BQYTE

..

Huang d&n dieu tr] va sil dl;lng thuoc

(Dung cho hac sj va duac sj tuyen co so)
(Tdi ban tan thit ba)

NHAXUATBANy HQC HA N(n - 2004

sa DUNG TAl
Y TE

LII;U ClIA CHuaNG TRiNH HQP TAc VieT NAM - THVY ell~N LiNH vue

.. CHi~H SACH

vA

QUAN LY

THu6c

(ADPC)

LOI
Trang Dang thu6c xuat han

Glen THIEU •
tinh hinh san xuat va cung irng phat trien luoug

10 nam qua, nbo chinh sach d6i moi cua buoc co chat

va Nha ruroc, da: co nrnrng nhieu thuoc

maio Cong nghiep

truoc. Nam. Nhieu Danh
.

ducc Viet Nam dii day manh d6i moi cong nghe va san tot han thuoc cua nuoc ngoai duoc hru hanh muc thuoc ngay cang phong thu6c va duoc thuoc.

a Viet

sy co

phu, tao dieu kien eho thay

them kha nang lira chon va

sa

dung

Danh muc thUDC rhiet yeu cua Viet Nam cong b6 cua B9 y yell do T6 sach thuoc thiet

Lin thir 3 trong nam 1995 th~ hien chit truong te tiep tuc thuc hien chinh chirc Y te The giai d6 xuat. Trong toan, hop

boi canh hien nay, van dt

1y

sa

dung trong

thuoc dac

an biet.

ngay

cang

c6 tam qllan

Thieu kien thirc dung dan v6 thuoc, hau qua nghiern trong: kh6ng

viec su dung thuoc

cua can bo y te va nguoi dung thuoc se c6 tht mang lai bao dam an toan cho sue khoe nguoi benh vagay lang phi tien cua ella Nha nuoc 3

y,\

ua nhan dan, an loan, hop l)i,

Dc' (him bao thuoc diroc str dung

cluing ta can mot
10,.\1

bien phap dong bo, trong do viec

cung cap nhirng

k icn tlnrc dung dan, din thiet vc dieu

cho can bo y Ie, nhfil III can bo y te

Ir! va sir d~lI1gthuoc

co sa, co mot lam quail trong dac bier. Cuon sach "Huang d,lll dieu tr]

va sir
CO

dung

thuoc"
SLI,

dung cho bac s9 va duoc sy tuyen Tien sy Hoang cua mot Tich Huyfn

sa do Giao
nghiem

chu bien va co su tham gia chuyen

tap th~ cac tac gia co kinh

rnon, da dap irng yell cau dip bach noi tren. Mong rang

cuon such se co Ich eho can b(> y Ie, dac bier 13 can bo yte
CO

sa trong cong viec thuc

te hang

ngay.

Xin tran rrong giai thieu cung ban doc.

Pho giao

SU,

Pho lien sy LE VAN TRUY£N

Thu trtrong B(> y

Ie

~
,

Chu bien: Gi::io su I-IOA.'\C; TjCl-IIILY~:N Tham gia bien

I. 2.
SO(lIl:

Pho lien Sf LE utc CHI'\II Pho giao sLiI'HAM (ilA Pho g iao Pho giao Giil.O str Pi10g iao

cuox«

3. 4. S. 6. 7. X. 9. ! O. 11.

Slf ,\(;LY{~!\ VA.I\· nA:\,(;

StT

Lt lJIEM
Ui!\H HAl

vr
SIJ

Ll~Dlfc HI\'H
TIcH IIUY£,\

Cii::io sir 1I0A.~<;

B<k Sf PH AI\' KIEM Ph6 lien Sf \'Gt:yt:\' VI NINII VIET THIEM

Pho gi.io

SLr N(;trYEN H(rc PH (lc

pho lien Sf MilIYE;\i

12.
13. 14.

Bile Sf PHAN KHANH TRVdNG

Pho g i{IO SL( LE V Al\' TR UYEN

Giao su LE TL· V AN
Pho tien Sf NGLYEN THI VINH

15. Bien tijp

va hieu

dinh:

vr

OhH HAl TICH HCYf~N

HOA\(;

:''I;(;l'YE'II THI VI\,H

MVC Ll)C
Trang Phan I: Huong dan dieu tr] J. Sot
')

vu
V;i

Dlnh H'·li Pham Gia Cuong .. __ _

Sill

dill

VlI Dlnh I-Lil

14 20 25 __ 29 .
38

J. Thicu m.iu
4. Phll

vn Dlnh H,\i
Vfi Dinh H,\i VlI Dlnh H,'Ii

5. Kilo tho'
6. Ho

vn Dlnh Hai
va Le Due Chinh

7. Ball nguc
g. T~lI1g hu yet ,ip 9.

YO Dinh Hai

44
50

v 1I81 nh

H,'l i _

Ia

chay cap

Vii Dinh Hai

56

10. Dal! h~lng 11. Dau khop

vn Dinh HAi v;\ Lc Dire Chinh

Vii Dinh H;'\i

64 _._ 70

12. H6n me
13. Nh icrn doc cap

Lc Due Hinh

7X XX

Vu Dinh Hai

14. D6ng kinh

Nguyen

Van D,-l11g

100 112
123 133

IS. Vet thuo'ng v~ bong Nguyen Dire Phuc 16. Mot so tnral~g hop c'-tp ciru trong t am than I19C Nguyen Viet Thiem
! 7. B¢nh ve mat

VO Dlnh Hili V~I Phan Kiern

1X. Mot s6 benh tai nuii hong tlurong g~lp

19.Cic bcnh da thong t lnrong

Phan Kh.inh Truong ..... 140 Lc TiT Vtlll lSI

I 60

20. Benh lily truycn qua duong ~lnh due 21. Phu san khoa

r.e

Tir V {Ill

Lc Diem

16B Ig I lS3

22. Lich ticm chung tre em Phan II: Huang dan Slr dung thuoc HO~H1g Tfch Huyen Nguyen Nguyen Phu luc
Ph() 1;1e dung ella khang sinh

Vi Ninh Thi Vinh

HUaNG DAN DIEU TRI. .

,

SOT

cs va Dlnh
va S61 HI khi than nhier do do

Hdi

pcs

Pham Cia Cuang

duoi nhirng

a true

if

nach cao han 37,5°C, hoac sot, du co earn giac "gai

trang

cao han 38"C. Than nhiet

con so d6 khong the' coi

gai", hoac

birth thuong, than nhiet cao len khi gang sire the life, khi an, khi nhiet do ben ngoai cao, va a phu nir trong giai doan sau cua chu ky kinh nguyet, tit ng ay r~ng rrung tra di. Than nhiet COil phu thuoc van
tuoi:

o ngiroi

sa tran

la

thay "am d.:l.u" ,

de sol hem nguoi Ion vII nguoi cao tuoi I hi it k hit h an nhiet lang! BUb i S;\ Il g, I han 11h icr bi nh
t re con

thuong

cling thttp han buoi chien.

cha ncn phai do than

n hiet 1. Ifill moi ngay

Trong tnrong hqp sot nhe, ngiroi benh hay thfiy 611 lanh, hoac nong birng, chan an, nlurc (hill, kho chiu, rap rnoi, cling co khi khong cam thfiy gl khac, Nlurng khi sot n~ng, tren 40"C, ngiroi benh hay ret run, co khi rung d gunmg chieu: sot cao nira co th~ me sang, co gi;)t, nil,'lt I~\ sot cao trc em. Trong thuc tien, it khi than nhiet
vLf01

qua 41 "C.

Nell sot kco dai qua 2-3 tuan I~, co the bi mat ruroc,
hao

ton calo, lam tim dap nhanh, sut can nhanh.

S61 la phan Ling nr nhien ella the. dt d6i

Nguyen nluin sift

C(1

rho

voi

nhicu lac nhan gay benh; nguoi qua gi~\ hoac qua yeu thuong

sot It hoac khong sot, ngay ca khi nhiem khuan

gap ella sot l a:

nang. Nhirng nguyen nhan thuong

1. Nhiern truong nguyen

khuan

(virus,

vi khuan, phai

ky

sinh

trung, 60%

narn). Day la nguyen

nhan hay g~p nhat, khoang

hop, eho nhan nay.

nen dau lien

nghi ngay

den

Tnroc her phai di tim cac diu hieu chi diem, xem co ehb nao dau hoac sung, nang, do, rmrng rnu khong? Vi du: • • • Dau dau: di tim ap-xe nao, viem nao. Dau va cling Dati nguc:
(j

g<l.y: viern mang nap. phoi, viern mang phoi, ap-xe

viem

phoi, vicm mang tim.

10

• Dau

bung:

viern

I"U¢t

thira,

ap-xe

gan,

viern

dirong mat
• Dau khop: Ihfip khop cap, viern khop dang thap, nhiem khudn khop,

• Dau hach: nhicrn khuan k hu vue, viern hach.

San do, xac dinh 'chan doan bang cac xet nghiern eric Ih[uTI do chuyen than, nhtr (huang han, lao ...

v11

khoa d~ tim cac nhiern khuan toan

2. Cac nguyen nhan khac khong phai nhiern khuA~1 thi it g~p han nhicu. Vai thi du:
• • Lupus ban do he thong de gay sot kco dai; U ng thu (-;c.ic phil tang nh If
V.V ...

gall,

nao, til y song,

phci, tuy, than

• tan mali ... •

Benh huyet hoc nhir benh

bach

cau, chay mau,

Nh6i mall

co tim cling co thti sot nhe;

• Do tiem truyen (chi nhiet to), do thuoc, er Dieu tri trieu chirng sot.
Truce mot ban, thao vi du: mang

ngiroi sot, chira nguyen

phoi, mang tim, corticoid

nhan HI can choc phap lieu

dit bo ruot thira, th.io mil ap-xe, ban.-d6) v.v ...

(trong lupus

II

Nhirng dong thai cung can chua trieu chung sot, \lhtit Ia khi chua hoac khoug tim thay nguyen sot lai cang can thict
sot them I "C, thl co the can them

nhan, Ihl chira

'if Tiep ruroc day du: khi than nhiet qua 37°C, elf
lOO-150ml iuroc moi ngay: khi troi k ho hanh, hoac ra nhieu mo hoi, eo Ih6 con can nhieu
ruroc han nita. Tot nhat

la bang duang

uong, co the dung mroc qua, nuoc che loang, nuoc rau ,

sfra, hoac ruroc dun soi giup ha than nhicr them.

de

nguoi tuy rhco kh[iu

V!

cua

nguoi bcuh. Uong diroc ruroc lanh hoac mroc d.i cang

o nguoi

sot keo dai, ncn chu

cung cap du calo, VI

khi than nhiet tang I"C, chuycn

Nen cho duong , sua, qua. Chi khi nao khong do non, kho nuot Phan 16'n twang

hoa co ban t~l1lg 1Yk.

the u6ng dll niroc thea yell cau , an, moi phai truyen
cac dung dich 5%, hoac dung dich. ding dich

hoac chan hoac

hop nen truyen glucose

truong,
Ringer dung

NaCl 0,9%
dich glucose

lactat. Trang nhirng ca dac bier, co the dung

uu truong (10%-30%)

de

tiep them iron them

calo, hoac nhuoc truong

(NaCI 4,5%0).

thuoc khac van dich truyen,

de tranh

Khong

tuong ky thuoc.

'U' H~ nhiet chi can khi sot cao, than nhict qua 4WC, nhat HI (1 Ire em, hoac khi kern theo eo thai, co giat, me
12

sang. Sot tren 41 "C phai coi la cap cuu.

o ngiroi 16n, neu khong

co benh gikhac, du sot ciing khan lanh

II khi phai dung ha nhiet. + Dan gian va an loan han ca 13. dung hoac HE mroc d:i d~t len trtin, bung, trong nach. Khi sot qua cao, co the boc khan lanh, Rat hiern khi pha] tam
mroc da, hoac thut mroc da.

+ Nhtrng

thuoc

sau day chi duoc dung khi nguoi

benh keu nong:

- Aspirin, nguoi Ion uong 2-4 vien 500mg/24 gio, chia lam 2-4 Ian, sau bira an no. Chong chi dinh: benh da day, benh chay mall. Hoac: - Paracetamol, •
vien

500mg, moi IAn uong

I vien,

dung 4-6 hln/24 gia .

13

SUT CAN
GS Vu Dinh Hdi
Siit can la mot dau hieu quan trong, thucng phan anh

met benh nang.

sa di sut

can, vi nang hrong an vao (thirc an) it han nang

luong tieu di (chuyen hoa

co ban cong voi hoar dong), VI vay, nguyen nhan sut ~an co th~ do an (t qua (bieng an,
thieu an, benh .man tinh ...) hoac do tieu thu nang IUQ'ng nhieu

qua (cnuyen hoa tang, heat dong th611!C qua mire ... ).
, ::" .:1
"t '

Co th~ mat mroc nhieu cfing gay sut can nhanh. Thf du: dung thuoc ~qi nieu, mat m6 hoi nhieu, thieu nuoc u6ng, kieng mu6i qua mire deu co th~ sut can,
Nhftng nguyen nhan sut can chu yeu g{ip trong tam

sang, khong ki nhiing truong h{1Pco thi mat nuoc: 1. Dai thao duong,
Siit can Ia trieu chirng quan trong cua benh dai thao

duong. Moi dc'iu, sut can chii yeu do mat nuoc (VI dai nhieu). Sau do, can tiep tuc giam do mat nhieu glucose
qua

rurerc ti6u (vi glucose nieu). Thieu insulin va thira

14

glucagon thai tang

cung

lam giam tong hop protein va rna, d~~~

qua trinh tieu protein va tieu rna.

nhung van sur can,

Ngiroi benh dai thao duong an khoe hon nguoi bmh

thirong, do benh.

VI nang hrong an vao, dii

nhttng

cao, ciing kh6ng

bu dap n6i nhirng tieu hao nang luong rna van sut din la mot trong

An nhieu

d~c diem cua dai thao dirong,

hrong glucose trong mau hie doi (dinh luong it nhat hai Ian lien tiep), neu
D~ chan doan, can phai djnh

qua l,4g/l

(7,8 mmol/lit)

la nghi ngo, Tim glucose

va

th~ ceton trong

mroc tieu giup them cho chan doan.

er DiI~u tri, Tnroc het, phai han che an chat bor va dtrong. Tuy tnrong hop, dung mot trong nhfrng vien ch6ng dai thao
duong sau day; , Glibenclamid

(Daonil, vien 5mg)

Gliclazid (Predian, vien ~Omg) Tolbutamid (Dolipol, vien 500mg) ,

Thuong

bat

dAU bang

J?9t

vien, sa~d~~~I~~~nh
m~c

dan.

Nhirng ca nang, can sut nhanh

dau an, rat .nhieu, huang

duong huyet qua cao, va nhat 111nhung tr~Ong hop co ceton nieu, can tiern insulin duoi da, ba~ dAu bang 20
dan cua vi. Neu dung lieu cao han,

can

GO su

dan

tuyen tren,

Khi da tinh

diroc

lieu thfch

hop, thi 15

nguoi bcnh co the' tu dung silt chat che

va

thuoc

a nha,

duoi sir gitim

thuong

ky

cua th.iy thuoc.

Ngiroi bcnh phai thee doi chc do an nghiem ngat, han

chc glucid, va neu beo thi han che d. hrong calo noi chung, 2. Cuong giap. Con goi Iii nhi~ru doc giap, rna 'the' hay g~p nhat la benh Basedow.
hermon, chu yeu Trong

benh nay, tuyen

giap tang tie"t

hria

a cac

Ia thyroxin

(T4), rang manh chuyen

rub va tieu hao·~fit nhieu nang hrqng.

Nguoi benh gay SLII nhanh chong, mac dau an ngon mieng va an nhieu, nhal 1a cac glucid 111m cam, dirong. '
Benh canh lam sang con co mat 16i, birou giap, run tay,

lim nhanh, sq nong, nhieu rub hoi, ia chay, n.lilg roc, d~ call kinh. Cling co khi (nhat 18. nglrai cao tuoi) chi co

sut can don thuan, kh6ng co cac trieu chirng tren.

De chan doan,

hien nay van can do chuyen hoa co ban: tlnrong xuyen hoa co ban >30% HI dil co
Nhirng xet nghiern

chi can milt 16i, bu611 giap, mach nhanh

tren 90 hin moi phut va chuyen
sau day

the biroc dau xac dinh benh Basedow.

chfnh xac hem, nhung thuoc tuyen tren:

Trong cuong giap, rhuong thay: Dt) tap trung [LI! cao qua 30% sal! 24 gia Dinh hrong T4> 200 microgam/Iit (260 nanornol/lft
16

Dinh luong T, > 2 rnicrogam/lit

'1"1--

f)i

cu

(3,

nanomol/Ift)

t r!

-+- Co

the chira tricu cluing de nguoi bcnh

vicn 40 mg.

de chiu

ngay:
lan,

Propranolol

U6ng 1/2 vien

dung 2 Ifin rrong 24 gi0. Sau do,

co the

moi

Dug dan lieu.

+ Nell khong dLIUg duoc

If\n trong 24 gio. Sau cling gio; chia 3 bill uong.
-t

thuoc chen beta, thi thay hang:

DiitiaZCI11 vicn 60 mg. U6ng I vien moi lan, dung 2

co tht

tang djn lieu. L10ng 30-60 gi9t/24

+ lod (dung dich Lugol manh)

Dong thai, dung ngay thuoc khang giap trang Icing.

(BTU, Basdenc, vien 25 mg):

hop, dung mot rrong cac thuoc salt: - Benzyl - thiouracil

Bih dau bang 6 vien/24 gio, dung trong vai tuan. Khi do, gi'\l11 dan lieu cho den lieu duy t ri 3-4 vien/24 gio, dung trong vai thang. mg) hoac propylthiouracil (PTU vien SO mg): bat diu bang 6 vien/24 gia, dung trong vai tuan, roi cling giarn lieu
Methylthiouracil (MTU vien 50 thco each nhu - Carbimazon bang 4-~ vicn/24

a trcn.

(Ncorncrazole

vicn 5mg): cling bat driu

a eric

gio,-r6i cling giam lieu theo each nlur

thuoc tren.
17

TUJOOTVSOT

+ Nell chtra bang thuoc

trcn xet chi d inh dung
1): Ngoai

khorig

kct qua, ncn giri tuycn so berth noi tier kluic

iod ph<lng x a hoac ph;'iu thuar. gtly sut can. D6 la:

CLTc1ng giap, con mot

cling bao Ira chrom:

(hicrn •

han nhieu) U

lang huyer ap t irng can EI dau hieu chfnh, nhung dong thai cling Slit can, VI catecholarnin lang trong 111<1u.
• • Suy toan tuyen yen (panhypopituitarism),

Ie

con
;111,

goi HI benh

Simmonds,

cling lam g.iy slit nhieu. sut can <1 day do chan hau

SUy thuong

than,

qua cua ihicu

cortisol.

3. Benh tieu hoa.

• Cac benh spru, viem tuy man, xo nang tuy, hay t<.IO chong mac d.:iu an van nhicu, hcp thuc quart, loet da
[\11,

phan c6 rna, g~IYsiit nhanh • sCI! dill. Viem ruot.

ky

sinh trung, chan

day ta trang,

thicu nuiu ..c t inh, xo gan ... deu co th~ gay i non mira, tac,

CO' chc CO nhieu: hap thu, vicm,

Dieu tri lily nguyen nhan.

kern

4. Mot

so benh

dac biet.

Lao, benh nam, ,1.PXC arnip, viem mang trong tim nhiern khuan dang ban cap, bcnh AIDS deu co the gfty Slit can.

IX

Ph.ii 11m ky nguyen nhan bcnlt va chu-a thea nguyen nhan,

S. Ung thu. Truong hop sut can m~l khong co bieu hicn gl dac

bier kluic. co kha nang li\ ung 11m & mot nao do. Ph <li t1 111 nguyen n han 0 6ng lie
II

V!

t rf

kin 0,10 gan, nhung

hoa,

t u y,

hach, mau ... Sut can co le do chan an la chinh, c hu yen hoa cii ng co tang it n h ieu,
6. Benh Dien

tam than.

hinh nhat la berth bicng an tam than. Mot so benh tam thiin k hac cilng gay silt can ([tun than phan liet, tdm cam ...)
Chan thuc ton. doiin chi'. yeu bang each

11'<li trir nhirng berth

7. Suy than man, Nhieu khi suy than bieu hien truoc ticn bang gay sut do chan an. Tom lai, ngiroi benh sut can ma an nhieu hen, nen nghi den dai tluio duong, nhicm doc giap, kern hap thu
tlurc ,'m, roi den bcnh bach cau, biuh
LI

lympho.

Neu

an van
nhiem

thuong

hoac

kern

di, nen 11m ung thu,

khuan, suy than, berth tarn than hoac benh uoi tiet.

19

THrEt] MAU
GS Vii Dinn Hai
Thiell hematocrit,
mau

Iii 'giam
giam

hoac

so

J(V{, hemoglobin

(Hb)

ho.ic

hroug bong cau, Cu the I~l

hemog lobin
num ,
hO~IC

diroi

1Og/ IOOml

nir, duoi

12g/ 100m I (1
('j

hematocrit

duoi 3(Vl i)' nir va dudi 3V;;- (; uarn, 3,5 tricu l111U vi'l diroi 4 t rieu nam.

hoac hong

call dual

Ciic chi s6 huyct hoc trcn khong

l1<) t hi ell rrui Ll. Ch iing

phun ,111h dung muc

t nroug

co

Ihe

c ao g i;'1 1,.10 t rong

1,,10

hop thai.

milt nuoc cJ<)1 ng()I, nhir suy tim

CT

ia chay cap, bong nang , c1<li qu.i

Irong pIlLI,

nhieu. Chung I '-.1i co the thap gi,\ binh thuong Irong

co

huyet. Khi mat mau cap. de

chi s6 nay co the tai oxy cua m.iu

IO:lI1

gio JilU ticn, r6i sau moi g iarn. VI

eo the, bieu

giam hong cau va Hb, kha nang chuyen bi giam sut, gay ncn nhicu roi IO'.lI1 cho

hicn ro nhat IA cac roi loan tuan

1. Lam

hO~1l1 V~I

ho hap.

sang.

1./. Trieu chting: thieu mau nhe chi Ihriy met mor. d.inh Irong ngirc VI tim dap nhanh vi'l manh; kho Ih6,
nhat

EI sau k hi g<"mg sire.

Khi thieu

mill!

nfll1g

hem,

20

nhirng

ricu

clurng trcn lim.

XU:.I

hicn
U'l)'j

c.i khi nghi

ngoi, I{\U

ng~IY d;'1ll den suy

t;)p trung hoa,

Nhicu khi c6 them on lanh,

dau

ch61lg nuu ,

nh ire d (Ill, Ll I ai , ng{it. Co ng ur unrng. hone

ngLfi1i bcnh

k lHl ng u , hue h() i, k ho

xLfong.

Vc

lieu rur

c lui n fill, k ho lieu,

huon

non; phu

hay bi roi 10•.11 k inh nguyct: 1

hay
t irng

dan oug co
V:I

the l ict duoug.

mac 1:\ u:.Yuhicu ugiroi , h~111 tay
long

1.2. Dtiu hieu: nhot mau cia

g~lp nhat , nlurng hie. Nhin ket cling
con
1ll'.IC,

nicm

ILly sik da urng

nicm mac mieng.

ncp nhan

d6 thay hon. Ncu nhftng

tluim hem da Ngoai chcnh

a ben

a long

bim lay khong

thi UI hcmog thay

lobin duoi 7g/l DOm!.

manh.

ra, con

lim It)]1 nhanh,

huyct

'\]1

lcch tang,

rhoi tarn thu iJ d.iy tim.

DC: tim nguyen

nhan do bcnh _lll.ill, can chu

hach, gan, lach, vang da,

TITBHC =

Hematocrit

S6 hong c lu trong 1 microlit (Tht rich trung binh hong cau

x 10"<)

= TITBHC;
J()-15

TIT BHe biult rlll(cmg = NO - 97 fi. ti« Ie, NO-9() microtnet klloj': jl = femtolit =

I if)

2. Nguyen nhan Vi:. nguyen

chinh:

nhan thieu nuiu. ncn x cp 3 loai thieu mall

21

2.1. Thieu nulu do

•

mat

mau: I~Ioai piJ(i bien nha]. l

moe.
1:1

\·1;\1 1ll,IU man Ifnh:thH(Jllg do gilln

dlft511g

ch.iy
cling

nuiu chay (rong trong

t icu

h():l

(clui )' tri, Im.;t

t roug

d;.l

d;I:;"

trang ),

m.iu

kin

d.io

phan.

ho,k

dl\"(511g II'\"

k inh, II \.0 ur cung). s61 rei 1au ng;ly. l3¢nh c.inh lam sang nhu d:i I,i o.ucn. Lilt dan -;0 d.in den Ihi0"u";'\1
m.iu.

Chua thco nguycn nhan va u(ing them muoi "tIl. •

bcnh
1ll{\1

Illlftmg

met. chtlng

rn.u, Sling

sli, da uii viI huy..:'l

11gLl"t'1i
LI

11IH11. \,\

mo hoi , ell k hi hun me. Trcn m.iu nhicu il dua vao

1:1111 <mg, c o t hc d.inh gi;i

lim

nhunh

;IP ha.

1\"0\1 so voi hie binh thuong

huyct day, truycn "leu .ip tam milt nuiu btl ngay.

va mach tung len 2:'i~;. houc bcuh ng()i c.in

dl(O"C

IhL! gi.im 20mm Hg khi

c'(, the' t{ji IrCIl l Tit. nghia

k hong

til nuiu nhicu () '-.11, x er nghiem m.iu co tilL' thay gi;im h61lg cau, hemoglobin vi, hcm.uocr it.
III

vi m.iu chua

kip loang.

do

do de

bo qua nhicu

mat m.iu

n,~l11g: 2-3 ng;ly sau IhSy h6ng

hong c.iu uhan xu It hicn.

c.iu mung

1i"l11g. ell khi

Chua ph.ii "-h{ln tnroug:

chi)' dqi ph.ii truycn Ringl.'l" lacuu.
II

uuycn IlHIU ngay. uoug khi ho;)c dung dich ngay noi chil)

dich muoi O.l)r;; lim v;\ gi;li tjuyCI

Ph.ii

n1<l11.

2.2. Tliieu nuiu do gian: sail 1l01lg ctiu ;t6t

c.m eli chia
r;1
V;lll

nh;'il

the

ich trung

hlBh hong

c.iu ClTTBHC)

de

lit

.1 luai gi'lm

san. etch linh: <XO Ii): nghllkn th icu

Ih-m);, du nho (TITBlIC

<It b ph(,; hicn nh;ft:

[g-

Dieu tri chu ycu

• Hong folic.

btl1lg

sit. thi du: vicn

s:H 3-6

vien/:24 gill".
d.ll lou: tlnn'fIlg do th icu vitamin
1312 noac acid Cling

co the do suy gall,

S;111

suy gi,ip, mat I11Jll

ctlp. tan m.iu , h:it

,]t_.

tliy. nghi¢n ruou.

nhun hiuh: tinh phan nhieu do c.ic benh g iam), n~lI1g gan

Dieu tr] tnco nguyen

• Hong
man tfnh

C:lU

trung man

nmr vicm

(:-;,'It huyet thanh

suy th(m (crcat iniu mau taug ), b¢nh gall {rink nhom hing

gi;lm)' suy gi6p (T4 gi;II11). D,}c bict u;iHg chu )' trong nay la tuicu
erythropoietin
IllUU

do suy than,

co khi nho thieu

mau rna tim ra suy than. x uong nhu bat san

t LIY

Dietl tr] bang ghep th;)I1. hoac

(c hoc tuy ), huy hoai til y (c hoc

ngltai. MQt so nho do bcnh ella tuy

tuy song thay u v. v ... ), loan siln tuy (choc tuy song thay
:\(1

hou).

Chua uhung bcnh nay rtit kho khan: can glri ICIl co

Sf)'

chuycn

k hna de iruycn mien dich ...

IH";ng cuu.

androgen.

ctl)'

Iii)"

XU()"Ug. gi,i!!l

2.3 Thieu malt do tall matt: hicm lion uhicu. V(~ l.uu
s~Ulg, ngoai clni nlurng hicu hicn chung cua t hieu m.iu. c an

tim villlg da, l.ich 10.

v«
trong han

dcm hong cau hroi co gi'l t ri Ion: thicu nuiu tan m.iu t h i hong CIU ltr6i ban giiJ cflng
xct nghicm, 11m c.ic nguyen nhan V~l phui Ji:1I11 xct llghi¢m g,"IY tan m.iu chuycn
t hi

li"lllg. Nhung nhicu

k ho nuri

khoa

chan do.in diroc. Ph.ii glfi chuycn phai dLlng corticoid

@~

k hoa huyct hoc de: dicu

11O:\C

r i, co k hi '

dl l.ich __

3. Chua thieu mau.

+ Phai co tim nguyen nhan

c10 clura, khong ncn voi

m.iu" nlur
Sill,

dung

de

thuoc folic. bicu

U

"chong
g
L

thieu k hon

vitamin I inn
11\(\

B12, acid nhat nhiing

Nell thira sjl trong

'--

rruiu cling

g:\y benh: cung kh(mg

vi tam in B 11 ncu dun hicn ncn t ru yen nui

g I h ic h

d.i n g
'--

C{) I he:

cua nhieu

bcnh

mau;

LJ u.i rong ra i.

+ Chira nguyen

nhan Ilnt(l"ng dcm lui kC"1 qua 161: chira

khuan h:lllg doc. chtra xo
• .

b¢nh IH)i Iict. dll ho u, ghcp I han. chua nhicm kh.inu sinh. loui bochat
...... . ~ II..

!!<l11

v.v..

24

PHU
GS Vii Dinh Hdi Trurrc m61 ngnoi bcnh phu, ph;ii phan biet phil ho" voi phLI "loan Ihe". 1. Phu • do,
CI,IC
"ClIC

bo thuong
khuan

de tim
k hu
t

nguyen "han.
Khi

Do nhiem

ru nhtr nhot , '\[1 xc.

t rich

mu (juan trong hon b JLlI1g kh.ing sinh. nlnr dung g iap, sai khop, gay

• vicm

Do chan Ihuo'ng
t ai

x irong. Co Ihe: d ung c.ic Ih uoc ehb, nhung "Y c'l tlnrong"). • c6 lhe chong

ma

hoac rurrrc d~ chong

t x cm h;:li

chu yell Ja chira dac hieu

Do I.k tinh mach, phu chi

liLf{1i

co

mot hoac hai hen,

t huoc

vicm (nong , (1<)

hoac khong. Nell t inh much

no i ]"0 rh 1 c h;111 do.in

dung l au V~IngLf(\i cao • chan Do giun

de.
t uoi

Ne n ho i e htill de" d llllg

if

dong vii kluing sinh. Suy tinh mach

nguoi hay

cling co the gay phil.

chi g[IY Itlc mach bach huyet: phil hai

hoac phil bo phau sinh due (btu dai, moi 10n ... ).

I.au ng ay cia vung dt'> h! day crrng lai (phu voi). Nhirng
25

hicu hicn hay kern bang dicthylcarbamazin

thco 1:1: Sl)l urng dot 3-5 ng:'y.

hay 3

\iii d i l,ii lai , m';i huch. co dlr(-Illl; Ir,\p. Dicu 11'1cl;)c hieu 5111g/kl;/24
hoac qu.i 1611.
git1.

uong

Ironl;

tuan JC hoac dllng ivcrmcctin Net] phil qu.i lau

fl t.ic dung
C()

phu hem.

k hi phai ph~\l
th.u.
1I

thuat.
• Do Ii'lc tinh mach chu trcn nlur Ll trung
Ihat.

phc q u.iu, v icm hone

Ph.u gLri tuycn t rcn.

Irim kh f Irung

Ph II

co

d ;.mg

<i 0 k ho.ic: ph II c hi treu, m(IL co, n t'ra Ire n long ng trc.

2. Phu tuan N he. chi thay neu nang

the. an 10m

hon I hI co ca

co truong

a mat

ca chan hoac

hoac nang mat:

I ran die h m aug

phoi. Nhieu
vai can Irong

kh i ph ..t h ien bang "len can q ua nh auh", i

vai ngay.

Tim

nguyen nhan

kho h<.1I1,nhAI (albumin).

thiet phai XCI nghicm

nuoc ticu 11m protein

2,J. Neu albumin

phu do benh than.

nieu ro ++ hoac +++, chac ch{1I1

+ Hoi chimg than lnr bay gap the' (rang van 161, khong sot.
Qr

a In: em:
nghi,
khi kel

phu dl Ian.

Dieu 1611:

tri:

[111

k icng

muoi, nam

chira hop

bcnh voi

nguyen

nh .. neu tn uong

co.

Thuoc loi nieu ncn dung k hi phu

qua 26

[urosemid.

eo

rnetolazouc Khong
\tr(1i

!A (11\, (t khi phili thuoc hop

t icm

furosemid

t inh

rnacl..

nell cho nhieu nc

lqi nicu qUit hoi eh{rng

elf khoi g iam

Ih<l11 hu dt111
bAt dau

nuiu
11

Ih.-in. Tnri1ng

thuan,

d LI ng con ic oid Iicu c ;10.

+ Vicm e:iu Ih(\ll e:ip do lien c.iu: thuong

hi'lng s61, vicm hong, 16n co lien Itwng 16t.
'fl'

th\i it, d6i khi huyct '\.p taug , M9t

s6 nho co the \l~'ng len, gily suy than, Ilt' vong; con ph.in

Hicll tr]: k icug muo i, nam I1gh\. uoug Iurosernid.

H) (,,(it.

Ncu nh icm khu:ln + Vrri de han

ell')

dau hong),
t icm

ncn cho pcnicilin trong 7-10 ngI1Y,

ucm h/,p 1-2 trieu don \'!/24 gjtj_

bcnl: c.iu Ih[\11 nguyen

nh<"111 htic nlnr luput k

Ifll1g

h¢ thong, 111:)n nhiem amylose,

huyct ap, can

116i eh<'in dt

clura nguyen nhan v:\ dicu Ir! d;:IC hieu ,

2.2. Neu prote i II IIi¢ II klll,ng co hoac crJ it, ncn ughi den de bcnh tim, gun. noi lic'\. Thicu Vitamin B1 11':\111
trong cung gtly phil.

+ Suy lim CThuyct g,\y phil do Ung ;_\p luc tinh mach va g iarn rnirc loc dill than. Nhirng b¢nh hay gay suy tim t'r huyet la: hcp hu i la, lim phoi man. viern mang ngoai tim ctlp hoac eo that. nh{ii m.iu co tim cii, bcnh co tim, nhicu bcnh tim bam sinh.

a tuycn

t rcu,

ph,'li hh,lm lim mach, tim nguyen

nhan 27

gil)' bcnh de: chira. nhu: cat rncp tjUL.. Chua

V;\I1,

C'lt bo lll;l[lg

ngo;li

phu do lim g{)m:

tro

t huoc

lo'i nicu (Iuroscmid,

hydroc lorothiazid),
nglu uroug doi.

tim (digoxin),

g iarn

an

muoi ,

+ Xo gall ciJng hay gily phu, VI albumin huyc! gi,'tm.

Tiurong kern thco

C(f tnrong,

t hc

tr,.mg

SI'J[

kern. di,

Chtin do.in can dinh hrong albumin hoa hoc),

gall

huyer (dicn

[y

l c prothrombin

trong malt. Chira phu do x o

cling chi gorn

an nhat nrong doi, {1l1 n h ic Ll prot id,

khong nell dung nhieu thuoc Iqi nieu.

+ M9t s6 phu nli" co phu truoc moi + PhLI niern co nguyen nhan
hang tinh chat tuyen giap.

ky

k inh, loai phu

nay chi can k ieng muoi may ng~ly do I~\du,

suy g iap trang, dicu tri

o mQI

so

nguoi

cao tuoi,

co

khi khong

co

benh

than, tim, gan

rna v,1.11 co phir, co th~ do mo duoi da

long leo d6 gur ntroc.

rg--

Dieu trl chi can nang sire khoc bang hoar dong di

lai nhieu han,

an it

muoi

va

nhieu protein han 1TI9t it. 8

1 ,

Nell phu do thieu vitamin vitamin 81,

th] phai ticrn durri du

2X

GS V it Dinb H di
Dong tac tho do-cac phan x a dieu khicn, cho ncn nguai binh thuong khong cam thay minh dang lila. Chi

khi gang sire nang, nhung

V~\y

ta moi co cam

giac

hoi kho tho.

earn g iac do

g:;11 nhir It!

nhicn,

VI khi nghi thi

qua eli rrlt nhanh,

va VI moi ngiroi gang sire nang nhu

kho Ih(1 khone e nrcns e xCfI1(T v6i mire e mot chut da kho

cling deu thay kho tho.

Chi khi .

cam

"j,l.c e

do gang strc, hoar dong chi hoi nang

tho roi, thi m6i l a tricu cluing cua bcnh. Cam giac kilo lhd nang hay nhe, con phu thuoc vao: • Mire de) gang sue d61 nguong
• nao thi g~ly kilo tho, neu chi gtm£ sire It c1J kho tho thi la benh nang. Tinh trang rcn luycn the: lire triroc day cua nguoi

benh: nell ren luyen the lire tot triroc day, thi benh nang cung chi thay k ho tho it; • Sire chiu dung cua ngiroi bcnh: co nguai benh

J1<~l11g mil

van knong keu kho tho nhieu. nhan chinh cua k ho tho iii. ciic benh he 29

Hai nguyen

I. Hen phi quan (PQ) PQ ,.Jt hay g~'jV kilo tl;a (chu yeu la hie tho raj xuat hien thanh can gi6ng nhau, co fen rfl khap hai phe'
Hell

tnroug,

tho' co the uhanh hoac cham.

Con nang

co Ih(1

nhanh tren 30, mach nhanh CJu;_\120, 1i1111IlgLrai benh co earn giac ngat 111m.dp chcr, va
chi tho "co

rna hoi,

xanh tfm: con nhc

cir" mot hie. Anh htrong thai Iic·( ro, nhirng co

ngiroi hay len can mua dong, co ngtroi mila he! Dang chii

la kho tha khong lien quan sot (trLr t nrong hop

SLf

den gfltlg em), IUe

strc, nguoi benh khong dau co the ho, nhuug

t rc

khong co dam, khi khac dtroc ban them di! co nhirng

hO~IC

dam ];1 can nhe di. Neu ticn

can kho tha nrong

nr,

gia dlnh co ngiroi hen thl

c1I<1ndoan cang chac chin.

<::ir

Dleu tr]: can sam, VI can keo dai nhieu Hill se gay

nhieu

bien chtrng phoi va tim sau nay.

("(1111

+ Thuo« kiell thich giao

beta: Rat tot, VI chi

meraprorerenol

giiin phe quan rna khong anh huang den tim. Tien nhfit

la

dung

salbutamol,

rerbutaline,

(Alupcnt)

diroi dang xit kht dung, co lieu t inh san.

Xii
1-2

ngay 2-3 lieu, sau 15 phur khong da, co the them

lieu nira. 30

Ciic I huoc I ren dell co dang I ibn, nh ung nell

S{)'Jl1,

X! I dtroc
chon

[hI il khi phai dung den dang

phc quan,

i icm.

Adrenal in cfing gian ha« SI c1l/1yt'll khoa

nhung

kh6ng

lac, ncn khong duoc dung cho ngtroi co bcnh tim. Chi

,~,6" dtta«

clit' diuh dung adrenal in,

corticoid.

Co the

tiem

dtrO-I cia 0,3mg

(nrc

1/3 6ng

1 mg), neu can co the riern 2-3 I:"in each nhau 20 phtit.

+ Corticoid
de). co
the" )

chong vicm, I iern 0,5-\

t inh

nen him tho d~ han. Ncu beta nhtr noi trcn mil k houg mach

sau 1 gia dung k ich t hich (Solumcdrol bctamethason,

rug/kg.

mcthylprcdnisolon () g io mol I:in,

sau 4-5

de x amcthason bcclomcthason

... Tac dung chain,

gieY Kill dung

nhanh hon.

cling rat lot de" dtl con

+ Aminophylin
t iern

lam glan

phe

quan

yell hall, eo Ihe"

cat can:

6ng O,24g pha loJ.ng them

de

ticm

tinh

mach nIt Ch{11l1 Irong

20 phut, VI co Ihe tai bien, nh:"it la

if nguoi cao tuoi.

+ Nhimg thuoc sal! day cit I can yell han, ncu thieu
nlurng thuoc t ren moi ph.ii dung:
cphedrin

theophylin

vien 0, I g; ruy can

vicn

0,0 I g. U6ng tir

1 den 3 vien,

n~mg nhe. + Tho oxy , btl mroc thicu ...

31

+ Dieu
thuoc:

Ifj duy

t r]

d6 ng;)n urn Ira lai. Co nhicu

corticoid. hit, kfeh u6ng.
t

thcophylin

vicn.

hich

beta

hit, kctoiifcn (Zadircn), corticoid

2. Cac benh khac cua duong tha. - v iem phe quan

11l ,:111,

g ian phe nang cung hay g rly 13 chinh,

co

kho tho, nhat la trong nhirng dot nhiern k huan. Chira bang khang sinh theophylin, thuoc long dam. the them

- Viern phc quart cap ciing vay

- T{IC duang tho rren do di vat, phu

thanh

mon,

ll,

sco ... Kh6 tho rit, nit 10m h6 trcn don.

(Jr

Dieu trj ph;'li dip ciru. 3. Cac benh nhu rub phoi,
• Chili phd;, thmrng la hau qua cua viem phe' quan

man, hoac hen phe quan. Chira bang tap the la chinh. • Vielll phd; (11): kho the kern theo s6t cao, ho.

dau ngtrc, Kham phoi thay hoi chirng dong dac. r:e-

Xu

trt: sinh ngay,

ILly theo
Ililtlg

Can cho khang saU: + Vi(>lJ/ phb'i

32

nhc uhu 1,5 trieu

/111((, dung

procain-penic

ilin

don

V!, 1iern

bap

I Hi.n/24 gia, trong

J

5 ngay; trong

hoac

cotrirnox azol 2 vicn m<'ii

2 gio, uong

5 ngny;
ticm
J

hoac amox ici lin 500 mg moi X gio.

+ v ieru phdi

\'/(0,

dung benzylpenicilin,

h{:p

tricu dan vi moi 4:6 g io, hoac

ccphalorin

,0 gam

tiem bap hoac 1111h much moi 6 gio, lrong 5 ngay.

+ ViJIII
ticm bap

,,!to'i

1I~/lIg,

dung gio,

gentamicin phoi hop voi

1-1,5mg/kg, penicilin. g io

lrin/24

cephalotin; hoac cephaiotin 1,0 gam tinh mach/d-S mot l.in, don doc hoac phoi hop voi gentamicin.
(DQc them sach "Huang dan sir dung khang
nam 1994, trang

sinh",

79-81).

4. Cae benh c~a mang phoi

• dich Kharn tlurong Viem mang phoi co tran dich hay gay kho tho, cang phoi nhieu thay thi kho Iho 'dmg hoi cluing tran nang. dich: Nguai benh thanh

sot, ho khan,

co khi dau ngl!c hen hi viern.

so rung

giarn; g5 due; nghe 1'1rao phe nang mat. Phai choc • Tran

do de: tim
mau mang

va chua nguyen phoi

nhan

co th~ do chan thuong,

gay kho tho dot ngot va

hoac do ung thu, cling gay kho tho. • Trim khi mang phoi, dau mot ben ngirc. Nguyen nhan co th~ do lao hoac ken
T3-HOOTVSOT

33

kh f

a phoi.

Ncu k ho tho nh ieu, phai c hoc hut kh f fa.

5. Cac benh tim mach, Co chc cua kho tho trong nlurng bcnh tim mach tang
thanh ap luc

ia
ra

cac mao mach

phoi,

Hun dich khl ding

thoat

khoang

gian bao va gii.l.m dQ dan hoi cua phoi. Lau dan, cac mach phoi day len. thong Ira ngai

va tho cang kho nhoc, Tinh trang trcn x ay ra Irong nhirng benh gay tang ap
hrc nhi trai , thong tlurong nhrll 1~1 h9P hai hi, roi den
t rai

tang h u yet ,i p va cac benh gay Slly tim

nhir he ha i ,

lao hC:i van chu,

hep van chu. ..

Kho tho do tim moi drill chi xuat hi911 khi gang sue

nang. Khi do suy tim con nhe, thuoc 10~i II thea Hoi Tim New Y ork. Khi suy tim nang han, loai Ill, rhi
nguoi benh kho Iha ca nhirng khi lam viec nhe, va den loai IV till ngay ca khi nghi cung kho tho.

Trong suy tim, nguoi beuh kho tho kh6ng nam duoc, bat buoc phai ngoi day hoac nam phu phuc, co khi phai
phu phuc suot dem, neu khong co thu6c. Ban dern, co khi dang ngu thicp nam ngu, bong di, nhung b] kho tho du doi buoc phai

ng6 i day. Mot IUc sau,

de

tho han, lai nam x u6ng

va

mot hie sau lai phai ngoi day VI

kh6ng tho diroc. Co khi trong mot dern co den 2-3 can 34

kho

tho n iHT

ViI

y. H ai k i6u kho thO' do, kho t hit khi nam phat han dem,
rat dac

va kho thrr kich tim.

@_.

trung

eho suy

Lam the nao phan biet duoc kho th")· do benh ho haphay do suy tim'!
_-

~-------

---Kh6 tho do beuh pheii -- phe' qmln

h
i

-'~

Kho thd do lim

I
I

Xu5t hi¢n khi gj.ng "tIC

Lien quan v6i gang Khong theo nr the'

Kh'.IC J(:1]11 ra thl do

SUe khong ro

Ngirug g;lng siic thl dOXunt hicn l.:hi nam Khac Jam ra kh6ng da Ticll sir co bcnh tim nhu NMCT, 1,-tIlg huyet ,ip, bcnh van tim ...
i

'Nglrng g;lllg SITe khong do

Tien su-khong co bcnh tim, nlurng hay co bcnh phoi nhu hen PQ,
viern PQ m~1ll

Kluim thay: benh tim. tieng I 3 ti~~~g 4',lim to, tl[_lh mach not, phu

Kham khong 111[IY nhiing drill hieu

tren
... _~

_ ____j_

NMCT = nhoi mau co tim

rff'

Dieu tr] kho tho do tim. Hit nhien phai chua 111m suy

tim:

+ ClIO

at,i

IIhihl:
t icm

d~ bot luong mau len phoi. Ncu vien 40 mg, truong hop

suy tim nang, thi cho furoscmid cap ciru, phai Sau do, co th~ thay bang: Hydroclorothiazid

mot 6ng 20 mg, trong val ngay dau.

uoug 25-50I11g/24 gio; uoug trong

35

vai ngay. N ell dung loi nieu c lorid 2 gam!24 gio.

cac t hUGC nit rat (neu

da i ngay, dn uong

them kal i

+ Gil/II

tinh /lW("/1." bang

HA

tam tim cao han 90 mmHg)

bat len phoi.

cling gilr m{IU Ct t inh mach,

- Ngam lau nitroglycerin

tan het, lac dung rat nhanh, - Nang
t ac dung

dual liroi vicn 0,5mg, nhung chong liang her. Hoac:

eho

nitrolyeerin keo dai han. d¢/lg

III~/(""

2,5 mg,

2-3 vien/24

gia,

+ Gil/II

d~ giam Slrc can ngoai vi, tim do'

ton sire: dung nhu captopril liang

thu6e

LlC chc men chuyen angiotensin

vien 20mg. Chi can diroc dung neu HA tarn

vien 2Smg, enalapril gia, khong

mot vie,n/24

thu thap diroi 90 mmHg.

+ Ttillg
ngay dung.

SI(("

h()fJ IL(

("0·

tim bang digoxin,

vien 0,25 mg. Clni

Nguoi Ian uong 2-3 vien ngay dau; nr ng ay thlr hai, moi chi liang
IllI<1

vien den mot vien.

neu nen

non, hoac tim cham diroi 60 nhip/phut,

thi khong

Can hru

den nhirng phan trng co hai va chang

chi dinh cua digoxin.

+ T/!6 oxy Irong nhirng ca nang.

36

6. Kho thu do qua 10 lang.

Loan kho tho dau ngoai ngtrc, Ihan
Vl\

kinh

Ch(TC

nang

co 'Iht

lam binh ui i

nguoi thuong
Cl.TC

bcnh nlur

tho nhanh hoac dien

(tang

thong kill).

D6i khi kern dt

Will d6 khong

tam thu Ih<1'1lC te, 11O(IC roi loan

Iai cang

c 6 the: dua den chan dOi.!'11nham 1a su y lim.

Ncn nghi lai binh dai, hoac
Iirng nhat,

den nguyen khi ngu, deu.

nhan tam than hoac Dau luon

thuong vi
t rf

co

khi thay tho Ira

nhimg Ian tho Nhirng k icu nhoi

tho khong

ngirc thirong

dau hie cho nay, hie cho khac. sue,

truong

hop kho, phai phan bier bang Jam tham do clurc

nang phoi va tim, hie nghi va khi gang

37

HO
GS Vii fJinh Hdi
I'G PTS

t.e f){rc

Chin"

Ho Iii mQI nh,i! Iha ra manh

CACH KHA'\1 H~l\'H NIL\i\ HO

va ubi ngor,

nharn day

nh fl'llg c h fil Iie'l vii d j vat ra k hoi kh i pile' q uan. 1. Hoi benh
• r:il gjJ rri. ChLI y hili x cm:

• Hoc fip (moi ho) hay man (eta 1au)?

C6 sol khong?

• Co dam khong?
•

M6 I,i dam.
1;\, i icm

• Co thco mua khong?

C6 nhan 16 nguy co khong? Thuoc mu

uiy. tinh due dong gi&i, nam bi.lt dong Ifill,

• Ticn
Slf

moi truong ...

hi¢l: bcnh lim 111'.ICh, benh h(l hap, co dia di irng, dang uong IhuDC rrc chc men chuycn
g). dac

co

angiotensin.

2. Kham thuc the.

van lim, barn sinh, tang huyc] .ip, nhoi m,IU co tim ...
Tnroc her rim suy lim:

eo

benh

benh tim

3X

Nghc •

pht)i ell gi,\

t ri, t lu dlj:

Ticng th« rit, Iht1 kho khc lrong bcnh thanh quan.

•
• •

Nhicu ran r it , rail ng.iy Irong con hen phc quun.

R an ,1m 111(>1 vung trong v icrn phoi. suy lim. de hoi
d~IC

Ran [1m nho IWt hai d,iy phoi troug

Go phoi, sa fung thanh

(go
(h,IC,

cling giiip ch[in doan

c h Crng 1rim die h (ba g iam), hO(IC h<)i clnrn g dong rung thanh t[lJlg, ran {im).
3. Chup X Quang phoi phci, pho]. sang Nhirng khong chi can chup chun do.in

co

Ihe cho Ih[\'y viem phrii,

phoi,
hO(IC hach

II

.ip xe phoi, tran dich mang diroc bcnh

r6n lam

phoi khi nao rna kluirn

gtly

ho,

11 ,"\1 Ji:1 a h

nhirng co sO thieu phirong t ien. 4. Khao satdom,

Rat can. due,

Th.iy thuoc

ph.ii nr mlnh nuiu

nhin

dom bcnh

nhan (hoi khong

dill) xem dac

hay 10<1ng, rrong hay k hong. co m ui gl I ,_I

V~lt

II hay n h icu, co ram

kh6ng?

