EM Evidence Rundown — Issue 10

EMERGENCY MEDICINE · UK EDITION

EM Evidence Rundown

Week of 30 April 2026 | Issue #10

Jake Turner

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

This week: The BMJ has published exclusive NHS data showing 493,751 patients spent at least 24 hours in Type 1 EDs in England in 2025 — a third more than 2023. 13,386 waited over three days. January 2026 was the worst single month on record. This is the data behind corridor care. CHANGE items: REMAP-CAP CAP corticosteroids — routine hydrocortisone may harm rather than help in severe CAP (CHANGE THIS MONTH) • Video laryngoscope first-line for emergency intubation • High-pressure injection injury — emergency surgery, not dressing (CHANGE TONIGHT) MHRA: Class 2 recall — Sertraline 100mg (Amarox) and Ramipril 10mg (Crescent Pharma) • EMA levamisole withdrawal — relevant to paediatric nephrotic syndrome

BOTTOM LINE UP FRONT — ISSUE #10

ACT ON THIS NOW

TONIGHT High-pressure injection injury: Do NOT incise and drain. Refer immediately to hand surgery — debridement within 6 hours improves outcome dramatically. Low-velocity injuries are deceptively benign but carry limb-loss risk.

TONIGHT Video laryngoscope: Should be first choice for emergency intubation in critically ill patients, not a rescue device. Higher first-attempt success, shorter intubation time, fewer complications vs iLMA.

SAFETY MHRA recall — Sertraline 100mg (Amarox) and Ramipril 10mg (Crescent Pharma): Class 2 recalls. Check your dispensary and advise patients. Replace affected batches.

THIS MONTH CAP corticosteroids: REMAP-CAP signals routine hydrocortisone in severe CAP may harm (OR 1.56 for 90-day mortality, though wide CI). Do not start routinely pending guideline review. Reserve for septic shock context.

THIS MONTH PE treatment (AHA Pt 2): CDT reasonable in Category E1; thrombolysis for E1 only; anticoagulation alone for stable C. Anticoagulate when imaging delayed if C2+ and bleeding risk low.

THIS MONTH Corridor care data: 17.7% of UK ED patients are in escalation areas right now. Your trust-level data goes public in May. Document correctly using the NHS England definition.

KNOW FOR NEXT TIME

UK DATA A&E waits (BMJ): 493,751 patients waited ≥24h in Type 1 EDs in 2025. 13,386 waited ≥72h. January 2026 worst month on record. The data are now public.

GUIDELINE WATCH PE D-dimer simplified: 1000 ng/mL threshold when PE not most likely + age-adjusted for others — 0% failure rate, 19% less imaging (13 EDs France, n=1221).

INFORMING G-FAST for LVO: SR/MA confirms G-FAST is a useful prehospital LVO screen. LR+ 2.15, LR- 0.26 — modest rule-in, better than nothing. Paramedic triage tool, not a diagnostic test.

PAEDS Cyanotic CHD: Duct-dependent lesions present in first week of life. Prostaglandin E1 — must know the dose (0.05–0.1 mcg/kg/min). SpO2 of 75–85% may be acceptable. Do not over-correct.

PAEDS Phimosis: Topical betamethasone 68% resolution regardless of severity. Circumcision avoidable in most cases. Refer to surgical outpatients, not ED management.

SAFETY Levamisole: EMA recommends withdrawal. Used off-label in children with nephrotic syndrome in UK. Alert your paediatric nephrology colleagues.

INFORMING Core revision: Hyponatraemia — acute symptomatic: 100mL 3% saline IV over 10 min (repeat ×3). Never exceed 10 mmol/L per 24h. ODS risk in alcohol/malnutrition: limit 6–8 mmol/L/24h.

NHS England data released this week confirm what every emergency clinician in England already knows from lived experience — but has not previously had quantified this precisely. 493,751 patients waited at least 24 hours in Type 1 emergency departments in 2025. That is roughly 1,350 patients every single day spending at least a full day in a space designed for rapid assessment. For January 2026, the worst month on record, nearly one in twenty patients presenting to Type 1 departments was waiting more than 24 hours. At the same time, the AHA has published the treatment half of its first-ever dedicated PE guideline, and REMAP-CAP has issued data that challenge the 2024 SCCM recommendation to use corticosteroids in severe community-acquired pneumonia. This week, evidence and reality arrive together.

