MindMap Gallery Internal medicine pulmonary thromboembolism

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!

Edited at 2023-12-24 15:50:02

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Internal medicine pulmonary thromboembolism

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Outline

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