EMERGENCY MEDICINE EVIDENCE RUNDOWN
EM Evidence Rundown
Issue 20 · 10 July 2026 · 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 Naloxone in PEA Cardiac Arrest (Resuscitation 2026, n=40,333): Matched cohort — survival OR 1.46 in PEA arrests receiving naloxone. No benefit in VF or asystole. In any
PEA of unknown cause, give naloxone.
CHANGE TONIGHT: UKHSA/MHRA heat alert — adrenaline auto-injectors and transdermal opioids degrade in heat; check ED stock. Active Amber heatwave alerts. MHRA FSNs: WEINMANN MEDUMAT, Maquet Flow-i, Chalice ECLS. | CHANGE THIS MONTH: Beta-blockers in sepsis — don't stop them unless shocked. POCUS infant bladder before catheterisation — 89.7% vs 72.5% first-attempt success. 2025 ACLS: cardioversion energy up to 100 J (narrow complex), 200 J (AF). Sotalol removed from stable VT algorithm.
BOTTOM LINE UP FRONT — ISSUE 20
ACT ON THIS NOW
TONIGHT MHRA/UKHSA heat alert: Check adrenaline auto-injectors and fentanyl/buprenorphine patches in ED stock — both degrade/absorb faster in heat. Active Amber alerts. MHRA FSNs: WEINMANN MEDUMAT, Maquet Flow-i, Chalice ECLS tubing.
THIS MONTH Naloxone in PEA (LEAD, n=40,333): Survival OR 1.46 in PEA arrests receiving naloxone. No benefit in VF/asystole. Give naloxone in all PEA of unknown cause.
THIS MONTH Beta-blockers in sepsis: Withholding home beta-blockers at sepsis admission → higher mortality (target trial emulation). Continue unless shocked.
GUIDELINE 2025 ACLS update: Cardioversion 100 J narrow complex, 200 J AF/flutter. Sotalol removed from stable VT. Post-arrest MAP >65, SpO2 90–98%. No neuroprog before 72h.
THIS MONTH POCUS infant bladder: SR/MA 3 RCTs. 89.7% vs 72.5% first-attempt success; dry taps 3.6% vs 23.9%. Scan before every catheterisation in children ≤36 months.
THIS MONTH Sepsis skin perfusion: SR/MA n=2,727. Mottling score, CRT, PPI all independently predict mortality. Use all three at every sepsis reassessment.
KNOW FOR NEXT TIME
GUIDELINE 2025 ACLS updates: Cardioversion energy ↑ (100 J narrow complex, 200 J AF/flutter). Sotalol removed from stable VT algorithm. Post-arrest MAP >65, SpO2 90–98%, no neuroprog before 72h.
GUIDELINE Lung US 2025 consensus: Updated ICM recommendations — B-lines, PTX, consolidation, effusion thresholds revised.
GUIDELINE AHA Stroke (1 item): TNK 0.25mg/kg = Class 1 (equal to alteplase). TNK 0.4mg/kg Class 3: No Benefit. Disabling vs non-disabling replaces NIHSS for IVT decision.
INFORMING AI sepsis bundle null: LLM raised compliance 70%→83%; no change in ICU admissions or 30-day mortality (JAMA NW Open, cluster-RCT). Process ≠ outcome.
INFORMING DanGer Shock 10yr: Impella in STEMI cardiogenic shock — survival benefit widens at 10 years (52.5% vs 68.8% mortality, HR 0.70). NNT 6 for survival, NNH 6 for complications. Know this for chest pain referrals.
PAEDS LUS + CRP for paeds pneumonia: Combined Sp 0.91 for bacterial vs viral. LUS consolidation + CRP >40 = treat as bacterial.
UK DATA RCEM (9 Jul): ED heatwave surge = exit block. DAUK calling for legal max NHS working temperature. UKHSA heatwave alerts active through 12 July.
This week's lead is one of those rare findings that changes what you do in the resus bay tonight: naloxone in PEA cardiac arrest. A matched cohort analysis of 40,333 out-of-hospital cardiac arrests shows a 46% higher odds of survival to discharge in PEA arrests where naloxone was given — with no benefit in VF or asystole. The effect is PEA-specific, the dataset is large, and the intervention is zero-risk. Beyond resuscitation, this is a sepsis week: bedside skin perfusion assessment (mottling score, CRT, peripheral perfusion index) gets its strongest prognostic evidence yet from 2,727 patients, and a large target trial emulation makes the case for not stopping home beta-blockers on sepsis admission. Plus urgent stock checks: during the third UK heatwave of 2026, your adrenaline auto-injectors may be subtherapeutic.
WHAT'S INSIDE — ISSUE 20
01 Cardiac Arrest & Resuscitation · 2 items incl. LEAD · Naloxone in PEA (LEAD), 2025 ACLS guideline updates 02 Sepsis · 3 items · Skin perfusion SR/MA, Beta-blockers in sepsis, AI bundle compliance null result 03 POCUS · 2 items · Lung US 2025 consensus update, POCUS infant bladder catheterisation (JournalFeed AaD) 04 Paediatric EM · 3 items · POCUS paeds catheterisation (full data), LUS + CRP paeds pneumonia, NLS telesimulation 05 UK Updates · 2 items · UKHSA/MHRA heatwave + medicines alert, RCEM heatwave statement 06 Quick Hits · 4 items · AHA stroke (1 item only), DanGer Shock 10yr data, AI pleural effusion SR/MA, PEEP in sepsis 07 Core Revision — ECG: ARVD/ARVC · 08 Action Points · 09 Trials to Watch
TAG LEGEND
01 — CARDIAC ARREST & RESUSCITATION
RESUSCITATION · RETROSPECTIVE MATCHED COHORT · N=40,333 OHCA · NIEDERBERGER ET AL. · 2026
Naloxone in PEA Cardiac Arrest — Survival OR 1.46 in Matched Cohort of 40,333: Give It in All PEA of Unknown Cause
- OR 1.46 SURVIVAL TO DISCHARGE IN PEA ARRESTS
- 11.1% vs 9.0% SURVIVAL TO DISCHARGE (MATCHED)
- PEA only NO BENEFIT IN VF OR ASYSTOLE
Naloxone is routinely given to OHCA patients with suspected opioid involvement, but its role in undifferentiated PEA arrest has been debated. This large retrospective matched cohort (40,333 OHCA patients in the US, 18.8% received naloxone) found a significant survival benefit specifically in PEA arrests: naloxone was associated with a 46% higher odds of survival to hospital discharge in matched PEA patients (11.1% vs 9.0%, OR 1.46). Crucially, there was no benefit in shockable rhythms (VF/VT) or asystole — the effect was PEA-specific.
The mechanism is uncertain but the leading hypothesis is that some PEA arrests — particularly in the context of opioid use or respiratory failure — have an opioid-reversible component that maintains PEA over VF/asystole. This is retrospective and observational; prospective RCT evidence is needed. However, the size of the matched cohort and the specificity of the PEA signal make this actionable now.
UK ED APPLICATION
Current RCUK ALS guidelines already recommend considering naloxone in cardiac arrest where opioid toxicity is suspected. This study supports a broader application: in any PEA arrest where the cause is unknown and opioid use is possible (this includes many resus bay arrests — patients on opioid patches, chronic opioid prescriptions, recreational opioid use), naloxone 0.4–2 mg IV should be given during the first cycle alongside standard ALS. There is no harm signal. For known non-opioid causes (massive PE, tension PTX, tamponade), manage the reversible cause directly. Do not delay defibrillation in shockable rhythms for naloxone.
Source: Niederberger SM, Wang RC, Rodriguez RM et al. Resuscitation 2026;111139. PMID: 42379417 | JEMS Prehospital Literature Review July 2026: jems.com
2025 AHA ACLS GUIDELINE UPDATE · CURBSIDERS PODCAST #531 · PUBLISHED 6 JULY 2026
2025 ACLS Guideline Updates — Higher Energy Cardioversion, Sotalol Removed from VT Algorithm, Post-Arrest Targets
The 2025 AHA ACLS guideline update (widely discussed following presentation at SHM Converge 2026) contains several changes directly relevant to ED resuscitation practice:
| DOMAIN | PREVIOUS | 2025 UPDATE |
|---|---|---|
| Cardioversion energy — narrow complex | 50–100 J | 100 J (theoretical myocardial injury concern not supported by evidence; higher energy = higher success rate, fewer total shocks) |
| Cardioversion energy — AF/flutter | 120 J | 200 J |
| Stable VT pharmacology | Amiodarone or procainamide or sotalol | Sotalol removed. Amiodarone or procainamide only. (Sotalol not better than lidocaine in trials; lidocaine may not be better than placebo.) |
| Refractory VF — pad position | Standard anterolateral | After 3 failed shocks, consider vector change (anterior-posterior) or double sequential defibrillation (DSED). Survival: standard 13.3%, vector change 21.7%, DSED 30.4% (DOSE-VF trial). Class 2b recommendation. |
| Post-arrest temperature | TTM 32–37°C | Avoid fever; liberal temperature range 32–37.5°C. No specific cooling target mandated. |
| Post-arrest MAP target | "Avoid hypotension" (vague) | MAP >65 mmHg (specific target) |
| Post-arrest oxygen target | General guidance | SpO2 90–98% (normoxia, avoid hyperoxia) |
| Neuroprognostication | Varies | Do not prognosticate until 72 hours post-arrest minimum; use trained neurologist where available |
| End-tidal CO2 in termination | Mentioned | ETCO2 <10 mmHg at 20 minutes = very low survival probability (can support termination decision) |
| IV vs IO access | Both acceptable | IV strongly preferred over IO; both substantially preferred over central line during active arrest |
UK CONTEXT — RCUK VS AHA
These are AHA (US) guidelines. RCUK (Resuscitation Council UK) is the formal UK standard and may differ in specific details. However, RCUK 2021 guidelines are broadly consistent with the AHA approach for most of these changes. Check your resus department's current protocol: is sotalol still listed as an option for stable VT? Is the cardioversion energy chart showing 50 J for narrow complex? These are the areas most likely to need updating when RCUK next publishes updates in line with 2025 International Liaison Committee on Resuscitation (ILCOR) evidence reviews.
