EM EVIDENCE RUNDOWN — ISSUE 26 — 21 AUGUST 2026
EM Evidence Rundown
Emergency medicine evidence for UK clinicians — weekly — emevidence.org
Jake Turner — Senior Registrar in Emergency Medicine, ST6 — Curated with the assistance of AI (Perplexity). All content editorially reviewed.
Lead: Serratus anterior plane block (SAPB) for acute rib fractures in the ED — the first ED-based RCT shows significant improvement in a composite pain-function score at 5 hours, with a 40% reduction in morphine equivalents at 24h (not statistically significant at n=38). Analgesia technique directly within the EM skill set. Practice Change: Single-dose dexamethasone for paediatric asthma is not inferior to two doses. In this retrospective cohort of 2,063 children, ED revisit and hospitalisation rates at 14 days were statistically identical. Evidence now supports switching to single-dose protocol at your department. UK Performance: July 2026 was the worst July on record for 12-hour waits in England — 47,000 trolley waits, 2,300 corridor care episodes per day. RCEM calling this a pre-winter breaking-point warning. Core Revision: Pulmonary embolism — risk stratification to disposition. The full ED pathway from NICE NG158 to outpatient anticoagulation.
BOTTOM LINE UP FRONT
ACT ON THIS NOW
CHANGE THIS MONTH SAPB for rib fractures (Acad Emerg Med): ED-based RCT. SAPB improved PIC score at 5h vs usual care. Opioid reduction of ~40% at 24h. Learn the technique; consider for lateral rib fractures T2-T9 with pain score ≥5.
CHANGE THIS MONTH Single-dose dexamethasone, paeds asthma (Ann Emerg Med, n=2,063): No difference in ED revisit or hospitalisation vs two doses at 14 days. If your department still uses two doses — one dose is sufficient. Discuss protocol change.
CHANGE THIS MONTH AZ-SWED RCT (NEJM, n=840, stopped for futility): Azithromycin for preschool wheeze provides no benefit over placebo, even in children with detectable nasopharyngeal bacteria. Do not prescribe azithromycin for viral-triggered wheezing in under-5s.
CHANGE THIS MONTH RSI in myasthenia gravis (EMA Daily): Standard rocuronium doses used in most non-OR RSIs in MG patients without obvious prolonged paralysis. Sugammadex immediately available is key; monitor neuromuscular recovery post-intubation.
UK DATA RCEM: July 2026 worst July on record — 47,000 trolley waits, 2,300 corridor care/day. 4-hour performance fell to 74.6%. RCEM warns of pre-winter breaking point.
KNOW FOR NEXT TIME
INFORMING PRACTICE Bandemia predicts bacteraemia mortality (EMA Daily): Higher band % on manual differential in ED bacteraemia patients predicts incrementally higher short-term mortality. Low-cost prognostic signal while cultures pending. Needs prospective validation.
INFORMING PRACTICE IO lines in paediatric emergencies (EMJ): Severe long-term complications after paediatric IO access are rare. Only one case of osteomyelitis in 282 papers reviewed. Do not hesitate to use IO when IV access fails in paediatric emergency.
INFORMING PRACTICE Paediatric e-scooter injuries (EMJ, 3 UK MTCs): Rising incidence. Only 1.8% wearing helmets. 74% from most deprived areas. 24.1% head injuries, 10.4% major. Strong public health message for ED discharge.
INFORMING PRACTICE POCUS for retinal detachment (JF AOTD): SR of 3 meta-analyses — sensitivity 97-100%, specificity 97-100% by ED clinicians. High accuracy. Consider in sudden visual loss presentations.
INFORMING PRACTICE Phoenix Sepsis Criteria SR/MA (Crit Care Med): Better sensitivity and specificity than old IPSCC criteria in paediatric sepsis. Familiarise with Phoenix Score (≥2 points with suspected infection = sepsis).
INFORMING PRACTICE Core revision this issue: PE risk stratification — Wells score, sPESI, PERC, imaging thresholds, and NICE NG158 outpatient pathway for low-risk PE.
Two themes define this week: evidence that expands what emergency physicians can safely do for patients in the department, and evidence that reinforces restraint. On the intervention side, the first ED-based RCT of serratus anterior plane block for rib fractures reports a meaningful improvement in the composite pain-function score at five hours — a technique that most senior EM trainees can learn, performed entirely within the ED without anaesthetic input. On the restraint side, the AZ-SWED trial confirms what clinical intuition should have been telling us: azithromycin does not help children wheezing in the ED, even when nasopharyngeal bacteria are detected, even when the bacteria are cleared by the antibiotic. The UK performance data framing this issue is stark: July 2026 was the worst July on record for twelve-hour trolley waits. RCEM is describing the pre-winter trajectory as a breaking-point warning. The core revision this week addresses one of the highest-volume diagnostic questions in any busy ED: is this PE, what is the risk, and where does this patient go?
WHAT'S INSIDE
- SAPB for acute rib fractures — ED RCT (LEAD)
- Bandemia and ED bacteraemia mortality (EMA Daily)
- Necrotizing fasciitis — mortality predictors (JF AOTD)
- RSI in myasthenia gravis — rocuronium data
- RCEM: July worst-on-record 12h waits
- NHS: A&E 2.49m attendances, busiest July ever
- POCUS for retinal detachment (JF AOTD)
- PEM: AZ-SWED — azithromycin no benefit in preschool wheeze (NEJM)
- PEM: Single-dose dexamethasone equivalent to two doses
- PEM: Paediatric e-scooter injuries — UK MTCs (EMJ)
- PEM: IO lines in children — long-term complications rare
- PEM: Phoenix Sepsis Criteria SR/MA
- Core Revision: PE — Risk Stratification to Disposition
CHANGE TONIGHT Act immediately CHANGE THIS MONTH Adjust practice GUIDELINE Formal guidance INFORMING PRACTICE
Background evidence SAFETY ALERT
Contents: 1. Key Trials & Articles — 2. Guidelines & UK Updates — 3. Paediatric EM — 4. FOAMed & Critical Appraisal — 5. Quick Hits — 6. Core Revision: PE — 7. Action Points — 8. Trials to Watch
1 — KEY TRIALS & ARTICLES
Serratus Anterior Plane Block for Acute Rib Fractures in the ED — First RCT
Perice L et al. Academic Emergency Medicine. 2026 May;33(5):e70338. PMID: 42159402 | EMA Daily 17 Aug 2026
- +0.90 PIC SCORE IMPROVEMENT AT 5H (95% CI 0.10–1.69)
- −21.9 mg OME REDUCTION AT 24H (32.2 VS 54.1 MG; P=0.44)
- n=38 UNDERPOWERED — LEVEL I TRAUMA CENTRE, USA
- p=0.03 PRIMARY OUTCOME (PIC SCORE) SIGNIFICANT
| MEASURE | SAPB + USUAL CARE (N=19) | USUAL CARE ALONE (N=19) |
|---|---|---|
| PIC score improvement at 5h | Significant (avg effect +0.90) | Reference |
| 24h oral morphine equivalents | 32.2 mg | 54.1 mg (p=0.44; NS) |
| Complications | None reported in either arm |
What they did: Prospective open-label RCT at a US Level I Trauma Centre. Adults with anterior/lateral rib fractures T2–T9 and pain score ≥5/10 were randomised to SAPB (performed by an emergency physician) plus usual care, or usual care alone. Primary outcome was improvement in the composite PIC score (Pain, Inspiratory Capacity, Cough) at 5 hours.
What they found: The SAPB group showed a statistically significant improvement in PIC score at 5 hours (estimated average effect +0.90; 95% CI 0.10–1.69; p=0.03). Opioid use at 24 hours was markedly lower in the SAPB arm (32.2 vs 54.1 mg OME) though this did not reach significance in a study of only 38 patients. No complications in either arm.
Critical appraisal: This is an important proof-of-concept RCT but is substantially underpowered (38 patients, single centre, USA). The PIC score is validated but the clinical meaning of a 0.90-point change needs contextualising — a larger multicentre trial is needed before widespread adoption. The opioid reduction signal (40% fewer OMEs) is clinically meaningful and consistent with regional anaesthesia evidence from orthopaedic literature. EMA Daily editor note (DeLaney): "Larger studies examining procedural competency requirements will be needed before this becomes standard practice."
UK context — worth learning now: SAPB is within the expanded procedural skill set recommended in the 2025 RCEM curriculum. Rib fractures are a high-volume ED presentation — particularly in elderly patients where undertreated pain drives respiratory failure and pneumonia. The technique is ultrasound-guided, requires only standard LA (e.g. levobupivacaine or ropivacaine), and does not require anaesthetic support. Consider initiating a departmental teaching session. The approach: US probe in sagittal plane at the 5th rib in the mid-axillary line; target the fascial plane superficial to serratus anterior; 30–40 mL dilute LA (e.g. 0.25% levobupivacaine).
