Pulmonary Embolism (PDF)

‫ﺗﻌﺮﯾﻒ آﻣﺒﻮﻟﯽ‬ ‫ﺗﺠﻤﻊ ﯾﮏ ﻣﺎده ﺑﻪ ﺻﻮرت ﻧﺎﺑﺠﺎ در ﺷﺮﯾﺎنﻫﺎي رﯾﻮي ﺑﻄﻮرﯾﮑﻪ ﻣﺴﯿﺮ ﺟﺮﯾﺎن ﺧﻮن را ﺑﺼﻮرت ﮐﺎﻣﻞ ﯾﺎ‬ ‫ﻧﺴﺒﯽ ﻣﺴﺪود ﮐﻨﺪ؛ اﯾﻦ ﻣﺎده ﻣﯽﺗﻮاﻧﺪ ﻟﺨﺘﻪ ﺧﻮﻧﯽ )ﺷﺎﯾﻊﺗﺮﯾﻦ( ﺗﺤﺖ ﻋﻨﻮان ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ‪ ،‬آﻣﺒﻮﻟﯽ ﻫﻮا‪،‬‬ ‫آﻣﺒﻮﻟﯽ ﭼﺮﺑﯽ )ﮐﻪ در ﺟﺮﯾﺎن ﺷﮑﺴﺘﮕﯽ اﺳﺘﺨﻮانﻫﺎي ﺑﻠﻨﺪ ﯾﺎ ﺟﺮاﺣﯽﻫﺎي ارﺗﻮﭘﺪي رخ ﻣﯽدﻫﺪ(‪ ،‬آﻣﺒﻮﻟﯽ‬ ‫ﻣﺎﯾﻊ آﻣﻨﯿﻮﺗﯿ...

‫ﺗﻌﺮﯾﻒ آﻣﺒﻮﻟﯽ‬ ‫ﺗﺠﻤﻊ ﯾﮏ ﻣﺎده ﺑﻪ ﺻﻮرت ﻧﺎﺑﺠﺎ در ﺷﺮﯾﺎنﻫﺎي رﯾﻮي ﺑﻄﻮرﯾﮑﻪ ﻣﺴﯿﺮ ﺟﺮﯾﺎن ﺧﻮن را ﺑﺼﻮرت ﮐﺎﻣﻞ ﯾﺎ‬ ‫ﻧﺴﺒﯽ ﻣﺴﺪود ﮐﻨﺪ؛ اﯾﻦ ﻣﺎده ﻣﯽﺗﻮاﻧﺪ ﻟﺨﺘﻪ ﺧﻮﻧﯽ )ﺷﺎﯾﻊﺗﺮﯾﻦ( ﺗﺤﺖ ﻋﻨﻮان ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ‪ ،‬آﻣﺒﻮﻟﯽ ﻫﻮا‪،‬‬ ‫آﻣﺒﻮﻟﯽ ﭼﺮﺑﯽ )ﮐﻪ در ﺟﺮﯾﺎن ﺷﮑﺴﺘﮕﯽ اﺳﺘﺨﻮانﻫﺎي ﺑﻠﻨﺪ ﯾﺎ ﺟﺮاﺣﯽﻫﺎي ارﺗﻮﭘﺪي رخ ﻣﯽدﻫﺪ(‪ ،‬آﻣﺒﻮﻟﯽ‬ ‫ﻣﺎﯾﻊ آﻣﻨﯿﻮﺗﯿﮏ )در ﺟﺮﯾﺎن ﺣﺎﻣﻠﮕﯽ‪ ،‬ﺳﺰارﯾﻦ ﯾﺎ زاﯾﻤﺎن ﻃﺒﯿﻌﯽ(‪ ،‬ﻧﺪرﺗﺎً آﻣﺒﻮﻟﯽ ﺳﻠﻮلﻫﺎي ﺗﻮﻣﻮرال و‬ ‫ﺑﯿﻤﺎريﻫﺎي آﻣﺒﻮﻟﯽ‬ ‫آﻣﺒﻮﻟﯽ ﻣﻮاد ﺧﺎرﺟﯽ )در ﺑﯿﻤﺎران ‪.(IV abuser‬از آﻧﺠﺎ ﮐﻪ ﺷﺎﯾﻊﺗﺮﯾﻦ ﻓﺮم آﻣﺒﻮﻟﯽ‪ ،‬ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ اﺳﺖ‪،‬‬ ‫ﻣﻨﻈﻮر از آﻣﺒﻮﻟﯽ ﻫﻤﯿﻦ ﻓﺮم ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ ﻣﯽﺑﺎﺷﺪ و اﮔﺮ ﻓﺮم دﯾﮕﺮي ﻣﻮرد ﻧﻈﺮ ﺑﻮد ﻧﺎﻣﺒﺮده ﺧﻮاﻫﺪ‬ ‫ﻣﺒﺎﻧﯽ ﮐﻮرس رﯾﻪ‬ ‫ﺷﺪ‪.‬‬ ‫ﺟﻠﺴﻪ ﭼﻬﺎرم‬ ‫ﺷﺎﯾﻊﺗﺮﯾﻦ ﻣﻨﺸﺎء ﻟﺨﺘﻪﻫﺎي درون ﺷﺮاﺋﯿﻦ رﯾﻮي‪ ،‬ورﯾﺪﻫﺎي ﻋﻤﻘﯽ اﻧﺪام ﺗﺤﺘﺎﻧﯽ )ﻋﻤﺪﺗﺎ زاﻧﻮ ﺑﻪ ﺑﺎﻻ( اﺳﺖ؛‬ ‫دﮐﺘﺮ ﮐﻔﺎن‬ ‫ﺳﺎﯾﺮ ﻣﻨﺸﺎﻫﺎ ورﯾﺪﻫﺎي ﻋﻤﻘﯽ ﺳﺎق ﭘﺎ و اﻧﺪام ﻓﻮﻗﺎﻧﯽ اﺳﺖ ﮐﻪ ﻗﺒﻼً اﺣﺘﻤﺎل ﺗﺮوﻣﺒﻮز و در اداﻣﻪ ﺑﺮوز‬ ‫آﻣﺒﻮﻟﯽ در اﻧﺪام ﻓﻮﻗﺎﻧﯽ ﮐﻤﺘﺮ ﺑﻮد؛ اﻣﺎ ﺣﺎل ﺑﻪ دﻟﯿﻞ ‪ CV line‬و دﻓﯿﺒﺮﯾﻼﺗﻮر ﮔﺬاﺷﺘﻦ ‪ Port‬رﯾﺴﮏ آن‬ ‫‪1402/1/19‬‬ ‫ﺑﺎﻻ رﻓﺘﻪ اﺳﺖ‪.‬ﻣﻨﺸﺎﻫﺎي ﻧﺎدر دﯾﮕﺮ ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ‪ ،‬ﺗﺮوﻣﺒﻮزﻫﺎي ﻗﻠﺐ ﻫﺴﺘﻨﺪ ﮐﻪ ﻣﻮارد ﮐﻤﯽ ﻣﯽﺑﺎﺷﻨﺪ؛‬ ‫ﺑﺎ اﯾﻨﮑﻪ ﺗﺮوﻣﺒﻮزﻫﺎي ﺳﺎق ﭘﺎ ﻣﻨﺸﺎء ﺷﺎﯾﻌﯽ ﺑﺮاي ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ ﻧﯿﺴﺘﻨﺪ؛ اﻣﺎ ﯾﮑﯽ از ‪Source‬ﻫﺎ ﺑﺮاي‬ ‫ﺑﺸﺮي زارﻋﯽ‬ ‫آﻣﺒﻮﻟﯽ ﭘﺎرادوﮐﺲاﻧﺪ؛ ﻣﻨﻈﻮر از آﻣﺒﻮﻟﯽﻫﺎي ﭘﺎرادوﮐﺲ‪ ،‬اﯾﻦ اﺳﺖ ﮐﻪ ﻟﺨﺘﻪ ﺧﻮن ﭘﺲ از ورود ﺑﻪ ﻗﻠﺐ‪،‬‬ ‫ﻣﺤﻤﺪﺣﺴﯿﻦ ﻣﺤﺮاﺑﯽ‬ ‫از ﻃﺮﯾﻖ ‪ Defect‬ﻫﺎي دﻫﻠﯿﺰ از ﺳﻤﺖ راﺳﺖ ﺑﻪ ﭼﭗ رﻓﺘﻪ و وارد ﺷﺮﯾﺎنﻫﺎي ﺳﯿﺴﺘﻤﯿﮏ ﺷﻮد‪.‬در‬ ‫ﺣﺎﻟﺖ ﻣﻌﻤﻮل‪ ،‬ﻟﺨﺘﻪ از ورﯾﺪ ﻋﻤﻘﯽ ﭘﺎ ﺣﺮﮐﺖ ﮐﺮده و از ﻃﺮﯾﻖ ‪ IVC‬وارد ﺑﻄﻦ راﺳﺖ ﺷﺪه و ﺑﺴﺘﻪ ﺑﻪ‬ ‫اﻣﯿﺮﺣﺴﯿﻦ ﺻﺎدق ﻣﻘﺪﺳﯽ‬ ‫اﻧﺪازه آن در ﺑﺨﺶﻫﺎي ﻣﺨﺘﻠﻔﯽ از ﺳﯿﺴﺘﻢ ﺷﺮﯾﺎﻧﯽ رﯾﻪ ﮔﯿﺮ ﻣﯽﮐﻨﺪ‪.‬‬ ‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﻄﺎﻟﺐ ﻓﻮق ﻣﯽﺗﻮان ﮔﻔﺖ ‪ (DVT) Deep Vein Thrombosis‬و ‪Pulmonary‬‬ ‫‪ (PTE) Thromboembolism‬دو ﺳﺮ ﯾﮏ ﻃﯿﻒ ﺑﯿﻤﺎري ﻫﺴﺘﻨﺪ‪.‬‬ ‫اﺗﯿﻮﻟﻮژي ﺗﺸﮑﯿﻞ ﻟﺨﺘﻪ‬ ‫ﯾﮏ ﺗﺮﯾﺎد ‪ Virchow‬وﺟﻮد دارد ﮐﻪ اﮔﺮ ﻫﺮ ﯾﮏ از اﺿﻼع آن ﺑﺮ ﻫﻢ ﺑﺨﻮرد ﺳﺒﺐ ﺑﺮوز ﻟﺨﺘﻪ ﻣﯽﺷﻮد؛‬ ‫ﭼﻪ ‪ DVT‬و ﭼﻪ ‪.PTE‬‬ ‫‪Virchow Triad‬‬ ‫‪ -1‬اﺳﺘﺎز )ﺗﺠﻤﻊ ﺧﻮن در رگ )ورﯾﺪ((‬ ‫‪ -2‬آﺳﯿﺐ ﺟﺪار ﻋﺮوﻗﯽ‬ ‫‪ -3‬اﻓﺰاﯾﺶ اﻧﻌﻘﺎدﭘﺬﯾﺮي‬ ‫ﭘﺲ رﯾﺴﮏﻓﺎﮐﺘﻮرﻫﺎي ﻣﺎ ﺑﺮاي‬ ‫ﺗﺸﮑﯿﻞ ﻟﺨﺘﻪ در واﻗﻊ از ﻫﻤﺎن‬ ‫اﺳﺘﺮاﺣﺖﻫﺎي‬ ‫اﺳﺖ؛‬ ‫اﺗﯿﻮﻟﻮژي‬ ‫ﻃﻮﻻﻧﯽ و ‪ Bedridden‬ﺑﻮدن‪ ،‬ﭘﺮوازﻫﺎي ﻃﻮﻻﻧﯽ‪ ،‬ﺟﺮاﺣﯽﻫﺎي ﺑﯿﺸﺘﺮ از ﻧﯿﻢ ﺳﺎﻋﺖ زﻣﯿﻨﻪﺳﺎز اﺳﺘﺎز‬ ‫ورﯾﺪي ﻣﯽﺑﺎﺷﻨﺪ‪.‬ﺟﺮاﺣﯽﻫﺎ ﺑﺨﺼﻮص در ﻧﺎﺣﯿﻪ ﻟﮕﻦ ﺑﺎ اﻓﺰاﯾﺶ رﯾﺴﮏ آﺳﯿﺐ ﺑﻪ ﻋﺮوق ﻣﯽﺗﻮاﻧﻨﺪ‬ ‫رﯾﺴﮏﻓﺎﮐﺘﻮر ﺑﺮاي آﻣﺒﻮﻟﯽ ﺑﺎﺷﻨﺪ‪.‬در ﻣﻮرد اﻓﺰاﯾﺶ اﻧﻌﻘﺎدﭘﺬﯾﺮي‪ ،‬ﻣﯽﺗﻮاﻧﺪ ارﺛﯽ ﯾﺎ اﮐﺘﺴﺎﺑﯽ ﺑﺎﺷﺪ ﮐﻪ‬ ‫ﻣﯽﺗﻮاﻧﻨﺪ رﯾﺴﮏ ‪ DVT‬و ‪ PTE‬را زﯾﺎد ﮐﻨﻨﺪ‪.‬‬ ‫اﻧﻮاع ارﺛﯽ‪ :‬ﮐﻤﺒﻮد ﭘﺮوﺗﺌﯿﻦ ‪ ،C‬آﻧﺘﯽﺗﺮوﻣﺒﯿﻦ ‪ ،3‬ﻓﺎﮐﺘﻮر ‪ 5‬ﻟﯿﺪن ﯾﺎ ﺟﻬﺶ در ژن ﭘﺮوﺗﺮوﻣﺒﯿﻦ‬ ‫‪1‬‬ ‫‪| 7‬‬ Definition of Embolism The term “‫ ”آمبولی‬refers to the accumulation of a substance in an inappropriate location in the pulmonary arteries, in such a way that it completely or partially obstructs the flow of blood. This substance can be a blood clot (the most common), known as thromboembolism, air embolism, fat embolism (which occurs during fractures of long bones or orthopedic surgeries), amniotic fluid embolism (during pregnancy, cesarean section or natural childbirth), rarely tumor cell embolism, and foreign substance embolism (in IV abuser patients). Since the most common form of embolism is thromboembolism, the term “embolism” usually refers to this form of thromboembolism, and if another form is intended, it will be named. The most common source of clots in the pulmonary arteries are the deep veins of the lower extremities (mostly above the knee). Other sources are the deep veins of the leg and upper extremities, which previously had a lower probability of thrombosis and subsequently the occurrence of embolism in the upper extremities; but now, due to the placement of CV lines and defibrillators, the risk has increased. Other rare sources of thromboembolism are heart thromboses, which are few in number; although leg thromboses are not a common source for thromboembolism, they are one of the sources for paradoxical embolism. Paradoxical embolisms refer to when a blood clot, after entering the heart, moves from right to left through the atrial defects and enters the systemic arteries. In the usual case, the clot moves from the deep vein of the leg and enters the right ventricle through the IVC, and depending on its size, it gets stuck in different parts of the pulmonary arterial system. Considering the above, it can be said that Deep Vein Thrombosis (DVT) and Pulmonary Thromboembolism (PTE) are two ends of a disease spectrum. Etiology of Clot Formation There is a Virchow’s triad, and if any of its sides coincide, it causes a clot to form; both DVT and PTE. Virchow’s Triad 1. Stasis (Blood accumulation in the vein) 2. Vascular wall damage 3. Increased coagulability So, our risk factors for clot formation are actually from the same etiology; long rests and being bedridden, long flights, surgeries longer than half an hour are predisposing factors for venous stasis. Surgeries, especially in the pelvic area, with an increased risk of vascular damage, can be a risk factor for embolism. In terms of increased coagulability, it can be hereditary or acquired, which can increase the risk of DVT and PTE. Hereditary Types Deficiency of Protein C, Antithrombin 3, Factor 5 Leiden, or mutation in the prothrombin gene.  ‫‪4‬‬ ‫اﻧﻮاع اﮐﺘﺴﺎﺑﯽ‪ :‬در اﺛﺮ اﺳﺘﻔﺎده از اﺳﺘﺮوژن‪ ،‬روشﻫﺎي درﻣﺎﻧﯽ ﻣﺒﺘﻨﯽ ﺑﺮ ﻫﻮرﻣﻮن‪ ،‬ﺑﺎرداري‪ ،‬ﺑﺪﺧﯿﻤﯽ‪ ،‬ﺑﯿﻤﺎريﻫﺎﯾﯽ ﻣﺎﻧﻨﺪ ﻟﻮﭘﻮس‪ ،‬آﻟﻮدﮔﯽ‬ ‫ﻫﻮا‪ ،‬ﭼﺎﻗﯽ و ‪COPD‬‬ ‫در ﮐﻞ ﯾﮑﺴﺮي ﻋﻮاﻣﻞ اﺣﺘﻤﺎل آﻣﺒﻮﻟﯽ را زﯾﺎد ﻣﯽﮐﻨﻨﺪ ﻣﺜﻞ ﻫﺎﯾﭙﺮﺗﻨﺸﻦ‪ ،‬ﺳﯿﮕﺎر و ﻫﻤﭽﻨﯿﻦ اﺣﺘﻤﺎل آﻣﺒﻮﻟﯽ در ﻓﺼﻞ زﻣﺴﺘﺎن ﺑﺎﻻﺗﺮ اﺳﺖ‪.‬‬ ‫ﭘﺎﺗﻮﻓﯿﺰﯾﻮﻟﻮژي‬ ‫ﺣﺎل اﯾﻦ ﻟﺨﺘﻪ ﺗﺸﮑﯿﻞ ﺷﺪ؛ ﭼﻪ ﺗﺎﺛﯿﺮي ﺑﺮ ﺑﺪن ﻣﯽﮔﺬارد؟ ﭘﺎﺗﻮﻓﯿﺰﯾﻮﻟﻮژي آن را ﻣﯽﺗﻮان ﺑﻪ دو ﻗﺴﻤﺖ ﺗﻘﺴﯿﻢ ﮐﺮد‪ -1 :‬ﺗﺎﺛﯿﺮ ﺑﺮ ﺳﯿﺴﺘﻢ ﺗﻨﻔﺴﯽ ‪ -2‬ﺗﺎﺛﯿﺮ‬ ‫ﻫﻤﻮدﯾﻨﺎﻣﯿﮏ‬ ‫ﺗﺎﺛﯿﺮ ﺑﺮ ﺳﯿﺴﺘﻢ ﺗﻨﻔﺴﯽ‬ ‫ﺗﺎﺛﯿﺮ آﻣﺒﻮﻟﯽ رﯾﻪ ﺑﺮ ﺳﯿﺴﺘﻢ ﺗﻨﻔﺴﯽ ﺑﻪ ‪ 4‬دﺳﺘﻪ ﺗﻘﺴﯿﻢ ﻣﯽﺷﻮد‪.‬‬ ‫‪ -1‬ﺑﺎ ﺗﺸﮑﯿﻞ ﻟﺨﺘﻪ‪ ،‬ﻣﻮاد ﻣﺨﺘﻠﻔﯽ از ﺟﻤﻠﻪ ﺳﺮوﺗﻮﻧﯿﻦ از ﻟﺨﺘﻪ آزاد ﻣﯽﺷﻮد ﮐﻪ ﺑﺎﻋﺚ اﻧﻘﺒﺎض ﻋﺮوق ﻣﯽﺷﻮد ﮐﻪ ﺳﺒﺐ اﻓﺰاﯾﺶ ﻓﺸﺎر درون آنﻫﺎ ﺧﻮاﻫﺪ‬ ‫ﺷﺪ‪.‬ﻫﻤﭽﻨﯿﻦ ﻣﻮاد ﺳﺮوﺗﻮﻧﯿﻦ ﺑﺎﻋﺚ اﻧﻘﺒﺎض و اﻓﺰاﯾﺶ ﻣﻘﺎوﻣﺖ راهﻫﺎي ﻫﻮاﯾﯽ ﻣﯽ ﺷﻮﻧﺪ ﮐﻪ ﺑﺎﻋﺚ ﺷﻨﯿﺪه ﺷﺪن ﺻﺪاي وﯾﺰ در ﻣﻌﺎﯾﻨﻪ ﺑﺎﻟﯿﻨﯽ ﺷﻮد )اﻟﺒﺘﻪ ﻫﺮ‬ ‫ﺻﺪاي وﯾﺰي ﻧﺸﺎﻧﻪ ‪ COPD‬ﯾﺎ آﺳﻢ ﻧﯿﺴﺖ(‪.‬‬ ‫‪ -2‬ﻫﻤﭽﻨﯿﻦ ﯾﮏ اﻧﺴﺪاد در ﻋﺮوق رﯾﻮي وﺣﻮد دارد ﮐﻪ ﺧﻮد ﺳﺒﺐ اﻓﺰاﯾﺶ ﻓﺸﺎر و ﻣﻘﺎوﻣﺖ ﺷﺮﯾﺎنﻫﺎي ﭘﻮﻟﻤﻮﻧﺮ ﻣﯽﺷﻮد‪.‬‬ ‫‪ -3‬ﺑﯿﻤﺎر دﭼﺎر ‪ Ventilation-Perfusion mismatch‬ﻣﯽﺷﻮد؛ در آﻣﺒﻮﻟﯽ ﻗﺴﻤﺘﯽ از ﺷﺮﯾﺎن دﭼﺎر اﻧﺴﺪاد ﯾﺎ ‪ Narrowing‬ﺷﺪه اﺳﺖ ﮐﻪ ﺳﺒﺐ اﺧﺘﻼل‬ ‫در ‪ Perfusion‬ﺷﺪه‪ ،‬در ﺣﺎﻟﯽ ﮐﻪ ﺗﻬﻮﯾﻪ در آﻟﻮﺋﻮلﻫﺎ اداﻣﻪ دارد؛ ﮐﻪ اﯾﻦ ﺷﺮاﯾﻂ ﻣﻨﺠﺮ ﺑﻪ ‪ Hypoxia‬و ﺗﻨﮕﯽ ﻧﻔﺲ ﻣﯽﺷﻮد‪.‬‬ ‫‪ -4‬ﮐﺎﻫﺶ ﮐﻤﭙﻠﯿﺎﻧﺲ رﯾﻪ؛ ﺑﺎ ﮐﻢ ﺷﺪن ﺟﺮﯾﺎن ﺧﻮن در ﻗﺴﻤﺖﻫﺎﯾﯽ از رﯾﻪ ﻣﻤﮑﻦ اﺳﺖ در آن ﻧﻮاﺣﯽ اﻧﻔﺎرﮐﺖ رخ دﻫﺪ و ﺳﻮرﻓﺎﮐﺘﺎﻧﺖ ﮐﻢ ﺷﻮد ﮐﻪ در ﭘﯽ‬ ‫اﯾﻦ اﺗﻔﺎق ﮐﻤﭙﻠﯿﺎﻧﺲ رﯾﻪ ﮐﻢ ﺧﻮاﻫﺪ ﺷﺪ‪.‬‬ ‫در ﻧﺘﯿﺠﻪ ﺑﺮوز اﯾﻦ ‪ 4‬اﺗﻔﺎق‪ ،‬ﯾﻌﻨﯽ اﻓﺰاﯾﺶ ﻣﻘﺎوﻣﺖ و اﻓﺰاﯾﺶ ﻓﺸﺎر ﺷﺮﯾﺎنﻫﺎي رﯾﻮي ‪ Ventilation-Perfusion mismatch‬و ﮐﺎﻫﺶ ﮐﻤﭙﻠﯿﺎﻧﺲ رﯾﻪ‪،‬‬ ‫ﯾﮏ ﻣﻘﺪار در ‪ Gas Exchange‬ﺑﻪ ﻣﺸﮑﻞ ﺑﺮ ﻣﯽﺧﻮرﯾﻢ و ﺑﯿﻤﺎر ﻫﺎﯾﭙﻮﮐﺴﯿﮏ ﻣﯽﺷﻮد و ﺑﻪ دﻧﺒﺎل آن ﺑﯿﻤﺎر ﺗﺎﮐﯽﭘﻨﻪ و ﻫﺎﯾﭙﺮوﻧﺘﯿﻠﻪ ﻣﯽﺷﻮد ﺗﺎ اﺧﺘﻼﻻت‬ ‫ذﮐﺮ ﺷﺪه را ﺟﺒﺮان ﮐﻨﺪ‪.‬‬ ‫ﺗﺎﺛﯿﺮات ﻫﻤﻮدﯾﻨﺎﻣﯿﮏ‬ ‫ﻫﻨﮕﺎﻣﯽ ﮐﻪ ﺷﺮﯾﺎن ﭘﻮﻟﻤﻮﻧﺮ ﺗﻮﺳﻂ ﯾﮏ ﻟﺨﺘﻪ ﻣﺴﺪود ﺷﻮد‪ ،‬در ﻧﺘﯿﺠﻪ روي ﻫﻤﻮدﯾﻨﺎﻣﯿﮏ ﻣﻮﺛﺮ اﺳﺖ ﺑﺨﺼﻮص اﮔﺮ ﻟﺨﺘﻪ ﺑﺰرگ ﺑﺎﺷﺪ؛ اﮔﺮ ﺳﺎﯾﺰ ﺑﺨﺘﻪ ﺑﺎﻋﺚ‬ ‫اﻧﺴﺪاد ﮐﺎﻣﻞ ﺷﺮﯾﺎن ﭘﻮﻟﻤﻮﻧﺮ ﺷﻮد و ﺑﺼﻮرت ﻧﺎﮔﻬﺎﻧﯽ ﺑﺎﻋﺚ ﺟﻠﻮﮔﯿﺮي از ﺧﺮوج از ﺑﻄﻦ راﺳﺖ ﺷﺪه و ﻓﺸﺎر ﮐﺸﯿﺪﮔﯽ ﻧﺎﺷﯽ از ﺗﺠﻤﻊ ﺧﻮن در ﺑﻄﻦ راﺳﺖ‪،‬‬ ‫ﺳﺒﺐ ﻧﺎرﺳﺎﯾﯽ ﺣﺎد در ‪ RV‬ﺷﺪه و ﺑﺪﻧﺒﺎل آن ﭼﻮن ﺧﺮوج از ﺑﻄﻦ راﺳﺖ ﻣﺨﺘﻞ ﺷﺪه و ﺧﻮﻧﯽ ﺑﻪ ﺑﻄﻦ ﭼﭗ ﻧﻤﯽرﺳﺪ‪ ،‬ﻧﺎرﺳﺎﯾﯽ ﺑﻄﻦ ﭼﭗ ﻧﯿﺰ ﺧﻮاﻫﯿﻢ داﺷﺖ‬ ‫و ﻣﻤﮑﻦ اﺳﺖ ﺑﯿﻤﺎر در ﻣﻮاردي ﮐﻪ ﻟﺨﺘﻪ ﺑﺴﯿﺎر ﺑﺰرگ اﺳﺖ دﭼﺎر اﻓﺖ ﻓﺸﺎر و ﺣﺘﯽ ‪ Syncope‬ﺷﻮد‪.‬ﻟﺨﺘﻪﻫﺎي ‪ submassive‬در ﻣﺤﻞ دوﺷﺎﺧﻪ ﺷﺪن‬ ‫ﺷﺮﯾﺎن ﻗﺮار ﻣﯿﮕﯿﺮد و اﺧﺘﻼل ﻋﻤﻠﮑﺮد ﺑﻄﻦ راﺳﺖ اﯾﺠﺎد ﻣﯽﺷﻮد‪ ،‬اﻣﺎ اﻓﺖ ﻓﺸﺎرﺧﻮن ﻧﺪارﯾﻢ‪.‬ﻫﻤﭽﻨﯿﻦ ﻟﺨﺘﻪﻫﺎي ﮐﻮﭼﮏ‪ ،‬ﻋﻼﺋﻢ ﻫﻤﻮدﯾﻨﺎﻣﯿﮏ ﻧﺪارﻧﺪ‪.‬‬ ‫ﻋﻼﺋﻢ ﺑﺎﻟﯿﻨﯽ‬ ‫ﻫﻨﮕﺎﻣﯽ ﮐﻪ ﯾﮏ ﻟﺨﺘﻪ در ﯾﮏ ورﯾﺪ اﻧﺪام ﺗﺤﺘﺎﻧﯽ اﯾﺠﺎد ﻣﯽﺷﻮد‪ ،‬ﺧﻮن ﭘﺸﺖ آن ﻟﺨﺘﻪ ﺗﺠﻤﻊ ﭘﯿﺪا ﮐﺮده و اﯾﺠﺎد ﺗﻮرم و اﻟﺘﻬﺎب ﺧﻮاﻫﺪ ﮐﺮد‪.‬ﺑﯿﻤﺎران اﺣﺴﺎس‬ ‫ﮔﺮﻓﺘﮕﯽ ﭘﺸﺖ ﺳﺎق ﭘﺎﯾﺸﺎن ﻣﯽﮐﻨﻨﺪ‪ ،‬وﻟﯽ اﯾﻦ ﻋﻼﺋﻢ ﻧﻪ ﺣﺴﺎساﻧﺪ ﻧﻪ اﺧﺘﺼﺎﺻﯽ؛ ﯾﻌﻨﯽ ﻣﻤﮑﻦ اﺳﺖ ﺑﯿﻤﺎر ‪ DVT‬داﺷﺘﻪ ﺑﺎﺷﺪ اﻣﺎ اﯾﻦ ﻋﻼﺋﻢ را ﻧﻪ ﯾﺎ ‪DVT‬‬ ‫ﻧﺪاﺷﺘﻪ ﺑﺎﺷﺪ و ﺗﺸﺨﯿﺺ اﻓﺘﺮاﻗﯽ دﯾﮕﺮي ﻣﻄﺮح ﺑﺎﺷﺪ ﮐﻪ ﺳﺒﺐ ﮔﺮﻣﯽ و ﻗﺮﻣﺰي ﻧﺎﺷﯽ از ﺗﻮرم ﺷﺪه اﺳﺖ ﻣﺎﻧﻨﺪ‪ :‬ﺳﻠﻮﻟﯿﺖ‪ ،‬ﭘﺎرﮔﯽ ﮐﯿﺴﺖ ‪ Baker‬و ﻫﻤﭽﻨﯿﻦ‬ ‫ﺗﺮوﻣﺎﻫﺎي ﻋﻀﻼﻧﯽ‪.‬‬ ‫‪ :Homan sign‬ﺑﺎ ‪ dorsiflexion‬اﻧﮕﺸﺖ ﺷﺴﺖ‪ ،‬ﭘﺎ درد ﻣﯽﮔﯿﺮد‪ ،‬اﻟﺒﺘﻪ ﺑﻪ ﻋﻠﺖ اﺣﺘﻤﺎل ﺟﺪا ﺷﺪن ﻟﺨﺘﻪ اﯾﻦ ﺣﺮﮐﺖ اﻧﺠﺎم ﻧﻤﯽﺷﻮد‪.‬‬ ‫ﺗﺸﺨﯿﺺ ‪DVT‬‬ ‫‪2‬‬ ‫‪| 7‬‬ Acquired Types These can occur as a result of using estrogen, hormone-based therapies, pregnancy, malignancy, diseases such as lupus, air pollution, obesity, and COPD. In general, several factors increase the likelihood of embolism, such as hypertension, smoking, and also the likelihood of embolism is higher in the winter season. Pathophysiology Now that this clot has formed, what effect does it have on the body? The pathophysiology of it can be divided into two parts: 1- Effect on the respiratory system 2- Hemodynamic effects Effect on the Respiratory System The effect of pulmonary embolism on the respiratory system is divided into 4 categories. 1. With the formation of a clot, various substances including serotonin are released from the clot, which causes vasoconstriction, which will increase the pressure inside them. Also, serotonin substances cause contraction and increase the resistance of the airways, which causes the sound of wheezing to be heard in the clinical examination (although every wheezing sound is not a sign of COPD or asthma). 2. There is also an obstruction in the pulmonary vessels, which itself causes an increase in pressure and resistance of the pulmonary arteries. 3. The patient suffers from Ventilation-Perfusion mismatch; in embolism, part of the artery is obstructed or narrowed, which causes a disturbance in Perfusion, while ventilation continues in the alveoli; this condition leads to Hypoxia and shortness of breath. 