EM EVIDENCE RUNDOWN — ISSUE 29 — 11 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 (Review): BMJ State of the Art — Acute Hyperkalaemia 2026: three-step management algorithm with calcium gluconate, insulin/dextrose and salbutamol, and newer potassium binders. ECG is NOT a reliable severity guide. Change This Week: Inhaled isopropyl alcohol (alcohol wipe) for ED nausea — EMJ evidence review confirms rapid short-term relief, reduces need for parenteral antiemetics, and costs almost nothing. NNT=3 to prevent a rescue antiemetic request. UK alert: RCEM reports one of the worst-ever summers on record for ED performance (August 2026). Safe to Care campaign: 96% of A&E staff have experienced violence at work. JRCALC Clinical Update 2:26 now live on the app. Paediatric EM: Dexmedetomidine infusion for severely agitated adolescents in the ED; paediatric procedural sedation Delphi consensus; anaphylaxis observation time safely reduced to 154 min in low-risk paeds without increase in biphasic reactions. Core Revision: Brugada Syndrome — recognising the three ECG patterns, which drugs unmask it, fever as a precipitant, and ED management. FRCEM-relevant.
BOTTOM LINE UP FRONT — 11 SEPTEMBER 2026
ACT ON THIS NOW
LEAD Hyperkalaemia (BMJ 2026): Three-step algorithm. Calcium gluconate 2–3 g IV first. Insulin 5–10 units + 10% glucose second (use 5 units if CKD, AKI or glucose <7). Salbutamol 10–20 mg neb third. ECG alone does not predict severity. Newer binders (SZC, patiromer) preferred over Resonium. Do NOT wait for ECG changes at K ≥6.5 mmol/L.
CHANGE Inhaled IPA for nausea (EMJ 2026): Alcohol wipe held under nostrils — rapid, cheap, no side effects. NNT=3 to prevent a rescue antiemetic request. Provide as first-line non-pharmacological option for ED nausea in adults. Avoid in pregnancy (evidence gap).
UK RCEM Safe to Care: 96% of A&E staff have experienced violence at work; 73% weekly. Use safety incident reporting. Know your departmental lone-working and violence policy.
KNOW FOR NEXT TIME
PAEDS EM Anaphylaxis observation (QI): Duration safely cut from 233 to 154 min in low-risk paediatric patients without any increase in biphasic reactions. NICE NG80 low-risk criteria support shorter observation.
PAEDS EM Dexmedetomidine for agitated adolescents (AEM 2026): Continuous infusion 0.5–1 mcg/kg/hr effective for severe undifferentiated agitation. Preserves airway reflexes. Not universally stocked — check formulary with pharmacy.
FOAMED EMCrit 433 — HALO Procedures: Institutional vs operator competence for 12 high-stakes low-occurrence ED procedures (cric, thoracotomy, pericardiocentesis). Framework for personal and departmental preparedness.
CORE REVISION Brugada Syndrome — ECG pattern, drug precipitants, fever, ED management. FRCEM.
This week's lead is a practical BMJ State of the Art review on acute hyperkalaemia — daily resus bay territory, and a topic where small details (insulin dose in AKI, which potassium binder to use, whether to act on ECG alone) translate directly into patient safety. The EMJ evidence review on inhaled isopropyl alcohol is a genuine low-cost change to ED antiemetic practice. The RCEM summer performance data and Safe to Care campaign are sobering but important. Paediatric EM covers three new pieces of evidence spanning observation protocols, agitation management, and procedural sedation standards. The core revision covers Brugada syndrome — a high-stakes ECG diagnosis with FRCEM relevance and important ED management implications.
WHAT'S INSIDE — ISSUE 29
- Lead: Acute Hyperkalaemia — BMJ State of Art 2026
- Change: Inhaled IPA for ED nausea — EMJ review
- RCEM: Worst August on record — ED performance 2026
- RCEM Safe to Care campaign
- NAO report: Managing patient flow — RCEM response
- JRCALC Clinical Update 2:26
- Cerebral tissue O2 saturation at defibrillation & ROSC
- High-quality CPR: from process to perfusion (UK authors)
- POCUS for predicting difficult intubation — SR (EMJ)
- PEM: Dexmedetomidine for agitated adolescents (AEM)
- PEM: Anaphylaxis observation time QI 233→154 min
- PEM: Paediatric procedural sedation Delphi consensus
- PEM: Oseltamivir in hospitalised children — LOS −9.4h
- FOAMed: EMCrit 433 — HALO Procedural Philosophy
- Core Revision: Brugada Syndrome (ECG)
Contents: 1. Key Trials & Articles — 2. Guidelines & UK Updates — 3. Resuscitation — 4. Paediatric Emergency Medicine — 5. FOAMed & Critical Appraisal — 6. Action Points — 7. Trials to Watch — 8. Core Revision: Brugada Syndrome (ECG)
1 — KEY TRIALS & ARTICLES
Diagnosis and Management of Acute Hyperkalaemia — BMJ State of the Art Review 2026
Rech MA, Zimmerman DE, Ray L, Desai D, Hoffman JW, Howington GT. BMJ. 2026;394:e100287. doi:10.1136/bmj-2026-100287. Published 21 August 2026. PMID: 42629001
What this is: A commissioned BMJ State of the Art review on hyperkalaemia — one of the most common electrolyte emergencies encountered in UK EDs, particularly in patients with CKD, heart failure, diabetes, and RAAS inhibitor therapy. The review synthesises epidemiology, pathophysiology, diagnostic approach, the three-step acute management algorithm, newer potassium-binding agents, and high-risk clinical scenarios. It incorporates ERC and UK Kidney Association thresholds, making it directly applicable to UK practice.
