For this podcast, I will only be covering obstructive shock. Uh, obstructive shock caused by pees, cardiac tampenod, tension, pneumothorax as some of your examples. For your clinical manifestations, your patient will be hypotensive due to that poor cardiac output. They'll be tacoc cardic from the body trying to compensate. Um, all signs and symptoms are going to be related to the decreased cardiac output. If your patient has a PE they will be short of breath, have chest pain, tacic cardia, anxiety. For cardiac tampenade, they will have muffled heart sounds from the fluid around the heart, hypotension and tacic cardia. And then if tension numo is the problem, they will have absent breath sounds on the um affected side, potential for a deviated trachea, shortness of breath and tacocardia as well. For treatment, it's all about fixing the cause. So anti-coagulants for pulmonary embolism, paricardioentesis for cardiac tampenade, needle decompression or chest tube placement for your tension numo. But overall what we need to be doing is providing oxygen support and cardiac monitoring and support for your pulmonary embisms. This is going to be most commonly caused by a blood clot that breaks off from a DVT and travels to the lungs. So pulmonary embism is going to block blood flow in the lungs causing an infar and tissue death. It can also result in decreased gas exchange and hypoxia. A chest X-ray is going to be performed to rule out a bunch of other potential issues because it's quick. Um, but a VQ scan is another option. Um, so a VQ scan is going to look at blood flow through the lungs. Like a PE will block the blood flow. Uh, this is for those individuals who are allergic to contrast dye or have kidney dysfunction. Um however we can also do a pulmonary angiogram which is the CT of the lungs with contrast. This is going to look inside the vessels of the lungs to find the PE. Big things to look out for here. Um allergies to iodine, shellfish, uh that would be the contrast diet and then again kidney function. But your signs and symptoms of your PE here um in addition to the ones I've already mentioned we got chest pain, hypoxia, tachicardia, typipia, hypotension, dispia, petici, anxiety and syninkable episodes. This is an IVC filter. This is going to be used for patients that have recurrent pees despite being on anti-coagulants. Um, another common name that you might hear is the green field filter. This is not going to be indicated for your patients who have their very first and only PE. This is for patients who have multiple pees or recurrent pees. We can also use this for a patient with multiple clots in the lower extremities or pelvis. again inserted through the femoral um artery or groin. Um if we are doing this, your patient needs to be on bed rest for at least 2 hours after the procedure. Vital signs every 15 minutes for the first hour, every 30 minutes for the next 2 hours, and then whatever it is per your unit protocol. We'll monitor the puncture site and distal pulses post placement. Your patient is going to go home. um with this. So there's going to be no strenuous activity for 24 to 48 hours, no lifting more than 10 pounds until the patient has been cleared by the physician. Um pelvic rest. So for your female patients, pelvic rest means no sex. Um they can't use a tampon um for their period. And then there's no driving for 2 days. PE management mostly focuses on prevention. So, liberal fluid intake. Dehydration is going to make the blood really thick um and which makes it easier to clot. Um leg pumping exercises if on prolonged bed rest, SCDs or TED hose. Um just be mindful though that if there is a clot in the lower extremities, these would be contraindicated. We're not going to raise the knees with a pillow or a raised knee gatch on a gurnie or stretcher. And we'd also don't want any prolonged dangling of the feet. We're only going to use thrombolysis for unstable patients. We're going to infuse activ um into the lungs. And we only do this for life or death situations. It's kind of like a lastditch effort to get the clot. Contra indications are the same um as what we look for when we do thrombolytics for stroke patients with es schemic strokes. No anti-coagulants or antiplatelets for 24 hours. And we want to watch for signs of bleeding and angioadema. Anti-coagulation for our stable patients. They're going to be given the first dose of the oral anti coagulant in the ER and then they're going to go home with a prescription referral for follow-up care. Usually they're going to be on couadin which is your warerin or eloquis are your most common. Eloquis is your aixabam. For your unstable patients we are admitting them to the hospital and they're going to be started on a hepin drip. We have to have p baseline PTT and a PTT and platelets. We also might get an order for a baseline INR. There will be no invasive procedures for this patient while they're on the heperin drip. They will be on bed rest and we are going to get frequent vital signs on them. A patient is also going to be bridged with an oral anti-coagulant before we discont continue the heperin to allow that um heperin drip to wear off in the oral anti-coagulant to kick in. Um they're probably going to stay on long-term anti-coagulants for like 6 months. Uh this could even be like lovox injections. They could be on anti-coagulant therapy indefinitely if they are a high-risisk patient or have a risk for reoccurrence and this is going to be that couadin or the eloquis ventilator support. Um this is only for patients who are hemodynamically unstable or unable to support their own airway. Otherwise no vent. We just do oxygen therapy. So they'll be on continuous oxygen in the hospital. Remember this patient is short of breath and their gas exchange is impaired and they're going to hate this but we are going to give them an incentives barometer and encourage them to cough and deep breathe to prevent adalcttois. Uh for pain your pharmacologic opioids are only going to be administered for severe pain. Otherwise we are going to try to treat non-farmacologically. So semifalers is going to help increase comfort with that breathing. Just remember that the pain here is puritic and it is not cardiac in nature. But we do have this patient on continuous cardiac monitoring. In case we have more clots, they can travel into the coronary arteries. And that's it for PE management and obstructive shock.