以短暂性意识丧失为主要症状成人急性肺血栓栓塞症误诊分析及文献复习

Misdiagnosis Analysis and Literature Review of Adult Acute Pulmonary Thromboembolism with Transient Loss of Consciousness as the Primary Symptom

目的分析以短暂性意识丧失为主要症状急性肺血栓栓塞症病例,探讨其误诊原因,总结经验。方法回顾性分析2019年1月-2022年6月被误诊的以短暂性意识丧失为主要症状急性肺血栓栓塞症7例的诊治过程及临床资料。结果7例均发生不同程度的短暂性意识丧失,短者3 s,最长达10 min,其中2例存在短时间内反复发生短暂性意识丧失;同时伴有胸闷、气短各4例,心悸2例,乏力、头晕各1例。误诊为体位性低血压1例、意识丧失原因待查1例、冠心病3例、急性冠状动脉综合征1例、胆囊结石1例。误诊时间10 h~1个月。7例均由肺动脉CTPA检查确诊为急性肺血栓栓塞症。本组4例行抗凝治疗,2例行静脉溶栓+抗凝治疗,1例因肺动脉狭窄率达到90%,行肺动脉球囊扩张术。死亡1例,好转6例。结论以短暂性意识丧失为主要症状急性肺血栓栓塞症临床误诊率高。对于突发意识丧失合并持续低氧血症时,要排除急性肺血栓栓塞症的可能,并关注血气分析和D-二聚体的动态变化。

Objective To analyze the cases of acute pulmonary thromboembolism(APTE)with transient loss of consciousness as the primary symptom,and to explore the causes of misdiagnosis and summarize the experience.Methods The diagnosis,treatment and clinical data of 7 patients with APTE with transient loss of consciousness as the primary symptom that were misdiagnosed from January 2019 to June 2022 were retrospectively analyzed.Results All 7 cases had different degrees of transient loss of consciousness,ranging from 3 seconds to 10 min,and 2 cases had repeated transient loss of consciousness in a short period of time.There were 4 cases of chest tightness,4 cases of shortness of breath,2 cases of palpitation,1 case of fatigue and 1 case of dizziness.They were misdiagnosed as postural hypotension in 1 case,loss of consciousness in 1 case,coronary heart disease in 3 cases,acute coronary syndrome in 1 case,and gallstone in 1 case.The duration of misdiagnosis was 10 h to 1 month.All 7 cases were diagnosed as APTE by pulmonary artery CTPA examination.In this group,4 patients received anticoagulant therapy,2 patients received intravenous thrombolysis plus anticoagulant therapy,and 1 patient underwent pulmonary artery balloon dilatation because the pulmonary artery stenosis rate reached 90%.One case died and 6 cases improved.Conclusion The clinical misdiagnosis rate of APTE with transient loss of consciousness as the main symptom is high.Possibility of APTE must be ruled out in cases of sudden loss of consciousness with persistent hypoxemia,and attention should be paid to dynamic changes in blood gas analysis and D-dimer.