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.

This episode reviews the newly released 2026 pulmonary embolism guidelines with an emphasis on what matters most for critical care and transport clinicians: identifying the sickest PE patients early and recognizing how quickly they can deteriorate. Dr. Michael Lauria stresses that although pulmonary embolism is common, the subset with hemodynamic instability carries very high mortality and often requires transfer for advanced therapies such as ECMO, catheter-based intervention, or surgery.

A major focus is the new classification system, which replaces the older “massive” and “submassive” terminology with categories A through E. Instead of emphasizing clot size, the new framework centers on clinical severity, especially hypotension, end-organ hypoperfusion, and progression toward cardiopulmonary failure. The episode also highlights that severe PE is fundamentally a problem of right ventricular failure: as pulmonary vascular resistance rises, the RV dilates, perfusion worsens, LV filling drops, and the patient can spiral into shock.

Management is therefore framed around supporting the failing RV while moving toward definitive reperfusion. The speaker recommends maintaining perfusion pressure, avoiding aggressive fluids, optimizing oxygenation, reducing RV afterload, and using inotropic support when needed, while also warning that intubation and positive pressure can worsen hemodynamics in these patients. For the sickest patients, especially category D and E PE, systemic thrombolysis is presented as the main reperfusion option available in many settings, though it remains underused and carries meaningful bleeding risk, including intracranial hemorrhage.

Key points

• The episode centers on the new 2026 PE guidelines and their practical relevance for emergency, ICU, and transport care.
• The old “massive/submassive” terms are replaced by categories A through E, with D and E representing the highest-risk patients.
• Severe PE is dangerous primarily because of right ventricular failure and shock, not just hypoxia.
• Initial treatment focuses on supporting the RV: maintain MAP, avoid excess fluids, improve oxygenation, reduce RV afterload, and add inotropy when needed.
• Systemic thrombolysis is a key reperfusion therapy for the sickest patients, but it is underused and has significant bleeding risks.

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 is a talk from FAST25: Lexington that covers a lot of ground, but it all comes back to one question: Why are we doing what we’re doing?

From cardiac arrest to seizures to traumatic arrest, this session challenges some of the most common practices in EMS:

• Amiodarone vs. lidocaine
• How we’re actually dosing benzodiazepines
• When ketamine makes more sense
• And whether epinephrine is helping at all in traumatic cardiac arrest

This isn’t about memorizing protocols. It’s about understanding the reasoning behind them and being willing to question them when the evidence doesn’t hold up. If you’ve ever felt like something didn’t quite add up in your protocols… this one will hit.

This is what FAST sounds like. Real conversations. Real challenges. Live from the room.

FAST26 is coming to Austin this year, co-located with EMS World Live, bringing together the FAST experience with a broader EMS community, while keeping what makes FAST what it is.

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

FAST26: Austin will be in Austin, Texas, from May 27 - 29, 2026.
Tickets are available as FAST26: Austin only, EMS World Live only, or a combination ticket that allows you to attend both events.