WEBVTT00:00:01.520 --> 00:00:02.440啊嗯00:00:02.440 --> 00:00:04.680今天啊我们来大家一起学习一下00:00:04.680 --> 00:00:07.840一个肺血栓栓塞症的一些嗯00:00:07.840 --> 00:00:08.920诊疗情况00:00:08.920 --> 00:00:11.500那么肺血栓栓塞症其实是一个00:00:11.840 --> 00:00:14.400我们说是一个隐形的一个健康杀手00:00:14.400 --> 00:00:16.120那么如果一旦发生的话00:00:16.120 --> 00:00:18.820它是可以引起病人的猝死00:00:18.960 --> 00:00:20.160那么所以说呃00:00:20.160 --> 00:00:20.800在临床上00:00:20.800 --> 00:00:22.160有时候呃00:00:22.160 --> 00:00:23.760病情演变非常快00:00:23.760 --> 00:00:25.720呃有时候病人这个胸闷气急00:00:25.720 --> 00:00:29.040一下子就可能出现一个猝死的可能00:00:29.040 --> 00:00:29.520所以说00:00:29.520 --> 00:00:32.380这个疾病还是比较危险的疾病00:00:36.000 --> 00:00:36.640那么今天00:00:36.640 --> 00:00:38.120我们就从这几个方面00:00:38.120 --> 00:00:39.860来跟大家介绍一下00:00:40.160 --> 00:00:41.360第一个就是一个00:00:41.360 --> 00:00:43.580他的一个肺血栓栓塞症的一些00:00:43.600 --> 00:00:44.800简单的一个介绍00:00:44.800 --> 00:00:45.560他的病因啊00:00:45.560 --> 00:00:46.740他的一些症状00:00:46.840 --> 00:00:49.780第二个讲他的一个病因和危险因素00:00:50.080 --> 00:00:50.440第三个00:00:50.440 --> 00:00:52.320我们从他的病理生理来看看00:00:52.320 --> 00:00:55.060这个肺血栓栓塞症的一些情况00:00:55.320 --> 00:00:55.760另外呢00:00:55.760 --> 00:00:58.720就是一个临床表现和诊断治疗策略00:00:58.720 --> 00:01:00.620最后是一个预后和预防00:01:02.400 --> 00:01:04.480那么首先我们说嗯00:01:04.480 --> 00:01:05.980肺血栓栓塞症00:01:06.200 --> 00:01:07.360嗯它是一个00:01:07.360 --> 00:01:08.980其实是一个比较00:01:09.200 --> 00:01:10.280在目前来说00:01:10.280 --> 00:01:12.280特别是近阶00:01:12.280 --> 00:01:13.240近阶段的话00:01:13.240 --> 00:01:14.940他的发病率越来越高00:01:15.000 --> 00:01:16.280那么手术以后啊00:01:16.280 --> 00:01:17.960病人如果长期卧床啊00:01:17.960 --> 00:01:19.580如果有些静脉血栓00:01:19.640 --> 00:01:21.180那么血栓就会脱落00:01:21.600 --> 00:01:23.780脱落以后就会引起肺栓塞00:01:24.480 --> 00:01:25.640那么所以他的定义00:01:25.640 --> 00:01:29.260就是由于血栓阻塞了肺动脉00:01:29.280 --> 00:01:30.360以及他的分支00:01:30.360 --> 00:01:32.380所引起的一种严重疾病00:01:32.640 --> 00:01:32.800那么00:01:32.800 --> 00:01:36.280一般他都是从下肢的神经脉来的00:01:36.280 --> 00:01:39.120那么如果很多病人想骨折术后啊00:01:39.120 --> 00:01:40.420做一些大手术00:01:40.520 --> 00:01:42.280或者是骨折手术以后00:01:42.280 --> 00:01:43.200现在我们常规00:01:43.200 --> 00:01:44.960为什么都要给他用抗凝药00:01:44.960 --> 00:01:47.620那就是为了预防下肢肾静脉血栓00:01:47.960 --> 00:01:49.900那么一旦一下子深静脉血栓00:01:49.960 --> 00:01:51.420它就很容易脱落00:01:51.520 --> 00:01:53.400脱落以后就会阻塞肺动脉00:01:53.400 --> 00:01:54.880通过血液循环到肺动脉00:01:54.880 --> 00:01:56.700引起肺动脉的一个衰衰00:01:56.760 --> 00:01:57.960那么肺动脉栓塞以后00:01:57.960 --> 00:01:59.860就会引起急性的一个肺梗00:02:00.000 --> 00:02:00.800那么肺梗以后00:02:00.800 --> 00:02:02.800病人就可以出现一下子呼吸衰竭00:02:02.800 --> 00:02:03.780甚至死亡00:02:04.200 --> 00:02:05.740那么所以说他的形成00:02:05.840 --> 00:02:09.140就是从腿部的深静脉脱落00:02:09.200 --> 00:02:11.400到达血流以后到达肺部00:02:11.400 --> 