EM Evidence Rundown — Issue 16

UK EDITION · ISSUE 16 · 11 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: UKHSA Measles — 736 cases YTD, 2 child deaths, all regions. Airborne precautions for febrile rash. MHRA Mirtazapine 30mg barcode alert — check automated dispensing cabinet. RCEM: 15,860 excess deaths linked to ED waits in 2025. LEAD: Paediatric septic shock (NEJM, 47 EDs) — balanced crystalloid = saline; use either. 2026 SSC guidelines: earlier vasopressors. Stroke: INSTANT (Tirofiban after TNK, NNT 8). Defibrillation (Core Revision).

BOTTOM LINE UP FRONT — ISSUE 16

ACT ON THIS NOW

TONIGHT Measles: 736 cases YTD, 2 deaths. Febrile rash = airborne precautions. Notifiable. HNIG within 6d for immunocompromised contacts.

TONIGHT Mirtazapine barcode: MHRA — incorrect barcode on 30mg tablets. Check automated dispensing cabinet now.

THIS MONTH Paeds septic shock fluids: NEJM (47 EDs): balanced = saline. No difference in mortality or kidney outcomes. Use either.

THIS MONTH SSC sepsis 2026: Start vasopressors earlier — don’t persist with fluids if MAP not responding. Dynamic fluid assessment. Vasopressin earlier.

THIS MONTH Stroke + failed TNK: INSTANT (JAMA, NNT 8): Tirofiban after TNK in non-LVO stroke gives 63.8% vs 52.2% excellent outcomes. Discuss with stroke team.

THIS MONTH TNK before EVT (4.5–24h): TNK-PLUS (JAMA): no benefit. Do not give bridging TNK before planned EVT in extended window.

KNOW FOR NEXT TIME

INFORMING Agitated elderly: IM olanzapine 2.5–5 mg first. Avoid BZDs. Lewy Body Dementia: quetiapine only if antipsychotic needed.

GUIDELINE SSC targets: NE first-line. Vasopressin when NE escalating (≥0.3 mcg/kg/min). MAP ≥65. Avoid fixed-volume protocols.

INFORMING POCUS dyspnoea: RCT: earlier certainty but no change in final diagnosis or management. Use POCUS targeted, not routine.

INFORMING HEART + eGFR: Modified HEART score with eGFR improves ACS rule-out. CKD patients may be under-scored on standard HEART.

PAEDS iRehab UK: 52 NHS ICUs, n=429: no overall QoL benefit, physical function improved. Refer ICU survivors to post-ICU follow-up.

INFORMING RCEM 2026: 15,860 excess deaths linked to ED waits. 2,241 corridor care patients/day. Use this data in your governance work.

This week brings two immediate changes to practice: the largest paediatric septic shock fluids trial to date settles the balanced vs normal saline debate in children, and the INSTANT trial shows that tirofiban after failed tenecteplase rescues stroke patients who don’t have a large vessel occlusion — a genuinely new treatment option. Simultaneously, the updated Surviving Sepsis Campaign guidelines formalise the shift away from fixed-volume resuscitation toward earlier vasopressors and precision haemodynamics. In stroke, TNK-PLUS adds to the growing evidence against bridging thrombolysis before planned EVT in extended windows.

WHAT’S INSIDE ISSUE 16

Section 1 — Key Trials: Paediatric septic shock fluids RCT (NEJM, LEAD) · 2026 Surviving Sepsis Campaign guidelines · INSTANT trial: Tirofiban after TNK (JAMA) · TNK-PLUS: TNK before EVT (JAMA) · POCUS pathway for ED dyspnoea RCT (EMA Daily) · Modified HEART score for ACS rule-out Section 2 — UK & Safety: Official bodies updates (RCEM, NICE, MHRA, UKHSA) · iRehab UK RCT (PulmCCM) Section 3 — Paediatric EM: Paediatric septic shock fluids (NEJM) · Agitated elderly/paediatric sedation (EM Cases) · Carotid Doppler for paediatric cardiac arrest Section 4 — FOAMed: St Emlyn’s — What makes a good EM physician · EMA Daily POCUS critique Quick Hits · Core Revision — Defibrillation · Action Points · Trials to Watch

SECTION 1 — KEY TRIALS & JOURNAL ARTICLES

NEJM · PUBLISHED 5 JUNE 2026 · RCT · 47 PAEDIATRIC EDS · 5 COUNTRIES · LEAD

Paediatric Septic Shock Fluids — Balanced Crystalloid vs 0.9% Saline: No Difference in Major Adverse Kidney Events or Mortality at 30 Days (47 Paed EDs, 5 Countries)

