casos com choque obstrutivo e necessidade de realização de drenagem desses casos, especialmente em nos quadros de choque de etiologia incerta e. geral de derrame pericárdico foi de As alterações hemodinâmicas do tamponamento cardíaco levam a um choque obstrutivo grave e de alta letalidade . Resultados: A presença de choque obstrutivo agudo pôde ser evidenciada pelo aumento da PMAP (de ± para. ± mmHg) (P<) e pela.

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The Portuguese Journal of Cardiology, the official journal of the Portuguese Society of Cardiology, was founded in with the aim of keeping Portuguese cardiologists informed through the publication of scientific articles on areas such choqhe arrhythmology and electrophysiology, cardiovascular surgery, intensive care, coronary artery disease, cardiovascular imaging, hypertension, heart failure and cardiovascular prevention. The Journal is a monthly publication with high standards of quality in terms of scientific content and production.

Since it has been published in English as well as Portuguese, which has widened its readership abroad. It is distributed to all members choqus the Portuguese Societies of Cardiology, Internal Medicine, Pneumology and Cardiothoracic Surgery, as well as to leading non-Portuguese cardiologists and to virtually all cardiology societies worldwide.

Choque diagnóstico e tratamento na emergência

It has been referred in Medline since The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published. SRJ is a prestige metric based on the idea that not all citations are the same.

SJR uses a similar algorithm as the Google page rank; it provides a quantitative and cuoque measure of the journal’s impact.

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Chique years, the treatment of high-risk pulmonary embolism PE was based on two well-defined strategies: In the presence of absolute contraindications or an inadequate response to thrombolysis, for years treatment consisted obstrutuvo surgical embolectomy. However, this is not always immediately available, and in recent years percutaneous techniques have been used in an increasing number of patients.

Currently available techniques for recanalizing the pulmonary arteries can be classified into four types: A combined technique, obstrurivo thrombolysis, has recently been evaluated. This aims to facilitate thrombolysis and thus permit the administration of lower doses of fibrinolytics.

Three orifices in the catheter tip enable three high-pressure jets to form towards the exhaust lumen, which creates a pressure gradient to fragment and aspirate the thrombus.

Various series have shown good results using these new techniques.

However, they have never been assessed in randomized clinical trials, and so doubts remain as to their efficacy and safety. A year-old man, with a history of cerebral arteriovenous malformation AVM treated by radiosurgery, was admitted to the neurosurgical oobstrutivo with right temporo-occipital intraparenchymal hemorrhage extending into the ventricular system for conservative treatment.

On the 14th day after admission he presented sudden-onset severe respiratory failure and shock.

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Thoracic computed tomography CT angiography confirmed the suspicion of bilateral PE, on the left with a saddle thrombus from the pulmonary artery bifurcation to the lobar and segmental branches of the upper and lower left lobes, and on the right with involvement of the upper lobe artery and segmental branches, the interlobar artery and the lobar and segmental branches of the middle and lower lobes.

Transthoracic echocardiography TTE showed marked right ventricular RV dilatation, mild tricuspid regurgitation and pulmonary flow suggestive of pulmonary hypertension PH. The setting was interpreted as high-risk PE and the patient was transferred to the intensive care unit ICU.

In view of the patient’s shock and absolute contraindication for intravenous thrombolysis, it was decided to perform RT and an inferior vena cava filter was placed. However, at the start of the procedure he suffered cardiopulmonary arrest CPA with asystole, reverted after four cycles of advanced life support ALS and obstrhtivo, which resulted in immediate obstrutlvo improvement and slight angiographic improvement.

Inotropic and ventilatory support were withdrawn after four days, low molecular weight heparin was begun on the fifth day, and craniotomy and removal of the AVM were performed two months later. Three months after the acute event, thoracic CT angiography showed complete resolution of the intraluminal thrombi.

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A year-old woman was admitted to the emergency room with shock, respiratory failure and impaired consciousness. She had undergone colorectal surgery 15 days previously.

There was no visible blood loss, although she had had severe rectal bleeding in the previous week. Given the absence of blood pressure response to fluid therapy, elevated troponin T and severe RV dilatation and functional impairment on TTE, it was decided to perform thoracic CT angiography, which revealed bilateral central PE, with subtraction images suggestive of multiple thrombi in the main right and left pulmonary arteries and all the lobar and segmental branches, causing significant luminal obstruction, particularly of the lower lobe arteries.

During the procedure she presented brief self-limited episodes of respiratory arrest and extreme bradycardia, followed by hemodynamic stabilization, withdrawal of vasopressor support and angiographic improvement. However, two hours after the procedure the patient again suffered shock refractory to fluid therapy and inotropic support, with persisting RV dilatation. Given probable rethrombosis, life-saving thrombolysis was performed with alteplase mg over two hours and non-fractionated heparin was administered.

Improvement was seen in hemodynamics and gas exchange, but various bleeding complications obwtrutivo, requiring blood transfusion and leading to multiple organ dysfunction necessitating renal replacement therapy. Invasive ventilation was not required.

Vasopressor support was discontinued after obstrutivoo days and dialysis after 10 days. Repeat TTE on the 11th day showed normal-sized right cardiac chambers, but pulmonary flow still suggested PH.

She was discharged choue 58 days. A year-old woman, obese and with peripheral venous insufficiency, was admitted to the emergency room with syncope, sudden-onset dyspnea, epigastric pain, severe respiratory obsttrutivo and shock.

She had begun taking oral contraceptives three days previously. Spontaneous return of circulation occurred several times but was immediately followed by CPA. Given the suspicion of obstructive shock due to high-risk PE, intravenous thrombolysis was performed with a mg bolus of alteplase, which resulted in spontaneous permanent return of circulation after around 45 min of ALS.

Thoracic CT angiography obshrutivo thromboembolic foci in the distal portion of both pulmonary arteries, in the origin of several lobar arteries, and most noticeably in the segmental branches of the right lower lobe artery Figure 2. The patient remained under ventilatory and inotropic support for 10 days, followed by a favorable clinical course and complete neurological recovery. The patient was discharged after 37 days. Computed tomography angiography, axial view with intravenous contrast, showing perfusion defects in both pulmonary arteries and the origin of several lobar arteries.

A Transthoracic echocardiogram in apical 4-chamber view in the emergency room revealing marked dilatation of the right chambers and straightening of the ventricular septum; B transthoracic echocardiogram one month after discharge showing no significant abnormalities.

A study choquw Meneveau et al. Surgical embolectomy is usually reserved for patients requiring cardiopulmonary resuscitation, when there is obstrutjvo contraindication to thrombolysis, as a rescue treatment when there is no response to intensive medical and thrombolytic therapy, and in those with patent foramen ovale and intracardiac thrombi.

There have been few studies comparing surgical embolectomy with thrombolysis, all of them retrospective. Percutaneous treatment of high-risk PE has also evolved. According to the current European Society of Cardiology guidelines and the American Heart Association Scientific Statement, catheter-based interventions can be performed as an alternative to thrombolysis when there are absolute contraindications, as adjunctive therapy chque thrombolysis has failed to improve hemodynamics, or as an alternative to surgery if the latter is unavailable or contraindicated.

Percutaneous techniques can be classified chouqe three types: The latter two are often used when there is relative contraindication to obdtrutivo thrombolysis, since local thrombolysis carries a lower risk of bleeding complications.

The evidence on catheter-based interventions is limited to case reports, retrospective analyses of small series and systematic reviews; there have been no randomized clinical trials comparing percutaneous treatment with systemic thrombolysis.

A systematic review by Shaft et al. Four patients had major bleeding and eight No event-related deaths were reported in long-term follow-up In all the series and case reports reviewed, RT with or without local thrombolysis invariably showed good clinical results and relatively low mortality in centers with experienced operators. As pointed out above, the evidence indicates that combined pharmacomechanical therapy is more effective than mechanical thrombectomy alone, although the latter remains the preferred approach in patients with absolute contraindication to thrombolysis.


The question remains as to whether local catheter-directed thrombolysis is superior to obsturtivo therapy in patients with no or only obstrutiivo contraindication to thrombolysis.

Despite the lower doses of thrombolytics, pharmacomechanical therapy was associated with more rapid hemodynamic recovery. Two of our patients were referred due to contraindication to thrombolysis and the other for failure of thrombolysis to improve hemodynamics. At the time of the procedure two patients were choquw and ventilated, and all were under inotropic support.

The right femoral vein was punctured and a 7F introducer was inserted, followed by arteriography of the pulmonary artery trunk and selective arteriography of cjoque right and obstrufivo pulmonary arteries using a 6F angled pigtail catheter. The catheter was activated proximally to distally, with one or two complete passes. The procedure was repeated for the affected lobar arteries and for the contralateral pulmonary artery if necessary.

An angiographic review was performed at the end of the procedure Figure obstrutibo. The intervention should be halted as soon as hemodynamic recovery is confirmed or if the total activation time recommended by the manufacturer is reached, irrespective of the final angiographic result. In the last patient, it was decided to implant a temporary transvenous pacemaker by a femoral route at the beginning of the procedure.

Following the procedure, all patients were transferred to cboque ICU. As well as complications related to vascular access, contrast reactions and anticoagulation, there are complications specifically related to percutaneous techniques, particularly the risk of perforation leading to hemoptysis or tamponade, pulmonary infarction, and reperfusion syndrome with alveolar hemorrhage.

Hemoglobinuria is common and should not be confused with hematuria. Teamwork is essential to minimize complications. The team should include an interventional cardiologist lbstrutivo experience in this area, an anesthetist and an internist who are responsible for the initial assessment and referral of the patientand an intensivist or cardiologist-intensivist able to deal with periprocedural complications.

The three obwtrutivo presented are examples of the application and results of current percutaneous techniques for the treatment of high-risk PE, which may even be considered first-line options in selected patients. In the light of current knowledge, our center is about to establish a protocol that includes concomitant local infusion obstrtivo thrombolytics in selected patients without absolute contraindication to thrombolysis. In the absence of controlled trials directly comparing different therapeutic options, the best strategy should be decided case by case by a multidisciplinary team, always bearing in mind the factors specific to each patient, the availability of different therapeutic options and the center’s experience.

The authors have no conflicts of interest to declare. Please cite this article as: Previous article Next article. June Pages Percutaneous thrombectomy in the treatment of acute pulmonary embolism: Initial experience of a single center. Rita Faria a. This item has received.

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Show more Show less. Three orifices in the catheter tip enable three high-pressure jets to form towards the exhaust lumen, which creates a pressure gradient to fragment and aspirate the thrombus. Computed tomography angiography, axial view with intravenous contrast, showing perfusion defects in both pulmonary arteries and the origin chooque several lobar arteries.

A Transthoracic echocardiogram in apical 4-chamber view in the emergency room revealing marked dilatation of the right chambers and straightening of the ventricular septum; B transthoracic echocardiogram one month after discharge showing no significant abnormalities. Estimated case fatality rate obstrtivo pulmonary embolism, to Am J Cardiol, 93pp. Guidelines on the diagnosis and management of acute pulmonary embolism.

Obsrtutivo Heart J, 29pp. Circulation,pp. Catheter-based reperfusion treatment of pulmonary embolism.