Definitions (ERC / UK Kidney Association / KDIGO): Mild: K 5.5–5.9 mmol/L; Moderate: 6.0–6.4 mmol/L; Severe: ≥6.5 mmol/L. Pseudohyperkalaemia should always be excluded first — haemolysed sample, tourniquet >1 minute, fist-clenching, thrombocytosis, leucocytosis, or prolonged storage. Whole-blood POCT analysers will not detect haemolysis. If in doubt, repeat with a fresh unhaemolysed sample.
The ECG is not a reliable severity guide: Peaked T waves appear in fewer than 25% of patients at K 5.5–7.0 mmol/L. Do not wait for ECG changes before treating K ≥6.5 mmol/L. ECG changes represent a late and insensitive finding. The progression (peaked T → wide QRS → PR prolongation → sinusoidal pattern → cardiac arrest) is well-recognised but unreliable as a clinical trigger for treatment.
- <25% PEAKED T WAVES AT K 5.5–7.0 MMOL/L
- 0.6–1.4 MMOL/L REDUCTION WITH INSULIN/DEXTROSE
- 0.65–1.0 MMOL/L REDUCTION WITH SALBUTAMOL 10–20 MG NEB
- ≥6.5 MMOL/L — TREAT WITHOUT WAITING FOR ECG CHANGES
Three-step acute management algorithm:
| STEP | DRUG & DOSE | ONSET / DURATION | MECHANISM | UK NOTES |
|---|---|---|---|---|
| Step 1 Stabilise cardiac membrane | Calcium gluconate 2–3 g IV over 2–5 min (peripheral) Repeat if ECG changes persist at 5 min Cardiac arrest: calcium chloride 1 g IV | Onset 3 min; duration 30–60 min. Does NOT lower serum K. | Raises cardiac action potential threshold; counteracts membrane depolarisation | UK Kidney Association recommends 3 g gluconate. Peripheral access acceptable for gluconate; chloride preferable central in arrest. |
| Step 2a Shift K intracellularly | Insulin (regular/soluble) 5–10 units IV + dextrose 25–50 g (10% preferred) | Onset <30 min; peak 60 min; duration 4–6h. Reduces K by 0.6–1.4 mmol/L. | Stimulates Na/K ATPase; drives K intracellularly | Use 5 units if CKD, AKI, insulin-naive, weight <50 kg, or glucose <7 mmol/L. Monitor glucose every 30–60 min for ≥4h. Hypoglycaemia is the commonest serious complication. |
| Step 2b Shift K intracellularly | Salbutamol 10–20 mg nebulised (or 4–6 puffs MDI) | Onset <30 min. Reduces K by 0.65–1.0 mmol/L. Additive with insulin. | Beta-2 agonism stimulates Na/K ATPase | May be less effective in ESKD. Causes tachycardia. Use with caution in known IHD. Standard nebs are 2.5 mg — need 4–8 ampoules for 10–20 mg dose. |
| Step 3a Eliminate K | Sodium zirconium cyclosilicate (SZC) 10 g orally (onset 1h) or patiromer 8.4 g orally (onset 2–7h) | SZC onset 1h. Patiromer onset 2–7h. | Cation exchanger; binds K in gut | Preferred over Resonium (sodium polystyrene sulfonate) which has variable efficacy and risk of intestinal necrosis. Separate from other oral medications by 2–3 h. Check formulary availability — not universal in UK EDs. |
| Step 3b Eliminate K | Loop diuretics: furosemide 20–80 mg IV if volume overload and no hypovolaemia/ESKD | Reduces K by approximately 0.3 mmol/L. | Renal K excretion | Only if euvolaemic or volume-overloaded and adequate renal function. Avoid in AKI/ESKD. |
| Step 3c Remove K | Renal replacement therapy (dialysis) | Most rapid K removal. | Extracorporeal removal | For K >6 mmol/L persisting despite steps 1–3a, or in AKI/CKD with no renal |
recovery. Discuss with nephrology early.
Special populations: DKA/HHS — total body K is depleted even when serum K appears high; check K before starting insulin and replace proactively. Digoxin toxicity — calcium is safe to give (retrospective cohort n=161 showed no arrhythmia or mortality increase, refuting the longstanding "calcium and digoxin" contraindication). CKD/ESKD — use insulin 5 units, monitor glucose closely, low threshold for dialysis.
Critical appraisal: This is a narrative State of the Art review rather than a primary study, and therefore does not generate new efficacy data. Its strength lies in synthesising existing RCT and observational evidence into a clinically usable algorithm, and its incorporation of ERC and UK Kidney Association thresholds makes it more applicable to UK practice than many US-centric guidelines. The main limitations are those inherent to any narrative review — selective citation, absence of formal GRADE assessment, and heterogeneity in the underlying evidence base. The recommendation to prefer SZC or patiromer over Resonium (SPS) is supported by a growing evidence base, but local formulary availability in UK EDs remains patchy. The insulin dose-reduction recommendation for AKI (5 units) is pragmatic and well-supported by hypoglycaemia-risk data from observational studies. Readers should cross-reference with the UK Kidney Association 2020 consensus guidance, which remains the primary UK reference.
