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--> 00:02.888\n大家好，\n\n00:02.888 --> 00:06.737\n今天我给大家讲的是肺动脉栓塞的诊断。\n\n00:07.566 --> 00:08.517\n及介入治疗。\n\n00:10.482 --> 00:10.781\n首先呢，\n\n00:10.781 --> 00:12.381\n我们来看什么叫肺栓塞。\n\n00:14.024 --> 00:15.524\n肺血栓栓塞症。\n\n00:16.403 --> 00:17.653\n他是来自。\n\n00:19.041 --> 00:23.941\n静脉或者右心的血栓堵塞肺动脉及其分支所致。\n\n00:25.316 --> 00:26.391\n那在临床上呢，\n\n00:26.391 --> 00:31.965\n以肺循环和呼吸循环功能障碍为其主要的临床和病理生理特征。\n\n00:33.729 --> 00:34.479\n肺栓塞呢，\n\n00:34.479 --> 00:35.828\n发生了栓塞以后呢，\n\n00:35.879 --> 00:37.953\n它所支配区的肺组织呢，\n\n00:37.953 --> 00:40.778\n因为一个血流的受阻或中断，\n\n00:40.879 --> 00:42.104\n从而发生坏死，\n\n00:42.104 --> 00:43.828\n我们称为肺梗死，\n\n00:45.278 --> 00:47.179\n肺栓栓的临床症状呢，\n\n00:47.179 --> 00:48.328\n它主要包括一个。\n\n00:48.967 --> 00:49.518\n呼吸困难。\n\n00:50.347 --> 00:50.797\n气促，\n\n00:51.196 --> 00:51.946\n胸痛。\n\n00:52.875 --> 00:53.900\n一般性的这个胸痛呢，\n\n00:53.900 --> 00:57.224\n主要是因为一个胸膜性炎症的胸痛。\n\n00:58.223 --> 00:59.023\n还有一个昏厥。\n\n00:59.984 --> 01:03.683\n全身症状如一个烦躁不安、惊恐等等。\n\n01:04.897 --> 01:05.671\n而在体征上的话，\n\n01:05.671 --> 01:08.196\n他可能会表现为一个呼吸急促。\n\n01:09.013 --> 01:12.664\n发干、肺部哮鸣音和细湿罗音等等。\n\n01:15.093 --> 01:20.943\n么血栓的肺栓塞的栓子来源主要来自一个下肢的深静脉血栓。\n\n01:22.045 --> 01:25.246\n它占的比例要达到75%.90%。\n\n01:26.870 --> 01:27.269\n然后呢。\n\n01:29.094 --> 01:32.393\n他这个肺动脉的原发性血栓形成比较少。\n\n01:33.285 --> 01:38.084\n近年来主要是来自于前列腺和子宫周围静脉丛的血栓的增多。\n\n01:40.129 --> 01:40.430\n然后呢，\n\n01:40.430 --> 01:44.629\n来自盆腔静脉、髂静脉或者肾静脉。\n\n01:45.435 --> 01:49.136\n上下髂静脉或者中心静脉留置导管的血栓形成的，\n\n01:49.136 --> 01:51.085\n占10%.20%。\n\n01:52.735 --> 01:54.084\n对于妇女来说，\n\n01:54.584 --> 01:59.834\n她的肺静脉血栓栓子重要来源主要是一个盆腔的静脉血栓。\n\n02:00.925 --> 02:01.349\n一般呢，\n\n02:01.349 --> 02:05.224\n比较多的发生于一个妇科手术和盆腔疾患等等。\n\n02:06.987 --> 02:07.688\n然后呢，\n\n02:07.987 --> 02:11.787\n极少数的一个血栓来自一个右心房或右心室。\n\n02:12.671 --> 02:13.121\n有时候呢，\n\n02:13.121 --> 02:16.621\n往往和一个房颤的这个疾病病因有关。\n\n02:19.007 --> 02:20.757\n那我们有哪些辅助检查呢？\n\n02:20.908 --> 02:21.733\n一般性呢，\n\n02:21.733 --> 02:24.057\n是一个可以进行一个血气分型，\n\n02:24.557 --> 02:30.207\n它通常会显示一个呼吸性的碱中毒伴低氧血症。\n\n02:31.570 --> 02:31.845\n第二呢，\n\n02:31.845 --> 02:33.671\n我们可以做一个心电图。\n\n02:34.645 --> 02:36.195\n在心电图的图案里面呢，\n\n02:36.195 --> 02:42.496\n我们可能会显示一个电轴右偏及非特异性的STT段的改变。\n\n02:44.145 --> 02:44.395\n然后呢，\n\n02:44.395 --> 02:46.546\n我们还可以做一个胸部的X线检查。\n\n02:47.296 --> 02:55.695\n它这个实验在影像学里面可能会显示一个肺不张、胸腔积液或者肺梗死时候一个气形的阴影。\n\n02:56.522 --> 02:56.796\n这个呢，\n\n02:56.796 --> 02:57.647\n肺心阴影呢，\n\n02:57.647 --> 02:59.496\n是由一个肺动脉栓塞以后，\n\n02:59.496 --> 03:04.272\n引起一个肺供应的血管丧失血流引起的。\n\n03:05.531 --> 03:06.182\n我们同时呢，\n\n03:06.182 --> 03:08.432\n还可以做一下一个超声心电图。\n\n03:09.917 --> 03:11.242\n做超心电图的目的呢，\n\n03:11.242 --> 03:15.468\n是一个有助于排除一下其他原因引起的一个右心室压力升高。\n\n03:15.968 --> 03:16.518\n偶尔呢，\n\n03:16.518 --> 03:18.417\n我们可以看到一个肺动脉血栓。\n\n03:20.225 --> 03:20.850\n同时呢，\n\n03:20.850 --> 03:23.526\n我们还可以在那个临床上面做一个。\n\n03:24.919 --> 03:25.070\n第二，\n\n03:25.070 --> 03:25.720\n具体的检测。\n\n03:27.046 --> 03:29.447\n第二具体第二具体的那个水平升高呢，\n\n03:29.496 --> 03:31.046\n一个具有高度的敏感性。\n\n03:31.783 --> 03:32.333\n但是呢，\n\n03:32.333 --> 03:33.184\n特异性较低，\n\n03:33.483 --> 03:35.483\n我们主要用一个排除性的诊断。\n\n03:36.979 --> 03:37.578\n同时呢，\n\n03:37.578 --> 03:41.479\n我们也可以做一个螺旋CT和肺血管造影。\n\n03:42.404 --> 03:43.854\n我们通过这两个检查呢，\n\n03:43.854 --> 03:47.203\n可以发现一个肺段以上的肺动脉内的栓子，\n\n03:47.804 --> 03:50.554\n这个是诊断肺栓塞的一个重要手段。\n\n03:51.970 --> 03:52.369\n还有一个呢，\n\n03:52.369 --> 03:55.070\n是一个磁共振的肺动脉造影。\n\n03:56.257 --> 03:58.483\n对于肺段以上的肺动脉栓塞，\n\n03:58.483 --> 04:01.507\n我们诊断的这个敏感性和特异性都比较高。\n\n04:03.936 --> 04:04.686\n然后呢，\n\n04:04.735 --> 04:06.785\n血栓形成几个基本条件。\n\n04:07.951 --> 04:10.300\n一个是血流的预期。\n\n04:11.410 --> 04:11.934\n一些病人，\n\n04:11.934 --> 04:13.410\n比方说一个肥胖病人啊。\n\n04:14.466 --> 04:14.990\n妊娠，\n\n04:14.990 --> 04:16.015\n妊娠病人啊。\n\n04:17.079 --> 04:19.929\n还有一个长期的卧床以心衰病人，\n\n04:20.279 --> 04:24.230\n他们与活动度的减少造成血液流速的。\n\n04:25.201 --> 04:25.701\n减缓，\n\n04:25.851 --> 04:28.002\n那么会造成一个血液淤积，\n\n04:28.101 --> 04:29.502\n然后形成一个血栓。\n\n04:30.489 --> 04:31.213\n第二个呢，\n\n04:31.213 --> 04:33.639\n是我们说一个血液的凝固性增高。