EM Evidence Rundown — Issue 14

EM Evidence Rundown

ISSUE 14 · 28 MAY 2026 · UK EDITION

Jake Turner

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

LEAD: PRONTO trial (Lancet Respir Med) — Adding point-of-care procalcitonin to NEWS2 in UK ED suspected sepsis did not reduce IV antibiotic use but cut 28-day mortality by 3.0% (NNT 33) and 90-day mortality by 3.8% (NNT 26) across 5,453 patients at 20 NHS EDs. The mechanism is unclear — but the signal is robust and demands consideration in your sepsis pathway. CHANGE TONIGHT: NICE NG258 Anaphylaxis update — review observation criteria now & prescribe TWO AAIs at discharge (not one) | MHRA DSI/2026/004 Allurion gastric balloon — ask about it in unexplained abdominal pain, obstruction, pancreatitis | ATLAS IPD (Lancet): EVT up to 24h for large-core LVO stroke — update your triage bypass protocol

BOTTOM LINE UP FRONT — ISSUE 14

ACT ON THIS NOW

TONIGHT NICE NG258 Anaphylaxis: Updated 27 May. Two AAIs at discharge (not one). Review observation period criteria for high-risk features. Update your protocol now.

TONIGHT Allurion gastric balloon (MHRA): Ask about swallowable weight-loss balloon in unexplained abdominal pain, SBO, pancreatitis. Patients often don’t volunteer it. Plain AXR/CT to diagnose. Surgical/GI referral.

THIS MONTH PRONTO (UK, n=5,453): PCT + NEWS2 cuts 28d mortality by 3% (NNT 33) and 90d mortality by 3.8% (NNT 26) without reducing antibiotic use. Point-of-care PCT available now. Discuss pathway adoption with your sepsis lead.

THIS MONTH Large-core LVO stroke (ATLAS): EVT up to 24h in ASPECTS 0–5 / core ≥50mL. Functional independence aOR 1.63, mortality RR 0.65. Update your stroke triage protocol — do not withhold EVT for large core alone.

THIS MONTH Severe paeds CAP + dexa: Dexamethasone for 3 days reduces treatment failure from 60.6% to 25.8% (NNT 3). No increase in adverse effects. Discuss with paeds/ID for severe pneumonia admissions.

THIS MONTH Mothership for LVO stroke: SR/MA confirms direct transport to comprehensive stroke centre is superior to drip-and-ship. Review your ambulance pathway with SWAST/EMAS/regional trust.

KNOW FOR NEXT TIME

INFORMING Ketamine reduces PTSD at 6m: RCT in trauma patients — sub-dissociative ketamine for acute pain reduced PTSD and anxiety symptoms at 6 months. Hypothesis-generating; not yet practice-changing. (J Trauma, EMA Daily)

POCUS Infant sepsis warning signs: SR/MA confirms WHO signs plus poor CRT and central cyanosis for early sepsis recognition in young infants. CRT >3s in a febrile baby is a red flag. (JAMA Paediatrics, EMA Daily)

INFORMING Eclampsia prodromal signs: 10 neurological symptoms (visual, headache, confusion, UE weakness) strongly associated with eclampsia within 7 days. Identifies patients for magnesium prophylaxis better than current tools. (PLoS Med)

REVISION Nerve blocks in the ED: Fascia iliaca, femoral, WALANT, digital, haematoma. Dosing, safety, LAST toxicity. See Core Revision.

The PRONTO trial this week delivers the largest NHS ED sepsis biomarker RCT ever run — 20 English and Welsh departments, 5,453 patients — with a mortality signal that will be hard to ignore even though the mechanism of benefit is unknown. Simultaneously, the ATLAS IPD meta-analysis in Lancet consolidates the case for EVT in large-core LVO stroke across the full 24-hour window, with implications for every ED that makes acute stroke triage decisions. In paediatrics, a small but dramatic RCT of dexamethasone in severe CAP achieves an NNT of 3 for treatment failure — a result that demands replication but is difficult to dismiss. And from your EMA Daily and JournalFeed inboxes this week: ketamine for acute pain may have a downstream effect on PTSD at 6 months, and a systematic review upgrades the clinical signs for sepsis in young infants beyond the standard WHO criteria.

WHAT’S INSIDE — ISSUE 14

Section 1 — Trials & Research: PRONTO trial (LEAD) · ATLAS IPD meta-analysis large-core LVO stroke · Mothership vs Drip-and-Ship SR/MA · Ketamine reduces PTSD at 6 months · Eclampsia prodromal symptoms Section 2 — Guidelines & UK: UKHSA Hantavirus update · NICE NG258 Anaphylaxis update (two AAIs, obs criteria) · MHRA DSI/2026/004 Allurion gastric balloon · MHRA FSNs Section 3 — Paediatric EM: Dexamethasone for severe paeds CAP (RCT, NNT 3) · Infant sepsis warning signs SR/MA · CT vs CXR for paediatric foreign body aspiration Quick Hits · Core Revision: Nerve Blocks 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] PRONTO Trial — PCT + NEWS2 in UK ED Suspected Sepsis: No ABx Reduction, But Mortality Benefit (NNT 33 at 28d, NNT 26 at 90d) 2. ATLAS IPD Meta-Analysis — EVT for Large-Core LVO Stroke up to 24h: aOR 1.63 for Functional Independence, Mortality RR 0.65 (Lancet) 3. Mothership vs Drip-and-Ship for LVO Stroke — SR/MA: Direct Transfer to Comprehensive Centre Superior (Ann Emerg Med) 4. Ketamine for Acute Traumatic Pain Reduces PTSD and Anxiety at 6 Months — RCT (J Trauma, EMA Daily) 5. Eclampsia Prodromal Symptoms — 10 Neurological Signs Predict Eclampsia, Informing Magnesium Prophylaxis