CONTENTS

Key Trials & Articles

1. AHA/ACC 2026 PE Guidelines Part 2 — Treatment Matrix, CDT vs Thrombolysis, PERT, Anticoagulation Duration 2. PE D-dimer Simplified Strategy — 1000 ng/mL Threshold, 0% Failure, 19% Less Imaging 3. REMAP-CAP CAP Corticosteroids: Hydrocortisone Signals Potential Harm in Severe CAP 4. G-FAST Score SR/MA for LVO Detection (Emerg Med J) 5. Video Laryngoscope vs Intubating LMA for Emergency Intubation — VL First Line 6. High Risk & Low Incidence: High-Pressure Injection Injury — Surgical Emergency

Guidelines & UK Updates

7. BMJ Investigation: 13,386 Patients Waited 3+ Days in England's EDs in 2025 [LEAD] 8. TERN Study: 17.7% of UK ED Patients Receiving Care in Escalation Areas (165 Departments) 9. MHRA Class 2 Recalls: Sertraline 100mg & Ramipril 10mg 10. RCEM Annual Conference 2026 — Key Themes from Birmingham

Paediatric EM

11. Paediatric OHCA International Incidence — SR/MA 50 Studies, 18 Countries 12. High Risk & Low Incidence: Cyanotic Critical Congenital Heart Disease 13. EMA Recommends Levamisole Withdrawal — Leukoencephalopathy Risk 14. Topical Betamethasone for Paediatric Phimosis — 68% Resolution (n=235)

Quick Hits, Core Revision, Action Points, Trials to Watch

1 — KEY JOURNAL ARTICLES & TRIALS

AHA/ACC · CIRCULATION · FEBRUARY 2026 · JOURNALFEED COVERAGE THIS WEEK

AHA/ACC 2026 PE Guidelines Part 2 — Treatment Matrix: CDT for Category E1, Thrombolysis in E1 Only, PERT Recommended, Anticoagulation Beyond 6 Months

GUIDELINE CHANGE THIS MONTH FRCEM

The treatment half of the AHA/ACC 2026 PE guideline (JournalFeed, Amanda Mathews). The diagnostic Part 1 was covered in Issue 9. This section covers the Advanced Therapy Matrix, anticoagulation decisions, PERT, and post-acute care. This guideline is co-authored by ACEP and represents the most detailed treatment decision framework for PE in clinical practice.

Advanced Therapy Matrix by Category

Key Treatment Points Systemic thrombolysis in stable Category C: A meta-analysis of 16 trials shows thrombolysis reduces all-cause mortality with NNT 59 but increases intracranial haemorrhage with NNH 78. These margins are so narrow that net benefit in haemodynamically stable patients is genuinely uncertain. The guideline does not recommend thrombolysis for Category C. Anticoagulation when imaging is delayed: If the patient is Category C2 or higher and has a low bleeding risk, it is reasonable to initiate therapeutic anticoagulation while waiting for imaging. This is a Class 2A recommendation — clinically important for overnight out-of-hours decisions. Duration: For a first PE without a major reversible risk factor, continuing anticoagulation beyond the initial 3–6 months into the extended phase is recommended (Class 1). Review at 3 months. CTEPD screening at every visit for 1 year. Clot in transit: Free-floating right atrial/RV clot in Categories C3–E2 — advanced therapy over anticoagulation alone is reasonable (Class 2A — new recommendation).

Critical appraisal: The majority of advanced therapy recommendations are Class 2A or 2B — "reasonable" or "may be considered" — not Class 1 mandates. This reflects genuine uncertainty in the evidence base for CDT and mechanical thrombectomy. The NNT of 59 vs NNH of 78 for systemic thrombolysis in stable PE is one of the most important numbers in EM — it encapsulates why this decision is genuinely hard and why the guideline is appropriately cautious. UK practice should follow NICE NG158 until a formal update, but these AHA recommendations represent the highest-quality synthesis of current evidence.

Tell your department: The single most actionable recommendation for ED practice: it is reasonable to start therapeutic anticoagulation in a Category C2+ patient with low bleeding risk if imaging is unavailable or delayed. Do not wait for CT-PA if clinical presentation is convincing and there is a delay. Document the risk-benefit decision. Have a clear PERT escalation pathway for any patient reaching Category D or E.