RCT CHANGE THIS MONTH PAEDS FRCEM SEPSIS

• p=0.92 PRIMARY: MAJOR ADVERSE KIDNEY EVENTS 30D (NS)
• NNT ∞ NO CLINICALLY MEANINGFUL DIFFERENCE
• 47 PEDs 5 COUNTRIES INCLUDING UK SITES
• Use either KEY MESSAGE: BOTH SAFE — USE WHAT IS AVAILABLE

A multicentre RCT conducted across 47 paediatric emergency departments in five countries (including UK sites, published NEJM 5 June 2026, DOI 10.1056/NEJMoa260196) randomised children presenting with suspected septic shock to initial resuscitation with balanced crystalloid (Lactated Ringer's or Plasmalyte) versus 0.9% saline. Primary composite outcome: major adverse kidney events (MAKE30) — persistent kidney dysfunction, renal replacement therapy, or death by 30 days. No significant difference (p=0.92). No difference in secondary outcomes including mortality, ventilator-free days, or vasopressor requirements.

This is the definitive trial for paediatric septic shock fluid selection. Previous trials in adults (SMART, PLUS, BaSICS) had demonstrated at best modest benefit from balanced crystalloids, with results often dependent on trial population. In paediatric septic shock, saline-induced hyperchloraemic acidosis was the theoretical concern driving balanced crystalloid use, but this RCT finds it does not translate to clinical outcomes in this population. The trial enrolled children across a broad acuity range, enhancing generalisability to the typical paediatric ED population.

UK context: Many UK paediatric EDs stock Hartmann’s (similar to Lactated Ringer’s) as their standard resuscitation fluid; others use 0.9% saline. This trial confirms that either is appropriate. Where there is a supply or availability issue (e.g. shortages of balanced crystalloids, which have occurred in the UK in recent years), clinicians can use 0.9% saline without concern about inferior outcomes in the paediatric septic shock population.

Change this month: Stop any departmental anxiety about which fluid to use in paediatric septic shock. Both balanced crystalloid and 0.9% saline are equally safe and effective. Use whichever is available, at 10–20 mL/kg bolus, with reassessment for fluid responsiveness after each bolus. The focus should be on early recognition, timely antibiotics, and vasopressor initiation — not fluid type.

Source: NEJM — Balanced Crystalloid vs 0.9% Saline in Paediatric Septic Shock (5 June 2026; DOI 10.1056/NEJMoa260196)

SURVIVING SEPSIS CAMPAIGN · 2026 UPDATE · INTERNATIONAL GUIDELINES

2026 Surviving Sepsis Campaign Guidelines — Earlier Vasopressors, Dynamic Fluid Assessment, Vasopressin as Strategic Adjunct: What Changes in the ED

GUIDELINE

CHANGE THIS MONTH

SEPSIS

FRCEM

The 2026 Surviving Sepsis Campaign international guidelines (published June 2026) represent the most significant update to sepsis management guidance since the 2021 edition. The key conceptual shift is away from rigid, sequential fluid-then-vasopressor protocols toward individualised, physiology-driven management with earlier vasopressor use. The changes that matter directly in the UK ED:

Vasopressors — start earlier

The 2026 guidelines explicitly state that vasopressors should be integrated early into the resuscitation pathway rather than reserved as a rescue intervention after prolonged fluid loading. If hypotension persists despite initial fluid boluses, do not continue to escalate fluids before starting norepinephrine. MAP target remains ≥65 mmHg. Norepinephrine remains first-line over dopamine, adrenaline, and phenylephrine. The recommendation to add vasopressin has been upgraded: it is now a strategic adjunct when norepinephrine requirements are escalating (not just at maximum doses), at a threshold of approximately 0.3 mcg/kg/min of norepinephrine.

Fluid resuscitation — dynamic assessment replaces fixed volumes

The updated guidelines move away from the historical 30 mL/kg fluid bolus target. Fluid responsiveness should be assessed dynamically: pulse pressure variation (PPV), passive leg raise (PLR), or stroke volume variation (SVV) where available. Crystalloid is still recommended

over colloid for initial resuscitation. The evidence against excessive fluid administration (fluid overload, TACO, oedema, worse outcomes) is now sufficiently robust that the guidelines explicitly warn against its continuation beyond initial stabilisation.

Antibiotics — unchanged

Within 1 hour for septic shock. Within 3 hours for sepsis without shock. Appropriate de-escalation as soon as culture/sensitivity results allow. This is unchanged from 2021.

ED protocol implications: If your department’s sepsis bundle still mandates 30 mL/kg fluids before vasopressor consideration, this guideline provides evidence to revise it. Proposed ED approach: 10–20 mL/kg fluid challenge → reassess fluid responsiveness → if persistent hypotension: start norepinephrine centrally or peripherally rather than giving further fluids. A second fluid challenge is appropriate if the patient is clearly fluid-responsive. Stop when fluid responsiveness is absent or fluid overload is developing.

Source: 2026 Surviving Sepsis Campaign Guidelines — Haemodynamic Management Update

JAMA · 9 JUNE 2026 · TWO RCTS PUBLISHED SIMULTANEOUSLY · TNK-PLUS (PMID 42099212) & INSTANT (PMID 42100960)

Stroke Double-Bill — TNK-PLUS and INSTANT (JAMA): TNK Before EVT Shows No Benefit; Tirofiban After Failed TNK Rescues Non-LVO Stroke Patients (NNT 8)

2× RCT CHANGE THIS MONTH STROKE FRCEM

• No benefit TNK-PLUS: TNK BEFORE EVT AT 4.5–24H (MRS 0–2 NS)
• NNT 8 — 63.8% vs 52.2% INSTANT: TIROFIBAN AFTER FAILED TNK FOR NON-LVO STROKE (EXCELLENT OUTCOME 90D)

TNK-PLUS (PMID 42099212): Wang Y et al (JAMA 2026) — patients with acute ischemic stroke presenting at 4.5–24 hours from symptom onset, eligible for EVT, randomised to IV tenecteplase (0.25 mg/kg) before EVT vs EVT alone. Primary outcome: mRS 0–2 at 90 days. No significant difference. Consistent with TIMELESS and earlier extended-window thrombolysis data. Conclusion: do not give TNK as bridging therapy before planned EVT at 4.5–24 hours. The mechanism makes physiological sense: if EVT is going to recanalise the vessel within minutes of arrival, pre-treatment with a thrombolytic adds bleeding risk without meaningful additional benefit.

INSTANT (PMID 42100960): This is the genuinely new finding of the week. Patients with acute ischemic stroke without large or medium vessel occlusion (i.e. small vessel disease or undetermined source) who had an inadequate response to TNK were randomised to adjunctive IV tirofiban (a GP IIb/IIIa inhibitor, platelet aggregation inhibitor) vs placebo. Excellent outcome at 90 days: 63.8% tirofiban vs 52.2% placebo (RR 1.22, 95% CI 1.02–1.46, p=0.03). NNT 8. Symptomatic intracranial haemorrhage: 0.9% vs 0% (1 patient in tirofiban group). 90-day mortality: 0.6% vs 1.6%.

This addresses the common clinical scenario: a patient with acute ischemic stroke receives TNK and at 60 minutes still has significant symptoms. Current practice offers limited options — most patients would be monitored or taken to mechanical thrombectomy assessment. INSTANT shows that for the subset without identifiable LVO, tirofiban is a meaningful intervention. The population is specifically patients with small-vessel or cryptogenic stroke — this does NOT apply to patients with LVO eligible for EVT (TNK was already a bridging therapy in that group).

Practical implementation: Tirofiban is available in UK acute stroke units and cardiac catheterisation labs. The protocol used in INSTANT should be discussed with your regional stroke and neurology team proactively. For ED teams: when a patient with acute stroke has received TNK and shows an inadequate response at 60 minutes with no LVO on CTA: document the INSTANT data and request urgent neurology/stroke physician review for tirofiban consideration. Do not initiate tirofiban independently in the ED without specialist input — this is a specialist decision requiring careful patient selection.