SECTION 2 — GUIDELINES & UK UPDATES

6. UKHSA Hantavirus (MV Hondius) — Outbreak Status Update 7. NICE NG258 Anaphylaxis Update — Two AAIs at Discharge, Revised Observation Criteria (CHANGE TONIGHT) 8. MHRA DSI/2026/004 — Allurion Gastric Balloon: Acute Abdominal Emergency Risk (CHANGE TONIGHT) 9. MHRA FSNs 22–28 May 2026 (DSI/2026/003 Reissued)

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

8. Adjunctive Dexamethasone for Severe Paediatric CAP — RCT: NNT 3 for Treatment Failure at 72h (JournalFeed)

9. Clinical Signs for Sepsis and Mortality in Young Infants — SR/MA: Poor CRT and Cyanosis Add to WHO Signs (JAMA Paediatrics, EMA Daily) 10. Low-Dose CT vs CXR for Paediatric Foreign Body Aspiration — CT More Sensitive, CXR Misses Diagnoses (J Pediatr, EMA Daily)

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

SECTION 1 — KEY JOURNAL ARTICLES & TRIALS

LANCET RESPIRATORY MEDICINE · MARCH 2026 (EPUBLISHED) · PHASE 3 RCT · 20 NHS EDS · LEAD ITEM · JOURNALFEED 28 MAY 2026

PRONTO Trial — Procalcitonin + NEWS2 in UK ED Suspected Sepsis: No Reduction in Antibiotic Use, But Robust 28-Day Mortality Benefit (NNT 33) Across 5,453 Patients

RCT CHANGE THIS MONTH UK FRCEM LEAD

• No diff IV ABX AT 3H (48.4% VS 48.2%)
• NNT 33 28D MORTALITY (13.6% VS 16.6%)
• NNT 26 90D MORTALITY (20.0% VS 23.8%)
• n=5,453 20 EDS, ENGLAND & WALES

Outcome

PCT+NEWS2

NEWS2 only

Effect

IV antibiotics at 3h (co-primary)

48.4%

48.2%

ARD −0.08pp, p=0.95 — NOT significant

The PRONTO trial (Todd S et al, Lancet Respir Med 2026, epublished 22 March) is the largest NHS emergency department biomarker RCT ever conducted in suspected sepsis. It enrolled 5,453 adults at 20 EDs across England and Wales. Participants were ≥16 years managed as suspected sepsis (NEWS2-triggered assessment) and were randomised 1:1 to PCT + NEWS2 versus NEWS2 alone. The PCT guidance algorithm used three thresholds (<0.5, 0.5–1.9, ≥2.0 μg/L) to risk-stratify and provide clinicians with a guidance recommendation — but clinicians were not compelled to follow it (point-of-care, guidance-only). Clinicians actually considered the PCT result in 64.7% of PCT-arm participants. Co-primary endpoint 1: IV antibiotic initiation at 3h — 48.4% vs 48.2% (not significant, p=0.95). Co-primary endpoint 2: 28-day mortality (non-inferiority comparison) — 13.6% vs 16.6% (ARD −3.12 percentage points; met both non-inferiority and superiority criteria; p=0.0009). 90-day mortality: 20.0% vs 23.8% (p=0.0018). No reduction in total antibiotic days, antibiotic-related adverse outcomes, or time to antibiotics. UK context: NEWS2 is embedded in all NHS EDs. Point-of-care PCT analysers (e.g. Biomérieux miniVIDAS, Roche cobas) are available in many UK labs and some ED point-of-care settings. This is the first RCT to demonstrate a mortality benefit from PCT-guided sepsis management in a UK ED population using NEWS2 as the baseline standard.

Critical appraisal: The trial has a critical interpretive puzzle: PCT + NEWS2 did not change antibiotic prescribing (same rate at 3h, same total days), yet mortality fell significantly. This dissociation is unexplained. Possible explanations include: (1) diagnostic re-classification — clinicians reconsidered non-infectious diagnoses in low-PCT patients, leading to better-targeted management; (2) performance effect — point-of-care PCT prompts clinicians to examine the patient more rigorously; (3) chance, despite large n and p=0.0009. The trial was open-label and clinicians knew the PCT result; performance bias cannot be excluded. PRONTO was designed primarily as a stewardship trial (reduce antibiotics) — the stewardship endpoint was negative. The mortality benefit was the secondary non-inferiority comparison that unexpectedly became the dominant result. GRADE: Moderate (large pragmatic RCT, mechanistically unexplained, open-label). This result demands replication and mechanistic investigation before universal adoption, but is sufficiently robust to start the conversation with your sepsis lead about PCT pathway implementation.

Why it matters: If the mortality benefit is real and reproducible, PCT + NEWS2 would represent the most impactful ED sepsis intervention since early antibiotics — reducing mortality by 3 percentage points in a population with ~15% mortality means preventing roughly 1 death per 33 treated patients. Point-of-care PCT is already available in many UK EDs and is NICE-approved for guiding antibiotic use in some respiratory infection contexts. PRONTO provides the evidence base for NHS-wide pilot implementation in suspected sepsis triage.

Tell your department: Discuss PRONTO at your next departmental governance or sepsis committee meeting. Key questions for your department: (1) Do you have access to point-of-care PCT? (2) Is your current sepsis pathway purely NEWS2-based? (3) Would a PCT-adjunct pilot be feasible at your trust? Do not change practice unilaterally — this requires a structured implementation plan. Monitor for NICE surveillance response to PRONTO (it will be triggered; existing NICE guidance on PCT for lower respiratory tract infection is NG120). Also watch for SSC 2026 updates in response to this trial.

Source: Todd S et al. Lancet Respir Med 2026 — PRONTO Trial · Critical Care Reviews trial summary · JournalFeed EM, 28 May 2026

LANCET · MAY 2026 · IPD META-ANALYSIS · PMID 42107392 · MCMASTER EVIDENCE ALERTS 6/7 (22 MAY 2026)

ATLAS IPD Meta-Analysis — EVT for Large-Core LVO Ischaemic Stroke up to 24h: Functional Independence aOR 1.63, Mortality RR 0.65 — Transforms Large-Core Stroke Triage

SR/MA CHANGE THIS MONTH FRCEM

• aOR 1.63 FUNCTIONAL INDEPENDENCE (MRS 0–2)
• RR 0.65 MORTALITY (95% CI 0.50–0.84)
• Higher sICH DOES NOT OUTWEIGH BENEFIT
• 7 RCTs IPD, ASPECTS 0–5 / CORE ≥50ML

The ATLAS individual patient data (IPD) meta-analysis (Sarraj A et al, Lancet 2026; PMID 42107392; McMaster score 6/7) pooled patient-level data from all 7 large-core LVO stroke trials (ASPECTS 0–5 or ischaemic core volume ≥50 mL) examining endovascular thrombectomy (EVT) versus best medical management. The analysis includes patients presenting up to 24 hours from onset. Primary outcome: ordinal mRS shift at 90 days — adjusted common OR 1.63 (95% CI 1.29–2.06) in favour of EVT. Functional independence (mRS 0–2): improved with EVT. Mortality: adjusted RR 0.65 (95% CI 0.50–0.84). sICH was higher with EVT but did not negate the net clinical benefit. Benefit was consistent across both the early (0–6h) and late (6–24h) windows, in older and younger patients, across different hemispheres, and in patients with core volumes up to 150 mL. UK context: Most UK stroke networks have previously applied conservative selection criteria for large-core LVO strokes — some centres used ASPECTS <6 as a relative contraindication to EVT. ATLAS, alongside ANGEL-ASPECT, RESCUE-Japan LIMIT, and SELECT2, provides the definitive evidence base that EVT confers net benefit in large-core LVO stroke. NICE NG128 (Stroke) surveillance review is expected to incorporate these data. UK EDs that receive large-core LVO strokes on transfer or bypass directly should review their pathway: ASPECTS alone should not preclude EVT referral.

Critical appraisal: IPD meta-analyses are the highest-quality evidence synthesis. The consistency across imaging modalities, ASPECTS scores (including 0–2), core volumes, geographies, and time windows is remarkable. sICH increased, consistent with earlier trial data — but mortality was lower and functional outcomes were better. The key limitation: most individual trials were conducted in high-volume stroke centres with significant operator experience; generalisability to lower-volume UK centres requires consideration. The benefit held regardless of mismatch profile, which is significant — it means you do not need sophisticated perfusion imaging to justify EVT referral in large-core LVO. GRADE: High (IPD from 7 RCTs).

Tell your department: Review your acute stroke triage pathway and criteria for EVT referral bypass. Large-core LVO stroke (ASPECTS ≤5 or estimated core ≥50mL on CTP) should not be withheld from EVT referral on the basis of core size alone. Contact your regional stroke network and hyper-acute stroke unit (HASU) to confirm they have updated their referral criteria in line with ATLAS. For time-zero ED decisions: if ASPECTS is low and LVO is confirmed/suspected, refer/bypass to HASU regardless — do not manage expectantly in the local ED.

Source: Sarraj A et al. Lancet 2026 — ATLAS IPD Meta-Analysis (PMID 42107392) · McMaster Evidence Alerts 6/7 (22 May 2026)

ANN EMERG MED · MAY 2026 · SR/MA · PMID 42084585 · MCMASTER EVIDENCE ALERTS 5/7 (24 MAY 2026)

Mothership vs Drip-and-Ship for LVO Stroke EVT — SR/MA: Direct Transfer to Comprehensive Centre Associated With Better Outcomes

SR/MA CHANGE THIS MONTH FRCEM

Guo L et al (Ann Emerg Med 2026; PMID 42084585; McMaster score 5/7) conducted a systematic review and meta-analysis comparing two out-of-hospital referral pathways for patients with acute ischaemic stroke due to large vessel occlusion (AIS-LVO): (1) Mothership — direct transfer to a comprehensive stroke centre (CSC) with EVT capability; (2) Drip-and-ship — initial assessment at a primary stroke centre (PSC) followed by transfer to a CSC after IV thrombolysis is initiated. The mothership strategy was associated with shorter onset-to-groin-puncture time and better functional outcomes across most analyses. The drip-and-ship strategy involves an additional care handover, additional transfer time, and potentially sub-optimal IV thrombolysis bridging. UK context: The UK

Major Trauma Network model already supports bypass of local EDs for major trauma; a similar rationale applies to LVO stroke. UK ambulance services (SWAST, NEAS, EMAS, etc.) use established stroke bypass protocols, but these vary by region and some use drip-and-ship by default when transport times to CSC are long. This SR/MA, combined with ATLAS, strengthens the case for mothership as the default strategy for LVO stroke when achievable within a clinically reasonable timeframe (≤60 min additional transport time to CSC vs local PSC).

Tell your department: If your ED receives stroke patients via drip-and-ship transfer, audit your door-to-CT and door-to-transfer times. Consider whether your regional stroke network could support a direct-to-CSC bypass protocol for high-likelihood LVO features. The key ED intervention: when a patient presents with FAST-positive symptoms and you suspect LVO (NIHSS ≥6, gaze deviation, severe limb weakness), initiate the CT and CSC pathway simultaneously — do not wait for local assessment to complete before alerting the CSC.

Source: Guo L et al. Ann Emerg Med 2026 — Mothership vs Drip-and-Ship SR/MA (PMID 42084585) · McMaster Evidence Alerts 5/7 (24 May 2026)

J TRAUMA ACUTE CARE SURG · FEBRUARY 2026 · RCT · PMID 41417647 · EMA DAILY 25 MAY 2026

Ketamine for Acute Traumatic Pain Reduces PTSD and Anxiety Symptoms at 6 Months — Prospective Double-Blind RCT

RCT INFORMING FRCEM

Trevino et al (J Trauma Acute Care Surg 2026; PMID 41417647) conducted a prospective, randomised, double-blind, placebo-controlled trial at a Level 1 trauma centre. Patients admitted with acute traumatic injury receiving standard analgesia were randomised to adjustable-dose ketamine infusion versus placebo for acute pain management during admission. Quality of life and psychological outcomes (PTSD, anxiety, depression) were assessed at 6 months using validated instruments (PCL-5, DASS-21). The ketamine group showed significantly lower PTSD symptom scores and anxiety at 6 months, with the effect most notable in re-experiencing symptoms. Depression and chronic pain outcomes were not significantly different. UK context: PTSD after traumatic injury is underdiagnosed and undertreated in ED follow-up pathways. The hypothesis that sub-dissociative ketamine, by blocking NMDA receptor-mediated encoding of traumatic memories at the time of injury, could reduce the risk of subsequent PTSD is biologically plausible (supported by existing PTSD ketamine therapy research). The EMA commentary appropriately flags: small sample size, significant attrition at 6 months, PTSD and anxiety were secondary outcomes, and confounders including subsequent opioid use and psychosocial support were not controlled. This is hypothesis-generating, not practice-changing.

Critical appraisal: This trial is not ready to change how you use ketamine in acute trauma. The PTSD and anxiety findings were secondary outcomes with the trial powered for pain. Attrition by 6 months was significant. The mechanism is plausible but the trial does not establish causality. What this result does: (1) builds the biological plausibility case for a definitive RCT; (2) raises the question of whether choice of analgesia in the acute setting has downstream psychosocial consequences worth considering. GRADE: Very Low for PTSD/anxiety outcomes (secondary, underpowered, high attrition).

Source: Trevino CM et al. J Trauma Acute Care Surg 2026 (PMID 41417647) · EMA Daily, 25 May 2026

PLOS MEDICINE · APRIL 2026 · CASE-CONTROL STUDY · PMID 42048280 · JOURNALFEED EM 28 MAY 2026

Eclampsia Prodromal Symptoms — 10 Neurological Signs in 7 Days Before Seizure, Including UE Weakness, Visual Disturbance, and Confusion: Implications for Magnesium Prophylaxis

OBSERVATIONAL INFORMING FRCEM

Hastie R et al (PLoS Med 2026; PMID 42048280) conducted a prospective two-country (South Africa and Pakistan) case-control study of women with eclampsia, pre-eclampsia without seizure, or normotensive pregnancies. 20 neurological symptoms were systematically enquired about for the 7 days before the index event. 10 symptoms were significantly more common in women who developed eclampsia compared to pre-eclampsia without seizure: visual disturbance (blurred vision, flashing lights), severe frontal headache, confusion, altered consciousness, upper limb weakness, and several others. These findings strengthen the evidence base for earlier, more liberal use of magnesium sulfate prophylaxis (which halves eclampsia risk) in women with pre-eclampsia reporting these symptoms. UK context: Magnesium sulfate prophylaxis for pre-eclampsia is currently guided by severity criteria (BP, proteinuria, symptoms). This study suggests that neurological symptom inquiry should be systematically expanded beyond the traditional "headache, visual disturbance" pair to include upper limb weakness, confusion, and altered consciousness. EDs receiving pregnant women with acute neurological symptoms should have a high index of suspicion for pre-eclampsia/eclampsia regardless of BP at triage (BP can be intermittently normal early).

Tell your department: For any pregnant woman (>20 weeks) presenting with neurological symptoms — headache, visual disturbance, confusion, upper limb weakness — check BP immediately and repeat it. A single normal BP does not exclude pre-eclampsia. If BP ≥140/90 at any point, check urine for proteinuria, consult obstetrics, and consider magnesium sulfate. Do not wait for a threshold neurological event before initiating the obstetric pathway.

Source: Hastie R et al. PLoS Med 2026 — Eclampsia Prodromal Symptoms (PMID 42048280) · JournalFeed EM, 28 May 2026

SECTION 2 — GUIDELINES & UK UPDATES

UKHSA / WHO / JAMA · WEEK OF 22–28 MAY 2026 · OUTBREAK UPDATE

Hantavirus MV Hondius Outbreak — Status Update: UK Community Risk Remains Very Low; WHO Perspective on Pandemic Preparedness Lessons Published in JAMA

UK SAFETY

As of 28 May 2026, the MV Hondius Andes hantavirus outbreak has not produced further confirmed UK cases beyond the repatriated group. All UK contacts undergoing monitoring have now passed or are approaching the end of the 40-day maximum incubation window without developing symptomatic infection. The specialist HCID unit at Guy’s and St Thomas’ reports its admitted patient remains clinically stable. UKHSA has not published a new major alert this week. Importantly, a JAMA Perspective (Hertelendy A, Gostin L, Ciottone G; PMID 42189668; published 26 May 2026) uses the MV Hondius outbreak to examine global health preparedness vulnerabilities, calling for improved international operational authority and cross-jurisdictional coordination for HCID events. UK ED relevance: the outbreak is transitioning to closure phase for UK clinicians, but maintain awareness — any patient presenting with ARDS and travel history to South America within the past 40 days warrants HCID screening. As of the date of this newsletter, no new UKHSA alerts had been issued for this event in the 22–28 May window.

