EM Evidence — Q2 2026 State of the Science

EM EVIDENCE — QUARTERLY REVIEW

Q2

2026

EM Evidence Rundown

State of the Science — April–June 2026

Emergency Medicine & Paediatric EM — UK Edition

Jake Turner | Emergency Medicine Registrar · West Midlands Deanery

Curated with the assistance of AI (Perplexity). All content editorially reviewed. 190 primary evidence items · 14 issues published · emevidence.org

USING THIS EBOOK

How to Use the EM Evidence Rundown

This quarterly ebook condenses 14 issues of the EM Evidence Rundown newsletter (April–June 2026) into a single clinical reference. It is designed for three primary use-cases:

Badge Colour Guide

Stat Terminology

NAVIGATION

Table of Contents

1. Q2 2026 Quarter in Review

5 themes · full practice change table

2. Sepsis & Critical Care

17 items — ARISE FLUIDS, SSC 2026, ANDROMEDA-SHOCK-2, SODa-BIC, BIHCA

3. Resuscitation

10 items — PARAMEDIC-3, LOGICAL, ARISE FLUIDS, ECPR, DSED defibrillation

4. Pulmonary Embolism & DVT

8 items — AHA/ACC 2026, HI-PEITHO, STORM-PE, PEERLESS

5. Stroke & Neurology

13 items — OPTION, EMPHASIS, FASTEST, TNK-PLUS, INSTANT

6. Airway, Respiratory & Ventilation

14 items — MARCH, VL vs DL, RSI agents, bronchiolitis, CAP

7. Trauma & Musculoskeletal

13 items — SWiFT, rib fractures, CRAFFT, pericardiocentesis, HEMS

8. Cardiovascular

8 items — LEGEND, troponin, NICE HTG, IHCA/NSTEMI, CLOSURE-AF

9. Paediatric Emergency Medicine

18 items — No OUCH, bolus fluids mortality, nirsevimab, concussion, CRAFFT

10. Infectious Disease & Outbreak

13 items — Measles, MenB, Ebola, Hantavirus, Mpox, iGAS

11. POCUS & Diagnostics

10 items — Ocular POCUS, AI-FAST, POCUS dyspnoea, G-FAST, US-IV

12. Toxicology, Pharmacology & Pain

9 items — Low back pain, CHS, methamphetamine, gabapentinoids, gonorrhoea

13. Guidelines, Systems & UK Policy

8 items — NICE NG258, Martha's Rule, SSC 2026, RCUK NLSr, NICE anaphylaxis

14. ED Systems, Workforce & UK Data

43 items — RCEM 15,860 excess deaths, corridor care, HSSIB, Martha's Rule

CHAPTER 1

Q2 2026 Quarter in Review

The five defining themes of April–June 2026 in Emergency Medicine

Theme 1: The Bicarbonate Evidence Collapse. Three landmark trials reporting within a single week of June 2026 dismantled routine sodium bicarbonate use across three distinct critical care scenarios. The BIHCA trial (JAMA, n=779, 21 Danish hospitals) randomised patients experiencing in-hospital cardiac arrest to sodium bicarbonate vs placebo: sustained ROSC was 39% vs 37% (RR 1.05, p=0.62) — a clear null result, while alkalosis occurred in 35% of the bicarbonate arm vs 20% controls, and hypernatraemia in 42% vs 29%. The SODa-BIC trial (n=500, 55 ICUs) tested bicarbonate in vasopressor-dependent metabolic acidosis, finding MAKE30 40.2% vs 39.4% (adjusted difference +1.2%, p=0.78). A concurrent meta-analysis of 1,111 patients did show bicarbonate reduced the need for renal replacement therapy (RR 0.69), which allowed a conditional SSC 2026 recommendation for its use only when pH ≤7.2 with AKI Stage 2-3 and vasopressor requirement. The MARCH trial (NEJM, n=1956) was not strictly about bicarbonate, but completed the triad of mucoactive therapy harms: carbocisteine caused GI bleeding (RR 6.51) and hypertonic saline caused bronchoconstriction (RR 5.73) and hypoxia (RR 13.29) without any reduction in mechanical ventilation duration. The clinical implication is unambiguous: stop routine bicarb in cardiac arrest (retaining exceptions for hyperkalaemia, TCA overdose, and sodium-channel toxicity), and stop routine mucoactive agents in ventilated patients.

Theme 2: The Sepsis Resuscitation Paradigm Shift. Q2 2026 produced a convergent body of evidence pointing away from liberal fluid resuscitation as the cornerstone of sepsis management. ARISE FLUIDS (NEJM, n=963, 51 ED sites) randomised ED patients with septic shock to vasopressor-forward vs fluid-liberal resuscitation: days alive and out of hospital at 90 days were identical at 76 days in both arms (difference 0.0, p=1.00), but pulmonary oedema occurred in only 0.6% of the vasopressor group vs 5.0% in the fluid arm (RR 0.12, ARD −4.4%, NNH 23), and crucially demonstrated that peripheral noradrenaline is safe. ANDROMEDA-SHOCK-2 (JAMA) showed that capillary refill time (CRT) as a resuscitation endpoint was superior to lactate-alone on composite organ support outcomes, with the CRT group receiving 250mL less fluid on average — validating CRT as a bedside tool. The 2026 Surviving Sepsis Campaign guidelines incorporated these findings, recommending earlier vasopressors (via peripheral route where central access is delayed), dynamic fluid assessment over fixed fluid volumes, and CRT as a resuscitation endpoint alongside lactate. The paediatric arm of this theme added critical weight: a NEJM RCT across 47 paediatric EDs found balanced vs saline fluids were not superior on the primary outcome, while a landmark Archives of Disease in Childhood study of 5,352 children found bolus volumes exceeding 55ml/kg vs less than 15ml/kg carried an OR of 20.5 (95% CI 8.0–52.5) for in-hospital mortality — compelling evidence to give 10–20ml/kg boluses with reassessment after each.

Theme 3: The PE Management Transformation. Pulmonary embolism management was fundamentally reorganised in Q2 2026. The AHA/ACC published their first joint PE guideline, abandoning the old low/intermediate/high-risk stratification in favour of a five-tier system: A (massive), B (high), C1 (intermediate-high), C2 (intermediate-low), and D (low-risk). The critical implication for UK emergency physicians is that Tier D patients can be discharged on a DOAC directly from the ED without inpatient admission, while Tier C1 patients who fail anticoagulation alone are candidates for catheter-directed therapy (CDT). The HI-PEITHO trial (NEJM) confirmed CDT significantly reduces haemodynamic decompensation compared to anticoagulation alone in intermediate-high risk PE, with an NNT of approximately 16. The STORM-PE and PEERLESS data further supported mechanical thrombectomy approaches. The term "submassive PE" — a category that generated clinical ambiguity for over a decade — is now formally retired in favour of the more actionable C1/C2 classification.

Theme 4: The Stroke Extended Window. Two trials extended the actionable window for acute ischaemic stroke intervention. The OPTION trial (JAMA, reporting at Issues 5 and 12) established that tenecteplase can be used in non-LVO stroke presenting at 4.5–24 hours if CT perfusion demonstrates a viable penumbra, improving mRS 0-1 at 90 days and meaningfully expanding the population eligible for thrombolysis. The EMPHASIS trial (Lancet) reported that oral minocycline, started within 24 hours of acute ischaemic stroke onset, achieved an NNT of 19 for functional independence at 90 days with an ARD of +5.2% — a finding that attracted significant attention given the drug costs pennies per dose. The FASTEST trial (Lancet) closed the door on recombinant Factor VIIa for spontaneous intracerebral haemorrhage: no benefit on outcomes and excess thromboembolic events. The TNK-PLUS trial showed no benefit from adding tenecteplase before endovascular thrombectomy at 4.5–24h for LVO stroke, while the INSTANT trial found tirofiban after failed tenecteplase in non-LVO stroke achieved an NNT of 8.

Theme 5: UK System Collapse Data. Q2 2026 produced the most comprehensive and alarming dataset yet on the state of emergency care in England. The RCEM State of Emergency Medicine 2026 Annual Report, published in Issue 16, attributed 15,860 excess deaths annually to delays in emergency care — a figure extrapolated from mortality data linked to ED waiting times. The same month, NHS England published corridor care data for the first time as an official national metric: 2,241 patients per day were receiving care in non-designated clinical spaces, alongside record 2.46 million A&E attendances in May 2026. Martha's Rule was made mandatory in all NHS Trusts by March 2027 via the NHS Standard Contract 2026/27; 18-month data showed 12,301 calls had been made, with 81% of deteriorating patients not flagged by standard early warning scores alone. The HSSIB interim report on mental health crisis in EDs exposed a fundamental legal void: EDs have no lawful power to detain mental health patients who wish to leave, creating systemic patient safety risks that cannot be resolved without primary legislation. Against this backdrop, measles re-emerged as a tangible public health emergency, with 801 confirmed cases by June 2026, two child deaths, and England losing its WHO measles elimination status.

Q2 2026 Practice Change Summary

All items rated CHANGE THIS MONTH or CHANGE TONIGHT across all chapters.

CHAPTER 2

Sepsis & Critical Care

ARISE FLUIDS · SSC 2026 · ANDROMEDA-SHOCK-2 · BIHCA · SODa-BIC · Fluid Paradigm Shift

Q2 2026 was the most consequential quarter for sepsis management in a decade. ARISE FLUIDS redefined the resuscitation endpoint, ANDROMEDA-SHOCK-2 validated CRT over lactate-alone, and the SSC 2026 incorporated both. Three bicarbonate trials closed the door on routine alkali therapy in critical illness. The net message: less fluid, earlier vasopressors, targeted endpoints.

NEJM · ISSUES 16/17 · JUNE 2026

ARISE FLUIDS — Vasopressor-Forward vs Fluid-Liberal Resuscitation in ED Septic Shock

CHANGE THIS MONTH FRCEM

ARISE FLUIDS enrolled 963 patients across 51 Australian and New Zealand emergency departments, randomising to a vasopressor-forward strategy (early peripheral noradrenaline with restricted IV fluids) versus a fluid-liberal control arm. Days alive and out of hospital at 90 days — the primary outcome — were identical at 76 days in both arms (difference 0.0, p=1.00), confirming non-inferiority and ruling out harm from the vasopressor-forward approach.

Pulmonary oedema: 0.6% vasopressor vs 5.0% fluids (RR 0.12, ARD −4.4%, NNH 23, p<0.001)

The vasopressor-forward arm received significantly less total IV fluid in the first six hours, and the trial definitively demonstrated that peripheral noradrenaline — administered via standard peripheral IV cannula — is safe without evidence of tissue necrosis or extravasation harm at the doses used. This removes a longstanding barrier to early vasopressor initiation in UK EDs where central venous access is delayed.

UK: The EVIS trial (NCT05179499) is the UK equivalent, examining vasopressor timing in ED septic shock. Pending EVIS results, ARISE FLUIDS provides strong support for early peripheral vasopressors in UK practice. Current UK practice of large-volume crystalloid boluses before vasopressor initiation should be reconsidered.

JAMA · ISSUES 17/18 · JUNE 2026

ANDROMEDA-SHOCK-2 — CRT-Guided Resuscitation Superior to Lactate-Alone in Septic Shock

INFORMING PRACTICE FRCEM

ANDROMEDA-SHOCK-2 built on the original ANDROMEDA-SHOCK trial, randomising septic shock patients to CRT-guided resuscitation versus lactate-guided resuscitation as the primary endpoint. The CRT-guided arm showed superiority on the composite endpoint of organ support requirements, while 28-day mortality was identical between groups.

CRT group received 250mL less IV fluid over resuscitation period

Clinically, CRT was measured at the fingertip using digital pressure for five seconds; abnormal was defined as refill time exceeding three seconds. The trial was incorporated into the SSC 2026 guidelines as a co-endorsed resuscitation endpoint alongside lactate, representing the first time a physical examination finding has been given co-equal status with a laboratory biomarker in a major resuscitation guideline.

UK practice implication: Use CRT alongside lactate as a resuscitation endpoint in ED septic shock. A normal CRT (<3 seconds) achieved alongside lactate clearance provides greater confidence that resuscitation is adequate. This supports limiting fluid administration once both targets are met.

CRIT CARE MED · ISSUES 16/17 · JUNE 2026

2026 Surviving Sepsis Campaign Guidelines — Earlier Vasopressors, Dynamic Fluid Assessment

GUIDELINE UPDATE FRCEM

The SSC 2026 guidelines represent the most significant update to sepsis management since the campaign began, incorporating ARISE FLUIDS and ANDROMEDA-SHOCK-2 data alongside years of accumulated evidence against liberal fluid resuscitation. Key changes include: earlier vasopressor initiation with peripheral venous administration now explicitly endorsed, CRT as a co-primary resuscitation endpoint alongside lactate, and a shift away from fixed fluid volume prescriptions towards dynamic assessment of fluid responsiveness.

Vasopressin timing was moved earlier, and the guidelines include a conditional recommendation to consider sodium bicarbonate only when pH ≤7.2 with concomitant AKI Stage 2–3 and vasopressor requirement — a narrow indication supported by the SODa-BIC meta-analysis showing RRT reduction (RR 0.69) without mortality benefit. Notably, ACEP did not formally endorse the SSC 2026 guidelines, citing concerns about generalisability from ICU-based evidence to ED practice — a tension that the EVIS trial is designed to resolve.

Note: ACEP non-endorsement reflects legitimate concerns about ED-specific implementation. The vasopressor timing and CRT recommendations are the most ED-relevant changes and have strong supporting evidence.

JAMA · ISSUE 18 · 25 JUNE 2026

BIHCA — Sodium Bicarbonate for In-Hospital Cardiac Arrest: No Benefit (n=779)

CHANGE THIS MONTH FRCEM

BIHCA enrolled 779 patients across 21 Danish hospitals experiencing in-hospital cardiac arrest, randomising to IV sodium bicarbonate versus saline placebo during advanced life support. The trial tested the hypothesis that correcting acidaemia during cardiac arrest would improve ROSC and survival.

Sustained ROSC: 39% bicarbonate vs 37% placebo (RR 1.05, p=0.62) — null result

Alkalosis: 35% bicarbonate vs 20% placebo · Hypernatraemia: 42% vs 29%

Secondary outcomes including 30-day survival and neurological recovery were identical. The bicarbonate arm experienced substantially more metabolic complications without any signal of benefit on any endpoint. Combined with earlier OHCA data, BIHCA provides definitive evidence to cease routine bicarbonate in cardiac arrest.

Stop routine sodium bicarbonate in cardiac arrest. Retained indications: hyperkalaemia-induced cardiac arrest, tricyclic antidepressant overdose, sodium-channel blocker toxicity, and prolonged arrest with suspected severe acidaemia (>30 minutes). All other uses are not evidence-based.

CRIT CARE MED · ISSUE 18 · 25 JUNE 2026 — N=500, 55 ICUS

SODa-BIC — Sodium Bicarbonate for Metabolic Acidosis in Vasopressor-Dependent Shock: Null on MAKE30

INFORMING PRACTICE

SODa-BIC randomised 500 patients across 55 ICUs who were receiving vasopressors and had metabolic acidosis to sodium bicarbonate infusion versus standard care. The primary outcome was MAKE30 (Major Adverse Kidney Events at 30 days: death, renal replacement therapy initiation, or ≥25% creatinine rise).

MAKE30: 40.2% bicarbonate vs 39.4% standard care (adjusted difference +1.2%, p=0.78) — null

A concurrent meta-analysis of 1,111 patients across SODa-BIC and prior trials found bicarbonate did reduce RRT initiation (RR 0.69) without a mortality benefit. This has informed the SSC 2026 conditional recommendation: bicarbonate may be used only when pH ≤7.2, AKI Stage 2–3, and vasopressors are required — a narrow window distinguishing it from routine acidaemia management.

The SSC 2026 position: bicarbonate in severe acidaemia with AKI may reduce dialysis burden. The primary endpoint null result means this should not be extrapolated to routine use. Dose: 100–150mL of 8.4% NaHCO3 targeting pH >7.2.

CRIT CARE MED · ISSUE 18 · 25 JUNE 2026 — N=1111 POOLED

Sodium Bicarbonate Meta-Analysis — Reduces RRT (RR 0.69) but not Mortality

INFORMING PRACTICE

This pooled analysis of 1,111 patients across bicarbonate trials in critical illness (including SODa-BIC) assessed the effect of sodium bicarbonate on renal replacement therapy initiation, mortality, and ICU length of stay. Bicarbonate reduced RRT initiation significantly (RR 0.69) but had no effect on 90-day mortality or ICU LOS.

RRT initiation: RR 0.69 favouring bicarbonate in severe metabolic acidosis with AKI

The clinical interpretation is nuanced: if reducing dialysis burden is the treatment goal in a patient with severe acidaemia and AKI on vasopressors, bicarbonate has a role. It cannot, however, be expected to improve survival or discharge outcomes. This evidence supports the SSC 2026 conditional recommendation while reinforcing that routine use in less severe acidaemia remains unjustified.

NEJM · ISSUE 12 (PMID 42028918) · 47 PAEDIATRIC EDS

Paediatric Septic Shock Fluids RCT — Balanced vs Saline: No Superiority on Primary Outcome

INFORMING PRACTICE PAEDS

This NEJM RCT enrolled children with septic shock across 47 paediatric emergency departments, randomising to balanced crystalloid (Plasmalyte or Hartmann's) versus normal saline (0.9% NaCl). The primary outcome — a composite of organ dysfunction — was not significantly different between groups, meaning balanced fluid was not statistically superior to saline.

However, the balanced fluid arm showed significantly fewer electrolyte disturbances, including less hyperchloraemia and metabolic acidosis, consistent with adult literature showing the metabolic burden of large-volume normal saline. The trial does not overturn use of balanced fluids; rather, it provides context that the primary endpoint difference may not be statistically detectable in well-conducted RCTs at this scale.

UK practice: Continue to use Hartmann's or Plasmalyte for paediatric fluid resuscitation in sepsis, consistent with NICE guidance. The absence of superiority on the primary endpoint does not support switching back to 0.9% saline, given the metabolic benefits of balanced solutions.

ARCHIVES OF DISEASE IN CHILDHOOD · ISSUE 18 — N=5352 CHILDREN

Paediatric IV Bolus Fluids and In-Hospital Mortality — Bolus >55ml/kg: OR 20.5

INFORMING PRACTICE PAEDS FRCEM

This large observational cohort of 5,352 children examined the association between cumulative IV fluid bolus volume and in-hospital mortality in paediatric critical illness. Bolus volume exceeding 55ml/kg versus less than 15ml/kg carried an adjusted OR of 20.5 (95% CI 8.0–52.5) for in-hospital death after controlling for illness severity.

Bolus >55ml/kg vs <15ml/kg: OR 20.5 (95% CI 8.0–52.5) for in-hospital mortality

While observational data cannot establish causation — sicker children receive more fluid — the magnitude of association, consistency with the FEAST trial data, and mechanistic plausibility (fluid overload, pulmonary oedema, abdominal compartment syndrome) make this clinically important. The dose-response relationship across quintiles of fluid volume strengthens the signal.

UK practice: Give 10–20ml/kg boluses in paediatric sepsis/shock and reassess after each. Resist the instinct to "push more fluid" in children who are not responding. Consider early vasopressors if there is no response after 40ml/kg.

CHEST · ISSUE 7 · APRIL 2026

Prescott et al — Timely Antibiotics and Fluids in Sepsis: Better Discharge Outcomes

INFORMING PRACTICE

This large observational study from Prescott et al. (Chest 2026) examined the association between timely administration of antibiotics and appropriate early fluid resuscitation in sepsis with discharge outcomes, finding that timely antibiotics were associated with a +3.0% increase in discharge to home, and timely fluids with +1.1% — both statistically significant after severity adjustment.

The finding reinforces that the fundamentals of sepsis care — early antibiotics and appropriate (not liberal) fluid resuscitation — remain the most impactful interventions available. Against the backdrop of ARISE FLUIDS showing equal outcomes with less fluid, the emphasis on "timely" rather than "large volume" fluids is important: the goal is appropriate early resuscitation, not fluid loading for its own sake.

Timely antibiotics in sepsis: target first dose within one hour of recognition. The evidence base for antibiotic timing is stronger than for any specific fluid volume or vasopressor threshold.

NEJM · ISSUE 11 · MAY 2026

Sodium Bicarbonate vs 3% Hypertonic Saline for Severe Hyponatraemia

INFORMING PRACTICE

This comparative study examined sodium bicarbonate versus 3% hypertonic saline for the emergency treatment of severe symptomatic hyponatraemia (Na <120 mmol/L with neurological symptoms). Bicarbonate achieved similar rates of sodium correction at 1 hour and 6 hours to hypertonic saline, with no difference in overshoot correction rates or osmotic demyelination syndrome risk.

Sodium bicarbonate 8.4% contains 1000 mmol/L of sodium — making it a potentially useful alternative when 3% NaCl is not immediately available. However, the alkalaemia produced by bicarbonate may confound blood gas interpretation in patients with co-existing acidosis, and the comparison group was 3% NaCl rather than 1.5% NaCl which is more commonly available in UK EDs. The study population was small and findings should be considered hypothesis-generating.

3% NaCl (or 2.7% NaCl where available) remains the preferred agent for severe symptomatic hyponatraemia in UK EDs. Bicarbonate may be used in extremis pending availability, with awareness of alkalaemia risk.

JAMA · ISSUE 18 · 25 JUNE 2026 — ICS SOA26

Critical Care Reviews 2026 Meeting Digest — BIHCA, MARCH, ANDROMEDA-SHOCK-2

CHANGE THIS MONTH

The Critical Care Reviews (CCR26) meeting in June 2026 presented trial data from BIHCA, MARCH, and ANDROMEDA-SHOCK-2 in rapid succession, creating the concentrated evidence convergence that characterised Q2 2026. Experts at CCR26 noted the consistency across these trials in pointing away from interventions previously considered standard: bicarbonate in arrest, mucoactive agents in ventilated patients, and high-volume fluid resuscitation in sepsis.

Discussion at CCR26 highlighted that MARCH and BIHCA, published simultaneously in the same week, should collectively trigger departmental education sessions and SOP updates. The ICS State of the Art meeting (30 June – 2 July, ICC Birmingham) followed immediately after, with dedicated sessions on BIHCA, ANDROMEDA-SHOCK-2, and the BICARICU-2 data on bicarbonate in ICU patients. Full session data from ICS SOA26 will be incorporated into the Q3 2026 issue.

ICS SOA26 (30 June–2 July, ICC Birmingham): BICARICU-2 and ANDROMEDA-SHOCK-2 full data sessions — watch for Q3 2026 updates.

ARCH DIS CHILD · ISSUE 4 · APRIL 2026 — >25,000 CHILDREN

Phoenix Sepsis Score External Validation in >25,000 Children

INFORMING PRACTICE PAEDS

The Phoenix Sepsis Score was externally validated in a cohort exceeding 25,000 paediatric patients across multiple international centres, reporting in Archives of Disease in Childhood. The score — based on respiratory, cardiovascular, coagulation, and neurological criteria — demonstrated consistent predictive validity for paediatric sepsis-related mortality across diverse healthcare settings.

The Phoenix criteria were designed to replace the paediatric SIRS-based Sepsis-2 definitions, using organ dysfunction criteria more analogous to adult Sepsis-3. This external validation in a large international cohort strengthens the case for adoption of Phoenix criteria in paediatric ED sepsis pathways. UK implementation is likely to follow as NICE paediatric sepsis guidance is reviewed. Clinicians should note that Phoenix score application requires point-of-care laboratory data (lactate, INR, creatinine) which may not be available in all paediatric ED presentations.

EMJ · ISSUE 16 · JUNE 2026

Bloodstream Infection Prediction at Triage

INFORMING PRACTICE

This study published in Emergency Medicine Journal evaluated clinical and physiological parameters at ED triage that predict confirmed bloodstream infection, aiming to identify patients who warrant immediate broad-spectrum antibiotics before culture results. Temperature extremes (fever >38.5°C or hypothermia <36°C), heart rate >100, systolic BP <100, and immunosuppression were the strongest independent predictors when combined into a triage-applicable score.

Positive predictive value for bacteraemia remained moderate (around 30–40% at high-risk thresholds), reflecting the inherent difficulty of predicting culture positivity at presentation. The study reinforces the value of clinical gestalt in the context of structured triage assessment, and supports early antibiotic initiation for patients who appear systemically unwell at triage even before formal NEWS2 escalation triggers are met.

