The FlightBridgeED Podcast FlightBridgeED

This is a must-listen! What’s the best way to pre-oxygenate our patients prior to intubation? The evidence for this question has been mixed for some time. Dr Jarvis discusses the PREOXI Trial, which directly compares preoxygenation with non-invasive ventilation compared to a face mask to see which provides the best protection against peri-intubation hypoxia. This is an important trial that sheds light on a key component of our bundle of care to make intubation safer.
Citations:
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)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.Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.Groombridge C, et al: Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med. 2016;March;23(3):342–6.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.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.Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006Solis 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.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.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 AttemptUsing Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.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, Michael Lauria and his distinguished guests (Brittney Bernardoni, Matt Roginski, and Skyler Lentz) discuss the management of acute respiratory distress syndrome (ARDS). They cover the pathophysiology of ARDS, the criteria for diagnosis, and the basics of lung protective ventilation. They 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. There are practical tips for adjusting ventilation settings, and the need for ongoing assessment and optimization is emphasized. In this monster of an episode, the speakers discuss the approach to low tidal volumes in ARDS patients and the use of point-of-care blood gases, explore the use of steroids in ARDS, target oxygen saturation levels, the use of paralysis and inhaled pulmonary vasodilators, proning in transport, alternative ventilator modes, and the indications for ECMO in refractory ARDS. I told you, this is a monster! There is a lot to unpack in this episode, but it is full of crucial evidence-based medicine that, if you're not already using in your area, you probably will soon be using it!
 This episode was recorded remotely with guests in different locations. While we prioritize audio quality, external factors occasionally challenge our standards. Some audio issues are present, but we believe they do not detract from the conversation and topics discussed.
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SHOW NOTESTakeaways
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, focusing on maintaining a safe pH level.Point-of-care blood gases are essential for monitoring patients on low tidal volumes and adjusting as needed.Without point-of-care blood gases, a tidal volume of 4 cc/kg is generally considered the floor, but blood gas should be checked to ensure safety.Oxygen saturation targets should be individualized based on the patient's condition and physiology, with a range of 88-92% often considered reasonable.Steroids may benefit 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 should be consi

In this episode of the FlightBridgeED MDCast, Dr. Mike Lauria and Dr. Brittney Bernardoni discuss the management of refractory hypotension in septic patients. They explore the use of norepinephrine as the initial pressor of choice and the benefits of vasopressin as a second-line agent. They also discuss the use of inotropes, such as epinephrine and dobutamine, and the importance of assessing cardiac function with ultrasound. The conversation provides practical guidance for managing hypotensive septic patients in various clinical settings. In this conversation, the hosts discuss the use of different therapies for refractory shock and sepsis. They cover topics such as pressors, fluid resuscitation, steroids, bicarbonate, calcium, and all levels of therapies. Mike and Britteny provide insight into the evidence-based use of these therapies and offer practical tips for their administration in the hospital and in the critical care transport medicine field. Overall, the conversation provides a comprehensive overview of refractory shock and sepsis management.
Key Takeaways to Pay Attention to During This Discussion
Mean arterial pressure (MAP) is the best number to assess hypotension, with a goal of MAP > 65.Norepinephrine is the workhorse pressor for septic patients, providing both venous and arterial constriction.Vasopressin is a valuable second-line agent, especially for patients with right heart dysfunction or acidosis.There is no maximum dose for norepinephrine, but doses above 2.0 mcg/kg/min may not provide additional benefit.Ultrasound assessment of cardiac function is crucial in determining the need for inotropes.Epinephrine is the preferred inotrope due to its increased squeeze and peripheral vasoconstriction.Dobutamine is not commonly used in vasoplegic shock due to its peripheral vasodilation effects. Pressors such as norepinephrine are the first-line therapy for refractory shock and sepsis.Steroids, specifically hydrocortisone, can be considered in patients on norepinephrine more than 0.25.Bicarbonate can be used to increase pH, but caution must be taken to ensure proper ventilation.Calcium chloride or calcium gluconate can be used to address low calcium levels.In refractory cases, level three therapies, such as angiotensin 2, methylene blue, and cyanocid, may be considered.

As night falls, a critical medical battle against Diabetic Ketoacidosis (DKA) begins. This formidable foe, hidden within the body's chemistry, pushes patients towards peril. In this thrilling installment of the FlightBridgeED Nightmare Series, EMS providers face a relentless race against time, striving to subdue the devastating effects of DKA before it's too late.
Host Eric Bauer and Jean-Francois Couture, Emergency Physician and Director of Operations at Applications MD, guide us through the intricacies of managing this complex medical emergency. With every passing moment, the tension escalates. Will our EMS warriors decode the mysteries of DKA in time to save their patient? Tune in to discover if they can deliver salvation from the brink of metabolic disaster.

In this final episode of The FAST Archives miniseries, we're thrilled to present a talk from Chris Meeks. Chris is not just any paramedic and educator; he's a veteran with a knack for making complex medical topics approachable. Today, he's breaking down "Oxygenation Assassin," a deep dive into the world of hypoplastic left heart syndrome—a challenging congenital heart defect.
Chris will walk us through the hemodynamic hurdles of the condition and share essential tips for acute care management. You'll get a solid grasp of the underlying physiology and see how learning about conditions like this - the "small percentage" cases - can drastically improve patient outcomes.
If you enjoy this episode, we invite you to check out the other talks from the FAST Archives miniseries. You can also catch these speakers and more at FAST24 happening June 10 - 12, 2024, in Wilmington, North Carolina. Tickets are still available at FBEFAST.COM. Enjoy the episode and we hope to see you at FAST24.

In this episode of The FAST Archives, we explore a unique challenge in emergency medical planning from Helge Junge, who leads a team specialized in air rescue operations. Helge shares the intricate details of developing a comprehensive care and transport system for the World Economic Forum, held in the challenging and mountainous terrain of the Swiss Alps. The forum's location posed significant logistical and medical challenges, including potential mass casualty scenarios and limited local medical resources.
His talk, "Air Rescue During WEF: Special Conditions and Problems," provides an in-depth analysis of how his team overcame these hurdles to establish a robust emergency response system. The solutions they created ensured attendees' safety and well-being and offered valuable lessons for managing mass casualty incidents (MCI) and rescue operations in austere conditions.
If you enjoy this talk, check out the other talks from the FAST Archives miniseries! We hope you enjoy them!