EMERGENCY MEDICINE EVIDENCE RUNDOWN
EM Evidence Rundown
Issue 19 · 2 July 2026 · UK Edition
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.
The full archive of every issue is available at emevidence.org — including audio summaries and PDF downloads.
PAEDS LEAD PRoMPT BOLUS (NEJM, n=9,071): Balanced crystalloids vs 0.9% saline in
paediatric septic shock — equivalent outcomes. No fluid preference mandated.
CHANGE TONIGHT: MHRA June safety roundup — flucloxacillin recall (wrong PIL), gabapentin particulate contamination. | CHANGE THIS MONTH: SSC 2026 adult guidelines — earlier vasopressors, source control within 6h. | Cefazolin now non-inferior to oxacillin for MSSA bacteraemia (NEJM, n=454).
BOTTOM LINE UP FRONT — ISSUE 19
ACT ON THIS NOW
TONIGHT MHRA: Flucloxacillin 500mg recall (wrong PIL). MHRA Gabapentin oral solution — particulate contamination. Check ED stock.
TONIGHT UKHSA VHF alert: Glasgow suspect Ebola case 30 June (cleared). Apply VHF algorithm to all febrile returning travellers from DRC/Uganda. Isolate immediately.
THIS MONTH Sepsis 2026: SSC guidelines — vasopressors earlier after initial bolus; source control target 6h.
THIS MONTH MSSA bacteraemia: Cefazolin non-inferior to oxacillin — switch if flucloxacillin unavailable.
THIS MONTH Paeds sepsis fluids: PRoMPT BOLUS — balanced vs saline equivalent (n=9,071). Follow local protocol.
THIS MONTH RCEM QIP: New time-critical medication report — review local compliance.
KNOW FOR NEXT TIME
GUIDELINE NICE NG258 Anaphylaxis: 3 tryptase samples now required (30-120 min, 3-4h, baseline). 4-6h observation minimum. Allergy referral mandatory.
GUIDELINE SSC paeds 2026: Phoenix criteria adopted; fluid bolus targets resource-stratified.
GUIDELINE LP + anticoagulation: UMEm — platelets >50, INR <1.5 before LP; bridging rarely needed in ED.
INFORMING Paeds POCUS: Ultrasound-guided catheterisation SR/MA — reduces failed first attempts.
INFORMING Enteral Mg: Non-inferior to IV in critical illness — consider for stable ICU patients.
INFORMING VExUS: SR/MA confirms grading predicts renal outcomes — IVC gating may miss early ED congestion.
UK DATA MPs + ED violence: Early Day Motion tabled — RCEM calling for legislative protection.
PAEDS GASTRIC-PICU: Routine GRV monitoring in PICU — no benefit over symptom-driven approach.
This week's issue lands in a fortnight defined by landmark evidence and urgent operational alerts. PRoMPT BOLUS from NEJM — the largest ever paediatric septic shock trial (n=9,071) — settles the fluid-type debate for now. The 2026 Surviving Sepsis Campaign guidelines reshape antibiotic timing and vasopressor strategy. NICE has quietly replaced CG134 with NG258, changing how we document and follow up anaphylaxis. RCEM has quantified what many of us have feared: 15,860 deaths in England in 2025 linked to long ED waiting times, a tenfold increase in a decade. And tonight, two drug recalls demand an immediate ED stock check. A full issue.
WHAT'S INSIDE — ISSUE 19
01 Key Trials & Research · 7 items incl. LEAD · PRoMPT BOLUS, SSC 2026, Cefazolin, VExUS, Enteral Mg, GASTRIC-PICU, REBOARREST 02 Guidelines & UK Updates · 6 items · MHRA drug recalls, RCEM 15,860 deaths/QIP data, NICE NG258 Anaphylaxis, UKHSA VHF alert 03 Paediatric EM · 4 items · PRoMPT BOLUS, SSC Paeds 2026, Paeds POCUS catheterisation, GASTRIC-PICU 04 FOAMed & Critical Appraisal · 3 items · PulmCCM ARISE-FLUIDS follow-up, LP in coagulopathy, Airway in obesity 05 Quick Hits · 4 items 06 Core Revision: Acute Kidney Injury in the ED 07 Action Points · 08 Trials to Watch
TAG LEGEND
01 — KEY JOURNAL ARTICLES & TRIALS
NEW ENGLAND JOURNAL OF MEDICINE · PECARN/PERC/PREDICT · 24 APRIL 2026
PRoMPT BOLUS: Balanced Crystalloids vs 0.9% Saline in Paediatric Septic Shock — Equivalent on All Outcomes
- 3.4% vs 3.0% MAKE30 — ARD +0.4%
- NS NO NNT — NULL RESULT
- Equal MORTALITY + HOSP-FREE DAYS
- n=9,071 47 HOSPITALS, 5 COUNTRIES
PRoMPT BOLUS is the largest paediatric septic shock fluid trial ever conducted — 9,071 children aged 6 months to 17 years randomised to balanced crystalloids (lactated Ringer's or Plasmalyte) or 0.9% saline for initial resuscitation and maintenance fluids over 48 hours, across 47 hospitals in Australia, New Zealand, the US, Canada, and Costa Rica. The primary outcome was MAKE30 (death, new renal replacement therapy, or creatinine ≥200% baseline within 30 days).