00:02:12.520因为他这个静脉以后00:02:12.520 --> 00:02:15.140到就通过血流就到了肺动脉00:02:15.160 --> 00:02:17.300那么导致一个肺循环的受阻00:02:17.440 --> 00:02:19.460那么这是他的一个形成机制00:02:19.800 --> 00:02:22.240那么他的流行病学我刚刚讲了00:02:22.240 --> 00:02:25.720那么肺血栓栓塞的发病率呃00:02:25.720 --> 00:02:27.540应该说在逐年的提高00:02:27.640 --> 00:02:29.400以前我们说肺栓塞00:02:29.400 --> 00:02:31.000临床上碰到很少的00:02:31.000 --> 00:02:33.360而现在我们在急诊可以碰到很多的00:02:33.360 --> 00:02:34.480一个病人00:02:34.480 --> 00:02:35.920有一个肺动脉的损塞00:02:35.920 --> 00:02:37.200病人如果胸闷气急00:02:37.200 --> 00:02:38.460第二句提升高00:02:38.520 --> 00:02:40.300那么你做个肺动脉的CT00:02:40.400 --> 00:02:42.300往往就能看到有肺血栓00:02:42.440 --> 00:02:44.040那么因为这阶段00:02:44.040 --> 00:02:46.080有了很多抗凝药物的治疗00:02:46.080 --> 00:02:47.340所以他的愈后00:02:47.560 --> 00:02:48.680如果及时的发展00:02:48.680 --> 00:02:50.220愈后还是比较好的00:02:50.560 --> 00:02:51.680那么临床表现呢00:02:51.680 --> 00:02:53.580我们说是多种多样00:02:53.640 --> 00:02:56.460那么轻的病人是可以没有症状的00:02:56.680 --> 00:02:57.440他没有症状00:02:57.440 --> 00:03:00.000因为他堵塞了肺动脉小的分支00:03:00.000 --> 00:03:01.200他可以没有任何症状00:03:01.200 --> 00:03:02.620有的人有点咳嗽00:03:03.200 --> 00:03:04.920那么如果严重的话00:03:04.920 --> 00:03:06.900他就会出现一个呼吸困难00:03:07.000 --> 00:03:08.740甚至一个心脏的骤停00:03:08.800 --> 00:03:10.240那么所以他的临床表现00:03:10.240 --> 00:03:11.640都是很复杂的00:03:11.640 --> 00:03:13.280都是很不典型的00:03:13.280 --> 00:03:15.440所以临床上往往可以呃00:03:15.440 --> 00:03:17.800很多人可以误诊或者漏诊的00:03:17.800 --> 00:03:19.140那么就是这个道理00:03:20.200 --> 00:03:23.000那么他的一个高危的一个人群呢00:03:23.000 --> 00:03:24.440我们说就是一个00:03:24.440 --> 00:03:25.440我刚刚讲过了00:03:25.440 --> 00:03:27.020长期卧床的病人00:03:27.240 --> 00:03:28.000由于运动比00:03:28.000 --> 00:03:29.760较少容易血液淤滞00:03:29.760 --> 00:03:31.980引起下肢的一个肾静脉的血栓00:03:32.200 --> 00:03:33.800第二个就是一个骨折手术00:03:33.800 --> 00:03:36.880或者是现在一些嗯妇科的手术啊00:03:36.880 --> 00:03:39.740包括现在一些的嗯胆囊的手术00:03:40.120 --> 00:03:41.100手术以后00:03:41.120 --> 00:03:44.080那么病人本身血液有点高凝状态00:03:44.080 --> 00:03:46.500那么也容易引起肺栓塞00:03:46.840 --> 00:03:48.140还有是一个高龄00:03:48.520 --> 00:03:50.520高龄的老人也比较容易引起00:03:50.520 --> 00:03:51.720还有肥胖的人00:03:51.720 --> 00:03:54.040那么这些都是一个肺血栓栓塞的00:03:54.040 --> 00:03:56.060一个高危的一个群体00:03:56.120 --> 00:03:59.240那么所以如果我们一旦有这些人群00:03:59.240 --> 00:04:01.040一旦出现有一些呼吸困难00:04:01.040 --> 00:04:01.760胸闷气急00:04:01.760 --> 00:04:03.320那么叫高度的重视00:04:03.320 --> 00:04:05.220有没有肺栓塞的发生00:04:08.480 --> 00:04:09.760那么我说呃00:04:09.760 --> 00:04:10.880肺栓塞呢00:04:10.880 --> 00:04:12.460其实首次00:04:12.560 --> 00:04:16.060以及对开始对他的一个了解非常少00:04:16.080 --> 00:04:16.920特别是以前00:04:16.920 --> 00:04:17.800我们不能做一些00:04:17.800 --> 00:04:19.400肺动脉的一个影像学00:04:19.400 --> 00:04:22.380那么就无法诊断他是肺动脉血栓00:04:22.640 --> 00:04:25.900所以说随着影像学技术的发展00:04:25.920 --> 