EM EVIDENCE RUNDOWN — ISSUE 28 — 4 SEPTEMBER 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 (American Guideline): ATS Clinical Practice Guideline on Noninvasive Respiratory Support 2026 — strong recommendation for HFNC first-line in acute hypoxaemic respiratory failure (RR 0.76 intubation; NNT ~12; moderate certainty). Strong recommendation for HFNC or NIV for pre-intubation preoxygenation (NIV RR 0.51; high certainty). Aligns with DAS 2025 peroxygenation emphasis. Change This Month: Routine CTCA after negative hs-Troponin does NOT reduce MI or cardiac death (TARGET-CTCA, NEJM, UK RCT, n=3,170; HR 0.95; p=0.71). Reserve CTCA for intermediate-risk patients only. FOAMed alert: SGEM#518 — Oseltamivir for hospitalised influenza: randomised preprint found no 90-day survival benefit and a possible harm signal. Do not prescribe reflexively outside UKHSA indications. Paediatric EM: Supraglottitis in children increasing; adenovirus now a common aetiology. Post-arrest prophylactic antibiotics: not routinely recommended. Febrile seizure in Kawasaki flags severe coronary involvement. Core Revision: RSI — DAS 2025 guidelines: peroxygenation, VL first-line, 3+1 rule, Plans A–D algorithm, eFONA scalpel-bougie-tube technique. FRCEM-relevant.
BOTTOM LINE UP FRONT — 4 SEPTEMBER 2026
ACT ON THIS NOW
GUIDELINE (AMERICAN) ATS NIRS Guideline 2026: Strong recommendation — HFNC over standard O2 for acute hypoxaemic failure (RR 0.76 intubation; NNT ~12). Strong recommendation — HFNC or NIV for pre-intubation preoxygenation. Review your ED preoxygenation SOP in light of DAS 2025 and this guideline.
CHANGE THIS MONTH TARGET-CTCA (NEJM, UK, n=3,170): Routine CTCA after troponin rule-out does NOT reduce MI or cardiac death (HR 0.95; p=0.71). Reserve CTCA for intermediate-risk patients (HEART ≥4, unexplained ECG changes). Do not request routinely.
FOAMED ALERT Oseltamivir in hospitalised influenza (SGEM#518): Randomised preprint — no 90-day survival benefit, possible harm signal. Do not give reflexively outside UKHSA/NICE indications. Await peer-reviewed publication.
INFORMING Physio-led MSK in ED (Lancet 2026): As safe and effective as physician-led, reduces LOS. Lancet-level evidence for the APP model in UK EDs.
KNOW FOR NEXT TIME
PAEDS EM Supraglottitis in children (Paediatr Pulmonol): Increasing; adenovirus now common. Even vaccinated children. Senior anaesthetics + ENT immediately. Do not examine oropharynx. Theatre for controlled intubation under GA.
PAEDS EM Post-paeds CA prophylactic antibiotics (Resuscitation 2026): Not routinely recommended. Individual judgement for documented aspiration. All post-arrest children to PICU.
PAEDS EM Kawasaki + febrile seizure: Flags more severe coronary artery involvement. Escalate to paediatric cardiology urgently for echo.
FOAMED EMCrit 432 (Aug 2026): Airway cases — physiologically difficult airway, real-world eFONA, petrified secretions. Essential listening alongside this month’s DAS 2025 RSI revision.
INFORMING Core revision: RSI — DAS 2025 complete algorithm, peroxygenation, Plans A–D, eFONA technique. FRCEM.
This week’s issue is anchored by the ATS 2026 Clinical Practice Guideline on Noninvasive Respiratory Support — the most comprehensive evidence synthesis on HFNC and NIV yet, with formal guideline support for HFNC first-line in acute hypoxaemic failure and for pre-intubation preoxygenation, directly complementing the DAS 2025 peroxygenation principle. TARGET-CTCA (NEJM, UK, n=3,170) closes the question of routine post-rule-out CTCA. The SGEM flag on oseltamivir in hospitalised patients deserves caution even as a preprint. The paediatric EM section covers viral supraglottitis, post-arrest antibiotic decisions, and Kawasaki-associated febrile seizures. EMCrit 432 is excellent listening alongside this month’s RSI revision, which covers the DAS 2025 guidelines in full. RCEM Learning modules are flagged at the end for CPD.
WHAT’S INSIDE — ISSUE 28
- Lead (American): ATS NIRS Guideline 2026 — HFNC + NIV evidence
- SGEM#518 — Oseltamivir hospitalised flu: no benefit, harm signal
- Physio-led MSK care in ED: Lancet trial
- CTCA after MI rule-out: TARGET-CTCA NEJM — not routinely beneficial
- Whole blood vs component therapy SR (AEM journal club)
- AHF + infection: independent mortality driver (EJEMA)
- VExUS POCUS de-resuscitation pilot RCT in septic shock
- Procedural sedation Delphi consensus (Ann Emerg Med)
- Dexmedetomidine bridge sedation for agitated adults
- DOAC Clinical Policy — ACEP (Ann Emerg Med)
- RCEM Corporate Plan 2027–2032
- Mobile AED deployment by community first responders
- Low-risk PE safe to discharge from ED
- PEM: Prophylactic antibiotics post-paeds cardiac arrest
- PEM: Supraglottitis increasing; adenovirus aetiology
- PEM: Paeds OHCA beyond witness status
- PEM: Febrile seizure in Kawasaki disease
- FOAMed: JournalFeed ATS NIRS emphasis
- FOAMed: EMCrit 432 — Airway cases and DAS 2025 application
- FOAMed: POCUS for ETT confirmation — TUS fastest at 4.6 seconds
- RCEM Learning — modules to flag to your team
- Core Revision: RSI — DAS 2025 guidelines
Contents: 1. Key Trials & Articles — 2. Guidelines & UK Updates — 3. Resuscitation — 4. Paediatric EM — 5. FOAMed & Critical Appraisal — 6. RCEM Learning — 7. Action Points — 8. Trials to Watch — 9. Core Revision: RSI (DAS 2025)
1 — KEY TRIALS & ARTICLES
Noninvasive Respiratory Support in Acute Respiratory Failure — Official ATS Clinical Practice Guideline 2026
Goel NN, Ferreyro BL, Pitre T et al. American Journal of Respiratory and Critical Care Medicine. 2026;212(9):2135–2158. doi:10.1093/ajrccm/aamag302 — American Thoracic Society (ATS) guideline — not a UK guideline body. McMaster Evidence Alerts, 2 Sep 2026. What this is: An official Clinical Practice Guideline from the American Thoracic Society, based on network meta-analyses across four PICO questions: 39 RCTs (acute hypoxaemic failure, n=7,640), 42 RCTs (hypercapnic failure, n=4,763), 15 RCTs (preoxygenation, n=3,420), and 52 RCTs (post-extubation, n=9,840). Frame as an American guideline when applying to UK practice.
- RR 0.76 HFNC VS STANDARD O2 — INTUBATION (95% CI 0.64–0.89; MODERATE CERTAINTY)
- ARD ~8% ESTIMATED ABSOLUTE REDUCTION IN INTUBATION; NNT ~12
- RR 0.81 HFNC VS STANDARD O2 — MORTALITY (95% CI 0.67–0.97; LOW CERTAINTY)
- n=7,640 39 RCTS; ANY AETIOLOGY; NETWORK META-ANALYSIS
Pre-intubation preoxygenation: Strong recommendation for HFNC or NIV over standard O2. NIV vs standard O2: RR 0.51 for intubation (95% CI 0.35–0.75; high certainty; 15 RCTs, n=3,420).
UK practice: This ATS guideline aligns well with current BTS HFNC guidance (2022) and directly supports DAS 2025’s peroxygenation principle — continuous oxygen delivery from before induction through all airway attempts. For ED RSI: HFNC at 30–60 L/min + FiO2 1.0 (NODESAT) or NIV preoxygenation (BiPAP with tight-fitting mask) are both strongly supported. Review your department’s preoxygenation SOP and ensure HFNC equipment is available at the bedside for RSI.
SGEM#518 — Oseltamivir for Hospitalised Influenza: No Survival Benefit, Possible Harm Signal
The Skeptics Guide to Emergency Medicine. SGEM#518. Published 23 August 2026. thesgem.com Critical appraisal of a randomised preprint examining oseltamivir in critically ill patients with confirmed influenza. No 90-day survival benefit from 5 or 10 days of oseltamivir vs no antiviral. A possible harm signal was raised (Bayesian posterior probability of harm >96%), but frequentist analysis (p=0.2–0.4) is not significant. Important study limitations: site selection, baseline imbalances, treatment crossover.
UK practice: This is a preprint — not peer-reviewed. Pre-test probability of a 5-day oseltamivir course causing significant mortality is low given large network meta-analyses showing no mortality effect. Do not prescribe oseltamivir reflexively to all hospitalised influenza patients. Follow current UKHSA/NICE indications (at-risk groups: immunosuppressed, severe illness, pregnancy, BMI >40). Await peer-reviewed publication before any policy change.
Physiotherapist-Led Care for Musculoskeletal Conditions in the ED — Lancet 2026
PMID: 42660158. Lancet. 2026. Physiotherapist-led assessment and management of MSK presentations in UK EDs is as safe and effective as physician-led care, with reduced ED length of stay and high patient satisfaction. Directly supports the advanced physiotherapy practitioner (APP) model in UK EDs.
UK practice: Lancet-level evidence for physiotherapy-led MSK pathways. If your ED does not have APP-led MSK streams, use this to build the business case with your clinical director. Share with your ED governance lead.
TARGET-CTCA — Routine CTCA After Troponin Rule-Out Does NOT Reduce MI or Cardiac Death (NEJM 2026, UK)
TARGET-CTCA Investigators; British Heart Foundation. New England Journal of Medicine. 2026. PMID: 42670980 — UK multicentre RCT, n=3,170 (14 hospitals) Design: UK multicentre open-label RCT at 14 hospitals (September 2019–May 2023). Enrolled 3,170 patients with suspected ACS whose MI had been ruled out by hs-Troponin and who had an intermediate-risk Tn result (Tn I or T >5 ng/L). 1:1 randomisation to outpatient CTCA-guided management vs standard care. Median age 61 years; 30% female. Median follow-up 3.0 years. BHF-funded (no commercial involvement).
Primary outcome — composite of MI or cardiac death at 3 years: 7.1% CTCA arm (112/1,587) vs 7.3% standard care (116/1,583). Adjusted HR 0.95 (95% CI 0.73–1.23; p=0.71). ARD −0.2% — clinically negligible. CTCA uptake was excellent: 92.1% of the CTCA arm received the scan, vs only 2.2% in standard care, confirming this genuinely compares routine vs selective CTCA.
Critical appraisal: This is a well-conducted trial. The 95% CI definitively rules out a clinically meaningful benefit (HR <0.73). The comparison is truly routine vs selective CTCA since the standard-care arm could still receive CTCA at physician discretion — making the result directly applicable to UK practice. The trial enrolled patients by Tn criteria alone rather than clinical risk score, so some enrolled patients may have been lower risk than a HEART score-based selection would produce. The 30% female enrolment is low but reflects the enrolled ACS-rule-out population. No commercial funding reduces the risk of publication bias. The event count exceeded the pre-specified minimum, confirming the trial was not underpowered for the null result.
