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--> 00:01.460\n特点及治疗策略。\n\n00:03.329 --> 00:03.555\n嗯，\n\n00:03.555 --> 00:04.329\n首先呢，\n\n00:04.679 --> 00:06.630\n我们从七个方面进行。\n\n00:07.532 --> 00:09.256\n讲述首第一点呢，\n\n00:09.256 --> 00:10.732\n是非三赛的一个概述。\n\n00:10.982 --> 00:11.682\n第二个呢，\n\n00:11.682 --> 00:13.232\n是诊断特点与流程。\n\n00:13.381 --> 00:16.832\n第三个是危险因素评估与危险分层。\n\n00:16.982 --> 00:19.232\n第四个是治疗策略与管理。\n\n00:19.916 --> 00:20.691\n第五个方面呢，\n\n00:20.691 --> 00:22.615\n是预防与长期的一个管理。\n\n00:22.715 --> 00:23.865\n第六个方面呢，\n\n00:23.865 --> 00:26.416\n是最新的研究进展与指南更新。\n\n00:26.766 --> 00:27.865\n第七个方面呢，\n\n00:27.865 --> 00:29.365\n是案例与临床应用。\n\n00:30.222 --> 00:32.521\n首先我们讲一下肺栓塞的概述。\n\n00:34.298 --> 00:35.097\n首先呢，\n\n00:35.647 --> 00:37.097\n我们看一下它的定义。\n\n00:37.907 --> 00:38.832\n急性肺栓塞呢，\n\n00:38.832 --> 00:43.407\n是内源性或外源性栓子阻塞肺动脉及其分支，\n\n00:43.556 --> 00:47.157\n引发肺循环障碍的一个临床病理生理综合症。\n\n00:47.407 --> 00:48.256\n其中呢，\n\n00:48.556 --> 00:50.606\n肺血栓栓塞综合征呢，\n\n00:50.606 --> 00:51.606\n占绝大多数。\n\n00:51.606 --> 00:54.907\n通常所称P一即指的是。\n\n00:55.764 --> 00:59.814\nPTE现在的一个全球发展情，\n\n00:59.814 --> 01:00.814\n发病情况呢，\n\n01:00.814 --> 01:05.527\n是全球每年新发急性肺栓塞了大概要150万人，\n\n01:05.527 --> 01:10.239\n是最常见的三大致死性心血管疾病之一。\n\n01:10.639 --> 01:12.190\n未经治疗病死率呢，\n\n01:12.190 --> 01:14.389\n达到25%.30%，\n\n01:14.540 --> 01:15.815\n规范治疗之后呢，\n\n01:15.815 --> 01:18.639\n可以降至到5%到百分8%。\n\n01:19.440 --> 01:19.839\n嗯，\n\n01:19.839 --> 01:21.665\n我国的一个流行病学特点呢，\n\n01:21.665 --> 01:23.639\n是我国住院患者呢，\n\n01:23.639 --> 01:25.589\n发病率呈上升趋势。\n\n01:25.807 --> 01:26.807\n2021年呢，\n\n01:26.807 --> 01:29.157\n达到了每10万里面呢，\n\n01:29.208 --> 01:30.708\n有14.19万，\n\n01:30.858 --> 01:32.657\n男性略高于女性，\n\n01:32.907 --> 01:37.008\n死亡率显著下降至10万分之一点零。\n\n01:37.958 --> 01:39.458\n与欧美国家相近，\n\n01:39.907 --> 01:41.508\n高危人群的分布呢，\n\n01:41.508 --> 01:43.657\n发病年龄多在45岁以上，\n\n01:43.807 --> 01:44.983\n随年龄增长了，\n\n01:44.983 --> 01:45.907\n发病率增加。\n\n01:46.008 --> 01:51.708\n长期卧床术后肿瘤患者等特定人群发病率显著升高。\n\n01:51.807 --> 01:53.682\n慢性心肺疾病患者呢，\n\n01:53.682 --> 01:56.157\n并发症达到19%.29%。\n\n01:57.834 --> 02:00.985\n下面我们看一下它的病理生理机制与临床分型，\n\n02:01.385 --> 02:05.035\n第一是血栓形成与肺动脉阻塞的一个机制。\n\n02:05.434 --> 02:08.735\n急性肺栓塞核心机制为血栓形成，\n\n02:09.035 --> 02:11.160\n深静脉血栓所占成，\n\n02:11.160 --> 02:15.585\n形成所占所有急性肺栓塞的60%.70%。