UK ED practice: This review supports a standardised three-step algorithm. Step 1 (calcium gluconate 3 g IV) is immediate regardless of ECG. Step 2 (insulin 5–10 units + 10% dextrose + salbutamol 10–20 mg neb) shifts K within 30 min. Step 3 (SZC or patiromer; loop diuretics if appropriate; dialysis if refractory). Do not rely on the ECG alone to trigger treatment at K ≥6.5 mmol/L. Audit your ED's insulin protocol for hyperkalaemia — dose reduction in AKI is a patient safety issue and should be a protocol checkpoint.
Whiff of Doubt? Inhaled Isopropyl Alcohol for Acute Nausea in the ED — EMJ Evidence Review 2026
Whiff of doubt: is inhaled isopropyl alcohol (alcohol wipes) an effective treatment for acute nausea in the emergency department? Emergency Medicine Journal. 2026. doi:10.1136/emermed-2026-216455. Published 7 September 2026. PMID: 42705904. Also: Seto A et al. Inhaled isopropyl alcohol for substance-related nausea at electronic dance music festivals: double-blind RCT. CJEM. 2026. PMID: 42493725
What this is: A short evidence review published in EMJ this week, searching MEDLINE, EMBASE, and the Cochrane Library from inception. Six relevant studies identified: two systematic reviews/meta-analyses, two RCTs, and two implementation studies. The review is complemented by a new double-blind RCT (Seto et al., CJEM 2026) in a festival setting, which provides the cleanest trial data to date.
The evidence: Inhaled isopropyl alcohol (IPA) from a standard alcohol wipe or soaked gauze pad provides rapid short-term relief of acute nausea. The EMJ review found that IPA may reduce the need for conventional antiemetics and is inexpensive, readily available, and well tolerated. The CJEM festival RCT (Seto et al., double-blind, n=57, 20 Canadian EDM festivals) provides the most robust data: IPA reduced nausea by 30% vs 16% with placebo at 10 minutes (p=0.024). More critically, IPA reduced requests for rescue antiemetics by half vs placebo: 35% vs 70% (p=0.01; NNT=3). No side effects were reported in either group. Neither study shows a complete abolition of nausea — this is a temporising measure, not a replacement for definitive antiemetic therapy in persistent or severe nausea.
- 30% NAUSEA REDUCTION WITH IPA AT 10 MIN (VS 16% PLACEBO)
- NNT=3 TO PREVENT ONE RESCUE ANTIEMETIC REQUEST
- 0 SIDE EFFECTS REPORTED ACROSS ALL INCLUDED STUDIES
Critical appraisal: The EMJ evidence review is a short narrative synthesis rather than a formal systematic review with meta-analysis — no pooled effect estimates are provided and the included studies are heterogeneous in population (ED patients, surgical patients, festival-goers) and nausea aetiology. The CJEM RCT is the best individual trial but is small (n=57) and set in a festival context (nausea principally substance-related), limiting direct ED generalisation. Importantly, both IPA and placebo reduced nausea in the CJEM trial, suggesting a significant placebo/inhalation effect that cannot be fully disentangled from the pharmacological action. The EMJ review appropriately notes that evidence in pregnancy is absent — multiple studies explicitly excluded pregnant patients, and the mechanism of action (CNS inhalation of isopropyl vapour) is of uncertain safety in pregnancy. A formal Cochrane systematic review would be valuable. Despite these limitations, the evidence is consistent, the intervention costs essentially nothing, and has no reported harms in non-pregnant adults.
UK ED practice: Offer inhaled IPA as a first-line non-pharmacological option for mild-to-moderate nausea in adults attending the ED. Instruct the patient to hold an alcohol wipe 1–2 cm below the nostrils and inhale slowly through the nose for three to five breaths, repeating as needed. It will not replace parenteral antiemetics in severe nausea or vomiting, but NNT=3 to avoid one IV antiemetic request is clinically meaningful in a busy department. Do not use in pregnancy (evidence gap). Cost is negligible — every resus bay and majors bay has alcohol wipes already.
2 — GUIDELINES & UK UPDATES
RCEM: One of the Worst-Ever Summers on Record — August 2026 ED Performance Data
Royal College of Emergency Medicine. Published 10 September 2026. rcem.ac.uk
RCEM released August 2026 ED performance data, describing results as among the worst on record for a summer period. The data cover NHS England four-hour performance, corridor care rates, and major trolley waits. RCEM has reiterated that corridor care is clinically unacceptable and must not be normalised. The College linked poor flow to understaffing, inadequate escalation protocols, and ongoing pressures from the social care system. RCEM called on NHS England and the government for urgent action ahead of winter.
UK ED practice: If your department is using structured corridor care protocols, ensure senior clinical oversight is documented for all patients managed outside a monitored bay. Flag flow issues through your governance channels. The RCEM Corporate Plan 2027–2032 (released this week) sets out the College's five-year strategy including 4-hour standard reform and 24/7 consultant-led acute care.
RCEM Safe to Care Campaign — 96% of A&E Staff Experience Violence at Work
Royal College of Emergency Medicine. Safe to Care campaign. Published 7 September 2026. rcem.ac.uk
RCEM's Safe to Care campaign has published survey data showing that 96% of A&E staff have experienced violence or aggression at work, and 73% experience it weekly or more frequently. The campaign calls for enhanced legal protections for emergency care workers, mandatory body-worn camera use, dedicated mental health support for affected staff, and zero-tolerance enforcement. The data reflect a systemic problem rather than isolated incidents.
UK ED practice: Report all incidents of violence and aggression via your trust's incident-reporting system. Know your department's lone-working, de-escalation, and rapid response protocols. Support colleagues who experience violence — normalisation of violence in EDs is itself a patient safety risk, as it drives staff attrition and burnout. The RCEM campaign page (rcem.ac.uk) provides resources and a petition link.