Source: AHA/ACC 2026 PE Guideline — Full Text (Circulation, February 2026)

JOURNALFEED ARTICLE OF DAY · 30 APRIL 2026 · PROSPECTIVE MULTICENTRE STUDY, 13 EDS, FRANCE

PE D-dimer Simplified: One Question (Is PE Most Likely?) — 1000 ng/mL Threshold When Not Most Likely, Age-Adjusted Otherwise — 0% Diagnostic Failure, 19% Less Imaging (n=1221)

OBSERVATIONAL CHANGE THIS MONTH FRCEM

• 0% DIAGNOSTIC FAILURE RATE
• −19% REDUCTION IN CHEST IMAGING
• 1000 NG/ML THRESHOLD (NON-LIKELY)
• n=1,221 13 EDS, FRANCE, PROSPECTIVE

Prospective, multicentre, open-label, single-arm interventional study across 13 French EDs. 1,221 adults with clinical suspicion of PE. The strategy: ask one question — "Is PE the most likely diagnosis?" If no (n=997, 81.6%), use a fixed D-dimer threshold of 1000 ng/mL. If yes (n=224, 18.4%), use the age-adjusted threshold (age × 10 µg/L for patients >50 years). Diagnostic failure (missed PE within 90 days of a negative workup): 0 of 1,221 patients. Chest imaging was reduced by 19% compared with expected rates using conventional PERC/YEARS/age-adjusted strategies.

Critical appraisal: JournalFeed reviewer Amanda Mathews describes this as "surprisingly good." The 0% failure rate is striking but must be contextualised: this is a single-arm study (no comparator arm), the 90-day follow-up period is appropriate, and the French ED context may differ from UK practice. The 1000 ng/mL threshold essentially extends the current YEARS algorithm logic (which uses 1000 ng/mL when YEARS = 0) to all patients for whom PE is not the most likely diagnosis. This is a simplification of existing strategies, not a new one. The most important validation question is: does it hold in a UK population? The YEARS and PEGeD studies provide supporting evidence for the underlying approach. Use with clinical judgement. Not yet in NICE NG158 or RCEM guidelines — but provides strong pilot data for UK adoption.

Why it matters: The D-dimer threshold question is one of the most debated in EM. A 19% reduction in chest imaging across your department would translate to reduced radiation exposure, shorter times to disposition, fewer incidental findings, and reduced cost. If your department still uses 500 ng/mL as a fixed D-dimer cut-off for all patients, this is the evidence base to propose adopting an age-adjusted or clinical-probability-modified strategy. The one-question simplification is particularly attractive for high-volume departments where complex stratification tools have poor compliance.

Source: JournalFeed — Is PE Most Likely? Surprisingly Good! (30 April 2026)

THE BOTTOM LINE · REMAP-CAP PLATFORM TRIAL · INTENSIVE CARE MED 2025

REMAP-CAP CAP Corticosteroids: Routine Hydrocortisone in Severe Community-Acquired Pneumonia Signals Potential Harm — OR 1.56 for 90-Day Mortality

RCT (Platform) CHANGE THIS MONTH FRCEM

• 15% 90-DAY MORTALITY, HYDROCORTISONE
• 9.8% 90-DAY MORTALITY, CONTROL
• OR 1.56 95% CRI 0.80–3.31 (WIDE)
• n=643 SEVERE CAP REQUIRING ICU

REMAP-CAP adaptive platform trial, severe community-acquired pneumonia domain. 643 patients with severe CAP requiring ICU admission (excluding septic shock, influenza). Randomised to hydrocortisone 50 mg IV every 6 hours for 7 days vs usual care. The result is striking: hydrocortisone was associated with higher 90-day mortality (15.0% vs 9.8%), with a median adjusted OR of 1.56. The 95% credible interval crosses 1.0 (0.80–3.31) so formal statistical significance is not reached — but the direction and magnitude are concerning.

Critical appraisal: The Bottom Line review (The Bottom Line is a UK critical care FOAMed resource) provides an authoritative analysis. Key points: the wide credible interval means this is not definitive proof of harm, but it is a strong signal against benefit. This sits in direct tension with the 2024 SCCM guidelines which gave a strong recommendation for corticosteroids in hospitalised patients with severe CAP (based largely on CAPE COD). CAPE COD was a single-centre French trial in a different patient population. REMAP-CAP is larger, adaptive, and more generalisable. The ED relevance: patients with severe CAP who you are escalating to ICU are the patients this trial enrolled. The question of "should I start steroids before ICU transfer?" now has a much less certain answer. Do not start routinely — discuss with ICU/respiratory on a case-by-case basis. Patients in septic shock still benefit from steroids by a separate evidence base.

