EM Evidence Rundown — Issue 12

EM Evidence Rundown

ISSUE 12 · 14 MAY 2026 · UK EDITION

Jake Turner

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

LEAD: No OUCH RCT (JAMA) — Ibuprofen alone equals ibuprofen + paracetamol and ibuprofen + opioid for children’s musculoskeletal pain. Adding opioids causes harm in 1 in 4 children (NNH 4). Stop routine opioid co-prescribing for paeds MSK pain tonight. CHANGE TONIGHT: Paeds MSK pain (no opioids) | RCEM MH QIP (observe all medium/high-risk patients throughout stay) | Paeds sepsis fluid (either balanced or saline is safe)

BOTTOM LINE UP FRONT — ISSUE 12

ACT ON THIS NOW

TONIGHT Paeds MSK pain: Ibuprofen alone is sufficient. Opioids add no benefit and cause 4-fold more adverse events (NNH 4). Remove from paeds analgesia protocols.

TONIGHT Mental health observation: Medium/high-risk self-harm patients must be observed throughout ED stay. Only 48.6% are. RCEM audit shows December rates fell to <35%.

TONIGHT Paeds sepsis fluids: Balanced crystalloid and 0.9% saline are equivalent for MAKE30 outcomes (n=7,933, NEJM). Use your departmental default without hesitation.

THIS MONTH Refractory VF: Start DSED after shock 3–4. New DOSE VF secondary analysis: DSED reduces time in VF by 30 seconds, improving survival. Consider moving it earlier.

THIS MONTH SSC 2026 sepsis: Antibiotics within 1h definite/shock, 3h possible sepsis without shock. Prehospital ABx for >60 min transport time. Anaerobic cover only if anatomical source.

KNOW FOR NEXT TIME

HCID ALERT Hantavirus (MV Hondius): Live UK outbreak. Travel history in unexplained ARDS. Isolate + UKHSA on-call. FFP3 for AGPs.

SAFETY HSSIB mental health: No lawful power to hold patients leaving ED awaiting MHA. Clarify trust position with governance now.

GUIDELINE WATCH OPTION stroke: Tenecteplase 4.5–24h, NNT 11 — but sICH NNH 36. Not yet practice-changing in UK without CTP imaging. Watch NICE NG128.

UK DATA A&E March 2026: Record 2.43M attendances, 77.1% in 4h (best in 5 yrs). Zero of 121 trusts hit 95%. 46,665 waited >12h.

DEVICE FSN Breas NIV firmware: FSN for Vivo 45 LS & Nippy 4+ (versions 3.2.1/4.2.1/7.2.1). Contact biomedical engineering today.

This week brings a practice-changing paediatric analgesic RCT that should immediately prompt every department to review its paeds MSK pain protocol — ibuprofen alone is not only sufficient but safer. Alongside this, the SSC 2026 Guidelines land with 129 statements and sharper ED-facing antibiotic timing rules, while RCEM’s Mental Health QIP data reveal a persistent observation gap that puts vulnerable patients at risk. The OPTION trial extends the thrombolytic window for non-LVO stroke to 24 hours — but with a sICH penalty that demands careful imaging selection. Across the week’s evidence: a theme of “less is often more” runs from whole blood in trauma to opioids in children.

WHAT’S INSIDE — ISSUE 12

Section 1 — Trials & Research: Paeds MSK analgesia No OUCH RCT (LEAD) · OPTION late-window stroke RCT · DOSE VF secondary analysis · SWiFT whole blood RCT · Paeds sepsis fluid RCT · STORM-PE · Mirtazapine for methamphetamine Section 2 — Guidelines & UK: SSC 2026 Sepsis Guidelines · RCEM Mental Health QIP · NHS A&E March 2026 data Section 3 — Paediatric EM: No OUCH RCT (LEAD, also here) · Paeds sepsis fluid RCT · Fast MRI vs CT for paeds neurology Section 4 — FOAMed: First10EM May Roundup · REBEL EM DOSE VF analysis Quick Hits · Core Revision: Headache in the ED · Action Points · Trials to Watch

RCT SR/MA GUIDELINE CHANGE TONIGHT CHANGE THIS MONTH WHEN GUIDELINE UPDATES

INFORMING FRCEM PAEDS UK

SECTION 1 — TRIALS & RESEARCH

1. [LEAD] Paeds MSK Analgesia — Ibuprofen Alone Equals Opioid + Paracetamol Add-Ons (No OUCH RCT, JAMA) 2. OPTION Trial — Tenecteplase 4.5–24h in Non-LVO Stroke: Benefit and Harm 3. DOSE VF Secondary Analysis — DSED Reduces Time in VF by 27% 4. SWiFT RCT — Prehospital Whole Blood: No Benefit in Traumatic Haemorrhage (NEJM) 5. STORM-PE — Mechanical Thrombectomy in Intermediate-High PE: RV Benefit, No Mortality Gain 6. Mirtazapine for Methamphetamine Use Disorder — First Positive RCT (JAMA Psychiatry)

SECTION 2 — GUIDELINES & UK UPDATES

7. Surviving Sepsis Campaign 2026 Guidelines — 129 Statements, Key ED Changes 8. RCEM Mental Health QIP — Only 48.6% of High-Risk Patients Properly Observed 9. NHS England A&E Data March 2026 — Record Attendances, Best 4h Performance in 5 Years 10. HSSIB Mental Health Crisis Care — No Lawful Holding Power in ED (Interim Report) 11. UKHSA Hantavirus Outbreak (MV Hondius) — HCID Awareness, Travel History Essential 12. MHRA: Breas NIV Firmware FSN & Finasteride Psychiatric Warning 13. Martha’s Rule 18-Month Data — 81% of Deterioration Calls Missed by EWS Alone 14. MenB Dorset/Kent Clusters — Ongoing IMD Vigilance for Southern England

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

10. [LEAD] No OUCH RCT — Ibuprofen Alone for Paeds MSK Pain (also Item 1) 11. Paeds Septic Shock — Balanced Crystalloid vs 0.9% Saline: No Difference in MAKE30 (NEJM) 12. Fast MRI vs CT for Paediatric Neurological Emergencies — Non-Inferior, No Radiation

SECTION 4 — FOAMED & CRITICAL APPRAISAL

13. First10EM May 2026 Roundup — Whole Blood, STORM-PE, Mirtazapine, Spinal BP

QUICK HITS · CORE REVISION · ACTION POINTS · TRIALS TO WATCH

SECTION 1 — KEY JOURNAL ARTICLES & TRIALS

JAMA · MARCH 2026 · RCT (TWO PARALLEL TRIALS) · LEAD ITEM

Paediatric MSK Pain — Ibuprofen Alone is Sufficient: Adding Paracetamol or Opioid Provides No Extra Pain Relief and Opioids Cause 4-Fold More Harm

RCT CHANGE TONIGHT PAEDS FRCEM UK

• NNH 4 ADDING OPIOID — ANY AE
• No diff PAIN SCORE AT 60 MIN
• 28.2% AE RATE: IBU + OPIOID
• n=734 TWO RCTS, CANADA

Group

Pain score (60 min)

Any adverse event

Ibuprofen + hydromorphone (opioid)

No difference

28.2% (NNH 4)

The No OUCH trial (Ali et al, JAMA 2026) randomised 734 children with acute non-operative musculoskeletal injury across Canada to three arms: ibuprofen alone, ibuprofen + acetaminophen, or ibuprofen + hydromorphone (oral opioid). All three groups received the same pain scores at 60 minutes after administration — the primary outcome showed no difference across any comparison. However, adverse events occurred in 28.2% of the ibuprofen + hydromorphone group versus 5.8% in the ibuprofen alone group (NNH 4), predominantly drowsiness, nausea, and vomiting. No serious adverse events occurred. UK context: The typical paediatric ED analgesia ladder involves ibuprofen ± codeine or oxycodone in some trusts. Codeine is already contra-indicated in children under 12 (MHRA, 2013), but this trial provides robust evidence that even for children above that threshold, opioid addition confers no analgesic benefit and significantly increases harm. The same argument extends to adding oral paracetamol to ibuprofen: it adds pharmacy complexity and no measurable benefit at the primary endpoint.

Critical appraisal: The trial was conducted in Canadian paediatric EDs using hydromorphone, which has a slightly different pharmacokinetic profile to oral codeine or oxycodone commonly used in the UK. However, the principle that oral opioid addition to adequate NSAID dosing confers no benefit and causes harm is biologically plausible and likely to generalise. Both trials used weight-appropriate ibuprofen dosing (10 mg/kg); ensure UK practice similarly uses adequate NSAID dosing before concluding opioids are not needed. Grade: High (two parallel RCTs, pre-registered, adequate power, patient-oriented outcomes).

Why it matters: This is the strongest paediatric analgesic trial in years. For every 4 children you give an opioid to alongside ibuprofen, one will have an adverse event — and none will have better pain control. This should trigger an immediate review of departmental analgesia protocols for paediatric MSK presentations, fracture, and sprain.

Tell your department: Review all paeds MSK analgesia protocols now. If your department is still prescribing oral opioids as a routine add-on to ibuprofen for fractures or sprains in children, this RCT provides the evidence to stop. Optimal strategy: weight-appropriate ibuprofen (10 mg/kg, max 400 mg) as sole oral analgesia. Escalate to intranasal diamorphine or ketamine for severe pain requiring additional analgesia — not to oral opioids.

Source: Ali S et al. JAMA 2026;335(10):863–873 — No OUCH RCT (PMID 41505155) · via First10EM / Broome Docs

JAMA · APRIL 2026 · RCT · PMID 41642827

OPTION Trial — Tenecteplase 4.5–24 Hours in Non-LVO Ischaemic Stroke: Improved Outcomes But Real sICH Risk

RCT CHANGE WHEN GUIDELINE UPDATES FRCEM

• +9.4% ARD — EXCELLENT OUTCOME
• NNT 11 MRS 0–1 AT 90 DAYS
• NNH 36 SICH (2.8% VS 0%)
• n=566 48 CENTRES, CHINA

Outcome

TNK

Control

Effect

Excellent outcome (mRS 0–1) at 90d

43.6%

34.2%

RR 1.28, p=0.02

Functional independence (mRS 0–2)

62.8%

55.3%

RR 1.14, p=0.07 (NS)

Symptomatic ICH at 36h

2.8%

0%

NNH 36

The OPTION trial (Ma G et al, JAMA 2026; PMID 41642827) randomised 566 patients with non-LVO acute ischaemic stroke presenting 4.5–24 hours after onset to IV tenecteplase (0.25 mg/kg, max 25 mg) vs standard care. Eligibility required CT perfusion-confirmed penumbral mismatch (salvageable tissue) and a disabling deficit (NIHSS 6–25). Primary outcome: excellent functional recovery (mRS 0–1) at 90 days — 43.6% vs 34.2%, RR 1.28 (95% CI 1.04–1.57), p=0.02. Functional independence (mRS 0–2) at 90 days was directionally favourable but did not reach significance (62.8% vs 55.3%, p=0.07). Symptomatic ICH occurred in 2.8% of the TNK group vs 0% in controls (NNH 36). Mortality at 90 days was similar (5.0% vs 3.2%, p=0.28). UK context: Current NICE NG128 (Stroke) does not support thrombolysis beyond 4.5 hours for non-LVO. OPTION is conducted in Chinese centres using CT perfusion selection — a tool not universally available in UK stroke networks. This trial will inform the NICE NG128 surveillance review; application requires dedicated CTP imaging and rigorous case selection.

