Тромбоэмболия легочной артерии
Тромбоэмболия легочной артерии (ТЭЛА) – это острая закупорка основного ствола или ветвей легочной артерии эмболом (тромбом) или иными объектами (капли жира, частицы костного мозга, опухолевые клетки, воздух, фрагменты катетеров), приводящая к резкому снижению легочного кровотока.
Причины
Установлено, что источником венозного эмбола в 85 % случаев является система верхней полой вены и вены нижних конечностей и малого таза, значительно реже – правые отделы сердца и вены верхних конечностей. В 80–90 % случаев у больных выявляют предрасполагающие к ТЭЛА факторы, наследственные и приобретенные. Наследственные предрасполагающие факторы связаны с мутацией определенного локуса хромосом. Врожденную предрасположенность можно заподозрить, если необъяснимый тромбоз возникает в возрасте до 40 лет при наличии сходной ситуации у близких родственников.
Приобретенные предрасполагающие факторы:
1) заболевания сердечно-сосудистой системы: застойная сердечная недостаточность, мерцательная аритмия, клапанные пороки сердца, ревматизм (активная фаза), инфекционный эндокардит, гипертоническая болезнь, кардиомиопатии; во всех случаях ТЭЛА возникает тогда, когда патологический процесс поражает правые отделы сердца;
2) вынужденная обездвиженность сроком не менее 12 недель при переломах костей, парализованных конечностях;
3) длительный постельный режим, например при инфаркте миокарда, инсульте;
4) злокачественные новообразования; наиболее часто ТЭЛА возникает при раке поджелудочной железы, легких, желудка;
5) оперативные вмешательства на органах брюшной полости и малого таза, нижних конечностях; особенно коварен своими тромбоэмболическими осложнениями послеоперационный период в связи с использованием постоянного катетера в центральной вене;
6) прием некоторых лекарственных препаратов: пероральных контрацептивов, мочегонных средств в высоких дозах, заместительная гормональная терапия; бесконтрольное употребление мочегонных и слабительных средств вызывает обезвоживание организма, сгущение крови и значительно повышает риск тромбообразования;
7) беременность, оперативное родоразрешение;
9) тромбофилические состояния – это патологические состояния, связанные со склонностью организма к образованию тромбов внутри сосудов, что обусловлено расстройствами механизмов свертывающей системы крови; существуют врожденные и приобретенные тромбофилические состояния;
10) антифосфолипидный синдром – это симптомокомплекс, характеризующийся появлением в организме специфических антител к фосфолипидам, являющимся составной частью клеточных мембран, собственных тромбоцитов, клеток эндотелия, нервной ткани; в результате каскада аутоиммунных реакций происходит разрушение этих клеток и высвобождение биологически активных агентов, что, в свою очередь, является основой патологического тромбообразования различной локализации;
11) сахарный диабет;
12) системные заболевания соединительной ткани: системные васкулиты, системная красная волчанка и др.
Симптомы
Остро возникшая одышка, учащенное сердцебиение, падение артериального давления, боль в грудной клетке у лиц с факторами риска тромбоэмболий и проявлениями тромбоза вен нижних конечностей заставляют заподозрить ТЭЛА.
Главный признак ТЭЛА – одышка. Для нее характерны внезапное возникновение и различная степень выраженности: от нехватки воздуха до заметного удушья с посинением кожи. В большинстве случаев это «тихая» одышка без шумного дыхания. Больные предпочитают находиться в горизонтальном положении, не ищут себе удобного положения.
Боли в грудной клетки – второй по частоте возникновения симптом ТЭЛА. Продолжительность приступа боли может быть от нескольких минут до нескольких часов. При эмболии мелких ветвей легочной артерии болевой синдром способен отсутствовать или быть не выражен. Тем не менее не всегда прослеживается зависимость интенсивности болевого синдрома от калибра закупоренного сосуда. Иногда тромбоз мелкого сосуда может давать инфарктоподобный болевой синдром. Если в патологический процесс вовлекается плевра, возникают плевральные боли: колющие, связанные с дыханием, кашлем, движениями туловища.
Нередко встречается абдоминальный синдром, обусловленный, с одной стороны, правожелудочковой сердечной недостаточностью, а с другой – рефлекторным раздражением брюшины с вовлечением диафрагмального нерва. Абдоминальный синдром проявляется разлитыми или четко определяемыми болями в области печени (в правом подреберье), тошнотой, рвотой, отрыжкой, вздутием живота.
Кашель появляется спустя 2–3 суток после возникновения ТЭЛА. Он выступает признаком инфарктной пневмонии. У 25–30 % больных при этом наблюдается отхождение кровавой мокроты.
Немаловажным является повышение температуры тела. Обычно она растет с первых часов заболевания и достигает субфебрильных цифр (до 38 °C).
При осмотре больного бросается в глаза синюшность кожных покровов. Чаще всего синюшная кожа имеет пепельный оттенок, но при массивной ТЭЛА возникает эффект «чугунного» цвета на лице, шее, верхней половине туловища. Кроме этого, ТЭЛА всегда сопровождают нарушения сердечной деятельности. Кроме учащения пульса, появляются признаки правожелудочковой сердечной недостаточности: набухание и пульсация шейных вен, тяжесть и боль в правом подреберье, пульсация в подложечной области.
При предшествующем ТЭЛА тромбозе вен нижних конечностей сначала появляются боль в области стопы и голени, нарастающая при движении в голеностопном суставе и ходьбе, боль в икроножных мышцах при тыльном сгибании стопы. Отмечают болезненность при ощупывании голени вдоль пораженной вены, видимый отек либо асимметрию окружностей голеней (более 1 см) или бедер (более 1,5 см) на уровне 15 см выше надколенника.
Неотложная помощь
Необходимо вызвать «скорую помощь». Следует помочь занять больному сидячее положение или уложить его с приподнятой головой, ослабить стесняющую одежду, удалить зубные протезы, обеспечить доступ свежего воздуха. Пациента по возможности нужно успокоить, не давать ему есть и пить, не оставлять одного.
При выраженном болевом синдроме показаны наркотические анальгетики, которые еще и дополнительно уменьшают одышку. Оптимальным препаратом является 1 %-ный раствор морфина гидрохлорида: 1 мл следует развести до 20 мл изотоническим раствором натрия хлорида. При таком разведении 1 мл полученного раствора содержит 0,5 мг действующего вещества. Вводят препарат по 2–5 мг с интервалом 5—15 мин. Если интенсивный болевой синдром сочетается с выраженным психоэмоциональным возбуждением больного, то можно использовать нейролептаналгезию – 1–2 мл 0,005 % – ного раствора фентанила вводят в сочетании с 2 мл 0,25 %-ного раствора дроперидола. Противопоказанием к нейролептаналгезии является снижение артериального давления. Если болевой синдром не выражен и боли связаны с дыханием, кашлем, изменениями положения тела, что яв ляется признаком инфарктной пневмонии, то целесообразнее воспользоваться ненаркотическими анальгетиками: 2 мл 50 %-ного раствора метамизола натрия или 1 мл (30 мг) кеторолака.
При подозрении на ТЭЛА как можно раньше следует начать антикоагулянтную терапию, так как от этого непосредственно зависит жизнь больного. На догоспитальном этапе одномоментно внутривенно вводят 10 000—15 000 ЕД гепарина. Противопоказанием для назначения антикоагулянтной терапии при ТЭЛА являются активное кровотечение, риск развития жизнеопасных кровотечений, наличие осложнений антикоагулянтной терапии, планируемая интенсивная химиотерапия. При снижении артериального давления показано капельное вливание реополиглюкина (400,0 мл внут ривенно медленно).
В случае развития шокового состояния необходимы прессорные амины (1 мл 0,2 %-ного раствора норадреналина битартрата) под контролем артериаль ного давления ежеминутно. При выраженной правожелудочковой сердечной недостаточности назначают внутривенно допамин в дозировке 100–250 мг/кг массы тела/мин. При выраженной острой дыхательной недостаточности требуются кислородотерапия, бронхолитические средства (5 мл 2,4 %-ного раствора эуфиллина внутривенно медленно, осторожно назначать при артериальном давлении ниже 100 мм рт. ст.). Антиаритмические средства вводят по показаниям. В случае остановки сердца и дыхания следует немедленно приступать к реанимационным мероприятиям (см. главу 1).
В 1/3 случаев причиной внезапной смерти является тромбоэмболия легочной артерии (ТЭЛА). Это закупорка легочной артерии кровяным сгустком, в результате чего нарушается функционирование легкого. Больному нужно предоставить медицинскую помощь.
Симптомы тромбоэмболии
Признаки появляются внезапно. Тяжесть клинической картины зависит от размера кровяного сгустка и места его локализации.
Если оторвался тромб, возникают такие симптомы:
- одышка;
- учащение сердцебиения и пульса;
- боль в грудной клетке;
- припухлость вен на шее;
- кашель с отделением мокроты с прожилками крови;
- отек верхней части тела;
- головокружение;
- сонливость.
В результате заболевания развивается инфаркт легких. При массивном поражении сосудов легких (более 50%) человек может потерять сознание, появляются судороги конечностей.
Важно. Более 20% случаев ТЭЛА заканчиваются летальным исходом, причем около 50% больных умирает в первые 2 ч. после появления первых симптомов.
Тромб при тромбоэмболии всегда является фрагментов другого тромба, который образовался вне легочной артерии. Даже отрыв тромба в ноге может спровоцировать ТЭЛА. На фото видна эта взаимосвязь.
Как помочь человеку
Предоставлять неотложную помощь необходимо при первых симптомах ТЭЛА. Это заболевание требует немедленного вмешательства врачей.
Именно первые 2 ч. играют решающую роль. Если не помочь человеку в этот промежуток времени, то летальный исход неизбежен.
Первая помощь при тромбоэмболии легочной артерии направлена на предотвращение острой сердечной недостаточности.
Все препараты вводят внутривенно. Если лекарственных препаратов под рукой нет, необходимо немедленно везти пострадавшего в больницу.
Инструкция по неотложной помощи при тромбоэмболии легочной артерии.
Действие | Описание |
---|---|
Вызвать скорую помощь. | |
Больного нужно уложить на ровную поверхность и обеспечить ему покой. | |
Внутривенно ввести обезболивающее средство, например «Промедол» с «Анальгином» или «Фентанил» с «Дроперидолом». | |
Внутривенно ввести «Гепарин» Если верхнее давление ниже 100 мм рт. ст., этот препарат не вводят. |
|
При низком АД необходимо ввести подкожно 2-4 мл раствора «Кордиамина» или капельно 10% раствора «Реополиглюкина». | |
Поставить капельницу «Эуфиллина» (сосудорасширяющее средство). | |
Ввести раствор «Лазикс» (мочегонное средство). | |
Поставить капельницу «Фибринолизина» или «Стрептокиназы» в растворе хлорида натрия. |
Дальнейшие действия по спасению жизни пациента медики проводят в стенах больницы. Больной в обязательном порядке подлежит госпитализации.
Более подробно о симптомах ТЭЛА в видео к этой статье
Алгоритм действий первой помощи при ТЭЛА зависит от тяжести состояния потерпевшего. Если констатируется клиническая смерть, то необходимо провести реанимационные мероприятия. При тяжелом состоянии нужна экстренная катетеризация центральной вены.
Тромбоэмболия легочной артерии – опасное состояние. Даже своевременная терапия не всегда помогает спасти жизнь пациенту. Единственный способ избежать ТЭЛА – это регулярное наблюдение у терапевта и профилактика тромбоза.
РЦРЗ (Республиканский центр развития здравоохранения МЗ РК)
Версия: Клинические протоколы МЗ РК — 2014
Общая информация
Краткое описание
ТЭЛА — окклюзия ствола или основных ветвей легочной артерии частичками тромба, сформировавшимися в венах большого круга кровообращения или правых камерах сердца и занесенными в легочную артерию с током крови. [3]
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Классификация
Риск ранней смертности при ТЭЛА | Маркеры риска | Стратегия лечения | |||
Клинические (шок или гипотония) | Дисфункция правого желудочка | ||||
Высокий | + | (+)* | (+)* | ||
Невысокий | Промежуточный | — | + | + | Госпитализация |
+ | — | ||||
— | + | ||||
Низкий | — | — | — | Ранняя выписка или лечение на дому |
Диагностика
II. МЕТОДЫ, ПОДХОДЫ И ПРОЦЕДУРЫ ДИАГНОСТИКИ И ЛЕЧЕНИЯ
• рентгенография органов грудной клетки (прямая и боковая проекции).
• определение количественного Д-димера в плазме крови.
Клиника ТЭЛА включает широкий диапазон состояний: от почти бессимптомного течения до внезапной смерти. В качестве классических вариантов течения заболевания в клинике ТЭЛА выделяют пять клинических синдромов.
• боль в правом подреберье.
Повышение уровня D-димера возможно также при остром инфаркте миокарда, септическом состоянии, при оперативном вмешательстве, злокачественном новообразовании и системных заболеваниях. В целях стратификации риска тяжести течения необходимо определением тропонина и proBNP.
Инструментальные исследования
Однодетекторная спиральная компьютерная томография имеет чувствительность 70 % и специфичность 90 %, а мультидетекторная спиральная компьютерная томография —чувствительность 83 % и специфичность 96 %.
С сердечно-легочной патологией в анамнезе: чувствительность — 80 %, специфичность —21 %.
Вентиляционно-перфузионная сцинтиграфия легких — точный метод исключения ТЭЛА. При внутривенном введении микросфер альбумина, меченных 99mTc, и вдыхании ксенона-133 или аэрозоля с 99mTc определяется дефект перфузии и проводится сравнение с наличием дефекта вентиляции.
Позитивный результат вентиляционно-перфузионной сцинтиграфии легких подтверждает ТЭЛА, однако требует дополнительных методов исследования при низкой клинической вероятности.
Ангиопульмонография — золотой стандарт диагностики ТЭЛА.
− Отсутствие или задержка венозной фазы контрастирования.
Рисунок 1. Алгоритм диагностики ТЭЛА невысокой степени риска смерти
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