4. Decrease in lung compliance; with the decrease in blood flow in parts of the lung, it is possible that infarction will occur in those areas and surfactant will decrease, which will result in decreased lung compliance. As a result of these 4 events, that is, increased resistance and increased pulmonary artery pressure, Ventilation-Perfusion mismatch, and decreased lung compliance, we have a bit of trouble in Gas Exchange and the patient becomes hypoxic and as a result, the patient becomes tachypneic and hyperpneic to compensate for the mentioned disorders. Hemodynamic Effects When a pulmonary artery is blocked by a clot, it has an effect on hemodynamics, especially if the clot is large; if the size of the clot causes complete obstruction of the pulmonary artery and suddenly prevents exit from the right ventricle and the pressure caused by the accumulation of blood in the right ventricle, it causes acute failure in the RV and as a result, since the exit from the right ventricle is disrupted and no blood reaches the left ventricle, we will also have left ventricular failure and the patient may experience a drop in pressure and even Syncope in cases where the clot is very large. Submassive clots are located at the bifurcation of the artery and cause right ventricular dysfunction, but we do not have a drop in blood pressure. Also, small clots do not have hemodynamic symptoms. Clinical Symptoms When a clot forms in a vein of the lower extremity, blood accumulates behind that clot and will cause swelling and inflammation. Patients feel a tightness behind their calf, but these symptoms are neither sensitive nor specific; that is, the patient may have DVT but not these symptoms or not have DVT and another differential diagnosis is raised that has caused warmth and redness due to swelling such as: cellulitis, rupture of Baker’s cyst, and also muscular traumas. Homan sign: with dorsiflexion of the big toe, the foot hurts, but due to the possibility of clot detachment, this movement is not performed.  ‫‪4‬‬ ‫روش ‪ Gold Standard‬ﺗﺸﺨﯿﺺ ‪ DVT‬ﮐﻪ در دﺳﺘﺮسﺗﺮﯾﻦ و ﺑﯽﺿﺮرﺗﺮﯾﻦ اﺳﺖ‪ ،‬ﺳﻮﻧﻮﮔﺮاﻓﯽ داﭘﻠﺮ ورﯾﺪ اﻧﺪام ﺗﺤﺘﺎﻧﯽ اﺳﺖ‪.‬‬ ‫ﻋﻼﺋﻢ ﺑﺎﻟﯿﻨﯽ و ﻣﻌﺎﯾﻨﻪ ‪PTE‬‬ ‫اﮐﺜﺮ ﺑﯿﻤﺎران ‪ PTE‬ﻋﻼﺋﻤﯽ ﻧﺪارﻧﺪ و ﺷﮑﺎﯾﺖ ﺧﺎﺻﯽ ﻧﻤﯽﮐﻨﻨﺪ ﺑﻪ ﺧﺼﻮص ﺑﯿﻤﺎران ﺟﻮانﺗﺮ ﮐﻪ ‪ Reserve‬ﻗﻠﺒﯽ و رﯾﻮي ﺑﻬﺘﺮي دارﻧﺪ ﺑﺎ اﺿﻄﺮاب و ﺗﻌﺮﯾﻖ‬ ‫ﻣﺮاﺟﻌﻪ ﻣﯿﮑﻨﻨﺪ‪ ،‬اﻣﺎ ﮐﺴﺎﻧﯽ ﮐﻪ ﻋﻼﺋﻢ دارﻧﺪ ﺷﺎﯾﻌﺘﺮﯾﻦ ﻋﻼﻣﺘﺸﺎن ﺗﻨﮕﯽ ﻧﻔﺲ اﺳﺖ و ﺑﺪﻧﺒﺎل آن ﻣﻤﮑﻦ اﺳﺖ درد ﭘﻠﻮرﺗﯿﮏ‪ ،‬ﺳﺮﻓﻪ و ﻫﻤﻮﭘﺘﯿﺰي داﺷﺘﻪ ﺑﺎﺷﻨﺪ‪.‬‬ ‫ﺷﺎﯾﻊﺗﺮﯾﻦ ﺷﮑﺎﯾﺖ ﺑﯿﻤﺎر در ﻣﻌﺎﯾﻨﻪ ﺗﻨﮕﯽ ﻧﻔﺲ و ﺷﺎﯾﻊﺗﺮﯾﻦ ﻋﻼﻣﺖ ﺑﯿﻤﺎر ﺗﺎﮐﯽﭘﻨﻪ اﺳﺖ‪.‬ﻏﯿﺮ از اﯾﻦ ﻋﻼﺋﻢ ﻣﻤﮑﻦ اﺳﺖ ﺻﺪاي ‪ Wheeze‬در ﺑﺎزدم‪،‬‬ ‫‪ Crackle‬در رﯾﻪ‪ ،‬ﻣﺸﺎﻫﺪه ‪ ،Low Fever‬ﺗﺎﮐﯽﮐﺎردي‪ Friction Rub ،‬و ﻫﻤﭽﻨﯿﻦ اﻓﺰاﯾﺶ ‪ P2‬در ﺿﺮﺑﺎن ﻗﻠﺐ ﻣﺸﺎﻫﺪه ﺷﻮﻧﺪ‪.‬ﺳﯿﺎﻧﻮز در ﻟﺨﺘﻪﻫﺎي‬ ‫‪ massive‬ﻫﻢ ﻣﻤﮑﻦ اﺳﺖ‪.‬‬ ‫ﺗﺸﺨﯿﺺﻫﺎي اﻓﺘﺮاﻗﯽ ﮐﻪ در ﺑﯿﻤﺎران آﻣﺒﻮﻟﯽ ﻣﯽ ﺗﻮاﻧﺪ ﻣﺪﻧﻈﺮ ﻗﺮار ﮔﯿﺮﻧﺪ ﺑﺮﺧﯽ ﻗﻠﺒﯽ و ﺑﺮﺧﯽ رﯾﻮياﻧﺪ؛ ﻣﻤﮑﻦ اﺳﺖ ﺑﯿﻤﺎر ﺣﻤﻠﻪ آﺳﻢ داﺷﺘﻪ ﺑﺎﺷﺪ‪COPD ،‬‬ ‫‪ Exacerbation‬ﺑﺎﺷﺪ‪ ،‬ﻧﻮﻣﻮﻧﯿﺎ‪ ،‬ﻧﻮﻣﻮﺗﻮراﮐﺲ ﮐﺮده ﺑﺎﺷﺪ ﯾﺎ اﺻﻼ ﻣﺸﮑﻞ ﻗﻠﺒﯽ ﺑﺎﺷﺪ ﻣﺜﻼ ﭘﺮﯾﮑﺎردﯾﺖ‪ CHF Decompensated ،‬ﯾﺎ ﺣﺘﯽ ‪ MI‬ﺑﺎﺷﺪ؛ ﭘﺲ‬ ‫ﺣﺘﻤﺎ ﺑﺎﯾﺪ ﺗﺸﺨﯿﺺﻫﺎي اﻓﺘﺮاﻗﯽ را ﮔﻮﺷﻪ ذﻫﻦ ﺧﻮد داﺷﺘﻪ ﺑﺎﺷﯿﻢ‪.‬‬ ‫ﺣﺎل ﭼﻪ ﮐﺎر ﮐﻨﯿﻢ ﮐﻪ راﺣﺖﺗﺮ ﺑﻪ ﺗﺸﺨﯿﺺ ﻗﻄﻌﯽ ﺑﺮﺳﯿﻢ؟‬ ‫درﺑﺎره آﻣﺒﻮﻟﯽ ﭼﻮن ﺑﺎ ﺷﮑﺎﯾﺖﻫﺎي ﻣﺨﺘﻠﻔﯽ ﺑﯿﻤﺎران ﻣﺮاﺟﻌﻪ ﻣﯽﮐﻨﻨﺪ و ﺗﺎﺑﻠﻮﻫﺎي ﻣﺨﺘﻠﻔﯽ ﺑﺮوز ﻣﯽﮐﻨﺪ‪ ،‬ﮐﺮاﯾﺘﺮاﯾﯽ وﺿﻊ ﺷﺪه ﺑﻪ ﻧﺎم ‪Well's Criteria‬؛ ﯾﻌﻨﯽ‬ ‫اﮔﺮ ﺑﻪ آﻣﺒﻮﻟﯽ در ﺑﯿﻤﺎري ﻓﮑﺮ ﮐﺮدﯾﻢ ﺑﺎﯾﺪ ‪ Well's Criteria‬ﺑﺮاي او ﻣﺤﺎﺳﺒﻪ ﮐﻨﯿﻢ ﮐﻪ ﻧﺸﺎن ﻣﯽدﻫﺪ ﭼﻘﺪر اﺣﺘﻤﺎل دارد ﮐﻪ ﺑﯿﻤﺎر آﻣﺒﻮﻟﯽ داﺷﺘﻪ ﺑﺎﺷﺪ‪.‬‬ ‫ﻣﻌﯿﺎر ‪ Well's‬ﺷﺎﻣﻞ دو آﯾﺘﻢ ‪ 3‬اﻣﺘﯿﺎزي اﺳﺖ‪ :‬ﯾﮑﯽ ‪Signs and Symptoms‬‬ ‫‪ DVT‬و دﯾﮕﺮي اﯾﻨﮑﻪ اﮔﺮ ﺗﺸﺨﯿﺺ ﻏﯿﺮ از ‪ PTE‬ﺗﻮﺟﯿﻪﮐﻨﻨﺪه ﻋﻼﺋﻢ ﺑﯿﻤﺎر ﻧﺒﺎﺷﺪ ﻧﯿﺰ‬ ‫‪ 3‬اﻣﺘﯿﺎز ﻣﯽﮔﯿﺮد‪.‬‬ ‫ﺿﺮﺑﺎن ﺑﯿﺸﺘﺮ از ‪ 100‬ﺑﺪون ﻋﻠﺖ دﯾﮕﺮ‪ ،‬ﺳﺎﺑﻘﻪ ﻗﺒﻠﯽ ‪ DVT‬ﯾﺎ ‪ PTE‬و ‪ 3‬روز ﺑﯽ‬ ‫ﺣﺮﮐﺘﯽ ﯾﺎ ﺟﺮاﺣﯽ در ‪ 4‬ﻫﻔﺘﻪ ﮔﺬﺷﺘﻪ ﻫﺮ ﮐﺪام ‪ 1,5‬اﻣﺘﯿﺎز‪.‬‬ ‫ﻫﻤﻮﭘﺘﯿﺰي و ‪ Cancer‬ﻫﺮ ﮐﺪام ‪ 1‬اﻣﺘﯿﺎز ﺧﻮاﻫﺪ داﺷﺖ‪.‬اﮔﺮ اﻣﺘﯿﺎز ‪ Well's‬ﺑﯿﺸﺘﺮ‬ ‫از ‪ 4‬ﺑﺎﺷﺪ ﯾﻌﻨﯽ اﺣﺘﻤﺎل آﻣﺒﻮﻟﯽ در ﺑﯿﻤﺎر ﺑﺎﻻﺳﺖ‪ ،‬ﭘﺲ ﺑﺎﯾﺪ از روشﻫﺎي ﻗﻮيﺗﺮي‬ ‫ﺑﺮاي ﺗﺸﺨﯿﺺ اﺳﺘﻔﺎده ﮐﻨﯿﻢ ﮐﻪ در اﯾﻦ ﻣﻮارد ‪ Choice‬ﻣﺎ ‪ Pulmonary CT Angiography‬اﺳﺖ‪.‬اﮔﺮ ﻣﻌﯿﺎر ‪ 4 Well's‬ﯾﺎ ﮐﻤﺘﺮ ﺑﻮد‪ ،‬اﺣﺘﻤﺎل آﻣﺒﻮﻟﯽ‬ ‫در ﺑﯿﻤﺎر ﮐﻢ ﺑﻮده و در اﯾﻦ ﺷﺮاﯾﻂ آزﻣﺎﯾﺶ ﺧﻮن و ﭼﮏ ‪ D-Dimer‬اﺳﺖ‪ Limit ،‬اي ﮐﻪ ﺑﺮاي ‪ D-Dimer‬در ﻧﻈﺮ ﻣﯽﮔﯿﺮﯾﻢ ‪ 500 ng/ml‬اﺳﺖ‪.‬اﮔﺮ‬ ‫ﺑﯿﺸﺘﺮ از‪ 500‬ﺑﺎﺷﺪ ﻣﺜﺒﺖ و اﮔﺮ ﮐﻤﺘﺮ از ‪ 500‬ﺑﺎﺷﺪ ﻣﻨﻔﯽ ﺧﻮاﻫﺪ ﺑﻮد ﮐﻪ رد ﮐﻨﻨﺪه آﻣﺒﻮﻟﯽ اﺳﺖ ﻣﮕﺮ اﯾﻨﮑﻪ ﺷﮏ ﻧﺎﺷﯽ از ﻣﻌﺎﯾﻨﻪﻣﺎن ﻗﻮي ﺑﺎﺷﺪ‪.‬اﻣﺎ ﻣﺜﺒﺖ‬ ‫ﺑﻮدن ﻗﻄﻌﺎ ﺑﻪ ﻣﻌﻨﯽ آﻣﺒﻮﻟﯽ ﻧﯿﺴﺖ زﯾﺮا ﺷﺮاﯾﻂ دﯾﮕﺮي ﻧﯿﺰ ﻫﺴﺘﻨﺪ ﮐﻪ ‪ D-Dimer‬را ﺑﺎﻻ ﻣﯽﺑﺮﻧﺪ‪ ،‬ﻣﺎﻧﻨﺪ ﺳﯿﻔﻠﯿﺲ‪ ،‬ﻧﻮﻣﻮﻧﯿﺎ‪ ،‬ﺗﺮوﻣﺎ‪ ،‬ﺟﺮاﺣﯽ‪ ،‬ﺳﻦ ﺑﺎﻻ و ﺣﺎﻣﻠﮕﯽ‪.‬‬ ‫ﺣﺎل اﯾﻨﮑﻪ ﭼﺮا ‪ D-Dimer‬در ﺗﺸﺨﯿﺺ آﻣﺒﻮﻟﯽ ﮐﻤﮏﮐﻨﻨﺪه اﺳﺖ‪ ،‬ﺑﻪ اﯾﻦ دﻟﯿﻞ اﺳﺖ ﮐﻪ ‪ D-Dimer‬ﺣﺎﺻﻞ از ﻟﯿﺰ ﻟﺨﺘﻪ اﺳﺖ‪.‬‬ ‫از آزﻣﺎﯾﺸﺎت دﯾﮕﺮ ﮐﻪ در ﺑﯿﻤﺎران ﺗﻨﻔﺴﯽ اﻧﺠﺎم ﻣﯽ ﺷﻮد‪ ABG ،‬اﺳﺖ‪.‬ﺧﯿﻠﯽ در ﺗﺸﺨﯿﺺ آﻣﺒﻮﻟﯽ ﮐﻤﮏ ﻧﺨﻮاﻫﺪ ﮐﺮد اﻣﺎ در آﻣﺒﻮﻟﯽ ﭼﻮن ﺑﯿﻤﺎر ﺗﺎﮐﯽﭘﻨﻪ‬ ‫ﻣﯽﺷﻮد ﺑﻨﺎﺑﺮاﯾﻦ ﺑﯿﻤﺎر ‪ Co2‬ﺑﯿﺸﺘﺮي دﻓﻊ ﻣﯽﮐﻨﺪ و ﺑﻪ دﻧﺒﺎل آن آﻟﮑﺎﻟﻮز ﺗﻨﻔﺴﯽ رخ ﻣﯽدﻫﺪ‪.‬ﺑﺴﺘﻪ ﺑﻪ وﺳﻌﺖ آﻧﻔﺎرﮐﺖ آﻣﺒﻮﻟﯽ ﻣﻤﮑﻦ اﺳﺖ ﻫﺎﯾﭙﻮﮐﺴﯽ‬ ‫ﺑﺒﯿﻨﯿﻢ ﯾﺎ ﻧﺒﯿﻨﯿﻢ‪.‬و ﺑﯿﺸﺘﺮ ﺗﺴﺖ ‪ ABG‬ﺑﻪ ﻣﻨﻈﻮر رد ﮐﺮدن ﺗﺸﺨﯿﺺ اﻓﺘﺮاﻗﯽﻫﺎﺳﺖ‪.