Thromboembolia pulmonary artery (TEL) - a sudden stop of blood flow in the pulmonary artery branch due to the blockage of its blood clots (thrombus), entailing the cessation of blood flow to the blood supply of lung tissue. It should be clarified that the thrombus mentioned is a fragment of another thrombus formed and located outside the pulmonary artery. The condition in which the proliferation of blood clots on the organism vessels is called thromboembolism.

Tel is one of the most common and terrible complications of many diseases of postoperative and postpartum periods, adversely affecting their current and outcome. A sudden death of 1/3 of cases is explained by the thromboembolism of the pulmonary artery. About 20% of patients with TEL die, more than half of them in the first 2 hours after the occurrence of embolism.

Causes leading to thromboembolism, and what happens?

For the possibility of its existence, the human body needs oxygen, and the flow of oxygen into the body should be carried out continuously. To do this, gas exchange is constantly in the lungs. With the branches of the pulmonary artery in the smallest formation of pulmonary fabric, called the venous blood spent by the body, is delivered. Here this blood is freed from carbon dioxidewhich is removed from the body during exhalation, and is saturated with oxygen of atmospheric air entering into the lungs when inhaling. As a result of gas exchange, blood becomes arterial, saturated with oxygen and is delivered to all organs and tissues of the body.

As a result of the thromboembolism, the plot of affected lung is practically no blood supply, it turns off from the gas exchange, respectively, through the lungs there is a smaller amount of blood, the passing blood is worse than oxygen, and this may lead to the organs that will make an insufficient amount of blood saturated with oxygen, in the worst case A sharp drop of blood pressure and shock. All this may be accompanied by aelectsis (decay of a piece of lung tissue) in the lungs.

Most often, the cause of TEL is thrombus arising in deep veins and most often in the deep veins of the lower extremities.

For the formation of thrombus it is necessary to have three conditions:

• damage to the vessel wall;
• slowing down blood current in this place;
• increase blood clotting.

The wall of the vein can be damaged in inflammatory diseases, intravenous injections, injuries.

The conditions for slowing blood flow occur due to heart failure, a long forced position: bedding, especially in patients with diseases of the lungs, myocardial infarction, operations over the thigh fracture. And most often in patients with damage spinal cord. Occasionally, the thromboembolism of pulmonary arteries may also occur in healthy people who are long in a forced position. For example, when flying by plane.

The reasons for increasing blood clotting are some hereditary violations In the coagulating blood system, the reception of contraceptives, AIDS.

Also, the risk factors, in addition to the above, are: an elderly and old age; surgical operations; malignant neoplasms; varicose veins of the legs; pregnancy and childbirth; injuries; obesity; Some diseases (crown disease, eritremia, nephrotic syndrome, paroxysmal night hemoglobinuria).

Symptoms of Tala

The manifestations of TELE depend on the massiveness of the process, the state of the cardiovascular system and the lungs.

Depending on the volume of damage to the vessels of the lungs, TEL can be:

• massive: more than 50% of the lung vessels;
• submassive: from 30 to 50% of the lung vessels;
• non-missive: less than 30% of the lung vessels.

The most frequent manifestation of pulmonary artery thromboembolism is shortness of breath and rapid breathing. Dyspnea arises suddenly. The patient is better feeling in the lying position. It has a different character. The patient may have severe pain or discomfort in the chest. Occasionally hemochkali occurs. Cyanosis may appear pallor or blue painting of the nose, lips, ears right up to the cast-iron shade.

Also, a rapid heartbeat, cough, cold sweat, drowsiness, inhibition, dizziness, short-term or long-term doctor can do?

The doctor will hold the necessary inspection, research, including ECG, radiography chest, ventilation and perfusion scintigraphy of the lungs (the study of the vessels of the lungs with the help), and on this basis will determine the volume of lesion. Depending on the volume of the lesion, treatment will prescribe. In any case, when confirming the diagnosis, the patient must be under the supervision of a hospital doctor.

One of the main causes of sudden death is a sharp impaired blood flow in the lungs. The pulmonary artery thromboembolis refers to states that in the overwhelming majority lead to an unexpected cessation of the body's life. Thrombosis of easy to cure extremely difficult, so it is optimally prevented by a deadly occasion.

Sudden occlusion of arterial stems in the lungs

The lungs perform an important task of saturation of venous blood oxygen: the main trunk vessel, which brings blood into the small branches of the arterial network of the lungs, departs from the right hearts of the heart. The pulmonary artery thrombosis causes the termination of the normal operation of a small circle of blood circulation, the outcome of which will be the absence of oxygen blood in the left cardiac chambers and rapidly increasing symptoms of acute heart failure.

Look at how the thrombus is formed and leads to thromboembolism of the lungs

Chances for saving the life above, if the lung and led to the blockage of the arterial sprig of a small caliber. It is much worse if the cardiac occlusion with a sudden death syndrome has been cut off and provoked. The main provocation factor is any surgical intervention, so it is necessary to strictly follow the preoperative appointments of the doctor.

Age of a great prognostic value (in people up to 40 years old, pulmonary thromboembolism is extremely rare, but for older people, the risk is very high - up to 75% of all deaths in the pulmonary artery occur in elderly patients).

An unpleasant feature of the disease is the incommodation of the diagnosis - at 50-70% of all cases of sudden death, the presence of pulmonary thromboembolism is detected only on the pathoanatomic autopsy.

Acute blockage of the pulmonary trunk: what is the reason

The appearance in light blood clots or fat Embolov is due to the blood current: most often the primary focus of the formation of thrombotic masses is the pathology of the heart or the venous leg system. The main reasons for the occlusal lesion of the main vessels of the pulmonary system:

• any kind of surgical interventions;
• severe lung diseases;
• congenital and acquired heart defects with different types of valve apparatus defects;
• anomalies of the structure of pulmonary vessels;
• acute chronic ischemia hearts;
• inflammatory pathology inside cardiac chambers (endocarditis);
• complicated variants of varicose disease (thrombophlebitis veins);
• bone injuries;
• entering the fetus and childbirth.

Of great importance for the occurrence of a dangerous situation, when it was formed and broke, they have predisposing factors:

• genetically predetermined blood coagulation disorders;
• blood diseases that contribute to the deterioration of fluidity;
• metabolic syndrome with obesity and endocrine disorders;
• age older than 40 years;
• malignant neoplasms;
• long immobility against the background of injury;
• any version of hormone therapy with constant and long-term reception of drugs;
• tobacco

Light artery thrombosis occurs when a blood clots from the venous system appears (in 90% of cases, the lungs in the lungs appear from the vascular network of the lower vein), so any form of atherosclerotic disease does not affect the risk of blockage of the main trunk, departing from the right ventricle.

The mechanism of bunch of blood from the venous system in the lungs

Types of life-threatening occlusion: classification

Venous bunch can disrupt blood circulation anywhere in a small circle of blood circulation. Depending on the location, the following forms are distinguished:

• the blockage of the main arterial trunk, in which a sudden and imminent death occurs in most cases (60-75%);
• occlusion of large branches that provide blood flow in pulmonary dollars (the probability of death is 6-10%);
• thrombembolia small branches of the pulmonary artery (minimum risk of sad outcome).

The volume of the lesion is prognostically, which is divided into 3 options:

1. Massive (almost complete cessation of blood flow);
2. Submassive (problems with blood circulation and gas exchange arise in 45% and more of the entire vascular system of the lung tissue);
3. Partial thromboembolism of the branches of the pulmonary artery (shutdown from gas exchange less than 45% of the vascular bed).

Depending on the severity of symptoms, 4 types of pathological blockage are distinguished:

1. Lightning (all symptoms and signs of pulmonary artery thromboembolism unfold in 10 minutes);
2. Acute (manifestations of occlusion rapidly grow up, limiting the lifetime of a patient man with the first days since the first symptoms);
3. Undercaping (slowly progressive cardiovascular violations);
4. Chronic (typical signs of heart failure, in which the risk of sudden cessation of the pump function is minimal).

Lightning thromboembolism is a massive occlusion of the pulmonary artery, death at which occurs within 10-15 minutes.

It is very difficult to assume how many people can live in the acute form of the disease, when in 24 hours it is necessary to fulfill all the necessary emergency medical and diagnostic procedures and prevent death.

The best percentage of survival with subacute and chronic species, when most patients undergoing treatment in the hospital can avoid sad outcome.

Symptoms of dangerous occlusion: what are the manifestations

The thromboembolism of the pulmonary artery, the symptoms of which are most often associated with venous diseases of the lower extremities, can occur in the form of 3 clinical options:

1. The initial presence of complicated varicose disease in the field of venous leg network;
2. The first manifestations of thrombophlebitis or phlebotromability occurs during an acute circulation of blood flow in the lungs;
3. There are no external changes and symptoms indicating venous pathology in the legs.

A large number of diverse symptoms of pulmonary artery thromboembolism are divided into 5 main symptoms:

1. Cerebral;
2. Cardiac;
3. Pulmonary;
4. Abdominal;
5. Renal.

The situation is most dangerous when pulmonary and completely blocked the clearance of the vessel, providing vital organs of the human body. In this case, the probability of survival is minimal, even with the timely provision of medical care in hospital conditions.

Symptoms of brain violations

The main manifestations of cerebral disorders with occlusing lesions of the main trunk, departing from the right ventricle, are the following symptoms:

• pronounced headache;
• dizziness with fainting and loss of consciousness;
• convulsive syndrome;
• partial paresis or paralysis on one side of the body.

Often there are psycho-emotional problems in the form of fear of death, panic, restless behavior with inadequate actions.

Cardial symptomatics

The sudden and dangerous symptoms of the thromboembolism of the pulmonary artery include the following signs of the impairment of the heart:

• strong stolen pain;
• frequent heartbeat;
• sharp drop in blood pressure;
• swollen cervical veins;
• pre-perspective condition.

Often expressed pain syndrome in the left side of the breast is due to the main cause of pulmonary thromboembolism.

Respiratory violations

Pulmonary disorders during thromboembolic state are manifested by the following symptoms:

• increasing shortness of breath;
• safety of suffocation with the advent of fear and panic;
• strong pain in the chest at the moment of inhalation;
• cough with hemochkump;
• cyanotic changes of skin.

The essence of all the manifestations in the thromboembolism of small branches of the pulmonary artery is a partial infarction of the lung, in which the respiratory function is necessarily disturbed.

With abdominal I. renal syndrome There are violations associated with internal bodies. Typical complaints will be the following manifestations:

• intense pain in the stomach;
• preferred localization of pain in the right hypochondrium;
• violation of the intestinal (paresis) in the form of constipation and termination of gases;
• detection of features typical for peritonitis;
• temporary termination of urination (Anuria).

Regardless of the severity and combination of the symptoms of the thromboembolism of the pulmonary artery, it is necessary to start therapy as soon as possible and quickly and quickly with the use of resuscitation techniques.

Diagnosis formulation: Is it possible to reveal early

Often, the pulmonary thromboembolism occurs after surgery or surgical manipulation, so the doctor will pay attention to the following atypical for the normal postoperative period of manifestation:

• repeated episodes of pneumonia or the lack of effect from the standard treatment of lung inflammation;
• unfinished arising funding states;
• Against the background of cardiac therapy;
• high temperature of obscure origin;
• sudden appearance of the symptoms of the pulmonary heart.

The diagnosis of acute state associated with the blockage of the main trunk, departing from the right ventricle of the heart, includes the following studies:

• general institutional analyzes
• assessment of blood coagulation system (coagulogram);
• electrocardiography;
• panoramic X-ray photograph of the chest;
• duplex echography;
• lung scintigraphy;
• angiography of thoracic vessels;
• phlebography of venous vessels of the lower extremities;
• tomographic study using contrast.

Light artery thromboembolia on x-ray

None of the methods of examination is capable of putting an accurate diagnosis, Therefore, only comprehensive application The technique will help identify signs of pulmonary artery thromboembolism.

Emergency Medical Events

Emergency assistance at the stage of ambulance brigades involves the solution of the following tasks:

1. Preventing death from acute cardiopulmonary failure;
2. Correction of blood flow in a small circulation circle;
3. Preventive measures to prevent repeated episodes of occlusion of pulmonary vessels.

The doctor will use all medication to help eliminate fatal risks, and will try to get to the hospital as quickly as possible. Only in the conditions of the hospital, you can try to save the life of a person with a pulmonary thromboembolia.

The basis of successful therapy - holding in the first hours after the occurrence dangerous symptoms Next treatment methods:

• the introduction of thrombolytic drugs;
• use in the treatment of anticoagulants;
• improving blood circulation in lung vessels;
• support of the respiratory function;
• symptomatic therapy.

Surgical treatment is shown in the following cases:

• blockage of the main pulmonary trunk;
• sharp deterioration in the patient's condition with a fall of blood pressure;
• no effect from drug therapy.

Thrombectomy

Main method operational treatment – . The 2 variants of surgical intervention are used - using the artificial blood circulation apparatus and during the temporary closure of blood flow along the veins of the lower hollow vein. In the first case, the doctor will eliminate the obstacle in the vessel using a special technique. In the second - the specialist during the operation will block the bloodstream at the bottom of the body and will quickly execute the thrombeectomy (the time for the operation is limited to 3 minutes).

Regardless of the selected tactics of therapy, the full guarantee of recovery is impossible to give: up to 80% of all patients with occlusion of the main pulmonary trunk die during or after a surgical operation.

Prevention: how to prevent death

In the case of thromboembolic complications, the optimal option of therapy is the use of non-specific and specific prevention measures at all stages of surveys and treatment. From nonspecific measures the best effect will be using the following recommendations:

• using compression knitwear (stockings, tights) for any medical procedures;
• early activation after any diagnostic and therapeutic manipulations and operations (it is impossible to lie for a long time or to make an forced postoperative period for a long time);
• constant monitoring of a cardiologist with courses of therapy of the pathology of the heart;
• complete smoking;
• timely treatment of complications of varicose disease;
• reducing body weight in obesity;
• correction of endocrine problems;

Specific prevention measures are:

• constant reception of prescribed medicines that reduce the risk of thrombosis;
• use with high risk of thromboembolic complications;
• the use of special physiotherapy techniques (intermittent pneumocompression, muscle electrostimulation).

The basis of successful prevention is neat and strictly implementing the recommendations of the doctor at a preoperative stage: often ignoring elementary methods (refusal of compression knitwear) causes the formation and separation of blood cloth with the development of deadly complications.

Forecast: What are the chances of life

Negative outcomes in the blockage of the pulmonary trunk are due to the lightning form of complications: in this case, the worst forecast for life. With the rest of the pathology, there are chances for survival, especially if the diagnosis is made on time and the treatment is started as quickly as possible. However, even with a favorable outcome of the acute occlusion of lung vessels, unpleasant consequences are formed in the form of pronounced shortness of breath and heart failure.

Complete or partial occlusion of the main artery, departing from the right ventricle, is one of the main reasons for sudden death after any medical interventions. It is better to prevent a sad outcome using a specialist advice at the preparation rate for medical diagnostic procedures.

Tel (or in decoding - pulmonary artery thromboembolism) is accompanied by the formation of a thrombus in the vessels of the lungs. Depending on the affected artery, it stops the blood supply to a certain section of soft tissues. As a result, ischemia of soft tissues is developing.

A person begins to choke, a sufficient amount of oxygen ceases to the body. There is a risk of fatal outcome, so it is important to know the first aid technique.

The pulmonary embolism is the closure of the lumen of the branches of the pulmonary artery by a piece of blood clot, which form a platelet glued with each other. In this case, the main thrombus can be located outside the respiratory system.

As a result of the formation of a bunch, the blood supply to a small piece of soft tissues is terminated. Because of this part of the lungs stops transporting oxygen into blood. A thromboembolism is developing - a condition characterized by choking due to the spread of small blood clots in the lung vessels.

The pathological process often arises during the operation, which increases the risk of fatal outcome by 30%. Without providing medical care, 20% of patients dying within 2 hours after the start of TEL.

Code of the ICD-10

Pulmonary embolism - I26. Infarction, thromboembolism, pulmonary arteries and veins thrombosis are included. Complicating abortions are excluded (O03-O07), ectopic or molar pregnancy (O00-O07, O08.2), pregnancy, childbirth and postpartum period (O88.-).

Pulmonary embolism with reference to the acute pulmonary heart - I26.0, without mentioning - I26.9.

Is the pulmonary thrombophlebitis?

Thrombophlebitis, in contrast to thrombosis, is characterized by inflammation of the wall of the venous vessel, followed by the formation of a thrombus. Theoretically, the disease may affect any veins in the body. At the same time in clinical practice It was revealed that the disease is often striking surface, subcutaneous veins exposed to temperature differences.

In the pulmonary artery flows blood saturated with carbon dioxide. Therefore, when developing severe infection respiratory tract The development of pulmonary thrombophlebitis is possible. Bacteria can provoke inflammation of the walls of the vessels, which can lead to TEL. Such pathology develops in exceptional cases in less than 0.01% of patients.

Most often, the pulmonary thromboembolism develops due to thrombophlebitis in the veins of the lower extremities. A trombus is formed in the legs, parts of which are chipped and fall into the vessels of the lungs.

What happens in the body at TEL?

For energy generation, constant oxidative reactions inside the cells, the main reagent of which is oxygen. In the process of breathing, the air falls into the lungs where Alveola is located.

Small tissue bubbles are enveloped by a network of capillaries in which gas exchange occurs. With the help of pulmonary artery in the alveoli, venous blood is delivered to release carbon dioxide and saturation with oxygen molecules.

When thromboembolization, blood flow in the affected vessel stops, due to which gas exchange does not occur. Entering in light blood ceases to be saturated with oxygen. Cells all over the body cease to generate the energy necessary for the operation of the organs. In hypoxia, the death of cerebral cells and myocardium begins, blood pressure drops, shock develops.

In the absence of treatment, a heart attack and atelectasis occurs (loss of lung shares).

Epidemiology in adults

Tel develops from 500-2000 per year. Pathology arises not only in the process of operation, but also during labor. The mortality of the feminine varies from 1.5% to 3% for 10,000 cases. 2.8-9.2% of women die from complications in the rehabilitation period.

Causes and pathogenesis

The following reasons may provoke the development of TELL:

• thrombosis of the deep veins of the lower extremities, in 90% of cases complicated by thrombophlebitis;
• generalized sepsis;
• cardiovascular pathologies with high risk of thrombosis development: ischemic disease, Mitral Stenosis, Hypertension, Cardiomyopathy, Infectious Endocarditis;
• thrombophilia;
• trombus in the lower vein;
• malignant neoplasms in the pancreas, lungs and stomach;
• hemorrhoids;
• artificial heart valve;
• antiphospholipid syndrome.

Tel begins with damage to the endothelium of the vascular wall. The latter normally produces nitrogen and endothelin oxide, which impede vessel spasms and platelet gluing.

With damage to the endothelial cells, blood clotting increases and sub-elements of blood flow is exposed. The latter throws into the blood substances that stimulate thrombosis. Blood plates activate the transformation of fibrinogen in fibrin, produce thrombin, gluing platelets with each other.

Only part of the thrombus is fixed on the wall of the vessels. 75-80% of blood clots remain free and can break. Spacked platelets on vessels fall into the right ventricle of the heart. On the path of its promotion, the chopped plot of thrombus can collapse into smaller parts.

From the heart of the microtromba fall into a small circle of blood circulation and begin to circulate on the vessels of the lungs, causing the blockage of the branches of the pulmonary artery.

The effects of TELE depend on the size and number of blood clots. Large bunches worsen the blood supply to the entire lobes and the segments of the lung, which leads to hypoxia, respiratory and hemodynamic disorders:

• hyperventilation of the lungs;
• shock;
• tahipne;
• light heart.

In some cases, the metabolism is possible. Smaller thrombles cause pulmonary heart attack.

Risk factors

Increase the risk of developing TELES The following factors:

• prolonged bedding in post-infarction and post-duty state;
• cardiovascular pathology: cleaning arrhythmia, heart failure, arterial hypertension, active phase of rheumatism;
• paralysis of the extremities, fractures or immobility of the body more than 12 weeks;
• surgery for organs abdominal cavity, lower limbs and a small pelvis;
• using a constant catheter in central vein;
• pregnancy, rapid promenade;
• purulent inflammatory diseases;
• long-term reception of drugs: hormonal, diuretics, laxatives, contraceptives for oral administration;
• diabetes;
• systemic lesion of connective tissue: red lupus, vasculitis.

Tala classification

For TEL, there is no uniform classification. To determine the type of pathology, the following criteria are used:

• degree of lesion of pulmonary fabric;
• the rate of development of the pathological process;
• severity of thromboembolism;
• clinical manifestations of TEL;
• the degree of blood flow.

Loop volume: massive, submassive, non-missive

By the level of lesion of the lungs, the pulmonary embolism is divided into 3 types:

1. Massive. In such a situation, the thrombus stop the blood supply to 50% and lighter. The main branch of the pulmonary artery is affected or the embolism of the pulmonary trunk begins. As a result, shock and systemic hypotension develops.
2. Submassive. It is affected by 30% to 50% of the lung vessels: the pathological process captures segments and share of organs. Patients have the lack of right ventricle.
3. Nemissive. Thromboembolism extends to 30% of the volume of the vascular channel of the lower departments of the respiratory system. Tel proceeds asymptomatic. The consequences may be absent.

Clinic and severity

According to the degree of severity, the following forms of Tel are distinguished:

1. Heavy. Pathology is characterized by a violation of the respiratory function and the disorder of hemodynamics. Tachycardia, severe shortness of breath and shock develop rapidly. Due to hypoxia, the skin acquires a blue tint. In some cases, the loss of consciousness is observed. In 40-60% of cases, a sense of anxiety and fear arises, pain behind the sternum appears.
2. Moderate. CSS reaches 100-120 ° C. / min, blood pressure is reduced, tachipne develops. The patient is observed painful syndrome in the pleural cavity, cough, departs a sputum with blood. A person feels fear, periodically loses consciousness.
3. Easy. The pulse reaches 100 UD / min. There is no hyperventilation of the lungs, short-term shortness of breath is developing. In rare cases, a dry cough appears, patients harbor blood.

The degree of violation of the blood supply to the lungs

Classify 3 forms of disorders:

1. Partial. Passes asymptomatic. Thromboms of small size clog the capillaries without harming the main gas exchange. The function of the affected vessels takes on the neighboring branches of the artery.
2. Average. Multiple thromboembolism branches leading to one of the lung segments. Pathology applies to 30% of tissues.
3. Full. It is characterized by the formation of thrombus in the central branch of the pulmonary artery with a stagnation or heavy slowdown. As a result, severe respiratory failure is observed.

Clinical classification

According to the distinctive features of the clinical picture, the following types of Tel are distinguished:

1. Infarction pneumonia: Tel develops in small arteries. The progressive disease is characterized by acute shortness of breath, blood expectoration and tachycardia. Respiratory failure is developing during the transition to vertical position. In place of damage to the organ in the field of chest develops pain syndrome due to the spread of pathology on pleural tissue.
2. Unmotivated shortness of breath: TELEL spreads through small lung vessels. The patient periodically suffers from sudden shortness of breath. The symptoms of the pulmonary heart appear, despite the absence of cardiopulmonary pathologies.
3. Acute lonantic Heart : Large arteries thromboembolism occurs. A sudden shortness of breath appears in the patient, blood pressure decreases. The development of cardiogenic shock and angina pain behind the sternum is observed.

Dynamics

Evalnamed classification of embolism by the flow of the pathological process. The following types of lung artery thrombosis are distinguished:

• lightning dynamics - death occurs within 5-30 minutes;
• acute current Diseases in which the symptoms appear suddenly consistently: stubborn pain, shortness of breath, hypotension, acute pulmonary heart;
• subacute - characterized by cardiac and respiratory failure, symptoms of infarction pneumonia and expectoration of blood clots;
• recurrent pathology: Repeating attacks of shortness of shortness of breath, symptoms of pneumonia, loss of consciousness.

Clinical picture

When developing Tel, shortness of breath immediately develops. With the defeat of the small arteries, the patient lacks the air, he starts panic. When blocking the central branches of large caliber, a pronounced suffocation is observed, accompanied by cyanosis.

In 85% of cases, shortness of breath is quiet, not accompanied by noisy breaths and exhalations. Patients are comfortable in a lying position. Respiratory failure leads to a number of other signs of violations.

Symptoms of brain violations

In a state of acute hypoxia, with damage to the branches of the pulmonary artery of large caliber, a violation of cerebral blood circulation is observed. Brain neurons do not receive the required amount of oxygenWhat provokes the development of the following symptoms:

• violation of consciousness;
• fainting;
• violation of coordination of movements;
• increase body temperature up to + 38 ° C;
• damage in the eyes;
• reduction of cognitive functions;
• dizziness and headache.

Signs in Cardiology

The second in the frequency of occurrence of the symptom of TEL is pain in the chest, which is felt from a few moments to 12 hours Depending on the degree of damage to respiratory.

With the tel of small branches of the pulmonary artery, pain syndrome is practically not felt, the symptoms of the erased. Thrombosis of large vessels leads to long-lasting greasing pain. If pathology applies to Plevra, arise stick pain During cough, movement and deep sighs.

In rare cases, the damage to the artery of a small caliber leads to the occurrence of pain, which is similar to a sign of a heart attack.

In most cases, abdominal syndrome developsArising due to violation of the work of the right ventricle or due to irritation of the diaphragmal nerve. In such a situation, pain is felt in the right hypochondrium. With justifying failure, the appearance of a vomit reflex, the bloating of the abdomen is possible.

Thal also appears tachycardia and decrease in blood pressure.

Respiratory violations

In addition to acute shortness of breath, after 2-3 days after the occurrence of the disease cough develops as a symptom of infarction pneumonia. At the same time, in 30% of cases, hemochkali is observed. Disturbance of gas exchange leads to the development of oxygen starvation of cells, so cyanosis is noted with a physical examination of the patient - the skin planning.

How to determine the likelihood before survey?

On the chipboard It is impossible to determine the beginning of the pulmonary embolism. It is almost impossible to prevent the development of the pathological process during surgery and delivery. To relieve acute conditions, resuscitation measures are carried out, the patient is transferred to the intensive care unit.

Financial urgent help: action algorithm

When suspected the development of pulmonary embolism you must call the paramedic team. After that, you need to help the victim to sit down or take a horizontal position with a raised head. It will be necessary to remove dentures in the patient, freeing the chest from clothes, to ensure the flow of fresh air into the room.

When the patient appears, a panic need to calm it to prevent the increase in breathing and heartbeat during stress. It is impossible to give a sick food and drink. In the development of pain syndrome, you need to give the injured drug painkillers. Such drugs will help further reduce the shortness of breath. Giving neuroleptanalgesia is prohibited by reducing blood pressure.

Pain during breathing or movement talks about the development of infarction pneumonia. This should be reported to doctors upon arrival.

Until the ambulance arrives, you should calculate the pulse and measure the pressure of the patient. The indicators need to be informed by the paramedic. When you stop the heart and respiration, you need to start resuscitation activities: 2 inhale mouth in the mouth, clamping the patient's nose, alternate with 30 presses in the heart area.

For thinning thrombus, it is necessary to start therapy with anticoagulants. In the critical situation, it will be necessary to introduce intravenously 15,000 units of heparin. It is forbidden to introduce the drug in the development of bleeding and hemophilia. During the hypotension, instead of heparin, a dropper with refooliglukin should be put.

Diagnostics

When suspected the development of TEL the main goal of the diagnosis is to find out the exact location of the thrombus. After that, the tasks are: to estimate the degree of lung damage and the severity of the pathological process, determine the impairment of hemodynamics, to establish a source of a pulmonary embolism. The latter is necessary for eliminating the main thrombus, which broke off a small clutch, and the prevention of relapses.

During diagnostics, history is collected, they record the manifested symptoms, instrumental examinations are performed, laboratory tests are prescribed.

Laboratory methods

For the diagnosis of TEL, the following laboratory tests are carried out:

• general and biochemical blood test;
• lipidogram;
• study gas composition blood;
• urine analysis as part of differential diagnostics;
• coagulogram;
• determining the level of D-dimers.

D-dimers are fibrinolysis products. There must be 500 μg of the compound. Increased concentration of the substance indicates a recent thrombosis. During the diagnosis of TEL in 90% of cases, the level of D-dimers is measured as the most sensitive method.

Tool methods

• Electrocardiography (ECG): at TELL develops right-hand deficiency and sinus tachycardiaThese changes can be fixed using a cardiogram. At the same time, some patients have signs of pulmonary embolism on ECG. In 20% of patients with a cardiogram, an acute pulmonary heart can be revealed due to the load on the right ventricle.
• Chest x-ray: A high standing of the diaphragm dome from the development of pathology can be fixed on the picture. X-ray signs - expansion of the right ventricle and the right downward pulmonary artery, an increase in the roots of the lung.

  

  Radiographs of the chest in patients with confirmed TELE left - disc-atelectasis on the background of the presence of fluid in the chest cavity and the expansion of the root of the lung, on the left - the mild heart attack due to TEL

  

  Easy heart attack on x-ray in a patient with confirmed TEL

  

  

• Echocardiography: The procedure allows you to identify the violation of the right ventricle, the displacement of the interventricular partition on the left side. During the diagnosis, hypertension is observed in a small circulation circle. In rare cases, clomes are recorded in the field of heart.
• Spiral computed tomography: During the diagnostics, it is possible to detect the location of the thrombus. The patient is introduced a contrast agent, with which you can get a surround image of the lungs. During the procedure, the patient must delay their breath for a few seconds. The research method is safer to the patient compared with angiography.

  The embolism of the upperband pulmonary artery on the left, revealed with the CT of the chest organs with the contrast, is clearly visualized by the emble in the enlightenment of the artery (marked by arrows and a circle)

  

  Massive Tel, detected in the patient of computed tomography in both pulmonary arteries, hypodense (on the background of contrasted blood) thrombus are visualized in their equity branches)

  

  An example of a natural infarction pneumonia identified in a patient with a tel of small branches of both pulmonary arteries in computed tomography

  

  

• Ultrasound of deep veins of the lower limb: The procedure allows you to determine the presence of thrombus in the legs of the legs that may cause the pulmonary embolism.
• Ventilation and Perfusion Scyntigraphy: In the course of the procedure, it is possible to determine the lights of the lung without blood supply in which air falls. Scintigraphy allows you to set the diagnosis of TEL with an accuracy of 90%.
• Angiography - The most accurate method of TEL diagnostics. Despite the accuracy, the procedure is invasive and not safe to the health of the patient. At a pulmonary embolism, a sharp narrowing of the pulmonary artery with slow removal of a contrast agent occurs.

Treatment: First Medical Support Standards

Treatment is focused on saving the life of the patient and restoring the natural blood supply to the lungs. For treatment patient is transferred to intensive care where it will stay until the thrombus remove. The operation of the intensive therapy is maintained by the operation of respiratory and blood system With the help of IVL.

In the presence of painful syndrome, painkillers are injected with a patient. Anticoagulant treatment is carried out to eliminate thrombosis. In some cases, due to the conduct of drug therapy, the thrombus is destroyed independently, but if this does not occur, the operation is assigned.

Treatment of patients with acute tel. Gilyarov M.Yu.:

Hemodynamic Correction and Hypoxia

When stopping the heart, resuscitation measures are carried out. To prevent hypoxia use oxygen therapy: Feed oxygen through masks or nasal catheters. IVL is used in the damage to the large branches of the artery.

To stabilize the pressure in vessels and warn venous stagnation, saline, adrenaline or dopamine is introduced intravenously. Anticoagulants are introduced into the reduction of blood circulation in a small circle.

Anticoagulant therapy

Anticoagulant therapy helps prevent death. Intensive care unit at high risk of TELE, heparin sodium is administered intravenously. The dosage of the drug affects the mass of the body of the patient, the indicators of thromboplasty time (ARTT). After 6 hours of the dropper, every 3 hours in the patient take blood test to control the indicator of the AFTT.

Heparinotherapy TAL is not prescribed with renal failure, hemophilia. In addition to Heparin on the first day of hospitalization, the patient is prescribed warfarin, which must be taken at least 3 months after discharge. The daily dosage establishes the attending physician depending on the individual characteristics of the patient and the severity of pathology.

Reperfusion therapy

To remove the thrombus and restore natural blood flow, reperfusion therapy is carried out. With a high risk of developing complications of TEL, thrombolysis is used. For tomb dissolution, the following drugs are used:

• streptokinase;
• alplaza;
• urokinase.

When carrying out thrombolytic therapy there is a high risk of bleeding. In 2% of patients there are hemorrhages in the brain, in 13% of cases - strong internal bleeding.

Hospital Surgery

Removal of thrombus is carried out by thrombeectomy. In such a situation, the surgeon performs a cut at the vessel damage site and removes blood clots using tools. After removal, the thrombus cut is sewn. As a result, normal blood circulation is restored.

Despite high efficiency, Surgical intervention is associated with a high risk for the patient's life. Cava filter is used as a safer TELE treatment method.

Cava filter installation

Cava filter is installed with patients with a high probability of developing a relapse of a pulmonary embolism. The testimony for the procedure is also the presence of contraindications for receiving anticoagulants.

The product is mesh filter that catches the sloping parts of the thrombus and prevents them from entering the vessels of the lungs. Cava-film is installed through a small cut in the skin, conducting a product through a femoral or jugular vein. Fix the tool below the renal veins.

Recurient TELA

In 10-30% of cases, patients who have suffered a pulmonary embolusion may face a relapse of the disease. Pathology can repeat many times. High frequency of transferred episodes is associated with blockage of small branches of the pulmonary artery. The reasons for the appearance of relapses are:

• malignant neoplasms;
• cardiovascular pathology;
• deep vein thrombosis, accompanied by the gradual destruction of large thrombus;
• cardiovascular and respiratory diseases;
• conduct operation.

The re-development of pathology does not have pronounced symptomsTherefore, it is practically not amenable to diagnosis. In most cases, the manifested signs are confused with other diseases.

You can deliver an accurate diagnosis only if you know about the previously transferred TAL and keep in mind the risk factors. Therefore, the main method of diagnostics is a detailed history of the patient. After the survey, X-ray, ECG, ultrasound of the lower extremities are carried out.

The recurrent thromboembolism of the pulmonary artery is able to lead to the following consequences:

• hypertension in a small circulation circle;
• perestroika vessels in the lower respiratory system with the formation of a pulmonary heart;
• plugging the central branch of the pulmonary artery.

Forecast of lung thrombosis

Acute pathology can lead to a stop of the heart and breathing. In the absence of resuscitation events, a fatal outcome occurs. If the organism compensatory mechanisms are triggered or arteries of small caliber are affected, the patient does not die. But in the absence of anticoagulant therapy, secondary hemodynamic disorders are developing.

With timely treatment, the forecast is favorable - After removal, the thrombus patient is rapidly restored.

With long hypoxia, there is a risk of brain damage, which leads to an irreversible loss of some vital functions or human abilities.

Primary and secondary prevention

In the primary prevention of TEL, it is necessary to treat varicose veins in time, passing anticoagulant therapy and wear compression stockings with high blood clotting. After the birth of a child or in postoperative period It is necessary to strictly follow medical recommendations. 2 times a year, people with high risk of TEL development should be given blood tests.

As secondary prevention measures, you need to adhere to a healthy lifestyle:

• treat infectious diseases;
• avoid injuries;
• eat right;
• prevent obesity;
• avoid stress;
• do sport;
• drink a lot of liquid;
• to refuse from bad habits.

Tel is a dangerous disease requiring immediate hospitalization. In most cases, develops in women during the child's birth or in the process of surgical operation. To eliminate the thrombus, anticoagulant treatment is carried out, thrombectomy, installation of Kava filter. With timely treatment, the patient fully recovers. Otherwise, hypoxia develops, violating the work of the brain, cardiac and respiratory failure. To reduce the risk of developing Tel, it is necessary to diagnose and treat cardiovascular pathologies in time.

Video "Live Great"

Pulmonary embolism. Live healthy! Fragment of release of 28.11.2016:

Now you know about Tel All: what it is in medicine, what are the causes of how to treat the disease of the lungs - modern principles and approaches to treatment, as well as the consequences of the disease.

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TELE treatment is a challenge. The disease occurs unexpectedly, quickly progresses, as a result of which the doctor has at its disposal a minimum of time to determine the tactics and the method of treating the patient. First, there can be no standard TELE treatment schemes. The choice of the method is determined by the localization of the emblem, the degree of violation of the pulmonary perfusion, the nature and severity of hemodynamic disorders in a large and small circle circle. Secondly, TAL treatment cannot be limited only to the elimination of an embol in the pulmonary artery. The source of embolization should not be overlooked.

Urgent Care

Emergency measures at TEL can be divided into three groups:

1) maintaining the life of the patient in the first minutes of Tala;

2) eliminate deadly reflex reactions;

3) Elimination of embol.

Maintaining life in cases of clinical death of patients is carried out primarily by resuscitation. The priority measures include the struggle against collapse using pressor amines, correction of acid-alkaline state, efficient hydroxygenobarotherapy. At the same time, it is necessary to begin thrombolytic therapy with nutritional preparations of streptokinase (streptodecadis, streptase, Avelizin, ocketaz, etc.).

Embol in the arteries cause reflex reactions, which is why heavy hemodynamic disorders come often and with non-massive tel. To eliminate pain syndrome, 4-5 ml of the 50% solution of the analgin and 2 ml of dropidol or sidercane are introduced intravenously. If necessary, drugs are used. With pronounced pain, the analgesia begins with the introduction of drugs in combination with droperidol or sider. In addition to the anesthetic effect, the sense of death fear is suppressed, the catecholaminemia, the need of myocardial in oxygen and the electrical heart instability is reduced, the rheological properties of blood and microcirculation are improved. In order to reduce arteriolospasm and bronchospasm, eufillin, papaverine, but-shpa, prednisone in ordinary doses are used. Elimination of embol (the basis of pathogenetic treatment) is achieved by thrombolytic therapy, started immediately after the diagnosis of TEL. Relative contraindications for thrombolytic therapy available in many patients are not an obstacle to its application. The high probability of death justifies the risk of treatment.

In the absence of thrombolytic drugs, constant intravenous administration of heparin is shown at a dose of 1000 units per hour. Daily dose will be 24,000 units. With this method of administration, TEL relapses occur significantly less often, re-thrombosis is exceeded.

When clarifying the diagnosis of pulmonary artery thromboembolism, the degree of occlusion of pulmonary blood flow, the localization of the emblem is selected a conservative or surgical treatment method.

Conservative treatment

The conservative method of treating the pulmonary artery thromboembolism is currently the main and includes the following events:

1. Ensuring thrombolysis and stop further thrombosis.

2. Reducing pulmonary arterial hypertension.

3. Compensation of pulmonary and robust failure.

4. Elimination of arterial hypotension and removal of a patient from a collapse.

5. Treatment of infarction of the lung and its complications.

The conservative treatment circuit of the pulmonary artery thromboembolism in the most typical form can be represented as follows:

1. Full of peace of the patient, a supreme position of the patient with a raised head end in the absence of a collapse.

2. With sicks in the chest and strong cough, the introduction of analgesics and spasmolitics.

3. Oxygen inhalations.

4. When collapse, the whole complex is held medical events acute vascular failure.

5. In cardiac weakness, glycosides are prescribed (stanfantine, korglikon).

6. Antihistamines: Dimedrol, Pipolfen, Supratin, etc.

7. Thromombolytic and anticoagulant therapy. The active start of thrombolytic drugs (streptase, velevisan, streptodecase) is the method of metabolism of hemolytic streptococcus - streptocinase, which, activating plasminogen, forms a complex with it, which contributes to the appearance of a plasmin that dissolves fibrin directly in the thrombus. The introduction of thrombolytic drugs is usually produced in one of the peripheral veins of the upper limbs or in connect venu. But with massive and submassive thromboembols, the most optimal is the introduction of them directly into the tomb zone, occlusive pulmonary artery, which is achieved by the sounding of the pulmonary artery and summing up the catheter under the control of the X-ray apparatus to Trombe. The introduction of thrombolytic drugs directly into the pulmonary artery faster creates their optimal concentration in the region of thromboembol. In addition, when probing simultaneously, a fragmentation or tunneling of thromboembols is performed in order to quickly restore pulmonary blood flow. Before the introduction of streptase, the following blood indicators are determined as the initial data: fibrinogen, plasminogen, protuberine, thrombin time, blood coagulation time, the duration of bleeding. Sequence of drug administration:

1. 5000 UZHPARIN and 120 mg of prednisolone are introduced intravenously inkjet.

2. The intravenously drip for 30 minutes is introduced 250,000 units (test dose), diluted in 150 ml of physiological solution, after which the blood indicators listed above are again investigated.

3. In no allergic reactionWhat testifies to the good tolerance of the drug, and the moderate change in the control indicators begins the introduction of the therapeutic dose of streptase at the rate of 75,000-100,000 units / h, heparin 1000 UR / H, nitroglycerin 30 μg / min. Exemplary composition of the solution for infusion:

The solution is injected intravenously with a speed of 20 ml / h.

4. During the introduction of streptase, 120 mg of prednisolone is introduced intravenously. The duration of the introduction of streptase (24-96 hours) is determined individually.

The control of the listed blood indicators is carried out every four hours. In the process of treatment, the fibrinogen decrease is not allowed below 0.5 g / l, the prothrombin index below 35-4-0%, changes in thrombin time above the six-time increase compared to the initial, changes in the coagulation time and the duration of bleeding above the three-time increase compared to the source data . The overall blood test is made daily or by testimony, platelets are determined every 48 hours and within five days after the start of thrombolytic therapy, the overall analysis of urine is daily, ECG - daily, perfusion scintigraphy of the lungs - by testimony. Therapeutic dose of streptase fluctuates within 125,000-3,000,000 units and more.

Treatment of streptowecasis provides for simultaneous administration of therapeutic dose of the drug, which is 300,000 products of the drug. Controls the same indicators of the coagulation system as in the treatment of streptase.

Upon completion of the treatment with thrombolitics, the patient is translated to the treatment of heparin supports at 25,000-45,000 units per day intravenously or subcutaneously for 3-5 days under the control of the coagulation time and the duration of bleeding.

In the last day of the introduction of heparin, indirect anticoagulants (Peltenan, Warfarin) are prescribed, daily dose which is selected in such a way that the prothrombin index is held in the range (40-60%), the international normalized relationship (MHO) - 2.5. The treatment of indirect anticoagulants can, if necessary, continue for a long time (up to three to six months or more).

Absolute contraindications for thrombolytic therapy:

1. Violated consciousness.

2. Intracranial and spinal education, arteriovenous aneurysms.

3. Heavy forms arterial hypertension With phenomena of violation of the cerebral circulation.

4. Bleeding of any localization, excluding the hemoptal, due to the lung infarction.

5. Pregnancy.

6. The presence of potential bleeding sources (ulcer of the stomach or intestines, operational interventions in terms of 5 to 7 days, state after aortography).

7. Recently transferred streptococcal infections (acute rheumatism, acute glomerulonephritis, sepsis, protracted endocarditis).

8. Recent brain injury.

9. Preceding hemorrhagic stroke.

10. Known violations of the chopping system.

11. Inexplicable headache or impairment of vision over the past 6 weeks.

12. Card-brain or spinal transactions over the past two months.

13. Acute pancreatitis.

14. Active tuberculosis.

15. Suspicion of the aortic aelastic aneurysm.

16. Acute infectious diseases at the time of receipt.

Relative contraindications for thrombolytic therapy:

1. The exacerbation of the ulceneous disease of the stomach and the 12th pans.

2. Ischemic or embolochetic strokes in history.

3. Reception indirect anticoagulantov At the time of arrival.

4. Serious injuries or surgical interventions of more than two weeks ago, but not more than two months;

5. Chronic uncontrollable arterial hypertension (diastolic hell of more than 100 mm Hg. Art.).

6. Heavy renal or liver failure.

7. Catheterization of the subclavian or internal jugular vein.

8. Introordial clomes or valve vegetation.

With vital testimony, you should choose between the risk of the disease and the risk of therapy.

The most frequent complications in the use of thrombolytic and anticoagulant drugs are bleeding and allergic reactions. Their prevention is reduced to the careful implementation of the rules for the use of these drugs. If there are signs of bleeding related to the use of thrombolitics, drip intravenously:

• epsilon-aminocapronic acid - 150-200 ml of 50% solution;
• fibrinogen - 1-2 g per 200 ml of saline;
• calcium chloride - 10 ml of 10% solution;
• freshly frozen plasma. Intramuscularly introduce:
• hemophobine - 5-10 ml;
• vikasol - 2-4 ml of 1% solution.

If necessary, the transfusion of fresh blood flows is shown. With an allergic reaction, prednisone, promotional, diphrolol is introduced. The antidote of heparin is Protamin-sulfate, which is introduced in an amount of 5-10 ml of a 10% solution.

Among the preparations of the latest generation, it is necessary to note the plasminogen tissue activator group (alteplosis, activation, retavase), which are activated, binding to fibrin, and contribute to the plasminogen transition to plasmin. When using these drugs, fibrinolysis is increased only in Trombe. Aldeptlaz is administered at a dose of 100 mg according to the scheme: the bolus administration of 10 mg for 1-2 minutes, then for the first hour - 50 mg, in the next two hours - the remaining 40 mg. Retavase has an even more pronounced lithical action, which is used in clinical practice since the late 1990s. The maximum lytic effect when applying it is achieved during the first 30 minutes after the administration (10 dams + 10 units intravenously). The frequency of bleeding using plasminogen tissue activators is significantly less than when the thrombolytic is used.

Conducting conservative treatment is possible only when the patient maintains the possibility of providing relative to sustainable blood circulation for several hours or day (submassive embolism or embolism of small branches). In the embolism of the trunk and large branches of the pulmonary artery, the effectiveness of conservative treatment is only 20-25%. In these cases, the method of choice is surgical treatment - Embolrombectomy from the pulmonary artery.

Surgery

The first successful surgery for thromboembolism of the pulmonary artery was held by the student of F. Trendelenburg M. Kirchner in 1924. Many surgeons made attempts to embroiderebectomy from the pulmonary artery, but the number of patients who died during the operation was significantly larger than her undergoing. In 1959, K. Vossschulte and N. Stiller proposed to perform this operation in the conditions of temporary occlusion of hollow veins with transternal access. The technique provided a wide free access, a quick approach to the heart and eliminating the dangerous dilatation of the right ventricle. The search for safer emburectomy methods led to the use of general hypothermia (P. Allison et al., 1960), and then artificial circulation (E. Sharp, 1961; D. Cooley et al., 1961). General hypothermia did not get distribution due to a shortage of time, but the use of artificial blood circulation opened new horizons in the treatment of this disease.

In our country, the method of Embolctomy in the conditions of occlusion of hollow veins developed and successfully applied by B.C. Savelyev et al. (1979). The authors believe that pulmonary emburectomy is shown to those who threatens death from acute cardiovascular insufficiency or the development of severe post-grate hypertension of a small circulation of blood circulation.

Currently, the optimal methods of emburectomy with a massive thromboembolism of the pulmonary artery are:

1 Operation in the conditions of temporary occlusion of hollow veins.

2. Embolectomy through the main branch of the pulmonary artery.

3. Operational intervention under artificial blood circulation.

The use of the first technique is shown in the massive embolism of the barrel or both branches of the pulmonary artery. In the case of a preferential one-sided lesion, an emburectomy is more justified through the corresponding branch of the pulmonary artery. The main indication for the operation under artificial blood circulation during a massive pulmonary artery embolusion is the common distal occlusion of the vascular bed of the lungs.

B.C. Savelyev et al. (1979 and 1990) allocate absolute and relative indications for embolrombectomy. They include absolute indications:

• thrombomembolism of the trunk and the main branches of the pulmonary artery;
• thromboembolism of the main branches of the pulmonary artery with a suspended hypotension (at a pressure in the pulmonary artery below 50 mm Hg. Art.)

Relative indications serve the thromboembolism of the main branches of the pulmonary artery in stable hemodynamics and severe hypertension in the pulmonary artery and the right hearts.

Contraindications to Embolctomy they believe:

• severe concomitant diseases with an unfavorable forecast, such as cancer;
• diseases of the cardiovascular system, in which the success of the operation is doubtful, and its risk is not justified.

A retrospective analysis of emblectomy opportunities in patients who died from a massive embolism showed that success can only be calculated in 10-11% of cases and even with successfully performed embolctomy, the possibility of repeated embolism is not excluded. Consequently, the main direction in solving the problem should be prevention. Tel is not a fatal state. Modern methods for the diagnosis of venous thrombosis make it possible to predict the risk of thromboembolism and carry out its prevention.

The method of endovascular rotary desobstructions of the pulmonary artery (ErDLA) proposed by T. Schmitz-Rode, U. Janssens, N.N. Schild et al. (1998) and used in a fairly large number of patients B.Yu. Bobrov (2004). The endovascular rotary disobelace of the main and equity branches of the pulmonary artery is shown in patients with massive thromboembolism, especially when it occludis. Erdell is performed during angioulmography with the help of a special device developed by T. Schmitz-Rode (1998). The principle of the method lies in the mechanical destruction of massive thromboembols in pulmonary arteries. It can be an independent method of treatment in contraindications or ineffectiveness of thrombolytic therapy or to precede thrombolysis, which significantly increases its effectiveness, reduces the time of its implementation, reduces the dosage of thrombolytic drugs and helps to reduce the number of complications. The performance of Erdell is contraindicated in the presence of an embol-rider in the pulmonary trunk due to the risk of occlusion of the main branches of the pulmonary artery due to the migration of fragments, as well as in patients with the non-conclusive and peripheral form of the embolism of the lung artery branches.

Prevention of pulmonary artery thromboembolism

The prevention of pulmonary artery thromboembolization should be carried out in two directions:

1) prevention of the occurrence of peripheral venous thrombosis in the postoperative period;

2) With already formed venous thrombosis, treatment must be carried out to prevent the thrombotic masses and throw them into the pulmonary artery.

To prevent postoperative thrombosis of the lower limbs and the pelvis, two types of preventive measures are used: non-specific and specific prophylaxis. Non-specific prophylaxis includes the fight against hypodynamines in bed and improving the venous blood circulation in the system of the lower hollow vein. Specific prophylaxis of peripheral venous thrombosis involves the use of antiagregants and anticoagulants. Specific prophylaxis is shown by thromachal patients, nonspecific - everyone without exception. In detail, the prevention of venous thrombosis and thromboembolic complications is set forth in the following lecture.

With the already formed venous thrombosis, surgical methods of anti-echolic prophylaxis are used: thrombectomy from or evaluated segment, plugging of the lower vein hollow, the relief of the main veins and the Implantation of the Cava filter. The most effective preventive measure that has been widely used in clinical practice in the last ten years is the implantation of Kava filter. The umbrella filter, proposed by K. Mobin-uddin in 1967, received the greatest distribution in 1967. Different modifications of the latter are offered for all years of filter: "Hourglass", a nitinol filter Simon, "Bird's nest", steel filter Greenfield. Each of the filters has its advantages and disadvantages, but none of them respond completely to all the requirements that determine the need for further searches. The advantage of the "Hourglass" filter, used in clinical practice since 1994, are high eambolving activity and low ability to perforation of the lower vein. Main readings for Cava filter implantation:

• embaspanic (floting) blood clots in the lower hollow vein, iliac and femoral veins, complicated or uncomplicated TEL;
• massive pulmonary thromboembolism;
• repeated TEL, the source of which is not installed.

In many cases, the implantation of Cava filters is more preferable than operational interventions on the veins:

• in patients of elderly and senile age with severe concomitant diseases and high degrees of risk of operation;
• in patients recently undergone operational interference on the abdominal organs, small pelvis and retroperitoneal space;
• with a thrombosis recurrence after thrombectomy from or evaluate and iliac-femur segments;
• in patients with purulent processes in the abdominal cavity and in the peritoneal space;
• with sharply pronounced obesity;
• during pregnancy more than 3 months;
• with old non-conclusive thrombosis of or film and iliac-femur segments complicated by TEL;
• if there are complications from the previously installed Kava filter (weak fixation, migration threat, incorrect size selection).

The most serious complication of the installation of Kava filters is the thrombosis of the lower venon with the development of the chronic venous insufficiency of the lower limbs, which is observed according to different authors, in 10-15% of cases. However, it is a low price for the risk of possible TEL. Cava filter itself may be caused by the flow of the lower hollow vein (NPB) in violation of the coagulation properties of blood. The occurrence of thrombosis in the late after the filter implantation time (after 3 months) may be due to the capture of embolts, and the thrombogenic effect of the filter on the vascular wall and flowing blood. Therefore, at present, in some cases the installation of a temporary kava filter is envisaged. The implantation of a permanent KAVA filter is advisable when identifying disorders of a coagulation system of blood, creating a risk of TEL relapse during the patient's life. In other cases it is possible to install a temporary Cava filter for up to 3 months.

Cava filter implantation does not solve the process of thrombosis and thromboembolic complications, so constant drug prevention should be carried out throughout the patient's life.

The serious consequence of the suffered thrombomembolism of the pulmonary artery, despite the treatment, is chronic occlusion or stenosis of the main barrel or the main branches of the pulmonary artery with the development of severe hypertension of the small circle of blood circulation. This condition is called "chronic post-leumbly pulmonary hypertension"(HPELG). The frequency of development of this state after thromboembolism of the arteries of a large caliber is 17%. The leading symptom of HPELG is shortness of breath, which can even be observed alone. Patients are often bothering dry cough, hemoptysis, heart pain. As a result of the hemodynamic insufficiency of the right hearts, the liver, expansion and ripple of the metering veins, ascites, jaundice are observed. According to the majority of clinicians, the forecast for HPELG is extremely unfavorable. The life expectancy of such patients, as a rule, does not exceed three to four years. With a pronounced clinical picture of post-leech lesions of pulmonary arteries, surgery is shown - intimomputectomy. The outcome of the intervention is determined by the duration of the disease (term of occlusion no more than 3 years), the level of hypertension in a small circle (systolic pressure up to 100 mm Hg. Art.) And the state of the distal pulmonary-arterial bed. Adequate operational intervention can be achieved by the regression of severe HPELG.

