Summary
Definition
History and exam
Key diagnostic factors
- 呼吸困难
- 胸痛
- 合并深静脉血栓形成（concurrent deep vein thrombosis, DVT）的体征
- 危险因素
- 缺氧
- 不符合肺栓塞排除标准（即 PERC 规则）
- Wells（或 Geneva）评分结果呈阳性
- 血流动力学不稳定或血流动力学储备严重减少的征象
Other diagnostic factors
- 咳嗽
- 发热
- 咯血
Risk factors
- 年龄增长
- 深静脉血栓形成 (DVT) 诊断
- 肥胖 (BMI ≥29 kg/m²)
- 近 2 个月内有手术史
- 卧床休息＞5 日
- 既往有静脉血栓栓塞病史
- 静脉血栓栓塞 (VTE) 家族史
- 恶性肿瘤活跃期
- 吸烟
- 慢性阻塞性肺疾病 (COPD)
- 有近期外伤或骨折病史
- 充血性心力衰竭 (CHF)
- 中心静脉置管
- 妊娠/产后
- 静脉曲张
- 近期乘坐飞机旅行
- 自然流产史
- 近期急性心肌梗死
- 脓毒症
- 近期输血史
- 复方激素避孕
- 口服激素替代治疗 (HRT)
- 下肢瘫痪
- 炎症性肠病
- 肾病综合征
- 白塞病
- 高同型半胱氨酸血症
- 费城染色体阴性的骨髓增殖性肿瘤
- 凝血因子 V Leiden 突变
- 凝血酶原 G20210A 突变
- 抗凝血酶缺乏
- 蛋白 C 缺陷
- 蛋白 S 缺陷
- 抗磷脂抗体综合征
Diagnostic tests
1st tests to order
- 计算机断层扫描肺动脉造影 (CTPA)
- 超声心动图
- D-二聚体
- 全血细胞计数
- 心电图（ECG）
- 尿素和电解质
- 凝血功能检查
- 肝功能检测
Tests to consider
- 动脉血气 （ABG）
- 胸部 X 线检查（CXR）
- 下肢静脉加压超声
- 心脏生物标志物
- 通气与血流灌注比值 (V/Q) 扫描
- 对无诱因 PE 的进一步检查
Emerging tests
- 生物标志物
- 床旁 D-二聚体检测
- 根据临床概率调整的 D-二聚体检测
- 磁共振血管成像 (MRA)
Treatment algorithm
疑似 PE：血流动力学不稳定和/或低氧血症
确诊 PE（通过超声心动图或 CTPA）；血流动力学不稳定
确诊（通过 CTPA）或高度怀疑（Wells >4 分或 D-二聚体阳性）PE；血流动力学稳定
确诊首次发作 PE（在急性期抗凝治疗期间开始出现 PE）
进行充分抗凝治疗后仍发生复发性 PE
Contributors
Expert advisers
Jonathan Bennett, MD
Honorary Professor of Respiratory Sciences
University of Leicester
Respiratory Consultant
Glenfield Hospital
Leicester
UK
Biography
JB is deputy medical director RCP Invited Service Reviews, and speaker at National Society (eg., BTS), Primary Care Respiratory Society, and Society Cardiothoracic Surgeons meetings.
Disclosures
JB declares that he has no competing interests.
Richard Russell, MBBS, PhD, MRCP
Specialty Registrar in Respiratory Medicine
Glenfield Hospital
Leicester
UK
Disclosures
RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).
Onyeka Umerah
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
OU declares that she has no competing interests.
Claire Vella
Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
CV declares that she has no competing interests.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Scott M. Stevens MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
Department of Internal Medicine
University of Utah
Salt Lake City
UT
Scott C. Woller MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
University of Utah
Salt Lake City
UT
Gabriel V. Fontaine PharmD, BCPS
Clinical Coordinator
Critical Care Pharmacy
Advanced Clinical Pharmacist
Neuroscience Critical Care
Intermountain Medical Center
Murray
UT
Disclosures
SMS is an investigator for two investigator-initiated clinical trials for which his institution receives funds from Bristol-Myers Squibb to enrol patients. SCW holds two investigator-initiated grants from Bristol-Myers Squibb/Pfizer paid to his employer Intermountain Healthcare for which he receives no compensation. He has been invited to serve as co-chair of the American College of Chest Physicians guideline on antithrombotic therapy for venous thromboembolic disease (AT11) and serves as an invited panelist for the US Centers for Disease Control and Prevention venous thromboembolism risk assessment model systematic review and guidance panel. GVF receives consulting fees and honoraria from Portola Pharmaceuticals for clinical consulting and speaking engagements.
Peer reviewers
Catherine Free
Consultant Respiratory Physician
Medical Director
George Eliot Hospital NHS Trust
Nuneaton
UK
Disclosures
CF declares that she has no competing interests.
Editors
Annabel Sidwell
Section Editor, BMJ Best Practice
Disclosures
AS declares that she has no competing interests.
Jo Haynes
Head of Editorial, BMJ Knowledge Centre
Disclosures
JH declares that she has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Differentials
- 不稳定型心绞痛
- 非 ST 段抬高型心肌梗死 (NSTEMI)
- ST 段抬高型心肌梗死 (STEMI)
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