Sau do, dua xct nghiem

tim cac vi sinh

gay

bcnh. Nen nho rang i:J phu nii, t re em

va ngiroi yeu qua,

nhieu khi nuot dam clur khong khac ra ngoiu. S. Nhtrng kharn nghiern chuyen khoa sau hon, nhu soi phe quan, do clurc niing phoi chi can lam trang mot
s6 t nrong hop k ho
Vl\

nang.

39

TIM ~Gl!YEN NHAN HO

1. Truong
kh6ng?

hop

ho dip tinh.

xcm co nhiern

khuan

1.1. Neu co nhiem khudn, nguyen nhan co tid la: + Vie1ll IU;JIIg ('(11):. ho it dam. hong do va dau, co tht
sung hach can khang

co

va diroi ham. Da so do virus,

nen khong

sinh.

Neu do lien cau hoac de vi khuan khac, eho uung

phenoxymethylpcnicilin (penicilin V) 500mg moi Ian

dung 2 lfin/24
Hoac: trong

g io. Trc cm: liang 25-50mg/kg/24

10 ngay lien.

gio,

chia Elm 4 Ifin. U6ng trong erythromycin 10 ngay. k huycn

500mg x 2 l<i.n/24 gio, nang tiern bap benzaihin-penicilin

mot

TCYlTG lieu duy nhar

• Viem

1.200.000 dan pitt' khang qIlUII sinh.

V!.
ho, dam moi dau nhiern,

cal):

it, sau

tang dan, ph6i nhieu ran phe quan. Da so do virus, nen khong khang
•

can

Khi co boi

thi dung

sinh nhu tren.

Viem

phdi: sol, hu, dau nguc. kho tho, kham thay hoi cluing dong dac. 6 Ire em va nguoi cao tuoi,
t hi

tien luong xau, Can eho k hang si nh: Bcnzylpenicilin, I trieu dan vi moi lan, ricm http 4-6

40

l{il1 trong erythromycin,

24 gio;

Co th~ thay
Trong ...

bang nhfrng

cotrimoxazol, ca nang, ph.ii

amoxicilin. cephalothin

dung gentamicin,
ra mLI hoac khi

• Ap.re phd'i: lam sang rat gi6ng viern phoi, khi khac

co phim

X quang moi pharr bier duoc. Chua

bang kluing sinh theo khang sinh do, hoac dung: Benzylpenieilin rnetronidazol tiern hap nhu tren, phoi hop voi

tiern tinh mach 500mg

moi Ian, ticm 3

1311/24 gio, dung trong 1-2 ngay dau, sau d6 uong 200400mg moi Lin, uong 3 ian trong 24 gia.
J .2.

Neu khong

co

bilu hien nhiem khudn, nen

1~IC...

nghi den:
• • HIt phai V(lt la vao duong tho nhu vien bi, nhan Phu phoi- cap: ho

co

nit nhieu

dam, kern theo

kho tho di) doi va nhieu dau hieu tim mach.

2. Truong
• ViJIII

hnp ho man tinh, nen nghi qen. phI?'

ql{(i/l III~III:

ho khac dorn it nhat 3 thang, e6 khi 2 narn. Ncn it dung thuoc ho, rna chu yeu la Him long dam.
• Chill phr/ qtuin: dom nhieu hon.

• Loa phdi: sot nhe, gay sur, khac fa mau, • Ung thu phe quan, trung that..;
• Viern hong 111<:1n: 41

ho khong

co dam.
rhuoc 1:1,thuoc 1;10. ho it dam. t ;Illg 1c n kh i linn n~Ulg hoac angiotensin:
n61

• Nghien
• SII Y filii:

khi nam.
• Dung thuoc LrC chc men chuycn

ho nhieu,
•
<ff->

phai ngirng thuoc 10,:!i nay.

Ho do Will

IY.
tri cot yell 1~1 phai

Dieu tri ho
Tnroc mot nguoi bcnh ho, dieu

tim xem ho do benh gl, roi chua benh db th,-)! lOt. V 12' tricu clurng ho, co ncn chua hay khong,
twang hop. nhirng .tnrong hop khong nen chira ho,

COil Illy Itfilg

Co

m;1 chi
co ich:

clura nguyen nhan benh.

Do

Ht VI ho khi
SiJC,

do con

ho tong fa khoi bQ may ho hap nhimg

ha" cho co the nlur cac di v~t (do

vat "gay phicn

hoc ... ), x.ic vi

khuan va bach cau (mLI (rang viern phe quan dip hone

man), rnanh niern mac phe quan (trong viern phe' quan
man ... ), cac chat nhay Cham dirt ho bang do tang trong tiet (hen phe quan ... ) vat eo thuoc nhirng tnrong hop nay

chi lam benh nang va kco dai them, VI giiJ' lai de hai va can tro thong khi.

Nhung 42

co khi can phai dung

thuoc

chong

110: 110

khan (vf du ho do suy tim. do k ich

hich duong

Ih6). ho

dcm linn m:ll ugu. ho nhicu kco d~lilam met ngui:'ii ... Nhirng th uoc hay dung de' chiia trieu cluing 110 Iii: + Codciu, vicu l t) IIIg; nguiii Ion moi bin uong mot vicn, dung 4-6 l[in/24 gii). Thuoc lam giarn phan x'.J ho
lot. nhung ncu dllll:,:"dtii IIgti_\" ('() f/i/g/iy
IIg/Ji~'II.

+ C odethylin . \';211 /2.,5

irong nhu code in.

IIIg, llguai 10n uong moi

I;'in

mot vien, uong 2-4 Vi(:I1/24 giii. Cling rae dung trung + Opi trong "(/(" vieu I/O gii.im thong, ho long dom va
Irong nhicu che pham kh.ic cling

co lac

dung chira ho.

khi dimg nlurng thuoc trcn, nhu codein, codcthy 1in, morph in (hoac che pham co thuoc phien), thay
LUll

y:

thuoc V:'I dtroc Sl- can

!l//(ii

11/(111

f/Il/

f}"i~'f

eft>' moi nguyen

ItlC

cua bao quan va slr dung 100.li thuoc gay nghien.

+ Cac thuoc larn loiing dam nhu acetylcyste in, bromhcx in cung g iam 110 hang each lam dam lofing ra
vii

de duoc

long ra ngoai.

+ Mot

so thuoc

dan gian nlur vien bac ha, cao b ..ch i

bo. vien cam thao cting

eo ich

trong nhfrngcon

ho nhe, b61 ho.

+ N uoc uong nh icu c ling I am loiing dom

va

43

DAU NG1JC
GS VII Dinh Hdi
Nhi6u quan (con benh khac- nhau CO th~ gay dau nguc, nhung

trong nhat d6i voi thay thuoc va nguoi benh goi la bcnh tim vanh) hay khong,

la

phan bier dan ngl.Tc co phai do thieu mau CL,lC bo co tim VI thai d(> xir tr i, each phong benh, tien luong hoan toan khac nhau.

1. Vau that ngl!c.

Goi

la

"dau sir.

that",

nhung nrc, nang, phan

trong nhieu

trnrc tc, phan

Ian It khi sau

ngtroi benh chi thay dau thuc xuong

chen ep i:J ngtrc,

Vi

1rf dau

i:J gitra nguc,

tIC, doi khi i:J nguc trai hoac nguc phai: nhirng ea tay den t~n ngon lay).

dien hlnh dau Ian len tren (xuong don, vai, ham, co khi dau doc canh di nhanh, gian,

Diem dac trung cua dau that nguc 1il xuat hien khi gang sue th~ hrc, nhu
chay, leo d6c, len thang gac, V3.c nang. hoac xuc dong ap, kharn Cling (We co hic dau khj an qua no, ra lanh, s("j hai ... ). Nghe tim, do huyet

thuc the

kh6ng thay gl dac biet.

Dau that nguc tlurong rat ngan, tir 1 den 10 plui t, it

44

khi qua 15 pluit.

LJi"

each cham dirt con dau nit dan gian: nhieu khi chi cfin ngirng g{lIlg sue la du, Ncu dau nhieu, thi thay

thuoc

chuyen

khoa

cho ngiroi

benh ngarn lau duoi

luoi mot vien nitroglycerin

0,5 mg cho tan trong

m ieng (dirng n uot l ), chi vai phut la hel dau. Sa 1I 15

phut, ncu con dau, thi them mot vien rhtr 2, va r6i co
t ht

vien th (r 3. N eu khong do, nen gfri len tuyen rren.

vanh bi hep, chi'! yeu la hep dung

Benh nay do dong mach do vira xo, hay g~\P iJ nguoi

tuoi, nam nhieu hon

nir. Dirci 40 ruoi, benh nlt hiern. Mot

so benh

tim khac khong

phai vira xo dong mach

vanh cling co the' gay nhirng can gi6ng dau that nguc va cling xuat hien, k hi gang sire nhu hep van chu, hi:1 van chu, benh co tim phi dai.

2. Nhoi mau co tim.

Dau cling

a giira

ngL!c, nhung dir doi han nhieu, co

giac sq hili, co khi keu la,

nitroglycerin.

va

cam

rna hoi, tut huyet ap. Dau keo

dai han dau thar ngirc, mac dau dau qua 30 pluit,

da

nam nghi tim.

va

ngam

Kham tlurc th~ khong thay gl dac bier. Neu

can

nghi Ia

da

nh6i mau

C(1

U\ bcnh rat nang, ItT vong nlt cao (khoang 25-30%), c.in phai den vieu ngay,
If!

hoan co the' nguy den t inh

45

m;_~ng. Neu dau qua, co rhe: t iem mot 6ng morphin

cia tnroc khi chuyen.

dmri

3. Vlern mang ngoiti tim, tran dich mung ngoal tim Dau cling
tho sau, nu6t.

a ngirc,
Ngoai

nhung keo dai d. ngay, chtr khong

ra, ngtroi benh

lien quan den gang sLfc. Nh i6u khi dau tang len khi ho,
phai ngoi day moi

de chiu.

con sot, kh6 tho',

Nghc tim co the: Ihay tieug CQ mang ngoai tim, ricng lim rna, go thay dien duc cua tim to nhieu d. 2 ben,
cling nhir X quang sau do thiiy T det, thay bong tim to. Tinh mach co noi len khi viern moi bJf dau, cac song len. Dien tim thay ST chcnh

thap xu6ng.

Chan

doan

quyer dinh phai do choc do mung tim.

rff>

Dieu tri: tuy nguyen nhan: + Neu dich vang ehanh, nen nghi den lao hoac virus.

can phai gjri len tuyen tren d~ thao mil va cho khang sinh Iieu cao. + Neu dich mau thuong kho nhan dinh, nguyen nhan ung thir rat hiem, van ell' nen chua nhu lao, trong khi cho doi cac xet nghiern khac.

+ Dich mil lil. viem nhiem khuan,

+ Neu dau nhieu,

nlur paracetamoJ,

co

tht them cac ihuoc

giam

dau

aspirin.

46

4. Phinh tach d(mg mach chu

Rat hiem. Dau ding dot ngor, dir doi, keo dai vi. xay

ra

ngLHJi dirng tuo]: luc dau, dau theo nhjp d~p cua g iam dau lieu C<:lO va gill ngay den Irung

lim, cho nen d~ nham voi nhoi nuiu co tim.

cJr

Cho IhuDC

lam phau thuat.

5. Cac benh ho hap
Btwg kham

lam sang hoac X quang,

da

so

co th~

chan doan diroc:

• Viern mang phrii, du nguyen nhan gr, cling gay dau nguc. Dau keo dai, dau lien quan voi nhip tho,
hoac kern sot va ho.
VY

Dieu tri tuy nguyen nhan lao hoac vi khuan khac,

• T6m khf mang phoi: dau dot ngot, kho tho (nghe

phoi: mat rl rao phe' nang, g6 vang). PMi hut khi bang kim.

- Viem phoi, viern khi phe' quan cling d~ gay dau ngirc.
r:ir

Dieu tri bang khang sinh thich hop 6. Cac benh tieu h6a. Dau

bung lit chinh,

nlurng

cling co khi dau len

nguc.

• Loet da day - 1<"i trang dil co khi chan doan nharn

47

hi

SlIY

vanh. Nhung dau

a day

co 1ien quan den bira an,

chup X quang • •

thi'y 6 loet.

Viern da day cling co the' nham nhu vay. Thoat vi khe thuc qU':IIl, viern thuc quan, viem

tui m~t... dell co

CiT'

t~e' gay

dau ngirc. nhan rieu hoa.

DieD trl

a day

13.chua nguyen

7. DaD thanh Iong ngtrc, Thanh long nguc gom nhieu

lap: da, mo duoi da,

can, co, S~1n, xirong, khop, day than kinh, viern lap 1130, cling co the' Wang la dau tim ca! Khong nhtrng the',
benh

dam r6i canh ray, i:J cot song c6 cling co the' gay dau nguc diroc. Dau fh;:mh
i:J cac khop vai hoac

long nguc co ~he' ngan vai giay hoac dai nhieu ngay. M¢t each phan biet nrong d6i dan gian: an lay len chb dau. Neu dau thanh long nguc, se tang dau, neu

dau do benh dong mach vanh thl dau van nhtr tnroc,
<7"

Dieu tr]: dung thu6c giam dau, hoac thuoc chong khong
steroid (aspirin, indometacin ... )~ co

viern

the'

dung thu6c hoi ngoai da tai cho dau.

4X

8. Dau do than kinh tam

IY.

so nguoi qua nhay cam, chi can 10 lang, hoac 10 sq benh, sq hai, nrc g ian cling co th~ dau nguc. Nhat la khi than nhan hoac hang xorn co nguoi nhoi mau co tim chang han th] cang Dau

6 mot

de dau.

khong lien quan den gang sire va thirong keo dai ttt mra gia den nhieu gio. Kham thuc th~ cling
nhu dien tim khong co dau hieu benh ly.

a day

Nell quyet doan nhirng tnrong hop nay 18. dau that

Jam ngirrri benh sq hai, nr minh bo hep hoar dong, kh6ng lam an gl duoc.
nguc se vo cung tai hai, VI Tuyet d6i khong diroc dung thuoc

tim mach,

rna chi

nen cho thuoc an thdn.

T<f.I1OOTVSOT

49

TANG HUYET

Ap
GS Vii Dinh Hdi

Huyet ap (HA) cao khong co trieu clurng dac hieu, chi do bang HA k€ rnoi bier, HA k€ thuy ngan ladting xac bang. NgLfai benh co tht narn hay ng6i, sau bira nhat, roi den HA k€ dong h6~ cac HA ke "hien so" kh6ng chinh

an

15

phut, nghi ngoi 5 phut. Khi xa hoi ra, nghe thny rieng dap dall tien, du nho, la HA lam tim, tiep tuc xa hoi den khi khong con tieng d.)p nua la HA

tam tnrong. tri s{/ huylt ap

HA lam tnrong

BUllg J: Phiin loai tang huyet tip theo

HA lam thu THA nhe THA
VU3

140 - 180 > 180 >200 THA =_tang huyet ap;

90 - 105 > 105 > 115

va nang

THA nang

(Cac chir viet tat:

HA TIr HA TIh
Khi do mot nguoi, thay

= huyet = huyet
lang

ap tam tnrong: ap tam thu)

HA nhe (140-180

va{ho~c 90- I05), khong nen cho thu6c n '! ay,

do di do iai nhieu .

rna

phai

Jan nhu sau:

.

50

I
r

HA do hai Ian vao hai di~ neu trunq binh c9n9 140-180190-105 flo I~i 2 dip nlla !rong vang 4 juan

I
I

1-

HA < 140190; !iep lye do 3 thang 1 Ian

tronq nam

HATTr 90-105 val hoac HA TThu 140-180: dieu !r! khOng thu6c va thee d6i HA

f
HATTr 90-95 val hoac HATThu 140-160: tang wang dieu tri kh6ng thu6c va theo d6i HA

I~
HA TT r 95-100 val hoac HATTh 160-180: tang wang dieu Ir! kh6ng !hu6c, va xet dung !hu6c neu ctJ y€u t6 nguy co

~
HATTr> 100; hoac HATTh 160-180 vrn HATIr > 95; tang wang dieu tri kh6ng thu6c va bat dau dung thu6c

t
HATTr 90-95 val hose HATTh 140160, co yeu t6nguyco: xet dung thu6e

t
HATIr90-95 va; ho~c HATTh 140160,yeut6 nguyccr: bat dau dung thu6e

HA TT r 90-95 val hoac HATThu 140-160, khOng co yeu t6 nguy co; tiep tt.Jcdi~u t~ kh6ng thu6c va thee d6i HA

Ht'1J1t1: Xii tri THA nhe. (HATTr

90-105 valhoac .

HATTh

140-180)

theo TCYTTG

- 1993 51

Tat nhien

la

neu HA

COlO

nhieu (tang HA vira va nang, HA tam tnrong HA, viec 105), rhi

HA lam thu tren Truce mot

I 80 va/hoac berth

can cho thuoc ngay ma kh6ng can qua nhirug buoc tren, nguoi lang

d,:ltl ticn HI.

kham lam sang kY,.nhim M¢f fiJ tim nguyen

2 muc dich sau:

nhan, nhar la nhirng benh nhan tre, 40 tu6i trc xu6ng. Vice nay it co kel qua, VI chi co 4-5o/r} nguoi tang HA la 11m duoc nguyen nh cln.
Hai hi danh gin. anh huang ella lang HA len de co quan dich, chu yeu 1iI tim, nao, than va cac mach mall. Phai kham

roan dicn, dung quen:

- Hoi xem co dung nhfrng thuoc co tht'f gay tang HA? - Tang HA co thanh con? - Tim: kho tha?nghe, dien tim, X quang? - Nao: liet? cac dau hieu khu tni? - Mat: day mat? mat nhin hoac roi IO<Jn nhin? - Xet nghiern rnroc ti~u tim protein va glucose, can

lang hoac can Addis. Xet

hemoglobin,

nghiern

mall:

.glucosc.

cholesterol,

kali, acid uric, creatinin.

wDieu trl tang HA g6m hai phan:

J. Die'll chillh khuyen sau: 52

cach

.1'011:5 clio hf!p Iy: theo tarn lai

+ Che' do an g iam muoi hoac it muoi, 4-5 garn/ngay

(ngLfoi thuong an X-J 0 gam/ngay ).

+ B6 hoan roan rhuoc hi; g iarn nrou va bia. + Tang van dong th~ hrc: 1h~ due th~ thao, khi cong, yoga, (hili cue quyen. Tap vira voi sue minh, + Giir rinh than lac quan, binh tinh. + An vira rrurc, dung d~ ben qua.

H<_l11

eh€ an

rna

dong vat, chuyen

sang

x ao nau

bang dau lac, dau virng, dau cam.

+ Do HA moi tuan mot I<in (neu

hang ngay).

co

dieu k ien, thl do

+ Uong thu6c theo loi dan cua thay thuoc.

2. DlllIg thuo« (Xern bang saul. Co th~ bat dilu bang mot trong nhirng thu6e rhier yeu sau:
Blillg 2: Chon thuoc chong THA lily theo benh.
B$nh co IrLI<'1c Elai thao d LIOng 19i Ij~u Th.dai Khong Chen Bela Th.dai ElIJl,1C Tr.cai Eluqc Khong Khang Th.dai LfCMC ElLIt'!c DlJQC Eluqc ElIJl,1C Duqc Ouqc Khang calci Eluqc Dttqc ElLIqc DLIqc Th.dai Ell1QC Dl1QC Duac

co san
Chen

AlQha
ElLIqc DlIqC DIJl,1C ElIJl,1C ElLIqc OLIqC

GOI
Loan Suylim Hen

ma rnau

Tr.cai
Eluqc Duqc

B$nh lim TMCB

ElIft,1C
Duqc

B$nh d(lng mach Hep dong mach Ihim

UCMC Th.dd!

= Ire clle men

Ouoc
,

Eluac

chnyen ; Tr.cdi tlieo ddi; TMCB thie'fllI/UII

Th.dOi
Kh6ng

DLIqc
Duac

= tranh

nil;

cue: h9

53

!",* Hydroclorothiazid
moi lan, u6ng

25mg.

ucng 1/2 vien den 1 vien can dung lieu cao

2 l<1n/24 gia, kh6ng

han. Nho bu kali bang thirc an hoac thu6c . . 'J'+,Atenolol vien 50mg, I vien/24 gia, ve sau, neu

can, tang len "2 vien/24

gia. Chu

chong

chi dinh: hen nhirng kh6ng

I.i ..

phe quan, tim cham duoi 60, suy tim nang.

t'6~ 'btmg.'
ten

+ Propranolol
,;

cung trong

nhom
,,

nay,

,i:·

+ Nifcdipin

10 mg, 1-2 vicn/24

gia. Thuocnay,

duoi

iu

Ad alate" 'lam 'ha huyet ap rat nhanh,

uen ngtroi

bqllli hay khochiu (tr6ng nguc, tut.huyet.ap .. ,h,' " + Amlodipin

5 mg,

#~n~)·fhi\;tli\Hrni~ !tho

th!l" f.H~H.\h.j'"

la'm !h~i I+A' 'rn:"iih;;IHhiiNg'tiifrr,

'h \\\\,''.) .
,r, \:;\

I, .-;':1"'+ ~et~.)l"jaop~_ 250 mg:_:qtll1g

t, thai, suy
._r,
! ,J .... , :

th.i;ln, uong

1-2 vl~»l24
_ •. _". ,

~i,¢n l~i ChO'llgubi eo gio. , :,',':~,' .,.

, :.... I I ~ •• ), ,.. , "..).~ .

bJt;,'4~ 1 v~'¢~/24 gia, VC"s,~~!, ,\:~,2, v.i~.n/24 gj.,q(;; Reserpin lam):,p'.l HA-<~h~m. v~dS~q,®iJ
0,1
. ,)... ' , .~.~:.

.'~.f~ Resefp?n
.I!'~._~

ODl'g,

'V~:~t

:::.~;:.!.~.

,J~.~(~

,.

""Qh(;m tRlJ.,OCnao con tuy, 'i!P d,a.J?¢nh kemrhco, kha , nang mua ... (bAng 2) va phan Duoc cua sach nay. Cac
thuoc

rren

co' the

ker

.hop,

ttlt

nhat

la

ket

hop

54

hydroclorothiazid

voi mot trong nhirng rhuoc khac, Da so phai dung

3. DII/lg
2 thang,

thuo: cho d(;,/ h~1O giil?

mJi maio Nlurng khl

dd\pieU·i!l;hin"h;lreu

HA

da/xlI6n'g!h1nh thuong diroc 1-

co the giam lieu nr t ir, dong thai do HA luon

I~rqng. Khong bao gi« nen ngirng

, r
.j

I_

::f[
I .. I"

... ,;,:!ji·*
r j
r•
j

_:fili.>'

:
I" )

:,

1 ., '_ r; ~
:} t:

_.!

_J ; ~ /

f; _'

',.'i.'

i·.i

r.u

rfr~lf[

. -, , i Ii -l

_--\, \ I'.

,',

~ ~ '. I

":

-,_,['·1
. !) ~

r;

,:

>

i : .'

.:

I .' : ~

:i .
; I : i : ~;

,(~~:.

:...~I-

~~

.:.'

:1
:I .~

'.")"

it)

t"i.~ )

.:»

i•

i t ~ :.'

i ; :"

, ~i

55'

iA

CHAY CAP
GS Vii Dinh Hai

La ia phan long qua 3 hin trong mot ngay (neu phan thanh khuon, chay). thi du 3-4

lan cfing khong phai la ia

Dmri 14 ngay goi

la

dip, qua 14 ngay lit keo dai.

Xir trf gam bu mroc da bi mat va dicu tr] nguyen nhan.

1. BiI mroc b] mat

Nguy hiern cua ia chay cap, dac bier

a tre

em,

la

co

th~ thieu mroc va dien giai. Do do, mac du nguyen

nhan nao, deu thiet yell Ia phai danh gii.l ngay rmrc do
thieu ruroc d~ btl eho du.
(jJ'

Xii tri fa chdy cap chua co dan hieu thieu nuoc

(Phac do A):

+ U6ng nhieu mroc, nhir

phut lai tiep tuc.

\lUOC

chao,

mroc sup, ruroc

cam ... Nell tre non, eho u6ng tirng thia nho, nghi 2-3 + An nhirng tlurc an
ca, tnrng, u6ng ca n uoc).

de

tieu nhir chao, cam, d6, thit,

qua (chuoi rat tot), rau xanh (I119c 11nuoc va

S6

'0

~ ':2 c C
::::I «IJ

01 C

·-

~Q)

1-

E0

= c...
......
..".c=
'0 <0

-g
i::::
-co

oE
c£

U 01 '0 C I<n:! :::J <0

::::I -::::I 'n:! 01'0

'0,

<CO

::.:;
0

c: c

~55

0=

= ~ :? E ;nf:g <0 u
.. Z
~

::::I

'<5 q;ro .' U,)

.D .s: - -><:

g
""0 OJ

::R
0

.......
1..0_

l-U

-:::J -0:::'::::

= -0 c: <0 :::.:::: '::I '2== .. Z l-:::':::: Z

= ..c: u= c~m c: E m m

<CO'

~
N

::::i!: ..c:
..

Z......J

'0

-m

.5:0

L_..L-..~

J........ __

.•

-L

...l-_--'L-

__

--'

57

Nen nghien no, kh~ng

nho cho de tieu, chia ra nhi&u ~iIa: bti

Cll'

an

du

can han che, Trc dang

van

tiep

t~IC

cho bu; ~t Wan

neu;.9<J;J1g an :siIa, n~1L*,ha loang trong nhfing gja dan.

l1~tla'~hay r6i,
n~a:~

::+'}~'u c6~san Orespl--'(ORS),,:ho,al,ar{ntQtj;6.i ~p m9t ;-=-~ r-- .. :--:-. '.; ----i .l!t:- rl1I6t dti'it sot dt-ngiJ~j. _Ti~ guri'i ~Z{lu5i':_u6ng s(};:
.-' :.r. ._....
C. "
""! "".

s~: :':~'

~4'ho c

~~.:; ~,: -~ :;,~:)r~,; ~ _-~_ ~~

C~""""5 .'_'

an

nhli;v~y trong,

I()()w f~bho
cac~jn~au
f~·
L.l,

~{>t:~lari :i :i~i~':Udng'd.1nd~n:tt&i-thla d
:" dati dan tirngng~h,l
1/) : .' ..

nh~

1-2 phiit.

.~

Ttl Z-IO tuan tuoi: ~6ng IDO-209ml cho mot ian

ia, nfHt~g pbai
:':' ~~ ,_-)

u6ng

.'.

I1h6. '-_'_ ,-_-' ~' :~.

..•.. ~ .. .'. ~ ," ~::._ _.::::: ~

':-:

.."

cfi

~JX~(jri ~':,' >~. \~

:.:_: _. -, - ~'.;

l~~c:hdy cap
r:.:-t

4~thieu ntiq4(i:fh~ d6iB~,,;

'~ . _;-'.,.1, .. J. . :" "
I ~ .• .._h·

can

_,cJtQ.uong:presol ng~ (pha vaca¢h:u6ilg n1iu'trcli»;-:, :'-::+;.4 ~ia ~u tie'n_c~o,tJ~hg t~~ can n~ng3 Neu kh6ng' - ," - _.' :--"" ' ',,,' c-- ,. ".
.. -': .. '

dui;c

thftfnh thee-

tut'fi-'(bang 2):' --

',

_.

Bdug ~~ Ldi,ng dring dich' Oresol phdi cho u(/ng thed::._

.; ::' """"1 "'

. ~,

cd,!, n4~g va thea tu6L'-

,;

;>

.-

,,'2'~4 --~:4'~1(, ' :315 tuoi ,,:,tij6(~' ,< lu6i:: "

._" '" -.:!-.

,;

..-

LUQ'ng Oresol

300ml, ~

400 -600ml
.; _,,

600· 800ml

0,8,1,21ft

1 ,2 . 21il.

2 ~ 41ft

58

J"Nell
phut.

non, cho uong tung thia nho, each nhau 2-3

Neu thay phu mi mat, phai ngimg Oresol va cho

u6ng nuoc trang hoac bu my.

+ Sau 4
bangI,

de xiI Iy
tuIarn
d
L

gio, danh .gia lai tinh trang thieu mrcc thea

tiep theo. Khi het dau hieu thieu mroc,

co the tho chua tai nha, phat tp~Pl 9q~;>ol,~d~n do each pha va each uong cho dung) .
..i
j~~ ~ r (;

ca. ph{S iril)'~u6J'an vi/8: thl~'dJb~~ {inh:~h~a van tan P Ht ritf8c 'S~c (khl dongdirng lay thUf c6rig<;>n m~ phai h
gat ngang). Chu

C6

f.'

the

~ ~.t: I

':

dung djch Oresol: HIy I thia nho (thra

".

:'

;.i

! I ,:~

i)

; i ri:
I

: _:

dirng nham mu6i voi duong. Tot nhat

la dung fWlf?i s~a~1,Fhp}h!!~3;;gam;~!-l~ttrong,1 lit nuoc chap; nhieu muoi qua se n~uy_ ~.i,~~, ;,
t. ~~ ~I, I l.. f '

qr

'Xu tri ia chdy cap thieu nuac

Iactat
"! ~ J
.;.~

~ i ~I'·,r, /

lj:

(1 f ~ j 1 j

l ~._: I.:

.~ I {I J

I ~ : ~ ~<:: ~:

~ ~~

.~ l

~.f

nang (Phac db, C):

,Iia

+ Phai truyen tinh mach ngay, t6t .nhat

Ringer hoac cac dung
...
I

Oresol trong khi chuan bi truycn. Neu khong co dieu kien ff-ti'i~H di8H,(d5! tl\~':'~(ls6hd~"'di~ ida~VJv~!rlh61 tJresol giQt

t··.~ ,';. , ~. .,.:! ~ ::

i .~ ".; i I

dich khac.
• ~.". :

dung dich Cho u6ng

' ; )... ' ~ :

~:. ( ;:

llig/kg.

~¥6'~" 6 ig:Wr neTl>:20 s

.. :- : ~,.\j: ;~; :.::. . . ~. .'r ' ,: i f ~1 Nell k??ng co ca dieu k ien dat sonde da day, danh
f : ~' ~ : " .

:~l{k:~/l ~ y t6'hgl \Ii~u' ia ';'120 'Kh'a~: I'<;ti ffil6i :giCf W1qt Un' 'de- di~u diinh 'khi can.

girt;!~~

cho uong Oresol 120 ml/kg/6 gio; 59

Theo khong truyen

doi 3 gia sau. tien tricn tinh mach.

Ncu cac dau dua

hieu

thieu

ruroc

t01, can phai

den benh

vien de'

Chti dung

y:
cac

trong thuoc

cac truong

hop ia chay, khong nen opi (vien nra) v.v ... cling nen than trong.

cam

ia nhir

Thuoc chong

non nhir atropin

2. Chua nguyen nhan,

Khi duong da bat d<ill bu ruroc bang dirong uong hoac

(inh mach, phai kharn

ky

d~ tim nguyen

nhan.

2.1. Truiing hlJPI: phan co rnau, kern sot. Ncn nghi den: - Ly tnrc khuan
- Salmonella
r:;r

(tuy da s6 phan khong (Biseptol;

co mall) ) 1I6ng 5

Dieu trl: bactrim

ngay.

Cotrirnoxazol

Tre em 30 mg/kg x 2 lcin/24 gio. Ngiroi Voi ly

Ian 960 mg moi lan, uong 2 lan/24 gia.

(f1!C

khuan co th~ thay bang tetracyclin:

tre ern

u6ng 12,5 mg/kg x 4 lan/24 gia x 3 ngay. Ngiroi IOn 500 mg x 4 ian/24 gia x 3 ngay. Dung tetraeyclin eho Ire em

Ia

bat dae di, phai so sanh loi hai (rrtrong hop thong
cho Ire diroi 9 tueli).

tlurong, earn dung tetracyclin

2.2. Truang hlJP 2: phan kh6ng

eo rnau,

co sot: Nghi

60

den:

• Enrerovi rus HI. nguyen nhan hay gap nhat iJ tre em. B~t diu dot rigor, non mira, la nhieu nuoc, sol nhe, doi khi phan co nhay. Thuong tu khoi, nhung cling co
khi nang. Khoug din. dung kharig sinh.

Salmonell a thuong

nh ieu nguoi

mac mot

1tic,

12-48 gi« sau cung mot bira an, sot ret run, reli non va ia chay.
rQ-'

Dieu ban

tri:

nen

cho

khang

sinh,

nhat

la

nhirng

ca

nang: if ngiroi Jan, sot keo dai qua 48 gia, lach to,

do khap

nguci;

& Ire con co dau hieu nhiern doc.

(400/80),

Sulfamerhoxazol

+ trimethoprim

moi bin
10 ngay

uong 2 vien, dung 3 Uin/24 gia cho den khi her sot, sau d6 moi Jan 2 vien, dung 2 liin/24 gia, va dung

lien. Tre em cho lieu {hap han (xem phan thuoc "Cotrimox azol ").
Hoac Ian cloramphenicol uong (chu ).

den

50mg/kg/24 gia, chia lam 4 nhfrng chong chi dinh ella

cloramphenicol

(.) Chu

y:

a tre

em, ia chay kern s6t co th~ do nhimg

benh khac nhu sot ret, viem phoi, nhiern

khuan tiet

nieu, viern amidan,

viern tai V.v ...

61

2.3. Truong hop 3: phan co mau, nhirng khong sot.

Co Ih~ He

Ly arn ip: di nhieu Ian, nhung phat , rim thay amip trong phan.

rfit It phan,

de lai

QrDieu tri: hang mctronidazol: moi Ian 3 vicn 0,25g, u6ng 3 IAn trong.24 gio, dung trong 5 ngay. Tre em 10 rng/kg, ciing u6ng 3 l£n/24 gio, dung 5 ngay. • Giun toe ncu nhieu cfing gay ia chay , w Dleu tr]: mebendazol (Vermox, IOOl11g) ngiroi Ian cung nhu Ire em uong I vicn hie sang va ] vien ILk
toi, dung trong 3 ngay lien. Tre em duai 2 tu6i khong duoc u6ng.

