Pulmonary embolism. Causes, symptoms, signs, diagnosis and treatment of pathology

Date: 01.07.2020

With a fulminant pulmonary embolism, the dynamics develops the insufficiency of coronary blood circulation with myocardial ischemia, a decrease in cardiac output and a cardiogenic shock.

The annual incidence of lung embolism is 150-200 cases per 100,000 population, so it relates to frequent cases of urgent therapy and in the first two weeks is associated with mortality to 11%.

Most embolts are a broken swipper from peripheral veins (more than 70% of cases of pellets and lower extremities phlebotromboosis). It is less likely to form a heart thrombus or blood clomes come from the upper hollow vein.

Causes of lung embolism

Risk factors include:

Immobilization (operation, accident / injury, severe disease, neurological or internal organs, such as stroke, severe renal failure)
HyperSevelopability of blood, thrombophilia, previous venous thromboembolism
Central venous catheter
Cardiomimulator probes
Malignant diseases, chemotherapy
Heart failure
Obesity
Pregnancy
Smoking
Medications.

Symptoms and signs of lung embolism

Acute or sudden dance, tachipne
Pleural pain, chest pain, angina complaints
Hypoxemia
Palpitalia, Tachycardia
Arterial hypotension, shock
Cyanosis
Cough (partially also hemoptysis)
Syncope
Nabult cervical veins

From a clinical point of view, patients with high and low risks should be distinguished (stable hemodynamics \u003d normal), as it is important for further diagnostic and therapeutic measures and for the forecast.

Diagnosis of lung embolism

In hemodynamic unstable patients, with suspicion of lung embolism, it is necessary to confirm the diagnosis as quickly as possible, and not just to perform extended diagnostics before the start of therapy.

For this serve:

Cardiovascular parameters: Tachycardia, arterial hypotension until shock
Visualization methods:
- Golden Standard for setting (or exception) to the diagnosis of pulmonary embolism - spiral CT lungs with a contrast agent (sensitivity up to 95%)
- the alternative method of lung scintigraphy has lost its importance and still applies only in special situations.
- in radiography, detect only (if they detect generally) nonspecific changes, such as atelectases or infiltrates
Blood Gas Analysis: Hypoxemia
Echocardiography plays an important role in emergency diagnostics! Depending on the degree of pulmonary embolism, signs of acute load of the right ventricle or the right-handed dysfunction (dilatation, hypokinesia, paradoxical movements of the partition), sometimes the detection of floating thrombus in the right cavities of the heart.
Laboratory data:
- - D-dimers: Indicators\u003e 500 μg / l in fibrinolysis. A positive result was initially nonspecific, a negative result with a fairly high probability excludes a pulmonary embolusion.
- sometimes the troponin is raised as a sign of myocardial ischemia.
- in dilatation of ventricles, the level of the sodium-ethical peptide may increase, which is associated with the worst outcome
Uzi veins of the lower extremities

Differential diagnosis of lung embolism

Myocardial infarction
Angina
Heart failure
Pneumothorax
Pulmonary edema
Bronchial asthma
Pneumonia
Pleurisy
Intercostal neuralgia
Aorti bundle
Hydro or hemopericard.

Treatment of lung embolism

With a high risk of hemodynamic instability or shock, it is necessary to immediately begin therapy with the thrombolysis method (or, in contraindications for lithic therapy, operational or endovascular ehmaballomy). When hemodynamic instability, catecholamines are used. Hemodynamically stable patients (normotensive \u003d low risk) recommended early therapy with low molecular weight heparinum or Fondaparinux, adapted to the patient weight.

The best therapeutic strategy in the case of patients with normal arterial pressure, but with the dysfunction of the right ventricle, has not yet been determined

An early anticoagulation of vitamin K antagonists (for example, Marcumar) is served as a secondary prophylaxis (for example, Marcumar), initially cross-heparin, until MHO is stably in the therapeutic range between 2.0 and 3.0. Patients with secondary pulmonary embolism, in which the risk factor was eliminated or cured, it is recommended to continue anticoagulation at least three months.

With the "idiopathic" embolism of lungs and trouble-free or stable antihoculation, such therapy should be continued constantly.

Every year, the pulmonary embolism becomes frequent cause of death (1 victim for 1000 people). This is a high indicator, if comparing thromboembolism with other diseases.

All danger lies in the fact that the development of pulmonary artery thromboembol (hereinafter TAL) is very rapid - for example, from the moment of the onset of the first symptoms before the occurrence of death from the fact that the thrombus broke into the lungs can pass literally a few seconds or minutes.

The reasons

Embolism of the pulmonary artery is the blockage of the switches of the main artery of the lungs. As a rule, the blockage is sudden, therefore the symptoms are developing rapidly. The cause of the pulmonary artery thromboembolism is most often becoming a blood clot (embol), listed in the pulmonary artery with a blood current from other vessels. The pulmonary artery can also clog:

It should be noted that during pregnancy, the risk of thromboms increases into the lungs, both due to the squeezing of the wizen venous vessels, and due to hormonal changes in the body, which increase the risk of developing the deep vein vendors. In addition, during natural genera or cesarean cross sections, thromboembolism can cause olive flooded water.

Despite the variety of clots, which can block the pulmonary artery, most often the cause becomes the thrombus formed in the lines of the lower extremities or the lower hollow vein. The part of the embol is torn away from the thrombus and is moving to the pulmonary artery. Depending on the size of the bunch, the pulmonary embolism can even pass asymptomatic.

Negative consequences from thrombus in the lungs can manifest even in a healthy person who had not previously had complaints about health. Doctors highlight the risk category among people who lead a low-wear lifestyle. Casting blood in limbs can cause thromboembolism, therefore office workers, as well as people associated with long crossing and flights (truckers, flight attendants), is periodically undergoing a medical examination for blood clots and blood pressure. Prevention of pulmonary artery thromboembolism In this case, the lifestyle change, regular sports.

Some drugs also contribute to the development of TAL small branches. First of all, these are diuretics. They lead to the dehydration of the body, which is negatively reflected in the state of blood. It becomes more viscous and thick. Hormonal drugs are also dangerous, since the change in the hormonal background may disrupt blood clotting. Hormonal drugs mainly include contraceptives, as well as drugs for the treatment of infertility.

Since the main cause of TEL is thrombosis of the lower limbs, the investigation of the second is overweight, varicose veins, a sedentary or standing lifestyle, some bad habits and many other factors.

Symptoms

Specific symptoms of pulmonary artery embolism depend on the magnitude of the thrombus. The external symptoms of Tel are quite diverse, but doctors noticed that all of them can be divided into certain groups:

Cardial or cardiovascular syndrome

It is manifested by syndrome, first of all, in the form of heart failure. Due to the overlap of blood flow in humans, pressure drops, but tachycardia is pronounced brightly. The frequency of heartbeat reaches 100 shots per minute, and sometimes more. Part of the patients also in this period feel pain for the sternum. In different people, pain attacks may have a different character: acute, stupid or pulsating. In some cases, the symptoms of the thromboembolism of the pulmonary artery lead to a fainting.

Elemental-pleural syndrome

The symptoms of the thromboembolism of the pulmonary artery in this case are the complaints of the patient associated with the work of the lungs and breathing as a whole. There is a shortness of breath, which significantly increases the number of breaths per minute (approximately 30 or more). At the same time, the required amount of oxygen does not get the body anyway, so the skin begins to acquire a bluish shade, especially this is noticeable on lips and nail beds. Sometimes you can notice whistling sounds during breathing, but most often the problems are expressed in the cough, right up to the hemoptia. Cough is accompanied by pain in the chest.

Cerebral syndrome

Some scientists stand out in a separate view also cerebral syndrome, which is associated with heart failure. This is justified by the fact that symptoms at pulmonary embolism may not be characteristic of acute vascular or coronary failure. The reduced pressure primarily affects the brain. Typically, such a state is accompanied by noise in the head, dizziness. The patient can nausea, often begins the convulsions that will continue even in a fainted state. The patient can go into a comatose state or, on the contrary, be too excited.

Fevering syndrome.

Tale's classification does not always highlight this type of syndrome. It is characterized by an elevated body temperature, as inflammation begins. Fever usually lasts from 3 days to 2 weeks. Complications from TEL can be expressed not only in the form of fever, but also in the lungs infarction.

In addition to the listed syndromes, TEL symptoms may be the other. For example, it was revealed that in the chronic form of TAL flow, several weeks are developing diseases associated with oppression of immunity. They can be expressed in a rash, pleution and some other signs of pulmonary artery thromboembolism.

Diagnostics

Tale's diagnosis is the most difficult and disposal moment. The symptoms of the pulmonary embolism are not too clear, and they can often be attributed to other diseases. At the same time, the lateralization of the diagnosis most often leads to the death of the patient, so in 2008 it was decided that the initial estimation of the risk of developing TELE will be the optimal yield. Such an approach provides closer attention to people with a high risk of illness. Until 2008, a massive tel and thromboembolism of small lung artery branches were distinguished.

For people with high risk of emblem of lungs, the following diagnostic procedures are held:

CT-angiopulmonography

Thanks to the CT, the doctor can visualize the picture of the state of the pulmonary artery. This is the most effective method of diagnosing a pulmonary artery thromboembolism, which today can be used. Unfortunately, in some cases, the use of tomography is impossible.

Angiopulmonography

The method based on the radiographic visualization of the pulmonary artery by introducing a contrast agent into it.

Ehoche

It is carried out as an alternative method, but it is impossible to put an accurate diagnosis based on this indicator only, so confirmation is also necessary using computed tomography or other methods.

Ventilation and Perfusion Scyntigraphy

The method is used, as a rule, after ECCG to wording the diagnosis of TEL in cases where the use of tomography is impossible. This method is applicable as a final hardware diagnostic method only in people with high risk of development of pathology.

With a moderate and low risk level, another thrombus detection algorithm is used, which begins with blood test for the presence of a D-dimer. If the indicator is overestimated, the patient is sent to the examination, with which you can confirm or disprove the diagnosis. In addition to these hardware methods for determining TEL, venous compression ultrasonography, ECG or contrasting phlebography can be used.

Treatment

The timely diagnosis of pulmonary artery thromboembolism significantly increases the chances of a prosperous outcome, because mortality decreases to about 1-3%. To date, the pulmonary embolism is still a problem for treatment, it is associated with the possibility of practically lightning patient's death.

Anticoagulant therapy can be assigned to the patient at the stage of diagnosing the disease to the final results of the inspection. The main purpose of this method is to reduce mortality among people with a high risk of disease, and also if there is a recurrent TEL. Anticoagulant therapy is suitable as TEL prevention.

