Pulmonary embolism yog ib hom kev puas tsuaj rau lub ntsws. Nws tsim los ntawm embolization ntawm cov ceg ntawm cov hlab ntsha pulmonary nrog cov pa roj npuas lossis pob txha pob txha, kua amniotic, thrombus. Thiab pulmonary embolism (PE) yog hom kev cuam tshuam ntau tshaj plaws (ntau dua 60%) ntawm cov hlab ntsha ntawm cov hlab ntsws, txawm hais tias tawm tsam keeb kwm ntawm lwm cov kab mob plawv nws muaj tsawg zaus (kwv yees li 1 kis ntawm 1000 tus neeg). Tab sis kev tuag siab ua ntej thawj zaug ntsib kev kho mob thiab nyuaj rau kev kuaj mob thiab kev kho mob ua rau tus kab mob no txaus ntshai heev rau tus neeg mob.
TELA yog dab tsi
Thromboebolism yog ib qho thaiv ntawm lumen ntawm cov hlab ntsha los ntawm cov ntshav txhaws, thrombus. Thiab nyob rau hauv cov ntaub ntawv ntawm pulmonary embolism, lub tsev kho mob, kev kuaj mob thiab kev kho mob uas yuav tau tham nyob rau hauv kev tshaj tawm, qhov no blockage tshwm sim nyob rau hauv cov hlab ntsha ntawm pulmonary ncig. Lub thrombus nkag mus rau hauv cov hlab ntsha pulmonary los ntawm cov hlab ntsha los ntawm cov kab mob hauv lub cev. Nyob rau hauv 95-98% ntawm PE loj, ib tug loj thrombus yog tsim nyob rau hauv cov hlab ntsha ntawm ob txhais ceg los yog pelvis me me, thiab tsuas yog nyob rau hauv 2-3% - nyob rau hauv cov hlab ntsha ntawm lub Upper ib nrab ntawm lub cev thiab nyob rau hauv lub pas dej ua ke ntawm jugular leeg.. Nyob rau hauv cov ntaub ntawv ntawm PE rov tshwm sim, ntau cov ntshav me me hauv cov kab noj hniav ntawm lub plawv. Qhov no feem ntau tshwm sim nrog atrial fibrillation lossis txoj cai plawv thromboendocarditis.
Pulmonary embolism yog ib qho kev kho mob, cov tsos mob tshwm sim los ntawm cov ntshav txhaws nkag mus rau cov hlab ntsha ntawm cov hlab ntsws. Qhov no yog ib yam kab mob uas yuav ua rau muaj kev phom sij heev uas tshwm sim thiab tshwm sim sai sai. Paub qhov txawv ntawm qhov loj, submassive thiab rov tshwm sim PE, nrog rau lub plawv nres-pneumonia - qhov tshwm sim ntawm PE nquag. Hauv thawj kis, lub thrombus loj heev uas nws thaiv cov hlab ntsha pulmonary nyob rau ntawm qhov chaw ntawm nws bifurcation los yog proximally.
Submassive pulmonary embolism tsim los ntawm kev cuam tshuam ntawm lobar pulmonary artery, thiab rov tshwm sim - raws li kev nquag embolism ntawm cov ntshav me me uas thaiv cov lumen ntawm cov hlab ntsha me me. Nyob rau hauv cov ntaub ntawv ntawm PE loj thiab submassive, daim duab kho mob (tom qab no hu ua lub tsev kho mob) yog ci thiab loj hlob tam sim ntawd, thiab tus kab mob tuaj yeem ua rau tuag sai sai. Kev rov tshwm sim PE yog tus cwj pwm los ntawm kev maj mam nce hauv qhov ua tsis taus pa ntev li ob peb hnub thiab kev txhim kho hnoos, qee zaum hnoos me me ntawm cov ntshav.
