EM Evidence Rundown — Issue 9

EMERGENCY MEDICINE · UK EDITION

EM Evidence Rundown

Week of 23 April 2026 | Issue #9

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed.

This week: The first dedicated AHA/ACC pulmonary embolism guideline in history introduces a five-category severity classification (A–E) that directly changes who you discharge, who you admit, and who gets advanced therapy. PERT teams are now formally recommended. CHANGE items: PE disposition by category (CHANGE TONIGHT) • Anteroposterior pad position in refractory VF (CHANGE TONIGHT) • Antibiotics for appendicitis counselling numbers updated • Single-dose dexamethasone for paediatric asthma UK data: New National Child Mortality Database analysis — at least 2 children die from knife injuries every month in England, average age 14, 90% male, 75% from areas of highest deprivation.

BOTTOM LINE UP FRONT — ISSUE #9

ACT ON THIS NOW

TONIGHT PE pathway: Category A (asymptomatic) & B (sPESI 0) — discharge with DOAC. Do not admit.

TONIGHT Refractory VF: After ≥2 failed shocks, switch to anteroposterior pad position before next attempt. NNT ∼7 for ROSC.

TONIGHT BRUE: If all low-risk criteria met (age >60d, ≥32wk, no prior BRUE, <1 min, no CPR, no NAI concern) — observe briefly, discharge, safety-net. Diagnostic yield <2%.

TONIGHT Non-injectable ketamine: Intranasal 3–9 mg/kg for paediatric procedural sedation — no IV access needed. Onset 10–15 min.

TONIGHT Balanced fluids: Default = Plasmalyte or Hartmann's. Hyperkalaemia is NOT an indication for saline — it worsens it. Reserve saline for TBI/raised ICP.

THIS MONTH Appendicitis NOM: 55.7% avoid surgery at 10 years (CI 49.6–61.8%); 44.3% eventually need it. Complications lower with antibiotics (8.5% vs 27.4%). Genuine shared decision — 74.7% of recurrences happen within 2 years.

THIS MONTH Paed asthma: Single-dose dexamethasone (0.15–0.3 mg/kg) is likely sufficient. Review your two-dose protocol.

THIS MONTH Corridor care: NHS England trust-level data goes public May 2026. Document using the formal definition now.

KNOW FOR NEXT TIME

GUIDELINE WATCH 2026 AHA/ACC PE Guidelines: New A–E classification. PERT teams recommended. DOACs over VKA. 7-day follow-up for all discharged PE.

GUIDELINE WATCH Gonorrhoea: Zoliflodacin (oral, single dose) Phase 3 non-inferiority vs ceftriaxone. FDA-approved. UK guideline update pending. NNH 19 vs combination.

INFORMING Buffered fluids vs saline: Cochrane SR confirms balanced crystalloids reduce AKI (NNT ∼40). Modest effect; evidence strongest in sepsis subgroup.

INFORMING SAH: CT >6h from onset → LP + spectrophotometry mandatory. Ottawa Rule — any one criterion → investigate. Document time-to-peak intensity.

PAEDS · UK Knife crime: ≥2 child deaths/month in England. Avg age 14. 71% rise since 2019. Ask your dept: do you have a violence intervention pathway?

INFORMING Hyponatraemia revision: Acute symptomatic → 100 mL 3% saline IV over 10 min (repeat ×3). Chronic → max 8–10 mmol/L per 24h. ODS risk if over-corrected.

INFORMING CHS: IV haloperidol (NNT ∼3–5) + topical capsaicin. Antiemetics largely ineffective. Only cure: cannabis cessation.

Pulmonary embolism kills approximately 25,000 people in the UK annually and is one of the most consequential diagnostic and disposition decisions an emergency physician makes. This week, for the first time, the AHA and ACC have published a dedicated PE guideline — replacing scattered recommendations from older cardiac and VTE documents. The new five-tier classification (A to E) operationalises severity in a way that directly maps to what happens in your resus bay and majors: asymptomatic PE can go home, low clinical severity PE should be discharged early, and only categories C, D, and E warrant admission. In paediatrics, a major SR/MA of BRUE confirms that serious diagnoses are rare and routine investigation has very low yield — the over-investigation of BRUE must stop. And in a first-of-its-kind analysis from the National Child Mortality Database, at least two children die each month from knife injuries in England. The average victim is a 14-year-old boy from a deprived area. These are patients your department sees.

WHAT'S INSIDE

Key Trials & Papers AHA/ACC PE Guidelines 2026 • APPAC 10yr appendicitis follow-up • Zoliflodacin gonorrhoea Phase 3 • Buffered vs saline Cochrane SR • Refractory VF pad position • GOLDEN BRIDGE II stroke CDS

Paediatrics • FOAMed • More BRUE SR/MA • Non-injectable ketamine • Paed asthma dexamethasone • Knife crime NCMD analysis • Subarachnoid haemorrhage ED review • Hyponatraemia revision

TAG LEGEND

RCT SR/MA GUIDELINE OBSERVATIONAL REVIEW CHANGE TONIGHT

CHANGE THIS MONTH CHANGE WHEN GUIDELINE UPDATES INFORMING PRACTICE FRCEM

PAEDS UK DATA

CONTENTS

Key Trials & Articles

1. 2026 AHA/ACC PE Guidelines — New 5-Tier Classification, PERT Recommendation, DOAC First-Line [LEAD] 2. Refractory VF: Anteroposterior Pad Positioning Improves ROSC 3. APPAC 10-Year Follow-Up: Antibiotics for Uncomplicated Appendicitis 4. Zoliflodacin vs Ceftriaxone + Azithromycin for Gonorrhoea (Phase 3 RCT, Lancet) 5. Buffered Solutions vs 0.9% Saline — Cochrane SR Update 2026 6. GOLDEN BRIDGE II: Stroke Clinical Decision Support RCT (BMJ, n=21,000+) 7. High Risk & Low Incidence: Aneurysmal Subarachnoid Haemorrhage

Guidelines & UK Updates

8. NHS England Corridor Care Data — First Publication Due May 2026 9. RCEM Annual Conference 2026 — 28–30 April, ICC Birmingham

Paediatric EM

10. Knife Crime Fatalities in Children in England (NCMD, EMJ) — At Least 2 Deaths/Month

11. BRUE SR/MA: Serious Diagnoses Uncommon, Routine Testing Very Low Yield (JAMA Pediatr) 12. Non-Injectable Ketamine for Paediatric Sedation in the ED — SR/MA 13. Dexamethasone: Single Dose as Effective as Two in Paediatric Asthma Exacerbation

Quick Hits, Core Revision, Action Points, Trials to Watch

1 — KEY JOURNAL ARTICLES & TRIALS

AHA/ACC · CIRCULATION · PUBLISHED 20 FEBRUARY 2026 · JOURNALFEED COVERAGE 23 APRIL 2026

2026 AHA/ACC Pulmonary Embolism Guidelines: New 5-Tier Clinical Category System, PERT Teams Recommended, DOAC Over VKA, Asymptomatic PE Dischargeable [LEAD]

GUIDELINE CHANGE TONIGHT FRCEM

The American Heart Association and American College of Cardiology have published the first dedicated clinical practice guideline for the evaluation and management of acute pulmonary embolism in adults. This is the most consequential PE publication in a decade — previous recommendations were embedded in broader cardiac or anticoagulation guidelines. The 2026 guideline is co-authored by ten major societies including ACEP, CHEST, and SHM. JournalFeed published a structured two-part summary for emergency clinicians today.

The New 5-Tier Acute PE Clinical Category System

Key Recommendations

Duration

First PE without major reversible risk factor: continue anticoagulation beyond initial 3–6 months into extended phase (recommended). Review at 3 months for duration decision.

Critical appraisal: This is a US guideline (AHA/ACC/ACEP) — not NICE or RCEM. UK practice follows NICE NG158 (2020) and local PERT/haematology protocols. The DOAC recommendation is already aligned with NICE NG158, which also recommends DOACs first-line for PE. The new classification system is the main addition — it is clinically intuitive and practice-changing. The key question is whether UK trusts will adopt the A–E system formally or whether it will sit as background knowledge informing decisions. NICE NG158 does not use this exact classification. Until NICE updates, use the 2026 AHA/ACC risk categories as a framework alongside sPESI, RV function, and troponin — which is what the categories operationalise anyway. The JournalFeed review notes the category scheme is "reasonable with a confusing sub-categorisation" — D1/D2 is a new addition that may need more clinical definition in practice.

Why it matters: Category A PE (asymptomatic, incidentally found) should not be admitted. This will be increasingly common as CT use rises. Category B (symptomatic, sPESI 0) should be discharged early with anticoagulation and a 7-day follow-up call or clinic. If your department is still admitting all PE patients, this guideline is the prompt to review your pathway. The formal PERT recommendation is significant — if your trust does not have a PERT team, this is the evidence base to propose one, particularly if you are getting Category D and E presentations out of hours.

Tell your department: Review your PE pathway against the new A–E categories. Category A (asymptomatic) and Category B (sPESI 0, no RV dysfunction, normal troponin) should not routinely be admitted. Ensure DOAC initiation is standard for eligible patients — not warfarin. If your trust has no PERT mechanism, this guideline supports creating one. 7-day post-discharge follow-up contact is now a formal recommendation.

Source: AHA/ACC 2026 PE Guidelines — Top 10 Things to Know · JournalFeed Part 1 (23 April 2026)

JOURNALFEED EM · RESUSCITATION · 2026 MAR 17 · PMID 41856454

Anteroposterior Defibrillation Pad Positioning in Refractory VF: Associated with Higher ROSC Rates in Secondary Analysis of 342 Patients

OBSERVATIONAL CHANGE TONIGHT FRCEM

• ~+15% ARD — ROSC RATE
• NNT ~7 NNT — ROSC
• Sec. analysis STUDY DESIGN
• n=342 REFRACTORY VF

Outcome

AP Positioning

Anterolateral (standard)

ROSC rate

~62%

~47%

Association

AP position independently associated with ROSC on multivariable analysis

Cheskes S, Drennan IR, Turner L, Pandit SV et al. Secondary analysis of a registry of 342 patients with refractory ventricular fibrillation (failed ≥2 standard shocks). Anteroposterior pad positioning (one pad anterior precordial, one pad posterior left infrascapular) was compared with standard anterolateral positioning. AP positioning was independently associated with ROSC after adjustment for confounders.

Critical appraisal: Secondary analysis — not an RCT. Selection bias is possible (operators may have chosen AP in specific patient anatomies). However, the physiological rationale is solid: AP positioning delivers current more directly through the myocardium in a transthoracic vector that avoids the spine and lung. The same principle underlies AP pacing and cardioversion in AF. The NNT of approximately 7 is clinically meaningful in a population where ROSC rates are otherwise low. RCUK 2025 guidelines already support AP positioning as an option after failed standard defibrillation — this data supports making it the active choice in refractory VF rather than a passive alternative.

Why it matters: Refractory VF (VF persisting after ≥2 shocks with CPR) has a very high mortality. In this population, every intervention that improves ROSC rates matters. AP positioning requires no equipment change — just repositioning of the posterior pad. This is a zero-cost, immediate intervention your entire team can do in the next resus. Double sequential external defibrillation (DSED) is also supported by recent trial data — AP positioning + DSED may become the standard approach to refractory VF.

Tell your department: In refractory VF (failed ≥2 shocks), actively consider switching to AP pad positioning on the next shock before escalating to DSED. Position: right anterior pad in standard precordial position + left posterior pad below left scapula. Brief your resus team now so this is pre-planned rather than ad-hoc in a cardiac arrest.

Source: Cheskes et al. Resuscitation 2026 — AP pad positioning in refractory VF (PMID 41856454)

EMA DAILY · JAMA · PUBLISHED ONLINE JANUARY 2026 · PMID 41563747

APPAC 10-Year Follow-Up: Antibiotics for Uncomplicated Appendicitis — More Than Half Avoided Surgery at 10 Years, But 48% Ultimately Required Appendicectomy

RCT CHANGE THIS MONTH FRCEM

• 55.7% SURGERY-FREE AT 10YR (CI 49.6–61.8%)
• 44.3% REQUIRED SURGERY BY 10YR (CI 38.2–50.4%)
• NNT 1.8 TO AVOID 1 SURGERY (10YR)
• NNT 5.3 TO AVOID 1 COMPLICATION VS SURGERY

Salminen P, Salminen R, Kallio J et al. JAMA 2026;335(12):1041–1049. The APPAC trial (n=530, 6 Finnish hospitals, 2009–2012) randomised adults with CT-confirmed uncomplicated appendicitis to antibiotics (ertapenem IV then oral levofloxacin + metronidazole) or appendicectomy. This 10-year observational follow-up of the antibiotic arm (n=257, 98.4% follow-up) provides the longest prospective dataset on nonoperative management (NOM) for appendicitis. Full text accessed via BMA library.

Outcome

Antibiotic arm

Appendicectomy arm

Cumulative complications at 10yr

8.5% (CI 4.8–12.1%)

27.4% (CI 21.6–33.3%)

ARD complications (antibiotics vs surgery): −18.9% favouring antibiotics — NNT 5.3 to avoid one complication by choosing NOM. Note: the antibiotic regimen used (ertapenem/levofloxacin) is non-standard and not used in UK practice. Appendicolith cases were excluded from this trial. 2 appendiceal tumours (LAMN) found on MRI follow-up in intact appendix patients (∼1.2% overall — both managed surgically, no adjuvant treatment required).

Critical appraisal: EMA Daily editor Sanjay Arora notes several key limitations. The antibiotic regimen used (IV ertapenem then oral levofloxacin + metronidazole) is non-standard and outdated — not what most UK units would use. Appendicolith cases were excluded — these are higher risk and failure rate may differ. The Finnish single-health-system context limits generalisability. The protocol-driven surgical threshold (any symptom recurrence) means the recurrence rate reflects their protocol, not a natural history. That said, the 98.4% follow-up rate is exceptional methodological strength. The bottom line from Arora: "More than half of patients avoided surgery over a decade is clinically meaningful, but the antibiotic regimen, appendicolith exclusion, and Finnish context warrant caution before these rates are broadly extrapolated."

Why it matters: The shared decision-making conversation in UK EDs about appendicitis nonoperative management is increasingly common. The full APPAC data adds three key points not available from the abstract. First: the surgery-free rate at 10 years is 55.7% (not “about half” — the confidence interval is 49.6–61.8%, clearly spanning a majority). Second and more striking: cumulative complications at 10 years were 8.5% in the antibiotic arm vs 27.4% in the appendicectomy arm — NNT 5.3 to avoid one complication by choosing antibiotics. This is not a negligible advantage. Third: 74.7% of recurrences happen within the first 2 years — patients who remain surgery-free at 2 years are unlikely to need surgery long-term (recurrence rate approximately 1% per year after that point). Frame the conversation accordingly: if the patient can get through 2 years without recurrence, they have a very high chance of never needing surgery. Two LAMN tumours were found incidentally on MRI surveillance in the intact appendix group — worth mentioning for completeness, but at ~1.2% overall this is not a reason to prefer surgery in an otherwise eligible patient.