Critical appraisal: OPTION is prospectively designed and adequately powered (pre-registered). However: (1) entirely Chinese centres — generalisability to UK populations uncertain; (2) CT perfusion selection is not routine in all UK stroke EDs; (3) the sICH rate of 2.8% vs 0% is clinically consequential — for every 36 patients treated, 1 will develop a symptomatic bleed; (4) functional independence (mRS 0–2) — the more patient-relevant outcome — did not reach significance. GRADE: Moderate (single-country, imaging-selected, questions about external validity). This is a signal trial that will inform future guidelines; it does not currently justify changing practice outside a stroke centre with CT perfusion capability and specialist input.

Why it matters: The 4.5–24h window has previously been the domain of EVT only. OPTION provides the first high-quality RCT evidence that late-window thrombolysis is biologically feasible in carefully selected non-LVO patients. NNT of 11 for excellent functional outcome is clinically meaningful. The NICE NG128 surveillance review (expected 2026) will incorporate OPTION alongside HOPE-ASiS data.

Tell your department: Do not change practice on the basis of this trial alone. Discuss with your stroke team and neuroradiologists whether your centre has CT perfusion capability and would be eligible to participate in a late-window pathway. Patients presenting 4.5–24h after non-LVO stroke who are currently being referred for consideration of EVT should prompt a conversation about imaging-guided thrombolysis eligibility.

Source: Ma G et al. JAMA 2026 — OPTION Trial (PMID 41642827) · via Critical Care Reviews / TCTMD

REBEL EM · SECONDARY ANALYSIS DOSE VF RCT · MAY 2026

Refractory VF — DSED Cuts Time in VF by 27%: Mechanistic Support for Earlier Double Sequential Defibrillation

RCT CHANGE THIS MONTH FRCEM

• −30s VF BURDEN: DSED VS STD
• −27% RELATIVE VF TIME REDUCTION
• 83s MEDIAN VF TIME: DSED
• 113s MEDIAN VF TIME: STANDARD

A secondary analysis of the DOSE VF RCT examined the mechanistic pathway by which alternate defibrillation strategies improve outcomes in refractory VF. The key finding: DSED (double sequential external defibrillation) reduced time spent in VF after the 4th shock from a median of 113 seconds (standard) to 83 seconds — a 30-second (27%) absolute reduction. Vector change (VC) also reduced VF time compared to standard, but DSED showed the largest effect. Crucially, Awad et al previously demonstrated that each minute in VF reduces odds of ROSC by approximately 20%, providing the mechanistic link from VF burden reduction to the survival improvement seen in the primary DOSE VF RCT. The secondary analysis suggests that DSED could be applied even earlier than “refractory” VF (after shock 3–4) — the biological rationale now supports considering it as a primary strategy in prolonged resus rather than a rescue measure. UK context: DOSE VF used paramedic-delivered DSED. Most UK resus bays have two defibrillators. The equipment barrier to DSED is low.

Critical appraisal: This is a secondary, non-pre-registered analysis of the DOSE VF RCT. VF burden was a mechanistic (not clinical) endpoint. The survival benefit is from the primary trial; this analysis provides insight into why DSED works. It does not independently prove that applying DSED earlier improves survival. Randomised evidence for timing of DSED initiation is pending. GRADE: Low (secondary analysis, mechanistic outcome).

Why it matters: Refractory VF carries very high mortality with standard care. Any intervention that reduces VF burden by 27% without additional harm represents a meaningful advance. DSED and VC are now the standard of care for refractory VF per RCUK guidance; this analysis suggests moving DSED earlier in the algorithm is biologically justified and further trials are in progress.

Tell your department: If your resus bay has two defibrillators, confirm your refractory VF protocol includes DSED after shock 3 or 4, not as a last resort. Consider adding this to your cardiac arrest simulation scenarios. RCUK ALS 2021 already includes alternate pad placement — this is an extension to dual-device strategy.

Source: REBEL EM — Alternate Defibrillation Strategies for Refractory VF (May 2026) · DOSE VF secondary analysis

NEJM · MARCH 2026 · UK RCT · PMID 41841706

SWiFT RCT — Prehospital Whole Blood Provides No Benefit Over Component Therapy in Traumatic Haemorrhage (UK, 10 Air Ambulance Services)

RCT INFORMING UK

• No diff DEATH OR MASSIVE TRANSFUSION 24H
• RR 1.02 95% CI 0.80–1.31, P=0.84
• n=616 ANALYSED (942 RANDOMISED)
• 40.7% ABNORMAL PT: WHOLE BLOOD ARM

SWiFT (Study of Whole Blood in Frontline Trauma) randomised 942 patients across 10 UK air ambulance services to up to 2 units of whole blood vs standard component therapy (up to 2 units each of RBCs and plasma) for life-threatening traumatic haemorrhage. Primary outcome: composite of death or massive transfusion (≥10 units blood components) within 24 hours. Result: 48.7% vs 47.7% — no significant difference (adjusted RR 1.02, 95% CI 0.80–1.31, p=0.84). Mortality at all timepoints was similar. A concerning signal: 40.7% of whole blood recipients had prothrombin times above normal range vs 30.5% in standard care. UK context: The trial was funded by NHS Blood and Transplant — this is direct UK evidence. The null result reflects the dose limitation (2 units) which were quickly diluted by subsequent identical hospital transfusion. Whole blood remains experimental in civilian prehospital systems; this trial does not mandate changing current practice, and HEMS services should not self-adopt without further evidence. Note: primary PHEM application — included here for completeness as patients arrive to your resus bay via these systems.

Critical appraisal: The dose limitation is the key flaw — 2 units of any blood product are unlikely to be practice-defining in a patient requiring massive transfusion. Both groups received identical management after hospital arrival, making the treatment arms nearly equivalent in total blood received. GRADE: High (phase 3, pragmatic, pre-registered) — but with important limitations in external validity for very high-volume haemorrhage.

