EM Evidence Rundown — Issue 17

#ISSUE 17 — 18 JUNE 2026

EM Evidence Rundown

Emergency Medicine · UK Edition

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.

LEAD: ARISE FLUIDS (NEJM, n=963): Vasopressor-forward vs fluid-liberal in ED septic shock — DAOH90 identical (76 days both arms). Pulmonary oedema 0.6% vs 5.0% with fluids (RR 0.12). Peripheral noradrenaline safe. Early pressors: three RCTs now support this. Mortality point estimates trend toward fluids — vasopressor-forward is safe and reasonable, not proven superior. TONIGHT: MHRA Class 3 recall — Orbit Pharma Cyclizine Lactate 50mg/ml injection (EL(26)A/29, 16 June). Check injectable cyclizine stock now — remove any Orbit Pharma batches. • MHRA Field Safety Notices 8–12 June 2026 — pass to equipment lead.

BOTTOM LINE UP FRONT — ISSUE 17

ACT ON THIS NOW

TONIGHT Cyclizine recall: MHRA EL(26)A/29 — Orbit Pharma injectable cyclizine 50mg/ml. Class 3. Remove from use, return to pharmacy.

TONIGHT MHRA FSNs 8–12 June: Medical device safety notices — pass to charge nurse/equipment lead for review.

TONIGHT ACE inhibitor angioedema (MHRA 17 June): Bradykinin-mediated — does NOT respond to adrenaline. Early airway. Stop ACE inhibitor. Consider icatibant. Do not treat as anaphylaxis.

TONIGHT Heat alert (UKHSA Amber, active to 23 June): Heat stroke = cooling emergency. Screen for drug toxicity (lithium, digoxin). Check U&E in all elderly/exertional heat presentations.

THIS MONTH ARISE FLUIDS (NEJM, n=963): Peripheral noradrenaline safe in ED septic shock. Early vasopressors + restricted fluids = same DAOH90. Pulmonary oedema 8× lower with vasopressor-forward. Don’t wait for a central line.

THIS MONTH Conservative oxygen post-ROSC (LOGICAL, NEJM): SpO&sub2; 90–95% targeting = no benefit vs liberal. Continue targeting SpO&sub2; 94–98% (RCUK guidelines).

KNOW FOR NEXT TIME

GUIDELINE CAP antibiotics (ATS/IDS 2025): Confirmed viral CAP (flu, RSV, COVID) in healthy adults — reassess antibiotic need. Min 3-day courses from stability. LUS validated for diagnosis.

INFORMING Appendicitis antibiotics: ~2/3 avoid surgery at 1yr. Appendicolith = surgery preferred (52% failure rate with antibiotics). Know the numbers for SDM.

INFORMING Pleural infection (SCOPE RCT): Saline lavage inferior to IET (longer drainage duration). First-line remains alteplase + DNase per BTS.

PAEDS Nirsevimab real-world: 59% reduction in RSV bronchiolitis hospitalisations. NHS Beyfortus programme on track. Reduced winter pressures expected.

PAEDS Bronchiolitis care: Guideline-discordant bronchodilator & antibiotic overuse persists in community EDs. Audit your practice — supportive care only (NICE NG9).

This issue is built around sepsis resuscitation. The ARISE FLUIDS trial — the third and largest negative RCT in the vasopressor-versus-fluids debate — arrives in the same week as a mechanistic framework from EMCrit that explains precisely why uncritical fluid-pushing fails. Meanwhile, the LOGICAL trial closes the book on conservative oxygen targeting post-cardiac arrest, the updated ATS/IDS CAP guidelines demand antibiotic stewardship in viral pneumonia, and two MHRA safety alerts require action tonight.

WHAT’S INSIDE ISSUE 17

Section 1 — Key Trials: ARISE FLUIDS — vasopressor-forward in ED septic shock (NEJM, LEAD) · LOGICAL — conservative oxygen post-cardiac arrest (NEJM) · Surgery vs antibiotics in appendicitis (SGEM/Ann Emerg Med) · ATS/IDS CAP guidelines — EM perspective · SCOPE RCT — saline vs IET in pleural infection Section 2 — Guidelines & UK: MHRA cyclizine injection recall · MHRA FSNs 8–12 June · ACE inhibitor angioedema — bradykinin alert · UKHSA Amber Heat Alert (active 23 June) Section 3 — Paediatric EM: Nirsevimab real-world data · Opioids in paediatric sickle cell VOC · Dexamethasone for paeds wheeze · Bronchiolitis guideline adherence · PET/CT in paediatric FUO Section 4 — FOAMed: EMCrit 427 — Four-Interface Shock Model · St Emlyn’s ARISE FLUIDS appraisal Section 5 — Quick Hits · Core Revision — Sepsis Physiology & Resuscitation Targets · Action Points · Trials to Watch

SECTION 1 — KEY TRIALS & JOURNAL ARTICLES

NEJM · PUBLISHED ONLINE 11 JUNE 2026 · DOI: 10.1056/NEJMOA2516225 · OPEN-LABEL RCT · 51 SITES (AUSTRALIA/NZ) · LEAD ITEM

ARISE FLUIDS — Vasopressor-Forward vs Fluid-Liberal Resuscitation in ED Septic Shock: Identical 90-Day Outcomes, 8-Fold Reduction in Pulmonary Oedema with Early Vasopressors (n=963)

RCT CHANGE THIS MONTH FRCEM SEPSIS

• −4.4% ARD PULMONARY OEDEMA (VASOPRESSOR VS FLUIDS)
• NNH 23 PULMONARY OEDEMA IF LIBERAL FLUIDS (NNH=23)
• RR 0.12 PULMONARY OEDEMA (VASOPRESSOR VS FLUIDS, P<0.001)
• n=963 ITT POPULATION (1000 RANDOMISED)

The ARISE FLUIDS trial randomised 1000 adults presenting to ED with septic shock (Sepsis-3 criteria) after ≤1000mL IV fluid but before 30mL/kg, across 51 sites in Australia and New Zealand (Peake SL, Macdonald SPJ et al; ARISE FLUIDS Investigators, ANZICS CTG, ACEM CTN). Patients were allocated to vasopressor-forward (restricted fluids plus early vasopressors targeting MAP ≥65) versus fluid-liberal (≥30mL/kg in 3 hours, vasopressors deferred). The primary outcome was Days Alive and Out of Hospital to day 90 (DAOH90).

Primary result: DAOH90 was 76 days in both arms (difference 0.0 days, 95% CI −2.7 to +2.7, p=1.00). A perfectly null result. The vasopressor arm received 1108mL less fluid over 24h (median 2640mL vs 3748mL) — good separation achieved. Vasopressor use was 86.5% vs 67.6% (an 18.9 percentage point difference). Peripheral vasopressors were used in 71.9% vs 55.4% of patients; extravasation occurred in 0.4% — no tissue necrosis reported.

Key safety signal: Pulmonary oedema occurred in 0.6% (vasopressor) vs 5.0% (fluids), RR 0.12, 95% CI 0.03–0.39, p<0.001. This is an 8-fold reduction and the most clinically meaningful finding in the trial. Mechanical ventilation was equal (15% both arms). ICU admission was 77% vs 68%, reflecting higher severity in the vasopressor arm.

Mortality signal: 90-day mortality was 16.4% (vasopressor) vs 14.4% (fluids), RR 1.14, 95% CI 0.85–1.54 (NS). 28-day mortality 12.9% vs 10.0% (NS). The point estimates favour fluids for mortality — not statistically significant, but a finding that prevents declaring vasopressor-forward superiority. The trial was not powered for mortality.

UK Caveat: ARISE FLUIDS was conducted in Australasia. UK sepsis management (Sepsis 6; 500mL fluid boluses) is more nuanced than the 30mL/kg liberal comparator arm, which many UK clinicians would already regard as excessive. The EVIS UK RCT (NCT05179499, n=3286) is the direct UK equivalent and remains ongoing. Do not extrapolate the Australasian comparator uncritically to UK practice.

Critical appraisal: Open-label design means clinician-reported pulmonary oedema is susceptible to ascertainment bias — a major limitation for the key safety finding. Not powered for mortality, and the mortality point estimates sit on the wrong side for vasopressors (RR 1.14). The 30mL/kg liberal comparator may represent the extreme end of current practice. This is the third large “negative” RCT (after CLASSIC 2022, CLOVERS 2023) — all showing null primary outcomes. Subgroup hints suggest benefit in younger women, higher APACHE, lactate >3, and respiratory sepsis source, but these are hypothesis-generating only.

Why it matters: Peripheral noradrenaline is safe, evidenced, and can be started without a central line. Restricting fluids and starting vasopressors early is now supported by three large RCTs and reduces pulmonary oedema substantially. But the mortality signal prevents declaring vasopressor-forward strategy superior — it is a safe and reasonable approach, not a mandate. Shared decision-making and clinical assessment remain central.

Tell your department: Early peripheral noradrenaline is safe (0.4% extravasation, no necrosis). There is no need to wait for a central line before starting vasopressors in ED septic shock. Three RCTs now support this. But maintain clinical nuance — vasopressor-forward is one reasonable strategy; it has not been shown to reduce mortality.

Source: Peake SL, Macdonald SPJ et al. NEJM, published online 11 June 2026. DOI: 10.1056/NEJMoa2516225 | St Emlyn’s appraisal: stemlynsblog.org

NEJM · PUBLISHED 10 JUNE 2026 · OPEN-LABEL RCT · MULTICENTRE · POST-CARDIAC ARREST / ICU

LOGICAL Trial — Conservative vs Liberal Oxygen After ROSC: No Difference in Survival with Favourable Outcome at 180 Days (n=1709)

RCT INFORMING PRACTICE FRCEM

• RR 0.97 PRIMARY OUTCOME: SURVIVAL WITH FAVOURABLE FUNCTION AT 180D (NS)
• 38.2% vs 39.7% CONSERVATIVE VS LIBERAL ARM (P=0.65)
• n=1709 TOTAL (819 CONSERVATIVE, 890 LIBERAL)

The LOGICAL trial randomised unresponsive adults after ROSC receiving mechanical ventilation in ICU to conservative oxygen (SpO&sub2; 90–95%, FiO&sub2; decreased to 0.21 if SpO&sub2; above lower limit) versus liberal oxygen (no upper SpO&sub2; limit, minimum FiO&sub2; 0.3). Primary outcome: survival with favourable functional outcome at 180 days. Result: 38.2% (313/819) conservative vs 39.7% (353/890) liberal; RR 0.97, 95% CI 0.87–1.09, p=0.65. A clear null result.

Conservative oxygen targeting after cardiac arrest has been advocated for years based on hyperoxia animal data and observational studies suggesting harm from high FiO&sub2;. This large RCT shows no functional outcome benefit from conservative targeting. The message for the resus bay: the oxygen targeting decision begins immediately post-ROSC, and current RCUK/ERC guidance (SpO&sub2; 94–98%) remains appropriate — neither hyper- nor hypoxia is beneficial, and neither extreme appears uniquely harmful in this range.

Critical appraisal: Open-label trial in an ICU setting — not ED-based, though the oxygen-targeting decision is typically made in the resus bay immediately post-ROSC. Consistent with prior meta-analyses showing no benefit from conservative oxygen in cardiac arrest populations. The null result is clinically reassuring rather than paradigm-shifting.

Why it matters: Continue targeting SpO&sub2; 94–98% as per RCUK and ERC post-resuscitation guidelines. Do not be pressured to pursue aggressive SpO&sub2; conservation below this range. This trial provides level 1 evidence that doing so does not improve outcomes.

Source: LOGICAL trial. NEJM, published 10 June 2026. ACC Journal Scan: acc.org

SGEM #512 · 13 JUNE 2026 · EVIDENCE REVIEW · TALAN ET AL. ANN EMERG MED / JAMA SURGERY 2026 · APPAC / CODA / MPSC / APPY TRIAL SYNTHESIS (>4000 PATIENTS)

Surgery vs Antibiotics for Uncomplicated Appendicitis — Updated Evidence Review: Two-Thirds Avoid Surgery at 1 Year; Appendicolith is the Red Flag

EVIDENCE REVIEW INFORMING PRACTICE FRCEM

SGEM #512 synthesises four major RCTs examining antibiotic-first management of uncomplicated appendicitis in adults and children: APPAC (Finland), CODA (USA), MPSC (children, UK/USA), and APPY. Together these enrol over 2000 adults and 2000 children. The synthesis is based on a narrative review by Talan et al. published in Annals of Emergency Medicine and JAMA Surgery 2026.

Why it matters for ED clinicians: You are increasingly involved in initiating shared decision-making conversations about appendicitis management before surgery. Know the numbers: approximately two-thirds of patients avoid surgery at 1 year with antibiotics alone; one-third will still need it. Appendicolith on CT doubles to triples the failure risk — this is a contraindication to antibiotics-first. Outpatient antibiotic treatment is safe and supported by the data, and has implications for ED pathway design.

Source: SGEM #512, 13 June 2026. thesgem.com | Talan et al. Ann Emerg Med / JAMA Surgery 2026

AM J EMERG MED · 2026 (PMID 42127879) · JOURNALFEED 17 JUNE · CLINICAL SUMMARY & REVIEW · LONG B, GOTTLIEB M.

2025 ATS/IDSA CAP Guideline Updates — Emergency Medicine Perspective: Viral CAP Antibiotics Not Needed, Minimum 3-Day Courses, LUS Validated

GUIDELINE CHANGE WHEN GUIDELINE UPDATES FRCEM

Long and Gottlieb summarise the 2025 ATS/IDSA Community-Acquired Pneumonia guidelines from an emergency medicine perspective. Four key changes affect ED practice:

UK Caveat: The UK follows BTS 2009 CAP guidelines (updated in part by NICE NG138). These ATS/IDSA 2025 updates have not been formally adopted by NICE but represent the direction of travel. LUS skills are increasing in UK EDs. Viral-only CAP antibiotic stewardship aligns with NHS England antibiotic stewardship priorities and existing CQUIN targets. Do not implement as a protocol change without checking your trust’s current guidelines; use this evidence in discussions with your antimicrobial stewardship team.

Why it matters: Antibiotic stewardship for viral CAP is increasingly supported by international evidence. If your ED regularly prescribes antibiotics for influenza-positive or COVID-positive pneumonia in otherwise healthy adults, this guideline challenges that practice. The 3-day minimum course supports earlier discharge in stable patients.

Source: Long B, Gottlieb M. Am J Emerg Med. 2026. PMID 42127879 — via JournalFeed 17 June 2026

EUR RESPIR J · 2026 FEB 19 (PMID 41713953) · MCMASTER SCORE 5/7 · PORCEL JM ET AL. · 2-CENTRE RCT · N=89

SCOPE RCT — Saline Lavage vs Intrapleural Enzyme Therapy in Pleural Infection: Saline Inferior; IET Remains Standard

RCT

INFORMING PRACTICE

+1 day

LONGER DRAINAGE DURATION: SALINE VS IET (4.0 VS 3.0 DAYS, P=0.01)

n=89

SMALL 2-CENTRE TRIAL (1:1:1 RANDOMISATION)

Small n

INTERPRET WITH CAUTION — LIMITED GENERALISABILITY

Porcel et al. randomised 89 adults with pleural infection (complicated parapneumonic effusion and empyema) 1:1:1 to saline lavage alone, saline plus intrapleural enzyme therapy (IET: alteplase + DNase), or IET alone. Primary outcome: duration of pleural drainage. Saline alone resulted in 4.0 days [IQR 3.0–6.75] vs 3.0 days [2.0–4.0] for IET (p=0.01). Adding saline lavage to IET conferred no additional benefit over IET alone.

Critical appraisal: Small (n=89), 2-centre trial with limited power for secondary outcomes. Results may not be generalisable to all empyema presentations. McMaster Evidence Score 5/7 — methodologically reasonable but limited by size. Confirms BTS guideline direction rather than overturning it.

Why it matters: Some units use saline irrigation as a cheaper alternative to alteplase + DNase. This trial demonstrates it results in longer drainage duration, with no cost-saving benefit that justifies inferior outcomes. First-line management remains IET (alteplase + DNase) as per BTS pleural infection guidelines. If your department or referring medical teams are using saline lavage instead of IET, this trial supports changing that practice.

Source: Porcel JM et al. Eur Respir J. 2026 Feb 19. PMID 41713953 — McMaster Evidence Alerts, 17 June 2026

SECTION 2 — GUIDELINES & UK UPDATES

MHRA · EL(26)A/29 · 16 JUNE 2026 · CLASS 3 MEDICINES RECALL · SAFETY ALERT

⚠ MHRA Class 3 Recall — Orbit Pharma Cyclizine Lactate 50mg/ml Solution for Injection: Check Your ED Stock Tonight

CHANGE TONIGHT SAFETY ALERT UK

Action required: MHRA has issued a Class 3 precautionary recall (EL(26)A/29, 16 June 2026) for Cyclizine Lactate 50mg/ml Solution for Injection manufactured by Orbit Pharma Limited. Reason: GMP (Good Manufacturing Practice) deficiencies at the manufacturing site. Class 3 = lowest risk category; product is unlikely to cause harm but must be removed from circulation as a precautionary measure. Check your ED’s injectable cyclizine stock — if from Orbit Pharma, remove from use immediately and return to pharmacy for quarantine and return.

Cyclizine injection is widely used in UK EDs for nausea and vomiting, including in palliative patients, acute migraine, and opioid-induced nausea. The Class 3 classification means the GMP deficiency is unlikely to have caused product failure or patient harm, but the recall is mandatory and time-sensitive. Alternative antiemetic preparations should be available from pharmacy while affected stock is quarantined.

Source: MHRA EL(26)A/29, 16 June 2026. gov.uk/drug-device-alerts

MHRA · FIELD SAFETY NOTICES · 15 JUNE 2026 · MEDICAL DEVICE SAFETY ALERTS

⚠ MHRA Field Safety Notices 8–12 June 2026 — Review for Relevant ED Device Alerts

CHANGE TONIGHT SAFETY ALERT UK

MHRA DRUG SAFETY UPDATE · 17 JUNE 2026

⚠ MHRA Drug Safety Alert — ACE Inhibitors: Bradykinin-Mediated Angioedema Does Not Respond to Adrenaline — Treat Differently

CHANGE TONIGHT FRCEM

CRITICAL CLINICAL POINT

ACE inhibitor-induced angioedema is bradykinin-mediated, not histamine-mediated. Adrenaline (epinephrine), antihistamines, and corticosteroids will NOT reliably reverse it. Approximately half of ACE inhibitor angioedema cases present ≥30 days after drug initiation — often after years of use.

The MHRA issued this Drug Safety Update on 17 June 2026, requiring product information for all ACE inhibitors to carry strengthened warnings about delayed-onset, bradykinin-mediated angioedema. Fatal cases involving airway compromise have been recorded.

ED management protocol for suspected ACE inhibitor angioedema:

Critical appraisal: This is a pharmacovigilance update, not an RCT. The bradykinin mechanism of ACE inhibitor angioedema has been established for many years. The MHRA update is a regulatory signal requiring product labelling changes; it does not introduce new clinical evidence but strengthens the warning. Icatibant evidence in ACE inhibitor angioedema comes from small RCTs (CAMEO, FAST-1/3/5) showing faster resolution vs placebo, though most cases resolve with supportive care alone. The key behavioural change is: do not treat it identically to anaphylaxis and be prepared for failure of standard treatment.

Why it matters: Millions of UK patients are on ACE inhibitors (ramipril, lisinopril, enalapril, perindopril). ED presentations with angioedema in this cohort are common. The mistake of repeated adrenaline administration without airway escalation has caused preventable deaths. Know the drug, know the mechanism, call the airway team early.

Tell your department: Include ACE inhibitor angioedema in your next airway emergency teaching session. Add to your anaphylaxis protocol: “If angioedema in ACE inhibitor user — bradykinin-mediated: escalate airway immediately, do not rely on adrenaline.”

Source: MHRA Drug Safety Update, 17 June 2026. gov.uk/drug-safety-update

UKHSA HEAT HEALTH ALERT · 18 JUNE 2026 · ACTIVE UNTIL 23 JUNE

UKHSA Amber Heat Health Alert — Active Until 23 June: Prepare for Surge in Heat-Related Presentations and Medication Toxicity

CHANGE TONIGHT UK DATA

AMBER ALERT ACTIVE NOW

Amber Heat Health Alert: London, South East, South West, East of England — active from 12:00 18 June to 20:00 23 June 2026. Yellow alert: East Midlands, West Midlands, Yorkshire. “Significant impacts are likely across health and social care services.”