The result is definitive: MAKE30 occurred in 3.4% (balanced) vs 3.0% (saline). Mortality was identical. Hospital-free days were identical. No subgroup showed a meaningful difference. The trial was adequately powered — this is not a precision problem, it is the answer.
CRITICAL APPRAISAL
The trial mirrors the adult data (SMART, SALT-ED, PLUS, BaSICS): balanced crystalloids and saline are functionally equivalent for clinically important outcomes. The physiological rationale for balanced fluids remains sound (avoiding hyperchloraemic acidosis), but the magnitude of benefit in real-world volumes is too small to detect. Notably, this is a multinational trial not directly UK-validated, and the Phoenix sepsis criteria used differ slightly from UK PEWS/NICE NG51 thresholds. Implementation friction is low — if you already use Hartmann's or Plasmalyte in paediatric sepsis, continue. If your department uses normal saline, this trial does not mandate an immediate switch, but physiological reasoning still favours balanced fluids where available.
WHY IT MATTERS FOR UK ED PRACTICE
This definitively reassures departments using normal saline in paediatric sepsis that they are not causing harm. It also closes the argument that balanced fluids must be used. The main lesson: focus on appropriate timing and volume of fluid, not fluid type. Use what is locally available and follow NICE NG51 / UK Sepsis Trust six goals. Where balanced fluids are available (most UK EDs), continue using them on physiological grounds.
TELL YOUR DEPARTMENT
Paediatric septic shock resuscitation: the fluid type (balanced vs saline) does not affect survival, renal outcomes, or length of stay. Fluid volume and timing matter more than type. Continue using your trust's standard fluid — no urgent formulary change needed.
Source: PRoMPT BOLUS Investigators, NEJM 2026 Apr 24. doi: 10.1056/NEJMoa2600200 | IBCC balanced vs saline: emcrit.org/ibcc/fluid/
CRITICAL CARE MEDICINE · SURVIVING SEPSIS CAMPAIGN · JUNE 2026
2026 Surviving Sepsis Campaign Adult Guidelines — Key ED Changes
The 2026 SSC update (129 total statements, 46 new) consolidates practice after the ARISE FLUIDS, BIHCA, SODa-BIC, and ANDROMEDA-SHOCK-2 era. Key changes relevant to UK EM:
| DOMAIN | 2021 GUIDANCE | 2026 CHANGE |
|---|---|---|
| Fluids | 30 mL/kg initial bolus | 30 mL/kg retained; dynamic assessment guides further resuscitation (not fixed volumes) |
| Vasopressors | After fluids | Earlier integration; peripheral IV vasopressor administration explicitly supported |
| Source control | Rapid (no specific time) | Source control within 6 hours where feasible — new time target |
| Antibiotics | Within 1 hour | Nuanced by NEWS2 risk: shock → immediate; non-shock high-risk
|
| Anaerobes | Broad empiric coverage | Suggest omitting anaerobic cover where no risk factors (intraabdominal, necrotising skin infection, gynae) |
| Deescalation | Suggestion | Upgraded to recommendation when susceptibilities available |
| Sepsis huddle | Not mentioned | New: code sepsis / sepsis huddle protocol suggested |
CRITICAL APPRAISAL
The 2026 SSC retains the 30 mL/kg initial bolus — explicitly acknowledging the observational evidence supporting it and the lack of harm in major RCTs. The move to dynamic assessment for further resuscitation is the important practical shift. The 6-hour source control target is aspirational rather than evidence-derived, but aligns with UK sepsis best practice. The antibiotic nuancing by NEWS2 risk band is a useful clarification that prevents overzealous 1-hour target application to lower-risk patients. Peripheral vasopressor endorsement is welcome and consistent with ARISE FLUIDS data.
WHY IT MATTERS FOR UK ED PRACTICE
The UK Sepsis Trust Sepsis Six remains the operational framework. SSC 2026 reinforces early vasopressors (consistent with what most UK resus teams already do) and adds the 6-hour source control target. The antibiotic guidance is important: you do not need to give antibiotics within 1 hour to all suspected sepsis — risk-stratify by NEWS2. High-risk patients (NEWS2 ≥5 + shock): immediate. NEWS2 3-4 without shock: 1 hour. Possible sepsis, low risk: short deliberate delay to confirm diagnosis is acceptable.
Source: Evans et al, Crit Care Med 2026. SSC 2026 Full Text | UK Sepsis Trust: sepsistrust.org
NEW ENGLAND JOURNAL OF MEDICINE · JUNE 2026 · PMID: 51829866
Cefazolin Non-Inferior to Oxacillin for MSSA Bacteraemia — A Practice-Changing RCT
- Non-inferior 90-DAY TREATMENT SUCCESS
- Fewer AEs LESS NEPHROTOXICITY
- OD dosing VS TDS OXACILLIN
- n=454 MULTICENTRE RCT
Methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia remains one of the most lethal ED diagnoses — 28-day mortality ~20–25%. Oxacillin/flucloxacillin has been first-line since the 1960s, but cefazolin offers significant practical advantages: once-daily dosing, less hepatotoxicity, lower nursing burden, and importantly, may now be preferred if flucloxacillin supply is interrupted (relevant in the context of today's MHRA recall).
