2022年医学专题—肺栓塞Pulmonary-embolism(1).pptx

Pulmonary embolism,Yao Mi2014-6-30,第一页，共十七页。,Definitions,Pulmonary embolism(PE):thrombosis originating in venous system and embolizing to pulmonary arterial circulation;1 case/1,000 person y;(Archives 2003;163:1711),第二页，共十七页。,Virchows triad for thrombogenesis Stasis bed rest,inactivity,CHF,CVA w/in 3 mo,air travel 6 h(NEJM 2001;345:779)Injury to endothelium trauma,surgery,inflammation Thrombophilia APSMalignancy(12%of“idiopathic”DVT/PE)History of thrombosisStatin therapy risk(NEJM 2009;360:1851),Risk factors,第三页，共十七页。,Clinical manifestations,Dyspnea(73%),pleuritic chest pain(66%),cough(37%),hemoptysis(13%)RR(70%),crackles(51%),HR(30%),fever,cyanosis,pleural friction rub,loud P2Massive:syncope,HoTN,PEA;JVP,Graham Steell murmur,第四页，共十七页。,Diagnostic studies,CXR(limited Se 295:172),第五页，共十七页。,Diagnostic studies,Echocardiography:useful for risk stratification(RV dysfxn),but not dx(Se 50%)V/Q scan:high Se(98%),low Sp(10%).Sp improves to 97%for high prob VQ.Use if prob of PE high and CT not available or contraindicated.CT angiography(CTA;see Radiology inserts):Se.90%CT may also provide other dx,第六页，共十七页。,acute pulmonary emboli in both main pulmonary arteries in a postoperative patient with the sudden onset of dyspnea,hypoxemia,and hypotension,第七页，共十七页。,High-probability ventilation-perfusion scan.,第八页，共十七页。,Approach to suspected PE using CTA,第九页，共十七页。,Treatment of VTE(Chest 2008;133;454S;NEJM 2008;359:2804),Acute anticoagulation(initiate immediately if high clinical suspicion!)IV UFH:80 U/kg bolus 18 U/kg/h goal PTT 1.52.3 cntl LWMH(eg,enoxaparin 1 mg/kg SC bid or dalteparin 200 IU/kg SC qd)LWMH preferred over UFH except:renal failure(CrCl 25),?extreme obesity,hemodynamic instability,(Cochrane 2004;CD001100)Attractive option as outPt bridge to long-term oral anticoagulationEarly ambulation,第十页，共十七页。,LWMH,Enoxaparin 4000IU/支 40mg 克赛Nadroparin 4000IU/支 0.4ml 速碧林Dalteparin 5000IU/支 0.2ml 法安明,第十一页，共十七页。,Treatment of VTE,Thrombolysis(eg,rt-PA 50 mg over 2 h)Use if PE a/w hemodynamic compromise(“massive PE”)Consider if PE w/o hemodynamic compromise,but high-risk(“submassive PE,”eg,marked dyspnea,severe hypoxemia,RV dysfxn on echo,RV enlargement on CTA)and low bleed risk.(NEJM 2002;347:1143;Cochrane 2006:CD004437).,第十二页，共十七页。,Long-term anticoagulation,Warfarin(goal INR 23):start same day as heparin overlap 5 d w/heparin,第十三页，共十七页。,Summary,Risk factorClinical manifestationsDiagnostic studiesTreatmentLMWH,第十四页，共十七页。,Homework,Deep vein thrombosis and pulmonary embolism in pregnancy：Treatment？,第十五页，共十七页。,Thanks！,第十六页，共十七页。,内容(nirng)总结,Pulmonary embolism。2014-6-30。sinus tachycardia,AF。CT angiography(CTA。High-probability ventilation-perfusion scan.。Thanks,第十七页，共十七页。,