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EM Evidence Rundown

EM Evidence Rundown ·

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ISSUE 7 · 16 APRIL 2026

EM Evidence Rundown

Emergency Medicine · UK Edition · Weekly Evidence Update

This week: two new RCTs — STRATIFY and STORM-PE — deal a significant blow to catheter-directed thrombolysis programmes for intermediate-risk PE. The UK-specific SWiFT trial (10 HEMS services, NEJM) finds prehospital whole blood no better than components in trauma. The first-ever RCT on blood pressure targets in spinal cord injury raises a meaningful safety signal against augmented MAP. The JournalFeed-mandated Chest 2026 sepsis bundle paper lands. Plus: new data on CPR in paediatric drowning that directly modifies bystander advice, EMCrit exposes systematic HINTS misapplication, and the first GRADE-based delirium CPG for EDs.

KEY TO TAGS

RCT SR/MA GUIDELINE OBSERVATIONAL SAFETY ALERT EXPERT OPINION

CHANGE PRACTICE Items requiring immediate practice change FRCEM Relevant to FRCEM examination curriculum

CONTENTS THIS ISSUE

KEY JOURNAL ARTICLES & TRIALS

STRATIFY + STORM-PE: Catheter-Directed Thrombolysis Offers Nothing Over Peripheral IV for Intermediate-Risk PE

First10EM, 13 April 2026 · STRATIFY: Cardiovascular Research 2026 · PMID 41610160 · STORM-PE: Circulation 2026 · PMID 41183181 RCT

CHANGE PRACTICE FRCEM

Two new RCTs simultaneously published challenge the premise behind NHS PERT (Pulmonary Embolism Response Team) programmes and catheter-directed therapy (CDT) for intermediate-risk PE.

STRATIFY (n=210; multicentre; three arms):

STORM-PE (n=100; single manufacturer design and funding):

Critical appraisal: STRATIFY is the more important trial. Its three-arm design is clever but the primary outcome is a surrogate that doesn't tell us whether patients live longer or feel better. The 0% mortality in the heparin-only arm is striking — this is a reminder that intermediate-risk PE often does well with anticoagulation alone, and that adding thrombolysis (by any route) carries risk without proven survival benefit. STRATIFY was not powered to detect a mortality difference; a larger trial would be needed. However, on the evidence available: if you are going to give thrombolysis, do it peripherally. And the signal suggests that for haemodynamically stable intermediate-risk PE, anticoagulation alone remains a very defensible choice.

Why it matters: NHS PERT programmes are being actively commissioned at significant cost. Catheter kits, lab time, and procedural expertise are expensive. These data suggest that if thrombolysis is warranted, peripheral IV alteplase achieves identical thrombus reduction with less procedural complexity. If your hospital is building a PERT programme, these trials must be part of the commissioning conversation.

Tell your department: For haemodynamically stable intermediate-risk PE: anticoagulation first. If thrombolysis is needed, peripheral IV alteplase is as good as CDT. No catheter required. See also PulmCrit: emcrit.org/pulmcrit/

SWiFT Trial — Prehospital Whole Blood No Better Than Component Therapy in UK Trauma (NEJM)

NEJM, 17 March 2026 · PMID 41841706 · The Resus Room, Papers of April 2026 · First10EM RCT

FRCEM

Pragmatic phase 3 multicentre RCT conducted across 10 English air ambulance services (NHS Blood and Transplant collaboration; MoD co-funded; 19 receiving hospitals). 942 patients randomised; 616 in the primary analysis.

Critical appraisal: This is the largest prehospital RCT ever conducted in the UK and the result is a clear null. Several caveats are worth noting: (1) the trial was pragmatic and unblinded, which introduces ascertainment bias risk; (2) the primary outcome combines two very different events (death and massive transfusion), which can muddy interpretation; (3) the whole blood product used in this trial had a shorter shelf life and slightly different composition to low-titre O-negative blood used in some US services — generalisability to all whole blood programmes is imperfect. The PT finding is interesting: standard care (with dedicated FFP) provided better coagulation factor replacement than whole blood, which challenges the theoretical advantage of whole blood. The bottom line is that the logistical argument for whole blood (simpler, single product) may still hold in some services — but the survival case is not there.

Why it matters: Multiple UK HEMS services have invested in or are considering whole blood programmes. SWiFT directly informs those decisions. The product is not harmful — but it does not reduce mortality compared to standard component therapy. Haemorrhage control and minimising scene time remain the dominant determinants of outcome. See also: St Emlyn's analysis

Timely Sepsis Bundle Adherence Associated with More Patients Discharged Home (Chest 2026)

JournalFeed Article-a-Day · Prescott et al. Chest. 2026 Mar 13. PMID 41833809 OBSERVATIONAL

FRCEM

Large retrospective cohort of ~39,000 sepsis patients (first author Hallie Prescott, University of Michigan) examining whether Hour-1 Bundle compliance was associated with the patient-centred outcome of discharge to home — not just survival.

Critical appraisal: This is observational — confounding is the major limitation and almost impossible to fully eliminate in a dataset of this kind. Patients who receive timely bundles may differ systematically from those who don't (e.g. less severe illness, better nursing ratios, daytime presentations). The effect sizes are modest (3 and 1.1 percentage points) and should not be over-interpreted. That said, the patient-centred framing — discharge to home rather than just 28-day mortality — is genuinely valuable for QI purposes. Most sepsis bundle outcome data focuses on survival; this paper adds functional recovery to the equation. The finding that fluids improve functional outcomes without a survival benefit is intriguing and biologically plausible (adequate resuscitation may prevent organ dysfunction even when it doesn't prevent death).

Why it matters: This supports the NICE NG51 Sepsis 6 bundle and provides patient-centred outcome data for QI presentations. The numbers are modest but directionally consistent — timely antibiotics and fluids get more patients home. Use this at your next Sepsis 6 compliance audit.

Blood Pressure Targets in Acute Spinal Cord Injury: First-Ever RCT — No Neurological Benefit, More Respiratory Harm

First10EM, 6 April 2026 · Sajdeya et al. JAMA Network Open. 2025 Sep;8(9):e2525364. PMID 40965887 RCT

CHANGE PRACTICE FRCEM

This is the first RCT ever conducted on the question of blood pressure targets in acute spinal cord injury — a practice that has been standard in UK neurosurgical centres based on consensus opinion alone for decades. 92 patients (13 US trauma centres); cervical or thoracic SCI with new AIS A, B, or C deficits; randomised to augmented MAP >85–90 mmHg for 7 days vs conventional MAP 65–70 mmHg.

Critical appraisal: The trial was substantially underpowered — 29% of patients were lost to follow-up at 6 months, which alone is enough to make any neurological outcome analysis unreliable. You cannot conclude from this trial that augmented MAP definitely doesn't help neurologically. However, the safety signal is different: the respiratory harm data (78% vs 39% complications) comes from the ICU stay, is relatively complete, and is large enough to be meaningful even in an underpowered trial. The effect size is substantial — almost doubling the rate of respiratory complications — and is biologically plausible (vasopressors promote pulmonary oedema; higher MAP may increase afterload burden). This is a classic example of where the harms are clearer than the benefits. Pending a properly powered trial, the burden of evidence has shifted.

Why it matters: Many UK spinal and neurosurgical units currently target MAP >85 mmHg in acute SCI — a practice based on 1990s observational data and expert consensus. This is the first RCT, and it shows no neurological benefit with real respiratory harm. Default to MAP 65–70 mmHg in the ED. If the receiving team requests augmented MAP, this evidence should form part of the explicit handover conversation.

Tell your department: Share this with your neurosurgical and spinal teams. The augmented MAP protocol deserves formal review given these data.

Preoxygenation Before Intubation of Critically Ill Patients: NIPPV Outperforms HFNC and Facemask — Network Meta-Analysis of 15 RCTs

REBEL EM, 13 April 2026 · Pitre et al. Lancet Respir Med. 2025;13(7):585–596. PMID 40127663 SR/MA

FRCEM

Network meta-analysis of 15 RCTs (n=3,420) comparing HFNC, NIPPV (mask-based BiPAP/CPAP), and facemask oxygen for preoxygenation before intubation in critically ill adults.

Critical appraisal: Network meta-analyses pool indirect comparisons across trials with different populations, definitions of hypoxaemia, and procedural contexts — this limits certainty of estimates. The individual trials that contribute most of the NIPPV signal (PREOXI, OPTINIV) are generally well-conducted, and the direction is consistent. The lack of mortality benefit is expected — preoxygenation is one step in a complex process and peri-intubation hypoxaemia, while clinically important, is not the sole determinant of outcome. The aspiration concern is clinically meaningful: the reassurance that pooled data show no excess aspiration with NIPPV is useful, though most trials exclude patients at the highest aspiration risk (full stomach, recent meal, GI obstruction). Helmet NIPPV is not assessed and may perform differently.

Why it matters: RSI and intubation are daily events in UK EDs and ICUs, and peri-intubation hypoxaemia is associated with downstream complications. This NMA provides the strongest current summary of the evidence: NIPPV is preferred for hypoxaemic patients who tolerate it. Consistent with post-PREOXI messaging. If your department defaults to facemask alone, there is now a well-powered reason to review that practice.

