EM Evidence Rundown — Issue 27

EM EVIDENCE RUNDOWN — ISSUE 27 — 28 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: The physiologically difficult airway — a definitive 2026 evidence-based update from Lacy, Long, Gottlieb and Mosier covering all five phenotypes: hypotension, hypoxaemia, metabolic acidaemia, right ventricular failure, and raised ICP. The RSI trial (n=2,367) supports etomidate over ketamine in catecholamine-depleted shocked patients. BVM ventilation between induction and laryngoscopy prevents severe hypoxia (NNT=9, PreVent trial). POCT hs-Troponin SR/MA (EMJ): In nearly 10,000 patients, point-of-care high-sensitivity troponin algorithms achieve sensitivity ≥97% for MI rule-out. Relevant as POCT hs-Trop deployment is accelerating in UK EDs. Rocuronium RSI Dosing: Using >1.2 mg/kg rocuronium with video laryngoscopy delivers 100% first-pass success vs 89.5% at standard doses. A direct prompt to audit your departmental RSI dose. Core Revision: Fever in Children under 5 — NICE NG143 traffic light system, red flags, PEWS, and safe discharge criteria.

BOTTOM LINE UP FRONT

ACT ON THIS NOW

CHANGE THIS MONTH Physiologically difficult airway (AJEM 2026): RSI trial (n=2,367): etomidate has LOWER peri-intubation cardiovascular collapse than ketamine in shocked patients (20.9% vs 30.6%). If your default is ketamine for all comers, review your crashed-patient protocol. BVM between induction and laryngoscopy: NNT=9 to prevent severe hypoxia (PreVent).

CHANGE THIS MONTH Rocuronium dosing (AJEM, n=154 intubations): >1.2 mg/kg with VL = 100% first-pass success vs 89.5% at standard doses. Check your department's default RSI rocuronium dose — underdosing is common.

CHANGE THIS MONTH HEART protocol + peer feedback (Ann Emerg Med, n=368,730 visits): Adding peer feedback to HEART-based chest pain protocols reduced admissions by 14% among highest-admitting clinicians. QIP opportunity.

CHANGE THIS MONTH Furosemide ADHF RCT (AJEM, n=50): Bolus and continuous infusion furosemide are equivalent in ED ADHF for early diuresis and urinary sodium. Use bolus (simpler). Monitor congestion with JVCI on POCUS.

CHANGE THIS MONTH EtCO2 in OHCA (Circulation): Dynamic EtCO2 capnography trajectories 7–21 min during CPR provide some prognostic data but should NOT be used to make TOR decisions. Continue resuscitation based on clinical criteria, not waveform trajectory alone.

KNOW FOR NEXT TIME

INFORMING PRACTICE POCT hs-Troponin SR/MA (EMJ, ~10,000 patients): Sensitivity ≥97% for MI rule-out. As POCT hs-trop rolls out in UK EDs, these algorithms are validated at high sensitivity — implementation is safe with appropriate protocol.

INFORMING PRACTICE IBI in febrile 60-90 day infants (JAMA Pediatr SR/MA, n=34,835): IBI prevalence 1.1%, bacteraemia 1.0%, meningitis 0.11%. Routine LP not warranted in well-appearing infants in this age group. Use validated risk stratification (NICE, PECARN, Step-by-Step).

INFORMING PRACTICE Acute ICH BP SR/MA (Crit Care Med, n=12,669): Aggressive vs conservative BP reduction: no difference in functional outcome or mortality. Aggressive strategy linked to fewer adverse events. Current NICE/AHA target (SBP 130-140 mmHg, avoid <130) remains appropriate.

INFORMING PRACTICE ED boarding older adults (Ann Emerg Med): Geriatric boarding has sharply escalated post-COVID; dementia patients disproportionately affected. UK equivalent: 2,300 corridor care instances/day; frail elderly are the most exposed group.

INFORMING PRACTICE Acute pericarditis in the ED: Gaps identified in aspirin dosing (weight-based) and early colchicine initiation. Start colchicine at diagnosis in ED; aspirin 500-1000 mg TDS (not PRN) for 1-2 weeks in low-risk patients.

INFORMING PRACTICE Core revision this issue: Fever in children under 5 — NICE NG143 traffic light system, red and amber flags, when to do LP, safe discharge criteria.

The physiologically difficult airway is the scenario that ends careers and haunts registrars. It is not the unexpected grade 4 view or the short neck — it is the patient who arrests in the 60 seconds between your ketamine push and your first laryngoscopy attempt, or who drops their oxygen saturation to 60% before you have placed the tube. This week's lead article from Lacy, Long, Gottlieb and Mosier in the American Journal of Emergency Medicine is a structured, evidence-based review of every phenotype that creates this risk, and — critically — what recent trials tell us about how to mitigate it. The RSI trial is the headline: the largest intubation RCT ever conducted, and its conclusion is that etomidate and ketamine are not equivalent in shocked patients. Etomidate now has the better haemodynamic data. Two other queued articles from your BMA library arrive this week: the furosemide ADHF RCT (bolus is fine) and the rocuronium dosing retrospective (go higher). In the PEM section, the JAMA Pediatrics SR/MA of 34,835 febrile infants aged 60-90 days gives the most precise contemporary prevalence estimate for invasive bacterial infection (1.1%), which lands directly in the core revision topic this issue: fever in children and how to risk stratify them.

WHAT'S INSIDE

• Physiologically difficult airway evidence update (LEAD)
• Rocuronium >1.2 mg/kg RSI first-pass success
• Furosemide ADHF: bolus = infusion in ED RCT
• EtCO2 during CPR and ROSC prediction (Circulation)
• POCT hs-Troponin SR/MA — Sn ≥97% for MI rule-out
• Aggressive vs conservative BP in ICH — SR/MA n=12,669
• HEART protocol + peer feedback — 14% admission reduction
• Acute pericarditis ED management gaps
• ED Boarding in older adults: geriatric boarding post-COVID
• PEM: IBI in febrile 60-90 day infants — JAMA Pediatr SR/MA
• FOAMed: SpO2 during CPR; low-field MRI in stroke
• Core Revision: Fever in Children Under 5 — NICE NG143

CHANGE TONIGHT Act immediately CHANGE THIS MONTH Adjust practice GUIDELINE Formal guidance INFORMING PRACTICE

Background evidence SAFETY ALERT

PAEDS EM

UK

FOAMED

Contents: 1. Key Trials & Articles — 2. Guidelines & UK Updates — 3. Paediatric EM — 4. FOAMed & Critical Appraisal — 5. Quick Hits — 6. Core Revision: Fever in Children — 7. Action Points — 8. Trials to Watch

1 — KEY TRIALS & ARTICLES

LEAD CHANGE THIS MONTH

The Physiologically Difficult Airway: A 2026 Evidence-Based Update

Lacy AJ, Long B, Gottlieb M, Mosier JM. American Journal of Emergency Medicine. 2026;108:180–191. doi:10.1016/j.ajem.2026.07.017 | Open access CC BY-NC-ND | JournalFeed 21 Aug 2026

What it covers: A 12-page structured evidence-based review of the physiologically difficult airway — the patient whose physiology, not anatomy, creates catastrophic intubation risk. Five phenotypes with dedicated management tables: (1) hypotension, (2) hypoxaemia, (3) metabolic acidaemia, (4) RV failure, and (5) raised ICP.

PHENOTYPE 1: HYPOTENSION

Pre-intubation hypotension carries a 3–6-fold increased risk of peri-intubation cardiac arrest. The shock index (SI = HR/SBP) is a bedside tool for stratification: SI ≥0.8–1.0 = strong predictor of cardiovascular collapse (OR 3.2–5.5).

