内科7--肺栓塞.pptVIP

图12000年8月27日（急诊）ECG大致正常 2000年8月29日（门诊）ECG示IRBBB SⅠQⅢTⅢV1V2T波倒置V3V4T波双向 二、X线胸片 急性PTE患者的胸片除少见的肺阴影或胸腔积液外，最为常见的是肺纹理稀疏，区域性肺透过度增强和肺血分布不匀。肺梗死时可见肺周围浸润性阴影，形状不一常累及肋膈角，也可出现盘状肺不张。 肺栓塞胸片检查 Peer Review Status: Externally Peer Reviewed by the AMA X-RAY FOR CHEST Atelectasis and parenchymal. Atelectasis are more common in the lower lobe as are the areas of parenchymal density Most of these densities are caused by pulmonary hemorrhage and edema and can be confused with infectious infiltrates or malignant masses Pleural effusions are common and most often unilateral despite the fact that most clots are bilateral. These effusions are usually visible when the patient seeks medical attention. They are almost always small, occupying less than 15% of a hemithorax and rarely increase in size after 3 days. Any increase in size after 3 or 4 days should raise the suspicion of a pulmonary infection or re-embolization. Pleural based opacities with convex medial margins are also known as a Hamptons Hump. This may be an indication of lung infarction. However, that rate of resolution of these densities is the best way to judge if lung tissue has been infarcted. Areas of pulmonary hemorrhage and edema resolve in a few days to one week. The density caused by an area of infarcted lung will decrease slowly over a few weeks to months and may leave a linear scar. The central pulmonary arteries may be prominent either from pulmonary hypertension or the presence of clot in those arteries. 三、超声心动图 直接征象:为主肺动脉及左、右肺动脉主干存在血栓回声 间接征象：右心房、室扩大，室间隔左移，左室由椭圆形变为“D”字形，右室壁收缩减弱，三尖瓣返流、跨瓣压差增加，以及估测肺动脉压增高等。 Color-Flow-Doppler-ultrasound 非挤压性充盈缺损 四、血气分析 是诊断肺栓塞可能有用的筛选方法。肺栓塞患者多有PaCO2下降，PH升高，肺泡-动脉血氧分压差（PA-aDO2）增加，PaO2下降或正常；当血管床堵塞15%—20%时可出现低氧血症，发生率约76%。93%有低碳酸血症；86%—95%有（PA-aDO2）增大，后二者正常有助于排除较大肺栓塞。 五、D-二聚体 很难用这项指标指导临床。 六、核素检查 据不完全统计，国内有超过1/3的医院在目前仍不能进行此项检查。 七、肺动脉造影： 是PTE诊断的“金标准” 不首选。 正常肺动脉造影 This selective study was done because of a perfusion defect in the left lower lobe on a ventilat