The Synapse Critical Care & Emergency Medicine Podcast

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I often find myself trying to rote-memorize something in medicine. This maybe yields immediate results, but for me at least, seems to fall away quickly. However, conditions like aortic stenosis are incredibly important for a variety of reasons and it is imperative to find a way to remember the importance of the condition via key understanding, not just memorizing. Starting with the concept of a narrow door, we will apply knowledge of anatomy and physiology to understand what else occurs!

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High-degree AV blocks can be challenging on their own. However in the setting of specific MI's, they can be very useful in telling us about the health of the conduction system and where in the conduction system the issue is, with the help of pattern recognition. This episode will look at how likely various types and presentations of blocks are in MI, particularly in the rare posterior MI. 

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EMTALA is one of those topics a lot of people hate discussing because sometimes there is just no easy way to talk about it and make it enjoyable. However, when we find ourselves in a situation that can potentially be construed as an EMTALA violation, I think we find ourselves wishing we had paid more attention. In this episode, I am looking at the issue posed by diverting to a different hospital during a transport other than the established receiving hospital and how that can be managed without becoming a violation. 

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We have touched on this topic before but similar to intubation of the metabolic acidosis patient, this is one that warrants closer look. There is a lot of danger surrounding intubation of these patients and many aspects of care to consider beyond just resuscitation and intubation. 

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I'm not spoiling the episode, so you will just have to tune in to find out what exactly "THIS" is, but this is one of those few times where the lack of a randomized control trial shouldn't necessarily preclude the use of/administration of this in the pre-hospital/inter-hospital realm. 

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If you have any experience with or knowledge of respiratory therapy and/or mechanical ventilation, terms like P/F, S/F, the OI and OSI, and the A-a are probably familiar to you. But what are they, how do we use them, and are there limitations to these?

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Recent studies have been published showing that the earlier Heparin is administered in certain cases, the better outcomes there can be. The information is nuanced as always, however it is interesting that at the exact same time that these studies and their data supporting pre-hospital administration of Heparin and administration as soon as possible by pre-hospital staff can alter the outcomes of patient prognosis, states like NH are actively seeking to remove Heparin from the pre-hospital protocols. Does this decision stack up? Let's see!

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Think back on your career to some of the bradycardic patients you have had in the past. Have you had a paramedic, nurse, or physician tell you not to treat bradycardia unless the patient was hypotensive? Is there any merit to that? What does ACLS say? At what point should we start becoming concerned about our bradycardic patients even if they haven't lost their blood pressure yet?

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Quite a mouthful of a title, but this is a very interesting case series review that discusses combat casualty care in a resource-limited setting, where surgeons and ED physicians administered intrapericardial TXA while performing emergent pericardiocentesis on traumatic pericardial tamponade. While not a large-cohort, multi-center, randomized control trial, it would something worth exploring more. 

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Taking a step in a different direction today with a neonatal topic review today on Tetralogy of Fallot. What is it, how does it occur and what does it do to the neonate, and how can infants actually temporarily relieve a Tet Spell on their own?

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If you have had bloodwork before, you know there is typically a reference range. For example, men are told their total testosterone should be between 300-500ng/dL, which is an average reference range. However, optimal ranges are 300-1,000ng/dL. In emergency medicine and critical care, we often hyperfocus on the reference ranges to fix the 95% of the problems out there, and let Functional Medicine focus on the optimal ranges. However this also brings up issues like just checking serum magnesium, when RBC Magnesium can be argued to be just as important...

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Load and go is something many of us in EMS are familiar with. However, when it comes to Hyperthermia cases, especially severe hyperthermia, the evidence has tipped very much in the opposite direction. Athletic trainers and sports medicine professionals have known this for years, but why is it so hard for EMS to accept? Let's answer this, as well as look at several ambulance services and fire departments around the country who have wholeheartedly accepted this change with aggressive protocols. 

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Is the patient you are looking at a sepsis patient? Or a hypothyroidism patient who is aggressively decompensating? Or is it both? How do you tell? Do the treatments change? 