Why it matters: If your department has a protocol that includes hydrocortisone as standard for severe CAP admission, this REMAP-CAP data is the prompt to review it. The important distinction is: severe CAP without septic shock (REMAP-CAP signal against) vs septic shock complicating any infection including CAP (evidence still supports steroids per SSC 2026). The clinical question to ask at handover: "Does this patient have septic shock (MAP <65 despite fluids) or severe CAP without shock?" The answer changes the steroid decision.

Source: The Bottom Line — REMAP-CAP Corticosteroids Review

MCMASTER EVIDENCE ALERTS · EMERG MED J · PUBLISHED ONLINE APRIL 2026

G-FAST Score for Large Vessel Occlusion Detection in Suspected Stroke: SR/MA of Diagnostic Accuracy — LR+ 2.15, LR− 0.26

SR/MA INFORMING PRACTICE FRCEM

• 84% SENSITIVITY
• 61% SPECIFICITY
• 2.15 LR+
• 0.26 LR−
• SR/MA NETWORK MA, EMJ 2026

Pre-test P(LVO) in stroke call

G-FAST positive → post-test

G-FAST negative → post-test

G-FAST = Gaze deviation, Facial droop, Arm weakness, Speech disturbance, Time. LR+ 2.15: small-to-moderate rule-in (useful for dispatch prioritisation). LR- 0.26: limited rule-out — a negative G-FAST does not exclude LVO. G-FAST is a prehospital triage tool, not a diagnostic test — its value is in routing patients to EVT-capable centres, not in replacing imaging.

Critical appraisal: An LR+ of 2.15 is a small-to-moderate probability shift. It is not a powerful rule-in. The practical value of G-FAST is at the population level for ambulance triage — if a paramedic's G-FAST is positive, the pre-test probability of LVO shifts from ~15% to ~27%, which is enough to justify bypassing the nearest stroke unit for an EVT centre if transfer time is acceptable. A negative G-FAST does not exclude LVO (post-test probability still 4.4%). The network meta-analysis design allows comparison across multiple prehospital scales — worth reading the full paper for comparative data against CPSS, BE-FAST, RACE, and PASS.

Source: Emerg Med J 2026 — G-FAST SR/MA via McMaster Evidence Alerts

JOURNALFEED EM · WORLD J CRIT CARE MED · MARCH 2026 · PMID 41883763

Video Laryngoscope vs Intubating LMA for Emergency Intubation in Critically Ill Patients: VL Shows Higher First-Attempt Success, Shorter Time, Fewer Complications

OBSERVATIONAL CHANGE TONIGHT FRCEM

• Higher FIRST-ATTEMPT SUCCESS (VL)
• Shorter INTUBATION TIME (VL)
• Fewer COMPLICATIONS (VL)

Aggarwal A et al. Critically ill patients requiring emergency intubation. Video laryngoscopy (VL) demonstrated significantly higher first-attempt success rates and shorter intubation times compared to the intubating laryngeal mask airway (iLMA), with fewer complications. JournalFeed EM Wednesday.

Critical appraisal: Observational study — limitations include potential selection bias and lack of randomisation. However, the direction of evidence is consistent with the growing body of literature favouring VL as the default for emergency intubation in critically ill adults. The preoxygenation NMA (Issue 6) and VL studies collectively build a strong case for standardising VL as first choice in ED RSI, with direct laryngoscopy reserved as a fallback. iLMA has a role in failed airway scenarios and cannot-intubate-cannot-oxygenate (CICO) management, but should not be first line when VL is available. RCUK 2025 supports VL as a preferred technique.

Tell your department: If your resus bay still defaults to direct laryngoscopy for RSI in non-predicted-difficult airways, review your airway protocol. VL as first line is now supported by multiple studies and RCUK 2025. Ensure VL proficiency is maintained with regular simulation, and that every resus nurse knows how to set up the VL quickly.