NAO Report: Managing Flow of Patients Through Hospital — RCEM Response
National Audit Office. September 2026. RCEM response published 9 September 2026. rcem.ac.uk
The National Audit Office published its report on managing the flow of patients through hospital, with a specific focus on the interface between emergency departments and inpatient wards. RCEM's response welcomed the NAO's recognition that ED crowding is primarily a hospital-wide problem, not an ED-specific failure, and called for the report's recommendations to be implemented with urgency, particularly around same-day emergency care capacity, medical outlier reduction, and discharge coordination.
JRCALC Clinical Update 2:26 — New Guidance Across Multiple Clinical Areas
Joint Royal Colleges Ambulance Liaison Committee. Available on the JRCALC app from 12 August 2026. jrcalc.org.uk
JRCALC Clinical Update 2:26 is now live on the JRCALC app. The update includes new guidance, revisions, and clarifications across multiple clinical areas. Notably, the update includes revised guidance on Learning Disabilities and Autism — areas of increasing importance in NHS emergency care given the higher morbidity and ED attendance rates in these patient groups. ED clinicians working closely with ambulance services should be aware of these updates, particularly in the context of handover and shared management decisions for neurodivergent patients.
3 — RESUSCITATION & CRITICAL CARE
Cerebral Tissue Oxygen Saturation at Defibrillation Predicts ROSC in Shockable OHCA
Kano H et al. Resuscitation. 2026 Aug 31;111286. doi:10.1016/j.resuscitation.2026.111286. PMID: 42674240. Nippon Medical School, Tokyo, Japan.
Design: Prospective observational study. Adults with shockable OHCA (VF or pulseless VT) undergoing in-hospital resuscitation with cerebral tissue oxygen saturation (SctO2) monitoring by near-infrared spectroscopy. Primary analysis: first monitored defibrillation per patient (n=87 patients). Secondary analysis: all 194 monitored defibrillations using a GLMM with patient-level random intercept. Adjusted for site, arrest-to-defibrillation time, and epinephrine timing. Japan, no commercial funding.
Results: Median SctO2 at defibrillation was 48.8% (IQR 47.2–53.6%) in patients achieving ROSC vs 38.1% (IQR 33.8–41.8%) in those without. Each 1% increase in SctO2 was associated with an adjusted OR of 1.48 for ROSC (95% CI 1.22–1.80; p<0.001; AUC 0.961). An exploratory SctO2 cut-off of 44.5% had sensitivity 94.7% and specificity 89.7% for ROSC. The association remained consistent across all 194 defibrillations (OR 1.56 per 1% increase; 95% CI 1.34–1.82).
Critical appraisal: This is an exploratory, hypothesis-generating study from a single Japanese centre. The AUC of 0.961 is striking but must be interpreted cautiously — it is derived from the same dataset used to identify the cut-off, making overfitting a significant concern. The 44.5% SctO2 cut-off is explicitly described by the authors as exploratory and requires external validation in different healthcare systems, patient populations, and with different NIRS devices. Critically, the authors state the cut-off must not delay guideline-directed defibrillation — this is a future monitoring and decision-support tool, not a gate to treatment. SctO2 monitoring during CPR is not standard in UK EDs and requires specific equipment and training. The Japanese cardiac arrest system differs from the UK in terms of ambulance response times, bystander CPR rates, and post-ROSC pathways.
UK ED practice: For information only at this stage. Cerebral NIRS monitoring during resuscitation is an area of active research; do not change defibrillation practice on the basis of this exploratory cut-off. Watch for the validation cohort. If your resuscitation service uses NIRS monitoring, this is useful contextual data to discuss at a cardiac arrest case review.
High-Quality CPR: From Process to Perfusion — UK Author Perspective
Price J, Palti G, Berry N, Lachowycz K, Barnard EBG. Resuscitation. 2026 Sep 4:111297. doi:10.1016/j.resuscitation.2026.111297. PMID: 42697467. East Anglian Air Ambulance; Cambridge University; Royal Centre for Defence Medicine, Birmingham.
A perspective piece from UK authors (East Anglian Air Ambulance, Cambridge University, and the Royal Centre for Defence Medicine) reframing high-quality CPR from a metric-based process (rate, depth, fraction) to a perfusion-based outcome goal. The piece argues that coronary and cerebral perfusion pressure — not CPR process metrics — should be the targets of resuscitation, and that haemodynamic-guided CPR (particularly monitoring aortic diastolic pressure or end-tidal CO2 as surrogates) represents the next frontier for improving cardiac arrest outcomes. The full abstract is not yet published; the paper is online ahead of print.
UK context: Relevant to HEMS teams and consultant-led resuscitation services. The concept of haemodynamic-guided CPR (ETCO2 >10 mmHg as a quality surrogate; arterial diastolic pressure >25 mmHg if arterial line in situ) is established in high-level resuscitation practice. Worth reading in full when published.
POCUS to Predict Difficult Intubation in the ED — Systematic Review (EMJ 2026)
Emergency Medicine Journal. 2026 Sep 7; online ahead of print. doi:10.1136/emermed-2025-216. PMID: 42705905
Design: Short systematic review of MEDLINE and EMBASE. Four prospective observational studies met inclusion criteria. Ultrasound parameters evaluated: hyomental distance (HMD), tongue thickness, and anterior neck soft tissue thickness. All correlated with Cormack-Lehane grade on laryngoscopy.
Results: Several POCUS parameters demonstrated fair to excellent diagnostic accuracy for predicting difficult laryngoscopy. Variability across studies in populations, measurement techniques, and diagnostic thresholds limits generalisability and pooled quantitative estimates.
Critical appraisal: Only four studies met inclusion criteria — the evidence base is small and heterogeneous. No pooled sensitivity or specificity estimates are provided. The studies vary significantly in the definition of "difficult intubation," operator POCUS training levels, and patient populations. Importantly, POCUS-based airway assessment adds time and requires training — it should complement, not replace, standard airway assessment tools (MACOCHA score, thyromental distance, mouth opening, cervical mobility). DAS 2025 recommends pre-induction assessment of all four plans (A, B, C, D) but does not yet incorporate POCUS as a standard step. This review is informing rather than practice-changing, but the concept of ultrasound assessment of hyomental distance and tongue thickness is practical to learn and applicable in a structured pre-RSI assessment.
UK ED practice: POCUS for airway assessment is a useful additional tool if you have the training and it does not delay preparation time. Hyomental distance in extended position and tongue base thickness are the most studied parameters. Do not use in isolation and do not delay RSI to obtain measurements. DAS 2025 recommends early call for help if difficulty anticipated in any plan — use POCUS as part of that planning assessment, not as a bottleneck.
4 — PAEDIATRIC EMERGENCY MEDICINE
Dexmedetomidine Continuous Infusion for Severely Agitated Adolescents in the ED
Annals of Emergency Medicine. 2026 Aug; online ahead of print. PMID: 42678315
Design: Prospective case series examining the use of continuous dexmedetomidine infusion as a management strategy for severely agitated adolescents presenting to the ED. The series evaluates feasibility, effectiveness in achieving sedation, and safety profile, including monitoring of airway reflexes and haemodynamic stability. US setting.
Key findings: Dexmedetomidine infusion at 0.5–1 mcg/kg/hr was effective in producing calm, cooperative sedation in adolescents with severe undifferentiated agitation (including psychiatric, substance-related, and neurodevelopmental presentations). Crucially, airway reflexes and spontaneous ventilation were preserved throughout — a major advantage over benzodiazepines and antipsychotics, which carry aspiration risk in combative patients. No serious adverse events were reported in the series. Haemodynamic monitoring showed bradycardia in a minority of patients, consistent with the known pharmacology, but this did not require intervention in any reported case.
Critical appraisal: A case series is the lowest level of primary study evidence and is susceptible to selection bias, absence of a comparator arm, and publication bias. The US healthcare context (psychiatric boarding, sedation culture, formulary access) may differ substantially from UK EDs. Dexmedetomidine is not universally stocked in UK emergency departments and requires pharmacy approval for non-ICU use in most trusts. The lack of a comparison group (e.g., haloperidol, lorazepam, or droperidol) makes it impossible to assess relative efficacy or harm. Despite these limitations, dexmedetomidine is a pharmacologically rational choice in this population — it produces predictable, titratable sedation without respiratory depression, which is especially valuable when the airway is a concern in a combative young patient. This series supports feasibility and safety signals; a prospective RCT is needed.
UK PEM practice: If your ED manages severely agitated adolescents and dexmedetomidine is on formulary (check with your pharmacy), this is a reasonable option for patients in whom respiratory depression from benzodiazepines or antipsychotics is a particular concern (e.g., unknown substance ingestion, neurodevelopmental conditions, obesity). Discuss with your paediatric emergency or CAMHS team. Ensure continuous cardiac monitoring and airway equipment immediately available. This is not yet standard practice but represents an evidence-informed option for a challenging presentation.
Anaphylaxis Observation Time Safely Reduced from 233 to 154 Min in Low-Risk Paediatric Patients
JournalFeed Paeds Speed Read. September 2026. journalfeed.org
What this is: A quality improvement study evaluating the impact of implementing a risk-stratified anaphylaxis observation protocol in a paediatric ED. The intervention reduced the median observation time from 233 to 154 minutes in low-risk patients (those not requiring more than one dose of adrenaline, without signs of severe reaction, and with good symptomatic recovery) without any increase in biphasic anaphylaxis reactions or return visits.
Critical appraisal: QI studies are designed to evaluate the effect of a process change in a specific setting and are not powered or designed for rigorous causal inference. The absence of biphasic reactions in the post-intervention period is reassuring but the observation cohort is not large enough to definitively exclude a small increase in risk. Biphasic anaphylaxis is itself rare in the paediatric population (<5% of cases), and most biphasic reactions are mild. NICE NG80 (Anaphylaxis: Assessment and Referral After Emergency Treatment, 2020) recommends a minimum 6-hour observation period for most patients, but acknowledges that the optimal duration is uncertain. The trend in the literature is towards shorter, risk-stratified observation for truly low-risk presentations.
UK PEM practice: Follow NICE NG80 and your trust's anaphylaxis protocol. For low-risk paediatric patients (single adrenaline dose, rapid full recovery, no high-risk features such as severe asthma, cardiovascular disease, or reaction to peanut/tree nut), this QI evidence supports the direction of travel towards shorter observation times in appropriately selected patients. Do not discharge before 4–6 hours without senior clinical sign-off. Ensure EpiPen prescription, written anaphylaxis plan, and allergy referral on discharge.
Paediatric Procedural Sedation and Analgesia in the ED — Delphi Consensus 2026
Paediatric Procedural Sedation and Analgesia in Emergency Departments: A Delphi Consensus Study. Emergency Medicine Australasia. October 2026. PMID: 42710898. 28 clinicians, 23 centres, Spain.
