MindMap Gallery Internal medicine pulmonary thromboembolism
This map contains the content of pulmonary thromboembolism in internal medicine, including patients, clinical manifestations, treatments, etc. You can use it if necessary!
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pulmonary thromboembolism
definition
A disease with pulmonary circulation and respiratory failure as the main clinical and pathophysiological characteristics caused by the obstruction of the pulmonary artery or its branches by thrombus from the venous system or right heart.
risk factors
Any factors that lead to venous blood stasis, venous system endothelial damage and blood hypercoagulability, namely Virchow's three elements
Pathophysiology
Source: inferior vena cava road, superior vena cava road, right heart cavity, most of them come from the deep veins of the lower limbs, especially the proximal deep veins of the lower limbs from the popliteal vein to the iliac vein segment
1. Hemodynamic changes 2. Gas exchange disorder 3. Pulmonary infarction 4. Chronic thromboembolic pulmonary hypertension
clinical manifestations
symptom
Symptoms are diverse and lack specificity
① Unexplained difficulty breathing and shortness of breath, especially after activity
② Chest pain, including pleuritic chest pain or angina-like chest pain
③Syncope may be the only symptom or the first symptom of PTE
④Irritability, panic or even a sense of near-death
⑤ Hemoptysis, usually a small amount of hemoptysis, large hemoptysis is rare
⑥Cough, palpitations, etc.
physical signs
respiratory signs
Symptoms of shortness of breath, cyanosis, wheezing or crackles in the lungs, or pleural effusion are common
circulatory system signs
Including tachycardia, blood pressure changes, blood pressure drop or even shock in severe cases, silent amyloid filling or pulsation, hyperactive second sound (P2>A2) or splitting in the pulmonary valve area, and tricuspid systolic murmur
other
May be accompanied by fever, mostly low-grade fever, a few patients have moderate or above fever
diagnosis
Three steps: suspected diagnosis, confirmed diagnosis, and seeking reasons
Suspicious diagnosis based on clinical circumstances (suspicious diagnosis)
Plasma D-dimer
High sensitivity to thrombosis, elevated in acute PTE
arterial blood gas analysis
Often manifests as hypoxemia, hypocapnia
electrocardiogram
Common changes are sinus tachycardia
Chest X-ray
It can show signs of pulmonary embolism, pulmonary hypertension and right heart enlargement.
Echocardiography, deep vein examination of lower limbs
Confirmed
CT pulmonary angiography
Radionuclide lung ventilation/perfusion
Magnetic resonance imaging and magnetic resonance pulmonary angiography
Pulmonary angiography "gold standard"
Seek cause
Identify the source of emboli and find predisposing factors
Types
acute pulmonary thromboembolism
High-risk PTE
Clinically, shock and hypotension are the main manifestations, that is, the systemic arterial systolic blood pressure is <90mmhg, or the decrease is >40mmhg from the basic value, lasting for 15 minutes.
medium risk
Hemodynamically stable, but with right ventricular dysfunction and myocardial damage
Diagnostic criteria for right ventricular dysfunction: clinical manifestations: echocardiography indicates right ventricular dysfunction, or BNP elevation >90, or N-proBNP elevation >500
low risk
chronic thromboembolic pulmonary hypertension
Often manifested as dyspnea, fatigue, and decreased exercise tolerance
Differential diagnosis
coronary heart disease
Coronary angiography shows coronary atherosclerosis, etc.
pneumonia
Corresponding manifestations of pulmonary infection, antibiotic treatment is effective
aortic dissection
High blood pressure, severe pain, CT angiography
treat
in principle
Early diagnosis, early intervention, and selection of appropriate treatment options based on patient risk levels
General management and respiratory and circulatory support treatment
Close monitoring of breathing, heart rate, blood pressure, electrocardiogram and blood gas changes; bed rest
Use nasal cannula or mask to inhale oxygen to correct hypoxemia.
For patients with right ventricular dysfunction and decreased blood pressure, dobutamine, dopamine and norepinephrine can be used
anticoagulant therapy
Unfractionated heparin
Give 2000~5000U or 80U/kg intravenously, followed by 18U (kg·h) continuous intravenous infusion; measure APTT, adjust the dose, and make it reach 1.5~2.5 times the normal value as soon as possible
During application, pay attention to detecting platelets to prevent heparin-induced thrombocytopenia.
low molecular weight heparin
Nadroparin calcium: 86U/kg subcutaneous injection, q12
Enoxaparin sodium: 1mg/kg subcutaneous injection, q12
Dalteparin sodium: 100U/kg, q12
Fondaparinux, warfarin, oral anticoagulants, etc.
Thrombolytic therapy
Applicable to: high-risk PTE cases (with obvious dyspnea, chest pain, hypoxemia, etc.), thrombolysis time window is within 14 days
Absolute contraindications: active internal bleeding, recent spontaneous intracranial hemorrhage
Relative contraindications: major surgery, delivery, bed examination within 2 weeks; gastrointestinal bleeding within 10 days; severe trauma within 15 days; neurosurgery or ophthalmology surgery within 1 month; severe hypertension that is difficult to control ; Stroke within 3 months; Traumatic cardiopulmonary resuscitation; Platelet count <100×10^9, etc.
Complications: Bleeding, the most serious is intracranial hemorrhage
Commonly used drugs: urokinase, streptokinase, rt-PA