EM EVIDENCE — QUARTERLY REVIEW
EM Evidence Rundown
Q3 2026 — JULY – SEPTEMBER 2026
State of the Science
Emergency Medicine & Paediatric EM
UK Edition — Quarterly Evidence Ebook — Corrected edition
- 13 WEEKLY ISSUES
- 146 ITEMS REVIEWED
- 67 PRACTICE-CHANGE ITEMS
- 13 CLINICAL CHAPTERS
Jake Turner, EM Registrar — West Midlands • Curated with the assistance of AI (Perplexity). All content editorially reviewed.
October 2026
HOW TO USE THIS EBOOK
| Safety-critical or immediate practice change. | |
| High-impact evidence; discuss at departmental governance and consider pathway change. | |
| CHANGE WHEN GUIDELINE UPDATES | Evidence ahead of current NICE/RCEM/RCUK guidance. |
| Useful context; no immediate change required. |
Corrected edition (October 2026). This edition replaces the version circulated on 29 September 2026, in which several entries did not accurately reflect the weekly issues they summarised. Every entry in this edition is drawn directly from the text of the published weekly issue that covered it; where that issue gave no effect estimate, none is quoted.
Scope: every primary-evidence, guideline and policy item from EM Evidence Rundown Issues 19–31 (July–September 2026), organised by clinical theme. MHRA device notices, FOAMed secondary sources and core-revision pieces are excluded. Always read the primary paper before changing practice, and follow local governance.
Contents — Q3 2026 State of the Science
Chapter 1 — Q3 2026 Quarter in Review
Executive summary and CHANGE TONIGHT table
Chapter 2 — Resuscitation & Cardiac Arrest
13 items
Chapter 3 — Airway & Respiratory
10 items
Chapter 4 — Trauma & Haemorrhage
8 items
Chapter 5 — Sepsis & Critical Infection
10 items
Chapter 6 — Cardiovascular Emergencies
10 items
Chapter 7 — Pulmonary Embolism & DVT
3 items
Chapter 8 — Stroke & Neurology
2 items
Chapter 9 — Toxicology & Analgesia
7 items
Chapter 10 — Infectious Disease & Public Health
12 items
Chapter 11 — POCUS, Diagnostics & AI
11 items
Chapter 12 — Paediatric Emergency Medicine
29 items
Chapter 13 — ED Systems & Patient Safety
25 items
Chapter 14 — Guideline & Policy Updates
6 items
CHAPTER 1
Q3 2026 — Quarter in Review
July – September 2026
Thirteen weekly issues (19–31) covered 146 primary-evidence, guideline and policy items this quarter, 45 of them paediatric. The clearest practice changes were in airway and paediatrics: videolaryngoscopy outperformed direct laryngoscopy for first-pass success in emergency trauma intubation (88% vs 68%), hyperpronation had a lower first-attempt failure rate than supination-flexion for pulled elbow (9.42% vs 25%), azithromycin gave no benefit in preschool wheeze (n=840), and a single dose of dexamethasone was equivalent to two in paediatric asthma (ED revisit 5.2% vs 5.7%, n=2,063). The morphine-alone versus morphine plus IV paracetamol trial did not show non-inferiority for morphine alone, supporting multimodal analgesia. System pressure was a constant theme: boarding beyond four hours was associated with higher mortality, RCEM reported record 12-hour waits, and repeated heat-health alerts accompanied 2,877 excess heat-related deaths in England.
CHANGE TONIGHT items
| PRIORITY | ITEM | CHAPTER |
|---|---|---|
| CHANGE TONIGHT | UKHSA Ebola/VHF Alert: Glasgow Suspect Case and Active ED VHF Algorithm | Infectious Disease & Public Health |
| CHANGE TONIGHT | Heatwave-related ED surge, exit block and NHS workplace temperature | ED Systems & Patient Safety |
| CHANGE TONIGHT | Boarding beyond four hours is associated with increased mortality and inpatient harm | ED Systems & Patient Safety |
| CHANGE TONIGHT | Garth Pretorius inquest: sepsis care failure during overcrowding at Hull Royal Infirmary | ED Systems & Patient Safety |
| CHANGE TONIGHT | 2,877 excess heat-related deaths in England in 2026 with active amber alert | Infectious Disease & Public Health |
| CHANGE TONIGHT | Needle thoracostomy in obesity: 4th/5th ICS anterior axillary line preferred over 2nd ICS midclavicular line | Airway & Respiratory |
| CHANGE TONIGHT | Amber heat-health alerts across England: emergency management of heat illness | Infectious Disease & Public Health |
| CHANGE TONIGHT | Azithromycin provides no benefit for preschool wheeze in the ED | Paediatric Emergency Medicine |
| CHANGE TONIGHT | Diagnosis and Management of Acute Hyperkalaemia |
Cardiovascular Emergencies
| CHANGE TONIGHT | Videolaryngoscopy versus direct laryngoscopy for emergency intubation in trauma: DEVICE trial secondary analysis | Trauma & Haemorrhage |
| CHANGE TONIGHT | Resuscitative hysterotomy for out-of-hospital cardiac arrest: maternal and neonatal outcomes | Resuscitation & Cardiac Arrest |
Q3 2026 statistics: 13 issues • 146 items • 45 paediatric • 11 CHANGE TONIGHT • 56 CHANGE THIS MONTH • 9 CHANGE WHEN GUIDELINE UPDATES
CHAPTER 2
Resuscitation & Cardiac Arrest
13 items · EM Evidence Rundown Issues 19–31
RESUSCITATION (2026) — PROGNOSTIC SCORE VALIDATION STUDY; VALIDATION COHORT SIZE NOT STATED · EM ISSUE 19
Pre-MIRACLE2 Score for Post-ROSC Neurological Risk Stratification
The Pre-MIRACLE2 score uses pre-hospital information available at return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA): age, initial rhythm, bystander CPR, EMS-to-ROSC time and blood glucose. It achieved an AUC of 0.88 in the validation cohort. In UK emergency departments, it may support early post-ROSC prognostication discussions and screening for possible ECPR candidacy, although it is primarily a pre-hospital emergency medicine tool. It should not replace multimodal neurological prognostication or be treated as a stand-alone determinant of ongoing care; the validation cohort size and implementation impact are not stated.
Key numbers: AUC 0.88 in the validation cohort; cohort size not stated
RESUSCITATION 2026; RETROSPECTIVE MATCHED COHORT; N=40,333 OUT-OF-HOSPITAL CARDIAC ARRESTS · EM ISSUE 20
Naloxone in PEA cardiac arrest
Naloxone is routinely used in cardiac arrest when opioid toxicity is suspected, but its role in undifferentiated PEA remains uncertain. In this large retrospective matched cohort, naloxone was associated with higher survival to hospital discharge in PEA arrests: 11.1% versus 9.0%, OR 1.46; no benefit was reported in VF/VT or asystole. In UK ED practice, consider naloxone during the first ALS cycle in PEA of unknown cause when opioid exposure is possible, alongside standard ALS and treatment of reversible causes; do not delay defibrillation in shockable rhythms. The finding is observational and may reflect confounding, so prospective randomised evidence is still required.
Key numbers: n=40,333 OHCA; 18.8% received naloxone; matched PEA survival to discharge 11.1% versus 9.0%; OR 1.46; no benefit in VF/VT or asystole
AMERICAN HEART ASSOCIATION (AHA) 2025 ACLS GUIDELINE UPDATE; GUIDELINE UPDATE; N NOT STATED · EM ISSUE 20
2025 ACLS updates: cardioversion energy, sotalol removal and post-arrest targets
The 2025 AHA ACLS guideline update changes several aspects of adult resuscitation practice. It recommends 100 J for narrow-complex cardioversion and 200 J for atrial fibrillation or flutter, while removing sotalol from the stable ventricular tachycardia algorithm in favour of amiodarone or procainamide. Post-arrest guidance specifies avoiding fever, targeting a temperature range of 32–37.5°C, maintaining MAP above 65 mmHg and targeting SpO2 90–98%; neuroprognostication should generally wait until at least 72 hours. These are AHA recommendations rather than the formal UK standard, so UK clinicians should check current RCUK and local resuscitation protocols before changing practice.
Key numbers: Narrow-complex cardioversion 100 J; AF/flutter 200 J; post-arrest temperature 32–37.5°C; MAP >65 mmHg; SpO2 90–98%; neuroprognostication minimum 72 hours
RESUSCITATION, 2026 — NATIONWIDE PROPENSITY-SCORE-MATCHED RETROSPECTIVE COHORT, N>58,000 · EM ISSUE 24
Epinephrine in non-shockable OHCA: stronger ROSC association in asystole than PEA
This nationwide observational study evaluated epinephrine in more than 58,000 adults with witnessed non-shockable out-of-hospital cardiac arrest, analysing asystole and PEA separately. Epinephrine was associated with increased ROSC overall, but the association was significantly stronger in asystole than in PEA; in PEA, any survival benefit was less certain. This does not alter RCUK 2021 ALS guidance to give adrenaline 1 mg IV every 3–5 minutes in non-shockable rhythms, but reinforces the importance of actively identifying and treating reversible causes using the 4H/4T framework. Interpretation remains cautious because this was not randomised, residual confounding and indication bias may remain, and PEA subtypes were not disaggregated.
Key numbers: More than 58,000 adults; epinephrine-associated ROSC was stronger in asystole than PEA; RCUK dose: 1 mg IV every 3–5 minutes.
EMERGENCY MEDICINE JOURNAL, 2026, COHORT STUDY, N>6,400 · EM ISSUE 24
Bystander and patient sex affect CPR provision in out-of-hospital cardiac arrest
In this cohort of more than 6,400 out-of-hospital cardiac arrests, bystander CPR provision varied according to both patient and bystander sex. CPR rates were lower when the bystander and patient were of different sex; dispatcher-assisted CPR partially, but not completely, compensated for this disparity. UK implications are chiefly for public CPR training, Restart a Heart messaging and dispatcher protocols, including reassurance about exposing the chest for compressions and AED pad placement. The study identifies an important disparity but does not establish its mechanism or demonstrate that targeted educational interventions improve outcomes.
Key numbers: n>6,400; CPR provision was lower when bystander and patient sex differed; dispatcher-assisted CPR partially compensated.
JAMA 2026; MULTICENTRE ADAPTIVE RANDOMISED CLINICAL TRIAL WITH BAYESIAN STOPPING RULES; N>1,800 · EM ISSUE 25
ICECAP: 24 versus 48 hours of therapeutic hypothermia after OHCA
In comatose adults after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation, the ICECAP adaptive RCT compared 24 versus 48 hours of targeted temperature management at 33°C. The trial stopped for futility: 90-day functional neurological outcomes, mortality and adverse events did not differ significantly between groups. In UK practice, 24 hours at 33–36°C may be a reasonable selected-patient strategy, with ICU handover and continued avoidance of fever; extending active cooling to 48 hours should not be assumed to provide benefit. However, current RCUK guidance recommending targeted temperature management with fever avoidance for at least 72 hours remains relevant, and the applicability of a 24-hour 33°C protocol should be considered alongside the full trial population and local critical-care guidance.
Key numbers: n>1,800; 24 versus 48 hours; 33°C; primary outcome at 90 days using modified Rankin Scale; no significant difference in neurological outcome, mortality or adverse events
RESUSCITATION, 2026; RETROSPECTIVE STUDY; APPROXIMATELY 1,600 PATIENTS · EM ISSUE 25
Pre-ICU sedation after ROSC associated with better 90-day neurological outcome
In patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, pre-ICU sedation was associated with better neurological outcome at day 90. The finding comes from a retrospective study of approximately 1,600 patients. For UK ED practice, it supports ensuring that sedation decisions and the sedation protocol are clearly addressed during the ED-to-ICU handover. The observational design means that the association may reflect differences in illness severity, treatment selection or other confounders, and it does not establish that pre-ICU sedation improves outcome.
Key numbers: Approximately 1,600 patients; better day-90 neurological outcome associated with pre-ICU sedation.
CIRCULATION, 2026; PROGNOSTIC STUDY OF OHCA PATIENTS; DESIGN AND SAMPLE SIZE NOT STATED · EM ISSUE 27
Dynamic EtCO₂ Trajectories During CPR Predict ROSC but Should Not Guide Termination Decisions
Dynamic EtCO₂ trajectories between 7 and 21 minutes of OHCA resuscitation provide prognostic information, with a rising trajectory associated with ROSC. However, these findings should not be used alone to make termination-of-resuscitation decisions. In UK practice, continue to follow current RCUK/ERC termination guidance; a persistently low static EtCO₂ value below 10 mmHg after 20 minutes is only one factor in a non-shockable rhythm alongside other criteria. Dynamic trajectory interpretation remains an informing-practice finding rather than an established TOR criterion.
Key numbers: Dynamic trajectories assessed between 7 and 21 minutes; persistently low static EtCO₂ <10 mmHg after 20 minutes is one factor supporting TOR in selected non-shockable arrests.
RESUSCITATION (2026), OBSERVATIONAL STUDY, N=98 OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS · EM ISSUE 27
SpO₂ During CPR and ROSC: Higher Saturations Associated with ROSC, but Interpretation Is Limited
In out-of-hospital cardiac arrest, pulse oximetry during CPR may provide information about perfusion and resuscitation quality. In this observational study of 98 patients, higher event-average SpO₂ during CPR was associated with a greater probability of return of spontaneous circulation, but was not associated with improved neurological outcomes. UK ED teams should not use these findings to introduce routine SpO₂ targets during CPR or to determine termination-of-resuscitation decisions. Interpretation is limited by the unreliability of pulse oximetry during low-flow states and the small observational sample, so the association does not establish a causal treatment effect.
Key numbers: n=98; higher event-average SpO₂ during CPR was associated with increased probability of ROSC, but did not improve neurological outcomes.
RESUSCITATION 2026; UK STUDY; DESIGN AND SAMPLE SIZE NOT STATED · EM ISSUE 28
Mobile AED Deployment by Community First Responders: Improved ROSC Rates
Early access to defibrillation is a key determinant of outcome after out-of-hospital cardiac arrest. This UK study found that community AED deployment by first responders was associated with improved bystander defibrillation rates and improved return of spontaneous circulation (ROSC). UK emergency care systems should support coordinated community defibrillation networks, including BHF PAD and St John Ambulance schemes, alongside effective dispatch and governance arrangements. The excerpt does not provide the study design, sample size, effect estimates or details of the deployment model, so the findings support service development but do not quantify the expected benefit for an individual locality.
Key numbers: No numerical outcomes, sample size or effect estimates stated.
RESUSCITATION 2026; PROSPECTIVE OBSERVATIONAL STUDY; N=87 PATIENTS (194 MONITORED DEFIBRILLATIONS) · EM ISSUE 29
Cerebral tissue oxygen saturation at defibrillation and ROSC in shockable OHCA
In adults with shockable out-of-hospital cardiac arrest undergoing in-hospital resuscitation with cerebral near-infrared spectroscopy monitoring, higher cerebral tissue oxygen saturation (SctO2) at defibrillation was associated with subsequent ROSC. Median SctO2 was 48.8% in patients achieving ROSC versus 38.1% in those who did not; each 1% increase was associated with an adjusted OR for ROSC of 1.48 (95% CI 1.22–1.80), with an exploratory cut-off of 44.5% showing 94.7% sensitivity and 89.7% specificity. This should not alter UK ED defibrillation practice or delay guideline-directed shocks; SctO2 monitoring is not standard in UK emergency departments and may be relevant only to services already using NIRS for research or case review. The single-centre Japanese design, small sample, device and healthcare-system differences, and derivation of the cut-off from the same dataset create substantial risk of overfitting, so external validation is required.
Key numbers: n=87 patients; 194 monitored defibrillations; median SctO2 48.8% with ROSC versus 38.1% without; adjusted OR 1.48 per 1% increase (95% CI 1.22–1.80); exploratory cut-off 44.5%, sensitivity 94.7%, specificity 89.7%.
RESUSCITATION 2026; PERSPECTIVE/REVIEW; NO SAMPLE SIZE STATED · EM ISSUE 29
High-quality CPR: From Process to Perfusion — UK Author Perspective
This UK-authored perspective argues that high-quality CPR should be framed around coronary and cerebral perfusion rather than process metrics such as rate, depth and chest-compression fraction. It identifies haemodynamic-guided CPR—using aortic diastolic pressure or end-tidal carbon dioxide as surrogates—as a potential next step in improving cardiac-arrest care; the excerpt cites ETCO2 >10 mmHg and arterial diastolic pressure >25 mmHg when an arterial line is in situ as established high-level resuscitation targets. This is relevant to HEMS teams and consultant-led resuscitation services, but does not itself justify changing routine ED protocols. The article is a perspective piece, with the full abstract not yet published, so its recommendations should be interpreted as conceptual and reviewed alongside current resuscitation guidance.
Key numbers: ETCO2 >10 mmHg; arterial diastolic pressure >25 mmHg if an arterial line is in situ; no study sample size or outcome statistics stated
RESUSCITATION 2024; SYSTEMATIC REVIEW; 42 PUBLICATIONS, 66 WOMEN AND 68 NEONATES · EM ISSUE 30
Resuscitative hysterotomy for out-of-hospital cardiac arrest: maternal and neonatal outcomes
Resuscitative hysterotomy is a rare, high-stakes intervention during maternal cardiac arrest, traditionally associated with a four-minute time target. This systematic review reported maternal survival to hospital discharge of 4.5% (3/66) and neonatal survival of 45.0% (27/60 viable neonates with follow-up data); maternal survival with normal neurological function occurred after an interval of 29 minutes, and good neonatal outcome after delivery at 47 minutes. In UK practice, consider resuscitative hysterotomy in a pregnant patient at or beyond 24 weeks’ gestation with OHCA when standard resuscitation is failing, and do not withhold it solely because of prolonged downtime; RCUK guidance still advises performing it within four minutes if ROSC has not been achieved. The evidence is very low certainty and dominated by case reports, with certain publication bias, so the survival estimates may overstate benefit and the longer time intervals should not be interpreted as justification for delaying the procedure.
Key numbers: Maternal survival to discharge 4.5% (3/66); neonatal survival to discharge 45.0% (27/60 viable neonates with follow-up); longest interval with maternal survival and normal neurological function 29 minutes; longest collapse-to-delivery interval with good neonatal outcome 47 minutes.
CHAPTER 3
Airway & Respiratory
10 items · EM Evidence Rundown Issues 19–31
UMEM EDUCATIONAL PEARL/IBCC AIRWAY, 2026 — EDUCATIONAL PRACTICE SUMMARY; N NOT STATED · EM ISSUE 19
Airway Management in Critically Ill Patients with Obesity: FRC Is Key
Obesity reduces functional residual capacity (FRC), shortening the safe apnoeic period and increasing the risk of rapid desaturation during emergency intubation. The UMEm Pearl recommends 25° head-up or ramped positioning, HFNO at 60 L/min for 3–5 minutes before RSI, and maintaining the ramped position during laryngoscopy; it reports that this may extend safe apnoea time from approximately 90 seconds to more than 5 minutes. Video laryngoscopy should be used first-line, with immediate access to surgical airway equipment; the pearl also recommends actual body weight dosing for ketamine, propofol and suxamethonium, and ideal body weight dosing for rocuronium. These are practical UK ED airway-planning measures, but the excerpt does not provide comparative trial data or a patient sample, so local airway expertise and drug protocols remain important.
Key numbers: 25° head-up/ramped positioning; HFNO 60 L/min for 3–5 minutes; reported extension of safe apnoea time from approximately 90 seconds to 5+ minutes; ketamine/propofol and suxamethonium dosed by actual body weight; rocuronium by ideal body weight; BMI >40 associated with higher failed-airway rate.
EUROPEAN JOURNAL OF PEDIATRICS 2026 · PROSPECTIVE OBSERVATIONAL STUDY · N NOT STATED · PMID: 42230808 · EM ISSUE 20
Lung Ultrasound Combined with CRP for Suspected Bacterial Pneumonia in Children
Distinguishing bacterial from viral pneumonia in children remains difficult and has important antibiotic-stewardship implications. In children aged 3 months to 5 years with suspected lower respiratory tract infection, combining lung-ultrasound consolidation with CRP >40 mg/L achieved specificity 0.91 for bacterial aetiology, compared with 0.72 for CRP alone; lung-ultrasound consolidation without raised CRP was more likely to represent viral pneumonitis or atelectasis. In UK ED practice, this combination may support antibiotic decisions alongside respiratory rate, work of breathing and oxygen saturation, while CRP >40 mg/L without consolidation should prompt consideration of sepsis rather than simple pneumonia. This was a prospective observational study, and the proposed bundle should not replace clinical assessment or be treated as definitive evidence of bacterial infection.
Key numbers: Combined LUS consolidation plus CRP >40 mg/L: specificity 0.91; CRP alone: specificity 0.72. Population described as children aged 3 months–5 years with suspected LRTI.
ANNALS OF EMERGENCY MEDICINE, 2026; CT-BASED COHORT STUDY; SAMPLE SIZE NOT STATED · EM ISSUE 24
Needle thoracostomy in obesity: 4th/5th ICS anterior axillary line preferred over 2nd ICS midclavicular line
In patients with class II and III obesity, chest wall thickness increases more significantly at the 2nd intercostal space midclavicular line than at the 4th/5th intercostal space anterior axillary line. The anterior axillary site had consistently lower chest wall thickness, making successful decompression with a standard 14G catheter-over-needle more likely. For UK ED practice, use the 4th/5th ICS anterior axillary line as the first-choice landmark in patients with visible obesity, or when the 2nd ICS approach fails; ensure adequate catheter length and have finger thoracostomy with tube drainage as a backup. This was a CT-based cohort study of anatomical measurements rather than a clinical intervention study, and the sample size and patient-outcome data are not provided in the excerpt.
Key numbers: Class II and III obesity; 4th/5th ICS anterior axillary line versus 2nd ICS midclavicular line; standard catheter length cited as 3.25 cm; sample size not stated
INT J EMERG MED, 2026, META-ANALYSIS; SAMPLE SIZE NOT STATED · EM ISSUE 25
Chest tube clamping before removal does not reduce pneumothorax recurrence
Chest tubes are sometimes clamped before removal to identify an occult ongoing air leak, although this adds a procedural step. This meta-analysis found no difference between clamping and non-clamping in pneumothorax recurrence, re-intervention rates or hospital length of stay. UK EDs and inpatient teams could consider a non-clamping approach where appropriate, subject to local thoracic surgery and respiratory guidance. The excerpt provides no sample size or effect estimates, and the findings should be interpreted in the context of the indication for drainage and local chest-drain protocols.
Key numbers: No sample size or effect estimates stated; no difference reported for pneumothorax recurrence, re-intervention rates or hospital length of stay.
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026 — SMALL RETROSPECTIVE COHORT; N NOT STATED · EM ISSUE 26
Neuromuscular Blockers for RSI in Myasthenia Gravis
Patients with myasthenia gravis may be vulnerable to prolonged neuromuscular blockade during emergency rapid sequence intubation. In this small retrospective ED cohort, most patients received standard-dose rocuronium without obvious deleterious effects, although a small minority had possible prolonged paralysis and objective recovery monitoring was infrequent. For UK ED practice, rocuronium 1.2 mg/kg with sugammadex immediately available is a reasonable approach when RSI is required; optimise ventilation before induction, prepare sugammadex 16 mg/kg, use train-of-four monitoring where available and alert ICU to the risk of prolonged paralysis. The retrospective design, small cohort and lack of standardised post-intubation neuromuscular monitoring mean that definitive dosing recommendations cannot be made, and the findings should not be interpreted as proof that MG patients have normal rocuronium sensitivity.
Key numbers: Rocuronium 1.2 mg/kg; sugammadex 16 mg/kg; small minority with possible prolonged paralysis; cohort size not stated
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026, STRUCTURED EVIDENCE-BASED REVIEW; RSI TRIAL CITED, RANDOMISED TRIAL, N=2,367 · EM ISSUE 27
Physiologically Difficult Airway: Evidence-Based Update
The physiologically difficult airway is defined by physiological vulnerability rather than difficult anatomy, with hypotension, hypoxaemia, metabolic acidaemia, right-ventricular failure and raised intracranial pressure identified as key phenotypes. In the cited RSI trial (n=2,367), peri-intubation cardiovascular collapse occurred in 30.6% with ketamine versus 20.9% with etomidate, an absolute difference of 9.7%; 28-day mortality was identical. For UK ED practice, this supports prioritising haemodynamic optimisation and considering etomidate rather than assuming ketamine is safer in shocked patients. Interpretation requires caution because most of the difference reflected new or increased vasopressor requirement rather than cardiac arrest or severe hypotension, and etomidate-related adrenal suppression remains a concern for 24 hours.
Key numbers: RSI trial n=2,367; cardiovascular collapse 30.6% with ketamine versus 20.9% with etomidate; absolute difference 9.7%; 28-day mortality identical; shock index ≥0.8–1.0 associated with increased risk of cardiovascular collapse (OR 3.2–5.5).
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026; SINGLE-CENTRE RETROSPECTIVE COHORT, 154 INTUBATIONS IN 144 PATIENTS · EM ISSUE 27
Higher-dose rocuronium for RSI and first-pass success
In this retrospective cohort of emergency and intensive care intubations performed with video laryngoscopy, rocuronium doses above 1.2 mg/kg were associated with 100% first-pass success, compared with 89.5% with doses of 1.2 mg/kg or less. There were no reported differences in 30-day mortality, ICU or hospital length of stay, or time to intubation. For UK RSI practice, actual-body-weight dosing at a minimum of 1.2 mg/kg is reasonable; 1.5 mg/kg may be considered for a physiologically difficult airway, and departments should review flat 100 mg protocols that may underdose patients over 83 kg. Interpretation is limited by the single-centre retrospective design, video-laryngoscopy-only setting and BMI imbalance between groups; no downstream mortality benefit was demonstrated.
Key numbers: First-pass success 100% with >1.2 mg/kg (mean 1.5 mg/kg) versus 89.5% with ≤1.2 mg/kg (mean 1.0 mg/kg); n=154 intubations in 144 patients; ARD −10.5%; 95% CI −0.2 to −0.03; P<0.01.
AMERICAN THORACIC SOCIETY, 2026 — CLINICAL PRACTICE GUIDELINE BASED ON NETWORK META-ANALYSES OF 39 RCTS (N=7,640) FOR ACUTE HYPOXAEMIC FAILURE AND 15 RCTS (N=3,420) FOR PREOXYGENATION · EM ISSUE 28
ATS 2026 guideline: HFNC and NIV for acute respiratory failure and preoxygenation
This American Thoracic Society Clinical Practice Guideline synthesised evidence for non-invasive respiratory support across acute respiratory failure and preoxygenation. In acute hypoxaemic failure, HFNC versus standard oxygen was associated with lower intubation risk (RR 0.76, 95% CI 0.64–0.89) and mortality (RR 0.81, 95% CI 0.67–0.97); for pre-intubation oxygenation, NIV versus standard oxygen reduced intubation (RR 0.51, 95% CI 0.35–0.75). In UK ED practice, this supports reviewing RSI preoxygenation pathways, with HFNC or NIV available alongside continuous oxygen delivery during airway management, consistent with the DAS 2025 peroxygenation principle. The guideline is American rather than UK-specific, and the mortality evidence for HFNC was low certainty, so local BTS, DAS and departmental protocols remain important.
Key numbers: HFNC versus standard oxygen: intubation RR 0.76 (95% CI 0.64–0.89), mortality RR 0.81 (95% CI 0.67–0.97); NIV versus standard oxygen for preoxygenation: intubation RR 0.51 (95% CI 0.35–0.75). Acute hypoxaemic failure: 39 RCTs, n=7,640; preoxygenation: 15 RCTs, n=3,420.
PAEDIATRIC PULMONOLOGY 2026 — RETROSPECTIVE SINGLE-CENTRE CASE SERIES, N=32 · EM ISSUE 28
Paediatric supraglottitis: increasing incidence and adenovirus as a common aetiology
This retrospective review of 32 children admitted to a tertiary PICU found that paediatric supraglottitis increased by 330% between the first and second decades of the 2004–2024 study period. A viral aetiology was identified in 19/30 children with microbiological data, with adenovirus accounting for 10/19 viral cases; invasive ventilation was required in 53% and non-invasive ventilation in 9%. In UK ED practice, do not be falsely reassured by vaccination history: involve senior anaesthetics and ENT immediately, avoid oropharyngeal examination in a distressed child, and proceed to controlled examination and intubation in theatre, with nebulised adrenaline as a temporising measure and broad-spectrum IV antibiotics plus dexamethasone 0.15 mg/kg IV. This was a small retrospective single-centre PICU case series without a denominator population, so the reported incidence increase may partly reflect changes in viral testing and the findings may not generalise to all children with supraglottitis.
Key numbers: Incidence increased by 330%; viral aetiology in 19/30; adenovirus in 10/19 viral cases; invasive ventilation 53%; non-invasive ventilation 9%.
EMERGENCY MEDICINE JOURNAL; 2026; SYSTEMATIC REVIEW; 4 PROSPECTIVE OBSERVATIONAL STUDIES · EM ISSUE 29
POCUS to Predict Difficult Intubation in the ED: Systematic Review
This systematic review examined whether point-of-care ultrasound can predict difficult laryngoscopy in the emergency department. Four prospective observational studies evaluated hyomental distance, tongue thickness and anterior neck soft-tissue thickness; several parameters showed fair to excellent diagnostic accuracy and correlated with Cormack–Lehane grade. In UK practice, POCUS may be used as an adjunct to standard airway assessment and structured RSI planning when appropriate training is available, but it should not delay preparation or intubation. The evidence base is small and heterogeneous, with variation in populations, measurement techniques, thresholds, operator training and definitions of difficult intubation; no pooled sensitivity or specificity estimates were provided, and POCUS should not replace standard assessment tools or preparation for Plans A–D.
Key numbers: Four prospective observational studies; parameters included hyomental distance, tongue thickness and anterior neck soft-tissue thickness; fair to excellent diagnostic accuracy reported; no pooled sensitivity or specificity estimates.
CHAPTER 4
Trauma & Haemorrhage
8 items · EM Evidence Rundown Issues 19–31
JOURNAL OF TRAUMA & ACUTE CARE SURGERY, 2026, LARGE OBSERVATIONAL COHORT; SAMPLE SIZE NOT STATED IN THE EXCERPT · EM ISSUE 21
FFP-first resuscitation associated with improved survival compared with PRBC-first in massive transfusion
Among severely injured patients requiring massive transfusion, an FFP-first strategy—giving fresh frozen plasma before or alongside packed red cells from the first product—was independently associated with improved survival to hospital discharge compared with a PRBC-first strategy. The finding supports early balanced damage-control resuscitation, consistent with 1:1:1 blood-component principles. UK emergency departments should review whether their major haemorrhage protocol delivers balanced products promptly; a sequence involving four units of RBC before the first FFP pack warrants consideration for local review with the trauma and haematology teams. This was observational evidence, so confounding by experienced teams, trauma-centre volume and wider major haemorrhage practice may explain some of the association; randomised evidence specifically comparing FFP-first with PRBC-first is limited.
Key numbers: No sample size stated in the excerpt; 1:1:1 damage-control resuscitation principle; some protocols may give four units of RBC before the first FFP pack
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026 — MULTIMODAL QUALITY-IMPROVEMENT INTERVENTION; SAMPLE SIZE NOT STATED · EM ISSUE 25
Multimodal QI intervention reduces CT use in adult blunt head injury without missed TBI or increased returns
CT overuse in adult blunt head injury exposes patients to radiation and cost, while underuse risks missed traumatic brain injury (TBI). A bundled intervention comprising guideline implementation, education, feedback and clinical decision-support tools significantly reduced CT utilisation without increasing missed TBI, return visits or other adverse outcomes. In UK EDs, a similar project could combine NICE head-injury criteria with structured documentation of applicable Canadian CT Head Rule or NEXUS criteria, supported by audit and electronic prompts. The excerpt does not provide the sample size, effect size, follow-up duration or detailed outcome definitions, so the findings should support local quality improvement rather than replace clinical judgement or NICE guidance.
Key numbers: No sample size or effect size stated in the excerpt; CT use was significantly reduced without increased missed TBI, return visits or adverse outcomes.
ACADEMIC EMERGENCY MEDICINE 2026 — PROSPECTIVE OPEN-LABEL RCT, N=38 · EM ISSUE 26
Serratus anterior plane block for acute rib fractures in the ED: first RCT
In adults with anterior or lateral T2–T9 rib fractures and pain of at least 5/10, serratus anterior plane block (SAPB) plus usual care was compared with usual care alone in a US Level I trauma centre. SAPB improved the composite Pain, Inspiratory Capacity and Cough (PIC) score at 5 hours by an estimated average of 0.90 points (95% CI 0.10–1.69; p=0.03). Twenty-four-hour oral morphine equivalent use was lower with SAPB (32.2 mg versus 54.1 mg), but this difference was not statistically significant (p=0.44), and no complications were reported. UK EDs could consider departmental training and selective use for painful rib fractures, while recognising that this small, single-centre, open-label study does not establish SAPB as routine standard practice or define procedural competency requirements.
Key numbers: +0.90 PIC score improvement at 5 hours (95% CI 0.10–1.69; p=0.03); 24-hour oral morphine equivalents 32.2 versus 54.1 mg (p=0.44); n=38
EMERGENCY MEDICINE JOURNAL, 2026 — UK MULTICENTRE OBSERVATIONAL STUDY, N=477. · EM ISSUE 26
Paediatric E-Scooter Injuries in UK Major Trauma Centres
This study examined 477 patients under 16 years with e-scooter injuries presenting to three UK Paediatric Major Trauma Centres between January 2019 and December 2024, with incidence rising throughout the study period. The median age was 12 years, 64.4% were male, 13.4% were admitted and 6.9% required surgery; head injuries occurred in 24.1%, of which 10.4% were major. In UK EDs, maintain a low threshold for careful head-injury assessment after apparently minor e-scooter trauma, and include helmet use, supervision and safeguarding-focused discharge advice. Generalisability is limited because the study involved three specialist centres, and its observational design cannot establish causation; nevertheless, the marked deprivation gradient and very low helmet use are important contextual findings.
Key numbers: n=477; median age 12 years; 64.4% male; 13.4% admitted; 6.9% required surgery; head injuries 24.1%; 10.4% of head injuries major; 1.8% wearing helmets; 74% from IMD deciles 1–2.
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY 2026; RETROSPECTIVE MULTICENTRE STUDY, N=275 · EM ISSUE 26
Blunt traumatic pneumothorax: non-invasive management appears safe in selected adults
Small, stable traumatic pneumothoraces may be suitable for observation rather than immediate tube thoracostomy. In this multicentre retrospective study of 275 adults with blunt traumatic pneumothorax, non-invasive management with observation and supplemental oxygen was used in 45.8% and was not associated with worse outcomes than tube thoracostomy. In UK ED practice, observation is consistent with NICE and EAST guidance for a small pneumothorax (<2 cm apex-to-pleura on upright chest radiograph) without clinical compromise. The findings are subject to selection bias, as smaller and more stable pneumothoraces were more likely to be managed conservatively.
Key numbers: n=275; non-invasive management used in 45.8%; small defined in the excerpt as <2 cm apex-to-pleura on upright chest radiograph
ANNALS OF EMERGENCY MEDICINE JOURNAL CLUB, 2026; REVIEW OF TWO PHASE 3 RANDOMISED CONTROLLED TRIALS (SWIFT AND TOWAR); SAMPLE SIZES NOT STATED · EM ISSUE 28
Whole Blood versus Component Therapy for Out-of-Hospital Trauma
Prehospital whole blood has been proposed as a simpler resuscitation strategy for major trauma, but the AEM Journal Club review of the SWiFT and TOWAR phase 3 trials found no superiority for the primary outcomes in either trial. The case for whole blood therefore rests on logistical advantages rather than demonstrated mortality benefit. UK trauma systems should not switch HEMS protocols to whole blood solely on the basis of pre-RCT observational evidence; balanced 1:1:1 therapy or 1:1 red cells plus fresh frozen plasma remains the evidence-based standard. The excerpt does not provide trial sample sizes or effect estimates, so the precise magnitude and precision of any difference cannot be assessed here.
Key numbers: No superiority for primary outcomes in either SWiFT or TOWAR; trial sample sizes and effect estimates not stated
J TRAUMA ACUTE CARE SURG 2026; PRE-PLANNED SECONDARY ANALYSIS OF A MULTICENTRE PRAGMATIC PARALLEL-GROUP RCT; N=338 TRAUMA PATIENTS · EM ISSUE 30
Videolaryngoscopy versus direct laryngoscopy for emergency intubation in trauma: DEVICE trial secondary analysis
In this pre-planned secondary analysis of the DEVICE trial, 338 critically ill adults intubated after traumatic injury were assessed for first-attempt success with videolaryngoscopy (VL) or direct laryngoscopy (DL). First-pass success was 88% with VL (151/171) versus 68% with DL (114/167), an absolute risk difference of 20 percentage points (95% CI 11–29%), approximately one additional first-pass success for every five patients. UK trauma teams should use VL as the default laryngoscope for trauma rapid sequence intubation where available, consistent with DAS 2025 recommendations. This was a subgroup analysis, with randomisation not stratified by trauma status and insufficient power for severe complications or in-hospital outcomes; the neutral secondary safety findings should therefore not be interpreted as proof of equivalent safety.
Key numbers: VL first-pass success 88% (151/171) versus DL 68% (114/167); absolute risk difference +20 percentage points (95% CI 11–29%); approximate NNT=5.
SCAND J TRAUMA RESUSC EMERG MED 2026 — SYSTEMATIC REVIEW AND META-ANALYSIS, 15 STUDIES, N=7,430 CHILDREN · EM ISSUE 31
CT in Paediatric Blunt Abdominal Trauma: Selective Use Supported
This systematic review and meta-analysis examined children with blunt abdominal trauma who underwent CT. In this selected population, intra-abdominal injury prevalence was 84.5%, but only 7.7% required an intervention and mortality was 1.4%; solid-organ injuries predominated. In UK practice, use the validated PECARN abdominal trauma prediction rule to identify very-low-risk children who can avoid CT, with FAST and urgent surgical referral for unstable patients. The high injury prevalence cannot be generalised to all children with blunt trauma because the studies included children already selected for CT, and certainty was low for several outcomes.
Key numbers: Intra-abdominal injury 84.5% (95% CrI 62–94%); intervention 7.7%; mortality 1.4%; 15 studies, 7,430 children.
CHAPTER 5
Sepsis & Critical Infection
10 items · EM Evidence Rundown Issues 19–31
EVANS ET AL., CRITICAL CARE MEDICINE 2026 — ADULT CLINICAL PRACTICE GUIDELINE; 129 STATEMENTS (46 NEW), N NOT STATED. · EM ISSUE 19
2026 Surviving Sepsis Campaign Adult Guidelines: Key ED Changes
The 2026 Surviving Sepsis Campaign update retains an initial 30 mL/kg fluid bolus but emphasises dynamic assessment for further resuscitation, earlier peripheral vasopressors and source control within 6 hours where feasible. Antibiotic timing is nuanced by NEWS2 risk: immediate treatment for shock, 1 hour for non-shock high-risk patients, and a short deliberate diagnostic delay for possible low-risk sepsis. For UK EDs, the Sepsis Six and NICE NG51 remain the operational framework, with the update supporting earlier vasopressors, risk-stratified antibiotics and sepsis huddles. The 6-hour source-control target is described as aspirational rather than evidence-derived, and local pathways should be reconciled with UK guidance.
Key numbers: 129 total statements; 46 new; initial fluid bolus 30 mL/kg; source control within 6 hours where feasible; NEWS2 3–4 without shock: antibiotics within 1 hour; NEWS2 ≥5 plus shock: immediate antibiotics.
SHOCK, 2026; SYSTEMATIC REVIEW AND META-ANALYSIS; N=2,727 · EM ISSUE 20
Mottling score, capillary refill time and peripheral perfusion index predict mortality in sepsis
Peripheral perfusion assessment complements MAP and lactate during sepsis resuscitation. In this systematic review and meta-analysis of 2,727 patients, mottling score, capillary refill time (CRT) and peripheral perfusion index (PPI) were each independently associated with mortality. In UK ED practice, add all three to reassessment at 1 and 6 hours: mottling score ≥3, CRT >2 seconds and PPI <0.7 indicate abnormal peripheral perfusion and should prompt continued concern despite apparently satisfactory macrohaemodynamic measures. These are prognostic markers rather than proven treatment targets, so the review does not establish that management guided by them improves outcomes.
Key numbers: n=2,727; mottling score, CRT and PPI independently predicted mortality; abnormal thresholds reported as mottling score ≥3, CRT >2 seconds and PPI <0.7.
CRIT CARE MED 2026 — TARGET TRIAL EMULATION USING OBSERVATIONAL ICU DATA; SAMPLE SIZE NOT STATED · EM ISSUE 20
Continuing versus withholding home beta-blockers at sepsis admission
Beta-blockers are often withheld at sepsis admission because of concern that limiting compensatory tachycardia may be harmful. In this target trial emulation, withholding home beta-blockers was associated with significantly higher in-hospital mortality than continuing them in haemodynamically stable patients. In UK ED practice, do not reflexively stop a home beta-blocker when SBP is ≥90 mmHg and the patient is not receiving vasopressors; consider dose reduction or withholding during hypotension or vasopressor treatment, with review for reinstatement as the patient stabilises. This was not a randomised trial, and unmeasured confounding remains a major concern because beta-blockers may have been withheld in patients who were already sicker.
Key numbers: SBP ≥90 mmHg and no vasopressors suggested as criteria for continuation; no mortality estimate stated.
CLINICAL INFECTIOUS DISEASES 2026 · MULTICENTRE OBSERVATIONAL COHORT · N=39,842 HOSPITALISATIONS · EM ISSUE 21
Delayed Antibiotics in Septic Shock Versus Sepsis Without Shock
This multicentre cohort examined whether the association between antibiotic delay and mortality differed according to shock status, including immunocompetent and immunocompromised patients. In septic shock requiring vasopressors, delayed antibiotics were independently associated with increased mortality; in sepsis without shock, delay was not significantly associated with mortality in either group. For UK ED practice, septic shock should prompt antibiotics within 1 hour, whereas in non-shock sepsis a brief, structured diagnostic assessment to confirm infection, obtain cultures and identify the source is more defensible, while still treating within the relevant clinical timeframe. This was an observational study, so confounding remains important because clinical factors may both delay antibiotics and increase mortality.
Key numbers: n=39,842 hospitalisations; delayed antibiotics were associated with higher mortality in septic shock but not significantly associated with mortality in sepsis without shock; no effect estimates reported.
INTENSIVE CARE MEDICINE, 2026, REVIEW · EM ISSUE 21
Distributive Shock in Sepsis: Beyond Vasoplegia
Distributive shock in sepsis is traditionally framed as nitric-oxide-mediated vasoplegia causing low systemic vascular resistance, but this review describes a broader model involving microcirculatory failure, mitochondrial dysfunction and endothelial injury. Microcirculatory heterogeneity can produce tissue hypoxia despite an apparently adequate systolic blood pressure or MAP, while mitochondrial dysfunction may cause cytopathic hypoxia and endothelial glycocalyx injury promotes capillary leak and oedema. In UK ED practice, assess perfusion alongside blood pressure and vasopressor requirement, using trends in lactate, capillary refill time and mottling, and avoid assuming that a normalised MAP alone indicates adequate resuscitation. This is a mechanistic review rather than evidence of benefit from a specific intervention, so it should inform clinical assessment without replacing established sepsis resuscitation guidance.
NICE, 2026; IN-DEVELOPMENT GUIDANCE UPDATE · EM ISSUE 22
NICE sepsis update on procalcitonin delayed to 11 September 2026
The anticipated NICE update to NG253, which is expected to add procalcitonin testing to the sepsis pathway, has been delayed again. Publication is now expected on 11 September 2026, rather than the previously projected July 2026 date. UK emergency departments should continue to follow current NICE NG253 guidance, published in November 2025; the NHS England Sepsis Modern Service Framework published on 14 July 2026 remains in effect. This is a timing update rather than a change to current sepsis assessment or management, and the proposed procalcitonin recommendations should not be implemented before the updated guidance is published.
Key numbers: Expected update date: 11 September 2026; previous projection: July 2026; current NG253: November 2025; NHS England Sepsis Modern Service Framework: 14 July 2026
BMC PEDIATRICS, 2026, RETROSPECTIVE COHORT, N=44 · EM ISSUE 22
Base Deficit and Alactic Base Excess for Early Shock Prediction in Paediatric Sepsis
In this small retrospective cohort of 44 paediatric sepsis patients, base deficit and alactic base excess showed better discrimination than lactate alone for predicting progression to septic shock. These markers may provide an early warning when the initial lactate is borderline. In UK emergency departments, a significant base deficit should prompt further assessment and consideration of earlier escalation, even when lactate is below 2 mmol/L; this does not replace the Sepsis 6 or NICE NG139 pathway. The single-centre retrospective design and very small sample mean that the findings are hypothesis-generating and should not independently change practice.
Key numbers: n=44; lactate <2 mmol/L with significant base deficit (<-4) should not be falsely reassuring
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026; RETROSPECTIVE SINGLE-CENTRE TAIWANESE COHORT; SAMPLE SIZE NOT STATED · EM ISSUE 26
Band neutrophil percentage and short-term mortality in ED bacteraemia
In ED patients with confirmed bacteraemia, a higher initial band neutrophil percentage on manual differential was associated with incrementally greater short-term mortality, with a dose-dependent relationship. The association was reported as independent of complete severity scores, but no mortality figures or effect estimates are provided in the excerpt. In UK practice, an already available manual differential showing more than 10% bands in a clinically concerning patient may reasonably increase concern while cultures are pending and support early senior review, monitoring and antibiotics according to local sepsis pathways. This should not be added to formal sepsis risk-stratification protocols yet: the study was retrospective and single-centre, used manual differentials that are not routine in most UK laboratories, and requires prospective multicentre validation.
Key numbers: >10% bands suggested as a high-risk finding in the newsletter; no mortality effect estimate stated
JOURNALFEED, 2026 — SYSTEMATIC REVIEW AND META-ANALYSIS; SAMPLE SIZE NOT STATED · EM ISSUE 26
Predictors of Mortality in Necrotizing Fasciitis
This systematic review and meta-analysis examined factors associated with short-term mortality in necrotising soft-tissue infections. Increased mortality was independently associated with older age, chronic liver or kidney disease, greater comorbidity burden, delayed surgery and failure to achieve source control at the first debridement; delayed surgery was the most consistently modifiable factor. In UK ED practice, involve the on-call surgical team early, minimise time to theatre, start intravenous broad-spectrum antibiotics promptly and do not delay source control for formal imaging when the clinical diagnosis is clear. LRINEC has limited sensitivity in isolation and should not be used to rule out necrotising fasciitis when clinical suspicion is high; the review’s sample size and detailed study characteristics are not provided in the excerpt.
Key numbers: LRINEC sensitivity 59–89% in validation; time-to-surgery was described as the most consistently modifiable predictor. Sample size not stated.
CRITICAL CARE MEDICINE / MCMASTER EVIDENCEALERTS, 2026, SYSTEMATIC REVIEW AND META-ANALYSIS · EM ISSUE 26
Phoenix Sepsis Criteria Outperform IPSCC for Paediatric Sepsis
This systematic review and meta-analysis evaluated the prognostic accuracy of the Phoenix Sepsis Criteria (PSC) versus the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria for predicting in-hospital mortality in children with suspected infection. PSC demonstrated better sensitivity and specificity than IPSCC, although performance varied by clinical setting, with better discrimination in higher-resource settings. In UK practice, clinicians should recognise Phoenix sepsis as suspected infection plus a score of at least 2 across respiratory, cardiovascular, coagulation and neurological systems; an additional cardiovascular point defines septic shock. This is a prognostic validation study rather than evidence that Phoenix-guided management improves outcomes, and UK pathway implementation is still aligning with the criteria.
Key numbers: Phoenix sepsis: ≥2 points across 4 organ systems; ≥1 additional cardiovascular point defines septic shock. Better sensitivity and specificity than IPSCC; no numerical estimates stated.
CHAPTER 6
Cardiovascular Emergencies
10 items · EM Evidence Rundown Issues 19–31
CRITICAL CARE MEDICINE, 2026, NON-INFERIORITY RCT; SAMPLE SIZE NOT STATED · EM ISSUE 19
Enteral versus IV magnesium replacement in critically ill adults
Hypomagnesaemia affects up to 65% of ICU patients and is associated with arrhythmias, prolonged ventilation and seizures. In haemodynamically stable critically ill adults, enteral magnesium delivered via nasogastric tube achieved non-inferior serum magnesium repletion at 72 hours compared with intravenous replacement, with no difference in clinical outcomes. In UK ED practice, enteral magnesium glycerophosphate or citrate is a reasonable option for stable patients with mild-to-moderate hypomagnesaemia when enteral access is already present, including SDEC or clinical decision unit patients. This should not change management of acute severe or symptomatic hypomagnesaemia, such as arrhythmias or seizures, for which IV replacement remains standard; the study population was ICU-based rather than acute ED resuscitation.
Key numbers: Hypomagnesaemia occurs in up to 65% of ICU patients; enteral replacement was non-inferior for serum magnesium repletion at 72 hours, with no difference in clinical outcomes.
AMERICAN JOURNAL OF EMERGENCY MEDICINE 2026; DOUBLE-BLIND SINGLE-CENTRE ED RCT, N=50 · EM ISSUE 27
Bolus versus continuous-infusion furosemide in acute decompensated heart failure
In acute decompensated heart failure, this double-blind single-centre ED RCT compared bolus with continuous-infusion intravenous furosemide in patients with NYHA III–IV disease and no chronic kidney disease. Four-hour urine output was 2,150 mL with bolus treatment versus 2,400 mL with infusion (P=0.60), with no significant difference in jugular vein collapsibility index change or spot urinary sodium; JVCI improved significantly over time in both groups (P<0.001). For UK ED practice, bolus IV furosemide is a simpler option without a syringe driver or infusion-rate errors; the excerpt gives a typical starting dose of 40–80 mg IV or double the usual oral dose, with IVC or jugular-vein POCUS to monitor decongestion. The small, single-centre study excluded patients with chronic kidney disease, so its findings may not generalise to all patients with acute heart failure.
Key numbers: n=50; 4-hour urine output 2,150 mL bolus versus 2,400 mL infusion (P=0.60); JVCI improved over time in both groups (P<0.001).
EMERGENCY MEDICINE JOURNAL, 2026 — SYSTEMATIC REVIEW/META-ANALYSIS, APPROXIMATELY 10,000 ADULTS · EM ISSUE 27
Point-of-care high-sensitivity troponin algorithms for myocardial infarction rule-out and rule-in
A 2026 systematic review/meta-analysis examined point-of-care high-sensitivity troponin algorithms, including 0/1-hour serial sampling, in approximately 10,000 adults. Sensitivity for myocardial infarction rule-out was at least 97%, comparable to laboratory high-sensitivity troponin pathways, while serial testing also had high specificity for rule-in. For UK emergency departments and ambulance services introducing point-of-care testing, validated assay-specific pathways may support safe rapid assessment alongside appropriate local governance. The principal caveat is that 99th-percentile thresholds and delta values vary between devices; use only algorithms validated for the specific assay, with laboratory testing remaining the NICE NG185 standard.
Key numbers: Approximately 10,000 adults; sensitivity ≥97% for MI rule-out using POCT hs-troponin algorithms; high specificity for rule-in with serial testing; 0/1-hour sampling.
ANNALS OF EMERGENCY MEDICINE, 2026; 368,730 CHEST PAIN VISITS ACROSS 38 EDS; DESIGN NOT STATED IN EXCERPT · EM ISSUE 27
Peer feedback with HEART protocols reduces admissions among high-admitting clinicians
In a large analysis of 368,730 chest pain visits across 38 emergency departments, adding peer feedback to HEART-based chest pain protocols reduced admissions among the highest-admitting clinicians by 14.3% in state A and 5.6% in state B. The effect was confined to clinicians with high baseline admission rates rather than occurring across the board. UK departments using HEART or hs-troponin pathways could consider targeted peer feedback as a quality-improvement intervention for admission outliers, consistent with NICE NG185. However, no patient-centred safety outcomes were presented, so the reduction should be regarded as a promising service signal rather than proof that all avoided admissions were appropriate.
Key numbers: 368,730 chest pain visits across 38 EDs; admission reduction 14.3% in state A and 5.6% in state B among highest-admitting clinicians; no patient safety data presented
EUROPEAN JOURNAL OF CLINICAL INVESTIGATION, 2026; RETROSPECTIVE SINGLE-CENTRE STUDY; SAMPLE SIZE NOT STATED · EM ISSUE 27
Acute pericarditis in the ED: colchicine initiation and aspirin dosing gaps
This retrospective single-centre study identified gaps in emergency department management of acute pericarditis. Aspirin was often under-dosed, despite the cited weight-based regimen of 500–1000 mg three times daily, and colchicine was not initiated in all eligible patients; the stated regimen is 0.5 mg twice daily for 3 months, reduced to once daily if body weight is below 70 kg. In UK practice, clinicians should assess for high-risk features, prescribe an appropriate anti-inflammatory plus colchicine when suitable, and arrange follow-up at 1 week if discharging a low-risk patient. The study does not provide reliable risk-stratification data and is limited by its retrospective, single-centre design.
Key numbers: Aspirin 500–1000 mg three times daily; colchicine 0.5 mg twice daily for 3 months, or 0.5 mg once daily if <70 kg; sample size not stated.
NEW ENGLAND JOURNAL OF MEDICINE 2026 — UK MULTICENTRE OPEN-LABEL RANDOMISED CONTROLLED TRIAL, N=3,170 · EM ISSUE 28
Routine CTCA after MI rule-out does not reduce MI or cardiac death
In patients with suspected ACS whose MI had been ruled out by high-sensitivity troponin, this UK trial compared routine outpatient CTCA-guided management with standard care. At 3 years, the composite of MI or cardiac death was similar with CTCA and standard care: 7.1% versus 7.3% (adjusted HR 0.95, 95% CI 0.73–1.23; p=0.71). UK ED practice should therefore avoid routinely requesting CTCA after a negative hs-troponin, reserving it for selected intermediate-risk patients, such as those with HEART ≥4, unexplained new ECG changes or persistent strong clinical suspicion. The trial enrolled patients using troponin criteria rather than a clinical risk score, and standard care allowed CTCA at clinician discretion, so selection remains important.
Key numbers: Primary outcome at 3 years: 7.1% with CTCA versus 7.3% with standard care; adjusted HR 0.95 (95% CI 0.73–1.23; p=0.71). CTCA uptake was 92.1% versus 2.2%.
EUROPEAN JOURNAL OF EMERGENCY MEDICINE, 2026, RETROSPECTIVE OBSERVATIONAL COHORT, N=1,296 · EM ISSUE 28
Acute heart failure with concurrent infection: an independent mortality driver
Concurrent infection was identified in 119 of 1,296 adult acute heart failure presentations and was associated with substantially higher in-hospital mortality: 30.3% versus 9.0% without infection, an absolute risk difference of 21.3 percentage points. After inverse probability weighting, infection remained associated with increased in-hospital mortality (OR 2.76, 95% CI 1.64–4.66) and poorer post-discharge survival (HR 1.64, 95% CI 1.14–2.37). In UK ED practice, actively seek an infective precipitant and manage it alongside acute heart failure, including blood cultures, empirical antibiotics when appropriate, diuresis and closer monitoring. This was a retrospective, single-centre French study from 2020; infection was adjudicated retrospectively, COVID-19 was not separated from other infections, and causality cannot be established.
Key numbers: Infection: 119/1,296 (9.2%); in-hospital mortality 30.3% versus 9.0% (ARD +21.3 percentage points); adjusted OR 2.76 (95% CI 1.64–4.66); post-discharge survival HR 1.64 (95% CI 1.14–2.37; p=0.008).
BMJ 2026 — COMMISSIONED STATE OF THE ART REVIEW; N NOT STATED · EM ISSUE 29
Diagnosis and Management of Acute Hyperkalaemia
This BMJ State of the Art review synthesises the diagnosis and emergency management of acute hyperkalaemia, including UK Kidney Association and ERC thresholds. For potassium ≥6.5 mmol/L, it describes a three-step approach: IV calcium gluconate 2–3 g, insulin 5–10 units with 10% glucose, then nebulised salbutamol 10–20 mg; 5 units of insulin may be used in CKD, AKI or glucose <7. ECG findings are an unreliable severity marker, with peaked T waves reported in fewer than 25% of patients at potassium 5.5–7.0 mmol/L, so treatment should not await ECG changes at ≥6.5 mmol/L. In UK ED practice, confirm or exclude pseudohyperkalaemia promptly, initiate the algorithm when indicated, and consider newer binders such as sodium zirconium cyclosilicate or patiromer rather than Resonium; the review is a synthesis rather than a new comparative trial, and local protocols and monitoring remain important.
Key numbers: Mild 5.5–5.9 mmol/L; moderate 6.0–6.4 mmol/L; severe ≥6.5 mmol/L. Calcium gluconate 2–3 g IV; insulin 5–10 units plus 10% glucose; salbutamol 10–20 mg nebulised. Peaked T waves in <25% at K 5.5–7.0 mmol/L.
AMERICAN JOURNAL OF EMERGENCY MEDICINE 2025; DOUBLE-BLIND, PLACEBO-CONTROLLED RANDOMISED TRIAL, N=217 · EM ISSUE 30
Intravenous calcium pre-treatment reduces diltiazem-associated hypotension in AF with rapid ventricular response
In haemodynamically stable adults with AF or atrial flutter and rapid ventricular response, intravenous diltiazem can cause hypotension. In this three-arm double-blind RCT, pre-treatment with 90 mg or 180 mg intravenous calcium chloride attenuated hypotension compared with placebo, while diltiazem’s rate-lowering effect was preserved; no significant differences were reported in additional diltiazem dosing or adverse events. For UK ED practice, calcium pre-treatment could be considered before intravenous diltiazem in stable AF with rapid ventricular response, subject to local formulary and protocol; it should not be used to justify diltiazem in an already hypotensive or borderline patient. The trial was small, conducted in a Turkish emergency department, and assessed short-term blood pressure rather than clinical outcomes; full numerical systolic blood pressure data were not available in the excerpt.
Key numbers: n=217; placebo n=73, 90 mg calcium chloride n=71, 180 mg calcium chloride n=73. Hypotension was attenuated at 5 minutes with 180 mg and at 15 minutes with both calcium doses; heart-rate control was preserved.
ACADEMIC EMERGENCY MEDICINE 2026; PROSPECTIVE MULTICENTRE OBSERVATIONAL SECONDARY ANALYSIS; N=1,263 · EM ISSUE 31
Syncope and Presyncope: Hospitalisation Has No Demonstrable Diagnostic Benefit in FAINT=0
In adults aged 40 years or older with syncope or presyncope and no serious diagnosis identified in the ED, this prospective multicentre observational study assessed whether hospitalisation detected serious adverse outcomes within 30 days. Serious adverse outcomes occurred in 5.9% overall; they were identified during admission in 8.0% of hospitalised patients compared with 2.1% among those discharged, while the adjusted odds ratio for hospitalisation versus discharge was 1.57 (95% CI 0.14–17.53) in the FAINT=0 subgroup and 3.35 (95% CI 1.78–6.31) in patients with FAINT ≥1. UK ED practice should avoid reflex admission for genuinely low-risk syncope or presyncope, while considering admission, monitoring and further cardiac assessment for patients with abnormal ECGs, raised biomarkers or cardiac history, alongside timely ambulatory monitoring after discharge. This was not a randomised trial, the FAINT=0 confidence interval was wide, and the six urban US academic ED setting limits certainty when applying the findings to younger patients or UK district general hospitals; hospitalisation was also associated with 13% iatrogenic adverse events.
Key numbers: 5.9% 30-day serious adverse outcome overall; 8.0% detected during admission in hospitalised patients; 2.1% within 30 days after discharge; FAINT=0 adjusted OR 1.57 (95% CI 0.14–17.53); FAINT ≥1 adjusted OR 3.35 (95% CI 1.78–6.31); 13% iatrogenic adverse events
CHAPTER 7
Pulmonary Embolism & DVT
3 items · EM Evidence Rundown Issues 19–31
JAMA 2026; MULTICENTRE RANDOMISED NON-INFERIORITY TRIAL, N=683 · EM ISSUE 22
HYDRA trial: YEARS algorithm for suspected PE in patients with cancer
In adults with active cancer and suspected PE, the HYDRA multicentre randomised trial compared a YEARS-based diagnostic algorithm with a CTPA-only strategy. The primary 90-day VTE or PE-related death outcome was 1.8% with YEARS versus 5.5% with CTPA-only; the algorithm met its pre-specified 2.6% non-inferiority margin, and 22% of patients avoided CTPA. In UK ED practice, patients with cancer who have no YEARS items and a D-dimer below 1000 ng/mL may be eligible to avoid CTPA, subject to local pathways and clinical judgement. The posterior risk may remain slightly higher than in non-cancer populations, so this evidence should not replace careful assessment or agreed local protocols.
Key numbers: n=683; 90-day VTE or PE-related death: 1.8% with YEARS versus 5.5% with CTPA-only; 22% avoided CTPA; non-inferiority margin 2.6%; ARD −3.7% (99.9% CI −8.8 to 1.4).
ACADEMIC EMERGENCY MEDICINE 2026; RETROSPECTIVE COHORT STUDY; N=6,427 · EM ISSUE 22
Outpatient PE management with DOACs in patients with sPESI 0–1
In a large retrospective cohort of 6,427 acute PE patients in the US Veterans Affairs system, patients with sPESI 0 or 1 treated with DOACs had very low 30-day mortality. Hospitalisation did not appear to improve outcomes compared with outpatient management, supporting outpatient treatment for haemodynamically stable, low-risk PE. In UK practice, consider outpatient management alongside NICE NG158, local PE pathways, anticoagulant counselling, and assessment of social suitability for discharge. The findings are observational and may have limited generalisability because the cohort came from a single US system and was younger and predominantly male; this approach does not apply to massive or submassive PE.
Key numbers: n=6,427; sPESI 0–1; very low 30-day mortality; no apparent outcome benefit from hospitalisation compared with outpatient management
UK SERVICE COHORT DATA AND NICE NG158, 2026; OBSERVATIONAL COHORT (N NOT STATED) · EM ISSUE 28
Low-Risk Pulmonary Embolism: Safe Discharge from the ED
Low-risk pulmonary embolism can be managed outside hospital in carefully selected patients using validated risk stratification and reliable follow-up. UK cohort data support ED discharge for patients with PESI class I–II or sPESI 0, provided same-day anticoagulation and rapid follow-up are arranged. In UK practice, rivaroxaban 15 mg twice daily for 21 days or apixaban 10 mg twice daily for 7 days are preferred single-agent options, consistent with NICE NG158. The cohort sample size and detailed methods are not provided in the excerpt, so local protocols should still address bleeding risk, comorbidity, social circumstances and follow-up reliability.
Key numbers: PESI class I–II or sPESI 0; rivaroxaban 15 mg twice daily for 21 days; apixaban 10 mg twice daily for 7 days; cohort n not stated
CHAPTER 8
Stroke & Neurology
2 items · EM Evidence Rundown Issues 19–31
CRITICAL CARE MEDICINE, 2026 — SYSTEMATIC REVIEW AND META-ANALYSIS OF 8 RCTS; N=12,669 · EM ISSUE 27
Aggressive versus Conservative Blood Pressure Reduction in Acute Intracerebral Haemorrhage
This systematic review and meta-analysis evaluated aggressive versus conservative blood-pressure reduction in acute intracerebral haemorrhage across 8 randomised controlled trials involving 12,669 patients. There was no difference in functional outcome, mortality or haematoma growth, while aggressive reduction was associated with fewer adverse events (RR 0.87, 95% CI 0.76–0.99; P=0.03). UK ED practice should continue prompt, protocolised blood-pressure lowering when tolerated, aiming for SBP 130–140 mmHg and avoiding SBP below 130 mmHg, using titratable intravenous agents such as labetalol or nicardipine. The mixed trial evidence does not support promising improved recovery or survival solely from pursuing a more aggressive target; the current NICE/AHA approach remains appropriate.
Key numbers: 8 RCTs; n=12,669; no difference in functional outcome, mortality or haematoma growth; fewer adverse events with aggressive reduction (RR 0.87, 95% CI 0.76–0.99; P=0.03); target SBP 130–140 mmHg and avoid <130 mmHg
STROKE 2026 — REVIEW ARTICLE; SAMPLE SIZE NOT STATED · EM ISSUE 27
Portable low-field MRI in acute stroke
Portable low-field MRI, such as the 0.064 T Hyperfine Swoop system, is being evaluated as an adjunct in acute stroke care. The review describes potential support for stroke-type classification and tissue confirmation when immediate CT or standard MRI is unavailable, particularly in rural or remote settings and intensive care. In UK emergency departments, this remains an emerging technology rather than standard practice; conventional neuroimaging pathways should therefore continue to guide acute assessment. The evidence is a review of an evolving field, and the excerpt does not provide comparative outcome data or establish that portable MRI improves patient outcomes.
Key numbers: Low-field MRI strength 0.064 T; sample size and outcome statistics not stated.
CHAPTER 9
Toxicology & Analgesia
7 items · EM Evidence Rundown Issues 19–31
AMERICAN JOURNAL OF EMERGENCY MEDICINE 2026; US-BASED RETROSPECTIVE OBSERVATIONAL COHORT; N=13,241 · EM ISSUE 22
Bedside toxicology consultation associated with better triage and fewer unnecessary admissions
In poisoned patients, bedside medical toxicology consultation was associated with higher rates of appropriate ED discharge and correct escalation to intensive care compared with management without toxicology input. The study included 13,241 patients, but the excerpt does not provide effect sizes or absolute rates. UK emergency departments without on-site toxicologists should use TOXBASE and contact the National Poisons Information Service early for complex overdose presentations. As a retrospective observational US study, it demonstrates an association rather than causation, and local service availability and pathways may differ.
Key numbers: n=13,241; higher rates of appropriate ED discharge and correct ICU escalation were reported, but no effect sizes are stated.
EUROPEAN MEDICINES AGENCY, 2026 — REGULATORY ASSESSMENT; N NOT STATED · EM ISSUE 23
EMA negative opinion on KemSu (intranasal sufentanil plus ketamine) for paediatric acute pain
KemSu (CT001) was an intranasal fixed-dose combination of sufentanil and ketamine proposed for acute pain management in children aged 1–18 years. The EMA’s CHMP concluded that it was not more effective than sufentanil alone, based on adult comparator data, while the paediatric study had no comparative arm; overall, benefits did not outweigh risks. The product’s refusal means that no licensed intranasal sufentanil–ketamine combination will be available in the near term, so UK ED practice remains reliant on established local protocols, including intranasal fentanyl or diamorphine for acute pain. This is a regulatory decision rather than evidence supporting or rejecting intranasal ketamine generally, and Proveca may request re-examination.
Key numbers: Children aged 1–18 years; combination not more effective than sufentanil alone; paediatric study lacked a comparative arm; no sample size stated.
ANNALS OF EMERGENCY MEDICINE 2026; MULTIDISCIPLINARY DELPHI CONSENSUS · EM ISSUE 28
Unscheduled Procedural Sedation: Multidisciplinary Delphi Consensus
This multidisciplinary Delphi consensus addresses procedural sedation for urgent emergency department care. It states that fasting status should not delay clinically urgent sedation, capnography should be standard for all deep sedation, and ketamine remains the dominant ED agent. Departments should maintain a documented sedation protocol, ensure a trained second operator is present, and use defined recovery criteria. These are consensus recommendations rather than outcome data, and the excerpt does not provide participant numbers or comparative effectiveness evidence; they are broadly consistent with RCEM/AAGBI guidance.
Key numbers: No sample size or outcome statistics stated.
ANNALS OF EMERGENCY MEDICINE, 2026; REVIEW/CASE SERIES · EM ISSUE 28
Dexmedetomidine bridging sedation before procedures in agitated adults
Dexmedetomidine may provide a bridge to procedural sedation in agitated adults who cannot yet tolerate a procedure. The review/case series reports reduced induction-agent requirements while preserving airway reflexes and spontaneous ventilation. In UK EDs, it may be considered where appropriate expertise, monitoring and formulary access exist, but local availability should be checked. Evidence is limited to a review/case series, with no sample size or comparative outcome data provided, so this should inform rather than mandate practice.
Key numbers: No numerical outcomes or sample size stated; reduced induction-agent dose reported.
EMERGENCY MEDICINE JOURNAL 2026, NARRATIVE EVIDENCE REVIEW; SETO ET AL., CJEM 2026, DOUBLE-BLIND RCT, N=57 · EM ISSUE 29
Inhaled isopropyl alcohol for acute nausea in the ED
Inhaled isopropyl alcohol (IPA) via an alcohol wipe or soaked gauze offers a rapid, inexpensive non-pharmacological option for acute nausea. In the double-blind festival-based RCT, nausea reduction at 10 minutes was 30% with IPA versus 16% with placebo (p=0.024), while rescue antiemetic requests were 35% versus 70% (p=0.01; NNT=3); no side effects were reported. UK EDs could offer IPA to non-pregnant adults with mild-to-moderate nausea, instructing them to hold the wipe 1–2 cm below the nostrils and inhale slowly for three to five breaths, repeating as needed. It is a temporising measure and should not replace assessment or antiemetic treatment for persistent or severe nausea. Evidence remains limited by the small, heterogeneous evidence base, the festival setting of the best RCT, and absent pregnancy data.
Key numbers: Double-blind RCT: n=57; nausea reduction at 10 minutes 30% with IPA versus 16% with placebo (p=0.024); rescue antiemetic requests 35% versus 70% (p=0.01; NNT=3); no side effects reported.
CJEM 2026 — DOUBLE-BLIND RANDOMISED CONTROLLED TRIAL, N=57; SUPPORTED BY AN EMJ 2026 EVIDENCE REVIEW · EM ISSUE 29
Inhaled isopropyl alcohol for acute substance-related nausea
Inhaled isopropyl alcohol from an alcohol wipe or soaked gauze pad may provide rapid, short-term relief of acute nausea. In the double-blind festival RCT, nausea reduction at 10 minutes was 30% with IPA versus 16% with placebo, while requests for rescue antiemetics were 35% versus 70% (NNT=3); no side effects were reported. In UK EDs, it could be offered as an inexpensive, non-pharmacological first-line option for mild-to-moderate nausea in adults, with the patient inhaling slowly through the nose for three to five breaths from a wipe held 1–2 cm below the nostrils. The evidence is limited by the small, festival-based, predominantly substance-related population, the short-term outcome and absent pregnancy data; it should not replace assessment or antiemetic treatment for persistent or severe nausea.
Key numbers: n=57; nausea reduction at 10 minutes 30% vs 16% with placebo; rescue antiemetic requests 35% vs 70%; NNT=3; no side effects reported
JAMA NETWORK OPEN 2026 — PROSPECTIVE MULTICENTRE DOUBLE-BLIND RANDOMISED PLACEBO-CONTROLLED NON-INFERIORITY RCT, N=424 · EM ISSUE 31
Morphine plus IV paracetamol versus morphine alone for acute ED pain
This multicentre trial assessed whether titrated IV morphine alone was non-inferior to morphine plus 1 g IV paracetamol in adults with severe acute pain. Morphine alone did not meet non-inferiority in either pain stratum; in non-traumatic pain, the per-protocol difference was 0.80 NRS points (95% CI 0.19–1.41), and rescue analgesia was required in 13% versus 2% with combination treatment. For UK ED practice, use multimodal analgesia when IV morphine is required, with paracetamol 1 g orally where the patient can swallow and IV administration when oral treatment is not possible. The traumatic-pain stratum was substantially underpowered after COVID-19-related protocol changes, and the study supports inclusion of paracetamol in the analgesic plan rather than universal use of the IV formulation.
Key numbers: Non-traumatic pain: per-protocol difference 0.80 NRS points (95% CI 0.19–1.41); rescue analgesia 13% with morphine alone versus 2% with morphine plus IV paracetamol; adjusted absolute risk difference −12 percentage points (95% CI −17.0 to −3.7; p=.01).
CHAPTER 10
Infectious Disease & Public Health
12 items · EM Evidence Rundown Issues 19–31
NEW ENGLAND JOURNAL OF MEDICINE 2026; MULTICENTRE NON-INFERIORITY RCT; N=454 · EM ISSUE 19
Cefazolin non-inferior to oxacillin for MSSA bacteraemia
MSSA bacteraemia carries substantial mortality, and oxacillin/flucloxacillin has traditionally been first-line treatment. In a multicentre RCT of 454 adults, cefazolin was non-inferior to oxacillin for 90-day treatment success, defined as survival without recurrence or further MSSA bacteraemia, with fewer adverse events, particularly nephrotoxicity. For UK ED practice, obtain blood cultures and involve infectious diseases or microbiology urgently; cefazolin 2 g three times daily intravenously is a validated alternative when flucloxacillin is unavailable, including during supply problems, with microbiology agreement. The trial used three-times-daily cefazolin, so the practical advantages of once-daily dosing described in the excerpt are supported by observational data rather than by this RCT, and local antimicrobial guidance remains important.
Key numbers: n=454; 90-day treatment success was non-inferior; cefazolin 2 g three times daily intravenously in the trial; fewer adverse events, particularly nephrotoxicity
UKHSA/NHS ENGLAND, 2026; URGENT PUBLIC-HEALTH ALERT AND OPERATIONAL VHF ALGORITHM UPDATE; N NOT STATED · EM ISSUE 19
UKHSA Ebola/VHF Alert: Glasgow Suspect Case and Active ED VHF Algorithm
UKHSA issued an urgent alert concerning Ebola virus disease in DRC/Uganda, after a suspect case was assessed in Glasgow on 30 June 2026 and subsequently cleared. The alert states that all UK EDs should apply the VHF risk algorithm to febrile returning travellers, including those presenting initially with fever, headache or myalgia, with relevant travel within the previous 21 days. If criteria are met, staff should institute single-room isolation and full barrier PPE, contact UKHSA before investigations, and avoid routine blood sampling until VHF risk has been excluded. This is an operational alert rather than comparative clinical evidence, and the excerpt does not provide case numbers or outcome data beyond the Glasgow case being cleared.
Key numbers: Relevant travel within the previous 21 days; one Glasgow suspect case assessed and cleared; UKHSA emergency number 0344 778 8990
NHS ENGLAND, 2026, SEPSIS MODERN SERVICE FRAMEWORK (SERVICE FRAMEWORK; NO SAMPLE SIZE STATED) · EM ISSUE 21
NHS England Sepsis Modern Service Framework: 25% Reduction Target by 2035 and Sepsis BPT from 2027/28
NHS England’s first formal Sepsis Modern Service Framework sets a 10-year ambition to reduce preventable sepsis deaths and serious harm by 25% by 2035. It proposes a Sepsis Best Practice Tariff from 2027/28, with financial incentives linked to quality metrics including bundle documentation, antibiotic timing and escalation thresholds, alongside an ICS-led quality-improvement programme across ambulance, ED and urgent and emergency care pathways. UK EDs should identify an active Sepsis Champion, audit antibiotic-to-door-time performance against current NICE NG253 thresholds, ensure documentation supports the anticipated BPT requirements, and engage with their ICS implementation plan. This is a commissioning and service framework rather than evidence of clinical effectiveness; the detailed BPT metrics and local implementation arrangements are not specified here, and the anticipated NICE update on procalcitonin should not be treated as current guidance until published.
Key numbers: 25% reduction target in preventable sepsis deaths and serious harm by 2035; Sepsis BPT planned from 2027/28; NICE update expected 11 September 2026; current guidance stated as NG253 (November 2025).
CLINICAL INFECTIOUS DISEASES, 2026 — MULTICENTRE OPEN-LABEL RCT, N=193 · EM ISSUE 22
Oral fosfomycin step-down for ESBL complicated UTI
In adults with ESBL-producing Enterobacterales complicated UTI who had clinically improved after initial IV antibiotics, this multicentre open-label RCT compared oral fosfomycin 3 g every 48 hours with continued IV beta-lactam therapy. Clinical and microbiological cure at test-of-cure was non-inferior with oral fosfomycin. For UK ED practice, this supports a carbapenem-sparing step-down and potential early discharge strategy in selected improving patients, but only after local microbiology confirms susceptibility and with microbiology input; it does not alter empirical ED antibiotic choice. The study was conducted in South Korea, included complicated UTI only, and its open-label design and relatively small sample limit direct transferability to UK practice.
Key numbers: n=193; oral fosfomycin 3 g every 48 hours; non-inferior clinical and microbiological cure
UKHSA 2026; SURVEILLANCE REPORT AND AMBER HEAT HEALTH ALERT; N NOT STATED · EM ISSUE 23
2,877 excess heat-related deaths in England in 2026 with active amber alert
UKHSA reported 2,877 excess heat-related deaths in England in 2026 to date, nearly double the entire 2025 total, with Amber Heat Health Alerts reissued on 27 July for the 29–30 July heatwave period. In the ED, heat stroke—core temperature above 40°C with neurological dysfunction—requires immediate cooling, targeting below 39°C within 30 minutes; heat exhaustion requires cooling and fluid replacement, with intravenous fluids when oral intake is not tolerated. Clinicians should review heat-sensitive medicines, including diuretics, ACE inhibitors, antipsychotics, lithium and anticholinergics, and consider social-care liaison for elderly or isolated patients. NHS trusts should consider the alert in operational planning, but the mortality figure is a population-level surveillance estimate and does not establish causation for individual presentations.
Key numbers: 2,877 excess heat-related deaths in England in 2026 to date; nearly double the entire 2025 total; heat stroke defined as core temperature >40°C with neurological dysfunction; target temperature <39°C within 30 minutes
PEDIATRICS 2026; PHASE 2/3 STUDY · EM ISSUE 23
Nirmatrelvir/ritonavir in children aged 6 years and older: comparable exposure and safety
Nirmatrelvir/ritonavir is used for selected patients at risk of severe COVID-19, but paediatric use in the UK has been off-label. This phase 2/3 study found that weight-adjusted dosing in children aged 6 years and older produced pharmacokinetic exposures comparable to adults, with similar safety, tolerability and antiviral effect. In UK ED practice, for a symptomatic COVID-positive child with significant comorbidity within 5 days of symptom onset, discuss eligibility for antiviral treatment with paediatric infectious diseases or the relevant local service. The study supports the pharmacokinetic and safety case but does not itself change UK licensing; formal MHRA/EMA paediatric licensing updates are awaited.
Key numbers: Children aged 6 years and older; weight-adjusted dosing; phase 2/3 study; no sample size stated.
RCEM + 2026 + ORGANISATIONAL ANNOUNCEMENT · EM ISSUE 23
Expansion of UK RSV vaccine eligibility
RSV is a significant driver of paediatric emergency department attendances and admissions among older adults each winter. RCEM welcomed the 2 July 2026 announcement that the RSV vaccination programme would be widened, including expansion of maternal vaccination and the programme for older adults. UK EDs should anticipate potential reductions in bronchiolitis and pneumonia admissions from autumn 2026 onwards and ensure local teams are familiar with the updated eligibility arrangements. The excerpt provides no precise eligibility criteria, vaccine effectiveness estimates, or supporting study design, so the announcement should not be interpreted as evidence of a quantified reduction in admissions.
Key numbers: No quantitative outcome data stated
THE JOURNAL OF PEDIATRICS, 2026; MULTICENTRE STUDY, SAMPLE SIZE NOT STATED · EM ISSUE 24
Febrile infants aged 61–90 days: variation in evaluation and management across centres
This study examined how febrile infants aged 61–90 days are assessed and managed across multiple centres. It found substantial variation in blood-culture use, urine-collection methods, lumbar-puncture rates, antibiotic prescribing and admission, despite published risk-stratification tools. In UK practice, NICE NG143 applies and the Step-by-step algorithm is validated in this age group; urine dipstick alone is insufficient, so a clean-catch MSU should be sent for culture, with blood cultures when serious bacterial infection is suspected. An infant who appears unwell, or has a temperature above 38°C without an identifiable source after initial assessment, should prompt consideration of lumbar puncture; antibiotic choice should follow local paediatric antimicrobial guidance. The excerpt does not report sample size, clinical outcomes or which strategy was superior, so it demonstrates practice variation rather than establishing a preferred pathway.
Key numbers: Age 61–90 days; fever >38°C; sample size and other numerical results not stated
JOURNALFEED ARTICLE-A-DAY (SNAP TRIAL), 2026; RANDOMISED CONTROLLED TRIAL; SAMPLE SIZE NOT STATED · EM ISSUE 24
SNAP RCT: Cefazolin Non-Inferior to Flucloxacillin/Cloxacillin for MSSA Bacteraemia
For confirmed MSSA bacteraemia, the SNAP randomised controlled trial found cefazolin to be non-inferior to flucloxacillin or cloxacillin for 90-day mortality, with lower rates of acute kidney injury and serious drug-related adverse reactions. In UK emergency practice, cefazolin is therefore an evidence-preferred option for suitable patients being transferred to or discharged with OPAT after MSSA has been confirmed. This does not alter empirical treatment while cultures and susceptibilities are pending, when local protocols commonly continue to favour flucloxacillin or co-fluampicil. The excerpt provides no sample size or numerical effect estimates, and antimicrobial choice should remain subject to microbiology or infectious diseases advice and patient-specific factors.
Key numbers: 90-day mortality; lower rates of acute kidney injury and serious drug-related adverse reactions; numerical rates, effect estimates and sample size not stated
UKHSA, 2026 — HEAT-HEALTH ALERT AND GUIDANCE UPDATE; N NOT STATED · EM ISSUE 25
Amber heat-health alerts across England: emergency management of heat illness
UKHSA issued amber heat-health alerts across all of England from 11 August 2026, with temperatures forecast to reach up to 38°C. The alert followed 2,877 excess heat deaths reported through July and anticipated increased ED attendance. In suspected heat stroke, defined in the excerpt as core temperature above 40°C with neurological dysfunction, start immediate whole-body cooling and aim for a core temperature below 39°C within 30 minutes; do not delay treatment while waiting for a temperature if the clinical picture is clear. Heat exhaustion without neurological dysfunction should be managed with cooling, oral or intravenous rehydration and observation, with particular attention to older or socially isolated patients and medication-related risk. These are alert-period recommendations rather than comparative clinical evidence, and the excerpt provides no outcome dataset or study design.
Key numbers: Amber alerts across all England from 11 August 2026; forecast temperature up to 38°C; 2,877 excess heat deaths reported through July; heat-stroke target core temperature below 39°C within 30 minutes.
PEDIATRICS, 2026 — CASE-COHORT ANALYSIS; OVER 1,200 PAEDIATRIC INFLUENZA DEATHS · EM ISSUE 25
Influenza vaccination and fatal paediatric influenza
A US case-cohort analysis examined influenza vaccine effectiveness against fatal paediatric influenza. Vaccine effectiveness against death was 80% overall, with higher protection reported in children without underlying conditions. In UK ED practice, this supports discussing seasonal influenza vaccination during autumn discharge planning, particularly for children with respiratory disease, immunosuppression or complex medical needs; UK vaccination is recommended for children aged 2–17 years via live attenuated intranasal vaccine. The findings concern fatal influenza rather than all influenza outcomes, and the excerpt provides limited methodological detail, so the estimate should be used as supportive rather than definitive evidence in individual counselling.
Key numbers: Over 1,200 paediatric influenza deaths; 80% effectiveness against fatal influenza overall; higher protection in children without underlying conditions.
JOURNALFEED PAEDS SPEED READ 2026 — LARGE RETROSPECTIVE OBSERVATIONAL COHORT; SAMPLE SIZE NOT STATED · EM ISSUE 29
Oseltamivir in hospitalised children with influenza: length of stay reduced by 9.4 hours
In a large retrospective observational cohort of children hospitalised with confirmed influenza, oseltamivir treatment was associated with an adjusted reduction in hospital length of stay of approximately 9.4 hours. ICU admission was also lower among treated children (adjusted hazard ratio 0.69); no safety signals were identified in the summary. UK ED clinicians should follow current UKHSA and NICE indications, offering oseltamivir to at-risk hospitalised children, including those with severe illness, immunosuppression, chronic conditions or age under 2 years, rather than prescribing routinely to low-risk children or outpatients. The observational design is vulnerable to confounding by indication and residual confounding, and the 95% confidence interval was not reported in the summary, so these findings support rather than extend existing guidance.
Key numbers: Adjusted hospital length of stay reduction approximately 9.4 hours; ICU admission adjusted hazard ratio 0.69; 95% confidence interval not reported; sample size not stated
CHAPTER 11
POCUS, Diagnostics & AI
11 items · EM Evidence Rundown Issues 19–31
CRITICAL CARE MEDICINE, 2026 — SYSTEMATIC REVIEW/META-ANALYSIS; SAMPLE SIZE NOT STATED · EM ISSUE 19
VExUS for Venous Congestion in the Emergency Department
VExUS combines IVC diameter with hepatic, portal and intrarenal venous Doppler to grade venous congestion from 0–3. In this systematic review/meta-analysis of observational data, Grades 2–3 were associated with acute kidney injury and poor outcomes; however, the standard IVC-gated approach may miss early congestion, as only about 24% of patients with early ED sepsis had IVC dilatation while 41% had organ Doppler abnormalities. In UK ED practice, VExUS is best used after initial resuscitation to support fluid decisions, particularly in cardiogenic shock or decompensated heart failure, where Grade 3 should prompt caution with further fluids. The evidence is observational, and no randomised trial has shown that VExUS-guided management improves outcomes; abnormal hepatic or portal Doppler should not be disregarded solely because the IVC is not dilated.
Key numbers: Grades 2–3 predicted AKI and poor outcomes; IVC dilatation ≥2 cm was present in about 24% of early ED sepsis patients, while 41% had organ Doppler abnormalities; no RCT evidence of outcome benefit
ACADEMIC EMERGENCY MEDICINE 2026 — SYSTEMATIC REVIEW/META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS; SAMPLE SIZE NOT STATED · EM ISSUE 19
POCUS for paediatric urethral catheterisation: improved first-attempt success
Urethral catheterisation is frequently required in febrile infants and young children when clean-catch urine samples are inadequate or culture is indicated. This systematic review/meta-analysis reports that POCUS bladder assessment improves first-attempt catheterisation success and reduces distress, principally by confirming that the bladder is adequately filled before attempting catheterisation. In UK emergency departments, a linear probe bladder view may be used as a rapid adjunct before catheterisation, with skilled operators also able to use ultrasound to guide suprapubic aspiration. The evidence is largely from trials of catheter guidance, and the excerpt provides no pooled effect estimate or sample size, so the magnitude and generalisability of benefit remain uncertain.
Key numbers: No numerical effect estimate or sample size stated
INTENSIVE CARE MEDICINE 2026 — INTERNATIONAL CONSENSUS UPDATE; SAMPLE SIZE NOT STATED · EM ISSUE 20
2025 International Consensus Update on Lung Ultrasound in Emergency Care
The 2025 focused update revises the international lung ultrasound recommendations for assessment of interstitial syndrome, pneumothorax, consolidation and pleural effusion. At least three B-lines per zone define a positive zone, with at least two bilateral positive zones required for an interstitial syndrome pattern; absent lung sliding alone is insufficient to diagnose pneumothorax, which is confirmed by absent sliding and B-lines with a lung point. In UK ED practice, apply the revised zonal approach and use dynamic air bronchograms, the shred sign, tissue sign and sinusoid sign to support differentiation of pneumonia, atelectasis and pleural effusion. Bilateral B-patterns with cardiac dysfunction on echocardiography support acute decompensated heart failure, with reported sensitivity of approximately 90% and specificity of approximately 85% versus non-cardiac dyspnoea. This is consensus guidance rather than a randomised outcome study, so findings should remain integrated with clinical assessment and other investigations.
Key numbers: ≥3 B-lines per zone; ≥2 bilateral positive zones for interstitial syndrome; pleural depth of 1 cm ≈200 mL; reported ADHF sensitivity ~90% and specificity ~85%.
J CLIN ULTRASOUND; SYSTEMATIC REVIEW/META-ANALYSIS; N=2,951 · EM ISSUE 20
AI-assisted ultrasound detection of pleural effusion
Pleural effusion detection on ultrasound is a potential early application for AI-assisted POCUS in UK emergency departments. The systematic review/meta-analysis reported sensitivity of 0.92 and specificity of 0.96, with an LR+ of approximately 23 and an LR− of approximately 0.08; performance approached that of expert sonography and was reported to substantially outperform chest radiography. Where AI ultrasound interpretation is being piloted, pleural effusion detection may be a reasonable application to evaluate alongside clinician-performed scanning. These are diagnostic-performance results rather than evidence of improved patient outcomes, and local validation, governance and clinician oversight remain necessary.
Key numbers: Sensitivity 0.92; specificity 0.96; LR+ approximately 23; LR− approximately 0.08; n=2,951
JOURNAL OF CLINICAL ULTRASOUND 2026 · RETROSPECTIVE STUDY · N NOT STATED · PMID: 41540593 · EM ISSUE 20
Lung Ultrasound in Paediatric Pneumonia: Reduced Radiation Exposure, Illness Duration and Costs Compared with Chest Radiography
In this 2-year retrospective comparison of lung ultrasound (LUS) and chest radiography (CXR) as first-line imaging for paediatric pneumonia, LUS reduced radiation exposure, enabled earlier antibiotic rationalisation and reduced overall costs. Across pooled studies cited in the excerpt, LUS sensitivity was 0.93–0.97 and specificity 0.83–0.96, with better detection of posterior consolidations and small effusions than CXR. In a UK ED with a competent sonographer, LUS can be considered first-line imaging for suspected community-acquired pneumonia in children under 10, reserving CXR for atypical presentations, suspected pleural complications or an inconclusive scan. Interpretation should remain cautious because the reported comparison was retrospective and the approach depends on local ultrasound competence and availability.
Key numbers: Pooled diagnostic accuracy: sensitivity 0.93–0.97; specificity 0.83–0.96. Two-year retrospective study; sample size not stated.
JOURNAL OF GENERAL INTERNAL MEDICINE 2026; QUALITY IMPROVEMENT PROJECT; SAMPLE SIZE NOT STATED · EM ISSUE 21
POCUS During Inpatient Cardiac Arrest: Protocol Increases Use from 16% to 35% and Changes Management in Over 30% of Cases
This quality improvement project evaluated a structured POCUS protocol during inpatient cardiac arrest. POCUS use increased from 16% to 35%, and it changed management in over 30% of arrests in which it was used, including identification of tamponade, massive PE, pneumothorax and severe LV dysfunction. In UK EDs, POCUS should be performed during pulse checks rather than compressions, with cardiac and anterior lung views prioritised; access to a machine within 30 seconds is a reasonable systems target. The findings are informative but derive from a hospital medicine service, and the sample size and comparative outcome data are not stated.
Key numbers: POCUS use increased from 16% to 35%; management changed in over 30% of cases where POCUS was used.
BMC EMERGENCY MEDICINE, 2026 — SIMULATION STUDY OF EMERGENCY PHYSICIANS; SAMPLE SIZE NOT STATED. · EM ISSUE 24
AI second-reader support for pneumothorax on ED chest radiographs redirects rather than reduces CT use
AI assistance for chest-radiograph interpretation may improve recognition of pneumothorax, particularly subtle cases, but does not necessarily reduce downstream imaging. In this simulation study, AI increased clinicians’ intention to order CT and improved diagnostic capture, at the cost of increased imaging. In UK ED practice, AI second-reader systems should be introduced with explicit escalation thresholds and local review of sensitivity, specificity and CT impact, rather than treating an AI flag as an automatic indication for CT. The findings are hypothesis-generating because they come from a simulation in Türkiye rather than real-world patient outcomes, and the excerpt provides no sample size or numerical effect estimates.
Key numbers: No numerical effect estimates or sample size stated; increased CT ordering intent and diagnostic capture were reported.
JAMA INTERNAL MEDICINE 2026; RANDOMISED CLINICAL TRIAL; SAMPLE SIZE NOT STATED · EM ISSUE 25
SAVE-O2 AI Trial: Autonomous AI Oxygen Titration Improves Normoxaemia in Acutely Ill Adults
Oxygen therapy is often poorly standardised in the ED, with prescribed targets inconsistently applied and oxygen frequently left at admission settings. In this randomised trial, autonomous AI-driven titration increased time within the predefined SpO2 target range of 94–98% and reduced both hyperoxaemic and hypoxaemic episodes compared with manual titration. UK ED practice should continue to prescribe oxygen with an explicit target range rather than a flow rate alone, treating oxygen as a drug with a dose and target. The system adjusted oxygen continuously without nursing intervention, but the excerpt does not report sample size, effect estimates, patient-centred outcomes or implementation safety data; such devices are not yet standard in most UK EDs.
Key numbers: Target SpO2 range 94–98%; sample size and effect estimates not stated
JOURNAL OF EMERGENCY MEDICINE, 2026 — RETROSPECTIVE STUDY, N=188 · EM ISSUE 26
Renal POCUS Hydronephrosis and Suspected Renal Colic
In patients undergoing renal POCUS for suspected renal colic, hydronephrosis was associated with higher rates of confirmed stone disease, early urological intervention and CT use. However, the excerpt states that hydronephrosis did not directly predict urological intervention. In UK ED practice, moderate-to-severe hydronephrosis should increase concern for obstructive uropathy and prompt urology involvement, particularly with fever; mild hydronephrosis without concerning symptoms may be managed with follow-up. The retrospective design and apparent distinction between association and direct prediction mean that POCUS findings should be integrated with the clinical presentation rather than used in isolation.
Key numbers: Retrospective study; n=188. Hydronephrosis was associated with confirmed stone disease, early urological intervention and CT use, but did not directly predict urological intervention.
JOURNAL OF ULTRASOUND MEDICINE, 2026 — US SINGLE-CENTRE PILOT FEASIBILITY RCT, N=19 · EM ISSUE 28
VExUS-guided de-resuscitation in septic shock: feasibility pilot RCT
VExUS-guided fluid management is intended to support de-resuscitation decisions in septic shock using hepatic vein, portal vein and intrarenal Doppler findings. In this pilot RCT, 12 patients received VExUS-guided management and 7 usual care; intervention-period fluid balance was −65 mL versus +2,608 mL, respectively (p=0.21). AKI, respiratory failure and 30-day mortality were numerically lower with VExUS, but no significance was reported and there were no intervention-related adverse events. In UK ED practice, this supports further evaluation of VExUS but does not justify routine VExUS-guided de-resuscitation; local POCUS expertise and standard clinical assessment remain important. The study was designed to assess feasibility and safety, and its very small, single-centre sample means the findings are hypothesis-generating only.
Key numbers: n=19; VExUS n=12 vs usual care n=7; intervention-period fluid balance −65 mL vs +2,608 mL (p=0.21); secondary outcomes numerically lower with VExUS; no intervention-related adverse events.
EUROPEAN RESPIRATORY JOURNAL 2026 — MULTICENTRE RANDOMISED CONTROLLED TRIAL, N=663 ANALYSED · EM ISSUE 30
POCUS-driven diagnostic pathway for emergency department dyspnoea
In this multicentre RCT across 10 Danish emergency departments, 663 adults with dyspnoea were analysed after randomisation to a POCUS-driven pathway or standard care. Discharge alive within 24 hours occurred in 42.6% versus 45.5%, respectively (risk difference −2.9 percentage points, 95% CI −10.4 to 4.7; p=0.45), and hospital length of stay was not significantly different (HR 0.93, 95% CI 0.79–1.08; p=0.35). UK EDs should not interpret this as support for mandating blanket POCUS screening for all dyspnoeic patients; use focused lung and cardiac ultrasound for specific clinical questions where the result changes management. The Danish setting, where POCUS may already be well integrated into emergency care, may have limited the incremental benefit of adding a formal pathway.
Key numbers: Randomised 674 patients; 663 analysed. Discharge alive within 24 hours: 42.6% with POCUS versus 45.5% with standard care; risk difference −2.9 percentage points (95% CI −10.4 to 4.7; p=0.45). Hospital LOS: HR 0.93 (95% CI 0.79–1.08; p=0.35).
CHAPTER 12
Paediatric Emergency Medicine
29 items · EM Evidence Rundown Issues 19–31
NEJM 2026 · COMPARATIVE TRIAL · N=9,071 · EM ISSUE 19
PRoMPT BOLUS: balanced crystalloids versus 0.9% saline in paediatric septic shock
Fluid choice in paediatric septic shock remains clinically important because both balanced crystalloids and 0.9% saline are used in emergency resuscitation. In PRoMPT BOLUS, involving 9,071 children, balanced crystalloids and 0.9% saline produced equivalent outcomes, with no fluid preference mandated. UK EDs should therefore follow local paediatric sepsis and APLS protocols, prioritising appropriate bolus volumes, repeated reassessment and escalation rather than selecting fluid type on the basis of this study alone. The excerpt does not provide the study’s detailed inclusion criteria, outcomes or follow-up, so applicability to every paediatric shock presentation should be considered cautiously.
Key numbers: n=9,071; balanced crystalloids and 0.9% saline had equivalent outcomes.
JAMA 2026; PAEDIATRIC RCT; SAMPLE SIZE NOT STATED · EM ISSUE 19
GASTRIC-PICU: Routine Gastric Residual Volume Monitoring in PICU — No Benefit
Routine 4-hourly gastric residual volume (GRV) measurement in mechanically ventilated children in PICU was compared with a symptom-driven approach, in which GRV was checked only for clinical signs of feeding intolerance. Routine monitoring did not improve feeding tolerance, reduce ventilator-associated pneumonia, or improve outcomes. For UK EDs caring for intubated children awaiting PICU transfer, this supports continuing enteral feeds where appropriate and responding to clinical signs rather than arbitrary GRV thresholds. The study was conducted in PICU patients, so its findings should not be automatically extended to children with specific contraindications to enteral feeding or suspected gastrointestinal pathology.
Key numbers: Routine 4-hourly GRV monitoring showed no benefit over symptom-driven monitoring; sample size not stated.
SURVIVING SEPSIS CAMPAIGN PAEDIATRIC GUIDELINES, PEDIATRIC CRITICAL CARE MEDICINE, 2026 — CLINICAL GUIDELINE UPDATE; 61 STATEMENTS (20 NEW, 13 REVISED). · EM ISSUE 19
2026 SSC Paediatric Sepsis Guidelines: Phoenix Criteria Adopted and Fluid Targets Resource-Stratified
The 2026 Surviving Sepsis Campaign update formally adopts the 2024 Phoenix criteria, replacing the SIRS-based paediatric sepsis definition used in the 2020 guidelines. Phoenix uses organ dysfunction scoring and is described as more specific but less sensitive; the update recommends reassessment after each 10–20 mL/kg bolus in high-resource settings and avoiding more than 40 mL/kg without reassessment. Antibiotics are recommended within 1 hour for suspected septic shock, with earlier vasopressor consideration after 20–40 mL/kg if the child remains fluid-unresponsive. This does not currently mandate a change in UK ED practice, where PEWS and NICE NG51 thresholds remain in use; the guideline is nevertheless relevant for interpreting international research and reinforces cautious, reassessment-led fluid administration.
Key numbers: 61 statements; 20 new and 13 revised. High-resource settings: reassess after each 10–20 mL/kg bolus and avoid a total of >40 mL/kg without reassessment. Antibiotics within 1 hour for suspected septic shock; consider vasopressors after 20–40 mL/kg if fluid-unresponsive.
RCEM/APLS GUIDANCE CONTEXT PIECE, 2026; EVIDENCE SYNTHESIS DRAWING ON PROMPT BOLUS (N=9,071) AND OBSERVATIONAL DATA (N=5,352) · EM ISSUE 19
Paediatric Fluid Resuscitation After PRoMPT BOLUS: Type, Volume and Escalation
For paediatric septic shock in UK emergency departments, current evidence suggests that balanced crystalloids and 0.9% saline have equivalent clinically important outcomes, while the volume and timing of resuscitation remain more important. PRoMPT BOLUS found equivalent outcomes in 9,071 children; accompanying observational data found that bolus volumes above 55 mL/kg were associated with increased mortality (OR 20.5). Use 10–20 mL/kg boluses with reassessment after each bolus, stop if there is no response, and consider PICU referral and vasopressors when hypotension persists after 20–40 mL/kg rather than giving fluid blindly. This synthesis aligns with NICE NG51, APLS 8th edition and the UK Sepsis Trust pathway, but the mortality association is observational and fluid decisions must remain guided by clinical response and senior review.
Key numbers: PRoMPT BOLUS: n=9,071; balanced crystalloids versus 0.9% saline with equivalent outcomes. Observational data: n=5,352; >55 mL/kg associated with mortality, OR 20.5. Give 10–20 mL/kg boluses with reassessment; avoid >40–60 mL/kg without senior/HDU decision.
ACADEMIC EMERGENCY MEDICINE, 2026 — SYSTEMATIC REVIEW/META-ANALYSIS OF 3 RCTS; SAMPLE SIZE NOT STATED · EM ISSUE 20
POCUS bladder assessment improves first-attempt catheterisation success in infants and young children
Urethral catheterisation in children aged ≤36 months may fail when the bladder is empty, resulting in a dry tap. In a systematic review/meta-analysis of three RCTs, pre-catheterisation bladder POCUS increased first-attempt success from 72.5% to 89.7% (RR 1.25; p=0.0022) and reduced dry taps from 23.9% to 3.6% (RR 0.25; p<0.0001). UK EDs should consider a brief suprapubic bladder scan before catheterisation in this age group, with reassessment if the bladder is not clearly visible or appears to contain <2 mL. The evidence base comprises only three RCTs, with the overall sample size and operator-training requirements not stated in the excerpt, so implementation should be supported by local POCUS competence and governance.
Key numbers: First-attempt success: 89.7% with POCUS vs 72.5% with blind catheterisation; RR 1.25 (95% CI 1.08–1.45), p=0.0022. Dry taps: 3.6% vs 23.9%; RR 0.25, p<0.0001. Systematic review/meta-analysis of 3 RCTs; children aged ≤36 months.
PEDIATRICS 2026 · LONGITUDINAL STUDY · N NOT STATED · PMID: 42229913 · EM ISSUE 20
Telesimulation for Rural NLS Training: Sustained Improvement at 6 and 12 Months
A longitudinal study of rural hospital clinicians found that telesimulation was associated with sustained improvement in adherence to the Neonatal Resuscitation Programme at 6 and 12 months. Improvement correlated with the number of training sessions completed. For UK emergency departments in rural or district-general settings, particularly those with infrequent neonatal emergencies and no on-site neonatal specialists, this supports exploring access to NLS telesimulation through local simulation networks. The excerpt does not report participant numbers, the specific adherence outcomes, or a direct comparison with face-to-face training, so the evidence should inform rather than mandate local training models.
Key numbers: Improvement sustained at 6 and 12 months; greater improvement correlated with more training sessions. Sample size and numerical outcome data not stated.
JOURNALFEED ARTICLE-A-DAY (2026) — MULTICENTRE RETROSPECTIVE STUDY, N=5.3 MILLION PAEDIATRIC ED VISITS · EM ISSUE 21
Hypothermia at Paediatric ED Triage and In-Hospital Mortality
In a multicentre retrospective study of 5.3 million paediatric ED visits, a triage temperature of ≤36°C was associated with an adjusted odds ratio of approximately 20 for in-hospital death, after adjustment for age, vital signs, mechanism and medical complexity. Hypothermia occurred in approximately 3% of visits, with the strongest mortality signal in children without pre-existing medical complexity. UK paediatric EDs should treat a triage temperature ≤36°C as a high-risk finding: escalate promptly, reassess clinically, check immediate blood glucose, consider sepsis and other causes, and provide active warming while assessment proceeds. The result may be particularly relevant to tertiary paediatric networks and could be affected by temperature-recording errors, so local validation and attention to the measurement context are required.
Key numbers: Triage temperature ≤36°C; approximately 3% of visits; adjusted odds ratio approximately 20 for in-hospital death; n=5.3 million visits.
PEDIATRICS 2026; DESIGN NOT STATED IN EXCERPT; N=1,391 · EM ISSUE 21
Suicidality after sexual abuse in children aged 10–17
Among 1,391 young people aged 10–17 assessed for sexual abuse at specialist services, 11.1% reported suicidality, including ideation or attempts, within 90 days of the index assessment. Suicidal attempts were significantly more frequent when the perpetrator was a non-relative than when the perpetrator was a family member. In UK ED practice, children presenting after sexual assault or abuse should have structured mental-health and suicidality screening before discharge, with SARC referral and explicit follow-up; same-day CAMHS review should be considered when a non-relative perpetrator is identified. The excerpt does not provide the comparative effect size, adjustment strategy or detail on how suicidality was assessed, so the finding should support rather than replace individual risk assessment and safeguarding procedures.
Key numbers: n=1,391; 11.1% reported suicidality within 90 days; attempts were significantly more frequent with a non-relative perpetrator.
JOURNALFEED 2026; RANDOMISED TRIAL, N NOT STATED · EM ISSUE 22
High-dose intranasal midazolam reduces rescue sedation in children undergoing paediatric ED procedures
Intranasal midazolam is used for minimal procedural sedation in children, but lower doses may require additional sedative medication. In a randomised trial, 0.5 mg/kg reduced the need for rescue sedation compared with 0.2 mg/kg, without an increase in adverse events or ED length of stay. UK paediatric EDs could consider whether their default intranasal dose should be aligned with 0.5 mg/kg, subject to local formulary maximums, appropriate monitoring, sedation documentation and immediate access to resuscitation equipment and reversal. The excerpt does not provide the trial sample size or journal, so local protocol changes should await review of the full publication and remain within established paediatric sedation governance.
Key numbers: Intranasal midazolam 0.5 mg/kg versus 0.2 mg/kg; no increase in adverse events or ED length of stay; trial sample size not stated.
BMC PEDIATRICS, 2026; RETROSPECTIVE COHORT, N=231 · EM ISSUE 22
Predictors of failed hydrostatic reduction in paediatric intussusception
In children with ileocolic intussusception, age >48 months, symptom duration >48 hours, constipation and bowel-wall thickening on ultrasound were identified as predictors of hydrostatic reduction failure requiring surgery. When two or more features are present, the index of suspicion for failed reduction should be higher and early paediatric surgical review is appropriate alongside the first reduction attempt. UK ED practice remains ultrasound-guided saline or pneumatic enema reduction with surgical standby, with peritonitis, perforation and shock contraindicating reduction. This retrospective cohort is hypothesis-generating, so the predictors should support rather than replace clinical judgement; surgical involvement should not be delayed when several risk factors are present.
Key numbers: n=231; predictors: age >48 months, symptoms >48 hours, constipation and ultrasound bowel-wall thickening; two or more predictors associated with higher suspicion of reduction failure.
EUR J PEDIATR 2026; RANDOMISED CROSSOVER CLINICAL TRIAL; N=13 STATED BY THE 1/13 AV-BLOCK RESULT · EM ISSUE 23
Intranasal dexmedetomidine versus nitrous oxide for paediatric procedural sedation: second-degree AV block signal
This randomised crossover trial compared intranasal dexmedetomidine with inhaled 50% nitrous oxide for procedural sedation during intra-articular corticosteroid injection in children with juvenile idiopathic arthritis. Pain control was equivalent, but dexmedetomidine was associated with more adverse events (11 versus 2) and one episode of second-degree AV block (1/13); the excerpt reports deep-sedation rates of 13% and 98% for dexmedetomidine and nitrous oxide, respectively, and 69% preferred nitrous oxide at follow-up. In UK paediatric EDs, consider pre-procedure ECG assessment for dexmedetomidine, avoid it in known second- or third-degree AV block, and ensure cardiac monitoring is available during sedation. The study population was children with juvenile idiopathic arthritis, so the safety profile may not generalise to all paediatric ED procedural sedation; review local sedation protocols.
Key numbers: Pain control equivalent; adverse events 11 versus 2; second-degree AV block 1/13; reported deep-sedation rates 13% versus 98%; 69% preferred nitrous oxide at follow-up.
EUROPEAN JOURNAL OF PEDIATRICS 2026; RETROSPECTIVE SINGLE-CENTRE STUDY OF CHILDREN UNDERGOING APPENDECTOMY, N=156 · EM ISSUE 23
Urine leukocyte count has limited diagnostic accuracy for complicated appendicitis in children
In children undergoing appendectomy for suspected appendicitis, urine leukocyte count had limited diagnostic accuracy for complicated appendicitis, defined as perforation or gangrenous appendicitis. CRP remained superior, and the authors concluded that routine urinalysis should not replace CRP in the paediatric appendicitis work-up. In UK ED practice, urinalysis remains appropriate when assessing urinary tract infection or renal colic, but mild pyuria should not reassure clinicians against appendicitis; CRP and WBC are preferred inflammatory markers. This was a retrospective single-centre study, so the findings reinforce rather than change current practice.
Key numbers: n=156; urine leukocyte count had limited diagnostic accuracy for complicated appendicitis; CRP was superior
EUROPEAN SOCIETY FOR PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION (ESPGHAN), 2026; EXPERT CONSENSUS POSITION PAPER; N NOT STATED · EM ISSUE 24
ESPGHAN Position Paper: Paediatric Foreign Body Ingestion, Including Button Batteries
This expert consensus position paper provides management algorithms based on object type, anatomical location, symptoms and time since ingestion. Button or disc lithium batteries require immediate endoscopy regardless of location, including the stomach, even when the child is asymptomatic; mediastinitis and fistulae can develop within 2 hours. In UK emergency departments, suspected button-battery ingestion should prompt urgent imaging and immediate discussion with the on-call paediatric surgical and gastroenterology teams, without watchful waiting or discharge. The recommendations are consensus-based rather than derived from a comparative clinical trial, and local pathways should be checked against current NICE and BSPGHAN guidance.
Key numbers: Button-battery complications can develop within 2 hours; asymptomatic gastric batteries still require immediate endoscopy.
AMERICAN ACADEMY OF PEDIATRICS, 2026 — UPDATED POLICY STATEMENT; SAMPLE SIZE NOT STATED · EM ISSUE 24
AAP updated policy statement: prevention of drowning, water-safety competencies and supervision
The American Academy of Pediatrics updated its drowning-prevention policy statement in August 2026. Recommendations include swimming lessons from age 1 year for children without significant developmental delay, constant adult supervision within arm’s reach for children under 5 years and non-swimmers, four-sided pool fencing, life jackets near open water and avoidance of alcohol by supervising adults. In UK emergency departments, the statement supports careful assessment of drowning and near-drowning presentations, including hypothermia management, aspiration-related respiratory complications, safeguarding and documented water-safety discharge advice. This is US guidance rather than UK policy; prevention advice should therefore be aligned with RNLI and NHS guidance, and apparently well near-drowning survivors may still require observation because pulmonary oedema can be delayed.
Key numbers: Swimming lessons from age 1 year; supervision within arm’s reach for children under 5 years and non-swimmers; drowning described as the second leading cause of accidental death in children globally.
LANCET RESPIRATORY MEDICINE, 2026; PROSPECTIVE VALIDATION STUDY; SAMPLE SIZE NOT STATED · EM ISSUE 25
PERC-Peds validated for pulmonary embolism exclusion in low-risk children
Pulmonary embolism is uncommon in children but may be life-threatening, while increasing CT pulmonary angiography use creates concern about unnecessary radiation. This prospective validation study found that children with a PERC-Peds score of 0, with all criteria negative, could have PE excluded without D-dimer or CT-PA. The rule incorporates age-adjusted heart rate, oxygen saturation, clinical DVT signs, recent surgery and trauma; in UK practice it may support imaging avoidance in carefully selected low-risk children alongside clinical assessment and Wells-Peds. It should not override high clinical suspicion, and children with malignancy, thrombophilia or central venous ports require particular caution because these risks may not be fully captured by the rule.
Key numbers: PERC-Peds score 0; no sample size or diagnostic performance statistics stated
PEDIATRIC EMERGENCY CARE, 2026 — STUDY DESIGN AND SAMPLE SIZE NOT STATED · EM ISSUE 25
Cardiac POCUS in paediatric suspected infection predicts vasoactive requirement and ICU admission
In children presenting to the ED with suspected systemic infection, reduced ventricular function on cardiac POCUS was associated with subsequent vasoactive medication requirement, ICU admission and worse clinical outcomes. A rapid parasternal long-axis or subcostal four-chamber assessment may help identify children at risk of haemodynamic deterioration before overt clinical decline. In UK practice, incorporate cardiac assessment into paediatric sepsis POCUS where appropriate expertise is available, prompting early ICU discussion and preparation for vasoactive support when dysfunction is identified. This is an association from a study whose design, sample size, effect estimates and diagnostic thresholds are not provided; POCUS should not delay standard sepsis assessment and resuscitation.
Key numbers: No numerical results reported in the excerpt
NEW ENGLAND JOURNAL OF MEDICINE 2026; MULTICENTRE RANDOMISED CONTROLLED TRIAL, N=840 · EM ISSUE 26
Azithromycin provides no benefit for preschool wheeze in the ED
In children aged 18–59 months presenting to eight PECARN emergency departments with moderate-to-severe acute wheeze, azithromycin was compared with placebo alongside standard care. Azithromycin produced no improvement in ADYC symptom scores, whether nasopharyngeal bacteria were detected or not: median 9.59 versus 9.72 in bacteria-positive children (p=0.70) and 9.30 versus 9.10 in bacteria-negative children (p=0.69); there was also no difference in ED length of stay, hospital length of stay or 72-hour revisits. UK ED clinicians should not prescribe azithromycin routinely for undifferentiated preschool wheeze, even when bacteria are detected; reserve antibiotics for clear bacterial infection and continue guideline-based bronchodilator and corticosteroid care. The trial was stopped early for futility, and bacterial clearance was a biological outcome without clinical benefit, so the findings apply specifically to this preschool wheeze population rather than to suspected pneumonia or otitis.
Key numbers: n=840; ADYC median 9.59 vs 9.72 in bacteria-positive children (p=0.70) and 9.30 vs 9.10 in bacteria-negative children (p=0.69); bacterial clearance 58.7% with azithromycin vs 11.4% with placebo.
ANNALS OF EMERGENCY MEDICINE, 2026, RETROSPECTIVE COHORT WITH PROPENSITY-SCORE IPTW ADJUSTMENT, N=2,063 · EM ISSUE 26
Single-dose dexamethasone is equivalent to two doses for paediatric asthma exacerbations
In children aged 2–20 years discharged from two emergency departments after dexamethasone for an asthma exacerbation, this retrospective cohort compared one dose with two doses. At 14 days, ED revisit occurred in 5.2% versus 5.7% (adjusted risk difference +0.45%, 95% CI −1.4% to +2.3%), while hospitalisation occurred in 0.85% versus 0.83% (risk difference +0.02%, 95% CI −0.93% to +0.89%). UK departments routinely using two doses should consider a protocol change towards a single dose, consistent with the excerpt’s description of NICE CKS and BTS/SIGN guidance, reducing discharge complexity and compliance burden. However, this was a retrospective study, so residual confounding and local practice differences remain possible despite IPTW adjustment.
Key numbers: n=2,063; ED revisit 5.2% with one dose vs 5.7% with two doses; risk difference +0.45% (95% CI −1.4% to +2.3%); hospitalisation 0.85% vs 0.83%; risk difference +0.02% (95% CI −0.93% to +0.89%); outcomes assessed at 14 days.
EMERGENCY MEDICINE JOURNAL, 2026; SHORT-CUT REVIEW OF 282 PAPERS, WITH 11 OBSERVATIONAL STUDIES INCLUDED · EM ISSUE 26
Intraosseous access in children: long-term complications are rare
Intraosseous (IO) access is an important alternative when intravenous access has failed in a paediatric emergency. This short-cut review found severe long-term complications to be rare: one case of osteomyelitis was reported, while no evidence of growth disturbance, venous thrombosis or fat embolism was found; compartment syndrome, fracture and extravasation were reported only as isolated rare cases. UK ED clinicians should not delay IO access because of concerns about growth-plate or long-term bone complications, consistent with the stated RCPCH and RCEM guidance. The evidence base comprised observational studies and the absence of identified evidence for some complications does not prove that they cannot occur.
Key numbers: 282 papers reviewed; 11 observational studies included; 1 reported case of osteomyelitis; no evidence found for growth disturbance, venous thrombosis or fat embolism; isolated rare cases of compartment syndrome, fracture and extravasation.
JAMA PEDIATRICS 2026 — SYSTEMATIC REVIEW/META-ANALYSIS; SAMPLE SIZE NOT STATED · EM ISSUE 27
Febrile 60–90-day infants: invasive bacterial infection risk
A systematic review and meta-analysis examined invasive bacterial infection (IBI) and meningitis in febrile infants aged 60–90 days. The reported risks were 1.1% for IBI and 0.11% for meningitis. In UK ED practice, well-appearing infants who meet a validated low-risk assessment, with reassuring inflammatory markers and urinalysis, may be considered for observation without routine lumbar puncture or antibiotics, with robust safety-netting and follow-up. The findings do not remove the need for senior clinical assessment: red flags or abnormal investigations should prompt admission and full septic evaluation, and the excerpt does not provide the review’s sample size or detailed study-level methods.
Key numbers: IBI 1.1%; meningitis 0.11%; sample size not stated
RETROSPECTIVE SERIES, 2026; SAMPLE SIZE NOT STATED · EM ISSUE 28
Febrile Seizure in Kawasaki Disease and Severe Coronary Involvement
In children with Kawasaki disease, a febrile seizure during the acute illness was associated with significantly higher rates of severe coronary artery involvement, including aneurysm formation. In UK emergency departments, this should not automatically be dismissed as a simple febrile convulsion: involve paediatric cardiology urgently and arrange echocardiography when Kawasaki disease is suspected or confirmed. Confirmed Kawasaki disease should be managed according to the relevant paediatric pathway, including IVIG 2 g/kg as stated in the source. This is a retrospective series with no sample size or further methodological details provided, so the association should not be interpreted as proof that febrile seizures predict coronary aneurysm in individual patients.
Key numbers: Significantly higher rates of severe coronary artery involvement, including aneurysm formation; IVIG 2 g/kg if Kawasaki disease is confirmed. Sample size not stated.
RESUSCITATION 2026; EDITORIAL; NO SAMPLE SIZE STATED · EM ISSUE 28
Prophylactic antibiotics after paediatric cardiac arrest
Aspiration is common during paediatric cardiac arrest, particularly because many arrests are asphyxial, and post-arrest immunosuppression may increase infection susceptibility. This editorial concludes that prophylactic antibiotics should not be routinely prescribed; paediatric-specific randomised trial evidence is absent, while adult randomised evidence, including PACA trial data, does not support routine prophylaxis. In UK practice, use individual clinical judgement, considering documented aspiration, prolonged arrest and pre-existing respiratory vulnerability; treat infection if clinical features develop and discuss all post-arrest children with PICU. This is expert opinion rather than new primary research, so it neither definitively supports nor excludes prophylaxis in selected cases.
Key numbers: No paediatric randomised trial data or sample size stated.
ANNALS OF EMERGENCY MEDICINE 2026; PROSPECTIVE CASE SERIES; N NOT STATED · EM ISSUE 29
Dexmedetomidine infusion for severe agitation in adolescents in the ED
A prospective US case series evaluated continuous dexmedetomidine infusion for severely agitated adolescents with psychiatric, substance-related and neurodevelopmental presentations. Infusions of 0.5–1 mcg/kg/hour produced calm, cooperative sedation while preserving airway reflexes and spontaneous ventilation; no serious adverse events were reported, although bradycardia occurred in a minority without requiring intervention. In UK practice, dexmedetomidine may be a specialist, evidence-informed option when respiratory depression is a particular concern, provided it is available locally and used with continuous cardiac monitoring and immediate access to airway equipment. Interpretation is limited by the case-series design, lack of a comparator, possible selection bias and differences between US and UK emergency care; it is not yet standard practice and prospective randomised evidence is needed.
Key numbers: Infusion 0.5–1 mcg/kg/hour; no serious adverse events reported; bradycardia occurred in a minority and required no intervention; sample size not stated.
JOURNALFEED PAEDS SPEED READ, 2026 — QUALITY IMPROVEMENT STUDY; SAMPLE SIZE NOT STATED · EM ISSUE 29
Risk-stratified observation safely reduced for low-risk paediatric anaphylaxis
A paediatric ED quality improvement study evaluated a risk-stratified observation protocol for children with low-risk anaphylaxis. Median observation time fell from 233 to 154 minutes, without an observed increase in biphasic reactions or return visits; low-risk patients had received no more than one adrenaline dose, had no severe features and recovered well. In UK practice, this supports the direction of travel towards shorter, risk-stratified observation, but clinicians should continue to follow NICE NG80 and local protocols, with senior review before any abbreviated discharge and appropriate adrenaline, written-action-plan and allergy-referral arrangements. The study was a local QI evaluation, was not designed for definitive causal inference, and its post-intervention cohort was not large enough to exclude a small increase in risk; NICE recommends a minimum six-hour observation period for most patients while acknowledging uncertainty about the optimal duration.
Key numbers: Median observation time: 233 to 154 minutes; biphasic reactions and return visits did not increase; sample size not stated.
EMERGENCY MEDICINE AUSTRALASIA 2026; MODIFIED TWO-ROUND DELPHI CONSENSUS STUDY; N=28 CLINICIANS FROM 23 CENTRES · EM ISSUE 29
Paediatric Procedural Sedation and Analgesia in the ED: Delphi Consensus
This modified two-round Delphi study assessed paediatric emergency procedural sedation across patient selection, fasting, monitoring, staffing, pharmacology, training and safety. Strong consensus was that fasting should not delay clinically urgent sedation, continuous capnography should be standard for all deep sedation episodes, and departments should have documented protocols, a trained second operator independent of the proceduralist, defined recovery criteria and simulation-based competency training. In UK practice, these findings support benchmarking local paediatric sedation governance against RCEM, AAGBI and NICE-aligned standards, particularly for urgent sedation and deep-sedation monitoring. The evidence is expert consensus rather than primary outcome data, and the exclusively Spanish panel from specialist tertiary centres may not represent a mixed UK district general hospital setting; pharmacological preferences for non-painful procedures remained variable.
Key numbers: n=28 clinicians; 23 centres; modified two-round Delphi; consensus threshold ≥70% agreement in both rounds.
AMERICAN JOURNAL OF EMERGENCY MEDICINE 2025; SYSTEMATIC REVIEW AND META-ANALYSIS OF 11 RCTS · EM ISSUE 30
Hyperpronation versus supination-flexion for radial head subluxation
Radial head subluxation (nursemaid’s elbow) is common in young children, and reduction is usually attempted without imaging when the presentation is typical. In this systematic review and meta-analysis of 11 RCTs involving children aged 0–6 years, hyperpronation had a lower first-attempt failure rate than supination-flexion (9.42% versus 25%), an absolute difference of approximately 15.6 percentage points and an NNT of approximately 6. Hyperpronation should therefore be the preferred initial manoeuvre in UK emergency departments, with supination-flexion available if reduction is unsuccessful; pain was broadly comparable between techniques. The evidence is limited by high risk of bias in 10 of 11 studies, heterogeneity in technique and operator experience, and imprecise pain assessment in young children.
Key numbers: First-attempt failure: 9.42% with hyperpronation versus 25% with supination-flexion; absolute risk difference approximately −15.6 percentage points; NNT approximately 6. Risk of bias was high in 10 of 11 RCTs.
AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON INFECTIOUS DISEASES, 2026, ANNUAL CLINICAL PRACTICE GUIDANCE; N NOT STATED · EM ISSUE 30
AAP influenza 2026–27: treat hospitalised and high-risk children with antivirals regardless of vaccination status
The AAP’s 2026–27 influenza guidance recommends annual vaccination for children from 6 months and antiviral treatment for children who are hospitalised, have severe or progressive disease, or are at high risk of complications. Oseltamivir should be started as soon as possible, regardless of illness duration or vaccination status; treatment remains an option for any child with suspected or confirmed influenza in ambulatory care. In UK EDs, do not withhold oseltamivir from a hospitalised or high-risk child because they have been vaccinated, and ensure local testing, prescribing and escalation pathways are available before the influenza season. This is American guidance, so prescribing should follow current UKHSA and local trust protocols; the excerpt does not provide comparative outcome data or quantify treatment benefit.
Key numbers: Vaccination recommended from 6 months; guidance applies to the 2026–27 influenza season; no sample size or effect estimates stated
AMERICAN HEART ASSOCIATION/CIRCULATION, 2026 — SCIENTIFIC STATEMENT AND CONSENSUS FRAMEWORK; N NOT STATED · EM ISSUE 30
Paediatric cardiogenic shock: definition, severity staging and escalation to mechanical circulatory support
This AHA Scientific Statement proposes a formal definition and severity-staging framework for paediatric cardiogenic shock, characterised by cardiac dysfunction causing inadequate systemic oxygen delivery, with or without hypotension. It describes progression from mild, compensated shock to severe, refractory shock requiring escalating support, and emphasises that children may deteriorate during the first 24 hours. In UK ED practice, use serial assessment and urgent POCUS, avoid reflexive aggressive fluid resuscitation when cardiogenic shock is suspected, and seek early PICU or regional paediatric cardiac-centre advice for possible inotropic support or mechanical circulatory support. This is a consensus statement rather than primary outcome research; recommendations are substantially informed by observational, registry and adult evidence, so local access to ECMO, VAD and specialist transfer pathways remains important.
Key numbers: No sample size or quantitative outcome data stated; deterioration may occur in the first 24 hours.
HEADACHE 2026 — RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL; N=116 ENROLLED, 87 IN THE MITT ANALYSIS · EM ISSUE 31
IV dexamethasone does not prevent paediatric migraine relapse
In children aged 8–17 years treated for acute migraine in a paediatric ED, adding IV dexamethasone 0.6 mg/kg before discharge did not significantly reduce relapse at 48 hours when compared with placebo. Relapse occurred in 39% (16/41) of the dexamethasone group versus 44% (20/46) with placebo, an absolute risk difference of −4% (95% CI −32% to 24%; p=NS). UK ED clinicians should not routinely add IV dexamethasone solely to prevent migraine relapse; use standard rescue treatment and arrange specialist input for refractory or diagnostically uncertain cases. The trial was appropriately blinded but underpowered, with only 87 of 116 enrolled patients contributing 48-hour outcome data, so clinically important benefit or harm cannot be excluded.
Key numbers: Relapse at 48 hours: 39% (16/41) with dexamethasone versus 44% (20/46) with placebo; ARD −4% (95% CI −32% to 24%), p=NS. n=116 enrolled; 87 analysed.
CHAPTER 13
ED Systems & Patient Safety
25 items · EM Evidence Rundown Issues 19–31
RCEM, 2026 — NATIONAL MORTALITY ESTIMATE AND EMERGENCY DEPARTMENT QUALITY-IMPROVEMENT REPORTS; 489,138 PATIENTS WAITED ≥24 HOURS · EM ISSUE 19
RCEM 2026: ED-Wait Mortality, Time-Critical Medication and Delirium-Screening Gaps
RCEM’s State of Emergency Medicine in England 2026 estimates that 15,860 excess deaths in England in 2025 were associated with prolonged ED waits; 489,138 patients waited at least 24 hours, with excess mortality risk reported to rise after 5 hours. The Time-Critical Medication QIP found that 66% of Parkinson’s and diabetes medication doses were administered late, around 40% were missed entirely, and only 44.4% of patients were identified within 30 minutes. The Care of Older People QIP found that four in five patients aged 75 years or over did not receive rapid 4AT delirium screening, while falls-assessment and post-fall safety-round completion remained 40%. UK EDs should review waiting-risk escalation, automated identification and prescribing of levodopa and insulin, and reliable 4AT and post-fall documentation; the mortality figures are estimates of association rather than proof that waiting alone caused each death, and QIP findings should support local audit rather than be treated as trial evidence.
Key numbers: 15,860 estimated excess deaths; 489,138 patients waited ≥24 hours; risk rises after 5 hours; one excess death per 72 patients waiting 8–12 hours; 66% of time-critical medication doses late; approximately 40% missed entirely; 44.4% identified within 30 minutes; 4 in 5 older patients did not receive rapid 4AT screening; falls assessment and post-fall safety-round completion 40%.
JAMA NETWORK OPEN, 2026 — CLUSTER-RANDOMISED TRIAL (UC SAN DIEGO; SAMPLE SIZE NOT STATED) · EM ISSUE 20
AI LLM Sepsis Bundle Alerts Improve Compliance but Not Patient Outcomes
A privacy-preserving large language model provided real-time alerts identifying patients with sepsis who were not receiving SEP-1 bundle-compliant care. Bundle compliance increased from 70.1% to 82.9%, but ICU admissions and 30-day mortality were unchanged. UK EDs should not commission or judge AI sepsis tools on process compliance alone; clinical judgement and outcome measures remain essential. The trial shows that improving adherence to a bundle does not necessarily improve patient outcomes, although individual components such as timely antibiotics may still be clinically important.
Key numbers: Bundle compliance 82.9% versus 70.1%; no difference in ICU admissions or 30-day mortality; cluster-randomised trial; sample size not stated.
RCEM/DAUK/BMJ, 2026, ORGANISATIONAL STATEMENT AND NEWS REPORT; NO SAMPLE SIZE STATED · EM ISSUE 20
Heatwave-related ED surge, exit block and NHS workplace temperature
RCEM attributed the heatwave-related rise in ED demand primarily to exit block, with departments already at capacity and insufficient downstream capacity to absorb additional attendances. DAUK reported clinical staff collapsing in areas reaching 43°C, while UK law sets a 16°C minimum workplace temperature but no upper limit; BMJ Open reporting suggested that up to one third of ED attendances could be redirected to SDEC if capacity existed. UK EDs should activate emergency surge plans and formally document inadequate cooling as an occupational health and patient-safety concern on the trust risk register. The evidence is largely organisational and media reporting rather than a controlled clinical study, so the scale of the effect and the proposed SDEC diversion should be interpreted cautiously.
Key numbers: 43°C reported workplace temperature; UK legal minimum 16°C; no upper legal limit; up to one third of ED attendances potentially redirectable to SDEC
RCEM/NHS ENGLAND, 2026 SERVICE PERFORMANCE DATA AND ORGANISATIONAL RESPONSE · EM ISSUE 21
RCEM June 2026 ED performance: record 12-hour waits and trolley delays linked to exit block
NHS England’s June 2026 data showed record attendance of 1,488,602, with 149,013 patients (9.7%) waiting at least 12 hours in major emergency departments. A further 49,466 patients experienced waits of 12 hours or more on trolleys after being marked for admission; fewer than two-thirds were discharged, admitted or transferred within 4 hours, against the 95% constitutional target. RCEM identifies exit block and insufficient inpatient capacity, rather than heatwaves alone, as the principal system problem, with 13,618 beds per day occupied by patients medically fit for discharge and reported corridor care affecting 2,432 patients per day. UK EDs should use these data to support escalation of whole-hospital flow, admission capacity and delayed-discharge mitigation; the figures describe system performance and do not establish a causal clinical-effect estimate.
Key numbers: Attendance 1,488,602; 149,013 patients (9.7%) waited 12 hours or more; 49,466 trolley waits of 12 hours or more after admission decision; fewer than two-thirds within 4 hours versus 95% target; 13,618 beds per day occupied by patients medically fit for discharge; 2,432 patients per day reported to experience corridor care.
NHS ENGLAND, 2026 — WINTER PLANNING LETTER; N NOT STATED. · EM ISSUE 22
NHS England winter planning 2026/27: corridor care named a patient safety priority
NHS England’s winter 2026/27 planning letter frames corridor care as a patient safety priority rather than solely a performance issue. It requires trusts to implement Model Emergency Department requirements, with 15-minute ambulance handovers expected and no handover exceeding 45 minutes; organisational winter plans are due by the end of August and board assurance statements by 30 September 2026. UK ED leaders should incorporate these requirements into winter preparation, escalation arrangements and board-level assurance, while recognising that effective discharge flow is also necessary to reduce corridor care. RCEM welcomed the planning timeline but expressed scepticism that the measures would substantially improve conditions without addressing discharge flow.
Key numbers: 15-minute ambulance handovers expected; none exceeding 45 minutes; organisational winter plans due end of August; board assurance statements due 30 September 2026; OPEL escalation framework to run 7 days/week.
GMC NATIONAL TRAINING SURVEY AND RCEM RESPONSE, 2026; NATIONAL SURVEY (N NOT STATED) · EM ISSUE 22
Corridor Care Is Damaging Emergency Medicine Training Quality
The GMC 2026 National Training Survey indicates that corridor care is adversely affecting emergency medicine training in the UK. RCEM reports reduced supervision, less exposure to appropriately managed cases and increased trainee stress, with particular concern that complex resuscitation cases cannot be supervised appropriately in corridor environments. Departments should raise the issue through governance and educational supervisor meetings, including the potential impact on supervised learning events and ARCP documentation. The excerpt provides no sample size or detailed survey methods, and the reported relationship should not be assumed to establish causation.
Key numbers: No numerical results or sample size stated.
AGE UK PARLIAMENTARY BRIEFING AND RCEM RESPONSE, 2026; SERVICE REPORT, SAMPLE SIZE NOT STATED · EM ISSUE 22
Delayed Discharge Incidents Increased to 570,957 in 2025/26
Age UK reported 570,957 delayed discharge incidents in 2025/26, an increase of nearly 70% over five years. RCEM linked delayed discharge and exit block directly to corridor care and emergency department overcrowding, describing the findings as a whole-system problem. UK ED leaders should use this evidence to support escalation of discharge-flow and hospital-capacity concerns through departmental and organisational governance. The briefing reports service activity rather than a clinical study, and it does not establish causality or quantify the direct effect on individual patient outcomes.
Key numbers: 570,957 delayed discharge incidents in 2025/26; up nearly 70% in five years
RCEM, 2026; ORGANISATIONAL SERVICE-POLICY STATEMENT; NO STUDY DESIGN OR SAMPLE SIZE STATED · EM ISSUE 22
Wales A&E crisis: RCEM calls for urgent Welsh Government action
RCEM characterises the emergency care crisis in Wales as a year-round problem rather than a seasonal winter phenomenon. It reports that waiting-time breaches of the four-hour standard remain worse in Wales than in England and calls for equivalent standards and resourcing based on NHS England’s Model ED requirements. Welsh ED leaders should consider this when reviewing capacity, flow, workforce and delayed-discharge pressures, while recognising that the statement does not provide additional comparative data or an evaluated intervention. This is an advocacy and service-policy update rather than new clinical evidence.
Key numbers: Four-hour standard breaches are reported as worse in Wales than England; no further numerical data stated.
EMERGENCY MEDICINE JOURNAL, 2026; STUDY DESIGN AND SAMPLE SIZE NOT STATED IN THE EXCERPT · EM ISSUE 23
Boarding beyond four hours is associated with increased mortality and inpatient harm
Boarding after the decision to admit has been associated with clinically important harm, and Howlett et al. quantify this signal for emergency and inpatient services. Each additional four hours of boarding beyond the admission decision was associated with an 8.4% increase in the odds of 30-day mortality; boarding for more than four hours was also associated with 8.6 additional inpatient hours and a 3.8% increase in 30-day readmission odds, with an NNH of 69 for 30-day death. UK EDs should treat prolonged boarding as a patient-safety concern, document and escalate it through local operational frameworks, and report incidents where appropriate. The excerpt does not state the study design or sample size, and the findings are observational associations rather than proof that boarding directly caused each outcome.
Key numbers: Each additional 4 hours of boarding: 8.4% increase in odds of 30-day mortality; boarding >4 hours: 8.6 additional inpatient hours and 3.8% increase in 30-day readmission odds; NNH 69 for 30-day death; RCEM estimated 15,860 excess deaths in England in 2025 associated with long emergency care waits.
BMJ 2026; JUDICIARY.GOV.UK 2026; CORONER INQUEST AND PREVENTION OF FUTURE DEATHS REPORT; SINGLE CASE · EM ISSUE 23
Garth Pretorius inquest: sepsis care failure during overcrowding at Hull Royal Infirmary
A 36-year-old man with recognised sepsis attended Hull Royal Infirmary A&E but the Sepsis 6 pathway was not initiated. During overcrowding and a communication error about an anticipated major incident, he and 15 other patients were told to leave; he died after an approximately 24-hour delay in sepsis treatment, which the coroner found had more than minimally, negligibly or trivially contributed to his death. UK EDs should initiate sepsis treatment at recognition, maintain clear clinical responsibility during redirection or corridor care, document handover, and use one consistently trained triage system. This is a single inquest and Prevention of Future Deaths report, so it cannot quantify the frequency or comparative impact of these failures, but it provides a serious patient-safety warning.
Key numbers: 36-year-old patient; 15 other patients also told to leave; approximately 24-hour delay; dual triage systems in use
AMERICAN JOURNAL OF EMERGENCY MEDICINE, 2026 — SYSTEMATIC REVIEW AND META-ANALYSIS; SAMPLE SIZE NOT STATED · EM ISSUE 23
Five-Level ED Triage Systems: No Single System Demonstrates Overall Superiority
This systematic review and meta-analysis evaluated five-level triage systems, including the Manchester Triage System (MTS), Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale/National Triage Scale (ATS/NTS). All systems showed acceptable diagnostic accuracy for predicting clinical severity and resource utilisation, but no single system was superior across all outcome domains. For UK EDs, the findings support continued use of MTS as a validated and defensible framework, while emphasising documented clinical override when concern persists. Sensitivity for identifying the most critically ill patients remains imperfect, particularly in atypical presentations, older patients and those with altered cognition; the review does not establish that any one system eliminates under-triage.
Key numbers: Five-level triage systems reviewed; no numerical sample size or accuracy estimates stated; sensitivity for identifying the most critically ill patients remained imperfect.