\n\n04:34.817 --> 04:37.118\n一些患者一个C蛋白缺乏，\n\n04:37.467 --> 04:38.618\nS蛋白缺乏，\n\n04:38.917 --> 04:41.118\n一些肿瘤病人他是高凝体质。\n\n04:41.928 --> 04:42.553\n还有一些病人呢，\n\n04:42.553 --> 04:44.627\n他口服那个长期口服避孕药。\n\n04:45.687 --> 04:47.386\n会引起血液凝固性增高。\n\n04:48.627 --> 04:52.227\n还有一个我们常见的是一个静脉的血管内皮损伤，\n\n04:52.877 --> 04:55.178\n有患者有时候有静脉炎啊，\n\n04:55.428 --> 04:58.178\n或者我们说做这个腔静脉导管置管啊。\n\n04:58.868 --> 04:59.819\n或是手术啊。\n\n05:00.600 --> 05:01.500\n或是外伤啊，\n\n05:01.500 --> 05:03.799\n都会导致一些患者血管内皮损伤，\n\n05:04.200 --> 05:08.250\n引起了患者容易更容易产成生这个血栓形成。\n\n05:10.430 --> 05:10.680\n然后呢，\n\n05:10.680 --> 05:17.480\n我们在肺栓塞的病人的患者可病理上面可以发现肺栓塞梗塞病呢，\n\n05:17.480 --> 05:20.580\n常见它一个多发性及双侧性。\n\n05:21.912 --> 05:23.363\n它在肺的下端呢，\n\n05:23.412 --> 05:25.213\n多于肺的上端。\n\n05:26.415 --> 05:28.765\n特别好发于右下叶的肺。\n\n05:29.812 --> 05:31.111\n大概会达到85%。\n\n05:32.640 --> 05:34.015\n但是在实验中呢，\n\n05:34.015 --> 05:37.740\n仅仅有5%或10%的肺栓塞梗患，\n\n05:37.841 --> 05:39.941\n肺栓塞患者发现肺梗死。\n\n05:41.332 --> 05:44.881\n如果说患有一些慢性的肺疾患，\n\n05:45.032 --> 05:46.182\n左心栓塞，\n\n05:46.631 --> 05:48.981\n就是说如果是小的肺栓栓栓子呢，\n\n05:48.981 --> 05:50.682\n也会引起一个发生肺梗死。\n\n05:52.493 --> 05:53.718\n他临床表现呢，\n\n05:53.718 --> 05:54.644\n还会有一些。\n\n05:55.665 --> 05:57.140\n些急性的肺栓塞呢，\n\n05:57.140 --> 05:58.714\n缺乏一些特异性的临床症状，\n\n05:59.114 --> 06:02.214\n症状的轻重与下列影响的因素有关。\n\n06:04.048 --> 06:08.548\n第一个栓子的机械梗阻肺动脉的程度，\n\n06:09.298 --> 06:12.697\n那么由于患者血栓的大小和多寡。\n\n06:13.546 --> 06:14.946\n以及栓塞的部位呢，\n\n06:15.247 --> 06:18.546\n会引起相应的不同的部位的一个梗阻，\n\n06:18.546 --> 06:20.846\n或者说栓塞的程度严重性。\n\n06:22.187 --> 06:23.937\n第二个我们说发病的速度，\n\n06:25.187 --> 06:27.687\n我们患者由于一个血管活性物质释放，\n\n06:27.837 --> 06:29.786\n会引起不同的发病速度。\n\n06:31.028 --> 06:31.627\n第三个呢，\n\n06:31.627 --> 06:35.278\n是一个发病前患者的心肺功能状态。\n\n06:36.286 --> 06:40.235\n如果说发病前患者本身的心肺功能比较正常的。\n\n06:40.832 --> 06:43.282\n那么可能它有一定的代偿作用。\n\n06:43.782 --> 06:46.481\n如果说患者本身的心肺功能已经属于。\n\n06:47.304 --> 06:49.554\n半衰竭或者是代偿失代偿期的话，\n\n06:49.904 --> 06:52.204\n那么患者的这个栓塞引起的症，\n\n06:52.255 --> 06:53.154\n并发症啊，\n\n06:53.154 --> 06:54.704\n这个症状就会很严重。