Source: Salminen et al. JAMA 2026 — APPAC 10-Year Follow-Up (PMID 41563747) · EMA Daily Commentary

EMA DAILY · LANCET 2026;407:147–160 · PMID 41391465

Zoliflodacin vs Ceftriaxone + Azithromycin for Uncomplicated Gonorrhoea: Phase 3 Non-Inferiority RCT — First Oral Alternative, But Slightly Lower Cure Rate

RCT CHANGE WHEN GUIDELINE UPDATES FRCEM

• −5.3% ARD CURE RATE
• NNH 19 EXTRA TREATMENT FAILURE
• Non-inferior WITHIN −10% MARGIN
• Phase 3 INTERNATIONAL RCT

Arm Microbiological cure rate

Critical appraisal: EMA Daily editor Mike Menchine: "Zoliflodacin achieved slightly lower cure rates but remained within the predefined noninferiority margin. The control regimen was statistically superior, but zoliflodacin was not unacceptably worse." The FDA has approved zoliflodacin. The NNH of 19 means treat 19 patients with zoliflodacin vs combination to produce one extra treatment failure — in a moderate-risk STI context, this is an acceptable trade-off only if the patient has a reason to avoid IM ceftriaxone. UKHSA and BHIVA have not yet updated UK STI guidelines. Until then, ceftriaxone remains UK first-line. Watch for UKHSA/BASHH updates in 2026.

Why it matters: Gonorrhoea rates are rising in the UK, with increasing antibiotic resistance. The single oral dose simplifies treatment and avoids IM administration. Zoliflodacin is the first new class of antibiotic for gonorrhoea in decades (a spiropyrimidinetrione, DNA gyrase B inhibitor). This trial demonstrates non-inferiority and provides a clear alternative for patients in whom IM injection is not feasible. This will likely enter UK guidelines within 12–18 months.

Source: Luckey A et al. Lancet 2026;407:147–160 — Zoliflodacin Phase 3 RCT (PMID 41391465)

COCHRANE DATABASE SYST REV · 2026 APR 21 · PMID 42011817

Buffered Solutions vs 0.9% Saline for Resuscitation in Critically Ill Adults and Children: Cochrane SR Update — Balanced Crystalloids Reduce AKI and Possibly Mortality

SR/MA INFORMING PRACTICE FRCEM

• −2.5% ARD AKI (BALANCED VS SALINE)
• NNT ~40 NNT — AVOID 1 AKI
• −1% ARD MORTALITY (APPROX.)
• Cochrane SR UPDATE 2026

De Paula Delgado Moya F et al. Updated Cochrane SR of buffered solutions (Plasmalyte, Hartmann's/Ringer's lactate) vs 0.9% normal saline in critically ill adults and children. This update incorporates the SMART, SALT-ED, PLUS, BaSICS, and BASICS-Paeds trials. The pooled analysis confirms: balanced crystalloids are associated with a reduction in AKI and a modest mortality signal in the critically ill. The AKI benefit is most consistent; the mortality signal is less certain across all subgroups.

Critical appraisal: The NNT and ARD figures above are approximate, derived from the component trials' pooled estimates — the full Cochrane SR numerical results may differ. The PLUS trial (Australia, plasmalyte vs saline, n=5,037) showed no mortality difference but reduced AKI. SMART and SALT-ED (US, balanced vs saline) showed mortality and AKI reduction. The heterogeneity across settings (ICU vs ED, adult vs paediatric) means the benefit may not be uniform. For the ED specifically: balanced crystalloids are associated with lower rates of hyperchloraemic acidosis and AKI in fluid-resuscitated patients. Normal saline in large volumes (>2L) reliably causes hyperchloraemic acidosis. The direction of evidence is consistent: use balanced fluids for resuscitation in the ED unless there is a specific contraindication. Note: hyperkalaemia is NOT a contraindication to Hartmann's or Plasmalyte — it is a contraindication to 0.9% saline. Normal saline causes hyperchloraemic metabolic acidosis, which drives extracellular potassium shift and worsens hyperkalaemia. Hartmann's (K+ 5 mmol/L) dilutes serum potassium in any patient with K+ >5 mmol/L, and its alkalinising effect (lactate → bicarbonate) drives intracellular potassium shift, actively lowering serum K+. Three RCTs in renal transplant patients confirm this: saline increased K+ by +0.37–0.50 mmol/L; Hartmann's produced no change or a fall (O'Malley 2005, Khajavi 2008, Modi 2012). True contraindications to balanced crystalloids: traumatic brain injury/raised ICP (use 0.9% saline); significant metabolic alkalosis (use 0.9% saline); severe hypercalcaemia (use Plasmalyte not Hartmann's — Plasmalyte contains no calcium). Source: IBCC Fluid Chapter (EMCrit); PaediatricFOAM — Hartmann's in Hyperkalaemia.

