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BNH HC NHI KHOA

TI LIU SU TM TNG HP DCH

Gii thiu Information Mc lc

Bin son ebook : L nh Sng I HC Y KHOA H NI Trang web : www.ykhoaviet.tk Email : Lesangmd@gmail.com, bachkhoayhoc@gmail.com in thoi : 0973.910.357

THNG TIN
THNG BO V VIC XUT BN BCH KHOA Y HC 2010 : Theo yu cu v nguyn vng ca nhiu bn c, khc vi Bch Khoa Y Hc cc phin bn trc, bn cnh vic cp nht cc bi vit mi v cc chuyn khoa mi,cng nh thay i cch thc trnh by, Bch Khoa Y Hc 2010 c chia ra lm nhiu cun nh, mi cun bao gm mt ch ca Y Hc, nh th s gip bn c tit kim c thi gian tra cu thng tin khi cn. Tc gi xin chn thnh

cm n tt c nhng kin ng gp ph bnh ca qu{ c gi trong thi gian qua. Tt c cc cun sch ca b sch Bch Khoa Y Hc 2010 bn c c th tm thy v ti v t trang web www.ykhoaviet.tk c L nh Sng xy dng v pht trin. NG H : Tc gi xin chn thnh cm n mi s ng h v mt ti chnh gip cho Bch Khoa Y Hc c pht trin tt hn v ngy cng hu ch hn. Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti liu hc tp v ging dy Y Khoa ca cc c nhn v Doanh nghip xin gi v : Tn ngn hng : NGN HNG U T V PHT TRIN VIT NAM Tn ti khon ngn hng : L nh Sng S ti khon : 5111-00000-84877

CNH BO :
TI LIU NY CH MANG TNH CHT THAM KHO nhm mc ch nng cao hiu bit v Y

khoa. Tuyt i khng c t p dng cc thng tin trong ebook ny chn on v t iu tr bnh, nht l vi nhng ngi khng thuc nghnh Y . Tc gi ebook ny khng chu bt c trch nhim g lin quan n vic s dng thng tin trong cun sch p dng vo thc tin ca bn c. y l ti liu su tm t nhiu tc gi khc nhau, nhiu cun sch khc nhau, cha c kim chng , v th mi thng tin trong cun sch ny u ch mang tnh cht tng i . Cun sch ny c phn pht min ph vi mc ch s dng phi thng mi, bt c hnh vi no lin quan n vic mua bn, trao i, chnh sa, in n cun sch ny vo bt c thi im no u l bt hp l . Ni dung cun ebook ny c th c thay i v b sung bt c lc no m khng cn thng bo trc.

GII THIU
B sch ny c L Sng su tm , bin dch v tng hp vi mc ch cung cp mt ngun ti liu tham kho hu ch cho cc bn sinh vin y khoa, v tt c nhng ai c nhu cu tm hiu, nghin cu, tra cu , tham kho thng tin y hc. Vi tiu ch l b sch m , c xy ng da trn ngun ti liu ca cng ng , khng mang mc ch v li, khng gn vi mc ch thng mi ha i bt kz hnh thc no , nn trc khi s dng b sch ny bn phi ng vi nhng iu kin sau . Nu khng ng , bn khng nn tip tc s dng sch : B sch ny c cung cp n tay bn , hon ton da trn tinh thn t nguyn ca bn. Khng c bt kz s thng lng, mua chuc, mi gi hay lin kt no gia bn v tc gi b sch ny. Mc ch ca b sch phc v cng tc hc tp cho cc bn sinh vin Y khoa l chnh, ngoi ra nu bn l nhng i tng ang lm vic trong nghnh Y cng c th s dng b sch nh l ti liu tham kho thm . Mi thng tin trong b sch u ch c tnh chnh xc tng i, thng tin cha c kim chng bi bt c c quan Php lut, Nh xut bn hay bt c c quan c trch nhim lin quan no . V vy, hy lun cn trng trc khi bn chp nhn mt thng tin no c cung cp trong b sch ny. Tt c cc thng tin trong b sch ny c su tm, tuyn chn, phin dch v sp xp theo trnh t nht nh . Mi bi vit d ngn hay di, d hay d d cng u l cng sc ca chnh tc gi bi vit . L nh Sng ch l ngi su tm v phin dch, ni mt cch khc, ngi gip chuyn ti nhng thng tin m cc tc gi bi vit cung cp, n tay cc bn .

B sch ny l ti liu su tm v dch bi mt sinh vin Y khoa ch khng phi l mt gio s tin s hay mt chuyn gia Y hc dy dn kinh nghim, o c th c rt nhiu li v khim khuyt khng lng trc , ch quan hay khch quan,

cc ti liu b tr c th cha hp l , nn bn cnh vic thn trng trc khi thu nhn thng tin , bn cng cn c k phn mc lc b sch v phn hng dn s dng b sch s dng b sch ny mt cch thun tin nht. Tc gi b sch in t ny khng chu bt c trch nhim no lin quan n vic s dng sai mc ch , gy hu qu khng tt v sc khe, vt cht, uy tn ca bn v bnh nhn ca bn . Khng c chuyn mn , khng phi l nhn vin y t , bn khng c ph p t s dng nhng thng tin c trong b sch ny chn on v iu tr. T trc ti ny, cc thy thuc IU TR BNH NHN ch khng phi l IU TR BNH. Mi ngi bnh l mt thc th c lp hon ton khc nhau, o vic b nguyn xi tt c mi thng tin trong b sch ny vo thc tin s l mt sai lm ln . Tc gi s khng chu bt c trch nhim g do s bt cn ny gy ra. V l b sch cng ng, to ra v mc ch cng ng, do cng ng , b sch ny c pht trin c hay khng mt phn rt ln, khng ch da vo sc lc, s kin tr ca ngi to ra b sch ny , th nhng ng gp, xy ng, gp , b sung, hiu chnh ca ngi c chnh l ng lc to ln b sch ny c pht trin. V mt mc tiu tr thnh mt b sch tham kho y khoa tng hp ph hp vi nhu cu v tnh hnh thc tin trong lnh vc y t ni ring v trong cuc sng ni chung . Tc gi b sch mong mi bn c nhng li ng gp chn thnh mang tnh xy dng, nhng ti liu qu m bn mun san s cho cng ng , v mt tng lai tt p hn. l tt c nim mong mi m khi bt u xy dng b sch ny , ti vn kin tr theo ui . Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu kh v hin ti hoc trong tng lai gn. Trong thi i cch mng khoa hc cng ngh tin nhanh nh v bo nh hin nay, khng ai bit trc c liu nhng kin thc m bn c c c th p dng vo tng lai hay khng . tr li cu hi ny, ch c chnh bn thn bn , phi lun lun khng ngng-T MNH-cp nht thng tin mi nht trong mi lnh vc ca i sng, trong c lnh vc y khoa. Khng ai c th, tt nhin b sch ny khng th, lm iu thay bn.

Nghim cm s dng b sch ny i bt kz mc ch xu no, khng c ph p thng mi ha sn phm ny i bt c anh ngha no. Tc gi b sch ny khng phi l tc gi bi vit ca b sch , nhng mt rt nhiu cng sc, thi gian, v tin bc to ra n, v li ch chung ca cng ng. Bn phi chu hon ton trch nhim vi bt kz vic s dng sai mc ch v khng tun th ni dung b sch ny nu ra. Mi l thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l thuyt, ch c thc t cuc sng mi l cun sch hon ho nht, bn khng phi l c gi m l din vin chnh. V Bch Khoa Y Hc cng ch l mt ht thc nh, vic s dng n xo nu hay nhn ging l hon ton ty thuc vo bn c. V ngi to ra ht thc ny s vui mng v c truyn thm ng lc tip tc c gng nu bit rng chnh nh bn m bit bao ngi khng cn phi xp hng ch cu tr. Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt mong nhn c phn hi t cc bn c gi cc phin bn sau c tt hn. Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong khe mnh, cuc sng ngy cng m no hnh phc. Lng, Ngh An. Thng 8/2010

ABOUT

ebook editor: Le Dinh Sang Hanoi Medical University Website: www.ykhoaviet.tk Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com Tel: 0973.910.357 NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010: As the request and desire of many readers, in addition to updating the new articles and new specialties, as well as changes in presentation, Medical Encyclopedia 2010 is divided into many small ebooks, each ebook includes a subject of medicine, as this may help readers save time looking up informations as needed. The author would like to thank all the critical comments of you all in the recent past. All the books of the Medical Encyclopedia 2010 can be found and downloaded from the site www.ykhoaviet.tk ,by Le Dinh Sang construction and development. DONATE The author would like to thank all the financially support to help the Medical Encyclopedia are developing better and more-and-more useful. All broken hearted support for building a website for the dissemination of learning materials and teaching Medicine of individuals and enterprises should be sent to: Bank name: BANK FOR INVESTMENT AND DEVELOPMENT OF VIETNAM Bank Account Name: Le Dinh Sang Account Number: 5111-00000-84877 DISCLAMER : The information provided on My ebooks is intended for your general knowledge only. It is not a substitute for professional medical advice or treatment for specific medical conditions. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified health professional. Please contact your health care provider with any questions or concerns you may have regarding your condition.

Medical Encyclopedia 2010 an any support from L nh Sng are provi e 'AS IS' and without warranty, express or implied. L Sng specifically disclaims any implied warranties of merchantability and fitness for a particular purpose. In no event will be liable for any damages, including but not limited to any lost or any damages, whether resulting from impaired or lost money, health or honnour or any other cause, or for any other claim by the reader. Use it at Your risks ! FOR NON-COMMERCIAL USER ONLY . YOU ARE RESTRICTED TO adapt, reproduce, modify, translate, publish, create derivative works from, distribute, and display such materials throughout the world in any media now known or hereafter developed with or without acknowle gment to you in Authors ebooks. FOREWORD These ebooks are Le Dinh Sangs collection, compilation an synthesis with the aim of providing a useful source of reference-material to medical students, and all who wish to learn, research, investigate to medical information. Just a set of open-knowledge, based on community resources, non-profit purposes, not associated with commercial purposes under any kind, so before you use this books you must agree to the following conditions. If you disagree, you should not continue to use the book: This book is to provide to you, completely based on your volunteer spirit. Without any negotiation, bribery, invite or link between you and the author of this book. The main purpose of these books are support for studying for medical students, in addition to others if you are working in health sector can also use the book as a reference. All information in the book are only relative accuracy, the information is not verified by any law agency, publisher or any other agency concerned. So always be careful before you accept a certain information be provided in these books.

All information in this book are collected, selected, translated and arranged in a certain order. Each artical whether short or long, or whether or unfinished work are also the author of that article. L nh Sng was only a collectors in other words, a person to help convey the information that the authors have provided, to your hand. Remember the author of the articles, if as in this book is clearly the release of this information you must specify the author of articles or units that publish articles. This book is the material collected and translated by a medical student rather than a professor Doctor experienced, so there may be many errors and defects unpredictable, subjective or not offices, documents can be arranged not reasonable, so besides carefull before reading information, you should also read carefully the contents of the material and the policy, manual for use of this book . The author of this e-book does not bear any responsibility regarding the use of improper purposes, get bad results in health, wealth, prestige ... of you and your patients. 7. Not a professional, not a health worker, you are not allowed to use the information contained in this book for diagnosis and treatment. Ever, the physician treating patients rather than treatment. Each person is an independent entity and completely different, so applying all information in this book into practice will be a big mistake. The author will not bear any responsibility to this negligence caused. 8. As is the community material, these books could be developed or not are not only based on their strength and perseverance of the author of this book , the contribution, suggestions, additional adjustment of the reader is great motivation for this book keep developed. Because a goal of becoming a medical reference books in accordance with general requirements and the practical situation in the health sector in particular and life. 9. The contents of this book, may only correct in a certain time in the past and the present or in the near future. In this era of scientific and technological revolution as sweeping as fast now, no one knew before is whether the knowledge that you

have obtained can be applied in future or not. To answer this question, only yourself, have to always update-YOURSELF-for latest information in all areas of life, including the medical field. No one can, of course this book can not, do it for you. 10. Strictly forbidden to use this book in any bad purpose, not be allowed to commercialize this product under any mean and any time by any media . The author of this book is not the inventor of the book-articles, but has made a lot of effort, time, and money to create it, for the advanced of the community. You must take full responsibility for any misuse purposes and does not comply with the contents of this book yet. 11. All theories are just gray, a thousand books or a book are only theory, the only facts of life are the most perfect book, in which you are not an audience but are the main actor. This Book just a small grain, using it to cook or fry breeding is completely depend on you. And the person who created this grain will begin more excited and motivated to keep trying if you know that thanks that so many people no longer have to queue to wait for relief. 12. All comments related to the books should be sent to the me at the address above. We hope to receive feedbacks from you to make the later version better. 13. We wish you, your family and Vietnamese people has always been healthy, happy and have a prosperous life.

MC LC
BNH HC NHI KHOA
THNG TIN GII THIU ABOUT MC LC CHNG 1. CP CU NHI KHOA
S1. S2. S3. S4. S5. S6. S7. S8. S9. S10. S11. S12. S13. S14. S15. S16. HN M SC MT MU DO CHN THNG PHN LOI BNH V X TR CP CU KH TH THANH QUN HI CHNG STEVENS-JOHNSON NGNG TH NGNG TIM SC PHN V SC KHI NIM V IMCI SUY GAN CP - HN M GAN SUY H HP CP NG C PHOSPHORE HU C PH PHI CP NG C THC N HN M D VT NG TH

CHNG 2. BNH L S SINH


S17. S18. S19. S20. S21. NHIM TRNG HUYT S SINH CO GIT S SINH VNG DA S SINH NHIM TRNG RN S SINH VIM RUT HOI T S SINH

CHNG 3. BNH NI TIT CHUYN HA


S22. S23. S24. U TU THNG THN U V THNG THN GY NAM HO TUYN HUNG PH I

CHNG 4. BNH BM SINH DI TRUYN


S25. S26. S27. S28. C THY TINH TH BM SINH TNG SN THNG THN BM SINH (CAH) BN CHN KHOO BM SINH LM LNG NGC BM SINH

CHNG 5. BNH L TIM MCH


S29. S30. S31. S32. S33. S34. S35. THNG LIN THT TLT CN NG NG MCH THNG LIN NH THP TIM T CHNG FALLOT CN NG NG MCH VIM M MNG TIM

CHNG 4. BNH L H HP
S36. S37. S38. S39. S40. S41. S42. S43. S44. S45. S46. S47. S48. S49. VIM PH QUN PHI TRN M MNG PHI NHIM KHUN H HP CP TNH SUY H HP S SINH HO G BNH VIM TIU PH QUN TR EM TRN DCH MNG PHI LON SN PHI VIM THANH KH PH QUN CP NHIM KHUN H HP CP TNH TR EM VIM TIU PH QUN CP TNH VIM THANH QUN CP VIM M MNG PHI VIM PH QUN PHI DO VI KHUN

CHNG 5. BNH L TIU HA


S50. S51. S52. S53. S54. S55. S56. S57. S58. S59. S60. S61. TIU CHY CP SUY DINH DNG TO BN VIM GAN VIRUS CP LOT D DY T TRNG VNG DA DO BT NG NHM MU ABO VIM LOT D DY T TRNG DINH DNG NG TNH MCH HON TON LUNG TRO NGC D DY THC QUN NI SOI TIU HA TRO NGC D DY THC QUN L TRC TRNG

CHNG 6. BNH L TIT NIU SINH DC

S62. S63. S64. S65. S66. S67. S68. S69. S70.

HI CHNG THN H TIN PHT TR EM VIM BNG QUANG CHY MU VIM CU THN CP VIM CU THN TRONG SCHOENLEIN-HENOCH HI CHNG THN H TIN PHT KHNG STEROID U NGUYN BO THN TINH HON N (LC CH) VIM CU THN CP TIN PHT SUY THN MN TNH

CHNG 7. BNH L THN KINH


S71. XUT HUYT NO MNG NO SM S72. VIM MNG NO M TR EM S73. XUT HUYT NO MNG NO MUN DO THIU VITAMIN K S74. THOT V MNG NO TU S75. CO GIT S76. CO GIT DO ST CAO TR EM S77. CO GIT TR EM S78. XUT HUYT NO - MNG NO TR LN S79. XUT HUYT NO - MNG NO TR NH S80. VIM NO NHT BN BNH L TRC TRNG VIM MNG NO M S81. VIM MNG NO LAO S82. VIM TU CT NGANG S83. VIM A R V DY THN KINH NGOI BIN S84. U NO S85. TRNG THI NG KINH

CHNG 8. BNH L TM THN


S86. S87. S88. S89. S90. RI LON TIC TRM CM RI LON LO U TRNG THI KCH NG TM THN RI LON PHN LY

CHNG 9. C XNG KHP


S91. S92. S93. S94. S95. GY XNG VIM M KHP VIM XNG TU XNG LON SN KHP HNG BM SINH CNG DUI KHP GI SAU TIM KHNG SINH TRONG C T U

CHNG 10. BNH TRUYN NHIM


S96. S97. NHIM TRNG DO T CU BNH SI

S98. S99.

IU TR VIM MNG NO M NHIM TRNG HUYT NO M CU

CHNG 11. BNH L HUYT HC


S100. S101. S102. S103. S104. XUT HUYT GIM TIU CU T PHT U LYMPHO KHNG HODGKIN THIU MU TAN MU T MIN THIU MU THIU ST U TU

CHNG 12. BNH L KHC


S105. S106. S107. VIM TAI GIA CP TR EM S DNG THUC TRONG NHI KHOA CHNG TRNH TIM CHNG M RNG

CHNG 13. TI NGHIN CU NHI KHOA


S108. HP EO NG MCH CH S109. NGHIN CU VI KHUN T DCH HT KH PH QUN CA BNH NHN NM VIN S110. NHN XT C IM LM SNG CA NHIM KHUN SHIGELLA TR EM TI BNH VIN NHI TRUNG NG 1998 - 2000 S111. MT S NHN XT V BNH NHI HEN PH QUN TR EM VO IU TR TI KHOA H HP A16 BNH VIN NHI TRUNG NG S112. TO HNH THC QUN BNG I TRNG NGANG QUA KHE THC QUN C TR GIP CA SOI LNG NGC S113. NGHIN CU MT S C IM DCH T LM SNG V BC U NH GI KT QU THAY MU CHO TR S SINH VNG DA TNG BILIRUBIN T DO TRONG MU S114. SNG LC S SINH BIN PHP PHT HIN SM BNH L RI LON NI TIT - CHUYN HO V DI TRUYN S115. U V THNG THN NAM HO BNH NHN TNG SN THNG THN BM SINH DO THIU 21HYDROXYLASE S116. TNH HNH BNH TT TR EM QUA SINH THIT TI KHOA GII PHU BNH BNH VIN NHI TRUNG NG NM 2002 S117. HI CHNG KHNG NHY CM HON TON VI ANDROGEN

CHNG 1. CP CU NHI KHOA

S1.

HN M

I. I CNG:

Hn m l s suy gim thc do tn thng bn cu i no hoc h thng li. Nguyn nhn


o o

Chn thng: xut huyt no, dp no. Tai bin mch mu no: nhn no, xut huyt no khng do chn thng. Nhim trng: vim no mng no, st rt th no. Chuyn ha: ri lon in gii, h ng huyt, tiu ng, suy gan, suy thn. Ng c: thuc ng, Morphin v dn xut, phospho hu c. Thiu mu no (sc), thiu oxy no (suy h hp). ng kinh

o o

o o o

II. CHN ON: 1. Cng vic chn on: a) Hi bnh:


Chn thng. St, nhc u, nn i. Tiu chy. Co git. Tip xc thuc, c cht, ru. Tin cn: tiu ng, ng kinh, bnh gan thn.

b) Khm lm sng:

Mc tiu: nh gi mc hn m v tm nguyn nhn:


o o

Du hiu sinh tn: Mch, huyt p, nhp th, kiu th, nhit . Huyt p cao: bnh l thn; huyt p cao km mch chm: tng p lc ni s. Th nhanh su: toan chuyn ha, tiu ng. Th chm nng, khng u: tn thng thn kinh trung ng.

o o

Khm thn kinh:


o

Mc tri gic:

Da vo thang im Glasgow cho tr em. Ri lon tri gic t ngt thng gp trong tt no.

BNG NH GA BNH NHN HN M DA THEO THANG IM GLASGOW CI TIN TR EM

Tr hn m khi im tng cng theo thang im Glasgow 10 im Glasgow < 8 im thng nng, t vong cao.

THANG IM BLANTYRE NH GI HN M TR EM

Tr hn m nu im tng cng theo thang im Blantyre < 3 im.

Khm mt:
o

ng t:

u hay khng, kch thc ng t, phn x nh sng Dn, c nh mt bn: xut huyt no, tt no. Cn loi tr n ng t o trc c ng thuc n ng t soi y mt. Co nh: ng c phospho hu c, thuc ng, Morphin, tn thng cu no.

o o

y mt: ph gai (tng p lc ni s) hoc xut huyt. Phn x mt bp b(+): tn thng cu no.

Du mng no: thp phng, c cng, Kernig, Brudzinsky. Du thn kinh khu tr:

Du hiu yu lit chi, lit dy s ch im tn thng khu tr nh t mu trong s, u no. Du hiu tng p lc ni s:

Phn x mt bp b: Khi xoay u qua phi hay tri mt khng di chuyn theo. Du hiu mt v (tay co chn dui) hoc mt no (dui t chi). ng t dn mt hay hai bn, ph gai th. Nhp th Cheynes Stokes hoc cn ngng th. Tam chng Cushing: mch chm, huyt p cao, nhp th bt thng l du hiu tr ca tng p lc ni s.

Phn x gn xng, u Babinsky: tng phn x gn xng km Babinsky (+): tn thng trung ng.

Khm ton din:


o

Tim bm sinh tm, m km du thn kinh khu tr: thuyn tc mch no. Bng: kch thc gan, lch, tun hon bng h. Gan lch to km st: st rt. Gan lch to km bng bng, tun hon bng h: hn m gan. Da: bm mu, vng da. Du hiu thiu mu.

o o

c) ngh cn lm sng:

Xt nghim thng qui:


o o o

Cng thc mu, k sinh trng st rt Dextrostix, ng huyt, ion , TPTNT, ng niu, keton niu Kh mu khi suy h hp c ch nh th my

Chc d ty sng sau khi loi tr tng p lc ni s. Chng ch nh chc d ty sng: suy h hp, sc, ri lon ng mu, nghi ng tng p lc ni s.

Xt nghim khi nh hng chn on:


o o o o o o

Siu m no xuyn thp (u no, xut huyt no). Chc nng ng mu (xut huyt no mng no, ri lon ng mu). Chc nng gan, thn (bnh l gan, thn). Xquang tim phi (bnh l tim, phi). Tm c cht trong dch d y, mu, nc tiu (ng c). CT scanner no nu nghi ng t mu, u no, p xe no m khng lm c siu m xuyn thp hoc siu m c lch M-echo. EEG (ng kinh, vim no Herpes).

III. IU TR: 1. Nguyn tc iu tr:


Bo m thng kh v tun hon. Pht hin cc bnh l ngoi thn kinh. iu tr nng v phng nga bin chng. iu tr nguyn nhn.

2. iu tr ban u: 2.1 Bo m tt s thng kh v tun hon: a. Thng ng th v m bo thng kh tt

T th nga u nng cm. Phi c nh c trc nu nghi ng chn thng ct sng c Ht m nht

t ng thng ming hu khi tht bi vi nga u nng cm v ht m nh Th oxy duy tr SaO2 92-96% t ni kh qun gip th: cn ngng th, tng p lc ni s

b. Chng sc:

Truyn dch Lactate Ringer hay Normal saline 20 ml/kg/gi v cc thuc tng sc co bp c tim (Dopamine, Dobutamine) duy tr huyt p n nh. Trnh truyn qu nhiu dch c th gy ph no v tng p lc ni s.

2.2 Khi c du hiu lm sng gi t mu, u no hay p xe no cn hi chn ngoi thn kinh. 2.3 Thit lp ng truyn tnh mch ly mu xt nghim. 2.4 Nu Dextrostix < 40 mg%, iu tr h ng huyt:

Tr s sinh: Dextrose 10% 2 ml/kg TMC. Tr ln: Dextrose 30% 2 ml/kg TMC.

2.5 Cao huyt p khng do suy h hp v tng p lc ni s: thuc h p (xem phc x tr cao huyt p). 2.6 Chng ph no nu c: xem phc vim no. 2.7 iu tr mt s nguyn nhn khi cha c kt qu xt nghim:

Nghi ng h ng huyt: dung dch ng u trng. Nghi ng ng c Morphin: Naloxone 0,1 mg/kg ti a 2g TM Nghi st rt: Artesunate TM. Nghi vim mng no (c chng ch nh chc d ty sng): khng sinh tnh mch sau khi cy mu. Nghi vim no do Herpes: Acyclovir TM.

2.8 iu tr nguyn nhn c xc nh (xem phc x tr theo nguyn nhn). 2.9 Truyn dch v dinh dng.

Truyn dch:
o o

2/3 nhu cu trnh ph no do tit ADH khng thch hp. Nu c tng p lc ni s: truyn 1/2 nhu cu.Natri: 3mEq/100 ml dch, Kali 1-2 mEq/100 ml dch. Dung dch thngchn l Dextrose 510% trong 0,2-0,45% saline.

Dinh ng:
o

Trong giai on cp khi c chng ch nh nui n qua son e dy th trong 3 ngy u ch cn cung cp glucose v in gii. Cn nhanh chng nui n qua son e dy nu khng c chng ch nh, chia lm nhiu ba n nh git chm, nu cn nui n tnh mch mt phn.

2.10 Phng nga nhim trng bnh vin:


Vt l tr liu h hp. Chm sc bnh nhn hn m.

3. Theo di

Mch, HA, nhp th, tri gic (ch s hn m), co git v cc du hiu ca tng p lc ni s. Ion , ng huyt.

LU X TR HN M

S2.

SC MT MU DO CHN THNG

I. I CNG:

Sc mt mu do chn thng l cp cu ni-ngoi khoa khn cp do gim lu lng mu lu thng. Bnh thng mu lu thng tr em khong 80 mL/kg cn nng. Sc xy ra khi lng mu mt trn 25%. Nguyn nhn:
o o o

V tng c (gan,lch, thn...) trong chn thng bng kn. Gy xng ln (xng i, xng chu). t cc mch mu ln.

Phn mt mu:
o

I: mt < 15% th tch mu: du hiu sinh tn t thay i, tim nhanh, huyt p bnh thng. II: mt 15 - 25% th tch mu: tim nhanh, huyt p kp, kch thch. III: mt 26 - 40% th tch mu: huyt p tt, mch nh, l m. IV: mt trn 40% th tch mu: sc nng, mch khng bt c, huyt p khng o c, hn m, da lnh.

o o o

Tr em c th khng c tt huyt p nh ngi ln d mt mt lng mu ng k. V cung lng tim v huyt p ng mch c duy tr bng nhp tim tng v co mch nn tt huyt p thng c giai on tr, sc nng.

II. CHN ON: 1. Cng vic chn on a) Hi bnh:


Chn thng: c ch chn thng. Xut huyt: v tr, lng mu mt.

Cch s cu cm mu.

b) Khm lm sng:

Du hiu sinh tn, thi gian phc hi mu da. Du hiu thiu mu, ni chy mu. Mc tri gic. Khm tim, phi, bng, u, chi.

c) Cn lm sng:

CTM, tiu cu m, Hct, nhm mu. ng mu ton b. Tm nguyn nhn:


o o

Xquang bng khng chun b X-quang xng nu c du hiu nghi gy xng, siu m bng.

2. Chn on xc nh:

Du hiu sc. ang chy mu hoc du hiu thiu mu hoc Hct < 30%.

III. IU TR: 1. Nguyn tc iu tr:


S cu cm mu. B lng mu mt. iu tr nguyn nhn: phu thut cm mu.

2. iu tr ban u: 2.1 Nu thy mu ang chy:

Nhanh chng cm mu bng cch: dng gc v n ngn tay vo ni mu ang chy, nng cao ch b thng ang chy mu, khng ct gar ngoi tr trng hp t la chi v khng kim sot c chy mu cc mch mu ln. Sau mi khm ngoi khoa ngay lp tc.

2.2 Th oxy. 2.3 Nm u phng, chn cao. 2.4 Lp 2 ng truyn tnh mch ln chi (thng chi trn) vi kim lun

Ly mu xt nghim: Hct, nhm mu, ng k{ mu. Truyn dch trong khi ch mu (ng truyn 1). Lactate Ringer hay Normal saline tng th tch tun hon v b lng dch thiu ht. Ban u truyn 20 mL/kg chy nhanh, sau ty theo p ng ca bnh nhn m iu chnh tc . tr i 6 tui m khng chch tnh mch c th c th truyn tm thi qua ng ty xng trong thi gian chch hoc bc l tnh mch.

2.5 Truyn mu ton phn (ng truyn 2)

Truyn mu ton phn cng nhm 20 mL/kg. Nu khng c mu cng nhm, truyn mu nhm O. Tc ty theo tnh trng huyt ng. Nu ang sc nng vi mch=0, huyt p = 0 th bm trc tip. Ch nh truyn mu: Hct thp < 30% hoc sau khi truyn nhanh 40 mL/kg dung dch in gii vn khng nng c huyt p. Tip tc truyn dung dch in gii qua ng truyn 1. Nu cn truyn mu tc nhanh, lng nhiu th mu cn c lm m trnh ri lon nhp tim. Nu cha c mu sau khi truyn dung dch in gii 40 mL/kg m bnh nhn cn sc: truyn cao phn t (Gelatine) 20 mL/kg, tc ty theo tnh trng sc.

3. iu tr tip theo:

Sau khi truyn mu ton phn 20 mL/kg:

a. Ci thin tt:

Bnh nhn ra sc v Hct bnh thng: tip tc duy tr dch in gii, tuy nhin trnh truyn qu nhanh c th gy qu ti. Nu nguyn nhn sc do v tng c th mi ngoi khoa can thip phu thut.

b. p ng nhng huyt p tt khi gim tc truyn dch:

Tip tc b dch v mu. Nu c ch nh phu thut th s hi sc song song vi phu thut.

c. Khng p ng:

Nu cn sc v Hct thp < 30% th cn truyn mu tip tc. S lng tip theo ty tnh trng huyt ng ca bnh nhn lc . Khi truyn mu khi lng ln > 50 mL/kg, cn xt nghim chc nng ng mu v tiu cu. Nu ri lon ng mu th truyn hng cu lng v huyt tng ti ng lnh 10 mL/kg. Nu gim tiu cu (<50.000/mm3) truyn tiu cu m c 1 n v/5 kg. o CVP hng dn b dch v mu. Mi bc s ngoi khoa xem xt ch nh phu thut cm mu. Calcium: khi truyn qu 40 mL/kg mu ton phn cn ch cho calci gluconate 10% 1-2 mL TMC.

4. Ch nh ngoi khoa:

t mch mu: can thip ngoi khoa ngay trong lc hi sc sc V tng c:


o o

Khi tnh trng bnh nhn tm n nh huyt ng hc Khi truyn mu trn 50 mL/kg m bnh nhn cn sc hay Hct i 30% chng t bnh nhn ang chy mu nng cn phu thut cm mu.

IV. THEO DI

Mch, huyt p, ti mu da mi 15 pht cho n khi ra sc v sau mi gi. Hct sau truyn mu v mi gi cho n khi n nh Nc tiu mi 4-6 gi. Vng bng bnh nhn chn thng bng kn, tnh trng chy mu ti vt thng

S3.

PHN LOI BNH V X TR CP CU

BV Nhi ng 1 TPCHM

T vong trong bnh vin thng xy ra trong vng 24 gi u. Phn ln cc trng hp t vong ny c th ngn nga c nu tr bnh nng c lc bnh, pht hin du hiu cp cu sm v x tr kp thi. Lc bnh phi c thc hin ni nhn bnh ca phng khm trc mi th tc hnh chnh nh ng k{ khm bnh. Ngi lc bnh l bc s hoc iu ng c kinh nghim v qua kho hun luyn lc bnh. Lc bnh l mt qui trnh sng lc nhanh tr bnh khi tr c a n c s y t phn loi tr thnh 3 nhm sau:
o o

Tr c du hiu cp cu cn cp cu ngay Tr c du hiu u tin s c khm trc nh gi v iu tr kp thi Tr khng c du hiu cp cu hoc u tin s c khm bnh theo th t.

Phn loi Cp cu u tin

Thi gian ti a phi x tr (pht) 0 10

Khng cp cu, khng u tin 120

TH T CC BC LC BNH

Hi b m l{ o a tr n khm cng lc quan st, s tay chn tr, pht hin kp thi nhng du hiu cp cu.

I. TM NHNG DU HIU CP CU NG THI X TR CP CU NGAY

Tm cc du hiu cp cu theo th t u tin:


o o o o

Du hiu cp cu h hp Du hiu sc Du hiu hn m hoc co git Du hiu mt nc nng tr bi tiu chy

Nu tr c bt kz du heu cp cu no phi cp cu ngay, ku gi gip , sau tip tc v hon thnh vic nh gi v lm x t nghim cp cu: th ng huyt bng que (Dextrostix), dung tch hng cu (Hct)

I.1. nh gi v cp cu h hp I.1.1. nh gi

Du hiu tc nghn ng th
o o

Khn tin Th rt th ht vo

Khi c du hiu tc nghn ng th hi tr c ht sc khng. Nu c: tr b d vt ng th

Du hiu suy h hp nng:


o o o

Ngng th hoc cn ngng th Tm ti Rt lm ngc nng

Khi tr ngng th, phi khai thc xem c chn thng u c khng. Nu c: phi c nh c ngay trc khi gip th. I.1.2. Cp cu h hp: X tr cp cu Ngng th

Nga u. C nh c khi nghi chn thng ct sng c. Bp bp qua mask. Th thut Heimlich nu tr > 2 tui. Th thut v lng n ngc nu tr 2 tui

D vt ng th

Rt lm ngc. Th rt khi nm yn

Th oxy

I.2. nh gi v cp cu sc I.2.1. nh gi

Du hiu tr b sc:
o o

Tay chn lnh Thi gian y mao mch chm = 3 giy(n lm trng mng tay. Thi gian y mao mch l thi gian lm hng tr li mng tay.)

Mch c tay yu hoc khng bt c

Khi tr c du hiu sc cn kim tra:


o o o

Tm vt thng ang chy mu cm mu Hi b m: xut hin t ngt sau chch thuc hay cn trng cn. Nu c: nghi sc phn v

I.2.2. Cp cu sc Sc Sc X tr cp cu

Th oxy Lp ng truyn: tnh mch ngoi bin. Truyn dch nhanh 20 ml/kg Gi m Cm mu Truyn dch nhanh, truyn mu 20ml/kg

Sc mt mu

Sc phn v

Adrenaline 1. 0,3ml TDD

I.3. nh gi v cp cu tr hn m hoc co git I.3.1. nh gi

Mc tri gic c nh gi nhanh bi thang im AVPU,


o o o o

A (alert): tr tnh V (voice): p ng vi li ni P (pain): p ng vi kch thch au (v o a hoc ko tc vng trn) U (unconscious): hn m.

Tr ang co git: co git khu tr hoc ton thn Nu tr hn m hoc co git, hi b m:


o o

Tr c b chn thng u c. Nu c hoc nghi ng, phi c nh c Tr c ng bt thng hay kh nh thc khng xc nh hn m

I.3.2. Cp cu tr hn m, co git: Trng thi X tr cp cu Hn m


Thng ng th C nh ct sng c nu nghi ng chn thng ct sng c Nm nghing Glucose TM Thng ng th Nm nghing Diazepam TM / bm hu mn

Co git

I.4. nh gi v cp cu mt nc nng tr tiu chy

I.4.1. nh gi

Mt nc nng khi c = 2 du hiu sau:


o o o

Tr li b hoc kh nh thc Du hiu mt trng Np vo da bng mt rt chm (>2 giy)

Khi c du hiu mt nc nng, kim tra suy inh ng nng (gy mn nng, du hiu ph c 2 bn chn). Nu c SDD nng, nn b dch qua sonde d dy.

I.4.2. Cp cu mt nc nng X tr Mt nc nng khng SDD nng Truyn dch Mt nc nng km SDD nng B ORS qua sonde d dy

II. TM CC DU HIU U TIN

Tr c du hiu u tin khi c mt trong cc du hiu sau:


o o

Li b, bt rt, khng yn Suy h hp: (Ngng th nhanh:


Tr < 2 thng: = 60 ln/pht Tr 2 thng - i 12 thng: = 50 ln/pht Tr 12 thng - 5 tui: = 40 ln/pht)

o o o o o o

Gy mn nng hoc ph 2 bn chn Lng bn tay rt nht Phng Tai nn, ng c Tr bnh i 2 thng tui C giy chuyn vin t tuyn trc

Nhng tr c du hiu u tin u c nguy c in tin nng v nhanh, v th cn khm, nh gi trc x tr kp thi, khng phi xp ch th t khm. Nu tr c chn thng hoc c vn ngoi khoa th cn c s h tr ca ngoi khoa.

III. TR KHNG C DU HIU CP CU, KHNG C DU HIU U TIN

Nu tr khng c du hiu cp cu cng nh u tin th ch khm theo th t. Tt c tr sau khi c lc bnh v x tr cp cu phi c hi bnh s, thm khm ton in, ch nh xt nghim c chn on xc nh v iu tr nguyn nhn

BNG GI TR BNH THNG TR EM

Tui < 1 tui 2 - 5 tui

Nhp th(l/ph) Nhp tim(l/ph) HA tm thu(mmHg) 30 - 40 25 - 30 110 - 160 95 - 140 80 - 120 60 - 100 70 - 90 80 - 100 90 - 110 100 - 120

5 - 12 tui 20 - 25 > 12 tui 15 - 20

S4.

KH TH THANH QUN

Kh th thanh qun c coi nh mt cp cu h hp tr em. 1. Chn on xc nh : 1.1. Chn on xc nh Ch yu da vo lm sng chn on kh th thanh qun.

C 3 triu chng c bn, c in l :

Kh th th ht vo, kh th chm. C ting rt thanh qun (Cornage) Co k o c h hp nht l lm c v rt lm lng ngc.

C 4 triu chng ph hay gp :

Khn ting hay mt ting (khi ni, ho, khc). u gt g khi th, thng nga u ra sau trong th ht vo. Quan st thy sn thanh qun nh ln khi ht vo. Nhn mt v n cnh mi.

1.2. Chn on mc kh th thanh qun nh gi mc kh th thanh qun rt quan trng. iu ny gip cho tin lng v c thi x tr kp thi. C 3 mc kh th thanh qun theo 3 mc nng nh : 1 : Khn v r ting khi khc, ni. Ting ho cn trong hay hi r.

- Biu hin kh th vo cha in hnh, ting rt thanh qun nh hoc cha r co ko c h hp ph t. Tnh trng ton thn cha nh hng.

2 : Mt ting, ni khng r t. Ting ho ng ng nh ch sa.

- Triu chng kh th thanh qun in hnh ting rt thanh qun r, co k o c h hp mnh. Tr kch thch, vt v, ht hong, lo s.

3 : Mt ting hon ton, khc hoc ni khng thnh ting, pho pho. Khng ho thnh ting hoc khng ho c.

- Triu chng kh th d di, c biu hin ca tnh trng thiu xy nng. Tr c th tm ti, ri lon nhp th. - Tnh trng ton thn b nh hng r thn kinh (hn m, l hay vt v), tim mch, da ti v m hi v.v 1.3. Chn on nguyn nhn kh th thanh qun 1.3.1. Kh th thanh qun cp tnh :

D vt ng th : C hi chng xm nhp. Vim thanh qun cp : Nguyn nhn c th do vi khun (H.influenzae, Streptocoque, Staphylocoque) hoc virus (hay gp nht l virus cm, sau l virus nhm myxovirus). T tanie : Thng tr ci xng c biu hin co tht thanh qun cp tnh.

Bch hu thanh qun : c th khi pht t t nhng khi c gi mc gy tc th kh th d di. Pht hin da vo khm hng, soi thanh qun, cy tm vi khun bch cu. Vim thanh qun do si : C biu hin vim long ng h hp, mc ban si v da vo dch t hc. p xe sau hng : Biu hin nhim trng nng v khng nut c.

1.3.2. Kh th thanh qun mn tnh :

Th rt thanh qun bm sinh (Stridor congenitale) do mm sn thanh qun, d dng sn thanh qun. Hp thanh qun mn tnh : Do hu qu ca chn thng hoc hp do u mu, d dng bm sinh. U nh thanh qun : l loi u nh, lnh tnh thanh qun, u pht trin nhanh, ti pht gy kh th thanh qun t t. Chn on nh soi thanh qun.

2. X tr kh th thanh qun tr em :

Mc kh th thanh qun. C st hay khng st. nh gi li sau 10 15 pht iu tr. iu tr nguyn nhn:

C th : Nguyn nhn * C st : - Vim thanh qun cp i thanh mn - Th khng kh m. X tr

- Corticoid 2mg/kg/ngy (TB v kh dung) - Vim np thanh qun cp - T th ngi, O2. - Khng sinh (bBactrim), Cephalosporin - t NKQ hoc m kh qun - Bch hu - p xe thnh sau hng - Huyt thanh khng c t - Khng sinh (tnh mch) - Chch p xe * Khng st : - Mm sn thanh qun - U mu i thanh mn - D ng - D vt ng th - Vitamin D, Canxi - Corticoid (tim bp) - Kh dung Adrenalin, tim Corticoid - Ni soi ph qun ly d vt

S5.

HI CHNG STEVENS-JOHNSON

I. I CNG:

Hi chng Stevens-Johnson l hi chng lm sng: tn thng hng ban a dng da v nim mc. Nguyn nhn thng do d ng (Sulfamide, Carbamazepine,...) hoc nhim siu vi (Herpes simplex), vi trng (Mycoplasma pneumoniae). Bin chng thng gp l nhim trng huyt, vim phi, mt nc, ri lon in gii.

II. CHN ON: 1. Cng vic chn on: a) Hi bnh:


Tin s c d ng. C dng thuc t vi ngy n vi tun. Khi pht c hoc khng st.

b) Khm lm sng:

Tn thng a v nim mc:


o o

Da: Hng ban a ng km bng nc trn hng ban. Nim mc: vim lot nim mc l t nhin: ming, mt, hu mn, sinh dc. Ngoi ra c th tn thng nim mc ng tiu ha, h hp, tit niu.

Triu chng khc: St cao, ho, chy mi, au hng, i, tiu chy au ngc, au c, au khp.

c) ngh cn lm sng:

CTM: bch cu tng cao, cng thc bch cu chuyn tri (thng do nhim trng hay bi nhim). Cy mu, cy dch bng nc, cy nc tiu khi c bi nhim tm tc nhn gy bnh v c hng chn la khng sinh thch hp. Huyt thanh chn on Herpes simplex, Mycoplasma pneumoniae in gii , ng huyt bnh nhn c nui ng ng tnh mch. X quang phi:c hnh nh vim phi, nu giai on sm gi nhim Mycoplasma hoc giai on mun gi vim phi bi nhim.

2. Chn on xc nh:

Tn thng a v nim mc c hiu: hng ban a ng, bng nc, km tn thng nim mc t nht 2 l t nhin. Tin s dng thuc.

III. IU TR: 1. Nguyn tc iu tr:


Ngng ngay thuc nghi ng l tc nhn. Phng nga bi nhim. m bo nhu cu dch v inh ng.

2. iu tr ban u: 2.1. iu tr c hiu:


Ngng ngay thuc nghi ng l tc nhn. Nu nghi ng do Mycoplasma pneumoniae:


o o o

Khng sinh nhm Macrolides Erythromycine: 50 mg/Kg/ngy, chia 3 - 4 ln, trong 10 - 14 ngy. Hoc Azithromycine: 10 mg/Kg/ngy, liu duy nht / ngy, trong 3 ngy.

Nu do Herpes simplex: Acyclovir (Zovirax): 20 mg/Kg ung mi 6 gi, trong 5 ngy.

2.2. Corticoide:

Nu nguyn nhn l do d ng thuc nn c ch nh corticoides. Cc nguyn nhn khc hiu qu ca corticoides cn bn ci. Dng trong giai on cp trong vng 48-72 gi sau pht ban. Methyl prednisolone 4mg/kg/ngy chia 2 ln tim mch trong 3-5 ngy

2.3. iu tr triu chng:

Nm phng v trng, hn ch thm ving phng bi nhim qua da. S dng drap vi v trng Sn sc a: Ra da bng dung dch NaCl 0,9% v trng. Sau , thoa ung dch Betadine 10% hoc p gc Betadine nhng ni tn thng a su, lo t. Khng c chc v cc bng nc. V sinh rng ming, b phn tit niu sinh dc, hu mn. Khm chuyn khoa mt trnh cc bin chng mt nh: nh mi, vim mng mt, vim lot hoc thng gic mc, m mt. Nh mt vi thuc nh mt khng c corticoid (Neocin, Chlramphenicol?).

2.4. Dinh dng

Truyn dch: ngoi nhu cu c bn cn b sung thm lng dch mt qua da (tng t phng). Nui n tnh mch mt phn hoc ton phn trong nhng ngy u: xem phc inh ng qua ng tnh mch. Nui n qua son e dy: khi bnh nhn khng chu n ung hoc n khng so vi nhu cu. Lu { khi nui n qua son e y nn t sonde nh nhng v thng c km theo tn thng nim mc thc qun, c th lu son e khong 1 tun.

2.5. Khng sinh:

Khi c bi nhim: Cephalosporin th h th 1: Cephapirine 50100mg/kg/ngy TM, chia 3 - 4 ln, hoc Cephalosporine th h th 3 100mg/kg/ngy TM, chia 3 - 4 ln. Nu c nhim trng bnh vin: peflacine ? vancomycine.

3. Theo di:

Sinh hiu: mch, huyt p, nhit , nhp th, nc tiu. Din tin tn thng a, nim.

in gii , ng huyt nu c ch nh nui n tnh mch.

4. Phng nga:

Nu nguyn nhn nghi ng l do d ng thuc: phi thng bo v ghi vo s khm bnh thuc gy di ng, dn d bnh nhn thng bo cho thy thuc mi khi i khm bnh. Khi dng thuc phi hi tin s d ng cu bnh nhn v gia nh, n d bnh nhn theo i, ngng thuc v ti khm ngay khi c du hiu nh ni mn , nga?

S6.

NGNG TH NGNG TIM

BV Nhi ng 1 TP HCM

I CNG

tr em ngng th thng l hu qu ca tnh trng suy h hp cp. Ngng tim thng sau ngng th. No s b tn thng khi ngng th ngng tim trn 4 pht v nu trn 10 pht thng t vong, nu sng s li di chng no nng n. V th khi ngng th ngng tim cn nhanh chng cung cp oxy v mu cho no. C 2 loi hi sc:
o o

Hi sc c bn: hi sc ti hin trng, khng y dng c Hi sc tin b: hi sc thc hin ti c s y t hoc trn xe cu thng vi y dng c thuc cp cu

I. HI SC C BN 1.1 Chn on ngng th ngng tim

Hn m: lay gi khng tnh Lng ngc khng i ng Khng mch trung tm Mch trung tm:
o o

Nh nhi: mch khuu, mch bn; Tr ln: mch c, mch bn

1.2 Hi sc c bn

Thc hin ti ni xy ra tai nn ngoi bnh vin Nguyn tc: nhanh v theo th t A, B, C. Thng ng th (Airway) Thi ngt (Breathing) An tim ngoi lng ngc (Circulation)

Cc bc thc hin theo th t u tin: 1. Lay gi, ku gip


Lay gi bnh nhn Nu khng p ng l hn m, nghi ng ngng th ngng tim khi hn m v ku gi ngi gip

2. Thng ng th

Nga u nng cm, nu nghi chn thng ct sng c th ng phng php nga u v c nh c trnh di lch ct sng c Trong trng hp hn m th cc c vng c mt trng lc gy chn p tc ng th Ly d vt nu c:

o o o

Th thut v lng n ngc: s sinh, nh nhi Th thut Hemlich: tr ln Khng dng tay mc m d vt v c th y d vt vo su hn v lm tn thng nim mc ming hu

3. Quan st di ng lng ngc v nghe cm nhn hi th


Lng ngc khng i ng Khng cm nhn c hi th BN

4. Thi ngt

Thi ngt 2 ci c hiu qu Thi c hiu qu khi thy lng ngc nh ln khi thi c 2 ci c hiu qu, mt s tc gi khuyn co nn thi 5 ci vi nhp bnh thng

5. Bt mch trung tm

S sinh, tr nh: mch cnh tay, mch bn Tr ln: mch c, mch bn Nu c mch trung tm th tip tc thi ngt Khng c mch trung tm trong vng 10 giy -> Ngng tim

6. An tim ngoi lng ngc


Khi khng c mch trung tm trong vng 10 giy -> ngng tim Tin hnh n tim ngai lng ngc
o

Tr s sinh nh nhi (di 1 tui):

V tr: X. c, i ng ni 2 v mt khot ngn tay

K thut:

2 ngn ci hoc 2 ngn tay An su 1 - 2 cm Hnh1: An tim 2 ngn tay

Tr ln (Trn 1 tui):

V tr:

trn mu xng c 1 khot ngn tay (1 - 8 tui) 2 khot ngn tay (> 8 tui)

K thut:

1 bn tay ( 1- 8 tui) 2 bn tay (> 8 tui) An su 2 - 3 cm Hnh: An tim 1 bn tay Tn s n tim 100 ln /pht An tim ng: mch trung tm c khi n

Ngng th ngng tim:

T l n tim/ thi ngt


S sinh: 3/1 Tr nh <8T: 5/1 Tr > 8T: 15/2

Nu c 2 ngi: ngi n tim m ln ngi thi ngt nghe phi hp

Tip tc thi ngt v n tim 1 pht. Sau nh gi li

Hnh 1: n tim 2 ngn tay

Hnh 2: n tim 1 bn tay

7. Quan st di ng lng ngc v bt mch trung tm


Nu mch trung tm r, u: tim p li ? ngng n tim, tip tc thi ngt Nu c i ng lng ngc: t th ? ngng thi ngt nu bnh nhn vn cn ngng th ngng tim phi tip tc n tim thi ngt Din tin tt: hng ho, t th, tim p li, mch r, tnh to.

II. HI SC TIN B

Thc hin ti c s y t, bnh vin c y dng c v thuc cp cu

1. Lay gi, ku gip


Lay gi bnh nhn Nu khng p ng, hn m, ku gi BS, D gip

2. Thng ng th:

Nga u nng cm (nghi chn thng ct sng c: nga u, c nh c ) Ht m Ly d vt nu c:


o o

Th thut v lng n ngc: s sinh, nh nhi Th thut Hemlich: tr ln

t ng thng ming hu khi tht bi vi nga u, ht m

3. Quan st di ng lng ngc v cm nhn hi th


Lng ngc khng i ng Khng cm nhn c hi th BN

4. Bp bng qua mask


Bp bng qua mask 2 ci c hiu qu vi FiO2 100% Bp bng c hiu qu: lng ngc nh khi bp Bp bng m lng ngc khng nh:
o o o o

ng th cha thng: kim tra nga u Mt n khng kn C bng nh so vi tr Bp bng nh tay

An nh sn nhn (th thut Sellick): trnh hi vo dy, gim chng bng v nguy c ht sc

5. Bt mch trung tm

S sinh, tr nh: mch cnh tay, mch bn Tr ln : mch c, mch bn Khng c mch trung tm trong vng 10 giy -> Ngng tim

6. An tim ngoi lng ngc


K thut n tim: xem phn hi sc c bn T l n tim/ bp bng


o o o

S sinh: 3/1 Tr nh < 8T: 5/1 Tr > 8T: 15/2

Nu c 2 ngi: ngi n tim m ln ngi bp bng nghe phi hp Tip tc bp bng v n tim trong vng 1 pht, sau nh gi li Trng hp khng t th li sau bp bng qua mask (1 - 5 pht): t ni kh qun ng ming v bp bng qua NKQ

7. Thuc: Thit lp ng tnh mch

Epinephrine
o

Epinephrine (Adrenaline) 0,1 TM


Ch nh: Ngng tim Cch pha dd Epinephrine 0.1 ng ng tim 10 ml rt 1ml dd Epinephrine 1 + 9 ml nc ct.

Liu: 0.1 ml/kg dung dch 0.1 TM. Sau khi bm Epinephrine, bm 2 - 5 ml Normalsaline y thuc. Sau 3 - 5 pht tim cha p li: lp li liu hai liu nh trn hoc gp 10 ln, v lp li mi 3 - 5 pht.

Epinephrine (Adrenaline) 1 bm qua NKQ


Dng trong trng hp khng c ng tnh mch Liu: 0,1 ml/kg dung dch Epinephrine 1 pha NaCl 9 cho 3-5 ml. Sau bm NKQ: bp bng thuc phn tn v hp thu vo h tun hon

Bicarbonate u trng: khng thng quy v nguy c CO2 gy nng thm tnh trng toan h hp.
o

Ch nh:

Toan chuyn ha nng, Nu khng th kh mu c: c th xem xt ch nh Bicarbonate sau 10 pht bp bng gip th v tim Epinephrine bnh nhn vn cn ngng th ngng tim.

Liu: dung dch bicarbonate 8,4% 1 ml/kg/ln hay dung dch 4,2% 2 ml/kg/ln TMC, khng c dng chung vi ng TM ang truyn Calcium.

Atropine
o o

Ch nh: chm nhp tim. Liu: 0,02mg/kg TMC liu ti thiu 0,15mg, ti a 0,5mg/liu hoc tng liu khng qu 1mg.

Amiodarone

Ch nh: y l thuc c la chn trong trng hp rung tht, nhp nhanh tht mt mch Liu 5 mg/kg bm TM nhanh hay qua tu xng Thuc thay th: Lidocain 2% (0,04g / 2ml), liu 1mg/kg TM, duy tr 20-50 g/kg/pht qua bm tim t ng.

Calcium: khng ng thng qui, ch ng trong trng hp c bng chng h calci huyt hoc ng c thuc c ch calci.
o o

Calcium chloride 10% 0,2ml/kg TM chm Calcium gluconate 10% 1ml/kg TM chm

Glucose:
o o o

Ch nh: h ng huyt (Dextrostix) Tr ln: Dung dch glucose 30% 2ml/kg TMC Tr s sinh: Dung ch glucose 10% 2ml/kg TMC

Truyn dch:
o

Nu nguyn nhn ngng th ngng tim l hu qu ca sc gim th tch: truyn nhanh Lactate Ringer 20 ml/kg/15 pht, nu tht bi dng cao phn t.

8. Sc in:

Ch nh:.
o o

Sc in khng ng b: Rung tht, Ngng tim . Sc in ng b: Nhp nhanh tht, Nhp nhanh kch pht trn tht, sau khi iu tr thuc tht bi hay c ri lon huyt ng

tr nh, dng bng in c tr em 4 - 5 cm. Nu khng c bn nh, c th dng bng ln t trc v sau ngc

Liu: 2 - 4 Jun/kg. Sau mi ln sc in, phi nghe tim v theo i nhip tim qua monitor c hng x tr tip

9. Theo di sau hi sc

Nhp th, mu da nim, mch, HA, tri gic, ng t mi 15 pht


o o o o

SaO2 ( bo ha oxygen) Nhp tim bng ECG monitoring, Kh mu, ion , Dextrostix, XQ tim phi Din tin tt: hng ho, t th, tim p li, mch r, tnh to.

Khi no ngng hi sc ?
o

Quyt nh thi im no ngng hi sc trng hp ngng th ngng tim k o i th kh khn. Tuy nhin c th xem xt vic ngng hi sc nu sau 30 - 60 pht m tim khng p li, khng th li, ng t n v sau khi gii thch thn nhn.

S7.

SC PHN V

BV Nhi ng 1 TP HCM I. I CNG:

Sc phn v l phn ng qu mn tc th e da tnh mng bnh nhn. Sc phn v do d nguyn (thuc) kt hp vi khng th d ng ca bnh nhn phng thch cc ha cht trung gian (histamine, prostaglandin) lm dn mch gy sc. Ngoi bin hin sc, bnh nhn cn c th c du hiu kh th do ph n thanh qun hoc kh kh do co tht ph qun. Nu khng cp cu kp thi s dn n t vong. Cc cht gy phn ng phn v thng l: khng sinh, SAT, thuc cn quang c Io e, ong t, thc n.

II. CHN ON: 1. Cng vic chn on: a) Hi bnh:

Tin s d ng (suyn, chm, vim mi ng), d ng khi tip xc vi thuc, thc n. Bnh s: mi tip xc (vi pht n vi gi) vi cht l.

b) Khm lm sng:

Ngoi da: ni m ay, da, nga. Biu hin tun hon: tnh trng sc phn v vi mch nhanh, huyt p thp, tay chn lnh, vt v bc rc. Biu hin h hp: nght mi, kh th thanh qun, kh kh, tm ti. Biu hin tiu ha: i ma, tiu chy, au bng.

2. Chn on xc nh

Phn ng phn v: ni m ay, da, nga, au bng, nn i,than mt nhng mch v huyt p bnh thng.

Sc phn v: C biu hin sc.

3. Chn on phn bit:


au khi tim bp: khc, mch chm, huyt p bnh thng. H ng huyt: xa ba n, tay chn lnh, v mi hi, mch, huyt p bnh thng. D ng: ni m ay, xut hin chm sau vi gi hay vi ngy, khng c du hiu khc km theo.

III. IU TR: 1. Nguyn tc iu tr:


Ngng thuc, d nguyn gy sc. m bo thng kh tt v cung cp oxy. Tim Adrenaline. Phng nga.

2. iu tr cp cu: 2.2 Cho bnh nhn nm u phng 2.3.H tr h hp:

Nu BN ngng th nhanh chng thng ng th, bp bng qua mask v t NKQ gip th. Nu c ngng tim phi n tim ngoi lng ngc. Th oxy sau tim Adrenaline.

2.4.Epinephrine 1 0.01 ml/kg (ti a 0.3 ml) TDD hay TB. 2.5.Garrot pha trn ni tim thuc nu c 2.6.Thit lp ng truyn TM ngay

Nu cn sc:

o o o

Epinephrine 0,1 0.01 mg/kg/ln (0,1ml/kg/ln) TMC mi 15 pht. Ti a 0,5 mg/ln (5ml/ln ). Khi cn tim TMC nhc li nhiu ln c th cho Epinephrine truyn TM 0,1g/kg/ph tng n n khi t hiu qu (ti a 1g/kg/ph)

Nu cn sc sau khi Epinephrine 0,1 TMC ln u :


o

Truyn Lactate Ringer hoc Normal Saline 20ml/kg truyn TM nhanh, sau truyn 10 - 20 ml/kg/gi. Nu cn sc, cho truyn dung dch cao phn t (Dextran 40 hoc Dextran 70) 10 - 20 ml/kg/gi, o CVP v iu chnh tc truyn theo CVP. Nu CVP bnh thng nhng cn sc ko di nn thay Epinephrine bng Dopamine hoc Dobutamine 3 10 g/kg/pht.

2.6.Hydrocortisone 5mg/kg/ln mi 4-6gi hoc Methyl prednisolone 1 - 2 mg/kg TMC. 2.7.Khng Histamine: Pipolphen 0,5-1mg/kg TB mi 6-8 gi 2.8.Khi c kh th thanh qun:

Epinephrine 1 2-3 ml kh dung. Nu tht bi, t NKQ gip th.

2.9. Nu c kh kh: (xem iu tr cn suyn) 3. Theo di:

Trong giai on sc: TD mch, huyt p, nhp th, tm ti, tri gic mi 15 pht cho n khi n nh. Trong giai on huyt ng hc n nh: TD mch, huyt p, nhp th, tm ti, tri gic, SaO2 mi 1-2 gi trong 24 gi tip theo. Tt c bnh nhn phn ng hoc sc phn v cn c theo di ti bnh vin t nht 24 - 48 gi v nguy c ti sc.

i vi bnh nhn ch biu hin d ng da: khng x tr adrenalin, ch cho khng histamin v theo di.

4. Phng nga: 4.1.Trc khi dng thuc cho bnh nhn cn:

Hi tin s d ng thuc, c bit ngi c c a d ng. y l bin php phng nga quan trng nht. Th test i vi Penicilline v Streptomycine:
o o

Tim trong da 0,02ml dung dch PNC 1/10.000 Cn lu { vi liu test cng c th gy sc phn v v test m tnh cng khng loi tr c sc phn v. Cn sn sng hp chng chong.

4.2. Ghi vo s khm bnh v thng bo thn nhn bnh nhn bit tc nhn gy sc phn v bo cho nhn vin y t bit khi khm bnh. LU CP CU SC PHN V

1. Ngng ngay thuc gy sc phn v. 2. t nm u phng. 3. Nu ngng th ngng tim: thng ng th, thi ngt hoc bp bng qua mask km n tim. 4. A renaline 1 0,3 mL TDD. 5. Ct garrot pha trn ni tim nu c. 6. Nu cn sc: A renaline 0,1 0,1 ml/kg TTM Truyn LR 20 ml/kg nhanh 7. Hydrocortisone 5 mg/kg TM mi 4 - 6 gi 8. Pipolphen 0,5-1mg/kg TB mi 6 - 8 gi

9. Nu kh th thanh qun, KD Epinephrine 1 2-3 ml 10) Nu kh kh, KD 2 giao cm iu ng c x tr t 1 - 5 khi khng c bc s

S8.

SC

I. I CNG:

Sc l tnh trng suy tun hon cp gy gim ti mu m so vi nhu cu, hu qu gim cung cp oxygen v glucose cng nh gim ly i nhng cht bin ng t bo nh: aci lactic, CO2. Nu khng iu tr kp thi s din tin tn thng t bo, tn thng a c quan a n t vong. Phn loi sc:
o

Sc gim th tch: thng gp nht tr em, do th tch mu lu thng gim nh tiu chy, mt mu, phng, nhim trng huyt. Sc phn b: gin mch, khng lc mch mu gim: nh shock phn v v nhim trng huyt. Sc tim: t gp tr em, do suy yu chc nng co bp c tim nh: tim bm sinh, vim c tim, ri lon nhp tim, trn dch mng tim.

II. CHN ON: 1. Cng vic chn on: a) Hi bnh:


Tin cn tim bm sinh, thp tim. Bnh s: st, tiu chy, nhim trng, chn thng, xut huyt tiu ha. Tin cn ng v cc thuc ng trc , cn trng t.

b) Khm lm sng:

Ch du hiu tim mch v h hp xc nh mc sc v loi tr nguyn nhn sc tim. Du hiu nghi ng sc tim: Gallop, m thi, tim to, gan to, tnh mch c ni. nh gi mch, huyt p, nhp th, mu da, tay chn m hay lnh, thi gian phc hi mu a, tri gic, nc tiu. tr em du hiu tiu t gip theo di p ng iu tr nhiu hn l nh gi ban u. Khm ton din t u n chn. c bit ch cc du hiu nh u mt nc; thiu mu; nhim trng; t ban; hng ban.

c) ngh cn lm sng:

Cng thc mu, dung tch hng cu, m tiu cu. in gii , ng huyt. Nu nghi sc nhim trng: Pht mu ngoi bin, cy mu, CRP, chc nng gan thn, TPTNT, cy nc tiu (nu c triu chng tit niu), soi cy phn (nu c tiu chy). Nu sc tim o ECG, X quang tim phi, siu m tim tm nguyn nhn hoc nh gi chc nng co bp c tim. Chc nng ng mu trong trng hp sc nhim trng, sc ko di, lm sng c biu hin ri lon ng mu. Kh mu khi c suy h hp.

2. Chn on sc:

Sc:
o o o o

Tim nhanh, mch nhanh, huyt p tt, kp. Thi gian phc hi mu da > 3 giy. L , bt rt. Tiu t (nc tiu < 1 ml/kg/gi).

Sc nng:
o o o o

Tay chn lnh c hoc khng da ni bng. Mch = 0, huyt p = 0. Vt v, hn m. Tiu t hoc khng c nc tiu.

3. Chn on nguyn nhn sc:


Sc phn v: tip xc d nguyn nh thuc, thc n l, cn trng t. Sc mt mu: vt thng ang chy mu, chn thng ngc bng, gy xng, i, tiu mu, km ung tch hng cu gim. Sc gim th tch: tiu chy mt nc, phng, CVP thp. Sc nhim trng:
o

Lm sng: st, v mt nhim trng, nhim trng, nu c ban mu ngh no m cu. Cn lm sng: bch cu tng chuyn tri, ht c, khng bo, CRP tng, cy mu ng tnh.

Sc st xut huyt: sc ngy th 4-5, xut huyt da nim, gan to km dung tch hng cu tng, tiu cu gim. Sc tim:
o

Lm sng: tin cn bnh tim, tim nhanh, gallop, gan to, tnh mch c ni. Cn lm sng: X-quang c bng tim to; siu m c bt thng tim hoc mch mu ln, chc nng co bp c tim gim.

III. IU TR: 1. Nguyn tc iu tr:

iu tr thiu oxy m. Phc hi cung lng tim. iu tr bin chng. iu tr nguyn nhn.

2. iu tr chng sc:

iu tr chung
o

Th oxy qua canulla, t ni kh qun th my nu tr sc nng km tm ti, ngng th. t bnh nhn nm phng chn cao tng lng mu v tim, khng nn t tr nm u thp v c th chn p c honh gy kh th. Ngoi tr sc tim cho nm t th na nm na ngi. Cm mu nu ang chy mu ( p hoc bng p). Thit lp 1 hoc 2 ng truyn TM: chn TM ln chi, dng kim lun ln nht c th c, nu sau 5 pht cha thit lp c ng truyn cn bc l tnh mch c chn hoc tr < 6 tui, c th truyn ty xng bng kim 18, tm thi trong khi ch bc l tnh mch.

o o

Sc nhim trng, sc gim th tch:

a. iu tr ban u:

Truyn nhanh Normal saline hoc Lactate Ringer 20 mL/kg/gi. Nu mch=0 v HA = 0 truyn nhanh trong 15 pht hoc bm trc tip. Nu sau tht bi m khng c du hiu qu ti th truyn dung dch cao phn t (Gelatine, Dextran) 10-20 mL/kg/gi.

Nu sc mt mu th cn nhanh chng x tr cm mu v truyn mu ton phn 10-20 mL/kg/gi, trong khi ch mu cn truyn dch in gii Lactated Ringer hoc Normal saline 20ml/kg/gi.

b. iu tr tip theo:

Nu huyt ng hc n nh duy tr bng Dextrose saline hoc Dextrose saline 10ml/kg/gi sau gim dch dn. Nu tng lng dch = 60ml/kg v khng p ng nn c ch nh o CVP:
o

Nu CVP thp < 4cmH2O tip tc truyn dch dung dch PT: Dextran 40 hoc Dextran 70: 10-20 mL/kg/gi. Nu khng du qu ti + CVP bnh thng (6-10 cm H2O): test dch truyn vi Dextran tc 5ml/kg/30 pht. Sau nh gi li lm sng, CVP. Nu p ng: tip tc b dch. Nu xu hn, qu ti: cho Dopamine Nu c du qu ti hoc CVP cao > 10 cm H2O: cho Dopamin liu bt u 2,5 g/kg/pht tng n cho n khi c hiu qu, liu ti a 10 g/kg/pht. Nu khng p ng Dopamine liu cao thay v tng Dopamine c th phi hp vi Dobutamine 3-10 g/kg/pht km Dopamine liu 3-5 g/kg/pht.

Cch pha Dopamine v Dobutamine:

Cn nng BN(kg) x 3 = s mg thuc pha trong 50 ml Dextrose 5% Tc bm tim: s ml/gi = s g/kg/pht

Trong trng hp sc nhim trng: nu tht bi Dobutamine + Dopamine: mt s tc gi ngh s dng Norepinephrine bt u 0,1 g/kg/pht TTM tng n n khi p ng, ti a 1g/kg/pht. Cn lu { Norepinephrine gy co mch, gim ti mu thn nn ch s dng trong cc tnh hung e da tnh mng v khng dng ko di.

Cng thc pha Epinephrine:

Cn nng BN(kg) x 0,3 = s mg thuc pha trong 50 ml Dextrose 5% Tc bm tim: 1ml/gi = 0,1g/kg/pht

Nu ang lc b ch nhanh xut hin du hiu qu ti nh: ho, kh th, TM c ni, gallop, ran phi, gan to nhanh -> ngng truyn dch v x tr nh ph phi cp.

Sc tim:
o o

Dopamine: 3-10 g/kg/pht qua bm tim Dobutamine: c ch nh trong trng hp tht bi Dopamine hay sc nng hoc km ph phi. Liu 3-10 g/kg/pht.

Sc phn v: Xem phc iu tr sc phn v

3. iu tr triu chng v bin chng:


H ng huyt: Dextrose 30% 2 ml/kg TMC. Toan bin ng nng: pH <7,10 hay bicarbonate < 10mEq/l: Natribicarbonate 8,4% 1 ml/kg/ln TMC.

Ri lon ng mu: DIC: truyn huyt tng ng lnh 10-20 ml/kg. Gim tiu cu < 40.000/mm3: truyn tiu cu 1 n v/5 kg.

4. iu tr nguyn nhn:

Nhim trng huyt: khng sinh tnh mch (xem phc nhim trng huyt). Tim bm sinh (xem phc tim bm sinh), thp tim (xem phc bnh thp). Sc mt mu do chn thng: phu thut cm mu. Xut huyt tiu ha: xem phc xut huyt tiu ha.

5. Theo di: 5.1. Theo di (TD):

TD Mch, huyt p, nhp th, tri gic, tm ti mi 15-30 pht trong giai on hi sc sc v sau mi 2-3 gi trong 24 gi u sau khi ra sc. TD lng nc tiu mi gi. Theo i lng nc tiu l thng s tt nht nh gi hiu qu iu tr sc, nhng o nguy c nhim trng nn ch t sonde tiu trong nhng trng hp sc ko di v tho b khi tnh trng huyt ng hc n nh. Khi sc nng cn o CVP, uy tr CVP t 6 -10 cm H2O v o huyt p ng mch xm ln. Theo di dung tch hng cu, c bit trong sc mt mu hoc sc st xut huyt v duy tr dung tch hng cu >30%. Du hiu ra sc: tnh to, mch huyt p nhp th tr v tr s bnh thng theo tui, tay chn m, thi gian phc hi mu a < 2 giy, nc tiu > 1 ml/kg/gi.

Tui (nm) <1 2-5 5 - 12 >12

Nhp th(nhp/pht) 30 - 40 25 - 30 20 - 25 15 - 20

Huyt p tm thu(mmHg) 70 - 90 80 - 100 90 - 100 100 - 120

Mch(nhp/pht)

110 - 160 95 - 140 80 - 120 60 - 100

5.2. Khm chuyn khoa:


Bnh l tim, sc tim: khm v iu tr theo chuyn khoa tim mch. Xut huyt tiu ha: khm chuyn khoa tiu ha, ni soi, ngoi. Mt mu do chn thng: khm ngoi khoa sm trong lc hi sc sc can thip phu thut cm mu kp thi.

S9.

KHI NIM V IMCI

(IMCI training player - WHO)

Hot ng lng ghp chm sc tr bnh (vit tt l IMCI) l mt chin lc nhm lm gim t l mc bnh v t vong ca cc bnh thng gp tr em di 5 tui. T chc Y t th gii (WHO) v Qu Nhi ng Lin hp quc (UNICEF) khi xng xy dng chin lc t nm 1992 vi mc tiu gim t l mc bnh, t vong v ci thin cht lng sng ca tr em trn ton cu. V hin nay, trn th gii c hn 100 quc gia trin khai hot ng ny nhng giai on khc nhau.

Hin nay, trn th gii, hn 70% trng hp t vong tr i 5 tui ti cc nc ang pht trin l do cc bnh c th phng v iu tr c nh tiu chy, vim phi, si, st rt, st xut huyt v suy inh ng hoc do kt hp ca cc bnh ny. T l t vong tr s sinh ang c xu hng gia tng, c bit khu vc Ty Thi Bnh Dng, nguyn nhn ch yu l o non, nhim khun, vim phi, un vn s sinh... Vi mc tiu gim t l mc bnh v t l t vong ca tr em i 5 tui, T chc Y t th gii (WHO) v Qu nhi ng Lin Hp Quc (UNICEF) xy ng chin lc Lng gh p chm sc tr bnh (IMCI). Chin lc ny trc ht tp trung vo ci thin cht lng chm sc sc khe ti y t tuyn c s, ni hng ngy c hng triu tr em n khm v iu tr mt hoc nhiu bnh trong s cc bnh thng gp k trn. Hot ng IMCI kt hp nhiu yu t ca cc chng trnh nh chng trnh phng chng cc bnh tiu chy, phng chng cc bnh nhim khun h hp cng nh cc hot ng lin quan n sc khe tr em trong cc chng trnh phng chng st r t, inh ng, tim chng v thuc thit yu, bao gm hng lot cc can thip nhm phng v iu tr nhng bnh thng gp tr em ti cc c s y t v gia nh. Mc ch ca hot ng IMCi nhm nng cao cht lng hot ng chm sc tr bnh ti cc c s y t, c bit l tuyn y t c s. Gim t l mc v t vong tr em ni chung thng qua thc hin cc hng dn phng v cha bnh c chun ha cho cc bnh thng gp tr em nh: vim phi cp, tiu chy, st rt, si, st xut huyt, suy inh ng.

Chin lc IMCI s tp trung vo: Ci thin k nng x tr tr bnh Ci thin h thng y t Ci thin thc hnh chm sc sc khe ti gia nh v cng ng.

MC TIU, THNH PHN V CAN THIP Mc tiu chnh ca chin lc IMCI:

gim t l mc v t vong tr em ci thin th lc v kh nng pht trin tr em.

Vic trin khai hot ng IMCI cc quc gia bao gm ba thnh phn:

ci thin k nng x tr tr bnh ca cn b y t thng qua cc hng dn v ti liu hun luyn v x tr lng ghp tr bnh ti tuyn y t c s. Thng qua cc kha hun luyn IMCI cho cn b y t tuyn c s. Qua gim st h tr sau hun luyn cng c v uy tr nng lc ca cn b y t; Cc hng dn v hun luyn ci thin cc k nng x tr tr bnh ti cc bnh vin. ci thin h thng y t:
o o

lp k hoch v qun l y t ti tuyn huyn. bo m s sn c cc thuc thit yu cho IMCI thng qua ci thin vic cung cp v qun l thuc. ci thin phng thc chuyn vin v chm sc chuyn vin ci thin cch t chc cng vic ti c s y t ci thin vic gim st cc dch v y t thng nht cc phn loi ca IMCI vi h thng thng tin y t;

o o o o

ci thin thc hnh chm sc sc khe ti gia nh v cng ng thng qua gio dc sc khe v tham vn cho cc b m v cch nui ng v chm sc tr bnh thng qua nng cao k nng tham vn ca cn b y t. Bo m a nhng thng ip thng nht v sc khe tr em n vi cc gia nh. Thc hin cc can thip da vo cng ng gp phn phng bnh, tng cng sc khe v thc y s pht trin ca tr em.

TIN TRNH X TR TR BNH Tin trnh x tr c th hin qua cc bng hng dn trong nu ln trnh t

cc bc tin hnh v cung cp thng tin cho vic thc hin cc bc . Cc hng dn c m t theo cc bc sau:

nh gi tr bnh Phn loi bnh Xc nh hng iu tr iu tr bnh Tham vn cho cc b m Khm li

Nhng bc ny v c bn tng t nh cch thc m cn b y t thng thc hin khi chm sc tr bnh, mc trc y c th chng c m t bng nhng thut ng khc. V d nh nh gi tr bnh" - c ngha l hi v bnh s v thm khm lm sng, phn loi bnh" - c ngha l xc nh mc nng ca bnh. Trong bc ny cn b y t s la chn mc hoc phn loi cho mi triu chng chnh ca tr tng ng mc nghim trng ca bnh m tr mc phi. Phn loi bnh khng phi l nhng chun on ring cho tng bnh m da vo mc nng hay nh ca bnh xc nh cch iu tr. Cc bng trong cun hng dn x tr a ra phng php iu tr thch hp i vi tng loi bnh. Khi s dng tin trnh iu tr ny, vic la chn mt phn loi bnh trn phc s cho php cn b y t c th xc nh c hng iu tr cho tr bnh. V d, mt tr bnh c phn loi bnh l bnh rt nng c st c ngha l c th tr mc phi mt trong cc chng bnh vim mng no, st rt nng hoc l nhim trng mu. Nhng phng php iu tr c lit k cho cc bnh c phn loi l bnh rt nng c st s thch hp o c la chn iu tr cho nhng bnh quan trng nht trong nhm phn loi ny. iu tr c ngha l thc hin cch x tr ti c s y t, k n thuc hoc hng dn cc cch x tr khc ti nh, v hng dn cho cc b m bit cch iu tr cho tr. Tham vn cho cc b m bao gm vic nh gi cch nui ng, cch ngi m cho tr b v hng dn cho cc b m bit cch la chn cc loi thc

n, thc ung cn thit cho tr v khi no cn phi a tr quay li c s y t. Tin trnh x tr bnh cho tr tui t 2 thng n 5 tui c trnh by trn 3 hng dn in mu ln vi tiu :

NH GI V PHN LOI TR BNH IU TR TR BNH THAM VN CHO CC B M

X tr bnh tr nh t 0 n 2 thng tui c hi khc so vi nhng tr tui ln hn. Vn ny c m t trn mt hng dn khc vi tiu l: NH GI, PHN LOI V IU TR BNH CHO TR NH. LA CHN CC HNG DN X TR THCH HP Hu ht cc phng khm u c th tc ng k{ khm bnh v xc nh xem tr n v b bnh hay v nhng l do khc, chng hn nh c nhng a tr khe mnh bnh thng c th n cc c s y t tim chng hoc iu tr mt vt au o b thng hay tai nn gy ra. Khi ngi m a tr n c s y t (do tr mc bnh, ch khng phi chn thng) m bn l ngi trc tip c giao nhim v tip nhn khm v iu tr cho tr , th bn cn phi bit c tui ca tr la chn mt hng dn iu tr thch hp v bt u thm khm theo tin trnh. Bn c th da vo phiu ng k{ bnh nhn ti c s y t, trong ghi chp tn, tui cng nh nhng thng tin khc v d a ch ca tr. Nu khng c phiu , bn c th bt u bng cch hi tn v tui ca tr. Tr b bnh c phn theo 2 nhm tui sau:

Nhm tui t 0 n 2 thng tui Nhm tui t 2 thng n 5 tui

Nu tr trong tui t 2 thng n 5 tui, th bn chn hng dn NH GI V PHN LOI TR BNH TUI T 2 THNG N 5 TUI. n 5 tui c ngha l tr tui trc ngy sinh nht ln th 5 ca tr. V d, trong nhm tui ny gm nhng tr c 4 nm v 11 thng ch khng phi l nhng tr

c trn 5 tui tr i. i vi nhng tr c trn 2 thng tui th c xp vo nhm tui t 2 thng n 5 tui, ch khng thuc trong nhm tui t 0 n 2 thng tui. Nu cha 2 thng tui th tr vn c coi l tr nh. Hy s dng nhng hng dn NH GI, PHN LOI V IU TR BNH CHO TR NH.

S10. SUY GAN CP - HN M GAN


Suy gan cp l mt hi chng lm sng, hu qu ca ri lon chc nng gan nng hoc hoi t phn ln nhu m gan gy ri lon ton b chc nng gan bao gm cc chc nng tng hp, bi tit v chng c. Hn m gan : (Bnh no do gan) L tnh trng bnh l gm cc triu chng thn kinh, ri lon ng mu, ri lon chuyn ho cc cht do chc nng gan b suy gim. 1.Chn on : 1.1.Triu chng lm sng : - Tin s : Vim gan do vi rt, tip xc sn phm ly nhim vim gan, thuc, ho cht, cc bnh gan mn tnh: x gan, bnh gan chuyn ho Vng da, gan to, lch to hoc mt, gim vng c gan. Xut huyt ch tim, ch va chm mc tim Vitamin K Ng g, n ung kh, nn, vt v mt, khch thch, hn m.

2.2. Cn lm sng : Tng bilirubine mu, tng Transaminaza mu SGOT - SGPT. Tng g GT; tng Phosphotaza kim mu.

Ri lon chc nng ng mu gim yu t V, gim t l Prothrombin gim i 20% - 25% t kh nng hi phc. Gim Albumin mu. H gim ng mu. Tng NH3 mu. Kim h hp o tng th bi ri lon trung tm h hp. Suy thn: Tng Cr atinin mu. Huyt thanh chn on vim gan vi rt A.B.C.D, CMV, Cc xt nghim chn on nguyn nhn khc gy suy gan cp.

2.3.Chn on cc giai on hn m gan : Giai on I : t ri lon tri gic, mt mi, bn chn hoc kch thch, p ph, nn, th nhanh. Giai on II : Ng g, l ln hoc kch thch, p ph cn p ng vi kch thch thnh gic, th gic. Cm gic au cn. Giai on III : Hn m nng mt p ng kch thch th gic, thnh gic. Cn p ng cm gic au. Giai on IV : Hn m su, khng p ng kch thch thnh gic, th gic, kch thch gy au, mt no. Cc yu t lm hn m gan nng thm : 1. 2. 3. Xut huyt tiu ho Gim th tch mu tun hon Mt kali

4. 5. 6. 7. 8. 9.

H ng huyt Thuc an thn, thuc gy m gy t, thuc li tiu Tng ur huyt Nhim khun Ch n giu protin To bn

2. iu tr : 2.1. Chng ph no : Cn pht hin v iu tr sm da vo theo di tri gic; p lc ni s, duy tr p lc ni s < 20 mmHg (bnh thng <10 mmHg) - Manitol 0,25 - 0,5 kg/ 1liu truyn tnh mch dung dch 12,5%: 2 - 4ml/kg dung dch 20%: 1,25 - 2,5 ml/kg dung dch 25% :1 - 2 ml/kg Truyn 2 gi a p lc thm thu < 320 - 330 mmol/L (theo i lng nc tiu - in gii ) Nu suy thn khng dng Manitol

Thng kh h tr t ni kh qun duy tr PCO2 25 - 30 mmHg. Trnh tnh trng u thn gy ph no. Nu Manitol khng c tc dng, truyn chm Thiopentone. Liu tn cng: 2 4 mg/kg trong 15 pht sau duy tr 1 -2 mg/kg/gi. (tai bin lm gim huyt p nn ng khi c thng kh, trnh suy h hp).

Khng nn ng Corticoi chng vim v phng ph no v c th lm tng nit ur mu, gy tng NH3 lm hn m trm trng hn. 2.2. m bo tun hon : Duy tr huyt p bo m ti mu cho gan mc ti a, nu gim khi lng tun hon: cho Albumine, plasma ti, mu ton phn. iu tr cn nhp nhanh xoang (75% c cn nhp nhanh xoang).

Tng cung lng mu tng ra ca c tim: ng Prostaglan in. Epoprostenol cng vi NAcetyl Cystine lm tng cung lng tim > 4,5 l/pht/m2 lm gim cc mao mch nh tng ti mu cc m, tng tiu th Oxy ti a > 150 ml/ pht/m2 khi hn m gan v sc. Nhp tim chm, h huyt p, ngng tim t ngt do c ch trung tm sy ra 25% trng hp. 2.3.Chng ri lon ng mu : Truyn Plasma ti 10 - 15ml/kg/1 ln c th lp li trnh chy mu, ch dng thi gian ngn cp, c th gy tng gnh. Vitamin K 5mg - 10 mg/ngy (hoc 1mg/1tui) tim tnh mch trong 3 ngy ti a 10 mg/1ln tr ln sau ng 3 ln/ 1 tun (tim TM chm trong 30 pht) dng tim 3 ngy gim liu tim: 1mgr - 2mg/ngy. Desmopressin (DDAVP): D Amino & D Arginin Vasopressin lm tng yu t VIII v VIIIc trong huyt thanh. ATIII iu tr nu c ng mu ni qun ri rc

2.4. Duy tr ng huyt : Truyn 8 - 12g/kg/24 gi chia u trong ngy trnh a t, c th dng nng glucose 20% - 25% nhng cn t Catheter trung tm. 2.5. iu ho cn bng kim toan v ri lon nc in gii :

Truyn nc hn ch 75% nhu cu, cung cp Natri hn ch 1-2 mmol/kg/24gi trnh ph no. Tng khng kh giai on u hn m gy kim hi,

Ht dch d dy lin tc, truyn nhiu dung dch kim, thiu Kali c th gy nn kim chuyn ho. Toan chuyn ho do acid lactic c th phi hp vi h ng huyt.

Tnh trng h Natri huyt c th gp do truyn nhiu dung dch, iu tr bng hn ch truyn dch, cung cp thm Natri c th lm ph no nng thm. 2.6. Gim sinh NH3 trong rut : nht l khi tr c xut huyt tiu ho Gim nhu cu Protin: 0,5 - 1gr/kgn/24gi.

Gim cc vi khun ng rut hn ch sn sinh NH3.bm qua son e nomyxin 125 mgr - 500 mgr 6 gi mt ln Lactulose (Dufalac) bm qua son e dy 1ml/kg/1liu.

4-8 gi 1 ln, tng lu thng rut, gim hp th NH3 . Khi bnh nhi hn m c th tht Lactulose 2 - 4 ln 1 ngy c hiu qu. Ung Magie Sulft, tht tho

2.7. Dinh dng Nhn n, t sonde d dy Nui ng tnh mch 50 - 60 Kcal/kg/24gi

hn ch protein 0,5g - 1g/kg/24gi phng xut huyt tiu ho.

Ranitidin 2 - 6 mg/kg/24 gi. Tim tnh mch 3 - 4 ln. Tr ln ti a ng 300 mg/24gi. 2.8. iu tr suy thn : c bit nu c hi chng gan thn

Nu Cratinin > 400 micromol/l, PH < 7,2, kali huyt >6 mmol/l ch nh lc mu ngoi thn. 2.9. Chng nhim khun : Nhim khun t cu, vi khun gram m, nm.. thng gp v dn n t vong. Theo di gim st cht ch, chn on kp thi nhim khun.

- Huyt ,vim phc mc, vim phi mng phi, nhim trng ng tit niu nn dng khng sinh ph rng ton thn, cc khng sinh ng rut phng qu pht cc vi khun ng rut. 2.10- Ghp gan : Nu thi gian Prothrombin cn ko di trn 90 sau khi tim vitamin K, t vong 100%. Ko di > 50 t vong l 80%. C ch nh ghp gan cp.

S11. SUY H HP CP
I. I CNG: Suy h hp l tnh trng h h hp khng kh nng uy tr s trao i kh theo nhu cu c th, gy gim O2 v/hoc tng CO2 mu. Hu qu ca suy h hp l thiu oxy cho nhu cu bin ng ca cc c quan c bit l no, tim v ng CO2 gy toan h hp. Suy h hp cp c th do bnh l ca ng th, tn thng phi hoc bnh l no, thn kinh - c. II. CHN ON: 1. Cng vic chn on: a) Hi bnh: Tin s suyn, tim mch, nhc c. Khi pht: st, ho, kh kh. Hi chng xm nhp. Co git v hn m i trc trong vim no mng no.

Ng c: thuc ng, Morphin v dn xut, ru, Methemoglobin b) Khm lm sng : Du hiu sinh tn: mch, nhp th, nhit , huyt p, SaO2. Du hiu co lm ngc, tm ti. Kiu th: kh th th ht vo hay th ra, th bng, ting rt, kh kh. Khm hng. Khm phi: ph m, ran phi. Khm tim: nhp tim, m thi, gallop. Khm bng: kch thc gan. Khm thn kinh: tri gic, pht trin tm thn vn ng, yu lit chi. c) ngh cn lm sng: CTM. Xquang phi. Kh mu: khi tm ti khng ci thin vi th oxy. Siu m tim: khi c tin cn bnh tim hay X-quang c bng tim to hoc c biu hin suy tim. 2. Chn on xc nh: Lm sng: - Th nhanh: Di 2 thng NT > 60 ln/pht, 2 thng - 2 tui: NT > 50 ln/pht, 2-5 tui: NT > 40 ln/pht - Co lm ngc. - C hoc khng tm ti: tm ti l du hiu mun. Cn lm sng: - SaO2 < 90%, hoc - Kh trong mu: PaO2 < 60 mmHg v /hoc PaCO2 > 50 mmHg vi FiO2=0,21. 3. Chn on nguyn nhn: Vim phi: th nhanh, ran phi, hi chng ng c phi, X-quang c hnh nh tn thng ph nang. Suyn: tin cn suyn, kh th ra, kh kh, ran rt. D vt ng th: hi chng xm nhp, kh th vo, rt thanh qun.

Vim thanh kh ph qun: vim h hp trn, khn ting, kh th vo, rt thanh qun. Bnh l no: hn m, th chm, khng u. Bnh thn kinh c: yu lit chi, th nng. 4. Chn on phn bit: Suy tim, ph phi cp: tim nhanh, nhp gallop, ran m dng cao dn, gan to v au, tnh mch c ni, X-quang c bng tim to, siu m tim: chc nng co bp c tim gim. Methemoglobinemia: Tm ti, khm tim phi bnh thng, Methemoglobin mu cao. III. IU TR : 1. Nguyn tc iu tr: m bo tt thng kh v oxy mu. Duy tr kh nng chuyn ch oxy. Cung cp nng lng. iu tr nguyn nhn. 2. iu tr ban u: 2.1. iu tr triu chng: a. Thng ng th: Hn m: Ht m nht, nga u - nng cm, nu tht bi t ng thng ming hu. Tc nghn ng h hp trn: D vt ng th: th thut Heimlich (> 2 tui), v lng n ngc (< 2 tui) Vim thanh kh ph qun: kh ung A renaline 1, Dexamethasone TM, TB (xem phc vim thanh kh ph qun) b. Cung cp oxy: Ch nh. Tm ti v/hoc SaO2 < 90% v/hoc PaO2 < 60 mmHg. Th co lm ngc nng, th nhanh > 70 ln/pht. Phng php cung cp: Oxygen cannula (FiO2 30-40%), tr nh: 0.5-3 l/ph, tr ln: 1-6 l/ph. Mask c hay khng c ti d tr (FiO2 40-100%) 6-8 l/ph. c. Nu bnh nhn ngng th, th khng hiu qu:

Bp bng qua mask vi FiO2 100%. t ni kh qun gip th. 2.2 iu tr nguyn nhn: xem phc iu tr c hiu theo nguyn nhn. 3. iu tr tip theo: 3.1. p ng tt vi th oxy. iu chnh lu lng oxy n mc thp nht gi SaO2 92-96% trnh tai bin oxy liu cao. 3.2. Tht bi vi oxygen: - Bnh nhn cn th nhanh. - Co lm ngc nng, hoc tm ti. - SaO2 < 90%, PaO2 < 60mmHg. ang th oxy canulla: tng lu lng n mc ti a (6 lt/pht), nu vn khng p ng: - Th qua mask c ti d tr 6-10 l/ph, mask th li 1 phn (FiO2 60-80%) hoc mask khng th li (FiO2 60-100%) - Hoc th NCPAP trong cc bnh l c gim compliance phi: vim phi, ph phi, bnh mng trong... - Tht bi vi oxy qua mask hoc NCPAP: t ni kh qun gip th. 3.3. iu tr h tr: a. Duy tr kh nng cung cp oxy cho m v t bo: Duy tr kh nng chuyn ch oxy: gi Hct t 30-40%. Duy tr cung lng tim y : dch truyn, thuc tng co bp c tim. Gim tiu th oxygen: h st nu nhit trn 38o5C. b. Dinh ng: Nn cho n ng ming, nu khng b/n c nn t sonde d dy, gavage sa hoc bt mn 10%. trnh vim phi ht o tro ngc d dy, cn chia lm nhiu c n v nh git chm. Nng lng cn tng thm 30-50% nhu cu bnh thng b tr tng cng h hp, trnh kit sc. Trong trng hp th my do kh cung cp c lm m y v th lng dch gim cn 3/4 nhu cu. Khi nui n tnh mch ton phn, trnh cho qu nhiu Glucose gy tng CO2, t l gia lipid v glucid l 1:1. c. Phng nga nhim trng bnh vin:

Dng c h hp v trng. K thut chm sc v trng: ht m, nht l ht m qua NKQ. 4. Theo di: Lm sng: - Nhp th, co lm ngc, tm ti, SaO2, mch, huyt p, tri gic, lc u mi 30 pht - 1 gi, khi n nh mi 2-4 gi. - Bin chng: trn kh mng phi, tc m. Cn lm sng: -Khng c CPAP - Kh mu: khng p ng oxy, cn thay i phng php h tr h hp, th my. - X-quang phi: nghi ng trn kh mng phi, xp phi.

S12. NG C PHOSPHORE HU C
BS. BCH VN CAM

* Phospho HC c ch choline esterase lm ng acetyl choline ti synapse, biu hin lm sng bng ba hi chng: muscarinic, nicotinic v biu hin thn kinh trung ng. * ng ng c: ung, ht, qua da. I.CHN ON Lm sng - Du hiu Muscarinic: au bng, tiu chy, co ng t, tng tit m nht, chm nhp tim, h huyt p. - Du hiu Nicotinic: rung git c, yu c, tim nhanh, cao huyt p. - Du hiu thn kinh trung ng: nhc u, hn m, co git. Cc du hiu trn thng xut hin ngay sau ng c. Mt s t trng hp sau

ng c 24-96 h xut hin lit mt, c, chi, c h hp (HC trung gian) khng p ng vi Atropnie v Oximes hoc cc du hiu lit chi ko di nhiu tun n nhiu nm (Hi chng tn thng thn kinh chm: organophosphate-induced delayed neuropathy). Cn lm sng - Dch d dy: Phosphore hu c (+). - Acetylcholin esterase trong hng cu v mu: gim trn 50% bnh thng. - Trong trng hp nng: ion , ng huyt, chc nng gan thn, xquang phi. II.IU TR II.1 Nguyn tc iu tr - Loi b c cht - PH cholinesterase - Chng acetyl choline - iu tr bin chng II.2. iu tr * iu tr cp cu: suy h hp, co git, sc, hn m. * Lp ngay ng truyn TM: tim Atropine * Atropine: - Atropine tim trc v trong khi ra d dy - Liu: 0.02-0.05 mg/kg mi 15 cho n khi c du thm Atropine. - Sau : . Gim liu hoc tim cch qung xa hn. . Hoc TTM lin tc 0.02 - 0.08 mg/kg/gi - Mc tiu: duy tr thm Atropine (ht ran phi, ng t hi n 3-4mm, kh ming) trong 12-24 gi, trnh ng c Atropine (sng, st cao, a, ng t dn to). - Chuyn sang Atropine TDD mi 2-4h khi n nh vi liu TTM < 0.02mg/kg/gi. Khi BN xut hin li du ng c cn tng liu Atropine. - Chn Atropine m c 1mg/1ml trnh ng c nc, h natri mu.

* Ra d dy - Thc hin cng sm cng tt - Ra d dy li d tuyn trc ra. - Ra k n nc trong v khng mi (20-30 lt) - Sau 3 gi cha ci thin: ra d dy ln 2 * Than hot tnh * Pralidoxim - Pralidoxim (2 PAM: 2 Pyridin Aldoxim Metho-chloride) - Tc dng: Hot ha li men AchE. - Ch nh: . Ngng th, suy h hp. . Yu c, run c. . Ung lng nhiu, c tnh cao. - Nn dng sm trong 12-24 gi u, ch dng phi hp vi Atropine - Bit c: Pampara 500mg, Contrathion 200mg, Protopam 500mg - Cch dng: 20-50 mg/kg/ln (ti a 1g) pha 100 mL Normal saline TTM trong 301h, lp li sau 1-2h nu cha ci thin. - Tc dng ph: truyn nhanh c th gy nhc u, bun nn, tim nhanh, co gng c. Khi BN n nh cn ch theo di 24-96h pht hin HC trung gian II.3 Theo di DHST Tri gic ng t, ran phi da, cu bng quang TI LIU THAM KHO 1. Peter Viccellio. Emergency Toxicology. 1998 2. George C. Rodgers. Poisonings: Drugs, chemicals, and plants. Nelson Textbook of Pediatric. 2000

3. Organophosphate and Carbamate. CD-INTOX. WHO. 1996 4. Kenneth W. Kulig. Poisoning and Overdose. Emergency Pediatrics: A Guide to Ambulatory care. 1999

S13. PH PHI CP

I. NH NGHA : Suy h hp cp do trn ngp huyt tng vo m k v sau vo ph nang C ch ch yu dn lu cht lng khi cht ny qua khi hng ro ni m a/ Ph do huyt ng hc do tng p ( Hmodynamique) : l nguyn nhn thng gp + + +

b/ Ph do tn thng tnh thm ( permabilit ) : do tn thng thc th mng ph nang - mao mch c/ Phi hp : c 2 c ch trn c th phi hp trong trng hp shock nhim trng

II. HU QU V MT CHC NNG : a/ Ph phi cp nh hng trn chc nng h hp : * Gim chc nng h hp : . Tng p lc mng phi l ---> Tng nhp th nng . Tng thng kh l * Ph m k + huyt ni mch ---> chn tiu ph qun ---> kh th b/ Ph phi cp nh hng trn s trao i oxy - mu (Hmatose) : * Gim oxy mu do bt thng t l thng kh - ti mu (rapport ventilation perfusion ) * Toan h hp (gim thng kh ph nang ton b) +/- toan chuyn ha (suy tun hon) trong cc dng nng (gim O2 , tng CO2) III. CHN ON LM SNG : Thng gp : - Suy tim cp - Bnh tim tri - Tng HA t ngt * Du hiu lm sng : a/ Triu chng c nng : - Xanh xao - Lnh - m hi - Th nhanh nng - Kh th khi nm (orthopne) ----> ngi cnh ging - Lo lng

- Cm gic ngp - V niu - Ho lin tc , rabt hng b/ Khm lm sng : -nh gi u hiu nng : +Ri lon tri thc (do gim thng kh ph nang) +Gim HA -Xc nh chn on : +Nghe tim : tim nhanh . galop (bn tri), +/- m thi tm thu (t l thun vi h van 2 l ) +Nghe phi : ran n 2 ph trng dn t i ln (nh thy triu dn ln) +HA: . Tng HA tm thu & tm trng : l nguyn nhn chnh hoc nguyn nhn phi hp . Gim HA v HA kp : du hiu nng * nh gi ban u v din tin : rt quan trng ( + + +) cho x tr v tin lng * Din tin : Ty thuc nguyn nhn & p ng iu tr -Din tin xu :nght th cp do gim thng kh ph nang nng cn gip th -Din tin tt : gim kh th , HA n nh , c nc tiu -Qua cn cp cu : +Nu ph phi cp ln u : . Cn hi tin s bnh tim (cao HA , thiu mu c tim , bnh van tim , bnh c tim , bnh thn i km) . Khm lm sng . ECG

. Phim phi . nh gi chc nng tht tri bng siu m v cc xt nghim khc . Tm nguyn nhn CHA +Nu l bnh nhn b ph phi : tm nguyn nhn gy ph phi (ngng thuc , khng theo ch n thch hp , tnh trng nhim trng mi xut hin , tc mch mu phi . . .) IV. DNG LM SNG : * Theo triu chng : -Hen tim : khng c hoc c rt t ran n , ran rt + + + -Ho ra mu -Dng ti cp : cht t ngt (vn php y) -Dng bn cp : . Kh th khi gng sc . Kh th khi nm . Kh th khi ho .C trn dch mng phi * Theo nguyn nhn : a/ Ph phi cp do ri lon huyt ng hc 1/ CHA : -Cn CHA o bin chng tim mch ( o ngng iu tr hoc khng theo ch n ph hp ) -Cn CHA c tnh vi tn thng thn kinh , thn , xut huyt. . . ) 2/ Suy ng mch vnh : (him thng ngi ln) -Nhi mu c tim -Thiu mu c tim 3/ Bnh van tim : bnh van tim tri

Bin chng ph phi cp l mt yu t thay van -Hep van 2 l -Hp van ng mch ch -H van ng mch ch 4/ Ri lon nhp tim kch pht -Lon nhp tim nhanh o run nh -Cn nhp nhanh trn tht -Nhp nhanh tht -Bloc nh - tht 5/ Bnh c tim gin n 6/ Nguyn nhn khc : -Vim c tim cp do nhim trng hoc nhim c : + + + -Bnh tim bm sinh b/ Ph phi cp do tn thng tnh thm : Tn thng hng ro gia ph nang v mao mch do nhiu nguyn nhn 1/ Do nhim c : -Kh CO -Kh c (chlore), cht c (du hi , xng , ch) -Qu ti oxy (hyperoxie) 2/ Do nhim trng : -Sc nhim trng -Nhim trng huyt gram m -Nhim virus c tnh -Bnh phi nng (+ + +) vi tn thng ph nang v m k 3/ Nguyn nhn khc : -ng mu ni mch ri rc + sc

-Cht ui -Hi chng Mendelson -Ph do nguyn nhn thn kinh -Tc mch -Qu ti do tim truyn qu nhiu dung dch i phn t trong sc V. CHN ON : * Chn on d dng trc bnh cnh suy h hp cp 1/ Vi kh th nhanh : -Xanh xao -Cm gic b chn p -Ho ko di -Ho ra bt hng 2/ Nhp tim nhanh , tnh mch c ni 3/ Nghe phi : ran n , th , ri rc 2 ph trng * Chn on kh khn tr nh nhi v s sinh *Suy h hp cp nng dn -Nhp th nhanh + + + -Xanh xao, co ko - +/- suy tim cp : tng cn nhanh , ph , thiu niu , nhp tim nhanh , galop , gan to * Xquang phi : -Lm ti ging -Khn -Tn thng ph nang : vng m ri rc , dng kt tm (floconneux) , gii hn khng r , hp lu v quanh rn phi , +/- c tn thng m k (vng m , theo

ng thng, i t rn phi ra ngoi , nm ngang , dy vch mao qun) * Khm ban u : Trong mi tnh hung KHN CP -Nghe phi -Nghe tim : nhp tim > 200 ECG loi b ri lon nhp (cn nhp nhanh trn tht ) -o HA : . C th bnh thng hoc thp . i lc c th cao (HA tm trng) :tm nguyn nhn : bnh thn cp , bnh thn mn , ng c -Khm bng : gan to , lch to, ph? -Tnh trng lm sng cho php . Cng thc mu . Kh mu ng mch (Giai on u : O2 gim + CO2 gim ; giai on tin trin : gim O2 + tng CO2) * Chn on nguyn nhn : -Nguyn nhn do huyt ng hc -Tn thng thc th -Phi hp c hai -Nguyn nhn thng gp theo tui :

tr s sinh : nguyn nhn o iu tr thng gp (+ + +) trong trng hp :

-iu tr bng th oxy qu liu (O2 > 25% . Theo di paO2 ) -Do thuc :v d Isuprel (beta - stimulant) gy nhp nhanh tht -Truyn dung dch u trng qu liu gy ph phi (+ + +) v ph no -Trn kh mng phi -Tc mch do cathter (do khng kh vcc mu ng) -Do gip th nhn to : . Xp phi . Trn kh mng phi . Ph m k . Tng CO2 , gim O2 * Chn on phn bit : 1/ Vim tiu ph qun (Bronchiolite) : bt ming , ran m o tng tit ph qun 2/ Tng tit ph qun (Bronchorre) do : . Tn thng thn kinh . Vim no . Co git lin tc Tm thm cc du hiu : ly trng mt , thay i ng t , lit dy thn kinh xc nh chn on) Tuy nhin ph phi cp cng c th thy trong cc trng hp trn PH PHI CP DO NGUYN NHN HUYT NG HC V TN THNG THC TH

VI. IU TR : * Ph phi cp : 1/ Lasilix : 2 mg / kg TM hoc TB nu khng c ng tim truyn trong vng 5 pht 2/ Suy tim : Digitalique TM : 15 g / kg (tc dng nhanh) 3/ T th ngi 4/ Oxy qua mi hoc Hood 5/ Nu khng c thuc th ng phng php vt l{ : garrot u chi , trch mu 10ml/kg trong 5 - 10 pht : theo di st HA 6/ Gip th nhn to : sm khi c km ri lon tri gic , try mch , xanh xao hoc 30 - 60 pht sau iu tr ni tht bi (p CO2 > 50 mmHg , toan chuyn ho hoc toan chuyn ho + toan h hp , gim PaO2 < 50 mmHg) t ni kh qun trong trng hp ny rt kh (v nguy c lm tng thiu oxy v ngng tim) nn chun b k lng bng thng kh qua mt n , ht m nht v t ni kh qun vi cung cp oxy lin tc Cn tm nguyn nhn v iu tr nguyn nhn * Ph phi bn cp : 1/ Lasilix : 1 mg / kg . C th lp li . iu tr cho n khi gim 5% ca cn nng 2/ Theo i : lng nc tiu , cn mi 12 gi , ion / ngy 3/ Khi ht ph , tng lng cung cp (TM hoc ng ung) mt cch thn trng

4/ iu tr d phng : -Theo di k nu truyn i phn t (HA , p sut TM, Xquang phi) -Gim cung cp mui -Theo di st cc bnh nhn tim v thn TI LIU THAM KHO : 1/ BEAUFILS F., AUJARD Y. : Oedme pulmonaire - Pdiatrie durgence 5 dition Mdecine - Sciences Flammarion 1998 - 58p 2/ M . PICHE, LARCAN A , M . C LAPREVOTE - HEULLY : Oedme aigu pulmonaire . Urgences mdicales - 3 dition . Masson 1987 - 21p 3/PROULX F, DIANE H.,LACROIX J.Oedme pulmonaire. Urgences et soins intensifs pdiatriques. Doin Editeurs Paris 1993: 652-9.

