Die akute Lungenembolie im Rettungsdienst | SpringerLink Lungenembolie pdf
Pulmonary embolism PE is a blockage of an artery in the lungs by a substance that has traveled from elsewhere in the body through the bloodstream embolism. PE usually results from a blood clot in the leg that Lungenembolie pdf to the lung. Efforts to prevent PE include beginning to move as soon as possible after surgery, lower leg exercises during periods of sitting, and the use of blood thinners after some types of surgery. Pulmonary emboli affect aboutpeople each year in Europe. Symptoms of pulmonary embolism are typically sudden in onset and may include one or many of the following: On physical examination, Lungenembolie pdf, the lungs are usually normal.
Occasionally, a pleural friction rub may be audible over the affected area of the lung mostly in PE with infarct. A pleural effusion is sometimes present that is exudative, detectable by decreased percussion note, audible breath sounds, and vocal resonance. As smaller pulmonary emboli tend to lodge in more peripheral areas without collateral circulation they are more likely to cause lung infarction and small effusions both of which are painfulbut not hypoxia, dyspnea or hemodynamic instability such as tachycardia.
Larger PEs, which tend to lodge centrally, typically cause dyspnea, hypoxia, low blood pressurefast heart rate and faintingbut are often painless because there is no lung infarction due to collateral circulation. The classic presentation for PE with pleuritic pain, dyspnea and tachycardia is likely caused by a large fragmented embolism causing both large and small PEs, Lungenembolie pdf.
Thus, small PEs are often missed Lungenembolie pdf they cause pleuritic pain alone without any other findings and large PEs often missed because they are painless and mimic other conditions often causing ECG changes and small rises in troponin and BNP levels, Lungenembolie pdf.
PEs are sometimes described as massive, submassive and nonmassive depending on the clinical signs and symptoms. Although the exact definitions of these are unclear, an accepted definition of massive PE is one in which there is hemodynamic instability such as sustained low blood pressure, slowed heart rateor pulselessness.
The conditions are generally regarded as a continuum termed venous thromboembolism VTE. The development of thrombosis is Lungenembolie pdf due to Lungenembolie pdf group of causes named Virchow's triad alterations in blood flow, factors in the vessel wall and factors affecting the properties of the blood.
Often, more than one risk factor is present. After a first PE, the search for secondary causes is usually brief, Lungenembolie pdf. Only when a second PE occurs, and especially when this happens while still under anticoagulant therapy, a further search for underlying conditions is undertaken.
This will include testing "thrombophilia screen" for Factor V Leiden mutationLungenembolie pdf, antiphospholipid antibodies, protein C and S and antithrombin levels, and later prothrombin mutation, MTHFR mutation, Factor VIII concentration and rarer inherited coagulation abnormalities. In order to diagnose a pulmonary embolism, a review of clinical criteria to determine the need for testing is recommended.
If there are concerns this is followed by testing to determine a likelihood of being able to confirm a diagnosis by imaging, Lungenembolie pdf, followed by imaging if other tests have shown that there Lungenembolie pdf a likelihood of a PE diagnosis. The diagnosis of PE is based primarily on validated clinical criteria combined with selective testing Lungenembolie pdf the typical clinical presentation shortness of breathchest pain cannot be definitively differentiated from other causes Lungenembolie pdf chest pain and shortness of breath.
The decision to perform medical imaging is based on clinical reasoning, Lungenembolie pdf, that is, the medical historysymptoms and findings on physical examinationfollowed by an assessment of clinical probability. The most commonly used method to predict clinical probability, the Wells score, Lungenembolie pdf, is a clinical prediction rulewhose use is complicated by multiple versions being available. Lungenembolie pdfPhilip Steven Wellsinitially developed a prediction rule based on a literature search to predict the likelihood of PE, based on clinical criteria.
There are additional prediction rules for PE, such as the Geneva rule. Lungenembolie pdf importantly, the use of any rule is associated with reduction in recurrent thromboembolism. Traditional interpretation   . Alternative interpretation  .
The pulmonary embolism rule-out criteria PERC helps assess people in whom pulmonary embolism is suspected, Lungenembolie pdf, but unlikely.
Unlike the Wells score and Geneva scorewhich are clinical prediction rules intended to risk stratify people with suspected PE, Lungenembolie pdf, the PERC rule is designed to rule out risk of PE in Lungenembolie pdf when the physician has already stratified them into a low-risk category. People in this low risk category without any of these criteria may undergo no further diagnostic testing for PE: The rationale behind this decision is that further testing specifically CT angiogram of the chest may cause more harm from radiation exposure and contrast dye than the risk of PE.
In people with a low or moderate suspicion of PE, a normal D-dimer level shown in a blood test is enough to exclude the possibility of thrombotic PE, with a three-month risk of thromboembolic events being 0.
In other words, Lungenembolie pdf, a positive D-dimer is not synonymous with PE, but a Lungenembolie pdf D-dimer is, with a good degree of certainty, an indication of absence of a PE. When a PE is being suspected, Lungenembolie pdf, several blood tests are done in order to exclude important secondary causes of PE.
This includes a full blood countclotting status PTaPTTTTand some screening tests erythrocyte sedimentation raterenal functionliver enzymes Lungenembolie pdf, electrolytes, Lungenembolie pdf.
If one of these is abnormal, further investigations might be warranted. In typical people who are not known to be at high risk of PE, imaging is helpful to confirm or exclude a diagnosis of PE after simpler first-line tests are used. CT pulmonary angiography is the recommended first line diagnostic imaging test in most people. Historically, the gold standard for diagnosis was pulmonary angiographybut this has fallen into disuse with the increased availability of non-invasive techniques.
CT pulmonary angiography CTPA Lungenembolie pdf a pulmonary angiogram obtained using computed tomography CT with radiocontrast rather than right heart catheterization. Its advantages are clinical equivalence, its non-invasive nature, its greater availability to people, Lungenembolie pdf, and the possibility of identifying other lung disorders from the differential diagnosis in case there is no pulmonary embolism, Lungenembolie pdf.
On CT scanpulmonary emboli can be classified according to level along the arterial tree. CT pulmonary angiography showing a "saddle embolus" at the bifurcation of the main pulmonary artery and thrombus burden in the lobar arteries on both sides. Assessing the accuracy of CT Lungenembolie pdf angiography is hindered by the rapid changes in the number of rows of detectors available in multidetector CT MDCT Liz Burbo Varizen ist. However, this study's results may be biased due to possible incorporation bias, since the CT scan was the final diagnostic tool in people with pulmonary embolism, Lungenembolie pdf.
The authors noted that a negative single slice CT scan is insufficient to rule out pulmonary embolism on its own. This study noted that additional testing is necessary when the clinical probability is inconsistent Lungenembolie pdf the imaging results. It is particularly useful in people who have an allergy to iodinated contrastimpaired renal function, or are pregnant due to its lower radiation exposure as Lungenembolie pdf to CT.
Tests that are frequently done that are not sensitive for PE, but can be diagnostic. The primary use of the ECG is to rule out other causes of chest pain. While certain ECG changes may occur with PE, none are specific enough to confirm or sensitive Lungenembolie pdf to rule out the diagnosis. The most commonly seen signs in the ECG are sinus tachycardiaLungenembolie pdf, right axis deviation, and right bundle branch block, Lungenembolie pdf.
In massive and submassive PE, dysfunction of the right side of the heart may be Teebaumöl und Krampfadern on echocardiographyan indication that the pulmonary artery is severely obstructed and the right ventriclea low-pressure pump, Lungenembolie pdf, is unable to match the pressure. Some studies see below suggest that this finding may be an indication for thrombolysis.
Not every person with a suspected pulmonary embolism requires an echocardiogram, but elevations in cardiac troponins or brain natriuretic peptide may indicate heart strain and warrant an echocardiogram,  and be important in prognosis.
The specific appearance of the right ventricle on echocardiography is referred to as the McConnell's sign. This is the finding of akinesia of the mid-free wall but a normal motion of the apex.
Ultrasound of the heart showing signs of PE . Pulmonary embolism Lungenembolie pdf be preventable in those with risk factors. People admitted to hospital may receive preventative medication, including unfractionated heparinLungenembolie pdf, low molecular weight heparin LMWHor fondaparinuxand anti-thrombosis stockings to reduce the risk of a DVT in the leg that could dislodge and migrate Lungenembolie pdf the lungs.
Following the completion of warfarin in those with prior PE, long-term aspirin is useful to prevent recurrence. Anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesiamay be required. People are often admitted to hospital in the early stages of treatment, and tend to remain under inpatient care until the INR has reached therapeutic levels.
Increasingly, however, low-risk cases are managed at home in a fashion already common in the treatment of DVT.
Usually, anticoagulant therapy is the mainstay of treatment. Unfractionated heparin UFHlow molecular weight heparin LMWHor fondaparinux is administered initially, while warfarinacenocoumarolor phenprocoumon therapy is commenced this may take several days, usually while the patient is in the hospital.
LMWH may reduce bleeding among people with pulmonary embolism as compared to UFH according to a systematic review of randomized controlled trials by the Cochrane Collaboration. There was no difference in overall mortality between participants treated with LMWH and those treated with unfractionated heparin. Warfarin therapy often requires a frequent dose adjustment and monitoring of the international normalized ratio INR. In patients with an underlying malignancy, therapy with a course of LMWH is Lungenembolie pdf over warfarin; it is continued for six months, at which point a decision should be reached whether ongoing treatment is required.
Similarly, pregnant women are often maintained on low Lungenembolie pdf weight heparin until at least six weeks after delivery to avoid the known teratogenic effects Lungenembolie pdf warfarin, especially in the early stages of pregnancy. Warfarin therapy is usually continued for 3—6 months, Lungenembolie pdf, or "lifelong" if there have been previous DVTs or PEs, or none of the usual risk factors is present.
An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus. In this situation, it is the best available treatment in those without contraindications and is supported by clinical guidelines.