‬‬ ‫‪EKG‬‬ ‫اﯾﻦ روش ﻫﻢ در ﺟﻬﺖ رد ﮐﺮدن ﯾﺎ رﺳﯿﺪن ﺑﻪ ﺗﺸﺨﯿﺺ ﻏﯿﺮ از آﻣﺒﻮﻟﯽ اﺳﺘﻔﺎده ﻣﯽﺷﻮد اﻣﺎ در ﺑﯿﻤﺎران آﻣﺒﻮﻟﯽ ﺷﺎﯾﻊﺗﺮﯾﻦ ﻧﮑﺘﻪاي ﮐﻪ در ‪ EKG‬ﻣﺸﺎﻫﺪه‬ ‫ﻣﯽﺷﻮد ﺳﯿﻨﻮس ﺗﺎﮐﯽﮐﺎردي اﺳﺖ‪.‬ﺑﺤﺚ دﯾﮕﺮ ﺑﯿﻤﺎران آﻣﺒﻮﻟﯽ اﻟﮕﻮي ‪ S1-Q3-T3‬اﺳﺖ‪.‬وﺟﻮد ﻣﻮج ‪ S‬ﻋﻤﯿﻖ در ‪ Lead 1‬و ﻣﻮج ‪ Q‬ﻋﻤﯿﻖ و ‪Invert T‬‬ ‫در ‪.Lead 3‬ﻣﻤﮑﻦ اﺳﺖ در ﻟﯿﺪﻫﺎي ‪ Pericordial‬ﻧﯿﺰ ‪ Invert T‬ﻣﺸﺎﻫﺪه ﺷﻮد‪.‬‬ ‫اﯾﻦ ﺷﻮاﻫﺪ ﺷﺎﯾﺪ ﻣﺎ را ﺑﻪ ﺳﻤﺖ آﻣﺒﻮﻟﯽ ﻫﺪاﯾﺖ ﮐﻨﻨﺪ اﻣﺎ اﺧﺘﺼﺎﺻﯽ ﻧﯿﺴﺘﻨﺪ و ﻣﺎ ﻣﻤﮑﻦ اﺳﺖ ﻣﺜﻼً اﻟﮕﻮي ‪ S1-Q3-T3‬در ﺷﺮاﯾﻄﯽ ﮐﻪ ﻗﺒﻼ ﺑﻄﻦ راﺳﺖ‬ ‫ﺗﺤﺖ ﻓﺸﺎر ﺑﺎﺷﺪ ﻣﺸﺎﻫﺪه ﮐﻨﯿﻢ و ﺑﯿﺸﺘﺮ ﺟﺎﯾﮕﺎﻫﺶ ﺑﺮاي رد ﮐﺮدن ﺗﺸﺨﯿﺺﻫﺎي اﻓﺘﺮاﻗﯽ ﻣﺎﻧﻨﺪ ‪ MI‬اﺳﺖ‪.‬‬ ‫‪3‬‬ ‫‪| 7‬‬ Diagnosis of DVT The most accessible and least harmful gold standard method for diagnosing DVT is Doppler sonography of the lower extremity veins. Clinical Symptoms and Examination of PTE Most PTE patients do not have symptoms and do not make specific complaints, especially younger patients who have better cardiac and pulmonary reserves, they present with anxiety and sweating. However, those who have symptoms, their most common symptom is shortness of breath, and following that, they may have pleuritic pain, cough, and hemoptysis. The most common patient complaint in the examination is shortness of breath and the most common patient sign is tachypnea. Apart from these symptoms, wheezing sound on exhalation, crackle in the lung, observation of low fever, tachycardia, friction rub, and also increased P2 in the heartbeat may be observed. Cyanosis in massive clots is also possible. Differential Diagnoses in Embolism Patients :Differential diagnoses that can be considered in embolism patients are some cardiac and some pulmonary; the patient may have had an asthma attack, COPD exacerbation, pneumonia, pneumothorax, or even a heart problem such as pericarditis, decompensated CHF, or even MI; so we must definitely have differential diagnoses in mind. What Should We Do to Reach a Definitive Diagnosis More Comfortably? About embolism, because patients present with various complaints and different pictures appear, a criterion has been established called Well’s Criteria; that is, if we thought of embolism in the patient, we should calculate Well’s Criteria for him/her, which shows how likely it is that the patient has embolism. Well’s criterion includes two 3-point items: one is Signs and Symptoms of DVT and the other is that if the diagnosis other than PTE does not justify the patient’s symptoms, it also gets 3 points. Heart rate more than 100 without another reason, previous history of DVT or PTE, and 3 days of immobility or surgery in the past 4 weeks each get 1.5 points. Hemoptysis and Cancer each will get 1 point. If the Well’s score is more than 4, it means the likelihood of embolism in the patient is high, so we should use stronger methods for diagnosis, in these cases, our choice is Pulmonary CT Angiography. If the Well’s criterion was 4 or less, the likelihood of embolism in the patient was low, and in these circumstances, the blood test and check D-Dimer is, the limit we consider for D-Dimer is 500 ng/ml. If it is more than 500, it is positive and if it is less than 500, it will be negative which rejects embolism unless our examination suspicion is strong. But being positive does not necessarily mean embolism because there are other conditions that raise D-Dimer, such as syphilis, pneumonia, trauma, surgery, old age, and pregnancy. Now why D- Dimer is helpful in diagnosing embolism, is because D-Dimer is the result of clot lysis. Among other tests that are performed in respiratory patients, ABG is. It won’t help much in diagnosing embolism but in embolism because the patient becomes tachypneic, therefore, the patient excretes more Co2 and as a result, respiratory alkalosis occurs. Depending on the extent of embolism infarct, we may or may not see hypoxia. And most of the ABG test is to rule out differential diagnoses. EKG This method is also used to rule out or reach a diagnosis other than embolism, but in embolism patients, the most common point observed in EKG is sinus tachycardia. Another discussion in embolism patients is the S1-Q3-T3 pattern. The presence of a deep S wave in Lead 1 and a deep Q wave and Invert T in Lead 3. Invert T may also be observed in Pericordial leads. These findings may guide us towards embolism but are not exclusive and we may, for example, observe the S1-Q3-T3 pattern in conditions where the right ventricle has been under pressure before and its main place is to rule out differential diagnoses such as MI.  ‫‪4‬‬ ‫‪Chest X Ray‬‬ ‫اﯾﻦ روش ﻫﻢ ﮐﻤﮏ ﺑﻪ ﺗﺸﺨﯿﺺﻫﺎي اﻓﺘﺮاﻗﯽ ﻣﯽ ﮐﻨﺪ ﻣﺜﻼً ﺑﯿﻤﺎر ﻧﻮﻣﻮﺗﻮراﮐﺲ ﻧﺒﺎﺷﺪ‪ CHF Decompensated ،‬ﻧﺒﺎﺷﺪ‪ ،‬ﻧﻮﻣﻮﻧﯿﺎ ﻧﺒﺎﺷﺪ‪،‬‬ ‫ﭼﻮن ‪ CXR‬در ﺑﯿﻤﺎران آﻣﺒﻮﻟﯽ ﻧﺮﻣﺎل اﺳﺖ؛ ﭘﺲ در ﺑﯿﻤﺎري ﮐﻪ ‪ Component‬رﯾﻮي دارد وﻟﯽ ‪CXR‬اش ﻧﺮﻣﺎل اﺳﺖ ﺑﯿﺸﺘﺮ ﺑﻪ آﻣﺒﻮﻟﯽ رﯾﻮي ﻓﮑﺮ ﻣﯽﮐﻨﯿﻢ‪.‬‬ ‫ﯾﮏ ﺳﺮي ﻋﻼﺋﻢ رو ﻫﻢ ﻣﯿﺘﻮان در ‪ CXR‬آﻣﺒﻮﻟﯽ ﻣﺸﺎﻫﺪه ﮐﺮد زﯾﺮا ﺑﻪ ﻫﺮ ﺣﺎل ﺧﻮنرﺳﺎﻧﯽ در ﺑﯿﻤﺎران آﻣﺒﻮﻟﯽ ﻣﺨﺘﻞ اﺳﺖ ﮐﻪ ‪Westernmark sign‬‬ ‫ﻧﺎم دارد‪.‬ﯾﺎ ﻣﺜﻼً ﻗﺴﻤﺘﯽ ﮐﻪ اﻧﻔﺎرﮐﺖ ﮐﺮده ﺑﻪﺻﻮرت ﯾﮏ ﺿﺎﯾﻌﻪ ‪ Wedge‬دﯾﺪه ﺷﻮد؛ ﺿﺎﯾﻌﻪ ‪ Wedge‬ﯾﮏ ﺿﺎﯾﻌﻪ ﻣﺨﺮوﻃﯽ اﺳﺖ ﮐﻪ ﻗﺎﻋﺪه آن ﮐﻪ‬ ‫ﭘﻬﻦﺗﺮ اﺳﺖ روي ﭘﻠﻮر ﻗﺮار ﻣﯽﮔﯿﺮد و راس آن ﺑﻪ ﺳﻤﺖ ﻧﺎف رﯾﻪ اﺳﺖ ﮐﻪ ‪ Hampton's hump sign‬ﻧﺎﻣﯿﺪه ﻣﯽﺷﻮد‪.‬ﻋﻼﻣﺖ دﯾﮕﺮ در ‪ ،CXR‬آﺗﻠﮑﺘﺎزي‬ ‫ﺧﻄﯽ اﺳﺖ ﭼﺮا ﮐﻪ ﮔﻔﺘﯿﻢ ﺳﻮرﻓﺎﮐﺘﺎﻧﺖ ﺗﺨﺮﯾﺐ و ﮐﻤﭙﻠﯿﺎﻧﺲ رﯾﻪ ﮐﻢ ﺷﺪه اﺳﺖ ﭘﺲ آﺗﻠﮑﺘﺎزي ﺧﻄﯽ و ﺑﺎﻻ زدﮔﯽ دﯾﺎﻓﺮاﮔﻢ در ‪ CXR‬ﻣﺸﺎﻫﺪه ﻣﯽﺷﻮد‪.‬اﯾﻦ‬ ‫ﺷﻮاﻫﺪ‪ ،‬ﻣﻤﮑﻦ اﺳﺖ در ‪ CXR‬آﻣﺒﻮﻟﯽ ﻣﺸﺎﻫﺪه ﺷﻮﻧﺪ‪ ،‬در ﺣﺎﻟﯿﮑﻪ ‪ CXR‬ﺗﯿﭙﯿﮏ آﻣﺒﻮﻟﯽ ﻧﺮﻣﺎل اﺳﺖ‪.‬‬ ‫اﮐﻮﮐﺎردﯾﻮﮔﺮاﻓﯽ‬ ‫اﮐﻮ اﮔﺮ ‪:‬‬ ‫ﺗﺮﻧﺲ ﺗﻮراﺳﯿﮏ ﺑﺎﺷﺪ‪ ،‬ﻟﺨﺘﻪ در ﺷﺮﯾﺎن ﭘﻮﻟﻤﻮﻧﺮ ﻣﺸﺎﻫﺪه ﻧﻤﯽﺷﻮد‪.‬‬ ‫‪ Massive‬ﺑﺎﺷﺪ؛ ‪ RV dilatation‬دارﯾﻢ‪.‬‬ ‫‪ Submassive‬ﺑﺎﺷﺪ؛ ‪ McConnell's sign‬دارﯾﻢ ﮐﻪ ﺑﻪ ﻧﻔﻊ آﻣﺒﻮﻟﯽ اﺳﺖ‪.‬‬ ‫اﯾﻦ ‪ Sign‬ﻫﯿﭙﻮﮐﯿﻨﺰي دﯾﻮاره ﺑﻄﻦ راﺳﺖ اﺳﺖ‪.‬در زﻣﯿﻨﻪ آﻣﺒﻮﻟﯽ رﯾﻪ ﺑﺎﯾﺪ دﻗﺖ ﺷﻮد ﮐﻪ ‪ Apex‬ﺑﻄﻦ راﺳﺖ ﻣﻌﻤﻮﻻ ﺣﺮﮐﺖ ﻧﺮﻣﺎل دارد‪.‬ﭘﺲ‬ ‫‪ McConnell's sign‬را ﻧﯿﺰ ﻣﻤﮑﻦ اﺳﺖ در اﮐﻮي اﯾﻦ ﺑﯿﻤﺎران ﺑﺒﯿﻨﯿﻢ؛ ﺑﻪ ﻫﺮ ﺣﺎل ‪ Echo‬ﺑﯿﺸﺘﺮ ﮐﻤﮏ ﻣﯽﮐﻨﺪ ﺗﺎ ﺗﺸﺨﯿﺺ اﻓﺘﺮاﻗﯽﻫﺎي دﯾﮕﺮ را رد ﮐﻨﯿﻢ‬ ‫ﻣﺎﻧﻨﺪ ‪ ،Pericardial effusion ،MI‬آﻧﮋﯾﻦ و‪...‬‬ ‫ﻣﻨﻔﯽ ﺑﻮدن اﮐﻮ ردﮐﻨﻨﺪه آﻣﺒﻮﻟﯽ ﻧﯿﺴﺖ‪.‬‬ ‫اﮔﺮ ‪ transesophagial echo‬اﻧﺠﺎم ﺑﺪﻫﯿﻢ‪ ،‬اﻃﻼﻋﺎت ﺑﯿﺸﺘﺮي ﺑﺪﺳﺖ ﺧﻮاﻫﺪ آﻣﺪ‪.‬‬ ‫داﭘﻠﺮ ﺳﻮﻧﻮﮔﺮاﻓﯽ‬ ‫‪ Choice‬ﺑﺮاي ﺗﺸﺨﯿﺺ ﺗﺮوﻣﺒﻮزﻫﺎي ورﯾﺪ اﻧﺪام ﺗﺤﺘﺎﻧﯽ اﺳﺖ‪.‬اﻣﺎ ﺳﻮﻧﻮﮔﺮاﻓﯽ داﭘﻠﺮ ﻣﻨﻔﯽ ردﮐﻨﻨﺪه ﻧﯿﺴﺖ زﯾﺮا ﻣﻤﮑﻦ اﺳﺖ ﮐﻪ ﻟﺨﺘﻪ در ورﯾﺪﻫﺎي اﻧﺪام‬ ‫ﺗﺤﺘﺎﻧﯽ ﺑﻮده و اﻻن ﮐﻨﺪه ﺷﺪه و ﺑﻪ ورﯾﺪﻫﺎي رﯾﻮي رﻓﺘﻪ ﺑﺎﺷﺪ و ﺑﻨﺎﺑﺮاﯾﻦ در اﻧﺪام ﺗﺤﺘﺎﻧﯽ دﯾﺪه ﻧﻤﯽﺷﻮد؛ ﯾﺎ اﯾﻨﮑﻪ ورﯾﺪﻫﺎي ﻟﮕﻨﯽ ﯾﺎ ﭘﺮوﮔﺰﯾﻤﺎل اﻧﺪام ﺗﺤﺘﺎﻧﯽ‬ ‫ﺑﻪ ﺧﻮﺑﯽ در داﭘﻠﺮ دﯾﺪه ﻧﺸﻮد‪.‬ﭘﺲ ﻣﻤﮑﻦ اﺳﺖ داﭘﻠﺮ ﻋﻠﯽرﻏﻢ اﯾﻨﮑﻪ ﺑﯿﻤﺎر آﻣﺒﻮﻟﯽ دارد ﻣﻨﻔﯽ ﺷﻮد‪.‬‬ ‫‪CT Angiography‬‬ ‫در ‪ CT‬آﻧﮋﯾﻮ ﻣﺎده ﺣﺎﺟﺐ را ﺑﻪ داﺧﻞ ﺷﺮﯾﺎن ﭘﻮﻟﻤﻮﻧﺮ از ﻃﺮﯾﻖ ورﯾﺪﻫﺎي ﻣﺤﯿﻄﯽ ﺗﺰرﯾﻖ ﻣﯽﮐﻨﻨﺪ‪.‬در ﺻﻮرﺗﯽ ﮐﻪ ﻟﺨﺘﻪ ﺳﺒﺐ اﻧﺴﺪاد ﺷﺪه ﺑﺎﺷﺪ ﺑﻪ ﺻﻮرت‬ ‫‪ Filling Defect‬ﯾﺎ ﺣﺘﯽ ﮔﺎﻫﯽ ﺑﻪ ﺻﻮرت ‪ Cutoff‬ﮐﺎﻣﻞ ﻣﯽﺗﻮاﻧﯿﻢ ﺑﺒﯿﻨﯿﻢ‪ Choice.‬ﺗﺸﺨﯿﺺ آﻣﺒﻮﻟﯽ ‪ CT Angio‬اﺳﺖ؛ ﻓﻘﻂ ﺗﻨﻬﺎ ﻣﺤﺪودﯾﺘﯽ ﮐﻪ دارد‪،‬‬ ‫در ﺑﯿﻤﺎراﻧﯽ ﮐﻪ ﺣﺴﺎﺳﯿﺖ ﺑﻪ ﻣﺎده ﺣﺎﺟﺐ دارﻧﺪ‪ ،‬ﯾﺎ ﮐﺮاﺗﯿﻦ ﺑﺎﻻ دارﻧﺪ)زﯾﺮا ﻣﺎده ﺣﺎﺟﺐ ﻧﻔﺮوﺗﻮﮐﺴﯿﮏ اﺳﺖ( ﻣﻤﮑﻦ اﺳﺖ ﻧﺘﻮان اﺳﺘﻔﺎده ﮐﺮد‪.‬ﮐﻪ در اﯾﻦ‬ ‫ﺻﻮرت از روشﻫﺎي ﺟﺎﯾﮕﺰﯾﻦ اﺳﺘﻔﺎده ﻣﯽﮐﻨﯿﻢ ﮐﻪ ‪ Scan Perfusion‬اﺳﺖ‪.‬‬ ‫دﻗﺖ ﺷﻮد ‪ CT angio‬ﻣﻨﻔﯽ در ﺻﻮرت ﺷﮏ ﺑﺎﻟﯿﻨﯽ ﺑﺎﻻ ردﮐﻨﻨﺪه آﻣﺒﻮﻟﯽ ﻧﯿﺴﺖ‪.‬‬ ‫‪Lung Scan‬‬ ‫در اﯾﻦ روش‪ ،‬اﺳﺎس ﮐﺎر ﺑﺮ اﯾﻦ اﺳﺖ ﮐﻪ ﻣﻮاد رادﯾﻮاﮐﺘﯿﻮ را اﺳﺘﻨﺸﺎﻗﯽ ﯾﺎ ورﯾﺪي وارد رﯾﻪ ﻣﯽﮐﻨﻨﺪ و ﺗﺼﻮﯾﺮي ﮐﻪ از اﯾﻦ ﻣﻮاد رادﯾﻮاﮐﺘﯿﻮ ﻣﻨﻌﮑﺲ ﻣﯽﺷﻮد‬ ‫را ﺛﺒﺖ ﻣﯽﮐﻨﻨﺪ‪.‬در ‪ Scan Perfusion‬ﻣﺎده رادﯾﻮاﮐﺘﯿﻮ روي آﻟﺒﻮﻣﯿﻦ ﺳﻮار ﻣﯽﺷﻮد و در ﻗﺴﻤﺖ ﻫﺎﯾﯽ ﮐﻪ ﺧﻮنرﺳﺎﻧﯽ ﺑﺪﻟﯿﻞ آﻣﺒﻮﻟﯽ ﻣﺨﺘﻞ ﺷﺪه‪،‬‬ ‫ﺑﻪﺻﻮرت ‪ Filling Defect‬روي ﺗﺼﻮﯾﺮ ﻣﺸﺨﺺ ﻣﯽﺷﻮد‪.‬ﯾﺎدﻣﺎن ﺑﺎﺷﺪ ﮐﻪ ‪ Scan Perfusion‬ﻣﻨﻔﯽ ﻗﻄﻌﺎ ردﮐﻨﻨﺪه آﻣﺒﻮﻟﯽ اﺳﺖ وﻟﯽ ﻫﺮ ﭘﺎﺳﺦ ﻣﺜﺒﺘﯽ‬ ‫ﻧﺸﺎﻧﻪ آﻣﺒﻮﻟﯽ ﻧﯿﺴﺖ زﯾﺮا ﻣﻤﮑﻦ اﺳﺖ ﺑﯿﻤﺎر ﻣﺸﮑﻞ ﻧﻮﻣﻮﻧﯿﺎ‪ COPD ،‬ﯾﺎ آﺳﻢ داﺷﺘﻪ ﮐﻪ در واﻗﻊ ﺑﯿﻤﺎر ﻣﺸﮑﻞ ﺗﻬﻮﯾﻪاي داﺷﺘﻪ و ﺑﻪدﻧﺒﺎل آن ﻣﺸﮑﻞ ﺧﻮنرﺳﺎﻧﯽ‬ ‫ﺑﺮوز ﮐﺮده ﺑﺎﺷﺪ‪.‬‬ ‫‪4‬‬ ‫‪| 7‬‬ Chest X Ray This method also helps with differential diagnosis, for example, the patient does not have pneumothorax, CHF Decompensated, pneumonia, because CXR in embolism patients is normal; so in a patient who has a pulmonary component and his/her CXR is normal, we think more about pulmonary embolism. We can also see some signs in CXR of embolism because after all, blood supply in embolism patients is disrupted, which is called Westernmark sign. Or for example, the part that has infarcted can be seen as a Wedge lesion; Wedge lesion is a conical lesion whose base, which is wider, is located on the pleura and its apex is towards the lung hilum, which is called Hampton’s hump sign. Another sign in CXR is linear atelectasis because we said surfactant is degraded and lung compliance has decreased, so linear atelectasis and diaphragm elevation are seen in CXR. These findings may be seen in CXR of embolism, while CXR of typical embolism is normal. Echocardiography If the echo is transthoracic, the clot in the pulmonary artery is not seen. If we have RV dilatation, it’s Massive. If it’s Submassive, we have McConnell’s sign which is in favor of embolism. This Sign is hypokinesis of the right ventricular wall. In the context of pulmonary embolism, it should be noted that the Apex of the right ventricle usually has normal movement. So we may also see McConnell’s sign in the echo of these patients; anyway, Echo helps more to rule out other differential diagnoses such as Pericardial effusion, MI, angina, and… A negative echo is not a rejector of embolism. If we perform a transesophageal echo, more information will be obtained. Doppler Sonography Choice for diagnosing deep vein thrombosis of the lower extremity. But Doppler sonography is not a rejector because it is possible that the clot was in the deep veins of the lower extremity and now it has been broken down and has gone to the pulmonary veins and therefore is not seen in the lower extremity; or that the pelvic veins or proximal lower extremity veins are not well seen in Doppler. So Doppler may be negative even though the patient has embolism. CT Angiography In CT Angio, the contrast material is injected into the pulmonary artery through the peripheral veins. If the clot has caused obstruction, we can see it as a Filling Defect or even sometimes as a complete Cutoff. Choice for diagnosing embolism is CT Angio; the only limitation it has is in patients who are sensitive to contrast material, or have high creatinine (because the contrast material is nephrotoxic) may not be able to use it. In this case, we use alternative methods which is Scan Perfusion. Note that a negative CT angio is not a rejector of embolism in case of high clinical suspicion. Lung Scan In this method, the basis of work is that radioactive materials are inhaled or venous into the lung and the image that is reflected from these radioactive materials is recorded. In Scan Perfusion, the radioactive material is mounted on albumin and in the parts where blood supply is disrupted due to embolism, it is seen as a Filling Defect on the image. Remember that a negative Scan Perfusion is definitely a rejector of embolism but any positive response is not a sign of embolism because the patient may have had pneumonia, COPD or asthma problems, in fact, the patient had a ventilation problem and as a result, a blood supply problem may have occurred.  ‫‪4‬‬ ‫ﺑﻨﺎﺑﺮاﯾﻦ در ﺻﻮرت ﻣﺜﺒﺖ ﺑﻮدن ‪ Scan Perfusion‬ﺑﻬﺘﺮ اﺳﺖ ﮐﻪ ‪ Specificity‬آن را ﺑﺎ ‪ Scan Ventilation‬ﺑﺎﻻ ﺑﺒﺮﯾﻢ‪.‬در ‪Scan‬‬ ‫‪ Ventilation‬ﺑﯿﻤﺎر ﻣﻮاد ‪ Vasoactive‬را اﺳﺘﺸﻤﺎم ﮐﺮده و ﺳﭙﺲ ﺗﺼﻮﯾﺮي از رﯾﻪ ﺗﺸﮑﯿﻞ و آﻧﺎﻟﯿﺰ ﻣﯽﺷﻮد‪.‬اﮔﺮ ﺑﯿﻤﺎر ‪Scan Perfusion‬‬ ‫ﻣﺜﺒﺖ و ‪ Scan Ventilation‬ﻣﻨﻔﯽ داﺷﺘﻪ ﺑﺎﺷﺪ‪ ،‬اﯾﻦ ﺷﺮاﯾﻂ ﺑﻪ ﻧﻔﻊ آﻣﺒﻮﻟﯽ اﺳﺖ‪.‬وﻟﯽ در ﺻﻮرﺗﯽ ﮐﻪ ‪ Scan Ventilation‬ﻫﻢ ﻣﺜﺒﺖ ﺑﺎﺷﺪ ﻣﻬﻢ اﺳﺖ‬ ‫ﮐﻪ آﯾﺎ اﯾﻦ اﺧﺘﻼل ‪ Perfusion‬و ‪ Ventilation‬در ﯾﮏ ﻧﻘﻄﻪاﻧﺪ ﯾﺎ ﻧﻪ‪.‬اﮔﺮ اﯾﻦ دو اﺧﺘﻼل از ﻧﻈﺮ ﻣﺤﻞ ﺑﺎ ﻫﻢ ﻣﻨﻄﺒﻖ ﻧﺒﺎﺷﻨﺪ و ‪ Mismatch‬داﺷﺘﻪ ﺑﺎﺷﻨﺪ‬ ‫ﺑﻪ ﻧﻔﻊ آﻣﺒﻮﻟﯽ اﺳﺖ‪.‬‬ ‫در ﻣﻮرد ‪ Scan Perfusion‬ﻣﻤﮑﻦ اﺳﺖ ‪ 4‬ﺣﺎﻟﺖ ﮔﺰارش ﺷﻮد‪:‬‬ ‫‪ :Negative -1‬رد ﻗﻄﻌﯽ آﻣﺒﻮﻟﯽ رﯾﻪ‬ ‫‪ %90 :High Probability -2‬ﺑﻪ ﻧﻔﻊ آﻣﺒﻮﻟﯽ رﯾﻪ‬ ‫‪ :Intermediate Probability -3‬در اﯾﻦ ﺣﺎﻟﺖ و ﺣﺎﻟﺖ ﺑﻌﺪي ﺑﺴﯿﺎر ﻣﻬﻢ اﺳﺖ ﮐﻪ ﺷﮏ ﺑﺎﻟﯿﻨﯽ ﻣﺎ ﭼﮕﻮﻧﻪ اﺳﺖ‪.‬‬ ‫‪low Probability -4‬‬ ‫‪MRI‬‬ ‫اﮔﺮ ﺑﺎ روشﻫﺎي ﻣﻮﺟﻮد و ﮔﻔﺘﻪ ﺷﺪه ﻧﺘﻮان ﺑﻪ ﺗﺸﺨﯿﺺ ﻗﻄﻌﯽ رﺳﯿﺪ‪ MRI ،‬ﻣﯽﺗﻮاﻧﺪ ﮐﻤﮏ ﮐﻨﻨﺪه ﺑﺎﺷﺪ )ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﯾﻨﮑﻪ اﺷﻌﻪاي را ﺑﻪ ﺑﯿﻤﺎر ﺗﺤﻤﯿﻞ‬ ‫ﻧﻤﯽﮐﻨﺪ(‪.‬‬ ‫درﻣﺎن‬ ‫درﺻﻮرﺗﯽ ﮐﻪ ﻣﺮﯾﻀﯽ آﻣﺒﻮﻟﯽ ‪ massive‬داﺷﺘﻪ ﺑﺎﺷﺪ‪ ،‬ﯾﮏ درﻣﺎن اوﻟﯿﻪ )ﻧﺠﺎتﺑﺨﺶ( دارﯾﻢ ﮐﻪ ﮐﻼ ﻟﺨﺘﻪ را از ﺑﯿﻦ ﺑﺒﺮﯾﻢ؛ ﺣﺎل ﻣﯽﺗﻮان ‪Embolectomy‬‬ ‫ﮐﺮد ﯾﺎ درﻣﺎن ﺗﺮوﻣﺒﻮﻟﯿﺘﯿﮏ داد ﯾﻌﻨﯽ ﻟﺨﺘﻪ را ﻟﯿﺰ ﮐﻨﯿﻢ ﻣﺜﻼً اﺳﺘﺮﭘﺘﻮﮐﯿﻨﺎز ﺑﺪﻫﯿﻢ ﯾﺎ از ﻓﯿﺒﺮﯾﻨﻮﻟﯿﺰ ﻟﻮﮐﺎل اﺳﺘﻔﺎده ﮐﻨﯿﻢ‪.‬‬ ‫درﻣﺎن ﺛﺎﻧﻮﯾﻪ ﻋﺒﺎرت اﺳﺖ از از داروﻫﺎي ‪ Anticoagulant‬اﺳﺖ ﻣﺎﻧﻨﺪ ﻫﭙﺎرﯾﻦ‪ Enoxaparin ،‬ﯾﺎ داروﻫﺎي ﺧﻮراﮐﯽ ﻣﺎﻧﻨﺪ وارﻓﺎرﯾﻦ‪،Rivaroxaban ،‬‬ ‫‪ Apixaban‬و ‪...‬‬ ‫ﭘﯿﺸﮕﯿﺮي‬ ‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺗﺸﺨﯿﺺ ﺳﺨﺖ آﻣﺒﻮﻟﯽ در ﺑﯿﻦ ﺑﯿﻤﺎران و اﺣﺘﻤﺎل ‪ Miss‬ﺷﺪن آن و ﻫﻤﭽﻨﯿﻦ ‪Procedure‬ﻫﺎي ﺗﺸﺨﯿﺼﯽ )ﻫﻢ از ﺑﺤﺚ اﺷﻌﻪ و ﻫﻢ ﻫﺰﯾﻨﻪاي‬ ‫ﮐﻪ ﺑﺮ ﻣﺎ ﺗﺤﻤﯿﻞ ﻣﯽﮐﻨﻨﺪ و ﻫﻤﭽﻨﯿﻦ دﺳﺘﺮﺳﯽ ﻣﺸﮑﻠﯽ دارﻧﺪ( و درﻣﺎنﻫﺎﯾﯽ ﮐﻪ ﻫﺰﯾﻨﻪﺑﺮ و ﻋﻮارض دارﻧﺪ‪ ،‬ﺧﯿﻠﯽ ﺑﻬﺘﺮ اﺳﺖ ﮐﻪ ﻣﺎ اﺟﺎزه ﻧﺪﻫﯿﻢ ﮐﻪ ﺗﺸﮑﯿﻞ‬ ‫ﻟﺨﺘﻪ اﺗﻔﺎق ﺑﯿﻔﺘﺪ‪ ،‬ﯾﻌﻨﯽ ﺑﺮ ﭘﺮوﻓﯿﻼﮐﺴﯽ ﺑﯿﺸﺘﺮ دﻗﺖ داﺷﺘﻪ ﺑﺎﺷﯿﻢ‪.‬ﺣﺎل اﯾﻦ روش ﭘﺮوﻓﯿﻼﮐﺴﯽ ﻣﯽ ﺗﻮاﻧﺪ داروﯾﯽ و ﺑﻪ ﺻﻮرت زﯾﺮ ﺟﻠﺪي ﻣﺎﻧﻨﺪ ﻫﭙﺎرﯾﻦ ﯾﺎ‬ ‫اﻧﻮﮐﺴﺎﭘﺎرﯾﻦ ﺑﺎﺷﺪ ﯾﺎ ﺑﺼﻮرت ﻣﮑﺎﻧﯿﮑﯽ ﻣﺎﻧﻨﺪ اﺳﺘﻔﺎده از ﻓﯿﻠﺘﺮ و ‪...‬ﮐﻪ ﺑﻪ ﺻﻮرت ﻣﺘﻨﺎوب در ﺑﯿﻤﺎراﻧﯽ ﮐﻪ ﻣﺜﻼً ‪ Bedridden‬ﻫﺴﺘﻨﺪ روي ورﯾﺪﻫﺎي ﺳﺎق‬ ‫ﭘﺎ ﻓﺸﺎر آورده و اﺟﺎزه ﺗﺠﻤﻊ ﺧﻮن را ﻧﻤﯽدﻫﻨﺪ ﺗﺎ ﺷﺮاﯾﻂ زﻣﯿﻨﻪﺳﺎز ﺗﺸﮑﯿﻞ ﻟﺨﺘﻪ اﯾﺠﺎد ﻧﺸﻮد‪.‬‬ ‫در ﺑﯿﻤﺎران ﺑﺴﺘﺮي‪ ،‬دﻫﯿﺪراﺗﻪ ﮐﺮدن‪ ،‬ﺑﺴﯿﺎر ﻣﺎﻧﻊ ﺗﺸﮑﯿﻞ ﻟﺨﺘﻪ ﻣﯽﺷﻮد‪.‬‬ ‫ﺗﻼش ﺑﺮاي ‪ out of bed‬ﮐﺮدن ﺑﯿﻤﺎر ﺑﺴﺘﺮي ﺻﻮرت ﮔﯿﺮد‪.‬‬ ‫ﺗﻮﺟﻪ ﺑﻪ ﺣﺮﮐﺖ ﻓﯿﺰﯾﮑﯽ‪ ،‬ﻫﺮ ‪ 1‬اﻟﯽ ‪ 2‬ﺳﺎﻋﺖ ﯾﮑﺒﺎر در ﺳﻔﺮﻫﺎي ﻃﻮﻻﻧﯽ‬ ‫ﺳﺨﻦ ﭘﺎﯾﺎﻧﯽ اﺳﺘﺎد‪ :‬ﻣﺒﺠﺚ آﻣﺒﻮﻟﯽ ﻣﺒﺤﺜﯽ اﺳﺖ ﮐﻪ از اﺑﺘﺪاي ﻃﺒﺎﺑﺖ ﺑﺎ آن درﮔﯿﺮ ﻫﺴﺘﯿﻢ و در ﻫﺮ رﺷﺘﻪ و ﺗﺨﺼﺼﯽ ﺑﺎ ﻣﺎ ﻫﻤﺮاه اﺳﺖ؛ ﻫﻤﯿﺸﻪ ﺑﻪ اﺣﺘﻤﺎل‬ ‫اﺑﺘﻼ ﺑﯿﻤﺎر ﺑﻪ آﻣﺒﻮﻟﯽ رﯾﻪ ﻓﮑﺮ ﮐﻨﯿﺪ و ﺑﻪ روشﻫﺎي ﭘﯿﺸﮕﯿﺮي ﺗﻮﺟﻪ داﺷﺘﻪ ﺑﺎﺷﯿﺪ‪.‬‬ ‫ﻧﻤﻮﻧﻪ ﺳﻮاﻻت‬ ‫‪-1‬ﮐﺪامﯾﮏ از ﺿﺎﯾﻌﺎت رﯾﻮي زﯾﺮ ﻧﻤﺎي ﺷﺒﯿﻪ آﺑﺴﻪي رﯾﻪ ﻧﻤﯽدﻫﺪ؟‬ ‫د( آﻣﺒﻮﻟﯽ رﯾﻮي‬ ‫ج(ﮐﺎرﺳﯿﻨﻮم ﻧﮑﺮوزان‬ ‫ب( ﺑﺮوﻧﺸﮑﺘﺎزي‬ ‫اﻟﻒ( وﮔﻨﺮ‬ ‫‪5‬‬ ‫‪| 7‬‬ Therefore, if the Scan Perfusion is positive It is better to increase its Specificity with Scan Ventilation. In Scan Ventilation, the patient inhales Vasoactive substances and then an image of the lung is formed and analyzed. If the patient has a positive Scan Perfusion and a negative Scan Ventilation, this condition is in favor of embolism. But if Scan Ventilation is also positive, it is important whether this Perfusion and Ventilation disorder are in one place or not. If these two disorders do not match in terms of location and have a Mismatch, it is in favor of embolism. Regarding Scan Perfusion Four conditions may be reported: 1. Negative: Definitive rejection of pulmonary embolism 2. High Probability: 90% in favor of pulmonary embolism 3. Intermediate Probability: In this case and the next case, it is very important how our clinical suspicion is. 4. Low Probability MRI If you cannot reach a definitive diagnosis with the available and mentioned methods, MRI can be helpful (considering that it does not impose radiation on the patient). Treatment If the patient has a massive embolism, we have a primary (lifesaving) treatment that completely removes the clot; now we can do Embolectomy or give thrombolytic treatment, that is, lyse the clot, for example, give streptokinase or use local fibrinolysis. Secondary treatment It consists of Anticoagulant drugs such as heparin, Enoxaparin or oral drugs such as