\n\n02:15.884 --> 02:16.610\n血栓呢，\n\n02:16.610 --> 02:18.134\n通常来源于下肢，\n\n02:18.335 --> 02:20.535\n通过血液循环到达肺动脉，\n\n02:20.585 --> 02:22.335\n导致肺动脉的一个阻塞。\n\n02:23.272 --> 02:23.472\n嗯，\n\n02:23.472 --> 02:24.046\n第二个呢，\n\n02:24.046 --> 02:26.671\n是看血流动力学与呼吸功能的一个改变。\n\n02:27.022 --> 02:28.246\n肺动脉阻塞呢，\n\n02:28.246 --> 02:30.522\n通常导致肺循环的阻力增加，\n\n02:30.671 --> 02:32.171\n右心的负荷增加，\n\n02:32.272 --> 02:33.222\n严重者呢，\n\n02:33.222 --> 02:34.972\n可以导致急性右心衰竭。\n\n02:35.171 --> 02:35.897\n同时呢，\n\n02:35.897 --> 02:38.472\n会引起通气血流比例失调，\n\n02:38.722 --> 02:41.121\n导致低氧血症和呼吸衰竭。\n\n02:41.839 --> 02:45.440\n肺血管阻塞面积与临床表现密切相关。\n\n02:47.542 --> 02:47.792\n嗯，\n\n02:47.792 --> 02:48.417\n第三个呢，\n\n02:48.417 --> 02:53.442\n我们看一下基于早期死亡风险的一个临床分型最新指南指出呢，\n\n02:53.492 --> 02:58.391\n肺栓塞严重程度应根据早期死亡风险进行评估，\n\n02:58.591 --> 03:00.641\n分为高危、中危和低危。\n\n03:00.891 --> 03:01.867\n高危患者呢，\n\n03:01.867 --> 03:03.692\n表现为休克或低血压，\n\n03:03.891 --> 03:05.091\n需要立即治疗。\n\n03:05.242 --> 03:09.516\n中危患者存在右心功能不全和或心肌损伤，\n\n03:09.516 --> 03:10.492\n标志物升高。\n\n03:10.692 --> 03:11.742\n低危患者呢，\n\n03:11.742 --> 03:13.091\n是没有上述表现的。\n\n03:13.867 --> 03:18.391\n下面我们看一下静脉血栓栓塞症的关联机制，\n\n03:18.391 --> 03:21.016\n首先我们看一下三要素的一个协同作用。\n\n03:21.617 --> 03:23.466\n静脉血栓栓塞症呢，\n\n03:23.567 --> 03:29.617\n它的核心机制涉及血流淤滞、血管内皮损伤和血液高凝状态。\n\n03:29.716 --> 03:31.417\n三者是相互作用。\n\n03:31.567 --> 03:34.667\n如长期卧床会导致一个血流缓慢，\n\n03:35.067 --> 03:37.817\n手术创伤会损伤血管内皮，\n\n03:38.117 --> 03:41.516\n肿瘤激活会激活凝血功能系统，\n\n03:41.567 --> 03:43.567\n共同促进一个血栓的形成。\n\n03:45.686 --> 03:45.985\n嗯，\n\n03:46.386 --> 03:50.035\n深静脉血栓与肺栓塞的一个病理联系，\n\n03:50.285 --> 03:53.960\n大概60%.70%的急性肺栓塞呢，\n\n03:53.960 --> 03:56.436\n源于下肢深静脉血栓的一个脱落。\n\n03:57.108 --> 03:59.358\n血栓随血流迁移至肺动脉，\n\n03:59.358 --> 04:00.707\n阻塞肺循环。\n\n04:02.264 --> 04:03.490\nDVT与PE呢，\n\n04:03.490 --> 04:05.764\n是同一疾病在不同阶段的表现，\n\n04:05.914 --> 04:07.615\n合称为VTE。\n\n04:08.464 --> 04:11.313\n我们看一下血栓与脱落的一个动态过程，\n\n04:11.664 --> 04:12.664\n早期呢，\n\n04:12.664 --> 04:13.764\n血栓松脆，\n\n04:14.014 --> 04:16.164\n在形成后数天内呢，\n\n04:16.264 --> 04:17.664\n脱落风险最高。\n\n04:18.164 --> 04:19.514\n静脉内压升高，\n\n04:19.514 --> 04:20.813\n血流突然增加，\n\n04:21.213 --> 04:22.864\n可促使血栓脱落，\n\n04:22.914 --> 04:23.813\n引发PE。\n\n04:25.010 --> 04:29.709\n瓣膜功能不全或静脉血流紊乱加剧血栓迁移的一个风险。\n\n04:31.131 --> 04:33.182\n右心功能不全的一个连锁反应，\n\n04:33.381 --> 04:36.932\n肺动脉阻塞会导致肺循环阻力增加。\n\n04:37.131 --> 04:41.731\n右心室负荷过重引发右心扩大和功能不全。\n\n04:42.032 --> 04:43.106\n严重的时候呢，\n\n04:43.106 --> 04:44.631\n可以出现急性右心衰，\n\n04:44.682 --> 04:46.231\n导致低血压，\n\n04:46.231 --> 04:47.981\n休克是急性。\n\n04:48.937 --> 04:51.537\n肺栓塞急性期死亡的主要原因。\n\n04:53.139 --> 04:54.039\n第二个部分呢，\n\n04:54.039 --> 04:57.188\n我们分享一下临床诊诊断特点与流程。\n\n04:58.575 --> 05:02.100\n肺栓塞临床表现的一个多样性与警示真相，\n\n05:02.250 --> 05:02.899\n首先呢，\n\n05:02.899 --> 05:04.750\n它的症状是缺乏特异性的，\n\n05:04.750 --> 05:06.600\n可以从没有症状到猝死。\n\n05:07.000 --> 05:09.649\n急性肺栓塞临床表现的差异比较大，\n\n05:09.799 --> 05:12.500\n可从完全无症状到突然猝死，\n\n05:13.000 --> 05:19.250\n是典型的呼吸困难、胸痛、咯血三联针发病率不足百分之十三十，\n\n05:19.399 --> 05:21.500\n容易导致一个漏诊和误诊。\n\n05:22.774 --> 05:24.274\n它的一个危险信号呢，\n\n05:24.274 --> 05:26.700\n一个是晕厥与血流血流动力学异常，\n\n05:27.049 --> 05:28.375\n晕厥的发生率呢，\n\n05:28.375 --> 05:30.799\n大概要到11%.20%，\n\n05:30.850 --> 05:32.750\n可能是唯一首发症状，\n\n05:32.850 --> 05:35.975\n提示了有大块血栓阻塞50%以上，\n\n05:35.975 --> 05:38.799\n肺血管低血压休克虽罕见，\n\n05:38.799 --> 05:41.500\n但提示高危需要紧急干预。\n\n05:41.899 --> 05:43.250\n它的核心症状呢，\n\n05:43.250 --> 05:45.250\n是一个呼吸困难与胸痛，\n\n05:45.500 --> 05:47.500\n呼吸困难是最常见症状，\n\n05:47.500 --> 05:48.325\n发生率呢，\n\n05:48.325 --> 05:49.750\n要达到85%，\n\n05:49.850 --> 05:51.049\n活动后加剧。\n\n05:51.200 --> 05:51.975\n胸痛呢，\n\n05:51.975 --> 05:52.950\n多为胸膜性。\n\n05:52.984 --> 05:57.234\n疼痛需要与急性冠脉综合症主动脉夹层的进行鉴别。\n\n05:58.933 --> 06:00.134\n有咯血的提示，\n\n06:00.134 --> 06:02.734\n肺梗死多在24小时之内出现。\n\n06:03.463 --> 06:04.813\n它的一个体征的提示呢，\n\n06:04.813 --> 06:06.914\n是呼吸与循环系统异常。\n\n06:07.364 --> 06:11.063\n常见的一个是呼吸急促大于20次每分，\n\n06:11.063 --> 06:13.914\n心动过速大于90次每分。\n\n06:13.963 --> 06:16.014\n发干右心衰竭时呢，\n\n06:16.014 --> 06:17.438\n可见颈静脉怒张，\n\n06:17.438 --> 06:18.164\n肝大，\n\n06:18.164 --> 06:19.264\n下肢水肿。\n\n06:19.414 --> 06:20.114\n肺部呢，\n\n06:20.114 --> 06:21.563\n可以闻及干湿罗音，\n\n06:21.563 --> 06:22.713\n胸膜摩擦音。\n\n06:24.035 --> 06:24.234\n嗯，\n\n06:24.234 --> 06:24.660\n下面呢，\n\n06:24.660 --> 06:28.584\n我们从实验室跟影像学检查体系来看一下。\n\n06:28.734 --> 06:29.334\n首先呢，\n\n06:29.334 --> 06:30.934\n实验室的检查指标呢，\n\n06:30.934 --> 06:31.559\n是第二，\n\n06:31.559 --> 06:33.010\n具体第二具体呢，\n\n06:33.010 --> 06:35.334\n是纤维蛋白降解产物，\n\n06:35.385 --> 06:36.309\n其升高呢，\n\n06:36.309 --> 06:37.535\n是提示血栓形成，\n\n06:37.684 --> 06:39.510\n对急性肺栓塞的诊断呢，\n\n06:39.510 --> 06:40.984\n是具有辅助价值，\n\n06:41.184 --> 06:42.734\n但其特异性较差，\n\n06:42.885 --> 06:44.785\n需要结合临床综合判断。\n\n06:45.234 --> 06:46.959\n在2025年的指南指出，\n\n06:46.959 --> 06:49.010\n建议使用年龄矫正的第二，\n\n06:49.010 --> 06:53.184\n具体临界值代替传统的0.5mg/L的标准，\n\n06:53.434 --> 06:54.234\n不推荐。\n\n06:54.276 --> 06:56.925\n第二距离检测用于肿瘤患者肺栓塞的一个诊断。\n\n06:57.671 --> 06:59.946\n第二个核心影像学诊断技术呢，\n\n06:59.946 --> 07:02.221\n是CTPA，\n\n07:02.272 --> 07:04.872\n是诊断急性肺栓塞的一个金标准，\n\n07:04.971 --> 07:06.796\n可以显示肺动脉内的血栓，\n\n07:06.796 --> 07:09.471\n其敏感可以达到90%，\n\n07:09.721 --> 07:11.721\n特异性达到95%。\n\n07:11.921 --> 07:14.122\n适用于临床高度怀疑的患者。\n\n07:14.321 --> 07:16.671\n对于疑似PTE的患者呢，\n\n07:16.671 --> 07:22.821\n如果因造影剂过敏严重肾功能不全或其他原因无法进行CDPA检查。\n\n07:24.070 --> 07:27.369\n特异行通气肺通气血流形象，\n\n07:28.220 --> 07:30.519\n其敏感性达到80%，\n\n07:30.519 --> 07:33.369\n特异性可以达到90%。\n\n07:33.369 --> 07:36.695\n对于高危疑似高危的肺栓塞患者呢，\n\n07:36.695 --> 07:38.545\n建议根据临床的实际情况，\n\n07:38.545 --> 07:44.070\n可以选择床旁超声心动图或急诊CTPA检查以协助诊断。\n\n07:44.269 --> 07:45.494\n超声心动图呢，\n\n07:45.494 --> 07:48.619\n是能够提供关于心脏结构和功能的信息。\n\n07:48.869 --> 07:51.545\n对于发现肺栓塞引起的右心功能不全呢，\n\n07:51.545 --> 07:52.570\n具有重要价值。\n\n07:52.869 --> 07:54.369\n可显示右心室扩大。\n\n07:54.415 --> 07:57.615\n大运动减弱或压力负荷过重等。\n\n07:58.865 --> 08:00.365\n对于妊娠期女性，\n\n08:00.566 --> 08:00.966\n如。\n\n08:01.895 --> 08:07.246\n疑似急性PTE建议检测第二具体第二具体阴性的呢，\n\n08:07.246 --> 08:10.496\n可以基本排除急性的PTE。\n\n08:10.545 --> 08:11.596\n在妊娠期，\n\n08:11.596 --> 08:14.496\n如疑似急性PTE，\n\n08:14.496 --> 08:18.045\n建议行下肢静脉加压超声检查，\n\n08:18.196 --> 08:20.621\n一旦确诊是DVT呢，\n\n08:20.621 --> 08:22.746\n可以按照VET进行抗凝治疗。\n\n08:22.846 --> 08:25.895\n如下肢CUS检查阴性，\n\n08:25.895 --> 08:28.295\n临床仍高度怀疑急性PTE的，\n\n08:28.295 --> 08:32.145\n可以行核素V比Q显像或C。\n\n08:32.346 --> 08:33.046\nCPA检查。\n\n08:35.731 --> 08:43.932\n临床上可能性评估的一个工具有威尔评分系统、修订版的GI评分系统，\n\n08:44.581 --> 08:50.132\n还有YEARS模型以及临床应用场景。\n\n08:51.041 --> 08:52.192\n我有评分系统呢，\n\n08:52.192 --> 08:59.892\n是包括了深静脉血栓症状、心率大于等于100次、近期手术或制动等七项指标。\n\n08:59.992 --> 09:00.966\n总分越高，\n\n09:00.966 --> 09:01.742\n风险越高，\n\n09:01.942 --> 09:03.291\n敏感性较高，\n\n09:03.591 --> 09:05.091\n适用于初步筛查。