GUIDELINES & UK UPDATES

UKHSA: Legionnaires' Disease Cluster — North West and South West London

UKHSA Health Protection Report · Alert issued ~9 April 2026 SAFETY ALERT

Key alert: 8 confirmed cases sharing an identical bacterial sequence; 13 further individuals under urgent investigation. Enhanced respiratory screening protocols active in hospitals in affected areas. Source likely an industrial water system; several cooling towers shock-dosed. The disease is not contagious person-to-person.

Action for ED clinicians in London: For any patient presenting with severe community-acquired pneumonia from North West or South West London — add urinary antigen testing for Legionella pneumophila. Consider this in any CAP with prominent gastrointestinal symptoms, hyponatraemia, or disproportionate myalgia. Alert your local HPT if a case is identified.

Why it matters: Legionella is one of those diagnoses that requires active clinical suspicion — urinary antigen is simple and cheap, but only gets ordered if you think of it. During an active cluster, the pre-test probability for severe London-area CAP is meaningfully elevated.

UKHSA: National Measles Guidelines Version 7 — Updated 2 April, Further Alert 8 April

UKHSA National Measles Guidelines v7 · Updated 2 April 2026 SAFETY ALERT

Version 7 incorporates the MMRV (measles, mumps, rubella, varicella) combined vaccine; revised outbreak management priorities; and updated case-finding guidance for clinicians. Measles cases are rising in England, with hundreds already documented in early 2026 following a decade of declining MMR uptake.

MHRA Field Safety Notices — 6 to 10 April 2026 (and 30 March to 3 April 2026)

MHRA FSNs 6–10 April 2026 · FSNs 30 March–3 April 2026 SAFETY ALERT

Two FSNs of direct emergency medicine relevance:

PAEDIATRIC EMERGENCY MEDICINE

Paediatric Drowning Cardiac Arrest: Compression-Only CPR Worse Outcomes — Rescue Breaths Essential

JournalFeed EM SpeedRead (16 April 2026) · Obara et al. Resuscitation. 2026 Mar 10. PMID 41819340

OBSERVATIONAL CHANGE PRACTICE FRCEM

Nationwide retrospective analysis of paediatric OHCA due to drowning in Japan (2012–2023). Compression-only CPR (CCO) was associated with significantly higher mortality and worse neurological outcomes vs standard CPR including rescue breaths.

Key message: Drowning cardiac arrest is asphyxial in mechanism — the arrest results from hypoxia, not primary VF. Ventilation is not optional. CCO CPR, which is appropriate for witnessed adult cardiac arrest of presumed cardiac cause, is inadequate for paediatric drowning. The CCO movement has unintentionally simplified the message too far in some bystander training programmes.

Critical appraisal: This is a large nationwide registry analysis with the usual limitations of observational data — unmeasured confounders, selection bias, and classification uncertainty. Patients who received standard CPR may have had bystanders who were more trained overall. However, the biological rationale is strong and consistent with existing RCUK guidance. The Japanese context may not map perfectly to UK drowning epidemiology, but the physiology is universal.

Why it matters: RCUK 2025 guidelines (implemented April 2026) specifically mandate 5 rescue breaths as the initial step in paediatric drowning arrest. This observational data provides outcome-level support for that approach. When briefing bystanders or reviewing your department's paediatric resuscitation posters, be explicit: the "hands only" message does not apply to paediatric drowning. Also in today's JournalFeed EM SpeedRead: meta-analysis of CCO vs standard CPR in adult OHCA (Hasanvand et al., Am J Med 2026; n>230,000 — similar outcomes in adults, confirming CCO is appropriate for the adult cardiac-cause arrest population. The distinction by mechanism and age group matters). PMID 41819400

DFTB: Hand, Foot and Mouth Disease vs Eczema Coxsackium — The Spring Distinction That Prevents Unnecessary Admission

Don't Forget the Bubbles, 14 April 2026 EXPERT OPINION

Spring is HFMD season. DFTB distinguishes classic HFMD (Coxsackie A16/EV71; predictable palmar-plantar-oral distribution; self-limiting) from Eczema Coxsackium (atypical HFMD affecting areas of pre-existing eczema; can appear dramatically alarming; child is systemically well). This distinction prevents unnecessary 999 calls, ED attendances, hospital admissions, and inappropriate prescribing.

Why it matters: Eczema Coxsackium is consistently misidentified as infected eczema, Stevens-Johnson syndrome, or varicella — each of which triggers a different (and unnecessary) management pathway. Getting this diagnosis right confidently prevents admission, avoids topical steroid prescribing that makes the rash worse, and reduces parental anxiety with authoritative reassurance.