Do not delay antibiotics in patients with suspected sepsis pending culture results. Blood cultures before antibiotics adds minutes; antibiotic delay adds mortality. Aim for both within 30 minutes of sepsis recognition.

ISSUES 18 · JUNE 2026

ICS State of the Art 2026 — BICARICU-2 and ANDROMEDA-SHOCK-2 Preview

INFORMING PRACTICE

The ICS State of the Art 2026 meeting (30 June – 2 July, ICC Birmingham) included dedicated sessions presenting BICARICU-2 — the follow-on to SODa-BIC examining bicarbonate in a broader ICU population — alongside the full ANDROMEDA-SHOCK-2 trial presentation with additional subgroup analyses. These sessions are expected to generate further guidance refinements for bicarbonate use and CRT-guided resuscitation.

BICARICU-2 was designed with a larger sample size and broader inclusion criteria than SODa-BIC, potentially providing more definitive guidance on which ICU patients may benefit from bicarbonate therapy. Full results will be reported in Q3 2026. The ICS meeting also included the EVIS trial investigators presenting interim UK data on vasopressor timing, contributing to the evolving evidence base that underpins the SSC 2026 vasopressor recommendations.

CHAPTER 3

Resuscitation

ARISE FLUIDS · LOGICAL · PARAMEDIC-3 · ECPR · Defibrillation · CPR Quality

Q2 2026 added important clarity to resuscitation practice. PARAMEDIC-3 confirmed IO access is adequate but not superior in OHCA. LOGICAL closed the debate on tight vs permissive oxygen post-ROSC. ARISE FLUIDS is covered fully in Chapter 2 but informs post-arrest care. ECPR continues to expand its evidence base, with helicopter delivery now demonstrated as feasible.

NEJM · ISSUE 17 · JUNE 2026 — N=1709

LOGICAL Trial — Conservative vs Liberal Oxygen After ROSC: No Difference at 180 Days

INFORMING PRACTICE FRCEM

The LOGICAL trial randomised 1,709 patients with return of spontaneous circulation after cardiac arrest to conservative oxygen targets (SpO2 90–94%) versus liberal oxygen (SpO2 98–100%) for 36 hours post-ROSC. The primary outcome was survival with favourable neurological outcome at 180 days.

Survival with favourable outcome: 38.2% conservative vs 39.7% liberal (RR 0.97, p=0.65) — null

Secondary outcomes including ICU length of stay, time to neurological recovery, and rate of poor neurological outcome were also not significantly different. The trial definitively ends the debate about whether tight oxygen control post-ROSC improves outcomes over permissive normoxia: it does not. Hyperoxia (SpO2 >98%) should still be avoided given the plausibility of free-radical harm, but aggressive oxygen titration targeting 90–94% offers no benefit over standard normoxic targets.

Post-ROSC oxygen target: SpO2 94–98% is appropriate and achievable without clinical disadvantage. Do not target the bottom of the normal range (90–94%) — target normal (94–98%).

UK RCT · ISSUE 13 · MAY 2026

PARAMEDIC-3 — IO-First vs IV-First in OHCA: No Survival Difference, Lower ROSC with IO

INFORMING PRACTICE FRCEM

PARAMEDIC-3 is the first UK RCT to directly compare intraosseous (IO) first versus IV first vascular access in out-of-hospital cardiac arrest, enrolling patients attended by UK paramedics. Overall survival was not significantly different between the two arms, but the IO-first strategy was associated with lower rates of ROSC compared to IV-first access.

ROSC rates: lower in IO-first arm vs IV-first arm — statistically significant signal

The mechanistic explanation is drug pharmacokinetics: IO access delivers drugs more slowly to the central circulation than IV, with delayed peak drug concentrations affecting epinephrine efficacy during CPR. PARAMEDIC-3 does not suggest IO access is harmful when IV is unavailable, but it does argue against defaulting to IO when IV access can be established promptly. The RCUK 2025 guidelines already recommend IV as the preferred route; PARAMEDIC-3 strengthens this position.

Clinical implication: Attempt IV access first in OHCA. If two IV attempts fail within 90 seconds, proceed to IO. Do not use IO as a first-line or convenience route in resuscitation.

JAMA NETWORK OPEN · ISSUE 12 · MAY 2026 — CARES REGISTRY 2013–2024

OHCA Nighttime Survival Disadvantage — 2013–2024 Registry Data

INFORMING PRACTICE

This analysis of the CARES registry (2013–2024) encompassing over 800,000 OHCA events identified a persistent and significant nighttime survival disadvantage: patients who suffer OHCA between 22:00 and 06:00 have consistently lower rates of survival to hospital discharge compared to daytime arrests, after adjustment for rhythm, bystander CPR, and response times.

Proposed explanations include reduced bystander CPR rates at night (fewer witnesses), longer EMS response times in some regions, reduced hospital capacity and staff availability for post-ROSC care, and circadian effects on resuscitation physiology. The finding has direct implications for ED post-ROSC care pathways, which should be assessed for nighttime degradation. It also informs public resuscitation training efforts targeting residential settings where nighttime arrests predominate.

Departments should audit nighttime OHCA outcomes and post-ROSC care quality compared to daytime. Specific protocols for out-of-hours cath lab activation, post-ROSC TTM management, and neurocritical care referral should be operationally equivalent to daytime.

ISSUE 12 · MAY 2026

DOSE VF Secondary Analysis — DSED Reduces Time in VF by 27%

INFORMING PRACTICE

This secondary analysis of the DOSE-VF trial examined the effect of double sequential external defibrillation (DSED) versus vector change defibrillation versus standard defibrillation on time spent in ventricular fibrillation during refractory OHCA. DSED reduced cumulative time in VF by 27% compared to standard defibrillation, providing a mechanistic explanation for the improved ROSC rates observed in the primary trial.

Refractory VF (VF persisting after three standard defibrillation attempts) affects approximately 10–15% of VF arrests and carries a substantially higher mortality than shock-responsive VF. The DSED strategy requires two defibrillators simultaneously applied in different electrode configurations and is increasingly available in UK HEMS and some ED environments. The 27% reduction in VF burden suggests earlier rhythm analysis and cardioversion — translating to improved likelihood of ROSC.

For refractory VF (>3 unsuccessful defibrillation attempts), consider DSED if two defibrillators are available. Anteroposterior pad positioning (Issue 9 data) should also be used. Document electrode position in all OHCA cases.

ISSUE 9 · APRIL 2026

Refractory VF — Anteroposterior Pad Positioning Associated with Improved ROSC

INFORMING PRACTICE

This cohort study examined defibrillation pad positioning in refractory VF cardiac arrest, comparing anteroposterior (AP: anterior chest and posterior thorax) versus anterolateral (AL: standard precordial positioning) electrode placement. AP positioning was associated with improved rates of ROSC across multiple analyses, consistent with the physiological rationale that AP placement delivers more energy directly through the ventricular myocardium.

The study adds to a growing body of evidence supporting AP positioning as the preferred configuration for refractory VF, complementing the DSED data. AP positioning requires the patient to be briefly rolled — acceptable during CPR — and significantly increases the transthoracic electrical vector alignment with the ventricular long axis. No defibrillation energy increase is required when switching to AP configuration.

In refractory VF: switch to anteroposterior pad positioning at or before the fourth defibrillation attempt. This is a simple, zero-cost intervention with consistent positive signal across observational data.

ISSUE 7 · APRIL 2026

Paediatric Drowning OHCA — CCO CPR Has Worse Outcomes; Rescue Breaths Essential

INFORMING PRACTICE PAEDS FRCEM

This large registry study (PMID 41819340) compared compression-only CPR (CCO CPR) versus standard CPR with rescue breaths in paediatric drowning OHCA, examining over 2,000 cases from multiple national registries. CCO CPR was associated with significantly worse outcomes in drowning victims compared to conventional CPR with rescue breaths.

Survival: significantly lower with CCO CPR vs conventional CPR in paediatric drowning

The mechanistic basis is well-understood: drowning arrests are typically asphyxial in origin, meaning the primary deficit is hypoxia rather than primary cardiac arrhythmia. Ventilation is therefore a critical component of effective resuscitation. This contrasts with adult witnessed VF OHCA where CCO CPR is broadly equivalent to conventional CPR. Bystander education must distinguish between these scenarios, and healthcare providers should always use conventional CPR with rescue breaths in any paediatric arrest.

Always use conventional CPR (30:2) in paediatric arrests. Compression-only CPR is not appropriate for children. In drowning specifically, early ventilation is critical — five rescue breaths before starting compressions.

ISSUE 7 · APRIL 2026 — SR/MA 230,000 PATIENTS (PMID 41819400)

CCO vs Standard CPR in Adult OHCA — Similar Outcomes at Scale

INFORMING PRACTICE

This systematic review and meta-analysis of 230,000 adult OHCA patients compared compression-only CPR versus standard CPR with rescue breaths on survival to hospital discharge. Outcomes were broadly similar between strategies in adults, with modest heterogeneity suggesting CPR type effects may vary by aetiology (cardiac vs asphyxial) and responder type (lay vs professional).

For bystander-initiated CPR in adults, compression-only remains an acceptable and guideline-endorsed strategy — particularly when there is a barrier to mouth-to-mouth ventilation. For professional rescuers in any arrest, and for all paediatric arrests, conventional CPR with rescue breaths is preferred. The data should not be used to justify compression-only CPR in healthcare settings.

RESUSCITATION 2026 · ISSUE 18

Helicopter ECPR (FLIGHT-to-ECPR) — Rural ECPR Feasible Without Compromising Outcomes

INFORMING PRACTICE

The FLIGHT-to-ECPR study examined whether helicopter transport of selected OHCA patients to ECPR-capable centres from rural and semi-rural areas is feasible and delivers comparable survival outcomes to direct ambulance transport to a non-ECPR centre. Across 47 cases transported by helicopter to ECPR centres, outcomes were comparable to matched controls at standard centres, suggesting ECPR access via air can be safely extended to rural populations.

ECPR (extracorporeal CPR, using VA-ECMO initiated during refractory cardiac arrest) has a growing evidence base in selected patients with refractory VF and shockable rhythms. The PRAGUE-OHCA and ARREST trials have established ECPR benefit in urban OHCA; FLIGHT-to-ECPR extends this framework to HEMS use. UK HEMS services are actively developing ECPR programmes, with London Air Ambulance and MERIT having performed cases. Criteria for ECPR candidacy include: witnessed arrest, shockable rhythm, estimated no-flow time <5 minutes, age <70, and refractory arrest after 20+ minutes of CPR.

SJTREM · ISSUE 16 (PMID 42098731)

Carotid Doppler for ROSC Prediction During CPR

INFORMING PRACTICE

This prospective study examined the utility of bedside carotid Doppler ultrasound during CPR as a predictor of ROSC in in-hospital cardiac arrest. A pulsatile carotid Doppler signal during CPR correlated significantly with subsequent ROSC, with sensitivity and specificity both exceeding 70% in the primary analysis. The technique requires minimal interruption to chest compressions and can be performed by a second operator.

Carotid Doppler during CPR provides adjunctive information on cardiac output status that pulse checks alone cannot — particularly relevant during pulseless electrical activity (PEA) where mechanical cardiac activity may vary significantly. Combined with echocardiographic assessment of cardiac motion during CPR pauses, carotid Doppler may help guide decisions on CPR duration and futility. It should not replace clinical judgment but may augment it in prolonged resuscitations.

ISSUE 5 · APRIL 2026

SPOTLESS-2 — Peripheral Vasopressors Safe in Prehospital Setting

INFORMING PRACTICE

The SPOTLESS-2 study (Acad Emerg Med) examined the safety of peripheral IV vasopressor administration in the prehospital setting, specifically examining extravasation rates and local tissue injury. Across over 300 prehospital vasopressor administrations via peripheral IV (predominantly noradrenaline and adrenaline), the rate of clinically significant extravasation was below 1%, and no cases of tissue necrosis occurred.

This study, combined with ARISE FLUIDS data on peripheral vasopressors in ED, consolidates the safety case for peripheral vasopressor use when central access is not yet established. UK PHEM services already use peripheral and intraosseous vasopressors in the field; SPOTLESS-2 provides RCT-grade safety data supporting this practice. Patients should be reassessed regularly for extravasation signs, and vasopressors should be transitioned to central IV access as soon as feasible once definitive care is established.

CHAPTER 4

Pulmonary Embolism & DVT

AHA/ACC 2026 Five-Tier Classification · HI-PEITHO · STORM-PE · CDT evidence

PE management has been comprehensively restructured in Q2 2026. The new AHA/ACC joint guideline retires the "submassive PE" term and introduces a clinically actionable five-tier classification. HI-PEITHO confirms CDT benefit in the critical C1 (intermediate-high risk) tier. STORM-PE adds mechanical thrombectomy data. Low-risk PE (Tier D) can now be discharged directly on DOAC from the ED.

AHA/ACC JOINT GUIDELINE · ISSUES 1/9 · APRIL 2026

2026 AHA/ACC PE Guidelines — New 5-Tier Classification, PERT, DOAC First-Line

CHANGE THIS MONTH FRCEM

The first joint AHA/ACC pulmonary embolism guideline replaces the previous risk-stratification model with a five-tier clinical classification: Tier A (massive, obstructive shock), Tier B (high-risk, clinical instability without frank shock), Tier C1 (intermediate-high risk, RV dysfunction + biomarker positivity), Tier C2 (intermediate-low risk, RV dysfunction or biomarker positivity but not both), and Tier D (low-risk, no RV dysfunction, no elevated biomarkers, haemodynamically stable).

A=Massive · B=High · C1=Intermediate-High · C2=Intermediate-Low · D=Low-Risk

The key practice changes for emergency physicians: Tier D patients meeting the PESI/sPESI low-risk criteria can be discharged directly on a DOAC from the ED without hospital admission — a formal guideline endorsement of practice that was already occurring in some UK centres. Tier C1 patients who fail anticoagulation or demonstrate early deterioration should be considered for catheter-directed therapy (CDT). Tier A patients should receive systemic thrombolysis or surgical embolectomy unless contraindicated. PERT (PE Response Teams) are endorsed but acknowledged as an aspiration rather than a universal requirement.

Retire the term "submassive PE" — it is no longer in the AHA/ACC 2026 guideline. Use C1 (intermediate-high risk) and C2 (intermediate-low risk) instead. Tier D PE: discharge on DOAC. Tier C1: anticoagulate and PERT referral if available.

AHA/ACC TREATMENT MATRIX · ISSUE 10 · APRIL 2026

AHA/ACC 2026 PE Guidelines Part 2 — Treatment Matrix, CDT vs Thrombolysis, PERT

CHANGE THIS MONTH

The second part of the AHA/ACC 2026 PE guideline publication detailed the treatment matrix for each tier and provided explicit guidance on CDT versus systemic thrombolysis. For Tier C1 (intermediate-high risk) patients, CDT is preferred over systemic thrombolysis due to lower major bleeding risk, provided access to an interventional radiology service with PE expertise. Systemic thrombolysis remains first-line when CDT is unavailable or when haemodynamic deterioration requires immediate response.

DOACs (apixaban or rivaroxaban) are endorsed as first-line anticoagulation for most PE tiers outside of massive PE requiring thrombolysis (where parenteral anticoagulation during the thrombolytic window is required). The guideline acknowledges that UK PERT teams are not uniformly available and provides an explicit pathway for centres without PERT: escalate to nearest CDT-capable centre for Tier C1 patients who are deteriorating. The treatment matrix also addresses extended anticoagulation duration, IVC filter indications (narrow: absolute contraindication to anticoagulation + PE), and follow-up with CTEPH surveillance.

NEJM · ISSUE 4 (ACC.26)

HI-PEITHO — Catheter-Directed Fibrinolysis in Intermediate-High Risk PE

INFORMING PRACTICE FRCEM

HI-PEITHO is the pivotal RCT for catheter-directed fibrinolysis in intermediate-high risk PE (Tier C1 equivalent), randomising patients to CDT plus anticoagulation versus anticoagulation alone. CDT significantly reduced the primary composite endpoint of PE-related haemodynamic decompensation (defined as haemodynamic deterioration requiring escalation of care) compared to anticoagulation alone, with an NNT of approximately 16.

NNT 16 to prevent one haemodynamic decompensation event with CDT vs anticoagulation alone

Major bleeding rates with CDT were not significantly higher than anticoagulation alone in this modern cohort, reflecting advances in low-dose ultrasound-assisted thrombolysis (USAT) catheters. HI-PEITHO provides the definitive evidence that CDT is a valid, guideline-supported escalation pathway for intermediate-high risk PE patients who are deteriorating on anticoagulation. It does not endorse CDT for all Tier C1 patients at presentation, but supports its use when clinical deterioration is observed.

UK context: CDT requires interventional radiology with PE expertise. Where this is unavailable, systemic thrombolysis remains the rescue escalation for C1 patients with haemodynamic deterioration. Early PERT or tertiary centre referral should be initiated for C1 patients who are clinically unstable.

CIRCULATION 2026 (PMID 41183181) · ISSUE 12

STORM-PE — Mechanical Thrombectomy for Intermediate-High Risk PE

INFORMING PRACTICE

STORM-PE evaluated the FlowTriever mechanical thrombectomy system specifically in intermediate-high risk PE patients (Tier C1 equivalent), comparing mechanical thrombectomy to anticoagulation alone. The trial demonstrated significant improvement in the primary endpoint of RV/LV ratio at 48 hours, with rapid haemodynamic improvement in the thrombectomy arm and no significant increase in major bleeding compared to anticoagulation alone.

Mechanical thrombectomy offers an advantage over CDT in that it avoids systemic fibrinolytic administration, potentially reducing ICH risk — particularly relevant in elderly patients and those with recent surgical history. STORM-PE adds to the PEERLESS trial data and supports mechanical thrombectomy as a valid CDT alternative for Tier C1 patients at centres with appropriate interventional capabilities. The choice between USAT-CDT and mechanical thrombectomy is currently institutional-preference-dependent pending direct comparison trials.

ISSUE 7 · APRIL 2026

STRATIFY + STORM-PE — CDT vs Peripheral IV Thrombolysis in Intermediate-Risk PE

INFORMING PRACTICE

The STRATIFY and STORM-PE trials together addressed the comparison between CDT and peripheral IV (systemic) thrombolysis in intermediate-risk PE, finding broadly equivalent outcomes on haemodynamic endpoints. CDT was not statistically superior to systemic thrombolysis for this indication, which has implications for resource allocation: if CDT and systemic thrombolysis are equivalent in efficacy, the reduced bleeding risk of CDT remains the key differentiator.

For emergency physicians without access to interventional radiology, systemic thrombolysis via peripheral IV retains guideline support as the primary escalation route in haemodynamically unstable PE (Tier A/B) and deteriorating Tier C1 patients where CDT is unavailable. Half-dose systemic thrombolysis (50mg alteplase in patients >65kg) remains used in some centres for Tier C1 patients though evidence for dose reduction is limited.

Systemic thrombolysis remains the most universally accessible intervention for haemodynamically unstable PE. Know your local referral pathway for CDT and the criteria for same-day transfer to an interventional centre.

ISSUE 10 · APRIL 2026

PE D-dimer Simplified Strategy — 1000 ng/mL Threshold: 0% Failure, 19% Less Imaging

INFORMING PRACTICE

This large validation study examined a simplified fixed D-dimer threshold of 1000 ng/mL (rather than age-adjusted thresholds) for PE exclusion in low-to-intermediate pre-test probability patients. The 1000 ng/mL threshold achieved a 0% failure rate (no missed PE within 90 days) while enabling 19% fewer imaging investigations compared to the standard 500 ng/mL threshold combined with clinical assessment.

The YEARS algorithm and age-adjusted D-dimer (age × 10 ng/mL in patients >50 years) are already established in UK practice as alternatives to the fixed 500 ng/mL threshold. A fixed 1000 ng/mL threshold offers the simplicity advantage of requiring no calculation, though it must be restricted to truly low pre-test probability patients — those with high clinical suspicion still require CTPA regardless of D-dimer level. This data is likely to inform the next NICE PE guidance update.

ISSUE 13 · MAY 2026

Radiologist Pre-Approval of CTPA — No Significant Difference in Diagnostic Yield

INFORMING PRACTICE

This study examined whether radiologist pre-approval (gate-keeping) of emergency CTPA requests alters the diagnostic yield for PE compared to unrestricted ordering. No significant difference in PE diagnosis rates was found between pre-approval and unrestricted CTPA systems, suggesting that pre-approval primarily adds delay without meaningfully improving imaging appropriateness — at least in the ED setting where clinical pathways already incorporate structured pre-test probability assessment.

UK departments with pre-approval requirements should review this evidence in the context of their local PE pathway adherence. If WELLS/YEARS assessment is reliably used before imaging, radiologist pre-approval generates administrative burden without clinical benefit. If pathways are inconsistently applied, pre-approval may provide an educational prompt rather than a gate-keeping function.

ISSUES 15/18 · JUNE 2026

2026 AHA/ACC + HI-PEITHO Summary — New A-E Classification; CDT NNT 16

CHANGE THIS MONTH

The consolidated Q2 2026 PE evidence can be summarised in a practical framework: the five-tier A–D classification replaces risk stratification language, HI-PEITHO validates CDT for Tier C1 with NNT 16 for decompensation prevention, low-risk (Tier D) patients can safely be discharged on DOAC from the ED, and systemic thrombolysis remains accessible when CDT is unavailable.

Tier D (low-risk): discharge on DOAC · Tier C1 (intermediate-high): anticoagulate + PERT/CDT consideration

For UK emergency departments without PERT teams or same-day CDT access, the practical algorithm is: Tier A — systemic thrombolysis + resuscitation; Tier B — systemic thrombolysis or urgent surgical referral; Tier C1 — anticoagulate, monitor closely, activate CDT pathway if deteriorating; Tier C2 — anticoagulate, low threshold for imaging escalation; Tier D — discharge on DOAC with follow-up arranged within 2 weeks.

Use the A-D classification in documentation from now. Remove "submassive PE" from your vocabulary. The AHA/ACC 2026 classification is internationally endorsed and will likely underpin all future PE guideline updates including forthcoming NICE revisions.

CHAPTER 5

Stroke & Neurology

OPTION · EMPHASIS · FASTEST · TNK-PLUS · INSTANT · Extended Thrombolysis Window

Stroke management advanced on multiple fronts in Q2 2026. The OPTION trial extended tenecteplase thrombolysis to 4.5–24 hours in non-LVO stroke, EMPHASIS showed a cheap antibiotic (minocycline, NNT 19) improves neurological outcomes, and FASTEST closed the door on haemostatic therapy for intracerebral haemorrhage. Stroke is increasingly a time-and-penumbra problem rather than a time-only problem.

JAMA 2026 (PMID 41642827) · ISSUES 5/12

OPTION Trial — Tenecteplase 4.5–24h in Non-LVO Stroke

INFORMING PRACTICE FRCEM

The OPTION trial randomised patients with non-large vessel occlusion (non-LVO) acute ischaemic stroke presenting at 4.5–24 hours with evidence of perfusion mismatch on CT perfusion imaging to tenecteplase versus standard care. The trial demonstrated significant improvement in mRS 0-1 at 90 days in the tenecteplase arm, establishing that the thrombolysis window can be safely extended beyond 4.5 hours when CT perfusion demonstrates viable penumbral tissue.

mRS 0-1 at 90 days: improved significantly in tenecteplase arm vs standard care (p<0.05)

The critical condition for benefit is perfusion imaging evidence of penumbra — patients with large core infarcts on CT perfusion (mismatch ratio <1.2 or core >70mL) were excluded. This aligns with the emerging paradigm that stroke is a "penumbra problem" as much as a time problem: some patients at 20 hours may benefit from thrombolysis if the penumbra is preserved, while others at 3 hours may not benefit if the core is large. OPTION applies to non-LVO stroke; for LVO stroke at 4.5–24h, EVT remains the primary intervention.

UK implication: CT perfusion imaging at 4.5–24h is now a consideration for all non-LVO stroke presentations. Discuss with your local stroke team or regional hyperacute stroke unit. Facilities without CT perfusion capability should have a clear escalation pathway for eligible late-presenting patients.

LANCET 2026 · ISSUE 11

EMPHASIS RCT — Minocycline for Acute Ischaemic Stroke: NNT 19, ARD +5.2%

INFORMING PRACTICE FRCEM

The EMPHASIS trial randomised patients with acute ischaemic stroke to oral minocycline (an inexpensive tetracycline antibiotic) initiated within 24 hours of symptom onset versus placebo. The primary outcome was functional independence (mRS 0-2) at 90 days. Minocycline significantly improved functional independence.

NNT 19 for functional independence at 90 days · ARD +5.2%

Minocycline is proposed to act via anti-inflammatory and neuroprotective mechanisms — inhibiting microglial activation, reducing matrix metalloprotease activity, and preventing secondary neuronal death in the ischaemic penumbra. The drug costs approximately £2–3 per course. EMPHASIS is not yet sufficient to change standard of care — it requires replication and NICE review — but the effect size (NNT 19 with an inexpensive, well-tolerated drug) makes this a significant finding that is likely to be incorporated into future stroke guidelines.

Minocycline is not currently standard of care for AIS in the UK. However, the EMPHASIS finding should prompt discussion at your hyperacute stroke unit. Replication in a second large RCT is needed before routine implementation. Watch for further trial data in Q3 2026.

LANCET 2026 · ISSUE 11

FASTEST Phase 3 RCT — rFVIIa in Spontaneous Intracerebral Haemorrhage: No Benefit, Thromboembolic Harm

INFORMING PRACTICE

The FASTEST Phase 3 trial randomised patients with spontaneous intracerebral haemorrhage to recombinant Factor VIIa (rFVIIa) versus placebo, testing the hypothesis that early haemostatic treatment reduces haematoma expansion and improves neurological outcomes. rFVIIa showed no benefit on the primary outcome of favourable functional outcome at 90 days.

No benefit on primary outcome · Excess thromboembolic events in rFVIIa arm

Thromboembolic complications (DVT, PE, arterial thrombosis) were significantly higher in the rFVIIa group, confirming the safety signal identified in earlier Phase 2 studies. FASTEST definitively closes the door on rFVIIa for spontaneous ICH outside of specific haemophilia-related or factor-deficiency scenarios. Blood pressure control (target SBP <140 within 1 hour, INTERACT2-supported) and reversal of anticoagulation in anticoagulant-associated ICH remain the primary evidence-based interventions in acute ICH management.

Do not use rFVIIa for spontaneous ICH. It does not reduce haematoma expansion, does not improve outcomes, and causes excess thromboembolic harm. This applies to all non-anticoagulant-related ICH.

JAMA 2026 (PMID 42099212) · ISSUE 16

TNK-PLUS — Tenecteplase Before EVT at 4.5–24h: No Benefit in LVO Stroke

INFORMING PRACTICE

TNK-PLUS randomised LVO stroke patients presenting at 4.5–24 hours to tenecteplase plus endovascular thrombectomy versus EVT alone. The trial found no benefit of adding tenecteplase to EVT in this extended time window, with similar rates of excellent outcome (mRS 0-2 at 90 days) and no significant difference in symptomatic ICH rates.

This contrasts with OPTION, which showed benefit of tenecteplase in non-LVO stroke at 4.5–24 hours. The distinction matters: for LVO stroke, EVT is the definitive treatment and thrombolysis does not add benefit; for non-LVO stroke, tenecteplase may provide functional benefit if penumbra is preserved. TNK-PLUS should not be interpreted as negative evidence for the OPTION findings — they address different populations with different treatment goals.

Algorithm: LVO stroke at 4.5–24h — proceed directly to EVT if eligible; do not add tenecteplase. Non-LVO stroke at 4.5–24h — consider tenecteplase if CT perfusion shows penumbra (OPTION criteria).

JAMA 2026 (PMID 42100960) · ISSUE 16

INSTANT — Tirofiban After Failed Tenecteplase in Non-LVO Stroke: NNT 8

INFORMING PRACTICE

The INSTANT trial examined the addition of tirofiban (IV glycoprotein IIb/IIIa inhibitor) in non-LVO stroke patients who had received tenecteplase but failed to achieve neurological improvement within 30–60 minutes. The trial demonstrated a significant improvement in excellent neurological outcome (mRS 0-1) at 90 days for tirofiban-treated patients, with an NNT of 8.

NNT 8 for mRS 0-1 at 90 days · tirofiban in failed TNK, non-LVO stroke

Tirofiban is already used in interventional cardiology for ACS, and its use post-thrombolysis in stroke is a novel paradigm. The proposed mechanism is that failed thrombolysis leaves a residual thrombus highly susceptible to platelet aggregation, and antiplatelet therapy at this stage may achieve further recanalisation or prevent re-occlusion. INSTANT is hypothesis-generating but the NNT of 8 is compelling; further replication is awaited. This is not current UK standard practice.

ISSUE 9 · APRIL 2026

GOLDEN BRIDGE II — Stroke Clinical Decision Support Cluster RCT

INFORMING PRACTICE

GOLDEN BRIDGE II was a cluster randomised trial examining whether implementation of clinical decision support software integrated into the stroke pathway reduces treatment delays and improves outcomes. The trial demonstrated significant reductions in door-to-needle times and door-to-groin times, with modest but statistically significant improvements in functional outcomes at 90 days attributable to faster treatment delivery.

The intervention included integrated electronic stroke assessment tools, automated imaging interpretation prompts, and real-time treatment timeline monitoring. This is directly applicable to UK NHS systems, where SSNAP (Stroke Sentinel National Audit Programme) already benchmarks door-to-needle time nationally. Clinical decision support does not replace clinical expertise but can reduce cognitive and logistical barriers to timely treatment, particularly for less experienced clinicians or during out-of-hours periods.

ISSUE 6 · APRIL 2026

GAS Meningitis in Children — iGAS Surge, 15% Mortality, 56% ICU

INFORMING PRACTICE

This multicentre case series reported outcomes of invasive GAS (group A Streptococcus) meningitis in children during the recent iGAS surge, finding a 15% case fatality rate and ICU admission in 56% of cases. Children with GAS meningitis had higher mortality and complication rates than historical HiB or meningococcal meningitis cohorts, reflecting the pathogen's propensity for vasculitis and infarction.

Clinical recognition of GAS meningitis requires standard LP in children with meningism; the presentation is indistinguishable from other bacterial causes. GAS is fully penicillin-sensitive, and early high-dose IV benzylpenicillin or ceftriaxone is the definitive treatment. The UK iGAS surveillance programme has recorded above-average incidence since 2022; paediatric emergency physicians should have a low threshold for LP and empirical antibiotic initiation in children with fever and meningism.

iGAS: children presenting with fever, rash, or meningism should receive empirical antibiotics without delay pending LP. Do not defer antibiotics for imaging or LP if the clinical presentation warrants treatment.

ISSUE 7 · APRIL 2026

BP Targets in Acute Spinal Cord Injury — First RCT: Augmented MAP No Benefit

INFORMING PRACTICE

This first-ever RCT in acute traumatic spinal cord injury examined whether maintaining augmented MAP (≥85–90 mmHg) versus standard MAP targets for 7 days post-injury improves neurological recovery. The augmented MAP arm showed no benefit on the primary neurological outcome.

Respiratory complications: 78% augmented MAP vs 39% standard MAP — significantly higher

Current NICE guidelines and ATLS protocols recommend MAP targets of 85–90 mmHg for 7 days in traumatic SCI — a recommendation now directly challenged by this RCT. The doubled rate of respiratory complications in the augmented MAP arm (78% vs 39%) represents a substantial harm signal. UK practice should await formal guideline review before changing MAP targets, but clinicians should be aware of this evidence when managing SCI patients and avoid aggressive vasopressor escalation beyond standard targets.

STROKE JOURNAL · ISSUE 16

Sex-Based Differences in Stroke Outcomes

INFORMING PRACTICE

This large registry analysis demonstrated persistent sex-based disparities in stroke outcomes, with women experiencing longer times to treatment, lower rates of thrombolysis and thrombectomy, and worse functional outcomes at 90 days compared to men of equivalent stroke severity after adjustment. The disparity was most pronounced in the 55–74 age group where women's stroke presentations were less likely to be triaged as high-priority.

Proposed contributing factors include atypical stroke presentations more common in women (fatigue, confusion without focal motor deficit), the older average age of female stroke patients (linked to more comorbidities and contraindications to thrombolysis), and potential unconscious bias in triage assessment. FAST-positive criteria — face, arm, speech — may under-detect posterior circulation strokes more prevalent in women. Departments should audit sex-disaggregated door-to-needle times and thrombolysis rates.

ISSUE 11 · MAY 2026

Paediatric Status Epilepticus — Midazolam Buccal/IM Best (NMA, 9 RCTs)

INFORMING PRACTICE PAEDS

This network meta-analysis of 9 RCTs in paediatric status epilepticus compared buccal, intranasal, IM, and rectal benzodiazepine formulations for first-line seizure termination. Buccal midazolam and IM midazolam ranked highest for seizure termination within 5–10 minutes and were superior to rectal diazepam and intranasal lorazepam in probability ranking analyses.

Buccal midazolam and IM midazolam: highest ranked for seizure termination in paediatric SE

This confirms current UK RCPCH and BNFc guidance endorsing buccal midazolam as the community first-line agent and supports IM midazolam as the preferred ED first-line in children without IV access. The data argues against routinely waiting for IV access before treating seizures in children — buccal or IM administration should not be delayed. For children with established IV access, IV lorazepam or IV diazepam remain appropriate first-line choices.

First-line in paediatric SE without IV access: buccal midazolam 0.5mg/kg (max 10mg). If IM access available: midazolam 0.1–0.2mg/kg IM. Establish IV access in parallel, not before, benzodiazepine administration.

NEJM/JAMA · ISSUES 5/12

SMART-DECISION — Beta-Blocker Discontinuation Post-MI

INFORMING PRACTICE

SMART-DECISION (NEJM) randomised post-MI patients with preserved ejection fraction (EF >40%) to beta-blocker continuation versus discontinuation after 6–12 months of treatment. Discontinuation was non-inferior to continuation for the composite cardiovascular outcome at 3 years, including MACE and all-cause mortality.

This is relevant to emergency physicians who encounter post-MI patients on long-term beta-blockers presenting with adverse effects (bradycardia, hypotension, fatigue). SMART-DECISION does not apply to patients with reduced EF (<40%) where beta-blockers retain strong evidence. However, for post-MI patients with preserved EF presenting to the ED with beta-blocker intolerance, the option to cease beta-blockers after discussion with cardiology is now evidence-supported. This does not change acute management of MI in the ED.

ISSUE 15 · JUNE 2026 — N=4215 (PMID 41925562)

ICP Monitoring in Paediatric Severe TBI — EVD vs IPM

INFORMING PRACTICE PAEDS

This large retrospective cohort of 4,215 children with severe TBI (GCS ≤8) compared ICP monitoring via external ventricular drain (EVD) versus intraparenchymal monitor (IPM) on outcomes including mortality, neurological recovery, and complications. EVD was associated with slightly higher rates of ventriculitis compared to IPM (8.1% vs 3.4%) but provided the additional benefit of therapeutic CSF drainage when ICP was elevated.

The choice of ICP monitoring modality in paediatric severe TBI should be guided by CT findings: if there is hydrocephalus, mass effect, or poor basal cisterns, EVD with drainage capability is preferred; for isolated raised ICP without ventricular pathway obstruction, IPM avoids infection risk. This does not change ED management of paediatric severe TBI, but informs neurosurgical referral conversations and goal-directed ICP management.

ISSUE 11 · MAY 2026

ED-Initiated Fall Prevention — SR/MA (Acad EM)

INFORMING PRACTICE

This systematic review and meta-analysis examined ED-initiated fall prevention interventions — structured risk assessment, medication review, physiotherapy referral, and patient education — on rates of recurrent falls in older adults at 6–12 months. ED-initiated interventions reduced recurrent falls by approximately 20–25% in older adults identified as high-risk, representing a significant public health benefit given the frequency of fall-related ED presentations.

The NICE falls in older adults guideline (NG127) already recommends structured falls risk assessment in the ED. This meta-analysis supports active implementation of brief ED-based interventions (medication review targeting high-fall-risk medications such as alpha-blockers, first-generation antihistamines, and opioids) alongside referral to community falls services. Simply completing a falls risk assessment without an associated intervention plan is insufficient.

CHAPTER 6

Airway, Respiratory & Ventilation

MARCH · VL vs DL · RSI Agents · Bronchiolitis · CAP · Pleural Infection

The MARCH trial is the defining airway story of Q2 2026 — stop carbocisteine and hypertonic saline in ventilated patients. Beyond this, video laryngoscopy consolidates its primacy for emergency intubation, the ketamine vs etomidate debate is largely settled (no mortality difference), and important data emerge on RSI neuromuscular blockade, bronchiolitis management, and CAP corticosteroids.

NEJM · ISSUE 18 · 25 JUNE 2026 — N=1956

MARCH RCT — Carbocisteine and Hypertonic Saline for Acute Respiratory Failure: No Benefit, Significant Harm

CHANGE THIS MONTH FRCEM

The MARCH trial (NEJM, n=1956) enrolled mechanically ventilated patients with acute respiratory failure, randomising in a factorial design to carbocisteine vs placebo and hypertonic saline (HTS) vs isotonic saline nebulisation. The primary outcome was duration of mechanical ventilation; neither intervention reduced this.

Carbocisteine: GI bleed RR 6.51 vs placebo · HTS: bronchoconstriction RR 5.73, hypoxia RR 13.29

The magnitude of harm from HTS is striking: patients receiving nebulised hypertonic saline were over 13 times more likely to develop hypoxia episodes requiring escalated ventilator support. Carbocisteine caused clinically and statistically significant gastrointestinal haemorrhage. No clinically important subgroup showed benefit from either intervention. Both drugs are commonly used in UK ICUs and EDs for secretion management in ventilated patients.

Stop carbocisteine in all ventilated patients. Stop hypertonic saline nebulisation in ventilated patients. Both cause serious harm without benefit. Exceptions for evidence-based HTS use in non-ventilated bronchiolitis (established evidence) are not affected by MARCH — which enrolled only mechanically ventilated adults.

ISSUE 5 · APRIL 2026

BMJ Airway Review — Video Laryngoscopy Over Direct Laryngoscopy for RSI

INFORMING PRACTICE FRCEM

This BMJ state-of-the-art review on airway management in adults (PMID 41951238, Issue 15) and the associated Issue 5 VL evidence synthesis confirmed video laryngoscopy (VL) as the preferred modality for emergency RSI across all patient subgroups, including those with anticipated difficult airways and those with cervical spine immobilisation. First-pass success rates with VL exceed direct laryngoscopy (DL) by 5–10 percentage points across multiple systematic reviews, and the benefit is amplified in out-of-hospital and resource-limited settings.

The review highlighted that VL does not eliminate the need for DL competency — VL failure rates are non-zero, and providers must maintain DL skills. The evidence does not support routinely using an intubating LMA (iLMA) over VL as a primary device; VL should be first-line with iLMA reserved for cannot-intubate situations. Bougie use with VL or DL should be standard in all emergency departments.

Standard emergency airway: video laryngoscope + bougie, with a pre-planned difficult airway algorithm including iLMA, surgical airway capability, and a named role for each team member. Ensure VL is available and charged at all times in your resuscitation bay.

NEJM 2026 (PMID 41369227) · ISSUE 13

Ketamine vs Etomidate RSI — No Mortality Difference; Ketamine: More CV Collapse

INFORMING PRACTICE FRCEM

This large NEJM RCT directly compared ketamine versus etomidate as RSI induction agents in critically ill patients (n=1800+). 90-day mortality was identical between groups, settling the question of whether etomidate's theoretical cortisol suppression translates to measurable patient harm — it does not at the population level.

Ketamine: significantly more cardiovascular collapse events during RSI vs etomidate

Etomidate had a small adrenal suppression signal on cortisol assays, consistent with its known pharmacology, but this did not translate to worse vasopressor requirements, shock duration, or mortality. Ketamine caused cardiovascular collapse (significant hypotension requiring resuscitation) more frequently than etomidate in critically ill patients — the opposite of the common teaching that ketamine "preserves haemodynamics." In shocked patients with pre-existing catecholamine depletion, ketamine may unmask cardiovascular instability.

For haemodynamically stable patients: ketamine or etomidate — both acceptable. For haemodynamically compromised patients (MAP <65, vasopressors running, or clinical shock): etomidate is the safer induction agent. Use ketamine with caution in critically ill patients with pre-existing CV compromise.

ISSUE 4 · APRIL 2026

PROMINE Trial — Propofol vs Ketamine for RSI in Critically Ill Patients

INFORMING PRACTICE

The PROMINE trial compared propofol versus ketamine for RSI induction in critically ill patients admitted to ICU or requiring emergency intubation. The trial found no significant difference in 28-day mortality between agents, but propofol was associated with significantly more post-induction hypotension (SBP <90 within 10 minutes of induction) compared to ketamine. Intubation conditions (Cormack-Lehane grade, first-pass success) were similar between groups.

Propofol has multiple desirable properties for RSI — excellent sedation depth, rapid offset, bronchodilation — but its cardiovascular depression profile makes it a poor choice in haemodynamically compromised patients. PROMINE confirms that ketamine is the safer haemodynamic choice versus propofol specifically. Combined with ketamine-vs-etomidate data, the hierarchy in haemodynamically compromised patients becomes: etomidate > ketamine >> propofol.

ISSUE 6 · APRIL 2026 — 14,072 PATIENTS

NMBAs for Critical Care Intubation — SR/MA: OR 2.72 for First-Pass Success

INFORMING PRACTICE

This systematic review and meta-analysis of 14,072 critical care intubations examined the effect of neuromuscular blocking agents (NMBAs) on first-pass intubation success, adverse events, and outcomes. Use of NMBAs was associated with OR 2.72 for first-pass success compared to induction without NMBAs, with significantly fewer failed intubations, intubation-related adverse events, and oesophageal intubations.

NMBA use: OR 2.72 for first-pass success in emergency intubation (14,072 patients)

This large-scale data reinforces that all emergency RSI should include an NMBA unless a specific contraindication exists. Succinylcholine (suxamethonium) and rocuronium at 1.2mg/kg both achieve adequate intubating conditions; the paediatric data from Issue 4 (Sux vs Roc) showing a mortality signal favouring succinylcholine applies specifically to paediatric RSI. In adults, choice between agents should be guided by contraindications (hyperkalaemia, burns, malignant hyperthermia risk for suxamethonium; rocuronium allergy for rocuronium).

ISSUE 4 · APRIL 2026 — UK RCT, 15 NHS PICUS

BESS Trial — Surfactant Does NOT Reduce Ventilation Duration in Severe Bronchiolitis

INFORMING PRACTICE PAEDS

The BESS trial enrolled ventilated infants with severe RSV bronchiolitis across 15 UK NHS PICUs, randomising to exogenous surfactant versus standard care. Duration of mechanical ventilation — the primary outcome — was not reduced by surfactant therapy, with no significant difference in any secondary outcome including PICU LOS, oxygen requirement, or complications.

Surfactant use in bronchiolitis has been an area of clinical uncertainty for over a decade. BESS, as a UK multicentre RCT, definitively answers the question for ventilated infants: do not use surfactant. Standard supportive care (appropriate PEEP, minimal sedation, lung-protective ventilation) remains the management framework. This is consistent with the broader evidence that bronchiolitis management should be supportive rather than interventional, avoiding unnecessary treatments.

Do not use surfactant in mechanically ventilated infants with bronchiolitis. This is now definitively answered by a UK multicentre RCT.

ISSUE 9 · APRIL 2026

Dexamethasone Single vs Two-Dose in Paediatric Asthma Exacerbation

INFORMING PRACTICE PAEDS

This RCT compared a single dose of oral dexamethasone versus a two-day course in paediatric asthma exacerbation in the ED, examining return visits, relapse rates, and parental satisfaction. A single dose of dexamethasone was non-inferior to two doses on primary outcomes of return visit within 7 days and relapse requiring further treatment.

Single-dose dexamethasone simplifies prescribing and reduces steroid exposure — both clinically and practically advantageous in ED settings. Current UK BTS/SIGN guidance already endorses single-dose dexamethasone (0.15mg/kg, max 10mg) for mild-moderate acute asthma in children. This RCT adds further confidence in the single-dose approach and suggests there is no benefit from extending to two days in most paediatric asthma presentations.

Paediatric asthma: single-dose oral dexamethasone 0.15mg/kg (max 10mg) is preferred over prednisolone 1mg/kg for 3 days. Better tolerability, equal efficacy, simpler regimen.

ISSUE 10 · APRIL 2026

REMAP-CAP CAP Corticosteroids — Hydrocortisone Signals Potential Harm in Severe CAP

INFORMING PRACTICE

This interim analysis from the REMAP-CAP adaptive platform trial examining hydrocortisone in severe community-acquired pneumonia (CAP) requiring ICU admission found a potential harm signal for hydrocortisone versus standard care, with the posterior probability of harm exceeding the prespecified threshold for clinical concern. The platform suspended the hydrocortisone arm pending further analysis.

This contradicts some prior smaller trials and meta-analyses suggesting steroid benefit in severe CAP. The REMAP-CAP finding — from a large adaptive platform designed specifically for signal detection — should prompt caution with corticosteroid use in severe CAP. Steroids remain indicated for CAP with septic shock requiring vasopressors (where the benefit is attributable to shock management rather than pneumonia treatment per se) but should not be routinely added to antibiotic therapy in CAP without shock.

Do not routinely add corticosteroids to antibiotic therapy in severe CAP. The REMAP-CAP harm signal affects hydrocortisone specifically in the ICU CAP population. Corticosteroids remain appropriate in CAP with concomitant septic shock as part of vasopressor-support therapy.

ISSUES 17/18 · JUNE 2026

2025 ATS/IDSA CAP Guideline Updates — Emergency Medicine Perspective

GUIDELINE UPDATE

The 2025 ATS/IDSA CAP guidelines (discussed in the context of the Issue 17 newsletter) update antibiotic regimen recommendations for outpatient, ward, and ICU-level CAP. Key EM-relevant changes include: narrowed indications for combination therapy with respiratory fluoroquinolone (reserved for ICU-level CAP or patients with specific comorbidities), de-emphasis of atypical coverage in mild-moderate CAP with low pre-test probability of Legionella/Mycoplasma, and antibiotic stewardship emphasis on duration (5 days for mild-moderate CAP without complications).

The guidelines reinforce that procalcitonin-guided antibiotic de-escalation is evidence-supported in hospitalised CAP, reducing antibiotic duration without increasing treatment failure rates. UK emergency physicians treating community-acquired pneumonia should be aware that a 5-day course of amoxicillin (or co-amoxiclav for moderate CAP) is appropriate for most presentations, with extended courses reserved for Legionella, empyema, or cavitating disease.

ISSUE 17 · JUNE 2026

SCOPE RCT — Saline Lavage vs Intrapleural Enzyme Therapy in Pleural Infection

INFORMING PRACTICE

The SCOPE RCT compared thoracoscopic saline lavage versus intrapleural enzyme therapy (DNase + tPA) as initial management for parapneumonic empyema. Saline lavage at thoracoscopy achieved better 3-month drainage outcomes (fewer residual collections, lower rates of repeat procedure) compared to intrapleural enzyme therapy, with similar safety profiles.

Intrapleural enzyme therapy (DNase + tPA, the MIST2 regimen) has been widely adopted in UK practice for loculated pleural infections. SCOPE data suggests that where thoracoscopic lavage is available, it is preferable. For EDs managing acute pleural infection, the first decision remains whether to use image-guided chest drain insertion or arrange thoracoscopy — SCOPE informs the latter decision but does not change initial ED drain placement for acute empyema.

ISSUE 17 · JUNE 2026

Guideline-Discordant Bronchiolitis Care in Community EDs

GUIDELINE UPDATE PAEDS

A national audit of bronchiolitis care in community EDs identified persistent guideline-discordant practice: 34% of infants with bronchiolitis in community EDs received nebulised adrenaline or salbutamol (both not recommended in NICE NG9), 28% received antibiotics without bacterial indication, and only 62% had documented nasogastric feeding consideration for infants with feeding difficulties.

The NICE NG9 bronchiolitis guideline explicitly states: no bronchodilators, no antibiotics (unless bacterial co-infection), no steroids, no physiotherapy as routine. Management is supportive: oxygen if SpO2 <92%, NG tube if feeding <50–70% normal, apnoea monitoring for infants under 2 months. The audit data suggests a significant implementation gap, particularly in smaller units. Regular bronchiolitis guideline education and integrated pathway prompts are recommended.

Bronchiolitis: no salbutamol, no adrenaline, no antibiotics, no steroids, no physiotherapy unless specifically indicated. Supportive care is the evidence-based management. Non-adherence exposes infants to treatment side effects without benefit.

ISSUE 17 · JUNE 2026

Dexamethasone for Acute Wheeze in Children — Adrenal Suppression Risk Commentary

INFORMING PRACTICE PAEDS

A pharmacovigilance commentary and case series raised awareness of adrenal suppression and steroid-induced hyperglycaemia following repeat dexamethasone courses for paediatric wheeze/asthma exacerbation, particularly in children receiving frequent ED visits within 4–6 week periods. The long half-life of dexamethasone (18–36 hours, vs 12–36 hours for prednisolone) means cumulative exposure from multiple courses can be more pronounced than equivalent prednisolone dosing.

The commentary does not suggest abandoning single-dose dexamethasone — the evidence for efficacy is strong. Rather, it advocates for careful documentation of total steroid exposure across ED visits, consideration of written steroid action plans to prevent repeated self-administration, and awareness that children with frequent admissions for wheeze should have inhaled corticosteroid therapy reviewed rather than repeated oral steroid courses without underlying treatment optimisation.

ISSUE 4 · APRIL 2026

Succinylcholine vs Rocuronium in Paediatric RSI — Mortality Signal Favours Succinylcholine

INFORMING PRACTICE PAEDS

This large retrospective cohort of paediatric RSI cases compared succinylcholine and rocuronium as the neuromuscular blocking agent, finding a mortality signal favouring succinylcholine on multivariate analysis. First-pass intubation success was similar between agents; the mortality difference was observed in the subset of critically ill children with haemodynamic instability.

A potential mechanism is that succinylcholine's ultra-short duration (4–8 minutes) allows faster return of spontaneous respiration if intubation fails — a critical advantage in children where bag-mask ventilation is the rescue technique. Rocuronium at 1.2mg/kg produces prolonged paralysis (60–90 minutes) that cannot be promptly reversed without sugammadex. UK paediatric RSI protocols should ensure sugammadex is co-drawn whenever rocuronium is used in children, and succinylcholine should be first-choice when the airway appears potentially difficult.

In paediatric RSI: if using rocuronium, always have sugammadex drawn and labelled (16mg/kg for immediate reversal). Consider succinylcholine as first choice in anticipated difficult paediatric airways.

ISSUE 15 · JUNE 2026 — CJEM 2026

Ketamine for Suicidal Ideation in Paediatric ED — Pilot RCT

INFORMING PRACTICE PAEDS

This pilot RCT examined sub-anaesthetic IV ketamine (0.5mg/kg over 40 minutes) versus placebo for acute suicidal ideation in adolescents aged 13–17 presenting to a paediatric emergency department. The trial demonstrated rapid and significant reduction in suicidal ideation scores at 4 hours in the ketamine arm, with no serious adverse events and acceptable tolerability in the pilot sample.

Sub-anaesthetic ketamine is established in adult psychiatry for treatment-resistant depression, but paediatric ED application is novel and this pilot should be considered hypothesis-generating only. UK paediatric mental health pathways focus on crisis assessment and inpatient referral for acute suicidality; ketamine is not an approved treatment for adolescent suicidal ideation. Further large RCT replication is required before any practice change. The study is nonetheless relevant to the growing body of evidence supporting ketamine's role in psychiatric emergencies.

CHAPTER 7

Trauma & Musculoskeletal

SWiFT RCT · Rib Fractures · CRAFFT Fractures · Pericardiocentesis · High-Pressure Injury

Q2 2026 saw SWiFT definitively settle the prehospital whole blood question for UK HEMS — component therapy remains standard. Rib fracture analgesia evidence continued to mature, with serratus anterior plane blocks now studied in ED-performed RCTs. CRAFFT showed cast-first is safe for paediatric distal radius fractures, reducing operative rates without compromising outcomes.

NEJM 2026 (PMID 41841706) · ISSUES 7/12 — N=616, 10 UK HEMS SERVICES

SWiFT RCT — Prehospital Whole Blood vs Components in UK Trauma: No Survival Difference

CHANGE THIS MONTH

SWiFT (Scottish and Welsh integrated Field Transfusion) enrolled 616 major trauma patients across 10 UK HEMS services, randomising to prehospital whole blood versus component therapy (packed red cells + fresh frozen plasma). The primary outcome was 24-hour mortality; secondary outcomes included 30-day survival, massive transfusion rates, and complications.

24-hour mortality: no significant difference between whole blood and component therapy

SWiFT is the definitive UK data answering whether whole blood should replace the existing HEMS component transfusion standard. It does not. The trial confirms that current UK HEMS practice — component-based prehospital transfusion — is safe and effective. There is no evidence to support replacing component packs with whole blood in UK pre-hospital trauma systems. This outcome contrasts with some US military experience where whole blood showed benefit, likely reflecting different patient populations, injury patterns, and transfusion logistics.

UK HEMS: maintain component-based transfusion protocols. Do not switch to whole blood based on overseas data — SWiFT directly tests the UK HEMS scenario and shows no benefit from whole blood.

ACAD EMERG MED 2026 · ISSUE 18 — N=38 RCT

Serratus Anterior Plane Block for Rib Fractures — EP-Performed RCT

INFORMING PRACTICE

This ED-based RCT examined serratus anterior plane (SAP) block performed by emergency physicians versus systemic analgesia for unilateral rib fractures (2–6 ribs). SAP block achieved significantly greater pain reduction at 30 and 60 minutes (NRS reduction 3.2 vs 1.4, p<0.001), reduced opioid requirements over 24 hours, and improved incentive spirometry values — all clinically meaningful outcomes in a population at high risk of respiratory complications.

Pain reduction at 60 min: NRS −3.2 SAP block vs −1.4 systemic analgesia (p<0.001)

The SAP block targets the serratus anterior plane at the mid-axillary line at the level of the fractures, depositing local anaesthetic beneath the serratus anterior fascia to achieve segmental chest wall analgesia. It is technically accessible to emergency physicians trained in regional anaesthesia and requires ultrasound guidance. The safety profile was excellent — no pneumothorax, haematoma, or significant adverse event in 38 patients. This adds to the growing evidence for ED-performed regional anaesthesia in rib fractures.

Consider SAP block or erector spinae plane (ESP) block for rib fractures in the ED — both achievable by trained EP and provide superior analgesia to systemic opioids. Reduce opioid requirements and improve respiratory function in at-risk patients.

ISSUES 4/11 · APRIL–MAY 2026 — 738 PATIENTS NMA

Single-Shot Regional Anaesthesia for Rib Fractures — Network Meta-Analysis

INFORMING PRACTICE

This network meta-analysis of 738 patients compared erector spinae plane (ESP) block, paravertebral block (PVB), serratus anterior plane (SAP) block, intercostal nerve block (ICNB), epidural, and systemic analgesia for rib fracture pain management. ESP block and PVB ranked highest for pain reduction at 24 hours and were associated with lowest opioid consumption. SAP block ranked slightly lower but still superior to systemic analgesia alone.

ESP block and PVB: highest ranked for rib fracture pain at 24 hours (NMA, 738 patients)

ESP block has largely supplanted PVB in emergency and acute care settings due to its more accessible deep-posterior approach and lower risk of pneumothorax compared to PVB. The NMA data supports a regional anaesthesia-first approach for rib fractures requiring admission, with systemic analgesia as an adjunct rather than primary treatment. For isolated anterior rib fractures, SAP block offers an excellent anterior approach option.

LANCET 2026 · ISSUE 13

CRAFFT RCT — Cast-First for Paediatric Distal Radius Fractures

INFORMING PRACTICE PAEDS

The CRAFFT trial randomised children with displaced distal radius fractures (angulation 10–30°) to immediate cast reduction versus operative fixation. Cast-first management was non-inferior on the primary functional outcome (PRWE score) at 12 months, with significantly fewer operative complications, lower total NHS costs, and higher family preference scores for the cast group.

Cast-first: non-inferior on 12-month function · Fewer complications · Lower cost

Approximately 20% of cast-first patients required secondary operative fixation, but the majority achieved acceptable outcomes without surgery. This applies to fractures in the 10–30° displacement range in children under 15 — it does not apply to severely displaced fractures, open fractures, or fractures with neurovascular compromise. CRAFFT supports UK practice in many departments where cast management is already first-line, but provides high-quality RCT evidence for those departments where operative fixation is performed more liberally.

Paediatric distal radius fracture (10–30° angulation): cast reduction is the evidence-based first-line treatment. Discuss operative fixation only if cast reduction fails to achieve acceptable position or if family preference strongly favours surgery after informed discussion.

ISSUE 13 · MAY 2026 (PMID 41760498) — 25 CASES

Pericardiocentesis + Intrapericardial TXA — 25-Case Series for Penetrating Cardiac Tamponade

INFORMING PRACTICE

This case series of 25 patients with penetrating cardiac tamponade described a novel technique: pericardiocentesis followed by instillation of intrapericardial tranexamic acid (TXA) to reduce reaccumulation of haemopericardium. In 23 of 25 patients, this technique achieved haemodynamic stabilisation sufficient to allow transfer to theatre for definitive repair, avoiding emergency thoracotomy in the ED or prehospital setting.

The technique is experimental and this small series does not constitute sufficient evidence to change standard practice. Emergency thoracotomy remains the definitive intervention for traumatic cardiac tamponade with arrest or impending arrest. However, in settings where emergency thoracotomy capability is not immediately available (community EDs, patient transfer scenarios), pericardiocentesis provides temporary decompression — and intrapericardial TXA may extend the window before reaccumulation. This should be discussed with regional trauma centre teams and incorporated into protocols only after appropriate training and governance.

ISSUES 2/7 (NEJM 2026) · N=616

SWiFT Trial — Full Publication Summary

INFORMING PRACTICE

The full SWiFT publication in NEJM detailed secondary outcomes beyond 24-hour mortality: 30-day survival rates, hospital LOS, massive transfusion protocol activation rates, and transfusion-related complications were all equivalent between whole blood and component therapy arms. Subgroup analyses including mechanism of injury, ISS strata, and time to intervention did not identify any group that derived benefit from whole blood over components.

The logistical challenges of maintaining prehospital whole blood (cold chain, ABO compatibility in field settings, short shelf life without additives) mean that even marginal equivalence with components would not justify a wholesale switch. SWiFT demonstrates that the UK's established component-based system — utilising type-O packed cells and FFP — is evidence-based and does not need to change.

ISSUE 9 · APRIL 2026

Aneurysmal Subarachnoid Haemorrhage — High Risk, Low Incidence: ED Recognition

INFORMING PRACTICE FRCEM

This high-risk, low-incidence disease review focused on aneurysmal SAH (aSAH) recognition in the ED, emphasising the "thunderclap headache" as the primary clinical flag and updating the evidence for LP vs CT angiography as the primary investigation pathway after a normal non-contrast CT. The review endorses the Ottawa SAH Rule as a validated tool for selecting patients for further investigation.

CTA of the head and Circle of Willis has largely superseded LP for SAH investigation in centres with rapid CTA access: sensitivity >98% for aneurysm detection when CT is performed <6 hours from onset. LP remains necessary when CT is negative and CTA is unavailable or when xanthochromia confirmation is required for medicolegal documentation. The review emphasises that a normal CT does not exclude aSAH — it rules out gross subarachnoid blood but misses small-volume bleeds in 2–5% of cases in the first 6 hours, and does not exclude unruptured aneurysm (sentinel headache).

Thunderclap headache (worst headache of life, maximal at onset): always investigate for SAH regardless of neurological examination, even if the patient appears well. Do not rely on clinical gestalt alone.

ISSUE 10 · APRIL 2026

High-Pressure Injection Injury — Surgical Emergency

INFORMING PRACTICE FRCEM

This high-risk, low-incidence review highlighted high-pressure injection injury as a time-critical surgical emergency frequently underappreciated in the ED. Substances injected under high pressure (paint, solvent, grease, hydraulic fluid) cause extensive deep tissue necrosis through mechanical injury and chemical toxicity, despite an often deceptively benign superficial wound appearance at presentation.

Amputation rate: up to 50–60% if surgical exploration delayed >6 hours from injury

Key recognition points: any high-pressure tool injury to the hand (even with a "pin-prick" entry wound) requires immediate hand surgery referral and cannot be managed with simple wound closure and discharge. Pain is often disproportionate to appearance. Oil-based substances (paint thinner, hydraulic oil) carry higher amputation rates than grease or water. Do not administer local anaesthetic before surgery — this may mask progression of compartment syndrome.

High-pressure injection injury: emergency surgical referral regardless of wound appearance. Do not suture, do not inject local anaesthetic, do not delay. Call plastics/hand surgery immediately.

ISSUE 9 · APRIL 2026

Lisfranc Injury — ED Recognition and Management

INFORMING PRACTICE FRCEM

This high-risk, low-incidence review addressed Lisfranc injury (tarsometatarsal ligamentous disruption), which is misdiagnosed in the ED in up to 20% of cases. The classic mechanism is axial loading on a plantarflexed foot (fall, dashboard injury) or forced abduction of the forefoot. Subtle radiographic signs include diastasis between first and second metatarsals >2mm, avulsion fragment at the Lisfranc ligament attachment, and interruption of the medial second metatarsal-middle cuneiform alignment.

Misdiagnosis rate in ED: up to 20%; missed Lisfranc leads to chronic instability and arthrosis

Weight-bearing X-rays (where clinically possible) dramatically improve sensitivity compared to non-weight-bearing views, as the diastasis may only be apparent under load. MRI is the gold standard when plain films are equivocal and Lisfranc injury is clinically suspected. All confirmed Lisfranc injuries require orthopaedic referral — no weight bearing and orthopaedic review within 24–48 hours.

ISSUE 15 · JUNE 2026

Transfusion Thresholds in High-Risk Surgical Patients — TOP Trial/MINT Analysis

INFORMING PRACTICE

The TOP trial and MINT analysis examined transfusion thresholds in high-risk post-surgical patients with cardiac comorbidities (ischaemic heart disease, heart failure). A liberal transfusion threshold (Hb 100 g/L trigger) was associated with better outcomes than a restrictive threshold (Hb 80 g/L) in this specific population, contrasting with the general evidence base supporting restrictive transfusion strategies in most patients.

Cardiac comorbidity patients: liberal threshold (Hb <100 trigger) superior to restrictive in post-surgical setting

This has nuanced implications for ED management of post-operative patients with known cardiac disease presenting with blood loss or anaemia. While the evidence generally supports a Hb 70–80 g/L transfusion threshold in most ED presentations, this should be individualised to Hb 90–100 g/L in patients with active myocardial ischaemia, known severe LV dysfunction, or recent cardiac surgery. Clinical signs of end-organ hypoperfusion should always take precedence over Hb threshold alone.

ISSUE 18 · JUNE 2026

Paediatric Trauma Score + Lactate for Compound Injuries — AUC 0.936

INFORMING PRACTICE PAEDS

This prospective study (Eur J Pediatr 2026) examined combining Paediatric Trauma Score (PTS) with lactate for early prediction of severe outcome in paediatric compound injuries (multiple injuries with suspected internal or vascular damage). The combined PTS + lactate model achieved an AUC of 0.936 for predicting ICU admission and significant morbidity, outperforming either tool alone.

Lactate ≥4.0 mmol/L combined with PTS <8 identified a high-risk group requiring immediate trauma team activation and definitive surgical assessment. Point-of-care lactate is routinely available in UK EDs; its combination with clinical scoring improves stratification accuracy in paediatric trauma. This supports incorporating lactate into paediatric major trauma assessment protocols alongside clinical scoring systems.

ISSUE 18 · JUNE 2026

Initial Management of Severely Injured Paediatric Trauma in Non-Paediatric EDs

INFORMING PRACTICE PAEDS

This J Trauma 2026 consensus statement addressed management of severely injured children (ISS >15) in non-paediatric EDs — the majority of UK district general hospitals. Key recommendations: activate trauma team regardless of age, use paediatric fluid resuscitation principles (not adult protocols), target MAP 60–70 mmHg rather than adult 65–75 mmHg in shock, use weight-based dosing for all drugs, and arrange urgent transfer to a paediatric major trauma centre if the child is haemodynamically unstable.

The paper highlighted that non-paediatric EDs should have laminated paediatric drug dosing cards, Broselow tape or equivalent, and at least one clinician with Advanced Paediatric Life Support (APLS) competency available 24/7. Transfer decisions should be made early — the window for safe transfer narrows rapidly in the seriously injured child. UK major trauma networks already have paediatric bypass protocols; these should be known to all ED staff.

ISSUE 6 · APRIL 2026

AI Ambient Scribe in ED — Noise Degradation and Omission Risk

INFORMING PRACTICE

This study examined AI ambient documentation systems in emergency departments, specifically testing transcription accuracy as a function of background noise levels and speaker-to-microphone distance. Transcription omissions (missed clinical content, including drug doses and clinical decisions) became the primary failure mode at distances exceeding 2 metres and in environments with background noise above 65dB — typical of busy resuscitation bays.

AI ambient documentation is being piloted in several UK NHS trusts. This data suggests that ambient scribes should not be relied upon in high-noise resuscitation settings without manual verification. For stable ambulatory bay consultations, the error rate at close range (<1m) was acceptably low. Clinical staff should review AI-generated notes before signing, particularly for drug doses, allergy documentation, and safety-netting instructions. AI documentation can supplement but does not replace deliberate clinical note-taking in high-acuity situations.

CHAPTER 8

Cardiovascular

LEGEND Trial · NICE HTG779 · Troponin Assays · IHCA/NSTEMI · CLOSURE-AF

Q2 2026 cardiovascular evidence centres on diagnostic optimisation. The LEGEND trial showed hs-Troponin LoD reduces ED LOS by 3.6 hours. A novel hs-TnT assay provides earlier MI rule-out. NICE approved AI-assisted echocardiography for heart failure. IHCA during NSTEMI is better served by early angiography, and CLOSURE-AF closes the door on left atrial appendage closure as a stroke prevention strategy.

ANN EMERG MED · ISSUE 5

LEGEND Trial — hs-Troponin Limit of Detection Reduces ED LOS by 3.6 Hours

INFORMING PRACTICE

The LEGEND trial examined implementation of high-sensitivity troponin limit of detection (LoD) — the very lowest measurable value, typically 1–2 ng/L — as the rule-out threshold in a 0/1-hour pathway, compared to the standard 0/3-hour pathway using higher cut-offs. Using LoD as the rule-out threshold reduced ED LOS by 3.6 hours for patients who were ultimately discharged without ACS, without any increase in 30-day MACE rates.

ED LOS reduction: 3.6 hours with hs-Trop LoD vs standard threshold pathway

This is clinically significant in the context of UK corridor care data — reducing unnecessary 3-hour observation slots for low-risk chest pain by using the LoD approach could meaningfully free department capacity. The 0-hour LoD rule-out requires both troponin values below the LoD AND a non-ischaemic ECG AND absence of high-risk features. It is not a standalone test result. Implementation requires laboratory validation of the specific LoD for your institution's hs-Trop assay — not all assays have equivalent LoD values.

Discuss with your local laboratory whether hs-Trop LoD is validated for your assay. If so, consider implementing a 0-hour LoD rule-out pathway for very low pre-test probability chest pain alongside standard 0/1-hour and 0/3-hour pathways.

JAMA CARDIOL 2026 · ISSUE 11

Novel High-Sensitivity Troponin T Assay for Early MI Rule-Out

INFORMING PRACTICE

A novel hs-TnT assay with improved analytical sensitivity was validated for early MI rule-out in the ED, achieving 99.4% NPV at the 0-hour time point with a limit of detection of 2 ng/L. This compares to the current ESC-validated pathway which uses a two-point 0/1-hour or 0/2-hour algorithm. The novel assay would, if validated in prospective outcome studies, enable rapid single-sample rule-out in selected patients.

Point-of-care hs-Troponin platforms are being evaluated in UK ambulances and walk-in centres, potentially enabling triage of chest pain before ED attendance. The analytical improvements in next-generation assays must be balanced against the clinical reality that troponin rise is a dynamic process and a single very-early sample may miss developing MI in patients who present immediately after symptom onset. Clinical risk stratification (HEART score, EDACS) remains essential alongside any troponin measurement.

NICE HTG779 · ISSUE 13

NICE HTG779 — AI-Assisted Echocardiography for Heart Failure Diagnosis

CHANGE THIS MONTH

NICE approved AI-assisted echocardiography (HTG779) for heart failure diagnosis and LVEF assessment, endorsing the use of AI-augmented echo analysis in clinical practice where validated systems are available. The recommendation covers AI tools that improve LVEF measurement accuracy, automate chamber quantification, and flag abnormal diastolic function patterns — tasks that are operator-dependent with standard echocardiography.

For emergency medicine, AI-assisted echo has potential application in undifferentiated dyspnoea assessment and rapid quantification of LV function at the bedside, reducing reliance on formal echo wait times. NICE endorsement means commissioners should assess adoption pathways. It does not mandate immediate implementation but creates the pathway for NHS trusts to procure validated AI echo platforms. Emergency clinicians performing POCUS for LV function assessment may benefit from AI augmentation in reducing inter-observer variability.

ISSUE 9 · APRIL 2026

IHCA in NSTEMI — Early Angiography Protective

INFORMING PRACTICE

This large registry study examined outcomes in patients who suffered in-hospital cardiac arrest (IHCA) in the context of NSTEMI, comparing outcomes with early coronary angiography (within 24 hours of arrest) versus standard NSTEMI pathway (within 72 hours). Early angiography was independently associated with improved survival to hospital discharge and favourable neurological outcome, even after adjustment for VF as the arrest rhythm.

The RCUK 2025 guidelines clarified that post-ROSC coronary angiography is not mandatory for all OHCA patients without STEMI — but this registry data suggests that IHCA occurring in the context of an evolving NSTEMI may represent a subgroup that benefits from early rather than delayed angiography. Discuss with your cardiology team: IHCA + NSTEMI + haemodynamic instability is a scenario where early rather than standard-pathway cath lab access may be appropriate.

ISSUE 5 · APRIL 2026

CLOSURE-AF — Left Atrial Appendage Closure Not Non-Inferior to Medical Therapy in AF

INFORMING PRACTICE

CLOSURE-AF (NEJM) randomised AF patients with contraindications to long-term anticoagulation to left atrial appendage closure (LAAC, Watchman device) versus continued suboptimal medical therapy. LAAC failed to demonstrate non-inferiority to medical therapy for the composite endpoint of stroke, systemic embolism, and death — a surprising negative result given the mechanistic rationale.

This has limited direct implications for emergency medicine, but is relevant when managing AF patients presenting to ED who mention they "can't take anticoagulants" and have a Watchman device in situ. CLOSURE-AF does not mean Watchman devices are useless — the patient population and endpoint choice influenced the result — but it significantly tempers the enthusiasm for LAAC as a routine alternative to anticoagulation. For ED management of acute AF, anticoagulation decisions should follow standard CHA2DS2-VASc assessment, with cardiology input for patients with complex anticoagulation histories.

ISSUE 16 · JUNE 2026

Modified HEART Score with eGFR for ACS Rule-Out

INFORMING PRACTICE

This prospective validation study added eGFR as a modifier to the HEART score for ACS risk stratification, finding that patients with eGFR <60 had significantly higher 30-day MACE rates at equivalent HEART score values compared to patients with normal renal function. Incorporating eGFR as a risk modifier improved the c-statistic of the HEART score from 0.82 to 0.87 in the CKD subgroup.

CKD is an independent cardiovascular risk factor that confounds biomarker interpretation — troponin is cleared renally, and both false-positive elevations and attenuated rise kinetics are more common in CKD. The modified HEART-eGFR score is not yet externally validated for routine use, but the data supports applying heightened caution to CKD patients with even borderline troponin elevations, particularly in the context of HEART score 4–6 (intermediate risk). Consider cardiology review for all CKD patients with any troponin rise.

ISSUE 6 · APRIL 2026

NICE HTG777 — Transvenous Embolisation for Spontaneous Intracranial Hypotension

CHANGE THIS MONTH

NICE approved transvenous embolisation (TV embolisation) as a therapeutic option for spontaneous intracranial hypotension (SIH) — a condition caused by spontaneous CSF leaks, characterised by orthostatic headache and often misdiagnosed as tension headache or SAH in the ED. TV embolisation targets epidural venous plexus drainage to reduce CSF pressure loss, with initial case series showing significant headache resolution rates.

SIH presents with positional headache (worse standing, better lying) — the reverse of raised ICP headaches. Key ED recognition: orthostatic headache + subdural hygroma on CT + slit ventricles = investigate for CSF leak. LP should not be performed acutely in suspected SIH. Management includes bed rest, caffeine, and neurosurgical/neuroradiology referral for epidural blood patch or TV embolisation. NICE approval creates the pathway for this intervention in NHS specialist centres.

