Optimizing the Intubation

In this episode I walk through my MCI experience and discuss my feelings and thoughts in the days, weeks, and months following. Plus some ranting.

In this episode we welcome our first guest Rob Mokszyscki PharmD, BCPS to the podcast. We discuss high dose Nitroglycerin for SCAPE, and also have a brief discussion on sedation agents.Agrawal, N., Kumar, A., Aggarwal, P., & Jamshed, N. (2016). Sympathetic crashing acute pulmonary edema. Indian Journal of Critical Care Medicine, 20(12), 719–723. https://doi.org/10.4103/0972-5229.195710Ashok, H., Shtembari, J., Achhami, E., Gaire, S., Shrestha, D. B., & Joshi, T. (2022). Valvular heart disease presenting as Sympathetic Crashing Acute Pulmonary Edema (SCAPE) phenomenon: A diagnostic and management paradigm. Cureus, 14(12), e32352. https://doi.org/10.7759/cureus.32352Kelly, R. P., Gibbs, H. H., O’Rourke, M. F., Daley, J. E., Mang, K., Morgan, J. J., & Avolio, A. P. (1990). Nitroglycerin has more favourable effects on left ventricular afterload than apparent from measurement of pressure in a peripheral artery. European Heart Journal, 11(2), 138–144. https://doi.org/10.1093/oxfordjournals.eurheartj.a059669Long, B., Brady, W. J., & Gottlieb, M. (2025). Emergency medicine updates: Sympathetic crashing acute pulmonary edema. The American Journal of Emergency Medicine, 90, 35–40. https://doi.org/10.1016/j.ajem.2024.12.061Wilson, S. S., Kwiatkowski, G. M., Millis, S. R., Purakal, J. D., Mahajan, A. P., & Levy, P. D. (2017). Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. American Journal of Emergency Medicine, 35(1), 126–131. https://doi.org/10.1016/j.ajem.2016.10.038

In this episode we discuss the physiology and management behind the traumatic cardiac arrest.

In this episode we discuss the basics of ECPR and VA-ECMO. Included is a case review and discussion. Later in the episode we outline some landmark ECPR studies, and review inclusion and exclusion criteria. Bartos, J. A., Grunau, B., Carlson, C., Duval, S., Ripeckyj, A., Kalra, R., Raveendran, G., John, R., Conterato, M., Frascone, R. J., Trembley, A., Aufderheide, T. P., & Yannopoulos, D. (2020). Improved survival with extracorporeal cardiopulmonary resuscitation despite progressive metabolic derangement associated with prolonged resuscitation. Circulation, 141(11), 877–886. https://doi.org/10.1161/CIRCULATIONAHA.119.042173Richardson, A. C., Tonna, J. E., Nanjayya, V., Abrams, D., Brodie, D., Pellegrino, V. A., Shekar, K., & Thiagarajan, R. R. (2021). Extracorporeal cardiopulmonary resuscitation in adults: Interim guideline consensus statement from the Extracorporeal Life Support Organization. ASAIO Journal, 67(3), 221–228. https://doi.org/10.1097/MAT.0000000000001344Schmitzberger, F. F., Haas, N. L., Coute, R. A., Bartos, J., Hackmann, A., Haft, J. W., Hsu, C. H., Hutin, A., Lamhaut, L., Marinaro, J., Nagao, K., Nakashima, T., Neumar, R., Pellegrino, V., Shinar, Z., Whitmore, S. P., Yannopoulos, D., & Peterson, W. J. (2022). ECPR²: Expert consensus on percutaneous cannulation for extracorporeal cardiopulmonary resuscitation. Resuscitation, 179, 214–220. https://doi.org/10.1016/j.resuscitation.2022.07.003Suvrein, C. G., van de Glind, E. M. M., de Bruin, S., van den Brink, F. S., van der Hoeven, J. G., & Hoedemaekers, C. W. E. (2023). Early extracorporeal CPR for refractory out-of-hospital cardiac arrest. The New England Journal of Medicine, 388(4), 299–309. https://doi.org/10.1056/NEJMoa2204511Yannopoulos, D., Bartos, J. A., Raveendran, G., Walser, E., Connett, J., Murray, T. A., Khatri, J., O’Connor, D., Bedi, A., & Aufderheide, T. P. (2020). Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): A phase 2, single centre, open-label, randomised controlled trial. The Lancet, 396(10265), 1807–1816. https://doi.org/10.1016/S0140-6736(20)32338-2

In this episode we start our dive into ACLS and managing a patient in Cardiac Arrest. We also discuss the debate surrounding giving epinephrine in cardiac arrest.Williams, C. A., Fairley, H. E., Tran, Q. K., & Pourmand, A. (2024). Use of epinephrine in cardiac arrest: Advances and future challenges. Medicina, 60(11), 1904. https://doi.org/10.3390/medicina60111904