- HR 0.95 MI OR CARDIAC DEATH (95% CI 0.73–1.23; P=0.71)
- 7.1% CTCA ARM (1,587 PATIENTS)
- 7.3% STANDARD CARE ARM (1,583 PATIENTS)
UK practice: Do not routinely request CTCA after a negative hs-Troponin. Reserve for intermediate-risk patients (HEART ≥4, unexplained new ECG changes, or strong clinical suspicion despite negative troponin). This confirms current practice of selective CTCA is correct.
Whole Blood vs Component Therapy for Out-of-Hospital Trauma — AEM Journal Club September 2026
Annals of Emergency Medicine Journal Club. September 2026. PMID: 42618180 AEM September 2026 Journal Club reviews SWiFT and TOWAR (NEJM 2026). Editorial conclusion: prehospital whole blood is not superior to balanced component therapy for primary outcomes in either phase 3 RCT. The case for whole blood now rests on logistics, not mortality benefit.
UK practice: Two independent NEJM RCTs confirm no survival superiority for prehospital whole blood. Balanced 1:1:1 or 1:1 red cells + FFP remains the evidence-based standard. Do not switch HEMS protocols to whole blood on the basis of pre-RCT observational data.
Acute Heart Failure + Concurrent Infection — Independent Mortality Driver in the ED (EJEMA, n=1,296)
PMID: 42047498. European Journal of Emergency Medicine. 2026. Design: Retrospective observational cohort study of all adult AHF presentations to a single university hospital ED in Strasbourg, France, over 2020 (n=1,296 ED visits). Infection trigger was identified by adjudication using clinical, imaging, and microbiological data collected throughout the hospital stay. Adjusted for confounders using inverse probability weighting (IPW).
Infection was identified in 119 cases (9.2%). In-hospital mortality: 30.3% with infection vs 9.0% without infection (ARD +21.3 percentage points). After IPW adjustment: OR 2.76 (95% CI 1.64–4.66). Reduced post-discharge survival: HR 1.64 (95% CI 1.14–2.37; p=0.008). Interestingly, atrial fibrillation as the AHF trigger was associated with lower in-hospital mortality (OR 0.45; 95% CI 0.23–0.87).
Critical appraisal: The study’s main strengths are its large all-comers AHF cohort and the use of IPW adjustment to reduce confounding by indication. However, important limitations apply: this is a single-centre French hospital (Strasbourg University), covering 2020 only — a pandemic year in which infection patterns and AHF presentations were substantially altered by COVID-19. The paper does not separate COVID-19-related infection from other infectious triggers, which is a significant omission for a 2020 cohort. Infection adjudication was retrospective and relied on medical record review, introducing misclassification risk. The mechanism linking infection to AHF mortality is plausible (sepsis-driven myocardial depression, fluid shifts, further haemodynamic compromise) but causality cannot be established from an observational design. Nonetheless, the magnitude of the mortality difference (30% vs 9%) and the independent effect after adjustment are clinically striking and biologically credible.
UK ED practice: The practical message is valid regardless of the French single-centre origin: when a patient presents with AHF, actively ask “what triggered this?” and treat infection as a high-risk precipitant that requires its own aggressive management — not a background finding to be addressed after the AHF is treated. Initiate blood cultures, empirical antibiotics (if appropriate), and diuresis in parallel. Infection-triggered AHF should not be managed as straightforward “wet heart failure” — it warrants a higher level of input and monitoring.
VExUS POCUS for De-Resuscitation in Septic Shock — Feasibility Pilot RCT (n=19)
PMID: 41804824. Journal of Ultrasound Medicine. 2026. JournalFeed POCUS Speed Read. Design: US single-centre pilot feasibility RCT. Adults with septic shock randomised to VExUS-guided fluid management (n=12) vs usual care (n=7); total n=19. Daily VExUS scans (hepatic vein, portal vein, intrarenal Doppler waveforms) performed on all participants; intervention arm received results and a fluid-management recommendation based on the score. NIH-funded (P20 GM 103652).
Intervention-period fluid balance: −65 mL (VExUS) vs +2,608 mL (usual care); p=0.21 — not statistically significant. Secondary outcomes (AKI, respiratory failure, 30-day mortality) numerically lower in the VExUS arm but no significance reported. No adverse events related to the intervention.
Critical appraisal: This is emphatically hypothesis-generating only. With n=19 and no formal primary efficacy outcome, the study is designed and powered to demonstrate feasibility and safety — not clinical benefit. The p=0.21 result on fluid balance cannot be interpreted meaningfully at this sample size; the numerical fluid-balance difference simply informs the sample-size calculation for a definitive trial. The VExUS score itself has emerging but not yet robust evidence for guiding clinical decisions in septic shock beyond standard clinical assessment. The study is single-centre and US-based, and POCUS competency in UK EDs varies significantly. Do not adopt VExUS-guided de-resuscitation as routine practice on the basis of this trial — watch for the powered definitive trial.
2 — GUIDELINES & UK UPDATES
Unscheduled Procedural Sedation — Multidisciplinary Delphi Consensus (Ann Emerg Med 2026)
Annals of Emergency Medicine. 2026. Multi-round Delphi consensus on procedural sedation in the ED. Key points: fasting status must not delay clinically urgent emergency sedation; capnography standard for all deep sedation; ketamine remains the dominant ED agent; documented departmental sedation protocol, trained second operator, and defined recovery criteria are mandatory. Consistent with RCEM/AAGBI guidance.
Dexmedetomidine for Bridging Sedation Before Procedures in Agitated Adults (Ann Emerg Med)
Annals of Emergency Medicine. 2026. Review/case series on dexmedetomidine as a bridging agent before procedural sedation in agitated adults. Reduces induction agent dose. Preserves airway reflexes and spontaneous ventilation. Not universally stocked in UK EDs — check your formulary.
DOAC Clinical Policy — ACEP (Ann Emerg Med 2026)
Annals of Emergency Medicine. 2026. ACEP evidence-based clinical policy on DOAC management in the ED. Covers reversal agents (andexanet alfa for Xa inhibitors; idarucizumab for dabigatran), timing of reversal in major bleeding, DOAC level interpretation. Consistent with MHRA/UKHSA guidance. Ensure andexanet alfa and idarucizumab are in-stock at your ED.
RCEM Corporate Plan 2027–2032
Royal College of Emergency Medicine. Published September 2026. rcem.ac.uk RCEM five-year strategic plan. Key themes: corridor care is clinically unacceptable and must not be normalised; 4-hour standard reform; workforce development and retention; consultant-led acute care 24/7. Relevant for clinical leadership and governance roles.
3 — RESUSCITATION & CRITICAL CARE
Mobile AED Deployment by Community First Responders — Improved ROSC Rates (Resuscitation 2026)
Resuscitation. 2026. UK study showing community AED deployment is associated with improved bystander defibrillation rates and improved ROSC. Supports expansion of UK community defibrillation networks (BHF PAD programme, St John Ambulance community AED schemes).
Low-Risk Pulmonary Embolism — Safe to Discharge from ED (UK cohort + NICE NG158)
UK service cohort data 2026 + NICE NG158. UK cohort data confirming safety of ED discharge in low-risk PE (PESI class I–II or sPESI 0) with same-day anticoagulation and rapid follow-up. Consistent with NICE NG158. Rivaroxaban 15mg BD for 21 days or apixaban 10mg BD for 7 days are preferred single-agent options.
4 — PAEDIATRIC EMERGENCY MEDICINE
Prophylactic Antibiotics After Paediatric Cardiac Arrest — Not Routinely Recommended (Resuscitation 2026)
PMID: 42648394. Resuscitation. 2026. Editorial. JournalFeed Paeds Speed Read. What this is: An editorial in Resuscitation (published online 26 August 2026) authored by paediatric intensivists from Great North Children’s Hospital, Newcastle (Day E, Agbeko RS) — a UK PICU. The editorial does not present primary data but synthesises the existing evidence on prophylactic antibiotics in paediatric cardiac arrest survivors, framing the question for PICU clinicians making this decision at the bedside.
The editorial notes: (1) aspiration at the time of paediatric cardiac arrest is common due to the high proportion of asphyxial arrests in children, (2) post-arrest immunosuppression from global ischaemia-reperfusion injury may increase susceptibility to infection, (3) in adult post-arrest care, randomised evidence (including PACA trial data) does not support routine prophylactic antibiotics despite an observational signal, (4) paediatric-specific RCT data on this question are absent. The authors conclude that individualised clinical judgement is required — with particular consideration of prolonged arrest duration, documented aspiration, and pre-existing respiratory vulnerability — rather than blanket prophylaxis.
Critical appraisal: An editorial carries the lowest level of evidence and does not itself provide new data. Its value is in synthesising expert opinion from a UK PICU centre and framing the clinical question. The absence of paediatric RCT evidence in this area means any practice is currently guided by extrapolation from adult data, physiological reasoning, and individual case factors. This editorial is worth knowing about as it represents current UK PICU thinking on this contested question — but it should be read as expert opinion, not as evidence that either supports or definitively opposes prophylactic antibiotics. The key practical message is: do not routinely prescribe; use individual clinical judgement; discuss with PICU.
UK PEM practice: Do not routinely prescribe prophylactic antibiotics after paediatric cardiac arrest. Treat documented aspiration as a clinical indication if features of infection develop. All post-arrest children: discuss with PICU. Follow RCUK Paediatric ALS post-resuscitation guidelines.
Paediatric Supraglottitis — Increasing Incidence; Adenovirus Now a Common Aetiology (Paediatr Pulmonol 2026)
PMID: 42544012. Paediatric Pulmonology. 2026. JournalFeed Paeds Speed Read, Thursday 4 September 2026. Design: Retrospective case-series review of 32 children admitted to a PICU in a tertiary paediatric hospital in Israel over a 20-year period (2004–2024). Reviewed epidemiology, clinical features, microbiological findings, and management. The study compared adenovirus-associated supraglottitis (10/19 cases with viral aetiology) against other aetiologies.
Incidence of paediatric supraglottitis increased by 330% between the first and second decades of the study. A viral aetiology was identified in 19 of 30 patients with microbiological data (63%); adenovirus was the most common pathogen in this group (10/19 cases). Bacterial pathogens (predominantly Group A Streptococcus) were isolated in 16/17 sputum cultures. Invasive mechanical ventilation was required in 53% of patients; non-invasive ventilation in 9%. Children with adenovirus-associated supraglottitis had significantly higher fever and CRP than those with other aetiologies.
Critical appraisal: This is a small retrospective single-centre case series (n=32) from a tertiary Israeli PICU, and all the usual limitations of such a design apply: selection bias (only the most severe cases requiring PICU admission were captured), absence of a denominator population, and retrospective microbiological ascertainment which may underestimate viral aetiology due to testing practices. The 330% incidence increase may partly reflect increased testing for viral pathogens over the 20-year period rather than a true epidemiological change. Despite these limitations, adenovirus as a driver of supraglottitis in vaccinated children is biologically plausible and consistent with case reports in UK and international literature. The key clinical message — do not be falsely reassured by vaccination history, and consider viral aetiology — is valid regardless of the study’s limitations.
Airway emergency: Senior anaesthetics + ENT immediately. Do NOT examine oropharynx in a distressed child. Theatre for controlled examination + intubation under GA. Adrenaline nebuliser to temporise while awaiting theatre. Broad-spectrum IV antibiotics + dexamethasone 0.15 mg/kg IV.
