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

This month's Papers of the Month is a real mix of papers that challenge some of the things we think we know, whilst also highlighting just how important systems and processes are in improving patient care.

We start with intracerebral haemorrhage and the tricky issue of blood pressure management. We've all been taught that early, aggressive blood pressure reduction is key, but this paper raises some important questions about whether we may sometimes be overshooting. It looks at whether rapidly driving the blood pressure down really improves outcomes, or whether going too low may actually be associated with harm.

From there, we move into trauma, with a sobering look at the timing of deaths from uncontrolled haemorrhage. Despite all of the advances in trauma systems, blood products, haemostatic resuscitation and major trauma care, this paper suggests that the overall timing of haemorrhagic deaths has changed very little in the last 30 years. It is a stark reminder that bleeding remains one of the biggest challenges we face, and that there is still plenty of work to do if we want to reduce preventable deaths.

Finally, we finish with something a bit different but arguably just as important: airway governance and quality improvement. This paper from Ireland looks at how a structured programme of airway training, governance, simulation and feedback can improve first-pass success and keep complication rates low. It's a really useful reminder that good outcomes are not just about kit and technical skills, but about systems, training, competency and making sure teams maintain currency through repeated exposure and practice.

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

This month we're heading firmly into the prehospital and community space, looking at how we make decisions when the diagnostics are limited and the system around us is evolving.

We start with a really practical question around traumatic pneumothorax. How good are we, clinically, at spotting the patients who actually need urgent decompression? This paper takes a hard look at the performance of the classic signs we're all taught, and challenges just how much we can rely on them in isolation when it really matters .

From there, we move into one of the biggest ongoing debates in prehospital trauma care: whole blood. The SWiFT trial gives us high-quality randomised data on whether early whole blood transfusion changes outcomes in major haemorrhage. It's a landmark UK study, and the results might not be quite what many were expecting .

Finally, we zoom out slightly and look at how senior decision-making in the community can change patient pathways. This service evaluation explores whether bringing experienced clinicians to the patient can safely reduce conveyance for head injuries, particularly in older and anticoagulated patients, without missing significant pathology.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

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

March's Papers of the Month is here and we've got three absolute crackers to get stuck into.

First up, we head prehospital to explore pseudo-pulseless electrical activity. This review challenges us to rethink how we approach organised electrical activity without a pulse. We discuss the role of POCUS, the concept of treating profound shock rather than "arrest," and what this means for decision-making and management.

Next, we move to cardiac arrest physiology with a systematic review examining intra-arrest diastolic blood pressure and coronary perfusion pressure. We take a look at the proposed thresholds, the heterogeneity in the evidence, and whether haemodynamic-guided resuscitation is ready for prime time.

Finally, we dive into airway nuance with a brand new taxonomy of performance errors in hyperangulated video laryngoscopy. We've covered a very similar paper before on standard geometry VL which was incredibly useful and this looks to do just the same for the alternative technique required with a hyperangulated device. We explore the microskills, the common errors, and what this means for how we train, feedback and improve our emergency intubations.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

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

Welcome back to February's Papers of the Month.

Across these three papers, a common theme emerges: many of the things we do every day are based on habit, extrapolation, or long-standing belief rather than direct evidence from the patients and settings we work in. These studies don't give us easy answers, but they do ask better questions — and that's exactly what Papers of the Month is about.

We start in the prehospital environment, looking at airway management and the question of where intubation actually happens. The idea that we need perfect conditions and 360-degree access before attempting an airway is deeply ingrained, particularly in prehospital care. But real life is messy. This paper explores whether intubating inside an ambulance is associated with worse outcomes or complications, or whether it might actually be a reasonable — and sometimes advantageous — option when time and context matter.

Next, we move into cardiac arrest and one of the most basic interventions we perform: defibrillation. Specifically, pad position. Anterior–lateral versus anterior–posterior placement is something many of us were taught early on, often without much discussion. This study looks directly at patients with shockable out-of-hospital cardiac arrest and asks whether initial pad position influences return of spontaneous circulation and downstream outcomes. It's a simple intervention, but one that could have important implications for practice.

Finally, we take on one of the most debated topics in emergency and critical care airway management: ketamine versus etomidate for induction. This large, pragmatic randomised trial examines whether sedative choice affects mortality and peri-intubation cardiovascular collapse in critically ill adults. It challenges some widely held assumptions, particularly around haemodynamic stability, and provides some much-needed clarity in an area that has generated more opinion than data for years.

Taken together, these papers remind us that resuscitation is built on dozens of small decisions. February's Papers of the Month isn't about changing practice overnight — it's about thinking more carefully, questioning dogma, and understanding the evidence behind the choices we make every day.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob