EMERGENCY MEDICINE EVIDENCE RUNDOWN
EM Evidence Rundown
Issue 21 · 17 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 Hypothermia at Paediatric ED Triage — OR 20x In-Hospital Death (n=5.3 million visits, multicenter retrospective). A child with temperature ≤36°C at triage without other
features carries a 20-fold increased mortality risk. Escalate immediately.
CHANGE TONIGHT: MHRA — Phenoxymethylpenicillin (penicillin V) 250mg/5ml recall (Bristol Laboratories, batch 7124002): label mismatch with 125mg/5ml bottle. Check oral antibiotic prescribing and discharge stock. | CHANGE THIS MONTH: NHS England Sepsis Modern Service Framework (14 Jul) — 25% reduction in sepsis deaths by 2035, sepsis Best Practice Tariff from 2027/28, quality improvement across ambulance/ED/UEC. Ketamine in trauma — St Emlyn's TTL guide for analgesic and DSI use.
BOTTOM LINE UP FRONT — ISSUE 21
ACT ON THIS NOW
TONIGHT Penicillin V recall: Bristol Laboratories phenoxymethylpenicillin 250mg/5ml (batch 7124002) — label mismatch with 125mg/5ml bottle. Check ED discharge antibiotic supply and pharmacy stock.
THIS MONTH Paeds hypothermia (LEAD): n=5.3M ED visits. OR 20x in-hospital death in children ≤36°C at triage, even without other red flags. Escalate any paeds hypothermia urgently.
THIS MONTH Sepsis — antibiotics in shock: n=39,842. Delayed antibiotics associated with mortality in septic shock but NOT in sepsis without shock. Don't delay in shock; nuanced in non-shock sepsis.
THIS MONTH Ketamine in trauma: St Emlyn's TTL guide — analgesia, procedural sedation, DSI, dosing, monitoring. Practical protocol for all ED trauma teams.
THIS MONTH Suicidality after child sexual abuse: 11.1% of 1,391 children report suicidality within 90 days — higher when perpetrator is non-relative. Routine mental health screen on SARC referral.
THIS MONTH FFP-first in massive transfusion: JTACS large observational — FFP-first independently associated with improved survival over PRBC-first strategy. Know for MHP activation sequence.
KNOW FOR NEXT TIME
GUIDELINE NHS England Sepsis Modern Service Framework (14 Jul): 10-year strategy. Sepsis Best Practice Tariff 2027/28. QI programme across ambulance, ED, UEC pathway. Wearable-device detection technology.
GUIDELINE RCEM June performance: Worst June ever. 9.7% patients 12h+ wait (149,013 patients). 49,466 trolley waits 12h+ after admission decision.
INFORMING Distributive shock physiology: Beyond vasoplegia — mitochondrial dysfunction, endothelial injury, microcirculatory failure. All three contribute to septic shock organ injury.
INFORMING VExUS in AHF: SR/MA confirms grade 2-3 predicts 30-day mortality in acute heart failure. Bedside congestion assessment before further fluids in ADHF.
INFORMING POCUS during cardiac arrest: QI project raised usage 16%→35% with protocol. LUS + echo during pulse check changes management in >30% of cases.
PAEDS TRACTION trial: TXA reduces transfusion in non-cardiac surgery without increasing VTE, including oncology patients.
UK DATA NICE sepsis update (GID-NG10467): Delayed — revised publication date now 11 September 2026. Procalcitonin guidance addition pending.
This week's lead arrives from a dataset of 5.3 million paediatric emergency visits: a child presenting with a temperature at or below 36°C at triage has a 20-fold increased risk of in-hospital death, even without other red flags. The finding is striking, immediately actionable, and almost certainly under-recognised in UK ED triage. Beyond paediatrics, the NHS has published its first formal Sepsis Modern Service Framework — a decade-long strategy with concrete targets, a Best Practice Tariff, and quality improvement infrastructure across ambulance, ED, and UEC. A high-quality MHRA recall requires an immediate stock check for penicillin V oral solution. And St Emlyn's has published one of the most practical trauma team leader guides on ketamine use in circulation.
