The Synapse Critical Care & Emergency Medicine Podcast

Send us Fan MailIt 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. 

Send us Fan MailOk, 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 dissecting the utility of cervical collars and log rolls, is just that, a dissection.

Send us Fan MailWe 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!

Send us Fan MailMaybe 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 why might Precedex be the answer? 

Send us Fan MailAspirin...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!

Send us Fan MailOn 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!

Send us Fan MailAdenosine 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.

Send us Fan MailMost 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!

Send us Fan MailHi 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?

Send us Fan MailMost 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? 

Send us Fan MailSo 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 the points being made!

Send us Fan MailStop 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. 

Send us Fan MailWhat 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?

Send us Fan MailWhat 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!

Send us Fan Mail"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 this into our practice?

Send us Fan MailYes, 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? 

Send us Fan MailIt 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.

Send us Fan MailHow 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...

Send us Fan MailWhat 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?

Send us Fan MailI 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. 

Send us Fan MailShock 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 medical and trauma patients and how quickly it can pick up on hidden shock when the other vitals don't necessarily scream at you. 

Send us Fan MailSodium 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. 

Send us Fan MailFor 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 stop at the abstract. 

Send us Fan MailWelcome 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 vital signs. Is there still utility in this, and if so, when? What does this procedure actually show us? How do we apply this and to which population is it most appropriate?

Send us Fan MailThis 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?

Send us Fan MailThank you for tuning into the last episode of Season 3! This episode dissects the highs and lows of ultrasound of the IVC for volume status. Where does it excel? Where does it let us down, and how do we add other components of assessments in to beef it up? This is very much an adjunct, not something to hang your hat and full spectrum of treatments on. Even if you are just starting out in the POCUS world, this is for you!

Send us Fan MailThis seems to be an area many people struggle with, trying to figure out sympathetic vs parasympathetic, muscarinic vs nicotinic, and how these all relate. Who has what for primary transmitters? How do we navigate this? I am showing you a quick and easy way to get this right that you can easily teach to others!

Send us Fan MailIs hand placement on the sternum mid-line halfway up the breastbone really the best place for compressions? What does the evidence show? How can we use POCUS in and out of the hospital to determine where hand placement is most effective, and how is it showing that traditional hand placement is actually obstructing the left ventricular outflow tract more than we think, causing resuscitation rates to stay low??

Send us Fan MailThere are certain aspects of Pharmacology and Pharmacokinetics that are non-negotiable. One of those is the aspect of time in relation to antibiotic effectiveness. How much time is the antibiotic in the system for, vs how long does it take to reach peak effect or be cleared before hand. Certain antibiotics must be ordered and administered over a much longer time than we are used to doing, especially in the ED where we often see antibiotics gravity-infused rapidly over 10-15 minutes "because it is what we do." Often these patients are not exposed to the antibiotic long enough before it is processed out, meaning it never reaches peak effect. The primary concept in pharmacology that refers to the time the body is exposed to antibiotics versus effectiveness is Time-Dependent Killing, often expressed as the percentage of time the free drug concentration remains above the Minimum Inhibitory Concentration.This parameter describes how long the antibiotic concentration stays higher than the minimum needed to inhibit bacteria, rather than how high the concentration peaks. This is different from Concentration-Dependent Killing, but both will be discussed here. 

Send us Fan MailOk...I get it. We were and still are often told that Calcium's role in the treatment of hyperkalemia is to "stabilize the cell membrane walls." In the most simplistic of explanations, this is still not entirely correct. This episode brings actual science, recent evidence-based study, and basic reasoning into the mix to explain what Calcium is ACTUALLY doing in hyperkalemia. 

Send us Fan MailPPV is notorious for dropping cardiac output by changing intrathoracic pressures and decreasing preload return by forcing lung tissue against major vessels and alveoli compression. However, is there ever a circumstance when PPV can actually improve cardiac output? This episode may just cover that!

Send us Fan MailMany of us were taught to place ECG precordial "V" leads under large breast tissue, replace/set down the tissue after, and then obtain the image. However, did you ever stop to think about how much large breast tissue can displace the ECG leads on the chest and dramatically alter the image? How do we get around this? Is there anything better that could be done?

Send us Fan MailToday is a review of most things having to do with spinal injuries. Anterior, posterior, and Brown-Sequard syndromes...Spinal vs Neurogenic shock differentiation (yes they are different!), and SCIWORA. We will examine each of these and what you need to know whether sitting for a board exam or just beefing up your knowledge for the next trauma patient!

