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Thromboembolism of a pulmonary artery
June 15, 2012
The thromboembolism of a pulmonary artery (the reduced option — TELA) is a morbid condition at which blood clots sharply cork branches of a pulmonary artery. Blood clots develop initially in veins of a big circle of blood circulation of the person.
Today very high percent of the people having cardiovascular diseases dies owing to development of a thromboembolism of a pulmonary artery. TELA a cause of death of patients during the period after operation becomes rather frequent. According to medical statistics, the fifth part of all people with display of a pulmonary thrombembolia dies approximately. At the same time the lethal outcome in most cases comes in the first two hours after development of an embolism.
Specialists claim that it is difficult to determine TELA frequency as about a half of cases of an illness passes imperceptibly. The general symptoms of a disease are often similar to symptoms of other diseases therefore diagnosis often happens wrong.
Reasons of a thromboembolism of pulmonary arteries
Most often the thromboembolism of a pulmonary artery arises because of the blood clots which initially developed in deep veins of legs. Therefore, most often development of a deep vein thrombosis of legs is the main reason of a thromboembolism of a pulmonary artery. In more exceptional cases the thromboembolism is provoked by blood clots from veins of the right departments of heart, a cavity of a stomach, a basin, upper extremities. Very often blood clots develop at those patients who owing to other illnesses constantly observe a bed rest. Most often it is people who have a myocardial infarction, pulmonary diseases, and also those who received injuries of a spinal cord transferred an operative measure on a hip. Considerably the risk of development of a thromboembolism in patients with thrombophlebitis increases. Very often TELA is shown as complication of cardiovascular illnesses: rheumatism, infectious endocarditis, cardiomyopathy, hypertension, coronary heart disease.
However TELA sometimes strikes also people without symptoms of chronic diseases. Usually it happens if the person a long time stays in forced situation, for example, often makes flights by the airplane.
That in a human body blood clot was formed, the following conditions are necessary: existence of damage of a vascular wall, the slowed-down blood stream in the place of damage, high coagulability of blood.
Damage of walls of a vein often happens at inflammations, in the course of injuries, and also at intravenous injections. In turn, the blood flow is slowed down because of development in the patient of heart failure, at long forced situation (carrying gypsum, a bed rest).
As the reasons for the increased coagulability of blood doctors define a number of disturbances of hereditary character, also similar state can provoke the use of oral contraceptives, a disease of AIDS. Higher risk of emergence of blood clots is defined at pregnant women, at the people having the second blood group and also at patients with obesity.
Blood clots which one end fasten to a vascular wall are the most dangerous, and the free end of blood clot at the same time is in a vessel gleam. Sometimes there are enough only small efforts (the person can cough, make the sharp movement, strain), and there is a separation of such blood clot. Further with a blood-groove blood clot appears in a pulmonary artery. In certain cases blood clot hits against vascular walls and breaks into small parts. In that case there can be an obstruction of small vessels in lungs.
Symptoms of a thromboembolism of pulmonary arteries
Specialists define three types of TELA, is dependent on what volume of defeat of vessels of lungs is observed. At massive TELA more than 50% of vessels of lungs are surprised. In this case symptoms of a thromboembolism are expressed by shock, sharp falling of arterial pressure, a loss of consciousness, insufficiency of function of a right ventricle takes place. Cerebral disturbances become a brain hypoxia effect at a massive thromboembolism sometimes.
The submassive thromboembolism is defined at defeat from 30 to 50% of vessels of lungs. At such form of a disease of people suffers from an asthma, however arterial pressure remains normal. Disturbance of functions of a right ventricle is expressed less.
At not massive thromboembolism function of a right ventricle is not broken, however the patient suffers from an asthma.
According to sharpness of a disease the thromboembolism is subdivided into acute, subacute and recurrent chronic. At an acute form of an illness of TELA begins sharply: hypotonia, severe pain in a breast, an asthma is shown. In case of a subacute thromboembolism increase of right ventricular and respiratory insufficiency, symptoms of infarctive pneumonia takes place. The recurrent chronic form of a thromboembolism differs in repetition of an asthma, pneumonia symptoms.
Thromboembolism symptoms directly depend on as far as massiven process, and also from a condition of vessels, heart and the patient's lungs. The main signs of development of a pulmonary thromboembolism is severe short wind and hurried breathing. Display of short wind, as a rule, sharp. If the patient stays in lying situation, then it becomes easier for it. Developing of short wind – the first and most characteristic symptom of TELA. An asthma demonstrates development of acute respiratory insufficiency. It can be expressed differently: sometimes it seems to the person that to him does not gasp a little, in other cases an asthma is shown is especially expressed. Also a symptom of a thrombembolia is severe tachycardia: heart is reduced with a frequency more than 100 beats per minute.
Except short wind and tachycardia pain in a thorax or feeling of some discomfort is shown. Pain can be different. So, most of patients notes sharp knife-like pain behind a breast. Pain can proceed both several minutes, and several hours. If the embolism of the main trunk of a pulmonary artery develops, then pain can have the tearing apart character and be felt behind a breast. At a massive thromboembolism pain can extend for area of a breast. The embolism of small branches of a pulmonary artery can be shown in general without pain. In certain cases there can be an expectoration of blood, a posineniye or blanching of lips, nose ears.
When listening the specialist finds rattles in lungs, systolic noise over area of heart. When carrying out an ekhokardiogramma blood clots in pulmonary arteries and the right departments of heart are found, signs of dysfunction of a right ventricle also take place. On a X-ray changes in the patient's lungs are visible.
