EM Evidence Rundown (v3)

ISSUE 3 · 15 MARCH 2026

EM Evidence Rundown

Emergency Medicine · Weekly Evidence Update

This week: the COBRRA trial lands in the NEJM and may change how every ED prescribes for VTE — apixaban halves the bleeding risk vs rivaroxaban with no difference in efficacy. Tenecteplase rewrites the extended stroke window as two new RCTs confirm benefit from 4.5 to 24 hours, aligned with the landmark 2026 AHA/ASA stroke guideline that finally endorses TNK alongside alteplase. Plus: three new RCEM guidelines, an MHRA pancreatitis warning for the millions now on GLP-1 agonists, ILCOR weighs in on video vs direct laryngoscopy during cardiac arrest, and ACEP makes headlines by refusing to endorse the new Surviving Sepsis Campaign guidelines.

KEY TO TAGS

RCT SR/MA GUIDELINE CONSENSUS OBSERVATIONAL EXPERT OPINION SAFETY ALERT

REVIEW

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

CONTENTS THIS ISSUE

1. RCUK 2025 Resuscitation Guidelines — Key Changes for EM
2. MHRA: Semaglutide & NAION — Sudden Vision Loss Alert
3. MHRA: GLP-1/GIP Agonists — Pancreatitis Warning (inc. Fatal Cases) CHANGE PRACTICE
4. RCEM: Sexual Assault/Rape Management in ED (Jan 2026)
5. RCEM: Haemophilia in Emergency Departments (Jan 2026)
6. AHA/ASA 2026 Acute Ischaemic Stroke Guideline (inc. TNK)
7. ACS in Premenopausal Women — AHA Scientific Statement
8. ACEP Refuses to Endorse SSC Sepsis Guidelines — A Controversy
9. COBRRA RCT — Apixaban vs Rivaroxaban in VTE (NEJM) CHANGE PRACTICE
10. OPTION RCT — Tenecteplase 4.5–24h in Non-LVO Stroke (JAMA)
11. TRACE-5 RCT — TNK for Basilar Artery Stroke up to 24h (Lancet)
12. LEGEND Trial — Single hsTroponin LOD Rule-Out for AMI
13. COACT 5-Year Outcomes — OHCA Without ST-Elevation (JACC)
14. VL vs DL During Cardiac Arrest — ILCOR SR/MA (Resuscitation)
15. Ipratropium in Paediatric Asthma — SR/MA (Arch Dis Child)
16. Quick Hits: Falsified Mounjaro Alert; NHSE Corridor Care; IN Naloxone Synthetic Opioids; NICE NG24 TXA Update; HEMS Survival; Prehospital ABD; SGEM RENOVATE; DFTB PECARN CT Equity; and more

GUIDELINES & OFFICIAL UPDATES

RCUK 2025 Resuscitation Guidelines — Key Changes for ED Practice

Resuscitation Council UK · Published October 2025 GUIDELINE

FRCEM

The 2025 RCUK guidelines, published in October 2025, represent the most comprehensive update since 2021. Key changes directly relevant to ED and prehospital practice include:

• Jaw thrust mandatory for all patients with suspected spinal injury requiring airway opening manoeuvres — head-tilt/chin-lift no longer default in trauma
• Drowning: 5 rescue breaths now specified as the initial step before chest compressions
• Paediatric ratio: 15:2 compression-to-ventilation ratio confirmed for paediatric BLS (single rescuer exception applies)
• Tourniquets for first aiders: Haemorrhage control with tourniquets and haemostatic dressings now endorsed in first aid training and first aid at work courses — not just advanced providers
• Infant CPR: Encircling (two-thumb) technique is now the preferred method (previously recommended for healthcare providers with two rescuers; now prioritised for all)
• Defibrillator pad placement: Second pad repositioned to just beneath the left armpit for improved transthoracic impedance
• Call 999 first: 999 should be called immediately on discovering unconscious casualty, even before confirming breathing (use speakerphone if alone)

Why it matters: These changes affect every ALS/PALS provider, first-aid trainer, and ED resuscitation protocol. The jaw thrust change is particularly important for trauma teams — review your department's primary survey teaching. The tourniquet change empowers bystanders and first aiders with critical haemorrhage control tools.

Tell your department: All simulation and teaching mannequin sessions need updating — jaw thrust first in trauma arrests, infants by encircling thumbs, second defibrillator pad lower under axilla.

