EM Evidence Rundown

EM EVIDENCE RUNDOWN — ISSUE 23 — 31 JULY 2026

Emergency medicine evidence for UK clinicians — weekly — emevidence.org

Jake Turner — Senior Registrar in Emergency Medicine, ST6 — Curated with the assistance of AI (Perplexity). All content editorially reviewed.

This week: The Howlett EMJ 2026 paper quantifies the boarding harm signal: every 4 hours of boarding beyond the admission decision is associated with an 8.4% increase in 30-day mortality odds, and a number needed to harm of 69. The Garth Pretorius inquest at Hull Royal Infirmary shows what happens when overcrowding, dual triage systems, and Sepsis 6 pathway failure combine — a preventable death, a coroner prevention of future deaths report, and a BMJ editorial. UKHSA reports 2,877 excess heat deaths in England so far in 2026 — nearly double the 2025 total. Paediatrics this week: dexmedetomidine sedation in children carries a risk of second-degree AV block; urine WCC is not a reliable marker for complicated appendicitis; and EMA has refused marketing authorisation for intranasal sufentanil/ketamine (KemSu) in paediatric pain. Core Revision: ECG interpretation — spotting the life-threatening patterns (STEMI, de Winter, Wellens, Sgarbossa, Brugada, hyperkalaemia, WPW).

BOTTOM LINE UP FRONT

ACT ON THIS NOW

CHANGE TONIGHT Boarding harm: NNH 69 for >4 hours boarding beyond admission decision. 30-day mortality odds +8.4% per additional 4 hours. Document and escalate every boarding case.

SAFETY Garth Pretorius PFD: Sepsis 6 pathway not initiated at Hull Royal. Dual triage systems operating simultaneously. Patient told to leave with sepsis diagnosis. Coroner: "more than trivially contributed to death."

SAFETY UKHSA excess heat deaths: 2,877 in England 2026 so far — nearly double 2025. Amber alerts reissued 27 July. Heat-sensitive medicines guidance active.

CHANGE THIS MONTH Provider in Triage (PIT): Deployment associated with increased advanced imaging use and higher negative CT rates for abdominal pain. Implement with diagnostic stewardship safeguards.

CHANGE THIS MONTH Paeds sedation: Dexmedetomidine 4 mcg/kg IN causes deep sedation and second-degree AV block in 1 of 13 children; route ECG first. Nitrous oxide preferred for JIA procedures.

KNOW FOR NEXT TIME

INFORMING PRACTICE 15,860 excess deaths: RCEM State of Emergency Medicine estimate for England 2025 — associated with long ED waits. Near-tenfold rise since 2015.

INFORMING PRACTICE Urine WCC & appendicitis: Limited diagnostic accuracy for complicated appendicitis in children vs CRP (n=156). Do not replace CRP with urinalysis in the appendicitis workup.

INFORMING PRACTICE EMA KemSu refusal: EMA refuses marketing authorisation for KemSu (intranasal sufentanil+ketamine) in paediatric pain — combination not superior to sufentanil alone.

INFORMING PRACTICE Nirmatrelvir/ritonavir: Paxlovid achieves comparable exposures in children ≥6 years (phase 2/3); safe and well-tolerated. Relevant to paediatric COVID presentations in ED.

INFORMING PRACTICE Triage accuracy meta-analysis: Five-level triage systems (MTS, ESI, CTAS, ATS) — systematic review confirms acceptable diagnostic accuracy for predicting severity; no system is superior in all domains.

INFORMING PRACTICE NICE sepsis update (GID-NG10467) still expected 11 September 2026. No change to NG253.

This week's newsletter has a unifying theme: the quantification of harm from ED overcrowding has never been more specific. The Howlett EMJ 2026 paper, synthesised beautifully in St Emlyn's, converts a decade of observational signal into an actionable number — NNH 69. The Garth Pretorius inquest at Hull Royal Infirmary converts that number into a named patient: a 36-year-old man with a sepsis diagnosis who was asked to leave an overcrowded A&E and died the following day when the Sepsis 6 pathway was never initiated. These are not the same paper, but they belong together in any honest clinical conversation about what corridor care and boarding actually cost. The UKHSA excess heat deaths data (2,877 to date in 2026) adds a further pressure axis going into August. On the paediatrics front, a randomised crossover trial confirms that intranasal dexmedetomidine produces unexpectedly deep sedation and AV block in children — a signal that changes pre-procedure assessment. The ECG core revision this week covers the patterns that kill when missed and the mimics that kill when you act on them.