Source: Curbsiders Podcast #531, 6 July 2026. thecurbsiders.com | DOSE-VF: Cheskes S et al, NEJM 2022.
02 — SEPSIS
SHOCK · SYSTEMATIC REVIEW & META-ANALYSIS · N=2,727 · PMID: 42258324 · JOURNALFEED EM SPEEDREAD 9 JULY 2026
Mottling Score, Capillary Refill Time, and Peripheral Perfusion Index in Sepsis — All Independently Predict Mortality (SR/MA, n=2,727)
- All 3 significant INDEPENDENT PREDICTORS OF MORTALITY
- n=2,727 SEPSIS PATIENTS POOLED
- Free tools 30 SECONDS, NO EQUIPMENT FOR MOTTLING + CRT
Peripheral perfusion assessment is one of the three macrocirculation–microcirculation targets in sepsis resuscitation alongside MAP and lactate. This SR/MA of 2,727 sepsis patients confirms that mottling score, capillary refill time, and peripheral perfusion index each independently predict mortality risk — all three tools add independent prognostic information beyond haemodynamic parameters alone.
| TOOL | HOW TO ASSESS | ABNORMAL THRESHOLD | CLINICAL IMPLICATION |
|---|---|---|---|
| Mottling Score | Grade 0 (no mottling) to 5 (extends beyond trunk). Assess knee and periphery. | Grade ≥3: extends beyond knee → mortality >75% in some cohorts | Grade ≥3 persisting at 6h = inadequate peripheral perfusion despite resuscitation. Escalate. |
| CRT | Press nail bed 5 seconds, release. Time to blanch return. | >2 seconds = abnormal (standardise for room temperature — warm room) | CRT >2 seconds at 6h: consider persistent tissue hypoperfusion |
| PPI | Peripheral perfusion index from pulse oximetry waveform amplitude. | <0.7 = reduced (most modern oximeters display this) | Useful continuous monitoring adjunct |
ED PROTOCOL POINT
Add mottling score, CRT, and PPI to your sepsis resuscitation reassessment chart at 1h and 6h. These take 30 seconds and no equipment beyond a pulse oximeter. A patient with MAP ≥65, lactate falling, but mottling grade 3 and CRT >2 seconds at 6 hours has inadequate peripheral perfusion — do not discharge the resus concern based on macrovascular parameters alone. Escalate to ICU referral.
Source: Shi LJ et al, Shock 2026. PMID: 42258324. JournalFeed EM SpeedRead 9 Jul 2026.
CRITICAL CARE MEDICINE · TARGET TRIAL EMULATION · JOURNALFEED EM SPEEDREAD 9 JULY 2026
Continuing vs Withholding Home Beta-Blockers at Sepsis Admission — Withholding Associated With Higher Mortality
Beta-blockers are reflexively withheld on hospital admission when patients are septic, on the assumption that blocking the compensatory tachycardia will be harmful. This target trial emulation — a causal modelling approach using observational ICU data to simulate a hypothetical RCT — found that withholding home beta-blockers at sepsis admission was independently associated with significantly higher in-hospital mortality compared with continuing them in haemodynamically stable patients.
