EM Evidence Rundown — Issue 15

UK EDITION · ISSUE 15 · 4 JUNE 2026

EM Evidence Rundown

Emergency medicine evidence for UK ED clinicians — weekly

Jake Turner

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

The full archive of every issue is available at emevidence.org — including audio summaries and PDF downloads.

URGENT: Ebola Bundibugyo WHO PHEIC — add 21-day DRC/Uganda travel screen to triage now (UKHSA 0344 778 8990). ChloraPrep recall expiry ≤02/2028. RCEM TCM QIP: 66% Levodopa/insulin doses late in ED. LEAD: HEPARIN STEMI RCT (Circulation 2026) — prehospital heparin for primary PCI: does timing still matter? 0/1-hr vs 0/3-hr troponin pathway RCT (JACC). Azithromycin in preschool wheeze (NEJM). SQuID DKA protocol. Defibrillation revision.

BOTTOM LINE UP FRONT — ISSUE 15

ACT ON THIS NOW

TONIGHT Ebola PHEIC: Add 21-day DRC/Uganda travel screen to triage. Suspect = isolate + UKHSA 0344 778 8990 before any blood-exposing procedure. Check PPE stocks.

TONIGHT ChloraPrep recall: MHRA EL(26)A/26 — quarantine all batches expiry ≤02/2028 from all ED areas. Contact pharmacy for alternatives.

TONIGHT Time-critical meds: RCEM QIP: 66% Levodopa/insulin doses late; 40% missed. Name a prescriber for every boarding Parkinson’s/diabetic patient within 1 hour of admission decision.

THIS MONTH DKA SQuID: Weight-based insulin + simplified K+ replacement. Reduces hypoglycaemia. Check your departmental DKA protocol against JBDS 2023.

THIS MONTH STEMI + heparin: HEPARIN STEMI RCT (Circulation 2026, n=455): prehospital vs ED-door heparin timing no difference in TIMI 3 flow at angiography. Do not delay primary PCI to give heparin first.

THIS MONTH ACS troponin pathways: 0/1-hr rule-out non-inferior to 0/3-hr (JACC RCT). Halves ED LOS for rule-outs. If not already using 0/1-hr, present this evidence to your cardiology team.

KNOW FOR NEXT TIME

PAEDS Preschool wheeze: Azithromycin at onset of wheeze episode (NEJM 2026, n=>600): NNT 11 to prevent hospital admission. Significant for UK winter respiratory season planning.

PAEDS Paeds TBI: EVD independently associated with lower mortality vs ICP monitor alone (n=4,200). Get neurosurgical review early in severe paeds TBI — ask specifically about EVD.

PAEDS COVID vaccine in pregnancy: Maternal 3rd-trimester COVID vaccination protects infant against COVID hospitalisation (n=78,000). Know this when counselling antenatal patients in ED.

INFORMING Trauma airway: JournalFeed: VL in trauma intubation improves first-pass success even without neuromuscular blockade. Consistent with the prior DEVICE data. Use VL as default in trauma RSI.

INFORMING POCUS for fractures: Sens 87.8% / Spec 91.7% for long bone fractures vs X-ray (n=174). Faster time to diagnosis. Useful for initial ED assessment before definitive imaging.

INFORMING ACS + transfusion: PulmCCM TOP trial: Hb target 10 g/dL reasonable in Type 1 MI with anaemia. Restrictive 7 g/dL threshold may be insufficient in active ACS.

This week the full inbox sweep turned up two genuinely novel clinical items: the first RCT of prehospital heparin timing in STEMI, and a head-to-head troponin pathway trial comparing 0/1-hr vs 0/3-hr rule-out directly. Both matter to every UK ED. Three safety alerts are active simultaneously — Ebola PHEIC, ChloraPrep recall, and the RCEM time-critical medication audit. In paediatrics: azithromycin for preschool wheeze at NEJM-level evidence arrives just before winter planning begins.

WHAT’S INSIDE ISSUE 15

Section 1 — Key Trials: HEPARIN STEMI RCT (LEAD) · 0/1-hr vs 0/3-hr troponin pathway RCT · TOP trial: transfusion in ACS · Trauma airways: VL in trauma intubation · POCUS for long bone fractures in ED · US-guided truncal blocks for chest drain · SQuID DKA protocol Section 2 — UK & Safety: Ebola Bundibugyo PHEIC (ACT NOW) · ChloraPrep recall (ACT NOW) · RCEM Time-Critical Medications QIP · RCEM Better Basics Better Care accreditation Section 3 — Paediatric EM: Azithromycin preschool wheeze (NEJM) · Maternal COVID vaccination pregnancy (n=78,000) · Paeds severe TBI: EVD vs ICP monitor · Ketamine suicidal ideation paeds (pilot RCT) Section 4 — FOAMed: REBEL EM — lower GI bleeding CTA decision · EM Cases — OUD pain management · PulmCCM — restraining vented patients Quick Hits · Core Revision — Defibrillation · Action Points · Trials to Watch

SECTION 1 — KEY TRIALS & JOURNAL ARTICLES

CIRCULATION · PUBLISHED ONLINE MARCH 2026 · RCT · PMID 41910504 · EMA DAILY 1 JUNE 2026 · LEAD

HEPARIN STEMI RCT — Prehospital vs In-Hospital Heparin Before Primary PCI: Timing Makes No Difference to TIMI Flow — Do Not Delay Primary PCI to Give Heparin First

RCT CHANGE THIS MONTH FRCEM

• No difference PREHOSPITAL VS IN-HOSPITAL HEPARIN: TIMI 3 FLOW AT ANGIOGRAPHY
• n=455 MULTICENTRE RCT (SLOVENIA + INTERNATIONAL SITES)
• No delay KEY MESSAGE: DO NOT DELAY PRIMARY PCI TO ADMINISTER HEPARIN

Fister M, Noc M, Radsel P et al (Circulation 2026; PMID 41910504) conducted a multicentre RCT across 455 STEMI patients randomised to prehospital unfractionated heparin (UFH) administration (bolus 60 IU/kg, max 4000 IU) vs standard in-hospital UFH at the catheterisation lab. Primary outcome: TIMI grade 3 flow at initial angiography (a marker of spontaneous reperfusion prior to primary PCI). There was no statistically significant difference between groups in TIMI 3 flow, infarct size, or 30-day MACE. EMA Daily editor Sanjay Arora summarises: “the trial might have been underpowered to detect a difference, if one really exists.”

UK context: the debate about prehospital anticoagulation in STEMI is longstanding. UK ambulance services (JRCALC guidelines) do not routinely administer UFH prehospital, with anticoagulation given in the cath lab as standard practice. This RCT provides the highest-quality evidence to date suggesting that earlier heparin administration does not improve the angiographic outcomes that matter (spontaneous reperfusion before wire crossing). The practical message: primary PCI should not be delayed to administer heparin. The goal remains door-to-balloon ≤90 minutes; any drug administration that delays this is harmful by the intervention time data.

Critical appraisal: This was predominantly a Slovenian trial with a specific high-performing primary PCI system — average door-to-balloon time in that system is <60 minutes. In a system where prehospital heparin would genuinely precede in-hospital heparin by 30+ minutes (e.g. remote rural UK ambulance with long transport times), the time difference between arms might be larger and a benefit might emerge. The underpowering caveat is real. However, for most UK STEMI patients in urban and semi-urban settings, this evidence supports current practice: get to the cath lab, do not add steps that delay arrival.

Source: Fister M et al. Circulation. 2026 (PMID 41910504) · EMA Daily 1 June 2026 — Editor Commentary

J AM COLL CARDIOL · 2026 · RANDOMISED TRIAL · MCMASTER EVIDENCE ALERTS 2 JUNE 2026

Accelerated Diagnostic Pathways for Suspected ACS: 0/1-Hour Non-Inferior to 0/3-Hour Troponin Testing — Halves ED Length of Stay for Rule-Outs

RCT CHANGE THIS MONTH FRCEM

• Non-inferior 0/1-HR VS 0/3-HR FOR MI RULE-OUT SAFETY
• ~50% LOS reduction ED LOS FOR RULE-OUT PATIENTS

This JACC randomised trial (McMaster Evidence Alerts, 2 June 2026, score 6/7) directly compares the 0-hour/1-hour high-sensitivity troponin rule-out pathway vs the 0-hour/3-hour pathway for suspected ACS in the ED. The 0/1-hr pathway was non-inferior for safety (MI or cardiac death within 30 days) and approximately halved ED length of stay for patients who were ultimately ruled out. High-sensitivity troponin assays (hs-cTnI, hs-cTnT) enable the 0/1-hr pathway by providing reliable delta changes at just 1 hour.

UK context: the European Society of Cardiology (ESC) 2020 guidelines already endorse the 0/1-hr pathway as the preferred strategy where validated hs-troponin assays are available. NICE NG185 (chest pain) supports both pathways. RCEM guidance leans toward 0/1-hr where available. However, implementation across UK EDs is inconsistent: many departments still use 0/3-hr or 0/6-hr pathways. This RCT provides the direct randomised evidence that the 0/1-hr approach is as safe and significantly more efficient. For departments still on 0/3-hr: present this evidence to your cardiology team and ED clinical lead. For departments on 0/6-hr: the 0/1-hr pathway represents a significant patient flow improvement.

Implementation: The 0/1-hr pathway requires a validated hs-troponin assay (not a standard troponin). The specific threshold values differ by assay manufacturer — verify your laboratory’s validated thresholds. Do NOT apply 0/1-hr pathway values from one assay to a different assay — this has caused missed MIs in published case series. ESC validation data is available for Roche Elecsys, Abbott ARCHITECT, Siemens ADVIA, and Beckman Access assays.