Paediatric OHCA — Resuscitation Pathways Beyond Witness Status (Resuscitation 2026)
Resuscitation. 2026. Witness status alone is insufficient to guide resuscitation intensity or TOR decisions in children. Asphyxial OHCA (drowning, choking) may respond well even when unwitnessed if oxygenation is restored early. RCUK paediatric BLS: 5 rescue breaths before compressions. For witnessed choking collapse: back blows, abdominal thrusts, Magill forceps under DL before rhythm check.
Febrile Seizure in Kawasaki Disease — Marker of More Severe Coronary Involvement
Retrospective series 2026. Children with Kawasaki disease who develop a febrile seizure during acute illness have significantly higher rates of severe coronary artery involvement (including aneurysm formation). Do not dismiss as simple febrile convulsion. Escalate urgently to paediatric cardiology for echo. IVIG 2g/kg if Kawasaki disease confirmed.
5 — FOAMED & CRITICAL APPRAISAL
JournalFeed SpeedRead — ATS NIRS Guideline: HFNC/NIV for Preoxygenation Before RSI
JournalFeed. Published 1 September 2026. journalfeed.org JournalFeed highlights the ATS guideline’s strong recommendation for HFNC or NIV for pre-intubation preoxygenation as the most immediately actionable finding for emergency physicians. HFNC at ≥30 L/min (NODESAT) and NIV preoxygenation now have strong, high-certainty guideline backing — directly aligning with DAS 2025’s central peroxygenation concept.
EMCrit 432 — Airway Cases & Q&A: Physiologically Difficult Airway, eFONA, Petrified Secretions
Scott Weingart. EMCrit. Published 23 August 2026. emcrit.org/emcrit/emcrit-432-members-airway-cases-and-qa Weingart works through member-submitted airway nightmares: managing petrified adherent secretions in a critically ill patient; a successful scalpel-finger-bougie cricothyroidotomy; induction decision-making in patients with severe hypoxaemia and haemodynamic compromise. Also covers: ketamine-only awake intubation, push-dose epinephrine for hypoxic bradycardia, CHOP criteria for physiologically difficult airway, and when to choose awake intubation vs optimised RSI.
Listen alongside this month’s DAS 2025 RSI revision. The eFONA case illustrates the Plan D technique. Note DAS 2025 prefers scalpel-bougie-tube as default — not the finger technique — but both have a place. Also from EMCrit this week: PulmCrit (5 Aug 2026) argues hyperangulated VL should be the mainstay of ICU intubations (four evidence-based reasons) — directly aligned with DAS 2025’s VL first-line recommendation. Worth a read alongside this revision.
POCUS for ETT Confirmation — Transtracheal US Fastest at 4.6 Seconds (Am J Emerg Med, n=200)
Kudu E et al. American Journal of Emergency Medicine. 2026. PMID: 42066651 — JournalFeed EM Speed Read, Thursday 4 September 2026 Design: Single-centre prospective 1:1:1 RCT at Marmara University ED, Istanbul, Türkiye. 217 adults undergoing RSI in the ED screened; 200 randomised: TUS group (n=66), LUS group (n=67), DUS group (n=67). Median age 75 years (IQR 63–84); 54.5% male. Reference standard for ETT position: waveform capnography + auscultation. Esophageal intubation occurred in 14% of patients (n=28) — an unusually high rate, likely reflecting a higher-acuity, older ED population. No commercial funding.
Diagnostic accuracy for tracheal placement: TUS sensitivity 98.2% (95% CI 90.4–100%), specificity 100% (95% CI 69.2–100%); LUS sensitivity 98.2% (95% CI 90.6–100%), specificity 100%; DUS sensitivity 96.6% (95% CI 88.3–99.6%), specificity 87.5% (95% CI 47.3–99.7%). No between-group difference in accuracy (p=0.44). Median confirmation times: TUS 4.6 s (IQR 3.3–6.0); LUS 9.4 s (7.3–12.2); DUS 13.4 s (11.8–15.1); auscultation 11.5 s; five capnography cycles 17.0 s. Time differences statistically significant (p<0.001).
Critical appraisal: The study is well-designed with prospective randomisation and a clinically relevant primary outcome. The 14% esophageal intubation rate is strikingly high — this cohort (median age 75, university hospital, Turkish context) may not reflect a typical UK ED population. The wide 95% CI for DUS specificity (47.3–99.7%) reflects the small number of esophageal intubations detected — the specificity estimate is unreliable. The reference standard (capnography + auscultation) is itself imperfect, though it is the current clinical gold standard. An important limitation: this trial was performed with US-trained ED physicians; the time advantage of TUS requires specific training in laryngeal/tracheal ultrasound views that is not yet standard in UK ED curricula. The clinical relevance of a 4.6 s vs 9.4 s difference in confirmation time is modest in most clinical scenarios; waveform capnography remains primary.
UK RSI practice: DAS 2025 mandates two confirmatory elements: waveform capnography + visualisation of the tube in the trachea. POCUS (particularly TUS) can serve as a rapid adjunct for additional confirmation. Waveform capnography remains the primary confirmation method and is not replaceable by POCUS. TUS requires dedicated ultrasound training in laryngeal/tracheal views — currently not standard in most UK ED curricula but growing in POCUS syllabi.
6 — RCEM LEARNING — MODULES TO FLAG
RCEMLearning — Selected Modules for Your Team This Month
RCEMLearning. rcemlearning.co.uk — Curriculum-mapped modules for RCEM members. All count towards CPD log.