Source: Aggarwal A et al. World J Crit Care Med 2026 (PMID 41883763)

SPACE FILE REVIEW · HIGH RISK & LOW INCIDENCE DISEASES SERIES

High Risk and Low Incidence: High-Pressure Injection Injury — a Surgical Emergency That Is Frequently Underestimated in the ED

REVIEW CHANGE TONIGHT FRCEM

High-pressure injection injuries (HPII) occur when a substance is injected through the skin under high pressure (paint guns, grease guns, hydraulic equipment). The entry wound is small — often a pinprick — and the injury looks innocuous. It is not. The injected material travels along fascial planes, causing ischaemia, chemical toxicity, and compartment syndrome.

Key alert: The injury looks minor. The patient may be minimally tender. This is the mechanism by which HPII causes the greatest harm — by appearing benign and triggering reassurance and discharge. The pressure of injection can exceed 10,000 psi. Treat every high-pressure injection to any site as a limb-threatening surgical emergency until proven otherwise by an experienced hand surgeon.

Source: High Risk and Low Incidence Diseases: High-Pressure Injection Injury (Space file review)

2 — GUIDELINES & UK UPDATES

BMJ · 22 APRIL 2026 · DOI 10.1136/BMJ.S756 · UK DATA

BMJ Investigation: 493,751 Patients Waited ≥24 Hours in Type 1 EDs in England in 2025 — 13,386 Waited Over Three Days. January 2026 Was the Worst Month on Record. [LEAD]

DATA CHANGE WHEN GUIDELINE UPDATES UK DATA FRCEM

• 493,751 WAITED ≥24H IN 2025
• 13,386 WAITED ≥72H IN 2025
• +33% RISE IN 24H+ WAITS SINCE 2023
• 66,847 WAITED ≥24H IN JAN 2026

Exclusive data published in the BMJ quantifying the scale of extreme A&E waits across NHS England Type 1 departments. The data show a year-on-year deterioration that accelerated sharply post-pandemic and has not reversed despite NHS England targets and interventions. January 2026 saw 66,847 patients waiting at least 24 hours in Type 1 departments — nearly 1 in 20 Type 1 attendances. 9,379 waited over 48 hours in January 2026 alone. Mumtaz Patel, President of the Royal College of Physicians: "I have heard of patients who say they would rather die at home than come into hospital and be waiting."

Context and Trend

Year

Patients waiting ≥24h

Year-on-year

2023

377,986

—

2024

487,608

+29%

2025

493,751

+1.3% (plateau, not recovery)

Why it matters: Evidence shows patients are more likely to die if they spend over 6 or 12 hours in the ED before admission. These are not statistics about inconvenience — they are mortality signals. Every clinician in a UK ED is working in the context of this data daily. The BMJ publication matters because it makes the data public, specific, and politically visible in a way that aggregate targets do not. It reinforces the case for every action that reduces avoidable admissions, speeds up senior decision-making, and improves same-day emergency care capacity. The corridor care trust-level data going public in May 2026 will follow this directly.

Source: BMJ 2026;393:s756 — A&E crisis: 13,386 patients waited over three days in England's EDs (22 April 2026)

EMERG MED J · FEBRUARY 2026 · RCEM TERN NETWORK · UK DATA

TERN National Snapshot Study: 17.7% of UK ED Patients Receiving Care in Escalation Areas Across 165 Type 1 Departments — Including Paediatric and Mental Health Patients

OBSERVATIONAL UK DATA INFORMING PRACTICE

RCEM Trainee Emergency Research Network (TERN) multicentre national snapshot study across 165 UK Type 1 EDs. Five snapshot points in March 2025. 10,042 patients (17.7%) were receiving care in escalation areas at the time of the snapshots. Both paediatric patients and those with mental health presentations were documented in escalation areas at all five snapshot points, despite national guidance explicitly recommending against this. Regional variation: highest rates in Northern Ireland, lowest in parts of south-west England.

Why it matters: This is the most comprehensive national quantification of corridor care in UK emergency medicine to date. 17.7% is not a marginal or exceptional figure — it represents approximately 1 in 6 patients in a Type 1 ED on any given shift. The finding that children and mental health patients are in escalation areas despite guidance against it is particularly important for safeguarding and governance. With NHS England corridor care data going public in May 2026, trusts should use this national benchmark as context.