Source: UKHSA Hantavirus Rolling Update · Hertelendy A et al. JAMA 2026 — MV Hondius Pandemic Preparedness Perspective (PMID 42189668)

NICE · 27 MAY 2026 · GUIDELINE UPDATE · NG258

NICE NG258 Anaphylaxis Update — New Observation Period Recommendations, Revised Admission Criteria, Updated Adrenaline Auto-Injector Prescribing Standards

GUIDELINE CHANGE TONIGHT UK FRCEM

NICE published an update to NG258 (Anaphylaxis) on 27 May 2026 incorporating recommendations from three sources: RCUK 2021 guidance (observation periods), MHRA communications (AAI prescribing), and updated BSACI position statements. The three key changes with immediate ED impact are: (1) Observation period (Rec 1.1.11) — Updated criteria for which patients require extended observation versus discharge at 4 hours. The revised recommendation specifically identifies high-risk features requiring a longer observation period: previous biphasic reaction, severe presentation requiring more than one adrenaline dose, asthma or respiratory comorbidity, reaction to venom or food allergens with unknown threshold. (2) Admission criteria — Clearer criteria for overnight admission versus 4-hour ED discharge with safety-netting; the revision emphasises shared decision-making with the patient and carer. (3) AAI prescribing at discharge (Rec 1.1.15) — Updated to align with current MHRA recommendations: two AAIs should be prescribed at discharge (not one), with written action plan; the prescriber should confirm the patient and carer can use the device before discharge. UK context: NG258 is the primary national standard for anaphylaxis management in NHS EDs. Any ED whose anaphylaxis protocol was last reviewed before May 2026 should update it against the new version now. The observation period changes are operationally significant — they affect patient flow and discharge decision-making.

Action required — review your protocol tonight: (1) Check your department’s anaphylaxis protocol observation period criteria against the new NG258 Rec 1.1.11. (2) Ensure all anaphylaxis discharges include prescription of two AAIs (e.g. two EpiPen 300 mcg or Jext 300 mcg) plus a written anaphylaxis action plan. Single AAI prescriptions at discharge are now explicitly insufficient per updated NICE guidance. (3) Confirm device demonstration is documented before discharge. (4) Ensure allergen referral is arranged for all new anaphylaxis presentations. NICE NG258 update is live at nice.org.uk.

Source: NICE NG258 — Anaphylaxis: Updated May 2026

MHRA · 27 MAY 2026 · DEVICE SAFETY INFORMATION · DSI/2026/004

MHRA DSI/2026/004 — Allurion Swallowable Gastric Balloon: Risk of Acute Abdominal Emergency — Patients May Not Volunteer Its Presence

UK SAFETY CHANGE TONIGHT

MHRA Device Safety Information DSI/2026/004 (27 May 2026) alerts clinicians to acute abdominal complications in patients with the Allurion (formerly Elipse) swallowable gastric balloon in situ. The Allurion balloon is swallowed as a capsule (no endoscopy required), self-inflates in the stomach, and is designed to deflate and pass spontaneously after approximately 16 weeks. Complications causing acute ED presentations include: bowel obstruction from early or incomplete deflation; gastric perforation; small bowel obstruction if the deflated balloon fails to pass; and pancreatitis from balloon migration. Critically: patients may not volunteer the presence of the balloon, as it is perceived as a consumer weight-loss product rather than a medical device. It does not appear on standard drug/medication lists. UK context: the Allurion balloon is available privately in the UK and is increasingly common given NHS weight management pathway backlogs. An acutely unwell bariatric patient or any patient with unexplained acute abdominal pain, nausea, obstruction symptoms, or unexplained pancreatitis should be asked directly: “Have you swallowed or been given a weight-loss balloon in the last 6 months?”

Add to your differential: Allurion gastric balloon obstruction/perforation for: (1) acute abdominal pain in any patient with a history of private bariatric treatment; (2) unexplained small bowel obstruction; (3) unexplained pancreatitis; (4) patients presenting with nausea/vomiting who cannot identify a cause. Plain AXR may show a radiopaque balloon (the fill valve is visible); CT is definitive. Management: urgent surgical/GI referral. Do not attempt nasogastric deflation without specialist guidance.

Source: MHRA DSI/2026/004 — Allurion Gastric Balloon (27 May 2026)

MHRA · 22–28 MAY 2026

MHRA Field Safety Notices 22–28 May 2026 — DSI/2026/003 Blood Transfusion Giving Set Warning Reissued; Routine FSN Batch

UK SAFETY

The MHRA reissued DSI/2026/003 (blood transfusion giving set — first issued 20 May) on 28 May 2026 with updated manufacturer clarification: colour coding of IV and blood giving sets is not standardised across manufacturers, meaning visual checks alone are insufficient. Always verify by reading the product label. DSI/2026/002 (Namic/Kimal syringe recall) remains active. Routine FSN batch for 18–22 May and 25–29 May published; no additional Class 1 ED-relevant device recalls identified.

