EMERGENCY MEDICINE EVIDENCE RUNDOWN
Week of 12 March 2026 | Issue #1
PE guidelines sparking controversy, RSI drug choice questioned by NEJM, TXA window shrinks to 90 minutes, and a new RCEM ambulatory care standard you need to know about.
KEY: CHANGE PRACTICE = act on this now RCT SR/MA GUIDELINE CONSENSUS OBSERVATIONAL = evidence type FRCEM = curriculum-relevant
IN THIS WEEK’S RUNDOWN:
- New AHA/ACC PE guideline — and why PulmCrit says don’t adopt it
- NEJM RSI Trial: Ketamine vs etomidate — the myth of haemodynamic safety
- TXA in trauma: the 3-hour window may be too generous
- RCEM EEMAC guideline sets boundaries on ambulatory care
- MHRA GLP-1 pancreatitis warning — ask every abdo pain patient
- PENG block RCT for hip fractures in the ED
- Dynamic LVOTO: EMCrit’s guide to the two-ventricle problem
- Perimortem caesarean: the 5-minute rule is dead
- NfL outperforms NSE for post-arrest prognostication
- Febrile neonates: PECARN rule validated — zero missed meningitis
🏛 GUIDELINES & OFFICIAL UPDATES
RCEM — Extended Emergency Medicine Ambulatory Care (EEMAC) GUIDELINE
Published: 10 February 2026
The rundown: First national EEMAC standard. Sets firm boundaries on ambulatory care beyond 4 hours.
The details:
- Must be EM-led, co-located with ED, separately resourced — not carved from existing ED staffing
- Maximum 8-hour stay; patients likely to need admission must NOT enter EEMAC
- Recorded as Type 5 ED activity — cannot be used to game 4-hour performance
- Only Tier 3+ EM clinicians can refer patients in; no direct primary care streaming
- Emergency Physician in Charge retains absolute primacy over EEMAC flow
Why it matters: This is RCEM’s direct response to the NHSE Model ED document. If your Trust is planning an EEMAC, this guideline defines what it can and cannot be. Know it before management meetings.
📢 Tell your department: “RCEM has published the EEMAC standard — any ambulatory care unit must be EM-led, separately resourced, and cannot be used to game the 4-hour target.”
🔗 Read the RCEM EEMAC guideline
⚠️ PAIRED CONTROVERSY
AHA/ACC/ACEP — First Joint Acute PE Guideline (A–E Classification) GUIDELINE
Published: 19 February 2026
The rundown: The first combined multisociety PE guideline introduces a 5-tier severity system (Categories A–E) and formalises ED discharge criteria for low-risk PE.
The details:
- Categories A–B: low risk, suitable for ED discharge and outpatient management
- Categories C–E: require hospitalisation; Category E = critical care
- Strong endorsement of PERTs (Pulmonary Embolism Response Teams)
- DOAC preference over VKAs; LMWH preferred over UFH
- Structured pre-test probability (Wells/Geneva) → PERC → age-adjusted D-dimer → CTPA pathway reinforced
Why it matters: This gives you a reproducible framework for PE disposition — but read the counterpoint below before updating your local protocol.
🔗 Read the full AHA/ACC PE guideline
⚠️ COUNTERPOINT — PulmCrit: Four Fatal Flaws EXPERT OPINION
Josh Farkas argues the new A–E system has critical errors: (1) allows sick patients into “low risk” Category B without RV assessment; (2) equates troponin and BNP as interchangeable; (3) treats any transient SBP <90 as shock; (4) invents a contradictory “normotensive shock” definition. His recommendation: stick with ESC 2019 for now.
St Emlyn’s (Rich Carden) offers a more balanced read: the A–E framework is a conceptual advance, even if the details need refinement. 🔗 St Emlyn’s review
📢 Tell your department: “New AHA/ACC PE guideline published with A–E classification, but PulmCrit identifies major flaws — do not update local protocol yet. Stick with ESC 2019 pending review.”
🚨 MHRA — GLP-1 Pancreatitis Warning (Strengthened) CHANGE PRACTICE SAFETY ALERT
Published: 29 January 2026
The rundown: 1,296 UK Yellow Card reports of pancreatitis with GLP-1/GIP agonists, including necrotising and fatal cases. Semaglutide, tirzepatide, dulaglutide, liraglutide, exenatide all implicated.
Why it matters: GLP-1 prescribing is surging. Privately prescribed GLP-1s often won’t appear in medication records. ASK every abdo pain patient about GLP-1 use. If pancreatitis suspected, stop the drug immediately.
Also: MHRA flagged semaglutide-associated NAION (sudden painless visual loss) — refer urgently to ophthalmology. Also: Falsified Mounjaro 15mg pens identified in the UK (batch D873576, via The Private Pharmacy Clinic, Birmingham).
📢 Tell your department: “MHRA strengthened GLP-1 pancreatitis warning — ask every abdo pain patient about GLP-1 agonist use, including private prescriptions not on hospital records.”
🔗 MHRA Safety Roundup February 2026
NICE NG28 — Type 2 Diabetes Management Update GUIDELINE
Published: 18 February 2026
The rundown: Metformin + SGLT-2 inhibitor is now first-line for T2DM. Around 810,000 more patients become eligible for GLP-1 RAs.
Why it matters for ED: More SGLT-2 inhibitor use = more euglycaemic DKA presentations (normal glucose, metabolic acidosis — easy to miss). More GLP-1 users = more pancreatitis risk. Know the new drug landscape.
📢 Tell your department: “NICE now recommends SGLT-2 + metformin first-line for T2DM — expect more euglycaemic DKA and GLP-1-associated pancreatitis in ED.”
🚨 MHRA — Quetiapine Oral Suspension Recall (Double Concentration) SAFETY ALERT
Published: 29 January 2026
The rundown: ALL batches of Eaststone quetiapine oral suspension contain active content at TWICE the correct concentration. Class 1 recall.
Why it matters: Psychiatric patient on quetiapine suspension presenting with unexpected toxicity (sedation, QTc prolongation, hypotension)? This recall may be the cause. Do not abruptly stop — risk of psychiatric decompensation.
📊 KEY JOURNAL ARTICLES & TRIALS
NEJM — Ketamine vs Etomidate for RSI (The RSI Trial) CHANGE PRACTICE
Multicentre RCT | n=2,365 | Late 2025/Early 2026
The rundown: Ketamine offers no mortality benefit over etomidate — and causes significantly more cardiovascular collapse.
The details:
- 28-day mortality: ketamine 28.1% vs etomidate 29.1% (no difference)
- Cardiovascular collapse: ketamine 22.1% vs etomidate 17.0% (NNH ~20)
- In septic patients / APACHE II >20: ketamine’s excess risk even greater (NNH ~10)
- Does not account for ketamine’s bronchodilatory/analgesic benefits or etomidate’s adrenal suppression
Practice implications: Ketamine is NOT the “haemodynamically safe” default in catecholamine-depleted patients. Either agent is acceptable, but prepare the resuscitation beyond drug selection. Have vasopressors drawn up regardless.
📢 Tell your department: “NEJM RSI Trial shows ketamine causes more cardiovascular collapse than etomidate in critically ill patients — have vasopressors drawn up for every RSI regardless of induction agent.”
🔗 NEJM full text | SGEM critical appraisal
Annals of EM — TXA Timing in Trauma (PATCH-Trauma Secondary Analysis) CHANGE
Secondary RCT analysis | n=1,287 | January 2026
The rundown: The effective TXA window may be 90 minutes — not 3 hours.
- TXA within 90 minutes: 28-day mortality 17% vs 25% placebo (adjusted RR 0.64; 95% CI 0.50–0.82)
- TXA beyond 90 minutes: no mortality benefit (adjusted RR 1.04)
- Risk of death increased continuously with each minute of delay
Practice implications: Give TXA at point of contact. Waiting for in-hospital administration may forfeit the mortality benefit entirely. Prehospital TXA matters more than ever.
📢 Tell your department: “TXA benefit may disappear after 90 minutes — ensure it is given at first patient contact in trauma, not deferred to hospital arrival.”
Lancet Respiratory Medicine — Prehospital Intubation Saves Lives in UK Trauma
OBSERVATIONAL
Causal modelling study | n=6,467 | 11 February 2026
The rundown: Prehospital emergency anaesthesia + intubation reduces 30-day mortality by 10.3% in high-risk trauma patients — estimated 170 UK lives saved per year.