WHAT'S INSIDE

Boarding harm: NNH 69, Howlett EMJ 2026 (LEAD)
Garth Pretorius inquest: Hull Royal Infirmary PFD
UKHSA excess heat deaths 2026: 2,877
Provider in Triage (PIT) model: imaging pitfalls
UK triage SR/MA: five-level system accuracy
PEM: dexmedetomidine vs nitrous oxide RCT (AV block)
PEM: urine WCC vs CRP in appendicitis (n=156)
PEM: nirmatrelvir/ritonavir COVID-19 children ≥6
PEM: ED suicide attempt visits, MMWR 2021-2025
EMA: KemSu (intranasal sufentanil+ketamine) refused
St Emlyn's: TTL tip — Sterile Cockpit
FOAMed: Bottom Line June 2026 critical care roundup
Quick Hits — 4 items
Core Revision: ECG Life-Threatening Patterns

Action Points & Trials to Watch

CHANGE TONIGHT immediate practice change CHANGE THIS MONTH act within the month GUIDELINE new or updated guidance INFORMING PRACTICE context for decisions SAFETY patient safety alert PEM paediatric EM UK SPECIFIC

FOAMED

SECTION 1 — OVERCROWDING & BOARDING HARM

LEAD CHANGE TONIGHT UK SPECIFIC ST EMLYN'S

Boarding Harm Quantified: NNH 69 for More Than 4 Hours Beyond Admission Decision — Howlett EMJ 2026

Howlett et al. Emergency Medicine Journal, 2026. Synthesised in: St Emlyn's, 27 July 2026. stemlynsblog.org/corridor-care-boarding-harm

Why it matters: Boarding — the period between a clinical decision to admit and actual inpatient transfer — has long been associated with harm. Howlett et al. 2026 quantify that harm with the precision needed to make the case to boards, beds managers, and system leaders.

Key findings:

Each additional 4 hours of boarding beyond the admission decision is associated with an 8.4% increase in the odds of 30-day mortality
Boarding >4 hours is also associated with 8.6 hours of additional inpatient stay and a 3.8% increase in 30-day readmission odds
Number Needed to Harm (NNH): 69 — for every 69 patients boarded for more than 4 hours, one additional 30-day death attributable to boarding

RCEM context: The RCEM State of Emergency Medicine in England (June 2026) estimated 15,860 excess deaths in England in 2025 associated with long emergency care waits — a near-tenfold rise from 1,657 in 2015. The RCEM described this as "conservative." St Emlyn's also references the ONS 2025 analysis and Jones 2022 study, which independently converge on the same harm signal.

Implications for practice: NNH 69 is a number every emergency physician should have available. Boarding is not an inconvenience — it is a clinical harm with a quantified mortality signal. Every patient boarding in a corridor or waiting area beyond 4 hours from admission decision represents a cumulative risk that the system has chosen to impose. This should be documented in clinical records, escalated through OPEL frameworks, and reported as a patient safety incident where appropriate under local governance policies.

FRCEM / Professional context: NHS England's definition of corridor care (March 2026: any patient spending ≥45 minutes in a clinically inappropriate area) and the winter planning letter (17 July 2026) name corridor care as a patient safety priority. The Howlett paper provides the empirical underpinning. All ED trainees should be aware of this data for FRCEM SAQs and for governance/ARCP portfolio documentation.

CHANGE TONIGHT SAFETY UK SPECIFIC

Garth Pretorius Inquest: Man Died After Being Asked to Leave Overcrowded Hull Royal Infirmary A&E — Sepsis 6 Pathway Never Initiated

BMJ 2026;394:e100420. PMID: 42521355. doi.org/10.1136/bmj-2026-100420 | Judiciary.gov.uk: Prevention of Future Deaths Report 2026-0273

Facts of the case: Garth Pretorius, 36, underwent a fertility procedure for Klinefelter syndrome in December 2024. He deteriorated one week later and was assessed at an urgent treatment centre, where sepsis was recognised and he was directed to Hull Royal Infirmary A&E. At A&E, the Sepsis 6 pathway was not initiated. Due to overcrowding and a communication error regarding an anticipated major incident, he — along with 15 other patients — was told to leave the department. He died following an approximately 24-hour delay in sepsis treatment.

Coroner findings (Ref 2026-0273, Coroner Paul Marks):

The delay "more than minimally, negligibly, or trivially contributed" to Garth Pretorius's death
Two different triage systems were in simultaneous use within the same department — Manchester Triage System and an alternative protocol — with insufficient training to support consistent application of either
A Prevention of Future Deaths report has been sent to the Chief Executive of HUTH (Hull University Teaching Hospitals)

Learning points for ED practice: (1) The Sepsis 6 pathway must be initiated at the point of sepsis recognition, not deferred to admission — even if the patient is being redirected or managed in a corridor. Document the time of recognition and intervention. (2) A single triage system must operate consistently within any department. Dual-system environments create accountability gaps. (3) When overcrowding requires patients to leave a department, clinical responsibility must be explicitly handed over and documented. A verbal instruction to leave does not constitute safe discharge. (4) This case is likely to be cited in FRCEM SAQs, governance questions, and ARCP reflection portfolios.

SECTION 2 — UK SAFETY & HEATWAVE 2026

CHANGE TONIGHT SAFETY UK SPECIFIC

UKHSA: 2,877 Excess Heat Deaths in England so Far in 2026 — Nearly Double 2025 Total — Amber Alert Active

UKHSA, 30 July 2026. Amber Heat Health Alert reissued 27 July 2026. gov.uk/ukhsa

UKHSA reported on 30 July 2026 that England has recorded 2,877 excess heat-related deaths in 2026 to date — nearly double the entire 2025 total. Amber Heat Health Alerts were reissued on 27 July for the 29-30 July heatwave period, active across multiple regions. NHS trusts should be on OPEL heightened alert.

ED actions: Heat stroke (core temperature >40°C with neurological dysfunction) requires immediate cooling — immersion or evaporative cooling, target <39°C within 30 minutes. Heat exhaustion is a clinical diagnosis of exclusion requiring fluid replacement and cooling; IV fluids for those unable to tolerate oral. Check all patients on heat-sensitive medications (diuretics, ACE inhibitors, antipsychotics, lithium, anticholinergics). Elderly, isolated patients and those with no air conditioning are at highest risk. Liaise with social care where appropriate. Heat-sensitive medicines guidance: consult UKHSA guidance at gov.uk/ukhsa.

CHANGE THIS MONTH TRIAGE / FLOW JOURNALFEED

Pitfalls of Provider in Triage (PIT): Increased Imaging Utilisation and Higher Negative CT Rates for Abdominal Pain

JournalFeed Article-a-Day, 27 July 2026. Primary study in press. journalfeed.org

JournalFeed Spoon Feed: In a single-centre study, advanced imaging utilisation increased significantly following deployment of a Provider-in-Triage (PIT) model. The rate of negative CT scans in patients with abdominal pain was higher in PIT-exposed patients than in the pre-PIT cohort.

Interpretation: PIT models — where a physician or advanced practitioner assesses patients at triage to initiate early investigations — have been widely adopted to address ED waiting time pressures. This study raises a diagnostic stewardship concern: when imaging is ordered before full clinical assessment, the pre-test probability framework may be bypassed, leading to lower-yield scanning. A negative CT is not harmless — it carries radiation exposure, contrast risk, and cost.

UK relevance: NHS England's Model ED recommendations and national flow initiatives have accelerated PIT adoption. This data suggests that PIT implementation should be paired with explicit diagnostic stewardship: imaging ordered at triage should have documented clinical indication and pre-test probability assessment. Consider local audit of negative advanced imaging rates before and after PIT deployment.

TRIAGE SYSTEMATIC REVIEW

Five-Level ED Triage Systems: Systematic Review Confirms Acceptable Diagnostic Accuracy for Predicting Clinical Severity — No Single System Superior

SR/MA published July 2026. Am J Emerg Med. McMaster EvidenceAlerts, 25 July 2026. Score 5/7.

This systematic review and meta-analysis of five-level triage scales (MTS, ESI, CTAS, ATS/NTS) across multiple studies found acceptable diagnostic accuracy for predicting clinical severity and resource utilisation. However, no single system demonstrated superiority across all outcome domains. Sensitivity for identifying the most critically ill patients remains imperfect across all systems.

Practical note: The Manchester Triage System (MTS) is the predominant UK standard. This SR/MA reinforces that MTS provides a validated and defensible triage framework, but does not eliminate under-triage risk — particularly in patients with atypical presentations, elderly patients, and those with altered cognition. Clinical override of triage category should be documented and is always appropriate when there is clinical concern.

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

PEM CHANGE THIS MONTH SAFETY SIGNAL

Intranasal Dexmedetomidine vs Inhaled Nitrous Oxide for Paediatric Procedural Sedation: AV Block Signal — Nitrous Oxide Preferred by Patients and Parents

Tervonen M et al. Eur J Pediatr. Published online 21 July 2026. PMID: 42479237. Summarised on Medscape 29 July 2026. pubmed.ncbi.nlm.nih.gov/42479237

Design: Randomised crossover clinical trial comparing intranasal dexmedetomidine (initial dose 4 mcg/kg, reduced to 2 mcg/kg after first four patients due to profound sedation) versus inhaled 50% nitrous oxide for procedural sedation during intra-articular corticosteroid injection in children with juvenile idiopathic arthritis.

13% DEX DEEP SEDATION
98% N2O DEEP SEDATION
1/13 AV BLOCK (DEX ARM)
69%

PREFERRED N2O AT FOLLOW-UP

Key findings: Pain control was equivalent between arms. However, dexmedetomidine produced significantly deeper and longer-lasting sedation (13% vs 98% deep sedation rate), more adverse events (11 vs 2), and one episode of second-degree AV block. 69% of patients preferred nitrous oxide for future procedures at follow-up. Authors recommend routine ECG monitoring before and during dexmedetomidine sedation.