Source: Accelerated Diagnostic Pathways for Suspected ACS: 0/1-hr vs 0/3-hr RCT. JACC. 2026 · McMaster Evidence Alerts, 2 June 2026 (Score 6/7)

PULMCCM · 4 JUNE 2026 · TOP TRIAL ANALYSIS

PulmCCM: TOP Trial — Transfusion Thresholds in High-Risk Surgical Patients With Cardiac Morbidity: Hb Target 10 g/dL Is Reasonable in Type 1 MI With Anaemia

INFORMING RCT DATA FRCEM

PulmCCM (4 June 2026) analysed the TOP trial in the context of the MINT trial secondary analysis for patients with acute MI and anaemia. The MINT trial (n=3,500 acute MI patients with anaemia, NEJM): liberal (Hb target 100 g/L) vs restrictive (70–80 g/L) transfusion trended toward benefit with liberal at p=0.07, with a significant result in the prespecified Type 1 MI (coronary occlusion) subgroup (13.8% vs 18.2%, p=0.04). TACO (transfusion-associated cardiac overload) was higher in the liberal arm (0.5% vs 1.3%). The TOP trial added supporting data that liberal transfusion can reduce postoperative cardiac events in high-risk surgical patients with cardiac morbidity.

Updated guidance: Hb 10 g/dL is now cited as a reasonable transfusion threshold by UpToDate and AHA guidance for patients with active Type 1 MI and anaemia. The restrictive 7 g/dL threshold that applies to most hospitalised patients is likely insufficient in this specific subgroup. For ED practice: when a patient with NSTEMI or STEMI has a Hb <10 g/dL, this evidence supports transfusion — document the indication clearly. TACO risk is higher with liberal transfusion; in patients with impaired LV function, balance carefully.

Source: PulmCCM — Can Transfusing Blood Prevent MIs? (4 June 2026) · The Bottom Line — MINT Summary

JOURNALFEED · 4 JUNE 2026 · ARTICLE OF THE DAY

Trauma Airways — VL Strikes Again: Video Laryngoscopy Improves First-Pass Success in Trauma Intubation Without Neuromuscular Blockade

INFORMING REVIEW FRCEM

JournalFeed’s Article of the Day (4 June 2026) covers a study on VL vs direct laryngoscopy in trauma intubations, including cases performed without neuromuscular blockade (NMB). VL improved first-pass success rates even in the non-NMB subgroup, addressing a practical scenario common in ED trauma: the rapid sequence where paralytic is withheld (distorted anatomy, cervical spine concern, or clinical choice). The consistent message from DEVICE, this study, and the accumulating observational data is that VL should be the default for all emergency intubations regardless of NMB use.

UK relevance: a small number of UK ED and trauma teams still default to direct laryngoscopy, particularly in teams where VL was not available during training. This is a persistent pattern in the audit data. The evidence now supports an unambiguous policy: VL is the first-line device for emergency airway management in the ED. Where both SGVL (standard-geometry) and HAVL (hyperangulated) blades are available, SGVL is the reasonable default with HAVL available for anticipated difficult airways.

Source: JournalFeed — Trauma Airways: VL Strikes Again (4 June 2026)

J EMERG MED · 2026 · PROSPECTIVE STUDY · PMID 41945995 · N=174 · JOURNALFEED EM 4 JUNE 2026

POCUS for Long Bone Fractures in the ED — Sensitivity 87.8%, Specificity 91.7% vs Radiography (n=174): Faster to Diagnosis, High Clinician Acceptance

INFORMING OBSERVATIONAL FRCEM

Tom E, Suseel A, Abraham SV et al (J Emerg Med 2026; PMID 41945995) studied POCUS for suspected long bone fractures in 174 ED patients. Sensitivity 87.8%, specificity 91.7% vs radiography as reference standard. Time to diagnosis was significantly faster with POCUS. Clinician acceptance was high. This adds to the SR/MA evidence base for POCUS in fracture diagnosis in the ED.

UK context: POCUS for fracture detection is not yet part of RCEM or British Society for Emergency Medicine standard practice guidelines, but is increasingly used in UK EDs with strong POCUS programmes. Clinically relevant scenarios: (1) Initial assessment of suspected rib fractures in elderly patients to guide pain management before formal imaging; (2) Scaphoid fractures where initial X-ray is unreliable — fracture cortex disruption sign on POCUS has been validated; (3) Suspected femoral neck fracture in frail patients where positioning for X-ray is difficult. Do not use POCUS to rule out fractures definitively in high-clinical-suspicion cases — sensitivity of 87.8% means 1 in 9 fractures are missed.

Source: Tom E et al. J Emerg Med. 2026 (PMID 41945995) · JournalFeed EM Speed Read, 4 June 2026

J EMERG MED · 2026 · REVIEW · PMID 41936304 · JOURNALFEED EM 4 JUNE 2026

Ultrasound-Guided Truncal Blocks for Tube Thoracostomy Analgesia in the ED — Opioid-Sparing Alternative for a Painful Procedure

REVIEW INFORMING FRCEM

Reeves MT, Lee Y, Shalaby M (J Emerg Med 2026; PMID 41936304) review ultrasound-guided truncal nerve blocks as an opioid-sparing analgesic option for tube thoracostomy (chest drain) insertion in the ED. Techniques discussed include serratus anterior plane block (SAPB) and erector spinae plane block (ESP block) — both are fascial plane blocks with good rib/pleural analgesia coverage that can be performed quickly by ED physicians with POCUS training.

UK context: chest drain insertion remains one of the most painful procedures performed in the ED and is often performed with inadequate or no regional analgesia in the acute setting. The ESP block was covered in Issue 5 of the Anaesthetics newsletter in the context of rib fractures.

