Explore every episode of the podcast The FlightBridgeED Podcast

What begins as respiratory distress quickly spirals into a critical care nightmare. In this episode of the FlightBridgeED Podcast, Eric Bauer is joined by Kari Young to break down a challenging case that tests clinical reasoning, airway management, and ventilatory decision-making under pressure.

Together, they walk through the patient's presentation, discuss the DASH-1A airway assessment, and explore the critical decision-making process behind when, and when not to intubate. From there, they examine the differential diagnosis, review the interventions that can either halt, or accelerate the hypoxic spiral, and highlight common pitfalls, evidence-based strategies, and practical pearls that every EMS, flight, and critical care clinician can apply on their next respiratory emergency.

Whether you're preparing for certification, sharpening your critical thinking, or simply enjoy learning through real-world cases, this is an episode you won't want to miss.

Because sometimes the nightmare isn't the airway, it's recognizing the spiral before it's too late.

In this compelling episode of the FlightBridgeED Podcast, Eric Bauer is joined by Kari Young, Advanced Practice Paramedic and educator, for another installment of The Nightmare Series. Together, they dissect a complex critical care case where the obvious diagnosis was only the beginning. What initially appeared to be a straightforward presentation quickly evolved into a diagnostic minefield involving diabetic ketoacidosis (DKA), end-stage renal disease (ESRD), pneumonia, sepsis, acute respiratory failure, hypoxemia, and acute encephalopathy.

Throughout the discussion, Eric and Kari walk listeners through the clinical presentation, differential diagnosis, decision-making process, and the cognitive biases that can lead providers to anchor on a single diagnosis while overlooking other life-threatening conditions. Filled with practical teaching points, evidence-based discussion, and real-world lessons, this episode challenges clinicians to think beyond the first diagnosis and embrace a more comprehensive approach to critically ill patients.

Whether you're an EMT, paramedic, flight clinician, nurse, or physician, The Nightmare Series: The Diagnostic Minefield will sharpen your clinical reasoning and remind you that sometimes the sickest patients aren't suffering from one disease, but several, all at once.

This episode of the FlightBridgeED podcast focuses on post-cardiac arrest care during critical care transport, particularly for crews moving patients from outside or critical access hospitals to higher levels of care. Dr. Mike Lauria frames the post-ROSC patient around a simple mental model: help the heart, hunt for the cause, sustain the brain, and then provide all the other good critical care support needed during transport. While not all post-arrest patients are the same, this framework helps crews prioritize the problems most likely to affect survival and neurologic outcome.

The first priority is stabilizing the cardiovascular system. After ROSC, crews should consider securing a definitive airway, especially if the patient is stable enough to safely exchange a supraglottic airway for an endotracheal tube. Perfusion should be optimized with a MAP goal around 65, cautious fluid administration, and early use of vasopressors when needed. Norepinephrine is presented as a reasonable first-line pressor, with epinephrine added when there is evidence of poor contractility or a need for inotropic support. The episode also emphasizes the usefulness of arterial lines, repeat EKGs, and point-of-care ultrasound when available, while cautioning against delaying transport for interventions that are not essential.

A major theme is that crews must continue to search for the cause of the arrest even after ROSC. The H’s and T’s still matter, and transport teams may have access to critical information that can disappear during the handoff chain. Speaking directly with family, bystanders, or the sending team can uncover symptoms or events that change the patient’s trajectory. The episode also highlights the risk of re-arrest, noting that pads should stay on, ACLS medications should remain immediately available, and crews should stay alert for reversible causes, worsening shock, recurrent ventricular arrhythmias, or signs that the patient may need more urgent cardiac intervention.

The final major priority is protecting the brain from secondary injury. Luria emphasizes normothermia, avoiding fever, maintaining perfusion, avoiding both hypoxia and hyperoxia, and targeting normal or high-normal CO2 rather than rapidly overcorrecting ventilation. Sedation should be minimized when possible so the receiving team can obtain a meaningful neurologic exam, while still treating pain, agitation, ventilator asynchrony, or unsafe movement. The episode closes with the “ALIVE-12” checklist: Airway secure, Look at the heart, Inotrope/pressor support, Ventilate safely, End-tidal CO2 monitoring, and a 12-lead ECG after enough time has passed for better diagnostic accuracy.

Key Points

• Post-cardiac arrest transport can be organized around four priorities: help the heart, hunt for the cause, sustain the brain, and provide good supportive critical care.
• A MAP around 65 is generally an appropriate perfusion goal; higher blood pressure targets have not clearly shown benefit.
• Norepinephrine is a reasonable first-line pressor, with epinephrine added when inotropic support is needed.
• Repeat 12-lead EKGs matter; an ECG immediately after ROSC may be misleading, so repeating around 8–10 minutes and again later can improve diagnostic accuracy.
• Brain protection means avoiding hypotension, fever, hypoxia, hyperoxia, and hypocapnia while minimizing unnecessary sedation.

This episode of the FlightBridgeED podcast focuses on acute decompensated left heart failure, especially in the transport setting. Dr. Mike Lauria frames these patients through the lens of the SCAI cardiogenic shock spectrum, with special attention to the earlier A and B stages that can be easy to underestimate. While the crashing, hypotensive cardiogenic shock patient often gets immediate attention, the episode emphasizes that patients with early decompensated heart failure may look “stable” because their blood pressure is still normal or high, even while they are beginning to slide toward shock.

The case centers on a 58-year-old man with coronary artery disease, hypertension, diabetes, atrial fibrillation, and known reduced ejection fraction who stops taking his antihypertensives and diuretics while traveling. After some dietary indiscretion and worsening fluid overload, he presents with dyspnea, hypoxia, pulmonary edema, crackles, pedal edema, and increased work of breathing. Although he is not hypotensive, his clinical picture suggests acute decompensated left ventricular failure with early cardiogenic shock physiology. Point-of-care ultrasound, chest X-ray, BNP, and clinical exam all support the diagnosis, but the episode stresses that crews often do not need to wait for labs to recognize a patient who is clearly congested and deteriorating.

Management focuses on reducing the burden on the failing left ventricle while supporting oxygenation and ventilation. In a hypertensive patient with pulmonary edema, nitroglycerin is highlighted as a key therapy because it reduces afterload and helps improve forward flow. Non-invasive positive pressure ventilation, whether CPAP or BiPAP, is presented not just as respiratory support but as hemodynamic support: by increasing intrathoracic pressure, it reduces venous return, decreases pulmonary congestion, and lowers the relative afterload faced by the left ventricle. The episode also emphasizes that crews should raise EPAP/PEEP when the goal is increasing mean airway pressure, and should coach anxious patients through NIV rather than reflexively sedating them.

Volume management and inotropic support round out the treatment strategy. If the patient is volume overloaded and not hypotensive, loop diuretics are appropriate, especially for longer transports, and doses should be meaningful rather than overly timid. If ultrasound or clinical assessment suggests reduced cardiac output despite adequate or elevated blood pressure, low-dose dobutamine may help improve forward flow. However, if the patient begins to transition from SCAI stage B into stage C cardiogenic shock, crews should reassess immediately: stop vasodilators, consider vasopressors or epinephrine, continue positive pressure ventilation when appropriate, repeat the ECG, and communicate the deterioration clearly to the receiving team.

Key Points

• Acute decompensated heart failure can represent early cardiogenic shock even when the patient is not hypotensive.
• Hypertensive pulmonary edema is often an afterload problem; nitroglycerin can be a powerful tool to reduce afterload and improve forward flow.
• CPAP and BiPAP are not just oxygenation tools; they also provide hemodynamic support for a failing left ventricle.
• Avoid sedating patients simply because they are anxious on NIV; coach them, start with tolerable pressures, and increase support as they adjust.
• If a heart failure patient deteriorates from SCAI stage B to stage C, reassess the cause, stop vasodilators, consider pressors/inotropes, repeat the ECG, and update the receiving facility.

This episode provides an overview of cardiogenic shock and explains why it remains such a major problem despite decades of progress in treating acute coronary syndromes. Dr. Mike Lauria notes that while STEMI and other ACS outcomes have improved dramatically with better systems, PCI, and modern cardiac care, mortality from cardiogenic shock has stayed stubbornly high. A central theme is that cardiogenic shock is becoming more common, especially among more medically complex patients with chronic heart failure and prior cardiac disease, and that critical care transport teams are increasingly encountering these patients because so many require transfer to higher-level centers. 

A major focus of the episode is the modern framework for thinking about shock, especially the SCAI stages A through E, which describe cardiogenic shock as a spectrum rather than a simple yes-or-no diagnosis. Dr. Lauria emphasizes that this shared language helps clinicians identify patients earlier, communicate severity more clearly, and escalate care before they progress into multi-organ failure. Dr. Lauria argues that early recognition, rapid team-based decision-making, and transfer to experienced shock centers are some of the most promising ways to improve outcomes, particularly because late interventions often fail once the patient has already tipped into severe end-organ injury. 

From a transport perspective, the episode frames care around recognition, resuscitation, and retrieval. Clinicians are encouraged to identify deterioration early, support perfusion by maintaining MAP, optimize oxygenation and ventilation, think carefully about volume status, add inotropic support when needed, and pay close attention to whether existing mechanical circulatory support is truly sufficient. Just as importantly, Dr. Lauria stresses the logistical and systems side of transport: moving quickly but safely, anticipating equipment and oxygen needs, and advocating for the patient to reach the right destination the first time, especially if advanced support such as Impella or ECMO may soon be needed. 

Key points

•  Cardiogenic shock remains a high-mortality condition even though outcomes for acute coronary syndromes have improved substantially. 
•  It is increasingly common, especially among complex patients with chronic heart failure and prior cardiac disease. 
•  The SCAI shock stages (A-E) provide a practical shared language for identifying severity and guiding escalation of care. 
•  Early recognition, shock teams, and transfer to experienced cardiogenic shock centers may improve outcomes by preventing delayed intervention. 
•  For transport teams, priorities include supporting MAP, optimizing oxygenation/ventilation, considering volume status and inotropy, checking device adequacy, and getting the patient to the right place quickly and safely. 

This episode is an overview of acute right heart failure, with a strong emphasis on why the right ventricle is so vulnerable and why clinicians often miss its role in critically ill patients. Dr. Mike Lauria explains that, unlike the left ventricle, the RV is designed to pump against a low-pressure, high-compliance pulmonary circulation. That makes it especially sensitive to sudden increases in afterload, whether from pulmonary embolism, pulmonary hypertension, ARDS, sepsis, or other cardiopulmonary stressors. The result is that RV dysfunction can develop quickly and become a major driver of shock in transport, emergency, and ICU patients. 

A major theme of the episode is the “RV spiral of death”: as RV afterload rises, the right ventricle dilates, pumps less effectively, and begins to impair left ventricular filling by bowing into the septum. This lowers cardiac output, worsens systemic perfusion, and reduces blood flow to the RV itself, which further weakens the ventricle and accelerates hemodynamic collapse. The transcript also reviews practical clues that can help identify RV failure, especially in transport, including CT evidence of an enlarged RV, bedside echo findings such as septal flattening, an increased RV:LV ratio, reduced TAPSE, tricuspid regurgitation, and a dilated vena cava. 

Management is organized around a practical resuscitation framework: maintain systemic blood pressure, optimize preload, reduce RV afterload, improve contractility, and address the underlying cause. Dr. Lauria discusses norepinephrine as a first-line vasopressor, warns that extra fluid is often not helpful and may make things worse, and stresses the importance of correcting hypoxia and hypercapnia to reduce pulmonary vascular resistance. Inhaled pulmonary vasodilators, low-dose inotropes such as epinephrine or dobutamine, and avoiding unnecessary positive-pressure ventilation are all highlighted as useful strategies, while definitive therapy depends on the cause, such as thrombolysis for PE or disease-specific treatment for pulmonary hypertension. 

Key points

•  The right ventricle is built for a low-pressure system and does not tolerate sudden increases in afterload well. 
•  Acute RV failure is commonly triggered by PE, pulmonary hypertension, ARDS, sepsis, and other causes of increased pulmonary vascular resistance. 
•  The RV spiral of death occurs when RV dilation, reduced LV filling, and worsening RV perfusion compound each other and drive shock. 
•  Useful bedside clues include RV enlargement, septal flattening, abnormal RV:LV ratio, reduced TAPSE, tricuspid regurgitation, and a dilated IVC. 
•  Management focuses on supporting MAP, being cautious with fluids, reducing RV afterload, adding inotropy when needed, and treating the underlying cause. 

This week’s FAST Replay is a double feature! Two talks that tackle high-stakes medicine from completely different angles, but with the same underlying theme: thinking differently when the usual approach isn’t enough.

First up, Brittany Bernardoni takes us into the rapidly evolving world of Extracorporeal Cardiopulmonary Resuscitation (ECPR). From the limitations of conventional CPR to the growing use of ECMO in cardiac arrest, this session explores what may become the next major leap forward in resuscitation care. Brittany walks through the physiology, patient selection, timing, and the real-world programs already bringing ECPR directly to patients in the field.

Then, Elizabeth Garcher dives into one of the most intimidating areas in prehospital and critical care medicine: pregnancy-related emergencies. This talk focuses on “errors of omission.”  The treatments clinicians hesitate to give because of fear of harming the baby, even when delaying care, can seriously harm both patients. From airway changes and hypertensive emergencies to eclampsia, DKA, blood products, and seizure management, this session is packed with practical pearls and critical reminders for managing pregnant patients in the field.

Two completely different topics. Two incredibly practical talks.
One common thread: understanding the physiology well enough to act decisively when it matters most.

We’re continuing our FAST Replay series, bringing you full sessions recorded live from past FAST conferences as we build toward FAST26: Austin. This episode features Jeff Jarvis and covers a wide range of topics that directly address how we practice in EMS.

From trauma care to airway to cardiac arrest, this session walks through current position statements and evolving recommendations, including:

•  Blood product use in trauma 
•  How to approach traumatic (circulatory) arrest 
•  Pneumothorax and chest decompression decisions 
•  Postpartum hemorrhage and hypertension management 
•  Airway timing and first-pass success 
•  And where some of our long-standing practices don’t hold up to the evidence 

More than anything, this talk highlights a core idea: not everything we do in EMS is built on strong evidence, and we need to be willing to question and refine our approach as new data emerge.

FAST26 is coming to Austin this year on May 27 - 29, 2026. We are co-locating with EMS World Live, bringing together the entire EMS community with FAST26: Austin and EMS World Live Austin, giving you the very best of every possible aspect from basics to critical care to administration!

👉 Learn more or grab your spot at https://fbefast.com

This episode focuses on the critically ill patient with pulmonary arterial hypertension (PAH) and explains why this subgroup is especially dangerous in emergency and transport medicine. Dr. Mike Lauria distinguishes PAH from the broader label of “pulmonary hypertension,” emphasizing that elevated pulmonary pressures can come from several very different disease processes, but group 1 PAH is a rare intrinsic disease of the pulmonary arteries that creates fixed resistance to blood flow. Over time, this chronic increase in pulmonary vascular resistance places an enormous burden on the right ventricle, which may initially compensate but can eventually dilate and fail, especially when stressed by infection, hypoxia, medication interruption, or other acute illness. 

A major theme of the episode is that right ventricular failure is the central problem when these patients decompensate. Dr. Lauria reviews how rising RV afterload leads to RV dilation, reduced RV output, impaired LV filling, worsening cardiac output, and eventual shock. He also highlights an important practical pearl: many PAH patients depend on specialized outpatient therapies such as endothelin receptor antagonists, PDE-5 inhibitors, and especially continuous prostacyclin infusions like epoprostenol or treprostinil. Abrupt interruption of these medications can trigger rebound pulmonary hypertension and rapid deterioration, making continuation of home therapy a critical part of transport and ICU management. 

Management is framed around supporting the failing RV while avoiding interventions that can worsen hemodynamics. The speaker recommends maintaining MAP, usually with norepinephrine, carefully managing preload, and recognizing that this is one of the few shock states where patients may need both vasopressors and diuresis. The episode strongly warns against aggressive fluid loading, stresses the importance of correcting hypoxia and hypercapnia, and supports use of inhaled pulmonary vasodilators such as nitric oxide or epoprostenol in the right setting. It also cautions that intubation is particularly dangerous in PAH because induction and positive-pressure ventilation can sharply worsen RV function and precipitate cardiovascular collapse. 

Key points

•  The episode distinguishes group 1 pulmonary arterial hypertension from the broader and more nonspecific category of pulmonary hypertension. 
•  PAH is dangerous because it creates fixed pulmonary vascular resistance, which can eventually cause right ventricular failure and shock. 
• Medication interruption, especially stopping continuous prostacyclin infusions, can cause rebound pulmonary hypertension and sudden collapse. 
•  Management focuses on supporting the RV: maintain MAP, avoid unnecessary fluids, optimize oxygenation and ventilation, and consider inhaled pulmonary vasodilators. 
• Intubation is high risk in these patients because positive pressure and induction can worsen RV afterload and trigger hemodynamic collapse. 

This episode reviews the newly released 2026 pulmonary embolism guidelines with an emphasis on what matters most for critical care and transport clinicians: identifying the sickest PE patients early and recognizing how quickly they can deteriorate. Dr. Michael Lauria stresses that although pulmonary embolism is common, the subset with hemodynamic instability carries very high mortality and often requires transfer for advanced therapies such as ECMO, catheter-based intervention, or surgery. 

A major focus is the new classification system, which replaces the older “massive” and “submassive” terminology with categories A through E. Instead of emphasizing clot size, the new framework centers on clinical severity, especially hypotension, end-organ hypoperfusion, and progression toward cardiopulmonary failure. The episode also highlights that severe PE is fundamentally a problem of right ventricular failure: as pulmonary vascular resistance rises, the RV dilates, perfusion worsens, LV filling drops, and the patient can spiral into shock. 

Management is therefore framed around supporting the failing RV while moving toward definitive reperfusion. The speaker recommends maintaining perfusion pressure, avoiding aggressive fluids, optimizing oxygenation, reducing RV afterload, and using inotropic support when needed, while also warning that intubation and positive pressure can worsen hemodynamics in these patients. For the sickest patients, especially category D and E PE, systemic thrombolysis is presented as the main reperfusion option available in many settings, though it remains underused and carries meaningful bleeding risk, including intracranial hemorrhage. 

Key points

•  The episode centers on the new 2026 PE guidelines and their practical relevance for emergency, ICU, and transport care. 
•  The old “massive/submassive” terms are replaced by categories A through E, with D and E representing the highest-risk patients. 
•  Severe PE is dangerous primarily because of right ventricular failure and shock, not just hypoxia. 
•  Initial treatment focuses on supporting the RV: maintain MAP, avoid excess fluids, improve oxygenation, reduce RV afterload, and add inotropy when needed. 
• Systemic thrombolysis is a key reperfusion therapy for the sickest patients, but it is underused and has significant bleeding risks. 

We’re continuing our FAST Replay series, bringing you full sessions recorded live from past FAST conferences as we build toward FAST26: Austin. This episode is a talk from FAST25: Lexington that covers a lot of ground, but it all comes back to one question: Why are we doing what we’re doing?

From cardiac arrest to seizures to traumatic arrest, this session challenges some of the most common practices in EMS:

•  Amiodarone vs. lidocaine 
•  How we’re actually dosing benzodiazepines 
•  When ketamine makes more sense 
•  And whether epinephrine is helping at all in traumatic cardiac arrest 

This isn’t about memorizing protocols. It’s about understanding the reasoning behind them and being willing to question them when the evidence doesn’t hold up. If you’ve ever felt like something didn’t quite add up in your protocols… this one will hit.

This is what FAST sounds like. Real conversations. Real challenges. Live from the room.

FAST26 is coming to Austin this year, co-located with EMS World Live, bringing together the FAST experience with a broader EMS community, while keeping what makes FAST what it is.

👉 Learn more or grab your spot:
 https://fbefast.com

FAST26: Austin will be in Austin, Texas, from May 27 - 29, 2026.
Tickets are available as FAST26: Austin only, EMS World Live only, or a combination ticket that allows you to attend both events.

We’re continuing our FAST Replay series, bringing you full sessions recorded live from past FAST conferences as we build toward FAST26: Austin! This episode takes on a topic everyone talks about… but few fully understand: evidence-based medicine. What does it actually mean in EMS?

This session breaks it down in a way that’s practical, honest, and directly applicable to how decisions get made in the field. From the limits of single studies to the importance of real-world context to the evolution of guidelines and what drives them. This is a deeper look at how evidence should (and shouldn’t) shape practice. It also challenges some long-standing habits in medicine, where tradition, opinion, or “how we’ve always done it” have influenced care just as much as actual evidence. If you’ve ever heard “the evidence says…”, this episode might change how you think about that.

This is what FAST sounds like. Real conversations. Real ideas. Live from the room. FAST26 is coming to Austin, Texas this year on May 27-29, 2026. We are co-locating with EMS World Live, giving you 2 HUGE events under 1 roof at the same time! Choose to join one, or the other, or come to both!

👉 Learn more or grab your spot: https://fbefast.com

Enjoy this talk from Eddy Lang! See you in Austin!

Over the next several episodes leading up to FAST26: Austin, we’re bringing you full sessions recorded live from past FAST conferences straight from the session recordings!

This episode features Bruce Hoffman, RN, paramedic, educator, and FlightBridgeED Senior Educator. Bruce is known for pushing beyond the “what” and getting into the why... challenging how we think, how we lead, and how we show up in critical care transport.

If you’ve never experienced FAST, this is a glimpse into what makes it different. It’s not just the content; it’s the people, the conversations, and the environment that stay with you long after the session ends.

FAST26 is coming to Austin this year, co-located with EMS World Live! We're bringing together the FAST experience with a larger EMS community, without losing what makes FAST what it is.

👉 Learn more or grab your spot:
https://fbefast.com

In this episode of the FlightBridgeED OB Critical Care Transport series, Dr. Mike Lauria is joined by maternal-fetal medicine specialist Dr. Liz Gartner to tackle one of the most commonly missed and dangerous metabolic emergencies in pregnancy: diabetic ketoacidosis (DKA). While DKA is familiar to most clinicians, pregnancy dramatically alters its presentation—often masking it behind symptoms that look indistinguishable from “normal” pregnancy complaints like nausea, vomiting, abdominal pain, fatigue, and polyuria.

The conversation breaks down the unique physiology of pregnancy that predisposes patients to DKA at much lower glucose levels than expected. Progressive insulin resistance, hemodilution, increased renal glucose losses, accelerated starvation, and baseline respiratory alkalosis combine to create a perfect storm where euglycemic or near-euglycemic DKA can develop. The result is a high-risk condition that is easy to dismiss unless providers intentionally look for it—especially in patients with type 1 diabetes, type 2 diabetes, or gestational diabetes.

From a transport and critical care perspective, the episode emphasizes early recognition, appropriate lab interpretation, and aggressive maternal resuscitation as the cornerstone of treatment. The hosts clarify that management principles remain largely unchanged from non-pregnant patients—fluids first, electrolytes (especially potassium), then insulin—while highlighting pregnancy-specific lab pitfalls and why delivery is not the treatment for DKA. Ultimately, stabilizing the mother is the most effective way to protect the fetus.

Key takeaways

• DKA can look like normal pregnancy: Nausea, vomiting, fatigue, abdominal pain, and polyuria should not be dismissed in pregnant patients with diabetes.
• Don’t be reassured by a glucose of ~200: Up to 30% of DKA cases in pregnancy are euglycemic.
• Pregnancy changes the labs: Baseline bicarbonate is lower, and a pH around 7.30 may represent severe acidosis.
• Beta-hydroxybutyrate is the gold standard for diagnosing ketosis; urine ketones and anion gap alone can miss cases.
• Fluids and electrolytes come first: Aggressive volume resuscitation and potassium correction are critical before insulin.
• Resuscitate mom to save baby: Delivery is not indicated for DKA alone and may worsen outcomes.
• High fetal risk: While maternal mortality is low, fetal mortality remains significant—making early recognition essential.

In this episode of FlightBridgeED, Dr. Mike Lauria is joined by maternal-fetal medicine specialists Dr. Alex Pfeiffer and Dr. Liz Gartner for a practical, transport-focused deep dive into trauma in pregnancy. With maternal morbidity and mortality rising in the U.S. and more obstetric patients requiring transfer from smaller facilities, the team breaks down what changes when you’re managing trauma with two patients sharing one circulation—and how pregnancy can mask shock until both mom and fetus suddenly decompensate.

They walk through the pregnancy-specific physiology that matters most in the field: increased blood volume and cardiac output, decreased SVR, and why hypotension is a late sign. You’ll hear why “normal blood pressure doesn’t equal normal perfusion,” how to recognize early compensated shock (including subtle mental-status changes and agitation), and the key resuscitation tweaks that make a major difference—especially oxygenation and ventilation targets that are tighter than what you might accept in non-pregnant trauma patients.

The conversation also covers the highest-yield operational pieces for EMS and critical care transport crews: aortocaval compression after ~20 weeks and how to relieve it with left tilt/uterine displacement (even on a backboard), what to do about chest trauma (tube placement one to two interspaces higher), why placental abruption is a clinical diagnosis (and often not seen on imaging), fetal heart tones as a “vital sign,” and how viability changes transport destination decisions. They also address Rh considerations, RhoGAM timing, intimate partner violence screening opportunities during transport, and what crews should understand about perimortem C-section even if it’s not in their scope.

Key takeaways

• Mom first = baby best: Maternal stabilization is fetal resuscitation. Prioritize ABCDs before fetus.
• After 20 weeks: relieve aortocaval compression with 15–30° left tilt, hip bump, or manual uterine displacement—don’t skip this during resuscitation/transport.
• Shock can hide: Pregnant patients may lose ~30–40% blood volume before hypotension—watch trends and early signs like tachycardia and altered/anxious behavior.
• Oxygen/ventilation goals are tighter: Aim SpO₂ ≥ 95%; pregnancy has a lower baseline CO₂—an EtCO₂ around 40 may represent hypoventilation in pregnancy.
• Placental abruption is clinical: Uterine tenderness + contractions + vaginal bleeding = high suspicion, even with “normal” ultrasound/CT.
• Chest tubes go higher: Due to diaphragmatic elevation, place chest tubes 1–2 intercostal spaces higher than usual.
• Think destination + monitoring: Viability (~23–24 weeks) drives need for OB capability and fetal monitoring; minimum observation discussed as ~4 hours post-trauma for viable gestations.
• Rh matters, but perfusion matters more: Use O-negative if available for known Rh-negative patients; don’t withhold lifesaving blood when it’s the only option.
• Transport is a screening opportunity: Consider intimate partner violence and create safe moments to ask when separated from partners.

References – 

·         American Academy of Family Physicians. Trauma in Pregnancy: Assessment, Management, and Prevention. Am Fam Physician. 2014;90(10):717–722.

·         Appelbaum RD, Yorkgitis B, Rosen J, Butts CA, To J, Knight AW, Zhang J, Kirsch JM, Levin JH, Riera KM, Kelley KM, Carter KT, Sawhney JS, Mukherjee K, Metz TD, Fiorentino MN, Cantrell S, Sapp A, Potgieter CJ, Kasotakis G, Como JJ, Freeman J. Trauma in pregnancy: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2025 Aug 1;99(2):298-309.

·         SOGC Clinical Practice Guideline. Guidelines for the Management of a Pregnant Trauma Patient. J Obstet Gynaecol Can. 2015;37(6):553–571.

·         Muench MV et al. Physiologic changes of pregnancy relevant to trauma management. Clin Obstet Gynecol. 2007;50(3):601–610.

·         Larson, Nicholas J. et al.Prehospital Management of the Pregnant Trauma Patient. Air Medical Journal, Volume 44, Issue 4, 236 - 241

·         Mendez-Figueroa, Hector et al. Trauma in pregnancy: an updated systematic review. American Journal of Obstetrics & Gynecology, Volume 209, Issue 1, 1 - 10

·         Jain V et al. Trauma in pregnancy. Clin Obstet Gynecol. 2015;58(3):613–624.

·         Clark SL et al. Amniotic Fluid Embolism: Diagnosis and Management Update. Am J Obstet Gynecol. 2016;215(2):B16–B24.

·         Lipman S, Cohen S, Einav S, Jeejeebhoy F, Mhyre JM, Morrison LJ, Katz V, Tsen LC, Daniels K, Halamek LP, Suresh MS, Arafeh J, Gauthier D, Carvalho JC, Druzin M, Carvalho B, Society for Obstetric Anesthesia and Perinatology The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg. 2014 May;118(5):1003-16. 

·         Strong TH, Lowe RA. Perimortem cesarean section. Am J Emerg Med. 1989 Sep;7(5):489-94.

·         Liggett MR, Amro A, Son M, Schwulst S. Management of the Pregnant Trauma Patient: A Systematic Literature Review. J Surg Res. 2023 May;285:187-196.

·         Greco PS, Day LJ, Pearlman MD. Guidance for Evaluation and Management of Blunt Abdominal Trauma in Pregnancy. Obstet Gynecol. 2019 Dec;134(6):1343-1357.

·         April MD, Long B. Trauma in pregnancy: A narrative review of the current literature. Am J Emerg Med. 2024 Jul;81:53-61.

Episode Description

In this powerful and highly practical episode, Eric Bauer is joined by Dr. Scott Weingart for a deep dive into mechanical ventilation strategy, critical thinking in metabolic acidosis, and the nuanced management of obstructive lung disease. You’ll hear honest, experience-driven insights that challenge outdated protocols and provide a real-world framework for decision-making in high-acuity transport and emergency environments.