Source: Smith JE et al. NEJM 2026 — SWiFT RCT (PMID 41841706) · First10EM / Broome Docs

CIRCULATION · JANUARY 2026 · RCT · PMID 41183181

STORM-PE — Mechanical Thrombectomy Improves RV/LV Ratio in Intermediate-High PE But Does Not Reduce Mortality

RCT INFORMING FRCEM

• Improved RV/LV RATIO AT 48H
• No diff MORTALITY / CLINICAL OUTCOMES
• 2 deaths THROMBECTOMY ARM (0 IN ANTICOAG)
• Int-High TARGET POPULATION

STORM-PE randomised patients with acute intermediate-high risk PE (troponin elevated, RV/LV >1, hemodynamically stable) to computer-assisted vacuum thrombectomy (CAVT, Indigo System) plus anticoagulation vs anticoagulation alone. CAVT was superior in reducing RV/LV ratio within 48 hours and achieved earlier normalisation of vital signs. However, all-cause mortality and clinically meaningful patient-centred outcomes (recurrent PE, bleeding) were not significantly different. There were 2 deaths in the CAVT arm and 0 in the anticoagulation-alone arm (not statistically powered for mortality). UK context: The 2026 AHA/ACC PE guideline supports catheter-based therapies in the haemodynamically unstable or intermediate-high risk patient where anticoagulation is failing, but demands evidence of patient-centred benefit before widespread intermediate-risk adoption. The STORM-PE result reinforces that improving imaging parameters is not the same as improving patient survival. Haemodynamically stable intermediate-high risk PE: anticoagulate and observe. Escalate to PERT for deterioration.

Critical appraisal: The fundamental problem with STORM-PE (and most intermediate PE trials) is patient selection. Patients with troponin elevation but no haemodynamic compromise have excellent outcomes on anticoagulation alone (mortality near 0%) — you cannot improve on that with an invasive procedure. The biologically relevant population (haemodynamically deteriorating, high mortality risk) was excluded. GRADE: Moderate (adequately powered for surrogate endpoint; underpowered for clinical outcomes).

Source: Sista AK et al. Circulation 2026;153(1):21–34 — STORM-PE (PMID 41183181) · via First10EM

JAMA PSYCHIATRY · APRIL 2026 · RCT · PMID 41920558

Mirtazapine for Methamphetamine Use Disorder — First Positive Phase 3 RCT: Modest but Real Reduction in Use Days

RCT INFORMING FRCEM

• 2.2 days ARD (USE DAYS/28D), P=0.02
• 30 mg/d DOSE, 12 WEEKS
• No serious AE SAFETY PROFILE
• Phase 3 DOUBLE-BLIND RCT, AUSTRALIA

This phase 3 double-blind RCT randomised adults with methamphetamine use disorder to mirtazapine 30 mg daily or placebo for 12 weeks. Primary endpoint: change in days of methamphetamine use in the past 28 days at week 12. Mirtazapine group: 7.0 days reduction vs 4.8 days in placebo (mean difference 2.2 days; 95% CI −4.2 to −0.2; p=0.02). Secondary outcomes (depression, insomnia, quality of life) showed no significant difference. Adverse effects: predominantly drowsiness and weight gain. No unexpected safety signals. UK context: Methamphetamine (predominantly crystal meth) use is rising in the UK, particularly in LGBTQ+ venues (chemsex) and some urban populations. No pharmacotherapy is currently licensed for methamphetamine use disorder. Mirtazapine is already available on NHS prescription for depression and anxiety — this result opens a conversation with patients in ED and drug liaison services about off-label use, pending NICE and MHRA review.

Tell your department: Discuss this result with your ED liaison psychiatry and drug and alcohol team. For patients presenting with methamphetamine-related ED attendances (psychosis, chest pain, ACS, trauma, overdose), an ED-initiated referral for mirtazapine consideration may be appropriate. Do not initiate independently — this requires drug and alcohol specialist input and follow-up. The effect is modest (2.2 fewer use days per 28 days) but is the first pharmacological foothold in a condition with no licensed treatment.

Source: McKetin R et al. JAMA Psychiatry 2026 — Mirtazapine for Meth Use Disorder (PMID 41920558) · First10EM / JAMA Psychiatry

SECTION 2 — GUIDELINES & UK UPDATES

SURVIVING SEPSIS CAMPAIGN · CRIT CARE MED · MARCH 2026 · PMID 41869847

Surviving Sepsis Campaign 2026 Guidelines — 129 Statements, 46 New: Key ED-Facing Changes

GUIDELINE CHANGE THIS MONTH FRCEM

The 2026 SSC Guidelines (Prescott et al, Crit Care Med 2026) update the 2021 version with 129 statements across 69 panellists from 23 countries. Below are the ED-relevant changes and clarifications. Full text at DOI: 10.1097/CCM.0000000000007075.

Critical appraisal: The 3-hour window for “possible sepsis without shock” is based on very low certainty evidence. The new recommendation permits a period of reassessment before antibiotic commitment — this is clinically important and prevents over-treatment of patients who turn out not to have infection. However, it requires systematic re-evaluation: if you defer antibiotics, you must have a plan to reassess within the timeframe. UK Sepsis Trust guidance and NHS England Sepsis CQUIN targets may conflict with the 3h window — discuss with your sepsis lead before changing departmental protocol.

Source: Prescott HC et al. Crit Care Med 2026;54(4):725–812 — SSC 2026 (PMID 41869847) · EMCrit 422

RCEM · 11 MAY 2026 · QIP FINAL REPORT

RCEM Mental Health QIP Final Report — Only 48.6% of Medium/High-Risk Patients Properly Observed Throughout ED Stay

UK CHANGE TONIGHT FRCEM

RCEM published the final report of its Mental Health and Self Harm Quality Improvement Programme (QIP 2022–2025) on 11 May 2026, coinciding with UK Mental Health Awareness Week. Key findings: only 48.6% of patients deemed medium or high risk of self-harm or absconding were appropriately observed throughout their entire ED stay. This fell to below 35% in early December 2025 — the busiest period for EDs. Triage performance: 76.1% of self-harm presentations received a mental health triage (down from 81.7% in year 2). Structured self-harm assessment covering all four required domains (type, trigger, social history, future plans) was documented in only 40% of cases in summer and approximately 20% in early December. Evidence of compassionate and practical care was recorded in 40.7% of cases. Over a 3-year period, observation rates have improved markedly (from 29.1% in 2023 to 48.6% in 2025), but remain below acceptable clinical standards.

Patient safety alert: Failure to observe a medium or high-risk patient who then self-harms or absconds within the ED represents a preventable adverse event. The core issue is not systemic failure alone — it is individual clinical accountability. Every clinician triaging a mental health patient must ensure an observation status is assigned and that the handover to nursing staff explicitly covers observation requirements. This is not optional and cannot be delegated to an “it’s a busy shift” exception. RCEM President Dr Ian Higginson: “The findings show how much still must be done to safeguard mental health patients in the ED.”

Tell your department: Review your mental health triage and observation process. Specifically: (1) Is there a formal mechanism to assign and hand over observation status for all medium/high-risk patients? (2) Is a structured 4-domain self-harm assessment being completed and documented? (3) Is observation maintained throughout the stay, not just at triage? Departments with high throughput must consider dedicated mental health bays or physically separated observation spaces where staffing allows. Consider raising this at your next governance meeting with reference to the RCEM QIP data.

Source: RCEM Mental Health and Self Harm QIP Final Report — 11 May 2026

NHS ENGLAND · APRIL 2026 · STATISTICAL RELEASE

NHS A&E March 2026 — Record 2.43 Million Attendances; 77.1% Within 4 Hours (Best in 5 Years); Zero Trusts Hit 95%

UK INFORMING

NHS England released March 2026 A&E data on 16 April. Headline figures: 2.43 million total attendances (record, driven in part by a mid-March meningitis outbreak). 77.1% of patients were admitted, transferred, or discharged within 4 hours — the best performance since early 2022 and a significant improvement on 74.1% in February 2026. However, 0 of 121 reporting Type 1 trusts achieved the 95% operational standard. At Type 1 departments only, 4-hour performance was 64.1%. There were 46,665 patients waiting over 12 hours from decision to admit, equating to 1,505 per day — marginally lower than March 2025 (0.2%). NHS England attributed part of the improved performance to an £80 million financial incentive scheme targeting 90% 4-hour performance per trust. RCEM Vice President Dr James Gagg: “These schemes often paper over the cracks and fail to tackle the root causes.”

Why it matters: 77.1% represents a genuine improvement but is still driven by financial incentives rather than structural change. 12-hour waits remain at over 46,000 per month. ED clinicians should document corridor care using the formal NHS England definition rigorously — the data now feeds into a nationally benchmarked metric and GIRFT review. The meningitis-driven surge in March underscores the importance of infectious disease surge planning within UEC frameworks.

Source: NHS England A&E Attendances and Emergency Admissions, March 2026 · Medscape UK

HSSIB · 8 APRIL 2026 · INTERIM INVESTIGATION REPORT 1 OF 2

HSSIB Mental Health Crisis Care — No Lawful Power to Prevent Patients Leaving ED: Staff Forced to “Choose the Least Harmful Way to Break the Law”

UK CHANGE TONIGHT SAFETY

This interim HSSIB report (Report 1 of 2; full report expected summer 2026) identifies a critical legal gap affecting every Type 1 ED in England. Key finding: there is currently no clear legal power to lawfully prevent a vulnerable individual in mental health crisis from leaving the ED while awaiting psychiatric assessment or MHA completion. Mental Health Act Section 136 has strict time limits and geographic constraints that do not reliably apply to patients who self-present to ED. The Mental Capacity Act does not bridge the gap for patients with fluctuating capacity. ED staff described being routinely forced to choose “the least harmful way to break the law” — a situation that exposes individual clinicians and trusts to legal risk while simultaneously failing the patient. Children are particularly poorly served: a Tier 4 CAMHS manager can decline admission following a valid MHA recommendation, leaving the child in the ED with no legal holding power. Two formal safety recommendations were issued: R/2026/082 requires DHSC to urgently address the legislative gap; R/2026/083 requires the CQC to issue a national position statement on current legal powers in this setting.

Patient safety — act now: Every ED clinical lead should: (1) Discuss this report with your trust’s legal/governance team and clarify the trust’s position on holding patients awaiting MHA assessment under common law or MCA; (2) Review local AMHP and Section 12 doctor availability and escalation routes — delays here leave patients legally adrift; (3) Ensure staff are aware they are not alone in this legal uncertainty — this is a systemic legislative failure, not individual clinical failing; (4) Share the report with your mental health liaison team and CAMHS colleagues. The second HSSIB report (expected summer 2026) will cover ED environment, knowledge gaps, and admission/discharge decision-making — watch for it.

Source: HSSIB — Mental Health Crisis Care: Legislative Challenges in Emergency Departments (April 2026)

UKHSA · 6 MAY 2026 (UPDATED 13 MAY 2026) · OUTBREAK ALERT

UKHSA: Andes Hantavirus Outbreak (MV Hondius Cruise Ship) — Person-to-Person Transmission Possible, Supportive Care Only, Mortality Up to 30–50%

UK SAFETY CHANGE TONIGHT

UKHSA is managing a live outbreak of Andes hantavirus (a High Consequence Infectious Disease, HCID) linked to the Dutch cruise ship MV Hondius. As of 13 May 2026: 8 confirmed/suspected global cases including British nationals, who have been repatriated and managed at Arrowe Park Hospital (Wirral) under strict infection control. All current Arrowe Park contacts have tested negative. General public risk: very low. ED clinicians need to be aware for the following reason: Andes hantavirus is the only hantavirus strain known to have documented person-to-person transmission (via close prolonged contact). Clinical course: flu-like prodrome (fever, extreme fatigue, myalgia, GI symptoms) for 3–5 days, followed by cardiopulmonary phase with rapid onset pulmonary oedema and cardiovascular collapse — resembling severe ARDS/cardiogenic shock. Incubation: 2–4 weeks (up to 40 days). Mortality: up to 30–50% (older data; likely lower with modern ICU care). No specific antiviral treatment available — care is entirely supportive with aggressive respiratory and cardiovascular support.

Action if you suspect hantavirus: (1) Obtain a detailed travel and contact history in any undifferentiated presentation with SIRS/sepsis + unexplained pulmonary oedema or ARDS; (2) If MV Hondius travel or close contact with a confirmed case is identified: isolate immediately, apply standard droplet + contact precautions (FFP3 for AGPs), and contact the UKHSA on-call specialist before further investigation; (3) Do not wait for confirmatory testing to isolate — treat as HCID until excluded; (4) Alert your infection control team and hospital management immediately. The outbreak is being actively managed; no UK community transmission has occurred.

Source: UKHSA — Hantavirus Cruise Ship Outbreak Update, 13 May 2026

MHRA / NHS ENGLAND · MAY 2026 · DEVICE FSN & DRUG SAFETY UPDATE

MHRA: Breas Vivo 45 LS & Nippy 4+ NIV Ventilator Firmware FSN — Check Affected Devices Now; Plus Finasteride Strengthened Psychiatric Warning

UK SAFETY

Breas Vivo 45 LS / Nippy 4+ (CAPA-385): MHRA Field Safety Notice issued for NIV ventilators running firmware versions 3.2.1, 4.2.1, or 7.2.1. These devices are used for NIV in COPD exacerbations, acute pulmonary oedema, and type 2 respiratory failure. EDs using affected firmware should contact biomedical engineering and follow manufacturer instructions — do not use until the firmware issue is resolved if your device is affected. Full FSN details via MHRA. Also: Hamilton Medical IntelliCuff (ventilator cuff pressure controller) and GE CARESCAPE telemetry server FSNs were published 4–8 May 2026 — notify biomedical engineering for any affected equipment in resus or HDU bays.

MHRA Drug Safety Update — Finasteride/Dutasteride (11 May 2026): Strengthened psychiatric warnings issued following European regulatory review. Sexual dysfunction associated with finasteride may contribute to mood disorders; depression and suicidal ideation have been reported. ED relevance: ask about finasteride/dutasteride use in patients presenting with depression, self-harm, or suicidal ideation. If implicated, advise not to stop without GP review (sudden cessation carries its own risks), and refer for follow-up. Report suspected adverse reactions via the Yellow Card scheme.

Source: MHRA FSN 27 Apr–1 May 2026 (Breas NIV) · MHRA Finasteride/Dutasteride Safety Update, 11 May 2026

NHS ENGLAND · 1 MAY 2026

Martha’s Rule — 18-Month Data: 12,301 Calls, 524 Potentially Life-Saving Interventions; 81% of Deterioration Calls Missed by EWS Alone

UK INFORMING

NHS England released 18-month data (September 2024 – February 2026): 12,301 total Martha’s Rule escalation calls, of which 4,047 (33%) related to acute deterioration. These resulted in 2,310 treatment changes, including 524 potentially life-saving interventions (transfers to enhanced care). The critical statistic: 81% of deterioration calls were made when the Early Warning Score alone would NOT have triggered escalation, validating the rationale for a patient/carer-facing escalation route independent of EWS triggers. Martha’s Rule is now a mandatory requirement in the NHS Standard Contract 2026/27 (Service Condition 33). EDs are not the primary setting, but patients boarding awaiting beds are covered — ensure your trust’s pathway includes them.

Source: NHS England — Martha’s Rule 18-Month Data, 1 May 2026

UKHSA · APRIL–MAY 2026 · ONGOING SURVEILLANCE

Invasive Meningococcal Disease — Dorset MenB Cluster and Kent Background: Maintain Heightened Awareness, Especially Southern England

UK SAFETY PAEDS

Two concurrent MenB clusters have been active in southern England. Dorset (Weymouth): 3 confirmed MenB cases in young people (20 March–15 April 2026), same sub-strain, different to Kent. Mass antibiotic prophylaxis and MenB vaccination offered to ~6,500 school-age individuals. No new cases confirmed as of May 2026 search. Kent/Canterbury (University of Kent): 21 confirmed cases, 2 deaths, March 2026; now classified as standard incident as of 1 April 2026, having transitioned from enhanced incident status. Both clusters highlight the continuing background threat of invasive meningococcal disease in young adults (15–25). UK EDs should maintain clinical vigilance: meningococcal sepsis can present without a rash. Treatment: immediate IV/IM ceftriaxone (adults/children ≥10y: 2 g IV/IM; benzylpenicillin 1.2 g IV/IM if ceftriaxone unavailable). All suspected cases are statutorily notifiable without waiting for microbiology confirmation.

Clinical reminder: Do not wait for a non-blanching rash before treating suspected meningococcal disease. Petechial rash is absent in the early stages and in up to 20% of cases overall. A rapidly unwell febrile young person with signs of shock + any combination of headache, photophobia, neck stiffness, altered consciousness, or severe limb pain should receive ceftriaxone immediately — before CT, before LP, before microbiology.

Source: UKHSA — MenB Dorset Cluster (April 2026, ongoing)

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

SEE SECTION 1, ITEM 1 FOR FULL DETAILS — JAMA · MARCH 2026 · PMID 41505155

No OUCH RCT — Ibuprofen Alone for Paeds MSK Pain: Remove Opioids and Paracetamol Add-Ons from Protocol [LEAD ITEM — Full Detail in Section 1]

RCT CHANGE TONIGHT PAEDS LEAD

See full analysis in Section 1. Key paediatric summary: ibuprofen alone provides equivalent pain control to ibuprofen + paracetamol or ibuprofen + opioid for acute musculoskeletal injuries in children. Adding opioids causes a 4-fold increase in adverse events (NNH 4, 28.2% vs 5.8%) with zero additional analgesic benefit at 60 minutes. Remove oral opioids from paediatric MSK analgesia protocols immediately.

Source: Ali S et al. JAMA 2026 — No OUCH RCT (PMID 41505155)

NEJM · 2026 · RCT · PMID 42028918

Paediatric Septic Shock Fluid Resuscitation — Balanced Crystalloid vs 0.9% Saline: No Difference in Death, Renal Replacement, or Kidney Dysfunction

RCT CHANGE TONIGHT PAEDS FRCEM

• 3.4% vs 3.0% MAKE30 (BALANCED VS SALINE)
• RR 1.10 95% CI 0.88–1.40, P=0.85
• n=7,933 LARGEST PAEDS SEPSIS FLUID TRIAL
• 2 mo–17y AGE RANGE

This large NIH-supported RCT (PMID 42028918) enrolled 7,933 children aged 2 months to 17 years with septic shock, randomising them to balanced crystalloid or 0.9% saline for 24–48 hours of fluid resuscitation. Primary composite outcome: death, new renal replacement therapy, or persistent kidney dysfunction at 30 days (MAKE30). No significant difference: 3.4% vs 3.0% (RR 1.10, 95% CI 0.88–1.40, p=0.85). Hospital-free days (median 23 in both groups), mortality, and overall safety were similar. As expected, the saline group had higher incidence of hyperchloraemia and hypernatraemia; the balanced group had slightly higher lactate. Neither biochemical difference translated to worse clinical outcomes. UK context: This is the largest paediatric sepsis fluid trial conducted. It provides reassurance that departmental choice between Plasmalyte and 0.9% saline in paediatric septic shock is not a critical determinant of outcome. Use your departmental default. Note the IBCC canonical rule: balanced crystalloid remains the physiological default for most presentations; saline is not contraindicated here.

Why it matters: Paediatric resuscitation guidelines and local protocols vary widely on fluid choice. This RCT definitively answers a decades-long debate: for children in septic shock, either balanced crystalloid or 0.9% saline is safe as the resuscitation fluid. The focus should be on rapid recognition, early antibiotics, and source control — not fluid composition. This result removes a source of inter-clinician variation and potential delay.

Source: Weiss SL et al. NEJM 2026 — Paediatric Sepsis Fluid RCT (PMID 42028918) · NIH / Children’s National Innovation District

PEDIATRICS · APRIL 2026

Fast MRI vs CT for Paediatric Neurological Emergencies — Non-Inferior to CT, Higher Sensitivity, No Sedation or Radiation Required

OBSERVATIONAL INFORMING PAEDS

A prospective study published in Pediatrics (2026) compared fast MRI (abbreviated motion-tolerant sequences, no sedation, approximately 6–10 minutes) versus CT for children presenting with new acute neurological symptoms to the paediatric emergency department. Fast MRI achieved higher sensitivity for neurological emergencies and missed fewer diagnoses compared to CT, without increasing emergency department length of stay or time to hospital admission. The absence of ionising radiation and sedation requirement makes fast MRI particularly advantageous in children. UK context: Fast MRI protocols are not uniformly available in UK EDs — their availability depends on MRI provision, radiographer hours, and departmental geography. However, for departments with adjacent MRI capability, this study provides evidence to support a fast MRI-first pathway for paediatric neurological emergencies where haemorrhage is not the primary concern. CT remains the modality of choice for suspected haemorrhage and acute trauma.

Tell your department: If your department has access to fast MRI protocols, discuss with your radiology colleagues whether a paediatric neurological fast MRI pathway is feasible. For children with new neurological symptoms without evidence of acute haemorrhage (e.g. new focal neurology, first seizure, suspected demyelination), fast MRI may replace CT and should be requested if available. Where CT is unavoidable, document the radiation exposure in the patient’s record as per IRMER regulations.

Source: Pediatrics 2026 — Fast MRI vs CT for Paediatric Neurological Emergencies · DFTB Bubble Wrap Plus May 2026

SECTION 4 — FOAMED & CRITICAL APPRAISAL

FIRST10EM · MAY 4, 2026

First10EM Research Roundup — May 2026: Whole Blood Null Result, PE Thrombectomy Limitations, Mirtazapine Signal, Spinal BP Targets

INFORMING

Justin Morgenstern’s May 2026 roundup covers several trials addressed in this issue (SWiFT, STORM-PE, mirtazapine) plus an additional high-interest item: a small, flawed RCT of MAP targets in spinal cord injury. The trial randomised patients to MAP 85–90 vs 65–70 and found no improvement in neurological outcomes at 6 months, with higher rates of respiratory adverse events in the high-MAP group. Trial was stopped early with outcome data on <50% of patients — profound uncertainty. Current position: conventional BP targets (MAP 65–70) should apply to SCI patients unless and until stronger evidence emerges. Morgenstern’s prehospital whole blood appraisal concurs with the SWiFT interpretation above: the 2-unit dose was inherently incapable of demonstrating an effect in patients who subsequently received many more units of identical products in hospital. On STORM-PE: he specifically raises the point that all deaths in the thrombolysis arms of PE trials (including STORM-PE) underscore the importance of correct patient selection before any escalation beyond anticoagulation.

Source: First10EM Research Roundup May 2026

SECTION 5 — QUICK HITS

JAMA NETWORK OPEN · APRIL 2026 · CARES REGISTRY 2013–2024 (N>500,000)

OHCA Nighttime Survival Disadvantage Persists Despite Decade of Improvement — 15% Lower Odds of Neurological Survival at Night

OHCA at night carries approximately 15% lower adjusted odds of neurologically favourable survival (6.7% vs 9.3%) and sustained ROSC (25.8% vs 30.6%) compared to daytime — a disparity that has not narrowed over 10 years. The disadvantage persists beyond ROSC, implicating post-resuscitation care quality as well as prehospital factors. UK relevance: out-of-hours staffing, night team composition, and post-arrest care pathways warrant regular simulation and review. The gap is not inevitable; it reflects modifiable system factors. JAMA Network Open 2026

SGEM#509 · JAMA 2026 · PMID 41661604 · OBSERVATIONAL COHORT

Coffee and Dementia Risk — 2–3 Cups/Day Associated With 35% Lower Risk, But Observational Caveats Apply

A large prospective cohort (n=131,821, up to 43-year follow-up) found that higher caffeinated coffee intake was associated with lower dementia risk (HR 0.82, 95% CI 0.76–0.89) and less subjective cognitive decline. Tea showed similar patterns. The SGEM appropriately notes this is observational — residual confounding is substantial (higher coffee drinkers were younger, drank more alcohol). No causal inference justified. ED relevance: minimal. Included as a staff wellbeing item. JAMA 2026 (PMID 41661604)

NHS ENGLAND · MAY 2026 · 18-WEEK REFERRAL TARGET

NHS Hits 18-Week Referral-to-Treatment Target for First Time Since 2020 NHS England announced that the 18-week referral-to-treatment standard (92% of patients treated within 18 weeks) has been achieved for the first time since 2020. This is primarily an elective care metric but has downstream ED implications: patients awaiting elective procedures who deteriorate are significant contributors to emergency admissions. As the elective backlog reduces, expect some reduction in admission pressure from this pathway. NHS England, May 2026

CORE REVISION — HEADACHE IN THE ED: NOT MISSING THE DANGEROUS ONES

FRCEM REVISION — HEADACHE IN THE ED

Headache accounts for approximately 2% of all ED attendances and up to 4% of medical emergency attendances. The vast majority are benign primary headaches, but the dangerous secondary causes carry high mortality if missed. This revision covers the systematic approach used in any FRCEM OSCE or clinical scenario.

ACTION POINTS — ISSUE 12

• Paeds MSK analgesia: Remove oral opioids as a routine add-on to ibuprofen from paediatric analgesic protocols. Ibuprofen alone (10 mg/kg, max 400 mg) is sufficient for acute MSK pain in children. Escalate to intranasal diamorphine for severe pain only. [No OUCH RCT, JAMA 2026]
• Mental health observation: Every medium/high-risk self-harm or absconding patient must have an observation status assigned at triage and maintained throughout the ED stay. Document handover explicitly. Do not allow busy periods to compromise this — the December drop to <35% is unsafe. [RCEM QIP, May 2026]
• Sepsis antibiotic refinement: For possible sepsis without shock: reassess within 3h before mandatory antibiotic commitment. Remove default anaerobic cover unless the anatomical source warrants it (intraabdominal, gynaecological, HEENT, necrotising). [SSC 2026]
• Refractory VF: Confirm your department has a DSED protocol. If you have two defibrillators, DSED should be invoked by shock 3–4 at the latest. Consider earlier initiation — the biological basis now supports this. [DOSE VF secondary analysis, REBEL EM]
• Paeds sepsis fluids: Either balanced crystalloid or 0.9% saline is safe in paediatric septic shock. Use your departmental standard without hesitation or delay caused by fluid choice indecision. [NEJM 2026 RCT, n=7,933]
• OPTION trial — do not yet change stroke practice: Discuss with your stroke team whether your centre has CT perfusion capability for late-window imaging selection. Do not administer tenecteplase beyond 4.5h based on this trial alone without specialist stroke input.
• Corridor care documentation: Continue meticulous documentation of all patients receiving care in non-designed spaces using the formal NHS England definition. Trust-level data is now a benchmarked metric.
• Mirtazapine for methamphetamine: Flag to drug liaison team and liaison psychiatry for patients with methamphetamine use disorder. Off-label use requires specialist co-prescription but this is now the first positive phase 3 pharmacotherapy trial in this condition.

TRIALS TO WATCH

UPCOMING TRIALS & GUIDELINE MILESTONES

Q2–Q3 2026

NICE NG185 Chest Pain Guideline — LEGEND Trial Response: NICE surveillance triggered by the LEGEND troponin limit-of-detection study. New assay thresholds for hs-cTnT 0h/1h rule-out pathway expected. Watch for updated ESC/NICE alignment. NICE NG128 Stroke Guideline — Surveillance Review: OPTION trial (this issue) plus HOPE-ASiS data will inform a review of late-window thrombolysis guidance. Significant practice implications for UK stroke networks. NHS England Corridor Care Trust-Level Data — First Public Publication: National benchmarking data due. Ensure trust-level documentation is systematic and consistent before data appears in the public domain.

2026–2027

PARAMEDIC-3 — IV-First vs IO-First in OHCA: UK NIHR-funded RCT comparing intraosseous vs intravenous access as the primary vascular strategy in OHCA. Results expected mid-2026. High relevance to UK resus practice. CoMiTED — Conservative vs Immediate Chest Drain in Traumatic Pneumothorax (UK): Ongoing UK RCT. Results awaited. Will directly inform RCEM/NICE guidance on pneumothorax management. BACHb — HFNC vs Standard O2 vs CPAP in Bronchiolitis (UK, 50 NHS hospitals): Multicentre UK trial. Will define optimal respiratory support in infants with bronchiolitis — the most common paediatric admission. Highly anticipated by paeds ED and PICU teams. HSSIB Mental Health Crisis Care — Final Report Part 2: Part 1 reviewed systemic issues; Part 2 expected to address ED-specific recommendations. Will complement the RCEM QIP data from this issue.

LONGER HORIZON

BEST-DKA — Balanced Electrolyte vs Saline in Adult DKA (Phase 3, Australia): Analogous to SCOPE-1. Results will settle the paediatric and adult DKA fluid debate definitively. On-Scene Trial — Prehospital ECPR in Refractory OHCA (Netherlands): If positive, will accelerate pressure for ECPR capability at major trauma/cardiac arrest centres in UK cities. Watch for results and subsequent RCUK guidance development.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 12 — 14 May 2026 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com