Pacouret Gérard, Charbonnier Bernard, Puglisi Raphaël, Frémont Benoît, de Labriolle Axel
Unité de soins cardiaques intensifs, service de cardiologie A, hôpital Trousseau, CHRU de Tours, 37044 Tours Cedex 1.
Rev Prat. 2007 Apr 15;57(7):743-6, 748-50.
The diagnosis of major pulmonary embolism should be considered in case of acute respiratory distress, particularly in high thrombo-embolic risk situation. Clinical examination, combined with blood gas analysis, electrocardiogram and chest X-ray are generally suggestive of pulmonary embolism but are not sufficient. In patients with shock, hypotension or after cardiac arrest (massive forms), bedside transthoracic echocardiography is the first choice diagnostic test whereas CT-scan should be considered in less severely ill patients. Troponin dosage and measurement of right upon left ventricular diameter ratio (by echocardiography or CT-scan) are mandatory in the prognostic evaluation of submassive forms (i.e. hemodynamically stable patients with right ventricular dysfunction). Thrombolysis is clearly indicated in patients suffering from massive pulmonary embolism and should be discussed in young patients (less than 70 years), with no identified bleeding risk, suffering from submassive form when troponin rate is increased and/or ventricular diameter ratio is over 0.9. Surgical embolectomy should be considered in case of contraindication or failure of thrombolysis.
在出现急性呼吸窘迫时，尤其是在高血栓栓塞风险情况下，应考虑诊断为大面积肺栓塞。临床检查结合血气分析、心电图和胸部X线检查通常提示肺栓塞，但并不充分。对于休克、低血压患者或心脏骤停后（大面积形式）的患者，床旁经胸超声心动图是首选诊断检查，而对于病情较轻的患者应考虑进行CT扫描。在次大面积形式（即血流动力学稳定但有右心室功能障碍的患者）的预后评估中，必须检测肌钙蛋白并测量右心室与左心室直径比（通过超声心动图或CT扫描）。大面积肺栓塞患者明确需要溶栓治疗，对于年轻患者（小于70岁）、无明确出血风险、次大面积形式且肌钙蛋白水平升高和/或心室直径比超过0.9的患者，应讨论是否进行溶栓治疗。在溶栓治疗禁忌或失败的情况下，应考虑手术取栓。
