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

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

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

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

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

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

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

Key Points

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

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

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

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

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

Key Points

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

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

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

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

Key points

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

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

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

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

Key points

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key points

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

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

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

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

Key points

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

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

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

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

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

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

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

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

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