\n\n06:56.824 --> 06:56.973\n然后，\n\n06:56.973 --> 06:58.973\n急性肺栓塞的患者呢，\n\n06:58.973 --> 07:01.924\n他的临床表现可以表现出很悬殊。\n\n07:02.789 --> 07:09.739\n可以从一到两个肺段的动脉栓塞引起的呼吸频率增加和憋气。\n\n07:10.710 --> 07:13.811\n一直到十几个段的肺动脉栓塞，\n\n07:14.311 --> 07:17.460\n会引起一个急性的肺源性的心脏病，\n\n07:18.061 --> 07:20.661\n右心功能不全和休克，\n\n07:21.110 --> 07:22.311\n但是严重的时候呢，\n\n07:22.311 --> 07:23.260\n会导致猝死。\n\n07:25.916 --> 07:26.791\n二期临床表现呢，\n\n07:26.791 --> 07:32.316\n它主要表现为一些其他原因比较难以解释的呼吸困难，\n\n07:32.916 --> 07:35.516\n最常见的比方说一个劳力性的呼吸困难。\n\n07:36.766 --> 07:37.541\n其次呢，\n\n07:37.541 --> 07:38.342\n他的胸痛呢，\n\n07:38.342 --> 07:40.066\n多数为胸膜的炎性疼痛，\n\n07:40.666 --> 07:41.541\n极少数呢，\n\n07:41.541 --> 07:44.416\n为胸骨下心绞痛样胸痛发作。\n\n07:45.979 --> 07:46.729\n有时候呢，\n\n07:46.729 --> 07:48.428\n患者还会有咯血。\n\n07:49.480 --> 07:50.006\n经常呢，\n\n07:50.006 --> 07:51.680\n表现为一个少量的咯血。\n\n07:52.799 --> 07:53.850\n大卡却比较少见。\n\n07:54.834 --> 07:55.859\n而少量咯血呢，\n\n07:55.859 --> 07:57.933\n它经常会提示一个肺梗死，\n\n07:58.234 --> 08:01.834\n一般性是在急诊发症后的24小时内产生。\n\n08:03.305 --> 08:06.605\n如果说肺栓塞发生在肺主动脉段的话，\n\n08:06.955 --> 08:10.205\n那么病人会因为血供不足引起一个昏厥。\n\n08:12.251 --> 08:16.550\n而我们说平时或者传统诊断肺栓塞三联症，\n\n08:16.901 --> 08:21.501\n即呼吸困难、胸痛、咯血同时存在，\n\n08:21.501 --> 08:23.351\n这个患者并不像，\n\n08:23.351 --> 08:24.376\n并不是很常见，\n\n08:24.376 --> 08:25.651\n占20%左右。\n\n08:28.015 --> 08:29.015\n那么会有哪些体征呢？\n\n08:30.092 --> 08:32.192\n一个是一个呼吸频率加快。\n\n08:33.182 --> 08:33.458\n这个呢，\n\n08:33.458 --> 08:35.882\n是肺栓塞的一个最常见的体征。\n\n08:37.085 --> 08:37.385\n同时，\n\n08:37.385 --> 08:39.484\n患者可以表现为一个心动过速。\n\n08:40.335 --> 08:40.909\n同时，\n\n08:40.909 --> 08:43.885\n血压监测表现为一个低血压，\n\n08:43.984 --> 08:45.885\n甚至于是低血压性休克。\n\n08:47.437 --> 08:48.112\n同时呢，\n\n08:48.112 --> 08:49.687\n患者会表现出一个紫绀。\n\n08:50.830 --> 08:52.431\n原因是一个血氧分压的异常，\n\n08:52.880 --> 08:53.481\n但是呢，\n\n08:53.481 --> 08:55.955\n有时候患者他的血氧分压，\n\n08:55.955 --> 08:57.431\n血氧分压正常的时候，\n\n08:57.580 --> 09:00.431\n也不能说排除一个肺动脉栓塞的可能。