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

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

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

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

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

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

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

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

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

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

Key points

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

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

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

Key points

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key takeaways

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

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

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

Key takeaways

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

References – 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key Takeaways

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

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

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

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

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

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

Key Takeaways

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

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

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

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

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

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

Key Takeaways

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

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

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

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

Contact Mark Piehl at mpiehl@410medical.com

Key Takeaways:

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

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

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

Key Takeaways

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

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

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

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

Key Takeaways:

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

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

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

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

Key Takeaways:

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

Key Takeaways

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

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

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

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

Takeaways

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Takeaways

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

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

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

Takeaways

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

TAKEAWAYS

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

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

Key Takeaways:

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

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.

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

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

Key Takeaways:

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

References

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

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

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

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

TAKEAWAYS

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

REFERENCES

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

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

Key Takeaways: 

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

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

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References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key Takeaways:

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

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

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

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References

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

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

Some Takeaways to Listen For in this Episode:

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

Some Takeaways to Listen For in this Episode:

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

KEY TAKEAWAYS:

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

Show Notes...

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

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

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

Takeaways

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

References:

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

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

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

Takeaways

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

References:

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

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.

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

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.

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!

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

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

In 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.

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

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

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

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

Life is like A Rollercoaster
A poem by Alex Schachter

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

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.

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.

Currently, access to ECPR is limited, with only 1.68% of eligible patients receiving this treatment. Jason discusses how his team is working to expand ECPR’s availability in the Twin Cities, detailing the challenges, successes, and potential for replication of their mobile ECMO program in other regions. This talk offers valuable insights into the future of cardiac care and the possibilities of extending high-quality life-saving interventions to a broader population.

Tune in to hear about the transformative efforts being made to increase ECPR access and how these advancements could serve as a blueprint for communities across the nation. If you enjoyed this talk, check out the other episodes of the FAST Archives miniseries! Thank you so much for listening.

Ketamine has long been a celebrated player in emergency and critical care for its versatility and effectiveness. However, like any celebrity, it has its controversies. His talk explores the evidence for and against the use of Ketamine in various settings and circumstances, challenging its pristine reputation and highlighting the importance of cautious and informed use. Whether you're a staunch supporter or a skeptic of Ketamine, this episode offers a balanced view that will enrich your understanding of one of the most talked-about drugs in medicine. Tune in to uncover the complexities of Ketamine through the expert lens of Rob Bryant.

If you enjoyed this podcast, check out the other FAST Archives episodes we've recently released, and don't forget to join us at FAST24! Thank you so much for listening!

Allison, who spent a decade flying with a hospital-based helicopter EMS program in California, has recently returned to the ER as the pediatric emergency care coordinator. Her passion for emergency medicine and high-risk obstetrics shines through as she recounts how her team tackled a challenging AFE case.

During this talk, you'll learn the importance of quick thinking, teamwork, and solid training in navigating unexpected emergencies during childbirth. Alli describes the collaborative efforts that led to a positive patient outcome and provides valuable insights into managing high-risk obstetrical cases.

Whether in emergency medicine, critical care, or simply interested in understanding how EMS teams handle rare and complex scenarios, this episode offers a compelling and educational experience.

If you enjoy this episode, please check out the other FAST Archives episodes that we have recently released. Enjoy the episode!

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.

Kris and Sara Kaull share personal stories and discuss why it's so hard to let go of the high-intensity mindset when we're not on duty. They challenge us to think about the impact this can have on our relationships and overall well-being. As they peel back the layers, they offer insights into building meaningful connections and prioritizing self-care.

Tune in to find out why maintaining balance is crucial for a healthy and fulfilling life. This episode provides a fresh perspective on stepping back from work, embracing a more balanced lifestyle, and rediscovering the things that matter most.

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!

Please subscribe to The FlightBridgeED Podcast anywhere you listen to podcasts, and don't forget to pass on the knowledge! Share the podcast with friends and co-workers. We couldn't make this podcast without you! Thank you so much for listening! Enjoy the episode.

** Special thanks to Mark Mennie, our wonderful and talented photographer at FAST for the last couple of years!

SHOW NOTES
More information about Finding Feedback at the Medic Mindset website:
https://medicmindset.com/2022/02/08/finding-feedback-uwash-great-rounds-notes/

First up:  Pediatric patients on ventilators... it's a high-stakes game where small changes mean everything. In this essential talk, "Silent Killers in Pediatric Mechanical Ventilation", our very own Eric Bauer takes center stage breaking down the pitfalls to avoid and the strategies that will level up your vent skills for the littlest patients.