This RCT randomised 454 adults with MSSA bacteraemia to cefazolin (2g TDS in the trial; OD regimens are also validated in observational data) vs oxacillin. 90-day treatment success (alive, no recurrence, no further MSSA bacteraemia) was non-inferior. Fewer adverse events occurred with cefazolin, particularly nephrotoxicity. Important for UK EDs: if your pharmacy is managing a flucloxacillin supply issue (see MHRA recall above), cefazolin is a formally validated alternative.
WHY IT MATTERS
MSSA bacteraemia empiric treatment in the ED: blood cultures + urgent infectious diseases involvement. If flucloxacillin not available (MHRA recall context), cefazolin 2g TDS IV is now RCT-validated. Switch with microbiology agreement. Cefazolin also crosses into OPAT programmes more easily, supporting earlier discharge.
Source: McMaster EvidenceAlerts, NEJM 2026 Jun 23. doi: 10.1056/NEJMoa2510047
CRITICAL CARE MEDICINE · SR/MA · JUNE 2026
VExUS Venous Excess Ultrasound Grading System — Diagnostic and Prognostic SR/MA
- Grade 2-3 PREDICTS AKI / POOR OUTCOMES
- IVC gating risk MISSES EARLY ED CONGESTION
- Observational NO RCT EVIDENCE YET
VExUS (Venous Excess Ultrasound Score) combines IVC diameter with pulsed-wave Doppler assessment of hepatic, portal, and intrarenal veins to grade venous congestion 0–3. This SR/MA in Critical Care Medicine pooled observational data and found Grade 2–3 VExUS reliably predicts AKI and poor outcomes in critical illness. However, an important caveat for ED use: the standard protocol requires IVC dilatation (≥2 cm) as an entry criterion before Doppler assessment, but in early ED sepsis, only ~24% of patients have IVC dilatation while 41% may have organ Doppler abnormalities — meaning the IVC-gated protocol may miss significant early congestion.
CLINICAL APPRAISAL: HOW TO USE VEXUS IN THE ED
VExUS is most useful post-resuscitation to guide fluid management, not as a routine first-pass assessment. In cardiogenic shock or decompensated heart failure, Grade 3 (monophasic renal Doppler + hepatic Doppler reversal) is a strong signal to withhold further fluids. In early sepsis, do not rely on IVC-gating alone — if hepatic or portal Doppler is abnormal without IVC dilatation, congestion may already be present. No RCT has shown VExUS-guided management improves outcomes yet.
Source: McMaster EvidenceAlerts, Crit Care Med 2026 Jun 25. VExUS review: Ultrasound Journal
CRITICAL CARE MEDICINE · NON-INFERIORITY RCT · JUNE 2026 · MCMASTER SCORE: 6/7
Enteral vs IV Magnesium Replacement in Critically Ill Adults — Non-Inferiority RCT
- Non-inferior MG REPLETION AT 72H
- Less IV access NURSING BURDEN REDUCED
- NGT only REQUIRES ENTERAL ACCESS
- ICU population NOT ACUTE ED RESUS
Hypomagnesaemia occurs in up to 65% of ICU patients and is associated with arrhythmias, prolonged ventilation, and seizures. IV replacement is standard but resource-intensive. This non-inferiority RCT (McMaster 6/7) showed enteral magnesium via NGT achieves equivalent serum levels at 72 hours vs IV replacement in haemodynamically stable ICU patients. No difference in clinical outcomes. For UK ED practice: this is relevant if you are managing patients on the SDEC or clinical decision unit with mild hypomagnesaemia who have NGT access — enteral replacement is appropriate and avoids IV access burden.
ED APPLICATION
Acute severe symptomatic hypomagnesaemia (arrhythmias, seizures): IV remains standard. Asymptomatic mild-moderate hypomagnesaemia in stable patients with NGT: enteral magnesium glycerophosphate or citrate is a reasonable ICU-adopted approach where NGT is already in situ.
Source: McMaster EvidenceAlerts 27 Jun 2026. Crit Care Med 2026.
CRITICAL CARE · INTERNATIONAL RCT · ST EMLYN'S CRITICAL APPRAISAL · JUNE 2026
REBOARREST: Prehospital REBOA in Non-Traumatic OHCA — No Benefit on Any Outcome
REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) was proposed as a way to improve coronary and cerebral perfusion during CPR in non-traumatic cardiac arrest by occluding the descending aorta. REBOARREST randomised patients to prehospital REBOA vs standard advanced life support. The result was comprehensively neutral: no difference in ROSC, survival to hospital, survival to discharge, or neurological outcome. The physiological rationale (increasing afterload to improve coronary and cerebral perfusion) was plausible, but REBOA insertion delays in the field and the complexity of the intervention appear to outweigh any haemodynamic gain.
CRITICAL APPRAISAL
This does not apply to traumatic cardiac arrest, where REBOA has ongoing evidence (UK-REBOA, Zone 1 occlusion for haemorrhagic arrest). The REBOARREST result is for non-traumatic OHCA only. ECPR (ECMO-CPR) remains the more promising intervention in selected refractory arrests (see Trials to Watch). For UK practice, prehospital REBOA for medical OHCA should not be adopted.
