The Synapse Critical Care & Emergency Medicine Podcast

Send us Fan Mail There once was an anticoagulant agent named tPA...hold up, this isn't a fairytale and this story doesn't cover tPA or TNK! Those are different stories for different days.  Does every stroke patient we encounter need to be anticoagulated? Or should we not be so quick to pull that trigger? If you are going to give a stroke patient anticoagulants, which types of strokes sho...

Send us Fan Mail Sliding scale insulin is often used in the hospital, especially in-patient. However, there is a multitude of issues that comes with it for our hyperglycemic patients, with the primary issue being that SSI is more of a knee-jerk reaction than a proactive treatment. Doing something because we have always done it that way is not something I enjoy hearing. This episode lays out all of...

Send us Fan Mail These are the voyages of the Starship AHA. And this episode is going to go where few have actually dared to go before...a path through space unencumbered by the numbingly binding dogma that is ACLS in cardiac resuscitation.  Let me be clear. This is not an attack on the AHA. I am an instructor in every discipline the AHA offers, and am affiliate faculty for the AHA. That being sai...

Send us Fan Mail In the absence of whole blood, if I had to choose between PRBC's or plasma in the prehospital environment for the bleeding patient with coagulopathy, and didn't get to carry both, I would choose (freeze-dried) plasma as the product to carry. Why is this? What reasoning is there to support this? In trauma, our concern is not just the oxygen carrying capacity in resuscitat...

Send us Fan Mail How do we prevent "death-by-induction?" How do you appropriately resuscitate a patient before intubation? Have you heard of the Shock Index before? Or are you aware that there is a difference between systolic shock index and diastolic shock index? In this episode we will explore all of this and more, and put significant emphasis on the diastolic shock index as the most r...

Send us Fan Mail With this case review (fictional) and dive into the pharmacology behind Dobutamine, by the end of this episode you should hopefully have a firm understanding of what it is, what it does, how it can be helpful to our patients, but also how it can harm them. I will also spend some time talking about Dobutamine in transport and how squeeze should never be the sole treatment. This con...

Send us Fan Mail Is your patient's tachycardia the primary issue or compensatory? Will you treat it or leave it? If you are going to treat it, what will you use? This episode will discuss the nuances of tachycardia, when it is dangerous to treat, and how we can evaluate the patient to see.

Send us Fan Mail Think back to the last sepsis patient you had. Maybe they had an elevated lactate to begin with and were hypotensive. Norepi was started, BP improves, but the serial lactate is even more elevated afterwards. Why is this happening? Is the patient getting worse? Maybe not. Join me in this episode as we explore why Beta-2 activation may actually transiently elevate lactate and what t...

Send us Fan Mail Right axis deviation with ST elevations? Listen in and I will explain why there is only one type of MI that will present like this. The purpose of this episode is to help cut down on false activations, understand how we can use the science behind vectors of electricity and basic pathophysiology to prove that right ventricular wall MI is the ONLY type of MI that will present with S...

Send us Fan Mail Let's examine this case study, and put your differential diagnosis skills to the test. Is this DKA? Withdrawals? Tox? Or something more like a combination of all three? In this episode we will dissect this case as well as the science behind it so you can make good care decisions in the future with these very challenging patients!

Send us Fan Mail Are you looking to test for CCRN, CFRN, CCP-C, FP-C, etc? One of the test items you'll need to know about is the Swan-Ganz catheter, or Pulmonary Artery Catheter. Not only should you know about it for the exams, but also in general. Most community hospitals will stop at dual or triple-lumen central catheters, and don't typically place anything beyond that. Usually seen i...

Send us Fan Mail In this episode, I dissect the DIFFOCCULT-3 Trial and the evidence that it continues to amass to further support getting away from STEMI and NSTEMI, and moving towards OMI/NOMI. Why does it make sense to make this change? What will actually change with that? What are we up against for logistical challenges?

Send us Fan Mail While this episode may be a bit Respiratory-"heavy," it is important to understand the basics of mechanical ventilation waveforms. If you are a paramedic tasked with transporting a patient on mechanical ventilation, or a paramedic or nurse in an ED or ICU monitoring a patient without RT being present, you should have a basic working knowledge of waveforms and loops to be...