Send us Fan MailHow does giving a loop diuretic actually cause the body to retain CO2??? What does that have to do with fluid management?! Surprise, quite a bit actually. Tune in and find out!

Send us Fan MailWe have most likely all had the phone call from the lab before, asking for a re-draw on our patient due to lab hemolysis. Have you ever thought about why that happens and how we can reduce it? It is not just the desire of a larger-bore IV catheter...you can pull fantastic non-hemolyzed labs off of a 24G IV catheter...let's talk about how!

Send us Fan MailSimilar to the Aortic Stenosis and head-bobbing, Mitral stenosis can also cause a peculiar side effect, that being Dysphagia. Can you figure out how this might happen before listening? See if you were right!

Send us Fan MailThrombocytopenia and Heparin aren't usually thought of together, at least Heparin not as being a potential cause. This episode will look at how that can be possible!

Send us Fan MailThere are some things in medicine that, when you learn the mechanics behind it, are just, well,...cool! Unfortunate, but cool to see. One wouldn't initially think something like aortic regurgitation would be that, but this episode looks at how AR can actually cause head-bobbing in patients. It is rarer than you think but still something to look for!

Send us Fan MailWe have heard about O2 and CO2 in patients like COPD'ers...but what happens truly when CO2 builds up to dangerous levels in the body? How does ventilation actually shut down? What do we do about it?

Send us Fan MailDKA is a wild animal. Taming it in our sick patients can be incredibly challenging. The newest criteria are out for diagnosis of DKA, and there have been a few bigger changes. Tune in to keep up!

Send us Fan MailWe are all most likely pretty adept at initial fluid resuscitation and repletion rates for pediatrics. What happens after the patient is more stable-ish? In that time period where we must now maintain the patient? How do we calculate appropriate fluid infusions and electrolyte infusions?

Send us Fan MailThis episode is a review on the pharmacology behind Phenylephrine, a very potent alpha vasopressor, its uses, cautions, and more!

Send us Fan MailIf you interpret lab values, you have most assuredly fallen into the same trap I have in the past of taking something at face value and not reasoning against trends or in conjunction with other lab values. In medicine this can cause dangerous conditions of either inappropriately-diagnosing someone with something they don't have, or missing a diagnosis of something they do have. Both have their consequences. In this episode I look at 4 of the more common lab interpretation traps and how to avoid them. Learn from my mistakes!

Send us Fan MailIf you are like me, you probably have trouble remembering the difference between heart murmur grades, whether S4 comes before S1, S3 after S2, and why it even matters. This episode breaks this down as simple as I think it can possibly be broken down, with the "why" behind it.

Send us Fan MailWho are you more concerned about, the patient with a blood pressure of 96/70 or the patient with a blood pressure of 200/35? Besides the fact that this episode is titled Isolated Diastolic Hypotension, can you figure out why option B is more concerning to me if I had to choose just based off of blood pressure? Tune in and see if you are correct in your reasoning! Your future patients may thank you!

Send us Fan MailSIRS and especially qSOFA just don't stack up. Not in adults, and definitely not in pediatrics. This has begged the question for a while of is there a better sepsis screening tool out there for children given how well they compensate and hide insult from occult shock...Recently a pediatric age/vitals-specific sepsis screening tool has been proposed, called the qPS4 scale, and early evidence is showing it is much more sensitive and specific in the pediatric population, especially when combined with the TAMSI, or the Temperature and Age-Adjusted Shock Index. In this episode I will tell you all you need to know about how this stands to help in your pediatric shock populations.

Send us Fan MailOne of the very first episodes I covered was on a concept called ALM Therapy. For those not familiar, this is a mix of Adenosine, Lidocaine, and Magnesium infusion therapy in trauma patients. Why? Great question. Tune into this episode as I outline more about what this is and what the advancements are that have been made since I last covered this.

Send us Fan MailTake a second and really think...how solid is your understanding of acute kidney injury vs chronic kidney disease? Are these conditions silos, or is there overlap? How do lab values play into diagnostics beyond face value? What does it really mean on a complexity level system-wide when someone has AKI superimposed on CKD?

Send us Fan MailOxygen nanoparticles? What the heck am I talking about now? Hypoxia can be an incredibly complex cascade in the body, and is not just a one-size-fits-all issue or treatment. We have to identify the type of hypoxia, the process(es) involved, where we are on the curve, and more. This episode will look at the concept of oxygen nanoparticles and how they play into all of this.

Send us Fan Mail2026 is the Year of Sepsis! There are big changes and pushes for identification and treatment of sepsis both in the hospital and pre-hospital. Tune into this episode for an overview of the changes to the guidelines with evidence-based recommendations!