2.4. Truong hqp 4: phan khong co rnau, khong sot.

Thuong g~p Ia:
,

Enterovirus

(x in doc iJ tren, rrircng hop 2)

Do doc t6 ruot non, vi du do tu cau: U benh 2-6

gio' va thtrong khoi sau 24 gio. Dbi· kh i ia chay va non rat nang. Do thtrc • •
nhieu,

an

b] ban,

Eicoli Benh ta: U benh 1-5 ngay, roi ia chay ngay. Phan gay thieu ruroc nang, Nhfrng ca nang (buyer
ap

rat nhieu, toan ntroc, trang due nhu mroc vo g~o. Non tut, chuor flit) co tht chet trong vong 24 gio, khong dau 62

bung, than nhiet rhap,

(j)

Dieu trl:
Khang sinh:

btl ruroc Tctracycl azol

thco

phac

d~ C (xem 0,25g, trong moi 3 ngay: (nhu

tren).

in vien

Ian 2
hoac trong

vien, u6ng 4 15n/24 g io. dung

sulfamcthox Salmonella

a truong

trirncrhoprirn hop 2).

63

DAU B1)NG
GS VU Dinh

va PTS t.e Due

Dau bung benh giun la mot trieu chimg (} nuoc

u.u
Tuy nen

Chinh

nit pho bien va nhieu ta, nhung khong

khi ngiroi thay thuoc tlurc hanh rat kho giai quyet. san pho bien

nghi ngay den dau bung do giun. Trai lai, nhirng tnrong
hop dau bung moi (vai gio, vai ngay)
ciru.

can

phai kham

ti

mi va toan dien d~ khoi lot lucri nhirng ca can xu tri cap

Bay nguyen nhan chfnh

1. Vtem mang bung

Vi du, thung ruot thira, rhung

da day, viem chau

phan

hong, viern tuy. Day la nhtrng cap ciru rat quan trong,
phai phat hien scm d~ xu tri ngay,
phau glan. thuat.

nhieu phai

Hoi benh phai ti mi, khong

diroc tiec thai

•
nhanh 64

Dau lien tuc, ngay tren vung bi viern, cuong d¢

vao mang bung nhieu hay it, hay cham, co tinh chat gi, vi du dich tuy gay dau

phu thuoc chat la chay

han mat, m.iu va rnroc tie'u Iai dau II nfra. Co hai dac diem quan trong bung. cua dau do viem mang

Dau tang len khi benh

an

vao, khi ho, khi ciT dong. VI

vay, nguoi

I~am im, tranh moi ctr dong va khong

giun, thl nguoi berth Iai hay day thay

muon ai dong vao. Nguoc lai, neu dau bung can (colic) do soi mat, soi nieu, dua, Ian Ion moi

cam

de

chiu.

Phan X<.I co cling

neu thung ruot thira

qua. Hoac
II

a V! trf

co bung vimg b! viern. Nlurug

sau manh [rang, hoac thung

da day dtroc bit lai, thi ctrng bung nhe han va nguoi benh cling da

de

bi b6'

gia yeu, nguai bcnh tam than

it va ctrng bung it han.

2. Tac cac 'ong rong.

Dau lung can, nhung cling co khi lien tuc. V] tr! dau cling giup eho chan doan:

TAc ruot non hay dau quanh

ron, rren ron hoac

khong ro rang. Dau bung do giun, nhat the xep vao nhorn nay. • •

la

giun dua, co

Tac ruot kef hay dau diroi ron, va" nhe han. Tac dirong mat, tui mat hay dau 0 ha siren phai,

Ian ra lung phai, den mom xuong ba, co khi dau thtrong

vi. Dau lien rue hay g~p han dau can. D~c bier rac IU ttr
rs.HOOTVSDr

65

nhu trorig ung thu dan tuy nhieu khi khong gay dau, • • • Tac ong tuy cfing dau i:1 vi tri tren. Tac bang quang gay dau it, tren xuong mu, ding

nrc kho chiu han l a dau th,}1 sl.r.

Tat nieu quan hay dau 0 rnang siren hoac goc suon - song, Ian xuong dtrrri.ira t6'i durmg vat, mat trong dui, 3. Benh & thanh bung,

Nhu chan thuang hoac nhiern khuan cac ca. Dau lien
t uc, tang

len kh i an vao hoac kh i cir dong.

Co kh i sa

rhay

tu

mau.

4. Dau vung khac quy chieu len bung

• Benh

i:J nguc nhu dau that

nguc,

nhoi

mall

Co'

tim, viern mang ,ngoai tim, viem phoi, tac mach phoi, viem rnang phoi, benh thuc quan cling co the: gay. dau
bung. Dac diem

la

dau
Co'

0 bung hoanh

rren

(thuong

vi, ha

siron); tho kern sau vi

It di dong, an vao bung

thi dan khong tang rna co khi lai giarn.

• Benh i:J cot song do kich thich cac rli than kinh.

b day, dau tang khi ho, dan, hal hal.

•
hO~II1.

Benh

b tinh hoan: dan tang khi an nhe vao tinh

66

5. Cac benh
porphyrin

chuyen

hoa nhir loan chuyen nguyen nhan hiern gap.

hoa

(porphyria);

nhiem doc chi; dai thao dirong,

ure huyet cao ... La nhung

6. Benh than kinh nhu erpes, u day than k inh, thoat

vi di a cot song, tahe~. Hay co roi loan cam giac; dau

tang khi cir dong C(H song. 7. Benh tam than nhu Hysteria
W

(it-te-n) v:v ...

Xu

tri dau bung

nguyen nhan

'If'

Chua

la

chinh,

trang phan

16n twang

hop.

+ Troug uhom 1 (viem maug bung), don phai gui di

mb dip ciiu ngay, thuoc morphin hay g~p nhat lil viern dO' dau, ruyet doi khong ruot thira va va thung da day. Trong khi cho doi, co the tiem atropin

an than

de

diroc dung

khi con dang theo doi chan doan.

+ Trang nhom 2 (tac cac 6ng rong), cling co mot so ea can mo, nhung khong cap
truong
CUll

bang, nhir tac rU(H, soi

nieu, soi bang quang, soi mat, so] 6ng tuy. Con nhieu hop, chi can chua n(li khoa.
vien

Dau bung do giun rat hay gap: cho pyrantel 125mg, nguoi
16n uong

4-6

vien/24

gio,

hoac vien 67

mebendazol chieu, dung

vien lOOmg, liang I vicn sang va 1 vien trong 3 ngay lien, hoac albendazol

200mg,

uong 2 vien lien.

Cac trtrong hop co soi, chua m6 hoac khong mo. co the' giam
t

dau bang

cac

thuoc

chong co that: (Buscopan)

atropin tiem.

iern, papaverin

ticm, hoac hyosein

+ Troug 11110111 3: (henh i:J thanh bung), dicu t ri chan

thuong.

chua nhiern khuan len bung da diroc noi

+ Troug 11110111 4, each chua cac benh

chien nguyen

a bai

ngirc quy

"Dau ngirc". Neu dau

ngoai

do cac

berth cot song va rinh hoan,

vice chua

nhau, nen giarn dau bang aspirin,

paracetarnol: ngan ng ay.

trong nhirng ca nang, co th~ cho morphin

+ Trang 1IIUJIII 5 (benh chuyen hoa): cac benh nay Illy

hiern g~p, nhtrng each chua rieng cho tirng benh da thanh k inh dien. Chira tri¢u chirng dau chi dong vai tro phu.

+ Trang 11110111 6 (benh than k inh), ciing phai chira

can nguyen: riern penicilin

~6

u than kinh va thoat

V! dia cot song;

cho nguoi tabes v.v ...

+ Trang 11"0111 7: can CO thay thuoc tam than.

If

Chua trieu chitng dau cfing co khi rat can, dong

nhan. Nhirng thuoc hay dung la: hyoscin d~ chong co that cac

thai voi chua nguyen

+ Atropin, eC1tron.

papaverin,

6X

+ Thuong
corticoid,

dung

asplfln,

paracetamol,

doi

khi

dung cho cac dau rc than kinh.

+ Morphin

chi nen dung cho nhfrng ca qua dau, rna

co ket qua, dien hinh Ja cac ling dt d6i khang khi

cac thu6e khac kh6ng thu gay dau. Nen

chuan bi naloxon

ngo doc morphin (xem bai "Nhiem dc)c cap"),

69

DAU KH()P
GS ViilJinh

IIdi

Hoi benh

phai Ii rni: tuoi, gi&i, lien sir gia dinh, btlt

t rieu

dau dot ngot (nh u f hap khop cap, g Li L,), hoac t Lr IIt (n h It rho.ii h6a x rrong k hop). ChCI )' LIen nhirng clurng kern thco nlur sot, ban do, benh phrii, nhiem khuan.

Kharn rhuc lilt •

•

dn <1'.11 ba muc lieu

V;I

chinh:

Dau mot hay nhicu k hop

khop nao?

Co Vie-Ill, nghia la e6 sung nong do dau k hong?

H~1Il che ci'r dong toi mtrc nao?

Chi can xet nghiem trong sO' it tnrong hop (Illy thea dieu k ien trang bi ella tuyen): cbng tlurc bach call; mau lang: acid uric trong rruiu; yell 10 d;~ng thap ... phil] chup X quang va xct nghiern l. Thap khop cap Con dau khop drill tien thuong
D(ic diem: • Viern

Co

khi

dich khrrp.

a tuoi
do

di hoc (6-15 tuoi).

nil ro, sung nong

dau nhieu,

de

co sol

39"-4()".

70

• chan,

Nh icu khop bi berth: k hop nay dang diu dan, thi

khop k h.ic btl! clan dau , nhfit iii c.ic khop g6i, khuyu,

co t ay.

co

•
ticng

Hay C{) bicu hien tim nhir: tieng thoi , ticllg

ngua phi, tim to, kho tho, suy tim .

co ,

Nell co them diJ k ien sal! day thi chan doan chile chan han: 1-1 tu.ln tnroc co vicm hong, ban do vong not duoi da; toe do mau It"mg r tit cao 60-100 mrn; PR
dill qua 0,2 gi:ly trcn dicn tim; cay hong thay lien cau A. • truong
ton

Dien bien benh k ho do.in hop, c.ic dot viern cir

taj

t nroc.

Trong

phan 16n

pluit. Sau mo i dot, de

bao

khrrp tro

vc

binh

tlurong,

khong

gii:r bj cirng, nhirng

V,'\

rhuong

tim n;lI1g len g:1y hcp hai Ja v~ ho chi'. iii

chinh.
vice
W

Cling co khi viem gl, hoac

khop tai phat

tim

khong

chi viern khrrp 1119t l an roi thoi.

Dietl tr]: dung kluing sinh va thuoc chong viern. + Khaug

- Penicilin

sinh chu yeu nham

diet

lien cau khuan.

Dung mot trong nhung cong tlurc sau: G: 1.000.000 dan v!J24 gio, tiem bap trong

10 ngay lien; hoac:

- Phenoxymethylpcnicilin (penicilin V): mbi

Ian u6ng

250 mg. tiling 4 J[in/14 gio, dung trang 10 ngay lien. Tre

71

duoi 20 kg chi can u6ng moi l<in 125 mg, dung 4 lao/24 giO', dung 10 ngay lito; hoac:

- Ncu di irng v6i penicil in, thay bang erythromycin u6ng moi Ian 250mg, lien. trong 24 gia. Nhtrng khang sinh co tht dung duoc, nhung amoxicilin. clorarnphenicol, khong dung 4 lan/24 gia, dung 10 ngay 2 Ian

Tre diroi 25 kg cho uong 40 rug/kg,

chia

t6t bang nhfrng thu6c tren la ampicilin, Khong nen dung: sulfamid, tri mel hoprim, co-trimoxazol. Cong phong thirc dieu tetracyclin,

tr] tren con goi 13 "khang

sinh

du

cap 1" cling can diroc dung cho viem hong, viern h6 hap tren, neu CO nghi ngo la do lien

cau

da, viern duong

khuan.

+ C ltdug vie!", giam -dau, Ill; sot:

- Aspirin rug/kg

a tre

thong

dung

nhat,

bat dau moi ngay

100

em hoac 3-4 gam b ngtroi

Io-n, chia lam 4-5

viem khop da do,

I<ln u6ng sau moi bira

an.

Khi sot

va

thuong sau 2 tuan, nen giam lieu dan toi 60 mg/kg/24

gio, thuong phai 4-8 man thi toe d¢ mau lang da ha

xuong gan binh thuong moi ngirng thu6e. chi nen cho khi co viern tim: prednisolon - Corticoid 2mg/kg,

chia lam 2-3

Ian trong 24 gio, u6ng lien trong

72

2 tuan. Sau do g iam lieu corticoid, aspirin vay, khoang 60 mg/kg/24 sau do ngirng corticoid,

dong thai u6ng kern con aspirin tiep tuc

gia. D~ 2 tuan dung song song nhu

mot rhang mra.

+ Khi dot thap khop da qua, du co kern viem tim hay

khong, nhfrng cling phai durig khang sinh du phong dot tai phat. Co th~ dung mot trong ky II chan hai c6ng

thirc sau: Benzathin-penicilin, tiern bap sau

1.200.000 dan vi, 3-4 tuan tiern mot Ian; kg, chi can tiem m6i miii 600_OOO don
phirong Neu di irng voi penicilin, thl thay bang: 1 gam/24

a tre

moi

Hin la

diroi 30

vi, Day

phap hieu qua nhar va tien Iqi nhat, gia.

- Ngiroi Ian u~ng erythromycin nam. Neu sau 5

Du phong ky II nhu vay trong bao lau? It nhat phai 5

nam rna nguoi benh chua d€n 18 tuOi,

them cho d€n 18 tu6L

thl phai du phong

viern tim hoac di clnrng

a van,

nguai

co

phai dl! phong

cho d€n

25 tuOi hoac lau hon nfra, nhieu khi den su6t drri, du
ngtroi benh da diroc pha.u thuat van.

2. Vlem khop dang thap (VKDT).

VKDT dau

a ruoi

hay gap

a nil

nhieu

han

nam,

phan

16"0 bat

35-50 va co tfnh chat gia dlnh, Do

la

viern

73

mang khcip keo dai hicn dang khop,

(Hin den pha huy sun va x uong, r6i

2.1, Lam sang: bcnh rhu(>"rlg bfit CHill tir t ir, nhicu khop, d hai hen dell dau, thldmg thay (1 ban t ay. co

co

tay, drill goi, b~H1chan. 0)1 song co the b! viern

t ren ,

a doan

khong

hao 'gia (; lung.

Co

k hi bcnh hat dfiLl

viem c,Yp, co s61, co khi bftt d<l.Ll bang mot khop thoi. Trong thi)'j

k5'

IO:1Il

phat , de

k hop b! dau nhieu, nhat cac k hop bi cirng. Trieu

I~\ khi cir dOllg_

Bu6i sang,

clnrng ioan 111,)11 gorn sot, doi khi tai 40". met moi, kern an. slll cun. CtC khop co dau hieu viern ro: sung nong do dun. ngll't:il bcnh khong dam elf dong. Cac bieu hien

llg_o;\i khop chfnh li'l vicm

mang ngoai

mang

phoi, XCi phoi, viem

lim, viem day than k inh ngoai

10,

bien, vicm

e u ng mac, hoi clilrng Fe Ity (hie h

gi am hu yet cau .. .).

2.2. Xet nghiem: uhirng yell 10 dang thap la nlurng II! khang the, Illy khong d(\c hieu, nlurng co gui tri chan doan.
Chup X quang, moi d.lu chua thuy gl dac bier, nlurng ding

ve sau, cang thay 1"0mal

qr

SI.Jn

khop va an mon xtrong.

Dieu tri: + Thuoc clio'/I.'< vi em ("//1/ tillllg

flgll_V, dung mot trong

nhirng rhuoc sau, nhrr uong. hie no, sau bira an va khong dung khi loet da day - t,\ ! rang, co thai, eho con bu:

74

- Aspirin

500 mg, 2-4 vien/24

gio, hoac

- Indomethacin - Diclofcnac

25 mg. 2-4 vien/24 gia, hoac

50 mg, 2-3 vien/24 g io, hoac gia
t uan

- Pirox icam 10 mg, 1-2 vien/24

Dung mot thir thuoc.r neu xau 2-3 phai thay bang thuoc thuoc dong thai. kh.ic, Khoug

k hong dO' rIH1i

diroc dung hai loui

+ Cortuoi d
V;l

t(IC

bien, ncn chi dung

a c.ic

d 1//lg nit IIW II h . n h ung de g[IY tui

the" vicm k hop dung
t hap

nang Smg,

kco dai, IUy dJ durrc dung truce bang gi«, uong sau bira an sang. chong.

thuoc chong Chu 'Y' nhirng

viern kh6ng steroid.

6-10 vicn/24 chong

Lieu lrung binh: prcdnisolou

chi dinh k inh dicn, Dot tan cong HI 1-2 tuan, sau

do

phai giam lieu nhanh

+ Thuoc liD tro: dung ICUI dai co the: lam benh nhc
han, nhung khong giarn dau. Thi du: cloroquin dung rrong nhieu moi th.ing.

ngay ucng mot vien 250mg,

Kh6ng nen dung khang sinh.

+ V~ill dong: khi dau nhieu, Qua giai doan viern,

dan ella {hay thuoc.

phai narn nghi thco

va bat

dong khop bi viem , Khi dO' dau , van dong

can

tang dan len.

huang

It}r IUy~J1 nhieu

75

3. Vlem cQt song dinh khop,

La benh man tinh, gap 0 nam tre 15-40 tuoi. Benh bar dau oCQt song lung, thay dau va cirng, nhal chi it bi hon.

la khi

ngu day.

