1、 大面積肺栓塞伴心肺驟?；颊叩膿尵炔呗耘丝缀憬髮W(xué)醫(yī)學(xué)院附屬邵逸夫醫(yī)院重癥醫(yī)學(xué)科 Impact of Clinical Instability at Presentation病例回顧 患者，女性，33歲，哥斯達黎加公民。 因“發(fā)熱寒戰(zhàn)2天”以“貧血待查：自身免疫性溶血性貧血；感染性發(fā)熱？ ” 入院。搶救過程2012-06-22 0700 患者出現(xiàn)血壓降至50/30mmHg、HR60bpm并進行性下降，迅速出現(xiàn)無脈性電活動(PEA)，立即給予CPR、Epi0704 HR120bpm 、BP100/50mmHg，VT：胺碘酮150mg iv.CPR過程中考慮多臟器栓塞談話溝通：本科、?？?、家屬0

2、759 給予阿替普酶rt-PA 5mg 2min 靜推一次，其余rt-PA 45mg iv搶救過程0802 患者自主心律恢復(fù)， HR132,BP129/81,SaO2100%, 瞳孔7/F、7/F,Epi 0.27g/kg/min0825 瞳孔7/6.5S、7/6.5S0920 DC Epi1000 瞳孔4.5/3.5N、4.5/4.0N1055 清醒病因血栓性血小板減少性紫癜（TTP）：是一種嚴重的彌散性血栓性微血管病，以微血管病性溶血性貧血、血小板聚集消耗性減少，以及微血栓形成造成器官損害（如腎臟、中樞神經(jīng)系統(tǒng)等）為特征。 VTE流行病學(xué)歐洲資料癥狀性VTE發(fā)生人數(shù)每年超過150萬 VTE

3、相關(guān)死亡人數(shù)每年約543,500 突發(fā)致死性PTE 435,000 癥狀性DVT為684,000VTE Impact Assessment Group in Europe (VITAE) .Thromb Haemost 2007; 98: 756764 VTE流行病學(xué)北美資料美國VTE年總發(fā)生例數(shù)2000,000 癥狀性VTE每年超過600,000 DVT, n=376,365, PE, n=237,058 VTE相關(guān)死亡人數(shù)每年約296,370 證實VTE并治療的患者為21,223 (7%) 突發(fā)致死性PTE 101,032 (34%) 可疑PTE為 174,115 (59%)Massive

4、 PEAcute PE with sustained hypotension systolic blood pressure 90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular LV dysfunctionpulselessness orpersistent profound bradycardia heart rate 40 b

5、pm with signs or symptoms of shockMassive PE流行病學(xué)The 30-day mortality rate for massive PE approaches 30%The presence of shock in these patients defines a threefold to sevenfold increase in mortality, with a majority of deaths occurring within 1 h of presentation. 診斷策略表1 VTE的原發(fā)危險因素抗凝血酶缺乏先天性異常纖維蛋白原血癥血栓

6、調(diào)節(jié)因子（thrombomodulin）異常高同型半胱氨酸血癥抗心脂抗體綜合征（anticardiolipin antibodys syndrome）纖溶酶原激活物抑制因子過量凝血酶原20210A基因變異XII因子缺乏V因子Leiden突變（活性蛋白C抵抗）纖溶酶原不良血癥蛋白S缺乏蛋白C缺乏表2 VTE的繼發(fā)危險因素創(chuàng)傷/骨折 髖部骨折（50%75%） 脊髓損傷（50%100%）外科手術(shù)后 疝修補術(shù)（5%） 腹部大手術(shù)（10%30%） 冠狀動脈搭橋術(shù)（3%9%）腦卒中（30%60%）腎病綜合征中心靜脈插管慢性靜脈功能不全吸煙妊娠/產(chǎn)褥期血液粘滯度增高血小板異?？肆_恩?。–rohns dise

7、ase）充血性心力衰竭（12%）急性心肌梗死（5%35%）惡性腫瘤腫瘤靜脈內(nèi)化療肥胖因各種原因的制動/長期臥床長途航空或乘車旅行口服避孕藥真性紅細胞增多癥巨球蛋白血癥植入人工假體高齡PEA vs VFPEA is more commonly associated with MPE versus MI due to near complete obstruction of pulmonary blood flow with an intact electrical conduction system. MI is more commonly associated with VF as the e

8、lectrical conduction system is affected more often by ischemia. In conclusion, the previous cases illustrate that initial rhythm may be a vital diagnostic clue.心超:血栓在右室及下腔V 治療策略In summaryThrombolytic therapy is the first-line treatment in patients with high-risk PE presenting with cardiogenic shock

9、and/or persistent arterial hypotension, with very few absolute contraindications危險度分層2008ESC Guidelines Thrombolysis should be undertaken in patients with high-risk PE unless there are absolute contraindications to its use2011AHA management 溶栓禁忌癥 外科手段Surgical pulmonary embolectomya valuable therapeutic option in patients with high-risk PE in whom thrombolysis is absolutely contraindicated or has failedPercutaneous catheter embolectomyand fragmentationcatheter embolectomy or fragmentation of proximal pulmonary arterial clots may be considered as an alternative t