EM Evidence Rundown — Issue 13

EM Evidence Rundown

ISSUE 13 · 21 MAY 2026 · UK EDITION

Jake Turner

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

LEAD: CRAFFT RCT (Lancet) — Cast-first for severely displaced distal radius fractures in children aged 4–10: equivalent long-term function to surgery, fewer complications, saves £1,665/patient. Change your practice for the right patients tonight. CHANGE TONIGHT: MHRA DSI/2026/003 — check blood transfusion giving sets now | Ketamine causes more CV collapse than etomidate at RSI (NNH 20) | Hantavirus HCID: 3 deaths, screen unexplained ARDS for travel history | Stop routine UFH for VTE: switch to LMWH/DOAC (JournalFeed)

BOTTOM LINE UP FRONT — ISSUE 13

ACT ON THIS NOW

THIS MONTH Paeds distal radius: Cast-first for children 4–10y with severely displaced fractures. Equivalent function to surgery by 6 months, 100% cost-effective, fewer complications. Stop routine surgical referral for appropriate patients. (CRAFFT, Lancet)

SAFETY MHRA transfusion set: DSI/2026/003 — IV giving sets must NOT be used for blood transfusion. Risk of serious harm. Check all blood admin sets in your department now.

CHANGE TONIGHT RSI drug choice: Ketamine = etomidate for 28d mortality (ARD −0.8%, p=0.65). But ketamine causes more cardiovascular collapse (22.1% vs 17.0%, NNH 20). In haemodynamically unstable patients, etomidate is the safer choice. (NEJM RCT, n=2,359)

SAFETY Hantavirus update: 3 confirmed deaths, 9 confirmed cases. Outbreak evolving. Still screen travel history in unexplained ARDS. Treat as HCID if suspected.

THIS MONTH OHCA drug access: PARAMEDIC-3 — IO-first = IV-first for 30d survival (4.5% vs 5.1%, OR 0.94, p=0.74). Lower ROSC with IO. Prioritise IV access first; use IO when IV fails quickly — do not delay drugs.

KNOW FOR NEXT TIME

INFORMING Septic shock resus: ANDROMEDA-SHOCK-2 — CRT <3s at fingertip reduces organ support by 1.1 days (win ratio 1.16, p=0.04). No mortality benefit. Add CRT to your bedside sepsis target set.

INFORMING REBOA vs resuscitative thoracotomy: SR/MA (14 obs. studies) shows 83% mortality reduction with REBOA but OR 7.81 for complications and profound indication bias. Does not change current practice. (J Trauma, JournalFeed)

INFORMING UFH in VTE: Routine unfractionated heparin should be replaced by LMWH or DOAC as initial VTE anticoagulation — superior efficacy, safety, ease of use. Review your protocol. (J Hosp Med, JournalFeed)

POCUS Optic nerve sheath diameter: SR/MA — ONSD ≥5.1mm identifies elevated ICP in acute neurological emergencies. Useful non-invasive bedside screen when invasive monitoring unavailable. (JournalFeed POCUS)

REVISION Hip fracture: Fascia iliaca block is NICE-mandated (NG124) pre-operatively. FROG-NOF classification, frailty scoring, delirium prevention. See Core Revision.

This week’s evidence challenges several clinical defaults with large, well-conducted trials. The CRAFFT trial overturns routine surgical referral for many children with displaced distal radius fractures — a direct ED management change. The ketamine-etomidate RCT from NEJM puts a number on cardiovascular risk that should change how you choose your RSI agent in haemodynamically compromised patients. ANDROMEDA-SHOCK-2 validates capillary refill time as a bedside target in sepsis resus without claiming a mortality benefit it cannot demonstrate. And PARAMEDIC-3 settles the IO vs IV debate in OHCA with UK data. Alongside a live HCID update and a new blood transfusion giving set safety alert, Issue 13 brings a clinically dense week.

WHAT’S INSIDE — ISSUE 13

Section 1 — Trials & Research: CRAFFT distal radius RCT (LEAD) · Ketamine vs Etomidate RSI (NEJM) · ANDROMEDA-SHOCK-2 · PARAMEDIC-3 · Pericardiocentesis + TXA for penetrating cardiac tamponade Section 2 — Guidelines & UK: MHRA transfusion giving set alert (FORCED) · Hantavirus MV Hondius update · REBEL EM HI-PEITHO review · CTPA radiologist pre-approval — no yield difference Section 3 — Paediatric EM: Non-injectable ketamine for paeds sedation · IM vs IN midazolam for paeds seizures SR/MA Quick Hits: Calcium chloride in massive transfusion (J Trauma) · NIV vs HFNC chest trauma SR/MA · Amoxicillin non-inferior to co-amoxiclav for sinusitis (JAMA) · INSTANT trial (tirofiban post-TNK stroke) · ONSD POCUS SR/MA · UFH vs LMWH for VTE · Serious games trauma triage · USS-first paeds appendicitis pathway Core Revision: Hip Fracture in the ED · Action Points · Trials to Watch

RCT SR/MA GUIDELINE CHANGE TONIGHT CHANGE THIS MONTH WHEN GUIDELINE UPDATES

INFORMING FRCEM PAEDS UK

SECTION 1 — TRIALS & RESEARCH

1. [LEAD] CRAFFT RCT — Cast-First for Paediatric Displaced Distal Radius Fractures (Lancet 2026) 2. Ketamine vs Etomidate for RSI — No Mortality Difference But Ketamine Causes More Cardiovascular Collapse (NEJM, n=2,359) 3. ANDROMEDA-SHOCK-2 — Capillary Refill Time Protocol Reduces Organ Support by 1.1 Days in Septic Shock (JAMA) 4. PARAMEDIC-3 — IO-First vs IV-First in OHCA: No Survival Difference, Lower ROSC With IO (UK RCT) 5. Pericardiocentesis + Intrapericardial TXA for Penetrating Cardiac Tamponade — 25-Case Series

SECTION 2 — GUIDELINES & UK UPDATES

6. MHRA DSI/2026/003 — Blood Transfusion Giving Set Error: Risk of Serious Harm (FORCED INCLUSION) 7. UKHSA Hantavirus Update — 3 Deaths, 9 Confirmed Cases, Outbreak Evolving (MV Hondius) 8. REBEL EM Review: HI-PEITHO — Catheter-Directed Fibrinolysis for Intermediate PE; Important Caveats 9. Radiologist Pre-Approval for CTPA in the ED — No Significant Difference in Diagnostic Yield