Send us Fan Mail Quite frequently I hear providers speaking about adjusting respiratory rates (f) on the mechanical ventilator with a heavy focus on I:E times. However, for those patients in whom the risk of AutoPEEP is high, there is a better way that takes into account the patient's actual condition and ventilator readings, rather than just arbitrary I:E changes. In this episode I will disc...

Send us Fan Mail Have you seen or heard of a patient being placed on ECMO? Not sure what the difference is between ECPR, ECMO, or ECLS? Not sure what patients are candidates or how it is performed? Join me on this episode as I explain these answers and so much more. This is not meant to make you an ECMO expert, but rather to open your eyes to the basics of this bridge procedure for your learning e...

Send us Fan Mail I am sure there is not a single healthcare provider out there who has not been told at some point to be careful of how much oxygen you administer to a COPD patient, because they will suddenly stop breathing. How much truth is there to this oxygen-dependent ventilatory drive? In this episode I will dissect this and see if it actually makes sense or not, based on anatomy, physiology...

Send us Fan Mail Now that we are getting back into Fall and soon to be Winter, it seems appropriate to take a deep dive into the chilly waters that are our hypothermic patients. More than just dialing down the thermostat for this cool talk on temperature, we will look at each body system that is affected and discuss what exactly happens. The episode is capped off with a look at hypothermic cardiac...

Send us Fan Mail All too often, even here on this podcast, we talk about PEEP as if all it really involves is the respiratory system. Have you ever stopped to consider what other body systems are actually affected by our PEEP settings whether via BVM, CPAP/BPAP/NiPPV, or other mechanical ventilation modes? Join me on this episode and see how far-reaching this one setting can be inside the body of...

Send us Fan Mail Can't get a reliable SpO2 probe reading on your intubated patient regardless of trying every trick you can think of? Hot packs, fingers, nose, cheek, ear lobe, even the fancy expensive forehead probes? Have you considered back-of-tongue oropharyngeal monitoring? How would you even do this? Join me and I'll explain this little-known Burn Center trick that can make the dif...

Send us Fan Mail In this episode, I will tackle the question surrounding whether or not to do CPR in a VAD (ventricular assist device) patient who is in cardiac arrest. For the longest time we were under the impression that to do CPR in these patients would cause device dislodgement and massive internal hemorrhage. Oh, but the winds of evidence are blowing again! Let's see where we stand on t...

Send us Fan Mail There are so many challenges surrounding blood administration, compatibility, cross-matching, sourcing, storage, shelf-life, etc. We have discussed the lyophilized plasma products that are making their way through FDA clearance, but what if there was a blood product alternative that was easy to create, actually carried oxygen, and had few associated reaction/side effect risks? Ent...

Send us Fan Mail You have heard me talk about Sgarbossa and Smith Modification Criteria, as well as dabble a bit on the newer Basel Criteria. If you missed it, here is a great little episode that specifically addresses the Basel Criteria in LBBB and more specifically, in ventricular-paced rhythms, to further help us identify OMI's underlying the superimposed ventricular paced rhythms. These a...

Send us Fan Mail When you think of Sepsis, you probably default to Lactate, maybe C-RP or procalcitonin, and most likely the CBD Differential. I am willing to bet not too many of you think of the Galectin-3's role in this process, or have even heard of it. What if I told you there is significant bodies of evidence looking at the role of Galectin-3 in sepsis, but not only that, a new easy-to-u...

Send us Fan Mail We have talked about Hyperkalemia in detail in other episodes, and you have seen it in the textbooks as well. However, we continue to see and hear things that are treated like dogma but in reality, they don't carry as much weight in the evidence side of the house. What am I talking about when it comes to Hyperkalemia? Tune in to find out.

Send us Fan Mail It should be abundantly clear by now that we should never arbitrarily be chasing EtCO2 as an end-goal for our treatments, whether in sepsis, mechanical ventilation, or any other times. There are many times where permissive hypercapnia will not immediately kill our patients and should be tolerated. What may not be very clear is a product of poor teaching, and that involves the so-c...