For EM clinicians: SAPB and ESP blocks are within scope for EM POCUS-trained practitioners. Both blocks can be performed in <5 minutes. They significantly reduce procedural pain and opioid requirements compared to local infiltration alone. For FRCEM candidates: regional anaesthesia in the ED is a recurring structured oral examination topic.

Source: Reeves MT et al. J Emerg Med. 2026 (PMID 41936304) · JournalFeed EM Speed Read, 4 June 2026

SGEM · 4 JUNE 2026 · SGEM #511 · FOAMED / PROTOCOL REVIEW

SGEM #511: The SQuID Protocol for DKA — Weight-Based Insulin and Simplified K+ Replacement Reduces Hypoglycaemia and Protocol Errors

CHANGE THIS MONTH REVIEW FRCEM

The Skeptics’ Guide to Emergency Medicine #511 (4 June 2026) reviews the SQuID (Simplified Quasi-Insulin-Dependent) DKA protocol, which uses weight-based insulin (0.1 units/kg/hr) with a simplified potassium replacement table and a clear glucose threshold (glucose <14 mmol/L) to switch to dextrose-containing fluids. Published retrospective and prospective data show lower rates of hypoglycaemia (glucose <4 mmol/L) and fewer calculation errors vs standard fixed-rate protocols. The evidence base is moderate (before-after comparisons; no large RCT) but the principles align closely with the Joint British Diabetes Societies (JBDS) 2023 DKA guidelines.

UK context: DKA accounts for approximately 40,000 hospital admissions per year in England. Suboptimal potassium management and hypoglycaemia from insulin infusions are preventable causes of harm. If your department’s DKA protocol uses a fixed-rate insulin infusion and a complex potassium replacement table, a SQuID-style simplification — aligned with JBDS 2023 — is worth implementing. Three questions to ask about your current protocol: (1) Is insulin weight-based? (2) Is your potassium replacement table unambiguous for all K+ ranges? (3) Does your nursing team know when to add dextrose?

Source: SGEM #511 — SQuID DKA Protocol (4 June 2026) · JBDS 2023 DKA Guidelines: jbds.org

SECTION 2 — UK GUIDELINES & SAFETY

UKHSA · 3 JUNE 2026 · URGENT PUBLIC HEALTH MESSAGE · WHO PHEIC ACTIVE

UKHSA URGENT: Ebola Virus Disease (Bundibugyo) — WHO PHEIC Declared 17 May 2026; Add 21-Day DRC/Uganda Travel Screen to Triage Now

ACT NOW SAFETY ALERT UK UKHSA

Action required tonight: WHO declared a PHEIC for Ebola Bundibugyo virus on 17 May 2026. UKHSA urgent message 3 June 2026. Add the following question to triage assessment today: “Have you travelled to or from the Democratic Republic of Congo, Uganda, or any neighbouring country in the past 21 days?” Any patient with: (1) travel to the affected region in the past 21 days AND fever or history of fever, OR (2) unexplained haemorrhagic symptoms, multi-organ failure, or reduced GCS even without fever or travel — is a VHF suspect until proven otherwise.

If a suspect is identified: (1) Isolate in a side room immediately with door closed; (2) Apply Level 3 PPE before entering (FFP3 respirator + full visor + fluid-repellent gown + double gloves + overshoes); (3) Call the UKHSA Duty Doctor: 0344 778 8990 (24h) before drawing any blood or performing any invasive procedure; (4) Do NOT send routine bloods until UKHSA risk stratification is complete using the ACDP VHF algorithm. The ACDP algorithm is available at gov.uk. Verify your trust’s VHF isolation room and PPE stock levels today. As of 3 June, no confirmed UK cases.

Source: UKHSA — Ebola Bundibugyo Urgent Message, 3 June 2026 · UKHSA 24h: 0344 778 8990

MHRA · 2 JUNE 2026 · CLASS 2 RECALL · EL(26)A/26

MHRA Class 2 Recall: ChloraPrep 2% Applicators (Becton Dickinson) — All Batches Expiry ≤02/2028; Packaging Sterility Breach

ACT NOW SAFETY ALERT UK MHRA

MHRA EL(26)A/26, 2 June 2026: Becton Dickinson has recalled all batches of ChloraPrep 2% chlorhexidine gluconate / isopropyl alcohol 70% applicators with expiry date on or before 02/2028 due to a packaging sterility breach. This affects the most widely used skin antiseptic preparation for cannulation, arterial lines, CVP lines, and procedural antisepsis across UK EDs. Quarantine all affected stock from all procedure trolleys, resus bays, and storage areas now. Contact your trust pharmacy for unaffected alternatives (povidone-iodine 10%, or unaffected-batch chlorhexidine products).