S14. NG C THC N

BS. BCH VN CAM

I- Nm: Nm c: mu sc sc s. 1. Nhm 1: Cyclopeptides (Amanita phalloides): T vong cao, t 30-90%, cha Amatoxine khng b bt hot bi nhit (nu n), c gan thn. a. Chn on * Lm sng - 6-24h sau n: i ma, au bng, tiu chy. Nng: sc, co git, hn m. - 24-48 gi sau: vng da, suy gan, suy thn, ECG c th block nhnh.

* Cn lm sng - Cng thc mu, HCT - Chc nng gan, thn, ECG - Chc nng ng mu - Ion , tng phn tch nc tiu... b. iu tr : - Ra d dy, than hot. - iu tr triu chng v bin chng. 2. Nhm 2: Muscarine (Inocybe v Clitocibe). c t nh hn so vi nhm trn. a. Chn on: * Lm sng: - Ri lon tiu ha, o gic, - Du hiu i giao cm: chm nhp tim, co tht ph qun, tng tit m nht. * iu tr: - Ra d dy, than hot. - Atropine liu 0,1mg/kg TM, c th lp li. II- C NC: c t Tetrodotoxine c ch bm So ium-potassium, block dn truyn thn kinh c. T l t vong cao, vo khong 60%. a. Chn on lm sng: - Sau 30 pht: t mi, ming i ma, au bng. - Lit chi hng ln, lit c h hp, ng t dn, h huyt p, tim p chm. T vong do lit h hp hoc try mch. Nu sng st, cc triu chng trn s hi phc sau 24 gi.

b. iu tr: - Thng ng th v gip th. - Ra d dy. - Nhp chm v gim HA: Atropine. - Lit chi, lit h hp: Edrophonium (TENSILON) 0.05 mg/kg/liu, TM. Neostigmine 0.01-0.04 mg/kg/liu mi 2-4 gi TM. III- TRNG CC: c t Bufotoxine c nhiu trong da, trng, gan. a. Chn on: Lm sng - Tiu ha: au bng, i, tiu chy. - Tim mch: mch chm, block AV, try mch. - Suy thn cp, suy gan: him v xut hin tr. Cn lm sng: Ion , ECG. b. iu tr: - Ra d dy, than hot. - Nhp tim chm: Atropine liu 0,02mg/kg, ti thiu 0,15mg, ti a 1mg TM. - Tht bi Atropine hoc RL huyt ng hc: Epinephrine TTM 0,1 - 1g/kg/ph. - Tht bi: t my to nhp tm thi v thng phc hi sau 48-72 gi. c. Theo di: - Nhp tim bng cardioscope - Mch, HA, nhp th mi gi n khi n nh. IV- NG C THC N DO VI TRNG: Thc n c vi trng hoc c t, thng xy ra trong tp th. 1. Chn on:

Lm sng: ri lon tiu ha: au bng, i ma, tiu chy...

Cn lm sng: - Soi, cy bnh phm ( cht nn, phn, mu...) 2. iu tr: - Ra d dy. - B dch: ORS, Lactate Ringer trng hp nng. - Ch nh khng sinh: Salmonella: khi st thng hn. V. Cholera, C. Botulinum, Streptococcus.

- Lit c h hp do C. Botulinum c ch nh gip th.

TI LIU THAM KHO 1. Peter Viccellio. Emergency Toxicology. 1998 2. George C. Rodgers. Poisonings: Drugs, chemicals, and plants. Nelson Textbook of Pediatric. 2000 3. CD-INTOX. WHO. 1996 4. Kenneth W. Kulig. Poisoning and Overdose. Emergency Pediatrics: A Guide to Ambulatory care. 1999

S15. HN M
Hn m l s suy gim thc do tn thng bn cu i no hoc h thng li. I. NGUYN NHN Chn thng: xut huyt no, dp no Tai bin mch mu no: nhn no, xut huyt no khng do chn thng Nhim trng: vim no mng no, st rt th no Chuyn ha: ri lon in gii, h ng huyt, tiu ng, suy gan, suy thn. Ng c: thuc ng, Morphin v dn xut, phospho hu c Thiu mu no (sc), thiu oxy no (suy h hp) ng kinh II. CHN ON: II.1. Cng vic chn on Hi bnh: - Chn thng - St, nhc u, nn i: vim no mng no - Tiu chy: ri lon in gii, h ng huyt - Co git - Tip xc thuc, c cht, ru

- Tin cn: tiu ng, ng kinh, bnh gan thn Khm lm sng: Mc tiu: nh gi mc hn m v tm nguyn nhn Du hiu sinh tn: Mch, huyt p, nhp th, kiu th, nhit Huyt p cao: bnh l thn; huyt p cao km mch chm: tng p lc ni s Th nhanh su: toan chuyn ha, tiu ng Th chm nng, khng u: tn thng thn kinh trung ng Khm thn kinh a. Mc tri gic: - Da vo thang im Glasgow cho tr em: p ng m mt, vn ng, li ni - Hoc da vo thang im Blantyre (thang im ny ci tin t thang im Glasgow, c th p dng trong thc hnh nh n gin hn) - Ri lon tri gic t ngt thng gp trong tt no - Du hiu mt v (tay co chn dui) hoc mt no (dui t chi).

b. Khm mt - ng t: u hay khng, kch thc ng t, phn x nh sng . Dn, c nh mt bn: xut huyt no, tt no. Cn loi tr n ng t do trc c ng thuc n ng t soi y mt. . Co nh: ng c phospho hu c, thuc ng, Morphin, tn thng cu no - y mt: ph gai (tng p lc ni s) hoc xut huyt - Phn x mt bp b(+): quay nhanh u bnh nhn sang mt bn quan st s di chuyn ca nhn cu (chng ch nh trong chn thng ct sng c, chn thng s no): Nu cu no, no gia bnh thng nhn cu di chuyn ngc hng quay u. Tn thng cu no: khng c du hiu trn # mt bp b ng tnh c. Du mng no: thp phng, c cng, Kernig, Brudzinsky d. Du thn kinh khu tr Du hiu yu lit chi, lit dy s ch im tn thng khu tr nh t mu trong s, u no e. Du hiu tng p lc ni s - Nhc u, nn i, thp phng

- Ri lon tri gic - Tam chng Cushing: mch chm, huyt p cao, nhp th bt thng l du hiu tr ca tng p lc ni s. - Ph gai th: trng hp cp c th khng c - ng t dn mt hay hai bn: tt no - Nhp th Cheynes Stokes hoc cn ngng th. f. Phn x gn xng , du Babinsky: tng px gn xng km Babinsky (+): tn thng trung ng. Khm ton din Tim bm sinh tm, m km du thn kinh khu tr: thuyn tc mch no, p xe no Bng: kch thc gan, lch, tun hon bng h. Gan lch to km st: st rt. Gan lch to km bng bng, tun hon bng h: hn m gan Da: bm mu, vng da Du hiu thiu mu Cn lm sng : Xt nghim thng qui: - Cng thc mu, k sinh trng st rt - Dextrostix, ng huyt, ion , TPTNT - Kh mu khi suy h hp c ch nh th my - Chc d tu sng sau khi loi tr tng p lc ni s: . Vim mng no m: dch c, p lc tng, tng bch cu a nhn, tng albumin, glucose gim. . Vim mng no lao: dch trong hoc vng, tng bch cu n nhn, tng nh albumin, glucose gim . Vim no: dch trong, s lnh bch cu, albumin, glucose trong gii hn bnh thng. . Xut huyt mng no: dch khng ng, tng p lc (phn bit vi chm mch: dch , ng, c khuynh hng trong dn ba chai lin tip)

q Chng ch nh chc d ty sng: Tng p lc ni s, ph gai th Sc, suy h hp Ri lon ng mu Xt nghim khi nh hng chn on: - Siu m no xuyn thp (u no, xut huyt no) - Chc nng ng mu (xut huyt no mng no, ri lon ng mu) - Chc nng gan, thn (bnh l gan, thn) - Xquang tim phi (bnh l tim, phi) - Tm c cht trong dch d y, mu, nc tiu (ng c) - CT scanner no nu nghi ng t mu, u no, p xe no m khng lm c siu m xuyn thp hoc siu m c lch M-echo. - EEG (ng kinh, vim no Herpes: tn thng no khu tr thuz thi ng) III. IU TR: III.1. Nguyn tc iu tr Bo m thng kh v tun hon Pht hin cc bnh l ngoi thn kinh iu tr nng v phng nga bin chng iu tr nguyn nhn III.2. iu tr ban u 1. Bo m tt s thng kh v tun hon: a. Thng ng th v m bo thng kh tt - T th nga u nng cm hay nm nghing - Ht m nht - t ng thng ming hu khi tht bi vi nga u nng cm v ht m nht - Th oxy duy tr SaO2 92-96% - t ni kh qun gip th: cn ngng th, tng p lc ni s b. Chng sc:

- Truyn dch Lactate Ringer hay normal saline 20 mL/kg/gi v cc thuc tng sc co bp c tim (Dopamine, Dobutamine) duy tr huyt p n nh. - Trnh truyn qu nhiu dch c th gy ph no v tng p lc ni s. 2. Khi c du hiu lm sng gi t mu, u no hay p xe no cn hi chn ngoi thn kinh can thp phu thut 3. Thit lp ng truyn tnh mch ly mu xt nghim 4. Nu Dextrostix < 40 mg%, iu tr h ng huyt Tr s sinh: Dextrose 10% 2 mL/kg TMC Tr ln: Dextros30% 2 mL/kg TMC 5. Cao huyt p khng do suy h hp v tng p lc ni s: thuc h p ng tnh mch hoc nh i li (nu khng c thuc h p ng tnh mch) 6. Chng ph no nu c - Nm u cao 30O to thun li cho mu t no v tim - Hn ch dch khong 1/2 - 3/4 nhu cu bnh thng - Th oxy - Tng thng kh bnh nhn th my, duy tr PaCO2 thp 25-35 mmHg, mc ch co mch mu no lm gim lng mu ln no. Tuy nhin khng nn PaCO2 < 25 mmHg v s lm thiu mu, oxy no. - Thuc: Mannitol 20% 1-2 g/kg/ln TTM trong 1 gi, c th lp li mi 6-8 gi. Furosemide 1 mg/kg TM khng lp li. Dexamethasone t tc dng, nht l ph no do thiu mu thiu oxy. 7. iu tr mt s nguyn nhn khi cha c kt qu xt nghim - Nghi ng h ng huyt: dung dch ng u trng - Nghi ng ng c Morphin: Naloxone 0,001 mg/kg TM - Nghi st rt: Artesunate TM - Nghi vim mng no (khi c chng ch nh chc d tu sng): khng sinh tnh mch sau khi cy mu

- Nghi vim no do Herpes: Acyclovir TM 8. iu tr nguyn nhn 9. Truyn dch v inh ng a. Truyn dch: - 2/3 nhu cu trnh ph no do tit ADH khng thch hp - Nu c tng p lc ni s: truyn 1/2 nhu cu - Natri: 3 mEq/ 100 mL dch, kali 1-2 mEq/100 mL dch. Dung dch thng chn l Dextrose 5-10% trong 0,2-0,45% saline b. Dinh dng - Trong giai on cp khi c chng ch nh nui n qua son e dy th trong 3 ngy u ch cn cung cp glucose v in gii. - Cn nhanh chng nui n qua son e dy nu khng c chng ch nh, chia lm nhiu ba n nh git chm, nu cn nui n tnh mch mt phn. 10. Phng nga nhim trng bnh vin - Vt l tr liu h hp - Chm sc bnh nhn hn m III.2. Theo di - Mch, HA, nhp th, tri gic (ch s hn m), co git v cc du hiu ca tng p lc ni s. - Ion , ng huyt

TI LIU THAM KHO 1. The child with a decreased conscious level. Advanced Paediatric Life Support. BMJ. 2001 2. Coma. Emergency Pediatrics: Aguide to Ambulatory Care. 1999 3. Curt M. Steinhart. Coma in the pediatric patient. Pediatric Critical Care. 1998 4. Gitte Y. Larsen. Evaluation and Monitoring of the Central Nervous System. Handbook of Pediatric Intensive Care. 1999

S16. D VT NG TH
I. I CNG: D vt ng th l cp cu Tai Mi Hng, c th gy t vong. Thng xy ra tr t 3 thng 6 tui. Nguyn nhn thng gp l cc ht tri cy, vin bi, hoc sc sa, bt II. CHN ON: 1. Cng vic chn on: a) Hi bnh: hon cnh xy ra, loi d vt, hi chng xm nhp. b) Khm lm sng: Mc kh th: ngng th, hn m, ti tm. Kh th vo, s dng c h hp ph. Nghe ph m phi 2 bn. c) Cn lm sng: Xquang phi: tm d vt cn quang, xp phi. Ni soi kh ph qun tt c cc trng hp c hi chng xm nhp. 2. Chn on nghi ng: Bnh s: t ngt tr ang chi vi ht hoc vt nh hoc ang n b. Lm sng: hi chng xm nhp hoc kh th thanh qun. 1. Chn on xc nh: Hi chng xm nhp. Ni soi: tm thy d vt trong lng kh ph qun. 2. Chn on phn bit: Vim thanh kh ph qun: c st, ho. U nh hoc khi u thanh qun: kh th thanh qun xut hin t t. III. IU TR: 1. Nguyn tc iu tr: Ly d vt. H tr h hp. iu tr cc bin chng. 2. X tr ban u:

Khi tr b d vt ng th hoc nghi ng d vt ng th a. Nu tr khng kh th hoc kh th nh: kh th thanh qun I v IIA: ng can thip v s lm di chuyn d vt c th lm tr ngng th t ngt. Tr cn c theo di st v mi hoc chuyn n chuyn khoa Tai Mi Hng, tt nht tr t th ngi hoc m bng b. Nu tr ngng th hoc kh th nng: kh th thanh qun IIB v III: Nu tr ngng th hoc kh th nng, ti tm, vt v, hn m cn cp cu ngay. Trnh mc d vt bng tay. Tr ln: th thut Heimlich - Tr cn tnh: Cp cu vin ng pha sau hoc qu ta gi vo lng tr (tr <7 tui). Vng 2 tay ngang tht lng. t mt nm tay vng thng v ngay i mu kim xng c, bn tay t chng ln. t ngt n mnh, nhanh 5 ln theo hng trc ra sau v i ln trn - Tr hn m: t tr nm nga, cp cu vin qu gi v t 2 bn tay chng ln nhau vng i xng c tr. t ngt n mnh, nhanh 5 ln. Tr s sinh v nh nhi: phng php v lng n ngc t tr nm sp u thp trn cnh tay. Dng lng bn tay phi v lng 5 ln mnh v nhanh vng gia 2 xng b vai. Sau lt nga tr nu cn kh th dng 2 ngn tay n ngc 5 ln. Nu tr ngng th phi thi ngt hoc bp bng qua mask trc v trong khi lm th tht Heimlich hoc v lng n ngc. Trong trng hp tht bi c th lp li 6-10 ln cc th thut trn. Nu tht bi ng n soi thanh qun nu thy c d vt s dng km Magill gp ra hoc m kh qun, chc kim xuyn mng gip nhn hoc t ni kh qun. K thut chc kim xuyn mng gip nhn: - Cho bnh nhn nm nga, k gi i 2 vai u nga tt. - Bn tay (T) c nh kh qun bng cch gi cht vng gip nhn v xc nh mng gip nhn. - Bn tay (P) cm kim lun s 14 m qua mng gip nhn theo ng gia ngay i sn gip, to mt gc 45O hng xung pha chn. - Rt nng ra, ni kim lun vi u ni ca ng NKQ s 3 v bp gip th Thng sau khi d vt c tng ra tr ht kh th ngay, tuy nhin sau tt c tr ny phi c khm chuyn khoa Tai Mi Hng

3. Soi gp d vt: Ch nh: tt c cc trng hp c hi chng xm nhp K thut: Chun b: chun b trc dng c soi, dng c gp d vt. Nghin cu v tr. C th th trc. Tin hnh: m ni kh qun. Soi h hng vi dng c Mc Intosh. Thy d vt gp ra ngay. Soi kh ph qun, dng ng soi Wolf a vo thanh mn, tm vt kh qun, ph qun gc phi, ph qun gc tri, ph qun thy. Thy d vt gp ngay. Sau soi kim tra li, c th cn d vt th 2. Trng hp kh, ngng soi. Dng khng sinh, Corticoi e. Soi li ngy hm sau. Dng khng sinh phng Cephalosporin th h 1 dng 1 liu trc soi v Dexamethasone 0,6 mg/kg TM 1 liu duy nht. iu tr bin chng : - Trn kh i da : rch hay m kim i da. - Trn kh mng phi : dn lu mng phi. - Ap xe trung tht : m trung tht. 4. Theo di v ti khm: a. Theo i kh th bnh nhn, bin chng sau soi nh trn kh i da, trn kh trung tht. b. Ra vin 1 - 2 ngy sau, khi cc triu chng n. c.Ti khm : mi tun cho n khi n nh.

CHNG 2. BNH L S SINH


S17. NHIM TRNG HUYT S SINH
I. NH NGHA:

Nhim trng huyt s sinh l bnh gy tn thng nhiu c quan km u khun huyt, xy ra trong thng u sau sinh. Tc nhn gy nhim trng huyt nguyn pht thng l: Streptococcus nhm B, E.coli, Listeria Vi khun gy nhim trng bnh vin thay i theo tng n v chm sc tr, thng l: Staphylococcus epidermidis, Staphylococcus aureus, Klebsiella,E.coli. II. CHN ON: 1. Cng vic chn on: a) Hi Khai thc tin s sn khoa: Sinh non, sinh nh cn. V i sm 24 gi, nc i c, hi. Sinh kh, sinh ngt (Apgar 1pht < 5, 5 pht < 7). M c st hay nhim trng trc, trong v sau sinh. C hi sc lc sinh hoc dng cc th thut xm ln. b) Khm: tm cc du hiu ca nhim trng: b.1. Tng qut: b km, st 38 C hoc h thn nhit < 36,5 C. b.2. Cc c quan: Thn kinh: L , hn m hay tng kch thch, co git, gim phn x nguyn pht, gim hay tng trng lc c, thp phng, du thn kinh khu tr. Tiu ha: nn i, tiu chy, chng bng, xut huyt tiu ha, gan

lch to. H hp : tm ti, cn ngng th > 20 giy hoc ngng th > 20 giy km nhp tim chm, th nhanh>60 ln/pht, th co lm . Tim mch : nhp tim nhanh hay chm, h huyt p, da xanh, lnh, ni bng. Da nim: vng a, xut huyt da nim, rn m, m da, cng b. b.3. Tm du hiu nng ca nhim trng: Cng b. Sc: mch nh, da ni bng, thi gian phc hi mu da > 3 giy. b.4. Tm nhim trng: nhim trng da, nhim trng rn, vim tnh mch ni tim chch, vim phi do gip th, nhim trng tiu o t sond tiu. c) ngh xt nghim: Pht mu ngoi bin. CRP. Cy mu. Cy nc tiu. Cy dch c th: phn, m da, dch khp khi cn. Chc d ty sng l ng tc bt buc loi tr vim mng no m i km khi c triu chng thn kinh Ion , ng huyt, bilirubin (nu c vng da) Kh mu ng mch (nhim trng huyt nng, suy h hp)

ng mu ton b (nhim trng huyt nng, c biu hin xut huyt) 2. Chn on xc nh: cy mu (+). 3. Chn on c th: khi cha c kt qu cy mu, Lm sng: triu chng nhiu c quan + nhim trng + Cn lm sng gi nhim trng huyt: Cng thc mu: phi c t nht 3 tiu chun sau: - Bch cu gim < 5.000/mm3 hoc tng > 25.000/mm3. - T l : bch cu ht non bch cu ht trng thnh 0,3. - C khng bo, ht c, th Dohl. - Tiu cu m <150.000 / mm3 CRP > 10 mg / L. 4. Chn on phn bit: cc triu chng lm sng thng khng c hiu .Chn on phn bit gm c cc bnh l gy suy h hp, bnh l tim mch, bnh h tiu ha, bnh v mu, bnh l h thn kinh trung ng. III. IU TR: 1. Nguyn tc iu tr: Dng khng sinh ngay khi nghi ng nhim trng huyt. Thng cc khng sinh c ph khng khun rng c phi hp vi nhau hoc chn khng sinh da vo loi vi trng tr c th b nhim, s nhy cm ca vi trng, kh nng t c nng dit khun ti v tr

nhim trng, tc dng ph, s non km ca chc nng gan, thn. liu, thi gian. Phi hp v iu tr nng v iu tr cc bin chng. 1. iu tr ban u: a) Bnh nhi cha c iu tr khng sinh: Phi hp: Ampicilline + Gentamycin. Hoc Ampicilline + Cefotaxim. Hoc Ampicilline + Cefotaxim + Gentamycin: khi c mt trong cc du hiu sau: - Nhim trng huyt trc 7 ngy tui. - Bnh c du hiu nng, nguy kch ngay t u. - Nhim trng huyt + vim mng no m. Nu c sc hoc nghi t cu: Cefotaxime + Oxacillin Gentamycin b) Bnh nhi c iu tr tuyn trc vi nhng khng sinh nh trnnhng khng ci thin hoc nghi nhim trng bnh vin: Ciprofloxacin / Pefloxacin / Cefepim Amikacin nu nghi nhim trng huyt Gr(-) Oxacillin / Vancomycine Amikacin nu nghi nhim trng huyt t cu, hoc: Vancomycine + Ciprofloxacin Amikacin nu cha r tc nhn. (u tin chn khng sinh u, nu khng sinh u ng th chn khng sinh k tip. V d: Ciprofloxacin / Cefepim: chn Ciprofloxacin,

nu ng chn Cefepim ). 3. iu tr tip tc: da vo kt qu cy mu v din tin lm sng. Thi gian iu tr khng sinh: 10 14 ngy. Thi gian iu tr k o i hn (3-4 tun) khi: - Nhim trng huyt gram m. - C vim mng no m i km. Thi gian s dng Aminoglycoside khng qu 5-7 ngy. 4. iu tr nng v iu tr cc bin chng: Sc nhim trng, ng mu ni mch lan ta (Xem bi sc nhim trng, DIC) Cung cp nng H tr h hp Nu c gim bch cu nng: truyn bch cu ht hoc thay mu nu c th.

S18. CO GIT S SINH


I. NH NGHA: Co git s sinh biu hin rt a ng, i khi kn o b st, gm: C ng bt thng hoc thay i trng lc c ca thn v chi: co git ton thn hoc khu tr, gng cng kiu mt v hoc mt no, hoc gim trng lc c ton thn. C ng bt thng mt, ming, li: mt, chu ming, nhai,... C ng bt thng mt: nhn mt ch, git nhn cu kiu

nystamus,... H thn kinh thc vt: cn ngng th, th kiu tng thng kh, thay i nhp tim, huyt p, phn x ng t. Khc vi tr ln, co git tr s sinh thng c nguyn nhn r rng, o tm v iu tr nguyn nhn l rt quan trng khi x tr co git tr s sinh. II. CHN ON: 1. Cng vic chn on: a) Hi: bnh s / tin cn sn khoa: Sanh ngt Sanh ht, sanh forceps B k m, b b St M c dng Pyridoxine trong thai kz b) Khm lm sng: Co git ton thn hay khu tr ng t, phn x nh sng Cn ngng th Tm bu huyt thanh hoc bu huyt xng s S thp tm du thp phng Tm u hiu thiu mu: mu sc da, nim nhim trng D tt bm sinh: no c) ngh xt nghim: Dextrostix H ng huyt. Ion : Na, Ca, Mg Ri lon in gii: h Na, h Ca, h Mg mu. X t nghim tm nguyn nhn nhim trng: pht mu, CRP, cy mu. Siu m no xuyn thp Xut huyt no, hnh nh tn thng no do thiu Oxy do sanh ngt Dch no ty Vim mng no. in no gip chn on co git do l thuc Pyri oxin (sng in no bt thng bin mt khi tim Pyridoxin) khng c ch nh thng qui, ch thc hin khi cc nguyn nhn co git khc c loi tr v tin s m c dng Pyridoxin.

2. Chn on: Vi cc xt nghim trn thng chn on nguyn nhn co git tr s sinh. Co git tr s sinh cng c th do phi hp nhiu nguyn nhn: gia ri lon chuyn ho-in gii + cc bnh l thn kinh trung ng. V : h ng huyt + sanh ngt; h Natri/Canxi/Magne + xut huyt no/sanh ngt/vim mng no III. IU TR: 1. Nguyn tc iu tr: Chng co git, h tr h hp iu tr c hiu theo nguyn nhn 2. Chng co git: Thng ng th: ht m nht Th oxy, hoc t ni kh qun gip th ty thuc mc thiu Oxy mu. Thuc chng co git: - Phenobarbital: 15 - 20mg/kg TM 15 pht. Sau 30 pht, nu cn co git: lp li liu th hai 10mg/kg TM 15 pht, tng liu ti a khng qu 30 - 40mg/kg. Ty nguyn nhn, sau c th duy tr Phenobarbital: 3 - 5 mg/kg/ngy (tim bp/ung) - Nu khng p ng sau khi dng liu cao Phenobarbital: Phenytoin 15 - 25mg/kg TTM 20 pht, sau duy tr: 4 -8mg/kg/ngy. Nu khng c Phenytoin: Diazepam: 0,1 - 0,3mg/kg TM 5 pht, duy tr: 0,1 - 0,5 mg/kg/gi, cn theo di st h hp trong khi tim Diazepam (gy ngng th) 3. iu tr c hiu: Ngay sau khi pht hin nguyn nhn, cn x tr ngay theo nguyn nhn ca co git: 3.1. H ng huyt (Glucose/mu < 40 mg%) Dextrose 10%: 2 ml/kg, tim mch chm trong 2 - 3 pht. Duy tr: 6-8 mg/kg/pht (Dextrose 10% 3-5ml/kg/gi). Theo i Dextrostix mi 2 - 4 gi n khi ng huyt n nh. 3.2. H Canxi mu (Ca ion < 4 mg% (1 mmol/l) hoc Ca ton phn < 7 mg%)

Calcium gluconate 10% 1 - 2 ml/kg, tim mch chm trong 5 pht. Theo i st nhp tim v v tr tim tnh mch trong khi tim. Nu khng p ng: lp li liu trn sau 10 pht. Duy tr: 5 ml Calcium gluconate 10% /kg/ngy truyn tnh mch hoc dng ung vi liu tng ng 3.3. H Mg mu (Mg/mu < 1,2 mg%) Magnesium sulfate 50%: 0,1 - 0,2 ml/kg, tim mch chm trong 5 pht,theo di st nhp tim trong khi tim. C th lp li liu trn mi 6 - 12 gi, nu Mg/mu vn thp. Duy tr: Magnesium sulfate 50%, ung 0,2 mg/kg/ngy. 3.4. L thuc Pyridoxine: Pyri oxine: 50 mg tim mch. Nu c iu kin, theo i in no trong lc tim thuc: sng bt thng bin mt ngay sau khi tim Pyridoxine. Duy tr: 10 - 100 mg, ung chia 4 ln/ngy. 3.5. Cc nguyn nhn khc: h Natri mu, vim mng no, xut huyt no- mng no (xem cc phc tng ng). Vn Mc chng c: Cha d kin chng minh tnh an ton khi s dng Midazolam cho tr s sinh. Phenobarbital liu cao 40mg/kg c th khng ch cn co git nng tr s sinh 1 cch an ton

S19. VNG DA S SINH


Vng da tr s sinh l o tng ph hy hng cu, gim chc nng ca cc men chuyn ha do gan sn xut v chu trnh rut gan tng. Tng bilirubin gin tip trong mu c th din tin nng n vng da nhn, bin chng ny cn ty thuc nhiu yu t: non thng hay thng, tr khe hay bnh l, bt ng I. NH NGHA: Vng da tr s sinh l o tng ph hy hng cu, gim chc nng ca cc

men chuyn ha do gan sn xut v chu trnh rut gan tng. Tng bilirubin gin tip trong mu c th din tin nng n vng da nhn, bin chng ny cn ty thuc nhiu yu t: non thng hay thng, tr khe hay bnh l, bt ng nhm mu. II. CHN ON: 1. Cng vic chn on: a) Hi: Thi gian xut hin vng da - Sm (1-2 ngy): huyt tn (bt ng nhm mu ABO, nhm mu khc) - T 3-10 ngy: ph bin: c bin chng hoc khng bin chng - Mun (ngy 14 tr i): vng a sa m, vng a tng bilirubin trc tip B b, co git b) Khm: nh gi mc vng da: Nguyn tc Kramer :

Tm bin chng vng da nhn: li b, mt phn x b, gng n ngi. Tm cc yu t gp phn vng da nng hn: - Non thng. - Mu t, bu huyt thanh. - Da ng o a hng cu. - Chng bng do chm tiu phn su. c) ngh xt nghim: Vng a nh (vng 1-2) xut hin t ngy 3-10, khng c biu hin thn kinh: khng cn xt nghim Vng a sm vo ngy 1-2 hoc vng da nng (vng 4-5), cn lm cc xt nghim gip nh gi nng v nguyn nhn: - Bilirubin mu: tng Bilirubin gin tip

- Cc xt nghim khc: Pht mu ngoi bin Nhm mu m-con Test Coombs trc tip 2. Chn on: a) nng vng da: Vng a nh: vng da nh t ngy 3-10, b tt, khng km cc yu t nguy c, mc Bilirubin mu cha n ngng phi can thip. Vng a bnh l: vng da sm, mc vng nng, km cc yu t nguy c, mc Bilirubin vt ngng phi can thip. Vng a nhn: - Vng da sm + Bilirubin gin tip tng cao > 20 mg% v: - Biu hin thn kinh b) Chn on nguyn nhn (thng gp): b.1. Bt ng nhm mu ABO: Ngh n khi: m nhm mu O, con nhm mu A hoc B. Chn on xc nh: m O, con A hoc B + Test Coombs trc tip (+). b.2. Nhim trng: vng da + nhim trng / biu hin nhim trng lm sng+ xt nghim. b.3. Mu t: vng a + bu huyt thanh/bu huyt xng s/ mu t ni khc. III. IU TR:

1. Nguyn tc iu tr: c hiu: chiu n, thay mu. iu tr h tr. 2. Chiu n: a) Ch nh: Lm sng: vng a sm, vng da lan rng n tay, chn (vng 3,4,5), hoc Mc Bilirubin mu:Cn nng- Bilirubin gin tip (mg%) : b) Nguyn tc: Chiu n lin tc, ch ngng khi cho b Vng a nng: nn chn nh sng xanh, nu khng c nh sng xanh th s dng ng sng trng vi h thng n 2 mt Tng lng dch nhp 10-20% nhu cu 3. Thay mu: a) Ch nh: Lm sng: vng a sm n lng bn tay, bn chn (< 1 tun) + bt u c biu hin thn kinh, hoc: Mc Bilirubin gin tip mu cao > 20 mg% + bt u c biu hin thn kinh (li b, b km). b) Nu khng th thay mu v: Qu ch nh: ang suy h hp nng hoc sc. Khng t c catheter tnh mch rn.

Khng c mu thch hp v mu ti (< 3 ngy). Bin php iu tr thay th: chiu n 2 mt lin tc, c th truyn thm Albumin. 4. iu tr h tr: a) Cung cp dch (tng 10-20% nhu cu). b) Chng co git bng Phenobarbital. c) Cho b m hoc cho n qua ng thng d dy sm. d) Tr non thng c chm tiu phn su: tht tho nh bng NaCl 0,9%. e) Nu do nguyn nhn nhim trng: khng sinh thch hp (xem nhim trng s sinh). f) Vt l tr liu nu vng a nhn qua giai on nguy him. 5. Theo di: a) Trong thi gian nm vin: Mc vng da, biu hin thn kinh mi 4-6 gi nu vng da nng, mi 24 gi trong trng hp vng da nh. Lng xut-nhp, cn nng mi ngy. Khng nht thit phi o Bilirubin mu mi ngy tr trng hp vng a p ng km vi iu tr (mc vng da khng gim, c biu hin thn kinh). b) Ti khm mi thng nh gi pht trin tm thn vn ng v c k hoch phc hi chc nng kp thi.

Vn Mc chng c: Chiu n l phng php iu tr hiu qu, an ton Ch nh chiu n ch cn da vo mc vng da trn lm sng

S20. NHIM TRNG RN S SINH

I. NH NGHI: Nhim trng rn l nhim trng cung rn sau khi sanh, c th khu tr hoc lan rng, khng cn ranh gii bnh thng gia da v nim mc rn ch tht hp v vng sung huyt s lan rng ra thnh bng km ph n, r dch hi, i khi c m. Theo t chc y t th gii, c ti 47% tr s sinh b nhim trng huyt c ng vo t nhim trng rn v khong 21% cc trng hp tr s sinh n khm v l do khc c km theo nhim trng rn. Hng nm t l nhim trng rn nhp vin ti khoa s sinh bnh vin Nhi ng I khong 18%. II. CHN ON: 1. Cng vic chn on: a) Hi nhng yu t nguy c lm cho tr d b nhim trng rn: Cn nng lc sanh thp, sanh khng v trng, c t catheter vo tnh mch rn, v i sm, m st khi sanh.. b) Khm tm cc du hiu ca nhim trng rn : Rn t hi, r dch m, rn ty . Vim ty m mm, vim mch bch huyt da thnh bng chung quanh rn. Vim ty cn c su lan rng Cc u hiu nhim trng ton thn: st, l , b b c) ngh xt nghim: Pht mu ngoi bin: nh gi tnh trng nhim trng ca tr. Cy dch rn: tm vi trng v lm khng sinh .

Cy mu khi tnh trng nhim trng rn nng. 2. Chn on : Chn on xc nh: Rn c m, qung n quanh rn + cy dch rn (+). Chn on c th: Rn c m, qung n quanh rn. Phn (theo T Chc Y T Th Gii): - Nhim trng rn khu tr: mt ranh gii bnh thng gia da v dy rn, dy rn vim c m, i khi c r mu. - Nhim trng rn nng: nhim trng lan ra m lin kt xung quanh, gy vim cng quanh rn, to qung rn ng knh 2cm. 3. Tiu chun nhp vin: Nhim trng rn nng. Hoc tr c km biu hin nhim trng ton thn (st cao, l , b b). III. IU TR: 1. Nguyn tc iu tr: iu tr nhim trng. Gip rn mau rng v kh. 2. Khng sinh iu tr : Trng hp chn rn c m ti ch: Oxacillin ung x 5-7 ngy, hoc Cephalosporin th h 2 ung (Cefaclor, Cefuroxime). Trng hp rn m v n cng quanh rn: Ampicillin TM/ Oxacillin TM + Gentamycin TB 3. Sn sc rn: y l mt vic rt quan trng cn lm mi ngy nhm mc ch: gim tnh trng nhim trng, rn mau kh v rng . 4. Sn sc ti nh v phng nga: a) Hng dn sn sc ti nh: Thn nhn cn c hng dn cch chm sc rn ti nh mi ngy 1-2 ln v dn em tr tr li ti khm nu rn cn chy m hay dch sau 2 ngy hoc khi tnh trng nhim trng nng hn. b) Phng nga:

Bo m v trng trc v sau khi sanh. Ct v ct rn bng dng c v trng Ra tay trc khi sn sc tr. rn h v kh , trnh p ho cht hay vt l vo rn Thn nhn cn phi quan st rn v chn rn mi ngy pht hin sm nhim trng. Vn Mc chng c h, khng bng kn l bin php lm rn mau kh v mau rng Phng php n gin gi cho rn sch c hiu qu v an ton tng ng vi s dng dung dch st trng hoc khng sinh ti ch

S21. VIM RUT HOI T S SINH


I. NH NGHA: Vim rut hoi t s sinh l bnh l{ ng tiu ha nng, thng gp tr non thng. Nguyn nhn cha r, nhiu yu t c lin quan n sinh bnh hc: nhim trng, inh ng qua ng tiu ha, tn thng mch mu ti ch. T l mc cng tng nu tr cng non thng, bnh thng khi pht trong vng 3-10 ngy sau sanh. II. CHN ON: 1. Cng vic chn on: a) Hi: Khai thc tin s tm cc yu t nguy c. Tiu ra mu, b k m, c sa. Cc yu t nguy c sau sanh: - Sanh ngt. - Suy h hp sau sanh (bnh mng trong). - C t catheter ng-tnh mch rn, thay mu. - Sc. - H thn nhit.

- Thiu mu, a hng cu. Dinh ng: - n sa cng thc. - Lng sa qu nhiu v tc qu nhanh. b) Khm: Cc triu chng ca vim rut hoi t s sinh gm 2 nhm: Triu chng ton thn rt ging nhim trng huyt. Triu chng tiu ha. b.1 Tm triu chng ton thn: - Li b - Cn ngng th - Thn nhit khng n nh - Ti mu da km b.2 Tm triu chng ng tiu ha: - Chng bng - Khng dung np sa - Oc sa hoc dch xanh - Tiu mu i th hoc vi th - S thy khi bng - Thnh bng n Cc triu chng c th khi pht t t hoc t ngt: Khi pht t ngt: - Tr thng hoc non thng - Tng trng din tin xu rt nhanh - Suy h hp - Sc, toan chuyn ha - Chng bng r rt Khi pht t t: - Thng tr non thng - Tng trng xu t t trong vng 1-2 ngy - Khng dung np sa - Tnh cht phn thay i - Bng chng tng t

- Mu n trong phn c) ngh xt nghim: Cc x t nghim nh gi nhim trng: pht mu, CRP, cy mu Kh mu, in gii , chc nng ng mu Tm mu n trong phn X quang bng: - Hnh nh hi trong thnh rut: l du hiu c trng gip chn on - Hi t do trong bng: cho bit bin chng thng rut - Quai rut bt ng dn to trn nhiu phim: cho bit quai rut hoi t - Khng c hi rut: vim phc mc 2. Chn on: Vim rut hoi t s sinh giai on I (chn on c th): - Triu chng ton thn: thn nhit khng n nh, cn ngng th, li b - Triu chng tiu ha: sa c tn ng tng n, chng bng, tiu mu vi th/i th - X quang bng: bnh thng hoc lit rut nh Vim rut hoi t s sinh giai on II A (chn on chc chn nh): - Triu chng ton thn: ging giai on I - Triu chng tiu ha: ging giai on I + mt nhu ng rut - X quang bng: quai rut n, hi trong thnh rut Vim rut hoi t s sinh giai on II B (chn on chc chn trung bnh): - Triu chng ton thn: ging giai on I + toan chuyn ha v gim tiu cu nh - Triu chng tiu ha: ging giai on IIA + khng thnh bng + vim m t bo thnh bng hoc s bng thy khi 1/4 i phi - X quang bng: ging IIA+ hi tnh mch ca dch bng Vim rut hoi t s sinh giai on IIIA (chn on chc chn nng): - Triu chng ton thn: ging IIB + sc, DIC - Triu chng tiu ha: ging IIB + Vim phc mc ton th - X quang bng: ging IIB+ nhiu dch bng Vim rut hoi t s sinh giai on IIIB (chn on chc chn bin chng thng rut):

- Triu chng ton thn: ging IIIA - Triu chng tiu ha: ging IIIA - X quang bng: ging IIB+ hi t do trong bng III. IU TR: 1. Nguyn tc iu tr: iu tr ni khoa: khng sinh, inh ng tnh mch, theo di bin chng ngoi khoa iu tr ngoi khoa: can thip phu thut kp thi 2. iu tr ni khoa: Cc bin php iu tr ni khoa nn c p dng ngay khi ngh n bnh vim rut hoi t (giai on I) khng ch n chn on chc chn v mun. Nhn n ng ming, t ng thng d dy dn lu ch d dy, ch cho n ng ming tr li khi din tin lm sng tt (ht tiu mu, bng khng chng) v / hoc t nht 5 ngy sau khi X quang bng tr v bnh thng (khng cn hi thnh rut) Nu ang t catheter tnh mch rn: rt b catheter tnh mch rn. Bi hon dch in gii, chng sc, iu tr DIC, khi huyt ng hc n nh chuyn sang inh ng qua ng tnh mch ton phn (1-2 tun) Khng sinh: - Khng sinh ban u: Ampicilline + Cefotaxime/Gentamycine + Metronidazol. - Nu khng p ng, thay i khng sinh theo khng sinh , nu khng c khng sinh : Pefloxacine phi hp Metronidazole. Thi gian cho khng sinh: 10 -14 ngy Theo i st: u hiu lm sng ca tc rut, vng bng, X quang bng mi 8-12 gi trong giai on bnh cha n nh kp thi pht hin bin chng ngoi khoa. 3. iu tr ngai khoa: Ch nh can thip phu thut: Thng rut: C hi t do trong bng / X quang bng Vim phc mc: Thnh bng n , chc d dch bng ra mu hoc m hoc soi ti c vi trng Gr(-)

Quai rut dn bt ng trn nhiu phim Lm sng: tc rut, s thy khi trong bng 4. Phng nga: Gim ti a cc nguy c lin quan sn khoa: sanh non, sanh ngt, suy h hp sau sanh Sa m c nhiu yu t bo v (IgA,IgG,IgM, lysozyme, lactoperoxi ase, lactoferrin,), sa m l sa duy nht lm gim nguy c vim rut hoi t nht l tr non thng. Ngng n ng ming khng phi l bin php phng nga, i khi tc dng ngc li v nim mc rut khng pht trin. Bin php tt nht i vi tr non thng l cho n t t tng lng nh, tng n khng qu 20 ml/kg/ngy v theo i st, nh gi tnh trng dung np.

CHNG 3. BNH NI TIT CHUYN HA


S22. U TU THNG THN
(Pheochromocytoma) U tu thng thn l u tit ra Catecholamine qu tha t u vng tu thng thn sinh ra. Nhng cng c th pht sinh t nhiu ni khc thuc h thng giao cm ca chui hch giao cm, ng mch ch, mc treo, khoang ngc, hoc vng c, i n. C khi tn ti a u cng mt lc. Bnh rt him tr em, bnh c tnh gia nh v i truyn. 1. chn on : 1.1. Lm sng - Bnh ch yu ngi ln, 10% gp tr em t 6 14 tui l tr trai nhiu hn gi. C t 30 40% u tm thy c hai bn hoc nhiu ni.

- Triu chng ch yu o tng cao nng epinephrine v norepinephrine gy tng huyt p, c tnh chu kz v lin tc v sau. - au u nhiu vi cc du hiu tng p lc ni s. Trong cn HA s au u d di, xanh ti, v m hi, c th co git. Gia cc cn HA tr c th bnh thng, nhng gy xanh, k m n, chm ln, a kh rp, u chi lnh tm, ngn nhn nheo. Huyt p tng cao nhiu n 180 260/120 210mmHg. Tim to, ph gai th, co tht ng mch. Gim dn th lc m mt dn n m lo hon ton v vnh vin.

1.2. Xt nghim : - Nng VMA (Vanilic Min alic Aci ) hay Catecholamin nc tiu, tng cao t 5 10 ln so vi bnh thng. Siu m hay CT s pht hin ra u tuyn thng thn.

- Nghim php Regitin ng tnh, sau khi tim Regitin TM, HA s gim dn n khng, trong vng 5 10 pht. 2. iu tr : - iu tr c hiu : ngoi khoa, ct b u tn gc s khi bnh. C th ti pht vn iu tr ct b u. - Cn ch duy tr huyt p trong qu trnh m v sau m vi ngy cho n khi HA tr li bnh thng. Theo di sau m :

+ Lm nguy VMA hay Catecholamin sau khi ct u, nu HA khng gim cn kim tra nguy v cha ct b ht u. + 3 6 thng v 1 nm sau kim tra li Chtecholimin phng ti pht.

S23. U V THNG THN GY NAM HO


(Androsteroma)

U v thng thn ti vng li s sn xut qu tha mt lng hocmon nam l An rogene, gy c th b nam ho chuyn gii vi tr gi. Bnh tng i him gp. 1. chn on : 1.1. Lm sng C th gp bt c la tui no nhng thng trc 10 tui. C 2 10% u gp c hai bn.

- Triu chng cng v thng thn, ch yu l du hiu nam ho, cng an rogne nh trong CAH, ln nhanh, pht trin c bp, ng vt to ln, mn trng c, mc lng thn v b phn sinh dc, ria mp, ru cm, dy th sm. - tr gi m vt to ln nh ng vt v nam ho ton thn nh tr trai, dy th sm. - C t 20 40% c kt hp triu chng Cushing nh b o ph, mt trng trn, cao huyt p. - Phn bit vi CAH : tr trc hon ton bnh thng. Cc triu chng lm sng xut hin rm r v t ngt trong 1 thi gian ngn. 1.2. Xt nghim chn on : - 17 cetosteroi , DHEA, DHEAS, An rostene ione, testosterone u tng rt cao t 5 10 ln so vi tui. - Siu m hay CT bng c th thy khi u v tr tuyn thng thn khong 1,5cm.

C th s thy khi u khi thm khm.

2. iu tr : Phu thut ct b khi u cn thc hin nhanh chng.

- Cn c hocmon, Corticoid h tr trong v sau phu thut bng : Hydrocortisone 10 25mg 6 gi 1 ln trong ngy phu thut, tip tc trong 3 4 ngy tip theo. - Cn c truyn dch, Natri Clorua 9 ; Glucoza 5% duy tr khi lng tun hon. Cn tip tc theo di cc ch s sinh ho, ni tit sau m. Thng gp ti pht sau 1 nm v tien lng xu, i cn gan, phi.

- C th cho mt s c ch tuyn thng thn nh OP DDD Mitotane, Ketoconazole, aminoglutethimi e, metyrapone c ch tng hp steroid v thng thn nhng hiu qu khng nhiu, tin lng xu.

S24. TUYN HUNG PH I


Tuyn hung ph i hay gp nht cc trng hp trung tht c khi m khng phi do hch. Bnh thng gp tr i 1 tui, him gp tr trn 4 tui. Tuyn hung c th to nhanh tr khi b nhim virus hay sau iu tr ngoi khoa cho chuyn gc ng mch. 1. Chn on : 1.1. Lm sng :

Thng khng c triu chng v c pht hin ngu nhin. S t c hi chng chn p trung tht.

Kh th do chn p kh qun : ting rt thanh qun, co k o c h hp. Ho, th kh kh c th xy ra tng lc, tng t th. B km, nut nghn, khn ting, au ngc. Hi chng chn p tnh mch ch trn him gp.

1.2. Xt nghim - X-quang phi thng v nghing : bng trung tht to hai bn, hoc mt bn nm sau xng c v trc mng ngoi tim. Phim thng cho thy c hnh thang, phim nghing cho thy mt khong sng trc tim. Siu m trung tht tuyn hung to. Chp ct lp trung tht khi c nghi ng c u trung tht.

1.3. Chn on phn bit : Cn chn on phn bit vi u tuyn hung, s nhim lao, u lympho, bnh Hodgkin. 2. iu tr 2.1. Ni khoa : Dng Prednisolon. - Ch nh khi c cc du hiu ho, kh kh, kh th nh, b km hoc phn bit vi u tuyn hung. - Liu dng Prednisolon : 1mg/kg/24 gi ung lc no chia 1 n 2 v dng trong 2 tun. - Thng p ng nhanh trong 1 tun u. Chp X-quang sau 1 thng iu tr nh gi kt qu. 2.2. Ngoi khoa :

- Ch nh khi c biu hin suy h hp 2, 3, hoc iu tr th bng Prednisolon khng c kt qu, hoc tr ln trn 4 tui. M ct b tuyn hung.

2.3. Theo di ti nh : - Tuyn hung ph i c th ti pht. Nu b li cn iu tr v theo di ti chuyn khoa nhi, ni tit.

CHNG 4. BNH BM SINH DI TRUYN

S25. C THY TINH TH BM SINH


nh ngha : c thy tinh th bm sinh l m my trong thu knh ca mt c t lc sinh. Thng thng thu knh ca mt l 1 cu trc trong sut, n tp trung nh sng nhn c t mt ti vng mc

Nguyn nhn: S ngi sinh ra b c thy tinh th thp, a s bnh nhn khng tm thy nguyn nhn c th, nhng nguyn nhn c th gy c thy tinh th bao gm: Hi chng lon sn sn Rubella bm sinh Hi chng Conradi Hi chng Down( trisomy 21)

Lon sn ngoi b c thy tinh th bm sinh gia nh Thiu galacto mu Hi chng Hallerman Streiff Hi chng Lowe Hi chng Marinesco Sjogren Hi chng Pierre Robin Nhim sc th 13

Triu chng : m my trong thy tinh th ging nh 1 m trng tri ngc vi mu en ca ng t, thng thy r lc sinh m khng cn 1 thit b quan st c bit Tr suy gim th lc khng thc th gii xung quanh n ( nu c thy tinh th 2 mt t lc sinh) Rung git gin cu ( C ng mt nhanh khng bnh thng)

Khm v xt nghim: Khm mt hon ton bi Bc s mt s d dng chn on c thy tinh th bm sinh. Vic tm kim nhng nguyn nhn c th gy c thy tinh th nn khm lm sng bi chuyn gia nhi khoa c kinh nghim v ri lon di truyn v c th lm xt nghim mu v chp X quang

iu tr:

Vi trng hp c thy tinh th nh v khng nh hng n th lc, nhng trng hp ny khng iu tr. iu tr nhng c thy tinh th nng, nh thng n th lc s tin hnh phu thut ly thy tinh th, sau thay th bng thy tinh th nhn to ( IOL) iu tr cc ri lon km theo c th cng cn thit

Tin lng : Phu thut ly thy tinh th c v thay thy tinh th nhn to l phu thut thng thng v thng c kt qu tt

Bin chng: Nhiu bnh cn bn km theo c thy tinh th bm sinh nh hng ti cc c quan mc nng Khi no nn n chuyn gia y t: Nn c mt cuc hn khn vi dch v chm sc sc khe tr em nu bn ch thy ng t ca 1 hoc 2 mt xut hin m my trng Phng nga: Nu bn c tin s gia nh v ri lan di truyn c th gy c thy tinh th, nn n t vn chuyn gia v di truyn.

S26. TNG SN THNG THN BM SINH (CAH)


Tng sn thng thn bm sinh (CAH) l mt bnh l{ gia nh c yu t di truyn, do ri lon tng hp hocmon v thng thn, v thiu ht cc enzym, ch yu

trong CAH l 21 hydroxylase nn khng sn xut c Cortisol. S thiu ht Cortisol trong c th dn ti s tng tit ACTH t tuyn yn, kch thch v thng thn tng sinh v qu sn ra cc cht trung gian, trong c An re gene gy nam ho vi tr gi v dy th sm trai v gi. 1. Chn on 1.1. Lm sng : Bnh c th gp trai hay gi. Bnh c phn chia lm 4 th. 1.1.1. Th nam ho n thun (Khng c mt mui) + Vi tr trai : Khi mi sinh pht trin c th v b phn sinh dc ngoi hon ton bnh thng. Trong 6 thng u ln nhanh. T 2 3 tui pht trin c th mnh, cao to hn so vi tui, ng vt to ln nhanh, c sm mu phn sinh dc ngoi. T 4 5 tui ln bng tr 8 10 tui, cc du hiu dy th : ng vt to, c lng mu, lng nch, mc ru v lng c th, mn trng c mt, ging trm, mt ga so vi tui, c bp rt pht trin, vm v ng n ng. Ring tinh hon vn u tr tng ng vi tui thc. Pht trin tr tu bnh thng, c th c mt s bt thng hnh vi. + Vi tr gi : Ngay lc mi c b phn sinh dc ngoi bt thng lng gii gi. m vt to, i nh ng vt.

- Cc mi ln v b dnh lin nhau, hnh ng nhn nheo ging bu ca tr trai, nhng bn trong khng s thy tinh hon. - Niu o v m o thng nhau vo mt xoang gc m vt (d nhm vi tt l i thp ca tr trai).

- Kiu hnh bin dng ca b phn sinh dc ngoi tuz mc thiu ht cc enzym c quy nh theo 5 th ca Prader, tt lng gii gi (Pseudohermaphrodites). Tr ngy cng ln nhanh, nam ho dn ton c th v b phn sinh dc ngoi. S chuyn gii hon ton khi tr c 4-5 tui triu chng dy th sinh dc sm. C hai th u ngng ln hon ton lc 8 10 tui nn chiu cao vnh vin khng qu 140 145cm. 1.1.2. Th mt mui : C th gp trai hay gi. Xut hin ngay tun u sau khi , du hiu ch yu nn nhiu, a chy mt nc v gim st cn. C th : Tm ti, lon nhp tim, cn ngng th apn, suy tun hon ngoi vi. Vi tr gi c th thy du hiu chuyn gii nh nh ph i m vt, b phn sinh dc ngoi sm mu. Vi tr trai khng c g khc thng, d nhm vi hp mn v, tc rut s sinh, tim bm sinh, hoc d ng sa b, a chy mt nc cp. Nu khng x l kp thi d nhanh chng t vong trong vi tun. 1.1.3. Th khng c in : Hu ht u c b phn sinh dc ngoi bnh thng c gi v trai khi sinh ra. Pht trin c th bnh thng cho n tui dy th (10 12 tui). Khi pht mun. C th mc lng sinh dc sm, rm lng tc, nhiu lng t lng, ngc, chn, mn trng c mt. Vi tr gi xut hin kinh nguyt tht thng, mt kinh, khng pht trin tuyn v. 1.1.4. Th cao huyt p :

Do thiu ht 11 b-OH (11-deoxycortisol). Hay gp tr trai, tui thiu nin, him thy trc 1 12 tui. Huyt p tng cao khng hng nh, c th lin tc hay tng t. Nam ho c th t trong bo thai hay ngay sau . Tr gi c biu hin lng tnh b phn sinh dc ngoi. Tr trai b phn sinh dc ngoi bnh thng, c tinh hon trong bi. c th c biu hin mt mui thong qua. Rt nhy cm vi iu tr hocmon liu php. * c im lm sng da vo chn on l Du hiu lng gii vi tr gi ngay mi . Triu chng chuyn gii khi ln 2 3 tui. Dy th sinh dc sm c 2 th. Nn, a chy mt nc, st cn tr s sinh. Cao huyt p tht thng tui thiu nin. Ngng pht trin cc du hiu dy th sau 10 12 tui. V kinh, khng pht trin tuyn v, mc ru, rm lng tc vi tr gi.

- Tin s gia nh c ngi mc bnh tng t, c tr cht sau sinh khng r nguyn nhn, c m hay sy thai 1.2. Xt nghim cn lm : 17 CS (Cetosteroi ) trong nc tiu 24 gi tng cao t 10 80mg/24h. Testosteron mu tng cao. Progesteron mu tng cao. in gii Natri gim, Kali tng cao trn 5 mEq/l. Tui xng pht trin nhanh hn tui i.

Nhim sc th l XX vi tr gi, XY vi trai. Siu m c t cung, bung trng vi gi, khng c khi u v thng thn.

- 17 OHP (17 hydroxy progesteron) tng cao, tiu chun vng chn on xc nh. in no , IQ phn bit vi dy th thc. Lm PCR xc nh t bin gen CYP21.

2. iu tr Hocmon Corticoid thay th sut i : Hydrocortison : 10 20mg/m2/24 gi ung lm 3 ln. Di 1 tui : 2,5 5mg/24 gi chia lm 2-3 ln Di 6 tui 5 10mg/24 gi chia 2 3 ln. Trn 10 tui 10 20mg/24 gi chia 2 3 ln.

- 9 a Fluorohydro cortisone (Florinef) vin 0,1mg 0,05 = 0,3mg/ngy, cho th mt mui. - Tng liu HC ln 2 3 ln trng hp c yu t stress nh nhim khun, can thip phu thut. - Prednisolon ch nh khi khng c hydrocortison, liu duy tr t 4,8 5mg/m2 c th/24 gi. B thm Natri vi th mt mui : Sodium cloride 1 3 g/ngy. X l cn suy thng thn cp th mt mui : Hy ro cortisone 25mg/1 mi tim bp hay tnh mch ngay khi c chn on.

- Tip tc tim hng ngy t 25-30mg HC chia u 3-4 ln trong 24 gi, trong 34 ngy. Tip tc liu duy tr bng Florinef ung t 0,05 0,3mg/24 gi.

- B dch bng Natriclorua 9 + Glucosa 5% truyn tnh mch vi liu lng v tc theo tnh trng mt nc c th. Khng c cho Kali.

Phu thut chnh hnh b phn sinh dc ngoi : Cn tin hnh sm 6 12 thng tui. Theo di qun l bnh nhn : Cn c Bc s chuyn khoa theo di lu di.

- Cn c s hp tc ca b m, gia nh v bnh nhn cht ch phng s dng thuc khng u, cc bin chng bt thng. 3. D phng : - Trng hp m c thai tip cn c li khuyn di truyn, nu c iu kin s tin hnh chn on v iu tr trc sinh, bng Dexamethasone vo thai tun th 5. Lm sng lc s sinh (CAH) ngay khi tr mi trong 5 ngy u.

S27. BN CHN KHOO BM SINH


Hnh thi tn thng chung ca bn chn khoo thng thy vi bn chn thung, kh p, ng v lm. 1. Lm sng - Bn chn nga

- Khp - Xoay trong - Thung Trong khm x t, nh gi gc bin dng 2 v tr th ng v ch ng. 2. X quang Film X quang cn chp 2 v tr thng, nghing v c hai bn so snh - Trn Film nghing : o gc to thnh gc gia trc xng sn v xng gt - Trn Film thng: + o gc to thnh gia trc xng s sn v thuyn + o gc to thnh gia xng gt v xng hp; 3. iu tr C hai phng php iu tr bn chn khoo bm sinh : iu tr bo tn bng nn, bng bt v phu thut. 3.1 3.1.1 iu tr bo tn bng nn, bng bt: Nguyn tc: - iu tr ti nh h sinh, mt vi ngy sau khi tr ra i. - Bn chn c kh nng a bin dng Varus th ng v v tr trung gian (0o) - Nn chnh v bng, bt tng th; u tin sa cha bin dng vo trong v nga - Hng dn cho cha m bnh nhn c th t nn, bng v theo i trong qu trnh iu tr. - nh gi kt qu khch quan sau 6 ln thay bt (2 tun mt ln

thay bt) v c th sau 3 n 5 thng; nhng trng hp tin trin km hoc p ng chm cn c ch nh phu thut. - Khng nn chnh v bng bt vi tr co cng dnh khp nhiu ni bm sinh. 3.1.2 K thut:

K thut Kite.1932: Nn chnh nh nhng cc bin dng bn chn

B bt i, bn chn. Sau 3 -4 ngy ct bt hnh "mi cam", hnh "chm" mt ngoi bn chn chnh dn varus. Ht bin dng varus, li tip tc ct "chm", "mi cam" pha mu c chn, chnh thung bn chn . K thut Sturin A.V.1955:

- Th 1: Nn chnh v bt t 1 - 3 T cng chn xung ti khp Lisfran. Nn chnh v tr khp ti khp ny, bt t 1/3 T cng chn ti ngn chn. - Th 2 : Ct bng bt ca th 1 t 1/3 T cng chn ti khp Chopart, nn chnh t th thung bn chn. 3.2 3.2.1 Phu thut: Nguyn tc:

(1) iu tr nn chnh v bng bt tht bi hoc bin dng bn chn p ng km, chm. (2) Phu thut c thc hin cng sm (theo tui) kt qu cng tt, k thut cng n gin. (3) Thc hin phu thut nh nhng trnh tn thng mt sn khp v tm ct ho.

(4) nh gi mc bin dng v tn thng gii phu bnh cn c kt hp gia lm sng v Xquang. Trn c s tn thng ny la chn k thut thch hp cho tng bnh nhn c th. (5) L chn k thut thc hin trn tr cn hn ch mc ti a thc hin trn xng. (6) Lm i gn c, chuyn gn c trnh qu mc ; to cn bng lc c, khng gy bin dng ngc li bin dng ban u. (7) Bt ng bt trong 3-5 thng, saub bt tr cn c i giy chnh hnh, iu tr vt l phc hi chc nng bn chn. (8) Thc hin k thut tun th theo phn chia nhm tui theo tnh trng ct ho xng t ct bn chn. 3.2.2 Chun b trc m:

- V sinh, lm sch ton chi bn phu thut t np bn ti ngn chn - Bng v khun vng m trc m Trong nhng trng hp Varus th ng < 45 cn bt giang ti a trc phu thut 3- 5 ngy. 3.2.3 K thut phu thut: Phn chia k thut theo nhm tui: > 4 thng > 24 thng > 06 tui - 24 thng - 6 tui - 13 tui > 13 tui a - Nhm th nht (> 4 thng - 24 thng) : Lm i gn c n thun

+ Sheell- Stewrt.1951: Lm i gn gt v gn c chy sau hnh ch Z. Gn gt c lm di hnh ch Z vi na trong ct i v na ngoi ct trn. + Ct bao khp trong b - Nhm th hai (> 24 thng - 6 tui): Chuyn gn c n thun. + Richley, Taylo.1952 chuyn bm tn gn c chy trc ra ngoi ti nn xng bn V nu nh lc c mc yu hoc mt. +Fried.1950, Singer.1961, Gartland.1964 chuyn bm tn gn c chy sau qua mng lin ct ra trc nh vo xng chm 3. - Palmer.1967 phu thut chuyn gn lm cn bng trng lc cc c khu trc ngoi v sau trong ca cng chn nhm gi bn chn t th chc nng. - Nguyn Ngc Hng.1985 chuyn bm tn gn c chy trc qua ng hm xng hp. c - Nhm th ba (> 06 tui- 13 tui): Lm i cc gn c, ct dy chng bao khp Codivilla.1906 & Vigliani.1975 b sung; Brockman. 1930; Mc Cauley.1951; Perkinhs.1961; Atterbrough. 1966; Ckark. 1968; Turco. 1971 K thut c bn l: - Lm i cc gn c co ngn: Gn gt, gn c chy sau, gn c gp chung ngn chn v gp ring ngn 1. - Ct cc dy chng v bao khp: Dy chng Deltoid, dy chng chy-thuyn; dy chng bao khp sn -gt, sn - thuyn. d - Nhm th t ( > 13 tui ): Phu thut phn mm kt hp vi ct xng chnh chc bn chn:

Phng php ny thc hin cho tr ln, c bin dng bn chn nng n hoc c can thip phu thut phn mm tht bi. K thut gm 2 th: Th 1: Lm i gn c co ngn, ct dy chng bao khp pha sau v pha trong bn chn. Th 2: Tuz thuc bin dng m c cc hnh thc ct xng khc nhau:

+ Masse, Tuoig v Bazin.1974 ct hnh chm xng mt ngoi xng gt, sa cha bin dng nga bn chn. + Kornhinov K.N.1960 ct chnh c xng sn, chnh li khp sn- thuyn, gii quyt bin dng khp v thung ca bn chn. + Samuel, Turek.L.1967 ct chm xng pha ngoi bn chn. y hnh chm ngoi bn chn v nh ni lm nht ca b trong bn chn. + Nguyn Ngc Hng.1989 thc hin ni i gn c chy sau gp chung ngn chn, gp ring ngn I v ly b xp xng hp li v xng qua mt np xng, chnh li bn chn bng bt. - Phu thut ng cng khp: Phu thut ng cng khp ch thc hin cho tr ln c bin dng nng n, i li au, mt chc nng khp hoc khng th chnh hnh bng cc phu thut khc. K thut thc hin can thip vo 3 khp: 3.2.4 Khp sn - gt (Lambrinudi) Khp sn - thuyn Khp gt hp Theo di sau m Tnh trng chn p bt

Trong nhng trng hp c Varus th ng > 45 trc m, theo ri cht ch tnh trng thiu mu cc ngn chn. Sau 3-5 ngy thay bt Quy trnh gi bt nh sau: + Thay bt ln th nht: sau 6 tun (t ngy phu thut) + Thay bt ln th hai: sau 12 tun (t ngy thay bt ln th nht).

S28. LM LNG NGC BM SINH


Lm lng ngc bm sinh l mt d tt thnh ngc trong xng c v cc xng sn i b lm v pha sau. T l tr trai / tr gi = 3/1. 90% cc trng hp c biu hin bnh la tui 1 tui. 1. 1.1 Chn on. Hai thnh phn ch yu gy ra d dng:

a) Thn ca xng c, (thng bt u t i ch bm vo ca xng sn th 2) b gp gc ra pha sau. b) Cc xn ca xng sn b gp gc ra pha sau, bm vo phn xng c gp gc ra sau. 1.2 nh gi mc d dng.

a) Khong cch trc sau t ni xng c lm nht n mt trc xng sng da vo o trc tip, xquang hoc chp ct lp. b) c) T l gia chiu su lm vo vi y trc sau ca lng ngc. S lng xng sn b d dng,

d) e) f) 2. 2.1

Th tch h lm lng ngc (s cm nc ng trong h lm khi tr nm nga). Mc gy nh hng ca d dng ti chc nng h hp v tun hon. Cc d dng km theo. iu tr Ch nh:

- Cc trng hp c nh hng ti v tr v chc nng ca cc c quan nm trong lng ngc. 2.2 2.3 Cc trng hp to thm m. Tui m : sau 2 tui. Chun b trc m Xt nghim : Cc xt nghim c bn Xquang ngc thng nghing, chp ct lp (khi iu kin cho php). in tim Chc nng h hp tun hon khi c cc du hiu lm sng. Cc xt nghim pht hin v xc nh cc mc ca cc d dng km theo. Trc ngy m : v sinh tt vng ngc bng. K thut m : k thut Ravitch ci tin: T th nm nga, trn bn cng, khng n.

- ng m: ng rch da nm ngang, bt u t gc phi ca vng lm i ngang qua v tr lm su nht ca xng c, i sang tri ca vng lm. Bc tch lp i da khi lp c ngc trong ton b din tch b lm.

- T ng gia xng c, bc tch lp c ngc khi xng c , sn xn, cc c lin xn vng b lm.Treo lp c ngc ny sang 2 bn. - Xc nh s sn sn v di cc sn sn b bin dng. - Bc tch mng sn, ct b cc sn xn gy bin dng, li nguyn vn lp mng sn ti ch. - Bc tch mt sau xng c. - Ti ni xng c gp gc ra sau, c ngang xng c hnh chm. y hnh chm m ra pha trc. - B gp xng c c nh xng c v tr ny bng 2, 3 mi khu ch kho, khng tiu. - t dn lu i v trn xng c. - Phc hi li cc lp cn, c ngc, ng a. 2.4 Chm sc sau m: Khng sinh Gim au tt sau m. Rt dn lu sau 1 ngy nu khng c hin tng chy mu.

Hn khm li sau khi ra vin 3 tun

CHNG 5. BNH L TIM MCH


S29. THNG LIN THT TLT
Ngoi tr bnh van ng mch ch (MC) ch c hai l van th thng lin tht (TLT) l bnh tim bm sinh hay gp nht, n chim khong 25% cc bnh tim bm sinh.

TLT l nh rt hay gp v thng dung np rt tt. Do n c th gp ngi trng thnh v c kh nng t ng. T l t ng li ca cc trng hp TLT l nh tr em ln n 75%. Ngc li TLT l ln s nh hng nhanh n h hp v p lc ng mch phi (MP) c th tng mt cch c nh rt sm t 6 n 9 thng. i vi cc trng hp sc cn mch phi tng c nh (hi chng Eisenmenger) bnh nhn him khi sng c qu tui 40. Cc bin chng hay gp nhm bnh nhn ny l chy mu phi, vim ni tm mc, p xe no, ri lon nhp tht v cc bin chng ca a hng cu. Tin lng s rt km cc bnh nhn c cc biu hin ngt, suy tim xung huyt v ho ra mu. Ngi ta nhn thy ngoi nguyn nhn do m b cm trong ba thng u, TLT hay gp trong cc hi chng bnh l{, c bit l hi chng c ba nhim sc th 21, hi chng do m nghin ru khi mang thai... I. Gii phu bnh

A. Phn loi: C rt nhiu cch phn loi gii phu bnh v TLT khc nhau c t ra nhng nhn chung li c 4 loi TLT chnh v gii phu bnh l: TLT phn quanh mng, TLT phn c, TLT phn bung nhn v TLT phn phu (TLT pha trn ca ca Wolff). 1. TLT phn quanh mng l loi TLT hay gp nht, chim khong 70-80% cc trng hp, nm cao thuc phn mng ca vch lin tht (VLT), ch ni gia van 3 l v van MC. Tuy nhin n c th dch chuyn ra sau, ra trc hay xung i mt cht ty tng trng hp. Tn thng thng phi hp to thnh mt ti nh i van 3 l hay xung quanh b van (thng cng c gi l ti phnh phn mng vch lin tht). N c th gy h van MC v hp phn thp ca ng ra tht phi. y l loi TLT c kh nng t ng cao. 2. TLT phn c hay TLT gn mm tim. N c th bt c v tr no ca phn thp VLT cho n mm tim. Th bnh ny chim khong 5 n 20% cc trng hp TLT v cng c kh nng t ng cao tr cc trng hp c nhiu l TLT.

Hnh 1: V tr gii ph?u ca cc loi thng lin tht 3. TLT phn bung nhn hay TLT kiu ng nh tht chung chim khong t 5 n 8% cc trng hp. TLT loi ny thng v tr cao ca VLT, rng, t kh nng t ng v hay i km tn thng ca cc van nh tht. Hay gp phnh vch lin tht v tr ny. 4. TLT phn phu hay TLT di van MC hoc di van MP: him gp hn (5 n 7%), l loi TLT m l thng nm phn rt cao ca vch lin tht ni c tip gip vi van MC v van MP (nn cn c gi l thng lin tht kiu '' i cc i ng mch''). im c bit quan trng ca loi TLT ny l l thng thng phi hp vi tn thng l van MC v c h ch i km (hi chng Laubry-Pezzy). B. Cc tn thng khc phi hp c th gp: hp van MP, hp trn van MP, h 3 l, thng trc tip t tht tri sang nh phi, mng ngn i MC II. Sinh l bnh

A. Lung thng ca shunt c lu lng ph thuc vo kch thc l TLT v sc cn h MP cng nh p lc tht phi. Lung shunt s gy ra qu ti phi, nh tri v tht tri.

B. Din bin xu dn s l tng p MP gy suy tim phi v v sau s chuyn thnh hi chng Eisenmenger (tng sc cn ca mch phi do bnh l{ MP tc nghn c nh lm gim dng shunt tri phi, lm tng ng shunt phi tri). III. Triu chng lm sng A. Triu chng c nng: hay gp nht bnh nhn ln tui l kh th, mt kh nng gng sc. Cc triu chng thng lin quan n mc ca lung thng tri phi, p lc v sc cn ca ng mch phi. B. Triu chng thc th: Nghe tim l du hiu ch yu chn on. Thng nghe thy c ting thi ton tm thu, cng mnh cnh c tri, tng i thp v lan ra tt c xung quanh. Ting thi ny c th nh hn nhng c m sc cao hn trong cc trng hp l thng nh phn c v c th ch lan ra mm hay sang tri nu l TLT mm tim. Nu l TLT qu ln, c th nghe thy ting thi nh v c rung tm trng lu lng mm tim. Cc trng hp TLT phi hp vi h van ng mch ch thng nghe thy thi tm trng van ng mch ch i km. Nu nghe thy ting thi tm thu tng mu b tri xng c lan ln trn cn nghi ng c hp phn phu ca tht phi hoc tht phi c hai bung. C. Chn on phn bit trn lm sng vi h van ba l, t chng Fallot khng tm (Fallot trng), hp i van ng mch phi n thun v bnh c tim ph i. IV. Cc xt nghim chn on A. in tm (T): thy hnh nh tng gnh bung tim tri vi dy tht tri, y nh tri. Trc tri hay gp trong cc trng hp TLT phn bung nhn hoc ng nh tht chung. Dy tht phi v trc phi gp trong cc trng hp tng gnh bung tim phi vi tng p ng mch phi. B. Chp Xquang tim phi

1. Hnh tim khng to v h mch phi bnh thng hay thy cc trng hp TLT l nh khng gy tng p ng mch phi.

2. Tim to va phi vi gin cung i tri. i khi thy du hiu gin cung MP. Tng ti mu phi hay gp cc bnh nhn c lung thng tri phi ln. 3. Bng tim khng to nhng c u hiu huyt phi nhiu thng gp trong cc trng hp TLT l rng c tng sc cn mch phi c nh (hi chng Eisenmenger). C. 1. Siu m tim Hnh nh gin tip: Kch thc bung tim tri v thn MP u gin.

2. Hnh nh trc tip ca l TLT trn siu m 2D: mt ct trc di cnh c tri (TLT phn phu); mt ct qua cc gc ng mch (TLT quanh mng, phu); mt ct i c, bn bung t mm (TLT phn c, quanh mng v bung nhn).

Hnh 28-2. TLT phn quanh mng: mt ct cnh c trc ngn (hnh tri) v mt ct 5 bung tim t mm (hnh phi). 3. nh gi mc ca dng shunt: dng shunt tri phi ln khi gin bung nh tri, tht tri v MP. o chnh p qua l TLT nh gi p lc MP (nu khng c cn tr ng ra tht phi) v mc bnh. Nu chnh p cn ln chng t l thng nh v khng c qu ti tim phi. Cn nh o huyt p ng mch khi lm siu m Doppler tim. 4. Trong trng hp p lc MP tng c nh: thnh tht phi dy, dng chy qua l TLT yu hoc hai chiu, p lc MP tng nhiu gn bng hay vt p lc i tun hon.

5. Siu m Doppler tim cn cn phi loi tr cc tn thng phi hp nh thng lin nh, cn ng ng mch, h ch, cn tr ng ra tht phi v tht tri. D. 1. Thng tim Ch nh:

a. Cc trng hp TLT vi cc du hiu qu ti ca tht tri (tim to, thi tm trng mm tim, suy tim huyt) hoc tng p MP m cn phi c cc bng chng khng nh mc lung shunt, p lc MP, v sc cn MP quyt nh hng iu tr. b. Cc trng hp TLT vi nghi ng c cc tn thng khc phi hp nh h ch, hp ng ra tht phi, hp di van MC... cng l cc trng hp c th ch nh thng tim. c. Thng tim ng l TLT bng dng c (Amplatzer, Coil, Buttoned device...). 2. Chp bung tim:

a. Chp bung tht tri s gip xc nh chnh xc v tr, kch thc ca l thng lin tht v c bit gip cho chn on thng lin tht c nhiu l. T th chp hay dng nht l nghing tri 45 - 700, nghing u 250. Tuy nhin ty loi l thng c th thay i cht t. TLT kiu quanh mng: thy r nghing tri 60-450. TLT phn c, ra pha trc chp nghing tri 450. TLT kiu di cc gc ng mch ln chp t th nghing 900 v nghing phi. b. Chp MC xc nh c h ch phi hp hay khng? c bit trong cc th TLT kiu di cc gc ng mch, hi chng Laubry - Pezzy. c. Chp bung tht phi xc nh xem c hp ng ra tht phi khng, c h van ba l khng v xem c phi ch vo ca dng shunt trc tip vo tht phi hay khng. V. Ch nh iu tr v tin trin

A.

iu tr ni khoa

1. TLT vi tng p MP nhiu tr nh cn c iu tr bng li tiu, tr tim v gim tin gnh trc khi phu thut. 2. Sau phu thut v cc trng hp cha phu thut (hoc khng cn phu thut) cn phng bin chng vim ni tm mc nhim khun (rt d xy ra vi cc trng hp TLT). B. ng l thng qua da bng dng c

Hin nay c th ch nh cc trng hp TLT l nh phn c, mm hoc sau NMCT c bin chng. Tng lai nhiu loi dng c ang c nghin cu ng TLT phn quanh mng-bnh bm sinh c tn sut gp cao nht. C. iu tr ngoi khoa

ng l TLT c th thc hin bng phu thut tim h vi tun hon ngoi c th (ng m dc xng c). Cn lu c mt t l kh ln l TLT c th t ng li. 1. i vi cc l thng b, shunt nh, p lc MP bnh thng cn theo di nh kz thng xuyn hng nm, phng chng vim ni tm mc nhim khun. Nguy c gp nhm ny l Osler, h ch (TLT phn phu) v hp phn phu MP (TLT phn quanh mng). 2. Khi l thng lin tht ln s nh hng r n ton trng tr i 6 thng: iu tr ni khoa vi li tiu, tr tim, c ch men chuyn. Nu khng p ng vi iu tr ni th cn ng l TLT. 3. Khi l TLT ln, nh hng r n ton trng tr trn 6 thng th cn phu thut ng l TLT. 4. Khi l thng ln, c tng p MP trn 50mmHg tr hn 6 thng: phu thut ng l TLT. 5. Khi l TLT phi hp vi h van MC va hoc hp ng k ng ra tht phi th cn phu thut ng l TLT.

6. Nu TLT c nhiu l, c nh hng n ton trng th cn lm phu thut nh ai (ban ing) MP cc tr nh i 6 thng v sau phu thut sa cha ton b. Tin trin ca TLT nu c ng kn (bng phu thut hay ng l thng qua da) c th coi nh bnh nhn c cha khi hon ton. Ri lon nhp cc bnh nhn ny l hn hu nh bloc nh tht sau phu thut. 7. Cc trng hp TLT nghi ng c tng p MP c nh: cn thng tim vi nghim php th xy v thuc gin mch, chp mao mch phi, o sc cn mch phi v cui cng c th sinh thit phi. Nu sc cn mch phi khng tng c nh th c th phu thut, nu tng c nh th l mt chng ch nh ca phu thut. Trong trng hp nghi ng c th phu thut nh ai MP v lm li cc thm sau vi nm. i vi cc trng hp khng cn ch nh m na th thng din bin c th nng ln bng cc du hiu suy tim phi, hn ch gng sc, a hng cu vi biu hin tm nhiu da v nim mc. Cc bin chng c th gp l chy mu phi, pxe no v t t. Gii php iu tr ch ng duy nht trong trng hp ny l phu thut ghp c tim v phi cho ngi bnh. Ti liu tham kho 1. Brecker SJD. Ventricular septal defect. In: Redington A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: WB Saunders, 1994:111-117. 2. Bridges ND, Perry SB, Keane JF, et at. Preoperative transcatheter closure ofcongenital muscular ventricular septal defects. N Engl J Med 1991;324:13121317. 3. Connelly MS, Webb GD, Sommerville J, et at. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395452. 4. Ellis JH, Moodie DS, Sterba R, Gill CC. Ventricular septal defect in the adult: natural and unnatural history. Am Heart J 1987;114:115-120.

5. Folkert M, Szatmari A, Utens E, et at. Long-term follow-up after surgical closure of ventricular septal defect in infancy and childhood. J Am Coll Cardiol 1994;24:1358-1364. 6. Gumbiner CH, Takao A. Ventricular septal defect. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of pediatric cardiology; 2nd ed. Baltimore: Williams & Wilkins, 1998:1119-1140. 7. Lock JE, Block PC, McKay RG, et at. Transcatheter closure of ventricular septal defects. Circulation 1985;78:361-368. 8. Mahoney LT. Acyanotic congenital heart disease: a trial and ventricular septal defects, atrioventricular canal, patent ductus arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. 9. Moore JD, Moodie DS. Ventricular septal defect. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. 10. O'Fallon MW, Weidman WH, eds. Long-term follow-up of congenital aortic stenosis, pulmonary stenosis, and ventricular septal defect. Report from the Second Joint Study on the Natural History of Congenital Heart Defects (NHS-2). Circulation 1993;87[Suppl II]:II-1-II-126. 11. O'Laughlin MP, Mullins CE. Transcatheter closure of ventricular septal defect. Catheter Cardiovasc Diagn 1989;17:175-179. 12. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 13. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis:Mosby, 1997:246-265. 14. Somerville J. How to manage the Elsenmenger syndrome. Int J Cardiol 1995;63:1-8.

S30. CN NG NG MCH
Bnh thng ng ng mch tn ti 2-6 ngy sau khi sinh. Nu sau thi gian ny ng khng ng li gi l cn ng ng mch 1. 1.1 Chn on Lm sng: Kh th Vim ph qun ti din. Chm pht trin th cht, suy inh ng. Pht hin tnh c.

Nghe tim: ting thi lin tc lin sn 2 tri. S c rung mu. i khi nghe ch thy c ting thi tm thu. 1.2 Xt nghim Xquang :

+ Tim to, cung ng mch phi phng. + Phi c hnh nh cc cc nhnh ph qun m. Siu m:

+ Hnh nh ng ng mch 2. 2.1 iu tr Ch nh phu thut

S sinh c kh th, tng p lc ng mch phi : m cp cu tht ng bng ng ngoi mng phi Cc trng hp khc m phin ct ng ng mch.

2.2 2.3

M ni soi cho cc trng hp ng b hn 9 mm Chng ch nh phu thut C km tim bm sinh tm. C i chiu. Cc bnh vim nhim cha n nh. Chun b trc m :

An thn cho tr ln. 2.4 K thut m

- Bnh nhn nm nghing bn phi c n ngang lng. - ng m: lin sn 3-4 sau bn, bn tri. - Phu tch on ng mch ch trn v i ng, t dy an ton. - Phu tch ng ng mch, cp 2 clamp, ct v khu 2 u ng bng ch prolene 6,0. - i vi tr s sinh : i ngoi mng phi, tht ng . sau khi rch da, tch v ct c lin sn. Dng ngn tay hoc tm bng nh y v tch mng phi khi thnh ngc sau v bn vo ng mch ch. Tm ng ng mch. Lun ch buc tht ng ng mch pha ng mch ch v ng mch phi. - t dn lu, gim au ti ch, ng thnh ngc. M ni soi: Bnh nhn nm nging tri. t 3 ca s: 1 ca s cho ng soi, 2 ca s lm vic. p lc kh duy tr t 2-4 mmHg. Bc tch ng ng mch.Cp ng bng 2 clip. 2.5 Chm sc v theo di sau m. Ht lin tc dn lu 6- 8 cm nc Khng sinh: cephalosporin th h th nht trong 48 gi.

Gim au bng paracetamol t hu mn trong vng 24 gi Sau 3 ting xt nghim Hb kim tra. Sau1 ngy chp phi kim tra, rt dn lu.

- Theo di pht hin v x l cc bin chng Chy mu sau m: Dn lu ra mu. Hi sc, truyn mu, theo ri lm sng v Hb.

M li khi Hb tip tc xung ( 5% lng mu c th / 1 ting trong 3-4 ting lin?). Trn dng chp: Dn lu ra ch trng nh sa. Ht lin tc Nui ng tnh mch .

Sau 1 tun cn chy ---> Xem xt ch nh m .

S31. THNG LIN NH


Thng lin nh (TLN) chim khong t 5% n 10% cc trng hp tim bm sinh. Cng vi bnh van ng mch ch hai l van v sa van hai l, TLN l bnh tim bm sinh cn hay gp nht ngi ln. Bnh ch yu gp n gii: t l gp n so vi nam l 2 so vi 1. i a s cc bnh nhn TLN khng c triu chng c nng m ch c cc triu chng lm sng rt kn o o thng b b st chn on cho n tui trng thnh.

i vi cc trng hp TLN khng c iu tr trit , cc bnh nhn s dn dn c cc triu chng lm sng. Lu di cc bnh nhn s biu hin cc du hiu ca s qu ti bung tim phi nh ri lon nhp nh (tng n nguy c theo tui ca bnh nhn), tng p ng mch phi v tng sc cn mch phi, cui cng hu qu tt yu l dn n suy tim xung huyt. Vic tn ti l thng lin nh cng l mt yu t thun li dn n tc mch nghch thng. I. Gii phu bnh: c bn dng thng lin nh thng thng: TLN kiu l th hai, TLN kiu l th nht, TLN kiu xoang tnh mch v TLN th xoang vnh. A. TLN kiu l th hai hay TLN th pht (l bu dc) l tn thng hay gp nht chim khong t 60% n 70% cc trng hp. L thng nm v tr gn l oval, trung tm vch lin nh (VLN). C th gp phi hp vi sa van hai l, c bit ph n (t l 2:1 so snh gia n v nam gii). B. TLN kiu l th nht hay TLN tin pht chim 15% n 20% cc trng hp. L thng nm thp, gc hp bi vch lin nh v mt phng ca vch ngn nh tht (mt phng van nh tht). Chnh v v tr thp nn loi ny hay i km vi khuyt tt ca van nh tht v vch lin tht. Khi c TLN l th nht th rt thng gp h van hai l i km o c k h ca l trc van hai l. Lc , bnh l ny c phn loi trong nhm c bit gi l thng sn nh tht (ng nh tht chung), c c ch sinh l bnh, din bin lm sng v phng hng iu tr khc. C. TLN th xoang tnh mch l loi TLN t gp, chim khong t 5% n 10% cc trng hp. L thng nm cao v ra sau ca VLN, n nm ngay st vi tnh mch (TM) ch trn do vy rt hay gp hin tng tnh mch phi (TMP) qua l thng vo nh phi (TMP lc ch). Ngoi ra c th gp cc th rt him ca TLN nh: TLN nm rt thp pha i st vi TM ch i (pha sau v i ca VLN). D. TLN th xoang vnh l th him gp nht, l thng nm ngay st pha trn xoang TM vnh, o ng shunt t nh tri s trc tip vo ''cu trc'' ny. Tn thng ny hay phi hp vi cc d tt bm sinh khc nh ng nh tht chung, tnh mch ch trn lc ch. II. Sinh l bnh

A. TLN thng dn n dng shunt t nh tri sang nh phi, lu lng shunt ph thuc vo ng knh l thng v ph thuc gin tip vo gin n ca tht tri v tht phi. Lung thng c th ngay lp tc ( i 1 nm) hoc dn dn (nhiu nm) n n s tng gnh ca bung tim phi lm ph i tht phi, tng ti mu phi v cui cng s dn n tng p lc ng mch phi (MP). cc bnh nhn ngi ln hoc do p lc bung tim phi tng ln hoc/v kh nng co bp ca tim tri gim xung (c tim b nh hng o tng cng hay o bnh ng mch vnh, tng huyt p... phi hp), lc ny ng shunt thng s gim xung dn dn v c th dn n shunt hai chiu hay o chiu dng shunt (him gp). B. Nguy c chnh ca vic khng ng l thng lin nh l s gy suy tim th pht o tng gnh mn tnh, tng p MP, ri lon nhp nh v tc mch. III. Triu chng lm sng A. Triu chng c nng: thng kn o, i khi bnh nhn n khm v kh th khi gng sc, vim ph qun phi nhiu ln hoc chm ln. Mt s t cc trng hp vi l TLN ln c th dn n shunt tri sang phi nhiu v tr c du hiu c nng rt sm khong t 6 n 12 thng, cn li i a s cc trng hp bnh thng pht hin mun nh thm khm thng kz. Cc trng hp bnh din bin lu di c th c cc biu hin ca ri lon nhp nh rung nh hay cung nh, tng p ng mch phi nng v suy tim xung huyt. B. Khm lm sng: Nghe tim c ting thi tm thu cng nh van MP o tng lu lng mu qua van MP. Ngoi ra cn nghe thy ting T2 tch i o s ng mun ca ba l van MP; ting T1 mnh v rung tm trng o tng lu lng van ba l c th gp trong cc trng hp dng shunt ln lm tng nhiu s y v tht phi. IV. Cc xt nghim chn on A. 1. a. in tm (T) TLN l th hai: in tm thng c dng: RSR hay rSR V1.

b. c.

QRS ln hn 0,11 giy. Trc phi.

d. i khi c th km theo PR ko di (khong 20% cc trng hp, hay gp cc bnh nhn TLN mang tnh cht gia nh). e. 2. a. b. c. d. Dy nh phi trong khong 50% cc trng hp. TLN l th nht: in tm c dng RSR V1. Trc tri. Bloc nh tht cp I. C th thy dy c 2 tht.

B. Chp Xquang tim phi: Tim to va phi vi gin cung MP. i khi thy du hiu gin b i phi ca tim do gin bung nh phi. Tng ti mu phi hay gp. C. Siu m tim: y l phng php ch yu v chnh xc nht chn on thng lin nh. i vi cc bnh nhn nh tui c th ch cn dng siu m qua thnh ngc cn i vi cc bnh nhn ln tui, thnh ngc y, i khi cn lm siu m qua thc qun. 1. Siu m qua thnh ngc: Mt ct siu m in hnh quan st l TLN l trc ngn cnh c tri, bn bung t mm v nht l mt ct i sn. a. Hnh nh gin tip s thy du hiu gin bung tht phi v nh phi. Mc gin bung tim phi ph thuc vo mc dng shunt tri phi hay kch thc l TLN. b. Thy hnh nh trc tip ca l TLN trn siu m 2D: bn bung t mm, 4 bung i mi c, hay trc ngn cnh c tri. Hnh nh TLN th xoang tnh mch kh thy hn, c bit ngi ln tui.

c. Tm kim s bt thng ca TM phi v TM ch: TM ch trn tri vo nh phi khng c thn TM v danh; TM phi lc ch vo TM ch trn, TM v danh, TM ch i hay nh phi... l cc bt thng bm sinh c th gp phi hp vi TLN. Cn quan st bng siu m 2D v c bit l siu m Doppler mu. d. nh gi mc ca dng shunt: gin tip thng qua kch thc tht phi so vi tht tri. Nu thy t l kch thc tht phi/tht tri t 1/2 n 2/3: TLN l nh. Nu t l ny t 2/3 n 1: TLN l trung bnh. Nu t l ny trn 1: TLN l rng.

e. Nn tin hnh o cung lng phi, so snh vi cung lng ch. Nu tng cung lng phi nhiu: TLN c dng shunt tri phi ln. f. nh gi p lc MP: bng dng chy qua van ba l v dng chy qua van MP (trong TLN p lc MP thng tng tng i mun). 2. Siu m qua thc qun: c p dng vi cc trng hp thng lin nh m siu m qua thnh ngc cn cha r. Siu m qua thc qun rt hu ch trong vic o chnh xc kch thc l thng lin nh cng nh kch thc cc ra pha trn v pha i ca l thng chun b bt cc l thng bng dng c. Siu m qua thc qun cng cn c p dng i vi cc th TLN him gp c bit l TLN th xoang tnh mch vi bt thng s v ca tnh mch phi. 3. Siu m cn m: Siu m vi tim cht cn m c bit rt hu ch cho vic chn on xc nh v loi tr cc bt thng bm sinh phi hp khc. D. 1. Thng tim Mc ch ca thng tim:

a. Chn on xc nh TLN ch yu da vo siu m tim (siu m 2D, Doppler, siu m cn m, siu m qua thc qun). Thng tim c th gip ch cho vic nh gi mc shunt, ngoi ra cn xc nh chnh xc p lc ng mch phi, o cung lng ng mch phi, cung lng ng mch ch...

b. Vit nam do c rt nhiu cc trng hp n mun nn vic thng tim xc nh chnh xc mc shunt, p lc MP, t l cung lng QP/QS v c bit l sc cn mch phi c vai tr quyt nh xem bnh nhn c cn ch nh phu thut hay khng. Vi cc bin php th xy, thuc gin MP lm gim p MP s l nhng nghim php cui cng quyt nh chn on bnh nhn c tng p lc ng mch phi c nh (hi chng Eisenmenger) hay khng ? c. Ngoi ra trong nhng nm gn y, thng tim cn nhm mc ch ng l TLN bng dng c qua da (Amplatzer, CardioSeal...). 2. Chp bung tim:

a. Nu l thng thy r trn siu m, c th khng cn thc hin chp bung tim. b. Khi c du hiu ca TM phi lc ch, c th chp MP cho hnh nh r rng v xc nh lung thng ( th thuc ''chm'' khi mu v TM phi). L thng lin nh s thy r gc chp nghing tri 20 n 450 nghing u 250, ng thng bm thuc cn quang nm tnh mch phi phi. c. Chp bung tht tri c th thc hin nh gi co bp tht tri v mc h van hai l. Nu nghi ng thng lin tht v h cc van nh tht phi hp th cn chp bung tht tri t th thng mt v nghing tri 60 70o, chch u khong 250. d. Cui cng cc bnh nhn c tui (nam hn 40, n hn 45), cn chp MV mt cch h thng xc nh c bnh ng mch vnh phi hp hay khng. V. Ch nh iu tr v tin trin

A. ng l TLN c th thc hin bng phu thut tim h vi tun hon ngoi c th (ng m dc xng c, i sn hoc sau bn lng). y l phng php iu tr kinh in c p dng t lu. Hin nay ngi ta c th ng qua da cc l TLN th pht m cn c g xung quanh l thng bng cc loi dng c c bit. B. Ch nh iu tr

1. i vi cc l thng b: ting thi nh, ting T2 tch i, ng knh tht phi/ tht tri nh hn 2/3 th cn theo i nh kz thng xuyn. 2. Vi cc l thng kch thc trung bnh: khng c du hiu c nng, bloc nhnh phi khng hon ton, t l ng knh tht phi/tht tri t 2/3 n 1, c tng ti mu phi trn phim chp Xquang: nu l n gii th nn phu thut khong nm 15 tui (phu thut ng ngang i v); nu l nam gii th nn phu thut lc 5 tui. Nu c kh nng ng qua a bng dng c (Amplatzer, CardioSeal...) th nn thc hin ngay khi c th cc l thng loi ny. 3. Vi cc l thng ln: ting T1 mnh, rung tm trng o tng lu lng, t l ng knh tht phi/tht tri ln hn: nu c tng p MP cn ng l thng ny cng sm cng tt. Nu khng tng p MP, ng l thng mt cch h thng lc tr 5 tui. 4. TLN nghi ng c tng p MP c nh: cn lm thng tim chn on. Ch phu thut khi cha c tng p MP c nh, lu lng mch phi vn tng hn lu lng i tun hon (vn cn shunt tri phi l ch yu) v sc cn mch phi vn cn trong gii hn cho ph p (cha tr thnh phc hp Eisenmenger). 5. Tin trin ca TLN thng dung np tt v vy i khi pht hin bnh rt mun tui trng thnh. Tng p MP c nh (khng cn ch nh phu thut) c th gp tui 20 n 30. Suy tim v ri lon nhp tim c th bt u xy ra tui 30 n 40. Nu l thng lin nh c ng kn (bng phu thut hay bng dng c qua da) th c th coi nh bnh nhn c cha khi hon ton. Ri lon nhp cc bnh nhn ny l hn hu. C. Phu thut ng TLN vi tun hon ngoi c th t rt lu tr thnh mt phu thut kinh in. Ty theo kch thc v v tr ca l TLN m phu thut vin c th khu trc tip hoc lm ming v bng mng ngoi tim ng kn hon ton l TLN. 1. Nguy c phu thut lin quan n c a bnh nhn nh tui, rung nh, p lc ng mch phi v sc cn mch phi tng cao.

2. Sau m, bnh nhn cn c th b nguy c mc hi chng sau m mng ngoi tim (hay gp hn cc phu thut tim bm sinh khc). Ri lon nhp nh c th vn ko di mt thi gian sau cho n khi kch thc ca nh v tht phi tr v kch thc bnh thng. Ti mt vi trung tm, thuc chn bta giao cm c s dng t 3 n 6 thng sau m phng nga cc ri lon nhp nh.

D. ng l TLN qua da bng dng c l th thut ngy cng c p dng nhiu nc trn th gii. Ti Vit Nam phng php ny hin nay c tin hnh thng quy ti Vin Tim mch Vit Nam. Tt c cc trng hp TLN l th hai c kch thc khng qu ln v g xung quanh l ln (hn 5mm) u c kh nng ng bng dng c qua a i mn tng sng. Phng php ny ngy cng chng minh c tnh hiu qu nh thi gian nm vin ngn, t au, khng c so m, t bin chng ngay c nhm bnh nhn c nguy c cao.

Ti liu tham kho 1. Brecker S,ID. Atrial septal defect. In: Redington A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: WB Saunders, 1994:103-110. 2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol l998;14:395452. 3. Gatzoulis MA, Redington AN, Somerville J, Shore DF. Should atrial septal defects in adults be closed? Ann Thorac Surg 1996;61:657-659. 4. Latson LA. Per-catheter ASD Closure. Pediatr Cardiol 1998;19:86-93.

5. Mahoney LT. Acyanotic congenital heart disease: atrial and ventricular septal defects, atrioventricular canal, patent ductus arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. 6. Mandelik J, Moodie DS, Sterba R, et al. Long-term follow-up ef children after repair of atrial septal defects. Cleveland Clin J Med 1994;61:29-33. 7. Moore JD, Moodie DS. Atrial septal defect. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. 8. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in Adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 9. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246. 10. Vick GW. Defects of the atrial septum including atrioventricular septal defects. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins, 1998:1141-1179.

S32. THP TIM


I - I CNG:

1/ nh ngha: Thp tim( thp khp cp) l mt bnh vim d ng xy ra sau nhim lin cu khun tan huyt nhm A gy nn; bnh tn thng h thng t chc lin kt theo c ch min dch d ng -> gy tn thng nhiu c quan ( tim, khp, phi, thn kinh, da , thn) c bit l tim v khp.

2/ Nguyn nhn: - Bnh thp tim l hu qu ca vim hu- hng, do lin cu khun tan huyt nhm A - Lin cu khun tan huyt nhm A l mt cu khun Gram (+)

3/ iu kin thun li: - Tui : 5-15 tui ( 90%), t gp tui< 5 v >25 tui. - C a d ng - Thi tit v kh hu: gp nhiu vng c kh hu n i v nhit i ( ma lnh, m, chuyn ma). - Yu t gia nh. - iu kin sinh hot thp km.

4/ C ch bnh sinh: + Thuyt MD d ng: Ngi ta cho rng lp v ca lin cu khun v t chc lin kt c tim ca c th c cu trc khng nguyn chung, v vt cc khng th khng lin cu nh lun vo c tim; khng nguyn gy nn phn ng ch o c cho l do Protein M ca lin cu khun; Halpern pht hin s ging nhau gia Protein M ca lin cu vi mt glucoprotein van tim, sn khp, ng mch ch v da. + Thuyt nhim c: Ngi ta cho rng thp tim l do cc yu t mng ngoi lin cu khun tan huyt nhm A gy nn gm: - Streptolysin 0 : l mt yu t gy tan mu, cng vi Proteinase gy c cho tim. - Streptolysin S : cng l mt yu t gy tan mu, ng vai tr quan trng trong qu trnh vim.

5/ Gii phu bnh: + Giai on ph nim: L giai on sm; tn thng ch yu l s thm nhim cc t bo vim khng

c hiu phc h Collagen ca t chc lin kt. + Giai on bin i dng Fibrin: C tn thng ni mc mch mu, lm tng tnh them, gy thot protein huyt tng v fibrinogen ra t chc gian bo. ng ch { l ng hi t fibrin ca cht to keo, c c im vim xut tit v thm nhim cc bch cu a nhn, L, tng bo. + Giai on tng sinh khu tr hoc tng sinh lan ta t bo t chc lin kt: Ht Aschoff ( tn thng khu tr) gm: - Trung tm l hoi t fibrin. - xung quanh l t chc tng sinh cc t bo lin kt. - Ngoi cng l cc t bo L, tng bo, BC a nhn v t bo si. Ht Aschoff thng gp c tim, cc mch mu, mng hot dch khp v ngoi da to nn ht Meynet. + Giai on x- so: Cc ht ASchoff teo dn v thay th bng qu trnh x- so ko di gy tn thng co k o x ha t chc lin kt.

II - TRIU CHNG: 1/ Lm sng: M u l triu chng nhim khun ng h hp do ngoi lin cu khun tan huyt nhm A : st, vim hng, vim Amy al, sng hch i hm, nut au. Sau 2-3 tun th xut hin cc triu chng cc c quan nh: 1.1/ Vim tim: L triu chng lm sng quan trng nht ca bnh thp tim v ay l triu chng c hiu v li hu qu nng n . + Vim tim gp 40-60% BN. C th vim mng ngoi tim, mng trong tim, c tim. + Cc triu chng : - Bin i ting tim: xut hin tp m bnh l . Ting tim trm, di mm tim do van 2 l vim ph n cc dy chng ct c . Ting thi tm thu mm ( giai on u o gin c tim gy h van 2 l c nng; sau 6 thng th l h thc th do tn thng van 2 l)

. Ting thi tm trng mm: do vim van 2 l, xut hin sm, tn ti tm thi, nghe g mm, m sc trm. . Khi tim to, bung tim gin-> dy chng ct c gin mu rn nhanh t nh xung tht th ting thi tm trng mm ging ting rng tm trng mm. . Ting thi tm trng nn tim: do vim van MC, o tro ngc mu t MC vo tht tri u thi kz tm trng . Ting thi tm thu nn do h van 2 l c nng, ting thi mt i khi ht triu chng suy tim. . Ting c mng ngoi tim: Thng xut hin giai on uca vim mng ngoi tim, nghe r nn tim hoc dc b tri xng c, nghe r hn khi BN nghin ra trc. - Ri lon nhp tim: nhp nhanh > 100ck/p, nhp nga phi , ri lon dn truyn: PR ko di > 20% giy - Tim to: o vim c tim, gin cc bung tim . Lm sng : BN nut kh, nut nghn, nh trng ngc. . XQ: Tim to , t l tim/ngc > 50% I : hi to, t l tim/lng ngc 50-55% II : to va, t l tim/lng ngc 55-60% III: rt to, t l tim/lng ngc > 60% . ECG: tng gnh cc bung tim. - Suy tim: o vim c tim: . Lm sng: kh th, gan to, ph, TM c ni, c ting nga phi, ri lon nhp tim, nghe phi c ting ran , 1.2/ Vim a khp( gp 75% trng hp Thp tim): + Vim a khp cp v au khp bao gm cc c im sau: - Xy ra t ngt. - Tn thng nhiu khp , hay gp cc khp ln( khp gi, c chn, vai, khuu tay, c tay), t gp cc khp nh. - Biu hin l sng nng au, c th c dch khp. - Khp vim thng khng i xng. - Thi gian vim mt khp t 3-5 ngy, c tnh cht lun chuyn. - Khp vim thng khi nhanh khi dng thuc khng vim v Corticoi ; nhng khng iu tr g khp cng t khi v khng li di chng g. c th ti pht.

1.3/ Biu hin ngoi da: + Ht Meynet( him gp): ht cng i a, ng knh 0,5-2cm, khng dnh vo da, nhng nh vo nn xng ( xng chem., b vai, ct sng, bnh ch) v cc gn dui, cc ht thng i xng, n khng au, tn ti vi ngy n vi tun ri mt i khng li di chng; trn vi th ht Meynet c cu trc: trung tm l mt vng thoi ha si fibrinoid, bao quanh l t chc bo, tn cu. + Ban vng( t gp): xut hin thn mnh, cnh tay, di, khng c mt. Ban c c im l ban mu hang hoc vng nht, ng knh 1-3cm, trn, c b vin, khng nga, khng cng, xut hin nhanh, mt i sau vi ngy khng li di chng.

1.4/ Biu hin thn kinh: + Ma git Sydenham( Chorea): l hin tng vn ng nhanh, khng t ch, khng nh hng, tng ln khi xc ng, mt i khi ng mt hoc tt c cc chi. + Lit, hn m, co git( biu hin ca bnh thp no): t gp 2/ Cn lm sng: 2.1/ XN mu: + Cng thc mu: - S lnh HC gim nh - BC tng, N tng - Vss tng cao, gim dn trong giai on hi phc. - Protein C (+). 2.2/ XN : ASLO - Hiu gi khng th ny tng n t tun u v t gi tr cao nht sa 3-5 tun; sau 2-4 thng ASLO tr li bnh thng - ASLO (+) trn 80% BN thp tim, nu kt hp vi XN khc nh : Anti DNA, anti hyaluronidase th t l chn on c th trn 95%.

2.3/ Cy khun tm Streptococcus tan mu nhm A nhy hng, mi, thanh qun. - T l (+) thng ch t 25-40% trng hp. - Phi cy t nht 3 ln - Kt qu (-) cng cha loi tr nhim lin cu khun ( v BN c th lm khng sinh trc). 2.4/ ECG: + Ri lon dn truyn nh-tht: on PR ko di(>0,20 giy): o vim c tim hoc cng ph giao cm. + Cc bin i nhp tim: - Nhp xoang nhanh( hay gp). - C th c tnh trng st, au khp gy nn. - Cn nhp nhanh kch pht. - Ngoi tm thu - Rung nh, cung ng nh.

III - CHN ON: 1/ Chn on xc nh: Tiu chun chn on ca hi tim mch M: + Tiu chun chnh: - Vim tim - Vim khp. - Ma vn. - Ht thp i da( ht Meynet). - Vng ban + Tiu chun ph: - Tin s thp tim hoc cc bnh van tim do thp. - St, au khp - Cn lm sng: Tng cc pha phn ng cp: BC, Vss, Protein C (+); PR ko di + Tiu chun bt buc: - C bng chng v s nhim lin cu khun tan huyt nhm A ( nh cy nhy hng(+), Test ASLO tng).

=> Chn on thp tim khi: - C 2 tiu chun chnh hoc 1 tiu chun chnh v 2 tiu chun ph. - ng thi phi c du hiu ca mt t nhim lin cu mi xy ra trc bng : ASLO(+) tng cao; cy nhy hng tm thy lin cu khun tan huyt nhm A. - Ch {: khi ly tiu chun chnh l vim tim th khng ly tiu chun ph l PR ko di, nu ly tiu chun chnh l vim khp th khng ly tiu chun ph l au khp.

2/ Chn on phn bit: 2.1/ Vim khp dng thp: Thng vim cc khp nh, c tnh cht i xng, thi giai di chuyn t khp ny sang khp khc lu v thng li di chng, XN yu t thp RF( Rheumatic Factor) thng (+). 2.2/ Vim mng trong tim nhim khun bn cp ( Osler): St hng nh, ko di, c th c rt run, ton trng sa st; Thng gp nhng BN c bnh tim bm sinh, bnh van tim; Cy mu dng tnh ( cy mu 2 ln ring bit phn lp c Streptococcus viridans, Streptococcus bovis, nhm HACEK, Straphylococcus hay Enterococcus); C bng chng tn thng ni tm mc rn siu m( hnh nh mnh si i ng lt pht trn van tim hay cnh van, hnh nh p xe trong tim, s bong ri ca mt s van nhn to, h van mi xy ra); c th biu hin ca tc mch mu( no, phi, chi, kt mc, DH Janneway); lch to, chn m, xut huyt i a

IV - IU TR:

1/ iu tr trong t hot ng ca bnh: 1.1/ Chm sc h l: - BN phi c ngh ngi ti ging n khi Vss tr v bnh thng, nhm mc ch gim bt gnh nng cho tim - n nh thc n tiu, gim mui. 1.2/ Khng sinh dit lin cu:

+ Phi dng sm + Penicillin V 1.000.000 UI/24h ung s,y 10 ngy - Nu d ng vi Penicillin th dng: - Erythromycin 250mg x 4v/24h chia lm 4 ln x 10 ngy ( hoc 40mg/kg/24h) 1.3/ Chng vim : + Vim a khp n thun: - Aspirin 100mg/kg/24h x 10 ngy sau 3-4 tun sau dng 60mg/kg/24h + Vim tim nh: - Prednisolon 2mg/kg/24h x 10ngy, sau gim dn liu. - T ngy th 11 ng Aspirin 100mg/kg/24h x 10 ngy, sau gim liu 60mg/kg/24h x 5-7 tun. + Vim tim nng: - Prednisolon 2mg/kg/24h x 2 tun sau 2 tun th gim liu. 1 tun trc khi gim liu th dng Aspirin 100mg/kg/24h x 10 ngy sau gim liu 60mg/kg/24h 1.4/ iu tr suy tim nu c: Cng tim, li tiu, ch ngh ngi hp l{

2/ Phng thp tim: 2.1/ Phng thp cp 1( phng ban u): - iu tr nhim khun h hp trn do thy lin cu khun tan huyt nhm A phng t u tin ca bnh thp tim. - C th dng Benzathin penicillin tim bp duy nht 1 liu: Tr > 30kg: 1.200.00 UI. Tr < 30kg: 600.000UI - Nu d ng vi Penicillin th thay bng Rovamycin 150.000UI/kg/24h x 10 ngy

2.2/ Phng thp cp 2: + p dng cho tr b bnh thp tim

- Penicillin chm nh : Retapen, Benzathin penicillinG tim bp su( trn c mng). Tr > 30kg: 1.200.00 UI/ln Tr < 30kg: 600.000UI/ln + Thi gian tim: - Vim a khp, tim nh: 5 nm, nu trong 5 nm vn c ti pht th ng n 21 tui. - Vim tim nng th dng sut i .

S33. T CHNG FALLOT


T chng Fallot l bnh tim bm sinh c tm hay gp nht, chim khong 10% cc bnh tim bm sinh. C th chn on c bnh ny t trc khi sinh bng siu m tim thai. Din bin t nhin ca bnh thng l tm ngy cng tng, i khi c cn mt xu. Chn on lm sng hay a vo cc du hiu tm da, ting thi cao ca hp ng mch phi, phi sng v tng gnh tht phi. Siu m tim thng gip khng nh chn on. Phu thut sa ton b c kt qu tt tr t 6 n 9 thng. Phu thut sa ton b hoc lm cu ni cp cu trong trng hp c cn xu, ngt do thiu oxy. T l t vong khi phu thut thp, tin lng tt. T chng Fallot l bnh tim bm sinh hay i km vi cc tn thng ngoi tim. C th c lin quan n: hi chng nhim c ru bo thai, hi chng Goldenhar, hi chng Cardiofacial, hi chng c 3 nhim sc th 21 (thng i cng vi ng nh tht chung) v c th c tnh cht gia nh. I. A. Gii phu bnh T chng Fallot gm 4 chng Hp ng ra ca ng mch phi (MP).

Thng lin tht (TLT).

ng mch ch (MC) lch sang phi v ci nga ngay trn l thng lin tht. Ph i tht phi.

1. Trong s cc chng ny th 2 "chng" quan trng nht l hp ng ra ca MP v TLT. Hp ng ra MP c rt nhiu th nhng bao gi cng c hp phn phu MP. Hp c th di hay ngn, cao hoc thp, kht hoc va. Ngoi ra c th hp ng ra MP phi hp vi hp van MP, hp trn van v cc nhnh MP. C th hp va hoc hoc rt kht, thm ch thiu sn nhnh MP. L TLT trong Fallot 4 thng rt rng, b ca c, ngay pha i ca ca Wolf (loi quanh mng chim khong 80% cc trng hp). 2. Chnh o 2 thng tn hp MP v TLT ny s dn n ph i tht phi, dng shunt t phi tri s c xu hng k o ng mch ch lch sang phi v dn dn "ci nga" trn l TLT. Mc lch phi ca MC ph thuc vo 2 yu t: kch thc ca MC v kch thc ca l thng lin tht (t l thun vi 2 thng s ny). B. 1. 2. 3. 4. 5. Cc thng tn phi hp MC quay phi (25% cc trng hp). Hp MP (10 - 20%). Thiu sn MP vi nhiu tun hon bng h (5-10%). TLT phn c phi hp (5 - 10%). Tun hon bng h ch - phi (5- 10%).

6. Bt thng MV (1 - 2%) trong hay gp l MVLTT bt u t MV phi. y c th l mt kh khn cho phu thut t chng Fallot. II. Sinh l bnh

A. Hp MP ngn cn ng mu ln MP v gy ra ting thi tm thu van MP. Tng gnh bung tim phi do hp MP, tuy nhin tn thng ny c dung np tt nh c l thng lin tht rng o mu s c "thot" sang i tun hon (do p lc tm thu bung tim phi cn bng vi p lc i tun hon). B. Lung thng qua l TLT s lin quan n mc hp MP v sc cn ca h mch i tun hon. Khi tc nghn ca ng ra tht phi tng ln (theo thi gian s pht trin ca c vng ph i tng) v sc cn ca h mch i tun hon gim (v d khi gng sc) dng shunt s i t phi tri v lm gim bo ho xy trong i tun hon. Kt qu l bnh nhn s b tm sm. Mc tm v gin MP t l thun vi mc hp MP. III. Triu chng lm sng A. Bnh s: mc tm nhiu hay t thng ph thuc vo mc hp ng mch phi. Tm thng i km vi gim vn ng. Tm c c im l khng hng nh, tng ln khi gng sc hoc khi lnh. Cn tm kch pht km ngng th v ngt, c th dn n t vong, co git v li triu chng thn kinh, nhng thng hi phc. Du hiu ngi xm v du hiu ngn tay di trng cng thng gp trn lm sng. B. Khm lm sng

1. Ting thi tm thu tng mu (do hp ng mch phi): cng t 3 n 5/6, thng nghe thy khoang lin sn II - IV st b tri xng c. C th nghe c ting clc tng mu MC, ting T2 mnh duy nht. Nu T2 tch i, loi tr chn on teo tt van MP. i khi c th nghe c thi lin tc i xng n ( o cn ng ng mch), hoc vng lng ( o tun hon bng h ch phi). 2. Tm nhiu da v nim mc; ngn tay di trng rt thng gp.

3. th khng tm: thi tm thu do TLT v hp phu, c th nghe c dc b tri xng c v bnh nhn khng tm (du hiu lm sng ca Fallot 4 khng tm ging vi TLT shunt nh). IV. Cc xt nghim chn on

A.

Xquang ngc

1. Bng tim bnh thng vi mm tim ln cao, cung gia tri lm, ph trng sng. 2. 20% quai MC bn phi kh qun.

B. in tm : ph i tht phi n thun, ph i 2 tht c th gp th khng tm.

Hnh 31-1. Hnh phim Xquang tim phi thng. C. 1. 2. Siu m Doppler tim TLT rng, cao, thng l phn quanh mng. MC gin rng c hnh nh ci nga ln VLT.

3. Hp MP: hp phu, van MP (phi o c ng knh vng phu, vng van v 2 nhnh MP). Siu m Doppler khng nh mc hp ng mch phi bng cch o chnh p qua phu v van MP (p lc MP thng bnh thng).

Hnh 31-2. Mt ct trc dc vi hnh nh thng lin tht cao (mi tn) v MC ci nga r. 4. Cn phi thm trn siu m xem c hay khng cc tn thng sau: hp cc nhnh MP, thng lin tht nhiu l, thng lin nh, ng chy lin tc trong MP chng t cn ng ng mch hoc tun hon bng h ch phi. 5. Xc nh cc tn thng phi hp nh thng lin nh, thng lin tht phn c... D. Thng tim

1. Ch nh: Trc phu thut tt c bnh nhn t chng Fallot nn c thng tim xc nh s tc nghn ca ng ra tht phi, c hp MP on gn hay cc nhnh ca n hay khng, v loi tr cc bt thng v v tr xut pht v ng i bt thng (nu c) ca ng mch vnh. 2. Cc thng s huyt ng:

a. o bo ho xy c th thy dng shunt 2 chiu qua l TLT vi bc nhy xy tht phi v gim bo ho xy tht tri cng nh MC. b. p lc tht phi, tht tri v MC bng nhau do l thng lin tht rng.

c. Hp ng mch phi thng mc va, vi p lc MP t mc thp n bnh thng. 3. Chp bung tim:

a. Chp bung tht phi t th nghing phi 30o, quay ln u 25 v t th nghing tri 60o n 70o, chch u 250. T th nghing phi s thy ng ra tht phi v MP, t th nghing tri s thy l thng lin tht. Nu cha r, c th chp t th nghing tri nh 30o v chch u 25o, t th ny thy r MP v ch phn i. b. Chp bung tim tri (nghing phi v/hoc nghing tri 60-75o chch u 25o) nh gi chc nng tht tri v xc nh cc dng ca l TLT. c. Chp MC t th nghing phi, nghing tri v chp MV chn lc l cn thit v t l bt thng ca n kh thng gp bnh nhn Fallot 4 (ch { ng mch lin tht trc). d. Nu c nghi ng shunt t MC - MP cn chp MC xc nh cu trc ny (nh chp chn on cn ng ng mch). V. A. Tin trin t nhin Tm ngy cng tng vi cc hu qu:

1. a hng cu, nguy c gy TBMN, nht l nhng trng hp hng cu nh, s lng hng cu ln hn 7 triu/mm3. Tng hng cu lm thay i cc xt nghim v ng mu v gim tc mu lng. 2. 3. 4. 5. 6. 7. Thng c ngn tay di trng. Hn ch hot ng th lc do thiu xy mn tnh. Bnh nhn rt d b p xe no, hu qu ca shunt phi sang tri. Thay i tun hon mao mch phi. Bnh c tim th pht c th c sau nhiu nm tin trin (10 - 20 nm). Bnh nhn rt d b lao phi do gim tun hon phi.

B. Cn thiu xy: thng xut hin vo bui sng khi ng dy hoc sau gng sc: khc, cu gin, kch thch au, st... Cn thiu xy thng c lp vi mc tm v c th dn n t vong hoc b TBMN. Cn thiu xy thng bt u

bng pha "cng" vi kch thch, khc, tm tng ln v nhp tim nhanh. Sau l pha c ch": da xm v nht, th nhanh v su do toan chuyn ho, nhp tim nhanh vi gim hoc mt ting thi do hp ng mch phi, gim trng lc c. Nu cn qua i, tr s ng v bnh tnh li.

VI. iu tr t chng Fallot A. iu tr d phng: pht hin v iu tr thiu mu thiu st tng i, phng thiu mu hng cu nh ca ph n mang thai. B. 1. iu tr cn thiu xy a tr ln vai hoc cho tr ngi u gi vo ngc.

2. Morphin sulfat 0,1 - 0,2 mg/kg tim di da hay tim bp c ch trung tm h hp, ct cn kh th nhanh, khng nn c gng tim tnh mch m nn s dng ng tim i da. 3. iu tr nhim toan bng natri bicarbonate 1 mEq/kg tnh mch, nhm lm gim kch thch trung tm h hp do toan chuyn ho. 4. Th xy cn hn ch v trong bnh l ny c gim dng mu ln phi ch khng phi do thiu cung cp xy t ngoi vo. 5. Nu khng p ng vi cc phng php trn, c th dng Ketamin 1-3 mg/kg tim TM chm thng c kt qu (gy tng sc cn i tun hon, an thn). Thuc co mch nh Phenylephrine. (Neo - synephrine) 0,02 mg/, Propranolol: 0,01 - 0,25 mg/kg tim TM chm thng lm gim tn s tim v c th iu tr cn thiu xy. 6. Ung Propranolol 2-4mg/kg/ngy c th ng phng cn thiu xy v tr hon thi gian m sa cha ton b. Hot tnh c li ca Propranolol l lm n nh phn ng ca mch ngoi vi. C. Phng vim ni tm mc nhim khun: Nh trong cc bnh tim bm sinh c tm khc.

D.

iu tr ngoi khoa

1. Phu thut tm thi: c ch nh tng ng mu ln phi tr tm nng v khng kim sot c cn thiu xy nhng bnh nhn m phu thut sa ton b kh thc hin an ton v tr nh hay phu thut sa ton b gp kh khn v mt k thut. a. Cu ni Blalock Taussig (ni gia ng mch i n v mt nhnh MP) c th thc hin tr nh. b. Cu ni Gore - Tex: ng Gore - Tex gia ng mch i n v mt nhnh MP. c. Phng php Waterston: ni gia MC ln v MP phi nhng phng php ny khng cn thng dng na do c nhiu bin chng. d. Phu thut Potts: ni gia MC xung v MP cng him khi c s dng. Tt c cc phu thut to cu ni ch phi u c m ngc theo ng bn, thi gian nm vin t 8 - 10 ngy; t l t vong rt thp, bin chng c th gp l trn kh, trn dch v ng chp mng phi; xon vn nhnh ca MP l bin chng lu di c th gp. 2. Phu thut sa ton b: bao gm ng l TLT bng ming v, m rng ng ra tht phi bng vic ct t chc c phn phu, thng t mt ming patch lm rng ng ra ca tht phi. C th m rng vng van MP bng ming patch nu cn thit. Phu thut c thc hin khi 2 nhnh MP v h lu pha xa tt, khng c bt thng MV. Phu thut c thc hin vi tun hon ngoi c th v ng m dc gia xng c. Thi gian nm vin trung bnh t 12 - 15 ngy v t l t vong 1 - 5%. Bin chng c th gp l bloc nh tht cp III, l TLT tn lu, nht l cn hp ng mch phi. 3. Nong van MP: ch p dng trong trng hp hp van ng mch phi, c nguy c gy cn thiu xy nng. Ch ginh k thut ny cho nhng trng hp c chng ch nh phu thut.

E.

Ch nh iu tr

1. T chng Fallot thng thng (MP tt, MV bnh thng, 1 l TLT) c tm nhiu v hng cu hn 6 triu/mm3: phu thut sa ton b bt kz tui no. 2. T chng Fallot thng thng (MP tt, MV bnh thng, 1 l TLT) vi cn thiu xy: phu thut tm thi vi cu ni Blalock-Taussig hoc sa ton b ty theo kh nng ca tng bnh vin. 3. T chng Fallot thng thng: phu thut sa ton b c thc hin mt cch h thng khi tr c t 6 - 9 thng tui. 4. T chng Fallot c bit (hp nhnh MP, TLT nhiu l), bt thng MV v d tt khc): Nu trc 2 tui th c th lm phu thut tm thi (cu ni Blalock). Nu sau 2 tui th ty tng trng hp v kh nng ca bnh vin m quyt nh phng php iu tr thch hp cho tng ngi bnh. F. Sau khi phu thut

1. Nu kt qu phu thut tt thng a bnh nhn tr v cuc sng bnh thng. Khi c hn ch kh nng gng sc th khng nn luyn tp th thao. C th c h van ng mch phi do m rng phu gy tng gnh tm trng tht phi. Theo i hng nm bng siu m tim v Holter in tim c th thy s tin trin ca hp ng mch phi hoc xut hin cc ri lon nhp: ngoi tm thu hoc nhp nhanh tht... Thng xut hin cc ri lon nhp nhng trng hp cn hp MP. 2. Trong mt s trng hp, nht l nhng trng hp MP m qu rng, suy tht phi o tng gnh tm trng nhiu v trong vi trng hp do h van ng mch phi nhiu. 3. Cc bc s tim mch s ngy cng gp nhiu cc bnh nhn b Fallot 4 m, nhng vn cn tn ti hp MP, cn l TLT, hoc h MP nng gy gin bung tht phi, ri lon chc nng tht phi v h van ba l (c nng hay thc th). Thng tim c th c ch nh nu cc bt thng cn nng n c ch nh m li. Ri lon nhp tht cng nh hng nhiu n tin lng xa o cng c

th c ch nh thm in sinh l cc bnh nhn Fallot 4 m sa cha ton b. Ti liu tham kho 1. Connelly MS, Webb GD, Somerville J, et at. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395-452. 2. Cullen S, Celermajer DS, Franklin RCG, et at. Prognostic significance of ventricular arrhythmia after repair of tetralogy of Fallot: a 12-year prospective study. J Am Coll Cardiol 1994;23: 1151-1155. 3. Harrison DA, Harris L, Siu SC, et at. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol 1997;30:13681373. 4. Murphy JG, Gersh BJ, Mair DD, et at. Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot. N Engl J Med 1993;329:593-599. 5. Nollert G, Fischlein T, Bouterwek 5, et at. Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair. J Am Coll Cardiol 1997;30:1374-1383. 6. Yemets IM, Williams WG, Webb GD, et at. Pulmonary valve replacement late after repair of tetralogy of Fallot. Ann Thorac Surg 1997;64:526-530. 7. Neches WH, Park S, Ettedgni JA. Tetralogy of Fallot and Tetralogy of Fallot with pulmonary atresia. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of pediatric cardiology, 2nd ed. Baltimore: Wmiams & Wilkins, 1998:1383-1411. 8. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 9. Redington A, Shore D, Oldershaw P. In: Tetralogy of Fallot. Redingion A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: Mm Saunders, 1994:57-67.

10. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246.11. Moore JD, Moodie DS. Tetralogy of Fallot. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.

S34. CN NG NG MCH
Cn ng ng mch (COM) (TBS) chim khong 10% cc bnh tim bm sinh (1 trong 2000 n 5000 tr s sinh). Dng shunt thng nh v t triu chng lm sng, tr khi c bin chng. Din bin t nhin ca bnh ph thuc vo kch thc ca ng ng mch v mc dng shunt triphi. Nu khng c iu tr c th dn n suy tim huyt do qu ti bung tim tri. Trong thc t rt t gp ng ng mch t ng sau khi tr ra i (tr cc trng hp rt sm) m thng phi ng ng bng phu thut hay ng qua a bng dng c. Nu ng ng mch qu mun m cha c can thip nh ngi trng thnh th c th gp cc ri lon nhp nh cung nh hoc rung nh, vim ni tm mc nhim khun, tng sc cn mch phi c nh (hi chng Eisenmenger). I. Gii phu bnh

A. Thng thng ng ng mch s t ng t gi th 15 n gi th 16 sau khi sinh. Cc yu t thc y vic ng ng ng mch l p lc ring phn ca xy trong mao mch phi tng, gim nng prostaglan ine lu hnh trong mu o tng chuyn ha tun hon phi v do cc hiu ng nhau thai gy ra. Cc yu t ny c th ko di tc dng n ngy th 21 sau khi sinh nhng nu cn thy tn ti ng ng mch sau 3 thng tui th gn nh chc chn ng ng mch

khng th t ng, tr mt s rt him cc trng hp t ng ng ng mch do phnh ng bnh nhn c tui v thng sau vim ni tm mc nhim khun. B. V gii phu, ng ng mch nm quai MC ngay ch chia ra ca ng mch i n tri v c vo thn hoc MP tri. ng ng mch thng c chiu i thay i v c th phi hp vi gin MC khi MC quay phi, ng ng mch c th xut pht t pha trc ni hnh nh soi gng ca thn ng mch khng tn tri hoc t pha sau ng mch i n tri bt thng hoc him gp hn l t quai MC bn tri. II. Sinh l bnh

A. Lung thng ca ng ng mch thng nh, nhng i khi lung thng ln c th gy qu ti phi v tng gnh nh tri, tht tri. Cui cng c th dn n huyt phi v suy tim huyt, tng p MP, hi chng Eisenmenger. B. Rt hay gp hin tng huyt phi, d dn n vim phi v c th gy Osler bt kz loi ng ng mch no. N cn lm gim p lc tm trng ca ng mch ch do hiu ng ca dng pht ngc tm trng. C. Tn thng phi hp hay gp l: Hp MC bm sinh, hp eo MC. Nu c TLT phi hp: c th che lp ting tm trng ca ting thi lin tc do thi tm thu ca TLT qu to. Khi hp eo MC phi hp hp MP: hi chng Rubella. III. Triu chng lm sng A. Triu chng c nng: Cng nh cc bnh tim bm sinh khng tm khc, ng ng mch rt t cc triu chng c nng c hiu. Cc du hiu c th gp l gim kh nng gng sc, kh th... B. 1. Triu chng thc th Nghe tim l du hiu ch yu chn on:

a. Nghe thy c ting thi lin tc cng ln i xng n bn tri. Ting thi ny c th ch c trong th tm thu, hi k o i ra trong th tm trng trong cc trng hp ng ln v c tng p MP nhiu. Ngoi ra c th nghe thy

ting thi nh trong cc trng hp ng nh. tr s sinh, ting thi thng v tr thp v thng ch c th tm thu. b. l. C th nghe thy ting rung tm trng o tng lu lng mu qua van hai

c. Nu lung shunt ln gy tng p MP th c th thy ting thi nh i, khng ko di v c ting th hai mnh ln. 2. Mch ngoi bin ny mnh v chm su, hay gp du hiu ny khi dng shunt tri phi ln. 3. Mm tim xung thp v sang tri do gin bung tim tri. Nu bnh nhn c tng p MP, tht phi s gin vi mm tim sang phi. Chn on phn bit: vi ng-tnh mch phi, ng mch vnh vo cc bung tim bn phi, ng tnh mch h thng, v ti phnh xoang Valsalva, thng lin tht vi h van ng mch ch phi hp, tun hon bng h ch-phi cc bnh nhn thng lin tht vi thiu sn van ng mch phi... IV. Cc xt nghim chn on A. in tm (T): thng khng c hiu, c th thy hnh nh tng gnh bung tim tri vi trc tri v dy tht tri. Ph i tht phi c th thy giai on mun vi tng p MP nhiu. B. Chp Xquang tim phi: tim to va phi vi gin cung i tri. i khi thy du hiu gin cung MP. C th thy gin nh tri vi hnh nh hai b. Hnh nh tng ti mu phi cng hay gp. Phim Xquang c th cho ta thy s b mc nh hng n huyt ng ca bnh. C. Siu m Doppler tim

1. Hnh nh trc tip ca ng ng mch trn siu m 2D thy c mt ct trn c v qua cc gc ng mch ln. o ng knh v nh gi hnh thi ca ng. Siu m Doppler mu xc nh chnh xc v tr vo MP ca ng ng mch. nh gi chnh p qua ng ng mch bng siu m Doppler, t xc

nh mt cch gin tip p lc ng mch phi (cn o huyt p ng mch khi lm siu m tim). Quan st quai MC tm cc tn thng phi hp. 2. Hnh nh gin tip: Gin bung tim tri v MP c th gp trng hp ng ng mch c shunt ln.

Hnh 29-1. Hnh nh ng ng mch: mt ct cnh c trc ngn (hnh tri) v mt ct hm trn c (hnh phi)

Hnh 29 - 2: Hnh nh dng chy qua ng ng mch trong siu m mu 3. nh gi mc ca dng shunt: dng shunt tri phi ln khi thy gin bung nh tri, tht tri v thn MP. Cn nh gi p lc MP tng c nh cha, dy ca thnh tht phi, dng chy qua ng ng mch yu hoc hai chiu, p lc MP tng nhiu gn bng hay vt p lc i tun hon. D. Thng tim

1. Ch nh thng tim: Khi khng thy ng ng mch trn siu m tim mt bnh nhn c ting thi lin tc hoc cn ng ng mch nhng p lc MP tng nhiu trn siu m Doppler tim. Ngoi ra thng tim cn ng ng ng mch qua da bng dng c (Coil, Amplatzer...).

2.

Cc bc tin hnh thng tim:

a. Thng tim phi theo cc phng php kinh in (nh trong thng lin nh): ng thng ln MP thng d dng qua ng ng mch xung MC xung (nu thng tim theo ng TM i n phi s thy hnh ch j kinh in). Nu gp kh khn c th dng dy dn iu khin. Khi ly mu mu cn phi ly on xa ca cc nhnh MP o ng shunt thng chy lch, nn bo ho xy thn v on gn ca MP khng phn nh ng bo ho xy c nh ca MP. Nu c tng p MP nhiu c th s dng cch ng ng ng mch tm thi bng bng v theo di p lc MP trong khi bm bng, nu p lc h xung tt th c th ch nh ng ng ng mch. b. Thm huyt ng:

Thy c bc nhy xy MP. o QP/QS vi bo ho xy on xa ca MP. a s cc trng hp ALMP thng bnh thng, i khi ng ng mch ln c th dn n tng ALMP. Trng hp p lc qu cao c th lm nghim php ng ng tm thi bng bng c l bn (ng thng u c gn bng, on gn u c l bn theo di p lc). Trong hi chng Eisenmenger c s o chiu dng shunt t phi tri, bo ho xy MC xung s thp hn MC ln, lc ny khng cn ch nh ng ng. c. Chp bung tim: bng cch bm trc tip thuc cn quang vo ng ng mch t th ngang 900. Nu nghi ng hp eo MC cng chp MC t th ny. ng ng ng mch cng ng t th ny nhng bm thuc t MC sang MP. V. 1. Ch nh iu tr Ch nh ng ng ng mch l bt buc nu cn dng shunt tri phi.

2. ng bng thuc: s dng prostaglan ine trong cc trng hp tr s sinh (bit c l Indocid 0,2mg/kg c th tim nhc li sau 8 gi). Cn ch l thuc cng c th gy suy thn hoc hoi t rut.

3. ng qua da bng dng c: C th dng coil hay cc loi dng c th h mi khc nh: Amplatzer, Buttone Device, Car ioSeal... Coil thng c ch nh trong cc trng hp ng ng mch kch thc b trn phim chp ( i 4mm). Cn cc dng c khc dc bit l Amplatzer th rt tt cho cc trng hp ng ln, ngn.

Hnh 29-3. ng ng ng mch bng Amplatzer. 4. ng ng ng mch bng phu thut theo ng bn sau ca lng ngc. Hin nay ti Vit Nam vn l phng php iu tr ch yu nhng trong tng lai gn y th ch l phng php c la chn th hai sau khi khng ng c ng qua da hoc khi c cc d tt bm sinh khc phi hp cn phu thut. 5. Phng vim ni tm mc nhim khun cn k o i 6 thng sau khi ng ng bng phu thut hay bng dng c qua ng ng thng. Ti liu tham kho 1. Burke RP, Wernovaky G, van der Velde M, et al. Video-assisted thoracoscopy surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-505. 2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395452. 3. Fisher RG, Moodie DS, Sterba R, Gill CC. Patent ductus arteriosus in adults: long-term follow-up-nonsurgical versus surgical management. J Am Coll Cardiol 1986;8:280284.

4. Harrison DA, Benson LN, Lazzam C, et al. Percutaneous catheter closure of the persistently patent ductus arteilosus in the adult. Am J Cardiol 1996;77:10841097. 5. Ing FF, Mullins CE, Rose M, et al. Transcatheter closure of the patent ductus arteriosus in adults using the Gianturco coil. Clin Cardiol 1996;19:875-879. 6. Mahoney LT. Acyanotic congenital heart disease: atrial and ventricular septal defeczs, atrioventricular canal, patent ductus arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. 7. Moore JD, Moodie DS. Patent ductus arteriosus. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000. 8. Mullins CE, Pagotto L. Patent ductus arteriosus. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins, 1998:1181-1197. 9. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 10. Schenk MH, 0 Laughlin MP, Rokey R, et at. Transcatheter occlusion of patent ductus arteriosus in adult patients. Am J Cardiol 1993;72:591-595

S35. VIM M MNG TIM


Vim m mng ngoi tim nhanh chng dn n p tim v t vong nu khng c chn on v iu tr sm. 1. 1.1 Chn on Lm sng

1.2

St Kh th. au vng ngc . Ph . Gan to. Tnh mch c ni Nghe tim: ting tim m; ting c mng tim giai on ht dch Mch yu. Xt nghim

X quang : Bng tim to , i khi c km hnh nh vim phi, trn m mng phi. 2. 2.1 Soi bng tim : Tim co bp yu. in tim : in th thp , ST chnh, T dt. Siu m : Hnh nh dch trong mng tim. o p lc tnh mch trung ng : Tng cao. Cy mu, cy m mng tim c th c vi khun gy bnh Chc gi khoang mng tim qua ng Macfan ht ra dch c hoc m iu tr iu tr trc m

Khng sinh theo khng sinh , nu nui cy m tnh dng cephalosporin th h th 3 + gentamixin. Li tiu.

2.2

Chc d, dn lu mng tim bng catheter tnh mch trung tm. Ch nh phu thut

Sau 7 ngy k t khi khi bnh nu bnh nhn cn kh th, gan to, siu m cn hnh nh trn dch hoc dy dnh. K thut ng vo : Khoang ngc tri, ng lin sn 5 trc bn. M ca s mng tim ht bt m. Ct mng tim rng ri pha trn n phu ng mch phi, pha i gii phng c mm tim, bn phi n b sau xng c, bn trii n b thn kinh honh. Phi bc c lp mng s bp cht c tim, n khi thy tim p tt. Kim tra hiu qu bng p lc TMT Ra, ly ht cn m v m trong khoang mng tim v khoang phi tri. t dn lu khoang mng phi tri.

Ct mng tim bng ni soi lng ngc Bnh nhn nm nghing 70 . t 3 troca: 1 troca cho ng soi qua lin sn 5 ng nch gia, 2 troca cho dng c phu thut qua lin sn 7 v 3 ng nch trc. Tin hnh ct mng tim nh phu thut quy c. 2.3 iu tr sau m

- Xt nghim : lm li Hb, in gii ,cht kh mu. Chp phi kim tra sau 24 gi. Khng sinh theo khng sinh hoc tip tc bng cephalosporin th h th 3 + gentamixin. Ht lin tc dn lu lng ngc vi p lc 6-8 cm nc cho n khi ht dch. Rt dn lu khoang mng phi khi dn lu khng cn ra ch.

CHNG 4. BNH L H HP
S36. VIM PH QUN PHI
I - I CNG:

1/ nh ngha: L mt bnh nhim khun ph qun v nhu m phi, tn thng vim thng lan ta ri rc 2 phi lm ri lon trao i kh gy suy h hp , bnh tin trin nng dn -> t vong.

2/ c im: - Bnh hay gp tr( c bit l tr < 3 tui), t l t vong cao

3/ Nguyn nhn: 3.1/ Do Vi khun : l NN ch yu. Nhng VK thng gp l: - Hemophilus influenae - Ph cu - Neisseria - T cu (Staphylococcus aureus): MRSA, MISA, MSSA - Lin cu ( Streptococcus pneumoniae): GAS - Klebssiella pneumoniae v cc VK khc. 3.2/ Do Virus: + Nhng Virus trng gp: - Virus hp bo h hp ( Respiratory Syncital Virus) - Virus cm ( Influenzae Virus): AD, AS ti hp to chng mi H5N1 - Virus cm ( Parainfluenzae Virus) - Virus si.

- Virus hch ( Adeno Virus) - Rhino Virus - Corna Virus v cc loi Virus khc.

3/ Nm: - Can i a albicans gy ta li pht trin xung ph qun, phi. - Aspergillus - Blastomyses - Cocidividomyces 4/ K sinh trng: - Pneumocystic carinii gy ph qun ph vim tr em. 5/ iu kin thun li: - thiu cn ( < 2500g) - Tui < 1 tui, tr s sinh - C i d ng - Suy inh ng. - Tr khng c nui ng bng sa m( trong sa m c c y cc thnh phn inh ng nh Protein, Vitamin c bit l cc yu t khng khun nhm tng cng MD cho tr) - Yu t thi tit: lnh, chuyn ma. - iu kin sinh hot, n ung

4/ C ch bnh sinh: 4.1/ ng xm nhp ca Vi khun: - a s VK c sn mi hng lan trn qua ng ph qun gy tn thng nhu m phi. Ngoi ra VK cn xm nhp qua ng mu v bch huyt 4.2/ S lan trn ca tn thng : + Vi khun xm nhp u tin vo ch chuyn vi ph qun sang ph nang ( v y lung khng kh i chm li) +Ti v tr xm nhp VK gy tng thng vim u tin chm ph nang v t VK lan sang t chc phi xung quanh qua cc ng sau:

- ng ph qun: Khi ho, th cc cht tit c VK bt ra ri vo ph qun bn cnh gy nn nhng vim mi - Theo ng bch huyt xung quanh ph qun, ph nang gy lan trn n ch khc v khu tr cc hch rn phi - Tn thng c th khu tr t chc k nu lan trn theo ng mu. 4.3/ Vai tr ca VK v phn ng ca c th: + Vai tr ca VK ph thuc vo tnh cht tng loi VK: - T cu vng c c lc cao c kh nng sn xut men v lm hoi t t chc phi -> gy nn nhiu p xe. - Ph cu gy hc phi nc + Ty theo phn ng c th tng tr: - Nu phn ng c th tr mnh th tn thng c th ch khu tr 1 phn thy hoc thy phi. - Nu phn ng c th yu th tn thng lan trn ri rc lm bnh nng. II - TRIU CHNG:

1/ Giai on khi pht: - C th t ngt vi nhng triu chng ton thn v c nng nng: st cao, kh th, tm ti, ri lon tiu ha. - a s khi pht t t v bt u bng triu chng vim long ng h hp trn: st nh, ho, ht hi, ngt mi, chy nc mi, tr quy khc. 2/ Giai on ton pht: c c hi chng sau: *H/C NTN: St cao ao ng 38-40 ( tr s sinh, non, suy inh ng c th khng st hoc b h nhit ); Tr mt mi, quy khc, mi kh, li bn, ra m hi, chn n, b bBC, N *H/C ph qun: + Ho khan, hoc ho c m i, c khi ho k o i nh ho g + Kh th: th kh kh, cnh mi php phng, u gt g theo nhp th, co rt khoang gian sn; tng tn s th ( > 60l/p tr < 2 thng; > 50 l/p tr > 2-12 thng; > 40 l/p tr 1-5 tui) + Nghe phi: ran m ( to hoc nh ht 2 ph trng), ngoi ra c th c ran rt,

ran ngy tr nh. *H/C suy h hp: + Tr kh th nng, tm ti: Tm ti quanh mi, u chi, li hoc ton thn; tm ti xut hin khi Hemoglobin < 5g/100ml; Ngoi ra tr tm ti cn ph thuc vo cc triu chng ngoi phi: try mch, suy tim *H/C mt nc- in gii: + Tr nn nhiu, i ngoi, ra m hi + Biu hin: kht nc, quy khc, ho nc, DH Gasper(+), vt v kch thch, li b. XN in gii *XQ tim phi: C nt m ri rc, nhiu vng rn phi; t gp xp phi, trn dch mng phi. *XN: - PaO2( < 60mmHg); PaCO2 ( > 50mmHg), Bnh thng: PaO2= 80-90mmHg; PaCO2= 35-45mmHg trong mu ng mch. - pH mu< 7,35( bnh thng pH mu =7,391 0,019), d tr kim( bt= 2225mmol/1HCO3),. PE(-) *Cy VK: dch m III - CHN ON: 1/ Chn on xc nh: - H/C NTN - H/C ph qun - Suy h hp - XQ : C nt m ri rc, nhiu vng rn phi

2/ Chn on phn bit: + Vim ph qun co tht: - BN thng st nh hoc khng st; bnh din bin nhanh-> th kh kh, kh th -> cc triu chng tr nn rm r. - Nghe phi: Ran rt, ran ngy, ran m.

- Dng thuc gin PQ, thuc long m, kh dung, chng vim th cc triu chng ht nhanh. + Vim long h hp trn + Lao. IV - IU TR:

*Nguyn tc iu tr: - Chng nhim khun - Chng suy h hp - B nc, in gii. - iu tr triu chng

1/ Chng nhim khun: C th dng cc loi khng sinh sau: + Benzyl Penixilin + Gentamycin: - Benzyl Penixilin: 100.000-200.000UI/kg - Gentamycin: 7,5mg/kg/24h chia lm 2-3 ln tim IM hoc IV + Chloramphenicol: 100mg/kg ung, IM,IV 4 ln/24h + Cephalosporin: 50-100mg/kg/24h chia lm 2-4 ln tim, IM,IV -> Nghi ng do t cu: + Oxacillin, Cloxacillin Meticillin; 100-200mg/kg/24h ung, IM,IV chia lm 2-4 ln/24h ca th phi hp vi Gentamycin -> Trng hp vim hng do lin cu: Benzathin penixilin ( tim bp tht mt mi uy nht) tr < 5 tui : 600.000 UI tr > 5 tui : 1.200.000 UI

2/ Chng suy h hp: 2.1/ Biu hin lm sng: *Cc triu chng ca tng CO2 mu:

+ Ng g hay hn m. + au u + V m hi. + Tng nhp tim, THA, gin mch ngoi vi. + Th nhanh hoc ngng th, + Th rt, kh kh. + Co rt c h hp ph. + RRPN gim hoc mt *Cc triu chng ca gim O2. + Tm ti. + L ln hay kch thch vt v. + v m hi + Co mch ngoi vi, tng nhp tim, THA + V sau mch chm, h HA. -> Tm li : biu hin ch yu ca suy h hp l kh th v tm ti *Da vo kh th v tm ti ngi ta chia suy h hp ra lm 3 mc : + Suy h hp I: kh th v tm ti khi tr gng sc. + Suy h hp II: kh th v tm ti thng xuyn. + Suy h hp III: kh th v tm ti thng xuyn v c cn ngng th. *Cn lm sng: + Chc nng h hp: - Th tch kh lu thng gim. - VC ( dung tch sng) gim(bt: VC >=80%). - Th tch kh ht vo gim. + Astrup: - pH mu gim( bt=7,3910,019) - PaO2 gim < 60mmHg( bt: PaO2 = 80-90mmHg). - PaCO2 tng > 50mmHg( PaCO2 = 35-45mmHg). - SaO2 gim < 80% ( bt: SaO2=95-97%) 2.2/ Nguyn tc iu tr suy h hp: -Bo m thng kh nhanh chng -Bo m tun hon ti thiu cho cc c quan trng yu -iu chnh tnh trng nhim toan.

*Bo m thng kh: + T th BN: Nm nga u nga ra sau. + Thng thong ming hng: ht sch cht tit mi hng. + H hi thi ngt. + t ni kh qun khi : - C tnh rng nguy kch v suy h hp t trc. - khi xut tit nhiu lm ng - Khi phng php h hi thi ngt khng c kt qu. - Xanh tm dai dng. - Nhp tim qu chm + H hp h tr: bp bng, th my qua ng ni kh qun + Ch nh th my: - RRPN gim hoc mt. - Co ko h hp r. - Xanh tm ( tuy vn th Oxy 40-60%). - thc u m - PaCO2 > 75 mmHg, PaO2 < 50 mmHg. + M kh qun: - Mc ch: Lm tng thng kh ph nang v gim khong cht. - Ch nh: Kh th thanh qun nng( vim ph n thanh qun , d vt thanh qun, bch hu). - Bin chng: T vong t ngt khi m hoc khi ht, trn kh i da, trn kh mng phi; chy mu kh qun; Nhim khun; Ngt th; xp phi + Liu php Oxy: - Ch nh: Kh th v tm ti c lc nm yn; PaO2 < 50mmHg; PaO2 50-70mmHg - Nng Oxy: 100% khi cp cu; Thng thng ch s dng 40-60% - Liu lng: S sinh : 1 lt/pht < 2 tui: 2lt/pht Tr ln: 3 lt/pht. -> Nu ngng th cho tng liu Oxy cao hn. *Bo m tun hon - p tim ngoi lng ngc.

- Dng thuc tr tim - Truyn dch: HTM 0,9%; Ringer lactate; HTN 10%. 50ml/kg/24h; tc 10-15 git/p *iu chanh tnh trng nhim toan: + Xc nh nhim toan da v lm sng v XN kh mu. + X tr: - Phc hi thng kh, liu php Oxy - Thuc chng nhim toan( Bicacbonat natri) - Nu khng c XN kh mu th dng Bicacbonat natri :2-3mEq/kg/24h - Nu c XN kh mu th b theo cng thc: Bicacbonat natri(mEq)= BE x P x 0,3 BE l lng kim ; P l cn nng(kg)

3/ B nc- in gii: + Khi b nc in gii cn ch tc phi chm, lng t, trnh ng phi v gnh nng vi tim. + HTM 0,9% ( 1/3 s lng dch truyn) + HTN 5%, 10% ( 2/3 s lng dch truyn) - liu lng : 50ml/kg/24h tc 10-15 git/p + Nu c hin tng gim K+ ( chng bng): b KCl 1-2mEq/kg + Nu c hin tng toan mu th cp cu kp thi.

4/ iu tr cc triu chng khc: + Co git: - Phenobacbital: 2-3mg/kg/ 1 ln, nhc li 6-8h - Diazepam: 0,5-2mg/kg/24h chia lm 2-3 ln tim TM + St cao th: chm lnh; Paracetamol 10mg/kg/ln + Ho: Dng chanh, qut, mt ong, khng lm dng thuc hng ho, nn cho thuc long m.

5/ Phng bnh: - Bo v sc khe b m , trnh non, suy inh ng cho tr. - B sa m, thc hin ch n sam hp l - Bo m v sinh n ung, v sinh mi trng sng - Khng ht thuc v un bp gn tr. - Thc hin tim phng cho tr ng lch - Cn cch ly vi nhng tr b bnh v ngi nh b bnh. 6/ n tham kho: tr 8 thng Vim ph qun phi: 1.Sentram 1,5mg x 2/3 l TMC s,c 2.Gentamycin 40mg x 2/3 ng TMC s,c 3.Hydrocortyson x 1ml -> Kh dung 4.Ventolin 2,5mg x 1mg-> Kh dung 5.Acemuc 0,1g x 2 gi ung s,c 6.VTM 3B x 2v ung s,c 7.Ringer lactate x 500ml 8.Cho- h l III 7/ Vim ph qun co tht: tr 8 thng tui: 1.Cefotaxim1g x 1l TMC s,c 2.Gentamycin 40mg x 1 TMC s,c 3.Hydrocortyson x 2ml -> Kh dung 4.Ventolin 2,5mg x 2mg-> Kh dung 5. 6.Depersolon 30mg x 2/3 TMC 7.Salbutamol 2mg x 1v ung s,t,c 8.Acemuc 0,1g x 2 gi 9.Cho- HLIII

S37. TRN M MNG PHI

I. I CNG : Trn m mng phi l s tch t m trong khoang mng phi, do nhiu nguyn nhn: vim mng phi, vim phi, phu thut lng ngc, chn thng hoc kt hp nhiu yu t gy nn. Tc nhn gy bnh ch yu l do vi trng, ch yu l Staphylococcus aureus. Trn m mng phi cn phi c chn on v iu tr sm, trnh li di chng . II. CHN ON: 1. Cng vic chn on : a) Hi : St Ho, kh th, au ngc T th nm nghing v bn bnh Tin s bnh l{ trc : vim phi, nhim trng a, vim c b) Khm lm sng : Tm u hiu nhim trng: tng trng, nhit Tm v nh gi mc suy h hp (Xem bi vim phi) Khm tm hi chng 3 gim bn phi bnh. Nu c trn kh km theo, g c vng thp v vang vng cao c) Xt nghim: Cng thc mu Dch mng phi: sinh ha, t bo, soi tui nhum Gram, cy v khng sinh . Cy mu Xquang ngc

Siu m ngc 2. Chn on xc nh: da vo +Hi chng nhim trng. +Khm phi :hi chng 3 gim. + Xquang ngc: m gc sn honh / m 1/2 i phi hoc ton b phi km y lch trung tht v pha i din hoc Siu m ngc: c dch mng phi. + Chc ht dch mng phi: m c hoc vng c thnh phn ch yu l a nhn, soi tui c vi trng hoc cy m ng tnh. 3. Chn on c th : Hi chng nhim trng, khm phi :hi chng 3 gim, Xquang ngc :m gc sn honh / m 1/2 i phi hoc ton b phi km y lch trung tht v pha i din hoc Siu m ngc: c dch mng phi ,Chc ht dch mng phi: dch vng m, tnh cht l dch tit: protein >30mg/100ml; glucose < 40-60mg/100ml; Lactate dehydrogenase (LDH) > 6001000UI/100mL, thnh phn t bo ch yu l a nhn trung tnh >50%; soi ti khng thy vi trng hoc cy m tnh. 4. Chn on phn bit: Lao mng phi: da vo tnh cht dch mng phi: vng chanh, tnh cht l dch tit, thnh phn t bo ch yu l n nhn, c yu t dch t lao; PCR lao/DMP(+); IDR (+). Trn ch mng phi o ng trp: dch c nh sa, nhiu t bo (>70% lympho), m >20g/L, Triglycerides >100mg%). III. IU TR : 1. Nguyn tc iu tr : Khng sinh. Dn lu m sm.

Vt l tr liu. 2. Khng sinh : Khng sinh ban u: bt u sau khi chc d mng phi v c kt qu soi ti: - Nu soi ti thy cu trng Gr(+) hnh chm; hoc kt qu soi ti () hoc chc khng ra dch ngay bt u KS chng t cu: Oxacillin + Gentamycin. - Nu soi tui thy Bacille Gr(-) bt u Cefotaxim +Gentamycin - Nu chc ra m thi, nghi ng ym kh: phi hp thm Metronidazole. nh gi sau 1 tun iu tr : - Din tin tt: ht st, ht kh th, lng m ra ng dn lu gim, Xquang phi gim tip tc KS cho 3-4 tun: 2 tun u Oxacillin TM + 2 tun sau Oxacillin ung hoc 2 tun u Cefotaxim TM + 2 tun sau Peflacine ung . - Din tin khng tt: cn st, ng dn lu mng phi ra m ko di, Xquang phi khng ci thin: da vo kt qu cy m mng phi v khng sinh quyt nh khng sinh; i vi t cu i sang Vancomycin TM. 3. Dn lu m : Ch nh: - Dch rt ra l m c - Dch vng c (ch yu l a nhn , soi ti c vi trng), lng nhiu.

Sn sc ng dn lu (ODL): c th ht ODL qua h thng dn lu kn vi p lc 20 n -30cm H2O. H thng ny nht thit phi thp hn ngc ngay c lc di chuyn hay ngh ngi. trnh nght ODL khi m qu c c th bm ra ODL hng ngy hoc mi 2 ngy bng nc mui sinh l. Ch nh rt ODL: cng sm cng tt, khi b - Th tr li bnh thng, n ng tt, khng st. - Khm lm sng thng kh tt. - Xquang hoc siu m khng cn dch. - ODL thng v khng cn ra m (ch ra khng qu 1ml/kg dch trong 1ngy) Thi gian t ODL trung bnh 3-7 ngy . Ch nh can thip ngai khoa: khi c cn vch ha hoc di chng dy dnh nng n. Ngy nay c khuynh hng can thip ngai khoa sm khi sau 3-7 ngy m lng m cn nhiu. 4. Tp vt l tr liu: thc hin 1 ngy sau khi t ODL mng phi v ko di t nht 3 thng. Mc ch tp sm m thot ra ngoi d ng hn v phng dy dnh mng phi v sau. K thut tp nhm : - Gip thng kh tt, th su gin n ph nang - Hot ng ca c lin sun, c honh thot m qua ODL nhanh v trnh c dy dnh. 5. iu tr triu chng v h tr : Cho paracetamol nu c st cao. Dinh ng: ch n giu Calori.

Oxygen liu php khi c suy h hp. iu tr shock nhim trng nu c. IV. THEO DI V TI KHM : Bnh nhn m mng phi c t ODL c iu tr ti tiu 3 tun l, nu din tin tt xut vin v ti khm mi 2 tun trong thi gian 2 thng hoc sm hn nu bt thng. Khi xut vin cn hng dn b m t tp vt l v ch dinh ng cng nh theo i nh.

S38. NHIM KHUN H HP CP TNH


I - I CNG:

1/ nh ngha: Nhim khun h hp cp tnh( NKHHCT) l qu trnh vim cp trong ng h hp, thng do vi khun hoc virus gy nn.

2/ c im: - NKHHCT l 1 trong 3 nguyn nhn chnh gy t vong tr em < 5 tui. - NKHHCT C t l mc bnh cao v ti din nhiu ln trong nm.

II - NGUYN NHN:

1/ Do Virus: + L nguyn nhn ch yu + Nhng Virus trng gp:

- Virus hp bo h hp ( Respiratory Syncital Virus) - Virus cm ( Influenzae Virus): AD, AS ti hp to chng mi H5N1 - Virus cm ( Parainfluenzae Virus) - Virus si. - Virus hch ( Adeno Virus) - Rhino Virus - Corna Virus v cc loi Virus khc.

2/ Do Vi khun : Nhng VK thng gp l: - Hemophilus influenae - Ph cu - Neisseria - T cu (Staphylococcus aureus): MRSA, MISA, MSSA - Lin cu ( Streptococcus pneumoniae): GAS - Klebssiella pneuumoniae v cc VK khc.

3/ Nm: - Can i a albicans gy ta li pht trin xung ph qun, phi. - Aspergillus - Blastomyses - Cocidividomyces

4/ K sinh trng: -Pneumocystic carinii gy ph qun ph vim tr em. 5/ iu kin thun li: - thiu cn ( 2500g) - Suy inh ng. - Tr khng c nui ng bng sa m( trong sa m c c y cc thnh

phn inh ng nh Protein, Vitamin c bit l cc yu t khng khun nhm tng cng MD cho tr) - Yu t thi tit: lnh, chuyn ma. - iu kin sinh hot, n ung

III - PHN LOI:

1/ Phn loi theo v tr gii phu(v tr tn thng): - Nhim khun ng h hp trn( tn thng pha trn np thanh qun). hay gp v thng nh, bao gm: cm lnh, ho, vim tai gia, vim mi-hng, Amidal(AV). - Nhim khun h hp i( cc tn thng i np thanh qun), t gp nhng thng nng, bao gm: vim thanh qun, kh qun, tiu ph qun v vim phi

2/ Theo mc nng, nh( Theo WHO): - Mc nh(khng vim phi): ch c du hiu vim long ng h hp ( ho, st,chy nc mi, khng kh th) - Mc va (c vim phi): C thm du hiu kh th. - Mc nng ( vim phi nng): Khi tr c mt trong cc du hiu7 nguy him sau: Rt lm lng ngc, khng ung c, co git, ng li b, th rt khi nm yn, suy inh ng nng. xy ra tr nh < 2 thng, c du hiu b b, h nhit , th kh kh IV - IU TR:

3/ S dng khng sinh trong NKHHCT tr : 3.1/ Khng sinh tuyn 1( Vim phi nh): - Amoxicilin 50-100mh/kg/24h x 5-7 ngy hoc - Roxithromycine 4-8mg/kg/24h - Spiramycine 150.000-300.000v/kg/24h 3.2/ Khng sinh tuyn 2 ( vim phi nng bnh vin) C th s dng mt trong cc phc sau: + Benzyl Penixilin + Gentamycin - Benzyl Penixilin: 100.000-200.000UI/kg - Gentamycin: 7,5mg/kg/24h chia lm 2-3 ln tim IM hoc IV + Chloramphenicol: 100mg/klg ung, IM,IV 4 ln/24h + Cephalosporin: 50-100mg/kg/24h chia lm 2-4 ln tim, IM,IV + Oxacillin, Cloxacillin + Gentamycin ( nu nghi ng do t cu). 3.3/ Trng hp vim hng do lin cu: Benzathin penixilin ( tim bp tht mt mi uy nht) tr < 5 tui : 600.000 UI tr > 5 tui : 1.200.000 UI

4/ Phng bnh NKHHCT: - B sa m sau sinh cng sm cng tt, cho tr n sam ng. - Gi m cho tr v ma ng, khi tray i thi tit. - Khng nn un bp, ht thuc l gn tr. - C chng trnh hng dn chm sc cho b m v cch pht hin, chm sc nui ng.

S39. SUY H HP S SINH

- Suy h hp l mt hi chng rt hay gp trong thi kz s sinh, nht l tr non (hu ht cc tr i 28 tun v khong 40% tr 34 tun b suy h hp do bnh mng trong), c bit thng xy ra trong nhng ngy u sau . T vong v suy h hp ng hng u ca t vong s sinh. Nu khng t vong tr s sinh suy h hp nng cng s d b nhng di chng v tinh thn kinh nng n. 1. nh ngha v sinh l bnh ca suy h hp 1.1. nh ngha Suy h hp l s ri lon nng n vic trao i oxy mu vi s gim tht s p lc ring phn ca kh oxy trong mu ng mch (PaO2 < 60 mmHg), p lc ring phn ca kh cacbonic tng (PaCO2 > 50 mmHg). 1.2. Sinh l bnh - Suy h hp s sinh biu hin s khng thch nghi ca phi; tr s sinh khng t cung cp c oxy bng 2 phi ca mnh lc ra mi trng bn ngoi. Ngay sau sinh hoc sau mt thi gian vi gi n vi ngy tr s sinh xut hin suy h hp khi khng c kh nng thch nghi ca cc c quan c lin quan; l h h hp, tun hon, thn kinh, chuyn ha. Sau khi ra i h h hp vi phi bt u hot ng biu hin nhp th u tin; duy tr hot ng h hp cn to c dung tch d tr c nng bo m s trao i kh lin tc gia cc ph nang v cc mao mch, ng thi sc cng b mt cn ph v (nh Surfactant) ph nang khng b xp. - Mun cho s trao i kh phi tt h tun hon phi bo m cung cp y cht lng mu qua phi, to s thng bng gia thng kh v tun hon. S thch nghi ca phi s sinh cn cn s phi hp ca h thn kinh trung ng ( duy tr ng tc th v iu ha nhp th) cng nh tnh trng nng lng do chuyn ha c th cung cp. Bt kz mt thng tn bnh l no, mt s khng hon chnh no ca cc c quan quan trng ny u dn n suy h hp. 2. Nhng du hiu lm sng 2.1. Ba du hiu chnh 2.1.1. Ri lon tn s th - Th nhanh 60 ln / pht. - Th chm < 30 ln / pht ( khi b tc nghn ng th hay giai on kit sc). - Th khng u vi cn ngng th >15 giy ti din hay th nc.

2.1.2. Du th gng sc Nhng du hiu ca s gng sc th c th hin bi ch s Silverman vi nhng triu chng sau Bng im ch s Silverman im Di ng ngc bng 0 1 2

Cng chiu Ngc t i ng Ngc chiu Va Va Va Mnh Mnh Mnh

Cnh mi php phng Khng Rt lm hm c Co ko lin sn Ting rn Khng Khng Khng

Qua ng nghe Nghe bng tai

- Tng s im bnh thng = 0 im - Suy h hp nh: < 3 im - Suy h hp va: 3 - 5 im - Suy h hp nng: > 5 im Nh vy qua tng s im ca ch s Silverman gip nh gi c mc suy h hp. Trong nhng pht u tin (1, 5 pht) sau ca tr s sinh, mc ny c th hin bng ch s Apgar. Bng ch s Apgar im Nhp tim Nhp th 0 Khng c Khng th 1 2

<100 ln/pht >100 ln/pht Yu, khng u Tt, khc to

im Trng lc c

0 Mm nhn

1 Co gp c t

2 Co gp tt Ho, ht hi Hng ho

p ng vi kch thch Khng p ng Nhn mt Mu da Xanh ti Tm chi

Tng s im: - Bnh thng: > 7 im. - C ngt: 4 - 7 im. - Ngt trm trng: 0 - 3 im. 2.1.3. Tnh trng tm Biu hin tm c th khu tr (mi, u chi) hay ton thn, kn o hay r rng, lin tc hay thong qua. 2.2. Cc du hiu khc Ngoi 3 biu hin trn cn cn hi v khm y v cc c quan sau - H hp: C ho; nhn nghe phi tm s bt cn xng, r ro ph nang, c ran. - Tun hon: Mch ngoi bin, huyt p, thi gian y mao mch, v tr ting tim r, nhp tim, nghe ting thi. - Tiu ho: B b, phn; nhn bng chng hay lm, s gan, lch to. - Thn kinh: Li b, kch thch, gim hay tng trng lc c, c ng bt thng, co git, hn m. - Th tch nc tiu... 3. Cc xt nghim cn lm sng - o kh mu : pH (< 7,1 - 7,2); PaO2 (< 60mmHg); PaCO2 (> 50mmHg). - ng mu, in gii , CRP. - Cng thc mu, tiu cu. - c bit l chp X quang lng ngc. - Ngoi ra cn lm cc xt nghim chn on nguyn nhn nh siu m qua

thp trong xut huyt no mng no... 4. Chn on theo nguyn nhn chnh 4.1. Nguyn nhn ti phi 4.1.1. Bnh mng trong - y l mt hi chng hoc do thiu s lng v s trng thnh ca t bo phi (t bo sn xut ra cht surfactant) hoc o stress nh ngt, gim th tch tun hon, toan mu, h thn nhit, h ng mu, m dng thuc an thn, xut huyt m gy cn tr sn xut cht surfactant ca t bo phi. - Thng th tr c tin s suy thai. Bnh mng trong hay gp tr non hn tr thng, ch yu xy ra tr cn nng lc sinh 1000 - 2000gr, tn sut mc bnh t l nghch vi tui thai v cn nng lc sinh. Nu l song thai th tr th 2 d b hn tr u. - Lm sng biu hin bng th nhanh, ting rn thi kz th ra, cnh mi php phng, co rt hm c - lin sn v tnh trng tm r. Biu hin ton b du hiu lm sng xy ra trong vng 6 - 12 gi sau khi sinh. Th nhanh, c khi ln qu 100 ln/pht l c im ca bnh mng trong. Ngoi ra c th thy ph bn tay, bn chn. - Tr cn phi th oxy vi FiO2 50 - 60 % mi c th m bo PaO2 > 50 mmHg. Toan h hp xy ra o tng PaCO2 hoc b ngng th, lc ny cn phi th my. - Bnh mng trong khng ngh n nu bnh nhi khng cn th oxy trong giai on 24 gi u sau sinh. - Hnh nh X quang c bit vi 3 giai on + Giai on 1 : Kh vo ph nang km v th kh ph qun to hnh nh kh cc nhnh ph qun. + Giai on 2 : Rt nhiu ph nang b xp, kh khng vo c to hnh nh lm tm m nhng ht mn. ng thi cc t chc k b ph n to hnh nh li. + Giai on 3 : Kh khng vo c ph nang, phi b xp hon ton to hnh nh m u nhu m, c th c 2 phi, kh phn bit vi tim. 4.1.2. Hi chng ht nc i, phn su - Ht phn su, nc i hay xy ra tr thng hoc tr gi thng (chim 5% dch i nhum phn su) b ngt do suy thai hay thiu mu rau thai nn xut hin ng

tc th u tin trc khi sinh ra, gy tc ng th bi phn su, nc i. Nguyn nhn gp nhng trng hp kh, chuyn d ko di, ri lon cn co t cung. - Triu chng lm sng vi ri lon h hp ngay sau sinh, ch s Apgar thp, ming c nc i ln phn su, phi nghe c ran hoc r ro ph nang km khi b xp phi. - Trn X quang cho thy hnh nh nh xp phi, c phi v kh ph thng. Trng phi c th tng sng vi tng ng knh trc sau. C th c trn kh trung tht v kh ph thng k. - Tr c rt nhiu nguy c b vim phi. 4.1.3. Vim phi - Tc nhn c th l vi khun (lin cu, E.coli, Listeria...) hoc virt; do ly nhim trc, trong hay sau sinh. - Vim phi do lin cu nhm B c th lm vi bnh mng trong. C tin s v i sm (tn sut nhim trng tng cng vi thi gian v i) hay m b st. Triu chng khi u vi gi sau sinh vi rn , du gng sc v tm. - X quang vi hnh nh thm nhim khng i xng vi tng sng phi hoc nu c trn dch mng phi hay trn dch k gip chn on vim phi do lin cu nhm B. Nhim khun s sinh cn phi nghi ng khi tr c cc d kin m hoc c cc biu hin lm sng nh vng a, cng b, gan lch ln. Xem trc tip dch d dy hay dch kh qun s thy bch cu b thoi ha. 4.1.4. Cn kh th nhanh thong qua - Bnh c th tr non hay thng, chim 1 - 5% tr s sinh; thng gp tr m , tr b ct rn mun, m dng thuc qu nhiu, m tiu ng. Nguyn nhn do chm hp thu cht dch ph nang. - Biu hin lm sng xy ra mt thi gian ngn sau khi sinh vi th nhanh n thun hay c th km theo rn , cnh mi php phng, co rt hm c - lin sn v tm nh. Tn s th c th ln n 80 - 140 ln/pht, ng knh lng ngc trc - sau tng. - X quang phi sm cho thy hnh nh m lan ta hay khu tr. Vi gi sau c th

c hnh nh vim phi k, vim rnh lin thy hay trn dch mng phi, phi tng sng ngoi bin. - Tin lng thng tt trong vng vi gi. Bnh n nh sau 48 gi. 4.2. Nguyn nhn ngoi phi 4.2.1. Cc bnh tim bm sinh - Khong 1% tr sinh sng. - Nhng bnh tim bm sinh c tm: Chuyn gc mch mu ln, tnh mch phi tr v bt thng, t chng Fallot, hp ng mch phi, teo van 3 l... - Nhng bnh tim c suy tim : Gim sn tim tri, hp ng mch ch, nhp nhanh trn tht... 4.2.2. Cc d tt bm sinh khc - Thot v c honh:Vi 80% xy ra bn tri, biu hin ngay lc mi sinh bng du suy h hp nng km ngc g ln, bng lm v nghe ting tim r bn phi. Trn X quang c hnh nh hi ca rut trong thot v c honh tri hay hnh nh m u (gan) trong thot v c honh phi. i khi thot v c honh c th c biu hin t nng hn ngay c khi thot v bn tri o n c honh hay o lit c honh v chn thng sinh . - Teo thc qun km theo l d kh-thc qun: Khong 1/3000 tr sinh sng.Biu hin bng du n cht xut tit ming, tr tm ti v vt v tng lc. t ng sonde d dy thy u ng cun li. X quang c cn quang ng tiu ha c th thy ti cng ca ch teo. - Hp l mi sau: Tr hng khi khc, tm khi ng v c bit tm kh th khi b. t son e mi 2 bn s thy khng a vo c. 4.2.3. Cc bnh l thn kinh Xut huyt no mng no, thiu oxy no, ph no, vim mng no m... u c th gy c ch v ri lon h hp. Ngoi suy h hp tr c nhng biu hin bt thng v thn kinh nh co git, thp phng, tng trng lc c... 4.2.4. Cc bnh l chuyn ha Tng, h ng mu, tng, h cc cht in gii, h thn nhit... c th l nguyn

nhn tin pht hoc th pht ca suy h hp. Ch cc nguyn nhn gy suy h hp c th ring l hoc phi hp bnh l. 5. iu tr 5.1. iu tr cp cu 5.1.1. Phng php tng qut - Khai thng ng th + T th nm nga c + Ht dch hu hng - t ng thng d y ht lm rng d dy. - iu ha thn nhit: Tr c nm bn si m hoc lng knh, nhit ty theo cn nng duy tr thn nhit n nh 36,5 370C. 5.1.2. Oxy liu php - Ch nh: S dng sm khi tr bt u c biu hin kh th, khng i tm. Tr cn c cung cp oxy khi PaO2 < 70mmHg. - Nguyn tc + Bo m oxy c trn ln kh tri, c lm m v m. + Nng oxy cho thch hp ty thuc mc nh nng ca bnh: t 30 - 40% cho n 100% nu tm nhiu. Khi tr ht tm c th gim dn FiO2 xung cn 21% (kh tri) nhng sao cho PaO2 vn t 70 - 80mmHg. - Cch cung cp oxy + Lu, mt n hay ng thng mi (1 mi hay 2 mi) nu tr t th c. + Thng kh h tr (th p lc ng lin tc hay th my). Nng oxy (FiO2) thay i theo cc dng c cung cp v lu lng oxy (lt/pht) Lu lng oxy 100% (lt/pht) FiO2( % ) ng thng 1 mi 0.125 0.250 25-26 30-32

Lu lng oxy 100% (lt/pht) FiO2( % ) 0.500 0.75 1 ng thng 2 mi 0,25 0.50 0.75 1 Lu 5-8 8-12 Mt n 6-8 40-44 50-56 60-63 30-35 40-45 60 56 28-40 40-85 40-60

5.1.3. Duy tr nng lng, nc, in gii Duy tr nc, in gii v nng lng duy tr huyt ng bng ng tnh mch bo m nhu cu nng lng: 130 - 140 kcal/kg/ngy ( non), 120 kcal/kg/ngy ( thng) vi dung dch glucose 10% 60 - 80ml/kg/ngy. 5.1.4. Chng toan mu - Nu suy h hp ko di hoc nng, bn cnh PaO2 gim v PaCO2 tng thng c toan mu pH < 7,2, cn tim tnh mch Bicarbonat theo cng thc sau S mEq cn b = 0,3 x P x s Bicarbonat thiu - Nu PaCO2 > 70mmHg nn cho thay bng dung dch THAM (Trihydroxyl methyl amine) vi s lng tng t, cn pha cng dung dch glucose 10 - 20%.

5.1.5. Chng nhim trng Cho khng sinh phi hp Ampicillin v Gentamycin, 5 - 7 ngy. 5.2. iu tr nguyn nhn - Ni khoa + Nhim trng phi: liu php khng sinh. + Ht nc i: t ni kh qun ht sm. + Bnh mng trong: dng Surfactant. - Ngoi khoa: c bit cn phu thut cp cu cc nguyn nhn d tt thot v c honh, teo thc qun bm sinh... Ch nhng im sau - iu tr kt hp chm sc phi bo m nguyn tc thn nhit n nh, sa m (khi c th) v v khun. - Chuyn ln tuyn trn c iu kin, c phng tin chm sc khi vn chuyn bo m nguyn tc an ton. 6. Phng suy h hp s sinh 6.1. i vi m - Trc + Hng dn cho sn ph bit nng cao th trng. + Gio dc v sinh thai nghn v qun l{ thai ngh n; c bit cc sn ph c nguy c cao. + Pht hin v iu tr cc nguyn nhn gy non, suy inh ng bo thai, suy thai, ngt chu sinh ... - Trong + Trnh lm dng thuc gim au, ch nh qu mc dch nhc trng v oxytocin. + Gip m th tt khi chuyn d, hn ch xut huyt. + Trnh kp rn mun. - Sau + M v gia inh bit cch chm sc v theo i tr.

6.2. i vi tr - Bo m chm sc v nui ng + Ht sch dch hu hng cn thn trc khi nhp th u tin bt u. + Tr c lau kh, gi m, bo m thn nhit n nh ngay sau . + Tr c cho b m sm v . + Bo m khu v trng, c bit ti bnh vin. - Bo m theo di: kp thi pht hin biu hin suy h hp. + Nhng tr c nguy c cao u c theo i st ngay sau v chuyn ln tuyn trn bo m nguyn tc vn chuyn an ton. + Tr s sinh cn c khm y v chi tit trong vng 96 gi u sau . Ti liu tham kho 1. Nguyn Quang Anh (2001), Hi chng suy h hp cp tr s sinh, Bi ging Nhi khoa- Trng i hc Y khoa H Ni , I, tr. 155 - 170. 2. Huznh Th Duy Hng (1997), Hi chng suy h hp tr s sinh, Bi ging Nhi khoa -Trng i hc Y Dc thnh ph H Ch Minh , 1, tr. 311 - 354. 3. Barbara J. Stoll, Robert M. Kliegman (2000), Respiratory Tract Disor ers, Textbook of pediatrics - Nelson's 16th edition, p. 496 - 510. 4. Eric C. Eichenwal (1998), Meconium Aspiration, Manual of neonatal care 4th edition,p. 388 - 392. 5. Helen G. Liley, Ann R. Stark (1998), Respiratory Distress Syn rome, Manual of neonatal care - 4th edition, p. 329 335.

S40. HO G
I. NH NGHA: Ho g l bnh nhim trng ng h hp do vi khun Bordetella pertussis v B. parapertussis gy ra. Bnh thng nng tr i 3 thng tui hay cha c chng nga.

II. CHN ON: 1. Cng vic chn on: a) Hi bnh Tip xc vi ngi b ho ko di nht l tr nh (ho > 2 tun) Chng nga ho g. Co git b) Khm lm sng Ho thnh cn kch pht, sau cn c ting rt, thng km mt, nn i Tr nh nhi < 3 thng thng khng c cn ho, thay vo ho thng km vi ngng th hoc ngng th tm ti xy ra m tr khng ho. Du hiu vim phi Xut huyt i kt mc hay vng quanh hc mt. Ri lon tri gic, co git: khi nghi ng c bin chng no. c) Cn lm sng Cng thc mu X Quang phi: khi nghi ng c bin chng vim phi Siu m tim: tr i 3 thng hoc khng loi c tim bm sinh tm. Tm khng nguyn IgG , IgM cha thc hin c. Cy phn lp vi trng ho g: t l ng tnh rt thp. 2. Chn on xc nh: Lm sng c biu hin nghi ng ho g v cy phn lp vi trng (+) 3. Chn on c th: Cn ho in hnh: ho cn, mt, nn i ko di > 10 ngy Bch cu mu tng a s lympho, vi s lng lympho > 10.000/ mm3 4. Chn on phn bit: Vim tiu ph qun (xem bi vim tiu ph qun) Vim phi (xem bi vim phi) Tim bm sinh tm: tr < 3 thng, siu m tim Vim hng mn tnh: thng ho khan k o i nhng khng thnh cn in hnh, khng c biu hin suy h hp. III. IU TR : 1. Nguyn tc iu tri: iu tr suy h hp nu c.

Khng sinh iu tr c hiu. iu tr bin chng Chm sc v iu tr h tr. 2. iu tr ban u a) X tr cp cu: iu tr suy h hp: (xem bi suy h hp) Khi tr ho kch pht, cho tr nm sp, u thp hoc nm nghing nga ht cht nn v gip tng m ra ngoi. Nu tr c cn tm, lm sch cht tit t mi hng bng cch ht m nh nhng v nhanh chng (ch { khi ht m c th gy kch thch lm tr tm ti). Nu tr ngng th, lm thng ng th ngay bng cch ht m nh nhng v nhanh, gip th bng mask, cho th oxy. Th oxy qua canulla: tr c cn ngng th hoc tm ti hoc ho kch pht nng. Khng ng catheter mi v c th kch thch gy ho. Kh ung Natri chlorua 0,9%. b) iu tr c hiu: Khng sinh: Erythromycin ung (12,5 mg/kg x 4 ln /ngy) trong 10 ngy. Thuc khng lm gim thi gian bnh nhng gim thi gian truyn bnh. Khi c bin chng vim phi iu tr nh phc vim phi. c) iu tr h tr: H st: paracetamol. Khuyn khch tr b m hoc ung: ch khi cho tr b hay ung cn cho chm v khi cho nhanh c th gy ht sc gy tm ti hay gy khi pht cn ho. Bo m lng dch nhp: dng lng dch t, nhiu ln, theo nhu cu dch ca tr d) Theo di : Tr < 6 thng: nn cho tr nm ging gn vi phng ca iu ng, ni c sn oxy, c th pht hin v x tr sm ngng th, tm ti hoc cc cn ho nng. Hng dn b m nhn bit du hiu ngng th v bo ngay cho iu ng.

S41. BNH VIM TIU PH QUN TR EM


Vim tiu ph qun (VTPQ) l bnh vim nhim cp tnh ca cc ph qun kch thc nh, c ng knh < 2 mm hay cn gi l cc tiu ph qun. Thnh ca cc TPQ ny khng c sn ch c c trn nn b co tht, xp li khi b vim. VTPQ l bnh ch xy ra tr < 24 thng tui, thng gp nht l 3-6 thng tui. Khi mc bnh, cc PQ nh ny b vim, sng ph, tit nhiu dch lm cho ng th ca tr b cht hp thm ch tc nghn. V vy, tr s b kh kh, kh th v nng hn na tr s b thiu oxy th. Nguyn nhn: Bnh do virt h hp gy ra, m hng u l loi virut c tn vit tt l RSV. Virt ny c 2 im c bit: 1. C kh nng ly lan rt mnh nn bnh c kh nng xy ra thnh dch. 2. Ngi ln, tr ln cng c th b nhim RSV nhng biu hin thng nh, ch nh cm ho thng thng. Nhng nu tr < 2 tui b ly nhim c th biu hin i dng nng l VTPQ. Bnh c th c quanh nm nhng thng l vo ma ma (cc tnh pha Nam), hay ma lnh (cc tnh pha Bc). Tm quan trng: VTPQ l nguyn nhn hng u ca cc trng hp nhim trng h hp nng tr nh c bit l cc nc u - M v bnh c kh nng tr thnh dch ln. Hoa Kz: 120.000 tr nhp vin v VTPQ/1 nm. Vit Nam: hin nay VTPQ c quan tm nhiu hn v tht s l bnh ph bin tr < 2 tui. Ti BV.Nhi ng 1 hng nm c 5.000 - 6.000 trng hp n khm ti phng khm h hp v VTPQ, VTPQ cng l nguyn nhn nhp vin hng u ti khoa h hp (40%, khong hn 2500 tr nhp vin/nm o VTPQ). Triu chng:

Thng tr s c triu chng cm trong 2-3 ngy u (st nh, ho, s mi). Sau , tr ho nhiu hn km kh kh v c th b kh th (th nhanh hn, th co ko lng ngc). Nng hn na tr c th b b, tm ti. Bnh c triu chng tng t suyn. Cn phi c BS thm khm c chn on chnh xc. Din tin: Thng thng, tr s kh kh ko di khong 7 ngy, ho gim dn trong khong 14 ngy ri khi hn nu c chm sc tt. Tuy nhin, trong khong 1/5 trng hp, bnh c th ko di nhiu tun l. Bin chng thng gp ca bnh l suy h hp, vim phi (do d b nhim thm vi trng), xp phi (do tc m), vim tai gia. Khong 1-2% tr cn phi nhp vin v kh th, thiu oxy. Cn lu { l bnh c th s nng hn, k o i hn, nhiu bin chng hn v t vong cng cao hn trong cc trng hp sau: tr i 3 thng tui, tr sanh non - nh cn, tr suy inh ng nng, tr c sn bnh tim, phi, suy gim min dch. y l nhng tr c coi l c yu t nguy c cn c cho nhp vin sm khi b VTPQ. Ngoi ra, bnh cng c kh nng ti pht. Gn y, ngi ta cng chng minh c mi lin quan ca VTPQ vi bnh suyn. Sau khi b VTPQ, ng th ca tr s tr nn nhy cm hn v khong 1/3 tr b VTPQ din tin thnh suyn sau ny. iu tr: Tr cn c nhp vin trong cc trng hp sau: - Tr c du hiu nng: kh th, b km, tm ti - C bin chng: suy h hp, vim phi, xp phi - Tr c yu t nguy c (nh nu trn) Ngoi ra, cc trng hp VTPQ nh, khng c bin chng, tr khng c yu t nguy c th c th c chm sc ti nh.

Chm sc ti nh: 1. Tip tc cho tr b hay n ung y . C th chia nh thnh nhiu c b, ba n tr b nn i khi ho nhiu. Cn cho tr ung nhiu nc trnh thiu nc (th thiu nc s lm m tr nn c c lm bnh nng hn). Ung nhiu nc s gip tr long m, u ho. 2. Cn lm thng thong mi cho tr gip tr d th hn v b tt hn. C th nh mi vi 2-3 git nc mui sinh l{ sau lm sch mi cho tr. 3. Cn cho tr dng thuc ng nh ch dn ca thy thuc. Khng nn t cho tr ung thuc v nu ng khng ng c th lm tr bnh nng hn hay c th c tc dng c hi nht l tr nh. 4. Trnh khi thuc l: khi thuc l c th lm tr s tr nng v d b suyn sau ny hn. 5. Cn i ti khm ng hn theo li khuyn ca thy thuc v ch pht hin nhng du hiu cn cho tr i khm li ngay. Khi no cm a tr n bnh vin ngay? Cn a tr n bnh vin ngay nu tr c mt trong nhng du hiu sau: - Tm ti - Tr b km, b b, khng ung c - Tr ng li b, kh nh thc - Th kh khn (th nhanh, th co ko lng ngc) Phng nga: Hin nay, thuc phng nga c hiu cn rt t tin v cha c VN nn bin php phng trnh ch yu l: - Trnh cho tr tip xc gn gi vi tr ln, ngi ln ang b cm lnh cng nh cc tr bnh khc.

- Cn ra tay sch s trc khi chm sc tr (v virt gy bnh ly lan ch yu qua vic tip xc trc tip). Tm li: VTPQ l 1 bnh l ph bin cn c quan tm ng mc tr nh i 2 tui. Tuy nhin, y khng phi l bnh ch lin quan n tr nh ang trong la tui cn b ny. Vic chm sc ng cch ca ngi ln, ca cc bc cha m s gp phn gip tr trnh c bnh, cng nh hi phc tt hn.

S42. TRN DCH MNG PHI


I.I CNG: Trn dch mng phi (TDMP) l s c mt bt thng ca dch trong khoang mng phi. Bnh thng khoang mng phi l khoang o, lng dch trong khoang mng phi khong 0,1 - 0,2ml/kg cn nng. II. CHN ON: 1. Cng vic chn on: a. Hi: St, ho, kh th, au ngc. Tin s bnh l{ trc : vim phi, tip xc lao, chn thng ngc b. Khm lm sng: Tng trng, nhit , cn nng. nh gi mc suy h hp. Khm v tm hi chng 3 gim. Khm hch ngoi bin (nghi ng lao hay bnh c tnh). c. Xt nghim: Cng thc mu X quang ngc Siu m ngc Phn tch ch mng phi: sinh ha, t bo, vi trng, PCR tm lao (nghi ng

lao), cell block hay ha m min dch (nghi ng bnh c tnh) VS, IDR Sinh thit mng phi 2. Chn on xc nh: a. Chn on co trn dch mng phi: Da vo: Khm phi c hi chng 3 gim XQ phi: c hnh nh trn dch Siu m ngc: c dch Chc d mng phi ra dch b. Chn on tnh cht trn dch: phn bit dch thm hay dch tit da vo phn tch dch mng phi:

3. Cc tnh hung lm sng thng gp: a. Vim m mng phi: Hi chng nhim trng. Dich mng phi c nh m, hoc dch m l dch tit. Thnh phn t bo ch yu NTT, soi ti hoc cy c vi trng. b. Trn dch ng trp: in hnh: dich m, c nh sa (khi hin din chylomicron) Tnh cht dch: v trng, thnh phn t bo ch yu l lymphocyte, protein > 3g/dl, glucose = glucose/mu, lipid t 400-660 mg/dl, Triglycerid > 100mg/dl (tiu chun chn on) c. Trn dch mng phi lao: Dch mng phi mu vng chanh, l dch tit, ch yu l lymphocyte, PCR lao(+) Bilan lao: VS tng, IDR(+); c ngun ly lao. d. Trn dch mng phi do bnh l c tnh:

Dch mng phi vng chanh hay , l dch tit, thnh phn ch yu l lymphocyte, lm cellblock thy t bo c tnh hoc sinh thit mng phi c hnh nh m hc c tnh. 4. Chn on phn bit: u trung tht, u phi. III.X TR: 1.TDMP dch thm: Ch chc gim kh th (mi ln rt dch khng qu 10ml/kg cn nng). Tm bnh cn i km: suy gan, hi chng thn h 2 TDMP dch tit: Nu l vim m mng phi m: x tr nh VMMP Nu nghi ng TDMP do lao: chc gim kh th, lm thm bilan lao, khng cn thit phi cho khng sinh ngay, khi c y kt qu ngh o lao cn hi chn chuyn khoa lao. Nu trn dch ng trp: chc gim kh th, inh ng y , cung cp cht bo bng MCT (medium chain triglyceri e), iu tr bnh i km nu bit (lao, ung th). Nu trn dch ng trp xy ra tr s sinh phi ch i, lng dch gim v ngng hn vo 4-5 tun sau.

S43. LON SN PHI


I. NH NGHA: Lan sn phi cn gi l bnh phi mn tnh, biu m cc ph qun nh b hai t v sng ha, gim cht hat din (surfactant), m k tng sinh ng si, hu qu gy x ha phi. Nguyn nhn ca lon sn phi l do thng kh p lc ng vi p lc cao hoc thi gian di. II. CHN ON: 1. Cng vic chn on: a) Hi : Khai thc tin s sau sanh:

Sanh non Suy h hp sau sanh c h tr h hp vi p lc ng (CPAP, th my) vi p lc cao hoc nng Oxy cao b) Khm: Biu hin suy h hp: th nhanh, rt lm ngc, tm ti khi ngng Oxy SaO2 < 90% khi ngng Oxy. c) ngh xt nghim: X quang: Cc x t nghim tm sot nhim trng (pht mu, CRP) Siu m tim: loi tr nguyn nhn suy h hp do cn ng ng mch. 2. Chn on xc nh: da vo: L thuc Oxy > 28 ngy + bt thng trn phim X quang phi: Giai on 1: kh phn bit bnh mng trong (1-3 ngy). Giai an 2: m m 2 ph trng (4-10 ngy). Giai on 3: m m chuyn sang dng nang (10-20 ngy). Giai an 4: tng th tch phi, si, nhiu vng kh (> 1 thng). 3. Chn on c th: L thuc Oxy > 36 tun tui sau sanh, khng cn bng chng nhim trng (vim phi). 4. Chn on phn bit: Vim phi k o i o khng p ng khng sinh: X quang phi tn thng nhu m + cc x t nghim v nhim trng (pht mu, CRP). Cn ng ng mch: khm tim m thi lin tc hoc tm thu + siu

m tim Doppler. III. IU TR: 1. Nguyn tc iu tr: H tr h hp. Thuc. Hn ch dch. 2. Cung cp Oxy: Cung cp Oxy vi nng thp nht sao cho SaO2 mc 90-95%, nn chn phng php th Oxy qua cannula, gim dn lu lng Oxy v chuyn dn qua th Oxy gin on trc khi ngng th Oxy. Nu bnh nhn ang gip th: trnh gy tng thng kh ph nang bng cch gim p lc ng th mc thp nht sao cho gi PaCO2 mc 45-55 mmHg v SaO2 t 90-95%. 3. Hn ch dch: Hn ch dch nghim ngt cha c chng c lm ci thin bnh m cn lm gim cung cp nng lng cho bnh nhn Duy tr lng dch nhp mc 130-150 ml/kg/ngy v tng n nu tnh trng suy h hp ci thin. 4. Thuc: 4.1. Li tiu: Li tiu c tc dng lm gim khng lc ng th v ci thin n hi ca phi. Do c nhiu tc dng ph v hiu qu lu di hn ch, ch nn s dng trong thi gian ngn khng qu 1 tun.

Furosemide: 0,5 -1 mg/kg tim mch 1-2 ln/ngy, c th dng cch ngy gim nguy c tc ng ph ca thuc li tiu, theo i ion v b sung Kali. 4.2. Dexamethasone: a) Ch nh: L thuc my th hoc Oxy (2-3 tun) iu kin: phi loi tr cc nguyn nhn khc - Nhim trng. - Cn ng ng mch. - Tc nghn ng ni kh qun. b) Liu: 0,5 mg/kg/ngy chia lm 2 liu 3 ngy 0,3 mg/kg/ngy chia lm 2 liu 3 ngy 0,2 mg/kg/ngy chia lm 2 liu 2 ngy 0,1 mg/kg/ngy chia lm 2 liu 2 ngy 0,05 mg/kg/ngy 1 liu 1 ngy 4 ngy Giai on u nn tim mch, sau c th chuyn sang ng ung. c) Cn theo di cc tc dng ph: xut huyt tiu ha, tng ng huyt, nhim trng. 4.3. Thuc v iu tr khc: a) Theophylline Caffein:

tr s sinh non thng, Theophylline hoc Caffein ngoi tc dng dn ph qun, cn gip kch thch nhp t th bnh nhn th my, tng sc co bp c honh, li tiu. C th cung cp thuc dng tim qua ng ung. b) Thuc dn ph qun kh dung: Salbutamol kh ung c ch nh v c hiu qu trong trng hp lon sn phi c biu hin co tht ph qun. Liu: 0,02 0,04 ml/kg dung dch 0,5% pha thm 2 ml NaCl 0,9% kh dung mi 6-8 gi. c) Truyn mu: Trong giai on cn l thuc Oxy nn duy tr Hct mc 30-35% (Hb: 8-10 g/l), nu truyn mu lu { cho li tiu ngay sau khi truyn mu trnh gy qu ti. d) Vt l tr liu h hp: Vt l tr liu h hp rt quan trng trong qu trnh iu tr gip tng m ra ngoi lm gim khng lc ng th. 5. Theo di: a) Trong thi gian nm vin: SaO2 nn c theo i thng xuyn k c lc ng, b. Kh mu ch cn thit trong giai on cn gip th, gip iu chnh p lc thch hp trnh gy tng thng kh ph nang. Ion cn theo di mi ngy trong thi gian s dng li tiu. Hct, x t nghim kim sot nhim trng nn kim tra mi tun. b) Xut vin: Hn ti khm nh kz theo di h hp, tng trng trong thi gian

di 1-2 nm.

S44. VIM THANH KH PH QUN CP


I. I CNG: Vim thanh kh ph qun cp hoc Croup l tnh trng vim ph n cp tnh vng h thanh mn thng o siu vi Parainfluenza, sau l RSV, A enovirus, i khi o vi khun nh Hemophilus influenza. Thng gp sau 2 tui (6 thng-5 tui). II. CHN ON: 1. Cng vic chn on: a) Hi bnh: Triu chng khi pht: st nh, ho, s mi. Sau 1-3 ngy t ngt xut hin du hiu khn ting v kh th thanh qun. Hi chng xm nhp loi tr d vt ng th. Tr cn n ung c, nut kh hay khng phn bit vim np thanh mn. Tin cn th rt hoc kh th thanh qun. b) Khm lm sng: St nh hay khng st Khn ting, ting rt thanh qun Th nhanh, co lm ngc Tm ti Khm hng tm gi mc loi tr bch hu Phn kh th thanh qun I: Ch khn ting, th rt khi khc II: IIA: Th rt khi nm yn IIB: Triu chng IIA km kh th, th nhanh, rt lm ngc III: Triu chng IIB km vt v, kch thch hoc tm ti c) ngh cn lm sng: CTM. Pht hng loi tr bch hu.

Khi suy h hp hoc cn chn on phn bit: Xquang phi v c thng pht hin tnh trng hp h thanh mn (du hiu nc nh th: Steeple sign). Ni soi thanh kh qun: ch nh Cn chn on phn bit d vt ng th Kh th thanh qun ti pht Tht bi iu tr ni khoa 2. Chn on xc nh: Triu chng khi pht: vim h hp trn Khn ting Rt thanh qun Ni soi: vim thanh kh qun 3. Chn on c th: C 3 du hiu lm sng nu trn nhng khng c kt qu ni soi thanh kh qun. 4. Chn on phn bit: Ngoi tr d vt ng th, 90% cc trng hp kh th thanh qun tr nh l Croup v vim np thanh mn. Vim np thanh mn cp: thng do vi khun Hemophilus influenza, lm sng st cao t ngt v nhanh chng c biu hin kh th thanh qun, bnh nhn c kiu ngi c bit ci ra trc, y l t th tt nht lm thng ng th, tuyt i khng c p buc tr nm xung v ng tc ny c th lm tr ngng th. Trn Xquang c nghing c hnh nh ph n vng thng thanh mn (du ngn tay). Vim kh qun do vi khun: thng do Staphyloccocus aereus, Streptoccocus hoc Hemophilus influenza type b. Tr st cao, v mt nhim trng km du hiu tc ng th trn. D vt ng th: Kh th thanh qun t ngt km hi chng xm nhp. U nh thanh qun: bnh nhn c triu chng khn ting ko di.

III. IU TRI: 1. Nguyn tc iu tr: Loi tr d vt ng th. Phc hi s thng thng ng th. m bo tnh trng thng kh v oxy ha mu. 2. iu tr c th: Nh: Kh th thanh qun I: phn ln cc trng hp t hi phc t 2-4 ngy. - iu tr ngoi tr. - Cho tr n ung bnh thng. - iu tr triu chng: h st, gim ho. - Hng dn b m chm sc tr ti nh v cc du hiu nng cn i ti khm (co lm ngc, ting rt khi nn yn). Trung bnh: kh th thanh qun IIA - C th iu tr ngoi tr, nu bnh nhn gn v c theo di st. - Ngoi cc iu tr nh ng nh cho ung Dexamethasone 0,15 mg/kg hoc Prednisone 1mg/kg/ln ung hay gavage mi 8 gi. - Cn ti khm mi ngy. Nng: kh th thanh qun IIB, III - Nhp vin iu tr. - Cn gi yn tr, cho m bng, trnh khc v lm tng ph n thanh qun v kh

th nhiu hn. - Th oxy qua cannulla duy tr SaO2 92-96%. - Kh ung A renaline 1 2-5 mL (tr<4 tui: 2ml), c th lp li liu 2 sau 30 pht 1gi nu cn kh th nhiu, v sau 1 2 gi nu cn i tc dng ca Dexamethasone. Adrenalin chng ch nh trong t chng Fallot v bnh l{ c tim ca tm tht gy tt ng ra v c th gy t ngt gim cung lng tim. - Dexamethasone 0,15 - 0,6 mg/kg TB hoc TM 1 ln, c th lp li sau 6-12 gi nu cn. Mt s tc gi nhn thy kh ung Bu esoni e cng c hiu qu trong kh th nh v trung bnh. - Khng sinh: Cefotaxime hoc Ceftriaxone - Hi chn chuyn khoa Tai mi hng - Ch nh t ni kh qun: Tm ti. L m, kit sc. Cn ngng th. Tht bi vi iu tr ni khoa (kh dung Adrenaline v Dexamethasone). Vi t ni kh qun, chn ni kh qun c nh hn bnh thng 0,5 (th d dng ng ID 3mm hay 3,5mm tr 12 24 thng); thi gian hi phc thng sau 24 48 gi s rt ni kh qun nn u tin chn t ni kh qun hn m kh qun. 3. Theo di: Tri gic, ting rt thanh qun, nhp th, nhp tim, SaO2.

S45. NHIM KHUN H HP CP TNH TR EM


1.Cc tc nhn gy nhim khun h hp cp tnh tr em 1.1.Vi khun - Ph cu khun - Hemophilus influenzae - T cu vng - Lin cu beta tan huyt nhm A

- Moraxella catarrhalis - Mycoplasma pneumoniae 1.2. Virus - RSV (Virus hp bo h hp) - Parainfluenzae (type 1,2,3) - Adenovirus - Influenza virus (type A,B,C) - Rhinovirus - Coxackie Virus nhm A, Herpes virus. 2. Phn loi nhim khun h hp cp tnh tr em 2.1. Da trn tc nhn gy bnh - NKHHCT o virus: C tin lng kh quan, ngoi tr mt s bnh nng nh vim tiu ph qun cp, vim phi do adenovirus tr nh, c th dn n t vong, a s cc trng hp ny khng cn n khng sinh. - NKHHCT do vi khun: Phn ln u nguy him v cn n khng sinh. c bit nguy him l vim phi do t cu vng, vim np thanh qun do H. influenzae. 2.2. Da trn v tr gii phu hc ca tn thng - NKHH trn: Bao gm nhng bnh l vim nhim trn thanh qun: + Vim mi hng cp + Vim hng cp v vim hng - amian cp + Vim xoang cp + Vim tai gia cp. - NKHH di: Bao gm nhng bnh l vim nhim t thanh qun tr xung: + Vim thanh qun do virus hoc bch hu + Vim np thanh qun do H. influenzae + Vim thanh kh ph qun cp + Vim ph qun cp + Vim phi cc loi + Vim tiu ph qun cp

3. Chn on v iu tr mt s nhim khun h hp cp tnh 3.1. Nhim khun h hp trn 3.1.1. Vim mi hng cp (VMHC) - Bnh nguyn: + Ch yu l do virus vi trn 150 tp huyt thanh khc nhau (ph bin nht l rhinovirus). V vi khun, lin cu bta tan huyt nhm A hay gp nht, k l C. diphteria, M. pneumonia, N. menigitidis. H. influenzae, ph cu, v t cu thng ch gy bi nhim v dn n cc bin chng nh vim xoang, vim tai gia, vim xng chm, vim cc hch bch huyt v vim phi. Mycoplasma pneumoniae c th gy VMHC vi bnh cnh lm sng rt ging vi virus. - Lm sng: + tr t 3 thng - 3 tui: Tr st cao t ngt (c th gy co git), kch thch, ht hi. Sau vi gi, tr chy mi nc v ngt mi c th lm tr khng b c. i khi tr nn hoc a chy. Giai on st ko di t vi gi n 3 ngy. Nu tr st tr li thng l do bin chng vim tai gia. + tr > 3 tui: bnh khi u bng cm gic kh v kch thch mi hng. Vi gi sau, tr ht hi, run lnh, au mi c, chy mi nc, ho khan, thng km theo nhc u, chn n v st nh. Sau mt ngy, nc mi c dn v tr thnh c. Giai on cp ny thng ko di 2- 4 ngy. - Bin chng: + Vim hch c (i khi nung m), vim xng chm, vim m mm quanh amian. Ph bin nht l vim tai gia cp (gp 25% tr nh b VMHC). Cn ngh n VTGC nu tr st tr li sau giai on cp. Ngoi ra, VMHC thng dn n vim thanh kh ph qun, vim tiu ph qun cp, vim phi o virus. VMHC cng thng khi ng triu chng hen nhng bnh nhi c c a hen. - Phng bnh: + Hin nay cha c vaccine. Vic cch ly cc tr b VMHC l khng cn thit. Tr nh nn trnh cho tip xc vi nhng ngi ang b VMHC.

- iu tr: + Khng sinh khng cn thit. Paracetamol c th lm gim st, au nhc, mt mi trong 1-2 ngy u. Khng nn dng aspirin. Tc mi lm tr khng b, khng ng c. tr nh c th nh mi vi nc mui sinh l. Tr ln hn, c th nh mi ung ch phenylephrine 1-2 git/mi l mi, 15-20 pht trc lc n hay i ng, lp li mt ln na 5-10 pht sau. Khng nn dng ko di qu 5 ngy. tr qu nh c th chng tnh trng tc mi bng cch t tr nm sp, u nghing hoc hng dn b m ht mi cho tr bng ming. tr ln c th dng thuc co mch theo ng ung (pseu oephe rine), thng phi hp vi cc thuc khng histamine. Ngoi ra nn cho tr ung nhiu nc. 3.1.2. Vim hng cp (VHC): L tn gi tnh trng vim amian hay vim hng-amian. - Dch t hc: + Bnh ph bin nht tr 4-7 tui, rt him gp tr <1 tui. Vim hng thng gp trong bi cnh b bch hu, nhim a enovirus, tng bch cu n nhn nhim khun. - Nguyn nhn + Ch yu l virus. Lin cu khun tan huyt nhm A chim khong 15% cc trng hp vim hng cp. - Lm sng: + VHC do virus: Bnh thng xut hin t t. Bt u tr st, mt mi, chn n v hi au hng. au hng nhiu nht vo ngy th 2 hoc 3. Tr thng ho, khn ting, chy nc mi, sung huyt kt mc. Vim hng thng nh. Tuy vy, i khi hng vim nng, c vt lot nng vm khu ci mm v thnh sau hng, vi lp xut tit ph ngoi rt kh phn bit vi vim hng do LCK. Cc hch c c th sng, cng v au. Bch cu mu trong khong t 6.000-30.000/mm3. Bch cu a nhn trung tnh c th chim u th trong giai on cp. Giai on cp ch ko di 24 gi, t khi qu 5 ngy. + VHC do LCK: tr t 2 tui tr ln, bnh bt u vi st cao (40C), nhc u, au bng, nn. Vi gi sau, hng bt u au rt, v khong 1/3 s bnh nhi

thng c amian sng to, c xut tit, v hng rc. Tuy nhin, 2/3 bnh nhi c hng nh m khng sng amian v khng c xut tit. Cc hch c sng sm v au. St ko di t 1- 4 ngy, mt s t c th ko di 2 tun. Triu chng gi nht l s vim ty lan ta vng amian v tr trc, tr sau amian vi nhng im xut huyt trn vm khu ci mm. Cc triu chng ny cng c th gp trong VHC do virus. Ngoi ra, VHC do LCK t khi km theo vim kt mc, ho, khn ting. Nu c t hai triu chng va k tr ln th c th do virus. - Bin chng: + Nu do virus, rt t khi c bin chng. Nu do LCK, c th gp p-xe quanh amian, vim xoang, vim tai gia, v him hn l vim mng no m. Vim cu thn cp v thp khp cp c th xy ra sau VHC do LCK. - iu tr: + Ch cho khng sinh khi c bng chng v lm sng, dch t, hay cy cht ngoy hng (+). Trong trng hp VHC do LCK: penicillin V ung vi liu 125-250 mg (tng ng vi 200.000-400.000 UI), 3 ln/ngy trong 10 ngy. Erythromycin l thuc thay th tt nht trong trng hp d ng vi penicillin. Cho paracetamol trong giai on cp. Tr ln c th ngm nc mui m lm gim au hng. Nn cho tr ch n lng trong giai on cp. 3.1.3. Vim tai gia cp (VTGC) - Bnh nguyn: + Theo Trung Tm Nghin Cu VTG ti Pittsburgh (M), 3 tc nhn gy VTGC ch yu l: ph cu 29.8%; H. influenzae 20.9%; M. catarrhalis 11.7%. - Lm sng: + Thng xy ra sau nhim virus h hp trn vi ngy. Ban u tr au tai, st, nghe km. Khm tai vi n soi tai c bm hi thy mng nh sung huyt, m c, phng ra v k m i ng. i khi thy tai chy m. Cn nghi ng VTGC do vi khun nu tr c mng nh k m i ng v m c. - iu tr:

+ Ph cu l tc nhn gy VTG ph bin mi la tui. tr s sinh, khong 20 % VTGC do vi khun gram m. Thng phi iu tr trc khi c kt qu cy v khng sinh : Amoxicillin 40 mg/kg/ngy trong 10 ngy. Nu cy m cho thy vi khun khng amoxicillin hay k m p ng trn lm sng, cn thay i khng sinh. Lc , c th chn Erythromycin (50mg/kg/ngy) phi hp vi Cotrimoxazol; hoc Cefaclor (40mg/kg/ngy); hoc Amoxicillin + clavulanate (40mg/kg/ngy); hoc Cefuroxime axetil (125-250 mg/24 gi). Nu bnh nhi d ng Penicillin, Erythromycin v Cotrimoxazol l thuc thay th. - iu tr nng : thuc gim au h st, chm nng ti ch. Thuc chng sung huyt theo ng ung (pseudoephedrin) c th lm gim tnh trng sung huyt mi. Thuc khng histamine c th hu ch trong nhng trng hp d ng ti mi. 3.2. Nhim khun h hp di 3.2.1. Vim thanh qun cp (VTQC): + y l mt nhm bnh l c din tin cp v nng c xp vo loi bnh trm trng theo chng trnh ARI. Cn c chuyn ngay ln tuyn trn c theo i v iu tr mt khi nghi ng. - Bnh nguyn v dch t hc: + Phn ln l do virus ngoi tr VTQ do bch hu, vim np thanh qun cp do H. influenzae. Parainfluenza virus l nguyn nhn ca khong 3/4 tt c cc trng hp vim thanh qun do virus. Adenovirus, RSV, Influenzavirus v virus si l nguyn nhn ca phn cn li. Trong mt nghin cu, 3,6% cc trng hp VTQC phn lp c Mycoplasma pneumoniae. H. influenzae hu nh lun lun l tc nhn duy nht gy vim np thanh qun cp. Phn ln bnh nhi b VTQC do virus tui 3 thng - 5 tui, trong lc VTQ do H. influenzae v C. diphteriae ph bin nht 3-7 tui. T l mc VTQC cao hn tr trai, v xy ra ch yu vo ma lnh. Khong 15% tr b VTQC c bnh s gia nh bnh VTQC, v nhng tr c yu t gia nh ny hay b VTQC lp li nhiu ln. - Lm sng:

+ Vim np thanh qun cp (VNTQC): tr nh t nhin vo gia khuya st cao, khn ting, n nc bt, v suy h hp t va n nng km ting rt. tr ln hn, bnh bt u vi au hng v kh nut. Suy h hp nng thng tip theo sau vi pht hoc vi gi vi ting rt kz th vo, khn ting, ho ng ng, kch thch, vt v. n nc bt v kh nut thng xy ra. C thng t th qu nga ra sau. Tr ln thng thch t th ngi, gp ngi ra trc, h ming v li hi th. Mt s trng hp c tnh trng ging sc vi da xanh nht, tm ti, v ri lon thc. Khm thy suy h hp va n nng vi ting rt kz th vo i khi c kz th ra, php phng cnh mi, co k o hm trn xng n, cc khong lin sn v rt lm lng ngc. Khm thy vng thanh qun vim v nhiu cht nhy v m gii. Dn dn, th rt v m th gim v bnh nhi ri vo tnh trng mt l. Tr vt v, sau tm ti gia tng, hn m, ri t vong. Mt cch din tin khc l tr ch khn ting nh, khm thy np thanh qun sng . + Vim thanh qun do nhim khun cp: ngoi tr bch hu thanh qun, a s cc trng hp u do virus. Bnh khi u vi vim h hp trn ri xut hin au hng, ho v kh th thanh qun. Bnh thng nh, suy h hp ch xy ra tr nh. Tuy nhin trong cc trng hp nng, ging khn rt r, th rt r kz th vo, rt lm, kh th v vt v. Khi bnh tin trin, tnh trng thiu kh, mt l xy ra v tr s chuyn t tnh trng kch thch sang l m. Khm bng n soi thanh qun c th thy giy thanh v vng i thanh qun ph vim.Vng tc nghn ch yu l i thanh mn. + Vim thanh kh ph qun cp (VTKPQC): l bnh ph bin nht trong nhm VTQ v ch yu do virus. a s bnh nhi c vim h hp trn trc vi ngy ri ho ting r, th rt, v suy h hp ngy cng r. Khi tnh trng nhim trng lan dn xung i, nh hng ph qun, tiu ph qun, kh th gia tng th kz th ra cng k o i v c gng sc. Tr lc rt kch thch vt v. St thng nh nhng c khi ln n 39-40C. Khm thng thy m th gim hai bn, ran ngy, v ran m ri rc. Triu chng thng nng ln v m v k o i trong vi ngy. Tr thng c vim mi hoc vim kt mc km theo. Bnh thng ko di vi ngy n vi tun. - iu tr: + VNTQC nu c chn on bng quan st trc tip, hoc bng X-quang, hoc

rt nghi ng trn mt bnh nhi c v nng n, nn c x tr ngay vi vic thit lp mt ng th nhn to. Khng sinh tt nht trong bnh ny l Ceftriaxone (100 mg/kg/24gi) hoc Ampicillin (200 mg/kg/24gi) hoc Chloramphenicol (100 mg/kg/24 gi), tt c theo ng tnh mch, trong khi ch kt qu cy v khng sinh . Tt c bnh nhi cn c th oxy trn ng ti phng m t ni kh qun hay khai kh qun. Epinephrine v corticosteroids khng c tc dng. Sau khi thit lp ng th nhn to, bnh nhi thng ci thin nhanh chng, suy h hp v tm ti gim, tr s kh mu tr li bnh thng. Bnh nhi thng c th c th ng c vo lc ny. Tnh trng vim np thanh qun gim dn sau vi ngy iu tr khng sinh v lc c th rt ng ni kh qun hay chm dt khai kh qun. Khng sinh nn c duy tr trong 7-10 ngy. 3.2.2. Vim ph qun cp (VPQC) hay vim kh ph qun cp (VKPQC) Thc ra, VPQC thng bao gm c vim kh qun v cc thnh phn khc ca ng h hp trn v i. VKPQC thng gp trong cc bnh cnh ca ho g, cm, si, thng hn, bch hu... VKPQ tin pht n thun thng ch xy ra tr ln, thiu nin v thng do virus. Bnh thng khi u vi vim h hp trn trong vi hm. Sau ho khan tng n, thng l vo ngy th 3-4 sau vim h hp trn. Ho khan khng c m di lm tr au rt vng sau xng c hoc au ran c lng ngc. Tr nh thng nn sau cc cn ho. Tr c th c c c nh. Sau vi ngy, ho bt u c m; lc u m trong, sau n c mu vng. Trong vng khong 10 ngy m lng dn ri ht. Khm thy tr khng st hoc st nh v thng c vim mi hng i km. V sau nghe phi c th c m th th, ri rc ran m va ht v ran rt. Tr khe mnh thng t b bin chng hn tr c sc khe km hoc suy inh ng. Cc bin chng thng gp l vim tai gia, vim xoang v vim phi. Khng c iu tr c hiu. tr nh, nn thng xuyn thay i t th nm dn lu cht tit, m gii, trnh ng. Ho nhiu v m lm tr mt ng, cho nn tr ln c th dng cc thuc gim ho mt cch thn trng. Cc thuc c ch phn x ho ng thi cng lm tng nguy c b cc bin chng nung m. Khng nn dng thuc khng histamine v thuc lm kh cht tit. Cch lm lng m tt nht v n gin nht l cho tr ung nc. Khng sinh khng lm rt ngn thi gian bnh hoc lm gim bin chng. Tuy nhin, nhng bnh nhi b VPQ ti din, khng sinh c th ci thin

tnh trng bnh. Ch c ch nh khng sinh khi c bng chng bi nhim thc s. 3.2.3. Vim phi - Trnh by 1 bi ring 3.2.4. Vim tiu ph qun cp (VTPQC): VTPQC l mt bnh ph bin ca ng h hp i tr nh, hu qu ca s tc nghn do vim cc kh o nh nh cc tiu ph qun. Bnh thng xy ra ch yu tr i 2 tui, vi nh cao nht 6 thng tui, vo ma ng v u xun. - Bnh nguyn v dch t hc: RSV gy ra 50% cc trng hp; phn cn li do parainflueza 3 virus, mycoplasma, vi loi adenovirus, v mt vi loi virus khc. A enovirus thng lin quan n nhng bin chng v lu v i nh vim tiu ph qun tc nghn v hi chng phi tng sng mt bn (hi chng SwyerJames). Ngun nhim bnh ch yu t nhng ngi trong gia nh b bnh h hp nh. Yu t thun li l tnh trng chc nng phi b st gim t trc khi b bnh. - Lm sng: + Thi kz khi bnh: tr c biu hin vim h hp trn trong vi ngy vi st cao 38,5-39C, ho khan, chy mi nc. + Thi kz ton pht: st gim, nhng xut hin suy h hp vi tng t ho, s s, kch thch. Tr thng b b v th nhanh. Trong trng hp nh, cc triu chng bin mt sau 1-3 ngy. mt s trng hp nng, cc triu chng xut hin t ngt, rm r v ko di. Tr thng khng st, hoc st nh. Khm thy tr kh th nhanh, rt thiu kh v tm ti, cnh mi php phng, rt lm khng r v tnh trng kh ph thng. Gan lch thng s c. Ran n mn c th nghe c cui kz th vo v u kz th ra. Kz th ra ko di, ting s s c th nghe bng tai thng. Trong trng hp nng, r ro ph nang rt gim, thm ch khng cn nghe c. X-quang cho thy phi qu cng n, tng ng knh trc-sau trn phim nghing. Khong 1/3 trng hp c th thy hnh nh m ri rc do xp phi hoc vim ph nang. S lng bch cu thng trong gii hn bnh thng. Giai on nghim trng nht l 48-72 gi u sau khi xut hin ho v kh th vi

bnh cnh lm sng rt nng vi nhng cn ngng th v nhim toan h hp. + Thi kz lui bnh: Sau giai on nng, bnh ci thin nhanh chng, khi bnh hon ton trong vng vi ngy. T l t vong khong 1%, o cc cn ngng th di, nhim toan h hp, mt nc do th nhanh. Cc bin chng nh PQPV, vim tai gia, v suy tim t gp. - iu tr: + Tr cn c iu tr ni tr ti cc trung tm c iu kin chm sc tch cc. Nn t tr trong mi trung mt c m cao v giu oxy, khng nn dng thuc an thn. T th tt nht l t tr ngi 30-40 so vi mt ging hay nm k vai u cao, c nga. Tng cung cho ung nc, hoc truyn dch theo ng tnh mch. Nu c nhim toan, cn iu chnh bng cc dung dch chng toan theo ng tnh mch. + Ribavirin (Virazol), mt loi thuc khng virus, rt c hiu qu trong cc trng hp VTPQC do RSV, vi iu kin cho sm. Thuc c ch nh tr i 2 tui vi bnh cnh lm sng nng v c bng chng nghi ng do RSV, hoc tr nh b VTPQC nh nhng c bnh km theo nh tim bm sinh, bnh phi mn tnh, suy min dch. Thuc c dng bng xng kh dung ht nh, 12-20 gi/ngy, trong 3-5 ngy. + Khng sinh khng c ch nh, tr phi c bng chng ca vim phi do vi khun. Corticosteroids khng c ch, thm ch cn c hi. Thuc dn ph qun i dng kh ung thng c dng. Khai kh qun khng cn thit. Trong trng hp suy h hp qu nng, i khi cn n h hp vin tr. 4. Phng bnh Vi tm quan trng ca n, vic phng v gim t l t vong do bnh NKHHCT c c th ha vi chng trnh ARI quc gia. Trong , bin php phng bnh ch yu l s gio dc cc b m c con i 5 tui cc kin thc c bn v phng bnh, pht hin v x tr NKHHCT: - Kin thc v chm sc con khe. - Bit lc no cn em con n c s Y t khi con b NKHHCT. - Bit li ch ca vic tim phng (c bit l tim phng lao, BH-HG-UV, si). - Bit li ch ca sa m.

- Bit tc hi ca khi bi c bit l khi thuc l. Ti liu tham kho 1. Herendeen N. E, Szilagy P. G (2000). Infections of the Upper Respiratory Tract. Nelson Textbook of Pediatrics, 16th Edition; 1261-1266. 2. Orenstein D. M. (2000). Acute Inflammatory Upper Airway Obstruction. Nelson Textbook of Pediatrics, 16th Edition; 1274-1279. 3. Orenstein D. M. (2000). Bronchitis. Nelson Textbook of Pediatrics, 16th Edition; 1284- 1285. 4. Orenstein D. M. (2000). Bronchiolitis. Nelson Textbook of Pediatrics, 16th Edition; 1286- 1287.

S46. VIM TIU PH QUN CP TNH


Vim tiu ph qun cp tnh hay gp tr nh, i 1 tui thng do virus hp bo h hp gy ra (Respiratory Syncytial Virus RSV). Tr non, c bnh tim bm sinh, c thiu sn phi d c nguy c b bnh. 1. Chn on : Da vo lm sng v x-quang 1.1. Lm sng C chy nc mi, ho, kh kh. Th nhanh, co k o c h hp. Biu hin thiu xy : tr vt v, tm ti quanh mi v cc u chi. Lng ngc cng phng, thng kh phi gim, ran rt, ran m. Cc b phn khc : gan to, mch nhanh.

1.2. Xt nghim + Cng thc mu Khng c hiu, c th c tng bch cu lympho. + X-quang phi Phi kh, c honh h thp. Biu hin m cc tiu ph qun

- i khi c biu hin xp cc b cc phn thuz. C khi xp c phn thuz phi do bt tc. Phn tch kh mu, ch cn lm vi th nng SaO2 gim < 92% PaO2 gim < 60 mmHg PaCO2 tng

2. iu tr 2.1. Th nh Bnh nhn tnh, mi hng, b c, SaO2 > 92%, kh th nh. iu tr ti nh :

+ n ung y + Hng dn b m pht hin nhng du hiu nng

2.2. Th trung bnh n k m Mt nc

Ng lm Kh th r SaO2 < 92%

iu tr : Ti bnh vin Th oxy, duy tr SaO2 > 93% n qua ng thng d dy Truyn dch :

+ Dung dch Glucose 5% + Natri Clorua 9 : 20 ml/kg/24 gi, truyn tnh mch 7 - 8 git/pht. + Khi c gan to, tnh mch c ni , i t, mch nhanh : khng c truyn 2.3. Th nng SaO2 < 92% Mt l Du hiu tng CO2 : v m hi, kch thch hay ngng th

iu tr : (chuyn iu tr tch cc) Theo di cht ch : mch, nhp th SpO2 Kim tra kh mu Th CPAP hay th my

- Truyn dch, glucose 5% hoc Natri Chlorua 9 ; 20ml/kg/24 gi, 7 - 8 git/pht. + Kh dung : Natri Clorua 9 x 2ml

+ +

Hoc Mucosolvin : 2ml C 4 gi cho 1 ln

- Khi bnh nhn ngng th, hoc PaO2 = 50 mmHg v PaCO2 70 mmHg t ni kh qun chy my th vi PEEP 2cm H2O.

2.4. Khng sinh + Ch dng khi c biu hin bi nhim : Bch cu trung tnh tng

+ X-quang phi c m m + Phi nghe c ran m ri rc

- Khi bnh nhn t ni kh qun hay chy my th cng cn cho khng sinh chng bi nhim. + Cn cy dch tm vi khun v khng sinh . Thng dng 2 loi : b lactamin :

+ Aminozid : Amikacin loi 0,5g : 15 mg/kg/24 gi. Tim bp 3. Chm sc bnh nhn nm u cao Ht m ri Cho n sa, cho. Nu bnh nhn nng t son e cho n V rung, dn lu t th. Theo di : mch, nhit , nhp th v bo ho oxy

4. xut vin Bnh nhn tnh to, ht st, n tt. Nhp th tr v bnh thng Ch s kh trong mu tr v bnh thng

S47. VIM THANH QUN CP


Vim thanh qun cp thng do virut Para influenza, hay xy ra tr t 6 thng 3 tui, vo ma ng. 1. Chn on : Ch yu da vo lm sng 1.1. Lm sng - Khi pht t t sau nhim khun ng h hp trn, thng xy ra vo ban m. C biu hin vim thanh qun :

+ Ho khan, ho ng ng. + Khn ting + Kh th, ch yu th th vo, c ting rt khi th vo. + n ung kh. + St 38 39oC. 1.2. Xt nghim : Khng c hiu - Cng thc mu : Bnh thng, i khi s lng bch cu tng, ch yu l bch cu lympho. X-quang phi : kh.

2. iu tr 2.1. Trng hp nh - Cho ung hay truyn dch : 20 ml/kg/24 gi dung dch Glucose 5% hoc Natri Chlorua 9, truyn 10 git trong 1 pht. Prometazine (Phenergan) : 5 - 10mg Khng kh ln cho : Hydrocortisone : 10mg

2.2. Trng hp va v nng bnh nhn t chn t th nm

- Th oxy qua ng thng, nng tuz vo SaO2. Nu SaO2 = 96% cho th 100% oxy SaO2 ln 99% ; sau gim nng oxy cn 45 - 50%. Cho Prometazine 5 - 10 mg (ung) Cho truyn dch :

+ Dung dch Glucose 5% : 20 ml/kg/24 gi + Truyn tnh mch 10 git/pht + Hoc ung theo yu cu bnh nhi. Hydrocortisone 100mg, 2 gi sau tim nhc li. Kh ung : Natri Chlorua 9 = 2ml Hydrocortisone 30mg Kh dung t 10 - 15 pht, ngy 2 ln. Theo di : nhit , nhp th, bo ho O2, nc tiu, mch.

Nu bnh nhn c triu chng nhim trng, cho khng sinh ng tnh mch theo khng sinh . 2.3. Chm sc

Ch { t th bnh nhn bnh nhn chn t th khng nn p bnh nhn. Thng nm u cao V sinh thn th

- Cho n cht d tiu (sa, cho, n nhiu ba). Nu bnh nhn khng n phi cho n bng sonde. - Lun c ngi cnh bnh nhn. Khi c nn phi nhanh chng ht v lm thng ng th. 2.4. Xut vin Bnh nhn tnh to, ht hoc ho. Ht st. Bo ho oxy tr v bnh thng. Phi khng cn ran. Bnh nhn thm n.

S48. VIM M MNG PHI


Vim m mng phi (VMMP) l mt tnh trng bnh l gy nn bi qu trnh vim km theo tch m trong khoang mng phi do cc vi khun sinh m. 1. Chn on + Lm sng : Bnh nhn c chn on VMMP khi c cc u hiu sau:

Hi chng nhim trng nh st. Kh th. Hi chng 3 gim phi ( tr nh : r ro ph nang gim + g c)

Chc d mng phi c m.

+ Xt nghim : - Mu ngoi bin : Bch cu tng, bch cu a nhn trung tnh tng, mu lng tng. - X-quang phi (thng nghing) : hnh nh gc sn hon t, m nhiu hay t tuz mc trn dch hoc c hnh nh vch ho khoang mng phi. - Siu m khoang mng phi : c hnh nh trn dch ton b hay vch ho to thnh cn. - Cc xt nghim dch mng phi : nhum gram, sinh ho, t bo, cy m tm vi khun. Vi khun gy bnh ph bin l nhm vi khun gram (+), hu ht l t cu vng. Nhm vi khun gram (-) ch yu l K.pneumoniae, ngoi ra c th gp P.aeruginosa, H.influenza 2. iu tr : Nguyn tc : Dng khng sinh - iu tr cn nguyn vi khun. Lm sch m khoang mng phi. iu tr h tr, iu tr triu chng.

2.1. iu tr khng sinh Qua qu trnh nghin cu cho thy vi khun gy bnh 3/4 l gram (+) trong ch yu l t cu vng, 1/4 l gram (-) u th l K.pneumoniae. Do vy cc khng sinh s dng trong iu tr nn nh sau : + Vi nhm vi khun gram (+) Kt hp nhm beta lactam v aminozit. Cloxacillin (100 150mg/kg/24h/TM) + Amikacin (15mg/kg/24h/TB)

Hoc Oxacillin (100 150mg/kg/24h/TM) + Amikacin (15mg/kg/24h/TB)

Bnh nhn trong bnh cnh nhim khun huyt nng dng : Vancomycin 10mg/kg/6h/nh git TM + Amikacin (15mg/kg/24h/TB)

+ Vi nhm vi khun gram (-) Ceftazidime (Fortum) (100 150mg/kg/24h) + Amikacin. Hoc Cefoperazone (Cefobis) (100 150mg/kg/24h/TM) + Amikacin. Hoc iu tr theo khng sinh nu c kt qu nui cy vi khun.

2.2. Cc bin php lm sch m khoang mng phi + Chc ht mng phi Bnh nhn n sm < 5 ngy.

- X-quang c dch < 3 khoang lin sn, hoc lp dch c y t hn 20mm trn hnh nh siu m. Dch chc ra c nh, xt nghim bch cu < 1g/l.

+ M mng phi ti thiu dn lu kn : p dng cho hu ht cc trng hp X-quang c hnh nh trn dch > 3 khoang lin sn.

- Hnh nh X-quang c hin tng vch ho nhng lng dch tn ng nhiu, m mng phi ti thiu dn lu trong khi ch phu thut. Thi gian dn lu trung bnh l 5-7 ngy, rt ng dn lu khi lng dch ht ra <50ml/ngy. + Phu thut bc tch mng phi v cc cn m khi : iu tr bng khng sinh v dn lu sau 7 ngy khng hiu qu. Tnh trng ton thn xu i. St dai dng.

Suy h hp dai dng. C hnh nh cn m trn X-quang v siu m. C hin tng r kh ph mc (ch nh m cp cu).

2.3. iu tr h tr, iu tr triu chng : Liu php xy (khi cn). Liu php b dch, gi thng bng toan kim, khi cn. m bo n v s lng v cht lng.

S49. VIM PH QUN PHI DO VI KHUN


Vim ph qun phi l tn thng cp din, lan to c ph nang, m k ln ph qun, thng do virus khi u, sau bi nhim do vi khun hoc c hai. Thng vi khun qua ng h hp, ngoi ra vi khun qua ng mu, bch huyt, khng iu tr kp thi d dn n t vong. 1. Chn on 1.1. Du hiu lm sng St Ho c m (mu vng, mu xanh hay r st) Nhp th nhanh so vi la tui Cnh mi php phng, si bt cua (tr s sinh) Rt lm lng ngc Li b Tm ti, co git, c cn ngng th

Phi c ran m nh ht ri rc hai ph trng

1.2. Xt nghim Cng thc mu S lng bch cu tng Bch cu trung tnh tng cao X-quang : c { ngha chn on xc nh Hai ph trng c nhng nt m ri rc C nhng m m tp trung nhu m phi C hnh bng hi (thng do t cu) Kh mu (ch cn lm khi c suy th) Nh cha thy thay i Va : Thng thy toan hoc kim h hp Nng :

PaO2 50 mmgH SaO2 < 96% PaCO2 70 mmHg BE -6mEq/l Cy dch tm nguyn nhn Ly dch t hu Ly dch ni kh qun Soi ti v nui cy tm vi khun lm khng sinh Lm xt nghim CRP (C-Reactive Protein) (nu cn)

CRP > 10 mg/l ( phn bit vi vim phi do virus) 2. iu tr 2.1. iu tr triu chng bnh nhn nm ni thong, kh, trnh gi la

- H nhit nu c st trn 38oC, dng Paracetamol 10 - 15 mg/kg, c 6 gi dng 1 ln n khi nhit h xung <38oC th ngng thuc. Khng dng Paracetamol qu 100mg/kg/24 gi. - Lm thng thong ng th, cho bnh nhn nm u cao, ht dch mi hng hoc qua ni kh qun. Nu bnh nhn co tht (ran rt, ran ngy hai ph trng...) cho kh dung.

Natri Chlorua 9 x 2ml Oxy nng 40 - 60% Cho bnh nhn th 5 - 10 pht, sau v rung v ht dch mi, mm. C 3 - 4 gi lm li 1 ln. 2.2. Dng khng sinh 2.2.1. Cc chng vi khun hay gy vim ph qun phi Vi khun hay gy vim ph qun phi tr em theo la tui nh sau : Tr di 1 thng tui :

+ Nhm B ca Streptocuccus + E. Coli + Staphylococcus Pneumoniae + Klebsiella, Pseudomonas Aeruginosa Tr 1 - 3 tui :

+ + + + +

Haemophilus Influenzae Streptocuccus Pneumoniae Tr trn 3 tui : Streptocuccus Pneumoniae Staphilococcus Aureus Mycoplasma Pneumoniae

2.2.2. Khng sinh v liu lng Bnh nhi cha dng khng sinh tuyn trc - Ampicillin : Liu dng : 50mg - 100mg/kg/24gi, pha nc ct 10ml, tim tnh mch chm, chia 2 ln trong ngy (lm test trc khi tim). + + C th phi hp : Vi Amikacin: Liu dng : 15 mg/kg/24 gi, chia 2 ln tim bp. Hoc vi Bruramycin : Liu dng 4mg/kg/24gi, chia 2 ln tim bp.

Bnh nhn dng khng sinh - Augmentin loi 0,5g hoc 1g : Liu dng 100mg/kg/24 gi ; pha long bng nc ct 20ml, tim tnh mch chm, chia 2 ln, sng v chiu. v Amikacin : Liu 15mg/kg/24 gi, tim bp chia 2 ln trong ngy. - Hoc Tarcefoksym (Cefataxim) loi 1g : Liu dng 100mg/kg/24 gi. Tim tnh mch chm chia 2 ln trong ngy. v Amikacin : Liu 15mg/kg/24 gi, tim bp chia lm 2 ln trong ngy. 2.2.3. Nu nghi l do t cu trng - Cloxacillin loi 0,5g : Liu lng 100mg - 200mg/kg/24 gi. Tim tnh mch, chia 2 ln trong 1 ngy.

- Hoc Bristopen loi 1g : Liu lng 100mg/kg/24 gi, tim tnh mch chia 2 ln trong ngy. - Hoc Vancomycin loi 0,5g : Liu dng 30 - 50g/kg/24 gi, pha vo huyt thanh mn ng trng 9 va truyn trong 1 gi (tc t 15 - 20 git trong 1 pht). - Hoc Cefobis loi 1g : Liu dng 100mg/kg/24 gi, chia 2 ln trong ngy, pha long tim tnh mch chm. 2.2.4. Nu nghi vimph qun phi do Haemophylus Influenzae. Tui thng 3 thng n 4 tui - Cloramphenicol loi 0,5g hoc 1g : Liu lng 30 - 50mg/kg/24 gi, pha long tim tnh mch tht chm (trong vng 5 pht). 2.3. Mt s im cn lu Truyn dch ch nn cho 20ml/kg/24 gi ; 7 git trong 1 pht. Khi thy gan to, mch nhanh, i t khng nn truyn dch, du hiu trn biu hin suy tim. Cn cho : Digoxin : Liu 0,02mg/kg/24 gi, chia lm 3 ln. Ung ln u 1/2 liu trn. Sau s cn li chia ra c 8 gi cho ung 1/4 liu cn li. 2.4. Chm sc, v sinh n ung Cp nhit sng, chiu ; theo di nhp th, tinh thn ca bnh nhn. Gi cho bnh nhn sch, c bit cc hc t nhin. Cho bnh nhn ung nc hoa qu ti, n thc n tiu (sa, cho, bt...) 2.5. Bnh nhn xut vin Ht st Tnh to

n, ung tt Bch cu tr v bnh thng Phi ht hoc ran X-quang phi ht cc m m ri rc ph trng.

CHNG 5. BNH L TIU HA


S50. TIU CHY CP
I. NH NGHA : Tiu chy: tiu phn lng hay te nc hay c mu trong phn > 2 ln trong 24 gi Tiu chy cp : tiu chy < 14 ngy II. CHN ON: 1. Cng vic chn on a) Hi bnh s: Tiu chy: - Thi gian tiu chy - c tnh phn: c mu / phn Dinh ng Thuc ng: Khng sinh, thuc cm tiu chy Khc cn km tm ti tr nh gi lng rut vng dch t t C st km theo khng b) Thm Khm: Du hiu mt nc: - Tri gic: Li b, kh nh thc, mt tri gic, hoc kch thch vt v. - Mt c trng khng. - Khng ung c hoc ung km, hoc ung ho hc, kht.

- Du vo da mt rt chm (> 2giy), hoc mt chm (< 2 giy). Du hiu bin chng: - Ri lon in gii: Co git, li b, hn m, bng chng, lit rut gim trng lc c . - Ri lon kim toan: Th nhanh su. - H ng huyt: v m hi, da nht, nhp tim nhanh, run git chi, ri lon tri gic, co git, hn m. - Suy thn cp: tiu t, ph, cao huyt p, l . Du hiu gp phn: - Suy inh ng: nh ga a vo bng cn nng / chiu cao - Bnh i km: vim phi, vim tai gia, nhim trng huyt c) Cn lm sng: X t nghim mu: khi c st, tiu phn c mu, c du hiu mt nc. Phn: - Soi phn khi nghi ng l hoc phn c m, nghi ng t (vng dch t, phn nh nc vo go, lng rt nhiu), hoc nhim trng nng. - Cy phn : khi iu tr tht bi. X t nghim khc : - Ion , ng huyt, kh mu khi nghi ng. - Chc nng thn khi nghi ng c suy thn. - Siu m bng: khi tiu mu, au bng, chng bng, i nhiu - XQ bng khng chun b khi bng chng. - XQ phi khi c nghi ng vim phi. - ECG khi Kali mu < 2,5mEq / L hoc >6,5 mEq / L. 2. Chn on a) Mc mt nc:

b) Chn on bin chng: Ri lon in gii : - Ri lon Natri + H Natri: Na < 125 mEq / L: i, co rt c, l m Na < 115 mEq / L: hn m, co git + Tng Natri: khi Natri mu > 145 mEq / L - Ri lon kali mu : + H kali mu: Kali < 3,5 mEq / L C : yu c , yu chi , lit rut , bng chng Tim: chm ti phn cc ca tm tht: ST xp, T gim bin , xut hin sng U. Nu gim kali mu qu nng: PR ko di, QT dn rng, ri lon nhp (ging ng c digitalis ). + Tng kali mu : Kali > 5 mEq / L C : yu c Tim : T cao nhn, QT ngn (K+ = 6.5 mEq / L), block A-V, rung tht (K+ 9 mEq / L) Ri lon toan kim: Thng l toan chuyn ha: pH mu ng mch < 7,2 , HCO3- < 15 mEq / L, nhp th nhanh su H ng huyt: ng huyt < 45 mg% Suy thn cp: BUN, Creatinin / mu tng. III. IU TR 1. Nguyn tc iu tr : iu tr c hiu: mt nc, khng sinh. X tr kp thi cc bin chng. Dinh ng. 2. X tr ban u : X tr cp cu X tr sc, co git, ri lon in gii, suy thn (xem phc tng ng) X tr h ng huyt: - Cho ung nc ng 50 ml (1mung c ph ng pha 50ml nc chn) - Hoc truyn TM Glucose 10% 5ml / kg / 15 pht X tr toan chuyn ha :

- Khi PH mu ng mch < 7,2 hoc HCO3 < 15 mEq/L - Lng HCO3 cn b tnh theo cng thc : HCO3 ( mmol ) = Base excess 0,3 P ( Kg ) 1ml NaHCO3 8,5% = 1 mmol HCO32. iu tr c hiu a) iu tr mt nc: iu tr mt nc nng: - Bt u truyn TM ngay lp tc. Trong khi thit lp ng truyn cho ung Oresol nu tr ung c - Dch truyn c la chn: Dextrose 5% in Lactate ringer hoc Lactate ringer. Nu khng c 2 loi trn dng Normal saline - Cho 100ml / Kg dung dch c la chn chia nh sau :

* Lp li ln na nu mch quay vn yu hoc khng bt c r . - nh gi li mi 15 30 pht n khi mch quay mnh. Nu tnh trng mt nc khng ci thin cho dch truyn tc nhanh hn sau nh gi li t nht mi gi cho n khi tnh trng mt nc ci thin. - Khi truyn lng dch truyn nh gi li tnh trng mt nc + Nu vn cn cc du hiu mt nc nng: truyn ln th 2 vi s lng trong thi gian nh trn. + Nu ci thin nhng cn u hiu c mt nc: Ngng ch truyn v cho ung Oresol trong 4 gi (phc B). Nu tr b m khuyn khch cho b thng xuyn. + Nu khng cn du mt nc: iu tr theo phc A v khuyn khch b m thng xuyn. Theo di tr t nht 6 gi trc khi cho xut vin . * Khi tr c th ung c (thng sau 3-4 gi i vi tr nh 1-2 gi i vi tr ln) cho ung Oresol (5ml / Kg / gi). iu tr c mt nc: - B dch bng Oresol 75 ml / kg ung trong 4 6 gi - Tr < 6 thng khng b sa m, c cho ung thm 100 200ml nc sch trong khi b nc. - Nu ung Oresol km < 20ml / Kg / gi: t sonde d dy nh git.

- Nu c bng chng hoc nn i lin tc trn 4 ln trong 2 4 gi hoc tc thi phn cao (>10ml / kg/ gi), hoc > 10 ln, TTM Lactate Ringer 75ml/ kg trong 4 gi. b) iu tr duy tr (phng nga mt nc): Cho bnh nhi ung nhiu nc hn bnh thng: nc chn, nc tri cy (nc da), nc cho mui, dung dch Oresol ... Trnh khng cho bnh nhi ung nc ng, nc ngt cng nghip Nu cho dung dch Oresol (ORS), p dng liu lng theo bng hng dn i y :

c) iu tr khng sinh: Ch nhng bnh nhn tiu chy phn c mu hoc nghi ng t mi cho khng sinh (xem phc iu tr l) Soi phn c vi trng dng t lin h chuyn Trung Tm Bnh Nhit i. ) iu tr h tr: Trong 4 gi u tin b nc khng cho tr n g ngoi sa m Tr iu tr phc B nn cho n sau 4 gi iu tr Khuyn khch tr n t nht 6 ln / ngy v tip tc nh vy 2 tun sau khi tiu chy ngng. IV .THEO DI V TI KHM Tiu chy cp: ti khm ngay khi c 1 trong cc du hiu nh: n ung km, st cao, nn i nhiu, tiu chy nhiu, phn c mu, kht nc nhiu, tr khng kh ln trong 3 ngy. V. CH NH NHP VIN: Mt nc nng C mt nc Mt nc nh c bin chng. Vn Mc chng c: S dng thng qui sa khng c lactose cho tr tiu chy cp l khng cn thit. Cc thuc chng nhu ng rut (nh n xut thuc phin), thuc hp ph

(kaolin, pectin), bishmus salicylate khng c khuyn co dng trong tiu chy cp. B dch bng ng ung trong iu tr tiu chy cp l phng php an ton v hiu qu, ch tht bi 3.6 %

S51. SUY DINH DNG


I - I CNG: 1/ nh ngha: Suy inh ng(SDD) l mt bnh o c th thiu Protein, nng lng v cc vi cht inh ng; Bnh hay gp tr em < 5 tui; nh hng ti s pht trin ca tr; tr SDD d mc cc bnh nhim khun, din bin thng nng-> t vong.

2/ c im: - Trn th gii 500 triu tr em SDD/ 1 nm - Vit nam c khong 40% tr suy inh ng < 5 tui .

3/ Nguyn nhn: 3.1/ Nguyn nhn do dinh dng: - Do m khng c sa hoc thiu sa phi nui sa nhn to - n b sung qu sm hoc qu mun khng ng khu phn n - Cai sa sm. 3.2/ Nguyn nhn do nhim trng: - Nguyn nhn cp tnh: vim phi, a chy cp - Nhim trng mn: lao, si, ri lon tiu ha ko di. - Mt s bnh do k sinh trng: giun, sn. 3.3/ Nhng yu t thun li: - Tr non, thiu cn.

- D tt bm sinh: sc mi, h hm ch, bnh tim bm sinh. - Kinh t kh khn.

4/ Phn loi : 4.1/ Phn loi theo mc SDD: *Phn loi theo t chc YTTG( 1981)(OMS): S dng biu pht trin theo di tnh trng inh ng ca tr em( da vo cn nng theo tui). Nu i 2 lch chun(-2SD) so vi qun th tham kho NCHS ca hoa kz th c coi l suy inh ng. + SDD I: cn ng i 2SD n 3SD tng ng vi cn nng cn 70-80% so vi cn nng tr bnh thng. + SDD II: cn ng i 3SD n 4SD tng ng vi cn nng cn 60-70% so vi cn nng tr bnh thng. + SDD III: cn ng i 4SD tng ng vi cn nng cn i 60% so vi cn nng tr bnh thng. *Phn loi ca Gomez F ( 1956): + Thiu inh ng I tng ng vi 75-90% cn nng chun. + Thiu inh ng II tng ng vi 60-75% cn nng chun. + Thiu inh ng III tng ng vi < 60% cn nng chun. *Phn loi ca Waterlow JC(1976): + Suy inh ng th gy cm( hin ang thiu inh ng):tng cn nng theo chiu cao thp hn so vi chun. + SDD th ci cc( thiu inh ng th trng din): chiu cao thp hn so vi chun. 4.2/ Phn loi theo cc th SDD ca Wellcome()1970nh gi cn ng theo tui v phi hp vi triu chng ph phn bit gia Marasmus v Kwashiorkor: -> lu {: + Th Marasmus: ch yu gim nng lng. + Th Kwashiorkor: ch yu gim Protid.

5/ C ch bnh sinh:

- Do thiu nng lng v Protein trong thc n-> c th phi huy ng nng lng d tr gan, lp m i da-> a teo t. - Do thiu Protid trong thc n nn Proti mu ( c bit l Albumin mu ) gim -> gim p lc keo-> ph. - Do gim Protid mu -> gim khng th-> mc cc bnh nhim khun. - Do thiu Protid, thiu cc aci amin c bit l acid amin hu m nn -> gan to, thoi ha m. - Do thiu nng lng-> qu trnh chuyn ha b d dang-> ng Xeton-> nhim toan chuyn ha.

II - TRIU CHNG:

1/ Lm sng: 1.1/ Suy dinh dng mc nh( I): - Cn ng i 2SD n 3SD tng ng vi cn nng cn 70-80% so vi cn nng tr bnh thng. - Lp m i da bng mng. - Tr vn thm n v cha c biu hin ri lon tiu ha. 1.2/ Suy dinh dng mc va( II) - Cn ng i 3SD n 4SD tng ng vi cn nng cn 60-70% so vi cn nng tr bnh thng. - Mt lp m i da bng, mng v chi. - Ri lon tiu ha tng t, tr k m n 1.3/ Suy dinh dng mc nng( III): *Suy dinh dng th teo t: + Cn ng i 4SD tng ng vi cn nng cn i 60% so vi cn nng tr bnh thng. + Mt ton b lp m i da bng, mng, chi -> tr teo t, a bc xng , v mt c gi. + C nho -> nh hng n s vn ng ca tr.

+ Tinh thn mt mi, t phn ng vi ngoi cnh, tr hay quy khc, khng chu chi. + Tr km theo n hoc k m n. + Thng xuyn c ri lon tiu ha: a chy, phn sng. + Gan to hoc bnh thng. *Th ph (Kwashiorkor): + Cn nng st t 20-40% so vi cn nng ca tr bnh thng ( xp x -2SD n -4SD). + Ph ton thn: ph trng, mm, n lm. + Xut hin cc mng sc t i da + Ri lon tiu ha nng: phn sng, lng, nhy m. + Tr n k m, nn, tr. + Tc tha, rng, mng mm d gy. + Km vn ng. *Th phi hp (Marasmus- Kwashiorkor): + Cn nng st > 40% so vi cn nng tr bnh thng. + Ph ton thn. + Mt lp m i da. + Ri lon tiu ha nng + Thiu mu, m la do thiu Vitamin A.

2/ Cn lm sng: - CTM: HC bnh thng hoc gim; HST; Hematocrid ; Mu lng ; Glucose ; Protid; - XN nc tiu: nc tiu t, mu vng, c th c t Albumin. T l Ure/Creatinin gim. - Phn: C nhiu cht cha tiu ha. - Dch tiu ha: toan ton phn, toan t do, men pepsin, trypsin dch rut v t trng u gim. - Min dch: IgA gim - XQ: c du hiu long xng , im ct ha chm.

III - CHN ON:

1/ Chn on nguyn nhn: - Do nguyn nhn n ung. - Do mc bnh nhim khun( cp hoc mn). - Do c th mc cc d vt.

2/ Chn on mc : theo t chc YTTG(1981)

3/ Chn on theo th lm lm sng Marasmus ; Kwashiorkor hay th hn hp Marasmus- Kwashiorkor

IV - IU TR: 1/ Suy dinh dng mc nh v va ( c th iu tr ti nh): + Ch n: - iu chnh ch n theo vung thc n. - Nu tr ang cn b th tip tc cho b - Khi tr cai sa th cho ung sa b, u nnh + iu tr cc bnh nhim khun nu c + Hng dn cho b m bit cch nui tr khoa hc v cch iu tr ngoi tr. 2/ Suy dinh dng mc nng( iu tr ti bnh vin): 2.1/ B nc- in gii: + Nu mt nc nh- trung bnh th: - Ung Oresol 50-100ml/kg x 6 h u. - Sau 6h nh gi li kt qu: . Nu tnh trng bnh khng thay i: tip tc cho ung . Nu tnh trng bnh nng ln th phitruyn Ringer lactatcho n khi ht du hiu mt nc

2.2/ Ch n: - Vi khu phn n phi tng n t 90-200Kcal/kg/24h; duy tr 120kcal/kg/24h. - Protein tng t 2-7g/kg/24h; duy tr 5g/kg/24h( ch yu l Proti ng vt); - Nu tr khng chu n phi a qua son e 2.3/ Bi ph Vitamin v khong cht: + Ung Vitamin A: - Tr i 1 tui: . Ngy th 1: Vitamin A 100.000 UI/ung . Ngy th 2: Vitamin A 100.000 UI/ung . Sau 2 tun : Vitamin A 100.000 UI/ung - Tr > 1 tui: dng vi liu gp i - Nu tr nn, a chy nhiu th ng ng tim liu =1/2 ng ung - Nh mt Vitamin A, Chloramphenicol 0,4% x 2-3ln/24h - Mui khong K+ 1 g/24h x 2 tun. 2.4/ iu tr thiu mu: + Khi Hb < 4g/dl th c ch nh truyn mu - S lng mu truyn t 10-15ml/kg; tt nht l truyn khi HC - Vin st 0,05-,1g/24h dng trong 3 thng. - Acid Folic 5g/24h dng 2 tun n 2 thng 2.5/ chng nhim khun: 2.6/ iu tr cc triu chng khc: - Chng h ng huyt: ung nc ng, sa hoc truyn TM gluycose 2030%. - Chng h nhit bng m, m nm gn con. - Chm sc a: v sinh da, nu c l lot th chem. xanh methylen hoc du c 2-3 ln/24h

3/ Phng bnh: - Chm sc tr ngay t trong bng m. - Gio dc nui con bng sa m v b sung - Tim chng

- Theo di cn nng. - Sinh c k hoch.

S52. TO BN
To bn c c trng bi khong cch gia hai ln i ngoi qu lu. phn rn, kh khn khi bi xut phn. (Tuz theo tng la tui - khong cch gia 2 ln bi xut phn c th thay i) : 1. Chn on to bn : Khong cch gia 2 ln bi xut phn i hn bnh thng theo la tui. 4 ln/ngy (tun u); 1,7 ln/ngy t 2 tui. (1) (2) (3) Phn rn, nh nh phn hoc qu to. Tr i ngoi kh khn khng t i ngoi c, au, sn phn. Km theo hoc khng km theo cc triu chng ton thn : au bng. Ln cn chm. Chn n, bun nn.

Bng chng - s c nhiu cc phn khung i trng. Thm hu mn : Tuz theo nguyn nhn to bn thc th hoc c nng m c cc triu chng : khng c phn, hoc y phn trong bng trc trng. Phn loi to bn theo : Din bin : To bn cp tnh: to bn vi ngy, mt t, vi tun. To bn mn tnh: ko di vi thng. C ch bnh sinh :

To bn do ri lon c nng. To bn do nguyn nhn thc th. Theo nguyn nhn chia ra : To bn do ri lon c nng. To bn do nguyn nhn thn kinh. To bn do nguyn nhn thc th gy tc nghn rut. To bn do nguyn nhn ni tit, chuyn ho. 2. iu tr : 2.1.Ch n ung : n nhiu rau, nc, qu, ng cc (20 -30 g/24 gi), ung nhiu nc. Nu m cho con b b to bn cn iu tr to bn cho m. 2.2.Thuc : * To bn cp tnh : khng dng ko di Tr nh: Microlax bb (Sorbitol 70%) 1 ng bm vo hu mn trc trng. Lauryl sulfoacitate Na, citratc Na) x 1 tube 1 ln. Tr ln: Microlax 1 ng (gp 2 ln liu lng Microlax bb x 1 tube 1 ln. * Thuc lm mm phn: Thuc nhun trng. + Docusate Sodique. (5 - 10 mgr/kg/24gi chia 2 ln - 3 ln. Trong vi ngy hoc vi tun. Tr ln ti a 200 mg/24gi. Norgalax Noboldolaxine. + Lactulose dung dch ung 10%: < 1 tui 5 - 20 ml ung 1ln/ngy

(Dufalac) 1ln gim liu b tiu chy

1 - 6 tui: 10 - 20 ml ung 7 - 14 tui: 20 - 50 ml ung

1ln/ngy sau uy tr 20 ml/ngy. 1 - 2 ml/kg/ngy Tr ln > 14 tui 50 ml ung 1 ln ngy khi u sau uy tr 20 ml/ngy + Du parafine: Trnh dng tr em 1 tui( nguy c cht sc). Liu ban u 3ml/kg/24 gi ung lm 2 ln c th tng n ti ti a 12ml/kg/24 gi (c th t mt ha vi nc cam) + Sulfat Magie: 2gr - 5gr ung vo bui sng. + PEG: Poly ethylne glycol. + Tht tho: ng nc m pha glyxerin: tr <1 tui 30 - 100 ml tr >1 tui 100 - 250 ml. +Sorbitol. 5gr; 1 gi - 1 gi /ngy ung hng ngy vo bui sng. 1. iu tr nt hu mn nu t a mu ti t u ti cui bi, c vt nt hu mn + Ra sch hu mn sau khi i ngoi. + Bi dung dch Nitrat Bc hoc Xanh Methyline : 2 ln/ngy.

S53. VIM GAN VIRUS CP


L bnh nhim trng do cc virus vim gan gy nn ; hin xc nh c t nht 6 loi : virus vim gan A (HAV), B (HBV), C (HCV), D (HDV), E (HEV) v G (HGV). HAV v HEV ch yu ly truyn qua ng tiu ho, cc virus vim gan cn li ch yu ly truyn qua ng mu ; song tt c u gy tn thng ch yu gan v

c bnh cnh lm sng giai on cp tnh ging nhau, t th khng r triu chng ti th suy gan cp. Vit Nam vim gan virus ch yu do HAV, HBV v HCV. 1. Chn on : Da vo lm ng v cc xt nghim sau 1.1. Lm sng : Biu hin lm sng thay i tuz theo thi kz bnh.

Thi kz tin hong m :

Thng ko di 7 10 ngy vi cc biu hin sau : Cc triu chng gi cm : st, mt mi, vim long ng h hp trn.

Cc triu chng tiu ho : chn n, bun nn, nn, c th tiu chy, y bng, au bng tr b m c th phn bc mu.

Gan c th to n au, c th au nh lin sn phi, nc tiu sm mu. Thi kz hong m :

Hi chng vng da - i nc tiu sm mu, vng da v nim mc (thng ko di 3-4 tun, vi cc th thng thng, cc triu chng c nng thng gim dn). Thng c gan to, n au, c th gp lch to (tuy nhin nu kch thc gan thu nh th tin lng xu). Bnh xut hin khng lin quan ti ng c hoc dng mt s loi thuc c vi gan v ti mt s bnh nhim trng khc (st rt, thng hn, nhim trng huyt, lao, v.v).

Thi kz hi phc :

Ht vng da, cc triu chng gim nhiu.

1.2. Xt nghim : Transaminase tng cao trong mu (thng tng hn bnh thng ti vi chc ln). Bilirubin mu thng tng, ch yu tng loi trc tip. Nc tiu : c mui mt, sc t mt. T l prothrombin c th gim.

Cc xt nghim tm cc du hiu ca virus vim gan nh Anti HAV IgM (+) trong vim gan A, HBsAg (+) v Anti HBcAg-IgM (+) trong vim gan B, Anti HCV (hin cha tch bit c loi IgG hay IgM) (+) trong vim gan C. 2. iu tr Nguyn tc iu tr : Ch yu l ch ngh ngi, n ung hp l{ v iu tr h tr. Ch ngh ngi : Nm ti ging, hn ch ti a cc vn ng c bp v hot ng tr c cho ti ht thi kz hong m. Trnh gng sc sau 3-6 thng tip theo. Ch n ung : n cc thc n tiu ho, hn ch m, du v tt c cc loi gia v, khng s dng cc nc ung c ga v tt c cc loi bia ru, tng cc loi rau, hoa qu, tinh bt, ng. Cc thuc h tr :

+ Truyn dung dch Glucoza 5% hoc 10% (30-50ml/kg/24h) trong thi kz vng da.

+ Dng cc loi vitamin nhm B (B1, B2, B6) v cc thuc b tr gan, chng xy ho (Anti oxy ant) nh : Legalon, Fotex, Carsil, v.v v cung cp cc yu t vi lng. + Vitamin K (nu t l prothrombin gim) liu 5mg/ngy trong 3 ngy. + Ch dng Corticoid trong cc th c bit (th tc mt, th din bin ko di hoc c nguy c hn m gan). + Khng dng cc loi thuc an thn, h st. Thn trng khi dng khng sinh (nu c nhim tng khc km theo). Tiu chun xut vin : Ht hong m. n ng bnh thng. Transaminase xu hng v bnh thng.

Khm li v lm xt nghim Bilirubin, Transaminase hng thng trong vng 6 thng, theo di cc du n ca virus vim gan (nu l vim gan do HBV hoc HCV phng kh nng in bin ti th mn tnh).

S54. LOT D DY T TRNG


Vim lot d dy t trng l tnh trng bnh l vim v mt t chc nim mc c gii hn phn ng tiu ho c bi tit acide v pepsin. Vim v lot d y t trng trc y l hai khi nim khc nhau, 10 nm tr li y vi nhng lin kt c ch bnh sinh v chn on cho thy vim v lot DDTT lun phi hp v lin quan cht ch vi nhau. Phn loi :

1. Vim, lot DDTT cp tnh - th pht khng lin quan n nhim Helicobater Pylory. Lin quan n stress, bng nng, chn thng nng, cc thuc Corticoid, NSAID, bnh ton thn nh bnh Crohn, bnh t min. 2. Vin lot DDTT mn tnh - tin pht lin quan ti tnh trng nhim HP. 1. Chn on : 1.1. Vim; lot DDTT cp tnh - th pht : 1.1.1.Triu chng lm sng t ngt, nng, cp tnh gp mi la tui Nn ra mu - xut huyt tiu ho, a phn en. Thng tng rng (giai on s sinh), chng bng.

- Bnh cnh, sc, bng, chn thng, ung thuc Cortiroid, aspirin, u no, vim no. Khng c tin s au bng, nn ko di.

- Triu chng au bng khng r rt. 1.1.2. Ni soi : Nim mc ph, n, lot cht, nhiu lot nng chy mu. - Vim d dy cp tnh clotest (-) HP (-).

1.2. Vim, lot DDTT mn tnh tin pht : 1.2.1 Triu chng lm sng: thng gp tr ln. + Tin s : au bng ko di; tin s xut huyt tiu ho ti pht; - au, y bng, kh tiu thng gp trong vim d dy mn tnh tin pht - au, xut huyt tiu ho k o i thng gp trong LDDTT mn tnh tin pht. + Triu chng lm sng:

VDDMT: - au bng k o i, y bng, kh tiu, hi, chua. - Nn, chn n chm ln cn. Lot DDTMT: - au bng thng v k o i, nn, k m n - Xut huyt tiu ho: nn ra mu, a phn en, thiu mu - Nn thng xuyn khi c hp mn v. 1.2.2. Cn lm sng : Cng thc mu : thiu mu nhc sc, gim Hb.

Chp Xquang : khng c gi tr chn on vim DDTT - Chp i quang c th pht hin 50% lot DD v 75% lot TT. Ni soi : xt nghim c tnh cht quyt nh chn on; cn c tn thng ni soi i th, ly nim mc sinh thit lm test ureaza, xt nghim gii phu bnh hc tm HP. Xt nghim chn on phn bit vi au bng do nguyn nhn khc: vim tu, si tit liu v.v... Tm li chn on xc nh VLDDTT Da vo tin s v tnh cht lm sng

Ni soi : Vim DD cp, mn tnh; lot nng sau cp tnh ang chy mu, ph n Test ureaza (+) chng t s hin din ca HP

M bnh hc : mnh sinh thit vng hang v cch mn v 2 cm v b lot. chn on vi th vim, lot DD, tm HP. 2. Chn on phn bit : 2.1.

Chn on phn bit: La tui

VLDDTT tin pht Tr ln

VLDDTT th pht Mi la tui c bit t < 5 tui. Khng r C

Tin s au bng Tin s sc, chn thng, nhim trng nng Tin s ung thuc Corticoid, NONSAID. Triu chng lm sng ch yu Du hiu ni soi

C Khng

Khng

au bng ko di XHTH ti pht. Vim mn tnh, lot mn tnh HP (+)

Xut huyt tiu ho cp tnh

Vin cp tnh nng Lot nng, lot cht, nhiu HP (-)

Test ureaza

2.2.Chn on phn bit vi cc nguyn nhn gy au bng ko di au bng do bnh Shoenlein Henoch. au bng vim tu cp - vim tu mn au bng do gan mt: si mt, u nang ng mt ch. au bng do si tit niu, si thn niu qun, nc i b thn.

au bng o cc nguyn nhn khc: ng kinh th bng, au bng ko di khng r nguyn nhn. 3.iu tr : 3.1.Vim lot DDTT cp tnh th pht :

Loi b cc nguyn nhn gy bnh: iu tr si, iu tr bnh ton thn, chn thng, nhim trng nng... loi b thuc gy vim lot Corticoide, NSAID; nu khng loi b c c th d phng nguy c XHTH. iu tr cc thuc c ch bm proton hoc khng th th H2 - dng 4 tun.

Cimetidine 20 mg - 40 mg/kg/24gi ung lm 2 - 4 ln. Cp tnh c th tim tnh mch 4-6 ln (ti a tr ln 2,4g/24 gi) dng 4-6 tun; duy tr 5 mg/kg/ngy ung 1 liu vo ban m. iu tr k o i 1 nm. Ranitidine 2 - 6 mgr/kg/24 gi chia 2 ln ung hoc tim tnh mch 2 ln (ti a tr ln 300 mg/24 gi) Ommazole dng tr ln 20 mg - 40 mg/24 gi/ ung 2 ln (20mg/1,73 m2 da. 1mgr/kg/ngy ti a 20 mgr ung 2 ln). Thuc bc: Sucralfate, 1gr/1,73 m2 ung1/2 gi sau khi n v trc khi i ng. Thuc trung ho Acid: (Phosphalugel, Maalox) 0,5 - 1,0 ml/kg ung 3 gi sau khi n v trc lc i ng Truyn mu cp nu XHTH cp tnh X tr ngoi khoa nu pht hin c thng d dy.

3.2.Vim, lot DDTT mn tnh tin pht iu tr lm sch Helicobacter Pylori :


Amoxixilline 50 mgr/kg/ngy (ti a 750 mg) chia 2 ln ung trong 14 ngy Metronidazole 20 - 30 mg/kg/ngy (ti a 500 mg) chia 2 ln ung, ung trong 14 ngy.

Clarithromycin 15 mg/kg ti a 500 mgr/ngy chia 2 ln thng c dng khi khng metronidazole.

Tr ln > 12 tui c th dng Tetraxyclim 50 mgr/kg/ngy chia 2 ln.

Phi hp khng sinh v thuc khng sinh bi tit aci . iu tr vim lot DDTT c lin quan ti Helicobacter Pylori.

La chn : La chn u tin Phi hp thuc. Amoxixiclin + Metronidazole + Omeprazole Amoxixiclin + Clarithromyxin + Omeprazole Clarith romyxin + Metronidazole + Omeprazole (2 ln/ngy dng trong 14 ngy) La chn bc hai nu bc 1 tht bi Bismuth + Metronidazole + Omeprazole hoc Metronidazole thay bng Tetraxylin hoc Clarithromyxin dng 4 tun l Ranitidine bismuth citrate + Clarithromyxin + Metronidazole (1 vin x 4 ln/ ngy) dng 4 tun l. Thuc c ch thc th H2: Gim bi tit Acid.HCL v thuc c ch bm Proton dng lin trong 4 - 6 tun l, k c sau khi kt hp vi thuc lm sch HP. Thuc c ch bm proton: Omeprazole 1 mg/kg/ngy ti a 20 mgr chia 2 ln ngy. trong 14 ngy ( Xem phn thuc c ch bi tit acid: thuc khng th th H2 v thuc c ch bm proton. Phn iu tr vim lot DDTT cp tnh tin pht). Thuc bc - Thuc trung ho axit (xem phn iu tr VLDDTT th pht cp tnh). Ch n (trnh thc n cay, chua). Ch ngh ngi - Trnh cho tr hc tp qu cng thng, thnh stress vi tr.

S55. VNG DA DO BT NG NHM MU ABO


I. I CNG: Bt ng nhm mu ABO thng gp tr c nhm mu A hay B vi b m c nhm mu O. y l tnh trng tn huyt ng min dch gy nn khi c bt ng nhm mu ABO gia b m v tr s sinh. Qu trnh tn huyt bt u t trong t cung v l kt qu ca qu trnh vn chuyn ch ng ng khng th ca m qua nhau thai. b m c nhm mu O, ng khng th chim u th l 7S-IgG v c kh nng xuyn qua mng nhau thai. V kch thc ln nn ng khng th 19SIgM gp b m c nhm mu A hay B khng th bng qua nhau thai. T l mc bnh xy ra khong 12-15 % nhng test e Coombs trc tip ch ng tnh khong 3-4%. Bnh tn huyt do bt ng nhm mu ABO c triu chng ch xy ra i 1% tt c tr s sinh nhng n chim khong 2/3 trng hp bnh thiu mu tn huyt tr. II. CHN ON: 1. Cng vic chn on: a) Hi : Thi gian xut hin vng da: ngy th my sau sanh. B k m, b b. Co git. Tin s vng da ca anh/ch. b) Khm: nh gi mc vng a: u-thn, n tay chn, ton thn n lng bn tay-bn chn. Thiu mu. Trng lc c, phn x nguyn pht. Thp: khng phng. c) ngh xt nghim: Nhm mu m v con Pht mu ngoi bin, Hct, CRP

nh lng Bilirubin/mu. Test e Coombs Nu c phng tin nn nh lng khng th IgG anti-A hay anti-B trong mu m v khng th tng t trn hng cu con. 2. Chn on xc nh: Vng da sm N1-2 + nhm mu m O, con A hoc B + test Coombs (+) 3. Chn on c th: Vng da sm N1-2 + nhm mu m O, con A hoc B III. IU TR: 1. Nguyn tc: iu tr c hiu: chiu n, thay mu iu tr h tr: Duy tr dch v nng lng, iu tr nhng yu t nguy c gp phn lm nng thm tnh trng vng da (nhim trng, s dng thuc gy tn huyt, ngt) 2. Chiu n liu php: Khi tr c vng da do bt ng nhm mu ABO cn ch nh cho chiu n khi:

Nu khng c kt qu Bilirubin sm, ch nh chiu n ch cn da vo lm sng: mc vng a (xem bi vng a s sinh) S dng n nh sng trng hay nh sng xanh, s lng t 6-8 bng,

khong cch t n n tr khong 30 - 40cm. Cn che mt tr khi chiu n. Tng nhu cu dch: 10-20 mL/kg/ngy 3. Truyn thay mu: Ch nh: Tr vng da do bt ng nhm mu ABO c du hiu vng da nng (vng da sm n bn tay bn chn hay km b km b b) v mc bilirubin mu (bng 1 & 2) Chn nhm mu thay: mu ti ( 3 ngy) nhm mu O c nng khng th anti -A v anti-B thp. Thay qua tnh mch rn, s lng mu thay= 160ml/kg/ ln thay.

S56. VIM LOT D DY T TRNG


I. NH NGHA Vim lot d dy t trng (ddtt) do dch v ch mt hay nhiu vng nim mc d dy t trng khng cn nguyn vn cu trc hay c thay i trn m hc, nhng tn thng ny thay i theo din tch, su, v tr, giai on bnh v nguyn nhn. Theo bnh sinh: Lot ddtt nguyn pht: Khi khng c bnh nn, bnh km theo hay thuc ph hy nim mc gy ra, vi trng Helicobacter Pylori c xem l nguyn nhn quan trng. Lot ddtt th pht: xy ra khi bnh nhn c bnh nn nh ngt th, th my, bng, chn thng u, u no, xut huyt no hay do thuc gy ra. II. CHN ON 1. Cng vic chn on a) Hi tin s: V tr au, thi gian au, au cn hay lin tc, au c lan i ni khc khng, cng au, au c lin h n i tiu hay ba n khng, c tng ln khi n khng, cch lm gim au, triu chng km theo khi

au, s ln au trong tun, trong thng. Ngi trong gia nh c ai au nh th khng, c ai au bao t khng? Tr c ung loi thuc g nh hng n bao t khng? C thay i g trong ch n trc khi au? St? Tiu vng? Tiu au? b) Thm khm: V u hiu lm sng v triu chng thc th ca bnh lot ddtt rt ngho nn nn bt u t chn on loi tr. Tm du hiu thiu mu, khm tt c c quan gan, ti mt, tit niu, thm trc trng. Du hiu suy inh ng. i khi thy du hiu bin chng nh xut huyt tiu ha (tiu phn en, i mu, thiu mu) hay hp mn v. c) ngh xt nghim: Chp xq ddtt c sa son: xc nh c 50 % lot dd v 89 % lot tt. Ni soi tt: chnh xc hn X quang, qua ni soi cn sinh thit kho st m hc tm nguyn nhn. Cng thc mu, men gan, amylase mu, tng phn tch nc tiu, soi phn, siu m: khi cn loi tr cc nguyn nhn au bng khc. 2. Chn on a) Chn on c th: au thng v khi n, i, tiu phn en, gia nh c tin s vim lot ddtt l yu t gip chn on. Khng c triu chng bnh ca c quan khc, xt nghim khc trong gii hn bnh thng. Bnh nhn khng c triu chng nng c th iu tr th. Nu bnh nhn khng gim hay c du hiu nng thm s tin hnh ni soi. b) Chn on nguyn pht hay th pht:

c) Chn on xc nh: Xq dy t trng c sa son baryte c hnh nh nim mc ph n, ng thuc.

Ni soi c th thy vim xung huyt, lot, nim mc khng u, tro ngc dch mt. X t nghim m hc: trong khi ni soi dd sinh thit vng hang v cch l mn v 2 cm, nhum eosin v trichome tm Helicobacter. d) Chn on phn bit: au bng chc nng: au quanh rn t ngt thng xy ra bui chiu ti, c c ng bt thng trong cn au, nhc u, chng mt. Ri lon co tht ng mt: au vng ti mt, im Murphy, i, vng mt. Vim ti mt: au, i, st, vng da, siu m bt thng. U nang ng mt ch: khi vng bng, au bng, siu m c nang dch. Vim gan : st nh vng kt mc, tiu vng, gan to au, men gan tng Vim ty : cn au cp tnh d di, amlylase tng. Vim dy rut do eosinophile Henoch scholein: c ban mu 2 chi i, au khp Nhim trng ng tiu, si thn: c du hiu bt thng trong tng phn tch nc tiu. III. IU TR iu tr vim lot d dy t trng ty thuc nguyn nhn. 1. Vim lot nguyn pht pht hin c Helocobacter pylori Thoi gian iu tr t 7 n 14 ngy:

2. Vim lot th pht Loi b yu t gy bnh, c th d phng nu khng loi b c yu t gy bnh. iu tr thuc c ch bm proton, hoc khng thc th H2 trong 4 tun. 3. Dinh ng: n y cc thc n theo 4 vung thc phm, king cc thc n kch thch.

S57. DINH DNG NG TNH MCH HON TON


I. I CNG:

Dinh ng ng tnh mch hon ton l a cc cht inh ng qua ng tnh mch vo mu nui ng c th. Cc cht dinh ng bao gm: protein, carbohy rate, lipi , nc, mui khong v cc cht vi lng. II. CH NH: Khi c chng ch nh inh ng ng tiu ha: - Giai on sm hu phu ng tiu ha. - Suy h hp c ch nh gip th (giai on u). - Xut huyt tiu ha. - Hn m km co git. Khi inh ng qua ng tiu ha khng hiu qu: hi chng rut ngn, hi chng km hp thu. III. NGUYN TC: Cung cp y nng lng v cc cht inh ng. Cc cht inh ng c a vo c th phi cng lc, chm v u n trong ngy. IV. CC BC TIN HNH: 1. nh gi bnh nhn: Du hiu sinh tn. Cn nng. Tnh trng inh ng hin ti. Bnh l hin ti v bnh nn: suy gan, suy thn, suy h hp. 2. Xt nghim: CTM, m tiu cu, ion , ng huyt. 3. Tnh nhu cu nng lng cn thit

Nhu cu nng lng tr bnh thng

Nhu cu nng lng : Trong nhng ngy u ch cn cung cp 40 - 50% nhu cu nng lng c bn (nhu cu c bn # 55 65 Kcalo/kg), tng n trong nhng ngy sau. 4. Tnh nhu cu dch cn thit (A): Nhu cu dch hng ngy tr bnh thng :

Ty theo tnh trng bnh l, nhu cu dch thay i so vi nhu cu c bn (NCCB)

5. Tnh thnh phn Protein (B), Lipid (C): Protein: bt u vi liu thp 1,5 g/Kg/ng, tng n t liu ti a 2,5 3 g/Kg/ng vo N3. Lipi : bt u vi liu thp 1 g/Kg/ng, tng n t liu ti a 3 g/Kg/ng vo N3.

6. Tnh th tch in gii :

7. Tnh th tch Glucose (D):

Th tch Glucose = Tng th tch (Th tch Protein + Th tch Lipid) n gin khng cn tr lng th tch in gii v t Tnh thnh phn Glucose 30 % v Glucose 10% hn hp dung dch Glucose Aci amin t c nng Glucose l 10 12,5% Thc t hin nay vic inh ng TM hon ton qua ng TM trung tm cn rt nhiu hn ch, ch yu l qua ng TM ngoi bin. V th khi tnh ton phi m bo nng Glucose trong chai dch truyn l < 12,5% T l th tch Glucose 30% v Glucose 10% t nng Glucose trn l : 1/6 Trng hp c ng TM trung tm th c th truyn dung dch c nng Glucose cao hn. 8. Tnh Osmol ca hn hp dung dch Glucose Acid amin in gii Ch tnh Osmol ca hn hp dung dch Glucose Acid amin v Lipid c truyn ring Cng thc:

truyn qua TM ngoi bin, Osmol phi < 1100 mOsmol/L 9. Tnh nng lng thc t cung cp :

V. CCH TRUYN TNH MCH CC DUNG DCH DINH DNG : 1. Cch pha dch: DD m v ng , in gii c th pha chung. DD lipi phi c truyn ring. C th truyn cng lc dung dch Lipid vi dung dch m-ng qua ba chia. 2. Chn tnh mch truyn: Tnh mch ngoi bin (TM mu bn tay, TM c tay, TM khuu tay, TM c chn): truyn dung dch < 1100 mOsm/L. Tnh mch trung tm (TM cnh trong, cnh ngoi, i n) : truyn dung dch > 1100 mOsm/L hoc dung dch Dextrose >12,5%. Xem xt ch nh t Implantrofix trong trng hp cn inh ng TM trung tm di ngy.

3. Tc truyn: DD m v ng, in gii nn c truyn lin tc sut 24 gi. DD lipi thng c truyn t 12 18 gi (c thi gian ngh nh gi tnh trng hp thu ca c th). 4. Dinh ng TM bn phn : Sm chuyn sang inh ng TM bn phn khi bnh nhn ht chng ch nh nui n ng tiu ha, hoc inh ng hon ton ng tiu ha. 5. Yu t vi lng v Vitamin : Nu bnh nhn c nui n tnh mch trn 2 tun cn b sung cc yu t vi lng v vitamine qua ng tnh mch Yu t vi lng : Nu bnh nhn c nui n tnh mch trn hai tun th cn b sung c yu t vi lng v vitamin:

S58. LUNG TRO NGC D DY THC QUN


Tro ngc d dy thc qun l mt tnh trng bnh l{ ch s hin din thng xuyn cht cha ng trong d dy tro ngc vo thc qun gy nn nhng biu hin bnh l: h hp, tiu ho, suy inh ng, thm ch gy ngng tim, ngng th c th dn ti t vong tr em nh. LTNDDTQ thng gp : - Tr nh nn ch, tr non, tr m hp thc qun. - Tr mc bnh h hp mn tnh: vim tai mi hng mn tnh, ho ko di, hen - Tr s sinh c cn tm ti ri lon nhp th. - Tr bi no, hi chng Down, gim trng lc, chm pht trin tinh

thn vn ng 1.Chn on : Da vo cc biu hin lm sng v cn lm sng 1.1. Biu hin lm sng : Tiu ho : - Nn ch ko di c th gy chm pht trin th cht - suy inh ng. - n k m, n nut au lm tr khc, li n. - Nn mu s lng t . - Khc v m k o i. H hp : Thng gp bnh h hp mn tnh khi pht thng v m: - Ho ti pht - Vim tiu ph qun, kh kh ti pht nhiu ln - Vim phi do ht ti pht - Ho k o i khng r cn nguyn v m S sinh : - Ngng th, tm ti, ngt khi cho tr nm, thng xy ra trong m - Chm nhp tim. - T vong t ngt 1.2. Xt nghim cn lm sng : - o PH thc qun trong 24 gi: ( hin cha lm c) c gi tr chn on xc nh khi PH thc qun i 4 c coi l lung tro ngc d dy - thc qun,

cc t lung tro ngc d dy vo thc qun c ghi chp li trong 24 gi. Cc ch s nh gi c LTNDDTQ. Khi : 1) Thi gian xut hin lung tro ngc DDTQ >5% (bnh thng <5%/24 gi) 2) S t lung tro ngc DDTQ > 20 (bnh thng < 20 t/24 gi) 3) S t lung tro ngc DDTQ ko di > 4 ln (bnh thng < 4ln lung tro ngc > 5 pht). - Siu m ngc bng c > 3 ln tro ngc DDTQ trong 5 pht quan st. siu m c xem nh c LTNDDTQ. Chp Xquang d dy thc qun c thuc cn quang

1- Chiu t th u thp c th pht hin lung tro ngc DDTQ 2- Chp on i thc qun c th thy vim cht hp thc qun qun. Ni soi thc qun v sinh thit pht hin vim, lo t on i thc

1.3. Chn on xc nh Da vo tnh cht lm sng v hin din ca LTNDDTQ qua siu m, Xquang, ni soi, o PH on i thc qun trong 24 gi. 2. iu tr : 3.1.i vi tr c nn ch nhiu cha pht hin c LTNDDTQ hoc cha c iu kin thm LTNDDTQ Cho tr b trnh nut phi hi, b ng v lng sau b cho ti lc tr hi.

- Cho thc n c hn (cho thm tinh bt) chia nh ba n trnh nn ch, chia khong qu 7 ln/ ngy. - Trnh lm tng p lc trong bng tr: qun t hoc mc qun o qu cht, tr ho nhiu (ho g), rn a thng xuyn do to bn.

- Trnh cc thuc lm gin c tht i thc qun (adrenaline, anti cholinnergic, Xanthine, Salbutamol, Ephedrin) Cho tr nm u cao 300

2.2. i vi tr c nn ch, pht hin c LTNDDTQ; Vim thc qun qua ni soi. iu tr thi gian 8 tun - nu khng c kt qu sau hai thng ngng iu tr. 2.2.1. Cisapride (Prepulsif) 0,2 - 0,3 mgr/kg/liu (ti a 20mgr/liu) 3 ln trong ngy ung trc ba n. Mtoclopamide 0,10 - 0,15 mgr/kg/1liu x4 ln ngy (0,5 mg/kg/24gi) ung trc ba n v trc khi ng. Betanechol chloride (urecholine) 2,9 mg/m2/liu x 3 ln ngy.

2.2.2. Thuc c ch bi tit acid HCL khi c vim thc qun : Cimetidine 5 - 10 mg/kg/liu (ti a 20 mgr) 4 ln/ngy hoc 20 mg/kg/24gi Ranitidine 2mg/kg/liu x 2ln ngy. 4mgr/kg/24 gi

Trng hp nng dng: Omeprazole: 20 mg/1,73 m2 da/ung 1 ln hoc 1mg/kg/ti a 20mg ung ln/ngy 2.2.3. Thuc khng Acid, thuc bc : Phosphalugel 1ml/kg/3-4ln ngy ung 1 - 3 gi sau khi n v khi i ng . Thuc bc Smecta x 1gi - 2 gi ngy. 2.2.4. iu tr phu thut : Khi iu tr ni khoa tht bi, c nhng biu hin nng: ngng th, vim lot thc qun ti pht, bnh phi mn tnh (thc hin phu thut Nissen).

S59. NI SOI TIU HA


I. CH NH NI SOI 1. Thc qun d dy t trng Bnh km hp thu au bng, au ngc cha r nguyn nhn Nghi ng vim nim mc tiu ha Xut huyt tiu ha Kh nut, nut au Ung ha cht hay nut d vt i khng gii thch c Ri lon h hp nghi o tro ngc d dy thc qun Chn on tng p lc tnh mch ca iu tr - t in, chch cm mu - Ly d vt - t ng d y nui n - Theo i ung th - Chch x tnh mch thc qun dn 2. Trc trng, i trng Ni soi i trng vi sinh thit - Thiu mu, thiu st khng th gii thch c - Tiu phn en khng th gii thch c - Tiu mu - Tiu chy nng khng th gii thch c ngun gc - nh gi bnh vim rut - nh gi bt thng XQ - Theo di lon sn c kh nng c tnh Ni soi iu tr - Ct polype

- Cm mu - Chch x iu tr sa trc trng - iu tr nt hu mn mn II. CHNG CH NH Tuyt i: tnh trng h hp, tim mch, thn kinh khng n nh Tng i: ri lon ng mu, c nguy c thng rut, tn thng thnh rut nng, n i trng nhim c, bn tc rut, nhim trng cp tnh nng ti rut, sa son rut khng sch, ri lon in gii. III. CHUN B TRC NI SOI 1. Nguyn tc chun b chung: Bnh nhn phi c chun b trc a) Nhn n:

b) Ngng mt s thuc nh Maalox, thuc c cht st, Bismuth. c) Ra rut, ra d dy d) Cc xt nghim cn thit e) Cng tc t tng 2. Chun b bnh nhn ni soi thc qun d dy t trng Trng hp thng thng: cn theo ng nguyn tc chung. Trng hp c xut huyt tiu ha: cn t thng d dy v ra d y trc. - Dng nc mui sinh l nhit thng 50 ml / ln cho tr s sinh x 3 ln. - 100-200 ml/ln cho tr ln x 3 ln. 3. Cch tht tho cho ni soi trc trng Ngy trc ni soi: - Tr i mt tui bm hu mn Glycerine Borat, 1 ng sng, 1 ng chiu. - Tr 1 tui 5 tui bm Norgalax: 1 ng sng, 1 ng chiu - Tr trn 5 tui Bisacodyl 5-10 mg ung sng chiu - Sng, tra: ung nc ng, sa, nc chn - Nhn n ung hon ton theo nguyn tc chung Ngy ni soi: - Bui sng: ra rut bng nc mui 90/00 m cho n khi nc trong (200 ml

cho 1 kg) 4. Cch tht tho cho ni soi i trng Tr i 10 tui: - Thuc theo ch nh ca ni soi trc trng - Ch n: sng, tra, chiu: ung sa nc ng, dch khng mu, khng n cht x - Sng ngy ni soi ra rut bng nc mui 90/00 m. Tr trn 10 tui: - Bisaco yl 5 n 10 mg ung sng, chiu - Ch n: sng, tra, chiu ung nc ng, dch trong - Nhn n ung 4 gi trc khi ung Fortran vo lc 18gi: 200 ml/kg mi 10 pht cho n khi i tiu ra nc trong - t ng thng d dy nu bnh nhn khng ung lng trong 30 pht u.

S60. TRO NGC D DY THC QUN


I. NH NGHA. Tro ngc d dy thc qun (TNDDTQ) l t ng ch s hin din cht cha trong d dy thc qun. Tro ngc d dy thc qun c th sinh l, chc nng (khng nh hng sinh hot v pht trin th cht ca tr) hoc bnh l c th gy ra suy dinh ng, vim thc qun , v mt s bin chng h hp khc, thm ch t vong. II. CHN ON. 1. Cng vic chn on a) Hi bnh: i, c sa, hoc thc n lin quan ti ba n. Quy khc v c, bing n. i mu, triu chng thiu mu mn. au bng, cm gic rt bng sau xng c, kh nut (tr ln) Triu chng h hp ko di: ho, kh kh, suyn khng p ng iu tr, cn ngng th.

Tin cn gia nh: ng, khi thuc. b) Khm: ton din, ch Tnh trng inh ng. Thiu mu. Triu chng h hp. Bnh l{ i km: bi no, hi chng Down, chm pht trin tm thn khc, Quan st gia nh cho tr n, b. c) Xt nghim: o pH thc qun: l xt nghim c gi tr chn on nhng hin cha thc hin c. Siu m ngc bng: c > 3 ln tro ngc/ 5 pht trn siu m, xem nh c TNDDTQ. XQ thc qun d dy cn quang: - Chiu: c th pht hin tro ngc t d dy ln thc qun. - Chp: khi nghi ng c vim hp thc qun, hoc cn phn bit bnh l lm hp ng tiu ha. Ni soi: nghi ng c vim thc qun. Datacells, mu n trong phn: khi c i mu, thiu mu. 2. Chn on a) Chn on xc nh: lm sng + o pH thc qun 24 gi. b) Chn on c th: Trng hp nh: c 1-2 ln/ngy lng t, tr hon ton khe mnh, khng suy inh ng, + khng c yu t nguy c + iu tr bo tn c kt qu. Lm sng gi + siu m (+). Lm sng gi { + p ng iu tr. c) Chn on phn bit: Theo triu chng ni bt i au thng v, rt bng sau xng c H hp III. IU TR. 1. Nguyn tc iu tr iu ho hot ng c tht thc qun i Trnh cc yu t lm gim trng lc c tht thc qun i

Ch dng thuc khi c biu hin TNDDTQ bnh l. 2. iu tr c hiu: khng c. 3. iu tr triu chng: a) Bc 1: iu tr khng dng thuc Nm sp, k u ging cao 300 Lm hi sau b. Trnh cc yu t lm tng p lc bng : ho, bn, qun o qu cht Trnh cc thuc, thc phm lm n c tht : anticholinergic, adrenergic, xanthine, khi thuc l, s c la, Lm c thc n. Thm bt vo sa tr b bnh. Chia nh ba n (khng qu 7 ln/ngy) Nu nghi ng d ng protein sa b: dng sa thy phn protein trong 2 tun hoc loi tr protein sa b ra khi ch n ca m nu tr b m. b) Bc 2: Dng thuc. Khi bc 1 tht bi sau 1 tun hoc c du hiu nng (h hp). Thi gian iu tr thng l 8 tun. Ngng ng nu sau 2 thng vn khng c kt qu. Ch vn gi bc 1 v thm Metocloprami e: 0.1-0.15mg/kg X 4 ln/ngy, trc ba n v trc khi ng. Antaci : phosphalugel (1ml/kg X 3-8 ln/ngy), Ranitidine (3.5mg/kg X2-3 ln/ngy): khi c nghi ng vim thc qun. c) Phu thut: Khi bc 2 tht bi Cn cn nhc phu thut sm nu c triu chng h hp nng (cn ngng th, bnh phi mn). IV. THEO DI Trng hp nh: 1 tun nh gi p ng, sau c th ngng ti khm. Trng hp khc: 1 tun trong thng u, 1 ln sau 1 thng. Sau mi 3 thng chnh liu theo cn nng.

S61. L TRC TRNG

I. NH NGHA L: L tt c cc trng hp tiu chy phn c mu. Nguyn nhn a phn l do Shigella (50%) ngoi ra c th do vi trng khc hoc k sinh trng. L Shigella thng la tui 6 thng 3 tui t khi tr i 6 thng. C th bnh nh t ht cho n dng rt nng vi nhim c nng, co git, tng thn nhit, ph no v t vong nhanh chng m khng c nhim trng huyt hay mt nc ng k (H/C Ekiri). Shigella gy triu chng nhim c ton thn nng nhng t khi c nhim trng huyt. Bin chng nhim trng huyt v ng mu ni mch lan ta thng ch gp tr nh, tr suy inh ng, t l t vong cao. II. CHN ON 1. Cng vic chn on a) Hi bnh: Thi gian bnh C st au bng, Mt rn Tnh cht phn: m ln mu iu tr trc Co git. Sa trc trng. Si trong 6 tun qua. b) Thm khm: Du hiu sinh tn: mch, huyt p, nhit , nhp th Du hiu mt nc: Xem thm phn thm khm tr b tiu chy trong phc iu tr tiu chy. Cn ch pht hin bin chng - Triu chng thn kinh: Co git, m sng, cng c, hn m. - Triu chng nhim trng nhim c. - Ri lon in gii: Li b, co git, gim trng lc c, chng bng - Toan chuyn ha: Th nhanh su - H ng huyt. - Sa trc trng. - Chng bng.

- Suy thn. - Suy inh ng. c) Xt nghim: Cng thc mu Soi phn: khi khng r mu i th Cy mu, cy phn trong nhng trng hp nng Ion , khi c ri lon tri gic, triu chng thn kinh, chng bng, gim trng lc c. ng huyt : khi nghi ng h ng huyt. XQ bng, siu m bng khi c chng bng, khi cn loi tr lng rut Pht mu, m tiu cu, chc nng thn khi nghi ng c Hi chng tn huyt ur huyt cao. 2. Chn on a) Chn on xc nh l Shigella: Hi chng l + cy phn Shigella (+) b) Chn on c th: St, tiu chy km triu chng thn kinh: co git, li b, hn m, h/c mng no St, tiu chy soi phn c bch cu, hng cu. c) Chn on phn bit: Lng rut: vi gi u c th vn cn i tiu phn bnh thng, sau tiu mu ti hoc bm (thng trong 12 gi ). Quy khc tng cn, nn i. (xem thm bi lng rut) Tiu mu o polyp trc trng: tiu phn c ln m mu, bnh lu ngy, khng st. Xc nh bng ni soi. L amip t gp tr < 5 tui. Soi phn c ng bo n hng cu. Tiu mu o thiu vitamine K tr s sinh: km xut huyt v tr khc. III. IU TR Nguyn tc iu tr: Khng sinh iu tr bin chng. Dinh ng. 1. Khng sinh a) i vi trng hp khng bin chng, cha iu tr :

Cotrimoxazole 5 mgTMP / 25 mg SMX / Kg/ ln x 2ln x 5 ngy (khng s dng Cotrimmoxazole cho tr < 1thng tui c vng da hoc sanh thiu thng) Theo di 02 ngy - C p ng : dng tip 05 ngy - Khng p ng : i sang acide Nalidixic 15 mg / Kg / ln x 4 ln / ngy. (khng s dng Nalidixic acid cho tr < 2 thng tui) Theo di 02 ngy. + p ng : Dng tip 05 ngy + Khng p ng: i sang: Ciprofloxacin : liu + < 20 Kg: 125 mg 2 ln / ngy 5 ngy + 20 50 Kg: 250mg 2 ln / ngy 5 ngy b) Cc trng hp nng c bin chng: Nu tr i 2 thng tui: Ceftriaxone 100 mg /Kg IV mt ln/ngy 5 ngy Tr t 2 thng n 5 tui: Bt u iu tr bng acide Nalidixic theo di 02 ngy nu khng p ng s i sang: - C kt qu khng sinh cy mu cy phn: theo khng sinh . - Cy (): dng Ciprofloxacin (hoc Pefloxacine) liu: + < 20 Kg: 125 mg 2 ln/ ngy 5 ngy + 20 50 Kg: 250mg 2 ln/ ngy 5 ngy hoc 20 30 mg/kg/ngy chia lm 2 ln / ngy TTM nu khng ung c hoc Pefloxacine: 20 30 mg/ kg/ ngy chia lm 2 ln/ ngy 5 ngy. c) Theo di cc du hiu sau nh ga c p ng hay khng: Ht st. Bt mu trong phn. Bt s ln i tiu. Thm n. Hot ng tr li bnh thng. Sau khi dng 02 loi khng sinh lin tip khng p ng tm chn on khc. C kt qu cy mu cy phn iu tr theo gi ca khng sinh 2. iu tr bin chng: Xem cc phc tng ng H ng huyt : Xem phc tng ng Co git : (Phc iu tr co git ) Sa trc trng : ng khn t y vo

Ri lon in gii thng l h Natri , Kali mu ( xem phc ) Mt nc : b nc theo phc iu tr tiu chy 3. Dinh ng Tr b l thng chn n cn khuyn khch tr n, cho n lm nhiu ba, n cc thc n m tr thch. IV. TIU CHUN NHP VIN C ri lon tri gic C co git Chng bng Tiu t Sa trc trng

CHNG 6. BNH L TIT NIU SINH DC


S62. HI CHNG THN H TIN PHT TR EM
BSCKII H Vit Hiu

1. i cng Hi chng thn h tin pht tr em (HCTHTPTE) l mt tp hp triu chng th hin bnh l cu thn m nguyn nhn phn ln l v cn (90%) khi nim thn h c Mller Frie rich Von ni n t nm 1905 vi mt qu trnh bnh l thn c tnh cht thoi ho m khng phi l o vim .1913, Munk a ra thut ng thn h nhim m v nhn thy thoi ho m thn .1928, Govert B v 1929, Bell M cho rng tn thng trong bnh thn h ch yu l cu thn. Sau ny quan im trn c khng nh nh nhng tin b k thut nh sinh thit thn, knh hin vi in t, min dch huznh quang.... 2. nh ngha v HCTHTPTE nh ngha v HCTHTP ch yu theo sinh hc-lm sng bao gm tiu m rt nhiu v ph ton . Nguyn nhn HCTHTP thng khng r rng v th cn gi l HCTH v cn . 3. Dch t hc: HCTHTPTE l mt hi chng th hin bnh l cu thn mn tnh thng gp tr em. T l mc bnh thay i theo tui, gii, chng tc, a , c a... 3.1. T l mc bnh Ti mt s khoa nhi hoc bnh vin nhi s tr em b HCTH chim khong 0,5-1% tng s bnh nhi ni tr v chim 10-30% tng s tr b bnh thn. Ti Khoa Nhi BVTW Hu s tr b HCTH chim 0,73% tng s bnh nhi ni tr v chim 30% tng s tr b bnh thn 3.2.Tui Tui mc bnh trung bnh tr em Vit Nam l 8,7 ( 3,5 ( tui i hc ) trong lc nc ngoi tui mc bnh thp hn thng gp tr em trc tui i hc. 3.3. Gii Tr nam gp nhiu hn tr n ( t l 2:1 ) 3.4. Chng tc Tr em Chu b bnh nhiu hn Chu u ( t l 6:1 ). Tr em Chu Phi t b HCTHTP, nhng nu tr em a en b bnh HCTHTP th thng b khng Steroid. 3.5. a

Vit Nam , Vin BVSKTE t l HCTHTPTE l 1,78% ( 1974-1988 ); BV Nhi ng I l 0,67% ( 1990-1993 ); Khoa Nhi-BVTW Hu l 0,73% ( 1987-1996 ). M t l mc bnh l 16/100.000 tr em i 16tui tc l 0,016% ( Schlesinger, 1986 ). 3.6.Mt s yu t thun li Bnh thng hay xut hin sau nhim khun h hp cp v trn c a d ng ( chm, hen..) , ngi mang HLA (Human Leucocyte Antigen) . 4. Sinh l bnh: Hi chng thn h tin pht tr em HCTHTPTE xy ra l o tng tnh thm mng mao mch cu thn i vi protein, mao mch cu thn b vim v c phc hp khng nguyn - khng th lu hnh ( bnh t min ). C ch tng tnh thm ny c th do mt phn sc in tch m ca mao mch mng y cu thn v s hin din mt s cht Lymphokines y lm thay i l lc ca mng y cu thn khin cho cc protein mang in tch m v c trng lng phn t nh thot ra ngoi thnh mch. 4.1.Tiu m Mt protein niu y c tnh chn lc, ch thot cc loi protein c trng lng phn t nh nh Albumin 69.000. Mt albumin qua nc tiu gy ra gim Albumin mu, khi Albumin mu gim xung i 25g/l th ph s xut hin. 4.2. Ph Thng thay i v lin quan n p lc keo gim ( lm nc v mui thot vo gian bo ); gim th tch mu ti cho thn gy cng Aldosterone th pht (lm tng ti hp thu Na ng ln xa ) v tng tit ADH bt thng ( lm tng ti hp thu H2O ng gp ). 4.3. Ri lon chuyn ha cht bo ti gan Gan tng tng hp m (nhm b tr protide mu gim ) trong c Lipoprotein v v vy s vn chuyn nhiu Triglyceride, Cholesterol ra mu ngoi vi lm tng Lipide mu, nu nhiu s gy tn thng thnh mch, tc mch. 4.4. Hin tng tng ng Tng ng lin quan n tng tng hp cc yu t ng mu nh yu t I, II, V ,VII, X, tiu cu v nht l yu t VIII, ng thi gim Antithrombin III. 4.5. Mt s cht protein khc ( ngoi Albumin ) thot ra trong nc tiu 4.5.1.Lipoprotein lipase

Lipoprotein lipase thot ra trong nc tiu lm gim d ha Lipide. Cc vt th lipides qua ng thn to thnh tr m. 4.5.2.Globulin kt hp Thyroxin Mt globulin kt hp Thyroxin lm ri lon cc test chc nng tuyn gip. 4.5.3.Protein kt hp Cholecalciferol Mt protein kt hp Cholecalciferol lm thiu vitamin D v h Calci mu. 4.5.4.Transferrin Mt Transferrin (trng lng phn t : 80.000) dn n thiu mu nhc sc khng st . 4.5.5.Globulin min dch Mt IgG min dch (trng lng phn t : 150.000) v cc b th lm gim kh nng opsonin ha vi khun,d b nhim trng. Ngi ta s dng ch s chn lc IgG/ Transferrin trong nc tiu tin lng: p ng corticoide tt nu ch s <0,10 v km nu >0,15 ( bnh nng ). 4.5.6.Cc loi protein khc Cc loi protein gn vi thuc lm nh hng n c ng hc v c tnh ca thuc. 4.6.Phn ng vim Phn ng vim ca bnh t min hoc c km bi nhim lm tng tc mu lng lin quan tng 2globulin. Ngoi ra c th tng bch cu a nhn v CRP . 5. Biu hin lm sng 5.1. Ph: Ph ton thn vi cc c tnh ph trng, mm, n lm ( du go et ng tnh ), khng au. Thng ph bt u t ngt t mt lan xung ton thn, ngoi ra c hin tng ph a mng ngha l c ph mng bng, mng tinh hon tr trai, c th mng phi, mng tim, mng no v vy khi khm lm sng cn ch cc c quan trn. 5.2. au bng: au bng l triu chng khng thng xuyn v khng c hiu, c th o cng mng bng khi dch bng qu nhiu gy au hoc do tc mch mc treo, do ri lon tiu ha, vim phc mc tin pht... 6. Biu hin cn lm sng 6.1. Xt nghim nc tiu

Hi chng thn h tin pht tr em - Sinh ho: Protein niu phn nhiu > 100mg/kg/24 gi, protein niu c tnh chn lc - T bo: Hng cu hu nh khng c hoc ch dng vi th nh v nht thi.Tr thu quang 6.2. Xt nghim mu - Protid ton phn gim nhiu, a s < 40g/l - in di protid mu thy: Albumin mu gim nhiu ( < 25g/l ) alpha2Globulin v bta Globulin tng, gama Globulin gim nhiu vo giai on mun . - in di min dch: IgM tng cao v IgG gim nhiu nht l khi bnh nng . - Lipi v Cholesterol mu tng . - Cng thc mu : Hng cu gim, bch cu v tiu cu c th tng . - Tc mu lng thng rt tng trong gi u > 50mm - in gii : Natri, Kali, Calci thng gim - Ure, Creatinin trong gii hn bnh thng 7. Phn loi hi chng thn h tr em 7.1.Theo nguyn nhn 7.1.1.HCTH bm sinh ( him gp ). 7.1.2.HCTH tin pht (v cn). 7.1.3.HCTH th pht ( sau cc bnh h thng, bnh chuyn ho, nhim trng-nhim c.. ). 7.2.Theo lm sng 7.2.1.HCTH tin pht n thun . 7.2.2.HCTH tin pht phi hp hay khng n thun ( thn vim-thn h ). 7.3.Theo tin trin 7.3.1.HCTH tin pht ln u . 7.3.2.HCTH tin pht ti pht ( ph v tng protein khi chuyn liu tn cng sang liu duy tr hoc sau khi ngng liu duy tr ). 7.4.Theo iu tr 7.4.1.HCTH nhy cm corticoi ( nc tiu sch protein trong vng 2tun ).

7.4.2.HCTH ph thuc corticoi ( ti pht khi chuyn liu hoc ngng thuc ) 7.4.3.HCTH khng corticoi (protein niu vn tng nhiu sau iu tr tn cng) 7.5.Theo gii phu bnh l 7.5.1.HCTH tn thng ti thiu (85%). 7.5.2.HCTH tng sinh mng (5%) 7.5.3.HCTH x ha tng im(10%) 7.6.S tng quan gia gii phu bnh v lm sng:Mt s tc gi nhn thy rng nu HCTHTP n thun thng nhy cm corticoi , p ng 90-95% th tn thng l ti thiuHCTHTP phi hp thng ph thuc corticoi , p ng 50-60% th tn thng l tng sinh HCTHTP ti pht nhiu ln, khng corticoid, c suy thn th tn thng l x ha cu thn 7.7.Tiu chun lnh bnh Hi chng thn h tin pht tr em gi l lnh khi ngng iu tr trn 2 nm m khng h c t ti pht no c 8. Chn on chn on sm cn da vo 8.1.Hon cnh pht hin Dch t hc, yu t thun li v du hiu lm sng xut hin sm l ph nhanh ton thn vi c im trng, mm, n lm, khng au 8.2.Xt nghim sinh hc Xt nghim sinh hc gip xc nh HCTH vi cc tiu chun sau - Protein niu trn 3g/24gi chim phn ln l Albumin hoc trn 50mg/kg/24gi i vi tr em. Protein niu chn lc (ngha l > 80% Albumin b mt ra trong nc tiu do trng lng phn t nh hn cc globulin) - Protide mu i 60g/l v Albumin mu i 25g/l - Ph v tng lipi e mu thng thy nhng khng phi l yu t cn thit cho chn on 8.3.Sinh thit thn tr eminh thit thn khng cn thit v a s (80-90%) c tn thng ti thiu v p ng tt vi corticoid, nht l i vi tr trc 8 tui. Ch sinh thit thn trong mt s t

trng hp nh HCTH bm sinh ( tr i 1tui ); HCTH phi hp; HCTH khng corticoid 9. Tin trin v bin chng 9.1.Tin trin C 4 cch nh sau 9.1.1. Ch mt t Ch duy nht mt t trong vi tun ( ht ph, protein niu mt ): y l th nhy cm corticoid (25%) 9.1.2.Ti pht nhiu t Ti pht nhiu t trong nhiu nm nhng cui cng vn lnh hon ton (25%) 9.1.3.Ti pht lin tc Ti pht lin tc khi gim liu hoc dng thuc : y l th ph thuc corticoid (30- 35%) 9.1.4.Tht bi ( trc ng pre nison sau Methyl- pre nison ): y l th khng corticoid (15-20%) 9.2. Bin chng 9.2.1.Bin chng ca bnh - Nhim trng l bin chng ph bin nht ( vim phc mc tin pht, vim phi, vim m t bo, nhim trng tit niu, nhim trng huyt ) - Hi chng thiu ht: Chm pht trin, suy inh ng, long xng, co git do h calci ( tetanie) thiu mu, bu gip n thun... - Thyn tc mch mc treo, phi, cc chi . - Cn au bng: C th do ph mc treo, ph tu, vim phc mc tin pht, lot ddy 9.2.2.Bin chng ca iu tr - Corticoi thng ch xy ra bin chng khi dng liu mnh v ko di s gy ri lon nc in gii; ri lon ni tit - chuyn ha; nh hng hu ht cc c quan trong c th...

- Thuc c ch min dch v c ch t bo ung th : c th gy suy ty, v sinh, ung th mu , nhim trng, vim bng quan chy mu, hi tc... - Thuc li tiu: khi dng nhiu t ngt c th gy ri lon nc in gii ( gim Natri mu, gim Kali mu ) gim th tch ( try tim mch, suy thn ) 10. iu tr v d phng 10.1. iu tr triu chng (ph) 10.1.1.Ngh ngi 10.1.2.Ch n ung Hn ch mui-nc v n nhiu m, cc vitamin (mui 2-3g/ngy; nc <15ml/kg/ngy; m 2-4g/kg/ngy) 10.1.3 Gi v sinh thn th; gi m 10.1.4.t khi cho li tiu v chuyn m 10.2. iu tr bnh sinh (c hiu ) 10.2.1.Liu php corticoid ( Prednison 5mg ) Corticoid c tc dng khng vim v c ch min dch - Liu tn cng: Prednison 2mg/kg/ngy x 4-8 tun.Ung trong hoc sau n mt ln bui sng hoc chia 2-3 ln trong ngy . Sau tuz theo protein niu m tnh hay cha chn liu duy tr - Liu duy tr + Nu protein niu m tnh: 1mg/kg/ngy x 6 tun lin ri ngng thuc hoc cng c thm vi liu 0,5mg-0,15mg/kg dng 4/tun trong 4-6thng + Nu protein niu cn ng tnh : 2mg/kg/cch nht x 4 tun lin + Nu liu tn cng tht bi c th th cho Methyl-prednison ( Solu-Medron) 30mg/kg (chuyn tnh mch).x 2-3ngy trong tun . Sau nh gi li s p ng iu tr steroid - iu tr tr li nh ban u nu ti pht hoc ph thuc. Nu khng thuc th i thuc khc 10.2.2.Thuc c ch min dch v c ch pht trin t bo ung th nhm Alkyl - Cyclophosphamide 50mg : Liu dng 3mg/kg/ngy, ung mt ln x 4-8tun ( tng liu < 170mg/kg ).Theo di cng thc mu ( ch bch cu ) . 10.2.3. Mt s thuc khc - Levamisol

- Indomethacin - Heparin - Chlorambucil - Cyclosporin... 10.3. iu tr bin chng 7.3.1.Khng sinh trong nhim trng - Penicillin 100.000n v trn kg cn nng trong ngy ung hoc tim bp 7.3.2.Heparin trong tc mch - Heparin liu 200-300n v trn kg cn nng trong ngy tim bp su 7.3.3.B cc cht thiu ht nh Calci, Kali.. . 10.4. D phng Do bnh thng ti pht nn cn theo i u n trong nhiu nm ( t nht 5 nm ) o phi thuyt phc bnh nhn v b m tun th ch iu tr ni tr v c bit l ngoi tr mt cch nghim tc, cht ch qua ch ngoi tr lp y b theo i ...Ngn chn cc yu t thun li dn n HCTHTP ti pht Theo di cc triu chng lm sng ( chiu cao, cn nng, huyt p ) ,cn lm sng ( tc mu lng, protein niu ) tc dng ph ca thuc.

S63. VIM BNG QUANG CHY MU


tr em (c th c nh nhi) c th vim bng quang cp chy mu, vim bng quang d ng. Nguyn nhn ch yu l do virut (Adenovirus typ III), bin chng ca vic dng cc thuc c ch min dch (Cyclophosphami e,), gh p tu, hn hu do mt s loi vi khun nh : lin cu khun, ph cu khun, E.coli, Klebshiella, Enterobarter, Pseudomonas, Proteus, cc loi vi khun trc tip gy bnh ti bng quang. I. Chn on : 1.1. Lm sng : da vo cc biu hin sau:

C st nh < 380C , i t, i au, i rn, nhiu khi a tr la khc khi i, t ra s hi ht hong lo s, bn tay khai do tr nm hoc k o ng vt, bnh nhi ku au vng h v. 1.2. Xt nghim : Nc tiu nh mu, a phn c ln cc mu ng (bng ht u xanh, ht ng hoc nh ht vng), hoc y mu ng nh si tc, que tm. Mt s trng hp tr i mu mu hng hoc nht , nhng cui bi r ra vi git mu ti. + Xt nghim: Nc tiu dy c hng cu. Protein niu: 100% (+) mc nh. Bch cu niu: Thng > +++ rt nhiu. 1.3. Chn on hnh nh : + Siu m: Thnh BQ dy, c hnh nh m m , to nh khng u gn c BQ.

+ Chp BQ c thuc cn quang: Thy nim mc BQ dy, sn si, hoc m to nh khng u khc nhau km ngm thuc, thm ch thy khuyt trn thnh BQ. Ch hnh nh siu m v chp BQ ngc dng: D nhm vi si v u BQ. + Nui cy nc tiu , chp bng khng chun b, khng c { ngha g.

2. iu tr: + Khng sinh chng bi nhim do chy mu v vim cht nim mc bng quang : Tuz mc nng nh, c th i thuc sau 3 ngy iu tr nu khng thy c hiu qu r. Nh : Bactrim 40 mg/kg/24h hoc clorocid 75-100 mg/kg/24h trong 7-10 ngy.

Nng : Gentamicine 4-5 mg/kg/24h + Ampicilline 100 mg/kg/24h tim tnh mch chm chia 2 ln trong 7-10 ngy. (C th dng cc ch phm khc ca b lactam v aminosid). + Vitamin C 0,1 x 4-6 vin/ ngy. + Thuc khng histamin: Claritine 10 mg x 1/2 1 vin/ng. Siro phenergan 1 x 10-15 ml (sng-chiu, tuz tui) + Ung nhiu nc un si ngui. + Ch n ung inh ng tt. + Trng hp cn thit: Dng gim au = Nospa hoc gardenan 1-2 mg/kg, sngchiu. + Ch khng dng thuc li tiu. Hng dn khi xut vin : - V sinh thn th, tim chng y theo lch, khng mc cc bnh nhim trng c bit cc bnh l do siu vi trng. - Hn kim tra khm li sau 1 thng x 1-2 ln phng v pht hin bin chng: Vim BQ x. - Phng bnh ti pht v khi ti pht v khi ti pht c iu tr sm.

S64. VIM CU THN CP


BS. Nguyn Vn Thanh

I - I CNG:

1/ nh ngha: Vim cu thn cp ( VCTC) l tnh trng vim lan ta khng lm m tt c cc cu thn ca 2 thn. Bnh thng xut hin sau vim hng hoc sau nhim khun ngoi da do lin cu khun tan mu nhm A. Bnh gy ra do s lng ng cc phc hp lu hnh ti thn. Nhng trng hp khng khng phi do lin cu khun tan mu nhm A th ch gi l H/C VCTC.

2/ Nguyn nhn: * Lin cu khun tan mu nhm A: cc typ thng gp l: 4,12,13,25,31,49 ( thng gp nht l typ 12). + Bnh thng xut hin sau nhim lin cu 10-15 ngy. + Ngi ta xc nh s c mt ca lin cu khun tan mu nhm A bng cch xc nh cc khng th chng li mt s men do lin cu tit ra trong qu trnh pht trin; nhng khng th l: - ASLO ( Anti Streptolysin O) - ASK ( Anti Streptokinase) - AH ( Anti Hyaluronidase). - ANADase ( Adenine Dinucleotidase) - ANDAse ( Anti Deoxy Ribonuclease) Trong s cc khng th trn th ASLO c gi tr nht, ASLO tng sm v ko di, 95% VCTC c tng hiu gi ASLO * Cc nguyn nhn khc gy vim cu thn gi l H/C VCTC: + Vim cu thn do lupus. + Tn thng thn o T + Vim mch nh dng nt. + Henoch- Scholein. + Vim cu thn trong bnh Osler. + Bnh Berger ( bnh thn do IgA). + H/C Goodpasture. + t bt pht ca vim cu thn tin pht. * Cc yu t thun li:

+ La tui 4-15 tui c bit l 4-6 tui. + Ma h, ng.

3/ C ch bnh sinh:

- Ph do: . Natri v nc khong gian bo . Gim p lc lc cu thn . Gim p lc keo ( do mt protein qua nc tiu) - THA do: . Thiu mu cc b thn-> tng tit renin . Co mch -> tng sc cn ngoi vi - i mu o: . Tn thng cu thn-> vim xut tit-> tng tnh thm mng y.

.........................................II - TRIU CHNG: 1/ Lm sng: 1.1/ Giai on khi pht: - Bnh xut hin sau vim hng hoc nhim khun ngoi da - Biu hin: mt mi, st nh, da xanh, ph nh mi mt, i t - C th khi pht nguy kch nh : THA, v niu, suy tim cp, ph no cp. - i khi khi pht tim tng, khng c triu chng lm sng. 1.2/ Giai on ton pht: bnh biu hin bng 3 triu chng chnh: *Ph: Cm gic nng mt, n 2 mi mt, ph 2 chn mt trc xng chy. Ph trng, mm, n lm r, ph nhiu v bui sng, n nht ph gim. ph thng gp trong 10 ngy u v thng gim i nhanh chng khi BN i c. *THA: + L triu chng thng gp, xut hin sm, mt i nhanh, a s THA nh t 1020mmHg c ti a v ti thiu. Mt s trng hp khng c iu tr HA c th tng kch pht, khin BN au u gi di, chong vng, co git, hn m, ph no, suy tim cp. + HA tr em c xc nh nh sau: - HAT: tr s sinh: 75mmHg 1tui: 80mmHg > 1 tui = 80 +2N( N l s tui N >=1). - HATT = HAT/2 + 10mmHg hoc 2/3 HAT. *i mu: Vi th hoc i th ko di 4 - 6 tun hoc 3 - 6 thng. c im: i mu ton bi, nc tiu nh nc ra tht, mu khng ng, xut hin ngay tun u v s ln i mu tha n. -> y l triu chng quan trng chng t vim cu thn, nu khng c i mu th cn xem li chn on. *Ngoi 3 triu chng chnh trn ta c th gp cc triu chc khc: + i t ( thiu niu < 0,5ml/kg/24h, v niu) + Suy tim km theo THA kch pht, co git, hn m + St nh 37,5 - 38,5

+ au tc vng thn. + au bng, chng bng, bun nn, i lng *Xc nh s ln v lng nc tiu ca tr : + S ln i gim theo tui: - Trong thng u: 15-25 ln/24h = 300-400ml - 3 thng tui: 15-20 ln/24h = 400-500ml - 1 tui: 12-16 ln/24h = 500-600ml - 3-5 tui : 8 ln/24h = 600-700ml - 5-8 tui : 6 ln/24h = 650-1000ml - > 8 tui: 5-6 ln/24h = 800-1400ml. C th tnh theo cng thc: M(ml) lng nc tiu trong 24h = 600 +100(N-1). 2/ Cn lm sng: 2.1/ XN nc tiu: + Nc tiu c HC, BC, tr HC, tr BC, tr trong, tr sp + Protein niu 0,5-2g/24h. thi gian tn ti c { ngha tin lng bnh, bnh c hi phc khi Protein niu (-) + T trng nc tiu tng( bt = 1,020 -1,035) 2.2/ XN mu: + Protein mu gim < 55g/l ( bnh thng 60-80g/l) + Albumin mu gim < 30g/l( bnh thng 38-54g/l) + Ure v Creatinin mu tng ( ure bnh thng: 3,3-6,6mmol/l; Creatinin : 60-110m/l) + Tc mu lng tng. + BC tng, HC gim, HST gim , Hb tng + Khng th khng lin cu ASLO tng . + B th gim ( c bit l C3) n tun th 6 th tr v bnh thng.

III - CC TH LM SNG: 1/ Th tim tng: 2/ Th THA.

3/ Th i ra mu. 4/ Th suy thn cp ( th v niu). 5/ Th kt hp ( kt hp vi H/C thn h).

IV- TIN TRIN V BIN CHNG: - Vim cu thn cp-> THA -> suy tim cp - Vim cu thn cp-> suy thn cp khi c: i mu i th > 3 tun hoc i mu vi th > 12 thng.

V - CHN ON: 1/ Chn on xc nh: + C tin s Vim hng, nhim khun ngoi da. + Ph, i mu, THA + Protein niu, HC niu.( tiu chun bt buc) + B th gim, ASLO (+). + Ngoi ra cn cc triu chng v iu kin khc ngh nhiu n VCTC: - i t. - Nhim khun ngoi da, hu hng. - Tui : 4-15 tui

2/ Chn on phn bit: - Vim cu thn do cc NN khc. - t cp vim cu thn mn. - Vim thn- B thn. - Hi chng thn h

VI - IU TR: 1/ Ch ngh ngi: - Ng ngi ti phng t nht 2 tun.

- Ch n ung: hn ch nc, hn ch mui, hn ch m khi c tng m mu hoc biu hin thn nhim m,khng cn hn ch m tr th v niu.

2/ Khng sinh: + Tt nht l Penixillin: - Penixillin G 1.000.000 UI/24h x 10 ngy, tim bp - Penixillin V 400.000 UI/24h ung hng ngy hoc Benzathin Penixillin1.200.000 UI/24h tim bp 3 tun/ln cho n khi mu lng tr v bnh thng, HC, Protein niu(-) + Nu d ng vi Penixillin th c th thay bng : - Rovamycin 3.000.000 UI/24h hoc - Erythromycin 1g/24h

3/ iu tr ph: - Furosemid ( Lasixvim 40mg, ng 20mg) 2- 4mg /kg/24h ung hoc ng ng tim.

4/ iu tr THA: - Ch cn dng Furosemid( Lasix) khi BN a niu th c th t iu chnh HA tr v bnh thng 110/70-120/80 mmHg - Nu HA vn tng th cho kt hp vi thuc c ch hoc chn Canxi. Lasixx 1-2mg/kg/24h -Thuc chn dng Canxi: -Nifedipin: ( tc dng trung bnh) vin nang 10-20 mg -Adalat gen:( tc dng nhanh, mnh) vin nang 10-20 mg -Adalat LA: ( tc dng ko di) vin gii phng chm 30-60-90mg -Nimodipin (Nimotop)( tc dng trung bnh u tin cho BN c B/C Q chy mu khoang i nhn gy co mch do chn p.) vin nn 30mg -Amlodipin( Amlo, normodipin, amtin).( tc dng ko di 24h) vin nn 2,5-5-10 mg

- Liu lng cho tr em: Adalat gen 0,25-0,5mg/kg *Ch -CC: nhp tim chm, Bloc tim. +Thuc c ch -Propranolol: 40mg x 2 - 4v/24h -Atenolol(Tenormin) : 50mg x 1- 2v /24h -Concor: 2mg x 1 - 2v /24h -Artex: 5mg x 1- 2v/24h -Ch : - C: Tt cho BN THA c RL nhp tim. - CC: Hen ph qun, lot DD-HTT, nhp tim chm, Blc. - Liu: tr em =1/2 liu ngi ln, ty theo mc THA v p ng ca tr m chn thuc ph hp. -Litroprosiod 5-10g/kg/p

5/ iu chnh m mu (nu c tng m mu): -Thuc h Lipid mu: Lipitor, Lopid, Lipanthyl 0,3g, Modalim. -Lipitor: vin nn 10;20;40;80 mg + TP: Atorvastatin Calcium l cht h Lipid mu tng hp + C ch tc dng :Atorvastatin l cht c ch tranh chp v chn lc men kh HMG- CoA( 3-Hydroxy-3-Methylglutathil- Coenzyme A) . men ny c tc dng quyt nh mc trong qu tng hp Cholesterol m chuyn i HMG-CoA-> Mevalonate( l mt tin cht ca Sterol bao gm c Cholesterol ) + C:BN tng Cholesterol ton phn, LDL-Cholesterol v tng Tryglyceri e. BN nhn b bnh tim mch v RL lipid mu. D phng tng Lipi mu .

6/ iu chnh nc - in gii theo in gii : 7/ Nu Albumin gim th b Albumin plasma 2-3 ln/thng. 8/ iu tr cc th c bit: -Th i mu: - Khng sinh nh trn:

- Prednisolon 0,5-1mg/kg/24h -Th suy thn cp ( v niu): Suy thn cp l tnh trng t nhin gim bi tit nc tiu cng vi n l tng Fibrin trong mu, biu hin bn ngoi l thiu niu, v niu. AL lc cu thn < 70mmHg - Lasix 20mg x 2- 4 tim TM tng liu dn n khi BN c p ng( liu ti a l 1g) uy tr lng nc tiu khong 1000ml. Nu sau 4- 5 ln ng Lasix m c th khng p ng th ngng, phi chy thn nhn to. - Truyn dch Glucose 30% x 300-500ml + 10-15 UI Isulin nhanh truyn TM, nhm mc ch h K+ mu . Lng dch a vo =<lng dch o thi trnh ph. - Dung dch Nabica 1,25%, x 250ml; 4,25; 8,4%/10ml truyn TM Cn ch cn bng lng nc vo v ra. 1 mEq Bicarbonat = 1 n v toan chuyn ha. - Prednisolon 0,5-1mg/kg/24h - Chy thn nhn to khi : v niu > 3 ngy; Ure> 300mg%; K+ 7mEq. -Suy tim cp ( th THA): + Li tiu: Lasix 1-2mg/kg/24h tim TM chm + Thuc h HA: Adalat 0,25-0,5mg/kg/24h chia lm 2 ln ngm i li. Hoc Aldomet 8-10mg/kg/24h + Thuc gin mch: - Lenitral: trong iu tr suy tim cp - Molsidomin( Corvasal): trong iu tr suy tim mn + Thuc cng tim Ch c ng sau khi ng thuc li tiu v h HA v mc cho ph p trnh ph phi cp) - Digoxin . TD: lm cho tim co bp mnh, chm, u . LL&CD: liu tn cng: tr < 2 tui : 0,06-0,08mg/kg/24h tr > 2 tui : 0,03-0,06mg/kh/24h chia lm 3 ln ung. Liu duy tr: tr < 2 tui : 0,015-0,02mg/kg/24h

tr > 2 tui : 0,01-0,015mg/kg/24h liu thng dng 0,04mg/kg/24h chi lm 3 ln ung s dng liu uy tr cho n khi tr ht cc triu chng suy tim - Dopamin:tin cht ca noradrenalin dng liu thp < 5g/kg/ pht; c tc dng lm tng co bp c tim, tng ti mu thn gy li tiu; liu cao gy kch thch TCT 1 gy co mch nguy him - Dobutamin ( Dobutrex) l mt amin giao cm; tc ng u tin ln TCT 1 tng co bp c tim; liu 2,5 g/kg/ pht. - Nhm c ch s phn hy AMPc thng qua c ch Phosphodiesterase c tc dng lm tng sc bp c tim nhng ng thi lm gin mch ( c M v TM):Amrinon( Inocor); Minirinon( Corotrope); Enoximon( Perfane) -Th kt hp ( kt hp vi H/C thn h): - iu tr VCTC + Corticoid + h m mu Prednisolon 1,5 - 2mg/kg/24h ung vo 8h sng sau n 9/ iu tr d phng: -> VCTC c 75 - 80 % trng hp ti pht, s ln ti pht trong mi nm tng dn, n 5-10 nm c khong 30% trng hp chuyn sang suy thn. - Gii qut nhim khun mn tnh c bit l nhim khun hu hng - Dng khng sinh Penixillin chm 1,2 triu UI/24h mi thng tim bp tht 1 ln x 6 thng.( chp hnh ng ch ung thuc) - Khng lao ng qu mc, trnh nhim khun, nhim lnh. - iu chnh ch n : n nht, gim m. - nh kz kim tra nc tiu v mu. - Theo i qu trnh tng trng ca tr

S65. VIM CU THN TRONG SCHOENLEINHENOCH

Ban xut huyt huyt Schoenlein Henoch (SH) Ban xut huyt dng thp, ban xut huyt d ng l 1 trong cc bnh vim mao mch, thng gp tr em vi cc biu hin xut huyt i xng cc chi, au mi khp, hi chng bng (au bng, a mu) v biu hin ca bnh cu thn. Tn thng thn c th l biu hin nng nht ca hi chng S.H v c nguy c gy ra bnh thn mn tnh v suy thn giai on cui. Tn sut thng gp khong 30-60% i 2 dng vim cu thn v hi chng thn h. 1. Chn on : 1.1. Lm sng Trn c s 1 bnh nhn S.H (c bit th bng chim 91,51%) c th c: - i mu, thng gp l i mu i th. - Ph, thng nh hoc c th khng ph. - Huyt p cao. 1.2. Xt nghim : 1.2.1. Chn on vim cu thn n thun : - Protein niu < 50 mg/kg/ng. - Hng cu niu . - Proti mu, Albumin mu, Cholesterol mu: bnh thng. - ASLO, cy dch hng hu c th (+) hoc (-). 1.2.2. Chn on vim cu thn kt hp thn h : - Protein niu > 50 mg/kg/ng. - Hng cu niu. - Protid mu < 56 g/l. Albumine mu < 25 g/l. Cholesterol mu > 5 mmol/l

- ASLO v cy dch hng hu c th (+) hoc (-). - ng mu ton b: - Fibrinogen , hoc bnh thng. - Gim tiu si huyt.

1.2.3. Vim cu thn tin trin nhanh : - Protein niu > 50 mg/kg/ng. - Hng cu niu . - Protid mu < 56g/l. Albumine mu < 25 g/l. Cholesterol > 5 mmol/l - Ure mu, creatinin mu tng. - ng mu ton b: Fibrinogen c th , hoc bnh thng. 2. iu tr : Tuz thuc vo chn on: 2.1. Vim cu thn n thun : Prednisolon 2 mg/kg/24h ngn ngy 10-15 ngy hoc 1 thng ph thuc vo din bin lm sng v xt nghim quyt nh, nu tt gim liu ri ngng. Penicillin G x 1 triu x 10 ngy sau ng Penicillin V 400000v x 1 vin/ ng x 3 thng nu ASLO (+). Khng Histamin: Claritine 10 mg x 1 vin/ng x 5-7 ng (cho tr > 5 tui). Vitamin C, canci.

Ch n: n nhan nht, trnh cc thc n v cc cht c nguy c gy ng cao. 2.2. Vim cu thn kt hp hi chng thn h :

iu tr v theo di ging nh 1 bnh nhn hi chng thn h kt hp: Penicillin, khng histamin, vitamin C, canci. - Nu tt : Tip tc iu tr v theo di ging nh bnh nhn hi chng thn h. + Nu khng tt (sau 2-4 tun) c th dng: Cyclophosphamid 2,5 mg/kg/24h x 3 thng (nu BC mu ngoi bin > 4000).

+ Heparin 100-150 UI/kg/24h x 2 ln/ng (nu c fibrinogen , t l prothrombin bnh thng) cho n khi thi gian Lee-white ko di so vi chun 2 ln (> 24 pht). + Nu bnh vn khng tin trin hoc tin trin chm c th dng: Methyl Prednisolon 30 mg/kg/ng x 3-6 mi.

Kt hp vi prednisolon ung theo phc . Ngoi ra cn phi iu tr phi hp: Cc bnh nhim trng km theo, iu tr triu chng Ch n : Ging trn. 2.3. Vim cu thn tin trin nhanh : iu tr ging nh vim cu thn kt hp. Ngoi ra : Truyn dch: bi ph in gii v thng bng toan kim trong giai

+ on u. + +

Li tiu tch cc. H p.

Nu vn tin trin khng tt (bnh nhn c iu kin) dng theo 2 cch: + C1: Human globulin tim tnh mch 2 g/kg/thng x 3 thng. Sau : Globulin min dch tim bp (16,5% 0,35 ml/kg, 15 ngy /ln x 6 thng.

+ C2: Globulin min dch 16,5%: 0,35 ml/kg/tun/1 ln x 1 thng, tim bp. Sau : 0,35 ml/kg/15 ngy/1 ln x 8 thng 2.4. Hng dn khi ra vin : - Tip tc iu tr thuc theo n. - Trnh lnh, trnh chy nhy, trnh cc hot ng th dc, th thao nng, trnh tim phng. - n nhan nht, trnh cc thc n v cc cht c nguy c gy ng cao. - Theo i v n khm li ng hn.

S66. HI CHNG THN H TIN PHT KHNG STEROID


- Thn h khng Corticoid chim khong 12 14% s bnh nhn thn h tin pht. - iu tr kh khn, k o i pht sinh cc bin chng : cao huyt p, gi nc, gim nng p lc keo, ri lon nc in gii, suy thn 1. chn on Thn h tin pht .

- iu tr liu tn cng (Prednisolone 2mg/kg/24 gi) trong 6 tun lin bnh nhn khng ht ph, Protein niu cn trn 40mg/kg/24h. 2. iu tr 2.1. Ch n v chm sc : Nh vi HCTH tin pht v ch thm :

- Glucid : Hn ch v thc y ri lon Lipid, dng dng tinh bt hoc Dextran, Maltose. Hn ch nc khi ph to, cung cp NaCl liu nh.

2.2. iu tr triu chng : + Khi c du hiu gim th tch tun hon (thng do gim p lc keo) : Plasma ti cng nhm x 20ml/kg/ln, hoc : Albumin Human 20% x 2ml/kg/ln.

+ Thuc li tiu : Phi hp Furosemid vi Spironolacton 2mg/kg/24h (khi c du hiu tng Al osterol th pht) x 7 10 ngy trong 1 t. + Heparin 200 300 v/kg/24 gi, tim tnh mch chm (sng : 9h ; chiu 14h) phng huyt khi, nghn mch cng cc tc dng tt khc ca Heparin. Xt nghim : + Cc yu t ng mu trc tim + Lm Lee White 3 ngy 1 tun/ln, khi thi gian Lee White > 30 pht ngng thuc. + Thuc h p (khi c cao huyt p) Nhm b blocker : Propranolon 1mg/kg/24h, chia 2 ln.

Nhm c ch men chuyn : Captopril 2mg/kg/24h, chia 2 ln, Captopril cn c tc dng gim Protein niu. Nhm chn knh Calci : Adalat 0,25mg/kg/ln, ngm i li x 2-3 ln/ngy. + Khng sinh : Khi c biu hin nhim tng. + iu tr tng Lipi mu : Nu c iu kin. Apotex (Gempibrozil) vin nang 300mg x 3 vin/24h, chia 2 ln. 2.3. Glucocorticoid v thuc c ch min dch :

+ iu tr liu cao Methylprednisolon 30mg/kg/ln ( khng qu 1000mg) truyn tnh mch khng qu 50 pht, cch 2 3 ngy/ln x 6 ln. nh gi kt qu ch nh tip (khi cn) theo phng php S.A. Men ozza v B.M. Tune. + Cyclophosphamid (Endoxan) Ung 2,5mg/kg/24h x 2 3 thng hoc liu cao 10mg/kg/ln/tun x 2 3 ln. Theo di cng thc mu 2 tun/ln, nu BC < 4000 ngng thuc. Hoc : + Azathioprine : 1mg/kg/ng x 2 3 thng hoc hn. Hoc : + Cyclosporin 150 20mg/m2/ln x 4 ln. 2.4. Hng dn khi xut vin : C thuyn gim cho xut vin hn kim tra theo di hng thng.

- Khi nm ni tr qu lu ( > 2 3 thng), d c thuyn gim hay khng r vn bnh nhn v theo i v iu tr tip ngoi tr.

S67. U NGUYN BO THN


U nguyn bo thn xut pht t nguyn bo thn, chim khong 85% cc ung th thn. 1. Chn on : Da vo lm sng, chn on hnh nh v m bnh hc

1.1. Lm sng : Khi u vng h thn i mu au bng

1.2. Chn on hnh nh : - Siu m CT Chp thn ng tnh mch

Trn siu m v CT cho thy kch thc, v tr ca khi u so vi thn v cc c quan xung quanh (gan, mch mu, hch....) Trn phim chp thn ng tnh mch thy c v tr ca i, b thn qua phn no thy c v tr ca khi u v s b nh gi c chc nng thn. 1.3. Chn on xc nh bng m bnh hc V mt m bnh hc c 3 thnh phn: Nguyn bo thn, m v biu m nhng khng phi lc no cng c c 3. Thng gp dng c m v biu m. C th thy cc cu trc ca thn cn nguyn hoc b xm ln. 1.4. Phn giai on + Giai on 1: Khi u nm bn trong thn v c kh nng ct b hon ton. V thn cn nguyn vn, cc mch ca xoang thn khng b i cn. Khng tm thy cc t bo ung th gn v ti vt ct. + Giai on II : Khi u vt ra ngoi thn nhng c th ct b hon ton. Cc mch ca xoang thn mch mu ngoi nhu m thn c t bo ung th. Khi u b v trc hoc trong khi m nhng ch nh vo sn, khng dch vo mng bng. Khng tm thy cc t bo ung th gn v ti vt ct. + Giai on III : Khi u i cn bng khng bng ng mu. C cc kh nng sau : Hch bng, khung chu b i cn (hch rn thn, quanh ng mch) Khi u i cn qu mng bng Khi u i cn vo mng bng

- Khi u cn li sau m vi th hoc i th (tm thy cc t bo ung th ti vt ct trn vi th) Khi u khng ct c ht o i cn vo cc c quan quan trng Khi u b v trc hoc trong khi m nhng khng ch dnh vo sn.

+ Giai on IV : Cc i cn theo ng mu : Phi, gan, xng, no... hoc hch ngoi khu vc bng, h chu b i cn. + Giai on V : Khi u c c 2 thn. 2. iu tr Gm c phu thut, ha cht v tia x. Phu thut L bc iu tr u tin trc ho cht v tia x, p dng cho mi giai on. Ct khi u cng vi thn. Ngoi ra ct ton b cc hch vng v t chc lin kt xung quanh. Quan st cc c quan khc, ng tnh mch ch i, m t v sinh thit khi c nghi ng. Gi ton b tiu bn n khoa gii phu bnh. Ha cht : Ngy phu thut c tnh l ngy 0. Vi u giai on I v II : 0 2 3 4 5 6 7 8 A A 9 10 11 12 13 14 15 16 17 18 A A* A * A* A A A

Tun : A

VVVVVVVVVVVV Vi u giai on III v IV :

Tun: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 A D+ A D+ A D* A D* A

VVVVVVVVVV Tia x

A* A* A* A*

A*

A Actinomycin D 0,045 mg/kg IV V Vincristine A* Vincristine D* Doxorubicin D+ Doxorubicin 0,05 mg/kg IV 0,067 mg/kg IV 1,0 mg/kg IV 1,5 mg/kg IV

Cc thuc c dng 1 ln vo 1 ngy c nh trong tun. iu tr ha cht kt thc vo thun th 18 vi giai on I, II v tun th 24 vi giai on III, IV. Ch : Gim liu thuc cn 50% khi tr < 12 thng Ngng iu tr vi Actinomycin D v Doxorubicin khi :

+ Bch cu ht < 1000/mm3 hoc + Tiu cu < 100.000/mm3. Tia x : Cho cc trng hp giai on III v IV vi liu thng nht l 10,8 Gy chia lm 6 ln (1,8 Gy x 6 = 10,8 Gy). Ngng iu tr tia x khi BC ht < 1000/mm3 v tiu cu < 75000/mm3. + Vi khi u giai on V (chim t l rt nh): Phu thut : Trong ln u sinh thit c 2 bn thn khng nh u giai on V v ct hch, nh gi giai on ca tng thn. Nu c 2 thn theo nh gi u giai on I hoc II : iu tr ha cht theo phc cho giai on I, II.

Nu c nh gi giai on III hoc IV : iu tr ha cht theo phc cho giai on III, IV. nh gi li sau 5 tun bng chn on hnh nh v phu thut ln 2: Ct ton b khi u 2 bn v nh gi giai on trong phu thut. iu tr ha cht tip tc theo giai on Nu bnh nhn c iu tr ha cht nh giai on I, II nhng khng ct thn ( bo ton) chuyn sang iu tr ha cht theo phc cho giai on III, IV. nh gi li vo tun th 12 : Phu thut ln 3 v tia x nu cn thit. + Theo di cc tc dng khng mong mun do ha cht : Thng t gp khi iu tr u nguyn bo thn. C th gp : Lot ming Nn To bn Bnh l thn kinh ngoi vi : au c, gim phn x gn xng....

- Tim mch : Biu hin bt tjng trn in tim (thng gp khi tng liu Doxorubicin > 360 mg/m2) Suy chc nng gan a chy.

Nu cc biu hin trn nng nn hon v gim liu ln tip theo cn 50% sau tng ln nh trc. iu tr ni khoa : Nh cc bnh l{ thng thng. + Theo di lu di bng cc xt nghim : Chc nng thn Siu m bng

X quang phi

Trong v sau khi iu tr ha cht. Trong : 2 nm u : 1 ln/1 - 2 thng T nm th 3 : 1 ln/3 - 6 thng.

S68. TINH HON N (LC CH)


Tinh hon lc ch hay tinh hon n, khng xung bu l mt d tt rt thng gp tr em. T l mc t 3 4% tr bnh thng v 30% tr s sinh non. Khuyt tt ny thng khng c gia nh pht hin, cn b y t x l mun, li hu qu lu di v sau, nh hng chc nng sinh sn v sinh, ung th ho lc v gi. 1. Chn on : 1.1. Lm sng Tinh hon khng c trong bu mt bn hay c hai bn. Tinh hon nm trn bu s thy. Tinh hon nm trong bng khng s thy.

- o kch thc tinh hon v so snh hai bn (nu s thy) i chiu vi tiu chun Prader. o kch thc ng vt.

- Khm v pht hin cc d tt sinh dc niu o khc nh tt l i thp, m vt ph i, bu khng pht trin bnh thng. - Cn nng, chiu cao v cc du hiu lin quan n dy th vi tr ln trn 10 tui.

Nu ch c tt tinh hon n, thng cc du hiu khc u bnh thng. 1.2. Xt nghim : LH v testosteron thp hn bnh thng hay bnh thng. Nhim sc th xc nh gii tnh. Nghim php HCG Cho HCG tim bp cch nht, 3 ln lin.

- nh lng testosteron huyt thanh trc khi tim v sau mi tim th ba 24 gi. Nu c tinh hon testosteron s tng ln sau khi tim mi th 2. Nu khng c tinh hon nng testosteron trc v sau tim khng thay i. Gi tr ca test : xc nh bnh c tinh hon hay khng. Siu m bng : xc nh v tr v kch thc tinh hon.

2. iu tr : + Cn cho hocmon tr liu trc khi lm phu thut : Cch cho : Pregnyl 1500 n v x 6 ng/mi tun tim 2 ng, 3 tun lin, ngh 1 tun. Testosterol 100mg/tim bp/1 thng 1 ln/ 4 6 thng.

Sau 3 thng kim tra li : nu khng c kt qu c th tip theo 1 t mi, nhng khng nn nhiu hn. Nu c tinh hon, t l t xung sau dng HCG t 30 60%. Nu khng xung c cng to thun li cho phu thut tt hn. + Ngoi khoa a tinh hon xung bu : Phu thut ch nh khi tinh hon lc ch, cn a v v c nh trong bu.

Hocmon liu php tht bi. Tc dng thm m v tm l. phng ung th ho v sau.

V vy phu thut l bt buc, khng c tinh hon trong bng. - Thi gian lm phu thut cng sm trc 12 24 thng cng tt, trnh tinh hon b thoi ho v nm lu trong bng.

S69. VIM CU THN CP TIN PHT


Vim cu thn cp tin pht (VCTC) l bnh vim cu thn lan to sau nhim khun, phn ln sau nhim lin cu tn huyt kiu b nhm A. Bnh din bin lnh tnh, nhng c th gy ra mt s bin chng trong giai on cp dn n t vong. 1. Chn on xc nh * Da vo tam chng c in : Ph : Thng ph nh, bt u t mt n chn.

- Tng huyt p : thng tng c huyt p tm thu v tm trng t 10 20mmHg. Tiu t, v i mu i th hoc vi th.

* Xt nghim nc tiu : C gi tr quyt nh C nhiu hng cu. Protein niu tng, nhng t khi qu 2g/m2/24h.

* Xt nghim mu : - Ure v Creatinin huyt thanh bnh thng hoc tng, nhng mc lc cu thn thng gim.

- B th ton phn, yu t 3 ca b th (C3) trong huyt thanh gim trong giai on cp. Khng th khng dung huyt lin cu (ASLO) thng tng > 250 n v Todd.

2. iu tr : Trc ht phi pht hin v iu tr kp thi cc bin chng.

- Nhng trng hp VCTC c bin chng hoc c nguy c phi c iu tr ti bnh vin theo di st. 2.1. Th VCTC thng thng (khng c bin chng)

Ch n v ngh ngi :

n nht trong khong 2 3 tun. Hn ch lng nc ung tuz theo s lng nc tiu nhiu hay t. Tr cn c ngh ngi ti ging.

Khng sinh : Nhm loi tr cc nhim khun do lin cu nhm A, bng :

Penicillin G 50.000 v/kg/ng, tim bp hoc tnh mch, trong 10 ngy.

- Nu tr d ng vi Penicillin, th thay bng Erythromycin 25 30mg/kg, ung chia 2 3 ln ngay trc ba n, trong 7 ngy. - Khng dng cc khng sinh nhm aminosid hoc cc khng sinh c i vi thn khc.

Chm sc v theo i :

Hng ngy cn, o s lng nc tiu, huyt p. Gi m v v sinh rng ming v thn th.

Tiu chun xut vin :

a s trng hp ch cn iu tr ti bnh vin 10 14 ngy, khi ht cc du hiu lm sng v xt nghim nc tiu thuyn gim. 2.2. Vim cu thn cp c bin chng tim mch : (c du hiu suy tim cp hoc do ph phi cp)

Ch n ung : nh th thng thng. Chm sc : Ch h l cp I. Theo di mch, huyt p, nhp th thng xuyn cho n khi ht suy tim. Cho th xy nu cn.

Thuc li niu tc dng nhanh :

Furosemid (Lasix) : 1 2mg/kg tim tnh mch.

Thuc h p tc dng nhanh :

Nifedipin (Adalate) 0,25mg/kg/1 ln x 2 ln, liu ti a 1 2 mg/kg/ng Hoc Hydralazin (Apresolin) 0,1 0,2mg/kg/1 ln, ung hoc tim tnh mch, 6 gi 1 ln (tng liu 1,7 3,5mg/kg/24gi).

Nu bnh nhn c mch nhanh khng suy thn, suy tim cp c th cho ung propranolol 1mg/kg/ln x 3 ln/ng. Thuc tr tim :

Digoxin : 0,04 mg/kg/ng, tim tnh mch 1/2 liu, sau 8 gi tim ln lt 1/4 liu (khi nhp cn trn 90 ln/pht). 2.3. Th vim cu thn cp gy ph no (Co git ton thn, hn m)

Ch n ung : nh trn

Chm sc : Ch { phng cn phi li.

Lm thng thong ng th

Thuc li niu : Nh trn Thuc h huyt p : Nife ipin (A alat) nh trn. hoc:

Diazoxid 3 5mg/kg/ln, tim tnh mch. Nu khng c kt qu, c th tim nhc li sau 30 pht.

Chng co git :

- Diazepam (Seduxen, Valium) 0,2 0,3mg/kg tim chm vo tnh mch, liu ti a 1 ln l 10mg. Magie sulfat 15% - 0,3ml/kg, tim bp hoc tim tnh mch chm.

2.4. Vim cu thn cp th v niu hoc suy thn cp

Ch n : Hn ch mui v Protid, ti a 1g/kg/ng, nhng vn phi bo m nhu cu nng lng ti thiu 50 cal/kg/ng. Ch cn bng lng dch cho vo v thi ra hng ngy. Thuc li niu : Furosemid liu cao tim tnh mch, 3 mg/kg/ln x 3 ln/ngy

S70. SUY THN MN TNH


Suy thn mn l hu qu ca bnh mn tnh ti thn gy gim s lng cc nephron (n v thn) chc nng lm gim dn mc lc ca cu thn, khi mc lc cu thn gim xung i 50% so vi mc bnh thng th c coi l suy thn mn (Mc lc cu thn c tnh theo tui, trn 2 tui l khong 100 ml/1/1,73 m2 da). Thn khng cn kh nng uy tr tt s cn bng ca ni mi s dn

n hng lot nhng bin lon v sinh ho v lm sng ca cc c quan trong c th. 1. Chn on : 1.1. V lm sng : Ch tin s bnh nhn c bnh thn - tit niu trc .

Ph : STM do bnh cu thn thng c ph, STM do vim thn b thn thng khng ph. C th gy t, ci cc, da xanh xm, kh. Thiu mu: Nng , nh tuz giai on.

Thiu mu a s nhc sc hoc bnh sc, hnh th kch thc hng cu bnh thng, c khi c hng cu to, nh khng u. Nhiu bnh nhn khi c khm v thiu mu mi c pht hin STM. Tng huyt p: Thng gp 80% bnh nhi. Suy tim: Khi xut hin th mun. Vim ngoi tm mc: Ting c mng tim l mt du hiu ca suy thn mn. Nn, a chy: C khi c xut huyt tiu ho c lot hoc khng.

Xut huyt: Chy mu mi, chy mu chn rng, chy mu i da l thng gp. Nga l mt biu hin ngoi a thng gp. Chut rt Vim thn kinh ngoi vi: do dn truyn thn kinh gim. Hn m: Do ur mu cao l biu hin lm sng cui cng ca STM.

1.2. Xt nghim :

Mc lc cu thn gim. Nit phi protein tng cao. Creatinnin tng cao. Natri mu thng gim. pH mu gim. Canxi mu gim, phospho mu tng, phosphatase kim tng. Protein niu: c, nhng tng t trong vim b thn mn. Hng cu niu t. Bch cu niu v vi khun niu. Zimniski ng t trng, thp.

1.3. Chn on tin trin ca STM : Di y l s ca cc giai on suy thn mn c quy c nh sau :

Giai on suy thn mn

Mc lc Creatinin mu * cu thn mmol/l mg/dl (ml/1/1,73 m2 da) 70-106 < 130 130299 300499

Lm sng

Bnh thng 100 I: Giai on tim tng II: Giai on tngure IIIa: Giai on suy 60-41 40-21 20-11 10-5

0,8-1,2 - Bnh thng < 1,5 1,5-3,4 - Gn bnh thng, thiu mu nh 3,5-5,9 - Chn n , thiu 6-10 mu va

thn IIIb: Mt b <5

500900

> 10

- Chn n , thiu mu nng, bt u ch nh lc mu - Hi chng ure mu cao, ri lon nghim trngv ch c th ko di cuc sng nh cc phng php lc mul bt buc hoc ghp thn

IV: suy thn giai on cui

> 900

* Cho tr > 2 tui

2. iu tr Tuz theo giai on suy thn c ch iu tr thch hp, bao gm + iu tr bo tn. + Lc mu ngoi thn chu kz : Lc mng bng.

Lc thn nhn to. + Ghp thn 2.1. iu tr bo tn : + Chng cc yu t gy bnh nng : Cao huyt p. Nhim khun-Ch { khng ng cc khng sinh c vi thn. iu chnh nc v in gii, thng bng toan kim.

Khng dng thuc c cho thn.

+ Trnh cc sai st thng mc phi: Dng li tiu khng ng. Dng thuc c cho thn. Dng thuc qu liu so vi chc nng thn.

2.2. Da vo giai on suy thn iu chnh cc ri lon v sinh ho v lm sng + Suy thn giai on I v II mc lc cu thn cn > 20 ml/1/1,73 m2 a. iu tr nh sau l : n t m hn bnh thng (1-2g/kg/ng), bo m nng lng, vitamin iu chnh cao huyt p: Bng Al omet, Nife ipin, + Suy thn giai on III, mc lc cu thn < 20 ml/1/ 1,73 m2 da. Ch n: Bo m nng lng, mui khong, vitamin nhm B Protit: 0,5-1 g/kg/24h.

Cui giai on III ch nn cho 1 bnh nhn nng 30 kg : 20 g Protit bng trng ,sa. Nng lng 1800-2000 kcal. m bo acid-amine cn thit bng vin amine hoc trng sa. Mui : n nht khi c ph v cao huyt p, ch kim tra natri mu. Nc : Ch ung bng lng i. Kali : Tng nhng giai on nht nh. Calci : Ch b liu nh thng xuyn v vitamin D2 Kim : B khi c toan. Thuc chng cao huyt p.

Tr tim : Khi cn, khng c chng ch nh vi coragoxin.

- Thuc chng thiu mu. Nu c iu kin dng erythropoetine (khi Hb < 10g%, Hct < 30%, liu khi u 40-50 UI/kh x 2 ln/tun, sau liu duy tr 20-25UI/kg x 2 ln/tun, tim i da. + Suy thn giai on cui (g IV), MLCT < 5 ml/1/ 1,73 m2 da. Lc mu ngoi c th chu kz l bt buc, c iu kin th ghp thn nu khng bnh nhi s t vong sau vi thng (1,2,3-6 thng). 2.3. Hng dn khi xut vin : Suy thn mn l mt hi chng din bin qua nhiu giai on v nhiu nm, o cn : + Cn ngh ngi, ch n gim m, mui nhng phi m bo nng lng v vitamin, trnh mc cc bnh nhim trng. + c theo di v khm li thng xuyn theo nh kz. + V nh phi tun theo ch nh ngt ngho ca thy thuc trnh cc din bin nng t xut kh lng trc (cn cao huyt p, vim mng ngoi tim, suy tim cp, hn m.) Gia nh cng vi bnh vin chia s v to iu kin lc mu chu kz hoc ghp thn cho cc chu STM giai on cui. + Phng bnh y l phng cc t cp hoc tin trin nhanh n cc giai on sau.

CHNG 7. BNH L THN KINH


S71. XUT HUYT NO MNG NO SM
I. I CNG: Xut huyt no mng no sm xy ra tr i 15 ngy tui. Nguy c mc bnh

cng cao nu cng non thng. Tn sut : 20-40% tr nh cn, cn nng i 1500g. 50% xy ra vo ngy u. 90% xy ra trc ngy th t sau sinh. II. CHN ON: 50% khng c triu chng lm sng. 1. Cng vic chn on : a) Hi: B b / b km. Co git. Tin s sanh non / nh cn. b) Khm: Kch thch, li b, hn m Xanh xao Thp phng Gim trng lc c Mt phn x nguyn pht Du thn kinh khu tr c) ngh xt nghim: Hct PT, PPT Siu m no Chc dch no ty: ch nn chc khi siu m no bnh thng 2. Chn on xc nh : Triu chng thn kinh + siu m no c xut huyt hoc chc d dch no ty ra mu khng ng. III.IU TR: 1. Nguyn tc iu tr: Vitamine K. Nng tng trng. Hn ch s lan rng ni xut huyt. Trnh truyn qu nhanh cc dch truyn c tnh thm thu cao. 2. Vitamine K: Vitamin K1 5mg TB. 3. iu tr h tr :

Truyn mu ti 10 20 ml/kg nu Hct thp Phenobarbital nu co git. Liu u l 20mg/kg TM. Nu na gi sau cn co git cho thm Phenobarbital 10mg/kg TM. C th tip tc nu cn co git. Vitamin E 25 n v / ngy n khi tr cn nng trn 2500g iu ng : - Nm ngh tuyt i - Nm u cao 300 - Cho n qua ng thng bao t: sa m hoc sa cng nghip - Trnh thm khm khng cn thit

S72. VIM MNG NO M TR EM


Vim mng no m l mt bnh nhim trng cp tnh do vi khun xy ra ti nomng no, l mt cp cu thng gp trong nhi khoa v nguy him tr em cn c chn on v x tr kp thi. 1. DCH T HC - Vim mng no m chim 1/3 trng hp vim mng no, trn th gii cng nh Vit nam,t l mc bnh VMNM tr em vn cn kh cao. Theo trung tm kim sot bnh truyn nhim Hoa kz t 1981-1991, t l b VMNM hang nm l 1.1/100.000 n, c tnh 2.600 trng hp/nm. Ti Vit Nam, theo Phm th Su (Vin nhi H Ni) t 1996-1999 c 162 trng hp, t l t vong 16,9%, t l di chng 7,74%, theo L thanh Bnh (BVT Hu) t 1999-2001c 65 trng hp, t l t vong 9%, t l di chng 11%, khng c s khc bit gia nam v n, nng thn b bnh cao hn thnh ph, i 1 tui chim 67,7%, nguyn nhn hng u l H .Influenzae 35,3%, th n l no m cu 18,4%, ph cu 9,2%, khng tm thy vi trng 36,8%. Hin nay M nh chng nga vaccin H .Influenzae nn VMNM ch yu l ph cu v no m cu, tn sut ph cu hng nm l 13/100.000 dn.

Tn sut mc bnh cn kh ph bin, t l t vong, cc bin chng v di chng tm thn kinhcn nng n o bnh cn c chn on sm, x tr kp thi v tch cc hn ch t vong cc bin chng v di chng. 2. TC NHN GY BNH - Cc vi khun gy VMNM thay i ty theo tng thi kz, ty theo tng vng a l, tng nc, c khi bng pht thnh dch nht l no m cu. Tn sut vi khun gy bnh cn c th thay i ty theo la tui, ma, thi tit, tnh trng mim dch, inh ng, bnh km theo v cc yu t thun li nh chn thng, vim tai... Vim mng no m tr s sinh ch yu l do lin cu nhm B, Listeria monocytogene, trc trng Gram (-), enterococci, t cu. i vi tr ngoi din s sinh, tr cng nh tn sut gp Haemophilus influenzae type b cng cao, th n l no m cu v ph cu . 2.1 Tn sut gp cc mm bnh gy VMNM theo tui Tn sut vi khun gy bnh VMNM trong din s sinh ch yu l cc vi khun gram m, E.coli, lin cu khun nhm b, v Listeria monocytogenes, i vi tr ngoi din s sinh, tr cng nh th tn sut mc Haemophilus influenzae cng cao, tr trn 6 tui ch yu l ph cu v no m cu. Mm bnh Haemophilus influenzae Neisseria meningitidis < 2 thng 2 thng - 6 tui > 6 tui 0 - 2% 0 - 1% 40 - 60% 20 - 30% 10 - 30% 5% 25 - 40% 40 - 50% 5 - 10% 1 - 3% 5 - 10% 5%

Streptococcus pneumoniae 1 - 4% E. coli (VK Gram m) Streptococci Staphylococci Listeria monocytogenes

30 - 50% 1 - 4% 30 - 40% 2 - 5% 2 - 5% 2 - 10% 1 - 2% 1 - 2%

Vi khun khng xc nh

5 - 10%

5 - 10%

5 - 10%

2.2 Theo iu kin xut hin v c a ngi bnh 2.2.1 Bnh tai mi hng mn tnh - Vim tai gia mn : ph cu, Haemophilus, VK k kh. - Vim xoang : ph cu, Haemophilus, VK k kh, c khi t cu. 2.2.2 Bnh nhim trng - Vim phi : ph cu. Vim h hp trn : ph cu, no m cu, Haemophilus. - Vim m t bo : lin cu, t cu. - p-xe no : t cu, VK k kh. 2.2.3 Chn thng u - V s kn : ph cu, lin cu nhm A, trc trng Gram (-). - V s h hoc m s : T cu vng, trc trng Gram (-). 2.2.4 Bnh tim n - Tiu ng : ph cu, trc trng Gram (-), Staphylococcus. - Leucmie : ph cu, Gram (-). - Tr suy inh ng, iu tr corticoides: M. tuberculosis, Cryptococcus. - Ct lch : ph cu, Haemophilus. - Van tim nhn to : Staphylococcus aureus hoc S. epidermidis. 3. C CH BNH SINH 3.1 Gii Phu Bnh Phn ng vim mng nui, mng nhn v dch no ty lm cho mng no dy ra, xung quanh cc tnh mch, dc theo chiu cong ca no b, theo cc khuyt su ca cc rnh, quanh tiu no. Cc cu trc cnh mng no cng c th c nhng thay i bnh l{ nh vim tc tnh mch v no, cc ng mch mng nui c th to thnh mch lu v tc mch. Nh c mng nui chn ngang nn vi khun khng xm nhp trc tip vo m no. Tuy nhin phn no v cc t chc tip cn mng no vn b nh hng, sung huyt v ph n. Nhng bin i bnh l{ thng gp l trn dch i mng cng v trng, vim ng mch no, vim tc tnh mch v no, vim tc mao mch lp v tip cn vi mng no vim. Ty sng cng c th cha m. M thng hin din trong khoang i nhn,

nhiu nht l phn y v khong gn tiu no, sau lan ra 2 rnh trn no. Thnh no tht cng c th cha m, mt lp t bo ph mt trong no tht. Tn thng y thn kinh s xy ra ni tch t nhiu dch vim. Thn kinh III v VI tn thng o chn p thy thi ng o thot v lu, hu qu ca tng p ni s. Dy III v VI cn c th b lit do huyt khi xoang hang nhim trng. Ph no, tng p ni s trong vim mng no m l do : - Do cht t bo (ph no o gy c t bo). - Do tng tnh thm mao mch do cht Cytokine (ph no do ngun gc mch mu). - Do gia tng p lc thy tnh (ph no k), do tc nghn ti hp thu DNT. - Do tng tit ADH bt thng v gy nc qu mc. No ng thy c th sinh ra do nghn s lu thng ca DNT trong no tht hoc ngoi no tht (do mng no y nh, x ha). 3.2 Sinh bnh hc Phn ln cc trng hp vim mng no nhim khun tun tin qua 4 giai on :

Th nht : nhim trng ng h hp trn. Th hai : xm nhp vo mu t cc nhim trng ng h hp. Th ba : cc vi khun theo ng mu trn vo mng no. Th t : vim mng no - no.

- i b phn tr em bnh thng la tui cn b v tr ln vo thi gian no , u b c tr hoc nhim khun ng h hp do cc vi khun gy vim mng no. Trong phn ln tr em c bnh nh ng h hp. mt s t tr, vi khun ny a xm nhp vo mu. mt s trong cc trng hp vi khun huyt ny, cc vi khun b qut sch khi dng mu nh cc c ch phng v t nhin. mt s khc, nhim khun c gii quyt ti giai on ny bng cc th thuc khng khun ung thng thng. Tuy vy mt s t tr (c iu tr hoc khng iu tr), bnh nhim khun tun tin v gieo rc vo h thn kinh trung ng ri vim mng no. - Cc nhim trng vng bn cnh no nh vim xoang m, vim tai gia, vim

tai xng chm, vim xoang sn, xoang bm, xoang trn, vim xng ty xng s, ct sng; chn thng s no h; u mng no ty c th gy vim mng no qua ng lan truyn ln cn, song thng l do vn khun huyt trc . - Vi khun theo ng mu qua m ri cc no tht bn, qua mng no vi khun s i vo NNT. Sau vi khun s lu thng n phn NNT ngoi no, n khoang i nhn v ti y chng nhanh chng sinh sn v nng b th v khng th ca NNT khng c ch chng. Tip n l mt phn ng vim khu tr do thm nhp ca bch cu a nhn qua trung gian cc yu t ha hng ng. S hin din ca Lipopolysaccharide v t bo (ni c t) ca vi khun gram (-) (H. influenzae b, no m cu) cng nh cc thnh phn ca v vi khun ph cu (acide teichoic, peptidoglycan) s kch thch v gy mt phn ng vim nng n km theo sn xut ti ch cc yu t : TNF (hoi t khi u ), Interleukin 1, Prostaglandin E2 v mt s cht trung gian gy vim khc vi Cytokin. - Vi s hin din ca cc cht trung gian vim ny, phn ng vim tip tc xy ra : thm nhp bch cu a nhn, tng tnh thm mch mu, tn thng hng ro mch mu - no v huyt khi mch mu. Sau khi NNT a sch vi khun, mt phn ng vim khc tip tc xy ra m nguyn nhn l do cc cht Cytokin tha thi a c tit ra m ngi ta cho rng di chng ca vim mng no m l do tnh trng vim mn tnh ny. - Tng protein NNT mt phn l o tng tnh thm ca hng ro mch mu no, mt phn l do mt cht dch giu albumin t cc mao mch v tnh mch i ngang qua khoang i mng cng. Vo giai on sau ca vim mng no m, hin tng thm dch ny s gy ra trn dch i mng cng. Glucose NNT gim l do mng no b vim gy gim vn chuyn glucose v o tng nhu cu s dng glucose ca t chc no. 3.2.1 Yu t thun li to iu kin cho s xm nhp ca vi khun qua mng no - C nhim trng ng h hp trn do virus hoc nhim trng phi do Pneumococcus. - Vi khun c i tnh vi mng no mt khi a lan trn vo mu (H. influenzae, ph cu v no m cu). - Tn thng mng chn mu - dch no ty vi khun vo n khoang i mng nhn do chn thng s no kn, h gy hy hoi tnh trng inh ng ti

ch. 3.2.2 Cc yu t c nguy c gy vim mng no m - Yu t vt ch : thiu ht min dch bm sinh hay mc phi, nam mc bnh nhiu hn n. Tr s sinh v tr nh mc bnh nhiu hn tr ln. Tr b ct lch d b vim mng no m do ph cu, H. influenzae tp b v trc trng gram (-). Tr b thiu mu hng cu hnh lim v b bnh l huyt sc t Hb b vim mng no m do ph cu v H. influenzae b. Tr thiu b th C5 - C8 d b vim mng no do no m cu. Bnh l b th d b vim mng no m do Salmonella. Bnh c tnh h vng ni m d b vim mng no do cc vi khun c c lc thp v t e a nhng tr ny. - Yu t gen : H. influenzae gy vim mng no m cao hn mt s chng tc. HLA B12 d b vim mng no m hn so vi HLA BW40. Chm p ng khng th IgG so vi khng nguyn v polysaccharide type b d b mc vim mng no m. - Mi trng , cng ng : Ngi ta nhn thy H. influenzae v no m cu c khi gy thnh dch trong mt cng ng. Tri li, ph cu th him hn. 4. TRIU CHNG LM SNG Cc triu chng v du hiu vim mng no m c nhiu v ty thuc mt phn vo nguyn nhn gy bnh, tui bnh nhi, thi gian mc bnh trc khi c thm khm v s p ng ca a tr vi nhim khun. 4.1 Cch biu hin khi bnh vim mng no m C hai cch biu hin vim mng no m tr cn b v tr em : - Cch th 1 l din bin m thm v xut hin tun tin trong mt hoc nhiu ngy. C th trc c mt bnh khng c hiu c st. Trong trng hp ny kh c th xc nh ch thc s khi pht vim mng no m t khi no, thng l do H. influenzae. - Cch th 2 l cp din, nh s t nh. Cc triu chng nhim khun huyt v vim mng no xut hin rt nhanh trong vi gi. Hnh thi tin trin mau l ny thng c km ph no nng, c th gy thot v qua lu dn ti chn p thn no. Nhng trng hp ny thng do mng no cu. T l t vong cao.

4.2 Triu chng lm sng ton pht thay i theo tui - Tr s sinh: Trong bnh cnh nhim trng huyt, ri lon thn nhit, h nhit Ri lon thc: l m, kch thch rn , ng lm hn m. Ri lon nhp th : suy h hp. Ri lon vn ng: co git. Ri lon tiu ho: b b, nn, a chy. Vng da. Thp phng. Du mng no khng r - Tr b m: Hi chng nhim trng: st,v mt nhim trng, xanh ti, ti nht, bch cu tng. Ri lon thc : l m, n, tng kch thch, khc khi c b, mt nhn sng, nhn ngc. Ri lon vn ng : co git. Ri lon tiu ho: b b, nn, a chy. Cc du mng no: c nhng khng in hnh.Thp phng nhng tr cn thp. - Tr ln:

Hi chng nhim trng: st cao. Tam chng mng no: nhc u, nn, to bn. Ri lon thc: l m, n, hn m. Ri lon vn ng: co git, lit. Du mng no r: nm t th c sng, cng c r, kernig (+), brudzinki (+), vch mng no(+)

4.3 Cc du hiu c nguy c trm trng 4.3.1. Ri lon huyt ng ngoi bin - Nht nht, xanh xao, nhim c. - Lnh u chi, tm ti u chi, v m hi. - Ko di thi gian vi tun hon a (bnh thng < 3 giy). 4.3.2. Ri lon huyt ng trung tm - Mch nhanh (ph thuc mt phn tui ca tr v tnh trng st). - Th gp th nhanh. - i t. - H huyt p (du hiu mun).

4.3.3. Ri lon thn kinh giao cm - Nhit khng n nh, h thn nhit. - Ri lon nhp th, c cn ngng th. 4.3.4. Hin din ca ban xut huyt dng hnh sao (vim mao mch nhim trng) thng l do no m cu. - Nh : chm xut huyt , dng hnh sao, ri rc trn da, tin trin hoi t. - Nng : xut hin nhanh, kch thc ln, lan ta nhiu, nhanh. 4.4 Cc du hiu hoc thng tn c th kt hp vi vim mng no m - St k o i trn 10 ngy sau iu tr gp 15% do H. influenzae, 9% do ph cu. Hoc l triu chng ca trn dch, trn m i mng cng, vim tnh mch, vim phi, vim khp, vim mng ngoi tim, nhim trng ti bnh vin hoc do khng sinh. - Chm xut huyt hoc ban xut huyt hnh sao gi cho chn on no m cu. T ban km h thn nhit v chong thng o CIVD v c { ngha tin lng xu. - Co git : co git trc khi vo vin hoc 1 hoc 2 ngy sau khi vo vin xut hin khong 20 - 30% trng hp. Co git ton th thng khng mang { ngha tin lng xu. Tri li tr co git cc b chc s c di chng thn kinh nhiu hn. Co git xut hin mun trong qu trnh iu tr l do tn thng no, trn ch i mng cng, nghn mch v hnh thnh p-xe. Cn tin hnh cc thm thch hp chn on. - Cc du hiu thn kinh cc b chng hn nh lit na ngi, lit t chi, lit mt, vim ni hu nhn cu, cc khuyt tt th trng, m, l , ic xut hin sm hay mun trong khong 15% bnh nhi VMNM ni ln kh nng nghn tnh mch hay ng mch v no l hu qu ca ph v vim. Cc du hiu thn kinh cc b c th l mt ch dn cho mt kt thc bt li. Ph gai th t thy trong giai on u VMN cp v nu c phi xem xt kh nng nghn tnh mch xoang, trn dch i mng cng hoc p-xe no. - Gim thc : mc thc ca mt tr vim mng no m lc nhp vin c mt { ngha tin lng. Mt a tr bn m hoc hn m lc vo vin th c nhiu kh nng tin lng xu hn nhng tr ng lm hoc ng g.

4.5 Giai on lui bnh Vim mng no m l mt bnh nhim trng nng n ti h thn kinh, thng khng c giai on t lui bnh, nu khng c chn on v iu tr bnh din bin nng dn v t vong, nu c pht hin sm v iu tr vi trng nhy cm vi khng sinh bnh tin trin thun li khng km theo cc bin chng th c th khi hon ton, nu c chn on mun bnh c th t vong trong 48- 72 gi u, nu khng t vong bnh c nguy c c nhiu bin chng xa v di chng lu di v tm thn kinh. 4.6 Chn on lm sng vim mng no m V nhng du hiu v triu chng lm sng vim mng no tr cn b v tr em c rt nhiu v thng ging cc bnh nhim khun hoc khng do nhim khun khc nn hu ht cc thy thuc nhi khoa u c kh nng nhn bit sm. Song, khng c mt du hiu lm sng duy nht no l c hiu i vi vim mng no m c. Trn nguyn tc th vim mng no m tr s sinh v tr b m t thng, cc du hiu t bc l v thng l t nh, d nhm ln nn vic chn on sm kh c th xc nh trn lm sng. St c trong mt na s tr b nhim trng. Ng lm, h hp nguy kch, vng da, b b hoc nn v a chy l nhng triu chng thng gp nhng l nhng biu hin khng c hiu ca cc bnh nhim khun xm ln s sinh. Chng 1/3 s tr cn b thy c tnh trng kch thch tng n, thng c km gim thc v trng lc c. Co git xut hin trong khong 40% tr s sinh b vim mng no cn thp phng hoc thp cng ch thy trong chng 1/3 trng hp. tr ln, st, nhc u, s nh sng, bun nn v nn, tm tr l ln v ng lm, tnh trng kch thch thi qu l nhng triu chng khi u thng gp. Nhng biu hin ny khng mang tnh c hiu v thng kh phn bit vi cc triu chng nhim khun mng no do virus hoc cc bnh khc c st cao. Mt thay i trong tnh cm hay tnh trng tnh to ca tr l mt trong nhng du hiu quan trng nht ca vim mng no. C cng (du Kernig v Brudzinski ), co git, thp phng v hn m t thy hn la tui cn b v thng l triu chng mun, song mang tnh c trng chn on l VMN. Thng l kh i vi mt ngi thy thuc phi nhn bit mt bnh nhi vim mng no trong s rt nhiu tr cn b v tr em n khm v mt bnh c st

cao. Nng lc phn bit trng hp vim mng no vi cc trng hp khc l kt qu tch ly kinh nghim trong vic x l cc bnh tr em. Khng c g thay th c tnh nhy bn lm sng trong vic nhn bit v chn on mau l vim mng no tr cn b v tr em. Tuy vy v mt cng ng mt s cc tnh hung sau cn nghi ng VMNM :

St cao + co git St + b b St + thp phng ( nhng tr cn thp ) St + ri lon thc (l m, kch thch, vt v, l ln) St + c du hiu mng no St + c km du thn kinh bt thng St + t ban dng hnh sao, thng do no m cu c th km nhim trng huyt St + nhim trng, nhim c nng n + v mt xanh ti (khng tm thy tiu im nhim trng). Theo hng dn ca chng trnh IMCI cc u hiu nguy him ton thn, cng c, thp phng l cc du hiu ch im ca bnh rt nng c th l Vim mng no.

5. CN LM SNG 5.1 Kho st dch no ty Xt nghim NNT bnh thng Vim mng no m

5.2 Mt s xt nghim khc lin quan n NNT - Phn ng Pandy - Rivalta (+) : tng globulin trong NNT. - CRP : tng trong NNT. - in i NNT : Gamma globulin tng. - Kho st nng men Lactate dehydrogenase (LDH) l mt d kin gip chn on. Tng qu 50 n v trong VMNM, trong LDH4 v LDH5 chim hn 15%. Kho st LDH thy c 5 gii hp th. Trng hp c 3 gii l do virus. - Nu cy NNT c vi khun, thng ngi ta lm khng sinh tm nhy cm ca khng sinh vi vi khun. - Phn ng tm khng nguyn - khng th trong NNT. + CIE (Counter immunoelectrophoresis) : chn on nhanh trong 1 gi. + LA (Latex agglutination) : nhy cm hn CIE vi 3 loi vi khun thng gp. Chn on nhanh trong 15 pht. + ELISA (Enzyme linkes immunosorbent assay) . 5.3 nh gi kt qu NNT - Yu t quan trng trong VMNM l c s hin din ca vi trng, th n l yu t t bo v protein. Trong trng hp chc NNT b chm mu th theo Badoux c 1000 hng cu/mm3 th tr bt 1 mg protein cho 100 ml NNT v khong 700

hng cu tng ng vi 1 bch cu. Ri ly s bch cu m c tr ra s c s bch cu thc. Yu t ng gim kh r trong VMNM, c khi ch cn vt. Mt s thay i ng mu thng k o theo thay i ng NNT sau 30 pht n 2 gi. nh gi ng ng NNT, nn xt nghim ng thi ng mu trc khi chc NNT. Vic iu tr khng sinh trc khi chc NNT mt tr b VMNM khng lm thay i ng k cc c tnh hnh thi hc v nhum gram ca vi khun. Cng khng lm thay i kt qu sinh ha hc NNT ngay c khi a tin hnh iu tr bng khng sinh thch hp theo ng tnh mch. Sau 24 - 48 gi, ngi ta vn cn pht hin c c tnh vi khun v nhng thay i sinh ha in hnh trong VMNM trong phn ln trng hp. Nu o H.influenzae c iu tr bng khng sinh ng ung th cy NNT vn thy mc H. influenzae. Nhng tr b VMNM do ph cu hoc mng no cu c iu tr trc vi cc khng sinh c hiu lc mi d c chiu hng lm sch vi khun trong NNT. 5.4 Cc xt nghim v cc k thut khc gip chn on v theo di VMNM - CTM, tiu cu, VSS. tm hi chng nhim trng - ng mu thng gim, hoc so snh vi ng NNT - in gii , ur e, creatinine. nh gi chc nng thn. - Chc nng ng mu. thng ri lon trong nhim no m cu. - Cy mu c th tm thy vi trng. - Cy dch mi hng, m tai, thng tn a, nc tiu. nu (+) thng t gi tr. - X-quang phi, xng s, xng chm.khi nghi ng nguyn nhn do tai. - Soi y mt.mc c tng p ni s song y mt cha c ph gai th. - Siu m thp, scanner s no pht hin cc bin chng, t dch, t m, n no tht, p xe no... 6. CHN ON V CHN ON PHN BIT 6.1 Chn on - Tin s, bnh s v dch t. - Lm sng. - NNT : bin i sinh hc r rt : nc m c, t bo tng ch yu neutrophile, protein tng, ng gim. - Vi trng : c vi trng trong nc no ty.

6.2 Chn on phn bit Nu khng xc nh c vi trng hin din trong NNT th cn gin bit loi tr cc vim mng no do cc nguyn nhn khc : - Vim mng no do cc loi vi khun khng gy m nh : Leptospira, lao, giang mai, bnh Lyme. NNT c th vng nh, bch cu lympho u th, ng khng gim. - nhim trng cnh mng no : vim xng chm, vim tai gia, p-xe no gy phn ng mng no. NNT c th trong, bch cu tng t, c th lympho u th, c tin s vim tai mn, chy nc tai, au tai, lit khu tr, st ko di khi c p xe no. - Vim mng no do siu vi (cn gi l vim mng no nc trong) : quai b, Enterovirus, Arbovirus, Epstein - Barr virus, Varicella - Zoster ...NNT trong, bch cu tng t, lympho u th, ng khng gim, vi trng khng c. - Vim mng no do nm : Candida albicans, Cryptococcus neoformans. him - Cc bnh c tnh : Hodgkin, bch huyt... i cn vo mng no. cc vt tch ca bnh gc a c chn on nay c biu hin i cn xut hin cc triu chng thn kinh - Vim mng no ha cht : gy t ty sng, ng c ch, thy ngn. him gp 6.3 Bin i NNT trong cc bnh thng gp NNT\Bnh Mu sc Protein ng Bch cu Vim mng no Vim no-mng no Xut huyt no Vim mng m (vi trng) vius mng no no do Lao m, c Tng r gim r Tng r trong Bnh thng,tng nh Bnh thng hng, Tng Bnh thng Vng chanh Tng Bnh thng Tng nh

Tng khng qu 500 Bnh thng 1000

Loi bch cu Vi trng

Trung tnh

Lympho ging cu trc trong mu

Lympho Kh tm thy BK

C th tm thy Khng c

Khng c

7. BIN CHNG 7.1 Cc bin chng gn : thng xut hin 48-72 gi u khi vo vin. - Suy h hp : o tng tit, tr, co git, chng bng, st cao, suy tim, vim phi. - Co git : h ng mu, h Natri, h Calci, tc tnh mch ng mch no, ph no... - Ph no : c th gy tt kt. - Chong nhim trng: thng do no m cu - ng mu ri rc trong lng mch : him. - Vim c tim : him - Ri lon thn nhit: h nhit tr s sinh v st cao, co git tr nh. - Ri lon nc - in gii. - H ng mu: thng xut hin ngay thi im vo vin, chn on - H Calci mu. 7.2 Cc bin chng xa : thng xut hin sau 2 tun iu tr. - Trn dch i mng cng : hay gp tr nh v b m, c bit trong trng hp H. influenzae v ph cu. Nghi ng khi st ko di, ti pht, ng lm, hn m, co git khu tr, vng u tng. Chn on nh siu m v scanner. - T m i mng cng : gp trong VMNM th pht sau vim tai gia, sau vim tai xng chm. Lm sng nh trn ch i mng cng nhng st cao dao ng. X tr bng dn lu, khng sinh. - Thuyn tc tnh mch v no : co git, lit khu tr. Khng c iu tr c hiu. - p-xe no : thng p-xe no gy VMNM. Chn on nh lm sng trn ch i mng cng nh siu m v scanner. iu tr dn lu, bc tch, khng sinh.

- Vim no tht : thng gp tr s sinh. Ri lon thc. NNT sch vi khun nhng protein tng cao, st hoc khng, n vng u, dn khp s. Chn on da vo siu m v chc d no tht . iu tr bng chc ht v khng sinh ti ch. - No ng thy : Ni tnh mch da, dn khp s, tng vng u. Chn on nh siu m. iu tr bng to cu ni c van p lc. 8. DI CHNG - 9% c nhng vn v nhn cch. - 28% gim hoc mt thnh lc, m, ri lon v ni, ng kinh, chm pht trin tinh thn vn ng. - 13% c di chng mc nh hn. 9. NGUYN TC X TR 9.1 Chm sc - Thng thong ng th, cho th O2 , nm nga c, ht m gii. Ch { i vi nhng tr c co git, hn m ch sn sc cn thch hp, gi v sinh thn th trnh lot, trnh bi nhim. 9.2 iu tr h tr 9.2.1 Chng ph no - Triu chng lm sng : tng cn, l ln, l m, co git, hn m, cn lm sng: gim ur, creatinin, axit uric, albumin huyt thanh, gim Na. - iu tr : Cho khng sinh ng, chng co git c hiu qu, h st tch cc, cho corticosteroi e, iu tr thm thu tt, c th Cho nm u cao, thng khi tt, hn ch nc : cho 1/2 - 2/3 lng nc nhu cu. Cho Lasix 1 -2 mg/Kg tim tnh mch c th lp li sau 6 -8 gi, cho manitol 0,5g/Kg tim tnh mch trong 10 pht c th lp li sau 4 - 6 gi .Cho Dexamethason liu 0,15mg/Kg tim tnh mch mi 6 gi/1 ln, trong 4 ngy u . 9.2.2 Chng co git - Thng ng th, th Oxy, lm rng d dy, cho thuc chng co git Phenobarbital :10 mg/Kg tim tnh mch, cho kt qu chm sau 20 pht, hiu qu chng co git ko di . Phenitoin (dilantin) : 7 -10 mg/Kg tim tnh mch, ct cn

git nhanh, c u im khng gy ng, v c tc dng c ch tit ADH. Diazepam (valium) : 1mg/tui .theo ng hu mn hoc tnh mch. Thuc gy ng v c ch h hp khi phi hp vi phenobarbital 9.2.3 H nhit : - Paracetamol theo ng ung, ng hu mn, ng qua sonde d dy hoc ng tnh mch ty theo tnh hung. 9.2.4 Gii quyt cc bin chng - Gii quyt tt cc bin chng thng gp, chng h ng mu, cn bng nc in gii, gii quyt tt tnh trng suy h hp, suy tun hon nu c, ty theo bin chng mun nu c gii quyt tt trong giai on sau. Cn cho thm vitamin K i vi tr i 6 thng. 9.3 iu tr theo nguyn nhn - Khng sinh ch nh trong VMNM, s dng thch hp theo vi khun gy bnh Tiu chun chn la: Khng sinh phi thm qua mng no tt, r tin, d kim, nhy cm vi vi khun gy bnh, thuc phi c cho bng ng tnh mch, thi gian iu tr , liu lng ng. 9.3.1 Khi cha bit loi vi khun - i vi tr s sinh: Ampicilin + Gentamicin hoc Ampicilin + Cephalosporin 3 - i vi tr ngoi din s sinh : + Ceftriaxone : 100mg/Kg/24 gi + Cefotaxime : 200mg/Kg/24 gi 9.3.2 Khi bit r loi vi khun - Kt qu nh danh vi khun thng c sau 3 ngy, nn tham kho khng sinh , NNT chc kim tra sau 48 gi v p ng trn lm sng sau 3 ngy iu tr quyt nh tip tc khng sinh a cho hay thay i khng sinh thch hp. - Lin cu khun nhm B : Ampicilin v Penicillin G l thuc chn la x 14 - 21 ngy - Listeria monocytogenes : Ampicilin l thuc chn la, Trimethoprimsulfamethoxazole ng tnh mch l thuc thay th x 14 ngy.

- Trc trng gram (-) : Ampicilin + Gentamicin hoc Cefotaxime + Gentamicin x 21 ngy. - Hemophilus Influenzae : Ceftriaxone hoc Cefotaxime x14 - 21 ngy. - No m cu : thuc chn la l Penicillin 300.000v/Kg/24 gi, chloramphenicol hoc Cephalosporin th h 3 l thuc thay th trong trng hp d ng vi Penicillin. -Ph cu : Penicillin x 10 - 14 ngy trong trng hp khng khng. Ceftriaxone, Cefotaxime hoc chloramphenicol l thuc thay th. - T cu : Methicillin, Nafcillin l thuc chn la . khng vi methicillin : Vancomycin 60mg/Kg/24gi + Trimethoprim-sulfamethoxazole ng tnh mch l thuc thay th. 10. TIN LNG - Tui cng nh, tin lng cng xu. - Thi gian b bnh trc khi iu tr khng sinh thch hp. - Loi vi khun c hiu gy bnh. - S lng vi khun hoc s lng cht Polysaccharide v trong NNT lc chn on. - C nhng ri lon lm gim phn ng ca c th i vi nhim trng. - V mc lm sng cc yu t sau l tin lng nng : vo vin sau 2 ngy, co git ti i ti li, hn m nng, protein trong NNT tng trn 2g/l, ng trong NNT vt, c km theo h ng mu, vi khun l ph cu hoc no m cu c km theo chong, c bnh km theo nh ph qun ph vim, suy inh ng thiu mu... 11. PHNG BNH 11.1 Vaccine : i vi Haemophilus influenzae v no m cu. 11.2 Phng bng thuc : tr nh c tip xc vi ngun bnh no m cu. Rifampicine :10 - 20 mg/Kg ung 2 - 4 ngy Spiramycine : 50 mg/Kg/ngy ung trong 5 ngy. 11.3 Gii quyt tt cc nhim trng ng h hp trn v cc bnh ng tai mi hng. Ti liu tham kho

1. Trng i Hc Y Dc TP. H Ch Minh - B Mn Nhi (2001). S tay x tr lng ghp bnh tr em. Nh Xut Bn Y Hc. 2. Nguyn Duy Thanh - Bnh truyn nhim - Trng i hc Y Dc TP H Ch Minh (1992). 3. Phm Th Su, Nguyn Vn Lm, Vin Nhi (2000), "Mt s c im dch t, lm sng theo cn nguyn mng no nhim khun tr em", K yu cng trnh nghin cu khoa hc , Hi ngh Nhi khoa ton quc ln th 17, nh xut bn Y hc, tr. 391- 395 4. Charles G. Prober (2000), "Acute Bacterial meningitis beyond the Neonatal period", Nelson Textbook of pediatrics, p. 751 - 760. 5. Michele Estabrook (2000), "Nesseria meningitidis", Nelson textbook of pediatrics, p. 826 - 828. 6. Roberi S. Daum (2000), "Haemophilus influenzae", Nelson textbook of pediatrics, p. 833 - 837

S73. XUT HUYT NO MNG NO MUN DO THIU VITAMIN K


I. I CNG : Xut huyt no mng no mun xy ra tr t 15 ngy tui n 6 thng tui v nhiu nht l trong khong t 1 n 2 thng tui. Thng cc triu chng xut hin t ngt v nhanh nn bnh nhn thng nhp vin trong tnh trng nng. a s cc tr u c b sa m hon ton. Xut huyt no mng no mun xy ra tr khng chch nga vitamin K lc sanh v cc tr c lng PIVKA cao (Proteins induced by vitamin K absence). II. CHN ON:

1. Cng vic chn on : a) Hi : B k m hoc b b. Khc tht. Co git. b) Khm tm cc du hiu: L m hoc hn m. Xanh xao, vng a. Thp phng Du thn kinh khu tr: sp m mt. c) ngh xt nghim: Hct. PT, PTT hoc TQ, TCK. Siu m no. Chc d ty sng: ch thc hin khi siu m no bnh thng, cn phn bit gia vim mng no v xut huyt no-mng no. 2. Chn on xc nh: B km / b b, thp phng, xanh xao + siu m no c xut huyt (hoc chc d dch no ty ra mu khng ng) v TQ, TCK k o i. 3. Chn on c th: B km / b b + thp phng + xanh xao. 4. Chn on phn bit : Vim mng no : khi c biu hin nghi ng nhim trng (st cao v/hoc c nhim trng) cn chc d tu sng loi tr vim mng no m. III.IU TR : 1. Nguyn tc iu tr: iu tr c hiu: vitamin K. Nng tng trng. Lm ch chy mu khng lan rng v thnh lp sang thng mi. 2. iu tr c hiu : Vitamin K1 5mg TB 3. iu tr triu chng : Truyn mu ti cng nhm v lng mu truyn c tnh theo cng thc : V = cn nng(kg) x 80 x (Hct mun t Hct o c) / Hct chai mu Hoc 10 20 ml/kg trong 2-4 gi

Huyt tng ti ng lnh (Fresh Frozen Plasma): 10-20ml/kg trong trng hp: - Xut huyt no nhng Hct khng gim. - Xut huyt nng: truyn ng thi huyt tng ti ng lnh v hng cu lng. Nu co git: Phenobarbital liu u (loading dose) = 20mg/kg TM v sau na gi cn co git 10mg/kg TM, c th tip tc na khi cn co git. Nu khng co git : Phenobarbital 5mg/kg TB. Nu khng c Phenobarbital, c th dng Diazepam: 0,3-0,5m/kg TM chm v ch vn suy h hp. Vitamin E : 50 n v / ngy (ung) n khi xut vin (t nht 7 ngy). Cc lu { trong chm sc: - Nm ngh tuyt i, trnh kch thch - Nm u cao 300 - Cho n qua ng thng bao t : sa m hoc sa cng thc - Trnh thm khm khng bt buc IV. THEO DI V TI KHM : 1. Theo di : o vng u mi ngy S pht trin vn ng tm thn Siu m no 2. Ti khm : Mi 3 thng n 2 nm (c iu kin th ti khm n 4-7 nm) pht hin cc di chng no: teo no, no ng thy, bi no, chm pht trin vn ng tm thn.

S74. THOT V MNG NO TU


Thot v mng no tu l do khuyt cung sau rng lm cho ng sng thng vi phn mm ngoi ng sng, qua mng cng tu d dng phnh ra v to thnh ti thot v.

Cn c vo ni dung ti thot v ngi ta chia ra : Thot v mng no tu (Meningocele) ti thot v cha mng cng, mng nhn, dch no tu Thot v mng no tu - tu

(Meningomyelocele) ti thot v cha mng cng , dch no tu v mt phn tu (hoc ui nga) Thot v tu (Myelocele) ti thot v lp y tu Thot v ng tu - tu

(Syringomyelocele) ti thot v cha tu v ng tu trung tm 1. Lm sng

Xut hin khi u vng tht lng - cng, u mm c che ph lp a nhn nheo. u Hnh thi ti thot v c th thy nh sau : Lp a tng i dy, rt t khi v gy r dch no tu. Lp da mng, cng bng, rch gy r dch no tu. Lp da v lp m i da ti thot v kh dy, s nn ngoi nh mt khi

Thot v mng tu thng khng c biu hin g v ri lon vn ng v cm gic. Biu hin lit mt phn hoc hon ton hai chn , mt cm gic v ri lon c tht thng gp trong cc tng hp ti thot v c cc r thn kinh v tu( c th c pht hin khi soi n pin qua ti thot v ) Gn 90% trng hp thot v mng no tu kt hp trn dch no.

Thng c d tt ct sng c cao v h s sau gi l hi chng Amold chiari l d tt bm sinh vng c chm, lm hnh tu v hai hnh nhn tiu no tt xung ng sng ca c1 v c2 p cng Sylvius v l Magendie dch no tu khng ra khoang i nhn gy no ng thu Chc ng sng tht lng thy lu thng ch no tu b tc nghn Xt nghim 2. 2.1 X - quang ct sng s thy v tr v mc khuyt cung sau. Cc xt nghim cn thit cho phu thut iu tr Chun b trc m

Ngay khi a tr sinh ra v c chn on cn t ngay mt ming gc v trng c tm nc mui ln ch tn thng trnh kh a. Khm nh gi mc gii hn vn ng v cm gic v mc no ng thu. Cho khng sinh ph rng : cephlosporin 2.2 K thut m Phu thut nn lm trong vng 24 gi u.

Tin hnh rch da quanh ti thot v v m rng sang 2 bn, bc tch chn ti thot v khi t chc xung quanh. Ct bt mt phn ti thot v v khu li. Dng cn vung tht lng hai bn che ph l khuyt xng. 2.3 Chm sc v theo di sau m Truyn dch trong nhng gi u Tip tc cho khng sinh tnh mch

Sau m phi lun theo i vng u, kch thc ca thp trc pht hin no ng thu.

S75. CO GIT
I. I CNG: Co git l mt cp cu thn kinh thng gp nht tr em. Trong nng nht l cn co git lin tc khi cn co git cc b hay ton th ko di trn 30 pht hay nhiu cn co git lin tip nhau khng c khong tnh. Bin chng co git l thiu oxy no, tc nghn ng th gy t vong. Nguyn nhn ca co git rt a ng, thng gp nht tr em l st cao co git. II- CHN ON: 1. Cng vic chn on: a) Hi bnh: Tin s: St cao co git ng kinh Ri lon chuyn ha. Chn thng u. Tip xc c cht. Pht trin tm thn vn ng. Bnh s: St, tiu chy, b n. Tnh cht cn git: ton th, cc b ton th ha hay khu tr, thi gian cn git. b) Khm lm sng: Tri gic. Du hiu sinh tn: mch, huyt p, nhit , nhp th, tm ti, SaO2. Du hiu tn thng ngoi a lin quan n chn thng. Du hiu thiu mu. Du hiu mng no: c cng, thp phng. Du hiu thn kinh khu tr. a) Cn lm sng: Cng thc mu, k sinh trng st rt.

Ngoi tr st cao co git, cc trng hp khc: ng huyt, Dextrostix, ion Chc d ty sng: sinh ho, t bo, vi trng, Latex, IgM. Huyt thanh chn on vim no (HI, Mac Elisa). EEG (nghi ng kinh). Echo no xuyn thp. CT scanner no nu nghi ng t mu, u no, p xe no m khng lm c siu m xuyn thp hoc siu m c lch M-echo. III. IU TR: 1. Nguyn tc iu tr: H tr h hp: thng ng th v cung cp oxy. Ct cn co git. iu tr nguyn nhn. 2. iu tr ban u: a. H tr h hp: t bnh nhn nm nghing, u nga. t cy li qun gc (nu ang git). Ht m. Cho th oxygen t SaO2 92-96%. t NKQ gip th nu tht bi vi oxygen hay c cn ngng th. b. Ct cn co git: Diazepam: 0,2 mg/kg/liu TMC, c th gy ngng th d tim mch hay bm hu mn v th lun chun b bng v mask gip th nht l khi tim mch nhanh. Trong trng hp khng tim mch c c th bm qua ng hu mn, liu 0,5mg/kg/liu. Nu khng hiu qu sau liu Diazepam u tin lp li liu th 2 sau 10 pht, ti a 3 liu. Liu ti a: tr < 5 tui: 5mg; tr > 5 tui: 10mg.

Chuyn Hi sc ngay khi dng Diazepam tng liu 1mg/kg m cha ct cn git. Hoc Midazolam liu 0,2 mg/kg/ln TM chm. Nu khng p ng c th lp li

liu trn. Liu Midazolam truyn duy tr : 1g/kg/pht tng n n khi c p ng khng qu 18g/kg/pht Tr s sinh u tin chn la Phenobarbital 15-20 mg/kg truyn tnh mch trong 30 pht. Nu sau 30 pht cn co git c th lp li liu th hai 10 mg/kg. c. iu tr nguyn nhn: Co git do st cao: Paracetamol 15 - 20 mg/kg/liu ta c. H ng huyt: Tr ln: Dextrose 30% 2ml/kg TM. Tr s sinh: Dextrose 10% 2 ml/kg TM. Sau uy tr bng Dextrose 10% TTM. H natri mu: Natri chlorua 3% 6-10mL/kg TTM trong 1 gi. Tng p lc ni s nu c (xem bi hn m). Nguyn nhn ngoi khoa nh chn thng u, xut huyt, u no: hi chn ngoi thn kinh. 3. iu tr tip theo: Nu co git vn tip tc hoc ti pht: Phenytoin 15-20 mg/kg truyn tnh mch chm trong 30 pht tc 0,5 - 1 mg/kg/pht, pha trong Natri Chlorua 9, nng ti a 1mg/ml. Cn monitor ECG, huyt p theo di bin chng lon nhp v tt huyt p. Liu duy tr 5-10 mg/kg/ngy TMC chia 3 ln. Phenytoin dng tim hin cha c ti cc bnh vin. Nu khng c Phenytoin: Phenobarbital 20 mg/kg TMC trong vng 30 pht qua bm tim, cn lu { nguy c ngng th s gia tng khi phi hp Diazepam v Phenobarbital. Liu duy tr 3-5 mg/kg/ngy, chia 2 ln. Mi azolam: tn cng 0,2 mg/kq sau uy tr 1g/kg/pht, tng liu dn c p ng (ti a 18g/kg/pht). Nu vn tht bi dng: Diazepam truyn tnh mch - Khi u: liu 0,25mg/kg TM - Sau : 0,1mg/kg/gi TTM qua bm tim tng n n khi t hiu qu, liu ti a 2 - 3mg/gi. Xem x t vic dng Pyridoxine TM (Vitamin B6) tr < 18 thng co git m khng st v khng p ng vi cc thuc chng co git. Mt s ca c p ng sau 10

60 pht. Phng php gy m: khi tt c cc thuc chng ng kinh trn tht bi, thuc c chn l Thiopental (Penthotal) 5 mg/kg TM chm qua bm tim. Sau truyn duy tr TM 2-4mg/kg/gi qua bm tim. Ch dng Thiopental nu c phng tin gip th v cn theo di st mch, huyt p, CVP (8-12 cmH20). Cn theo di st nu c du hiu suy h hp th t ni kh qun gip th ngay. Tht bi vi Thiopenthal c th dng thm thuc n c nh Vecuronium 0,1 0,2mg/kg/liu TMC v phi t NKQ gip th. 4. Theo di v ti khm 1. Theo di: Tri gic, mch, huyt p, nhp th, nhit , SaO2. Tm v iu tr nguyn nhn. Theo i cc x t nghim: ng huyt, ion khi cn. 2. Ti khm: Bnh nhn ng kinh cn c khm v iu tr chuyn khoa ni thn kinh.

S76. CO GIT DO ST CAO TR EM


nh ngha co git do st xy ra khong 3% tr em. Bnh thng gp la tui s sinh v tr nh, t 3 thng n 5 tui. Bnh lin quan n st nhng khng c bng chng ca nhim trng h thn kinh trung ng hoc mt nguyn nhn khc xc nh nh ri lon chuyn ho hay ng kinh trc khng o st. Co git do st thng biu hin co git ton th ( co cng co git hay co git) NHNG YU T NH HNG CO GIT DO ST Di truyn Yu t di truyn c vai tr quan trng v nguyn nhn co git do st. Vic xc nh tnh tri hay ln ca nhim sc th v nhiu c ch di truyn khc. nhng gia nh c ngi co git do st th nguy c co git tr tng gp 2- 3 ln. Nu c b

ln m c tin s co git do st th nguy c tng ln nhiu, c trai ln gi u c th b, nhng th h con ci cng c th b. T l co git do st cng tuz theo vng, theo Duchowny cc nc Chu tr em b nhiu hn cc nuc pha Ty v Chu u. Tui Co git do st thng xy ra 3 nm u ca tr em, 4% ca trc 6 thng, 6 % ca sau 3 nm, 1/2 ca xy ra nm th hai, cc tc gi nhn mnh n thi gian 18 24 thng l tui thng c co git do st. St Co git st xy ra lin quan sm bnh l nhim trng, khi ang st t ngt nhit tng cao theo ng biu din nhit hnh cung, nhit lc ny khong 39.2 C ( ly hu mn), xp x 25% ca xy ra khi nhit trn 40.2 C. Theo di mi lin h gia nhit v cn co git th s gia tng hay gim nhit khng nh hng n ngng ca cn. Trong nhm tui 6-18 thng c nhit trn 40 C, co git ti pht gp 7 ln tr em st nhit i 40 C. Co git st thng lin quan n nhim trng ng h hp trn, vim tai gia, h thng tiu ho, m virus l tc nhn chnh, trong khi vi trng c th gy nhim trng huyt, vim phi, vim mng no th him hn c co git do st. Nhng b gi, tui cng nh cng d b co git hn so vi cc b trai cng nhm tui. Nhng ri lon in gii, Vitamin B6 cng l nhng yu t lm tng nguy c co git. LM SNG Co git do st cao thng xy ra sm, cn co git hu ht l cn ton th, vn ng hai bn, ch c 15% ca l cc b: 80 % cn co git, 14% ca l cn trng lc, 6 % l cn mt trng lc. Da theo mc trm trng ca bnh c 3 dng lm

sng c bn: co git st n thun, co git st phc tp, trang tha ng kinh do st . Co git st cao n gin, c thi gian co git < 15 pht, khng c du thn kinh cc b v khng c cn th hai. Bnh thng khi, 90 % ca kt thc m khng li di chng no. Co git do st phc tp Co git do st phc tp l co git do st km mt trong nhng du hiu sau: thi gian co git ko di > 15 pht, co git vn ng cc b hoc sau cn c lit Todd, trn mt cn trong 24 gi, tnh trnh thn kinh khng bnh thng, cha m, anh em c co git khng st. Nhng bnh nhn c t hai du hiu trn tr ln sau 7 tui khong 6% ca mc bnh ng kinh. Bnh vin Mayo Clinic nhn thy khong 7% ca co git do st phc tp s suy gim thn kinh v tin ti mc bnh ng kinh, t l ny l 2,5% tr co git khng c cc du hiu trn. Trng thi ng kinh do st a s cc bnh nhn t khi, nhng co git ko di tng t v trng thi ng kinh do st khng phi l him. Nhiu bo co cho thy khi xy ra trng thi ng kinh do st cao gy hoi t no, hay t vong. Trong nghin cu ghi nhn 1706 tr em co git do st (NCCPP) th 8% trng hp co git < 15 pht, 4% trng hp co git > 30 pht, 25% trng hp trng thi ng kinh do st tr em. Nghin cu t thi nhng tr em trng thi ng kinh do st c hoi t v no, hch nn, i th, tiu no v cu trc thuz thi ng. Mt s tr nh c co git na ngi sau yu hay lit na ngi, loi co git ny s pht trin thnh lit cng v ng kinh cc b vn ng. CC XT NGHIM B TR TRONG CO GIT DO ST CAO

Cho n nay khng c mt xt nghim c hiu no cho co git do st, cc xt nghim thc hin khi co git do st ch yu vn l nhng xt nghim nh hng v loi tr. V tnh phc tp ca co git do nhiu nguyn nhn gy ra v tnh trm trng ca cc nguyn nhn dn n t vong, nn cc xt nghim lin quan n st cng nh tm nguyn nhn co git phi t ln hng u. Cc xt nghim huyt hc Cng thc bch cu: Tnh trng nhim trng ton thn hay cc b. Sinh ho : ng mu, Calcium, Natrium, Kalium Dch no tu Ly dch no tu khi nghi ng l vim mng no, nhng tr em < 1 tui nn chc d dch no tu cho tt c cc trng hp. Theo di st lm sng cn thit khi nghi ng cy dch no tu, v trong giai on u vim mng no cha c s thay i dch no tu. in no Ghi in no trong khi co git do st c vi tr quan trng v gip xc nh c tnh cc cn hay nhng bin i in no: trong tun u thng thy sng chm v mt cn i hai bn bn cu, trong nhiu trng hp sng in no bt thng kiu ng kinh xy ra t 2-5 tui v n khng lin quan n co git do st. EEG khng c tnh c hiu cho co git do st, v cng khng phn bit c co git do st n gin v co git do st phc tp. Hnh nh hc CTscan v MRI him c cc ch nh trong trng hp co git do st cao, tuy nhin khi c mt khim khuyt v thn kinh nh lit cc b, tng p lc ni s, nghi ng

mt chon ch trong s th cch tt nht loi tr chng l chp CT scan hay MRI. IU TR ST CAO CO GIT iu tr cp a s cc cn co git do st thng t ht theo thi gian, m cha cn x tr g, nhng trng hp ny khng cn thit phi nm vin. Tuy nhin nu n bnh vin c th theo di ti phng cp cu vi gi sau khm li lm sng, nu thy n nh v nguyn nhn st r th iu tr st v iu tr nguyn nhn. Mt s trng hp cn theo di tip: nghi ng c bnh nng ang xy ra, co git st cao phc tp, tr nh <18 thng. Mt s trng hp cn k o i hay tip tc cn th hai hay nhiu hn nhng khng phi l trng thi ng kinh do st: Cp cu h hp nh thng thong ng h hp trn, cung cp oxy v tim TM diazepam vi liu 0,3mg/kg hoc c th cho bng ng hu mn vi liu 0,5 mg/kg. Trng thi ng kinh do st cao khong 5% ca (co git ko di trn 30 pht) diazepam (0,3mg/kg,TM chm) hay lorazepam (0,1mg/kgTM, c th cho ti 4mg), tip sau l phenobarbital, dihydantoin. iu tr st cao: cha c bng chng g ni dng thuc h st phng c cn co git mc d cho thuc h st lm phn lo lng. Nhng iu quan trng ca thuc h st c th lm gim bt nhng tn thng o st cao gy ra iu tr phng nga ti pht v ng kinh Co git do st cao ti pht: mc d co git do st ti pht khng nhiu nhng khi ti pht cn th hai th nguy c cc cn tip theo c th xy ra, v th cn theo di v phng con ti pht. Mt s cc yu t nguy c nh hng ti s ti pht: Tr cng nh cng d ti pht, tin s gia nh c st cao co git, st xy ra ngn co git hay st cha cao co git.

Quan im iu tr co git do st cao l cho iazepam c bit l ng hu mn trc trng, v hp thu nhanh v t c bin chng suy h hp. Khi phng nga ti pht co git diazepam (0,5mg/kg) c 12 gi mt ln khi nhit (38,5C). Valproate cng tc ng phng nga cn ti pht, t l tc dng ph thp nhng li c cho cc c quan gan thn, tu o thuc cha c s dng rng ri cho tr em b st cao co git. Carbamazepine v phenytoin: c hai thuc khng c hiu qu phng nga ti pht co git do st cao. ng kinh Khong 5% tr em bi co git do st cao v sau c th tr thnh ng kinh. Nelson v Ellenberg a ra mt s cc yu t nguy c gy ng kinh : nghi ng c du thn kinh cc b trc khi co git do st cao u tin, tin s co git khng st cao, cn co git st cao phc tp u tin. Cha c bng chng g ni vic s dng thuc chng co git ko di cho tr co git do st cao c th phng nga c pht trin ng kinh, cng c nhng bo co mc iu tr rt ng vn pht trin bnh ng kinh. Hi ngh v co git do st cao ca Vin Sc Kho Quc Gia t chc nm 1980 xc nh 5 tnh hung trong cn thit xem xt dng thuc chng co git vi mc ch phng sau co git do st cao: (1) Cn co git cc b hoc ko di. (2) Nhiu cn co git xy ra trong 24 gi. (3) Cc thiu st thn kinh. (4) Cn co git khng do st cao xy ra trong gia nh. (5) Tr em i 1 tui. Thuc chng co git

Vic iu tr hng ngy lin tc vi phenobarbital hoc valproate lm gim nguy c ti pht co git do st cao. Ring phenobarbital thuc c dng rng ri vi tr em co git do st cao, hiu qu ca thuc l r rng, nhng thuc lm gim ch s tr tu (IQ) v th khi dng lu di c th nh hng n chc nng nhn thc ca tr. Mt vi cng trnh nghin cu cho thy vi mc ch phng nga ti pht cn, hng nm c th cho diazepam vi ln th gim t l thi pht t 50-75%. Tuy nhin cng cn phi cn thn nga suy h hp mc d rt him KT LUN St cao co git tr em l chng bnh thng gp, mt chu b c th nguy him nu s chm sc khng c tt. Ngi ta nhn mnh vai tr chm sc ban u m ngi c vai tr quan trng l b m. Nhiu kin nhn thy thung b m chu hay qun hoc t ch . B m cn phi bit rng tr b st cao co git thng t b tn thng no v t l tr thnh ng kinh cng thp, tuy nhin s ti pht co git l thng gp, phng nga ti pht l vic lm cn thit, bn cnh phi bit cch chm sc ngay t u khi cha c thy thuc. Khi tr b co git th b m cn t chu ni thun tin, cho chu nm nghing, khng nn li vo mm c th gy nght th (vic ny l ca cc nh chuyn mn). Nu ko di trn 10 pht th nn cho chu vo vin ngay. V Anh Nh (TS BS, Ging Vin Chnh; B Mn Ni Thn Kinh (Thn Kinh Hc), Trng i Hc Y Dc Tp H Ch Minh) TI LIU THAM KHO 1. Duchowny Michael (1993). Febrile Seizures in Childhood. In Elaine Wyllie ed The Treatment Of Epilepsies, Principles And Practice, Lea & Febiger, Philadelphia, p 647-653.

2. Vining P.G.E. (1997). Febrile Seizures. In Current Therapy in Neurologic Disease, 5th edition, Mosby- Year Book Inc, p 31-33. 3. Wllee (2000). Co git do st cao: Mt cch nhn mi vn tranh lun. Hi tho v ng kinh, Bnh vin Bch Mai, H Ni 4/2000, p 27-38. 4. Leppik I.E. (1993). Status Epilepticus. In Elaine Wyllie ed The Treatment Of Epilepsies, Principles And Practice, Lea & Febiger, Philadelphia, p 678 685

S77. CO GIT TR EM
I - I CNG:

1/ nh ngha: Co git l tnh trng ri lon tm thi v thc, vn ng, cm gic, thn kinh t ng do s phng in t ngt qu mc nht thi ca mt s neuron thn kinh. - Co git c : l s co c t ngt ngn, khng c nhp iu, ty thuc tng trng hp lin quan n mt c, mt chi hoc ton thn.

II - NGUYN NHN:

1/ Co git triu chng ( co git c tn thng thc th no) L nhng co git bt ngun t 1 vng tn thng no, c th 1 hoc nhiu . C th trn hoc i v no. Do nhim khun , chn thng hoc khi u. - Ti vng tn thng no c nhng t bo thn kinh cn sng st, nhng sng vt vng trong trng thi nui ng tht thng; nhng t bo ny vn tip tc hot ng nhng b kch thch nn gy ra tnh trng co git. 1.1/ Sang chn no:

- Nhng th thut sn khoa nh: gic ht, Forceps, gy t, gy m qu mc, chuyn d qu nhanh hoc qu lu. - Sa dy rau, vng rau qun c, ngt..-> thiu Oxy cho thai nhi 1.2/ Do nhim khun no- mng no: - Vim mng no: do Virus ( si, ho g, quai b, thy u); VK m no cu, lin cu; E.coli; lao. - Apxe no: c nhim khun t cc xoang hay vim tai gia. - KST: Toxo plasma, KST st rt. 1.3/ U tiu no, thn no: thng gp tr em 5 - 8 tui. 1.4/ D dng mch mu no, tc mch no. 2/ Co git do ri lon chc nng v chuyn ha no: 2.1/ Co git do ri lon chc nng no: * Co git do st ( chim 2/3 trng hp): - Tui thng gp : 6 thng -> 5 tui ( thng 2-3 tui) - Xut hin khi nhit tng t ngt : 39-40. - Thng l co git ton thn, lan ta. - Thi gian mi cn khng qu 10 pht. - EEG : Bnh thng, dch no ty bnh thng. - Lnh tnh, cn git cng ngn th tin lng cng tt. * Co git do st cao n thun:Xut hit khi nhit cao t ngt, co git lan ta, thi gian < 10p; thng gp tui 6 thng ->5 tui, EEG bnh thng; * Co git do st phc hp: Khng ph thuc nhit ; cn co git cc b; thi gian > 10p; xut hin mi la tui, EEG c th c bin i, c tin s ng kinh v c kh nng chuyn sang ng kinh. * iu tr: + Ct cn co git: Diazepam (seduxen, Valium): 0,2-0,25mg/kg tim TMC; sau pha ch glucose 5% truyn 10 git/pht hoc ung Gacdenal 3-5mg/kg/24h; Depakine 20-25mg/kg/24h chia lm 2 ln. - Ch nh dng thuc lin tc: Tr < 1 tui c s pht trin tm thn vn ng chm. Tr c cn k o i > 15 pht.

C lit vn ng sau cn. Thi gian iu tr n 4 tui. + H st v an thn: - H st : Chm lnh, Paracetmol 30-60mg/kg/24h chia lm 3 ln ung hoc nlgin 10-20mg/kg/24h hoc Aspirin 60mg/kg/24h - An thn: Seduxen * Cn khc ln ( cn co tht khi khc): Gp tr 6 thng ->5 tui, xut hin khi tr khc xc ng; biu hin lm sng: tr khc, sau nn th, ngi mm nhn, tm en, mt thc sau t bnh phc. 2.2/ Co git do ri lon chuyn ha: * Bnh phenyl xeton niu:L mt bnh di truyn ln do thiu men Phenyl alanin 4 hydroxylaza. + Lm sng: . Da chm . Chm pht trin tinh thn. . Co git cc b t th gp * Bnh nhim leucin: L mt bnh di truyn ln do ri lon qu trnh kh Carboxy: * Co git do h Canxi mu: ( Bnh thng Ca2+= 2-2,5mmol/l) + Thng gp nhng tr cn b. + Nguyn nhn : ci xng sm; a chy + Lm sng: xut hin t ngt, tr co rt ngi; DH Chvostek- Trousscau (+). Tr c nhng cn co git ni tng, co tht thanh qun. + iu tr: ung Gluconat canxi 10% x 10ml hoc Lactat Canxi 6% x15ml, chia lm 3 ln Tim TM chm trong trng hp cp cu: Gluconat canxi 10% x 10ml + Glucose 5;10% * Co git do tng Bilirubin t do:hay cn gi l vng da nhn no, do hin tng tng qu nhiu Bilribin t do v mui mt ( tauro cholat, glycol cholat) -> nhim c thn kinh. + Lm sng: . Thng xy ra tr s sinh o tan mu.

. Vng da . Co git tng trng lc c. * Co git do ri lon ng mu( Bnh thng= 3,9-6,4mmol/l) + Lm sng: Mt mi, nhc u, da xanh ti, v m hi, chn tay lnh, tim p nhanh, ri lon th gic v ngn ng, run ry, co git, rung git nhn cu nn, v m hi, tay co cp, ng g, b km, ng lm. + nh lng glucose mu, test dung np glucose + iu tr: Glucose 30% x 20-30ml TMC Glucagon 1mg tim bp khi c cn. + Khi ng mu tng cao > 220mg% cng xut hin co git ; iu tr bng Isulin. * Co git do tng natri hoc h Natri mu( Bnh thng = 135-145mmol/l) + H Natri mu: khi natri mu < 120mmol/lt c th xut hin co git, thng gp trong a chy mt nc nhc trng, n king lu ngy. - Lm sng: RL thc, vt v kch thch, suy tun hon, co git, hn m + Tng natri mu: khi nng natri mu > 150mmol/lt th c biu hin co git, gp trong a chy u trng, i tho nht, bng, st cao ko di, say nng, say nng. - Lm sng: tr kht, vt v kch thch, RL thc, co git, hn m * Co git do h magie( Bnh thng = 0,6-1mmol/l): + Khi nng Magie < 0,5mmol/l hay < 1mEq/kg + Lm sng: thng gp tr ci cc: biu hin yu c, run ton thn, co git, chng mt. + iu tr: Gluconat magie 3 mEq/kg hoc Magie sulfat 50% : 0,1- 0,2ml/kg tim bp. * Co git do thiu vitamin B6: + Thng gp tr s sinh, tr dng Rimifon ko di + Lm sng: Co git, vim a, mi, li + iu tr: Vitamin B6 100mg tim bp * Co git do dng mt s thuc: Long no, Strycin * Co git do tng HA: Vim cu thn 3/ ng kinh: - ng kinh l s ri lon chc nng thn kinh trung ng theo tng cn o s

phng in t ngt qu mc ca cc neuron. - Cn ng kinh l nhng cn ngn vi giy n v pht, cn c tnh cht nh hnh, cn sau ging cn trc, xy ra t ngt khng kp phng, biu hin chc nng thn kinh trung ng b ri lon. - Lm sng: . Khi pht t ngt, khng st. . C tnh nh hnh . Ri lon thc ( tr ng kinh cc b). . Thi gian cn ngn ( vi giy n vi pht). . Phc hi nhanh. 3.1/ ng kinh lan to ( ton th): 3.1.1/ ng kinh ton th tin pht: * ng kinh cn ln: thng gp tr nam 10-20 tui. + Lm sng l cn co cng co git xy ra t ngt, bt tnh. * ng kinh cn nh: thng gp tr < 10 tui. + Lm sng: - Cn bt tnh: xy ra khong vi giy - Cn git c: git c tnh cht i xng 2 b vai, 2 chi i - Cn vng thc: tr t nhin ng lng, mt o ngc, cc ng tc hoc cu ni b d dang. 3.1.2/ ng kinh ton th th pht: * H/C West ( Co git t th gp): + Thng xy ra tr nam 3 18 thng + Lm sng: Xut hin t ngt, tr rm ngi, u ci vo thn, 2 tay khp li hnh ch thp, 2 chn gp vo bng hnh s 4. Hoc c th l cn co git dui hay cn git hn hp. + EEG: c trng l lon nhp a ng, lon nhp cao in th: dy lin tip nhng on sng chm khng gin on v nhn, bin cao, ton b cc o trnh. * Cn nh kinh rung git c: + Thng xy ra tr nh < 1 tui. + Lm sng: L nhng cn co cng c, khng t ch, k c tnh trng mt thc, thng ch c mt nhm c chu nh hng. + EEG: bnh thng

* H/C lennox Gastaut ( cn ng kinh mt vn ng): + Chim 10% ng kinh tr em, gp tr 2-6 tui. + Lm sng: Cn vng mt trng lc c; tn thng tr t nng, ri lon hnh vi + EEG: Sng chm lan ta tn s 2-2,5 c/s 3.2/ ng kinh cc b: Gy ra do mt hng phn v no, c th ty thuc cm gic hay vn ng do v tr ca pht ra xung ng gy nn cn git cc b. + ng kinh cc b thy trn ln: Git khu tr mt na ngi sau lan rng. Cn Bravais Jackson : git mt, c mt, sau d lan ra tay chn + Cn tm thn vn ng: Ngi bnh c nhng c ng v hnh vi bt thng nh: Ci v ci khuy o, chp ming, b i. + Cn ng kinh thc vt ( ri lon thn no): Da mt lc lc ti, ri lon nhp tim, nhp th, tt HA, au bng. + ng kinh kch pht vng trung tm( Rolandique): - Gp tr 5-10 tui; - Lm sng: co git ngn 1-2 pht, git 1/2 ngi, thng xut hin v m, Cn tht hu hng, chy nc mi nhiu, khng c s thay i thc, khm khng c du hiu thn kinh khu tr - EEG: C sng nhn vng thi ng v nh chm, 2 pha, bin ln, mt hoc 2 bn bn cu. - Khng cn iu tr cng t khi. + ng kinh kch pht vng chm: - Gp tr 18 thng-7 tui. - Lm sng: Co git cc b na ngi hoc au u gi di kiu Migraine - EEG: c sng nhn, chm kch pht, ngng khi m mt. - iu tr : 60% c kt qu tt, 5% chuyn sang ng kinh. 3.3/ iu tr: 3.3.1/ Nguyn tc iu tr: - iu tr di ngy, t nt 2 nm. - Cho thuc lc bt u l mt thuc, liu t thp n cao - Ch cho thuc ng kinh khc khi tht bi iu tr.

- Cho thuc ty theo th ng kinh. - Liu lng thuc theo quy nh. - Khng ngng thuc t ngt. - Phi m bo cho bnh nhn ung u hng ngy, khng qun. - Cm ung ru trong qu trnh ung thuc. * Cc nhm thuc chng ng kinh: - Thuc chng ng kinh cn ln: phenobarbital; deoxybarbital, phenyltoin - Thuc chng ng kinh cn nh: Sucinimid; oxazolidin; Benzodiazenpin (BZD) - Thuc chng ng kinh th tm thn vn ng: Carbamazepin - Thuc chng ng kinh a tr: Nalproicacid; Progabid (Gabren). * C ch tc dng: Cc thuc cha ng kinh c th tc ng theo mt trong 3 c ch sau: - Lm tng n truyn c ch cc h tit GABA. - Lm gim dn truyn kch thch, th*ng l h tit glutamat. - Lm thay i s dn truyn ion qua mng nron . 3.3.2/ ng kinh lan ta tin pht: * ng kinh cn ln: - Depakin (acid valproic):Vin 250mg liu 20-40mg/kg - Gardenal(Phenobarbital):3-5mg/kg vng kinh cn nh. - Depakin (acid valproic): 20-40mg/kg - Seduxen * Cn vng thc: - Depakin (acid valproic): 20-40mg/kg - Seduxen Hoc: - Depakin (acid valproic): 20-40mg/kg. - Tegretol (Carbamazepin)100mg liu 20mg/kg 3.3.3/ ng kinh lan ta th pht: * ng kinh cn rung git c: - Depakin (acid valproic): 20-40mg/kg - Hydrocortisol - Gardenal 3-5mg/kg.

* ng kinh th West: - Depakin (acid valproic): 20-40mg/kg - Hydrocortisol - Benzodiazepin. 3.3.4/ ng kinh cc b: * Cn ri lon vn ng: - Depakin (acid valproic): 20-40mg/kg. - Tegretol (Carbamazepin)100mg liu 20mg/kg - Gardenal 3-5mg/kg - Benzodiazepin. * Cn ri lon tm thn: - Gardenal 3-5mg/kg - Tegretol (Carbamazepin)100mg liu 20mg/kg

S78. XUT HUYT NO - MNG NO TR LN


Xut huyt no tr ln a s do d dng thnh mch bm sinh, v phnh mch gp nhiu hn v cc d dng thng ng tnh mch. 1. Chn on 1.1. Lm sng : Bnh xy ra t ngt : au u d di, ri lon thc, hn m, lit na ngi. 1.2. Xt nghim : Dch no tu : dch mu khng ng, ch hng, dch vng (xut huyt sau 24 gi), t bo bnh thng. Cng thc mu a s trong gii hn bnh thng.

Chp ct lp in ton cho bit cc v tr chy mu no : chy mu i mng cng, i mng nhn, mu t trong no, chy mu trong no tht. 2. iu tr : Chuyn phu thut thn kinh khi bnh nhn hn m, mu t ln trong s no. Bc u theo i, iu tr ni khoa khi mu t trong su, bnh nhn khng hn m. 2.1. Chm sc bnh nhn : Nm u cao 30 , trnh kch thch. Theo di mch, huyt p, nhp th, s tin trin thc, triu chng thn kinh. 2.2. m bo h hp : Ht m, duy tr khng kh, p lc PCO2 32 34mmHg, th xy. 2.3. m bo tun hon : Duy tr thng bng nc in gii. Truyn cc dung dch Ringer Lactat 50ml/kg/ngy, khng dng cc dung dch ngt v ng huyt cao s lm toan ho vng tn thng, bnh s nng ln. 2.4. Chng ph no, gim p lc s no : Truyn Manitol 20% liu 0,5g/kg, truyn nhanh 60 git/pht, 2 ln/ngy, khng dng qu 3 ngy. + C th dng Dexamethasone 0,4mg/kg, 2 ln ngy khi c ph no. + Lasix 1,5 2mg/kg cho bnh nhn c tng p lc s no, cao huyt p. iu tr triu chng : Gim au u Paracetamol 15mg/kg, ung 2 3 ln/ngy.

Bnh nhn vt v : an thn Diazepam 0,3 0,5mg/kg/ln, ung hoc Gacdenal 3 5mg/kg/ngy, ung. Cc thuc bo v t bo thn kinh : Cerebrolysin 0,2ml/kg tim tnh mch trong 10 ngy, Nootropin 50mg/kg, Duxil 1 2 vin/ngy. Dinh ng m bo s lng, cht lng. Kim sot dch a vo, ch thi ra, nc tiu.

2.5. Chp mch mu no, hi chn ngoi : Can thip trc tip d dng phng mch bng cch nt mch. Ra vin, k n, hn khm li, iu tr ngoi tr.

S79. XUT HUYT NO - MNG NO TR NH


Xut huyt no mng no hay gp tr 1 2 thng tui, a s do thiu Vitamin K, vim gan. 1. Chn on 1.1. Lm sng : Hi chng thiu mu cp : da xanh, nim mc nht.

Hi chng no mng no : co git, rn , thp cng phng, li b, hn m, gim vn ng na ngi. 1.2. Cc xt nghim : Cng thc mu : Hb gim < 70g/l, mu ng k o i > 7 pht, t l prothrombin gim.

Chc dch no tu : dch mu khng ng, ch hng, dch vng, t bo bnh thng. Siu m no qua thp, chp ct lp in ton cho bit cc v tr chy mu no : chy mu i mng cng, chy mu i mng nhn, mu t trong no, chy mu trong no tht. Tr nh thng chy mu no v mng no.

2. iu tr + + T th nm u cao 30o iu tr thiu mu : Truyn mu 20ml/kg. Tim Vitamin K 5mg x 3 ngy lin iu tr hi chng tng p lc s no, gim ph no :

+ Manitol 20%, 0,5g/kg x 2 ln/ngy cch 8 10 gi, truyn nhanh tc d 40 git/pht, trong 2-3 ngy. Truyn tip Ringer Lctt 40 50ml/kg/ngy. + Dexamethasone 0,4mg/kg TM x 2 ln/ngy, trong 2 3 ngy.

+ Nu thp cn cng phng : Lasix x 1,5 2mg/kg TM, tim nhc li sau 8 10 gi, kim sot in gii .

Theo di st thc, mch, nhp th, th xy nu nhp th chm. Dinh ng : n son e s lng, cht lng.

iu tr h tr : cc thuc bo v t bo thn kinh, Cerebrolysin 0,2ml/kg tim tnh mch trong 10 ngy, Nootropin 50mg/kg/ngy, ung. 3. D phng Vitamin K 5mg tim bp cho m c thai vo 2 tun cui trc sinh.

S sinh sau Vitamin K 2mg tim bp hoc ung 5mg. Tim nhc li lc 1 thng.

S80. VIM NO NHT BN


Phm Th Su v cng s

Vim no Nht Bn l bnh nhim trng cp tnh h thn kinh Trung ng o virus vim no Nht Bn gy ra, l mt bnh nng, nguy c t vong v di chng cao. Virus vim no Nht Bn truyn sang ngi do mui t. Vt ch chnh mang virus l ln v mt s loi chim. Bnh khng truyn trc tip t ngi sang ngi. 1. Chn on 1.1. Dch t : ang c ch lu hnh, hoc c ngi xung quanh mc bnh, ph bin t thng 5 thng 7. 1.2. Lm sng : Da vo cc biu hin sau y : St cao t ngt 39 40oC au u (nu tr cn b thng c nhng cn khc th t). Nn hoc bun nn. Ri lon tri gic cc mc (ng g, li b, au u hoc hn m). Co git, thng co git ton thn.

C th c cc du hiu : lit, tng trng lc c, ri lon h hp, b i tiu tin. 1.3. Xt nghim : + + + + + Mu ngoi bin : s lng bch cu tng hoc bnh thng. Dch no tu : Trong, p lc tng. Protein tng nh (thng < 1 g/lt). ng, mui bnh thng. Bch cu tng t vi chc n vi trm/mm3. Phn ng Pandy (+).

Cn chn on phn bit vi mt s bnh c biu hin thn kinh nhng khng phi vim no Nht Bn nh : st cao co git, ng kinh, vim mng no cp do vi khun, st rt c tnh th no. 2. iu tr 2.1. Nguyn tc : Khng c thuc c hiu, iu tr triu chng l ch yu. Cn c iu tr kp thi. H nhit :

Khi tr st 38oC Paracetamol 15mg/kg/ln ung hoc t hu mn, c th nhc li sau 6 gi. Khng dng qu 60mg/kg/24 gi, chm mt, t tr phng thong. Chng co git :

Diazepam 0,5mg/kg tim bp hoc Diazepam 0,2 0,3mg/kg pha long vi 5 10ml dung dch ng trng tim chm tnh mch (ch thc hin c s c iu kin hi sc v c th gy ngng th). Nu co git khng ht, c th dng thm hoc phenobacbital (gardenal) 5 8mg/kg/24h chia 3 ln hoc aminazin 0,5 1mg/kg tim bp. Chng suy th : Ht m i lm thng thong ng th. Th xy nu co git hoc kh th. H hp h tr nu c ngng th (th my, t ni kh qun bp bng). Chng ph no :

Dung dch Manitol 20% cho 1,5 2g/kg/ln truyn tnh mch trong 30 60 pht. Nn cho sm, khi c biu hin ph no nh au u, nn, ri lon thc. C th truyn nhc li sau 8 gi nu biu hin ph no khng ca thin, nhng khng truyn qu 3 ln trong 24 gi v khng truyn qu 3 ngy. Dexamethason 0,2 0,4mg/kg/ln cch nhau 8 gi. Tim tnh mch chm, khng dng qu 3 ngy. Cn bng nc, in gii, thng bng kim toan

Dung dch Ringerlactat 30 50ml/kg, tc 20 30 git/pht sau mi ln truyn Manitol. Nu khng c Ringerlactat th thay bng dung dch ng trng Natriclorua 9 %o v Glucoza 5% mi thu 1/2. Da vo in gii v ng mu iu chnh nu c ri lon.

Nu c iu kin o cc thng s v kh mu iu chnh thng bng toan kim. Dinh dng chm sc :

Dinh ng : n thc n tiu, nng lng cao, mui khong v Vitamin. Nu tr khng n c th cho n qua ng thng d y, m bo 1500 KCalo/ngy. Chm sc :

+ ht m di, v rung + Chng lot : nm m chng lo t, thay i t th. + V sinh ton thn : rng, ming, a Chng bi nhim :

C th dng khng sinh tuz theo tnh trng bnh, thng gp l vim phi : Ampixillin 100mg/kg/24 gi tim tnh mch chia 3 ln.

BNH L TRC TRNG


Phm Th Su v cng s

Hi chng l c ba c im lm sng chnh : au qun, mt rn, a phn c mu hoc nhy mi. Cn nguyn ph bin tr em l l trc trng. 1. Chn on : 1.1. Lm sng :

Tr st : Nhit thng giao ng t 37o5 39oC

C th c hi chng nhim trng, nhim c thng do S.Flexneri

Hi chng l : au bng lin tc v di ln tng cn km theo bnh nhi mt i ngoi, mt rn v a phn c ln nhy mu hoc l l mu c, 10 30 ln/ngy.

1.2. Xt nghim :

Soi phn :

Thy c nhiu bch cu, hng cu.

Nu do Amib : Thy Amib hot ng th n hng cu

Cy phn : Pht hin trc khun Shigella

1.3. Chn on phn bit vi lng rut : Thng tr b bm, c khc tng cn. Thm khm hoc siu m bng thy c bi lng. Thm trc trng c mu theo tay.

2. iu tr : 2.1. iu tr c hiu

i vi l trc trng :

Trimethoprim Sulfamethoxazole : 48mg/kg/ngy, chia lm 2 ln, ung trong 5 ngy. Nu bnh khng thuyn gim (khng khng sinh), cho Nalidixic acid 30 50mg/kg/ngy, chia 2 ln, ung trong 5 ngy.

Khi c khng sinh : Cho theo khng sinh . i vi l Amib th n hng cu :

Flagyl 30 40mg/kg/ngy, chia 2 ln, ung trong 5 ngy. 2.2. Bi ph nc v in gii : Cn c thc hin nh cc trng hp tiu chy khc vi dung dch ORS hoc dch truyn nu mt nc in gii nng.

VIM MNG NO M
Phm Th Su v cng s

Vim mng no m l tnh trng nhim khun mng no do vi khun gy nn. Ba loi vi khun gy bnh chnh l : Hemophilus Influenza, no m cu v ph cu, ring tr s sinh c th gp cc vi khun gram m nh E.coli, Klebsiella, Pseudomonas. 1. Chn on 1.1. Chn on xc nh da vo : lm sng v xt nghim dch no tu

Lm sng St l biu hin hay gp. Hi chng mng no :

+ Th in hnh : hay gp cc triu chng au u, nn vt, a lng (hoc to bn). Khm c du hiu gy cng, Kerning v thp phng. + Tr i 1 tui : bnh thng t ngt, hay gp cc biu hin b b, khc tht, ng li b, du hiu c mm. + Tr s sinh : Khng in hnh, cc biu hin hay gp nh b b, li b, c th co git, suy h hp, nhim khun huyt. Tr s sinh cn ngh n vim mng no m khi c cc triu chng st, b k m, nn cha r nguyn nhn, c bit khi c nghi ng nhim khun huyt.

Xt nghim : Cng thc mu : Bch cu tng cao, bch cu trung tnh chim u th. Xt nghim dch no tu thng thy :

+ p lc tng, nc c (m khi hoc c nh m). + S lng bch cu trn 500/ml, trung tnh chim u th. + Protein tng trn 1 g/l, Glucose gim i 2,2 mmol/l. Ch :

Bnh nhn n khm trong nhng gi u hoc iu tr khng sinh dch no tu c th thay i khng in hnh. Chng ch nh chc dch no tu khi c nhim khun lan to ti v tr chc, hoc c biu hin tng p lc ni s.

1.2. Chn on cn nguyn : Da vo kt qu nhum gram soi knh v cy dch no tu. 1.3. Cn chn on phn bit vi : Vim mng no hoc vim no do virut : dch no tu trong, s lng bch cu thng i 500/ml trong bch cu lympho chim u th, protein tng i 1g/l. VMN do lao : c tip xc ngun lao, X-quang phi c tn thng lao. Dch no tu trong hoc vng chanh, t bo t 300 500/ml, protein trn 1g/l. Sau 14 ngy iu tr khng sinh khng hiu qu cn xem xt c vim mng no do lao hay khng. 2. iu tr : 2.1. Liu php khng sinh : Khi cha c kt qu nhum gram soi knh v cy dch no tu : dng liu php khng sinh kinh nghim : Tr t 0 4 tun Tr t 4 12 tun : Ampixillin + Aminoglycoside hoc Claforan : Cephalosporin III

Tr t 3 thng 18 tui : Ampixilin + Chloramphenicol hoc Cephalosporin III. Ch :

Chn Cephalosporin III (Claforan, Rocephin, Fortum) khi bnh nhn c du hiu nng : hn m, co git nhiu, vo vin sau 3 ngy b bnh, iu tr nhiu khng sinh v c bnh ton thn. Khi c kt qu nhum soi knh : iu chnh khng sinh cho ph hp vi tng loi vi khun. Khi c kt qu cy dch no tu : thay i khng sinh theo khng sinh .

Sau 48 72 gi iu tr din bin lm sng khng ci thin : xt nghim li dch no tu quyt nh i khng sinh iu tr thch hp hn. Thi gian iu tr trung bnh i vi no m cu : 7 ngy, H.influenzae t 7 n 10 ngy, ph cu : 10 n 14 ngy, trc khun i kh Gram m : 3 tun. Tuy nhin, thi gian iu tr c th thay i theo mc p ng lm sng. 2.2. iu tr kt hp : Chng vim : Dexamethasone 0,4mg/kg/ngy ng trong 4 ngy u.

Chng ph no cho bnh nhn c hn m : nm u cao 30o so vi mt ging, dng liu php tng thng kh tt ( thng thong ng th, v rung), truyn tnh mch dung dch Manitol liu : 1g 1,5g/kg/ln (cn b nc in gii sau mi ln truyn). Phng co git : Barbituric liu 5 20mg/kg/ngy

Ct cn git : Se uxen 0,1mg/kg pha trong 2ml NaCl 0,9% tim tnh mch chm cho n khi ngng git hoc tht hu mn (c 10 pht nhc li mt ln nu tr vn cn co git, khng qu 3 ln). Ch ch chm sc v inh ng. Nu bnh nhn c hn m nn nm nghing mt bn trnh ng m i v cho n qua son e. 2.3. Xut vin khi : iu tr khng sinh thi gian v ht st t nht 3 ngy. 3. Phng bnh :

3.1. Ho d phng : Dng cho nhng ngi tip xc trc tip vi tr bnh (sng cng trong gia nh, ngi chm sc tr bnh, trong cng nh tr). H.influenzae : ung Rifampin 20mg/kg/ngy x 4 ngy (tr s sinh 10mg/kg/ngy), khng dng cho ph n c thai, hoc tim bp Ceftriaxone 125mg/ngy (ngi ln 250mg/ngy) tim trong 2 ngy. No m cu : ung Rifampin 10mg/kg/ngy x 2 ngy, hoc tim bp Ceftriaxone 125mg/tr em (250mg/ngi ln) tim 1 ln. 3.1. Min dch d phng Tim vaccin H.influenza Typ B (Hib), ph cu, no m cu nhm A v C.

S81. VIM MNG NO LAO


Vim mng no lao l tnh trng nhim khun mng no do trc khun lao M.tuberculosis Hominis gy nn. 1. Chn on 1.1. Chn on xc nh da vo : lm sng, xt nghim dch no tu v ngun ly

Lm sng : cn chn on theo giai on

St cao 39 40oC (tr suy inh ng ch st nh). Tr quy khc, k m n, mt mi. Hi chng mng no :

+ T ngy th 5 xut vin, cc du hiu v triu chng ca mng no nh : au u, bun nn, nn vt, a lng (hoc to bn) thm ch co git. Khm c th thy cc du hiu mng no nh gy cng, Kerning v thp phng.

+ T tun th 2 tr i u hiu mng no biu hin r. Ngoi ra cc du hiu thn kinh khu tr nh lit na ngi, lit dy thn kinh s no (hay gp dy III, VI, IV, VII) hoc tng trng lc c, tng phn x gn xng xut hin tng n, mun hn tr i vo hn m.

Xt nghim : Xt nghim dch no tu thng thy : Dch mu vng chanh, nu bnh nhn n sm dch c mu trong. S lng bch cu thng i 500/ml, lympho chim u th. Protein tng trong khong 1g 5g/l. Cng thc mu : S lng bch cu khng tng, lympho chim u th.

X-quang phi (thng nghing) : c tn thng phi v vim hch trung tht (60 70% s trng hp). Phn ng Teberculin ng tnh.

Ngun ly bnh : l mt du hiu ch im quan trng. 1.2. Chn on cn nguyn : Tm vi khun lao bng mt trong cc k thut : Nhum gram soi snh v cy dch no tu. Xt nghim Polymerase Chain Reaction ( nhy 50%, c hiu 100%). Pht hin khng th khng lao trong mu hoc trong dch no tu.

1.3. Chn on giai on : Giai on 1 (chn on sm trong 10 ngy u ca bnh ) : cha c thay i v thc v tn thng thn kinh. Giai on 2 (chn on t ngy 10 14 ca bnh) : c tn thng thn kinh nhng cha c thay i v thc. Giai on 3 (chn on mun sau 3 tun) : c thay i v thc.

1.4. Chn on phn bit vi : Vim mng no hoc vim no do virut : bnh xy ra cp tnh, dch no tu trong, s lng bch cu thng 500/ml, protein tng i 1g/l. Vim mng no m : bnh t ngt, dch no tu c, t bo trn 500 bch cu/ml, protein trn 1g/l, p ng vi iu tr khng sinh. 2. iu tr 2.1. Liu php khng sinh : iu tr tn cng : bng 4 loi thuc RHSZ trong 2 thng.

iu tr cng c : bng 2 loi thuc RH trong 6 n 10 thng (R = Rifampicin liu 10mg/kg/ngy ; H = Isoniazid liu 5mg/kg/ngy ; S = Steptomycin liu 15mg/kg/ngy ; Z = Pyazinamid liu 25mg/kg/ngy). Trng hp iu tr nh trn khng kt qu hoc bnh ti pht dng phc : iu tr tn cng : bng 5 loi thuc SHRZE trong 2 thng. iu tr cng c : bng 4 loi thuc RHZE trong 1 thng.

iu tr duy tr : bng 3 loi thuc RHE trong 5 thng (E = Ethabuton liu 15mg/kg/ngy). 2.2. iu tr kt hp : Chng dy dnh mng no : Prednisolon 1 3mg/kg/ngy trong 4 6 tun ch gim liu theo nguyn tc chung. Chng ph no cho bnh nhn c hn m : nm u cao 30o so vi mt ging, dng liu php tng thng kh tt (thng thong ng th, v rung), truyn tnh mch dung dch Manitol liu : 1g/kg/ln (cn b nc - in gii sau mi ln truyn).

Ct cn git : Se uxen 0,1mg/kg pha trong 2ml NaCl 0,9% tim tnh mch chm cho n khi ngng git, hoc tht hu mn (c 10 pht nhc li mt ln nu tr vn co git, khng qu 3 ln). Ch ch chm sc v inh ng. Nn cho n thc n mm, chia lm nhiu ba, chnh n no hn ch nn. Nu bnh nhn hn m nm nghing mt bn trnh ng m i, cho n qua sonde. 2.3. Theo di : Theo i iu tr : da vo s ci thin v lm sng v dch no tu. Ngng iu tr khi dch no tu tr v bnh thng (sau 8 12 thng). Cn theo di tc dng ph ca thuc cn nhc s dng. i vi Rifamycin tr c biu hin n k m tr li, au bng, tiu chy, men gan tng. i vi Streptomycin : c biu hin tai. i vi Ethambutol tr c biu hin m mt. i vi Pyrazinamid c biu hin au khp. 3. phng bnh : Min dch d phng : tim vaccin theo lch tim chng. Pht hin gii quyt ngun ly. iu tr cc th lao hn ch bin chng vim mng no lao.

S82. VIM TU CT NGANG


Vim tu ct ngang l hi chng lm sng c trng bi thng tn cp tnh mt on tu sng, biu hin lit vn ng, mt cm gic i ni tn thng, ri lon c trn. Bnh thng gp tr 5 15 tui, nguyn nhn khng r rng, nhng thng kt hp vi bnh nhim virus khng c hiu (herpes, zona, Epstein Barr, Echo). Bnh tn thng mng myelin ca t bo cht trng, cht xm v mch mu.

1. chn on : 1.1. Lm sng : Ngy u au, mi, t b 2 chn, au tht lng. St gp 50% trng hp. T t yu hai chn ngy th 2 3 hoc t nhin lit hai chn. Lit mm i ni tn thng, mt phn x gn xng. Mt cm gic nng, su i ni tn thng. Ri lon c trn (b tiu tin, to bn).

Din bin bnh : sau 2 3 tun t lit mm c th chuyn sang lit cng (phn x gn gi tng, phn x Bakinsky ng tnh, c clonus). Bnh c th tin trin i ln, gy lit t chi v h hp.

1.2. Xt nghim : CTM thng trong gii hn bnh thng. Dch no tu : Bch cu n nhn tng nh

Protein tng i 1 g/l. 1.3. Chn on phn bit : Vim a r v dy thn kinh (hi chng Guillair Barre), lit mm hai chi, hoc t chi xong khng ri lon c trn. U tu : Bnh xut hin t t, lit cng u th mt chi. Chn on xc nh bng chp cng hng t.

2. iu tr

2.1. Chm sc : Thay i t th nhm chng lot. phng nhim khun ng tit niu khi thng nc tiu.

2.2. Thuc : Methylprednisolone (Solumedrone) 10 15mg/kg tim tnh mch, 7 ngy. Prednisolone 1 1,5mg/kg trong 3 4 tun, gim dn liu ri ngng. Vitamin nhm B : B1, B6, B12. Sau 2 tun iu tr bnh nhn cn c phc hi chc nng.

2.3. Dinh dng m bo cht lng, s lng Methylprednisolone (Solumedrone) 10 15mg/kg tim tnh mch, 7 ngy. Prednisolone 1 1,5mg/kg trong 3 4 tun, gim dn liu ri ngng.

2.4. Tin lng 60% c triu chng hi phc sau 2 12 tun, bnh sau 3 thng khng hi phc c tin lng xu. 15% khng c triu chng hi phc.

3% c th chuyn thnh x cng ri rc tu, bi v c hin tng mt myelin ti pht.

S83. VIM A R V DY THN KINH NGOI BIN


(HI CHNG GUILLAIN BARRE)

Vim a r v dy thn kinh tc vim v mt myelin h thng dy thn kinh ngoi bin. Thng gp tr trn 4 tui. 1. Chn on : 1.1. Lm sng : Triu chng ban u 50% cc trng hp ri lon cm gic au, cm cc chi hoc bnh xut hin t ngt yu hay lit 2 chi i vi c im sau : Lit c tnh cht i xng, lit ngn chi nhiu hn gc chi, c nhiu trng hp lit ng u gc chi nh ngn chi. Lit c th lan ln 2 chi trn, lit cc dy thn kinh s no IX, X, XI. 10% lit mm tin trin nng, lit c h hp phi cn n h hp vin tr.

H thn kinh giao cm b tn thng c th bin lon tun hon, lon nhp tim, tng huyt p hoc h huyt p. 1.2. Cn lm sng : Cng thc mu trong gii hn bnh thng.

Dch no tu : nhng ngy u c th bnh thng (BT), phn ly protein t bo sau ngy th 7 10, t bo BT, albumin tng i 1 g/l. Dch no tu c th B trong sut qu trnh ca bnh. in c : Tc dn truyn gim, thi gian tim tng ko di.

2. iu tr : Theo di st chc nng h hp, nu lit c h hp chuyn hi sc cp cu th my. Methylprednisolone (Solumedrol) 5 10mg/kg x 5 ngy sau chuyn Prednisolone 1 2mg/kg x 3 4 tun.

Gmm globulin 400mg/kg x 2 5 ngy truyn tnh mch, c bit th i ln. Cc Vitamin nhm B : B1, B6, B12 ung.

Dinh ng s lng v cht lng, xoa bp vn ng, thay i t th thng xuyn.

S84. U NO
U no l s tn to bt thng mt loi t bo thn kinh ( Astrocytoma t bo hnh sao, Oligodroglyoma t bo t ui gai, Me uloblastoma nguyn tu bo thn kinh) ni s. U no ng th hai trong cc bnh ung th tr em (sau bch cu cp, u h thng to mu). 1. chn on : 1.1. Da vo lm sng : Triu chng lm sng tuz thuc vo v tr v tnh cht khi u. Triu chng chung l : Hi chng tng p lc s no : au u, nn, mt mi, thay i tnh kh, hc tp sa st, tr nh vng u to. Hi chng thn fkinh khu tr : xem bng 1.

Bng 1. V tr, dng u, c im lm sng

V tr v dng u

c im lm sng

Tng p lc s no

I. U trn lu tiu no

1. U no gia : u i th, u Thp, ngng pht trin, th gic, u s hu, u tuyn hn ch trng th gic, mt th lc, teo dy th, yn, u no tht. ri lon ni tit. 2. U bn cu no (u t bo hnh sao, u si ui gai thn kinh, u t bo t ui gai, u mch mc) Lit na ngi, lit dy VII trung ng, au u. Triu chng cn tuyn yn i th hoc khng triu chng.

C nhng chm

Chm

II. U h sau 1. U tiu no (u t bo hnh sao, u nguyn tu bo thn kinh) Tc ng lu thng ch Sm no tu, au u nn, c cng, long chong, gim trng lc c. Lit dy s VI, VII, IX, X ni ngng, lit na ngi bn i din. Lit vn nhn, au u, nn. Chm

2. U cu no

3. U tuyn tng v u qui

Sm

1.2. Cn lm sng : Soi y mt : ph gai th.

X-quang s thng, nghing : gin khp s, mm yn sau b ph hu v b canxi ho, du hiu du n ngn tay trn phim, tuy nhin c th xut hin mun. Chp ct lp vi tnh c gi tr quyt nh, chp c cn quang phn bit t trng, kch thc khi u, v tr. 2. iu tr :

iu tr triu chng : Trnh thay i t th t ngt phng tt kt. iu tr gim ph n : Dexamethasone 0,4mg/kg tim tnh mch. Chuyn phu thut ct b u. Ring u cu no khng th phu thut. X tr liu. Ho tr liu tuz thuc vo loi t bo gy u.

S85. TRNG THI NG KINH


1. nh ngha : L trng thi trong cc cn co git lin tip trn 15 pht, gia 2 cn bnh nhn trong tnh trng hn m, ri lon thn kinh thc vt, bin i h hp, tim mch, ni mi. Sau cn trkhng tnh trn 30 pht. Trng thi ng kinh c th ko di vi gi n vi ngy. 2. X tr : t bnh nhn t th nm nga (u cao 30 nu c tng p lc s no) hoc nm hi nghing sang phi. Ht m di. Th xy.

Cp nhit , nu st cho ung Paracetamol 15mg/kg/1 ln cch 5-6 gi, khng qu 60mg/kg/24 gi. Tim tnh mch Seduxen 0,2 0,3mg/kg hoc t hu mn 0,5mg/kg. Nu cn tip tc git sau 5 pht tim tnh mch nhc li Seduxen 0,3mg/kg.

Xt nghim ng mu, canxi mu, in gii , kh mu nu c iu kin.

Theo di nhp th, pht hin sm s c ch h hp, t ni kh qun, bp bng nu ngng th. Sau 15 pht cn git Phenobarbital 10mg/kg tim tnh mch trong 10 pht hoc tim bp. Sau 20 pht khng kt qu tim nhc li Phenobarbital 10mg/kg tnh mch trong 10 pht. + Chng ph no : Dexamethazone : 0,4mg/kg tnh mch trong 2 ln cch 8 gi.

+ Manitol 20% - 0,5g/kg truyn 40 60 git/pht, sau truyn tip Ringer Lactat 20 50ml/kg. B ng nu ng mu h < 2,5mmol/l, truyn dung dch glucoza 10 % 5ml/kg. iu chnh thng bng nc in gii, cn bng toan mu.

Sau 10 pht cn git chuyn hi sc cp cu iu tr Thiopentane 3 5mg/kg, th my.

3. Bin chng ca trng thi ng kinh Thiu xy no v cc c quan.

Bin chng tim mch : mch nhanh, chm, dng tim, cao HA, suy tim, Shock tim. Suy h hp : th chm, ngng th, nhp th Cheyne Stokes, th nhanh, ph phi, toan h hp, tm. Suy thn : i t, hoi t cu thn cp tnh o tiu c vn cp.

Ri lon thn kinh thc vt : nn, ra nhiu m hi, tng tit nc bt.

Ri lon chuyn ho : toan chuyn ho, thiu xy, tng Kali, Natri mu, gim ng, Natri mu, suy thn mt nc, bnh ty cp.

CHNG 8. BNH L TM THN


S86. RI LON TIC
Tch l nhng ng tc khng hu , xy ra nhanh, nh hnh, khng nhp iu (thng bao gm nhng nhm c hn ch) hoc s pht m xut hin t ngt khng c mc ch r rng. Cc tic c cm nhn nhu khng th cng li c nhng c th dng tic li hu trong nhng khong thi gian khc nhau. 1. chn on : 1.1. Theo { ngha v mt tm l{, tic c chia thnh 2 loi khc nhau l tic n gin v tic phc tp :

Tic n gin :

Tic vn ng n gin l nhng ng tc nhanh, nh hnh do nhng nhm c c cng mt chc nng tham gia, l nhng ng tc khng c { ngha tm l{, cha hon chnh, v d : nhy mt, lc u, nhn vai, nhch m p, nng cnh mi, c ng cc ngn tay Tic m thanh n gin l s pht ra nhng m thanh nhanh v v ngha nh : hng ging, ho khc, kht kht, lm bm, ting ku, ting rt

Tic phc tp :

Tic vn ng phc tp l nhng ng tc din ra ng thi trong mt tp hp, ng nh c mc ch v k o i lu hn so vi tic n gin, v d : vut tc, cn, n m, nh, nhy, s, nhi ng tc ca ngi khc Tic m thanh phc tp l s pht ra nhng m, nhng t khng lu lot v khc thng v nhp iu,

nhng li ni b tc nghn, nhng cu ni bt ra nh hnh khng ph hp vi hon cnh, ni tc khng ch , lp li bn thn hoc nhi li ngi khc. 1.2. Theo ICD - 10 tic c chia lm 3 th chnh : (1) Tic nht thi : C mt hay nhiu tic vn ng hoc m thanh (khng c c 2 loi tic ng thi), c tic hng ngy, ko di trn 4 tun nhng khng qu 12 thng. (2) Tic vn ng hoc m thanh mn tnh : C mt hay nhiu tic vn ng hoc m thanh (khng c c 2 loi tic ng thi), tic c hu nh hng ngy, k o i trn 1 nm, trong thi gian khng c 3 thng lin tc no l khng b tic. (3) hi chng Tourette : C tic vn ng nhiu loi kt hp vi tic m thanh cng tn ti trong mt khong thi gian mc d khng nht thit phi lun c ng thi, tic c nhiu ln trong ngy (thng thnh cn), c hu nh hng ngy, k o i trn 1 nm, trong thi gian khng c 3 thng lin tc no l khng b tic. Ngoi nhng tiu chun ring nu cho mi th, c 3 th u phi p ng vi nhng tiu chun chung l : tic khi pht trc 18 tui, trc khng s dng cc thuc an thn kinh, khng c bnh thuc h thn kinh trung ng (v d nh ma vn, Huntington, di chng vim no ), tia gy nh hng ti hc tp, ngh nghip v hot ng ca bnh nhn. Tic thng mt i lc ng, gim i khi tp trung ch vo mt hot ng hng th. Tic thng b tng ln khi bnh nhn c sang chn tm l{, c th mt mi. Tic nht thi chu tc ng tm l{ r hn so vi tic mn tnh v hi chng Tourette. 1.3. nh gi lm sng ca tic cn c tin hnh theo nhng mc sau : (1) Tic :

V tr gii phu, s lng tic, tn s, cng , tnh phc tp, mc gy nh hng. Khi pht : la tui, c im, lin quan ti sang chn tm l.

Tin trin : xu hng tng ln hay gim dn, tic xut hin dn theo hng t u xung chn, tng tnh phc tp, thi gian ko di ca bnh, yu t lm tng hoc gim tic. Biu hin ri lon tm l lin quan : cm gic khn thit hoc kh chu trc khi b tic. Tic gy nh hng ti lng t tin, hot ng gia nh, thch ng x hi, hc tp, ngh nghip, nguy c t gy thng tch c th. (2) Triu chng m nh v hnh vi nghi thc m nh c th km theo vi tic, nht l trong hi chng Tourette. (3) Tin s sn khoa, qu trnh pht trin, bnh mc (4) Nhng ri lon v cm xc, hnh vi, ch . (5) Quan h vi gia nh v bn b. (6) Cc s kin cuc sng c lin quan vi khi pht v lm tic trm trng thm. (7) Tin s trong gia nh c ngi b ri lon cm xc, ri lon hnh vi, tic. (8) Tnh hnh hc tp. (9) Khm ni khao v thn kinh : hu ht bnh nhn u bnh thng, nhng mt s c du hiu thn kinh nh khng khu tr. (10) nh gi kh nng p ng vi iu tr Lu { chn on tic ch yu da vo lm sng m khng c phng php cn lm sng c hiu. in no khong 50% bnh nhn c nhng thay i bt thng khng c hiu ; lm test tm l 80% bnh nhn c lo u,k t ti, thoi li.

2. iu tr : iu tr bng liu php ho c kt hp vi liu php tm l. 2.1. Liu php ho dc : p dng cho bnh nhn tic mn tnh v hi chng Tourette.

Haloperidol (vin 1,5mg) : liu s dng ban u 0,02mg/kg/ngy, sau tng n n 0,05mg/kg/ngy. Nu xut hin tc dng ph ca thuc nh ng nhiu, ri lon trng lc c th phi gim liu v dng thm Artan (Borakin). iu tr bng haloperidol cho kt qu tt 70 80% bnh nhn. Clonidin (Catapresan, vin 0,15mg) : y l thuc chn la thu hai nu iu tr bng haloperidol khng hiu qu. Liu ban u l 3mcg/kg, sau tng n n 0,025 0,05mg/ngy. Khong 20 35% bnh nhn ht triu chng tic sau 8 12 tun iu tr. Lu { thuc gy ra nhng tc dng ph nh kh ming, h huyt p (gp 20%). Thuc ny c tc dng iu tr tt i vi tic ng hn l i vi tic m thanh.

2.2. Liu php tm l : p dng cho tt c bnh nhn. S dng liu php hnh vi mang li kt qu tt, c bit i vi tic nht thi. Liu php ny bao gm : bnh nhn lp bng theo di tn s tic hng ngy, nh u nhng ngy khng b tic, gia nh trnh nhc n tic, khng ph phn tr ; t chc nhng hot ng thu ht s tp trung ch v li cun tr tham gia vo, ng vin khen thng khi tr t b tic (phng php tng cng cng c ng tnh). Bn cnh a vo c s phi hp hai qu trnh : bt ng cc vn ng v vn ng cc bt ng ca nguyn tc iu tr tm vn ng, a ra k thut : tr c hng dn thc hin cc bi tp trc gng, lm cc ng tc nhng phn c th khng b tic kt hp vi bi tp gin c.

Da vo thuyt iu kin ho cho bnh nhn thc hin bi tp s ch ng lm cc ng tc tic 30 pht mi ngy trong 3 tun lin. 2.3. Cc phng php iu tr h tr : T chc cc hot ng vui chi gii tr, nng tm l{ ngi bnh kt hp vi hng dn gia nh. iu tr cc ri lon lo u, trm cm, m nh hoc tng ng nu c km theo vi tic. 2.4. Tiu chun ra vin v theo di iu tr : Thng thng bnh nhn tic c iu tr ngoi tr v ch vo vin khi b tic mn tnh nhiu loi hoc hi chng Tourette. Bnh nhn c ra vin khi cc triu chng tic thuyn gim v khng gy nh hng nng n i vi cc hot ng hc tp, sinh hot hng ngy. Bnh nhn c theo i iu tr ngoi tr v thm khm nh kz.

S87. TRM CM
Trm cm l mt loi ri lon kh sc bao gm kh sc trm dai dng, mt mi quan tm thch th hay mt mi v gim hot ng lm gim kh nng thch ng ca ngi bnh vi cuc sng. 1. chn on : Da vo 4 nhm triu chng : (1) Ba triu chng c trng : Kh sc trm, Mt quan tm thch th, Tng s mt mi.

(2) By triu chng ph bin :

Gim tp trung ch , gim tnh t trng v lng t tin, { tng b ti v khng xng ng, nhn tung lai m m v bi quan, { tng v hnh vi t hu hoi hoc t st, ri lon gic ng, n khng ngon hoc n nhiu. (3) Mt s triu chng sinh hc trong trm cm nng : Gim 5% trng lng c th trong 1 thng, kh sc gim v bui sng, chm chp tm l vn ng, thc gic sm. Sng s, hoang tng v o gic c th gp trong trm cm nng. Ni dung hoang tng thng l c ti, khng cng ng, b truy hi hoc khng tn ti, o gic thng gp l o thanh.

Chn on mc nng ca trm cm :

Mc nng : gm 3 triu chng c trng kt hp vi trn 4 triu chng ph bin. Mc va : c 2 triu chng c trng kt hp vi 3 hoc 4 triu chng ph bin. Mc nh : c 2 triu chng c trng kt hp vi 2 triu chng ph bin.

Chn on theo th bnh : Giai on trm cm : ch b 1 giai on trm cm Ri lon trm cm ti din : c s ti pht ca nhng giai on trm cm

(1) (2)

(3) Ri lon cm xc lng cc : giai on trm cm xen k vi giai on hng cm. tr nh trm cm c th biu hin i dng cu knh hoc kh sc thay i nhanh, bt rt, ng nhiu, n nhiu, cc triu chng au c th Gim vn ng ch {, t uy chm gy ra nhng suy gim v hc tp. i vi tr v thnh nin cm gic t ti, mc cm ti li gp kh ph bin v c th s bi quan, tht vng dn n { ngh toan t st hoc hnh vi t st. mt s tr em trm cm c th

biu hin bng nhng hnh vi chng i x hi nh b hc, phm php, trn nh, gy ri ni cng cng Test tm l{ thng ng nhn nh trm cm l test Beck : nu kt qu tng im trn15 l trm cm nng, 8 14 im l trm cm va, 5 7 im l trm cm nh. Ngoi ra test CBCL cng c s dng nh gi trm cm. 2. iu tr : iu tr bng ho c l ch yu kt hp vi liu php tm l. Cn theo i c bit ti nhng bnh nhn trm cm nng, chn n, cso bnh c th km theo, c { tng hoc hnh vi t st. 2.1. Liu php ho dc : Thuc chng trm cm 3 vng nh Amitriptilin, Anafranin liu 25 75mg/ngy, ung. Thuc chng trm cm i : Fluoxetin (Prozac) 20mg/ ngy, ung.

i vi nhng bnh nhn c hoang tng, o gic cho ung thm an thn kinh nh Tisersin 25 75mg/ngy hoc Haloperidol 1,5 3mg/ngy. Lu { tc ng ph ca thuc chng trm cm 3 vng nh c th gy kh ming, nhn m, gin ng t, chn n, b tiu tin, chng mt, tng nhip tim trong trng hp cn phi gim liu. 2.2. Liu php tm l : C th p dng nhiu liu php khc nhau nhng thng s dng liu php hnh vi nhn thc v liu php gia nh nhm h tr tm l{ ngi bnh, phc hi chc nng tm l{ x hi, gip cho h sm thch nghi vi cuc sng trong cng ng. 2.3. Cc phng php iu tr h tr khc : Nng tm l{ ngi bnh, a vo cc hot ng vui chi gii tr, th thao, lao ng hp l{ Cn lu { ti ch n m bo inh ng.

2.4. Tiu chun ra vin v theo di iu tr ngoi tr :

Tiu chun ra vin :

Kh sc n nh, khng c tng t st, ngi bnh bc u c th tr li sinh hot bnh thng, giao tip v hc tp c.

Theo di v diu tr ngoi tr :

iu tr bng thuc chng trm cm ti thiu t 6 n 9 thng k t khi bnh n nh v bnh rt hay ti pht. i vi bnh nhn b trm cm ti din phi dng thuc chng trm cm k o i hn kt hp vi epami liu tung 200 400mg/ngy nhm d phng nguy c ti pht. Bnh nhn c theo di v khm nh kz trong thi gian di.

S88. RI LON LO U
Ri lon lo u l s lo s qu mc trc mt tnh hung xy ra, c tnh cht m h, v l, lp li v ko di gy nh hng ti s thch nghi vi cuc sng. Nguyn nhn lo u gm nhiu yu t khc nhau, nhng ch yu lin quan ti cc sang chn tm l kt hp vi yu t nhn cch c xu hng lo u. 1. chn on : Cc ri lon lo u sau hay gp tr em : (1) Ri lon lo u m nh s : m nh s c hiu : s cc tnh hung rt c hiu nh s ti gn cc ng vt, s ch cao, s bng ti, s ch ng kn m nh s khong trng : lo u hong s khi ra khi nh, s i vo cc ca hng, s m ng v cc ni cng cng, s i mt mnh

m nh s x hi : s n ung ni cng cng, s ni trc cng chng, s gp ngi khc gii (2) Ri lon m nh nghi thc : Nh ra tay nhiu ln, kim tra nhiu ln mt vic, sp xp cc vt theo mt cch thc nht nh, cc ng tc nghi thc bt thng (3) Ri lon lo u chia ly : Tr lo lng c iu khng may s xy ra vi ngi m tr gn b (thng l m), tr khng chu i hc do s phi chia ly vi ngi gn b, khng chu ng mt mnh hoc nh mt mnh, xut hin nhng triu chng gin d, khc lc hoc bun ru. (4) Ri lon hong s (lo u kch pht tng giai on) : C nhng cn lo u xy ra nhiu ln trong mi thng. Trong cn c nhiu triu chng ri lon thn kinh t tr trm trng. (5) Ri lon lo u lan to : Ngi bnh cm thy thng xuyn lo lng s hi v tng lai bt hnh, cng thng vn ng, bn chn run ry, khng c kh nng th gin v kh tp trung ch . (6) Ri lon stress sau sang chn : Cc triu chng in hnh thng xy ra trong vng 6 thng k t thi im b sang chn, bao gm : s ti hin nhng hnh nh ca sang chn trong gic m, cm xc th hoc t lit, n trnh cc kch thch thu mnh hoc khng p ng vi moi trng xung quanh, mt thch th, hay b git mnh, mt ng. Cc trc nghim tm l cn lm xc nh lo u : Test lo u ca Zung Bng lit k hnh vi tr em (thang o CBCK ca Achenbach)

V tranh, k theo 10 cu chuyn ca Duss, CAT

2. iu tr : Nguyn tc iu tr lo u ch yu l bng cc liu php tm l, nu cn dng thuc th khng dng ko di v khng dng nhiu loi thuc.

S dng thuc : iu tr thuc khi co lo u nng nhm lm gim cc triu chng ri lon thn fkinh thc vt v cc triu chng c th giai on u.

Nhm thuc gii lo u : Benzo iazepam (Se uxen, Tranxen) hoc atarax ung vi liu thp ; Seduxen vi liu 0,1 0,2mg/kg/ngy. Khi ngi bnh c cn hong s c th cho tim bp Seduxen liu 5 10mg/ln. Thuc chng trm cm : Amitriptilin c th ch nh cho nhng bnh nhn c nhiu than phin v c th hoc c kt hp b trm cm, ung theo liu 25 50mg/ngy. i vi bnh nhn c cc triu chng m nh nn ch nh anafranin cng vi liu trn. Lu { cc thuc chng trm cm 3 vng ch pht huy tc dng iu tr sau khi ung thuc t 10 n 14 ngy.

Cc vitamin v cc yu t vi lng nh magie, can xi Cc liu php tm l :

y l phng php iu tr ch yu v lu di nhm thay i nhn thc v gip ngi bnh c kh nng ng ph vi lo u mt cch tch cc v ch ng. Tham vn tm l.

Liu php th gin : hng dn ngi bnh nhng bi tp th lng c kt hp vi tp th kh cng. Liu php hnh vi nhn thc : gip cho ngi bnh hiu v bnh, nhn ra nhng suy ngh cha hp l{ v thay vo bng nhng suy ngh hp l.

Kt hp tr liu gia nh v liu php nhm. Cc iu tr h tr :

Sinh hot iu , trnh cng thng, t chc cho bnh vui chi, thng xuyn ng vin bnh nhn v gia nh.

Tiu chun ra vin v theo di ngoi tr :

Bnh nhn c ra vin khi cc triu chng lo u thuyn gim v c kh nng tr li sinh hot hc tp bnh thng, hn khm nh kz t nht 1 ln trong 1 thng.

S89. TRNG THI KCH NG TM THN


Kch ng tm thn l mt trng thi hng phn tm l vn ng qu mc hoc l nhng cn xung ng do mt s kim sot ca thc xut hin t ngt, khng mc ch r rng, khng thch hp vi hon cnh. Trong trng thi ny ngi bnh c th ku go, la ht, chng i, p ph, vng vy, chy nhy, leo tro nhng ni khng thch hp 1. Chn on : 1.1. Chn on xc nh cn kch ng : Da vo cc biu hin lm sng bnh nhn c nhng hnh vi cm xc bt thng xut hin t ngt nh go th t, chng i, vng vy, p ph mang tnh cht hng phn qu mc v xung ng mt s kim sot ca l tr. 1.2. Chn on nguyn nhn ca tnh trng kch ng tm thn tr em v v thnh nin Cn gin d do mt kim ch cm xc nhng tr b ri lon tng hot ng gim ch , ri lon hnh vi chng i, chm pht trin tm thn. Cn kch ng do lo u nhng tr b ri lon lo u chia ly, ri lon hong s, m nh nghi thc, o gic do hong s cp tnh (c bit tr 2 6 tui).

Sang chn tm thn mnh gy ra trng thi kch ng mt s bnh nhn ri lon phn ly (hysteria), lon thn phn ng. thc m sng do thc tn gp trong nhng trng hp sau :

Bnh ni khoa : st, ri lon thng bng in gii, nhim trng h thn kinh trung ng, u no, xut huyt no mng no, co git, ri lon ni tit, bnh t min, thiu xy no, ri lon chuyn ho ng kinh c ri lon tm thn. Phn ng ph i vi mt s thuc. Ng c thc n. Phn ng i vi mt s thuc gy nghin.

Lon thn : tm thn phn lit, lon thn cp, hng cm, trm cm kch ng. B ngc i hoc b b mc.

2. X tr : Ngay t u phi s dng nhng bin php thch hp m bo an ton cho bnh nhn, gia nh v nhn vin y t. Hi ngi nh s b tm hiu hon cnh pht sinh kch ng c cch x tr kp thi. S dng liu php tm l tm cch n nh ngay trng thi tm thn ca bnh nhn : dng li l thn mt, n tn gii thch thuyt phc, d nh, c thi bnh tnh lng nghe kin ca bnh nhn v nguyn nhn kch ng. Nu bnh nhn mi n lo s b giam gi, c th cho tham quan bung bnh v sinh hot ca nhng bnh nhn khc. Nu bnh nhn qu kch ng chng i, p ph khng chu tip xc, c th nhiu ngi dng p lc a bnh nhn vo bung ring tim thuc (trnh tri buc). Khng i trc ngi bnh. Ch kim tra

bnh nhn, thu gi vt nguy him nu c. Phng ca bnh nhn khng dng c vt nhm m bo an ton cho mi ngi. s. Nu bnh nhn chu cho khm bnh th nn tin hnh khm ngay : Tim, phi, mch, huyt p, du hiu nhim khun Cc thng tch trn ngi. Cc triu chng thn kinh khu tr, hi chng mng no v tng p lc ni

Lm cc xt nghim cp : cng thc mu, ur huyt, ng huyt, huyt thanh chn on (nu nghi nhim khun) Nu bnh nhn qu kch ng khng cho khm bnh phi tin hnh iu tr ngay: Gi u : Aminazin 25mg 1/2 1 ng tim bp tuz theo la tui (liu trung bnh 1mg/kg cn nng). Gi th 3 nu bnh nhn cha ht kch ng dng thuc kt hp sau : Aminazin 25mg x 1 ng Pipolphen 50mg x 1 ng c th tim bp 1 ln hoc chia 2 ln cch nhau 30 pht. Gi th 6 nu bnh nhn cha ht kch ng cho tim li 2 ng thuc trn mt ln na. Thng th ht t 3 hu ht bnh nhn ht kch ng v ng yn. Trong khi bnh nhn yn, cn tin hnh khm bnh t m v ni khoa, thn kinh v lm cc xt nghim cn thit xc nh nguyn nhn nhim khun, nhim c, bnh c th, bnh thn kinh ng thi tip xc vi ngi nh hon thnh bnh n. Khi bnh nhn tnh dy, thy thuc nn c mt ngay tin hnh liu php tm l cho bnh nhn yn tm, trnh kch ng th pht do lo lng s hi trc mi trng mi.

Khi bnh nhn ht kch ng phi nhanh chng chn on nguyn nhn, iu tr theo nguyn nhn ca bnh. Chm sc v ch n ung : Theo di cc du hiu sinh tn (nhit , mch, huyt p), cc in bin bt thng, trng thi tm thn c bit. Trong trng thi kch ng bnh nhn thng mt mi, suy kit cn ch bi ng c th bng iu chnh chuyn ho (nc, in gii), ch n ung y calo, vitamin v cc nguyn t vi lng. Nu bnh nhn khng chu n phi cho n bng ng thng. Sau vi ngy tim bnh nhn kch ng c kh nng tip xc, ng vin bnh nhn ung thuc, tin tng iu tr. i vi gia nh bnh nhn hng dn ng vin h, trnh gy sang chn tm l cho bnh nhn. Khi tnh trng bnh n nh gii thch cho gia nh to mi iu kin thun li cho ngi bnh ho nhp tr li gia nh v cng ng, cho n thun thuc iu tr ngoi tr.

S90. RI LON PHN LY


Ri lon phn ly (trc y c gi l bnh tm cn, hysteria) l nhng ri lon thn kinh chc nng thng xut hin sau nhng sang chn tm l nhng ngi c nhn cch yu hoc loi hnh thn kinh ngh s. Ri lon phn ly biu hin rt a ng vi cc triu chng ging nh cc bnh thc th ca h thn kinh, tun hon, h hp, tiu ho nhng khng c bng chng ca tn thng. c im c bn ca ri lon ny l bnh nhn c biu hin tng cm xc, tng tnh m th v t m th v c th iu tr nhanh khi bng liu php tm l m th. 1. chn on : 1.1. Chn on xc nh : 1.1.1. C cc nt lm sng bit nh cho cc loi ri lon phn ly, biu hin bng nhng cn hoc nhng trng thi khc nhau :

Cc cn phn ly : Cn co git phn ly :

Biu hin bng nhiu ng tc khng t , ln xn nh vng vy, p mnh chn tay, un cong ngi, rt tc, co cu, ln ln Trong cn, { thc b thu hp m khng b mt hon ton, vn cn kh nng phn ng vi cc tc ng ca mi trng, khng tm ti, khng c ri lon i tiu tin Nu vch mt ca bnh nhn vn thy nhn cu a qua a li. Lu { cn thng ch xut hin khi c ngi xung quanh, bnh nhn bit trc cn sp xy ra nn thng khng b ng mnh gy chn thng. Cn co git mt nhanh nu iu tr liu php m th bng li ni hoc kch thch mnh. Nu khng c iu tr cn c th ko di trn 15 pht ti vi gi. Tuy vy c nhng cn xut hin rt ngn nn c th d b nhm vi cn ng kinh. Sau cn hi bnh nhn vn nh v cn v c th m t li c mt phn ca cn. Cn ngt phn ly :

Bnh nhn cm thy ngi mm yu dn, t t ng ra v nm nh ng, mt chp nh, khng tm ti, mch v huyt p vn n nh. Cn k o i t 15 pht n hng gi.

Cc ri lon vn ng phn ly :

Run : run khng u, khng c h thng, run mt phn c th hoc run ton thn, run tng ln khi c ch . Lit : lit cng hoc lit mm vi nhng mc nng nh khc nhau mt chi, hai chi hoc t chi nhng khm thy trng lc c bnh thng, khng c phn x bnh l, khng b teo c, khng c u hiu tn thng b thp, khng ri lon c trn Tr c th khng i, khng ng c nhng khi nm vn c ng bnh thng. Cc ri lon pht m : ni kh, ni lp, khng ni, ni th tho, mt ting trong khi c quan pht m vn bnh thng.

Cc ri lon cm gic phn ly :

Mt hoc gim cm gic au : Vng mt cm gic khng ng vi vng nh khu ca thn kinh cm gic. i khi v tr mt cm gic c th di chuyn khc nhau trong nhng ln khm li. Tng cm gic au : Rt phc tp, khu tr khc nhau. C mt s au ging nh trong cc bnh ni khoa hoc ngoi khoa.

Cc ri lon gic quan phn ly : M phn ly. ic phn ly. Mt v gic v khu gic phn ly.

Cc ri lon thc vt ni tng phn ly :

Thng biu hin thnh tng cn nh lnh run, cn nng bng, cn au vng ngc, au bng, au u, chng mt, cn kh th, kh nut, cn nt hoc nn phn ly.

Cc ri lon tm thn :

Ri lon tr nh : Thng qun cc s kin mi xy ra hoc qun cc s kin sang chn tm l. Ri lon cm xc : D xc ng, cm xc khng n nh, d nhy cm vi cc kch thch, d b nh hng bi cm xc ca ngi khc. Ri lon t duy : Li ni mang mu sc cm xc, thng ni v bn thn, k v bnh tt li cun s ch ca ngi khc, tng tng phong ph, thch ph trng. Ri lon tc phong : Hnh vi iu b kch tnh, t pht, ph trng. C th xy ra hin tng trn nh phn ly. 1.1.2. Khng c bng chng ca mt ri lon c th no c th gii thch cho cc triu chng.

1.1.3. Bng chng c cc nguyn nhn tm l{ i dng kt hp r rt v thi gian vi s kin gy sang chn hoc cc mi quan h b ri lon. 1.2. Chn on phn bit : Cn phn bit vi cc bnh thc th v tm thn c biu hin ging vi cc nt lm sng ca ri lon phn ly. 2. iu tr : Nguyn tc iu tr cc triu chng ri lon phn ly ch yu bng liu php tm l v rn luyn nhn cch phng ti pht. 2.1. iu tr triu chng : Ch yu bng liu php m th khi thc : bng li ni mang tnh cng quyt v khng nh ca thy thuc hoc kt hp vi nhng bin php ph tr nh ng thuc mang tnh placebo, bm huyt, chm cu gy cho bnh nhn tin tng v lm mt i cc triu chng chc nng. S dng liu php m th trong gic ng thi min nu iu tr m th khi thc khng thnh cng. Cn ch ti thi i vi bnh nhn phm ly : Khng cho l tr gi v v y l mt trng thi bnh l tht s, khng coi thng, khng ch giu ht hi bnh nhn. Ngc li cng nn trnh thi qu chiu chung, qu lo lng, v tnh m th lm cho ngi bnh tng rng bnh qu nng iu tr s kh khn. iu chnh hot ng thn kinh cao cp v tng cng c th gip chng vi sang chn tm l bng cc thuc : Bronua, an du gii lo u (Seduxen), cc sinh t (B1, B6, C), cc yu t vi lng (canxi, magie). Phi hp vi cc liu php tm l{ khc nh vui chi nhm, lao ng, nhn thc hnh vi. 2.2. Rn luyn nhn cch : Cn c s kt hp v h tr cht ch gia tr em gia nh v nh trng.

Gip tr hiu c nhng thiu st ca mnh v khc phc sa cha, ng vin mt tch cc trong tnh cch tr pht huy. a ra nhng tnh hung tr tp luyn bit cch t kim ch cm xc v hnh vi ca mnh, tp thch nghi vi cc s kin tc ng ca cuc sng v sn sng i u vi nhng sang chn khc nhau.

CHNG 9. C XNG KHP


S91. GY XNG
1. c im xng tr em. Xng tr em mm v d un cong, nhiu l xp , o chu c bin dng v nn p. Xng tr em t n c th lm thng c nhng khng phi l tt c.

Ct mc vng ln duy tr lin tc o gip ngn nga di lch v d lin xng. Trong gy xng tr em tn thng sn tip hp cao t 10 - 15% t gp gy vn tr chn thng mnh. Sn tip hp yu hn giy chng bao khp , gn , o cng mt lc chn thng ngi ln c th tch hoc rch dy chng - trt khp nhng tr em li c th b tn thng sn tip hp dn n ri lon pht trin xng. gy t n kch thich s pht trin ca xng nh tng cp mu cho sn tip hp.

Xng tr em lin nhanh do ct mc lin tc , s cp mu phong ph, tr cng nh lin xng cng sm ( s sinh 2 - 3 tun , 7 - 10 tui l 6 tun , trn 10 tui l 8 - 10 tun Khng lin xng tr em thng khng xy ra (tr mt s chn thng nng gy h, vim, xng bnh l). Do phu thut chnh li gy khng c ch nh tr em v nh hng ti s lin xng. 2. Phn loi gy xng c tn thng sn tip hp. Salter v Halrris chia lm 5 nhm . Nhm 1 : Tch u xng khi hnh xng. Nhm 2 : ng gy theo khu vc n to ca sn tip hp lm thay i u i v xuyn ra ngoi hnh xng .

Nhm 3 : Gy u xng trong khp, mt tch ko di t khu vc yu ca t bo n to sau k o i song song vi sn tip hp ra ngoi vi (hay gp xng chy). Nhm 4 : ng gy bt u t mt khp k o i xuyn qua u xng i ht phn dy nht ca sn. tip hp sau i qua mt phn hnh xng (hay gp u i xng cnh tay). Nhm 5 : Trong trng hp khp hoc dng mt lc p ln chuyn qua u xng ti mt phn sn tip hp p lp t bo mm ca t bo sn, di lch ti thiu nhng nhm vi bong gn). (Hay gp trong khp gi, c chn ) 3. Chn on - Bnh s kh xc nh vi tr nh. - Gy hon ton c triu chng.

+ au vng gy. + Bt lc vn ng. + Sng n. + Bin dng. + C th c bm tm. - X- quang : tr em cn c chp ton b 2 khp trn i gy v chp i xng so snh , tr nh c tn thng u xng i , trong tm ct ho cha xut hin trn x - quang : nn chn on s gp kh khn. 4. iu tr : Tuz theo mc tn thng , tui c quyt nh s tr. iu tr bo tn l chnh, vi gy m v t vng ko nn hoc ko lin tc > bt ng bt trn i, thi gian theo la tui.bt ng bt trn i khp ca gy. Tip sc chnh xc mt gy l khng cn thit v gp gc u xng < 20 l chp nhn c . iu tr phu thut khi c cc yu t sau :

+ Tn thng mch mu, thn kinh, gy h, chn p khoang- hoc c tn thng khc km theo. + iu tr bo tn tht bi. + Gy phm khp IV. 1. Gy trn li cu xng cnh tay. - Gy m ko nn b bt nu tht bi m xuyn inh Kirschner c nh ngoi vi. Bt t th cng tay sp. 7 - 10 ngy thay bt trnh di lch th pht trong bt - Nu gy h tn thng mch, thn kinh ,m kt xng.

2. Gy u trn xng cnh tay : - Gy m : Nn bt ngc vai cnh tay giang 90, gp trc 60 v xoay trung gian. - M : Khi ko nn tht bi , gn c nh u chn gy > xuyn inh Kirschner. 3. Gy thn xng cnh tay: - Nn b bt ngc vai cnh tay cng tay. - M khi tn thng thn kinh, mch mu, h. 4. Gy li cu ngoi xng cnh tay: - Gy khng di lch: B bt chp li sau 2 tun. - Gy di lch : M c nh bn trong. 5. Gy mm trn li cu trong xng cnh tay. - t di lch : b bt. - Di lch r : phu thut c nh. Nu tr ln ly b mnh gy v c nh gy. 6. Gy Monteggia- gy xng v sai khp (Gy 1/3 trn xng tr v sai khp quay tr trn). - Nn b bt sm . - Nu tht bi kt xng tr t li u xng quay v ti to giy chng vng khi cn thit . 7. Gy 2 xng cng tay: - Gy t hoc khng c di lch : bt cng bn tay. - Di lch nhiu nn chnh bt bt ng. + Gy 1/3 trn : cng tay nga ti a.

+ Gy 1/3 gia: cng tay trung gian. +Gy 1/3 i : cng tay sp ti a. 8. Gy Galeazzi v sai khp quay tr di (gy 1/3 i xng quay). Gy m nn b bt. 9. Gy xng ngn v bn tay. - Gy vn u i t ngn - np. - Gy gia t- nn chnh np t khuu ti ngn. - Gy xng bn tay - nn b bt. - Gy ch T - M xuyn inh Kischner. 10. Gy c xng i . - iu tr c nhiu phng php. + Ko lin tc. + Nn chnh +bt whitman. + Nn chnh - np Thomas. + M nn chnh c nh trong bng np vt. - Bin chng : + Hoi t v khun. + Bin dng coxavara. + Ln sm u xng - ngn chi. 11. Gy thn xng i. Chng shock: Do mt mu v au.

Gy m ko nn b bt c th chp nhn c di lch chng < 2cm v gp gc khng qu 20 ( tr i 10 tui) M khi c bin chng mch, thn kinh, gy h hoc theo nguyn vng ca gia nh. 12. Gy xng bnh ch. - t di lch : Bt ng bt vi gi dui. - Di lch : Khu li mt ngoi v trong c t uv nn li xng. 13. Gy thn xng chy mc: Nn chnh b bt. 14. Gy ct sng: - Khng lit : Ko lin tc - ging bt trong 2 thng. - C lit : m c nh hoc dnh khp 15. Gy xng chu : Chng shock. Tuz v tr v tn thng c th iu tr. - Gy khng vng c lm ri cung xng chu. + Gy p trc sau to ln gy cung xng chuv khp mu - bt ng khp hng t th xoay trong. + Gy p ngoi : Gy c 2 xng chu + 2 xng mu - nm ging bt. 16. Gy xng trong sn khoa : - Gy thn xng i : Bng hoc np tuz v tr - Gy sn tip hp. 5. Bin chng : 1. Bin chng ngay : - Shock - Gy h.

- Chn p khung. - Tm ngay khi nn c th xy ra

2. Bin chng sm. - Ri lon inh ng. - Hi chng Volkman. 3. Bin chng mun: - Lit thn kinh. - Vo trc v can lch. - Tiu chm hoc u xng sn. - Vim xng. - Khp gi.

S92. VIM M KHP


Vim m khp l hu qu ca vim xng tu xng m vng hnh xng nm trong bao khp hoc c th vim xng ph v t chc khp a m vo trong khp 1. Chn on 1.1 Lm sng: - Hi chng nhim khun - Vng khp lp y rnh t nhin - Gi lit quay trong vim m khp vai s sinh

- Sai khp hng (nu c) thng gp sai khp hng th chu - Chc d khp, c hoc cha ht c m khp. 1.2 X.quang: - Du hiu sai khp hoc sai khp mt phn - Khe khp dong rng - Hnh nh vim xng vng hnh xng st vi khp vim m. 2. iu tr : 2.1 Nguyn tc phu thut : Phu thut cp cu Dn lu m trit Khnh sinh liu php Bt ng 2.2 K thut phu thut : 2.2.1 Phu thut vo khp theo ng mt trc khp hng (Shede hoc Hueter) - u im : +T th bnh nhn thut li (Nm nga) +Thao tc phu thut khng kh khn nht l trong nhng trng hp c sai khp +Vt m mt trc khp nn chm sc sau m thut tin - Nhc im : Dn lu m khng trit

2.2.2 Phu thut vo khp theo ng mt sau khp (OBER) - u im : + Dn lu m tt - Nhc im : + Vo khp phi qua mt lp c y + Do ng m mt sau khp nn chm sc sau m kh khn. 2.2.3 ng m vo nhng khp khc theo k thut c in 2.3 Phu thut, ti ra khng sinh khp: Rch da v m khp theo nguyn tc c in t Catheter s 6 hoc 8 trong khp v t dn lu ngoi khp ng kn bao khp

2.4 Dung dch ti ra: Dung dch Chloramphenicol 0,05% x 2.000ml / 24 h hoc Dung dch Natri Clorua 0,9 % + Gentamycin 80 mg x 2.000ml / 24 h Lin tc ti ra trong 48 h

S93. VIM XNG TU XNG


Vim xng tu xng l trng thi vim m tt c cc thnh phn ca xng. 1. Chn on: 1.1 Lm sng : Phn chia giai on trong VXTX :

(1) Giai on cp : Trong 48 72 gi u (2) Giai on trung gian : Ngoi 48 gi ti 3 tun (3) Giai on mn tnh : C xng cht, c r m + Giai on cp v trung gian : Hi chng nhim khun in hnh . St . Nn . Co git hoc li b . Bch cu cao, tc mu lng cao au : au tp trung vng hnh xng

au pht sinh t nhin, au tng ln khi vn ng v khi c s nn. Sng n ti ch : Thc t l sng n lan rng

+ Giai on mn tnh : Vim r ko di Dch m vim thi, c km theo mnh xng cht.

- C t bt php cp ca giai on mn tnh (Lm sng nh trong giai on cp v trung gian). Vi mu sc a khng ng nht 1.2 Xt nghim

Cng thc mu . S lng bch cu v t l bch cu a nhn trung tnh tng cao. Tc lng mu tng cao. - Chc ht vng hnh xng (Trong 72 gi u) hoc thn xng (sau 72 gi) c m.

- Chp phng x nu c iu kin + Siu m? + Chp cng hng t? X.Quang : Du hiu X. quang trong vim xng tu xng thng xut hin mun. - Trong giai on cp hoc trung gian, phn ng ct mc thy c trn Film X quang thng ngoi 2 n 3 tun. - Trong giai on mn tnh : + in hnh vi hnh nh xng cht + vim khuyt xng + Xng x kt (x chai) 2. iu tr : 2.1 Nguyn tc iu tr : + Nguyn tc iu tr trong vim xng tu xng giai on cp v trung gian : Dn lu m trit Gim p lc ng tu sm Khng sinh liu php v Bt ng. + Nguyn tc iu tr trong vim xng tu xng giai on mn tnh : Lm sch vim (T chc vim, xng cht) San bng, lp y khuyt vim xng Dn lu trit

2.2

Khng sinh liu php . Khng sinh liu php:

* Nguyn tc : S dng theo khng sinh Thi gian s dng lin tc trong 6 tun (Tim tnh mch v ung) Phu thut khoan xng ti ra khng sinh

2.3

+ K thut khoan xng, t h thng ti ra khng sinh - Rch da trc tip qua vng vim m, theo ng rch c in. - Lm rch vim, m. - Khoan xng c theo xng - Bm ra sch ng tu bng dung dch Natri Clorua 0,9 % - t Catheter s 6 hoc 8 trong ng tu t dn lu ngoi xng + Dung dch ti ra Dung dch Chloramphenicol 0,05% x 2.000ml/24h hoc dung dch Natri Clorua 0,9 % + Gentamycin 80 mg x 2.000ml / 24 h Lin tc ti ra trong 7 ngy

S94.

LON SN KHP HNG BM SINH

Lon sn khp hng bm sinh bao gm sai khp mt phn, lon sn ci, v sai khp ton b ca u xng i vi ci. 1. Chn on

1.1 Lm sng - Ortolani test: Nh nhng giang, khp gp hng pht hin sai khp u xng i vi ci. - Barlow test : Tng vn ng pht hin sai khp mt phn hoc sai khp ra sau bng p trc tip theo trc dc xng i trong khi khp hng khp - Galeazzi sign: u xng i khng ch sai lch m cn ln trn do c s ngn ca xng i 1.2 Xquang ng Perkins: ng thng ng Hilgenreiner: ng ngang Xc nh v tr u xng i ng Shenton: Vng cung c bt

Bnh thng ch s ci bng hoc nh hn 30

2. iu tr Chia lm 5 nhm tui: 1. S sinh ti 6 thng tui, (2) Tr nh, 6 - 18 thng tui (3) tui chp chng, t 18 ti 36 thng (4) Tr nh v b, t 3 ti 8 tui v (5) Tr ln, trn 8 tui 2.1 T sinh ti 06 thng tui

Nn bt, bt theo t th sn khoa trong 06 tun- 03 thng 2.2 T 06 thng n 18 thng Bt hoc Phu thut:

+ Ct c kh p, c tht lng chu, ct ra ci + To hnh bao khp 2.3 T 18 thng n 36 thng tui

Phu thut: + Chun b trc m: V khun vng khp hng , mng v sinh dc + K thut: Chn la k thut tuz thuc vo gc c xung i, ch s ci : Tr nm nga, k n mng Th 1 : Rch da mt sau ngoi mng, mt trc khp hng, ko di v mt ngoi i Ct c thng i, tht lng chu Th 2: Ct xng chu, to hnh ci Kt hp xng Th 3: To hnh bao khp Ct bao khp, ct Lymbus Th 4: Ct xng i tng ng lin mu chuyn Ct to chm xng, lm ngn xng 1-2 cm Xoay ngoi khong 15-30 Kt hp xng + Theo ri sau m: Theo ri chn p bt

Bt gi trong 6 tun Sau 6 tun b bt, tp vn ng 2.4 Tr t 3 tui ti 8 tui:

Tuz thuc chiu di chi, ch s ci, gc c - thn xng i. - To hnh bao khp v c hoc khng - To hnh ci vi ct xng chu v c hoc khng - To hnh gc c-thn xng i vi ct xng i Trong trng hp cn thit, ct c kh p, c tht lng chu 2.5 Tr ln (trn 8 tui)

Tuz thuc vo chiu di chi, tnh trng ci, tnh trng u xng i Phu thut theo Chiari. + K thut: Bnh nhn nm nga, k n mng Rch da mt trc hng Bc l v ct nguyn u c may,c thng i (phc hi sau khi ct xng chu) Ct xng chu trn nguyn u c may + Theo ri sau m: Theo ri cheo p bt Bt gi trong 8 tun Sau 8 tun b bt, tp vn ng

S95. CNG DUI KHP GI SAU TIM KHNG SINH TRONG C T U


Cng dui khp gi l tnh trng bnh l vi hnh thi khp gi hn ch gp vi khp gi v tr trung gian o x ho c t u i sau tim khng sinh trong c tr em.

1. Chn on : 1.1 Lm sng: Tin s c tim khng sinh trong c t u XBC nh v cao hn bn i din Chu vi vng i nh Lm da (r khi gp gi, c th c 2 lm da) Da mng , kh nng n hi v np gp gim Khng c kh nng t co c Dng i bt thng : lun giang v xoay i ra ngoi Khng gp c khp gi hoc gp hn ch

2.1 X Quang Xt nghim Long xng u i xng i, u trn i chy Xng bnh ch nh v long xng, nm cao hn bn lnh Li cu xng i bt, bin dng mt khp xng chy Gy xng u i xng i, u trn xng chy Cc xt nghim khc cn thit cho phu thut iu tr

2. iu tr 2.1 2.2 Ch nh : Gc gp gi i 600 Gc gp ch ng v th ng khng thay i Thi gian mang bnh trn 1nm v c iu tr vt l khng kt qu Lc c t u t t 3 im tr ln. Nguyn tc trong phu thut CDKG : Tuz thuc tn thng nhn thy trong m Khng dp khun theo mt k thut c chn sn Th t ct, tch c C rng ngoi C rng gia C rng trong C thng i Tch x nh n thun

2.3 2.3.1

K thut phu thut: K thut thompson T.C .1944

- Tch r 4 c ca c t u i - Ct c rng gia y l k thut t tn thng c t u 2.3.2 K thut BENNETT G.E .1922

To hnh c t u hnh ch V. C v gn c khu gc gp gi 800 K thut khng phi bc tch c nn t chy mu

2.3.3

K thut PAYR E. 1917 (LENART G. 1975 m t li k thut PAYR E.1917)

2.3.4 -

K thut c ni i c thng i v rng gia Tn thng c t u nng n, gy mt dui K thut ca JUDET J .1956,1980. Ct v lm trt c t u, chy mu Di chu chy ni di ch Z 1/3 i i (1956) V 1/3 trn i (1980)

2.3.5

N.N. Hng . 1984

Thc hin khi c t u x ho nng n Chuyn di chu chy v c cng cn i cho c t u Chuyn trc tip bng qun bc hoc ni tng cng

3. Tp luyn sau phu thut: - Tp vn ng 3 ngay sau phu thut, gp gi ti a 90 - Ln tp vn ng u tin do phu thut vin trc tip thc hin. - Sau ln tp u tin, iu ng vin thc hin ngy 2 ln - Hng dn cha m bnh nhn tp vn ng cho bnh nhi lin tc trong 3 -6 thng 4. Bin chng.

5.1 Hoi t m p a theo ng m gp 31% Khc phc bng to hnh da ch z 5.2 Gy xng u i xng i, u trn x.chy

CHNG 10. BNH TRUYN NHIM


S96. NHIM TRNG DO T CU
I. I CNG:

T cu gy nhim trng c hai loi: Staphylococcus aureus v coagulase negative staphylococci. Nhim trng do coagulase negative staphylococci t gp v thng l nhim trng lin quan t cc dng c trong lng mch mu. Phn lc cc t cu hin nay khng Penicillin, cn nhy Methicilline v Aminiglycoside ngoi tr nhim t cu trong bnh vin.

II. CHN ON: 1. Chn on cc bnh do t cu: a) Vim m t bo v nht da, p xe:

Sng nng au vng a b vim (vim m t bo) hoc km theo c m (nht, p xe).

b) Vim phi, trn m mng phi:

Thm nhim phi hai bn dng m, c bng kh, din tin nhanh (vim phi) hay km trn m mng phi.

c) Vim xng, vim khp:

Sng nng au pha trn xng vim, khp km gii hn c ng

Xquang xng: hnh nh vim xng thng xut hin sau 10-20 ngy nhim trng

d) Vim ni tm mc, trn m mng tim:

Bnh nhn c bnh tim trc, st cao ko di, si van tim (vim ni tm mc) nhim trng da, trn dch mng tim trn siu m.

e) Nhim trng huyt:

Bnh cnh lm sng nhim trng huyt trn bnh nhn c nht da, vim xng, vim phi c bng kh. Cc vi khun Gram (-), Chromobacterium cng c th c bnh cnh lm sng tng t t cu.

2. Xt nghim:

CTM Xquang phi khi c suy h hp Xquang xng Cy mu khi c biu hin nhim trng ton thn, nhim trng huyt, vim ni tm mc Chc ht m: nhum gram, phn lp vi khun v khng sinh .

III. IU TR: 1. Nguyn tc:


Phn lp vi khun trc khi cho khng sinh Khng sinh chng t cu Dn lu m iu tr bin chng

2. iu tr: 2.1. Khng sinh:

Bnh nhn phi c phn lp vi khun c bit l nhum gram m ly t p xe s thy cu trng gram ng ng chm

a) Khng sinh ban u:

Vim m t bo v p xe, nht khng c biu hin ton thn: Oxacilline ung hoc Cephalexine ung Cc trng hp khc c biu hin ton thn hoc nhim trng nng: Oxacilline TM + Gentamycine. Bnh nhn trong tnh trng nguy kch: suy h hp nng, sc th c th dng Vancomycine ngay t u.

b) Sau khi c kt qu phn lp vi khun v khng sinh :

Lm sng p ng tt: tip tc khng sinh ang iu tr cho 7 ngy trong trng hp nht a. Cc trng hp khc tip tc khng sinh trong 3-4 tun, ring Gentamycine ch cho trong 5-7 ngy u. Thng sau 1 tun, khi bnh nhn ht st, n ung c c th i sang Oxacilline ng ung nu bnh nhn ang ng Oxacilline chch. Lm sng xu hn hoc cha ci thin:
o

Khng sinh cn nhy Oxacilline: nu bnh nhn ch cn st nhng cc du hiu khc khng nng hn th vn tip tc Oxacilline Khng sinh khng Oxacilline: i sang Vancomycine v c th phi hp Rifampicine ung. Phn lp vi khun m tnh: nh gi li lm sng, tm nhim trng khc v sau khi loi b tc nhn l trc khun gram m th i sang Vancomycine. Nu khng loi b c trc khun gram m hoc vim phi hp mt khng sinh khc c tc dng trn trc khun gram m nh Cefotaxime.

c) Thi gian iu tr khng sinh t nht


Vim m t bo: 7 ngy Vim phi, trn m mng phi: 3-4 tun Vim ni tm mc: 4-6 tun Vim xng: 3 - 6 tun

2.2. Dn lu m 2.3. iu tr bin chng:


Suy h hp: th oxy, chc gii p trn m mng phi, mng tim Sc: xem phc iu tr sc Vt l tr liu trong trn m mng phi Dn lu mng phi, mng tim hay phu thut bc tch mng phi, mng tim.

2.4. Theo di:


Du hiu sinh tn Du hiu suy h hp, chn p tim Din tin p xe ch nh dn lu. Theo i lng nc tiu v TPTNT, chc nng thn ngy th 5 sau iu tr.

S97. BNH SI

1. i cng - Si l bnh c m t ln u tin vo th k th X o y s Persan Rhazes. Mi n th k th XVIII, Home mi c nhng cng trnh thc nghim v s truyn bnh. Vi rt si thuc h Paramyxovirus influenzae. Vi rt thuc nhm ny ging nhau v tnh khng nguyn, nhng vi rt si khng c men neuraminidase, v vy n khng c hp thu bi nhng receptor ca t bo c cha acid neuraminidic. Vi rt si c cha ngng kt t hng cu, trong khi o vi rt thuc nhm Paramyxovirus nh Rin erpest v Canine istemper th khng c. Vi rt si d b tiu dit bi nhit. 560C n b ph hu trong 30 pht. N b bt hot bi nh sng, siu m v mt s tc nhn l{ ho khc. Ngc li n t sng st c trn 5 nm nhit - 700C. Cng nh cc loi Myxovirus , vi rt si nhy cm vi ether v lm cho vi rt v ra thnh tng mnh nh. 2. Dch t hc - Si l bnh nhim vi rt cp tnh, ly truyn rt mnh, xy ra quanh nm, cao nht vo ma xun v c khp mi ni trn th gii. Bnh hay gy thnh dch, chu kz 3 - 4 nm 1 ln. Trc thi kz c vc xin, bnh ph bin tui t 2-6 . Hin nay nhng nc s dng vc xin ROR th t l mc si gim xung 99% . Bnh si c khuynh hng chuyn dch sang tr ln. Nm 1994 ti Vit Nam xy ra v dch, tr mc si ln n 11.000 trng hp. Tnh hnh bnh si trong 20 nm qua ( 1979 - 1999 ) tr em c nc b mc 579.678 ca , t vong 2190 trng hp . Ti Bnh vin Trung ng Hu cui nm 1999 n nm 2000 c 119 tr mc si iu tr ti Khoa Nhi . Nm 2000 min Bc bnh si xy ra 25/28 tnh thnh , tng hn nm 1999 l 1.091 trng hp . Xt nghim huyt thanh (+) l 81,2% . - Hng nm ton th gii c khong 50 triu tr b si , trong c tnh khong 722.000 tr < 5 tui t vong do cc bin chng t si v 40% t vong do suy dinh ng . Bnh thng xy ra cc nc chu Phi v ng Nam Vi rt si gy bnh cho ngi qua ng h hp trn, ngoi ra ng kt mc cng rt quan trng. Vi con ng truyn bnh trc tip qua nhng ht nc bt c cha vi rt, n s tn cng vo nim mc mi ming, hu hoc khu tr nim mc, kt mc mt. Vi rt t nhn ln trong biu m ng h hp v h thng lympho, sau qua h tun hon v lan to vo cc c quan.

Yu t nguy c ca bnh si l : - Tr < 1 tui v tr ln. - Tr b suy inh ng. - Tr khng c tim chng . - Tr b nhim HIV . - Cc ph huynh c con b si khng tun th s hng dn ca cn b y t.

3. Sinh bnh hc - Khi vi rt xm nhp vo ng h hp trn hoc kt mc, sau vi rt nhn ln ti nim mc v trong vng hch lympho. Vo ngy th 5 v 6 xy ra nhim vi rt huyt ti pht v gy nn s nhim trng cc m. Vo ngy th 11, cc triu chng tin triu bt u xut hin v n khong ngy th 14 th ban xut hin. T 24 - 48 gi sau khi ban xut hin th khng th nhanh chng xut hin. Thng thng nh lng c khng th vo ngy th 2 v 3 k t khi pht ban. T l tng ln nhanh t c 1/256, 1/512 trong vi ngy. T l ny ch gim xung t t v thng ngi ta cn tm thy khng th vi t l 1/16 hoc 1/32 sau 10 hoc 15 nm k t khi b mc bnh si. - Trong khong gia hai pha nhim vi rt huyt, vi rt si pht tn ch yu trong cc bch cu. Chnh s nhn ln ca vi rt trong bch cu gii thch c s gim bch cu v gia tng tn sut v nhim sc th ca t bo. S gim sn xut oxy v thiu ht cc men sinh hc trong bch cu lc vi rt si ti c th lm d dng cho s bi nhim th pht ca vi trng. Cc ht Koplik bt ngun t tuyn i nim mc nh l mt tn thng vim, bao gm dch r huyt thanh v s tng sinh t bo ni m. Trong vim no cht xm x ho bn cp, ngi ta c th phn lp c vi rt bng phng php sinh thit no v ng thi cng c c khng th ca bnh nhn vi chun kh cao. 4. Lm sng 4.1.Giai on bnh - Ko di 10 - 12 ngy . Cha c triu chng c hiu , c th c st nh v du

hiu v ng h hp khng r rng . 4.2.Giai on xm nhp - Ko di 3 - 4 ngy , st cao 39o - 40o C , dn dn cc du hiu lm sng r rng hn :

Xut tit mi - mt Xut hin du ni ban : l ht Koplik hoc c tn thng nim mc m h rt c gi tr chn on . Phi hp vi nhng du hiu khng thng xuyn : hch ln , ban thong qua , chn n, bun nn .

4.3.Giai on pht ban - Xut hin sau nhim trng khong 14 ngy . Ban dng dt sn xut hin t u n chn . T lc ban xut hin cho n khi ban bay ko di t 5 - 6 ngy 4.4.Giai on trc vy da - Khi ban si bay , trn da bong vy v lai nhng nt thm en khng ng u , c hnh nh ging da bo . Sau 7 - 10 ngy da tr lai bnh thng . Ngoi si th thng thng , cn c Si Xut Huyt , y l th lm sng rt nng biu hin xut huyt trong da ,nim mc ming - mi v rut , thng bnh nhi t vong . 5.Bin chng 5.1.ng h hp 5.1.1.ng h hp trn - Vim mi c m, vim hng hng ban. Vim tai gia l bin chng thng gp tr nh, xy ra trong giai on tin trin ca bnh. - Vim thanh qun thng xut hin sm . 5.1.2. ng h hp di - Vim phi l mt bin chng ph bin ca si. N l hu qu ca :

+ Nhim trng vi rt lan to. + Bi nhim vi trng nh ph cu, lin cu, t cu hoc H.I... + Phi hp c vi rt v vi trng. - Vim phi t bo khng l, cn gi l vim phi Hecht , l mt vim phi ko di, nguy him, e o t vong, thng xy ra tr suy gim min dch . 5.2. H thng thn kinh trung ng - Vim no cp hay vim no tu . Tn sut mc bnh 0.1 - 0.2% tr b si nhng him gp tr < 2 tui. T l t vong khong 5 - 10%. 5.3.Si v HIV - tr em b nhim HIV, t l t vong do si cao hn 10 ln so vi tr bnh thng. M v chu Phi u ging nhau v bin chng v t vong. T l t vong trong si c bin chng vim phi nhm HIV (+) khong 33 - 45%. 5.4.Vim tai gia - Xy ra khong 10% bnh nhn b si, thng tr c tin s nhim trng tai v sau c th b vim tai xng chm th pht. 5.5. Mt - Vim gic mc, lot gic mc, vim m ton mt. 5.6.ng tiu ho - au bng khng c hiu do s tng sn lympho nh hng n hch lympho mc treo rut. C th c vim rut tha cp trong giai on bnh ang tin trin. Ngoi ra c th a chy. 5.7.Si vi b m mang thai - Giai on thai nghn, nu mc si th s a n hu qu : thai cht lu, sy thai hoc non nhng khng c tt bm sinh. Mt s bnh nh : hen, thn h, chm tm thi c th gim trong giai on b nhim trng si.

5.8.Suy dinh dng - Suy inh ng xut hin trong qu trnh bnh tin trin l o lng thc n a vo khng v cht v lng v tr chn n km theo ming b nhim trng nh cam tu m, hoi th hoc nhim nm Candida hoc Herpes. 6. Chn on gin bit 6.1.Si c - y l mt bnh nhim trng cp c y s ngi c m t ln u tin . Bnh th hin st cao , vim hch sau tai , nch v bn . Sau pht ban ton thn dng dt sn . Sau khi ban bay khng c li vt thm en , v khng c hin tng bong vy a . c bit khng c ht Koplick . 6.2.Nhim trng do vi rt rut - Biu hin st cao , i cu phn lng nhiu ln ; km theo pht ban ton thn dng xung huyt. Ban tn ti trong vng 2 3 ngy . Sau ban bay khng li vt thm en . 6.3.Nhim Adenovirus - St cao , c du hiu vim long . Pht ban ton thn dng xung huyt . Sau ban bay khng c bong vy da v khng c vt thm en . 7. iu tr 7.1.Chm sc - Tr b si cn nm ni thong mt - V sinh thn th , cn phi ch { 3 c quan : Mt - Mi - Ming . C ch inh ng y . i vi cng ng phi gio dc tm quan trng ca Chng Trnh Tim Chng M Rng . 7.2.Thuc - Vitamine A : iu tr trong 2 ngy : Tr > 1 tui cho ung 200.000 UI / ngy .Tr < 1 tui cho ung 100.000 UI / ngy . H st . iu tr triu chng . Khng sinh khi c bin chng .

Ti liu tham kho 1. Huznh Th Phng Lin ( 2000 ) " Nghin cu p ng khng th v s tn lu khng th si tr em t 9 thng n 15 tui ti Hi Phng " . Hi ngh tng kt chng trnh tim chng . Trang 41 - 43 . 2. Cao th Mai - Nguyn nh Sn ( 1996 ) " Nhn xt tnh hnh bnh si 1993 1995 ti Tha Thin - Hu " Tp ch v sinh phng dch 6 ( 2 ) . Trang 39 . 3. ng Th Hoi Tm ( 1997 ) " Bnh si " . Bnh truyn nhim , Trng i hc Y Dc thnh ph H Ch Minh . Trang 332 - 334 . 4. Huznh nh Chin ( 1998 ) " Tn thng o p ng min dch chng vi rt gy ra " . Min dch hc lm sng . NXB gio dc , trang 115 - 125 . 5. Maldonado Yvonne ( 2000 ) " Measles , viral infections " Nelson Textbook of Pediatrics . P. 946 - 951 . 6. Sperling Gisela ( 2001 ) " Measles , Infectious diseases " Hue Medical college Pediatric Department . P . 17 . 7. Le Popi ( 1999 ) " Vaccinations " . Maladies infectieuses . p. 264 - 269 .

S98. IU TR VIM MNG NO M


(PHC THAM KHO) I. CHN ON 1. Lm sng

St Li b Hi chng mng no
o

Tr nh:

Thp phng Nn nhiu

a chy Cng gy Co git

Tr ln: Tam chng mng no


au u Nn (nn vt, d nn) To bn

2. Xt nghim

DNT: mu c l nh nc da hoc nc vo go, p lc tng


o

Sinh ha:

Protein tng Glucose gim in gii bnh thng Pandy (+)

T bo:

Bch cu tng ( ch yu dng N)

Cy DNT: (+) , lm KS

II. IU TR 1. Chng nhim khun - Khng sinh ngay t u - La chn mt trong cc KS sau

Ceftriaxone: 100mg/kg/24h tim TM 1 hoc 2 ln Ampicilin: 100 - 200mg/kg/24h tim TM chia lm 3 ln

Choloramphenicol: 100mg/kg/24h tim TM chia lm 2 ln

- Sau 3-5 ngy iu tr khng th i KS theo KS. - Cho Dexamethazone 0,6mg/kg x 1 ln/ngy x 4 ngy nu tr n sm v cha dng khng sinh. Liu u tin ng trc khi cho bnh nhn dng khng sinh. 2. Chng tng p lc ni s (nu c) - Manitol 20%: 10-20ml/kg truyn trong 1h hoc 5-10ml/kg x 3 ln, cch nhau 8h, truyn trong 30 pht. 3. Khi c shock nhim khun. - Ringer Lactat - Depersolon hoc Methyl Prednisolon 4. iu tr triu chng - St: Paracetamol - Co git: Seduxen hoc Hypnovel hoc phenolbarbital (gardenal) 5. Dinh dng - n lng, chia nhiu ba - Nu hn m: n qua son e

S99. NHIM TRNG HUYT NO M CU

I. NH NGHA:

Nhim trng huyt no m cu l bnh nhim trng huyt do vi trng Nesseria Meningitidis gy ra, c hoc khng km vim mng no. Bnh c

th biu hin i bnh cnh ti cp gy sc nng v t l t vong rt cao, cn iu tr tch cc. Tui thng gp: 3- 6 tui II. CHN ON 1 Cng vic chn on: a) Hi bnh s - tin s:

St: thng khi pht t ngt vi st cao 39 - 40?C. T ban: thng xut hin ngy u hay ngy th 2 sau st.

b) Thm khm:

T ban: thng xut hin trong vng 1-2 ngy sau st. T ban mu thm hoc tm, kch thc t 1-2mm n vi cm, i khi c hoi t trung tm, b mt bng phng, khng g ln mt da. V tr c th phn b khp ngi nhng thng tp trung nhiu vng hng v 2 chi i. i khi t ban lan nhanh c dng nh hnh bn , hay c dng bng nc. Sc: cn pht hin sm x tr kp thi. Mch nhanh, nh hay khng bt c, huyt p kp hay khng o c. i khi sc xut hin sm v din tin rm r trong vng 12 gi u ca bnh (th ti cp). Du hiu khc:
o o o

Thay i tri gic: vt v, l , l m. Du mng no. Vim khp...

c) Cn lm sng:

Cng thc mu. Pht t ban: soi tm vi trng song cu Gram(-). Pht hng: khng c gi tr trong chn on nhim trng huyt, ch c gi tr trong pht hin ngi lnh mang trng.