warfarin, Rivaroxaban, Apixaban, and … Prevention Given the difficult diagnosis of embolism among patients and the possibility of missing it and also diagnostic procedures (both in terms of radiation and the costs that they impose on us and also have difficult access) and treatments that are costly and have complications, it is much better that we do not allow the formation of a clot to happen, that is, we should pay more attention to prophylaxis. Now this prophylaxis method can be a drug and subcutaneously like heparin or enoxaparin or mechanically like using a filter and … which intermittently in patients who are, for example, Bedridden, put pressure on the veins of the calf and do not allow blood accumulation to create conditions conducive to clot formation. Final words of the professor The subject of embolism is a subject that we have been involved with from the beginning of medicine and is with us in every field and specialty; always think about the possibility of the patient suffering from pulmonary embolism and pay attention to prevention methods.  ‫‪4‬‬ ‫‪-2‬ﮐﺪام ﺟﻤﻠﻪ ﺻﺤﯿﺢ اﺳﺖ؟‬ ‫اﻟﻒ( ﺷﺎﯾﻊﺗﺮﯾﻦ ﻋﻠﺖ ﻣﺮگ ﻧﺎﺷﯽ از آﻣﺒﻮﻟﯽ رﯾﻪ‪ ،‬ﺗﮑﺮار آﻣﺒﻮﻟﯽ اﺳﺖ‪.‬‬ ‫ب( در ﺻﻮرت ﻋﺪم درﻣﺎن ﻣﻨﺎﺳﺐ آﻣﺒﻮﻟﯽ‪ ،‬ﻣﯿﺰان ﻣﺮگ ﺑﯿﺶ از ‪ 70‬درﺻﺪ ﺧﻮاﻫﺪ ﺑﻮد‪.‬‬ ‫ج( در ﻣﻮارد ‪ DVT‬اﺣﺘﻤﺎل آﻣﺒﻮﻟﯽ‪ ،‬ﻧﺰدﯾﮏ ﺑﻪ ﺻﺪ در ﺻﺪ اﺳﺖ‪.‬‬ ‫د( ‪ ،Saddle Emboli‬ﻣﻌﻤﻮﻻً ﻣﺎﺳﯿﻮ ﻫﺴﺘﻨﺪ‪.‬‬ ‫‪-3‬در ﺑﯿﻤﺎر ﻣﺒﺘﻼ ﺑﻪ آﻣﺒﻮﻟﯽ رﯾﻪ ﺑﺎ ﻓﺸﺎر ﺧﻮن ﺳﯿﺴﺘﻮﻟﯿﮏ ﮐﻤﺘﺮ از ‪ 90‬ﻣﯿﻠﯽﻣﺘﺮ ﺟﯿﻮه‪ ،‬ﮐﺪام ﺗﻌﺮﯾﻒ اﻃﻼق ﻣﯽﺷﻮد؟‬ ‫د( آﻣﺒﻮﻟﯽ ﻣﺰﻣﻦ‬ ‫ج( ‪saddle PTE‬‬ ‫ب( آﻣﺒﻮﻟﯽ ﺳﻮب ﻣﺎﺳﯿﻮ‬ ‫اﻟﻒ( آﻣﺒﻮﻟﯽ ﻣﺎﺳﯿﻮ‬ ‫‪-4‬ﺑﯿﺶﺗﺮﯾﻦ ﺧﻄﺮ آﻣﺒﻮﻟﯽ رﯾﻪ در ﮐﺪام ﻣﻮرد‪ ،‬وﺟﻮد دارد؟‬ ‫د( ﺣﺎﻣﻠﮕﯽ‬ ‫ج( ﺳﺎﺑﻘﻪي ‪ DVT‬ﻗﺒﻠﯽ‬ ‫ب( ﺷﮑﺴﺘﮕﯽ اﻧﺪام ﺗﺤﺘﺎﻧﯽ‬ ‫اﻟﻒ( ﺑﺪﺧﯿﻤﯽ‬ ‫‪-5‬اوﻟﯿﻦ درﻣﺎن در ﺑﯿﻤﺎر ﺑﺎ آﻣﺒﻮﻟﯽ رﯾﻪ ﺑﺎ ﻓﺸﺎر ﺧﻮن ﻃﺒﯿﻌﯽ ﮐﺪام اﺳﺖ؟‬ ‫ب( داروﻫﺎي آﻧﺘﯽ ﮐﻮآﮔﻮﻻﻧﺖ‬ ‫اﻟﻒ( ﺗﺰرﯾﻖ ﻣﺎﯾﻌﺎت ورﯾﺪي‬ ‫د( ﺗﺰرﯾﻖ داروﻫﺎي وازوﭘﺮﺳﻮر ﻣﺜﻞ اﭘﯽ ﻧﻔﺮﯾﻦ‬ ‫ج( داروﻫﺎي ﺗﺮوﻣﺒﻮﻟﯿﺘﯿﮏ‬ ‫‪-6‬ﺑﯿﻤﺎري ﺑﺎ ﺷﮏ ﺑﻪ آﻣﺒﻮﻟﯽ رﯾﻪ ﺗﺤﺖ ﺑﺮرﺳﯽ اﺳﺖ؛ در ﻣﻌﺎﯾﻨﻪ ﻧﺸﺎﻧﻪﻫﺎي ﺗﺮوﻣﺒﻮز ورﯾﺪ ﻫﺎي ﻋﻤﻘﯽ اﻧﺪام ﺗﺤﺘﺎﻧﯽ راﺳﺖ ﻣﺸﺨﺺ اﺳﺖ‪.‬در ﺿﻤﻦ‬ ‫ﺑﯿﻤﺎر ﺗﺎﮐﯽ ﮐﺎردي ﻫﻢ دارد)‪.(HR=120‬ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﮐﺮاﯾﺘﺮﯾﺎي وﻟﺰ‪ ،‬ﺣﺪاﻗﻞ ﭼﻪ ﻧﻤﺮهاي درﯾﺎﻓﺖ ﻣﯽﮐﻨﺪ؟‬ ‫د( دو و ﻧﯿﻢ‬ ‫ج( ﭼﻬﺎر و ﻧﯿﻢ‬ ‫ب( ﺳﻪ‬ ‫اﻟﻒ( ﺷﺶ‬ ‫‪-7‬ﺑﯿﻤﺎري ﺑﺎ ﺗﻨﮕﯽ ﻧﻔﺲ ﻧﺎﮔﻬﺎﻧﯽ و درد ﻧﯿﻢ ﺗﺮاﮐﺲ و ﻫﻤﻮﭘﺘﯿﺰي ﻣﺮاﺟﻌﻪ ﮐﺮده اﺳﺖ؛ ﮐﺪام ﺗﺸﺨﯿﺺ ﻣﺤﺘﻤﻞ اﺳﺖ؟‬ ‫د( ﭘﻠﻮرﯾﺖ واﯾﺮال‬ ‫ج( آﻣﺒﻮﻟﯽ‬ ‫ب(ﭘﻨﻮﻣﻮﺗﺮاﮐﺲ ﺧﻮدﺑﺨﻮد‬ ‫اﻟﻒ( اﻧﻔﺎرﮐﺘﻮس ﻣﯿﻮﮐﺎرد‬ ‫‪-8‬آﻗﺎي ‪64‬ﺳﺎﻟﻪ ﺑﺎ ﺷﮑﺎﯾﺖ ﺗﻨﮕﯽ ﻧﻔﺲ ﮐﻪ ﺑﻪ ﻃﻮر ﻧﺎﮔﻬﺎﻧﯽ از ﭼﻨﺪ دﻗﯿﻘﻪ ﭘﯿﺶ ﺷﺮوع ﺷﺪه اﺳﺖ‪ ،‬ﺑﻪ اورژاﻧﺲ ﻣﺮاﺟﻌﻪ ﮐﺮده اﺳﺖ؛ ﻋﻼﺋﻢ دﯾﮕﺮي‬ ‫ذﮐﺮ ﻧﻤﯽﮐﻨﺪ‪.‬ﺳﺎﺑﻘﻪ ي ﺑﯿﻤﺎري ﺧﺎﺻﯽ ﻧﺪارد ﺟﺰ ﻋﻤﻞ ﺟﺮاﺣﯽ روي اﻧﺪام ﺗﺤﺘﺎﻧﯽ راﺳﺖ ﺳﻪ ﻫﻔﺘﻪ ﭘﯿﺶ ﺑﺪﻟﯿﻞ ﺷﮑﺴﺘﮕﯽ ﻓﻤﻮر ﻧﺎﺷﯽ از ﺗﺮوﻣﺎ‪.‬در‬ ‫ﻣﻌﺎﯾﻨﻪ ﺗﻨﻬﺎ ﻧﮑﺘﻪ ﻣﺜﺒﺖ ﺗﺎﮐﯽﮐﺎردي)‪ (HR=110/min‬اﺳﺖ‪.‬ﺑﻬﺘﺮﯾﻦ ﺗﺴﺖ ﺗﺸﺨﯿﺼﯽ ﮐﺪام اﺳﺖ؟‬ ‫ج( ﺳﯽ ﺗﯽ آﻧﮋﯾﻮﮔﺮاﻓﯽ ﻗﻔﺴﻪ ﺻﺪري د( اﮐﻮﮐﺎردﯾﻮﮔﺮاﻓﯽ‬ ‫ب( ﺳﻮﻧﻮﮔﺮاﻓﯽ داﭘﻠﺮ اﻧﺪام ﺗﺤﺘﺎﻧﯽ‬ ‫اﻟﻒ( دي داﯾﻤﺮ‬ ‫‪-9‬ﺧﺎﻧﻢ ‪56‬ﺳﺎﻟﻪ ﺑﺎ ﺗﺸﺨﯿﺺ آﻣﺒﻮﻟﯽ رﯾﻪ ﺑﺴﺘﺮي ﺷﺪه اﺳﺖ‪.‬ﺣﺎل ﻋﻤﻮﻣﯽ ﺑﯿﻤﺎر ﺧﻮب و در ﻣﻌﺎﯾﻨﻪ ﺟﺰ ﺗﺎﮐﯽﭘﻨﻪ و ﺗﺎﮐﯽﮐﺎردي ﺧﻔﯿﻒ ﻧﮑﺘﻪي ﻣﺜﺒﺖ‬ ‫دﯾﮕﺮي ﻧﺪارد‪.‬ﻣﻨﺎﺳﺐﺗﺮﯾﻦ اﻗﺪام درﻣﺎﻧﯽ ﮐﺪام اﺳﺖ؟‬ ‫د( ﺟﺮاﺣﯽ آﻣﺒﻮﻟﮑﺘﻮﻣﯽ‬ ‫ج( ﺗﻌﺒﯿﻪي ﻓﯿﻠﺘﺮ‪IVC‬‬ ‫ب( داروﻫﺎي ﺗﺮوﻣﺒﻮﻟﯿﺘﯿﮏ‬ ‫اﻟﻒ( آﻧﺘﯽ ﮐﻮآﮔﻮﻻﻧﺖ درﻣﺎﻧﯽ‬ ‫‪-10‬ﺧﺎﻧﻢ ‪ 50‬ﺳﺎﻟﻪ اي را ﺑﺪﻟﯿﻞ ﺗﻨﮕﯽ ﻧﻔﺲ ﻧﺎﮔﻬﺎﻧﯽ و درد ﻗﻔﺴﻪ ﺳﯿﻨﻪ ﺑﻪ اورژاﻧﺲ آورده اﻧﺪ‪.‬ﺳﺎﺑﻘﻪي ﻋﻤﻞ ﺟﺮاﺣﯽ زاﻧﻮ را ﺑﻪ ﺳﻪ ﻫﻔﺘﻪ ﭘﯿﺶ ذﮐﺮ‬ ‫ﻣﯽﮐﻨﺪ‪.‬در ﻣﻌﺎﯾﻨﻪ ﺑﺎﻟﯿﻨﯽ‪:‬‬ ‫‪HR=140/min‬‬ ‫‪BP=70/40 mmHg‬‬ ‫‪O2Sat=85% tem=37.4 C‬‬ ‫ﺳﻤﻊ رﯾﻪﻫﺎ ﻧﺮﻣﺎل ا ﺳﺖ و درد و ﺗﻮرم در اﻧﺪام ﺗﺤﺘﺎﻧﯽ را ﺳﺖ ﻣ ﺸﺎﻫﺪه ﻣﯽ ﺷﻮد‪.‬در ‪ ECG‬ﺗﺎﮐﯽﮐﺎردي ﺳﯿﻨﻮ ﺳﯽ دﯾﺪه ﻣﯽ ﺷﻮد‪.‬در ﮔﺮاﻓﯽ ﭘﺮﺗﺎﺑﻞ‬ ‫ﻗﻔ ﺴﻪي ﺳﯿﻨﻪ ﯾﺎﻓﺘﻪي اﺧﺘ ﺼﺎ ﺻﯽ ﻣ ﺸﻬﻮد ﻧﯿ ﺴﺖ‪.‬ﻋﻼوه ﺑﺮ ﺗﺠﻮﯾﺰ اﮐ ﺴﯿﮋن و ﻣﺎﯾﻊ درﻣﺎﻧﻬﯽ ﮐﺪامﯾﮏ از داروﻫﺎي زﯾﺮ در اﺑﺘﺪا ﺑﺮاي ﺑﯿﻤﺎر ﺗﻮ ﺻﯿﻪ‬ ‫ﻣﯽﮐﻨﯿﺪ؟‬ ‫د( ﺗﺠﻮﯾﺰ ﻧﯿﺘﺮوﮔﻠﯿﺴﯿﺮﯾﻦ‬ ‫ج( ﺗﺠﻮﯾﺰ آﻣﻨﯿﻮﻓﯿﻠﯿﻦ‬ ‫ب( ﺗﺠﻮﯾﺰ وارﻓﺎرﯾﻦ‬ ‫اﻟﻒ( ﺗﺠﻮﯾﺰ ﺗﺮوﻣﺒﻮﻟﯿﺘﯿﮏ‬ ‫‪-11‬آﻗﺎي ‪70‬ﺳﺎﻟﻪاي ﺑﺎ ﺳﺎﺑﻘﻪي ﮐﻨﺴﺮ ﭘﺮوﺳﺘﺎت ﺑﺪﻟﯿﻞ ﺗﻨﮕﯽ ﻧﻔﺲ و ﺗﭙﺶ ﻗﻠﺐ ﺑﻪ اورژاﻧﺲ ﻣﺮاﺟﻌﻪ ﻧﻤﻮده اﺳﺖ‪.‬در ﻣﻌﺎﯾﻨﻪي ﺑﺎﻟﯿﻨﯽ ﺗﺎﮐﯽﮐﺎرد اﺳﺖ‬ ‫و ﺳﻤﻊ رﯾﻪﻫﺎ ﻧﺮﻣﺎل اﺳﺖ‪.‬در ‪ ECG‬ﺗﺎﮐﯽﮐﺎردي ﺳﯿﻨﻮﺳﯽ و در ﮔﺮاﻓﯽ ﻗﻔﺴﻪي ﺳﯿﻨﻪ ﮐﺎﻫﺶ ﻃﺮح ﻋﺮوﻗﯽ در ﺳﻤﺖ راﺳﺖ ﻣﺸﺎﻫﺪه ﻣﯽﺷﻮد‪.‬در‬ ‫آزﻣﺎﯾﺸﺎت ﻟﮑﻮﺳﯿﺘﻮز و آﻧﻤﯽ ﺧﻔﯿﻒ وﺟﻮد دارد‪.‬اوره و ﮐﺮاﺗﯿﻨﯿﻦ ﺑﯿﻤﺎر ﺑﺎﻻﺗﺮ از ﺣﺪ ﻧﺮﻣﺎل اﺳﺖ‪.‬آﻧﺰﯾﻢﻫﺎي ﮐﺒﺪي ﻃﺒﯿﻌﯽ اﺳﺖ‪.‬ﮐﺪام ﯾﮏ از اﻗﺪاﻣﺎت‬ ‫زﯾﺮ را ﺑﺮاي ﺗﺸﺨﯿﺺ آﻣﺒﻮﻟﯽ رﯾﻪ در اﯾﻦ ﺑﯿﻤﺎر ﺗﻮﺻﯿﻪ ﻣﯽﮐﻨﯿﺪ؟‬ ‫د( اﺳﮑﻦ ﭘﺮﻓﯿﻮژن رﯾﻪ‬ ‫ج( آﻧﮋﯾﻮﮔﺮاﻓﯽ ﻋﺮوق رﯾﻮي‬ ‫ب( ﺳﯽ ﺗﯽ آﻧﮋﯾﻮﮔﺮاﻓﯽ رﯾﻪ‬ ‫اﻟﻒ( اﮐﻮﮐﺎردﯾﻮﮔﺮاﻓﯽ‬ ‫‪-12‬در آﻧﺎﻟﯿﺰ ﮔﺎزﻫﺎي ﺷﺮﯾﺎﻧﯽ ﺑﯿﻤﺎر ﻣﺒﺘﻼ ﺑﻪ آﻣﺒﻮﻟﯽ رﯾﻮي ﮐﺪامﯾﮏ از ﯾﺎﻓﺘﻪﻫﺎي زﯾﺮ ﻣﻌﻤﻮﻻً ﻣﺸﺎﻫﺪه ﻣﯽﺷﻮد؟‬ ‫د( اﻓﺰاﯾﺶ ‪PO2‬‬ ‫ج( ﮐﺎﻫﺶ ‪PCO2‬‬ ‫ب( اﻓﺰاﯾﺶ ﺑﯽﮐﺮﺑﻨﺎت‬ ‫اﻟﻒ( ﮐﺎﻫﺶ ‪PH‬‬ ‫‪-13‬ﺑﻬﺘﺮﯾﻦ ﺗﺴﺖ ﺗﺸﺨﯿﺼﯽ ﺑﺮاي آﻣﺒﻮﻟﯽ رﯾﻪ ﮐﺪام اﺳﺖ؟‬ ‫‪6‬‬ ‫‪| 7‬‬ multiple choice questions: 1. Which of the following lung lesions does not look like a lung abscess? o A. Wegner o B. Bronchiectasis o C. Necrotising carcinoma o D. Pulmonary Embolism 2. Which sentence is correct? o A. The most common cause of death from pulmonary embolism is recurrence of embolism. o B. If the embolism is not properly treated, the death rate will be more than 70%. o C. In cases of DVT, the probability of embolism is close to one hundred percent. o D. Saddle emboli are usually massive. 3. Which definition is used in a patient with pulmonary embolism with systolic blood pressure less than 90 mm Hg? o A. Massive embolism o B. Submassive embolism o C. Saddle PTE o D. Chronic embolism 4. In which case is there the greatest risk of pulmonary embolism? o A. Malignancy o B. Fracture of lower limb o C. History of previous DVT o D. Pregnancy 5. What is the first treatment in a patient with pulmonary embolism with normal blood pressure? o A. Intravenous fluid injection o B. Anticoagulant drugs o C. Thrombolytic drugs o D. Injection of vasopressor like epinephrine 6. The disease is suspected to be a pulmonary embolism. In the examination, the signs of thrombosis of the deep veins of the right lower limb are clear. In addition patients have tachycardia (HR 120) according to the Wells criteria, what is the minimum score o A. Six o B. Three o C. Four and a half o D. Half past two 7. The patient presented with sudden shortness of breath, hemithorax pain, and hemoptysis, which diagnosis is likely? o A. Myocardial ketosis o B. spontaneous pneumothorax o C. Embolism o D. Viral pleuritis 8. A 64-year-old man went to the emergency room complaining of shortness of breath that started suddenly a few minutes ago. Other symptoms not mentioned. He has no history of any special disease, except surgery on the right lower limb three weeks ago due to femur fracture caused by trauma. The only positive point in the examination is tachycardia (HR=110/min). What is the best diagnostic test? o A. D-Dimer o B. Doppler ultrasound of the lower limb o C. CT angiography of the chest o D. Echocardiography 9. A 56-year-old woman was hospitalized with a diagnosis of pulmonary embolism. The general condition of the patient is good and in the examination except for tachypnea and mild tachycardia, There is no other symptom, which is the most appropriate treatment? o A. Anticoagulant therapy o B. Thrombolytic drugs o C. Installation of IVC filter o D. Surgical embolectomy  ‫‪4‬‬ ‫ب( اﮐﻮﮐﺎردﯾﻮﮔﺮاﻓﯽ‬ ‫اﻟﻒ( اﺳﮑﻦ ﭘﺮﻓﯿﻮژن‪-‬وﻧﺘﯿﻼﺳﯿﻮن رﯾﻪ‬ ‫د( ﺗﺴﺖ ﺳﯽ ﺗﯽ اﺳﮑﻦ رﯾﻪ ﺑﺎ ﺗﺰرﯾﻖ )ﺳﯽ ﺗﯽ آﻧﮋﯾﻮﮔﺮاﻓﯽ رﯾﻪ(‬ ‫ج( ﺗﺴﺖ دي‪-‬داﯾﻤﺮ‬ ‫‪-14‬در ﭼﻪ ﺻﻮرت آﻣﺒﻮﻟﯽ رﯾﻪ ‪ Massive‬ﺗﻠﻘﯽ ﻣﯽﺷﻮد؟‬ ‫ب(ﮐﺎﻫﺶ ﻓﺸﺎر ﺧﻮن ﺷﺮﯾﺎﻧﯽ‬ ‫اﻟﻒ( وﺟﻮد ﻧﺎرﺳﺎﯾﯽ ﻗﻠﺐ راﺳﺖ‬ ‫د( وﺟﻮد ﻫﯿﭙﻮﮐﯿﻨﺰي ﺑﻄﻦ راﺳﺖ‬ ‫ج( ﻫﻤﺮاﻫﯽ ﺗﺮوﻣﺒﻮز وﺳﯿﻊ در ورﯾﺪﻫﺎي ﻋﻤﻘﯽ )‪(DVT‬‬ ‫‪-15‬اﺳﺎس درﻣﺎن ﺗﺮوﻣﺒﻮآﻣﺒﻮﻟﯽ ﻏﯿﺮ ﻣﺴﯿﻮ رﯾﻪ ﮐﺪام اﺳﺖ؟‬ ‫ب( داروﻫﺎي وازوﭘﺮﺳﻮر ﺑﺮاي اﻓﺰاﯾﺶ ﻓﺸﺎر ﺧﻮن‬ ‫اﻟﻒ( داروﻫﺎي ﺗﺮوﻣﺒﻮﻟﯿﺘﯿﮏ‬ ‫د( داروﻫﺎي آﻧﺘﯽ ﮐﻮآﮔﻮﻻﻧﺖ‬ ‫ج( ﻣﺎﯾﻌﺎت ورﯾﺪي‬ ‫‪15‬‬ ‫‪14‬‬ ‫‪13‬‬ ‫‪12‬‬ ‫‪11‬‬ ‫‪10‬‬ ‫‪9‬‬ ‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫‪4‬‬ ‫‪2‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪4‬‬ ‫‪1‬‬ ‫‪1‬‬ ‫‪3‬‬ ‫‪3‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪3‬‬ ‫‪1‬‬ ‫‪4‬‬ ‫‪4‬‬ ‫‪7‬‬ ‫‪| 7‬‬ 10. A 50-year-old woman was brought to the emergency room due to sudden shortness of breath and chest pain. She mentions that she has the history of knee surgery done three weeks ago. In clinical examination 02sat 85% temp=37.4 C BP-70/40 mmHg HR=140/min Auscultation of the lungs is normal and pain and swelling in the lower limbs are observed. Sinus tachycardia is seen in the ECG. In portable graphics a dedicated chest is not evident. In addition to prescribing oxygen and liquid therapy, which of the following drugs should be recommended for the patient at first? o A. Thrombolytic administration o B. Prescribing warfarin o C. Amniophylline administration o D. administration of nitroglycerin 11. A 70-year-old man with a history of prostate cancer visited the emergency room due to shortness of breath and palpitations. In the clinical examination, he has tachycardia. Auscultation of lungs is normal. In ECG sinus tachycardia and in chest x ray decrease in vascular pattern is observed on right side. There are positive tests of leukocytosis and mild anemia. The patient’s urea and creatinine are higher than normal. Liver enzymes are normal. Which of the actions do you recommend the following to diagnose pulmonary embolism in this patient? o A. Echocardiography o B. CT lung angiography o C. Pulmonary vessel angiography o D. Lung perfusion scan 12. Which of the following findings is usually observed in the arterial gas analysis of a patient with pulmonary embolism? o A. Decrease in ph o B. increase in bicarbonate o C. Reduction in pco2 o D. Increase in po2 13. What is the best diagnostic test for pulmo… (The question seems to be incomplete. Could you please provide the complete question along with the options?) A Ventilation perfusion scan of the lung B. Echocardiography C. D-dimer test D. CT scan of the lung with injection (CT angiography of the lung) 14. In what case is massive pulmonary embolism considered? o A. Presence of right heart failure o B. Decreased arterial blood pressure o C. Accompanying extensive thrombosis in deep veins (DVT) o D. Presence of right ventricular hypokinesia 15. What is the basis of non-massive pulmonary thromboembolism treatment? o A. Thrombolytic drugs o B. Vasopressor drugs to increase bp o C. Intravenous fluids o D. Anticoagulant drugs