Catheter-directed thrombolysis CDT is a new technique found to be relatively safe and effective for massive PEs. This Lungenembolie pdf accessing the venous system by placing a catheter into a vein in the groin and guiding it through the veins by using fluoroscopic imaging until it is located next to the PE in the lung circulation.
Medication that breaks up blood clots is released through the catheter so that its highest concentration is directly next to the pulmonary embolus, Lungenembolie pdf.
CDT is performed by interventional radiologistsand in medical centers that offer CDT, it may be offered as a first-line treatment. The use of thrombolysis in non-massive PEs is still debated. There are two situations when an inferior vena cava filter is considered advantageous, and those are if anticoagulant therapy varifort Bewertungen von Krampfadern contraindicated e.
Inferior vena cava filters should be removed as soon as it becomes safe to start using anticoagulation. The long-term safety profile of permanently leaving a filter inside the body is not known. Surgical management of acute pulmonary embolism pulmonary thrombectomy Lungenembolie pdf uncommon and has largely been abandoned because of poor long-term outcomes.
However, recently, it has gone Lungenembolie pdf a resurgence Operation Krampfadern Bein auf Video the revision of the surgical technique and is thought to benefit certain people.
Pulmonary emboli occur in more thanLungenembolie pdf, people in the United States each year. There are several markers used for risk stratification and these are also independent predictors of adverse outcome, Lungenembolie pdf.
These include hypotension, cardiogenic shock, syncope, evidence of right heart dysfunction, and elevated cardiac enzymes. Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation Lungenembolie pdf the lung can lead to pulmonary hypertension. After a Lungenembolie pdf PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, Lungenembolie pdf, the blood clot may be broken down by fibrinolysisor it may be organized and recanalized so that a new channel forms through the clot.
Blood flow is restored most rapidly in the first day or two after a PE, Lungenembolie pdf. There is controversy over whether small subsegmental PEs need treatment at all  and some evidence exists that patients with subsegmental PEs may do well without treatment.
Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0, Lungenembolie pdf. This figure comes Lungenembolie pdf a trial published in by Barrit and Jordan,  which compared anticoagulation against placebo for the management of PE.
Barritt and Jordan performed their study in the Bristol Royal Infirmary in
Lungenembolie pdf Lungenembolie PDF Download - DylanLindon
Für die Prognose der betroffenen Patienten ist die frühzeitige Einbeziehung der LE in differentialdiagnostische Überlegungen von entscheidender Bedeutung, Lungenembolie pdf. Die klinischen Beschwerden sind unspezifisch und vielgestaltig. Für das diagnostische Vorgehen sind Algorithmen verfügbar. In der Diagnostik besteht ein grundsätzlicher Unterschied zwischen klinisch stabilen und instabilen Patienten, Lungenembolie pdf, wobei das Kriterium für Stabilität in erster Linie die Hämodynamik ist.
Beim hämodynamisch instabilen Patienten ist der entscheidende Diagnostikschritt die Echokardiographie. Die Therapieziele umfassen in Abhängigkeit vom Schweregrad der LE die hämodynamische Stabilisierung des Patienten, die Verhinderung des appositionellen Thrombuswachstums, Lungenembolie pdf, die Rekanalisierung der pulmonalen Strombahn, die Beseitigung der Hypoxämie und die Rezidivprophylaxe.
Bei stabilen Patienten ist die alleinige Antikoagulation Therapie der Wahl. Interventionen wie Thrombolyse oder Embolektomie sind vor allem bei hämodynamisch instabilen Patienten indiziert. Lungenembolie pdf annual incidence of pulmonary embolism PE in western industrial nations is about 1 to 1.
For the prognosis of the patients it is important to consider PE early as a differential diagnosis. The Lungenembolie pdf disorders are non-specific and varied.
The most frequent clinical signs of PE are dyspnoea, tachypnoea, tachycardia and chest pain. Diagnostic algorithms are available for the diagnosis of PE. Lungenembolie pdf is a cardinal difference in diagnostic procedure between clinically stable and instable patients.
The criteria for stability are mainly hemodynamic values. In hemodynamically instable patients echocardiography is the most important diagnostic tool. Therapeutical goals depend on the severity of PE and include hemodynamic stabilisation, prevention of the growth of the thrombus, recanalisation of pulmonal arterial vessels, removal of hypoxemia, and prophylaxis of recurrence.
Anticoagulation is the only therapy of choice in stable patient of risk classification I. Interventions like thrombolysis and embolectomy are Lungenembolie pdf indicated in hemodynamically instable patients. Unable to display preview. Accuracy of clinical assessment in the diagnosis of pulmonary embolism.
Use of a clinical model for Lungenembolie pdf management of patients with suspected pulmonary embolism, Lungenembolie pdf. Ann Intern Med, Lungenembolie pdf, Walther A, Böttiger BW. Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism.
Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Pulmonary embolism in the critically ill. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J, Antithrombotic therapy for venous thromboembolic disease: Modern management of pulmonary embolism.
Br J Surg, Inferior vena cava filters in the management of venous thromboemolism. Am J Med, Update in the prevention and tratment of deep vein thrombosis and pulmonary embolism.
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