The FlightBridgeED Podcast

By FlightBridgeEDHealth & Fitness

The FlightBridgeED Podcast episodes

July 04, 2024 Every Breath They Take: ARDS Part 1
PART 1 of 2

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

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

Takeaways

• ARDS is a syndrome characterized by acute onset, bilateral infiltrates on imaging, and hypoxemia.

• The diagnosis of ARDS is based on criteria such as acute onset, infectious or inflammatory etiology, bilateral opacities on imaging, and impaired oxygenation.

• Lung protective ventilation aims to minimize lung injury by using low tidal volumes (6-8 ml/kg), maintaining plateau pressures below 30 cmH2O, and keeping FiO2 below 60%.

• Driving pressure, the difference between plateau pressure and PEEP, is a marker of lung compliance and can be used to guide ventilation adjustments.

• Individualized management is crucial, considering factors such as patient characteristics, response to therapy, and monitoring parameters.

• Regular assessment and optimization of ventilation settings are necessary to ensure effective and safe management of ARDS.

• Low tidal volumes should be based on the patient's pH and PCO2, with a focus on maintaining a safe pH level. If crews are unable to measure these parameters not decreasing tidal volumes lower than 4 cc/kg is reasonable.

• Point-of-care blood gases are essential for monitoring patients on low tidal volumes and making adjustments as needed.

• Oxygen saturation targets should be individualized based on the patient's condition and physiology, with a range above 88-92% often considered reasonable. However, this issue is controversial, and occasionally, lower saturations are considered acceptable.

• Steroids may be beneficial in ARDS patients, especially those with severe pneumonia, but the timing and dosing should be determined based on the patient's specific situation.

• Paralysis can be considered in unstable ARDS patients who cannot tolerate low tidal volumes, but it should be used selectively and in conjunction with deep sedation.

• The use of inhaled pulmonary vasodilators in ARDS is controversial, and no significant mortality benefit has been demonstrated. However, they may be considered a salvage therapy in patients on their way to an ECMO center or when other interventions have been exhausted. Inhaled pulmonary vasodilators, such as epoprostenol, can improve oxygenation and pulmonary arterial pressure in patients with ARDS and RV failure.

• The use of inhaled pulmonary vasodilators should be based on individual patient characteristics and the availability of resources.

• Proning in transport has been shown to be safe and effective. It should be considered for select cases, such as patients with high pulmonary arterial pressure or basilar atelectasis.

• Transport teams should be prepared to continue inhaled pulmonary vasodilator therapy if the patient is already receiving it.

• ECMO should be considered when conventional therapies have failed, and the patient's condition is reversible and not contraindicated.

• ECMO transport requires specialized training, clear guidelines, and ongoing communication with the receiving center.

• Alternative ventilator modes, such as APRV, have not shown significant benefit in large trials. Their use is controversial but not unreasonable in certain circumstances. Implementing these settings requires training, education, and clear protocols. Generally speaking, they should be used judiciously and in consultation with the receiving physician.

• Optimizing conventional therapies and providing high-quality care can often obviate the need for ECMO.

• Transport teams should be proactive in discussing potential ECMO candidates with the receiving physician and considering the appropriateness of ECMO for each patient.

References:

• 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

• 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

• 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

• 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

• 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

• 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

• 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.

• 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.

• 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.

• Matthay MA, Arabi Y, Arroliga AC, Bernard...
1 hr 2 min
June 18, 2024 Refractory Vasodilatory Septic Shock with Dr. Brittney Bernardoni
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.
45 min
May 20, 2024 Nightmare Series: The DKA Dilemma with Jean-Francois Couture
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.
43 min
May 10, 2024 FAST Archives: Oxygenation Assassin
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.
26 min
May 09, 2024 FAST Archives: Air Rescue During WEF: Special Conditions and Problems
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!
18 min
May 08, 2024 FAST Archives: A Change of Heart
In this enlightening episode of The FAST Archives, we feature a compelling talk by Bruce Hoffman titled "A Change of Heart." Bruce, a seasoned critical care nurse and paramedic with a rich background in ICU, ER, trauma, and cardiology, challenges conventional wisdom in the treatment of STEMI patients. Drawing on the latest evidence, he questions the rush to percutaneous coronary intervention (PCI) and whether our current metrics, like door-to-reperfusion times, are truly in the best interest of patient outcomes.

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

Check out all the talks from the FAST Archives series for more great talks like this one! Interested in seeing these speakers in person? This is your official invitation to come join us for FAST24! We hope to see you there!
17 min
May 07, 2024 FAST Archives: Equity in Emergency Care: What Does That Even Mean?
In this episode of The FAST Archives, Ritu Sahni explores the essential topic of equity in emergency care. With a background that includes EMS Medical Director roles, emergency medicine, and air ambulance experience, Ritu provides a comprehensive look at what it means to care for entire communities.

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

Tune in to gain a deeper understanding of how we can achieve equity in emergency care and why it's so crucial in our roles as public health providers.
15 min
May 06, 2024 FAST Archives: Parkland
In this deeply impactful episode of The FAST Archives, we focus on the tragic events of the Parkland school shooting on February 14, 2018, through the lens of Peter Antevy, who served as the EMS Medical Director on the scene that day. With his vast expertise in pre-hospital pediatrics and emergency medicine, Peter offers a detailed and respectful reflection on that tragic day, shedding light on what unfolded, what could have been improved, and the critical importance of being prepared for such events.

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

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

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

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

Life is like A Rollercoaster
A poem by Alex Schachter

Life is like a roller coaster
It has some ups and downs
Sometimes you can take it slow or very fast
It maybe hard to breath at times
But you have to push yourself and keep going
Your bar is your safety
It’s like your family and friends
You hold on tight and you don’t let go
But sometimes you might throw your hands up
Because your friends and family will always be with you
Just like that bar keeping you safe at all times
It maybe too much for you at times: the twists, the turns, the upside downs
But you get back up
You keep chugging along
Eventually it comes to a stop
You won’t know when or how
But you will know that’ll be time to get off and start anew
Life is like a roller coaster
49 min
May 03, 2024 FAST Archives: Do Any of These Medications Work in Cardiac Arrest? Demystifying the Controversies!
In this episode of The FAST Archives, William Heuser brings his extensive experience as a clinical critical care pharmacist, clinical toxicologist, and certified Flight Paramedic to demystify the controversial world of resuscitative medicine. In his dynamic talk, "Do Any of These Medications Work in Cardiac Arrest? Demystifying the Controversies!", Will examines the debate surrounding the administration of certain medications during cardiac arrest.

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

Don't forget to check out the other podcasts in the FAST Archives miniseries and join us at FAST24 for more talks like this one, including a brand-new one from Will! We hope to see you there! Enjoy the episode.
24 min
May 02, 2024 FAST Archives: Teaching, Trusting, and Teen Driving
Welcome back to The FAST Archives! In this episode, Ashley Liebig delivers a compelling talk, "Teaching, Trusting, and Teen Driving," where she explores the nuanced realities of learning, teaching, and belonging. Through her insights into psychological safety, cognitive learning theory, and feedback culture, Ashley opens up how the intricacies of how humans learn and interact... both the good stuff and the things we don't always have a great track record with as an industry. Maslow's hierarchy of needs emphasizes that our basic requirements must be met before we can focus on growth and learning. So grab yourself a snack and tune in to gain valuable knowledge from Ashley’s expertise, as she provides actionable advice that can enhance your approach to education and personal growth.
18 min

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The FlightBridgeED Podcast provides convenient, easy-to-understand critical care medical education and current topics related to the air medical industry. Each topic builds on another and weaves…