MHRA Safety Alert: Semaglutide (Ozempic/Wegovy) — Risk of Sudden Vision Loss (NAION)

MHRA Safety Roundup: February 2026 · Published 25 February 2026 SAFETY ALERT

Key alert: Very rare cases of Non-arteritic Anterior Ischaemic Optic Neuropathy (NAION) have been reported with semaglutide, causing sudden unilateral vision loss (blurring or cloudiness).

Following Commission on Human Medicines (CHM) review, product information has been updated with a new warning.

Action for ED clinicians:

• Any patient presenting with sudden/partial vision loss in one eye — ask about semaglutide use (including privately prescribed GLP-1s, which may not appear on hospital drug history)
• Refer urgently to ophthalmology; advise eye casualty/A&E if sudden vision change develops at home
• Discontinue semaglutide if NAION confirmed
• Report via Yellow Card scheme

Why it matters: GLP-1 use is exploding in the UK — Ozempic/Wegovy prescribing has increased dramatically including via private prescriptions that often do not appear on NHS records. This is a new, potentially sight-threatening complication that EDs must be alert to. Always ask about weight loss injections in patients presenting with monocular visual symptoms.

MHRA Safety Alert: GLP-1/GIP Receptor Agonists — Strengthened Pancreatitis Warning (Including Fatal Cases)

MHRA Drug Safety Update · 29 January 2026 SAFETY ALERT

CHANGE PRACTICE

Key alert: Product information updated for ALL GLP-1 receptor agonists (dulaglutide, exenatide, liraglutide, semaglutide) and dual GLP-1/GIP agonists (tirzepatide) to highlight risk of severe acute pancreatitis, including necrotising and fatal cases. 1,296 UK Yellow Card reports (2007–2025), of which 19 fatal.

Action for ED clinicians:

• Ask about GLP-1/GIP use in every patient presenting with acute pancreatitis symptoms or severe abdominal pain — privately prescribed products (Ozempic, Wegovy, Mounjaro) may not appear on hospital records
• Stop immediately if pancreatitis suspected; do not restart if confirmed
• Consider GLP-1 use in your differential for unexplained acute abdominal pain — millions of patients are now on these agents
• Report suspected ADRs via Yellow Card scheme

Why it matters: GLP-1 agonists are now used by millions of patients for both diabetes and weight loss — and many won't declare them proactively. ED clinicians must include GLP-1/GIP use in history for any patient presenting with acute pancreatitis or severe abdominal pain. This is the second major MHRA GLP-1 safety signal in two months (after the semaglutide/NAION alert above).

Tell your department: Add "GLP-1 agonist use?" to your acute abdomen clerking template. Ensure triage staff know to ask about weight loss injections — patients may not consider these as "medications".

RCEM: Management of Adult Patients Who Attend EDs after Sexual Assault and/or Rape

RCEM Best Practice Guideline · January 2026 GUIDELINE

Comprehensive "one-stop" guideline for ED clinicians managing adults presenting after rape or sexual assault — the first revision since 2015. Key recommendations:

• Always direct to local SARC (Sexual Assault Referral Centre) where feasible
• Prioritise urgent injuries over forensic considerations — the ED must manage acute medical needs that SARCs cannot
• Forensic examination only by specially trained clinician
• Non-fatal strangulation must be routinely assessed
• Post-exposure antibiotic prophylaxis against STIs no longer routinely recommended (but doxycycline for MSM/transgender women as PEP)
• Emergency contraception, HIV/Hepatitis B PEPSE, and safeguarding must be addressed in the ED even if SARC attendance is planned
• Embed trauma-informed care principles throughout

Why it matters: Replaces a decade-old guideline with substantially updated evidence. This is a high-frequency sensitive ED presentation. The change in post-exposure antibiotic prophylaxis position is clinically important. Clarifies ED vs SARC responsibilities — know what your ED must manage acutely even when referring to a SARC.

RCEM: Management of Patients with Haemophilia in Emergency Departments

RCEM Best Practice Guideline · January 2026 GUIDELINE

First UK-specific ED-focused guideline for emergency management of adults with haemophilia A/B, von Willebrand disease, and similar heritable bleeding disorders. Key standards:

• Triage within 15 minutes; senior review within 30 minutes for life/limb-threatening bleeds
• Haemostatic treatment within 60 minutes — critically, "treat first, don't wait for results"
• Avoid NSAIDs/COX-1 inhibitors
• Specialist haematologist consultation before invasive/surgical procedures
• Audit standards: 95% triaged ≤15 min; 80% receive haemostatic therapy ≤60 min for severe bleeds

Why it matters: Haemophilia patients are at high risk of mortality from delayed treatment, and most EDs lack robust local protocols. This sets nationally auditable standards for the first time. The "treat first" principle is critical — do not delay factor replacement while awaiting coagulation results in a patient with known haemophilia and a significant bleed.