Safety implication for UK EDs: Intranasal dexmedetomidine is increasingly being used in paediatric EDs for procedural sedation (minor procedures, anxiety reduction, wound closure). This study confirms a cardiac conduction risk at standard dosing. Before using IN dexmedetomidine in any paediatric patient: (1) Check ECG for pre-existing conduction disease; (2) Dexmedetomidine is contraindicated in patients with 2nd or 3rd degree AV block; (3) Have cardiac monitoring available during procedure; (4) Note that this was a JIA population — the safety profile in general paediatric ED use needs further validation. Review your local paediatric sedation protocol.

PEM ABDOMINAL

Urine Leukocyte Count Has Limited Diagnostic Accuracy for Complicated Appendicitis in Children — CRP Remains Superior (n=156)

Cansaran S et al. Eur J Pediatr. 2026. PMID: 42478642. JournalFeed Paeds Speed Read, 30 July 2026. pubmed.ncbi.nlm.nih.gov/42478642

In 156 children undergoing appendectomy for suspected appendicitis, urine leukocyte count demonstrated limited diagnostic accuracy for complicated appendicitis (perforation or gangrenous appendicitis) compared with CRP. The authors conclude that routine urinalysis should not replace CRP measurement in the workup of paediatric appendicitis.

Clinical note: Urinalysis may be performed in paediatric abdominal pain to exclude UTI or renal colic — this remains appropriate. However, the finding of mild pyuria should not falsely reassure against appendicitis (particularly in pelvic appendix location where bladder irritation is common). In any child with suspected appendicitis, CRP and WBC are the preferred inflammatory markers, not urinalysis. This is a retrospective single-centre study (156 patients) — findings are consistent with existing guidance and reinforce current practice.

PEM INFECTIOUS DISEASE

Nirmatrelvir/Ritonavir (Paxlovid) in Children Aged 6+: Phase 2/3 Confirms Comparable Exposures to Adults, Safe and Well-Tolerated

Gerhart J et al. Pediatrics. 2026. PMID: 42342255. JournalFeed Paeds Speed Read, 30 July 2026. pubmed.ncbi.nlm.nih.gov/42342255

This phase 2/3 study demonstrated that weight-adjusted dosing of nirmatrelvir/ritonavir (Paxlovid) in children aged 6 years and older achieves comparable pharmacokinetic exposures to adults, with a similar safety and tolerability profile and antiviral effect. This supports the use of Paxlovid in paediatric patients meeting criteria for antiviral treatment following COVID-19 infection.

UK context: Nirmatrelvir/ritonavir is currently licensed for adults at risk of severe COVID-19. Paediatric use has been off-label. This phase 2/3 data strengthens the pharmacokinetic and safety case for its use in children ≥6 years who are at high risk (immunocompromised, severe comorbidities). In the ED context: a symptomatic COVID-positive child with significant comorbidities within 5 days of symptom onset — consider paediatric infectious disease advice about eligibility for antivirals. MHRA/EMA formal paediatric licensing update expected following this data.

PEM PSYCHIATRIC

ED Visits for Suspected Suicide Attempts in the US, 2021–2025: Continued Elevation in Adolescents and Young Adults (MMWR)

Singichetti B et al. MMWR Morb Mortal Wkly Rep. 2026. PMID: 42348443. pubmed.ncbi.nlm.nih.gov/42348443

Analysis of US ED visit data from 2021–2025 shows that visits for suspected suicide attempts remain elevated above pre-pandemic levels, particularly in adolescents and young adults. The trend did not return to baseline. While this is US surveillance data, the direction is consistent with UK paediatric mental health presentations and RCEM's own data on ED mental health attendances.

UK applicability: This is US MMWR surveillance data — direct numerical comparison to UK EDs is not appropriate. However, the sustained elevated trend in adolescent and young adult self-harm and suicidal crisis presentations is consistent with NHS England data and the Mental Health Crisis Care Concordat. UK EDs should ensure access to mental health liaison teams, SAFE messaging, and appropriate safety planning tools for all adolescent self-harm presentations. NICE CG133 and CG16 remain the relevant UK guidelines.

REGULATORY PEM EU/UK

EMA Refuses Marketing Authorisation for KemSu (Intranasal Sufentanil + Ketamine) in Paediatric Pain — Combination Not Superior to Sufentanil Alone

European Medicines Agency, 23 July 2026. ema.europa.eu

The EMA Committee for Medicinal Products for Human Use (CHMP) adopted a negative opinion on 23 July 2026 for KemSu (CT001) — an intranasal sufentanil/ketamine fixed-dose combination intended for acute pain management in children aged 1–18 years. The CHMP concluded that the combination was not more effective than sufentanil alone (based on adult comparator data), and the paediatric study lacked a comparative arm. Benefits did not outweigh risks. Proveca may request re-examination.

