PulmonaryembolismYaoMi2014-6-30第一页，共十七页。Definitions•Pulmonaryembolism(PE):thrombosisoriginatinginvenoussystemandembolizingtopulmonaryarterialcirculation;1case/1,000persony;(Archives2003;163:1711)第二页，共十七页。•Virchow’striadforthrombogenesisStasisbedrest,inactivity,CHF,CVAw/in3mo,airtravel6h(NEJM2001;345:779)Injurytoendotheliumtrauma,surgery,inflammationThrombophiliaAPS•Malignancy(12%of“idiopathic”DVT/PE)•Historyofthrombosis•Statintherapy↓risk(NEJM2009;360:1851)Riskfactors第三页，共十七页。Clinicalmanifestations•Dyspnea(73%),pleuriticchestpain(66%),cough(37%),hemoptysis(13%)•↑RR(70%),crackles(51%),↑HR(30%),fever,cyanosis,pleuralfrictionrub,loudP2•Massive:syncope,HoTN,PEA;↑JVP,GrahamSteellmurmur第四页，共十七页。Diagnosticstudies•CXR(limitedSe&Sp)•ECG(limitedSe&Sp):sinustachycardia,AF;signsofRVstrain→RAD,Ppulmonale,RBBB,SIQIIITIII•ABG:hypoxemia,hypocapnia,respiratoryalkalosis,(Chest1996;109:78)•D-dimer:highSe,poorSp(25%);canbeusedtor/oPEinPts(JAMA2006;295:172)第五页，共十七页。Diagnosticstudies•Echocardiography:usefulforriskstratification(RVdysfxn),butnotdx(Se50%)•V/Qscan:highSe(98%),lowSp(10%).Spimprovesto97%forhighprobVQ.UseifprobofPEhighandCTnotavailableorcontraindicated.•CTangiography(CTA;seeRadiologyinserts):Se.90%&Sp95%(NEJM2006;354:2317);CTmayalsoprovideotherdx第六页，共十七页。acutepulmonaryemboliinbothmainpulmonaryarteriesinapostoperativepatientwiththesuddenonsetofdyspnea,hypoxemia,andhypotension第七页，共十七页。High-probabilityventilation-perfusionscan.第八页，共十七页。ApproachtosuspectedPEusingCTA第九页，共十七页。TreatmentofVTE(Chest2008;133;454S;NEJM2008;359:2804)•Acuteanticoagulation(initiateimmediatelyifhighclinicalsuspicion!)•IVUFH:80U/kgbolus→18U/kg/h→goalPTT1.5–2.3cntl•LWMH(eg,enoxaparin1mg/kgSCbidordalteparin200IU/kgSCqd)•LWMHpreferredoverUFHexcept:renalfailure(CrCl25),?extremeobesity,hemodynamicinstability,(Cochrane2004;CD001100)•AttractiveoptionasoutPtbridgetolong-termoralanticoagulation•Earlyambu...