\n\n09:01.880 --> 09:03.330\n有时会引起一个发热，\n\n09:04.431 --> 09:08.981\n还有一个肺部的哮鸣音和或者湿啰音。\n\n09:10.375 --> 09:10.799\n同时呢，\n\n09:10.799 --> 09:12.200\n会表现出C上影像，\n\n09:12.200 --> 09:14.375\n学会表现出一个胸腔的积液。\n\n09:15.960 --> 09:17.809\n在患者听诊里面会发现。\n\n09:19.083 --> 09:20.684\n心音的亢进或分裂，\n\n09:20.783 --> 09:24.184\n第三、第三、三尖瓣期的那个收缩期的有个杂音。\n\n09:25.648 --> 09:26.323\n同时呢，\n\n09:26.323 --> 09:27.249\n有时候患者呢，\n\n09:27.249 --> 09:31.749\n还会合并有一个下肢深静脉血栓的一个体征，\n\n09:32.049 --> 09:35.348\n就是一个下肢的静脉静脉的一个轻肿症，\n\n09:35.799 --> 09:37.698\n肿胀肿大肿胀，\n\n09:37.749 --> 09:39.448\n颜色发暗紫绀，\n\n09:40.049 --> 09:42.398\n那通常不伴有明显的疼痛。\n\n09:44.604 --> 09:47.703\n而我们说怎么确诊肺栓塞？\n\n09:48.971 --> 09:50.370\n它的确诊性检查呢，\n\n09:50.370 --> 09:53.421\n一个就是我们前面说的一个螺旋CT的肺动脉造影，\n\n09:54.070 --> 10:00.520\n它可以清晰的表现出检出段及段以上的动脉腔内栓子。\n\n10:01.807 --> 10:06.158\n在影像学表现为一个动脉腔内的充盈缺损或截断者。\n\n10:07.367 --> 10:07.718\n第二个呢，\n\n10:07.718 --> 10:11.817\n我们说一个放射放射性的核素肺通气或者灌注扫描，\n\n10:12.617 --> 10:16.567\n它的影像学表现成为一个肺段分布的灌注缺损区，\n\n10:17.117 --> 10:19.567\n而肺通气的显象大致是正常的。\n\n10:20.755 --> 10:22.604\n同时我们说还有一个肺动脉造影，\n\n10:23.505 --> 10:25.429\n在影像学检查阳性，\n\n10:25.429 --> 10:27.755\n表现为动脉腔内一个充盈缺损，\n\n10:27.955 --> 10:29.455\n决断值、决断针，\n\n10:29.854 --> 10:33.705\n或者说肺动脉的分支缺损或粗细不均匀。\n\n10:35.620 --> 10:39.020\n我们可以在这张片子的。\n\n10:39.981 --> 10:41.981\n左边和右边的两个片子可以看出。\n\n10:43.385 --> 10:47.734\n分别都表现出一个肺动脉的充盈圈所叫箭头所致啊。\n\n10:51.971 --> 10:52.271\n然后呢，\n\n10:52.271 --> 10:53.221\n我们再看一下，\n\n10:53.521 --> 10:59.021\n然后说在肺动脉的DA数码检线造影里面会发现一个肺动脉的缺损。\n\n11:01.239 --> 11:03.189\n那么后面讲讲肺动脉栓塞的防治。\n\n11:04.791 --> 11:10.642\n深静脉血栓的形成是静脉血栓栓塞过程中的两种临床表现，\n\n11:11.192 --> 11:11.942\n一次般性呢，\n\n11:11.942 --> 11:13.442\n会常常合并发生。\n\n11:15.757 --> 11:19.307\n而肺静脉栓塞是深静脉血栓最严重的并发症，\n\n11:19.807 --> 11:23.706\n我们说加强对下肢静脉血栓的预防和治疗，\n\n11:23.956 --> 11:29.206\n可以降降低肺动脉栓塞并发率和一个猝死的危险性。\n\n11:30.776 --> 11:31.476\n我们说治疗呢，\n\n11:31.476 --> 11:32.526\n有几下几个方案。\n\n11:33.758 --> 11:34.333\n一个呢，\n\n11:34.333 --> 11:37.359\n是我们说一般治疗卧床休息啊，\n\n11:37.809 --> 11:38.434\n然后呢，\n\n11:38.434 --> 11:40.309\n患者如果确认后就需要一个绝对卧床，\n\n11:40.708 --> 11:43.133\n避免剧烈活动和用力排便后呢，\n\n11:43.133 --> 11:44.033\n增加腹压动作，\n\n11:44.033 --> 11:45.708\n防止血栓再次脱落。\n\n11:46.208 --> 11:46.859\n第二个呢，\n\n11:46.859 --> 11:47.458\n是吸氧，\n\n11:47.758 --> 11:49.809\n那么通过鼻导管或面罩吸氧呢，\n\n11:49.809 --> 11:51.059\n我们纠正低氧血症。\n\n11:51.708 --> 11:53.357\n改善呼吸困难，\n\n11:53.507 --> 11:54.757\n提高血氧饱和度。\n\n11:55.107 --> 11:55.958\n还有一个呢，\n\n11:55.958 --> 11:57.507\n是一个生命监测体征。\n\n11:57.507 --> 11:58.257\n我们说，\n\n11:58.257 --> 12:02.682\n密切监测呼吸、心率、血压、心电图及血气变化，\n\n12:02.682 --> 12:05.007\n以便及时发现一个病情变化。\n\n12:06.552 --> 12:06.776\n然后呢，\n\n12:06.776 --> 12:08.752\n我们说下肢静脉血栓，\n\n12:08.752 --> 12:10.452\n或者是我们可以说呢，\n\n12:10.452 --> 12:12.552\n预防性可以放一个下肢静脉的滤器。\n\n12:14.065 --> 12:15.465\n它的腔静脉滤器的制作呢，\n\n12:15.465 --> 12:16.640\n主要是用于一个高危人群。\n\n12:16.640 --> 12:17.664\n高危人群的预防，\n\n12:18.114 --> 12:20.664\n它只能预防肺栓塞的复发，\n\n12:20.965 --> 12:24.715\n而并不能治疗下肢静脉血栓或者腔静脉血栓。\n\n12:25.164 --> 12:26.215\n安装了之后呢，\n\n12:26.215 --> 12:27.465\n仍然需要一个抗凝治疗。\n\n12:28.143 --> 12:29.544\n防止进一步的选项形成。\n\n12:30.831 --> 12:32.781\n如果说对于上肢的肾静脉血栓病呢，\n\n12:32.781 --> 12:35.132\n我们可以植入一个上肢静脉滤器。\n\n12:36.588 --> 12:37.562\n植入氯气后呢，\n\n12:37.562 --> 12:38.788\n如果没有明显的禁忌症呢，\n\n12:38.788 --> 12:40.987\n我们可以长期的口服口服华法林。\n\n12:41.288 --> 12:41.963\n同时呢，\n\n12:41.963 --> 12:44.187\n定期复查氯气上的血栓情况。\n\n12:45.874 --> 12:48.374\n我们说肺血栓栓塞介入治疗呢，\n\n12:48.374 --> 12:49.523\n还分以下几种，\n\n12:49.573 --> 12:51.874\n一个是导管溶栓术。\n\n12:52.986 --> 12:54.637\n一个是导管碎栓术。\n\n12:55.984 --> 12:56.734\n导管溶栓术呢，\n\n12:56.734 --> 12:58.033\n还有一个是导管吸栓术。\n\n12:59.043 --> 13:00.492\n我们说导管溶栓术呢，\n\n13:00.492 --> 13:01.692\n它有一个最佳时间窗。\n\n13:03.099 --> 13:04.849\n在发病或者复发以后，\n\n13:05.250 --> 13:08.799\n溶栓这个时间窗是越早效果越好。\n\n13:10.067 --> 13:10.841\n在一天里面呢，\n\n13:10.841 --> 13:12.767\n它的好转率可以达到86%。\n\n13:14.093 --> 13:18.093\n而如果说患者在6.14天以内进行一个溶栓治疗的话，\n\n13:18.494 --> 13:20.843\n它的效果好转率可以达到69%。\n\n13:22.382 --> 13:22.833\n但是呢，\n\n13:22.932 --> 13:24.132\n每延迟一天，\n\n13:24.132 --> 13:27.333\n它的疗效评分会下降百0.8%，\n\n13:27.932 --> 13:29.583\n而超过14天以后呢。