WHAT'S INSIDE — ISSUE 21
01 Paediatric EM · 3 items incl. LEAD · Hypothermia at triage OR 20x, suicidality post-sexual abuse, POCUS cardiac arrest QI 02 Sepsis · 3 items · Sepsis MSF (NHS England), antibiotic timing in shock vs non-shock (CID n=39,842), distributive shock pathophysiology 03 Trauma & Haemorrhage · 2 items · Ketamine in trauma (St Emlyn's TTL), FFP-first in massive transfusion (JTACS) 04 UK Updates · 2 items · MHRA penicillin V recall, RCEM worst-ever June performance data 05 Quick Hits · 3 items · VExUS in AHF, TRACTION TXA trial, EM Cases facial injuries airway 06 Core Revision — Toxicology: TCA Overdose 07 Action Points · 08 Trials to Watch
TAG LEGEND
01 — PAEDIATRIC EMERGENCY MEDICINE
MULTICENTER RETROSPECTIVE · 5.3 MILLION PAEDIATRIC ED VISITS · JOURNALFEED ARTICLE-A-DAY 16 JULY 2026
Hypothermia at Paediatric ED Triage — OR 20x In-Hospital Death Even Without Other Red Flags (n=5.3 Million Visits)
- OR 20× IN-HOSPITAL DEATH — ADJUSTED
- 3% of visits HYPOTHERMIA PREVALENCE AT TRIAGE
- Largest effect NO OTHER MEDICAL COMPLEXITY
- n=5.3M MULTICENTER, PAEDIATRIC HOSPITALS
This large multicenter retrospective study examined over 5.3 million paediatric ED visits across multiple paediatric hospital networks. The key finding: hypothermia at triage (temperature ≤36°C) was a strong, independent predictor of in-hospital death even after adjustment for age, vital signs, mechanism (trauma vs medical), and medical complexity. The adjusted odds ratio of approximately 20x is striking and substantially exceeds the predictive value of any single vital sign abnormality except frank haemodynamic collapse. Crucially, the mortality signal was strongest in children without pre-existing medical complexity — a previously healthy child presenting with hypothermia at triage carries a higher relative mortality risk than a chronically ill child with hypothermia.
Hypothermia in children presenting to ED is frequently attributed to environmental exposure (cold weather, wet clothing) and risk-stratified down. This study suggests that is unsafe: a child who is genuinely hypothermic at triage — not just transiently cool from a cold environment — requires urgent systematic assessment regardless of other presenting features. The mechanism is likely that hypothermia represents either a direct physiological insult (sepsis, hypothyroidism, hypoglycaemia, adrenal crisis, encephalitis) or a marker of severe decompensation preventing normal thermoregulatory response.
IMMEDIATE TRIAGE PROTOCOL CHANGE
Any child presenting to the paediatric ED with a triage temperature ≤36°C requires: (1) immediate senior nursing escalation (equivalent to a flag-1 vital sign); (2) rapid reassessment by a clinician regardless of other apparent acuity; (3) systematic consideration of: sepsis (NBI, blood cultures, lactate, CRP), hypoglycaemia (immediate BM), hypothyroidism/adrenal crisis (in infants), encephalitis (assess GCS carefully), and environmental/physiological cause; (4) active warming while assessment proceeds. Do not reassure on the basis of a well-appearing child alone — the OR 20x finding was independent of initial apparent severity.
CRITICAL APPRAISAL
This is a retrospective multicenter study from paediatric hospital networks — primarily tertiary centres — which may not fully generalise to DGH paediatric EDs where the case mix is different (fewer complex medical children, more primary care overflow). Documentation errors in temperature recording may have influenced results. However, the sample size (5.3 million) and consistent adjusted OR across subgroups give this finding meaningful weight. The recommendation to escalate paediatric hypothermia is low-risk and the biological rationale is sound.
Source: JournalFeed Article-a-Day, 16 Jul 2026. Written by Kathryn Sulkowski & Rebecca DiFabio. Full study: journalfeed.org/article-a-day/2026/cold-hard-facts-hypothermia-means-trouble/
PEDIATRICS · N=1,391 CHILDREN AGED 10–17 · PMID: 42276546 · JOURNALFEED PAEDS SPEEDREAD 16 JULY 2026
Suicidality Following Sexual Abuse in Children Aged 10–17 — 11.1% Report Suicidality Within 90 Days; Higher Risk When Perpetrator is Non-Relative
- 11.1% REPORT SUICIDALITY WITHIN 90 DAYS
- Non-relative HIGHER ATTEMPT RATE VS RELATIVE PERPETRATOR
- n=1,391 YOUTH EVALUATED FOR SEXUAL ABUSE
Among 1,391 young people aged 10–17 evaluated for sexual abuse at specialist services, 11.1% reported suicidality (ideation or attempts) within 90 days of the index assessment. The rate of suicidal attempts was significantly higher when the perpetrator was a non-relative (acquaintance, stranger, or online contact) compared with a family member — potentially reflecting different trauma processing and disclosure dynamics. The findings highlight that suicidality risk in this group is not limited to those with pre-existing mental health conditions.
UK ED AND SARC PROTOCOL POINT
Any child presenting to the ED following sexual assault or abuse should have a structured mental health screen before discharge, not only clinical assessment of physical injuries. In UK practice: (1) all children should be referred to the Sexual Assault Referral Centre (SARC) or equivalent; (2) SARC referrals should include a specific flag for suicidality screening and CAMHS early contact; (3) ED documentation should record whether suicidality screening was completed; (4) in children aged 10–17 where the perpetrator is identified as a non-relative, consider same-day CAMHS review before discharge from the ED if clinically feasible. The 90-day window is long — community follow-up must be explicit in the discharge plan.
Source: Sornabala D et al, Pediatrics 2026. PMID: 42276546. JournalFeed Paeds SpeedRead 16 Jul 2026.
JOURNAL OF GENERAL INTERNAL MEDICINE · QUALITY IMPROVEMENT PROJECT · PMID: 41772363 · JOURNALFEED POCUS SPEEDREAD 16 JULY 2026
POCUS During Inpatient Cardiac Arrest — Protocol Raises Usage from 16% to 35% and Changes Management in Over 30% of Cases
This quality improvement project implemented a structured POCUS protocol during inpatient cardiac arrest across a hospital medicine service. Before the protocol, POCUS was used in only 16% of arrests; after implementation, this rose to 35%. Among arrests where POCUS was used, it changed clinical management in over 30% of cases — identifying reversible causes including cardiac tamponade, massive PE (McConnell sign), pneumothorax, and severe LV dysfunction. The main barriers to wider adoption were knowledge gaps (how to acquire images during CPR) and equipment availability (machine not in the room).
UK ED APPLICATION
POCUS during cardiac arrest is a 2021 RCUK ALS recommendation (Class IIb) and should be performed during pulse checks — not during compressions. The two most immediately useful views: (1) subcostal cardiac (identify cardiac standstill, pericardial effusion, gross LV dysfunction, RV dilation suggesting PE); (2) anterior lung bilateral (pneumothorax — absence of lung sliding). If your resus bay POCUS machine is not immediately accessible during arrests, this is a systems problem to address with your department lead. Target: POCUS machine accessible in every resus bay within 30 seconds.
Source: Donat C et al, J Gen Intern Med 2026. PMID: 41772363. JournalFeed POCUS SpeedRead 16 Jul 2026.
02 — SEPSIS
NHS ENGLAND · SEPSIS MODERN SERVICE FRAMEWORK · PUBLISHED 14 JULY 2026
NHS England Sepsis Modern Service Framework — 25% Reduction in Sepsis Deaths by 2035, Best Practice Tariff 2027/28, ED/UEC Quality Improvement Programme
NHS England published its first formal Sepsis Modern Service Framework on 14 July 2026 — a 10-year strategy targeting a 25% reduction in preventable sepsis deaths and harm by 2035. This is a significant commissioning document with direct operational implications for UK EDs:
| ELEMENT | DETAIL | ED IMPLICATION |
|---|---|---|
| Target | 25% reduction in sepsis-related deaths and serious harm by 2035 | Basis for future CQC and ICB performance assessment |
| Best Practice Tariff | Sepsis BPT from 2027/28 financial year. Hospitals meeting defined sepsis quality metrics will receive a financial uplift; non-compliant providers may face clawback. | ED compliance with bundle documentation, antibiotic timing, and escalation thresholds will be financially incentivised from next year |
| QI Programme | Structured QI programme across ambulance services, EDs, and UEC pathways. Each ICS required to have a named Sepsis Lead and improvement plan. | Every major ED should expect an ICS-mandated sepsis QI visit; designated ED Sepsis Champion required |
| Technology | Wearable device and continuous monitoring technology for early sepsis detection — specifically in care homes and community settings for early identification before ED arrival | This may reduce "cold" sepsis presentations and increase the proportion of earlier-stage patients reaching ED |
| Antibiotic access | Commitment to improving access to IV antibiotics in pre-hospital and urgent care settings — direct response to the NICE sepsis guidance recommendation | Community IV antibiotics pathways (via district nurses or IV therapy teams) may reduce ED presentations for IV antibiotic-requiring infections |
| NICE update | NICE sepsis guideline update (GID-NG10467, adding procalcitonin guidance) now expected 11 September 2026 — delayed from original July target | Current guidance in force: NG253 (November 2025). Use NG253 thresholds until the September update. |
WHAT THIS MEANS FOR YOUR ED NOW
The Sepsis BPT is the most immediately significant element — financial incentives and penalties will flow through ICSs to providers based on sepsis quality metrics from 2027/28. Now is the time to: (1) ensure your ED Sepsis Champion is identified and active; (2) audit your antibiotic-to-door-time compliance against NG253 thresholds; (3) review your sepsis screening tool (NEWS2/qSOFA-adapted) and ensure documentation captures all elements that will be required for BPT compliance; (4) engage your ICS lead about the framework's local implementation plan.
Source: NHS England Sepsis Modern Service Framework, 14 Jul 2026. england.nhs.uk/publication/sepsis-modern-service-framework/
CLINICAL INFECTIOUS DISEASES · MULTICENTER COHORT · N=39,842 HOSPITALISATIONS · OXFORD ACADEMIC
Delayed Antibiotics in Septic Shock — Associated With Mortality. Delay in Sepsis Without Shock — No Significant Association (n=39,842 Including Immunocompromised)
- Septic SHOCK DELAYED ABX = HIGHER MORTALITY
- Sepsis (no shock) DELAY NOT SIGNIFICANTLY ASSOCIATED WITH MORTALITY
- n=39,842 BOTH IMMUNOCOMPETENT AND IMMUNOCOMPROMISED
This large multicenter cohort study of 39,842 hospitalisations with suspected sepsis found that the relationship between antibiotic delay and mortality depends critically on whether the patient is in septic shock. In patients with septic shock (vasopressor-requiring hypotension): delayed antibiotics were independently associated with increased mortality in both immunocompetent and immunocompromised patients. In patients with sepsis but without shock: delayed antibiotics did not show a statistically significant association with mortality in either group.
CRITICAL APPRAISAL AND UK APPLICATION
This is an observational cohort — confounding is the key concern (sicker patients may have had antibiotics delayed for clinical reasons). However, the finding is biologically plausible and consistent with the SSC 2026 update (Issue 19): the hour-1 antibiotic mandate applies most strongly to septic shock, and a more deliberate approach (confirm diagnosis, appropriate culture, source identification before antibiotic choice) is more defensible in non-shock sepsis. For UK EDs, this supports the NEWS2-stratified approach: NEWS2 ≥5 + shock → antibiotics within 1 hour (no negotiation); NEWS2 3-4, no shock → diagnostic work first, antibiotics within 1 hour of clinical assessment; possible/borderline sepsis → short deliberate delay to confirm is acceptable and may be safer (avoid driving resistance, avoid ADRs, avoid allergy risk in someone without confirmed infection).
Source: Multicenter cohort, Clin Infect Dis 2026. academic.oup.com/cid
INTENSIVE CARE MEDICINE / CRITICAL CARE MEDICINE · REVIEW · PMID: 42440111 · PUBMED RESUS SEARCH 15 JULY 2026
Pathophysiology of Distributive Shock in Sepsis — Beyond Vasoplegia: Microcirculatory Failure, Mitochondrial Dysfunction, Endothelial Injury
The classic model of distributive shock in sepsis focuses on vasoplegia — excessive vasodilation driven by nitric oxide overproduction, causing a low-SVR state requiring vasopressor support. This high-impact review article published in Intensive Care Medicine challenges that model as incomplete: distributive shock in sepsis involves at least three independent and synergistic mechanisms, each requiring distinct management considerations:
| MECHANISM | PATHOPHYSIOLOGY | CLINICAL CORRELATE |
|---|---|---|
| Vasoplegia | Endothelial and smooth muscle dysfunction; massive NO production; loss of vascular tone. The "classic" distributive shock mechanism. | Low SVR on echocardiography; vasopressor requirement; responds to noradrenaline and vasopressin |
| Microcirculatory failure | Loss of functional capillary density; heterogeneous flow distribution; some capillaries with no flow, others with excessive flow — "functional shunting." SBP may be adequate at the macro level while tissues remain hypoxic. | Persisting elevated lactate despite adequate MAP; mottling; abnormal CRT despite apparent haemodynamic stability. Explains why MAP alone is insufficient as a resuscitation target. |
| Mitochondrial dysfunction | Cytopathic hypoxia: cells cannot utilise oxygen even when delivery is adequate. Mitochondria are inhibited by reactive oxygen species, NO derivatives, and sepsis-associated cytokines. | Lactic acidosis without tissue hypoxia; organ dysfunction disproportionate to perfusion impairment; "hyperdynamic failure" |
| Endothelial injury | Glycocalyx shedding, increased vascular permeability, capillary leak. Drives oedema formation with fluid resuscitation; interstitial oedema can worsen tissue oxygen delivery. | Fluid refractory shock; oedema formation; contributes to pulmonary oedema with liberal fluids |
FRCEM REVISION POINT
The FRCEM exam tests understanding of septic shock beyond "give noradrenaline." The key insight: a MAP of 65 with good urine output does not guarantee adequate tissue perfusion if microcirculatory failure is the dominant mechanism. This is why CRT and mottling score (Issue 20) add independent prognostic value beyond MAP and lactate. Understanding these mechanisms also explains why aggressive fluid resuscitation can worsen outcomes (glycocalyx shedding, oedema) and why some patients with vasopressor-adequate MAP still have elevated lactate (mitochondrial dysfunction).
Source: PMID: 42440111. Intensive Care Med 2026. PubMed resus search 15 Jul 2026.
03 — TRAUMA & HAEMORRHAGE
ST EMLYN'S · TRAUMA TEAM LEADER (TTL) TIPS SERIES · PUBLISHED 15 JULY 2026
Ketamine in Trauma — St Emlyn's Practical Guide: Analgesia, Procedural Sedation, Delayed Sequence Induction, Dosing, and Monitoring
St Emlyn's Trauma Team Leader (TTL) Tips series has published one of the most practically useful ketamine guides in UK EM, specifically oriented to the trauma team leader role. Ketamine is uniquely suited to trauma: it maintains airway reflexes, preserves haemodynamics via catecholamine release, provides analgesia and dissociation, and has a favourable safety profile in haemodynamically unstable patients. This guide covers four clinical contexts:
| CONTEXT | DOSE | KEY POINTS |
|---|---|---|
| Analgesia | 0.1–0.3 mg/kg IV slow bolus. Sub-dissociative doses — repeat PRN. IM: 0.5–1 mg/kg if no IV access. | Does NOT elevate ICP at sub-dissociative doses in ventilated patients (historical concern now refuted). Safe in traumatic brain injury. Combine with midazolam 1–2 mg IV to prevent emergence phenomena. |
| Procedural sedation | 1–2 mg/kg IV over 60 seconds. Wait 2–3 minutes for effect. Top-up: 0.5 mg/kg. | Maintain airway reflexes. Monitor for laryngospasm (rare — have bag-valve-mask ready). Do NOT use in patients with known psychosis history unless essential. |
| Delayed Sequence Induction (DSI) | Ketamine 1.5 mg/kg IV slow push
| Used when patient is not tolerating BVM pre-oxygenation (agitated, combative) or when SpO2 is falling before RSI. Ketamine buys time to optimise preoxygenation without apnoea. Most useful in trauma airway. |
| Haemodynamically unstable RSI | Ketamine 1–1.5 mg/kg IV (preferred over propofol or thiopentone). | Catecholamine release maintains BP. In truly catecholamine-depleted patients (end-stage shock), ketamine's direct myocardial depressant effect can unmask: be prepared with vasopressors running. |
THE ONE RULE FOR KETAMINE IN TRAUMA
Ketamine is almost always safer than its alternative in trauma. The historical contraindications (head injury, hypertension, psychosis) have largely been refuted by evidence. The practical exception: in a patient with known catecholamine depletion (hypotension despite maximal vasopressors), ketamine's direct cardiac depressant effect can cause sudden deterioration. In that scenario: use a very low induction dose (0.5 mg/kg) or consider etomidate (single dose, not infusion) as an alternative, accepting the cortisol suppression for one induction dose.
Source: St Emlyn's TTL Tips 15, 15 Jul 2026. stemlynsblog.org/ttl-tips-15-ketamine-in-trauma/
JOURNAL OF TRAUMA & ACUTE CARE SURGERY · LARGE OBSERVATIONAL COHORT · PMID: 42275580
- JOURNALFEED EM SPEEDREAD 16 JULY 2026
FFP-First Approach in Massive Transfusion — Independently Associated With Improved Survival Over PRBC-First Strategy
- FFP-first INDEPENDENTLY BETTER SURVIVAL
- Observational CONFOUNDING REMAINS POSSIBLE
- Severely injured REQUIRING MASSIVE TRANSFUSION
In a large observational cohort of severely injured patients requiring massive transfusion, an FFP-first resuscitation approach (giving fresh frozen plasma before or alongside packed red cells from the first product delivered) was independently associated with improved survival to hospital discharge compared with a PRBC-first approach. The mechanism: immediate plasma provides coagulation factors preventing dilutional and traumatic coagulopathy from the very first product. Packed red cells alone dilute the remaining clotting factors and platelet function.
CRITICAL APPRAISAL AND UK APPLICATION
This is observational evidence — the decision to give FFP-first may correlate with other quality-of-care markers (experienced team, higher-volume trauma centre, more sophisticated MHP). Randomised evidence for FFP-first vs PRBC-first specifically is limited. However, the finding is consistent with damage control resuscitation (DCR) principles and the 1:1:1 ratio underpinned by the PROPPR RCT (JAMA 2015). UK practice: the NHS major haemorrhage protocol (MHP) should already be delivering products in a 1:1 ratio (RBC:FFP). If your institution's MHP still delivers 4 units RBC before first FFP pack, this data supports updating that sequence. Alert your major trauma network haematology lead.
Source: Hynes AM et al, J Trauma Acute Care Surg 2026. PMID: 42275580. JournalFeed EM SpeedRead 16 Jul 2026.
04 — UK UPDATES
MHRA · CLASS 2 RECALL · EL(26)A/33 · 9 JULY 2026
MHRA Class 2 Recall — Phenoxymethylpenicillin (Penicillin V) 250mg/5ml Oral Solution (Bristol Laboratories, Batch 7124002): Label Mismatch With 125mg/5ml Bottle
IMMEDIATE STOCK CHECK REQUIRED BRISTOL LABORATORIES, PHENOXYMETHYLPENICILLIN (PENICILLIN V) 250MG/5ML SUGAR FREE ORAL SOLUTION, BATCH 7124002.
Root cause: carton labelled 250mg/5ml, but the bottle inside is labelled 125mg/5ml. Patients or carers may receive — or have already received — double the prescribed dose if they use the bottle label, or half the dose if they use the carton. The discrepancy has been present in product dispensed since 29 April 2026. Penicillin V is commonly prescribed at ED discharge for: tonsillitis (phenoxymethylpenicillin 500mg QDS for 10 days), impetigo, erysipelas (mild cellulitis), dental infections, and prophylaxis in asplenia. ACTION: (1) Remove batch 7124002 from ED discharge dispensing supply and pharmacy stock immediately. (2) Alert pharmacy and prescribers. (3) If patients have been dispensed this batch since 29 April 2026, consider pharmacist review call-back for high-risk prescriptions (children, immunocompromised). Full FSN at gov.uk/drug-device-alerts, reference EL(26)A/33.
Source: MHRA Class 2 Recall EL(26)A/33, 9 Jul 2026. gov.uk/drug-device-alerts
RCEM · JUNE 2026 ED PERFORMANCE DATA RESPONSE · 9 JULY 2026
RCEM: Worst June on Record — 9.7% of Patients Waited 12+ Hours (149,013 Patients); 49,466 Trolley Waits 12h+ After Admission; Exit Block, Not Heatwave
NHS England published June 2026 ED performance figures (covering the highest-ever June attendance at 1,488,602 — a June record), and RCEM President Dr Ian Higginson responded directly:
Key figures: 9.7% of patients (149,013) waited 12 hours or more at major EDs. 49,466 patients experienced trolley waits of 12+ hours after being marked for admission — the worst June on record. Fewer than two-thirds of patients were discharged, admitted, or transferred within 4 hours (NHS constitutional target: 95%). 13,618 hospital beds per day occupied by patients medically fit for discharge — 1,547 more than June 2025. 2,432 patients reportedly experiencing corridor care per day (RCEM notes this is likely an underestimate). 12-hour waits have increased more than tenfold in a decade while attendances increased only 16%.
RCEM's message: "The notion of the annual winter crisis in our EDs is becoming outdated given that we face a year-round crisis which gets worse in winter. Heatwaves and sporting events contribute but driving this total breakdown is exit block: the lack of available beds for patients." RCEM's message to government: without resource, effort into EDs, hospital flow, and delayed discharge reduction, more patients will suffer and die.
Source: RCEM press release 9 Jul 2026. rcem.ac.uk
05 — QUICK HITS
VExUS Protocol in Acute Heart Failure — SR/MA: Grade 2–3 Predicts 30-Day Mortality (Curr Probl Cardiol, JournalFeed POCUS Wed). This SR/MA confirms VExUS grading (IVC diameter + hepatic, portal, intrarenal Doppler) predicts 30-day mortality in acute heart failure. Grade 2–3 is the threshold associated with significantly worse outcomes. For UK EDs: before giving the third litre of IV fluid to a decompensated ADHF patient, perform a 2-minute VExUS assessment — any grade 2-3 signal is a strong indicator to stop fluids, start diuresis, and escalate. Note: VExUS was also covered in sepsis context in Issue 20; in AHF the application is slightly different (looking for venous congestion as an indication to start decongestion, not to stop sepsis resuscitation).
TRACTION Trial — TXA Reduces Transfusion in Major Non-Cardiac Surgery Without Increasing 90-Day VTE (JournalFeed AaD 15 Jul). TXA (tranexamic acid) reduced red-cell transfusion across a broad range of major non-cardiac surgical procedures without increasing 90-day venous thromboembolism, including in oncology patients (where VTE concern is highest). This provides additional RCT evidence underpinning the NICE NG24 update (covered in EM Issue 19 and Anaesthetics Issue 6): TXA should now be offered routinely to all patients undergoing in-theatre surgery with any bleeding risk. The TRACTION data specifically addresses the oncology hesitancy and should reassure surgeons who were reluctant to adopt the NICE update for cancer patients.
EM Cases Ep 220 — Facial Injuries: Airway, Haemorrhage Control, Key Injuries, and Disposition (Pts 1–3). The three-part EM Cases series on facial trauma covers: Part 1 (C-ABCDE in facial trauma, airway threats from midfacial fractures, haemorrhage from the face); Part 2 (mandible fractures, orbital blowout, Le Fort classification, zygoma); Part 3 (disposition, transfer decisions, when neurosurgical or ophthalmic referral is urgent). Available at emergencymedicinecases.com. Facial trauma represents a high-stakes, poorly-timetabled presentation in UK EDs — a structured framework is valuable for all trainees preparing for FRCEM OSCE.
06 — CORE REVISION — TOXICOLOGY: TCA OVERDOSE
FRCEM CORE REVISION — TOXICOLOGY MODULE — TRICYCLIC ANTIDEPRESSANT OVERDOSE: THE SODIUM CHANNEL EMERGENCY
Mechanism · ECG Changes · Sodium Bicarbonate · Seizures · What Never to Give · Intubation Risks · Disposition
Why TCAs Matter: Despite being superseded by SSRIs and SNRIs as antidepressants, TCAs (amitriptyline, dosulepin, nortriptyline, imipramine, clomipramine) remain commonly prescribed for chronic pain, migraine prophylaxis, and neuropathic pain. They have a narrow therapeutic index — the lethal dose can be as little as 10–20 mg/kg. TCA overdose is one of the few toxicological emergencies where the ECG alone should drive immediate treatment decisions.
Three Mechanisms of Toxicity:
| MECHANISM | EFFECT | CLINICAL RESULT |
|---|---|---|
| Sodium channel blockade | Blocks fast Na+ channels in myocardium and CNS | Widened QRS; VT/VF; seizures; coma. The most life-threatening mechanism. |
| Anticholinergic | Muscarinic receptor blockade | Tachycardia, mydriasis, dry flushed skin, urinary retention, ileus, hyperthermia, agitation. The "anti-SLUDGE" toxidrome. |
| Alpha-1 adrenergic blockade | Peripheral vasodilation | Hypotension (often refractory without sodium bicarbonate) |
The ECG of TCA Overdose — Three Key Signs:
| ECG FINDING | THRESHOLD | SIGNIFICANCE |
|---|---|---|
| QRS widening | >100 ms = risk of arrhythmia; >160 ms = high risk of VT/VF | Most sensitive ECG marker of sodium channel blockade. Treat with bicarb at >100 ms. |
| Terminal R wave in aVR | >3 mm | Terminal R wave in aVR is the most specific ECG sign for TCA toxicity. May predict seizures and arrhythmias independently of QRS width. |
| R/S ratio in aVR | >0.7 | Additional marker of sodium channel blockade severity. Use alongside terminal R wave. |
| QTc prolongation | Any QTc >500 ms | Risk of torsades de pointes, especially if combined with hypokalaemia |
| Brugada-like pattern | Coved ST elevation V1-V3 | TCA can unmask Brugada pattern via sodium channel blockade — treat the same as TCA toxicity (bicarb), not Brugada |
Sodium Bicarbonate — Mechanism and Use:
| INDICATION | MECHANISM | DOSE |
|---|---|---|
| QRS >100 ms on ECG | Alkalinisation: higher pH increases protein binding of TCA, reducing free drug. Also provides Na+ load to overcome the blocked channels ("outcompete" the block). | 1–2 mmol/kg (usually 50–100 mmol = 50–100 mL of 8.4% NaHCO3) IV bolus. Repeat every 5–10 min. Target: pH 7.45–7.55 and QRS <100 ms. Haemodynamic instability Refractory arrhythmia Seizures (second-line, after benzodiazepines) What You Must NEVER Give in TCA Overdose: DRUG WHY FORBIDDEN Flumazenil Can precipitate seizures in TCA overdose (benzodiazepines are the treatment for TCA seizures; reversing them is dangerous) Physostigmine Cholinesterase inhibitor; can cause bradycardia, seizures, and cardiac arrest in TCA overdose despite the anticholinergic features Class 1a antiarrhythmics (procainamide, quinidine, disopyramide) Same mechanism as TCA (sodium channel blockade) — additive toxicity, worsens QRS widening and arrhythmia risk Class 1c antiarrhythmics (flecainide, propafenone) Same — contraindicated Phenytoin for seizures Also a sodium channel blocker — worsens cardiac toxicity. Use benzodiazepines (and propofol infusion for refractory status). Amiodarone Prolongs QTc — additive risk of torsades in already-prolonged QT Seizure Management: TCA-induced seizures are driven by sodium channel blockade in the CNS, not GABA pathways. Benzodiazepines are first-line (lorazepam 4 mg IV or diazepam 10 mg IV — repeat every 5 min). Give sodium bicarbonate as adjunct. If seizures are refractory: propofol infusion (not phenytoin, not sodium valproate alone). If persistent seizures in TCA overdose → intubation and propofol infusion are preferred over phenytoin. Intubation in TCA Overdose — High-Risk Procedure: Intubation in TCA overdose is dangerous because: (1) the laryngoscopy attempt causes catecholamine release, which can trigger VT in a heart already sensitised by sodium channel blockade; (2) positive pressure ventilation after intubation causes respiratory alkalosis briefly (which can be beneficial) but acidosis during the apnoeic period before intubation worsens TCA binding. Pre-treatment strategy: give sodium bicarbonate BEFORE intubation to alkalinise the patient and reduce free TCA. Use ketamine or midazolam/fentanyl as induction agents — avoid etomidate (may worsen seizure threshold). RSI with suxamethonium is safe (duration of action is short — if patient seizes post-intubation, drug has worn off). |
TCA OVERDOSE MNEMONIC: "WIDENED QRS KILLS — GIVE BICARB"
