6 1 year-old female, surnamed Huang.

Let's call it Ms. Huang.

Ms Huang is in good health. There is nothing wrong with her except high blood pressure. Hypertension also insists on taking antihypertensive drugs, and the measured blood pressure is up to standard. The doctor also praised Ms. Huang, joking that obedient patients live the longest.

But it didn't last long. One day six years ago, Ms. Huang began to feel uncomfortable in her chest and suddenly felt uncomfortable chest pain. Is this coronary heart disease? Is it a myocardial infarction? Ms. Huang pays great attention to health care. As soon as she felt sick, she went to the hospital at once.

I did a lot of tests and electrocardiogram, and found a new problem: atrial fibrillation.

Ms. Huang has atrial fibrillation.

What is atrial fibrillation? Ms. Huang herself was very confused and asked the doctor.

To explain atrial fibrillation, we must first understand the heart. The doctor said that the heart has four chambers, namely the left atrium, the left ventricle, the right atrium and the right ventricle, just like a house with four chambers. Atrial fibrillation refers to atrial fibrillation. A normal heartbeat is strong and regular. When there is arrhythmia (arrhythmia), the atrium will vibrate rapidly. This disorder of atrial fibrillation will lead to the loss of effective contraction and relaxation of the heart and the inability to pump blood normally. The task of the heart is to deliver blood to all organs. Once the heart pumps blood, all organs will be ischemic, and head ischemia will lead to dizziness and even syncope.

Will I die suddenly? Ms. Huang asked nervously.

Simple heart ischemia, not sudden death. The doctor said that this made Aunt Huang feel a little relieved, but the doctor went on to say that when atrial fibrillation occurred, the heart lost its original rhythm and became disordered. At this time, the blood flow in the atrium will produce a vortex, which is very easy to form a thrombus. Once the thrombus is large enough, it may fall off and flow out along the blood stream. Once it gets into the brain, it's the brain that gets stuck.

This short passage made Ms. Huang look pale.

Patients with atrial fibrillation, if they want to avoid sudden death and cerebral embolism, must take anticoagulants, in order to prevent atrial thrombosis, so that the subsequent embolism time will not occur. The doctor explained.

I eat, I eat. When Ms. Huang heard that there were drugs to prevent it, she seemed to be grasping at straws.

This anticoagulant is warfarin, which can prevent thrombosis and cerebral embolism. However, taking warfarin is more troublesome. At the beginning, you need to take blood tests frequently to see if the dose is large enough. If it is not enough, it is necessary to increase the dose. If it is big, it will be reduced. If it is very large, it will lead to excessive anticoagulation and lead to bleeding. If it is small, it will not achieve the effect of preventing embolism. It's a little troublesome. The doctor continued to explain.

I'm not afraid of trouble, as long as I don't die suddenly. Ms. Huang quickly said.

In this way, Ms. Huang began to eat warfarin for a long time.

In recent years, Ms. Huang's atrial fibrillation has been very calm and there has been no embolism. Because I also took betaloc tablets at the same time, my heart rate was not very fast, and my angina symptoms were almost gone.

You are very lucky. A friend of mine has atrial fibrillation and cerebral embolism in less than 2 years. Now he is lying in bed like a vegetable. An old colleague of Ms. Huang said.

That's a matter of life and death. I take the medicine prescribed by the doctor every day. Ms. Huang said.

The days passed day by day.

Six years later this year, the accident came.

This spring, Ms. Huang accidentally fell down while running in the park. She cried with pain when she fell to the ground. Her family was sent to the hospital for examination. Oh, no, her bones are broken!

This is the initial judgment of the emergency doctor. Ms. Huang Can can't move her left foot. She is a little deformed. The whole foot looks obviously shorter than her right foot. An experienced doctor can tell at a glance that this is a fracture.

Regardless of Ms. Huang's scream, the doctor immediately sent her to take an X-ray of the left hip joint to confirm that it was a fracture of the left femoral neck.

I quickly called an orthopedic consultation.