• +9.7% ARD — PERI-INTUBATION CV COLLAPSE (KETAMINE VS ETOMIDATE; 95% CI 4.6–14.9%)
• 30.6% KETAMINE: CV COLLAPSE (NEW/INCREASED VASOPRESSOR, OR SBP <65)
• 20.9% ETOMIDATE: CV COLLAPSE — P<0.01 (RSI TRIAL, LARGEST INTUBATION RCT EVER)
• n=2,367 RSI TRIAL; 8 ICUS + 6 EDS; 28-DAY MORTALITY IDENTICAL

RSI trial takeaway: The 9.7% absolute difference in CV collapse (mostly driven by vasopressor requirement, not cardiac arrest or severe hypotension) is the strongest signal yet favouring etomidate in the shocked patient. This reverses years of dogma that ketamine is always the safer induction choice. Etomidate adrenal suppression remains a concern for 24h post-intubation outcomes — but in the acutely shocked patient, getting the airway without cardiovascular collapse is the priority. Avoid propofol, midazolam, and fentanyl as primary/co-induction agents in any hypotensive patient (ACEP guidance confirmed).

PREPARE / PREPARE II: Routine 500 mL pre-intubation fluid bolus does NOT prevent cardiovascular collapse for all-comers. Individualise: volume resuscitate hypovolaemia (blood for haemorrhagic shock), use vasopressors (noradrenaline infusion) for those who are volume-intolerant. Push-dose vasopressors are safe for unexpected hypotension but do not reliably prevent peri-intubation collapse as prophylaxis.

PHENOTYPE 2: HYPOXAEMIA

HFNO vs HFNC: High-flow nasal oxygen (HFNO, 40–70 L/min, heated/humidified) is distinct from high-flow nasal cannula (HFNC, >15 L/min flush-rate). These are different devices. HFNO significantly prolongs safe apnea time vs facemask (SR/MA of 3,914 patients from 52 studies).

• NNT=9 TO PREVENT 1 EPISODE OF SEVERE HYPOXIA (SPO2 <80%) WITH BVM BETWEEN INDUCTION AND LARYNGOSCOPY
• 10.9% SEVERE HYPOXIA WITH BVM (PREVENT TRIAL, N=401, 7 ICUS)
• 22.8% SEVERE HYPOXIA WITHOUT BVM (CONTROL ARM, APNEIC OXYGENATION ALLOWED)
• RR=0.48 95% CI 0.30–0.77 FOR SEVERE HYPOXIA

Practical technique (BVM between induction and laryngoscopy): O2 flow ≥15 L/min, PEEP valve (5–10 cmH2O), oropharyngeal airway, two-handed mask seal, 10 breaths/min. Can be left running during laryngoscopy attempt via apneic oxygenation (HFNC/HFNO stays on nose).

PHENOTYPE 3: METABOLIC ACIDAEMIA | PHENOTYPE 4: RV FAILURE | PHENOTYPE 5: RAISED ICP

UK clinical summary: This review belongs on every EM registrar's reading list. Download it via your BMA library (open access, Am J Emerg Med 2026;108:180–191). In the resus bay: (1) Use shock index to risk-stratify before RSI. SI ≥0.8 = high risk; personalise fluids/vasopressors before pushing ketamine or etomidate. (2) Etomidate now has stronger evidence than ketamine in catecholamine-depleted shocked patients. (3) Ventilate between induction and laryngoscopy in hypoxaemic patients — NNT=9. (4) In DKA or severe metabolic acidaemia, match the patient's respiratory rate before you have the tube in.

CHANGE THIS MONTH

Rocuronium >1.2 mg/kg for RSI: 100% First-Pass Success vs 89.5% at Standard Doses

Szesnat M, Watts A, Tobin MA, Cason TH, Gibbs M. American Journal of Emergency Medicine. 2026;109:75–80. PMID: 42385663 | JournalFeed 21 Aug 2026

• 100% FIRST-PASS SUCCESS: >1.2 MG/KG (MEAN 1.5 MG/KG)
• 89.5% FIRST-PASS SUCCESS: ≤1.2 MG/KG (MEAN 1.0 MG/KG)
• ARD −10.5% 95% CI −0.2 TO −0.03; P<0.01
• n=154 INTUBATIONS, 144 PATIENTS; ED + ICU; ALL VL; RETROSPECTIVE

Single-centre retrospective cohort; all intubations performed with video laryngoscopy. No difference in 30-day mortality, ICU/hospital LOS, or time to intubation. No significant differences in subgroup analyses (obesity, sepsis, heart failure).