Band Neutrophil Percentage Predicts Short-Term Mortality in ED Bacteraemia
Cheng H et al. American Journal of Emergency Medicine. 2026;107:1–7. PMID: 42127878 | EMA Daily 20 Aug 2026
What they found: In ED patients with confirmed bacteraemia, a higher initial band neutrophil percentage (on manual differential) was associated with incrementally greater short-term mortality. The relationship was dose-dependent — higher band percentage = worse outcome — independent of complete severity scores.
Critical appraisal: Retrospective, single-centre, Taiwanese cohort — not directly generalisable to UK practice. The key limitation is reliance on manual differential, which is not routinely performed on auto-analysers in most UK labs; automated band counts are less reliable. Prospective multicentre validation needed before adding to sepsis risk-stratification protocols. That said, when a manual differential is already available, a high band count should increase your concern level while cultures are pending.
ED action: If a manual differential is available and shows >10% bands in a patient with fever and clinical concern for bacteraemia — treat this as a high-risk sepsis presentation regardless of NEWS2 score. Do not wait for formal severity scores before antibiotics. Consider escalation to resus-level monitoring.
Neuromuscular Blockers for RSI in Myasthenia Gravis — Real-World ED Data
Polito NB et al. American Journal of Emergency Medicine. 2026;103:21–25. PMID: 41638015 | EMA Daily 14 Aug 2026
What they found: In this small retrospective cohort of myasthenia gravis patients undergoing RSI outside the operating room, most received standard rocuronium doses and did not experience obvious deleterious effects. Only a small minority showed possible prolonged paralysis, and objective recovery monitoring was infrequently used.
Critical appraisal (EMA Daily, Beck-Esmay): Small cohort, retrospective, without standardised post-intubation neuromuscular monitoring. Definitive dosing recommendations cannot be made from this data. This study challenges the traditional teaching (from anaesthesia colleagues) that MG patients are uniquely sensitive to rocuronium and risk catastrophic over-paralysis. The current evidence does not support using suxamethonium as default in MG — standard rocuronium (1.2 mg/kg) with sugammadex immediately available is a reasonable approach in the emergency setting.
UK ED approach: In MG crisis requiring RSI: (1) Optimise ventilatory status pre-intubation (BiPAP, positioning); (2) Rocuronium 1.2 mg/kg for intubating conditions; (3) Ensure sugammadex 16 mg/kg is drawn up and at bedside before induction; (4) Post-intubation: use train-of-four monitoring where available; expect potentially prolonged paralysis. Alert ICU before transfer.
What Predicts Mortality in Necrotizing Fasciitis? SR/MA
JournalFeed Article of the Day, 18 Aug 2026 | Systematic Review & Meta-Analysis
This systematic review and meta-analysis (covered by JournalFeed 18 Aug) evaluated factors associated with short-term mortality in necrotizing soft tissue infections (NSTIs). Variables independently associated with increased mortality included: older age, chronic liver or kidney disease, high comorbidity burden, delayed surgery (the most modifiable factor), and failure to achieve source control at first debridement.
Key number: Time-to-surgery is the most consistently modifiable predictor in the literature. "Time is tissue" — any delay between ED diagnosis and operating theatre should be minimised. The LRINEC score has low sensitivity for NSTI in isolation (sensitivity 59-89% in validation); do not use LRINEC to rule out NSTI when clinical suspicion is high.
UK ED action: NSTI is a surgical emergency. Call the on-call surgical registrar early — do not wait for formal imaging if clinical diagnosis is clear. MRI is most sensitive (93-100%) but should not delay theatre if the patient is deteriorating. IV broad-spectrum antibiotics (e.g. Meropenem + Clindamycin per local protocol) immediately on NSTI diagnosis. Consider clindamycin specifically for its anti-toxin effect in group A Strep NSTI.
2 — GUIDELINES & UK UPDATES
July 2026 — Worst July on Record for 12-Hour ED Waits in England
RCEM, 13 August 2026 | BMA Backlog Analysis, 13 August 2026
NHS England data for July 2026 shows: 2.49 million A&E attendances (busiest July ever); 47,000 patients waiting over 12 hours on a trolley for an emergency admission (worst-ever July figure); 2,300 corridor care instances per day in EDs; and a four-hour performance of 74.6% against a target of 78%. Ambulance response times for Category 2 calls averaged 29 minutes 49 seconds.
RCEM statement (13 August): "Overcrowding is rife yet meaningful action to tackle it is nowhere to be seen. Without urgent help, EDs will be at breaking point before the challenges of winter even begin." The figure of 47,000 trolley-waits in a single month is approximately 105 times higher than July 2019.
Scotland update: RCEM Scotland Vice President Dr Fiona Hunter (17 August) responded to the Scottish Health Secretary actively considering collecting corridor care data — a first step toward accountability, though no mandatory reporting framework exists yet.