Cy mu. Dch no ty: khi nghi ng c vim mng no km theo.

2. Chn on xc nh

St v mt trong 3 du hiu sau:


o o o

T ban in hnh: hnh bn , lan nhanh, c hoi t trung tm. Cy mu ng tnh: vi trng Nesseria Meningiti is. Pht t ban c song cu Gr (-)

3. Chn on c th:

Chm xut huyt dng t ban xut hin sm ngy 1, ngy 2 sau khi st, cng thc mu bch cu tng a s a nhn: nn iu tr khng sinh v cy mu trc khi iu tr khng sinh.

4. Chn on phn bit:

Nhim trng huyt do vi trng : do H. influenzea B, bnh cnh i khi rt ging, da vo cy mu. St xut huyt: chm xut huyt, gan to, Hct tng, tiu cu gim. Xut huyt gim tiu cu: chm xut huyt, xen k mng xut huyt, thng khng st, xt nghim tiu cu gim.

III. IU TR 1. Nguyn tc iu tr:


Khng sinh. iu tr sc (nu c).

2. X tr ban u: a) Chng sc:

Th Oxy m.

Dch truyn:
o

Dung dch Lactate Ringer 20 ml/kg/gi u nu mch huyt p n, sau uy tr 10ml/kg/gi trong nhng gi sau ty thuc vo tnh trng mch huyt p. Nu sau khi truyn 20 ml/Kg/gi u m mch huyt p khng n, cn thay bng dung dch i phn t (Gelatine); lng dch truyn tng t nh in gii.

Dopamine: nn s dng sm trong gi u b dch. Liu tng n t 3 - 5 7 - 10 g/kg/pht n khi huyt p n nh. Dobutamine: khi ng opamine liu ti a nhng huyt p cha n, liu tng t dopamine. o CVP sau khi b Gelatine 20 ml/Kg/gi m tnh trng mch, huyt p cha n: theo i iu chnh lng dch nhp. Hydrocortison: 10 -15 mg /kg/ 1liu dng mi 6 gi khi lm sng c sc hay e a sc (bnh khi pht cp tnh, mch nhanh, tr bt rt vt v) dng trong 2 - 3 ngy. Cn theo di bo m mch, huyt p n nh trong 48 gi.

3. X tr c hiu:

Pnicilline: 300.000 - 400.000 v/kg/ngy chia 4 ln tim mch (chia 6 ln nu c vim mng no), nu chn on ng tnh Cefotaxim 200 mg/kg/ngy chia 4 ln tim mch, hay Ceftriaxone 80 100mg/ Kg chia 2 ln nu chn on c th. Thi gian s dng khng sinh: 5-7 ngy nu chn on ng tnh, 10 ngy nu chn on c th.

4. Theo di:

Theo di st du hiu sinh tn: mch, huyt p, nhp th, lng nc tiu c bit trong 48 gi u ca iu tr. Sn sc vt t ban nga bi nhim. Khi c bi nhim i khi cn phi ct lc.

5. Phng nga:

Cho nhng ngi trong gia nh c tip xc vi tr bnh.


o

Rifampicine:

Ngi ln 600mg/ngy trong 2 -3 ngy. Tr em 20mg/Kg/ngy trong 2 -3 ngy, hay

Ciprofloxacine: 500mg ung mt liu duy nht.

- Vn : Corticoid c hiu qu trong nhim no m cu th vim mng no v suy thng thn cp. - Chng c: I Conn 2000 Mandell, Text book of Infectious disease 2000

CHNG 11. BNH L HUYT HC


S100. XUT HUYT GIM TIU CU T PHT
Ban xut huyt gim tiu cu t pht (ITP) l cc trng hp xut huyt gim tiu cu tin pht, khng r nguyn nhn, loi tr cc trng hp gim tiu cu th pht sau mt bnh r rng : 1. Chn on 1.1. Lm sng : Bnh xy ra t t, hoc nhanh, cp hoc mn tnh. Xut huyt :

+ Di da : Chm, nt, mng bm mu. + Nim mc : Chy mu mi, li, chn rng. + Ni tng : No, mng no, phi, tiu ho, tit niu, sinh dc (a kinh, rong kinh). + Thiu mu tng xng vi mc chy mu. + Gan, lch, hch khng to. 1.2. Cn lm sng : Mu chy ko di. S lng tiu cu i 100 x 109/l Tu bnh thng hoc tng mu tiu cu.

2. iu tr : 2.1. iu tr c hiu : + Trng hp cp : S lng tiu cu < 20 x 109/l

Solumedrol 5mg/kg/ngy trong 5 ngy Sau Pre nisolon 2mg/kg/ngy trong 2 tun Ri gim liu v ngng thuc sau 4 tun. S lng tiu cu > 20 x 109/l

Prednisolon 2mg/kg/ngy trong 3 tun. Ri gim liu v ngng thuc sau 4 tun. + Trng hp mn tnh : Gim tiu cu dai dng trn 6 thng S lng tiu cu < 50 x 109/l

Xut huyt nng :

Dng li mt t nh xut huyt gim tiu cu cp hoc Imumunoglobulin tim tnh mch 1g/kg/ngy truyn chm 8 12 gi trong 2 ngy. Sau kt hp dng cc thuc gim min dch khc nh : Azathioprin 2mg/kg/ngy trong 3 4 thng hoc Sandimum Neoral 2mg/kg/ngy trong 4 6 thng. + Xut huyt nh : Prednisolon 0,1mg/kg/ngy. Kt hp vi cc thuc min dch khc (azathioprin, Sandimum Neoral). S lng tiu cu > 50 x 109/l, khng xut huyt :

Khng dng thuc. Theo i nh kz. Hn ch hot ng mnh nh th dc th thao. + + + Ch nh ct lch : C nhiu t xut huyt nng e o tnh mng. Dng thuc khng p ng sau 6 thng. Tr trn 5 tui.

2.2. iu tr h tr : + + Cm mu ti ch : Chy mu mi : nh t gc hoc Gelaspon mi trc. R mu chn rng : p cht bng c tm A renalin vo ni chy mu. Truyn khi tiu cu :

Khi xut huyt nng :Tiu ho, thn, tit niu 1v/5 10kg cn nng. 2.3. Chm sc v theo di : Ngh ngi ti ging, hn ch vn ng. V sinh rng ming. Trnh n nhng thc n gy xc nim mc ming, li nh ma Theo di tnh trng xut huyt, mc mt mu. Hn khm nh kz.

S101. U LYMPHO KHNG HODGKIN


U lympho khng Hodgkin (ULKH) l cc khi u c tnh c ngun gc t h thng li bch huyt khng phi l bnh Hodgkin. 1. Chn on 1.1. Lm sng : Biu hin lm sng l triu chng u, thay i khc nhau tuz thuc vo v tr u tin pht v s lan to ca bnh. Khi u c th bng, trung tht, hch ngoi bin, vng tai mi hng v cc ni khc nh a, i a, xng, thn 1.2. Xt nghim chn on xc nh : Da vo kt qu m bnh hc v ho m min dch qua sinh thit hch hoc khi u. Da vo xt nghim ho m min dch phn ra ULKH t bo B, t bo T, khng B khng T. 1.3. Chn on giai on : Theo bnh vin tr em St. Jude

Giai on 1 : Ch c 1 khi u hoc 1 vng hch (ngoi tr trung tht v bng) Giai on 2 : Khi u v hch nhng vng cng 1 pha ca c honh 2 hay nhiu vng hch. 2 khi u + c/khng tn thng hch. Khi u u tin ng tiu ho, thng vng hi manh trng, c/khng c hch mc treo rut. Giai on 3 : Khi u v hch tn thng c 2 pha ca c honh 2 khi u ring bit 2 hay nhiu vng hch U tin pht trung tht, mng phi, tuyn c U bng nhng khng ct ht c U cnh ct sng Giai on 4 : C biu hin thm tu xng v h thn kinh trung ng

2. iu tr ulkh t bo b + Cch s dng cc thuc trong phc nh sau : Prednisolone : 60mg/m2 da, ung, 2 ln/ngy, ung lc no Vincristine : 1 2mg/m2 a, tim tnh mch chm trn 10 pht Doxorubicine : 60mg/m2, truyn tnh mch trn 1 gi

- Methotrexate : 3g/m2 da, truyn tnh mch trn 3 gi. Dch trc truyn Methotrexate 4 gi : 125ml/m2 da/gi vi 60mmol/l Natribicarbonate, 5mmol/l KCl. Dch sau truyn Methotrexate : 31/m2 da/24 gi. - Acid Folinic : 15mg/m2 a, tim tnh mch 6 gi/ln, bt u tim 24 gi sau truyn Methotrexate, tim trong 3 ngy.

Aracytine : 60mg/m2 da, truyn tnh mch trong 24 gi.

- Endoxan : 500mg/m2/ln chia 2 ln/ngy, truyn tnh mch trn 30 pht, kt hp vi truyn dch 31/m2/ngy. - Mesna : 250mg/m2 da, chia 2 ln trc mi ln En oxan. Sau , 500mg/m2 da/24 gi cng vi truyn dch sau truyn Endoxan. - Etoposide : 200mg/m2 da, truyn tnh mch trn 2 gi sau liu cao ca Aracytine. Thuc tim tu sng :

Methotrexate (MTX) <1 tui 1 tui 2 tui 3 tui 2.1. Nhm A : 8mg 10mg 12mg 15mg

Hydrerocortisol (HC) 8mg 10mg 12mg 15mg

Aracytine (Ar C)

16mg 20mg 24mg 30mg

Bnh nhn c iu tr theo nhm A khi : Khi u khu tr bng giai on I v II c ct b hon ton. Thi gian iu tr gm 2 t, mi t cch nhau 21 ngy. Thi gian iu tr nhm A ko di 5 tun. Thuc cho mi t : Ngy Prednisolone Vincristine 1 ** # 2 ** 3 ** 4 ** 5 ** 6 7

Endoxan Adriamycine 2.2. Nhm B

Bnh nhn c iu tr theo nhm B khi : c xc nh chn on l giai on I v II vi v tr u vng u v c ; Giai on III v IV nhng cha c thm nhim h thng thn kinh trung ng. * t 1 : COP Ngy Prdenisolone ngy 1 - 7 Vincristine 1,0mg/m2 (ngy 1) Endoxan 300mg/m2 (ngy 1) Tim tu sng MTX + HC (ngy 1) * t 2 : COPADM1 Ngy Ngy th 1 l ngy th 8 ca phc Prednisolone ngy 1 5 Vincristine 2mg/m2, ngy 1 Methotrexate ngy 1 Acid Folinic ngy 2 4 Endoxan ngy 2 4 Mesna 1 2 3 4 5 6 7 1 2 3 4 5 6 7

Adriamycine ngy 2 Tim tu sng MTX + HC (ngy 2, ngy 6)

Sau ngh 21 ngy, bt u ng t tip theo khi bch cu ht > 1000/mm3 v tiu cu > 100.000/mm3. * t 3 : COPADM2 Ngy th nht ca t 3 l ngy th 35 ca phc . Thuc v cch dng nh COPADM1 tr Endoxan liu tng gp i. Sau t 3 ngh 21 ngy. * t 4 : CYM1 Ngy Ngy th 63 ca phc Prednisolone ngy 1 5 Vincristine 1,5mg/m2, ngy 1 Methotrexate ngy 1 Acid Folinic Cytarabine ngy 2 6 Tim tu sng ngy 2 : MTX+HC ngy 7 : HC + Ar-C 1 2 3 4 5 6 7

C th kim tra chc nng gan, thn, chp CT, chp xng, bnh nhn s c phu thut ct ht khi u ln 2 nu phu thuth ln 1 cha ct ht trc khi bt u CYM2. * t 5 : CYM2 : Ngy th 1 ca t 5 l ngy th 91 ca phc .Thuc v cch ng nh CYM1.

* t 6 : COPADM3 : Ngy th 1 ca t 6 l ngy th 118 ca phc . Thuc v cch ng nh COPADM1. Sau khi hon thnh qu trnh iu tr, bnh nhn c th c kim tra chc nng gan, thn, tu xng. Thi gian iu tr nhm B ko di 18 tun. 2.3. Nhm C : Bnh nhn c iu tr theo nhm C khi c lymphoblast trong tu > 70% ; c thm nhim h thng thn kinh trung ng. * t 1 : COP : Thuc v cch ng nh t 1 ca nhm B, tr tim tu sng ngy 1, 3, 5 vi thuc : MTX + HC + Ar C. * t 2 : COPADM1 : Ngy th 1 ca t 2 l ngy th 8 ca phc . Thuc v cch ng nh COPADM1 ca nhm B tr Methotrexate liu 8gm2 da v tim tu sng ngy 1, 3, 5 vi thuc MTX + HC + Ar C. * t 3 : COPADM2 : Bt u t ngy th 35 ca phc . Thuc v cch ng nh COPADM1 ca nhm C. * t 4 : CYT/VP : Ngy th 1 ca t 4 l ngy th 63 ca phc . Ngy Ar-C 50mg/m2 ngy 1 5 Ar-C 3g/m2 ngy 1 4 Etoposide ngy 1 4 1 2 3 4 5 6 7

Truyn Ar-C 3g/m2 trn 3 gi, bt u v kt thc ca 12 gi truyn dch cng vi truyn Ar-C 50mg/m2. * t 5 : CYT/VP : Bt u t ngy th 91 ca phc . Thuc v cch ng nh t 4. * t 6 : COPADM3 : Bt u t ngy th 118 ca phc . Thuc v cch ng nh t 2. Sau t 6, bnh nhn c tia x vng s vi liu 18Gy. * t 7 : CYT/VP Ngy Ar-C 100mg/m2 , chia 2 ln, N1 5 Etoposide 150mg/m2, N2 - 4 Tim tu sng MTX + HC + Ar-C, N2 * t 8 : COPAD : Sau khi kt thc t 7 ba tun. Thuc v cch ng nh t 2 nhng khng c Methotrexate. * t 9 : CYT/VP : Thuc v cch ng nh t 7 Thi gian iu tr nhm C ko di 27 tun. 2.4. iu tr h tr : iu tr nhng tc dng ph ca ho cht - Nu bnh nhn gim sn tu nng, c th dng G-CSF (Neupogen) vi liu 5 microgam/kg/ngy cho n khi xt nghim cng thc mu ngoi bin mu tr v mc bnh thng. Chng lot ming : Thuc bi ming Zytee, Glycerine Borate 1 2 3 4 5 6

Chng nhim khun : Dng khng sinh Chng nn : Primperan tim tnh mch hoc t hu mn. Gim au Nu c duhiu ca c gan v thn : ngng iu tr ho cht

S102. THIU MU TAN MU T MIN


Thiu mu tan mu t min l thiu mu o c th t sinh ra khng th khng li trc tip vi khng nguyn hng cu. Bnh thng xy ra phi hp vi mt s bnh nhim khun nh vim gan, vim phi o vius, tng bch cu n nhn nhim khun, hoc trn c s b mt s bnh nh U lympho, Ho gkin, Lupus ban , hi chng suy gim min dch. 1. Chn on : 1.1. Lm sng : + Th cp : + t xy ra tr <1 nm Bnh t ngt Thiu mu Vng da, cng mc mt vng Lch to nhanh hoc khng to C th i Hb niu Th mn : Bnh k o i, cn tan mu tip tc, ti din nhiu thng, nhiu nm

Lch to.

1.2. Xt nghim : + Mu ngoi bin: - Hb gim - SLBC bnh thng hoc gim - SL tiu cu bnh thng (i khi gim, gp trong hi chng Evans). - Hng cu li tng + Bilirubin ton phn v gin tip tng + Nc tiu : urobilinogen ng tnh, Hb niu c th ng tnh nu tan mu trong mch. + Nghim php Coombs trc tip ng tnh, i khi nghim php Coombs gin tip cng ng tnh. Khng th t min phn ln thuc nhm IgG (85%), ngoi ra c th thuc nhm IgM, C3, o cn tin hnh nghim php Coombs n gi vi cc loi khng th trn. + Cn xt nghim Ure, Creatinin mu: c th bnh thng, hoc tng trong hi chng huyt tn - ure huyt cao, pht hin bin chng thn do tan mu trong mch. 2. iu tr : 2.1. iu tr c bn l quan trng : 2.2. iu tr c ch min dch : + Corticoid: Solu-medrol 5-10 mg/kg/24 gi trong 3-5 ngy. Sau ng tip Pre nisolon 2 mg/kg/ngy cho n khi triu chng tan mu ngng th gim liu v ngng thuc (thng thng khong 2-4 tun) + Trng hp corticoid khng kt qu c th cho: Azathioprin hoc Cyclophosphamid, Cyclosporin A.

2.3. iu tr h tr : + Truyn mu: hn ch truyn mu. Truyn khi Hb (50g/L) hoc khi c bin chng do thiu mu gy ra. Truyn khi hng cu: 10-15 ml/kg Trng hp khng nh c nhm mu do mu bnh nhn t ngng kt, ch nh truyn hng cu nhm O. + Trng hp tan mu cp c biu hin thn, Hb niu: - Truyn dch: Glucose 10%, Natri clorua 9%0 theo t l 3/ hay Ringer lactat 50-100 ml/kg/ngy. - Lasix 2 mg/kg/ngy: 2-3 ngy 2.4. Ct lch : ch nh khi + Bnh ko di mn tnh, xut hin nhiu t cp nng, + iu tr ni khoa khng kt qu + Lch to.

S103. THIU MU THIU ST


Thiu mu thiu st c c im l thiu mu nhc sc, st v Ferritin huyt thanh gim. Thiu mu thiu st rt ph bin v l thiu mu inh ng ch yu tr em. 1. Chn on : Chn on a vo lm sng v xt nghim huyt hc, sinh ha. 1.1.Lm sng :

Thiu mu xy ra t t, mc thng nh n va, t khi thiu mu nng, da xanh, nim mc nht ; mng tay v mng chn nht nht, c th c kha d gy. Km theo thiu mu c mt s biu hin:

Tr mt mi, t vn ng, chm pht trin, vi tr ln hc km tp trung. Chn n, vim teo gai li, km hp thu. Mch nhanh, tim to ra. Th nhanh.

1.2. Xt nghim : Hemoglobin gim. Hng cu nh, nhc sc : MCV < 80fl

MCH < 27pg MCHC < 300g/L RDW >17. St huyt thanh <9 mmol/L. Ferritin huyt thanh <12 ng/ml Ch s bo ha st <16% Porphyrin t do hng cu > 400mg/L

2. iu tr : 2.1.B xung st - Ung ch phm st, tt nht l sulfat st : 4-6 mg Fe/kg/ngy, trong 6-8 tun l.

Nu ng l thiu mu thiu st : Sau 5-10 ngy: Hng cu li tng, Hemoglobin tng 2,5-4,0 g/L/ ngy. Trn 10 ngy: Hemoglobin tng 1,0-1,5 g/ L ngy.

Tim trong trng hp khng th ung c, khng hp thu c Hb (bt) - Hb (bn) Lng Fe (mg) tim = ----------------------------- V (ml) 3,4 1,5. 100 Hb (bt) Hb (bn) V (ml) 3,4 1,5 : : : : : Hemoglobin bnh thng (12g/dL) Hemoglobin bnh nhn 80ml/kg. 1g Hb cn 3,4 mg Fe Thm 50% cho st d tr.

Thm vitamin C 50-100 mg / ngy d tng hp thu st.

2.2.Truyn mu, ch nh khi : Hb < 50g/L Cn nng nhanh lng Hb (cn phu thut, nhim khun nng). Suy tim do thiu mu nng.

2.3. iu tr bnh gy thiu st, nh : iu chnh ch inh ng. iu tr cc bnh mn tnh ng rut gy km hp thu st. iu tr cc nguyn nhn mt mu mn tnh.

2.4.T vn dinh dng, d phng thiu mu thiu st : B m hon ton 6 thng u sau sinh. B xung sa c b xung st nu khng c sa m. Thc n b xung c nhiu st v vitamin C ( t ng vt v thc vt) B sung st cho tr sinh thp cn : 2,0-2,5 kg 1,5-2,0 kg 1,0-1,5 kg < 1,0 kg : 1mg/kg/ngy : 2 mg/kg/ngy : 3mg/kg/ngy : 4mg/ kg/ngy.

Vi tr

S104. U TU
U tu l s pht trin bt thng ca cc t bo thn kinh khu tr trong tu, i mng cng ngoi tu hoc ngoi mng cng. U tu chim 10% trng hp u no. 1. chn on : 1.1. Chn on xc nh 1.1.1. Lm sng : Hi chng p tu : ri lon cm gic dn truyn dng au nhc, t b. Lit cng u th mt chn, i khi c ri lon c trn.

1.1.2. Cn lm sng : Dch no tu : Protein tng trn 1 g/l.

T bo bnh thng Chp cng hng t tu :

+ U i mng cng ngoi tu : cho bit v tr u, kch thc ca u, trn nh T1, T2 c cng tn hiu cng vi tu hoc gim cng T1, tng cng T2. + U mng tu : Pht hin r trn nh T1, cho tn hiu c cng cng so vi cu trc thn no. T2 u mng tu c cng tn hiu thp, nhn thy r trn nn ca tng cng tn hiu dch no tu. + U r thn kinh : nh T1 u c cng cng hoc tng cng tn hiu, u c ng vin r v cu trc thun nht. + U ni tu : Ra u li lm v khng thun nht, mt phng ct dc v ngang cho bit u ko di ti u so vi chiu di ca tu. 1.2. Chn on phn bit : Chn on phn bit vi vim tu (xem bng 1)

Bng 1. Phn bit vim tu v u tu

Bnh Khi u Triu chng

Vim tu t ngt St, nhim khun

U tu T t au, t b, i li kh khn

Din bin Ri lon cm gic

Lit mm sau chuyn sang lit cng. Mt cm gic i ni tn thng

Lit cng tng n

Bnh thng hoc tng ni tn thng gim i ni tn thng. ++ U ngoi hoc trong tu

Phn x t ng tu Cng hng t tu 2. iu tr

- hoc + vim

2.1. Phu thut thn kinh : Ct b u. Sau phu thut : iu tr khng sinh chng vim 7 ngy, gim ph n Dexamethasone 0,4mg/kg trong 7 ngy. 2.2. Phc hi chc nng vn ng : T vn Bc s khoa phc hi chc nng c k hoch tp vn ng.

CHNG 12. BNH L KHC


S105. VIM TAI GIA CP TR EM
BS.CK2. Cao Minh Thc

Vim tai gia cp (VTGC) lm bnh l thng gp tr em. Nu khng theo di v iu tr kp thi s nh hng rt ln cho b do cc tai bin v cc bin chng ca bnh l ny. VTGC l mt tnh trng vim cp tnh tai gia, c t bng

pht nhanh, ngn vi cc du hiu v triu chng ca tnh trng nhim trng tai gia, km du hiu c dch trong tai gia. Bnh thng gp tr em, tin trin trong vng 2-3 tun vi cc triu chng tiu biu ca 1 qu trnh vim cp. Ty theo nguyn nhn gy bnh, ty theo sc khng ca c th, tai gia c th b vim nhiu mc khc nhau: Vim tai gia xut tit Vim tai gia sung huyt Vim tai gia m

Trong vim tai gia cp tr em, vim tai gia tit dch ko di nu khng iu tr ng s gy cc di chng nng n trn tai gia v lm suy gim chc nng nghe. Vic iu tr vim tai gia tit dch bao gm cc phng php iu tr khc nhau nh: iu tri ni khoa

iu tr phu thut: trong vai tr ca ng thng nh trong iu tr vim tai gia vn cn rt cn thit Vim tai gia cp thng xy ra ch yu tr em, thng gp tr t 1 -> 6 tui. Cc yu t lin quan n vim tai gia cp gm: gii (Nam, N), t b sa m lc nh nhi, i hc nh tr ng c, ma thu v ng, ng nm v gi, tip xc cc cht nhim ( khi thuc l). VTGC thng xy ra nhng thng ma ng v ma thu hn ma h. Tip xc trc vi vi khun hay do chng nga c th c ch vi khun -> gy bnh vm mi hng. Nguyn nhn gy bnh: Yu t thng gp nht l nhim trng ng h hp trn / hoc ri lon chc nng vi nh.

Nhim siu vi vm mi hng dn n vim, ph n vi nh, nhim siu vi nh l mt tc nhn gy bnh tai gia Vi khun thng gp: Steptococcus, Pneumomiae, Heamophilus influenza . tr s sinh thng gp nht l vi khun gram m: Escheria coli, enterrococci. Triu chng: Thay i ty theo la tui ca tr: tr s sinh biu hin khng r rng, c khi ch l kch thch, quy khc, c khi b b. Tr ln hn th b st c km theo hoc khng km theo vi vim h hp trn, au tai nn b thng hay ko tai hay di tai, thng than phin c cm gic y tai, thng xut hin trc khi pht hin c dch trong tai gia. Ngoi ra cn c cc triu chng khc t gp hn: tai, chng mt, mt thng bng, bun nn, nn, tiu chy. Nghe km: l triu trng quan trong i vi VTG thanh dch, pht hin nghe km tr em khng phi d, ty thuc tui v hon cnh gia nh. Trong giai on u mng nh vim , sung huyt, mt trong sut. iu tr khng kp thi v ng phng php s dn ti chy m (thng nh). iu tr: Vic dng thuc nh tai dng thuc t gim au ti ch thng c ch nh khi bnh nhi au nhiu v vi iu kin bnh nhn cha thng nh (cha chy dch tai). Khi c du hiu chy dch tai, ngi nh nn a b n cc c s y t c chuyn khoa TMH BS hng dn sn sc + lm sch Tai. Khi tr c biu hin st, ho, chy mi, au hng,. Ngi nh nn a n c s y t khm bnh nga bin chng Tai.

S106. S DNG THUC TRONG NHI KHOA


BS. Nguyn Vn Thanh

I - I CNG:

- Tr em l mt c th ang ln v pht trin, s dng thuc cho tr em cn phi hiu r tnh cht c l ca thuc v c im c th ca tr. II - CC PHNG PHP IU TR BNG THUC: 1/ iu tr c hiu: l dng thuc c hiu vi nguyn nhn 2/ iu tr theo kinh nghim: 3/ iu tr th: nhm nh hng chn on. 4/ iu tr triu chng: 5/ iu tr v: iu tr tm l

III - MT S C IM CA TR LIN QUAN TI DNG THUC:

1/ Tr em l mt c th ang ln v pht trin, cn nm r c im sinh l, gii phu v tnh trng bnh l ca tr. 2/ Chc nng gan, thn ca tr cha hon thin-> Kh nng chuyn ha, tch

ly, o thi km-> d ng c thuc. 3/ S cnh tranh trong vic gn Protein: - Thuc vo c th c gn vi Protein vn chuyn n ni tc ng. - tr em kh nng gn thuc vi protein cn km v c s cnh tranh gia cc thuc ng thi cnh tranh vi Bilirubin t do -> mt s thuc khng gn c vi Protein-> d gy ng c thuc v tng Bilirubin t do trong mu -> vng da. Thuc + Protein ( Albumin) --------> V ni c tc ng ........................................Gluconyltranferaza Bilirubin t do + Albumin -----------------------> Bilirubin-Al ---.............................................-Gan----------------------------Bilirubin-Al + Protein Y,Z ------- ------> Bilirubin trc tip ( Tr s sinh HC nhiu, sau my ngy HC v tr v bnh thng-> Bilirubin t o tng cao-> H/C vng da nhn tr s sinh. Nu ta s dng thuc cp mt Albumin -> Bilirubin t o cng tng cao-> cng d dn ti H/C vng da nhn) 4/ c im chuyn ha thuc v s phn b nc trong c th : tr em lng nc ton phn v s phn b nc trong v ngoi t bo thay i theo la tui, o s phn b khi lng thuc cng rt khc nhau tng la tui. 5/ c im thn kinh trung ng v hng ro mu no: No ca tr em c nhiu nc, nhiu mch mu v chc nng h thn kinh cha hon chnh nn d c tnh trng phn ng thuc. 6/ Mt s thuc c th qua rau thai v qua sa m.

IV - NG DNG V C IM CC NG DN THUC VO C TH TR.

1/ ng ung: *y l ng thng dng v hp l nht i vi tr em v: - Tin li, khng gy au cho tr - D thc hin - Kh nng hp thu thuc d dy tr em cao hn ngi ln v h thng vi nhung mao dy c, rut tr em di . - pH d dy ca tr em kim tnh hn ngi ln nn tr dng mt s thuc t bi xut huyt v chu c liu hn ngi ln *Mt s men ph hy cha hnh thnh( nh men ph hy Streptomycin) nn khi s dng thuc cn lu : - Cc thuc nn s dng i dng lng, xir, nc thm, ngt - S lng khng qu nhiu cc thuc kh ung, nn chia lm nhiu ln ung. - Nn nghin nh thuc c bit tr i 5 tui - Khi tr nn nhiu khng nn dng thuc trnh sc vo phi.nn chuyn sang ng tim. - Khng dng cn, ru pha thuc.

2/ ng tim: - Tim TM theo gi s tp trung c nng thuc cao nht. - Tim bp v i da: ch dng trong nhng trng hp bt buc Khi tim bp nn tim 1/4 trn ngoi mng.

3/ Qua ty sng: Dng bm khng sing khi tr b vim mng no. Bm ha cht trong bnh BC cp. V - CCH TNH LIU LNG THUC CHO TR EM: 1/ Theo kinh nghim: - Tr s sinh ng liu = 1/8 liu ngi ln - Tr i 6 thng dng liu = 1/5 liu ngi ln. - Tr 1 tui dng liu = 1/4 liu ngi ln.

- Tr 3-4 tui dng liu = 1/3 liu ngi ln - Tr 7 tui dng liu =1/2 liu ngi ln. - Tr 12 tui dng liu = 2/3 liu ngi ln. - Tr = 15 tui dng liu = liu ngi ln. Hoc tnh theo cng thc: ...............................................Tui tr em( nm) Liu tr em= Liu ngi ln x ------------------------...............................................Tui ( nm) + 12 ................................Tui tr em x 20 Liu tr em= 4 x--------------------------------- x liu ngi ln ......................................100 2/ Theo cn nng: V d: Ngi ln dng 1mg/kg cn nng th: - Tr < 1 tui l 2 mg/kg - Tr 1- 4 tui l 1,75mg/kg - Tr 4-7 tui l 1,5 mg/kg - Tr 7-15 tui l 1,25mg/kg - Tr >15 tui l 1 mg/kg

3/ Theo din tch da: ................................Din tch da tr em(m) x liu ngi ln Liu lng thuc = ---------------------------------------------------.................................................. .....1,73 m *Bng i chiu din tch da ca c th : cn nng(kg); Din tch da(m): P(kg).......3,5........7........12.....19......30......40......50 S(m).......0,25......0,35...0,5....0,75....1.......1,25....1,5 5/ Mt s liu lng cn lu : 1 gr nc ct = XX git 1 gr cn = LV git

1 gr du = Lgit 1 Tha c f = 5gr nc = 5ml 1 Tha c f = 4,5gr du 1 Tha c f = 20gr xi r 1 Tha sp = 15gr nc = 15ml

6/ Nguyn tc s dng thuc cho tr: - Nu thuc cng tc dng th nn chn thuc t c hn. - Hai thuc cng tc dng , cng c tnh th nn chn loi r tin - Khng phi hp nhiu loi khng sinh cng lc( tr KS chng lao) - Thn trng dng thuc khi cha c chn on r rng.

VI - MT S THUC KHNG DNG CHO TR S SINH V TR DI 1 TUI.

- Acid boric-> gy a chy, try mch, co git, v niu. - Bismuth -> Gy MetHemoglobin mu - Chloramphenicol gy hi chng xm - Cocain gy st, co git, m sng - Coramin gy co git. - Gardenal chuyn ha rt chm tr em - Lobelin gy suy h hp th pht - Mentol gy ngt - Morphin gy suy h hp - Polimycin B c vi gan v t bo thn kinh tr s sinh - Rifammyxin c vi gan v t bo thn kinh tr em.

VII - MT S THUC THNG DNG THNG DNG CHO TR:

1/ Khng sinh: *Beta- Lactam: + Pennicilin G: 500.000-2 triu UI/kg/24h ung 200.000-500.000 UI/kg/24h tim IM.IV + Ampicilin: 50-100mg/kg/24h ung, IM,IV + Methixillin: 200-300mg/kg/24h( pha Bicarbonat natri) tim IV (iu tr vim phi t cu ) + Oxaxilin: 25-50mg/kg/24h ung. + Cephalosporin: - TH1: Cephalothin, Cephazolin, Cephaloridin, Cephalexin : 30-50mg/kg/24h ung C tc dng T cu c sinh men penixillinaza, Gram(-)gm: E coli, Klebsiella, Enterobacteria, t tc dng vi Hemophilusinfluenza - TH2:Cephamandole, Cefaclor, Cefuroxime, Ceforanide, Cefotiam - TH3:Cefotaxime, Ceftriaxome, Cytazindime, Ceftrizoxime *Amynoglycozid(AG): + Gentamycin : 3-5mg/kg/24h Tim IM,IV( nh hng thnh lc) + Kanamycin 15mg/kg/24h Tim IM,IV + Neomycin : 100mg /kg/24h ung *Phenicol: - Chloramphenicol: 30-50mg/kg/24h ung hoc tim TM(c ch ty xng) *Macrolid: - Erythromycin : 30-50mg/kg/24h ung

*Quinolon - Acid nalidixic( negram, nelidix): 40-50mg/kg/24h ung *Khng sinh a Peptid: - Polymycin B: 10-20mg/kg/24h ung, 5mg/kg tim IM ( khng hp thu qua ng tiu ha , ch ung khi NK tiu ha) *Khng sinh chng lao: - Ethambutol : 10-15mg/kg/24h ung - Isoniazit: 5-10mg/kg/24h *Sulfamid: - Biseptol 0,48g( Vin 80mg Trimethoprim v 400mg Sulfamethoxazol): 3050mg/kg/24h ung - Colistin 15mg/kg/24h ung; 10mg/kg/24h tim bp - Rulid: 5-7mg//kg/24h ung 2/ Thuc tc dng trn thn kinh trung ng: - Phenobacbital (Gardenal): 4-10mg/kg/24h, Tim IM,IV( liu ng, chng co git) + 15-30mg/kg/24h liu iu tr ng kinh - Diazepam( Valium, Seduxen): 0,2-0,8mg/kg/24 ung, IM,IV - Aminazin: Vin, ng 25mg, liu 1-2mg/kg/24h ung, tim bp su. - Carbamazepin (Tegretol): vin 200mg, liu 20mg/kh/24h ung - Sodanton: 10mg/kg/24h ung - Depakin: 10-20mg/kg/24h ung - Elavil : 25mg x 1-2 v/24h x 2 thng, ung ti cha i m tr > 4 tui.

3/ Thuc h nhit: *Nhm Salixilat( aspirin, aspegic): 50-100mg/kg/24h *Nhm c cha Paracetamol: + Paracetamol: 10-20mg/kg/ln ( Efferagan, dafalgan, algotropyl) + Analgin : 10mg/kg/24h

4/ Thuc tr tim: - Uabain: 0,01mg/kg/ln, tim IV - Coramin 20%: 0,1mg/kg/ln, tim IM ( 15mg/kg/24h) - Dopamin: 2-6mg/kg/p Tim TM chm - Digoxin: < 2 tui: 0,02-0,04 mg/kg/24h -> ung, tim bp hoc > 2 tui: 0,01-0,015mg/kh/24h -> tim i da - Isupren: 0,1-0,5mg/ln, tim i da

5/ Thuc h HA: *Thuc c ch giao cm T: + Aldomet vin250mg : 5-10mg/kg/24h ung hoc t i li + Reserpin vin0,25mg: 0,03mg/kg/24h ung *Thuc c ch beta: + Propranolol: vin40mg : 1-3mg/kg/24h, ung *Thuc c ch Canxi: + Nifedipin: ( tc dng trung bnh) vin nang 5-10-20 mg Liu: 0,5/kg/24h hay 5mg/ln + Adalat gen:( tc dng nhanh,mnh) vin nang 10-20 mg + Adalat LA: ( tc dng ko di) vin gii phng chm 30-60-90mg

6/ Thuc li tiu: - Furosemid( lasix, laisilix): 0,5-1mg/kg/24h ung , IM,IV - Hydroclorothiazid( Hypothiazid): 1mg/kg/24h - Spironolacton( Aldacton): 2-3mg/kg/ln ung

7/ Thuc gin ph qun: *Nhm Metylxanthin khng dng cho tr < 5 tui: + Theophylin vin 0,1g: 5-10mg/kg/24h ung + Syntophylin ng 0,24g + Aminophylin ng 0,48g

->Pha dich truyn TM *Nhm kch thch giao cm( kch thch th cm th ): + Salputamol vin 2mg( Ventolin- Anh): dng xi r 5ml=2mg Liu 0,2mg/kg tim i da, ung, kh dung + Terbutalin sulfat( bicanyl- Thy in), kch thch Adrenergic vin 2,5mg, 5mg: 0,02mg/kg/ln ung, kh ung, tim i da + Adrenalin, Epinnephrin: cng Adrenergic: ng 1ml=1mg Adrenalin 1% dng liu 0,03 -0,05 mg/kg tim i da

8/ Thuc ty giun: *Piperazin: 0,3g/ tui + Giun a x 3 ngy; + Giun kim x 5 ngy *Decaris( levamisol): vin 50mg, 100mg, 150mg + < 10mg : 25mg + < 20mg : 50mg + < 30mg : 75mg + < 40mg : 100mg ->Ty 1 ln *Helmintox : vin 125mg, 250mg: 10kg/125mg( ty 1 ln)

S107. CHNG TRNH TIM CHNG M RNG


I. Tng quan v vaccine: Chng ai thch chch c! Chch gy au, v thm ch c ngi ln ri m mi khi thy nhn vin y t cm ng chch n l khc a ln. Tuy nhin, c bnh & phng bnh mi cn n chch (k c nhng ngi nghin cht kch thch). Bi vit ny cp n cc mi tim chng phng bnh (vaccine). Vaccine l

mt loi thuc c ng phng bnh (khng phi cha bnh). Vaccine l dung dch c bo ch mt cch nghim ngt v chnh xc a vo c th. Vaccine c tc dng ngn nga bnh tt tng ng cho c th trong sut qung i cn li hoc mt khi bnh dch c th xy ra. Khi tr c sanh ra, tr c tha hng mt s cht min dch t m (trong thi gian trong t cung) c th chng chi li vi mt s bnh tt. K tip, lng min dch tip tc c cung cp cho tr trong thi gian b m (min dch t m truyn qua sa m cho con). C hai trng hp ny u l nhng min dch tm thi v s cn dn khi tr khng cn b m na- l mt l do v tm quan trng ca vic nui con bng sa m. Song song vi khong thi gian , h min dch t thn ca tr bt u hot ng & pht trin. Ch ng min dch (tim chng vaccine) l cch to min dch nhn to cho mt s bnh l{ c bit nguy him hoc cha c thuc iu tr c hiu. Bng cch a vo c th cc tc nhn gy bnh (hoc cc mm bnh lm yu lit hoc lm cht i, hoc cc tc nhn c cu trc tng t vi mm bnh), mi tim vaccine to mt tnh trng nhim bnh gi to kch thch c th tp t v hnh thnh cc kiu nh trn c th c nhiu kinh nghim hn. Qu trnh tp t ny lm cho c th nhn bit trc hnh dng & bn cht ca cc yu t gy bnh. T , c th sn xut ra cc khng th d phng trc sau ny cn ng n khi c th tht s nhim mm bnh tng t. Mt s bc cha m c th ngi ngng khng cho tr i tim chng vaccine v h cho rng bnh kh c th xy ra cho tr hoc tr c th b nhim bnh do chnh vaccine gy ra. Mc d thc t cho thy c mt vi biu hin ging nh bnh tht xy ra sau khi tim vaccine, song cc triu chng rt nh & khng phi l bnh tht s. Ngc li, vic khng tim chng c th dn n bnh tht, vi cc triu chng tht, tn tin tht & c th mt mng tht. II. Tim chng- mt ni dung chnh ca cng tc phng bnh cng ng:

Tim chng l rt cn thit v l mt ni dung chnh trong cng tc phng bnh cng ng. Nh Bn cng bit, mt s bnh vn cha c phng php iu tr trit hoc chi ph khi iu tr cao hn rt nhiu khi bnh khi pht hoc bnh gy ra qu nhiu phin toi & cc bin chng nguy him e a n tnh mng hoc ch t li nhng hu qu khng mong mun. Do vy, phng bnh bng cch tim chng c xem l phng php khn ngoan, kinh t & hiu qu. Mt khi c th c kh nng phng c mt bnh no , khi y c gi l c th c min dch v bnh l{ c phng kh c c hi gy bnh c th Bn. iu ny c ngha l khng hn 100% s ngi c min dch u khng b bnh. Tuy nhin, ch c mt s nh vn mc bnh & tnh trng bnh s khng trm trng nh trong trng hp khng c tim chng trc. Hin nay, c 4 dng vaccine khc nhau ang c lu hnh: - Loi vaccine cha cc virus c lm yu i trc khi a vo c th, v d MMR - Loi vaccine cha xc virus, v d IPV - Vaccine cha cc c t ca vi khun, v d vaccine phng bch hu & un vn - Vaccine cha cc cht sinh hc tng hp, v d nh HiB cha cc phn t lin kt tng hp ging nh vi khun Haemophilus influenza nhm B nhm nh la c th sn xut ra khng th chng li cc vi khun tht tn cng sau ny. III. Thi gian tim chng vaccine & thi gian hiu qu phng bnh: Nhng khuyn co v thi gian tim chng cho tng loi vaccine l khc nhau. Tuy nhin, cc vaccine c tim chng theo lch nh sn, bt u khi tr c 2 thng tui cho n khi tr c 6 tui. Hu ht cc mi tim chng u c chch vo c th trc khi Bn c 2 tui. Mt s vaccine c th phng bnh c i sau mt hoc mt chui mi tim theo lch, mt s loi khc ch c thi gian bo v c th theo tng nm (v nh vaccine phng cm chng hn). Mt s mi tim chng thc hin tr hn hoc khi tai nn xy ra mi tim chng (v d nh tim chng tetanus- phong n gnh- khi

tr c 12 tui hoc ngay sau khi b chn thng rch da bi cc vt bn). Cc mi tim chng thng c chch vo bp tay, ni gn vi khp vai, thnh thong thy tim bp i. Vic tim chng c th gy ra mt vi triu chng khng mong mun. Tuy nhin cc triu chng ny vn nh hn nhiu so vi cc triu chng tht ca bnh. Cc triu chng thng thy sau khi tim chng nh au ti ch chch, au u, st nh, bun nn, ... Tuy nhin, rt him thy bo co cc trng hp tai bin nghim trng sau khi tim chng. IV. Cc tc dng ngoi ca vaccine: Vaccine, cng nh tt c cc loi thuc khc, u c th gy ra cc phn ng qu mn nghim trng (sc do d ng vi thuc). Nhn chung, tim chng vaccine tng i an ton. Sau khi tim chng vaccine, thng thy xut hin cc triu chng au & sng vng chch, c th km theo st nh, hi u u hoc cm gic bun nn. Tuy nhin cc triu chng ny s bin mt sau vi ngy thm ch khng cn iu tr g. C mt s trng hp tuyt i khng c tim chng hoc phi rt thn trng khi tim chng. V d nh ngi b d ng vi trng th khng nn tim nga cm. L{ o l virus cm tim vo c th c nui ng trong lng trng g v gy ra sc cho ngi c tim chng. Ni chung, nu ngi no b d ng vi bt kz thnh phn no ca liu tim chng u phi bo trc cho BS trc khi quyt nh mi tim. Trong thi gian sau khi tim chng, nu c th tr phn ng qu mc vi bt kz mi tim no trc th khng nn cho tr tim chng tip mi tip theo (cng loi). ng ngn ngi cht vn BS ca Bn nu nh cn bt kz thc mc no. V. Theo di & x tr sau khi tim chng: Sau khi tr c tim chng, Bn nn theo di tr trong vng vi gi tip theo xem c nhng phn ng bt thng no nh st cao hoc cc triu chng ca d ng. Cc biu hin khc i y c cho l cc tnh trng phn ng mnh ca

c th i vi mi tim chch: - Kh th - Th kh kh, nghe nh ting so hoc ting th bnh nhn khi ang trong cn hen suyn - Pht ban - Nht nht, xanh xao - Yu mt, l - Tim p nhanh - Hoa mt, chong vng - Sng ty c hng VI. Lch tim chng

Vaccine DTaP phng 3 bnh Bch Hu- Un Vn- Ho G: DTaP (Diptheria- Tetanus & Pertussis) gi l vaccine Bch hu- un vn- ho g. Mi vaccine ny phng cho tr c 3 bnh l{ nu cng mt lc (vaccine 3 trong 1). V c chch lin tc 5 mi theo cc khong thi gian: mi th nht khi tr c 2 thng, mi th 2 khi tr c 4 thng, mi th 3 khi tr c 6 thng, mi th 4 khi tr c 15-18 thng & mi cui cng khi tr c 4-6 tui. Bch hu l mt bnh l tn cng vo vng hu hng & tim c th dn n suy tim & t vong. Un vn cn gi l bnh cng hm, dn n tnh trng co git c nghim trng & t vong. Ho g l tnh trng ho nghim trng n ni khng th th, n, ung g c- ho g c th dn n vim phi, co git, tn thng no & thm ch t vong. Cc mi DTaP c th phng bnh c trong vng 10 nm sau . Tuy nhin, khi tr c 10-11 tui, Bn nn cho tr tim nhc li mt mi na c th c min dch sut i. Cc bin chng nh thng thy do tim vaccine ny l kch thch ngay ti vng da chch, st nh, hi cu gt, b n. Mt s bin php l gim cc triu chng ny l cho b ung cc thuc gim au hoc chm m ti vng da chch. Cc tc dng ph nghim trng rt him gp. Tuy nhin, cc trng hp nu i y cn thit phi tr hon hoc ngng hn cc mi tim chch k tip: * Tr ang c mt bnh l{ khc, cho l nhng triu chng n gin nht ca mt t cm lnh * Tr b co git m khng th kim sot c bng thuc * Tr phn ng qu mc vi mi tim trc Du hiu tr b phn ng vi vaccine: * Tr ln cn co git trong vng 3-7 ngy sau khi tim chng * Cc cn co git trc tr nng & xut hin nhiu hn sau khi tim chng * Cc biu hin d ng nh sng mt, mi & vng hng * Kh th * St cao trn 40 C sut 2 ngy sau khi tim chng hoc khng bt mc

thc hin nhiu bin php h st. Tnh trng st ny cng l nguyn o bc pht cc cn co git (st cao co git) * L , yu mt sut hai ngy sau tom chng * Khc nhiu, lin tc, d khng nn trong st 3 gi ng h bt kz trong khong 2 ngy sau tim chng

Vaccine IPV phng bnh bi lit: Vaccine phng bi lit (IPV- Inactivated Polio Virus) c chc nng phng bi lit do Virus Polio gy ra tnh trng yu lit c mt hoc hai chn, tay. Virus ny cng gy ra yu lit cc c h hp & c nut dn n t vong. Hiu qu phng bnh hiu qu n 90%. Vaccine ny cn c tim 4 mi cho tr theo cc mc thi gian sau: mi th nht khi tr c 2 thng tui, mi th 2 khi tr c 6 thng tui, mi th 3 khi tr c 6-18 thng tui & mi cui cng khi tr c 4-6 tui. Lu {, khng nn tim chng vaccine ny khi tr c cc biu hin d ng vi cc thuc nh neomycin, streptomycin hoc polymyxin B. Khng tim chng cc mi k tip khi tr c phn ng qu mnh vi mi tim u tin, trc . Ngoi cc biu hin ca cc kch thch vng da b tim chch, vaccine phng bi lit hu nh rt an ton & chc chn n khng gy ra ... bi lit cho tr do IPV. Trng hp sau khi tim chch, tr b cc biu hin nh kh th hoc e a sc (l , yu mt, lnh run, v m hi ht), gi ngay cp cu hoc nhanh chng a tr n trung tm y t gn nht v cung cp y cho BS cc thng tin lin quan n mi tim & cc bnh l sn c khc. Vaccine MMR (Measles, Mumps & Rubella) phng Si- Quai b & Rubella: Si gy ra st, mn nga trn da (pht ban), ho, chy mi & chy nc mt.

Si c th dn n nhim trng tai, vim phi & cc bin chng nghim trng nh ph no & thm ch t vong. Quai b gy ra st, au u & sng + au mt hoc c hai bn tuyn nc bt. Quai b c th dn n vim mng no v ph no (him). Bin chng him thy khc l sng ph tinh hon c th dn n v sinh khi tr trai ln ln. Rubella cn c gi l bnh si c. Bnh c biu hin st nh, pht ban & sng ph cc tuyn vng c. Si c c th dn n tai bin ph no & cc bin chng xut huyt ni. D tt bm sinh thng thy khi m ang mang thai b mc si c l gy cho tr b m hoc ic hoc cc bin chng gy tr tr vic hc tp v sau. Vaccine ny c tim chng 2 mi, mi u tin tim khi tr c 12-15 thng, mi th hai khi tr c 4-6 tui. Vaccine MMR hiu qu hn 90% & c th phng cc bnh ny sut i. Cc tai bin him thy sau khi tim MMR ngoi tr cc phn ng nh nh sau khi tim chng cc vaccine khc. Tuy nhin, nu tr lt vo cc trng hp trnh by bn i th Bn nn tr hon hoc khng nn tim hoc theo tip tc cc mi k tip: *Tr ang c mt bnh l{ khc i km cho l nhng triu chng ca mt t cm lnh thng thng *Tr b d ng qu mc vi mi tim u tin *Tr c tin cn ng vi trng, cht gelatin hoc khng sinh neomycin * Trong khong thi gian 3 thng tr ang iu tr vi cht gamma globulin *Tr b suy gim min dch do bt kz nguyn do no Mt s BS hc nghi ng mi vaccine MMR gy ra chng t k m th (mt dng bnh l tm thn). Tuy nhin, cng c nhng nghin cu khng nh khng c mi lin quan gia MMR & bnh t k m th.

Vaccin HiB phng nhim Haemophilus influenza nhm B: Vcxin Hib gip phng chng Haemophilus influenza nhm B, c th gy ra cc bnh nguy him tr nh vim mng no, vim phi v vim hng nghim trng, c th dn n nght ng th. HiB cn c tim chng 4 mi: mi th nht vo khi tr c 2 thng, mi th hai vo thng th 4, mi th 3 vo thng th 6 & mi cui cng lc tr c 12-15 thng tui Hiu qu phng bnh hn 90% tr nhn t nht 3 mi tim, vaccine ny phng c cc bnh nh vim mng no, vim phi, vim mng ngoi tim & cc nhim trng mu, xng, khp gy ra do vi khun Haemophilus influenza nhm B. Chm sc & theo i tr sau tim chch ging nh khi tr tim cc vaccine khc.

Vaccine HBV phng bnh vim gan siu vi B: HBV (hepatitis B virus) l virus gy ra bnh vim gan siu vi B, bnh ny c th dn n ung th gan v t vong. Vaccine phng vim gan siu vi B c tim 3 mi. C th ho chung HBV & HiB tim mt ln cho tr. Mi th nht sau sanh, trc khi tr c cho v nh; trong trng hp nu nh m c nhim virus HBV, mi ny phi c chch cho tr trong vng 12 ting u sau khi b cho i. Mi th hai c chch vo thng th 1 hoc thng th 2. Mi th 3 vo thng th 6. Trong trng hp v mt l{ o no m mi th nht ch c chch khi tr c 1-2 thng th mi th 2 c chch khi tr c 3-4 thng & mi th 3 c chch trong khong thi gian tr c 6-18 thng. Vaccine ny c tc dng ngn nga bnh vim gan siu vi B gy ra do virus Hepatitis nhm B (HBV). Bnh l ny c th ko di trong nhiu nm v gy ra cc bin chng nguy him n tnh mng nh ung th gan hoc x gan. Vaccine phng vim gan siu vi B ng nh c tc ng min dch c i (trong trng hp tim chng ng). Tr ln nu cha tim chng khi cn b cng nn

c chng vaccine ny. Cc tc dng ngoi mong mun do tim vaccine HBV rt him xy ra. Mt s phin toi nh nh st nh & b kch thch vng da quanh vt chch. Bn c th s dng mt s loi thuc gim au nh acetaminophen hoc ibuprofen cho tr. Tuyt i khng cho tr s dng Aspirin. Mt s trng hp cn phi tr hon hoc khng nn tim vaccine ny tip tc, nh: * Tr ang c mt bnh l{ khc i km cho l nhng triu chng ca mt t cm lnh thng thng * Tr b d ng qu mc vi mi tim u tin

L do nn tim chng vaccine ny: Vaccine Pneumococcal Conjugate (PCV) bo v c th trc s tn cng ca vi khun lin ph cu gy ra cc bnh nguy him nh vim mng no & nhim trng mu. Bnh thng khi pht bng cc nhim trng tai. Vaccine c tim 4 mi cho tr con. Vaccine cng c tim chng cho tr ln c nhng du hiu nguy c n n vim mng no & nhim trng mu. Ph cu khun l nguyn nhn chnh gy ra cc nhim khun cho mng no. M, s liu nhim khun lin quan n ph cu khun tr i 5 tui mi nm nh sau: *C hn 700 trng hp b vim mng no. *Khong 17,000 trng hp b nhim trng mu *Khong 5 triu trng hp b nhim trng tai. Tr i 2 tui c nguy c rt cao b nhim ph cu khun. Ph cu khun l th phm gy ra gn 200 ci cht cho tr i 5 tui mi nm ti M.

Vaccine phng ph cu khun c hiu qu cao trong vic phng cc chng bnh nguy him nu trn. V vaccine c cng dng trong 3 nm v v t l xy ra nhiu nht tr i 2 tui nn mi vaccine ny thng c tim khi tr c 1 tui. Mc d vaccine ch c cng hiu trong 3 nm nhng cc nghin cu cho thy c gim t l mc cc bnh do ph cu ngi ln khi c c tim chng t lc nh. V ph cu khun ly lan trc tip t ngi sang ngi & ph cu khun l vi khun c tnh khng thuc rt cao nn rt kh kim sot c bnh tnh mt khi chng xy ra. Vic phng bnh c cho l khn ngoan, hiu qu & kinh t hn rt nhiu so vi nhng hu qu ca bnh. Nhng ai nn tim chng vaccine PCV: C hai nhm c khuyn co nn tim chng ph cu khun: Nhm 1: bao gm cc tr i 2 tui nn c tim 4 mi phng ph cu khun theo lch trnh bn i: *Mi u tin khi tr c 2 thng tui *Mi th hai khi tr c 4 thng tui *Mi th ba khi tr c 6 thng tui *Mi cui cng khi tr c 12-15 thng tui Tr khng c tim mi u tin khi c 2 thng tui cn tip tc theo ui cc mi cn li. Trao i vi BS hiu r hn! Nhm 2: bao gm cc tr t 2-5 tui khi c km theo cc bnh l{ bn i *Bnh t bo hng cu hnh lim *C tn thng l lch hoc khng c l lch (do bm sinh hoc b phu thut ct b)

*B nhim HIV/AIDS *C cc bnh l lm suy yu h thng min dch (v d nh ung th, tiu ng) *Mt s loi thuc nh ha tr liu ung th hoc steroids gy ra suy yu h min dch Vaccine ny cng c khuynh hng tim chng i tr cho tr t 2-5 tui. Tuy nhin, tp trung vo cc trng hp sau: *Tr i 3 tui *Tr vng Alaska, hoc ging n a en *Nhm tr c bnh l cn c chm sc c bit Vaccine phng ph cu khun c th c tim cng khong thi gian khi tr phi tim chng cc vaccine khc theo lch. Cc lu khi tim vaccine PCV: Vaccine phng ph cu khun cng c mt s trng hp chng ch nh: *Tr b phn ng qu mnh sau ln tim mi u tin *Tr ang b cc chng bnh khc trong khong thi gian phi tim chng mi u tin hoc cc mi k tip. Kt qu ca cc th nghim lm sng cho thy vaccine ny gy ra mt s phn ng nh nh: *Khong 30% s trng hp c tim chng c cc phn ng ti ch nh , sng mm & hi au ti ch tim chch *Khong 10% b st nh Min dch bng vaccine l cch tt nht bo v c th tr chng li cc bnh l c tnh ly nhim nghim trng. Ngoi cc vaccine buc phi tim chng cho tr

theo chng trnh phng bnh ca mi quc gia, cc bnh l sau y cng cn c tim chng. Vaccine thy u & bnh u ma: u ma l mt bnh l rt d ly lan t ngi sang ngi, thng thy tr con (hu ht cc trng hp b u ma thng i 15 tui). u ma c cho l mt bnh l nh. Tuy nhin, nu khng c chm sc & theo i iu tr tt, u ma c th gy ra cc bin chng nghim trng nh ph no, vim phi & nhim trng da. Vaccine thy u c th phng bnh u ma. S c tn l vaccine thy u v virus thy u gy ra bnh u ma- bnh thng thy xut hin tui u th. Tr trn 12 thng l c th tim chng vaccine ny. Vaccine ny ch cn tim mt mi v c hiu qu phng bnh t 85 n 90%. Sau khi chch, tr c th b pht ban bt kz lc no trong vng mt thng sau tim chch. Ban c th t bin mt sau vi ngy m khng cn iu tr g. Do tnh cht ly lan mnh ca bnh u Bn nn xin ngh hc hoc ngh lm bnh mau lnh hn & trnh ly lan cho ngi khc. Vaccine u ma ch cn tim 1 ln trong i v khng cn thit phi tim mi nhc li no khc. Tuy nhin, an ton hon Bn c th cho tr chch mt mi nhc li vo tui t 12-18 tui (mi u tin c chch trc khi tr c 2 tui). Nhn vin y t lm vic trong mi trng d nhim virus thy u cng nn tim chng bnh. Ph n trong tui sinh nn tim chng thy u trong nhng lc bit chc chn khng c mang thai. Ngi chun b i u lch n nhng ni c trung tm dch thy u cng nn tim chch trc khi i. Tc dng ph ca vaccine u ma thng nh (nh st nh, au hoc sng vng chch). Cc tc dng do phn ng vi vaccine him thy xy ra.

Cc trng hp khng nn tim chng thy u: Khng phi ai cng c th tim chng bnh u ma. Hin ti c 3 nhm ngi khng nn tim chng bnh thy u hay bt kz bnh no khc (nu khng c ch nh c bit ca BS) l: *Ngi b suy yu h min dch d bt kz l do no (HIV/AIDS hay suy gim min dch do s dng thuc khng ng cch, nht l cc prednisone & cc thuc steroid khc) *Ph n ang mang thai, nht l 3 thng u ca thai kz *ang b nhng t bnh cp tnh nguy him hn cn c cha tr cp tc Nhng trng hp i y cng khng nn tim chng vaccine u ma: *C tin cn b chm hoc cc bnh l mn tnh trn da khc *Ngi ang b cc bnh l a nh ang b u ma hoc cc nhim trng da (mn bc, mn nht, gh chc, ...) *Sng chung vu nhng ngi b cc bnh l v da nu trn *Ngi b suy gim min dch do bt c nguyn nhn no (HIV, ct lch, ung th, tiu ng, do tc hi ca thuc steroid hoc thuc dng trong ha tr ung th, cy ghp tng) *D ng vi bt kz thnh phn no ca vaccine *ang mang thai hoc ang cho con b *Tr i 12 thng tui Vaccine nga bnh u ma ch c cng dng trong khong thi gian t 3-5 nm. Do vy, nu qu thi hn trn & dch ang bng pht th Bn nn i tim chng tr li. Nhng ai d mc bnh cm? C mt s ngi c nguy c cao mc bnh cm & b cc bin chng ca cm (nh

vim phi, suy h hp, ...). Nu Bn c mt trong nhng yu t nguy c bn i th Bn nn i tim chng vaccine phng cm hng nm: *Tr con tui t 6 n 23 thng tui. *Ngi ln t 65 tui tr nn. *Tt c nhng ph n ang hoc d nh c thai trong ma bnh cm. *Nhng ngi phi nm lu trong bnh vin v mt bnh l no khc. *Ngi c nhng vn v sc khe ko di, khng phn bit tui tc. *Tr em tui t 6 thng tui n 18 tui c ng aspirine thng xuyn iu tr mt chng bnh mn tnh khc. *Nhn vin y t thng xuyn tip xc vi cc bnh nhn. *Ngi nui bnh hoc ngi gi tr. *Ngi gip vic nh hoc trng nom chu b i 6 thng tui.

Cc i tng cn thit tim nga cm: i vi tr nh: *Tt c cc tr t 6-23 thng tui *Thng th tr nh i 6 thng tui khng nn tim nga cm. Tuy nhin, ngay c tr s sinh c nhng yu t nguy c lm gia tng cc bnh l phi mt khi b nhim cm li nn tim chng cm *Tr c bnh l tim phi, k c hen suyn *Tr thng phi i khm BS bi cc bnh l mn tnh nh tiu ng, bnh thn, thiu mu hoc cc bnh l suy gim min dch (nh HIV/AIDS & cc tnh trng suy gim min dch do s dng thuc) *Tr c cc bnh l buc phi s dng Aspirin lu di *Tr sng chung vi nhng ngi c nguy c b bnh cm hoc ang b bnh cm

i vi ngi ln:

*Ngi c bnh l tim phi mn tnh *Ngi thng phi i khm BS o cc bnh l mn tnh nh tiu ng, thn, thiu mu hoc suy gim min dch (nh HIV/AIDS & cc bnh min dch do thuc) *Ph n mang thai trong 6 thng cui thai kz khi dch cm ang honh hnh hoc ang trong ma cm. *Ph n mang thai c cc bnh l{ lm gia tng cc bin chng phc tp khi mc cm, bt k thi gian mang thai. *Ngi nui bnh hoc cc nhn vin y t *Nhng ngi lm vic mang nhiu tnh cht cng ng nh cnh st, cng nhn trong mt x nghip, ... *D nh du lch n nhng ni thng c dch cm *Ngi cao tui (trn 65 tui) *Ngi sng chung vi nhng ngi c cc yu t nguy c nu trn Nu gia nh Bn c b s sinh, hoc l Bn ang sng chung vi ngi ln tui (ng b trong gia nh chng hn) th Bn cng cn phi i tim chng cm trnh ly nhim cho h. Tuy nhin nu nh Bn khng ri vo bt c cc trng hp va k trn, th Bn khng cn phi tim nga bnh cm trong nm ny. Ti sao? Bi v s khng thuc cho tt c mi ngi. V nu nh c qu nhiu ngi khe mnh tim nga bnh cm th s thuc tim nga cn li cho nhng ngi tht s cn c tim nga s b thiu ht i.

Nhng ai khng nn tim vaccine nga cm? *Tr con i 6 thng tui *Lu khng nn tim chch vaccine phng cm trong thi gian ang b cc bnh l nhim trng khc *Trong qu kh, Bn tng b d ng vi cc ln tim chng cm trc *Ngi b d ng vi trng, v virus cm c nui cy trong trng trng.

*Ngi c tin s mc hi chng Guillain-Barr (mt phn ng gy ra yu lit hoc d cm cc b mt phn c th) trong vng 6 tun sau mi tim vaccine phng bnh cm trc . Nhng ai khng nn dng vaccine nga cm dng xt qua mi? Nhng trng hp i y nn bo cho BS trc khi c s dng vaccine phng cm dng phun xt mi: *Tr em i 5 tui. *Ngi ln tui 50 hoc hn *Nhng ngi c vn v sc khe ko di *Nhng ngi c h min dch km *Tr em tui t 6 thng n 18 thng tui ang p ng ch iu tr bng aspirin cho bnh l mn tnh *Ngi c tin s mc hi chng Guillain-Barr. *Ph n ang mang thai. *Nhng ngi tng b d ng vi vaccine phng cm hoc c d ng vi trng.

CHNG 13. TI NGHIN CU NHI KHOA


S108. HP EO NG MCH CH
Nguyn Thanh Lim - Bnh vin Nhi Trung ng

t vn Hp eo ng mch ch l mt bnh him gp, c tin lng tt nu c chn on v iu tr sm. Tuy nhin hin nay nhiu bnh nhn vn c chn on mun.

Mc ch ca bo co ny l nhm thng bo 5 trng hp hp eo ng mch ch gp trong thi gian gn y nhm rt ra mt s kinh nghim chn on sm bnh. Cc trng hp bnh n Bnh n 1 Bnh nhn nam 3 tui, vo vin ngy 24/5/01 theo hn n chun b m. M s bnh n 201363. Bnh nhn l con th nht, cn nng lc 1,8 kg. T lc 6 thng tui n vin v a chy. Nghe tim c ting thi tm thu khong lin sn 2 bn tri, siu m tim pht hin thy hp eo ng mch ch. Khm hin ti nng 11,5 kg. Huyt p chi trn 145/70mmHg, huyt p chi i 60/40mmHg. Mch quay r, mch mu chn khng bt c. Nghe tim c ting thi tm thu 3/6 lin sn 3 bn tri. Siu m thy hp eo n mch ch i ng mch i n, cn ng ng mch. Tm tht tri dn va thnh dy. M ngy 15/6/01 thy ng mch ch hp di khong 1cm i ng mch i n. Cn ng ng mch ng knh khong 5mm, ng mch ch trn ch hp kch thc bng 2/3 on i ch hp. Buc v tht ng ng mch. Ct on ng mch ch hp. Ni ng mch ch tn - tn. Sau m khng cn chnh lch huyt p. Mch mu bt r. Din bin sau m tt. Bnh n 2 Bnh nhn Trn vn Kin 2 thng tui vo vin ngy 2/4/02 v a chy. M s bnh n 220109. Bnh nhn l con u thng, cn nng lc sinh l 2,1 kg. Trc khi vo vin 5 ngy tr xut hin a chy ngy > 10 ln. Khm lc vo c du hiu mt nc, cn nng 3,5 kg. Phi th th, nhp th 62/pht. Tim nhp nhanh 170 ln /pht, ting thi tm thu 3/6 khoang lin sn 3 bn tri. Khng o huyt p, khng bt mch bn. Xt nghim: hng cu 4.050.000, Hg:11g Siu m: Cn ng ng mch, ng knh 3,3 - 4,5 mm i 7mm. Nh tri v tht tri n to, phnh vch lin nh.

Chn on cn ng ng mch m ngy 25/4/02. Trong m nhn thy hp eo ng mch ch i ch xut pht ca ng mch i n i khong 1cm. Cn ng ng mch ng knh khong 5mm nm v tr ng mch ch b hp. Cp ct ng ng mch. Cp ct on ng mch ch b hp. Ni li 2 u ng mch ch. Sau m mch bn s r. Th my 5 ngy. Din bin sau khi dng my th bnh thng. Bnh n 3 Bnh nhn nam 9 thng vo vin ngy 23/10/01 do bnh vin Ngh an chuyn n vi chn on thng lin tht. M s 214018. T trc khi vo vin 11 ngy tr ho st, vo bnh vin Ngh an c chn on l thng lin tht nn chuyn n Bnh vin Nhi Trung ng. Khm lc vo: cn nng 6 kg. Mch quay r, khng bt mch bn v mu, khng o huyt p. Nghe tim thy ting thi3/6 khoang lin sn 3. Siu m tim thy cn ng ng mch kch thc 14 mm, thn ng mch phi dn rt to 24 mm, tht tri dn thnh dy. Chn on cn ng ng mch. M ngy 10/1/02. Trong m thy ng mch ch b hp ngay i ch xut pht ca ng mch i n i khong 1cm. Cn ng ng mch kch thc khong 1cm. Ct v khu ng ng mch. Ct ng mch ch b hp. Ni li ng mch ch tn - tn. Sau m s mch quay r. Din bin sau m thun li. Bnh n 4 Bnh nhn n 4 thng vo vin ngy 31/1/03, m s 242 881. Bnh nhn l con u cn nng lc sinh 1500g. Trc khi vo vin 1 tun b ho st v a chy iu tr bnh vin tnh nhng khng nn chuyn Bnh vin Nhi. Khm lc vo: tr suy inh ng, cn nng 3100g. Nghe tim c ting thi tm thu 3/6 khoang lin sn3 bn tri. Khng o huyt p v s mch mu v bn. Siu m thy hp eo ng mch ch, cn ng ng mch, tht tri dy. M ngy 4/3/03 thy hp eo ng mch ch i ch xut pht ca ng mch i n i 1cm, cn ng ng mch. Ct v khu ng ng mch. Ct on

ng mch ch b hp. Ni ng mch ch tn-tn. Sau m s r mch mu v bn, khng c chnh lch huyt p chi trn v i. Trn ng chp xut hin ngy th 2 sau m, ht sau dn lu khoang mng phi 1 tun. Bnh n 5 Bnh nhn nam 5 thng vo vin ngy 24/6/03 do Bnh vin Hi phng chuyn n vi chn on vim phi v tim bm sinh. M s bnh n: 260617. Bnh nhn l con u cn nng lc sinh l 2,9 kg. Trc khi vo vin 3 ngy xut hin ho st, vo Bnh vin Hi phng c chn on l bnh tim bm sinh nn chuyn Bnh vin Nhi. Khm lc vo cn nng 5,5kg, tim c ting thi tm thu 2/6 mm. Khng o huyt p, khng s mch mu v bn. Siu m thy tm tht tri dn. Khng thy hp eo ng mch ch. Chn on bnh c tim n. Bnh nhn c chuyn v bnh vin Samsung, Hn quc. Siu m thy hp eo ng mch ch di 1 cm. ct on ng mch hp v ni mch tn-tn. Sau m din bin tt. Bn lun Hp eo ng mch ch l d tt tim bm sinh ng hng th 3 sau thng lin tht v cn ng ng mch. V ttr hp c th trc ng ng mch hoc sau ng ng mch. Bnh gp con trai nhiu gp 3 ln con gi. Khong 20% tr nh nhp vin v suy tim l do hp eo ng mch ch. T l tm thy trn m t thi l 1/4000 (1). Triu chng ca bnh ph thuc vo v tr hp. Bnh nhn hp eo ng mch ch trn ng thng biu hin ngay giai on s sinh hoc tr cn b bng chm pht trin th cht v suy tim. Bnh nhn c v tr hp sau ng c biu hin lm sng a ng ph thuc vo mc hp. tr cn b, cc triu chng khng c hiu nh chm tng trng, k m n, kch thch c th l hu qu ca hp nh. Tri li, hp nng c th biu hin l mt cp cu vi cc hu qu ca ti mu t chc km dn n suy sp a ph tng(1). Biu hin ca s sinh hoc tr b rt nguy kch. Sau khi sinh, tr khng c triu chng vi ngy hoc vi tun nhng ngay sau khi ng ng mch ng li cc triu chng ca suy tun hon xut hin nhanh chng vi h huyt p, nhp nhanh, th nhanh, khng s thy mch chi

i. Trong nhng trng hp nng mch chi trn cng yu do suy tht tri. V niu v toan chuyn ho c th xut hin trong vng vi gi (2). Trn khm lm sng, nghe thy ting thi bn ngc tri hoc sau lng l u hiu c in. Chnh p gia chi trn v chi i l du hiu gi { ng quan tm. Cn phi lun ngh n hp eo ng mch ch trn tr c cao huyt p(1). Ting thi nghe r nht gia hai xng b vai (2). X quang thy tim hi to hoc khng c g c bit. Mc d CT, MRI hoc chp mch l cc phng php chn on chnh xc nhng a s cc trng hp c th c chn on bng siu m. Chn on hp eo ng mch ch khng kh tuy nhin t l b st chn on kh cao. 3/5 bnh nhn trong bo co ny chn on nhm trc m: 2 bnh nhn c chn on cn ng ng mch v 1 bnh nhn chn on l bnh c tim dn. Nguyn nhn chn on sai lm trc ht l do cc thiu st trong khm lm sng. 4/5 bnh nhn trong lot nghin cu ny khng c o huyt p v bt mch chi i. Huyt p cao chi trn, thp chi i v mch mu hoc mch bn yu hoc khng bt c l cc du hiu lm sng quan trng cn phi c tin hnh mt cch h thng cho cc bnh nhn tim mch khng b st hp eo ng mch ch. Ting thi tm thu trong hp eo ng mch ch cng c cc c im khc trong cn ng ng mch. Ting thi trong cn ng ng mch nghe r lin sn II bn tri, trong khi ting thi trong hp eo ng mch ch nghe r khoang lin sn III bn tri v pha sau gia 2 xng b vai (2). Siu m mc l phng tin xc nh chn on nhng trn thc t vn c th nhm ln. 3/5 bnh nhn c nhm ln trong chn on siu m: 2 trng hp chn on cn ng ng mch v 1 trng hp chn on l bnh c tim n. Hai trng hp chn on cn ng ng mch o ngi lm siu m ch ch { n thng tn cn ng ng mch km theo m khng ch { n tn thng chnh l hp eo ng mch ch. Trng hp chn on bnh c tim n c l o ngi lm siu m ch ch { n cc biu hin dn cc bung tim do hu qu ca hp eo ng mch ch m khng thm k ng mch ch. Chnh v vy trc khi khng nh chn on bnh c tim dn cn thm k ng mch ch loi tr hp eo ng mch ch.

iu tr cn ng ng mch ch yu bng phu thut tuy nhin trong cc trng hp cp cu c th iu tr tm thi bng mt s thuc. ProstaglandinE c tc dng duy tr m ng ng mch s sinh v vy c th ti mu chi i bng tht phi v thm ch nu ng ng th vn lm n ng mch ch sau ch hp, v vy vn lm tng lung mu qua ch hp. Phu thut hp eo ng mch ch thnh cng u tin l do Gross Boston v Crafoord Nylin nm 1945(2). Cc trng hp hp eo ng mch ch nh c th thch nghi vi cuc sng khng cn phu thut. Do vy, ch nh phu thut c dnh cho cc bnh nhn c chnh lch p lc gia chi trn v chi i >20mmHg khi ngh hoc hp >50% ng knh ng mch (1). Cho n nay c nhiu k thut m nhng c th chia 3 loi chnh(1, 2, 3, 4, 5, 6): - Phu thut ct on hp v ni u trn vi u i - To hnh ng mch ch bng ng mch i n - To hnh ng mch ch bng ming v nhn to. Mi loi k thut c ch nh khc nhau, tuy nhin phu thut ct on hp v ni u trn vi u i l phu thut c a thch. Kt qu phu thut rt khch l. Trong s 138 bnh nhn c phu thut ti bnh vin Boston ch c 14 trng hp t vong trong nhm <1 thng tui ch yu l c km theo cc d tt phi hp khc. Mc d vy, theo di lu di cho thy 12 bnh nhn (9%) c biu hin hp li, ch yu l cc bnh nhn m trong thi k s sinh (2). Trong nhng nm gn y nhiu tc gi tin hnh iu tr hp eo ng mch ch bng nong ch hp bng bng(7, 8, 9). Kinh nghim t Mexico cho thy trong s 333 bnh nhn c nong bng c t l thnh cng t n 93,7%(7). Kt lun Hp eo ng mch ch l mt d tt d b b st chn on. o huyt p v bt mch c chi trn v chi i l cc bin php cn thit trong khm lm sng. Phu thut c kt qu tt. Nong ch hp bng bng nn thc hin cc trung tm c iu kin.

Ti liu tham kho 1- Pegoli W. Pericardium and great vessels. IN: Oldham KT, Colombani PM, Foglia RP,eds. Surgery of infants and children. Lippincott-Raven Publisher,Philadelphia 1997:987-1004. 2- Castaneda A R, Jonas RA, Mayer JE, Hanley F. Cardiac surgery of the neonate and infant. WB Saunders company. Philadelphia1994:333-352 3- Castaneda AR, Jonas RA, Mayer JE, Hanley FL.Cardiac surgery of the neonate and infant. W.B. Saunder company. Philadelphia 1994:333-339. 4- Khatami D, Backer CL, Mavroudis C. Risk factor for recoartation and results of reoperation: a 40 year review. J Card Surg 2000,15:369-377 5- Corno AF, Botta U, Hurni M,et al. Surgery for aortic coartation : a 30 years experience. Eur J cardiothorac Surg 2001,20:1202-1206. 6- Bacha EA, Almodovar M, Wessel DL,et al. Surgery for coartation of the aorta in infants weighing less than 2kg. Ann Thorac Surg 2001,71:1260-1264. 7- Calderon MJ, Cerdeira ZC, Velazco LM,et al. Balloon angioplasty in aortic coartation : a multicentric study in Mexcico. 8- McMahon CJ, Alromani A, Nihill MR. Balloon angioplasty of critical coartation in a 970 gram premature infant. Cardiol young 2001,11:468-471 9- Rao PS, Jureidini SB, Balfour IC,et al. Severe aortic coartation in infants less than 3 months: successful palliation by balloon angioplasty. J Invasive cardiol 2003,15:202-208.

S109. NGHIN CU VI KHUN T DCH HT KH PH QUN CA BNH NHN NM VIN


Ng Th Thi - ng Th Thu Hng - Nguyn Thanh Lim

Bnh vin Nhi Trung ng Summary With 1092 positive samples of bronchial aspirates from 1568 patients: 15 types of bacteria were isolated Klebsiella spp. ranks first accounting for 42.12%, P.aeruginosa ranks second accounting for 26.92%. It was found that there is a relationship between the bacteria isolated in bronchial aspirates and the bacteria in oxygen moisture bottle and aspirates machines. The result shows that the risk of infection in children is very high and nosocomial infection may occur in hospital. The treatment for infection caused by the above mentioned types of bacteria is time-consuming and costly because of their strong antibiotic resistance to normal antibiotics such as: CE, GEN, SXT and CHL (more than 63% ). The effective antibiotics in treatment are AMK, NOR, IPM and some antibiotics of cephalosporin group 3,4. There is a favorable relationship between the length of time of intra-tracheal Catheterization and the bacteria isolated, and the duration of treatment and the result of treatment.

Tm tt : T 1.092 mu xt nghim (+) dch ht kh ph qun 1568 bnh nhi phn lp c 15 loi vi khun. Trong Klebsiella spp ng u vi t l 42,12% P.aeruginosa ng th hai 26,92%. C mi lin quan v trng hp gia vi khun phn lp c t dch ht kh ph qun vi vi khun bnh lm m O2 v my ht m i, c bit l hai nhm vi khun : Klebsiella spp v P.aeruginosa. Kt qu cho thy s nhim khun tr em v cng nng n, kh nng nhim khun cho trong bnh vin c xy ra. Vic iu tr nhim khun do hai loi vi khun trn s ko di v tn km bi tnh a khng khng sinh rt cao vi cc khng sinh thng thng nh CE,

GEN, SXT v CHL t 63% tr ln. Cc khng sinh c tc dng trong iu tr l AMK, NOR v IMP v mt s khng sinh thuc nhm Cephalosporin th h 3,4. C mi lin quan t l thun gia thi gian t ni kh qun, loi vi khun phn lp (+), thi gian iu tr v kt qu iu tr. Nu thi gian t ni kh qun so vi thi gian bnh nhi nhp vin cng di th: t l phn lp vi khun (+) tng; thi gian iu tr ko di hn; kt qu iu tr tin trin chm v t l t vong tng n. I. t vn : Nhim khun bnh vin (NKBV) ang v s tr thnh mt thch thc ln i vi y hc ton cu. NKBV tc ng rt xu n hiu qu iu tr, ko di thi gian nm vin, tng chi ph iu tr v t l t vong. Mt khc NKBV lm gia tng v lan truyn cc dng vi khun khng thuc khng sinh trong bnh vin v cng ng. * Theo CDC (trung tm kim sot bnh M) C t 5 15% bnh nhn nhp vin b NKBV.

Thi gian nm iu tr k o i thm 4 n 8 ngy v chi ph thm 1,5 t USD/nm. Chi ph cho 1 bnh nhn c NKBV t 1000 8000 USD v c 19.000 bnh nhn t vong/nm. Ti Vit nam mc d t l NKBV cao nhng s cng trnh nghin cu v ti ny cn t. Trong s NKBV , nhim khun ng h hp chim mt v tr quan trng. Chng ti tin hnh ti nghin cu ny nhm 2 mc ch: 1. Xc nh vi khun trong dch ht kh ph qun ca bnh nhi v mc khng khng sinh ca cc chng phn lp c. 2. Tm hiu mi lin quan gia vi khun t dch ht kh ph qun vi vi khun phn lp t bnh lm m O2 v my ht m di. Mi lin quan gia thi gian t ni kh qun, loi vi khun, thi gian iu tr v kt qu iu tr.

II. i tng v phng php nghin cu II.1 i tng nghin cu Dch kh ph qun ca bnh nhn iu tr ti Bnh vin Nhi Trung ng t 01/2002 n 6/2003. Bnh lm m O2 v my ht m di mt s khoa phng t 1/2000 n 6/2003. II.2. Phng php nghin cu Dch kh ph qun c ht qua ng ni kh qun Ly mu nc trong bnh lm m oxy v dch trong bnh ht m ri.

Nui cy nh danh vi khun theo k thut chun ho ca WHO v chng trnh ASTS. Th nghim khng sinh theo phng php khoanh giy khng sinh khuych tn trong thch Kirby Bauer. III. Kt qu nghin cu 1. Kt qu nui cy dch ht kh ph qun T thng 1/2002 n 6/2003 khoa Vi sinh thc hin 11.945 mu xt nghim nui cy phn lp vi khun, trong nui cy dch ht kh ph qun (ni kh qun) chim 1568 mu t 13,13%. T l (+) dch ni kh qun l 1092 ln ( 69,6 %). T l nui cy ng tnh theo cc khoa c trnh by trong bng 1: Bng 1. Tnh hnh xt nghim dch ni kh qun ca cc khoa phng Khoa Tng s Dng tnh 683 %

Khoa s sinh

929

62,55

iu tr tch cc 413 H hp Cc khoa khc Tng s 164 62 1568

275 98 36 1092

25,18 8,97 3,30 100

T 1092 mu xt nghim (+) phn lp c 15 loi vi khun. Kt qu c trnh by bng 2: Bng 2 : Cc loi vi khun c phn lp. TT Loi vi khun * Nhm TK gr (-) 1 2 3 4 5 6 7 Klebsiella spp P.aeruginosa E.Coli Citrobacter H.influenzae Enterobacter Proteus spp * Nhm cu khun gr (+) 8 9 10 S.viridans S.aureus S.pneumoniae 54 25 4 4,94 2,29 0,36 460 294 159 23 18 12 8 42,12 26,92 14,56 2,10 1,65 1,10 0,73 n %

11 12

S.pyogenes Enterococcus * Nhm cu khun gr (-)

4 4

0,36 0,36

13 14 15

N.meningitidis M. catarrhalis Acinetobacter * Nm * 15 mu c 2 loi vi khun

1 4 14 8

0,09 0,36 1,28 0,73

2. Kt qu kim tra NKBV qua nui cy phn lp vi khun bnh lm m O2 v my ht m di Kt qu nui cy vi khun t bnh lm m oxy v my ht m ri c trnh by bng 3: Bng 3 . Kt qu nui cy t bnh lm m o xy v bnh ht m ri Mu kim tra Mu kim K.leb. tra Bnh lm 8 m (n=31) My ht m di (n=8) Vi khun P.aeru S.aur. S.epid m tnh 6

11

3. Lin quan gia loi vi khun phn lp c t dch ht kh ph qun vi thi gian t ni kh qun, thi gian iu tr v kt qu iu tr

Qua 135 bnh n c ly ngu nhin t cc khoa (khoa s sinh : 69 bnh n, khoa iu tr tch cc : 19 bnh n v cc khoa khc : 18 bnh n) cho thy 135 trng hp nui cy vi khun (+) l(78%). Lin quan gia thi gian nm vin v xt nghim vi khun ng tnh c trnh by bng 4: Bng 4: Lin quan gia thi gian nm vin v kt qu nui cy Thi gian Tng s xt nghim S xt nghim ng tnh 23 T l phn trm ng tnh

Ngay sau khi vo vin sau 24 gi sau 48 gi Sau 72 gi Tng s

38

60

18 7 72 135

12 5 66 106

66 71 91

Trong s 135 bnh nhn c 39 bnh nhn t vong (36%) 4. Mc khng khng sinh ca mt s vi khun thng gp trong dch ht kh ph qun. Mc khng khng sinh ca cc vikhun phn lp c trnh by qua bng 5: Bng 5. Mc khng khng sinh ca mt s loi vi khun

Khng sinh

Kleb : 460

P.aerug : 294 n R%

E.Coli : 159

R%

R%

Ampicillin Cephalothin Ceftazidim Cefotaxim Ceftriaxon Axeprim

450 422 195 235 263 186

97,8 91,7 42,4 51,1 57,2 40,4 77,6 79,5 70 30,2 79,5 31,9 21,5

* * 131 121 167 111 * * 186 83 149 59 44

* * 44,5 41,1 56,8 37,7 * * 63,2 28,2 50,6 20,0 14,9

139 101 56 61 77 63 119 113 89 29 81 49 26

87,4 63,5 35,2 38,3 48,4 39,6 74,8 71,1 55,9 18,2 50,9 30,8 16,3

Chloramphenicol 315 Co-trimoxazole Gentamycin Amikacin Tobramycin Norfloxacin Imipenem * Khng th nghim IV. Bn lun 366 322 139 366 147 99

Kt qu nghin cu t bng 1 v bng 2 cho thy t l ng tnh qua nui cy dch kh-ph qun rt cao (69,6%). Hai khoa c t l nui cy cao nht l s sinh v iu tr tch cc. Trong dch kh-ph qun c s hin din dn 15 loi vi khun khc nhau tuy nhin cc vi khun nhm gram m chim a s m hng u l Klebsiella (42,1%), Trc khun m xanh( 26,9%) v E.Coli(14,5%). Kt qu t bng 5 cho thy cc vi khun ny c kh nng khnhg khng sinh rt cao. Hu nh tt c cc loi khng sinh k c cc loi khng sinh mi v rt t tin nh Axepim v Imipenem cng b khng vi t l cao( bng 5). iu ny gii thch ti sao nhim trng bnh vin c tin lng nng n. Mc c iu tr bng cc khng

sinh mi nht v t tin nht nhng t l t vong ca cc bnh nhn b nhim trng ng h hp do nhim khun bnh vin vn chim n 36%. Kt qu t bng 4 cho thy t l nhim trng lin quan vi thi gian nm vin. Bnh nhn nm vin cng lu th t l nhim trng cng cao. Nhim trng ng h hp do nhim trng bnh vin c th do nhiu nguyn nhn nhng bnh lm m o xy v bnh ht l nhng ngun ly quan trng. Kt qu t bng 3 cho thy 80% bnh lm m o xy v 75% my ht m ri c vi khun. V vy ngoi vic ra tay trc khi lm th thut, thc hin cc th thut t ni qun, ht m ri, th oxy theo nguyn tc v trng th vic kh khun bnh lm m oxy v my ht m ri l cc bin php quan trng gim bt t l nhim trng ng h hp do nhim trng bnh vin. IV. Kt lun Vi 1568 mu nui cy phn lp vi khun t dch ht kh ph qun ca bnh nhi v 39 mu kim tra vi khun bnh lm m O2 v my ht m di cho cc kt lun sau : 1. T l nui cy (+) dch ht kh ph qun l 69,6% vi 3 loi vi khun gram m c t l cao l Klebsiella spp : 42,12%, P.aerug : 26,92% v E.coli 14,56%. Nhm vi khun gram m chim a s v gp gn 9 ln cc nhm vi khun khc. 2. Cc loi vi khun phn lp c t cc mu kim tra c mi lin quan n vi khun phn lp c t dch ht kh ph qun. 3. C mi lin quan t l thun gia thi gian t ni kh qun, loi vi khun phn lp (+), thi gian iu tr v kt qu iu tr. 4. Mc khng khng sinh ca Klebsiella P.aerug, E.coli l rt cao vi cc khng sinh thng thng nh CE, GEN, SXT v CHL t 63% tr ln. c bit Klebsiella spp lun c t l khng khng sinh cao hn 2 loi vi khun cn li. Cc khng sinh c tc dng trong iu tr l AMK, NOR, IPM v mt skhng sinh nhm Cephalosporin th h 3,4. V. Ti liu tham kho

1. Dc th quc gia Vit Nam 2002. 2. Ti liu hng dn quy trnh chng NKBV tp I B Y t - 2003. 3. V Bo Chu : Tm hiu nguyn nhn gy nhim khun vt m v mt s yu t lin quan. Lun n TS y hc 2001. 4. Mt s cng trnh nghin cu v nhy cm ca vi khun vi thuc khng sinh cc nm 1996, 1997, 1998. Hot ng ASTS. 5. Hong Ngc Hin. Nhim trng bnh vin. Sch Vi sinh vt y hc. Hc vin Qun y. H Ni 1997 : 13 16. 6. Kawana R. Nosocomial Infection. Hokkaido , Igaku , Zasshi : 1994 : 5: 12. 7. Pechere. JC Microbiology of nosocomial infections. Bull Acad. Natl Med. 1993 May ; 177 (5) : 705 .

S110. NHN XT C IM LM SNG CA NHIM KHUN SHIGELLA TR EM TI BNH VIN NHI TRUNG NG 1998 - 2000

Lu M Thc Nguyn Gia Khnh

Ng th Thi Bnh vin Nhi Trung ng

Tm tt Qua 132 bnh n bnh nhn l trc khun c cy phn ng tnh vi Shigella trong nghin cu ca chng ti thy: c im dch t: Bnh thng gp tr nh c bit t 1-3 tui chim 59,1%. Nhim Shigella thng gp vo ma h, ma ma phn nhiu . c bit vo cc thng 7, 8. Tc nhn gy l trc khun hin nay tr em l S. Flexneri chim 78% v ng th hai l S. Sonnei chim 18%. S. Boydii v S. Dysenteriae chim t l thp khng ng k (2,4% v 1,6%). c im lm sng: t l triu chng thng gp mi la tui chim 81% trong 53% l st cao, thng xy ra trc khi phn c mu. Phn c nhy mu l c im ca bnh l trc khun, nhng tr em phn c nhy mu ch gp 61,3%, phn khng c mu chim 17% v phn lng n thun chim 19,7%. Tnh cht phn thay i theo thi gian, 3 ngy u thng biu hin bng tiu chy n thun (28%), nhng sau 3 ngy tng ln 63%. Nhng trng hp phn c mu ngay t u thng l nhng th nng. Tr cng nh tui th thi gian b bnh cng ko di. Tr i 6 thng thi gian b bnh trung bnh 13 ngy trong khi tr 3-5 tui th thi gian b bnh ch c 5-7 ngy.

Soi phn ti tm hng cu, bch cu xt nghim quan trng chn on l. Hng cu v bch cu y c thng gp 89% trng hp, 11% soi phn c hng cu, bch cu m tnh gp nhng trng hp phn lng. 1. t vn : Bnh l do Shigella l bnh c kh nng ly nhim mnh nht trong cc bnh tiu chy nhim khun. Vit Nam, bnh l trc khun v vim gan virus l hai bnh truyn nhim c s lng ngi mc ln nht [1], [2]. Bnh l trc khun l bnh nhim trng cp tnh, cn c chn on nhanh v iu tr sm bng khng sinh thch hp. Vic chn on sm v ng nhim khun ng rut do Shigella kh v bnh cnh lm sng phong ph, mt khc c nhiu nguyn nhn gy tiu chy phn mu c biu hin nh l. Bng chng chc chn chn on xc nh l cy phn ng tnh nhng t l khng cao, t 15-20% trng hp ( ngi tnh nguyn khe mnh) [3], [4], [5] v kt qu cy phn thng mun so vi s cn thit ca iu tr. V vy trn lm sng cn c vo c im lm sng, dch t v tnh cht phn c chn on sm bnh l trc khun v tin hnh iu tr l iu ht sc cn thit. Xut pht t thc tin trn, chng ti tin hnh ti ny nhm mc tiu sau: Nghin cu c im lm sng ca bnh l trc khun tr em .

2. i tng v phng php nghin cu 2.1. i tng nghin cu: Nghin cu c tin hnh ti Vin Nhi quc gia t 1998-2002. Cc bnh nhn c a vo nghin cu phi c y cc tiu chun sau: Bnh nhn c iu tr v theo di ti vin cho n khi khi Cy phn ng tnh vi Shigella

2.2. Phng php nghin cu: Nghin cu iu tra m t, tin cu. Mi bnh nhn vo vin u c hi, khm, nh gi triu chng theo mt mu in sn 3. X l kt qu: Cc s liu thu thp c x l theo thut ton thng k trn my vi tnh bng chng trnh chng trnh Epi-info 6.0. 4. Kt qu: 4.1. c im dch t hc: Bng 1. Tnh hnh nhim Shigella theo thng trong nm

Thng 1 BN mc T l % 7

2 2

3 10

4 8

5 13

6 11

7 19

8 16

9 3

10 13

11 6

12 14

Cng 132

5,3 1,5 7,6 6,1 9,8 8,3 14,4 12,1 2,3 9,8 12,1 10,6 100

Nhn xt: Bnh thng gp vo ma h, c bit tng cao vo thng 7,8. Nhim Shigella cng tng t nh cc bnh nhim khun ng tiu ha khc, l bnh c th gp tn pht quanh nm, nhng cao hn vo cc thng ma nng v ma ma phn m t. Nguyn nhn l do mt s yu t truyn nhim thng tng ln vo nhng thi gian ny trong nm.

Bng 2. Tnh hnh nhim Shigella theo tui < 1 tui 1-3 tui 3-5 >5 Cng P

tui 6 th BN 14 %

tui

7123>5tui 11th 2tui 3tui 5tui 7 42 31,8 36 27,3 21 15,9 12 9,1 132 100 <0,05

10,6 5,3

Nhn xt: Bnh thng gp la tui 1-3 tui (59,1%). Tr i 6 thng cng chim t l ng k 10,6%, gp nhng tr phi n nhn to.Tui thp nht l 1 trng hp s sinh 20 ngy tui. Bng 3. S chng Shigella phn lp c qua nghin cu: Dysenteriae BN % 2 1,6 Flexneri 103 78 Boydii 3 2,4 Sonnei 24 18 Cng 132 100

Nhn xt: S. Flexneri chim a s (78%), tip n l S. Sonnei (18%) S. Boydii (2,4%) v S. Dysenteriae (1,6%).

4.2. c im lm sng: Bng 4. Triu chng st Rt cao Cao Va Nh Bnh Cng thng

Cng 2(1%) 70(53%) 22(17%) 13(10%) 25(19%) 132 Nhn xt:St l triu chng thng gp mi la tui chim 81% trong st cao hay gp nht 53%. St thng xy ra trc khi phn c mu. st cng mt nhanh khi c iu tr ng.

Bng 5. Mi lin quan gia tui v thi gian b bnh <3ngy 4-7ngy 814ngy <6 th 4(29%) 4(29%) >15ngy Cng X sx

6(42%)

14

13,7 6,3 9 3

711th 12(4%) 2tui 22(6%) 3tui 31(5%) 5tui >5 tui Cng 5

2(29%)

4(57%)

1(14%)

13(31%) 19(45%) 8(20%)

42

9,8 5

19(53%) 14(38%) 1(3%)

36

8,19 4,9 7 5

12(57%) 5(24%)

3(14%)

21

7(59%)

1(8%)

4(33%)

12

11,58 11

57

47

23

132

Tr cng nh tui th thi gian b bnh cng ko di. Tr i 6 thng th thi gian b bnh ko di trung bnh trn 1 tun.

Bng 6. Tnh cht phn ca cc chng Shigella Tnh cht S.Flexneri S.Dysenteriae S.Boydii S.Sonnei Cng

phn Lng 20(19%) 1(50%) 2(66,7%) 3(13%) 26 (19,7%) C mu 64(62%) 1(50%) 1(33,3%) 14(58%) 80 (61,3%) 0 0 7(29%) 23 (17%) 0 0 0 3(2%)

Khng 16(16%) c mu Bnh 3(3%) thng

Nhn xt: c im phn c mu l triu chng hay gp chim t l l 62% i vi S. Flexneri, 50% vi S. Dysenteriae 33,3% vi S. Boydii, 58% vi S. Sonnei. S. Flexneri: c im phn c nhy mu cao hn hn phn lng n thun, (p<0,05). S. Sonnei: c im phn c nhy mu so vi tiu chy thng thng v tiu chy c nhy th hai bn c t l tng ng (p<0,05). Nh vy c s khc bit v tnh cht phn ca hai nhm vi khun ny(p<0,05). Bng 6. Mi lin quan gia tnh cht phn v tui bnh nhi b Shigella Phn lng Phn c mu Phn khng c mu 2 (14%) 1 (14%) Cng

<6 thng 7-11

7 (50%) 2 (29%)

5 (36%) 4 (57%)

14 7

thng 1-2 tui 2-3 tui 3-5 tui >5 tui Cng 8 (20%) 5 (14%) 2 (10%) 2 (20%) 26 27 (66%) 21 (58%) 17 (80%) 6 (60%) 80 6 (14%) 10 (28%) 2 (10%) 2 (20%) 23 41 36 21 10 129

Nhn xt: Nhn chung c im phn c mu l triu chng in hnh ca Shigella v u chim t l cao tt c cc la tui, 58% tr i 2 tui v 66% nhm tr trn 2 tui. Tuy vy tr i 2 tui c im phn lng chim 27% cao gp i so vi tr ln. 4.3. Vai tr ca soi phn trong chn on: Qua kt qu nghin cu, chng ti nhn thy s c mt bch cu trong phn ph thuc vo tnh cht phn, vi phn lng n thun th ch c 11% trng hp c bch cu trong phn. c im phn c mu th kt qu soi phn thng c hng cu, bch cu rt nhiu c bit l bch cu a nhn trung tnh (89%). Tuz vo s c mt ca hng, bch cu trong phn cng gp phn cho tin lng bnh. Hng cu,bch cu(-) th 67% c st nh hoc khng st. Hng cu, bch cu rt nhiu th 64% bnh nhn c st cao. Hng cu ri rc, bch cu nhiu th 67% st cao Hng cu nhiu v bch cu ri rc 38% bnh nhn hon ton khng st Nh vy s c mt bch cu trong phn nhiu biu hin ca tnh trng xm nhp vim nng do vi khun, bnh nhn thng st cao v thi gian b bnh cng k o i hn. 5. bn lun:

Xem phn l mt du hiu quan trng trn lm sng gip cho ngi thy thuc trong chn on, la chn thuc iu tr, theo di kt qu iu tr, tin lng bnh. Phn c mu l c trng ca bnh, song tr nh c mt t l ng k l phn lng n thun (19,7%), phn khng c mu (17%), phn c mu (61,3%). Tnh cht phn thay i theo thi gian, 3 ngy u thng biu hin bng tiu chy n thun, t l phn c mu trc 3 ngy ch chim 28% nhng sau 3 ngy tng ln 63%. Nhng trng hp phn c mu ngay t u c bit l nhng th phn ton nc mu th trn lm sng bnh nhn trong tnh trng nng. Do vy nhng trng hp ny khi iu tr nn ng nali ixic aci ngay. c im phn c nhy mu l triu chng ph bin, gp c 4 nhm do vy vic kt hp gia xem phn v soi phn rt c gi tr ln trong chn on v tin lng. Biu hin tnh trng nng ca bnh nh: co git (19%), hn m (2%), li b (9%), mt nc nng (3%), shock nhim khun (5%), shock gim th tch (2%) thng gp tr i 3 tui v nhng th nng dn ti t vong.

Ti liu tham kho

1. Trnh Minh Lin (1994), Bnh l trc trng tr em : Lm sng- Xt nghimiu tr- Tin lng. 2. Nguyn Th Vn Anh (2000), Antimicrobial resistance in Shigella isolated from diarrhoeal patients in Viet nam. 3. Abraham M. Rudolph, MD(1996), Shigella. Ru olphs pe iatrics, 20th edition, 605-607 4. Henry F. Gomez and Thomas G. Cleary(1996), Shigella. Text book of pediatrics, 15th edition, 791-792 100.Tadataka Yamada, MD.(1999), Shigella infection. Text book of gastroenterology, 1614-1615; 1958-1961; 1946-1950

S111. MT S NHN XT V BNH NHI HEN PH QUN TR EM VO IU TR TI KHOA H HP A16 BNH VIN NHI TRUNG NG
TS. o Minh Tun ThS. L Hng Hanh Khoa H Hp - Bnh vin Nhi Trung ng

Tm tt Nghin cu h cu 120 bnh nhi hen ph qun vo iu tr ti khoa H hp A16 trong nm 2002, chng ti rt ra mt s nhn xt sau: 1. T l bnh nhi hen ph qun c xu hng tng ln, chim khong 6,4% so vi tng s bnh nhn bnh l h hp chung phi vo vin iu tr. 2. Tr trn 5 tui mc hen ph qun phi vo vin c u th hn nhm tr nh tui. Tr trai b nhiu hn tr gi. 3. Mc nng ca cn hen thng khng qu nng n, p ng tng i tt vi thuc gin ph qun nhm b2 Adrenergique. Tuy nhin tnh trng s dng Corticoid cn kh lm dng, ngay c i dng tnh mch. 4. Cn quan tm n tnh trng nhim trng h hp th pht trong iu tr hen ph qun tr em. Summary Asthma in children was public health problem in Vietnam. There a lot of asthma patient was treated in National Children Hospital each year. The research focus on Epidemiology and clinical aspect of Asthma in children.