\n\n09:05.742 --> 09:08.841\n对于修订版的GENEVA评分呢，\n\n09:08.841 --> 09:16.041\n涵盖年龄大于65岁、DVT或P病史、一个月内手术后骨骨折等7项评分。\n\n09:17.031 --> 09:18.557\n低危的是0.3分，\n\n09:18.557 --> 09:20.081\n中危的4到十分，\n\n09:20.481 --> 09:22.331\n高危的是大于等于11分。\n\n09:22.331 --> 09:26.507\n特异性在低风险人群中表现较好。\n\n09:26.507 --> 09:27.481\nYEARS模型呢，\n\n09:27.481 --> 09:31.781\n是2025年指南推荐用于疑似P患者，\n\n09:31.932 --> 09:33.932\n通过是否有深静脉血栓，\n\n09:34.081 --> 09:39.307\n咯血是否为P最可能诊断三项指标减少，\n\n09:39.307 --> 09:40.182\nCDPA过度使用，\n\n09:40.231 --> 09:42.182\n尤其适用于妊娠期患者。\n\n09:43.085 --> 09:44.286\n临床应用场景。\n\n09:45.934 --> 09:47.184\n结合第二具体检测，\n\n09:47.385 --> 09:50.635\n对低可能性患者阴性可排除PE，\n\n09:50.885 --> 09:53.585\n高可能性患者直接行CDPA检查，\n\n09:53.784 --> 09:56.085\n指导下一步诊断策略，\n\n09:56.135 --> 09:57.585\n提高诊断效率。\n\n09:58.429 --> 10:01.179\n诊断流程跟分层决策路径，\n\n10:01.729 --> 10:09.005\n嗯临床可能性评估我们可以使用YAR模型优先应用2025年指南呢。\n\n10:09.005 --> 10:15.979\n建议对疑似肺栓塞患者含妊娠期产后首选YEARS模型评估，\n\n10:16.179 --> 10:18.130\n通过是否有深静脉血栓，\n\n10:18.380 --> 10:19.330\n是否咯血，\n\n10:19.330 --> 10:23.929\n是否进行手术制动三项指标分层低风险结合第二，\n\n10:23.929 --> 10:28.280\n具体检测可减少CDPA过度使用辅助检查。\n\n10:28.676 --> 10:32.276\n从快速筛查到确诊年龄，\n\n10:32.276 --> 10:37.476\n矫正的第二具体临界值替代传统的0.5ng/L的标准。\n\n10:37.676 --> 10:38.676\n肿瘤患者呢，\n\n10:38.676 --> 10:40.526\n是不推荐DR具体检测的。\n\n10:41.080 --> 10:42.630\n临床低度的可能。\n\n10:43.523 --> 10:47.723\n者新评估排除标准高度可能直接行CTPA，\n\n10:47.723 --> 10:51.874\n高危患者根据条件选择床旁超声或者急诊CTPA。\n\n10:53.780 --> 10:57.679\n危险的一个核心分层早期死亡风险评估体系，\n\n10:57.929 --> 11:03.405\n以血流动力学状态为首要分层依据休克低血压定义为高危，\n\n11:03.405 --> 11:05.429\n需要立即干预稳定者。\n\n11:05.429 --> 11:08.304\n结合右心功能超声心动图，\n\n11:08.304 --> 11:13.530\nCDPA显示右心扩大和心肌损伤标志物如肌钙蛋白分为中危。\n\n11:14.372 --> 11:15.372\n和低危。\n\n11:16.203 --> 11:17.679\n分层处置策略，\n\n11:17.679 --> 11:20.778\n从抗凝到再关注治疗高危患者呢，\n\n11:20.778 --> 11:22.854\n我们首选静脉肝素抗凝，\n\n11:23.004 --> 11:23.854\n无禁忌症，\n\n11:23.854 --> 11:25.304\n实行系统性溶栓。\n\n11:25.504 --> 11:29.703\n中危患者抗凝后密切监测恶化时补救性溶栓。\n\n11:30.054 --> 11:31.104\n低危患者呢，\n\n11:31.104 --> 11:35.203\n是评估U型功能后可考虑早期出院抗凝治疗，\n\n11:35.354 --> 11:37.504\n优选直接口服抗凝剂。\n\n11:39.479 --> 11:40.505\n第三个部分呢，\n\n11:40.505 --> 11:43.130\n我们讲危险因素评估与危险分层。