Tell your department: Default resuscitation fluid in the ED should be Plasmalyte or Hartmann's for adults and children requiring ≥1L of IV crystalloid. Reserve 0.9% saline for: traumatic brain injury/raised ICP, significant metabolic alkalosis, or specific neurosurgical instruction. Hyperkalaemia is an indication for balanced crystalloids, not saline. Use Plasmalyte (calcium-free) if hypercalcaemia is also present. If a patient has both TBI and hyperkalaemia, this is a genuine dilemma — discuss with neurosurgery and ICU; use the smallest volumes required. Source: IBCC Fluid Chapter.

Source: De Paula Delgado Moya F et al. Cochrane Database Syst Rev 2026 — Buffered vs 0.9% Saline (PMID 42011817)

JOURNALFEED EM · BMJ 2026 MAR 20 · PMID 41862204

GOLDEN BRIDGE II: Clinical Decision Support System for Acute Ischaemic Stroke — Cluster RCT (n=21,000+) Reduces Vascular Events at 3 and 12 Months

RCT INFORMING PRACTICE FRCEM

• Reduced VASCULAR EVENTS AT 3+12M
• Cluster RCT HOSPITAL-LEVEL CLUSTER
• China GENERALISABILITY CAVEAT
• n>21,000 AIS PATIENTS

Zhang X, Ding L, Jing J et al. Cluster RCT of 21,000+ patients with acute ischaemic stroke in China. Hospitals randomised to implement a CDSS vs standard care. CDSS implementation reduced composite vascular events at 3 months and 12 months. The intervention was a pathway-embedded decision support tool, not an AI diagnostic system.

Critical appraisal: Large, well-executed cluster RCT. The main caveat is the Chinese setting — stroke system differences, prescribing culture, and baseline guideline adherence differ substantially from UK NHS practice. However, the principle is generalisable: standardised pathway-embedded decision support improves compliance with evidence-based stroke care. The UK has implemented several CDSS tools in stroke (e.g. RCP Stroke Audit, NHS England pathway tools). This trial provides the highest-quality evidence that they are worth implementing. The NNT for composite vascular event reduction is in the low-to-moderate range across the trial — see full text for precise figures.

Source: Zhang X et al. BMJ 2026 — GOLDEN BRIDGE II (PMID 41862204)

SPACE FILE REVIEW · HIGH RISK & LOW INCIDENCE DISEASES SERIES

High Risk and Low Incidence: Aneurysmal Subarachnoid Haemorrhage — ED Approach, Sentinel Headache, Lumbar Puncture Decision, and CT Angiography Pathways

REVIEW CHANGE TONIGHT FRCEM

SAH accounts for approximately 5% of all strokes but disproportionate morbidity — and is the presentation most commonly associated with missed diagnosis litigation in UK emergency medicine. This high-risk/low-incidence review covers the complete ED approach.

Key ED Decision Points

Tell your department: Document the precise onset and time-to-peak-severity for every severe headache presentation. "Worst headache of my life" is not the question — "How quickly did it reach maximum intensity?" is. If it reached maximum in seconds to <1 minute, that is thunderclap regardless of previous headache history. If CT is negative and onset was >6 hours ago, LP with spectrophotometry is mandatory unless the patient declines after informed discussion.

Source: High Risk and Low Incidence Diseases: Aneurysmal Subarachnoid Haemorrhage (Space file review)

2 — GUIDELINES & UK UPDATES

NHS ENGLAND · DUE MAY 2026

NHS England Corridor Care Trust-Level Data: First Public Publication Due May 2026 — Every Department's Figures Will Be Visible

POLICY CHANGE TONIGHT UK DATA

NHS England published a formal definition of corridor care and began mandating trust-level data collection in March 2026. The first public publication of trust-level corridor care figures is scheduled for May 2026. GIRFT is already deployed to the highest-burden trusts. Your department's data will be publicly visible within weeks.

Action required: If your department is not yet documenting corridor care using the NHS England formal definition — a patient receiving any form of treatment or care in a space not designed for patient care, including corridors, waiting rooms, and ambulance vehicles — that documentation must start now. Once data is public, significant variances between peer trusts will attract scrutiny. Begin consistent documentation immediately. The RCEM position is that corridor care data reporting is welcomed as an accountability measure, but that publishing figures without accompanying investment in inpatient capacity will demonstrate the problem rather than solve it.

Source: NHS England — Corridor Care Programme Update (April 2026)

RCEM · 28–30 APRIL 2026, ICC BIRMINGHAM

RCEM Annual Conference 2026 — This Weekend at ICC Birmingham

NEWS FRCEM

RCEM Annual Conference 2026 runs 28–30 April at the ICC, Birmingham. This is the first combined Annual Scientific Conference + CPD Conference. Pre-conference workshops include Bridging EM and ICM Skills, Focused Quantification and AI, and POCUS MSK Trauma. If you are attending, look out for RCEM's forthcoming position statements on EEMAC (Extended Emergency Medicine Ambulatory Care) and corridor care reporting. For those not attending: sessions will likely appear on the RCEM website in the weeks following. FRCEM candidates: the conference includes structured CPD relevant to exam preparation.

