The Resus Room

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

Anaphylaxis is one of those conditions we think we have got pretty well sorted. Recognise it early, give adrenaline, support the airway and circulation, and crack on. And in fairness, for the vast majority of patients, that approach works really well. But in this Roadside to Resus episode we take a step back and ask a pretty uncomfortable question, have we actually been thinking about anaphylaxis in the wrong way? Using some fascinating new evidence from the UK National Child Mortality Database, we explore the emerging understanding that fatal food-triggered anaphylaxis may be much more of a respiratory catastrophe than the classic circulatory collapse we often picture in our heads. The findings are genuinely thought provoking. Many of the fatal paediatric cases reviewed showed overwhelming airway and breathing compromise long before cardiovascular collapse occurred, with deterioration happening frighteningly quickly in the prehospital phase. We work through the current Resuscitation Council UK and NICE guidance, look at where diagnostic confusion still exists, and discuss why early adrenaline absolutely remains the cornerstone of treatment. But we also explore whether our mental model of anaphylaxis needs updating, particularly when it comes to respiratory assessment, escalation and oxygenation strategies. We're also incredibly grateful to be joined by Ben McKenzie, who shares the devastating personal story behind the development of the AMAX4 approach and the lessons it holds for all of us managing critically unwell patients in the ED and prehospital environment. This is a really powerful episode about recognition, trajectory and reframing how we think about severe anaphylaxis. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Timely and effective defibrillation is fundamental to excellent outcomes in cardiac arrest care. But there is a growing body of evidence suggesting that how we deliver those shocks may matter just as much as when we deliver them. Over the last few years we've seen increasing interest in alternative defibrillation strategies, particularly AP pad positioning and double sequential external defibrillation, and the potential impact they can have on outcomes in refractory VF. The DOSE-VF trial was a landmark trial in the area, showing markedly better survival to hospital discharge with both vector change defibrillation and DSED compared with standard antero-lateral pad positioning. Since then, further analyses have suggested that the timing of DSED shocks, pad positioning and the vectors of defibrillation my all play an important role in improving the chances of ROSC and good neurological recovery. Now we've got new evidence from Sheldon Cheskes and colleagues exploring what may actually be driving these improved outcomes. Is it simply that AP pad positioning delivers more current? Or is there something more important about the direction that current travels through the myocardium? The findings from this piece of the puzzle has potential to change the fundamentals of resuscitation strategies. In this episode we take a deep dive into the emerging evidence around defibrillation, what the latest guidelines are saying and, importantly, what this means for practice. We're also hugely fortunate to be joined by Sheldon Cheskes himself to talk through the science behind defibrillation, the evidence and how systems can implement change. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & James

Decision making sounds like a slightly academic, niche topic… but in reality, it sits underneath every single thing we do in emergency and pre-hospital care. Every patient contact, every test we order, every treatment we start and every one we choose not to – is a decision made in an environment that is time critical, information-light and full of uncertainty. In this episode we take a step back and look at how we actually make decisions at the front door and on the roadside. We talk about why the importance of the decision really matters, not just whether a diagnosis is possible, but how severe it is, how common it is, and whether finding it will genuinely change what we do for the patient. We explore pre-test probability and prevalence, and why knowing how often a condition really occurs in the group of patients in front of you is one of the most powerful tools in emergency medicine. We then move into testing. What actually counts as a test? It's not just bloods, scans and ECGs. It's how someone looks, how they move, what hurts when you examine them and how the story fits together. From there, we build into likelihood ratios and Bayesian thinking; how a piece of information should genuinely shift your estimate of risk, rather than just making you feel more or less comfortable. We also tackle test and treatment thresholds; the idea that there are times when we should stop chasing a diagnosis, and times when the probability is high enough that we should treat without waiting for more tests. Finally, we bring all of this back to real life, with human factors, competing priorities and the reality that sometimes the technically "correct" decision isn't the best decision in that moment. This one is all about becoming more comfortable with uncertainty and making better decisions because of it. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

This episode is an absolute cracker! And we can say that as we've got outsider help... We've all been involved with patients where securing the airway with a prehospital anaesthetic feels intuitively right; the patient with a severe head injury after a fall from height, the unrestrained driver in a high-speed collision with devastating chest injuries, or the patient with significant maxillofacial trauma following assault. In these situations, advanced airway management appears clearly beneficial. What remains a bit ambiguous is the effect of that intervention. Does it play out into a mortality benefit and if so how should we redesign systems to meet a 24 hour need for this (with many prehospital critical care services not being available fully around the clock), bearing in mind competing financial priorities for optimum health care. Maybe it's okay that for some patients the anaesthetic is delayed to the Emergency Department? Worldwide, trauma accounts for an estimated 4.4 million deaths annually and carries a substantial economic burden. Despite decades of improvements in trauma systems, medications such as tranexamic acid, and the development of prehospital critical care teams, some key aspects of trauma care remain really difficult to study well. Prehospital emergency anaesthesia is a prime example. It is time-critical, ethically complex, highly operator dependent and almost impossible to study using conventional randomised trial designs. As a result, clinicians have largely been forced to rely on observational studies, despite the well-recognised problems of bias and confounding that accompany them. In this episode, we explore the existing evidence base and then focus on a landmark new study published in The Lancet Respiratory Medicine. This paper applies machine-learning techniques to a large UK trauma dataset to address the question; does prehospital intubation improve survival in patients who are predicted to need early airway intervention? We walk through how the authors developed a predictive model to identify high-risk patients, how doubly robust estimation was used to move beyond simple association, and how survival and health-economic outcomes were assessed. The results suggest a clinically meaningful reduction in 30-day mortality for selected high-risk trauma patients who receive prehospital intubation. And we're then joined by two of the study's authors, Amy Nelson and Julian Thompson. Together, we explore what these findings may mean for the future of prehospital emergency anaesthesia, how we should think about evidence in complex emergency care environments, and whether this type of analytical approach could reshape trauma research more broadly. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Paediatric seizures are common, time-critical events and they're something most of us will deal with, whether that's pre-hospital, in the emergency department, or on the ward. They make up around 1–2% of ED attendances, and about 1 in 20 children will have a seizure at some point. Most seizures self-terminate, but the longer they go on the harder they are to stop, and the higher the risk of harm. In paediatric seizures, time really matters. In this episode we take a step-by-step look at how to assess and manage a child who's seizing. We start with the fundamentals; how seizures are defined and classified, what status epilepticus actually means in practice, and why recognising it early makes such a difference. We then dig into the physiology behind seizures, exploring why early benzodiazepines work well and why delayed treatment often doesn't. Understanding what's happening at a receptor level helps make sense of when to escalate treatment and why different drugs work at different stages of a prolonged seizure. Pharmacology is a big part of this episode. We talk through first- and second-line anti-seizure medications, routes of administration, and how effective they really are. We cover the EcLiPSE and ConSEPT trials comparing levetiracetam and phenytoin, and look at newer evidence from the Ket-Mid study and what that might mean for managing refractory status and thinking about RSI. We also work through the approach to cases, pre-hospital management and in-hospital care aligned with UK and European recommendations. There's a clear focus on febrile seizures too, separating simple from complex presentations and helping you decide who needs investigating, admitting, or reassuring and discharging. As ever, the aim is to turn guidelines and evidence into something usable on the shop floor. Paediatric seizures are stressful, but with a structured approach, early treatment, and good airway management, they're absolutely manageable and we can make a real difference on outcomes. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome to this special edition of Roadside to Resus where we're diving into some of the progressive and practice-defining developments in pre-hospital emergency care. This episode brings together a superb group of clinicians, educators and leaders who are shaping the future of PHEM across the UK, and we caught up with them at the recent Faculty of Pre-hospital Care Conference entitled 'The Wider World of Pre-hospital Care'! We start with Pam Hardy, the Chair of the FPHC, who offers an introduction to the College and its ongoing work to elevate standards across pre-hospital care. Next, Camella Main guides us through the brand-new Pre-hospital Maternity Decision Tool designed to support clinicians facing complex decision making in this complex group of patients. Camella breaks down how the tool came to fruition and how teams can use it to enhance safety and decision-making on scene. We then hear from Ben Sheppey, who explores the growing move to formalise and professionalise voluntary pre-hospital care. Ben reflects on the challenges, opportunities and cultural shifts required to align voluntary responders with national standards. Harriet Tucker then walks us through the new FPHC consensus statement on managing penetrating neck injuries. She distils the key principles, the recommendations, and how the guidance aims to bring clarity to one of the most complex and time-critical presentations we face. From there, Cosmo Scurr unpacks the latest AAGBI PHEA Guideline, highlighting the key movements in delivering anaesthesia in the pre-hospital environment. We also hear from Felix Wood, who provides a sharp, practical look at crush injury and crush syndrome. Finally, Zane Perkins explores the rapidly advancing world of AI in PHEM. From practical application to decision making support. Zane describes how emerging technologies have the potential to change prehospital care in ways we may have never considered before! A huge thanks to the expert speakers for their time recording highlights from the superb conference. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Whether you're just stepping into your first cardiac arrest or you've been running them since the days of paddles, this one's for you. The 2025 resuscitation guidelines have landed after further collaboration between ILCOR, the ERC and the Resuscitation Council UK and in this episode we break down exactly what's new, what's stayed the same, and how it all fits into day-to-day practice. Across the board the 2025 updates represent evolution, a steady refinement of evidence rather than wholesale change. Adult ALS remains rooted in early recognition, high-quality compressions and rapid defibrillation, but you'll notice sharper guidance around ventilation, pad positioning, and the sequence of vascular access and drugs. There's a new section on physiology-guided CPR and the emerging science behind arterial-line-driven resuscitation as we covered in the SPEAR epsiode. We also take a look at the special circumstances algorithms from hypothermia to traumatic and obstetric arrest and discuss how an emphasis on reversible causes, data-driven debriefing and system performance might reshape post-event learning. Paediatric and newborn life support see subtle but important refinements too, including pad placement, shock energy escalation, simplification of adrenaline timings and a new Out-of-Hospital Newborn Life Support algorithm aimed squarely at the pre-hospital world. All this and more in the episode! Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