Study Method: We conducted a retrospective study, sample size selected 120 children asthma patients, whose was treated in Department of respiratory (A16) National Children Hospital in 2002, including patients met WHO standard for diagnosis asthma, the data was analyze by using STATA version 6.0. Conclusions: 1. The trend of rate of asthma in children is increasing to 8, 3% among general total of respiratory patients. 2. Rate of Asthma in children >5 years of age higher than group children <5 years. 3. Most patients were graded average, whose have good respond with 2 adrenergique. I. t vn Hen ph qun ni chung v hen ph qun tr em ni ring tr thnh mt bnh l x hi, mang tnh ton cu. Tn xut mc hen ph qun ang c xu hng tng cao trn ton th gii. Hin nay nhiu ni t l hen ph qun con s ng lo s nh c l13 15%, Php 8 10% ; M 5 7%. nc ta cha c s liu iu tra thng k chnh thc cho ton quc v t l mc hen ph qun. Tuy nhin hin nay, mt s ni, mt s trung tm nghin cu v theo di v hen ph qun cng c nhng s liu s b v tn xut hen ph qun nh ca khoa Min dch d ng lm sng Bch Mai l 6 7%, theo s liu ca S Y t H Ni tng kt hen ph qun (nm 2001), tn xut hen ph qun ni chung H Ni l khong 7%. Hen ph qun tr em c d bo l c t l mc cng rt cao. Hn na hu qu ca hen ph qun v tnh trng lm sng ngy cng nng l vn rt cp thit hin nay. Khoa H hp Vin Nhi hng nm tip nhn rt nhiu tr b hen ph qun vo iu tr. Trong vi nm gn y s lng bnh nhi hen ph qun tng ln r rt.

Nghin cu tnh hnh hen ph qun tr em vo iu tr ti khoa H hp Vin Nhi trong nm 2002 nhm mc ch : 1. Nhn xt v t l mc bnh hen ph qun so vi cc bnh l h hp chung phi vo vin iu tr. 2. Tm hiu nhng c im lm sng ca cc bnh nhi hen ph qun vo iu tr ti khoa. 3. nh gi hiu qu ca iu tr v xut mt s vn v qun l d phng hen ph qun. II. i tng v phng php nghin cu : 2.1. i tng nghin cu Bao gm cc bnh nhn vo iu tr ti khoa H hp (A16) Vin Nhi trong nm 2002 c chn on xc nh l hen ph qun da vo cc tiu chun chn on ca T chc y t th gii. 2.2. Phng php nghin cu p dng phng php hi cu.

- Tiu chun chn on hen ph qun : Theo TCYTTG, mt bnh nhn c chn on hen ph qun da vo cc triu chng lm sng, cc xt nghim cn lm sng (X-quang chc nng h hp), khai thc tin s bn thn v gia nh. - Triu chng lm sng : th in hnh tr nga hng, mi, ho tng cn, xut hin cc cn kh th kiu co tht, tc nghn, kh th ra l chnh, phi c ran rt ran ngy, thng kh phi gim. Nhiu khi c biu hin suy h hp, rt lm lng ngc r rt. Cui con ho kh th tr c th ho khc ra m trng nh, sau thuyn gim. Cn kh th thng xut hin na m v sng, t ngt hay c tin triu nng ngc, kh chu trc . Cn kh th thuyn gim hay p ng tt vi thuc gin ph qun.

- Khai thc tin s bn thn : tr thng c nhng cn kh th nh trn ti pht nhiu ln, thng c lin quan n yu t khi pht nh thay i thi tit, tip xc d nguyn, gng sc, nhim trng v.v - Tin s gia nh : thng c lin quan n cc bnh d ng nh chm, ni m ay, vim mi xoang ng v.v + + Xt nghim cn lm sng : Cng thc mu. X-quang phi : tnh trng kh trong phi giai on kh th.

+ o chc nng h hp : suy gim r rt cc thng s FEV1, FVC, sc cn tng, trong cn kh th. Cc test d nguyn gip chn on tm nguyn nhn. * Phn loi mc hen ph qun (da vo TCYTTG) - nh gi mc nng ca cn hen ph qun cp theo 4 : t nh nng ( 1 4). - nh gi mc nng ca bnh hen ph qun da vo phn bc hen : 4 bc (t nh nng) (bc 1 bc 4). III. Kt qu nghin cu 3.1. Tui v gii ca i tng nghin cu Trong nm 2002, c 120 bnh nhi iu tr ti khoa H hp A16 l hen ph qun. Trong s bnh nhi c iu tr do cc bnh h hp ni chung. Bng 1. Tui v gii ca cc i tng nghin cu

Gii

Nam Bnh Bnh

N Bnh Bnh

Tng s Bnh Bnh

Tui

nhi HPQ

nhi h hp chung 560 188

nhi HPQ

nhi h hp chung 438 164

nhi HPQ

nhi h hp chung 998 352

<1 tui 15 tui

7 32

5 24

12 56

> 5 tui 30 Tng cng 69

68 816

22 51

57 659

52 120

125 1.475

Nhm la tui hen ph qun gp nhiu l > 1 tui. T l Nam/N = 69/51

T l bnh nhn hen ph qun so vi bnh h hp chung phi vo vin iu tr l 120/1475. T l bnh nhn hen ph qun so vi bnh h hp chung c lin quan n la tui : + + % + la tui nh < 1 tui, t l hen ph qun ch l 12/998 = 1,2% La tui 1 5 tui : T l hen ph qun/bnh h hp chung l 56/352 = 15,8

La tui > 5 tui : T l hen ph qun/bnh h hp chung l 52/125 = 41,5%

3.2. Tin s 3.2.1. Tin s bn thn Nghin cu tp trung v tin s bnh tt c lin quan ca bnh nhn hen ph qun. Bng 2. Tin s bnh tt v yu t lin quan cc bnh nhn hen ph qun

Bnh tt v yu t lin quan

S bnh nhn

T l %

Biu hin d ng (ni m ay, vim 27 mi ng, ban mn nga, d ng vi thc n, chm th tng). Vim ph qun phi ti nhim Lin quan thay i thi tit Khng c tin s d ng, hoc cc yu t lin quan. Tng s 41 18 34

22,5

34,2 15,0 28,3

120

100,0

S bnh nhn c tin s mc vim ph qun phi ti nhim (>3 ln) c t l kh cao (41/120 = 35%). 3.2.2. Tin s gia nh Bng 3. Tin s gia nh c bnh l hoc yu t lin quan n hen ph qun

Bnh tt v yu t lin quan

S bnh nhn 19 32

T l %

Gia nh c ngi b hen ph qun S gia nh c ngi biu hin d ng (chm, ni m ay, vim mi ng, d ng thc n v.v..) Gia nh khng c biu hin bnh l hay yu t d ng lin quan.

15,7 26,6

69

58,7

Tng s

120

100,0

S gia nh c ngi b hen ph qun v d ng chim 19 32 = 51/120 (ch tnh nhng ngi thn c quan h rut tht vi bnh nhn nh cha m , c d ch bc rut, ng b ni ngoi v anh ch em rut ca bnh nhn).

3.3. Mc nng ca cn hen ph qun khi vo vin nh gi mc nng ca cn hen ph qun da vo 4 mc : t 1 n 4 da vo cch nh gi ca TCYTTG. Bng 4. Mc nng ca cn hen ph qun

Mc nng cn hen I II III IV Tng s

S bnh nhn

T l %

54 55 11 0 120

45,0 45,8 9,2 0,0 100,0

a s bnh nhi vo vin trong tnh trng cn hen I v II (109/120 bnh nhn) ch c 11/120 bnh nhn mc cn hen nng 3. Khng c trng hp no cn hen nng 4 (hen c tnh). 3.4. Tnh trng nng ca bnh hen ph qun khi vo vin

Phn loi mc nng ca hen ph qun da theo TCYTTG, chia ra 4 bc ca bnh hen ph qun, t bc I n bc IV. Bng 5. Mc nng ca bnh hen ph qun

Bc hen ph qun S lng bnh nhn Bc I Bc II Bc III Bc IV Tng s 61 40 19 0 120

T l %

50,8 33,3 16,9 0,0 100,0

a s bnh nhn hen ph qun vo Vin bc I v bc II (chim t l 101/120) = %). 3.5. Tnh trng bi nhim ca hen ph qun Chn on tnh trng bi nhim ca cc bnh nhn hen ph qun da vo biu hin lm sng l st, ho, khc m vng xanh, nghe phi thng c ran m, cng thc bch cu v t l bch cu a nhn trung tnh tng cao, mu lng tng. Bng 6. Tnh trng bi nhim ca bnh nhn hen ph qun

Biu hin bi nhim h hp Vim ph qun Vim ph qun phi

S bnh nhi 36 29

T l % 30,0 29,2

Vim mng phi Khng c biu hin bi nhim Tng s

02 53 120

1,6 39,8 100,0

S112. TO HNH THC QUN BNG I TRNG NGANG QUA KHE THC QUN C TR GIP CA SOI LNG NGC
Nguyn Thanh Lim, Nguyn Thnh Cng Bnh vin Nhi Trung ng

Summary The aim of the report was to present experiences in transhiatal esophagoplasty by the transverse colon with assisted thoracoscopy. The technique is performed as following: With a longitudinal abdominal incision, transverse colon with the left colic artery was isolated. The hiatus was opened then the transhiatal esophagectomy was realized . Cervical esophagostomy was freed. Thoracoscopy was set up. Under vision of thoracoscopy, a retropleuaral tunnel was made by a cervical and transhiatal combined approaches.The transverse colon was anastomose with an abdominal esophagus above the cardia then pull up through the tunnel to be anastomosed with the cervical esophagus. An antireflux valve was made by suturing the fundus with a new esophagus.

From March to October,2001 , 3 children suffered from esophageal atresia were operated on with a good success. The technique is safe and could avoid the complications due to a tunnel was performed blindly without a thoracoscopy. Tm tt Mc ch ca bo co l nhm trnh by nhng kinh nghim bc u trong k thut to hnh thc qun bng i trng ngang qua ng khe thc qun c s tr gip ca soi lng ngc. K thut c tin hnh nh sau: M bng ng gia trn rn.Ly on i trng ngang c cung mch nui ng l ng mch i trng tri. M khe thc qun, ct thc qun qua ng khe thc qun. t ng soi lng ngc. To ng hm pha sau mng phi qua v tr giI phu bnh thng ca thc qun bng ng c v khe thc qun phi hp i s hng dn ca soi lng ngc. Ni u i i trng ngang vi thc qun bng st tm v. Lun thc qun qua ng hm ln c ni vi thc qun c.Khu phnh v ln vi thc qun to hnh to van chng tro ngc. T thng 1 n thng 10/2001 ,3 bnh nhn c phu thut c kt qu tt. y l mt k thut an ton v trnh c cc bin chng do to ng hm mt cch m qung nh trc y. I. t vn To hnh thc qun bng ng sau mng phi qua khe thc qun l mt k thut c nhiu u im tuy nhin kh nng lm rch mng phi v tn thng cung mch phi l nguyn nhn chnh lm cho nhiu phu thut vin e ngi khc phc nhc im ny trong thi gian gn y chng ti s dng soi lng ngc tr gip . Bo co ny nhm trnh by nhng kinh nghim bc u qua ba trng hp. II. Bo co bnh n Bnh n 1. Bnh nhn nam 9 thng vo vin ngy 2/3/2001, Bnh nhn l con u thng, cn nng lc 2800g.Lc 2 ngy tui tr c m v teo thc qun c r u trn vi kh qun. Bnh nhn c m ct v khu r kh qun nhng khng th ni hai u thc qun vi nhau v khong cch qu xa. c m thng d dy, dn lu thc qun c. Ln ny n m to hnh thc

qun. M bng ng gia trn rn v ko di xung i rn. Ly on i trng ngang c cung mch l i trng tri.M rng khe thc qun. Ct thc qun bng tr 1 cm trn tm v. Bc tch dn l thc qun c. t troca lng ngc qua lin sn 5 soi lng ngc. To ng hm qua v tr ng i ca thc qun sau khoang mng phi t pha c v t pha bng qua khe thc qun i s quan st trc tip qua soi lng ngc. a i trng ngang qua ng hm ny, mt u ni vi thc qun c, mt u ni vi thc qun bong st tm v. Khu phnh v ln vi thc qun to hnh to van chng tro ngc Sau m bnh nhn b r ming ni thc qun c vo ngy th by nhng t lin sau 3 tun. Bnh n 2. Bnh nhn n 9 thng vo vin ngy 6/6/2001. Bnh nhn c m lc 2 ngy tui v teo thc qun. Khi m thy quai ng mch ch quay phi, c r gia u i thc qun vi kh qun, hai u thc qun cch nhau khong 3 cm nn khng th ni trc tip. c ct v tht ng r thc qun-kh qun,m thng d dy, dn lu thc qun c. Ln ny n m to hnh thc qun bng i trng ngang i s tr gip ca soi lng ngc. K thut tin hnh tng t nh trng hp trn. Sau m tr b vim ph qun phi nng phi th my ko di v m kh qun. Sau 3 thng tr tr li rt ng m kh qun. Sau khi rt ng m thng kh qun, tr th bnh thng, n ung tt. Bnh n 3.Bnh nam vo vin ngy1/10/2001 lc 6 thng tui. Bnh nhn x c m lc 2 ngy tui v teo thc qun khng c r vi kh qun. trong khi m khng tm they u i thc qun. tin hnh m thng d dy, dn lu thc qun c. M th hai ngy 8/10/2001. Tin hnh to hnh thc qun bng i trng ngang qua khe thc qun c s tr gip ca soi lng ngc . Sau m din bin tt. III Bn lun. a s cc trng hp teo thc qun c iu tr bng phu thut ni thc qun tn-tn mt th tuy nhin mt s bnh nhn cn phi c tin hnh phu thut nhiu th khi hai u thc qun qu xa nhau . Phu thut th u bao gm ct v tht r thc qun kh qun nu c, m thng d dy v dn lu thc qun c.

Phu thut to hnh thc qun tip theo c th tin hnh bng phu thut tnh tin dn u trn thc qun ni vi u i(1) hoc dng mt cht liu khc thay th thc qun. Cht liu thay th c th bng ton b d y c nh trt ln lng ngc hoc bng mt phn d d dy (2,3) , bng rut non hoc bng i trng ngang (2,3,4 ). Chng ti a ng i trng ngang v hp sinh l hn. i trng c kch thc gn tng ng thc qun nn khng gy chn p cc tng trung tht, d y c gi nguyn v tr v kch thc nn khng nh hng n qu trnh tiu ho thc n. Trc y to hnh thc qun bng ng sau xng c hay c s dng v l k thut an ton khng gy cc bin chng o p vo tim v cc mch mu ln ( 4,5 ).Tuy nhin nhng nghin cu gn y cho thy con ng sau xong c khng tht ph hp tr con v s pht trin ca i trng khng tng xng vi lng ngc nn d lm cho lng ngc b bin dng khi ln. Ct thc qun v to hnh thc qun qua khe thc qun c Turner thc hin ln u tin nm 1933 v c Orringer pht trin rng ri vo nm 1984 (5,6). Trong k thut ny i trng c t ng v tr gii phu bnh thng ca thc qun qua mt ng hm pha sau mng phi c to nn bng ng c v ng qua khe thc qun phi hp K thut tuy c u im v thc qun to hnh c t ng v tr giI phu v sinh l bnh thng nhng do khi to ng hm phu thut vin khng th quan st c trc tip nn c nguy c lm rch mng phi v thng tn cc thnh phn ca cung phi c bit trong cc trng hp m c hoc bng thc qun ( 7 ). Trong nghin cu ny chng ti tin hnh to ng hm i s quan st v hng dn ca soi lng ngc. Phng php ny gip cho qu trnh to ng hm kh m qung trc y c thc hin doi s quan st trc tip v vy trnh c bin chng rch mng phi v thng tn cc thnh phn ca cung phi. Kinh nghim qua 3 trng hp cho thy y l mt phng php an ton. Ti liu tham kho 1. Kenkimura MD, Nishijima E, Tsaugawa C,et al. Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: our experience

in 12 patients.34th annual meeting. Pacific Association of Pediatric Surgeons.Kyoto,Japan 2001:55. 2. Gravilliu D. Etat actuel de procede de reconstruction de lesophage par tube gastrique. Ann Chir 1965,19:219-221. 3. Spitz L. Esophageal replacement. In: Oneil JA, Rowe MI, Grosfeld JL,et al.eds.Pediatric surgery. St Louis:Mosby,1997:981-997. 4. Waterson D. Colonic replacement of esophagus. Surg Clin North Am, 1964,44:1441-1445. 5. Jeaubert de Beaujeu M. Plasties de remplacement de lesophage. In:Pellerin D,ed.Technique de chirurgie pediatrique. Paris:Masson.1978:194-204. 6. Turner GG. Excision of thoracic esophagus for carcinoma and constructed of extrathoracic route. Lancet 1933,2:1315-1317. 7. Orringer MB. Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus. Ann Surg 1984,200:282-288. 8. L quang Ngha. Kt qu p dng k thut Orringerr trong bnh l thc qun. Ngoi khoa s 2 nm 2001:18-23

S113. NGHIN CU MT S C IM DCH T LM SNG V BC U NH GI KT QU THAY MU CHO TR S SINH VNG DA TNG BILIRUBIN T DO TRONG MU
BS CKII Trn Lin Anh - Khoa S sinh Bnh vin Nhi Trung ng

Tm tt Mc ch tm hiu mt s c im dch t lm sng, mc vng da, nng bilirubin v t l B/A (bilirubin/albumin) , c kh nng lin quan ti tn thng no ca 145 tr s sinh c thay mu ti khoa s sinh . nh gi bc u kt qu thay mu. Phng php nghin cu: Chn on vng da da vo quan st mc vang da trn lm sng, nh lng nng bilirubin huyt thanh, t l B/A. Ch nh thay mu theo phc ca Charles cho tr thng khi bilirubin TP mu l 25-29 mg/dl, B/A= 8, cho tr non khi bilirubin TP mu l 18-20 mg/dl v B/A= 7,2. Thay mu 2 th tch (160 ml/kg) c p dng cho tt c cc trng hp. Nghin cu tp trung vo tui nhp vin( tui c thay mu), mc vng da quan st ic trn lm sng, nhng yu t nguy c dn ti tn thng no v mi lin quan gia tng nng bilirubin , t l B/A vi cc du hiu nghi vng nhn no( VNN). Nghin cu theo di lu di da vo test nh gi pht trin tr em ca Denver vo lc tr c 3,6,9 thng sau xut vin. Kt qu: trong thi gian t 5/2001-5/2002 c 145/513 (28,2%) tr s sinh vng da nng c thay mu. Tui thay mu a phn vo lc 4-6 ngy sau ; 62,1 % tr thay mu l khng do bt ng h ABO m con; khng c trng hp no bt ng Rh. Nng bilirubin mu trung bnh trc thay mu l 31,6 7,27 mg/dl ( 20,2 => 53,3 mg/dl). T l B/A trung bnh trc thay mu l 9,1 2,93 (5,6 => 17,9). 62,5 % tr trc thay mu c cc du hiu thn kinh nghi c VNN. C s tng quan thun gia tng nng bilirubin mu, tng t l B/A trc thay mu vi cc du hiu nghi c tn thng no. T l cu sng nh thay mu l 97,1 %; khng gp tai bin trong thay mu; 75% tr c kt qa tt (pht trin ph hp thng tui) theo nh gi bng test Denver lc 9 thng tui. C s tng quan nghch gia mc vng da nng vi triu chng thn kinh nghi VNN, nng bilirubin mu cao, c bit t l B/A cao trc thay mu vi t l tr pht trin tt (theo test Denver).

Kt lun: T l tr s sinh vng da nng phi thay mu cn cao (28,2%) so vi cc thng bo ca th gii). Kt qu tt sau thay mu ph thuc mt s yu t: (1) vng da nng do pht hin mun (2) c cc triu chng thn kinh nghi VNN; (3) c nng bilirubin mu cao, c bit l t l B/A cao trc thay mu.

Abstract Objective To describe epidemiological aspects and severity of jaundice, serum bilirubin level and B/A ratio for 145 jaundiced newborns in ralation to kernicterus and to report initial evaluations of exchange transfussion (ET) outcome for them. Methodology: Severity of neonatal jaundice due to hyperbilirubinemia has been definied by clinical observation, by cheking the serum bilirubin level and the B/A ratio (bilirubin/albumin) .Using Charles guiderline, the ET has been taken for fullterm babies and prematures with bilirubin levels of 25-29 mg/dl and 18-20 mg/dl, the B/A ratio of 8 and 7,2 respectively. The double volume ET through umbilical vein was performed for all patiens . The study is focused on the age of addmission, the severity of jaundice, the risk factors of kernicterus and the relation between an increase of serum bilirubin as well as B/A ratio and the brain injury. The follow up study using Denver test has been applied for all patients at age of 3, 6, 9 months after hospitalization. Results: During the period from 5/2001-5/2002, 145/ 513 (28,2 %) of severely jaundiced neonates have been treated by ET . The most of ET has been performed at the age of 4 to 6 days after birth. 62,1% of ET is not associatted with ABOincompatibility. There is no case of Rh- incompatibility. The mean pre- transfussion total serum bilirubin level is 31,6 7,27 mg/dl (20,1 to 53,3 mg/dl). The mean B/A ratio is 9,1 2,93 (5,6 to 17,9). 62,5 % of severely jaundiced cases is shown to have pre-transfussion definite signs of kernicterus. The observation of these signs becomes more frequent for higher pre-transfussion serum bilirubin level and B/A ratio. 97,1% severely jaundiced newborns survived thanks to ET. There was no procedure complications. 75% of exchanging cases have a good outcome as shown by Denver test at the age of 9 month. We observed that the percentage of

good outcome is inversely proportional to the severity of jaundice, definite signs of kernicterus, high pre-transfussion serum bilirubin level, and particularly, high B/A ratio. Conclusion: The percentage of jaundiced newborns who have to be treated by ET is still considerably higher than the international reports (28,2%). The outcome is mostly affected by (1) the severity of jaundice because of prolonged observation. (2) clinical signs of kernicterus; (3) high serum bilirubin level, and particularly, high B/A ratio. Vng da bnh l{ s sinh gp khong 5-25% do nhiu nguyn nhn khc nhau. Ti cc nc pht trin, nh sm iu tr min dch d phng v s dng rng ri phng php chiu n sm nn t l tr vng da phi iu tr bng thay mu ch cn <1%[9,10,11]. nc ta, cha c con s thng k c th v rt tic cho ti nay t l tr vng da c triu chng tn thng no vn cn rt cao (25 % trong tng s vng a vo khoa s sinh Vin nhi trong cc nm 1996-2000). Xut pht t tnh hnh trn, chng ti tin hnh nhgin cu ny nhm 2 mc nh : (1)Tm hiu mt s yu t dch t, lm sng, cn lm sng ca tr s sinh vng da nng do tng bilirubin t do, phi thay mu. (2) Bc u nh gi kt qu thay mu iu tr tr vng da do tng bilirubin t do ti Vin nhi Quc gia. Nhiu nghin cu trc y tm thy c mi lin quan h t l thun gia tng nng bilirubin GT mu vi kh nng tr b tn thng no, nht l khi tr b tng bilirubin mu k o i khng c iu tr . Trong nhng nm gn y, thng qua kt qu nghin cu thc nghim, nghin cu lm sng, theo di lu di tr vng a sau thay mu cho thy tn thng no tr s sinh vng a thng xy ra do c s phi hp ca nhiu yu t*1,2,9+: tng bilirubin dng t do, gim albumin tr trong c th, tr c bnh km theo (nhim trng, ngt, non...) gy toan mu, v ph thuc s nhy cm ca tng c th vi c tnh ca bilirubin. Cc nghin cu ca Malik (1986)[8], Charles[2](1994) cn ch ra mi tng quan thun cht ch gia tng nng bilirubin t do vi t l Bilirubin/Albumin (B/A) v nng bilirubin gn vi hng cu (HC) . Trn c s

cc tc gi xut ch nh thay mu khng nhng ch da trn nng bilirubin TP, m cn c t l B/A hay nng bilirubin gn HC. Cc nghin cu ng dng thm thay i p ng thnh lc no(ABR)[3,5] ca mt s tc gi cng cho thy bilirubin t do hay t l B/A c gi tr hn trong tin lng tn thng no so vi bilirubin TP hay GT. Ngy nay trong iu tr tr vng da bnh l{ s sinh c 3 phng php chnh, c th p dng ring bit hay kt hp. l chiu n, ng thuc v thay mu. Thay mu l phng php ch ng ly bilirubin khi lng mch. Cng vi bilirubin, HC min dch, cc khng th cng c ly ra theo. Nh thay mu, lng Hb s c iu chnh trong cc trng hp b thiu mu, ci thin tnh trng toan mu (nu c). Hn na nh thay mu cc thnh phn tham gia gn vi bilirubin s c b xung t albumin trong mu ngi cho. V o bilirubin s c ko nhanh t t chc vo lng mch, dn ti s gim nhanh nng bilirubin mu[[10]. i tng nghin cu l 145 tr vng da nng , c chn on xc nh v c thay mu ti khoa s sinh Vin nhi Quc gia t 5/2001-5/2002. Ch nh thay mu vi tr thng- bilirubin TP 25-29 mg/dl, B/A= 8, vi tr nonbilirubin TP 18-20 mg/ l, B/A= 7,2. Cc trng hp loi tr l c bnh nng khc km theo, hay c bin chng nng ca bnh chnh . Sau xut vin tt c u c hn khm li nh gi s pht trin theo test Denver. K thut thay mu : X dng mu ti, hay mu lu tr < 72h, c chng ng bng CPD (Citrate Phosphate Dextrose). Nhm mu c chn tuz thuc nguyn nhn. ng thay mu thng nht p dng mt ng qua tnh mch rn. Khi lng mu ng k{ : 160 ml/kg (2 th tch). Cc bc tin hnh thay mu c thc hin theo phc . Ngi thc hin thay mu l cc bc s c nhiu kinh nghim. Phng php nghin cu c thc hin theo phng php tin cu, lm sng m t. S liu c x l bng phng php thng k y hc, s dng chng trnh Epi-info 6.0 Kt qu T thng 5/2001 n 5/2002 ti khoa s sinh Vin nhi c 145 tr vng da nng phi iu tr bng phng php thay mu, chim 28,2% tng s tr vng da nhp

vin. a phn tr c thay mu vo ngy th 4 n 6 sau sinh, tr non nhiu hn thng. V yu t bnh l gy vng da cho thy: a phn tr vng da nng khng phi do bt ng nhm mu h ABO (62,1%), t l bt ng gp 31%. Hn mt na l tr non(51%). 39,3% tr m c tin s dng thuc kch sinh . 35,9% tr c tin s ngt. Nng bilirubin TP trung bnh trc thay mu ca 145 tr l 36,1 7,27 mg/dl( 20,1-53,3 mg/dl), t l B/A trung bnh trc thay mu 9,1 2,23. Ch c 21,4% s tr c thay mu khi bilirubin TP cng nh t l B/A nm trong ngng ch nh. C s tng quan thun gia tng nng bilirubin v t l B/A (bilirubin mu cng tng th t l B/A cng tng). Hnh 1: Lin quan gia tng nng bilirubin mu vi mc vng da lm sng

c2 = 44,55, p < 0,001

Bng 1:Lin quan gia mc tng bilirubin mu vi triu chng thn kinh lc nhp vin BilirubinTP (mg/dl) 25 (n=31) > 2535 > 3545 > 45 (n=9) P

(n=70) Tr/chng thn kinh Li b Mt phn x mt Tng trng lc c r Cn xon vn th chm <40 ln/pht Cn tm ti St trn 37,5 C n % n % n

(n=35) % n %

7 22,4 43 61,4 31 88,6 5 6,1 34 48,6 30 85,7

100 P<0,001

8 88,9 P<0,001

3,2 18 25,7 24 68,6

100 P<0,001

0 3

7,1 21 60

8 88,8 P<0,001 7 77,8 P<0,001

9,6 16 22,9 19 54,3

9,6 14 20

14 40

5 55,6 P< 0,05 9 100 P<0,001

8 25,8 30 42,9 29 82,9

Kt qu thay mu: sng ra vin 142/145 (97,1%), t vong 3 (2,9%). T l tr pht trin tt sau thay mu(theo test Denver) tng n theo thi gian, ti 9 thng tui t 75%. Bng 2: T l tr pht trin tt sau thay mu , qua test Denver, theo mc tng bilirubin Mc tng bilirubin (mg/dl) T l B/A TS 3 thng 6 thng 9 thng TS n %

TS

25 1,03

16 7,4

12

75

85,7

100

>2535 8,5 1,32 >3545 11,05 1,73

40

27

67,5

18 13 72,2

11 8

72,7

21

14,3

10 6

60

> 8 45 13,6 2,11 TC 85

25

33,3

39

20

Bng 3: Yu t dch t lm sng Khi, xut vin, Cc yu t nh hng pht trin tt Khi, xut vin, chm pht trin n =19 19 1,49 %, TB 5,31 P <0,001 P

n = 42

%, TB

Tui vo 42 3,55 vin 1,48 (ngy) Tui thai 42 36,89 (tun) 2,89 Cn nng (g) Tin s 42 2485 652,9 15 35,7

19 38,56 1,46 19 2624 505,01 6 31,6

P< 0,05 P< 0,05 P>

ngt( nh,va) Bnh khc km theo 27 64,3 10 52,6

0,05

P> 0,05 RR=0,72

Bng 4: Yu t lm sng v cn lm sng Khi, xut vin, pht trin tt n = 42 Tnh trng ton thn Nh/ trung bnh St trn 37, 5 C Tm ti %, TB n = 19 19 0,67 %, TB 37,6 P< 0,001 Khi, xut vin chm pht trin P

Cc yu t nh hng

42 36,38 0,57

12

28,6 15

79

P< 0,001

9,5 14

73,7

P< 0,001 RR=6,16

Triu chng thn kinh

Li b

17

40,5 19

100

P< 0,001 P< 0,001

Mt phn x b

13

30,9 19

100

Tng 14 trng lc c r Cn xon vn ton thn Ri lon h 2 hp (th chm < 40l/ph) Bilirubin TP (mg/dl) lc vo vin Bilirubin GT (mg/dl) lc vo vin T l B/A (lc vo vin) Bn lun 1

33,3 18

94,7 P < 0,001

2,4 18

94,7 P < 0,001 RR=39,7

4,8 14

73,7

P< 0,001 RR=7,88

42 28,69 4,64

19 5,39

41,01

P < 0,05

42 27,38 4,58

19 37,05 5,66

P < 0,05

42 1,22

8,21

19 11,64 2,42

P< 0,001

Trong thi gian t 5/2001-5/2002 t l tr vng da phi thay mu ti khoa s sinh Vin nhi Quc gia cn cao (28,2 % ) so vi cc nc pht trin hin nay, do tr c pht hin v nhp vin mun. iu ny thy r kt qu nghin cu v tui

nhp vin, a phn cc chu c thay mu ngy th 4-6, ngha l mun. Nghin cu ny cha c iu kin i su tm hiu v nguyn nhn hay yu t bnh l phi hp gy vng a. Cng cn lu { rng, mt tr c th gp ng thi nhiu yu t bnh l, nn t l phn trm cc yu t quan st c ch mang { ngha tng i. Kt qu ca chng ti v c bn ph hp vi nghin cu ca Panagopoulos (1969)[13] v nguyn nhn gy vng da. Ch nh thay mu ca chng ti ch yu da vo kt qu xt nghim bilirubin mu khi nhp vin. Nh trnh by v nng bilirubin , t l B/A trung bnh trc thay mu, th c 2 con s trn u cao hn ch nh thay mu ang c p dng ti khoa. Ch c 21% tr trc thay mu c nng bilirubin cng nh t l B/A thp hn ngng ch nh. Ngoi ra, chng ti cn thy c s tng quan thun gia nng bilirubin v t l B/A: bilirubin cng cao, t l B/A cng ln. iu ny ph hp vi kt qu nghin cu ca Marlik[8], Charles[2] cho rng cn tnh n gi tr ca t l B/A khi quyt nh thay mu trong trng hp khng th nh lng nng bilirubin t do trong mu. V nng bilirubin trung bnh ca tr trc thay mu l rt cao, nn tt c tr khi nhp vin c vng a ton thn (vng hn nhiu so vi mc cho php ca vng da sinh l). Tuy nhin mc vng ngh m, hay nht hn c khc nhau tuz thuc nng bilirubin trong mu. Nh c th thy trn hnh 1, vi nng bilirubin i 25 mg/dl th ch 22,6 % tr c mu vng ngh m ton thn. Nng bilirubin mu cng cao, t l phn trm tr b vng m ton thn cng ln (bilirubin trn 45 mg/dl th 100 % tr c da mu vng ngh m ton thn). Nh vy bng vo quan st mc , vng da b vng, cc bc s lm sng c th d on tng i nng bilirubin mu c quyt nh x tr kp thi hn cho tr lc nhp vin. Nghin cu ca chng ti cn cho thy mi lin quan cht ch gia mc tng nng bilirubin mu v cc biu hin thn kinh nghi c tn thng no. 62,1 % tr trc thay mu c cc biu hin thn kinh khc nhau nghi tn thng no. ng lu { l, (bng 1) t l tr c cc du hiu in hnh ca vng nhn no (VNN) nh mt phn x b, tng trng lc c r, nht l cn xon vn ton thn, tng r rt cng vi nng bilirubin mu. Trong khi nng

bilirubin < 25 mg/dl khng gp trng hp no c cn xon vn ton thn, th nng bilirrubin >35-40 mg/dl c 60% v > 45 mg/dl c ti gn 90% tr c du hiu ny. Kt qu ca chng ti tng i ph hp vi kt qu ca Keneth(1960)[7] v Maisel(1995)[11]. Trong nghin cu ca Ng Minh Xun[12], nng bilirubin lc nhp vin ca tr thay mu thp hn ca chng ti (22,7 mg/dl) nn ch c 2/21 trng hp c du hiu tn thng no nng. V kt qu iu tr : trong 145 tr c thay mu th 142 tr ht vng a, c xut vin, t t l gn 98%. Ch c 3 trng hp t vong , trong 2 chu c bnh nng khc km theo (NTM, XHNMN), chu cn li c bin chng ca ca bnh chnh trc thay mu (VRHT). S t l t vong ca chng ti thp hn ng k so vi nghin cu ca mt s tc gi khc Bogg(1960)-7,3%[6] ; Taylor(1962)-7,7%[6] ; Panagopoulos (1969)-3,6%[6,13]; Diksh(1989)[4]-10,2%, mt phn do chng ti ch quyt nh thay mu cho cc chu vng da c tnh trng ton thn cn kh, c kh nng chu ng cuc thay mu. Ngoi ra, trong nhm nghin cu ca chng ti khng c i tng bt ng Rh . Khng c tai bin v tim mch cng nh tai bin lin quan ti k thut thay mu. Trc thay mu c 36/145 (24,6%) tr suy th tm, phi th oxy qua ng thng, sau thay mu t l ny gim r, ch cn 11 chu (7,5%). iu ny cng cho thy c s lin quan nht nh gia nng bilirubin mu v triu chng suy h hp. cng l l{ o v sao c s khc nhau v t l tai bin h hp ca chng ti v ca Panagopoulos[13] v Holvi[6]. Trong nghin cu ca 2 tc gi ny, tai bin ch yu lin quan ti tim mch cc i tng bt ng Rh, hay kh rt mu v tc mch. bc thm nh k qu iu tr cho tr vng da bng thay mu chng ti s dng test Denver nh gi s pht trin ca tr cc thi im 3,6,9 thng tui. Kt qu cho thy s tr pht trin tt, ph hp vi thng tui tng n theo thi gian, t 75 % lc 9 thng. S t l tr pht trin tt ca chng ti cha cao v a phn cc chu c thay mu nhng mun, c nng bilirubin cng nh t l B/A trc thay mu cao hn ngng ch nh, i tng nghin cu cha ng nht, bao gm c tr non, thng. Nhng chng ti thy c mi lin quan cht ch gia t l tr pht trin tt sau thay mu theo test Denver v nng bilirubin cng nh t l B/A trc thay mu (bng 2). nng

bilirubin v t l B/A thp ( 25mg/dl) th ti 9 thng tui 100% cc chu pht trin tt, ph hp vi thng tui. Trong khi nng bilirubin v t l B/A cao, s tr pht trin tt ch t khong 1/3. Nhng quan trng l, d nng bilirubin no th s tr pht trin tt sau thay mu cng tng n theo thi gian. Bi vy chng ti cho rng, ngay c vi cc chu c nng bilirubin mu cao, b nhp vin mun th thay mu vn l bin php iu tr tt nht, khng ch cu sng bnh nhn m cn phn no hn ch di chng thn kinh cho tr. V nguyn nhn (yu t) c th nh hng ti kt qu iu tr, chng ti thy gia 2 nhm pht trin tt v chm pht trin sau thay mu c s khc bit r rt v tui nhp vin vi p < 0,001. Nhm pht trin tt c nhp vin sm hn tr chm pht trin l (3,551,48) ngy so vi (5,311,49) ngy. Nh vy kh nng ln s tr nhm chm pht trin b tng bilirubin mu k o i trc iu tr. Kt qu ny ca chng ti ph hp vi mt trong nhng xut trc y v kh nng tn thng no nhng tr b tng bilirubin mu k o i khng c iu tr. V lm sng cng c s khc bit r c v tnh trng ton thn , cng nh cc du hiu tn thng nng h thn kinh trc thay mu. V cn lm sng, gia 2 nhm c s khc bit v nng bilirubin TP,GT trc thay mu, nhng r nht l s khc bit v t l B/A ( p<0,001): trong khi nhm pht trin tt t l B/A trc thay mu l xp x ngng ch nh thay mu, th nhm chm pht trin t l ny cao hn gp gn 1,5 ln. Kt qu ny ca chng ti ph hp vi xut ca mt s tc gi trnh by trn v vai tr ca t l B/A trong tin lng tn thng no, cng nh cc yu t lin quan c th dn ti tn thng no tr vng da nng [2,3,5]. Kt lun Qua nghin cu 145 tr s sinh vng a o tng bilirubin t o c thay mu ti Vin nhi, chng ti c th rt ra mt s kt lun sau: Vng a o tng bilirubin t do nng phi thay mu tr s sinh kh ph bin (28,2%). a phn tr c thay mu vo ngy th 4-6 sau sinh; hn mt na l tr sinh non (51%); 39,3% s tr sinh ra ngi m c dng oxytocin lc chuyn d; 31% tr c bt ng nhm mu m-con; 11,7% tr c nhim trng mu. V lm sng, a s bnh nhi khi vo vin c vng a m ton thn v c

cc triu chng tn thng thn kinh (62,1%), bilirubin TP trung bnh ca 145 tr l 31,6 7,27 mg/dl, bilirubin GT l 29,8 6,6 mg/dl v t l B/A trung bnh l 9,1 2,23.T l tr c cu sng nh thay mu cao ( 97,1% ), t l t vong ch c 2,1% do bnh nng khc km theo, hoc c bin chng ca bnh chnh. Khng c tai bin do k thut thay mu. Theo di s pht trin ca tr sau xut vin bng nghim php Denver lc 9 thng tui cho thy s tr pht trin tt l 75%. C s tng quan nghch gia tng bilirubin v t l B/A trc thay mu vi pht trin tt sau iu tr, nhng s tr pht trin tt tng n theo thi gian. Cc yu t nguy c chm pht trin tr vng da nng l: nhp vin mun, bilirubin mu tng cao, c bit lt l B/A tng cao, c triu chng thn kinh nng, tm ti, ri lon thn nhit trc thay mu. Kin ngh Qua kt qu nghin cu ny, chng ti c mt s kin ngh sau y: 1- Vng a o tng bilirubin t do kh ph bin tr s sinh, cn c quan tm thch ng. Cn hng dn cho cn b y t, gia nh bnh nhi cch pht hin vng a, cch nh gi mc vng a c thi x tr ng. 2- Cc trng hp vng da sm, vng nhiu cn c pht hin v chuyn ti bnh vin sm. Cn ph cp hn phng tin chiu n , c th ngay t tuyn huyn, hn ch bt cc trng hp phi thay mu. 3- Nguyn nhn gy vng a tng bilirubin t o s sinh cn cha c nghin cu y , cn c nhng nghin cu su hn v vn ny a ra nhng bin php d phng l yu cu cn thit. Li cm n. Tc gi xin chn thnh cm n GS. TS Nguyn Cng Khanh v s gip tn tnh v nhng kin qu bu lin quan vi nghin cu ny. Tc gi cng chn thnh cm n tp th bc s, y t khoa s sinh Vin nhi Quc gia v s gip , hp tc rt hiu qu.

Ti liu tham kho 1. Brodersen R and Stern L Deposition of Bilirubin Acid in the Central Nervous System-A Hypothesis for the Development of Kerniterus. Acta Paediatr Scand 1990 79;1219 2. Charles E.Ahlfors,MD. Criteria for exchange Trasfusion in Jaundiced Newborns. Pediatrics 1994 93, 3: 488-494. 3. ChukwumaG.Nwaesei,MD,MPH,FRCP(C); JohnVanAerde, BS,MD;Marilyn Boyden, MSc and Max Periman, MB,FRCP(C) .Change in Auditory Braistem Responses in Hyperbilirrubinemia infants Before and After exchange Transfusion. Pediatrics 1984 74,5: 801-803. 4. Dikshit SK, Gupa PK .Exchange transfusion in neonatal hyperbilirrubinemia. Indian. Peditr 1989 26: 1939-1145. 5. Esbjorner.E,Larsson.P,Leissner.P,Wranne. L.The Serum Reserve Albumin

Concentration for Monoacetyl-diaminodiphenyl Sulphone and Auditory Evoked Responses during Neonatal Hyperbilirrubinemia. ActaPaediatr Scand 1991 80: 406-412. 6. Hovi L and Siimes MA .Exchange Tranfusion with Fresh Heparinized Blood is a Safe Procedure, experiences from 1069 Newborns. Acta Paediatr Scand 1985 74: 360-365 7. Kenneth Hugh-Jones, Joan Slack, Kenneth Simpson, Aaron Grossman and David Yi-Yung Hsia (Chicago). Clinical Course of Hyperbilirrubinemia in Premature Infants : Preliminary Report. New England J. Med.1960 263,15:1223-1229. 8. MaLik GK;Goel GK;Vishwanathan PN. Free and Erytrocyte -Bound Bilirubin in Neonatal Jaundice. Acta Paediatr Scand 1986 75:545-549

9. Maisels JM, MB, BCh; Kathleen Gifford, RNC; Charles. Antle, PhD,and Gregory R.Leib,MD. Jaundice in the Healthy Newborn infant: A New Approach to an Old Problem. Pediatrics 1988 81, 4: 505-510. 10. Maisels MJ, Jaundice. In Neonatology Pathophysiology and Managemend of the Newborn, fourth edition, edited by Gordon B. Avery, Mary Ann Fletcher. J.B Lippincott Company Philladelphia (1994). Chapter 38. 11. Maisel MJ . Kernicterus in Otherwise Healthy, Breat-fed Term Newborns. Pediatrics 1995 96,4: 730-733 12. Ng Minh Xun. Vng da s sinh nng do tng bilirubin gin tip. Y hc thnh ph H Ch Minh 1997 1, 3:140-145 13. Panagopoulos,MD; Valaes T,MD; Doxiadis SA,MD. Morbility and mortality realated to Exchange Transfusion. The Journal of Pediatrics 72: 247-254 .

S114. SNG LC S SINH BIN PHP PHT HIN SM BNH L RI LON NI TIT CHUYN HO V DI TRUYN
GS. Ts. Nguyn Thu Nhn CH TCH HI NHI KHOA VIT NAM NGUYN VIN TRNG VIN NHI QUC GIA

I. t vn Thnh tu v i trong y hc ca th k XX l tm ra c khng sinh v sn xut Vaccin iu tr v phng chng cc bnh gy nn do vi khun. Nhng e o n sc kho con ngi khng ch c vi sinh m cn c c mi sinh.

T gia th k XX ngi ta quan st thy c mt s bnh tt u sinh ra trong mt s gia nh, mt a phng, mt chng tc nht nh. l nhng bnh l phn t, mang yu t di truyn v gia nh. l nhng bnh l ri lon ni mi bn trong ca c th con ngi. Nhng ri lon ny khng gy cht ngi ngay nh cc bnh cp tnh, nhim khun nhng tc hi to ln dn qu trnh pht trin v trng thnh ca con ngi. Nu khng kp thi pht hin, iu tit, b sung kp thi nhng khuyt tt mang tnh bm sinh, s dn a tr n tn ph, gnh nng cho gia nh v x hi khng nh, v s ngi mc bnh l l khng t trong cng ng, n c th l m thm lan truyn trong ging h, chng tc, nh hng n cht lng dn s. l tin ngnh sc kho th gii xut bin php lm sng lc s sinh, nhm pht hin sm, can thip sm nhng bnh ri lon ni tit chuyn ho v di truyn. II. ngha ca sng lc s sinh Phn ln cc bnh l ri lon ni tit chuyn ho v di truyn trong thi kz s sinh hay mt s nm u ca a tr thng cha bc l r rng rt kh pht hin v chn on, in hnh nh bnh thiu nng gip bm sinh hay suy gip trng (Myxoedeme) thng khng chn on ng. n khi cc du hiu lm sng v xt nghim c chng minh, y l giai on mun, khng cn kh nng hi phc hon ton, c bit i vi chc nng hot ng ca h thn kinh trung ng, tr tu v tinh thn ca tr. Hu ht cc bnh l ri lon ni tit chuyn ho v di truyn u tc ng n qu trnh pht trin c th, th lc, tinh thn kinh ca tr. Nhng ri lon bm sinh ny lm cho qu trnh ln ln v pht trin ca tr b ngng tr, nh n n v tr tu, chm ln, chm pht trin v th cht, khng pht trin dy th hay ri lon pht trin gii tnh, tm li l mt c th tn ph, khng c kh nng hon thnh c cc chc nng sinh trng. Tuy nhin, nhng ri lon bm sinh ny nu pht hin sm, iu chnh kp thi, b xung nhng thiu ht trong c th, gi thnh iu tr d chp nhn, a tr s c hi phc gn nh bnh thng.

V vy, sng lc s sinh mt bin php hin i trong y t d phng, d phng sm, d phng chu sinh c { ngha kinh t, x hi to ln, gp phn nng cao cht lng dn s, ci to ging ni c y t th gii xng l mt bin php chin lc sc kho ton cu trong th k XXI. III. Tnh hnh pht trin ca chng trnh sng lc s sinh trong 50 nm qua trn th gii Ngay t nhng nm 50 ca th k trc (XX), mt nhm Bc s nhi khoa v Sn khoa ti bang Texac ca Hoa Kz nghin cu thy c mt s tr trong cng mt gia nh mc mt s bnh ging nhau. T h ngh lm mt s xt nghim n gin nh test ferric chlori e chn on bnh phenylketonuria. y l nhm nghin cu u tin trn th gii ca vn phng sc kho b m tr em ca Masssachasetts tham gia vo chng trnh y t cng ng v sng lc s sinh cho tr em. n nm 1963, Bc s Robert Gubert pht trin thnh k thut mu git trn giy thm lm thnh qui trnh hng lot chng trnh sng lc s sinh cho 29 nc trong hp chng quc Hoa Kz cho mt s bnh l huyt sc t, ri lon ni tit, chuyn ho, v mt s bnh nhim khun. Cng thi im ny, gia nhng nm 60, Australia v Newzaelan bt u lm th nghim im, n u 1970 th pht trin thnh chng trnh quc gia vi 8 loi bnh Phenylketorunia,Galactosemia, thiu ht Biotinidase, Cystic fibrosic, thiu nng gip bm sinh, tng sn thng thn bm sinh, v MSUD (lit tu bm sinh) Ti cc nc Chu u nh Php. c, , H Lan, Thu S, Thu in, B, cng c t chc thnh trng trnh quc gia vo nhng nm 70. Chu c Singapore c bt u sm nht bng sng lc G6 PD vo nm 1965. Sau l Nht Bn, nm 1977 lm sng lc 4 bnh l PKU, MSUD, HCY v Histi inemia, n nm 1979 lm thm thiu nng gip (CH) v tng sn lng thn bm sinh (CAH) v test Wilson disease cho tr t 1 3 tui.

Hu ht cc nc khc trong khu vc trin khai chng trnh t nhng nm 80. C Hng Kng, Ma Cao lm nm 1984 vi 2 loi bnh l thiu nng gip (CH) v G6PD. Pht hin tn s mc bnh CH l 1/2404 s sinh sng. Trung Quc bt u lm nm 1980, pht hin t l mc ca CH l 1/3.600/ SS v PKU l 1/11.200/ SS. Hin nay Bc Kinh v Thng Hi lm c 95% tr s sinh ra hng nm. Nhng tnh trong ton quc th cn thp l 5% tr em c lm sng lc. i Loan cng c chng trnh sng lc s sinh t nm 1981. n nay 95% tr s sinh ra c lm sng lc 5 bnh: thiu nng gip, PKU, HCY, Galactosemia v G6PD, nm 2000 lm thm CAH. Nhng nc trong khu vc ng Nam v Ty Thi Bnh Dng nh Philippin bt u t 1990, lm c CH, CAH, Galactosemia, PKU, HCY v G6PD. 6 bnh, Thi Lan lm nm 1996 vi 3 loi bnh CH, PKU v CAH. Pht hin t l mc CH l 1/3.314/ SS. PKU l 1/285.005 / SS Vit Nam : bt u tham gia chng trnh sng lc s sinh t 1998, vi d n khu vc c tn gi l RAS/ 6/ 032 do Nguyn t nng quc t ti tr. Chng trnh bt u khi ng ti Vin Nhi quc gia. Qua 3 nm lm im ti H Ni, hin nay n giai on m rng pht trin n pha Nam v min Trung. T l mc ca thiu nng gip bm sinh ta H Ni c pht hin l 1/ 2.500/ SS v thiu ht G6PD l 2% tr trai. Nh vy qua 5 thp k nghin cu v thc hnh, chng trnh sng lc s sinh hin nay c ton cu ho khp 5 chu lc. Chng trnh thnh lp Ban ch o quc t vi s tham gia ca cc nh nhi khoa, sn khoa, di truyn hc, khoa hc k thut ht nhn. Nguyn t nng quc t l ngi ti tr ln cho chng trnh vi mc tiu s dng nng lng nguyn t vo mc ch ho bnh. Va qua hi ngh quc t ln th 4 ti Philippin cho khu vc Chu v Ty thi bnh ng nm 2001, c 25 nc tham d. Bangladesh, Trung Quc, Hng Kng, Nht Bn, Triu Tin, Thi Lan, i Loan, Singapore, Malaysia, In onesia, Nam Phi, Pakistan, n , Vit Nam, Min in, Mng C, Newzeland, Australia, o, Phn Lan, c, Guam, , M, Philippin. IV. K thut tin hnh

C 2 k thut tin hnh ph bin hin nay trn cc nc : K thut xt nghim ELISA K thut min dch huznh quang RIA Cch ly mu : Mu gt chn hay cung rn. Thi gian ly mu 3 5 ngy sau sinh ra. Mi mt bnh ly mt git mu, cho ln giy thm kh chuyn bit. phi kh ln gi trong nhit phng. Sau khi mu thm kh, cho vo phong b v gi v trung tm lab quc gia. Kt qu xt nghim tr li khng qu 1 tun.

- Trng hp ng tnh phi tin hnh iu tr trong vng 15 ngy u sau sinh. V. Nhng ri lon chuyn ho - di truyn hin nay ang c th gii lm SLSS : 1. Galactosemia. Do thiu galactokinase hoc UDP galactose 4 epimerase enzyme, s dn ti chm pht trin tinh thn, pht trin khng bnh thng thm ch t vong. Tn s mc trn th gii : 1 : 60,000 1 : 80,000/SS. 2. Tng sn thng thn bm sinh CAH. Do thiu ht enzyme 21 hydroxylase gy mt mui, chuyn gii, c th cht o cn suy thng thn cp v pht trin gii tnh bt thng nam ho hay dy th sm. T l mc 1 : 12,000 1 : 14,000/SS. Xt nghim nng 17 OHP. 3. Thiu men glucose 6 phosphate dehyogenese G6PD. Bnh c t l mc cao 200 triu trn ton cu, t l t 2 25% dn s. Gy tan mu do v hng cu.

4. Thiu nng gip bm sinh CH. C tn s mc cao, t l mc trn th gii 1 : 4000/SS, Chu 1 : 2500/SS. Nng TSH tng cao vi tr sau sinh 3 5 ngy. 5. PKU Phenylketonuria gy thiu nng tr tu nu khng c iu tr. Tn s mc m l : 1 : 10,000/SS 1 : 25,000/SS. 6. Alpha thalassemia . Tr bnh thng trong mu cung rn s khng c Hb Bart. Trng hp tr l alpha thalassemia 2 s tng ln 1- 2% Hb Bart v alpha thalassemia 1 s cao n 5 6% Hb Bart. 7. Bnh hng cu hnh lim Sickel Cell disease. Bnh t bin gn trong bta globin, sn xut ra Hb S thay cho A. 8. MSUD Maple syrup urine disease. 9. Histidinemia. 10.Biotinidase deficiency. 11.Cystic fibroris. 12.HCY Hmcystia niu. 13.RBC Red blood cell 14.Bnh teo c Duchenne. 15.Thnh lc, ic bm sinh. 16.Bnh PAH (Phenylalanine hydrroxylase aporuzyme). Tuz tnh hnh mi nc chn u tin. VI. Hng dn h thng cc bc tin hnh SLSS Chng trnh SLSS phi c m bo 5 bc sau : 1. Screening : Bc sng lc u tin vi tr SS (testing of newborn). 2. Follow up : Nhanh chng xc nh nhng trng hp ng tnh.

3. Diagnosis : Xc nh chn on sm nhng test ng tnh gi. 4. Management : Nhanh chng ln k hoch x l{ iu tr lu di v sut i cho tr. 5. Evaluation : nh gi cht lng lab, quy trnh x l. Can thip v to iu kin thun li cho bnh nhn, gia nh v cng ng thc hin chng trnh. y l 5 bc quan trng v bt buc m bo chng trnh SLSS t c mc tiu. VI. Qun l chng trnh : Mc tiu ca SLSS l a a tr t mt bnh nhn thnh mt ngi kho mnh. Nn tuz theo trng hp bnh l khc nhau, cn c s hp tc lin ngnh gia cc chuyn khoa huyt hc, ni tit, di truyn, tm thn, cc bnh nhim khun cp tnh nhi khoa, gio dc, t vn. Cn c s tr gip ca nh nc, ngnh Y t, cc on th qun chng nh t chc ph n, cc hi t thin phi chnh ph. Truyn thng i chng, hng ng v t ng gp ca gia nh, cng ng, nhiu quc gia, nh nc u t trang thit b lab, nhng chi ph cng ca ns, ho cht do gia nh tr. VIII. nh gi quc t vi chng trnh SLSS Mc tiu ca chng trnh l rt thit thc v cn thit, c hiu qu i vi sc kho cng ng. Chng trnh cn c t chc cht ch, vi nhng cng tc vin c lc, nhit tm, vi h thng sng lc cht lng, chn on v theo i, iu tr lu di ca cc chuyn gia. S h tr ca nh nc v hng ng ca cng ng s gp phn to ln trong chin lc con ngi tng lai ca ton nhn loi, nng cao cht lng dn s, ci to ging ni. IX. Kt lun Sau gn na th k khi ng, nghin cu, lm im v pht trin m rng, n nay CTSLSS chng minh hiu qu to ln, n gip a tr ln ln vi cuc sng bnh thng. Chng trnh em li hnh phc v tng lai cho hng triu

tr em trn th gii; l mt bin php chin lc d phng quan trng vi sc kho cng ng. X. Ti liu tham kho 1. The Journal of Pediatric. U.S Newborn Screening System Followw-up of children, Diagnosis, management and Evaluation. October 2000 Volumn 137 No 4. 2. Report of 4th Asian Pacific Regional Meeting of Intenational Sociaety for Neanatal Screening. October 19 2001. 3. Regional Program for the National Neonatal Screening for Congenital Hypothyroidism in East Asia. Bo co ti Hi ngh iu phi vin khu vc thin tn, Trung Quc thng 12 2002. 4. Bo co tng kt CTSLSS bnh suy gip trng bm sinh ti H Ni, Vit Nam t 1998 2001.

S115. U V THNG THN NAM HO BNH NHN TNG SN THNG THN BM SINH DO THIU 21-HYDROXYLASE
Nguyn Th Hon; Nguyn Thanh Lim; V Ch Dng. Bnh vin Nhi Trung ng.

Summary Virilizing adrenocortical tumor in patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency

Adrenocortical tumour have been described in patients with 21-hydroxylase deficiency. These tumours are usually considered to be ACTH dependent, as commonly seen diffuse cortical hyperplasia is commonly seen . We report adrenal cortical tissue tumours developed in three patients with untreated congenital adrenal hyperplasia due to 21-hydroxylase deficiency. All of them had symptoms of adrenogenital vililizing syndrome. A diagnosis of adrenocortical tumour was established by the symptoms, hormonal tests, ultrasonography, and CT scan. Two of the tumours were located in the right side, all the patients were treated by surgery before replacement therapy, and the histological diagnosis indicated an adrenocortical adenoma. After removal of tumours, the size of adrenal gland was monitored by serial ultrasonography, and the congenital adrenal hyperplasia was confirmed by extremely high levels of basal serum progesterone, testosterone, increasing virilizing syndrome, diffuse hyperplasia of adrenal gland.

Tm tt U v thng thn c y vn m t nhng bnh nhn tng sn thng thn bm sinh thiu 21-hydroxylase (TSTTBS) khng c diu tr. Cc khi u ny lun c coi l u ph thuc ACTH nh trong trng hp tng sn lan ta ca v thng thn. Chng ti bo co khi u v thng thn xut hin trn 3 bnh nhn mc TSTTBS thiu 21-hydroxylase khng c iu tr. C 3 bnh nhi ny u c cc triu chng nam ho. Vic chn on khi u v thng thn c thc hin da vo cc triu chng lm sng, cc xt nghim hormon, siu m v chp CT thng thn. Trong s 2/3 bnh nhi ny, khi u nm thng thn phi, c 3 bnh nhn u c diu tr bng phu thut ct b khi u trc khi dng liu php hormon thay th. Chn on m bnh hc ch ra khi u v thng thn lnh tnh. Sau khi ct b khi u, c 3 bnh nhn u c khm lm sng, xt nghim hormon, siu m nh k theo di kch thc ca tuyn thng thn, TSTTBS 3 bnh nhn ny c chn on da trn c s: cc triu chng nam ho tng

ln, testosteron, progesteron mu tng rt cao sau khi ct b u, trong khi siu m thng thn khng thy u ti pht m thy ph i ng u c hai tuyn.

1.

t vn :

Tng sn thng thn bm sinh (TSTTBS) l mt nhm cc ri lon di truyn ca tng hp steroi thng thn, mi ri lon gy nn bi s thiu ht mt trong nm enzym cn thit cho qu trnh tng hp cortisol. Nng cortisol thp trong mu khng gy ra feedback m tnh trn thuz trc tuyn yn v dn n s tng bi tit b tr ACTH. S tng ca ACTH lm cho v thng thn tng sn cng nh gy ra s tch t cc sn phm chuyn ho l tin cht pha trn v tr enzym b thi ht trong qu trnh tng hp cortisol (8, 12). Nguyn nhn ch yu ca TSTTBS l thiu ht 21-hydroxylase (21-OH): chim 90% cc trng hp. nhng bnh nhn ny: tng hp cortisol v al osteron u gim, o chuyn hng sang nhnh tng hp androgen lm tng nng 17-OH-progesterone (17-OHP), androstenedione v testosterone. S thiu ht enzym c th mt phn hoc hon ton gy ra cc bnh cnh lm sng khc nhau. Biu hin lm sng c th c chia thnh th c in v khng c in. Th c in c th biu hin bng cc triu chng mt mui trong 2/3 cc trng hp v kt hp vi nam ho, hoc ch biu hin bng cc triu chng nam ho n thun. Tnh trng nam ho c biu hin bng cc triu chng ca dy th sm gi (khng ph thuc gonadotropin) tr trai v cc biu hin nam ho vi mc khc nhau ngay t trong bo thai tr gi. Th khng c in c th khng c triu chng lm sng m ch c thay i v xt nghim hormon hoc c triu chng lm sng, nhng xut hin mun vi cc biu hin ca tng bi tit androgen cc mc khc nhau. Vic iu tr bnh bao gm liu php hormon thay th corticosteroid v mineralocorticoi phng trnh cn suy thng thn v c ch s bi tit ACTH v androgen (12).

Mt s tc gi bo co v s pht trin ca khi u v thng thn lnh tnh hoc him hn l carcinomas v thng thn, xut hin trn bnh nhn c chn on TSTTBS thiu 21-OH. Hn na, nhng nghin cu khc li nhn mnh tm quan trng ca vic loi tr TSTTBS nh mt chn on phn bit trc mt bnh nhn c u thng thn (2, 3, 4, 5, 6, 7, 8, 9, 10, 11). Chng ti gii thiu kt qu nghin cu 3 trng hp c khi u v thng thn nam ho xut hin trn nn ca TSTTBS thiu 21-OH c iu tr ti khoa Ni tit- Chuyn ho- Di truyn, bnh vin Nhi Trung ng. 2. 2.1. Gii thiu bnh n: Bnh n 1:

Bnh nhn L Vn L, nam, sinh ngy 9/8/1994, sau tr nn nhiu sau n, tr khng c khm tm nguyn nhn nn. Sau 5 tui tr ln nhanh, c bp vm v, nhiu trng c, ging m, trc khi n vin 6 thng c biu hin mc lng sinh dc, ng vt pht trin nhanh. Khm ln u lc tr 7,5 tui (thng 1/2002): thm da r, trng c, chiu i ng vt 7 cm, chu vi ng vt 7 cm, lng mu P3, th tch tinh hon hai bn 3,5 ml, huyt p 90/50 mmHg. Cc xt nghim ln u: siu m bng 2 ln: vng h thng thn phi c khi kch thc 24 x 17 mm, vng trung tm tng m, vng ngoi vi gim m khng ng nht; XQ tui xng: 13 tui, c xng vng; in gii , ng mu bnh thng; FSH = 2,05 mIU/ml; LH = 0,11 mIU/ml (bnh thng); testosteron mu = 12, 4 nmol/l (tng cao) (bnh thng trc dy th < 1 nmol/l). Chn on ban u: u v thng thn nam ho; iu tr: phu thut ct u (thng 1/2002); kt qu gii phu bnh vi th: hnh nh cu trc v thng thn, cc t bo lp li qu sn lnh tnh, ch yu l t bo xp sng, cha nhng git m nh, c c nhng t bo thm, nguyn sinh cht toan tnh, t ht, nhn t bo trn nm gia bo tng, c vng thoi ho mt nhn t bo, c vng mao mch tng sinh. Kt lun gii phu bnh : u v thng thn lnh tnh. Din bin sau m: cc biu hin nam ho vn c xu hng tng, thm a nng, c iu tr hydrocortison 10mg/m2 da/ngy t 31/12/2002 (sau m 1 nm),

khm lm sng sau m ct u 1,5 nm (lc tr 9 tui): P = 25 kg, H = 134 cm, da thm r, nhiu trng c, ng vt di 10 cm, chu vi 8 cm, th tch tinh hon hai bn 4 ml. Xt nghim: testosteron mu sau m ct u 10 ngy: 2,5 nmol/l; sau ct u 4 thng 23,3 nmol/l; sau ct u 1,5 nm: 20,4 nmol/l. Progesteron mu sau ct u 1,5 nm tng cao 22,3 nmol/l. LH 0,074 UI/l. FSH 3,3 UI/l (bnh thng), cortisol mu sau ct u 3 thng: 168,7 nmol/l, sau ct u 1,5 nm 160,5 nmol/l. Siu m thng thn sau m 3 thng; 1 nm; 1,5 nm u khng c u, cc xt nghim tm t bin ca gen CYP21; 17-OHP cha c kt qu. Nhn xt: Bnh nhn nam, c biu hin dy th sm gi v c pht hin c u v thng thn lc 7,5 tui, sau m ct u cc biu hin nam ho vn tng, cc xt nghim testosteron, progesteron mu vn tng rt cao sau m, siu m nhiu ln khng c u ti pht hoc di cn. Chn on xc nh: u v thng thn xut hin trn bnh nhn tng sn thng thn bm sinh. iu tr tip theo t thng 7/2003: tng liu hydrocortison n 15 mg/m2 da/ngy. 2.2. Bnh n 2:

Lng c K, nam, ngy sinh 03/8/1996. Ch gi u kho mnh, m c 1 ln thai cht lu, tr l con th 2, m v rau bm thp, ngay sau m pht hin thy ng vt to v thm, nn nhiu khng lin quan n n t 2 tun tui, lc mt thng tui xut hin tm ti, th ngp v c cp cu ti bnh vin Thu in, Qung Ninh bng th oxy, truyn dch, tim thuc g khng r trong 1 tun sau ra vin. Ti nh, tr vn nn n 5-6 thng tui mi ht, t 2 tui thy ln nhanh, ging m, trng c, c bp pht trin, mc lng mu. Khm lm sng lc 3,5 tui (2/2000): P= 24 kg, H= 110 cm, huyt p 100/55 mmHg; mt gi so vi tui, ging m, nhiu trng c, c bp vm v, lng mu P4, chiu i ng vt 7 cm, chu vi 7 cm, th tch tinh hon 2,5 ml. Xt nghim ln u: siu m thng thn: thng thn phi c khi t m 2,5 cm, khi nm ngang trc tnh mch ch i, thng thn tri 1,5 x 1 cm; chp CT: c u thng thn phi; XQ tui xng 10 tui (tui thc 3,5 tui); ng mu; in gii bnh thng; LH 0,12 IU/l, FSH 0,32 IU/l; progesteron mu 19,14 ng/ml; testosteron 10,72 nmol/l (tng cao).

Chn on ban u: u v thng thn nam ho. iu tr (lc 3,5 tui): phu thut ct b u thng thn phi 3 cm. Gii phu bnh vi th khi u: ngoi vi i bao x cn thy t lp t bo v thng thn tng i bnh thng, pha trong chim u th l cc t bo u to thnh m phn cch nhau bi nhng vch x mng, c ch t bo to thnh b, c ni cc t bo to thnh hnh tuyn. Bo tng c nhiu ht a toan, c ni bo tng c hc sng, cc nhn t bo hnh trn hoc hnh trng, mng nhn u, trong nhn c hc sng, khng thy hnh nhn chia, khng c hnh nh c tnh. Kt lun ca gii phu bnh: u v thng thn lnh tnh. Din bin sau m: cc biu hin nam ho vn nng ln: khm 23/7/2003 (7 tui) (sau m ct u 3,5 nm): P=35,5 kg; H = 133 cm; HA= 100/70 mmHg; Mt gi trc tui, da thm nng ton thn, trng c nng ton thn, nhiu mt, c bp vm v, lng mu P5, ng vt i 8 cm, chu vi ng vt 9 cm, th tch tinh hon hai bn 3 ml. Cc xt nghim theo di sau m: siu m thng thn sau m 3 thng, 6 thng, 1 nm u khng c u. Sau m 3,5 nm: siu m tuyn thng thn hai bn to hn bnh thng, nhu m u v cn gi hnh dng ch Y (khng c hnh u), kch thc thng thn phi 3,6 x 1,2 cm, thng thn tri 4,6 x 1,1 cm. XQ tui xng = 13 tui, c xng vng . Testosteron mu > 52 nmol/l, progesteron mu 29,8 nmol/l (tng rt cao). Cc xt nghim 17-OHP v phn tch gen CYP21 cha c kt qu. Nhn xt: bnh nhn nam c biu hin dy th sm gi, tin s c biu hin mt mui, cn suy thng thn cp cc thng u sau , u v thng thn phi c pht hin v ct b lc 3,5 tui, cc biu hin nam ho vn nng ln sau ct u, progesteron v testosteron mu trc v sau ct u 3,5 nm tng rt cao. Chn on xc nh: u v thng thn nam ho kt hp vi tng sn thng thn bm sinh. iu tr tip theo t 23/7/2003: hydrocortison 15 mg/m2 da/ngy. 2.3. Bnh n 3:

L Tu M, n, 13 tui. sau tr nn nhiu, dch sa, khng lin quan n ba n, st cn, da xm, b phn sinh dc ngoi bt thng. Tr c iu tr ti bnh

vin Nhi Hi phng 1 nm vi chn on: hi chng sinh dc thng thn, sau gia nh b iu tr. T nm 8 tui tr xut hin nhiu trng c, c bp vm v. Khi tr 11 tui (9/2001) tr c khm ti bnh vin Vit c v c chn on: u tuyn thng thn tri v c m ct u. Tr c chuyn vin Nhi ngy 3/6/2002, khm: ngoi hnh tr gi nhng nam ho nng, huyt p 110/60 mmHg, c bp pht trin, da thm nhiu, m vt di 5 cm, hai mi ln dnh lin, khng s thy tinh hon (Prader typ III). Cc xt nghim: karyotype 46,XX; XQ tui xng: c xng vng; progesteron mu 28,36 nmol/l (sau m 9 thng), 36,9 nmol/l (sau m 20 thng); testosteron 13,1 nmol/l (sau m 9 thng), 18,6 nmol/l (sau m 20 thng). Nhn xt: tr n, c biu hin nam ho (prader typ III) v mt mui t sau , b iu tr hormon thay th, c ct u v thng thn tri lc 11 tui. Sau ct b u, biu hin nam ho vn nng, progesteron v testosteron mu tng rt cao. Chn on xc nh: u v thng thn xut hin trn bnh nhn TSTTBS thiu 21-OH th mt mui. iu tr tip theo t 3/6/2002: hydrocortison 20 mg/m2 da/ngy. 3. Bn lun:

Cc nghin c v chn on hnh nh (CT scan hoc MRI) ch ra rng: tuyn thng thn bnh nhn TSTTBS nhn chung c kch thc ln hn, khi lng nng hn v c th pht trin thnh dng nhn nh khi u (1, 8). Nguyn nhn ca khi u thng thn xut hin trn bnh nhn TSTTBS vn cn cha r, nhng tnh trng kch thch ACTH mn tnh rt c th ng mt vai tr quan trng. chng minh cho gi thit ny Luciano R v cs s dng liu php hormon thay th iu tr cho 6 bnh nhn u v thng thn kt hp vi TSTTBS khng c iu tr hoc iu tr khng tt, sau mt nm khi u mt hon ton 3 bnh nhn v gim kch thc mt phn 3 bnh nhn khc (8). Nh vy vic iu tr hormon thay th c tc dng c ch bi tit ACTH v lm gim kch thc khi u. Vai tr ca ACTH cng c coi nh ngun gc ca cc khi u thng thn i dng cc nhn ln ca hi chng Cushing. Hu ht cc khi u ny c xu hng biu hin lm sng rt kn o v khng phi lun lun c s kt hp tng bi tit th pht cc tin cht ca cortisol v androgen (8). Chng ti khng c iu kin o 17-OHP c 3 bnh nhn gii thiu phn trn, nhng theo cc

nghin cu ca Seppel T v cs; Al-Alwan v cs th s tng ca 17-OHP s khng cn thit chn on TSTTBS trong trng hp ny bi v s gim hot ca 21-OH cng c th c tm thy cc khi u thng thn. Cc tc gi ny cng nhn xt rng: vic chn on TSTTBS thiu 21-OH da trn bng chng tng sn ph i c hai tuyn thng thn (1,8). Trong nghin cu ca chng ti: c 3 bnh nhn xut hin khi u thng thn trc khi phu thut ct b u u khng c iu tr ni khoa vi liu php hormon thay th mt cch tho ng: mt bnh nhn n th mt mui c chn on t tui s sinh nhng gia nh b iu tr, hai bnh nhn nam u c biu hin lm sng ca th mt mui ca TSTTBS thi k s sinh v b m nhng khng c chn on v b b qua. Kt qu ny cng ph hp vi nghin cu ca nhiu tc gi nc ngoi: Luciano R v cs, trong mt nghin cu gm 26 bnh nhn TSTTBS, pht hin c khi u thng thn mt bn 6 bnh nhn bng chp CT scan v MRI, trong : 4/6 bnh nhn khi u thng thn c pht hin ti thi im chn on TSTTBS, tc l trc khi iu tr bng liu php hormon thay th; 2/6 bnh nhn c iu tr thi gian i trc khi pht hin khi u, nhng c 2 bnh nhn ny u c kt qu kim sot hormon khng tt; 15/26 bnh nhn c kt qu kim sot hormon tt u khng pht hin c u ( 8). Mt lot cc trng hp khc v xut hin u v thng thn bnh nhn TSTTBS khng c iu tr liu php hormon thay th cng c thng bo bi Van Seters AP v cs (1981); Takayama K v cs (1988); Jaursch-Hancke C v cs (1988); Bathia V v cs (1993); Lee CY (2000) (2, 6, 7, 10, 11). Kch thc khi u ca 3 bnh nhn ca chng ti u 3 cm. Kt qu ny cng ph hp vi thng bo ca Luciano R v cs: tt c 6 khi u pht hin c u c ng knh nh hn 3 cm (8). C 3 bnh nhn ca chng ti u c phn thut ct b khi u thng thn v sau c iu tr liu php hormon thay th nh cc trng hp TSTTBS khc m khng c u. Cho n nay, quan im vn cn cha hon ton thng nht v vic iu tr cc khi u ny: liu cc khi u thng thn bnh nhn TSTTBS c kh nng pht trin t pht v tr thnh c tnh hay khng. Nhng bo co v khi u thng thn kt hp vi TSTTBS trong y vn cha nhiu. Mt khi khi u

thng thn c pht hin, s cn thit phi xc nh l u bi tit hay khng bi tit, cng nh u c hay u lnh tnh, iu l thit yu la chn phng php iu tr thch hp. Hin nay c s nht tr l: cc khi u thng thn bi tit phi c phu thut ct b. i vi cc khi u khng bi tit th kch thc u tr nn rt quan trng: nhng khi u c ng knh nh hn 5 cm lun l mt vn bi v cch tip cn c th khc nhau, trong khi u c ng knh trn 5 cm i hi phi phu thut ct b hu ht cc trung tm chuyn khoa (4,8). pht hin sm cc khi u thng thn, cc tc gi cn khuyn: kh nng ca mt u v thng thn phi lun lun c xem xt nhng bnh nhn ph i tuyn thng thn dng nhn v tin trin tng ln hoc c s thay i v xt nghim sinh ho ( 8). 4. Kt lun:

Bnh TSTTBS c pht hin ngy cng nhiu, theo bo co ca khoa Ni titChuyn ho- Di truyn, bnh vin Nhi Trung ng: mi nm c khong 20 trng hp c chn on TSTTBS. Trong nghin cu ny, t thng 2/2000 n thng 6/2002 chng ti gp 3 trng hp u v thng thn xut hin trn bnh nhn TSTTBS. Trong , 1 bnh nhn n c chn on TSTTBS t thi k s sinh nhng gia nh b iu tr, 2 bnh nhn nam cn li khng c chn on l TSTTBS trc khi phu thut ct b u. C 3 bnh nhn u c biu hin nam ho nng trn lm sng trc v sau ct b u, trong bnh nhn n c b phn sinh dc ngoi nam ho c pht hin ngay sau (Prader typ III). Testosteron v progesteron mu vn tng rt cao sau ct b u. Chn on u v thng thn c da vo cc triu chng lm sng, testosteron mu tng cao, siu m c 3 bnh nhn v chp CT scan thng thn xc nh khi u. C 2/3 khi u nm thng thn phi, tt c cc bnh nhn u c phu thut ct b u, kt qu gii phu bnh vi th cho php kt lun t chc u v thng thn lnh tnh. Qua nghin cu, chng ti nhn thy: sau ct b khi u v thng thn nam ho m bnh nhn vn tip tc c biu hin nam ho nng v tng ln, trong khi

khng c bng chng ca i cn hoc u ti pht cn ngh n: u v thng thn xut hin trn bnh nhn TSTTBS.

Ti liu tham kho

1.

Al-Alwan, Ibrahim MB, Navarrro et al. Clinical utility of adrenal ultrasonography in the diagnosis of congenital adrenal hyperplasia. J of pediatr 1999; 135(1): 71-75. Bathia V, Shukla R, Mishra SK et al. Adrenal tumor complicating untreated 21-hydroxylase deficiency in a 5 year-old boy. Am J Dis Child 1993; 147: 1321-1323. Bauman A, Bauman CG. Virilizing adrenocortical carcinoma: development in a patient with salt-losing congenital adrenocortical hyperplasia. J Am Med Assoc 1982; 248: 3140-3141. Cook DM, Loriaux DL. The incidental adrenal mass . Am J Med1996; 101: 88-95. Hamwi GJ, Serbin RA, Kruger FA. Does adrenocortical hyperplasia result in adrenocortical carcinoma? N Engl J Med 1957; 257: 1153-1157. Jaursch-Hancke C, Allollo B, Metzler V et al. Adrenocortical carcinoma in patients with untreated congenital adrenal hyperplasia (CAH). Acta Endocrinol (Copenhagen) 1988; 177 (Suppl): 146-147. Lee CY. Congenital adrenal hyperplasia (CYP21) complicated with adrenal tumor. Paediatric endocrinology and chemical pathology course in Queen Elizabeth hospital, Hong Kong, China. 2000. Luciano R.G, Berenice B.M, Guiomara M et al. Adrenal nodules in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: regression after adrequate hormonal control. J pediatr endocrinol metab 2001; 14: 415-419. Pang S, Becker D, Cortalingam J et al. Adrenocortical tumor in a patient with salt-losing congenital adrenal hyperplasia. Pediatrics 1981; 68: 242-

2.

3.

4.

5.

6.

7.

8.

9.

246. 10. Takayama K, Ohashi M, haji M et al. Adrenocortical tumor in a patient with untreated congenital adrenocortical hyperplasia owing to 21hydroxylase deficiency: characterization of steroidogenic lesions. J Urol 1988; 140: 803-805. 11. Van Seter AP, Van Aalderen W, Molenaar AJ et al. Adrenocortical tumor in untreated congenital adrenocortical hyperplasia associated with inadequate ACTH aupressibility. Clin Endocrinol 1981; 14: 325-334. 12. Walter L Miller. 2002. The adrenal cortex. In pediatric endocrinology. 385-416.

S116. TNH HNH BNH TT TR EM QUA SINH THIT TI KHOA GII PHU BNH BNH VIN NHI TRUNG NG NM 2002
L Phc Pht Ng Vn Tn Hong Ngc Thch

Tm tt Nghin cu 1148 trng hp sinh thit ti khoa Gii phu bnh Bnh vin Nhi Trung ng nm 2002 , kt qu nh sau: Cc khi u Vim : 40,2% : 34,9%

D tt bm sinh v bnh khc

: 24,9%

Nhm u: U lnh U c : 71,1% : 28,9%

Trong 62,4% cc khi u c tnh l u phi Nhm vim: Vim rut tha Vim lao Vim khc : 82% : 3% : 15%

Nhm d tt bm sinh v bnh khc: Bnh thuc ng tiu ho : 66,4%

Trong 94,2% l cc tt bm sinh c lin quan n s pht trin bt thng ca hch thn kinh. Summary Histo Pathological studies were carried out with 1148 cases in National Children Hospital in 2002. Result showed that: Turmors Inflammations Abnomalities and others : 40,2% : 34,9% : 24,9%

Tumor group: Benign Malignant : 71,1% : 28,9%

62,4% of the malignant cases were those of embryonic tumors.

Inflammation group: Appendicitis Tubeculosis Others : 82% : 3% : 15%

Abnomalities and other diseases: - Diseases of alimentary canal ( highest rate ) : 66,4%

All of them ( 94.2% ) is the result of abnomal increase of neuro ganglion cells. I. t vn Bnh tt tr em c rt nhiu im khc bit so vi ngi ln. Trn th gii, mi khu vc li c c im bnh l khc nhau do nh hng ca iu kin kinh t, chnh tr, x hi, a l... khc nhau. Cho n nay, c nhiu cng trnh nghin cu v bnh tt tr em, tuy nhin mt s lnh vc, s lng cc cng trnh nghin cu cn t, c bit l nghin cu c im bnh tt tr em qua sinh thit. Ngy nay, trong m hnh phn b bnh l{ ni chung, ung th ngy cng c v tr quan trng do cht lng chn on v iu tr cc bnh khc nh nhim khun, suy inh ng c ci thin ng k. M nm 1992 (10 ) , t l t vong o ung th chim10,4% nguyn nhn t vong tr em. n nm 1998, theo Richard & Ramzis t l ny l 23% ( 9 ). Vit Nam, theo Nguyn Vng v cng s ( 3 ), t l cht o ung th chim 6,7% nguyn nhn t vong tr em. gp phn chn on chnh xc v iu tr c hiu qu ung th v mt s bnh khc, sinh thit c vai tr rt quan trng. Chn on m bnh hc cho php xp loi cc khi u, phn loi bit ho t bo c tnh t cho bit tin lng v la chn phng php iu tr thch hp.

V nhng l do nu trn, chng ti tin hnh nghin cu c im bnh tt tr em qua sinh thit nhm mc ch: S b phn loi bnh tt tr em da trn c s chn on m bnh hc nh gi s phn b v c im tng loi bnh l.

T nhng kt qu thu c, chng ti hy vng gp phn nng cao cht lng chn on v iu tr cho bnh nhn. II. i tng v phng php nghin cu 1. i tng:

1.148 trng hp sinh thit ti Bnh Vin Nhi Trung ng nm 2002 c h s lu tr ti Khoa Gii phu bnh. Tiu chun thu nhn h s nh sau: H s ghi r h tn, tui, gii tnh. Tui: 0 - 15. C chn on lm sng, chn on Gii phu bnh r rng. 2. Phng php nghin cu: Nghin cu hi cu. Bnh phm c m t c im, tnh cht, kch thc, c nh v chuyn c parafin, ct mnh dy 3m, nhum H.E ( Hematoxylin Erosin ). Chn on vi th c thc hin ti khoa Gii phu bnh Bnh Vin Nhi Trung ng, c i knh hin vi quang hc. Cc trng hp phc tp c lm thm Ho M Min Dch hoc nhum phng php khc, hi chn lin vin. III. Kt qu - Bn lun 1. Bng 1. Phn b chung:

Phn loi S trng hp T l (%)

U 461 40,2%

Vim 401 34,9%

D tt & bnh l khc 286 24,9%

Tng s 1.148 100%

Bng 1 cho thy: Nhm cc khi u c t l cao hn cc nhm khc, chim 40,2%. 2. U lnh: U c: Nhm cc khi u: 328/461 133/461 71,1%. 28,9%.

Nh vy u c tnh c t l kh cao. T l Nam - N phn b nh sau: Nam: N: T l Nam/N: 86/133 47/133 1.8 - 64.7% - 35.3%

Hu ht cc tc gi u thy ung th nam gp nhiu hn n. Theo Nguyn Cng Khanh (2), t l Nam/N l 1,62. Malaysia (7) t l ny l 1,43. Theo Bi Mnh Tun v cng s (1), trong 4 nm 1989 1992 ti bnh vin BVSKTE c 107 trng hp u c tnh. Ring nm 2002, theo nghin cu ca chng ti c ti 133 trng hp. R rng lng bnh nhn ung th vo vin cao hn hn so vi nhng nm trc. Bng 2: U c tnh v lin quan tui

Tui S trng hp T l %

<1 14 10,5%

1-<5 55 41,4%

5 - < 10 33 24,8%

10 - 15 31 23.3%

Tng s 133 100%

Bng 2 cho thy: Tui c t l cao nht l 1- <5 : 41,4%. Theo Bi Mnh Tun v cng s (1), bnh ung th c t l gp cao nht 1 5 tui ( 61,68% ), kt qu ny kh ph hp vi kt qu ca chng ti. Bng 3: U c tnh v s phn b.

Phn loi U c ngun gc thn kinh U thuc h lympho U m mm U thn U xng sn U gan U qui U sinh dc U khc Tng s Bng 3 cho thy:

S trng hp 33 28 20 19 9 8 7 7 2 133

T l (%) 24,8% 21,1% 15,0% 14,2% 6,8% 6,0% 5,3% 5,3% 1,5% 100%

- U c tnh ngun gc thn kinh c t l cao nht, chim : 24,8% Ring u nguyn bo thn kinh chim ti 20,3% tng s u c tnh.

U c tnh cc v tr khc c t l thp hn, theo th t l: U thuc h lympho (21,1%), U m mm ( 15,0%), U thn (14,2%) - Theo Lesil L. Robinson (8), M nm 1993: U thn kinh trung ng v u nguyn bo thn kinh chim U lympho U thn ( Wilms ) :13% :6% :27%

- Trong nghin cu ny, chng ti thy: Cc khi u phi c t l cao chim 62,4% cc khi u c tnh. Theo Bi Mnh Tun v cng s (1), t l ny l 67,29%. Bng 4. Phn b u lnh tnh, u c tnh ti c quan:

Phn loi M mm ng tiu ho U c ngun gc TK U sau phc mc U xng sn U thn U bung trng U tinh hon U gan U qui Bng 4 cho thy:

U lnh 149 (88,2%) 97 15 10 16 2 11 4 2 26 ( 99,0%) ( 30,6%) (34,5%) (64,0%) (9,5%) (78,6%) (40,0%) (20,0%) (78,8%)

U c 20 1 34 19 9 19 3 6 8 7 (21,8%) (1,0%) (69,4%) (90,5%) (36,0%) (90,5%) (21,9%) (60,0%) (80,0%) (21,2%)

Tng s 169 98 49 29 25 21 14 10 10 33 (100%) (100%) (100%) (100%) (100%) (100%) (100%) (100%) (100%) (100%)

U c tnh thn c t l cao nht (90,5%), tip theo l gan (80%) v cc c quan khc. ng tiu ho c t l u c tnh rt thp chim 1%, 99% l u lnh, 97% l Polype tp trung i trng sigma v trc trng.

3.

Nhm vim:

- Vim c hiu ( Vim lao ) - Vim khng c hiu Ring vim rut tha ( VRT ) VRT v c im:

: 11/401

- 3%

: 390/401 - 97% : 329/401 - 82%

Vim rut tha cp ( VRTC )

: 118/329 - 35,9%

Vim rut tha cp Vim phc mc( VRTC-VPM ) : 211/329 - 64.1% Nam N Nam/N : 193 :136 :1,42 - 58,7% - 41.3%

Nghin cu ca cc tc gi trong v ngoi nc cho thy VRTC gp Nam nhiu hn N. cc nc pht trin, t l VPM do VRT t 20 -30%, thp hn nghin cu ca chng ti. Theo Nguyn Thanh Lim v cng s (4), t l ny l 53%.

Bng 5 : VRTC v lin quan tui:

Tui

<1

1- < 5

5- <10

10 - 15

Tng s

S trng hp T l %

1 0,3%

44 13,4%

159 48,3%

125 38,0%

329 100%

Qua bng 5, chng ti nhn thy: T l VRTC cao nht 5 10 tui (48,3%). Nghin cu ca nhiu tc gi khc cng cho kt qu tng t.

Bng 6: T l VRTC v VRTC VPM theo tui:

Tui VRTC VRTC-VPM Tng s Bng 6 cho thy:

<1 0 ( 0% ) 1 (100%) 1 (100%)

1- < 5 9 (20,4%) 35 (79,6%) 44 (100%)

5 - < 10 60 (37,7%) 99 (62,3%) 159 (100%)

10 15 49 (39,2%) 76 (60,8%) 125 (100%)

Tui cng thp, t l VPMRT cng cao. tui < 1, chng ti ch gp 1 trng hp c VRT VPM . Bng 7: D tt bm sinh v bnh khc: V tr ng tiu ho Thn niu qun Gan mt Xng S trng hp 190 26 17 11 T l (%) 66,4 9,1 5,9 3,9

Lch M mm Tu Tinh hon C quan khc Tng s Bng 7 cho thy:

11 7 6 5 4 286

3,9 2,4 2,1 1,7 1,4 100%

Nhm bnh ng tiu ho c t l cao nht (66,4%), trong 94,2% l cc tt bm sinh gy ra do s thiu ht hoc cha trng thnh ca hch thn kinh tp trung ch yu i trc trng ( Bnh phnh i trng bm sinh ). Theo Berverly (6), tn sut gp phnh i trng bm sinh l 1/5000 tr kho mnh, 10% lin quan n hi chng Down. IV. Kt lun Bnh l U ngy cng c v tr quan trng trong m hnh phn b chung bnh tt tr em. Ung th v t l cht o ung th ngy cng cao. Kt qu nghin cu cho thy: Nhm cc khi u: U c tnh chim Nam gp nhiu hn n, t l Nam/N l 62,4% u c tnh l u phi. : 28,9%. : 1,8%.

Nhm vim: Vim rut tha c t l cao nht trong nhm ny : 82%. VPMRT chim 64,1% cc trng hp VRT.

Tui cng ln, t l VPMRT cng gim.

Nhm d tt bm sinh v bnh l khc: Bnh thuc ng tiu ha c t l rt cao : 66,4%

Trong cc tt bm sinh chim 94,2%, lin quan n s thiu ht hoc cha trng thnh ca hch thn kinh tp trung i trc trng (Bnh phnh i trng bm sinh). Sinh thit lnh gp phn gii quyt vn chn on nhanh, chnh xc, rt ngn thi gian v nng cao cht lng iu tr Phnh i Trng Bm Sinh tr em. Ti liu tham kho Trong nc: 1. Bi Mnh Tun, Ng Vn Tn, L Phc Pht, Nguyn Trung Trc, L nh Ho. Cc khi u c tnh tr em qua sinh thit 4 nm 1989 1992 ti Vin BVSKTE . Nhi Khoa, 1994, tp 3 s 1, trang 31 34. 2. Nguyn Cng Khanh, Bi Ngc Lan, Trn c Hu. Bnh ung th vo iu tr ti vin BVSKTE trong 5 nm 1991 1995. Nhi Khoa 1996, tp 5, s 4, trang 156 162. 3. Nguyn Vng v cng s. Tnh hnh t vong do ung th trung tm Y t Bch Mai trong 18 nm . Gii phu Bnh v Y php 1974, tp 4 trang 1 -18. 4. Nguyn Thanh Lim, Nguyn Quc Vit, Nguyn Xun Thu. Biu hin lm sng ca VRT v cc yu t nguy c trong VPMRT T.E. Tm tt k yu cng trnh nhi khoa 1994, trang 291 - 292. Nc ngoi: 5. Beverly. B. Dahms. Pediatric Phathology. Volume two, second edition Lippincott Williams & Wilkin . P. 649 650. 6. Colin. L. Berry, Jean. W. Keeling Pediatric Pathology. Colin. L. Berry, Springger Verlag Berlin Heidelberg NewYork, 1981, P 247.

7. Lin HP, Khuzaigh. R, Ariffin. W, Chan.LL, Hoe TS, Ho. C, Lam. S. K.., His Ham, Tharam and Jaclson. N. Epidemiology of Childhood cancer. Malaysia Journal of Child Health, 1996, 8, P. 37 38. 8. Lesil L. Robinson. General Princplee of the Epidemionlogy of Childhood cancer. Pediatric Oncology, 1993, P. 3 -10. 9. Richard N. Mitchell, Ramzis. Cotram. Pathologic Basic of disease. Sixth edition. W.B Company, 1999, P. 260 -261. Robison. General Priciples of the Epidemiology of Childhood. In principles and Practice of Pediatric Oncology. Second edition. J. B. Lippincott Company, 1992, P. 3- 9.

S117. HI CHNG KHNG NHY CM HON TON VI ANDROGEN


Nguyn Th Tn Sinh (Bnh vin Bch Mai) Nguyn Thanh Lim (Bnh vin Nhi Trung ng)

SUMMARY The authors present two patients suffered from Androgene complete insensibility syndrome. They are 2 women with 46 XY chromosome. Phenotype is female. LH and Testosterone elevated. Two testis were revealed during operation and removed. t vn : Hi chng khng nhy cm hon ton vi An rogene c Morris m t ln u tin nm 1953. Nhng bnh nhn mc hi chng ny l cc c th c ngoi hnh l ph n nhng nhim sc th l XY. Mc d bnh him gp nhng

li gy nhiu kh khn v chn on v iu tr. Chng ti xin thng bo 2 trng hp gp gn y nhm trnh by cc biu hin lm sng ca bnh ny v thi x tr. Bnh n 1 Bnh nhn Phm Th L., 26 tui, vo vin ngy 13/9/2001, m s bnh n : 211336. L do vo vin : S thy khi vng bn phi gy au khi giao hp. Bnh nhn l con th 7 trong gia nh, ly chng 5 nm. Hng thng khng c kinh, cha c con. Sinh hot v chng bnh thng. Khm lm sng, ngoi hnh, tnh cch, ging ni ca n. Tuyn v 2 bn tng i pht trin. Khng c lng mu v lng nch. m vt c kch thc bnh thng, mi ln v mi b hnh thnh r. L tiu tch ri m o. m o l ti cng su khong 7cm. Vng bn hai bn s nn thy mt khi tng i nhn, di ng, n au, c kch thc v hnh th nh ca tinh hon. Thm trc trng khng thy t cung. Xt nghim : Nhim sc th : 46 XY. Xt nghim sinh ho : Testosterone : 34 nmol/l FSH : 4,16 mU/ml, LH : 32,92 IU/l, estrogene (E2) : 77,01 Pg/ml (bnh thng 283), Progesterone : 0,8 ng/mo. Chn on : Hi chng khng nhy cm vi Androgene. Do bnh nhn au khi sinh hot v chng do khi bn b chn p nn c ch nh m. M ni soi ngy 14/9/2001. Trong khi soi bng khng thy c t cung v bung trng. Tinh hon phi nm trong bng, tinh hon tri s thy trong l bn. Ct tinh hon phi bng ni soi, ct tinh hon tri ngoi bng. Hu phu din bin bnh thng. Kt qu sinh thit 2 tuyn sinh dc u l tinh hon. Bnh n 2 Bnh nhn Phm Th N., 24 tui, vo vin ngy 13/9/2001, m s bnh n : 211337. L em gi ca bnh nhn trn. L do vo vin v khi u vng bn. Ly

chng 3 nm. Khng c kinh, tuy nhin giao hp bnh thng. Gn y xut hin 2 khi u vng bn, au khi giao hp. Khm lm sng, ngoi hnh, tnh cch, ging ni l n. Hai v c kch thc trung bnh. S thy 2 khi ng bn kch thc 3 x 4cm. Khng c lng mu v lng nch. m vt c kch thc bnh thng. Hai mi ln v mi b hnh thnh r. L tiu tch khi m o. m o ct nhng rng, su khong 7cm. Thm trc trng khng thy t cung. Xt nghim nhim sc th : 46 XY. Xt nghim sinh ho : Testosterone : 25 nmol/l FSH :11,37 mU/ml, LH : 34,23 IU/l, estrogene (E2) : 43 Pg/ml, Progesterone : 0,43 ng/mo. Bnh nhn c soi bng ngy 13/9/2001. Soi bng khng thy t cung v bung trng. Hai tuyn sinh dc c hnh th ca tinh hon, c b mch tinh v ng dn tinh nm v tr l bn su. Ct hai tuyn sinh dc ngoi bng. Hu phu bnh thng. Xt nghim 2 tuyn sinh dc u l t chc tinh hon. Bn lun 1. C ch bnh sinh v chn on Testosterone c th trc tip tc ng ln cc t bo ch hoc c chuyn thnh dihydrrotestosterone (DHT) nh men 5a reductase. Testosterone hoc DHT sau khi vo t bo c gn vi mt protein tip nhn c hiu trong bo tng hnh thnh mt phc hp tip nhn hormone. Phc hp ny sau i vo trong nhn t bo, cht nhim sc c sao ch p sn xut RNA thng tin ch huy vic tng hp protein (1) (s 1). 5a reductase Receptor +

DHT

DHT-receptor complex

Receptor + T T-receptor complex t bo mRNA

tng hp protein S 1 - C ch hot ng ca Testosterone v DHT Hi chng khng nhy cm c phn lm 2 loi : loi hon ton v loi khng hon ton. Hi chng khng nhy cm hon ton vi Androgene l mt bnh di truyn ln ca nhim sc th X gy nn cc khuyt tt v cm nhn vi Androgene mc t bo. Biu hin ca b phn sinh dc ngoi rt thay i, t b phn sinh dc n vi "m vt" hi to n b phn sinh dc nam c l tiu lch thp. Mc d tinh hon c th xung bu hon ton nhng bnh nhn vn khng c tinh trng. V c th to khi n tui dy th. Trong cc trng hp nh, ngoi hnh hon ton l nam v bnh nhn ch khm v l do v sinh. Xt nghim sinh ho thy tng LH, testosterone v estrogene. Sinh thit tinh hon bnh thng nhng chp ng sinh dc tit niu thy c m o hoc ti cng tin lit tuyn (1,2). Hi chng khng nhy cm khng hon ton vi Androgene cng c th do thiu ht men 5 reductase lm cho Testosterone khng chuyn c thnh DHT. Khi mi sinh, tr c l tiu lch thp th bu-tng sinh mn, tch ri khi l m o v thng c khai sinh l con gi. n tui dy th, cc c tnh nam bt u xut hin, ng vt to ln, ging khn, mc lng mu v lng nch. Khng bao gi c v to. Estradiol rt thp. Testosterone tng cao nhng DHT gim, v vy t l Testosterone/DHT tng cao (2).

Hi chng khng nhy cm hon ton vi Androgene l do DHT khng c vn chuyn vo nhn t bo do khng c protein tip nhn. L bnh di truyn gy nn o t bin gene khu tr Xq11-12, do m truyn cho con trai (3). Nhim sc th ca bnh nhn l 46XY. B phn sinh dc ngoi hon ton ging ca con gi. C m o ct, mi ln v mi b, "m vt khng to". Tuyn v pht trin. Tinh hon nm trong bng hoc ng bn. Nghin cu trn 23 bnh nhn, Alvarez Nave thy 65% c tinh hon hai bn nm trong bng, 26% c tinh hon phi trong bng, tinh hon tri trong ng bn, 9% c tinh hon phi trong l bn v tinh hon tri trong bng (3). Bnh nhn thng n khm sau tui dy th v v kinh v khng c lng mu v lng nch. Xt nghim thy LH v testosterone tng cao. Hai bnh nhn ca chng ti thuc nhm khng nhy cm hon ton vi Androgene. V lm sng rt in hnh. Ngoi hnh l n, ging ni v tnh cch n, b phn sinh dc ngoi l n, ly chng nhng khng c kinh. X t nghim LH v Testosterone tng cao. Nhim sc th l XY. Khi m thy tuyn sinh dc l tinh hon. 2. iu tr V iu tr, a s tc gi u thng nht nn gi nguyn gii tnh n cho cc bnh nhn b hi chng khng nhy cm hon ton vi Androgene. Kt qu theo di lu di cho thy, cc bnh nhn ny u hi lng vi vic la chn gii tnh n v hi lng v hot ng tnh dc (4). Mc d vy, khi no nn ct b tinh hon vn cn l mt vn cn c tranh lun. Cc kin mun ct b tinh hon sm thng xut hin t pha b m. Tuy nhin, sau khi ct b tinh hon, o lng estrogene gim xung, v vy cn phi c iu tr estrogene thay th pht trin cc c im n tnh khi bnh nhn n tui dy th (1,5). Thc t cho thy, tinh hon trong bng cc bnh nhn b hi chng khng nhy cm hon ton vi Androgene c t l c tnh rt thp. Trong 121 bnh nhn c sinh thit tinh hon, trong c 29% tinh hon c ct sau tui dy th, Ahmed thy khng c trng hp no c biu hin c tnh (6). Kt lun Tc gi trnh by 2 trng hp khng nhy cm hon ton vi Androgene. C hai bnh nhn c biu hin tnh cch v ngoi hnh l n nhng

nhim sc th l XY. ly chng nhng v kinh. X t nghim thy LH, Testosterone v estrogene tng cao. C hai bnh nhn u c ct b tinh hon. Ti liu tham kho 1. A. Aronson IA.. Ambiguos genitalia and intersexuality. In : O'Donnell B, Koff SA, eds. Pediatric urology. Oxford : Butterworth, 1997 : 651-679. 2. Kuttenn F. Les anormalies de la diferenciation sexuelle. In : Mauvais - Javis D, Sitruk-Ware R, Labrie P. eds. Medecin de la production gynecologie. Paris : Flamarion, 1982 : 260 - 287. 3. Alvarez Nave F, Gonzalez S, Soto M, et al. Complete androgen insensitivity syndrome : clinical and anatomopathological findings in 23 patients. Genet Couns 1997, 8 : 7 - 12. 4. Wisniewski AB, Migeon CJ, Meyer Bahlburg HF, et al. Complete androgene insensitivity syndrome : long term medical, surgical and psychosexual outcome. J Clin Endocrinol Metab 2000, 85 : 2664 - 2669. 5. Leow MK, Loh KC. 46 XY female a case report. Ann Acad Med Singapore 2001, 30 : 71 - 75. 6. Ahmed SF, Ccheng A, Dovey L, et al. Phenotypic features androgene receptor binding and mutational analysis in 278 clinical cases reported as androgene insensitivity syndrome. J Clin Endocrinol Metab 2000, 85 : 658 - 665.

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