肺拴塞.ppt

pulmonaryarteryembolism,DalianmedicaluniversityEmergencyDepartment,一.definition:,pulmonaryarteryembolism是内源性endogenous或外源性ectogenesis栓子堵塞肺动脉或其支引起肺循环障碍circulatorydisorder的临床和病理生理综合征，又称肺血栓栓塞病pulmonarythrombo-embolicdisease.,临床上最常见的血栓来自下肢深静脉deepveinoflowerlimbs及盆腔静脉veinofcavitaspelvis。,二.incidencerate,美国每年约70万以上人患有症状的肺栓塞pulmonaryarteryembolism我国肺栓塞诊断逐年增高，北京协和医院生前确诊率7.8%。,basedisease,1、eld2、heartdisease3、adipositas4、tumour5、pregnancyandparturition6、long-termbed7、drugs8、deepveinthrombosis,三.PathogenyandPathophysiology,Typesofembolia:1.thrombusembolism2.fatembolism3.amnionicfluidembolism4.airembolism5.tumorandbacterialembolus,thelowerlimbsandcavitaspelvisdeepveinthrombosisabout68%ChronicheartandlungdiseaseandmalignantneoplasmAfterinterventionaltherapycongenitaldefectsofbloodclottingandfibrinolysis,pathology,1、acutelargepulmonaryarteryembolism2、骑跨型血栓3、acutehypolargepulmonaryarteryembolism4、moderatelyPulmonaryembolism5、micro-Pulmonaryembolism,Pathophysiology,thedistinguishoflunginfarctandpulmonaryarteryembolism肺梗死存在局部组织缺血、坏死,1、changeofrespirationphysiology肺泡无效腔增大通气受限lossofalveolarsurfactantanoxemia,2、thechangeofbloodstreambloodstreamlossofpulmonaryvascularbed，resistanceofpulmonaryarteryincreaseandrightcardiacloadincrease.,3、changeofneurohumorplateletactivatingfactorThromboxaneA2catecholamine5-hydroxytryptamine,inducement:,静脉内压发生急剧变化或静脉血流bloodstreamofvein量明显增加，均可造成血栓部分和完全脱落。Exertiondefecationexertionsuddenlymovementafterlong-termbed,predilectionsite:,1、rightlungleftlung、下肺上肺2、bothsidelungsingleblung,pathogenesis,themechanismofdeepveinthrombosis1、bloodstreamstagnant2、abnormalityofvesselwall3、bloodviscosityincrease,pathogenesis,pulmonaryarteryembolism肺血管床血流急剧减少.肺A痉挛、肺血管阻力增加、肺A高压右心负荷增加、右心衰左心排血量下降、晕厥、血压下降、休克,effectofhemodynamics:mechanicalnessblockageofemboliareleaseofinflammationmediatorafterembolism,临床表现(clinicrepresentation),symptom：absencespecificity临床上出现所谓“肺梗死三联征”dyspnoea、chestpainlessthan30hemoptysis,sign,shortnessofbreathisthemostoftensign,venothromboticsymptomandsign：下肢深静脉血栓主要表现为患肢肿胀、周径增粗、疼痛或压痛、浅静脉扩张、皮肤色素沉着、行走后患肢易疲劳或肿胀加重。,四:diagnosticmethod,clinicstyle：1.Acutecorpulmonale2.tipicalpulmonaryarteryembolism3.dyspneahardtoexplain4.hypertensionpulmonaryhardtoexplain,diagnosemainpoints:1、dyspnea：占84-90%2、chestpain：占88%3、hemoptysis：3%。典型的三联症不足1/3。三联症不出现可除外肺梗塞。