How, when and why to make the call… The pre-alert is one of the most powerful and sometimes most painful parts of emergency care. It can feel like the Spanish Inquisition, trigger tension between pre-hospital and ED teams, or drop another challenge into an already overflowing department. But done well, a pre-alert isn't an irritation; it's an opportunity to line up critical care for the next patient and genuinely improve outcomes. In this episode, Simon, Rob and James break down The UK NHS Ambulance Services and Emergency Department Pre-Alert Guideline, jointly released in July 2025 by RCEM and the Association of Ambulance Chief Executives. It's the first national attempt to give clear, shared expectations on who to pre-alert, what to say, and how to receive those calls, it's full of practical recommendations for both sides of the phone. We kick things off with a review of the evidence base, including brand-new studies showing just how varied pre-alert practice is across the UK. From inconsistent criteria and mixed training to the problem of "pre-alert fatigue", the data make a strong case for standardisation. We then walk through the new guideline's key principles: pre alerting for pre-specified physiological parameters or specific conditions. We finish off with top tips for making and taking better pre-alerts - selling a story, leading with the headline, and understanding what the other side actually needs. This episode combines frontline pragmatism with real-world research and might just make your next pre-alert smoother, faster, and better received. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

a focus on its acute presentations and the care we can deliver to improve outcomes for our patients. Sickle cell disease (SCD) is a lifelong inherited blood disorder that affects over 15,000 people in the UK, and millions worldwide. It's caused by the production of abnormal haemoglobin molecules, which distort red blood cells into a crescent, or "sickle," shape. These rigid cells can block small blood vessels, leading to painful vaso-occlusive crises and organ damage. While the condition has long been most prevalent in parts of Africa, the Middle East, the Mediterranean and India, today it's a global health issue, and one we encounter regularly in UK emergency care. Tragically, failings in care have too often led to avoidable harm. The 2021 parliamentary report "No One's Listening" laid bare some of these cases, highlighting missed opportunities, poor awareness, and systemic issues that cost lives, such as the death of Evan Nathan Smith. So why are we revisiting this now? In 2024, RCEM published new Best Practice Guidelines on managing sickle cell disease in the ED. These provide clear, evidence-based standards for recognition, triage, analgesia, infection control, and safe discharge. In this episode, we take you through the key elements; Pathophysiology – how a genetic mutation drives sickling, vaso-occlusion and inflammation. Clinical presentations – from painful crises and acute chest syndrome, to stroke, anaemia, infection, priapism and pregnancy-related complications. Recognition and triage – why timely pain control within 30 minutes is a must, and how to spot red flags. Investigations and treatment – including the role of reticulocytes, the importance of knowing a patient's baseline haemoglobin, and principles of analgesia, transfusion, oxygen, and supportive care. Discharge and ongoing care – ensuring safe, joined-up planning, and involving haematology and specialist pathways wherever possible. The take-home message? Every sickle cell crisis is a medical emergency. We need to listen to patients, escalate early, involve haematology, and deliver care that meets the standards they deserve. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back! First up a paper to challenge the way we think about rhythm recognition in cardiac arrest to start with, looking at the rate of VF identified on echo but not on the defibrillator. We have a huge amount of strategies to rule out acute coronary syndrome in the UK, our next paper looks at the clinical effectiveness of these, whilst also giving us some hugely important information about the incidence of ACS in those presenting to Eds. Finally we look at a paper quantifying the effect of hypertonic saline in those patients with a TBI. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom. We'll be taking a short break over the summer, but will be back in September with another Papers of the Month and Roadside to Resus, until then have a fantastic summer! Simon & Rob

Welcome back to Papers of the Month! Three more papers to both inform and challenge our practice across the spectrum of emergency care. First up we look at a systematic review and meta-analysis on noradrenaline vs adrenaline for our medical post-ROSC patients; what evidence exists out there and should we all be delivering noradrenaline as our first line treatment for those with shock? Next up a paper to really challenge the treatment algorithm for status epilepticus in paediatrics, with an RCT of midazolam and ketamine versus midazolam alone. There are some huge differences here in the form of termination rates and some great discussion to be had around the specifics of the paper and how that might translate into future practice. Finally we look at a paper assessing the impact of i.m. versus i.v. metoclopramide for migraines and acute severe headaches. The paper looks at the impact of length of stay within the Emergency Department and also the efficacy of the treatment. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Welcome back to June 2025's papers podcast! Having been cynical about CPR feedback devices in the past we take a look at a recent paper on their use and their potential impact to both ROSC and survival for patients, when compared to standard practice; is it time to integrate them more definitively into our practice? Next up we take another look at the use of adrenaline in traumatic arrest. We've covered this before and there's some interesting data and discussion to be had around the topic and the paper. Finally, we all know about the unprecidented pressure on ED's and all forms of healthcare at the moment. Many patients waiting for hours and hours to be seen. But there may be systems and routes by which others can be identified with lower acuity presentations that may not need to wait overnight for long periods, and our final paper looks at this with a paper on 'deflection'. Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob