Pulmonary embolism symptoms treatment death. Thromboembolism of small branches of the pulmonary artery: causes, symptoms and diagnosis. Activities that are carried out with massive pulmonary embolism

One of the main causes of sudden death is an acute violation of blood flow in the lungs. Pulmonary embolism refers to conditions that in the vast majority of cases lead to an unexpected cessation of the body's vital functions. Pulmonary thrombosis is extremely difficult to cure, so it is optimal to prevent a deadly situation.

Sudden occlusion of arterial trunks in the lungs

The lungs perform an important task of saturating venous blood with oxygen: the main main vessel, which brings blood to the small branches of the arterial network of the lungs, departs from the right heart. Thrombosis of the pulmonary artery causes the cessation of the normal functioning of the pulmonary circulation, the outcome of which will be the absence of oxygenated blood in the left cardiac chambers and the rapidly growing symptoms of acute heart failure.

See how a blood clot forms and leads to pulmonary embolism

The chances of saving life are higher if the pulmonary and led to blockage of the arterial branch of a small caliber. Much worse if it came off and provoked cardiac occlusion with sudden death syndrome. The main provoking factor is any surgical intervention, therefore, it is necessary to strictly follow the doctor's preoperative prescriptions.

Age is of great prognostic value (in people under 40 years of age, pulmonary thromboembolism during surgery is extremely rare, but for an older person the risk is very high - up to 75% of all cases of fatal blockage in the pulmonary artery occur in elderly patients).

An unpleasant feature of the disease is the delay in diagnosis - in 50-70% of all cases of sudden death, the presence of pulmonary thromboembolism was detected only at a post-mortem autopsy.

Acute obstruction of the pulmonary trunk: what is the cause

The appearance of blood clots or fat emboli in the lung is explained by blood flow: most often, the primary focus of the formation of thrombotic masses is the pathology of the heart or the venous system of the legs. The main causes of occlusive lesions of the main vessels of the pulmonary system:

any type of surgical intervention;
severe lung disease;
congenital and acquired heart defects with various types of valvular defects;
anomalies in the structure of the pulmonary vessels;
acute and chronic ischemia of the heart;
inflammatory pathology inside the cardiac chambers (endocarditis);
complicated variants of varicose veins (vein thrombophlebitis);
bone injury;
gestation and childbirth.

Of great importance for the occurrence of a dangerous situation, when it formed and came off, are the predisposing factors:

genetically predetermined blood clotting disorders;
blood diseases that contribute to the deterioration of fluidity;
metabolic syndrome with obesity and endocrine disorders;
age over 40;
malignant neoplasms;
prolonged immobility due to injury;
any variant of hormone therapy with constant and long-term use of drugs;
smoking.

Pulmonary artery thrombosis occurs when a blood clot enters the venous system (in 90% of cases, blood clots in the lungs appear from the vasculature of the inferior vena cava), therefore, any form of atherosclerotic disease does not affect the risk of blockage of the main trunk extending from the right ventricle.

Mechanism of getting a blood clot from the venous system to the lungs

Types of life-threatening occlusion: classification

A venous clot can disrupt circulation anywhere in the pulmonary circulation. Depending on the location, the following forms are distinguished:

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

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

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

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

Fulminant (all symptoms and signs of pulmonary embolism unfold in 10 minutes);
Acute (manifestations of occlusion are growing rapidly, limiting the life of a sick person to the first day from the moment of the first symptoms);
Subacute (slowly progressing cardiopulmonary disorders);
Chronic (typical signs of heart failure, in which the risk of a sudden cessation of the pumping function of the heart is minimal).

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

It is very difficult to guess how long a person can live with an acute form of the disease, when all the necessary emergency medical and diagnostic procedures must be performed within 24 hours and a fatal outcome must be prevented.

The best survival rate is in the subacute and chronic types, where a large proportion of patients treated in the hospital can avoid a sad outcome.

Symptoms of dangerous occlusion: what are the manifestations

Pulmonary embolism, the symptoms of which are most often associated with venous diseases of the lower extremities, can occur in the form of 3 clinical variants:

The initial presence of complicated varicose veins in the area of the venous network of the legs;
The first manifestations of thrombophlebitis or phlebothrombosis occur during an acute disturbance of blood flow in the lungs;
There are no external changes and symptoms indicating venous pathology in the legs.

A large number of various symptoms of pulmonary embolism are divided into 5 main symptom complexes:

Cerebral;
Cardiac;
Pulmonary;
Abdominal;
Renal.

The most dangerous situations are when the pulmonary and completely blocked the lumen of the vessel that provides the vital organs of the human body. In this case, the probability of survival is minimal, even if medical care is provided in a timely manner in a hospital setting.

Symptoms of brain disorders

The main manifestations of cerebral disorders in case of an occlusive lesion of the main trunk extending from the right ventricle are the following symptoms:

severe 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 inappropriate actions.

Cardiac symptoms

The sudden and dangerous symptoms of pulmonary embolism include the following signs of heart failure:

severe chest pain;
frequent heartbeat;
a sharp drop in blood pressure;
swollen neck veins;
pre-fainting state.

Often, a pronounced pain syndrome in the left side of the chest is due, which has become the main cause of pulmonary thromboembolism.

Respiratory disorders

Pulmonary disorders in a thromboembolic state are manifested by the following symptoms:

increasing shortness of breath;
feeling of suffocation with the appearance of fear and panic;
severe pain in the chest at the time of inspiration;
cough with hemoptysis;
cyanotic changes in the skin.

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

With abdominal and renal syndrome, disorders associated with internal organs come to the fore. Typical complaints will be the following manifestations:

intense pain in the abdomen;
predominant localization of pain in the right hypochondrium;
disruption of the intestines (paresis) in the form of constipation and cessation of gas discharge;
detection of signs typical of peritonitis;
temporary cessation of urination (anuria).

Regardless of the severity and compatibility of symptoms of pulmonary embolism, it is necessary to start therapy as soon as possible and quickly using resuscitation techniques.

Diagnosis: is it possible to detect early

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

repeated episodes of pneumonia or lack of effect from standard treatment for pneumonia;
unexplained fainting;
against the background of cardiac therapy;
high fever of unknown origin;
sudden onset of symptoms of cor pulmonale.

Diagnosis of an acute condition associated with blockage of the main trunk extending from the right ventricle of the heart includes the following studies:

general clinical tests
assessment of the blood coagulation system (coagulogram);
electrocardiography;
plain x-ray of the chest;
duplex echography;
lung scintigraphy;
angiography of the vessels of the chest;
phlebography of venous vessels of the lower extremities;
tomography with contrast.

Thromboembolism of the pulmonary artery on x-ray

None of the methods of examination is able to make an accurate diagnosis, therefore, only the complex application of techniques will help to identify signs of pulmonary embolism.

Emergency medical measures

Emergency care at the stage of the ambulance team involves the following tasks:

Prevention of death from acute cardiopulmonary failure;
Correction of blood flow in the pulmonary circulation;
Preventive measures to prevent repeated episodes of pulmonary vascular occlusion.

The doctor will use all medications that will help eliminate the mortal risk, and will try to get to the hospital as quickly as possible. Only in a hospital setting can you try to save the life of a person with pulmonary thromboembolism.

The basis of successful therapy is the following treatment methods in the first hours after the onset of dangerous symptoms:

the introduction of thrombolytic drugs;
use in the treatment of anticoagulants;
improvement of blood circulation in the vessels of the lungs;
support of respiratory function;
symptomatic therapy.

Surgical treatment is indicated in the following cases:

blockage of the main pulmonary trunk;
a sharp deterioration in the patient's condition with a drop in blood pressure;
lack of effect from drug therapy.

Thrombectomy

The main method of surgical treatment -. 2 variants of surgical intervention are used - with the use of a heart-lung machine and with temporary closure of blood flow through the vessels of the inferior vena cava. In the first case, the doctor will remove the obstruction in the vessel using a special technique. In the second, the specialist will block the blood flow in the lower part of the body during the operation and perform the thrombectomy as quickly as possible (the time for the operation is limited to 3 minutes).

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

Prevention: how to prevent death

In the case of thromboembolic complications, the optimal therapy option is the use of non-specific and specific preventive measures at all stages of examination and treatment. Of the non-specific measures, the best effect will be when using the following recommendations:

the use of compression stockings (stockings, tights) for any medical procedures;
early activation after any diagnostic and therapeutic manipulations and operations (you can’t lie down for a long time or take a forced posture for a long time in the postoperative period);
constant monitoring by a cardiologist with courses of therapy for heart pathology;
complete cessation of smoking;
timely treatment of complications of varicose veins;
weight loss in obesity;
correction of endocrine problems;

Measures of specific prevention are:

constant intake of medicines prescribed by a doctor that reduce the risk of thrombosis;
use at high risk of thromboembolic complications;
the use of special physiotherapeutic techniques (intermittent pneumocompression, electrical muscle stimulation).

The basis of successful prevention is the careful and strict implementation of the doctor's recommendations at the preoperative stage: often ignoring elementary methods (refusal of compression stockings) causes the formation and separation of a blood clot with the development of a deadly complication.

Prediction: what are the chances of life

Negative outcomes in case of blockage of the pulmonary trunk are due to the fulminant form of the complication: in this case, the prognosis for life is the worst. In other variants of the pathology, there are chances of survival, especially if the diagnosis is made on time and treatment is started as quickly as possible. However, even with a favorable outcome after acute pulmonary vascular occlusion, unpleasant consequences can form in the form of severe shortness of breath and heart failure.

Complete or partial occlusion of the main artery originating from the right ventricle is one of the main causes of sudden death after any medical intervention. It is better to prevent a sad outcome, using the advice of a specialist at the stage of preparation for diagnostic and treatment procedures.

The annual number of cases of pulmonary embolism (PE) reaches 60-70 per 100,000, half of them occur in a hospital setting. As a percentage of total mortality in hospital conditions - from 6 to 15%. The most common cause is venous thromboembolism (VTE), but in addition to a thrombus, vascular occlusion can be caused by air, fat embolus, amniotic fluid, and tumor fragments.

The diagnosis of pulmonary embolism should be based on physical examination and imaging findings.

Causes of pulmonary embolism

Lead to the development of pulmonary embolism:

deep vein thrombosis of the lower extremities, especially the iliac-femoral (surgical interventions on the abdominal organs and lower extremities, heart failure, prolonged immobilization, oral contraceptives, pregnancy and childbirth, obesity);
diseases of the cardiovascular system (mitral stenosis and atrial fibrillation, infective endocarditis, cardiomyopathy);
generalized septic process;
malignant neoplasms;
primary hypercoagulable states (deficiency of antithrombin III, proteins C and S, insufficiency of fibrinolysis, platelet abnormalities, antiphospholipid syndrome and other diseases);
diseases of the blood system (true polycythemia, chronic leukemia).

Most often complicates the course of DVT (in the vast majority of cases of the lower, and not the upper extremities).

Based on some clinical data, it is possible to suggest the occurrence of PE.

The basis for the assumption are:

sudden onset of symptoms such as chest pain, shortness of breath or choking, cough, tachycardia, drop in blood pressure, anxiety, cyanosis, swelling of the jugular veins;
the presence of risk factors: congestive heart failure, venous disease, prolonged immobilization, obesity, injuries of the lower extremities, pelvis, pregnancy and childbirth, malignant neoplasms, old age, previous embolism, etc.;
differential diagnosis (myocardial infarction, pericarditis, cardiac asthma, pneumonia, pleurisy, pneumothorax, bronchial asthma).

Clinical manifestations of pulmonary embolism are due to:

impaired blood flow in the pulmonary circulation (tachycardia, arterial hypotension, deterioration of coronary circulation);
development of acute pulmonary hypertension;
bronchospasm (scattered dry rales over the lungs);
acute respiratory failure (shortness of breath, predominantly inspiratory type).

The disease begins suddenly, often with shortness of breath (with orthopedic, as a rule, no). Short-term loss of consciousness and hypotension are observed only with massive pulmonary embolism. Often there is pain in the chest, a feeling of fear, coughing, sweating. When a lung infarction occurs, chest pain acquires a “pleural” character (intensifies with deep breathing, coughing, body movements), hemoptysis is characteristic. With a slight thromboembolism of the pulmonary artery, there are usually no pronounced hemodynamic disturbances, blood pressure is normal.

The classic manifestations of PE include acute onset, pleuritic pain, dyspnea, and hemoptysis.
Sometimes postural dizziness and fainting are observed.
Massive PE may present with cardiac arrest (often with electromechanical dissociation) and shock. There may be atypical manifestations in the form of unexplained dyspnea or hypotension, as well as only in the form of syncope. Consider PE in all patients with dyspnoea who have risk factors for DVT or confirmed DVT. Recurrent PE may present with chronic pulmonary hypertension and progressive right ventricular failure.
When examining a patient, only tachycardia and tachypnea can be detected. Reveal postural hypotension (with swelling of the jugular veins).
Attention should be paid to signs of increased pressure in the right heart (increased pressure in the jugular vein with a pronounced α-wave, tricuspid insufficiency, paresternal pulsation, the appearance of a III tone in the right ventricle, a loud tone of closing the pulmonary valve with splitting of the second tone, regurgitation on the pulmonary valve arteries).
With cyanosis, thromboembolism of large branches of the pulmonary artery should be assumed.
Determine the presence of pleural friction rub or pleural effusion.
Examine the lower limbs for the presence of severe thrombophlebitis.
Moderate fever (above 37.5 ° C) is possible, which can also be a sign of concomitant COPD.

Diagnosis of pulmonary embolism

The data of physical, radiological and electrocardiographic studies are important mainly for the exclusion of the listed diseases, but are not mandatory for the diagnosis of PE. They are taken into account only to confirm the diagnosis (for example, ECG signs of acute cor pulmonale or focal radiolucency of the pulmonary pattern on x-ray), but not to exclude it.

Basic diagnostic criteria

Sudden shortness of breath for no apparent reason.
Early symptoms of PE: shortness of breath, chest pain, cough, anxiety, hemoptysis, tachycardia, arterial hypotension, wheezing in the lungs, fever, pleural rub.
Signs of pulmonary infarction (pain, pleural friction noise, hemoptysis, fever due to the development of peri-infarction pneumonia).
The presence of risk factors in history.

Due to the non-specific symptoms of pulmonary embolism, it is called the "great masker". Therefore, the consideration of risk factors is of particular importance in the diagnosis.

The diagnosis is confirmed by clinical examination data. Of the instrumental methods, radiography of the lungs is important (pathological changes are detected in 40% of patients), spiral computed tomography with contrasting of the vessels of the lungs (100%), ECG (changes in 90%).

Other instrumental diagnostic methods include ventilation-perfusion scintigraphy with Tc99m (two or more defects of inappropriate segmental perfusion confirm the diagnosis), high-resolution multi-detector computed tomography for visualization of pulmonary vessels (sensitivity 83%, specificity 96%), EchoCT to assess the size of the right ventricle and tricuspid regurgitation (sensitivity 60-70%, a negative result cannot rule out pulmonary embolism), pulmonary angiography (no longer the "gold standard" in diagnosis). In order to determine the source of pulmonary embolism, ultrasound of the veins of the lower extremities with a compression test is performed.

Laboratory methods examine the content of gases in the blood (normal pO 2 makes the diagnosis of pulmonary embolism unlikely) and the content of d-dimer in plasma (more than 500 ng / ml confirms the diagnosis).

Specific Research Methods

d-Dimer:

highly sensitive but non-specific test method.
Important in terms of excluding PE in patients with low or moderate probability.
The reliability of the results is lower in elderly patients during pregnancy, trauma, after surgery for tumor and inflammatory processes.

Ventilation-perfusion lung scintigraphy:

Perfusion lung scintigraphy (albumin labeled with 99 technetium is administered intravenously) should be performed in all suspected cases of PE. With simultaneous ventilation scintigraphy (inhalation of 133 xenon), the specificity of the study increases due to the possibility of determining the ratio of ventilation and perfusion of the lungs. In the presence of pulmonary pathology preceding PE, the interpretation of the results becomes difficult.

Normal values of perfusion scintigraphy make it possible to exclude thromboembolism of large branches of the pulmonary artery.
Pathological changes in scintigraphy are described as low, medium and high probability:

High degree of probability - scintigraphy data with a high degree of probability indicate PE, the probability of false positive results is very low.
The low probability, combined with poor clinical presentation, means that another cause should be searched for causing symptoms resembling PE.
If the clinical picture is very similar to PE, and the findings of scintigraphy have a low or moderate degree of probability, alternative methods of investigation are required.

