Thromboembolism

Thromboembolic syndrome is a symptom complex that develops with acute thrombus formation in the blood and lymphatic vessels or in the introduction of an embolus (blood clot, lymph, air) leading to the development of heart attacks (strokes, if it concerns the brain or spinal cord) and gangrene.

Thromboembolism is affected by vessels of the brain, lungs, intestines, heart, limbs. This article deals only with arterial thromboembolism.

Thromboembolism of cerebral vessels

The arterial thromboembolism of the cerebral vessels is most often noted, mainly in the elderly against the background of atherosclerosis, hypertensive disease, but it can also be in young people against the background of heart defects, vasculitis, obliterating endarteritis, etc.

A thrombosis can occur at any time of the day, but is more often noted in a dream or immediately after a dream. The cerebral symptoms are not expressed clearly or the consciousness is absent in most cases, some stun, drowsiness, disorientation is observed. Focal neurological symptoms develop slowly over a period of several hours, or even a day. Manifestations of it depend on the basin of the affected vessel, the extent of the stroke, the state of the collateral circulation. But in all cases, there is a formation of meningeal syndrome or cerebellar syndrome. The same picture is given and brain tumors, so patients should be hospitalized in neurosurgical units. Thrombosis of the sinuses of the dura mater can develop, more often with purulent otitis, mastoiditis, eye diseases, soft facial tissues, sepsis. In this case, against the backdrop of a pronounced local purulent process, the intoxication syndrome develops a clinic of meningeal syndrome.

Tactics: patients who have thromboembolism of cerebral vessels are hospitalized in the departments in accordance with the primary pathology for the treatment of the underlying cause, but lead them in the intensive care unit, with the involvement of a neurologist in the postoperative period.

Thromboembolism of pulmonary arteries

Thromboembolism of the pulmonary arteries - acute occlusion of the pulmonary trunk or branches of the arterial system of the lungs with a thrombus formed in the veins of the large or small circle of blood circulation.

Primary thrombus formation in the pulmonary arteries is extremely rare, in 75-95% of cases. The source of thrombi is the system of the inferior vena cava (predominantly the ileocaval segment), 5-25% of the thrombus comes from the heart cavities and in 0.5-2% of cases system of the superior vena cava. A special threat is represented by streamlined floating thrombi loosely connected at one end to the venous wall. Their separation occurs when straining, coughing, physical exertion, etc. The clinic develops suddenly and rapidly. If there is no sudden death, what happens with thromboembolism of large branches or bilateral pulmonary embolism, the clinic is variable; depends on the prevalence of embolism and the patient's condition before thromboembolism, but in all cases in various variations and dominant manifestations there are: respiratory insufficiency syndrome, hypoxia, hypertension of the small circulation, hypoxia of the consciousness as a hypoxic coma.

More or less dynamically flow thromboembolism of small branches of the pulmonary artery, when the process develops for several hours, and even days. The disease begins with the onset of chest pain as angina pectoris, but they do not have a characteristic irradiation and are associated with breathing (intensified by inhalation). At the same time, dyspnea develops up to 30-60 breaths per minute, but, unlike the pulmonary heart, it does not necessitate a vertical or semi-sidereal position. Often hemoptysis occurs. Tachypnea leads to hyperventilation of the lungs with the development of hypoxemia (oxygen tension in the arterial blood at the level of 70 mm Hg, but at the same time due to leaching carbon dioxide is formed respiratory alkalosis, only in the subsequent develops acidosis. Rhythm. "With pronounced hypotension, there may be oliguria, proteinuria, microhematuria." With the development of a lung infarct, hemoplethritis is often formed.

These patients have the opportunity to conduct instrumental and laboratory studies. A characteristic feature is the presence of hypercoagulation. X-rays reveal the expansion and deformation of the lung root, the high standing of the dome of the diaphragm and the restriction of its mobility, the impoverishment of the pulmonary pattern and the increase in the transparency in the zone turned off from the blood flow (symptom of oligemia). As the infarction of the lung is formed, there is a decrease in the pneumatization of the lung area, the emergence of infiltration sites, intense dimming of a round, triangular, conical shape with a vertex facing the lung root is possible. In a radionuclide study using iodine-131 albumin on scintigraphy, zones of prolapse of accumulation of the drug in capillaries are revealed. Angiopulmonography has a great diagnostic capability, but it is not always possible.

Tactics: emergency care for patients who have thromboembolism of the pulmonary arteries is to be hospitalized or transferred to the intensive care unit with the involvement of a thoracic surgeon or cardiac surgeon.

Thromboembolism of the arteries of the extremities

Thromboembolism is formed when a blood clot or other substrate is displaced (a piece of a valve, a lost catheter, etc.) into the peripheral artery from the proximal parts of the arterial system - the cavities of the left heart, the aorta, the iliac artery. The most common cause is heart disease, especially mitral stenosis. Most often, a thrombus forms in the zone of bifurcations of the aorta and arteries (femoral and popliteal). The entry of the primary embolus, sometimes sufficiently small, leads to a distal and proximal spasm of the vessel and an increase in the ascending and descending thrombus, the so-called "tails".

The clinical picture depends on the level of occlusion of the vessel and the state of blood flow in the limb. Thromboembolism at the aortic level is accompanied by a bilateral defeat of the limbs and proceeds according to the type of Lerish syndrome. Thromboembolism at the level of the iliac artery is accompanied by a one-sided lesion of the limb, with ischemia and absence of pulsation noted throughout the limb, including the common femoral artery from this side. At lower thromboembolisms, the level is determined by the absence of pulsation in the limb segments, but. With "its presence on the common femoral artery. Depending on the condition of the blood supply to the limb, there are 3 degrees of blood flow disturbance and limb ischemia.

• 1 degree - relative compensation of blood supply - is characterized by a fairly rapid disappearance of pain, restoration of sensitivity and function of the limb, the usual color of the skin, capillary pulsation (determined by capillaroscopy).
• 2 degree - the subcompensation of the blood supply - is provided by the limiting tension of the collateral blood flow, which supports the life-support of soft tissues at a critical level; accompanied by severe pain syndrome, limb edema, pallor of the skin, a decrease in their temperature, sensitivity, capillary pulsation, but active and passive movements are preserved. Any violation of collateral blood flow at any time can lead to decompensation of blood supply.
• 3 degree - decompensation of the blood supply - the outcome depends on the duration of ischemia. There are 3 phases of the course of absolute ischemia:
  • reversible changes (the next 2-3 hours) - is manifested by sharp pains in the distal parts of the limb, which quickly disappear, expressed by the waxy pallor of the skin, the absence of all kinds of sensitivity and active movements with the passive ones preserved, the absence of capillary and trunk pulsations;
  • the growth of irreversible changes in soft tissues (up to 6 hours from the moment of occlusion) - the above described clinical picture joins the stiffness of the joints;
  •  irreversible changes, i.e. Biological death of soft tissues - the muscle contracture of the limb is supplemented, brown spots appear on the skin, indicating the onset of gangrene.

Tactics: the ideal option is immediate hospitalization at the center of vascular surgery, but this is rarely possible due to time limitations; hospitalization in the intensive care unit for anticoagulant and disaggregant therapy with the call of the vascular surgeon "on himself" to address the issue of thrombectomy.

Thromboembolism of mesenteric arteries

It is rare to be diagnosed before the operation too, very rarely, as it is clinically accompanied by sudden abdominal pains and periietal symptoms, such patients usually come with diagnoses of peritonitis, perforated stomach ulcer and are urgently operated, thromboembolism is an operational finding.