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All right, so that's just the 
one thing that I want to talk 

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about with pediatric 
respiratory, but what I really 

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want to dive into it, I want to 
dive into pulmonary emboli, 

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pulmonary emboli, Pulmonary 
emboli is not only caused by a 

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DVT or a thrombus there 
actually. 

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Other ways to form an emboli 
that can cause this respiratory 

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distress. 
So, the pneumonic is fat bat, 

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this is what I learned in med 
school or starting for my boys. 

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And help me remember fat because
you can have a fat emboli and 

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how do we develop a fat emboli? 
Fracture of long bones. 

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Exactly, good job, pelvic bones 
long bones. 

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That flat got globulin, will 
enter the bloodstream. 

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That bloodstream will come back 
into the right side of the heart

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and it will Lodge into the 
lungs. 

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The next one is amniotic fluid. 
That amniotic fluid is going to 

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stay as a globule as well in the
blood during pregnancy. 

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And during delivery specifically
and once it enters the 

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bloodstream, same thing is going
to come up. 

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It's going to hit the right, 
atrium, right ventricle, right 

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into the lungs. 
Now, we've got an amniotic 

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emboli, The one that we 
commonly, see. 

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Is the thrombus. 
Thrombotic emboli. 

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When does this happen? 
This happens when we're 

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hypercoagulable When we throw a 
clot, you get a DVT it 

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dislodges. 
Through that venous return is 

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going to come again to the 
right, atrium down to the right 

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ventricle into the lung. 
And now we've got a thrombus Or 

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thrombotic MLA. 
B is bacteria. 

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When do we see bacterial emboli?
The most. 

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Common one is going to be an IV 
drug users bacterial 

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endocarditis. 
Bacterial endocarditis is. 

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This is a septic emboli. 
So IV drug user is constantly 

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using a dirty needle. 
They're not worried about clean 

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needles, they're just trying to 
get high. 

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So they're injecting themselves 
injecting themselves with all 

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this bacteria that bacteria 
starts to grow. 

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On the leaflets of the tricuspid
valve. 

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So you got your tricuspid valve 
and now you've got a bacteria 

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that is continuously growing 
growing growing. 

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And as this gets bigger well, 
eventually it breaks off and 

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then now it will go right into 
the lung. 

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The next one is air. 
How do we get an air embolus a? 

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Central line. 
Yeah, absolutely start a line. 

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And and you can get air into the
bloodstream, the other one. 

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Is not commonly tested by. 
It is another way to get air 

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emboli. 
Are I'm bleeding gasps emboli 

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when people go scuba diving. 
When people go scuba diving, 

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when they come up, they have to 
come up slowly. 

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And the reason being is that, if
you come up too fast, the 

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nitrogen in your blood will 
start to become Bubbles and that

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bubble can go right into your 
right heart and into your lungs.

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It's cool. 
Little fun fact. 

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Yeah, pretty interesting, right?
And the last one is tumor tumor 

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cells, can obviously Aggregate 
and that aggregation of tumor 

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cells can cause an MBA light fat
bat. 

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So what happens here? 
What happens here, let's take 

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the DVT. 
Let's just take the DBT because 

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that's probably gonna be the 
most common one that you're 

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going to see. 
So this person's got what 

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unilateral unilateral or right 
leg or left leg. 

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They're not going to have 
bilateral. 

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Leg swelling. 
So they've got a clot in here. 

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It's warm red. 
Painful swollen. 

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You don't want them dorsiflex 
saying okay you want them to 

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stay still until the body 
reabsorbs it, but in the off 

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chance that it does dislodge, 
what is it going to do? 

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It's going to go into the IVC 
and then into the right atrium 

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into the right ventricle and 
then into the lungs. 

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So the most common one that 
we're going to see is going to 

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be the zbt. 
Dislodging now it's become a 

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pulmonary emboli. 
So, what happens? 

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Let's take a look at the lung. 
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So now we've got this clot, that
is dislodged, and it's now made 

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its way into the lung, and it's 
blocking off the ability to get 

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oxygen to that area. 
So, what's going to happen? 

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Well, we're going to have chest 
pain. 

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We're going to have decreased 
O2, sats are going to start to 

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drop. 
We're going to have increased 

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heart rate. 
We're going to be to Kip Nick, 

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look for these signs. 
We could even have a low-grade 

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fever. 
What's happening on the 

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physiological level? 
This is where students get 

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really, really tripped up. 
What's supposed to happen here 

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normally. 
Normally what happens is we get 

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Co2 out? 
And we're taking 02. 

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In oxygen into the body and 
where X greeting CO2. 

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So, what normally happens, 
right? 

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So, this part is your 
ventilation and this part is 

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your perfusion. 
Our ventilation our breathing, 

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our gas exchange is now 
perfusing. 

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Our bloodstream, we're getting 
into a proper oxygen and CO2 

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exchange. 
Both of these are gases. 

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So this is just gas exchange, is
it not? 

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We're getting rid of CO2 and 
we're bringing in 02. 

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That's just an exchange of 
gases. 

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Our ventilation is occurring and
now it is going to perfuse our 

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bloodstream. fancy words, but 
they're just basically saying 

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this But now, we've gone and 
we've gotten a PE. 

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This clot now. 
Is going to prevent oxygen from 

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getting in and CO2 from getting 
out. 

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Now, we've got impaired gas 
exchange, my gas exchange is 

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just not working. 
Are ventilation and are 

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perfusion are now mismatched. 
We've got decreased O2. 

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And we're going to end up 
getting increased CO2. 

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So what are we going to do? 
What are we going to do about 

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this personal? 
Give me some oxygen. 

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First and foremost, but we got 
to anticoagulate them. 

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So I'm going to go into some 
hard core cardio cardio Farm on 

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top of it. 
So what are we going to do? 

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The first thing we've got to do,
is we've got to anticoagulate 

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them, they've got a DVT. 
Now the develop the PE why are 

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we going to anticoagulate them? 
How do we know that they need to

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be anticoagulated? 
Well they got a clot obviously. 

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So let's talk about those two 
drugs. 

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What we've got to do right away 
as we've got to anticoagulate 

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them. 
We know that they're in a 

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hypercoagulable state, we don't 
care what it is. 

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It could have been them sitting 
on a plane for 14 hours and not 

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getting up stasis. 
They could be pregnant. 

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Hypercoagulable, they could be 
post-op. 

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They could be on hormone 
replacement therapy or 

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contraceptives and a smoker 
blood thickens. 

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Anytime you give somebody extra 
testosterone their blood 

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thickens. 
If you give extra estrogen blood

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thickens, look at their H&H 
rise. 

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That's going to cause decreased 
movement of the blood and when 

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blood does not move it clots 
think about when you scrape your

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leg. 
And what do you do? 

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You put pressure on it and what 
does it do? 

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It's scabs over. 
What's the difference between 

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that in a clot? 
Nothing. 

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That's exactly how the body 
works. 

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So now we're going to 
anticoagulate them. 

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We need to make sure that they 
don't throw another clot. 

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So get them anticoagulated. 
Heparin. 

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This is how I was taught to 
remember. 

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For short. 
What do we call? 

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Heparin on the floor? 
Hap Jana have trip. 

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Give me some hap. 
How many letters in Hep? 

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Three, three letters in Hep 
three letters and PTT. 

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Easy way to remember it. 
So three letters in Hep three 

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letters in PT so by default I 
know that Warfarin is pt/inr, 

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don't mix them up ever again. 
Keep them simple and clear. 

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The antidote for heparin. 
Is protamine sulfate. 

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Hap PTT protamine sulfate. 
Look at the alliteration. hap PT

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pour myself a when you guys are 
setting these notes that you're 

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taking every single day, You 
should be sitting there and 

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going through these repetitively
repetitively. 

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So when it comes to test date, 
you're like all right. 

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I do have her in our PT, put 
himself at cool. 

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Alright, what else? 
What else you got? 

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Didn't even waste some time. 
Is it away? 

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Sometime. 
All right, so now we've got 

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happy TT protamine sulfate. 
Now you need to know what the 

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therapeutic level is. 
You need to know what the 

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therapeutic level is. 
What is it? 

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They're up, you take level. 
Well 1.5 to 2 times, the normal 

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value 1.5 to 2 times 1.5 to 2 
times, the normal value which 

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now becomes in seconds. 46 270 
seconds. 

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They can ask you either, or this
is how the boards are going to 

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ask a question. 
Person was brought in for DVT 

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and now they're started on 
Heparin. 

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Their PTT is at 120. 
What is going to be the priority

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action? 
What are we going to do? 

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This person's PT is 120. 
Stop it. 

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Stop it. 
Then what are we going to do? 

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Stop and give podium in. 
There you go, stop, and then 

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give part of my selfie. 
So, look for that. 

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They may even tell you the same 
thing, but instead of saying 120

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seconds, they may say it's four 
times. 

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The normal value, same thing, 
you're going to stop it. 

200
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Discontinued it and start or get
ready to start protamine 

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sulfate. 
The reason why we start with 

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heparin is because its onset is 
in seconds. 

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We're not wasting any time. 
It's going to be Sub-Q. 

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Or IV, so we can get them 
anticoagulated super fast. 

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So now we've got Warfarin. 
Warfarin is oral, but it takes 

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some time to get to this 223. 
INR. 

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What's War? 
Friends antidote? 

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Vitamin K. 
So what types of foods are we 

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going to monitor? 
Yeah. 

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Green leafy foods. 
So spinach. 

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Kale cabbage, broccoli. 
We're not going to tell them and

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liver. 
Yeah, that's, that's it. 

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00:14:24,800 --> 00:14:27,000
I didn't know that till I 
honestly, I didn't know that 

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till I did until I saw it on you
and I was like liver. 

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00:14:29,900 --> 00:14:32,600
I never read this before, but 
apparently liver has vitamin K 

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in it. 
What about banana? 

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Do we avoid banana? 
Do we monitor banana? 

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No, that's potassium, don't fall
for that, don't fall for that. 

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So vitamin K foods, we don't 
stop them, we don't avoid them, 

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00:14:50,100 --> 00:14:52,700
we don't tell them to not eat 
healthy foods. 

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Just eat them. 
In moderation, monitor them. 

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Keep an eye out for that if they
keep it. 

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Consistent of say, hey, look, I 
eat two. 

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Spinach salads a week, keep it 
consistent because then, when we

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adjust your Warfarin dose, we 
know that that's what's 

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happening, okay? 
We know that you're going to 

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keep it consistent, so it's not 
going to fluctuate. 

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So, keep it consistent monitor. 
Don't look at those little words

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on the boards. 
I'm telling you, when you hear 

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00:15:27,900 --> 00:15:30,200
students talking like little 
words on the boards, make a 

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world of a difference, world of 
a difference. 

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So yeah, green leafy foods and 
liver. 

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We also avoid grapefruit. 
Why grapefruit affects the 

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cytochrome p450? 
Enzyme in your liver, which is 

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responsible for breaking down 
Warfarin. 

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So we do not want that to be 
affected because, again, the 

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efficacy and the availability of
it is going to be decreased 

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significantly. 
So look out for that one, as 

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well. 
Not super high yield but for the

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sake of completion, if someone 
has a valve replacement, if they

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have a valve replacement, we up 
it. 

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To 2.5 to 3.5. 
Now if this doesn't work on 

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somebody that's consistently 
getting dvts Then we can go in 

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and we can place an IVC filter 
which is what an inferior vena 

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cava filter. 
And all that's going to do is in

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the inferior vena cava it's 
going to catch the clock. 

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It's just a little filter, and 
it's going to catch the clot. 

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All right, now let's talk about 
Bridging. 

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So patient comes in. 
They've got a warm unilateral 

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painful swollen, right calf. 
That right there should be a red

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00:17:06,400 --> 00:17:08,400
light saying hey wait a minute 
stop. 

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What's going on? 
This person's got a DVT. 

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First thing we're going to do is
we're going to start them on. 

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Heparin Heparin is subcutaneous 
or IV and it works in seconds. 

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So we're good now. 
We've got them anticoagulated. 

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Well now we've got to wait for 
the body to break down. 

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Those clotting factors. 
And reabsorb them. 

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So the body will naturally do 
that. 

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Just give it some time. 
As long as you're not throwing 

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another clot and our body. 
Our blood is anticoagulated, it 

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00:17:40,100 --> 00:17:44,400
will happen in a couple of days 
as we start to see. 

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00:17:46,800 --> 00:17:50,500
The blood thinned out and the 
size of the clock now is 

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decreasing. 
We're doing ultrasounds or 

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00:17:52,408 --> 00:17:56,600
checking it out. 
We're going to start them. 

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Simultaneously. 
On Warfarin. 

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00:18:01,700 --> 00:18:04,900
Why are we doing that? 
We're not going to send them 

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home on Heparin sub Q IV. 
But Warfarin is oral and we can 

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definitely send them home on 
oral medication, right? 

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00:18:15,700 --> 00:18:22,200
But it takes some time for 
warfarin to get to that 2 to 3 

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00:18:22,300 --> 00:18:26,500
INR. 
One works on PTT. 

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One works on PT, so we're not 
worried about it having this 

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00:18:31,000 --> 00:18:34,400
compounding effect. 
We're worried about them getting

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to a therapeutic level. 
Once we've got them on a 

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therapeutic level. 
Now we can discontinue the 

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00:18:41,800 --> 00:18:48,400
heparin And we send them home on
Warfarin this time frame. 

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Is called bridging. 
You're Bridging the person. 

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From Heparin to Warfarin and 
you're going to send them home 

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on Warfarin, probably going to 
be on it for about six to nine 

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00:19:06,900 --> 00:19:10,800
months. 
So try not to use brand names if

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you're going to be doing your 
drugs because the boards are not

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00:19:13,708 --> 00:19:17,400
going to use brand names. 
I tell you what they are in real

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00:19:17,400 --> 00:19:18,800
life too. 
So you can make that 

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correlation. 
But always, always, always stick

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00:19:22,600 --> 00:19:27,300
to the generic, no set of 
boards, not my not PA is not 

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00:19:27,300 --> 00:19:30,300
nursing boards are ever going. 
Give you brand names. 

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00:19:30,400 --> 00:19:32,900
The type of question that 
they're going to ask you here. 

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00:19:33,100 --> 00:19:36,200
Okay, the type of question that 
they're going to ask you here is

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going to be one. 
Identifying that it's okay to be

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00:19:41,700 --> 00:19:44,500
giving both at the same time so 
there's going to be that 

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00:19:44,500 --> 00:19:47,900
question which, which one of the
following statements by The 

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00:19:47,900 --> 00:19:50,600
Graduate nurse, you know, the 
pie throwing something like 

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00:19:50,600 --> 00:19:52,600
that. 
Are you going to question or 

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00:19:52,600 --> 00:19:55,300
further intervene and they're 
going to say something, the 

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00:19:55,300 --> 00:19:56,900
effective? 
Oh, no, we don't want to give 

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00:19:56,900 --> 00:19:59,600
them or friend they're already 
on heparin. 

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00:20:00,600 --> 00:20:02,100
And you're going to educate 
them. 

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00:20:02,400 --> 00:20:05,500
You're going to say, no. 
Actually, this is a concept of 

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00:20:05,500 --> 00:20:07,200
bridging. 
I learned it from dr. 

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00:20:07,200 --> 00:20:11,000
Z and this is how it works. 
So that's how you're gonna 

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00:20:11,000 --> 00:20:14,300
explain to that graduate nurse, 
give me my credit and I'm just 

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00:20:14,300 --> 00:20:18,100
kidding. 
So, yeah, we give them half from

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00:20:18,100 --> 00:20:19,900
region of that. 
Type of question, they're going 

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00:20:19,900 --> 00:20:23,500
to ask the other one, is going 
to be educating the patient on 

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00:20:23,900 --> 00:20:27,200
warfarin. 
So what do we need to know about

305
00:20:27,200 --> 00:20:31,500
Warfarin? 
Well, we want to make sure in 

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00:20:31,500 --> 00:20:34,600
their Management in the 
management of Warfarin. 

307
00:20:34,600 --> 00:20:37,300
We have to educate them, right? 
Especially if they've never been

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00:20:37,300 --> 00:20:38,600
on it. 
It's a blood thinner. 

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00:20:38,600 --> 00:20:45,900
So things like making a clear 
pathway between your bed in the 

310
00:20:45,900 --> 00:20:49,500
bathroom, something simple like 
that, right? 

311
00:20:49,900 --> 00:20:53,100
Keep a night light on so you're 
not running into things. 

312
00:20:53,400 --> 00:20:58,300
Not only for Falls which is 
obviously a big deal but also 

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00:20:58,400 --> 00:21:00,900
because we don't And bumping 
into things bleeding 

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00:21:00,900 --> 00:21:03,000
precautions. 
Yeah, make sure that they're 

315
00:21:03,000 --> 00:21:05,800
using things like soft bristle 
toothbrush. 

316
00:21:06,200 --> 00:21:08,900
You don't want their gums 
bleeding, because can be hard 

317
00:21:08,900 --> 00:21:12,200
for them to stop use an electric
razor again. 

318
00:21:12,200 --> 00:21:13,400
You just talking to go to stop 
bleeding. 

319
00:21:13,400 --> 00:21:15,500
That's a problem. 
Make sure that they don't have 

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00:21:15,500 --> 00:21:17,200
anything. 
They can slip on trip over. 

321
00:21:17,800 --> 00:21:19,500
So yeah, make sure we're 
educating them. 

322
00:21:19,500 --> 00:21:24,900
Make sure that they know to wear
a med tag bracelet because in 

323
00:21:24,900 --> 00:21:28,500
the case that they do fall, we 
need to make sure that they know

324
00:21:28,900 --> 00:21:31,700
or that Whoever's attending to 
them knows that they are 

325
00:21:31,700 --> 00:21:33,700
anticoagulated because the first
thing we're going to have to 

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00:21:33,700 --> 00:21:38,000
give them is What vitamin K. 
Make sure that we're educating 

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00:21:38,000 --> 00:21:44,400
these patients thoroughly on how
to go about their daily lives. 

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00:21:45,600 --> 00:21:50,200
Prior to surgery, we want to 
make sure that we DC any 

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00:21:50,200 --> 00:21:53,500
anticoagulant. 
Hey guys, dr. 

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00:21:53,500 --> 00:21:55,200
Zeeshan here. 
Thank you so much for joining us

331
00:21:55,200 --> 00:21:57,300
on this podcast. 
Hope you guys enjoyed it. 

332
00:21:57,300 --> 00:22:00,900
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333
00:22:00,900 --> 00:22:03,900
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334
00:22:03,900 --> 00:22:06,000
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335
00:22:06,000 --> 00:22:07,700
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336
00:22:08,100 --> 00:22:09,800
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337
00:22:09,800 --> 00:22:11,500
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