During Amber heat alerts, expect increased ED presentations including: heat exhaustion and heat stroke (core temp ≥40°C, reduced GCS — this is a resuscitation emergency), dehydration and AKI, cardiovascular exacerbations (AF, decompensated heart failure), respiratory deterioration, and drowning/cold water shock (public typically seek water during heatwaves). Medication-related emergencies in heat: lithium toxicity (reduced GFR + dehydration), digoxin toxicity, diuretic-induced electrolyte disturbances, and drug storage failures (insulin, glyceryl trinitrate, adrenaline autoinjectors).

Source: UKHSA Heat Health Alerts, 17–18 June 2026. ukhsa-dashboard.data.gov.uk

Action required: MHRA published a batch of Field Safety Notices covering the period 8–12 June 2026. FSNs cover medical devices including infusion pumps, defibrillators, and monitoring equipment. ED teams should review the full list at gov.uk for any alerts affecting devices in current use. Forward to your charge nurse, equipment lead, and clinical governance team for device-specific action.

Source: MHRA Field Safety Notices 8–12 June 2026, published 15 June 2026. gov.uk/drug-device-alerts

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

PEDIATR PULMONOL · 2026 (PMID 42214018) · JOURNALFEED PAEDS 17 JUNE · RETROSPECTIVE COMPARATIVE STUDY · LA REGINA DP ET AL.

Nirsevimab Real-World Data — 59% Reduction in RSV Bronchiolitis Hospitalisations After Introduction: UK Beyfortus Programme Validated

OBSERVATIONAL INFORMING PRACTICE PAEDS

• −59% REDUCTION IN RSV-RELATED BRONCHIOLITIS HOSPITALISATIONS POST-NIRSEVIMAB
• Retrospective OBSERVATIONAL DESIGN — SEASONAL CONFOUNDING POSSIBLE

La Regina et al. compared RSV-related bronchiolitis hospitalisation rates across two consecutive seasons before and after introduction of nirsevimab (Beyfortus), finding a 59% reduction in the post-nirsevimab season. The JCVI approved nirsevimab for NHS use from the 2024–25 RSV season, with rollout to all infants born on or after 1 September 2024. This real-world observational data supports programme effectiveness.

UK context: With nirsevimab now NHS-funded, expect to see a real reduction in bronchiolitis presentations and admissions this winter. This matters for ED capacity planning and for reassuring parents of infants who have received the injection. Retrospective design and seasonal confounding limit causal certainty, but the magnitude of effect is consistent with Phase 3 trial data and other real-world programmes (Spain, Luxembourg).

Source: La Regina DP et al. Pediatr Pulmonol. 2026. PMID 42214018 — JournalFeed Paeds, 17 June 2026

AM J EMERG MED · 2026 (PMID 42190636) · MCMASTER SCORE 6/7 · SYSTEMATIC REVIEW & META-ANALYSIS

Early vs Delayed Opioids for Paediatric Sickle Cell Vaso-Occlusive Crisis — SR/MA: No Difference in Admission Rate, LOS, or Pain Outcomes

SR/MA INFORMING PRACTICE PAEDS

• RR 0.96 HOSPITAL ADMISSION (95% CI 0.85–1.10, NS)
• SR/MA SYSTEMATIC REVIEW & META-ANALYSIS (MULTIPLE STUDIES)
• Heterogeneous HETEROGENEOUS INCLUDED STUDIES

This systematic review and meta-analysis examined early versus delayed opioid administration in paediatric patients presenting to the ED with sickle cell vaso-occlusive crisis (VOC). Primary outcomes: hospital admission (RR 0.96, 95% CI 0.85–1.10), ED discharge (RR 1.04, 95% CI 0.89–1.22), ED length of stay (MD −6.02 min, 95% CI −122.45 to 110.42), and pain reassessment (SMD 0.85, 95% CI −1.92 to 3.63). No significant difference in any primary outcome.

Critical appraisal: Heterogeneous included studies limit the meta-analytic conclusions. The finding that “early” opioid timing does not change outcomes should not be interpreted as opioids being ineffective or unnecessary in VOC — the question studied was timing specifically. Current NICE/BHS guidance recommends opioids within 30 minutes of arrival; this SR/MA does not contradict that recommendation.

Why it matters: Concern about opioid timing in paediatric sickle cell VOC is sometimes cited as a reason for delays. This SR/MA shows no benefit from very early administration over standard timely delivery. Do not withhold opioids, but equally, the evidence does not support aggressive early administration as a strategy to change downstream outcomes. Continue with institutional VOC protocols and ensure opioids are given promptly but without making timing the sole focus of care.

Source: PMID 42190636. Am J Emerg Med. 2026 — McMaster Evidence Alerts, 17 June 2026

ARCH DIS CHILD · 2026 JUN 16 (PMID 42303466) · COMMENTARY / CORRESPONDENCE · NORMAN-BRUCE H, GROVES H, WATERFIELD T. QUEEN’S UNIVERSITY BELFAST.