Clinical context: KemSu was intended to combine the rapid analgesic effect of sufentanil with the sedative/analgesic properties of ketamine in a single intranasal dose. Its refusal means no licensed product of this type will be available in the near term. Current paediatric acute pain management remains: intranasal fentanyl (0.5–1 mcg/kg per nostril via MAD) or intranasal diamorphine for acute pain; intranasal midazolam (0.5 mg/kg) for procedural sedation, per local protocols.

SECTION 4 — FOAMED & CRITICAL APPRAISAL

ST EMLYN'S TEAM LEADERSHIP

St Emlyn's TTL Tip #17: "No Chat Below 10,000" — Sterile Cockpit Principle for Trauma Team Leaders

Simon Carley, St Emlyn's, 29 July 2026. stemlynsblog.org/sterile-cockpit-trauma-team-leader

In aviation, the "sterile cockpit" rule prohibits non-essential communication during critical flight phases below 10,000 feet. St Emlyn's applies this to the resus bay: during critical procedures (RSI, thoracostomy, CPR rhythm checks), the trauma team leader should call a "No Chat" period to eliminate cognitive interference. A busy, noisy resus creates errors. The leader's role is to control the acoustic environment as much as the clinical one.

Application: Before RSI: brief the team, assign roles, then call sterile cockpit for the pre-oxygenation, drug delivery, and intubation phase. Resume full team communication after tube secured and confirmed. This is a non-technical skill (NTS) directly assessable at FRCEM OSCE and ARCP CbD level. Cite St Emlyn's TTL series as a reference for your supervision documentation.

THE BOTTOM LINE CRITICAL CARE

The Bottom Line: Critical Care Evidence Updates — June 2026 (Roundup)

The Bottom Line, published 25 July 2026. thebottomline.org.uk

The Bottom Line's June 2026 critical care roundup covers a range of resuscitation and ICU papers with direct ED relevance. Highlighted items include further data on restrictive fluid strategies in sepsis, updated findings on vasopressor timing in septic shock (consistent with Issue 21 data: early vasopressor is not clearly superior to delayed initiation for mortality), and a review of the ARRIVE trial on tracheal intubation in cardiac arrest.

ED take-homes: For septic shock: the evidence increasingly supports earlier vasopressor use to maintain MAP ≥65 mmHg while avoiding excessive fluid loading, rather than a fixed fluid bolus before vasopressor. For cardiac arrest: the ARRIVE trial data on intubation timing (early vs supraglottic airway with delayed intubation) does not support delayed intubation but also shows no survival benefit from early intubation over high-quality BVM in the first minutes. Follow Resus Council UK 2021 guidance. Full review at thebottomline.org.uk.

SECTION 5 — QUICK HITS

NEW UK PRIME MINISTER: ANDY BURNHAM TAKES OVER FROM YVETTE COOPER

BBC News, 28 July 2026.

Andy Burnham MP, the former Greater Manchester Mayor and former Shadow Health Secretary, was appointed UK Prime Minister on 28 July 2026. Burnham has a well-documented track record on NHS emergency care, mental health crisis services, and social care reform. His appointment is likely to shift national health policy focus toward integrated care and community-based demand reduction. Watch for emergency care and NHS reform announcements in August.

ALBUMIN FOR LIVER CIRRHOSIS WITH BACTERIAL INFECTIONS: COCHRANE SR/MA PUBLISHED

Simonetti RG et al. Cochrane Database Syst Rev. 2026 Jul 28. CD014636. PMID: 42517322. pubmed

A new Cochrane SR/MA assesses the evidence for IV albumin supplementation alongside antibiotics in people with liver cirrhosis and bacterial infections. This is primarily an inpatient/ICU consideration, but relevant to the resus bay management of decompensated cirrhosis with infection. ED implication: in patients with cirrhosis presenting with infection (SBP, UTI, pneumonia), early microbiology input and consideration of albumin is appropriate. Full Cochrane review at the link above.

MHRA FIELD SAFETY NOTICES 20-24 JULY 2026: BIOFIRE FILMARRAY TORCH BASE AND LOWENSTEIN VENTILATOR

MHRA, 28 July 2026. gov.uk/drug-device-alerts

Two device FSNs of potential ED relevance: (1) BioFire Diagnostics FILMARRAY TORCH Base — thermal cycler; check local pathology for any service notification. (2) Löwenstein elisa series critical care ventilators (elisa 300/500/600/800) — check with clinical engineering if these are used in your HDU/resus. Details and affected serial numbers in the full FSN.

RCEM WELCOMES EXPANSION OF RSV VACCINE ELIGIBILITY (2 JULY 2026)

RCEM, 2 July 2026. rcem.ac.uk

Dr Adrian Boyle, RCEM Immediate Past President, welcomed the announcement that the RSV vaccine programme will be widened. RSV (respiratory syncytial virus) is a significant driver of paediatric ED attendances and elderly admissions each winter. Expansion of the maternal RSV vaccination programme and the programme for older adults is expected to reduce ED bronchiolitis and pneumonia admissions from autumn 2026 onwards.

EM EVIDENCE RUNDOWN — CORE REVISION — ISSUE 23

ECG Interpretation: Life-Threatening Patterns

Spotting the diagnoses that kill when missed — and the mimics that kill when acted on — FRCEM & FRCA edition

Approach: For every 12-lead ECG in the resus bay, run through: Rate → Rhythm → Axis → Intervals (PR, QRS, QTc) → ST changes → T-wave morphology → Compare with previous. A systematic approach catches the diagnosis the first time and is defensible in governance.

The ECG patterns below are the ones that appear in exam scenarios because they appear in real resus bays. Each one has a clear diagnostic criterion, a common pitfall, and a direct action. The patterns are ordered from highest immediate lethality to "must not miss on discharge." Treat any ECG concern in a symptomatic patient as the pattern it most resembles — act first, refine later.

STEMI ACT IN <90 MIN
LBBB NEW = STEMI EQUIV
WPW AVOID AV BLOCKERS
Brugada CARDIOLOGY NOW

STEMI & STEMI EQUIVALENTS — ACTIVATE THE CATH LAB

1 — Classic STEMI CATH LAB ACTIVATION

Criteria (ESC 2023): New ST elevation at the J-point in ≥2 contiguous leads — ≥1mm in all leads EXCEPT V2-V3; V2-V3: ≥2mm in men ≥40 yrs; ≥2.5mm in men <40 yrs; ≥1.5mm in women. New LBBB or RBBB is a STEMI equivalent.

Territories: Inferior (II, III, aVF) → RCA/LCx. Anterior (V1-V4) → LAD. Lateral (I, aVL, V5-V6) → LCx. Posterior (V7-V9, or ST depression V1-V3 with dominant R in V1) → LCx/RCA.

Pitfall: ST elevation in V1-V4 with concave (smiley face) morphology and J-point notching + PR depression is early repolarisation / pericarditis — not STEMI. Distinguish: pericarditis ST elevation is diffuse and concave; STEMI ST elevation is regional and convex.

Action: Activate PPCI pathway. Dual antiplatelet therapy (aspirin 300mg + ticagrelor 180mg or prasugrel 60mg). Oxygen only if SpO2 <90%. Call cardiology. ECG to door-balloon <90 minutes.

2 — de Winter T-Wave Pattern LAD OCCLUSION

Criteria: In V1-V6: 1-3mm upsloping ST depression at the J-point followed by tall, symmetric, peaked positive T-waves. There is often no (or minimal) ST elevation. aVR may show ST elevation. Sinus rhythm, no LBBB.

The de Winter pattern represents proximal LAD occlusion in 1-2% of LAD occlusion cases. The ST does not elevate — it depresses. This pattern is missed because the classic teaching is "look for ST elevation." There is none. The key is the upsloping ST depression with tall symmetric T-waves in the precordial leads.

Pitfall: Dismissed as "non-specific ST changes" or "anterior ischaemia" without cath lab activation. Any patient with chest pain and this pattern has a proximal LAD occlusion until proven otherwise.

Action: Treat as STEMI. Activate PPCI pathway immediately. Do not wait for serial ECGs.

3 — New LBBB / Sgarbossa Criteria STEMI EQUIVALENT

Sgarbossa Criteria (modified, Smith 2012): 1. Concordant ST elevation ≥1mm (ST elevation in same direction as QRS deflection) — score 5 — most specific 2. Concordant ST depression ≥1mm in V1-V3 — score 3 3. Excessive discordant ST elevation: ST/S ratio >0.25 (modified) — score 2 Score ≥3 = high specificity for AMI in LBBB context.

New or presumed new LBBB with ischaemic symptoms is a STEMI equivalent per ESC 2023 and NICE guidelines. Old LBBB with concordant ST changes (Sgarbossa positive) requires the same response.

Pitfall: Old LBBB dismissed as "the LBBB" without checking for new concordant ST changes. Always compare to previous ECG if available.

Action: New LBBB + symptoms = PPCI pathway immediately. Old LBBB + Sgarbossa-positive = PPCI pathway. Cardiology decision required for old LBBB + Sgarbossa-negative in symptomatic patient.

4 — Wellens Syndrome REPERFUSING LAD — HIGH-RISK UNSTABLE ANGINA

Two patterns: Type A (less common, 25%): Biphasic T-waves in V2-V3 (initially positive then negative) Type B (more common, 75%): Deep symmetric T-wave inversion in V2-V3 (may extend to V4-V5) Occurs in pain-free period (intermittent LAD occlusion reperfusing) — enzymes may be normal or mildly elevated.

Wellens syndrome represents critical proximal LAD stenosis with intermittent occlusion. Patients present with chest pain that resolves — the ECG is taken when they are pain-free. The danger is that it looks reassuring (no ST elevation, minimal enzyme rise), and the patient is discharged home to re-present with a massive anterior STEMI.

Pitfall: Patient pain-free, enzymes normal/borderline, pattern attributed to "non-specific T-wave changes." This patient is admitted urgently for inpatient angiography — not discharged home.

Action: Cardiology review on same admission. Do NOT exercise stress test (can precipitate LAD occlusion). Admit for inpatient angiography. Dual antiplatelet, heparin per ACS pathway.

LIFE-THREATENING NON-ISCHAEMIC PATTERNS

5 — Brugada Pattern / Syndrome VF / SCD RISK

Type 1 (diagnostic): Coved ST elevation ≥2mm in ≥1 of V1-V3 placed in standard or high position (2nd/3rd intercostal space), followed by a negative T-wave. "Shark fin" appearance. Spontaneous or drug-induced (fever, class 1c antiarrhythmics, sodium channel blockers).

Type 2 (saddle-back) is not diagnostic — it may indicate susceptibility but requires electrophysiology study. Only Type 1 is diagnostic for Brugada. Brugada syndrome is the most common cause of sudden cardiac death in young men without structural heart disease. It is autosomal dominant (SCN5A mutation). Fever unmasking Brugada is a genuine emergency — sodium channel blockade in febrile patients can precipitate VF.

Pitfall: Coved ST pattern in febrile patient dismissed as "fever-related ECG changes." Treat any Type 1 Brugada pattern as Brugada syndrome.

Action: Cardiology urgently. ICD considered in symptomatic Brugada (syncope, resuscitated VF). Treat fever aggressively. Avoid class 1c antiarrhythmics, tricyclics, cocaine, excessive alcohol. Ajmaline challenge (if Type 2) must be done in a controlled setting — not in ED.

6 — Wolff-Parkinson-White (WPW) AVOID AV BLOCKERS

Baseline ECG criteria: Short PR interval (<120ms) + Delta wave (slurred upstroke at start of QRS) + Wide QRS (>120ms) + Discordant ST/T changes (ST depression and T inversion in leads with upright delta wave).

WPW in AF (pre-excited AF): Irregular, wide-complex tachycardia with varying QRS morphology. Rates can exceed 200-300 bpm. This is immediately life-threatening — the accessory pathway bypasses the AV node rate-limiting function, leading to VF. 50% of WPW deaths occur in previously asymptomatic patients.

Pitfall: Wide-complex irregular tachycardia treated with AV blockers (adenosine, verapamil, digoxin, metoprolol) — this can precipitate VF by slowing the normal AV conduction and accelerating accessory pathway conduction. DO NOT GIVE AV BLOCKERS IN WPW WITH AF.

Action: Haemodynamically unstable WPW/AF → synchronised DCCV immediately. Haemodynamically stable → procainamide IV (preferred) or flecainide IV. Call cardiology. Definitive treatment: radiofrequency ablation.

7 — Hyperkalaemia ECG Progression DIALYSIS / AKI / ADDISON'S

Progressive ECG changes with rising K+: K+ 5.5-6.0: Tall, narrow, peaked ("tented") T-waves — most prominent in V3-V5 K+ 6.0-7.0: PR prolongation, P-wave flattening/disappearance K+ 7.0-8.0: QRS widening (sinusoidal pattern), QRS merging with T-wave K+ >8.0: Sine wave pattern, VF, asystole

The ECG is more reliable than serum K+ alone as a marker of cardiac toxicity. Normal-looking ECG with K+ 6.5 = less urgent than peaked T-waves with K+ 5.8. Treat the patient, not the number.

Pitfall: Tall T-waves dismissed as "early repolarisation" or "benign variant." Always check K+ in any patient with peaked T-waves, especially in the context of AKI, dialysis, ACE inhibitors, or DKA.

Action: Any ECG change with hyperkalaemia = calcium gluconate 10ml 10% IV immediately (membrane stabilisation). Then: insulin/dextrose (10 units ActRapid in 50ml 50% dextrose over 15 min), salbutamol 10-20mg nebulised. Dialysis if refractory. Treat the underlying cause.

8 — Prolonged QTc / Torsades de Pointes Risk DRUG-INDUCED / INHERITED

QTc thresholds (Bazett formula): Normal <440ms (men), <450ms (women). QTc >500ms = high risk for Torsades de Pointes (TdP). QTc 450-500ms = intermediate risk — review medications.

Torsades de Pointes: Polymorphic VT with twisting of QRS complexes around the isoelectric line. Often self-terminating but can degenerate to VF. Treatment: IV magnesium sulphate 2g over 10 min (even if Mg is normal). Common ED causes of drug-induced QT prolongation: haloperidol, droperidol, erythromycin, azithromycin, methadone, amiodarone, ondansetron (at high doses), sotalol, class 1A antiarrhythmics, tricyclic antidepressants.