00:04:28.600特别是CT的肺动脉造影以后00:04:28.600 --> 00:04:30.220那么它的准确率00:04:31.000 --> 00:04:32.920诊断的准确性就显著的提高00:04:32.920 --> 00:04:33.760那么现在我们也是00:04:33.760 --> 00:04:35.300就做一个肺动脉CT00:04:35.360 --> 00:04:37.740就能看到有肺动脉的血栓00:04:37.760 --> 00:04:40.060那么就可以考虑是一个肺00:04:40.080 --> 00:04:41.720肺栓塞的一个呃00:04:41.720 --> 00:04:43.940症状肺栓塞的一个诊断00:04:44.040 --> 00:04:44.600那么特别00:04:44.600 --> 00:04:46.320而且我们现在有了一个很多的00:04:46.320 --> 00:04:47.620DNC的技术00:04:47.920 --> 00:04:50.420就是可以在肺动脉的穿刺00:04:50.560 --> 00:04:52.360我们可以做一个肺动脉的造影00:04:52.360 --> 00:04:54.420然后做一个肺动脉的一个溶栓00:04:54.480 --> 00:04:56.000那么所以说早期的话00:04:56.000 --> 00:04:58.300如果能够诊断肺栓塞的话00:04:58.360 --> 00:05:00.840那么它的治疗还是现在的手段00:05:00.840 --> 00:05:02.060也非常多的00:05:02.320 --> 00:05:04.080那么所以呃00:05:04.080 --> 00:05:05.520就刚刚我也讲了00:05:05.520 --> 00:05:07.960现在很多大规模的临床试验00:05:07.960 --> 00:05:09.560都推动了抗凝药物00:05:09.560 --> 00:05:11.480在肺栓塞治疗当中的应用00:05:11.480 --> 00:05:12.320我们很多艾00:05:12.320 --> 00:05:13.900多沙巴立法沙斑00:05:14.040 --> 00:05:16.460都做了很多的大型的临床研究00:05:16.480 --> 00:05:18.680都是在肺栓塞病人当中用的00:05:18.680 --> 00:05:20.980那么预后疗效都是比较好的00:05:21.160 --> 00:05:23.540另外呢我们说治疗手段的进步00:05:23.600 --> 00:05:25.480他的误诊和漏诊率呢00:05:25.480 --> 00:05:26.780还是比较高00:05:26.960 --> 00:05:28.400所以说我们很多病人00:05:28.400 --> 00:05:30.400如果一旦出现一个呃00:05:30.400 --> 00:05:31.120呼吸困难00:05:31.120 --> 00:05:32.240就有时候猝死00:05:32.240 --> 00:05:34.340往往想到会不会肺栓塞了00:05:34.520 --> 00:05:34.840那么现在00:05:34.840 --> 00:05:37.020我们医生的认识也越来越多00:05:37.040 --> 00:05:39.620对这个疾病的了解也越来越深入00:05:39.640 --> 00:05:40.880所以说呃00:05:40.880 --> 00:05:42.040基本上在急诊00:05:42.040 --> 00:05:44.560很多医生都都会记住要做一个第二00:05:44.560 --> 00:05:47.380具体看看是不是会有肺栓塞00:05:47.800 --> 00:05:50.340那么所以呢早期诊断00:05:50.400 --> 00:05:52.920那么还是医生要进行一个早期00:05:52.920 --> 00:05:54.120要有个的意识00:05:54.120 --> 00:05:56.880能够想到会不会病人有肺栓塞00:05:56.880 --> 00:05:59.260那么这样呢就有助于早期诊断00:05:59.800 --> 00:06:01.680那么还有就是一个基因研究00:06:01.680 --> 00:06:02.960和精准医疗00:06:02.960 --> 00:06:04.800也为会发生的个性化治疗00:06:04.800 --> 00:06:06.180带来一个新的突破00:06:06.200 --> 00:06:08.580我们说很多肺栓塞病人00:06:08.600 --> 00:06:09.880就是一些病人00:06:09.880 --> 00:06:12.160他这个高龄状态它就很多00:06:12.160 --> 00:06:13.680有一个像我们以前碰到00:06:13.680 --> 00:06:15.360抗凝血酶3缺乏的00:06:15.360 --> 00:06:17.180那么它就容易引起血栓00:06:17.240 --> 00:06:20.480那么血栓就容易引起肺动脉的栓塞00:06:20.480 --> 00:06:22.720所以说这部分基因缺陷的病人00:06:22.720 --> 00:06:23.960我们也要注意的00:06:23.960 --> 00:06:24.480那么现在00:06:24.480 --> 00:06:26.440我们可以做很多一些基因的检测00:06:26.440 --> 00:06:29.840包括抗凝血酶3啊那种检测00:06:29.840 --> 00:06:32.940那么看看他有没有医学方面的缺陷00:06:33.240 --> 00:06:34.760那么这对于有助于我们00:06:34.760 --> 00:06:36.100早期的一个诊断00:06:38.520 --> 