Dexamethasone for Acute Wheeze in Children — Have the Risks Been Adequately Considered? Commentary Flags Adrenal Suppression and Hyperglycaemia Concerns

COMMENTARY

INFORMING PRACTICE

PAEDS

UK

Norman-Bruce, Groves, and Waterfield (Queen’s University Belfast) raise concerns in this correspondence piece about the widespread replacement of prednisolone with single-dose dexamethasone (0.15–0.3mg/kg PO) in paediatric wheeze protocols. They highlight that while single-dose convenience has driven adoption, the potential risks of adrenal suppression and hyperglycaemia — particularly with repeated exposure — may not be adequately considered in clinical practice guidelines. A related cited article examines significant practice variation in steroid choice across UK and Irish paediatric EDs.

Important context: This is a commentary with no original data. The evidence base for single-dose dexamethasone for acute paediatric wheeze is well-established and robust. This paper does not contraindicate its use, but raises a monitoring question about repeated exposure, adrenal suppression risk, and whether local protocols include appropriate safety-netting. If your department has switched to dexamethasone for paeds wheeze, ensure: (1) protocols include glucose monitoring guidance for diabetic patients, (2) parents are safety-netted about adrenal suppression symptoms with repeated episodes, (3) repeated short-burst steroid use is documented and tracked.

Source: Norman-Bruce H, Groves H, Waterfield T. Arch Dis Child. 2026 Jun 16. PMID 42303466

J PEDIATR · 2026 (PMID 42297337) · OBSERVATIONAL STUDY · COMMUNITY EMERGENCY DEPARTMENTS

Guideline-Discordant Bronchiolitis Care in Community EDs: Significant Overuse of Bronchodilators and Antibiotics Despite AAP/NICE Guidance

OBSERVATIONAL INFORMING PRACTICE PAEDS

This observational study examined bronchiolitis management across community hospital EDs, finding significant overuse of bronchodilators (salbutamol, ipratropium) and antibiotics despite clear AAP and NICE guideline recommendations against both. Practice variation was substantial across sites.

NICE NG9 (bronchiolitis) — reminders: Do NOT use salbutamol; do NOT use ipratropium; do NOT use antibiotics; do NOT use systemic steroids; do NOT use chest physiotherapy. Supportive care only: adequate hydration, oxygen if SpO&sub2; <90-92% (depending on context), nasopharyngeal suction if needed. High-flow humidified oxygen if clinically indicated. Admit if feeding <50–75% of normal, SpO&sub2; persistently low, or if parental concern high.

Tell your department: Audit your bronchiolitis management this winter. If your trust still prescribes bronchodilators or antibiotics for bronchiolitis routinely, this is your evidence base to raise at the next governance meeting. The evidence against these interventions is of the highest quality — multiple Cochrane reviews — and practice variation in UK community EDs needs to be addressed proactively.

Source: J Pediatr. 2026. PMID 42297337

PEDIATRICS · 2026 (PMID 42150770) · JOURNALFEED PAEDS 18 JUNE · RETROSPECTIVE COHORT · N=112 · BERLAK N ET AL.

PET/CT in Paediatric Fever of Unknown Origin — Contributed to Diagnosis in 45.5% and Influenced Treatment in 35.7%

OBSERVATIONAL INFORMING PRACTICE PAEDS

Berlak et al. retrospectively reviewed 112 paediatric patients investigated with PET/CT for fever of unknown origin (FUO) after conventional investigations were non-diagnostic. PET/CT contributed to diagnosis in 45.5% and influenced treatment decisions in 35.7%; it was particularly useful for infectious aetiologies. Most UK tertiary centres have FUO protocols that do not routinely include PET/CT. This supports its use in the investigative pathway after negative first-line investigations (including blood cultures, echocardiogram, and CT). PED clinicians managing complex FUO should consider early discussion with tertiary paediatric teams about whether PET/CT referral is appropriate.

Source: Berlak N et al. Pediatrics. 2026. PMID 42150770 — JournalFeed Paeds, 18 June 2026

SECTION 4 — FOAMED & CRITICAL APPRAISAL

EMCRIT PODCAST 427 · SCOTT WEINGART · JUNE 2026 · CONCEPTUAL FRAMEWORK · ROLA ET AL. J PERS MED 2025;15:207 + CRAGER EMERG MED CLIN N AM 2026;44:315–331

EMCrit 427 — The Four-Interface Model of Shock Physiology: A Framework for Understanding Why Fluids Fail

FOAMed INFORMING PRACTICE FRCEM SEPSIS

Scott Weingart synthesises two recent papers into a practical four-interface model for evaluating and treating shock physiology, directly relevant to the ARISE FLUIDS lead item and this issue’s Core Revision topic.

Crager’s Pressure Vector Sum: Tissue Perfusion Pressure = MAP − (greater of critical closing pressure or CVP). This formulation explains why fluid loading that raises CVP above the critical closing pressure can paradoxically reduce tissue perfusion even as MAP appears adequate — the physiological basis for the ARISE FLUIDS pulmonary oedema signal and for why Interface III is the mechanistic key to fluid restriction in sepsis.

Weingart’s synthesis: A qualitative 4-step framework: Stabilise → Interface assessment → Intervene → Reassess. Apply iteratively rather than as a one-time checklist.

Why it matters: This framework directly explains the ARISE FLUIDS result. Interface III (venous back-pressure) is why liberal fluid-pushing causes pulmonary oedema even in normotensive patients. Interface II (microcirculation) is the endpoint tested in ANDROMEDA-SHOCK-2 (CRT normalisation). Understanding these interfaces allows you to reason about your patients rather than follow a protocol blindly — especially important in complex shock presentations. Directly relevant to this issue’s Core Revision section.