\n\n11:45.039 --> 11:46.140\n危险因素呢，\n\n11:46.239 --> 11:48.940\n分类与识别要点首先呢，\n\n11:48.940 --> 11:51.239\n我们有有遗传性的危险因素，\n\n11:51.390 --> 11:53.190\n有获得性的危险因素，\n\n11:53.739 --> 11:56.590\n还有三个要素与风险叠加，\n\n11:56.840 --> 11:59.039\n以及重点人权筛查建议。\n\n12:00.221 --> 12:01.721\n遗传性的危险因素呢，\n\n12:01.721 --> 12:09.296\n主要包括微因子突变、蛋白C缺乏、蛋白S缺乏以及抗凝血酶缺乏等。\n\n12:09.296 --> 12:14.521\n遗传变异家族中有类似血栓疾病病史者需要高度警惕，\n\n12:14.622 --> 12:16.521\n应进行相关基因检测。\n\n12:16.671 --> 12:29.021\n获得性的涵盖骨折、创伤、手术、恶性肿瘤、口服避孕药、妊娠或产后期长期卧床、长途乘空和乘坐旅行、慢性心肺疾病。\n\n12:29.521 --> 12:33.572\n中心静脉插管、高龄、肥胖以及吸烟等。\n\n12:33.671 --> 12:39.171\n其中手术、长期卧床、恶性肿瘤是临床常见高危因素。\n\n12:41.281 --> 12:43.831\n三因素的风险叠加，\n\n12:43.831 --> 12:45.182\n静脉血流瘀滞，\n\n12:45.331 --> 12:46.731\n比如说长期卧床，\n\n12:46.831 --> 12:53.132\n静脉系统内皮损伤如创伤手术和血液高凝状态如妊娠肿瘤，\n\n12:53.182 --> 12:55.382\n是血栓形成的三大促进因素。\n\n12:55.632 --> 12:59.481\n多种因素同时存在时风险显著增加。\n\n12:59.932 --> 13:03.932\n如术后长期卧床患者风险远高于单一因素者。\n\n13:04.382 --> 13:05.882\n重点人群筛查。\n\n13:06.471 --> 13:11.021\n年龄小于50岁且无可逆性诱发因素的急性肺栓塞患者，\n\n13:11.122 --> 13:13.622\n或家族性静脉血栓栓塞症，\n\n13:13.622 --> 13:16.021\n且无确切可逆因素。\n\n13:16.851 --> 13:19.252\n可诱发因素者建议进行。\n\n13:23.986 --> 13:24.286\n嗯，\n\n13:24.286 --> 13:28.085\n评估评估相关风险因素，\n\n13:28.536 --> 13:28.935\n嗯，\n\n13:29.135 --> 13:32.236\n像风险评估模型的一个临床应用，\n\n13:32.236 --> 13:32.960\n常见的呢，\n\n13:32.960 --> 13:35.710\n有常用的一个风险评分系统，\n\n13:35.710 --> 13:39.585\n风险评分标准解读以及评分的一个临床应用。\n\n13:40.607 --> 13:43.757\n危险分层标准与预后关联呢，\n\n13:43.807 --> 13:45.107\n我们从三个方面看，\n\n13:45.107 --> 13:46.783\n一个是血流动力学状态呢，\n\n13:46.783 --> 13:48.357\n是首要的一个分层依据。\n\n13:48.607 --> 13:49.382\n第二个呢，\n\n13:49.382 --> 13:50.732\n是非高危患者呢，\n\n13:50.732 --> 13:52.158\n结合右心功能呢，\n\n13:52.208 --> 13:54.057\n与生物标志物进行分层。\n\n13:54.307 --> 13:55.158\n第三个呢，\n\n13:55.158 --> 13:57.408\n是危险分层指导的一个策略的选择。\n\n13:57.807 --> 13:58.632\n第四个呢，\n\n13:58.632 --> 13:59.932\n要从右心功能呢，\n\n13:59.932 --> 14:01.807\n是评估预后预测观。\n\n14:02.765 --> 14:03.815\n预测的一个关键。\n\n14:05.547 --> 14:06.572\n第四个部分呢，\n\n14:06.572 --> 14:08.197\n我们讲治疗策略与管理。\n\n14:09.190 --> 14:09.815\n首先呢，\n\n14:09.815 --> 14:11.739\n是抗凝治疗的一个药物选择。\n\n14:11.989 --> 14:12.465\n它呢，\n\n14:12.465 --> 14:14.039\n有传统的一个抗凝药物，\n\n14:14.039 --> 14:16.489\n以及新型的一个口服的抗凝药物，\n\n14:16.590 --> 14:17.765\n还有特殊人群呢，\n\n14:17.765 --> 14:19.590\n我们可以选择的一些抗凝药物。\n\n14:20.200 --> 14:20.400\n嗯，\n\n14:20.400 --> 14:22.349\n抗凝治疗的一些初始方案。