00:06:41.340那么接下来讲一个病因和危险因素00:06:41.480 --> 00:06:42.920其实病因和危险因素00:06:42.920 --> 00:06:45.140刚刚已经我们已经也讲过了00:06:45.200 --> 00:06:48.800呃病因主要就是下肢深静脉血栓00:06:48.800 --> 00:06:50.160以后脱落00:06:50.160 --> 00:06:52.300而引起的一个肺栓塞00:06:52.480 --> 00:06:54.680那么这个深静脉血栓一00:06:54.680 --> 00:06:57.260般都发生在下肢的深静脉00:06:57.360 --> 00:06:58.240特别是右侧00:06:58.240 --> 00:06:59.480特别容易引起00:06:59.480 --> 00:07:02.480那么这是一个血栓的形成00:07:02.480 --> 00:07:04.700然后血栓一旦形成以后00:07:04.760 --> 00:07:07.060我们说它就很容易脱落00:07:07.080 --> 00:07:08.980随着血流就跑00:07:09.080 --> 00:07:11.220那么最终跑到肺动脉00:07:11.280 --> 00:07:13.120肺动脉阻塞了以后00:07:13.120 --> 00:07:14.600那肺动脉栓塞以后00:07:14.600 --> 00:07:17.660就引起肺梗引起的肺循环的障碍00:07:18.160 --> 00:07:19.720那么在病理机制里面00:07:19.720 --> 00:07:21.360我们说血栓形成00:07:21.360 --> 00:07:22.920有一个金三角的一个因素00:07:22.920 --> 00:07:25.280一个是我们说的13个因素00:07:25.280 --> 00:07:26.600它可以引起血栓00:07:26.600 --> 00:07:27.820哪三个因素呢00:07:27.880 --> 00:07:30.140第一个就是一个血管壁的损伤00:07:30.480 --> 00:07:32.980我们说血管壁的内皮损伤以后00:07:33.040 --> 00:07:35.520它容易启动医学机制00:07:35.520 --> 00:07:38.560还促进血栓的形成和进展00:07:38.560 --> 00:07:39.620这是第一个00:07:39.680 --> 00:07:40.400第二个因素00:07:40.400 --> 00:07:42.120就是一个血液的高凝状态00:07:42.120 --> 00:07:43.040这是第二个00:07:43.040 --> 00:07:45.300一个三角里面的第二个部分00:07:45.520 --> 00:07:47.320就是说某些遗传性的00:07:47.320 --> 00:07:49.220或者是获得性的因素00:07:49.320 --> 00:07:51.820它都可以导致血液的高凝00:07:51.920 --> 00:07:53.200那么血液高凝以后00:07:53.200 --> 00:07:55.240就增加了血栓形成的风险00:07:55.240 --> 00:07:56.580这是第二个因素00:07:56.880 --> 00:07:59.180第三个就是一个血液动力学的改变00:07:59.200 --> 00:08:01.900我们说由于血流的速度的减慢00:08:01.920 --> 00:08:04.200或者说漩涡啊涡流啊00:08:04.200 --> 00:08:05.980它就可以导致血栓00:08:06.000 --> 00:08:08.760容易在血管壁当中的形成和附着00:08:08.760 --> 00:08:10.500那么这样就形成血栓00:08:10.760 --> 00:08:14.080所以说我们说血栓形成有三大因素00:08:14.080 --> 00:08:16.700第一个血管内内皮细胞的损伤00:08:16.760 --> 00:08:17.800第二个高凝状态00:08:17.800 --> 00:08:19.620第三血液动力学的改变00:08:19.720 --> 00:08:21.300那么形成血栓以后00:08:21.320 --> 00:08:22.680特别在下肢形成的00:08:22.680 --> 00:08:25.540那么它就会引起肺动脉的栓塞00:08:26.160 --> 00:08:28.280那么我们说呃如何00:08:28.280 --> 00:08:30.800那么既然讲到了呃00:08:30.800 --> 00:08:34.200肺栓塞它的致命有容易引起猝死00:08:34.200 --> 00:08:36.440而且它的死亡率也非常高的00:08:36.440 --> 00:08:36.720那么00:08:36.720 --> 00:08:39.780我们怎么样来识别它的高危因素00:08:39.800 --> 00:08:40.600那么第一个00:08:40.600 --> 00:08:41.700就是一个遗传00:08:42.200 --> 00:08:44.740我们说某些遗传基因的突变00:08:44.840 --> 00:08:46.540像因子500:08:46.680 --> 00:08:48.280它都可以导致一个风险00:08:48.280 --> 00:08:50.480我们说现在有很多嗯抗凝00:08:50.480 --> 00:08:52.600我们可以检测一些凝血因子00:08:52.600 --> 00:08:54.540那么可以早期能够发现00:08:54.640 --> 00:08:55.920它有没有个遗产因素00:08:55.920 --> 00:08:57.100第二个年龄00:08:57.480 --> 00:09:00.760年龄一般我们说随着年龄的增大00:09:00.760 --> 00:09:01.560年龄越大00:09:01.560 --> 00:09:02.720特别是女性00:09:02.720 --> 00:09:04.300她的发病率会越高00:09:04.440 --> 00:09:06.620第三个是生活方式的干预00:09:06.680 --> 00:09:08.600如果你一直久坐啊00:09:08.600 --> 00:09:10.040或者是不运动啊00:09:10.040 --> 00:09:11.000一直缺乏运动00:09:11.000 --> 00:09:12.320一直长期卧床00:09:12.320 --> 00:09:13.660那么这种病人00:09:13.840 --> 00:09:15.600往往容易引起下肢神经00:09:15.600 --> 00:09:17.340特别你说有的人坐飞机00:09:17.360 --> 00:09:18.880坐了10个小时以后00:09:18.880 --> 00:09:20.120有的人一下子脚肿00:09:20.120 --> 00:09:21.080引起肺栓00:09:21.080 --> 00:09:21.840引起肺栓塞00:09:21.840 --> 00:09:22.760我们也碰到过00:09:22.760 --> 00:09:23.680在临床上00:09:23.680 --> 00:09:25.320就是坐飞机坐了十几个小时00:09:25.320 --> 00:09:27.080因为他的下肢一直没有动00:09:27.080 --> 00:09:28.480然后形成了血栓00:09:28.480 --> 00:09:29.320一下子脱落00:09:29.320 --> 00:09:29.840引起00:09:29.840 --> 00:09:31.800他一旦起来以后就引起肺栓塞00:09:31.800 --> 00:09:33.220一下子胸闷气急00:09:33.520 --> 00:09:35.060那非常的危险的00:09:35.440 --> 00:09:37.280那么还有一个是一个疾病的因素00:09:37.280 --> 00:09:38.680包括我们说一些糖尿病啊00:09:38.680 --> 00:09:39.640高血压啊00:09:39.640 --> 00:09:42.420它也会增加那个呃血栓那个风险00:09:43.440 --> 00:09:44.920还有就是药物的影响00:09:44.920 --> 00:09:47.340我们说如果长期使用避孕药00:09:47.360 --> 00:09:49.400或者使用些激素替代的人00:09:49.400 --> 00:09:51.940他也会增加血栓的风险00:09:52.680 --> 00:09:54.580还有就是一个手术和外伤00:09:55.200 --> 00:09:58.120那么我们说如果是手术以后00:09:58.120 --> 00:09:59.640或者是外伤以后00:09:59.640 --> 00:10:00.880他也会增加风险00:10:00.880 --> 00:10:02.360我们说特别在手术00:10:02.360 --> 00:10:04.320不管你是目前的腹部手术00:10:04.320 --> 00:10:06.340妇科手术还是骨科的手术00:10:06.440 --> 00:10:08.700他都会引起血栓的形成00:10:08.920 --> 00:10:10.120那么现在我们很多病人00:10:10.120 --> 00:10:11.320为什么在术前00:10:11.320 --> 00:10:13.620就进行一个抗凝的一个预防治疗00:10:13.640 --> 00:10:15.780也是为了防止术后的一个血栓00:10:16.240 --> 00:10:18.720还有就是一些高危的环境00:10:18.720 --> 00:10:20.360那么这般是在高原啊00:10:20.360 --> 00:10:21.840中高海拔的地方00:10:21.840 --> 00:10:24.960那么它容易引起血液动力性的改变00:10:24.960 --> 00:10:26.340容易引起血栓00:10:26.400 --> 00:10:27.440特别的高原00:10:27.440 --> 00:10:28.740海拔一高的话00:10:28.880 --> 00:10:30.680病人有的时候到了高原上面00:10:30.680 --> 00:10:31.900往往会发生的00:10:33.440 --> 00:10:34.840那么病理生理的机制00:10:34.840 --> 00:10:37.200我们说那么即使病理生理00:10:37.200 --> 00:10:38.240刚刚其实也讲了00:10:38.240 --> 00:10:40.260从微观到宏观的一个变化00:10:40.400 --> 00:10:43.100其实一个也是一个血栓形成和扩展00:10:43.440 --> 00:10:46.020那么血栓我们说从形成到扩展00:10:46.040 --> 00:10:48.700总归就是刚刚讲的一个近三角因素00:10:48.760 --> 00:10:50.260血管内皮的损伤00:10:50.480 --> 00:10:51.740由血液的高凝00:10:51.760 --> 00:10:54.080加上一些纤维蛋白的网络形成00:10:54.080 --> 00:10:56.100促使了一个凝血机制的发生00:10:56.240 --> 00:10:59.700那么血栓在动肺动脉内就造成阻塞00:11:00.040 --> 00:11:01.760他就引起血流淤滞00:11:01.760 --> 00:11:03.520那么引起局部的肺梗00:11:03.520 --> 00:11:05.100我们说叫肺梗死00:11:05.280 --> 00:11:07.980就是肺的局部的缺血和坏死00:11:08.200 --> 00:11:10.600另外呢如果肺循环受阻的话00:11:10.600 --> 00:11:13.340他还会引起右心室的负荷增大00:11:13.360 --> 00:11:16.080因为右心室那么导致右心衰竭00:11:16.080 --> 00:11:17.600病人可以有呃00:11:17.600 --> 00:11:18.440下肢水肿啊00:11:18.440 --> 00:11:20.780肝淤血啊等等右心衰的表现00:11:21.280 --> 00:11:23.680另外呢血管阻塞了肺组织的话00:11:23.680 --> 00:11:25.460它可以导致足部的00:11:25.480 --> 00:11:27.120肺组织的一个梗死00:11:27.120 --> 00:11:29.480那么它的氧化的通气功能障碍00:11:29.480 --> 00:11:31.700那么引起呼吸功能的一个衰竭00:11:32.320 --> 00:11:32.920另外就是00:11:32.920 --> 00:11:35.480血栓还可以引起一个炎症反应00:11:35.480 --> 00:11:36.920那么加重病情00:11:36.920 --> 00:11:39.540增加了一个并发症的一个风险00:11:44.200 --> 00:11:45.560那么在生理变化里面00:11:45.560 --> 00:11:46.640我们看啊00:11:46.640 --> 00:11:48.440还有个功能生理功能的改变00:11:48.440 --> 00:11:48.720就是00:11:48.720 --> 00:11:51.920第一个是呼吸功能的一个异常受损00:11:51.920 --> 00:11:53.640那么血栓栓塞症以后00:11:53.640 --> 00:11:56.080可以导致通气血流比例的失调00:11:56.080 --> 00:11:57.560那么造成一个低氧血症00:11:57.560 --> 00:11:59.640刚刚我们讲了一个呼吸功能的受损00:11:59.640 --> 00:12:00.360呼吸衰竭00:12:00.360 --> 00:12:03.380低氧第二个对血液动力学的影响00:12:03.560 --> 00:12:06.520那么如果血栓堵塞了肺动脉以后00:12:06.520 --> 00:12:07.740引起肺高压00:12:07.840 --> 00:12:09.440那么肺动脉高压以后00:12:09.440 --> 00:12:11.320影响了心脏的一个正常功能00:12:11.320 --> 00:12:13.180我们可以看到肺动脉高压00:12:13.200 --> 00:12:14.580如果出现心衰00:12:15.080 --> 00:12:16.700第三个代谢的异常00:12:16.760 --> 00:12:18.480那么他本身疾病00:12:18.480 --> 00:12:19.640也可以导致代谢增加00:12:19.640 --> 00:12:20.800加重器官00:12:20.800 --> 00:12:23.060那么影响了他的一个整体的健康00:12:23.440 --> 00:12:25.820另外一个一个就是这个神经体液00:12:26.040 --> 00:12:28.840那么神经体液因为有了这些嗯00:12:28.840 --> 00:12:30.320肺的低氧血症以后00:12:30.320 --> 00:12:33.160那么他的神经体液的调节也失衡00:12:33.160 --> 00:12:34.920那么导致血管收缩00:12:34.920 --> 00:12:36.000心率加快00:12:36.000 --> 00:12:37.900那么加重了病期的发展00:12:38.280 --> 00:12:39.980还有一个就是一个免疫功能00:12:40.040 --> 00:12:41.760那么也会影响免疫功能00:12:41.760 --> 00:12:43.720那么增加这个感染的风险00:12:43.720 --> 00:12:44.600那么这样的话00:12:44.600 --> 00:12:46.320有的病人可以合并一个感染00:12:46.320 --> 00:12:48.460那么就延迟了他的康复00:12:48.560 --> 00:12:50.040那么延缓了康复00:12:50.040 --> 00:12:50.880那么对疾病00:12:50.880 --> 00:12:53.460也就是本身也造成了一定的00:12:53.480 --> 00:12:55.460就等于加重了疾病的发生00:12:56.840 --> 00:12:58.680那么刚刚其实临床表现00:12:58.680 --> 00:12:59.760我们也讲了一点了00:12:59.760 --> 00:13:00.720那我们再来看一下00:13:00.720 --> 00:13:02.540临床表现和他的诊断00:13:02.800 --> 00:13:06.220那么所以说你要早期能够鉴别00:13:06.520 --> 00:13:07.640他出现这些症状00:13:07.640 --> 00:13:09.000你就要首先考虑00:13:09.000 --> 00:13:10.660是不是出现了肺栓塞00:13:10.960 --> 00:13:12.080那么临床症状里面00:13:12.080 --> 00:13:14.260我们说最常见的就是一个00:13:14.400 --> 00:13:16.180第一个就是一个呼吸困难00:13:16.640 --> 00:13:18.000那么呼吸困难00:13:18.000 --> 00:13:19.400往往病人可以出现一个00:13:19.400 --> 