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All right, so that's just the one thing that I want to talk
about with pediatric respiratory, but what I really
want to dive into it, I want to dive into pulmonary emboli,
pulmonary emboli, Pulmonary emboli is not only caused by a
DVT or a thrombus there actually.
Other ways to form an emboli that can cause this respiratory
distress. So, the pneumonic is fat bat,
this is what I learned in med school or starting for my boys.
And help me remember fat because you can have a fat emboli and
how do we develop a fat emboli? Fracture of long bones.
Exactly, good job, pelvic bones long bones.
That flat got globulin, will enter the bloodstream.
That bloodstream will come back into the right side of the heart
and it will Lodge into the lungs.
The next one is amniotic fluid. That amniotic fluid is going to
stay as a globule as well in the blood during pregnancy.
And during delivery specifically and once it enters the
bloodstream, same thing is going to come up.
It's going to hit the right, atrium, right ventricle, right
into the lungs. Now, we've got an amniotic
emboli, The one that we commonly, see.
Is the thrombus. Thrombotic emboli.
When does this happen? This happens when we're
hypercoagulable When we throw a clot, you get a DVT it
dislodges. Through that venous return is
going to come again to the right, atrium down to the right
ventricle into the lung. And now we've got a thrombus Or
thrombotic MLA. B is bacteria.
When do we see bacterial emboli? The most.
Common one is going to be an IV drug users bacterial
endocarditis. Bacterial endocarditis is.
This is a septic emboli. So IV drug user is constantly
using a dirty needle. They're not worried about clean
needles, they're just trying to get high.
So they're injecting themselves injecting themselves with all
this bacteria that bacteria starts to grow.
On the leaflets of the tricuspid valve.
So you got your tricuspid valve and now you've got a bacteria
that is continuously growing growing growing.
And as this gets bigger well, eventually it breaks off and
then now it will go right into the lung.
The next one is air. How do we get an air embolus a?
Central line. Yeah, absolutely start a line.
And and you can get air into the bloodstream, the other one.
Is not commonly tested by. It is another way to get air
emboli. Are I'm bleeding gasps emboli
when people go scuba diving. When people go scuba diving,
when they come up, they have to come up slowly.
And the reason being is that, if you come up too fast, the
nitrogen in your blood will start to become Bubbles and that
bubble can go right into your right heart and into your lungs.
It's cool. Little fun fact.
Yeah, pretty interesting, right? And the last one is tumor tumor
cells, can obviously Aggregate and that aggregation of tumor
cells can cause an MBA light fat bat.
So what happens here? What happens here, let's take
the DVT. Let's just take the DBT because
that's probably gonna be the most common one that you're
going to see. So this person's got what
unilateral unilateral or right leg or left leg.
They're not going to have bilateral.
Leg swelling. So they've got a clot in here.
It's warm red. Painful swollen.
You don't want them dorsiflex saying okay you want them to
stay still until the body reabsorbs it, but in the off
chance that it does dislodge, what is it going to do?
It's going to go into the IVC and then into the right atrium
into the right ventricle and then into the lungs.
So the most common one that we're going to see is going to
be the zbt. Dislodging now it's become a
pulmonary emboli. So, what happens?
Let's take a look at the lung. This NCLEX high-yield podcast is
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So now we've got this clot, that is dislodged, and it's now made
its way into the lung, and it's blocking off the ability to get
oxygen to that area. So, what's going to happen?
Well, we're going to have chest pain.
We're going to have decreased O2, sats are going to start to
drop. We're going to have increased
heart rate. We're going to be to Kip Nick,
look for these signs. We could even have a low-grade
fever. What's happening on the
physiological level? This is where students get
really, really tripped up. What's supposed to happen here
normally. Normally what happens is we get
Co2 out? And we're taking 02.
In oxygen into the body and where X greeting CO2.
So, what normally happens, right?
So, this part is your ventilation and this part is
your perfusion. Our ventilation our breathing,
our gas exchange is now perfusing.
Our bloodstream, we're getting into a proper oxygen and CO2
exchange. Both of these are gases.
So this is just gas exchange, is it not?
We're getting rid of CO2 and we're bringing in 02.
That's just an exchange of gases.
Our ventilation is occurring and now it is going to perfuse our
bloodstream. fancy words, but they're just basically saying
this But now, we've gone and we've gotten a PE.
This clot now. Is going to prevent oxygen from
getting in and CO2 from getting out.
Now, we've got impaired gas exchange, my gas exchange is
just not working. Are ventilation and are
perfusion are now mismatched. We've got decreased O2.
And we're going to end up getting increased CO2.
So what are we going to do? What are we going to do about
this personal? Give me some oxygen.
First and foremost, but we got to anticoagulate them.
So I'm going to go into some hard core cardio cardio Farm on
top of it. So what are we going to do?
The first thing we've got to do, is we've got to anticoagulate
them, they've got a DVT. Now the develop the PE why are
we going to anticoagulate them? How do we know that they need to
be anticoagulated? Well they got a clot obviously.
So let's talk about those two drugs.
What we've got to do right away as we've got to anticoagulate
them. We know that they're in a
hypercoagulable state, we don't care what it is.
It could have been them sitting on a plane for 14 hours and not
getting up stasis. They could be pregnant.
Hypercoagulable, they could be post-op.
They could be on hormone replacement therapy or
contraceptives and a smoker blood thickens.
Anytime you give somebody extra testosterone their blood
thickens. If you give extra estrogen blood
thickens, look at their H&H rise.
That's going to cause decreased movement of the blood and when
blood does not move it clots think about when you scrape your
leg. And what do you do?
You put pressure on it and what does it do?
It's scabs over. What's the difference between
that in a clot? Nothing.
That's exactly how the body works.
So now we're going to anticoagulate them.
We need to make sure that they don't throw another clot.
So get them anticoagulated. Heparin.
This is how I was taught to remember.
For short. What do we call?
Heparin on the floor? Hap Jana have trip.
Give me some hap. How many letters in Hep?
Three, three letters in Hep three letters and PTT.
Easy way to remember it. So three letters in Hep three
letters in PT so by default I know that Warfarin is pt/inr,
don't mix them up ever again. Keep them simple and clear.
The antidote for heparin. Is protamine sulfate.
Hap PTT protamine sulfate. Look at the alliteration. hap PT
pour myself a when you guys are setting these notes that you're
taking every single day, You should be sitting there and
going through these repetitively repetitively.
So when it comes to test date, you're like all right.
I do have her in our PT, put himself at cool.
Alright, what else? What else you got?
Didn't even waste some time. Is it away?
Sometime. All right, so now we've got
happy TT protamine sulfate. Now you need to know what the
therapeutic level is. You need to know what the
therapeutic level is. What is it?
They're up, you take level. Well 1.5 to 2 times, the normal
value 1.5 to 2 times 1.5 to 2 times, the normal value which
now becomes in seconds. 46 270 seconds.
They can ask you either, or this is how the boards are going to
ask a question. Person was brought in for DVT
and now they're started on Heparin.
Their PTT is at 120. What is going to be the priority
action? What are we going to do?
This person's PT is 120. Stop it.
Then what are we going to do?
Stop and give podium in. There you go, stop, and then
give part of my selfie. So, look for that.
They may even tell you the same thing, but instead of saying 120
seconds, they may say it's four times.
The normal value, same thing, you're going to stop it.
Discontinued it and start or get ready to start protamine
sulfate. The reason why we start with
heparin is because its onset is in seconds.
We're not wasting any time. It's going to be Sub-Q.
Or IV, so we can get them anticoagulated super fast.
So now we've got Warfarin. Warfarin is oral, but it takes
some time to get to this 223. INR.
What's War? Friends antidote?
Vitamin K. So what types of foods are we
going to monitor? Yeah.
Green leafy foods. So spinach.
Kale cabbage, broccoli. We're not going to tell them and
liver. Yeah, that's, that's it.
I didn't know that till I honestly, I didn't know that
till I did until I saw it on you and I was like liver.
I never read this before, but apparently liver has vitamin K
in it. What about banana?
Do we avoid banana? Do we monitor banana?
No, that's potassium, don't fall for that, don't fall for that.
So vitamin K foods, we don't stop them, we don't avoid them,
we don't tell them to not eat healthy foods.
Just eat them. In moderation, monitor them.
Keep an eye out for that if they keep it.
Consistent of say, hey, look, I eat two.
Spinach salads a week, keep it consistent because then, when we
adjust your Warfarin dose, we know that that's what's
happening, okay? We know that you're going to
keep it consistent, so it's not going to fluctuate.