Critical appraisal: Retrospective, single-centre, confounded by BMI difference between groups (leaner patients got higher weight-based doses). No downstream mortality benefit, only procedural success. That said, this is consistent with multiple earlier studies and the dose-response relationship is physiologically coherent. JournalFeed (21 Aug): "When paralysis is the goal, an appropriate RSI dose of 1.2–1.5 mg/kg provides the best intubating conditions."

UK practice: Many UK EDs and ambulance services use flat-dose 100 mg rocuronium, which underdoses patients over 83 kg. Actual-body-weight-based dosing at 1.2 mg/kg (minimum; consider 1.5 mg/kg for physiologically difficult airway) is appropriate for routine RSI. Ensure sugammadex 16 mg/kg is drawn up before pushing. Review your departmental RSI drug chart.

CHANGE THIS MONTH

Bolus vs Continuous Infusion Furosemide in ED ADHF: No Difference — RCT

Korkmaz HK, Güngör AC, Çevik E. American Journal of Emergency Medicine. 2026. doi:10.1016/j.ajem.2026.08.009 | Pre-proof; BMA ClinicalKey access

• 2,150 mL CUMULATIVE 4H URINE OUTPUT: BOLUS GROUP
• 2,400 mL CUMULATIVE 4H URINE OUTPUT: INFUSION GROUP (P=0.60)
• n=50 DOUBLE-BLIND RCT; SINGLE ED, ISTANBUL. NYHA III–IV, NO CKD.
• JVCI IMPROVED SIGNIFICANTLY OVER TIME IN BOTH GROUPS (P<0.001) — USEFUL POCUS CONGESTION MONITOR

No significant difference in 4h urine output, JVCI change, or spot urinary sodium between bolus and continuous infusion furosemide. Consistent with prior Cochrane SR data showing no superiority of either strategy. JVCI (jugular vein collapsibility index on POCUS) improved significantly in both groups over time — suggesting it is a useful real-time ED congestion monitoring tool.

UK practice: Use bolus IV furosemide (simpler, no syringe driver required, no infusion rate errors). Typical ED starting dose: 40–80 mg IV bolus (or double the usual oral dose). NICE guidance on acute heart failure supports IV furosemide without specifying bolus vs infusion mode. Use bedside IVC or jugular vein POCUS to monitor decongestion response over 1–2 hours before deciding on repeat dosing. Refer to cardiology for failure to respond or haemodynamic compromise.

CHANGE THIS MONTH

EtCO2 Capnography Trajectories During CPR and ROSC: Prognostic but Not for TOR

Nassal MMJ, Smith RM, Aramendi E, et al. Circulation. 2026;154(2):88–95. PMID: 42145111 | EMA Daily 21 Aug 2026

What they found: Dynamic EtCO2 capnography trajectories observed between 7 and 21 minutes during the resuscitation of OHCA patients provide some prognostic data — rising EtCO2 trajectory is associated with ROSC. However, the editorial commentary from EMA Daily (DeLaney) is critical: these findings should NOT be used to make termination-of-resuscitation decisions. EtCO2 waveform interpretation during OHCA does not reliably identify futile resuscitations on its own.

Do not TOR based on EtCO2 alone: The current Resuscitation Council UK (RCUK) and ERC guidance for TOR decisions in OHCA does not include EtCO2 trajectory as a criterion. The single recognised use of EtCO2 in TOR is a persistently low static value (<10 mmHg after 20 minutes) as one factor supporting a TOR decision in a non-shockable rhythm, when combined with other criteria. Dynamic trajectory interpretation remains research, not practice.