The treatment of thromboembolism of the pulmonary artery by anticoagulants on average lasts about 3 months, although according to the testimony, the period of therapy can be increased. Thrombolytic therapy is based on the use of drugs, accurate dosage and reception of which the doctor calculates, based on the weight of the patient and the current state. Here is a list of the most popular drugs that the history of TAL disease requires for use:

Unfractionated heparin;
EnoCaparin;
Rivroxabah;
Warfarin.

During the treatment of symptoms of thromboembolism of the pulmonary artery, the patient also takes special drugs. Unlike anticoagulants, which only slow down growth and are often accepted as a prophylactic agent, thrombolysis involves dissolving an embol. This method is considered more effective, however, recommendations on the treatment of TEL make it use only in life-threatening cases. Thrombolytic therapy is combined with the reception of anticoagulants. Such a treatment method is not completely safe, since the dissolution of thromboms often leads to bleeding, among which is the greatest harm caused intracranial.

The most rapid solution to the problem is surgical thrombecomy. The operation will help even in cases if the pulmonary artery embolism is rapidly developing, but the patient will be delivered in a timely manner into the cardiac surgery department. This method involves cutting both pulmonary arteries and tomb seizure.
Another possibility to solve the problem of repeated episodes of pulmonary embolism are venous filters. The main technique is used in contraindications to anticoagulants. The essence of filters is that they do not give a broken embol, together with the bloodstream to reach the pulmonary artery. Filters can put both for several days and for a longer period. However, a similar treatment of TEL is usually associated with a multitude of risks.
It is worth noting the peculiarities of treatment in specific patients. Embolism of the lungs can occur in pregnant women, but they are difficult to determine the diagnosis. With a moderate or low risk, the blood test on the D-dimer is practically useless, since during this period its indicators will differ in any case from normal. CRT and other diagnostic procedures are associated with the exposure of the fetus, which often negatively affects its development. Treatment is carried out by anticoagulants, since most of them are absolutely safe both during pregnancy and during lactation. There is no possibility to use only vitamin K antagonists (warfarin). Special attention in the treatment of pulmonary embolism, the doctor draws to carry out birth.
If the cause of the blockage was not a thrombus, but another clutch, the pulmonary artery embolism will be treated, based on the reasons for its formation. The foreign body can be extracted only by surgical path. However, if the clot, which was formed after the injury, consists only of fat, treatment does not require surgical intervention, since fat is distributed over time independently, it is only necessary to maintain a patient in the normal state.
Removal of air bubbles from blood flow is carried out by introducing a catheter. Infectious emble is cleaned by intensive treatment of the disease, which caused. Unfortunately, the most common cause of the development of an infectious embolism is the intravenous administration of drugs by an infected catheter. In this case, TEL complications are not simply manifested in the form of a clutching bunch, but also in sepsis.

Pulmonary artery thromboembolization (Tel) - a state-threatening condition in which the blockage of the pulmonary artery or its branches occurs embol - a piece of thrombus, which, as a rule, is formed in the pelvis veins or lower limbs.

Some facts about pulmonary artery thromboembolism:

Tel is not an independent disease - it is a complication of veins thrombosis (most often the lower limb, but in general, the fragment of the thrombus can fall into the pulmonary artery from any vein).
Tel takes the third place among all causes of death (inferior only to stroke and coronary heart disease).
On the territory of the United States, about 650,000 cases of pulmonary artery thromboembolism and 350,000 deaths associated with it are registered.
This pathology takes 1-2 place among all the causes of death in the elderly people.
The prevalence of pulmonary artery thromboembolism is 1 case per 1000 people per year.
70% of patients who died from Tel was diagnosed on time.
About 32% of patients with pulmonary artery thromboembolism die.
10% of patients die in the first hour after the development of this state.
With timely treatment, mortality from the pulmonary artery thromboembolism is much reduced - up to 8%.

Features of the structure of the circulatory system

There are two circle of blood circulation in the human body - big and small:

Big circle circulation Starts with the largest artery in the body - aortic. It carries arterial, saturated with oxygen, blood from the left ventricle of the heart to the organs. All over the aorta gives branches, and in the lower part is divided into two iliac artery, the blood supply to the pelvis and legs. Blood, poor oxygen and carbonated gas (venous blood), is collected from organs into venous vessels, which, gradually connecting, form an upper (collects blood from the top of the body) and the bottom (collects blood from the bottom of the body) hollow veins. They fall into the right atrium.

Small circle circulationbegins from the right ventricle, which comes in blood from the right atrium. The pulmonary artery leaves it - it carries the venous blood into the lungs. In the pulmonary alveoli, venous blood gives carbon dioxide, is saturated with oxygen and turns into arterial. It returns to the left atrium on the four lung veins falling into it. Then, from the atrium, the blood enters the left ventricle and in a large circle of blood circulation.
Normally, microtromb is constantly being formed in the veins, but they quickly destroy. There is a fragile dynamic equilibrium. With its violation, the trombo begins to grow on the venous wall. Over time, it becomes more loose, movable. His fragment is broken and begins to migrate with blood flow.
When the pulmonary artery thromboembolism, the thrombus fragment first reaches at the bottom of the vein of the right atrium, then gets out of it into the right ventricle, and from there to the pulmonary artery. Depending on the diameter, the embol clogs either the artery itself, or one of its branches (larger or small).

Causes of pulmonary artery thromboembolism

There are many causes of lung artery thromboembolism, but they all lead to one of the three violations (or to all at once):

blood stagnation in veins - the slower it flows, the higher the likelihood of blood cloth;
raising blood clotting;
inflammation of the venous wall - It also contributes to the formation of thromboms.

A single cause that is from 100% probability led to a pulmonal artery thromboembolism does not exist.

But there are many factors, each of which increases the likelihood of this condition:

Violation	The reasons
Blood stagnation in veins
Long stay in immobilized state - At the same time, the work of the cardiovascular system is disturbed, venous stagnation occurs, the risk of blood cloves and TEL is rising.
Raising blood clotting
Increased blood viscosityAs a result, the blood flow is disturbed and the risk of thrombus formation increases.
Vascular wall damage

What happens in the body during pulmonary arteries thromboembolism?

Due to the occurrence of the obstacle to the blood current increases the pressure in the pulmonary artery. Sometimes it may increase very much - as a result, the load on the right ventricle of the heart sharply increases, develops acute heart failure. It can lead to the death of the patient.

The right ventricle is expanding, and in the left there is an insufficient amount of blood. Because of this, blood pressure drops. High probability of heavy complications. The larger vessel is blocked by the emblem, the stronger these violations are expressed.

With TEL, blood flow into the lungs is disturbed, so the whole body begins to test oxygen starvation. The frequency and depth of breathing increases reflectically, there is a narrowing of the lumen of the bronchi.

Symptoms of lung artery thromboembolism

Doctors are often called pulmonary artery thromboembolism "Great Maskigrovier". There are no symptoms that would definitely indicated this condition. All the manifestations of TEL, which can be found during the inspection of the patient, are often found with other diseases. Not always the severity of symptoms corresponds to the severity of the defeat. For example, when blocking a large branch of the pulmonary artery of the patient, only a small shortness of breath may be disturbed, and when an embol is hit in a small vessel - severe pain in the chest.

The main symptoms of Tala:

pain in the chest, which are enhanced during a deep breath;
cough, during which a sputter with blood can move (if hemorrhage in light);
reduction of blood pressure (in severe cases - below 90 and 40 mm. RT. Art.);
frequent (100 shots per minute) weak pulse;
cold sticky sweat;
pallor, gray skin shade;
increase body temperature up to 38 ° C;
loss of consciousness;
skin sinusiness.

In light cases, symptoms are absent at all, or there is a slight increase in temperature, cough, easy shortness of breath.

If the patient with the thromboembolism of the pulmonary artery was not provided for emergency medical care, then death can come.

Tale's symptoms can strongly resemble myocardial infarction, lung inflammation. In some cases, if thromboembolism has not been identified, chronic thromboembolic pulmonary hypertension is developing (increase in pressure in the pulmonary artery). It manifests itself in the form of shortness of breath during exercise, weakness, fast fatigue.

Possible complications of Tala:

heart stop and sudden death;
infarction of the lung with the subsequent development of the inflammatory process (pneumonia);
pleurisy (inflammation of the pleura - the films from the connective tissue, which covers the lungs and lifts the chest from the inside);
recurrent - thromboembolism may occur again, and at the same time the risk of the patient's death is also high.

How to determine the likelihood of lung artery thromboembolism before survey?

Thromboembolism usually does not have a clear visible cause. Symptoms that take place at TEL can occur with many other diseases. Therefore, the patients are far from always in time establish the diagnosis and begin treatment.

At the moment, special scales have been developed to evaluate the likelihood of TEL in the patient.

Geneva scale (revised):

Sign	Point
Asymmetric swelling of legs, pain in feeling in the course of veins.	4 points
Cardiac frequency indicators: 75-94 beats per minute; more than 94 beats per minute.	3 points; 5 points.
Pain in the leg on one side.	3 points
Thrombosis of deep veins and pulmonary artery thromboembolism.	3 points
Blood adherence in sputum.	2 points
The presence of a malignant tumor.	2 points
Murdered during the last month injury and operation.	2 points
Patient age more than 65 years.	1 point

Interpretation of results:

11 points and more - High likelihood of TEL;
4-10 points - average probability;
3 points and less- Low probability.

Canadian scale:

Sign	Point
After evaluating all the symptoms and consideration of different variants of the diagnosis, the doctor concluded that the thromboembolism of the pulmonary artery is most likely.	3 points
The presence of deep veins thrombosis.	3 points
The number of heart abbreviations is more than 100 shots per minute.	1.5 points
Recently transferred surgical intervention or long bed mode.	1.5 points
Thrombosis of deep veins and pulmonary artery thromboembolism.	1.5 points
Blood adherence in sputum.	1 point
The presence of an oncological disease.	1 point

Interpretation of the results on a three-level scheme:

7 points and more - High likelihood of TEL;
2-6 points - average probability;
0-1 points - Low probability.

Interpretation of the result on a two-level system:

4 points and more - high probability;
up to 4 points - Low probability.

Diagnosis of pulmonary thromboembolism

Studies that are used to diagnose lung artery thromboembolism:

Research name	Description
Electrocardiography (ECG)	Electrocardiography is the registration of electrical pulses arising during the heart of the heart, in the form of a curve. During ECG, you can identify the following changes.: heartbearance; signs of overload of the right atrium; signs of overload and oxygen starvation of the right ventricle; impairment of electrical pulses in the wall of the right ventricle; sometimes the atrial fibrillation (flickering arrhythmia) is revealed. Similar changes can be identified with other diseases, for example, with inflammation of the lungs and during a severe attack of bronchial asthma. Sometimes on the electrocardiogram of the patient with a pulmonary artery thromboembolism there are no pathological changes.
Radiography of the chest	Symptoms that can be revealed on radiographs:
Computed tomography (CT)	In suspected of a pulmonary thromboembolism, a spiral KT-angiography is carried out. The patient is introduced intravenously a contrast drug and conduct scanning. With this method, you can accurately determine the location of the thrombus and the affected branch of the pulmonary artery.
Magnetic resonance Tomography (MRI)	The study helps to visualize the branches of the pulmonary artery and discover the thrombus.
Angiopulmonography	X-ray system, during which a solution of a contrast substance is introduced into the pulmonary artery. Angiopulmonography is considered the "gold standard" in the diagnosis of pulmonary artery thromboembolism. In the pictures, the vessels scratched by the contrast are visible, and one of them breaks down sharply - the thrombus is located in this place.
Ultrasonic Heart Study (Echocardiography)	Symptoms that can be identified with ultrasound examination of the heart:
Ultrasound examination of veins	Ultrasonic veins scan helps to identify a vessel that has become a source of thromboembolism. If necessary, you can supplement the ultrasound of dopplerography, which helps assess the intensity of blood flow. If the doctor presses the ultrasonic sensor to the vein, and it does not fall down, then this is a sign that the thrombus is being lured.
Scintigraphy	If the pulmonary thromboembolism is suspected, ventilation and perfusion scintigraphy is carried out. The informativeness of this method is 90%. It is used in cases where the patient has contraindications to conduct computer tomography. Scintigraphy reveals the lung plots in which the air flows, but at the same time the influx of blood is broken.
Determination of D-dimers	The D-dimer is a substance that is formed during the decay of fibrin (protein playing a key role in the process of blood coagulation). The increase in the level of D-dimers in the blood testifies to the recent formation of thrombus. Increasing the level of D-dimers is detected in 90% of patients with TEL. But it is also found under a number of other diseases. Therefore, it is impossible to rely only on the results of this study. If the level of D-dimers in the blood within the normal range, it is often possible to eliminate the thromboembolism of pulmonary arteries.

Treatment

The patient with the thromboembolism of the pulmonary artery should be immediately placed in the ward of intensive therapy (resuscitation compartment). At the time of treatment, it is necessary to observe the compliance with the beddown in order to prevent complications.

Medical treatment of pulmonary artery thromboembolism

A drug	Description	Application and dosage
Preparations that reduce blood clotting
Heparin sodium (sodium heparin)	Heparin is a substance that is formed in the human body and other mammals. It suppresses thrombin enzyme, which plays an important role in the blood coagulation process.	Optionally introduced intravenously 5000 - 10,000 Uzh Heparin. Then - drip 1000-1500 units per hour. The course of treatment is 5-10 days.
Outropean calcium (fraxipart)	Low molecular weight heparin, which is obtained from the intestinal mucosa of pigs. Suppresses blood coagulation process, and also has an anti-inflammatory effect and suppresses immunity.	The course of treatment is 5-10 days.
Eanoxaparin sodium	Low molecular weight heparin.	0.5-0.8 ml is introduced subcutaneously 2 times a day. The course of treatment is 5-10 days.
Warfarin	The drug that suppresses the synthesis in the liver of the proteins required for blood coagulation. It is assigned in parallel with heparin preparations on the 2nd day of treatment.	Form release: Tablets of 2.5 mg (0.0025 g). Dosage: In the first 1-2 days of Warfarin prescribed 10 mg dosage 1 time per day. Then the dose is reduced to 5-7.5 mg 1 time per day. Course treatment - 3-6 months.
Fondaparinux	Synthetic preparation. Suppresses the function of substances that take part in the blood coagulation process. Sometimes used for the treatment of pulmonary artery thromboembolism.
Thrombolytics (preparations that dissolve blood clots)
Streptokinaza	Streptokinase is obtained from β-hemolytic streptococcus groupC.. It activates the plasmin enzyme, which splits the thrombus. Streptocinase acts not only on the surface of the blood closet, but also penetrates inside. The most active in the recently formed thromboms.	Scheme 1. We administered intravenously in the form of a solution in the dosage of 1.5 million IU (international units) within 2 hours. At this time, the introduction of heparin is stopped. Scheme 2. We introduce 250,000 drugs intravenously for 30 minutes. Then - 100 000 IU per hour for 12-24 hours.
Urokinza	The drug, which is obtained from the culture of human kidney cells. Activates the plasmin enzyme that destroys the thrombus. In contrast to streptocinase, allergic reactions are less common.	Scheme 1. Enter intravenously in the form of a solution in a dosage of 3 million IU for 2 hours. At this time, the introduction of heparin is stopped. Scheme 2. Enter intravenously for 10 minutes at the rate of 4400 meters per kilogram of the patient's weight. Then introduced within 12-24 hours at the rate of 4400 IU per kilogram of the body mass of the patient per hour.
Alplaza	The drug that is obtained from human tissues. Activates the plasmin enzyme, which carries out the destruction of the thrombus. Does not have antigenic properties, therefore it does not cause allergic reactions and can be reused. Acts on the surface and inside the thrombus.	Scheme 1. 100 mg of the drug is introduced within 2 hours. Scheme 2. We introduce the drug for 15 minutes at the rate of 0.6 mg per kilogram of the body mass of the patient.

Events that are carried out with a massive thromboembolism of the pulmonary artery

Heart failure. Conduct cardiovascular resuscitation (indirect heart massage, artificial ventilation of lungs, defibrillation).
Hypoxia(reduced content in oxygen body) as a result of respiratory impairment. Conduct hydrocerapy - the patient is inhaled by a gas mixture enriched with oxygen (40% -70%). It is served through a mask or through the catheter introduced into the nose.
Pronounced Breath Violation and Heavy Hypoxia. Conduct artificial ventilation of the lungs.
Hypotension (reduction in blood pressure). The patient is injected intravenously through a dropper various saline solutions. Preparations are used that cause narrowing of the lumen of vessels and an increase in blood pressure: dopamine, dobutamine, adrenaline.

Surgical treatment of pulmonary artery thromboembolism

Indications for surgical treatment with TEL:

massive thromboembolism;
deterioration of the patient's condition, despite the conservative treatment;
thromboembolism of the lung artery or its large branches;
a sharp limitation of blood flow to an easy, accompanied by a violation of general blood circulation;
chronic recurrent thromboembolism of the pulmonary artery;
sharp decrease in blood pressure;

Types of operations for lung artery thromboembolism:

Embolectomy - Removal of embol. This surgical intervention is carried out in most cases, with acute tel.
Thrombandadertectomy - removal of the inner wall of the artery with a plaque attached to it. It is used for chronic tel.

The surgery during pulmonary artery thromboembolism is quite complicated. The patient's body is cooled to 28 ° C. The surgeon reveals the patient's chest, cutting it to the sternum along, and gets access to the pulmonary artery. After connecting the system of artificial blood circulation, they open the artery and remove the emblem.

Often, with TEL, as a result of an increase in pressure in the pulmonary artery, the right ventricle and the three-rigid valve are stretched. In this case, the surgeon additionally conducts an operation on the heart - performs the plastic of the trilateral valve.

Cava filter installation

Kava filter - This is a special grid that is installed in the lumen of the lower hollow vein. The broken fragments of thrombus cannot go through it, reach the heart and pulmonary artery. Thus, the Kava filter is a measure of the prevention of TEL.

The Kava filter installation can be carried out when the pulmonary artery thromboembolism has already arisen or in advance. This is an endovascular intervention - it is not necessary to do it on the skin. The doctor makes a puncture on the skin and introduces a special catheter through a jugular vein (on the neck), a subcipient vein (in the region of the clavicle) or a large subcutaneous vein (on the hip).

Usually intervention is performed under light anesthesia, while the patient does not experience pain and unpleasant sensations. The cava filter installation takes about an hour. The surgeon spends on the veins of the catheter and, after it reaches the desired place, introduces the grid into the lumen, which immediately straightens and fixes. After that, the catheter is removed. Suts at the site of the intervention do not impose. The patient is prescribed bedding for 1-2 days.

Prevention

Measures for the prevention of pulmonary artery thrombomembolis depend on the patient's condition:

State / disease	Preventive actions
Patients who were in bed for a long time (under 40 years of age, which have no risk factors for TEL).	As early as possible activation, stacking from bed and walking. Wearing elastic stockings.
Therapeutic patients having one or more risk factors. Patients older than 40 years who have undergone operation that do not have risk factors.	Wearing elastic stockings. Pneumatic massage. On the foot, along its entire length, the cuff is placed in which air with a certain frequency is supplied. As a result, alternate squeezing of legs in different places is carried out. This procedure activates blood circulation and improves Lymph outflow from the lower extremities. Application of calcium oarparin or sodium enocaparin in preventive purposes.
Patients older than 40 years who have undergone operation and having one or more risk factors.	Heparin, calcium nipper or sodium enochaparin in preventive purposes. Pneumatic massage legs. Wearing elastic stockings.
Fracture of femur	Pneumatic massage legs.
Operations for women about malignant tumors of the reproductive system organs.	Pneumatic massage legs. Wearing elastic stockings.
Operations on the organs of the urinary system.	Warfarin, or Parcarin Calcium, or EnoCaparine sodium. Pneumatic massage legs.
Heart infarction.	Pneumatic massage legs. Heparin
Operations on the chest organs.	Warfarin, or Parcarin Calcium, or EnoCaparine sodium. Pneumatic massage legs.
Operations on the head and spinal cord.	Pneumatic massage legs. Wearing elastic stockings. Obloparin calcium or sodium enochaparin.
Stroke.	Pneumatic massage legs. Obloparin calcium or sodium enochaparin.

What is the forecast?

24% of patients with pulmonary artery thromboembolies die during the year.
30% of patients who have no pulmonary artery thromboembolism, and timely treatment has not been conducted, die during the year.

With repeated thromboembolism, 45% of patients die.
The main causes of death in the first two weeks after the occurrence of TEL - complications from the cardiovascular system and inflammation of the lungs.

Emless embolism in most cases has an acute course and develops at the moment when large blood clots overlaps a light artery. Trombo begins the movement along the circulatory system, breaking away from the wall of the veins. 30% of patients dies due to pathology, even when providing timely assistance.