Research aimed at finding out the cause of thromboembolism

Ultrasound of the veins of the lower extremities.
Ultrasound of the abdominal organs.
Screening for congenital defects in coagulation factors leading to hypercoagulability.
Autoimmune screening (anticardiolipin antibodies, antinuclear antibodies).

Computed tomography angiography of the pulmonary arteries:

It is recommended as an initial diagnostic method in patients with small branch PE.
Allows direct visualization of emboli, as well as the diagnosis of parenchymal lung diseases, the clinical manifestations of which may resemble PE.
In relation to the lobar pulmonary arteries, the sensitivity and specificity of the study is high (more than 90%) and lower for segmental and subsegmental pulmonary arteries.
Patients with positive results of this study do not need additional studies to confirm the diagnosis.
Patients with negative results with a high or moderate likelihood of PE should be further investigated.

Ultrasound examination of the veins of the lower extremities:

Insufficiently reliable method. In almost half of patients with PE, DVT thrombosis of the lower extremities is not confirmed, therefore, negative results do not exclude PE.
A useful second-line diagnostic method in combination with CT angiography of the pulmonary arteries and ventilation-perfusion scintigraphy.
The study of the outcomes of PE demonstrated the benefit of not taking anticoagulant therapy in patients with negative pulmonary artery CT angiography and lower extremity ultrasonography and a low or moderate probability of PE.

Angiography of the vessels of the lungs:

"Gold standard".
It is indicated for patients in whom the diagnosis of PE cannot be established using non-invasive methods. Determine the sudden disappearance of blood vessels or obvious filling defects.
Invasive research method with a risk of death of 0.5%.
In the presence of an obvious filling defect, it is possible to recanalize the thrombus by bringing a catheter or flexible conductor directly to the site of the thrombus.
After angiography, the catheter can be used for thrombolysis directly at the site of pulmonary artery occlusion.
Contrast may cause systemic vasodilation and collapse in patients with underlying hypotension.

Magnetic resonance angiography of the pulmonary arteries:

In preliminary studies, the performance of this study is comparable to that of pulmonary angiography.
Allows simultaneous assessment of ventricular function.

Forecast

The prognosis for patients with PE varies widely and depends to some extent on the condition that caused the embolism. Usually, a poor prognosis is characteristic of thromboembolism of large branches (large blood clots). Unfavorable prognostic factors include:

hypotension;
hypoxia;
electrocardiographic changes.

Practical note

The normal content of d-dimer refutes the diagnosis of PE with 95% accuracy, while an increased content of d-dimer is observed in many other diseases.

Emergency care and treatment for pulmonary embolism

Hospitalization in the intensive care unit is required. To restore blood flow in the pulmonary artery and prevent potentially fatal early recurrences of pulmonary embolism, anticoagulant therapy is prescribed: heparin. Low molecular weight heparins are administered subcutaneously. Anticoagulation with heparin is carried out for at least 5 days, and then the patient is transferred to oral anticoagulants for at least 3 months (if the risk factor is eliminated) and at least 6 months or for life if the likelihood of recurrence of pulmonary embolism persists.

For the purpose of thrombolysis within 48 hours from the onset of the disease, and with persistent symptoms - up to 6-14 days, a recombinant tissue plasminogen activator (alteplase, tenecteplase) or streptokinase is used (the hemodynamic advantages of thrombolysis compared with heparin are noted only in the first few days). If indicated, surgical embolectomy or percutaneous catheter embolectomy and thrombus fragmentation, as well as the installation of venous filters, can be performed.

Dopamine and/or dobutamine are indicated for hypotension, low cardiac index, and pulmonary hypertension. To expand the vessels of the lungs and increase the contractility of the right ventricle, levosimedan is used, with bronchospasm - eufillin. Atropine also helps to reduce pressure in the pulmonary artery. For the prevention and treatment of heart attack-pneumonia, broad-spectrum antibiotics (aminopenicillins, cephalosporins, macrolides) are prescribed.

Pulmonary embolism: treatment

Stabilization of the patient's condition

Until the diagnosis of PE is ruled out, a patient with suspected PE should be treated according to the principles of PE management.
Check heart rate, pulse, blood pressure, respiratory rate every 15 minutes against the background of constant monitoring of pulse oximetry and cardiac activity. You should make sure that you have all the necessary equipment for IVL.
Provide venous access and start intravenous infusion (crystaploid or colloidal solutions).
Provide the maximum possible concentration of oxygen inhaled through the mask to eliminate hypoxia. IVL is indicated when the patient develops fatigue of the respiratory muscles (you should beware of the appearance of collapse when sedating drugs are administered before tracheal intubation).
Give LMWH or UFH to all patients at high and moderate risk of PE before the diagnosis is confirmed. A meta-analysis of multicenter studies has shown the superiority of LMWH over UFH in terms of mortality and bleeding rates. Regarding the dose of heparin, refer to the protocol adopted in a particular medical institution.
With hemodynamic instability (hypotension, signs of right ventricular failure) or cardiac arrest, improvement is achieved by thrombolysis with a recombinant tissue plasminogen activator or streptokinase [at the same dose as in the treatment of AMI with ST segment elevation].

Anesthesia

NSAIDs may be effective.
Narcotic analgesics should be used with caution. The vasodilation they cause may potentiate or exacerbate hypotension. Enter slowly 1-2 mg of diamorphine. With hypotension, intravenous administration of colloidal infusion solutions is effective.
Avoid intramuscular injections (dangerous during anticoagulant and thrombolytic therapy).

Anticoagulant therapy

Once the diagnosis is confirmed, the patient should be given warfarin. It must be administered simultaneously with LMWH (UFH) for several days until the MHO reaches therapeutic levels. In most cases, the target value of MHO is 2-3.
The standard duration of anticoagulant therapy is:

4-6 weeks in the presence of temporary risk factors;
3 months for a first-time idiopathic case;
at least 6 months in other cases;
with repeated cases or the presence of factors predisposing to thromboembolism, lifelong use of anticoagulants may be required.

Heart failure

Massive PE may present with cardiac arrest secondary to electromechanical dissociation. Other causes of electromechanical dissociation should be excluded.
Conducting an indirect heart massage can lead to the splitting of a thrombus and its advancement into more distal branches of the pulmonary artery, which to some extent contributes to the restoration of cardiac activity.
With a high probability of PE and the absence of absolute contraindications for thrombolysis, a recombinant tissue plasminogen activator is prescribed [at the same dose as in AMI with ST-segment elevation, maximum 50 mg, followed by a heparin value].
When restoring cardiac output, the issue of conducting angiography of the vessels of the lungs or catheterization of the pulmonary artery with the aim of mechanical destruction of the thrombus is decided.

hypotension

An acute increase in vascular resistance in the lungs leads to dilatation of the right ventricle and its pressure overload, which makes it difficult to fill the left ventricle and leads to a violation of its function. These patients require a higher right heart filling pressure, but may be worsened by fluid overload.
With hypotension, colloid infusion solutions (500 ml of hydroxyethyl starch) are prescribed.
If hypotension persists, invasive monitoring and inotropic therapy may be required. In such cases, jugular pressure is a poor indicator of right heart filling pressure. Among the inotropic drugs, epinephrine is the most preferred.
Femoral-femoral cardiopulmonary bypass can be used to maintain circulation prior to thrombolysis or surgical embolectomy.
Pulmonary angiography in patients with hypotension is dangerous because the radiopaque agent can cause systemic vascular dilatation and collapse.

Embolectomy

If thrombolytic therapy is contraindicated, as well as in shock requiring the appointment of inotropic therapy, embolectomy is possible, provided there is sufficient experience for this manipulation.
Embolectomy can be performed by percutaneous access in a specialized operating room or during a surgical operation on the background of cardiopulmonary bypass.
Percutaneous intervention can be combined with peripheral or central thrombolysis.
You should consult a specialist as soon as possible. The effectiveness of therapy is higher if it is started before the development of cardiogenic shock. Prior to performing a thoracotomy, it is desirable to obtain radiological confirmation of the extent and level of thromboembolic occlusion of the pulmonary vessel.
Mortality is 25-30%.

cava filter

It is rarely established, as it has little effect on improving early and late mortality rates.
Filters are placed through a percutaneous approach and, if possible, patients should continue to receive anticoagulants to prevent further thrombus formation.
Most filters are installed in the infrarenal part of the inferior vena cava (bird's nest filters), but it can also be installed in its suprarenal part (Greenfield filter).