Source: MHRA EL(26)A/26 — ChloraPrep 2% Recall, 2 June 2026

RCEM · 3 JUNE 2026 · QIP AUDIT REPORT

RCEM Time-Critical Medication QIP — 66% of Levodopa and Insulin Doses Late in UK EDs; 40% Missed Entirely: Systemic Failure

ACT TONIGHT PATIENT SAFETY UK RCEM

The RCEM Time-Critical Medication (TCM) QIP report (3 June 2026) presents national audit data on medication administration for patients boarding in UK EDs: 66% of Levodopa and insulin doses were administered late; 40% were missed entirely. The RCEM attributes this to system design failures: unclear prescribing responsibility for admitted-but-boarding patients, absent or incomplete ePMA, poor communication at handover, and insufficient nurse-to-patient ratios for complex medication management. The simultaneously published HSSIB ePMA Procurement Safety Report (27 May 2026) identifies the lack of national ePMA safety standards as a contributing systemic factor.

Highest-risk groups in the ED: Parkinson’s disease patients (even brief Levodopa delay causes rigidity, dysphagia, aspiration risk, and in severe cases neuroleptic-like crisis); insulin-dependent diabetics; anticonvulsant-dependent patients; immunosuppressed transplant patients. In each of these groups, missing even one dose in the ED can cause serious harm.

What to do in your ED tonight: (1) Check which boarding patients have TCM needs — ask the triage nurse and bedside nurse right now; (2) Ensure each has a named prescriber responsible for their medication while in the ED; (3) If your ED does not have a TCM flag system or boarding medication protocol, escalate to your pharmacy and medicine safety team. This is a patient safety requirement, not optional. The RCEM and HSSIB data make non-compliance indefensible.

Sources: RCEM Time Critical Medication QIP Report, 3 June 2026 · HSSIB ePMA Procurement Safety Report, 27 May 2026

RCEM · JUNE 2026 MEMBER NEWSLETTER

RCEM Better Basics Better Care Accreditation Programme — Launching Summer 2026: Formal Recognition for EDs Improving Working Conditions and Culture

INFORMING UK

The RCEM June 2026 member newsletter announces the launch of the Better Basics, Better Care (BBBC) accreditation programme later this summer. BBBC provides a structured framework for EDs to improve working environment, staff wellbeing, and team culture, with formal RCEM accreditation recognition. Focus areas: protected breaks, adequate facilities, supportive rota design, team communication, and psychological safety. Crucially, it is not a clinical outcomes programme — it addresses the structural day-to-day conditions that RCEM’s own census identifies as primary drivers of burnout and workforce attrition in UK emergency medicine.

Source: RCEM Better Basics Better Care — June 2026 Newsletter

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

NEJM · 2026 · RCT · MCMASTER EVIDENCE ALERTS 31 MAY 2026

Azithromycin for Preschoolers With Wheeze in the Emergency Department — NEJM RCT: Reduces Hospital Admission at Episode Onset; NNT 11

RCT CHANGE THIS MONTH PAEDS FRCEM

• NNT 11 TO PREVENT HOSPITAL ADMISSION AT EPISODE ONSET
• NEJM MCMASTER SCORE 4/7 — SIGNIFICANT PAEDS ED FINDING

This NEJM RCT (McMaster Evidence Alerts 31 May 2026) randomised preschool children (approximately 1–5 years) presenting to the ED with an acute wheeze episode to early azithromycin vs placebo at wheeze onset. Azithromycin (a macrolide with anti-inflammatory as well as antimicrobial properties) reduced hospital admission rates with NNT 11. The effect is thought to be anti-inflammatory rather than antimicrobial — rhinovirus-triggered wheezing is the predominant phenotype in this age group, and macrolides have known immunomodulatory effects on airway inflammation. McMaster score 4/7 (lower than the 6/7 threshold for ACS papers, but the NEJM venue and paeds ED relevance make this significant).

UK context: recurrent preschool wheeze is one of the most common presentations to UK paediatric EDs and paediatric assessment units. Current NICE guidance (CG16, asthma) and the British Thoracic Society/SIGN guideline do not currently recommend azithromycin for acute wheeze in preschoolers. This NEJM RCT is likely to prompt a NICE evidence review. Do not implement as practice change yet — await NICE/BTS guidance update. However, be aware that azithromycin at wheeze onset may become a standard intervention for this specific phenotype, with implications for prescribing in both the ED and ambulatory paediatric follow-up. An important caveat: antimicrobial stewardship — azithromycin resistance is a real concern, and widespread use would need to be balanced against population-level macrolide resistance.

Bottom line: Watch this space. This is a NEJM-level RCT with a meaningful NNT for a very common presentation. NICE/BTS/RCPCH will need to respond. For now: do not change prescribing; do brief your paeds colleagues so the evidence is on their radar for guideline discussions.

Source: Azithromycin for Preschoolers with Wheeze. NEJM. 2026 · McMaster Evidence Alerts, 31 May 2026

PEDIATRICS · 2026 · RETROSPECTIVE COHORT · PMID 42014094 · N=78,000+ · JOURNALFEED EM 4 JUNE 2026

Maternal COVID-19 Vaccination Before and During Pregnancy — Infant Protection Against COVID Infection and Hospitalisation (n=78,000)

INFORMING OBSERVATIONAL PAEDS

Jacobson KB, Merchant M, Fireman B, Klein NP, Zerbo O (Pediatrics 2026; PMID 42014094) analysed over 78,000 infant-mother pairs in a large integrated healthcare system. Maternal COVID vaccination during pregnancy, particularly in the third trimester, was independently associated with reduced infant COVID infection and hospitalisation. Third-trimester vaccination produced the highest infant antibody titres and the most robust protective effect, consistent with the passive immunity mechanism (IgG transfer across placenta). The association held after adjustment for confounders.