INFORMING PRACTICE

Point-of-Care hs-Troponin for MI Rule-Out/Rule-In: Sensitivity ≥97% in SR/MA of ~10,000 Patients

Capodifoglio S, De Iuliis V. Emergency Medicine Journal. 2026. doi:10.1136/emermed-2026-215922 | JournalFeed 25 Aug 2026

• ≥97% SENSITIVITY FOR MI RULE-OUT USING POCT HS-TROPONIN ALGORITHMS
• ~10,000 ADULTS INCLUDED IN THE SR/MA
• High Sp SPECIFICITY ALSO HIGH FOR RULE-IN USING SERIAL ALGORITHM
• EMJ SR/MA; PUBLISHED 2026; MCMASTER FLAGGED AUG 2026

This meta-analysis of approximately 10,000 adults confirms that POCT hs-troponin algorithms (0/1-hour serial sampling) achieve sensitivity ≥97% for MI rule-out, comparable to laboratory hs-troponin pathways. Rule-in specificity was also high with serial testing.

UK relevance: Several UK emergency departments and ambulance services are now piloting or deploying POCT hs-troponin devices. This SR/MA provides confidence that POCT-based 0/1-hour algorithms are diagnostically safe for rule-out when implemented with appropriate protocols. The key limitation is assay-specific: different POCT devices have different 99th percentile thresholds and delta values — use only validated algorithms for the specific device in use. NICE guidance (NG185) recommends laboratory hs-cTn as the standard; POCT-based pathways should be implemented with local pharmacy and cardiology agreement.

INFORMING PRACTICE

Aggressive vs Conservative BP Reduction in Acute ICH: SR/MA of 12,669 Patients

Semione G, Ferreira MY, Gunkan A et al. Critical Care Medicine. 2026. PMID: 42484370 | JournalFeed 26 Aug 2026

• No difference FUNCTIONAL OUTCOME, MORTALITY, OR HEMATOMA GROWTH (8 RCTS, 12,669 PATIENTS)
• RR 0.87 FEWER ADVERSE EVENTS WITH AGGRESSIVE BP LOWERING (95% CI 0.76–0.99; P=0.03)
• n=12,669 8 RCTS; MIXED RCTS INCLUDING INTERACT2, ATACH-2, ENCHANTED SERIES
• Target SBP 130–140 MMHG STILL APPROPRIATE; AVOID <130 MMHG

Bottom line (Vera Health): "Continue prompt, protocolised BP lowering for acute ICH when tolerated, but do not promise improved recovery or survival solely by pursuing an aggressive target." The current NICE/AHA approach — target SBP 130–140 mmHg, avoid <130 mmHg, use titratable IV agents (e.g. labetalol, nicardipine), avoid GTN (vasodilator, proven harmful in ICH) — remains evidence-based and is not overturned by this SR/MA.

INFORMING PRACTICE

Peer Feedback + HEART Protocol Reduces High-Admitter Chest Pain Admissions by 14%

Oskvarek JJ, Zocchi MS, Jouriles N et al. Annals of Emergency Medicine. 2026. PMID: 42080778 | EMA Daily 24 Aug 2026

In 368,730 chest pain visits across 38 EDs, adding peer feedback to HEART-based chest pain protocols reduced admissions by 14.3% among the highest-admitting clinicians in state A (95% CI −21.7% to −6.9%) and 5.6% in state B. Effect was confined to outlier-high admitters, not across-the-board. No patient safety data presented.

EMA Daily (Beck-Esmay): "The absence of patient-centred safety data means this finding should be considered a promising quality-improvement signal rather than proof that these avoided admissions were truly avoidable." QIP opportunity for any UK department where HEART is used but admission rates remain high. NICE NG185 (chest pain) already recommends hs-troponin-based pathways; peer feedback on outlier admitters is a low-cost intervention.

2 — GUIDELINES & UK UPDATES

UK INFORMING PRACTICE

ED Boarding in Older Adults Has Sharply Escalated Since COVID — Dementia Patients Most Affected

Lee S, Gunaga S, Liu SW et al. Annals of Emergency Medicine. 2026. PMID: 42084584 | EMA Daily 27 Aug 2026

This national (US) analysis with temporal weighting confirms that geriatric ED boarding has sharply escalated since the COVID-19 pandemic, with patients with Alzheimer's disease and related dementias (ADRD) disproportionately affected and at highest risk. EMA Daily (DeLaney): "useful national confirmation that geriatric boarding has sharply escalated, though it does not offer granular detail about specific risk factors."

UK framing: The UK corridor care data is stark: in July 2026, an average of 2,300 corridor care episodes per day across English EDs, and 60.1% of patients who no longer meet criteria to remain in hospital remain admitted due to discharge delays. Frail elderly and dementia patients are the primary victims. The RCEM has called this a pre-winter breaking-point and has published updated DoLS and frailty guidance. Within your ED: identify patients with ADRD early, flag for rapid social care assessment, and use the RCEM Frailty toolkit for discharge pathway planning.

INFORMING PRACTICE

Acute Pericarditis in the ED: Colchicine and Aspirin Dosing Gaps Identified

Caldera L, Lovati C, Vecchié A et al. Eur J Clin Invest. 2026;56(5):e70206. PMID: 42032877 | EMA Daily 25 Aug 2026

Retrospective single-centre study of acute pericarditis management in the ED. Highlights two key gaps identified: aspirin often under-dosed (should be weight-based, 500–1000 mg TDS) and colchicine not initiated in the ED in all eligible cases (should be started at diagnosis, 0.5 mg BD for 3 months). EMA Daily (DeLaney): "does not provide reliable risk stratification data, but highlights areas for improvement."

UK practice reminder (ESC 2015/NICE CKS guidance): Acute pericarditis without features of concern: NSAIDs (ibuprofen 400–600 mg TDS with food, or aspirin 500–1000 mg TDS) + colchicine 0.5 mg BD (if <70 kg: 0.5 mg OD) for 3 months. No NSAID allergy or renal contraindication. Admit or refer urgently if: high-risk features (fever >38°C, large effusion >20 mm, tamponade, myopericarditis, immunocompromised, on anticoagulation, traumatic). Outpatient follow-up at 1 week if discharged.

3 — PAEDIATRIC EMERGENCY MEDICINE

PAEDS EM CHANGE THIS MONTH

Invasive Bacterial Infection in Febrile Infants 60–90 Days: IBI 1.1%, Meningitis 0.11% — SR/MA

Dionisopoulos Z, Sabhaney V, D'Arienzo D et al. JAMA Pediatrics. 2026;180(8):838–850. PMID: 42189531 | EMA Daily 26 Aug 2026

• 1.11% POOLED IBI PREVALENCE (95% CI 0.84%–1.47%)
• 1.01% BACTERAEMIA PREVALENCE (95% CI 0.76%–1.34%)
• 0.11% BACTERIAL MENINGITIS PREVALENCE (95% CI 0.08%–0.16%)
• n=34,835 INFANTS; 59 STUDIES; 20 DISTINCT DATASETS; WELL-APPEARING ONLY

What they found: In well-appearing febrile infants aged 60–90 days, the contemporary pooled prevalence of invasive bacterial infection (IBI) was 1.11%; bacteraemia accounted for most cases; bacterial meningitis was rare (0.11%). Results were consistent across sensitivity analyses. Study included infants evaluated in ED or outpatient settings.

EMA Daily (Beck-Esmay): "Clinicians can reasonably consider selective testing strategies and use validated risk-stratification tools to further individualise care. Routine lumbar puncture in well-appearing infants in this age group is unlikely to be warranted, given the very low meningitis prevalence." UK context: NICE CG160/NG143 and UK NICE/NICE CKS guidance for 1-3 month infants uses traffic light + clinical assessment + inflammatory markers (CRP, FBC, PCT where available) to risk stratify. Risk stratification tools validated in Europe include the Rochester Criteria (age 60-89 days), Step-by-Step algorithm, and PECARN low-risk rule — these perform better than old dogma of reflexive LP in all 1-3 month infants. The 0.11% meningitis prevalence here supports not doing LP in clinically well infants who meet low-risk criteria.

4 — FOAMED & CRITICAL APPRAISAL

FOAMED INFORMING PRACTICE

SpO2 During CPR and ROSC: Higher Saturations Associate with ROSC, But Interpretation is Limited

Malinverni S, et al. Resuscitation. 2026. PMID: 42492623 | JournalFeed 27 Aug 2026

In 98 OHCA patients, higher event-average pulse oximetry saturation during CPR was associated with increased probability of ROSC. However, higher SpO2 did not improve neurological outcomes. JournalFeed summary: "SpO2 monitoring during OHCA may be useful but did not improve neurological outcomes." Observational, n=98, significant limitations around SpO2 reliability during CPR (pulse oximetry accuracy during low-flow states is unreliable). The physiological premise is sound — adequate perfusion during CPR matters — but this study cannot guide routine SpO2 monitoring during resuscitation or TOR thresholds.

FOAMED INFORMING PRACTICE

Portable Low-Field MRI in Acute Stroke: Role and Evidence Review

Sorby-Adams A, Pinter NK, Muir KW et al. Stroke. 2026. | JournalFeed 24 Aug 2026

Review article summarising the evolving role of portable low-field MRI (e.g. Hyperfine Swoop) as an adjunct in acute stroke care. Key points: low-field MRI (0.064 T) can support stroke-type classification and tissue confirmation in settings where immediate CT or standard MRI is unavailable, particularly in rural/remote settings and ICU. JournalFeed: "a promising adjunct, particularly where timely conventional neuroimaging is unavailable." Not yet a standard of care in UK EDs, but watch this space — portable MRI deployment in stroke pathways is an active NHS England research area.

5 — QUICK HITS

Novel POCUS Approaches for Shoulder Dislocation (JF EM Speed Read 21 Aug)

Am J Emerg Med 2026 | JournalFeed 21 Aug 2026

Review of alternative POCUS windows, diagnostic signs, and a stepwise protocol for shoulder dislocation. Useful for any department where glenohumeral dislocation management is done bedside. POCUS reduces time to diagnosis, guides procedural access, and can confirm reduction without post-procedural X-ray in straightforward cases. Consider for your next department POCUS teaching session — this paper provides a stepwise protocol.

Reducing Unnecessary Bronchoscopies in Children: Predictive Model (JF PEM Tue 25 Aug)

Pediatr Emerg Care 2026 | JournalFeed Speed Read

A predictive model for identifying paediatric patients with suspected foreign body inhalation who do NOT require diagnostic bronchoscopy. Relevant to any ED where suspected paediatric airway foreign body is managed — a clinical decision tool to reduce unnecessary procedures. Contact paediatric respiratory team before bronchoscopy in asymptomatic patients with clear CXR.

ICH Blood Pressure Lowering for Secondary Prevention (Lancet Neurology, RECAP-ICH)

RECAP-ICH SR/MA; Lancet Neurol. 2026 Sep;25(9):830–839. PMID: 42586098

Individual patient data meta-analysis of long-term BP lowering after ICH (n=2,944; 4 trials including RECAP, PROGRESS, RESPECT, TRIDENT). Intensive long-term BP lowering reduced recurrent stroke hazard by 38% (adjusted HR 0.62; p=0.0002), driven by fewer recurrent haemorrhages. Time to 1% absolute benefit: 6 months. UK ED relevance: ensure all ICH survivors are counselled on long-term BP control and anticoagulation is reviewed at discharge. Refer to stroke/neurology for long-term BP management at <130/80 mmHg target.

CORE REVISION — ISSUE 27

Fever in Children Under 5: Risk Stratification to Safe Discharge

NICE NG143 traffic light system, red flags, serious bacterial illness, and when to do an LP

FRCEM exam relevance: Fever in children is a high-frequency paediatric EM scenario. This revision covers the NICE NG143 traffic light system, the clinical decision for LP in young infants, management of the febrile under-5, and safe discharge criteria. Directly complemented by this week's JAMA Pediatrics SR/MA on IBI in febrile 60–90 day infants.

