Phlegmasia Cerulea Dolens, Massive Iliofemoral DVT, ndi Zowawa Zowawa za Blue kapena White Leg Emergency¶

Phlegmasia cerulea dolens (lomasuliridwa kuti "kutupa kowawa kwa buluu") ndivuto lalikulu, lomwe limawopseza miyendo komanso kuwopseza moyo chifukwa cha mtsempha wakuya kwambiri wa thrombosis (DVT) womwe umatsekereza 100 peresenti ya njira zonse zakuya ndi zowongolerera zomwe zimatuluka m'mitsempha yakumanzere ndi kumanzere. ntchafu yapamwamba. Mosiyana ndi DVT ya m'miyendo wamba, pomwe magazi amatha kubwereranso kumtima kudzera m'mitsempha yaying'ono yolumikizirana, kutsekereza kwathunthu kwa mpweya kumatseketsa magazi obwera mkati mwa mwendo popanda potuluka. M'maola ochepa chabe, kupanikizika kwa hydrostatic mkati mwa mabedi a capillary kumakwera kasanu, kukakamiza malita amadzimadzi kulowa m'minyewa yozungulira, kutembenuza mwendo wonse kuchokera ku groin kupita ku zala zala zolimba komanso kutupa kwambiri, kuchititsa khungu kukhala lofiirira-buluu, kukweza matuza amadzimadzi otuluka m'magazi (mafupa akunja otuluka m'mitsempha) Matenda a compartment, venous gangrene, hypovolemic circulatory shock, ndi kufatal pulmonary embolism. Ngati wina ayamba kutupa mwadzidzidzi, mopweteka, kutupa kwa mwendo wonse (kuyambira mchiuno mpaka kuphazi) kutsatizana ndi kuyera koyera (phlegmasia alba dolens, kapena "mwendo wamkaka") kapena kusinthika kofiirira-buluu (phlegmasia cerulea dolens), imbani foni kwanuko. manambala angozi nthawi yomweyo. Pamene mukuyembekezera mayendedwe adzidzidzi, funsani malangizo okhudzana ndi mitsempha ndi matenda pulmonary embolism ndi deep vein thrombosis (DVT), pachimake chiwalo cha ischemic, arterial occlusion, ndi pulseless extremity,ndi Kutupa kwa cellulitis, erysipelas, lymphangitis, ndi sepsis.

Chifukwa chotchinga chachikulu chomwe chili mumtsempha wa m'chiuno pomwe pa khomo la vena cava yotsika, malamulo anu awiri ofunika kwambiri achipatala ndi osati kutikita, kusisita, kufinya, kapena kugwiritsa ntchito makina opondereza ng'ombe pa mwendo wotupa (womwe ungathe kumeta chingwe chachikulu chapamtima) mwendo womwe uli pamwamba pa mlingo wa mtima** (mosiyana ndi acute arterial ischemia, pamene kukwera kumawonjezera njala, kukweza mwendo wotsekedwa ndi venous kumagwiritsa ntchito mphamvu yokoka kuti kuchepetsa kuthamanga kwa magazi ndi kutsika kwa chipinda).

Chitani izi tsopano¶

1. Imbani foni nambala yanu yazadzidzi nthawi yomweyo ndikupempha zoyendera kupita kuchipatala ndi Vascular Surgery and Interventional Radiology. Imbani 911 ku United States ndi Canada, 112 kudutsa European Union, 999 ku United Kingdom, 000 ku Australia, kapena onani mndandanda wathu wa manambala angozi. Nenani momveka bwino kuti: "Oganiziridwa kuti phlegmasia cerulea dolens / massive iliofemoral deep vein thrombosis: mwendo wonse kuchokera ku groin mpaka kuphazi ndi wolimba kwambiri, wotupa kwambiri, wopweteka kwambiri, ndipo umakhala wofiirira-buluu."
2. Mukhazikitseni wodwalayo pabedi nthawi yopumula (musamulole kuti ayende ku bafa kapena kupita ku galimoto). Kuyenda kumapangitsa minofu yamphamvu ya ntchafu ndi chiuno kuti igwirizane ndi chiphuphu chachikulu chomwe chili m'kati mwa minyewa yachikazi ndi ya m'chikazi, yomwe imatha kutulutsa chitseko chachikulu chamkati mkati mwa mtima ndi m'mapapu*
3. OSATI kutikita, kusisita, kukanda, kapena kuphatikizira ntchafu kapena chibayo pa mwendo. Chifukwa phlegmasia imayambitsa kupweteka koopsa kofanana ndi kavalo wa charley kapena ntchafu, achibale omwe ali ndi cholinga chabwino nthawi zambiri amasisita ntchafu kapena mwana wa ng'ombe kapena lamba pamanja kapena mfuti yothamanga. Kufinya kulikonse kwakunja kumatha kutulutsa embolus yakupha kapena kuphwanya mabedi a capillary a ischemic.
4. Chotsani mathalauza onse, masokosi, nsapato, zibangili za akakolo, ndi mphete zakumapazi nthawi yomweyo, ndipo kwezani mwendo pang’ono pa mapilo ofewa (pafupifupi madigiri 15 mpaka 30 pamwamba pa mlingo wa mtima). Dulani mathalauza othina kapena thukuta ndi lumo m’malo mokoka mwendo. Kukwera pang'onopang'ono pamwamba pa mlingo wa mtima kumachepetsa kuthamanga kwa hydrostatic venous mkati mwa capillary network ndipo kumathandizira kuchepetsa kupita ku compartment syndrome (pokhapokha ngati mitsempha ya mitsempha yatha kale ndipo kukwera kumawonjezera kupweteka kwa phazi la ischemic, motero sungani mwendo ndi mtima).
5. OSATI kupaka zoyatsira zotenthetsera, mabotolo a madzi otentha, kapena ayezi pakhungu la buluu kapena loyera. Khungu la phlegmasia cerulea dolens lasokoneza kwambiri microcirculation ndi kusamva bwino; zoyatsira zotenthetsera zimafulumizitsa kufunidwa kwa okosijeni wa minofu ndikuwotcha kwambiri, pomwe ayezi amayambitsa reflex arterial vasospasm yomwe imathandizira kuphulika kwa venous.
6. Ikani wodwalayo mosamalitsa NPO (pakamwa) ndi kuyang'anira ngati akupuma mwadzidzidzi, kupweteka pachifuwa, kapena kukomoka. Chifukwa chakuti madzi ochuluka kwambiri mkati mwa ntchafu ndi mwendo umodzi wotupa amatha kutsekereza ** 3 mpaka 5 malita (0.8 mpaka 1.3 malita)** magazi ndi madzi a m'magazi kutuluka m'magazi ambiri, ofooka kwambiri, ofooka kwambiri kutsika kwa magazi) ngakhale popanda kukhetsa magazi kunja, ndipo amafunikira kukonzeka mwachangu kwa catheter-directed thrombolysis kapena opaleshoni ya thrombectomy.

Mtengo wosankha: kupweteka kwambiri, kutupa, kufiyira, koyera, kapena kupendekera kwa mwendo wabuluu¶

flowchart TD
    Start["Kupweteka Kwambiri kwa Miyendo Mwadzidzidzi, Kutupa, kapena Kusintha Kwa Mtundu (Ofiyira, Oyera, kapena Ofiirira-Buluu)"] --> CheckExtent{"Khwerero 1: Yang'anani Kutupa & Kugawidwa Kwa Mitundu: Kodi mwendo YONSE watupa kuchokera pa ntchafu/ntchafu mpaka kuphazi?"}

    CheckExtent -->|"INDE: Kutupa kwakukulu kwa mwendo wonse kuchokera ku groin mpaka kumapazi"| CheckColor{"Gawo 2: Mwendo Wotupa Kwambiri Ndi Mtundu Wanji?"}

    CheckColor -->|"Ma Mottled Cyanotic Purple-Blue or Violaceous, Rock-Hard Woody Edema, Agonizing Pain, Skin Blusters (Bullae), Mapazi Ofooka kapena Osapezeka"| PCD["PHLEGMASIA CERULEA DOLENS (FULMINANT VENUUS OUTFLOW OCLUSION): Imbani 911 / 112 / 999 Nthawi yomweyo; Zenera la Maola 4 mpaka 6 Kuti Mupewe Gangrene ya Venous, Kudulidwa, ndi Kugwedezeka"]

    CheckColor -->|"Stark Waxy White / Wotumbululuka ('Mwendo Wamkaka'), Edema Yovuta Kuchokera Kumapazi Kupita Kumapazi, Khungu Lofunda kapena Lozizira, Mapazi Akadali Palpable"| PAD["PHLEGMASIA ALBA DOLENS (SUBTOTAL ILIOFEMORAL DVT WITH ARTERIAL SPASM): Imbani Ntchito Zadzidzidzi Nthawi yomweyo; Kalambulabwalo wa Phlegmasia Cerulea Dolens"]

    CheckExtent -->|"AYI: Mwendo suli wotupa (kapena wopunduka), Stark Pale/Mottled, Ice-Cold, Pulseless, with Foot Drop / numbness"| AcuteArterial["ACUTE ARTERIAL LIMB ISCHEMIA (ARTERIAL EMBOLISM KAPENA THROMBOSIS): Imbani Ntchito Zadzidzidzi Nthawi yomweyo; Khalani Wodalira Mwendo (Pang'ono Pansi Pamtima), OSATI KUKWEZA"]

    CheckExtent -->|"AYI: Kutupa kumangopita kumunsi kwa mwendo/mwana wa ng'ombe kokha, KAPENA chigamba chofiira chamoto chokhala ndi malungo"| DiffCellDVT{"Khwerero 3: Siyanitsa Ng'ombe Yokhazikika DVT vs. Acute Cellulitis vs. Necrotizing Fasciitis"}

    DiffCellDVT -->|"Khungu lofiyira lotentha limafalikira mwachangu, kutentha thupi kwambiri / kuzizira, kuwonda kwa lymph node, malire owoneka bwino kapena osadziwika bwino."| CheckNecFasc{"Kodi pali kupweteka kopitilira muyeso, matuza ofiirira, dzanzi pakhungu, kapena crepitus?"}

    CheckNecFasc -->|"INDE"| NecFasc["NECROTIZING FASCIITIS (KUDYA THUPI): Imbani Ntchito Zadzidzidzi Nthawi yomweyo Kuti Muwononge Opaleshoni Yodzidzimutsa"]
    CheckNecFasc -->|"AYI"| Cellulitis["Acute Limb Cellulitis kapena Erysipelas: Fufuzani Kuwunika Kwachipatala Kwatsiku Limodzi Kwa Ma Antibiotics a Oral kapena IV (ndi Duplex Ultrasound ngati DVT Co-Exists)"]

    DiffCellDVT -->|"Kutupa kwa ng'ombe (3 cm kapena kupitilira apo kuposa ng'ombe ina), kupweteka kwambiri, mitsempha yapakhungu, opaleshoni yaposachedwa / kusayenda / khansa."| StandardDVT["Wokayikira Distal kapena Femoropopliteal DVT: Musati Masisita; Pitani Mwamsanga ku Dipatimenti Yadzidzidzi kwa Venous Duplex Ultrasound ndi Anticoagulation"]

    PCD --> PreHospBundle["Protocol ya Pre-Hospital: Mpumulo Wamtheradi, Kusisita ZERO, Dulani Zovala Zolimba, Kukweza Miyendo Yofatsa (15 mpaka 30 Madigiri), NPO Yolimba, Heparin Yosasinthika Yomwe Imodzi + Catheter-Directed Mechanical Thrombectomy kapena Surgical Venous Thrombectomy"]
    PAD --> PreHospBundle

Pathophysiology: kupita patsogolo kwa magawo atatu kuchokera ku DVT yosavuta kupita ku mwendo wamkaka, mwendo wabuluu, ndi venous gangrene.¶

Kuti mumvetse chifukwa chake phlegmasia cerulea dolens imachita mosiyana kwambiri ndi magazi omwe amaundana mwa ng'ombe, zimathandiza kufufuza mawonekedwe a venous ngalande m'munsi ndi m'chiuno. Kawirikawiri, magazi omwe amaponyedwa m'mwendo kudzera mu mitsempha ya chikazi amabwerera kumtima kudzera mu machitidwe awiri ogwirizana: mphamvu yapamwamba ** deep venous system ** (anterior tibial, posterior tibial, peroneal, popliteal, deep femoral [profunda femoris], femoral, ndi iliac mitsempha) ndi dongosolo * * lateral colsuperficial mtsempha waung'ono wa saphenous, ndi maukonde olumikizana m'chiuno).

Mumtsempha wakuya wa ng'ombe kapena mitsempha yachikazi, profunda femoris (mtsempha wa ntchafu) ndi mtsempha waukulu wa saphenous umakhala wotseguka. Magazi amangodutsa magaziwo kudzera m'misewu yachikoleyi, zomwe zimapangitsa kutupa pang'onopang'ono mpaka pang'ono m'munsi mwa mwendo popanda kuopseza kupulumuka kwa mwendo. Vuto likamatuluka m'mwamba kuti litseke **mtsempha wamba wachikazi ** ndi mtsempha wakunja / wamba wa Iliac mu groin ndi chiuno, komabe, zotuluka zofunikazi zimatsekeka. Kuwonongeka kwachipatala kumadutsa magawo atatu osiyana a hemodynamic:

Gawo 1: Phlegmasia Alba Dolens ("Mwendo Wamkaka" kapena Mwendo Woyera Wopweteka)¶

• Kutsekeka kwa venous kokhala ndi ma patent micro-collaterals: Thrombus yayikulu imatchinga thunthu lalikulu la venous, pomwe kachigawo kakang'ono ka minyewa yapakhungu ndi m'chiuno imakhalabe yotseguka.
• Kusuntha kwakukulu kwa madzimadzi a hydrostatic popanda capillary stasis: Kuthamanga kwa venous kumakwera kwambiri, ndikuyendetsa madzi ochuluka a plasma kudutsa makoma a capillary kupita ku subcutaneous interstitial space (Starling force force). Because the subcutaneous tissue fills with high-pressure clear edema fluid that physically compresses the tiny superficial subpapillary dermal capillaries (and triggers reflex sympathetic vasospasm of the skin arterioles), the skin over the entire thigh and calf turns stark, chalky, milky white (phlegmasia alba dolens).
• Dzina Lakale ("Mwendo Wamkaka"): Kwa zaka mazana ambiri, madokotala anaona kutupa kwadzidzidzi, kowawa koyera kwa mwendo wonse wakumanzere kwa amayi kumapeto kwa trimester yachitatu ya mimba kapena atangobereka kumene (pamene chiberekero cholemera kwambiri chimakanikizira mtsempha wakumanzere ndi msana) ndipo molakwika ankakhulupirira kuti mkaka wa m'mawere unalowa m'mbuyo.
• ** Chifukwa chiyani ndi gawo lochenjeza lofunika kwambiri: ** Pa siteji ya * alba *, kulowetsedwa kwa mitsempha kudakalibe, mpweya ukufikabe m'maselo a minofu, ndipo ischemia ya minofu siinayambe. Komabe, popanda kutsekeka m'mitsempha mwachangu komanso kutsika kwa venous, mpaka 40 mpaka 50 peresenti ya phlegmasia alba dolens milandu imatsekereza minyewa ing'onoing'ono yotsalayo ndikupita ku fulminant phlegmasia cerulea dolens.

Gawo 2: Phlegmasia Cerulea Dolens (Myendo Wopweteka Wabuluu)¶

• 100 peresenti kutsekeka kwakuya NDI chikole/kutuluka kwa venous: Pamene thrombosis imayenda motalikirana mpaka kutheratu mtsempha uliwonse wotsalira (kuphatikiza profunda femoris, mphambano ya saphenous, ndi minyewa yamkati/yakunja), *magazi azizindikiro amatha kuchoka pamlendo *m’mwendo ndi kugunda kwa mtima kulikonse.
• Kuthamanga kowirikiza kasanu mu capillary hydrostatic pressure ndi malo achitatu: Pakadutsa maola 2 mpaka 6, kuthamanga kwa hydrostatic mkati mwa ma venules ndi ma capillaries kumakwera mpaka 50 mpaka 80 mmHg (kasanu zachilendo). Mwendo umafufuma mochulukira, kuthamangitsa 3 mpaka 6 malita a magazi ndi madzimadzi mkati mwa malekezero.
• Kusakhazikika kwa oxygen ndi cyanosis: Maselo ofiira amagazi otsekeka amakhala osasunthika mkati mwa timitsempha tambirimbiri ta dermal ndi subdermal, momwe minofu yozungulira imachotsa molekyu iliyonse ya okosijeni ku hemoglobin. Kuchuluka kwa hemoglobin ya deo oxygenated (>5 g/dL mu capillary bed) tembenuzira mbali yonse kuchokera ku groin crease kupita ku nsonga za zala ** zozama, zakuda, zofiirira zamtundu wa buluu-buluu kapena wakuda-buluu **, nthawi zambiri zimatsagana ndi pinpoint dermal hemorrhages (**petechiae ** ndi purpura) pamene ma capillaries amaphulika pansi pa kupanikizika.
• Kugwa kwachiwiri ndi matenda a venous compartment: Monga momwe kupanikizika kwa minofu mkati mwa zipinda zotsekedwa za ng'ombe ndi ntchafu zimakwera pamwamba pa 30 mpaka 50 mmHg (ndipo pamapeto pake zimapitirira systolic arterial blood pressure), minyewa yokhazikika, yodzaza madzimadzi ** imaphwanya mitsempha yotsekeka, ngakhale kutuluka kunja kwa magazi kulibe * Mitsempha yokha. Panthawiyi, kuphulika kwa phazi la distal (** dorsalis pedis ** ndi ** posterior tibial **) kutha, phazi limatembenuza madzi oundana, ndipo mitsempha yamaganizo imayamba kufa ( dzanzi ndi ziwalo).

Gawo 3: Venous Gangrene (Irreversible Tissue Necrosis)¶

• **Pakati pa maola 4 mpaka 12 osathandizidwa ndi phlegmasia cerulea dolens **, kumangidwa kwathunthu kwa capillary perfusion kumapangitsa kuti khungu likhale lolimba kwambiri, mafuta ochepa, ndi minofu ya mafupa (**venous gangrene **).
• Zizindikiro zachipatala: Matuza amadzimadzi akulu, olimba odzazidwa ndi magazi ofiirira kapena akuda (madontho a hemorrhagic) amaphulika phazi, akakolo, ndi kumunsi kwa mwendo; khungu limafooka; zala zam'mapazi ndi zakumaso zimasanduka zakuda komanso zosasangalatsa; Kuwonongeka kwakukulu kwa minofu yakufa ya mwendo kumasefukira m'magazi ndi potaziyamu (**hyperkalemia **), myoglobin (**rhabdomyolysis ndi kulephera kwa impso ), ndi lactic acid ( kwambiri metabolic acidosis **).
• Ziŵerengero za imfa ndi kudulidwa ziŵalo: Pamene phlegmasia cerulea dolens ifika ku venous gangrene, kudula mwendo waukulu kumafunika mu **20 mpaka 50 peresenti ya opulumuka **, ndipo imfa zonse m'chipatala zimafika 25 mpaka 40 peresenti.