AHA/ASA 2026 Acute Ischaemic Stroke Guideline — Tenecteplase Endorsed, Extended Thrombectomy Window, First Paediatric Guidance

Stroke (AHA Journals) · Published 26 January 2026 GUIDELINE

FRCEM

The 2026 AHA/ASA guideline replaces the 2018 version and 2019 update, incorporating landmark trial data from the past 7 years. Key practice-relevant changes:

• Tenecteplase (TNK) formally endorsed alongside alteplase within 4.5 hours. TNK is a single IV bolus (vs 60-min alteplase infusion) — preferred for operational simplicity
• Broader thrombectomy eligibility: Extended time windows, less stringent imaging requirements at non-comprehensive centres — simplifying access for more hospitals
• Basilar artery occlusion thrombectomy now explicitly endorsed
• Mobile stroke units formally endorsed for the first time — EMS triage refined
• Paediatric AIS guidance for the first time: Alteplase may be considered within 4.5 hours for children 28 days–18 years with disabling deficits; EVT for LVO ≥6 years within 6h (up to 24h if imaging shows salvageable tissue)
• Dual antiplatelet therapy for non-disabling stroke/TIA within the 4.5-hour window
• Contraindications to thrombolysis are modified — fewer absolute contraindications

Why it matters: This is the most significant stroke guideline update in a decade. TNK endorsement is practice-changing for many UK trusts — check whether your hospital formulary includes TNK. The extended thrombectomy eligibility and reduced imaging requirements may increase the proportion of patients eligible for intervention. Paediatric stroke guidance fills a long-standing evidence gap.

Tell your department: Discuss TNK availability and formulary status with your pharmacy team. Review your local stroke pathway for thrombectomy eligibility criteria — the window has widened.

ACS in Premenopausal Women — First AHA Scientific Statement on Integrated Management

Circulation (AHA) · 3 February 2026 · PMID: 41631393 GUIDELINE

FRCEM

First AHA scientific statement addressing integrated management pathways for premenopausal women with ACS. Key points:

• Premenopausal women are often under-recognised and under-treated for ACS
• Non-atherosclerotic causes (SCAD, MINOCA, coronary spasm) are disproportionately common in this group
• Diagnostic delays and implicit gender bias contribute to worse outcomes vs young men
• Includes ED-specific guidance on recognising atypical ACS presentations in young women
• Proposes algorithms for invasive vs non-invasive testing; recommends cardiac rehab
• Considerations for pregnant/breastfeeding patients, contraception counselling, fibromuscular dysplasia screening

Why it matters: Directly relevant to ED assessment — includes ED-specific guidance on recognising atypical ACS presentations in young women. Calls for systematic interventions to address diagnostic bias in EDs. Particularly relevant to SCAD, which is commonly missed and disproportionately affects young women. For FRCEM, understand the sex-specific differences in ACS presentation and aetiology.

Paired Controversy: ACEP Refuses to Endorse New Surviving Sepsis Campaign Guidelines

⚡ PAIRED CONTROVERSY

The new SSC guidelines (SCCM/ESICM) have been published. ACEP has formally refused to endorse them — only the third time in history a major EM society has rejected a sepsis guideline update. This is a live controversy with direct ED implications.

ACEP Statement (2 February 2026) EXPERT OPINION

FRCEM

ACEP's objections:

• Adult and paediatric SSC guidelines are misaligned — different criteria, pathways and timing for the same condition, creating confusion at the ED/paediatric interface
• Aggressive fluid and antibiotic protocols may cause harm when applied to too broad a population to meet arbitrary time targets
• No emergency physician representation in SSC governance — guideline authors are exclusively critical care physicians
• ED realities (crowding, boarding, concurrent critical patients) not reflected in the guideline's operational recommendations

SSC position: Guidelines are evidence-based and represent the best available data on early goal-directed care for sepsis/septic shock. One-hour antibiotic target for septic shock is supported by mortality data.

Caution: This controversy reflects a genuine evidence/implementation tension. UK practice follows NICE NG51 sepsis guidelines (now replaced by NG253/254/255), which are not identical to SSC guidance. The NICE sepsis update (November 2025) emphasised smaller initial fluid volumes and reassessment after each infusion — closer to the ACEP position than to aggressive fixed-protocol SSC recommendations.