UK context: NHS England recommends COVID vaccination in pregnancy (any trimester). This large cohort study provides further reassurance for vaccine safety and effectiveness for infant protection. ED relevance: when parents of a young infant (<6 months) with respiratory illness ask about COVID risk, knowing the maternal vaccination history is clinically relevant. A vaccinated mother’s baby has some degree of passive immunity, though this wanes. This is also relevant to antenatal counselling for any patient encountered in the ED.

Source: Jacobson KB et al. Pediatrics. 2026 (PMID 42014094) · JournalFeed EM Speed Read, 4 June 2026

J TRAUMA ACUTE CARE SURG · 2026 · RETROSPECTIVE COHORT · PMID 41925562 · N=4,215 · JOURNALFEED EM 4 JUNE 2026

ICP Monitoring in Paediatric Severe TBI — EVD Associated With Lower Mortality and Fewer Surgical Interventions vs ICP Monitor Alone (n=4,215)

INFORMING OBSERVATIONAL PAEDS FRCEM

Stewart C, Al Ma’ani M et al (J Trauma Acute Care Surg 2026; PMID 41925562) analysed 4,215 paediatric patients with severe TBI (GCS ≤8) from a nationwide US database. EVD (external ventricular drain) placement was independently associated with lower mortality and reduced need for surgical intervention compared to ICP monitor (parenchymal monitor) placement alone. The mechanism: EVD both monitors ICP and provides therapeutic CSF drainage, reducing elevated ICP that the parenchymal monitor can only detect.

ED relevance: the choice of EVD vs ICP monitor is a neurosurgical decision, made after admission. The ED role is: (1) early CT and recognition of raised ICP features; (2) urgent paediatric neurosurgical referral in any child with GCS ≤8 post-TBI; (3) ICU/PICU bed request; (4) initial ICP management — head up 30°, avoid hypotension (MAP ≥60 mmHg in children), avoid hypoxia, osmotherapy if GCS is deteriorating. When referring, it is now appropriate to specifically ask “please review for EVD suitability” rather than just “ICP monitoring needed.”

Source: Stewart C et al. J Trauma Acute Care Surg. 2026 (PMID 41925562) · JournalFeed EM Speed Read, 4 June 2026

CJEM · 2026 · PILOT RCT · PUBMED ALERT

Subanesthetic Ketamine for Suicidal Ideation in the Paediatric ED — Pilot RCT: Feasibility Confirmed; Rapid Reduction at 2 and 4 Hours; Full Trial Planned

PILOT RCT INFORMING PAEDS

This CJEM 2026 pilot RCT evaluated subanesthetic ketamine (0.5 mg/kg IV over 40 minutes) vs placebo for adolescents with active suicidal ideation in the ED. Feasibility confirmed: blinding maintained, recruitment targets met, no serious adverse events. Ketamine produced rapid reduction in suicidal ideation scores at 2 and 4 hours post-infusion. This is a pilot only — not powered for efficacy. A definitive RCT is planned. Do not change practice on this evidence alone.

Context: suicidal ideation in adolescents is one of the most frequent and highest-stakes presentations to UK paediatric EDs. Current management is psychosocial, with pharmacological options limited to specialist CAMHS settings. The concept of rapid pharmacological intervention in the ED for this indication has significant potential implications. Awareness of the developing evidence is useful for EM colleagues with research interests, and for senior trainees preparing for FRCEM structured oral topics on the management of acute mental health crises in paediatric patients.

Source: PMID 42234079 — CJEM 2026 — Ketamine for Suicidal Ideation Paeds ED (pilot RCT)

SECTION 4 — FOAMED & CRITICAL APPRAISAL

REBEL EM · 18 MAY 2026 · CLINICAL CONUNDRUM

Clinical Conundrum: Lower GI Bleeding — Who Actually Needs a CT Angiogram? Most Don’t — CTA for Active or Recent Bleed Only

FOAMed CHANGE THIS MONTH FRCEM

REBEL EM Clinical Conundrum (18 May 2026) addresses the growing overuse of CT angiography (CTA) for lower GI bleeding (LGIB) in the ED. CTA use for LGIB has increased sevenfold in some centres over the past 8 years while diagnostic yield has fallen from 20% to 6.3% (JAMA Network Open 2025). The REBEL EM and ACR/AGA guidance is clear: CTA is indicated for patients with active bleeding in the ED, bleeding within 4 hours of arrival, haemodynamic instability, recent transfusion requirement, or altered mental status. Stable patients without active bleeding should be admitted for colonoscopy, not CTA.

UK context: LGIB is a common ED presentation. NICE NG149 (LGIB) recommends the Oakland Score for risk stratification in suspected LGIB. Oakland Score ≤8 points = safe for same-day discharge with outpatient colonoscopy follow-up. Oakland Score >8 = admission for inpatient investigation. CTA is specifically recommended only for haemodynamically unstable patients or those with continued active bleeding where colonoscopy cannot be performed urgently. Using CTA for all LGIB patients exposes them to radiation, contrast risk, and resource consumption for an investigation that is frequently negative in stable presentations.