Chifukwa chiyani mwendo wakumanzere umamenyedwa 3 mpaka 4 nthawi zambiri kuposa Kumanja: May-Thurner Syndrome (Iliac Vein Compression)¶

Chochititsa chidwi chachipatala cha phlegmasia alba dolens ndi phlegmasia cerulea dolens ndi chakuti ** 75 mpaka 85 peresenti ya zochitika zonse zimachitika pa mwendo wakumanzere ** osati mwendo wamanja. Kusatetezeka kwa anatomical uku kumachitika ndi May-Thurner syndrome (iliocaval compression syndrome):

1. Mtsempha wa anatomical scissor mu chiuno: Mu thupi la munthu, pamene mtsempha wa m'mimba umatsikira kumanzere kwa msana wa lumbar ndikugawanika kumanja ndi kumanzere kwa mitsempha yodziwika bwino ya iliac, yokhuthala, yolimba, yothamanga kwambiri ** kumanja wamba mtsempha wamphuno umadutsa kutsogolo kwa khoma lopyapyala, kumanzere mwamphamvu, kumanzere kumanzere * fupa la mafupa a **chisanu chachisanu cha lumbar vertebra (L5) **.
2. Kugunda kwamphamvu kosalekeza ndi "venous spurs": Ndi kugunda kwamtima kumodzi (kupitilira 100,000 patsiku), mtsempha wakumanja wakumanja umakhota mtsempha wakumanzere kumanzere kumanzere. Kwa zaka zambiri, kupsa mtima kwamakina kumeneku kumapangitsa kuti mtsempha wamkati (intima) wa mtsempha wakumanzere ukhale ulusi, ma synechiae, ndi milatho yamkati yamkati ("venous spurs") yomwe imachepetsa njira ya mitsempha ndi 50 mpaka 80 peresenti.
3. Zoyambitsa mwadzidzidzi: Pamene kugunda kwachiwiri kwa prothrombotic kumachitika, monga matenda aakulu (khansa ya pancreatic, mapapo, ovarian, kapena ya m'mimba, yomwe imayambitsa 20 mpaka 40 peresenti ya phlegmasia cerulea dolens cases), mimba, kugwiritsa ntchito kulera m'kamwa, opaleshoni yaikulu ya m'chiuno kapena mafupa, opaleshoni yochotsa mafupa, (HIT), kapena inferior vena cava (IVC) thrombosis, kutsekeka kwa mtsempha wakumanzere kutsekeka nthawi yomweyo, zomwe zimayambitsa kuphulika kwa thrombosis kutsika mwendo wonse wakumanzere.

Kusiyanitsa Phlegmasia Cerulea Dolens, Phlegmasia Alba Dolens, Acute Arterial Ischemia, ndi Acute Cellulitis¶

Chifukwa kusazindikira bwino phlegmasia cerulea dolens ngati bakiteriya cellulitis (ndi kutumiza wodwalayo kunyumba pakamwa mankhwala opha tizilombo) kapena kusokoneza ndi arterial embolism (ndi kupachika mwendo pansi pa bedi) kumabweretsa kutayika kwa miyendo kapena imfa, madokotala amagwiritsa ntchito tebulo lofananiza la bedi:

Momwe mungayendetsere cheke chotetezeka, chopanda manja pamitsempha ndi hemodynamic kunyumba¶

Mukudikirira ambulansi, sonkhanitsani zidziwitso zoyambira kwa dokotala wa opaleshoni ya mitsempha popanda kufinya mwendo:

1. Yang'anani malire a kumtunda kwa kutupa pamimba ndi pamimba: Yang'anani chiuno cha m'chiuno (inguinal ligament), matako, ndi khoma lakumunsi kwa mimba. Ngati mtundu wofiirira wabuluu kapena minyewa yopindika imadutsa pamimba pamimba kapena pachifuwa, magaziwo amafika ku common iliac vein kapena inferior vena cava (IVC).
2. Onani kumverera kwa chala, kuyenda, ndi matuza ("The Venous 6 Ps"):
3. Gwira chala chachikulu kwambiri mopepuka: Funsani ngati khungu likumva bwino, likunjenjemera (paresthesia), kapena dzanzi (anesthesia).
4. Yang'anani kugwedezeka kwa chala: Funsani wodwalayo kuti agwedeze zala zake mmwamba ndi pansi (**musakankhire phazi lake mmwamba mwa inu nokha , chifukwa kachitidwe kachikale ka Homans ndikosadalirika kumankhwala ndipo kumatha kutulutsa magazi). Kulephera kusuntha zala zala kapena akakolo ( phazi dontho **) kumasonyeza yovuta compartment ischemia.
5. Yang'anani matuza a pakhungu: Onani ngati matuza owoneka bwino (serous bullae) kapena matuza akuda magazi (hemorrhagic bullae) apanga; matuza amagazi amawonetsa kuyandikira kwa venous gangrene.
6. Yang'anirani kugunda kwa mtima ndi zizindikiro zodzidzimutsa: Chifukwa 3 mpaka 5 malita amadzimadzi amatha kulowa mkati mwa mwendo, kugunda kwamtima kupitirira 100 mpaka 120 kugunda pa mphindi, khungu lotukuta lotukuta, kapena chizungulire zimasonyeza hypovolemic shock.
7. Konzani mndandanda wa mbiri yachipatala: Lembani khansa iliyonse yodziwika, zochepetsera magazi zomwe zilipo panopa (ndi mlingo uliwonse womwe mwaphonya), kukhalapo kwa IVC fyuluta, ndi kukhudzana kulikonse ndi heparin mkati mwa masiku 5 mpaka 14 apitawa. Kuwonekera posachedwa kwa heparin m'chipatala kumatha kuyambitsa Heparin-Induced Thrombocytopenia (HIT), chitetezo chamthupi chomwe chimayambitsa kuphulika kwa mitsempha yamagazi ndi mitsempha yamagazi yomwe imafuna nthawi yomweyo anticoagulation ya non-heparin (argatroban kapena bivalirudin).

Kutsitsimutsa chipatala ndi njira zotsimikizirika zopulumutsa miyendo¶

Wodwala yemwe ali ndi phlegmasia cerulea dolens akafika ku dipatimenti yazadzidzidzi, chithandizo chimangoyang'ana pakuchepetsa kwa venous nthawi yomweyo:

1. Immediate Intravenous Anticoagulation and Fluid Resuscitation: Madokotala amapereka bolus mtsempha ndi kulowetsedwa kosalekeza kwa unfractionated heparin (UFH) (kapena argatroban ngati HIT ikuganiziridwa) pamodzi ndi aggressive intravenous isotonic crystal crystal fluloids kuchokera ku impso ndi respovoshyomic hypovoshyomic. Mwendo umakhala wokwera kwambiri ( 30 mpaka 60 madigiri **) kuti achepetse edema.
2. Bedside Duplex Ultrasound ndi CT Venography (CTV): Kupanikizika kwa bedi kumatsimikizira thrombus m'mitsempha yachikazi ndi popliteal mumphindi, pamene pelvic CT Venography imapanga mapu a kumtunda kwa magazi mu mitsempha ya m'mitsempha ya mtsempha ndi kutsika kwa vena cava ndikuzindikiritsa kupanikizika kwa chiuno *May-Thurner
3. Active Clot Removal (Endovascular vs. Open Surgical Thrombectomy): Chifukwa zochepetsera magazi zokha sizingathe kusungunula chotchinga chachikulu chotchinga mwachangu kuti chiteteze zilonda zam'mitsempha, Society for Vascular Surgery (SVS)* ndi European Society for Vascular Surgery (ESVS) malangizo amachotsa mwachangu:
4. Catheter-Directed Mechanical Thrombectomy (PMT) ndi Thrombolysis (CDT): Akatswiri ochitapo kanthu amapititsa patsogolo chikhumbo chachikulu kapena ma catheter a rheolytic (monga ClotTriever, Indigo, kapena AngioJet) kapena ma catheters othandizidwa ndi ultrasound (EKOS infusing to **alteplase) [alteplase] Sungunulani chikhomo cha iliofemoral, chotsatiridwa ndi **iliac vein stenting ** ngati May-Thurner compression lesion imapezeka pa intravascular ultrasound (IVUS).
5. Otsegula Opaleshoni Iliofemoral Venous Thrombectomy: Odwala omwe ali ndi fulminant venous gangrene, kugwa kwa mtsempha, kapena zotsutsana ndi mankhwala a thrombolytic, maopaleshoni amitsempha amavumbulutsa mtsempha wa chikazi mu groin, amadutsa Fogarty balloon catheter yokhala ndi minyewa yomangika ** bandeji** kuti atulutse magaziwo. Ngati kupanikizika kwa chipinda kumakhalabe kupitirira 30 mmHg pambuyo pobwezeretsa kutuluka kwa venous, **chipinda cha ng'ombe ya ng'ombe inayi ** imachitidwa.

Nambala zangozi zachigawo ndi ndondomeko za bungwe¶

Oganiziridwa kuti phlegmasia cerulea dolens kapena phlegmasia alba dolens amafunikira mayendedwe ambulansi mwachangu kupita ku chipatala chachikulu chapamwamba chomwe chili ndi 24-hour Vascular Surgery, Interventional Radiology, and Intensive Care:

• United States ndi Canada: Imbani 911. Pemphani zoyendera kupita ku dipatimenti yayikulu yachipatala yomwe ili ndi luso la Vascular Surgery ndi Interventional Radiology (musapite ku chipatala chachangu). Imayendetsedwa pansi pa Society for Vascular Surgery (SVS), American Venous Forum (AVF), ndi malangizo a American Heart Association (AHA).
• United Kingdom: Imbani 999 kuti mupeze ambulansi yofulumira kupita ku chipatala chachikulu chovuta kwambiri Dipatimenti Yadzidzidzi (A&E) yomwe imagwira ntchito ngati chigawo cha Arterial/Vascular Surgery Hub. Imayendetsedwa pansi pa National Institute for Health and Care Excellence (NICE NG158) ndi Vascular Society of Great Britain and Ireland (VSGBI) protocol.
• European Union: Imbani 112. Imayendetsedwa pansi pa **European Society for Vascular Surgery (ESVS) Malangizo Othandizira Zachipatala pa Management of Venous Thrombosis **.
• Australia ndi New Zealand: Imbani 000 ku Australia kapena 111 ku New Zealand. Imayendetsedwa pansi pa Australian and New Zealand Society for Vascular Surgery (ANZSVS) ndi Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) malangizo.
• India ndi Asia-Pacific: Imbani 112 (kapena 108 ku India), 995 ku Singapore, 119 ku Japan ndi South Korea, kapena 999 ku Malaysia ndi Hong Kong. Funsani chipatala chapamwamba chokhala ndi ma endovascular and vascular opareshoni.

Mafunso omwe amafunsidwa pafupipafupi¶

Kodi pali kusiyana kotani pakati pa phlegmasia alba dolens ("mwendo wamkaka") ndi phlegmasia cerulea dolens ("mwendo wabuluu")?¶

Mitsempha yonseyi imayamba chifukwa cha kutsekeka kwa mitsempha yozama kwambiri (DVT) kutsekereza mitsempha yayikulu ya m'chiuno ndi yachikazi m'chiuno ndi groin, ndipo imayimira magawo awiri amtundu womwewo wowopseza moyo. Mu phlegmasia alba dolens (gawo loyambirira la "mwendo wamkaka"), mitsempha yayikulu yakuya imatsekeka ndi 100 peresenti, koma mitsempha yaying'ono imakhala yotseguka; madzimadzi amalowa m'minyewa ndikufinya minyewa yapakhungu kotero kuti mwendo wonse ukutupa ndikusanduka woyera ngati wamkaka, pomwe kutuluka kwa magazi ndi kugunda kwa phazi kumakhalabe. Mu phlegmasia cerulea dolens (gawo lotsogola la "blue leg"), mitsempha yakuya ndi mitsempha yokhazikika imatseka kwathunthu; Ziro magazi amatha kutuluka m'mwendo, magazi osasunthika opanda okosijeni amatembenuza mwendo wonse kukhala wofiirira-buluu wokhala ndi matuza amagazi, ndipo kuthamanga kwa minofu yokwera kumwamba kumaphwanya misempha, zomwe zimapangitsa kuti venous gangrene ikhale mkati mwa maola angapo ngati sanatsike.

Chifukwa chiyani simuyenera kusisita kapena kusisita mwendo wotupa, wopweteka womwe ungakhale ndi DVT?¶

Pamene magazi aakulu apanga m'mitsempha yakuya ya ng'ombe, ntchafu, kapena chiuno, gawo lapamwamba la chotupacho ndi lofewa, lophwanyika, ndipo nthawi zambiri limayandama momasuka mkati mwa mtsempha wa chikazi kapena iliac ngati soseji yokhala ndi mchira waulere. Mukasisita, kukanda, kusisita, kapena kuyika nsapato pa mwendo kuti muchepetse kupweteka kwa minofu, kufinyako kumatha kuthyola gawo lalikulu la chotupacho. M’mphindi zochepa chabe, magazi oswekawo amayenda m’munsi mwa vena cava, n’kudutsa mbali ya kumanja kwa mtima, n’kutsekereza mitsempha ya m’mapapo ya m’mapapo (a massive pulmonary embolism), zimene zingachititse mtima kugunda mwadzidzidzi.

Kodi muyenera kukweza mwendo kapena kuutsitsa ngati wina ali ndi phlegmasia cerulea dolens motsutsana ndi kutsekeka kwa mitsempha?¶

Ichi ndi kusiyana kwakukulu mu chithandizo choyamba cha mitsempha. Pakutsekeka kwakukulu kwa mitsempha (kumene chotsekeka chimatseka mtsempha wa chikazi kapena popliteal kotero kuti magazi sangathe kulowa mu mwendo wotumbululuka, wosweka, wozizira kwambiri), simuyenera kukweza mwendo pamwamba pa mtima chifukwa mphamvu yokoka imatsutsana ndi kutsetsereka kofooka kwa mitsempha; sungani mwendo wa ischemic kapena wodalira pang'ono. Mosiyana ndi zimenezi, mu phlegmasia alba dolens kapena phlegmasia cerulea dolens, mitsempha imaponyera magazi m'mwendo, koma mitsempha imakhala yotsekedwa ndi 100 peresenti kotero kuti magazi sangatuluke pa mwendo wofiirira wotupa kwambiri; kukweza mwendo pang'onopang'ono pamapilo (madigiri 15 mpaka 30 pamwamba pa mulingo wa mtima) kumagwiritsa ntchito mphamvu yokoka kuti ichepetse kuthamanga kwa venous hydrostatic ndikuchepetsa kutupa kwa chipinda podikirira thrombectomy yachipatala.

Chifukwa chiyani kutsekeka kwakukulu kwa magazi kwa iliofemoral kumachitika 3 mpaka 4 pafupipafupi pamwendo wakumanzere kuposa wakumanja?¶

Mu thupi la chiuno cha munthu, mtsempha wokhazikika, wothamanga kwambiri kumanja wamba wa iliac umawoloka kutsogolo kwa mtsempha wofewa, wopyapyala wakumanzere wakumanzere, ndikumangirira mwamphamvu kumanzere kwa fupa lachisanu la fupa la msana. Imadziwika kuti May-Thurner syndrome (iliac vein compression syndrome), kugunda kwa mtima kosalekeza kumeneku kumapangitsa kuti mtsempha wakumanzere ukhale pansi ndikupanga maukonde amkati mkati mwa nthawi. Pamene choyambitsa ngati mimba, opaleshoni, kutaya madzi m'thupi, kapena khansa kumawonjezera kutsekeka kwa magazi, mitsempha ya kumanzere ya iliac imatsekeka mosavuta kuposa mtsempha wa iliac wosakanizidwa.

Kodi mungadziwe bwanji kusiyana pakati pa deep vein thrombosis (DVT) ndi bakiteriya cellulitis?¶

DVT yokhazikika ndi bakiteriya cellulitis zimatha kuwoneka zofanana chifukwa zonse zimayambitsa kutentha, kutupa, kufewa, kutsika kwapinki komanso kutentha thupi pang'ono. Komabe, cellulitis ndi matenda a pakhungu (nthawi zambiri amayamba kuchokera ku khungu losweka pakati pa zala kuchokera ku phazi la wothamanga kapena kukanda kwa shin) zomwe zimayambitsa khungu lofiira kwambiri, kutupa komwe kumakhala pansi pa bondo, ma lymph nodes, ndi kutentha kwakukulu / kuzizira, pamene kugunda kwa phazi kumakhalabe kolimba. DVT yayikulu kwambiri yomwe imayambitsa kutupa padziko lonse lapansi kwa mwendo WONSE kuchokera ku groin mpaka kuphazi, mitsempha yowoneka bwino yapamtunda, kupweteka kwambiri kwa minofu, komanso kusinthika kwamtundu koyera kapena kofiirira. Chifukwa awiriwa amatha kuwoneka ofanana koyambirira (kapena kuchitikira palimodzi), mwachangu venous duplex ultrasound ndiyo njira yokhayo yotetezeka yowalekanitsira.

Kodi phlegmasia cerulea dolens ingakhale chizindikiro choyamba cha khansa yosadziwika kapena heparin reaction?¶

Inde. M'maphunziro azachipatala, pakati pa 20 ndi 40 peresenti ya odwala omwe amakhala ndi phlegmasia cerulea dolens amakhala ndi vuto la hypercoagulable (monga kapamba, mapapo, m'mimba, ovarian, kapena khansa ya hematologic) yomwe imatulutsa zinthu zomwe zimalimbikitsa magazi kulowa m'magazi. Komanso, odwala omwe adalandira mankhwala ochepetsa magazi a heparin m'chipatala mkati mwa 5 mpaka masiku 14 apitawo amatha kukhala ndi Heparin-Induced Thrombocytopenia (HIT), chitetezo chamthupi chomwe ma antibodies amayambitsa kuphulika kwa venous ndi mitsempha ya magazi; nthawi zonse auzeni dokotala wadzidzidzi ngati wodwalayo adagonekedwa m'chipatala posachedwa kuti athe kuyang'ana kuchuluka kwa mapulateleti ndikugwiritsa ntchito mankhwala ochepetsa magazi omwe si a heparin ngati pakufunika.

Magwero ndi malangizo ovomerezeka¶

• European Society for Vascular Surgery (ESVS, Europe): ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis (Kakkos et al., European Journal of Vascular and Endovascular Surgery, Gawo 4.6: Management of Phlegmasia Cerulea Dolens, immediate legleg, immediate leg kutsitsimuka, thrombolysis yoyendetsedwa ndi catheter, ndi kutsegula kwa venous thrombectomy).
• Society for Vascular Surgery (SVS) & American Venous Forum (AVF, United States): Njira Zoyamba Zochotsa Thrombus for Acute Deep Venous Thrombosis: Clinical Practice Guidelines (mwachangu pharmacomechanical kapena opaleshoni thrombectomy kwa iliocerulea woopsa iliofemoral DV).
• American Heart Association (AHA, United States): Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement from the American Heart Association (Circulation, immediate endovascular or pcerugleagnie lumbar de ceruglesia de May 1999). kutsika kwa mitsempha ya iliac).
• American College of Chest Physicians (CHEST, United States): Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report (zizindikiro za catheter-directed thrombolysis ndi opaleshoni ya venous thrombectomy yomwe ili pafupi ndi venous gangrene).
• National Institute for Health and Care Excellence (NICE, United Kingdom): Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing (NICE Guideline NG158).

Maupangiri ogwirizana¶

• Pulmonary embolism ndi deep vein thrombosis (DVT)
• Acute ischemic mwendo, arterial occlusion, ndi pulseless extremity
• Cellulitis, erysipelas, lymphangitis, red streaking, ndi abscess sepsis kupita patsogolo.
• Compartment syndrome ya dzanja, phazi, kapena kutsogolo, kugawanika kolimba, ndi 6 Ps triage
• Necrotizing fasciitis (matenda odya nyama) ndi mbendera zofiira za cellulitis