深静脉血栓DVT.ppt
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深静脉血栓DVT.ppt
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R1R1胡家瑞胡家瑞主持:
刘忠传副主任LOWEREXTREMITYDEEPVENOUSTHROMBOSISPATIENTDATAName:
吴志强Gender:
MaleAge:
44yearsoldAdmissiondate:
2010.07.08CHIEFCOMPLAINTRightlowerextremityswelling2month.PRESENTILLNESSThe44year-oldmalewasadrugabuser(1.5year).Hestartedusingvenousdruginjection3monthago.(armandfemoralvein;cylindersharing)Hefeltweak,rightlowerextremityswellingandpain2monthago.Methadonemaintenancetreatment2week.PHYSICALEXAMINATIONT38P81次/分R20次/分BP118/61mmHgTenderness,swellingoftherightlowerextremity.Rightinguinalregionandlegskintemperaturerising.An1X1cmrightinguinalsubcutaneousmasswasnoted,rednessandswelling.ULTRASONOGRAPHYFINDING1、右下肢股总静脉至腘静脉广泛血栓形成2、右下肢小隐静脉血栓形成3、双下肢深动脉内膜欠光滑,未见明显血栓WBC20.9109/LHM3.9-10.6F3.5-11RBC3.821012/LLM4.5-5.9F4.0-5.2Hemoglobin102g/LLM135-175F120-160Platelets277109/L150-400Segment88.5%H42-74Band1.0%0-3Albumin21.6g/LL35-55BUN3.76mmol/L2.14-7.5Creatinine55.39umol/LLM:
56.58-112.27,LabData检验项目检验值单位H/L参考值改=P.T14.2secH10-13Nor.plasmamean11.3secINR1.3(INR:
预防治疗1.5-3.0静脉血栓治疗2-3.0动脉疾病治疗2.6-4.5)APTT35.8sec23.3-39.3(治疗围1.5-2.5x正常血浆平均值)Nor.plasmamean28.8secD-dimer0.593mg/LH0.25PRIMARYDIAGNOSIS1.Rightlowerextremitydeepvenousthrombosis.2.Sepsis?
DIFFERENTIALDIAGNOSIS1、原发性下肢静脉曲张。
2、原发性下肢深静脉瓣膜功能不全。
3、动脉栓塞。
TREATMENT1、完善各项辅助检查:
如血常规、凝血四项、心电图、肝肾功、HIV、RPR。
2、安排腹部靜脉CT血管成像、胸部CT扫描。
3、给予肝素、华法林、右旋糖酐抗凝治疗并严密监测凝血功能。
4、每日测量双下肢周径。
5、阿莫西林克拉维酸抗炎治疗。
RADIOLOGYFINDING右侧股静脉、右侧髂外静脉及右侧髂总静脉静脉血栓形成伴右侧髋部软组织明显肿胀。
ANTICOAGULANTTHERAPY右旋糖酐40ml静滴维持24小时肝素10,000IUIV每天2次华法林2.5mgBID口服监测凝血功能Q8H2010/07/11BLOODCULTURE细菌名称生长状态抹片检查1Staph.aureus1Staph.aureus1/11/1(金黄色葡萄球菌)(金黄色葡萄球菌)-药敏试验_1(浓度)Ampicillin.R,Clindamycin.S,Erythromycin_.S_,Oxacillin.S,Penicillin.R,Teicoplanin_.S_,Vancomycin.S,考虑考虑Sepsis-Sepsis-改用改用ClindamycinClindamycin抗炎治疗抗炎治疗检验项目检验值单位H/L参考值P.T20.1secH10-13Nor.plasmamean11.3secINR1.8(INR:
预防治疗1.5-3.0静脉血栓治疗2-3.0动脉疾病治疗2.6-4.5)APTT39.7secH23.3-39.3(治疗围1.5-2.5x正常血浆平均值)Nor.plasmamean28.8sec停用肝素、右旋糖酐停用肝素、右旋糖酐,改华法林改华法林2.5mgQD2.5mgQDCoagulationFunction2010/07/12Patientsuddenlyhematemesistwice.Vomitusofredanddarkredbloodclot.Nochestpain,nodyspnea.Bloodystoolthrice,notarrystools.Lipsandconjunctivapaleness.Checkbloodroutine:
RBC:
2.391012/L,Platelets360109/L,Hb65g/LAlbumin:
15.2g/L。
Quicklytransfusionnormalsaline1000ml,VitKintramuscularinjections,arrangechestX-ray,consultdigestive.TransfertoICU,setCVP,arrangeendoscopyexploration.1.1.Impression:
Duodenalpolypwithactiveoozingpostpolypectomyandlocaltreatment.2.2.Suggestion:
HighdosePPIuseandcorrectbleedingtendency.2010/07/12-14TREATMENT1.Omeprazoleintravenousinfusioncontinuity.(3day)2.Monitoringvitalsign,bloodroutine,coagulationfunction.3.FFPandRBCinfusion.4.07/14transfertocommonward.5.Clindamycinforanti-inflammatorytherapy.6.Arrangeinferiorvenacavafilterimplantationforpreventionofriskofpulmonaryembolism.DISCUSSIONDVTEPIDEMIOLOGYAnnualincidenceinurbanpopulationis1.6Annualincidenceinurbanpopulationis1.6cases/1000persons.cases/1000persons.ApproximatelyonethirdofcasescausedbyPEApproximatelyonethirdofcasescausedbyPEandtwothirdsofcasescausedbyDVT.andtwothirdsofcasescausedbyDVT.TheriskofrecurrentthromboembolismisTheriskofrecurrentthromboembolismishigheramongmenthanwomen.higheramongmenthanwomen.TherateseemstoincreasesharplyafterageTherateseemstoincreasesharplyafterage45.45.FerrisClinicalAdvisor2011,1sted.ETIOLOGY-DVT/VTERISKFACTORSAnythingthatplacesapatientatriskfor:
1.1.StasisStasis(reducedbloodflowvelocity)2.2.HypercoaguablestatesHypercoaguablestates(changesinbloodelements)3.EndothelialdamageEndothelialdamage(veinwallinjury)ThesearethecommoncausesofDVTknownasVirchowsTriad(1856)VirchowsTriad(1856)DVT/VTERISKFACTORSRISKFACTOR=1POINTRISKFACTOR=2POINTSAge41-60yearsAge41-60yearsBedrestBedrestCOPDCOPDCHF(1month)CHF(1month)AcuteMIAcuteMIPneumonia(Imonth)Pneumonia(Imonth)Sepsis(month)Sepsis(25)Obesity(BMI25)SwollenlegsSwollenlegsPregnancyPregnancyOralContraceptivesOralContraceptivesAge60-74yearsAge60-74yearsAthroscopicsurgeryAthroscopicsurgeryLaparoscopicsurgeyLaparoscopicsurgeyMalignancy(presentorMalignancy(presentorhistory)history)Majorsurgery(45Majorsurgery(45Minutes)Minutes)PatientconfinedtobedPatientconfinedtobed(72hours)(72hours)ImmobilizingplasterImmobilizingplastercast(1month)cast(75yearsMajorsurgery(3hours)HxofDVT/PEFamilyhxofThrombosisHeparin-inducedthrombocytopeniaThrombophiliaHxofclottingdisorderElectivemajorlowerextremityarthroplastyHip,pelvis,orlegfracture(1month)Stroke(1month)Acutespinalcordinjury(paralysis100秒表明用药过量)。
出血严重时可用鱼精蛋白静注中和,通常1mg鱼精蛋白能中和100单位UFH。
TheWashingtonManualofMedicalTherapeutics31/eLOWMOLECULARWEIGHTHEPARIN
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- 关 键 词:
- 静脉 血栓 DVT
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