Source: gov.uk/drug-device-alerts — FSN batches 22–28 May 2026

SECTION 3 — PAEDIATRIC EMERGENCY MEDICINE

JOURNALFEED PAEDIATRICS · 27 MAY 2026 · RCT · IN PRESS

Adjunctive Dexamethasone for Severe Paediatric CAP — RCT: Treatment Failure at 72h Reduced from 60.6% to 25.8% (NNT 3), No Increase in Adverse Effects

RCT INFORMING PAEDS FRCEM

• NNT 3 TREATMENT FAILURE AT 72H
• 25.8% vs 60.6% DEXA VS PLACEBO (ARD 34.8%)
• No AE increase SAFETY: COMPARABLE BOTH GROUPS
• n=132 RCT, TERTIARY CENTRE, INDIA

This double-blind, placebo-controlled RCT (JournalFeed Paediatrics, 27 May 2026; paper in press, tertiary centre, South India) randomised 132 children admitted with severe community-acquired pneumonia (CAP) to 3 days of adjunctive dexamethasone versus placebo alongside standard antibiotics and supportive care. Primary endpoint: treatment failure at 72 hours (defined as deterioration in clinical/physiological parameters requiring escalation). Treatment failure: 17/66 (25.8%) in the dexamethasone group vs 40/66 (60.6%) in placebo — ARD 34.8%, NNT 3. No significant increase in adverse events in the dexamethasone group. Context: adjunctive corticosteroids in adult CAP are well-established (multiple SR/MAs show mortality benefit). Their role in paediatric severe CAP has been less clear. Dexamethasone is widely used in paediatric croup and bacterial meningitis; this extends that principle to pneumonia. UK context: children admitted with severe CAP in UK paediatric EDs typically receive antibiotics and supportive care; corticosteroids are not part of standard UK guidance for paediatric CAP (NICE NG143). This single-centre Indian trial provides early evidence for efficacy but cannot alone change UK practice.

Critical appraisal: The NNT of 3 is extraordinary and should prompt immediate scrutiny. Key limitations: single-centre, single-country (India) — patient population (nutritional status, pathogen mix, prior antibiotic exposure) may differ significantly from UK children. "Treatment failure" definition requires scrutiny: it includes physiological parameters that may be variably assessed. n=132 is small for a clinical trial on which practice change would be based. No long-term follow-up. GRADE: Low (single-centre, small n, limited generalisability). This is a compelling hypothesis-generating result — look for replication in UK/Western settings before routine adoption. Discuss with your paeds ID colleagues. The result is dramatic enough to consider a formal UK trial.

Why it matters: If this NNT of 3 holds in UK populations, adjunctive dexamethasone in severe paediatric pneumonia would be one of the most impactful paediatric ED interventions available. NICE NG143 (Pneumonia in children and young people) does not currently recommend corticosteroids — this trial should trigger a surveillance review. Monitor for replication.

Source: JournalFeed Paediatrics — Severe Paeds CAP + Dexamethasone RCT (27 May 2026) · Paper in press, tertiary centre South India

JAMA PAEDIATRICS · APRIL 2026 · SR/MA · PMID 41627835 · EMA DAILY 21 MAY 2026

Clinical Signs for Sepsis and Mortality in Young Infants — SR/MA: Poor CRT and Central Cyanosis Added to WHO Danger Signs, Most Signs Have Moderate Diagnostic Accuracy

SR/MA INFORMING PAEDS FRCEM

Driker S et al (JAMA Paediatrics 2026; PMID 41627835) conducted a systematic review and meta-analysis of clinical signs predicting sepsis and mortality in young infants (<60 days). The analysis confirms the value of existing WHO-recommended clinical danger signs (fast breathing, poor feeding, lethargy, temperature instability, bulging fontanelle, seizures) and adds two new candidate signs with meaningful diagnostic accuracy: poor capillary refill time (>3 seconds) and central cyanosis. Most individual signs have moderate sensitivity and specificity in isolation; combination of multiple signs significantly increases predictive value. The EMA editorial commentary notes the findings are most directly applicable to low-income and middle-income settings with limited laboratory access, but the clinical signs are worth knowing for any setting. UK context: in UK paediatric EDs, sepsis recognition in young infants relies on physiological parameters and clinical examination. This SR/MA validates CRT assessment and cyanosis inspection as meaningful bedside additions. A febrile infant under 60 days with CRT >3 seconds should prompt urgent blood cultures, FBC, CRP, and empiric IV antibiotics without delay.

Tell your department: For all unwell neonates and young infants (<60 days): explicitly assess and document CRT (press fingertip for 10 seconds, release, time to blanching — normal <2s in infants). Central cyanosis (assessed on lips, mucous membranes, tongue) should be noted separately from peripheral. CRT >3s or any central cyanosis in a febrile or unwell infant is a red flag requiring urgent escalation. Do not rely on SpO2 alone for cyanosis detection.

Source: Driker S et al. JAMA Paediatr 2026;180(4):384–393 (PMID 41627835) · EMA Daily, 21 May 2026

J PEDIATR · FEBRUARY 2026 · RETROSPECTIVE COHORT · PMID 41692225 · EMA DAILY 26 MAY 2026

Low-Dose CT vs CXR for Paediatric Foreign Body Aspiration — CT More Sensitive, CXR Misses Diagnoses; But Wide CIs and Study Limitations Require Caution

OBSERVATIONAL INFORMING PAEDS

Li R et al (J Pediatr 2026; PMID 41692225) conducted a single-centre retrospective review of 330 children evaluated for suspected foreign body aspiration (FBA) using CXR only (n=171), CT only (n=47), or both (n=112). Ultra-low-dose CT (ULDCT) demonstrated higher sensitivity and specificity for FBA compared to multiview CXR, with bronchoscopy rates confirming CT superiority in detection. CXR missed a significant proportion of FBA cases, particularly for radiolucent foreign bodies. The EMA editorial notes that while CT appears more reliable, the study has significant limitations: retrospective design, single centre, wide confidence intervals, and selection bias (sicker patients more likely to receive CT). UK context: current UK practice uses CXR with clinical assessment as the primary triage tool; CT (with radiation exposure) is reserved for equivocal cases with high suspicion.

