EM Evidence Rundown — Issue 33

EM EVIDENCE RUNDOWN — ISSUE 33 — 8 OCTOBER 2026

EM Evidence Rundown

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.

Full archive and PDF downloads at emevidence.org

Lead: BMJ State of the Art Review on acute hyperkalaemia — calcium for ECG changes (UK Kidney Association: 3 g calcium gluconate), lower insulin doses (5 units or 0.1 unit/kg) to cut hypoglycaemia, salbutamol as an adjunct, bicarbonate only for marked acidosis. Change Tonight: RCEM safety flashes — ask every patient about weight-loss drugs before sedation; treat a pulseless limb with fracture or dislocation as time-critical. MHRA recall of two MOVICOL Plain batches (EL(26)A/41). Paediatric EM (5 items): commercial paediatric sepsis alert (sensitivity 36%), MAP centiles for children, system noise in febrile infant decisions, HFNC weaning, nitrous oxide in autistic children.

BOTTOM LINE UP FRONT — 8 OCTOBER 2026

ACT ON THIS NOW

LEAD Hyperkalaemia (BMJ SOTA): calcium for ECG changes; insulin 5 units or 0.1 unit/kg reduces hypoglycaemia (OR 0.55) without losing potassium effect; hypoglycaemia in 17.2% overall.

RCEM Weight-loss drugs: GLP-1 and GIP/GLP-1 drugs slow gastric emptying, raising aspiration risk at sedation even after about 20 hours’ fasting — ask directly, including non-prescribed use.

RCEM Arterial trauma: absent distal pulse = arterial injury until proven otherwise; reduce a pulseless fracture or dislocation immediately in resus.

CHANGE D10 vs D50 (n=375): rebound hypoglycaemia 43.4% with D50 vs 27.2% with D10; time to euglycaemia not significantly different.

UK Martha’s Rule in EDs: rolling out to all English EDs by March 2028 — patients, families and staff can call for an urgent review.

KNOW FOR NEXT TIME

DIAGNOSTICS Brain Injury Guidelines (SR/MA): BIG1 sensitivity about 98% but specificity only 13% — a rule-out tool, not a substitute for NICE CT rules.

DIAGNOSTICS ADvISED validation (n=1,000): low ADD-RS plus negative D-dimer: NPV 99.4%, one intramural haematoma missed.

TOX Drug-induced hyperthermia (SR, 71 studies): ice or cold water immersion cools fastest; ice-water-soaked sheets are the practical ED option.

PAEDS Epic paediatric sepsis alert (n=166,943): sensitivity 36%, PPV 3% — do not rely on electronic alerts to find septic children.

UKHSA Flu: week 40 positivity 6.5% and rising since August; drifted A(H1N1) noted by WHO.

Hyperkalaemia is one of the commonest resus-room emergencies and one of the easiest to get subtly wrong, and this week’s lead is a BMJ State of the Art Review that sets the current evidence against UK Kidney Association guidance. Two RCEM safety flashes deserve a place on every department noticeboard: weight-loss drugs before sedation and the pulseless injured limb. Martha’s Rule is coming to every English ED, and UKHSA is signalling an early flu season. On the research side there are new data on D10 versus D50, phenobarbital for severe withdrawal, cooling the hyperthermic poisoned patient and rule-out tools for aortic syndromes and head injury. Paediatrics brings an uncomfortable finding: a widely used commercial sepsis alert missed nearly two-thirds of septic children. The Core Revision is shock.

WHAT’S INSIDE — ISSUE 33

• Lead: Acute hyperkalaemia — BMJ State of the Art Review, with UK Kidney Association framing
• D10 vs D50 for hypoglycaemia; phenobarbital vs benzodiazepines for severe alcohol withdrawal
• Brain Injury Guidelines SR/MA (with Bayesian table); ADvISED aortic rule-out validation
• Cooling methods for drug-induced hyperthermia (SR); DOAC reversal in mild TBI
• Needle decompression in obesity; sPESI 2–3 PE outcomes; amiodarone after rhythm conversion in OHCA
• Oral cephalosporins for pyelonephritis; embedded psychiatric care model
• UK: RCEM safety flashes and Safe to Care; Martha’s Rule in EDs; UKHSA flu; MHRA MOVICOL recall
• PEM (5): sepsis alert accuracy, MAP centiles, febrile infant system noise, HFNC weaning, nitrous oxide in autism
• FOAMed: EMCrit 435 on the ACEP procedural sedation guidelines; EM Cases on peripheral noradrenaline
• Core Revision: Shock — differentiating and treating all four types (Clinical)

Contents: 1. Key Trials & Articles — 2. Guidelines & UK Updates — 3. Paediatric Emergency Medicine — 4. FOAMed & Critical Appraisal — 5. Quick Hits — Core Revision — 6. Action Points — Trials to Watch

1 — KEY TRIALS & ARTICLES

LEAD CHANGE THIS MONTH FRCEM STATE OF THE ART REVIEW

Lead: Diagnosis and Management of Acute Hyperkalaemia — What the 2026 Evidence Says, and Where It Meets UK Practice

Rech MA, et al. Diagnosis and management of acute hyperkalaemia. BMJ. 2026;394:e100287 (published 21 August 2026). doi:10.1136/bmj-2026-100287. US authors.

