This week’s FAST Replay is a double feature! Two talks that tackle high-stakes medicine from completely different angles, but with the same underlying theme: thinking differently when the usual approach isn’t enough.

First up, Brittany Bernardoni takes us into the rapidly evolving world of Extracorporeal Cardiopulmonary Resuscitation (ECPR). From the limitations of conventional CPR to the growing use of ECMO in cardiac arrest, this session explores what may become the next major leap forward in resuscitation care. Brittany walks through the physiology, patient selection, timing, and the real-world programs already bringing ECPR directly to patients in the field.

Then, Elizabeth Garcher dives into one of the most intimidating areas in prehospital and critical care medicine: pregnancy-related emergencies. This talk focuses on “errors of omission.” The treatments clinicians hesitate to give because of fear of harming the baby, even when delaying care, can seriously harm both patients. From airway changes and hypertensive emergencies to eclampsia, DKA, blood products, and seizure management, this session is packed with practical pearls and critical reminders for managing pregnant patients in the field.

Two completely different topics. Two incredibly practical talks.
One common thread: understanding the physiology well enough to act decisively when it matters most.

We’re continuing our FAST Replay series, bringing you full sessions recorded live from past FAST conferences as we build toward FAST26: Austin. This episode features Jeff Jarvis and covers a wide range of topics that directly address how we practice in EMS.

From trauma care to airway to cardiac arrest, this session walks through current position statements and evolving recommendations, including:

• Blood product use in trauma
• How to approach traumatic (circulatory) arrest
• Pneumothorax and chest decompression decisions
• Postpartum hemorrhage and hypertension management
• Airway timing and first-pass success
• And where some of our long-standing practices don’t hold up to the evidence

More than anything, this talk highlights a core idea: not everything we do in EMS is built on strong evidence, and we need to be willing to question and refine our approach as new data emerge.

FAST26 is coming to Austin this year on May 27 - 29, 2026. We are co-locating with EMS World Live, bringing together the entire EMS community with FAST26: Austin and EMS World Live Austin, giving you the very best of every possible aspect from basics to critical care to administration!

👉 Learn more or grab your spot at https://fbefast.com

This episode focuses on the critically ill patient with pulmonary arterial hypertension (PAH) and explains why this subgroup is especially dangerous in emergency and transport medicine. Dr. Mike Lauria distinguishes PAH from the broader label of “pulmonary hypertension,” emphasizing that elevated pulmonary pressures can come from several very different disease processes, but group 1 PAH is a rare intrinsic disease of the pulmonary arteries that creates fixed resistance to blood flow. Over time, this chronic increase in pulmonary vascular resistance places an enormous burden on the right ventricle, which may initially compensate but can eventually dilate and fail, especially when stressed by infection, hypoxia, medication interruption, or other acute illness.

A major theme of the episode is that right ventricular failure is the central problem when these patients decompensate. Dr. Lauria reviews how rising RV afterload leads to RV dilation, reduced RV output, impaired LV filling, worsening cardiac output, and eventual shock. He also highlights an important practical pearl: many PAH patients depend on specialized outpatient therapies such as endothelin receptor antagonists, PDE-5 inhibitors, and especially continuous prostacyclin infusions like epoprostenol or treprostinil. Abrupt interruption of these medications can trigger rebound pulmonary hypertension and rapid deterioration, making continuation of home therapy a critical part of transport and ICU management.

Management is framed around supporting the failing RV while avoiding interventions that can worsen hemodynamics. The speaker recommends maintaining MAP, usually with norepinephrine, carefully managing preload, and recognizing that this is one of the few shock states where patients may need both vasopressors and diuresis. The episode strongly warns against aggressive fluid loading, stresses the importance of correcting hypoxia and hypercapnia, and supports use of inhaled pulmonary vasodilators such as nitric oxide or epoprostenol in the right setting. It also cautions that intubation is particularly dangerous in PAH because induction and positive-pressure ventilation can sharply worsen RV function and precipitate cardiovascular collapse.

Key points

• The episode distinguishes group 1 pulmonary arterial hypertension from the broader and more nonspecific category of pulmonary hypertension.
• PAH is dangerous because it creates fixed pulmonary vascular resistance, which can eventually cause right ventricular failure and shock.
• Medication interruption, especially stopping continuous prostacyclin infusions, can cause rebound pulmonary hypertension and sudden collapse.
• Management focuses on supporting the RV: maintain MAP, avoid unnecessary fluids, optimize oxygenation and ventilation, and consider inhaled pulmonary vasodilators.
• Intubation is high risk in these patients because positive pressure and induction can worsen RV afterload and trigger hemodynamic collapse.