Patterns of development of PE
Rau txoj kev loj hlob ntawm PE, nws yog txaus kom muaj ib qho chaw ntawm thrombosis nyob rau hauv ib feem ntawm lub venous txaj ntawm lub systemic ncig los yog nyob rau hauv txoj cai qhov chaw ntawm lub plawv. Qee lub sij hawm, thrombi thaum lub sij hawm paradoxical txav los ntawm lub qhov rais qhib oval ntawm lub interatrial septum tuaj yeem nkag los ntawm sab laug atrium. Tom qab ntawd, txawm tias muaj cov kab mob endocarditis sab laug, txoj kev loj hlob ntawm PE tuaj yeem ua tau, txawm tias cov xwm txheej zoo li no tsis tshua muaj heev thiab suav tias yog casuistic. Thiab txhawm rau muab cov ntaub ntawv tsis meej uas yuav tsis ua rau muaj qhov tsis sib xws thiab yuav tsis ua rau tus neeg mob yuam kev, qhov kev tshaj tawm no yuav tsis cuam tshuam rau lub ntsiab lus ntawm kev txav tsis sib xws ntawm cov ntshav txhaws los ntawm sab laug lub plawv.
Thaum lub xov tooj ntawm tes tau tsim nyob rau hauv cov hlab ntsha ntawm cov kab mob hauv lub cev lossis hauv lub plawv sab xis, nws muaj qhov ua tau zoo ntawm nws qhov ntws mus rau hauv cov hlab ntsha pulmonary. Feem ntau ntawm cov ntshav txhaws yog varicose veins ntawm qis extremities thiab me me pelvis. Nyob rau hauv thaj tsam ntawm cov hlab ntsha, vim stagnation ntawm cov ntshav, parietal thrombus maj mam tsim, uas pib txuas mus rau subendothelial hauv ob sab phlu. Thaum nws loj tuaj, ib feem ntawm cov hlab ntsha tawg tawm thiab mus rau sab xis ntawm lub plawv thiab lub ntsws, qhov chaw uas nws ua rau cov hlab ntsha pulmonary lossis nws cov ceg.
Mechanism rau kev txhim kho ntawm TELA
Los ntawm txoj cai atrium thiab txoj cai ventricle, lub thrombus nkag mus rau hauv lub cev ntawm cov hlab ntsha pulmonary. Ntawm no nws irritates lub receptors, ua rau pulmonary-cardiac reflexes: ib tug nce nyob rau hauv lub plawv dhia, nce nyob rau hauv feeb ntim ntawm cov ntshav ncig. Ntawd yog, rau lub teeb liab hais txog kev khaus ntawm receptorsCov hlab ntsha pulmonary, lub cev teb nrog kev nce hauv kev ua haujlwm ntawm lub plawv, uas yog qhov tsim nyog los thawb lub thrombus mus rau hauv qhov nqaim ntawm cov hlab ntsha hauv txaj thiab txo qis qhov tshwm sim ntawm kev puas tsuaj. Qhov kev nyuaj siab no twb hu ua pulmonary embolism, cov tsos mob thiab qhov hnyav ntawm uas linearly nyob ntawm qhov loj ntawm cov thrombus.
Nyob rau hauv ib cheeb tsam ntawm lub ntsws pulmonary phiab, txawm hais tias qhov kev sim ntawm cov hlab plawv system los thawb cov hlab ntsha ntxiv, qhov kawg yuav tau daig. Raws li qhov tshwm sim, cov kab mob arteriolospasm sai sai tsim, cov ntshav ntws hauv thaj tsam cuam tshuam ntawm lub ntsws raug thaiv. Nrog rau PE loj, nws tsis tuaj yeem thawb lub thrombus loj rau hauv cov hlab ntsha me me, thiab yog li ntawd tag nrho cov kev cuam tshuam tsim.
Vim li no, cov ntshav muab rau lub hauv paus tseem ceeb ntawm cov hlab ntsws hlab ntsha raug thaiv, thiab yog li ntawd cov ntshav oxygenated tsis ntws mus rau sab laug ntawm lub plawv - lub cev qhuav dej tau tsim. Tus neeg mob tam sim ntawd tsis nco qab vim cerebral hypoxia thiab poob siab, arrhythmic kev ua ntawm lub plawv provoked, ventricular extrasystole tsim, los yog ventricular fibrillation pib.
Cov cim qhia ntawm qhov loj thiab submassive embolism
Qhov piv txwv saum toj no qhia tau hais tias mob ntsws embolism hnyav heev uas tsis tshua kho. Raws li txoj cai, cov xwm txheej zoo li no tshwm sim hauv cov neeg mob postoperative lossis ntev immobilized tom qab thawj zaug sawv. Outwardly, nws zoo li no: tus neeg mob tau mus rau nws ob txhais taw, vim li casvenous outflow los ntawm cov hlab ntsha ntawm qis extremities yog ceev thiab kev sib cais ntawm thrombus yog provoked. Nws taug kev mus rau qhov tsis zoo vena cava thiab ua rau pulmonary embolism.