Source: TERN — Corridor and Escalation Care in 165 UK EDs (Emerg Med J, February 2026)

MHRA · SAFETY ROUNDUP APRIL 2026 · 28–29 APRIL 2026

MHRA Class 2 Recalls: Sertraline 100mg (Amarox Ltd) — Manufacturing Error; Ramipril 10mg (Crescent Pharma) — Manufacturing Error

SAFETY ALERT UK DATA

Sertraline 100mg film-coated tablets (Amarox Limited): Class 2 recall, EL(26)A/22 (28 April 2026). One batch recalled as a precautionary measure due to a manufacturing site error. Replace affected stock. Advise patients on this batch to return tablets to pharmacy. Sertraline is commonly prescribed for depression and anxiety — patients attending the ED with self-harm or overdose on sertraline should have batch details documented.

Ramipril 10mg capsules (Crescent Pharma Limited): Class 2 recall, EL(26)A/19 (20 April 2026). One batch recalled, manufacturing site error. Replace affected stock. Relevant for ED patients on ramipril for hypertension, heart failure, or renal protection.

Source: MHRA Safety Roundup April 2026 · Field Safety Notices 20–24 April 2026

RCEM · ANNUAL CONFERENCE 2026 · ICC BIRMINGHAM · 28–30 APRIL 2026

RCEM Annual Conference 2026 — Landmark First Combined Scientific and CPD Conference at ICC Birmingham

NEWS FRCEM

RCEM's first combined Annual Scientific Conference and CPD Conference concluded yesterday in Birmingham. Key themes: emergency medicine research and its translation into practice, FRCEM exam preparation, systems-level approaches to corridor care and SDEC expansion, and EEMAC (Extended Emergency Medicine Ambulatory Care). Pre-conference workshops included Bridging EM and ICM Skills, Focused Quantification and AI, and POCUS MSK Trauma. Sessions will be available virtually via RCEM. FRCEM trainees should check the RCEM website for CPD certificates and any position statement updates following the conference.

Source: RCEM Annual Conference 2026 — rcem.ac.uk

3 — PAEDIATRIC EMERGENCY MEDICINE

JOURNALFEED EM · CRIT CARE MED · MARCH 2026 · PMID 41885565

International Incidence of Paediatric Out-of-Hospital Cardiac Arrest: SR/MA of 50 Studies, 18 Countries — 5.56 per 100,000 Person-Years

SR/MA INFORMING PRACTICE PAEDS FRCEM

• 5.56 PER 100,000 PERSON-YEARS
• 50 studies 18 COUNTRIES, INTERNATIONAL
• Rare PAEDIATRIC OHCA IS UNCOMMON

Mellett-Smith A, Caunt M, Buckle A, Fothergill R, Couper K et al. (several UK-based Resuscitation Council researchers). SR/MA quantifying global paediatric OHCA incidence. Pooled incidence: 5.56 per 100,000 person-years (compared to adult OHCA which runs at approximately 50–80 per 100,000). The study highlights substantial variation between countries and inconsistent reporting definitions, limiting direct comparisons.

Critical appraisal: The 5.56/100,000 figure establishes that paediatric OHCA is genuinely rare — which is clinically important for calibrating preparedness and simulation priorities. The rarity also means most paediatric OHCA studies are underpowered. The heterogeneity in definitions (age cut-offs, inclusion of infants, congenital vs acquired cause) is substantial. UK-specific incidence may differ from the global pooled estimate. The Resuscitation Council UK authorship (Couper K) gives this particular relevance to UK practice — the data will likely inform future RCUK paediatric training recommendations.

Tell your department: Paediatric OHCA is rare enough that individual clinicians may encounter very few cases in a career. This argues strongly for high-fidelity simulation with structured debrief as the core preparation strategy — not reliance on accumulated experience. Ensure your department has a dedicated paediatric OHCA simulation at least annually, with particular focus on initial ventilation (5 rescue breaths, 15:2) and drug dose calculation under pressure.

Source: Mellett-Smith A et al. Crit Care Med 2026 — Paediatric OHCA SR/MA (PMID 41885565)

SPACE FILE REVIEW · HIGH RISK & LOW INCIDENCE DISEASES SERIES

High Risk and Low Incidence: Cyanotic Critical Congenital Heart Disease — ED Recognition, Duct-Dependent Physiology, and Prostaglandin E1

REVIEW CHANGE TONIGHT PAEDS FRCEM

Critical congenital heart disease (CCHD) with cyanosis presents in the first days to weeks of life and is one of the most time-critical paediatric emergencies in the ED. Duct-dependent lesions depend on a patent ductus arteriosus (PDA) for either pulmonary or systemic blood flow — when the duct closes, the baby collapses.

