Обьяснение авторов задачи:
The correct answer is B. This patient has almost certainly suffered a pulmonary embolism. All postoperative patients are at increased risk for this disorder, but orthopedic patients have a much-increased risk above that for venous thrombosis and embolism. For this reason, all of these patients are placed on aggressive prophylaxis measures postoperatively. Once present however, the best intervention to reduce 24-hour mortality is aggressive anticoagulation with intravenous unfractionated heparin at 80U/kg bolus and 18U/kg/hr infusion titrated to a PTT of 60-75.
Embolectomy (choice A) is reserved for patients with pulmonary emboli who have acute right heart failure as a result. These patients have elevated jugular venous pulsations, hypotension, and tachycardia. Even when present, embolectomy, or its less-invasive option, thrombolysis (choice E), have not been shown to be efficacious in terms of mortality prevention. Clearly thrombolysis is less invasive but does carry a substantial risk of bleeding (3-10%).
Starting oral warfarin (choice C) in the absence of heparin is not appropriate. The correct therapy involves a standard regimen of heparin overlapped with warfarin until an international normalized ratio (INR) of 2.0 to 3.0 is obtained on two consecutive days. This regimen is sufficient for the prevention of skin necrosis, which may occur during the initiation of warfarin therapy in patients with a deficiency of protein C.
Mini-dose or subcutaneous heparin (choice D) is used for prophylaxis, not treatment.
Видимо, в варианте D авторы не имели ввиду низкомолекулярный гепарин.
