We assess the pupils in almost every significantly unwell or injured patient - but how much are they really telling us? It is easy to document 'pupils equal and reactive' and move on, yet a changing pupil may be one of the earliest outward signs of a developing intracranial catastrophe. Equally, anisocoria in a completely well patient may be longstanding and entirely benign.

In this Roadside to Resus episode, we work through the anatomy and physiology of the pupillary light reflex before applying it to three important clinical situations: the blown pupil following a significant head injury, unequal or irregular pupils in a patient with a GCS of 15, and bilaterally fixed and dilated pupils in and following cardiac arrest, along with a deep dive into the evidence base.

We discuss how to decide which pupil is abnormal, the warning signs of third nerve palsy and Horner's syndrome, ocular and drug-related causes, and why serial change matters more than an isolated measurement. We also explore automated pupillometry, what the NPi can add, and why fixed pupils should never be used alone to determine futility or neurological prognosis.

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 2026's Papers of the Month, and this month we've got three papers that are really focused on the practical end of emergency and prehospital care.

First up, we're looking at what happens after we've performed a prehospital RSI. We put a huge amount of emphasis on getting the induction right, but what about maintaining adequate anaesthesia afterwards? This paper looks at intermittent bolus sedation following prehospital emergency anaesthesia, the variation in dosing between patients, and whether we might actually be running the risk of under-sedating some of them and compromising their care.

Then we're staying prehospital and asking a really simple question in trauma: how good are the physiological numbers we use to identify the sick patient? We've all used shock index, but could NEWS actually do a better job of predicting mortality, transfusion requirements and subsequent resource utilisation?

And finally, we're back to RSI and rocuronium. A variety of dosing strategies can be seen in practice but could going higher improve first-pass success? And importantly, does that relationship still hold in patients with obesity or hypoperfusion?

Three clinically relevant papers, plenty to challenge our current practice, and as always, lots to get into.

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

Simon & Rob

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