THE NICE NG143 TRAFFIC LIGHT SYSTEM

AGE-SPECIFIC TACHYPNOEA THRESHOLDS (RED FLAG)

FEVER IN INFANTS UNDER 3 MONTHS — SPECIAL GROUPS

UK STEP-BY-STEP ALGORITHM (60–90 DAY INFANTS)

The Step-by-Step algorithm classifies 60-90 day febrile infants as low-risk for IBI if ALL of the following are met:

Low-risk Step-by-Step: NPV for IBI ~99.7%. Discharge with close safety-net. LP not required if all criteria met and clinician confident in assessment. High-risk Step-by-Step or ANY red flag: admit, full septic screen including LP, blood culture, IV antibiotics.

ANTIPYRETICS — EVIDENCE AND UK PRACTICE

SAFE DISCHARGE SAFETY-NET (NICE NG143)

Advise parents/carers to return immediately if the child:

• Develops a non-blanching rash
• Has a bulging fontanelle (infant)
• Has a new seizure, or seizure lasting >5 min
• Becomes significantly more unwell (pale, cold, mottled, very drowsy)
• Fever persists >5 days
• Has signs of dehydration: no wet nappy for 12h, dry mouth, sunken eyes, no tears, poor feeding
• Parents are significantly worried or cannot manage at home

FRCEM exam focus: Traffic light system definitions (know amber vs red criteria). Threshold temperatures by age. When to do LP vs when validated tools allow withholding LP. Rochester / Step-by-Step criteria for 60-90 day infants. When NOT to use ibuprofen. The number 0.11% for meningitis in well-appearing 60-90 day febrile infants (JAMA Pediatr 2026 SR/MA, n=34,835).

EM Evidence — emevidence.org

FRCEM RELEVANT

6 — ACTION POINTS THIS WEEK

• RSI protocol review: Check your departmental RSI drug card. Rocuronium dose should be 1.2 mg/kg actual body weight (consider 1.5 mg/kg for physiologically difficult airway). If your default is 100 mg flat-dose, propose a protocol change. Sugammadex 16 mg/kg must be drawn up before induction in all RSI scenarios.
• Shocked patient — induction agent: Discuss with your team: in the catecholamine-depleted shocked patient (SI ≥1.0), the RSI trial supports etomidate over ketamine. Not a blanket rule, but a patient-centred consideration. Document your reasoning.
• BVM between induction and laryngoscopy: Make this standard practice for all hypoxaemic patients undergoing RSI. Set up the BVM (PEEP valve 5–10 cmH2O, oropharyngeal airway, two-handed seal) BEFORE you push drugs. NNT=9 to prevent severe hypoxia.
• ADHF furosemide: Use bolus IV furosemide (no syringe driver needed). Monitor congestion response with bedside JVCI POCUS at 1–2 hours. If JVCI not improving, reassess dose and haemodynamic status before repeating.
• Febrile 60–90 day infants: Apply Step-by-Step or Rochester risk stratification. Well-appearing infants meeting all low-risk criteria (WBC <15, CRP <20, PCT <0.5, negative UA, no red flags) do not require routine LP. IBI 1.1%, meningitis 0.11%. Document decision and ensure clear safety-net.
• Acute pericarditis: Start colchicine at diagnosis in the ED (0.5 mg BD; or 0.5 mg OD if <70 kg) and ensure aspirin is prescribed at adequate dose (not PRN). Document discharge plan and 1-week follow-up.
• ICH BP: Target SBP 130–140 mmHg rapidly with titratable IV agent (labetalol infusion, nicardipine if available). Avoid GTN (worsens outcome). Avoid SBP <130 mmHg. Aggressive and conservative targets yield equivalent functional outcomes — current target is the sweet spot.

TRIALS TO WATCH

Q3–Q4 2026

2026–2027 HORIZON

LONGER HORIZON