The FlightBridgeED Podcast (Long Pause Media | FlightBridgeED)

We all know that the first thing you need to do when treating a patient is throw on a non-rebreather mask, right? What happens when that’s not doing the trick? How can we leverage the gas laws to our patient’s advantage? Join us for all this and more in this episode of The FlightBridgeED Podcast with Eric Bauer. Download, rate, and review wherever you get your podcasts. Reviews are critical to keeping us visible and viable so we can keep making the great, free content you love to hear, and we love to make! Thanks for listening!

Throughout the course of modern medicine, old methods fall as new ones emerge safer, more reliable, better for patient outcomes, and more. Sims et al., Says this: "Resuscitation strategies that decrease the need for transfusions without increasing complications, therefore, would represent a clinically important innovation". Research is deep and results are shared throughout the world. One of the fastest-growing, most industry-related sections of medicine today is that of resuscitation. In this episode of The FlightBridgeED Podcast, the team of Dr. Jeff Jarvis and Mike Verkest from the highly-rated EMS LightHouse Project Podcast dissect the actual study from a statistical analysis standpoint. Is the data as good as it seems? Is it statistically significant? Is there a place for vasopressin administration early in the resuscitation phase within the realm of trauma-induced massive hemorrhage? Join them and find out! Don’t forget to rate and especially review wherever you got your podcasts. These reviews are especially key to keeping us high on the charts where your friends and colleagues can find us. Thank you for listening.

In this episode of The FlightBridgeED Podcast, Eric is joined by a curio collection of some of the most brilliant minds in the pre-hospital critical care industry to review the top 5 most downloaded podcasts from 2017. It was an incredible year and 2018 is shining just as bright! Download, rate, and review wherever you get your podcasts. The FBE family of podcasts is now available on TuneIn! Get the app now and listen to your favorite podcast and more! Remember that reviews are key to help keep us high on the charts where your friends, and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode of The FlightBridgeED Podcast, Eric is joined by Mike Verkest to review the top 5 most downloaded podcasts from 2018. It was an incredible year, and 2019 is shining just as bright! Download, rate, and review wherever you get your podcasts. The FBE family of podcasts is now available on TuneIn! Get the app now and listen to your favorite podcast and more! Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode, Eric discusses the current evidence and analysis of the RCT on Ketamine use in RSI as published in the Air Medical Journal. Does this RCT show us anything we didn't already know? How can we optimize a neutral hemodynamic response in our sickest patients? Join us for "Prehospital Ketamine Use for Rapid Sequence Intubation - RCT Review"! Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more.

In this episode of The FlightBridgeED Podcast, below the tempest-driven surface of the deep and plunging into the murky, gray depths, a struggling soul descends to join the silence of fate. Join us to discover the horrifying fate and as death wraps its icy hand around the lungs of our patient. What is this terror? Find out in this nightmare series podcast episode, Ventilator Associated Pneumonia.

We generally never mix these two very unique podcasts, but this podcast is quite possibly the most important podcast we have ever published. A pillar of our practice is under fire and we need everyone's help. Back in the 70's there were several laws written regarding the use and distribution of controlled substances. Unfortunately for us, back in the 70's EMS looked very different. In fact, it was so different that there were never any laws written specifically to direct the function of EMS within those laws. We have been operating for years under a sort of combined mishmash of laws. Recently, the DEA and other members of the US government have been investigating how we operate and you won't believe what they have determined. There is hope for our profession, but it starts with each of us doing our part. Listen to this podcast, contact your representative, and encourage them to rally to our side. Failure with this matter means rapid access to lifesaving medication will go away for our patients, and the pre-hospital industry will be turned upside down. Download this podcast, listen, distribute, share, and get the word out to your friends, family, co-workers, medical directors, and anyone who will listen. We have to band together for the sake of our patients and our profession.

New ACLS standards regard quality CPR above advanced airway placement. Are they right?

In this episode of The FlightBridgED Podcast, Eric and Dave Olvera carve out some time while they are on the road to talk about airway management preparation strategies. Dave has invested many years of his professional career investigating, and researching, among other important projects, how to best optimize intubation success. For as long as I can remember, we have used difficult airway predictors in our field practice, such as LEMON(S), to help prepare for eventualities when placing an endotracheal tube. Dave and his colleagues have determined that those predictors are great, but may not be as applicable to field intubations. With mountains of research at hand the HEAVEN criteria was created, along with best-practice strategies for increasing intubation success in an ever-changing environment. Join us for this episode as Eric and Dave discuss HEAVEN criteria and more! Download, rate, and review wherever you get your podcast. Each review is so important to our success. Your reviews on iTunes, Google Play Music, Stitcher, or other platforms help to make us a recommended podcast so we are more visible, and easily discovered. If you believe in the value of what FlightBridgeED brings in this podcast, please take a few minutes and write a short review. We couldn’t make this podcast without you!

In this episode of The FlightBridgeED Podcast, we take an in-depth look at the concept of passive oxygenation and camp out in the literature and studies regarding it. Join us for the podcast and discover together how to apply the concept of passive oxygenation to your practice!

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 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.

Disseminated Intravascular Coagulation 

This is the fourth of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport.

The topic of this podcast is Disseminated Intravascular Coagulation (DIC) in the pregnant patient.  Although very rare, this disease carries a high morbidity and mortality.  The key features are the disease are diffuse and dysregulated coagulation that causes consumption of clotting factors (resulting in a paradoxical coagulopathic state), widespread endothelial damage, and is essentially always the result of some other disease process.  In this podcast we go over how critical care transport crews can recognize DIC and identify the underlying process causing it.  In addition, Dr. Garchar and I review the management in the transport environment and pearls regarding treating coagulopathy. 

In the podcast we give a shout out to a phenomenal OB Critical Care course that is put on by Banner University Medical Center and the Society for Maternal Fetal Medicine.  Unfortunately, it’s a little late to sign up for this year’s session (November 2023), but put it on your radar for next year!  Here is a link to the brochure and conference content to give you an idea.  There is also a healthy component of simulation education.  I have no conflict of interest with this course at all…it’s just a phenomenal educational opportunity.

https://s3.amazonaws.com/cdn.smfm.org/media/1807/Brochure-Banner(FINAL).pdf

References

1.          Erez O. Disseminated intravascular coagulation in pregnancy: New insights. Thrombosis Update. 2022;6doi:10.1016/j.tru.2021.100083

2.          Erez O, Novack L, Beer-Weisel R, et al. DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9(4):e93240. doi:10.1371/journal.pone.0093240

3.          Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med. 2022;13:21-44. doi:10.2147/JBM.S273047

4.          Foley MR, Strong TH, Garite TJ. Obstetric Intensive Care Manual. 5th ed. McGraw-Hill Education; 2014.

5.          Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost. Jun 1998;79(6):1111-5. 

6.          Kadikar SK, Divan FJ, Topiwala U, Agasiwala S. Study of pregnancy with disseminated intravascular coagulation. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2021;10(11)doi:10.18203/2320-1770.ijrcog20214335

7.          Krikun G, Huang ST, Schatz F, Salafia C, Stocco C, Lockwood CJ. Thrombin activation of endometrial endothelial cells: a possible role in intrauterine growth restriction. Thromb Haemost. Feb 2007;97(2):245-53. 

8.          Levi M, Scully M. How I treat disseminated intravascular coagulation. Blood. Feb 22 2018;131(8):845-854. doi:10.1182/blood-2017-10-804096

9.          Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. Apr 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x

10.        Papageorgiou C, Jourdi G, Adjambri E, et al. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost. Dec 2018;24(9_suppl):8S-28S. doi:10.1177/1076029618806424

11.        Rabinovich A, Abdul-Kadir R, Thachil J, Iba T, Othman M, Erez O. DIC in obstetrics: Diagnostic score, highlights in management, and international registry-communication from the DIC and Women's Health SSCs of the International Society of Thrombosis and Haemostasis. J Thromb Haemost. Sep 2019;17(9):1562-1566. doi:10.1111/jth.14523

12.        Rattray DD, O'Connell CM, Baskett TF. Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009). J Obstet Gynaecol Can. Apr 2012;34(4):341-347. doi:10.1016/S1701-2163(16)35214-8

13.        Taylor FB, Jr., Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. Nov 2001;86(5):1327-30. 

14.        Toffaletti JG, Buckner KA. Use of Earlier-Reported Rotational Thromboelastometry Parameters to Evaluate Clotting Status, Fibrinogen, and Platelet Activities in Postpartum Hemorrhage Compared to Surgery and Intensive Care Patients. Anesth Analg. Mar 2019;128(3):414-423. doi:10.1213/ane.0000000000003499

15.        Veronika A L, John V, Xuezhi J. Disseminated Intravascular Coagulation due to Amniotic Fluid Embolism in an Early Molar Pregnancy. Clinical Medical Reviews and Case Reports. 2018;5(1)doi:10.23937/2378-3656/1410199

16.        Walker J, Bonavia A. To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise. Case Rep Anesthesiol. 2020;2020:9642438. doi:10.1155/2020/9642438

17.        Zhao Z, Zhang J, Li N, et al. Disseminated intravascular coagulation associated organ failure in obstetric patients admitted to intensive care units: a multicenter study in China. Sci Rep. Aug 12 2021;11(1):16379. doi:10.1038/s41598-021-95841-7

This is part 1 of a 2-part series covering 12-lead ECG fundamentals.

In this episode of The FlightBridgeED Podcast, Eric takes a suggestion from our community and dives into the "other" fluids. While these fluids aren't our normal go-to solutions, they all have a place in the great field of "Fluidology." Join us as we explore plasmalyte, normosol, and dextran.

A tedious and trembling silhouette ascends a precarious perch into a tower thrust high in the skies. A moment's mistake forces the twisted hand of fate as our patient succumbs to the fierce pull of gravity. Plunging to the cold ground, unable to move, and fearfully close to the end it's up to you to fight the hollow heart of death in this episode of The FlightBridgeED Podcast.

In this episode, I ask for your support in my submission for the open board position within the IAFCCP Association. Thank you for all your support! Remember that reviews are key to helping keep us stay high on the charts and where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode, we dive into Congenital Heart Defects Part 3 of 3. In this podcast, we will review tricuspid atresia and hypoplastic left heart. Despite these patients often being transported by NICU teams, there are cases of congenital heart defects that have been undiagnosed and something you may encounter on-scene fights that decompensate once the PDA has closed. This places the care in the pre-hospital provider's hands and brings forth a high-stress case that can be overwhelming for most. Couple this with the high quantity of questions seen on all advanced certification exams and it is a must that we review these congenital heart defects. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

From the authors of David Olvera, FP-C, and Daniel Davis M.D. The abstract introduction: Rapid sequence intubation (RSI) is associated with several complications that can increase morbidity and mortality. Among RSI agents used to blunt awareness of the procedure and produce amnesia, ketamine is unique in its classification as a dissociative agent rather than a CNS depressant. Thus, ketamine should have a lower risk of peri-RSI hypotension due to the minimal sympatholysis as compared to other agents. The main goal of this analysis was to explore the incidence of hypotension and/or cardiopulmonary arrest in patients receiving ketamine versus other agents during RSI. We hypothesized that ketamine would be associated with a lower risk of hemodynamic complications, particularly after adjusting for co-variables reflecting patient acuity. In addition, we anticipated that an increased prevalence of ketamine use would be associated with a decreasing incidence of peri-RSI hypotension and/or arrest. We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

Join us at AMTC 2018 for a discussion that has been a hot topic around the United States for the past few years. Dr. Mike Hudson, medical director for Classic Air Medical in Utah, joins us. He is one of just a few medical directors in the United States taking a stance on this hot topic. Are we close to following in the footsteps of our brothers across the pond? Join us to find out more about "Soft Vs. Hard is the Question?" Lastly, we couldn’t make this podcast without you. Please rate and review wherever you download the podcast. Thanks for listening!

The transition from a more rigid protocol into a more guideline-based thought process can be overwhelming. Many of us can be very black-and-white with our thinking. This can be dangerous! We all need to have the "Fifty Shades Of Gray" mindset. This podcast is meant to challenge the black-and-white thinking many of us struggle with. Join me on the tough topic and take a journey with me as we explore our thinking methodology. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

Push dose pressor administration in the pre-hospital and air medical industry is becoming a more standard guideline. However, there is very little evidence of its application in our environment. The Vasopressor Intravenous Push to Enhance Resuscitation (VIPER) study takes a prospective observational look at Phenylephrine and Vasopressin in non-trauma and trauma patients in the air medical environment. Listen and find out more. Download, rate, and review wherever you get our podcast. Remember that reviews help us stay high on the charts where your friends and colleagues can find us. If you love our podcasts, please help us out and spread the word online and in the streets. Thanks for listening!

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!

This is the second of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport.

The topic of this podcast is maternal cardiac arrest.  This is, possibly, one of the most stressful clinical encounters we can have as flight crew.  Critical care transport crews are masters of ACLS and resuscitation during cardiac arrest, but what do you do if the patient is pregnant?  Often crews have questions: Can we use the same drugs?  Do you change the dose of different ACLS drugs?  Can you defibrillate a pregnant patient?  Do we change hand position for chest compression?   In this podcast, Dr. Garchar and I go over the recommendations and guidelines from major organizations and clarify some of these important questions.  

References

1.          Beckett VA, Knight M, Sharpe P. The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study. BJOG. Aug 2017;124(9):1374-1381. doi:10.1111/1471-0528.14521

2.          Bennett TA, Katz VL, Zelop CM. Cardiac Arrest and Resuscitation Unique to Pregnancy. Obstet Gynecol Clin North Am. Dec 2016;43(4):809-819. doi:10.1016/j.ogc.2016.07.011

3.          Biderman P, Carmi U, Setton E, Fainblut M, Bachar O, Einav S. Maternal Salvage With Extracorporeal Life Support: Lessons Learned in a Single Center. Anesth Analg. Oct 2017;125(4):1275-1280. doi:10.1213/ANE.0000000000002262

4.          Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. Nov 2012;120(5):1029-36. doi:10.1097/aog.0b013e31826d60c5

5.          Campbell TA, Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. Jan 2009;2(1):34-42. doi:10.4103/0974-2700.43586

6.          Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG. Feb 2010;117(3):282-7. doi:10.1111/j.1471-0528.2009.02461.x

7.          Ducloy-Bouthors AS, Gonzalez-Estevez M, Constans B, Turbelin A, Barre-Drouard C. Cardiovascular emergencies and cardiac arrest in a pregnant woman. Anaesth Crit Care Pain Med. Oct 2016;35 Suppl 1:S43-S50. doi:10.1016/j.accpm.2016.06.008

8.          Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation. Oct 2012;83(10):1191-200. doi:10.1016/j.resuscitation.2012.05.005

9.          Enomoto N, Yamashita T, Furuta M, et al. Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses. BMC Pregnancy Childbirth. Feb 25 2022;22(1):159. doi:10.1186/s12884-021-04334-y

10.        Fischer C, Bonnet MP, Girault A, Le Ray C. Update: Focus in-hospital maternal cardiac arrest. J Gynecol Obstet Hum Reprod. May 2019;48(5):309-314. doi:10.1016/j.jogoh.2019.02.007

11.        Fisher N, Eisen LA, Bayya JV, et al. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training. Am J Obstet Gynecol. Sep 2011;205(3):239 e1-5. doi:10.1016/j.ajog.2011.06.012

12.        Ford ND, DeSisto CL, Galang RR, Kuklina EV, Sperling LS, Ko JY. Cardiac Arrest During Delivery Hospitalization : A Cohort Study. Ann Intern Med. Apr 2023;176(4):472-479. doi:10.7326/M22-2750

13.        Helviz Y, Einav S. Maternal cardiac arrest. Curr Opin Anaesthesiol. Jun 2019;32(3):298-306. doi:10.1097/ACO.0000000000000719

14.        Jeejeebhoy FM, Morrison LJ. Maternal cardiac arrest: a practical and comprehensive review. Emerg Med Int. 2013;2013:274814. doi:10.1155/2013/274814

15.        Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. Nov 3 2015;132(18):1747-73. doi:10.1161/CIR.0000000000000300

16.        Jeejeebhoy FM, Zelop CM, Windrim R, Carvalho JC, Dorian P, Morrison LJ. Management of cardiac arrest in pregnancy: a systematic review. Resuscitation. Jul 2011;82(7):801-9. doi:10.1016/j.resuscitation.2011.01.028

17.        Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. Feb 2018;42(1):33-38. doi:10.1053/j.semperi.2017.11.007

18.        Ko RE, Chung CR, Yang JH, et al. Use of extracorporeal membrane oxygenation in postpartum patients with refractory shock or respiratory failure. Sci Rep. Jan 13 2021;11(1):887. doi:10.1038/s41598-020-80423-w

19.        Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol. Aug 2010;203(2):179 e1-5. doi:10.1016/j.ajog.2010.02.022

20.        Mizuno A, Saito A, Shibata A. You can never be too prepared: ECMO for MCA. Am J Obstet Gynecol. Jan 2019;220(1):122-123. doi:10.1016/j.ajog.2018.09.019

21.        Naoum EE, Chalupka A, Haft J, et al. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc. Jul 7 2020;9(13):e016072. doi:10.1161/JAHA.119.016072

22.        Ong J, Zhang JJY, Lorusso R, MacLaren G, Ramanathan K. Extracorporeal membrane oxygenation in pregnancy and the postpartum period: a systematic review of case reports. Int J Obstet Anesth. Aug 2020;43:106-113. doi:10.1016/j.ijoa.2020.04.004

23.        Shields AD, Battistelli JD, Kavanagh LB, Thomson BA, Nielsen PE. A modified Delphi approach to determine current treatment advances for the development of a resuscitation program for maternal cardiac arrest. BMC Emerg Med. Aug 26 2022;22(1):149. doi:10.1186/s12873-022-00704-7

24.        Sommerkamp SK, Gibson A. Cardiovascular disasters in pregnancy. Emerg Med Clin North Am. Nov 2012;30(4):949-59. doi:10.1016/j.emc.2012.08.007

25.        Stokes N, Kikucki J. Management of Cardiac Arrest in the Pregnant Patient. Curr Treat Options Cardiovasc Med. Jun 19 2018;20(7):57. doi:10.1007/s11936-018-0652-9

26.        Webster CM, Smith KA, Manuck TA. Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series. Am J Obstet Gynecol MFM. May 2020;2(2):100108. doi:10.1016/j.ajogmf.2020.100108

27.        Wu Y, Luo J, Chen T, et al. Successful ECMO-assisted open chest cardiopulmonary resuscitation in a postpartum patient with delayed amniotic fluid embolism. Eur J Med Res. Feb 3 2022;27(1):19. doi:10.1186/s40001-021-00628-1

28.        Zelop C, Einav S, ...

Join Dr. Peter Antevy for this exclusive FAST21 video talk: "Hail to the Receptor in Chief"! This insightful video podcast will take an in-depth look at the evidence surrounding Ketamine and its impact on MDMA receptors. Join Dr. Antevy for this excellent look at one of the hottest topics in pre-hospital and emergency medicine. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more.

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.

---
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 Eric chooses to move off the well-worn path for a moment, motivating us to breathe more passion into what inspires and ignites our mind. We live in an incredible era of information and discovery. Dare to dream!

In this episode of The FlightBridgeED Podcast, Eric is joined by Mike Verkest to review the top 5 most downloaded podcasts from 2019. It was an incredible year, and 2020 is shining just as bright! Download, rate, and review wherever you get your podcasts. The FBE family of podcasts is now available on TuneIn! Get the app now and listen to your favorite podcast and more! Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this video podcast, Eric discussed the acronym developed by Jared Patterson, an educator for FOAMfrat. This clever memory aid is used to identify the atypical 12 lead tracings that often go unnoticed or missed. Join us for this information-packed episode on evidence-based 12 lead interpretation. So much good stuff! Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more.

While safety in, and around the aircraft is of paramount importance it is also equally important to train for what happens when safety turns into survival. We have all attended survival training in some form, or fashion. How was your experience? If you’re like most, you unfortunately get run through a quick day of training just to check the box. In the face of life, and death there is certainly a box waiting for you to check, but why not choose to survive? You are choosing life when you demand serious, quality survival training. Join us in this episode as we talk with Chief Flight Nurse, Deb Witte, and Chief Flight Paramedic, Nathan Morreale, from AirMed at the University of Utah Health to talk about a program they developed to teach, test, and overcome in an emergency survival situation. Download, rate, and review wherever you get your podcasts. Remember reviews are key to keeping us high on the charts so your friends and colleagues can find us. Thank you for listening to The FlightBridgeED Podcast.

In this episode, we dive into another Nightmare Series Patient Case of the Undifferentiated Overdose. Join Ashley, Mike, and Eric during our recent visit to the National Teaching Institute Critical Care Nursing Conference. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

Join FlightBridgeED's new Chief Medical Director, Mike Lauria, as we launch the FlightBridgeED MDCast. Dr. Lauria will hijack these episodes for a new perspective on current topics in critical care medicine. In this episode, Dr. Lauria looks at Eric's previously published podcast [episode 224] on ASA Overdose and gives his insight, practical application, and overall thoughts on these difficult-to-manage patients. Don't miss this episode! So much good stuff! Please like, subscribe, and leave any questions or comments.

References for Acute Salicylate Intoxication

1. Anderson RJ, Potts DE, Gabow PA, Rumack BH, Schrier RW. Unrecognized adult salicylate intoxication. Ann Intern Med. Dec 1976;85(6):745-8. doi:10.7326/0003-4819-85-6-745
2. Chyka PA, Erdman AR, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. doi:10.1080/15563650600907140
3. Dargan PI, Wallace CI, Jones AL. An evidence-based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. May 2002;19(3):206-9. doi:10.1136/emj.19.3.206
4. Delaney TM, Helvey JT, Shiffermiller JF. A Case of Salicylate Toxicity Presenting with Acute Focal Neurologic Deficit in a 61-Year-Old Woman with a History of Stroke. Am J Case Rep. Feb 15 2020;21:e920016. doi:10.12659/AJCR.920016
5. Espírito Santo R, Vaz S, Jalles F, Boto L, Abecasis F. Salicylate Intoxication in an Infant: A Case Report. Drug Saf Case Rep. Nov 27 2017;4(1):23. doi:10.1007/s40800-017-0065-9
6. Goldberg MA, Barlow CF, Roth LJ. The effects of carbon dioxide on the entry and accumulation of drugs in the central nervous system. J Pharmacol Exp Ther. Mar 1961;131:308-18.
7. Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. Aug 2015;66(2):165-81. doi:10.1016/j.annemergmed.2015.03.031
8. Kuzak N, Brubacher JR, Kennedy JR. Reversal of salicylate-induced euglycemic delirium with dextrose. Clin Toxicol (Phila). Jun-Aug 2007;45(5):526-9. doi:10.1080/15563650701365800
9. McCabe DJ, Lu JJ. The association of hemodialysis and survival in intubated salicylate-poisoned patients. Am J Emerg Med. Jun 2017;35(6):899-903. doi:10.1016/j.ajem.2017.04.017
10. Miyahara JT, Karler R. Effect of salicylate on oxidative phosphorylation and respiration of mitochondrial fragments. Biochem J. Oct 1965;97(1):194-8. doi:10.1042/bj0970194
11. Oliver TK, Jr., Dyer ME. The prompt treatment of salicylism with sodium bicarbonate. AMA J Dis Child. May 1960;99:553-65. doi:10.1001/archpedi.1960.02070030555001
12. Oualha M, Dupic L, Bastian C, Bergounioux J, Bodemer C, Lesage F. [Local salicylate transcutaneous absorption: an unrecognized risk of severe intoxication: a case report]. Arch Pediatr. Oct 2012;19(10):1089-92. Application cutanée localisée d'acide salicylique : un risque méconnu d'intoxication : à propos d'un cas. doi:10.1016/j.arcped.2012.07.012
13. Palmer BF, Clegg DJ. Salicylate Toxicity. N Engl J Med. Jun 25 2020;382(26):2544-2555. doi:10.1056/NEJMra2010852
14. Penniall R. The effects of salicylic acid on the respiratory activity of mitochondria. Biochim Biophys Acta. Nov 1958;30(2):247-51. doi:10.1016/0006-3002(58)90047-7
15. Shively RM, Hoffman RS, Manini AF. Acute salicylate poisoning: risk factors for severe outcome. Clin Toxicol (Phila). Mar 2017;55(3):175-180. doi:10.1080/15563650.2016.1271127
16. Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med. Sep 2008;15(9):866-9. doi:10.1111/j.1553-2712.2008.00205.x
17. Thurston JH, Pollock PG, Warren SK, Jones EM. Reduced brain glucose with normal plasma glucose in salicylate poisoning. J Clin Invest. Nov 1970;49(11):2139-45. doi:10.1172/JCI106431

In this two-part series, Eric discusses RSI and all aspects of related drug pharmacology, providing insight into implementation in the critical care setting.

In this episode of The FlightBridgeED Podcast, Eric helps us develop the concept of the oxyhemoglobin dissociation curve, left and right shifts, and other important principles of oxygen delivery at the tissue level. Although this is a difficult subject, it’s incredibly relevant and enlightening, and it has real applications for our patients. Join us as we study the Oxyhemoglobin Dissociation Curve - A Resuscitation Paradigm.

When it comes to RSI in the pre-hospital setting, Ketamine is our new best friend. There are many more benefits to using this medication within several subgroups of patients for RSI than our old standby, etomidate. We have read the accolades and positives in several studies, and trials, but what are the negatives? Are there any negatives? Could Ketamine be the perfect drug? Is it all just hype? Join the podcast as Eric discusses a new study and you will not believe what it says about your new favorite drug. Download, listen, rate, and review! Help FlightBridgeED keep our podcasts at the top of the charts so your friends and colleagues can find us!

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.

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.

This is the fifth of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams as a retrieval OBGYN/MFM and acts as one of our Assistant Medical Directors for the flight program.

The topic of this podcast is Amniotic Fluid Embolism (AFE).  Another rare, but devastating disease that can often progress rapidly to cardiac arrest.  In this podcast, we go through the epidemiology and definition/diagnosis of the disease.  We also go into depth on underlying pathophysiology and the current hypotheses on what causes AFE.  Spoiler alert: it’s not as simple as an embolism of amniotic fluid.   Then we review the management, specifically focusing on the management of acute right heart failure in the setting of abrupt and pronounced pulmonary hypertension. Finally, Dr. Garchar and I deliver some spaced repetition and go over the management of maternal cardiac arrest, in the likely event that AFE progresses to that point.

References

1. Abenhaim HA, Azoulay L, Kramer MS, Leduc L. Incidence and risk factors of amniotic fluid embolisms: a population-based study on 3 million births in the United States. Am J Obstet Gynecol. Jul 2008;199(1):49 e1-8. doi:10.1016/j.ajog.2007.11.061

2. Aissi James S, Klein T, Lebreton G, et al. Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation. Crit Care. Apr 7 2022;26(1):96. doi:10.1186/s13054-022-03969-3

3. Clark SL, Montz FJ, Phelan JP. Hemodynamic alterations associated with amniotic fluid embolism: a reappraisal. Am J Obstet Gynecol. Mar 1 1985;151(5):617-21. doi:10.1016/0002-9378(85)90150-4

4. Clark SL, Romero R, Dildy GA, et al. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol. Oct 2016;215(4):408-12. doi:10.1016/j.ajog.2016.06.037

5. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol. Nov 2009;201(5):445 e1-13. doi:10.1016/j.ajog.2009.04.052

6. Creel-Bulos C, Hassani B, Stentz MJ, et al. Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report. Crit Care Explor. Jul 2020;2(7):e0162. doi:10.1097/CCE.0000000000000162

7. Crissman HP, Loder C, Pancaro C, Bell J. Case report of amniotic fluid embolism coagulopathy following abortion; use of viscoelastic point-of-care analysis. BMC Pregnancy Childbirth. Jan 3 2020;20(1):9. doi:10.1186/s12884-019-2680-1

8. Durgam S, Sharma M, Dadhwal R, Vakil A, Surani S. The Role of Extra Corporeal Membrane Oxygenation in Amniotic Fluid Embolism: A Case Report and Literature Review. Cureus. Feb 26 2021;13(2):e13566. doi:10.7759/cureus.13566

9. Foley MR ST, Garite TJ. Obstetric Intensive Care Manual. 5th ed. McGraw-Hill Education; 2014.

10. Huybrechts W, Jorens PG, Jacquemyn Y, Colpaert C, Vrints C, Conraads V. Amniotic fluid embolism: a rare cause of acute left-sided heart failure. Acta Cardiol. Dec 2006;61(6):643-9. doi:10.2143/AC.61.6.2017964

11. James CF, Feinglass NG, Menke DM, Grinton SF, Papadimos TJ. Massive amniotic fluid embolism: diagnosis aided by emergency transesophageal echocardiography. Int J Obstet Anesth. Oct 2004;13(4):279-83. doi:10.1016/j.ijoa.2004.03.008

12. Lao TT. Acute respiratory distress and amniotic fluid embolism in pregnancy. Best Pract Res Clin Obstet Gynaecol. Dec 2022;85(Pt A):83-95. doi:10.1016/j.bpobgyn.2022.06.004

13. Lockwood CJ, Bach R, Guha A, Zhou XD, Miller WA, Nemerson Y. Amniotic fluid contains tissue factor, a potent initiator of coagulation. Am J Obstet Gynecol. Nov 1991;165(5 Pt 1):1335-41. doi:10.1016/0002-9378(91)90363-v

14. McDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxide in a parturient with amniotic fluid embolism. Int J Obstet Anesth. Jul 2007;16(3):269-73. doi:10.1016/j.ijoa.2006.10.008

15. Moore J, Baldisseri MR. Amniotic fluid embolism. Crit Care Med. Oct 2005;33(10 Suppl):S279-85. doi:10.1097/01.ccm.0000183158.71311.28

16. Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol. Jan 2020;222(1):48-52. doi:10.1016/j.ajog.2019.07.036

17. Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol. Mar 2016;214(3):340-4. doi:10.1016/j.ajog.2015.08.068

18. Shamshirsaz AA, Clark SL. Amniotic Fluid Embolism. Obstet Gynecol Clin North Am. Dec 2016;43(4):779-790. doi:10.1016/j.ogc.2016.07.001

19. Shechtman M, Ziser A, Markovits R, Rozenberg B. Amniotic fluid embolism: early findings of transesophageal echocardiography. Anesth Analg. Dec 1999;89(6):1456-8. doi:10.1097/00000539-199912000-00025

20. Simard C, Yang S, Koolian M, Shear R, Rudski L, Lipes J. The role of echocardiography in amniotic fluid embolism: a case series and review of the literature. Can J Anaesth. Oct 2021;68(10):1541-1548. Le role de l'echocardiographie dans l'embolie de liquide amniotique : une serie de cas et une revue de la litterature. doi:10.1007/s12630-021-02065-4

21. Society for Maternal-Fetal Medicine . Electronic address pso, Pacheco LD, Saade G, Hankins GD, Clark SL. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol. Aug 2016;215(2):B16-24. doi:10.1016/j.ajog.2016.03.012

22. Stanten RD, Iverson LI, Daugharty TM, Lovett SM, Terry C, Blumenstock E. Amniotic fluid embolism causing catastrophic pulmonary vasoconstriction: diagnosis by transesophageal echocardiogram and treatment by cardiopulmonary bypass. Obstet Gynecol. Sep 2003;102(3):496-8. doi:10.1016/s0029-7844(03)00161-3

23. Sultan P, Seligman K, Carvalho B. Amniotic fluid embolism: update and review. Curr Opin Anaesthesiol. Jun 2016;29(3):288-96. doi:10.1097/ACO.0000000000000328

24. Wu HD, Song ZK, Cao HY, et al. Successful treatment of amniotic fluid embolism complicated by disseminated intravascular coagulation with rivaroxaban: A case report. Medicine (Baltimore). Jan 2020;99(4):e18951. doi:10.1097/md.0000000000018951

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.

WOW! FAST19 was so amazing. So inspiring! If you missed FAST19.. Don't worry, FAST20 will be - May 18-20, 2020 in Murfreesboro, TN. This is the first of a few releases from FAST19. This was a very popular talk by our own Bruce Hoffman as he perfectly goes through the case-based study called - RVAD vs. Air Embolus | A Lesson in CRM. Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

Join us for an insightful episode from The FAST Archives, featuring "Stayin' Alive: Impella Device and Left Ventricular Mechanical Circulatory Support in Critical Care Transport," presented by Michael Lauria. A former USAF Pararescueman and Critical Care/Flight Paramedic, Michael is now an EMS and Critical Care Fellow at the University of New Mexico Health Science Center. He brings his extensive experience to this engaging talk on Left Ventricular Assist Devices (LVADs) and their use in critical care transport.

In this episode, Michael dives into the technical aspects of LVADs, including their design, application, and relevance in transport situations. You'll learn about anatomy, physiology, pharmacology, pressure waveforms, and point-of-care ultrasound (POCUS) as they relate to these devices. Michael’s presentation is thorough and engaging, perfect for anyone in critical care or emergency transport.

Whether you're already familiar with LVADs or new to the topic, this episode offers valuable insights and practical knowledge. As these devices become more common in the field, you'll want to be prepared. Tune in to expand your understanding and equip yourself for future transports involving LVADs.

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.

In this episode of The FlightBridgeED Podcast we discuss oxygenation and ventilation. These important concepts are cornerstone principles in properly managing patients on the ventilator, and understanding respiratory function.

Eric continues our update of ventilator application in part 2 of this series. Discover the proper use of I:E ratios and I-time, a breakdown of manipulating PIPs and pPlats, and much more! Download, subscribe, and rate wherever you get our podcast! Don’t forget to check out the brand new Ventilator Management: A Pre-hospital Perspective (2nd Edition) book available now!

In this compelling episode of the FlightBridgeED podcast, recorded at CCTMC24, we dive deep with Kevin Collopy, a distinguished figure in trauma care and awarded Best Research for his poster during the conference's Scientific Assembly. Kevin shares his groundbreaking work with just-in-time prehospital trauma training in Ukraine, a project that has garnered significant attention for its impact and innovation.

Amidst the backdrop of conflict, Kevin, along with a dedicated team of providers and organizations, developed and delivered seven different trauma courses, (including Pre-Hospital Trauma Fundamentals, which he and his team created specifically for this area of need) tailored for Ukrainian communities. These courses aim to mitigate civilian casualties and enhance patient outcomes amid wartime conditions especially when there are a limited number of responders and providers available and civilians are helping other civilians. Throughout the podcast, Kevin unpacks the process of creating these programs, their execution, and the potential future of just-in-time training in other conflict and disaster zones.

Kevin and host, Eric Bauer, also delve into a critical discussion on the undervalued importance of basic trauma skills (such as splinting, tourniquet and wound packing) which, as Kevin's research shows, play a vital role in managing war and disaster scenarios and are often overshadowed by more advanced skills. Tune in to this enlightening episode to understand the pivotal shifts in trauma training and how these lessons from the front lines can reshape our approach to emergency preparedness and response.

In this episode of The FlightBridgeED Podcast, a perfect storm is rising over a terribly complicated case. Juggling a multitude of therapies and way behind, the flight team must fight to keep their heads above water. Find out what happens as the flight team and patient struggle for survival!

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.

We have all been trained to make the numbers “normal” for so many years, that it seems so unnatural to leave a number alone. It’s like a terrible itch that we have to scratch, and we feel satisfaction when we finally optimize our patient’s ETCO2 by shoving it right back to 40 mmHg. We take off our work boots, and strap on our favorite running shoes as we run headlong chasing numbers into oblivion. What if we told you that what you are doing could be considered… murder? Maybe the patient is already dead… Join Eric in this episode of The FlightBridgeED Podcast as we learn how to troubleshoot an out-of-sorts ETCO2 with the 3 P’s of ETCO2. Download, rate, and review wherever you get your podcasts! Remember that reviews are the key to our future success and the intelligence of your peers by keeping us high on the charts where people can find us more easily. We love making this podcast, and we thank you, our listeners, so much for being the reason we get to come to work!

The debate regarding vasopressor use in trauma has been going on for years. FOAMfrat recently released a blog article called. "Levophed Assisted Transfusion". In this article written by Tyler, he lays out his thoughts on this subject and advocates for vasopressor administration in the early resuscitation phase with patients suffering from multi-system trauma and associated TBI. This podcast is a rebuttal podcast on that article and the current evidence. Are vasopressors in trauma warranted? Is there clinical evidence? I say... Join me in this review and find out my stance! These reviews are especially key to keeping us high on the charts where your friends and colleagues can find us. Thank you for listening.

In this episode of The FAST Archives miniseries, we're replaying Geoff Murphy's talk from a previous FAST event, "Paramedics: The Master Multitasker... Right?" In this captivating talk, Geoff, from Master Your Medics, delves into the challenge paramedics (as well as nurses, physicians, and other medical professionals) face in multitasking, especially when they're often the most experienced provider.

How well do we juggle life-saving skills while making critical decisions? And is multitasking always in the best interest of our patients? Through a personal story and insightful research, Geoff challenges our assumptions and invites us to consider the potential risks and rewards of multitasking in pre-hospital, critical care, and emergency medicine.

If you're interested in learning more about Geoff Murphy and Master Your Medics, visit https://www.masteryourmedics.com, and if you're interested in joining us at FAST24 for more talks like this, visit https://flightbridgeed.com/fast24. Thanks for listening, and we hope you enjoy this episode!

Join Eric and Miles Dunagan, President of the National Pilots Association at AMTC ELEVATE 2022, to discuss Just Culture, safety, risk, past air medical accidents, and much more. Just culture has become the foundation for organizational learning, transparency, and the overall safety initiative within the industry we all serve. The evaluation of risk is always part of our collective jobs. Whether you are a pilot, a paramedic, or a nurse, we have all experienced risk. Risk is always around us. How can risk be mitigated? It starts with open communication, transparency, each team member feeling like they have a voice and a company culture that drives this message from the top down. 

Join us for this information-packed podcast highlighting how Just Culture collides with risk, which drives awareness and good decision-making. 

In this episode of the podcast, Eric explains and offers insight into an old argument that has recently been given a spotlight by industry professionals. Are adult bag valve masks a dangerous tool? Should we be using pediatric equipment for adults? Join the conversation with our community on FaceBook and Twitter! Don't forget to rate, and review our podcast from wherever you get your podcasts. Taking the time to write a review helps keep our podcast high on the charts so it can easily be found by everyone. If you love the podcast, you can give back to us by reviewing the content we make on iTunes, Google Play Music, Stitcher, or any other podcast platform. Thanks for listening!

In this episode of The FlightBridgeED Podcast, Eric Bauer and special guest Michael Verkest discuss TXA in traumatic brain injuries. Join us for the first interview podcast from FlightBridgeED as we learn from these two incredibly talented educators.

In this episode of The FlightBridgeED Podcast, we are joined by Dr. Zaffer Qasim to discuss the history, application, and data of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) for a variety of reasons including aortic aneurysm, trauma, and so much more. You won't believe what these things can do, and you might be carrying them in the field sooner than you think!

Come and taste what's been cooking in the FlightBridgeED kitchen for 2015! During this podcast, Eric talks about a few things that are in the works, made possible by the suggestions we have collected from our community! We are proud to roll out the new FlightBridgeED YouTube channel with 13 brand-new videos for you to enjoy right now. Check it out now...

In this episode of The FlightBridgeED Podcast, Eric unpacks the often complicated subject of clinical trials. We all want to know the latest and greatest treatments, and best practices so we can apply them to our clinical practice. To know that, we have to see what’s going on in the realm of research medicine. Clinical trial papers have a lot to offer, but how do we know the information we are reading is accurate and appropriate for us? Join us for this episode to learn more! Help keep us high on the charts so your friends and co-workers can find our podcast! Download, rate, and comment wherever you get your podcasts!

When it comes to ventilator management, and critically ill patients it can sometimes get a little scary. Have you ever had a patient on a ventilator who starts declining only to pull them off and go back to that good old BVM? Why does the magical BVM work and not the ventilator? Join us for this episode to find out! Download, subscribe, rate, and review wherever you get your podcast goodness!

In this episode, we dive into another Nightmare Series Patient Case of the decompensating infant.  Join Eric as he discusses neonatal to full-term infant resuscitation based on current standards by NRP, PALS, STABLE, and Pediatric Fundamentals of Critical Care Support (PFCCS).  This is a great case that highlights key factors in neonatal and infant resuscitation.  Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode of the FlightBridgeED podcast, Eric pulls together the evidence for the traditional drugs we push during RSI, for sedation and paralytics. Join us for an incredibly thought-provoking discussion that will challenge your foundational knowledge of these medications and further your clinical expertise.

As healthcare providers, much of what we struggle with is not what we take with us to the scene (our equipment, medications, and techniques) it's what we take back home with us after we have helped others in the most terrible situations of their lives. We are empathetic creatures, and we share in other people's pain. In addition, we may find ourselves struggling with our terrible situations at work or outside of work. In either case, those traumatic events take a little piece of us with them every time we encounter them.

Dave Olvera shared an incredibly impactful talk at FAST22 detailing his struggles with post-traumatic stress disorder (PTSD) and how he continues to overcome it daily. If there is something that you struggle with, it's important for you to find someone to help you move forward in a healthy way. You don't have to suffer, and you aren't alone. If you need help, FlightBridgeED can connect you with a mental health professional.
If you didn't make it out to FAST22 in Las Vegas, you won't want to miss FAST23! We are returning to Planet Hollywood Resort and Casino in Las Vegas this year, which promises to be bigger and better than last year! Tickets go on sale soon, so be sure to find out more information at FASTSYMPOSIUM.COM. Also, please share this content with your friends and rate and review it wherever you get your podcasts. Thanks so much for listening!

In this 3 part education series, Eric Bauer discusses ventilator management in the critical care environment and the different ventilation modes.

In this episode of The FlightBridgeED Podcast, we survey cardiac pharmacology as it relates to beta blockers and vasopressors.

In this episode of The FlightBridgeED Podcast, Eric introduces Damage Control RSI. While some of the concepts discussed are not necessarily new concepts, this package of best practice procedures, tips and tricks, and more will streamline your advanced airway practices. This podcast covers procedures, medications, and critical care concepts that you can begin using right away. Download this podcast from your favorite source and help us stay high on the charts so more people can find us. If you enjoy these podcasts, take a second to rate and review our podcast on iTunes, Google Play Music, Stitcher, or anywhere you find us. It really does make a big difference!

In this episode of The FlightBridgeED Podcast, Eric talks with ASTNA President Allen Wolfe.

In this three-part education series, Eric Bauer discusses ventilator management in the critical care environment. We look closely at cellular respiration and the different terminology related to ventilator management.

Claustrophobic and dark hallways surround our patients as they hysterically shake and fly to free themselves from the ever-tightening grasp of a hypoxic straightjacket. There are worse things than death, and as time fights against the minds of the providers, the insane realization that this critical patient may very well be toeing the edge of oblivion sets in. Join your host, Eric Bauer, as he walks with you down the terrifying corridors of the newest Nightmare Series podcast... The Hypoxic Status Seizure.

A Nightmare Series Podcast

In this video podcast, Eric dives into all things neuro and ischemic stroke pathophysiology. We discuss brain physiology, circulation, common thrombotic and embolic stroke etiology, recognition, assessment, and management based on current evidence-based practice. Don't miss this episode! So much good stuff! Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more.

This podcast is going to dive into the topic of TIME CONSTANT. Have you ever wondered how we truly determine the exhalation time for our ventilator patients? Time Constant is the concept that guides our care and determines the time needed for proper alveolar filling or emptying. We couple this podcast with a downloadable worksheet for practice that can be found in the show notes on the FlightBridgeED website under this podcast. The worksheet gives calculation examples, practice questions, and answers to check your work. I promise this podcast will challenge you, bring insight into problems you've encountered in the transport environment, and ultimately give you new tools that will make you better as a clinician. We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

Part 1: Bad information abounds. We wanted to get the band back together and give you a no-nonsense, non-political, non-biased easy to understand podcast about the COVID Vaccines (well, the mRNA versions) and talk about safety, efficacy, and everything else you wanted to know. We want you to be able to share this with your non-medical friends and family who may be on the fence when it comes to getting vaccinated. Thanks for continuing to support our podcast! Did you know many of our episodes can also be watched? Be sure to check out the FlightBridgeED channel on YouTube! We appreciate your subscriptions and views! Be sure to leave us a review and rating!

In this special episode, Ashley has kicked Eric out of the podcast studio and has gone solo. Join Ashley Bauer as she hosts the podcast and takes you through a Nightmare case study of a COVID-19 positive patient. She breaks down the initial presentation and moves through diagnostic studies, including labs, chest x-ray findings, and much more! This is a can't miss episode! We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks so much for listening!

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, Mike Verkest joins Eric and Dr. Dimitri Yannopoulos to discuss the role of ECMO in out-of-hospital cardiac arrest. Dr. Yannopoulos’s research involves cardiopulmonary resuscitation, hypothermia, and myocardial salvage during acute coronary syndromes. He is considered an authority in cardiorespiratory interactions and hypothermia during CPR. His work in the laboratories of Dr. Keith Lurie (at the University of Minnesota) and Dr. Henry Halperin (at Johns Hopkins University) has helped change current CPR practices. We will discuss the ARREST trial and learn about the trials he is blazing in cardiac arrest care.

The FlightbridgeED Podcast has been taken over! Chris Meeks joins us to discuss how the devil is in the details of our RSI procedures! Tune in to learn how applying a high-flow nasal cannula can significantly improve patient outcomes and your workload! Be sure to listen to the end for a huge announcement! 

This is a plug and introduction to all the FBE listeners to our newest podcast. The EMS Lighthouse Project Podcast exists to foster knowledge translation from peer-reviewed scientific journals to the street. Join Mike Verkest and Dr. Jeff Jarvis as they shine the bright light of science on EMS practice in an informative and fun way as they look deep into the research on epi in cardiac arrest. Does it help? Are there better outcomes? How do patients do based on neurological outcomes? Remember that reviews are key to helping keep us high on the charts where your friends and family can find us. We couldn’t make this podcast without you. Thanks for listening!

In this episode of The FlightBridgeED Podcast, we take a look at CVP and what it means to modern critical care practice. There are a lot of misconceptions about the correct ranges, what it tells us, and so much more. You won’t want to miss this incredibly informative podcast to get you on the road from Zero to Flow! If you love The FlightBridgeED Podcast, rate, and review wherever you get your podcasts. Thanks for listening!

In this episode of The FlightBridgeED Podcast, Eric clarifies and defines the role of Auto-PEEP. This often neglected measurement has big implications for our patients and adjustments should be made, but with caution and in small increments. Join us as we explore Ventilator Management - Ventilation Failure: Auto-PEEP Strategies.

Hot Off the Press! In this podcast, we dive into the 2018 Surviving Sepsis Update and look at the new recommendations, evaluate the evidence, and take a look at how this does or does not fit with other high-level evidence. We dive into the fluid debate, with a focus on Normal Saline vs. Lactated Ringers, whether 30mL/kg is based on the best evidence, whether fluid should be given based on true body weight or ideal body weight, and lastly, the hot topic of EtCO2 guided fluid resuscitation when coupled with passive leg raising. This is always a hot topic! Take a journey with me on this often disagreed subject! Lastly, we couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

In this episode of The FlightBridgeED Podcast, we pick up a conversation we began in a previous podcast (Forget the PARALYSIS and Treat the PAIN). Now, we will discuss the need for choosing appropriate medications and correctly managing their dosing to improve patient outcomes in critical care environments.

In this episode, Eric breaks down some of the changes that were made to the new sepsis protocols in 2021. Sepsis is one of the most common illnesses that we see in critical care medicine. It's important to understand the many dimensions of sepsis and how to treat it as a critical care provider. A 30-minute transport could make the difference in your patient's outcome; maybe even life, or death. Arm yourself with the latest information and ensure that you are providing the right care for your septic patients.

Using push dose pressors has become common practice in pre-hospital and critical care environments. We have seen many companies adopt protocols that guide the use of medications such as Epinephrine and Phenylephrine as the go-to medications in the setting of Rapid Sequence Intubation, with associated hemodynamic compromise. However, are these the best medications? We know that both Epinephrine and Phenylephrine come with many potential side effects. Is there a better option? Join us to find out more about "The New KID On The Block." Lastly, we couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

In this episode of The FlightBridgeED Podcast, a nightmare creeps from the tattered remains of a beaten and bruised patient. The wrenching grasp of death casts a long, dark shadow over the flight team as a crucial decision means life or death. What will happen? Will the patient survive? Join us for the mesmerizing tale of The Traumatic Airway.

In this episode of The FlightBridgeED Podcast, Eric covers neo-synephrine, and vasopressin as they are used in the pre-hospital and critical care clinical environments. He also discusses the research regarding methylene blue as a vasopressor.

In this episode of The FlightBridgeED Podcast, Eric catches up with our good friend and ultrasound guru Branden Miesemer of EMSPOCUS at AMTC. Recorded right from the convention floor, the guys discuss just what is EMSPOCUS and how it is being used in the pre-hospital world. Download, rate, review and subscribe from wherever you get your podcasts!

Eric Bauer introduces himself and The FlightBridgeED Podcast. In this first episode, he briefly describes this educational podcast series and the origins of FlightBridgeED.

In this episode of The FlightBridgeED Podcast, special guest Dave Olvera joins Eric on the show to bring our community some incredible facts, figures, and real-world applications of powerful, research-based advanced airway management best practice techniques. With years of evidence and statistics, this podcast will challenge you to critically analyze your airway skills and why it is that we perform the way that we do. You won't want to miss it! Join us for Changing Airway Management Culture: Using HEAVEN Criteria, VL & Decision Making with Dave Olvera.

In this episode of The FlightBridgeED Podcast, Eric picks up his magnifying glass and takes a close look at serum lactate. Is there enough evidence to support it, or is it snake oil? Join us as we uncover the evidence together.

In this episode of The FlightBridgeED Podcast, terror from the deep rises from the blackest abyss to wrap its tentacles around an innocent woman who has lost everything. The flight crew struggles to comprehend the twisted and strange horror but presses on in search of escape. Join us to discover the ending and what happens to our suffering victim. - A Nightmare Series Podcast -

Ashley Bauer continues her COVID conversation, with a focus on the pediatric population. The number of cases involving children and changes in symptoms have sparked a worldwide discussion as to what to do with these cases. Join the conversation! Download, subscribe, listen and share this podcast. We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks so much for listening!

You are called for an 18-year-old male who was intubated at a community hospital. That is probably the best thing they could have done. Listen to Eric as he describes the challenge of this patient and the associated ventilator strategies. Join the conversation! Download, subscribe, listen, and share this podcast. Don’t forget to subscribe wherever you get your podcasts!

In this episode, Eric dives into an amazing case of survival and breaks down all things hypothermia. We look at the current resuscitation recommendations and evaluate this case, the decision-making, and the ultimate outcome. How should you focus your approach on working with a hypothermia patient with a long downtime? You don't want to miss this episode. So much good stuff! Please like and review your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more.

FAST18 was Epic! If you missed FAST18... Don't worry, FAST19 is right around the corner - May 6-8, 2019 in Murfreesboro, TN. This is the fourth release of many FAST18 Rewinds that will be released throughout the next year, leading up to FAST19. This talk is a groundbreaking look into our mental ability to be ready for duty. This was one of my favorite talks and something everyone must hear! I promise you this will knock you down and pick you back up! Join James Boomhower a Flight Paramedic from Boston MedFlight with his talk "Fit For Duty"! We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

The "Pandemic Immunity Gap" is likely behind the massive surge in respiratory syncytial virus (RSV), with current CDC data showing a 275% increase from 2020-2021 to 2022-2023. The most vulnerable population is between 0-6 months old, which often raises the stress level for providers across all spectrums. Join Eric for a deep dive into a case study involving a 4-month-old male in acute respiratory compromise. We break down the progression of RSV and its association with bronchiolitis. Dive deep into the current evidence on fluid management, bronchodilators, corticosteroids, NS 0.9%, Hypertonic 3%, racemic epinephrine, HFNC, NiPPV, intubation, and much more. 

Recommended flow settings and cannula sizes for high-flow nasal cannula therapy in pediatric patients https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027347/table/t1-kjp-2019-00626/?report=objectonly

Corticosteroid Therapy During Acute Bronchiolitis in Patients Who Later Develop Asthma: Hosp Pediatr (2017) 7 (7): 403–409. https://doi.org/10.1542/hpeds.2016-0211

Efficacy of 3% hypertonic saline in bronchiolitis: A meta‑analysis,  Received May 10, 2018; Accepted August 22, 2018. DOI: 10.3892/etm.2019.7684

Respiratory syncytial virus: diagnosis, prevention and management: Ther Adv Infectious Dis 2019, Vol. 6: 1–9 DOI: 10.1177/2049936119865798

https://journals.sagepub.com/doi/epdf/10.1177/2049936119865798

Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;12CD001266.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001266.pub4/full

Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis

https://www.bmj.com/content/342/bmj.d1714

High-dose inhaled corticosteroids’ effect on wheezing in infants after respiratory syncytial virus infection: a randomized, double-blind placebo-controlled trial.

Ermers MJ, Rovers MM, van Woensel JB, Kimpen JL, Bont LJ; RSV Corticosteroid Study Group. High-dose inhaled corticosteroids’ effect on wheezing in infants after respiratory syncytial virus infection: a randomized, double-blind placebo-controlled trial. BMJ. 2009;338:b897.

Heliox inhalation therapy for bronchiolitis in infants

Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Database Syst Rev. 2010;4:CD006915.

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.

We are back to the horrors associated with "The Nightmare Patient". The flight crew is tenuously attempting to rip the patient out of death’s mouth and bring him back from the roaring mouth of oblivion. Will she be saved? How will her care be rendered? In this episode, Bruce Hoffman joins Eric for a look at the complexities associated with Tylenol toxicity. We look specifically at the physiology, associated labs, the four phases of toxicity, and associated treatment PEARLS. Don't miss this podcast. This is a highly tested subject on all advanced certification exams and can be a difficult patient to manage in general. Lastly, we couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

We have not seen anything like this... I would dare to say the COVID-19 pandemic will live in our memories for a lifetime. As the world watches, healthcare providers around the world are dealing with patients that have mild to severe symptom morphology. This podcast goes into the disease escalation and how the sickest patients end up in acute respiratory failure. Join me in part 1 of 2 in the COVID-19 series as we identify the disease evolution and look at the specific pathophysiology associated with the secondary effects seen with COVID-19 patients. Download, rate, and review wherever you get your podcasts. Reviews help us stay high on the chart where your friends and co-workers can find us. If you love our free podcast, help us spread the word!

FAST18 was Epic! If you missed FAST18... Don't worry, FAST19 has been planned and booked for May 6-8, 2019 in Murfreesboro, TN. This is the second of many FAST18 Rewinds that will be released throughout the next year, leading up to FAST19. This talk is a groundbreaking look into pediatric resuscitation by a true visionary. Join Dr. Peter Antevy with his talk "A Paradigm Shift In Pediatrics. We couldn’t make this podcast without you. Please rate, and review wherever you download the podcast. Thanks for listening!

Join Eric for a quick explanation of the shock index and how it applies to your practice in this Teachable Moment Mini Episode of the FlightBridgeED Podcast.

In this episode of The FlightBridgeED Podcast, a cardiac patient with a genetic anomaly is in a precarious battle for life against a deadly attacking disease. Conventional wisdom may not be the best medicine, and the flight crew has a choice to make. Will they fend off certain doom, or is there a second chance waiting for the victim? Find out now!

Join us for the NAEMT EMS World Expo in New Orleans and for a limited time, pick up the brand new 2nd edition of Ventilator Management: A Pre-Hospital Perspective for a special price!

In this episode of The FlightBridgeED Podcast, like a creature stepping forth from another dimension, an unexpected delivery catches the bewildered flight crew off guard in a dizzying rush to get on the ground. Join Eric as he presents the thrilling case of the In-Flight Delivery.