Suspect SIH in patients with orthostatic headache — headache worse standing, resolves lying down. Do not perform LP acutely. Refer to neurology/neuroradiology for CT myelography and blood patch assessment.

ISSUE 11 · MAY 2026

Penicillin Allergy Direct Oral Challenge — 97% Tolerance Rate (iNAAN)

INFORMING PRACTICE

The iNAAN study and associated penicillin allergy de-labelling literature confirm that 97% of patients with a documented penicillin allergy label can tolerate direct oral amoxicillin challenge without allergic reaction. The majority of penicillin allergy labels in UK NHS records are based on adverse drug reactions from childhood that represent intolerance, viral rash co-incidence, or mislabelled reactions rather than true IgE-mediated allergy.

97% of patients with penicillin allergy label: tolerate direct oral challenge

Penicillin allergy labels lead to use of second-line antibiotics (fluoroquinolones, clindamycin) that carry higher rates of CDI, treatment failure, and antimicrobial resistance. UK NHS England has a national penicillin allergy de-labelling programme. Emergency physicians should document allergy severity details when taking an allergy history and refer patients with low-risk allergy labels for formal de-labelling. In the ED, if the documented allergy is "rash as a child" without anaphylaxis, senior clinician-directed amoxicillin use may be appropriate after individualised risk-benefit assessment.

CHAPTER 9

Paediatric Emergency Medicine

No OUCH · IV Bolus Mortality · Nirsevimab · Concussion · Ketamine Sedation · Mental Health

Paediatric EM saw major trial data in Q2 2026. No OUCH (JAMA) establishes ibuprofen alone as first-line for paediatric MSK pain — opioids not routinely needed. Paediatric bolus fluids and mortality data (OR 20.5 for bolus >55ml/kg) should fundamentally reshape resuscitation practice. Nirsevimab delivers a 59% reduction in RSV hospitalisations in real-world data. Knife crime fatalities in children rise.

JAMA 2026 (PMID 41505155) · ISSUE 12

No OUCH RCT — Ibuprofen Alone for Paediatric MSK Pain: Non-Inferior to Ibuprofen + Morphine

CHANGE THIS MONTH PAEDS FRCEM

The No OUCH trial randomised children with acute musculoskeletal pain (fractures, soft tissue injuries, joint pain) to ibuprofen alone versus ibuprofen plus oral morphine, examining pain scores at 60 minutes as the primary outcome. Ibuprofen alone was non-inferior to the combination for pain reduction at 60 minutes, with no clinically meaningful difference in secondary outcomes including pain at 4 hours, return visits, or patient/parent satisfaction.

Pain at 60 min: no significant difference ibuprofen alone vs ibuprofen + morphine (non-inferiority met)

Children in the morphine arm experienced significantly more adverse effects including nausea, vomiting, and sedation. The trial covered the majority of paediatric ED MSK presentations across the severity range, using validated paediatric pain scales with standard ibuprofen dosing (10mg/kg up to 400mg). This is a direct and clinically applicable finding: adding oral morphine to ibuprofen for children with MSK pain is unnecessary, increases adverse effects, and should not be routine practice.

Paediatric MSK pain: ibuprofen 10mg/kg (max 400mg) is the evidence-based first-line agent. Do not routinely add opioids. Consider opioids only for severe refractory pain not controlled by adequate NSAID dosing plus non-pharmacological measures.

ADC 2026 · ISSUE 18 — N=5352

Paediatric IV Bolus Fluids and In-Hospital Mortality — OR 20.5 for Bolus >55ml/kg

INFORMING PRACTICE PAEDS FRCEM

This large cohort of 5,352 children examined the association between cumulative IV fluid bolus volume and in-hospital mortality in paediatric critical illness. The magnitude of association for bolus >55ml/kg versus <15ml/kg was striking at OR 20.5 (95% CI 8.0–52.5), with a clear dose-response relationship across five bolus-volume quintiles.

Bolus >55ml/kg vs <15ml/kg: OR 20.5 (95% CI 8.0–52.5) for in-hospital mortality

This is observational data and confounding by indication (sicker children receive more fluid) is a real concern. However, the FEAST trial (which showed IV bolus harm in African children with febrile illness) and ANDROMEDA-SHOCK-2 (showing benefit of fluid restriction in sepsis) provide convergent mechanistic support. In UK paediatric ED practice, the prudent interpretation is: give small boluses (10–20ml/kg), reassess after each bolus for response and adverse effects, and escalate to vasopressors before reaching high cumulative fluid volumes.

Give paediatric fluid boluses in 10–20ml/kg increments. Reassess after each bolus. Avoid cumulative volumes >40ml/kg without clear clinical indication and vasopressor consideration. This applies to sepsis, DKA (where cerebral oedema risk makes fluid restriction even more critical), and other paediatric shock states.

ISSUE 17 · JUNE 2026

Nirsevimab Real-World Data — 59% Reduction in RSV Bronchiolitis Hospitalisations

INFORMING PRACTICE PAEDS

Real-world data from the 2024–25 RSV season, following the JCVI-approved national nirsevimab programme for infants, demonstrated a 59% reduction in RSV bronchiolitis hospitalisations in the vaccinated cohort compared to pre-programme baseline and matched controls. Nirsevimab (Beyfortus) is a monoclonal antibody providing passive immunity for the first RSV season of life, now offered to all infants born from 1 September 2024.

59% reduction in RSV bronchiolitis hospitalisations in nirsevimab-protected infants

Emergency physicians and paediatric clinicians should be aware of the nirsevimab programme when assessing infants with respiratory illness — a history of nirsevimab administration reduces (but does not eliminate) the probability of RSV as the causative agent. Children who did not receive nirsevimab (born before programme start, early arrival for Sept babies) remain fully susceptible. The programme represents one of the most impactful paediatric preventive interventions in a generation, with bronchiolitis being the leading cause of infant hospitalisation in the UK.

ISSUES 5/11 · APRIL–MAY 2026

Paediatric Concussion — Rational Clinical Examination (JAMA SR)

INFORMING PRACTICE PAEDS

This JAMA Rational Clinical Examination systematic review evaluated the diagnostic accuracy of individual clinical features for paediatric concussion diagnosis. Loss of consciousness (LR+ 3.4), post-traumatic amnesia (LR+ 2.8), and headache (LR+ 1.6) were the strongest positive predictors, while the absence of all three substantially reduced the post-test probability of concussion. The PECARN concussion tool remained the best-validated decision aid for CT imaging decisions.

The review also evaluated return-to-learn and return-to-sport protocols, confirming that staged return protocols are associated with lower rates of prolonged post-concussion syndrome compared to premature return to activity. For ED management, the key actions are: document detailed symptom assessment using a validated tool (ACE, SCAT6), provide written information on concussion recognition and red flags, arrange GP/paediatrician follow-up within 48 hours, and advise no school return until asymptomatic at rest.

Paediatric concussion ED discharge: provide written post-concussion information, advise complete cognitive and physical rest for 24–48 hours, and arrange follow-up within 48 hours. No "it's just a knock" — formal documentation and follow-up are essential.

ISSUES 9/13 · APRIL–MAY 2026

Non-Injectable Ketamine for Paediatric Sedation — SR/MA (Acad Emerg Med)

INFORMING PRACTICE PAEDS

This systematic review and meta-analysis examined non-injectable ketamine formulations (intranasal, oral, buccal, nebulised) for paediatric procedural sedation in the ED. Intranasal ketamine at 3–9mg/kg achieved adequate sedation in 75–85% of cases for minor procedures (laceration repair, IV cannulation, brief orthopaedic procedures), with an onset time of 10–15 minutes and acceptable recovery profiles.

Non-injectable ketamine is particularly valuable in the paediatric ED for reducing the burden of IV access — facilitating the very procedure that makes IV sedation difficult in distressed or vein-challenged children. Intranasal administration using a mucosal atomisation device (MAD) is the preferred route. Emergence reactions occur in 5–10% (compared to 10–15% with IV ketamine) and are managed with standard supportive care. Monitoring requirements are identical to IV sedation: continuous SpO2, HR, capnography where available, and trained recovery nurse.

ISSUE 9 · APRIL 2026 — NCMD/EMJ

Knife Crime Fatalities in Children in England 2019–2024

INFORMING PRACTICE PAEDS

This National Child Mortality Database (NCMD) and Emergency Medicine Journal analysis examined knife crime fatalities in children and young people aged 5–17 in England between 2019 and 2024. Fatalities increased by 34% over the study period, with the majority of deaths occurring in young males aged 15–17, predominantly in urban areas, from penetrating thoracic or abdominal injuries.

Almost all knife crime fatalities reaching hospital alive had prehospital on-scene times contributing to outcome — emphasising the importance of HEMS response and rapid police/paramedic REBOA availability in urban settings. For ED teams, penetrating injury in adolescents should prompt highest-level trauma activation; the "walking wounded" presentation with a stab wound to the thorax or abdomen can decompensate rapidly. UK emergency departments in high-prevalence areas should have rehearsed penetrating trauma protocols.

Adolescent stabbing victim: treat as major trauma regardless of apparent initial stability. Tachycardia, anxiety, and tachypnoea in a stab wound victim represent compensated haemorrhagic shock until proven otherwise. Activate trauma team immediately.

ISSUES 9/10 · APRIL 2026

BRUE SR/MA — Infant Outcomes, Risk Factors, Diagnostic Yield (JAMA Pediatr)

INFORMING PRACTICE PAEDS

This systematic review and meta-analysis of Brief Resolved Unexplained Events (BRUE) in infants examined diagnostic yield of investigations, risk factors for serious underlying pathology, and outcomes. Serious underlying diagnoses were found in only 3% of low-risk BRUE (meeting AAP low-risk criteria: age >60 days, gestation >32 weeks, first event, duration <1 minute, no CPR by trained provider, no concerning features). ECG was the highest-yield single investigation (identifying prolonged QTc in 1.2% of low-risk BRUE).

Serious diagnosis in low-risk BRUE: 3% · Highest yield investigation: ECG (1.2% QTc prolongation)

The AAP 2016 BRUE guideline recommends ECG and brief ED observation as sufficient for low-risk BRUE, without the extensive battery of investigations historically performed. This SR/MA validates that approach — extensive investigation in low-risk BRUE yields little and increases parental anxiety. High-risk features (first event, age <60 days, prematurity, concerning mechanism) require admission and broader investigation including metabolic screen, imaging, and respiratory monitoring.

ISSUE 6 · APRIL 2026

Paediatric Blunt Abdominal Trauma — PECARN Deferred CT Reduces Imaging

INFORMING PRACTICE PAEDS

This study examined application of the PECARN blunt abdominal trauma decision rule in a paediatric ED, comparing rates of abdominal CT in standard practice versus PECARN-guided deferred imaging strategy. PECARN-guided management reduced CT rates by 20.5% (37.1% standard vs 20.5% PECARN), without any missed clinically important intraabdominal injuries in the deferred imaging group at 7-day follow-up.

CT reduction: 37.1% standard vs 20.5% PECARN-guided (CT avoided in 37% more patients)

The PECARN blunt abdominal trauma rule identifies children at very low risk of intraabdominal injury who do not need immediate CT: no evidence of abdominal wall trauma, GCS 14–15, no abdominal tenderness, no thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, no vomiting. Children meeting all low-risk criteria can be observed rather than scanned. UK paediatric MTC centres are increasingly adopting PECARN-guided observation pathways.

ISSUE 6 · APRIL 2026

BENEFICIAL Trial — Model-Informed Precision Vancomycin Dosing in Children (Lancet CAH, RCT)

INFORMING PRACTICE PAEDS

The BENEFICIAL RCT examined model-informed precision dosing (MIPD) of vancomycin in critically ill children versus standard weight-based dosing, comparing AUC/MIC target attainment rates and nephrotoxicity. MIPD achieved target AUC/MIC (400–600 mg·h/L) in significantly more children (78% vs 49%) with significantly lower rates of vancomycin-associated nephrotoxicity (6% vs 18%).

Target AUC/MIC attainment: 78% MIPD vs 49% standard dosing · Nephrotoxicity: 6% vs 18%

Vancomycin AUC-guided dosing (rather than trough-guided dosing) is already endorsed in adult ID guidelines. BENEFICIAL provides the first RCT evidence for MIPD superiority in children. For UK paediatric EDs, the implication is to involve clinical pharmacology or microbiology in vancomycin dosing decisions in critically ill children, particularly those with renal impairment or severe infection requiring prolonged courses.

ISSUE 17 · JUNE 2026

Early vs Delayed Opioids for Paediatric Sickle Cell VOC — SR/MA: No Difference in Outcomes

INFORMING PRACTICE PAEDS

This systematic review and meta-analysis compared early (within 30 minutes of ED arrival) versus delayed opioid administration for paediatric sickle cell vaso-occlusive crisis (VOC), finding no significant difference in hospital admission rates, length of stay, or 30-day readmission. Both groups had equivalent pain control at 4 hours.

This finding should not be misread as support for delaying opioids in VOC — rather, it suggests that with appropriate non-opioid analgesia initiated rapidly (ibuprofen, intranasal fentanyl, patient-owned opioid analgesia already in use at home), the timing of first IV opioid may be less critical than previously assumed. Sickle cell disease is a high-frequency ED diagnosis with well-established analgesic protocols; the emphasis should be on total analgesia burden optimised from triage, not sequential opioid-first escalation.

ISSUE 17 · JUNE 2026

PET/CT in Paediatric Fever of Unknown Origin (n=112)

INFORMING PRACTICE PAEDS

This prospective study of 112 children with fever of unknown origin (FUO: fever >38.5°C for >2 weeks without diagnosis despite standard workup) examined the diagnostic utility of PET/CT. PET/CT identified a diagnosis in 62% of cases where standard workup including CT, MRI, and bone marrow was unrevealing, with inflammatory/rheumatological conditions (JIA, systemic vasculitis) and occult infection (osteomyelitis, endocarditis) accounting for the majority of diagnoses.

PET/CT is not an ED investigation, but the study has relevance for emergency physicians who manage children with prolonged undifferentiated febrile illness. Knowing that PET/CT has high diagnostic yield in this population supports early specialist referral (paediatric infectious disease or rheumatology) after initial ED evaluation rather than repeated empirical treatment. FUO in a child should prompt expedited outpatient specialist workup — rarely is the ED able to establish a cause, but ensuring safe discharge with appropriate follow-up is the key ED contribution.

ISSUE 10 · APRIL 2026

Topical Betamethasone for Paediatric Phimosis — 68% Resolution (n=235)

INFORMING PRACTICE PAEDS

This cohort study of 235 boys with physiological phimosis treated with topical betamethasone 0.05% cream twice daily for 8 weeks demonstrated 68% resolution rate (complete preputial retraction) with an additional 18% showing partial improvement, giving an overall response rate of 86%. No significant side effects were observed at this dose and duration.

Physiological phimosis is extremely common in pre-pubertal boys and is a frequent cause of parental anxiety and ED attendance, often after a failed attempted retraction causing balanitis or minor tears. Emergency physicians should advise that physiological phimosis is normal until adolescence, does not require emergency intervention, and can be managed with topical steroid cream prescribed by the GP. Circumcision referral should be reserved for true pathological phimosis (lichen sclerosus, recurrent balanitis, voiding obstruction) not responding to topical therapy.

ISSUE 15 · JUNE 2026 — PEDIATRICS (PMID 42070784)

Maternal RSV Vaccination vs Infant Nirsevimab — Interim RCT Data

INFORMING PRACTICE PAEDS

This interim RCT compared maternal RSV vaccination (Abrysvo, given at 32–36 weeks gestation) versus infant nirsevimab at birth, and a combination arm, on rates of RSV lower respiratory tract infection in the first 6 months of life. Both interventions reduced RSV LRTI compared to placebo; the combination arm showed additive but not synergistic protection. Nirsevimab appeared to provide marginally higher protection in the first 3 months of life compared to maternal vaccination alone.

The NHS currently offers nirsevimab through the infant immunisation programme rather than maternal vaccination. This interim data does not suggest the maternal vaccine programme is inferior — the UK decided on nirsevimab for logistical and equity reasons (ensuring all infants receive protection regardless of maternal uptake). The combination approach showed no safety concerns and is the focus of ongoing analysis to determine whether dual-strategy implementation is warranted.

ADC 2026 · ISSUE 18

Risk Mitigation for Paediatric Mental Health Crisis in Acute Paediatric Care — 16 Strategies

INFORMING PRACTICE PAEDS

This consensus document (ADC 2026) described 16 evidence-informed risk mitigation strategies for managing paediatric mental health crises in acute paediatric care settings, addressing the growing challenge of prolonged ED waits for children with acute psychiatric presentations. Strategies included structured safe-space protocols, liaison psychiatry availability benchmarks, parental support frameworks, safeguarding integration, and environmental modifications to reduce self-harm risk during ED boarding.

Paediatric mental health presentations account for a growing proportion of paediatric ED workload. The 2026 RCEM Mental Health QIP data (Issue 12) showed 48.6% of mental health presentations required observation or de-escalation space. The ADC strategies are directly actionable at department level: establish a designated safe space, ensure liaison psychiatry is accessible within 4 hours for CAMHS referrals, provide parents with clear written information about the wait, and conduct regular environmental safety checks for ligature risks.

ISSUE 12 · MAY 2026

Fast MRI vs CT for Paediatric Neurological Emergencies

INFORMING PRACTICE PAEDS

This Pediatrics 2026 study compared fast MRI protocols (5–10 minutes, no sedation) versus CT for common paediatric neurological emergencies including suspected VP shunt malfunction, hydrocephalus assessment, and first seizure workup. Fast MRI was equivalent or superior to CT for all these indications, with complete avoidance of ionising radiation and no sedation requirement in the majority of children.

Fast MRI: equivalent sensitivity to CT for shunt malfunction, hydrocephalus, and first seizure — no ionising radiation

Fast (rapid-sequence) MRI protocols are increasingly available in UK paediatric centres with 24/7 MRI access. They allow clinicians to answer the clinical question (is the ventricle dilated? is there an acute lesion?) without exposing the child to cumulative radiation from serial CTs. For emergency departments with on-site MRI, establishing a fast-MRI protocol for neurological emergencies in children is the recommended next step.

CHAPTER 10

Infectious Disease & Outbreak

Measles · MenB · Ebola Bundibugyo · Hantavirus MV Hondius · Mpox · iGAS

Q2 2026 was the most demanding quarter for infectious disease vigilance in UK emergency medicine since the COVID-19 pandemic. Measles re-emerged as a genuine public health emergency. England was struck by a novel Hantavirus cluster from a cruise ship. Ebola Bundibugyo triggered a WHO PHEIC with mandatory ED triage screening. Multiple MenB clusters required urgent vaccination responses.

UKHSA · ISSUES 16/17/18 · JUNE 2026

UKHSA Measles — 801 Confirmed Cases, 2 Child Deaths, England Loses WHO Elimination Status

CHANGE TONIGHT FRCEM

By 25 June 2026, UKHSA had confirmed 801 measles cases across England, representing the largest outbreak since UK measles elimination status was achieved in 2016. Two child deaths were attributed directly to measles-related encephalitis and pneumonitis. England formally lost WHO measles elimination status in June 2026 — a significant public health milestone reflecting a decade of declining MMR uptake.

801 confirmed cases · 2 child deaths · England loses WHO elimination status · All regions affected

MMR uptake has fallen to a decade-low, with first-dose coverage at 91.6% (below the 95% herd immunity threshold) and second-dose coverage at 84.5% nationally. Urban areas, particularly London, have coverage as low as 70%. Cases are concentrated in unvaccinated children under 10 and unvaccinated adults aged 20–35 who missed vaccination during the 1990s Wakefield controversy fallout.

ED action from triage: all febrile children with rash should be isolated immediately and considered for measles. Apply airborne precautions (FFP3 mask, negative pressure room if available). Take travel and vaccination history. Notify public health HPT immediately for any suspected case. Do not wait for laboratory confirmation to isolate.

ED staff should check their own MMR status — any clinician born between 1970 and 1994 may have incomplete vaccination. Confirm two doses via occupational health if uncertain. Measles is highly contagious (R0 12–18) and an unvaccinated clinician in an ED can sustain a nosocomial outbreak.

UKHSA · ISSUE 15 (WHO PHEIC) · JUNE 2026

UKHSA URGENT: Ebola Bundibugyo — WHO PHEIC Declared; ED Triage Screen Required

CHANGE TONIGHT

The WHO declared a Public Health Emergency of International Concern (PHEIC) for Ebola Bundibugyo strain in June 2026, following an outbreak in East-Central Africa. UKHSA elevated the UK importation risk assessment and mandated ED triage screening for any patient with recent travel to affected regions combined with fever, haemorrhagic symptoms, or unexplained severe illness.

Bundibugyo ebolavirus (BDBV) is one of six Ebola species and has historically had lower case fatality (30–40%) compared to Zaire Ebola (60–90%), but is fully capable of human-to-human transmission via direct contact with body fluids. UK HCID units at RNOH/GSTT, Royal Victoria, and Royal Free are on heightened alert. All EDs should have an active UKHSA contact number and a current HCID referral protocol visible in the resuscitation area.

Ebola triage screen: any patient with travel to affected Sub-Saharan African regions in the past 21 days + fever + haemorrhagic features (bleeding, ecchymosis, unexplained bruising) must be isolated immediately in a single room with standard HCID PPE (FFP3 + apron + gloves + eye protection). Call UKHSA on the national emergency line. Do not conduct standard investigations until HCID team advises.

UKHSA · ISSUES 12/13 · MAY 2026

UKHSA Hantavirus MV Hondius — 3 Deaths, 11 Cases, HCID Unit at GSTT

CHANGE TONIGHT

An outbreak of Hantavirus haemorrhagic fever was identified in passengers from the cruise ship MV Hondius following a voyage through rodent-endemic environments in South America. By Issue 13, 11 confirmed cases had been identified in UK returnees, with 3 deaths attributed to Hantavirus Pulmonary Syndrome or Haemorrhagic Fever with Renal Syndrome (HFRS). GSTT HCID unit was activated to manage the cluster.

MV Hondius cluster: 11 cases · 3 deaths · HCID unit activated at GSTT

Hantavirus is transmitted by rodent excreta (urine, faeces, saliva) — not human-to-human transmission. It is not a person-to-person contact hazard in most cases, though HCID precautions are maintained pending species confirmation. Clinical features: febrile illness followed by pulmonary oedema (Hantavirus Pulmonary Syndrome) or renal failure (HFRS). Incubation 1–8 weeks. Any patient with MV Hondius travel history + unexplained fever + respiratory or renal deterioration should trigger urgent UKHSA consultation.

If a patient presents with fever + respiratory or renal illness + recent MV Hondius travel history: isolate and contact UKHSA. Standard infection control precautions are appropriate — Hantavirus does not spread person-to-person, but the diagnosis must be confirmed through UKHSA pathways.

UKHSA · ISSUE 5 · APRIL 2026

UKHSA Mpox Clade Ib — UK Importation Risk Elevated to HIGH (45 Cases)

CHANGE TONIGHT

UKHSA elevated the UK Mpox Clade Ib importation risk to HIGH in April 2026, following identification of 45 imported cases across European countries and multiple UK returnees from Central and East Africa. Clade Ib is the more transmissible and pathogenic clade than Clade IIb (which drove the 2022 global outbreak) and has a higher case fatality rate (approximately 3–5% in immunocompetent adults).

Clinical features of Clade Ib Mpox include systemic illness (fever, lymphadenopathy, myalgia) followed by distinctive vesiculopustular rash in centrifugal distribution, including palms and soles. Sexual transmission is documented but respiratory droplet transmission is also reported for Clade Ib. UK contact tracing should include household contacts not just sexual contacts. Tecovirimat (TPOXX) is available through UKHSA for confirmed severe cases.

Suspect Mpox: fever + rash (vesicular/pustular) + travel to Central/East Africa or contact with confirmed case. Isolate, apply contact + droplet precautions, notify UKHSA. Do not attempt vesicle sampling without PPE and UKHSA guidance.

UKHSA · ISSUES 4/12/13 · APRIL–MAY 2026

MenB Clusters — Canterbury (21 Cases, 2 Deaths) and Dorset/Kent

CHANGE TONIGHT

Two separate MenB clusters were managed across Q2 2026. The Canterbury cluster (21 cases, 2 deaths) was initially classified as a major incident before being downgraded to a standard incident after the incidence curve flattened. A second cluster in Dorset and Kent involved multiple cases across student populations, leading to reactive vaccination campaigns and the announcement of the UK university vaccination programme opening 20 July 2026.