Decision framework: LGIB + any of (haemodynamic instability / active bleeding at triage / blood within 4h / recent transfusion) → CTA. LGIB + none of these → Oakland Score → if ≤8: consider discharge + outpatient colonoscopy; if >8: admit for inpatient colonoscopy, not CTA.

Source: REBEL EM — Lower GI Bleeding: Who Needs a CTA? (18 May 2026) · NICE NG149 — Lower GI Bleeding

EM CASES · 3 JUNE 2026 · JUST THE NUGGETS EP 218

Pain Management in Patients With Opioid Use Disorder — OUD Does Not Mean Reduced Pain; Undertreated Acute Pain Drives AMA Discharges

FOAMed CHANGE THIS MONTH

EM Cases Just the Nuggets Episode 218 (3 June 2026) provides a structured framework for acute pain management in patients with opioid use disorder (OUD). The key reframe: opioid tolerance and dependence do not reduce pain perception — they require higher doses for equivalent analgesia. Multi-modal analgesia (paracetamol + NSAIDs + regional nerve blocks + opioids at tolerance-appropriate doses + pain-dose ketamine 0.3–0.5 mg/kg IV) is the evidence-based approach. Do not withhold opioids from a patient in acute pain because they have a history of OUD; undertreated pain is a major driver of patient-directed discharges (AMA), return visits, and mistrust.

UK context: fentanyl-using patients present to UK EDs with increasing frequency, particularly in urban centres. The US opioid epidemic phenotype (illicitly manufactured fentanyl) is arriving in

UK cities. These patients have extremely high opioid tolerance. Usual ED doses of IV morphine (5–10 mg) will be sub-analgesic. Multi-modal strategies with ketamine co-administration and regional blocks are the appropriate approach. Liaison with the drug and alcohol team for buprenorphine initiation before discharge is possible at some UK centres following NHS England guidance.

Source: EM Cases Just The Nuggets Ep 218 — OUD Pain Management (3 June 2026)

PulmCCM (26 May 2026) — Restraining Ventilated Patients: Unhelpful and Distressing: PulmCCM reviews evidence that routine wrist restraints in mechanically ventilated ICU patients do not reduce unplanned extubation rates and are associated with increased patient distress, delirium, and post-traumatic stress. Primarily an ICU practice, but relevant to ED physicians managing resuscitation patients awaiting ICU transfer. In the ED resus bay, routine wrist restraints for intubated patients are not evidence-based; adequate sedation and analgesia, nursing assessment, and RASS-guided titration are the appropriate approach. Source: pulmccm.org

QUICK HITS

Upper GI Bleeding ED Predictors of Mortality (PMID 41863907, JournalFeed Wed 3 June): 476 adults, 5-year retrospective. Admission lactate, haemodynamic instability, and active endoscopic bleeding were independent mortality predictors. Glasgow-Blatchford Score (GBS) ≥12 = high risk, same-day endoscopy. GBS is NICE-endorsed for UGIB risk stratification — ensure your team can calculate it at triage. Source: PMID 41863907

ED Boarding and Clinical Deterioration (PMID 41860510, EMA Daily 4 June): Large retrospective cohort: ED boarding time independently associated with clinical deterioration requiring higher levels of care, though effect size was small and likely confounded by patient severity. Commentary (Dr Menchine, EMA Daily): “does not provide strong evidence that reducing boarding alone would meaningfully improve outcomes.” Relevant for governance and safety audit documentation. Source: PMID 41860510

TEG/ROTEM vs Usual Care — Cochrane Update 2026 (McMaster May 29, Score 5/7): Updated Cochrane review of viscoelastic testing (VET) vs conventional coagulation testing for guiding haemostatic treatment in adults and children with bleeding. VET-guided strategies reduce allogeneic blood transfusion, FFP, and platelet use in cardiac surgery and trauma. UK relevance: ROTEM is increasingly available in UK major trauma centres and cardiac surgery units; this Cochrane update supports its broader use for goal-directed haemostatic resuscitation. Source: Cochrane Database Syst Rev. 2026 (McMaster 29 May)

AUD Medications in Severe Alcohol-Related Liver Disease (PMID 41670995, EMA Daily 22 May): Retrospective JAMA Netw Open study (n=large): MAUD (Medication for Alcohol Use Disorder — naltrexone, acamprosate, disulfiram) treatment was strongly associated with improved survival in patients with severe alcohol-related liver disease. Practical ED point: in any patient presenting with decompensated liver disease secondary to alcohol, document AUD treatment status and refer to hepatology and addiction services if not already on MAUD. Do not assume MAUD is contraindicated in liver disease without specialist review. Source: PMID 41670995

Phenobarbital vs Benzodiazepines for Alcohol Withdrawal (Cureus, June 2026): Retrospective ED study: phenobarbital monotherapy associated with comparable seizure prevention and shorter ED LOS in moderate-severe alcohol withdrawal compared to benzodiazepine monotherapy. This is consistent with the growing evidence base for phenobarbital in severe/benzodiazepine-resistant alcohol withdrawal. Load: 10–15 mg/kg IV. Available in most UK EDs. Include on your CIWA escalation protocol. Source: Cureus Emergency Medicine, June 2026

CORE REVISION — DEFIBRILLATION: HOW IT WORKS AND WHEN TO USE IT

FRCEM REVISION — DEFIBRILLATION

Minimise the pre-shock pause. Charge during CPR. Shock. Resume CPR immediately — do not wait for rhythm interpretation. 2 minutes of CPR, then reassess. Every second without CPR during charging costs survival.

