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TVP ed Embolia Polmonare: Definizione

TVP ed Embolia Polmonare: Definizione. TVP Sintomi & Segni. NON SPECIFICI o ASSENTI. Dolore Tensione Edema. DD: crampi o strappi muscolari, rottura cisti poplitea, contusioni, artriti anca-ginocchio, gotta, tendiniti. . EP Sintomi & Segni. NON SPECIFICI, dipendono da:.

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TVP ed Embolia Polmonare: Definizione

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  1. TVP ed Embolia Polmonare: Definizione

  2. TVP Sintomi & Segni NON SPECIFICI o ASSENTI • Dolore • Tensione • Edema DD: crampi o strappi muscolari, rottura cisti poplitea, contusioni, artriti anca-ginocchio, gotta, tendiniti.

  3. EP Sintomi & Segni NON SPECIFICI, dipendono da: • Entità dell’ostruzione • Rapidità dell’ostruzione • Vaso-broncocostrizione associata • Stato cardiopolmonare preesistente

  4. EP:Ostruzione completa e rapida Sincope Shock Ipotensione prolungata Diagnosi urgente Diagnosi differenziale: Infarto miocardico, Tamponamento cardiaco, Emorragia massiva, Setticemia, Pneumotorace, Aneurisma dissecante

  5. Ostruzione parziale Sintomi* Segni* • Dispnea • Dolore toracico • Tosse • Dolore AAII • Tachipnea (>20 min) • Rantoli (crepitii) • Tachicardia • IV tono * Più frequenti Diagnosi differenziale (dispnea): Polmonite, Ostruzione vie aeree, Pneumotorace, Edema polmonare, Atelettasia

  6. ECG Diagnosi Differenziale: IMA Negativo • Suggestivo per EP • (emodinamicamente significativa): • Sottoslivellamento ST • Inversione onda T • Nuovo Blocco di branca dx • S1Q3T3 non preesistente

  7. Rx torace Spesso Negativo • Esclude: • Pneumotorace • Aneurisma aorta • Altro Alterazioni Non-specifiche

  8. Emogasanalisi Ridotta PO2: aspecifica Puntura Arteriosa: Attenzione! Normale nel 10-15% di EP

  9. Presentazione Esami semplici (Sintomi e segni) Sospetto clinico Situazione clinica Anamnesi

  10. Situazione clinica Anamnesi • Periodo Postoperatorio • Trauma arti inferiori • Allettamento • Gravidanza/puerperio • Neoplasia • Pregresso VTE • Trombofilia • Famigliarità • Estroprogestinici

  11. Sospetto clinico EP DEBOLE Solo agitazione + tachicardia + dipnea non spiegabile + storia di tromboembolismo venoso + trombofilia famigliare + estroprogestinici + recente trauma arti inferiori + allettamento FORTE

  12. Trattamento Sospetto clinico Diagnosi

  13. Sospetto clinico • UFH Bolo (5.000 IU or 80 IU/kg IV)

  14. SCORE di Wells 1 1 1 1 1 1 1 1 -2 Neoplasia in fase attiva (trattamento in corso o nei 6 mesi precedenti o palliativo) Paralisi , paresi o recente immobilizzazione degli arti inferiori Chirurgia maggiore nelle 4 settimane precedenti o paziente allettato e da poco rimesso in piedi Gonfiore localizzato lungo la distribuzione del sistema venoso profondo Gonfiore di tutta la gamba Gonfiore del polpaccio > 3 cm rispetto all’arto asintomatico (misurati 10cm sotto la tuberosità tibiale) Edema con fovea maggiore nell’arto interessato Vene collaterali superficiali (non varicose) Diagnosi alternativa altrettanto o più probabile della TVP  3 alta 1-2 moderata <1 bassa

  15. Diagnosi D-dimero CUS Ecocolordoppler TAC spirale Angiografia polmonare Scintigrafia v/p Clinica +

  16. Scintigrafia perfusoria

  17. Risonanza magnetica

  18. Risonanza magnetica

  19. Angiopneumografia

  20. Flebografia

  21. TRATTAMENTO

  22. Anticoagulant drugs in the treatment of pulmonary embolism: a controlled clinical trial • Patients with PE (clinical signs, EKG, chest x-rays) • Treated group: heparin 10.000 U IV every 6h for 36 h • plus nicoumalone, orally for 14 days • Trial terminated after randomization of 35 patients • Among 19 control pts, 5 fatal (autopsy-verified) and 5 nonfatal • recurrent PE • Among 16 treated pts, 1 death from pneumonia and a bleeding • duodenal ulcer Barritt, Lancet 1960

  23. A.T.H.O.S Randomized trial comparing heparin plus acenocoumarol (n=60) with acenocoumarol alone (=60) in proximal vein thrombosis Brandjes, N Engl J Med 1992

  24. LMWH vs standard heparin in proximal DVT -85 patients in each group, follow-up 6 mo. -No difference in bleeding complications Prandoni, Lancet 1992

  25. Koopman et al. N Engl J Med 1996

  26. The Columbus investigators. N Engl J Med 1997

  27. Gould et al. Ann Intern Med 1999

  28. LMWH therapy in VTE • Nadroparin calcium (Fraxiparine) 85 IU/kg q12h or 170 IU/kg/d • Enoxaparin sodium (Clexane) 100 U/kg q12h (1mg/kg q12h or 1.5 mg/kg/d) • Dalteparin sodium (Fragmin) 200 IU/kg/d • Tinzaparin sodium 175 IU/kg/d

  29. LMWH - Criteria for early discharge or outpatient therapy • Patient in stable condition • Patient willingness to collaborate • Low bleeding risk and normal renal function • Oral anticoagulant surveillance facilities • Early medical contact facilities

  30. Baseline lab in suspected VTE • APTT, PT-INR, CBC • Sceening for thrombophylia in selected patients (idiopathic VTE, transient risk factors but age < 50 years, recurrent VTE, positive family history) • Antithrombin III, Protein C, Protein S, APC resistance, Factor V Leiden, Prothrombin G210A, homocysteinemia, lupus anticoagulant, antiphospholipid antibodies (anti-beta-2-glycoprotein I)

  31. Heparin - VTE • UFH Bolus (5.000 IU or 80 IU/kg IV,suspected VTE) • UFH: maintenance infusion 30-35.000 IU IV/SC or 18 IU/kg/h; appropriate dosage of LMWH • UFH: Lab after 6h to keep aPTT 1.5-2.5 times the control • Check platelet count between days 3 to 5 • Start warfarin at day 1 at 5 mg/day • Continue both drugs at least 5 days • Stop heparin when INR>2 fot 2 consecutive days • Continue warfarin to keep INR between 2.0 and 3.0

  32. A study demonstrated that recurrent VTE is infrequent if continuous IV heparin is administered in doses Adjusted to prolong the APTT > 1.5. Basu D et al., N Engl J Med 1972 Blood heparin level of at least 0.2 IU/ml Heparin infused IV in a dose of at least 1250 U/h

  33. Heparin dose-adjustment nomogram Cruickshank et al, Arch Intern Med 1991; 151:333

  34. Weight-based nomogram Initial dose APTT, < 35 s (<1.2 x control) APTT, 35 to 45 s (1.2 to 1.5 x control) APTT, 46 to 70 s (1,5 to 2.3 x control) APTT, 71 to 90 s (2,3 to 3.0 x control) APTT, > 90 s (> 3 x control) 80 U/Kg bolus, then 18 U/Kg/h 80 U/Kg bolus, increase by 4 U/Kg/h 40 U/Kg bolus, increase by 2 U/Kg/h NO CHANGE Decrease infusion by 2 U/Kg/h Hold infusion 1 h, then decrease by 3U/Kg/h Raschke et al., Ann Intern Med 1993; 119:874

  35. Thrombolytic therapy • Usually not indicated in DVT • Reserved to hemodinamically unstable patients with • proven PE in the absence of bleeding risk

  36. Duration of oral anticoagulant treatment First event associated with transient or reversible risk factors (patients may have underlying eterozygous factor V Leiden or prothrombin G20210A) 3-6 mo > 6 mo First event of idiopathic VTE. First event associated with permanent high risk factors (unresolved cancer, high risk thrombophilia) Recurrent VTE, idiopathic or associated with thrombophilia 12 mo or lifelong

  37. Indications to inferior vena cava filters • Contraindication/complication of anticoagulation • in high risk patients • Recurrent VTE despite adequate anticoagulation • Pulmonary embolectomy or endarterectomy

  38. Chronic thromboembolic pulmonary hypertension • Not rare (2-5%?) • Perfusion defects at pulmonary scan • Proximal obstruction: • pulmonary thromboendarterectomy • Nonproximal obstruction: angioplasty

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