RCEM Clinical Standards and Guidance update (August 2026): New RCEM guidance published this month includes updated standards for children and young people in emergency care (Facing the Future 2026 update) and a new guideline on acute behavioural disturbance in the ED. Full list at rcem.ac.uk.
3 — PAEDIATRIC EMERGENCY MEDICINE
AZ-SWED: Azithromycin Provides No Benefit for Preschool Wheeze in the ED
Denninghoff KR, Casper TC, Zorc JJ et al. New England Journal of Medicine. Published online 18 May 2026. doi:10.1056/NEJMoa2516505. PMID: 42149992 | EMA Daily 18 Aug 2026
- No benefit ADYC SYMPTOM SCORES IDENTICAL (P=0.70 BACTERIA-POSITIVE; P=0.69 NEGATIVE)
- Stopped STOPPED EARLY FOR FUTILITY BY DSMB
- n=840 AGE 18–59 MONTHS, 8 PECARN EDS, MULTICENTER
- 58.7% BACTERIAL CLEARANCE WITH AZITHROMYCIN VS 11.4% PLACEBO — NO CLINICAL BENEFIT
What they did: PECARN multicentre RCT (8 EDs) randomising children aged 18–59 months with moderate-to-severe acute wheeze (PRAM ≥4) to azithromycin 12 mg/kg once daily for 5 days vs matching placebo, all receiving standard care. Primary outcome: sum of Asthma Flare-up Diary for Young Children (ADYC) scores over 5 days.
What they found: No significant difference in ADYC symptom scores in bacteria-positive children (median 9.59 vs 9.72; p=0.70) or bacteria-negative children (9.30 vs 9.10; p=0.69). No difference in ED length of stay, hospital LOS, or 72-hour revisits. Azithromycin cleared nasopharyngeal bacteria far more effectively (58.7% vs 11.4%) but this biological effect had no clinical translation. Trial stopped early for futility.
Bottom line: This is a definitive practice-changing trial from NEJM. Azithromycin has no role in undifferentiated ED preschool wheeze — even when bacteria are detected. The bacteria are not driving the acute wheeze (viral inflammation is). Routine antibiotic prescribing in this group is now unsupported and should be stopped. Reserve antibiotics for clear bacterial infections (pneumonia, otitis, etc.). EMA Daily (Beck-Esmay): "Continue to prioritise guideline-based bronchodilator and corticosteroid care, and reserve antibiotics for clear indications." SGEM#515 (July 2026) reviewed this study and arrived at the same bottom line.
Single-Dose Dexamethasone Equivalent to Two Doses for Paediatric Asthma Exacerbations
Dave S, Green-Hopkins I, Bardach NS, Grupp-Phelan J, Shapiro DJ. Annals of Emergency Medicine. 2026 Jan 22;S0196-0644(25)01451-9. PMID: 41575401 | JournalFeed Article of the Day, 20 Aug 2026
- +0.45% ARD — ED REVISIT (95% CI −1.4% TO +2.3%)
- +0.02% ARD — HOSPITALISATION (95% CI −0.93% TO +0.89%)
- n=2,063 CHILDREN AGED 2–20 YEARS, 2 EDS, IPTW ADJUSTED
- 61.9% STILL GIVEN 2 DOSES DESPITE NO EVIDENCE FOR BENEFIT
What they did: Retrospective cohort of 2,063 children aged 2–20 years discharged from two EDs after dexamethasone for asthma exacerbation. Propensity score analysis (IPTW) to mitigate confounding. Outcomes: ED revisit and hospitalisation at 14 days.
What they found: Risk of ED revisit: 5.2% (1 dose) vs 5.7% (2 doses); ARD +0.45% (95% CI −1.4% to +2.3%) — not significant. Risk of hospitalisation: 0.85% vs 0.83%; ARD +0.02% (95% CI −0.93% to +0.89%) — not significant. Despite these findings, 61.9% of children still received two doses.
UK practice context: NICE CKS and BTS/SIGN asthma guidelines permit single-dose dexamethasone (0.15–0.3 mg/kg, max 10 mg) for acute exacerbations in children. This retrospective cohort, with its large n and propensity-score adjustment, is now the strongest available evidence for equivalence of single-dose regimens. If your paediatric ED still prescribes two doses routinely, this is a direct evidence base for a QIP or protocol change. This also reduces out-of-hospital compliance burden and simplifies the discharge prescription.
Paediatric E-Scooter Injuries — UK Multi-Centre Study: An Emerging Public Health Crisis?