Orthopedics, skin traction first, the purpose is to restore the continuity of bones, reduce pain and injury, in case the broken end of the fracture cuts into the surrounding large blood vessels, causing massive bleeding, it will be troublesome. I also gave some painkillers.

Painkillers didn't help, and Ms. Huang was still screaming.

Let's go to the hospital. It must be solved by surgery. The orthopedic surgeon told his family. Surgery can be fixed with nails or hip replacement. The broken femoral head can be directly taken out and replaced with a new one, and the patient can walk later. Without surgery, the patient will die of pain and it will be difficult to walk on the ground in the future.

This is only in his early 60 s, and he must have an operation. Emergency doctors are helpful.

Family members don't have much hesitation, surgery!

Ms. Huang has a history of hypertension and atrial fibrillation, and taking warfarin for a long time has brought a little difficulty to the operation. Because the operation will definitely hurt, which will lead to bleeding. Now the patient is taking warfarin, will it lead to bleeding? It would be terrible if it kept bleeding after operation.

The orthopedic surgeon did not dare to ask for a big one. Immediately after he was admitted to the hospital, he invited a cardiologist to come over for consultation to see how to adjust the dose of warfarin and whether he could stop taking the medicine.

After admission, check coagulation indexes and all other related tests. Cardiologists suggest stopping warfarin, switching to heparin, and then stopping heparin the day before surgery, which can minimize bleeding complications and make anticoagulation effective. Well, it's a little troublesome. We can't attend to one thing and lose another.

On the fifth day of admission, the operation was performed under anesthesia.

The doctor said that internal fixation can be done, that is, the broken bone can be directly connected with nails, or the whole hip joint can be replaced. Each has its own advantages and disadvantages. Ms. Huang chooses for herself. Like a flat tire with a nail. Can be repaired or replaced with a new one.

In the end, Ms. Huang chose brand-new tires. Oh, no, it's hip replacement.

Preoperative cardiac color Doppler ultrasound found that Ms. Huang's atrium was slightly enlarged. After so many years of atrial fibrillation, it is not surprising that the atrium is enlarged. But the overall cardiac function is still good, and it is no problem to tolerate surgery. In addition, color Doppler ultrasound did not find thrombosis in blood vessels of lower limbs.

Surgery is generally safe, but any operation will be risky. Especially in broken bone surgery, there is fat in the bone, and the broken end is particularly prone to thrombosis. If these fats or thrombi enter the blood, they may run to the pulmonary artery along the blood flow defense line, leading to pulmonary embolism, which will be fatal. The doctor explained it before the operation.

Compared with cerebral embolism, which is more serious? Ms. Huang asked the doctor that she used some painkillers at this time and felt much more comfortable. Because the doctor said that I had atrial fibrillation before, I had to take warfarin, otherwise I would have a cerebral embolism, that is, the blood vessels in my brain were blocked by blood clots. You will die suddenly.

The doctor said with a smile, we hope there will be no cerebral embolism or pulmonary embolism, both of which are not easy to provoke. Severe pulmonary embolism can also cause death, and you may not even notice it slightly.

That's still a serious cerebral embolism. If you can't die or be paralyzed, you will suffer. Ms. Huang sighed. Pulmonary embolism is quite refreshing, and it kills you with one blow.

Bah, don't mention this dead word all day. Now that we are all ready for the operation, everything will be fine. Ms. Huang's husband looked unhappy and quickly blocked Ms. Huang's mouth.

Surgeons are also in distress situation.

Sign off on the operation, but it's a hip replacement.

At the beginning of the operation, Ms. Huang's husband couldn't stay, walking up and down the corridor at the door, and her back was lonely and pitiful. Ms. Huang has a daughter who didn't come back because she was studying abroad. At this critical moment, only her husband can take care of her.

The operating room is in full swing.

The operation went well at first, and the surgeon gagged several nurses. But there was a problem halfway through.

Director Ma, the patient's oxygen saturation has dropped to 90%. The anesthesiologist whispered a sentence.

