Standardized diagnosis and treatment of acute pulmonary embolism

Release date: 2007-09-04

Standardized diagnosis and treatment of acute pulmonary embolism (Pulmonary Embolism) is the most common fatal emergency in developed countries such as Europe and the United States, and is the leading cause of death in all age groups. The mortality rate of pulmonary embolism in the United States ranks third only after malignant tumors and myocardial infarction, and at least 650,000 people die of pulmonary embolism each year. The annual incidence rate in the UK is 60-70/100 million and the annual mortality rate is 100/10 million. Pulmonary embolism has been considered a rare disease in China, but the clinical epidemiological survey in the past 10 years shows that the number of pulmonary embolism cases in China has steadily increased, which should cause the clinician to be vigilant. To this end, Professor Deng Yuelin of Xiangya Hospital of Central South University introduced to us the latest clinical guidelines for the diagnosis and treatment of acute pulmonary embolism in the current issue of the disease weekly for reference by domestic counterparts.
Pulmonary embolism has been considered a rare disease in China, but the clinical epidemiological survey in the past 10 years shows that the number of pulmonary embolism cases is steadily increasing, which should cause the clinician to be vigilant. Clinical manifestations of pulmonary embolism Typical symptoms of pulmonary embolism are dyspnea, chest pain, and hemoptysis, which is known as the triad of pulmonary infarction. The incidence of dyspnea is as high as 60%, and it is often manifested as labor dyspnea. Clinicians should pay attention to the cause, nature, extent and duration of dyspnea. Dyspnea, which is mainly based on chest tightness, needs to be differentiated from exertional angina. The incidence of chest pain was 17%. Mostly pleural pain, caused by pulmonary infarction involving the pleura. A small number of patients presented with "angina pectoris", possibly due to coronary artery spasm or right ventricular hypertrophy. The incidence of hemoptysis was 3%, the amount of blood was not much, bright red, and turned dark red after a few days, suggesting the presence of pulmonary infarction. Other symptoms include coughing, which is usually characterized by dry cough, which may be accompanied by wheezing and panic, caused by chest pain or hypoxemia. When a large pulmonary embolism or severe pulmonary hypertension occurs, it can cause temporary cerebral ischemia, which is manifested as syncope, which may be the first symptom of pulmonary infarction. It is important to emphasize that less than 20% of patients with a typical triad of typical pulmonary infarction. 96% of patients with pulmonary infarction have increased breathing, 58% of patients can smell dry and wet, 53% can hear high-pitched second heart sound, 44% have tachycardia (>100/min), 43% The patient had fever (>37.8 °C), 36% of patients had sweating, and 32% had symptoms and signs of thrombophlebitis. 24% of patients had lower extremity edema and 23% had heart murmur. Tachycardia and decreased blood pressure usually indicate pulmonary embolism or massive pulmonary embolism, and cyanosis suggests severe disease. Chest examination can be free of any abnormal signs. If the extent of pulmonary embolism on one side is large, lung volume reduction, pericardial friction and pleural friction may occur, or signs of pleural effusion, pulmonary hypertension, and right heart failure may occur. Severe chronic embolic pulmonary hypertension can be complicated by pericardial effusion. Jugular vein filling and abnormal pulsation have diagnostic and differential diagnostic significance.
New concept of standardized diagnosis and treatment procedures for acute pulmonary embolism In order to continuously improve the diagnosis rate of acute pulmonary embolism, facilitate early treatment and reduce mortality, the international diagnosis and treatment procedures for acute pulmonary embolism have been improved and updated, and new concepts and new ideas have been proposed. The standardization of the diagnosis and treatment of acute pulmonary embolism in the UK in 2006 is described below.
1. Any patient with dyspnea, chest pain, cough and hemoptysis should consider acute pulmonary embolism and enhance the diagnosis of acute pulmonary embolism. Only in this way can the diagnosis and misdiagnosis be reduced.
2. For patients suspected of acute pulmonary embolism, clinical likelihood scores should be based on their medical history, symptoms, and signs. According to the results of the score, follow the corresponding process for treatment.
3. The clinical likelihood score of acute pulmonary embolism (Table 1) is an internationally accepted clinical possibility score for acute pulmonary embolism. If the score is <2.0, the clinical possibility of pulmonary embolism is considered to be small. The score is >6.0. Sexually large, the score is 2.0 to 6.0. Considering the clinical possibility of pulmonary embolism is moderate, it may or may not be, and further investigation by a clinician is required. Re-recognition of blood D-dimer The blood D-dimer is a metabolite of fibrin glue protein. The content of blood D-dimer increases during acute pulmonary embolism, and the sensitivity is high, but the specificity is not strong. Surgery, trauma and acute myocardial infarction were excluded. If the D-dimer is less than 500 μg/L, the diagnosis of acute pulmonary embolism can be ruled out without pulmonary angiography.
In clinical work in the UK, the hospital's biochemical laboratory also uses plasma D-dimer as an indicator for the diagnosis and exclusion of pulmonary embolism. In the emergency department, many hospitals mainly use the Shortness of Breath Panel to measure myocardial creatine kinase (CK-MB), myoglobin, troponin I, B-type natriuretic peptide and D-dimerization. The body can determine whether the patient's dyspnea is cardiogenic or pulmonary, and can also diagnose whether the patient has acute myocardial infarction and heart failure and its severity. X-ray chest X-ray, CT pulmonary angiography, and ventilated blood perfusion ratio imaging can provide preliminary clues for diagnosis. Patients with X-ray films have abnormal changes, but they are often non-specific. The most common signs are sparse, reduced lung texture, increased permeability, and uneven distribution of pulmonary blood. Occasionally, the shape of the lung is not infiltrated. Typically, the base is oriented toward the pleura or the diaphragm on the diaphragm, with minimal to moderate pleural effusion. In addition, the trachea is moved to the affected side or the heavier side, and the diaphragm is elevated. When complicated pulmonary hypertension or right heart enlargement or failure, the superior vena cava is widened, the pulmonary artery segment is convex, the right lower pulmonary artery is widened, and the right ventricle is enlarged.

CT pulmonary angiography (CTPA) can be used for the initial identification of acute or chronic pulmonary thrombosis. In the UK, CTPA is basically used to diagnose pulmonary embolism. Suspected cases of acute non-large area pulmonary embolism can be listed as the first choice and completed within 24 hours of the visit. CTPA can not only confirm the presence of pulmonary embolism, but also observe the relationship between the size, specific location, distribution of the emboli in the affected pulmonary artery and the wall of the vessel, as well as the presence or absence of thrombus in the right atrium and right ventricle, cardiac function status, and lung tissue perfusion. , lung infarction lesions and pleural effusion.
Ventilation perfusion ratio (V/Q) imaging is currently replaced by CTPA. For those patients with normal chest radiographs and no cardiopulmonary disease, they can be used as first-line examinations. If the scan results are negative, pulmonary embolism can be excluded. In addition, V/Q has unique value for the diagnosis of pulmonary embolism and chronic pulmonary embolism pulmonary hypertension. Excessive smoking, chronic obstructive pulmonary disease or left heart failure can cause changes in lung perfusion imaging and should be identified. Echocardiography has only diagnostic value for suspected acute large-area pulmonary embolism, showing right heart size, intrapulmonary and intracardiac thrombosis. Critically ill, hemodynamic instability can be included in the first choice, completed within 2 hours of the patient visit, after the condition is stable, lower extremity venous ultrasound can be found in deep venous thrombosis of the lower extremity. Conventional pulmonary angiography is the "gold standard" for the diagnosis of pulmonary embolism with a sensitivity of 98% and a specificity of 95% to 98%. However, it is an invasive examination and should be strictly in accordance with the indications. Conventional pulmonary angiography can be used to rupture large embolizations, but most of them are now replaced by CT angiography. Pulmonary embolism treatment principle The goal of pulmonary embolism treatment is to save lives, stabilize the condition, and re-open the pulmonary blood vessels. Hemodynamic instability is a feature of acute large-area pulmonary embolism with a mortality rate of 20%. Basic treatments include oxygen inhalation, establishment of venous access, pain relief, treatment of cardiogenic shock, anticoagulation and intravenous thrombolytic therapy. For such shocks, mainly rehydration and positive inotropic drugs to ensure right ventricular perfusion. Intravenous thrombolysis is currently used internationally, thrombolytic therapy is mainly used for acute large-area pulmonary embolism in patients with hemodynamic instability. In view of the wide indications for thrombolytic therapy in China, attention should be paid. The drugs and usages commonly used abroad are as follows. Reteplase (r-PA): 10 MU was administered intravenously twice, and the administration time was more than 30 minutes. Alteplase (rt-PA): 100 mg intravenous drip for more than 2 hours. Streptokinase: 250,000 units were administered in 30 minutes, followed by 100,000 units/hour for 24 hours. Anticoagulant therapy is currently used internationally for the treatment of patients with hemodynamically stable, non-large-area pulmonary embolism. Anticoagulant drugs include low molecular weight heparin and warfarin, active gastrointestinal bleeding and intracranial hemorrhage. . The commonly used drugs and methods in Europe and the United States are as follows: Low molecular weight heparin calcium: 4100 IU, subcutaneous injection, q12h. Enoxaparin: 4000 IU, subcutaneous injection, q12h. Dalteparin sodium: 200 IU/kg, subcutaneous injection, qd. Tinzaparin: 175 IU/kg, subcutaneously, qd, administered at the same time every day for 6 consecutive days until warfarin or other long-acting anticoagulant is effective. During the application of anticoagulant therapy, the activated partial prothrombin time (APTT) should be monitored to maintain the APTT at 1.5 to 2.5 times the normal value. For patients with high suspicious pulmonary embolism, including elderly patients, anticoagulant therapy should be started to prevent the spread and recurrence of blood clots. Low molecular weight heparin has fewer adverse reactions, good curative effect and wide indications. Warfarin can be taken orally, but it has a slow onset, and the anticoagulant treatment should be long enough. The recommended treatment time in the world is 4 to 6 weeks. The international standardized ratio should be maintained at 2.5, and the starting dose of warfarin should be 5-15 mg/d orally qd. Antiplatelet drugs such as aspirin are not suitable for anticoagulant therapy for venous thromboembolism alone. Patients with high risk factors for pulmonary embolism and undergoing surgery, patients with severe cardiopulmonary disease, and most intensive care units should have preventive anticoagulation to prevent pulmonary embolism. Surgical treatment of catheter thrombolysis, catheter thrombectomy, catheter thrombectomy and other interventional treatment applications, only for hemodynamic instability, large-area pulmonary embolism, thrombolytic therapy contraindications or invalid, currently abroad It can only be implemented in a few qualified hospitals. There is currently no evidence that inferior vena cava filter placement can improve survival or reduce the rate of pulmonary embolism, and it is equally effective to switch to low molecular weight heparin. However, it can be used for: acute venous thrombosis, contraindications for anticoagulation and thrombolytic therapy; acute venous thrombosis, anticoagulation and thrombolytic therapy, high-risk patients who are still recurrent; large-area pulmonary embolism survivors; pulmonary hypertension After pulmonary endarterectomy. A small number of patients with acute pulmonary embolism and chronic recurrent pulmonary embolism can develop chronic pulmonary hypertension. Commonly used therapeutic drugs are anticoagulant warfarin, antiplatelet aggregation drugs, vasodilators and anti-heart failure drugs. Pulmonary thrombosis intimal and venous filter placement may also be considered when necessary. ——Midi Medical Network

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