Tus neeg mob quaj tawm hauv qhov mob thiab poob siab, tsis nco qab thiab ntog, ventricular fibrillation tsim, ua tsis taus pa, kev tuag tshwm sim. Raws li txoj cai, nws yog ib qho nyuaj heev kom tsis txhob ventricular fibrillation hauv PE, vim nws cuam tshuam nrog myocardial hypoxia. Nws tshem tawm nrog loj embolism yuav luag tsis yooj yim sua, uas yog vim li cas nws tsis yooj yim sua los pab tus neeg mob nrog tag nrho cov kev cuam tshuam thiab kev loj hlob ntawm arrhythmia txawm tias tam sim ntawd kuaj mob thiab pib kho. Tsis tas li ntawd, tus nqi ntawm kev loj hlob ntawm arrhythmias siab heev uas qhov chaw kho mob tuag txawm tias ua ntej cov neeg nyob hauv tib chav nrog tus neeg mob muaj sij hawm hu rau kev pab.
Subtotal PE
Raws li subtotal PE, tus nqi ntawm kev loj hlob ntawm cov tsos mob tsawg dua, tab sis qhov no tsis txo qhov txaus ntshai rau lub neej. Ntawm no, ceg ntawm lub lobar pulmonary hlab ntsha yog obstructed, thiab yog li ntawd pib lub ntim ntawm qhov txhab yog ntau me me. Tus neeg mob tsis nco qab sai li sai tau, thiab lub arrhythmia tsis tshwm sim tam sim ntawd. Txawm li cas los xij, vim muaj kev cuam tshuam ntawm kev cuam tshuam ntawm arteriolospasm thiab pom cov tsos mob ntawm kev poob siab, tus neeg mob tus mob deteriorates sharply, ua tsis taus pa hnyav zuj zus, thiab mob hnyav ntawm lub plawv thiab ua pa tsis ua hauj lwm nce..
Yog tsis kho pulmonary embolism thiab thrombolysis ua tsis tau, txoj kev tuag yog txog.95-100%. Cov txheeb ze ntawm tus neeg mob yuav tsum nkag siab tias tus neeg mob zoo li no xav tau kev kho mob thrombolytic thaum muaj xwm ceev, thiab yog li nws tsis tuaj yeem ncua kev hu rau EMS. Rau kev sib piv, nrog thromboembolism ntawm cov ceg ntawm cov hlab ntsha pulmonary, qhov twg cov hlab ntsha me me yog obturated, tus neeg mob tuaj yeem muaj sia nyob yam tsis muaj kev kho mob.
Kom ciaj sia, vim peb tsis tau hais txog kev rov qab los sai, tab sis hais txog kev muaj sia nyob nrog cov teeb meem tam sim no hauv cov hlab plawv thiab ua pa. Qhov hnyav ntawm nws tus mob yuav maj mam nce ntxiv thaum ua tsis taus pa, hemoptysis thiab kev loj hlob ntawm infarction pneumonia zuj zus. Yog tias cov tsos mob no tshwm sim, koj yuav tsum hu rau chav kho mob ceev ceev ntawm lub tsev kho mob lossis lub tsheb thauj neeg mob tam sim ntawd.
Cas of PE
Txhua yam tshwm sim uas ua rau muaj kev loj hlob ntawm thrombosis ntawm cov hlab ntsha ntawm qis qis lossis lub plab me me, nrog rau kev tsim cov ntshav txhaws hauv txoj cai atrium lossis ntawm txoj cai atrioventricular valve, tuaj yeem ua rau pulmonary embolism. Cov laj thawj ntawm PE yog raws li hauv qab no:
- kab mob varicose ntawm ob txhais ceg nrog phlebothrombosis, mob thrombophlebitis tsis noj tshuaj tiv thaiv kab mob;
- paroxysmal lossis atrial fibrillation tas mus li yam tsis muaj tshuaj tiv thaiv kab mob;
- mob plawv mob endocarditis;
- ncua ntev immobilization ntawm tus neeg mob;
- kev phais mob;
- ntau yam tshuaj tiv thaiv qhov ncauj;
- mob qog noj ntshav ntawm lub raum, metastases nyob rau hauv inferior vena cava thiab lub raum leeg, kab mob oncohematological;
- hypercoagulation,thrombophilia, DIC;
- tsis ntev los no pob txha ntawm lub plab lossis cov pob txha ntawm lub cev;
- cev xeeb tub thiab yug menyuam;
- rog, metabolic syndrome, ntshav qab zib mellitus;
- haus luam yeeb, ntshav siab, sedentary life.
Cov laj thawj no tuaj yeem ua rau pulmonary embolism. Kev kuaj mob thiab kev kho mob ntawm cov kab mob no, nrog rau kev noj tshuaj anticoagulants, tuaj yeem tshem tawm lossis txo qhov kev pheej hmoo ntawm PE. Piv txwv li, cov qauv kev kho mob ntawm cov pob txha thaum lub sij hawm rov kho dua tom qab lawv fusion, nrog rau tom qab kev phais thiab kev xa tawm, suav nrog cov tshuaj tiv thaiv kab mob.
Cov tshuaj no kuj tau qhia rau atrial fibrillation thiab kab mob endocarditis nrog cov nroj tsuag ntawm lub plawv li qub. Cov xwm txheej zoo li no feem ntau ua rau thromboembolism ntawm cov ceg me me ntawm cov hlab ntsha pulmonary, tsis yog loj thiab submassive PE. Txawm li cas los xij, cov no tseem yog cov kab mob hnyav uas xav tau kev kho mob. Cov tshuaj zoo tshaj plaws rau kev tiv thaiv yog cov tshuaj tiv thaiv qhov ncauj tshiab (NOACs). Lawv tsis xav tau INR tswj. Lawv kuj muaj cov nyhuv anticoagulant tas mus li uas tsis muaj kev noj haus, ib yam li Warfarin.
Kev kuaj mob ua ntej tsev kho mob
Txawm hais tias qhov tsim nyog ntawm cov neeg ua haujlwm kho mob hauv pulmonary embolism loj heev, lub tsev kho mob, kev kuaj mob thiab kev kho mob tuaj yeem haum rau thawj 30 feeb, tshwj xeeb tshaj yog nyob rau hauv cov ntaub ntawv ntawm kev loj hlob sai ntawm arrhythmia thiab kho mob tuag. Ces tus neeg mob tuag sai,txawm tias qhov kev kuaj mob nws tus kheej tsis nyob rau hauv tsis ntseeg. Feem ntau, PE raug kuaj pom ntawm theem SMP, thiab cov tsos mob tseem ceeb yog:
- tsis txaus siab tam sim ntawd nias thiab stabbing "dagger" mob hauv siab, tom qab ntawd tus neeg mob quaj tawm thiab qee zaum poob tsis nco qab;
- ua rau pom ua pa luv, xav tias tsis muaj cua thiab nyem hauv siab;
- nce lub plawv dhia nrog kev txhim kho ntawm qhov mob hauv lub plawv, tsis ua haujlwm ntawm lub plawv;
- pom tshwm sim thawj zaug hnoos qhuav tawm tsam keeb kwm ntawm kev noj qab haus huv tag nrho, thiab tom qab ntawd nrog cov hnoos qeev ntshav;
- suddenly tsim cyanosis (xiav-bluish xim) ntawm daim di ncauj, grey (lub ntiaj teb) complexion, o ntawm cov leeg ntawm caj dab;
- txo qis ntshav siab nrog loj lossis nce siab hauv cov ntshav siab nrog submassive thiab rov tshwm sim PE, tsaus muag lossis tsis nco qab.
Lub hom phiaj tseem ceeb ntawm kev kuaj mob nrog cov tsos mob zoo li no yog kom tsis suav nrog myocardial infarction. Yog tias ECG tsis pom cov tsos mob ntawm transmural infarction, tom qab ntawd nrog qhov tshwm sim siab ntawm qhov tshwm sim tam sim no yuav tsum tau txhais raws li PE thiab kev kho mob xwm txheej ceev yuav tsum tau muab. Nrog PE, ECG tuaj yeem pom: kev hloov pauv ntawm T nthwv dej thiab qhov pom ntawm Q nthwv dej hauv cov hlau lead III, qhov pom ntawm S nthwv dej hauv cov hlau lead I. Ib qho ntawm cov txheej txheem kuaj mob yog qhov nthuav dav ntawm P nthwv dej thiab kev loj hlob ntawm nws qhov hluav taws xob hauv thawj ntu. Tsis tas li, ECG cov kev hloov pauv yog "tsis hloov pauv", uas yog, lawv tuaj yeem hloov pauv nyob rau lub sijhawm luv luv, uas tsis ncaj qha lees paub PE thiab txo tus naj npawb ntawm cov qauv kev ntseeg siab hauv kev pom zoo ntawm myocardial infarction.