Why it matters: The strongest evidence yet for equitable HEMS access. Directly supports funding and service expansion for UK prehospital critical care teams.
JAMA Network Open — Morphine Alone Is NOT Noninferior to Morphine + Paracetamol RCT
RCT | n=430 | 24 February 2026
The rundown: Morphine alone did NOT meet noninferiority vs morphine + IV paracetamol for acute ED pain.
Practice implications: Keep giving paracetamol alongside opioids. The “paracetamol adds nothing” narrative is not supported by this trial.
📢 Tell your department: “New RCT confirms multimodal analgesia is superior — keep giving paracetamol alongside opioids.”
Academic Emergency Medicine — PENG Block for ED Hip Fracture RCT SR/MA
RCT + Systematic Review | March 2026
The rundown: Ultrasound-guided PENG block is safe, effective, and opioid-sparing for hip fracture analgesia in the ED.
- ED-PENG-B RCT: PENG block significantly reduced morphine consumption (0.2 vs 0.4 mg/hr; p=0.03)
- SR of US-guided FNB (Feb 2026): 5 RCTs (551 patients), 2–4 point NRS reduction, 56–80% less preoperative opioid use, zero serious complications
Practice implications: Every EM registrar should be competent in at least one hip block technique (FICB, PENG, or FNB). FNB may achieve faster relief in extracapsular fractures.
Resuscitation — Perimortem Caesarean: Neonatal Survival at 45% SR/MA FRCEM
Systematic Review | n=66 women | 2025; highlighted at TBS 2026
The rundown: Neonatal survival was 45% — even after maternal arrests lasting >29–47 minutes. The rigid 5-minute rule is not supported.
Practice implications: Do not delay resuscitative hysterotomy based on time alone. It also relieves aortocaval compression, potentially improving maternal circulation.
📢 Tell your department: “New SR shows 45% neonatal survival after perimortem caesarean even beyond 29 minutes — the 5-minute rule should not delay resuscitative hysterotomy.”
🎙 FOAMED & CRITICAL APPRAISAL HIGHLIGHTS
EMCrit 420 — Dynamic LVOTO: The Two-Ventricle Problem CHANGE PRACTICE EXPERT
Trina Augustin | 8 March 2026
The rundown: Comprehensive guide to dynamic LVOTO (incidence up to 22% in septic ICU patients). Critical nuance: when RV failure drives the obstruction, treating it as primary LVOTO with fluids/beta-blockers will kill the patient.
Key bedside takeaways:
- Any shock patient with hyperdynamic LV: echo BEFORE inotropes — inotropes worsen primary LVOTO
- Primary LVOTO: fluids, phenylephrine/vasopressin, esmolol, target HR 55–70
- RV-driven LVOTO: vasopressin/noradrenaline, inhaled pulmonary vasodilators; AVOID beta-blockers
📢 Tell your department: “Dynamic LVOTO occurs in up to 22% of septic ICU patients — echo before inotropes in any hyperdynamic shock. Treatment differs completely depending on whether it is LV-driven or RV-driven.”
PulmCrit — STRATIFY Trial: Catheter-Directed = Peripheral tPA for PE RCT FRCEM
Josh Farkas | 6 March 2026
The rundown: STRATIFY RCT (n=210) confirms 20mg alteplase via USAT catheter = 20mg peripheral IV for clot lysis in intermediate-risk PE. Catheter adds no benefit.
Key takeaway: For intermediate-risk PE requiring thrombolysis, peripheral slow low-dose tPA is equally effective — without the procedural risk or cost of catheter delivery.
TheNNT — IV Thrombolysis for Minor Stroke: BLACK Rating (Harm > Benefit) SR/MA
12 February 2026 | 4 RCTs, n=3,364
The rundown: IV thrombolysis for minor non-disabling AIS (NIHSS ≤5): no benefit in recovery, increased harm (NNH 40 for reduced independence; NNH 66 for death).
Key takeaway: Do NOT give thrombolysis for minor non-disabling stroke based on NIHSS alone. If symptoms are disabling despite low NIHSS, treatment may still be appropriate — disability matters more than the number.
