) panel.ResultsIn round 1, 78 participants submitted 394 research questions relating to prehospital critical care delivery in the UK. These were refined and categorised into 192 questions, which were scored for importance in round 2. Fifty questions were discussed and scored by the SME panel in round 3. Round 4 created a ranked top 20 list. The top research priority was ‘Which cardiac arrest patients should critical care teams be dispatched to; how do we identify these patients during the emergency call?’. Other priorities included dispatch optimisation, out-of-hospital medical cardiac arrest management, optimising resuscitation in haemorrhagic shock, improving traumatic brain injury outcomes and optimising management of traumatic cardiac arrest.ConclusionsThis modified Delphi study identified 20 research priorities where efforts should be concentrated to develop collaborative prehospital critical care research within the UK over the next 5 years.

Background Timely and effective pre-hospital management of penetrating neck injuries (PNI) is critical to improve patient outcomes. Pre-hospital interventions in patients with PNI can be especially challenging due to the anatomical injury site coupled with a resource-limited environment. Nationally, in the United Kingdom, no consensus statement or expert agreed guidance exists on how to best manage PNI in the pre-hospital setting. Method We conducted a national modified e-Delphi study with subject matter experts (SMEs) from multiple professional specialities with experience in the management of PNI. Pre-identified SMEs were contacted and consented prior to participation allowing for a remotely conducted Delphi using REDCap and Microsoft Teams. In Round 1, statements drawn from the literature base were distributed to all SMEs. Round 2 comprised a facilitated and structured discussion of the statements and then an online survey provided final ratification in Round 3. Of the participating SMEs consensus was set a priori at 70%. Results Of the 67 pre-identified SMEs, 28 participated, resulting in a response rate of 42%. From the first two rounds, 19 statements were derived with every statement achieving consensus in Round 3. Subsequently, an algorithm for the pre-hospital management of PNI was developed and agreed with SME consensus. Conclusion Curation of national consensus statements from SMEs aims to provide principles and guidance for PNI management in a complicated patient group where pre-hospital evidence is lacking. Multi-professional national consensus on the best approach to manage these injuries alongside a novel PNI management algorithm aims to optimise time critical care and by extension improve patient outcomes.

Background Resuscitative thoracotomy (RT) in traumatic cardiac arrest, in particular for penetrating trauma features within several national guidelines. However, evidence surrounding its practice is poor, consisting of predominantly small-scale observational studies. Survival is generally poor, estimated at 3–13%, with better outcomes in penetrating trauma. There is no national RT database and the Trauma Audit Research Network data misses those who have died pre-hospital. It is important that a more in-depth and accurate national picture of thoracotomy practice is developed nationally to guide future practice. Traumatic emergency thoracotomy for resuscitation in shock (TETRiS) is a multi-centre, prospective and observational evaluation of current RT practice in the UK. Aims and objectives The aim of TETRiS is to evaluate the pathway of care for RT patients within the UK. This will be undertaken over a period of 12 months. This project will evaluate thoracotomies undertaken both pre-hospital and in emergency departments, examining various parameters including frequency, who performs the procedure, clinical indications, time from injury to initiation, mechanism of injury, injuries identified, interventions performed and patient outcomes. Methods This project is being conducted as a collaboration between the National Trauma Research and Innovation Collaborative, the Pre-Hospital Trainee Operated Research Network, the Trainee Emergency Research Network and the National HEMS Research and Audit Forum (NHRAF). All UK HEMS, helicopter emergency medicine services and major trauma centre (MTCs) nationally have been recruited, with site investigators identified within each participating unit. Inclusion criteria: All patients undergoing RT, pre-hospital or in an MTC emergency department will be included.

Glioblastoma multiforme (GBM) is highly aggressive primary brain tumor with a 5-year survival rate of 7%. Previous studies have shown that GBM tumors have a reduced capacity to produce cholesterol and instead depend on the uptake of cholesterol produced by astrocytes. To target cholesterol metabolism to induce cancer cell death, synthetic high-density lipoprotein (sHDL) nanodiscs delivering Liver-X-Receptor (LXR) agonists and CpG oligonucleotides for targeting GBM were investigated. LXR agonists synergize with sHDL nanodiscs by increasing the expression of the ABCA1 cholesterol CpG oligonucleotides are established adjuvants used in cancer immunotherapy that work through the toll-like receptor 9 pathway. In the present study, treatment with GW-CpG-sHDL nanodiscs increased the expression of cholesterol efflux transporters on murine GL261 cells leading to enhanced cholesterol removal. Experiments in GL261-tumor-bearing mice revealed combining GW-CpG-sHDL nanodiscs with radiation (IR) therapy significantly increases median survival compared to GW-CpG-sHDL or IR alone. Furthermore, 66% of long-term survivors from the GW-CpG-sHDL +IR treatment group showed no tumor tissue when rechallenged.

John Major is \"very sorry at the outcome\" (The fall of [Jeffrey Archer], July 20). What he ought to be sorry about is the crime Archer committed. His party claims, does it not, to be the party of law and order, the family, back to basics?