Nrog cov pulmonary embolism rov tshwm sim, cov tsos mob, kev kho mob thiab kev kuaj mob sib txawv me ntsis, uas cuam tshuam nrog qhov mob me dua. Piv txwv li, yog hais tias nrog loj PE, qhov loj ntawm lub thrombus yog kwv yees li 8-10 hli nyob rau hauv dav thiab los ntawm 5-6 mus rau 20 cm nyob rau hauv ntev, ces nrog recurrent PE, ntau me me clots 1-3 mm nyob rau hauv loj nkag mus rau hauv lub ntsws. Vim li no, cov tsos mob tsis zoo thiab muaj xws li mob me mus rau nruab nrab ua tsis taus pa, hnoos, qee zaum muaj cov ntshav me me, kub siab. Cov tsos mob no tshwm sim dhau sijhawm, ua rau mob ntsws lossis mob angina, tshwj xeeb tshaj yog tias tsis nrog hemoptysis.
Kev kho mob Prehospital
Kev kho mob suav nrog kev kho cov pa nrog 100% oxygen, zoo dua ua kom lub tshuab ua pa, kho qhov mob narcotic (morphine lossis fentanyl, neuroleptanalgesia tau tso cai), kev kho anticoagulant nrog unfractionated heparin 5000-10000 IU, thrombokin nrog "000IU, Strepto". Kev qhia ua ntej ntawm "Prednisolone 90 mg".
Ntxiv rau qhov kev kho mob ntawm pulmonary embolism, kev kho cov tshuaj infusion thiab kev them nyiaj rau cov kev mob uas twb muaj lawm yuav tsum tau: defibrillation rau qhov sib thooj arrhythmia thiab cardiotonic tshuaj rau hypotension. Cov kev kho mob qhia tau zoo heev, tab sis nws yuav tsis pab kom cov ntshav txhaws tag - yuav tsum tau mus pw hauv tsev kho mob hauv tsev kho mob hnyav.
Nws yog ib qho tseem ceeb kom nkag siab tias tus nqi ntawm qhov yuam kev prehospital yuav tsis yog qhov tseem ceeb rau tus neeg mob qhov kev mob tshwm sim. Piv txwv li, yog tias kev hloov pauv tshwm sim ntawm ECG,Cov yam ntxwv ntawm lub plawv nres tawm tsam keeb kwm yav dhau los ntawm kev tsim PE, kev kho mob narcotic thiab anticoagulant kho nrog cov tshuaj zoo sib xws kuj tau qhia. Tsuas yog kev teem caij ntawm nitrates tuaj yeem ua rau muaj kev phom sij, uas yuav ua rau kom poob ntshav siab.
Tus neeg mob thiab EMS cov neeg ua haujlwm kuj yuav tsum nco ntsoov tias yog tias muaj myocardial infarction nrog ntshav siab (tsawg dua 100\50 mmHg) lossis xav tias PE, nitrates yuav tsum tsis txhob noj. Yog li, kev saib xyuas ntawm tus neeg mob nrog PE yuav luag zoo ib yam li myocardial infarction nrog sab laug ventricular tsis ua haujlwm tiv thaiv keeb kwm ntawm hypotension. Qhov no txhais tau hais tias ib tus neeg ua haujlwm EMS yuav muaj sijhawm ntxiv rau kev kuaj mob tiv thaiv keeb kwm yav dhau los ntawm kev kho mob zoo rau PE.
Kev kuaj mob PE ntawm lub tsev kho mob theem
Kev kuaj mob thiab kev kho mob pulmonary embolism ntawm lub tsev kho mob theem tau zoo dua li ntawm tsev kho mob ua ntej. Nyob rau hauv ib feem, qhov no yog ib qho kev txiav txim siab nkaus xwb, vim tias vim muaj cov thromboembolism loj heev, lawv feem ntau tsis txawm mus rau hauv tsev kho mob vim muaj kev tuag ua ntej tsev kho mob siab. Thiab nyob rau hauv cov ntaub ntawv ntawm submassive pulmonary embolism, myocardial pneumonia thiab recurrent pulmonary embolism, tus kab mob "muab sij hawm" rau high-zoo kuaj mob thiab kev kho mob. Cov tsos mob uas pom tau zoo ib yam li cov uas tau tshwm sim thaum kuaj mob nyob rau theem prehospital.
Kev cais tawm ntawm lub plawv nres ntawm ECG thiab cov tsos mob ntawm cov tsos mob ntawm overload ntawm sab xis ntawm lub plawv tam sim ntawd taw qhia tus kws kho mob nyob rau hauv kev coj ntawm pulmonary embolism. Txhawm rau kom paub meej qhov kev kuaj mob, kuaj x-ray, kuaj qhov ntsuas kub ceev: kev ntsuas ntau rau D-dimers, troponin T, CPK-MB, myoglobin. Nrog PED-dimers ntau ntxiv nrog rau qib troponin ib txwm (tus cim ntawm myocardial infarction).
Tus qauv kub rau kev kuaj mob PE yog txoj kev tsis tshua muaj ntawm angiopulmonography lossis perfusion scanning. Nws muaj peev xwm ntseeg tau los yog tsis lees paub qhov kev kuaj mob ntawm thromboembolism, txawm li cas los xij, txoj kev tshawb no tsis tuaj yeem ua tau hauv tsev kho mob feem ntau, lossis vim qhov mob hnyav, tus neeg mob tuag ua ntej nws ua tiav. Kev pabcuam hauv kev kuaj mob kuj yog muab los ntawm echocardiography, ultrasound ntawm cov leeg ntawm sab qis, dopplerography. Txoj cai atrial catheterization thiab kev ntsuas siab tuaj yeem ua intraoperatively kom paub meej tias pulmonary hypertension.
Kev kho mob hauv tsev kho mob PE yuav tsum tau ua tib zoo saib xyuas tus neeg mob tus mob hauv chav kho mob hnyav. Tom qab lees paub qhov kev kuaj mob, nws yog ib qho tsim nyog yuav tsum pib kho thrombolytic nrog cov ntaub so ntswg plasminogen proactivators - Tenecteplase lossis Alteplase. Cov no yog cov tshuaj thrombolytic tshiab, lub ntsiab kom zoo dua uas yog qhov tsis muaj ntshav txhaws. Lawv lyse nws hauv txheej, tsis zoo li Streptokinase.
Thrombolytic therapy (TLT) yog tsim los kom yaj cov ntshav yog tias ua tau. Txawm li cas los xij, yog tias nws tsis tuaj yeem ua TLT, kev phais thromboextraction tuaj yeem ua tau - qhov kev ua haujlwm nyuaj tshaj plaws rau tus neeg mob nyob rau hauv cov xwm txheej ntawm cov ntshav khiav, uas yuav tsum tau siv rau hauv cov xwm txheej uas tus neeg mob yuav tuag yam tsis muaj kev cuam tshuam.
Nws tseem ceeb kom nco ntsoov tias tsis muaj qhov ntawdlub tswv yim ntawm "kev pab txhawb nqa kev kho mob" nrov ntawm cov pej xeem ntawm CIS tsuas yog tsis tuaj yeem nyob hauv qhov xwm txheej no. Ntawm no nws yog ib qho tseem ceeb kom tsis txhob cuam tshuam nrog cov neeg ua haujlwm thiab ua raws li cov lus pom zoo kho mob. Pulmonary embolism yog ib yam kab mob uas mus txog rau tam sim no nyob rau hauv cov ntaub ntawv ntawm submassive los yog loj embolism yeej ib txwm tuag thiab incurable.
Tag nrho cov dej num hauv kev kho mob tam sim no yog tsom rau kev ua haujlwm zoo thrombolysis thiab kev kho mob hnyav: kev kho cov pa oxygen txaus, kev txhawb nqa cardiotonic, kev kho infusion, kev noj zaub mov zoo rau parenteral. Los ntawm txoj kev, PE yog ib qho kab mob uas txhua qhov kev teem caij yog "sau hauv cov ntshav" vim tag nrho cov neeg tuag uas tau tshwm sim ua ntej. Yog li ntawd, txhua qhov kev sim ntawm tus neeg mob thiab nws cov txheeb ze, nrog rau kev hloov pauv tsis txaus ntseeg los ntawm cov tuam tsev thiab cov tsev kho mob, ntawm qhov kev thov, yuav tsum raug cais tawm.