Source: St Emlyn's, stemlynsblog.org/reboarrest/
JAMA · PAEDIATRIC RCT · JUNE 2026 · MCMASTER SCORE: 5/7
GASTRIC-PICU: Routine Gastric Residual Volume Monitoring in PICU — No Benefit
- Null result NO BENEFIT FROM GRV MONITORING
- Symptom-driven SAME OUTCOMES
- PICU only ICU VENTILATED CHILDREN
Routine 4-hourly gastric residual volume (GRV) measurement in mechanically ventilated PICU patients does not improve feeding tolerance, reduce VAP, or improve outcomes compared with a symptom-driven approach (checking GRV only when clinical signs of intolerance). This mirrors adult ICU data. For ED departments managing intubated children awaiting PICU transfer: routine GRV monitoring is not evidence-based. Continue enteral feeds early; respond to clinical intolerance signs rather than arbitrary GRV targets.
Source: GASTRIC-PICU, JAMA 2026 Jun 29. McMaster EvidenceAlerts. JAMA link
02 — GUIDELINES & UK UPDATES
MHRA · SAFETY ROUNDUP · 30 JUNE 2026 + FIELD SAFETY NOTICES 22-26 JUNE 2026
MHRA June 2026 Safety Roundup — ED-Critical Drug Recalls and Alerts
ACTION REQUIRED — ED STOCK CHECK CLASS 3 RECALL: FLUCLOXACILLIN CAPSULES 500MG (FLAMINGO PHARMA) — Certain packs
contain the PIL for Amoxicillin 500mg instead of flucloxacillin. Risk of patient confusion and incorrect dosing instructions. Check your ED supply immediately. Flucloxacillin IV is unaffected; cefazolin is a validated alternative for MSSA (see Item 3).
CLASS 4 DEFECT: GABAPENTIN 50MG/ML ORAL SOLUTION (RELONCHEM) — Visible particles
observed inside bottles. Do not administer. Remove from stock and quarantine. Contact pharmacy. Gabapentin tablets are unaffected.
The MHRA June 2026 safety roundup also includes a benzylpenicillin benzathine injection notice (PIL outdated — no immediate patient risk). Review FSNs at gov.uk/drug-device-alerts. Alert your pharmacy team and charge nurses immediately.
Source: MHRA Flucloxacillin recall | MHRA Gabapentin defect
RCEM · MULTIPLE REPORTS · JUNE–JULY 2026
RCEM UK Data: 15,860 ED-Wait Deaths in 2025 — Plus Time-Critical Medication QIP Failures and New Delirium Screening Gaps
State of Emergency Medicine in England 2026 (8 June): RCEM estimates 15,860 excess deaths in England in 2025 were associated with long ED waiting times — a tenfold increase since 2015 (1,657 deaths). 489,138 patients waited 24 hours or more. Excess mortality risk begins rising after 5 hours; one excess death occurs per 72 patients waiting 8–12 hours. RCEM is calling for eradication of ED-wait-associated mortality by end of the decade. This is now the primary national patient safety argument for four-hour target restoration.
Time-Critical Medication QIP Year 2 (3 June): 66% of time-critical medication doses for Parkinson's (Levodopa) and diabetes (Insulin) were administered late in EDs; ~40% were missed entirely (given >6 hours late or not at all). Fewer than half (44.4%) of TCM patients were identified within 30 minutes of arrival. The QIP calls for automated triage flagging of TCM patients and dedicated prescribing/administration protocols. Delayed Levodopa causes irreversible deterioration in Parkinson's patients.
Care of Older People QIP Year 3 (16 June): 4 in 5 older patients (≥75) still do not receive rapid delirium screening using the 4AT tool. Clinical Frailty Score completion improved modestly (56% to 63%) but falls assessment completion (40%) and post-fall safety ward rounds (40%) remain inadequate. This is the penultimate report — use findings for local QI work ahead of the final report.
MPs Early Day Motion on ED Violence (July 2026): Bath MP Wera Hobhouse introduced an EDM recognising EM contributions and calling for legislative measures against violence and aggression in EDs. If you or your team experience violence, document via Datix — RCEM is compiling national evidence for parliamentary submission.
ACTION FOR ED DEPARTMENTS
Three immediate actions from RCEM data this month: (1) Review your ED's time-critical medication identification process at triage — automated flagging for Parkinson's and insulin-dependent diabetes should be present; (2) Audit 4AT delirium screening compliance in patients ≥75 — a rate below 20% is well below the national average; (3) Ensure complete post-fall assessments are documented consistently, not just at audit time.
Sources: RCEM Excess Deaths Report · RCEM TCM QIP · RCEM Older People QIP
NICE · NG258 · 27 MAY 2026 (REPLACES CG134)
NICE NG258 Anaphylaxis — Updated Post-Anaphylaxis Assessment, Tryptase Timing, and Observation Standards
NICE NG258 replaces the 2011 CG134 and substantially updates post-anaphylaxis management in the ED. The key changes affecting emergency departments:
| AREA | CG134 (2011) | NG258 (2026) CHANGE |
|---|---|---|
| Observation period | Not clearly specified | Minimum 4–6 hours after acute treatment for biphasic reaction risk; 24h admission if severe or incomplete response |
| Mast cell tryptase | Take at 1–2h and 24h | Take at 30–120 minutes (peak), at 3–4 hours, and a baseline (>24h or follow-up). Three samples now recommended. |
| Allergy referral | Recommended | Mandatory for all confirmed or suspected anaphylaxis. ED must document referral at discharge. |
| Documentation | General | Standardised: suspected trigger, severity, treatment given, tryptase results, referral confirmation |
WHY IT MATTERS
The tryptase protocol change is the most operationally significant. Many UK EDs currently only take one tryptase sample. NG258 requires three: peak at 30–120 min, 3–4h, and a baseline. If you do not have a baseline tryptase, the peak result cannot be interpreted (you cannot distinguish mastocytosis from acute anaphylaxis). Update your anaphylaxis proforma and discharge checklist to capture all three sample timings and to confirm allergy referral is made at discharge. The 4–6 hour observation minimum should be reflected in your department's anaphylaxis pathway.