FOAMED & CRITICAL APPRAISAL

EMCrit Wee: You Don't Understand Dizziness — HINTS Is Being Used in the Wrong Patients (96.9% of the Time in One ED)

EMCrit, 9 April 2026 EXPERT OPINION

FRCEM

A chart review found that 96.9% of patients who received HINTS examination in one ED did not actually meet criteria — HINTS requires documented spontaneous nystagmus that is continuous (not intermittent) and present at rest. Most dizzy patients who get HINTS do not have these features. The test's impressive diagnostic accuracy (sensitivity 96.5%, specificity 84.4% for central cause in the right population) becomes meaningless when applied indiscriminately.

Weingart introduces two validated practical alternatives for the broader dizzy patient: STANDING-M (sensitivity 88.2%, specificity 91.6%, NPV 99%; fixes the gait assessment limitations of original STANDING) and the Sudbury Risk Score (score <5 has 100% sensitivity for ruling out central cause, specificity 72%). Despite these tools, 48% of patients in the STANDING-M study still received non-contrast CT — a persistent QI target.

Why it matters: Posterior circulation stroke is one of the most feared missed diagnoses in EM. HINTS is a powerful tool — but only in the patient with continuous spontaneous nystagmus and continuous dizziness at rest. For the much larger population of dizzy patients in the ED (most of whom have intermittent or positional symptoms), STANDING-M is more appropriate. This episode is worth sharing with any trainee who has started reflexively doing HINTS on every dizzy patient.

SGEM#507 — First GRADE-Based ED Delirium Guidelines: 4AT Endorsed, Routine Head CT Not Recommended

SGEM, 11 April 2026 · Lee et al. Academic Emergency Medicine, February 2026 (GED 2.0 CPG) GUIDELINE

FRCEM

The first GRADE-based clinical practice guideline for ED delirium management in older adults (GED 2.0 initiative; guest Dr Christina Shenvi). Delirium affects 6–38% of older ED patients and is underdiagnosed in 60–70% of cases. Six conditional recommendations — all based on very low certainty evidence, which reflects the paucity of quality research in this population rather than clinical unimportance.

Why it matters: This guideline validates 4AT use in UK EDs and provides the first GRADE framework for delirium CPG development. The explicit recommendation against routine CT for undifferentiated delirium has potential to reduce unnecessary imaging and its associated harms (radiation, contrast, departmental bottlenecks). For FRCEM: know 4AT, understand its domains, and be able to articulate when you would and would not scan a delirious patient.

St Emlyn's: UK Physician-Based HEMS 2024 — 30 Teams, Half with 24/7 Cover, Still a Postcode Lottery

St Emlyn's Blog, 22 March 2026 · Macdonald et al. EMJ 2026 (100% response from all 21 UK HEMS)

OBSERVATIONAL

The most complete national survey of UK physician-based HEMS provision yet published. Physician teams increased from 11 (2009) to 30 (2024); 24/7 physician coverage from 1 service (5.9%) to 11 (52.4%). Blood transfusion available from 19/21 services (90.4%); REBOA from only 1/21 (4.7%). Only one service is fully government-funded. Significant geographic inequity persists — East of England is well served; Northern Ireland, South West England, and Northern England have least coverage. The majority of advanced HEMS capability in the UK is funded by public charitable donation, not NHS commissioning.

Why it matters: Understanding your local HEMS capability is directly relevant to trauma activation decisions, triage choices, and realistic expectations of what a HEMS team can and cannot deliver on scene at 2am in your region. For anyone involved in PHEM governance, commissioning, or advocacy, this paper maps the inequity comprehensively.

QUICK HITS / ALSO NOTABLE

ACTION POINTS / THIS WEEK

TRIALS TO WATCH

SOURCES CHECKED THIS ISSUE

UK Official Bodies: NHS England ✓ · RCEM ✓ · RCUK ✓ [No new publications this period] · UKHSA ✓

Priority FOAMed: JournalFeed (EM SpeedRead + POCUS SpeedRead, 16 April) ✓ · EMCrit + PulmCrit ✓

Key Journals: NEJM ✓ · Chest ✓ · JAMA + JAMA Netw Open ✓ · Lancet Respir Med ✓ · Resuscitation ✓ · Cardiovascular Research ✓ · Circulation ✓ · Academic Emergency Medicine ✓ · Am J Med ✓ · SJTREM ✓ · BMC Emergency Medicine ✓

Email feeds: JournalFeed EM SpeedRead (clay@journalfeed.org) ✓ · JournalFeed POCUS SpeedRead ✓

Next briefing: Thursday, 23 April 2026

Disclaimer: This newsletter is a curated educational summary for postgraduate medical professionals. It does not constitute clinical guidance or replace local protocols, national guidelines, or individual clinical judgement. Always refer to current NICE guidance, RCUK protocols, and your trust's clinical policies for patient management decisions. Drug safety information sourced from MHRA — verify with current product information. All URLs verified at time of publication.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed.

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