Sabir L, Waheed S, Rushmer C et al. Emergency Medicine Journal. Published online 11 Aug 2026. PMID: 42580879
Setting: Three UK Paediatric Major Trauma Centres (Alder Hey Children's Hospital, Sheffield Children's Hospital, Royal Manchester Children's Hospital). 477 patients under 16 with e-scooter injuries, January 2019–December 2024. Incidence rising throughout the study period.
Key numbers: Median age 12 years (IQR 10–13); 64.4% male; 94.8% rider injuries; ≥80% on private e-scooters; 2.5% on private land (i.e. nearly all were technically illegal road use); 1.8% wearing a helmet; 13.4% admitted; 6.9% required surgery.
Injury patterns: Lower limb 40.6%; upper limb 36.2%; head injuries 24.1%; facial injuries 18.4%. Of head injuries, 10.4% were major (AIS 3–4), requiring imaging, admission, and/or surgery. Deprivation: 74% of patients lived in IMD deciles 1–2 (most deprived areas).
ED relevance: E-scooter injuries are common, under-documented, predominantly illegal, and disproportionately affect deprived paediatric populations without helmets. Be alert to occult head injury in children presenting with minor e-scooter trauma — a significant minority have major head injuries. Discharge counselling should include helmet use and age-appropriate supervision. The social determinants gradient (74% from most deprived areas) should inform your safeguarding threshold.
Intraosseous Lines in Children — Long-Term Complications Are Rare
Carley ELJ, Yates GP. Emergency Medicine Journal. Published online 11 Aug 2026. PMID: 42580875
Short-cut review of 282 papers (11 observational studies included) examining long-term outcomes of IO access in children. Results: severe long-term complications are rare. Osteomyelitis: 1 case reported in the literature. Growth disturbance, venous thrombosis, fat embolism: no evidence found. Compartment syndrome, fracture, and extravasation: isolated rare cases only.
Bottom line: Do not hesitate to insert IO access in a paediatric emergency when IV access has failed. The evidence supports IO as safe with very low long-term complication risk. This should reassure clinicians who delay IO due to concerns about growth plate damage or bone complications. RCPCH and RCEM guidelines already recommend IO without IV access delay; this literature review supports the guideline stance.
Phoenix Sepsis Criteria Outperforms Old IPSCC in Paediatric Sepsis — SR/MA
SR/MA. Critical Care Medicine. Published August 2026. McMaster EvidenceAlerts, 18 Aug 2026. doi:10.1097/CCM.0000000000007312
This systematic review and meta-analysis (McMaster EvidenceAlerts 18 Aug) evaluated the prognostic accuracy of the Phoenix Sepsis Criteria (PSC) for in-hospital mortality in children with suspected infection, comparing performance against the old 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria.
Key finding: Phoenix Sepsis Criteria demonstrated better sensitivity and specificity than IPSCC for predicting in-hospital mortality, though performance varied by clinical setting (higher resource settings showed better discrimination). The Phoenix Score defines paediatric sepsis as ≥2 points across four systems (respiratory, cardiovascular, coagulation, neurological) in a child with suspected infection.
FRCEM/UK context: Phoenix Sepsis Criteria (2024) are the current international standard for paediatric sepsis definition, replacing the old SIRS-based IPSCC 2005 criteria. UK paediatric guidelines and the NHS paediatric sepsis pathway are aligning to Phoenix. Be familiar with the four Phoenix organ systems: (1) Respiratory: SpO2/FiO2, PaO2/FiO2, or invasive ventilation; (2) Cardiovascular: lactate, vasoactives, or severe age-appropriate hypotension; (3) Coagulation: platelet, INR, D-dimer, or fibrinogen; (4) Neurological: GCS ≤11 or AVPU ≤Voice. A score ≥2 = paediatric sepsis. Score ≥1 cardiovascular point added = paediatric septic shock.
4 — FOAMED & CRITICAL APPRAISAL
POCUS for Retinal Detachment — Can You Trust It? JournalFeed AOTD 19 Aug
JournalFeed Article of the Day, 19 August 2026 | Three SR/MAs synthesised
JournalFeed reviewed three systematic reviews and meta-analyses evaluating ocular POCUS for retinal detachment in the ED setting. Sensitivity: 97–100%. Specificity: 97–100%. These figures apply when performed by emergency clinicians after appropriate training. The meta-analyses included varied ED and non-ED ultrasound operators.
UK ED application: Ocular POCUS for retinal detachment is highly accurate when performed by trained ED clinicians. The technique: high-frequency linear probe (10–15 MHz), gentle pressure over closed eyelid with transducer gel, scan in both longitudinal and transverse planes. Retinal detachment appears as a hyperechoic "V-shaped" or undulating membrane attached at the optic disc. In sudden painless visual loss (or visual field defect after trauma), a negative ocular POCUS from an experienced clinician provides meaningful reassurance. However, all positive and equivocal cases still require urgent ophthalmology review. Ensure adequate POCUS training before relying on this in isolation.
5 — QUICK HITS
Blunt Traumatic Pneumothorax — Noninvasive Treatment Safe in 46%
JF Speed Read Wed 19 Aug | J Trauma Acute Care Surg | Retrospective, n=275
In this multicentre retrospective study of 275 adults with blunt traumatic pneumothorax, noninvasive management (observation, supplemental O2) was used in 45.8% and was not associated with worse outcomes compared to tube thoracostomy. Selection bias applies — smaller, stable PTX were managed conservatively. This aligns with NICE and EAST guidelines recommending observation for small (<2 cm apex-to-pleura on upright CXR) traumatic PTX without clinical compromise.
Renal POCUS Hydronephrosis Predicts Stone Disease and Urological Intervention
JF AOTD Mon 17 Aug | Retrospective, n=188 | J Emerg Med
In 188 patients undergoing renal POCUS for suspected renal colic, hydronephrosis on POCUS was associated with higher rates of confirmed stone disease, early urological intervention, and CT use — but did not predict urological intervention directly. Moderate-severe hydronephrosis should prompt urology involvement, especially with fever or obstructive uropathy features. Mild hydronephrosis without symptoms can be managed expectantly with urology follow-up.
Paediatric Readiness Intervention in General EDs — Multicomponent RCT
PubMed Aug 12 | CJEM 2026 | Matched-pair RCT
A matched-pair RCT of a multicomponent paediatric readiness intervention (guideline implementation, simulation, equipment standardisation) in general EDs showed improved paediatric readiness scores. Relevant to UK general EDs (i.e. not specialist children's hospitals) which manage significant volumes of paediatric emergencies without dedicated paediatric staff. NHS England's paediatric transfer network guidance requires a minimum level of paediatric readiness in all Type 1 EDs — simulation-based interventions directly support this.
Carotid Artery Injury Management — Contemporary Evidence Summary
JF Speed Read Thu 20 Aug | J Trauma Acute Care Surg 2026 | Review
Summary of contemporary evidence for both penetrating (PCAI) and blunt (BCAI) carotid artery injuries: CTA is now the first-line diagnostic modality. Selective operative repair is appropriate for haemodynamically unstable or actively bleeding patients; stable patients may be managed with antithrombotic therapy. Early antithrombotic therapy reduces stroke and mortality. BCAI (e.g. from seatbelt injury) can present with delayed neurological deterioration hours to days after trauma — maintain index of suspicion in high-energy neck trauma patients.
Pending: High-Sensitivity Troponin POCT SR/MA (McMaster EvidenceAlerts 14 Aug)
McMaster EvidenceAlerts 14 Aug 2026 | SR/MA
McMaster flagged a new SR/MA on diagnostic accuracy of point-of-care high-sensitivity troponin algorithms for ED rule-out and rule-in of MI. Full paper pending access; title: "Diagnostic accuracy of point-of-care high-sensitivity troponin algorithms for emergency department rule-out and rule-in." This is directly relevant to UK chest pain units — the ESC 0h/1h algorithm using hs-cTnT is the current standard (NICE NG185). A POCT equivalent would have significant operational value in ambulance-to-needle or pre-hospital settings. Watch for publication in full.
CORE REVISION — ISSUE 26
Pulmonary Embolism: Risk Stratification to Disposition
The complete ED pathway — from pretest probability to outpatient anticoagulation
FRCEM exam relevance: PE appears in OSCE stations, SAQ papers, and EMQ banks. High-frequency clinical scenario in the ED. This revision covers the full pathway from clinical probability assessment through to disposition decision-making, in line with NICE NG158 (reviewed May 2026) and ESC 2019/2023 guidance.
STEP 1 — CLINICAL PROBABILITY ASSESSMENT
| WELLS SCORE ITEM | POINTS |
|---|---|
| Clinical signs/symptoms of DVT (leg swelling, tenderness) | 3 |
| Alternative diagnosis less likely than PE | 3 |
| Heart rate >100 bpm | 1.5 |
| Immobilisation ≥3 days or surgery in past 4 weeks | 1.5 |
| Previous PE or DVT | 1.5 |
| Haemoptysis | 1 |
| Malignancy (on treatment, or treated in past 6 months) | 1 |
| WELLS SCORE | PROBABILITY | NEXT STEP (NICE NG158) |
|---|---|---|
| ≤4 (unlikely) | Low (∼10%) | D-dimer first; if negative, no CTPA needed |
| ≥5 (likely) | Moderate-high (∼30–50%) | Proceed directly to CTPA without D-dimer |
PERC RULE — FOR VERY LOW PROBABILITY
If gestalt probability is <15%, apply PERC. All 8 criteria must be absent to rule out PE without D-dimer.
