TRNG I HC Y KHOA THI NGUYN B MN NI

BNH HC NI KHOA
TP 2

NH XUT BN Y HC H NI - 2006

CH BIN:
BS. CKII. Doanh Thim Thun THAM GIA BIN SON: 1. BS. CKII. Doanh Thim Thun 2. BS. CKI. Bi Duy Qu 3. BS. CKI. Nng Minh Chc 4. BS. CKII. Nng Th Minh Tm 5. ThS. Nguyn ng Hng 6. TS. Dng Hng Thi 7. TS. Trnh Xun Trng 8. ThS. Nguyn Vn Tha 9. ThS. Nguyn Trng Hiu 10 ThS. V Th Hi Yn 11. ThS. Nguyn Tin Dng 12. ThS. L Th Thu Hin 13. ThS. Phm Kim Lin

LI NI U
nng cao cht lng o to sinh vin Y khoa, to iu kin cho sinh vin ang hc trong trng c ti liu hc tp v sau khi ra trng c th c li, tham kho khi cn thit. Tp th ging vin B mn Ni Trng i hc Y khoa Thi Nguyn bin son tp Bnh hc ni khoa. Ti liu ny l nhng vn c bn v ni khoa, c chia lm 2 tp. Bao gm 54 bnh ni khoa v hi sc cp cu. y l nhng bi ging v cc bnh l thng gp ti bnh vin tuyn c s v tuyn tnh. Hai tp bnh hc ni khoa ny c bin son da vo cc ti liu theo quy nh ca V Khoa hc v o to, B Y t, da trn nhng mc tiu v ni dung trong khung chng trnh c thng nht, c cp nht nhng thng tin kin thc mi, gip cho sinh vin nng cao kin thc cng nh thc hnh v t nh gi. Tuy nhin, trong qu trnh bin son, khng th trnh khi nhng thiu st. Chng ti rt mong c cc bn ng nghip v cc c gi ng gp kin ln ti bn sau ni dung cun Bnh hc ni khoa s hon chnh hn. Xin trn trng cm n! T/M BAN BIN SON TRNG B MN NI

BS. CKII. Doanh Thim Thun

MC LC
TP 2

VIM GAN MN...............................................................................5 AN TON TRUYN MU..............................................................11 CHN ON V X TR AU NGC........................................15 CHN ON V X TR AU LNG........................................21 NHC U.......................................................................................28 SUY THN CP...............................................................................35 VIM CU THN MN.................................................................43 SUY THN MN..............................................................................47 VIM I B THN CP, MN..................................................53 VIM BNG QUANG, NIU O................................................58 SC.....................................................................................................60 CHN ON V X TR HN M.............................................66 CP CU HO RA MU..................................................................69 CHN ON V X TR TRN KH MNG PHI................75 CN AU THT NGC.................................................................82 NHI MU C TIM........................................................................87 TAI BIN MCH MU NO.........................................................93 TO BN........................................................................................104 HI CHNG RUT KCH THCH............................................107 CHN ON V IU TR THIU MU................................109 UNG TH PHI.............................................................................117 LEUCMIE CP............................................................................121 LEUCMIE KINH DNG HT...................................................125

VIM GAN MN
M U Vim gan mn tnh (VGM) l nhng bnh gan c nhiu nguyn nhn khc nhau m trong hin tng vim v hoi t tip din t nht trong 6 thng. Trong cng ng t l vim gan mn do virus B chim mt t l kh cao trong nhng ngi mang virus, theo ti liu ca hi gan mt Vit Nam 2001 t l nay chim 7-10%. Nhng nm gn y s pht trin ca khoa hc min dch, ha t bo v cc xt nghim huyt thanh, sinh hc phn t gp phn quan trng trong chn on v tin lng bnh. 1. NH NGHA V PHN LOI VIM GAN MN nh ngha: vim gan mn tnh l bnh gan c tn thng hoi t t bo v vim c hoc khng c km theo x ha din ra trn 6 thng. V mt m bnh hc c ba tn thng ni bt - Hoi t gm nhm v hoi t bc cu khong ca - Thoi ha trong tiu thu v hoi t - Thm nhp t bo vim khong ca ch yu l cc t bo mt nhn v x ha khong ca Phn loi: c nhiu cch phn loi, trc y thng phn loi theo hnh nh gii phu bnh v c th chia vim gan mn tn ti v vim gan mn tn cng. Ngy nay a s tc gi mun phn loi theo nguyn nhn.. C th chia 4 loi nh sau: - Vim gan mn do virus - Vim gan mn do t min - Vim gan mn do thuc - Vim gan mn tim tng M bnh hc gip cho chn on, phn loi, nh gi mc hot ng vim cng nh tin lng bnh 2. CHN ON 2.1. Triu chng lm sng: thng lun khng c hiu - Ri lon tiu ha: y bng chn n, chm tiu chng hn - St nh 37- 380C - C th c gan to mt nhn, mt chc, c khi khng s thy gan, vng da v
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nim mc trong t tin trin bnh. - C th xut hin mt s triu chng ngoi gan: + au khp xng nhng khng sng v hay ti li nhiu ln nhng khng li di chng v khng bin dng khp + Da sm kh, gin mch, gin mao mch hnh sao, lng bn tay son... Ch khai thc triu chng ca mt s bnh t min khc nh vim tuyn gip, vim lot i trc trng chy mu, vim khp dng thp... Ngoi ra cn tm hiu mt s yu t nguy c gy bnh vim gan mn: tin s vim gan virus, s dng thuc chng lao, thuc h p, thuc iu tr bnh tm thn, tin s nghin ru, tip xc mt s cht c 2.2. Triu chng cn lm sng - Thm d chc nng gan + Chc nng to v d tr ng: nghim php Galactoze (+) + Chc nng chuyn ha m: nh lng albumin huyt thanh gim (bnh thng 56g 7g/l), globulin tng, nht l gam ma globulin in di min dch: c s thay i thnh phn ca IgA, IgG, IgM, IgE theo tng giai on ca bnh + Chc nng chuyn ha lipid: gim lng cholesterol este ha lm cho t l cholesterol este ha/ cholesterol ton phn gim di 50%. + Chc nng to cc yu t ng mu: t l prothrombin gim di 80%. + Chc nng chuyn ha mt: bilirubin mu tng (BT 19 mol/l) Trong t tin trin ca vim gan mn chc nng gan thng b ri lon mt vi hoc nhiu chc nng - Thm d s hu hoi t bo gan: + Men OCT (Ocnithin Cacbamyl Transferase) bnh thng 168 g/100ml + Men AST tng (Aspartate amino Transferase BT < 37U/1) + Men ALT tng (Alanine amino Transferase BT < 40U/1) - Soi bng: mt gan mt tnh cht nhn bng, nhn nheo, ln gn, c nhiu fibrin trng, co so lm. Mt gan nht mu hoc ti. B gan sc mt tng. Qua soi bng c th sinh thit gan lm xt nghim m bnh hc, qua c th chn on chnh xc vim gan mn, chn on giai on cng nh tin trin ca bnh. - Siu m gan: l hnh nh khng c hiu thng thy nhu m gan khng u. 3. CHN ON 3.1. Chn on xc nh
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Da vo triu chng lm sng. Quan trng hn l chn on nguyn nhn t mi a ra phng n iu tr thch hp. Ti cc c s vic chn on vim gan mn thng khng c iu kin lm cc xt nghim thm d phc tp nht l khng th p dng cc chn on huyt thanh hc vi cc marker min dch hin i. Vic chn on ch yu da vo triu chng lm sng v tin s mc bnh, s dng cc cht, thuc, ru c c vi gan. Cn quan nim rng cc chn on ca c s c gi tr chm sc sc khe ban u v lm cng tc sng lc trong chn on chnh xc sau ny. 3.2. Chn on nguyn nhn 3.2.1. Vim gan do virus Vim gan B: Khong 10-17% bnh nhn mang virus B chuyn thnh vim gan mn tnh. chn on xc nh vim gan B cn da vo mt s xt nghim huyt thanh hc Khng nguyn khng theo ngi vim gan B
Khng nguyn HBsAg HBeAg HBcAg HBV- DNA DNA polymerase Khng th Anti HBs Anti HBe Anti HBC Huyt thanh (+) (+) (+) (+) (-) (+) (+) (+) Gan (+) (-) (+) (-) (+) (-) (+) (+)

Du n virus vim gan B giai on cp v mn

Du n HBsAg AntiHBs HbeAg Anti HBe Anhti HBclgM Anti HBclgG HBV - DNA Vim gan cp (+) (-) (+) ---- (-) (-) ---- (+) (+) ---- (+) (+) ---- (+) (+) Vim gan mn (+) (-) (+) ---- (-) (+) (+) --- (-) (+) (+) ------ (-) Khi (-) (+) (-) (+) --- (-) (+) --- (-) (+) (-)

Trong vim gan virus B cp c cc biu hin nh mt mi, au m h sn phi, ri lon tiu ha cng vi men Transaninase tng ko di trn 6 thng m c
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HBsAg (+) thng chuyn sang vim gan mn tnh. Khi vim gan B mn tnh c th chia 3 giai on: GI: virus vim gan B tng ln rt nhanh, xt nghim thy HBsAg (+), HBeAg (+), HBV-DNA (+). Giai on ny gi l giai on dung np virus. G2: giai on khng c min dch, s sao chp ca virus rt thp, virus trong mu dao ng. Transaminase trong mu lun cao. Nu sinh thit gan lm xt nghim m bnh hc trong giai on ny c th chn on c vim gan mn tnh G3: Giai on nhim virus tim tng, khng c hin tng sao chp virus. HBeAg (-), Anti HBe (+), transaminase bnh thng. Sinh thit gan khng c hin tng vim gan nhng c th c x gan. Trong mt s trng hp ngi mang virus vim gan B c th c mt hoc nhiu t bin vng pres- C ca gen v vy khng c kh nng tng hp HBeAg cho s phin m ca tin cht. HBeAg b phong b nhng phin m ca HBeAg khng b thay i, v vy vn cn lm thm xt nghim HBV- DNA nh gi s nhn ln ca virus trong trng hp virus c t bin. Ngi vim gan mn do virus B cn thit c theo di cc c s y t, t 3-6 thng c kim tra 1 ln: Transaminase, HBsAg HBeAg hoc HBV- ADN, a FP v siu m gan mt theo di din bin ca bnh. Vim gan virus C L loi virus ARN c Houghton phn lp ln u tin nm 1989. Virus C thng xut hin sau truyn mu. Vim gan virus C thng khng c triu chng lm sng ch khong 20% c vng da. Hin nay ngi ta xc nh c 12 loi gen khc nhau ca virus C, kh nng gy bnh v p ng min dch ca cc genotype khc nhau. Trong giai on cp chn on da vo s pht hin ca ARN ca virus trong huyt thanh bng phng php PCR (polymerase chain reaction) ARN xut hin trong 1-2 tun u sau ly nhim. 80-90% virus C chuyn thnh mn tnh, trong khi nng khng th anh HCV vn cn rt cao trong nhiu nm. V vy tm thy khng th HCV khng cho php nh gi giai on ca bnh. Hin nay cha c k thut huyt thanh min dch cho php xc nh s hin din ca virus C trong mu. pht hin virus C ch yu vn da vo s c mt ca anh HCV v loi tr cc virus khc. Sinh thit gan thy tn thng ging hnh nh vim gan B. Vim gan virus D L loi virus RNA khng hon chnh, c pht hin nm 1976 ch c th nhn ln khi c mt virus B. V vy virus D l ng nhim hoc bi nhim. Nu ng nhim th 90% c th khi cn nu bi nhim th d chuyn sang mn tnh. Virus D ly theo ng mu. Chn on da vo s pht hin khng nguyn delta v khng th khng delta (Anti HDV).
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Khi virus D di dng bi nhim ngi nhim HBV mn tnh 80% s chuyn sang vim gan mn tnh vi s tn ti HDV trong gan lm tn thng gan nng hn, do d dn n x gan Ngoi ra cn c cc virus vim gan E ly theo ng tiu ha v virus vim gan G ly theo ng mu. S hiu bit v cc virus ny cha nhiu. 3.2.2. Vim gan t min Vim gan t min l tnh trng mt hoc gim kh nng thch ng min dch ca gan vi chnh nhng tn thng ca gan. Khng tm thy trong huyt thanh ca ngi bnh c du hiu no ca virus, nhng li thy cc yu t gi ln bnh t min. Trong huyt thanh ngi bnh thy cc t khng th nh khng th khng c trn, khng th khng DNA, khng th gama globulin, cc typ HLA tng rt cao. Nguyn nhn v c ch cha c r nhng hay gp n v iu tr bng cc thuc gim min dch c hiu qu. 3.2.3. Vim gan mn do thuc Thc cht y l mt vim gan do nhim c mn tnh ko di. Ngi bnh c tin s dng cc thuc hoc tip xc vi c cht c th gy vim gan mn. Tu theo p ng ca tng ngi, vim gan mn xut hin sm hoc mun sau khi dng thuc, c s tham gia ca c ch min dch, c th xut hin t khng th. Khi ngng thuc c th lm cho vim gan mn khi hn hoc gim nh. Mt s thuc c th gy vim gan: cc thuc chng lao, cc thuc khng gip trng, methyldopa, sulfolanid... 3. 2. 4. Vim gan tim tng T l vim gan tim tng t 10- 25% trong cc loi vim gan du hiu chnh l s thm nhim cc t bo lympho hoc tng bo, s thm nhim ny ch khong ca ch khng lan ti cc tiu thu. Cn nguyn cha bit r, pht hin nh xt nghim m bnh hc. 4. IU TR V D PHNG 4.1. iu tr * n ung, ngh ngi: khng ung ru, bia. n nhiu protid, ng v vitamin, cc thc n d tiu, hn ch m nu c vng da. Ngh ngi tuyt i trong t tin trin * Ch thuc: tu theo nguyn nhn m c thuc ph hp - iu tr vim gan virus B mn tnh: Thuc c ch s pht trin ca virus. iu tr trong giai on th hin HBsAg (+), HBeAg (+) hoc HBV-DNA (+); men transaminase tng gp 2 ln tr s bnh thng + Interferon- thuc c tc dng c ch s pht trin ca virus khng cho virus xm nhp vo cc t bo, c tc dng iu ho min dch, tng sn xut
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khng th. Liu: 3-6 triu UI/ngy hoc 5-10 triu UI/ tun, chia 3 ln, dng lin tc trong 6 thng. C khong 40 % BN p ng thuc lm mt virus, transaminase tr li bnh thng, m bnh hc c ci thin r. Ch theo di bch cu, tiu cu, transaminase... c th c mt s tc dng ph nh st gi hi chng cm... + Lamivudin: (3-thiacytidin; 3-CT) l thuc iu tr HIV nay c s dng iu tr vim gan B mn tnh. Lamivudin c ch enzym sao chp ngc ca virus. Ung vi liu 100mg/ ngy trong 12 thng lin tc c tc dng a transamiase tr v bnh thng. ADN ca virus tr nn m tnh. Hiu qu t c khong 30 - 40% cc trng hp. Ngoi ra cn mt s thuc khc cng c dng iu tr vim gan mn do virus B nh: Famcyclovir, adeflovir dipivocit, ribarvin, interleukin 2, interleukin 1, Tymosin a. Cy Ch rng ca (Phylantus Amarus, H dip chu) cng c nghin cu v thy c tc dng khng virus. Cy Ng v t (Fructus schisandrea) c tc dng lm h nhanh men transaminase BN vim gan virus, ci thin tnh trng hoi t gan. - iu tr vim gan C Gn ging vi vim gan B nhng thi gian ko di n 18 thng. Ch khi phi hp interferon vi ribarivin cn theo di tc dng ph lm tan huyt. - iu tr vim gan t min Dng thuc gim min dch iu tr tn cng lm lui bnh sau duy tr cng c kt qu iu tr prednisolon 50mg /ngy n thun hoc phi hp vi Azathioprin 50 100mg/ ngy sau gim liu v duy tr. Tuy nhin d ti pht sau iu tr 3 - 4 nm. - Cc thuc iu tr h tr t bo gan 4.2. D phng Khng c d phng chung cho tt c cc loi vim gan mn m tu tng nguyn nhn c d phng ring. i vi vim gan mn do virus B cch tt nht l gy min dch ch ng bng vacxin vim gan B. Tim cho i tng cha nhim, tt nht l tim cho tr s sinh v 99% nhim lc s sinh. i vi vim gan do thuc nn trnh cc thuc c nguy c, theo di thng xuyn chc nng gan nu bt buc iu tr. Dng thuc khi c du hiu suy gan. D phng bin chng nng ca vim gan mn nh x gan, ung th gan... cng c t ra song hin nay cha c bin php g ng k ngoi iu tr bo tn v chng hu hoi t bo gan.

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AN TON TRUYN MU
1. I CNG Mu l sinh phm v cng qu gi trong iu tr bnh m cho n nay vn cha c mt vt phm no c th thay th c. Theo c tnh ca Vin huyt hc truyn mu, nc ta (nm 2001), vi dn s 76 triu ngi mi nm c tnh cn khong 1 triu lt mu, 5000 lt huyt tng. Mu chim 1/13 n 1/15 trng lng ca c th, mu rt cn cho c th v mang nhng cht nui dng cc t bo v chuyn nhng cht thi n cc b phn bi tit. Mu cn cn thit duy tr huyt p v chuyn ch cc cht. Mi thnh phn cu to ca mu c chc nng ring. - Hng cu chuyn ch oxy. - Bch cu gi vai tr bo v. - Tiu cu lm nhim v cm mu. - Cc cht protein trong huyt tng duy tr p lc thm thu gip cho vic trao i trong cc m. - Cht globulin bo v min dch. - Cc yu t ng mu trong huyt tng. Mt ngi mt 250ml mu, hemoglobin trn 35% khng nht thit phi truyn mu v c th c kh nng t hi phc d dng (c th truyn huyt thanh thay th). Truyn mu l lm cho ngi bnh c nguy c ly vim gan virus, thm ch nhim HIV nu cng tc sng lc ngi cho mu khng m bo theo quy nh. 2. CC THNH PHN CA MU LU TR Mu lu tr l mu ly xong lu tr vo t lnh dng dn. Mu ti l mu ly xong truyn ngay. Mu ton phn: Mt chai mu bnh thng khi lu tr trong t lnh phi t 3 lp. - Lp trn: l huyt tng mu vng chanh, trong sut, khng c hin tng tan mu v ng si huyt hay ln bng. - Lp gia: l lp bch cu, tiu cu rt mng, trng lp lnh, khng c cc ng v m m. - Phn di: mu thm ng nht, l lp hng cu. Khi hng cu: Khi hng cu ly t mu c chng ng ti hoc lu tr, phi iu ch theo iu kin m bo k thut quy nh. Phn khi hng cu khi ln truyn phi pha long bng dung dch NaCL 0, 9% hoc dung dch bo qun hng cu. Huyt tng giu tiu cu:
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Tiu cu ly ca mt ngi hoc tiu cu ca nhiu ngi cho cng nhm, ty t mu ti, sau khi ly xong l phi dng ngay, khng qu 2 gi. Khi tiu cu. Huyt tng ti ng lnh. Sau khi ly ra dng phi vo bnh cch thu 370c Cho tan ng v dng trong 2 gi. 3. QUY TC V CH NH TRUYN MU 3.1. Quy tc C in: truyn mu sao cho hng cu ngi cho khng b ngng kt bi huyt tng ngi nhn: S truyn mu c in: Tuy nhin, khng c truyn 1 ln qu 1 n v mu v khng c truyn 2 ln vi khong cch qu gn. Hin nay:

m bo an ton tuyt i cho ngi c nhn mu, hin nay quy nh: - Ch c php truyn mu cng nhm, hoc truyn mu t thn. - Tuyt i khng c truyn mu khc nhm d trong bt c hon cnh no. 3.2. Ch nh truyn mu Cp cu: ch nh truyn mu cp cu trong sc mt mu, sc chn thng: - Trong ngoi khoa: + Xut huyt tiu ha nng, v tnh mch thc qun, trong chn thng v gan, lch, thn. + Trong v sau khi m bi ph lng mu mt. - Trong sn khoa: t cung sau , rau tin o trung tm, v t cung, cha ngoi d con v, chy mu nng do tai bin sn khoa. Truyn mu ngoi cp cu: - Truyn mu trc m. - Cc thiu mu mn tnh: ch gii hn nhng bnh nhn thiu mu nng m nguyn nhn khng th iu tr c. + Trong thc hnh vn li, hi ca truyn mu cn c cn nhc nht l
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nhng trng hp suy tim, tan huyt cp, vim thn, cc trng thi sc khng c gim khi lng mu, nhng trng hp c truyn mu nhiu ln hoc c nhng phn ng tng t. 4. CC QUY NH TRONG TRUYN MU 4.1. i vi khoa huyt hc - Nhn giy xin lnh mu ca khoa lm sng v ng mu ca bnh nhn ( ghi r tn, tui, khoa, phng, s ging). - Xc nh li nhm mu h ABO bng 2 phng php (huyt thanh mu v hng cu mu). - Chn mu ngi cho ph hp. - Th phn ng cho. - Kim tra cht lng chai mu ngi cho. - Ghi tn, tui bnh nhn c truyn vo nhn chai mu. - Khi c bo c tai bin truyn mu, khoa huyt hc phi phi hp vi lm sng x tr tai bin theo quy nh. 4.2. i vi khoa lm sng - Khi truyn mu, bc s l ngi chu trch nhim chnh. - Bc s ch nh r rng trong bnh n v loi mu, s lng, tc truyn, ghi phiu lnh mu. - Y t bnh phng ly mu bnh nhn gi n phng tr mu. - Chun b cc phng tin truyn mu v phng tin cp cu tai bin. - Dn bnh nhn nhn n trc v sau truyn 2h, i ngoi, i tiu trc khi truyn. - Kim tra li mch, nhit , huyt p trc khi truyn. - Kim tra chai mu, phiu th mu, nhm mu: trong bnh n, chai mu, phiu th phn ng cho. - Mu lnh v khoa phi truyn ngay. - Lm phn ng tin cy trc khi truyn. - Lm phn ng sinh vt (Ochlecker): t lm. Cho truyn 10 - 15 ml vi tc XXX git/pht sau ngng li kim tra li mch, nhit , huyt p, sc mt bnh nhn v cc phn ng khc. Nu c s thay i phi ngng truyn tm nguyn nhn. - iu chnh tc truyn theo ng y lnh. - Ghi nhn xt vo phiu truyn mu ca bnh nhn v vo bnh n. - Theo di tip bnh nhn sau truyn mu phng tai bin mun. - Gi li dy, chai mu (cn 5ml). Nu sau 2h khng thy c tai bin g mi b.
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5. CHN NGI CHO MU, TIU CHUN V QUN L NGI CHO MU 5.1. Tiu chun chn ngi cho mu Vic chn ngi cho mu t tiu chun kh phc tp. - Khe mnh, c th pht trin tt. - Tui: - Cn nng: Nam t 18 - 55 tui N t 18 - 50 tui Nam 46 kg N 42kg - S lng ly mu mi ln khng qu 1 n v mu (250ml), mun cho li phi sau 3 thng. - Phi c khm lm sng, khng c mc 1 trong 24 bnh theo quy nh ca T chc Y t Th gii v phi c lm cc xt nghim theo quy nh. 5.2. Qun l ngi cho mu - Trnh tnh trng mt ngi cho mu nhiu ni, th ngn hng mu (hoc phng truyn mu) m nhn qun l h s ngi cho mu. 6. NHNG TAI BIN THNG GP KHI TRUYN MU 6.1. Tai bin tc th - Tai bin do tan mu: do khng ph hp nhm mu ABO. - St: c th do bnh nhn c truyn mu nhiu ln dn ti phn ng nhm mu ph, phn ng vi nhm bch cu ngi cho hoc c cht gy st trong cc phng tin truyn mu. - D ng: c th do mu ngi cho c d nguyn. - Phn ng do chai mu b nhim trng: st, au bng, nn, a chy. 6.2. Tai bin xy ra chm - Tai bin do min dch ng loi (xy ra 4 - 10 ngy sau truyn). - Bnh ly do truyn mu: vim gan virus, st rt, giang mai, HIV. - Xut huyt gim tiu cu sau truyn mu: do khng th khng li tiu cu - Nhim thit huyt t: do truyn mu nhiu ln dn ti tng st. 6.3. Tai bin do k thut truyn mu - Tc truyn qu nhanh: gy ph phi cp. - Vim tc tnh mch. - Do tc hi, do fibrin. 6.4. Cc tai bin khc - Ng c citrat: do truyn mu nhiu. - Ng c kali: do truyn mu tr lu ngy.
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- H thn nhit: mu khng c lm m trc khi truyn. 7. PHNG hn ch cc tai bin do truyn mu v m bo an ton truyn mu: - Phi ch nh truyn mu ng (truyn. mu tng phn). - Chai, dy ly mu, k thut ly mu, truyn mu phi ng quy nh. - Phi xc nh nhm mu ABO bng 2 phng php.
- Phi lm phn ng cho, phn ng tin cy trc khi truyn mu.

- Chn ngi cho mu m bo theo ng quy nh. Phi t chc tuyn truyn cho cng ng hiu v li ch v tc hi ca vic truyn mu. Ch trng ti cng tc ng vin, khuyn khch ngi nh bnh nhn cho mu. Cn hng ng v lm tt chng trnh hin mu nhn o c nhng ti mu c cht lng, gp phn cu sng ngi bnh v phng trnh c cc tai bin do truyn mu gy ra.

CHN ON V X TR AU NGC
1. I CNG au ngc l mt triu chng thng gp trong lm sng v do rt nhiu nguyn nhn. au ngc nhiu khi e da n tnh mng ngi bnh. Do vy ng trc mt bnh nhn au ngc cn hi k v triu chng c nng, khm k v thc th hng ti chn on v tin hnh cp cu ban u, c bit l cc nguyn nhn gy au ngc nguy him. 2. MT S NGUYN NHN GY AU NGC THNG GP 2.1. au ngc do tim mch - Cn au tht ngc - Nhi mu c tim cp - Vim mng ngoi tim cp - Tc ng mch phi. 2.2. Bnh phi v mng phi - Trn dch mng phi - Trn kh mng phi 3. TRIU CHNG LM SNG 3.1. Cn au tht ngc 3. 1. 1. Cn au tht ngc in hnh - Cn au thng xy ra khi i, thi tit lnh. - au vng sau xng c, au ngang ngc, lan ln vai tri, ra cnh tay nht l
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bn tri, c khi lan ln c di hm. - Thi gian ca cn au ko di vi giy n vi pht. - Ngm Nitroglyxerin th ct c cn au. - Nhng du hiu km theo: bnh nhn cm thy hi hp, lo u, kh th, v m hi nghe tim c th pht hin ting nga phi tin tm thu. 3.1.2. Cn au tht ngc khng in hnh - au v tr khc thng - Th khng au - Cn au t th nm - Cn au kiu Prinzmetal + Xy ra lc ngh ngi, khng xy ra sau gng sc mnh. + Trong cn au ST chnh ln D1 v cc chuyn o trc tim. + Chp ng mch vnh thy tn thng va x ng mch. - Cn au tht ngc tht thng. L tnh trng chuyn nng nhanh chng ca hi chng au tht ngc, c th tin ti nhi mu c tim cp. 3.2. Nhi mu c tim 3.2.1. Th in hnh - au vng trc tim, au vng sau xng c. - Thi gian cn au ko di vi chc pht, vi gi. - Ngm Nitroglyxerin khng . - Khm: + Chn tay lnh, huyt p ng mch bnh thng hoc thp. Nhng gi u thng khng st, nhng sau nhit tng ln 38-38,50C trong 2-3 ngy. + Ting tim yu, nht l T1 mm i khi nghe c ting nga phi u tm trng, c th nghe thy ting c ngoi tm mc. 3.2.2. Th khng in hnh - Tai bin mch mu no. - Ph phi cp. - T vong 3.3. Vim mng ngoi tim cp -au ngc l triu chng thng gp. V tr au thng vng trc tim. - Kh th: kh th nhanh, nng. - Mt s triu chng khc: kh nut, ho khan, nc, nhn v s khng thy mm tim p, g din tim to ton b.
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- Nghe nhp tim nhanh, ting tim m. Ting c mng ngoi tim l du hiu c trng. - Cc du hiu tr tun hon ngoi bin. + Tnh mch c ni, gan to, ph hai chi di. + p lc tnh mch ngoi bin tng + Mch nhanh nh, huyt p ng mch h v kt nu lng dch nhiu v xut hin nhanh thng thy du hiu mch nghch thng ca Kussmaul. 3.4. Nhi mu phi - au ngc t ngt d di, kh th, nhp th nhanh 60-70 ln/ pht. - Mt ti tm mi - Nhp tim nhanh c nga phi phi, gan to, tnh mch c ni, c th tru mch. - Ngy hm sau ho ra mu, mu sm. - C th tnh trng sc do tim 3.5. Trn dch mng phi - au ngc bn trn dch - Kh th, nhanh nng, ngi bnh phi ngi dy th. - Khm thc th: + Nhn lng ngc bn c trn dch nh ln, khoang lin sn gin rng v km di ng, thng c ph nh lng ngc bn trn dch. + S rung thanh gim hoc mt. + G c r rt, c th pht hin c ng cong Damoisean. + Nghe r ro ph nang gim hoc mt vng c, c th c ting c mng phi giai on u. 3.6. Trn kh mng phi - t nhin au ngc, au nh x phi, c th gy sc, ngi v m hi. - Khm thc th: + Mch nhanh nh, huyt p h + Nhn lng ngc bn trn kh bt ng, khong lin sn gin ra. + S rung thanh mt. + Nghe mt ting r ro ph nang i khi nghe c ting thi v. 4. CN LM SNG 4.1. Cn au tht ngc - in tm : ST chnh xung 2-3mm cc chuyn o ngoi bin v chuyn o trc tim. - Chp lp lnh khi gng sc vi Thellium 99 hoc chp ng mch vnh.
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4.2. Nhi mu c tim - Xt nghim mu: bch cu tng 10.000 - 20.000 tc lng mu tng. i khi ng huyt tng nht thi. - Xt nghim men: + Creatin Phosphokinase (CPK) v isoenzym c hiu ca c tim men ny tng. + Lc tat dehydrogenase (LDK) tng. + SGOT, SGPT tng sau 12-18 gi sau khi nhi mu. + Alpha hydrobutyra (AHBDH) xut hin 6-12 gi sau khi nhi mu. - in tm : bin i phc tp QRS, xut hin sng Q bnh l ST chnh ln sng vm Pardee. V tr nhi mu V1V2 nhi mu trc vch V3V4V5V6, trc bn DIII v aVF nhi mu sau di. - X quang: chp lng ngc c th pht hin du hiu xung huyt phi. C dch ng cc vch lin tiu thy, i khi pht hin c hnh nh m ca ph phi. - Siu m: thy chuyn ng bt thng ca thnh tim v vch. C th pht hin c thng vch lin tht, hot ng bt thng ca b van hai l. C th pht hin c huyt khi thnh tim. - Chp lp lnh: chp lp lnh vi albumin nh du bng Technitium phng x cho php nh gi c chc nng tht tri, kh nng tng mu. 4.3. Vim mng ngoi tim - X quang: thy tim to, p yu hoc gn nh khng p. Tim to b ra hai bn. - in tm : ri lon ti cc tht, bin i on ST v T. + Giai on I: ST chnh ln vi sng T dng + Giai on II: Sng T dt + Giai on III: ST tr li ng ng in sng T m. + Giai on IV: cc sng tr li bnh thng. - Xt nghim mu: tc lng mu tng, t l alphaglobulin v si huyt tng. - Chc d mng ngoi tim: nu ht c dch l tiu chun quan trng nht chn on xc nh. 4.4. Tc ng mch phi - in tm : + P ph DI v DIII + Trc QRS chuyn sang phi + Blc nhnh phi hon ton hay khng hon ton. + T o ngc vi V4, V5, V6.
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- Chp X quang tim phi. + Tm tht v tm nh phi to + ng mch phi phng to + Phi qu sng vng ngng ti mu. + Du hiu mun: hnh m kiu vim phi, c trn dch mng phi. - Chp ng mch phi c cn quang. + Hnh ct ct mt nhnh to ca ng mch phi + Hnh phi qu sng khu tr - Chp phi nhp nhy: thy hnh nh ct ct, hnh nh gim tp trung. - Cc kh trong mu: SaO2 gim, PaCO2 gim. 4.5. Trn dch mng phi - X quang: nu dch trung bnh thy ng cong Damoiseau Nu dch nhiu thy na lng ngc b m, khoang lin sn gin rng, km i ng, tim b y sang bn i din. - Chc d: l ng tc gip chn on quyt nh, c tc ng chn on nguyn nhn, c tc dng iu tr. 4.6. Trn kh mng phi - X quang: phi qu sng bn b trn kh, khoang lin sn gin, phi b co li thnh mt cc xp xung st rn phi, c honh khng di ng v b y xung, trung tht b y sang bn lnh. - Triu chng p lc k: pht hin c ba loi trn kh mng phi; trn kh mng phi m, trn kh mng phi ng v trn kh mng phi c van. 5. CHN ON y t tuyn c s chn on xc nh i vi cn au tht ngc, nhi mu c tim, vim mng ngoi tim, tc mch phi, trn dch mng phi, trn kh mng phi ch yu da vo triu chng c nng v khm thc th. 5.1. Cn au tht ngc * Xc inh: - Da vo tnh cht cn au - Ngm Nitroglyxerin ct c cn - in tm : ST chnh xung * Phn bit: - Nhi mu c tim - Tc mch phi bn tri - Trn kh trn dch bn tri. - au do thoi khp hoc vim ct sng lng - c; vai, v cc khp sn sn.
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- Bnh tm cn. 5.2. Nhi mu c tim * Xc nh: - au vng trc tim kiu cn au tht ngc nhng ko di, ngm Nitroglyxerin khng . - Bin i sng Q v on ST chnh - Tng cc men trong huyt thanh. * Phn bit: - Cn au tht ngc: cn au ngn, p ng vi Nitrit, khng c sng Q trn in tm , men tim bnh thng. - Tc ng mch phi. - Vim tu cp, thng lot d dy t trng. 5.3. Vim mng ngoi tim cp * Xc nh: - Tim to, trn X quang thy tim ng yn. - in tim: bin i on ST v sng T. * Phn bit: - Tim to do nguyn nhn c tim: vim c tim, bnh c tim gin ta phn bit da vo: + Thng hay c ri lon nhp tim. + Ting thi tm thu do h van hai l c nng. + in tm thng c dy tht tri. + SA tim l xt nghim tin cy. 5.4. Tc mch phi * Chn on xc nh: - au ngc t ngt d di. - Ho ra mu - in tm : hnh nh P ph cp. * Phn bit: - Vim phi cp: bnh nhn c st, au ngc, bch cu tng cao. 5.5. Trn dch mng phi * Chn on xc nh: - au ngc tng dn - C hi chng 3 gim - X quang
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- Chc d * Phn bit: - Vim mng phi dy dnh: cn khai thc k v tin s trn dch mng phi do lao, chc d khng c xc nh. - X quang trung tht co ko v bn xp. 5.6. Trn kh mng phi * Chn on xc nh: - au ngc t ngt bn trn kh - Khm pht hin c tam chng Gallia * Phn bit: - Nhi mu c tim - Tc ng mch phi. 6. X TR BAN U 6.1. Cn au tht ngc - Nitroglyxerin, hoc y t c s dng papaverin. 6.2. Nhi mu c tim - Papaverin. - Nitroglyxerin, Nifedipin, an thn. 6.3. Vim mng ngoi tim - tuyn y t c s ch yu l iu tr triu chng. - Dng thuc gim au: Aspirin, an thn, chm nng ni au. 6.4. Tc mch phi - iu tr triu chng bng thuc gim au thng thng Aspirin, an thn. 6.5. Trn dch mng phi - Chc ht kh bng bm tim. 7. D PHNG - Kim tra sc khe nh k, tm cc yu t nguy c iu tr. i vi ngi trn 45 tui, c 6 thng nn i kim tra sc khe mt ln. - Dng thuc d phng huyt khi bnh nhn c nguy c.

CHN ON V X TR AU LNG
1. I CNG V DCH T HC au tht lng l mt triu chng th hin bng hin tng au vng c gii hn t ngang t sng tht lngl pha trn v ngang a m t sng tht lng 5 v
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cng 1 pha di; bao gm a, t chc di da, c, xng v cc b phn su. au c th km theo bin dng, hn ch vn ng hoc khng. au vng tht lng do rt nhiu nguyn nhn gy nn i hi phi khm t m, ton din gip xc nh nguyn nhn iu tr hiu qu. au vng lng v tht lng rt hay gp trong i sng hng ngy, trong iu tra tnh hnh bnh tt au tht lng chim 12% trong nhn dn, chim 17% nhng ngi trn 60 tui (Phm Khu, 1979); 6% tng s cc bnh xng khp (Khoa C Xng khp Bnh vin Bch Mai 1988); 80% dn s c th c triu chng au lng t hoc nhiu (theo David B.Hellman), gp c nam v n, cc la tui, nht l tui lao ng, nh hng n lao ng v sinh hot. 2. TRIU CHNG LM SNG 2.1. Biu hin ti ch 2.1.1. Triu chng c nng - Triu chng au: + V tr: c gi tr gip cho nh hng chn on, c th au mt im hay mt vng. + Tnh cht: au m hay au nhc, au mi, au tng cn, au ngy hay m, lc vn ng hay ngh ngi. + Hng lan: lan ra trc, ln trn, cng chn.... + iu kin xut hin: t ngt sau lao ng hoc thay i thi tit, - Cc du hiu km theo: + D cm, cm gic kin b, t b. + Gim c lc. + Hn ch vn ng ct sng. + Ri lon c trn: khi c tn thng vng ui nga + Cc tn thng khc tu thuc nguyn nhn gy au vng tht lng: au vng thng v km chua (tn thng d dy t trng) ; i but, i c (tit niu)... 2.1.2. Triu chng thc th - S thay i hnh thi ct sng: mt ng cong sinh l tr nn thng , g vo, qu n ra trc. - Quan st phn da, t chc di da v c vng tht lng: c l r, sng so, khi u, tnh trng c cnh vng ct sng (teo hoc li ra) - Khm cc ng tc vn ng: ci nga, nghing, quay xem hn ch mc no. 2.2. Biu hin lin quan - Khm cc on ct sng khc: lng c, cng ct v khp cng chu
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- Khm thn kinh: ch cc dy thn kinh c xut pht vng tht lng nh dy thn kinh ta, dy i b... - Khm cc b phn trong bng, ch b my tiu ha, thn, sinh dc n, ng mch ch bng. - Khm ton thn v cc b phn khc... 3. TRIU CHNG CN LM SNG 3.1. Chn on nh nh 3.1.1. Ccphng php chp Chp thng thng vi 3 t th thng, nghing, chch. Chp ct lp vi tnh c th cho thy nhng tn thng rt sm ca xng, phn mm quanh ct sng. Chp cn quang pht hin cc tn thng ra m, mng no tu, ui nga v tu. C th chp bao r thn kinh, chp ngoi mng cng, chp a m. 3.1.2. C th thy mt s hnh nh bt thng nh - Nhng thay i v hnh thi ct sng tht lng: mt ng cong sinh l cc du hiu ca thoi ha (mc gai xng, x c xng), du hiu ca vim ct sng do lao (t sng hnh chm, nham nh, hnh p xe lnh), thay i hnh thi ma m (xp, dnh, ph hu), hnh nh cu xng, vim khp cng chu.... - Nhng d dng ct sng: gai i, cng ha tht lng... - Nhng thay i v thu quang ca xng: mt vi, hnh hc v khuyt (do long xng, ni tit, di cn ung th); c xng (ung th di cn...) - Thot v a m - Thay i phn mm quanh khp nh p xe lnh (lao ct sng) 3.2. Cc xt nghim khc Tu theo hng chn on nguyn nhn m lm cc xt nghim cho ph hp - Cc xt nghim v vim: cng thc mu, tc mu lng, si huyt.. - Cc xt nghim v t bo vi khun: lao.. - Huyt tu , dch no tu, phn ng Waaler Ro se, calci mu, nc tiu... 4. NGUYN NHN AU THT LNG 4.1.Cc bnh ni tng Mt s bnh ni tng trong bng hoc tiu khung c th au vng tht lng, hoc au t pha trc lan ra sau lng 4.1.1. c im chung au c mt vng khng xc nh c v tr r rt, au hai bn hoc mt bn ca ct sng. Khm khng thy thay i hnh thi ct sng, vn ng bnh thng. C cc triu chng ca bnh ni tng.
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4.1.2. Nhng bnh ni tng c th gy au vng tht lng - Tiu ha: + Lot d dy t trng, ung th d dy: cn hi tin s, cha, hi, nn, xut huyt.... kt hp soi d dy, chp X quang xc nh. + Bnh ty tng: si ty, vim ty cp v mn c th au vng tht lng, amylase mu tng... + Gan mt: vim gan mn, si gan, bnh ti mt, ng mt. - Thn tit niu: au thnh cn vng tht lng, km theo c i but, i dt, i mu... c th do si tit niu, lao thn, vim thn b thn... - Sinh dc: au bng kinh, u x t cung, bnh tuyn tin lit.. 4.2. Nguyn nhn do vim, u, chn thng, lon sn.... Thng chn on v du hiu ti ch, ton thn, iu kin pht sinh v cc du hiu X quang. 4.2.1. Chn thng 4.2.2. Vim t sng - Vim do vi khun: vim do lao (bnh Pott) hay gp, on tht lng v lng b tn thng nhiu nht so vi cc on khc, au c nh ngy cng tng, du hiu nhim lao, hnh nh X quang thy hnh chm, hnh p xe lnh, hu xng v a m. Vim do cc vi khun khc: t cu, thng hn, ph cu... chn on da vo iu kin pht bnh (mn nht, vim c...), km theo c tnh trng nhim khun, xt nghim, X quang. - Vim do bnh khp: Vim ct sng dnh khp thng au vng tht lng phi hp vim khp hng v khp gi, hnh nh X quang c vim khp cng chu, hnh cu xng cnh ct sng. Biu hin vim ct sng trong mt s bnh khp nh vim khp dng thp, vim khp vy nn, vim khp phn ng thiu nin.... 4.2.3. Nguyn nhn do u (ung th di cn, u lnh) - Ung th di cn: ung th cc tng khc di cn n, hnh nh X quang thng thy khuyt xng gn hoc xp t sng - Cc khi u lnh tnh ca xng, mng no tu - Cc bnh lon sn, ri lon chuyn ha: vim xng sn (c thot v a m vo thn t sng). - Cc bnh mu gy tn thng xng: bnh lxmi, thiu mu tan mu, a u tu xng... 4.3. Cc nguyn nhn do thay i cu trc ca t sng v a m
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4.3.1. Thoi ha Thoi ha vng ct sng tht lng xut hin sm hn cc on khc ca ct sng, l nguyn nhn thng gp ca au vng tht lng. - H khp t sng: biu hin c mc gai xng cnh thn t, hnh c xng mm sn, gp nhiu ngi trn 40 tui, phn ln khng c biu hin lm sng. - H a m ct sng: l nguyn nhn quan trng ca au tht lng cc loi. C nhiu mc khc nhau: + Mc sm khi a m c kh nng cng phng nhiu, gy nhng cn au tht lng cp sau nhng ng tc mnh t ngt v tri t th. + Mc trung bnh gy au tht lng mn tnh, trn phim X quang thy chiu cao a m gim v chp cn quang a m thy bin dng v nt. + Mc nng: xut hin ri hoc thot v a m vo ct sng. C du hiu au tht lng hng, co cng c cnh ct sng, au thn kinh ta, teo c v lon cm chi di. 4.3.2. Tnh trng mt vi ca t sng - Long xng (khi xng mt trn 30% trng lng, do long xng c tnh trng xp t sng gay au): long xng ngi gi (long xng nguyn pht), long xng th pht sau cc bnh ni tit (bnh Cushing, bnh u tuyn cn gip, i tho ng), o lm dng thuc (steroid), o nm lu, do mt trng lc ko di (du hnh v tr). - Mt cht vi ri rc to nn cc , hc, khuyt (bnh Kahler, di cn ung th)... 4.3.3. Ct sng c xng Do ng c nuorose, ung th xng th to xng. Trn phim X quang thy mt hoc nhiu t cn quang hn bnh thng. 4.3.4. Cc di dng bm sinh hay th pht vng tht lng Chng gai i, cng ha tht lng 5, thoi ha tht lng cng, trt t sng ra trc... Hu ht khng c du hiu lm sng, hoc au t. 4.4. Cc nguyn nhn khc au do t th ngh nghip: mt s ngh nghip, t th c th gy au tht lng (cng nhn bc vc, ngh s xic, lc s c t..) au do tm thn. au trong hi chng thp khp cn ung th; mt s ung th ni tng c biu hin au xng di, ct sng v khp, au rt nhiu nhng khng c tn thng thc th v du hiu di cn trn Xquang (ung th ph qun, d dy, t cung, tin lit tuyn...).
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5. CHN ON NGUYN NHN AU VNG THT LNG 5.1. au vng tht lng n thun khng c thay i v hnh thi v vn ng - au c vng, khng c im au c nh. - Khng nh hng n hnh thi ct sng v vn ng vng tht lng. - Ch khai thc cc du hiu km theo: tiu ha, tit niu, sinh dc, ton thn, iu kin lao ng... 5.2. au vng tht lng c nhng thay i v hnh thi ct sng v hn ch vn ng - Cc tn thng nt rn, ln, di lch thng do chn thng - Hin tng mc thm xng: gai xng (thoi ha), cu xng (vim ct sng dnh khp), vi ha dy chng. - Du hiu ca vim t sng do vi khun: + Hnh nh hu a m, thn t sng hnh chm, hnh p xe lnh (lao ct sng) + Hu a m v thn t (vim m) - Hnh nh tiu xng: bnh Kahler, cng cn gip, ung th xng hay di cn ung th. - Hnh nh c xng: nhim nc (c nhiu t), khi u (c mt t). - Hnh nh long xng v ln t sng km theo: long xng nguyn pht v long xng th pht. - Cc hnh nh d dng - Cc bnh v a m - Hi chng hp ng sng. 5.3. au vng tht lng m nhng du hiu lm sng v Xquang khng xc nh c nguyn nhn - H a m. - Cc nguyn nhn do ngh nghip, thi quen - Long xng v h khp ngi ln tui - Mt s bnh vim: lao, vim ct sng dnh khp - Mt s t do d dng bm sinh hoc th pht. Nh vy au vng lng v tht lng do rt nhiu nguyn nhn gy ra, cn phi hi bnh v khm bnh tht t m, nhm pht hin bnh nht l nhng ni cn thiu trang thit b h tr chn on. 6. IU TR 6.1. Nguyn tc chung - Ngh ngi v bt ng khi au nhiu.
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- Dng cc thuc gim au. - Dng thuc gin c khi c co c. - Kt hp iu tr vt l, chm cu bm huyt. - S dng mt s bin php c bit khi cn: tim ngoi mng cng, tim vo a m, ko gin ct sng... - Phu thut trong mt s trng hp - iu tr nguyn nhn. 6.2. iu tri ni khoa - Thuc gim au: ung hoc tim tu mc , dng cc thuc Aspirin, Indomethacin, Profenid, Brufen... C th dng cao dn, thuc m c Salicylat. Khng nn dng cc thuc c Steroid. - Thuc gin c: Diazepam, myocalm... khi c co c. - Cc phng php vt l: Chm nng, xoa bp Dng in: hng ngoi, sng ngn, in dn thuc... Thao tc ct sng (khng lm khi nghi c vim, ung th, long xng nng) - Y hc dn tc: chm cu bm huyt, thuc nam nh cy xu h, l lt, hy thim... - Cc phng php c bit: Ko gin ct sng bng dng c, ch nh cho thot v a m Tim ngoi mng cng vi Novocain v vitamin Bi2 trong au tht lng hng. C nh bng ai, np, ym khi c nguy c ln v di lch ct sng (lao, ung th..) Th dc liu php v bi trong vim ct sng dnh khp, h khp. 6.3. Phu thut Ch nh trong cc trng hp: - Cc bnh di lch chn p vo tu, ui nga (lao, chn thng, u) - Phu thut lm cng, c nh khi c nguy c ln t sng, g vo nhiu... - Phu thut iu tr thot v a m: m ly nhn thot v, m ct cung sau. Tm li: rt nhiu nguyn nhn dn n au vng lng v tht lng, chn on nhiu khi d nhng nhiu khi kh chn on, nn cn phi khm bnh t m chnh xc, trong iu tr cn chn la v phi hp phng php ph hp iu kin v kinh t ca ngi bnh iu tr c hiu qu.

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NHC U
1. I CNG 1.1. c im dch t hc nhc u Thut ng nhc u hay au u bao hm tt c cc loi au u, nhng thng thng ta dng t nhc u ch ni ti nhng cm gic kh chu vng vm s. Nhc u l mt trong nhng cm gic kh chu thng gp nht ca con ngi, l mt triu chng thng gp do nhiu nguyn nhn khc nhau, xut hin trong rt nhiu bnh. Nhc u c th l du hiu u tin, duy nht trong mt thi gian di ca mt bnh thn kinh thc th. Nhc u cng hay gp trong cc bnh ni tng, bnh ton thn hoc bnh tai mi hng, mt, rng. Nhc u c xp vo 10 l do hng u khin bnh nhn ti thy thuc khm bnh. Cc cuc iu tra cng ng cho thy c 65 - 80% ph n v 57 - 75% nam gii b nhc u mi thng. S hin tng mc nhc u gim xung theo tui, trong khi tn s ti bc s khm bnh v nhc u li tng. Nhc u l nguyn nhn lm mt nhiu ngy cng lao ng. Phn ln nhc u thng l lnh tnh, nhng i khi c nhng vn rt nghim trng c th cng c mt vi nhc u. iu tr nhc u khng phi ch l iu tr triu chng m cn bn l iu tr nguyn nhn, iu tr bnh. 1.2. C ch nhc u Mt tc ng vo thnh phn c cm gic ca cc t chc trong s u gy nhc u theo nhiu c ch. * C ch thn kinh: - Tc nhn kch thch: + Tn thng ti ch: vim mng no, vt thng s no nh hng ti mng cng, xm nhp ca khi u. + Kch thch c hc: p, co ko mng no v cc mch mu no trong tng p lc ni s, u no, p xe no, hoc ri lon tun hon mu v dch no tu. - B phn kch thch: Mng cng, thnh mch mu trong s c nhiu c quan nhn cm, c nhiu tn cng thn kinh cm gic. - ng dn truyn kch thch: Khi cc th th b kch thch, xut hin cc xung ng thn kinh. Cc xung
28

ng c truyn ln no bng dy V, dy IX, dy X v dy c I, II, III. ng dn truyn ny i qua hai chng quan trng l qua i th v qua cht li. * C ch phn x: Do r cm gic ca dy V nm trong vng cu - hnh no, bn cnh nhng y thc vt. C l v vy nhiu bnh ca c quan ni tng gy au u * C ch thn kinh thdich: Do kch thch cc th th ha hc thnh mch mu, mng no trong nhim c nhim khun ton thn, ri lon chuyn ha, ri lon ni tit. * Tng tnh hng phn ca t bo v no: Trong suy nhc thn kinh, v no trng thi m ngng chu kch thch ca v no b h thp. V no tip thu c nhng kch thch nh, thng xuyn t cc c quan ni tng truyn ti, do bnh nhn hay cm thy nhc u. * c im tm thn: C ngi chu au tt, c ngi chu au km. 2. NH GI BNH NHN V XC NH CC TRIU CHNG I KM VI NHC U 2.1. Hi bnh - Khai thc bnh s: bnh s bnh nhn l phn quan trng nht ca vic nh gi nhc u, cn khai thc k v s khi pht, tn s, thi lng, tnh cht, cng , v tr, cc yu t tng gim, cc triu chng phi hp, cc biu hin thn kinh, vic dng thuc trong qu kh v hin nay. Cc d ng v chn thng cn c xc nh. - Lch s gia nh: nhc u Migren c khuynh hng di truyn. Nguyn nhn dn ti nhc u th pht c th pht hin t s hiu bit v tin s bnh trong gia nh nh tng huyt p, nhim khun, i tho ng, ung th. - Cc tress x hi v c nhn: cn tm hiu cng vic, gic ng, n ung, thi gian hot ng. Xc nh s tiu th ru, nc ung c c ph, ht thuc l, thuc lo v tin s dng cc thuc khc. 2.2. Khm thc th Mc ch xc nh v loi tr nhng nguyn nhn th pht ca nhc u. - Khm v u, c, thn kinh: xc nh tng nhy cm au, s khng u v hnh dng, cc ting bt thng trn hc mt, cc ng mch cnh, thi dng v ng mch chm. - nh gi cm gic au khi ming m v ng, cc khp cn lch v s nhy cm au ca khp thi dng - hm. G trn xoang trn v xoang hm tm nhy cm au. - Trong nhc u vng chm nn nh gi t sng c, nh gi ng tc nga
29

gp v quay. Bnh t sng c c th dn n nhc u gy ra do co c hoc bnh d thn kinh chm. Cn c bit ch ti cc dy thn kinh s no, thn kinh th gic. - nh gi v tm l: s dng cc test chun v tm l. - Khm cc chuyn khoa: khm mt, khm th lc, th trng. - Khm rng hm mt: pht hin rng su, rng mc lch. - Khm tai mi hng: pht hin vim tai gia, vim tai xng chm, vim xoang, vim hng v amydal... 2.3. Cc xt nghim - Cc nghin cu phng th nghim cn c ch dn bng cc kt qu v tin s bnh v thm khm thc th. - Xt nghim dch no tu, m s lng hng cu - bch cu, cy mu v dch no tu. - Tc mu lng: tng trong nhc u do vim ng mch thi dng. - in git . - ng huyt lc i chn on i tho ng hoc h ng huyt. - Chp ct lp vi tnh trong nhng trng hp nghi u no, chn thng s no. - Cng hng t ht nhn. - o nhn p chn on glaucome. 3. NGUYN NHN NHC U 3.1. Nguyn nhn mch mu * Nhc u vn mch: l th thng thng nht, do mt ri lon vn mch trong no, thng gp trong cc bnh nhim trng, st, cc trng thi thiu oxy no, i, nhim c ru v thuc l mn tnh. * au na u (Migren thng thng): - c im c bn ca Migren l au na u tng cn, ti din c chu k, km theo bun nn, nn. Trc khi au thng c tin triu. Ngoi cn hon ton bnh thng n b bnh nhiu hn nam. Gp nhiu la tui 15 - 30. - Yu t khi pht cn thng l yu t tm l, lo lng, xc cm. Migren tng ln trong thi k kinh nguyt, tin mn kinh v dng thuc trnh th thai. Yu t mi trng, nh sng, ting ng, bnh tng huyt p, mt s thuc cng lm tng tnh trng nng ca bnh. - V tr au thng mt bn u, tu tng cn, au u c th lun phin bn phi, bn tri. - Tnh cht au: cm gic nng u rt kh chu, ny theo mch p ng thi vi nhp tim. - Cng au: au va n d i. Trn cng mt bnh nhn cng au
30

mi cn c th khc nhau. au tng khi ln cu thang, khi vn ng, hoc bi nh sng, ting ng, mi thuc (thuc l, thuc cha bnh). Do , bnh nhn phi tm ch yn tnh, bung ti, khng mun tip xc vi mi ngi. - Hng lan: xut pht t vng trn - thi dng, au c th lan ln nh u, ra vng chm, xung hm di hoc ra hc mt cng bn. 84% au ch lan ra na u. - Thi gian ca cn: xy ra thnh tng cn lu 4 - 24 gi, giai on au nht t 30 pht n 2 gi. - au u gim sau khi nn hoc gim dn trong ngy, thng ng c mi ht cn, gic ng cng su cng nhanh ht. - Khm trong cn thy ng mch thi ng cng, ni ngon ngoo, ny, p mnh bn au. * Tng huyt p: - Ngoi nhc u, bnh tng huyt p cn c nhng triu chng khc nh: chng mt, nh trng ngc, chy mu cam, tai, mt ng, i i m... - Tnh cht nhc u trong tng huyt p thng gp trong tng huyt p nng, hay nhc vng chm, xy ra bui sng v gim dn trong ngy. * Gin mch na u: au mt bn v nhy cm vi histamin. * Vim ng mch thi dng (bnh Horton): - L mt bnh vim h thng ng mch, ch yu l ng mch thi dng. N b nhiu hn nam, hu ht l trn 60 tui, c yu t di truyn. Thng au mt bn thi dng, au thng xuyn, tng ln khi kch thch nh (chi u, eo knh...). - Trong cn kch pht: nhc u d i. - C th au but theo mch p. - au nhc vng thi dng lan ra vng trn v hc mt cng bn. - Khi khm pht hin thy mt on thng ng mch thi dng cng mu tm, n au. S thy ng mch c ch to nh khng u, mch p yu hoc khng p. - C th pht hin tn thng khu tr mt s ng mch khc. - Ton thn bnh nhn c st, mt mi, chn n, gy st. - C th c biu hin m mt t ngt, do nghn hon ton ng mch mt, mt s trng hp biu hin thiu mu no, vim ng mch ngoi s v vim ng mch cc chi. 3.2. Nguyn nhn ni s * Tng p lc ni s: thng nhc u vo bui sng, lc gng sc, i khi thng xuyn.
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* U no: - Lc u, nhc u xut hin thnh nhng cn ngn, ri sau ko di v tr thnh thng xuyn, i khi khng chu ni. - au c th xut hin tng ln v mt i theo s thay i t th ca u: khi bnh nhn c t th bt buc, nm nghing sang bn hoc nm nga, u ci ra trc, ra sau. Nguyn nhn gy nn cc t th bt buc ca u l do: + Kch thch cc d thn kinh cm gic. + Kch thch tai trong. + Nhng thay i ca tun hon dch no tu. - Nhc u xut hin hoc au tng ln khi: + p ng mch cnh hoc truyn cc trung dch u trng. + au khu tr di ln khi g vo u. - V tr nhc u xut hin u tin c lin quan n v tr khi u, 1/3 s bnh nhn u no c v tr nhc u trng vi v tr khi u. Nhc u ch c v tr nh khu khi khng c tng p lc ni s. * p xe no: km theo st, tng p lc ni s. * Vim mng no v chy mu di mng nhn: bnh thng mng nui v mng nhn khng nhy cm au. Nhng trong vim mng no v chy mu di mng nhn th bnh nhn li nhc u d di l do: - Nhng cu trc (bnh thng c sn tnh nhy cm vi au) chy qua hoc p st vo mng nui b kch thch nh: nhng ng mch ln ca nn s v cc nhnh ca n, nhng xoang tnh mch ln. - Cc dy thn kinh s no b kch thch: + Cc dy thn kinh gic quan b kch thch s pht sinh s nh sng, s ni to. + Cc dy thn kinh cm gic b kch thch s gy tng cm gic au. + Cc dy thn kinh vn ng b kch thch gy nn co cng mng no, co cng au gy, co cng hm. - i khi m ri mng mch b kch thch gy tng p lc dch no tu. 3.3. Cc nguyn nhn s - Thng gp trong bnh Kahler, cc u xng di cn vo hp s, pht hin bng chp Xquang s. - Tn thng cc dy thn kinh cm gic: au c theo cc y thn kinh b tn thng, n vo au c th l zna. 3.4. Cc nguyn nhn ngoi s - Nhc u do bnh mt: + Cc tt chit quang, vim mng mt th mi, nhc u nhiu khi trn, tng ln khi gng nhn.
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+ Glaucome: au u d di, nhc trong h mt, nhn vo n thy c qung xanh nh cu vng, n nhn cu thy cng cng, tng nhn p. + Ngoi ra cn gp nhc u sau khi lm vic bng mt, c sch, xem v tuyn. - Nhc u do bnh tai mi hng: + Vim tai gia, vim xng chm, nhc u thng thi dng, mt bn v cch hi, nn vo xng chm gy au. + Vo vch ngn mi, ph i xng cun mi. + Vim xoang trn, xoang mi hoc xoang sng: nhc u ch yu vo bui sng v tng ln khi lnh. - Nhc u do bnh rng: Cc bnh su rng, p xe chn rng, rng khn mc lch thng au ti ch, nhng c th au ln thi dng, nh u, khi cn vt cng au tng ln. 3.5. Nguyn nhn khc * Nhim c: ru, nhim c ch, asen, ht nhiu thuc l: thng nhc ton b u. * Nhc u sau chn thng: - au u xut hin vi ngy sau chn ng no hay ng gip no, thng khu tr ch b thng, tng ln do cc trng thi xc cm v thay i t th. - Mt thi gian sau chn ng no hoc ng gip no, au u xut hin ngy mt tng, ng thi li xut hin nhng triu chng thn kinh thc th th phi ngh ti kh nng c bc mu t di mng cng mn tnh. * Nhc u sau chc tu. sng: - Xy ra vi gi sau chc d tu sng v ko di 1 - 2 ngy. au c tnh cht cng ko, i khi nh mch p, au tng t th ng hoc ng, hoc sau cc c ng mnh ca u, ho, gng sc. - Chc ng tht lng bng kim c ln, gy nhc u nhiu v ko di hn dng kim nh. - p lc dch no tu gim lm thay i cn bng thu tnh ca no v tc ng p ti cc cu trc nhy cm au. - S cng thng ni tm v lo lng s hi sau chc d tu sng l yu t thun li gy nhc u. * St: st cao gy gin mch gy nn nhc u. au nhiu vng trn, chm hoc ton b u. * Thiu mu: xut hin trong trng hp thiu mu nng, hoc nhng ngi bnh thng cao. Nhc u do thay i p lc tai, xoang mt. Lm ng tc nhai, nut hay
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nghim php Valsalva th s chnh lch p lc s c thng bng nhanh chng. * Vim x cc c c. xc nh im au ch bm cc c c. 4. IU TR Bc quan trng nht trong iu tr au u l cc bin php pht hin v loi b cc bnh chnh hoc cc ri lon chc nng. - i vi au u hng ngy thng thng do mt mi, sang chn tm l hoc dng qu nhiu ru, thuc l, tng stress, Aspirm 0,6g hay Acetamiophen 0,6 g, 6 - 8 gi 1 ln. - au na u (Migren): + Cho ti nay cha c phng php iu tr trit , cn phi phi hp phng php iu tr nhm lm gim tn s cn, cng cn, thi gian ca mi cn v triu chng km theo. + Trnh yu t gy au, trnh cc ung c ru, nht l ru vang + iu tr cn au u: dng thuc no l tu thuc vo mc nng, nh ca bnh, vo kinh nghim ca thy thuc cng nh p ng ca mi ngi bnh. + Th nh ch cn Analgin (500mg - ung sau ba n). + Cn au nng hn cn dng mt trong s cc thuc nh: Ergotamin leng, ung hoc t di li, ngay t bt u cn, sau 30 pht (nu khng ) th ung thm 1 vin, khng dng qu 3 vin/ ngy. Khng dng qu 10 vim tun. Khng dng gia cc cn au. Ch phm ny thn trng khi dng cho ph n c thai hoc nhng ngi b bnh mch mu. Paracetamol, Tamik. Thuc chng vim khng steroid: Voltaren, Indomethacin. Cc thuc an thn: Seduxen, gacdenan nhng cng khng nn lm dng. + iu tr d phng cc cn au, ch p dng vi th nng: Avlocardyl, tamik, laroxyl hoc Sibelium. + Cn phi iu tr cc yu t lm tng bnh nh ri lon ni tit, tiu ha, gan mt v liu php tm l, trnh cc ung c ru. - au u do tng huyt p: + Nhc u thuyn gim ng thi vi con s huyt p h. + Tc dng iu tr c hiu qu tt nht l dng thuc h huyt p kt hp vi thuc an thn. + Trong qu trnh iu tr cn theo di huyt p v mc nhc u.
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- au u do cng c: xoa bp, th gin, kt hp vi cc thuc trm cm Amitriptylin, an thn Seduxen, cc thuc gim au Analgin, kt hp tm l liu php. - au u sau chn thng: tm l liu php, chm nng, xoa bp, cc thuc Indomethacin hoc Phenylbutazon. - Vim ng mch: Prednisolon 40 - 60 mg/ngy, dng t nht 1 thng sau gim dn liu cho n khi triu chng lm sng, xt nghim v bnh thng. C th kt hp vi thuc chng vim khng Steroid trong giai on cng c. - Do u no: tt nht l chuyn tuyn trn iu tr phu thut ct b hon ton khi u. - Nhc u do st: iu tr theo cn nguyn v dng bin php h nhit bng chm lnh, hoc dng cc thuc h st nh Paracetamol, Analgin kt hp vi thuc an thn. Trong khi iu tr au u cn phi ht sc ch , trnh lm dng cc thuc gim au nh Analgin, Aspirin, Indomethacin, Seda... nht l nhng bnh nhn c tin s lot d dy hnh t trng, v c th gy bin chng chy mu ng tiu ha rt nguy him. Nu ch nh dng thuc gim au khng Steroid phi khuyn bnh nhn ung sau ba n, sau phi c gng tm nguyn nhn iu tr. 5. PHNG BNH - Tm quan trng ca cng tc v sinh chung, mt ch n y , ngh ngi ph hp, lao ng hp l, xc nh v loi b nhng yu t lo u hng ngy l gip cho vic phng nhc u c hiu qu. - Thay i tp qun sinh hot, trnh cc tc nhn gy cn, tm l liu php, tp luyn dng sinh, cc bin php ny cn c coi trng trong phng nga nhc u Migren. - Cn chuyn tuyn trn kp thi chn on v iu tr i vi nhng trng hp iu tr bng nhng bin php thng thng khng thy kt qu, kh xc nh nguyn nhn.

SUY THN CP
1. I CNG 1.1. nh ngha Suy thn cp l mt hi chng xut hin khi chc nng thn b suy sp nhanh chng do nhiu nguyn nhn cp tnh dn n. Mc lc cu thn gim v c th b gim st hon ton, bnh nhn s i t v niu, Nitphiprotein tng dn, cng tng nhanh th cng nng. Ri lon nc in gii, thng bng kim toan ca mu l khng trnh khi. bnh nhn s cht do kim mu tng, do ph phi cp, do hi chng m mu
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cao hoc do bnh chnh. Cho n nay mc d c nhng phng tin hi sc tch cc nh lc mu ngoi thn nhng t l t vong cn rt cao. Tuy nhin nu c x l kp thi v chnh xc th nhiu trng hp c th chc nng thn hi phc hon ton hoc gn hon ton, ngi bnh c th tr li cuc sng bnh thng. 1.2. c im dch t Suy thn cp c coi nh mt s suy gim nhanh chng, tc lc mu ca cu thn v ng trong mu nhng sn phm ca chuyn ha no, hi chng ny xy ra trong 5% tng s cc ca nhp vin v c th chim ti 30% cc ca iu tr tch cc (theo thng k ca PGS. Trn Vn Cht v BS. Trn Th Thnh 1991 - 1995). Suy thn cp l mt bnh cp cu ni khoa t l mc bnh khng lin quan g n gii v a d. Vic chn on iu tr kp thi v chnh xc nht l trong cng ng c chn on sm th rt nhiu trng hp chc nng thn c khi hon ton hoc gn hon ton trnh c cc bin chng t vong. 2. NGUYN NHN 2.1. Nguyn nhn trc thn L nhm nguyn nhn gy bnh suy thn cp chc nng. - Sc gim th tch. - Sc tim. - Sc nhim khun. - Sc phn v. - Cc nguyn nhn gy gim khi lng tun hon khc nh: hi chng thn h, x gan, thiu dng gy gim protid mu. 2.2. Nguyn nhn ti thn - Bnh l cu thn cp: chim 3 - 12% bnh nhn suy thn cp + Bnh cu thn nguyn pht. Suy thn cp c th l bin chng ca vim cu thn cp sau nhim lin cu + Bnh cu thn th pht: Vim cu thn Lupus trong t tin trin cp tnh. Hi chng Good pasture Schoenlein Henoch c tn thng thn... - Cc bnh ng thn k cp tnh chim 58 - 65% bnh nhn suy thn cp + Ng c: ng c mt c trm, thuc nam... + Ng c thuc: thuc khng sinh, thuc chng ung th, thuc gim vim, gim au. + Tan mu cp tnh: Truyn nhm nhm mu.
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 St rt c tnh. Dng thuc gy tan mu: Quanh. RifamDVcin... + Tiu c vn cp tnh: Chn thng c Thiu mu c. Hn m ko di, co git. Nghin heroin, lm dng thuc chng ng knh... + Cc tnh trng sc lc u l suy thn cp chc nng, sau c th dn n hoi t ng thn cp. + Nguyn nhn nhim trng: Nhim trng mu, nhim xon khun gy hi chng gan thn cp... Hoc theo con ng ngc dng: vim thn b thn cp + Nguyn nhn thng qua c ch min dch d ng: khng sinh, thuc chng co git. + Nguyn nhn gy ri lon chuyn ha: nh tng acid uric mu. + Cc nguyn nhn khc: Myelome... - Chn thng thn. - Tc mch thn - Cc nguyn nhn khc 2.3. Nguyn nhn sau thn L cc nguyn nhn gy tc nghn ng bi niu - Si b thn, niu qun - U chn p tc ng bi niu - Nguyn nhn do vim x cht hp: lao thn, giang mai... - X ha sau phc mc. 2.4. Cc nguyn nhn khc cha r 3. TRIU CHNG LM SNG V CN LM SNG Cc triu chng lm sng v cn lm sng tu thuc vo tng giai on ca bnh. 3.1. Giai on khi u L giai on tn cng ca tc nhn gy bnh. Din bin tu theo tng nguyn nhn. Bnh nhn ng c th din bin nhanh c th dn n v niu ngay, bnh nhn sc th din bin nhanh hay chm tu theo nguyn nhn gy sc v k thut hi sc ban u. 3.2. Giai on i t, v niu
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V niu c th din bin t t, bnh nhn c th i t ri dn n v niu, nhng v niu cng c th xy ra t ngt. i t, v niu c th ko di 1 n 2 ngy, c khi 3 n 4 tun, trung bnh l 7 - 12 ngy v c cc triu chng sau: - Lng nc tiu gim (<500ml/24h) v niu l nc tiu <100ml/24h. - C ri lon in gii + Ph + Kim mu tng dn + Biu hin tim mch l bin chng nguy him nht, c th c lon nhp, chm nhp ri ngng tim. Trn in tm thy sng T cao nhn, i xng v thy ST chnh ln hoc chnh xung. + Triu chng v thn kinh c: bnh chng c th thy yu, lit c. + Khi kali mu tng trn 6,5mmol/1 l mt tnh trng cp cu ni khoa cn phi c lc mu cp. - Nit phi protein mu tng cao dn. - Ur mu tng dn. - Creatinin mu tng dn - Acid mu tng dn - Khi tc tng ca ur v creatinin mu cng nhanh th tin lng cng nng, n ph thuc vo ch n nhiu hay t protid, ph thuc vo qu trnh ging ha protid trong c th v ph thuc vo mc v niu. - Toan ha mu l khng trnh khi do tch t cc acid c nh l mt trong nhng tiu chun ca lc mu. - Cc triu chng khc. + Cao huyt p + Biu hin tim mch, h hp, thn kinh, tiu ha... ca hi chng m mu cao. + Nc tiu c protein niu, hng cu, bch cu, tr niu, t trng nc tiu thng thp, tr suy thn cp chc nng. 3.3. Giai on i tr li Lng nc tiu tng dn >21/24h, c trng hp 4 -51/24h, i nhiu ph thuc vo nguyn nhn gy bnh v lng nc a vo trong giai on i t v niu. Nguy c chnh ca giai on ny l: - Mt nc - Mt in gii (K+, Na+ mu h) - Ur mu, creatinin mu giai on u thi k ny vn tng sau 3-5 ngy i nhiu ur mu, creatinin mu gim dn, chc nng thn dn hi phc. Thi gian i nhiu trung bnh khong 1 tun, sau lng nc tiu gim dn
38

v tr v bnh thng. Tuy nhin c nhng trng hp sang thng th 2 nc tiu >21/24h. 3.4. Giai on hi phc - Khi lng nc tiu dn tr v bnh thng - Cc ri lon v sinh ha dn tr v bnh thng Tuy nhin kh nng c c nc tiu ca ng thn c khi hng nm mi hi phc hon ton, mc lc cu thn hi phc nhanh hn. S hi phc nhanh hay chm tu thuc vo tng nguyn nhn, vo tnh trng ban u, ch iu tr v cng tc h l i vi bnh nhn. 4. CHN ON 4.1. Chn on xc nh: da vo - C nguyn nhn cp tnh: ung mt c trm, ng c kim loi nng, a chy mt nc, vim cu thn cp... - Xut hin: + Thiu niu, v niu + Ur mu, creatinin mu tng dn + K+ mu tng dn + Toan chuyn ha + Din bin qua 4 giai on (nh trn) 4.2. Chn on phn bit - Phn bit vi t cp ca suy thn mn: suy thn mn: + Tin s c bnh thn, tit niu + Thiu mu tng ng vi mc suy thn + Cao huyt p, suy tim + Siu m c th thy hai thn teo nh. - Phn bit gia suy thn chc nng v suy thn cp thc tn. + Suy thn cp chc nng l do gim th tch tun hon, tt huyt p: mt mu cp, a chy, suy tim... Huyt p tt, mch nhanh nh, kim niu cao hn nan niu, t trng nc tiu cao. Nu khng iu tr kp thi s chuyn thnh suy thn thc tn (sau 72h) + Suy thn cp thc tn: thn b tn thng thc th do hoi t ng thn (ng c, sc) hoc vim cu thn cp, nhi mu thn... Da vo: Lm sng c tt huyt p, mt nc, mt mui, ging ha nhiu th ngh n suy thn cp chc nng.
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 Thi gian v niu cng ko di cng chc chn c hoi t ng thn, thng sau 72h v niu th gn nh chc chn l bt u c tn thng thc th. Da vo kt qu xt nghim ta c th phn bit suy thn cp chc nng v suy thn cp thc tn nh sau:
Ch s - Natri nc tiu - Na/K nc tiu - Ur nc tiu/ur mu - Ur mu/creatinin mu Suy thn cp chc nng Suy thn cp thc tn < 20mEq/1 > 40mEq/1 >1 > 10 > 30 <1 < 10 < 20 <2