Sources: TNK-PLUS (PMID 42099212, JAMA 9 June 2026) · INSTANT (PMID 42100960, JAMA 9 June 2026)

EUR J EMERG MED · MARCH 2026 · RCT SUBSTUDY · PMID 41870288 · EMA DAILY 11 JUNE 2026

POCUS Pathway vs Standard Care for ED Dyspnoea — RCT: Earlier Diagnostic Certainty But No Change in Final Diagnosis Accuracy or Management Decisions

RCT

INFORMING

FRCEM

Higher certainty

DIAGNOSTIC CERTAINTY AT 1 HOUR: POCUS ARM VS STANDARD

No difference

FINAL DIAGNOSIS ACCURACY OR TREATMENT DECISIONS CHANGED

Ovesen SH et al (Eur J Emerg Med 2026; PMID 41870288) conducted an RCT substudy of a POCUS-driven diagnostic pathway vs standard care in adult ED patients presenting with acute dyspnoea. The POCUS pathway (cardiac echo + lung POCUS as part of structured initial assessment) increased diagnostic certainty at 1 hour significantly. However, this did not translate into improved final diagnosis accuracy or changes in concurrent treatment decisions compared to standard care. EMA Daily editor Dr Sanjay Arora commented: “Earlier certainty that doesn’t translate into better diagnoses or changed management is, at best, a cognitive comfort and not a clinical advance.”

This is an important nuance for POCUS advocates. The evidence for POCUS in specific diagnostic applications (e.g. cardiac tamponade, tension pneumothorax, aortic aneurysm, FAST) remains strong and unaffected by this trial. But POCUS as a blanket routine pathway for undifferentiated dyspnoea does not improve outcomes in this well-designed substudy. The implication: POCUS is best used in targeted fashion based on clinical probability, not as a default screening tool for all dyspnoeic patients. Clinician gestalt and clinical history continue to carry significant independent diagnostic weight.

Source: Ovesen SH et al. Eur J Emerg Med. 2026 (PMID 41870288) · EMA Daily 11 June 2026 — Editor Commentary

INTERN EMERG MED · 2026 · PROSPECTIVE VALIDATION · PUBMED ALERT

Modified HEART Score for ACS Rule-Out — Adding eGFR Improves Low-Risk Discrimination in High-Volume Chest Pain Pathways

OBSERVATIONAL INFORMING FRCEM

This prospective validation study (Intern Emerg Med 2026, PubMed alert) of a modified HEART score incorporates eGFR (estimated glomerular filtration rate) as an additional variable alongside the standard HEART components (History, ECG, Age, Risk factors, Troponin). In a derivation and validation cohort, the modified HEART score with eGFR showed improved C-statistic for identifying low-risk patients (those who could be safely discharged without further inpatient investigation) compared to the standard HEART score alone. The addition of eGFR exploits the well-established association between renal impairment and cardiovascular event risk.

UK context: HEART is widely used in UK EDs alongside hs-troponin pathways (NICE NG185). This modification is not yet endorsed by NICE or RCEM but provides a logical evolution. For departments already using HEART: note that patients with CKD 3–5 may be scoring lower than their true risk on standard HEART. Adding eGFR-based adjustment addresses this. Await local validation before protocol-level adoption.

Source: Modified HEART score with eGFR. Intern Emerg Med. 2026 (PubMed alert)

SECTION 2 — UK & SAFETY UPDATES

RCEM · 8 JUNE 2026 · REPORT

RCEM State of Emergency Medicine in England 2026 — 15,860 Excess Deaths Linked to ED Waits in 2025: Near-Tenfold Increase Since 2015

CHANGE THIS MONTH UK RCEM FRCEM

15,860 excess deaths in England in 2025 were linked to prolonged ED waiting times — a near-tenfold increase since 2015. This is the headline finding of the RCEM State of Emergency Medicine in England report published 8 June 2026. The data come from analysis of the association between ED waiting time breaches and 30-day mortality, adjusted for case-mix. The report also documents record A&E attendances (2.46 million in May 2026 alone, NHS England data published simultaneously) and 2,241 corridor care patients per day — the first time NHS England has published corridor care data in this format.

The RCEM calls for urgent political action: ED capacity expansion, urgent workforce plan, and meaningful reform of the 4-hour standard to reflect true patient harm. The report aligns with NHS England’s own May 2026 A&E performance publication, which confirmed that the 7-point winter and corridor care plan is active but has not reversed the trend. For clinical teams: this report is important context for your governance work, clinical audit, and ARCP/portfolio evidence. It is the strongest published evidence base for the harm caused by ED crowding and corridor care in England.

Corridor care data (first published, NHS England May 2026): The May 2026 NHS England A&E performance bulletin included, for the first time, officially published data on corridor care patients — patients receiving clinical care in non-designated clinical spaces. 2,241 such patients per day in May 2026. This is a landmark in NHS transparency: corridor care was previously acknowledged but not formally quantified in national statistics. This data can and should be used in local governance discussions about patient safety and staffing.