Why it matters: Hyperkalaemia is common across acute care and is associated with malignant arrhythmias and sudden cardiac arrest. The review notes substantial variability in definitions, risk stratification and treatment, and synthesises the evidence for a stepwise approach: protect the myocardium, shift potassium into cells, then remove it.

• 17.2% HYPOGLYCAEMIA WITH INSULIN (SCOPING REVIEW, 62 STUDIES)
• OR 0.55 LOWER VS 10-UNIT INSULIN DOSE: HYPOGLYCAEMIA
• −0.02 mmol/L DIFFERENCE IN K+ FALL, LOWER VS 10 UNITS

Critical appraisal: This is a narrative state-of-the-art review rather than a systematic review, written by US emergency and pharmacy authors and commissioned with a US and international readership in mind. Its strongest data points come from observational studies: the lower-dose insulin meta-analysis pooled retrospective cohorts, and the authors note that two more recent cohorts gave conflicting results on potassium-lowering efficacy, so the optimal dose still needs prospective trials. Hypoglycaemia risk factors are useful and consistent: CKD, AKI, no diabetes, lower pre-treatment glucose, lower body weight, insulin 10 units or more, or dextrose 25 g or less. The calcium dosing evidence remains thin (one observational study drives the 3 g recommendation), and the claim that calcium mainly helps conduction slowing rests partly on a canine myocyte study.

UK practice: The UK Kidney Association guideline remains the UK reference: 30 mL 10% calcium gluconate (3 g) for ECG changes, insulin with glucose, salbutamol as an adjunct, and regular capillary glucose monitoring for several hours after insulin. Departments still using 10 units of insulin in high-risk patients (CKD, AKI, low body weight, no diabetes, low starting glucose) should review their protocol against the lower-dose evidence and their local renal team’s advice. Mini-GRADE: low to moderate. Implementation friction: low.

CHANGE THIS MONTH ENDOCRINE

D10 vs D50 for ED Hypoglycaemia: More Rebound Hypoglycaemia With D50, No Significant Gain in Speed

Fischer D, Lutz G. D10 vs. D50 for the treatment of hypoglycemia in the emergency department. J Emerg Med. 2026;89:100–108. doi:10.1016/j.jemermed.2026.08.009. PMID: 42731515. Featured in JournalFeed, 8 October 2026.

Design: Single-centre US retrospective cohort of adults with blood glucose below 70 mg/dL (3.9 mmol/L) given D10 (n=246) or D50 (n=129).

Results: Time to euglycaemia 38.0 min with D50 vs 51.0 min with D10 (p=0.053). Rebound hypoglycaemia within 6 hours 43.4% vs 27.2% (p=0.002). In severe hypoglycaemia (below 40 mg/dL, 2.2 mmol/L), time to euglycaemia was identical (34.5 vs 34.5 min).

• +16.2 pts ARD — REBOUND HYPOGLYCAEMIA WITH D50
• ~6 NNH (CALCULATED)
• 38 vs 51 min TIME TO EUGLYCAEMIA (P=0.053)
• n=375 ADULTS, SINGLE CENTRE

Appraisal: Retrospective and non-randomised, so the choice of D50 may reflect clinician perception of severity or other confounders; the abstract does not report adjusted analyses. The finding is consistent with prehospital trials showing similar efficacy and fewer adverse effects with D10. In the UK, 10% or 20% glucose is already standard in JBDS guidance, and 50% glucose is discouraged because of extravasation risk.

UK practice: Use 10% (or 20%) glucose as recommended by the Joint British Diabetes Societies; recheck glucose and consider ongoing infusion where rebound is likely (sulfonylureas, long-acting insulin).

INFORMING PRACTICE TOXICOLOGY

Phenobarbital vs Benzodiazepine-Only Treatment for Severe Alcohol Withdrawal: Fewer Doses, Fewer ICU Admissions

Nguyen V, Rauschenbach A, Panning A, et al. Phenobarbital vs. diazepam-based strategies for treating severe alcohol withdrawal syndrome in the emergency department. J Emerg Med. 2026;88:193–203. doi:10.1016/j.jemermed.2026.07.002. PMID: 42575030.

Retrospective US study of 490 ED patients with severe alcohol withdrawal: 432 received phenobarbital, 58 benzodiazepines only. Drug administrations in the first 6 hours were 4 vs 9 (propensity-matched adjusted difference 4). Respiratory depression (31% vs 38%) and intubation (13% vs 14%) did not differ significantly; ICU admission was 29% vs 66%. The phenobarbital group also received more diazepam equivalents in the first 6 hours (243 vs 120 mg).

Appraisal: The comparator group was small (n=58), and choice of strategy was not random, so the large ICU difference may partly reflect local admission practice. UK practice remains chlordiazepoxide or diazepam, with phenobarbital reserved for benzodiazepine-resistant withdrawal under senior or toxicology advice; this study adds observational support for that escalation.

INFORMING PRACTICE DIAGNOSTICS FRCEM

Brain Injury Guidelines (BIG): Pooled Sensitivity About 98% but Specificity About 13% (SR/MA)

Zelt N, Graham J, Altuntur S, Davidson A, Saluja SS. Brain injury guidelines for the management of traumatic brain injury: a systematic review and meta-analysis. CJEM. 2026 (epub 2 October). doi:10.1007/s43678-026-01218-y. PMID: 42827223.

PROSPERO-registered review of 47 articles; 23 studies of the original BIG were meta-analysed. For BIG1 the pooled sensitivity and specificity were 98.3% (95% CI 95.7–99.4) and 12.7% (1.5–58.7) for neurological deterioration, 98.7% and 14.4% for neurosurgical intervention, and 98.2% and 12.8% for death.

• 98.3% SENSITIVITY (DETERIORATION)
• 12.7% SPECIFICITY
• 1.13 LR+ (CALCULATED)
• 0.13 LR− (CALCULATED)

LRs and post-test probabilities calculated by EM Evidence from the pooled point estimates; illustrative priors. The wide specificity CI (1.5–58.7%) makes the LR+ especially uncertain.

Appraisal: BIG applies to patients who already have a CT-positive head injury; it decides whether neurosurgical consultation, repeat CT and admission are needed, not whether to scan. The low specificity means most patients categorised as higher risk will not deteriorate.

UK practice: NICE NG232 governs who gets a CT. BIG-type stratification may help discussions with regional neurosurgery about patients with small injuries, but it is not part of UK guidance.

INFORMING PRACTICE DIAGNOSTICS FRCEM

ADvISED Aortic Rule-Out Externally Validated in New Zealand: NPV 99.4% With Low ADD-RS Plus Negative D-dimer

Beaumont M, Udhani C, Wilson B. SOAR Study: Southern Outcomes in Aortic Rule-Out (ADvISED external validation study). J Med Imaging Radiat Oncol. 2026 (epub 30 July). doi:10.1111/1754-9485.70154. PMID: 42530064. EMA Daily commentary, 5 October 2026.

Retrospective cohort of 1,000 ED patients who had CTA for suspected acute aortic syndrome (2018–2024) in a southern New Zealand network; 41 (4.1%) had AAS. Among 180 with ADD-RS 0–1 and D-dimer below 500 ng/mL, one intramural haematoma was found: NPV 99.4%, failure rate 0.6%; no Stanford type A AAS was missed.

• 99.4% NPV (1/180 MISSED)
• 4.1% AAS PREVALENCE
• n=1,000 PATIENTS SCANNED

Appraisal: Only patients who were scanned were included, so the results apply to a population already selected for CTA, and ADD-RS was scored retrospectively from notes. EMA Daily’s editor judged ADvISED a reasonable adjunct for truly low-risk chest pain but cautioned about how far the reassurance travels.

UK practice: UK best practice guidance on acute aortic syndrome (RCEM/RCR) emphasises structured clinical risk assessment; any D-dimer-based rule-out should follow an agreed local pathway with documented reasoning and safety-netting.

INFORMING PRACTICE TOXICOLOGY

Cooling Drug-Induced Hyperthermia: Ice or Cold Water Immersion Is Fastest; Ice-Water-Soaked Sheets Are the Practical ED Option

van Dijken GD, Muradin I, den Haan C, et al. Comparison of cooling methods for drug-induced hyperthermia in a pre-hospital and emergency department setting: a systematic review. Clin Toxicol (Phila). 2026 (epub 7 October). doi:10.1080/15563650.2026.2738599. PMID: 42841411.

71 studies (1,932 patients, 12 cooling modalities), including exertional hyperthermia data because drug-specific evidence is sparse. Cooling rates: ice water immersion 0.169 ± 0.027 °C/min, cold water immersion 0.162 ± 0.037 °C/min, ice-water-soaked sheets or towels 0.121 ± 0.030 °C/min, room-temperature immersion 0.089 ± 0.020 °C/min; all other modalities were inadequate alone. Meta-analyses confirmed that cold and ice water immersion outperform passive cooling.