\n\n14:23.731 --> 14:26.531\n溶栓治疗的一些适应症与实施要点？\n\n14:27.841 --> 14:28.567\n它的首先，\n\n14:28.567 --> 14:31.892\n第一个是高危急性的PTE患者的一个首选治疗，\n\n14:32.341 --> 14:36.392\n是中危PTE患者的一个补救性的溶栓指针。\n\n14:37.192 --> 14:37.591\n嗯，\n\n14:37.692 --> 14:41.442\n溶栓的药物的跟方案常用的溶栓药物呢，\n\n14:41.442 --> 14:44.492\n包括尿激酶链激酶溶栓呢，\n\n14:44.492 --> 14:46.192\n我们也注意评估它的禁忌症。\n\n14:47.291 --> 14:48.367\n溶栓治疗呢，\n\n14:48.367 --> 14:51.591\n要注意监测以及注意并发症的一个发生。\n\n14:53.357 --> 14:53.932\n另外呢，\n\n14:53.932 --> 14:55.482\n还有介入于外科治疗，\n\n14:55.482 --> 14:56.607\n外科技术应用，\n\n14:56.708 --> 14:59.857\n比如说像经皮肺动脉血栓抽吸术。\n\n15:00.867 --> 15:02.168\n下腔静脉滤器。\n\n15:03.809 --> 15:06.659\n置入术、肺动脉血栓切除术，\n\n15:06.809 --> 15:08.409\n经导管溶栓治疗，\n\n15:09.109 --> 15:11.710\n另外还有特殊人群治疗策略的一个调整，\n\n15:11.909 --> 15:14.210\n像妊娠期患者的一个抗凝管理，\n\n15:14.210 --> 15:15.809\n肿瘤患者的抗凝管理，\n\n15:15.909 --> 15:17.659\n儿童患者的抗凝管理，\n\n15:17.809 --> 15:19.835\n血小板减少患者的处理策略，\n\n15:19.835 --> 15:23.010\n以及抗磷脂综合征患者的一个抗凝治疗。\n\n15:23.762 --> 15:24.562\n第五个呢，\n\n15:24.562 --> 15:28.461\n我们是要从预防与长期管理进行探讨。\n\n15:29.349 --> 15:31.424\n那么血栓预防的一些措施呢，\n\n15:31.424 --> 15:33.450\n是包括一个基础的预防措施，\n\n15:33.650 --> 15:35.200\n机械的一个预防措施，\n\n15:35.250 --> 15:36.650\n药物预防策略，\n\n15:36.650 --> 15:39.500\n风险分级与预防适配的。\n\n15:41.770 --> 15:42.195\n另外呢，\n\n15:42.195 --> 15:46.070\n长期的抗凝的疗程的一个决策依据可以包括，\n\n15:46.070 --> 15:53.320\n基础抗凝疗程标准、危险因素分层决策、复发风险评估要点、出血风险动态评估。\n\n15:54.255 --> 15:55.630\n在并发症上面呢，\n\n15:55.630 --> 15:58.755\n我们也要做好一个监测与管理的策略，\n\n15:59.056 --> 16:01.906\n像急性右心衰竭的一个监测与干预，\n\n16:02.056 --> 16:04.255\n出血风险的评估与处理，\n\n16:04.606 --> 16:10.205\n慢性肺血栓、慢性血栓、栓塞性肺高压的一个早期筛查，\n\n16:10.306 --> 16:13.205\n感染与血栓形成的一个双重防控。\n\n16:14.073 --> 16:15.098\n第六个部分呢，\n\n16:15.098 --> 16:18.424\n我们要看一下最新的研究进展跟指南更新。\n\n16:18.674 --> 16:24.148\n2025的核心那个指南核心更新要点呢，\n\n16:24.148 --> 16:26.448\n诊断手段与策略进行了优化，\n\n16:26.448 --> 16:28.124\n危险分层标准明确，\n\n16:28.273 --> 16:30.174\n抗凝治疗方案进行了更新。\n\n16:30.323 --> 16:31.973\n溶栓与介入治疗呢，\n\n16:31.973 --> 16:33.424\n也是推荐的，\n\n16:33.523 --> 16:34.198\n并且呢，\n\n16:34.198 --> 16:36.573\n注意随访并发症管理强化。\n\n16:38.304 --> 16:40.013\n在诊断技术创新应用方面，\n\n16:40.013 --> 16:44.679\n有第二具体检测优化YEARS模型评估策略，\n\n16:44.679 --> 16:49.205\n影像学检查应应用进展特殊人群诊疗方案的一个更新。