pe symptoms

pe symptoms


 PE


тэла фото EP is an acute cardiovascular disease due to sudden coagulation of the pulmonary artery with thrombus embolus. Most often, the thrombi, closing off the branches of the pulmonary artery, are formed in the right heart or venous vessels of the circulatory system and cause a blatant violation of the blood supply of lung tissue.
The chronic mortality rate has a high mortality rate, the reasons for which lie in a premature diagnosis, as well as inadequate treatment. The mortality of the population by cardiovascular diseases ranks first, and the EP represents 30% of this indicator.
The fatal outcome of PE can occur not only in cardiac conditions, but also in the postoperative period with extensive surgical interventions, during delivery, and significant traumatic injury.
The risk of PE increases with age and there is a dependence of this pathology on gender (the incidence in men is 3 times higher in women).
PE is classified by the location of a thrombus in the pulmonary artery system: massive (thrombus located in the main trunk projection), segmental (thrombotic masses in the lumen of segmental pulmonary arteries) and small emboli branches of the pulmonary arteries.
Causes of the EP
Causes of PE include:
- Acute venous phlebothrombosis of the lower extremities, complicated by thrombophlebitis (90% of cases);
- Ileofemoral thrombosis;
- diseases of S.S.S. accompanied by an increase in thrombus formation in the pulmonary artery system (coronary heart disease, rheumatic heart defects, inflammatory and infectious cardiac diseases, cardiomyopathy of various origins);
a ciliary form of arrhythmia, which results in the formation of a thrombus in the right atrium;
generalized sepsis;
- Blood diseases, accompanied by a violation of the regulation of hemostasis (thrombophilia);
- autoimmune syndrome of antiphospholipids (increased synthesis of antibodies against phospholipids of the endothelium and platelets, accompanied by an overestimated tendency to thrombosis).
- sedentary lifestyle;
- concomitant diseases accompanied by cardiovascular insufficiency;
a combination of a constant intake of diuretics with insufficient liquid consumption;
- take hormonal medicines;
- Varicose disease of the lower extremities, which is accompanied by congestion of the venous blood and is marked by the creation of thrombosis conditions;
- diseases accompanied by a violation of metabolic processes in the body (diabetes mellitus, hyperlipidemia);
- cardiac surgery and invasive intravascular manipulation.
All thromboses are not complicated by thromboembolism, but only flotation thrombins can detach from the vessel wall and enter the pulmonary bloodstream system with blood flow. The most common source of these flotation thrombi is the deep vein of the lower limbs.
Now, there is a genetic theory of the origin of phlebothrombosis, which is the cause of PE. This theory is supported by the development of thrombosis at a young age and confirmed episodes of PE in the patient's parents.
PE symptomsThe degree of clinical manifestations of pulmonary embolism depends on the location of the thrombus and the volume of pulmonary blood flow, disconnected due to blockage.
If the damage does not exceed 25% of the pulmonary arteries, a small PE is developed, in which the function of the right ventricle is preserved and the only clinical symptom is shortness of breath.
If there is a 30 to 50% occlusion of the pulmonary vessels, a submissive PE develops, in which initial manifestations of right ventricular failure appear.
A brilliant clinical picture develops when more than 50% of the pulmonary arteries are disconnected from the bloodstream in the form of consciousness disorders, lowering of blood pressure to development of cardiogenic shock and other symptoms of acute right ventricular failure. .
In a situation where the volume of the affected pulmonary vessels exceeds 75%, a fatal result occurs.
Depending on the rate of increase in clinical symptoms, there are 4 variants of PE flow:
- lightning (death occurs in minutes due to the development of acute respiratory failure due to blockage of the main trunk of the pulmonary artery). The clinical symptoms are acute on the background of complete well-being, cardiotherapy, psycho-emotional excitement, pronounced dyspnea, cyanosis of the skin of the upper body and head, swelling of the veins in the neck);
- Acute (characterized by symptoms of rapidly increasing respiratory and cardiac failure and develops within a few hours) During this period, the patient complains of pronounced dyspnea until attacks of choking, coughing and hemoptysis , a pronounced compressive pain, a compressive nature with irradiation at the upper end testifies to the development of myocardial infarction);
- subacute (clinical manifestations increase over a period of several weeks, during which many small areas of the lung infarct form, period during which there is an increase in temperature to sub-febrile figures, a low cough , chest pain, worse with movement and breathing, the appearance of pneumonia at the bottom of a pulmonary infarction);
- Chronic (characterized by frequent episodes of repeated embolism and the formation of multiple heart attacks associated with pleurisy). The asymptomatic pattern of this variant of PE is often observed and the clinical manifestations of concomitant cardiovascular diseases appear in the foreground.
PE has no specific clinical symptoms that are unique to this condition, but the main difference between PE and other diseases is the appearance of a brilliant clinical image in a context of complete well-being. However, there are signs of PE that are present in each patient, but the degree of their manifestation is different: increased heart rate, chest pain, tachypnea, cough with bloody discharge, fever, wheezing without clear localization, collapse, pallor and cyanosis of the skin.
The classical variant of the development of PE signs consists of five basic syndromes.
Cardiovascular syndromes:- a sharp drop in blood pressure combined with an increase in heart rate, as a manifestation of acute vascular insufficiency;
- a sharp contraction of pain behind the sternum with irradiation in the lower jaw and upper limb in combination with signs of atrial fibrillation, indicating the development of acute coronary insufficiency;
- Tachycardia, a positive pulse of the vein and swelling of the veins of the neck are signs of the development of an acute pulmonary heart;
- Dizziness, tinnitus, altered consciousness, convulsive syndrome, vomiting not associated with food intake and positive meningeal signs indicate the development of acute cerebrovascular insufficiency.
Pleural-pulmonary syndromes:
- the symptomatic complex of acute respiratory insufficiency manifests itself in dyspnea until smothering and pronounced cyanosis of skin;
- the presence of dry wheezing testifies to the development of the bronchospastic syndrome;
- infiltrative changes in the lungs following the emergence of foci of pulmonary infarction manifested as an increase in body temperature, the appearance of a cough with sputum difficult to recover, a pain in the chest on the side of the lesion and the accumulation of fluid in the pleural cavities. With auscultation of the lungs, the presence of local wheezing and pleural friction sound is determined.
проявляется в повышении температуры тела до 38 градусов на протяжении 2-12 суток и обуславливается воспалительными изменениями в легочной ткани. Hyperthermic syndrome is manifested in the increase of body temperature to 38 degrees for 2 to 12 days and is caused by inflammatory changes in the lung tissue.
проявляется в наличии острой боли в правом подреберье, рвоты и отрыжки. The complex of abdominal symptoms is manifested by the presence of acute pain in the right hypochondrium, vomiting and rash. Its development is associated with intestinal paresis and dilation of the hepatic capsule.
проявляется в появлении уртикароподобной сапи на кожных покровах и повышении показателей эозинофилов в крови. The immunological syndrome is manifested by the appearance of an urticaroid rash on the skin and by an increase of eosinophils in the blood.
EP presents many long-term complications in the form of pulmonary infarction, chronic pulmonary hypertension and embolism in the circulatory system.
PE diagnosisAll diagnostic measures of PE are aimed at early detection of thrombus localization in the pulmonary artery system, diagnosis of hemodynamic disorders, and mandatory detection of the source of thrombus formation.
The list of diagnostic manipulations for PE suspicion is quite large, so for diagnostic purposes it is recommended to hospitalize a patient in a specialized vascular department.
Mandatory diagnostic measures for the early detection of PE signs are:
- careful objective examination of the patient with compulsory collection of anamnesis of the disease;
- a detailed analysis of blood and urine (to determine inflammatory changes);
- determination of the blood gas composition;
Holter monitoring of the ECG;
- Coagulogram (to determine the coagulation capacity of the blood);
- Radiation diagnostic methods (radiography of the organs of the shell) make it possible to determine the presence of complications of PE in the form of infarction-pneumonia or presence of effusion in the pleural cavity;
ultrasound examination of the heart to determine the condition of the heart chambers and the presence of thrombi in their lumen;
- Angiopulmonography (makes it possible to accurately determine not only the location, but also the size of the thrombus.) At the location of the supposed location of the thrombus, the filling defect of the cylindrical shape is determined and, with the filling complete light of the vessel, we note the symptom of "amputation of the pulmonary artery." It should be kept in mind that this manipulation has a number of adverse reactions: allergy to contrast introduction, myocardial perforation, various forms of arrhythmia, increased pulmonary arterial pressure and even death due to the development of a acute heart failure;
- ultrasonic examination of the veins of the lower limbs (in addition to establishing the location of the thrombotic occlusion, it is possible to determine the extent and mobility of the thrombus);
- contrast venography (allows to determine the source of thromboembolism);
- computed tomodensitometry (the thrombus is defined as a filling defect in the pulmonary artery lumen)
- perfusion scintigraphy (the degree of saturation of lung tissue with radionuclide particles, administered intravenously before the test, is evaluated). Sites of pulmonary infarction are characterized by the total absence of radionuclide particles;- determination of the level of cardiospecific markers (troponins) in the blood. High indices of troponins indicate lesion of the right ventricle of the heart.
If there is suspicion of PE, the ECG helps a lot to establish the diagnosis. The changes in the electrocardiographic model are already apparent in the early hours of the beginning of PE and are characterized by the following parameters:
• Unidirectional movement of the RS-T segment in thoracic tract III and right;
• Simultaneous inversion of the T wave in the III, AVF and right thoracic pathways;
Combination of the appearance of a Q wave in lead III with a pronounced upward shift of RS-T in leads III, V1, V2;
• Gradual increase in the degree of blockage of the right branch of the beam;
• Signs of acute overload of the right atrium (increase of wave P in lanes II, III, aVF).
The characteristic of PE is a rapid reverse development of ECG changes within 48-72 hours.
The "gold standard" of diagnosis, which reliably establishes the diagnosis of PE, is a combination of radiopacial investigation methods: angiopulmonography and retrograde or neokavagrafiya.
In urgent cardiology, there is a developed algorithm of diagnostic measures to diagnose in a timely manner and to determine individual patient treatment tactics. According to this algorithm, the entire diagnostic process is divided into 3 main steps:
♦ Stage 1 is conducted at the patient's pre-hospital observation period and includes careful collection of historical data with identification of concurrent illnesses, as well as objective patient review, during which attention should be given the appearance of the patient, the percussion and the auscultation of the lungs and the heart. Already at this stage, you can identify important signs of PE (cyanosis of the skin, strengthening tone II to the point of listening to the pulmonary artery).
♦ Step 2 of the pulmonary embolism diagnosis involves non-invasive research methods available in any hospital setting. Electrocardiography is performed to exclude myocardial infarction, which has a similar clinical picture with PE. All patients suspected of PE present a chest x-ray to perform a differential diagnosis with other pulmonary diseases accompanied by acute respiratory failure (exudative pleurisy, polysegmental aselectosis, pneumothorax). In a situation where acute violations in the form of respiratory failure and hemodynamic disorders are identified during the examination, the patient is transferred to the intensive care unit for further examination and treatment.
♦ Step 3 involves the use of more sophisticated investigation methods (scintigraphy, angiopulmonography, Dopplerography of lower limb veins, spiral CT) to clarify thrombus location and possible elimination.
Treatment of pulmonary embolismIn the acute period of PE, a major problem in the treatment of the patient is the preservation of the patient's life and, in the long term, the treatment aims to prevent possible complications and to prevent the recurrence of PE.
The main directions in the treatment of PE are correction of hemodynamic disorders, elimination of thrombotic masses and restoration of pulmonary blood flow, prevention of thromboembolism recurrence.
In a situation where the segmental branches of PE are diagnosed, accompanied by minor haemodynamic disorders, it is sufficient to carry out an anticoagulant treatment. The preparations of the anticoagulant group have the ability to stop the progression of existing thrombosis, and small thromboembolism in the lumen of the segmental arteries are lysed independently.
Under hospital conditions, the use of low molecular weight heparins, free of hemorrhagic complications, is highly bioavailable, does not affect platelet function and is easily administered when used. The daily dose of low molecular weight heparins is divided into two methods, for example, fraxiparin is administered subcutaneously by 1-dose up to 2 times daily. The duration of treatment with heparin is 10 days, after which it is advisable to continue the anticoagulant therapy with the use of indirect anticoagulants in tablet form for 6 months (Warfarin 5 mg once a day).
All patients taking anticoagulant therapy should be selected for laboratory indicators:
- excrement analysis for occult blood;
- indicators of blood coagulability (APTT daily during all heparin therapy). A positive effect of anticoagulant therapy is an increase in APTT compared to the initial index of 2 times;
- an expanded blood test with the determination of the number of platelets (an indication to stop treatment with heparin is a decrease in the number of platelets by more than 50% of the initial value).
The absolute contraindications for the use of direct and indirect action of pulmonary embolism in PE are severe disorders of cerebral circulation, oncological diseases, any form of pulmonary tuberculosis, hepatic and renal failure chronic at the stage of decompensation.
Thrombolytic therapy is another effective area in the treatment of PE, but there must be convincing evidence of its use:
- massive PE, where there is an exclusion of blood circulation of more than 50% of the blood volume;
- serious violations of pulmonary perfusion accompanied by severe pulmonary hypertension (pulmonary arterial pressure greater than 50 mmHg);
contraction of the contractility of the right ventricle;
- Hypoxemia in severe form.The drugs of choice for thrombolytic therapy are: Streptokinase, Urokinase and Alteplase according to the schemes developed. Streptokinase application regimen: For the first 30 minutes, a loading dose of 250,000 units is administered, then the dose is reduced to 100,000 units per hour for 24 hours. Urokinase is administered at a dose of 4400 IU / kg body weight for 24 hours. Alteplase is used in a dose of 100 mg for 2 hours.
Thrombolytic therapy is effective at lysing the thrombus and restoring blood flow, but the use of thrombolytics is dangerous because of the risk of bleeding. The absolute contraindications for the use of thrombolytic agents are: early and post-partum postoperative period, persistent hypertension.
To evaluate the effectiveness of thrombolytic therapy, it is recommended that the patient repeat scintigraphy and angiography, which are screening methods in this situation.
There is a selective thrombolysis technique that involves the insertion of thrombolytic into a pulmonary vein blocked with a catheter, but this manipulation is often accompanied by hemorrhagic complications at the catheter insertion site.
After the end of thrombolysis, anticoagulant treatment with low molecular weight heparins is always performed.
In the absence of the effect of the use of medical methods of treatment, the use of surgical treatment is demonstrated, whose main purpose is to eliminate embolism and restore blood flow in the main trunk of pulmonary artery.
The most optimal method of embolectomy is the execution of the operation by excessive access under the conditions of a venoarterial auxiliary circulation. The embolectomy is performed by the method of thrombus fragmentation using an intravascular catheter located in the lumen of the pulmonary artery.
PE acute care
PE is an acute condition, so the patient must take emergency medical measures to provide primary health care:
Provide complete rest to the patient and immediate implementation of a full range of resuscitation measures, including oxygen therapy and mechanical ventilation (if indicated).
Perform pre-hospital anticoagulant therapy (intravenous administration of unfractionated heparin at a dose of 10,000 units with 20 ml of reopolyglucin).
Intravenous administration of No-shpas in a dose of 1 ml of a 2% solution, a solution of Platyfilin 1 ml to 0.02% and Euphylline to 10 ml of a solution at 2.4%. Before applying Eufillina, it is necessary to clarify a number of points: if the patient has epilepsy, no sign of myocardial infarction, no severe hypotension, no episodes of paroxysmal tachycardia in the anamnesis .
In the case of compressive chest pain, neuroleptanalgesia (intravenous administration of Fentanyl 1 ml of 0.005% solution and 2 ml of 0.25% Droperidol solution) is indicated.
When signs of heart failure increase, intravenous strofantin is recommended to use 0.5-0.7 ml of a 0.05% solution or 1 ml of Korglikona of a 0.06% solution. in combination with 20 ml of isotonic sodium chloride solution. Intravenous injection of Novocaine 10 ml of a 0.25% solution and Cordiamine 2 ml.
In the presence of signs of persistent collapse, a 400 ml intravenous Reopoliglyukine infusion should be used with the addition of the 3% prednisolone 2 ml solution. The contraindications to the use of rheopolyglucin are: organic lesions of the urinary system, accompanied by anuria, severe disorders of the hemostatic system, heart failure at the stage of decompensation.
Severe pain syndrome is an indication for the use of the narcotic analgesic Morphine 1 ml of a 1% solution in 20 ml of an isotonic solution intravenously. Before applying morphine, it is necessary to clarify the presence of a convulsive syndrome in a patient in an anamnesis.
After stabilization of the patient's condition, it is necessary to provide emergency cardioscurrent hospital to determine other treatment tactics.
Prevention of pulmonary embolismThere is primary and secondary prevention of PE. The primary preventive measures of PE are aimed at preventing the presence of phlebothrombosis in the system of deep veins of the lower limbs: elastic compression of the lower limbs, reduction of bedtime and early activation of patients in the postoperative period, medical therapy with patients having a bed. All these measures must necessarily be carried out by patients who have long-term hospital treatment.
As compression therapy, special "anti-embolic" stockings in medical knitwear are widely used and their constant wearing significantly reduces the risk of venous phlebothrombosis of the lower limbs. The absolute contraindication to the use of compression knits is the atherosclerotic disease of vessels of the lower extremities with a marked degree of ischemia and the postoperative period after the autodermoplasty operation.
As a drug prevention, low molecular weight heparins are recommended for patients at risk of phlebothrombosis.
Secondary preventive measures of PE are used when the patient has symptoms of phlebothrombosis. In this situation, the use of direct anticoagulants in a therapeutic dose is used and, if there is a thrombus floating in the lumen of the venous vessel, surgical correction methods should be used: inferior vena cava , installation of cava filters and thrombectomy.
An important value in the prevention of PE is the modification of lifestyle: the elimination of possible risk factors that cause thrombotic processes, as well as the maintenance of concomitant chronic diseases at the stage of compensation.
To determine the likelihood of developing PE, patients are advised to take a Geneva scale test, which consists of answering simple questions and summarizing the results:
- Heart rate greater than 95 beats per minute - 5 points;
- Heart rate 75-94 beats per minute - 3 points;
- the presence of obvious clinical manifestations of phlebotrombosis of the deep veins of the lower limbs (swelling of soft tissues, painful palpation of the vein) - 5 points;
- Assumption of venous thrombosis of the lower limb (traction in a limb) - 3 points;
- presence of reliable signs of anamnesic thrombosis - 3 points;
- perform invasive surgical manipulations for the last month - 2 points;
- distribution of blood sputum - 2 points;
- presence of oncological diseases - 2 points;
- age after 65 years - 1 point.
When the sum of the scores does not exceed 3, the probability of PE is low, if the score is 4 to 10, we shouldtalk about moderate probability, and patients with more than 10 points belong to the risk group for thispathology and need preventive drug treatment.