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

1、Venous Thromboembolism,Abi Senthivel MDPGY 3Emory Family Medicine Residency Program,Objective,IncidencePathophysiologyDiagnosisTreatmentPrevention,Venous Thromboembolism,Deep Venous Thrombosis,Pulmonary Embolism,Incidence of VTE,900,000 each year in USSeveral 100,000 hospitalizations300,000 deathsTh

2、ese numbers are estimates only.1 in 100 in people over 80yrsAm J Prev Med.2010 Apr;38(4 Suppl):S502-9.doi:10.1016/j.amepre.2010.01.010.,Why is is important to recognize DVT/PE?,High Mortality,10 to 30%of people with PE will die within one month of diagnosis.Sudden Death is the first presentation in

3、25%of patients with PE,And High Morbidity,50%will have long term complications(post-thrombotic syndrome)33%will have recurrence within 10 years,PathoPhysiology of VTE,Virchows Triad,Rudolph Virchow,1858,Risk Factors,Inherited ThrombophiliaFactor V Leiden mutationProthrombin gene mutationProtein S de

4、ficiencyProtein C deficiencyAntithrombin(AT)deficiencyDysfibrinogenemia,Acquired DisordersMalignancyPresence of a central venous catheterSurgeryTraumaPregnancy/OCP/HRT Drugs ImmobilizationCongestive failure,Acquired Risk Factors cont,Antiphospholipid antibody syndromeMyeloproliferative disordersPoly

5、cythemia veraEssential thrombocythemiaParoxysmal nocturnal hemoglobinuriaInflammatory bowel diseaseNephrotic syndrome,Pathophysiology of PE,Most PEs arise from DVT of LEBut some may arise fromRight heartPelvic veinsRenal veinsUE veins,Lets Meet Ms Maria,Maria,38 yr old female presents with pain and

6、mild swelling in L LE.Pt was hiking recently when she slipped,fell and injured R knee.Her knee immediately swelled.She felt unstable w/walking due to pain and sought care at a local ER.A knee immobilizer was placed.She followed up with an orthopedic doctor who diagnosed an acute ACL rupture.An MRI c

7、onfirmed this and she underwent allograph repair 3 weeks ago.She is currently doing rehab with a PT.,Maria(cont),PMH:NegativePSH:ACL repair(6/22/13)Meds:Ibuprofen prn/Vicodin prn/Ortho TricyclenAllergies:NKDASoc Hx:Scrub tech at EUH No Tob/Rare Etoh,Maria on exam,Vitals:T 97.2 P 90 BP 110/70 R 14Pul

8、m:CTACV:RegularExt:Moderate swelling about R knee w/healing incision.1+pitting edema L LE.Mild pain with squeezing calf on L leg.None on R leg.Negative Homans sign.Calf circumference is 1 cm larger L than R.,What is the probability that Maria has a DVT?,Modified Wells Criteria for DVT,Modified Wells

9、 Criteria for DVT,2 or more Likely0 to 1 UnlikelyWells PS,Anderson DR,Rodger M et al.(2003).Evaluation of D-dimer in the diagnosis of 8 suspected deep-vein thrombosis.New England Journal of Medicine 349:122735.,Lets Meet Mr Albert,Albert,62 yr old male presents to the ER with complaint of pleuritic

10、CP.Present x 1 day.No injury.Feels SOB with walking.No fever.No cough.No LE pain.PMH:Colon CA s/p L colectomy on 6/20/HTN/BPHMeds:Lisinopril/Tamsulosin/ASA/MVINKDASoc Hx:No Tob/No Etoh,Albert,PhysicalT 99.1 P 110 BP 135/85 R 22 O2 sat 95%RAPulm:CTA,good AECV:Regular,No murmursExt:No edema.Negative H

11、omans sign,What is the likelihood of a PE in Mr.Albert?,Wells Criteria for PE,Modified Wells Criteria for PE,4:Likely4 or less:UnlikelyWells PS,Anderson DR,Rodger M et al.(2003).Evaluation of D-dimer in the diagnosis of 8 suspected deep-vein thrombosis.New England Journal of Medicine 349:122735.,Dia

12、gnosing DVT,DVT-Physical Exam,Calf tenderness,Homans Sign,Differential Swelling,Diagnostic Tests for DVT,D-dimerUltrasoundContrast Venography,Ultrasonography,Duplex scan of LECompressibility of the veinDoppler flow within the veinSymptomatic patient with proximal LE DVTSensitivity:89-96%Specificity:

13、94-99%,Ultrasonography,Asymptomatic patient with proximal LE DVTSensitivity:47-62%Symptomatic patient with distal LE DVTSensitivity:73-93%,Venography,Gold standard for DVTBut not recommended as first line due to high cost,risks ad technical difficulties,Adapted with permission from Institute for Cli

14、nical Systems Improvement.Copyright 2012.Health care guideline:venous thromboembolism diagnosis and treatment.,Diagnosing PE,Signs and Symptoms of PE,Signs in Massive P.E.,“Massive PE”:Hemodynamic instability SBP/=40mmHg over 15 min Elevated central venous pressureSigns as before PLUS:Acute right he

15、art failureElevated J.V.P.Right-sided S3Parasternal lift,Diagnostic Tests,Imaging StudiesCXRV/Q ScansSpiral Chest CTPulmonary AngiographyEchocardiograpyLaboratory AnalysisCBC D-DimerABGsBNPCardiac Enzymes-TroponinAncillary TestingEKGPulse Oximetry,Common findings,D-Dimer elevation 500 ng/ml A-a grad

16、ient 20 mm Hg BNP or proBNP elevationSensitivity and Specificity are approx 60%Troponin elevation30-50%of mod/large PEs have troponin elevation,ABG,ABG:HypoxemiaHypocapnia(low CO2)Respiratory AlkalosisMassive PE:hypercapnia,mix resp and metabolic acidosis(inc lactic acid)Patients with RA pulse ox readings 95%are at increased risk of in-hospital complications,resp failure,cardiogenic shock,death,But,Most patients with a PE have a normal pulse oximetry,and most patients with an abnormal pulse oxim