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

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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,andmostpatientswithanabnormalpulseoximetrywillnothaveaPE.TheA-agradientisabettermeasureofgasexchangethanthepO2,butitisnonspecificandinsensitiveinrulingoutPEBNPisinsensitivebutisagoodprognosticmeasurewhencombinedwithTroponin,D-dimer,Degradationproductoffibrin500isabnormalSensitivity:

High,80-85%Specificity:

LowNegativePredictiveValue:

Excellent93%to100%,D-dimerTestFalsePositives,PregnancyPostPartum80SepsisHemorrhageCVAAMICollagenVascularDisorderHepaticImpairment,41,ChestradiographfindingsinpatientswithPE,ResultPercentCardiomegaly27%Normalstudy24%Atelectasis23%ElevatedHemidiaphragm20%PulmonaryArteryEnlargement19%PleuralEffusion18%ParenchymalPulmonaryInfiltrate17%,AlbertsChestX-ray,WestermarksSign,HamptonsHump,ChestX-ray,WestermarkssignAdilationofthepulmonaryvesselsproximaltotheembolismalongwithcollapseofdistalvessels,sometimeswithasharpcutoff.HamptonsHumpAtriangularorroundedpleural-basedinfiltratewiththeapextowardthehilum,usuallylocatedadjacenttothehilum.,But,Mostchestx-raysinpatientswithPEarenonspecificandinsensitive,Albert-EKG,EKGFindingsinPE,MostCommonFindings:

TachycardiaornonspecificST/T-wavechangesAcutecorpulmonaleorrightstrainpatternsTallpeakedT-wavesinleadII（Ppulmonale）RightaxisdeviationRBBBS1-Q3-T3（occursinonly20%ofPEpatients）,Echocardiogram,IncreasedRightVentricleSizeDecreasedRightVentricularFunctionTricuspidRegurgitationRarely:

RVthrombusRegionalwallmotionabnormalitiesthatsparetherightventricleapex（McConnellsSign）,49,Spiral（Helical）ChestCT,AdvantagesNoninvasiveandRapidSensitivity:

40-100%Specificity:

78-100%DisadvantagesCostly（$600-900/scan）RisktopatientswithborderlinerenalfunctionHardtodetectsubsegmentalpulmonaryemboli,Ventilation/PerfusionScan,RelativelynoninvasivePreferredtestinpregnantpatients,contrastallergypatients50mremvs800mrem（withspiralCT）,50,51,V/QScan,TechniqueInterpretationNormalLowprobability/”nondiagnostic”（mostcommon）HighProbabilitySimplifiedapproachedtotheinterpretationofresults:

HighprobabilityTreatforPENormalScanIflowpre-test,nofurthertestingLowprobabilityPursueanotherstudy（CT,Angio）,52,PulmonaryAngiography,“GoldStandard”PerformedinanInterventionalCathLabPositiveresultisa“cutoff”offloworintraluminalfillingdefect“LastResort”,PEDiagnosis,VQscanningversusSpiralCTChestRandomizedtrialofpatientssuspectedofhavingPE,n=1471FalseNegativeRateSpiralCT0.6%VQScan1.0%,PEandDVTDiagnosisAlgorithm,AmFamPhysician.2007Dec1;76（11）:

1712-1713,AnothernewerAlgorithm,AmFamPhysician.2012Nov15;86（10）:

913-919,HypercoagulabilityWorkUp,AmFamPhysician.2004Jun15;69（12）:

2841-2848.,TreatmentofVTE,GoalsofTreatmentofDVT,TostopclotpropagationPreventclotrecurrencePreventPEandsecondarypulmonaryhypertension,DVTTreatment,Atleast6-12weeksofAnticoagulationusingheparinfollowedbywarfarin（Coumadin）.Nonpharmacologicmeasureslimbelevationandlocalapplicationofheat.ActivityshouldbeminimalforseveraldaysGradedelasticcompressionstockings50percentreductionintheincidenceofpostphlebiticsyndrome.,GoalsofTreatmentofPE,PreventdeathfromacurrentemboliceventReducethelikelihoodofrecurrentemboliceventsMinimizethelong-termmorbidityoftheevent,63,TreatmentofP.E.,RespiratorySupport:

Oxygen,intubationHemodynamicSupport:

IVF,vasopressorsAnticoagulationThrombolysisIVCFilter,Anticoagulation,StartduringresuscitationphaseitselfEvaluatepatientforabsolutecontraindicationIfsuspicionhigh,startempiricanticoagulation,Anticoagulation（contd）,HEPARIN:

Lovenox:

ifhemodynamicallystable,norenalfunction1mg/kgBIDOR1.5mg/kgQDayHeparingtt:

ifhypotension,renalfailure80units/kgbolusthen18units/kginfusionGoalPTT1.5to2.5timestheupperlimitofnormalProvidesimmediatethrombininhibition,whichpreventsthrombusextensionDoesnotdissolveexistingclotWillnotworkinpatientswithantithrombinIIIdef.InthiscaseusehirudinsFewabsolutecontraindications,68,Anticoagulants,COUMADIN:

StartonceacuteanticoagulationachievedStartwith5mgPOqdayOR10mgPOqdayIfstartwith10mgthenachievetherapeuticINR1.4dayssoonerComplicationsandmorbiditynodifferentin5mgor10mgstartGoalINR2to3,DurationofAnticoagulationforVTE,*FromAmericanCollegeofChestPhysicians,70,Thrombolysis,FibrinolyticTherapy（Alteplase）Indications:

DocumentedPEwith:

PersistenthypotensionSyncopewithpersistenthemodynamiccompromiseSignificanthypoxemia+/-patientwithacuterightheartstrainApprovedAltivaseregimenis100mgasacontinuousIVinfusion.,Thrombolysis,Holdanticoagulationduringthrombolysisinfusion,thenresumedAssociatedwithhigherincidenceofmajorhemorrhage,IVCFilter,Indication:

Absolutecontraindicationtoanticoagulation（i.e.activebleeding）RecurrentPEduringadequateanticoagulationComplicationofanticoagulation（severebleeding）A