• 0.169 °C/min ICE WATER IMMERSION
• 0.121 °C/min ICE-WATER-SOAKED SHEETS
• 71 studies N=1,932

Appraisal: Extrapolation from exertional heat stroke is the main limitation: stimulant hyperthermia persists because of ongoing drug effects, and these patients often have concurrent complications needing simultaneous monitoring and treatment.

UK practice: For stimulant toxicity with severe hyperthermia, combine benzodiazepine sedation with aggressive external cooling; ice-water-soaked sheets allow monitoring in resus. See TOXBASE and seek NPIS advice.

INFORMING PRACTICE TRAUMA

DOAC Reversal in Mild TBI After Ground-Level Falls: No Measurable Benefit in a Retrospective Cohort

Chen LB, Stiffler M, Pawar OS, Ross JT, Rushing AP. To reverse or not to reverse: direct oral anticoagulants in mild traumatic brain injury. J Trauma Acute Care Surg. 2026 (epub 17 July). doi:10.1097/TA.0000000000005133. PMID: 42468510. EMA Daily commentary, 6 October 2026.

273 adults with isolated mild TBI (GCS 13–15) after ground-level falls at a US level I centre; 96 (35%) were taking a DOAC, of whom 41 received 4-factor PCC and 18 andexanet alfa. DOAC use was not associated with more radiographic progression (subdural growth 47.5% vs 44.8%; p=0.70), and reversal was not associated with better outcomes.

Appraisal: EMA Daily’s editor highlighted confounding by indication, inadequate measurement of key variables and an unusual primary outcome. Small numbers make this hypothesis-generating; it does not justify withholding reversal from patients with expanding haemorrhage.

INFORMING PRACTICE PROCEDURES

Needle Decompression in Obesity: The 2nd Intercostal Space, Midclavicular Line Is Shallower Than the 4th/5th Space, Anterior Axillary Line

Schaefer L, Stein E, Schwarz A, Beck G, Krebs J, Boesing C. Needle thoracostomy: implications of chest wall thickness for anatomical location and needle length. Ann Emerg Med. 2026 (epub 1 July). doi:10.1016/j.annemergmed.2026.06.014. PMID: 42383960. EMA Daily commentary, 7 October 2026.

Prospective ultrasound study of 110 patients with class II–III obesity (BMI 36–71). Chest wall thickness exceeded 50 mm in 22% at ICS 2-MCL vs 82% at ICS 4/5-AAL; no patient exceeded 83 mm at ICS 2-MCL, vs 21% at ICS 4/5-AAL. Thickness rose 4.2 mm vs 11.3 mm per 10 kg/m² BMI.

• 22% vs 82% CWT >50 MM: 2-MCL VS 4/5-AAL
• 0% vs 21% CWT >83 MM
• n=110 BMI 36–71

Appraisal: Anatomical, not outcome, data; it does not address the safety concerns at the 2nd ICS (proximity to vessels). In obese patients a longer needle at 2-MCL is more likely to reach the pleura; finger thoracostomy remains definitive in the intubated patient.

INFORMING PRACTICE PE

PE With sPESI 2–3 and Negative Biomarkers on DOACs: 30-Day Mortality 1.4–2.2%; Admission Not Associated With Lower Mortality

Dore M, Duffy R, Melikechi O. Risk stratification of acute pulmonary embolism: outcomes in patients with intermediate sPESI scores and negative cardiac biomarkers. Acad Emerg Med. 2026;33(10):e70425. doi:10.1111/acem.70425. PMID: 42842303.

US Veterans Affairs cohort (2015–2024) of ED-diagnosed PE treated with a DOAC within 24 hours: 1,365 with sPESI 2 and 455 with sPESI 3, all with negative cardiac biomarkers. 7-day and 30-day mortality: 0.44% and 1.39% (sPESI 2); 0.22% and 2.20% (sPESI 3). About 71–75% were admitted; admission was not associated with lower mortality.

Appraisal: A retrospective veteran cohort; admission decisions were confounded by unmeasured factors. It supports prospective trials, not immediate discharge of sPESI 2–3 patients.

INFORMING PRACTICE RESUS

Amiodarone After Conversion From a Non-Shockable to a Shockable Rhythm in OHCA: Higher Survival to Discharge (German Registry)

Knapp J, Greif R, Bathe J, et al. Amiodarone after conversion from a non-shockable to a shockable rhythm in out-of-hospital cardiac arrest. Resuscitation. 2026 (epub 6 October). doi:10.1016/j.resuscitation.2026.111349. PMID: 42838501.

