The Association of Anaesthetists has published an updated guideline on pre-hospital emergency anaesthesia, known as PHEA. It appeared in Anaesthesia in 2026 and replaces the 2017 edition. For UK pre-hospital, offshore and diving clinicians it sets out what a safe anaesthetic looks like outside hospital, who should deliver it, and what everyone else on scene should be doing.
Why this matters
PHEA means giving drugs to induce anaesthesia and muscle paralysis, then placing a tracheal tube, outside hospital. The guideline describes it as a high-risk intervention in patients who are often unstable with conditions that carry a high mortality. Common indications include hypoxia, ventilatory failure, a threatened airway, reduced consciousness and severe agitation with head injury.
The Association first published guidance in 2009 and updated it in 2017. The 2017 guideline did not mention videolaryngoscopy and stated that cricoid pressure should be applied during induction. Difficult Airway Society guidance in 2025 now says a videolaryngoscope should be used whenever possible. Pre-hospital anaesthesia is routine in the UK but was historically under-standardised, with controversy remaining around cricoid force, manual in-line stabilisation, apnoeic oxygenation, competence and checklists.
What the researchers did
The guideline was written by a ten-member working party chaired by David Lockey, a consultant in intensive care and anaesthesia at North Bristol NHS Trust and London’s Air Ambulance. Members represented the Royal College of Anaesthetists, the Royal College of Emergency Medicine, the Difficult Airway Society, the Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh, the British Association for Immediate Care, Defence Medical Services and pre-hospital emergency medicine trainees.
A modified Delphi process, meaning structured rounds of voting used to reach expert agreement, generated and ranked clinical questions. The top six went to targeted literature review: videolaryngoscopy, required competence, routine cricoid force, manual in-line stabilisation, apnoeic oxygenation and checklists. Authors considered the last ten years of evidence plus key earlier papers. Consensus required at least 80% agreement. Evidence was expected to grade low, at C or D on a modified Centre for Evidence-Based Medicine scale, and the strength of recommendations could not be graded.
It was endorsed by the bodies above plus the Intercollegiate Board for Training in Pre-hospital Emergency Medicine. It was published online on 24 March 2026 and appears in Anaesthesia 2026, volume 81, issue 8, pages 1132 to 1147. It is written for UK practice; Scandinavian and US guidance differs because of service structure.
What they found
There are ten key recommendations. PHEA should only be provided by services with robust governance and regular review of training, practice and outcomes. Techniques should be simple, reproducible and supported by standard operating procedures and checklists. A rapid on-scene assessment of benefit against harm comes first, with particular care in children and penetrating trauma, where anaesthesia may be delayed until the major trauma centre. PHEA should be performed only by an appropriately trained anaesthesia provider with a trained assistant. That provider should be competent to deliver unsupervised emergency anaesthesia in an emergency department, and because pre-hospital case numbers are low, continued in-hospital practice is likely to be needed. Association monitoring standards apply. Patients should be extricated rapidly before induction, since true entrapment is rare. Cricoid force, manual in-line stabilisation and cervical collars may make intubation harder and their benefits are poorly evidenced. Videolaryngoscopy should always be available.
On technique, the guideline recommends at least three minutes of high-flow oxygen through a tight-fitting mask where breathing is adequate. Ketamine, fentanyl and rocuronium are the standard drugs; suxamethonium and etomidate have largely been discontinued. Fentanyl is commonly given at 1 to 3 micrograms per kilogram, with vasopressors immediately available. Tube placement is confirmed with seven consecutive capnography waveforms. Targets after intubation are oxygen saturations of 94 to 96%, end-tidal carbon dioxide of 4.0 to 4.5 kPa, and avoiding a systolic pressure below 90 mmHg, noting that 90 to 130 mmHg has also been linked to poorer outcomes. Cricoid force is no longer mandated and should be removed if the view is poor. In-line stabilisation should be removed early if intubation is difficult.
Sedation before PHEA should meet in-hospital procedural sedation standards, typically midazolam in 1 to 2 mg increments or ketamine in 10 to 20 mg increments up to 1 mg per kilogram. Intramuscular ketamine at 4 mg per kilogram is suggested for severe agitation without intravenous access. A 14-item minimum equipment list includes video and direct laryngoscopes, bougies, a second-generation supraglottic airway, a surgical airway kit and a ventilator with alarms. A minimum of six months of in-hospital anaesthesia training is recommended. Physicians generally show higher intubation success and fewer complications than non-physicians, and no UK programme currently trains non-physicians to the required standard.
Strengths and limitations
This is a consensus document, not a trial. Its strengths are the breadth of the working party, endorsement across seven specialist bodies, a transparent Delphi method and candour about weak evidence. Most recommendations rest on grade C or D evidence and expert opinion. Search dates and databases are not reported. It is built around the UK model of physician-led enhanced care teams, so it says little about remote, offshore or maritime settings where no such team exists and hospital-standard monitoring and senior advice are unavailable. Paediatric evidence is thin.
What it means for your practice
- Ambulance paramedics: PHEA remains a physician-led team intervention in the UK. Your contribution is early recognition, an early request for enhanced care, rapid extrication, and preparation: oxygen, monitoring, access and suction. If trained as an anaesthetic assistant, expect a challenge-response checklist and dose checks before induction.
- HEMS and critical care teams: Compare your standard operating procedures against the ten recommendations, particularly videolaryngoscope availability, cricoid force, manual in-line stabilisation, seven-waveform confirmation and the post-intubation targets.
- Offshore and diver medics: You will not be delivering PHEA, but the physiological targets and the principle of simple, rehearsed, checklist-driven airway care still apply. Where PHEA is unavailable, the 2017 guidance advises maintaining oxygenation and ventilation with basic manoeuvres, adjuncts and a second-generation supraglottic airway. Plan evacuation early.
- First responders: Airway opening, suction, oxygen and an early call for enhanced care are your tasks. Stay within your scope.
Do not drop cricoid force or in-line stabilisation, or change drug doses, on the strength of this document alone. Local protocols, employer procedures and JRCALC govern practice.
Reflect
- When did you last prepare a patient for PHEA, and what could you have had ready before the team arrived?
- How does your service’s position on cricoid force and manual in-line stabilisation compare with the 2026 recommendations?
- In your setting, what would you do for a patient who needs PHEA when no team can reach you?
Read the original
- Anaesthesia: Safer prehospital anaesthesia: updated guidelines from the Association of Anaesthetists, 2026
- Sheffield Hallam University Research Archive: open access version of record and publication details, 2026
- Association of Anaesthetists: Safer prehospital anaesthesia guideline page, 2026
- Air Ambulance Charity Kent Surrey Sussex: KSS contributes to new national guidance on pre-hospital emergency anaesthesia, 2026
- Anaesthesia: AAGBI Safer pre-hospital anaesthesia 2017, the guideline this edition replaces
Published 25 October 2026. Last reviewed October 2026.
These summaries are for education and CPD only. They are not clinical guidelines. Always practise within your scope of practice and follow your employer’s protocols and national guidance such as JRCALC and Resuscitation Council UK.