This is is the list of papers we discussed at TBS from emergency medicine practice. Again we were focusing on the early hours management/assessment of the sickest patients. Here are 6 papers we discussed as most influential over the last year. This was the second part of the first day presentation I did with Brian Burns and Iain Beardsell.
Emergency centre thoracotomy in a resource-limited setting
Resuscitative thoracotomy sits right at the edge of emergency medicine’s comfort zone. It’s dramatic, invasive, and rare, which makes it both mythologised and poorly understood. Most of the data we quote come from high-income trauma centres with resources many emergency departments will never have. Which is why this South African study is so interesting , and why we reviewed this paper in depth on the blog here.
The authors reviewed four years of emergency centre thoracotomies performed at two district-level hospitals in Cape Town. These were not tertiary trauma centres. There was no on-site cardiothoracic surgery, no ICU, and often no specialist immediately available. They don’t even have a blood bank! Thoracotomies were frequently performed by non-specialist emergency physicians because, in that context, there simply wasn’t another option.
Over the study period, 67 thoracotomies were performed, almost all for penetrating trauma. Survival to hospital discharge was 24% overall and 32% for stab wounds. There were no survivors following gunshot wounds. Where neurological outcomes were documented, survivors generally had good functional recovery.
This is not a perfect study. It’s retrospective. Records are incomplete. There’s no comparator group. But those criticisms miss the real value of the paper. This isn’t about proving efficacy in ideal conditions. It’s about showing what actually happens when clinicians are forced to make decisions in environments where doing nothing is the default alternative.
The uncomfortable message is this: context matters more than infrastructure labels. In the right population, with the right mechanism, emergency centre thoracotomy can result in meaningful survival — even when performed far from the safety net we’re used to.
A couple of other things came out of this paper and a later talk by Kat Evans, one of the authors. Firstly although the resident doctors were very junior, they do have a lot more surgical training than an equivalent UK doc. They will all have done C-sections and so they are trained in putting knife to skin. I think that makes a huge difference. Secondly, they use a lot of autotransfusion via chest drains. That, combined with the lack of a blood bank changes their sequence in thoracotomy. They will usually get a drain in first to collect the blooks that they can then transfuse back into the patient after the thoracotomy. Does anyone know why we don’t use chest drain autotransfusion in the UK? It seems to work really well in SA.
Ketamine versus etomidate: the RSI trial
Few topics in emergency airway management generate as much heat as induction agent choice. Ketamine is often framed as the haemodynamically “safe” option. Etomidate, depending on who you ask, is either sensible pragmatism or adrenal heresy. Personally I started doing RSIs with Thio and Sux for EVERYONE……, then the cool kids started using Etomidate, so I did that, and now I mostly use Ketamine.
Until recently, this debate has been fuelled largely by observational data and strong opinions. The RSI trial finally brought some proper evidence to the table .This large, pragmatic, multicentre randomised trial enrolled over 2,300 critically ill adults undergoing emergency tracheal intubation in US emergency departments and ICUs. Patients were randomised to ketamine or etomidate for induction, with 28-day in-hospital mortality as the primary outcome. We covered the trial in depth here.
There was no significant difference in mortality between the two groups, and that’s key as this was the primary outcomes data for this study. In terms of the secondary outcomes they did find some interesting data BUT we should consider these to be exploratory. Cardiovascular collapse during intubation occurred more frequently in patients receiving ketamine.
This is a high-quality trial: large, prospectively designed, and focused on outcomes that matter. It also does something more important than settling a score — it dismantles a narrative. Ketamine is not magically protective. Etomidate is not obviously lethal. The physiology is more complicated than the folklore. That was defined as a very low BP, cardiac arrest, arrythmias or new vasopressors. I think it’s interesting that they only looked for 2 mins, is that really enough to determine what is or is not cardiovascularly stable? Arguably we need better data here before we conclude, hence my view that this hypothesis generating.
What does seem to be the case is both drugs can cause hypotension, but the doses were pretty high in this study and the patients were quite different to the ones I see, notbaly because trauma patients were excluded, which limits direct translation for many emergency departments. But the broader lesson is clear. Drug choice alone does not rescue poor preparation, inadequate resuscitation, or failure to anticipate physiological collapse. Airway management is a system, not a syringe.
Plasma or factor concentrates in bleeding trauma patients
Trauma-induced coagulopathy is a real challenge for us in trauma care and there has been a lot of research in this area over the last 10 years or do. We’ve seen some great trials that we’ve mentioned here on St Emlyn’s and I’ve had the privilige to be part of those research teams for many of them. One thing that we do know is that many patients with major trauma develop coagulopathies. Factor concentrates are attractive because they feel elegant: fast to administer, easy to store, and theoretically precise. Plasma, by comparison, feels clunky and a bit random. Surely if we could give people the factors they need, then they would do better. Well, past studies such as PROCOAG, CRYOSTAT, iTACTIC have not really found that to be the case, but there are signals in all of those studies that certain group may benefit.
The FiiRST-2 trial tested FFP x4 units vs. Fibrinogen concentrate 4g plus PCC 2000iu.
This multicentre Canadian randomised controlled trial compared early administration of fibrinogen concentrate plus prothrombin complex concentrate with standard frozen plasma in patients requiring massive haemorrhage protocols. The primary outcome was total allogeneic blood product use within 24 hours. That’s arguably not the best outcome from a patient perspective, and mortality/morbidity would be better, but if there is any signal on product use it might be indicative.
The bottom line was. that there was no significant difference between groups. Transfusion requirements, thromboembolic complications, and mortality were similar. The trial was stopped early after interim analysis suggested that demonstrating superiority would require an impractically large sample size. The difference was small 20.8 units for concentrates vs. 23.8 units for FFP
Negative trials rarely get the attention they deserve, but this one matters. It tells us that replacing plasma with factor concentrates, at least in this context, does not obviously improve outcomes. This doesn’t mean factor concentrates have no role. It does mean that enthusiasm should not outpace evidence, particularly when system-wide change is being proposed.
Emergency physician–led ECPR
Extracorporeal CPR is often framed as a technological intervention. In reality, it’s a systems problem wearing a circuit. This prospective observational study describes the first year of a regional, emergency physician–initiated ECPR system for out-of-hospital cardiac arrest in San Diego County .
Paramedics screened patients using predefined criteria and transported eligible cases directly to ECPR-capable centres. Emergency physicians performed cannulation and initiated ECMO on arrival. Over 12 months, 22 patients received ECPR. Survival to discharge was 36%, with neurologically intact survival of 32%.
These numbers are interesting, they need to screen lots of patients to find the small number suitable for ECPR, but the real value of this paper isn’t the survival rate. It’s the demonstration that emergency physicians can safely lead ECPR programmes at scale when training, governance, and integration are done properly. it’s also a different model to many other programs that are pushing ECPR into prehospital teams. This tells us that there are alternatives. Sadly in Virchester we are still EC-NO rather than ECMO.
The study is observational and small. Complications are difficult to fully capture. But it offers something that randomised trials often don’t: a credible blueprint. This isn’t about individual brilliance. It’s about designing systems that give patients a chance before physiology runs out.
Resuscitative hysterotomy after out-of-hospital cardiac arrest
Few decisions in emergency medicine are as emotionally charged as resuscitative hysterotomy. The clock is loud. The stakes are overwhelming. The evidence is thin.
This systematic review attempts to bring some clarity to an area where certainty is impossible .
The authors identified 42 publications describing 66 women and 68 neonates who underwent resuscitative hysterotomy during out-of-hospital cardiac arrest. Most reports were case reports or small series. Maternal survival to hospital discharge was rare at 4.5%. Neonatal survival, however, was much higher at 45%. S othis is about the child more than the mother.
Perhaps most importantly, neonatal survivors were reported after prolonged maternal arrest and at extremely preterm gestations. Maternal survival with good neurological outcome was documented up to 29 minutes after collapse, and neonatal survival up to 47 minutes. So the 5min cut off is almost certainly wrong. It also makes sense physiologically. Babies are designed to be born, a process that is in itself massively physiologically challenging. So maybe they are more tolerant to maternal cardiac arrst than we thought.
The certainty of evidence is very low. Publication bias is inevitable. But this review reframes the decision. It reminds us that fetal outcome is not simply a function of maternal survival, and that rigid time-based cut-offs may deny meaningful neonatal benefit.
So what do we take from this?
Good to see some high quality papers and some observational papers that make us think . As always TBS focuses on the first few hours and the sickest patients. That’s a tough place to do research so it’s great to see some data. These papers remind us that emergency medicine rarely offers certainty. Context, physiology and systems matter more than fashionable interventions, and good outcomes depend less on individual choices than on preparation and judgement. We can’t always be sure of the ight answer, it’s making the least wrong decision when time, information and options are all limited……, and that’s what EM is all about!
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References
Sittmann JC, Gool F, Van Koningsbruggen C, Evans K. Emergency centre thoracotomy for penetrating trauma: insights from two South African district-level emergency centres. Injury. 2025;56:112083. doi:10.1016/j.injury.2024.112083.
Casey JD, Seitz KP, Driver BE, Gibbs KW, Ginde AA, Trent SA, et al. Ketamine or etomidate for tracheal intubation of critically ill adults. N Engl J Med. 2025;393:xxxx–xxxx. doi:10.1056/NEJMoa2511420.
da Luz LT, Karkouti K, Carroll J, Grewal D, Jones M, Altmann J, et al. Factors in the initial resuscitation of patients with severe trauma: the FiiRST-2 randomized clinical trial. JAMA Netw Open. 2025;8(9):e2532702. doi:10.1001/jamanetworkopen.2025.32702.
Shinar Z, Hoon J, Assof M, et al. Implementation of a regional emergency physician–initiated extracorporeal cardiopulmonary resuscitation system. Ann Emerg Med. 2025;86(5):552–553.
Jessen MK, Andersen LW, Djakow J, Chong NK, Stankovic N, Staehr C, et al. Pharmacological interventions for the acute treatment of hyperkalaemia: a systematic review and meta-analysis. Resuscitation. 2025;208:110489. doi:10.1016/j.resuscitation.2025.110489.
Leech C, Nutbeam T, Chu J, Knight M, Hinshaw K, Appleyard TL, et al. Maternal and neonatal outcomes following resuscitative hysterotomy for out-of-hospital cardiac arrest: a systematic review. Resuscitation. 2025;207:110479. doi:10.1016/j.resuscitation.2024.110479.
Simon Carley, “TBS 2026: Key Prehospital Emergency Medicine papers,” in St.Emlyn’s, February 6, 2026, https://www.stemlynsblog.org/tbs-2026-key-prehospital-emergency-medicine-papers/.