Key ED Decision Points

Prostaglandin E1 (Dinoprostone / Alprostadil) — know this dose Dose: 0.05–0.1 mcg/kg/min IV infusion (start at 0.05, may increase to 0.1 if no response). Aim to reopen or maintain the ductus. Side effects: Apnoea (be prepared to intubate), fever, hypotension, seizures. Have bag-valve-mask and intubation equipment ready before starting.

Target SpO2: 75–85% is acceptable in duct-dependent cyanotic lesions — do not over-oxygenate. High O2 in some lesions (e.g. HLHS) can cause pulmonary vasodilation, overcirculation, and systemic steal.

Tell your department: Any neonate (<28 days) presenting collapsed, grey, or deeply cyanotic must have cyanotic CHD considered immediately. The key question: "Is this a duct-dependent lesion?" If yes or uncertain: start PGE1 while waiting for echo/cardiology. Four-limb saturations and blood pressure differences help identify coarctation. Do not give 100% O2 to a known HLHS neonate. Have your local paediatric cardiology team's emergency number readily available.

Source: High Risk and Low Incidence Diseases: Cyanotic Critical Congenital Heart Disease (Space file review)

MHRA / EMA · APRIL 2026 SAFETY ROUNDUP

EMA Recommends Withdrawal of Levamisole — Rare Leukoencephalopathy: Relevant to Paediatric Nephrotic Syndrome Management in UK

SAFETY PAEDS CHANGE WHEN GUIDELINE UPDATES

The European Medicines Agency (EMA) has recommended withdrawal of marketing authorisations for levamisole-containing medicines following a safety review confirming leukoencephalopathy as a rare but serious side effect. Levamisole is used off-label in the UK for children with frequently-relapsing or steroid-dependent nephrotic syndrome. This is a low-volume but specialist-relevant finding for any ED team managing a child with nephrotic syndrome on levamisole who presents with neurological symptoms.

Alert: Any child with known nephrotic syndrome on levamisole presenting with new neurological symptoms (encephalopathy, focal deficit, seizures, personality change) should have levamisole-induced leukoencephalopathy on the differential. Urgent MRI and paediatric neurology/nephrology review. Alert your paediatric nephrology colleagues to the EMA withdrawal recommendation.

Source: MHRA Safety Roundup April 2026 — EMA levamisole withdrawal

JOURNALFEED PAEDS · J PEDIATR SURG · MARCH 2026 · PMID 41887565

Topical Betamethasone for Paediatric Phimosis: 68% Resolution Rate Regardless of Severity or Age — Multicenter Cohort (n=235)

OBSERVATIONAL CHANGE THIS MONTH PAEDS

• 68% RESOLUTION RATE (BETAMETHASONE)
• Any severity NO SEVERITY CUT-OFF IDENTIFIED
• n=235 MULTICENTER COHORT

Campos JM et al. 235 boys with pathological phimosis, multicenter cohort. Topical betamethasone (0.05% or 0.1%) applied twice daily to the phimotic ring for 4–8 weeks. 68% resolution rate regardless of phimosis severity grade or age. JournalFeed Paeds notes this "may reduce unnecessary circumcision." The ED relevance: boys presenting with phimosis are frequently referred directly to urology, bypassing conservative management. This data supports a pathway of conservative treatment first.

Tell your department: Boys presenting with non-acute phimosis (no balanoposthitis, urinary retention, or paraphimosis) can be referred to paediatric outpatients for topical steroid trial, not emergency urology referral. Document clear safety-netting: return if unable to urinate, fever, or severe pain. Acute paraphimosis and retained foreskin remain urgent referrals. This study does not affect acute management.

Source: Campos JM et al. J Pediatr Surg 2026 — Topical Betamethasone for Phimosis (PMID 41887565)

4 — QUICK HITS

WORKFORCE & WELLBEING

Burnout, Stress, and Moral Injury in EMS Clinicians — SR: Space file. High prevalence of burnout across paramedics and emergency physicians in multiple systems. Modifiable risk factors identified include organisational culture, perceived lack of control, high call volume with limited recovery time, and inadequate debriefing after traumatic events. The SR confirms that individual-level resilience programmes are less effective than organisational-level interventions (workload management, access to psychological support, peer support programmes). The RCEM has a wellbeing hub at rcem.ac.uk/wellbeing. Relevant to any clinical lead designing rotas or support structures.