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We know about Potassium and the issues surrounding repletion of this vital electrolyte. We have talked about how Potassium relies on Magnesium as well, and if the Mg is low, the K won't budge. But what about the relationship between Potassium and Sodium? What can happen when we try to fix one, and don't keep an eye on the other?

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Ok, considering we just did an episode on the many uses of Fentanyl, why in the world would someone want to create a vaccine for Fentanyl? Well, in this episode I will talk about the why behind this, who is pushing for it, and the potential implications for prehospital medicine, especially for those of our brothers and sisters who work in states where Fentanyl is the only narcotic analgesic they are allowed to carry. 

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It would seem we have talked extensively about the SpO2, and that is true. This episode continues where we last left off, and hopefully opens your eyes to how overlooked, over/under-utilized this vital sign can be, and how much there is to really know about it. 

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Ok, so we kind of went after ATLS and the other alphabet-soup trauma courses on their continuing support of rigid cervical collars when the evidence makes no sense to do so. Well what about setting our sights on another target, Crystalloids in Trauma?! Have they progressed from the suggestion of 2 liters of crystalloids wide-open to a more appropriate response? Guess we will find out on this episode!

*Disclaimer, ATLS is a fantastic course full of good information, and none of this is an attack against them. This, like...

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We know Fentanyl is a fantastic analgesic for a wide variety of pain control reasons. But what else is it good for? And who uses it for something other than just pain control? For this episode, I look to my good friends in Anesthesia, who really know how to put drugs like Fentanyl through its paces and get the most out of them. Let's dive in and look at the possibilities!

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Maybe you are already familiar with a scenario like this:

24-year old male with suspected opioid overdose. You give Naloxone, his breathing improves, but he remains heavily sedated and bradycardic. Several hours later in the ED his HR spikes from 45 to 180, he becomes profoundly hypertensive, with tremors, severe agitation, nausea, and vomiting. Despite normal treatments of benzodiazepines, Zofran, and phenobarbital, he does not get any better.

What is driving this? What did we miss here, and if these traditional medication "cocktails" are not helping control this patient, how and...

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On their own, these are some of the more commonly-prescribed medications, antibiotics, and other drugs that we have for various treatments. Most of the time, while they do have contraindications, we see little issue. However, if you mix these together, the risk window widens exponentially. Take a look, see if you were aware of these interactions!

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Aspirin...simple little old Aspirin, a staple of our drug boxes and ACS care. Often our teaching stops at "It's an anti-platelet, it makes the platelets slippery." Is it more than that though? How does this little drug actually work? Tune in to find out!

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Adenosine has for quite some time been the go-to for the medication side of the Edison vs Medicine (Sick vs "Not-so-sick-with-the-potential-to-become-sick") part of ACLS when it comes to conversion of PSVT. What if another drug could do it better? Let's look at these three medications against each other and see if there is a better option.

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Most likely you are familiar with the respiratory and kidney buffer systems in acid-base disorders. Were you aware there are several more? We don't often talk about them, and many have never even heard of these, but they are still important! Today we discuss these other buffer systems, re-hash the respiratory and kidney buffers, and look at the Strong Ion Difference!

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Hi Everyone!

We are back after a brief break with more content for you! Today's episode discusses a deep dive into Sepsis, well-beyond the fluids and antibiotics. What is actually happening at the cellular level, and in each organ system, and furthermore, how do these organ systems directly affect each other's dysfunction when they start to fail?

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Most of us are familiar with the trauma triangle of death. Recently the trauma diamond of death was touted as the shiny upgrade, focusing heavily on calcium's role amongst the three other components. However, is there more to this than meets the eye? Is it really so simple as giving everyone calcium? 

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Stop killing our trauma arrest patients...sounds weird to say right? But many of them may not actually be in arrest. So yes, stop killing them with improper care! Let's look at what happens when the right thing is the wrong thing here, and how standard BLS and ACLS is often not what these patients need. 