Canterbury: 21 cases, 2 deaths · Dorset/Kent: additional cluster, student population

The UK childhood MenB vaccination programme (Bexsero) protects infants from 8 weeks but does not currently include adolescents or adults. The university vaccination programme (Bexsero for all first-year university students) targets the highest-risk demographic for meningococcal disease outside infancy. ED clinicians must remain vigilant for IMD features: non-blanching rash, meningism, photophobia, severe headache, altered consciousness, or high fever + shocked physiology in any age group. Benzylpenicillin 2.4g IV (adult) or ceftriaxone should be given immediately without waiting for LP results.

Any suspected meningococcal disease: IV benzylpenicillin or ceftriaxone immediately — do not delay for LP or CT. Notify HPT immediately. Time to antibiotics is the most important prognostic factor.

UKHSA · ISSUE 4 · APRIL 2026

UKHSA Legionnaires' Disease Outbreak — NW and SW London

CHANGE TONIGHT

A Legionnaires' disease outbreak was identified in Northwest and Southwest London in April 2026, linked to cooling towers in commercial buildings. UKHSA identified a common-source cluster affecting predominantly male adults aged 50–75 with comorbidities. Clinical features: community-acquired pneumonia with associated hyponatraemia, confusion, and marked diarrhoea — features distinguishing Legionella from typical CAP.

The key ED implication is clinical recognition: Legionella should be considered in all severe CAP presentations in the affected geographic areas, particularly in older males with hyponatraemia on bloods. Urinary Legionella antigen (UAG) is the rapid diagnostic test of choice and should be requested alongside standard CAP investigations in any patient with severe CAP during an outbreak period. Treatment: fluoroquinolone (levofloxacin) or macrolide (azithromycin), not beta-lactam alone. Notify PHE if Legionella suspected — mandatory notifiable disease.

UKHSA · ISSUES 13/16 · MAY–JUNE 2026

iGAS UK Seasonal Surveillance — Above-Average Incidence Continues

INFORMING PRACTICE

UK invasive Group A Streptococcus (iGAS) incidence remained above seasonal average through Q2 2026, following the surge that began in autumn 2022. Streptococcal toxic shock syndrome, necrotising fasciitis, and streptococcal bacteraemia cases continued at elevated rates across all age groups, with children under 5 and adults over 65 at highest risk of severe disease.

Emergency physicians should maintain heightened awareness of necrotising fasciitis (NF) as a presentation of iGAS: disproportionate pain, pain beyond apparent wound margins, skin changes (erythema, bullae, dusky discolouration) with systemic sepsis. NF is a surgical emergency — early aggressive surgical debridement is the only definitive treatment. The "finger test" at wound margins has limited sensitivity; any clinical suspicion of NF in a septic patient with soft tissue involvement mandates urgent surgical consultation and theatre preparation without CT delay if the patient is haemodynamically unstable.

Necrotising fasciitis: do not delay surgical assessment for CT if the patient is unstable. CT can be performed in theatre preparation if stable. Pain out of proportion to wound + systemic sepsis = NF until proved otherwise. Call surgeons immediately.

ISSUE 9 · APRIL 2026

Zoliflodacin vs Ceftriaxone + Azithromycin for Gonorrhoea — Phase 3 RCT

INFORMING PRACTICE

Zoliflodacin (a novel spiropyrimidinetrione antibiotic) achieved equivalent cure rates to ceftriaxone + azithromycin for uncomplicated gonorrhoea in a Phase 3 international RCT. Zoliflodacin acts on GyrB (DNA gyrase subunit B), a distinct mechanism of action from fluoroquinolones, making it potentially active against ciprofloxacin-resistant N. gonorrhoeae strains.

This is significant given the global trajectory of N. gonorrhoeae antimicrobial resistance: reduced susceptibility to ceftriaxone has been documented in several countries, and azithromycin resistance is widespread. Zoliflodacin represents the first genuinely new class of antibiotic active against gonorrhoea in decades. It is not yet licensed in the UK. Current UK BASHH guidance remains ceftriaxone 1g IM + azithromycin 1g PO for uncomplicated gonorrhoea — or ceftriaxone 500mg IM if test of cure is arranged. Any suspected cephalosporin-resistant gonorrhoea should be referred to GUM urgently.

ISSUE 16 · JUNE 2026 — ONGOING FROM ISSUE 15

Ebola Bundibugyo PHEIC — Ongoing Vigilance Update

CHANGE TONIGHT

The Ebola Bundibugyo PHEIC remained active through the end of Q2 2026 with no resolution in sight. UK EDs must maintain triage screening at all points. UKHSA updated the list of affected regions: all clinicians should check the UKHSA website for the current travel risk map before managing any febrile traveller from Sub-Saharan Africa.

Standard HCID management approach: isolate immediately in a single room, apply enhanced PPE (FFP3, gown, gloves x2, eye protection), call the UKHSA emergency line (0344 338 5745), and await HCID guidance before proceeding with any investigations or treatment. Do not take blood cultures, perform LP, or insert urinary catheter without UKHSA/HCID team direction. Clinical deterioration requiring intubation in a suspected HCID patient should prompt the most senior clinician available and specialist HCID team input.

ISSUE 18 · JUNE 2026

MenB University Vaccination Programme — Opens 20 July 2026

CHANGE TONIGHT

Following the Dorset/Kent MenB clusters, NHS England and JCVI announced a MenB university vaccination programme offering Bexsero to all first-year university students, opening for registration on 20 July 2026 for the September 2026 academic intake. Students who attend university in England can register via their GP or university health centre.

Emergency physicians seeing unvaccinated students presenting with meningococcal-compatible symptoms should be aware of this background. The window between meningococcal exposure and severe disease can be hours; a student who was well at lecture and is in the ED with headache, photophobia, and fever has meningococcal disease until proven otherwise. The new programme will reduce but not eliminate university meningococcal risk; vigilance remains essential for students who have not yet received the vaccine.

ISSUE 16 · JUNE 2026 — 736 YTD

UKHSA Measles Update — 736 Cases YTD at Issue 16, 2 Child Deaths, All Regions

CHANGE TONIGHT

The measles case count at Issue 16 (Week of 11 June 2026) stood at 736 year-to-date, with cases spread across all NHS England regions. By Issue 18 (Week of 25 June), the count reached 801. The UKHSA confirmed both child deaths occurred in children who were unvaccinated and developed measles encephalitis and secondary bacterial pneumonia respectively.

UKHSA issued updated guidance on ED management: all suspected measles patients (Koplik spots, coryza, high fever, generalised maculopapular rash) must be placed in airborne isolation immediately, with all staff attending wearing FFP3 respirators. Nasopharyngeal and throat swabs for measles PCR should be taken within 24 hours of rash onset. Oral fluid testing kits are available via UKHSA for community surveillance. Notify HPT for all suspected cases by telephone the same day — statutory notification.

ISSUES 4/12 · APRIL–MAY 2026

UKHSA Measles Resurgence — MMR Uptake at Decade Low (Issue 4)

CHANGE TONIGHT

The Issue 4 measles alert (April 2026) documented the trajectory: MMR first-dose uptake had fallen from 95.7% in 2012 to 91.6% in 2025, driven by vaccine hesitancy, social media misinformation, and reduced GP access during and after the COVID-19 pandemic. Second-dose coverage (age 5 booster) fell to 84.5% nationally. London coverage in some boroughs had fallen below 70%.

At this coverage level, endemic measles transmission is fully plausible — the outbreak of 2026 reflects this mathematical reality. Emergency physicians play a role in opportunistic vaccination — any unvaccinated or incompletely vaccinated child (or adult born after 1970) attending the ED should have MMR discussed and recommended, with GP referral or direct immunisation service referral if the ED has vaccination capability. Emergency measles vaccination of exposed contacts can be given up to 72 hours post-exposure (live MMR) to prevent or attenuate disease.

CHAPTER 11

POCUS & Diagnostics

Ocular POCUS · AI-FAST · POCUS Dyspnoea RCT · G-FAST Score · Stellate Ganglion Block

Q2 2026 saw POCUS diagnostics advance on multiple fronts. Ocular POCUS for retinal detachment achieves excellent sensitivity and specificity but has an important blind spot for non-vitreoretinal pathology. The POCUS pathway RCT for dyspnoea produced a nuanced finding: POCUS improves diagnostic certainty without consistently changing management. AI-assisted FAST achieves near-expert performance.

J EMERG MED 2026 · ISSUE 18

Ocular POCUS for Retinal Detachment — Sn 93.8%, Sp 93.8%, LR+ 15.1, LR− 0.066

INFORMING PRACTICE FRCEM

This prospective validation study examined emergency physician-performed ocular POCUS for retinal detachment in patients presenting with acute visual symptoms (flashes, floaters, acute visual loss). Against ophthalmology referral and dilated fundoscopy as the gold standard, ocular POCUS achieved sensitivity 93.8% and specificity 93.8%.

Sn 93.8% · Sp 93.8% · LR+ 15.1 · LR− 0.066 · Moderate agreement with ophthalmology κ=0.48

The LR+ of 15.1 means a positive ocular POCUS finding convincingly raises the post-test probability of retinal detachment, justifying urgent ophthalmology referral without waiting for formal fundoscopy. The LR− of 0.066 allows reasonable exclusion of retinal detachment when the scan is clearly negative. However, there is a critical caveat: non-vitreoretinal pathology (retinal artery occlusion, optic neuritis, acute glaucoma, macular pathology) had a sensitivity of only 13.3% on ocular POCUS — essentially undetectable.

Ocular POCUS is excellent for retinal detachment (the echogenic, undulating membrane sign in the vitreous). It does NOT exclude other causes of acute visual loss. All patients with acute visual symptoms require ophthalmology review regardless of ocular POCUS findings.

ISSUE 16 · JUNE 2026 (PMID 41870288)

POCUS Pathway for ED Dyspnoea RCT — Improved Certainty Without Management Change

INFORMING PRACTICE

This RCT randomised dyspnoeic ED patients to a structured POCUS pathway (cardiac, lung, IVC assessment) versus standard assessment with clinical examination and chest X-ray. POCUS significantly improved clinician diagnostic certainty scores at 1 hour — clinicians felt more confident in their diagnosis. However, this improved certainty did not translate into statistically significant differences in management decisions or patient outcomes.

Diagnostic certainty: significantly higher with POCUS pathway vs standard assessment

The finding is nuanced rather than negative for POCUS. Diagnostic certainty has independent value — it reduces unnecessary investigation, supports earlier initiation of treatment, and reduces diagnostic doubt-driven delays. The absence of management change may reflect that standard UK assessment (CXR + clinical examination) already identifies the major treatable diagnoses in most dyspnoeic patients. POCUS likely has greatest incremental value in undifferentiated presentations where CXR is non-diagnostic or in patients too unwell for formal imaging.

POCUS for dyspnoea: most valuable in undifferentiated presentations, very unwell patients, or when CXR is non-diagnostic. Consider structured lung + cardiac POCUS as a first-line assessment tool before CXR in haemodynamically unstable dyspnoeic patients.

ISSUE 17 · JUNE 2026 — BMC EMERG MED

AI-Assisted POCUS for FAST in Trauma — Diagnostic SR/MA

INFORMING PRACTICE

This systematic review and meta-analysis examined AI-assisted interpretation of FAST (Focused Assessment with Sonography in Trauma) examination, comparing AI performance versus experienced emergency physician POCUS readers. AI-assisted FAST achieved sensitivity 91% and specificity 95% for haemoperitoneum detection, comparable to experienced EP performance and superior to novice performers.

AI-assisted FAST is particularly relevant in settings where POCUS expertise is limited — rural EDs, community hospitals, nighttime assessments by less experienced clinicians. Current AI FAST tools are primarily software-assisted quality improvement tools rather than fully autonomous systems; they augment clinician interpretation by flagging abnormal findings rather than replacing clinical review. Expect increasing integration of AI POCUS assistance into mobile ultrasound platforms over the next 1–2 years in UK EDs.

EMJ 2026 · ISSUE 10

G-FAST Score SR/MA for LVO Detection — LR+ 2.15, LR− 0.26

INFORMING PRACTICE

This systematic review and meta-analysis evaluated the G-FAST score (Gaze deviation, Facial droop, Arm weakness, Speech/language, Time) as a prehospital and ED screening tool for large vessel occlusion (LVO) stroke. G-FAST had LR+ 2.15 and LR− 0.26, indicating modest but statistically significant diagnostic value as a pre-imaging LVO screen.

A positive G-FAST (particularly gaze deviation, which has the highest LVO likelihood) should increase pre-CTA probability of LVO and support direct transfer to a mechanical thrombectomy-capable centre rather than thrombolysis at the nearest hospital. LR+ 2.15 is not high enough to make independent management decisions on — G-FAST should be used in conjunction with clinical assessment, NIHSS, and triage protocols rather than as a standalone tool. Most UK HASU centres have LVO screening protocols incorporating NIHSS and clinical features.

ISSUE 4 · APRIL 2026

US-Guided Peripheral IV — 80% Improved First-Attempt Success (SR/MA)

INFORMING PRACTICE

This systematic review and meta-analysis of 28 studies and over 4,000 patients demonstrated that ultrasound-guided peripheral IV cannulation improved first-attempt success rate by approximately 80% relative to landmark technique in patients with difficult venous access. Procedure time was longer for US-guided PIVC but total attempts, patient discomfort scores, and escalation to central line were all reduced.

US-guided PIVC is now considered standard of care for patients with predicted or confirmed difficult access. The technique requires only basic POCUS training (short-axis or long-axis vein identification) and a standard linear probe. Investment in departmental training is rapidly recovered in reduced failed cannulation attempts, reduced central line insertions, and reduced time spent managing difficult IV access in acutely unwell patients. Dynamic needle tip visualisation is superior to static guidance — train to see the needle throughout its path.

US-guided PIVC: standard of care for difficult IV access. Two failed attempts with standard technique should trigger US guidance rather than escalation to IO or central line. Most UK ED ultrasound training programmes now include PIVC as a core competency.

ISSUE 6 · APRIL 2026

GFAP + UCH-L1 mTBI Biomarkers — 100% NPV, 31% CT Reduction

INFORMING PRACTICE

This systematic review and meta-analysis examined GFAP (Glial Fibrillary Acidic Protein) and UCH-L1 as serum biomarkers for CT decision-making in mild traumatic brain injury (mTBI/concussion). Combined GFAP + UCH-L1 within 12 hours of injury achieved 100% NPV for intracranial injury on CT (meaning no CT-positive cases were missed in assay-negative patients) while reducing CT scans by 31%.

The FDA-cleared Banyan Brain Trauma Indicator (GFAP + UCH-L1) is approved in the US and increasingly available in European centres. UK clinical adoption is in early stages — NICE has not yet issued guidance on these biomarkers for CT decision-making. Current NICE CG176 (Head Injury) relies on clinical criteria for CT decisions. If these biomarkers achieve NICE approval, they could substantially reduce ED head CT volume while maintaining safety — a significant benefit given radiation exposure in a frequently young population.

ISSUE 16 · JUNE 2026 (PMID 41653848)

AI-Automated POCUS Skill Assessment

INFORMING PRACTICE

This study validated an AI-based automated tool for assessing POCUS technical skill during training, comparing AI skill scores against expert faculty evaluation across 200 scans from novice and experienced practitioners. AI scoring correlated strongly with expert assessment (r=0.89) and could distinguish novice from expert performance with 91% accuracy.

Automated POCUS skill assessment has potential implications for training quality assurance — enabling remote or low-resource training environments to assess competency reliably, and providing formative feedback to learners between supervised sessions. As POCUS becomes a core competency across UK emergency medicine training programmes (RCEMlearning, FCEM curriculum), scalable assessment tools become increasingly relevant.

ISSUE 16 · JUNE 2026 (PMID 41698390)

Stellate Ganglion Block for Electrical Storm

INFORMING PRACTICE

This series of stellate ganglion block (SGB) for refractory electrical storm (ES: three or more sustained VT/VF episodes within 24 hours) described outcomes in 22 patients at two UK tertiary centres. SGB — performed under ultrasound guidance at C6 level, blocking sympathetic innervation to the heart — achieved VT/VF storm suppression in 18/22 cases (82%), with 14 patients surviving to hospital discharge.

Electrical storm is a high-mortality emergency with limited therapeutic options beyond amiodarone, beta-blockade, deep sedation, and anaesthesia. SGB represents an elegant intervention that can be performed in a cardiac catheterisation lab or intensive care setting by a clinician trained in ultrasound-guided regional anaesthesia. The technique is gaining traction in UK centres with POCUS-trained intensivists; emergency physicians should be aware of this intervention as an escalation option and know their local referral pathway for refractory ES.

Electrical storm refractory to amiodarone + beta-blockade: discuss stellate ganglion block with your cardiology/electrophysiology team. If locally unavailable, transfer to tertiary centre with cardiac ablation capability. Do not prolong futile repeated defibrillation without addressing the sympathetic trigger.

ISSUE 17 · JUNE 2026 (PMID 41936304)

US-Guided Truncal Blocks for Tube Thoracostomy Analgesia

INFORMING PRACTICE

This observational study examined ultrasound-guided truncal blocks (serratus anterior plane or intercostal nerve block) for analgesia following tube thoracostomy insertion in the ED. Blocks performed prior to or immediately after drain insertion significantly reduced pain scores at 30 minutes and 2 hours, reduced morphine requirements by 40%, and reduced nausea rates compared to systemic analgesia alone.

Tube thoracostomy is inherently painful, and inadequate analgesia leads to patient distress, respiratory splinting, and under-cooperation with physiotherapy. US-guided truncal blocks take 5–10 minutes to perform with appropriate training and provide consistent 4–6 hour analgesia. This technique is particularly valuable in pneumothorax and haemothorax management where incentive spirometry and deep breathing are essential to outcome. Consider pre-emptive truncal block as standard preparation for chest drain insertion in the ED where the expertise is available.

ISSUE 11 · MAY 2026

Paediatric Abscess I&D — POCUS Improves Volume Prediction

INFORMING PRACTICE PAEDS

This study compared clinical examination alone versus bedside POCUS for pre-procedural assessment of paediatric soft tissue abscesses requiring incision and drainage. POCUS-measured abscess volume more accurately predicted procedural complexity, adequacy of simple I&D versus requirement for formal surgical drainage, and need for wound packing compared to clinical palpation alone.

POCUS assessment of abscess anatomy — depth of fluid collection, presence of surrounding cellulitis, proximity to neurovascular structures — informs the approach to I&D and reduces incomplete drainage. For superficial abscesses in children, POCUS-guided needle aspiration as an alternative to I&D is increasingly used for small collections (<2cm in maximum dimension), reducing the need for sedation or general anaesthesia. Linear probe at 10–15MHz provides optimal resolution for superficial skin and soft tissue collections.

CHAPTER 12

Toxicology, Pharmacology & Pain

Low Back Pain · Cannabinoid Hyperemesis · Methamphetamine · Gabapentinoids · Gonorrhoea

The dominant Q2 2026 toxicology story is the JAMA low back pain review: 90% of LBP is nonspecific, imaging is not indicated for uncomplicated presentations, and bed rest is actively harmful. Beyond this, mirtazapine emerges as the first RCT-supported pharmacotherapy for methamphetamine use disorder, and the evidence against routine gabapentinoids solidifies further.

JAMA 2026 (CASHIN ET AL) · ISSUE 18

Low Back Pain: A Review — 90% Nonspecific; Imaging Not Indicated for Uncomplicated LBP

CHANGE THIS MONTH FRCEM

This comprehensive JAMA review of low back pain management (Cashin et al, 2026) provides the most current evidence synthesis on diagnosis and treatment of acute and chronic LBP. The headline figure remains: approximately 90% of all low back pain is nonspecific (no identifiable structural cause on imaging), with imaging altering management in only a small minority of appropriately selected cases.

90% LBP: nonspecific — imaging does not alter management in the majority of presentations

The review confirms NSAIDs (ibuprofen, naproxen) as first-line pharmacotherapy for acute LBP, with short-course muscle relaxants (diazepam, methocarbamol) as a second-line addition for severe acute spasm. Opioids are not first-line for LBP — they provide modest short-term pain relief with higher addiction risk and equivalent functional outcomes to NSAIDs at 3 months. Bed rest is not recommended and is associated with worse outcomes versus remaining active. For chronic LBP, multidisciplinary rehabilitation including exercise and psychological support is more effective than continued pharmacotherapy.

Do not routinely image uncomplicated acute LBP. Red flags requiring urgent imaging: age >50 with new LBP + night sweats/weight loss (malignancy), saddle anaesthesia/bowel/bladder disturbance (cauda equina), fever + IV drug use (discitis), recent significant trauma. Absent red flags: reassure, NSAIDs, mobilise, no routine X-ray or MRI.

ISSUE 9 · APRIL 2026

Managing Cannabinoid Hyperemesis Syndrome in the ED

INFORMING PRACTICE FRCEM

Cannabinoid hyperemesis syndrome (CHS) is a cyclical vomiting disorder in chronic cannabis users characterised by nausea, vomiting, and abdominal pain temporarily relieved by hot bathing. This narrative review synthesised current evidence for ED management of acute CHS presentations, which are increasing in frequency with the liberalisation of cannabis use and rising potency of products.

Acute CHS treatment: IV haloperidol (5–10mg) or IV droperidol are the most effective antiemetics — significantly superior to ondansetron and metoclopramide. Topical capsaicin cream (0.1%) applied to the abdomen and chest provides rapid symptom relief in many patients through TRPV1 receptor activation, mirroring the hot shower mechanism. Rehydration is necessary; antiemetics beyond haloperidol/droperidol add little. The key ED function is diagnosis (distinguish from cyclic vomiting syndrome, acute abdomen, and other causes), symptom control, and clear cannabis cessation counselling — CHS resolves permanently with cessation.

CHS treatment: IV haloperidol 5mg (first-line antiemetic) + topical capsaicin cream to abdomen + IV rehydration. Arrange GP referral for cannabis cessation support on discharge. Document CHS clearly — future presentations should be managed with the same protocol, avoiding unnecessary investigation.

JAMA PSYCHIATRY 2026 (PMID 41920558) · ISSUE 12

Mirtazapine for Methamphetamine Use Disorder — Phase 2 RCT

INFORMING PRACTICE

This Phase 2 RCT examined mirtazapine (an alpha-2 antagonist and tetracyclic antidepressant) as a pharmacotherapy for methamphetamine use disorder, randomising 120 participants to mirtazapine 30mg nocte versus placebo for 12 weeks. The mirtazapine group showed significantly reduced methamphetamine use (confirmed by urine drug screen), with a greater proportion achieving 3 consecutive weeks of abstinence.

Mirtazapine: first Phase 2 RCT-supported pharmacotherapy for methamphetamine use disorder

Methamphetamine use disorder has no approved pharmacotherapy in the UK, making this finding potentially practice-changing if replicated in Phase 3 trials. Mirtazapine is inexpensive, widely available, and has a well-characterised safety profile. The mechanism in meth use disorder is proposed to involve reduction of catecholamine-driven craving and improved sleep architecture. Emergency physicians managing methamphetamine intoxication or withdrawal should be aware of this emerging evidence and refer patients to addiction services with knowledge of this option.

ISSUE 4 · APRIL 2026

Gabapentinoids — Seldom Help, Often Harm (Narrative Review)

INFORMING PRACTICE

This JournalFeed narrative review synthesised the evidence on gabapentin and pregabalin use in acute and chronic pain management in the ED context, concluding that the analgesic evidence for most indications is weak or absent while harm data — sedation, respiratory depression, abuse potential, increased mortality with concurrent opioids — is substantial. Gabapentinoids have NNTs of 8–14 for neuropathic pain in optimal trial conditions; in real-world mixed pain presentations, the analgesic benefit is even lower.

Critically, gabapentinoid prescribing for acute musculoskeletal pain (back pain, sprains, fractures) is not supported by RCT evidence and is associated with significant harm. UK data shows a 6-fold increase in gabapentinoid prescribing between 2004 and 2018, with concurrent increases in gabapentinoid-associated deaths in combination with opioids. The review recommends against gabapentinoids as routine acute pain agents in the ED, reserving them for confirmed neuropathic pain conditions with specialist oversight.

Do not prescribe gabapentinoids for acute non-neuropathic pain (LBP, sprains, fractures). There is no evidence of benefit and significant evidence of harm, particularly in combination with opioids. Reserve for confirmed neuropathic pain with specialist review.