EM:RAP March 2026 — PECARN Rule for Febrile Neonates ≤28 Days SR/MA FRCEM
Pooled analysis | 4 cohorts, n=1,537 | March 2026
The rundown: PECARN rule (negative UA + ANC ≤4,000 + procalcitonin ≤0.5) had 94.2% sensitivity, 99.4% NPV. ZERO missed cases of bacterial meningitis.
Key takeaway: For febrile infants 8–28 days: if PECARN criteria all negative and infant well-appearing, LP can be discussed with admitting team rather than mandated. Still admit all ≤28-day febrile infants. Infants ≤7 days: full septic screen, no shortcuts.
⚡ QUICK HITS / ALSO NOTABLE
- CATHETER Trial (NEJM): RCT Deferring arterial lines in ICU shock is noninferior for 28-day mortality. Selective strategy is safe. Link
- Lancet Sepsis Seminar (Feb 2026): REVIEW Comprehensive updated review. Phenotyping and individualised approaches over rigid bundles. Link
- ImmunoSep Trial (JAMA): RCT First precision sepsis immunotherapy trial — phenotype-guided therapy improved SOFA scores (35% vs 18%) but no mortality benefit. Proof of concept. Link
- NfL post-cardiac arrest (Lancet Resp Med/TTM2): OBSERVATIONAL FRCEM Neurofilament light chain outperforms NSE and S100B for neuroprognostication (AUROC 0.93 at 48h). Watch for assay availability. Link
- SGEM #504 — Paediatric Anaphylaxis Observation: OBSERVATIONAL 2h observation may be safe for most; 4h for cardiovascular involvement. No RCT supports any specific duration. Link
- EM Cases Quick Hits 71: Medetomidine withdrawal (clonidine first-line), unstable PTX (finger thoracostomy > needle decompression), fever of unknown origin workup. Link
- FOAM Cortex: Free AI-powered clinical search tool for EM/CC — draws from curated FOAMed sources. Worth trialling. Link
- FPHC Crush Injury Consensus (Dec 2025): CONSENSUS De-emphasises aggressive fluids and prophylactic anti-hyperkalaemia treatment. Individualised monitoring instead. Link
- RCEM New Clinical Guidelines (Jan–Mar 2026): GUIDELINE Haemophilia in ED, sexual assault/rape management, paediatric frequent attenders. Check all three. Link
✅ ACTION POINTS / THIS WEEK
- READ IN FULL: PulmCrit’s PE guidelines critique before updating any local PE protocol — the AHA/ACC A–E system may not be ready for adoption (link)
- READ IN FULL: NEJM RSI Trial — revisit your RSI drug choice framework; ketamine is not inherently haemodynamically safe (link)
- READ IN FULL: EMCrit 420 on dynamic LVOTO — essential echo knowledge for undifferentiated shock (link)
- CLINICAL PRACTICE: Start asking every abdo pain patient about GLP-1/GIP agonist use — privately prescribed versions won’t be on hospital records
- CLINICAL PRACTICE: Ensure TXA is given at first patient contact in trauma, not deferred to hospital — the 90-minute window changes the urgency calculus
- READ THE GUIDELINES: Review the 3 new RCEM guidelines (haemophilia, sexual assault, paediatric frequent attenders) — directly applicable to your ED shifts (link)
Sources checked this week:
RCEM, RCUK, RCOG, RCoA, FPHC/RCSEd, FICM/ICS, NICE, MHRA, NHS England, AHA, ACC, ACEP, ESC, SSC, EAST EMJ, Annals of EM, Resuscitation, NEJM, Lancet, JAMA, Crit Care Med, Acad EM, Prehospital Emergency Care EMCrit/PulmCrit, REBEL EM, St Emlyn’s, SGEM, EM Cases, DFTB, The Bottom Line, TheNNT, EM:RAP, LITFL, JournalFeed
RCOG: No confirmed new Green-top Guidelines this window (GTG42 & GTG27a expected — monitoring). RCoA, ESC: No new EM-relevant guidelines. JournalFeed, LITFL Reviews: Not indexed this period.
Next briefing: Thursday 19 March 2026
All links point to original sources. Content based on abstracts and open-access summaries unless otherwise stated. Not a substitute for reading the full papers.
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.