Indications for installing a cavafilter include:

ineffectiveness of anticoagulant therapy, despite the use of adequate doses of drugs;
prophylaxis in high-risk patients: eg progressive venous thrombosis, severe pulmonary hypertension.

Treatment of pulmonary embolism (PE), its diagnosis is an important task of medicine. High mortality in PE is due to the rapid development of the disease, many patients die in the first 1-2 hours, the reason is that adequate treatment has not been received. The spread of pathology has received due to the fact that the etiology includes many factors. The pathogenesis of PE (thromboembolism) includes 3 stages. In the first period, a thrombus is formed in the veins of the systemic circulation. In the second period, there is a blockage of the vessels of the small circle. In the third period, clinical symptoms develop.

How does thrombus formation occur?

There are three main reasons:

Signs of damage to the walls of blood vessels. The formation of a blood clot due to this reason can be called a natural process. This cause leads to thromboembolism due to the fact that there was a long-term treatment in the form of surgical interventions.
Slow down blood flow. Blood circulation slows down in the systemic circulation during pregnancy, varicose veins are the main reasons. Red blood clots are formed, consisting of fibrin filaments and erythrocytes - thromboembolism develops.
Thrombophilia - this cause causes the body's tendency to form blood clots. Thrombogenesis is associated with factors that activate this process and interfere with it. An excess of the former or a lack of the latter is a provoking syndrome, which causes thromboembolism.

Blockage of blood vessels

The detached blood clot through the veins reaches the heart, passes through the atrium and right ventricle, enters the pulmonary circulation. There is a complete or partial blockage of the branches of the pulmonary artery, which causes the main symptoms of such an ailment as thromboembolism. Lung nutrition stops, and this cause leads to respiratory and hemodynamic disturbances in PE. As a result of blockage and increased pressure, blood clotting increases. Due to the occurrence of conditions for thrombus formation, complication symptoms develop, additional thrombosis of small vessels and capillaries occurs. And the release of vasoactive substances (histamine, serotonin) increases the constriction of the bronchi. As a result, respiratory failure in PE worsens, and treatment should begin as soon as possible.

As you can see, even such a reason as a slight blockage of the lungs leads to a chain, cascade reaction, due to which the patient's condition may worsen within 1-2 days. Also, PE can be complicated by other diseases (pneumonia, pleurisy, pneumothorax, chronic emphysema, and others). If thromboembolism of small branches of the pulmonary artery has occurred, then the body can compensate for the pathology at the expense of other vessels.

Thromboembolism classification

The classification of PE takes into account the severity of the disease, the location of the embolus, and the rate of flow.

By localization

The classification takes into account the level of vascular blockage, which determines how severe the symptoms will be:

Grade 1 (mild) - embolism occurs at the level of small branches.

Grade 2 (medium) - thromboembolism affects the level of segmental branches.

Grade 3 (severe) - thrombopulmonary pathology of the lobar branches.

4 degree (extremely severe) - a blood clot clogs the trunk of the pulmonary artery or its branches.

By severity

Depending on the proportion, the number of affected vessels of pulmonary embolism, the severity of pulmonary embolism changes:

Small PE - up to 25%. Symptoms are limited to shortness of breath and cough.

Submassive PE - from 25 to 50%. Symptoms are supplemented by severe right ventricular failure, but blood pressure is normal.

Massive - from 50% to 75%. An extremely serious condition is observed, the main symptoms are low blood pressure with tachycardia, increased pressure in the arteries of the small circle. Develops cardiogenic shock (extreme degree of left ventricular failure), acute right ventricular failure. Treatment must be urgent.

Fatal PE - more than 75%. There is a lethal outcome.

By the speed of the current

PE is divided into acute, recurrent and chronic forms.

Lightning. Thromboembolism of this form occurs with instantaneous and complete blockage of the pulmonary artery trunk. Symptoms develop rapidly: breathing stops, collapse immediately develops (loss of consciousness, pallor, low blood pressure) and signs of ventricular fibrillation. Death in this type of PE occurs in 1-2 minutes, other symptoms do not have time to develop. Timely treatment is of great importance in this case.

Acute. Occurs when blockage of large lobar or segmental pulmonary vessels is the main cause. PE of this form arises and develops quickly, the following symptoms appear - shortness of breath, increased heart rate, hemoptysis appears. If there is no treatment, then after 3-5 days a heart attack will develop.

Subacute. The symptoms are the same, but increase within 2-3 weeks, occurs with blockage of the middle pulmonary arteries. If treatment is not given on time, symptoms worsen and lead to death from PE.

Recurrent PE. It develops against the background of cardiovascular, cancerous pathologies, at the postoperative stage - this is a common cause. Often the syndrome gradually increases, becoming stronger, complications occur (symptoms of bilateral pleurisy, pneumonia, pulmonary infarction appear). Treatment should take into account all the causes of the development of the disease.

Etiology of the disease

The immediate etiology of pulmonary embolism is the formation of a thrombus or the entry into the systemic circulation of other emboli (neoplasms, gas, foreign bodies). A common etiology is deep vein thrombosis (DVT). As a result, 40-50% of patients sooner or later develop symptoms of a pathology such as pulmonary embolism.

A common etiology is deep vein thrombosis (DVT).

The etiology of PE includes factors that are divided into congenital (genetic anomalies) and acquired (diseases, various physiological conditions).

Acquired

Most factors increase the risk of pathologies such as DVT and PE (pulmonary embolism) by less than 1%. But the combination of 3-4 points should alert, especially people over 40 need to take care of their health, treatment will help to avoid complications.

Acquired Factors:

Treatment using surgery.
Taking oral contraceptives and HRT, estrogens.
Pregnancy and childbirth.
Sedentary lifestyle, overweight.
Malignant tumors, infection, burns.
Nephrotic syndrome and stroke.
Heart failure.
Phlebeurysm.
Treatment with artificial tissues.
Regular air travel over long distances.
Inflammatory bowel disease.
Systemic lupus erythematosus.
DIC syndrome.
Lung disease and smoking.
Treatment with contrast agents.
The presence of a venous catheter.

It is not uncommon for blood clots in PE to form after surgery has been performed. The reason is simple - surgeons cut the skin, along with capillaries, and sometimes blood vessels. As a result, blood clotting factors are released. Due to the high degree of danger after surgery, vascular studies are carried out for the risk of developing thrombosis and, if necessary, appropriate treatment.

It is not uncommon for blood clots in PE to form after surgery has been performed.

A low risk of blood clots is possible if treatment involves minimal surgery in people younger than 40 years without congenital thrombophilia factors. The average level of risk is in people from 40 to 60 years old or in patients with congenital factors for thrombosis. High risk of thrombosis - if surgical treatment was performed in people over 60 years of age or with large-scale interventions in patients with congenital thrombophilia factors.

Congenital

Also pay attention to the condition of the veins should be people with congenital factors. Conditions with a predisposition to thrombosis and the formation of PE are divided into:

Vascular thrombophilia. Conditions with damage to the walls of arteries and veins (atherosclerosis, vasculitis, aneurysms, angiopathy, etc.).
hemodynamic thrombophilia. Different intensity of circulatory disorders due to myocardial damage (the main cause), anomalies in the structure of the heart, local mechanical obstruction.
Blood thrombophilia. Coagulation factor disorders.
Violation of the mechanisms that form blood clots, regulate their formation and dissolve excessive formation of hemocoagulant.

The first reason, like the second, often develops due to other ailments, but can also be of a genetic nature. The third group is a direct congenital factor for thrombosis. It is possible to suspect thrombophilia and prescribe appropriate treatment in the presence of heart attacks (lung, heart), thrombosis in the past.

Clinical manifestations

Symptoms of such a pathology as PE depend on the nature and severity of the course of the disease, hemodynamic disturbances, and the rate of development. There are no characteristic clinical symptoms that would be present in all types of pulmonary embolism. Also, thromboembolism is often complicated by pulmonary diseases (there are symptoms of pleurisy, pneumonia, pneumothorax, and others), the effective treatment of which is also important.

