_embolism肺栓塞课件

PulmonaryEmbolism PE EpidemiologyPathophysiologyPrevention RiskfactorsScreeningDiagnosisTreatment PE EpidemiologyFivemillioncasesofvenousthrombosiseachyear10 ofthesewillhaveaPE10 willdieCorrectdiagnosisismadeinonly10 30 ofcasesUpto60 ofautopsieswillshowsomeevidenceofpastPE PE Epidemiology90 95 ofpulmonaryembolioriginateinthedeepvenoussystemofthelowerextremitiesOtherrarelocationsincludeUterineandprostaticveinsUpperextremitiesRenalveinsRightsideoftheheart RiskFactors CHFMalignancyObesityEstrogen OCPPregnancy esppostpartum LowerextinjuryCoagulopathy VenousStasisPriorDVTAge 70ProlongedBedRestSurgeryrequiring 30minutesgeneralanesthesiaOrthopedicSurgery Virchow sTriad RudolfVirchowpostulatedmorethanacenturyagothatatriadoffactorspredisposedtovenousthrombosisLocaltraumatothevesselwallHypercoagulabilityStasisofbloodflowItisnowfeltthatptswhosufferaPEhaveanunderlyingpredispositionthatremainssilentuntilaacquiredstressoroccurs FactorVLeidenmutationProteinCdeficiencyProteinSdeficiencyAntithrombindeficiencyProthrombingenemutationA20210AnticardiolipinantibodiesLupusanticoagulantHyperhomocystinemia FactorVLeiden MostfrequentinheritedpredispositiontohypercoagulabilityResistancetoactivatedProteinCSinglepointmutation FactorVLeiden SinglenucleotidesubstitutionofglutamineforarginineFrequencyisabout3 inhealthyAmericanmalephysiciansparticipatinginthePhysicians HealthStudy PE Whenvenousembolibecomedislodgedfromtheirsiteoforigin theyembolizetothepulmonaryarterialcirculationor paradoxicallytothearterialcirculationthroughapatentforamenovaleAbout50 ofptswithpelvicorproximallegdeepvenousthrombosishavePEIsolatedcalforupperextremityvenousthrombosisposealowerriskforPE Pathophysiology IncreasedpulmonaryvascularresistanceImpairedgasexchangeAlveolarhyperventilationIncreasedairwayresistanceDecreasedpulmonarycompliance RightVentricularDysfunction ProgressiverightheartfailureistheusualimmediatecauseofdeathfromPEAspulmonaryvascularresistanceincreases rightventricularwalltensionrisesandperpetuatesfurtherrightventricledilationanddysfunctionInterventricularseptumbulgesintoandcompressesthenormalleftventricle RiskFactors immobilizationsurgerymalignancypreviousthrombophlebitislowerextremitytraumaestrogenuseStroke3monthspost partum ClinicalSyndromes PtswithmassivePEpresentwithsystemicarterialhypotensionandevidenceofperipheralthrombosisPtswithmoderatePEwillhaverightventricularhypokinesisonechocardiogrambutnormalsystemicarterialpressurePtswithsmalltomoderatePEhavebothnormalrightheartfunctionandnormalsystemicarterialpressure Diagnosis ClinicalSyndromesPulmonaryInfarctionusuallyindicatesasmallPE butisverypainful becauseitlodgesneartheinnervationofthepleuralnervesNonthromboticPulmonaryEmbolismFatEmbolismAmnioticFluidEmbolismIVDA Talc cotton etc Diagnosis H PAlwaysaskaboutpriorDVT orPEFamilyHistoryofthromboembolismDyspneaisthemostfrequentsymptomofPETachypneaisthemostfrequentphysicalfindingDyspnea syncope hypotension orcyanosissuggestamassivePEPleuriticCP cough orhemoptysis Symptomlist 73 Dyspnea66 PleuritcPain43 Cough33 LegSwelling30 LegPain15 Hemoptysis12 Palpitations10 Wheezing5 Angina Likepain SymptomsinthosewithoutaPE Dyspnea72 PleuritcPain59 Cough36 LegSwelling22 LegPain24 Hemoptysis8 Palpitations18 Wheezing11 Angina Likepain6 DifferentialDiagnosis PEisknownas thegreatmasquerader USA MIPneumonia bronchitisCHFAsthmaCostochondritis RibFx PneumothoraxPEcancoexistwithotherillnesses PhysicalSigns Symptoms Dyspnea73 PleuritcPain66 Cough43 LegSwelling33 LegPain30 Hemoptysis15 Palpitations12 Wheezing10 Angina Likepain5 