Cac kh6'p hang va vai ciing hay bj dau va cling, cac khop

co

khi dau

ngirc, S6 it benh nhan

co

ca nguc,

co the' nham voi dan that the s6t, m¢t moi, sut din ...

Dau keo dai hang thang, hang nam, JUc tang Iuc giarn,

Cuoi cung, cQt song bi cUTIg do bien dang, hie do rhirong het dau, nhung ngucJi benh khong con lam viec diroc nira.
OUlP CQl song hie dau van binh thuCmg.

Ve sau,
ITIQC

cac khe . ra, cuoi

lien dot hep Iai, dot song mat voi, gai xirong

cung cac dot song dinh nhau nhir hlnh mot "doan tre".

c::r Dit~u tri: + Khuyen nguai benh giiI lung thang khi dirng, di, ngoi, mac dau dau. Khi ngu nen nam sap, hoac flam ngjra tren gurong ctmg, khong dung g6i. Tap tho deu.

+ Trong d<.Jt tiln trien, nen tiern phenylbutazon

mg, tiem bap sau each nhat mot 6ng, dung trong

600 20

ngay hoac diclofenac (Voltaren) ding tiern hap mot 6ng 75 rug mbi ngay, dung 10 ngay. DOng thai, cho gian co bang Mydocalm vien 50mg, u6ng 3 vien/24 gia, hoac diazepam 10-15 mg/24 gia.

+ Dieu tri duy

duoc cho corticoid.

tr]

hang uong phenylburazon,

Khong

76

+ eli Ihe kel IW11 them cham ciru, vat 19 tri lieu. + M (')1 so it I nr.mg hop co the: phau thuat chinh hi n h.

4. Dau cot song.

Truce

nhat HI.

a nguoi Ire. L.Am

khuan tnrong kh6ng

het phai tim nguyen

nhan de di~u tr] d~c hieu, co th~ chan

simg va X quang

dean duoc lao cot song, cot song, nhiem Nhicu (dau lung) iuyen nhieu, nghieng:

ung thu cet song, ch<1n thirong toan than ...

{j

hap dau cot song

nguoi dung !ueli

thay nguyen
nam giuong

nhan d~c hieu, Chi can cirng, tot nhat la narn Trong nhirng dQ1 dau

t(tp cot song;

t ranh mang

x ach nang.

dung vai ngay thuoc chong viern da noi

a tren.

5. Viern mot khop.

Trong nhieu
rat dn

nhirng benh noi tren, da so benh nhan bi vicm Nlnrng neu chi viern mQI khop, can phai nhan va giri di chuycn khoa. Chup X quang

khop,

tim nguyen

d~ h6 tro lam sang trong nhfrng twang hop nay. Nhirng nguyen nhan thuong g~p hem ca la: Lao khop:
nguai benh thuong

khop goi hoac khop

khuan,

hang

tre lu6i.
ch.}n doan

Viern khop mu: beuh canh nhiem

bang choc khop.

Chan rhucng khop: t icn str...

77

HONME
PGS

t.e {Ute Hinh

La tmh trang mat y thirc keo dai; do Ibn tlurong anh

lnrong tai hoar dong ella he than kinh trung trong. Dac diem chung hoat dong la tinh trang mat

thrrc, mat van khi de

dong va mat cam giac cua roan bo co the, trang vfin diroc duy tri.

ve tuan hoan, ho hap va chirc nang bai tier

nguyen nhan, tir roi loan chuycn hoa den ton thtrong vt cau true trong nao, Hon me
13 mot trieu chung, chir khong phai

Hon me co the do nhieu

la

mot benh dac hieu,

Ngiroi benh hon me phai duoc chan doan kip thai, xfr tri tfch eire, theo d5i chat che de tranh rnoi tai bien va

bien cluing co the xay fa, de doa tinh mang ngiroi benh. 1. Tham kharn nguei benh hon

me.
y
toi tinh chat cua

1.1. B~nh sir:

Phai khai thac

ky

benh str: chu

hen me, Ilk khoi phat, hoan canh xuat hien, thai gian keo dai cua hon me tit khi
7S

bar

dau tai hie den vien, tien

sir ca nhan, vice dung thuoc vii. chat gay nghien

chan thuong, kinh trong qua khir.

khac,

ngo doc, cac loai con co giat hoac dong

Cac dieu nghi van k hac ding

qua hoi true tiep gia dinh, ban

can duoc lam sang to

be

hoac nguoi quen bier

cua nguoi benh, Cac 'nguoi khac co lien quan nhu co

quan cong tac cua nguoi benh, cong an hoac dan vi

cap

ciru dua ngiroi bcnh

thong tin can thiet.

toi cling co th~ cung

dip nhtrng

1.2. Thurn kham loan lhi':

Chu

xem co gan to, lach to, vang da, diem

chay

mau, vet tich chan tlurong ... hay khong? • DAu hieu cua chan thirong: h6 mil, sung kiem tra

a dau

co th~

phat hien diroc V0 day S9, bao gam cac bieu hien nhu barn tim quanh phil va bien

mau vung
ra,

xuong chum sau tai, chay mall mang nhi, dich nao - tuy chay ra ngoai qua duong

sa nan
•

rniii hoac dirong tai. Ngoai thirong.

dau benh nhan cling co the thay diem hin xirong

hoac phil n~ mo mern

a V! tri bi chan
do

Do huyet

ap ngiro! benh hon me, nell thay cao

CO lang huyet ap til truce. Mat mall trong nao

co the do nguoi benh benh

khac, tang huyet ap co the 13 hau qua cua qua, trinh

19

gay ra hon me, VI du do chay

79

hoac chay mau diroi nhen. • nhiem Than nhiet ha thirong gap trong lion me do

doc nrou hoac ngo doc thuoc

an than,

ha dirong

huyet,

benh nao do' gan va phi) niern. Than

nhict tang
ho hap, ngo

co the rhay trong say nong, ac t inh lien quan den thuoc d¢c thuoc chong cholin,

dong kinh lien tuc, sot cao

gay me duong

chay mau vung diu nao va mot

s6 t6n tlurong khac b vung ha khau nao.

1.3. Thiim kham thtin kinh:

Can kharn day du, nen co k€ hoach k iem Ira lai trong qua trinh lien trien cua nguoi benh, khau quan trong chan thirong. doan trieu
,

Kham

th1n kinh Iii nhan tru khi

giup cho chan doan chung, hoi clurng

nguyen va khu

gi;lp nguoi benh han me. Qua kham lim sang, co the: d~t

ton
thuc.

Can d~c bier chu

toi:

Rtii

IOc_JII

j tlurc: co nhieu mire d¢ r6i loan

Co khi han me bat dong, nlurng cilng co khi hon me vat vii, Can dung

tit ngfr chinh xac

de noi

len tlnh trang hon r5 rang

me,' vi du: hon me nhe, hon me nong, hon me vira, hon me sau, han me qua. Tranh dung cac tir khong nhir: bat tinh nhan su, 1<1 rna, me man, XIU, • co,

lim v.v ... rruong luc

kinh
SQ

Can danh gia dung ctic bien deli cua van dong, phan
X<:J.,

cam giac,

day than

nao ... dac biet lil cac dau hieu cua dong

tir.

80

+ D6ng tIl: binh thirong dong nr co duong

k inh 3-4

mm, can doi hai ben va co vao mau le khi dap irng voi kfch thich anh sang. Neu dong tir gian tren 7 mm dirong kinh va khong thuong phan irng voi anh sang, thi thuong do t6n day than -kinh van nhan chung (day lII), cling co

khi do nhiem d9C thuoc chong i:J 1119t ben va khong IQI thuy thai

cholin. Dong Ilt chi g ian

phan ung voi anh sang co th~ do tren nguoi benh hon

dirong VI co kh6i u chen ep. Dong nr co rat

Irong

nho, dtrong kinh chi con 1-1,5mm me co the" gap

ngo doc phospho

hCTUco, q ua I ieu

loai thuoc phien, giang mai than kinh hoac do tac dong ella thuoc tra mal IO,!i gay co dong tiI.

+ D¢lIg tac Cllil nltdu cdu: can xem tu the ella nhan cau iJ nguoi benh hon me, trang thai ella mi mat (co sup
mi hoac khong), dap ling ella nhan

call

khi ta xoay dau

nguoi benh sang hai ben (phan xa dau - mar).

+ Kiil1l tra day

chay
truong mau

mcIt: co th~

thay phu gai thi hoac dau hieu gap trong

S9 hoac lrong tang

cr

v6ng

mac

la

nhirng

hop ap Il!C qua cao trong

huyet ap, • Irong Nhirng viem dau hieu rnang nao bi kich thich nao hoac chay (vi du

gay cirng) kha quan trong, vi giup huang toi 16n thirong
mang mau diroi nhen;

tuy

nhien trong hon me sau lai khong thay cac dau hieu do.
T6-HDDTV$OT

Rl

tai tu the cua nguO'i benn trong hon me; vi du tu the ciing dO' Iia vo (co cung gap chi tren, co cling duoi chi duoi) va tir the cirng do Ita nao
• Cung phai chu (co ctrng duoi nr chi) lam han chc' moi phan ling doi voi kich thieh dau,

Ro'j

IO~1!I

tlu«: 1'~/f: 13 bieu hien quan trong, bao

g6m cac roi 10'.\11 ho hap (cac nhip tho benh (hon me nong thuong hay bi
(r

19, xuat

tier

dom rai, li dong phe' quan), tuan hoan, than nhiet, co tron

co bieu hien tu dong; hon me sau dong). Nhirng r6i loan tuan hoan thuOng dien ra

muon, nhung co tht dan tai tinh trang truy tim - 111~ch.

2. Chan doan hon me. Mot qua trinh benh 19 co th~ gay ra hon me, neu qua trlnh do x am pham toi ca hai ben ban Call nao va/hoac

Call

tao luoi

than

nao. Nhirng .qua trlnh benh

chi anh huang toi 1111)t en ban b

cau nao

19

neu

thuong

It gay ra

hon me. Tuy nhien, trong truong

hop nhu cac khoi u

nao, nhoi mall nao hoac chay mau nao, du chi khu tni
mot ben van co kha nang dan tai hon me, VI anh huong toi ban

call

nao ben doi dien hoac toi vung than nhir vay, nell x am pham

nao.

Cac tbn thuung

van tieu nfio

cling co th~ gay ra hon me, do 13m cho ap lire tang qua
cao trong so, chen ep vao than nao.

82

VI Ie tren, khi tharn kharn danh gia tinh trang nguoi benh, can nhan dinh

cua mot t6n thuong

xem h6n me c6 phai la hau qua cau true b nao (nhu vay phai tri

xu

cap ciru phau thuat than k inh) hoac do rei loan chuyen h6a (can duoc chua noi khoa) hay chi l a mot trang thai sau dot quy (khong
thuar).

co yeu

call

phai

can

thiep phau

co y nghia:
•
nguyen
vung

Ciin cu vilo benh su, eo the'rut ra nUlt s(/ thong tin

H6n

me khoi

phat

dot

ngot

chi

huang

mot

nhan mach mau, vi du tai bien mach mau nao

nao hoac chay

than

mall diroi
ch6ng

nhen,

• ngon

Tien tri~n nhanh ngu,

IlIIa nguo i, roi loan,

den viti gia thuong trong nao.

cam

bat dan tu bai hoac liet

g iac mra ngiroi

hoac roi loan

roi di van han me trong vong

to-

viti phut

bao hieu mot truong

hop chay

mall

Nell benh keo dai

to- vai

ngay den vai Wall tnroc

khi nguoi benh di vao han me, c6 the huang toi u, ap-

xe hoac mau tu man tinh duoi mang cirng.

• Nguoi

benh trai qua mot trang thai hi I<in hoac

g~p h6a.

me sang kfch dong rruoc khi bi han me, thirong trong rei loan chuyen

X3

Kh6 khan ella chan doan la phan biet mot ton rhirong choan cho

a nao

voi benh canh cua roi loan chuycn

hoa

nao. Tham kham than kinh cho phep phat hien cac dau hieu khu tru va

vi

trf ella ton thuang neu

co

iJ nao:

2.1. Him

me co ddu
.

hieu tluin kinh khu tru:

Thuong do nhtrng ton thuong nhu khoi choan cho iJ

nao, tai bien mach

mau nao, chen ep than nao ...

2.2. Him
Tlnrong • thuong, Hon

me
me

khong

co ddu hieu
huyct:

thtin kinh khu tnt

do r6i loan chuyen ha dirong mo hoi,

hoa, nhu: dot ngot, tho

va

co

khi co gi~t. Xet

nghiern

binh thay

dirong huyet rat thap, • Duong • Hon me dai thao dtrong: xuat hien tiT Ill', tho sau hoi

va nhanh,

tha

co mui ceton, tien str dai thao dtrong. va ccton. bang ure hoac

huyet cao, nuoc ticu co glucose

Hon me do suy than: eh,1n doan

creatinin

tang nhieu Irong huyet luang ...

mot s6 trirong hop nhu benh nao do ton

Tuy nhien,

rhuong gan, ha duong

van thay kern thea

huyer, tang duong

huyet

eo khi

mot so dau hieu than kinh nhu bai

nhe rura nguoi; truong hop nang d~ co bieu hieu cung

da lia
X4

vo hoac cirng

do Ila

nao.

2.3. R6'i loan j thuc do benh' tam thdn hoij.e nguyen nluin tam Ij .
Can dua van berth sir, tham kharn chu dao d~ loai trir

de dau hieu than k inh k hu tni. Trong chan doan nguyen

10<).11

niio do rei

chuycn

nhan d6i voi nhom benh hoa, can phan biet: ha diroug
lieu (rhuoc an
Sli y

huyet, thieu ox y-nao, dung thuoc qua

than; loai th uoc ph i en). bcnh niio do

gan, ha nat ri-

rruiu, than nhicl ha, thrill nhi¢t tang, viern mang nao, viern nao, chay mau diroi nhen, hon me sau dong k inh lien t uc.
qr-

3. Nguyen tac

xu trt.
hon me, can thuc hien nhirng

D6i voi ng,uO-i benh

yell dill CC1ban sau: + Bao dam hru thong ho hap, + Bao dam tuan hoan toL + Xet nghiern
glucose,

mall: cong

thirc hong

bach

cau, mall",

ure, creatinin, dien giai, cac khf trong Xet nghiem mroc ti~ll (clui y tim d(>c chat),

+ Duy trl than nhiet trong ranh giai blnh thuong.

+ Nhanh
hen chong

xac dinh va chua nguyen

nhan gay

me.
85

Trong giai doan chira nguai benh lion me, nhieu khi can ticn hanh khan cap; ghi dien lim, ghi dien nao,
Chl.IP

X quang k ien trang

tlurong (so, phoi, cot song ... ) va, tuy thee

dieu

hi

{1 tuyen

minh,

xet nghicm

dich

niio-

tuy, chup

<:til lap vi tinh, chup d¢ng mach nao v.v ...

4. Cham soc nguai benh hun me nol chung, Trong qua trinh dicu tri cap ciru nguoi benh hon me, din dac bier cluj trong mot so vfin d~ sau day:
•
trd

D~ phong va chong 10cL nguoi bcnh can diroc

1111nh thay doi IU the each

2 gio mot ];"in.

Co

the: d(lt
nlur .

nam trcn cac dern chong

loet. Cac vi t ri g6 xuang

got chan, khuyu tay ... can duoc q IIan Iinn bao vc. • De phong
}Ill

duoc sach se
• phong

viern loci gi<.k mac: gii1 cho mi mat khep kin. Tra thuoc nho mat (kh6ng

ncn dung loai thuoc mo). Thuong xuyen thay doi khan lraj giuong: co Ihe: boi nhiern sinh.
V~\

dung 6ng thong tieu va ong dan ltru nuoc tieu, CAn de
do dar eng thong tieu. Khi can, phai dung khang

•
• dong chan, X6

Duy tri nuoi dirong, bao (1<'Imdu mroc

Lam cac dong lac thu dong:

dien giai .

de phong

de khop, de chi.

chan,

din rhuc hieu van can dat van do ban

co cirng khop co chan.

•
d'.1 d;IY. •
sa

Nell ch.iy mall duong lic:u hoa, co khi ph;_\i cho qua 6ng thong miii

thuoc chong acid v;l/ho~c cimctidin

Theo doi el1[11chc unh trang

phauthuat

!Idn kinh

a tuycn

tlurc: Irong cac co

nIH(

tren, cling

rai mot
diem

s6 Irung tam cap cinr hoi sire, co the dung Glasgow de drinh gia tinh trang y thirc.

rhaug

'n' lJ(Jllg vien nguoi than va gia dinh nguai benh:

1:1

vice 1;1111 rill ccln, mang

1,.10

nghia Ngoai

tarn

Iy

y hoc, nham rhao ky

mot khung

earth thuan

loi cho coug tile ciru chfra viec thanh

CUll

vii charu co mot canh

soc ngtroi bcnh.

thuat chuyen

mon, t(111 tinh dip

dieu tri, con can (inh de

thai do, ctr chi, cau noi phil hop vo'i hoan hieu qua mong muon. Tinh thtin

thuc rc, darn bao mot khong khi binh

vice ciru chira' dat

"con ntroc con tat" can diroc quan trier cho moi
nguoi thum gia trirc

tier

hoac gian

tier

V~lO

cong lac

dieu tri va cham soc ngurri benh hon me.