The most common symptoms are associated with pain (58-88%), which develops in half of the cases. Most patients complain of a sharp onset of intense pain, which occurs with acute thromboembolism. In a chronic course, the symptoms are implicit, characterized as "discomfort behind the sternum", they are not always. Severe tearing pain in the chest appears with embolism of the main trunk of the pulmonary artery.

A symptom such as pain that increases with breathing or coughing indicates a pulmonary infarction. It is created due to the appearance of reactive pleurisy. These symptoms occur 2-3 days after the onset of the disease. Stitching pains in the chest during breathing, swallowing, coughing, or shortness of breath accompany thromboembolism in most situations.

Pain that increases with breathing or coughing indicates a pulmonary infarction.

Syndrome with pain in the right hypochondrium rarely occurs with pulmonary embolism. Such a painful sensation occurs due to swelling of the liver (the etiology of liver enlargement is right ventricular failure).

Dyspnea

Pulmonary embolism in most situations (70-85%) develops with shortness of breath. It is inspiratory, appears suddenly. Its causes are blockage of large pulmonary arteries and the resulting oxygen deficiency. Gradual, within 2-3 weeks, the increase in shortness of breath indicates subacute or chronic thromboembolism.

Tachycardia

The third most common syndrome is tachycardia, which occurs in about half of patients with PE (30-58%). The syndrome is characterized by a heart rate of 100 beats per minute. A rapid heartbeat occurs suddenly, gets worse over time, and can be the cause of a person's death if treatment is delayed.

Cyanosis

With blockage of small branches, cyanosis is noticeable on the wings of the nose, lips, oral mucosa. With blockage of the lobar and segmental vessels, pallor of the skin of the face and neck is noted, which acquires an ashy color. Massive pulmonary embolism comes with severe cyanosis, which extends only to the upper half of the body.

fainting

Symptoms such as cerebral hypoxia and syncope develop with massive thromboembolism. Cerebral disorders are varied. Often there are dizziness, drowsiness, vomiting, fear of death, anxiety because of this. There are disturbances of consciousness of various depths, confusion of thoughts, psychomotor agitation can be expressed by convulsions.

Hypoxia of the brain can cause fainting.

Cough and hemoptysis

At first, the cough in PE is dry, without secretions. After 2-3 days, it turns into a wet one, often a characteristic syndrome appears - hemoptysis. Pulmonary embolism often occurs with hemoptysis, so the symptom is quite reliable, but it does not appear immediately and develops only in 30% of cases. Usually hemoptysis is not massive, in the form of small streaks, blood clots in the sputum.

Temperature increase

A common syndrome, but it does not appear immediately, it develops in 2-3 days. In addition, the symptom is nonspecific and indicates a variety of diseases. Body temperature rises due to inflammation in the lungs or pleura. With pleurisy, the temperature rises by 0.5-1.5 degrees, with a lung infarction - by 1.5-2.5 degrees. The temperature lasts from 2 days to 2 weeks.

Research Options

Since there are no reliable symptoms that accurately indicate the disease, the diagnosis is made solely on the basis of hardware research methods. There are recommendations to do, at the slightest symptoms, an examination for the presence of DVT and the likelihood of developing pulmonary embolism, since PE is deadly if treatment is delayed.

A detailed history can only give a suspicion of the disease. The main criteria are cough, hemoptysis, sudden onset pain. A clearer picture can be given by the presence of thrombosis or complex operations in the patient in the past, by taking hormonal drugs.
If PE is suspected, the patient should be sent for a chest x-ray. In most situations, radiological signs will not allow a diagnosis of thrombopulmonary pathology, but they will help to exclude other diseases from the list (pericarditis, lobar pneumonia, aortic aneurysm, pleurisy, pneumothorax).
A more reliable method of research is the ECG. But it will help only if the thrombopulmonary pathology is massive, with blockage of large branches of the artery, ECG changes occur in 65-81% of cases (depending on the extent of the lesion).
Ultrasound of the heart (echocardiography) makes it possible to detect signs of overload of the right departments (cor pulmonale). The absence of pathologies on the echocardiogram is not a reason for thrombopulmonary pathology to be excluded.
Laboratory methods include the study of the amount of dissolved oxygen in the blood and d-dimer in plasma. The natural content of dissolved oxygen will make it possible to remove the diagnosis. And d-dimer in an amount of 500 ng / ml will confirm it.
Angiopulmonography is an x-ray examination with the introduction of contrast agents. Angiopulmonography is the most reliable method of investigation, since pulmonary embolism is detected in 98% of cases. Pulmonary angiography is not harmless, but today the danger has decreased (0.1% - fatal cases, 1.5% - non-fatal complications).

Ultrasound of the heart (echocardiography) makes it possible to detect signs of overload of the right departments.

As you can see, no study can give a 100% diagnosis, therefore, all diagnostic methods are used in turn to make a diagnosis, ranging from simple methods to complex ones. Angiopulmonography is performed only as a last resort. Recommendations for its implementation are the unsatisfactory results of previous research methods. Treatment cannot be delayed, it is often prescribed already at the examination stage.

How to eliminate pathology effectively

Often the patient needs treatment in intensive care. To save a life, Heparin, Dopamine are administered, a catheter is installed to facilitate breathing. Conventional treatment involves the use of anticoagulants and similar hormonal agents. Surgical treatment is rarely used. To eliminate the risk of complications and subsequent death, all patients with PE are hospitalized.

Thrombus removal

Surgical operation is used only for massive damage to the lungs, blockage of the trunk of the pulmonary artery, its large branches. During the operation, a thrombus is removed that prevents blood flow, if necessary, a filter of the inferior vena cava is placed. The operation is risky, so it is used only in severe cases, if the specialist has the appropriate experience.

Surgical operation is used only for massive damage to the lungs, blockage of the trunk of the pulmonary artery, its large branches.

Any of the methods has a high mortality, on average - 25-60%. A good indicator is 11-12%. When performing operations in a cardiology center, if the hospital has an experienced specialist, as well as excluding patients with severe shock from the statistics, a mortality rate of no more than 6-8% can be achieved.

Anticoagulant therapy

After providing first aid and eliminating a serious condition in a patient, it is necessary to continue treatment until the thrombus in the pulmonary artery is completely dissolved and the likelihood of subsequent relapses is excluded.

Heparin. It is administered within 7-10 days by drip intravenously. At the same time, blood coagulability indicators are monitored.
Warfarin tablets are prescribed 3-4 days before stopping the use of heparin. Warfarin is taken for a year, also controlling blood clotting.
Once a month, Streptokinase and Urokinase are injected intravenously.
A tissue plasminogen activator is also injected intravenously.

Anticoagulant therapy should not be used if the patient has internal bleeding, in the postoperative period, in the presence of a stomach or intestinal ulcer.

What to expect in the end

With timely assistance in full, the prognosis is favorable. The problem is that it happens 10% of the time. With the manifestation of a vivid clinical picture in the acute form, the mortality rate is 30%. If the necessary assistance is provided, the probability of death remains at the level of 10%. Often, a heart attack of the lung tissue is complicated, pleurisy, pneumonia, and other diseases appear. However, careful prevention and health management provide a positive prognosis. After completing the entire course of treatment, the patient may be given a disability of the 3rd degree (rarely - the second). Rehabilitation will come faster, and the prognosis is more favorable if you follow the instructions of the doctor.

With timely assistance in full, the prognosis is favorable.

Disease prevention

Thromboembolism of the pulmonary artery often flows into a chronic form, therefore, after an attack, it is necessary to monitor your condition and perform prevention. Certain preventive procedures are needed after long and complex operations, difficult childbirth (especially with a caesarean section) - this is the reason for special attention.

Also, PE prevention is needed for people at risk:

Over 40 years old;
Having thrombosis in the past - a heart attack (lung, heart) or stroke;
With overweight;
Patients with cancer.

People at risk need to constantly check their veins for blood clots using ultrasound. If necessary, tight bandaging of the legs should be used, static loads should be avoided, a diet with vitamin K is indicated. After a case of thromboembolism, patients are recommended to take direct-acting anticoagulants (Xarelto, Inochen, Fragmin and others).