Together, Eric and Scott unpack what matters when setting minute ventilation for acidotic patients, when and why to abandon rigid tidal volume formulas, and how to navigate the delicate dance of airway management without causing more harm than good. You’ll also hear an unfiltered discussion about ventilation in DKA, PEEP misconceptions, and how to safely manage the crashing COPD or asthmatic patient when time and tolerance are in short supply.

Key Takeaways

• Minute ventilation must be tailored to context: “one-size-fits-all” protocols often fail in real-world acidotic patients.
• A tidal volume of 8–10 mL/kg is not only SAFE, it’s often necessary in early transport, especially when facing deadly acidosis.
• Not all PEEP is good PEEP! Learn when zero is the right number.
• In obstructive lung patients, the “expiratory phase” isn’t the whole story. Inspiratory flow rate and sedation play crucial roles.
• End-tidal CO₂ readings must be interpreted in a clinical context. Chasing normalization can kill.
• Sometimes the best vent setting… is no vent at all. Preserving spontaneous respiration in compensated DKA may save lives.
• DON'T default to 100% FiO₂. Understand how oxygen strategy influences alveolar recruitment and long-term outcomes.

Listen anywhere you get your podcasts or at flightbridgeed.com. While you're there, explore our award-winning critical care courses, trusted by thousands of providers to prepare for advanced certification exams, or to recertify advanced, national, state, and local certifications and licenses.

In this episode of the FlightBridgeED Podcast, Dr. Mike Lauria welcomes back Dr. Nick George to dissect a topic that’s long overdue for critical discussion: airway management in critical care transport—and whether your background matters.

Does being a paramedic or a nurse predict first-pass success rate? Does prior training or clinical experience truly change how well you manage airways in high-stakes situations?

Drawing from new research involving over 7,800 intubations at a major HEMS program, Dr. George presents data that challenges long-held assumptions and explores the impact of training, experience, and clinical culture on airway outcomes. From the historical roots of EMS to the realities of modern-day prehospital practice, this episode bridges the past, present, and future of one of the most defining and debated skills in critical care.

Whether you're placing tubes daily or just entering the field, this episode delivers real insights for every provider level.

Listen anywhere you stream podcasts, or at FlightBridgeED.com. While you're there, explore our award-winning, trusted courses, specifically designed for critical care professionals like you.

Key Takeaways

• Success in airway management isn't about your credentials—it’s about training, experience, and repetition.
• In a study of 7,812 intubations, there was no statistically significant difference in first-pass or last-pass success between nurses and paramedics.
• A slight initial gap in first-year performance disappears by year three, suggesting a washout effect driven by experience, not title.
• Historical models and current cultures (like “owning the airway”) influence skill allocation, sometimes more than evidence.
• Airway success is more than just getting the tube—metrics like DASH-1A aim to measure outcomes that matter (hypoxia, hypotension), even if imperfect.
• High-quality, consistent training programs—like annual OR intubations and in-situ simulation—are the real equalizers in skill development.
• The origin of airway obsession in EMS traces back to Peter Safar, whose daughter’s death from an asthma attack helped spark the creation of modern paramedicine.

References
George, Nicholas H et al. “Prehospital Endotracheal Intubation Success Rates for Critical Care Nurses Versus Paramedics.” Prehospital emergency care, 1-7. 23 Jan. 2025, doi:10.1080/10903127.2024.2448246

https://pubmed.ncbi.nlm.nih.gov/39786721/

In this episode of the FlightBridgeED Podcast, Dr. Mike Lauria is joined by Dr. Nick George, a retrieval and EMS physician currently practicing full-time in Darwin, Australia. Together, they break down the often-overwhelming topic of aortic emergencies in a way that’s brilliantly simple, practical, and immediately applicable for all providers—whether you’re in the ICU, on the flight line, or working your way up in emergency medicine.

Dr. George introduces a clean mental model—1 tube, 2 major problems, 3 causes—to guide listeners through the classification, diagnosis, and critical transport considerations for aortic dissections and aneurysms. From understanding penetrating ulcers to navigating hypertensive vs hypotensive presentations, this episode dives deep without drowning you in jargon.

We also explore the science behind anti-impulse therapy, challenge long-held dogmas about esmolol vs nicardipine, and reveal eye-opening findings from a two-decade analysis of over 1,000 aortic emergency transports. Whether you’re flying patients to tertiary care, working in rural EDs, or prepping for boards, this episode will sharpen your edge.

Available anywhere you listen to podcasts or at FlightBridgeED.com. While you’re there, explore our highly successful, award-winning courses trusted by critical care providers around the world.

Key Takeaways

• The aorta can be simplified into “1 tube, 2 problems (tearing or weakening), caused by 3 forces: pressure, pulsatility, and geometry.”
• Distinguishing between dissection and aneurysm—and whether it’s hypertensive or hypotensive—can guide safe transport decisions, even if you're not making the diagnosis.
• Dissections may present without pain in up to 30% of cases, underscoring the importance of clinical vigilance and recognizing subtle signs.
• Classic signs (pulse deficits, BP differentials) are often unreliable. Don’t dismiss vague or mismatched symptoms.
• Ultrasound, although not definitive, can provide useful data en route—especially in cases of hypotension or ambiguity.
• Anti-impulse therapy isn't as evidence-backed as we've been taught. Recent studies show nicardipine may be just as effective—and possibly safer—than esmolol.
• Transport crews must be empowered to advocate for patients when findings don’t line up with the presumed diagnosis.

In this powerful and unfiltered episode, Eric Bauer sits down with Dr. Mark Piehl—pediatric ICU physician, trauma resuscitation expert, and inventor of the LifeFlow device—for a deep conversation that will reshape how you think about blood product administration in trauma care. From pediatric hemorrhagic shock to adult penetrating trauma, from urban EMS to rural ground teams, they unpack the most critical emerging concepts in early resuscitation.

You’ll hear eye-opening real-world cases, challenges in implementation, and candid debates about whole blood, plasma vs. PRBCs, and whether saline still has a place. If you’ve ever questioned how fast, how early, or even if we should be administering blood products in the field—this episode is essential listening.

Whether you're just getting into critical care or you're a seasoned physician or flight clinician, there’s something here that will challenge you, inspire you, and push your practice forward.

🎧 Available anywhere you get your podcasts—or right now at flightbridgeed.com. While you're there, explore our award-winning critical care and certification prep courses trusted by over 30,000 providers worldwide.

Contact Mark Piehl at mpiehl@410medical.com

Key Takeaways:

• Early blood product administration in the field dramatically increases survival—especially in penetrating trauma.
• Whole blood may be ideal, but component therapy (plasma + PRBCs) is a powerful and proven alternative—even in urban EMS with short transport times.
• Traumatic arrest is not always the end. With witnessed arrest and early transfusion, survival is possible—even likely in the right cases.
• Shock index is an underused but powerful indicator for when to trigger blood administration, and its value applies to both adults and pediatrics.
• Volume matters, but so does composition: PRBCs deliver oxygen, plasma helps heal vessels—both are needed, and timing is everything.
• Saline isn’t dead—there are valid, lifesaving uses for crystalloids in certain TBI and pediatric cases when blood isn’t available.
• Implementing a blood program builds better clinical teams. It’s not just about saving lives—it sharpens every aspect of your trauma care.

Get ready for a transformative episode of the FlightBridgeED Podcast, where host Eric Bauer teams up with EMS trailblazer Dr. Peter Antevy to dive into the life-saving world of pre-hospital hemorrhage control and blood product administration. Discover how whole blood is reshaping trauma care, doubling survival rates for patients bleeding out from trauma, OB emergencies, or medical crises. Dr. Antevy shares hard-won lessons from Palm Beach County, revealing the vital signs that trigger transfusions, the logistics of launching a blood program, and why resuscitating before intubating is a game-changer. From a child saved on I-95 to a police officer revived after a ricochet wound, these gripping stories bring the science to life. Plus, peek into the future with spray-dried plasma and TBI protocols that could redefine EMS. Whether you’re a seasoned critical care provider or just starting your journey, this episode will ignite your passion for saving lives.

Listen anywhere you enjoy podcasts or at flightbridgeed.com, where you can also explore our award-winning courses to fuel your growth in critical care medicine.

AS PROMISED, HERE IS DR. ANTEVY'S EMAIL ADDRESS IF YOU WANT TO REACH OUT: peter@handtevy.com

Key Takeaways

1. Whole blood administration in pre-hospital trauma care achieves a ~90% 24-hour survival rate for non-arrest patients with massive hemorrhage, using criteria like systolic BP <70, heart rate ≥110, or end-tidal CO2 <25, emphasizing the need for precise patient selection and rapid intervention within 35 minutes of injury.
2. Prioritizing resuscitation over intubation prevents peri-intubation cardiac arrest in hypotensive trauma patients, as shown by a tenfold reduction in intubation rates in New Orleans’ advanced resuscitative care bundle, highlighting the importance of restoring perfusion first.
3. Plasma or packed red blood cells can be effective alternatives when whole blood isn’t available, but providers must manage citrate-induced hypocalcemia (e.g., with calcium chloride) and use tools like the LifeFlow infuser for rapid transfusion.
4. Networking and advocacy are critical for EMS innovation: connecting with resources like San Antonio’s summits or the SPARC Academy can help overcome barriers to implementing blood programs, empowering providers to drive change in their communities.

In this episode of the FlightBridgeED Podcast, Dr. Michael Lauria sits down with Dr. Bryce Taylor—flight physician, trauma educator, and surgical critical care expert—for a deep dive into one of the most visually shocking and physiologically demanding scenarios in transport medicine: the patient with an open abdomen.

From trauma-based damage control laparotomies to the high-stakes management of abdominal compartment syndrome, this episode unpacks the pathophysiology, decision-making, and transport logistics for these fragile patients. Whether you're facing hemostatic chaos, rising pressures, or metabolic unraveling, you'll gain insight into recognizing, stabilizing, and safely transporting these complex cases.

You'll learn not just how to manage the wound—but how to manage the why behind the wound.

Get this episode wherever you listen to podcasts—or listen directly at flightbridgeed.com. While you're there, explore our award-winning, nationally recognized courses in critical care and emergency medicine. No pressure. Just professional growth.

Key Takeaways:

• Surgical damage control isn’t about definitive repair—it's about temporizing a dying patient. Understanding what was done (packing, foams, drains) matters less than knowing why it was done.
• Open abdomens are dramatic but misleading. The real threat is usually hidden: bleeding, inflammatory storms, obstructive shock, or silently rising compartment pressures.
• A vacuum dressing isn't just a dressing—it’s part of the resuscitation strategy. Ensuring it's functioning correctly could mean the difference between success and multi-organ failure.
• Watch the urine output. Sudden drops are a red flag. It’s your non-invasive window into renal perfusion, evolving abdominal pressures, and even early septic deterioration.
• Fluid is a drug. Over-resuscitating these patients doesn’t just cause swelling—it can prevent surgical closure, increase infections, and result in months of additional recovery or death.

What if the biggest mistake you’re making with your COPD vent patients isn’t in what you’re doing—but in how fast you’re doing it?

In this episode, Eric Bauer takes us deep into the nuances of ventilating a COPD patient in acute respiratory failure. Through a complex case breakdown, Eric challenges conventional thinking around rate, tidal volume, and ventilator pressures, offering critical insights into the obstructive approach.

You’ll hear the step-by-step evolution of ventilator management from a real-world interfacility transfer of a hypercapnic, non-compliant COPD patient. Discover why high respiratory rates can be catastrophic, how static compliance and RCexp should influence your strategy, and what “minute ventilation” really means in obstructive physiology.

This is more than a case review—it's a clinical recalibration.

Key Takeaways:

• Ventilator strategy must match the pathophysiology—blindly applying high respiratory rates in COPD can worsen outcomes by truncating inspiratory time and impairing ventilation.
• Minute ventilation is king. Tidal volume and rate must be adjusted not for numbers but to optimize both inspiratory and expiratory phases—especially in patients with increased resistance.
• Understand the math behind I:E ratios. Your ventilator isn’t a magic box—if you don’t understand how to calculate cycle times, you’ll miss what’s happening with your patient.
• Static compliance is dynamic. Don’t trust low numbers blindly—evaluate whether your lung is being adequately filled before calling compliance “low.”
• Auto-PEEP and high-pressure alarms can silently sabotage your tidal volumes if you don't actively adjust them to meet the demands of inspiratory resistance.
• 
  

Join Eric Bauer and Dr. Mike Lauria as they dissect two challenging critical care transport cases centered on managing respiratory failure in obese and morbidly obese patients. Get ready for a deep dive into advanced physiological concepts, practical tips for troubleshooting ventilator settings, and real-world lessons you can apply to patient care right away. From recognizing unique challenges in the obese population to fine-tuning pressures and understanding how to balance protective ventilation with the realities of chest wall resistance, this episode offers clear, expert-level insights delivered in an approachable way.

Key Takeaways

• Appreciating that obesity significantly reduces functional residual capacity, requiring thoughtful increases in ventilatory pressures.
• Using waveform analysis, plateau pressures, and driving pressures to differentiate between obstructive and restrictive components, especially when chronic illnesses overlap with acute processes.
• Strategic positioning such as ramping or partial proning can be employed to recruit lung volume and improve oxygenation.
• Recognizing that some patients will need alarm limits and inspiratory pressures far beyond standard protocols—especially when chest wall resistance is extremely high.
• Incorporating a systematic approach, including incremental changes and close monitoring, rather than relying on one-size-fits-all protocols.
• Leveraging collaborative practice and direct medical oversight to fine-tune treatment in the face of complex physiology.

The FlightBridgeED Podcast has been your go-to resource for critical care, EMS, and emergency medicine education since 2012. Access this episode and the entire library wherever you get your podcasts or by visiting flightbridgeed.com. While you’re there, you can also explore our award-winning courses that have helped countless professionals master advanced practice concepts.

We invite you to explore our full range of podcast shows, where our network of FlightBridgeED creators and contributors deliver dynamic discussions on everything from critical care to cutting-edge EMS topics. You’ll also find unique blogs, training resources, and opportunities to engage in our growing community. And don’t forget to check out our upcoming courses and see what’s happening at FAST this year.

In this episode of the FlightBridgeED Podcast, Dr. Michael Lauria and guest Dr. Alex Pfeiffer, a maternal-fetal medicine (MFM) fellow, delve into the critical and complex topic of Placenta Accreta Spectrum Disorder (PAS). With its rapidly evolving complications, this condition demands acute recognition, careful transport coordination, and multidisciplinary care. Together, they unpack the spectrum’s pathophysiology, risk factors, diagnostic strategies, and advanced management protocols essential for critical care and transport teams. Whether you’re a seasoned provider or new to pre-hospital medicine, this episode provides practical knowledge and actionable insights to elevate your clinical practice.