Why it matters: UK trainees should know both the NICE sepsis guidance (NG253 for adults ≥16) and understand why international guidelines differ. The tension between time-sensitive bundles and avoiding harm from over-treatment is central to the FRCEM exam and to consultant-level clinical decision-making. Follow your trust/NICE guidance; use SSC as contextual international evidence.

KEY JOURNAL ARTICLES & TRIALS

COBRRA RCT — Apixaban Halves Bleeding Risk vs Rivaroxaban in Acute VTE

NEJM, 12 March 2026 · DOI: 10.1056/NEJMoa2510703 RCT

CHANGE PRACTICE

FRCEM

The first head-to-head RCT comparing apixaban vs rivaroxaban in 2,760 patients with acute symptomatic PE or proximal DVT (Phase IV, open-label, blinded-endpoint; 32 sites — Canada, Australia, Ireland). Publicly funded (CIHR + Australian MRFF).

• Clinically relevant bleeding at 3 months: 3.3% apixaban vs 7.1% rivaroxaban — RR 0.46 (95% CI 0.33–0.65; P<0.001) — a 54% relative risk reduction
• Recurrent symptomatic VTE: 1.1% vs 1.0% — no significant difference
• Mortality: 0.1% vs 0.3% (NS)

Why it matters: DOACs are the dominant therapy for acute VTE in the ED. This landmark trial settles a decade-long clinical question: within the same drug class, apixaban has significantly lower bleeding risk than rivaroxaban with no difference in efficacy. Practice-changing for ED discharge prescribing of acute DVT/PE. If your department defaults to rivaroxaban for VTE, this trial makes a compelling case to switch.

Tell your department: Review your ED's DOAC prescribing protocol for acute VTE. If rivaroxaban is the default, take COBRRA to your next clinical governance meeting — a 54% relative reduction in clinically relevant bleeding with equal efficacy is hard to ignore.

OPTION RCT — Tenecteplase for Non-LVO Stroke at 4.5–24 Hours: Positive Again

JAMA, February 2026 · PMID: 41642827 · DOI: 10.1001/jama.2026.0210 RCT

FRCEM

The OPTION trial enrolled patients with non-large vessel occlusion (non-LVO) ischaemic stroke presenting 4.5–24 hours from onset, with CT perfusion mismatch. TNK vs usual care.

• Good functional outcome (mRS 0–1) at 90 days: 43.6% TNK vs 34.2% usual care (RR 1.28; NNT = 11)
• Symptomatic intracranial haemorrhage: 2.8% TNK vs 0% usual care (NNH = 35)

Why it matters: This is the second major RCT (after HOPE, in our carry-over list) showing that tenecteplase in the 4.5–24h window benefits selected non-LVO stroke patients with perfusion mismatch. Combined with TRACE-5 (below) for basilar strokes, and the 2026 AHA guideline, a new extended window is crystallising. The NNT of 11 is impressive; the sICH risk (NNH 35) requires careful patient selection using perfusion imaging. Discuss with your neurology/stroke teams how to operationalise this.

TRACE-5 RCT — Tenecteplase for Basilar Artery Stroke Within 24 Hours

The Lancet, 21 February 2026 · Vol 407(10530):763–772. PMID: 41655588 RCT

FRCEM

TRACE-5 enrolled patients with confirmed basilar artery occlusion presenting within 24 hours of onset. TNK vs standard medical treatment.

• TNK improved disability outcomes (mRS distribution) vs standard treatment at 90 days
• No significant increase in adverse events including sICH

Why it matters: Basilar artery occlusion carries some of the worst outcomes in stroke — mortality and severe disability are high. This trial provides the first robust RCT evidence for TNK up to 24 hours in this specific, often difficult-to-diagnose population. Together with OPTION and the 2026 AHA guideline endorsing basilar thrombectomy, this is a convergent evidence base that should prompt local protocol updates for posterior circulation strokes.

Tell your department: A patient presenting with acute-onset vertigo, diplopia, ataxia, or bulbar symptoms >4.5h ago is no longer automatically outside the treatment window. Urgent CT angiography to identify basilar occlusion, then discussion with the stroke team about TNK ± thrombectomy.

LEGEND Trial — Single hsTroponin Limit-of-Detection Rule-Out Safely Reduces ED Length of Stay

Annals of Emergency Medicine, December 2025 · PMID: 41405523 · DOI: 10.1016/j.annemergmed.2025.10.014 RCT

FRCEM

A large pragmatic stepped-wedge cluster RCT. The LEGEND pathway enables safe ED discharge for selected chest pain patients using a single undetectable high-sensitivity troponin (at the limit of detection) combined with a non-ischaemic ECG and symptom duration >2 hours.

• Substantially reduced ED length of stay and hospital admission rates
• No increase in adverse cardiac events at 30-day follow-up

Why it matters: Many UK EDs already use 0/1h or 0/2h hsTroponin pathways (NICE-aligned). This provides RCT-level evidence for an even faster single-sample LOD approach in low-risk patients with symptoms >2 hours. If your trust hasn't adopted a rapid rule-out pathway yet, this trial strengthens the case for implementation review. Check your hsTroponin assay's documented limit of detection.

COACT 5-Year Outcomes — Immediate vs Delayed Angiography After OHCA Without ST-Elevation

JACC, February 2026 · DOI: 10.1016/j.jacc.2025.12.018 RCT

FRCEM

5-year follow-up of the COACT RCT (19 Dutch centres, shockable-rhythm OHCA without ST-elevation; n=514 of original 552).

• Survival at 5 years: 54.8% immediate vs 51.8% delayed (HR 0.95; 95% CI 0.74–1.23; P=0.72) — no significant difference
• No significant differences in MI, revascularisation, heart failure hospitalisation, or ICD shocks
• Exploratory landmark analysis suggested possible late benefit after 90 days in the immediate group (HR 0.56; P=0.04) — but investigators caution this is likely chance and the study was not powered for 5-year analysis

Why it matters: Confirms the long-term durability of the original COACT finding: immediate coronary angiography is not superior to a delayed strategy in OHCA without ST-elevation. Supports current guidelines recommending against routine emergency catheterisation in this cohort. For FRCEM, know the COACT evidence and when to activate the cath lab post-arrest.

VL vs DL During Cardiac Arrest — ILCOR Systematic Review & Meta-Analysis

Resuscitation, January 2026 · DOI: 10.1016/j.resuscitation.2026.110981 SR/MA

FRCEM

ILCOR ALS Task Force-commissioned SR/MA (PRISMA + ILCOR methodology). 16 studies included: 3 RCTs (n=331) and 13 observational studies (n=29,595).

• RCT data (very low certainty): No significant difference in first-pass success (RR 0.88) or overall intubation success (RR 1.00)
• Observational data: Generally favoured video laryngoscopy for intubation success
• Oesophageal intubation rates consistently lower with VL — RCT: 4.3% DL vs 0% VL; observational: 5.6% vs 1.4%
• No evidence of improved ROSC or survival with either approach

Why it matters: Directly informs airway management during resuscitation. ILCOR-commissioned means this will feed into 2026 resuscitation guideline updates. The oesophageal intubation finding is the clearest benefit signal — VL virtually eliminates oesophageal intubation during arrest. For FRCEM, know the evidence for VL vs DL in cardiac arrest and the ILCOR position.

Ipratropium Bromide in Paediatric Asthma — SR/MA: Nebulised IB Reduces Hospitalisation

Archives of Disease in Childhood, March 2026 · DOI: 10.1136/archdischild-2024-327898 · PMID: 41224524 SR/MA

FRCEM

SR/MA of 24 RCTs (n=3,238) assessing nebulised/inhaled ipratropium bromide (IB) added to standard first-line treatment (SABA + systemic steroids) in children with acute asthma.

• Nebulised IB specifically: Hospitalisation rate significantly lower — RR 0.76 (95% CI 0.64–0.90; I²=0%) — high-certainty evidence
• When inhaled + nebulised IB analysed together: hospitalisation similar (RR 0.84; P=0.05) — moderate certainty
• IB improved asthma clinical scores (low certainty)
• No serious adverse events reported

Why it matters: Paediatric asthma is one of the most common paediatric ED presentations. High-certainty evidence that nebulised ipratropium reduces hospitalisation rates is practice-relevant. The key nuance: the benefit is specific to nebulised IB — MDI-delivered ipratropium did not show the same effect. Ensure your paediatric asthma protocol includes nebulised ipratropium for moderate-severe exacerbations.