ACTION POINTS — ISSUE 15 — 4 JUNE 2026

• Ebola triage screen: Add 21-day DRC/Uganda travel question to triage today. Suspect = isolate, apply Level 3 PPE, call UKHSA 0344 778 8990 before any blood-exposing procedure. Verify trust VHF isolation room availability and PPE stocks now. [UKHSA, 3 June 2026]
• ChloraPrep recall: Remove and quarantine all ChloraPrep 2% applicators with expiry ≤02/2028 from all ED and resus areas. Contact pharmacy for alternatives. Report adverse events via MHRA Yellow Card. [MHRA EL(26)A/26, 2 June 2026]
• Time-critical meds tonight: Identify boarding patients with Parkinson’s, insulin-dependent diabetes, epilepsy, or transplant. Ensure each has a named prescriber for ED medications within 1 hour of admission decision. Escalate to medicines safety team if no protocol exists. [RCEM TCM QIP, 3 June 2026]
• STEMI and heparin: Primary PCI should not be delayed to give heparin. HEPARIN STEMI RCT: prehospital vs in-hospital UFH timing makes no difference to TIMI 3 flow. Door-to-balloon ≤90 min remains the target. [HEPARIN STEMI RCT, Circulation 2026, PMID 41910504]
• ACS troponin pathway: If your ED uses 0/3-hr or 0/6-hr hs-troponin rule-out, present this JACC RCT to your cardiology lead. 0/1-hr is non-inferior and halves LOS for rule-outs. Verify your lab’s validated assay-specific thresholds before switching. [JACC 2026, McMaster 2 June]
• DKA protocol: Check your protocol has weight-based insulin and a clear K+ replacement table against JBDS 2023. Know when to add dextrose (glucose <14 mmol/L). [SGEM #511, 4 June 2026]
• LGIB imaging: CTA for LGIB only if: haemodynamically unstable, active bleeding in ED, or bleeding within 4 hours. Stable patients without active bleeding: Oakland Score then colonoscopy, not CTA. [REBEL EM Clinical Conundrum, 18 May 2026]
• OUD pain management: Brief your senior nurses and SHOs: OUD patients in acute pain need adequate analgesia at tolerance-appropriate doses. Multi-modal: paracetamol + NSAIDs + regional + opioids + pain-dose ketamine. Undertreated pain = AMA discharges. [EM Cases Ep 218, 3 June 2026]
• Paeds TBI referral: In severe paeds TBI (GCS ≤8): urgent neurosurgical referral, early ICU/PICU bed request, and specifically ask about EVD suitability. EVD is associated with lower mortality vs ICP monitor alone (n=4,215). [PMID 41925562]
• Preschool wheeze alert: Azithromycin at wheeze onset — NNT 11 for hospital admission in NEJM RCT. Do NOT prescribe yet pending NICE/BTS guidance update. Alert your paeds colleagues to watch this space for the winter planning cycle. [McMaster May 31, NEJM 2026]

TRIALS TO WATCH

UPCOMING TRIALS & MILESTONES

2026 — EXPECTED RESULTS

DOSE VF — Double Sequential External Defibrillation vs Standard in refractory VF. Multicentre RCT. If positive, DSD becomes standard rescue strategy rather than ad hoc. Results expected 2026. Directly links to this week’s defibrillation core revision.

OPERA Trial (France) — Paralytic-first RSI sequence vs standard induction-then-NMB. Bayesian analysis of n=2,216 suggests 95.7% probability of improved first-pass with paralytic-first. If confirmed by this RCT, will change the standard drug administration sequence in emergency RSI globally.

Azithromycin preschool wheeze confirmatory trial — Following the NEJM RCT (this issue), a larger confirmatory trial is expected before guideline bodies act. Watch for NICE/BTS response. Will change prescribing in paediatric ED and ambulatory paediatrics if confirmed.

UK-SPECIFIC

BACHb Trial (UK, 50+ NHS hospitals) — HFNC vs CPAP vs standard O2 in acute bronchiolitis in infants. Primary: hospital LOS. Will directly inform the NIV vs standard O2 debate in UK paediatric ED practice for one of the most common winter presentations.

CoMiTED (UK) — Conservative vs immediate chest drain in traumatic pneumothorax. Results will directly affect ED chest trauma management protocols and the debate about observation vs intervention in small traumatic pneumothoraces.

ATOM-ACS (UK multicentre) — Optimal P2Y12 inhibitor choice and timing in hs-troponin-positive NSTEMI presenting to the ED. Direct ED prescribing implications for antiplatelet therapy at the time of NSTEMI diagnosis.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 15 — 4 June 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