Source: RCEM Annual Conference 2026

3 — PAEDIATRIC EMERGENCY MEDICINE

EMERGENCY MEDICINE JOURNAL · 20 APRIL 2026 · PMID 42009598

Knife-Related Fatalities in Children and Young People in England 2019–2024: National Child Mortality Database Analysis — At Least 2 Deaths Per Month, Average Age 14, 75% From Most Deprived Areas

OBSERVATIONAL CHANGE WHEN GUIDELINE UPDATES PAEDS UK DATA FRCEM

Roberts T, Odd D, Coveney J et al. University of Bristol/North Bristol NHS Trust. First analysis linking National Child Mortality Database data with hospital, social care, and police records for 145 children and young people under 18 who died from knife wounds in England between April 2019 and March 2024. This is the most comprehensive national dataset on child knife crime fatalities ever published in the UK.

Critical appraisal: Strong ecological study using linked national databases — a methodological advance over prior case series. Limitations: the NCMD may not capture all deaths; causal pathways between adverse childhood experiences and knife crime death are not established from this study design. The population-standardised ethnic disparity figures require careful interpretation — they reflect social and environmental inequalities rather than individual risk. The study cannot be used to profile individuals but is powerful for designing systemic interventions. Dr Tom Roberts is a UK emergency medicine academic — this is directly clinician-led research.

Why it matters: Every major UK ED sees stab wound presentations in young people. This study changes the clinical narrative: these are not random events. The victims are predominantly young men from areas of severe deprivation who were already known to services, had experienced domestic violence, and had no targeted intervention. The ED encounter — whether the victim or a sibling or friend accompanying them — may be one of the few healthcare contact points before a fatal event. Violence Intervention Programmes (e.g. the Redthread model, rolled out to trauma centres) represent the evidence-based response at ED level. If your trust does not have one, this research is the impetus to advocate for it.

Tell your department: If your department sees penetrating trauma in young people, does it have a formal violence intervention pathway? If not, review the Redthread/Navigator programme model — brief intervention by youth workers at the point of ED contact has demonstrated behaviour change. Link with your safeguarding team to ensure young victims of violence are systematically reviewed, not just medically discharged.

Source: Roberts T et al. Emerg Med J 2026 — Knife Crime Fatalities in Children (PMID 42009598) · University of Bristol press release

EMA DAILY · JAMA PEDIATR 2026;180(3):250–262 · PMID 41587068

BRUE: Infant Outcomes, Risk Factors, and Diagnostic Yield After a Brief Resolved Unexplained Event — SR/MA: Serious Diagnoses Rare (1.9%), Mortality Extremely Rare, Routine Testing Very Low Yield

SR/MA CHANGE TONIGHT PAEDS FRCEM

• 1.9% SERIOUS DIAGNOSIS RATE
• <0.1% MORTALITY
• <2% DIAGNOSTIC YIELD, LOW-RISK BRUE
• SR/MA JAMA PEDIATR 2026

Nama N, Liebert S, Abaji M et al. SR/MA examining infant outcomes, risk factors, and diagnostic yield after BRUE (Brief Resolved Unexplained Event). EMA Daily editor Mike Menchine: "Serious diagnoses after BRUE are uncommon, and mortality is extremely rare, thus supporting the generally benign prognosis of these events. Although certain high-risk features were associated with elevated risk, routine diagnostic testing had very low yield. The findings reinforce following a selective, clinically guided approach to evaluation rather than broad testing."

Critical appraisal: Note that this SR/MA overlaps with the BRUE review covered in Issue 8. However, this is a distinct primary SR/MA (JAMA Pediatr, Nama et al.), not a narrative review — the pooled diagnostic yield figure (<2% in low-risk BRUE) is a new quantified estimate from systematic analysis, not a clinical opinion. This is the definitive quantitative evidence base for the conservative BRUE approach. The JAMA Pediatr publication carries high methodological standards. EMA Daily's expert appraisal further validates the conclusion.

Tell your department: For low-risk BRUE (criteria met: age >60 days, born ≥32wks, corrected GA ≥45wks, no prior BRUE, duration <1 minute, no CPR by medical provider, no NAI concerns): brief observation and safety-netting is appropriate. Do not routinely perform bloods, ECG, EEG, CXR, or request admission. Diagnostic yield <2% does not justify a full work-up for all. High-risk features (prematurity, recurrence, prolonged event, CPR required) require full investigation.

Source: Nama N et al. JAMA Pediatr 2026;180:250–262 — BRUE SR/MA (PMID 41587068)

ACAD EMERG MED / SPACE FILE · SR/MA · 2025

Non-Injectable Ketamine for Paediatric Procedural Sedation in the ED: SR/MA — Intranasal and Oral Routes Are Safe and Effective Alternatives

SR/MA CHANGE TONIGHT PAEDS FRCEM

SR/MA examining non-injectable (intranasal and oral) ketamine for paediatric procedural sedation in the ED. Pooled data demonstrate effective sedation with acceptable side-effect profiles for both intranasal and oral routes, avoiding the need for IV access prior to procedural sedation in children. This is directly relevant to fracture reduction, laceration repair, and wound care in paediatric patients where IV access is distressing or difficult.