Light embolism - what is it?

Pulmonary embolism - High risk of fatal outcome

Light artery thromboembolization refers to pathologies that threaten the life of the patient and requiring urgent medical care. Thromb, depending on the size, can clog the light artery in different areas. If the bunch is not large, then the prognosis for the patient is more favorable. Pathology is not an independent illness, but is a complication of the thrombosis of the foot or pelvis. It ranks 3rd in the world among all the causes of death.

Causes of appearance

The formation of thrombus contributes to many factors

The reason for the blockage of the light artery is a thrombus. It can be formed due to blood stagnation in the legs of the feet, inflammation of venous walls or excessive blood intake. Also significantly increases the risk of thromboms in the body with a long period of staying in immobilized state, when normal blood circulation is broken.

In part of patients with installed stents, venous catheters and veins, the formation of thromboms becomes complications. Doctors for the prevention of this phenomenon are prescribed by patients a number of drugs for thinning blood and lowering its viscosity.

Pathogenesis of light embolia

The cause of embolism - circulating thrombus

When blocking the artery, normal blood flow violates or completely stops. As a result, the pressure in the light artery begins to quickly increase, leading to the overload of the right heart ventricle, which provokes acute heart failure, which can quickly lead to death.

The larger vessel in the light turns out to be blocked, the higher the heart load. Also, the state leads to a violation of the supply of internal organs with oxygen, as a result of which their work deteriorates and changes occur, some of which may be irreversible.

Classification of light embolia

The affected artery determines the arms of the embolism

The disease is divided into three groups depending on the volume of blood flow overlap.

Not massive. Violated the permeability of less than half of the vessels in the lung. Heart work is not broken. Forecast for patient favorable.
Submassive. The overlap also affects less than half of the vessels, the pressure remains within the normal range, but violations begin to be determined in the heart. Forecast - Serious.
Massive. The blood circulation is broken in more than half of the vessels of the lung, and hypotension and clinical shock are observed. Forecast for the patient bad.

The lightning form of the disease is distinguished separately, at which the main light arteries are completely overlapped. Man dies in a few minutes. Save the patient at the same time, even if it is in the hospital, it is impossible.

Signs and symptoms of blockage of pulmonary vessels

Dyspnea and chest pain - a sign of a pulmonary embolism

The symptoms that are available only with light artery thromboembolism are missing; Because of what the disease can be confused with a different violation. The main manifestations of the disease are:

pain in the chest
dyspnea,
cough with bloody sputum,
full blood pressure
raising pulse
strong pallor of skin,
loss of consciousness.

Often the symptoms of pathology is close to signs of myocardial infarction.

Risk factors

Risk factor - obesity

To a large extent, the probability of the appearance of the disease increases in such cases:

long bed
passive lifestyle,
obesity,
smoking,
alcohol abuse
oncological diseases,
hypertonic disease.

In the presence of predisposing factors, health care is required especially careful.

Diagnosis of Light thromboembolia

An important diagnostic value is a snapshot of the lungs.

Several methods are used to diagnose the disease. The patient with suspected pathology is carried out an electrocardiogram, an x-ray of the chest, angiopulmonography, scintigraphy or MRI. Depending on the patient's condition, the doctor may, if necessary, assign it to him and an additional examination to determine the degree of damage to the internal organs suffering from oxygen starvation.

Treatment

Treatment is carried out in a hospital. Patients are prescribed drugs for blood liquefaction and dissolution of thromboms. If there is an indication, the operation is carried out. It refers to severely for a patient and difficult for a doctor. When interfering, the patient's chest is revealed and, after connecting the artificial circulation apparatus, the artery is carried out and the removal of the thrombus. During the entire operation, the patient's body is in the cooled state.

Prediction and prevention

The prevention of thromboembolism of the light artery is reduced to preventing the formation of thromboms in the body. In the presence of a tendency to pathology, regular state control is required.

The prognosis for the patient depends on the form of pathology and the speed of medical care. During the year, 25% of patients die after the transferred violation. With the development of re-blocking artery, mortality reaches 45%.

The pulmonary embolism is a pathological condition, when a part of the blood clot (Embol), who escaped from the primary place of its formation (often legs or hands), moves along the blood vessels and clogs the clearance of the pulmonary artery.

This is a serious problem that can lead to an infarction of a piece of lung tissue, low blood oxygen content, damage to other organs due to oxygen starvation. If the emblem of large sizes or at the same time is blocked by several branches of the pulmonary artery - it can lead to a fatal outcome.

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Causes of appearance

Most often, blood clot is falling into the pulmonary artery system (medical term-thromboembolism of the pulmonary artery) as a result of separation from the wall of the deep veins of the legs. The state is known as deep vein thrombosis (TGV). In most cases, this process is long in nature, not immediately all the thrombus opens and clog the arteries of the lungs. Blocking the vessel is able to lead to the development of a heart attack (eliminating fabrics). The gradual "death of the lungs" leads to a deterioration in the oxygenation (oxygen saturation), respectively, other organs suffer.

Pulmonary embolism, the reasons for which in 9 out of 10 cases is thromboembolism (described above), may arise as a result of the blockage by other substrates that have fallen into the bloodstream, for example:

bone fat droplets with a fracture of the tubular bone;
collagen (part of the connective tissue) or a fragment of the tissue during damage to any organ;
a piece of tumor;
air bubbles.