Newly published or reviewed in August–September 2026 (verified):
- White-Eye Orbital Blowout Fracture — New module published 27 August 2026. Recognition of the subtle “white-eye” blowout fracture — mainly paediatric/adolescent, high risk of missed diagnosis. No periorbital bruising; restricted upward gaze is the key sign. This is the “don’t miss” eye presentation in younger patients. rcemlearning.co.uk
- How to Write an Excellent Abstract — New blog published 25 August 2026. Practical guidance on structuring research, QI, and case-report abstracts for conference submission or journal publication. Directly useful for trainees approaching ARCP portfolio deadlines or conference abstract submission seasons. rcemlearning.co.uk
- Trauma in the Older Adult (Silver Trauma) — Reviewed 1 September 2026 (original 2018). Updated case-based module for major trauma in elderly fall patients. TARN data confirms older adults now represent the majority of major trauma presentations in England. Good refresher for pre-hospital, ED and MTC teams. rcemlearning.co.uk
- Non-Invasive Ventilation — Reviewed 18 August 2026 (original 2021). Updated practical NIV guide — timely alongside this week’s ATS NIRS Guideline lead item. Good module to signpost to SHOs and ACPs who are building HFNC/NIV confidence. rcemlearning.co.uk
- Malignant Spine Presentations — Reviewed 11 August 2026. Oncological and palliative spinal cord emergencies in the ED — cauda equina, cord compression, spinal mets. High-stakes, frequently delayed diagnosis. rcemlearning.co.uk
- Digoxin Toxicity — Reviewed 4 August 2026. Narrow therapeutic index, toxicity recognition (bradyarrhythmias, GI symptoms, yellow-green visual disturbance), management with digoxin-specific antibody fragments (Digibind/DigiFab). ECG recognition of digoxin effect vs toxicity. rcemlearning.co.uk
- Managing Parkinson’s in the ED — Reviewed 7 August 2026. Medication timing, NEVER-miss drugs (selegiline, MAO-B inhibitors interact with opioids and serotonergic drugs), aspiration risk, and dopamine agonist-related presentations. rcemlearning.co.uk
- Acute Compartment Syndrome: Limb-Saving Diagnosis in the ED — Published 28 July 2026. Recognition, pressure measurement thresholds (delta pressure <30 mmHg = surgical threshold), and fasciotomy urgency. Directly relevant alongside the trauma newsletter’s ACS content on obtunded patients. rcemlearning.co.uk
Access via rcemlearning.co.uk with your RCEM membership login. All modules count towards CPD log. Note: the rcem.ac.uk/rcem-learning URL returns a 404 — the correct address is rcemlearning.co.uk.
7 — ACTION POINTS
| 1 | Preoxygenation SOP: DAS 2025 + ATS 2026 both strongly recommend HFNC or NIV for pre-intubation preoxygenation. Review your ED RSI preoxygenation protocol. Ensure HFNC equipment is available at the bedside for RSI and that all senior clinicians know how to apply it. |
| 2 | CTCA after troponin rule-out: Do not routinely request CTCA. Reserve for HEART ≥4, unexplained new ECG changes, or strong clinical suspicion. Brief your team and update local chest pain pathway documentation if it suggests routine post-rule-out CTCA. |
| 3 | Oseltamivir prescribing: Do not give reflexively to all hospitalised influenza patients. Follow UKHSA/NICE indications (at-risk groups only). Await peer-reviewed publication before any protocol change. |
| 4 | Paediatric supraglottitis: Any child with suspected supraglottitis: call senior anaesthetics and ENT immediately. Do not examine the oropharynx. Move to theatre. Do not be falsely reassured by vaccination history. |
| 5 | Post-paeds cardiac arrest antibiotics: Do not prescribe prophylactic antibiotics routinely. Treat documented aspiration as a clinical indication if features of infection develop. All post-arrest children to PICU. |
| 6 | Physio-led MSK: Use the Lancet 2026 evidence to support a business case for APP-led MSK pathways in your ED if not already in place. This is now Lancet-level evidence for a model already recommended by RCEM and NHS England. |
| 7 | DAS 2025 RSI briefing: At your next departmental teaching, brief staff on the key DAS 2025 changes: VL first-line, peroxygenation throughout, 3+1 rule, eFONA vertical incision default, GLP-1 agonists as aspiration risk. Point them to EMCrit 432 for supplementary airway case discussion. |
8 — TRIALS TO WATCH
ONGOING / EXPECTED
| TROOP | Next prehospital whole blood RCT — will test whether different blood age or subgroups benefit. Expected 2027. |
| EVITA | Running locally at BHH. |
| REMAP-CAP oseltamivir | Full peer-reviewed publication awaited. Will clarify whether the Bayesian harm signal is real or noise in the data. |
CORE REVISION — ISSUE 28 — 4 SEPTEMBER 2026
Rapid Sequence Induction (RSI)
DAS 2025 guidelines — peroxygenation, VL first-line, Plans A–D, eFONA technique, post-intubation management
Exam goal: State the DAS 2025 paradigm shift; define peroxygenation; know VL as first-line; apply the 3+1 attempt rule; state Plans A–D with correct attempt limits; describe the eFONA scalpel-bougie-tube technique; select drugs by physiological context; state post-intubation confirmatory requirements. DAS 2025 published November 2025 — not the 2015 version.