4、Syncope,laboratoryexamination：,1、ECG：基础检查。一过性、动态观察。1）rightaxisdeviation2）ppulmonary3）SIOIIITIII4）Rightbundlebranchblock（about65%）,2、X片：,具有筛选作用，敏感性低为其缺点。X线正常不能除外肺栓塞。可作为治疗和随诊复查的依据。,3、arterialbloodgasanalysis,non-specificity。仍是一个重要筛选指标。动脉血气分析检查是首诊常规检查的一部分。动脉血气分析检查可以对临床可疑病例进行评估。,4、d-dimer：,Ddimer对急性肺栓塞有较大的排除诊断价值，若其含量低于0.5mgl，可基本除外急性肺栓塞。,5、ultrasoniccardiogram,noninvasivetesting适合发现肺动脉主干、及其左右分支动脉的栓塞。具有鉴别和除外其它疾病的可能。下肢深静脉血栓是肺栓塞血栓的主要来源，下肢深静脉超声作为诊断深静脉血栓的首选检查。,6、radionuclidescanning：,核素肺通气灌注扫描检查对诊断亚段及以下的肺栓塞和慢性肺栓塞性肺动脉高压有独到的价值。,7、spiralcomputedtomograph,是肺栓塞的确诊手段之一，还可以显示肺及肺外的其他胸部疾患，有鉴别诊断的作用。螺旋CT对亚段肺栓塞的诊断价值有限。,8、magneticresonanceangiography,refertoallergywithdiodone,9、pulmonaryangiography,是目前诊断肺栓塞的金标准，属有创检查，有一定危险性，目前主要用于临床上高度怀疑肺栓塞，而无创性检查又不能确诊者。且临床上拟仅采取内科治疗时，则不必进行此项检查。,10、examinewithveinsoflowerextremity：,1）phlebography2）radioactivenuclideopacification（accuracyrate90%）3）vascularultrasound（93%）4）肺扫描联合肢体阻抗容积描记图,DifferentialDiagnosis：1、acutemiocardialinfarction2、acuteleftheartfailure3、severepneumonia4、pleurisy,DifferentialDiagnosis：,1、acutemiocardialinfarction2、acuteleftheartfailure3、severepneumonia4、pleurisy,generaltreatment：1、absolutebedrest2、高浓度吸氧3、sedationandacesodyne,五：progressionoftreatment,4、Countershock5、cardiotonic、antiarrhythmia6、antibronchialspasm7、hormonal,anticoagulanttherapy：,heparin+warfarinindication：只要可疑肺栓塞就可应用抗凝治疗，同时做ECT、DSA确诊以决定溶栓治疗。,absolutelycontraindication：,1、intracranialhemorrhages、malignantdiseaseorarterior-venousmalformation2、activebleeding,relativecontraindication：,1、majoroperationandtraumawithintwoweeks2、pregnancyandpuerperium3、原有出血倾向或出血性疾病4、gravenesshypertension,肝素监测指标：,1、APTT稳定在正常值的1.52.0倍。2、血小板计数,sideeffectofheparin：,1、allergy2、bleeding3、plateletdescend4、Osteoporosisafterlong-termuse,VitKantagonist：,prolongedaction：dicoumarol72h起效lente：warfarin48h起效短效：新凝令24h起效warfarin：applicationdosage：maintenancedose、courseoftreatment、detection、调整剂量。,thrombolysis,ThrombolysisisthemostimportantprogressionoftherapyforPTE.溶栓续以抗凝优于单纯抗凝治疗。,thrombolytictherapy：,单存抗凝存在的问题：1、再栓塞的发生率：17-23%。2、自然溶解率低肺栓塞4个月时50%不能完全溶解。,thrombolysisindication：,largeareaPulmonaryembolism只要无溶栓禁忌症不论是否伴有血液动力学障碍都需溶栓治疗。,usageofrt-PA：,secondfilialgenerationthrombolysispharmaceutics。高度选择性地与血栓表面的纤维蛋白结合，将血栓结合的纤溶酶原活化为纤溶酶使血栓溶解。作用强，lowerside-effect。,surgerytherapy：,indication：Contraindicationofanticoagulationorthr