Critical Levels – Details, episodes & analysis

In this episode, Zach sits down with Dr. Ian Drennan and Dr. Sheldon Cheskes to dissect the newly released 2025 AHA and ILCOR resuscitation guidelines. They break down the evidence, controversies, and real-world implications for paramedic practice.

🔹 How guidelines are actually created
🔹 Mechanical CPR
🔹 Heads-Up CPR

🔹 IV vs IO Access

🔹 Medications
🔹 Defibrillation Science

🔹 Airway Management
🔹 Post Cardiac Arrest Care

In this episode, we explore the science, history, and frontline application of End-Tidal CO₂ (ETCO₂) — a tool that offers real-time insight into ventilation, perfusion, and metabolism. Danny and Rance from DnR explain how paramedics can use ETCO₂ to assess and guide care across multiple patient presentations.

Key Takeaways:

• ETCO₂ is the sixth vital sign — reflecting ventilation, perfusion, and metabolism in real time.

• Capnography vs. Oximetry: SpO₂ shows what was happening; ETCO₂ shows what's happening now.

• Waveform interpretation: Alpha and beta angles reveal underlying pathology like bronchospasm, obstruction, or air trapping.

• Clinical uses:

  • Tube confirmation: Real-time verification in 6 breaths or less.

  • CPR: Values <10 mmHg after 20 mins indicate poor prognosis.

  • Ventilation: Real-time feedback for rate and volume.

  • Head injuries: Maintain normocapnia; hyperventilate only during herniation.

  • Sepsis, trauma, PE, and DKA: Trending ETCO₂ helps identify metabolic and perfusion problems.

• Practical tips:

  • "Filter first, end-tidal to the sky."

  • Inline sensors outperform sidestream for accuracy.

  • End-tidal is not just for intubated patients — use it with nasal prongs for sedation and respiratory monitoring.

How prepared do you feel to care for children and youth who have experienced abuse or assault?

• 1 in 10 Canadians (7.8%) over 15 report at least one instance of sexual abuse before age 15 (Stats Canada)
• Up to 88% of people being trafficked access health care (Polaris Project) - many don't disclose they are being trafficked
• Highest rates of intimate partner violence occur between age 12-24 (Stats Canada)
• Young people aged 15-24 years have the highest rate of sexual assault (Gov't of Canada)

In this episode, we will explore the presentation of sexual abuse, sexual assault and sex trafficking in the pediatric setting and discuss trauma and violence informed care practices to guide paramedic care. We will also discuss: 

- gaps and barriers to care in this population

- practical tips to guide trauma and violence informed care including what not to ask 

- role of the Sexual Assault Nurse Examiner and care available in Ontario through the Network of Sexual Assault and Domestic Violence Treatment Centers (SADVTC's) 

- mandatory and consent based reporting 

- prevelence and risks of strangulation in the context of sexual assault and intimate partner violence and the importance of thorough assessment and imaging

On this month's episode, we dive deep into the world of military medicine with special forces paramedics, pulling back the veil of secrecy surrounding their vital work. Join us as we explore the unique challenges and high-stakes scenarios these elite medics faced on the front lines.

From advanced trauma care in combat zones to the mental resilience required for their demanding roles, our guests share their incredible experiences and insights.

What is CANSOFCOM/JTF 2?

What is your role within the team? What does training look like?

Medical vs trauma treatment

TCCC

MARCHE management 

Blood

Challenges of providing austere medicine 

Attributes of a great SOF medic

Equipment selection 

Mindset/attitude/standards

Relationship building

On this month's episode, we're joined by Dr. Justin Mausz to discuss violence against paramedics. 

During the episode, you'll hear us cover:

• How often are we seeing violence against paramedics
• What is violence? Is it different from harassment? Does intent matter? 
• Incident reporting
• How does it compare to other industries?
• What does violence against paramedics look like?
• How do we balance paramedic and patient safety?
• What do we do with this?
• PPE
• Policy development 
• External vs internal violence
• The value of research

On this month's episode, we're joined by Dr. Steven Sanders to discuss heat related illnesses. 

During the episode, you'll hear us cover:

Health impacts of temperature increase 

Physics/physiology of temperature vs heat

Spectrum of heat related illness

• heat rash
• heat cramps
• heat edema
• heat syncope
• heat exhaustion 
• heat stroke
• exertional vs classic

Comorbidities/confounders/risk factors

Temperature assessment

Disease management & treatment

On this month's episode, we're joined by Dr. Bonnie Snyder to discuss BVM as well her recently published paper in Resuscitation: Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. 

During the episode, you'll hear us cover:

There is nothing basic about the BVM - it is not a benign intervention

Rate and volume based on the guidelines 

• Consequences of excessive rate/volume
• Consequences of under ventilation 

General airway management

• positioning 
• suction
• airway adjuncts
• mask seal
• C-E technique
• 2 person technique 
• waveform capnography and other real time feedback
• importance of proper volume
• importance of proper pressure 

BVM sizing 

Dr. Snyder's study 

• research question/impetus
• P-I-C-O
• results
• feedback 
• next steps

On this month's episode, we're joined by Dr. Katie Lin to discuss TBI and the crashing brain. 

During the episode, you'll hear us cover:

head injury differentials and history gathering 

ischemic vs hemorrhagic 

head injury etiology 

head injury pathophysiology 

assessment

3 step neuro exam 

pupil assessments 

signs/symptoms of herniation 

ECG changes

management 

• avoid/manage the H bombs (hypoxia, hypotension, hyperventilation)
• airway management 
• ICP management 
• other medications 
• seizure management 

paediatrics 

neuroprognostication 

On this month's episode, we're joined by Dr. Janice Tijssen to discuss pediatric cardiac arrest. During the episode, you'll hear us cover:

The importance of our early interventions

What is cardiac arrest

• incidence/epidemiology
• etiology 
• risk factors/past medical history
• outcomes
• sociodemographics

Differences between adult and pediatric cardiac arrest

Simplifying our response

Symptomatic bradycardia

The importance of scene time

The importance of CPR/ventilation

IV vs IO, SGA vs ETT

Epinephrine  

PRIME study

Family presence during arrest 

Disposition

On this month's episode, we're joined by Dr. Louisa Marion-Bellemare to discuss Suboxone (buprenorphine/naloxone) and managing patients who use illicit and controlled drugs. During the episode, you'll hear us cover:

• history of the drug crisis 
• lay of the land of the current drug crisis
• historical treatments
• opiate pharmacology 
• healthcare utilization 
• stigma 
• suboxone use 
• patient advocacy