CRITICAL APPRAISAL
This is a target trial emulation, not an RCT. Unmeasured confounding is the main concern (patients in whom beta-blockers were withheld may have been sicker). However, the finding is biologically plausible: catecholamine-driven tachycardia increases myocardial oxygen demand and may worsen cellular injury in sepsis. The esmolol RCT data (Morelli 2013, n=154) showed HR reduction with esmolol was associated with improved outcomes in septic shock. The message for UK EDs is proportionate: do not reflexively stop home beta-blockers in every septic patient. If haemodynamically stable (SBP ≥90, no vasopressors): continue at the usual dose. If hypotensive or requiring vasopressors: dose-reduce or hold, with plan to reinstate as stabilisation occurs.
Source: JournalFeed EM SpeedRead 9 Jul 2026. Crit Care Med 2026. journalfeed.org
JAMA NETWORK OPEN · CLUSTER-RANDOMISED TRIAL · UC SAN DIEGO · 25 JUNE 2026
AI LLM Raised Sepsis Bundle Compliance 70%→83% — Zero Change in ICU Admissions or 30-Day Mortality
- 82.9% vs 70.1% BUNDLE COMPLIANCE: AI VS CONTROL
- No difference ICU ADMISSIONS OR 30-DAY MORTALITY
- Process ≠ Outcome CLUSTER-RCT, UC SAN DIEGO
A privacy-preserving LLM provided real-time AI alerts to clinicians identifying sepsis patients not receiving SEP-1 bundle-compliant care. Bundle adherence rose from 70.1% to 82.9% — a 12.8 percentage point improvement. ICU admissions and 30-day mortality: identical. The metric moved. The patient did not. This is the most important finding in health AI this year. The SEP-1 bundle was built on associations between compliance and outcomes. When you isolate bundle compliance from clinical judgement, the process metric appears to be measuring administrative adherence rather than care quality. Individual elements still matter — antibiotics in sepsis clearly save lives — but AI compliance tools that improve process without improving outcomes should not be commissioned based on compliance metrics alone.
Source: JAMA Network Open 25 Jun 2026. ICCN Substack: iccn.substack.com
03 — POCUS
INTENSIVE CARE MEDICINE · INTERNATIONAL CONSENSUS · PMID: 42257880 · JOURNALFEED EM SPEEDREAD 9 JULY 2026
Lung Ultrasound 2025 Updated International Consensus — Revised Thresholds for B-lines, Pneumothorax, Pleural Effusion (Volpicelli et al.)
The 2025 focused update to the 2012 international LUS recommendations (Volpicelli et al., Intensive Care Medicine) is the most comprehensive revision to lung ultrasound guidance in a decade. Key changes for UK ED POCUS practice:
| DOMAIN | KEY 2025 UPDATE |
|---|---|
| B-lines threshold | ≥3 B-lines per zone = positive zone (validated). ≥2 bilateral positive zones = interstitial syndrome (pulmonary oedema or interstitial pneumonia). The threshold itself is unchanged but the bilateral zonation requirement is now explicit. |
| Pneumothorax | Absence of lung sliding + absence of B-lines + presence of lung point = PTX confirmed. Lung sliding absent alone is insufficient. In cardiac arrest: LUS for PTX should precede needle decompression in PEA of unknown cause. |
| Consolidation patterns | Shred sign = subpleural consolidation with irregular deep margin (pneumonia). Tissue sign = hepatisation (lobar consolidation). Dynamic air bronchograms = pneumonia; static = atelectasis. This distinction matters for antibiotic vs physiotherapy decision. |
| Pleural effusion volume | Depth at posterior axillary line: 1 cm ≈ 200 mL (rough estimate for tapping threshold discussions). Sinusoid sign (respiratory movement of floating lung) confirms simple effusion. |
| ADHF diagnosis | Bilateral B-pattern (≥2 positive zones each side) + cardiac dysfunction on echo = ADHF confirmed. Sensitivity ~90%, specificity ~85% vs non-cardiac dyspnoea in ED. |
Source: Volpicelli G et al, Intensive Care Med 2026. PMID: 42257880. JournalFeed EM SpeedRead 9 Jul 2026.
ACADEMIC EMERGENCY MEDICINE · SR/MA OF 3 RCTS · PMID: 42246462 · JOURNALFEED ARTICLE-A-DAY 8 JULY 2026
POCUS for Infant Bladder Before Catheterisation — 89.7% vs 72.5% First-Attempt Success, Dry Taps 3.6% vs 23.9%
- RR 1.25 FIRST-ATTEMPT SUCCESS (95% CI 1.08–1.45)
- 89.7% vs 72.5% SUCCESS RATE — POCUS VS BLIND
- 3.6% vs 23.9% DRY TAPS — P<0.0001
- RCTs only SR/MA OF 3 RCTS, ≤36 MONTHS
UTI accounts for approximately 7% of serious bacterial infection in febrile infants. Urethral catheterisation is the gold standard for diagnostic sample collection but fails in nearly 1-in-4 attempts (dry tap from an empty bladder) when done blind. This SR/MA of three RCTs definitively shows POCUS bladder assessment before catheterisation in children ≤36 months increases first-attempt success from 72.5% to 89.7% (RR 1.25, p=0.0022) and cuts dry taps from 23.9% to 3.6% (RR 0.25, p<0.0001). JournalFeed article-of-the-day (8 July) featured this as an immediate practice change.
TECHNIQUE — 30 SECONDS BEFORE EVERY PAEDIATRIC CATHETERISATION
Linear or curvilinear probe on the suprapubic area. Two views (sagittal + transverse). Measure the three dimensions of the bladder. Volume formula: 0.52 × L × W × H. IF BLADDER VOLUME <2 ML OR BLADDER NOT CLEARLY VISIBLE: wait 20–30 minutes and reassess — do not attempt catheterisation. IF BLADDER CLEARLY SEEN AND VOLUME ≥2 ML: proceed. This should be standard practice for all urethral catheterisation attempts in children under 3 years.
Source: Vieira da Silva HF et al. Acad Emerg Med 2026. PMID: 42246462. JournalFeed AaD 8 Jul 2026: journalfeed.org
04 — PAEDIATRIC EMERGENCY MEDICINE
EUROPEAN JOURNAL OF PAEDIATRICS · PROSPECTIVE OBSERVATIONAL · PMID: 42230808 · JOURNALFEED PAEDS SPEEDREAD 8 JULY 2026
Lung Ultrasound Combined With CRP for Bacterial Pneumonia in Children — Specificity 0.91 for Bacterial Component
Distinguishing bacterial from viral pneumonia in children is a common ED challenge with significant antibiotic stewardship implications. This prospective study combined LUS consolidation findings with CRP >40 mg/L. The combined approach achieved specificity 0.91 for bacterial aetiology — substantially better than CRP alone (Sp 0.72) or LUS alone. LUS consolidation without CRP elevation is more likely to represent viral pneumonitis or atelectasis.
PRACTICAL ED BUNDLE FOR PAEDIATRIC LOWER RESPIRATORY TRACT INFECTION
For febrile children (3 months–5 years) with suspected LRTI: (1) Perform LUS — look for consolidation >1cm, dynamic air bronchograms (bacterial), vs B-lines only (viral interstitial); (2) CRP >40 mg/L: if CRP elevated AND LUS shows consolidation = treat as bacterial pneumonia; (3) CRP <40 mg/L AND LUS shows B-lines only: likely viral — watchful waiting, no antibiotics; (4) CRP >40 but no consolidation: consider sepsis screen rather than simple pneumonia. This approach reduces radiation and helps target antibiotics. Does not replace clinical assessment of respiratory rate, WOB, and oxygen saturation.
Source: Fremuth J et al, Eur J Pediatr 2026. PMID: 42230808. JournalFeed Paeds SpeedRead 8 Jul 2026.
PEDIATRICS · LONGITUDINAL STUDY · PMID: 42229913 · JOURNALFEED PAEDS SPEEDREAD 8 JULY 2026
Telesimulation for Rural NLS Training — Sustained Improvement in Neonatal Resuscitation at 6 and 12 Months
A longitudinal telesimulation programme for rural hospital clinicians showed sustained improvement in NRP (Neonatal Resuscitation Programme) adherence at both 6 and 12 months, with improvement correlating to number of training sessions completed. Relevant to UK EDs in rural or district general settings where neonatal emergency presentations are low-volume but high-stakes. NHS England's digital training expansion includes remote simulation platforms. For UK EDs without on-site neonatal specialists: advocate for NLS telesimulation access through your local simulation network. Evidence base now supports it as equivalent to in-person for skill maintenance.
Source: Melendi M et al, Pediatrics 2026. PMID: 42229913. JournalFeed Paeds SpeedRead 8 Jul 2026.
JOURNAL OF CLINICAL ULTRASOUND · RETROSPECTIVE · PMID: 41540593 · JOURNALFEED POCUS SPEEDREAD 9 JULY 2026
Lung Ultrasound in Paediatric Pneumonia — Reduces Radiation Exposure, Duration of Illness, and Costs vs CXR
This 2-year retrospective study comparing LUS vs CXR as first-line imaging in paediatric pneumonia found LUS reduced radiation exposure, enabled earlier antibiotic rationalisation (shorter time to consolidation assessment), and reduced overall costs. The diagnostic accuracy of LUS for paediatric pneumonia is established (sensitivity 0.93–0.97, specificity 0.83–0.96 across pooled studies), outperforming CXR for posterior consolidations and small effusions. In a UK ED with a competent sonographer: LUS should be first-line imaging for suspected CAP in children under 10. Save CXR for atypical presentations, suspected pleural complications, or when LUS is inconclusive.
