The Resus Room

Welcome back to November's Papers of the Month! This month we're looking at three papers that all ask a deceptively simple question: how confident should we be in the decisions we make before we have the full picture? First up, we've got a huge Australian cohort of patients whom paramedics thought had a STEMI. How many actually ended up with that diagnosis, what else was going on, and what happened to those with alternative diagnoses? Then we're getting the pelvic binder out. We all know the guidance around suspected pelvic haemorrhage, but can the physiology and mechanism of injury tell us which fracture patterns are actually mechanically suited to a binder? This paper might challenge some assumptions – although we need to be very careful about what it does and doesn't prove. And finally, we're looking at the blood pressure drop after intubation. Could a prophylactic push-dose of metaraminol make septic ICU intubations more haemodynamically stable? The results are interesting, but is an observational improvement enough to change practice? As ever, we'll unpack the numbers, pick apart the methods and work out what's useful for our patients. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

In this Roadside to Resus, we take the 2026 Fifth Universal Definition of Myocardial Infarction back to the patients we see in the ED and pre-hospital setting. We start with the key question, when does myocardial injury become an infarction? From there, we work through the new primary, secondary and procedure-related MI categories—and why finding the cause matters more than attaching a number to the event. We also get into the troponin decisions that cause debate on shift. Does a percentage rise mean more than the absolute change? And how should sex-specific thresholds and rapid rule-out pathways fit together? Then we look beyond classical STEMI criteria for an occluded artery: posterior changes, de Winter's T waves, Wellens, and Sgarbossa in patients with known LBBB or ventricular pacing. We finish with MINOCA, unrecognised MI and a question that still divides clinicians: what should we do with suspected unstable angina when high-sensitivity troponins are negative? Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

This month we have three really clinically relevant papers that take us from a very common ED presentation, through an everyday diagnostic dilemma, and then right into a high-risk paediatric airway. We start with abdominal pain in older adults and ask whether the history and examination are giving us as much reassurance as we think. The paper looks at how CT use, diagnostic yield, admission and surgery change with age - and whether we should think of geriatric abdominal pain as a distinct high-risk presentation. Then move on to unexplained syncope and a large UK randomised trial of immediate 14-day ambulatory ECG monitoring. The didn't reduce recurrent syncope at one year, but it found substantially more clinically significant arrhythmias, found them earlier and led to more treatment. That leaves us with a really interesting question about the difference between diagnosing more disease and improving the outcome the patient actually experiences. What will it mean for our strategies moving forwards? Finally, we look at paediatric emergency intubation through recorded video laryngoscopy. Which technical errors occur most often, which ones cluster around failure, and what can the airway coach spot early enough to change the attempt? As ever, we will take you through what the teams did, what they found, and whether any of it should change practice on your next shift. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

We assess the pupils in almost every significantly unwell or injured patient - but how much are they really telling us? It is easy to document 'pupils equal and reactive' and move on, yet a changing pupil may be one of the earliest outward signs of a developing intracranial catastrophe. Equally, anisocoria in a completely well patient may be longstanding and entirely benign. In this Roadside to Resus episode, we work through the anatomy and physiology of the pupillary light reflex before applying it to three important clinical situations: the blown pupil following a significant head injury, unequal or irregular pupils in a patient with a GCS of 15, and bilaterally fixed and dilated pupils in and following cardiac arrest, along with a deep dive into the evidence base.  We discuss how to decide which pupil is abnormal, the warning signs of third nerve palsy and Horner's syndrome, ocular and drug-related causes, and why serial change matters more than an isolated measurement. We also explore automated pupillometry, what the NPi can add, and why fixed pupils should never be used alone to determine futility or neurological prognosis.  Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon. Rob & James

Welcome back to September 2026's Papers of the Month, and this month we've got three papers that are really focused on the practical end of emergency and prehospital care. First up, we're looking at what happens after we've performed a prehospital RSI. We put a huge amount of emphasis on getting the induction right, but what about maintaining adequate anaesthesia afterwards? This paper looks at intermittent bolus sedation following prehospital emergency anaesthesia, the variation in dosing between patients, and whether we might actually be running the risk of under-sedating some of them and compromising their care. Then we're staying prehospital and asking a really simple question in trauma: how good are the physiological numbers we use to identify the sick patient? We've all used shock index, but could NEWS actually do a better job of predicting mortality, transfusion requirements and subsequent resource utilisation? And finally, we're back to RSI and rocuronium. A variety of dosing strategies can be seen in practice but could going higher improve first-pass success? And importantly, does that relationship still hold in patients with obesity or hypoperfusion? Three clinically relevant papers, plenty to challenge our current practice, and as always, lots to get into. Once again we'd love to hear any thoughts or feedback either on the website or via social media @TheResusRoom! Simon & Rob

This month we've got another really varied mix of papers that all have the potential to influence everyday emergency and prehospital practice. We start by asking a question that's becoming increasingly relevant as prehospital critical care teams develop ever more advanced capabilities: are all those extra interventions costing us precious scene time, and if so, how much? We then move into post-cardiac arrest care with one of the biggest oxygen trials we've seen to date, looking at whether aiming for conservative oxygen targets actually improves neurological outcomes after ROSC.  Finally, we tackle one of emergency medicine's diagnostic challenges, necrotising soft tissue infection. We'll look at what the latest evidence tells us about physical examination, imaging and the much-debated LRINEC score, and whether any of them are good enough to confidently rule this devastating disease in or out. As always, we'll pull apart the methodology, discuss what these studies mean for our own practice and, perhaps most importantly, ask whether they should actually change what we do tomorrow. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Tracheostomy and laryngectomy emergencies are classic high-acuity, low-frequency situations. They do not happen every day, but when they do, airway problems can develop quickly, and the wrong intervention can make things significantly worse. In this episode, we work through the practical approach to these patients, starting with the most important distinction: a patient with a tracheostomy may still have a patent upper airway, whereas someone who has undergone a total laryngectomy is an obligate neck breather. That single anatomical difference determines where oxygen and ventilation need to be delivered. We'll look at the different tubes, cuffs, inner cannulas, speaking valves and humidification devices you may encounter, before moving through the common causes of deterioration, particularly obstruction, displacement and bleeding. Using the National Tracheostomy Safety Project's green and red emergency algorithms, we break management down into simple, sequential steps: apply oxygen, remove attachments, remove the inner cannula, pass a suction catheter, deflate the cuff when appropriate and remove a non-functioning tube when necessary. These cases can initially feel intimidating, but a calm, structured approach can make them far more manageable. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon. Rob & James

Welcome back to July's Papers of the Month. This month we've got three papers that tackle some of the biggest questions we face in emergency and critical care medicine. They're all very different studies, but each one looks at an intervention that many of us use, or at least think about, on a regular basis. First up, we look at ARISE FLUIDS, a major trial examining one of the longest-running debates in sepsis care. Should we be reaching for fluids or vasopressors first in septic shock? We've spent years worrying about giving too much fluid, and equally worrying about starting vasopressors too early. This study gives us some of the best evidence yet about what happens when we take a more restrictive fluid approach and start vasopressors earlier. Next, we move to cardiac arrest and the BIHCA trial, looking at sodium bicarbonate during in-hospital cardiac arrest. Despite guideline recommendations and a lack of convincing evidence, bicarbonate continues to be used in many arrests around the world. This study finally gives us some high-quality data on whether it's actually helping our patients. And finally, we head back to the ECG with a fascinating paper looking at the lead V5 T-wave to R-wave ratio as a marker of right ventricular dysfunction in pulmonary embolism. It won't change practice tomorrow, but it raises some interesting questions about what the ECG may still have to tell us about risk stratification in PE. So let's get into it! Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Face mask ventilation is one of those skills that can easily be overlooked. It's often seen as the simple bit of airway management — something that sits below the glamour of videolaryngoscopy, fibre-optics and endotracheal intubation. But the reality is that excellent face mask ventilation is one of the most important airway skills we have. In this episode, we take a deep dive into bag-valve-mask ventilation and airway adjuncts, exploring why this is far more than just putting a mask on a face and squeezing a bag. We discuss when facemask ventilation is indicated, how to identify patients who may be difficult to ventilate, and the practical steps that can dramatically improve success rates. We cover positioning, airway opening manoeuvres, mask seal techniques, the role of airway adjuncts and how to recognise whether your ventilations are actually working. We also look at troubleshooting common problems, the evidence comparing bag-mask ventilation with supraglottic airways and endotracheal intubation, and how to decide when it's time to move to another airway strategy. Whether you're working in the emergency department, prehospital environment or critical care, this episode is packed with practical tips, cognitive aids and evidence-based advice to help you deliver facemask ventilation with confidence and excellence. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon. Rob & James

This month's episode takes us deep into trauma care, but not just the medicine we deliver but also the systems, circumstances and social factors that shape who survives and who doesn't. We start by looking at a remarkable paper from Gaza describing the use of ultrasound-guided pericardiocentesis, large-bore drainage and intrapericardial tranexamic acid as definitive management for penetrating cardiac tamponade. In a setting where immediate thoracotomy simply wasn't always possible, the authors report some pretty incredible survival figures and challenge a lot of the dogma around penetrating cardiac injury. It's a fascinating example of innovation being driven by necessity. We then move onto a huge epidemiological study from the London Trauma System exploring when and where trauma deaths occur in a mature major trauma network. The findings are stark — most deaths now occur before hospital arrival, often within minutes, and many from potentially reversible causes. It really makes us think about where the next advances in trauma care need to happen. Finally, we finish with an incredibly important and sobering paper examining knife-related deaths in children and young people across England. This isn't just about anatomy and interventions — it's about deprivation, adverse childhood experiences, safeguarding and public health. It's a paper that's difficult to read at times, but absolutely essential for anyone involved in emergency and prehospital care. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob