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

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