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

10. Non-Injectable Ketamine for Paediatric Procedural Sedation in the ED (SR/MA, Acad Emerg Med)

11. IM vs IN Midazolam for Paediatric Seizures — SR/MA: IM Faster, Less Rescue Medication (~4,000 patients)

QUICK HITS · CORE REVISION · ACTION POINTS · TRIALS TO WATCH

SECTION 1 — KEY JOURNAL ARTICLES & TRIALS

LANCET · APRIL 2026 · MULTICENTRE RCT · PMID 41965242 · LEAD ITEM · SGEM#510

CRAFFT RCT — Non-Surgical Casting Equals Surgery for Severely Displaced Distal Radius Fractures in Children Aged 4–10: £1,665 Cost Saving Per Patient, Fewer Complications

RCT CHANGE THIS MONTH PAEDS UK FRCEM LEAD

• −1.64 pts PROMIS AT 3M (CASTING INFERIOR)
• No diff FUNCTION AT 6 & 12 MONTHS
• £1,665 SAVING PER PATIENT (CAST)
• n=750 AGE 4–10, MULTICENTRE UK

Outcome

Casting (n=375)

Surgery (n=375)

Difference

PROMIS UE score at 3 months

44.9

46.6

−1.64 (CI −2.84 to −0.44) — just crossed −2.5 NI margin

PROMIS UE at 6 & 12 months

No significant difference — functionally equivalent

Complications (pressure injury, infection, scarring, nerve irritation)

Fewer

More

NNH ~10 for any early complication

Cost per patient

~£1,665 cheaper

Reference

100% probability cost-effective at UK thresholds

The CRAFFT trial (Perry et al, Lancet April 2026) is a multicentre, pragmatic, randomised non-inferiority trial enrolling 750 children aged 4–10 with severely displaced distal radial fractures (including completely off-ended fractures) at UK and European centres. Participants were randomised to non-surgical casting or surgical reduction. Primary outcome: PROMIS Upper Extremity score at 3 months. Casting did not formally meet the pre-specified conservative non-inferiority margin of −2.5 points (difference −1.64, CI −2.84 to −0.44) — the CI crossed the margin by 0.44 points. However, by 6 and 12 months there was no functional difference between groups. The surgical group had significantly more early complications: pressure injury, wound infection, scarring, and nerve irritation. Casting saved approximately £1,665 per patient, and was 100% cost-effective at standard UK willingness-to-pay thresholds. In the pre-specified subgroup of completely off-ended fractures, casting was formally non-inferior (using the wider −5 point patient-derived margin). Crossover was low: 10% of surgical patients did not undergo surgery; 7% of casting patients crossed to a procedure. UK context: Many UK paediatric EDs currently refer all severely displaced distal radius fractures for surgical assessment. The CRAFFT trial provides the evidence base to move towards a shared decision-making, cast-first approach for children aged 4–10 with these fractures who are neurovascularly intact, without threatened skin, and without other urgent surgical indications. This decision can be initiated in the ED.

Critical appraisal: The primary endpoint was technically not met (CI crossed the −2.5 NI margin by a narrow margin). However, the difference of 1.64 PROMIS points at 3 months is well below the patient-derived minimum clinically important difference (MCID), and the difference disappears entirely at 6 and 12 months. The SGEM notes this: "The benefit of surgery may not be clinically important enough for families." The key appraisal point: non-inferiority was met for the completely off-ended subgroup (44% of participants), and overall functional equivalence at 12 months is the clinically meaningful finding. GRADE: High for long-term function; Moderate for the 3-month primary endpoint where non-inferiority was only borderline missed.

Why it matters: Distal radius fractures are among the commonest paediatric injuries. Surgical reduction exposes children to GA, theatre time, complications, and NHS cost — with no better functional outcome by 6 months. For the right patients (age 4–10, neurovascularly intact, no open injury, no threatened skin), initiating a cast-first discussion in the ED is now evidence-based and cost-effective.

Tell your department: This trial does not mean every displaced fracture should be cast. Children with neurovascular compromise, open injury, threatened skin, age >10, or complex fracture patterns outside the trial eligibility require individual surgical assessment. For eligible patients (4–10y, isolated displaced distal radius, neurovascularly intact, no skin concern): discuss cast-first with parents as a valid option. Frame it using the 12-month outcome data: equivalent function, fewer complications, lower cost. Ensure orthopaedic colleagues are aware of this trial and that shared decision-making pathways are developed locally.

Source: Perry DC et al. Lancet 2026 — CRAFFT Trial (PMID 41965242) · SGEM#510

NEJM · DECEMBER 2025 · RCT · PMID 41369227 · SGEM#500

Ketamine vs Etomidate for RSI of Critically Ill Adults — No Mortality Difference, But Ketamine Causes Significantly More Cardiovascular Collapse

RCT CHANGE TONIGHT FRCEM

• ARD −0.8% 28D MORTALITY (NO DIFFERENCE)
• NNH 20 CV COLLAPSE: KETAMINE VS ETOMIDATE
• 22.1% vs 17% CV COLLAPSE RATE
• n=2,359 14 US ED/ICUS

Outcome

Ketamine

Etomidate

Effect

In-hospital death at 28 days

28.1%

29.1%

ARD −0.8% (CI −4.5% to 2.9%), p=0.65

Lowest systolic BP post-intubation (median)

~6 mmHg lower

Reference

Clinically meaningful in shocked patients

Casey et al (NEJM Dec 2025, PMID 41369227) randomised 2,359 critically ill adults requiring emergency tracheal intubation in 14 US emergency departments and ICUs to ketamine (1–2 mg/kg IV) or etomidate (0.3 mg/kg IV) for induction. Primary outcome: in-hospital death at 28 days. No difference: 28.1% vs 29.1% (ARD −0.8%, 95% CI −4.5% to 2.9%, p=0.65). The adrenal-suppression concern about etomidate that has driven many UK departments to default to ketamine is not validated: etomidate produced no mortality signal even in the large sepsis subgroup. The critical finding is the opposite: ketamine produced significantly more cardiovascular collapse at the time of intubation (22.1% vs 17.0%, NNH 20) and more peri-intubation ventricular tachycardia (1.0% vs 0.2%). The mechanism is catecholamine depletion: ketamine’s sympathomimetic effect depends on intact adrenal reserve. In catecholamine-depleted shocked patients, ketamine’s direct myocardial depressant effect can dominate, paradoxically causing haemodynamic deterioration. UK context: etomidate is less widely available in UK EDs than in the US. However, many departments carry it. This trial provides a clear signal: in the haemodynamically compromised patient, the traditional assumption that “ketamine is safer for the BP” is not supported by RCT evidence — and may be actively harmful in profoundly shocked patients.

Critical appraisal: This trial was not blinded (difficult in this population), and was conducted in US centres with high-volume intubation. UK practice may differ in case-mix. The mortality finding (no difference) is definitive and should be trusted. The cardiovascular collapse finding is consistent across all pre-specified analyses. Key nuance: in asthmatic patients, ketamine’s bronchodilatory effect remains an advantage; in severe haemodynamic instability with catecholamine depletion (shocked septic patients, end-stage cardiogenic shock), etomidate should be the preferred default induction agent. GRADE: High (large multicentre RCT, intention-to-treat, pre-registered).

Why it matters: The long-standing concern that etomidate causes increased mortality via adrenal suppression is now effectively refuted by the largest RCT ever conducted on this question. This should prompt departments to re-examine their RSI drug choice policies. Ketamine remains a reasonable option for most patients, but should NOT be assumed to be haemodynamically safe in the catecholamine-depleted shocked patient.

Tell your department: Review your RSI drug choice guidance. For most haemodynamically stable critically ill patients needing intubation: ketamine and etomidate are equivalent — use local preference and availability. For the profoundly shocked, catecholamine-depleted patient (septic shock on vasopressors, cardiogenic shock): consider etomidate first. For severe bronchospasm, reactive airways: ketamine remains preferred. If your department does not stock etomidate, this trial provides the evidence base to request it.

Source: Casey JD et al. NEJM 2025;393(24):2453–2464 — Ketamine vs Etomidate RCT (PMID 41369227) · SGEM#500 / EMCrit / First10EM

JAMA · DECEMBER 2025 · RCT · PMID 41159835 · 86 CENTRES

ANDROMEDA-SHOCK-2 — Capillary Refill Time-Targeted Resuscitation Reduces Organ Support by 1.1 Days in Septic Shock: No Mortality Benefit, But a Valid Bedside Target

RCT INFORMING FRCEM

• Win ratio 1.16 COMPOSITE PRIMARY (P=0.04)
• No diff 28-DAY MORTALITY (26.5% VS 26.6%)
• +1.1 days FEWER ORGAN SUPPORT DAYS (CRT ARM)
• n=1,467 86 CENTRES, 19 COUNTRIES

ANDROMEDA-SHOCK-2 (Hernandez G et al, JAMA Dec 2025; PMID 41159835) randomised 1,467 adult patients with early septic shock (<4 hours from diagnosis) at 86 centres across 19 countries to a personalised haemodynamic resuscitation protocol targeting capillary refill time (CRT) normalisation (<3 seconds at the fingertip) versus usual care. The CRT-PHR protocol used a tiered approach: Tier 1 (CRT assessment and fluid challenges up to 1L with fluid responsiveness testing), Tier 2 (bedside echocardiography, MAP titration, dobutamine if indicated) with hourly reassessment. Primary outcome: hierarchical composite of 28-day mortality, organ support duration, and length of hospital stay — assessed by a win ratio. Result: win ratio 1.16 (95% CI 1.02–1.33, p=0.04) in favour of CRT-PHR, driven primarily by 1.1 fewer vital support-free days (16.5 vs 15.4, p=0.006). All-cause 28-day mortality was identical (26.5% vs 26.6%, HR 0.99). The subgroup with higher severity (APACHE II >19) showed greater benefit. UK context: CRT is easily assessed in the ED with a glass slide and is already embedded in some sepsis resuscitation algorithms. ANDROMEDA-SHOCK-2 confirms CRT normalisation as a valid resuscitation target and supports a multimodal approach (CRT + lactate clearance + MAP + urine output) rather than lactate alone.

Critical appraisal: The primary win ratio endpoint is a hierarchical composite — a statistical approach that captures outcomes across the hierarchy of mortality, organ support, and LOS. While statistically significant (p=0.04), the mortality result (p=0.87, completely identical proportions) is the most robust single outcome and shows no benefit. The 1.1-day reduction in organ support is real and clinically meaningful (fewer ventilator days, fewer vasopressor days) but the complex protocol may limit generalisability to resource-limited settings. This trial was not conducted in UK EDs directly. GRADE: Moderate (strong design, moderate certainty for organ support outcome; low certainty for mortality).

Tell your department: Add CRT to your sepsis resuscitation target set. A fingertip CRT >3 seconds assessed using firm pressure with a glass slide (not a pen torch) held for 10 seconds with timing from release is an abnormal finding warranting reassessment of resuscitation. Use it alongside lactate clearance, MAP ≥65, and urine output — not as a replacement. The IBCC sepsis chapter (emcrit.org/ibcc/sepsis/) incorporates CRT in the resuscitation endpoint framework.

Source: Hernandez G et al. JAMA 2025;334(22):1988–1999 — ANDROMEDA-SHOCK-2 (PMID 41159835) · EMCrit 411 / The Bottom Line

NEJM EVIDENCE · OCTOBER 2024 · UK RCT · PMID 39480216

PARAMEDIC-3 — IO-First vs IV-First in OHCA: No 30-Day Survival Difference, Lower ROSC With IO — UK Trial Supports IV-First Strategy

RCT CHANGE THIS MONTH UK FRCEM

• OR 0.94 30D SURVIVAL IO VS IV (NS)
• 36% vs 39% ROSC: IO-FIRST VS IV-FIRST
• ARD −3.2% ROSC DEFICIT WITH IO (CI −5.9 TO −0.6)
• UK RCT PRE-HOSPITAL, OHCA ADULTS

The PARAMEDIC-3 trial randomised UK adults with OHCA requiring drug therapy to an intraosseous-first (IO) or intravenous-first (IV) vascular access strategy. Primary outcome: 30-day survival. No significant difference: 4.5% vs 5.1% (adjusted OR 0.94, 95% CI 0.68–1.32, p=0.74). However, ROSC was significantly lower in the IO-first group: 36.0% vs 39.1% (adjusted risk difference −3.2%, 95% CI −5.9 to −0.6). Survival to hospital discharge, favourable neurological outcome, and length of hospital stay did not differ significantly. The trial was conducted by UK ambulance services and represents directly UK-generalisable evidence. Context: IO access is faster and more reliably achieved in OHCA, and is taught as a valid alternative in ALS algorithms when IV access fails. PARAMEDIC-3 suggests that IV-first is associated with better ROSC even if 30-day survival is equivalent — possibly because faster drug delivery via IV translates to ROSC but not to sustained survival (complex post-resuscitation factors dominate long-term outcome).

Critical appraisal: The 30-day survival primary outcome was not significantly different, but the ROSC difference (statistically significant) is biologically plausible: tibial IO access delivers adrenaline more slowly to the coronary circulation than IV access. The question of whether ROSC without long-term survival benefit is a meaningful outcome is legitimate. However, ROSC is the necessary precondition for any survival, and a 3.2% lower ROSC rate with IO-first is clinically important. The trial does not argue against IO use — it argues against IO-first when IV access is achievable. GRADE: High (pre-registered, UK ambulance service RCT, large n).

Tell your department: For in-hospital cardiac arrest (and for post-ROSC patients arriving in your resus bay with only IO access from HEMS/ambulance service): understand that IO delivers drugs more slowly. For OHCA: the prehospital message is IV-first when achievable; IO if IV fails promptly. In the resus bay, convert IO to IV access as soon as ROSC is achieved. Do not delay drug administration chasing IV if IO is readily available — the absolute ROSC difference (3.2%) applies to IV-first being pursued quickly, not to prolonged IV attempts that delay epinephrine delivery.

Source: Couper K et al. NEJM Evidence 2024 — PARAMEDIC-3 (PMID 39480216) · SGEM#462

J TRAUMA ACUTE CARE SURG · MARCH 2026 · SR/MA · PMID 41885281 · JOURNALFEED 21 MAY 2026

REBOA vs Resuscitative Thoracotomy for Non-Compressible Torso Haemorrhage — SR/MA: 83% Mortality Reduction With REBOA But Higher Complication Rates and Major Confounding

SR/MA INFORMING FRCEM

• OR 0.17 MORTALITY REBOA VS RT (95% CI 0.10–0.28)
• OR 7.81 COMPLICATIONS REBOA VS RT (95% CI 3.88–15.72)
• 14 studies ALL OBSERVATIONAL — SIGNIFICANT CONFOUNDING
• High het. PATIENT POPULATION & PROTOCOL VARIABILITY

This SR/MA (DiFabio et al, J Trauma Acute Care Surg March 2026; PMID 41885281) pooled 14 observational studies comparing resuscitative endovascular balloon occlusion of the aorta (REBOA) versus resuscitative thoracotomy with supraceliac aortic cross-clamping in patients with haemorrhagic shock or traumatic cardiac arrest from non-compressible torso haemorrhage. The headline finding is dramatic: REBOA was associated with an 83% reduction in the odds of mortality compared to RT (OR 0.17, 95% CI 0.10–0.28, p<0.0001). This effect was seen in both haemorrhagic shock and traumatic cardiac arrest subgroups. However, REBOA was associated with significantly higher complication rates (OR 7.81, 95% CI 3.88–15.72, p<0.0001) — predominantly vascular access complications, limb ischaemia, and catheter-related issues. Times to aortic occlusion were inconsistent across studies, with most reporting longer times to occlusion with REBOA than with RT. UK context: REBOA is delivered by HEMS teams and major trauma centres in the UK (primarily BASICS doctors, HEMS physicians, and trauma surgeons). Resuscitative thoracotomy for penetrating cardiac arrest is performed in a small number of UK major trauma EDs. This SR/MA provides important aggregate data, but the observational design means results should not be used to change practice; systematic differences in patient selection between REBOA and RT recipients are likely the primary driver of the mortality difference.

Critical appraisal: This is a meta-analysis of 14 observational studies — almost certainly the most confounded possible evidence base for this question. Patients selected for REBOA are likely to be more haemodynamically stable than those who receive RT (which is typically a last-resort intervention for traumatic cardiac arrest). Indication bias is profound and cannot be adjusted away. The 83% mortality reduction almost certainly reflects case selection rather than a true treatment effect. The complication rate signal is more plausible and reinforces the need for appropriate training and patient selection. The EAST 2025 guidelines conditionally support REBOA for traumatic cardiac arrest with suspected subdiaphragmatic bleeding based on level IV evidence. GRADE: Very Low (all observational, high heterogeneity, profound confounding).

Tell your department: The JournalFeed summary captures it well: “this won’t change my practice — not yet.” If you work in or refer to a major trauma centre with REBOA capability, understanding the current evidence base (and its limitations) is important for coordinating with your HEMS team and trauma surgeons. REBOA remains a specialist intervention requiring specific procedural training and real-time fluoroscopic or landmark guidance for catheter placement. Do not attempt REBOA without formal training and institutional approval.

Source: DiFabio R et al. J Trauma Acute Care Surg 2026 — REBOA vs RT SR/MA (PMID 41885281) · JournalFeed Spoon Feed, 21 May 2026

INJURY · FEBRUARY 2026 · CASE SERIES · PMID 41760498

Pericardiocentesis with Intrapericardial Tranexamic Acid — Definitive Management in Penetrating Cardiac Tamponade: 25-Case Series

OBSERVATIONAL INFORMING FRCEM

Qandil et al (Injury 2026; PMID 41760498) report 25 consecutive cases of penetrating cardiac tamponade managed with ultrasound-guided pericardiocentesis followed by intrapericardial injection of tranexamic acid (TXA) as definitive treatment, without formal surgical thoracotomy. Median presentation: haemopericardium on FAST, haemodynamically compromised. Technique: drain pericardial blood, then instil 500 mg TXA into the pericardial space to reduce re-accumulation from the wound. 24 of 25 patients survived to discharge. UK context: penetrating cardiac trauma is uncommon in most UK EDs but occurs in major trauma centres. In austere or resource-limited settings (or when surgical thoracotomy is not immediately available), pericardiocentesis remains a lifesaving bridge. The addition of intrapericardial TXA is a novel technique — not established practice — but this case series provides early proof-of-concept data. Emergency department thoracotomy (EDT) remains the definitive intervention for penetrating cardiac arrest or tamponade with deterioration despite pericardiocentesis. This should not substitute for surgical referral.

Critical appraisal: This is a 25-case series with no control arm. Selection bias is substantial: patients fit enough to receive pericardiocentesis rather than immediate thoracotomy are likely those with less severe injury. The technique is not validated for use outside of this specific setting. GRADE: Very Low (case series, no comparator). Do not adopt as standard practice; use as hypothesis-generating data and discuss with your trauma surgical team.

Source: Qandil M et al. Injury 2026 — Pericardiocentesis + Intrapericardial TXA (PMID 41760498) · First10EM

SECTION 2 — GUIDELINES & UK UPDATES

MHRA · MAY 2026 · DEVICE SAFETY INFORMATION · DSI/2026/003 · FORCED INCLUSION

MHRA DSI/2026/003 — Risk of Serious Harm From Use of Incorrect Giving Set for Blood Transfusion: IV Infusion Sets Must Not Be Used for Blood or Blood Components

UK SAFETY CHANGE TONIGHT

The MHRA has issued Device Safety Information (DSI/2026/003) warning of the risk of serious patient harm when an intravenous (IV) infusion giving set is used instead of a blood transfusion giving set to administer a transfusion of blood or blood components. IV infusion giving sets do not contain the required 170–200 micron filter for blood products. Without this filter, microaggregates of cellular debris, fibrin, and platelets can be administered directly to the patient, leading to embolic events, pulmonary complications, and transfusion reactions. The MHRA has received incident reports of this error occurring in clinical practice. The alert applies to all settings where blood transfusions are administered, including emergency departments.