Pitfall: QTc not calculated because the automated machine calculation is "close enough." Always manually verify QTc if prescribing a QT-prolonging drug, particularly in: hypokalaemia, hypomagnesaemia, baseline QTc >450ms, or known LQTS.

Action: TdP → IV magnesium 2g over 10 min, consider overdrive pacing if recurrent. Remove QT-prolonging drugs. Correct K+ and Mg2+. Cardiac monitoring. Cardiology input for hereditary LQTS.

FRCEM / FRCA Quick Reference: The patterns that consistently appear in exams and vivas are STEMI criteria, de Winter T-waves, Wellens syndrome, Brugada Type 1, and WPW-in-AF. Know the single action for each: STEMI → PPCI. de Winter → PPCI. Wellens

admit, no discharge, no exercise test. Brugada → cardiology, avoid class 1c. WPW+AF unstable → DCCV. WPW+AF stable → procainamide (NOT verapamil/adenosine). Hyperkalaemia ECG changes → calcium gluconate first. TdP → magnesium first.

EM Evidence Rundown — Core Revision — Issue 23 · emevidence.org

FRCEM REVISION

Sources: LITFL ECG Library (pattern references) · EMCrit IBCC (ECG interpretation) · ESC Guidelines on STEMI 2023 · Resuscitation Council UK 2021 Advanced Life Support

SECTION 6 — ACTION POINTS

Boarding harm documentation: Every patient who is boarding beyond 4 hours from admission decision should have this documented in the clinical record with time of decision to admit and time of transfer. Escalate through OPEL. Boarding is a patient safety event — treat it as one.
Sepsis 6 pathway: In response to the Garth Pretorius inquest — check your department's process for Sepsis 6 initiation at point of recognition, not at point of admission. If a patient is being managed in a corridor or waiting area, the pathway must still run. Sepsis recognition in an overcrowded department is not a reason to defer treatment.
Triage consistency: If your department uses more than one triage approach (e.g., MTS plus a local urgency scale), review whether this creates accountability gaps. The Pretorius coroner specifically cited dual triage systems as a contributing factor. A single validated system, consistently applied, is safer.
Heat-sensitive medications: With the UKHSA amber alert active and 2,877 excess heat deaths in 2026, check every patient presenting with heat illness or dehydration for heat-sensitive medications: diuretics, ACE inhibitors, lithium, antipsychotics, metformin in dehydrated patients, NSAIDs. Adjust or hold as clinically indicated.
Dexmedetomidine in children — pre-procedure ECG: Before using intranasal dexmedetomidine for paediatric procedural sedation, obtain a baseline ECG to exclude pre-existing AV conduction disease. Dexmedetomidine is contraindicated in 2nd/3rd degree AV block. Cardiac monitoring required during procedure. Consider nitrous oxide as preferred alternative for non-painful procedures.
WPW in AF — do not give AV blockers: Any irregular wide-complex tachycardia in a young patient (particularly male, <40) must be assessed for WPW pre-excited AF before giving rate control agents. If in doubt, treat as

WPW: synchronised DCCV if unstable, procainamide if stable. NEVER adenosine, verapamil, diltiazem, or metoprolol in pre-excited AF.

ECG review before QT-prolonging drugs: Before prescribing haloperidol, droperidol, ondansetron, erythromycin, or azithromycin — always check the QTc. If QTc >500ms, discuss with the prescribing team before administering. If TdP is suspected in a resuscitation, magnesium 2g IV before anything else.
PIT model imaging stewardship: If your department uses or is planning to implement a Provider in Triage model, audit advanced imaging utilisation and negative imaging rates before and after. Implement explicit clinical indication documentation requirements for all imaging ordered at triage.

TRIALS TO WATCH

NEAR-TERM (AUGUST–SEPTEMBER 2026)

NICE GID-NG10467	Procalcitonin in sepsis pathway (NG253 update) — expected 11 September 2026. Major ED pathway implications.
Burnham NHS Review	New PM Andy Burnham expected to announce NHS emergency and social care reform direction. Watch for announcements August 2026.
ARREST-2	Lidocaine vs amiodarone vs placebo for refractory VF — follow-up publication expected Q3 2026.

2026–2027 HORIZON

PARAMEDIC-3	UK OHCA enhanced community resuscitation interventions trial — results expected late 2026/2027.
REMAP-CAP	Ongoing adaptive platform — immunomodulation domain results (IL-6 inhibitors, corticosteroids) in sepsis expected 2026.
Model ED Programme	NHS England Model ED requirements implementation — board assurance statements due 30 September 2026. Audit data expected November 2026.

EM Evidence Rundown — Issue 23 — 31 July 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine (ST6). Curated with the assistance of AI (Perplexity). All content editorially reviewed. Published by EM Evidence — emevidence.org

This newsletter is for educational purposes only and does not constitute clinical advice. Always apply clinical judgement and follow local guidelines. Links verified at time of publication. To unsubscribe or provide feedback: emevidence.org