PERC CRITERIA — ALL MUST BE ABSENT
| Age ≥50 | SpO2 <95% on room air |
| HR ≥100 bpm | Leg swelling (unilateral) |
| Haemoptysis | Oestrogen use (OCP, HRT, pregnancy) |
| Recent surgery or trauma requiring hospitalisation (in past 4 weeks) | Prior PE or DVT |
If ALL 8 absent: PERC-negative. In a low pre-test probability population, miss rate ∼1.4% — acceptable for rule-out without D-dimer. PERC is not validated for moderate or high pre-test probability. Do not apply if Wells ≥5.
SEVERITY ASSESSMENT — SPESI (SIMPLIFIED PESI)
Once PE is confirmed, use sPESI to guide admission vs outpatient decision (NICE NG158 recommendation).
| SPESI VARIABLE | POINTS |
|---|---|
| Age >80 years | 1 |
| Cancer (active) | 1 |
| Chronic cardiopulmonary disease (chronic heart failure or COPD) | 1 |
| HR ≥110 bpm | 1 |
| SBP <100 mmHg | 1 |
| SpO2 <90% | 1 |
| SPESI SCORE | RISK | 30-DAY MORTALITY | DISPOSITION |
|---|---|---|---|
| 0 | Low | ∼1% | Outpatient if no contraindications (see below) |
| ≥1 | High | ∼10.9% | Admit for monitoring and treatment |
MASSIVE PE (HIGH-RISK) — IMMEDIATE HAEMODYNAMIC COMPROMISE
| FEATURE | ED MANAGEMENT |
|---|---|
| Cardiac arrest | ACLS + consider immediate systemic thrombolysis (alteplase 50 mg IV) or surgical/catheter embolectomy if available. Discuss with interventional team. |
| Obstructive shock (SBP <90, RV failure) | Systemic thrombolysis first-line unless absolute contraindication. Unfractionated heparin 80 IU/kg IV bolus. Vasopressors for haemodynamic support (noradrenaline preferred). Avoid aggressive fluid loading (can worsen RV distension). Call CTPA only if rapid diagnosis needed; do not delay thrombolysis for imaging if high clinical probability + haemodynamic collapse. |
| Transient hypotension (<15 min) | Intermediate-high risk. Consider thrombolysis if deteriorating despite anticoagulation. Discuss with haematology/cardiology. |
OUTPATIENT ANTICOAGULATION — NICE NG158 ELIGIBILITY
| CRITERION | CONSIDER OUTPATIENT IF... |
|---|---|
| sPESI score | 0 (low risk) |
| Haemodynamic status | Haemodynamically stable (SBP ≥100, HR <110, SpO2 ≥90%) |
| Symptoms | No severe dyspnoea, no significant pleuritic pain requiring IV analgesia |
| Social | Reliable follow-up, supportive home environment, able to understand anticoagulation |
| Renal function | eGFR ≥30 (for most DOACs; apixaban preferred if eGFR 15–29) |
| DOAC choice (NICE first-line) | Apixaban 10 mg BD for 7 days, then 5 mg BD; or Rivaroxaban 15 mg BD for 21 days, then 20 mg OD |
| Safety netting | Written discharge advice, clear return criteria (increasing dyspnoea, syncope, haemoptysis). Follow-up arranged within 5 working days. |
KEY NUMBERS FOR THE FRCEM EXAM
| CONCEPT | KEY NUMBER/FACT |
|---|---|
| Wells ≤4 + negative D-dimer | NPV 99.5% for PE (VIDAS D-dimer) |
| PERC-negative miss rate | ∼1.4% in low pre-test probability |
| sPESI 0, 30-day mortality | ∼1.0% |
| sPESI ≥1, 30-day mortality | ∼10.9% |
| Massive PE (obstructive shock) mortality without treatment | >50% |
| Alteplase dose for massive PE | 50 mg IV over 2 min (or 100 mg over 2h); hold heparin during infusion |
| CTPA sensitivity for PE | ∼83% (sub-segmental PE lower); negative CTPA has NPV >99% when used appropriately |
| D-dimer age-adjusted threshold | Age × 10 μg/L (for patients >50 years) — NICE NG158 recommends considering this |
| Contraindication to thrombolysis (absolute) | Active intracranial haemorrhage, recent (<3 months) intracranial surgery/trauma, known AVM/malignant intracranial tumour |
FRCEM exam focus: Wells score calculation; interpreting a raised D-dimer with a Wells ≤4; applying sPESI after confirmed PE; knowing when to thrombolyse (massive PE = cardiac arrest + obstructive shock + refractory hypoxia despite anticoagulation); DOAC choice for outpatient management; and criteria for safe discharge. Also know that PERC is not NICE-endorsed for formal use in the UK but appears in FRCEM SAQs as a clinical probability tool.