So, keep it consistent monitor. Don't look at those little words
on the boards. I'm telling you, when you hear
students talking like little words on the boards, make a
world of a difference, world of a difference.
So yeah, green leafy foods and liver.
We also avoid grapefruit. Why grapefruit affects the
cytochrome p450? Enzyme in your liver, which is
responsible for breaking down Warfarin.
So we do not want that to be affected because, again, the
efficacy and the availability of it is going to be decreased
significantly. So look out for that one, as
well. Not super high yield but for the
sake of completion, if someone has a valve replacement, if they
have a valve replacement, we up it.
To 2.5 to 3.5. Now if this doesn't work on
somebody that's consistently getting dvts Then we can go in
and we can place an IVC filter which is what an inferior vena
cava filter. And all that's going to do is in
the inferior vena cava it's going to catch the clock.
It's just a little filter, and it's going to catch the clot.
All right, now let's talk about Bridging.
So patient comes in. They've got a warm unilateral
painful swollen, right calf. That right there should be a red
light saying hey wait a minute stop.
What's going on? This person's got a DVT.
First thing we're going to do is we're going to start them on.
Heparin Heparin is subcutaneous or IV and it works in seconds.
So we're good now. We've got them anticoagulated.
Well now we've got to wait for the body to break down.
Those clotting factors. And reabsorb them.
So the body will naturally do that.
Just give it some time. As long as you're not throwing
another clot and our body. Our blood is anticoagulated, it
will happen in a couple of days as we start to see.
The blood thinned out and the size of the clock now is
decreasing. We're doing ultrasounds or
checking it out. We're going to start them.
Simultaneously. On Warfarin.
Why are we doing that? We're not going to send them
home on Heparin sub Q IV. But Warfarin is oral and we can
definitely send them home on oral medication, right?
But it takes some time for warfarin to get to that 2 to 3
INR. One works on PTT.
One works on PT, so we're not worried about it having this
compounding effect. We're worried about them getting
to a therapeutic level. Once we've got them on a
therapeutic level. Now we can discontinue the
heparin And we send them home on Warfarin this time frame.
Is called bridging. You're Bridging the person.
From Heparin to Warfarin and you're going to send them home
on Warfarin, probably going to be on it for about six to nine
months. So try not to use brand names if
you're going to be doing your drugs because the boards are not
going to use brand names. I tell you what they are in real
life too. So you can make that
correlation. But always, always, always stick
to the generic, no set of boards, not my not PA is not
nursing boards are ever going. Give you brand names.
The type of question that they're going to ask you here.
Okay, the type of question that they're going to ask you here is
going to be one. Identifying that it's okay to be
giving both at the same time so there's going to be that
question which, which one of the following statements by The
Graduate nurse, you know, the pie throwing something like
that. Are you going to question or
further intervene and they're going to say something, the
effective? Oh, no, we don't want to give
them or friend they're already on heparin.
And you're going to educate them.
You're going to say, no. Actually, this is a concept of
bridging. I learned it from dr.
Z and this is how it works. So that's how you're gonna
explain to that graduate nurse, give me my credit and I'm just
kidding. So, yeah, we give them half from
region of that. Type of question, they're going
to ask the other one, is going to be educating the patient on
warfarin. So what do we need to know about
Warfarin? Well, we want to make sure in
their Management in the management of Warfarin.
We have to educate them, right? Especially if they've never been
on it. It's a blood thinner.
So things like making a clear pathway between your bed in the
bathroom, something simple like that, right?
Keep a night light on so you're not running into things.
Not only for Falls which is obviously a big deal but also
because we don't And bumping into things bleeding
precautions. Yeah, make sure that they're
using things like soft bristle toothbrush.
You don't want their gums bleeding, because can be hard
for them to stop use an electric razor again.
You just talking to go to stop bleeding.
That's a problem. Make sure that they don't have
anything. They can slip on trip over.
So yeah, make sure we're educating them.
Make sure that they know to wear a med tag bracelet because in
the case that they do fall, we need to make sure that they know
or that Whoever's attending to them knows that they are
anticoagulated because the first thing we're going to have to
give them is What vitamin K. Make sure that we're educating
these patients thoroughly on how to go about their daily lives.
Prior to surgery, we want to make sure that we DC any
anticoagulant. Hey guys, dr.
Zeeshan here. Thank you so much for joining us
on this podcast. Hope you guys enjoyed it.
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