The FlightBridgeED Podcast

Mechanical Ventilation and ARDS – Podcast Summary and References

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...

In this episode, we uncover the enigmatic world of refractory shock in prehospital trauma patients. Shock, often recognized as a critical condition, becomes even more complex when it resists conventional treatment. Join Eric as he discusses resuscitation in vasoplegic patients refractory to fluids and blood products. Tune in to "Hidden Harms" and embark on a journey to unveil the complexities of refractory shock in prehospital trauma patients. 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 12 years! 

In this episode, we delve into the complexities surrounding a challenging COPD patient scenario, focusing on treatment considerations and the broader scope of mechanical ventilation management. We underscore essential lessons gleaned from this case, emphasizing the significance of adopting an obstructive approach, the nuanced application of I:E ratio, and the comprehensive management strategies for hypercapnic patients. Join us as we navigate through this intricate medical terrain, shedding light on effective approaches and valuable insights crucial for optimizing patient care in similar scenarios. 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 12 years! 

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Disseminated Intravascular Coagulation 

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Join Eric and Will Heuser, PharmD, discussing "The Influence of Low pH on Efficacy of Critical Care Pharmacology."

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

Since the 2012 Berlin Definition of the Acute Respiratory Distress Syndrome (ARDS), several developments have supported the need for an expansion of the definition, including the use of high-flow nasal oxygen (HFNO), expanding the use of pulse oximetry in place of arterial blood gases, use of ultrasound for chest imaging, and the need for applicability in resource-limited settings. Join Eric as he dives into the previous ARDS definitions, the pathophysiology around "PseudoARDS," and the new global definition. 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!

New Global Definition for Acute Respiratory Distress Syndrome

This is the third episode of a special podcast series on obstetric critical care.  Although I am the sole host of this podcast, the content was reviewed and edited 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 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

In this episode, Eric looks at warm fluids... or lack thereof in resuscitation. We will cover the current evidence around hypothermia in resuscitation secondary to the infusion of cold IV fluids. We discuss current strategies in warming fluids before administration in warm and cold ambient environments and the impact on body systems that ultimately contribute to increased mortality. 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! 

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

28.        Zelop C, Einav S, ...

This is the first 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 special 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.

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...

Calcium administration to trauma patients has become a hot topic with the rise of the “Lethal Diamond."  While evidence exists regarding the association between hypocalcemia and mortality, it remains unclear whether hypocalcemia is the problem or simply a finding secondary to critical injury.  In this podcast, Dr. Lauria reviews the evidence behind calcium administration in trauma and identifies which patients, given the available evidence, might benefit from calcium administration. Don't miss another FlightBridgeED Podcast feature episode of the MDCast! So much good stuff! Please like, subscribe, and leave any questions or comments.

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

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

References for Acute Salicylate Intoxication

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

In this podcast, Eric discusses the art of having a "Resuscitative Mindset" when performing advanced airway management with guest host Kevin Collopy. When is it ok to perform advanced airway management rapidly? Is it ever ok? When do we deploy delayed sequence strategies?  Should we always use a "Resuscitative" sequence intubation mindset regardless of our assessment findings?  So much good conversation about all things airway and decision-making. Please like, subscribe, and leave any questions or comments.

Contact information for Kevin Collopy

Twitter: @ktcollopy

Email: Kevin.Collopy@novanthealth.org 

In this podcast, Eric takes a look at a very difficult case of multifactorial resuscitation within ASA overdose. We dive deep into all things resuscitation and analyze factors that drive our decision-making. This takes the "acidosis rodeo podcast series to another level. Don't miss this episode! So much good stuff! Please like, subscribe, and leave any questions or comments.

Eric is joined by Joe Hylton, a respiratory therapist, flight paramedic, and Hamilton RT, as they dive into all things Volume Control [Adaptive], ASV, and Pressure Control (Biphasic) ventilation. There are many misconceptions and questions answered within this information-packed podcast. We use the Hamilton simulator to show the differences between patients and accompanying interactions while in Volume Control [Adaptive] ventilation. We discuss when it's best to use Pressure Control [Biphasic] over Volume Control [Adaptive] and the hazards associated with this common mistake. We dive into the long-discussed debate of Assist Control vs. SIMV. Lastly, we discuss the topic of ASV and the technology around this method/mode of delivery.

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

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

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

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

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

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

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

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

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

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

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

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

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

Heliox inhalation therapy for bronchiolitis in infants

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

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

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

In this episode, Eric is joined by Kevin Collopy at Elevate 2022 to discuss his team's recent research on TBI and 3% hypertonic saline. The conversation quickly progressed to overall resuscitation in TBI, with a focus on decision-making in airway management, ICP management, herniation, and the secondary injuries that impact TBI patients. This is a must-listen, with many great discussion points. 

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."

This episode is a must listen. Join Eric as he sits down with an exclusive interview with American Siren author Kevin Hazzard. Do you know the true origins of emergency medical services?  This story highlights the TRUE origins of ems. A story of poverty, hope, diversity, change, success, and the forgotten.

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.