00:13:20.780活动后的气促00:13:21.000 --> 00:13:23.200那么休息他也不能缓解00:13:23.200 --> 00:13:25.220而且可以越来越明显00:13:25.240 --> 00:13:26.640胸闷气急越来越明显00:13:26.640 --> 00:13:28.000呼吸感到很压抑00:13:28.000 --> 00:13:29.020呼吸急促00:13:29.120 --> 00:13:30.440那么养分压越低了00:13:30.440 --> 00:13:32.140有的人这是这时候00:13:32.240 --> 00:13:34.040这是一个很常见的一个症状00:13:34.040 --> 00:13:36.260呼吸第二个就是胸痛00:13:36.800 --> 00:13:39.900胸痛通常为锐痛或者压榨痛00:13:40.200 --> 00:13:42.680可以放射到肩部或者背部00:13:42.680 --> 00:13:43.920和心脏疾病很类00:13:43.920 --> 00:13:46.540似这病人可以出现剧烈的胸痛00:13:46.560 --> 00:13:49.600那么通常是一种压榨一样的00:13:49.600 --> 00:13:52.000就像压住了以后还可以放射痛00:13:52.000 --> 00:13:52.680那么胸痛00:13:52.680 --> 00:13:53.640呼吸困难00:13:53.640 --> 00:13:55.980这是它最最典型的临床表现00:13:56.280 --> 00:13:56.960另外病人00:13:56.960 --> 00:13:58.400有的病人可以有咳嗽00:13:58.400 --> 00:14:01.260落血那么有的病人可以有干咳00:14:01.520 --> 00:14:04.200那么或者有一些若粉红色痰00:14:04.200 --> 00:14:05.840这个相对来说比较少一点00:14:05.840 --> 00:14:08.740那么刺激性的干咳还是比较多的00:14:10.840 --> 00:14:12.840还有就是一个心悸和晕厥00:14:12.840 --> 00:14:16.000那么这个相对来说也发生率呃00:14:16.000 --> 00:14:17.400一般病人呼吸困难话00:14:17.400 --> 00:14:18.560他已经来救走了00:14:18.560 --> 00:14:19.960心悸晕厥相对00:14:19.960 --> 00:14:21.540那么但是晕厥很多00:14:21.560 --> 00:14:23.380有的病人就一下子晕厥00:14:24.400 --> 00:14:25.700那么我们就要考虑00:14:25.800 --> 00:14:28.100会不会有肺栓塞的可能00:14:28.160 --> 00:14:30.360那么这时候可能是因为他呼吸困难00:14:30.360 --> 00:14:32.140以后心右心衰竭了00:14:32.160 --> 00:14:32.920心率加快00:14:32.920 --> 00:14:33.800血压下降00:14:33.800 --> 00:14:35.540那么导致的晕厥00:14:35.960 --> 00:14:38.700那么还有就是一个焦虑和烦躁00:14:38.800 --> 00:14:40.400那么因为呃00:14:40.400 --> 00:14:42.000病人一直有呼吸困难啊00:14:42.000 --> 00:14:44.040胸痛他就会影响他的情绪00:14:44.040 --> 00:14:46.240那么出现一些焦虑的状态00:14:46.240 --> 00:14:48.120那么这往往是呃00:14:48.120 --> 00:14:51.180在早期一般都能够鉴别诊断出来了00:14:53.040 --> 00:14:55.540那么诊断的方法我们刚刚说了00:14:55.560 --> 00:14:58.120现在随着那个技术的发展以后00:14:58.120 --> 00:15:00.800那么一般我们通过影像学的检查00:15:00.800 --> 00:15:03.200肺动脉的CT往往能够看到00:15:03.200 --> 00:15:04.780第二通过血液的00:15:05.040 --> 00:15:07.360我们可以看到有第二具体的升高00:15:07.360 --> 00:15:08.160通过心电图00:15:08.160 --> 00:15:10.260有一些右心衰的一个表现00:15:10.440 --> 00:15:12.080那么通过心电图啊00:15:12.080 --> 00:15:14.900超声心动图可以有肺高压的表现00:15:15.080 --> 00:15:17.680那么另外如果你做肺通气灌注啊00:15:17.680 --> 00:15:18.840做磁共振啊00:15:18.840 --> 00:15:19.560都能发现00:15:19.560 --> 00:15:20.360那么金标准00:15:20.360 --> 00:15:21.760也可以做血管造影00:15:21.760 --> 00:15:23.320一方面他可以诊断00:15:23.320 --> 00:15:25.080第二他可以做溶栓治疗00:15:25.080 --> 00:15:26.240把肺血栓溶掉00:15:26.240 --> 00:15:27.320那么病人一下子症00:15:27.320 --> 00:15:28.420状就好转了00:15:29.320 --> 00:15:30.720那么治疗策略里面呢00:15:30.720 --> 00:15:31.160我们说00:15:31.160 --> 00:15:33.160现在我们主要用的就是一个00:15:33.160 --> 