EM Evidence — emevidence.org
6 — ACTION POINTS THIS WEEK
Learn or consolidate SAPB: Serratus anterior plane block for rib fractures. Identify a departmental trainer or arrange a POCUS-based regional anaesthesia teaching session. Particularly valuable for elderly patients with 3+ rib fractures where undertreated pain drives respiratory failure.
- Single-dose dexamethasone for paediatric asthma: Check your department's current protocol. If still prescribing two doses routinely, raise at your next departmental or paediatric EM governance meeting with this evidence (Dave et al., Ann Emerg Med 2026, n=2,063).
- Stop prescribing azithromycin for preschool wheeze: AZ-SWED (NEJM, 18 May 2026) is definitive. No role for azithromycin in under-5s with viral/inflammatory wheeze in the absence of clear bacterial indication. Update any standing prescribing habits.
- RSI in myasthenia gravis: Draw up sugammadex 16 mg/kg before induction in any known MG patient. Standard rocuronium dosing appears reasonable; post-intubation neuromuscular monitoring should be documented.
- PE pathway: Know your trust's outpatient PE anticoagulation pathway. In low-risk (sPESI=0) confirmed PE, safe discharge with apixaban or rivaroxaban reduces unnecessary admission. Ensure written discharge advice and 5-day follow-up is in place.
- E-scooter injuries: Add e-scooter to your high-risk mechanism list for paediatric head injury. Mandatory safeguarding awareness given 74% from most deprived areas and the illegal status of most private e-scooter use.
- IO access in children: Do not delay or avoid IO when IV access has failed. Severe long-term complications are rare. Compartment syndrome risk exists but is low; monitor insertion site carefully and remove IO once IV access secured.
- Phoenix Sepsis Criteria: Familiarise yourself with the four Phoenix organ systems if not already. This is the current international standard for paediatric sepsis definition (replaces SIRS-based IPSCC 2005 criteria) and is appearing in FRCEM material.
TRIALS TO WATCH
Q3–Q4 2026
| ARREST II | Prehospital ECPR vs conventional CPR for refractory OHCA — UK multicentre. Results expected late 2026. |
| AIRWAYS-3 | Video laryngoscopy vs direct laryngoscopy for cardiac arrest in UK EDs — extended follow-up analysis. |
| NICE PE update | NICE NG158 (VTE) reviewed May 2026 — no change to recommendations. Next surveillance due 2027. |
2026–2027 HORIZON
| ADAPT-IA | Tenecteplase plus EVT vs EVT alone in acute ischaemic stroke — UK arm results. |
| SAPB trial expansion | Multicentre follow-up to Perice et al. for rib fracture regional anaesthesia in the ED — power calculation to detect OME difference. |
| ECMO for PE | UKTSSA registry analysis of ECMO use in massive PE — national case series expected 2027. |
LONGER HORIZON
| HEAT RCT | IV paracetamol vs placebo in septic patients with fever — phase III results due 2027. |
| eFONA outcome | UK registry of emergency front of neck airway outcomes (all CICO events) — ongoing registration via DAGGER. |
EM Evidence Rundown — Issue 26 — 21 August 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine (ST6), West Midlands. With the assistance of AI (Perplexity). All content editorially reviewed. Not a substitute for individual clinical judgement. This newsletter is for educational purposes only. Published by EM Evidence — emevidence.org | Archive and back issues available at emevidence.org. Feedback: jaketurner2503@gmail.com
Sources this issue include: EMA Daily (contact@emrap.org), JournalFeed (clay@journalfeed.org), McMaster EvidenceAlerts (evidencealerts@mcmasterhkr.com), PubMed MyNCBI saved searches (efback@ncbi.nlm.nih.gov), RCEM (rcem.ac.uk), NHS England, NICE NG158, BMA Backlog Analysis, SGEM, AliEM. Full citations with PMIDs and DOIs embedded in each item above.