Sources: RCEM State of Emergency Medicine in England 2026 (8 June 2026) · NHS England May 2026 A&E Performance Bulletin (11 June 2026)

UKHSA · 11 JUNE 2026 · DISEASE ALERT

UKHSA Measles Alert — 736 Cases YTD 2026; Two Child Deaths; All Regions Affected Including Worcestershire Adult Cases

ACT NOW SAFETY UK UKHSA PAEDS

UKHSA 11 June 2026: 736 measles cases recorded year-to-date in England — the highest figure since the 2013 outbreak. Two child deaths have been confirmed. All NHS regions are affected. Recent adult cluster in Worcestershire confirms spread beyond the predominantly under-5 unvaccinated cohort. The outbreak is driven by MMR vaccine coverage falling below herd immunity thresholds (<95%) in multiple areas.

ED action: (1) Any child with fever + rash: apply airborne precautions (negative pressure room where available, FFP3 mask, eye protection). Measles is highly infectious (R0 12–18); a single case in a waiting room can generate multiple secondary cases. (2) Ask vaccination history in all febrile rash presentations. (3) Notifiable disease: suspected measles must be reported to the UKHSA Health Protection Team. (4) Post-exposure prophylaxis: for unvaccinated immunocompromised contacts, human normal immunoglobulin (HNIG) within 6 days. MMR for eligible exposed contacts within 72 hours of exposure. (5) Adult cases in Worcestershire: raise index of suspicion in adult patients with fever and Koplik’s spots (white spots on buccal mucosa — pathognomonic, appear before rash).

Source: UKHSA Measles Alert — 11 June 2026 · UKHSA HPT: 0344 778 8990 (24h)

Ebola Bundibugyo PHEIC — Ongoing: The UKHSA urgent public health message (3 June, covered in Issue 15) remains active. As of 11 June 2026, the WHO PHEIC is ongoing. No confirmed UK cases. Continue to apply the 21-day DRC/Uganda/affected-region travel screen at triage. UKHSA 24h duty doctor: 0344 778 8990. Source: UKHSA Ebola guidance (updated 11 June 2026)

MHRA · 8 JUNE 2026 · DRUG SAFETY ALERT

MHRA Drug Safety Alert — Mirtazapine 30 mg Tablets: Incorrect Barcode in Automated Dispensing Systems — Do Not Use in Automated Dispensing Robots

ACT NOW SAFETY ALERT UK MHRA

MHRA alert 8 June 2026: A batch of mirtazapine 30 mg tablets has an incorrect barcode that may cause automated dispensing systems (Omnicell, Pyxis, etc.) to return an incorrect drug. ED automated dispensing cabinets that stock mirtazapine 30 mg should have their barcode verified. Do not use this product in automated dispensing robots until the batch is confirmed as unaffected or replaced. Manual dispensing is safe if the physical product label is checked. Mirtazapine is used in ED for its sedating properties in agitated patients and for acute psychiatric prescribing.

Source: MHRA Mirtazapine 30mg Barcode Alert (8 June 2026)

RCUK NLSr (Newborn Life Support Recertification) Course Launched — 9 June 2026: A new Newborn Life Support Recertification course is available from July 2026, providing a shorter update pathway for practitioners who have already completed full NLS training. Directly relevant for ED clinicians who manage unexpected deliveries or neonatal emergencies in the ED. Register at resus.org.uk. Mandatory if you have an NLS certification due for renewal.

JAMA · 2026 · RCT · 52 NHS ICUS · N=429 · PULMCCM 10 JUNE 2026

iRehab UK RCT — Remote Multicomponent Post-ICU Rehabilitation at 52 NHS Hospitals: No Overall QoL Benefit; Physical Function Improved in Shorter-Ventilation Subgroup

RCT INFORMING UK

O’Neill et al (JAMA 2026) randomised 429 ICU survivors from 52 UK NHS hospitals (mechanically ventilated for ≥48h) to either usual care or a 6-week remote multicomponent rehabilitation programme (symptom management, personalised exercise plan, psychological support, peer support group). Primary outcome: health-related quality of life at 8 weeks (EuroQoL EQ-5D-5L). No significant difference overall (0.69 vs 0.67). However, in the prespecified subgroup intubated ≤7 days (approximately half of each arm): significant benefit (0.74 vs 0.66). Physical function (sit-to-stand repetitions) and self-reported anxiety and fatigue were improved in the intervention group overall.

