PE - an acute cardiovascular disease, caused by a sudden blockage of the pulmonary artery embolus in a blood clot.The most common blood clots, occlusive pulmonary artery branches are formed in the right heart or venous vessels of the systemic circulation and cause severe disruption blood supply to the lung tissue.
PE has a high mortality rate, the causes of which lie in the late diagnosis and inadequate treatment.Mortality from cardiovascular diseases ranked first, and the share of PE accounted for 30% of this figure.
deaths from pulmonary embolism may occur not only in cardiac pathologies, but also in the postoperative period after extensive surgical interventions during labor and extensive traumatic injury.
risk of pulmonary embolism increases with age and there is a dependence of this pathology of sex (incidence among men is 3 times higher than among women).
PE is classified by location of the thrombus in the pulmonary artery on: massive (thrombus located in the projection of the
Among the causes of pulmonary embolism should be noted:
- acute phlebothrombosis veins of lower extremities, complicated by thrombophlebitis (90%);
- ileofemoralny thrombosis;
- SSS diseaseaccompanied by increased thrombus in the pulmonary artery (ischemic heart disease, heart defects of rheumatic origin, heart disease inflammatory and infectious nature cardiomyopathy different genesis);
- atrial fibrillation form, giving rise to the formation of thrombus in the right atrium;
- generalized sepsis;
- blood diseases, accompanied by dysregulation of hemostasis (thrombophilia);
- autoimmune antiphospholipid syndrome (increased synthesis of antibodies to phospholipids of platelets and endothelium, accompanied by excessive tendency to thrombosis).
- a sedentary lifestyle;
- comorbidities, accompanied by cardiovascular collapse;
- a combination continuous use of diuretics with inadequate fluid intake;
- hormonal agents;
- varicose veins of the lower extremities, which is accompanied by stagnation of venous blood and marked the creation of conditions for thrombus formation;
- illness, accompanied by violation of the metabolic processes in the body (diabetes, hyperlipidemia);
- cardiac surgery and invasive intravascular manipulation.
Not all complicated by thrombosis thromboembolism and only floating thrombus can break away from the vessel wall and enter the bloodstream in pulmonary blood flow.Most often the source of such floating thrombi are the deep veins of the lower extremities.
Currently there phlebothrombosis genetic theory of occurrence, which is the cause of pulmonary embolism.In favor of this theory suggests thrombosis at a young age and confirmed episodes of pulmonary embolism with relatives of the patient.
degree of clinical manifestations of pulmonary embolism depends on the location and extent of the thrombus in pulmonary blood flow, disabled as a result of the blockage.
If the damage does not exceed 25% of the pulmonary arteries develop small pulmonary embolism, in which right ventricular function is preserved and the only clinical symptom is shortness of breath.
If there is a 30-50% obstruction of pulmonary vessels, the submassive developing pulmonary embolism, in which there are initial manifestations of right heart failure.
bright clinical picture develops when you turn off the flow of more than 50% of the pulmonary arteries in the form of impaired consciousness, low blood pressure up to the development of cardiogenic shock and other symptoms of acute right heart failure.
In a situation where the volume of the affected pulmonary vessels greater than 75%, there comes death.
slew rate of clinical symptoms are 4 types of the course of pulmonary embolism:
- lightning (death occurs within minutes due to the development of acute respiratory failure due to blockage of the main pulmonary artery trunk. The clinical symptoms is - acute onset against the backdrop of well-being, false angina,psycho-emotional arousal, dyspnea, cyanosis of the skin of the upper half of the torso and the head, swelling of the veins in the neck);
- sharp (characterized by rapidly growing symptoms of respiratory and heart failure develops within a few hours. During this period, the patient complains of dyspnea until the attacks of breathlessness, cough and hemoptysis, pronounced chest pain compressive nature radiating to the upper limb favor the developmentmyocardial infarction);
- subacute (Clinical manifestations grow for several weeks, during which the image of small areas of pulmonary infarction. In this period there was an increase in temperature to subfebrile, unproductive cough, chest pain, aggravated by movement and breathing. All these symptomsevidence of the occurrence of pneumonia on a background of pulmonary infarction);
- chronic (characterized by frequent episodes of recurrent emboli and the formation of multiple infarcts in conjunction with pleurisy. Often there is asymptomatic pulmonary embolism, and this option to the fore the clinical manifestations associated pathologies of the cardiovascular system).