Source: Guo X et al, J Clin Ultrasound 2026. PMID: 41540593. JournalFeed POCUS SpeedRead 9 Jul 2026.
05 — UK UPDATES
UKHSA / MHRA · JOINT GUIDANCE · 8 JULY 2026 · ACTIVE ALERT
Third 2026 Heatwave — UKHSA/MHRA Guidance on Heat-Sensitive Medicines + Active Amber Alerts + MHRA Resuscitation Equipment FSNs
IMMEDIATE ED STOCK CHECK REQUIRED ADRENALINE AUTO-INJECTORS (EPIPEN/JEXT): Degrade above 25°C. Check resus bay and
emergency bags — if temperature has exceeded 25°C, replace. Advise patients to carry in insulated
pouch; never leave in cars. TRANSDERMAL OPIOIDS (FENTANYL, BUPRENORPHINE PATCHES):
Heat significantly increases absorption rate — patient presenting with opioid toxicity in heatwave may have patch-induced overdose. Remove the patch. INSULIN: In-use insulin degrades above 25°C — check diabetes patients' insulin if they've been in the heat.
Amber/Yellow Heat-Health Alerts (8–12 July, third heatwave of 2026): Heat stroke (core temp >40°C + altered consciousness) = medical emergency — ice packs to groin/axilla/neck, fan and mist, target <38.5°C within 30 minutes. Older patients on anticholinergics (antihistamines, bladder medications, antipsychotics) at elevated heat stroke risk due to anhidrosis. MHRA FSNs (7 July 2026): WEINMANN MEDUMAT Standard² ventilator, Maquet Flow-i/c/e anaesthetic workstations, Chalice Medical ECLS tubing packs — alert biomedical engineering and check serial numbers at gov.uk/drug-device-alerts.
UKHSA/MHRA Medicines in Hot Weather | UKHSA Heat-Health Alerts
RCEM / DAUK / BMJ · 7–9 JULY 2026
RCEM: ED Heatwave Surge Is Exit Block Not Weather — DAUK Calls for Legal Maximum NHS Working Temperature
RCEM's statement (9 July) directly attributes the heatwave surge to exit block — departments were already at capacity and the additional demand has nowhere to absorb. RCEM is calling for emergency surge plan activation across England. DAUK reported clinical staff collapsing in areas reaching 43°C and is calling for a legal maximum NHS working temperature (UK law sets no upper limit — only a 16°C minimum). If your department lacks cooling during heatwave conditions, document this formally on the trust risk register as an occupational health and patient safety concern — you are legally entitled to do so. BMJ Open (6 July): up to a third of ED attendances could be redirected to SDEC if capacity existed.
RCEM statement 9 Jul | DAUK/BMJ News 7 Jul
06 — QUICK HITS
2026 AHA Stroke Guideline — One Change You Need to Know (stroke item quota: 1/issue). Tenecteplase 0.25 mg/kg is now Class 1 LOE A — equal to alteplase — and the 0.4 mg/kg dose is Class 3: No Benefit (do not use). This is the only stroke-specific change requiring immediate ED action; it applies to thrombolysis decisions you make in the first 60 minutes. The disabling vs non-disabling paradigm (disabling deficit = IVT eligible; non-disabling mild deficit = DAPT preferred, not IVT) is the other key cognitive shift. All other stroke content from this guideline (large core EVT, basilar window, paeds EVT, post-reperfusion BP) can wait for NICE NG128 update and RCP Stroke guideline alignment.
DanGer Shock 10-Year Follow-Up: Impella Survival Benefit Widens Over Time in STEMI Cardiogenic Shock. The original DanGer Shock trial (NEJM 2024, n=360) showed 180-day mortality benefit for micro-axial flow pump (Impella CP) in STEMI cardiogenic shock. The 10-year follow-up (presented at ESC 2025, published 2026) shows the survival benefit did not fade — it widened. At 10 years: 52.5% mortality (Impella) vs 68.8% (standard care), HR 0.70, absolute reduction 16.3%, NNT 6. NNH for complications also 6. The indication remains narrow: STEMI cardiogenic shock, not routine MI or non-STEMI shock. Know this for chest pain referral discussions and haemodynamic instability transfer decisions.
AI for Pleural Effusion Detection on Ultrasound — SR/MA Sn 0.92, Sp 0.96 (J Clin Ultrasound, n=2,951, PMID:41508653). AI-assisted detection of pleural effusion on ultrasound achieves performance approaching expert sonography. LR+ approximately 23 (highly rules in), LR− approximately 0.08 (highly rules out). This substantially outperforms CXR. If AI POCUS tools are being piloted in your trust (several NHS trusts are now trialling AI ultrasound interpretation), pleural effusion is the best-evidenced application.
Higher PEEP in Ventilated Sepsis — Multi-Cohort Analysis: Associated With Lower Mortality (J Crit Care, PMID:42242063, n=844, observational). This observational analysis found higher PEEP (above ARDSnet low PEEP table) was associated with lower mortality in mechanically ventilated septic patients without haemodynamic deterioration. Note: this is an observational multi-cohort analysis, not an RCT. It contradicts the SR/MA we cited earlier — discordance reflects heterogeneous patient populations and PEEP titration methods. Clinical bottom line: PEEP should be individualised to oxygenation, compliance, and haemodynamics. The LUS 2025 consensus (Item 7) provides a practical POCUS-guided framework for PEEP titration.
07 — CORE REVISION — ECG: ARVD/ARVC
FRCEM CORE REVISION — ECG MODULE — ARVD/ARVC: THE EPSILON WAVE AND SUDDEN DEATH IN YOUNG ATHLETES
Epsilon Wave · Fontaine Leads · 2010 Task Force Criteria · LBBB-Morphology VT · ED Management · Differentials
What is ARVD/ARVC? Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy is an autosomal dominant genetic disorder of the myocardium characterised by progressive fatty infiltration of the right ventricular free wall. Prevalence ~1 in 5000. It is the second most common cause of sudden cardiac death in young people (after HOCM) and accounts for up to 10% of sudden cardiac deaths in patients under 65. The first presenting event may be sudden cardiac death.
The Six ECG Features of ARVD:
| FEATURE | DETAILS | FREQUENCY / KEY POINT |
|---|---|---|
| T-wave inversion V1–V3 | In absence of RBBB. If RBBB present, TWI V1–V3 is expected and not diagnostic. | 85% of patients — most sensitive sign |
| Epsilon wave | Small deflection just after the end of QRS in V1–V3. Represents delayed depolarisation of fatty-infiltrated RV. Best seen with double speed (50mm/sec) + double amplitude (20mV/10mm). | 50% of patients — most specific sign. Use Fontaine leads to increase sensitivity. |
| Localised QRS widening V1–V3 | >110ms in right precordial leads but <120ms globally (otherwise = RBBB) | Major 2010 Task Force criterion |
| Prolonged S-wave upstroke V1–V3 | S-wave upstroke duration ≥55ms (measured from S nadir to return to baseline) | Specific for ARVD; measured at 25mm/sec |
| LBBB-morphology VT | QRS negative in V1 (LBBB pattern) arising from RV. Classic RVOT tachycardia morphology. | Exercise-triggered in many cases |
| PVCs >1000/24h | Frequent ectopics with LBBB morphology | Minor Task Force criterion |
How to Find the Epsilon Wave — Fontaine Leads:
| ELECTRODE | PLACEMENT | PURPOSE |
|---|---|---|
| RA (Right Arm) | Manubrium (top of sternum) | These three bipolar chest leads (FI, FII, FIII) capture right ventricular potentials from infundibulum to diaphragm. FI can also detect AV dissociation during VT. Run at 50mm/sec, 20mV/10mm. LA (Left Arm) Xiphoid process LL (Left Leg) Standard V4 position (5th ICS midclavicular line) ED Management Algorithm: |
| SCENARIO | ACTION |
|---|---|
| Cardiac arrest / VF | Standard ALS. Post-ROSC: urgent electrophysiology referral. Do not cardiovert electrically without senior cardiology input if patient is stable. |
| Haemodynamically unstable LBBB VT | Synchronised DC cardioversion. IV amiodarone as bridge. NEVER adenosine, NEVER verapamil. |
| Stable LBBB VT | IV amiodarone. Urgent cardiology input. Do NOT discharge without senior review. |
| Incidental T-wave inversion V1–V3 / epsilon wave | Exercise restriction. Urgent outpatient cardiology referral. Echocardiography + cardiac MRI. Family cascade screening. |
| High-risk features (syncope, recurrent arrhythmias, family SCD) | ICD referral. No competitive sport until reviewed. |
Key Differentials: Benign RVOT tachycardia: LBBB+inferior axis VT but normal RV structure. Responds to verapamil. Low SCD risk. Brugada syndrome: Type 1 coved ST elevation V1–V2; VF during sleep/fever; SCN5A mutation. Normal variant TWI V1–V3 in women: Common normal finding in females — absence of other criteria reassuring.