Action required now: (1) Verify that all blood transfusion giving sets in your department’s stock are specifically labelled for blood administration and contain the in-line filter. IV infusion sets (used for saline, glucose, fluids) must not be used. (2) Ensure that all clinical staff administering blood products — doctors, nurses, healthcare assistants — are aware of this distinction. (3) Where IV fluid bags and blood product giving sets are stored in the same location, consider clear physical separation or labelling. (4) Complete a clinical incident report via your trust’s DATIX system if you identify or have previously identified this error. Report to the MHRA via the Yellow Card scheme. (5) Check your department’s blood transfusion competency framework ensures giving set selection is an explicit assessment point.

Source: MHRA DSI/2026/003 — Blood Transfusion Giving Set Error (May 2026)

UKHSA / WHO · UPDATED 18 MAY 2026 · HCID ALERT (UPDATE FROM ISSUE 12)

Hantavirus MV Hondius Outbreak Update — 3 Confirmed Deaths, 9 Confirmed Cases, Outbreak Evolving; UK Patients Repatriated to Arrowe Park

UK SAFETY

Update from Issue 12. As of 19 May 2026, the WHO/UKHSA report 11 cases (9 confirmed Andes virus, 2 probable) and 3 deaths — a case fatality rate of approximately 27%. Key events this week: (1) UKHSA deployed a rapid-response mobile HCID laboratory to St Helena (15 May) to support contact tracing on the island; (2) a symptomatic contact (a medic who had been on board) was evacuated from Ascension Island and transferred to the specialist HCID unit at Guy’s and St Thomas’ NHS Foundation Trust, London (16 May); (3) 9 asymptomatic contacts from the UK repatriation were transferred from Arrowe Park to home isolation with daily monitoring (17 May); (4) Japan donated favipiravir (an antiviral with theoretical but unproven activity against hantaviruses) to the UK national stockpile (18 May) — favipiravir is not licensed for this indication and its use is experimental; (5) the MV Hondius arrived in Rotterdam on 18 May for vessel disinfection, estimated 3–4 days. Canada confirmed its first positive case (18 May). A French passenger remains in critical condition. UK community risk: very low. No evidence of wider UK community transmission. UK ED relevance: unchanged from Issue 12. Screen for MV Hondius travel or close contact with confirmed cases in any unexplained ARDS presentation. Andes virus incubation period is 2–4 weeks (up to 40 days), so exposures from April 2026 onwards remain within the window.

Clinical reminder: Andes hantavirus presents with flu-like prodrome (fever, fatigue, myalgia, GI symptoms) progressing to cardiopulmonary phase with pulmonary oedema and cardiovascular collapse. Incubation: 2–4 weeks (up to 40 days). No antiviral treatment — supportive care only. If you encounter a patient with these symptoms and any link to the MV Hondius or travel to South America: isolate immediately, apply droplet and contact precautions, use FFP3 for AGPs, and contact UKHSA on-call before further investigation. Do not delay isolation pending confirmatory testing.

Source: WHO Disease Outbreak News — Hantavirus MV Hondius (DON601, updated 18 May 2026) · Wikipedia case timeline

REBEL EM · 19 MAY 2026 · CRITICAL APPRAISAL (HI-PEITHO COVERED IN ISSUE 4)

REBEL EM on HI-PEITHO — Catheter-Directed Fibrinolysis for Intermediate-Risk PE: Positive Primary Endpoint but Mortality and Bleeding Went the Wrong Way

INFORMING FRCEM

REBEL EM published a critical appraisal of HI-PEITHO (NEJM March 2026, PMID 41910345) on 19 May 2026. This newsletter covered HI-PEITHO in full in Issue 4 (March 2026), where we noted significant concerns. The REBEL EM appraisal adds important editorial context: the primary composite endpoint (4.0% vs 10.3%, RR 0.39, NNT 16) was largely driven by persistently elevated NEWS ≥9 in 15 patients (1 in US-CDT vs 14 in control) — a soft surrogate endpoint highly susceptible to detection bias in an open-label trial. PE-related deaths: 3 vs 1 (mortality went the wrong way, though not statistically significant). Major bleeding: 4.1% vs 3.0% at 30 days (not significant). REBEL EM conclusion: "No one should be using this device at this time." This aligns with our Issue 4 appraisal. UK applicability remains limited: US-CDT (EKOS system) is not widely available in UK centres, is funded by Boston Scientific (device manufacturer), and the trial remains underpowered for patient-oriented outcomes. The British Society for Haematology and BTS PE guideline groups have not yet issued updated recommendations based on HI-PEITHO.

Source: REBEL EM — HI-PEITHO Critical Appraisal (19 May 2026) · HI-PEITHO full coverage: Issue 4

EMERG MED AUSTRALAS · 2026 · PILOT STUDY

Radiologist Pre-Approval for CTPA in the ED — No Significant Difference in Diagnostic Yield in Single-Centre Pilot

OBSERVATIONAL INFORMING

Tan and Chandru (Emerg Med Australas 2026) conducted a single-centre pilot study examining whether mandatory radiologist pre-approval of CTPA requests in the ED improves diagnostic yield (rate of positive CTPA findings). They found no statistically significant difference in yield with or without pre-approval, though the study was significantly underpowered. The CTPA over-investigation problem in EDs remains real: rates of positive CTPA vary from 8–25% across UK departments. However, mandatory pre-approval creates delays, which carry risk in submassive and massive PE. UK context: the Wells score, PERC rule, and D-dimer (age-adjusted or YEARS algorithm) remain the appropriate pre-test probability tools for CTPA gating in UK EDs. This pilot does not provide evidence to change current practice, and its findings should not be used to justify removing existing probability-based gating tools.

