Valenzuela T D
Department of Surgery, University of Arizona College of Medicine, Tucson.
Emerg Med Clin North Am. 1988 May;6(2):253-66.
Pulmonary embolism remains a challenging problem in diagnosis and management for the emergency physician. Although its clinical presentation is protean and often ambiguous, risk stratification can be accomplished based on the predictive power of a limited number of physical and historical characteristics. Ventilation-perfusion lung scanning occupies a central position in the work-up of suspected PE; however, evidence exists that it may be misused by many physicians. A low probability V-Q scan does not exclude the diagnosis of PE. Patients with other than normal- or high-probability patterns of pulmonary ventilation and perfusion on lung scanning require further investigation. Noninvasive venous studies are useful when indicative of proximal deep venous thrombosis, but are normal in many patients with acute PE. Heparin remains the standard of treatment for most patients with PE. Vena cava filters effectively reduce the incidence of recurrent PE in patients with contraindications to anticoagulation. Thrombolytic therapy offers potential advantages in the treatment of patients with shock due to their PE. Case reports of PE treated with tissue-type plasminogen activator, a new thrombus-specific fibrinolytic agent, are encouraging but preliminary.
对于急诊医生而言，肺栓塞在诊断和治疗方面仍然是一个具有挑战性的问题。尽管其临床表现多样且常常模糊不清，但基于有限数量的体格检查和病史特征的预测能力，可进行风险分层。通气-灌注肺扫描在疑似肺栓塞的检查中占据核心地位；然而，有证据表明许多医生可能会滥用该检查。低概率的通气-灌注扫描并不能排除肺栓塞的诊断。肺扫描显示肺通气和灌注模式既非正常也非高概率的患者需要进一步检查。当无创静脉检查提示近端深静脉血栓形成时很有用，但在许多急性肺栓塞患者中结果为正常。肝素仍然是大多数肺栓塞患者的治疗标准。对于有抗凝禁忌证的患者，腔静脉滤器可有效降低复发性肺栓塞的发生率。溶栓治疗在治疗因肺栓塞导致休克的患者中具有潜在优势。用新型血栓特异性纤溶药物组织型纤溶酶原激活剂治疗肺栓塞的病例报告令人鼓舞，但尚属初步结果。