In fact, the blood oxygen saturation decreased for a few minutes, and the anesthesiologist adjusted it to be stable, but then it decreased. This is problematic.

There must be something wrong. The anesthesiologist checked all the instruments, so there is only one possibility that the problem itself lies with the patient.

The surgeon felt a little guilty when he heard the news that the blood oxygen saturation had decreased.

Can it last? He asked the anesthesiologist.

The decrease of oxygen saturation means that the patient is deprived of oxygen. How can a patient be deprived of oxygen by continuously injecting oxygen with an anesthesia machine? The anesthesiologist stopped the patient's lungs, and the breathing sound was symmetrical, unlike pneumothorax or atelectasis. If the breathing sound on one side is weak, be alert to pneumothorax or atelectasis.

A terrible thought flashed through everyone's mind: shouldn't it be so unlucky that the patient got pulmonary embolism?

The blood vessels and veins of patients' lower limbs were all good before operation, and there was no thrombosis. The surgeon said. If the patient really has pulmonary embolism, then the most likely source of embolus is thrombus in the deep vein of lower extremity, but now it is clear that there is no thrombus there, so don't worry.

However, no one knows whether there will be a thrombus at the broken end of this bone and whether the thrombus will run into the blood. If so, it will be very difficult.

Pulmonary embolism means that the main or branch of pulmonary artery is blocked by thrombus and blood cannot pass through. Blood must pass through the pulmonary artery to reach the alveoli and meet with oxygen, thus bringing oxygen back to the left heart. If the pulmonary artery is really blocked, or blocked by more than half, then the patient will be seriously deprived of oxygen.

Ordinary people will show shortness of breath because of lack of oxygen. The patient lying on the anesthesia operating table, because the pain has been fully relieved and the muscles have been calmed down, will not experience shortness of breath, and will only show the monitored decrease in blood oxygen saturation.

This is a danger signal!

The anesthesiologist adjusted the parameters of the machine and tried his best to improve the patient's oxygen saturation to 95%. Just a sigh of relief.

How is your blood pressure? The surgeon asked.

Blood pressure is normal. I can bear it. No medication. The anesthesiologist said.

The communication is short, but I can already smell the thrilling breath in the air. If the patient really has pulmonary embolism, his heart may stop beating in the future, then it is really a pot of cooking.

Fortunately, several surgeons finally got the operation done after much sweat.

Successfully changed the left hip joint.

It will take nearly 2 hours.

The intraoperative bleeding was about 300ml.

At this time, the patient's oxygen saturation is only 92%, and his blood pressure is OK.

Send it to ICU quickly. The surgeon said as he took off his gloves. Then I went out to communicate with my family.

After the family learned the situation during the operation, it was a little unacceptable. I didn't mean to blame the doctor, but I felt very painful.

We're not sure it's pulmonary embolism, but it's possible. It could be another problem. Now that the operation is over, it needs to be sent to ICU for further monitoring and treatment.

Ms. Huang's husband agreed to go to ICU.

In his cognition, all patients who entered the ICU were narrow escapes. So when he said he agreed to go to ICU, he almost collapsed in his chair.

After the ICU doctor accepts the patient, he immediately goes to full care. After checking the arterial blood gas, the partial pressure of oxygen is only 60mmHg (using ventilator at this time), so it should not be. At such a high oxygen concentration, the partial pressure of oxygen must be at least 200 mm Hg. ICU doctors are also lost in thought.

What happened to the patient? Is it really pulmonary embolism? To be sure, the best way is to send it for a chest CTA. In the patient's current situation, it is obviously not suitable for painstaking transportation.

Let's do a heart color ultrasound first. ICU has its own color Doppler ultrasound, which can be done. If the patient really has pulmonary embolism, you can also find something when doing color Doppler ultrasound, such as seeing pulmonary artery thrombosis, or measuring the pressure of pulmonary artery will be much higher. Very easy to understand. Once the pulmonary artery is blocked by a thrombus, the blood can't get through, and the pressure in front will definitely get higher and higher, just like a traffic jam.

I quickly did a heart color ultrasound.

Really found the problem!

The patient's double atria are still enlarged, which is not important. It was also enlarged before operation, which was caused by atrial fibrillation. The key point is that the patient can see something about 3cm in the right atrium. What is this? No preoperative color Doppler ultrasound. Is it really a thrombus? Looking at the pulmonary artery, there is no obvious thrombus in the pulmonary artery, but the measured pulmonary artery pressure is surprisingly high. It is estimated that the systolic pressure of pulmonary artery reaches 50mmHg (normal 25).

The normal blood flow is as follows: venous blood, right atrium, right ventricle, pulmonary artery capillary (alveoli), pulmonary vein, left atrium, left ventricle, systemic arterial capillary network, venous blood, right atrium .............................................................................................................. Now there is a foreign body (probably a thrombus) in the right atrium, and the pulmonary artery pressure is very high, indicating that there may be a thrombus behind the pulmonary artery (probably a branch of the pulmonary artery, which can't be seen by color Doppler ultrasound), and the blood flow is not smooth in the past, so the pressure will become high.

ICU doctors believe that patients can be definitely diagnosed with pulmonary embolism!

Pulmonary embolism is everyone's nightmare.

When the family members heard about this pulmonary embolism, they almost lost all hope. The ICU doctor comforted him that although pulmonary embolism is dangerous, not all pulmonary embolism will be fatal. Just like a patient, although he lacks oxygen, his blood pressure is still stable and may not be fatal. You can treat him first.

Doctor, please help her. The family members almost fell to the ground, and the 60-year-old man was red-eyed and crying. Few people are really strong in the face of death. Even though they look strong, most of them work hard.

We will. The ICU doctor said that in order not to cause trouble, it is still necessary to communicate all the risks with family members and let him know that the disease may kill people, but it may not kill people. It is necessary to observe while treating.

The ICU doctor closed the door to discuss it himself and called an orthopedic surgeon. What should I do? Now it seems that pulmonary embolism is beyond doubt. Do you need thrombolytic therapy?

We have heard a lot about thrombolysis, such as myocardial infarction, thrombosis blocking coronary artery, leading to cardiac ischemia. If the obstruction is not cleared in time, the heart will die immediately, requiring rapid thrombolysis or stent opening. And cerebral embolism. Once the thrombus blocks the cerebral vessels, thrombolysis should be considered as long as conditions permit. Thrombolysis is to use some drugs that can dissolve thrombus into blood vessels, hoping to melt thrombus and restore the patency of blood vessels.

If the solution is just right, the patient will be saved. If the thrombolysis is slightly excessive and the dose is too large, it may lead to bleeding. If it's a cerebral hemorrhage, it's over.

So the risk of thrombolysis is very high. Especially for patients like this, the wound is still bleeding just after the operation. If thrombolysis is carried out at this time, maybe the wound will bleed until all the blood is lost, which may lead to death.

The patient's blood pressure is still stable. According to the current knowledge, it belongs to non-high risk pulmonary embolism, and it can be temporarily anticoagulated without thrombolysis. The director has made a decision. So do cardiologists.

Although the patient has pulmonary embolism, the embolism may not be the most serious, at least the blood pressure can be tolerated, not the state of landslide, so I would rather not thrombolysis. It's just anticoagulation Thrombolysis is different from anticoagulation. Thrombolysis is a drug that directly dissolves the formed thrombus. It seems that the effect is the best, but it is also the most risky. Anticoagulation is to use drugs to prevent new thrombosis, prevent it from expanding and let the body dissolve itself. This is a relatively mild method.

So, we just choose anticoagulation.

Life or death, it is really resigned. If the thrombus does not continue to increase, the patient may be lucky to survive. If the thrombus continues to increase, seriously affecting ventilation and blood pressure, it will be a narrow escape.

Everyone was silent for an instant.

One more question, where does the thrombus come from? Asked the bed doctor.