Source: Tan H, Chandru P. Emerg Med Australas 2026;38(1):e70237 · First10EM May Roundup

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

ACAD EMERG MED · 2025 · SR/MA (FROM SPACE FILES)

Non-Injectable Ketamine for Paediatric Procedural Sedation in the ED — SR/MA Demonstrates Efficacy and Safety Across Oral, Intranasal, and Rectal Routes

SR/MA INFORMING PAEDS FRCEM

Mirfazaelian et al (Acad Emerg Med 2025) conducted a systematic review and meta-analysis of non-injectable routes of ketamine for paediatric procedural sedation in the ED. Three routes were examined: oral (PO), intranasal (IN), and rectal (PR). Across 14 studies and 1,847 paediatric patients, non-injectable ketamine achieved adequate sedation in the majority of cases (pooled sedation success rate ~85% for IN route at 3 mg/kg; ~70% for oral at 5–6 mg/kg). Adverse events were mild (nausea, transient oxygen desaturation, recovery agitation) and serious adverse events were rare. Onset time for IN ketamine was 5–10 minutes, consistent with clinical expectations. UK context: IV/IM access in children requiring procedural sedation can be distressing and lead to procedure delay. IN ketamine (atomiser device, 3 mg/kg) is a practical alternative for short procedures (abscess I&D, foreign body removal, laceration repair) where IV access has not been obtained. Intranasal diamorphine is the more established UK non-injectable analgesic; IN ketamine provides sedation rather than purely analgesia and should be considered when a sedation level is required. Cross-reference with local pharmacy availability.

Critical appraisal: Study heterogeneity was significant (different dosing protocols, different procedures, different age ranges). Success rate definitions varied. No head-to-head comparison with IV ketamine. GRADE: Low to Moderate. The evidence supports use in appropriately selected patients with appropriate monitoring, but IN ketamine should not replace IV ketamine for higher-risk procedures where deeper sedation monitoring is required.

Source: Mirfazaelian H et al. Acad Emerg Med 2025 — Non-Injectable Ketamine for Paediatric Procedural Sedation (SR/MA)

• Space file upload (March 2026)

PREHOSP EMERG CARE · APRIL 2026 · SR/MA · PMID 41996547 · JOURNALFEED 15 MAY 2026

Intramuscular vs Intranasal Midazolam for Paediatric Seizures — SR/MA: IM Achieves Faster Termination and Less Rescue Medication in ~4,000 Patients

SR/MA INFORMING PAEDS FRCEM

Mohnkern et al (Prehosp Emerg Care 2026; PMID 41996547) conducted a SR/MA in nearly 4,000 paediatric patients with acute seizures and delayed IV access (primarily prehospital and ED settings) comparing intramuscular versus intranasal midazolam. IM midazolam demonstrated faster seizure termination and reduced need for rescue medication compared to intranasal midazolam. Both routes achieved adequate seizure control in the majority of patients. UK context: current RCUK and APLS guidance supports buccal or intranasal midazolam as first-line for paediatric seizures when IV access is not available; IM midazolam is an alternative but less commonly used in UK paediatric practice. This SR/MA provides the most comprehensive evidence yet suggesting IM is modestly superior in efficacy — though IN remains highly practical (no needle, less distressing). The takeaway is not to abandon IN midazolam but to know that IM is a strong fallback if IN is ineffective or unavailable, and should be drawn up ready for any paediatric seizure. Intranasal diamorphine or fentanyl atomiser devices are generally preferred for analgesia in UK paeds EDs; this data specifically pertains to seizure management.

Tell your department: Ensure both IN and IM midazolam are available and drawn up for paediatric seizure management. If IN midazolam fails to terminate a seizure within 5–10 minutes, IM midazolam (0.1–0.2 mg/kg, max 10 mg) is an evidence-based next step if IV access has not been established. Do not delay to IV lorazepam if IM/IN have already been given and seizure continues — secure IV access and escalate per your status epilepticus protocol.

Source: Mohnkern JD et al. Prehosp Emerg Care 2026 — IN vs IM Midazolam Paeds Seizures SR/MA (PMID 41996547) · JournalFeed EM, 15 May 2026

SECTION 4 — FOAMED & CRITICAL APPRAISAL

SGEM · FIRST10EM · EMCRIT · MAY 2026

This Week in FOAMed — SGEM#510 CRAFFT, REBEL EM on HI-PEITHO, First10EM on Ketamine/Etomidate and ANDROMEDA-SHOCK-2

INFORMING

SGEM#510 (16 May 2026): Dr Andy Tagg joins Ken Milne for a detailed appraisal of the CRAFFT trial (covered in full as LEAD above). Key SGEM bottom line: for younger children (4–10y) with displaced fractures, a cast-first approach is now supported by evidence and the absence of long-term functional difference is the critical message for families. SGEM emphasis: do not read the 3-month non-inferiority result in isolation. REBEL EM (19 May 2026): Full HI-PEITHO review (covered in Section 2 above). Mark Ramzy’s key concern: the trial was entirely funded by Boston Scientific and uses a disease-oriented primary endpoint. First10EM (May Roundup, extended version): Justin Morgenstern adds that the 22.1% cardiovascular collapse rate with ketamine in the NEJM RSI trial is the most practice-relevant finding of the trial — and highlights that UK clinical lore (“ketamine is safe for the BP”) has never been based on high-quality RCT evidence and is now contradicted by the largest trial ever conducted on this question.

Source: SGEM#510 · REBEL EM (19 May 2026) · First10EM May Roundup

SECTION 5 — QUICK HITS

JAMA · MAY 2026 · PMID TBC · MCMASTER EVIDENCE ALERTS 6/7

INSTANT Trial — IV Tirofiban After Tenecteplase in Acute Ischaemic Stroke: GP IIb/IIIa Inhibition Post-Thrombolysis

The INSTANT RCT (JAMA, McMaster score 6/7) evaluated IV tirofiban (a glycoprotein IIb/IIIa inhibitor used in ACS) added immediately after tenecteplase thrombolysis in acute ischaemic stroke. Full results pending direct access, but the McMaster alert scores this as 6/7 — among the highest-rated items this week. GP IIb/IIIa inhibitors are already used post-EVT in some centres; post-thrombolysis application is a newer paradigm. UK relevance: not yet in NICE NG128. Watch for details and NICE surveillance response. JAMA 2026 — INSTANT Trial (via McMaster Evidence Alerts, 20 May 2026)

J NEUROL · APRIL 2026 · SR/MA · PMID 41925916 · JOURNALFEED POCUS

Optic Nerve Sheath Diameter ≥5.1 mm Identifies Intracranial Hypertension: SR/MA Supports POCUS Use in Acute Neurological Emergencies

Wang et al (J Neurol 2026; PMID 41925916) — SR/MA finds that sonographic ONSD ≥5.1 mm identifies elevated ICP with useful sensitivity and specificity in acute neurological crises. The threshold is consistent with the widely cited ≥5.0 mm values used in existing UK POCUS guidelines. UK ED relevance: for patients presenting with unexplained reduced GCS, severe headache, or acute neurological deterioration where invasive ICP monitoring is not immediately available, ONSD POCUS provides a non-invasive bedside screen. Does not replace CT. Measure the optic nerve sheath 3 mm behind the globe on both sides; average >5.1 mm is abnormal. Findings should lower the threshold for urgent CT and neurosurgical review. Wang X et al. J Neurol 2026 (PMID 41925916)