The pulmonary artery thromboembolism is one of the most important problems of medical science and practical health care. Currently, all opportunities are available in order to reduce mortality from this disease. It is impossible to put up with the opinion that Tala is something fatal and unexpected. The accumulated experience speaks about the opposite. Modern diagnostic methods make it possible to predict the outcome, and timely and adequate treatment gives successful results.

It is necessary to improve the methods of diagnosis and treatment of phlebombosis as the main source of embolism, increase the level of active prevention and treatment of patients with chronic venous insufficiency, to identify patients with risk factors and in a timely manner.

Selected lectures on angiology. E.P. Kohan, I.K. Zavarina

Table 5. Selection of the NFG dose intravenous administration Depending on the AFTV

Tactics of TEL treatment at low risk of early death:

1) Anticoagulant therapy:

NFG, NMG, Fondaparinux, Rivroxabahn or Dabigatran Etixelit are appointed immediately when the diagnosis is confirmed, and against the background of the high or medium clinical probability of TELE - even before establishing the final diagnosis. In patients with high risk of bleeding and with pronounced kidney dysfunction use NFG. Further the selection of doses is carried out taking into account the ACTV (Table 5). Treatment should be continued until the risk factors for venous thromboembolism remain.

Initial parenteral anticoagulant therapy should be carried out at least 5 days and then replaced by vitamin K antagonists only after reaching the target MNO (2.0-3.0) for at least 2 consecutive days.

When taking anticoagulants - inhibitors of the HA and IIA factors, the use of which do not require monitoring the coagulation system of blood, therapy continues in supporting doses.

2) thrombolytic therapy Not recommended

3) at intermediate risk in hemodynamically stable patients, but having data on PJ dysfunction and / or myocardium damage, is shown thrombolesisBut if the treatment of heparin was started earlier, thrombolysis will not be effective.

Patients with low risk without hypotension and shock have a favorable short-term forecast.

Tactic treatment of TEL with high risk of early death:

(Dosage and multiplicity of drug administration is presented in Table 4):

1) Immediate anticoagulant therapy NFH (Class I a)

2) TLT (class I a)

Indications to TLT:

TELEL complicated by shock and / or resistant arterial hypotension in the absence of absolute contraindications to the use of thrombolytic agents.

Contraindications for TLT:

Absolute contraindications:

Transferred hemorrhagic stroke or a stroke of an unknown character;

Ischemic stroke for the last 6 months;

Disease or tumor CNS;

Recently suffered injury or surgery (for 3 weeks);

Gastrointestinal bleeding during the last month;

Bleeding unclear genes.

Relative contraindications:

Transit ischemic Attack over the past 6 months;

Reception of oral anticoagulants;

Pregnancy or within 1 month after childbirth;

Puncture of vessels with the impossibility of compression;

Injury due to resuscitation activities;

Refractory hypertension (Health Health\u003e 180 mm.rt.)

Progressive liver disease;

Infectious endocarditis;

Ulcerative disease Stomach in the stage of exacerbation.

Thrombolysis is carried out under the conditions of the intensive care unit, while monitoring the main parameters of hemodynamics and respiration.

Generally accepted modes of thrombolytic therapy (TLT):

Streptocinase at a dose of 250,000 I intravenously drip for 30 minutes, then drip at a speed of 100,000 me / h for 12 to 24 hours.

Accelerated regime - 1,500,000 IU in 2 hours;

- Urokinase in a dose of 4400 IU / kg intravenously drip for 10 min, then 4400 IU / kg / hour intravenously drip within 12 - 24 hours.

Accelerated regime 3000000 IU in 2 hours.

- Althelza as a load dose of 15mg in / in Bolusno, more than 0.75 mg / kg for 30 minutes, more than 0.5 mg / kg for 60 minutes.

3) correction of systemic hypotension For prevention of heart failure progression (Class I C)

4) introduction of vasopressors under hypotension (class I c)

5) oxigenotherapy (Class I C)

6) with absolute contraindications to the TLT or in its inefficiency - surgical pulmonary emisball (Class I C)

7) dobutamine and dopamine In patients with low heart emissions against the background of normal blood pressure (class IIA B)

8) catenta Embacitomy or fragment of thromboms in the proximal branches of the pulmonary artery In the presence of absolute contraindications to the TLT or when it is ineffective as an alternative surgical treatment (class IIB c)

Patients with shock or hypotension (probably massive tel) have a high risk of internal hospitality during the first hours.

Emergency Tale's High Risk Tale:

1) Hemodynamic and respiratory support for TEL, complicated by shock or hypotension.

Acute PJ deficiency accompanied by low system emissions are one of the main causes of death with high risk tel. Thus, in the treatment of right-hand deficiency on the background of pulmonary embolism, hemodynamic and respiratory support is also vital.

Correction of hypoxia:

Oxygen therapy through the nasal catheter;

Auxiliary IVL;

IVL in low respiratory mode (6 ml / kg) without a positive PDKV (PEEP).

Correction of hypotension:

Adrenaline hydrochloride 0.5 - 1 mg intravenously with a syringe dispenser in dilution in a 0.9% solution of sodium chloride under the control of blood pressure;

Noraderenalin 0.5 - 1 mg intravenously with a syringe dispenser in dilution in a 0.9% solution of sodium chloride under control of blood pressure;

When stopping the blood circulation, proceed to cardiovascular and cerebral resuscitation.

2) correction of acute worldwide failure:

Dopamine intravenously with a syringe dispenser in dilution of 0.9% solution of sodium chloride at a rate of 1.5 - 5 μg / kg / min under control

Restricting the infusion program up to 500 ml of colloidal solutions

Levosiminean -in / in infusion 0.05-0.2 μg / kg / min, 24 hours:

Restores the interaction between PJ and LA during acute TEL as a result of a combination of pulmonary vasodilation and an increase in the reduction of PJ;

Levosiminean leads to a dose-dependent increase in the minute and shock volume of the heart, a dose-dependent reduction in pressure in the lung capillaries, medium blood pressure and total peripheral vascular resistance.

Sildenafil reduces pressure in LA.

Medicia treatmentinpatient

List of basic medicines:

Heparin

Eanoxaparin sodium

Dabigatran Etexlate

Rivroxaban

Sodium Fondaparinux

Warfarin

Alplaza

Urokinza

Streptokinaza

List of additional drugs:

Dopamine

Epinephrine

Sodium chloride

Dextrose

Medical treatment rendered on an outpatient level:

Permanent maintenance therapy is carried out at the outpatient level of direct action by anticoagulants (Dabigatran Etexlate, Rivroxaban) and indirect anticoagulants (Warfarin) (Table 4).

Medical treatment rendered at the stage of ambulance:

Hemodynamic and respiratory support for TEL, complicated by shock or hypotension (see above)

Anticoagulant therapy (see above)

Other types of treatment:do not be held.

Surgical intervention rendered in stationary conditions:

Surgical Embacitomy from Lait is recommended that as an alternative in the presence of absolute contraindications to the TLT or with the ineffectiveness of the TLT, patients with intracardular thrombus with an open oval window.

Cressing catheter Embolctomy and fragmentation of thromba The proximal pulmonary arteries are recommended as an alternative to surgical treatment in high-risk patients if thrombolysis is absolutely contraindicated or turned out to be ineffective, while using a cardio-pulmonal shunt.