Design: Modified two-round Delphi study. 28 clinicians with expertise in paediatric emergency care and procedural sedation from 23 centres across Spain. Consensus threshold: ≥70% agreement in both rounds. Domains assessed: patient selection, fasting, monitoring, staffing, pharmacological strategies, training, and safety standards.
Key consensus points: Fasting status must not delay clinically urgent emergency sedation (strong consensus). Continuous capnography standard for all deep sedation episodes. Ketamine preferred for painful procedures; pharmacological preferences for imaging/non-painful procedures varied more widely. Standardised departmental sedation protocols, trained second operator (independent from the proceduralist), and defined recovery criteria are mandatory. Training requirements and simulation for sedation competency received strong consensus.
Critical appraisal: Delphi methodology generates expert consensus rather than primary evidence. The panel was exclusively Spanish and drawn from specialist tertiary paediatric emergency centres — not representative of a mixed UK DGH paediatric ED environment. Despite this, the core consensus points (fasting not a reason to delay urgent sedation; capnography standard; documented protocol required) are consistent with RCEM, AAGBI, and NICE guidance and are broadly applicable. The variability in pharmacological preferences for non-painful procedures likely reflects genuine uncertainty in this area rather than a resolvable consensus question. The study is useful for benchmarking and for informing departmental sedation protocol development.
UK PEM practice: Consistent with RCEM procedural sedation guidance. Key takeaways: (1) urgent sedation should not be withheld pending fasting period; (2) capnography should be available for all deep sedation in paediatric patients; (3) a documented departmental protocol with defined competency requirements and recovery criteria should be in place. Use this consensus to benchmark your department's sedation governance.
Oseltamivir in Hospitalised Children with Influenza — LOS Reduced by 9.4h, ICU Admission aHR 0.69
JournalFeed Paeds Speed Read. 9 September 2026. journalfeed.org
Design: Large retrospective observational cohort study of children hospitalised with confirmed influenza. Compared clinical outcomes between children who received oseltamivir and those who did not. Primary outcomes: hospital length of stay (LOS) and ICU admission. Adjusted analysis for confounders.
Key findings: Oseltamivir was associated with a reduction in hospital LOS of approximately 9.4 hours (adjusted). ICU admission was significantly lower in the oseltamivir group: adjusted hazard ratio 0.69 (95% CI not reported in JF summary). No safety signals identified.
Critical appraisal: This is an observational study and is susceptible to confounding by indication — children who received oseltamivir may have been treated earlier in their illness course, in higher-resource settings, or by clinicians with a lower threshold for aggressive management. The adjusted analysis attempts to address this but residual confounding is likely in a retrospective design. The LOS reduction of 9.4 hours, while statistically significant, must be contextualised against the risk of antiviral resistance and the cost-benefit of routine prescription. This contrasts with SGEM#518 (Issue 28), which found no survival benefit for oseltamivir in critically ill hospitalised adults. The paediatric population may respond differently. Importantly, the UKHSA recommends oseltamivir for at-risk hospitalised children with influenza, and these data support that guidance — this is not a signal to prescribe more broadly.
UK PEM practice: Follow UKHSA and NICE indications for oseltamivir in children. At-risk children hospitalised with confirmed influenza (those with severe illness, immunosuppression, chronic conditions, or age <2 years) should receive oseltamivir as per current guidance. These data add observational support to the existing recommendation. Do not extrapolate to routine prescribing in low-risk children or outpatient presentations.
5 — FOAMED & CRITICAL APPRAISAL
EMCrit 433 — HALO (High Acuity, Low Occurrence) Procedural Philosophy
Scott Weingart. EMCrit. Published 5 September 2026. emcrit.org/emcrit/halo/
Weingart introduces a conceptual framework for the 12 highest-stakes, lowest-occurrence procedures in emergency and critical care medicine: cricothyrotomy, paediatric difficult airway/eFONA, resuscitative thoracotomy, pericardiocentesis, lateral canthotomy/cantholysis, finger thoracostomy, resuscitative hysterotomy, transvenous pacing, Minnesota/Blakemore tube, emergency delivery, escharotomy, and catastrophic post-tonsillectomy haemorrhage control. ECMO/ECPR and REBOA are included as "bonus" procedures.
The episode's central argument is that a skilled clinician in a broken institutional system is doomed to fail with these procedures, and that institutional competence — not just individual skill — is the determinant of outcomes. Weingart distinguishes between individual skill decay (technical, knowledge) and institutional failure (indications not protocolised, equipment not maintained, downstream pathways not established). He introduces the "Recipe Method" for procedural self-mastery — a structured approach covering indications/contraindications, anatomy, microskills, set-up, technique, tacit knowledge, complications, aftercare, team roles, and quality improvement.
The framework is directly applicable to UK EDs. Many UK emergency departments have competency requirements for cricothyrotomy and resuscitative thoracotomy but lack protocolised institutional governance for the full range of HALO procedures. Key action item: identify which HALO procedures your department is expected to perform, and for each: (1) are indications clearly defined? (2) is equipment available and regularly checked? (3) are downstream pathways (theatre, ITU, cath lab) established and tested? (4) is there a competency and training schedule?
UK ED practice: Use this framework to audit your department's HALO procedure readiness. Ensure cricothyrotomy and resuscitative thoracotomy kits are pre-prepared, stored accessibly, and staff know their location. Run simulation for at least one HALO procedure per quarter at departmental level. Set your own indications clearly before you need them — cognitive load in extremis should be spent on technique, not on deciding whether to act.
6 — ACTION POINTS
| 1 | Hyperkalaemia protocol: Review your ED's insulin dosing protocol for hyperkalaemia. Ensure it includes a 5-unit dose for patients with AKI, CKD, weight <50 kg, or glucose <7 mmol/L. Glucose monitoring for at least 4 hours after insulin is mandatory. ECG alone should not be the trigger to act at K ≥6.5 mmol/L. |
| 2 | Inhaled IPA for nausea: Introduce alcohol wipes as a first-line non-pharmacological antiemetic option in your department. Brief your nursing and ACP teams. NNT=3 for avoiding a rescue antiemetic. Avoid in pregnancy. |
| 3 | RCEM Safe to Care: Report all violence and aggression incidents. Know your trust's escalation pathway. Support colleagues proactively — staff experiencing violence benefit from debrief and peer support. |
| 4 | JRCALC update 2:26: Download the latest JRCALC app update. Review the Learning Disabilities and Autism guidance, particularly if your department has high paramedic handover volume from patients with neurodevelopmental conditions. |
| 5 | Paeds anaphylaxis observation: Ensure your anaphylaxis protocol includes risk stratification for observation duration. Low-risk children (single adrenaline dose, full rapid recovery, no high-risk features) can be considered for shorter observation per NICE NG80 — but senior sign-off and adrenaline auto-injector prescription are mandatory before discharge. |
| 6 | HALO procedure readiness: Identify one HALO procedure in your department to audit this month. Check equipment availability, location, and expiry. Define the trigger for use. Run a brief simulation or mental walkthrough with your team. |
| 7 | Brugada ECG: If you see Type 1 Brugada pattern (coved ST elevation >2 mm V1–V2 at standard or high right precordial placement) with ANY clinical correlate (syncope, nocturnal agonal |
respiration, family history sudden death <45 years), admit for cardiology review. Remove or avoid sodium-channel-blocking drugs. Treat fever aggressively.
7 — TRIALS TO WATCH
ONGOING / EXPECTED
| EVITA | Running locally at BHH. |
| TROOP | Next prehospital whole blood RCT — different blood age and subgroup analyses. Expected 2027. |
| REMAP-CAP oseltamivir | Full peer-reviewed publication awaited. Will clarify Bayesian harm signal from SGEM#518 review (Issue 28). Do not change prescribing until published. |
CORE REVISION — ISSUE 29 — 11 SEPTEMBER 2026
Brugada Syndrome
ECG recognition, drug precipitants, fever as trigger, ED management — FRCEM-relevant
Exam goal: Identify the three Brugada ECG patterns and state which is diagnostic; know where to place leads to maximise detection; list drugs that unmask Brugada; explain why fever is a precipitant and what to do about it; describe the ED management pathway including ICD referral and drugs to avoid. This is an ECG revision topic — focus on pattern recognition and clinical context.
1. WHAT IS BRUGADA SYNDROME?
Brugada syndrome is a primary electrical cardiac disorder characterised by ST-segment changes in V1–V3 and a high risk of sudden cardiac death from ventricular fibrillation, in the absence of structural heart disease. First described by the Brugada brothers in 1992. It is a sodium channelopathy — the majority of mutations are in SCN5A (cardiac sodium channel gene); however, >60 mutations are described and at least 50% are spontaneous (not inherited).
Epidemiology: Mean age of sudden death 41 years. Diagnosed from 2 days to 84 years. Predominantly male (8:1 male predominance). Higher incidence in Southeast Asia. Previously described as Sudden Unexplained Nocturnal Death Syndrome (SUNDS), Pokkuri (Japan), Bangungut (Philippines), and Lai Tai (Thailand). The classic presentation is sudden nocturnal death in a young Asian male — but Brugada syndrome occurs in all ethnicities. Estimated mortality without ICD: 10% per year in high-risk individuals.
2. THE THREE ECG PATTERNS
There is effectively only one diagnostic ECG pattern (Type 1). Types 2 and 3 are non-diagnostic but warrant further investigation.
| PATTERN | ECG APPEARANCE | DIAGNOSTIC? | CLINICAL SIGNIFICANCE |
|---|---|---|---|
| Type 1 (Coved) | Coved ST elevation >2 mm in ≥1 of V1–V2 (or high right precordial V1–V2 at 2nd/3rd ICS), followed by a negative T wave | YES — potentially diagnostic when combined with clinical criteria | The "Brugada sign." Diagnosis requires Type 1 pattern PLUS at least one clinical criterion (see below). Spontaneous Type 1 is higher risk than drug-induced Type 1. |
| Type 2 (Saddleback) | Saddleback-shaped ST elevation >2 mm in V1–V2. Positive or biphasic T wave. | No | Non-diagnostic. May warrant pharmacological testing — sodium channel blockers can convert Type 2 to Type 1, aiding diagnosis. This subgroup appears to have low or no increased mortality compared with the general population. |
| Type 3 | Type 1 or Type 2 morphology with ST elevation <2 mm. | No | Non-diagnostic. Consider further investigation if clinical suspicion. |
3. CLINICAL CRITERIA (REQUIRED ALONGSIDE TYPE 1 ECG FOR DIAGNOSIS)
Type 1 Brugada pattern alone (a "Brugada sign") is of questionable significance without clinical context. Diagnosis of Brugada syndrome requires the Type 1 pattern PLUS at least one of:
- Documented ventricular fibrillation or polymorphic VT
- Syncope (unexplained, potentially arrhythmic)
- Nocturnal agonal respiration
- Family history of sudden cardiac death before age 45 years
- Coved-type ECG pattern in a first-degree family member
- Inducibility of VT/VF with programmed electrical stimulation (EPS)
4. WHERE TO LOOK — HIGH RIGHT PRECORDIAL LEADS
Standard lead placement may miss Brugada pattern. Move V1 and V2 to the 2nd or 3rd intercostal space (high right precordial placement) if Brugada is suspected but standard ECG is non-diagnostic. This is the recommended approach in the European guidelines and LITFL guidance. Some centres use dedicated Brugada lead placement routinely in patients with unexplained syncope.
5. FACTORS THAT UNMASK OR AUGMENT THE ECG CHANGES
ECG changes in Brugada syndrome are often dynamic and may be absent on a single resting ECG. Unmasking factors are clinically important — they may provoke the diagnostic ECG and, more dangerously, may trigger arrhythmia.
| CATEGORY | EXAMPLES | ED ACTION |
|---|---|---|
| Fever | Any febrile illness. Fever impairs sodium channel function. | Treat fever aggressively with paracetamol. Do not wait for ECG normalisation before treating fever. A febrile patient with known Brugada needs aggressive antipyresis and cardiac monitoring. |
| Sodium-channel blockers | Flecainide, propafenone, ajmaline (used diagnostically) | Avoid all class IC and some class IA antiarrhythmics in patients with known or suspected Brugada. Flecainide is used in AF in UK EDs — ensure Brugada has been excluded before prescribing in unexplained syncope presentations. |
| Other drugs | Beta blockers, calcium channel blockers, alpha agonists, nitrates, cocaine, alcohol, tricyclics, lithium, some antihistamines | Review all drugs and recreational substances in patients with suspected Brugada. The Brugadadrugs.org website lists current evidence for individual drugs. |
| Electrolyte disturbances | Hypokalaemia, hyperkalaemia, hypothermia | Correct electrolytes and treat hypothermia. Hyperkalaemia in particular can produce a Brugada phenocopy — consider K level in all Brugada-pattern ECGs. |
| Post-cardioversion | Changes may appear transiently after DC cardioversion | Awareness rather than treatment; context-dependent. |
6. ED MANAGEMENT
Acute VF/VT: Defibrillate immediately per ALS algorithm. Isoprenaline IV infusion (not widely available, discuss with cardiology) may suppress electrical storm in Brugada syndrome — quinidine is an alternative. Do NOT use class IC antiarrhythmics (flecainide, propafenone) or amiodarone in confirmed Brugada — they may worsen the arrhythmic substrate.
Type 1 ECG pattern + clinical criteria — without acute arrhythmia: Admit for cardiac monitoring. Urgent cardiology review. Refer for outpatient electrophysiology study (EPS) to assess inducibility. If diagnosis confirmed: ICD referral. Note — EPS has a negative predictive value of <50% for Brugada risk stratification; a negative EPS does not exclude meaningful risk.
Asymptomatic Type 1 pattern / Type 2 or 3 patterns: These patients may be appropriate for urgent outpatient cardiology review rather than emergency admission, depending on the clinical context. Discuss with on-call cardiology. Avoid discharging with drugs that unmask Brugada. Advise patients to avoid fever, excess alcohol, and to report any symptoms of pre-syncope or nocturnal breathlessness immediately.
Definitive treatment: ICD is the only proven therapy. Quinidine is an alternative where ICD is unavailable (e.g., neonates), used to suppress electrical storm, and has a role as adjunctive therapy in high-risk patients.
7. DIFFERENTIALS FOR BRUGADA-PATTERN ECG (BRUGADA PHENOCOPY)
The following conditions can produce an ECG pattern mimicking Brugada, without the underlying channelopathy:
- Hyperkalaemia — always check K in a Brugada-pattern ECG, especially if unwell
- Right bundle branch block (RBBB) with early repolarisation
- Right ventricular outflow tract (RVOT) artefact from lead placement
- Pulmonary embolism (S1Q3T3 and RBBB morphology can sometimes mimic)
- Ischaemia involving the right ventricular outflow tract
- Hypothermia (Osborn wave)
Brugada phenocopy — transient Brugada pattern from a reversible cause without the underlying gene mutation — typically resolves with treatment of the underlying condition. It does not necessarily require ICD referral but should prompt cardiology review.
Memory aid — Type 1 Brugada triggers (FEND BANCA): Fever — Electrolytes (hypo/hyperkalaemia) — Na-channel blockers (flecainide, propafenone) — Drugs (cocaine, alcohol, TCAs, CCBs, beta blockers) — Beta blockers — Alcohol — Nitrates — Cardioversion (post) — Anaesthesia (particularly propofol infusion)
FRCEM exam focus: The exam tests (1) recognising Type 1 vs Type 2 vs Type 3 patterns from a 12-lead ECG, (2) knowing that ONLY Type 1 + clinical criteria is diagnostic, (3) knowing which leads to use (standard V1–V2 AND high right precordial placement at 2nd/3rd ICS), (4) listing drugs to avoid, (5) knowing that fever unmasks Brugada and must be treated aggressively, and (6) that ICD is the definitive treatment. EPS negative predictive value <50% is a commonly tested fact. Brugada ECG in a febrile patient with syncope: treat the fever, call cardiology, monitor closely. Do not prescribe flecainide, propafenone, or amiodarone.
EM Evidence Rundown — Issue 29 — 11 September 2026 Curated by Jake Turner, Senior Registrar in Emergency Medicine (ST6). Produced with the assistance of AI (Perplexity). All content editorially reviewed. Not a substitute for clinical judgement or local guidelines. For feedback: Submit feedback | Archive: emevidence.org Unsubscribe: Reply UNSUBSCRIBE to this email. To update your preferences, visit emevidence.org