J HOSP MED · APRIL 2026 · PMID 42007523 · JOURNALFEED EM

“Things We Do For No Reason” — Routine UFH for VTE Anticoagulation Should Be Replaced by LMWH

Saklawi et al (J Hosp Med 2026; PMID 42007523) review the evidence for routine UFH as initial anticoagulation in VTE, concluding it should be abandoned in favour of LMWH (superior efficacy, safety, and ease of use) or direct oral anticoagulants. UK context: UFH infusions are still used in some UK EDs for PE or DVT pending haematology review, or where renal dosing requires adjustment. NICE NG158 (VTE in adults) recommends LMWH (e.g. dalteparin, tinzaparin) or apixaban/rivaroxaban as first-line. If your department is still starting UFH infusions routinely for PE or DVT without a specific indication (renal failure, planned thrombolysis, extreme obesity), review your protocol. Saklawi Y et al. J Hosp Med 2026 (PMID 42007523)

JAMA · APRIL 2026 · RCT · PMID 42008277 · JOURNALFEED EM

Serious Game Training Reduces Undertriage of Severely Injured Older Adults at Non-Trauma Centres (JAMA RCT)

Mohan et al (JAMA 2026; PMID 42008277) randomised emergency physicians at non-trauma centres to a video game-based simulation for trauma triage decision-making. The intervention reduced undertriage of severely injured older adults from 57% to 49% (p=0.02). UK context: undertriage of major trauma in older adults remains a known problem at UK EDs that are not designated major trauma centres. TARN data consistently shows older adults are disproportionately undertriaged. This RCT provides proof-of-concept that simulation-based training (which can be delivered online at low cost) can shift triage behaviour. For consideration in your departmental simulation programme. Mohan D et al. JAMA 2026 (PMID 42008277)

PEDIATR EMERG CARE · APRIL 2026 · PMID 42011037 · JOURNALFEED EM

Paeds Appendicitis Pathway — USS-First Clinical Pathway Reduces CT Use Without Missing Diagnoses

Barricelli et al (Pediatr Emerg Care 2026; PMID 42011037) — implementation of a clinical pathway prioritising ultrasound before CT for suspected appendicitis in children significantly reduced CT utilisation rates without increasing missed diagnoses or adverse outcomes. UK context: USS-first for paediatric appendicitis is already standard at many UK centres (in line with NICE guidance), but CT rates vary significantly. This cohort study reinforces the safety of a structured USS-first pathway and provides data to support local QI initiatives. Ensure your pathway includes a clear escalation route to CT when USS is non-diagnostic and clinical suspicion remains high. Barricelli E et al. Pediatr Emerg Care 2026 (PMID 42011037)

J TRAUMA ACUTE CARE SURG · APRIL 2026 · PMID 41995161 · JOURNALFEED 15 MAY 2026

Calcium Chloride in Trauma Resuscitation — ≥1g per 2 Units Blood Associated With 84% Reduction in 24-Hour Mortality

Rajesh et al (J Trauma Acute Care Surg 2026; PMID 41995161) — retrospective study of trauma patients receiving whole blood resuscitation. Administering ≥1 g calcium chloride per 2 units of blood was associated with an 84% reduction in 24-hour mortality compared to lower calcium dosing. Mechanism: citrate in stored blood chelates ionised calcium, causing hypocalcaemia that impairs cardiac contractility, coagulation, and vasomotor tone. UK relevance: hypocalcaemia during massive transfusion is under-recognised and under-treated. Check ionised calcium in all major haemorrhage activations. Target iCa ≥1.1 mmol/L. Use calcium chloride (not gluconate) in the acute setting for faster ionisation. This is observational data only — but the physiological rationale is strong and aligns with existing MHP guidance. Rajesh A et al. J Trauma 2026 (PMID 41995161)

J TRAUMA ACUTE CARE SURG · APRIL 2026 · SR/MA · PMID 41989256 · JOURNALFEED 14 MAY 2026

NIV Superior to HFNC for Hypoxaemic Respiratory Failure in Chest Trauma — Network Meta-Analysis

Taniguchi et al (J Trauma Acute Care Surg 2026; PMID 41989256) SR/MA in adults with hypoxaemic respiratory failure after chest trauma: NIV was associated with lower escalation of respiratory support and improved in-hospital outcomes compared to HFNC and conventional O2 therapy. UK relevance: rib fracture and chest trauma are common ED presentations and the choice between NIV, HFNC, and standard O2 is often made empirically. This SR/MA supports NIV as the preferred mode in patients with chest trauma who require respiratory support beyond simple O2. Note: patients with SpO2 adequately maintained on standard O2 may not require escalation. Ensure your department has early physiotherapy and pain management (FICB for rib fractures) in place alongside respiratory support. Taniguchi H et al. J Trauma 2026 (PMID 41989256)

JAMA · APRIL 2026 · COHORT STUDY · PMID 41999289 · JOURNALFEED 18 MAY 2026

Amoxicillin Alone Non-Inferior to Amoxicillin-Clavulanate for Acute Sinusitis — With Fewer Adverse Events

Savage et al (JAMA 2026; PMID 41999289) — large retrospective cohort study demonstrating standard amoxicillin was non-inferior to co-amoxiclav for treatment failure in acute sinusitis, with fewer adverse events (primarily GI). UK relevance: NICE NG236 (sinusitis) recommends antibiotics only when symptoms are severe or not improving; when prescribing is indicated, amoxicillin (not co-amoxiclav) is first-line. Co-amoxiclav is frequently overprescribed for sinusitis in UK EDs and urgent care settings. This large study reinforces current NICE guidance and supports antibiotic stewardship. Savage TJ et al. JAMA 2026 (PMID 41999289)

MHRA · FSN 11–15 MAY 2026

MHRA Field Safety Notices 11–15 May 2026 — No Class 1 Recalls; Routine Review Recommended

The MHRA published its weekly FSN batch for 11–15 May 2026. No Class 1 (immediate serious harm) device alerts specific to emergency medicine equipment were identified in this period. The transfusion giving set alert (DSI/2026/003) remains the highest-priority MHRA safety item this week. Contact your biomedical engineering team to confirm all remaining FSNs from the 4–8 May batch (Hamilton IntelliCuff, GE CARESCAPE) have been reviewed. gov.uk/drug-device-alerts

NICE · 19 MAY 2026 · HTG779

NICE HTG779 — AI-Assisted Echocardiography for Heart Failure: Early-Use Guidance with Evidence Generation Requirements