PE has no specific clinical symptoms unique to this disease, but the fundamental difference between PE from other diseases is the appearance of a bright clinical picture on the background of well-being.However, there are signs of pulmonary embolism, which are available for each patient, but the extent of their different manifestations: increased frequency of heart rate, chest pain, tachypnea, cough with bloody sputum, fever, crackles without a clear localization, collapse, pallor and cyanosis of the skin.
Classic symptoms of PE scenario consists of five main syndromes.
- a sharp drop in blood pressure, combined with an increase in heart rate, as a manifestation of acute circulatory failure;
- sharp compressive chest pain radiating to the lower jaw and upper limb, combined with signs of atrial fibrillation, showing the development of acute coronary insufficiency;
- tachycardia, positive venous pulse and swelling of the neck veins are signs of acute pulmonary heart;
- dizziness, tinnitus, impaired consciousness, convulsions, vomiting not related to eating and positive meningeal signs indicate the development of acute cerebrovascular insufficiency.
- acute respiratory distress syndrome is manifested in dyspnea until suffocation and marked cyanosis of the skin;
- the presence of dry wheezing indicates the development of bronchospastic syndrome;
- infiltrative changes in the lungs as a result of the emergence of foci of myocardial lung tissue appear as fever, appearance of cough with difficult expectoration, chest pain on the affected side, and the accumulation of fluid in the pleural cavity.Auscultation of the lungs is determined by the presence of local wet wheezing and pleural friction noise.
hyperthermia syndrome manifested in increase in body temperature to 38 degrees for 2-12 days and is caused by inflammatory changes in the lung tissue.
Abdominal syndrome manifests itself in the presence of acute pain in the right upper quadrant, vomiting and belching.Its development is due to paresis of the intestine and the liver capsule stretch.
Immunological syndrome manifests itself in the appearance of urtikaropodobnoy rash on the skin and improving the performance of eosinophils in the blood.
PE has a number of long-term complications in the form of heart attacks the lungs, chronic pulmonary hypertension and embolism in the systemic circulation.
All diagnostic activities PE aimed at early detection of the localization of the thrombus in the pulmonary artery, the diagnosis of hemodynamic disorders and mandatory identification of the source of thrombosis.
list of diagnostic procedures for suspected pulmonary embolism is large enough, so to diagnose recommended for hospitalized patients to a specialized vascular compartment.
mandatory diagnostic measures for the early detection of signs of pulmonary embolism are:
- a thorough objective investigation of patients with compulsory medical history of the disease;
- detailed analysis of blood and urine tests (to determine the inflammatory changes);
- determining blood gas;
- Holter ECG monitoring;
- coagulation (for determination of blood clotting);
- ray diagnostic methods (chest X-ray) to determine the presence of complications of pulmonary embolism in the form of a heart attack, pneumonia or the presence of pleural effusion;
- ultrasound of the heart to determine the state of the heart chambers and the presence of blood clots in their lumen;
- angiography (allows to accurately determine not only the location but also the size of a blood clot. The location is determined by the estimated location of the thrombus filling defect cylindrical shape, and the full obturation lumen marked symptom of "amputation of the pulmonary artery").Note that the manipulation has a number of adverse reactions, allergy to contrast administration, myocardial perforation, various forms of arrhythmias, increase the pressure in the pulmonary artery and even death due to the development of acute heart failure;
- ultrasound of the veins of the lower extremities (in addition to the establishment of the localization of thrombotic occlusion is possible to determine the length and mobility of a blood clot);
- contrast venography (to determine the source of thromboembolism);
- computed tomography with contrast (thrombus is defined as a filling defect in the lumen of the pulmonary artery)
- perfusion scintigraphy (estimated degree of saturation of the lung tissue radionuclide particles that are administered intravenously prior to the study. Lots of pulmonary infarction are characterized by the complete absence of radionuclide particles);
- determining the level of cardiac markers (troponin) in the blood.Elevated troponin figures indicate the defeat of the right ventricle of the heart.
