首页 肺动脉栓塞的诊治

肺动脉栓塞的诊治

举报
开通vip

肺动脉栓塞的诊治null肺动脉栓塞的诊治肺动脉栓塞的诊治制作 XGHRH敬请指正基本概念基本概念肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称,包括肺血栓栓塞症,脂肪栓塞综合征,羊水栓塞,空气栓塞等。 肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。 肺梗死为肺动脉发生栓塞后,其支配区的肺组织因血流受阻或中断而发生坏死。 肺栓塞的现状肺栓塞的现状发病率高:仅次于CAD和HBP。 易漏诊及误诊:警惕性不高,漏诊率高。 不经治疗死亡率高:达20%-30%。 明确诊疗者死亡率明显下降:可降至2...

肺动脉栓塞的诊治
null肺动脉栓塞的诊治肺动脉栓塞的诊治制作 XGHRH敬请指正基本概念基本概念肺栓塞是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称,包括肺血栓栓塞症,脂肪栓塞综合征,羊水栓塞,空气栓塞等。 肺血栓栓塞症为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病。 肺梗死为肺动脉发生栓塞后,其支配区的肺组织因血流受阻或中断而发生坏死。 肺栓塞的现状肺栓塞的现状发病率高:仅次于CAD和HBP。 易漏诊及误诊:警惕性不高,漏诊率高。 不经治疗死亡率高:达20%-30%。 明确诊疗者死亡率明显下降:可降至2-8% 。 EpidemiologyEpidemiologyThere is no accurate data for pulmonary embolism because we has limit knowledge of it. In the United States, it is responsible for about 2.3 new cases per 10,000 persons and 50,000 deaths every year. 流行病学流行病学Arch.Intern.Med.154:861,1994生存率比较生存率比较Arch.Intern.Med.154:861,19941.0123Risk Factors for DVT/Pulmonary Embolism (Essential)Risk Factors for DVT/Pulmonary Embolism (Essential)Risk Factors for DVT/Pulmonary Embolism (Second)Risk Factors for DVT/Pulmonary Embolism (Second)深静脉血栓形成深静脉血栓形成肺血栓与深静脉血栓肺血栓与深静脉血栓肺栓塞的大体解剖观肺栓塞的大体解剖观肺栓塞的显微镜下观肺栓塞的显微镜下观肺栓塞的病理生理肺栓塞的病理生理肺血管阻塞,神经体液因素或肺动脉压力感受器的作用,引起肺血管阻力增加; 肺血管阻塞→肺泡死腔↑→气体交换↓→肺泡通气↓→低氧血症→V/Q单位↓→气体交换面积↓→二氧化碳↑ 刺激性受体反射性兴奋(过度换气) 支气管收缩,气道阻力增加 肺水肿、肺出血、肺泡 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 面活性物质减少,肺顺应性降低。肺栓塞后右心功能不全的病生肺栓塞后右心功能不全的病生肺栓塞↓冠状动脉灌注↑右心室氧需↑右心室壁张力↓右心室排血量↓右心室氧供↓左心室排血量↑肺动脉压力 ↑右心室后负荷解剖阻塞 神经体液作用右心室扩张/功能不全 右心室缺血室间隔移向左心室低血压↓体循环灌注↓左心室前负荷肺栓塞后肺血流动力学变化肺栓塞后肺血流动力学变化 前毛细血管高压 血管床减少 支气管收缩 小动脉血管收缩 侧支血管的形成 支气管-肺动脉吻合形成 肺内动静脉分流 血流改变: 血流重分布 Westermark征呼吸动力学改变呼吸动力学改变 过度通气: 肺动脉高压 顺应性下降 肺不张 气道阻力增加 : 局限性低碳酸血症 化学介质 临床分型临床分型大面积PE(massive PE): 休克和低血压; 动脉收缩压<90mmHg 或下降幅度≥40mmHg,持续15min以上; 除外其他原因所致血压下降。 次大面积PE (submassive PE)亚型 超声心动图示右心室运动功能减弱 右心功能不全表现。 非大面积PE(non-massive FE): 不符合以上大面积PE标准的PE。 症状症状Peer Review Status: Externally Peer Reviewed by the AMA体征体征D-二聚体 分析 定性数据统计分析pdf销售业绩分析模板建筑结构震害分析销售进度分析表京东商城竞争战略分析 D-二聚体分析Adapted from Bounameaux et al, 1997 肺栓塞胸片检查肺栓塞胸片检查Peer Review Status: Externally Peer Reviewed by the AMA X-RAY FOR CHESTX-RAY FOR CHESTAtelectasis and parenchymal densities are quite common. The areas of atelectasis are more common in the lower lobe as are the areas of parenchymal density nullMost of these densities are caused by pulmonary hemorrhage and edema and can be confused with infectious infiltrates or malignant masses nullPleural effusions are common and most often unilateral despite the fact that most clots are bilateral. These effusions are usually visible when the patient seeks medical attention. They are almost always small, occupying less than 15% of a hemithorax and rarely increase in size after 3 days. Any increase in size after 3 or 4 days should raise the suspicion of a pulmonary infection or re-embolization. null Pleural based opacities with convex medial margins are also known as a Hampton's Hump. This may be an indication of lung infarction. However, that rate of resolution of these densities is the best way to judge if lung tissue has been infarcted. Areas of pulmonary hemorrhage and edema resolve in a few days to one week. The density caused by an area of infarcted lung will decrease slowly over a few weeks to months and may leave a linear scar. nullA diaphragm may be elevated, reflecting volume loss in the affected lung. null The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of clot in those arteries. nullCardiomegally is a non-specific finding but may imply an enlarged right ventricle as seen in the patient who presented with large bilateral pulmonary emboli. nullA Westermark's sign implies an area of decreased vascularity and perfusion accompanied by an enlarged central pulmonary artery on the affected side. 肺栓塞的心动超声征象肺栓塞的心动超声征象直接看到血栓 右室扩张 右室活动减弱 室间隔异常活动 三尖瓣反流速度增快 肺动脉扩张 无吸气性下腔静脉塌陷减弱Br.Heart.J.1994,72:52室间隔异常活动室间隔异常活动舒张期收缩期Color-Flow-Doppler-ultrasound Color-Flow-Doppler-ultrasound 非挤压性充盈缺损心电图表现心电图表现不完全性或完全性右束支传导阻滞 Ⅰ、avL的S波>1.5mm Ⅲ、avF有Qs波,但Ⅱ无Qs波 QRS轴>900或不确定 肢导联低电压 Ⅲ、avF的T波倒置或V1~V4T波倒置null图12000年8月27日(急诊)ECG大致正常2000年8月29日(门诊)ECG示IRBBB SⅠQⅢTⅢV1V2T波倒置V3V4T波双向Ventilation/Perfusion Lung Scan Ventilation/Perfusion Lung Scan PIOPED:肺扫描分类与肺动脉造影结果的比较PIOPED:肺扫描分类与肺动脉造影结果的比较J Nucl Med 1993; 34: 1119肺扫描肺扫描怀疑PE的患者约25%可因肺灌注正常而否定诊断,而且不用抗凝治疗可能是安全的 怀疑PE的患者约25%具有高度的肺扫描结果,他们可能需要行抗凝治疗 其余的患者需要进一步的诊断性检查,而这些检查是更广泛的诊断策略典型肺栓塞典型肺栓塞 null不典型肺栓塞It is high sensitivity but low specificityIt is high sensitivity but low specificity The differential diagnosis for a ventilation perfusion mismatch includes: acute pulmonary embolus previous pulmonary embolus congenital vascular abnormalities vasculitis, bronchogenic carcinoma, radiation therapy,et al. null When a ventilation/perfusion scan does not fit into either the normal or high probability category, then we consider the study to be non-diagnostic and further investigation is required. The majority of cases fall into this category which is characterized by scans with subsegmental defects or defects of any size that match abnormalities on the chest x-ray or the perfusion scan. nullA low probability category has been suggested by a number of authors. However, as we can see from the PIOPED data this is not a particularly reliable category. Disagreement among experienced readers is common when perfusion defects are small and limit the utility of this category. This study was originally read as showing a small subsegmental defect. Without the arrow, this study has subsequently been called normal by a number of experienced readers ConclusionConclusion Lung scans are sensitive exams that essentially rule out the diagnosis of pulmonary embolus when they are normal. Patients with high probability lungs can often be treated without further workup. Those patients with non-diagnostic studies require further diagnostic investigation. CT of Pulmonary EmbolismCT of Pulmonary Embolism Pulmonary infarcts are more readily identified on CT. Modern CT scanners now have faster acquisition times and are providing a detailed assessment of the lung parenchyma that is not available from the chest radiograph. The typical appearance of a pulmonary infarct on CT includes a pleural based density with convex borders and a linear strand at the apex of the triangle nullThe apex of the triangle is often truncated and not wedge shaped which corresponds to the normal configuration of a secondary lobule in the lung periphery. Low attenuation areas within the infarct represents viable lung. It is important to note, however, that this appearance is not specific for pulmonary infarction. The differential diagnosis for this abnormality includes infarct, hemorrhage, pneumonia, fibrosis, neoplasia and edema null Since the clinical presentation of pulmonary embolus is usually non-specific, the findings on CT are often the first clinical indication that the patient may be suffering from pulmonary embolus. In addition to visualizing the area of infarction we are often able to see the clot itself. null CT has been show to be especially useful in the assessment of patients with chronic dyspnea and known pulmonary artery hypertension. These patients are often difficult to diagnose as is exemplified by this patient with known sclerodema and pulmonary artery hypertension whose CT unexpectedly showed a large calcified clot in the right pulmonary artery. 肺动脉造影肺动脉造影正常肺动脉nullThis selective study was done because of a perfusion defect in the left lower lobe on a ventilation perfusion scan. The first angiographic study was inconclusive. Therefore, a subselective study was done that demonstrated the clot with certainty. nullThe most reliable signs of pulmonary embolus are: An Intraluminal filling defect An Abrupt termination of a branch vessel ConclusionConclusionAngiography is most accurate in segmental and larger sized arteries. The reproducibility of readings is subsegmental and smaller vessels is poor. Angiography is a safe procedure that is most accurate when imaging emboli that lodge in segmental or larger arteries. The Diagnosis Algorithm The Diagnosis Algorithm Plasma D-Dimer AssayNormal to Near-NormalLow or Intermediate ProbabilityHigh ProbabilityClinical AssessmentLow ProbabilityIntermediate or High ProbabilityAngiographyPositiveNegative < 500mg/L ≥500mg/LUltrasonogramNo DVTDVTLung ScanInterpretation Criteria Interpretation Criteria High Probability (80-100% likelihood for PE ): Greater than or equal to 2 large mismatched segmental perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. Intermediate Probability (20-80% likelihood for PE ): 1. One moderate to 2 large mismatched perfusion defects or the arithmetic equivalent in moderate or large and moderate defects. 2. Single matched ventilation-perfusion defect with a clear chest radiograph .  3. Difficult to categorize as low or high, or not described as low or high. 4. Nonsegmental perfusion defects (e.g., cardiomegaly, enlarged aorta, enlarged hila, elevated diaphragm). 5. Multiple matched V/Q abnormalities, even when relatively extensive, are low probability for PE . The prevalence of PE in patients with extensive matched V/Q defects and no CXR abnormality was 14% (low probability). J Nucl Med 1995; 36: 2380-2387Low Probability (0-19% likelihood for PE )Low Probability (0-19% likelihood for PE ) Perfusion defects matched by ventilation abnormality provided that there are: (a) clear chest radiograph and (b) some areas of normal perfusion in the lungs. Extensive matched V/Q abnormalities are appropriate for low probability, provided that the CXR is clear. Any perfusion defect with a substantially larger chest radiographic abnormality. Any number of small perfusion defects with a normal chest radiograph. J Nucl Med 1995; 36: 2380-2387Diagnostic Criteria for Clinically Suspected Pulmonary EmbolismDiagnostic Criteria for Clinically Suspected Pulmonary EmbolismPulmonary embolism absent Negative pulmonary angiogran Normal or near-normal lung scan D-dimer level<500 mg/L Pulmonary embolism present Positive pulmonary angiogram High-or intermediate-probability lung scan and ultrasonogram evidence of deep-vein thrombosisThorax 51:23, 1996 鉴别诊断鉴别诊断呼吸困难、咳嗽、咯血、呼吸频率增快等呼吸系统表现为主的患者多被诊断为其它的胸肺疾病如肺炎、胸膜炎、肺不张等 以胸痛、心悸、心脏杂音、肺动脉高压等循环系统表现为主的患者易衩诊断为其它的心脏疾病如冠心病、风心病等 以晕厥、惊恐等表现为主的患者有时被诊断为其它心脏或神经及精神系统疾病如心律失常、脑血管意外、癫痫等原发性肺动脉高压与肺栓塞复发原发性肺动脉高压与肺栓塞复发相似点: 症状:疲乏,活动时呼吸困难最常见,胸痛、昏厥、咯血、紫绀也较常见 临床经过:进行性呼吸困难,右心衰竭 血流动力学:右心室压力升高、肺毛细血管嵌压正常 治疗:包含抗凝治疗区别点区别点急性PE的治疗急性PE的治疗一般处理: 送入监护病房,加强生命体征的监护 防止栓子脱落,绝对卧床 情感支持 对症治疗:如咳嗽、发热等急性PE呼吸循环支持治疗呼吸循环支持治疗一般患者均采用经鼻导管或面罩吸氧治疗低氧血症 无创伤性或经气管插管机械通气治疗呼吸衰竭,避免气管切开。 尽量减少正压通气对循环的不种影响。急性PE溶栓治疗的适应证溶栓治疗的适应证栓塞面积超过2个肺叶血管者 合并休克或低血压者 合并右心功能不全者 排除禁忌证者急性PE溶栓禁忌证溶栓禁忌证绝对禁忌证 活动性内出血 近期的自发性颅内出血 相对禁忌证 大手术、分娩、器官活检或不能压迫的血管穿刺史(10天内) 2月内缺血性中风 10天内胃肠道出血 15天内严重外伤 1月内神经外科或眼科手术 控制不好的重度高血压 近期心肺复苏 血小板<100000/mm3,PT<50% 怀孕 细菌性心内膜炎 糖尿病出血性视网膜病变肺动脉栓塞的溶栓及抗凝治疗肺动脉栓塞的溶栓及抗凝治疗12小时溶栓法: 4400u/Kg尿激酶溶于100ml于不少于10分钟静推 2200u/Kg尿激酶溶于250ml用12小时维持 每4~6小时监测APTT,当其降到正常2倍时,加用低分子肝素钙(0.1ml/10Kg,每天二次,皮下注射) 同用华法令,3~5天后监测INR,当重复为1.5~2倍二天时,停用低分子肝素, 维持剂量华法令6周~6月,同时监测INR 2小时溶栓法: 尿激酶2万u/Kg溶于250ml用2小时静泵,余治疗同上 rt-PA10mg加入10ml液体中10分钟内静推,后rt-PA40~90mg加入90ml液体中110分钟内静滴,余治疗同上急性PE依据体重的肝素(普通)计算图依据体重的肝素(普通)计算图Ann.Intern.Med.119:874,1993下腔静脉过滤网适应证下腔静脉过滤网适应证抗凝治疗禁忌而肺栓塞已证实 活动性出血可能引起贫血(如胃肠道) 担心可能是灾难性的出血(如开颅术) 现存的抗凝并发症 计划强化的癌症化疗 尽管治疗充分但抗凝失败 在高危病人中预防性使用 广泛的进展性静脉血栓 和导管或外科肺去栓术并用 严重肺高压或肺心病急性PE肺动脉血栓摘除术肺动脉血栓摘除术大面积PTE,适合手术且无固定肺动脉高压者者。 有溶栓禁忌证者。 经溶栓和其他积极的内科治疗无效者。急性PE经静脉导管碎解和抽吸血栓经静脉导管碎解和抽吸血栓肺动脉主干或主要分支大面积PTE者 溶栓和抗凝治疗禁忌 经溶栓或积极的内科治疗无效者 缺乏手术条件急性PE慢性栓塞性肺动脉高压的治疗慢性栓塞性肺动脉高压的治疗手术治疗:严重肺动脉高压。 介入治疗:球囊扩张肺动脉成型术。 抗凝治疗:华法令。 下腔静脉滤器:反复深静脉血栓脱落者。 降低肺动脉压力:血管扩张剂 治疗心衰预防策略预防策略机械措施: 分级加压长筒袜 间歇性序贯充气泵 下腔静脉波器 药理学制剂 普通肝素 低分子肝素 华法令 情感支持对高危人群:
本文档为【肺动脉栓塞的诊治】,请使用软件OFFICE或WPS软件打开。作品中的文字与图均可以修改和编辑, 图片更改请在作品中右键图片并更换,文字修改请直接点击文字进行修改,也可以新增和删除文档中的内容。
该文档来自用户分享,如有侵权行为请发邮件ishare@vip.sina.com联系网站客服,我们会及时删除。
[版权声明] 本站所有资料为用户分享产生,若发现您的权利被侵害,请联系客服邮件isharekefu@iask.cn,我们尽快处理。
本作品所展示的图片、画像、字体、音乐的版权可能需版权方额外授权,请谨慎使用。
网站提供的党政主题相关内容(国旗、国徽、党徽..)目的在于配合国家政策宣传,仅限个人学习分享使用,禁止用于任何广告和商用目的。
下载需要: 免费 已有0 人下载
最新资料
资料动态
专题动态
is_456958
暂无简介~
格式:ppt
大小:4MB
软件:PowerPoint
页数:0
分类:
上传时间:2010-01-07
浏览量:34