ED relevance: while iRehab is primarily an ICU-to-community trial, ED clinicians encounter ICU survivors frequently — in follow-up visits, acute re-presentations, and via post-ICU liaison. The trial confirms that structured post-ICU rehabilitation programmes are evidence-based and should be accessible via NHS ICU follow-up pathways. For the ED: when an ICU survivor re-presents with functional decline, fatigue, or psychological symptoms, a referral to post-ICU follow-up services is now supported by JAMA-level evidence. The benefit is most pronounced in younger, stronger patients with shorter ICU stays — exactly the group most likely to present to the ED independently after discharge.

Source: PulmCCM — iRehab Trial (10 June 2026) · O’Neill et al. JAMA. 2026

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

Paediatric Septic Shock Fluids RCT (NEJM): Covered in full in Section 1 as the Issue Lead. Balanced crystalloid = 0.9% saline in 47 paediatric EDs. Use either. Jump to full item

EM CASES · 7 JUNE 2026 · PEARL OF THE WEEK

Agitated Elderly Patient in the ED — EM Cases Pearl: IM/PO Atypical Antipsychotics First, Avoid Benzodiazepines and Anticholinergics; Lewy Body Dementia Caution

INFORMING REVIEW FRCEM

EM Cases Pearl of the Week (7 June 2026) addresses the agitated elderly patient with delirium in the ED. This is one of the most common and highest-risk presentations in UK emergency medicine, with the ageing population and rising prevalence of dementia. The key clinical points from Dr Anton Helman’s pearl, aligned with current UK evidence:

First: avoid IV access attempts in severe agitation. Attempting IV access before pharmacological de-escalation leads to patient and staff harm and escalates the agitation further. Administer IM or PO medication first.

Drug choice — Prefer atypical antipsychotics at lower doses than in younger patients:

• Olanzapine 2.5–5 mg PO/SL/IM (first choice if no QTc contraindication)
• Risperidone 0.25–1 mg PO (for mild-to-moderate agitation)
• Quetiapine 25–50 mg PO (preferred in Lewy Body Dementia)
• Haloperidol 0.5–1 mg PO/IM (acceptable if above unavailable; risk of EPS in elderly)

Avoid: Benzodiazepines (paradoxical disinhibition, respiratory depression, falls, delirium worsening in elderly). Anticholinergics (worsens confusion, urinary retention, constipation). Promethazine (anticholinergic + respiratory risk).

Lewy Body Dementia (LBD) safety alert: In patients with known or suspected Lewy Body Dementia, ALL antipsychotics except quetiapine carry a risk of severe neuroleptic sensitivity reaction (acute rigidity, reduced consciousness, autonomic instability — potentially fatal). Ask carers about existing diagnosis. If antipsychotic is unavoidable in LBD: quetiapine is the preferred agent. Start at 12.5–25 mg PO. Document the risk-benefit discussion.

Source: EM Cases Pearl of the Week — Agitated Elderly Patient (7 June 2026)

SCAND J TRAUMA RESUSC EMERG MED · 2026 · PROSPECTIVE OBSERVATIONAL · PMID 42098731 · JOURNALFEED EM 11 JUNE 2026 · N=51

Carotid Artery Doppler During CPR — Prospective Study: VTI and Flow Parameters Significantly Different Between ROSC and Non-ROSC Groups (n=51)

OBSERVATIONAL INFORMING FRCEM

• Higher VTI CAROTID VTI DURING CPR: SIGNIFICANTLY HIGHER IN ROSC GROUP
• n=51 REQUIRES LARGER VALIDATION STUDY BEFORE CLINICAL USE

Zhou S et al (SJTREM 2026; PMID 42098731) prospectively studied 51 adult cardiac arrest patients undergoing CPR in an ED. Carotid artery Doppler parameters — specifically velocity-time integral (VTI) and peak flow velocity (Vmax) — were significantly higher in patients who achieved ROSC compared to those who did not. The study suggests carotid Doppler may provide real-time haemodynamic feedback during CPR, indicating CPR quality and circulatory response.

This is preliminary but intriguing data. Most POCUS during cardiac arrest focuses on cardiac views (cardiac standstill, tamponade, ROSC confirmation). Carotid Doppler during CPR is technically feasible and does not require pausing compressions. It may provide an objective marker of CPR quality that is more sensitive than manual pulse checks. Important caveats: n=51 is small, retrospective Doppler parameter selection creates overfitting risk, and no LR data are available. This requires prospective validation in larger cohorts before clinical use. For interested POCUS practitioners: watch this space.