As a result of obstruction pumping function of a right ventricle decreases owing to what not enough blood comes to a left ventricle. It is fraught with reduction of blood in an aorta and an artery that provokes sharp lowering of arterial pressure and a state of shock. Under such circumstances at the patient the myocardial infarction, an atelectasis develops.
Often at the patient increase of body temperature to subfebrile, sometimes febrile indicators is observed. It is connected with the fact that many biologically active agents are thrown out blood. Fever can proceed from two days to two weeks. Several days later after a pulmonary thromboembolism some people can have thorax pain, cough, an expectoration of blood, pneumonia symptoms.
Diagnosis of a thromboembolism of a pulmonary artery
In the course of diagnosis physical inspection of the patient is made for identification of certain clinical syndromes. The doctor can define short wind, arterial hypotonia, determines the body temperature which increases already during the first hours developments of TELA.
The main methods of inspection at a thromboembolism have to include carrying out an ECG, X-ray analysis of a thorax, an ekhokardiogramma, a biochemical blood analysis.
It should be noted that approximately in 20% of cases development of a thromboembolism cannot be defined by an ECG as no changes are observed. There is a number of the specific characters defined during the specified researches.
Ventilating and perfused scanning of lungs is considered the most informative method of research. Also research is conducted by an angiopulmonografiya method.
In the course of diagnosis of a thromboembolism also carrying out tool inspection during which the doctor defines existence of phlebothromboses of the lower extremities is shown. The X-ray contrast flebografiya is applied to detection of a vein thrombosis. Carrying out ultrasonic dopplerography of vessels of legs allows to reveal disturbances of passability of veins.
Treatment of a thromboembolism of a pulmonary artery
Treatment of a thromboembolism is directed, first of all, to activation of perfusion of lungs. Also the purpose of therapy is the prevention of displays of post-embolic chronic pulmonary hypertensia.
If there was a suspicion on development of TELA, then at the stage preceding hospitalization it is important to provide at once to the patient observance of the most strict bed rest. It will allow to prevent recurrence of a thromboembolism.
Catheterization of the central vein is made for infusional treatment, and also careful tracking of the central venous pressure. If acute respiratory insufficiency takes place, to the patient make a trachea intubation. To reduce severe pain and to unload a small circle of blood circulation, the patient needs to accept narcotic analgetics (for this purpose mainly use 1% morphine solution). This drug also effectively reduces an asthma.
To patients at whom acute insufficiency of a right ventricle is observed shock, arterial hypotension, intravenously enter reopoliglyukin. However this drug is contraindicated with a high central venous pressure.
For the purpose of pressure decline in a small circle of blood circulation intravenous administration of an Euphyllinum is appointed. If systolic arterial pressure does not exceed 100 mm of mercury., this drug is not used. If infarctive pneumonia is diagnosed for the patient, to him appoint therapy antibiotics.
To recover passability of a pulmonary artery, both conservative, and surgical treatment is applied.
Methods of conservative therapy include implementation of a thrombolysis and ensuring prevention of thrombosis for the prevention of a repeated thromboembolism. Therefore thrombolytic treatment for operational recovery of a blood flow through okklyuzirovanny pulmonary arteries is carried out.
Such treatment is carried out if the doctor is confident in the accuracy of diagnosis and can provide complete laboratory control of process of therapy. It is necessary to consider surely a number of contraindications for use of such treatment. It the first ten days after carrying out operation or getting injured, existence of the accompanying illnesses at which the risk of hemorrhagic complications, an active form of tuberculosis, hemorrhagic diathesis, a gullet varicosity takes place.
If there are no contraindications, then treatment with heparin begin at once after the diagnosis was established. Doses of drug should be selected individually. Therapy continues purpose of indirect anticoagulants. Warfarin the patient not less than three months are shown to accept drug.
Removal of blood clot is shown to people who have accurate contraindications to carrying out thrombolytic therapy by a surgical method (thrombectomy). Installation of kava-filters in vessels is also in certain cases reasonable. These are mesh filters which can detain the come-off blood clots and do not allow them to get into a pulmonary artery. Such filters are entered through skin – mainly through an internal jugular or femoral vein. Establish them in renal veins.
Prevention of a thromboembolism of a pulmonary artery
For prevention of a thromboembolism it is important to know what states contribute to emergence of venous thromboses and a thromboembolism. Especially people who suffer from chronic heart failure should show consideration for own state, are forced long time to observe a bed rest, pass massive diuretic treatment, throughout a long time accept hormonal contraceptives. Besides, risk factor is a number of system diseases of connecting fabric and system vasculites, a diabetes mellitus. The risk of development of a thromboembolism increases at strokes, injuries of a spinal cord, long stay of a catheter in the central vein, existence of oncological diseases and carrying out chemotherapy. Especially it is necessary to show consideration for a condition of own health that for whom the varicosity of legs, to the corpulent people sick with oncological diseases is diagnosed. Therefore, for avoiding of development of a thromboembolism of a pulmonary artery it is important to leave a condition of a postoperative bed rest in time, to treat thrombophlebitis of veins of legs. Preventive treatment is shown to people who treat risk groups by low-molecular heparins.
Reception of antiagregant is periodically actual for the prevention of displays of a thrombembolia: that there can be small doses of acetylsalicylic acid.
Section: Diseases of vessels