Source: EMCrit Podcast 427, Scott Weingart, June 2026. emcrit.org | Rola et al. J Pers Med. 2025;15:207 | Crager. Emerg Med Clin N Am. 2026;44:315–331

ST EMLYN’S BLOG · 17 JUNE 2026 · CRITICAL APPRAISAL

St Emlyn’s — To Squeeze or Not to Squeeze? Critical Appraisal of ARISE FLUIDS

FOAMed INFORMING PRACTICE SEPSIS

St Emlyn’s provides a thorough and balanced critical appraisal of ARISE FLUIDS. Key points from their analysis:

Source: St Emlyn’s blog, 17 June 2026. stemlynsblog.org

SECTION 5 — QUICK HITS

BMC EMERG MED · JOURNALFEED EM 18 JUNE · SR/MA

AI-Assisted POCUS for FAST in Trauma: SR/MA shows AI assistance improves diagnostic accuracy for abdominal free fluid detection. Evidence is promising but heterogeneous. Preliminary data only — not yet ready for protocol implementation. Watch this space as ED-specific AI POCUS tools mature.

J EMERG MED · 2026 (PMID 41936304) · REEVES MT, LEE Y, SHALABY M · POCUS JOURNALFEED 17 JUNE

USS-Guided Truncal Blocks for Tube Thoracostomy Analgesia: Ultrasound-guided truncal blocks (serratus anterior plane block, erector spinae plane block) as alternatives to opioids or procedural sedation for chest drain insertion in the ED. RSS/thoracocentesis blocks are already in some UK ED protocols; this supports broader expansion. Appropriate skill-building required — discuss with your regional PoCUS lead.

UMEM EDUCATIONAL PEARL (CRITICAL CARE) · 13 JUNE 2026 · UMEM.ORG

Can Lactate Lie? Five Pitfalls in Lactate Interpretation: (1) Type B lactic acidosis — metformin, thiamine/B1 deficiency (Wernicke’s), linezolid, liver failure, malignancy; not due to tissue hypoxia. (2) Tourniquet effect — prolonged tourniquet during blood draw increases lactate artefactually. (3) Delayed processing — red cells metabolise glucose to lactate in vitro, especially in warm samples. (4) Arterial vs venous variation — point-of-care variation is clinically significant. (5) Elevated lactate ≠ tissue hypoxia — always contextualise. Lactate is a trigger and resuscitation endpoint in sepsis; misinterpretation leads to unnecessary fluid loading and missed Type B diagnoses. Relevant to this issue’s Core Revision.

UMEM EDUCATIONAL PEARL (PHARMACOLOGY) · 12 JUNE 2026 · UMEM.ORG

Toxin Suppression in NSTIs: In confirmed or suspected Group A Streptococcal or clostridial necrotising soft tissue infections, add clindamycin or linezolid (protein synthesis inhibitors) to suppress exotoxin production (TSST, streptococcal pyrogenic exotoxins SPE-A, SPE-C). This is adjunct therapy, not a replacement for surgical debridement — surgery remains the definitive treatment. UKHSA invasive GAS guidance supports clindamycin adjunct. Check your trust’s NSTI protocol and antimicrobial guidelines.

SCAND J TRAUMA RESUSC EMERG MED · 2026;34:105 · DOI: 10.1186/S13049-026-01638-W · BERGLUND M ET AL. · QUALITATIVE STUDY

What Makes an EM Physician Productive? Six Themes from Swedish Qualitative Study (n=8): (1) Initial situational awareness; (2) Parallel case progression; (3) Cognitive offloading; (4) Anticipatory communication; (5) Selective resource utilisation; (6) Pragmatic responsiveness. Context: RCEM 2026 data attributes 15,860 excess deaths to ED waits annually — individual clinical efficiency is increasingly a patient safety issue, not just an operational one. Limitation: n=8, single-centre Sweden, self-reported — treat as hypothesis-generating, not prescriptive.

CORE REVISION — SEPSIS PHYSIOLOGY & RESUSCITATION TARGETS

J EMERG MED · 2026 (PMID 41936304) · REEVES MT, LEE Y, SHALABY M · POCUS JOURNALFEED 17 JUNE

USS-Guided Truncal Blocks for Tube Thoracostomy Analgesia: Ultrasound-guided truncal blocks (serratus anterior plane block, erector spinae plane block) as alternatives to opioids or procedural sedation for chest drain insertion in the ED. RSS/thoracocentesis blocks are already in some UK ED protocols; this supports broader expansion. Appropriate skill-building required — discuss with your regional PoCUS lead.

UMEM EDUCATIONAL PEARL (CRITICAL CARE) · 13 JUNE 2026 · UMEM.ORG

Can Lactate Lie? Five Pitfalls in Lactate Interpretation: (1) Type B lactic acidosis — metformin, thiamine/B1 deficiency (Wernicke’s), linezolid, liver failure, malignancy; not due to tissue hypoxia. (2) Tourniquet effect — prolonged tourniquet during blood draw increases lactate artefactually. (3) Delayed processing — red cells metabolise glucose to lactate in vitro, especially in warm samples. (4) Arterial vs venous variation — point-of-care variation is clinically significant. (5) Elevated lactate ≠ tissue hypoxia — always contextualise. Lactate is a trigger and resuscitation endpoint in sepsis; misinterpretation leads to unnecessary fluid loading and missed Type B diagnoses. Relevant to this issue’s Core Revision.

