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

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