In this episode we take a look into some general intubation practices and principles. Also examine best practices to take during RSI and discuss some tips and tricks to optimize your practice. Reference:Baker, J., Khan, N., Singh, M., & Kuza, C. M. (2022). The efficacy of apneic oxygenation to prevent hypoxemia during rapid sequence intubation in trauma patients. Current Opinion in Anaesthesiology, 35(2), 182–188. https://doi.org/10.1097/aco.0000000000001103Fuller, B. M., Ferguson, I. T., Mohr, N. M., Drewry, A. M., Palmer, C., Wessman, B. T., Ablordeppey, E., Keeperman, J., Stephens, R. J., Briscoe, C. C., Kolomiets, A. A., Hotchkiss, R. S., & Kollef, M. H. (2017). Lung-protective ventilation initiated in the Emergency Department (LOV-ed): A quasi-experimental, before-after trial. Annals of Emergency Medicine, 70(3). https://doi.org/10.1016/j.annemergmed.2017.01.013Ye, N., Wei, C., Deng, J., Wang, Y., & Xie, H. (2025). PREOXYGENATION strategies before intubation in patients with acute hypoxic respiratory failure: A network meta-analysis. Frontiers in Medicine, 12. https://doi.org/10.3389/fmed.2025.1532911

In this episode we take a look into a handful of penetrating trauma cases to understand the nuances and share some tips along the way. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006 Mar 24;1:4. (License: CC BY-2.0)

In this episode we review a trauma case that took an unexpected turn. Viewer discretion is advised. Reference:Dalal, R. (2024, November 23). Epinephrine. StatPearls . https://www.ncbi.nlm.nih.gov/books/NBK482160/#:~:text=Through%20its%20action%20on%20α1,renin%20release%20via%20β1%20receptors. Farkas, J. (2025, January 4). Bradycardia. EMCrit Project. https://emcrit.org/ibcc/bradycardia/#3rd_degree_block Knabben, V. (2023, July 31). Third-degree atrioventricular block. StatPearl. https://www.ncbi.nlm.nih.gov/books/NBK545199/ Robichaud L;Ross D;Proulx MH;Légaré S;Vacon C;Xue X;Segal E; (n.d.). Prehospital nitroglycerin safety in inferior st elevation myocardial infarction. Prehospital emergency care. https://pubmed.ncbi.nlm.nih.gov/26024432/ Sonne, J. (2023, July 3). Dopamine. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK535451/ Warner, M. J. (2023, February 12). Inferior myocardial infarction. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470572/ 

In this episode, we review a handful of trauma activation criteria, and speak on their merits and potential downfalls. Viewer discretion advised. Citations: Adult trauma team activation criteria. Trauma Protocols. (2023, July 10). https://wp.uthscsa.edu/surglearning/docs/adult-trauma-team-activation-criteria/#1689019243695-de1fef58-5ce4School, M. M. (2024, September 17). Trauma team activation policy. Surgery. https://med.uth.edu/surgery/trauma-team-activation-policy/Trauma activation protocol. (n.d.-a). https://www.waterburyhospital.org/contentassets/97aa09c644df40b0b65000308863a0de/wh-trauma-response-protocol-7.1.19.pdfTrauma alert/activation criteria. (n.d.-b). https://www.ucdenver.edu/docs/librariesprovider74/trauma-and-acute-care-surgery-pdfs/trauma-protocols/trauma-activation-alert-criteria-checklist.pdf?sfvrsn=910abeb9_2Trauma and burn activation criteria. (n.d.-c). https://www.vumc.org/trauma-and-scc/sites/default/files/public_files/Protocols/2024 Trauma and Burn Activation Criteria.pdfTrauma team activation criteria. (n.d.-d). https://health.mo.gov/living/healthcondiseases/chronic/tcdsystem/pdf/MU-ActivationCriteriaFinal.pdfTrauma team activation guideline. (n.d.-e). https://doh.wa.gov/sites/default/files/legacy/Documents/Pubs/689164.pdf

In this episode we review a case of an ascending aortic dissection and talk about the pathology and typical plan of care prior to OR. Reference:Harris KM, Nienaber CA, Peterson MD, et al. Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. JAMA Cardiol. 2022;7(10):1009–1015. doi:10.1001/jamacardio.2022.2718Nappi, F., Gambardella, I., Singh, S. S., Salsano, A., Santini, F., Spadaccio, C., Biancari, F., Dominguez, J., & Fiore, A. (2023). Survival following acute type A aortic dissection: A multicenter study. Journal of Thoracic Disease, 15(12), 6604–6622. https://doi.org/10.21037/jtd-23-1137 Flower L, Arrowsmith JE, Bewley J, Cook S, Cooper G, Flower J, Greco R, Sadeque S, Madhivathanan PR. Management of acute aortic dissection in critical care. J Intensive Care Soc. 2023 Nov;24(4):409-418. doi: 10.1177/17511437231162219. Epub 2023 Mar 29. PMID: 37841293; PMCID: PMC10572474.