German Resuscitation Registry: 1,843 propensity-matched pairs with an initial non-shockable rhythm and at least two later defibrillations. With amiodarone: hospital admission with ROSC 26.7% vs 23.0% (OR 1.22), 24-hour survival 21.4% vs 14.7% (OR 1.58), survival to discharge 6.5% vs 4.2% (OR 1.58, 95% CI 1.18–2.12); favourable neurological outcome 3.7% vs 2.9% (OR 1.31, 95% CI 0.91–1.89).

Appraisal: Observational, with likely resuscitation-time and immortal-time biases (patients must survive long enough to receive the drug). It is consistent with following the RCUK/ERC ALS algorithm (amiodarone after the third shock) regardless of the initial rhythm.

INFORMING PRACTICE INFECTION

Oral Cephalosporins for Pyelonephritis Discharged From the ED: First, Second and Third Generations Perform Similarly

Mattson AE, Spolsdoff D, Brown CS, et al. DO generations matter for treatment of outpatient pyelonephritis with cephalosporins in the emergency department? DOGMA-ED study. Ann Emerg Med. 2026 (epub 6 October). doi:10.1016/j.annemergmed.2026.08.001. PMID: 42841836.

11 US academic EDs, 1,147 adults discharged on an oral cephalosporin (618 first generation, mostly cephalexin). 14-day treatment failure: 19.6% (first) vs 17.6% (second; difference 2.0%, 95% CI −7.1 to 11.1) vs 18.0% (third; difference 1.6%, −3.4 to 6.5).

UK practice: Supports NICE NG111, where cefalexin is a first-line oral option for acute pyelonephritis; send a urine culture and review against sensitivities.

INFORMING PRACTICE MENTAL HEALTH

Embedded Psychiatric Nurse Practitioners in the ED: Median Length of Stay Down by 1.6 Hours

Hewlett MM, Addo N, Kwan E, et al. Effectiveness of a novel emergency department psychiatric care model in reducing length of stay. Ann Emerg Med. 2026 (epub 8 July). doi:10.1016/j.annemergmed.2026.06.008. PMID: 42421276. EMA Daily, 8 October 2026.

Interrupted time series (5,222 encounters, 2023–2024) at one US academic centre after embedding psychiatry-specialised nurse practitioners and support staff 24/7. Median ED length of stay fell from 8.35 to 5.61 hours (adjusted median difference −1.64 hours, 95% CI −3.15 to −0.13), driven by patients on involuntary holds and those transferred to psychiatric facilities. EMA Daily’s editor noted the lack of a concurrent control group.

UK practice: Consistent with the Core 24 standard for 24/7 liaison psychiatry in acute hospitals; useful evidence for local business cases.

2 — GUIDELINES & UK UPDATES

CHANGE TONIGHT UK RCEM

RCEM Safety Flashes: Weight-Loss Drugs Before Sedation, and the Pulseless Injured Limb

Royal College of Emergency Medicine. Safety Flash: Weight Loss Drugs; Safety Flash: Management of Arterial Trauma (October 2026). rcem.ac.uk (weight-loss drugs); rcem.ac.uk (arterial trauma).

Weight-loss drugs: GLP-1 (semaglutide, liraglutide) and dual GIP/GLP-1 (tirzepatide) agonists slow gastric emptying, increasing aspiration risk during sedation even after prolonged fasting (around 20 hours). Patients may have bought licensed or unlicensed products and may not disclose use unless asked. Other risks: gallstones, pancreatitis, rare non-arteritic anterior ischaemic optic neuropathy (sudden painless vision loss), and altered absorption of narrow-therapeutic-index drugs (for example digoxin) and oral contraceptives. In the ED: ask directly and include in pre-sedation checks; consider aspiration risk, dehydration and pancreatic complications; refer suspected complications and report via the Yellow Card scheme.

Arterial trauma: an absent distal pulse should be assumed to be arterial injury until proven otherwise. Higher-risk injuries: supracondylar fractures, knee dislocation, elbow dislocation and tibial plateau fractures. Pulses may be present initially, so repeat assessment. In the ED: document perfusion on arrival; for a pulseless limb with fracture or dislocation, reduce immediately in resus and reassess; discuss early with orthopaedics and vascular; treat a suspected ischaemic limb as time-critical.

Tell your department: Add “weight-loss drugs (including bought online)?” to the procedural sedation checklist this week.

CHANGE THIS MONTH UK

Martha’s Rule Is Extending to Every Emergency Department in England by March 2028

BBC News. Martha’s Rule: families welcome right to challenge A&E care, 1 October 2026. bbc.co.uk.

Martha’s Rule lets patients, families and staff request an urgent review from a different team when they believe a patient is deteriorating and concerns are not being acted on. It is being extended to all emergency departments in England by March 2028; patients and families can call a dedicated number, any staff member can request a review, and patients are asked at least daily how they feel, with responses acted on in a structured way. it has been piloted in A&Es in Gloucester, Cheltenham, Taunton and Yeovil; Health Innovation West of England reported that 30% of calls nationally related to acute deterioration and led to changes in treatment or enhanced care.

Tell your department: Agree now who responds to a Martha’s Rule call in the ED (a different team from the treating one), how quickly, and how it is documented.

INFORMING PRACTICE UK

UKHSA: Flu Activity Higher Than at This Point in the Previous Four Seasons, With a Drifted A(H1N1) Strain

UK Health Security Agency. Flu levels low at start of season but higher than previous 4 years, 8 October 2026. gov.uk.

In the first weekly winter surveillance report (week 40, 28 September to 4 October), flu positivity was 6.5% (up from 5%) and hospitalisations 1.97 per 100,000. Flu activity through September was higher than at the same point in each of the previous four seasons, with possible signs of an early season, driven by young adults; subtyping showed an equal mix of A(H3N2) and A(H1N1). A WHO technical report indicated a recently seen A(H1N1) virus has drifted from this year’s vaccine component.

UK practice: Prepare for an early surge in respiratory presentations; encourage staff vaccination and follow NICE and local guidance on antivirals for at-risk patients.

SAFETY UK

MHRA: Class 3 Recall of Two MOVICOL Plain 13.7 g Batches (EL(26)A/41)

MHRA. Class 3 Medicines Recall: Norgine Limited, MOVICOL Plain 13.7g powder for oral solution, EL(26)A/41, 5 October 2026. gov.uk.

Batches 487069 (expiry 28/02/2029) and 474919 (expiry 31/08/2028) are being recalled as a precaution because some units contain incorrect amounts of active ingredients. Healthcare professionals should stop supplying these batches, quarantine stock and return it to the supplier. Worth checking any ED-held stock with your pharmacy team.

INFORMING PRACTICE UK RCEM

RCEM Launches Safe to Care: Violence and Aggression Toolkit for Emergency Departments

Royal College of Emergency Medicine. Safe to Care campaign (launched September 2026) and Toolkit for the Prevention and Management of Violence in the ED. rcem.ac.uk/safe-to-care-campaign.

RCEM’s campaign calls for action at trust, health board and government level on three priorities: preventing violence (tackling crowding, poor environments and long waits; national security standards for EDs), ensuring perpetrators face justice, and supporting victims (easier reporting, stronger links with police, psychological first aid and follow-up). It is informed by a UK-wide survey of more than 2,100 ED staff (April–May 2026), and the College has published a toolkit on drivers, training and practical measures.

3 — PAEDIATRIC EMERGENCY MEDICINE

CHANGE THIS MONTH PAEDS SEPSIS

A Widely Used Commercial Paediatric Sepsis Alert Missed Nearly Two-Thirds of Septic Children

Mitchell CM, Zhang Z, Ranard BL, et al. Evaluation of a commercial pediatric sepsis early detection alert in the emergency department. JAMA Pediatr. 2026 (epub 5 October). doi:10.1001/jamapediatrics.2026.4575. PMID: 42832216.

Retrospective multicentre evaluation (8 EDs, New York, January 2024 to June 2025) of the Epic Pediatric Sepsis Early Detection Model across 166,943 encounters, with 189 Phoenix-defined sepsis cases in the first 24 hours. Sensitivity 36% (95% CI 29–43%), PPV 3%, NPV >99%; sensitivity for alerting before sepsis onset was 30%. Sensitivity was lower in Black children (22%), children under 5 (20%) and EDs outside tertiary children’s hospitals (25%).

• 36% SENSITIVITY
• 3% PPV
• n=166,943 ED ENCOUNTERS (189 SEPSIS)

Appraisal: Independent evaluation of a proprietary tool, using the Phoenix criteria, which define organ dysfunction rather than early sepsis; an alert may not be designed to catch every Phoenix case. The equity gaps are the most concerning finding.

UK practice: Electronic alerts do not replace clinical assessment, NICE sepsis risk stratification and the paediatric sepsis screening tools used in UK EDs. Audit any alert locally before relying on it.

INFORMING PRACTICE PAEDS

Paediatric MAP Centiles From 4.2 Million ED Encounters: Lower MAP Linked to Mortality and Vasoactive Use

Ramgopal S, Crowe R, Treichel A, Martin-Gill C. Mean arterial pressure for children in US emergency department and prehospital settings. Arch Dis Child. 2026 (epub 6 October). doi:10.1136/archdischild-2026-330623. PMID: 42838724.

4,784 critical care transports, 4,221,048 ED encounters and 529,475 EMS encounters. Calculated and oscillometric MAP agreed closely (ICC 0.996). With previously published criteria, 0.1% of ED encounters fell below the 5th centile and 17.7% above the 95th. Lower MAP was associated with mortality, vasoactive use and IV fluid use.

UK practice: Age-adjusted MAP centiles complement, but do not replace, APLS physiological ranges and capillary refill; hypotension remains a late sign in children.

INFORMING PRACTICE PAEDS

Febrile Infants 8–90 Days: Lumbar Puncture and Admission Vary With Weekday, Time of Day and Shift Change

Pendyala S, Karki P, Yaeger JP. Associations of system noise with lumbar puncture and hospitalization for young febrile infants. Am J Emerg Med. 2026;110:547–550. doi:10.1016/j.ajem.2026.09.046. PMID: 42843172.

New York State all-payer data, 53,625 febrile infants (2016–2023): 16.8% had an LP and 31.9% were admitted. Higher odds of LP on weekdays (aOR 1.07), during the day (aOR 1.1) and at shift change (aOR 1.06); higher odds of admission at shift change (aOR 1.34). As an administrative-data study, it may not capture clinical severity fully, so some differences may be appropriate.

UK practice: Structured febrile infant pathways (NICE NG143 and local guidance) help reduce unwarranted variation; handover is a point of vulnerability.

INFORMING PRACTICE PAEDS

Abrupt vs Gradual HFNC Discontinuation in Children: Shorter High-Flow Duration, No More Weaning Failure

Mart ZÖ, Er A, Ulusoy E, et al. Abrupt versus gradual HFNC discontinuation in children. Am J Emerg Med. 2026;110:534–539. doi:10.1016/j.ajem.2026.09.050. PMID: 42837916.

Prospective observational study in a Turkish paediatric ED, 87 children (median age 10 months) meeting improvement criteria (FiO2 ≤30%, S/F >270, PEWS <3). Weaning failure occurred in two patients in each group; among successfully weaned patients, HFNC duration was shorter with abrupt discontinuation (59 vs 87 hours, p=0.012); length of stay did not differ significantly. Small and non-randomised.

INFORMING PRACTICE PAEDS SEDATION

Nitrous Oxide for Procedures in Autistic Children: Adverse Events in 1.6%

Reddy N, Call N, Burger RK. Nitrous oxide use in autistic children: a descriptive study. Pediatr Emerg Care. 2026 (epub 8 October). doi:10.1097/PEC.0000000000003726. PMID: 42844729.

Single-system retrospective study of 186 autistic children aged 3–18 (2014–2023), mostly for IV cannulation; most received 70% nitrous oxide for a median of 6 minutes. Adverse events occurred in 3 (1.6%), with no vomiting or aborted procedures.

UK practice: Supports offering nitrous oxide (Entonox or titrated delivery where available) with reasonable adjustments for autistic children undergoing minor procedures.

4 — FOAMED & CRITICAL APPRAISAL

FOAMED

EMCrit 435: The New ACEP Unscheduled Procedural Sedation Guidelines — Definitions, Fasting and Governance

Weingart S. EMCrit 435 — Procedural Sedation — Part VI — Guidelines, Definitions, and Boundaries in 2026. EMCrit, 3 October 2026. emcrit.org. Guideline: Green SM, Roback MG, et al. Ann Emerg Med. 2026;88(3):332–345. PMID: 42618173. doi:10.1016/j.annemergmed.2026.06.038.

Weingart reviews Part 1 of the multidisciplinary Delphi guidelines on unscheduled procedural sedation (approved by the ACEP Board on 29 April 2026). Points he highlights: a definition of unscheduled sedation for time-sensitive procedures; qualified nurses may administer all sedation drugs under direct bedside supervision of the ordering practitioner; the TROOPS quality improvement tool; a sedation committee with representation of all involved specialties; moving away from the ASA classification for emergency pre-assessment; and the position that there is no evidence that compliance with elective fasting guidelines reduces aspiration or other adverse events. He notes the guidance makes no firm statement on GLP-1 agonists.

UK appraisal: US-led guidance; UK practice follows RCEM and Academy of Medical Royal Colleges sedation standards. Read alongside this week’s RCEM weight-loss drug safety flash, which takes a more cautious line on GLP-1 agonists and aspiration.

FOAMED

EM Cases Pearl of the Week: Don’t Delay Noradrenaline for a Central Line

Helman A. Q&A Pearl of the Week, Emergency Medicine Cases, 4 October 2026.

Citing a 2026 systematic review and meta-analysis (49 studies, 33,060 catheters), EM Cases notes that minor adverse events occurred in 2.6% with peripheral noradrenaline and only one major event (tissue necrosis) among nearly 30,000 short peripheral catheters; the four VTE cases were in midline catheters, and about 60% of patients avoided a central line. With site selection and close monitoring, short-term peripheral noradrenaline appears safe.

UK practice: Many UK EDs now have peripheral noradrenaline protocols (large proximal vein, ultrasound-confirmed placement, hourly site checks); check yours exists and is used.

5 — QUICK HITS

MTP activation tool (Dutch, n=463): pH, lactate, BP, HR, temperature and eFAST criteria gave sensitivity 92.1%, specificity 55.8% for justified activation. Am J Emerg Med 2026. PMID: 42837917

Time to ROSC in OHCA survivors (Danish registry, n=2,583): anoxic brain damage rose with time to ROSC (0.3%, 1.8%, 3.2%), but 5-year survival (79%) and return to work did not differ. Resuscitation 2026. PMID: 42838497

Paramedic-suspected STEMI (Victoria, n=7,205): STEMI confirmed in 60.1%; noncardiac diagnoses carried higher long-term mortality (HR 1.75). Ann Emerg Med 2026. PMID: 42841835

AEDs for in-hospital arrest (SR, 5 cohorts): insufficient evidence that ward AEDs improve outcomes; the largest cohort found no difference (aRR 1.01). Resuscitation 2026. PMID: 42838496

Older adults with poisoning (Korea, n=1,774): 7.2% mortality; a five-item bedside score of 3 or more identified 27.5% mortality. Needs external validation. Clin Toxicol 2026. PMID: 42841420

Gastric POCUS (scoping review, 35 studies): applications in aspiration risk, feeding and diagnosis (outlet obstruction, volvulus, perforation); no harms reported. CJEM 2026. PMID: 42832132

Ambulance and trolley waits (Unison survey, more than 600 staff): three in five ambulance workers said patients’ conditions deteriorated while in their care; waits of up to 12 hours in ambulances or on trolleys were reported. Unison, reported 8 October 2026.

CORE REVISION — ISSUE 33 — 8 OCTOBER 2026

Clinical: Shock — Differentiating and Treating All Four Types

Haemodynamic profiles, POCUS, and vasopressor choice — FRCEM

Exam goal: Classify shock as distributive, hypovolaemic, cardiogenic or obstructive using bedside haemodynamics and POCUS, and match the first treatment to the mechanism.

1. HAEMODYNAMIC PROFILES

2. DISTRIBUTIVE SHOCK SUBTYPES

3. POCUS IN UNDIFFERENTIATED SHOCK (RUSH)

4. VASOPRESSOR AND INOTROPE CHOICE BY TYPE

Mnemonic — “Fill, Fix, Squeeze”: Fill the tank (fluid or blood), Fix the cause (antibiotics, decompression, reperfusion, haemorrhage control), Squeeze the vessels or the pump (vasopressors or inotropes) only once the cause is being addressed. FRCEM focus: haemodynamic profile table; RUSH components; why neurogenic shock is bradycardic; why vasopressors do not fix obstructive or haemorrhagic shock.

6 — ACTION POINTS

• Hyperkalaemia: Review your protocol against UKKA guidance and the lower-dose insulin evidence for high-risk patients; make sure glucose monitoring after insulin happens.
• Sedation checklist: Add a direct question about weight-loss drugs (including bought online).
• Pulseless limb: Reduce fractures or dislocations with absent pulses immediately in resus and involve vascular early.
• Hypoglycaemia: Use 10% or 20% glucose, not 50%; recheck for rebound.
• Martha’s Rule: Agree who responds to a call in the ED and how quickly.
• Flu season: Prepare for an early respiratory surge; staff vaccination now.
• MOVICOL: Quarantine batches 487069 and 474919 in ED stock.
• Paediatric sepsis: Do not rely on electronic alerts; use structured clinical screening.

TRIALS TO WATCH

Q4 2026

ACEP sedation Part 2 Clinical recommendations from the unscheduled procedural sedation Delphi guidelines (Ann Emerg Med).

2026–2027

LONGER HORIZON

Outpatient PE (sPESI 2–3) Prospective studies of outpatient management in biomarker-negative intermediate sPESI patients.

EM Evidence Rundown — Issue 33 — 8 October 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine, ST6 | Curated with the assistance of AI (Perplexity). All content editorially reviewed. Feedback: Submit feedback | emevidence.org | Contact: emevidence999@gmail.com Educational evidence summaries only. Not a substitute for clinical judgement, local guidelines or the primary sources.