SYSTEMS

Urgent Care Delivery Categorisation (EMA Daily, Ann Emerg Med): PMID 40650646. Sarma D, Shapiro NI et al. propose a 5-tier model to standardise the definition and capacity of urgent care centres. EMA Daily editor Mike Menchine: "Although imperfect, the framework provides a useful starting point for emergency medicine to more actively engage in shaping acute outpatient care delivery." UK context: NHS UTC, SDEC, and UEC hubs serve different roles — this US framework does not map directly but the principle of standardising what each tier can and cannot safely manage is relevant to UK pathway design. Informing practice only, but worth reading for anyone involved in SDEC or UTC planning.

5 — CORE REVISION: HYPONATRAEMIA

FRCEM REVISION FOCUS — HYPONATRAEMIA: CLASSIFICATION, INVESTIGATION, AND SAFE TREATMENT IN THE ED

Classification by onset and severity

Safe correction rates

Cause investigation: urine sodium and osmolality

Key rule: Acute symptomatic → 3% saline now. Chronic → slow down. Never exceed 10 mmol/L per 24h or you risk ODS. In alcohol use disorder and malnutrition: lower limit is 6–8 mmol/L. SIADH requires: low serum osmolality, concentrated urine (Uosm >100), euvolaemia, urine Na >40, and exclusion of other causes. First-line treatment: fluid restriction.

6 — ACTION POINTS THIS WEEK

• High-pressure injection injury: Brief your whole department — a small puncture wound from a grease or paint gun is a surgical emergency. Do not incise, dress and discharge. Refer immediately to hand surgery or plastics. Debridement within 6 hours.
• MHRA recalls: Check your dispensary stocks of Sertraline 100mg (Amarox) and Ramipril 10mg (Crescent Pharma) for affected batch numbers. Replace and report affected stock. Advise patients in possession of these batches.
• CAP corticosteroids: Review any local protocol that includes routine hydrocortisone for severe CAP. REMAP-CAP signals potential harm in this population (without septic shock). Until guidelines update, do not start routinely. Septic shock complicating any infection: steroids still indicated.
• VL as default: If your department's RSI protocol still lists direct laryngoscopy as first line, propose a protocol update to VL first with DL as fallback. Ensure team VL competency is maintained with quarterly simulation.
• PE treatment (before imaging): If a Category C2+ PE patient has delayed imaging and low bleeding risk — it is now guideline-supported (AHA Class 2A) to start therapeutic anticoagulation while waiting. Document the risk-benefit decision explicitly.
• Corridor care data: May 2026 trust-level figures go public. Ensure every patient receiving care in a non-standard space is documented using the NHS England formal definition — before the data is collected, not after.
• Levamisole alert: Any child with nephrotic syndrome on levamisole presenting with encephalopathy or focal neurology — include levamisole-induced leukoencephalopathy in your differential. Urgent MRI and specialist review.

7 — TRIALS TO WATCH

IMMINENT — Q2 2026

On-Scene ECPR Netherlands Trial: Results expected Q2–Q3 2026. If positive, defines the ECPR-eligible patient and logistics. Watch for NHS England response given UK ECMO network distribution. NHS England Corridor Care Trust-Level Data: First publication due May 2026. All trust-level figures public. Documentation must start now. RCEM Sepsis Toolkit Update: Expected Q2 2026 following SSC 2026 guidelines. Watch for RCEM position on antibiotic timing, MAP targets, and vasopressor thresholds for UK EDs.

2026–2027

HSSIB Mental Health Crisis Care Part 2 (summer 2026): Binding recommendations on liaison psychiatry response times and ED MH assessment protocols expected. Follow-up to Part 1 covered in Issues 5–6. NICE NG128 Stroke Guideline Surveillance: Following AHA/ASA 2026 guideline and REMAP-CAP, NICE expedited review of tenecteplase, post-EVT BP, and extended-window thrombolysis expected Q3 2026. BACHb — Bronchiolitis UK RCT: Antibiotic subgroup therapy in bronchiolitis. Anticipated 2026–2027.

HORIZON

CoMiTED — UK Chest Drain RCT (2027): Conservative vs immediate drain in traumatic pneumothorax. Directly relevant to ED pleural procedure and disposition decisions.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue #10 — Week of 30 April 2026 — UK Edition Published by EM Evidence. Sent to subscribers in emergency medicine across the UK. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com