EstimationofPretestClinicalProbabilityofPulmonaryEmbolismPretestClinicalProbabilityClinicalFindings Low probability unlikely 1 Symptomsincompatiblewithpulmonaryembolismorcompatiblesymptoms seebelow high probabilitysection thatcanbeexplainedbyanalternativeprocess suchaspneumonia pneumothorax orpulmonaryedema2 Noradiographicorelectrocardiographicabnormalitiescompatiblewithpulmonaryembolism orfindingsthatcanbeexplainedbyanalternativediagnosis3 AbsenceofriskfactorsforvenousthromboembolismIntermediate probability possible probable 1 Symptomscompatiblewithpulmonaryembolism butnoassociatedradiographicorelectrocardiographicfindings2 ConstellationoffindingsnotconsistentwithloworhighclinicalprobabilityHigh probability verylikely 1 Symptomscompatiblewithpulmonaryembolism sudden onsetdyspnea pleuriticchestpain tachypnea orsyncope notexplainedotherwise2 Radiographicorelectrocardiographicfindingscompatiblewithpulmonaryembolism orwidenedalveolar arterialoxygengradient notexplainedotherwise3 Presenceofriskfactorsforvenousthromboembolism Diagnosis SerumStudiesD dimerElevatedinmorethan90 ofptswithPEReflectsbreakdownofplasminandendogenousthrombolysisNotspecific CanalsobeelevatedinMI sepsis oralmostanysystemicillnessNegativepredictivevalueABG contrarytoclassicteaching arterialbloodgaseslackdiagnosticutilityforPE A aGradient Alveolararterialoxygengradient148 1 2 PaCO2 PaO2Gradient 15 20isconsideredabnormal DoneatRoomair Diagnosis CXRUsuallyrevealsanonspecificabnormality 14 normalClassicabnormalitiesinclude Westermark sSign focaloligemiaHampton sHump wedgeshapeddensityEnlargedRightDescendingPulmonaryArtery Palla ssign PE HamptonsHump PE Westermark sSign PEwhichappearslikeamass PEwithhemorrhageorpulmonaryedema PEwitheffusionandelevateddiaphragm VenousUltrasonography ReliesonlossofveincompressibilityastheprimarycriterionAbout1 3ofptswillhavenoimagingevidenceofDVTClotmayhavealreadyembolizedClotpresentinthepelvicveins U Susuallyinadequate WorkupforPEshouldcontinueevenifdopplers inaptinwhichyouhaveahighclinicalsuspicion V QScan Historically theprincipalimagingtestforthediagnosisofPEAperfusiondefectindicatesabsentordecreasedbloodflowVentilationscanobtainedwithradiolabeledgasesAhighprobabilityscanisdefinedastwoormoresegmentalperfusiondefectsinpresenceofnlventilationscan V QScan Usefuliftheresultsarenormalornearnormal orifthereisahighprobabilityforPEAsmanyas40 ofptswithhighclinicalsuspicionforPEandlowprobabilityscanshaveaPEonangiogram HighProbabilityV QScan PulmonaryAngiogram MostspecifictestavailablefordiagnosisofPECandetectemboliassmallas1 2mmMostusefulwhentheclinicallikelihoodofPEdifferssubstantiallyfromthelungscanresultorwhenthelungscanisintermediateprobability Echocardiogram UsefulforrapidtriageofptsAssessrightandleftventricularfunctionDiagnosticofPEifhemodynamicsbyechoareconsitentwithclinicalhx SpiralCTScan IdentifiesproximalPE whicharetheonesusuallyhemodynamicallyimportant NotasaccuratewithperipheralPE CTrevealingpulmonaryinfarct CTrevealingemboliinpulmonaryartery Treatment BegintreatmentwitheitherunfractionatedheparinorLMWH thenswitchtowarfarin Preventsadditionalthrombusformationandpermitsendogenousfibrinolyticmechanismstolyseclotthathasalreadybeenformed DoesNOTdirectlydissolvethrombusthatalreadyexists Warfarinforatleast3months INR2 3 Treatment PainReliefSupplementalOxygenDobutamineforptswithrightheartfailureandcardiogenicshockVolumeloadingisnotadvisedbecauseincreasedrightventriculardilationcanleadtofurtherreductionsinleftventricularoutflow Treatment Thrombolysis1 HemodynamicallycompromisedbyP