The IRMER regulations in the UK mandate that any CT in children is clinically justified and optimised. This study supports a lower threshold for ULDCT when clinical suspicion is moderate-to-high and CXR is negative.

Source: Li R et al. J Pediatr 2026 — CT vs CXR for Paediatric FBA (PMID 41692225) · EMA Daily, 26 May 2026

SECTION 4 — FOAMED & CRITICAL APPRAISAL

EMA DAILY / JOURNALFEED · 22–28 MAY 2026

This Week in FOAMed — PRONTO JournalFeed Coverage, EMA Daily P-Values in Table 1, Cluster RCTs in EM Research

INFORMING

JournalFeed EM (28 May): PRONTO trial featured as the lead item. JournalFeed notes the paradox of the negative stewardship endpoint and positive mortality endpoint directly. EMA Daily (28 May) — P-values in Table 1 (PMID 41391426): Cole JB et al (Am J Emerg Med) argue that P-values in Table 1 (baseline characteristics) are misleading and should be replaced by clinical effect sizes. This is methodologically important for all EM clinicians appraising trials — an imbalanced Table 1 with a statistically significant P-value does not mean the trial is invalid; it is expected by chance in 5% of RCTs. Focus on clinical relevance of any imbalance, not statistical significance. EMA Daily (27 May) — Cluster-RCTs in Emergency Care (PMID 41157894): A methodological review from Northwestern University provides a clinician-oriented guide to interpreting cluster-randomised trials, which are increasingly common in ED research (e.g. quality improvement studies, pathway studies). Understanding allocation unit (cluster vs individual) and intra-class correlation (ICC) is essential for appraising such trials correctly.

Source: JournalFeed EM, 28 May 2026 · Cole JB et al. Am J Emerg Med 2026 (PMID 41391426) · EMA Daily, 28 May 2026

SECTION 5 — QUICK HITS

PUBMED EM JOURNALS ALERT · AM J EMERG MED · MAY 2026 · PMID 42190636

Early vs Delayed Opioid in Paediatric Sickle Cell Vaso-Occlusive Crisis — SR/MA: Early Administration Reduces Pain and Length of Stay

Khalid A et al (Am J Emerg Med 2026; PMID 42190636) — SR/MA demonstrating that early opioid administration in paediatric sickle cell vaso-occlusive crisis (within 30 minutes of arrival) is associated with reduced pain scores at 60 minutes and shorter ED length of stay compared to delayed administration. UK context: NICE NG143 (Sickle cell disease, acute painful episode) recommends analgesia within 30 minutes — this SR/MA provides meta-analytic support for that target. If your ED does not have a dedicated sickle cell acute pain protocol with a 30-minute opioid target, this provides evidence to develop one. PMID 42190636

UKHSA · WEEK 20/21 · ONGOING

Mpox Clade Ib — UKHSA Monitoring Ongoing; 3 UK Cases Year to Date, No ED-Relevant Cluster

UKHSA continues to monitor mpox clade Ib (the more severe DRC strain) at the national level. As of week 21 2026, 3 UK cases confirmed year-to-date, all travel-associated. No community transmission detected in the UK. ED relevance: maintain awareness for patients presenting with atypical rash (especially genital, oral, periorbital) with DRC/central African travel history. Notify UKHSA HPT if suspected; isolate promptly; PCR for confirmation.

MHRA / NICE · ONGOING

NICE NG253 Sepsis Update — Expected July 2026; SSC 2026 + PRONTO Will Inform Surveillance Review

NICE NG253 (Sepsis) surveillance review is expected in July 2026. The PRONTO trial (this issue’s LEAD), the SSC 2026 guidelines (Issue 13), and evolving evidence on PCT and lactate-clearance monitoring are all expected to be incorporated. This will be the most significant NICE sepsis update since NG51 (2016). Ensure your department is aware and that your sepsis lead is tracking NICE communications.

PUBMED EM JOURNALS ALERT · EMJ · MAY 2026 · PMID 42185029

POCUS Superiority Over CXR for Soft Tissue Foreign Bodies in the Extremities: Systematic Review (EMJ)

Philippou P, Darbyshire D (Emerg Med J 2026; PMID 42185029) — systematic review confirming that POCUS is significantly more sensitive than plain radiography for detecting radiolucent soft tissue foreign bodies (wood, plastic, organic material) in the extremities. UK EDs with POCUS capability should consider this the first-line imaging modality when clinical suspicion for a soft tissue foreign body is high and plain films are negative. Radiolucent FBs are commonly missed on CXR/plain films and are a significant source of missed diagnosis claims. PMID 42185029

CORE REVISION — NERVE BLOCKS IN THE ED

FRCEM REVISION — NERVE BLOCKS IN THE ED: A PRACTICAL GUIDE

Regional anaesthesia in the ED reduces systemic opioid requirements, provides superior analgesia for specific injuries, and has an excellent safety profile when performed correctly. This revision covers the most commonly examined and clinically relevant blocks for emergency medicine.

ACTION POINTS — ISSUE 14

• NICE NG258 Anaphylaxis — update your protocol tonight: (1) Review your observation period criteria against updated Rec 1.1.11 — high-risk features including biphasic history, multiple adrenaline doses, asthma, or unknown allergen threshold require extended observation. (2) Prescribe TWO AAIs at discharge, not one — this is now the explicit NICE standard. (3) Document device demonstration before discharge. (4) Arrange allergen referral for all new diagnoses. [NICE NG258, updated 27 May 2026]
• Allurion gastric balloon — add to acute abdomen differential: In any patient with unexplained abdominal pain, small bowel obstruction, unexplained pancreatitis, or nausea/vomiting, ask: “Have you swallowed or been given a weight-loss balloon in the last 6 months?” They may not volunteer it. Plain AXR (fill valve visible) or CT for diagnosis. Surgical/GI referral. [MHRA DSI/2026/004, 27 May 2026]
• PRONTO — start the conversation: Discuss the PRONTO trial result with your sepsis lead and clinical lead. Key question: does your ED have access to point-of-care PCT? If yes, is there a pathway for integrating it alongside NEWS2? Do not change practice unilaterally. Monitor for NICE NG253 surveillance (expected July 2026) incorporating PRONTO data. [Lancet Respir Med 2026]
• Large-core LVO stroke — update triage criteria: ASPECTS ≤5 or ischaemic core ≥50mL on imaging should NOT automatically preclude EVT referral. Review your stroke bypass/triage protocol with your regional HASU. ATLAS IPD provides definitive evidence: EVT up to 24h improves functional independence and reduces mortality even in large-core LVO. [Lancet 2026, PMID 42107392]
• LVO stroke — mothership protocol: For high-suspicion LVO stroke, direct transfer to comprehensive stroke centre (mothership) is superior to drip-and-ship in most scenarios. Review your ambulance service bypass protocol. For patients already in your ED with confirmed LVO: expedite transfer to EVT centre without delay for IV thrombolysis at your site when EVT is within reach. [Ann Emerg Med SR/MA, PMID 42084585]
• Paeds sickle cell crisis — 30-minute opioid target: Ensure your department has a paediatric sickle cell acute pain protocol with analgesia (opioid) within 30 minutes of arrival. This is already in NICE NG143 — this SR/MA provides meta-analytic validation. Measure your current compliance with this target. [Am J Emerg Med SR/MA, PMID 42190636]
• Young infant sepsis signs: For any febrile or unwell infant <60 days, explicitly assess and document CRT and inspect for central cyanosis. CRT >3s or central cyanosis = immediate escalation for blood cultures, FBC, CRP, and empiric IV antibiotics. [JAMA Paediatrics SR/MA, PMID 41627835]
• Eclampsia — expand neurological history: In pregnant women (>20 weeks) presenting with ANY neurological symptom (headache, visual disturbance, confusion, upper limb weakness, altered consciousness), measure BP immediately and repeat. Do not rely on a single normal BP reading to exclude pre-eclampsia. [PLoS Med, PMID 42048280]
• Nerve blocks — build department capability: FICB is NICE-mandated for hip fractures (NG124). If your department does not perform FICB routinely, this is a governance priority. Consider training needs assessment and simulation for digital nerve blocks, haematoma blocks, and WALANT. Ensure Intralipid 20% is immediately accessible in any area where blocks are performed. [Core Revision]

TRIALS TO WATCH

UPCOMING TRIALS & GUIDELINE MILESTONES

Q2–Q3 2026

NICE NG253 Sepsis Surveillance Review — expected July 2026: Will incorporate SSC 2026 Guidelines, PRONTO trial, and evolving PCT/lactate evidence. The most significant NICE sepsis update in a decade. Monitor NICE communications closely. NICE NG128 Stroke — Late Window Surveillance Review: OPTION trial (Issue 12), ATLAS IPD (this issue), and HOPE-ASiS data feeding into NICE surveillance. UK stroke networks should not change large-core stroke criteria unilaterally before NICE guidance updates. NICE NG185 Chest Pain — LEGEND Trial Response: hs-cTnT assay threshold update expected. Watch for NICE/ESC alignment on new platform-specific cut-offs. HSSIB Mental Health Crisis ED Full Report (Part 2) — due summer 2026: Will address ED environment, knowledge gaps, and admission/discharge decision-making. Part 1 (April 2026) identified the legislative gap on holding powers; Part 2 will make systemic recommendations.

2026–2027

BACHb — HFNC vs CPAP vs Standard O2 in Bronchiolitis (50 NHS hospitals): Multicentre UK trial. Will define optimal respiratory support for infants with bronchiolitis. CoMiTED — Conservative vs Chest Drain in Traumatic Pneumothorax (UK): Ongoing. Direct RCEM guideline relevance. BEST-DKA — Balanced Electrolyte vs Saline in Adult DKA (Australia, Phase 3): Will settle the adult DKA fluid debate. Results awaited. NHS Mental Health Act Reform (Mental Health Bill 2025–26): Parliamentary progress ongoing. HSSIB R/2026/082 calls for urgent legislative fix to ED holding power gap.

LONGER HORIZON

On-Scene ECPR (Netherlands) — Prehospital ECPR in Refractory OHCA: Landmark trial; positive result would generate significant pressure for ECPR capability at UK cardiac arrest centres. PEERLESS II — Mechanical Thrombectomy vs Anticoagulation in Intermediate-Risk PE: Will complement HI-PEITHO data on catheter-based strategies.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 14 — 28 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