MNEMONIC: ARVD ECG — "ELITE TV"
Epsilon wave (most specific) · LBBB morphology VT · Inferior axis VT · T-wave inversion V1–V3 (no RBBB) · Exertional syncope / SCD family history · Think young athlete · Ventricle MRI to confirm
LITFL: litfl.com/arrhythmogenic-right-ventricular-dysplasia-arvd/ | ECG Waves: ecgwaves.com | BHF: bhf.org.uk/arvc
08 — ACTION POINTS — ISSUE 20
| Check heat-sensitive ED stock: Replace any adrenaline auto-injectors or ampoules stored in areas that have exceeded 25°C during the heatwave. Remove any fentanyl/buprenorphine patches from patients presenting with unexplained drowsiness. MHRA FSNs: check WEINMANN MEDUMAT, Maquet Flow-i/c/e, and Chalice ECLS tubing batch numbers against gov.uk/drug-device-alerts. | |
| THIS MONTH | BIHCA — Update ALS practice: Brief your resus team: no routine bicarb after adrenaline in IHCA. Reserve for TCA overdose arrest, hyperkalaemic arrest, and severe pre-arrest metabolic acidosis (pH <7.1). Check your resus trolley — bicarb ampoules should not be drawn up as a default ALS drug. |
| THIS MONTH | Naloxone in PEA: In any PEA arrest of unknown cause — especially where opioid use is possible (patch, chronic prescription, recreational) — give naloxone 0.4–2 mg IV during the first cycle alongside standard ALS. Survival OR 1.46 in matched cohort of 40,333. No harm in non-opioid causes. |
| THIS MONTH | Beta-blockers in sepsis: Do not reflexively stop home beta-blockers in haemodynamically stable septic patients. Continue at usual dose if SBP ≥90 and no vasopressors. Dose-reduce or hold if shocked; plan reinstatement early. |
| THIS MONTH | Paeds POCUS catheterisation: Implement POCUS bladder scan before every urethral catheterisation attempt in children ≤36 months. 30 seconds, suprapubic linear probe, two views. If bladder volume <2 mL: wait 20–30 minutes. Reduces dry taps from 23.9% to 3.6%. |
| THIS MONTH | Skin perfusion in sepsis: Add mottling score + CRT to your sepsis reassessment at 1h and 6h. Grade ≥3 mottling or CRT >2s persisting at 6h despite adequate MAP and falling lactate = inadequate peripheral perfusion. Escalate to ICU. |
| 2025 ACLS updates: Check your resus department cardioversion energy settings — should be 100 J for narrow complex (not 50–100 J range) and 200 J for AF/flutter (not 120 J). Check stable VT algorithm — sotalol should be removed. If refractory VF after 3 standard shocks, consider vector change (AP pads) or DSED if equipment available. | |
| LUS 2025 consensus: Update POCUS training materials — bilateral ≥2 positive zones (each ≥3 B-lines) = interstitial syndrome. Dynamic air bronchograms = pneumonia; static = atelectasis. Update your departmental POCUS SOP to reflect current LUS standards. |
TRIALS TO WATCH
Q3 2026 (Imminent)
- BACHb RCT (UK) — HFNC vs CPAP vs standard O2 in infant bronchiolitis (n=500). UK multicentre. Will set the UK standard for bronchiolitis respiratory support.
- HSSIB Mental Health Crisis Report Part 2 — Final report expected Q3 2026. Recommendations on safe assessment rooms, CAMHS thresholds, liaison psychiatry reform.
2026–2027
- BEST-DKA — Balanced vs saline in DKA Phase 3. Will answer definitively whether fluid choice matters in DKA outcomes.
- On-Scene Trial (Netherlands) — Prehospital ECPR in refractory OHCA. Alongside ARREST, INCEPTION, PRAGUE — will inform UK ECPR candidacy criteria.
- EVIS UK (NCT05179499) — Early vasopressor in ED sepsis. UK-specific evidence for ED vasopressor timing following ARISE FLUIDS.
Longer Horizon
- NICE NG128 Stroke and TIA Update — Expected to align with 2026 AHA TNK and disabling deficit changes. Current NG128 predates these recommendations.
- CoMiTED — Conservative vs immediate chest drain in traumatic haemothorax. UK multicentre. Common resus bay decision.
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.
EM Evidence Rundown — Issue 20 — 10 July 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