UMEM EDUCATIONAL PEARL (PHARMACOLOGY) · 12 JUNE 2026 · UMEM.ORG

Toxin Suppression in NSTIs: In confirmed or suspected Group A Streptococcal or clostridial necrotising soft tissue infections, add clindamycin or linezolid (protein synthesis inhibitors) to suppress exotoxin production (TSST, streptococcal pyrogenic exotoxins SPE-A, SPE-C). This is adjunct therapy, not a replacement for surgical debridement — surgery remains the definitive treatment. UKHSA invasive GAS guidance supports clindamycin adjunct. Check your trust’s NSTI protocol and antimicrobial guidelines.

SCAND J TRAUMA RESUSC EMERG MED · 2026;34:105 · DOI: 10.1186/S13049-026-01638-W · BERGLUND M ET AL.

• QUALITATIVE STUDY

What Makes an EM Physician Productive? Six Themes from Swedish Qualitative Study (n=8): (1) Initial situational awareness; (2) Parallel case progression; (3) Cognitive offloading; (4) Anticipatory communication; (5) Selective resource utilisation; (6) Pragmatic responsiveness. Context: RCEM 2026 data attributes 15,860 excess deaths to ED waits annually — individual clinical efficiency is increasingly a patient safety issue, not just an operational one. Limitation: n=8, single-centre Sweden, self-reported — treat as hypothesis-generating, not prescriptive.

CORE REVISION — SEPSIS PHYSIOLOGY & RESUSCITATION TARGETS

CORE REVISION: SEPSIS PHYSIOLOGY & RESUSCITATION TARGETS — ISSUE 17 This issue’s revision topic is timed to coincide with the ARISE FLUIDS lead trial and the SSC 2026 guidelines covered in Issue 16. Relevant to FRCEM Primary and STA domains.

1. Definitions (Sepsis-3) Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Operationalised as SOFA score ≥2 in the context of suspected infection. Septic shock: Sepsis PLUS vasopressor requirement to maintain MAP ≥65mmHg AND serum lactate >2mmol/L despite adequate fluid resuscitation — associated with >40% in-hospital mortality. 2. Pathophysiology — Three Key Mechanisms

3. Current Resuscitation Targets (UK post-SSC 2026)

4. ARISE FLUIDS Summary (This Issue’s Lead Trial)

5. Vasopressor Choice in ED Septic Shock

6. FRCEM Mnemonic: SALT Resuscitation Endpoints

S — Sats: SpO&sub2; 94–98% (avoid hyperoxia AND hypoxia; LOGICAL trial confirms no benefit from conservative targeting post-arrest) A — Arterial pressure: MAP ≥65mmHg (higher if known hypertensive). Use vasopressors early; peripheral route is safe. L — Lactate trend: Clearance ≥10% per 2 hours. Not just absolute value. Beware Type B causes. CRT is an alternative/complementary endpoint. T — Temperature correction: Identify and treat source. Fever drives metabolic demand; hypothermia in sepsis is an ominous sign.

SECTION 6 — ACTION POINTS

TRIALS TO WATCH — Q2/Q3 2026 AND BEYOND

Imminent (Q2–Q3 2026)

• ICS State of the Art Conference (30 June–2 July, ICC Birmingham): BICARICU-2 full data, ANDROMEDA-SHOCK-2 deep-dive, iRehab results. All directly relevant to ED sepsis and post-ICU practice.
• EVIS UK Trial (NCT05179499): Early peripheral vasopressors in UK ED septic shock, n=3286 — the direct UK equivalent to ARISE FLUIDS. Expected 2026–2027. This is the trial that will determine UK clinical guidelines on vasopressor timing. Watch closely.
• BACHb Trial: HFNC vs Standard O&sub2; vs CPAP in bronchiolitis, UK multicentre (50+ sites). Due 2026. Directly relevant to paediatric ED practice and winter preparedness.

2026–2027

• BEST-DKA Phase 3: Balanced electrolyte vs saline in DKA — could change fluid selection in one of the most common ED critical illness presentations.
• ADAPT-Sepsis: PCT-guided antibiotic discontinuation in sepsis — with growing pressure on antibiotic stewardship, this could influence ED antibiotic prescribing duration.
• HSSIB Mental Health Crisis in EDs — Final Report 2 of 2: Expected summer 2026. Following Report 1 (Issue 5), which identified no lawful power to detain mental health patients in ED. Final report expected to include recommendations on HBPoS alternatives and ED mental health liaison models.

Longer Horizon

• CoMiTED: Conservative vs immediate chest drain insertion in traumatic pneumothorax — could change one of the most common ED thoracic procedures.
• CABARET: Head-up CPR bundle feasibility trial — exploring whether repositioning patients during cardiac arrest (head/thorax elevation) improves cerebral perfusion pressure and ROSC.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown · Issue 17 · 18 June 2026 · UK Edition Sent weekly to emergency medicine clinicians across the UK. emevidence.org · feedback@emevidence.org · This newsletter does not constitute clinical advice. Always follow local guidelines and your professional judgement.