Source: Zhou S et al. Scand J Trauma Resusc Emerg Med. 2026 (PMID 42098731) · JournalFeed EM Speed Read, 11 June 2026

SECTION 4 — FOAMED & PROFESSIONAL

ST EMLYN’S · 11 JUNE 2026 · ACADEMIC BLOG

What Makes a Good Emergency Physician? — St Emlyn’s: Communication, Humility, and Reflective Practice Matter More Than Technical Speed

FOAMed INFORMING

Prof Simon Carley’s latest St Emlyn’s post (11 June 2026) synthesises the academic literature on excellence in emergency medicine. The evidence consistently shows that peer-identified exemplary emergency physicians are characterised first by interpersonal skills, communication, and professionalism — not by speed or technical mastery. A systematic review across specialties identified competence, motivation, and personality (flexibility, humility, empathy) as the central domains. Deliberate practice, simulation, structured feedback, and reflective practice contribute meaningfully to long-term performance. Some cognitive abilities (multitasking under time pressure) do decline with age, but communication, judgment, and empathy remain stable or improve.

The practical message for UK trainees and consultants: excellence in emergency medicine is relational and intellectual in equal measure. The resus bay is important but represents a fraction of ED practice. Building the communication structures that allow nurses and juniors to speak up, challenge decisions, and maintain psychological safety is as important as clinical technical skill. Good departments need both youthful energy and mature judgment.

Source: St Emlyn’s — What Does a Good Emergency Physician Look Like? (11 June 2026)

QUICK HITS

Bloodstream Infection Prediction Using Triage Variables in the ED (EMJ 2026, PubMed alert): Prospective study developing and validating a clinical score for predicting bacteraemia at ED triage, prior to culture results. Key predictors included temperature, lactate, heart rate, and CRP. The model had modest discriminative ability (AUC ~0.74) but could support earlier antibiotic decision-making in high-risk patients. UK relevance: ED bacteraemia is underrecognised and often diagnosed after 48-hour cultures. A triage-stage prediction tool could complement NEWS scores. Awaits external validation in UK EDs. Source: EMJ 2026 (PubMed alert)

AI-Automated POCUS Skill Assessment (Am J Emerg Med, PMID 41653848 — JournalFeed POCUS 11 June): Duggan NM et al demonstrate that computer vision can objectively assess POCUS skills in emergency medicine clinicians, differentiating novice from expert and tracking skill development over time. The system analyses image acquisition quality, probe mechanics, and structure identification. This provides a scalable, objective competency assessment tool that does not require a supervisor present for every scan. For UK EM training: ultrasound competency assessment is currently largely subjective and supervisor-dependent. Automated AI assessment could standardise this process. Source: PMID 41653848

Sex-Based Differences in Stroke Outcomes (Stroke Journal 2026 — JournalFeed EM 11 June): Large analysis examining sex as a biological variable in acute ischemic stroke outcomes. Women with stroke have different presentation patterns, thrombolysis eligibility rates, and outcomes. Women are more likely to present outside typical hours, present with atypical symptoms (headache, confusion, altered consciousness rather than focal deficits), and have longer time-to-door. UK FAST campaign recognition of atypical strokes has improved but a sex disparity in recognition and treatment timelines persists. Know this and apply a lower threshold for stroke team activation in women with atypical presentations. Source: Stroke Journal 2026

Stellate Ganglion Block for Electrical Storm (Eur Heart J Cardiovasc Pharmacother, PMID 41698390 — JournalFeed POCUS 11 June): 298 patients, dual local anaesthetic regimen for percutaneous stellate ganglion block associated with significantly higher VT/VF suppression rates at 1 and 3 hours. This is highly specialist territory (electrophysiology / cardiac ICU) but worth knowing for ED resus when a patient with refractory VT storm is awaiting transfer to a cardiac centre. Stellate ganglion block is an emerging bridge therapy. Discuss with your regional cardiac team if relevant. Source: PMID 41698390

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

FRCEM REVISION — DEFIBRILLATION

Minimise the pre-shock pause. Charge during CPR compressions. Shock immediately. Resume compressions immediately after — do not wait for a rhythm interpretation. 2-minute CPR cycle then check. Every second without CPR during charging costs survival.