- Nng thm thu ca nc > 2 tiu/mu - Nng thm thu ca nc tiu > 600 mos/kg - T trng nc tiu >1,018

<600 mos/kg <1,018

Cc kt qu xt nghim ny ch c gi tr tng i cn kt hp vi lm sng chn on phn bit. Trn cng ng nu bnh nhn c nguyn nhn cp tnh nh: ung mt c trm, a chy mt nc... nu thy xut hin thiu niu hoc v niu th vn phi a n trung tm cp cu ngay x tr kp thi trnh nguy c t vong. 5. IU TR 5.1. Nguyn tc chung - Nhanh chng loi b cc nguyn nhn gy suy thn cp c th iu tr c - Tp trung phng tin cha tr cho ph hp vi tng giai on ca bnh, lc mu khi cn thit. - m bo tt cng tc iu dng v chng nhim khun. 5.2. iu tr c th Tu tng giai on ca bnh: 5.2.1 Giai on u Cn loi b tc nhn gy suy thn cp: - B ch, b mu: Phi b dch hoc mu trong trng hp bnh nhn mt nc, mt mu. Phi nng nhanh huyt p. huyt p tt, ko di trn 72h d c nguy c dn n suy thn cp c tn thng thc th do thiu mu thn. Nguyn tc l khng huyt p ti a xung di 80mmHg.
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- iu tr c hiu: rt cn thit trong giai on ny v d: + Dng BAL trong iu tr ng c kim loi nng nh thu ngn, asen. + M ly st niu qun... - V ch n: ch nn cho lng m ti thiu (0,5g/kg) bng Protein gi tr sinh hc cao, khong 1 lng c, tht nc mi ngy. 5.2.2. Giai on i t v niu Mc ch c bn iu tr trong giai on ny l: Gi cn bng ni mi. Hn ch tng kali, nit phi protein mu. - Nc: bnh nhn v niu m bao cn bng m, ngha l vo t hn ra, thng ch cho 500ml/24h k c n ung, ma h c th cho nhiu hn. Trng hp v niu do mt nc, mt mui th phi b dch. Cn phi lu lng nc mt do nn, a chy, m hi, hi th... - in gii v toan mu + Chng tng kim mu. Hn ch thc n c nhiu khu Loi b hoi t, chng nhim khun. Li tiu thi kim: liu khi u Lasix t 40-80mg c th tng 1000mg/24h. Truyn kim. Truyn ng a trng, pha insulin nhm a bt K+ vo trong t bo. Tim calci tnh mch cng hn ch c nh hng ca K+ cao. Nu K+ trn ln hn 6,5mmol/1 th ch nh lc mu ngoi thn. iu tr cc ri lon in gii khc nam mu h do nc tt nht l hn ch nc, nu h nhiu cn b nam: calci mu thp th cho calci clorua... Hn ch tng nit phi protein mu ch yu hn ch tng m mu bng cch: - Ch n gim m 0,4g/kg/24h, cam (35kcalo/kg), vitamin. - Loi b cc nhim khun: Rt thn trng khi dng khng sinh v a s khng sinh c cho thn, c bit i vi ngi gi. Cc loi Penicilin, Methicylin, Erythromycin, clorocid t c nht. Khi cn cho ventamycin do nhim khun huyt Giam m, t cu th nn cho liu thp 40 mg/24h. * Ch nh lc mu: Khi K+ mu >6,5mmol/1 Khi ur mu >35 mmol/1 Khi cretinin mu >600 mol/l
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Khi c biu hin toan mu 5.2.3. Giai on i tr li - Tip tc hn ch protid trong thc n, ch cho n tng protid khi m mu tr v bnh thng. - Ch cho n qu chn khi khng c tng kali mu. - Nu cn th phi tip tc lc mu. - Truyn dch hoc trong chng mt nc v in gii. + Trong trng hp i nhiu va phi ch cn cho ung Oresol (2-2,5l/ 24h) + Khi nc tiu >31/24h th phi b bng ng truyn tnh mch, lng truyn tu thuc vo lng nc tiu. - Cn theo di st in gii mu c bit l Na+ v K+ mu. - Bnh nhn i nhiu c 2 n 3 ngy th m niu, creatinin niu tng dn, ur mu, cretinin mu gim dn, bnh nhn s chuyn sang giai on hi phc. Cn tng dn lng protid trong ch dinh dng. 5. 2. 4 Giai on h i phc s c khe - Sc khe bnh nhn dn c hi phc khi m mu tr v bnh thng th cn tng proti trong khu phn n m bo cm v vitamin. - Ch n cng tc iu dng ngay t u chng lot, chng bi nhim do nm lu - Tip tc iu tr nguyn nhn nu c: nguyn nhn tc nghn, bnh l ton th. 6. PHNG BNH - Theo di nh k hng thng i vi cc bnh l c th tr thnh mn tnh nh bnh cu thn, bnh l k thn do thuc hay do nhim trng, cn khm nh k cho bnh nhn lu di. - iu tr nguyn nhn (nu c) - Gio dc tuyn truyn trong cng ng, phng mt s nguyn nhn hay gy suy thn cp thng gp: mt nc, mt mui, ng c mt c trm, mt cc... Kt lun: suy thn cp l mt hi chng nng nhng c th hi phc chn on ch yu da vo triu chng: i t, v niu, m mu tng, kim mu tng cao dn. Theo di phi o lng nc tiu 24h. Phi tnh m niu o thi 24h, ur mu phi xt nghim hng ngy. X tr phi theo tng giai on, phi kin tr tp trung sc lc v phng tin v bnh nhn c th c cu sng hon ton. Nhng trng hp m, kim mu khng tng nhanh iu tr ni khoa bo tn cng . Nu ur, kali mu tng qu nhanh th phi lc mu ngoi thn.

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VIM CU THN MN
1. I CNG Vim cu thn mn l mt bnh c tn thng tiu cu thn tin trin dn n suy thn mn, c nhiu nguyn nhn dn n v c kh nng xy ra nhiu bin chng nguy him. Nu c pht hin sm v iu t ng th c th hn ch c qu trnh tin trin ca bnh v hn ch c nhng bin chng c th xy ra. 1.1. nh ngha Vim cu thn mn l mt bnh c tn thng tiu cu thn tin trin t t ko di nhiu nm c biu hin lm sng c th c tin s ph, protein niu, hng cu niu, cao huyt p nhng cng c th ch c hng cu niu, Protein niu n c. Cui cng dn n suy thn mn vi cc triu chng: - C s bt thng trong nc tiu ko di (hng cu niu v tr niu) - Suy gim chc nng thn t t 1.2. c im dch t - Vim cu thn mn l mt bnh gp tng i ph bin cng ng. Theo thng k ca PGS Trn Vn Cht v BS. Trn Th Thnh (1991 - 1995) ti khoa Tit niu Bnh vin Bch Mai th bnh vim cu thn mn chim 31,5% trong la tui hay gp l 16-44 tui chim 88,32%. Nh vy bnh gp nhiu la tui lao ng nn nh hng sc lao ng cng ng. Cng theo 2 tc gi trn th bnh khng c s lin quan n gii v vng a d. iu tr ch yu l bo tn, cn c k hoch pht hin sm cc trng hp vim cu thn mn trong cng ng, c gng trnh cc yu t gy giai on cp c bit l nhim trng ko di tui th cho bnh nhn. 2. NGUYN NHN GY BNH - Do vim cu thn cp (10- 20%) - Do vim cu thn c hi chng thn h - Do cc bnh ton th nh Lupus, bnh h thng nh ban dng thp... Bnh chuyn ha: i tho ng... - Bnh cu thn di truyn. - Khng r nguyn nhn. Ngoi tr bnh cu thn nguyn pht vi tn thng ti thiu hu ht cc bnh cu thn u dn n vim cu thn mn. Do vic pht hin sm v phng nga cc nguyn nhn gy vim cu thn cp, ci thin mi trng v sc khe cng ng v gii quyt tt cc bnh nhim trng c ngha rt quan trng trong vic phng bnh v lm chm s tin trin ca vim cu thn mn, ko di tui th cho bnh nhn.
43

3. TRIU CHNG LM SNG V CN LM SNG 3.1. Protein niu T 2 - 3g/24h trong giai on vim cu thn mn tim tng th c th t hn. Nu tng trn 3,5g/24h l biu hin c hi chng thn h. 3.2. Ph Ph trng, mm, n lm, c khi ch nng m mt, giai on tim tng ph khng r rt. Nu c hi chng thn h th ph to ton thn c th trn dch cc mng. i t lng nc tiu thay i tu tng bnh nhn v tng giai on ca bnh. 3.3. Cao huyt p giai on cha c suy thn hoc suy thn nh t l bnh nhn cao huyt p thp. Khi suy thn giai on III, IV th t l trn 80% c cao huyt p 3.4. Hng cu niu Thng c, t khi c i mu i th 3.5. Tr niu, tr hng cu, tr trong, tr ht, khi c suy thn thng c tr to 3.6. Thiu mu Thng gp khi c suy thn cng nng th thiu mu cng nng. Hng cu, huyt sc t gim khi c suy thn, thiu mu ng sc hoc nhc sc rt kh hi phc. 3.7. Cc triu chng biu hin hi chng m mu cao: (Khi c suy thn r) Nn, ri lon tiu ha, xut huyt, c biu hin tim mch, thn kinh cc biu hin ca lm sng toan mu: (Th su, ri lon kiu th) v nng nht l hn m do m mu tng cao. 3.8. X quang Bng thn teo nh u hai bn giai on c suy thn. Khi cha c suy thn nu chp UIV th thy hnh nh i b thn bnh thng. 3.9. Siu m thn Kch thc thn bnh thng khi cha c suy thn. Thn teo nh u hai bn khi c suy thn. Mc teo nh tu thuc vo giai on tin trin ca suy thn v tu vo nguyn nhn khi u. 3.10. Sinh thit thn Trong giai on cha c suy thn hoc suy thn nh 1,2 c th tin hnh sinh thit thn. Qua sinh thit thn s cho bit loi tn thng m bnh hc. 4. CHN ON 4.1. Chn on xc nh Da vo: - Ph.
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- Protein niu. - Hng cu niu. - Tr niu. - Cao huyt p. - Ur mu. - Creatinin mu tng. - Hnh nh X quang chp thn. - Tuy nhin trong giai on tim tng chn on xc nh phi sinh thit thn 4.2. Chn on phn bit - Vim thn b thn mn tnh. Trong vim thn b thn mn bnh nhn thng c tin s vim nhim tit niu, si thn - tit niu nhng khng c ph, Protein niu thp, t khi qu lg/24h, bch cu niu nhiu, c vi khun niu. Nu c tr th l tr bch cu. Hai thn to nh khng u, b thn thng g gh, i thn b thn c th gin rng (chp UIV). - X mch thn lnh tnh (tc l bnh cao huyt p) trong vim cu thn mn, Protein niu thng xut hin trc khi c cao huyt p hoc cng mt lc. Trong bnh cao huyt p protein niu nu c th xut hin mun v s lng t. - X mch thn c tnh (cao huyt p c tnh) trong vim cu thn mn ko di, hai thn thng teo nh v c thiu mu, trong cao huyt p c tnh hai thn khng teo nh, bnh thng tin trin nhanh, suy thn nng nhng khng c thiu mu nng. - Protein niu lnh tnh trng hp ny protein niu thng ch c tng lc, khng thng xuyn, khng bao gi dn n suy thn nh vim cu thn mn. - Vim cu thn cp: bnh nhn c tin s nhim khun hng v da, sau xut hin ph, i t, i mu, cao huyt p. Chn on xc nh bng siu m hoc chp thn nu hai thn nh hn bnh thng l vim cu thn mn. - Vim cu thn cp tin trin nhanh: bnh nhn c tin s nhim khun hng v da, sau xut hin ph, i t, i mu, cao huyt p, ur mu v creatnin mu tng. Chn on xc nh bng chp thn hoc siu m thn, thy thn nh hn bnh thng l vim cu thn mn. 4.3. Chn on th - Th tim tng: Da vo bnh nhn c tin s bnh cu thn, xt nghim c hng cu niu, tr niu ko di. Chn on chc chn da vo sinh thit thn. - t cp ca vim cu thn mn: Bnh nhn c tin s vim cu thn mn v c cc yu t thun li nh: + Cao huyt p c tnh
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+ C cc t nhim khun + C thai... Vim cu thn mn l mt bnh mn tnh do cc bnh ti cu thn tin trin, ko di hng thng, n hng nm. Vic pht hin ra sm da vo bnh nhn b bnh cu thn nhng c hng cu niu v protein niu ko di v xut hin thm cc triu chng: ph, cao huyt p, thiu mu nn rt d pht hin sm cng ng. 5. IU TR 5.1. iu tr triu chng v bin chng - Ngh ngi, n nht v dng li tiu khi c ph v cao huyt p. - Khi huyt p cao th: + n nht, hn ch nc a vo. Khi c suy thn cn hn ch protid trong khu phn thc n. + Li tiu: Lasix 40mg x 1 vin/24h. C th cho liu cao hn nu vn cn ph. + Thuc h p cc nhm thuc u dng c. Khi c suy tim th khng dng thuc chn giao cm. Niphedipin 20mg x l - 2 vin/24h Coversyl 40mg x 1-2 vin/24.... Nu bnh nhn p ng tt vi nhm c ch men chuyn c th gip bo v nhu m thn lu di - Cho khng sinh khi c t vim nhim: Cn cho dng cc khng sinh thch hp, trnh cc khng sinh c cho thn, dng ko di t 7 - 14 ngy. i vi vim hng th tt nht l Penicilhn hoc Ampicihn 5.2. iu tr bnh chnh nh Bnh ton th, h thng, chuyn ha: Lupus ban h thng hoc i tho ng... 5.3. iu tr bnh phi hp nh Hi chng thn h (nu c). 6. PHNG BNH 6.1. Phng bnh vim cu thn cp Phng vim hng v chng cc nhim trng da. 6.2. Pht hin sm bnh bng cch xt nghim nh k nc tiu nhng bnh nhn b vim cu thn 6.3. Phng v iu tr cc yu t gy vim cu thn mn nng thm - iu tr cao huyt p nu c - iu tr cc nhim khun nu c
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- Hn ch khng nn c thai nhng bnh nhn vim cu thn mn - Hn ch m khi bnh nhn c biu hin suy thn - Khng dng thuc c vi thn Vim cu thn mn l bnh hay gp, vic iu tr vim cu thn mn mc ch chnh l iu tr bo tn, phng cc yu t nguy c dn n s tin trin nhanh ca bnh l vn ht sc quan trng trong qu trnh ko di cuc sng ca ngi bnh.

SUY THN MN
1. I CNG 1.1. nh ngha Suy thn mn l hu qu cc bnh mn tnh ca thn gy gim st t t s lng Nephron chc nng lm gim dn mc lc cu thn. Khi mc lc cu thn gim xung di 50% (60ml/pht) th c gi l suy thn mn. Suy thn mn l mt hi chng lm sng v sinh ha tin trin mn tnh qua nhiu thng, nm, hu qu ca s x ha cc Nephron chc nng gy gim st t t mc lc cu thn dn n tnh trng tng nitphiprotein mu. c trng ca suy thn mn l: - C tin s bnh thn tit niu ko di. - Mc lc cu thn gim - Nitphiprotein mu tng cao dn. - Kt thc trong hi chng m mu cao. 1.2. c im dch t Suy thn mn l mt bnh tng i ph bin v hay gp trong cc bnh thn tit niu. Theo thng k ca PGS Trn Vn Cht v Trn Th Thnh (1991 - 1995) ti Khoa Tit niu Bnh vin Bch Mai th suy thn mn chim 40,4% v khng thy c s khc bit gia nam v n. Ring tui 16 - 24 th thy nam nhiu hn n. Khng thy c s khc bit gia cc vng, a d, la tui hay gp l la tui lao ng t 16 54 tui nn nh hng rt nhiu ti sc khe ca cng ng. 1.3. Nhng yu t lm bnh nng thm Suy thn mn l mt bnh ko di hng thng, hng nm c nhng yu t lm thc y qu trnh suy thn: - Cao huyt p - Nhim khun, xut huyt tiu ha, mt nc - Tc ng dn niu - n qu nhiu protid - Dng thuc c vi thn - Ri lon nc in gii: a chy mt nc, dng Lasix qu nhiu...
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Nn vic lm gim cc yu t nguy c trn s c ngha ko di qu trnh suy thn lm ko di tui th cho bnh nhn. 2. NGUYN NHN GY BNH Hu ht cc bnh mn tnh khi pht l bnh cu thn, bnh ng k thn hay bnh mch thn u c th dn n suy thn mn. 2.1. Bnh vim cu thn mn: thng hay gp nht chim t l 40% - Do vim cu thn cp dn n - Do vim cu thn nhng bnh nhn c bnh chuyn ha, h thng - Do bnh cu thn c hi chng thn h 2.2. Bnh vim thn, b thn mn Chim t l khong 30% 2.3. Bnh vim thn k Thng do dng thuc gim au lu di, hoc do tng acid uric, tng calci mu 2.4. Bnh mch thn - X mch thn lnh tnh hoc c tnh - Huyt khi vi mch thn - Vim nt quanh ng mch - Tc tnh mch thn 2.5. Bnh thn bm sinh (di truyn hoc khng di truyn) - Thn a nang - Lon sn thn - Hi chng Alport - Bnh thn chuyn ha Qua trn thy nguyn nhn hay gp l bnh vim cu thn mn v vim thn, b thn mnh do vic khai thc tin s ca bnh nhn v pht hin hai nguyn nhn ni trn iu tr sm c ngha rt quan trng trong vic gim t l ca bnh suy thn mn. 3. TRIU CHNG LM SNG V CN LM SNG CA SUY THN MN Mc du tn thng khi pht cu thn, h mch thn hay t chc k thn th cc Nephron b thng tn nng cng s b loi khi vai tr chc nng sinh l. Chc nng ca thn ch c m bo nguyn vn bi cc Nephron nguyn vn cn li. Khi khi lng Nephron chc nng b tn thng qu nhiu, s cn li khng cn duy tr s hng nh ca ni mi th bt u xut hin cc bin lon v nc in gii, v tun hon, v h hp, v tiu ha, v thn kinh to nn hi chng suy thn mn. 3.1. Triu chng lm sng 3.1.1. Ph
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- Suy thn mn do vim thn, b thn thng khng c ph. Bnh nhn thng i nhiu do tn thng nng k thn, giai on cui c th c ph do c km cao huyt p v suy dinh dng, suy tim. - bnh nhn suy thn mn do vim cu thn mn thng l c ph (tr giai on i nhiu). Ph y c th do hu qu ca hi chng thn h, do suy tim kt hp v do cc yu t ni tit khc gy gi mui v gi nc. 3.1.2. Thiu mu - Thng gp, nng nh tuy theo giai on, suy thn cng nng th thiu mu cng tng. y l mt du hiu qu trn lm sng chn on phn bit vi nhng trng hp m mu cao do cc nguyn nhn cp tnh. - Thiu mu a s l bnh sc hnh th kch thc bnh thng c khi c hng cu to nh khng u. Nhiu bnh nhn c chn on khi n khm v thiu mu. - Thiu mu rt kh hi phc do thn khng sn xut Erythropoietin l yu t cn thit c ha tin hng cu. 3.1.3. Tng huyt p - Tng huyt p thng gp chim khong 80% bnh nhn c tng huyt p C bit c bnh nhn c t tng huyt p c tnh lm chc nng thn suy sp nhanh chng dn n t vong. 3.1.4. Suy tim - Khi xut hin thng mun v thng do gi mui, nc v tng huyt p lu ngy ca qu trnh suy thn mn. 3.1.5. Vim ngoi tm mc - Ting c mng tim l mt biu hin giai on cui cng ca suy thn mn v l du hiu bo hiu t vong t 1 - 4 ngy nu khng c lc mu hoc iu tr tch cc. 3.1.6. Nn, a chy - Triu chng tiu ha ca suy thn mn giai on u thng l chn n, giai on III tr i th c bun nn, a chy. C khi c xut huyt tiu ha, c lot hoc khng lot. 3.1.7. Xut huyt - Chy mu mi, chy mu chn rng, chy mu di da l thng gp. C trng hp tiu cu gim rt kh cm mu. Xut huyt tiu ha nu c th me mu s tng ln rt nhanh. 3.1.8. Nga L mt biu hin ngoi da thng gp do lng ng calci trong da. y l triu chng gi ca cng cn gip trng th pht.
49

