大面积肺栓塞伴心肺骤停患者的抢救策略课件

1、 大面积肺栓塞伴心肺骤停患者的抢救策略潘孔寒浙江大学医学院附属邵逸夫医院重症医学科 Impact of Clinical Instability at Presentation病例回顾 患者，女性，33岁，哥斯达黎加公民。 因“发热寒战2天”以“贫血待查：自身免疫性溶血性贫血；感染性发热？ ” 入院。抢救过程2012-06-22 0700 患者出现血压降至50/30mmHg、HR60bpm并进行性下降，迅速出现无脉性电活动(PEA)，立即给予CPR、Epi0704 HR120bpm 、BP100/50mmHg，VT：胺碘酮150mg iv.CPR过程中考虑多脏器栓塞谈话沟通：本科、专科、家属0

2、759 给予阿替普酶rt-PA 5mg 2min 静推一次，其余rt-PA 45mg iv抢救过程0802 患者自主心律恢复， HR132,BP129/81,SaO2100%, 瞳孔7/F、7/F,Epi 0.27g/kg/min0825 瞳孔7/6.5S、7/6.5S0920 DC Epi1000 瞳孔4.5/3.5N、4.5/4.0N1055 清醒病因血栓性血小板减少性紫癜（TTP）：是一种严重的弥散性血栓性微血管病，以微血管病性溶血性贫血、血小板聚集消耗性减少，以及微血栓形成造成器官损害（如肾脏、中枢神经系统等）为特征。 VTE流行病学欧洲资料症状性VTE发生人数每年超过150万 VTE

3、相关死亡人数每年约543,500 突发致死性PTE 435,000 症状性DVT为684,000VTE Impact Assessment Group in Europe (VITAE) .Thromb Haemost 2007; 98: 756764 VTE流行病学北美资料美国VTE年总发生例数2000,000 症状性VTE每年超过600,000 DVT, n=376,365, PE, n=237,058 VTE相关死亡人数每年约296,370 证实VTE并治疗的患者为21,223 (7%) 突发致死性PTE 101,032 (34%) 可疑PTE为 174,115 (59%)Massive

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

5、pm with signs or symptoms of shockMassive PE流行病学The 30-day mortality rate for massive PE approaches 30%The presence of shock in these patients defines a threefold to sevenfold increase in mortality, with a majority of deaths occurring within 1 h of presentation. 诊断策略表1 VTE的原发危险因素抗凝血酶缺乏先天性异常纤维蛋白原血症血栓

6、调节因子（thrombomodulin）异常高同型半胱氨酸血症抗心脂抗体综合征（anticardiolipin antibodys syndrome）纤溶酶原激活物抑制因子过量凝血酶原20210A基因变异XII因子缺乏V因子Leiden突变（活性蛋白C抵抗）纤溶酶原不良血症蛋白S缺乏蛋白C缺乏表2 VTE的继发危险因素创伤/骨折 髋部骨折（50%75%） 脊髓损伤（50%100%）外科手术后 疝修补术（5%） 腹部大手术（10%30%） 冠状动脉搭桥术（3%9%）脑卒中（30%60%）肾病综合征中心静脉插管慢性静脉功能不全吸烟妊娠/产褥期血液粘滞度增高血小板异常克罗恩病（Crohns dise

7、ase）充血性心力衰竭（12%）急性心肌梗死（5%35%）恶性肿瘤肿瘤静脉内化疗肥胖因各种原因的制动/长期卧床长途航空或乘车旅行口服避孕药真性红细胞增多症巨球蛋白血症植入人工假体高龄PEA vs VFPEA is more commonly associated with MPE versus MI due to near complete obstruction of pulmonary blood flow with an intact electrical conduction system. MI is more commonly associated with VF as the e

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

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