Catch this episode and more wherever you listen to podcasts or on our website at flightbridgeed.com. While there, explore our award-winning courses and other free content in our Culture section to advance your career and expand your critical care expertise.

Takeaways

• Advanced Insight: The importance of understanding PAS as a spectrum, including the implications of invasive placentation on maternal hemorrhage and the role of multidisciplinary teams in patient outcomes.
• Practical Application: Early recognition of PAS through clinical and diagnostic signs, such as Doppler flow abnormalities, hypervascularity, and placental lakes, to facilitate timely and appropriate interventions.
• Foundational Knowledge: Awareness of risk factors like prior cesarean sections, placenta previa, and uterine surgeries that increase the likelihood of PAS and necessitate careful monitoring.

References
1.             Dunbar N, Cooke M, Diab M, Toy P. Transfusion-related acute lung injury after transfusion of maternal blood: a case-control study. Spine (Phila Pa 1976). Nov 1 2010;35(23):E1322-7. doi:10.1097/BRS.0b013e3181e3dad2

2.             Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. Feb 2011;117(2 Pt 1):331-337. doi:10.1097/AOG.0b013e3182051db2

3.             Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. Bjog. Apr 2009;116(5):648-54. doi:10.1111/j.1471-0528.2008.02037.x

4.             Jauniaux E, Bunce C, Grønbeck L, Langhoff-Roos J. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol. Sep 2019;221(3):208-218. doi:10.1016/j.ajog.2019.01.233

5.             Murphy EL, Kwaan N, Looney MR, et al. Risk factors and outcomes in transfusion-associated circulatory overload. Am J Med. Apr 2013;126(4):357.e29-38. doi:10.1016/j.amjmed.2012.08.019

6.             Pachtman S, Koenig S, Meirowitz N. Detecting Pulmonary Edema in Obstetric Patients Through Point-of-Care Lung Ultrasonography. Obstet Gynecol. Mar 2017;129(3):525-529. doi:10.1097/aog.0000000000001909

7.             Padilla CR, Shamshirsaz A. Critical care in obstetrics. Best Pract Res Clin Anaesthesiol. May 2022;36(1):209-225. doi:10.1016/j.bpa.2022.02.001

8.             Padilla CR, Shamshirsaz AA, Easter SR, et al. Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. Am J Perinatol. Jul 2023;40(9):988-995. doi:10.1055/s-0043-1761638

9.             Panigrahi AK, Yeaton-Massey A, Bakhtary S, et al. A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta. Anesth Analg. Aug 2017;125(2):603-608. doi:10.1213/ane.0000000000002050

10.          Pegu B, Thiagaraju C, Nayak D, Subbaiah M. Placenta accreta spectrum-a catastrophic situation in obstetrics. Obstet Gynecol Sci. May 2021;64(3):239-247. doi:10.5468/ogs.20345

11.          Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. Hematology Am Soc Hematol Educ Program. Nov 30 2018;2018(1):585-594. doi:10.1182/asheducation-2018.1.585

12.          Sawada M, Matsuzaki S, Mimura K, Kumasawa K, Endo M, Kimura T. Successful conservative management of placenta percreta: Investigation by serial magnetic resonance imaging of the clinical course and a literature review. J Obstet Gynaecol Res. Dec 2016;42(12):1858-1863. doi:10.1111/jog.13121

13.          Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E. FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management. Int J Gynaecol Obstet. Mar 2018;140(3):291-298. doi:10.1002/ijgo.12410

14.          Shamshirsaz AA, Fox KA, Erfani H, et al. Coagulopathy in surgical management of placenta accreta spectrum. Eur J Obstet Gynecol Reprod Biol. Jun 2019;237:126-130. doi:10.1016/j.ejogrb.2019.04.026

15.          Silver RM, Barbour KD. Placenta accreta spectrum: accreta, increta, and percreta. Obstet Gynecol Clin North Am. Jun 2015;42(2):381-402. doi:10.1016/j.ogc.2015.01.014

16.          Simonazzi G, Bisulli M, Saccone G, Moro E, Marshall A, Berghella V. Tranexamic acid for preventing postpartum blood loss after cesarean delivery: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand. Jan 2016;95(1):28-37. doi:10.1111/aogs.12798

17.          Tadayon M, Javadifar N, Dastoorpoor M, Shahbazian N. Frequency, Risk Factors, and Pregnancy Outcomes in Cases with Placenta Accreta Spectrum Disorder: A Case-Control Study. J Reprod Infertil. Oct-Dec 2022;23(4):279-287. doi:10.18502/jri.v23i4.10814

18.          Tinari S, Buca D, Cali G, et al. Risk factors, histopathology and diagnostic accuracy in posterior placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound Obstet Gynecol. Jun 2021;57(6):903-909. doi:10.1002/uog.22183

19.          Toy P, Gajic O, Bacchetti P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. Feb 16 2012;119(7):1757-67. doi:10.1182/blood-2011-08-370932

20.          Toy P, Popovsky MA, Abraham E, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. Apr 2005;33(4):721-6. doi:10.1097/01.ccm.0000159849.94750.51

21.          Warshak CR, Ramos GA, Eskander R, et al. Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol. Jan 2010;115(1):65-69. doi:10.1097/AOG.0b013e3181c4f12a

Explore the fascinating world of 12-lead ECG interpretation with a special guest, Reid Gilbert-Vass, PA-C, creator of "ECG Lectures with Reid" on YouTube. Reid discusses his journey from Marine Corps logistics to EMS and ultimately becoming a PA specializing in cardiology. Learn his structured, anatomy-driven approach to ECG interpretation, designed to help clinicians at all levels—from beginners to seasoned critical care professionals—develop a deeper understanding of cardiac physiology and electrophysiology.

Join the FlightBridgeED Podcast: MDCAST host, Michael Lauria, as they discuss Reed's innovative teaching methods, his passion for lifelong learning, and how his work transforms how clinicians approach ECGs. Don’t miss the practical insights and compelling stories that make this episode a must-listen for anyone in pre-hospital, emergency, or critical care medicine.

Listen to the FlightBridgeED Podcast wherever you get your podcasts or at flightbridgeed.com/fbe-podcast. You should also check out ECG Lectures with Reid on YouTube @ECGwithReid. Thank you so much for listening! We couldn't make this podcast with you.

Takeaways

1. Understanding ECGs Through Anatomy
   Reid’s step-by-step anatomical approach to ECG interpretation emphasizes the flow of electricity through the heart, helping clinicians localize issues and correlate findings with physiology.
2. The Importance of Lifelong Learning
   Reid’s journey highlights how continual study and curiosity can lead to advanced clinical insights, inspiring providers to deepen their understanding of medical concepts.
3. Practical Application of ECG Skills
   Reid shares actionable advice from EMS to PA school on applying ECG interpretation skills in high-pressure environments, empowering learners to improve patient care.

In this episode of the FlightBridgeED Podcast, Dr. Michael Lauria dives deep into the art and science of non-invasive positive pressure ventilation (NIPPV), exploring how to optimize CPAP and BiPAP for critically ill patients. Discover advanced techniques to fine-tune ventilator settings, evaluate effectiveness, and reduce mortality and morbidity in COPD, CHF, and other conditions. Learn how to align ventilatory support with patient pathophysiology and understand the tools that predict success or failure in non-invasive ventilation.

Whether you're a seasoned critical care provider or just starting to explore advanced practice concepts, this episode offers valuable insights to elevate your understanding of respiratory management.

Listen anywhere you get your podcasts or directly on our website at flightbridgeed.com/fbe-podcast. While there, explore our award-winning courses and resources designed to empower healthcare professionals.

Takeaways

1. Advanced Insight: Using effective PEEP and pressure support in BiPAP can dramatically reduce breathing work and improve outcomes for COPD and CHF patients.
2. Practical Guidance: Titrating CPAP and BiPAP requires continuous evaluation of patient response and adjusting settings like pressure support, PEEP, rise time, and expiratory trigger.
3. Foundational Knowledge: Understanding when and why to choose non-invasive ventilation based on patient pathophysiology is critical for improving care quality.

References
1.             Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. Ann Transl Med. Sep 2018;6(18):355. doi:10.21037/atm.2018.04.39

2.             Berbenetz N, Wang Y, Brown J, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. Apr 5 2019;4(4):Cd005351. doi:10.1002/14651858.CD005351.pub4

3.             Carrillo A, Lopez A, Carrillo L, et al. Validity of a clinical scale in predicting the failure of non-invasive ventilation in hypoxemic patients. J Crit Care. Dec 2020;60:152-158. doi:10.1016/j.jcrc.2020.08.008

4.             Chong CY, Bustam A, Noor Azhar M, Abdul Latif AK, Ismail R, Poh K. Evaluation of HACOR scale as a predictor of non-invasive ventilation failure in acute cardiogenic pulmonary oedema patients: A prospective observational study. Am J Emerg Med. May 2024;79:19-24. doi:10.1016/j.ajem.2024.01.044

5.             Coleman JM, 3rd, Wolfe LF, Kalhan R. Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. Sep 2019;16(9):1091-1098. doi:10.1513/AnnalsATS.201810-657CME

6.             Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. Dec 2002;28(12):1701-7. doi:10.1007/s00134-002-1478-0

7.             D'Andrea A, Martone F, Liccardo B, et al. Acute and Chronic Effects of Noninvasive Ventilation on Left and Right Myocardial Function in Patients with Obstructive Sleep Apnea Syndrome: A Speckle Tracking Echocardiographic Study. Echocardiography. Aug 2016;33(8):1144-55. doi:10.1111/echo.13225

8.             Duan J, Chen L, Liu X, et al. An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study. Crit Care. Jul 3 2022;26(1):196. doi:10.1186/s13054-022-04060-7

9.             Duan J, Han X, Bai L, Zhou L, Huang S. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med. Feb 2017;43(2):192-199. doi:10.1007/s00134-016-4601-3

10.          Duan J, Yang J, Jiang L, et al. Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure. Ann Intensive Care. Dec 5 2022;12(1):110. doi:10.1186/s13613-022-01085-7

11.          Esnault P, Cardinale M, Hraiech S, et al. High Respiratory Drive and Excessive Respiratory Efforts Predict Relapse of Respiratory Failure in Critically Ill Patients with COVID-19. Am J Respir Crit Care Med. Oct 15 2020;202(8):1173-1178. doi:10.1164/rccm.202005-1582LE

12.          Ferreyro BL, De Jong A, Grieco DL. How to use facemask noninvasive ventilation. Intensive Care Med. May 27 2024;doi:10.1007/s00134-024-07471-y

13.          Giovannini I, Chiarla C, Boldrini G, Terzi R. Quantitative assessment of changes in blood CO2 tension mediated by the Haldane effect. Journal of Applied Physiology. 1999;87(2):862-866. doi:10.1152/jappl.1999.87.2.862

14.          Ho KM, Wong K. A comparison of continuous and bi-level positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Crit Care. 2006;10(2):R49. doi:10.1186/cc4861

15.          Klocke RA. Mechanism and kinetics of the Haldane effect in human erythrocytes. Journal of Applied Physiology. 1973;35(5):673-681. doi:10.1152/jappl.1973.35.5.673

16.          Leatherman J. Mechanical ventilation for severe asthma. Chest. Jun 2015;147(6):1671-1680. doi:10.1378/chest.14-1733

17.          Lenique F, Habis M, Lofaso F, Dubois-Randé JL, Harf A, Brochard L. Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Am J Respir Crit Care Med. Feb 1997;155(2):500-5. doi:10.1164/ajrccm.155.2.9032185

18.          Martin JG, Shore S, Engel LA. Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma. Am Rev Respir Dis. Nov 1982;126(5):812-7. doi:10.1164/arrd.1982.126.5.812

19.          Nava S, Carbone G, DiBattista N, et al. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J Respir Crit Care Med. Dec 15 2003;168(12):1432-7. doi:10.1164/rccm.200211-1270OC

20.          Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Jul 13 2017;7(7):Cd004104. doi:10.1002/14651858.CD004104.pub4

21.          Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet. Apr 8 2006;367(9517):1155-63. doi:10.1016/s0140-6736(06)68506-1

22.          Rittayamai N, Pravarnpat C, Srilam W, Bunyarid S, Chierakul N. Safety and efficacy of noninvasive ventilation for acute respiratory failure in general medical ward: a prospective cohort study. J Thorac...

In this episode of the FlightBridgeED Podcast: MDCAST, we continue our OB Critical Care Series, focusing on airway management in critically ill obstetric patients. Hosted by Dr. Michael Lauria and featuring special guest Dr. Emily McQuaid-Hanson, Director of OB Anesthesia at the University of New Mexico, this episode delivers essential insights into managing one of the most intimidating and dynamic challenges in pre-hospital and critical care transport medicine.

Join us as we discuss modern advancements in airway safety, the physiological challenges of gravid patients, and the critical techniques and tools for managing obstetric airways effectively. Dr. McQuaid-Hanson shares invaluable strategies for pre-oxygenation, intubation, medication selection, and post-intubation care, along with a reminder to approach every airway with preparation and respect—without fear.

Whether new to pre-hospital medicine or a seasoned critical care professional, wherever you are on your journey, this episode offers actionable insights and pearls of wisdom.

Listen to this podcast on your favorite platform or visit flightbridgeed.com/fbe-podcast. While you're there, explore our award-winning courses and check out our website's Culture section, which offers free content like this podcast, blogs, YouTube videos, TikTok creators, and more! Enjoy, and thank you for being part of the FlightBridgeED community!

Takeaways

1. Advanced Insights: Modern airway equipment like video laryngoscopes and better preparation have made obstetric airway management comparable in difficulty to other critical care populations, emphasizing preparation and respect for physiological challenges.
2. Clinical Strategies: Proper positioning, effective pre-oxygenation techniques, and having a well-thought-out plan with appropriate tools are key to successful airway management in obstetric patients.
3. Foundational Knowledge: Awareness of the physiological changes during pregnancy—such as reduced functional residual capacity and increased aspiration risk—helps providers anticipate and mitigate challenges during airway management.

References
1.        Aziz MF, Kim D, Mako J, Hand K, Brambrink AM. A retrospective study of the performance of video laryngoscopy in an obstetric unit. Anesth Analg. 2012 Oct;115(4):904-6.

2.        Ahuja P, Jain D, Bhardwaj N, Jain K, Gainder S, Kang M. Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study. Int J Obstet Anesth. 2018 Feb;33:17-22.

3.        Bryson PC, Abode K, Zdanski CJ. Emergent airway management in the labor and delivery suite. Int J Pediatr Otorhinolaryngol. 2016 Aug;87:83-6.

4.        Šklebar I, Habek D, Berić S, Goranović T. AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS. Acta Clin Croat. 2023 Apr;62(Suppl1):85-90. 

5.        Dongare PA, Nataraj MS. Anaesthetic management of obstetric emergencies. Indian J Anaesth. 2018 Sep;62(9):704-709.