\n\n16:49.755 --> 16:50.130\n嗯，\n\n16:50.130 --> 16:52.705\n在药物了治疗药物研发上面呢，\n\n16:52.804 --> 16:53.179\n嗯，\n\n16:53.179 --> 16:56.054\n有新型的口服抗凝药的一个优化应用。\n\n16:57.119 --> 16:57.270\n嗯，\n\n16:57.270 --> 16:59.869\n抗凝药物出血风险拮抗剂的研发，\n\n16:59.869 --> 17:02.320\n特殊人群抗凝药物的研发与应用。\n\n17:03.020 --> 17:04.094\n第七个部分呢，\n\n17:04.094 --> 17:07.219\n我们探讨一下案例的分析与临床应用。\n\n17:07.875 --> 17:10.125\n典型的病例诊疗过程分析，\n\n17:10.475 --> 17:10.875\n嗯，\n\n17:11.125 --> 17:12.625\n像这样一个患者，\n\n17:12.625 --> 17:14.000\n68岁的患者呢，\n\n17:14.000 --> 17:15.100\n是因为呼吸困难，\n\n17:15.100 --> 17:15.975\n一天急诊。\n\n17:17.092 --> 17:21.666\n就诊肺动脉CT的是提示双侧肺动脉栓塞患者呢，\n\n17:21.666 --> 17:22.491\n长期卧床，\n\n17:22.491 --> 17:23.592\n无明显胸痛，\n\n17:23.741 --> 17:25.567\n以突发呼吸困难为主要症状。\n\n17:25.567 --> 17:26.442\n生命体征呢，\n\n17:26.442 --> 17:27.567\n显示呼吸急促，\n\n17:27.567 --> 17:28.391\n心率加快。\n\n17:29.180 --> 17:30.430\n根据临床评估呢，\n\n17:30.430 --> 17:31.530\n为中危患者，\n\n17:32.579 --> 17:33.880\n那么治疗呢？\n\n17:33.880 --> 17:35.780\n采用了微创介入治疗，\n\n17:35.880 --> 17:37.655\n行血栓抽吸，\n\n17:37.655 --> 17:39.204\n清除肺动脉内血栓，\n\n17:39.204 --> 17:40.579\n术后立刻启动抗凝，\n\n17:41.130 --> 17:42.729\n给予低分子皮下注射，\n\n17:42.729 --> 17:45.180\n病情稳定后过渡为口服利伐沙班。\n\n17:47.578 --> 17:47.828\n嗯，\n\n17:47.878 --> 17:48.552\n术后呢，\n\n17:48.552 --> 17:50.478\n患者呼吸困难症状的缓解，\n\n17:50.578 --> 17:52.677\n24小时内氧饱和度恢复正常。\n\n17:53.590 --> 17:55.916\n右心功能指标是逐渐改善了，\n\n17:55.916 --> 17:56.490\n出院后呢，\n\n17:56.490 --> 17:57.816\n继续抗凝治疗3个月。\n\n17:57.965 --> 17:58.715\n定期呢，\n\n17:58.715 --> 18:00.965\n是复查凝血功能及下肢超声，\n\n18:01.015 --> 18:03.316\n没有发现血栓复发及出血风险。\n\n18:05.207 --> 18:05.381\n嗯，\n\n18:05.381 --> 18:08.207\n我们要注意一个诊断决策的难点与处理，\n\n18:08.607 --> 18:12.906\n像临床表现非特异性的容易导致一个整早期识别的困难。\n\n18:13.057 --> 18:13.482\n第二，\n\n18:13.482 --> 18:15.457\n具体检测的有一定的局限性。\n\n18:15.756 --> 18:18.707\n影像学选择也有时候也会存在一些困难。\n\n18:19.967 --> 18:21.616\n特殊人群的诊疗呢，\n\n18:21.616 --> 18:25.891\n是有一点复杂的危险分层指导下的一个动态决策管理呢，\n\n18:25.891 --> 18:26.866\n要注意加强。\n\n18:27.913 --> 18:29.364\n今天的分享就到这里。\n\n","v0d47cg10004d76bptaljhtdbnk2o5g0",1114,840,"2026-01-26 11:56:17"," 肺栓塞的诊断特点及治疗策略 - 胡小燕专家解析  "," 肺栓塞诊断,肺栓塞治疗,肺栓塞症状,胡小燕,静脉血栓,抗凝治疗,溶栓疗法  "," 本视频由胡小燕专家详细讲解肺栓塞的临床诊断特点、常见症状及最新治疗策略，涵盖抗凝与溶栓疗法的选择，帮助医疗从业者掌握关键诊疗要点。","2026-05-01 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