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So many people lately seem to have very negative views of Dopamine. And for good reason! I have heard the arguments of how bad of a drug it is, how there are so many better options out there, how it causes all kinds of issues and is unpredictable...but. Could it be that there is an underlying factor which is us? That we haven't historically been the best at determining when, how, how much, how fast, etc to administer it? Humor me, listen in, and see if we can at least agree on...

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What is MetHb? How does it affect our body? Is this something that occurs naturally, or is a foreign invader of sorts? Once we know what it is, how do we detect it, and what can we do to lower the levels?

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I recently had a few EMS crews asking about the pregnancy-related emergencies they may encounter. When I asked them about what is "normal" in each trimester, it became clear that this is a topic area that is not often covered in initial training let alone in follow-up education, which spurned this podcast episode. This is a short and to-the-point compilation of some of the "normal" pregnancy-related changes so that you can recognize abnormal in the field. 

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What does it mean when the left ventricle is hyperdynamic? What are we looking at exactly on ultrasound? What do the ventricular walls "kissing" tell us about the patient?

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How many times have you run into issues with dampening, arterial monitoring collapse, etc? How often have you stopped to wonder if the issues you were having in the shock patients with poor arterial tracing might be avoided if you switched from peripheral to central monitoring sites? Many might argue it isn't worth it, or the femoral site is dirty, full of issues, etc, but let's look at this scientifically and see if this stacks up...

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It is the same drug, right? Whether I give NO via IV or nebulization, it will do the same thing, won't it? Won't it??? If I had to devote an entire episode to this one topic, I am sure you have guessed at this point that this is not the case. Join me and see why these are two very different concepts even though it is the same medication.

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Yes, Cyanokits...Hydroxocobalamin...the same expensive medication we can administer to patients who have been exposed to smoke inhalation from say, a structure fire. Why would we ever consider giving it to a patient suffering from Vasoplegic shock? How does this even help out patients who have been exposed to dangerous chemicals in smoke, let alone vasoplegia? 

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"Shoot for a target MABP of 65mmHg!" It sounds great in theory, except like many other numbers and concepts in medicine, this is one of those that I truly feel make us as the Provider feel better than it actually does much for our patient. We know patients need a MABP of at least 65, but then again, some don't...some can go lower and not suffer from it...and some need it significantly higher either because of concurrent TBI or...maybe because their own usual MABP is well above 65...? How do we work...

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What do these three sedative drugs have in common when it comes to status epilepticus? Are there uses for them? Together or separate? How do they work in our favor and our patient's favor? Tune in to find out!

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Welcome to Episode 1 of our 4th Season! I can't express how grateful I am for the continued support from around the world as this podcast continues to grow! We are now hosted on multiple streaming sites and have listeners regularly tuning in from as far away as India, Great Britain, Australia, and more! Thank you so much and I look forward to continuing to deliver the very best I can for you!

Today's episode kicks off the new season with a discussion on the antiquated practice of orthostatic...

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For those who aren't aware, there really isn't much benefit to SpO2 >94%. We have talked about this ad nauseum in other episodes before. The AHA tells us 94-99% for an SpO2 range for various reasons. However a recently-released trial, the Oxy-PICU trial, a multi-center randomized control trial, recently released data showing that children actually fair better if kept in the 88-92% range during certain medical conditions especially when intubated. It is a very interesting study to read through, but like any other study, do not just take it at face value or just...

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Sodium channel blockers can cause a host of nasty effects in the body, and the heart unfortunately can take the brunt of a lot of it. We will examine this in today's episode with what to look for, signs and symptoms, treatments, etc. 

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Shock is not just about BP. In fact, in adults in hemorrhagic shock, we typically need to lose at least 1.5L of blood before BP changes, which is stage III shock. In kids? That can vary but is much more on the occult side. You can be in shock with severe anemia and have no blood pressure change. So how do we better evaluate our patients for shock??? Enter systolic and diastolic shock indices, as well as the reverse shock index. Join me and find out how easy this is to apply to...

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This episode brings a review of the appropriate diagnostics and care for patients with aortic dissections and rupture as well as a review of the pathophysiology and classification types. Are you familiar with the newer HR and BP goals? Why is this a pulsatility issue more than anything else? What is your bundle of care?