ISSUE 9 · APRIL 2026

Zoliflodacin vs Ceftriaxone for Gonorrhoea — Phase 3 (Covered in Chapter 10)

INFORMING PRACTICE

The zoliflodacin Phase 3 gonorrhoea RCT (full entry in Chapter 10) has implications for pharmacology: zoliflodacin represents the first new antibiotic class active against N. gonorrhoeae in decades. For ED practice, this is a future therapeutic option rather than a current change — current UK guidance remains ceftriaxone 500–1000mg IM as first-line.

The issue relevant to toxicology is management of potential cephalosporin-resistant gonorrhoea. If a patient has a true cephalosporin allergy or lives in a region with documented ceftriaxone MIC shift, discuss with GUM or microbiology urgently. Do not substitute with oral antibiotics (amoxicillin, doxycycline) without specialist guidance — inadequately treated gonorrhoea leads to PID, epididymo-orchitis, and disseminated gonococcal infection.

ISSUE 9 · APRIL 2026

Buffered Solutions vs 0.9% Saline — Cochrane SR Update 2026

INFORMING PRACTICE

The 2026 Cochrane systematic review update on buffered versus 0.9% saline in critically ill adults confirmed: balanced crystalloids (Plasmalyte, Hartmann's) reduce rates of hyperchloraemic acidosis and are associated with modest (non-significant) reductions in AKI and 90-day mortality compared to 0.9% NaCl. No single large RCT has definitively shown mortality benefit, but the biological plausibility and consistent direction of observational and RCT data support buffered solutions as the preferred crystalloid in the ED and ICU.

For ED use, this means: Hartmann's (Compound Sodium Lactate) for fluid resuscitation in sepsis, trauma, and most acute illness where crystalloid is required. Avoid large volumes of 0.9% NaCl. Exceptions: mild hyperkalaemia (Hartmann's contains 5mmol/L potassium — use 0.9% NaCl in severe hyperkalaemia), and some neurosurgical settings where small volumes of saline are preferred. 0.9% NaCl remains appropriate for drug dilution and small-volume infusions.

ISSUE 10 · APRIL 2026

EMA Recommends Levamisole Withdrawal — Leukoencephalopathy Risk

INFORMING PRACTICE

The European Medicines Agency recommended withdrawal of levamisole from clinical use following an updated safety review identifying levamisole-induced leukoencephalopathy (LILE) as a significant and underrecognised adverse effect in patients treated for nephrotic syndrome and other indications. LILE presents with subacute cognitive decline, ataxia, and white matter lesions on MRI — distinct from infectious or vasculitic causes.

Levamisole is primarily used as a paediatric nephrotic syndrome treatment in some European countries and as a veterinary anthelmintic. Emergency physicians may encounter LILE in patients presenting with new neurological symptoms, particularly children on nephrotic syndrome treatment or adults who have used levamisole-adulterated cocaine (levamisole is commonly used as a cocaine cutting agent in UK heroin supplies, exposing recreational cocaine users to levamisole-induced agranulocytosis and LILE). Any cocaine user presenting with unexplained neutropenia or neurological symptoms should have levamisole exposure considered.

ISSUE 15 · JUNE 2026

Phenobarbital vs Benzodiazepine for Alcohol Withdrawal

INFORMING PRACTICE

This Cureus 2026 meta-analysis compared phenobarbital versus benzodiazepines (diazepam, lorazepam, chlordiazepoxide) for alcohol withdrawal syndrome management in the ED and hospital setting. Phenobarbital was associated with comparable seizure prevention rates, lower rates of ICU admission, and lower rates of delirium tremens compared to standard benzodiazepine protocols in several included studies, particularly in severe withdrawal presentations.

Phenobarbital loading for alcohol withdrawal is already practised in some UK EDs as an alternative for patients who are benzodiazepine-refractory or who have very high CIWA scores requiring large benzodiazepine doses. A single phenobarbital load (10–15mg/kg IV over 30 minutes) can achieve equivalent CNS depression to multiple benzodiazepine doses with more predictable pharmacokinetics. This meta-analysis does not establish phenobarbital as first-line but supports its use as an escalation option or alternative in severe withdrawal. Discuss with your local clinical toxicology or addiction medicine team before protocol implementation.

ISSUE 15 · JUNE 2026

Recreational Drug Use in Children and Adolescents Presenting to EDs

INFORMING PRACTICE PAEDS

This UK-based observational study documented recreational drug presentations by children and adolescents (age 10–17) to paediatric EDs, identifying a significant increase in synthetic cannabinoid (Spice/K2), ketamine, and MDMA presentations over 2023–2026. Presentations with synthetic cannabinoids were associated with disproportionately high rates of seizure, agitation, and cardiac arrhythmia compared to natural cannabis.

Synthetic cannabinoids are not detected by standard urine drug screens — a child presenting with agitation, altered consciousness, or seizure may have synthetic cannabinoid toxicity even with a negative THC screen. Management is supportive: airway protection, benzodiazepines for agitation and seizure, cardiac monitoring. All adolescent drug presentations require safeguarding assessment and CAMHS/addiction referral as appropriate. Reporting to the MHRA Yellow Card system and local drug information network enables public health monitoring.

Synthetic cannabinoid (Spice) toxicity: not detected by standard UDS. Present with agitation, seizure, arrhythmia. Manage with benzodiazepines + supportive care. Safeguarding assessment mandatory for all adolescent drug presentations.

CHAPTER 13

Guidelines, UK Policy & Implementation

NICE NG258 Anaphylaxis · Martha's Rule · RCUK NLSr · GPICS V3 · ITP · NHS 18-week target

Q2 2026 brought important UK guideline changes for emergency clinicians. NICE NG258 now mandates two AAIs at anaphylaxis discharge. Martha's Rule is written into the NHS Standard Contract 2026/27, making it mandatory by March 2027. The RCUK NLSr course launches, and GPICS V3 updates intensive care standards.

NICE NG258 · ISSUE 15 · JUNE 2026

NICE NG258 Anaphylaxis Updated — Two AAIs Mandatory at Discharge

CHANGE THIS MONTH FRCEM

The updated NICE NG258 anaphylaxis guideline mandates prescription of two adrenaline auto-injectors (AAIs) at discharge for all patients presenting with anaphylaxis, replacing the previous single AAI recommendation. The evidence base for dual AAI stems from data showing approximately 30% of biphasic anaphylaxis reactions occurring beyond the first hour of treatment, requiring a second adrenaline dose, and real-world data showing inadequate adrenaline delivery rates with a single AAI (misfiring, inadequate dosing, delayed use).

Two AAIs mandatory at anaphylaxis discharge — NICE NG258 (updated June 2026)

The guideline also includes updated timing for discharge: minimum 2 hours of observation for mild-moderate anaphylaxis; 4–6 hours for severe anaphylaxis or those requiring more than one adrenaline dose; 12–24 hours for biphasic-risk patients (previous anaphylaxis, severe reaction, asthma, unknown trigger). Allergy referral within 6 weeks is recommended for all anaphylaxis discharges. Emergency physicians must document: trigger if identified, number of adrenaline doses given, discharge AAI devices provided, and allergy letter submitted.

Update your ED anaphylaxis discharge proforma and drug chart immediately: prescribe TWO AAIs at discharge (Emerade, EpiPen, or Jext as locally available). Ensure nurses and pharmacists are aware of the guideline change. Document referral to allergy services.

NHS STANDARD CONTRACT 2026/27 · ISSUES 5/12

Martha's Rule — Mandatory in All NHS Trusts by March 2027

GUIDELINE UPDATE

The NHS Standard Contract 2026/27 enshrined Martha's Rule as a mandatory requirement for all NHS Trusts, with full implementation required by March 2027. Martha's Rule provides patients and their families with a mechanism to escalate concerns about clinical deterioration independently of the treating team, accessing a rapid review by a senior clinician not involved in their care.

18-month data: 12,301 calls · 81% of deteriorating patients not flagged by standard EWS alone

The 18-month national data (Issue 12) showed 12,301 Martha's Rule calls since implementation, with 81% of patients flagged by family/patient call showing clinical deterioration not captured by NEWS2 or equivalent early warning scores. This is a powerful validation of the rule's purpose: standard EWS misses the majority of patients whom families recognise as deteriorating. Emergency departments are both users of Martha's Rule (for in-patients in resus or short-stay areas) and contributors — clinicians must be trained to explain the rule, facilitate rapid escalation, and respond within the mandated timeframe.

All NHS Trust staff must understand Martha's Rule: what it is, how families access it, and what the response obligation is. If your Trust does not yet have a functional Martha's Rule pathway, the March 2027 deadline is a governance and contractual obligation.

RCUK · ISSUE 16 · JUNE 2026

RCUK NLSr (Newborn Life Support Recertification) Course — Launches July 2026

GUIDELINE UPDATE

The Resuscitation Council UK launched the new Newborn Life Support Recertification (NLSr) course from July 2026, reflecting updates to the RCUK 2025 neonatal resuscitation guidelines. Key changes incorporated into NLSr include: updated initial assessment sequence for the newborn, revised threshold for positive pressure ventilation initiation, updated guidance on cord clamping in the context of NLS, and revised drug dosing for neonatal adrenaline.

The NLSr course is designed as a shorter, competency-focused recertification pathway for clinicians who have previously completed the full NLS course. Target audience includes emergency physicians who manage unexpected deliveries in the ED — a rare but genuinely high-stakes scenario requiring confident skills. UK emergency departments should ensure at least two NLS-current providers are available per shift in departments with any maternity co-location or high-risk obstetric population.

FICM/ICS · ISSUE 4 · APRIL 2026

FICM/ICS GPICS V3 — 3rd Edition in Active Implementation

INFORMING PRACTICE

The Faculty of Intensive Care Medicine and Intensive Care Society published GPICS (Guidelines for the Provision of Intensive Care Services) Version 3 in early 2026, now in active NHS implementation. Relevant ED-interface changes include: updated ICU-to-ED communication standards for deteriorating ward patients, updated ED observation unit standards for short-stay critical care patients, revised multidisciplinary team composition requirements for Level 2 care, and updated family communication standards aligned with Martha's Rule.

GPICS V3 also introduces enhanced standards for early rehabilitation in the ICU (aligned with the iRehab UK RCT findings) and updated post-ICU psychological support pathways. Emergency physicians working in departments with co-located Level 2 areas (HDU-equivalent ED beds) should review the GPICS V3 staffing and monitoring standards applicable to their setting.

MCMASTER/BLOOD ADVANCES · ISSUE 11

ITP Critical Bleeding Guideline — Immediate Interventions

GUIDELINE UPDATE

The McMaster-led ITP critical bleeding guideline (Blood Advances 2026) updated the approach to life-threatening bleeding in immune thrombocytopenic purpura (ITP). Recommended immediate interventions include: IV methylprednisolone 1g/day for 3 days (or dexamethasone 40mg/day), IV immunoglobulin (IVIg) 1g/kg as a rapid platelet-count-raising strategy (effect within 24–48 hours), platelet transfusion at higher-than-standard doses (3–4 adult therapeutic doses) for critical bleeding, and romiplostim or eltrombopag consideration for refractory cases.

The guideline emphasises that ITP platelet transfusions, while less effective than in thrombocytopenic states from platelet production failure, can provide temporary haemostasis in critical bleeding — the transfused platelets are consumed rapidly but may create a window for definitive treatment. Emergency physicians should contact haematology immediately for any ITP patient with ICH, severe GI bleeding, or bleeding into a critical site.

ITP + critical bleeding: immediate IVIg 1g/kg + methylprednisolone 1g IV + platelet transfusion (high dose, 3–4 adult therapeutic doses) + emergency haematology review. Do not withhold platelets in life-threatening bleeding solely because the patient has ITP.

ISSUE 12 · MAY 2026

NHS 18-Week Referral-to-Treatment Target Achieved

INFORMING PRACTICE

NHS England reported achievement of the 18-week referral-to-treatment (RTT) target for the first time since 2016, with 92.1% of patients waiting less than 18 weeks for elective treatment. This milestone, achieved through the NHS Elective Recovery Programme and significant waiting list management investment, represents a meaningful improvement in upstream capacity that should reduce some patient acuity at the ED interface over the coming months.

For emergency physicians, this is contextually important: patients who have been waiting extended periods for elective orthopaedic, cardiac, or gastrointestinal procedures frequently present to the ED with complications of their untreated conditions. As waiting times reduce, the frequency of these avoidable emergency presentations should decrease. The target achievement does not, however, address the underlying corridor care and 4-hour target failures documented elsewhere in this chapter.

ISSUE 2 · FEBRUARY 2026

NICE NG24 TXA Update — Earlier Administration, Extended Indications

GUIDELINE UPDATE

The NICE NG24 major trauma update endorsed earlier tranexamic acid (TXA) administration, reinforcing the CRASH-2 and CRASH-3 time-dependency data showing diminishing benefit beyond 3 hours from injury and potential harm beyond 3 hours. The updated guidance extends TXA recommendation to more injury types where significant haemorrhage is possible, including pelvic fractures and solid organ injuries in haemodynamically unstable patients.

Pragmatic UK approach: TXA 1g IV over 10 minutes should be given in the first 30 minutes of assessment for all major trauma patients with suspected significant haemorrhage, without waiting for coagulation results. A second dose of 1g over 8 hours is given if the first was within 3 hours of injury. Do not give TXA to stable patients with minor injuries — the benefit is confined to patients with clinically significant haemorrhage risk.

TXA in major trauma: 1g IV in first 30 minutes. Second dose 1g over 8 hours if first was within 3 hours. Do not give if >3 hours from injury — evidence suggests potential harm. Document time of injury and time of first TXA dose.

ISSUE 2 · FEBRUARY 2026

RCUK 2025 Resuscitation Guidelines — Key Changes for ED

GUIDELINE UPDATE FRCEM

The 2025 RCUK resuscitation guidelines update (informing Q2 practice) made several ED-relevant changes: TTM at 33°C is no longer recommended over 36°C for post-ROSC temperature management — normothermia (36°C) is the target, avoiding fever (>37.5°C). Post-ROSC coronary angiography is not mandatory for all patients without STEMI; it should be guided by clinical assessment and ECG findings rather than performed routinely. CRT is incorporated as a resuscitation endpoint. The NLSr course reflects updated NLS guidance.

TTM at 33°C requires ICU-level hypothermia induction with active cooling, which is resource-intensive and potentially harmful. The RCUK position — supported by the TTM2 trial — is that normothermia (strict fever prevention, target 36°C) achieves equivalent neurological outcomes with less intervention. This does not mean "do nothing" post-ROSC: active temperature management preventing fever is required; it simply means 33°C is not the target.

Post-ROSC temperature target: 36°C (avoid fever >37.5°C). Do not induce hypothermia to 33°C. Active temperature monitoring and management to maintain 36°C is required for 72 hours. This applies to all rhythms, not just VF.

CHAPTER 14

ED Systems, Workforce & UK Policy

RCEM 15,860 Excess Deaths · Corridor Care 2,241/day · HSSIB Mental Health · Martha's Rule · BBBC

Q2 2026 generated the most comprehensive and damning dataset on emergency care system failure in NHS history. The RCEM State of Emergency Medicine 2026 report linked 15,860 excess annual deaths to ED waits. NHS England published corridor care data for the first time. HSSIB exposed an irreducible legal void in mental health ED detention. Against this backdrop, Martha's Rule became mandatory and RCEM launched a new accreditation programme.

A — CAPACITY, WAITS & ACTIVITY DATA

RCEM STATE OF EMERGENCY MEDICINE 2026 · ISSUE 16 · JUNE 2026

RCEM State of Emergency Medicine 2026 — 15,860 Excess Deaths Linked to ED Waits

GUIDELINE UPDATE

The RCEM Annual Report 2026 (State of Emergency Medicine, published June 2026) calculated that 15,860 excess deaths per year are attributable to prolonged ED waits and boarding — defined as deaths that would not have occurred if the NHS had met its own access standards. The methodology linked national A&E waiting time data with mortality outcomes in matched patient cohorts, adjusting for case mix and comorbidity.

15,860 excess deaths per year · 2,241 corridor care patients per day · 493,751 patients waited 24h+ in 2025

The report described 493,751 patients who waited 24 hours or more in English EDs during 2025, with 13,386 patients waiting 72 hours or more. The 2,241 corridor care patients per day represents the first official national count of patients receiving care in non-designated clinical spaces — previously only estimated through RCEM surveys. These figures constitute the most granular public documentation of the humanitarian and mortality cost of ED overcrowding in NHS history.

These are not abstract statistics — they describe preventable deaths happening now, every day, in our departments. Every clinician and manager in UK emergency care should have read this report. It is publicly available at rcem.ac.uk and should be used to drive local improvement conversations and system change advocacy.

NHS ENGLAND · ISSUES 16/18 · JUNE 2026

NHS England May 2026 A&E Data — First Corridor Care Data Published (2,241/day)

INFORMING PRACTICE

NHS England published trust-level corridor care data for the first time in May 2026, accompanying the monthly A&E statistics release. May 2026 recorded 2,241 patients per day receiving care in corridor or escalation spaces nationally. The same month recorded 2.46 million total A&E attendances — a record high — with the 4-hour Type 1 performance at 64.2% nationally (target 95%).

The publication of corridor care as an official metric is a significant shift in transparency. Trust-level data will enable benchmarking and public accountability in a way that was previously impossible. For frontline clinicians, the figure of 2,241 patients per day means that at any given moment, approximately 93 patients across England's EDs are receiving care in a non-designated clinical space. The TERN study (Issue 10) found 17.7% of UK ED patients were in escalation areas in 2024 — corridor care is not a deviation; it is the operational default in many departments.

ISSUES 6/7 · APRIL 2026

RCEM Response to March 2026 A&E Data — 64.1% 4-Hour Performance, 135,000+ 12-Hour Waits

GUIDELINE UPDATE

RCEM's formal response to the March 2026 A&E statistics highlighted that 64.1% 4-hour Type 1 performance and 135,000+ 12-hour decision-to-admit (DTA) waits represent a system at breaking point. 93.7% bed occupancy across NHS acute trusts directly prevents patient flow from the ED — when there are no beds to admit to, patients wait. RCEM called for a national discharge target (similar to the German 'Weiterverlegung' system) to create pull from ward to community.

March 2026: 64.1% 4-hour · 135,000+ 12-hour DTA waits · 93.7% bed occupancy

BMJ INVESTIGATION · ISSUE 10 · APRIL 2026

BMJ: 493,751 Patients Waited 24h+ in England EDs in 2025 — 13,386 Waited 72h+

INFORMING PRACTICE

This BMJ investigation using FOI-obtained data from NHS England provided the most detailed breakdown of extreme waits in English EDs. 493,751 individual patients waited 24 hours or more in 2025. Of these, 13,386 patients waited 72 hours or more — three days in an emergency department environment without admission to an appropriate inpatient bed. The data was broken down by trust, month, and patient age group, showing the very old (75+) were disproportionately represented in extreme wait groups.

493,751 waited 24h+ · 13,386 waited 72h+ · Elderly patients disproportionately represented

ISSUE 10 · APRIL 2026 — 165 DEPARTMENTS

TERN Study — 17.7% of UK ED Patients in Escalation Areas

INFORMING PRACTICE

The TERN (Trauma & Emergency Research Network) study examined 165 UK emergency departments, finding that 17.7% of all patients at any given time were being managed in escalation spaces (corridors, non-designated areas, extra chairs, ambulance queues inside departments). This nationally representative figure is the epidemiological context for the 2,241/day official figure — it is not an emergency; it is the standard operating condition.

TERN also documented that patients in escalation areas had fewer pain assessments per hour, longer median time to initial treatment, and lower rates of timely NEWS2 recording compared to patients in designated cubicle spaces. Corridor care is not only uncomfortable — it is clinically inferior by measurable standards. ED boarding and clinical deterioration data (Ann Emerg Med, Issue 15) confirmed an independent association between boarding time and in-hospital deterioration events.

ANN EMERG MED 2026 (PMID 41860510) · ISSUE 15

ED Boarding and Clinical Deterioration — Independent Association Confirmed

INFORMING PRACTICE

This Ann Emerg Med study confirmed the independent association between ED boarding duration and in-hospital clinical deterioration events (RRT calls, unplanned ICU admission, cardiac arrest). For every additional 4 hours of ED boarding, the adjusted OR for deterioration increased by 1.18 (95% CI 1.12–1.24), confirming boarding as a mechanistic cause rather than a confounding marker of severity.

Every 4h additional boarding: OR 1.18 for clinical deterioration (independent of severity)

ISSUE 5 · APRIL 2026

RCEM Scotland A&E Crisis — Record 12-Hour Waits February 2026

GUIDELINE UPDATE

Scottish A&E data for February 2026 recorded the highest rate of 12-hour waits since Scottish Government metrics began. RCEM Scotland called for immediate Holyrood intervention, citing bed occupancy rates exceeding 95% at major Scottish centres and a 23% reduction in ED consultant staffing since 2019 due to burnout and emigration. The Scottish picture mirrors the England data with additional rural access challenges — HEMS callouts per capita in rural Scotland increased 18% year-on-year as community services deteriorated.

B — MARTHA'S RULE, PATIENT SAFETY & INVESTIGATIONS

ISSUE 12 · MAY 2026

Martha's Rule 18-Month Data — 12,301 Calls, 81% Missed by Standard EWS

INFORMING PRACTICE

The 18-month evaluation of Martha's Rule in pilot NHS Trusts found 12,301 calls were made by patients and families who felt clinical deterioration was not being adequately recognised. Of these calls, 81% resulted in a clinician review that identified deterioration not captured by NEWS2 or equivalent early warning systems. The data provides powerful validation that subjective family concern is a clinically valid and non-redundant signal for deterioration.

The evaluation also identified areas for improvement: 34% of Trusts had not fully communicated the rule to all ward staff, and 19% of calls resulted in initial dismissal by a floor nurse before reaching the escalation clinician. These implementation gaps will need to be addressed as the rule becomes mandatory across all NHS Trusts by March 2027.

ISSUE 15 · JUNE 2026

RCEM Time-Critical Medication QIP — 66% Levodopa/Insulin Doses Given Late

GUIDELINE UPDATE

The RCEM Time-Critical Medication Quality Improvement Programme audit (Issue 15) found that 66% of levodopa doses and a similar proportion of insulin doses were administered late or omitted in boarding ED patients. Time-critical medications include levodopa (omission causes acute Parkinson's crisis with rigidity and akinesis), insulin (omission causes hyperglycaemia and DKA risk), anti-epileptics (omission causes breakthrough seizures), and immunosuppressants (omission causes transplant rejection or flare).

66% of levodopa doses given late or omitted in ED boarding patients · Insulin similarly delayed

RCEM recommends: dedicated medication reconciliation within 2 hours of ED arrival for all admitted patients, a named time-critical medication coordinator per shift, and electronic prescribing alerts for medications requiring time-critical administration. Parkinson's UK and DVLA both issue guidance that levodopa omission beyond 4 hours can trigger a Parkinson's crisis requiring IV apomorphine — a complication that is entirely preventable with timely oral dosing. Keep the patient's own medications at the bedside and use them if pharmacy is delayed.

C — HSSIB INVESTIGATIONS & MENTAL HEALTH CRISIS

HSSIB · ISSUES 5/7/12 · APRIL–MAY 2026

HSSIB Mental Health Crisis in EDs — No Lawful Power to Detain; Legal Void

INFORMING PRACTICE FRCEM

The HSSIB (Health Services Safety Investigations Body) interim report on mental health crisis care in emergency departments (Safety Recommendations R/2026/082 and R/2026/083) identified a fundamental legal void: EDs have no lawful power to detain mental health patients who wish to leave before assessment is complete. Section 136 MHA applies only to public places; Section 5(2) (doctor's holding power) applies only to inpatients on a mental health ward, not ED patients.

EDs are holding mental health patients without lawful authority — this affects every NHS ED in England

The legal position: an ED patient with a mental health presentation who wishes to leave cannot be lawfully detained unless: they meet criteria for involuntary admission under MHA (Section 2/3, requiring AMHP and two doctors), they lack mental capacity under MCA (in which case the MCA's best-interests framework applies, but this does not permit indefinite detention), or a police officer exercises Section 136. The practical consequence is that ED clinicians are frequently placed in an impossible position: release a patient who may harm themselves, or detain them without legal authority, exposing themselves to potential legal liability.

HSSIB Recommendations R/2026/082 and R/2026/083 call for emergency primary legislation to create an ED-specific holding power and immediate interim protocols. While awaiting legislation, document all decisions meticulously, involve senior clinicians and liaison psychiatry in all cases where a patient wishes to leave against advice, and use MCA best-interests framework where capacity is genuinely in question. Do not physically restrain without police support.

RCEM Mental Health QIP (Issue 12) data: 48.6% of mental health presentations in the audit period required observation or de-escalation space. The scale of mental health presentations to ED is not decreasing — the legal framework must evolve to match clinical reality.

D — WORKFORCE, WELLBEING & SYSTEM INNOVATION

ISSUE 10 · APRIL 2026

Burnout, Stress and Moral Injury in EMS Clinicians — Systematic Review

INFORMING PRACTICE

This systematic review of burnout, stress, and moral injury in emergency medical services clinicians documented prevalence rates of burnout at 23–58% across included studies, with moral injury (the distress from acting against one's professional values due to systemic constraints) emerging as a distinct and underaddressed construct. Moral injury differs from burnout in that it specifically relates to ethical conflict — being asked to provide substandard care due to resource constraints, corridor conditions, or organisational decisions that conflict with professional duty of care.

The Q2 2026 UK system context — 15,860 excess deaths linked to waits, 2,241 daily corridor patients, legal voids in mental health — creates fertile ground for moral injury in ED clinicians. Protective factors identified in the review include psychological safety at team level (ability to speak openly about concerns without fear of penalty), peer support programmes, and regular clinical supervision. UK departments scoring well on RCEM Mental Health QIP accreditation demonstrated lower burnout scores, suggesting that organisational quality improvement reduces clinician psychological burden alongside patient outcomes.

If you are experiencing moral injury or burnout: speak to your educational supervisor, access BMA Doctor Support Service (0330 123 1245), or RCEM's SpeakUp service. Burnout is not a personal failing — it is a predictable response to sustained moral conflict in an underfunded system.

ISSUE 17 · JUNE 2026

Productive EM Physicians — Six Themes from Qualitative Study (Berglund et al 2026)

INFORMING PRACTICE

This qualitative study from SJTREM (Berglund et al 2026) examined the characteristics and working practices of consistently high-performing emergency physicians as identified by peers and patient outcome data, identifying six themes: anticipatory thinking (planning several steps ahead), active handover culture, selective cognitive closure (knowing when to commit to a diagnosis vs continue uncertainty), team activation competency, feedback-seeking behaviour, and effective self-care habits during shifts.

The study is relevant to both individual practice and departmental training. The most consistently high-performing physicians were not necessarily the most experienced — they were the most structured in their cognitive approach and most proactive in seeking feedback. The findings align with the cognitive debiasing literature and support embedding explicit clinical reasoning teaching into EM training rather than relying solely on experiential learning.

ISSUES 15/18 · JUNE 2026

RCEM BBBC Accreditation Programme — Launching Summer 2026

GUIDELINE UPDATE

RCEM's Better Basics, Better Care (BBBC) accreditation programme launches in summer 2026, providing EDs with a structured quality improvement framework assessing performance against 8 clinical quality domains: pain assessment and management, time-critical medications, analgesia in fractures, mental health crisis care, sepsis bundle compliance, documentation quality, patient experience, and staff wellbeing metrics.

Accreditation carries reputational and potentially commissioning value — NHS England has indicated BBBC status will be a quality indicator in commissioning frameworks from 2027. For departments considering BBBC, the baseline audit phase is recommended to begin in Q3 2026 to be ready for the formal accreditation cycle. The time-critical medication domain directly addresses the 66% levodopa/insulin late-dose finding; pain management domain addresses analgesic prescribing quality. BBBC represents RCEM's operational response to decades of quality variance across English EDs.

ISSUES 4/6 · APRIL 2026

Resident Doctors' Strike — NHS England Operational Framework and Post-Action Impact

INFORMING PRACTICE

The resident doctors' strike (7–13 April 2026) resulted in mass cancellation of elective activity and significant emergency department impact in trusts without full strike-proof cover arrangements. NHS England's operational framework, published in response, included explicit standards for maintaining emergency cover through mutual aid arrangements, HEMS and ambulance bypass protocols, and communication pathways for deteriorating strike-affected patients.

The post-action review (Issue 6) documented that EDs bore the primary operational burden during the strike period, absorbing patients who would otherwise have received elective care. RCEM expressed concern about the precedent of EM clinicians — including consultants — being expected to cover strike gaps in specialties with entirely different workflows. Post-strike junior doctor welfare review data documented significant distress in strike-participating doctors who felt moral conflict between professional duty and collective action.

ISSUE 6 · APRIL 2026

DHSC Corridor Care Programme — 40 UTCs/SDECs, First Formal Definition, GIRFT Deployment

INFORMING PRACTICE

The Department of Health and Social Care published the first formal national definition of "corridor care" in April 2026, opening the door to official measurement (which followed in May 2026 with the first NHS England publication of corridor care data). The Corridor Care Programme committed to funding 40 additional Urgent Treatment Centres and Same-Day Emergency Care units, and deployed GIRFT (Getting It Right First Time) teams to the 20 EDs with the highest corridor care rates.

GIRFT methodology — direct peer comparison of clinical practice variation to drive improvement — has been successful in reducing unwarranted variation in elective orthopaedics and other specialties. Application to ED corridor care is new and politically complex. The GIRFT deployment will report findings in Q4 2026; departments in the initial cohort are already conducting baseline assessments of corridor care drivers including delayed discharges, community care gaps, and diversion pathway effectiveness.

ISSUE 4 · APRIL 2026

NHS England 2026/27 GP Contract — Same-Day Urgent Access + Mandatory A&G

INFORMING PRACTICE

The 2026/27 GP Contract includes mandatory same-day urgent access provision and mandatory Advice and Guidance (A&G) for GP-to-specialist referrals. The same-day urgent access requirement aims to reduce emergency department attendance for conditions manageable in primary care — the original motivation for NHS 111, MIUs, and UCCs. A&G mandation means GPs must seek specialist telephone or electronic advice before formal referral, reducing inappropriate outpatient referrals and potentially ED attendance for patients on long waiting lists seeking clinical input.

Emergency physicians should be aware that A&G requests may come to them for acute presentations — particularly in departments co-located with or providing telephone advice services to primary care. Clear protocols for ED-based A&G provision, including appropriate scope of advice and documentation requirements, should be established before this becomes routine.

ISSUES 9/10 · APRIL 2026

RCEM Annual Conference 2026 — Key Themes from ICC Birmingham (28–30 April)

GUIDELINE UPDATE

The RCEM Annual Conference 2026 (28–30 April, ICC Birmingham) covered three dominant themes: system capacity reform (BBBC accreditation launch, Martha's Rule operationalisation, HSSIB mental health response), clinical evidence (Q2 2026 trial data preview including ARISE FLUIDS and SSC 2026), and workforce sustainability (moral injury, LTFT working patterns, international medical graduates equity issues).

Notable conference announcements included: RCEM's new position statement on corridor care as a patient safety emergency requiring primary legislation, the launch of the BBBC accreditation programme, and a call for a dedicated Emergency Medicine Research Institute to address the systemic underfunding of UK emergency medicine research. Full conference abstracts are available on the RCEM website.

ISSUE 9 · APRIL 2026

NHS England Corridor Care Trust-Level Data — First Publication Due May 2026

INFORMING PRACTICE

This issue item anticipated the first trust-level publication of corridor care data (which arrived as predicted in May 2026). The data is now available on the NHS England statistics portal, broken down by trust, region, and month. Departments should access and review their own trust's corridor care data and share with departmental governance and board-level clinical leadership.

JAMA · ISSUE 16 · N=52 UK ICUS

iRehab UK RCT — Post-ICU Rehabilitation: Physical Function Improved in Subgroup

INFORMING PRACTICE

The iRehab UK RCT (JAMA, 52 UK NHS ICUs) examined structured in-ICU and post-ICU rehabilitation versus standard care on physical function at 3 months. The overall trial was neutral on the primary endpoint, but a prespecified subgroup of patients with severe ICU-acquired weakness (MRC sum score <48 at ICU discharge) showed statistically significant improvement in physical function with structured rehabilitation.

Post-intensive care syndrome (PICS) — the constellation of physical, cognitive, and psychological impairment following critical illness — affects the majority of ICU survivors. iRehab UK's null primary endpoint should not deter structured rehabilitation for high-risk subgroups. Emergency physicians play a role in this pathway by ensuring timely ICU discharge documentation, PICS follow-up referral, and community physiotherapy referral at ED re-presentation.

ISSUE 13 · MAY 2026

Avalanche Burial Breathing Device — RCT (JAMA, PMID 41060661)

INFORMING PRACTICE

This JAMA RCT examined a novel breathing device designed for avalanche burial survival — a sealed air pocket system incorporated into ski jacket collars that creates a CO2 scrubbing air reserve to extend the survivable window in avalanche burial. The device extended mean survival time in simulated burial by 19 minutes (p<0.001), with no increase in device-related complications.

While avalanche presentations are rare in UK EDs (primarily Scottish mountain rescue and ski resort events), this evidence is relevant to PHEM clinicians working in mountain rescue settings. The key ED/HEMS principle for avalanche burial remains: aggressive rewarming, ECPR for hypothermic cardiac arrest (K+ <12 mmol/L threshold for resuscitability), and avalanche burial duration as the primary prognostic factor. A 19-minute extension of survivable window is potentially life-changing in remote rescue settings.

ISSUES 9/10 · APRIL 2026

APPAC 10-Year Follow-Up — Antibiotics vs Appendicectomy

INFORMING PRACTICE

The APPAC 10-year follow-up examined the long-term outcomes of patients treated with antibiotics versus appendicectomy for uncomplicated acute appendicitis. At 10 years, 61% of the antibiotic group had not required appendicectomy — meaning antibiotic-first treatment avoided surgery in the majority of patients over a decade of follow-up. Recurrence requiring surgery was 39% at 10 years, primarily within the first 2 years.

For ED practice: antibiotic-first management of uncomplicated appendicitis (CT-confirmed, no perforation, no appendicolith) remains a valid shared decision-making conversation with surgical teams, particularly for patients who strongly prefer to avoid surgery or who have significant operative risk. The 10-year data provides longer follow-up than previously available, strengthening the case for offering antibiotic treatment as an option rather than an emergency default. Complex appendicitis (perforation, abscess, appendicolith) requires surgical management.

ISSUE 9 · APRIL 2026

Core Revision: Hyponatraemia — Classification, Correction Rates, ODS Risk

INFORMING PRACTICE FRCEM

This core revision item covered the classification and emergency management of severe hyponatraemia, addressing both the common errors in correction rate (overcorrection causing osmotic demyelination syndrome, ODS) and the evidence for emergency hypertonic saline use. Hyponatraemia classification: hypervolaemic (cardiac failure, cirrhosis, nephrotic syndrome), euvolaemic (SIADH, hypothyroidism, psychogenic polydipsia), and hypovolaemic (GI losses, Addison's disease).

ODS risk: correction >10-12 mmol/L/day · Maximum 4-6 mmol/L in first 4-6 hours for symptomatic

Symptomatic severe hyponatraemia (seizures, coma, Na <120): give 150mL 3% NaCl IV over 20 minutes — this raises Na by approximately 1–2 mmol/L, which is sufficient to terminate most seizures. Repeat once if seizures continue. Do not target rapid full normalisation. Maximum correction: 10 mmol/L in 24 hours, 18 mmol/L in 48 hours. Overcorrection can be partially reversed with dextrose 5% + desmopressin (seek specialist input). Causes of acute hyponatraemia (<48 hours duration) can be corrected more rapidly than chronic — but duration is rarely known with certainty.

ISSUE 11 · MAY 2026

Core Revision: Lactate — Beyond the Number

INFORMING PRACTICE FRCEM

This core revision addressed lactate interpretation in the ED, emphasising that lactate is not simply a marker of tissue hypoxia but reflects a balance between production and clearance, with multiple non-hypoxic causes relevant to ED presentations. Causes of elevated lactate without hypoxia include: beta-agonist-induced lactataemia (salbutamol nebs cause LA+), thiamine deficiency (B1, particularly in alcoholics and malnutrition), metformin (rare, associated with AKI/hepatic impairment), propofol infusion syndrome (in ICU), liver failure (reduced clearance), seizures (brief marked LA+), and intense exercise.

Lactate >2.0 mmol/L: investigate cause — do not automatically equate with sepsis

In the context of ANDROMEDA-SHOCK-2 (Chapter 2), lactate should be used alongside CRT as a resuscitation endpoint, not as a standalone trigger for fluid administration. Serial lactate clearance (target >10% reduction per 2 hours) is more informative than a single absolute value. For ED sepsis: lactate is one component of assessment, not a binary switch to escalate treatment.

ISSUE 11 · MAY 2026

Emergency CT Head Score — UK External Validation (EMJ)

INFORMING PRACTICE

The Emergency CT Head Score (ECTHS), a novel CT head decision rule for head injury, was externally validated in a UK cohort (EMJ 2026), demonstrating sensitivity 99.2% and specificity 23.4% for any intracranial abnormality on CT. The modest specificity reflects the broad population in which it was tested — similar to NICE CG176 criteria — but the high sensitivity suggests it as a safe rule-out tool.

NICE CG176 remains the primary UK guideline for CT head decision-making. ECTHS provides additional validation evidence but does not replace the established pathway. Any new CT head decision tool requires prospective UK multicentre validation before NHS-wide adoption. Emergency physicians should be familiar with the NICE CG176 high-risk criteria for immediate CT: GCS <13 at any time, GCS 13–14 at 2 hours, focal neurological deficit, suspected open/depressed skull fracture, any sign of basal skull fracture, post-traumatic seizure, vomiting ≥2 episodes.

ISSUE 15 · JUNE 2026

Airway Management of Adults in Acute Care — BMJ State of the Art 2026 (PMID 41951238)

INFORMING PRACTICE

This BMJ state-of-the-art review on adult acute care airway management synthesised evidence across VL vs DL, NMBA use, RSI induction agents, difficult airway prediction, and human factors in emergency intubation. Key messages: VL is the preferred primary device for all emergency intubations; NMBA use is mandatory without specific contraindication; no induction agent is universally superior — choice should be individualised to haemodynamic status; pre-oxygenation for 3 minutes with high-flow oxygen (or CPAP/NIV in desaturating patients) before induction reduces peri-intubation hypoxia.

The review also covered human factors: team briefing before intubation (even 30 seconds: "plan A is video laryngoscope, plan B is iLMA, plan C is surgical airway — who is doing what?") significantly reduces failure rates and adverse events. All EDs should have a practiced difficult airway protocol, printed and laminated in the resuscitation room, reviewed at departmental simulation days at least twice per year.

ISSUE 15 · JUNE 2026

Upper GI Bleeding ED Predictors (PMID 41863907)

INFORMING PRACTICE

This study examined ED clinical predictors of significant upper GI bleeding requiring endoscopic intervention or blood transfusion, comparing the Glasgow-Blatchford Score (GBS), AIMS65, and clinical gestalt. GBS remained the superior predictor, with GBS 0 identifying patients safe for outpatient management with near-zero risk of requiring intervention (sensitivity 99.6%, specificity 23.1%).

For UK emergency departments: GBS should be calculated for all upper GI bleed presentations. GBS 0–1: consider outpatient management with GP follow-up if haemodynamically stable and no high-risk features. GBS ≥6: high-risk, requires hospital admission and same-day or next-day endoscopy. Current NICE CG141 supports outpatient management of low-GBS presentations, reducing hospital admissions and freeing ED capacity for patients who genuinely need intensive monitoring.

ISSUE 12 · MAY 2026

RCEM Mental Health QIP 2026 — 48.6% Observation Rate in ED

GUIDELINE UPDATE

The RCEM Mental Health Quality Improvement Programme 2026 audit found 48.6% of mental health presentations required either continuous observation, de-escalation space, or both during their ED stay. This represents the growing clinical burden of psychiatric crisis on ED physical and staff resources. The QIP also documented that dedicated mental health liaison availability (target: <1 hour first response) was achieved in only 62% of EDs during standard hours and 31% out of hours.

The QIP data alongside the HSSIB legal void report paints a picture of EDs as the de facto 24/7 mental health crisis centre without the legal framework, physical environment, or specialist staffing to fulfil this role safely. RCEM is calling for ring-fenced mental health liaison funding in every ED operating 24 hours, dedicated safe space provision with appropriate ligature-risk environmental design, and the emergency legislation required to resolve the detention power void.

ISSUES 11/15 · MAY–JUNE 2026

NHS England Corridor Care Data — Imminent / Published

INFORMING PRACTICE

Issue 11 anticipated the publication of trust-level corridor care data (published May 2026 as reported in Issues 16/18). The data is now publicly available and should be accessed by all departmental clinical leads. Access at: england.nhs.uk/statistics (A&E Attendances and Emergency Admissions monthly data).

ISSUE 12 · MAY 2026

First10EM May 2026 Research Roundup

INFORMING PRACTICE

The First10EM May 2026 research roundup highlighted the convergent evidence from Q2 2026 as the most significant quarterly evidence bundle for emergency medicine in recent years. The editorial perspective emphasised that the simultaneous publication of ARISE FLUIDS, BIHCA, MARCH, and the AHA/ACC PE guideline in a 6-week window created an unusual and demanding evidence integration challenge for practising clinicians.

The roundup also advocated for better mechanisms of evidence dissemination to frontline clinicians: trial results that demand practice change cannot rely on individual clinicians encountering journal publications — systematic departmental communication, SOP updating processes, and simulation-based implementation are all required to translate trial evidence into bedside practice change at speed and scale.

ISSUES 9/13 · APRIL–MAY 2026

Massive Haemoptysis — ED Management

INFORMING PRACTICE FRCEM

This high-risk, low-incidence review addressed massive haemoptysis (>200ml/24h or haemodynamic instability) in the ED. The primary risk is asphyxiation rather than haemopoietic failure — the airway fills with blood. Key management: position the patient with known bleeding side down (to protect the contralateral lung), consider single-lung intubation of the contralateral (non-bleeding) bronchus in extremis, notify interventional radiology immediately for bronchial artery embolisation (BAE) — the primary definitive treatment.

Cause of death in massive haemoptysis: asphyxiation (>haemorrhage) — protect the airway first

Causes: TB/post-TB bronchiectasis most common globally; in UK EDs: bronchiectasis (most common), lung malignancy, aspergilloma, and vascular malformations. TXA 500mg IV can reduce haemoptysis volume. Do not give anticoagulants unless the cause is confirmed coagulopathy. Rigid bronchoscopy + BAE in a tertiary centre is definitive management — arrange urgent transfer if local BAE capability is unavailable.

ISSUE 10 · APRIL 2026

Urgent Care Delivery Categorisation — EMA Daily

INFORMING PRACTICE

The Emergency Medicine Association's (EMA) daily briefing item on urgent care delivery categorisation described the UK's evolving urgent care landscape across UTCs, MIUs, GP OOH services, NHS 111, and EDs. A new categorisation framework was proposed distinguishing between: Immediate Emergency Care (life/limb threat, Type 1 ED only), Urgent Emergency Care (acute illness requiring same-day assessment, Type 1 or UTC), and Urgent Primary Care (exacerbation of chronic conditions, UTC or GP OOH).

This framework has relevance for streaming decisions at triage — not all urgent presentations are emergency presentations. Effective ambulatory streaming reduces the "emergency" workload in Type 1 departments and allows acute triage nurses to focus on genuinely high-risk patients. UK EDs with robust streaming protocols (GP in ED, acute assessment units, direct-to-specialty pathways) demonstrate better 4-hour performance without compromising safety.

ISSUE 10 · APRIL 2026

High Risk, Low Incidence: Cyanotic Critical Congenital Heart Disease

INFORMING PRACTICE PAEDS FRCEM

This high-risk, low-incidence review addressed cyanotic critical congenital heart disease (CCHD) presenting to non-specialist EDs. Key presentations: Tet spell (hypercyanotic episode in ToF — knee-chest position, morphine, IV propranolol or esmolol, phenylephrine), ductal-dependent lesions presenting in first weeks of life (pulmonary atresia, coarctation, HLHS — give prostaglandin E1 immediately, avoid supplemental O2 in ductal-dependent pulmonary circulation), and TGA presenting as blue baby without respiratory distress.

Ductal-dependent CCHD: prostaglandin E1 (alprostadil) STAT — this can be lifesaving

Any newborn aged 0–6 weeks presenting with cyanosis not responding to oxygen, or SpO2 discordance (preductal vs postductal difference >3%), should be considered for CCHD. Maintain prostaglandin E1 (alprostadil) in your ED resus drug protocol for neonates. Transfer to specialist paediatric cardiac centre immediately — do not attempt definitive intervention in a non-specialist ED.

ISSUE 16 · JUNE 2026

RCEM Better Basics, Better Care (BBBC) — June 2026 Newsletter

GUIDELINE UPDATE

The June 2026 RCEM newsletter focused on Better Basics, Better Care accreditation programme preparation, providing a detailed self-assessment checklist for departments beginning their baseline audit. Key self-assessment domains: pain management (% patients with pain score documented within 1 hour of arrival), time-critical medications (% doses given on time), sepsis bundle compliance (antibiotics within 1 hour of recognition), mental health environment (designated space, ligature risk assessment completed), and documentation quality (discharge summaries with safety-netting).

The June newsletter also announced that RCEM Training is developing an EM Evidence educational package aligned with BBBC accreditation — relevant trial summaries from Q2 2026 (ARISE FLUIDS, BIHCA, MARCH, AHA/ACC PE, No OUCH) will be incorporated into the FRCEM preparation materials for the 2026/27 cycle.

ISSUE 18 · JUNE 2026

RCEM Better Basics, Better Care — Launching Summer 2026 (Issue 18 Final Update)

GUIDELINE UPDATE

The final Q2 2026 RCEM update confirmed BBBC accreditation opens for applications in August 2026, with the first cohort of departments expected to receive accreditation decisions in Q1 2027. Application involves: baseline self-audit completion, submission of 3-month quality improvement data, departmental clinical lead endorsement, and peer review site visit. Successful departments receive a 3-year accreditation with annual review.

RCEM confirmed that NHS England will incorporate BBBC status into A&E quality indicator reporting from April 2027, making BBBC accreditation publicly visible alongside existing performance metrics. For department leads, this timeline means beginning baseline audit in Q3 2026 is essential to be in the first accreditation cohort.

ISSUE 4 · APRIL 2026

Gabapentinoids — Narrative Review: ED Prescribing Concerns

INFORMING PRACTICE

The gabapentinoid narrative review (covered in Chapter 12) has direct ED prescribing implications: audit your ED's gabapentinoid prescribing patterns. Common scenarios of unjustified ED gabapentinoid prescribing include: LBP (no evidence), non-specific limb pain (no evidence), anxiety/insomnia (not an approved indication, and associated with significant harm in combination with benzodiazepines or opioids), and discharge prescriptions for new-onset neuropathic pain without specialist assessment.

A prospective audit of 50 consecutive ED gabapentinoid prescriptions would reveal the scale of this problem in your department. RCEM's BBBC documentation quality domain specifically assesses prescribing appropriateness — gabapentinoid audit data can contribute to this assessment.

ISSUE 18 · JUNE 2026

NHS England May 2026 A&E Statistics — Record 2.46M Attendances

INFORMING PRACTICE

May 2026 A&E statistics recorded 2.46 million total attendances — a record high for any calendar month. Type 1 (major ED) performance: 64.2% seen within 4 hours. 12-hour DTA waits: 138,000+ for the month. Corridor care: 2,241 patients per day averaged over May. Ambulance handover delays (>30 minutes): 34.7% of handovers above target nationally.

May 2026: 2.46M attendances (record) · 64.2% 4-hour · 2,241 corridor patients/day

The ambulance handover delay data is particularly concerning: 34.7% of handovers taking >30 minutes means ambulances are frequently queued outside EDs unable to hand over patients, simultaneously reducing operational ambulance availability across the region. This is a systemic loop — ED overcrowding delays handover, delayed handover reduces ambulance availability, reduced ambulance availability worsens prehospital response times, worse response times increase ED attendance rates from deteriorating community patients.

LOOKING AHEAD

Trials to Watch — Q3 2026 and Beyond

Imminent results that will shape Q3 evidence

Q2 2026 closes with several high-profile trials either completing recruitment or presenting first data. The ICS State of the Art meeting (30 June–2 July) will present BICARICU-2 and full ANDROMEDA-SHOCK-2 data. EVIS, BACHb, and BEST-DKA Phase 3 are expected to report in Q3 2026.

Jake Turner

Emergency Medicine Registrar · West Midlands Deanery · EM Evidence (emevidence.org)

Curated with the assistance of AI (Perplexity). All content editorially reviewed. © Q2 2026 EM Evidence.