ResusX:Podcast

A new podcast of just me in my car

Is the reign of "Normal" Saline over, or is the classic bag of salt water actually the hero of the trauma bay? For years, the critical care community has debated whether we should abandon 0.9% sodium chloride in favor of balanced crystalloids like Lactated Ringer’s or Plasma-Lyte to protect the kidneys and prevent acidosis. But a new study suggests we might be writing off saline too soon—especially when the brain is involved.  In this episode, we break down a 2026 systematic review and meta-analysis from the American Journal of Emergency Medicine .  The researchers pooled data from six randomized controlled trials involving nearly 2,000 trauma patients to compare efficacy and safety . The results might surprise proponents of balanced fluids. While there was no significant difference in acute kidney injury or general mortality for non-head trauma, the data revealed a vital signal for Traumatic Brain Injury (TBI).  In TBI patients, Normal Saline was actually associated with lower mortality and more ventilator-free days compared to balanced solutions . So, what does this mean for your next trauma alert?  It suggests that the slight hypertonicity of saline might be protective against cerebral edema, making it a potentially superior choice for head-injured patients . Tune in as we dissect the pathophysiology, the "chloride load" myth, and why Normal Saline remains a safe, standard option for undifferentiated trauma resuscitation.

Is Ketamine really the "hemodynamically stable" hero of airway management, or have we been unfairly vilifying Etomidate for decades? The debate over the perfect induction agent for critically ill patients just got a major influx of data that flips conventional wisdom on its head .   In this episode, we break down the landmark "RSI" trial, a massive multicenter randomized controlled study involving over 2,300 critically ill adults in EDs and ICUs across the US .  The headline results are a shocker: Ketamine did not reduce 28-day mortality compared to Etomidate . Even more surprising? The "hemodynamically neutral" reputation of Ketamine took a hit.  Patients randomized to Ketamine actually experienced significantly higher rates of cardiovascular collapse—including hypotension and increased vasopressor needs—during intubation compared to those receiving Etomidate .   We unpack what this means for your next shift: why the theoretical fears of Etomidate-induced adrenal suppression didn't translate to patient harm, and why Ketamine might be less forgiving in shock states than we previously thought . Tune in as we dissect the data and discuss whether it’s time to stop hesitating and reach for the Etomidate.

Is the "best of both worlds" actually saving lungs, or just complicating care?  Theoretically, combining the powerful pressure support of Non-Invasive Ventilation (NIV) with the comfort and washout mechanisms of High-Flow Nasal Cannula (HFNC) sounds like the ultimate strategy to prevent intubation . But does this physiological synergy actually translate to patient survival?  In this episode, we break down a new meta-analysis from the American Journal of Emergency Medicine that pooled data from six RCTs and over 700 adults with Acute Respiratory Failure (ARF) .   The researchers investigated whether alternating or combining these devices as an initial strategy is superior to using just one alone .  The headline result might surprise you: the study found no significant reduction in intubation rates or mortality compared to monotherapy .  However, don't write off the combo just yet—the devil is in the details.  We explore a fascinating data split where the efficacy of the combination hinged entirely on lung-protective strategies .  We discuss why unchecked tidal volumes during NIV might be masking the benefits of the combination, leading to ventilator-induced lung injury (VILI) .  Tune in for a critical look at why "more support" isn't always "smarter support," and how to identify the specific patients who might still benefit from this tag-team approach .

For decades, a single dogma has ruled neurotrauma resuscitation: Never use ketamine in TBI. The historical fear that ketamine spikes intracranial pressure (ICP) has kept one of the most versatile, hemodynamically friendly induction agents on the shelf—but is that fear based on fact or outdated physiology?     In this episode, we dissect a massive 2026 systematic review and meta-analysis from the Journal of Critical Care .  By analyzing over 6,000 patients across 15 studies—including four RCTs and strictly post-2015 data—this paper puts the "old myth" to the ultimate test .  We break down how the researchers compared ketamine against other agents like propofol and etomidate to evaluate hospital mortality, ICP crises, and adverse events in both adult and pediatric populations .  The findings are practice-changing.  The data reveals zero association between ketamine use and ICP spikes or increased mortality, effectively debunking the classic contraindication .  However, the review uncovers a controversial "plot twist": a potential link to hypotension that challenges our assumptions about ketamine's stability in catecholamine-depleted trauma patients .   Tune in as we analyze the "study dominance bias" that complicates these hemodynamic results and discuss exactly how this evidence should reshape your airway strategy for the severe TBI patient .

In this episode, we tackle one of the most persistent questions in perioperative care: how low is too low when it comes to hemoglobin in high-risk cardiac patients after major surgery? The long-standing restrictive threshold of 7 g/dL has been considered safe for years, but the TOP Trial challenges that comfort zone. More than 1,400 high-risk veterans were randomized to either a liberal transfusion strategy (Hgb <10 g/dL) or a restrictive one (Hgb <7 g/dL). The primary outcome showed no significant difference in death or major ischemic events. That part was expected. The surprise came in the secondary outcomes. Patients in the restrictive group had nearly double the rate of non-fatal cardiac complications, including new heart failure and dangerous arrhythmias. The liberal strategy cut those complications by almost 40 percent. This episode breaks down what these findings mean for real-world practice, how they challenge current transfusion guidelines, and when you might reconsider your trigger for your most vulnerable post-op patients. If you take care of surgical patients with cardiac risk, this is an episode you cannot skip.

Can a Single Word Change the Culture of an ICU? Burnout is an epidemic in our Intensive Care Units, affecting staff well-being, patient care, and even hospital costs. But what if the solution to this widespread problem was simpler than we think? This week, we’re diving into the Hello Trial, a massive 1:1 cluster-randomized controlled trial conducted across 370 ICUs in 60 countries. Researchers tested a simple, four-week, unit-based intervention designed to promote positive workplace culture and within-team support using tools like posters, email nudges, positive message boxes, and role modeling. The results are practice-changing: The intervention significantly reduced burnout prevalence from 63.3% in the control group to 52.2% in the intervention group (P < 0.001). It improved perceptions of job satisfaction, workplace safety, ethical climate, and patient- and family-centered care. Staff in the intervention arm were less likely to consider changing jobs. They also had lower emotional exhaustion, lower depersonalization, and higher personal accomplishment scores. Here’s the bedside “so what”: A pragmatic, system-level focus on positive communication and team cohesion can rapidly and meaningfully shift your unit’s culture—directly improving staff well-being. Forget the individual-focused, time-draining wellness programs. The answer might be in a simple, collective shift in how we interact. Tune in as we break down the specific components of the Hello intervention and how you can bring this powerful, low-cost strategy to your ICU.

For decades, we’ve been told vasopressors belong only through central lines — but what if that’s not the whole story? In this episode, we unpack a groundbreaking multicenter study from Addis Ababa that dares to challenge convention. Researchers followed 250 patients in shock, tracking survival outcomes, complications, and safety when vasopressors were given peripherally instead of through central access. The result? A strikingly low extravasation rate of just 1.2%, with all complications occurring only after five days of infusion. For short-term management, the data suggests — peripheral might be not only feasible, but safe. We’ll explore what this means for critical care teams everywhere — especially in resource-limited settings where central access isn’t always an option. Is it time to rewrite the playbook for shock management? What are the risks, the predictors of survival, and the real-world tradeoffs? Tune in as we dig into the data, the debates, and the bedside lessons from this landmark study — and ask the question every critical care clinician should be thinking about: Are we overcomplicating vasopressor delivery? Science meets practicality. Evidence meets the frontline. And the future of shock resuscitation might just look a little different.

Why are we still arguing about the best way to give fluids to patients with traumatic brain injury (TBI)? 🤔 This seems like a basic question, but the answer is complex and could mean the difference between life and death at the bedside. A recent comprehensive review article from the Journal of Clinical Medicine dives deep into the clinical and physiological challenges of fluid resuscitation in TBI patients. The authors conducted a non-systematic literature review of studies over the last two decades, focusing on fluid management, types of fluids, and transfusion strategies. The research highlights a critical paradox: while hypotension (low blood pressure) is a known killer in TBI, giving too much fluid can be just as deadly by worsening cerebral edema.                   The key takeaway? There is no one-size-fits-all approach. For fluid choice, the review argues against using balanced crystalloids like Ringer's lactate, suggesting they could worsen cerebral edema due to their relative hypotonicity. Instead, normal saline is often the preferred first-line fluid . As for blood transfusions, the data is contradictory. While some studies suggest a liberal transfusion strategy (aiming for a higher hemoglobin target) improves outcomes, others found no benefit and even a higher risk of adverse events    . This means that transfusion decisions should be highly individualized, based on the patient's specific physiological parameters, not a fixed number    .  This research is a wake-up call for frontline clinicians. It reminds us that blindly following protocols can be harmful. Every fluid bag, every pressor drip, and every unit of blood must be a thoughtful, personalized decision guided by robust hemodynamic and neuromonitoring .  Want to know how to make smarter, more precise fluid decisions for your TBI patients? Tune in to this episode as we break down the latest evidence and translate it into actionable steps for your daily practice.

Are we giving our older patients with out-of-hospital cardiac arrest (OHCA) a fair shot? ⏱️ Current guidelines say an ECPR initiation time of up to 60 minutes is acceptable, but is that really the case for everyone? This is a question clinicians grapple with every day at the bedside. A new nationwide observational study from South Korea tackles this head-on, analyzing data from 483 adult patients who received ECPR for non-traumatic OHCA. The study found that while both age and time to ECPR independently predict survival, the combination of the two is critical. The key takeaway? The "golden hour" for ECPR may not apply to our elderly patients. The results are practice-changing and frankly, a wake-up call. The study found that in patients over 65, the probability of survival plummeted to less than 10% when ECPR was delayed beyond just 21 minutes. For their younger counterparts, a 10% survival rate was maintained for nearly twice as long, up to 38 minutes    . This finding suggests that for older patients, the effective window for ECPR is much shorter than previously thought . The authors recommend a sense of urgency, urging clinicians to activate ECPR in carefully selected elderly patients almost immediately upon hospital arrival    .  This isn't just about a new number; it's about re-evaluating our clinical protocols and embracing an age-specific approach to resuscitation. Tune in as we break down the data and discuss what this means for your next OHCA case.