Prevention of PE is essential after complex operations on the legs, joints, abdominal or chest cavity. For this, it is recommended to use Heparin and Reopoliglyukin:

Heparin. Begin to apply a week before surgery, continue to use until the patient is fully mobilized. One dose - 5 thousand units. Injections are made 3 times a day with an eight-hour interval. The second option is also 5 thousand units, but 2 times a day with an interval of 12 hours.
Reopoliglyukin is used before, during and after surgery to reduce the likelihood of a blood clot, the development of complications. Use 1000 milliliters from the beginning of anesthesia and continue for 5-6 hours after surgery. Enter intravenously drip.

The specialist can also refer the patient to an operation to implant venous cava filters, which reduce the risk of thrombus formation and the development of complications.

As a result, we can conclude that pulmonary embolism is an extremely dangerous syndrome. Thrombopulmonary pathology creates a problem not so much with lethality as with the difficulty of diagnosis and a high probability of exacerbation. To eliminate the risk of examinations are carried out if there are the slightest signs of thromboembolism.

Pulmonary embolism (or simply PE) is an occlusion of the pulmonary vessels, as well as branching with thrombotic clots. This process leads to impaired hemodynamics in the lungs, as well as other deadly conditions. The standard symptoms of a pulmonary embolism include asthma attacks, chest pain, heart palpitations, and facial collapse.

In order to make sure that the diagnosis is correct, and also not to confuse the disease with other conditions, an ECG is required, as well as an x-ray of the lungs. Therapeutic measures for PE include conservative infusion treatment, as well as oxygen inhalations. If the proposed methods do not have the desired effect, then pulmonary thromboembolectomy may be necessary.

Here are some important facts about pulmonary embolism:

Thromboembolism almost never acts as an independent pathology. It comes as a complication.
PE is in third place in the world in terms of the spread of this kind of disease. More frequent causes of death are only ischemic stroke and heart disease.
In America, more than 600 thousand cases of thromboembolism are recorded annually, of which 300 are fatal.
This disease is the leading cause of death in elderly patients.
About 30% of the total number of patients die from pulmonary embolism.
During the first 60 minutes after the separation of a blood clot in the lung, 10% of all patients die.
Timely assistance can save about 12% of victims from death.

Classification of pulmonary thrombophlebitis (PE)

There are several classifications of pulmonary thromboembolism (PE). They are distinguished by the location of the thrombus in the vascular bed, as well as by the volume of blood flow turned off. An important role is also played by how advanced the pulmonary embolism is and how the disease proceeds.

According to the location of the thrombus, there are:

massive pulmonary thrombosis;
embolism of branches of segments and lobes of the pulmonary artery (LA);
small branches pulmonary embolism (bilateral).

In the first variant, the thrombus is localized in the main trunk of the LA or in its main branches. In the second variant, the pulmonary thrombus is already localized in the segmental or lobar branches of the LA.

In the third variant, the blockage of the pulmonary artery is localized in the small branches of the LA. Despite the fact that in all cases an acute illness (pulmonary embolism) is equally dangerous, a person may not feel its presence.

Classification by blood flow dysfunction

According to the volume of blood flow turned off, pulmonary embolism is divided into the following forms:

small;
submassive;
massive;
deadly.

What is minor pulmonary thrombosis? With this form of pulmonary embolism, 25% of the arterial bed of the lungs suffers.

From the embolism of the pulmonary artery, the symptoms, in this case, are as follows: there is a violation of breathing in the form of shortness of breath. The muscle of the right ventricle is functioning normally. However, how long a person can live with this problem can only be answered by the attending physician.

With submassive (also called submaximal), 30–50% of the arterial bed of the lungs suffers. It is characterized by an acute violation of blood flow.

With such a pulmonary embolism, the symptoms are not rosy: pronounced shortness of breath, mild right ventricular failure, arterial pressure is normal. Submassive pulmonary thrombophlebitis is always a high risk of occlusion of the clogged lumen in the vessels.

With a massive form, the volume of the lesion in people is more than 50% of the pulmonary arterial bed. Symptoms of this type of pulmonary embolism abound: loss of consciousness, hypotension against the background of tachycardia, pulmonary hypertension, acute right ventricular failure and cardiogenic shock.

We have listed only the main manifestations of pulmonary thrombophlebia. If a blood clot suddenly breaks off, then the patient has practically no chance of surviving.

If the thrombus came off in a fatal form, the volume of the lesion is more than 75% of the arterial bed of the lungs. How many people can still live if a blood clot in the lungs breaks off is not so easy to answer. As a rule, an acute illness with such a scale of damage is incompatible with life.

Classification of PE by clinic and form of severity

According to the severity of the PE process, they are divided into:

heavy;
moderate severity;
light.

According to the TELA clinic, they are divided into:

the most acute course;
acute course;
subacute course;
chronic course.

The most acute form

In the first variant (also called fulminant septic embolism), there is a rapid blockage of the main trunk of the artery or both branches of the LA at once in full.

The blood flow stops completely. There is a complete cessation of breathing against the background of increasing respiratory failure, collapse and ventricular fibrillation. Pulmonary infarction is not observed, as there is not enough time for its development.

Thromboembolism of the pulmonary artery of this type leaves practically no chance of survival for a person. The presence of thrombosis in PE suggests that pulmonary embolism did not give a favorable prognosis in treatment. The lethal outcome is inevitable and comes the first minutes.

Acute course

Thromboembolism of the pulmonary artery, namely this type of it is no less dangerous, from the point of view of medicine, than the previous one. In an acute course, the main branches of the LA are obturated very quickly.

Thromboembolic disease gets a sudden rapid development with an increase in acute respiratory failure, heart failure, cerebral is formed. A pulmonary infarction develops.

In this situation, breaking off a blood clot is not difficult. The maximum duration that patients live is up to three to five days.

Thrombopulmonary (pulmonary embolism) insufficiency does not always mean that blood clots will break off. At the very beginning of the pathology, the patient can still be helped.

lingering current

Thromboembolism of the pulmonary artery is also possible with a protracted course of pathology. In a subacute course (also called protracted), large and small branches of the LA are thrombosed.

As a complication, there is a multiple pulmonary infarction. There is a growing dysfunction of the respiratory system, right ventricular failure is formed. There are not many signs of pulmonary embolism in this case.

Arterial thrombophilia proceeds slowly, can last up to several weeks. The main cause of pulmonary embolism and the symptoms of its manifestation are inextricably linked.

The cause of PE is the neglected state of varicose vessels. If emergency care is not provided for pulmonary embolism, a person may lose his life.

Recurrent form

Pulmonary embolism or a diagnosis of chronic PE has a measly survival rate. A detached blood clot in this case can become critical for the life of the patient. In a chronic course (it can also be called recurrent), recurrent thrombosis occurs in the branches of the lobes and segments of the LA of the lung.

The pulmonary artery of this form is not long in coming. There are repeated multiple pulmonary infarcts with chronic pleurisy on both sides.

There is a rapid spread of insufficiency from the right atrium. Caused by a complication of tumor pathology, diseases of the heart and blood vessels. This phenomenon is also typical for the rehabilitation period after surgery.

Effective diagnosis in PE

If there is a history of thromboembolism of small branches of the pulmonary artery, then on examination, increasing shortness of breath, fever, and low blood pressure are determined.

The symptoms and treatment of a pulmonary thrombus depend on the final diagnosis. Of the laboratory methods of examination, a blood test for biochemistry is necessary.

Instrumental diagnostic methods include the following algorithm of actions:

x-ray of the lungs;
echocardiography.

Important! An ECG may not be helpful in identifying the risks of PE. This was noted in a fifth of patients in PE.

Therefore, it is important to confirm the diagnosis using other methods. Namely:

ventilation-perfusion scanning of the lungs;
angiopulmonography;
radiopaque phlebography;
dopplerography of the vessels of the lower extremities.

Emergency care for PE

If the patient was diagnosed with an embolism, then he may need urgent medical care at any time. Emergency actions to stabilize the patient's condition necessarily imply resuscitation.

These include the following main points:

adherence to strict bed rest;
catheterization of the main vein of the central blood flow: through the catheter, medications will be delivered to the vessel, as well as pressure control in the vein;
single intravenous injection of up to 10 thousand units of heparin;
urgent delivery of oxygen through a mask or catheter for the nasal cavity;
regular injection of dopamine into the vessel at regular intervals;
if there is such a need, an urgent start of antibiotic therapy is necessary.

PE detection and treatment

A full range of rescue measures in patients with a diagnosis of LA thromboembolism are carried out in the conditions of ICU and resuscitation.

Emergency care for pulmonary embolism treatment involves emergency placement of the patient in a hospital. The patient must comply with bed rest. This is the only way to urgently neutralize a blood clot in the lungs and the consequences of its appearance.

Treatment of LA thromboembolism can be conservative and surgical.

Surgery on the lung is indicated in the absence of the effect of ongoing conservative measures. The final diagnosis of pulmonary embolism and treatment of the disease consists of actions in this sequence.

So, the therapeutic measures of a conservative nature include:

Standard methods of resuscitation, which include mechanical ventilation, chest compressions, defibrillation. Shown in cardiac arrest.
Oxygen therapy - administration through an oxygen mixture through a special mask or nasal catheter containing at least 40% oxygen. The indication is hypoxia.
IVL is also indicated for respiratory failure, hypoxia.
Intravenous administration of saline solutions (adrenaline, dobutamine or dopamine is dripped). Task: to make the diameter of the vessels narrower and in this way increase blood pressure (BP).

Surgical treatments include:

embolectomy;
thromboendarterectomy;
setting up a cava filter.

Surgery

When a lung thrombus breaks off, first aid should be provided immediately. The operation of embolectomy is performed in the acute course of LA embolism. As a result of the operation, the embolus itself is removed, thus, the blood flow is restored in full.

The operation thromboendarterectomy is performed in the chronic course of the disease. Its meaning is that not only the embolus itself is given, but also the inner wall of the artery along with the atherosclerotic plaque. This allows you to virtually eliminate the repetition of embolization of the vessel in this place.

Both operations are considered quite complex. It is recommended to treat the patient with them as an emergency. After preliminary cooling of the body to twenty-eight degrees, it is necessary to cut the sternum in the direction along.

If, according to the diagnostic data obtained, the right ventricle is highly hypertrophied, there are defects in the tricuspid valve, then the valve plasty is immediately performed, which will fix the result.

Operation - setting up a cava filter

This intervention can be called quite easy, especially compared to the two described, since no incisions are required.

Often, this intervention is performed even before the occurrence of LA thromboembolism as a prophylaxis and prevention of undesirable consequences of the disease. It can also be performed with an already existing disease.

A special catheter is inserted into the jugular vein through a puncture in the neck. Such an insertion can be made into the subclavian vein, into the great saphenous vein on the thigh.

Note! It is allowed to resort to this method only after a qualitative diagnosis of pulmonary embolism. And also with PE, the symptoms should indicate the need for urgent intervention.

The cava filter is a mesh filter for collecting the remaining particles, fragments of blood clots. Install it in the inferior vena cava. The fragments of the thrombus will linger in the filter and will not get into the heart and pulmonary artery. Accordingly, the risk of LA thromboembolism is significantly reduced.

Intervention technique

The operation is performed under light anesthesia so that the patient does not feel soreness and anxiety. The doctor inserts a catheter into the venous bed and guides it.

Having reached a certain place, a mesh filter is placed. Next, the mesh is straightened and fixed in the right place, and the catheter is carefully removed. Sutures are usually not applied.

With pulmonary embolism, treatment in this way gives significant results. The entire operation takes no more than an hour.

Further, the patient is prescribed bed rest for no more than two days. The operation is considered an endovascular intervention. With properly observed tactics of managing a patient with LA thromboembolism, the risk of re-embolization is significantly reduced.

It can be concluded that pulmonary embolism and its causes pose a direct threat to the health and life of the patient.

In the most deplorable cases, everything ends with lifelong disability or sudden death of the patient. Due to the fact that the disease is more than serious, you should immediately inform your doctor about suspected symptoms of PE.

If the patient is in a difficult situation, then it is urgent to call for emergency help. In the event that the patient has already suffered an attack of thromboembolism or he has an increased risk for this pathology, it is imperative to carry out the prevention of pulmonary embolism. Before you start taking any action, be sure to get the approval of a specialist.

Closure of the lumen of large pulmonary arteries is accompanied by signs of acute cardiopulmonary failure. These include:

shortness of breath - rapid shallow breathing;
chest pain, often aggravated by deep breathing and coughing;
dizziness, severe weakness, fainting;
a sharp decrease in blood pressure;
tachycardia - rapid heartbeat (more than 90 beats per minute);
swelling and pulsation of the cervical veins;
cough (first dry, then with the release of scanty sputum streaked with blood);
hemoptysis;
pallor of the skin;
cyanosis (cyanosis) of the face and upper half of the body - occurs with massive thromboembolism of large pulmonary arteries;
increase in body temperature.

When closing the lumen of the small arteries of the lungs, all these symptoms may be mild or completely absent.

Forms

Damage level:

massive (thrombus overlaps the main trunk or main branches of the pulmonary artery) - characterized by rapid development and severe course: pronounced shortness of breath, loss of consciousness, drop in arterial (blood) pressure, convulsions, in most cases death occurs;
embolism of the segmental or lobar branches of the pulmonary artery - characterized by a moderate course: moderate chest pain, shortness of breath, palpitations, a mild decrease in blood pressure, clinical manifestations last for several days;
embolism of small branches of the pulmonary artery - clinical manifestations are mild, often the disease is not recognized. The patient may be disturbed by recurrent chest pain, shortness of breath, repeated pneumonia (pneumonia).

With the flow:

acute (fulminant) - occurs abruptly when a thrombus completely clogs the main trunk or both main branches of the pulmonary artery. Acute respiratory failure develops (oxygen deficiency in the body), respiratory arrest, heart rhythm disturbance, death;
subacute (protracted) - due to blockage of large and medium branches of the pulmonary artery and the development of multiple pulmonary infarcts. It lasts for several weeks, accompanied by an increase in respiratory and heart failure. Recurrent thromboembolism may occur with exacerbation of symptoms, in which death often occurs;
chronic (recurrent) - characterized by repeated thrombosis of medium and small branches of the pulmonary artery. It is manifested by repeated pulmonary infarctions or repeated pleurisy (inflammation of the pleura - the outer lining of the lungs), as well as a gradually increasing increase in pressure in the pulmonary circulation and the development of heart failure.

Causes

Source of thrombus (blood clot):
- for most patients, the source of the thrombus is the veins of the lower extremities and pelvis;
- less often - a thrombus:
  - initially located in the right atrium (with atrial fibrillation - non-rhythmic work of the heart);
  - on the leaflets of the heart valves (with infective endocarditis, that is, inflammation of the inner lining of the heart);
  - in the renal or hepatic veins;
  - in the system of the superior vena cava (veins of the arms, subclavian vein).

As the thrombus moves along the vascular bed, it may break into fragments. This leads to the simultaneous closure of several arteries of the lung. There is simultaneous thromboembolism of the arteries of the right and left lungs.

Greatest risk of venous thrombosis and pulmonary embolism - in patients with increased blood clotting. These are the patients:
- with oncological diseases (tumors located in any organs);
- sedentary people - patients who observe bed rest after surgery, strokes (cerebrovascular accidents), injuries; elderly, obese patients;
- patients with a history of venous thrombosis (formation of blood clots), a hereditary predisposition to increased blood clotting, varicose veins (thinning of the vein wall with the formation of its protrusion, most often located on the lower extremities);
- with sepsis - a severe pathological condition characterized by infection in the blood and disruption of all organs and systems of the body;
- with hereditary blood diseases, characterized by its increased ability to coagulate;
- with antiphospholipid syndrome - a condition characterized by the production of antibodies to one's own cells, in particular, to platelets (blood cells responsible for blood clotting), as a result of which the ability to form blood clots increases.

Predisposing factors for PE:
- prolonged state of immobility (bed patients, prolonged bed rest in the postoperative period);
- varicose veins - a disease accompanied by the expansion of the wall of the veins;
- smoking;
- obesity;
- elderly age;
- anticancer therapy (chemotherapy);
- taking a large number of diuretics;
- massive trauma or surgery;
- an indwelling catheter (a device through which drugs are administered) in a vein.

Diagnostics

Analysis of the history of the disease and complaints (when (how long ago) did shortness of breath, chest pain, weakness, fatigue appear, is there a cough with blood, with which the patient associates the occurrence of these symptoms).
Life history analysis. It turns out what the patient and his close relatives were ill with, whether there were cases of thrombosis (formation of blood clots) in the family, whether the patient took any drugs (hormones, drugs for weight loss, diuretics), whether tumors were detected in him, whether he was in contact with toxic (poisonous) substances. All these factors can trigger the onset of the disease.
Physical examination. The color of the skin, the presence of edema, noises when listening to heart sounds, stagnation in the lungs, and whether there are zones of a “silent lung” (areas where breath sounds are not heard) are determined.
Analysis of blood and urine. It is carried out to identify comorbidities that can affect the course of the disease, to identify complications of the disease.
Blood chemistry. The level of cholesterol (a fat-like substance), blood sugar, creatinine and urea (protein breakdown products), uric acid (a breakdown product of substances from the cell nucleus) is determined to identify concomitant organ damage.
Determination of blood troponin T or I (substances that are normally inside the cells of the heart muscle and released into the blood when these cells are destroyed) - helps to identify the presence of acute myocardial infarction (death of a section of the heart muscle due to a cessation of blood flow to it), the signs of which resemble PE.
A detailed coagulogram (determination of indicators of the blood coagulation system) - allows you to determine increased blood clotting, a significant consumption of coagulation factors (substances used to build blood clots), to identify the appearance of blood clots decay products (normally there should be no clots and their decay products).
Determination of the amount of D-dimers in the blood (a product of the destruction of a blood clot) - this substance indicates the presence of a blood clot in the body with a prescription of no more than 14 days. Ideally, the examination of a patient with suspected PE should begin with this study. If the result of the study is negative, thromboembolism that occurred in the last two weeks is excluded.
Electrocardiography (ECG). With massive pulmonary embolism, ECG signs of acute cor pulmonale (overload of the right heart) occur: syndrome S1 Q3 T3. The absence of ECG changes does not exclude the presence of PE. In some cases, the ECG picture resembles signs of acute myocardial infarction (death of a section of the heart muscle) of the posterior wall of the left ventricle.
Plain chest x-ray - allows you to exclude lung diseases that can give similar symptoms, as well as to see the area of \u200b\u200bpneumonia infarction (inflammation of the area of \u200b\u200bthe lung that received blood from a vessel closed by a blood clot). In almost a third of patients, radiographic signs of embolism are absent.
Echocardiography (ultrasound examination (ultrasound) of the heart) - allows you to detect the occurrence of acute cor pulmonale (enlargement of the right heart), assess the condition of the valves and myocardium (heart muscle). With its help, it is possible to detect blood clots in the cavities of the heart and large pulmonary arteries, to determine the severity of the increase in pressure in the pulmonary circulation. The absence of changes in echocardiography does not exclude the diagnosis of PE.
Ultrasound scanning of the veins of the lower extremities (USDG, duplex, triplex) - makes it possible to detect the source of blood clots. It is possible to assess the location, extent, size of blood clots, to assess the risk of their separation, that is, the risk of recurrent thromboembolism.
Consultation.
Modern methods for diagnosing PE are performed with a positive blood test for D-dimer (a level of more than 0.5 mg/l). These studies allow you to determine the localization (location) and size of the lesion, even see the vessel closed by a thrombus. They require the use of expensive equipment and highly qualified specialists, therefore they are not used in all hospitals.

Modern methods for diagnosing PE include:

spiral computed tomography of the lungs (spiral CT) is an X-ray method of examination that allows you to identify a problem area in the lungs;
angiopulmonography - X-ray examination of the vessels of the lungs with the introduction of contrast - a special substance that makes the vessels visible on the X-ray;
lung perfusion scintigraphy is a method for assessing pulmonary blood flow, in which radioactively labeled protein particles are injected intravenously into the patient. These particles pass freely through large lung loans, but get stuck in small ones and emit gamma rays. A special camera captures gamma rays and translates them into an image. By the number of stuck protein particles, it is possible to estimate the size and location of the zone of deterioration in pulmonary blood flow;
color Doppler study of blood flow in the chest (ultrasound research method).

Treatment of pulmonary embolism

Treatment of PE depends on the volume of pulmonary vascular lesions and the state of hemodynamics (blood pressure, heart rate, etc.).

Oxygen therapy is the inhalation of a mixture of gases enriched with oxygen.
Taking anticoagulants (substances that impair blood clotting) - helps prevent the formation of new blood clots (blood clots).
- With the defeat of small and medium branches of the pulmonary artery and intact hemodynamics (close to normal blood pressure and heart rate), the use of anticoagulants is sufficient, since the dissolution of the formed small blood clots occurs independently.
- They use intravenous or subcutaneous administration of direct anticoagulants - drugs from the groups of unfractionated heparin (prevent the appearance of blood clots, reducing its clotting; it is necessary to use at least 4 times a day and constantly conduct a blood test to monitor clotting) and low molecular weight heparins (also reduce blood clotting , but are applied 2 times a day and give less bleeding at the injection sites).
- Before discontinuation of drugs from the heparin groups, the patient is prescribed indirect anticoagulants (drugs in tablets that slow down blood clotting) for at least 6 months. This reduces the risk of recurrent thromboembolism.

Thrombolytic therapy is vital for patients with massive pulmonary embolism and severe pulmonary dysfunction. In the patient's vein, drugs from the group of thrombolytics are injected, which dissolve the formed blood clots.
Embolectomy is the surgical removal of a blood clot from a pulmonary artery. It is used urgently for the most severe patients - with the closure of the pulmonary artery trunk or both of its main branches, a pronounced violation of pulmonary blood flow, low systolic (the first digit when measured) blood pressure. Operations are performed according to various methods, accompanied by an extremely high risk. The most promising is the removal of blood clots by percutaneous vascular access, that is, by piercing the skin and introducing special devices into the patient's vessels under the control of an X-ray machine. If necessary, an open operation is performed under cardiopulmonary bypass, which saves every second of previously hopeless patients.
With a recurrent (repeating PE) course, the installation of a cava filter is indicated (a special device installed in the system of the inferior vena cava, which prevents blood clots from entering the pulmonary artery).
Antibiotics - for pulmonary infarction (infarction pneumonia (pneumonia)).

Complications and consequences

With massive PE - sudden death.
Pulmonary infarction (infarction pneumonia) - the death of a section of the lung with the development of an inflammatory process at this site.
Pleurisy (inflammation of the pleura, the outer lining of the lungs).
Respiratory failure (lack of oxygen in the body).
Relapse (repeated thromboembolism), more often during the first year.

Prevention of pulmonary embolism

There are primary, that is, before the occurrence of pulmonary embolism in people at high risk, and secondary prevention - the prevention of repeated episodes of thromboembolism.
Primary prevention of PE - This is a set of measures to prevent venous thrombosis (the formation of blood clots in veins - vessels that carry blood away from organs) in the system of the inferior vena cava. This set of measures should be used to prevent the disease in all sedentary patients. It is used by doctors of any specialty. Includes:

elastic bandaging of the lower extremities;
early activation of patients (refusal of prolonged bed rest, performance of increasing physical exertion) after surgery, cerebrovascular accident or heart attack (death of a section of the heart muscle);
medical gymnastics;
taking anticoagulants (drugs that reduce blood clotting) - used in cases of high risk of thromboembolic complications;
surgical removal of a part of the vein of the lower extremities filled with blood clots;
implantation (installation) of a cava filter - used to prevent thromboembolism in people with blood clots in the vessels of the lower extremities. The filter trap of various design is fixed below the mouths of the renal veins in the inferior vena cava. Such a trap freely passes normal blood flow, but delays detached blood clots and does not allow them to penetrate further. The cava filter can be replaced as needed;
intermittent pneumocompression of the lower extremities (inflating and deflating special balloons worn on the legs). With this method, edema is reduced in case of varicose veins of the lower extremities (thinning of the section of the vein wall with the formation of a protrusion in which blood clots can accumulate), oxygen supply to all tissues of the legs improves, and the body's ability to dissolve formed blood clots increases;
giving up bad habits (smoking, drinking alcohol).

Secondary prevention of PE (prevention of repeated thromboembolism) is vital, since the patient may die not from the first, but from subsequent thromboembolism. Are used:

taking direct and indirect anticoagulants;
implantation (installation) of a cava filter (traps for blood clots).