QUICK HITS / ALSO NOTABLE

• MHRA: Falsified Mounjaro (Tirzepatide) 15mg KwikPens — Batch D873576 (25 Feb 2026): Falsified Mounjaro 15mg KwikPens (Batch D873576) identified in circulation; faulty dose knob, substandard quality. Stop use immediately; do not attempt to extract doses. Report to MHRA. MHRA SAFETY ALERT
• NHSE Corridor Care Definition — RCEM Response (4 Mar 2026): NHS England published a national definition of corridor care; RCEM says the definition is "interesting" but meaningful action must follow — definitional frameworks without resource commitment risk becoming management tools rather than patient safety levers. RCEM EXPERT OPINION
• Intranasal Naloxone in Synthetic Opioid Overdose (Feb 2026): Standard 4mg IN naloxone may be insufficient for potent synthetic opioids; pCO₂ normalisation delayed despite ventilation recovery. Consider repeat/IV dosing for fentanyl/nitazene overdoses and monitor pCO₂ after apparent reversal. PubMed RCT
• REBEL EM — Diastology: Using E/e' to Estimate Left Atrial Pressure (9 March 2026): POCUS pearl explaining how to capture E and e' waves from the apical 4-chamber view to estimate LAP in real time. Practical guidance for undifferentiated dyspnoea/suspected acute cardiogenic pulmonary oedema. Not a diagnosis of chronic diastolic dysfunction — a real-time haemodynamic assessment. rebelem.com EXPERT OPINION
• Modified Valsalva vs Standard Valsalva in Paediatric SVT — RCT (BMC Pediatrics, 2025; PMID 41408522): Modified Valsalva (recline 45° then supine with legs elevated after strain) achieves higher SVT termination rates in children vs standard technique. Consistent with adult REVERT trial data. Limitations: single centre, no blinding, excludes <7 years. Reasonable to adopt modified technique in appropriate paediatric patients. link.springer.com RCT
• High FFP:pRBC Ratio Linked to Lower AKI and ARDS in Trauma (J Trauma Acute Care Surg, Feb 2026; PMID 41636705): Propensity-matched TQIP data analysis. Higher FFP:pRBC ratios in massive transfusion protocols associated with significantly lower rates of acute kidney injury and ARDS. Supports 1:1 balanced damage control resuscitation. Relevant to PHEM and trauma teams. PubMed OBSERVATIONAL
• The Bottom Line: Critical Care Evidence Updates — February 2026 (13 March 2026): Key items from the monthly roundup: PRINCESS2 pilot RCT (on-scene brain cooling in VF arrest — no significant benefit in pilot), Albumin in Septic Shock RCT (JAMA Netw Open — null), FIBERTRACH RCT (fiberoptic bronchoscopy during tracheostomy — mixed results), Perioperative Fasting "Sip Til Send" Consensus (Anaesthesia 2026 — allows clear fluids until transfer). thebottomline.org.uk
• The Bottom Line: Emergency Evidence Updates — February 2026 (13 March 2026): Highlights from the emergency medicine monthly review: prehospital emergency anaesthesia in risk-stratified major trauma patients (Lancet Resp Med — supports PHEA benefit in carefully selected patients); prehospital TEE vs conventional ALS in OHCA (pilot RCT — feasibility data only). thebottomline.org.uk
• MHRA Class 2 Recall: Ramipril 5mg Capsules (Crescent Pharma, Batch GR164099) (6 March 2026): Packaging error — packs may contain Amlodipine 5mg tablets. Risk: low BP and dizziness. Return stock immediately. GOV.UK SAFETY ALERT
• JAMA Network Open: ED-Initiated Buprenorphine — Precipitated Withdrawal Uncommon (J Addict Med, online Dec 2025; PMID 41413779): Retrospective study of ED buprenorphine induction. Precipitated withdrawal occurs but is uncommon. Fear of precipitated withdrawal should not be a barrier to ED-initiated buprenorphine for opioid use disorder. Consistent with growing evidence for the BRIDGE protocol. PubMed OBSERVATIONAL
• JournalFeed Week of 14 March: EMPHASIS RCT — Minocycline in Acute Ischaemic Stroke: Multicenter RCT examining minocycline as neuroprotection in acute ischaemic stroke. Limited summary data available; full paper pending review. Watch this space — minocycline has pleiotropic anti-inflammatory effects that have generated interest as a repurposed neuroprotectant. journalfeed.org RCT
• St Emlyn's — TBS 2026: Best ICM Papers (12 February 2026): Rich Carden and the Emlyn's team review the key intensive care medicine papers from The Big Sick conference. Topics: NfL vs NSE post-arrest prognostication (already sent), cryopreserved platelets inferior to standard, augmented MAP in spinal cord injury — no benefit with higher respiratory complications. stemlynsblog.org
• Trauma Care UK Webinar — European Guidelines on Bleeding after Trauma: Thursday 19 March 2026, 20:00 UK time. Hosts: Prof Tim Coats and Prof Keith Porter. Timely ahead of potential ATLS/damage control resuscitation guideline updates. Register at: traumacareuk.krtra.com
• RCEM: Guidance for Care of the Child/Young Person Who Attends the ED Frequently (March 2026): New RCEM guidance on managing children and young people who are high-frequency ED attendees. Addresses clinical, safeguarding, and systemic factors behind frequent paediatric attendance. Provides frameworks for identifying and supporting these patients, including social care and mental health pathways. rcem.ac.uk GUIDELINE
• ECPR at a Czech Republic Tertiary Centre — 3-Year Experience (SJTREM, 12 March 2026): Single-centre ECPR registry data (n=74; 2022–2024). Cannulation success >93%. ICU survival 39.1%; 6-month survival 33.3%. Good neurological outcome (CPC 1–2) at Day 30: 29%. Median collapse-to-ECMO 75 min — longer than most published centres yet comparable outcomes. Median QALY/year 0.90 in survivors. Supports broader ECPR implementation. PubMed OBSERVATIONAL
• S-Ketamine Reduces Postoperative Delirium in Elderly Arthroplasty Patients — RCT (Anesthesiology, Jan 2026; PMID 41086424): Double-blind RCT (n=372, ≥60 years). S-ketamine 0.2 mg/kg/h intraoperatively reduced POD from 20.4% to 8.1% (aOR 0.29; NNT=8). Lower postoperative pain and rescue analgesia. More transient hallucinations/dizziness. EM crossover: raises the question of routine perioperative S-ketamine for older patients and has implications for ED procedural sedation in the elderly. PubMed RCT
• Propofol Recall in 16% of ED Procedural Sedation Patients (J Emerg Med, Dec 2025; PMID 41205307): Prospective multicentre study (n=248). At 2 hours, 16% recalled something; at 24 hours, 18.9%. Satisfaction high overall but significantly higher without recall (95/100 vs 83/100; P=0.01). Compare to operating theatre rate of <1%. Has implications for pre-procedure counselling and consent — patients should be warned recall is common with ED sedation. PubMed OBSERVATIONAL
• NICE NG28 Updated — SGLT2 Inhibitors Now First-Line for T2DM (18 February 2026): Major update — SGLT2 inhibitors (flozins) now recommended first-line alongside metformin for most T2DM patients. Could prevent ~17,000 deaths over 3 years. EM relevance: more patients will present on SGLT2 inhibitors — know the risk of euglycaemic DKA (normal glucose, raised ketones, metabolic acidosis). Check for SGLT2i use in any patient with unexplained acidosis. nice.org.uk GUIDELINE
• NICE NG24: Blood Transfusion Guideline Updated (TXA) (NICE, 26 Feb 2026): Updated TXA recommendations for perioperative use — simplified guidance on when TXA should be used including for minor surgical blood loss. Does not change prehospital trauma TXA protocols but reinforces the evidence base. NICE NG24 GUIDELINE
• HEMS Attendance & Survival in Major Trauma (EMJ, Feb 2026; PMID 41633812): Retrospective analysis of 3,225 major trauma patients: ~5 additional survivors per 100 severely injured patients with HEMS attendance. PHEA independently associated with improved survival. Observational, not causal, but magnitude is large. EMJ OBSERVATIONAL
• Prehospital Acute Behavioural Disturbance — Systematic Review (EMJ, Feb 2026; PMID 41760406): ILCOR-registered SR (42 studies) on prehospital ABD management. Ketamine most effective (79–98% adequate sedation at ~5 mg/kg IM); midazolam associated with more respiratory side effects; droperidol showed no excess mortality or QT effect. Evidence quality generally low. EMJ SR/MA
• SGEM#505 — RENOVATE Trial: HFNO vs NIV in Acute Respiratory Failure (SGEM, 14 Mar 2026): Multicentre RCT (n=1,800): HFNO noninferior to NIV overall for ETI/death at 7 days in 4 of 5 ARF groups. Exception: immunocompromised patients — NIV superior. Caution: broad non-inferiority margin (OR 1.55); do not overinterpret HFNO non-inferiority in COPD/ACPE. SGEM RCT
• DFTB — PECARN Rules & CT Equity in Paediatric Trauma (Pediatrics, 2026; DFTB, 10 Mar 2026): Secondary analysis of 17,339 children: PECARN prediction rules largely mitigated racial disparities in CT use. Exception: Hispanic children <2 years with head trauma still received fewer CTs. Validates PECARN as both a radiation-reduction and health equity tool. DFTB OBSERVATIONAL

ACTION POINTS / THIS WEEK

1. RCUK 2025: Review your department's resuscitation teaching — update for jaw thrust in

trauma, infant encircling technique, defibrillator pad positioning, and tourniquet teaching

for first aiders. Confirm simulation mannequin setup matches 2025 guidelines.