ACTION POINTS — ISSUE 16 — 11 JUNE 2026

• Paediatric septic shock fluids: Stop any departmental discussion about which fluid to use in paediatric septic shock. Balanced crystalloid and 0.9% saline are equally safe. Use what is available. Focus on early recognition, antibiotics, and vasopressor initiation. [NEJM, 5 June 2026]
• Sepsis vasopressors: Present the 2026 SSC guideline update to your department. If your sepsis bundle still requires 30 mL/kg before considering vasopressors, it is now out of date. Consider: 10–20 mL/kg challenge, assess fluid responsiveness, if persistent hypotension → start norepinephrine. [2026 SSC Guidelines]
• TNK before EVT (4.5–24h): Share TNK-PLUS with your stroke team. If a patient presents at 4.5–24 hours and is eligible for EVT: go straight to EVT. Do not administer TNK as bridging therapy. This does not affect the standard 0–4.5 hour TNK window (unchanged). [JAMA, PMID 42099212]
• Tirofiban after failed TNK: Discuss INSTANT with your regional stroke team. For patients with AIS without LVO who have an inadequate response to TNK: tirofiban may be an option. This is a specialist decision — your role is to know the trial, document TNK response, and initiate urgent neurology referral. [JAMA, PMID 42100960]
• Agitated elderly patients: Brief your team: IM olanzapine 2.5–5 mg or IM/PO risperidone is first-line for elderly agitated delirium. Avoid benzodiazepines. Ask about Lewy Body Dementia history before any antipsychotic. If LBD known or suspected: quetiapine only if antipsychotic absolutely necessary. [EM Cases, 7 June 2026]
• Stroke: atypical presentations in women: Women are more likely to present with atypical stroke symptoms (headache, confusion, altered consciousness). Apply a lower threshold for stroke team activation in women with atypical presentations. Document time of symptom onset carefully even with atypical presentations. [Stroke Journal 2026]
• POCUS for dyspnoea: POCUS is NOT a routine screening protocol for all dyspnoeic patients. Use it in targeted fashion based on clinical probability: tamponade, pneumothorax, aortic aneurysm, effusion, acute LVF. Routine POCUS pathway does not improve downstream diagnosis or treatment decisions. [PMID 41870288, EMA Daily 11 June]
• Measles alert: Apply airborne precautions immediately for any febrile rash presentation. Report to UKHSA HPT (0344 778 8990). Confirm MMR status. Post-exposure: HNIG within 6 days for unvaccinated immunocompromised; MMR within 72 hours for eligible contacts. [UKHSA, 11 June 2026]
• Mirtazapine barcode alert: Check your ED automated dispensing cabinet. Verify barcode on mirtazapine 30 mg. Do not use affected batch in dispensing robots. Manual dispensing is safe with physical label check. [MHRA, 8 June 2026]
• Defibrillation checklist: Know your defibrillator. Know where it charges to. Know how to minimise the pre-shock pause. Know how to perform synchronised cardioversion (SYNC mode → R-wave delivery) and what it is for (AF/SVT/VT with pulse, NOT VF). Test DSED readiness if you have two defibrillators available. [RCUK 2021; DOSE VF trial pending]

TRIALS TO WATCH

UPCOMING TRIALS & MILESTONES

RESULTS EXPECTED 2026

DOSE VF — Double Sequential External Defibrillation vs standard in refractory VF. Multicentre RCT. If positive, DSED becomes standard rescue strategy in refractory VF. Links directly to this week’s Core Revision. Results expected late 2026.

BaCHb Trial (UK) — HFNC vs CPAP vs standard O2 in infant bronchiolitis, 50+ NHS hospitals. Primary: hospital LOS. Will directly inform the NIV-vs-standard debate in paediatric ED during the winter respiratory season.

OPERATION trial (UK multicentre) — Oxygen targets in prehospital STEMI. Very relevant to both ED receiving teams and the STEMI pathway.

2026–2027

ATOM-ACS (UK multicentre) — Optimal P2Y12 inhibitor choice and timing in hs-troponin-positive NSTEMI at ED presentation. Direct ED prescribing implications.

EMANATE-3 (UK) — AI triage tool vs Manchester Triage System in NHS EDs. Primary outcome: 30-day adverse events. Results not expected until 2027.

HEROIC (UK) — High-flow O2 vs standard in ED COPD exacerbations. Addressing ongoing uncertainty about O2 delivery in hypercapnoeic COPD in the ED.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 16 — 11 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