Widened QRS (>100ms) = treat · Infuse NaHCO3 (1-2 mmol/kg bolus) · Do NOT give flumazenil, phenytoin, or class 1 antiarrhythmics · ECG: terminal R in aVR >3mm is pathognomonic · Never use physostigmine · Escalate to ICU if QRS >160ms · Dose: target pH 7.45–7.55 · Seizures: BZD first, then bicarb
Sources: LITFL TCA toxidrome: litfl.com/tricyclic-toxidrome/ | EMCrit TCA: emcrit.org/ibcc/tca/ | TOXBASE: toxbase.org (NHS login required) | iatrox UKMLA guide: iatrox.com
07 — ACTION POINTS — ISSUE 21
| MHRA Penicillin V recall (EL(26)A/33): Remove Bristol Laboratories phenoxymethylpenicillin 250mg/5ml batch 7124002 from ED discharge dispensing and pharmacy stock. Alert pharmacy lead. Consider call-back review for patients dispensed this batch since 29 April 2026, particularly children and immunocompromised patients. | |
| THIS MONTH | Paediatric triage hypothermia: Brief your triage nursing team — any child ≤36°C at triage requires immediate escalation regardless of other apparent acuity. Consider adding hypothermia as an automatic "see immediately" flag in your triage system alongside fever in young infants. OR 20x in-hospital death in 5.3 million visits is not ignorable. |
| THIS MONTH | Sepsis antibiotics in shock vs non-shock: Review your ED's sepsis antibiotic pathway — ensure "give antibiotics in 1 hour" is clearly stratified by shock status. Shock (vasopressor-requiring hypotension or SBP <90 despite fluid): antibiotics immediately, no diagnostic delay. Non-shock sepsis: confirm diagnosis first (including cultures), then antibiotics within 1 hour of assessment — short deliberate delay is acceptable per CID n=39,842 evidence and SSC 2026. |
| THIS MONTH | NHS Sepsis Modern Service Framework: Identify your ED's designated Sepsis Champion and ensure they are engaged with the ICS implementation plan. Begin auditing antibiotic-to-door-time and sepsis bundle documentation against NG253 thresholds — this data will feed into BPT compliance assessments from 2027/28. Raise the framework at your next clinical governance meeting. |
| THIS MONTH | Ketamine in trauma — update team protocol: Ensure all ED doctors performing RSI or procedural sedation know the ketamine DSI sequence: 1.5 mg/kg IV → dissociation → 3 minutes pre-oxygenation → RSI. Distribute St Emlyn's TTL Tips 15 to your registrar and SHO group. Brief on intubation risks in TCA overdose (pre-treat with bicarb before laryngoscopy). |
| THIS MONTH | Suicidality after child sexual abuse: Update your department's SARC/sexual assault referral pathway documentation to include explicit mental health screening for suicidality. Flag that 11.1% of children aged 10–17 report suicidality within 90 days; higher risk when perpetrator is non-relative. Ensure CAMHS/safeguarding referral is triggered at ED attendance, not left to community follow-up alone. |
| TCA overdose — bicarb before intubation: When intubating a TCA overdose patient: give NaHCO3 1–2 mmol/kg IV before laryngoscopy to reduce free TCA and lower arrhythmia risk. Do NOT give phenytoin for TCA seizures (sodium channel blocker — worsens cardiac toxicity). Benzodiazepines are first-line; propofol infusion for refractory. | |
| POCUS during cardiac arrest: Establish whether your resus bay POCUS machine is accessible within 30 seconds of a cardiac arrest call. If not, this is a system gap to document and escalate. POCUS during pulse checks (subcostal cardiac + bilateral lung) changes management in >30% of arrests in the QI study; it should be standard in all UK ED cardiac arrests. |
TRIALS TO WATCH
Coming Soon
- NICE Sepsis Guideline Update (GID-NG10467) — Now expected 11 September 2026. Will add procalcitonin-guided testing to the sepsis pathway (replacing NG51 with NG253+addition). Watch for NHS England implementation guidance alongside publication.
- BACHb RCT (UK) — HFNC vs CPAP vs standard O2 in infant bronchiolitis (n=500). Results expected Q3 2026. Will define the UK respiratory support standard for bronchiolitis.
- HSSIB Mental Health Crisis in EDs — Part 2 — Expected Q3 2026. Will carry recommendations on safe assessment rooms, CAMHS thresholds, and liaison psychiatry. Watch for implementation requirements following publication.
2026–2027
- BEST-DKA — Balanced vs saline in DKA Phase 3. Phase 3 results expected late 2026. Will answer definitively whether fluid choice matters in DKA outcomes — a very common ED resus decision.
- EVIS UK (NCT05179499) — Early vasopressor in ED sepsis. UK-specific trial building on ARISE FLUIDS. Will provide UK ED-specific evidence for vasopressor timing.
- 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 21 — 17 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