2. Semaglutide/NAION: Brief your nursing and triage team — any patient with sudden

monocular visual symptoms, ask about GLP-1 use including privately prescribed

(Ozempic, Wegovy, Mounjaro, Rybelsus). Urgent ophthalmology referral required.

3. Stroke: Check your trust formulary for tenecteplase availability. Review your hospital's

acute stroke pathway for TNK dosing and eligibility criteria. With OPTION + TRACE-5 +

2026 AHA guideline, the case for TNK adoption is now compelling.

4. Chest Pain Pathways: If your ED hasn't adopted a rapid hsTroponin LOD rule-out

pathway, bring LEGEND to your next quality improvement meeting. A single undetectable

hsTroponin + non-ischaemic ECG + symptoms >2h = strong candidate for early

discharge.

5. Sepsis: Re-familiarise yourself with NICE NG253 (Sepsis ≥16 years, November 2025

update) — fluid volumes are now calibrated differently. Understand the ACEP/SSC

controversy, especially for FRCEM.

6. ARF: If your ED has HFNO available, use a phenotype-first approach: HFNO is

appropriate first-line for most ARF; default to NIV if immunocompromised or if clear

COPD/ACPE with significant hypercapnia.

7. Synthetic opioids: Review your local opioid overdose protocol — ensure guidance

covers repeat/IV naloxone for synthetic opioid presentations. Consider monitoring pCO₂

after apparent reversal.

SOURCES CHECKED THIS ISSUE

UK Guidelines & Official Bodies: RCEM (rcem.ac.uk) ✓ · RCUK (resus.org.uk) ✓ · RCOG (rcog.org.uk) ✓ [No new Green-top guidelines in past 14 days] · RCoA (rcoa.ac.uk) ✓ · FPHC/RCSEd ✓ · NICE (nice.org.uk) ✓ · MHRA (gov.uk/drug-device-alerts) ✓ · NHS England (england.nhs.uk) ✓ · FICM/ICS ✓ [No new guidelines identified]

International Guidelines: AHA/ACC ✓ · ACEP ✓ · ESC ✓ [No new guidelines published in this period] · SSC/SCCM ✓ · EAST ✓ · NAEMSP ✓ · ILCOR ✓

Major Journals: NEJM ✓ · The Lancet ✓ · JAMA / JAMA Network Open ✓ · Annals of Emergency Medicine ✓ · Emergency Medicine Journal (BMJ) ✓ · Resuscitation ✓ · Critical Care Medicine ✓ · Academic Emergency Medicine ✓ · Prehospital Emergency Care ✓ · Intensive Care Medicine ✓ · SJTREM ✓ · JACC ✓ · Circulation (AHA) ✓ · Archives of Disease in Childhood ✓ · Anesthesiology ✓ · Journal of Emergency Medicine ✓

FOAMed: EMCrit / PulmCrit (emcrit.org) ✓ [No new posts confirmed in cached page] · REBEL EM (rebelem.com)

• · St Emlyn's (stemlynsblog.org) ✓ · SGEM (thesgem.com) ✓ · EM Cases (emergencymedicinecases.com) ✓ · DFTB (dontforgetthebubbles.com) ✓ · TheNNT (thennt.com) ✓ [No new analyses confirmed] · The Bottom Line (thebottomline.org.uk) ✓ · EM:RAP (emrap.org) ✓ · LITFL (litfl.com) ✓ [No new dated posts confirmed] · JournalFeed (journalfeed.org) ✓

Email feeds searched: JournalFeed (Spoon Feed), EM:RAP EMA Daily, EvidenceAlerts (McMaster), SJTREM BioMed Central alerts, Elsevier Journal of Emergency Medicine alerts, Trauma Care UK.

Next briefing: Thursday, 19 March 2026 Upcoming event: Trauma Care UK Webinar on European Guidelines for Bleeding after Trauma — 19 March 2026, 20:00 UK. Register: traumacareuk.krtra.com

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.