venousthrombosispulmonaryembolism深静脉血栓形成和肺栓塞课件.ppt

venousthrombosispulmonaryembolism深静脉血栓形成和肺栓塞课件.ppt

《venousthrombosispulmonaryembolism深静脉血栓形成和肺栓塞课件.ppt》由会员分享，可在线阅读，更多相关《venousthrombosispulmonaryembolism深静脉血栓形成和肺栓塞课件.ppt（82页珍藏版）》请在冰豆网上搜索。

VenousThromboembolism,AbiSenthivelMDPGY3EmoryFamilyMedicineResidencyProgram,Objective,IncidencePathophysiologyDiagnosisTreatmentPrevention,VenousThromboembolism,DeepVenousThrombosis,PulmonaryEmbolism,IncidenceofVTE,900,000eachyearinUSSeveral100,000hospitalizations300,000deathsThesenumbersareestimatesonly.1in100inpeopleover80yrsAmJPrevMed.2010Apr;38（4Suppl）:

S502-9.doi:

10.1016/j.amepre.2010.01.010.,WhyisisimportanttorecognizeDVT/PE?

HighMortality,10to30%ofpeoplewithPEwilldiewithinonemonthofdiagnosis.SuddenDeathisthefirstpresentationin25%ofpatientswithPE,AndHighMorbidity,50%willhavelongtermcomplications（post-thromboticsyndrome）33%willhaverecurrencewithin10years,PathoPhysiologyofVTE,VirchowsTriad,RudolphVirchow,1858,RiskFactors,InheritedThrombophiliaFactorVLeidenmutationProthrombingenemutationProteinSdeficiencyProteinCdeficiencyAntithrombin（AT）deficiencyDysfibrinogenemia,AcquiredDisordersMalignancyPresenceofacentralvenouscatheterSurgeryTraumaPregnancy/OCP/HRTDrugsImmobilizationCongestivefailure,AcquiredRiskFactorscont,AntiphospholipidantibodysyndromeMyeloproliferativedisordersPolycythemiaveraEssentialthrombocythemiaParoxysmalnocturnalhemoglobinuriaInflammatoryboweldiseaseNephroticsyndrome,PathophysiologyofPE,MostPEsarisefromDVTofLEButsomemayarisefromRightheartPelvicveinsRenalveinsUEveins,LetsMeetMsMaria,Maria,38yroldfemalepresentswithpainandmildswellinginLLE.Ptwashikingrecentlywhensheslipped,fellandinjuredRknee.Herkneeimmediatelyswelled.Shefeltunstablew/walkingduetopainandsoughtcareatalocalER.Akneeimmobilizerwasplaced.ShefollowedupwithanorthopedicdoctorwhodiagnosedanacuteACLrupture.AnMRIconfirmedthisandsheunderwentallographrepair3weeksago.SheiscurrentlydoingrehabwithaPT.,Maria（cont）,PMH:

NegativePSH:

ACLrepair（6/22/13）Meds:

Ibuprofenprn/Vicodinprn/OrthoTricyclenAllergies:

NKDASocHx:

ScrubtechatEUHNoTob/RareEtoh,Mariaonexam,Vitals:

T97.2P90BP110/70R14Pulm:

CTACV:

RegularExt:

ModerateswellingaboutRkneew/healingincision.1+pittingedemaLLE.MildpainwithsqueezingcalfonLleg.NoneonRleg.NegativeHomanssign.Calfcircumferenceis1cmlargerLthanR.,WhatistheprobabilitythatMariahasaDVT?

ModifiedWellsCriteriaforDVT,ModifiedWellsCriteriaforDVT,2ormoreLikely0to1UnlikelyWellsPS,AndersonDR,RodgerMetal.（2003）.EvaluationofD-dimerinthediagnosisof8suspecteddeep-veinthrombosis.NewEnglandJournalofMedicine349:

122735.,LetsMeetMrAlbert,Albert,62yroldmalepresentstotheERwithcomplaintofpleuriticCP.Presentx1day.Noinjury.FeelsSOBwithwalking.Nofever.Nocough.NoLEpain.PMH:

ColonCAs/pLcolectomyon6/20/HTN/BPHMeds:

Lisinopril/Tamsulosin/ASA/MVINKDASocHx:

NoTob/NoEtoh,Albert,PhysicalT99.1P110BP135/85R22O2sat95%RAPulm:

CTA,goodAECV:

Regular,NomurmursExt:

Noedema.NegativeHomanssign,WhatisthelikelihoodofaPEinMr.Albert?

WellsCriteriaforPE,ModifiedWellsCriteriaforPE,4:

Likely4orless:

UnlikelyWellsPS,AndersonDR,RodgerMetal.（2003）.EvaluationofD-dimerinthediagnosisof8suspecteddeep-veinthrombosis.NewEnglandJournalofMedicine349:

122735.,DiagnosingDVT,DVT-PhysicalExam,Calftenderness,HomansSign,DifferentialSwelling,DiagnosticTestsforDVT,D-dimerUltrasoundContrastVenography,Ultrasonography,DuplexscanofLECompressibilityoftheveinDopplerflowwithintheveinSymptomaticpatientwithproximalLEDVTSensitivity:

89-96%Specificity:

94-99%,Ultrasonography,AsymptomaticpatientwithproximalLEDVTSensitivity:

47-62%SymptomaticpatientwithdistalLEDVTSensitivity:

73-93%,Venography,GoldstandardforDVTButnotrecommendedasfirstlineduetohighcost,risksadtechnicaldifficulties,AdaptedwithpermissionfromInstituteforClinicalSystemsImprovement.Copyright2012.Healthcareguideline:

venousthromboembolismdiagnosisandtreatment.,DiagnosingPE,SignsandSymptomsofPE,SignsinMassiveP.E.,“MassivePE”:

HemodynamicinstabilitySBP/=40mmHgover15minElevatedcentralvenouspressureSignsasbeforePLUS:

AcuterightheartfailureElevatedJ.V.P.Right-sidedS3Parasternallift,DiagnosticTests,ImagingStudiesCXRV/QScansSpiralChestCTPulmonaryAngiographyEchocardiograpyLaboratoryAnalysisCBCD-DimerABGsBNPCardiacEnzymes-TroponinAncillaryTestingEKGPulseOximetry,Commonfindings,D-Dimerelevation500ng/mlA-agradient20mmHgBNPorproBNPelevationSensitivityandSpecificityareapprox60%Troponinelevation30-50%ofmod/largePEshavetroponinelevation,ABG,ABG:

HypoxemiaHypocapnia（lowCO2）RespiratoryAlkalosisMassivePE:

hypercapnia,mixrespandmetabolicacidosis（inclacticacid）PatientswithRApulseoxreadings95%areatincreasedriskofin-hospitalcomplications,respfailure,cardiogenicshock,death,But,MostpatientswithaPEhaveanormalpulseoximetry,andmostpatientswithanabnormalpulseoxim