87

NHIEM DOC CAP

GS
do do hoi benh can clui cluing: thu6c chong chira benh

va Dinh

Hdi

Hall het nhiem dQC dip iii. do ur van hoac nharn thuoc

den hoan canh xuat hien trieu chung goi

kho khan v~ gia dinh, doi song v.v ... va da: dung gl. Trieu

thuong

la

non,

mat; nang nira la hon me, co giat, tim moi, truy

mach,
r.:ir

va mo

hoi; khong

co sot.

1. each

xu tri chung
him
Ira ("(1("("/11((" 1/(111·gthitt yell:

c{f Trude lIlt "plllli

+ Nghe tim va

sa

mach,

neu khong

thay

dap, phai

bilt dan ngay ep tim ngoai ngirc. + Xem co Iha khong? Nell khong, phai giai toa ngay duong tho, va bat dau th6i ngat true t iep mom - mom:
co khi phai dat 6ng noi khi quan, hoac tha

may.

+ Do huyet ap: neu thap qua, nhat 18. co benh canh

soc, phai truyen hoac tro tim. dich; co khi phai dung thuoc co mach

+ Neu 88

co

giat nhieu,

phai

chong

co

giat

bang

diazepam V.v ... + Chu <; den thang bang nuoc, dien giai, toan-kiern v.v ...
<{l' Doug thili voi nhiiug dong ta« trill, chiill JOUII cluj! gay 09C, WI tint dich loai chit'f dr)e ra ngoai ca the':

ho

+ Gay non va nra da day, neu nguoi benh nu6t chat doc.

+ Hap phu bang than hoat, neu chat gay doc HI.
alcaloid. + Cho loi tieu, neu chat doc qua duong than (nhu barbi turat). + Neu chat doc a th~ khi, phai keo ngiroi benh ra k hoi khu vue nguy hiern, coi het quan ao, giu nam yen,
dam bao dirong tho.

+ Neu chat doc bam van da va niern mac, phai x6"i nhieu nuoc d~ nra di.
<{l'

CIIII/lg d9C bang tI1ll&' diJe hifU:

+ B.A.L. chong doc cac kim loai nang.

+ EDT A Calci, trong nhiern doc cht.

+ Desferrioxamin, vai nhiem dqc sat. + PAM, trong nhiem doc phospho hiru co.

+ Atropin, rat can de; chua nhiem doc phospho hiiu co.
+ Naiorphin, khang dac bier voi loai thuoc phien,

+ Xanh methylen,

can trong nhiem dqc san, nhiem

89

doc nitrit, donn ...

+ Vitamin
methemoglobin elora!...

lieu - rruiu

cao, trong

cling

chi

dinh doc

d~ san,

chfr; nitrit

nhiem

2. MQt

so nhiem

doc chinh thuong gap,

2.1. Thutic diet chuot: G6m:

ANTU hl chat khang giap trang tOng h0P. Nhirng ca nang la do pllll ph6i cap.
':§r

Xu tri

nlnr nhfing phll ph6i khac.

Kern phosphur: thung da day.

(ff~

bong micng , non, ia clray , co thi

Xu trt:

tua da day, uong cac chat bao v¢ niern mac

da day; chong soc: truyen dich, riern corticoid ... Warfarin: doc VI gay chay mau toan than nhu diii ru mau, non fa mau, bang huyet, chay mall mang nao v.v ...
qr

Xu

trt:

dung tro

vitamin

cho

rai

khi

!y

I¢

prothrombin

ve

btnh rhuoug. Truyen

mati

nroi.

chong soc.

Fluoacetat: nang nhat la can co gi~)t, co the suy ho

hap va truy tim mach.
qr

Xu tri:

nra da day; calci gluconat

ticrn tinh mach 4-

90

10 III 1 dung dich hang diazepam

t iem

10%; chong tinh mach

soc; chong co gi(11 IOmg ...

,
~.

Natri arseniat: non co the ngay sau 15 pluit, dau bung, ia chay, milt nuoc, soc co th~ chet ngay. Sau 2-3 ngay d~
co vang da, gan to vii dau, dai ra rnau, noi mi.1n da.
tiT"

Xu tri: rlta da day ngay, chua trieu chtrng: Chua dac

hieu bang B.A.L: ticm 3 mg/kg moi 3 gia trong ngay d.iu rien, mbi 6 gia ngay tlnr hai, moi 12 gia ngay
tlur ba.

2.2. Thuoc tru sau:

Cac hoa chat rrir clo chat hiru
CO

sau g6m sau loai: phospho hiru co;

DDT,

nhir

666,

carbamat

nhu

Bassa,
... ; hoa

Furadan ... ; pyrethrin

nhu allethrin,

pennethrin

phun khoi nhu Aerox,

dibromomethan pyrerhan.

... ; vii cac Duoi day, xin

hoa chat thao moe nhu nicotin, doc nang: Duong wofatox
uong:

viet ve phospho hiru co (nhu Wofatox)

d~ gay nhiern

vao hay g~p va nang nhat l a dirong

cns« doan
•

dua vao mui dac bier cua hoi tho, chat non,

tharn vao quan ao ... Lim sang co 2 hoi chirng chinh: CI(elllg phi 1'[: tang tiet mroc bot, mo hoi, dam, dong 91

co that phe quan g{IY kho tha cap; nhip lim cham;

tu co rAt nho (dirci

2mm la nang),

• Kif'n nicotin: co gi~t the co mi mat, mat, luoi, c6 khi toan than; nang thl hon me va chet ngay.

~ Xu trt

phai rat nhanh ch6ng:

+ Tiern ngay atropin vao tinh mach 1ieu nit cao (2mg m6i 10 phut) cho den khi da: da n6ng, dong nr gian 5mm. Sau d6 tiep tuc atropin lieu thap han.

+ Rira da day lam dong thai voi tiern atropin.

rira nhieu Hln, nhieu khi tai 40-50 lit.

Phai

nuoc, den khi het ITILli thu6c, co

(6ng 200 rug) hoac PAM (6ng 500 mg), Tiem ngay tinh mach cham 400-800 mg, sau do co the CII nira gia hoac I gia lai tiern mot lan, tuy dien
bien. Litu 16i da co th~ tai 15 gam trong nhirng rnrong

+ Pralidoxim

hop nang.

+ Chuyen di benh vien: nhirng ca nang nhir hon me, rut huyet ap, suy ho hap chi can tiern atropin roi chuyen
ngay, kh6ng kip rira da day mra. 2.3. T.hutJc ngil

va an

than'

Nhiern dQc cap nhirng thu6c nay chu yeu ia do II! van. Thuong dung nhat la cac barbiturat (luminal, .barbital...) va cac benzodiazepin (diazepam ... ), co khi

la

meprobarnat.

92

Trieu chimg nhiem doc nhe chi

co

ngu say; mach, neu nang, nhan, chi'!

huyet up, than nhiet v~n binh thu(mg.Nhung

co

th~ hen me, mach

nhanh,

huyet ap ha, Hon me keo

dai co tht khong

hoi phuc duoc. Tim nguyen

yeu lil. hoi gia dinh, tim thay thu6c thua ...
tJr

Xu tri

nhiem doc 'barbiturat

+ Rt'(u d~i da», du ngo

doc

uong da qua 8 gio van

co

ich. Neu hon me sau, pnai d0-t 6ng nQi khi quan truoc khi rira, hoac chi dung 6ng thong da day nho hUI dich
da day ra bot. + Trlfy/n khong dung truyen
nltie'lI dicl,

d/ gillp h(/i fiet ch(li doc, Neu

4-8 lit, nhung chu

co berth tim, co th~ truyeu d ich glucose.

qua nhieu dung dich man dang tnrong,

dungrlich

rna

phai x en ke voi dung

thi truyen +

Neu co dieu k ien, natri bicarbonat l,4clr:, de' de thai

.bang Iuroscmid 20 mg, 1-2 ong

trir phenobarbital
LQ'j

(luminal).
niauh

lIifll

tiern tinh mach. Chu

truycn dtl nuoc bu.

+ N 111(1/ g ca lit! /I g,. phai cha Y than n han t ao. + Buo dum tudn hO£1I1, ho hap.
Khi nhiern dQC benzodiazepin,
hieu, la flumazcnil (Anexate mach cham, t611g lieu khong co thuoc giai doc dac mg), tiern tinh DOg 0,5-1

qua 2 mg. 93

2.4. MtJ.t ca:

MQt s6 nguoi da dai dot dung mat ca d~ "chua" s6 benh man tinh: dau bung, loet da day ta trang, mot hen

phe q uan, di ling, sci tiet n ieu, due th uy tin h the v. v ... Mat ca tram hay diroc dung nhat, cling nguy hiern

nhat, sau do nuot den. m~ t d. chep, ca me, ca. Hoi v. v ... Du nuot ca lui mat hoac hoa voi nrou hoac mat ong de: uong, thi ngo doc cling nguy hiem nhu nhau!

Trieu ("/I/fllg: bat dau sau mra gio hoac vai gio la dau
bung, non mira, co khi non ra mau, chong mat, nhirc dau, dau that lung. Sau

do la

benh canh suy than cap nang: vt» nieu hoac nira den co giar, tim ta i,

dfli it, vang da, gan to. Nang sui bot hong, hon me va chet.
(if'

Xu tri
+ Furosemid
tiern tinh mach, lieu rat cao. Co th~

dung toi 10 ang x 20 mg mui dau tien, sau dat 50 ml/gio,

do

cli I gio

lai tiern tinh mach 2-10 ang nira, cho den khi mroc rieu

+ Neu khong 2.5. San:

dap ling, phai giri tuyen tren

de

tham

phan mang bung hoac chay than nhan tao,

Chat gAy doc trong san

la

acid cyan hydric,

nguoi 160

94

uong 20 mg la ngo doc, uong 50 mg co th~ chet.; loai san doc chua tren 7 mg chat gay doc trong Trieu clurng nhiem vai gio sau khi • • nang cheL
(jj-.

Cac

i00 gam.

doc x uat hien rat sorn, co khi chi

an.
mat, kinh,

Roi loan tieu hoa nhu non, ia chay, dau bung. Trieu clurng than kinh nhir vang dau, chong hon mra la vat vii, run, co gi~t kieu dong

Xu
=

tri

+ Rira da day, hoac gay non. +

10mI Xanh methylen (bier duoc: Glutylen 0,1 Og), ticm cham vao tinh mach voi lieu thap:

1-2 mg/kg ..

a tre em,
dang

can phai tfnh lieu dn than. truong .nho giot tinh mach, dong

+ Glucose

thoi eho liang mroc dirong.

+ Tho oxy trong nhimg ea nang, co khi phai ho hap

nhan tao. Phong b4111t: tranh

an cac loai san dang. Phai bo vo

va dau, thai nho, phoi kho vii nang, ngam mroc. Khi

nau phai rno vung. 2.6. Coc loai th utic phien (opiat):
Nhiem dqc CUI) opiat co the do: 95

• •

Tiern trich Dolosal,

ma niy qua lieu meperidin

morphin,

pethidin

(Dolargan,

... ), heroin ...

Dung qua Iieu thuoc co chua opiat nhu vicn nra,

vien ho giam thong, vien ho long dam, vien opizoic ... Trieu clntng nllie,n do« dil):
• • •
r::o-

Tho nong va cham, Dong

co khi

chi

co 2-4

Ian/phut.

tit co hep.
h,~\than nhict, hon me, ngirng thtr ...

Tim cham,

XiI tri:

+ Chong doc dac hieu bang naloxone (Narcan ong, 0,4 mg ), tiern tinh mach mot ong, roi cu 3-10 phtit lai tiern them mot 6ng, tdng li~u khong qua 10 6ng. nalorphin (6ng 10 mg), tiem bap hoac tinh mach 1/2-1 6ng, sau 15 phiit co th~ tiern nira, nhung tdng lieu khong qua 4 6ng (40 mg),
Hoac

+ Rira da day neu nguoi benh uong 10<:1ithuoc phien

(opiat), nen d~t 6ng noi khf q uan d~ t ranh n u6c trao vao khl quan.

2.7. Digital
Cac
strophantin

va True

dao:
tim (digoxin, phd bien

glycosid
... ) diroc

trq
dung

de

digitalin,

chua

suy tim.

Lieu gay chet d6i voi digitalin

(digitoxin)

Ia 3 mg, doi

voi digoxin

la

10 mg. Nhirng

ngiroi gia, tre em, ha kali

96

huyet,

benh

tim nang

de hi

ngo doc han.

Hoan

canh

ngo doc co the do uong mot Iicu rat cao, hoac do m6i

ngay uong qua lieu mot cluit, trong nhieu ngay. Chat
neriol in trong digital. True dao cling co th~ gay ngo doc nhu

Trieu Clll(lIg
• Nluing

co 2 loai:
trieu
Clllfllg ugoa! tim

nhu non

mila,

bieng •
han

an,

rna

mat, nhin loa, met 1;:\, chong mat..; Day l a

nhip tint, dac hieu va nguy hiern xoang, bloc nhi that kich phar nhat

nhfrng tricu clurng khong dac hieu va it nguy hiern.

Nllirllg "0/·
nhieu: ngoai

IO~lII

tam thu, cham nhi, Nang

cac do, bloc xoang that, rung that, chet.

la

nhanh

Chan doan ean phai ghi dien tim.

Qr

Xu tri
+ Gay non, nra da day. + Ngirng ngay cac loai digital va thuoc loi nieu kieu

furosernid,

thiazid.

Thay vao

do

Ia thuoc loi nieu giU

amilorid.

kali nhu spironolacton,

triamteren,

+ Kali nen eho, neu kali huyet khong tang va khong

co bloc nhi that. Uong 3-6 gam kali clorid, hoac rruyen cham tinh mach 1,5 gam trong 2 gio; + Truong
T1-HOf)TVSOT

hop tim cham,

tiem

atropin

0,5 mg tinh

97

mach,
neu

can.

co th~ tiern 2-3 Jan/24 gia. Chutin hi tao nhip,

+ Truong hop ngoai tam thu, nhanh that, tiern ngay diphenylhydantoin (phenytoin) 50-100 mg tinh mach,
hoac

procainamid

i,O gam

truycn

tinh

mach

trong

I gio'; hoac l idocain

50 mg tiern tinh mach.

2.S. Isoniazid Vien isoniazid isoniazid.

(Rimifon;
dung

INH): vien 50 mg

d~ chira lao, moi

Lieu trung binh eho nguoi Ian IS. 5-6 vien;

neu u6ng lieu ga'p 20 Ian, nrc 90 mg/kg, gay co giat, co th€' chct.
Tr ieu chirng chinh

se

ngQ doc,

la

nhirng can co g iat k ieu dong

k inh toan the', x uat h ien 1 gia sal! khi u6ng th u6c. Con lien tiep rat mau, co khi moi 3-5 pluit lai mot can. Nang han, co'the: hon 111e, ngung tho.
Xet nghiern

huyet
trong
CiF

eho thay nhiern acid the: chuyen hoa, pH lUang giam co khi tai duoi 7; CO2 roan phan

mall giam co khi toi 5,8 mEq/Ht.

Xu tri
+ Gay non va rira da day, can than trong khi co co + Truyen dich, nhat ia cac dung dich k iem hoa nhu:

gi~t.

natri bicarbonat

dung dich

i,4%, natri lactat dung dich

98

1/6 mol/lit

(M/6).

Dung dung dich

dung rieu

chuan

DLH;ic dien va theo doi chat che.

+ Chong co g i,~t bang diazepam

hoac phenobarbital 0,2g-0,4g

10 mg tinh mach,

tinh mach, neu can co tht

+ Pyridoxin

500 mg tiem Ilnh mach,

tiem lall thu 2-3, sal! 1-3 ·giO'.

+ Khi qua nang, phai ho hap ho tro,

rna

khi quan ... ,

tham phan mimg bung hoac than nhan tao.

o Chli y:

khong duoc dung theophylin

va cafein.

99

DONG KINH
PGS. Nguyen Van Dang
V

e bien

hien lam sang,

can co gi~t chi lit can d6ng

kinh van dong. Dong kinh

co nghia

rong hO'O, VI

co khi

kh6ng bieu hien

bang con giat. VI du: dong k inh c.. giac chi bieu hicn roi im
10;:.10 Irong con rhuc vat bang roi 10';\0 than kinh thuc vat,

nhu tim dap nhanh, can dau bung; hoac bieu hicn bang c..c i ao giac nhu

au

khiru, ao thanh, ao thi

trong con dong

kinh thai dirong, con vang

Can phan bier kinh (la benh man tfnh),

y thirc

i:J tre ern .

bcnh

tan dong kinh co giat voi benh dong

gifra hai can thi nguoi

sinh hoat binh thuong: CO'n d(Jng kinh than (can co giat) thuong xay ra nhan co ha

mot benh dang phat trien cua nao, hoac khi benh tO~1Il

co

anh hui:Jng den nao, nhu ha duong - huyet,

/(11 g

calci - huyet, sot eao i:J tre em, sang chan cap ... ; do chi

HI. mot phall

lilt/it thoi thoang qua; khi cac yell to

("0

gil.y benh da diroc giai quyet, nguoi benh se het can, hoac neu de: lai di ell/rug udo, ("(Ie can gi~Jf fiel)
'1.1("

100