00:15:34.140抗凝治疗00:15:34.160 --> 00:15:37.180那么从最原始的抗凝就是华法林00:15:37.680 --> 00:15:38.480华法林治疗00:15:38.480 --> 00:15:40.720那么但是因为华法林很容易出血00:15:40.720 --> 00:15:43.140而且要监测他的凝血酶原时间00:15:43.160 --> 00:15:46.440所以呢现在我们越来越多的用了00:15:46.440 --> 00:15:48.660一个抗凝和溶栓的一个组合00:15:48.760 --> 00:15:50.440就是像用些尿激酶00:15:50.440 --> 00:15:51.560那么静脉滴00:15:51.560 --> 00:15:52.800那么让他早期能够00:15:52.800 --> 00:15:54.940这个一般我们都在早期使用00:15:55.040 --> 00:15:56.540如果你晚期的话00:15:56.840 --> 00:15:58.280效果就比较差了00:15:58.280 --> 00:16:00.060就抗凝和溶栓的结合00:16:00.440 --> 00:16:01.240现在我们最的00:16:01.240 --> 00:16:03.120最多的还就是辅助治疗00:16:03.120 --> 00:16:05.460那么还有就是要监测凝血功能00:16:05.720 --> 00:16:07.020那么一定要监测的00:16:07.200 --> 00:16:08.560那么我们现在用最多的00:16:08.560 --> 00:16:10.240就是新型的抗炎药物00:16:10.240 --> 00:16:11.600我们用的立法沙班00:16:11.600 --> 00:16:12.560艾多沙班00:16:12.560 --> 00:16:14.680这些都是新型的抗炎药物啊00:16:14.680 --> 00:16:17.000可还有就是我们可以打低分子肝素00:16:17.000 --> 00:16:18.940那么这就是他的一些药物治疗00:16:19.200 --> 00:16:20.400另外呢我们目前00:16:20.400 --> 00:16:22.920由于DAC的技术的越来越进步00:16:22.920 --> 00:16:25.180我们可以做介入手术的干预00:16:25.320 --> 00:16:26.600包括导管取栓啊00:16:26.600 --> 00:16:27.900导管溶栓啊00:16:27.920 --> 00:16:29.460包括外科手术啊00:16:29.560 --> 00:16:31.800那么这主要是有赖于00:16:31.800 --> 00:16:34.360新型的这些介入技术的提高00:16:34.360 --> 00:16:35.720那么我们用的非常多00:16:35.720 --> 00:16:37.380我们医院也做的非常多00:16:37.640 --> 00:16:39.300另外就是一个术后的护理00:16:39.400 --> 00:16:40.720那么我们说术后的话00:16:40.720 --> 00:16:42.320就一般就是呃00:16:42.320 --> 00:16:45.000还是要进行一个下肢的一个锻炼啊00:16:45.000 --> 00:16:46.420那么术前的评估00:16:46.920 --> 00:16:48.340那么预后和预防00:16:48.440 --> 00:16:49.880那么我们刚刚说了一个00:16:49.880 --> 00:16:51.360就是要改变生活方式00:16:51.360 --> 00:16:52.540定期的体检00:16:52.760 --> 00:16:54.860要么我可以用些抗凝药物00:16:54.920 --> 00:16:56.120像我们做手术以前00:16:56.120 --> 00:16:57.280就可以打点低分子00:16:57.280 --> 00:16:58.180手术以后00:16:58.240 --> 00:17:00.240一般我们手术后62小时以后00:17:00.240 --> 00:17:01.840就要给他用抗凝治疗低00:17:01.840 --> 00:17:02.820分子肝素00:17:03.040 --> 00:17:03.640那么另外嘛00:17:03.640 --> 00:17:05.320就进行一些健康宣传00:17:05.320 --> 00:17:07.700宣教让病人有这个意思00:17:08.040 --> 00:17:09.960那么影响孕后的因素00:17:09.960 --> 00:17:12.000我们说还是一些患者的异常性啊00:17:12.000 --> 00:17:13.240早期发现啊00:17:13.240 --> 00:17:14.800定期的随访啊00:17:14.800 --> 00:17:16.820还有个健康的一个生活质量00:17:17.080 --> 00:17:18.400好吧那么嗯00:17:18.400 --> 00:17:20.060肺栓塞其实这个疾病00:17:20.160 --> 00:17:22.120现在临床上发病率也是比较多的00:17:22.120 --> 00:17:23.640那么这个疾病主要的就是00:17:23.640 --> 00:17:24.960一定要早期诊断00:17:24.960 --> 00:17:25.980早期治疗00:17:26.040 --> 00:17:27.380那么一旦入诊00:17:27.520 --> 00:17:29.760那么他的死亡率也是非常高的00:17:29.760 --> 00:17:30.600好吧嗯好00:17:30.600 --> 00:17:31.720今天我们就讲到00:17:31.720 --> 00:17:32.660谢谢大家