Please subscribe to The FlightBridgeED Podcast anywhere you listen to podcasts, and don't forget to pass on the knowledge! Share the podcast with friends and co-workers. We couldn't make this podcast without you! Thank you so much for listening! Enjoy the episode.

** Special thanks to Mark Mennie, our wonderful and talented photographer at FAST for the last couple of years!

This is the sixth 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 is one of our Assistant Medical Directors for the flight program. 

The topic of this podcast is Mechanical Ventilation and ARDS in pregnancy.  Although respiratory distress requiring intubation and ARDS in pregnancy is not very common, it is more common than some of the other pathologies we have discussed recently.  Mechanical ventilation of the pregnant patient can be intimidating, but rest assured that if you have the capabilities to manage other patients on a vent, you can manage the pregnant patient.  Generally speaking solid outcomes data is sparse and, generally speaking, most guidelines recommend vent management of mechanical ventilation in patients with or without ARDS similarly to non-pregnant patients…with a few exceptions.  This podcast reviews the basics of ARDS and evidence-based management.  It reviews some specific features of obstetric physiology and fetal gas exchange that are important to keep in mind.  Finally, we will review what guidance is available and review general recommendations for managing these patients in transport.

For additional learning and a more in-depth review of the evidence check out this talk on gas exchange and mechanical ventilation in critically ill patients by Dr. Allison Lankford (part of the amazing Maryland CC Project lecture series): http://maryland.ccproject.com/2023/05/30/lankford-gas-exchange-and-pulmonary-ventilation-in-the-critically-ill-obstetric-patient/

References

1. Abou-Arab O, Huette P, Debouvries F, Dupont H, Jounieaux V, Mahjoub Y. Inhaled nitric oxide for critically ill Covid-19 patients: a prospective study. Crit Care. Nov 12 2020;24(1):645. doi:10.1186/s13054-020-03371-x
2. Barrantes JH, Ortoleva J, O'Neil ER, et al. Successful Treatment of Pregnant and Postpartum Women With Severe COVID-19 Associated Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation. Asaio j. Feb 1 2021;67(2):132-136. doi:10.1097/mat.0000000000001357
3. Bhatia PK, Biyani G, Mohammed S, Sethi P, Bihani P. Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature. J Anaesthesiol Clin Pharmacol. Oct-Dec 2016;32(4):431-439. doi:10.4103/0970-9185.194779
4. Boelig RC, Saccone G, Bellussi F, Berghella V. MFM guidance for COVID-19. Am J Obstet Gynecol MFM. May 2020;2(2):100106. doi:10.1016/j.ajogmf.2020.100106
5. Campbell LA, Klocke RA. Implications for the pregnant patient. Am J Respir Crit Care Med. Apr 2001;163(5):1051-4. doi:10.1164/ajrccm.163.5.16353
6. Carter AM. Factors affecting gas transfer across the placenta and the oxygen supply to the fetus. J Dev Physiol. Dec 1989;12(6):305-22. 
7. Carter AM. Placental Gas Exchange and the Oxygen Supply to the Fetus. Compr Physiol. Jul 1 2015;5(3):1381-403. doi:10.1002/cphy.c140073
8. Cavalcante FML, Fernandes CDS, Rocha LDS, Galindo-Neto NM, Caetano J, Barros LM. Use of the prone position in pregnant women with COVID-19 or other health conditions. Rev Lat Am Enfermagem. 2021;29:e3494. doi:10.1590/1518-8345.5181.3494
9. Cojocaru L, Turan OM, Levine A, et al. Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19. J Matern Fetal Neonatal Med. Dec 2022;35(25):9043-9052. doi:10.1080/14767058.2021.2013464
10. Cole DE, Taylor TL, McCullough DM, Shoff CT, Derdak S. Acute respiratory distress syndrome in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S269-78. doi:10.1097/01.ccm.0000182478.14181.da
11. D'Souza R, Ashraf R, Rowe H, et al. Pregnancy and COVID-19: pharmacologic considerations. Ultrasound Obstet Gynecol. Feb 2021;57(2):195-203. doi:10.1002/uog.23116
12. Danish MA. Mechanical Ventilation in Critically Ill Obstetric Patient. Principles of Critical Care in Obstetrics. 2016:133-141:chap Chapter 14.
13. Delyoa-Tomas E M-LT, Lopez-Fermin J, Perez-Nieto OR, et al. Consideration for Mechanical Ventilation in the Critically Ill Obstetric Patient. Crit Care Obst Gyne. 2020;6(10):1-8. 
14. Douglass KM, Strobel KM, Richley M, et al. Maternal-Neonatal Dyad Outcomes of Maternal COVID-19 Requiring Extracorporeal Membrane Support: A Case Series. Am J Perinatol. Jan 2021;38(1):82-87. doi:10.1055/s-0040-1718694
15. Ende H, Varelmann D. Respiratory Considerations Including Airway and Ventilation Issues in Critical Care Obstetric Patients. Obstet Gynecol Clin North Am. Dec 2016;43(4):699-708. doi:10.1016/j.ogc.2016.07.002
16. Gattinoni L, Camporota L, Marini JJ. Prone Position and COVID-19: Mechanisms and Effects. Crit Care Med. May 1 2022;50(5):873-875. doi:10.1097/ccm.0000000000005486
17. Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. Jul 2023;49(7):727-759. doi:10.1007/s00134-023-07050-7
18. Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. Dec 22 2005;353(25):2683-95. doi:10.1056/NEJMra051884
19. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. Jun 6 2013;368(23):2159-68. doi:10.1056/NEJMoa1214103
20. Huang C-Y, Tsai Y-L, Lin C-K. The prone position ventilation (PPV) as an approach in pregnancy with acute respiratory distress syndrome (ARDS). Taiwanese Journal of Obstetrics and Gynecology. 2021/05/01/ 2021;60(3):574-576. doi:https://doi.org/10.1016/j.tjog.2021.03.036
21. Khalil M, Butt A, Kseibi E, Althenayan E, Alhazza M, Sallam H. COVID-19-Related Acute Respiratory Distress Syndrome in a Pregnant Woman Supported on ECMO: The Juxtaposition of Bleeding in a Hypercoagulable State. Membranes (Basel). Jul 17 2021;11(7)doi:10.3390/membranes11070544
22. Kodali BS, Wong MJ, Lankford A, Lee K, Bharadwaj S. Effect of Fetal Delivery on Pao2/Fio2 Ratio During Mechanical Ventilation in Parturients With COVID-19: A Case Series. A A Pract. Jul 1 2022;16(7):e01587. doi:10.1213/xaa.0000000000001587
23. Lam GK, Stafford RE, Thorp J, Moise KJ, Jr., Cairns BA. Inhaled nitric oxide for primary pulmonary hypertension in pregnancy. Obstet Gynecol. Nov 2001;98(5 Pt 2):895-8. doi:10.1016/s0029-7844(01)01549-6
24. Lapinsky SE. Acute respiratory failure in pregnancy. Obstet Med. Sep 2015;8(3):126-32. doi:10.1177/1753495X15589223
25. Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients. Crit Care. 2009;13(2):206. doi:10.1186/cc7146
26. Lapinsky SE, Viau-Lapointe J. Mechanical Ventilation and Delivery During Pregnancy. Chest. Mar 2023;163(3):473-474. doi:10.1016/j.chest.2022.10.025
27. Lim MJ, Lakshminrusimha S, Hedriana H, Albertson T. Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment. Seminars in Fetal and Neonatal Medicine. 2023;28(1)doi:10.1016/j.siny.2023.101426
28. Linassi F, Campagnolo M, Busato E, Ortolani V, Peta M. Prolonged prone position in pregnant woman with COVID-19 pneumonia. Journal of Anesthesia, Analgesia and Critical Care. 2022/04/12 2022;2(1):16. doi:10.1186/s44158-022-00044-9
29. Lucarelli E, Behn C, Lashley S, Smok D, Benito C, Oyelese Y. Mechanical Ventilation in Pregnancy Due to COVID-19: A Cohort of Three Cases. Am J Perinatol. Aug 2020;37(10):1066-1069. doi:10.1055/s-0040-1713664
30. Magala Ssekandi A, Sserwanja Q, Olal E, Kawuki J, Bashir Adam M. Corticosteroids Use in Pregnant Wom...

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

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

Changes in acid-base balance have a profound influence on many aspects of the action of drugs. This is illustrated by data on the absorption of drugs from the stomach and intestine, changes in the distribution of drugs between plasma and cells, and the effect of changes in pH. Join us as Will breaks down the pathophysiology and decision-making in these low pH states. When do we deploy sodium bicarbonate? Is there a trade-off?  How is pharmacology affected by low pH states?  This episode is a can't-miss, with the brilliant Will Heuser, PharmD, BCCCP, MS, EMT-P, FP-C. Please like and review on your current podcast app, including Spotify, Google Play, iTunes, PodBean, and many more. We appreciate your support over the past 11 years!

Contact Info:
Will Heuser, PharmD, BCCCP, MS, EMT-P, FP-C
wheuser@northwell.edu

New Global Definition for Acute Respiratory Distress Syndrome

The topic of this podcast is peripartum cardiomyopathy.  Acquired cardiac conditions in otherwise healthy pregnant patients can be a serious and life-threatening condition.  Sometimes, critical care transport crews are called to transport pregnant or recently postpartum females with severe, acquired cardiomyopathy or in frank cardiogenic shock.  This podcast reviews the presentation, underlying pathophysiology, and management of this patient population.  

References

 1.          Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. Apr 5 2016;133(14):1397-409. doi:10.1161/CIRCULATIONAHA.115.020491

2.          Cherubin S, Peoples T, Gillard J, Lakhal-Littleton S, Kurinczuk JJ, Nair M. Systematic review and meta-analysis of prolactin and iron deficiency in peripartum cardiomyopathy. Open Heart. Oct 2020;7(2)doi:10.1136/openhrt-2020-001430

3.          Cooper LT, Mather PJ, Alexis JD, et al. Myocardial recovery in peripartum cardiomyopathy: prospective comparison with recent onset cardiomyopathy in men and nonperipartum women. J Card Fail. Jan 2012;18(1):28-33. doi:10.1016/j.cardfail.2011.09.009

4.          Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol. Jan 21 2020;75(2):207-221. doi:10.1016/j.jacc.2019.11.014

5.          Dinic V, Markovic D, Savic N, Kutlesic M, Jankovic RJ. Peripartum Cardiomyopathy in Intensive Care Unit: An Update. Front Med (Lausanne). 2015;2:82. doi:10.3389/fmed.2015.00082

6.          Djordjevic I, Rahmanian P, Zeriouh M, et al. Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center. J Card Surg. Jan 2020;35(1):254-257. doi:10.1111/jocs.14324

7.          Elkayam U, Akhter MW, Singh H, et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. Apr 26 2005;111(16):2050-5. doi:10.1161/01.CIR.0000162478.36652.7E

8.          Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. Apr 13 2000;342(15):1077-84. doi:10.1056/nejm200004133421502

9.          Gorog DA, Vilahur G. Peripartum cardiomyopathy: can the link between prolactin and PAI-1 provide a clue? Cardiovasc Res. Sep 1 2020;116(11):1791-1793. doi:10.1093/cvr/cvaa109

10.        Habedank D, Kuhnle Y, Elgeti T, Dudenhausen JW, Haverkamp W, Dietz R. Recovery from peripartum cardiomyopathy after treatment with bromocriptine. Eur J Heart Fail. Nov 2008;10(11):1149-51. doi:10.1016/j.ejheart.2008.09.001

11.        Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J. May 7 2015;36(18):1090-7. doi:10.1093/eurheartj/ehv009

12.        Hilfiker-Kleiner D, Kaminski K, Podewski E, et al. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell. Feb 9 2007;128(3):589-600. doi:10.1016/j.cell.2006.12.036

13.        Iorgoveanu C, Zaghloul A, Ashwath M. Peripartum cardiomyopathy: a review. Heart Fail Rev. Nov 2021;26(6):1287-1296. doi:10.1007/s10741-020-10061-x

14.        Kim MJ, Shin MS. Practical management of peripartum cardiomyopathy. Korean J Intern Med. May 2017;32(3):393-403. doi:10.3904/kjim.2016.360

15.        Kumar A, Ravi R, Sivakumar RK, et al. Prolactin Inhibition in Peripartum Cardiomyopathy: Systematic Review and Meta-analysis. Curr Probl Cardiol. Feb 2023;48(2):101461. doi:10.1016/j.cpcardiol.2022.101461

16.        Maning J, Ebner B, Vincent L, et al. Abstract 15717: Impact of Mechanical Circulatory Support on Outcomes and In-hospital Mortality of Peripartum Cardiomyopathy Patients With Cardiogenic Shock: An Analysis of the Nis Database. Circulation. 2020;142(Suppl_3)doi:10.1161/circ.142.suppl_3.15717

17.        Metz TD, Khanna A. Evaluation and Management of Maternal Cardiac Arrhythmias. Obstet Gynecol Clin North Am. Dec 2016;43(4):729-745. doi:10.1016/j.ogc.2016.07.014

18.        Sieweke JT, Pfeffer TJ, Berliner D, et al. Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy. Eur Heart J Acute Cardiovasc Care. Mar 2020;9(2):173-182. doi:10.1177/2048872618777876

19.        Sliwa K, Blauwet L, Tibazarwa K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation. Apr 6 2010;121(13):1465-73. doi:10.1161/CIRCULATIONAHA.109.901496

20.        Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary Management of Cardiogenic Shock During Pregnancy. J Card Fail. Feb 2023;29(2):193-209. doi:10.1016/j.cardfail.2022.09.014

21.        Triebel J, Clapp C, Martinez de la Escalera G, Bertsch T. Remarks on the Prolactin Hypothesis of Peripartum Cardiomyopathy. Front Endocrinol (Lausanne). 2017;8:77. doi:10.3389/fendo.2017.00077

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, ...

This podcast focuses on severe postpartum hemorrhage.  We discuss the epidemiology and risk factors as well as the nuances of diagnosis, specifically how blood loss is actually quantified in this setting.  We also go through the importance of point-of-care ultrasound to help identify and manage the causes of postpartum hemorrhage.  Then, we transition to the discussion of management, focusing on the medical management of uterine atony, and also go over advanced interventions such as uterine packing, balloon tamponade devices, and REBOA.  Finally, Dr. Garchar discusses the indication and procedure for emergent hysterectomy as well as the post-procedure management critical care transport crews may have to perform.

References

1. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. Oct 2017;130(4):e168-e186. doi:10.1097/aog.0000000000002351
2. Abdel-Aleem H, Singata M, Abdel-Aleem M, Mshweshwe N, Williams X, Hofmeyr GJ. Uterine massage to reduce postpartum hemorrhage after vaginal delivery. Int J Gynaecol Obstet. Oct 2010;111(1):32-6. doi:10.1016/j.ijgo.2010.04.036
3. Abul A, Al-Naseem A, Althuwaini A, Al-Muhanna A, Clement NS. Safety and efficacy of intrauterine balloon tamponade vs uterine gauze packing in managing postpartum hemorrhage: A systematic review and meta-analysis. AJOG Glob Rep. Feb 2023;3(1):100135. doi:10.1016/j.xagr.2022.100135
4. Aibar L, Aguilar MT, Puertas A, Valverde M. Bakri balloon for the management of postpartum hemorrhage. Acta Obstet Gynecol Scand. Apr 2013;92(4):465-7. doi:10.1111/j.1600-0412.2012.01497.x
5. Bagga R, Jain V, Kalra J, Chopra S, Gopalan S. Uterovaginal packing with rolled gauze in postpartum hemorrhage. MedGenMed. Feb 13 2004;6(1):50.
6. Borger van der Burg BLS, van Dongen T, Morrison JJ, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. Aug 2018;44(4):535-550. doi:10.1007/s00068-018-0959-y
7. Castellini G, Gianola S, Biffi A, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg. Aug 12 2021;16(1):41. doi:10.1186/s13017-021-00386-9
8. Collaborators WT. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. May 27 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4
9. Cunningham FG, Nelson DB. Disseminated Intravascular Coagulation Syndromes in Obstetrics. Obstet Gynecol. Nov 2015;126(5):999-1011. doi:10.1097/AOG.0000000000001110
10. D'Alton M, Rood K, Simhan H, Goffman D. Profile of the Jada(R) System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage. Expert Rev Med Devices. Sep 2021;18(9):849-853. doi:10.1080/17434440.2021.1962288
11. Dildy GA, 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. Jun 2002;45(2):330-44. doi:10.1097/00003081-200206000-00005
12. Dueckelmann AM, Hinkson L, Nonnenmacher A, et al. Uterine packing with chitosan-covered gauze compared to balloon tamponade for managing postpartum hemorrhage. Eur J Obstet Gynecol Reprod Biol. Sep 2019;240:151-155. doi:10.1016/j.ejogrb.2019.06.003
13. Erez O. Disseminated intravascular coagulation in pregnancy: New insights. Thrombosis Update. 2022;6doi:10.1016/j.tru.2021.100083
14. Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol. Oct 2015;213(4):452-63. doi:10.1016/j.ajog.2015.03.054
15. 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
16. Feng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia. Jul 2017;72(7):853-858. doi:10.1111/anae.13895
17. Higgins N, Patel SK, Toledo P. Postpartum hemorrhage revisited: new challenges and solutions. Curr Opin Anaesthesiol. Jun 2019;32(3):278-284. doi:10.1097/ACO.0000000000000717
18. Ji SM, Cho C, Choi G, et al. Successful management of uncontrolled postpartum hemorrhage due to morbidly adherent placenta with Resuscitative endovascular balloon occlusion of the aorta during emergency cesarean section - A case report. Anesth Pain Med (Seoul). Jul 31 2020;15(3):314-318. doi:10.17085/apm.19051
19. Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev. Jul 1 2020;7(7):CD013663. doi:10.1002/14651858.CD013663
20. Kogutt BK, Vaught AJ. Postpartum hemorrhage: Blood product management and massive transfusion. Semin Perinatol. Feb 2019;43(1):44-50. doi:10.1053/j.semperi.2018.11.008
21. 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
22. Liu C, Gao J, Liu J, et al. Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage. Front Med (Lausanne). 2021;8:656422. doi:10.3389/fmed.2021.656422
23. Lohano R, Haq G, Kazi S, Sheikh S. Intrauterine balloon tamponade for the control of postpartum haemorrhage. J Pak Med Assoc. Jan 2016;66(1):22-6.
24. Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol. Aug 1993;169(2 Pt 1):317-21; discussion 321-3. doi:10.1016/0002-9378(93)90082-t
25. Makin J, Suarez-Rebling DI, Varma Shivkumar P, Tarimo V, Burke TF. Innovative Uses of Condom Uterine Balloon Tamponade for Postpartum Hemorrhage in India and Tanzania. Case Rep Obstet Gynecol. 2018;2018:4952048. doi:10.1155/2018/4952048
26. Natarajan A, Alaska Pendleton A, Nelson BD, et al. Provider experiences with improvised uterine balloon tamponade for the management of uncontrolled postpartum hemorrhage in Kenya. Int J Gynaecol Obstet. Nov 2016;135(2):210-213. doi:10.1016/j.ijgo.2016.05.006
27. Natarajan A, Kamara J, Ahn R, et al. Provider experience of uterine balloon tamponade for the management of postpartum hemorrhage in Sierra Leone. Int J Gynaecol Obstet. Jul 2016;134(1):83-6. doi:10.1016/j.ijgo.2015.10.026
28. Okoye HC, Nwagha TU, Ugwu AO, et al. Diagnosis and treatment of bbstetrics disseminated intravascular coagulation in resource limited settings. Afr Health Sci. Mar 2022;22(1):183-190. doi:10.4314/ahs.v22i1.24
29. Ordonez CA, Manzano-Nunez R, Parra MW, et al. Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abno...

References for the use of Calcium in Severe Trauma

1. Chanthima P, Yuwapattanawong K, Thamjamrassri T, et al. Association Between Ionized Calcium Concentrations During Hemostatic Transfusion and Calcium Treatment With Mortality in Major Trauma. Anesth Analg. Jun 1 2021;132(6):1684-1691. doi:10.1213/ANE.0000000000005431
2. D B. Prehospital administration of calcium in trauma J Paramed Prac. 2022;
3. DeBot M, Sauaia A, Schaid T, Moore EE. Trauma-induced hypocalcemia. Transfusion. Aug 2022;62 Suppl 1:S274-S280. doi:10.1111/trf.16959
4. Ditzel RM, Jr., Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. Mar 2020;88(3):434-439. doi:10.1097/TA.0000000000002570
5. Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. May 1 2016;202(1):182-7. doi:10.1016/j.jss.2015.12.036
6. Kronstedt S, Roberts N, Ditzel R, et al. Hypocalcemia as a predictor of mortality and transfusion. A scoping review of hypocalcemia in trauma and hemostatic resuscitation. Transfusion. Aug 2022;62 Suppl 1(Suppl 1):S158-S166. doi:10.1111/trf.16965
7. Leech C, Clarke E. Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice. Resusc Plus. Sep 2022;11:100282. doi:10.1016/j.resplu.2022.100282
8. Messias Hirano Padrao E, Bustos B, Mahesh A, et al. Calcium use during cardiac arrest: A systematic review. Resusc Plus. Dec 2022;12:100315. doi:10.1016/j.resplu.2022.100315
9. Moore HB, Tessmer MT, Moore EE, et al. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg. May 2020;88(5):588-596. doi:10.1097/TA.0000000000002614
10. Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines (Basel). Mar 24 2021;8(4)doi:10.3390/medicines8040016
11. Steele T, Kolamunnage-Dona R, Downey C, Toh CH, Welters I. Assessment and clinical course of hypocalcemia in critical illness. Crit Care. Jun 4 2013;17(3):R106. doi:10.1186/cc12756
12. Stueven H, Thompson BM, Aprahamian C, Darin JC. Use of calcium in prehospital cardiac arrest. Ann Emerg Med. Mar 1983;12(3):136-9. doi:10.1016/s0196-0644(83)80551-4
13. Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. Dec 14 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929
14. Vallentin MF, Povlsen AL, Granfeldt A, Terkelsen CJ, Andersen LW. Effect of calcium in patients with pulseless electrical activity and electrocardiographic characteristics potentially associated with hyperkalemia and ischemia-sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial. Resuscitation. Dec 2022;181:150-157. doi:10.1016/j.resuscitation.2022.11.006
15. Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients: A systematic review. J Trauma Acute Care Surg. Feb 1 2021;90(2):396-402. doi:10.1097/TA.0000000000003027
16. Vettorello M, Altomare M, Spota A, et al. Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion. J Pers Med. Dec 28 2022;13(1)doi:10.3390/jpm13010063
17. Wray JP, Bridwell RE, Schauer SG, et al. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emerg Med. Mar 2021;41:104-109. doi:10.1016/j.ajem.2020.12.065
18. Zhang Z, Xu X, Ni H, Deng H. Predictive value of ionized calcium in critically ill patients: an analysis of a large clinical database MIMIC II. PLoS One. 2014;9(4):e95204. doi:10.1371/journal.pone.0095204

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
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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
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Contact information for Kevin Collopy

Twitter: @ktcollopy

Email: Kevin.Collopy@novanthealth.org 

This is an audio version only. For the best experience, we highly recommend watching the full video version. Please visit the YouTube link below or the FlightBridgeED channel. 

Episode Link: https://youtu.be/nhlll1hI7XU

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.

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

Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury

https://doi.org/10.1016/j.amj.2022.04.004

Abstract

"A 25-year-old male patient was critically injured in a high-speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increased intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport, paramedics initiated a severe traumatic brain injury protocol which included the administration of 3% hypertonic saline."

Kevin Hazzard is the author of A 1000 Naked Strangers, a 10-year veteran Paramedic in Atlanta, and current nursing student. In this podcast, we discuss the inspiration for the book, why its a must read, the history of EMS as we know it and the true origins of EMS as told in this story. We discuss the first 24 Paramedics in the United States and how this group paved the way for thousands of pre-hospital providers today.

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!

We invite you to listen wherever you get your podcasts, and if you like the content, please don't forget to share it. Thanks so much for listening, and don't forget to listen to episode 3, which is coming soon!

Among many concepts, you will learn why it's wrong to bolus your pediatric DKA patients with tons of fluid and why sodium bicarbonate is not your friend in these cases. Also, check out the show notes! These are incredible resources that you can use in your own practice!

Show Notes:

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/Bicarb_DKA_Pediatrics.pdf

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/DKA-pathway.pdf

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/Kupperman+NEJM+2018_Fluids.pdf

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/NEJM.pdf

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/Neonatal_DKA+case+report.pdf

https://f001.backblazeb2.com/file/flightbridgeed-podcast/shownotes/episode210/peds_protecting+the+brain.pdf

Download the Referenced Study Information