1. THE PARADIGM SHIFT — DAS 2025 VS DAS 2015
| DAS 2015 | DAS 2025 (BJA 2026;136:283–307) |
|---|---|
| Focused on recognising and rescuing failed intubation | Prioritises maximising first-attempt success — a suboptimal first attempt is a wasted attempt |
| Direct laryngoscopy standard; VL as an option | Videolaryngoscopy first-line wherever available |
| Preoxygenation as a pre-induction step only | Peroxygenation — continuous O2 delivery before induction, during apnoea, throughout all attempts until airway secured |
| Cricoid pressure routinely applied in RSI | Cricoid force only when aspiration risk is particularly high; remove if laryngoscopy difficult, SAD inserted, or vomiting |
| eFONA kit prepared when CICO is declared | eFONA kit opened at declaration of failed intubation (Plan B) — not only at CICO |
| Help called when difficulty arises | Help called whenever any difficulty encountered; who calls help is allocated by name in the pre-intubation briefing |
| Blind bougie use with grade 3/4 view: acceptable | Blind bougie with grade 3/4 view: not recommended — trauma and misplacement risk. Do not rely on hold-up sign alone. |
| Intubation confirmed by waveform capnography | Two confirmatory elements required: waveform capnography + visualisation of tube through cords or in trachea |
Reference: Ahmad I et al. Br J Anaesth. 2026;136(1):283–307. doi:10.1016/j.bja.2025.10.006. Published November 2025. Open access. Endorsed by DAS, Association of Anaesthetists, ICS, FICM, RCEM, Faculty of Prehospital Care. 65 recommendations from systematic review of 1,241 papers over 3 years.
2. PEROXYGENATION — THE CENTRAL CONCEPT
| PHASE | METHOD | TARGET / NOTES |
|---|---|---|
| Preoxygenation | HFNC ≥30 L/min + FiO2 1.0; or tight-fitting NRB mask; or NIV (BiPAP IPAP 10–15, EPAP 5–8 cmH2O) | Target ETO2 ≥0.9 where measurable. Head-up ≥30 degrees. NIV: strong recommendation by ATS 2026 for pre-intubation preoxygenation (RR 0.51 intubation; high certainty). |
| Apnoeic oxygenation | HFNC left running through laryngoscopy (NODESAT); or nasal cannulae 15 L/min | Delays hypoxaemia but does not always prevent it. Do NOT initiate HFNC as rescue after facemask ventilation has failed. |
| Throughout all plans | O2 delivered continuously across Plans A–D | Apply O2 to upper airway throughout eFONA (facemask, nasal cannula, or SAD). No phase without oxygenation delivery. |
3. RSI PREPARATION CHECKLIST (DAS 2025)
| ELEMENT | DAS 2025 RECOMMENDATION |
|---|---|
| Airway assessment | Assess for difficulty in Plans A, B, C AND D before induction. Locate and palpate cricothyroid membrane; document whether palpable; consider ultrasound marking. If difficulty anticipated in any plan → consider awake tracheal intubation. |
| Position | Head-up ≥30 degrees. Ramped position for obesity. |
| Equipment | Videolaryngoscope + direct laryngoscope backup; bougie AND stylet prepared; second-generation SAD; eFONA kit (scalpel size 10, bougie, cuffed 6.0 ETT, suction); waveform capnography. |
| Team briefing | State Plans A–D, attempt limits, who calls help (allocated by name to a specific team member — not the airway assistant), who performs eFONA, who manages haemodynamics. |
| GLP-1 receptor agonists | New in DAS 2025: Semaglutide, liraglutide, tirzepatide delay gastric emptying regardless of fasting duration. Treat as full stomach. Consider gastric ultrasound pre-induction. Increasing prevalence in ED patients. |
| Cricoid force | 10 N before unconsciousness; 30 N after. Apply only when aspiration risk is particularly high. Remove if laryngoscopy becomes difficult, SAD inserted in Plan B, or vomiting occurs. Does not impair VL first-pass success. |
4. DRUG SELECTION
| DRUG | DOSE | USE WHEN | AVOID / CAUTION |
|---|---|---|---|
| Ketamine | 1–2 mg/kg IV | Haemodynamically unstable, shock states, bronchospasm, trauma, most ED RSIs. DAS 2025 explicitly supports ketamine in the physiologically difficult airway. Safe in raised ICP (modern evidence refutes old contraindication). | Severe hypertension; severe ischaemic heart disease (tachycardia) |
| Propofol | 0.5–2 mg/kg IV (reduce in elderly/shocked) | Haemodynamically stable; status epilepticus | DAS 2025: propofol can worsen haemodynamic instability. Avoid in shock states. Dose carefully in elderly. |
| Etomidate | 0.3 mg/kg IV | Haemodynamically unstable when ketamine not available. DAS 2025 includes etomidate for physiologically difficult airway. | Single dose acceptable in ED (adrenal suppression effect minimal); avoid repeat dosing. |
| Rocuronium | 1.2 mg/kg IV (RSI dose) | Standard NMBA for ED RSI. DAS 2025 explicitly recommends 1.2 mg/kg. Reversible with sugammadex 16 mg/kg IV for immediate reversal. | If sugammadex already given and reversal achieved, cannot re-use rocuronium for eFONA — use suxamethonium. |
| Suxamethonium | 1.5 mg/kg IV | When rapid offset is clinically important. DAS 2025 alternative NMBA for RSI. | Hyperkalaemia; burns/crush/denervation >24h; personal/family history malignant hyperthermia; myopathy; penetrating eye injury. |
| Sugammadex | 16 mg/kg IV (immediate); 4 mg/kg (routine at T2) | Reversal of rocuronium — Plan B stop-think-communicate decision to wake patient. Do NOT delay eFONA to give sugammadex in CICO. | If already given, cannot use rocuronium again for eFONA block; use suxamethonium instead. |
Cricoid force (DAS 2025): Apply only when aspiration risk particularly high. Remove if laryngoscopy or intubation becomes difficult, if SAD inserted in Plan B, or if vomiting occurs. GLP-1 receptor agonists (semaglutide, liraglutide) delay gastric emptying — treat all patients on these as full stomach regardless of fasting duration.