MMWR MORBIDITY AND MORTALITY WEEKLY REPORT, 2026; US ED SURVEILLANCE ANALYSIS, N NOT STATED · EM ISSUE 23
US ED Visits for Suspected Suicide Attempts Remained Elevated in Adolescents and Young Adults, 2021–2025
Analysis of US ED visit data from 2021–2025 found that visits for suspected suicide attempts remained above pre-pandemic levels, particularly among adolescents and young adults, without returning to baseline. The findings are consistent with UK concerns about sustained self-harm and suicidal-crisis presentations, although direct numerical comparison with UK ED data is not appropriate. UK EDs should maintain access to mental health liaison teams and use appropriate safety-planning and SAFE messaging approaches for adolescent self-harm presentations, alongside NICE CG133 and CG16. This is US surveillance data, so it demonstrates a sustained population trend rather than evaluating a specific intervention or establishing causation.
Key numbers: 2021–2025; visits remained above pre-pandemic levels, particularly in adolescents and young adults; no numerical estimates stated
RCEM AND UK GOVERNMENT, 2026; POLICY ANNOUNCEMENT AND PROFESSIONAL RESPONSE; N NOT STATED · EM ISSUE 24
RCEM response to 59 new mental health services co-located with emergency departments
The UK government announced 59 new mental health services co-located with emergency departments across England through the Mental Health Emergency Care programme. RCEM welcomed the expansion but stressed that physical proximity alone may not improve care unless services are fully integrated with ED teams, including joint governance, shared patient lists and integrated triage pathways. ED clinicians should seek clear escalation routes to new services, audit liaison psychiatry response times and support 24/7 mental health access during local implementation planning. The announcement provides no outcome data, and the effect of co-location will depend on staffing, governance and operational integration; NHS England implementation guidance is awaited.
Key numbers: 59 new services across England; no outcome data or sample size stated
RESUSCITATION, 2026 — NATIONWIDE MODELLING STUDY; SAMPLE SIZE NOT STATED · EM ISSUE 24
Community First Responder Density Needed for Sub-4-Minute OHCA Response
This nationwide study modelled the number of community first responders (CFRs) needed per population area to achieve a median response time to out-of-hospital cardiac arrest (OHCA) of under 4 minutes. CFR density was reported to matter as much as defibrillator access, while low-density rural areas required disproportionately larger responder networks to achieve equivalent response times. UK ambulance services and community resuscitation coordinators should benchmark local CFR density against response-time targets and align training and retention programmes accordingly. The excerpt does not provide the modelling methods, effect estimates or uncertainty, so local implementation should be guided by area-specific response data.
Key numbers: Target median OHCA response time: under 4 minutes; sample size and effect estimates not stated.
ROYAL COLLEGE OF EMERGENCY MEDICINE (RCEM), 2026; PROFESSIONAL COMMENTARY AND SUSTAINABILITY GUIDANCE; SAMPLE SIZE NOT STATED · EM ISSUE 24
GreenED and climate resilience in emergency departments
RCEM highlights the impact of the 2026 summer heatwaves and the vulnerability of ageing NHS buildings to extreme heat. Its GreenED initiative supports environmentally sustainable emergency department practice, including reducing single-use plastics, improving energy efficiency and reducing waste. UK EDs should review their summer heat protocols, including cooling facilities, patient hydration policies and staff welfare measures. This is a professional commentary rather than outcome-based research, so the clinical effectiveness of individual GreenED measures is not quantified.
UKHSA, 2026; PUBLIC HEALTH HEAT-HEALTH ALERT AND CLINICAL MANAGEMENT UPDATE; NO SAMPLE SIZE STATED · EM ISSUE 24
Amber heat-health alerts in four English regions, 3–5 August 2026
UKHSA reported Amber Heat Health Alerts in the East Midlands, East of England, South East England and London from 3–5 August 2026; the alerts had lapsed by the end of the newsletter period. The update followed 2,877 excess heat deaths in England to July 2026. For suspected heat stroke, emergency management includes immediate whole-body cooling, aiming for a core temperature below 39°C within 30 minutes, IV rehydration and monitoring for rhabdomyolysis. UK EDs should review heatwave escalation, cooling, hydration and staff-welfare arrangements, while recognising that the regional alerts themselves are no longer active.
Key numbers: 2,877 excess heat deaths in England to July 2026; alerts active 3–5 August 2026; target core temperature <39°C within 30 minutes
RCEM/NHS NORTHERN IRELAND, 2026; SERVICE-PERFORMANCE STATEMENT AND ADMINISTRATIVE DATA; N NOT STATED · EM ISSUE 25
Northern Ireland A&E: 1 in 5 patients wait more than 12 hours
RCEM described prolonged waits in Northern Ireland A&E as a year-round structural problem rather than a purely seasonal winter phenomenon. The August 2026 performance update reported that 1 in 5 patients waited more than 12 hours, with tens of thousands waiting over 12 hours in recent months. UK EDs should treat corridor care and ambulance or inpatient boarding as patient-safety concerns, document each episode, and escalate sustained pressure through local OPEL and governance processes. These are service-performance data and RCEM statements; the excerpt does not provide the underlying denominator, methodology, or causal analysis, so the figures should not be interpreted as an evaluation of a specific intervention.
Key numbers: 1 in 5 patients waited more than 12 hours; tens of thousands waited over 12 hours in recent months. Underlying denominator and methodology not stated.
RCEM/NHS ENGLAND/BMA, 2026; UK EMERGENCY CARE SERVICE AND PERFORMANCE DATA · EM ISSUE 26
July 2026: worst-ever July for 12-hour ED trolley waits in England
NHS England data for July 2026 showed record emergency department demand and severe access pressure, with 2.49 million A&E attendances and 47,000 patients waiting more than 12 hours on a trolley for emergency admission. Corridor care occurred approximately 2,300 times per day, four-hour performance was 74.6% against a 78% target, and mean Category 2 ambulance response time was 29 minutes 49 seconds. UK ED leaders should treat crowding, corridor care and prolonged waits as patient-safety risks requiring local escalation, senior oversight and active mitigation. These are service-level data and do not establish the clinical effects of the reported delays or evaluate a specific intervention.
Key numbers: 2.49 million A&E attendances; 47,000 trolley waits over 12 hours; approximately 2,300 corridor-care instances per day; four-hour performance 74.6% versus 78% target; Category 2 ambulance response time 29 minutes 49 seconds; 47,000 trolley waits approximately 105 times the July 2019 figure.
ANNALS OF EMERGENCY MEDICINE, 2026; NATIONAL US ANALYSIS WITH TEMPORAL WEIGHTING · EM ISSUE 27
ED boarding in older adults after COVID-19, with disproportionate impact on dementia patients
A national US analysis with temporal weighting found that geriatric emergency department boarding has sharply increased since the COVID-19 pandemic, with patients with Alzheimer’s disease and related dementias disproportionately affected. UK framing is concerning: English emergency departments recorded an average of 2,300 corridor-care episodes per day in July 2026, and 60.1% of patients who no longer met criteria to remain in hospital were still admitted because of discharge delays. UK EDs should identify patients with dementia or frailty early, expedite social-care assessment and use the RCEM Frailty toolkit for discharge planning. The US analysis confirms the scale and disparity but does not provide granular detail on specific risk factors, and its findings may not directly generalise to NHS services.
Key numbers: UK data: 2,300 corridor-care episodes per day in July 2026; 60.1% of patients no longer meeting criteria to remain in hospital remained admitted because of discharge delays. The US analysis reported disproportionate impact on patients with Alzheimer’s disease and related dementias but no sample size was stated.
ROYAL COLLEGE OF EMERGENCY MEDICINE (RCEM), 2026 PERFORMANCE DATA REPORT; AUGUST 2026 NHS ENGLAND ED DATA, SAMPLE SIZE NOT STATED · EM ISSUE 29
RCEM: One of the Worst-Ever Summers on Record — August 2026 ED Performance Data
RCEM described the August 2026 emergency department performance data as among the worst on record for a summer period. The data covered NHS England four-hour performance, corridor care rates and major trolley waits, although no numerical results are provided in the excerpt. UK EDs should ensure senior clinical oversight is documented for patients managed in corridor-care areas or outside monitored bays, and escalate flow concerns through local governance channels. The findings are service-performance data rather than an intervention study, and the excerpt does not provide denominators, numerical performance results or comparative effect estimates.
Key numbers: August 2026 NHS England ED performance data covered four-hour performance, corridor care rates and major trolley waits; no numerical results or sample size stated.
ROYAL COLLEGE OF EMERGENCY MEDICINE, 2026, SURVEY DATA; SAMPLE SIZE NOT STATED · EM ISSUE 29
RCEM Safe to Care: violence and aggression experienced by A&E staff
RCEM’s Safe to Care campaign reports that 96% of A&E staff have experienced violence or aggression at work, with 73% experiencing it weekly or more frequently. The campaign describes this as a systemic problem and calls for enhanced legal protections, mandatory body-worn cameras, dedicated mental health support and zero-tolerance enforcement. UK EDs should ensure that staff know local incident-reporting, lone-working, de-escalation and rapid-response procedures, and should support colleagues affected by violence. The survey methodology and sample size are not provided in the excerpt, so the figures should be interpreted as campaign survey findings rather than a fully characterised prevalence estimate.
Key numbers: 96% had experienced violence or aggression at work; 73% experienced it weekly or more frequently; sample size and survey methodology not stated
NATIONAL AUDIT OFFICE + RCEM 2026; SERVICE EVALUATION/REPORT; N NOT STATED · EM ISSUE 29
NAO Report: Managing Flow of Patients Through Hospital — RCEM Response
The National Audit Office examined patient flow through hospital, focusing on the interface between emergency departments and inpatient wards. RCEM welcomed the report’s recognition that ED crowding is primarily a hospital-wide problem rather than an ED-specific failure, and called for urgent implementation of recommendations on same-day emergency care capacity, medical outlier reduction and discharge coordination. UK ED leaders should use these findings to support whole-hospital flow improvement and escalation discussions, rather than treating crowding solely as an ED operational problem. This is a service and policy report rather than an experimental clinical study, and the excerpt provides no quantitative outcome data or sample size.
Key numbers: No quantitative outcome data or sample size stated
HSSIB 2026 — INVESTIGATION REPORT; N NOT STATED · EM ISSUE 30
Mental health crisis care in emergency departments: legal gaps and prolonged waits
HSSIB reports that around 3% of ED attendances are mental-health-related, with patients in mental health crisis twice as likely to wait more than 12 hours; 24% of patients waiting over 72 hours have mental health presentations, and waits of 5–15 days for a mental health bed have been documented. Timely Mental Health Act assessment within 1 hour was described as nearly always impossible because of shortages of AMHPs and Section 12 doctors, while Section 5 MHA does not apply to ED patients and there is no clear general legal power to hold a capacitous patient awaiting assessment or an inpatient bed. UK EDs should escalate prolonged delays, document competing risks and the least restrictive approach, clarify responsibilities with police under Section 136, and seek senior legal and clinical advice; Section 4B MCA has limited application where a patient lacking capacity requires life-sustaining treatment. This is an important patient-safety and medico-legal warning rather than a new clinical intervention: the legal framework remains unresolved, with HSSIB calling for urgent DHSC review and a CQC position statement.
Key numbers: Around 3% of ED attendances are mental-health-related; approximately 9,000 per week nationally; twice as likely to wait >12 hours; 24% of patients waiting >72 hours have mental health presentations; documented waits of 5–15 days, longest 110 hours; MHA assessment target within 1 hour.
ANNALS OF EMERGENCY MEDICINE, 2026 — SCOPING REVIEW; 145 PUBLICATIONS, INCLUDING 62 ORIGINAL STUDIES INVOLVING 34,836 PATIENTS · EM ISSUE 31
Medical Screening of Adult Psychiatric Patients in the ED: Routine Laboratory Testing Is Not Supported
This scoping review mapped evidence on medical screening of adults presenting to the ED with psychiatric emergencies across 145 publications, including 62 original studies involving 34,836 patients. Most society recommendations discouraged routine laboratory testing, while the evidence base was predominantly retrospective (59.7%) and covered eight screening domains. In UK ED practice, use a targeted history, vital signs including temperature, SpO2 and blood glucose, and physical examination; request investigations only for specific clinical indications rather than routinely ordering FBC, U&E, LFT, glucose or TFT for every patient. The review does not provide pooled diagnostic accuracy estimates, and none of the society recommendations used gold-standard guideline methodology, so the findings support rather than establish a definitive screening protocol.
Key numbers: 145 publications; 62 original studies; 34,836 patients; 59.7% of studies predominantly retrospective; laboratory testing addressed in 62.9% of studies
ROYAL COLLEGE OF EMERGENCY MEDICINE, 2026, PRESS RELEASE · EM ISSUE 31
RCEM Reaffirms Support for Advanced Clinical Practice in Emergency Departments
RCEM reaffirmed its support for credentialled Advanced Clinical Practitioners (ACPs) from nursing, paramedic science, physiotherapy and pharmacy backgrounds as an integral part of the ED workforce. It emphasised that ACPs should work collaboratively with doctors rather than act as medical substitutes, and that the most senior clinician in any ED should be a tier 4 or 5 doctor with overall responsibility for clinical care and supervision. UK EDs should ensure that ACP scope of practice, supervision, training pathways, qualifications and governance arrangements are clearly defined, using the RCEM EM:ACP curriculum and credentialing framework as the reference standard. This is a professional position statement rather than new clinical outcomes evidence, and local implementation must account for departmental staffing, capability and governance arrangements.
CHAPTER 14
Guideline & Policy Updates
6 items · EM Evidence Rundown Issues 19–31
NICE NG258 (2026) — CLINICAL GUIDELINE; SAMPLE SIZE NOT APPLICABLE · EM ISSUE 19
NICE NG258: Updated Post-Anaphylaxis Assessment, Tryptase Timing and Observation Standards
NICE NG258 replaces CG134 and updates post-anaphylaxis management in UK emergency departments. It recommends a minimum 4–6 hours of observation after acute treatment, with 24-hour admission for severe reactions or incomplete response, and three mast-cell tryptase samples: at 30–120 minutes, 3–4 hours, and a baseline at more than 24 hours or during follow-up. Allergy referral is recommended for all confirmed or suspected anaphylaxis, with standardised documentation of the suspected trigger, severity, treatment, tryptase results and referral confirmation. EDs should update anaphylaxis pathways, proformas and discharge checklists; this is a guideline update rather than comparative outcome evidence, and the excerpt provides no supporting study data.
Key numbers: Minimum observation 4–6 hours; 24-hour admission if severe or response is incomplete; tryptase at 30–120 minutes, 3–4 hours and baseline at >24 hours or follow-up; allergy referral for all confirmed or suspected cases.
RCEM (2026), UPDATED POSITION STATEMENT; N NOT STATED · EM ISSUE 25
RCEM updated position statement on DoLS in the emergency department
RCEM’s updated position statement clarifies the application of Deprivation of Liberty Safeguards (DoLS) to emergency department patients who lack mental capacity because of conditions such as dementia, acute confusion, intoxication or mental illness. DoLS may apply when a patient is under continuous supervision, is not free to leave and cannot consent to these arrangements; it is not required for every patient with reduced capacity. In practice, a confused, sedated patient prevented from leaving the department may require a DoLS application if the restrictions will persist, whereas an unconscious patient undergoing immediate assessment should have the process documented and reviewed. Clinicians should also consider the interaction with the Mental Health Act and monitor DHSC implementation guidance for the proposed transition to Liberty Protection Safeguards, expected from 2026/27.
ANNALS OF EMERGENCY MEDICINE 2026 — ACEP EVIDENCE-BASED CLINICAL POLICY; DESIGN AND SAMPLE SIZE NOT STATED
- EM ISSUE 28
DOAC Management in the Emergency Department — ACEP Clinical Policy
This ACEP evidence-based clinical policy addresses emergency department management of direct oral anticoagulants, including reversal agents, timing of reversal in major bleeding and interpretation of DOAC levels. It identifies andexanet alfa for factor Xa inhibitors and idarucizumab for dabigatran, and is described as consistent with MHRA and UKHSA guidance. UK EDs should ensure that local protocols cover urgent DOAC assessment and reversal, with appropriate access to these agents. The excerpt does not provide the policy’s evidence grading, outcome data or detailed recommendations, so local UK guidance and formulary arrangements should be checked before changing practice.
JOINT ROYAL COLLEGES AMBULANCE LIAISON COMMITTEE (JRCALC), 2026; CLINICAL GUIDELINE UPDATE; SAMPLE SIZE NOT STATED · EM ISSUE 29
JRCALC Clinical Update 2:26: New Guidance Across Multiple Clinical Areas
JRCALC Clinical Update 2:26 was released on the JRCALC app on 12 August 2026 and contains new guidance, revisions and clarifications across several clinical areas. It includes revised guidance on Learning Disabilities and Autism, areas of increasing importance in NHS emergency care given the higher morbidity and emergency department attendance reported in these patient groups. UK ED clinicians should review the update when working with ambulance services, particularly for handover and shared management decisions involving neurodivergent patients. The excerpt does not provide the detailed recommendations, so their specific clinical implications cannot be assessed here; clinicians should consult the full JRCALC guidance rather than rely on this summary.
Key numbers: Available on the JRCALC app from 12 August 2026; no sample size or outcome statistics stated.
ASRM PRACTICE COMMITTEE/ACOG, 2026, POSITION STATEMENT/CLINICAL PRACTICE UPDATE; N NOT STATED; FERTIL STERIL 2026;126:492–493 · EM ISSUE 30
RhIg prophylaxis is not routinely required before 12 weeks
The ACOG/ASRM update addresses Rh testing and RhIg prophylaxis after first-trimester bleeding, pregnancy loss or abortion. It states that patients at less than 12+0 weeks do not require routine Rh testing or RhIg prophylaxis; fetal red-cell concentrations remain below the estimated sensitisation threshold in 99.8% of pregnancies before 12 weeks. At or beyond 12+0 weeks, routine testing and prophylaxis remain recommended for Rh-negative, unsensitised patients with bleeding or pregnancy loss. UK ED clinicians should follow their trust protocol and current RCOG guidance rather than change practice individually, while referring this evidence to early pregnancy or gynaecology services for local review; individualised discussion may still be appropriate in complex cases or where patients strongly prefer prophylaxis.
Key numbers: Before 12 weeks, fetal red-cell concentrations remain below the estimated sensitisation threshold in 99.8% of pregnancies; historical sensitisation estimates were 1.5–2% after spontaneous miscarriage and 4–5% after surgical evacuation.
INTERNATIONAL JOURNAL OF EMERGENCY MEDICINE 2026; NARRATIVE REVIEW; N NOT STATED · EM ISSUE 31
Risk-stratified observation after anaphylaxis: the 6-hour inflection point
Biphasic anaphylaxis occurs in approximately 4–6% of cases, with a median onset of 11 hours, and the need for two or more adrenaline doses is the most consistent risk factor. In the cited meta-analysis, negative predictive value was 95.8% after 2 hours and 97.3% after 6 hours, with only marginal additional benefit beyond 8 hours. In UK ED practice, follow NICE CG134: consider shorter observation for promptly resolved, low-risk reactions with robust aftercare, while patients with two or more adrenaline doses, delayed response, unknown trigger, cardiovascular compromise, asthma or limited home support generally require at least 6 hours, often 6–12 hours. The review is narrative rather than systematic, and heterogeneity in definitions, populations and observation periods limits confidence in the precise 6-hour threshold.
Key numbers: Biphasic anaphylaxis 4–6%; median onset 11 hours; NPV 95.8% at 2 hours and 97.3% at 6 hours; marginal benefit beyond 8 hours.
Jake Turner, EM Registrar — West Midlands
Curated with the assistance of AI (Perplexity). All content editorially reviewed. Not a substitute for appraisal of the primary sources.
EM Evidence — emevidence.org — EM Q3 2026 State of the Science