case of suspected pulmonary embolism ECG provides essential help in establishing the diagnosis.Electrocardiographic pattern changes occur in the first hours of occurrence of pulmonary embolism and are characterized by the following parameters:
• Unidirectional displacement of RS-T segment in the III and right chest leads;
• Simultaneous T wave inversion in III, aVF and right chest leads;
• The combination of appearance Q wave in lead III with a pronounced upward bias in the RS-T III, V1, V2 leads;
• Gradual increase in the degree of blockade of the right branch of the His bundle;
• Signs of acute overload of the right atrium (an increase of P wave in II, III, aVF leads.
for PE is characterized by rapid regression of ECG changes within 48-72 hours.
«gold standard" diagnostic can reliably establish the diagnosis of pulmonary embolismIt is a combination of X-ray contrast research techniques: angiography and retrograde iliokavagrafii.
in emergency cardiology there developed algorithm of diagnostic measures aimed at timely diagnosis and determination of the individual patient management. According to this algorithm, the whole diagnostic process is divided into three main stages:
♦ Stage 1carried out on the pre-hospital follow-up of the patient and includes a thorough data collection history with the identification of comorbidities and objective study of the patient, during which you should pay attention to the appearance of the patient, percussion and auscultation of exercise the heart and lungs.Already at this stage we can determine important features of pulmonary embolism (cyanosis of the skin, strengthening II tone at the point of listening to the pulmonary artery).
♦ Stage 2 PE diagnosis is to conduct non-invasive methods of research available in any hospital environment.Electrocardiography performed to exclude myocardial infarction, which has a similar clinical picture with PE.All patients with suspected pulmonary embolism shows the use of X-rays of the chest cavity for the purpose of differential diagnosis with other diseases of the lungs, accompanied by acute respiratory failure (pleural effusion, polysegmental atelectasis, pneumothorax).In a situation where during examination revealed acute disturbances in the form of respiratory failure and hemodynamic disorders, the patient is transferred to the intensive care unit for further examination and treatment.
♦ Stage 3 involves the use of more sophisticated techniques (scintigraphy, angiography, Doppler veins of the lower limbs, spiral CT) to clarify the location of the thrombus and its possible solutions.
In the acute phase of PE a matter of principle in the treatment of a patient is to preserve the patient's life, and in the long term treatment is aimed at preventing possible complications and prevention of recurrent pulmonary embolism cases.
main directions in the treatment of pulmonary embolism are the correction of hemodynamic disturbances, the removal of thrombotic masses and pulmonary blood flow recovery, relapse prevention of thromboembolism.
In a situation when diagnosed with pulmonary embolism segmental branches, accompanied by minor hemodynamic compromise enough of anticoagulation.Anticoagulant drugs have the ability to stop the progression of the existing thrombosis, thromboembolism and small lumen segmental arteries alone lysed.
In the hospital recommended the use of low molecular weight heparins, which are devoid of bleeding complications, have high bioavailability, does not affect the functioning of platelets and easily dosed when used.The daily dosage of LMWH is divided into two stages, for example Fraksiparin applied subcutaneously Monodose 1 to 2 times per day.Duration of heparin was 10 days, after which it is advisable to continue anticoagulant therapy with anticoagulants in tablet form, for 6 months (5 Warfarin 1 mg once a day).
all patients receiving anticoagulant therapy, should be screening study in laboratory parameters:
- fecal occult blood test;
- indicators of coagulation (APTT daily throughout heparin).A positive effect is the increase anticoagulation APTT compared to baseline by 2 times;
- full blood count with platelet count definition (cessation of heparin therapy indication for a reduction in the number of platelets by more than 50% of the initial value).
Absolute contraindications to the use of anticoagulants in the PE indirect and direct actions are severe violations of cerebral circulation, cancer, any form of pulmonary tuberculosis, chronic liver and kidney failure decompensation.
Another effective direction in the treatment of pulmonary embolism is a thrombolytic therapy, but its application must be convincing evidence:
- massive pulmonary embolism, in which there is a shutdown of blood flow for more than 50% of blood volume;