5. THE DAS 2025 ALGORITHM: PLANS A–D
| PLAN | TECHNIQUE & LIMIT | KEY DAS 2025 POINTS |
|---|---|---|
| Plan A | Tracheal intubation Max 3+1 attempts | VL first-line wherever available. Each attempt must involve a change (position, blade, operator, introducer, external laryngeal manipulation, remove cricoid force). Confirm: waveform capnography + visualisation of tube through cords or in trachea. Can declare failed at any point if no change would improve outcome. At declaration of failed intubation: open eFONA kit immediately. |
| Plan B | Second-generation SAD Max 3 attempts | Second-generation SAD preferred (i-gel, ProSeal, Supreme) — lower aspiration risk; rescues 60–65% of failed intubations. Each attempt: change device size or type, or ensure full NMB. Once oxygenation achieved: STOP — THINK — COMMUNICATE. Default: discontinue anaesthesia and wake patient up. Other options (continuing with SAD, intubating through it) are high-risk; require senior input. Blind intubation through SAD: not recommended. Intubate through SAD under VL or flexible bronchoscope only. |
| Plan C | Facemask ventilation Final attempt | Final rescue attempt. Optimise: full NMB, adequate anaesthesia depth, correct positioning, OPA + NPA adjuncts, two-person four-handed technique. If ventilation achieved: senior decision. If ventilation fails: declare CICO, allocate roles, proceed immediately to Plan D. |
| Plan D | eFONA No delay in CICO | CICO scenario: cannot intubate, cannot oxygenate. Maximal neck extension. Full NMB mandatory. Default: vertical skin incision (suitable for palpable or impalpable membrane). Transverse stab incision: only if membrane definitively palpable or ultrasound-marked. Maintain O2 to upper airway throughout (SAD, facemask, or nasal cannula). |
6. EFONA — SCALPEL-BOUGIE-TUBE TECHNIQUE (DAS 2025 DEFAULT: VERTICAL INCISION) Kit: Scalpel (number 10 blade) • Bougie (coude tip) • Size 6.0 mm cuffed ETT • Suction. Confirm full NMB in place. Maximal neck extension (pillow under shoulders or extend head of bed).
| STEP | ACTION |
|---|---|
| 1 | Stand on patient’s left (if right-handed). Non-dominant hand: stabilise larynx, apply tension to skin, locate midline. |
| 2 | Dominant hand: vertical midline skin incision up to 8 cm (caudad to cephalad). |
| 3 | Blunt dissection with both hands to separate tissue. Non-dominant index finger identifies cricothyroid membrane. |
| 4 | Dominant hand: transverse stab incision through cricothyroid membrane, cutting edge toward you. Rotate scalpel 90° so sharp edge points caudally. |
| 5 | Swap hands: non-dominant holds scalpel with gentle lateral traction, handle vertical. |
| 6 | Dominant hand: slide coude tip of bougie down side of scalpel into trachea. Advance 10–15 cm. Remove scalpel. |
| 7 | Railroad size 6.0 cuffed ETT over bougie (rotate as advancing). Remove bougie. |
| 8 | Inflate cuff. Ventilate 100% O2. Confirm: waveform capnography. Exclude bronchial intubation and pneumothorax. Secure tube. After eFONA (DAS 2025 mandatory steps): Psychological support offered to all team members involved. Formal team debrief. Document airway course fully in medical record. Verbal and written handover to all future airway providers (airway alert). Appropriate diagnostic coding. |
7. POST-INTUBATION MANAGEMENT
| PARAMETER | TARGET | NOTES |
|---|---|---|
| Tube confirmation | Waveform capnography (sustained ETCO2) + visualisation of tube through cords or in trachea | DAS 2025: both required. Chest rise, misting, auscultation alone are unreliable and not sufficient. |
| Tidal volume | 6–8 mL/kg IBW | Ideal body weight (height-based), not actual weight. Lung-protective in all patients. |
| PEEP | 5–8 cmH2O | Start 5; titrate up for ARDS. |
| SpO2 | 94–98% | Avoid hyperoxia. Post-cardiac arrest: 94–96%. |
| PaCO2 | 4.5–6.0 kPa | Raised ICP: 4.5–5.0 kPa. DKA: maintain pre-intubation minute ventilation. |
| MAP | ≥65 mmHg | Push-dose adrenaline (10–20 mcg IV boluses) for peri-intubation hypotension. Start vasopressor infusion if needed. |
| Sedation | RASS −2 to −3 initially | Propofol + fentanyl or midazolam + morphine. Avoid prolonged paralysis unless ventilator dyssynchrony or raised ICP. |
| Documentation | DAS 2025: mandatory full documentation | Airway course, devices used, reason for any failure, extubation plan. Written airway alert for all future providers. Verbal handover. |
FRCEM exam points (DAS 2025): State the paradigm shift — first-attempt success, not failure rescue. VL is first-line. Define peroxygenation: continuous O2 delivery before induction, during apnoea, throughout all plans. State Plans A–D with attempt limits (A: max 3+1; B: max 3; C: final; D: eFONA on CICO). eFONA default: vertical skin incision, scalpel number 10, bougie, size 6.0 cuffed ETT. Confirm intubation with two elements: waveform capnography + visualisation. Sugammadex 16 mg/kg for immediate rocuronium reversal — do NOT delay eFONA for it in CICO. GLP-1 agonists = aspiration risk regardless of fasting. Cricoid force: only if particularly high aspiration risk; remove if laryngoscopy difficult. After eFONA: psychological support + debrief mandatory.
EM Evidence Rundown — Issue 28 — 4 September 2026 — emevidence.org
Archive: All previous issues at emevidence.org. Feedback: feedback form. Educational purposes only; not clinical guidance.
EM Evidence Rundown — Issue 28 — 4 September 2026 Authored by Jake Turner, ST6 Emergency Medicine. Curated with the assistance of AI (Perplexity). All content editorially reviewed. emevidence.org
Intended for qualified healthcare professionals. Educational in nature; not clinical guidance. Evidence current at 4 September 2026.