NICE published an early-use guidance (HTG779) on 19 May 2026 recommending NHS adoption of AI-assisted echocardiography analysis tools for heart failure diagnosis and monitoring, conditional on prospective evidence generation. ED relevance: EDs with established POCUS programmes or that routinely perform or refer for point-of-care echo in acute heart failure may benefit from these tools as they become integrated into echo reporting workflows. This does not create an immediate ED obligation, but is worth noting for departments developing acute HF pathways that include echo. NICE HTG779

UKHSA · ONGOING · WEEK OF 21 MAY 2026

Group A Streptococcus (iGAS) — UK Seasonal Decline; Remain Alert in Paediatric Presentations

UKHSA Health Protection Report (HPR Vol.20) continues to track invasive Group A Streptococcus. iGAS incidence is declining from its winter peak but remains above pre-pandemic baseline. In paediatric presentations with pharyngitis + systemic features (high fever, rapid deterioration, toxic appearance, periorbital involvement, or necrotising soft tissue features): consider iGAS and treat empirically with IV benzylpenicillin + clindamycin (for toxin inhibition) pending culture. All cases are statutorily notifiable. UKHSA HPR Vol.20

MENB · DORSET/KENT · ONGOING SURVEILLANCE

Invasive Meningococcal Disease — No New Cluster Cases Since Issue 12; Maintain General Vigilance

No new cases linked to the Dorset or Kent MenB clusters have been confirmed since Issue 12 reporting. The Kent incident reverted to standard status in early April. General vigilance for IMD in all young adults (15–25) and children continues as the UK enters the traditional post-winter surveillance period. Clinical reminder: Immediate ceftriaxone 2 g IV/IM for suspected meningococcal disease, before CT, before LP, before microbiology. Notify PHE/UKHSA for all suspected cases.

CORE REVISION — HIP FRACTURE IN THE ED

FRCEM REVISION — HIP FRACTURE IN THE ED: GETTING THE BASICS RIGHT

Hip fractures account for approximately 70,000 UK admissions per year with a 30-day mortality of 5–8% and a 1-year mortality of 20–30%. They are predominantly injuries of older, frail adults. The ED role is: correct early analgesia, identify time-critical complications, initiate the geriatric frailty pathway, and ensure patients reach theatre within the 36-hour NICE standard. Missed hip fractures (occult fractures with normal plain X-ray) remain a key medicolegal risk.

ACTION POINTS — ISSUE 13

• MHRA transfusion giving set alert (DSI/2026/003): Check your blood administration sets today. IV infusion sets must not be used for blood products. Ensure clear separation of blood transfusion giving sets and IV fluid giving sets in your resus bay and your blood fridge storage area. [MHRA DSI/2026/003]
• Paeds distal radius fracture: For children aged 4–10 with displaced distal radius fractures who are neurovascularly intact: offer cast-first as a valid, evidence-based option in shared decision-making. Do not default to surgical referral. Inform families: equivalent function at 6 and 12 months, fewer complications, lower cost. [CRAFFT, Lancet 2026]
• RSI drug choice review: Ketamine and etomidate are equivalent for 28-day mortality. In profoundly haemodynamically compromised patients (septic shock, cardiogenic shock, catecholamine-depleted), etomidate may be the safer induction choice — it causes significantly less cardiovascular collapse (NNH 20 with ketamine). If etomidate is not stocked in your department, consider adding it. [NEJM RCT, n=2,359]
• Sepsis bedside monitoring: Add capillary refill time (CRT) to your bedside sepsis resuscitation target set. Abnormal CRT: >3 seconds at fingertip, measured by pressing with a glass slide for 10 seconds then releasing. Use alongside lactate clearance, MAP ≥65, and urine output. [ANDROMEDA-SHOCK-2, JAMA]
• OHCA vascular access: IV-first strategy is supported by PARAMEDIC-3 (UK RCT). Prioritise IV access in OHCA; use IO promptly when IV fails — do not delay epinephrine chasing IV if IO is readily available. After ROSC, convert IO to IV as soon as stable. [PARAMEDIC-3]
• Hip fracture analgesia: Fascia iliaca block is NICE-mandated (NG124) for all hip fractures pre-operatively. If your department is not routinely performing FICB for hip fractures, this is a clinical governance priority. Weight-based bupivacaine (0.25%, max 2 mg/kg) is the standard. Ensure competency assessment covers this skill. [FRCEM Core Revision]
• Hantavirus vigilance: Outbreak ongoing with 3 deaths. Screen any unexplained ARDS for MV Hondius travel or South American exposure. Treat as HCID if suspected: isolate, droplet + contact precautions, FFP3 for AGPs, UKHSA on-call before investigation. [UKHSA, updated 18 May 2026]

TRIALS TO WATCH

UPCOMING TRIALS & GUIDELINE MILESTONES

Q2–Q3 2026

NICE NG185 Chest Pain Guideline — LEGEND Response: NICE surveillance triggered by the LEGEND trial. New hs-cTnT assay thresholds for 0h/1h rule-out expected. Watch for updated NICE/ESC alignment. NICE NG128 Stroke — Late Window Thrombolysis Surveillance: OPTION trial (Issue 12) and HOPE-ASiS data feeding into NICE surveillance review. UK stroke networks should not change practice until formal NICE guidance. CoMiTED — Conservative vs Immediate Chest Drain in Traumatic Pneumothorax (UK): Ongoing. Will inform RCEM/NICE guidance on pneumothorax management — currently very limited RCT evidence in this area. BACHb — HFNC vs Standard O2 vs CPAP in Bronchiolitis (50 NHS hospitals): Multicentre UK trial still enrolling. Will define optimal respiratory support for infants with bronchiolitis — most common paediatric admission.

2026–2027

HSSIB Mental Health Crisis ED Full Report: Part 1 (April 2026) identified the legislative gap (no lawful holding power). Part 2 due summer 2026 — will address ED environment, knowledge, and decision-making. Watch for systemic recommendations. BEST-DKA — Balanced Electrolyte vs Saline in Adult DKA: Phase 3, Australia. Will settle the adult DKA fluid debate alongside existing SCOPE-1 data. On-Scene ECPR Trial (Netherlands) — Prehospital ECPR in Refractory OHCA: If positive, will generate pressure for ECPR capability at UK cardiac arrest centres.

LONGER HORIZON

PEERLESS II — Mechanical Thrombectomy vs Anticoagulation in Intermediate-Risk PE: Enrolment ongoing. Will provide further evidence alongside HI-PEITHO on catheter-based strategies for PE. Results 2027+. NHS Mental Health Act Reform (Mental Health Bill 2025–26): Parliamentary progress continues. HSSIB R/2026/082 calls for urgent legislative fix to ED holding power gap. Watch for Royal Assent timeline and ED-specific provisions.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 13 — 21 May 2026 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com