Why it matters: IV access in distressed children causes pain, anxiety, and procedure failure. Non-injectable ketamine circumvents this. Intranasal ketamine has a 10–15 minute onset compatible with most ED procedural timelines. Standard precautions apply: age-appropriate airway support, monitoring, and senior clinician presence. This is already in use at several UK paediatric EDs and this SR/MA provides the evidence base for those who have not yet adopted it.

Source: Non-Injectable Ketamine for Pediatric Sedation in the ED — SR/MA (Acad Emerg Med; Space file)

EMA DAILY · ANN EMERG MED PUBLISHED JANUARY 2026 · PMID 41575401

Dexamethasone in Paediatric Asthma: Single Dose as Effective as Two Doses — No Benefit from Second Dose at Discharge

OBSERVATIONAL CHANGE THIS MONTH PAEDS FRCEM

• No difference ADMISSIONS: SINGLE VS 2-DOSE
• No difference RETURN VISITS
• Retrospective 2 PAED EDS, 1 ACADEMIC CENTRE

Dave S, Green-Hopkins I, Bardach NS et al. Retrospective cohort study from 2 affiliated paediatric EDs at a single academic health system. Children with asthma exacerbations treated with single-dose vs two-dose dexamethasone (second dose given at discharge). No significant difference in admission rates or return ED visits. EMA Daily editor Sanjay Arora: "One dose of dexamethasone seems to be enough, but a trial would add confidence to this opinion."

Critical appraisal: Retrospective single-centre design. Selection bias is likely — the clinician who decided to give a second dose may have had a higher-acuity patient in mind. This is a limitation that limits the firmness of the "no difference" conclusion. A prospective RCT is needed. However, the direction of evidence is consistent with existing data: dexamethasone has a long half-life (36–72 hours), making a second dose at 24 hours physiologically redundant. Until a trial confirms this, the pragmatic message is: single-dose dexamethasone in paediatric asthma exacerbation is likely sufficient for most presentations, but the more severe the presentation, the less confident we can be in omitting a second dose.

Source: Dave S et al. Ann Emerg Med 2026 — Dexamethasone in paediatric asthma (PMID 41575401)

4 — QUICK HITS

CARDIOLOGY

In-Hospital Cardiac Arrest in NSTEMI: JournalFeed EM Wednesday (PMID 41856453). Large retrospective cohort of 32,000+ NSTEMI patients in China — IHCA occurred in 1.24% with extremely high in-hospital mortality (65.74%). Early coronary angiography was the strongest independent protective factor (adjusted OR significantly below 1.0). Take-home for UK EDs: NSTEMI patients who deteriorate before angiography are at highest risk of IHCA. If your patient with NSTEMI develops haemodynamic instability or arrhythmia while waiting for angiography, escalate to cardiology urgently for expedited catheter lab access.

PAEDIATRICS

IVIg vs Steroids for Paediatric Acute Myocarditis: PubMed J Pediatr (PMID 41850419). Comparative effectiveness study: IVIg alone or with steroids showed broadly similar outcomes to steroids alone in hospitalised children with acute non-COVID myocarditis. Myocarditis is a rare but high-stakes paediatric ED presentation — your job is to diagnose it (ECG changes, troponin, Echo request) and refer urgently to paediatric cardiology. Treatment decisions are made with PICU/paediatric cardiology, not in the ED.

ChatGPT for Paediatric ED Discharge Instructions: EMA Daily (PMID 41533280). Small Canadian study: ChatGPT-4 slightly better than Google Translate for translating 15 paediatric ED discharge instructions into Arabic and Simplified Chinese. Neither replaces professional interpreters. Clinical bottom line: language-accessible discharge instructions matter — use a professional interpreter service or your trust's telephone translation service for high-stakes instructions. ChatGPT is a last resort, not a standard tool, and requires human review.

TRAUMA & ORTHOPAEDICS

High Risk and Low Incidence: Lisfranc Injury: Space file review. Lisfranc injuries are missed in approximately 20–40% of ED presentations. The key ED points: (1) request weight-bearing foot X-rays if the patient can bear weight — non-weight-bearing views frequently appear normal; (2) >2mm widening between the base of the 1st and 2nd metatarsals is diagnostic; (3) fleck fracture at the base of the 2nd metatarsal is pathognomonic; (4) if non-weight-bearing X-rays are normal but clinical suspicion remains, refer for MRI or orthopaedic outpatient with non-weight-bearing and a moon boot. A missed Lisfranc leads to chronic instability, arthritis, and litigation.

High Risk and Low Incidence: Massive Haemoptysis: Space file review. Defined as >100–600mL/24h (varied definitions) or sufficient to cause haemodynamic compromise or airway obstruction. Key ED management: position the patient affected-side down (to protect the good lung). Call for urgent bronchoscopy — interventional pulmonology or thoracic surgery. Intubate if airway at risk — large-bore ET tube or single-lung intubation may be needed. Causes in UK EDs: bronchiectasis, aspergillosis, malignancy, TB (increasingly rare). CT chest angiography guides bronchial artery embolisation planning.

INFECTIOUS DISEASE & TOXICOLOGY

Managing Cannabinoid Hyperemesis Syndrome: Space file review. CHS is increasingly common as cannabis potency increases in the UK. Classic triad: cyclical vomiting, nausea, and compulsive hot bathing. ED management: IV haloperidol (2.5–5mg) is now the most evidence-supported agent (NNT ~3–5 from small RCTs); capsaicin cream applied to the abdomen provides rapid symptomatic relief. Antiemetics (ondansetron, metoclopramide) are largely ineffective. Identify the pattern, counsel about cannabis cessation as the only cure, and avoid unnecessary investigations in repeat presenters.

5 — CORE REVISION: HYPONATRAEMIA

FRCEM REVISION FOCUS — HYPONATRAEMIA: CLASSIFICATION, INVESTIGATION, AND SAFE TREATMENT IN THE ED

Classification by onset and severity

Safe correction rates

Cause-led investigation in the ED

Memory: Acute symptomatic → 3% saline now. Chronic → slow down. Never exceed 10 mmol/L per 24h or you risk ODS. In alcohol use disorder/malnutrition, the limit is 6–8 mmol/L. The SIADH diagnosis requires: low serum osm, concentrated urine (Uosm >100), euvolaemia, urine Na >40, and no other cause. Fluid restriction is the first-line treatment for stable SIADH.

6 — ACTION POINTS THIS WEEK

• PE Pathway Review: Map your current PE pathway to the new AHA/ACC A–E categories. Category A (asymptomatic) and Category B (sPESI 0, no RV dysfunction, normal troponin): both should go home with DOAC and 7-day follow-up call/clinic, not be admitted. If your pathway currently admits all PE, this is the week to propose a change.
• Refractory VF Preparation: Brief your resus team on AP pad positioning for refractory VF (failed ≥2 standard shocks). Position: right anterior standard + left posterior infrascapular. Zero cost, immediate application. Log in your departmental resus protocol.
• BRUE Documentation: When documenting a BRUE, state which low-risk criteria are met and which are not. If all low-risk criteria are met: document the decision to observe briefly and discharge with safety-netting rather than investigate. This demonstrates clinical reasoning and reduces medicolegal risk.
• Corridor Care Documentation: Begin documenting corridor care using the formal NHS England definition now, before May data publication. Ensure nurses and senior clinicians all use the same wording. Audit your department's baseline figure this week.
• Paediatric Asthma Dexamethasone: Single-dose dexamethasone (0.15–0.3 mg/kg) is likely sufficient for most paediatric asthma exacerbations. Review whether your department's standard operating procedure still issues a two-dose course routinely — if so, consider updating to single-dose as default with escalation criteria.
• Violence Intervention: Following the knife crime NCMD analysis, does your department have a youth violence intervention pathway? If not, review the Redthread/Navigator model for implementation. Raise at your next departmental meeting.
• Balanced Crystalloids: Confirm that your ED's default resuscitation fluid is Plasmalyte or Hartmann's, not 0.9% saline. Reserve saline for TBI/raised ICP and significant metabolic alkalosis. Hyperkalaemia is not an indication for saline — balanced crystalloids are safer. Normal saline causes hyperchloraemic acidosis, which worsens hyperkalaemia. Hartmann's dilutes serum K+ and its alkalinising effect drives intracellular K+ shift. Use Plasmalyte (not Hartmann's) if hypercalcaemia co-exists.

7 — TRIALS TO WATCH

IMMINENT — Q2 2026

On-Scene ECPR Netherlands Trial: RCT of prehospital ECMO-facilitated CPR in refractory OHCA. Results expected Q2–Q3 2026. If positive, will define the ECPR-eligible patient and logistics. Watch for NHS England response given current UK ECMO network distribution.

RCEM Sepsis Toolkit Update: Expected Q2 2026 following SSC 2026 guidelines. Watch for updated RCEM position on antibiotic timing, lactate-guided resuscitation, and vasopressor thresholds. JRCALC/AACE Annual Guidelines Update: Expected Q2 2026. Ambulance triage and prehospital drug protocol changes directly affect what paramedics can do before ED arrival — review once published. NHS England Corridor Care Data — First Publication: Due May 2026. All trust-level corridor care figures will be public. Ensure documentation is in place now.

2026–2027

HSSIB Mental Health Crisis Care — Full Report Part 2 (summer 2026): Expected to include binding recommendations on liaison psychiatry response times and ED mental health assessment protocols. NICE NG128 Stroke Guideline Surveillance: Following AHA/ASA 2026 guideline, NICE expedited review of tenecteplase, post-EVT BP targets, and extended-window thrombolysis expected. BACHb — Bronchiolitis UK RCT: Antibiotic subgroup therapy in bronchiolitis. Most relevant active paediatric trial post-BESS. Anticipated 2026–2027.

LONGER HORIZON

CoMiTED — Chest Drain RCT (UK): Conservative vs immediate chest drain in traumatic pneumothorax. Anticipated 2027. Directly relevant to ED pleural procedures and disposition.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. EM Evidence Rundown — Issue #9 — Week of 23 April 2026 — UK Edition Published by EM Evidence. Sent to subscribers in emergency medicine across the UK. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com