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

This month we’ve got three really interesting papers that shine a light on aspects of cardiac arrest management that many of us will recognise from clinical practice.

First up, we look at the feasibility of arterial line placement during ongoing cardiac arrest in the Emergency Department. In our SPEAR episode we talked about the balance between securing invasive monitoring versus the potential distraction from other essential parts of resuscitation. This paper takes a pragmatic look at whether arterial access is achievable in that critical period in the Emergency Department, the success rate and the time required. 

Next up, we look at a paper that helps to give us a more accurate feel for the rate and predictors of high-risk adverse events for Emergency Department paediatric ketamine sedation.

Our final paper looks at ultrasound during cardiac arrest. Specifically, whether the hands-off time during the pulse check are longer with traditional manual checks or with ultrasound. This systematic review and meta-analysis puts some numbers to the best way to minimising hands-off time.

So whether you’re a regular on the arrest team, sedating children, or supporting resuscitation from the periphery, these papers provide some useful food for thought on where our focus should be in those critical minutes.

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

Simon & Rob

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 to September’s Papers of the Month. We’ve got three cracking studies for you this time, each tackling really core questions in pre-hospital and emergency care and each giving us plenty to chew over when it comes to the evidence base and what it means for our practice.

First up, we’re heading down under to Sydney with the PRECARE pilot feasibility study on pre-hospital extracorporeal CPR for refractory cardiac arrest. Now, we all know survival from refractory OHCA is pretty dismal with conventional CPR alone, and that the big limiting factor with ECPR is time to flow. So could we meaningfully shorten that window by bringing ECMO to the roadside rather than the hospital? This study tested whether pre-hospital physicians could safely and effectively deliver ECPR on scene and the results are some of the fastest low-flow times yet reported. But of course, feasibility is only one piece of the puzzle…

Next, we’re back in the UK with a service evaluation from Devon Air Ambulance looking at endotracheal intubation by critical care paramedics during cardiac arrest. Airway management in OHCA has always been a hot topic, with long-running debates over supraglottic devices versus intubation, and questions about who should be putting a tube in. This six-year dataset explores how structured education, theatre placements, and the introduction of video laryngoscopy have changed practice and whether CCPs can consistently meet the ERC’s benchmark of 95% success, or more, within two attempts. 

And finally, we’re heading to Switzerland with a study on the HOPE score in hypothermic cardiac arrest. Hypothermia remains one of those rare but high-stakes presentations where patients in cardiac arrest can sometimes make remarkable recoveries if we select the right ones for extracorporeal rewarming. The HOPE score is designed to guide those decisions by predicting survival. This study takes a retrospective cohort across two hospitals and asks: does the score actually deliver in real-world practice, and can it help avoid futile attempts at ECLS?

So, three papers, ECMO on the roadside, paramedic-led intubation in cardiac arrest, and the precision of the HOPE score. As ever, plenty to think about for both the evidence and our day-to-day practice.

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

Simon & Rob

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

This is a pretty special episode! If you're involved in cardiac arrest management or care of critically unwell patients then there's some ground breaking practice we'll be discussing with the two founders of the SPEAR course;

Jon Barratt;

• Lt Col, British Army
• Emergency Medicine and PHEM Consultant, University Hospitals of the North Midlands
• Clinical Lead - Research and Clinical Innovation, Yorkshire Air Ambulance
• MERIT Consultant, West Midlands Ambulance Service
• Senior Lecturer, Academic Department of Military Emergency Medicine

Paul Rees;

• Surgeon Commander Royal Navy
• Consultant, East Anglian Air Ambulance & Barts Heart Centre
• Lead for Resuscitation Barts Health NHS Trust
• Reader in Cardiology & Resuscitation, University of St Andrews & QMUL London
• Defence Lead for Endovascular Resuscitation
• SPEAR co-founder

Ultimately in the episode we navigate through to the delivery of endovascular resuscitation both pre and in-hospital, building on the fundamentals of care and logistics which enable its delivery. We'll be covering;

• Blood pressure monitoring both invasive and non-invasive, the evidence and the cohort of patients we should be targeting with invasive blood pressure monitoring
• Delivering complex medical interventions in unpredictable circumstances and environments
• Balancing the benefits of interventions with time required and workflow
• REBOA for medical arrests, the theory and the ERICA trial
• Improving recognition of ROSC
• The SPEAR course
• How to prepare services and departments for upcoming advances in resuscitation

There is something for everyone in here and a huge thanks to Jon and Paul for their time. Make sure to check out the links to the papers discussed in the episode below.

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 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

It’s something we all encounter in emergency and prehospital care, probably more than anything else, yet it’s a topic we’ve not given a full episode to… until now!

Up to 70% of prehospital patients and 60–90% of ED attendees report pain, with half of all ED presentations having pain as the primary complaint. That’s millions of patients across Europe every year and we’re not always optimising our approach!

In this episode, we’re diving deep into acute pain management; from understanding the complex biopsychosocial definition of pain, right through to tailored pharmacological and non-pharmacological strategies, plus everything in between.

We’ll be looking at how we define and assess pain and the importance of validating patient experience. Then we’ll work through management options: from paracetamol to ketamine, NSAIDs to regional anaesthesia, and talk through barriers like bias, opiophobia, and the persistent inequalities in analgesic delivery.

We'll also shine a light on special groups;  from paediatrics to chronic pain patients and those with opioid use concerns, finishing with key takeaways on safe discharge planning.

This one’s about being better at recognising, respecting, and relieving pain. Because pain is an emergency, and we’ve got the tools to do something about it.

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 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

Welcome back! In this episode, we’re diving deep into something we all think we know, the Glasgow Coma Scale.

The GCS has been a fundamental part of assessing patients with altered consciousness for over 50 years. You’ll find it in trauma scores, neurology exams and practically every prehospital and ED handover. But here's the thing, is it as reliable and useful as we think?

In this episode, we’ll explore the origins of the scale, what it was designed for and how it’s been used (and maybe misused...) since. We take a look at how reproducible it really is, particularly when different clinicians score the same patient. Spoiler alert: it’s not always as consistent as you might hope!

We’ll also unpack the individual components; eyes, voice, motor and ask if they all carry equal weight, or are some more prognostically useful than others? Because a GCS of 4 isn’t always the same GCS of 4, depending on how you get there…

We’ll be looking at real-world implications, how we make decisions around airway management, imaging, and referral, all based on that one number.

So whether you’re in prehospital care, the ED, or intensive care - stick with us as we try to answer the question: is the GCS still doing what we need it to, or is it time to move on?

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

Simon, Rob & James