There are two possibilities, one is deep vein of lower limb, and the other is broken bone. The possibility of deep vein of lower extremity is not great, because B-ultrasound didn't see thrombus in deep vein of lower extremity, but it doesn't mean there isn't. It's probably broken. The director explained. Broken bones, messy surrounding tissues and exposed blood vessels are very easy to form thrombus.

Do you want to put a vena cava filter? Asked the bed doctor.

Anticoagulation therapy was originally designed to prevent further increase of thrombus. But that's not enough. Who knows if there is a bigger thrombus waiting to fall off at the patient's fracture? If it really falls off again, the patient's pulmonary embolism will be aggravated, and the possibility of sudden death is very high.

then what Can't be dissolved with thrombolytic drugs. There may be a whole cerebral hemorrhage, or the surgical wound can't stop bleeding. That's terrible. After all, thrombolytic drugs have no eyes, and they don't know where to dissolve or not. Thrombolytic drugs will run around like crazy people and bite everyone they meet.

So it is a good choice to put a filter here in the inferior vena cava. The director agreed to this practice. So I invited the interventional department to come over for consultation.

All the blood in the lower body will flow into the right atrium and right ventricle through the inferior vena cava. In other words, both venous thrombosis of lower limbs and femoral neck stump thrombosis belong to the upstream. If we put a filter downstream of them, like an umbrella filter, in case there is a bigger thrombus falling off, the filter can catch it halfway to prevent it from entering the heart and pulmonary artery, so as not to aggravate pulmonary embolism.

This is really a wonderful method.

Placement of inferior vena cava filter at the same time of anticoagulation can provide double insurance.

Anticoagulation can not only deal with pulmonary embolism, but also deal with atrial fibrillation. Don't forget that Ms. Huang has atrial fibrillation. If she doesn't anticoagulate, she may form an atrial embolus and then cerebral embolism. Fortunately, the first and second color Doppler ultrasound examination showed that there was no thrombus in the left atrium and the risk of cerebral embolism was relatively low.

Without any thinking, the family agreed to the intervention doctor's advice and put on the filter.

The patient's condition is slightly stable.

After careful evaluation, I first transferred to the CT room and improved the CTA examination of the chest. After a dozen contrast media, the embolus in pulmonary artery was developed, and the filling defect shadow was very obvious. Ms. Huang, who has bad karma, was once again diagnosed by the gold standard of CT: pulmonary embolism. Fortunately, the main pulmonary artery is not blocked, but the branches are blocked.

Go directly to the interventional department after CT.

The interventional doctor quickly placed the inferior vena cava filter for Ms. Huang. This filter is placed in the blood vessel. Just like a roadblock, if the thrombus below can't get through, it can ensure that the thrombus will not block the pulmonary artery again.

Go back to the ICU.

After intense treatment, Ms. Huang's oxygen saturation finally reached 100%.

Blood pressure has been stable.

Ms. Huang later woke up smoothly and had some chest tightness at first.

Later, it got better and better. After 5 days, arterial blood gas and oxygen partial pressure decreased to 200mmHg (oxygen inhalation state).

Re-do color Doppler echocardiography, the lump in the right atrium is gone!

This is really exciting news.

In addition, the re-measured pulmonary artery pressure has also dropped to 35mmHg, which is still high, but obviously lower than last time (last time it was 50mmHg).

What does this mean? Ms. Huang's atrial and pulmonary thrombosis has dissolved, disappeared or been significantly alleviated. Anticoagulation is working! Although the doctor did not use thrombolytic drugs, the body itself has a thrombolytic mechanism. Once a thrombus is formed, the thrombolytic mechanism will also start. Thrombolysis is the body's own thrombolytic system.

This is the most gratifying ending.

Ms. Huang finally survived and left the ICU smoothly.

Orthopedics doctors say they can walk in the fields soon. If it weren't for this pulmonary embolism, many people would be able to walk the next day after surgery.

Besides, you warfarin will insist on eating again. If you don't eat, you may have a cerebral embolism.

How scary it is to say it.

If you don't listen, it's really scary.