Signs of blockage of pulmonary vessels

The symptoms of the pulmonary embolism for each particular patient can vary significantly, which largely depends on the number of blood clouded vessels, their caliber and the presence of a patient present to this pulmonary or cardiovascular pathology.

The most frequent signs of the layout of the vessel are:

Intermittent, difficult breathing. The symptom, as a rule, appears suddenly and always worsens with the slightest physical activity.
Chest pain. Sometimes it resembles the "hearty toad" (pain behind the sternum), as with a heart attack, is intensified with a deep breath, cough, when the position of the body changes.
Cough, which is quite often a bloody (in the wet bombing of blood or it is brown).

Embolism of lungs can manifest itself other signs that can be expressed in the following:

swelling and pain in the legs, as a rule, in both, are more often localized in the ion muscles;
sticky leather, cyanosis (sinushnosis) of skin;
fever;
increased sweating;
heart rate impaired (rapid or irregular heartbeat);
dizziness;
cramps.

Risk factors

Some diseases, medical procedures, certain conditions may contribute to the occurrence of pulmonary artery thromboembolism. These include:

sedentary lifestyle;
prolonged bedding;
any operation and some surgical procedures;
overweight;
installed pacemaker or venous catheterization;
pregnancy and childbirth;
the use of contraceptive pills;
family history;
smoking;
some pathological conditions. Quite often, the thromboembolism of the pulmonary artery occurs in patients with an active oncological process (especially, it concerns the pancreatic cancer, ovaries and lungs). Also, the pulmonary embolism associated with tumors may appear in patients receiving chemotherapy or hormone therapy. For example, this situation may occur in a woman with a history of breast cancer, which for preventive uses taking tamoxifen or raloxifene. People suffering from hypertension, as well as inflammatory bowel diseases (for example, ulcerative colitis or Crohn's disease), has an increased risk of developing this pathology.

Diagnosis of pulmonary thromboembolia

The pulmonary embolism is quite difficult to diagnose, it is especially true for patients who are simultaneously present by the pathology of the heart and lungs. To establish an accurate diagnosis, doctors sometimes assign several studies, laboratory tests that allow not only to confirm embolism, but also to find the cause of its occurrence. The following tests are most often applied:

radiography of the chest,
isotopic lung scanning
pulmonary angiography,
spiral computed tomography (CT),
blood test on D-dimer,
ultrasound procedure,
phlebography (X-ray examination of veins),
magnetic resonance tomography (MRI),
blood tests.

Treatment

The treatment of pulmonary embolism puts the main goal to prevent the further increase in the thrombus and the emergence of new ones, which is important in the prevention of serious complications. For this, drugs are used or surgical procedures:

- Preparations that dilute blood. A group of medicines that prevents the formation of new clots and helps the body dissolve already formed. Heparin is one of the most commonly used anticoagulants, which is used both intravenously and subcutaneously. It begins to act a lightning room after entering the body, unlike oral anticoagulants, such as, for example, warfarin. The recently emerged class of drugs of this group is new oral anticoagulants: (Rivaroksoban), Pradaksa (Dubegaran) and Elikvis (Apiksaban) - a real alternative to warfarine. These drugs act quickly and have less "unforeseen" interactions with other drugs. As a rule, there is no need to apply them to duplicate with heparin. Nevertheless, all anticoagulants have a side effect - serious bleeding is possible.
Thrombolytics - Solvents of blood clots. Usually, when forming a thrombus in the body, mechanisms are launched to dissolve. Thrombolytics after the introduction of them in Vienna also begin to dissolve the formed thrombus. Since these drugs are able to cause sudden and serious bleeding, they are usually used in sick-threatening patient situations associated with pulmonary arterial thrombosis.
Removing thrombus. In the event that it is very large (the thrombus in lung threatens the life of the patient), the doctor can offer it to remove it with a flexible thin catheter, which is introduced into the blood vessels.
Venous filter. With the help of endovascular procedure, special filters are installed in the lower hollow vein, which prevent the movement of blood clots from the lower extremities into the lungs. The venous filter is established by those patients who are contraindicated to the use of anticoagulants, or in situations where their action is not effective enough.

Prevention

The thromboembolism of the pulmonary artery can be warned before the development. The activities begin with the prevention of the thrombosis of the deep veins of the lower extremities (TGV). If a person has an increased risk of TGV - it is necessary to take all measures to prevent this condition. If a person has never had a deep vein thrombosis, but there are the above-described risk factors of the lung embolism, then the following should be taken on:

If the anamne was already incidents with a TGV or a pulmonary embolism, to prevent further formation of blood clots, the following recommendations should be followed:

to regularly visit your attending physician for preventive inspections;
do not forget to take medicines that the doctor appointed;
use to prevent further aggravation of the chronic insufficiency of the lower limbs if doctors advise;
to immediately consult a doctor if there are any signs of deep veins thrombosis or pulmonary embolism.

The emblem of the pulmonary artery is most often due to the separation of the part of the thrombus formed in the legs, and its migration into the pulmonary artery system, which leads to blocking the blood flow of a certain piece of lung. A condition that often ends with a fatal outcome. Treatment, as a rule, depends on the severity of the situation, from the symptoms that appeared. Some patients require immediate aid assistance, while others can be treated outpatient. If you suspected that you have a thromboembolism of deep veins, there are symptoms of pulmonary artery thromboembolism - you must immediately consult a doctor!