6.        Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia. 2009 Nov;64(11):1168-71.

7.        McKeen DM, George RB, O'Connell CM, Allen VM, Yazer M, Wilson M, Phu TC. Difficult and failed intubation: Incident rates and maternal, obstetrical, and anesthetic predictors. Can J Anaesth. 2011 Jun;58(6):514-24.

8.        Hannig KE, Hauritz RW, Jessen C, Herzog J, Grejs AM, Kristensen MS. Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup. Case Rep Anesthesiol. 2021 Oct 8;2021:6778805.

9.        Preston R, Jee R. Obstetric airway management. Int Anesthesiol Clin. 2014 Spring;52(2):1-28.

10.  Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC; Obstetric Anaesthetists' Association; Difficult Airway Society. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia. 2015 Nov;70(11):1286-306.

11.  Goldszmidt E. Principles and practices of obstetric airway management. Anesthesiol Clin. 2008 Mar;26(1):109-25, vii.

12.  Kurdi MS, Rajagopal V, Sangineni KS, Thalaiappan M, Grewal A, Gupta S. Recent advances in obstetric anaesthesia and critical care. Indian J Anaesth. 2023 Jan;67(1):19-26.

13.  Ende H, Varelmann D. Respiratory Considerations Including Airway and Ventilation Issues in Critical Care Obstetric Patients. Obstet Gynecol Clin North Am. 2016 Dec;43(4):699-708.

14.  Mhyre JM, Healy D. The unanticipated difficult intubation in obstetrics. Anesth Analg. 2011 Mar;112(3):648-52.

15.  Stopar Pintarič T. Videolaryngoscopy as a primary intubation modality in obstetrics: A narrative review of current evidence. Biomol Biomed. 2023 Nov 3;23(6):949-955.

Join Dr. Mike Lauria and guest Dr. Bryce Taylor, an experienced flight physician, as they delve into the complexities of transporting patients with severe gastrointestinal (GI) bleeding. From the nuances of variceal versus non-variceal bleeds to cutting-edge resuscitation strategies and critical airway management, this episode equips providers with the insights they need for optimal care. Discover evidence-based approaches to managing medications, product resuscitation, and the intricacies of using balloon tamponade devices like Minnesota tubes. Whether you're in EMS, critical care, or just stepping into advanced prehospital medicine, this episode has pearls for every provider.

Stream this episode wherever you listen to podcasts, or visit FlightBridgeED.com to explore our award-winning critical care education courses. Your journey to excellence starts here.

TAKEAWAYS

1. Advanced Insight: The pathophysiological understanding of variceal bleeding highlights elevated portal pressures causing venous backflow into superficial veins of the esophagus and stomach, creating high-risk hemorrhage scenarios.
2. Clinical Pearls: Intubating a patient with massive hematemesis requires preparedness for anatomical and physiological challenges. Techniques like SALAD (suction-assisted laryngoscopy) and appropriate suction setups are vital.
3. Foundational Concept: Differentiating upper vs. lower GI bleeds begins with understanding anatomical landmarks like the ligament of Treitz, guiding early diagnosis and management in the field.

In this episode of the FlightBridgeED MDCAST Podcast, Dr. Michael Lauria and Dr. Elizabeth Garchar delve into a vital topic for EMS and critical care: managing preterm labor in transport. They tackle the complexities of diagnosing preterm labor, the nuances of patient risk factors, and the pillars of effective preterm care. Discover how understanding these principles can make a profound difference for both mother and baby, especially when timely, evidence-based intervention is crucial. This is an essential listen for any paramedic, nurse, or medical professional seeking to deepen their knowledge in obstetric critical care and improve their hands-on approach.

Listen on your preferred podcast platform or directly from our website at flightbridgeed.com/fbe-podcast. While you’re there, explore our award-winning courses crafted for your continuing education in critical care and emergency medicine.

Key Takeaways:

1. Recognize the four pillars of preterm labor management: transport to the appropriate facility, antibiotic administration, antenatal steroids, and magnesium for neuroprotection (before 32 weeks).
2. To prevent neonatal complications, maintain close monitoring during transport and prioritize fetal head control in the event of precipitous delivery.
3. Understanding preterm labor risk factors—such as infection, smoking, limited access to care, and history of preterm births—can help guide critical care decisions.
4. Tocolytic options like calcium channel blockers or beta sympathomimetics are helpful for delaying delivery short-term but require careful consideration of contraindications.
5. The preterm infant’s immediate needs at birth include delayed cord clamping and potential neonatal resuscitation, underscoring the importance of being prepared for rapid response.

Join us for another captivating episode of The FlightBridgeED MDCAST as Dr. Michael Lauria explores trauma medicine's most critical and evolving skill: the finger thoracostomy. Featuring special guest Dr. Bryce Taylor, a seasoned emergency physician, and flight medicine fellow currently doing a retrieval medicine fellowship at the University of Wisconsin Med Flight. This episode takes a deep dive into the nuances of trauma-induced tension pneumothorax and the art of rapid chest decompression in the field.

They cover everything from recognizing life-threatening tension physiology to deciding between a needle decompression and a finger thoracostomy and the evolving prehospital protocols that could save lives. Dr. Taylor shares insights on resuscitative ultrasound, operational challenges, and why empirical chest decompression may be the next standard of care for flight and EMS crews. Whether you’re a seasoned critical care provider or new to trauma medicine, this discussion will leave you better equipped to handle the unpredictable.

Available wherever you listen to podcasts or directly on our website, flightbridgeed.com. While there, explore our award-winning courses designed to elevate your critical care knowledge and professional practice.

TAKEAWAYS

• Understanding the difference between tension pneumothorax and regular pneumothorax is crucial in trauma care.
• Ultrasound can be a valuable tool for identifying pneumothorax in trauma patients.
• The choice between needle decompression and finger thoracostomy depends on the clinical scenario and the availability of a sterile environment.
• Proper identification of landmarks is essential for successful finger thoracostomy.
• Chest tube placement may be appropriate in a controlled environment with access to sterile equipment. Finger thoracostomy is a crucial intervention in the pre-hospital setting for trauma patients with chest injuries and hemodynamic compromise.
• Training and education for nurse medics in performing finger thoracostomy are essential for safe and effective implementation.
• The safety and efficacy of finger thoracostomy in the pre-hospital setting make it a valuable skill for managing trauma patients in critical care transport.
• The decision to perform a finger thoracostomy should be guided by the presence of hemodynamic compromise and the need for timely intervention in trauma patients with chest injuries.
• The use of finger thoracostomy as an empiric decompression in polytrauma patients with suspected tension pneumothorax is reasonable and can be performed in parallel with other resuscitative measures.

Welcome to another essential episode of the FlightBridgeED Podcast: MDCAST, where we dive deep into the complexities of critical care and continue our high-risk OB transport conversation. This episode focuses on the often overlooked yet rapidly increasing crisis of hypertensive disorders in pregnancy. Host Dr. Mike Lauria and maternal-fetal medicine specialist Dr. Elizabeth Garchar discuss the full spectrum of hypertensive disorders—from gestational hypertension to the life-threatening condition of eclampsia—and share practical insights on managing these critical patients in prehospital and transport settings.

Starting with foundational definitions of specific disorders like pre-eclampsia vs. eclampsia and HELLP syndrome, they explore the physiological mechanisms driving preeclampsia, the increased mortality rates, and why transport providers are seeing more cases in rural or under-resourced facilities. Learn how to distinguish between different diagnoses, manage acute cases in transit, and navigate treatment protocols with a detailed look at magnesium sulfate's role and the right blood pressure control strategies. This episode brings expert-level insight to providers of all backgrounds, from the basics to the most advanced interventions.

Listen to The FlightBridgeED Podcast anywhere you enjoy podcasts, or find this episode and more podcasts at https://flightbridgeed.com/explore. While there, explore our award-winning courses that empower pre-hospital and critical care transport medicine professionals to build their critical care expertise.

Key Takeaways:

1. Pathophysiology of Preeclampsia: This condition often arises from placental abnormalities that lead to widespread vascular issues, impacting both the mother and fetus.
2. Magnesium Sulfate in Management: Magnesium sulfate is vital for preventing eclampsia and should be monitored for toxicity, especially in patients with reduced kidney function.
3. Identification of Hypertensive Disorders: A blood pressure reading of 160/110 mmHg or greater post-20 weeks' gestation is a significant indicator of hypertensive disorders, warranting immediate medical attention.

References

1. Sperling JD, Dahlke JS, Huber WJ, Sibai BM.  The role of Headache in the classification and management of hypertensive disorders in pregnancy.  Obstetrics and Gynecology. 2015; 126:297-302. 
2. Sabai BM.  The HELLP syndrome (hemolysis, elevated liver enzymes and low platelets): much ado about nothing? Am J of Obstetrics and Gynecology. 1990; 162:311-6.
3. Steegers EA, von Daselszen P, Duvekot JJ, Pijnenborg R.  Pre-Eclampsia.  Lancet. 2010; 376:631-44.
4. Redman CW, Sargent IL.  Latest advances in understanding preeclampsia.  Science. 2005; 308:1592-4
5. von Dadelszen P, Magee LA, Roberts JM. Subclassification of preeclampsia.  Hypertens Pregnancy. 2003; 22:143-8
6. Dekker GA, Sibai BM. Etiology and pathogenesis of preeclampsia: current concepts.  Am J Obstet Gynecol. 1998; 179; 1359-75. 
7. Gillon TE, Pels A, von Dadelszen P, MacDonell K, Magee LA. Hypertensive disorders of pregnancy: a systematic review of international clinical practice guidelines. PloS one. 2014; 9(12): e113715.
8. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260.

In this episode of our series on respiratory critical care called Every Breath They Take, Dr. Lauria is joined by EM/Critical Care and Flight Physician Brittney Bernardoni as they discuss how to grapple with optimizing lung protective ventilation in ARDS.  

Lung protective ventilation at 6 cc/kg and maintaining plateau pressures of less than 30 cmH2O have been the cornerstones of invasive respiratory support since the findings of the ARMA trial in 2000.  In recent years, some interesting new developments have resulted in changes and improvements in lung protective ventilation strategies.  With a particular focus on ventilator "jiu-jitsu," this episode explores the intricate adjustments required to optimize patient care during ARDS management. From ventilator modes and plateau pressure to the impact of PEEP, FiO2, and mechanical power, this episode equips listeners with actionable knowledge for mastering the art of ventilation. Whether in the field or the ICU, the nuanced approaches discussed in this episode will enhance your understanding of optimizing respiratory support in critical patients. 

Listen to the episode wherever you get your podcasts or directly on our website at https://flightbridgeed.com/explore. While you're there, explore our award-winning courses that have helped thousands of providers clarify and understand the world of critical care transport and pre-hospital medicine.

Takeaways
• Early care in managing respiratory failure in the transport environment is crucial and can significantly impact patient outcomes.
• Lung protective ventilation with low tidal volumes is the foundation of ARDS management.
• The choice of ventilation mode (volume control or pressure control) depends on the clinician's comfort and ability to titrate the settings, but neither has proved superior.
• Permissive hypercapnia is generally well-tolerated in ARDS patients if the pH exceeds 7.15-7.20.
• The initial PEEP setting should be at least eight -  several strategies can be used to guide titration.
• High FiO2 levels can be detrimental to ischemic organs, alveolar patency, and the lung tissue itself.  Aiming for a FiO2 of less than or equal to 60% is important.
• Set, check, and change parameters to ensure optimal ventilation!
• Driving pressure may be an important factor in patient outcomes.
• Mean airway pressure and inspiratory time can improve oxygenation and minimize lung damage

References
1. Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol. Jun 2020;73(3):194-204. doi:10.4097/kja.20041
2. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. Feb 19 2015;372(8):747-55. doi:10.1056/NEJMsa1410639
3. Azizi BA, Munoz-Acuna R, Suleiman A, et al. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care. Apr 6 2023;11(1):14. doi:10.1186/s40560-023-00662-7
4. Battaglini D, Fazzini B, Silva PL, et al. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med. Feb 9 2023;12(4)doi:10.3390/jcm12041381
5. Battaglini D, Sottano M, Ball L, Robba C, Rocco PRM, Pelosi P. Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome. J Intensive Med. Jul 2021;1(1):42-51. doi:10.1016/j.jointm.2021.01.003
6. Bellani G, Laffey JG, Pham T, et al. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med. Jan 1 2017;195(1):67-77. doi:10.1164/rccm.201606-1306OC
7. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. Jama. Mar 3 2010;303(9):865-73. doi:10.1001/jama.2010.218
8. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. May 4 2000;342(18):1301-8. doi:10.1056/nejm200005043421801
9. Chacko B, Peter JV, Tharyan P, John G, Jeyaseelan L. Pressure-controlled versus volume-controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev. Jan 14 2015;1(1):Cd008807. doi:10.1002/14651858.CD008807.pub2
10. Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. Aug 15 2008;178(4):346-55. doi:10.1164/rccm.200710-1589OC
11. Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. Sep 2017;70(3):406-418.e4. doi:10.1016/j.annemergmed.2017.01.013
12. Gattinoni L, Collino F, Camporota L. Mechanical power: meaning, uses and limitations. Intensive Care Med. Apr 2023;49(4):465-467. doi:10.1007/s00134-023-06991-3
13. Harvey CE, Haas NL, Chen CM, et al. Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference? Crit Care Explor. Feb 2022;4(2):e0632. doi:10.1097/cce.0000000000000632
14. Laffey JG, Bellani G, Pham T, et al. Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study. Intensive Care Med. Dec 2016;42(12):1865-1876. doi:10.1007/s00134-016-4571-5
15. Maddry JK, Mora AG, Perez CA, et al. Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs). Mil Med. Jan 4 2023;188(1-2):e125-e132. doi:10.1093/milmed/usab474
16. Maddry JK, Mora AG, Savell SC, et al. Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality. J Trauma Acute Care Surg. Jan 2018;84(1):157-164. doi:10.1097/ta.0000000000001607
17. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-33. doi:10.1001/jama.2012.5669
18. Roginski MA, Burney CP, Husson EG, Harper KR, Atchinson PRA, Munson JC. Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care. Air Med J. Jan-Feb 2022;41(1):96-102. doi:10.1016/j.amj.2021.10.005
19. Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study. Respir Care. May 2020;65(5):583-589. doi:10.4187/respcare.07102
20. Yoshida T, Uchiyama A, Fujino Y. The role of spontaneous effort during mechanical ventilation: normal lung versus injured lung. J Intensive Care. 2015;3:18. doi:10.1186/s40560-015-0083-6
21. Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med. Mar 9 2024;13(1):88385. doi:10.5492/wjccm.v13.i1.88385

In this episode of the FlightBridgeED Podcast, part of our "Every Breath They Take" series on respiratory critical care, Dr. Michael Lauria explores whether we truly protect the lungs during mechanical ventilation. While the best evidence suggests keeping tidal volumes at 6 cc/kg and plateau pressures below 30 cm H2O, is that enough? ARDS is a complex lung pathology, and as we unravel its intricacies, there may be more to consider.

Join us as we explore the popular concept of driving pressure and introduce the emerging idea of mechanical power. While plateau pressure remains the gold standard, these additional metrics may provide further guidance for adjusting ventilation strategies and minimizing ventilator-induced lung injury, especially in critical care transport settings. Whether you're new to the field or a seasoned professional, this episode offers valuable insights into advanced respiratory management.

Listen to FlightBridgeED anywhere you get your podcasts, or visit us at flightbridgeed.com/explore. While there, explore our other fantastic, free content and award-winning courses to help you excel in your critical care practice.

TAKEAWAYS

• Mechanical ventilation is a double-edged sword. It can maintain oxygenation and ventilation but can also damage the lungs.
• Lung protective ventilation prevents ventilator-induced lung injury, especially in acute respiratory distress syndrome (ARDS).
• Maintaining a plateau pressure below 30 cmH2O is an essential goal in lung protective ventilation.
• Driving pressure, the difference between plateau pressure and PEEP, is a surrogate for transpulmonary pressure and may be a useful parameter to consider in lung protective ventilation.
• Keeping driving pressure < 15 cmH2O may be beneficial. 
• Driving pressure might be helpful in titrating peep and optimizing lung recruitment, as well as in identifying patients who may benefit from smaller tidal volumes, even if the plateau pressure is below 30.
• Mechanical power, which represents the energy delivered to the lung over time, is a newer concept that requires further research to determine its role in lung protective ventilation.
• Optimizing the ventilatory and inspiratory flow rates (in addition to peep, plateau pressure, and tidal volume) may help reduce mechanical power below 17-22 J/min.

REFERENCES

1. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. Feb 19 2015;372(8):747-55. doi:10.1056/NEJMsa1410639
2. Azizi BA, Munoz-Acuna R, Suleiman A, et al. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care. Apr 6 2023;11(1):14. doi:10.1186/s40560-023-00662-7
3. Battaglini D, Fazzini B, Silva PL, et al. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med. Feb 9 2023;12(4)doi:10.3390/jcm12041381
4. Battaglini D, Sottano M, Ball L, Robba C, Rocco PRM, Pelosi P. Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome. J Intensive Med. Jul 2021;1(1):42-51. doi:10.1016/j.jointm.2021.01.003
5. Bellani G, Laffey JG, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. Jama. Feb 23 2016;315(8):788-800. doi:10.1001/jama.2016.0291
6. Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? Crit Care. Aug 4 2017;21(1):199. doi:10.1186/s13054-017-1779-x
7. Chiumello D, Froio S, Mistraletti G, et al. Gas exchange, specific lung elastance and mechanical power in the early and persistent ARDS. J Crit Care. Feb 2020;55:42-47. doi:10.1016/j.jcrc.2019.09.022
8. Coppola S, Caccioppola A, Froio S, et al. Effect of mechanical power on intensive care mortality in ARDS patients. Crit Care. May 24 2020;24(1):246. doi:10.1186/s13054-020-02963-x
9. Cressoni M, Cadringher P, Chiurazzi C, et al. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. Jan 15 2014;189(2):149-58. doi:10.1164/rccm.201308-1567OC
10. Duan J, Wang S, Liu P, et al. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann Intensive Care. Sep 30 2019;9(1):108. doi:10.1186/s13613-019-0585-9
11. Gattinoni L, Collino F, Camporota L. Mechanical power: meaning, uses and limitations. Intensive Care Med. Apr 2023;49(4):465-467. doi:10.1007/s00134-023-06991-3
12. Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The "baby lung" became an adult. Intensive Care Med. May 2016;42(5):663-673. doi:10.1007/s00134-015-4200-8
13. Gattinoni L, Tonetti T, Quintel M. Regional physiology of ARDS. Crit Care. Dec 28 2017;21(Suppl 3):312. doi:10.1186/s13054-017-1905-9
14. Goligher EC, Dres M, Patel BK, et al. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med. Oct 1 2020;202(7):950-961. doi:10.1164/rccm.202003-0655CP
15. Guérin C, Papazian L, Reignier J, Ayzac L, Loundou A, Forel JM. Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials. Crit Care. Nov 29 2016;20(1):384. doi:10.1186/s13054-016-1556-2
16. Ogbu OC, Martin GS, Murphy DJ. A Few Milliliters of Prevention: Lung-Protective Ventilation Decreases Pulmonary Complications. Crit Care Med. Oct 2015;43(10):2263-4. doi:10.1097/ccm.0000000000001234
17. Paudel R, Trinkle CA, Waters CM, et al. Mechanical Power: A New Concept in Mechanical Ventilation. Am J Med Sci. Dec 2021;362(6):537-545. doi:10.1016/j.amjms.2021.09.004
18. Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study. Respir Care. May 2020;65(5):583-589. doi:10.4187/respcare.07102
19. Serpa Neto A, Deliberato RO, Johnson AEW, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. Nov 2018;44(11):1914-1922. doi:10.1007/s00134-018-5375-6
20. Simonis FD, Binnekade JM, Braber A, et al. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. May 24 2015;16:226. doi:10.1186/s13063-015-0759-1
21. Tongyoo S, Viarasilpa T, Deawtrakulchai P, Subpinyo S, Suppasilp C, Permpikul C. Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial. Ther Adv Respir Dis. Jan-Dec 2024;18:17534666241249152. doi:10.1177/17534666241249152
22. van Meenen DMP, Algera AG, Schuijt MTU, et al. Effect of mechanical power on mortality in invasively ventilated ICU patients without the acute respiratory distress syndrome: An analysis of three randomised clinical trials. Eur J Anaesthesiol. Jan 1 2023;40(1):21-28. doi:10.1097/eja.0000000000001778
23. Wu HP, Chu CM, Chuang LP, et al. The Association between Mechanical Power and Mortality in Patients with Pneumonia Using Pressure-Targeted Ventilation. Diagnostics (Basel). Oct 10 2021;11(10)doi:10.3390/diagnostics11101862
24. Yehya N, Hodgson CL, Amato MBP, et al. Response to Ventilator Adjustments for Predicting Acute Respiratory Distress Syndrome Mortality. Driving Pressure versus Oxygenation. Ann Am Thorac Soc. May 2021;18(5):857-864. doi:10.1513...

In this compelling episode of the FlightBridgeED Podcast, Dr. Michael Lauria delves into one of the most critical yet underappreciated aspects of emergency and critical care medicine: maternal sepsis and septic shock. As maternal mortality rates rise across the U.S., critical care transport providers are increasingly faced with the challenge of managing septic mothers and post-partum patients. Dr. Lauria, alongside special guest  Dr. Elizabeth Garchar, MD, FACOG, an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care, breaks down the latest evidence and best practices for diagnosing and treating septic shock in obstetrical patients.

Explore the pathophysiology of sepsis, the role of cytokine release in organ dysfunction, and the management strategies for ensuring maternal and fetal well-being. Whether you're in pre-hospital care, the ICU, or critical care transport, this episode is packed with insights for all levels of healthcare providers.

Key Takeaways: 

• Early Sepsis Detection & Organ Impact: Sepsis isn't just about blood pressure. Inflammatory cytokines can cause brain dysfunction (septic encephalopathy), kidney damage, and even septic cardiomyopathy. Be vigilant with these patients.
• Unique Obstetric Considerations: Pregnancy causes physiological changes that can mask early sepsis signs. Differentiating between normal pregnancy symptoms and systemic inflammatory response can be challenging but is crucial for survival.
• Aggressive Management is Key: Whether it's antibiotics, fluid resuscitation, or early norepinephrine administration, aggressively managing septic obstetric patients can significantly improve outcomes.
• Antibiotics First, Always: Ensure that septic patients receive broad-spectrum antibiotics within the first hour. It’s a key factor in preventing further deterioration.
• Fluid Responsiveness: Use dynamic assessments to determine fluid responsiveness instead of blindly administering large amounts of fluid.
• Pressors are Safe: Norepinephrine is a safe and recommended first-line vasopressor for septic pregnant patients. Don't hesitate to use it.

Listen anywhere you get your podcasts or directly from our website at flightbridgeed.com. While you’re there, be sure to explore our award-winning courses designed to elevate your critical care expertise.

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References

1. Albright CM, Ali TN, Lopes V, Rouse DJ, Anderson BL. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol. Jul 2014;211(1):39 e1-8. doi:10.1016/j.ajog.2014.03.010

2. Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. Sep 2012;120(3):689-706. doi:10.1097/AOG.0b013e318263a52d

3. Bauer ME, Bateman BT, Bauer ST, Shanks AM, Mhyre JM. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg. Oct 2013;117(4):944-950. doi:10.1213/ANE.0b013e3182a009c3

4. Chau A, Tsen LC. Fetal optimization during maternal sepsis: relevance and response of the obstetric anesthesiologist. Curr Opin Anaesthesiol. Jun 2014;27(3):259-66. doi:10.1097/ACO.0000000000000077

5. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol. Aug 2017;130(2):366-373. doi:10.1097/AOG.0000000000002114

6. Dellinger RP, Rhodes A, Evans L, et al. Surviving Sepsis Campaign. Crit Care Med. Apr 1 2023;51(4):431-444. doi:10.1097/CCM.0000000000005804

7. Evans L, Rhodes A, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. Nov 1 2021;49(11):1974-1982. doi:10.1097/CCM.0000000000005357

8. Fan S-R, Liu P, Yan S-M, Huang L, Liu X-P. New Concept and Management for Sepsis in Pregnancy and the Puerperium. Maternal-Fetal Medicine. 2020;2(4):231-239. doi:10.1097/fm9.0000000000000058

9. Guarino M, Perna B, Cesaro AE, et al. 2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department. J Clin Med. Apr 28 2023;12(9)doi:10.3390/jcm12093188

10. Guinn DA, Abel DE, Tomlinson MW. Early goal directed therapy for sepsis during pregnancy. Obstet Gynecol Clin North Am. Sep 2007;34(3):459-79, xi. doi:10.1016/j.ogc.2007.06.009

11. Joseph J, Sinha A, Paech M, Walters BN. Sepsis in pregnancy and early goal-directed therapy. Obstet Med. Sep 2009;2(3):93-9. doi:10.1258/om.2009.090024

12. Knowles SJ, O'Sullivan NP, Meenan AM, Hanniffy R, Robson M. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG. Apr 2015;122(5):663-71. doi:10.1111/1471-0528.12892

13. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. Jun 2006;34(6):1589-96. doi:10.1097/01.CCM.0000217961.75225.E9

14. Oud L, Watkins P. Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study. J Clin Med Res. Jun 2015;7(6):400-16. doi:10.14740/jocmr2118w

15. Plante LA. Management of Sepsis and Septic Shock for the Obstetrician-Gynecologist. Obstet Gynecol Clin North Am. Dec 2016;43(4):659-678. doi:10.1016/j.ogc.2016.07.010

16. Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol. Apr 2019;220(4):B2-b10. doi:10.1016/j.ajog.2019.01.216

17. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. May 21 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162

18. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. Jun 2014;2(6):e323-33. doi:10.1016/S2214-109X(14)70227-X

19. Shields A, de Assis V, Halscott T. Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis. Obstet Gynecol. Aug 1 2021;138(2):289-304. doi:10.1097/aog.0000000000004471

20. Snyder CC, Barton JR, Habli M, Sibai BM. Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes. J Matern Fetal Neonatal Med. Mar 2013;26(5):503-6. doi:10.3109/14767058.2012.739221

21. Timezguid N, Das V, Hamdi A, et al. Maternal sepsis during pregnancy or the postpartum period requiring intensive care admission. Int J Obstet Anesth. Jan 2012;21(1):51-5. doi:10.1016/j.ijoa.2011.10.009

22. van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. Jun 2010;23(3):249-54. doi:10.1097/QCO.0b013e328339257c

23. Wang T, Liao L, Tang X, Li B, Huang S. Effects of different vasopressors on the contraction of the superior mesenteric artery and uterine artery in rats during late pregnancy. BMC Anesthesiol. Jun 30 2021;21(1):185. doi:10.1186/s12871-021-01395-6

24. Xu S, Shen X, Liu S, Yang J, Wang X. Efficacy and safety of norepinephrine versus phenylephrine for the management of maternal hypotension during cesarean delivery with spinal anesthesia: A systematic review and m...

In this episode of the FlightBridgeED Podcast: MDCAST, Dr. Michael Lauria is joined by Dr. Elizabeth Garchar, MD, FACOG, an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care and is unique in that she flies regularly with our
critical care transport teams as a retrieval OBGYN/MFM. They are also joined by Dr. Alixandria Pfeiffer, an MFM Fellow at the University of Texas in San Antonio. Together, they dive into the complex and underexplored world of obstetric critical care transport. With maternal mortality rates on the rise in the U.S., this episode addresses the vital role critical care transport teams play in improving outcomes for high-risk pregnancies.

The discussion focuses on monitoring pregnant patients during transport, exploring topics such as flight physiology, continuous fetal monitoring (CFM), and the challenges posed by different transport environments. Dr. Pfeiffer shares her groundbreaking research on the feasibility of fetal monitoring during transport and its potential impact on both maternal and fetal outcomes.

Key Takeaways:

• In obstetric transport, continuous fetal monitoring (CFM) is feasible and can provide critical insights during maternal transport, though it poses unique challenges depending on transport type (flight, ground).
• Flight transport often results in a slight decrease in maternal oxygen saturation and systolic blood pressure, suggesting the need for standardized oxygen therapy protocols during transport.
• Understanding fetal physiology and monitoring techniques is essential, especially in high-risk pregnancy transports where the health of both mother and baby is at stake.

Whether you're a seasoned critical care provider or just beginning your journey in EMS or critical care transport medicine, this episode delivers insights into the practical realities of OB transport.

Listen now on any podcast platform or directly from our website at flightbridgeed.com. While you're there, explore our highly successful and award-winning courses, designed to elevate your career in critical care medicine. Thank you so much for listening! We couldn't make this podcast without you.

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References

1. Pfeiffer AF, Munter BT, Munoz J, Ramsey PS, Byrne JJ. Maternal Physiologic Adaptations During Transport. Am J Obstet Gynecol. 2023; 228(1): S259-S260.
2. Pfeiffer AF, Munoz JL, Neuhoff BK, Boyd AR, Moreno A, Ramsey PS. Fetal Cardiotocographic Monitoring During Maternal Transport. Am J Obstet Gynecol. 2022; 226(1): S609.
3. Foley MR, Strong, Jr TH, Garite TJ. eds. Obstetric Intensive Care Manual, 5e. McGraw Hill; . Accessed May 24, 2022. https://obgyn.mhmedical.com/content.aspx?bookid=2379&sectionid=185956675

H.R.315 - Improving Access to Maternity Care Act, (2018). Available at: https://www.congress.gov/bill/115th-congress/house-bill/315.

In Episode 264 of the FlightBridgeED Podcast: MDCAST, Dr. Mike Lauria, Dr. Jeff Jarvis, and trauma anesthesiologist Dr. Chris Stevens return for Part 2 of their deep dive into airway management in profoundly hemodynamically unstable patients. In this episode, the trio explores controversial topics such as the use of pressors in trauma patients, mechanical ventilation in the pre-hospital setting, and the pharmacology of paralytic agents like rocuronium. They also address the highly debated practice of withholding sedatives in certain critically ill patients and emphasize the importance of proper timing when using neuromuscular blockade. This episode provides practical insights for new and seasoned pre-hospital and critical care transport medicine providers, especially when managing CRASH airways and peri-arrest situations.

Some Takeaways to Listen For in this Episode:

• Pressors in Trauma Patients: Dispels the myth that trauma patients shouldn’t receive pressors. Pressors can temporarily stabilize blood pressure while awaiting blood products or other resuscitation efforts.
• Mechanical Ventilation Post-Intubation: Highlights the importance of gentle, positive-pressure ventilation to avoid worsening hypotension in trauma patients.
• Rocuronium Use: This episode discusses optimal dosing and the importance of waiting the full 60–90 seconds for the drug to take effect to ensure successful intubation.
• Withholding Sedation: Explores the controversial practice of omitting sedatives in patients with a GCS of 3 who are completely unresponsive and peri-arrest. This is common in trauma anesthesia but remains debated in pre-hospital and critical care transport settings.

In this thought-provoking episode of the FlightBridgeED Podcast: MDCAST, Dr. Mike Lauria is joined by Dr. Jeff Jarvis and Dr. Chris Stevens to tackle the critical and potentially controversial topic of airway management in hemodynamically unstable patients. The discussion dives into complex scenarios, decision-making challenges, and balancing the benefits of sedation with the risks of compromising a patient’s stability. From discussing medication-assisted intubation to exploring the concept of "crash airway" situations, the episode challenges conventional wisdom and encourages providers to think critically about their approach to airway management. This episode not only raises important questions but also provides valuable insights for both new and seasoned practitioners.

Some Takeaways to Listen For in this Episode:

• Balance Between Sedation and Hemodynamic Stability: It is important to understand how sedative agents like ketamine and etomidate affect blood pressure in critically ill patients. Over-sedation, especially in hemodynamically unstable patients, can lead to adverse outcomes. A nuanced approach to dosing is necessary.
• Awareness During Intubation: Awareness under paralysis can increase the risk of PTSD and depression. The conversation highlights the importance of avoiding awareness during airway management, especially using longer-lasting paralytics like rocuronium.
• Resuscitate Before Intubate: Emphasizes the need to stabilize patients, particularly their hemodynamics, before intubation. This can prevent worsening outcomes and cardiac arrest during emergency airway procedures.
• Decision-Making in Airway Management: Highlights that airway decisions are not black and white. Situational awareness, clinical judgment, and crew confidence are crucial, especially in determining whether to intubate pre-hospital or manage the airway in transit.
• Use of Supraglottic Airways: In emergencies where intubation is difficult or risky, supraglottic airways are recommended as a temporary measure to ensure oxygenation and ventilation until more definitive care is available.

In this engaging and insightful episode of the FlightBridgeED Podcast, Eric Bauer is joined by Dr. Michael Lauria as they delve into the intricacies of post-intubation care and the critical factors that impact patient outcomes during the first 10 minutes after intubation. Building on the well-established concepts of airway management and resuscitation, the discussion introduces the new acronym PHACTORS, which stands for Positive Pressure, Hypoxia, Acidemia, Cardiac Output, Transfer, Ongoing Pharmacology, Resuscitation, and Suction. Eric and Dr. Lauria explore how these elements play a pivotal role in the success or failure of post-intubation management, emphasizing the importance of maintaining vigilance during this critical phase. With practical tips, evidence-based insights, and real-world examples, this episode is a must-listen for anyone involved in pre-hospital critical care.

KEY TAKEAWAYS:

1. Prioritize Post-Intubation Monitoring: The first 10 minutes after intubation are critical. Continuously monitor for hypotension and hypoxia, even if the initial intubation appears successful.
2. Transition to Ventilator Early: Whenever possible, transition intubated patients from BVM to a mechanical ventilator as soon as possible to ensure consistent and controlled ventilation, which reduces the risk of over- or under-ventilation.
3. Use Head-Elevated Positioning: Intubate patients in a head-elevated position (30 degrees) whenever possible to maintain functional residual capacity and reduce the risk of derecruitment and hypoxia.
4. Suction Regularly: Proactively suction the ET tube and oral cavity to maintain airway patency. This helps prevent complications like ventilator-associated pneumonia and ensures optimal oxygenation.
5. Be Ready with Push-Dose Pressors: Have push-dose pressors ready during and after intubation, especially in trauma patients or those with borderline hemodynamics, to quickly address any sudden drops in blood pressure.
6. Assess and Manage Acidosis Individually: Not all acidosis requires aggressive ventilation. Consider the patient's overall condition, and tailor your ventilation strategy based on the specific type and cause of acidosis.
7. Regular Sedation and Analgesia Dosing: Avoid under-sedation, particularly with long-acting paralytics like rocuronium. Set regular intervals for administering sedation and analgesia to ensure patient comfort and avoid awareness of paralysis.
8. Proactively Manage Cardiac Output: In patients with compromised cardiac function, focus on optimizing preload, afterload, and contractility. Use fluids, inotropes, and vasopressors as needed to maintain stable hemodynamics.
9. Secure and Streamline Lines for Transport: Before transferring a patient, ensure all lines are secured and organized to prevent dislodgement or kinking during movement. Keep access points readily available for quick medication administration.
10. Understand the Impact of Positive Pressure: Transitioning from spontaneous breathing to mechanical ventilation can significantly impact venous return and cardiac output. Be prepared to manage these changes, especially in hemodynamically unstable patients.

Show Notes...

• A human, even when paying attention can deliver injurious tidal volume breaths that may go in "easy" but are probably injuring the lungs (Dafilou B, Schwester D, Ruhl N, Marques-Baptista A. It's in the bag: tidal volumes in adult and pediatric bag valve masks. West J Emerg Med. 2020;21(3):722–2021.)
• Not only are the volumes too big, but we likely WAY over breath for patients and that can be really, really bad especially after cardiac arrest or in TBI (common reasons patients get intubated...right?) (Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010;27(7):1233–41.)
• More issues with BVM ventilation that shows it's not consistent
• Siegler J, Kroll M, Wojcik S, Moy HP. Can EMS providers provide appropriate tidal volumes in a simulated adult-sized patient with a pediatric-sized bag-valve-mask? Prehosp Emerg Care. 2017;21(1):74–8.
• Turki M, Young MP, Wagers SS, Bates JH. Peak pressures during manual ventilation. Respir Care. 2005;50(3):340–4.
• Kroll M, Das J, Siegler J. Can altering grip technique and bag size optimize volume delivered with bag-valve-mask by emergency medical service providers? Prehosp Emerg Care. 2019;23(2):210–4.
• Mechanical ventilation provides more consistency and automation of a simple task with monitoring parameters (alarms) that can make it safe and effective for paramedics to actually put their brain energy to important clinical decisions and complete other tasks (Weiss SJ, Ernst AA, Jones R, Ong M, Filbrun T, Augustin C, Barnum M, Nick TG. Automatic transport ventilator versus bag valve in the EMS setting: a prospective, randomized trial. South Med J. 2005;98(10):970–6.)
• Starting mechanical ventilation and safe ventilator settings in the prehospital setting seems to make ED providers more likley to put in the right settings and continue appropriate lung protective ventilation...at least in ARDS (Stephens RJ, Siegler JE, Fuller BM. Mechanical ventilation in the prehospital and emergency department environment. Respir Care. 2019;64 (5):595–603.)
• Here's a really solid position paper from NAEMSP on it that kind of summarizes everything including the specific clinical times when it may be more helpful like cardiac arrest, trauma, etc (Baez, A. A., Qasim, Z., Wilcox, S., Weir, W. B., Loeffler, P., Golden, B. M., … Levy, M. (2022). Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(sup1), 88–95. https://doi.org/10.1080/10903127.2021.1994676)

PART 2 of 2

In this episode, Dr. Michael Lauria is joined by several EM/Critical Care and Transport/Retrieval physicians as we discuss the management of acute respiratory distress syndrome (ARDS) in the critical care transport setting. We cover the pathophysiology of ARDS, the criteria for diagnosis, and the basics of lung protective ventilation. We also explore the concept of driving pressure and its role in determining optimal ventilation settings. The conversation highlights the importance of individualizing treatment based on patient characteristics and monitoring parameters such as plateau pressure, driving pressure, and compliance. 

Our team provides practical tips for adjusting ventilation settings and emphasizes the need for ongoing assessment and optimization. In the previous episode, we started out with some fundamental concepts of mechanical ventilation: the approach to low tidal volumes in ARDS patients and the use of point-of-care blood gases. We also explored the use of steroids in ARDS, the target oxygen saturation levels, and the use of paralysis in unstable patients. In addition, we touched on controversial topics such as inhaled pulmonary vasodilators in ARDS as well as the application of evidenced-based therapies such as proning in the transport environment (in this episode, part 2). Also, in this part of the conversation, we review the use of alternative ventilator modes, such as APRV, and the indications for ECMO in refractory ARDS. We emphasize the importance of optimizing conventional, evidence-based therapies before considering ECMO and highlight the need for clear guidelines and training when using these advanced interventions. We also discuss the challenges and potential complications associated with ECMO. 

Takeaways

• ARDS is a syndrome characterized by acute onset, bilateral infiltrates on imaging, and hypoxemia.
• The diagnosis of ARDS is based on criteria such as acute onset, infectious or inflammatory etiology, bilateral opacities on imaging, and impaired oxygenation.
• Lung protective ventilation aims to minimize lung injury by using low tidal volumes (6-8 ml/kg), maintaining plateau pressures below 30 cmH2O, and keeping FiO2 below 60%.
• Driving pressure, the difference between plateau pressure and PEEP, is a marker of lung compliance and can be used to guide ventilation adjustments.
• Individualized management is crucial, considering factors such as patient characteristics, response to therapy, and monitoring parameters.
• Regular assessment and optimization of ventilation settings are necessary to ensure effective and safe management of ARDS. 
• Low tidal volumes should be based on the patient's pH and PCO2, with a focus on maintaining a safe pH level.  If crews are unable to measure these parameters not decreasing tidal volumes lower than 4 cc/kg is reasonable.
• Point-of-care blood gases are essential for monitoring patients on low tidal volumes and making adjustments as needed.
• Oxygen saturation targets should be individualized based on the patient's condition and physiology, with a range above 88-92% often considered reasonable. However, this issue is controversial, and occasionally, lower saturations are considered acceptable.
• Steroids may be beneficial in ARDS patients, especially those with severe pneumonia, but the timing and dosing should be determined based on the patient's specific situation.
• Paralysis can be considered in unstable ARDS patients who cannot tolerate low tidal volumes, but it should be used selectively and in conjunction with deep sedation.
• The use of inhaled pulmonary vasodilators in ARDS is controversial, and no significant mortality benefit has been demonstrated. However, they may be considered a salvage therapy in patients on their way to an ECMO center or when other interventions have been exhausted. Inhaled pulmonary vasodilators, such as epoprostenol, can improve oxygenation and pulmonary arterial pressure in patients with ARDS and RV failure.
• The use of inhaled pulmonary vasodilators should be based on individual patient characteristics and the availability of resources.
• Proning in transport has been shown to be safe and effective.  It should be considered for select cases, such as patients with high pulmonary arterial pressure or basilar atelectasis.
• Transport teams should be prepared to continue inhaled pulmonary vasodilator therapy if the patient is already receiving it.
• ECMO should be considered when conventional therapies have failed, and the patient's condition is reversible and not contraindicated.
• ECMO transport requires specialized training, clear guidelines, and ongoing communication with the receiving center.
• Alternative ventilator modes, such as APRV, have not shown significant benefit in large trials.  Their use is controversial but not unreasonable in certain circumstances.  Implementing these settings requires training, education, and clear protocols.  Generally speaking, they should be used judiciously and in consultation with the receiving physician.
• Optimizing conventional therapies and providing high-quality care can often obviate the need for ECMO.
• Transport teams should be proactive in discussing potential ECMO candidates with the receiving physician and considering the appropriateness of ECMO for each patient.

References:

1. Abou-Arab O, Huette P, Debouvries F, Dupont H, Jounieaux V, Mahjoub Y. Inhaled nitric oxide for critically ill Covid-19 patients: a prospective study. Crit Care. Nov 12 2020;24(1):645. doi:10.1186/s13054-020-03371-x
2. Gattinoni L, Camporota L, Marini JJ. Prone Position and COVID-19: Mechanisms and Effects. Crit Care Med. May 1 2022;50(5):873-875. doi:10.1097/ccm.0000000000005486
3. Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. Jul 2023;49(7):727-759. doi:10.1007/s00134-023-07050-7
4. Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. Dec 22 2005;353(25):2683-95. doi:10.1056/NEJMra051884
5. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. Jun 6 2013;368(23):2159-68. doi:10.1056/NEJMoa1214103
6. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-33. doi:10.1001/jama.2012.5669
7. Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801.
8. Grasselli G, Calfee CS, Camporota L, et al; European Society of Intensive Care Medicine Taskforce on ARDS. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023 Jul;49(7):727-759. doi: 10.1007/s00134-023-07050-7.
9. Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024 Jan 1;209(1):24-36. doi: 10.1164/rccm.202311-2011ST.

This is a must-listen! What’s the best way to pre-oxygenate our patients prior to intubation? The evidence for this question has been mixed for some time. Dr Jarvis discusses the PREOXI Trial, which directly compares preoxygenation with non-invasive ventilation compared to a face mask to see which provides the best protection against peri-intubation hypoxia. This is an important trial that sheds light on a key component of our bundle of care to make intubation safer.

Citations:

1. Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, et al.: Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. (2024)
2. Jarvis JL, Gonzales J, Johns D, Sager L: Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Annals of Emergency Medicine. 2018;72:272–9.
3. Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.
4. Groombridge C, et al: Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med. 2016;March;23(3):342–6.
5. Baillard C, et al: Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;July 15;174(2):171–7.
6. Ramkumar V, et al: Preoxygenation with 20-degree head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011;25:189–94.
7. Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006
8. Solis A, Baillard C: Effectiveness of preoxygenation using the head-up position and noninvasive ventilation to reduce hypoxaemia during intubation. Ann Fr Anesth Reanim. 2008;June;27(6):490–4.
9. April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, et al.: Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;May;162:403–11.
10. Trent SA, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gibbs KW, Ghamande S, Hughes CG, et al.: Defining Successful Intubation on the First Attempt
11. Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.
12. Pavlov I, Medrano S, Weingart S: Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. AJEM. 2017;35(8):1184–9.

PART 1 of 2

In this episode, Dr. Michael Lauria is joined by several EM/Critical Care and Transport/Retrieval physicians as we discuss the management of acute respiratory distress syndrome (ARDS) in the critical care transport setting. We cover the pathophysiology of ARDS, the criteria for diagnosis, and the basics of lung protective ventilation. We also explore the concept of driving pressure and its role in determining optimal ventilation settings. The conversation highlights the importance of individualizing treatment based on patient characteristics and monitoring parameters such as plateau pressure, driving pressure, and compliance. 

Our team provides practical tips for adjusting ventilation settings and emphasizes the need for ongoing assessment and optimization. We start out with some fundamental concepts of mechanical ventilation: the approach to low tidal volumes in ARDS patients and the use of point-of-care blood gases. We also explore the use of steroids in ARDS, the target oxygen saturation levels, and the use of paralysis in unstable patients. In addition, we touch on controversial topics such as inhaled pulmonary vasodilators in ARDS as well as the application of evidenced-based therapies such as proning in the transport environment (part 2). In the final part of the conversation, we review the use of alternative ventilator modes, such as APRV, and the indications for ECMO in refractory ARDS. We emphasize the importance of optimizing conventional, evidence-based therapies before considering ECMO and highlight the need for clear guidelines and training when using these advanced interventions. We also discuss the challenges and potential complications associated with ECMO. 

Takeaways

• ARDS is a syndrome characterized by acute onset, bilateral infiltrates on imaging, and hypoxemia.
• The diagnosis of ARDS is based on criteria such as acute onset, infectious or inflammatory etiology, bilateral opacities on imaging, and impaired oxygenation.
• Lung protective ventilation aims to minimize lung injury by using low tidal volumes (6-8 ml/kg), maintaining plateau pressures below 30 cmH2O, and keeping FiO2 below 60%.
• Driving pressure, the difference between plateau pressure and PEEP, is a marker of lung compliance and can be used to guide ventilation adjustments.
• Individualized management is crucial, considering factors such as patient characteristics, response to therapy, and monitoring parameters.
• Regular assessment and optimization of ventilation settings are necessary to ensure effective and safe management of ARDS. 
• Low tidal volumes should be based on the patient's pH and PCO2, with a focus on maintaining a safe pH level.  If crews are unable to measure these parameters not decreasing tidal volumes lower than 4 cc/kg is reasonable.
• Point-of-care blood gases are essential for monitoring patients on low tidal volumes and making adjustments as needed.
• Oxygen saturation targets should be individualized based on the patient's condition and physiology, with a range above 88-92% often considered reasonable. However, this issue is controversial, and occasionally, lower saturations are considered acceptable.
• Steroids may be beneficial in ARDS patients, especially those with severe pneumonia, but the timing and dosing should be determined based on the patient's specific situation.
• Paralysis can be considered in unstable ARDS patients who cannot tolerate low tidal volumes, but it should be used selectively and in conjunction with deep sedation.
• The use of inhaled pulmonary vasodilators in ARDS is controversial, and no significant mortality benefit has been demonstrated. However, they may be considered a salvage therapy in patients on their way to an ECMO center or when other interventions have been exhausted. Inhaled pulmonary vasodilators, such as epoprostenol, can improve oxygenation and pulmonary arterial pressure in patients with ARDS and RV failure.
• The use of inhaled pulmonary vasodilators should be based on individual patient characteristics and the availability of resources.
• Proning in transport has been shown to be safe and effective.  It should be considered for select cases, such as patients with high pulmonary arterial pressure or basilar atelectasis.
• Transport teams should be prepared to continue inhaled pulmonary vasodilator therapy if the patient is already receiving it.
• ECMO should be considered when conventional therapies have failed, and the patient's condition is reversible and not contraindicated.
• ECMO transport requires specialized training, clear guidelines, and ongoing communication with the receiving center.
• Alternative ventilator modes, such as APRV, have not shown significant benefit in large trials.  Their use is controversial but not unreasonable in certain circumstances.  Implementing these settings requires training, education, and clear protocols.  Generally speaking, they should be used judiciously and in consultation with the receiving physician.
• Optimizing conventional therapies and providing high-quality care can often obviate the need for ECMO.
• Transport teams should be proactive in discussing potential ECMO candidates with the receiving physician and considering the appropriateness of ECMO for each patient.

References:

1. Abou-Arab O, Huette P, Debouvries F, Dupont H, Jounieaux V, Mahjoub Y. Inhaled nitric oxide for critically ill Covid-19 patients: a prospective study. Crit Care. Nov 12 2020;24(1):645. doi:10.1186/s13054-020-03371-x
2. Gattinoni L, Camporota L, Marini JJ. Prone Position and COVID-19: Mechanisms and Effects. Crit Care Med. May 1 2022;50(5):873-875. doi:10.1097/ccm.0000000000005486
3. Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. Jul 2023;49(7):727-759. doi:10.1007/s00134-023-07050-7
4. Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. Dec 22 2005;353(25):2683-95. doi:10.1056/NEJMra051884
5. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. Jun 6 2013;368(23):2159-68. doi:10.1056/NEJMoa1214103
6. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-33. doi:10.1001/jama.2012.5669
7. Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801.
8. Grasselli G, Calfee CS, Camporota L, et al; European Society of Intensive Care Medicine Taskforce on ARDS. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023 Jul;49(7):727-759. doi: 10.1007/s00134-023-07050-7.
9. Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024 Jan 1;209(1):24-36. doi: 10.1164/rccm.202311-2011ST.
10. Matthay MA, Arabi Y, Arroliga AC, Bernard...

In this episode of the FlightBridgeED MDCast, Dr. Mike Lauria and Dr. Brittney Bernardoni discuss the management of refractory hypotension in septic patients. They explore the use of norepinephrine as the initial pressor of choice and the benefits of vasopressin as a second-line agent. They also discuss the use of inotropes, such as epinephrine and dobutamine, and the importance of assessing cardiac function with ultrasound. The conversation provides practical guidance for managing hypotensive septic patients in various clinical settings. In this conversation, the hosts discuss the use of different therapies for refractory shock and sepsis. They cover topics such as pressors, fluid resuscitation, steroids, bicarbonate, calcium, and all levels of therapies. Mike and Britteny provide insight into the evidence-based use of these therapies and offer practical tips for their administration in the hospital and in the critical care transport medicine field. Overall, the conversation provides a comprehensive overview of refractory shock and sepsis management.

Key Takeaways to Pay Attention to During This Discussion

• Mean arterial pressure (MAP) is the best number to assess hypotension, with a goal of MAP > 65.
• Norepinephrine is the workhorse pressor for septic patients, providing both venous and arterial constriction.
• Vasopressin is a valuable second-line agent, especially for patients with right heart dysfunction or acidosis.
• There is no maximum dose for norepinephrine, but doses above 2.0 mcg/kg/min may not provide additional benefit.
• Ultrasound assessment of cardiac function is crucial in determining the need for inotropes.
• Epinephrine is the preferred inotrope due to its increased squeeze and peripheral vasoconstriction.
• Dobutamine is not commonly used in vasoplegic shock due to its peripheral vasodilation effects. Pressors such as norepinephrine are the first-line therapy for refractory shock and sepsis.
• Steroids, specifically hydrocortisone, can be considered in patients on norepinephrine more than 0.25.
• Bicarbonate can be used to increase pH, but caution must be taken to ensure proper ventilation.
• Calcium chloride or calcium gluconate can be used to address low calcium levels.
• In refractory cases, level three therapies, such as angiotensin 2, methylene blue, and cyanocid, may be considered.

As night falls, a critical medical battle against Diabetic Ketoacidosis (DKA) begins. This formidable foe, hidden within the body's chemistry, pushes patients towards peril. In this thrilling installment of the FlightBridgeED Nightmare Series, EMS providers face a relentless race against time, striving to subdue the devastating effects of DKA before it's too late.

Host Eric Bauer and Jean-Francois Couture, Emergency Physician and Director of Operations at Applications MD, guide us through the intricacies of managing this complex medical emergency. With every passing moment, the tension escalates. Will our EMS warriors decode the mysteries of DKA in time to save their patient? Tune in to discover if they can deliver salvation from the brink of metabolic disaster.

In this final episode of The FAST Archives miniseries, we're thrilled to present a talk from Chris Meeks. Chris is not just any paramedic and educator; he's a veteran with a knack for making complex medical topics approachable. Today, he's breaking down "Oxygenation Assassin," a deep dive into the world of hypoplastic left heart syndrome—a challenging congenital heart defect.

Chris will walk us through the hemodynamic hurdles of the condition and share essential tips for acute care management. You'll get a solid grasp of the underlying physiology and see how learning about conditions like this - the "small percentage" cases - can drastically improve patient outcomes.

If you enjoy this episode, we invite you to check out the other talks from the FAST Archives miniseries. You can also catch these speakers and more at FAST24 happening June 10 - 12, 2024, in Wilmington, North Carolina. Tickets are still available at FBEFAST.COM. Enjoy the episode and we hope to see you at FAST24.

In this episode of The FAST Archives, we explore a unique challenge in emergency medical planning from Helge Junge, who leads a team specialized in air rescue operations. Helge shares the intricate details of developing a comprehensive care and transport system for the World Economic Forum, held in the challenging and mountainous terrain of the Swiss Alps. The forum's location posed significant logistical and medical challenges, including potential mass casualty scenarios and limited local medical resources.

His talk, "Air Rescue During WEF: Special Conditions and Problems," provides an in-depth analysis of how his team overcame these hurdles to establish a robust emergency response system. The solutions they created ensured attendees' safety and well-being and offered valuable lessons for managing mass casualty incidents (MCI) and rescue operations in austere conditions.

If you enjoy this talk, check out the other talks from the FAST Archives miniseries! We hope you enjoy them!

In this enlightening episode of The FAST Archives, we feature a compelling talk by Bruce Hoffman titled "A Change of Heart." Bruce, a seasoned critical care nurse and paramedic with a rich background in ICU, ER, trauma, and cardiology, challenges conventional wisdom in the treatment of STEMI patients. Drawing on the latest evidence, he questions the rush to percutaneous coronary intervention (PCI) and whether our current metrics, like door-to-reperfusion times, are truly in the best interest of patient outcomes.

Bruce's engaging discussion not only covers cardiac care insights but also includes a curious anecdote about grand pianos and emails, adding a touch of humor and relatability to a deeply technical subject. Join us to explore how these insights could transform STEMI care protocols and improve patient care.

Check out all the talks from the FAST Archives series for more great talks like this one! Interested in seeing these speakers in person? This is your official invitation to come join us for FAST24! We hope to see you there!

In this episode of The FAST Archives, Ritu Sahni explores the essential topic of equity in emergency care. With a background that includes EMS Medical Director roles, emergency medicine, and air ambulance experience, Ritu provides a comprehensive look at what it means to care for entire communities.

In his talk, "Equity in Emergency Care: What Does That Even Mean?", Ritu unpacks the challenges of delivering equitable care in EMS and what it takes to make sure every individual gets the support they need. His insights, drawn from years of experience and his passion for public health, offer valuable guidance for EMS professionals committed to serving their communities.

Tune in to gain a deeper understanding of how we can achieve equity in emergency care and why it's so crucial in our roles as public health providers.

In this deeply impactful episode of The FAST Archives, we focus on the tragic events of the Parkland school shooting on February 14, 2018, through the lens of Peter Antevy, who served as the EMS Medical Director on the scene that day. With his vast expertise in pre-hospital pediatrics and emergency medicine, Peter offers a detailed and respectful reflection on that tragic day, shedding light on what unfolded, what could have been improved, and the critical importance of being prepared for such events.

The talk also pays tribute to the efforts of Max Schachter, whose son Alex was among the victims. Max has since dedicated himself to preventing future tragedies, and Peter highlights his efforts to make a difference in school safety.

In the show notes, you'll find resources mentioned in the talk and additional materials that have been provided to support responders and communities in preparing for and preventing similar tragedies.

We present this episode in memory of the 17 lives lost and in support of the families and communities affected by the Parkland shooting.

Show notes:
Safe Schools for Alex: https://www.safeschoolsforalex.org/
The Panic App/Rave Mobile Safety: https://www.ravemobilesafety.com/
Pulsara Wristbands: https://www.pulsara.com/why-wristbands/
"We all need to learn 'Stop the Bleed'" Article: https://www.ems1.com/mass-casualty-incidents-mci/articles/fla-medical-director-on-60-minutes-we-all-need-to-learn-stop-the-bleed-bLUgR7O0Lxa9J14S/

Life is like A Rollercoaster
A poem by Alex Schachter

Life is like a roller coaster
It has some ups and downs
Sometimes you can take it slow or very fast
It maybe hard to breath at times
But you have to push yourself and keep going
Your bar is your safety
It’s like your family and friends
You hold on tight and you don’t let go
But sometimes you might throw your hands up
Because your friends and family will always be with you
Just like that bar keeping you safe at all times
It maybe too much for you at times: the twists, the turns, the upside downs
But you get back up
You keep chugging along
Eventually it comes to a stop
You won’t know when or how
But you will know that’ll be time to get off and start anew
Life is like a roller coaster

In this episode of The FAST Archives, William Heuser brings his extensive experience as a clinical critical care pharmacist, clinical toxicologist, and certified Flight Paramedic to demystify the controversial world of resuscitative medicine. In his dynamic talk, "Do Any of These Medications Work in Cardiac Arrest? Demystifying the Controversies!", Will examines the debate surrounding the administration of certain medications during cardiac arrest.

He discusses how these medications impact patient outcomes during resuscitation and offers a clear, evidence-based analysis of their risks and benefits. William’s unique blend of humor, energy, and knowledge makes this talk as entertaining as it is informative. Tune in to gain valuable insights into the evolving field of resuscitative medicine and explore the complexities of pharmacological interventions during cardiac arrest.

Don't forget to check out the other podcasts in the FAST Archives miniseries and join us at FAST24 for more talks like this one, including a brand-new one from Will! We hope to see you there! Enjoy the episode.

Welcome back to The FAST Archives! In this episode, Ashley Liebig delivers a compelling talk, "Teaching, Trusting, and Teen Driving," where she explores the nuanced realities of learning, teaching, and belonging. Through her insights into psychological safety, cognitive learning theory, and feedback culture, Ashley opens up how the intricacies of how humans learn and interact... both the good stuff and the things we don't always have a great track record with as an industry. Maslow's hierarchy of needs emphasizes that our basic requirements must be met before we can focus on growth and learning. So grab yourself a snack and tune in to gain valuable knowledge from Ashley’s expertise, as she provides actionable advice that can enhance your approach to education and personal growth.