This month we've got another really varied mix of papers that all have the potential to influence everyday emergency and prehospital practice.

We start by asking a question that's becoming increasingly relevant as prehospital critical care teams develop ever more advanced capabilities: are all those extra interventions costing us precious scene time, and if so, how much?

We then move into post-cardiac arrest care with one of the biggest oxygen trials we've seen to date, looking at whether aiming for conservative oxygen targets actually improves neurological outcomes after ROSC.

Finally, we tackle one of emergency medicine's diagnostic challenges, necrotising soft tissue infection. We'll look at what the latest evidence tells us about physical examination, imaging and the much-debated LRINEC score, and whether any of them are good enough to confidently rule this devastating disease in or out.

As always, we'll pull apart the methodology, discuss what these studies mean for our own practice and, perhaps most importantly, ask whether they should actually change what we do tomorrow.

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

Simon & Rob

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