Source: NICE NG258 | Anaphylaxis UK summary
UKHSA · NHS ENGLAND · ONGOING SINCE 3 JUNE 2026
UKHSA Ebola / VHF Alert — Confirmed Glasgow Suspect Case 30 June; ED VHF Algorithm Active
ACTIVE ALERT — ED ACTION REQUIRED
UKHSA issued an urgent NHS alert on 3 June 2026 regarding Ebola virus disease in DRC/Uganda. On 30 JUNE 2026, a suspect case was assessed in Glasgow. All UK EDs must apply the viral haemorrhagic fever (VHF) risk algorithm to ALL FEBRILE RETURNING TRAVELLERS. Do not wait for obvious haemorrhagic features — initial presentation is fever + headache/myalgia with travel to endemic region. Isolate immediately if criteria met, alert infection control and public health, and do not attempt routine blood sampling until VHF risk excluded by UKHSA consultation (0344 778 8990).
The VHF algorithm requires: (1) fever OR relevant symptoms in a traveller from an endemic region within the past 21 days; (2) immediate single-room isolation with personal protective equipment (full barrier nursing); (3) UKHSA emergency duty team contacted before any investigations. The Glasgow case was assessed and cleared, but the incident demonstrates that suspect cases will present to UK EDs. Ensure your department's VHF protocol folder is accessible and that all nursing staff know where it is.
UKHSA VHF guidance: gov.uk/guidance/viral-haemorrhagic-fever-vhf-algorithm | UKHSA emergency: 0344 778 8990
03 — PAEDIATRIC EMERGENCY MEDICINE
PEDIATRIC CRITICAL CARE MEDICINE · SURVIVING SEPSIS CAMPAIGN · JUNE 2026
2026 SSC Paediatric Sepsis Guidelines — Phoenix Criteria Adopted, Fluid Targets Resource-Stratified
The 2026 paediatric SSC update (61 statements, 20 new, 13 revised) formally adopts the 2024 Phoenix sepsis criteria, replacing SIRS-based paediatric sepsis definitions used in the 2020 guidelines. Phoenix uses organ dysfunction scoring rather than SIRS criteria — more specific, less sensitive, but better calibrated to outcomes.
KEY CHANGE
PREVIOUS (2020)
2026 UPDATE
Sepsis definition
SIRS-based + suspected infection
Phoenix criteria — organ dysfunction score
Fluid bolus
10-20 mL/kg repeated
Resource-stratified: high-resource (UK): reassess after each 10-20 mL/kg; avoid total >40 mL/kg without reassessment
Antibiotics
ASAP
Within 1 hour for suspected septic shock
Vasopressors
After adequate fluids
Consider earlier if fluid-unresponsive after 20-40 mL/kg; adrenaline/dopamine both acceptable first-line in resource-limited settings
UK APPLICATION
UK EDs currently use PEWS and NICE NG51 thresholds (not Phoenix criteria) — Phoenix has not been mandated in the UK. However, understanding Phoenix helps interpretation of paediatric sepsis research. The fluid bolus recommendation (do not exceed 40 mL/kg without reassessment) aligns with existing UK evidence (paediatric bolus fluids harm data from Issue 18) and current APLS teaching. Dopamine has been removed from APLS 8th edition first-line recommendations in favour of adrenaline — SSC 2026 is more permissive in resource-limited settings.
Source: SSC Paediatric Guidelines 2026, Pediatr Crit Care Med. journals.lww.com/pccmjournal
ACADEMIC EMERGENCY MEDICINE · SR/MA · JUNE 2026 · MCMASTER SCORE: 5/7
POCUS for Paediatric Urethral Catheterisation — Reduces Failed First Attempts: SR/MA
- Fewer fails FIRST-ATTEMPT SUCCESS HIGHER
- Confirms filled bladder AVOIDS FUTILE ATTEMPTS
- Observational DATA LARGELY FROM RCTS OF CATHETER GUIDANCE
Urethral catheterisation in children for CSU sample collection is a common ED procedure, particularly in febrile infants and young children where clean-catch samples are inadequate or NICE criteria mandate cultures. This SR/MA of RCTs confirms POCUS bladder assessment improves first-attempt catheterisation success and reduces patient distress by (a) confirming bladder is filled before attempting catheterisation, and (b) in skilled hands, guiding needle positioning in suprapubic aspiration. In practice: use a linear probe with bladder view before catheterisation in infants — a simple and fast adjunct requiring minimal skill.
Source: McMaster EvidenceAlerts 27 Jun 2026. Acad Emerg Med 2026.
RCEM / APLS GUIDANCE · CONTEXT PIECE FOLLOWING ISSUE 18 AND PROMPT BOLUS
Paediatric Fluid Resuscitation — Synthesising the Evidence After PRoMPT BOLUS and Issue 18 Data
Following Issue 18 (paediatric bolus fluids and in-hospital mortality, n=5,352 — bolus >55 mL/kg associated with OR 20.5 for mortality) and this week's PRoMPT BOLUS (fluid type is irrelevant), the current evidence synthesis for paediatric sepsis fluid resuscitation in UK EDs is:
| QUESTION | ANSWER (2026 EVIDENCE) |
|---|---|
| Which fluid type? | Either balanced or 0.9% saline — equivalent outcomes (PRoMPT BOLUS, n=9,071) |
| How much? | 10-20 mL/kg boluses with reassessment. Stop if no response. Avoid >40-60 mL/kg total without senior/HDU decision. Harm signal above 55 mL/kg (Issue 18 observational data) |
| When to escalate? | If hypotension persists after 2 boluses (20-40 mL/kg): PICU referral + vasopressor consideration. Do not give more fluid blindly. |
| UK guidance reference | NICE NG51 (Sepsis), APLS 8th edition, UK Sepsis Trust paediatric pathway |
NICE NG51: nice.org.uk/guidance/ng51
04 — FOAMED & CRITICAL APPRAISAL
PULMCCM · SUBSTACK · 2 JULY 2026
PulmCCM: Sodium Bicarbonate in Cardiac Arrest — BIHCA in Context: When (if ever) Does Bicarb Have a Role?
Following BIHCA (covered Issue 18 — bicarb in in-hospital cardiac arrest null/harmful, JAMA), today's PulmCCM post provides useful context. Despite BIHCA showing no benefit, the full evidence picture is nuanced:
Bicarb may still have a role in specific contexts: (1) Tricyclic antidepressant overdose — sodium bicarb remains first-line for TCA-induced broad-complex arrhythmia regardless of cardiac arrest; (2) Hyperkalaemia-induced cardiac arrest — bicarb helps shift K+ intracellularly; (3) Pre-existing severe metabolic acidosis (pH <7.1) before arrest — correcting acidosis may improve myocardial catecholamine sensitivity. BIHCA enrolled patients with in-hospital arrest without these specific indications — the null result applies to routine undifferentiated bicarb use during CPR.
PRACTICAL GUIDANCE FOR UK RESUS
Routine bicarb in ALS: not indicated (consistent with RCUK 2025 guidelines, covered in prior issues). Targeted bicarb: TCA overdose (>12 mm/s QRS, haemodynamic compromise), hyperkalaemic arrest (1-2 mmol/kg 8.4%), severe pre-arrest acidosis (pH <7.1 on VBG). Do not give bicarb "just in case" — alkalosis worsens catecholamine binding and increases hypernatraemia risk.
Source: PulmCCM, pulmccm.org | BIHCA (JAMA 2026): covered in Issue 18.
UMEM EDUCATIONAL PEARL · UNIVERSITY OF MARYLAND EM · 30 JUNE 2026
UMEm Pearl — LP in the Coagulopathic Patient: "Champagne or Chianti?"
Lumbar puncture in anticoagulated or thrombocytopenic patients is a common ED dilemma — the fear of spinal haematoma, which is a devastating complication but extremely rare. Evidence-based thresholds for safe LP:
| COAGULATION FACTOR | THRESHOLD FOR SAFE LP | EVIDENCE BASIS |
|---|---|---|
| Platelets | ≥50 × 10&sup9;/L (ideally ≥80 for traumatic tap risk) | Expert consensus; BCSH guidelines |
| INR | ≤1.5 | Expert consensus; risk begins to rise significantly >2.0 |
| LMWH (therapeutic) | Wait ≥24 hours after last dose | Regional anaesthesia guidelines (extrapolated) |
| Direct oral anticoagulants | Wait ≥48 hours (or ≥72h if eGFR <30) | ESAIC/ASRA guidelines |
| Warfarin | Reverse to INR ≤1.5 before procedure in elective; emergent LP → risks must be weighed | BCSH; individual case |
CRITICAL APPRAISAL
Spinal haematoma risk from LP in anticoagulated patients is real but very low (estimated 1:150,000 — 1:220,000 in neuraxial procedures; LP is lower risk than epidural). The key risk in NOT doing LP is missing bacterial meningitis or subarachnoid haemorrhage. For urgent LP in suspected bacterial meningitis: do not delay >1 hour for coagulation correction (start antibiotics first, LP later if INR correctable). For non-urgent LP (e.g. xanthochromia for suspected SAH): correct coagulopathy before procedure.
Source: UMEm Educational Pearl, 30 June 2026. umem.org/educational_pearls
UMEM EDUCATIONAL PEARL · CRITICAL CARE · 1 JULY 2026
UMEm Pearl — Airway Management in Critically Ill Patients with Obesity: FRC is Key
Obesity significantly reduces functional residual capacity (FRC), the oxygen reserve during apnoeic period — placing a critically ill obese patient at much higher risk of precipitous desaturation during intubation. Key ED RSI principles for obese patients:
| STEP | RECOMMENDATION | RATIONALE |
|---|---|---|
| Pre-oxygenation | 25° head-up position (ramped or reverse-Trendelenburg) | Gravity improves FRC by ~30% vs supine in morbid obesity |
| HFNO during pre-oxygenation | 60 L/min for 3-5 minutes before RSI (HFNO apnoeic oxygenation) | Extends safe apnoea time from ~90s to 5+ minutes |
| Positioning during laryngoscopy | Maintain ramp position (ear-to-sternal-notch) | Improved laryngeal view; avoid sniffing position in obese |
| Dose adjustment | Ketamine/propofol: actual body weight; suxamethonium: actual body weight; rocuronium: ideal body weight | Accumulation risk with large doses in morbid obesity |
| Backup plan | Video laryngoscope first-line; have surgical airway equipment immediately available | BMI >40 has significantly higher failed airway rate |
Source: UMEm Pearl, 1 July 2026. IBCC Airway: emcrit.org/ibcc/airway/
05 — QUICK HITS
Pre-MIRACLE2 Score for Post-ROSC Neurological Risk Stratification (Resuscitation, PMID: 42379417). Razak et al, published online 30 June 2026. The Pre-MIRACLE2 score uses pre-hospital data available at ROSC (age, initial rhythm, bystander CPR, EMS-to-ROSC time, blood glucose) to stratify neurological prognosis after OHCA. AUC 0.88 in validation cohort. While this is primarily a PHEM tool, ED clinicians should be aware of it for post-ROSC prognostication discussions and ECPR candidacy screening. Full analysis in PHEM newsletter.
MSSA bacteraemia: OPAT and cefazolin. Following the cefazolin non-inferiority RCT (Item 3), UK Outpatient Parenteral Antibiotic Therapy (OPAT) services may now consider cefazolin as a first-line agent for MSSA bacteraemia step-down. Cefazolin's once-daily dosing (2g OD has validated data in observational series) is ideal for OPAT pathways. Contact your local OPAT team early in the ED pathway for eligible patients.
Dizzying clinical decision rules (Acad Emerg Med editorial, PMID: 42377357, Edlow JA). Edlow's editorial in Academic Emergency Medicine (issue 33:7) raises an important point: proliferation of clinical decision tools in EM risks cognitive overload and implementation fatigue. Rules with similar predictive performance are often developed in overlapping populations — the field needs evidence for which tool changes decisions in the real world, not just validation papers. Relevant when implementing new tools in your department: insist on evidence of implementation benefit, not just diagnostic accuracy.
RCEM ACP Credentialing 2022 Curriculum Update. RCEM published revised guidance for Advanced Clinical Practitioner (ACP) credentialing: evidence window increased from 3 to 5 years, greater flexibility around maternity/parental leave, PGDip remains the minimum academic requirement. Relevant if you supervise ACPs. Application windows for 2026: spring round notifications sent June 2026; autumn round opens August 2026. Full details at rcem.ac.uk/acp-curriculum-2022/
06 — CORE REVISION: ACUTE KIDNEY INJURY IN THE ED
FRCEM CORE REVISION — ACUTE KIDNEY INJURY IN THE ED
KDIGO Staging · AKI Causes · Triple Whammy · Contrast Myths · Hyperkalaemia Management
KDIGO AKI Staging (NICE NG148): AKI is defined by any of: (a) rise in creatinine ≥26 µmol/L within 48 hours; (b) rise ≥1.5× baseline within 7 days; (c) urine output <0.5 mL/kg/h for ≥6 hours.
| STAGE | CREATININE CRITERION | URINE OUTPUT CRITERION | MANAGEMENT |
|---|---|---|---|
| 1 | 1.5–1.9× baseline OR +26 µmol/L | <0.5 mL/kg/h for 6–12h | Correct cause, stop nephrotoxins, monitor U&E |
| 2 | 2.0–2.9× baseline | <0.5 mL/kg/h for ≥12h | Senior involvement, nephrology referral, HDU consideration |
| 3 | ≥3.0× baseline OR Cr ≥354 AND acute rise ≥27 µmol/L | <0.3 mL/kg/h for ≥24h or anuria ≥12h | ITU/nephrology consult, RRT consideration, strict fluid balance |
Causes — the three categories:
| PRE-RENAL (60–70%) | INTRINSIC (25–35%) | POST-RENAL (5%) |
|---|---|---|
| Hypovolaemia (vomiting, diarrhoea, haemorrhage) Septic shock Cardiogenic shock Hepatorenal syndrome NSAID-induced vasoconstriction (efferent arteriole) | ATN (ischaemic, nephrotoxic) Glomerulonephritis Interstitial nephritis (drug-induced) Vasculitis, TTP/HUS Myoglobinuria (rhabdomyolysis) | BPH / prostate obstruction Ureteric calculi Pelvic malignancy Retroperitoneal fibrosis |
The Triple Whammy: NSAIDs + ACE inhibitor (or ARB) + diuretic. Each impairs renal blood flow or tubular function separately; combined, they frequently precipitate AKI. In community-acquired AKI presenting to ED, check the drug chart. Stopping the triple whammy (temporarily) is often the most important initial intervention.
Contrast-induced AKI — the myth: The risk from modern low-osmolar contrast is lower than previously thought. AMACING RCT and systematic reviews show no increase in AKI with IV contrast vs no contrast in patients with eGFR >30 mL/min. Pre-hydration is NOT required for eGFR >30. For eGFR 15–30: discuss with radiology and nephrology. Do not withhold urgent CT imaging due to fear of contrast nephropathy in a haemodynamically stable patient with eGFR >30.
Hyperkalaemia management in AKI (FRCEM favourite):
| K+ LEVEL / ECG CHANGES | MANAGEMENT |
|---|---|
| K+ >6.5 OR any ECG changes (peaked T waves, broad QRS, sine wave) | 10 mL 10% calcium gluconate IV (membrane stabilisation) — repeat at 5 minutes if ECG not improving. Does NOT lower K+. |
| All levels requiring K+ shift intracellularly | Insulin-dextrose (10 units Actrapid in 50 mL 50% dextrose IV) — acts in 15-30 min, lowers K+ by ~0.6–1.0 mmol/L |
| Nebulised salbutamol | 10–20 mg nebulised — additive to insulin-dextrose; use together. Onset 15–30 min. |
| Fluid choice | Balanced crystalloids (Hartmann's/Plasmalyte) — NOT 0.9% saline (worsens acidosis, worsens hyperkalaemia). See Issue 17 fluid choice reference. |
| Removal therapies | Calcium resonium (rectal or oral) — slow/unreliable; rarely used in acute setting. Dialysis for refractory cases. |
| Sodium bicarbonate | Only if pH <7.2 + hyperkalaemia + AKI Stage 2-3 (as per SODa-BIC and BICAR-ICU criteria). Not routine. |
NICE NG148 AKI: nice.org.uk/guidance/ng148 | LITFL AKI: litfl.com/aki/ | IBCC AKI: emcrit.org/ibcc/aki/
07 — ACTION POINTS — ISSUE 19
| MHRA Flucloxacillin recall: Check ED, pharmacy, and CDU/resus stocks for Flamingo Pharma Flucloxacillin Capsules 500mg. Quarantine affected batches. Use IV flucloxacillin or cefazolin (if MSSA confirmed). | |
| MHRA Gabapentin liquid recall: Remove Relonchem Gabapentin 50mg/mL oral solution from stock. Particulate contamination confirmed. Do not administer. Alert ward pharmacists. | |
| THIS MONTH | SSC 2026 — Update sepsis protocol: Review your ED's sepsis SOP against new SSC guidance: (1) source control target 6 hours; (2) antibiotic timing nuanced by NEWS2 risk band (not blanket 1-hour for all); (3) peripheral vasopressors explicitly supported. |
| THIS MONTH | Cefazolin for MSSA: Inform your ED pharmacy that cefazolin is now RCT-validated for MSSA bacteraemia at 2g TDS IV. Discuss as flucloxacillin supply alternative and OPAT candidate drug with local microbiology. |
| THIS MONTH | RCEM QIP Time-Critical Medication: Review the new RCEM QIP report against your department's time-critical medication administration times. Identify any gaps (e.g. antibiotics, stroke thrombolytics, PPH oxytocin). |
| Paediatric sepsis fluids: PRoMPT BOLUS confirms fluid type does not matter — focus on volume (10-20 mL/kg boluses, reassess) and timing. Follow NICE NG51 and APLS 8th edition. No flucloxacillin supply issue affects paeds fluids. | |
| AKI: Stop the triple whammy — NSAIDs + ACE/ARB + diuretic is the most common cause of community-acquired AKI in older patients. Check and stop acutely on presentation. Use balanced crystalloids for fluid resuscitation. Do not withhold contrast CT for eGFR >30. | |
| LP in anticoagulated patients: Safe thresholds: platelets ≥50, INR ≤1.5, no DOAC within 48h (72h if eGFR <30). In suspected bacterial meningitis: do not delay antibiotics for LP reversal if correction will take >1 hour. |
TRIALS TO WATCH
Q2–Q3 2026 (Imminent)
- HSSIB Mental Health Crisis Report 2 of 2 — Final report on mental health crisis care in UK EDs expected Q3 2026. Will include recommendations on safe assessment rooms, liaison psychiatry thresholds, and CAMHS pathway reform.
- On-Scene Trial (Netherlands) — Prehospital ECPR in refractory OHCA. Results anticipated by end of 2026. Will complement ARREST, INCEPTION, and PRAGUE data.
- BACHb RCT (UK) — HFNC vs CPAP vs standard O2 in infant bronchiolitis (n=500). UK-based multicentre trial. Results expected Q3 2026.
2026–2027
- BEST-DKA — Balanced electrolytes vs 0.9% saline in diabetic ketoacidosis, Phase 3. Will give RCT-level evidence for a common ED question.
- CoMiTED — Conservative vs immediate chest drain in traumatic haemothorax. UK multicentre.
- EVIS Trial (NCT05179499) — UK trial on early vasopressor in sepsis, building on ARISE FLUIDS ED context.
Longer Horizon
- NICE Late-Window Stroke Thrombolysis Assessment — Assessment of extending IV tPA to 9-hour window ongoing. Will affect UK stroke pathways.
- NAP8 — Regional Anaesthesia Complications Audit — UK RCOA active recruitment. Will provide UK-specific complication rates for nerve blocks in ED and post-operative settings.
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue 19 — 2 July 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