\n\n13:30.927 --> 13:32.328\n这时间窗最佳小为十天，\n\n13:32.728 --> 13:34.377\n如果超过四十天以后呢，\n\n13:34.377 --> 13:35.153\n它溶栓呢，\n\n13:35.153 --> 13:35.828\n一定效果，\n\n13:35.828 --> 13:37.778\n但是可能是比之前要差一点。\n\n13:39.276 --> 13:39.577\n同时啊，\n\n13:39.577 --> 13:41.877\n我们可以采取一个口抗凝治疗。\n\n13:42.945 --> 13:43.919\n我们说在急性期的话，\n\n13:43.919 --> 13:46.744\n一般是先进驻3000到五千单位的肝素，\n\n13:47.344 --> 13:49.844\n然后按照每公斤250单位的话，\n\n13:50.244 --> 13:53.544\n这个剂量来进行Q12区的皮下注射。\n\n13:54.622 --> 13:54.872\n然后呢，\n\n13:54.872 --> 13:57.421\n我们要进行一个可以改成一个华法口服，\n\n13:58.122 --> 13:59.721\n一般性的手机口服。\n\n14:00.655 --> 14:01.554\n第二次第二天呢，\n\n14:01.554 --> 14:03.255\n是3到五毫克，\n\n14:03.455 --> 14:05.854\n维持量在两点5.5mg/d，\n\n14:06.255 --> 14:06.880\n但是呢，\n\n14:06.880 --> 14:10.655\n他要定期进行一个pt PTINR的一个监测。\n\n14:11.820 --> 14:12.020\n然后呢，\n\n14:12.020 --> 14:14.671\n我们说现在一个新型的抗凝口服制剂叫利伐沙班，\n\n14:15.020 --> 14:15.671\n那么呢，\n\n14:15.671 --> 14:20.070\n它可能对那个第二具体监测就没这么密切。\n\n14:21.906 --> 14:24.106\n我们可以通过溶栓前后的对比，\n\n14:24.106 --> 14:28.856\n可以看出下肢深静脉血栓明显一个消失的过程。\n\n14:30.046 --> 14:30.245\n然后呢，\n\n14:30.245 --> 14:31.145\n在溶栓术中呢，\n\n14:31.145 --> 14:33.546\n我们必须监测一个凝血机制以及各项指标。\n\n14:34.245 --> 14:35.695\n如果凝血酶原时间，\n\n14:35.945 --> 14:37.145\n我们就说所谓的。\n\n14:38.075 --> 14:40.401\n血PT正常在11到素，\n\n14:40.401 --> 14:41.976\n如果说在正常两倍以上，\n\n14:42.325 --> 14:45.351\n或者纤维蛋白纤维蛋白原小于150mg，\n\n14:45.351 --> 14:47.851\n我们要减少溶栓的剂量啊。\n\n14:47.851 --> 14:49.825\n如果说纤维蛋白原小于100mg的话，\n\n14:49.825 --> 14:51.575\n我们这个溶栓就有一定的风险，\n\n14:51.575 --> 14:53.125\n我们建议是停止溶栓。\n\n14:54.715 --> 14:55.090\n嗯，\n\n14:55.090 --> 15:00.090\n今天以上就是我给大家讲的一个肺栓塞的诊断和介入治疗，\n\n15:00.090 --> 15:01.015\n谢谢大家聆听。\n\n","v0347cg10004d60m45iljht5i8b5va4g",908,927,"2026-01-24 19:26:34","肺栓塞的诊断和介入治疗 - 症状识别与微创手术方案  ","肺栓塞诊断,肺栓塞介入治疗,肺血栓症状,CTPA检查,肺动脉溶栓,导管取栓术,抗凝治疗  ","本文详解肺栓塞的早期诊断方法（如D-二聚体、CTPA）及介入治疗方案（溶栓/取栓术），涵盖症状识别、风险评估和微创手术优势，帮助患者了解救治流程与预后管理。","2026-02-28 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