3.1.9. Chut rt - Thng xut hin ban m c th l do gim nghi v calci mu. 3.1.10. Vim thn kinh ngoi vi - Tc dn truyn thn kinh gim. Bnh nhn c cm gic rt bng chn, kin b. Cc triu chng ny rt kh iu tr k c lc mu ngoi thn. 3.1. 11. Hn m - Hn m do m mu tng cao l biu hin lm sng cui cng ca suy thn mn. giai on tin hn m bnh nhn c th c co git, c ri lon tm thn. Nhng triu chng lm sng rt hay gp l: ph, thiu mu, tng huyt p, do da vo cc triu chng chnh ny ti tuyn c s c th chn on c bnh suy thn mn. 3.2. Biu hin cn lm sng 3.2.1. Mc lc cu thn gim - Cng gim nhiu suy thn cng nng 3.2.2. Nitphiprotein tng cao - Ur mu trn 50mg% l bt u tng - Creatinin mu l, 5mg% l tng r - Acid c cng tng - Ur mu ph thuc vo ch n v qu trnh ging ha ca c th (nhim khun, xut huyt, mt mu thng tng nhanh). - U r mu v creatinin mu tng song song l biu hin ca suy thn n thun. - U r mu tng nhiu v creatinin mu tng t l biu hin tng m ngoi thn 3.2.3. Natri mu thng gim Kali mu bnh thng hoc gim. Khi kali mu cao c biu hin t cp c km theo thiu niu hoc v niu. 3.2.4. pH mu gim Suy thn giai on III - IV, pH mu s gim, d tr kim gim. 3.2.5. Calci mu gim Phospho mu tng C kh nng cng cn gip trng th pht. 3.2.6. Protein niu suy thn mn giai on III-IV bao gi cng c nhng khng cao. Nu l vim thn b thn th ch di lg/24h, nu l vim cu thn mn th khong 2 n 3g/24h. 3.2.7. Hng cu niu Nu c i mu th phi ngh n si tit niu trong vim cu thn mn cng c hng cu trong nc tiu.
50

3.2.8. Bch cu niu v vi khun niu Trng hp suy thn do vim thn b thn mn c khi c i m. 3.2.9. Tr niu C tr ht hoc tr trong l du hiu ca suy thn mn. 3.2.10. Ur niu Suy thn cng nng m niu cng thp, giai on cui ch o thi c 64g/24h. 3.2. 11. Th tch nc tiu Giai on u nc tiu nhiu 2-3 lt/24h, i nhiu v m l du hiu ca suy thn mn, suy thn mn nng nc tiu vn c 500-800ml/24h. C i t, v niu l c t cp, hoc l suy thn mn giai on cui. 4. CHN ON 4.1. Chn on xc nh Suy thn mn do bnh cu thn: + C tin s ph + Ph - cao huyt p - thiu mu + U r mu, creatinin mu cao, mc lc cu thn gim. + Protein niu 2 - 3g/24h. - Suy thn mn do bnh vim thn b thn mn: + C tin s nhim khun tit niu + Cao huyt p - thiu mu. + U r mu, creatinin mu cao, mc lc cu thn gim. + Protein niu c nhng t khng qu lg/24h. + Bch cu niu bao gi cng c, vi khun niu c th c hoc khng. tuyn c s c th da vo cc triu chng trn ngh n bnh nhn b suy thn mn v nu c iu kin th lm cc xt nghim m mu, creatinin mu chn on xc nh. 4.2. Chn on phn bit - t cp ca suy thn mn da vo: + Tin s + T l ur mu / creatinin mu >40 + Mc thiu mu tng xng mc suy thn 4.3 Chn on giai on
Giai on Suy thn mn Mc lc cu thn (ml/pht) Creatinin mu mol/1 mg/dl 51 Lm sng

Bnh thng I II IIIa IIIb IV

120 60-41 40-21 20-11 10-05 <5

70-106 < 130

0,8-1,2 < 1,5

Bnh thng Gn bnh thng Gn bnh thng thiu mu nh Chn n - thiu mu va Chn n - thiu mu nng, bt u ch nh lc mu Hi chng ur mu cao, lc mu l bt buc

130-299 1,5-3,4 300-499 3, -5,9 500-900 6,0-10 > 900 > 10

Da vo triu chng lm sng: thiu mu v cm gic n tuyn c s c th chn on sm c giai on ca suy thn mn ra quyt nh iu tr sm. 5. IU TR 5.1. iu tr bo tn 5.1.1. Chng cc yu t gy nng bnh - Cao huyt p - Nhim khun (khng dng cc thuc khng sinh c vi thn) - iu chnh nc v in gii - Khng dng thuc c cho thn 5.1.2. Trnh cc sai st thng mc phi - Dng li tiu khng ng: Dng Lasix gy mt nc, Hypothiazid gy gim mc lc cu thn.
- n nht qu mc ko di khng cn thit gy gim natri mu

- Dng thuc c cho thn gy gim mc lc cu thn: Gentamycin, Kanamycin... - Dng thuc qu liu so vi chc nng thn: V d: Digitoxin d gy lon nhp tim nhng bnh nhn suy thn, mc d liu khng cao so vi ngi bnh thng. 5.1.3. iu tr theo giai on - Suy thn giai on 1 v 2 +n t m hn bnh thng. + iu chnh huyt p: Aldomet 250mg x 2-4vin/24h, c th dng Propranolol, Nifedipin... + n nht nu c ph v cao huyt p + Li tiu nu c ph v tng huyt p - Suy thn giai on III: + Ch n l bin php ch o hn ch m mu tng, protid = 0, 5kg/24h, m bo vitamin, tng cm bng bt t m. m bo cc acid quan
52

bng trng, sa trong thc n. cui giai on 3 ch nn cho vi mt ngi sng: 20g protid m bo 1800 - 2000 calo/24h. + Mui: n nht khi c ph, cao huyt p. + Nc: ch ung bng lng nc tiu 24h + Kali: giai on u thng khng tng kim mu, cui giai on 3 c th tng kim mu nn hn ch cc rau qu v thc n c nhiu khu. + Calci: cho vitamin D v calci khi c calci mu gim + Kim: cho khi c toan mu + Tr tim: khng dng ko di, gim liu lng khi c suy thn nng + Chng thiu mu: c th truyn mu, khi hng cu cho vin st, Erythropoietin - Suy thn giai on IV + Lc mu ngoi c th l ch nh bt buc, c iu kin th ghp thn 5.2. Lc mu ngoi thn - Ch nh bt buc: giai on IV - Ch nh sm: giai on IIIb - Suy thn mn l mt hi chng din bin qua nhiu giai on v ko di nhiu nm. iu tr rt phc tp v t kt qu, c nhiu bin chng nng n nn cn phi sm pht hin v iu tr sm cc bnh tit niu phng dn n suy thn mn

VIM I B THN CP, MN

1. I CNG 1.1. nh ngha Vim i b thn l nhim khun t chc k ca thn nguyn nhn do vi khun. giai on cp ca bnh c th cha khi hon ton nu c loi b nguy c v nguyn nhn gy bnh. Nu b ti pht nhiu ln s chuyn thnh mn, v hu qu cui cng s dn n suy thn mn. Bnh nhn c th t vong do bin chng suy thn mn, do nu c pht hin sm, iu tr ng v trit bnh nhn phc hi hon ton. 1.2. c im dch t Vim i b thn cp v mn l mt bnh gp nhiu n, gp mi la tui nht l la tui lao ng v hot ng sinh dc nhiu. N gii c s lin quan vi tnh trng c thai. Theo J.Conte khi nghin cu cng ng bnh chim t l 10% dn s. Ti khoa Thn Bnh vin Bch Mai (1997- 2000) c 17% bnh nhn b suy thn l nguyn nhn do vim i b thn mn (PGS. Trn Vn Cht). Trong nhm nguyn nhn do si chim 27% v nhiu thng k cho thy vim i b thn mn l nguyn nhn ng
53

hng th hai dn n suy thn. Qua trn ta thy vim i b thn mn l bnh hay gp c nguy c dn n suy thn do vic tuyn truyn gio dc cho cng ng nhng nguy c gy bnh s gim bt t l mc bnh. 2. NGUYN NHN GY BNH V C CH BNH SINH 2.1. Nguyn nhn 2.1.1. Nguyn nhn do vi khun - Vi khun Gram (-) chim khong 90% cc trng hp: + E. Coli: 60-70% + Klebsiella: 20% (15-20%) + Proteus mirabilis: 15% (l0-15%) + Enterobacter: 5- 10% + V mt s vi khun Gram (-) khc. - Vi khun Gram (+) chim < 10% + Enterocoque: 2% + Staphylocoque: 1% + Cc vi khun khc: 3-4%. 2.1.2. Nguyn nhn thun li L nguyn nhn gy tc nghn ng bi xut nc tiu, gy tr dng nc tiu, to iu kin cho nhim trng v khi c nhim trng th duy tr nhim trng. V vy vim i b thn xy ra trn mt bnh nhn c tc nghn dng nc tiu thng rt dai dng v nng. - Cc nguyn nhn thng gp l: + Si thn tit niu + U thn tit niu + U bn ngoi p vo niu qun + U tuyn tin ht + D dng thn, niu qun - Cc nguyn nhn khc: + Thn a nang + Thai nghn + i tho ng Cn khm ton din, chp thn khng chun b, UIV, siu m thn, UPR pht hin cc nguyn nhn thun li iu tr trit trnh tin trin bnh nng thm. 2.2. C ch bnh sinh Ch yu l ng ngc dng c th l nhim khun ngu nhin. n t l
54

thng cao hn, nam t l thng t gp hn do ng niu o di, hp hn, xa l hu mn hn. Cht tit ca tuyn tin lit cng c kh nng st khun. - Vi khun c th n gy vim i b thn qua ng mu v ng bch tuyt nhng him gp hn. 3. TRIU CHNG LM. SNG V CN LM SNG CA VIM I B THN CP V MN 3.1. Vim i b thn cp - Hi chng bng quang: i trut, i dt, i mu, i m cui bi. Tuy nhin hi chng bng quang c th xut hin trc khi c vim i b thn cp. Khi c triu chng vim i b thn cp th triu chng vim bng quang nn d b qua chn on. - au vng tht lng + Thng au mt bn, nhng cng c khi au c hai bn + au m thnh thong tri thnh tng cn. + V hng lng (+) l triu chng rt c gi tr, nht l trong trng hp ch c au mt bn - Khm c th thy thn to v au. - Triu chng ton thn - Bnh nhn c hi chng nhim trng: st cao, rt run, mi kh, lu. bn, c th thy du hiu mt nc do st. -Nc tiu c c th c i m i th, bch cu niu dng tnh, vi khun niu dng tnh, Protein niu c nhng <lg/24h. -Xt nghim mu: + Bch cu a nhn trung tnh tng + i khi c suy thn cp: m mu, creatimin mu tng. + Cy mu khi c st > 38,50C c th dng tnh. - Siu m thn: + Thn hi to hn bnh thng + i b thn gin + C th thy nguyn nhn thun li nh si, thn a nang... - X quang: + Chp bng khng chun b nu nghi ng c si. + C th thy nguyn nhn thun li gy tc nghn ng bi niu. 3.2. Vim i b thn mn 3.2.1. Vim i b thn mn giai on sm - Tin s nhim khun tit niu, vim i b thn cp nhiu ln hoc c tin s
55

c bnh gy tc nghn ng bi tit nc tiu. - au vng tht lng - Tiu tin v m tng t nht mt hoc nhiu ln trong mt m gi chc nng c c ca thn gim. - C th c cao huyt p. - Thiu mu nh hoc khng. - Protein niu thng xuyn nhng thng < lg/24h - Bch cu niu nhiu, bch cu a nhn thoi ha dng tnh s bch cu a nhn tng khi c t cp. - Vi khun niu dng tnh khi c t cp. - Kh nng c c nc tiu gim: + Lm nghim php c c, t trng ti a khng vt qu 1,025. + Lc ny mc lc cu thn cn bnh thng gi l c s phn ly chc nng cu thn, ng thn. y l mt xt nghim c gi tr trong chn on vim thn mn trong giai on sm. - Siu m thn c th thy b thn g gh, thn teo nh t, i b thn gin t. - Chp thn (UIV) thy tn thng i b thn mc khc nhau. 3.2.2. Vim i b thn mn giai on mun Ngoi nhng triu chng trn xut hin thm: - Suy thn (Suy chc nng lc): + Mc suy thn t nh n nng, khi suy thn mc nng c th c cc triu chng ca hi chng m mu cao trn lm sng v c th c ph. + Ur mu tng creatinin mu tng: bnh nhn y triu chng ca hi chng tng nh mu biu hin cc c quan: tiu ha, thn kinh, tun hon, h hp, c th c xut huyt... + Mc lc cu thn gim. - Thiu mu r: mc nng nh ca thiu mu i i vi giai on ca suy thn mn. - Da xanh, nim mc nht, s lng hng cu hemoglchin v hematocrit mu gim - Tng huyt p: (>80%) c th tng va hoc tng rt cao. - Siu m v X quang thn: hai thn teo nh nhng khng u, x ha c th thy nguyn nhn thun li: si, d dng ng niu... 4. CHN ON 4.1. Chn on xc nh - Vim i b thn cp:
56

Da vo tam chng c in: + Bnh nhn c hi chng nhim trng: st cao, rt run. + au mi vng tht lng + i but, i dt, i mu, i m, nc tiu c bch cu, t bo m v vi khun. - Vim i b thn mn: Da vo cc triu chng sau: + C tin s vim i b thn cp ti pht nhiu ln + Suy thn: hi chng tng m mu, tng huyt p, ph, thiu mu. + Siu m thn hoc chp X quang thn thy thn teo nh khng u. 4.2. Chn on phn bit 4.2.1. Vim i b thn cp phn bit vi t cp ca vim i b thn mn Vim i b thn mn t cp c cc triu chng ca vim i b thn cp ngoi ra c thm triu chng suy thn, siu m thn v X quang thn thy thn teo nh khng u. 4.1.2. Vim i b thn mn - Giai on tim tng phn bit vi cc bnh gy i nhiu nh: i tho ng, i nht... Ch yu phn bit da vo triu chng ca cc bnh trn - Vim thn k do ung qu nhiu thuc gim au, chng vim: da vo tin s - Vim thn b thn k do tng acid c mu, tng calci mu: da vo in gii v khng c triu chng nhim khun. - Thn teo mt bn bm sinh: thn teo nh mt bn nhng khng c triu chng nhim khun, da vo X quang v siu m thn chn on xc nh. Nh vy tuyn c s c th da vo bnh nhn c hi chng nhim trng, hi chng bng quang v au mi vng tht lng ngh ti vim i b thn cp. Nu bnh nhn c tin s nhim trng ng tit niu ti pht nhiu ln, c hi chng bng quang v i tiu nhiu v m l c th ngh n vim i b thn mn. 5. IU TR 5.1. iu tr vim i b thn cp Dng khng sinh chng nhim khun: - Tt nht l cy nc tiu tm vi khun gy bnh v lm khng sinh , da vo kt qu khng sinh dng khng sinh cho thch hp. Trong khi ch kt qu cy vi khun v khng sinh cn cho khng sinh ngay. Nu vi ba ngy iu tr, triu chng lm sng khng bt s iu chnh khng sinh theo kt qu khng sinh . - Cc khng sinh thng dng hin nay cho vim i b thn cp l:
57

+ Nhm Quinolon: Peflacin, Nonoxacine... + Cephalosporin: Zinnat, Fortum... + Nhm Aminosid: Amikacin, Gentamycin... + Nhm lactamin: Ampicillin, Unasyn... - Dng liu cao v phi hp khng sinh, thi gian dng khng sinh t nht l 2 tun l. Trong trng hp c bit nh trc khun m xanh hoc t cu vng hoc khi vim t tuyn tin lit, khng sinh c th dng ko di 1 thng. - Khi ngng khng sinh 5 ngy cy li nc tiu tm vi khun niu (m tnh), UIV khng c tn thng coi nh khi hn. 5.2. iu tr vim i b thn mn - Khng sinh chng nhim khun dng khng sinh khi c t cp ca vim i b thn mn. Cn lu la chn khng sinh khng c vi thn, khng lm gim mc lc ca cu thn v lu chnh liu khng sinh theo mc suy thn - iu tr triu chng: + iu tr tng huyt p + iu tr thiu mu + iu tr suy thn bng iu tr bo tn ni khoa hoc iu tr thay th thn suy tu tng giai on ca suy thn. 5.3. iu tr chung cho vim i b thn cp v mn - Ung nhiu nc m bo nc tiu >l,5l/24h. - Loi b c cc nguyn nhn thun li: m ly si, iu tr u tuyn tin lit... 6. PHNG BNH - m bo v sinh trnh vim thn ngc dng - Trnh cc th thut khng cn thit: thng i... - Loi b cc yu t nguy c. - Khi c suy thn: + m bo ch n + Dng khng sinh khng c vi thn + iu tr tng huyt p, ph, thiu mu (nu c)

VIM BNG QUANG, NIU O

1. I CNG 1.1. nh ngha L tnh trng nhim trng cp tnh hay mn tnh bng quang, niu o.
58

1.2. c im dch t Vim bng quang, niu o l mt bnh l rt thng gp vi cc triu chng i dt, kh i v i m, bnh khng dn n t vong nhng gy kh chu nh hng n sc khe ca ngi bnh, nu bnh khng c chn on v iu tr sm th s dn n vim thn ngc dng v hu qu cui cng dn n suy thn mn. Nu c chn on v iu tr sm th trnh c nguy c suy thn ng tic xy ra... Theo J. Con te nghin cu cng ng thy vim bng quang, nim o chim 10% dn s, bnh gp nhiu n gii, t l n/nam - 9/1. tui gi th 2 gii bng nhau. Bnh khng lin quan n ni sng, gp rt nhiu la tui lao ng v hot ng sinh dc nhiu. 2. NGUYN NHN GY BNH 2.1. Nguyn nhn vi khun - E.coli: 60 - 70% - Lin cu - T cu - Trc khun m xanh - Lao - Cc vi khun khc 2.2. Yu t thun li - L nguyn nhn tc nghn bi sut nc tiu gy tr dng nc tiu to iu kin cho nhim trng v khi c nhim trng th duy tr nhim trng v vy vim bng quang, niu o xy ra trn bnh nhn c tc nghn ng tit niu thng rt dai dng v nng - Cc nguyn nhn thng gp l: + Si bng quang, niu o. + U tuyn tin lit + Ung th b phn sinh dc ngoi + Ung th c bng quang + B i ko di - Cc nguyn nhn khc: + Hp niu o bm sinh + L thng bng quang trc trng + Thng i 3. TRIU CHNG LM SNG V CN LM SNG 3.1. Triu chng lm sng Ba triu chng quan trng l:
59

- i dt (hay i tiu) - Kh i (au trc, trong v sau i tiu) Cm gic but mt lc cui, nhiu khi au d di, chut rt lan ti quy u n hai bn v hu mn - i m: nc tiu c ton b nhng ch yu l u bi v cui bi cn vn c kh c c khi ln i mu nu c vim bng quang xut huyt. - Triu chng ton thn: bnh nhn c th c hi chng nhim trng cp tnh. 3.2. Triu chng cn lm sng - Xt nghim nc tiu thy t bo biu m, t bo m. - Cy nc tiu c th tm thy vi khun gy bnh. - Soi bng quang thy nim mc xung huyt c nhng gi mc v c nhiu vt lot. 4. CHN ON 4.1. Chn on xc nh - Da vo i m phi hp vi i kh v i dt - Cy nc tiu tm vi khun gy bnh v lm khng sinh 4.2. Chn on phn bit Vi cc bnh ly qua ng tnh dc: - Bnh nhn c tin s tip xc vi ngun ly - Xt nghim m chn on xc nh 5. IU TR - Loi tr nguyn nhn gy cn tr ng bi niu (nu c th) - Dng khng sinh theo khng sinh - Gim au, an thn, chng co tht - Ngm mng vo nc m Giai on mn tnh cc th thuc khng sinh thng khng c hiu qu thng i tho sch nc tiu cn li trong bng quang ri bm cc thuc st trng (Nitrat bc 0,05% hoc 0,l%). 6. PHNG BNH - iu tr trit t cp. - iu tr cc nguyn nhn gy cn tr ng bi niu - V sinh c nhn.

SC
60

M U Danh t sc c dng trong lm sng ch cc trng hp tt huyt p, tru tim mch hoc suy tun hon cp. Thc ra trong sc ngoi vn tru tim mch cn c cc biu hin khc ca mt tnh trng ti mu cc t chc b suy sp. y chnh l cn nguyn ca cc biu hin trong sc. Nh vy sc ch l mt biu hin nng do nhiu nguyn nhn gy nn. Vic x tr sc i hi phi khn trng, chnh xc v cn tm nguyn nhn iu tr tn gc. 1. NH NGHA Sc l tnh trng thiu oxy t chc do nguyn nhn tun hon, thc cht l thiu ti mu t chc, biu hin trn lm sng bng cc du hiu: - Mt ti, tm cc u chi, mng tm trn da, khi n vo cc chi th nht i v chm tr li - Da lnh, mi, cc u chi lnh, tot m hi - Mch nhanh, huyt p h, HA dao ng v kt - Nhp th nhanh - V niu (Di 50ml trong gi u - ng thng) - in tm c ri lon ti cc 2. CC BIU HIN LM SNG, CN LM SNG 2.1. Lm sng - H huyt p: khng c con s cng nhc cho huyt p. Nu bit c s huyt p lc bnh thng th rt tt. Trong tru mch HA tt nhanh t ngt m khng dao ng, cn trong sc HA thng dao ng trc khi try mch. Trong sc HA thng kt - khong cch HA ti a v ti thiu nh do c tr tun hon. Thng o p lc tnh mch trung tm trong sc nhm gip chn on v theo di sc. Thng t 0-5cm nc. Nu p lc gim thng sc do gim th tch, nu tng thng do suy tim hoc p tim cp - Nhp tim thng nhanh hoc rt nhanh, nhng trong ng c gacdenal hoc meprobamat thng chm hoc sc nhi mu c tim mch li bnh thng... - thc: bnh nhn thng tnh hoc c lo s ht hong, cng c khi l kh tip xc c khi hn m, nu hn m phi ngh n nguyn nhn ng c, chn thng s no - Da: da thng lnh, tot m hi, c mng tm. i khi da li nng do gin mch, l trng hp sc nng him gp hn (sc nhim khun) - Nc tiu: nn theo di bng ng thng. Thng trong sc lng nc tiu gim hoc v niu, khi nc tiu tng chng t tin trin tt. - Thn nhit: thng tng trong sc nhim khun, lc u rt run sau nhit
61

c th v bnh thng. Ch cy mu cho bnh nhn khi st - Nhp th: khi c sc nng nhp th nhanh v su do tng thng kh tin pht. Ch tm cc tn thng ng h hp - Cc biu hin khc: khm ton thn tm nhng tn thng, tm nguyn nhn: thm m o, trc trng cn thn. Ch tm du hiu xut huyt ni, du hiu thng tng rng, du hiu vim tu.... 2.2. Cn lm sng - in tm : thng c ri lon ti cc T (-) v ST (-). Nu sc do nhi mu c tim s c Q v QS l c hiu. Cng c th thy cn nhp nhanh hoc tc nh tht hoc blc nh tht - Natri mu thay i, c th thy nam niu gim, kim mu tng - Ur huyt tng, m niu tng hoc gim. Ur niu cao chng t c suy thn chc nng nhng nu gim c th do tn thng thn khi truyn dch nht l dch c nghi phi cn nhc k. - ng huyt thng tng lc u - Thng bng kim toan: thng khng c ri lon ng k v thng bng kim toan trong sc nu sc nng c th thy tng lactat mu. - Men: CK, AST, ALT tng trong sc do nhi mu c tim, c th tng trong mt s sc khc. Amylase tng trong vim tu cp - ng mu: sc nng c th dn n ng mu trong mao mch xt nghim c Fibrrin gim, Prothrombin gim, tiu cu gim... ng mu ni mch l hu qu ca sc ch khng phi l nguyn nhn gy sc 3. CHN ON Trn lm sng khi c bnh nhn tru mch, tt huyt p ngi ta thng ngh n sc. chn on sc cn phi i chiu cc biu hin nh mch, huyt p, nhp th, thn nhit, da mt... nh nu nh ngha. Cn thm khm cc c quan, lm cc xt nghim tm cc du hiu lm sng v cn lm sng ca sc. Khi iu kin khng cho php khng th lm c cc xt nghim ngi ta cn c vo cc du hiu lm sng nht l huyt p, tnh trng tun hon, h hp chn on sc. Trn thc t ngi ta phn ra cc loi sc theo nguyn nhn v mi loi sc c c im ring c th nhn thy v x tr kp thi 4. PHN LOI V NGUYN NHN GY SC Phn loi sc thng da vo c ch bnh sinh v nguyn nhn gy sc l ng n v d hiu nht. Tuy nhin cng c nhng phn loi da trn tnh cht ca sc: sc tin pht gm cc nguyn nhn thn kinh v d ng, thng xut hin nhanh, khi nhanh hoc cht. Sc chm thng xut hin mun tin trin chm, iu tr phc tp Phn loi theo nguyn nhn bao gm cc sc sau y:
62

* Sc do tim: Thng do nhi mu c tim, nhi mu phi gy tnh trng tm ph cp. Ngoi ra cn c cc nguyn nhn khc nh nhim c nc cc, quinidin, nhim khun thng hn, bch hu. C khi do cc nguyn nhn ri lon nhp qu nhanh hoc qu chm, ngay sau m tim, p tim do trn mu, trn dch mng ngoi tim cp... Thng sc nng trn bnh nhn c bnh tim t trc, x tr rt kh khn * Sc gim th tch Thng do mt mu trong chy mu tiu ha, cha ngoi t cung v, v lch, phu thut. Do mt huyt tng trong bng, vim phc mc, vim tuy Mt nc, mt mui do nn ma, a chy cp nhim khun, tc rut, hn m tng p lc thm thu, suy thng thn cp * Sc nguyn nhn thn kinh, ng c, d ng lm gim tun hon ngoi vi: in hnh l sc phn v. Thng xy ra sau khi tim hoc ung mt cht c tnh khng nguyn nh khng sinh, cc peptid l hoc mt s thc n. Biu hin rm r bng ph n ton thn, ph n ng h hp, tru tim mch, tnh trng nng c th t vong. X tr khn trng v ng phc c th cu c bnh nhn * Sc nhim khun: Xy ra trn bnh nhn c nhim khun nng t trc li c mt mu mt nc, mt mui hoc c bnh tim phi hp. Cng c khi xy ra sau truyn mu, truyn dch b nhim khun. Thng l sc ni c t nhng cng c khi do cc vi khun c ngoi c t nh t cu, lin cu, trc khun m xanh... * Sc chn thng: Xy ra sau cc chn thng nng, a chn thng. Cc sc chn thng c nhiu c ch gy nn: mt mu, mt huyt tng, au n, nhim c sn phm chuyn ha ca cc t chc p nt... iu tr kh khn o tn thng thng ln v nghim trng. 5. NGUYN TC X TR SC NI CHUNG Tu theo nguyn nhn c cch x tr ring bit. y l 10 ng tc c bn khi x tr sc - S cu chy mu nu c - m bo thng kh: oxy, ht m di, ni kh qun hoc h hp nhn to khi cn - o huyt p, ly mch - t catheter tnh mch trung tm, qua o p lc tnh mch trung tm, ly mu lm xt nghim, truyn dch qua catheter thng thng hoc dch cao phn t hoc truyn mu nu cn - Ghi in tim, in no, t my monitor theo di tim mch - t ng thng bng quang ly nc tiu xt nghim, theo di lng nc tiu
63

tng gi. + Ly nhit , nu st phi cy mu. + Chp phi ti ging + Theo di tnh cht, khi lng phn, nu c a chy ly phn soi ti tm a mp, vi khun, cy phn Tm v x tr nguyn nhn gy sc Ti tuyn c s khng phi lc no cng c iu kin lm c mi bc x tr sc, thng ch thc hin c ba bc u sau truyn dch v nu c th duy tr huyt p bng Dopamin, Noradrenalin ri tm phng tin vn chuyn ln tuyn trn. Ch trong khi vn chuyn vn cn x tr tip tc. 6. CC LOI DCH TRUYN - Trong sc do gim th tch mu: dch truyn c s dng rt rng ri. Ngay sau khi t polyten TMTT truyn ngay dung dch nam clorrua 0,9%, glucose 5%, huyt tng, dextran, cc dung dch cao phn t nh hemacel, heasteril 6%, plasma... ni chung c th truyn bt c loi dch truyn no c trong tay trong khi ch mu truyn (ch khng truyn glucose 30%). Trong sc do mt nc mt mui: natriclorua 0,9%. Glucose 5%, bicarbonat 0,14%, c th cho thm khu vo dch truyn nhng cn nh gi kali mu - Tc v lng dch truyn ph thuc p lc TMTT, tnh trng sc v mc gim th tch mu - i vi sc nhim khun, sc chn thng: vic truyn mu ht sc cn thit v thng trong sc nhim khun c tan mu v xut huyt. Sc chn thng thng c chy mu nhiu khi chy mu v mt huyt tng nng. Khi khng c mu hoc huyt tng mi dng cc dch truyn nh nu trn. - Truyn dch trong sc cn ch phng ph phi cp bng cch theo di mch, huyt p, p lc tnh mch trung tm, nc tiu, th tch gan, tnh mch c, nghe tim, nghe phi. Khi c bt thng nn thn trng. Tm li cn tm tng quan gia chc nng tim tri v phi, gia khi lng nc tiu v p lc tnh mch trung tm. - Trong sc tim v sc phn v: vn truyn dch khng phi l c bn. Dch truyn ch va duy tr ng tnh mch cho php truyn cc loi thuc vn mch, tr tim... 7. CC THUC TRONG IU TR SC * Cc thuc co mch: Noradrenalin, Adrenalin, Dopamin: c tc dng co mch, nng huyt p. Cn c tc dng trong mt s nguyn nhn thn kinh nhim c, d ng, nhng khng nn lm dng khi dng qu 6 gi khng thy hiu qu phi ngng Noradrenalin 4mg trong 500ml glucose 5% nh git TM. Adrenalin ung tim bp trng bm tim TM c tc dng trong sc phn v, sc d ng. Dopamin: ng 50
64

m pha long truyn tnh mch. Bt u liu 2-5g/kg/ pht sau tng dn ln 7lo~g/kg/ pht, c th tng liu ln n 20g/kg/ pht. Khng pha vo cc dung dch kim. * Cc thuc kch thch th thbeta - Isoproterenol (isupren, novodrrin) c tc dng lm gin c trn trc v sau mao mch. Dng sau khi hi phc th tch mu m huyt p khng ln, hiu qu trong cc sc khng c gim th tch mu nh sc nhim khun, sc do tim - Cch dng: Isupren 1-2mg trong 500ml glucose 5% bc kn l thuc bng giy en truyn trong 6h. Khi mch nhanh >120 ln/ pht cn gim truyn hoc ngng hn * Corticoid: c th s dng hydrocortison hemisucinat (Solu-cortef), depersolon hoc Metylprednisolon (Solu-medrol) truyn nh git tnh mch hoc tim tnh mch chm * Tr tim: - Digitan ch dng khi c sc do tim da ph phi cp. Chng ch nh khi c sc do ng c digitan. Liu 0, 5mg Digoxin tim TM hoc truyn TM - Glucagon: 5-15mg tim hoc truyn TM c tc dng trong cc loi sc k c sc do ng c digitan * Chng toan mu: (ch s dng khi pH mu <7,2) - THAM 0,3 mol 500ml truyn TM kt hp vi thng kh nhn to hoc ni kh qun - Natri bicarbonat 0,14%: ch lng ion natri - Li niu Trofurit, lc ngoi thn cng l bin php chng toan ha * X tr cc ri lon ng mu: - Heparin: chng huyt khi v ng mu ni mch ri rc liu cho huyt khi phi: 25mg TM, 2-4 gi 1 ln. Liu ch ng mu ni mch loomg truyn tnh mch - Transamin. E.A.C chng tan si huyt. Ch dng khi chc chn khng c ng mu ni mch 8. IU TR CC NGUYN NHN Tu theo nguyn nhn m c bin php iu tr thch hp mi c hiu qu trong hi sc sc. 9. D PHNG SC 9.1. D phng chung Trong iu tr thng ngy cc khoa phng cn nh gi ng tnh trng nng ca bnh nhn khng bnh nhn ri vo tnh trang sc nht l cc sc nh nhim
65

khun, sc do tim... Trong i sng hng ngy trc cc nguyn nhn gy au n nh chn thng, bng nng... cn c x tr ngay nh c nh gim au, v chuyn ln tuyn trn khng bnh nhn au qu dn n sc 9.2. D phng c hiu v d phng tai bin iu tr B lng dch cn thit cho cc bnh nhn c nguy c sc trong bnh vin. Cho khng sinh v ng vi cc bnh nhn nhim trng nng, vi cc bnh nhn nhim trng ng mt cn ht sc phng sc mt. Trong chn thng nht l gy xng i, a chn thng phi gim au an thn tt c th cho morphin phng sc do au n. Phng tai bin sc phn v khi dng khng sinh v mt s thuc c th gy sc nh novocain... bng cch th phn ng trc tim

CHN ON V X TR HN M
I CNG Hn m l tnh trng bnh nhn mt thc khng p ng vi kch thch bn ngoi, theo Harison's hn m chim khong 3% bnh nhn vo cp cu nhng bnh vin ln. Hn m thng gp khoa hi sc, phng cp cu, l mt tnh trng nng, do nhiu nguyn nhn gy ra. N cn c chn on sm v cp cu kp thi, ng phng php cu sng ngi bnh. 1. NH NGHA V PHN LOI HN M Hn m l trng thi mt thc, mt s thc tnh. Mt thc l mt s nhn bit bn thn v th gii bn ngoi. Mt s thc tnh tc l mt kh nng nhn bit, phn ng vi cc kch thch 1.1. Phn loi hn m theo c in - Hn m nh (Giai on1) bnh nhn l m tr li khng chnh xc - Hn m mc va (G 2) bnh nhn khng tip xc c nhng cu vo cn p ng yu hoc khng p ng, cn phn x nut, phn x gic mc - Hn m su (G3) hon ton khng tip xc, khng p ng mt cc phn x nut, phn x gic mc 1.2. Phn loi theo bng im Glassgow - Mt m M t nhin M khi ra lnh M khi gy au Khng m 4 im 3 im 2 im 1 im
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- p ng bng ting ni Tr li c nh hng tt nht Tr li ln xn Tr li khng ph hp Khng hiu BN ni g Khng ni - Cho im p ng vn ng Thc hin ng ng tc khi ra lnh nh khu khi gy au Co chi li khi gy au Gp chi bt thng Dui chi Mm nho 6 im 5 im 4 im 3 im 2 im 1 im 5 im 4 im 3 im 2 im 1 im

Cho im vi tng p ng ca bnh nhn v tnh tng s im. 15 im: tnh hon ton, cng thp im tnh trng hn m cng nng. 3 im l hn m su. Bng im Glassgow cn c gi tr cao trong tin lng hn m. Hng ngy nh gi im s, nu im s tng l c tin trin tt, im s gim l tin trin xu. 2. MT S NGUYN NHN HN M 2.1. Do tun hon no b nh hng - Ngt, kch thch xoang cnh - Ri lon nhp tim: nhanh trn 160 ln/ 1' hoc chm di 30 ln 1' - Tc mch no, v mch no 2.2. Do nh hng n chuyn ha ca no - Bnh chuyn ha ni tit, ri lon nc in gii - Nhim c ni sinh do suy gan, suy thn. - Nhim c cp: ru, thuc ng, om... - Ph no, vim no, p xe no 2.3. Do ri lon in no - Cn ng kinh nng - Chn thng s no 3. THM KHM NGI BNH HN M 3.1. Hi bnh - Hi bnh nhn nh gi mc hn m - Hi ngi nh tm hiu tin s, tai nn, bnh mn tnh 3.2. Khm ton thn
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- Tim mch, c bnh van tim, bnh cao huyt p - T mu sau tai, dch no tu chy ra t mi, tai do v nn s trc, gia - Da vng (bnh gan mt) da nht nht (thiu mu, mt mu) - St: c ri lon iu ho thn nhit - H hp: ngng th, ri lon kiu th, nhp th 3.3. Khm thn kinh - thc: khm xem p ng n u - Do kch thc ng t v phn ng ca ng t vi nh sng - Pht hin lit khu tr hay lit lan to, lit mm hay cng - Vn ng nhn cu bnh thng hay lit - T th ngi bnh: dui cng mt no, mt v 3.4. Khm chuyn khoa khc - y mt: xut huyt, ph gai - in tim - Sinh ha, huyt hc - Chc d dch no tu lm xt nghim v nh gi p lc. Chng ch nh khi c ph gai th. Khi c nghi ng chy mu no mi cn cn nhc Ch nh tt nht cho cc trng hp nghi ng vim no, vim h thn kinh trung ng. - Chp s no - in no - Chp ct lp. - Chp ng mch no nu cn Cn la chn xt nghim cho ph hp vi c s, vi iu kin ca ngi bnh, trnh lng ph, trnh lm dng xt nghim. Chn on xc nh hn m thng khng i hi xt nghim g. C th chn on d dng ti tuyn c s. Cc xt nghim ch gip cho chn on nguyn nhn, khi bnh nhn kh, c chuyn ln tuyn trn. 4. X TR HN M 4.1 Cp cu ban u -T th bnh nhn: nm nghing an ton, c th k mng cao ln - t ni kh qun, thng kh h tr nu cn, th oxy. - Truyn dch duy tr huyt p n nh, b nc v in gii - Dng thuc, nht l cc thuc i khng khi c ng c Seduxen dng anecxate. Morphin dng nalocphin - Chng co git 4.2. Vn chuyn
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Ch vn chuyn bnh nhn khi m bo thng kh v huyt ng. i vi tuyn c s nh trm y t hoc bnh vin huyn ch cn x tr nh trn l t yu cu, cc x tr cao hn i hi bnh nhn c chuyn ti c s y t hin i hn 4.3. iu tr tch cc - Hn m su: thng kh nhn to - Nghi ng h ng huyt hoc hn m gan cho glucose 20% tnh mch nu khng c h ng huyt th ngng glucose - Chng ph no nu c tng p lc ni s: Mannitol, nu c u no dng corticoid - iu chnh nc, in gii - Chng co git - Nui dng, chng lot, chng bi nhim 4.4. iu tr nguyn nhn khi pht hin ra nguyn nhn 4.5. iu tr ngoi khoa nu c ch nh - T mu ngoi mng cng - p xe no, phnh mch no. 5. D PHNG 5.1. D phng chung Cc nguyn nhn gy hn m c nhiu, trong thc t lm sng d phng hn m phi tu thuc tnh trng ca tng bnh nhn, tu thuc din bin ca bnh. Thy thuc phi lun nhy bn trc cc din bin ca bnh nhn nht l khi thy cc biu hin tin hn m trn bnh nhn, cn khm k tm nguyn nhn c th a bnh nhn ra khi tnh trng tin hn m 5.2. Phng c hiu v phng bin chng Ch yu l d phng cc bin chng ca hn m nh lot vng t : cho bnh nhn tr mnh 30 phm ln, khng vng ny b t, xoa bp mt xa cc vng t, . Phng bi nhim nht l bi nhim phi, tit niu bng cc thuc khng sinh d phng, khi c nhim trng trn c th cn c iu tr trit .

CP CU HO RA MU
1. I CNG 1.1. nh ngha Ho ra mu l khc ra mu trong khi ho. Mu xut pht t thanh qun tr xung. 1. 2. c im dch t hc Ho ra mu l mt cp cu ni khoa hay gp, l mt triu chng ca nhiu
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nguyn nhn. Trc nhng nm 1945 - 1960 nhiu nc c t l cao, sau gim dn. Vit Nam, t l ny trn cc tnh min Bc l 14 - 33% c s tuyn 3,26 66% c s tuyn 4,50% thnh ph H Ch Minh. So vi cp cu trn kh mng phi t pht th t l ho ra mu cp cu gp 10 - 14 ln. 1.3. C ch bnh sinh C nhiu thuyt gii thch ho ra mu, hin nay ngi ta ang ch cc c ch bnh sinh sau y: - V mch hoc lot mch: cc phnh mch ca Rasmussen b v. iu kin thun li ca v mch l gng sc, xc cm mnh, hoc nhng thay i v ni tit, v sinh hot, p lc trong mch mu thay i t ngt lm v thnh mch. - Thot hng cu qua thnh mch do ri lon vn mch (nh trong ph phi cp). - D ng: histamin lm gin mao mch phi - Ri lon v mu: c lin quan ti thay i v ni tit, lm ko di thi gian chy mu, gp trong ho ra mu 2 - 3 ngy trc khi hnh kinh. 2. CC NGUYN NHN GY HO RA MU Trc nhng nm 70, hi lng ngc M lit k 101 nguyn nhn ca ho ra mu, nhng trn lm sng ch c mt s nguyn nhn thng gp: 2.1. Tn thng phi ph qun - Lao phi ang tin trin, hoc ti pht hoc di chng ca lao phi: nguyn nhn hay gp nht hin nay, t 28,6 n > 50% theo Massin F.v cs (l996) v t 13,4 n 38% theo tc gi Vit Nam (1995 - 1996). Ho ra mu do lao thng c ln bt v ui khi huyt. - Gin ph qun: gp t 15 n 30%, nh du mt bc ngot ca gin ph qun, hay ti din nhiu ln, d xut hin khi c bi nhim ph qun. Th ho ra mu ca gin ph qun khng khc m thng gp Vit Nam, d chn on nhm vi lao phi - Ung th ph qun: gp t 20 - 38%, thng ho ra mu t, mu c th ti hoc sm mu hoc mu tm, nu khi u bo mn ng mch phi th c th ho ra mu nng. - Nhim khun phi - ph qun: ho ra mu do p xe phi gp vo khong 14%, cn c th do vim phi hoi t do Klebsiella pneumoniae, mu khc ln vi m ging keo mu gch, vim kh ph qun chy mu do vi khun hoc nhim c hoc d ng thng ho ra mu t. + Cc nguyn nhn t gp hn: u nm aspergrllus trong hang phi, d vt ni ph qun, bnh bi phi sillic, bnh sn l phi v bnh amip phi. 2.2. Nguyn nhn tim mch - Bnh hp van hai l:
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- Hi chng Lutembacher (Hp van hai l kt hp vi thng lin nh) - Suy tht tri, ph phi cp tnh - Nghn tc ng mch phi - Phnh ng mch ch r vo ph qun - Tng p lc ng mch phi nguyn pht - Khi dng thuc chng ng ko di 2.3. Cc nguyn nhn khc - Chn thng lng ngc lm gy xng sn hoc dp nt phi. - Hi chng sc p do sng n - Cc bnh v mu (Lxemi cp v mn tnh, bnh a chy mu, chy mu do gim tiu cu) - Bnh st xut huyt: ho ra mu khi c chy mu phi - Khng r nguyn nhn.: gp khong 1,2 - 5 %. 3. TRIU CHNG Ho ra mu c nhng nt c bit ca bnh gy ra, nhng ni chung cng c nhng im ging nhau. Ho ra mu c th xy ra t ngt, ngi bnh cm thy kh th nh hoc sau khi hot ng mnh, sau khi n nhiu, ni nhiu, xc cm mnh, thay i thi tit t ngt, hoc trong giai on hnh kinh. 3.1. C nng Ngay trc khi ho, ngi bnh c cm gic nng trong ngc, kh th nh, nga trong hng ri ho. Gia cn ho khc ra mu ti ln bt, thng ln m. Khi lng mu chy ra t hoc nhiu, t vi mi n 500- 600 ml c khi hn. Mu ti, si bt, khng ln thc n. C bit c ngi bnh khng ho, mu chy rng rng ti gi l xut huyt phi. Cn ho c th ko di vi pht ti vi ngy. Mu khc ra dn c mu thm, nu, ri en li, gi l ui ho ra mu. ui ho ra mu l mu ng cn li trong ph qun, c khc ra ngoi sau khi mu ngng chy. ui kt thc ho ra mu Mt s bnh nhn, mi t ra mu ngc rt au bn b bnh, phi nm nghing bn phi lnh cho ti khi mu gim dn, cm hn mi nghing c c hai bn nh bnh thng. T th nm ca bnh nhn gip chn on bn chy mu v tin lng bnh. 3.2. Ton thn Khi mt mu nhiu, da mt xanh xao, tim p nhanh, kh th, giy gia, lo lng, v m hi, chn tay lnh, huyt p tt. St tht thng, hay gp st nh thong qua (st tiu mu), hoc st cao (lao tin trin, bi nhim phi).
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3.3. Thc th - Nghe thy ran m r rt hoc kn o khu tr mt vng ca phi, c th c ran n. 3.4. X quang Hnh nh X quang phi: nu bit hnh nh tn thng phi trc, chng ta c th thy nhng thay i quan trng: mt m m gii hn khng r rt, hi m, to nhanh; mt m m mi xut hin cng bn hay i din vi tn thng c; hnh hang mi xut hin; mc nc trong hang vi ngy sau chp li bin mt (mu ng c khc ra ngoi); khng thy thay i tn thng. Hnh nh c bit khc: m m rng co ko h thng - Hnh nh xp phi do cc mu cht ph qun. Hnh ht cc ri rc sau ho ra mu, ging ht k khu tr vng gia, y phi mt bn hay hai bn. Tn thng lao vng rn phi, y phi thng gy ho ra mu nng; cha kh v l nhng vng nhiu mch mu v l vng phi hot ng mnh. 3.5. Xt nghim m tm vi khun BK, nm aspergillus, sn l phi trong m khi lm sng gi nguyn nhn ny. 4. PHN LOI HO RA MU - Ho ra mu t, khi mu khc ra < 50 ml trong 24 gi. - Ho ra mu trung bnh, t 50 n < 200 ml trong 24 gi. - Ho ra mu nng: > 200 ml trong 24 gi. Hin nay c phn loi mc nng nh ca ho ra mu cn cha thng nht. C nhiu tc gi da vo s lng mu khc ra trong 24 gi hoc 48 gi, coi l ho ra mu nng nu tng s lng mu khc ra trong 48 gi t 600 mi tr ln. - Ho ra mu st nh l khi mu chy t, trn ngp hai phi gy ngt th v t vong nhanh chng. - Ngi ta cn chia ho ra mu thnh: ho ra mu triu chng v ho ra mu bnh l (thng gp nhng bnh nhn khng c tin s bnh phi). 5. CHN ON PHN BIT Cn chn on phn bit ho ra mu vi: - Nn ra mu: mu nn ra ln thc n, thm, c khi ln mu cc, t bt sau ngi bnh i a ra phn en. Cm gic trc khi nn ra mu l nn nao, khc vi ho ra mu l nng v nga trong ngc v c. - Chy mu cam: nn khm xem hai l mi c mu khng. - Chy mu trong ming: khng nng v nga trong ngc v c. Nn khm ming: nim mc ming, li, li.
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6. X TR 6.1. Nguyn tc chung Phi tm nguyn nhn ho ra mu v mi trng hp ho ra mu u bt u bng iu tr ni khoa gm iu tr triu chng v iu tr cn nguyn, do cn: - Bt ng bnh nhn: dng cc thuc gim ho, an thn, thuc co mch cm mu, truyn mu liu nh, chng bi nhim do vim phi ht xung, ch dng morphin khi bnh nhn khng c suy h hp v khi ng th thng thong. i vi ho ra mu trung bnh hoc nhiu cn kt hp iu tr cm mu ni khoa vi iu tr ni soi v bt tc ng mch ph qun. - Phi nm vng s lng mu khc ra trong 24 gi v hng ngy i vi ho ra mu nng ng thi theo di mch, nhit , huyt p, tn s th, tnh trng thiu mu, sc, suy h hp, cn lm ngay cc xt nghim: nhm mu, hng cu, huyt sc t, hematocrit, bch cu, cng thc bch cu, tiu cu, thi gian mu ng, mu chy. - Ch nh phu thut ct thu hoc mt l phi i vi ung th ph qun, gin ph qun khu tr, ho ra mu ti din nhiu ln, p xe phi mn tnh, lao phi iu tr ni khoa tht bi khng nhiu thuc chng lao. - Bnh nhn ho ra mu mc trung bnh v nng cn c chuyn ln tuyn trn iu tr. Song vic x tr ban u ti tuyn y t c s nh: bt ng bnh nhn, dng thuc gim ho (Terpincodein), thuc an thn, m bo h hp cng rt quan trng lm gim mc nng ca bnh v vic thu gom x l cht thi tit ca bnh nhn gp phn phng chng bnh tt cho cng ng. 6.2. Ho ra mu nh - Bt ng tng i, ch n mm nh cho, m, ph ngui. - Thuc gim ho: Terpin codein hoc paxeladin 40 mt x 3 ln/ ngy. - Thuc an thn: seduxen 5mg x 1 vin hoc tranxene 5 mg x 1 vin. - Nu ho ra mu t 30 n 50 ml: gladuitrin 5 UI pha vi 20 ml dung dch glucose 30% tim tnh mch chm, 1- 2 ln/ngy (thn trng khi bnh nhn c suy mch vnh). 6.3. Ho ra mu trung bnh - Chng ho: + Tecpin codein: 1 vin x 6 ln/ngy hoc paxeladin vin 40 m x 3 ln/ngy. + C th dng morphin 0,01 g tim di da hoc bp tht nu bnh nhn khng c suy h hp. - Gardenal 0,05 g hoc seduxen 5 mg tim bp tht 1 - 2 ng/ ngy. - iu tr co mch c theo di huyt p hng gi: Hypantin 5 IU pha trong 20 ml dung dch glucose 30% tim tnh mch chm, 3- 4 ln/ ngy, c th truyn tnh mch.
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- Nu c du hiu tiu flbrin + Hemocaprol ng tim 10 ml = 2 g tnh mch chm hoc ng ung 20ml, c 6 gi 1 tn. Cn theo di tnh trng tng ng. + Hoc transamin 10% tim tnh mch chm 5-10 ml hoc ung 2-4g/ ngy. + Nu t l prothrombin gim, cho tim hoc ung vitamin K + Vitamin C v cc thuc tr tim: coramin, ouabain... + Nu bnh nhn c du hiu vim phi do ht xung (nhit tng cao) th cho ampicilin 1,5 - 2 g/ ngy hoc cc khng sinh mnh hn nh Augmentin 2g/ngy, cefotaxin 2 g/ngy tim bp tht. 6.4. Ho ra mu nng - Bt ng tuyt i, bung thong, yn tnh, khng di chuyn bnh nhn. Khi ang ra mu t bnh nhn nm nghing v bn phi c tn thng chy mu, u thp hn ngc. Khi ht ra mu th nm theo t th Fowler (na nm na ngi). Ch n lng hon ton (sa, nc cho) ngui. C th chm ln ngc. - Th oxy 2 - 3 pht/1n, nu cn cho th lin tc. - Morphin (nu khng c suy h hp) tim di da 1 ng 0,01g hoc 1/2 ng pha long vi 10 ml dung dch glucose 30% tim tnh mch chm, gardenal 0,1 g hoc seduxen 10 mg tim bp tht 1 ng, cho 2 ln/ngy. - C th cho bnh nhn ng nh bng hn hp gardenal + aminazin + pipolphen nhng cho liu nh, tim ri rc lm nhiu ln trong ngy. C th cho Theralene. - Cho cc thuc cm mu: truyn tnh mch hormon tuyn hu yn v thuc chng tiu fibrin nh iu tr ho ra mu trung bnh. - Nu hng cu < 2 triu, hematocrit < 30% hoc bnh nhn c sc, tt huyt p th truyn mu cng nhm hoc truyn mu ti trc tip t 150 ml n 200 ml/1n trong vi ngy cho n khi ngng ra mu, khng truyn mu qu nhiu trong 1 ln v c th lm tng huyt p gy nn ho ra mu lin tc. - Chng try tim mch: truyn tnh mch Dopamin hoc Noradrenalin. - Tr tim: Coramn, Ouabain, Isoland... : - Nu bi nhim: Ampicillin 2 g/ ngy tim bp tht hoc cc khng sinh mnh hn. - iu tr ni soi: lm lu thng ng th, bt ng mch ph qun khi c ch nh. - iu tr phu thut cp cu: ch thc hin c khoa phu thut lng ngc c kinh nghim khi cc bin php x tr ni khoa tht bi. C th m lng ngc tht mch mu cp cu, hoc kt hp vi ct b thu tn thng chy mu.
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6.5. iu tr nguyn nhn - Sau khi ht ho ra mu tu theo nguyn nhn m iu tr. - Nguyn nhn ho ra mu thng gp nht l lao phi, do vy vic qun l v iu tr bnh nhn lao phi cng ng c ngha rt ln trong vic lm gim t l bin chng ho ra mu.

CHN ON V X TR TRN KH MNG PHI

I CNG Trn kh mng phi l hin tng khng kh trn vo khoang mng phi tch l thnh v l tng ra to mt khoang cha kh. Khng kh c th xm chim ton b khoang mng phi gi l trn kh mng phi ton b, hoc c th ch khu tr mt phn gi l trn kh mng phi cc b. Trn kh mng phi l cp cu thng gp c trong ni khoa v ngoi khoa. Theo GS. Hong Minh, t 1990-1994 ti Vin Lao - Bnh phi Trung ng cp cu trn kh mng phi chim 20,12%, ng th 3 sau ho ra mu v trn dch mng phi. Triu chng trn kh mng phi thng rm r, vic x tr cp cu ban u thng khng kh song rt c ch, v vy mi tuyn c s cn khm t m pht hin sm v c thi x tr ng n, kp thi hn ch bin chng v kh nng t vong. 2. TRIU CHNG 2.1. Trn kh mng phi ton b Cc triu chng in hnh, phong ph. 2.1.1. C nng - au chi ngc: xut hin t ngt, bnh nhn thy au chi ngc, au nh x phi. - Kh th: xut hin ngay sau khi au ngc kh th 2 th, th nhanh nng lng kh thot vo khoang mng phi cng nhiu bnh nhn cng kh th. 2.1.2. Ton thn Bnh nhn thng trong tnh trng sc: Da xanh ti, v m hi, mch nhanh, huyt p gim. 2.1.3. Thc th Trong trn kh mng phi ton b triu chng thc th thng rt r rng biu hin: 1 * Nhn: Lng ngc bn b trn kh bt ng, cc khoang lin sn gin rng, lng ngc
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cng hn bnh thng, c s co ko cc c h hp. * S: rung thanh mt * G: ting g vang trng * Nghe: r ro ph nang mt Ba triu chng: rung thanh mt, g vang trng, r ro ph nang mt, to thnh tam chng Galliard, rt c gi tr pht hin trn kh mng phi trn lm sng. Ngoi ra khi nghe chng ta cn c th thy: ting thi v, ting vang kim kh, ting vang v ca ting ni v ting ho, nhng khng thng xuyn v xut hin mun. * Mt s triu chng do thay i v tr cc c quan: - Mt vng c ca gan trong trng hp trn kh mng phi phi. - Mt ting g c vng trc tim trong trng hp trn kh mng phi tri. 2.1.4. Triu chng X quang Chiu hoc chp lng ngc t th thng. Thy bn trn kh c hnh nh: - Ph trng qu sng, mt ht cc vn ph qun. - Khoang lin sn gin, xng sn nm ngang. - Phi b p li thnh mt cc xp st rn phi. C hin tng y: c honh b y xung di, trung tht b y sang bn lnh. 2.1.5. Triu chng p lc k C gi tr chn on xc nh, gip cho iu tr v tin lng bnh. Thng o p lc khng kh trong khoang mng phi bng my Kuss c ba trng hp. - p lc trn kh mng phi bng p lc kh tri: trn kh mng phi m, tc l vn c l thng gia khoang mng phi v khng kh bn ngoi. p lc trn kh mng phi thp hn p lc kh tri; trn kh mng phi ng, tc l ch thng c gn li khng kh khng vo thm c na. - p lc trn kh mng phi cao hn p lc kh tri: trn kh mng phi c van. Tc l khng kh vo khoang mng phi c, nhng khng ra c cho nn th tch khng kh cng ngy cng tng, bnh nhn ngy cng kh th nu khng cp cu kp thi s t vong nhanh chng v ngt v sc. Nu ti c s khng c my Kuss c th dng bm tim xc nh mt cch tng i p lc trong khoang mng phi, k thut n gin d p dng song rt c gi tr. Chc kim c gn vi bm tim vo mng phi, nhn xt: - Nu pt tng ng yn: trn kh mng phi m. - Nu pt tng b ht vo: trn kh mng phi ng. - Nu pt tng b y ra: trn kh mng phi c van.
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2.2. Trn kh mng phi cc b Triu chng lm sng rt kn o, thng khng pht hin c c s khng c Xquang. Nu kim tra X quang c th thy hnh nh ca trn kh cc b l mt hnh hi (sng hn bnh thng) ra phi, gia nhu m phi v lng ngc. Cn nhn xt gc ca hnh hi phn bit vi mt hang phi. Nu khi chiu X quang bo bnh nhn ho s thy trn kh mng phi cc b th khng nhy cn hang phi th s nhy. 3. CHN ON 3.1. Chn on xc nh Da vo cc du hiu sau: - Lm sng: au ngc, kh th xut hin t ngt vi cc tnh cht m t trn. - Du hiu X quang: c hnh nh trn kh... 3.2. Chn on mc nng ca trn kh mng phi Phi xc nh sm, ngay c khi cha kp chp Xquang phi nu cn trc bnh nhn ang kh th ngt ngt c th gii quyt ngay tnh trng ngt th ch bng mt kim tim chc vo mng phi lm thot bt kh. Cc bnh phi - ph qun nhim khun cp tnh khng do lao c th gy trn kh v c vim ph nang to nn vim nhim di v v vim nhim mng phi, bnh nhn c nhng lon dng nh ngoi bin phi to nn nhng bng kh trong vng b vim. Khi ho, gng sc, cc bng ny v gy r ph qun mng phi to nn trn kh mng phi thng l trn kh ton th, nhng khng nng lm v phn phi cn li chc nng cn tt. Cc bnh phi - ph qun mn tnh gy lon dng to nn cc bng kh l nguyn nhn gy trn kh mng phi. Hay gp nht l do gin ph nang nht l loi gin ph nang ton tiu thu. Trng hp ny nu ch nh th my khng ng c th gy trn kh mng phi. Loi gin ph nang cnh so nh trong lao, bi phi thng gy trn kh cc b nhng thng tin lng nng v phn phi cn li tn thng nhiu, khng m nhim c tt chc nng h hp, khng c kh nng b tr. Chn on mc nng ch yu da vo du hiu suy h hp, kh th v tnh trng ton thn (ngt xu, sc...). Mc kh th tu thuc vo mc trn kh, loi trn kh: trn kh c van, trn kh c mng sn di ng l nng. Ph thuc vo bnh phi, ph qun c sn: mi suy h hp cp xy ra ngi c bnh phi ph qun mn tnh, km theo c au ngc, kh th phi ngh n do trn kh gy ra v mi trn kh loi bnh nhn ny phi c iu tr cc trung tm chuyn khoa c y iu kin chc ht, dn lu, hi sc h hp. Xc nh mc suy h hp tt nht l o kh mu (PaO 2 gim v PCO2 tng), c s khng c iu kin o kh mu th phi da vo du hiu kh th, th nhanh
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nng, nhp th trn 25-30 chu k/pht, mc tm mi v ngn chi chn on suy h hp. Chn on sc da vo tnh trng ton thn nhp tim nhanh, huyt p h... 3.3. Chn on nguyn nhn Rt cn thit cng vi vic dn lu kh, lm n li phi kt hp iu tr c hiu nguyn nhn trn kh cho bnh nhn. Trnh vic chn on n gin ch mc trn kh khng r nguyn nhn v trong nhiu trng hp nu c gng tm c th s thy mt nguyn nhn no . Nhng nguyn nhn thng gp l: 3.3.1. Do lao - L nguyn nhn thng gp: chim ti 60% cc trng hp, nu c trn dch mng phi phi hp th gn nh chc chn l do lao. - C th l du hiu m u mt qu trnh lao, nhng thng l mt bin chng ca lao phi tin trin. 3.3.2. Do ung th Thng l loi ung th n vo lng ph qun gy tn thng ph qun ch nhn thy khi soi chp ph qun, khng th hin trn phim X quang. Do vy c s khng c iu kin soi ph qun khi khng tm thy nguyn nhn trn kh, ngi c tui, ht thuc lo, thuc l nhiu (c bit nhng ngi ht trn 20 iu/ngy) phi ngh n nguyn nhn ny v gi bnh nhn i soi ph qun trnh b st. 3.3.3. Do chn thng Mi trng hp b kh th, au ngc sau chn thng nn chp X quang pht hin trn kh. 3.3.4. Trn kh t pht * Trn kh t pht ngi phi lnh: - Trn kh mng phi xy ra ngi tr, khe mnh, xut hin t ngt sau gng sc. - Trn kh mng phi ton b mt bn nhng khng tin trin thnh mt trn dch. - Rt hay ti pht. Loi ny t gy kh th, iu tr n gin, tin lng tt * Trn kh mng phi ngi bnh (suy h hp mn tnh, bnh phi ph qun mn tnh...): loi trn kh ny gy kh th nhiu, iu tr phc tp, tin lng d dt. Trong trn kh mng phi khng r nguyn nhn, thng l trn kh do v bng kh, gin ph nang c th do tn thng lao c t trc hoc nhng ngi c bt thng v th tng: Hi chng Marfan, thng lin nh... Nhng ngi ny c lon dng a phng nn c cc bng kh, thng nh phi nu b v s gy trn kh.
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Cng c th do vim phi ph qun mn tnh, ht thuc l lu ngy... to nn cc bng kh khi v gy trn kh. C trng hp trn kh mng phi khng r nguyn nhn chp ct lp vi tnh thy c gin ph nang, c th do bm sinh. 3.4. Chn on phn bit 3.4.1. Vi nhng nguyn nhn gy kh th cp - Vim phi, ph qun ph vim: c du hiu nhim khun, Xquang khng c hnh tng sng. - Ph phi cp: nghe phi c ran m nhiu nht vng y phi, g c. - Ho c m ln bt mu hng. Nghe tim c ting nga phi. Kh th ngy mt tng, Xquang phi c hnh m cnh bm. - Hen: c tin s hen, nghe phi c ran rt, ran ngy, kh th th th ra. Xquang phi sng nhng cn cc vn ph qun. - Tc mch phi v nhi mu phi: m ln mu. Nghe phi c ran n, xung quanh vng phi b tn thng v vng phi bnh thng c ting thi ng, i khi c ting c mng phi. Kh th km theo triu chng sc X quang c hnh bng m ng c ca nhi huyt. Bnh xy ra nhng ngi c iu kin thun li lm mu d ng. - Nhi mu c tim: au vng tim. Hi chng sc: mch nhanh, huyt p h, chn tay lnh, v m hi... Nghe tim ting tim m ting nga phi, ting c mng tim. St, in tim c hnh nh nhi mu. Xt nghim mu: CKMB tng, SGOTSGPT tng. - Hi chng suy h hp cp ngi ln: kh th xut hin t ngt sau mt tnh trng bnh l: sc nc d dy, vim ph qun phi, sc, bng...Kh th nhanh, mch nhanh, huyt p h, tru mch, xanh tm, ri lon thc. Nghe phi c ran n, ran m, X quang phi m do ph n ph nang. PaO2 gim, SaO2 gim. - Chng hi d dy, gin d dy thng gp tr em. Trn X quang thy bng hi b gii hn bi vm honh v thnh d dy. Cho ung baryt thy thuc cn quang di vm honh. - Thot v c honh: thng sau mt chn thng. Tr em gp nhiu hn ngi ln. Chp X quang phi sau khi ung baryt gip chn on d dng. 3.4.2. Vi nhng nguyn nhn gy au cp - Trn dch mng phi: vng phi trn dch g c. Xquang c hnh mc nc trong khoang mng phi. - Xp phi: vng phi xp c hi chng 3 gim: rung thanh gim, r ro ph nang gim, g c. X quang phi thy hnh ng c ca phi xp v quanh l hnh cc vng ln cn b ko v pha ny. - Chn thng ngc: nghe phi bnh thng.
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- Cn au bng cp: nghe phi bnh thng. 3.4.3. Vt nhng bnh phi c hnh X quang d nhm vt trn kh mng phi - Vi hang lao ln vng nh phi: gc to bi thnh hang v thnh ngc l gc t, trng hp trn kh mng phi gc ny nhn. - Vi kn gin ph nang: nghe phi vn cn r ro ph nang khi bnh nhn th su. - Vi cn mng phi: trn phim Xquang c cn mng phi c b dy, ng vi. Cn khai thc k c qu trnh bnh l to nn cn. - Vi kn ph qun ln: trn phim X quang thy b rt mng ca kn ph qun, kn ph qun khng ch c mt nn thng thy mt s hnh trn sng ca cc kn ph qun khc. 4. IU TR Tu theo dng lm sng, hnh nh X quang v nguyn nhn gy trn kh mng phi m iu tr cho thch hp. 4.1. X tr trn kh mng phi 4.1.1. Bin php khng ht kh, iu tr bo tn Vi bin php ny khng chc ht kh ch theo di s tiu dn ca kh v n li ca phi qua X quang v lm sng. Thi gian theo di tu thuc mc trn kh, mc n li hon ton ca phi. Kh nng hp thu ca kh trong khoang mng phi rt t, ch t 0,5-lml/ngy. V th thi gian theo di kh lu 20-30 ngy hay hn na. Ch nh liu php ny vi loi trn kh mng phi kn, lng kh trong khoang mng phi t, nhng v tr rt kh chc ht, trn kh khng r nguyn nhn, lnh tnh, phi khng b ng c, khng xp nhiu, khng c trn m mng phi, khng c bi nhim trong khoang mng phi, ngi bnh v thy thuc c iu kin theo di mt cch y . 4.1.2. Cc phng thc x l bng chc ht, dn lu kh *Chc kim: Trn kh mng phi l mt cp cu. Trong iu kin khng c phng tin th trc khi chuyn bnh nhn n ni c iu kin gii quyt tt hn, iu ti thiu m ngi thy thuc cn lm l chc mt kim tim, d ch l kim tim bp vo khoang mng phi c trn kh kh c th thot ra ngoi lin tc qua kim , khng tch cng trong lng ngc c th gy nguy him do p phi v cc tng trong lng ngc. * Dn lu mng phi: - Dng c chc ht dn lu: cc loi kim tim, ng thng nh bng cht do polyethy!che, ng dn lu va v ln bng cao su Monaldi, Monod, Nelaton, ng dn lu bng cht do Joly. - im chc ht:
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+ Trn kh ton th: im chc khoang lin sn 2 trn ng gia n. ph n v vn thm m c th chc ng nch, pha sau c ngc ln. Lun i st b trn ca xng sn di. Nu km theo c trn dch, trn mu, trn m th phi t ng dn lu vng mng phi c dch ny (thng lin sn 4 hay 6 trn ng nch gia, nch sau hay nch trc tu trng hp) dn lu ngay lp tc v dch v mu trong mng phi lu gy dnh v d b bi nhim. + Trn kh khu tr: im chc ht, m mng phi: vng c trn kh, ng dn lu t su trong lng ngc 5-6 cm, hai bn thnh ng tr thm ca s, ng ni thng vi h thng ht lin tc bng cc l hay bng my ht. H thng ht phi m bo mt chiu t khoang mng phi ra pha cc l khng kh bn ngoi v dch trong l khng tro ngc li. - Cch dn lu: + Dn lu n gin: ng dn lu ni vi mt l trong ng dung dch Dakin hoc dch st khun tng ng (u ng phi ngp trong dung dch), nu p lc khoang mng phi dng tnh s thy bt si ln trong l ng dch, nht l khi bnh nhn th mnh, ht hi. Nu p lc trong khoang mng phi khng dng th nc trong l s vo mt on trong ng ni, chnh on nc ny c tc dng nh van mt chiu ngn khng kh khng vo khoang mng phi c. Khi di chuyn bnh nhn c th thay l nc bng van Heimlich hay n gin hn l ngn tay gng cao su. K thut dn lu ny n gin c th lm mi tuyn song li rt c gi tr cho chn on, iu tr nn cn c p dng rng ri. + Dn lu bng my ht lin tc: C iu kin th t trn ng ng dn lu xupp Jeanneret hay dng c Foures iu chnh p lc ht, thng ht vi p lc -15 n -40 cm nc tu trng hp. - Theo di, chm sc: Khng tc ng dn lu, m bo kn ca h thng ht, khng nhim khun, lun thay ra l, h thng dy dn, thay bng hng ngy vng m mng phi. Nu c trn dch, trn mu phi dn lu dch, mu. Cho khng sinh. 4.1.3. Gy dnh mng phi C th gy dnh mng phi cho cc loi trn kh mng phi hay ti pht gy nguy him cho bnh nhn, thng nhng bnh nhn c tn thng rng. Bng cch rc bt khe, bm dung dch tetraxyclin, bm mt t mu... vo khoang mng phi, ch xt mng phi bng kh kh hay bng gc.
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4.2. Cc iu tr khc - Gim au, chng sc: Dng thuc an thn, gim au. Khng dng Morphin nhng trng hp c kh nng suy h hp. - Liu php oxy: Nu bnh nhn kh th, suy h hp. - Khng sinh. - Cc thuc khc: corticoid, long m, tr tim...nu chy mu, mt mu: truyn dch, truyn mu. 4.3. iu tr cn nguyn Cho thuc chng lao nu trn kh mng phi do tn thng lao, cho khng sinh chng t cu nu trn kh mng phi do v bng kh trong nhim t cu phi...

CN AU THT NGC
1. I CNG DCH T HC - Cn au tht ngc hay bnh thiu mu c tim xy ra khi mt cn bng gia cung v cu v oxy ca c tim. - Bnh mch vnh ch yu gp la tui trn 50-60 tui. T l gp nam nhiu hn n (4/1). - Va x ng mch l nguyn nhn hng u, ngoi ra cn mt s yu t nguy c khc: co tht ng mch vnh, vim ng mch trong mt s bnh to keo, d dng mch vnh bm sinh. - Bnh c Heberden m t 1772 vi c tnh co tht, lo u, cm gic rt kh chu trong ngc. Biu hin s gim thiu xy cho c tim trong chc lt, tuyt i hay tng i. 2. NGUYN NHN V C CH 2.1. Nguyn nhn * Bnh ng mch vnh: - Va x ng mch gy bt tc - Do co tht ng mch vnh. * Bnh van tim: - Bnh van ng mch ch + Hp van ng mch ch + H van ng mch ch
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+ Giang mai gy bt tc l vo ng mch ch. - Bnh van 2 l: + Sa van 2 l + Hp van 2 l - Hp van ng mch phi * Bnh c tim ph i: - Cn gi l hp trn vn ng mch ch. * Cc yu t b tr. - Nhiu mu - Nhp tim nhanh - Sc (gim lu lng tim v lu lng vnh). - Cng gip trng. 2.2. C ch bnh sinh * Nhng yu t lm tng nhu cu oxy c tim. - Nhp nhanh - Tng co bp tm c - Tng trng lc ton th c tim * Nhng yu nhm gim cung cp oxy cho tm c. - Hp lng ng mch - Gim hm lng oxy trong mu - Gim hm lng hemoglobin - Gim p lc ng mch th tm thu lm gim lu lng vnh. 3. TRIU CHNG 3.1. Cn au tht ngc in hnh * Cn au tht ngc khi gng sc. - Xy ra khi i b, sau khi n, tri lnh i ngc chiu gi. * Tnh cht cn au: - au sau xng c, au ngang ngc lan ln vai tri, ra pha mt trong cnh tay v bn tay tri. - C khi lan ln c, di hm. * Thi gian ca cn au: - Thng ko di vi giy n vi pht. - S ln xut hin cc cn rt thay i. * Tc dng ca Nitroglyxerin: - t di li thuc c tc dng ct cn au trong vi pht. y l test c gi
83

tr chn on cn au tht ngc. * Mt s du hiu km theo: - Trong cn au bnh nhn thy hi hp lo u, kh th, v m hi, nghe tim c th pht hin ting nga phi tin tm thu, ting thi tm thu. 3.2. Cn au tht ngc khng in hnh * V tr au khc thng: - au vng thng v, au ln ln tay phi. * Th khng au: - Ch c cm gic nng n vng trc tim t di tay tri, nght th, ho. * Cn au t th nm: - Xy ra khi bnh nhn ngh ngi, hay gp v ban m, vo 1 gi c nh. * Cn au Prinzmetal (cn au co cng mch): - Xy ra khi ngh ngi, trong cn au nu ghi in tim thy on S chnh ln chuyn o DI v cc chuyn o trc tim bn tri. - Chp ng mch vnh khng thy tn thng g, mt s trng hp thy tn thng va x ng mch i khi thy hin tng co tht ng mch vnh t nhin. * Cn au tht ngc tht thng: - Cn gi l cn au tin nhi mu. Cn au tht ngc mi khi vn c, nay t nhin thay i tnh cht. 4. CC XT NGHIM 4.1. in tm - ST chnh xung 2-3mm cc chuyn o ngoi bin cc chuyn o trc tim bn tri. - C th ghi in tm gng sc 4.2. Theo di in tim lin tc 24 gi 4.3. Siu m tim v Doppler - Phn tch s hot ng tng phn nh gim co bp, khng co bp, thm ch ri lon co bp khu tr. - Tm ch s co hi tht tri nhm nh gi chc nng tht tri ton b. 5. CHN ON 5.1. cng ng da vo - Cn au xut hin t ngt vng trc tim - Cn au ht khi ngh ngi - Cn au ngn, vi giy n vi pht. - Khm bnh nhn c cao huyt p.
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5.2. bnh vin - Cn au sau xng c, km theo hi hp lo u, xut hin khi gng sc, gim khi ngh ngi hoc dng Nitrit, ko di vo pht. - au lan ln vai, tay tri, c v di hm. - in tm on ST chnh xung trong lc c cn au hoc khi gng sc - Hnh nh chp lp lnh hoc chp ng mch vnh bt thng. 5.3. Chn on phn bit - Vi tt c cc trng hp gy au vng trc tim. - au do thoi khp hoc do vim ct sng lng - c, vai, cc khp sn sn au vng trc tim do bnh tm cn. 6. IU TR S tin trin v iu tr cn au tht ngc n nh (cui bi) . 6.1. Trong cn au Ti cng ng: tim papaverin. Ti bnh vin: * Nitrit: Nitroglyxerin 0,15 - 0,6mg t di li kt qu ht au trong vng 12 pht. Bnh nhn cn bit cch s dng thuc trc mi hot ng c th gy cn au tht ngc. - Irosorbid dinitrat 2,5 - 5mg t di li cng c tc dng tng t. C th dng cha suy mch vnh lu di 20-40mg x 2 lm ngy * Thuc khng calci: - Nifedipin 10mg iu tr cn au tht ngc do co cng mch (Prinzmetal) . 6.2. Ngoi cn au * Loi b nhng yu nhm khi pht cn au: - i li sinh hot, lao ng. - Nn n t mi ba n. - Trnh lnh, trnh gng sc t ngt. - Cha cc bnh: thiu mu, i tho ng. * iu tr cn nguyn: - Gim cn nng i vi ngi bo bu. - iu tr tng huyt p - iu tr tng m mu * Ch sinh ht: - C ch ngh ngi v th cht v tinh thn mt cch hp l. - C ch luyn tp theo chng trnh c quy nh c th.
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- B thuc l, king ru mnh. *Nitrit: - Dng Nitrit thng xuyn ngn chn cn au tht ngc. - Isosorbid dinitrat 10-40 mg mi ngy 3-4 ln. * Thuc chn giao cm . Propranolol80 mg x 2 ln/ ngy. * Thuc khng calci: Nifedipin dng ch yu cn au tht ngc kiu Prinzmetal. * Cc phng php ni khoa khc: - Digitan v li tiu ch nh dng khi c suy tim. - C th cho thuc chng ng ung. - Khi c ri lon nhp cn dng thuc iu tr lon nhp. - i vi ngi bn chn, lo u cho Diazepam. 6.3. Phu thut bc cu ni ng mch ch v ng mch vnh Th thut ny nhm mc ch t mt hoc nhiu mch ni gia ng mch ch v ng mch vnh. 6.4. K thut nong p trong ng mch vnh - a 1 ng thng c qu bng nh qua ng mch i n l vo ca ng mch vnh b hp. Khi t ng ch qu bng nh c bm cng lm gin ng mch vnh v p ni m v mng va. - Ch nh ny c p dng trong cn au tht ngc m iu tr ni khoa khng kt qu. 7. D PHNG 7.1. Xc nh c yu t nguy c - Thu thp ng thi cc thng tin v cc yu t nguy c phi hp cho php nh gi ton b mc rng nguy c mang tnh c th ca ng mch vnh c li khuyn c hiu. 7.2. T vn Cho c ngi b bnh v ngi cha b. - Ht thuc l: b hon ton thuc l nguy c thuc l ln hn khi c nhiu yu t phi hp. - Huyt p: cn c ch iu tr theo di cht ch. - Tng cholesterol mu: cn c iu tr cc thuc lm h m mu. - Tng cng luyn tp v hot ng th lc iu , lm gim bt cn bao hm vic gim r cc yu t nguy c. - i tho ng: iu tr v theo di cht ch phng cc bin chng c bit
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l bin chng tim mch.

NHI MU C TIM
1. NH NGHA Nhi mu c tim l hoi t mt phn ca c tim do thiu mu cc b, xy ra sau khi tc nghn ko di dng mch mu mch vnh nui dng vng . 2. DCH T HC - Hng nm M c khong 1 triu ngi b nhi mu c tim. - vit Nam trc nm 1954 ch thy mt trng hp nhi mu c tim. Bnh vin Bch Mai t nm 1989 n 1993 mi nm c ti 91 trng hp nhi mu c tim vo iu tr ti Bnh vin Bch Mai (V nh Hi - Nh xut bn Y hc H Ni 1995) - T l t vong chung Vit Nam do nhi mu c tim khong 50%. Trong
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25% t vong cha kp ti bnh vin. - Tui thng gp nhi mu c tim 50-60 tui nam nhiu gp 4 ln n. 3. NHNG YU T NGUY C GY NHI MU C TIM 3.1. Ht thuc l - Nicotin l cht c cc mnh. Ngi ln ch cn ung 50mg nicotin nguyn cht l c th gy t vong. - Thuc l gy tng cholesterol mu y nhanh s pht trin ca va x ng mch. 3.2. Tng cholesterol mu - S ri lon chuyn ha lipid ko theo s ri lon chuyn ha glucid m cc sn phm trung gian ca s ri lon chuyn ha ny l cholesterol, triglyxerit. . . , cc cht ny to nn va x ng mch. 3.3. Tng huyt p - Ch gi tng huyt p khi huyt p tm thu trn 140 mmHg v huyt p tm trng trn 95mmHg. - Tuy nhin tng huyt p khng phi l yu t duy nht gy nn va x ng mch v nhi mu c tim. Nh vy nhi mu c tim vn c th xy ra ngi c huyt p bnh thng. 3.4. i tho ng - i tho ng gy ra gim dung np glucid. Ngi ta thy ngi khng c bnh i tho ng t l mc bnh mch vnh 0,8%, ngi i tho ng t l mc bnh mch vnh 1,5% (tng gn gp i) . 3.5. Bo ph - Ngi bo ph cht v nhi mu c tim nhiu hn 40% so vi ngi bnh thng. 3.6. Nhng cng thng tinh thn 4. NGUYN NHN 4.1. Huyt khi ti mt vng ca ng mch vnh b hp do va x ng mch 4.2. Xut huyt di mng trong ng mch vnh ca mt mng va x 4. 3. C trng hp nhi mu c tim khng c tc nghn ng mch vnh trn phim chp XQ. Ngi ta ngh n co tht ko di ng mch vnh 4.4. Nhng nguyn nhn t gp - Nghn ng mch vnh do cc mu t xa a ti. - Hp l ng mch vnh do tn thng ng mch ch. - Vim ng mch trong cc bnh t min. - D dng ng mch vnh.
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4. 5. Nhng iu kin d lm nhi mu c tim xut hin - Tt huyt p, trng thi sc. - Phu thut. - Nhp nhanh, lon nhp hon ton. - Cc bnh van tim, c tim 5. TRIU CHNG 5.1. Lm sng 5.1.1. Th in hnh ca nhi mu c tim * au vng trc tim. - au d di ngm Nitroglyxerin khng . - C th xut hin lc ngh ngi hay sau gng sc, sau ba n thnh son - Km theo cm gic hi hp, bn chn, v m hi. * Khm bnh: - Chn tay lnh, huyt p ng mch bnh thng hoc thp. - Trong nhng gi u thng khng st, nhng sau nhit tng ln 3838,50C trong 2-3 ngy tr li bnh thng sau 7-10 ngy. - Nghe tim T1 yu mm, i khi nghe thy ting nga phi u tm trng hoc u tm thu. - Ting c ngoi tm mc. 5.1.2. Th khng in hnh * Th khng au: - Trong 10-15% trng hp nhi mu c tim khng au hoc ch au nh, bnh nhn ch thy tc vng trc tim. * Tai bin mch mu no: - Trn mt s bnh nhn tui cao, c khi nhi mu c tim ch bin hin di dng tai bin mch mu no. * Ph phi cp: - C bnh nhn t ngt b ph phi cp. * T vong t ngt: - 80% trng hp cht t ngt ngi ln tui l do ng mch vnh, nguyn nhn dn n cht t ngt trong ng mch vnh thng do rung tht hoc cn nhp tim nhanh kch pht tht. 5.2. Cn lm sng * in tm : - Chn on nhi mu c tim cp phi da vo nhng bin i ca phc b QRS (sng Q bnh l) . Bin i ca on ST: ST chnh c hnh vm gi l sng
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vm pardee. - V tr nhi mu: + Trc vch: V1, V2 + Trc bn: V3, V4, V5, V6 +Sau di: DIII. aVF * X quang: - XQ lng ngc c th pht hin cc du hiu xung huyt phi, hnh nh cc tnh mch phi gin rng cc thu trn. * SA tim: - Trn hnh nh SA hai bnh din thy nhng chuyn ng bt thng ca thnh tim v vch tim. * Chp lp lnh: - Chp lp lnh vi albumin c nh du bng technetium phng x cho php nh gi c chc nng tht tri, kh nng tng mu, kch thc v mc nng nh ca nhng vng gim v mt vn ng. * Cc xt nghim: - Bch cu tng 10.000 - 20.000. Tc lng mu tng. ng huyt i khi tng. - Creatin - Phosphokinase (CPK) v Isoenzym c hiu ca c tim (CK - MB) tng 3 n 4 gi sau khi nhi mu. - Lacticdehydrogenase (LDH) tng 2, 3 ngy sau khi nhi mu tng cao nht vo ngy th 5 v 7. - Men Transaminase (SGOT, SGPT) tng 12 n 48 gi khi b nhi mu. - Alpha - Hydroxybutyrat - dehydrogenase (HBDH) xut hin sau 6 - 12 gi sau cao nht vo gi th 30 - 72. 6. BIN CHNG CA NHI MU C TIM 6.1. Lon nhp tim v ri lon dn truyn - Nhp nhanh xoang, nhp chm xoang, ngoi tm thu tht, cn nhp nhanh tht hoc rung tht. - Blc nh tht. 6.2. Suy tim 6.3. Sc tim - Xut hin khi 40% c tim b ph hu - T l t vong cao, (80%) mch nh, yu, HA ng mch tt, HA tm thu di 70 mmHg, u chi lnh, xm xp m hi. 6.4. V tim
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Xut hin vo ngy th 7 v ngy th 10 thng l thng vch lin tht. C th thng thnh tm tht gy trn mu mng ngoi tim gy tnh trng p tim. 6.5. H van 2 l Nghe thy ting thi tm thu mm do hng b van 2 l. Ting thi to dn chim ton th tm thu, mnh, th rp. 6.6. Vim mng ngoi tim Nghe thy ting c mng ngoi tim 2-3h sau nhi mu. on ST chnh ln trn in tm . 6.7. Hi chng Dressler St au ngc gp khong 30% trng hp nhi mu c tim. 6.8. Huyt khi - tc mch Do huyt khi chi di gy nn, nht l i vi bnh nhn nm lu do ri lon tun hon. 6.9. au lon dng phn x chi trn Biu hin vim quanh khp vai, c th trnh c nu bit vn ng sm. 6.10. Phng thnh tim 7. CHN ON 7.1. Xc nh * ti nh hoc ni lm vic: ngh ti nhi mu c tim khi c du hiu lm sng. - Ngi trn 50 tui, thng c tng HA. - au tht ngc, ko di trn 20 pht, d di, t ngt. - Kh th, v m hi. - Bun nn, nn * bnh vin: - au vng trc tim kiu cn au tht ngc ko di. - Cho ngm cc dn cht nht khng . - vin tm bin i sng Q v on ST. - Tng cc men tim trong huyt thanh. 7.2. Chn on phn bit * Cc bnh tim mch: - Cn au tht ngc thng thng - Vim mng ngoi tim - Phng tch ng mch ch * Cc bnh h hp:
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- Tc mch phi - Trn kh mng phi t pht. * Bnh tiu ha: - Vim tu cp - Vim ti mt cp 8. IU TR 8.1. i vi nhi mu c tim cha c bin chng * Giai on trc khi vo bnh vin: - An thn Diazepam 10mg ung - Thuc gin mch vnh papaverin - Chuyn bnh nhn n bnh vin * Giai on bnh vin: - H l: nm yn ti ging, n nh d tiu, trnh cc cht kch thch. - Thuc an thn v chng au + Th xy + Nitroglyxerin 0,5mg t di li + Nu khng ht au cho propranolol 20mg (ung) x 2-4 ln/ngy. + Thuc c ch calci Nifedipin 10-20mg x 3-4 ln trong ngy. + Aminophylin 250-500mg (tim TM chm) . - Thuc chng ng: + Heparin 75 U/kg/ tim TM sau 15mg 15mg/kg/gi, Truyn TM lin tc + Aspezic 250mg ung 8.2. i vi cc bin chng - Ngoi tm thu tht: Lidocain - Cn nhp nhanh tht: sc in, to nhp tim. - Nhp chm xoang: Atropin. - Suy tim: li tiu - Sc tim: Dopamin, Dobutamin. - H/c Dressler: Corticoid - au khp: chng vim, gim au, vt l tr liu. - iu tr huyt khi: cho men streptokinase 8.3. iu tr ngoi khoa - Bc cu ni ng mch ch v ng mch vnh. - Nong ng mch vnh 9. D PHNG
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Tuyn truyn gio dc cho bnh nhn v cng ng. - Ht thuc: b hon ton thuc l. - Huyt p: c ch iu tr theo di cht ch. - Tng cholesterol: Hn ch m ng vt v nhng thc n giu cholesterol. - c khm xt v iu tr c bit khi tng > 260mg % - i tho ng: iu tr tch cc. - Tng cng luyn tp v hot ng th lc nhiu hn.

TAI BIN MCH MU NO

1. I CNG 1.1. nh ngha "Tai bin mch mu no l s xy ra t ngt cc thiu st chc nng thn kinh, thng l khu tr hn l lan to, tn ti qu 24 gi hoc gy t vong trong 24 gi. Cc khm xt loi tr nguyn nhn chn thng". Theo T chc Y t Th gii 1990. 1.2. c im dch t hc T nhiu thp k cho n nay tai bin mch mu no (TBMMN) vn l mt vn thi s cp thit. - T l mc bnh chung: theo Hi Tim mch Hoa K nm 1977 M c 1,6 triu ngi b TBMMN. - T l mi mc bnh: hng nm Hoa K c khong 5 triu trng hp b tai bin mi, phn ln xy ra sau tui 55 (Rusell 1983) . - T l t vong: Hoa K nm 1977 c khong 182 nghn ngi cht do TBMMN chim gn 1/10 tng s t vong mi loi. Theo Ruseu 1983 t l t vong giai on u l 15% v 50% bnh nhn sng st th tn ph. - Theo cc nghin cu trn th gii tuy s liu khc nhau (cao hoc thp) nhng 2 thp k qua TBMMN tng hng nm, Thi Lan t l mi mc nm 1980 l 12,7/100. 000 n 1984 l 18,7/100.000. T l t vong bt u gim, n nm 1990 Hoa K cng b t l t vong gim 27% so vi thp k trc. - Vit Nam, theo nghin cu dch t hc TBMMN 1989 - 1994 ca B mn Thn kinh trng i hc Y H Ni t l hin mc trung bnh l 115,92, t l mi mc trung bnh l 28,25, t l t vong trung bnh l 21,55. Nam gii b TBMMN nhiu hn, t l nam/n l 1/1,48. Nhm tui di 50 tui b TBMMN chim t l thp (9,5%) trong cng ng nhng li chim t l ng quan tm (36%) trong bnh vin. Tai bin th xut huyt chim 35% s bnh nhn ni tr.
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Yu t nguy c nghim trng nht l tng huyt p c 59,3% s bnh nhn trong cng ng v c 47,5% s bnh nhn ni tr. D dng mch mu no ngi tr pht hin thy 50% s trng hp c chp mch. Di chng nh v va chim t l cao (68,42%) do t ra nhu cu phc hi chc nng rt ln. Di chng vn ng l ch yu c 92,62% bnh nhn. T l bnh nhn iu tr ti nh cn cao 51%. - Theo nghin cu ca B mn Thn kinh trng i hc Y khoa thnh ph H Ch Minh nm 1994 - 1995 t l hin mc chung l 415/100.000, t l mi mc chung l 161/100.000. Yu t quan trng nht l tng huyt p chim 55% s bnh nhn. 1.3. Phn loi TBMMN gm 2 loi chnh: - Nhi mu no hoc thiu mu no cc b (nhn no) : xy ra khi mt nhnh mch mu no b tc, nghn, khu vc ti mu bi nhnh b thiu mu v hoi t. - Xut huyt no: xy ra khi mu thot khi thnh mch chy vo nhu m no. T mu no v xut huyt no khng c g khc nhau, t mu no l danh t ca cc nh ngoi khoa mang ngha cn xem xt iu tr phu thut. - Theo cc thng k cc nc u - M cho thy trong TBMMN th chy mu no, mng no chim 15%, tc mch do huyt khi 80%, lp tc mch 5%. 1.4. Nguyn nhn v cc yu t nguy c gy TBMMN * Xut huyt no: - Ch yu l tng huyt p, nht l th tng huyt p kch pht thng kt hp vi va x ng mch, i tho ng. - Phng ng mch bm sinh hay mc phi, phng ng mch - tnh mch. - U no hoi t gy chy mu. - Cc bnh do thiu yu t ng mu, suy gan nng, gim Prothrombin mu. - Bnh lxmi cp tnh. - Hi chng tiu fibrin. - Dng thuc chng ng khng ng. - Bnh st xut huyt. - Bnh vim no cht trng gy chy mu no ca Hurst. - Bnh Amyloid no. * Nguyn nhn gy thiu mu no cc b: - Va x ng mch. - Vim ng mch (ng mch thi dng) . - Phu tch ng mch.
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- Bnh a hng cu. - U no - Bnh Moyamoya. - Bnh lon sn t chc x - c ng mch no. - Do co tht mch. - Do lp mch: do mng va x, do huyt khi. * Cc yu t nguy c TBMMN - Tng huyt p - i tho ng - Cc bnh tim mch. - Ht thuc l. - Thiu mu no cc b thong qua. - Dng thuc trnh thai. - Protein niu. - Bo ph - Ung ru. - Tng dnh tiu cu. - Ri lon lipid mu. - Tng acid uric mu. - Yu t di truyn, gia nh. 2. TRIU CHNG 2.1. Chy mu no M t th thng gp l chy mu no vng bao trong - nhn u do tng huyt p ngi c tui (75%) . 2.1.1. Tin chng Thng thng nht l nhc u, nht l ban m. Km theo hay c chng mt tai. 2.1.2. Giai on khi u Thng thng t ngt, bnh nhn ng vt ra v hn m nng ngay. Nhng cng c th bt u bng nhc u d di, thc thu hp v trong vng 1 - 2 gi bc vo giai on ton pht. 2.1.3. Giai on ton pht C ba hi chng ni bt l hn m, lit na ngi v ri lon thc vt (tng tit ph qun, ri lon nhp th, nhp tim, huyt p dao ng) . 2.1.4. Tin trin
95

Khong 2/3 t vong. T vong thng xy ra trong nhng gi u hoc cui tun u. Nhng yu t tin lng xu l: hn m su, st cao ko di, ri lon nhp th, ri lon tim mch v huyt p Sau ngy th 10 tuy nguy him hn nhng vn c th c t vong v cc bin chng nhim khun ng h hp, tit niu cng nh cc ri lon nc in gii, ri lon dinh dng. V sau vn c th ti pht; hu ht u li di chng nng n. 2.1.4. Xt nghim Dch no tu hi hng, thng c nhiu hng cu. Trong mu, bch cu tng, ng tng, m tng. Trong nc tiu c ng v protein. Mch no ch cn lm khi nghi c bc mu t. 2.2. Chy mu no - mng no 2.2.1. Th chy mu no - mng no C ba bnh cnh khc nhau: - Th ti cp (lt no tht) : hn m rt nhanh, c hi chng chy mu no, hi chng mng no, hi chng v no, hi chng thc vt rt trm trng. - Th cp: ri lon thc xut hin mun hn, du hiu Babinski hai bn. - Th khng y : c bin i v mu sc v thnh phn ca dch no tu. 2.2.2. Th mng no - no Bt u bng cc cn co git ton b, lin tc hoc kiu Bravais - Jackson hoc bng cc triu chng thiu st, v sau mi thy r hn cc du hiu thn kinh khu tr. 2.3. Chy mu mng no M t th trung bnh thng gp. 2.3.1. c im triu chng - Giai on khi u: nhc u t ngt d di ri mt thc. - Giai on ton pht: ni bt l cc hi chng sau: ri lon thc, hi chng mng no, ri lon thn kinh thc vt (vn mch, thn nhit, nhp th, nhp tim) Babinski hai bn. - Tin trin: ph thuc vo nguyn nhn v mc chy mu. Trng hp nng c th hn m su, st cao, t vong. Nhng trng hp qua khi lc nguy him hay li di chng nh nhc u, ri lon tm thn. Bnh c th ti pht v ln sau bao gi cng nng hn ln trc. 2.3 2. Cc th lm sng - Th nng: t vong trong vi gi, vi ngy, co git - hn m su - ri lon thc vt nng. - Th khng y : biu hin gi to ca vim mng no - Tm thn u am. - Th khc: th tm thn, th nhc u n c. 2.3 3. Xt nghim
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- Dch no tu lc u c nhiu hng cu v sau chuyn sang mu vng, protein dch no - tu c th tng. - Mu: ng mu tng, c th km theo ng niu v ceton niu - Ur mu tng, Bilirubin, SGOT, CPK u c th tng. 2.4. Khi mu t trong no Cn c gi l mu t t pht trong no cn c pht hin v c kh nng gii quyt bng phu thut. - Lit na ngi. - Hn m ngt qung. C th hn m vi ngy ri tnh, n khong ngy th 10 li hn m li. Cng c khi hn m xy ra sau khi lit na ngi hoc hn m chp chn. - Hi chng tng p lc trong s. Khi mu t to dn v biu hin trn lm sng nh mt khi u. Khm y mt ch c 1 phn 3 trng hp c ph gai th. - Hi chng thu hay gp. Tu theo v tr c th c hi chng thu nh, thu thi dng, thu chm. 2.5. Nhn no 2.5.1. c im bnh l C th phn bit hai trng hp: tc mch (thrombus) v lp mch (embolus) . Thng cc nhnh nng v trn nhnh ny, tun hon c th b nghn bt c qung no. V th tu theo v tr tn thng m c nhng hi chng lm sng ca v no khc nhau. 2.5.2. c im triu chng - Tin chng: thng c triu chng bo ng. V d nu bn cu u th b xm phm s c mt li ni vn ng kiu Broca. Nu vo khu vc chi phi cm gic s c ri lon cm gic. - Giai on khi u: v lm sng c th c hn m, lit na ngi. - Ring i vi nhn no do tc mch th khi u thng t t. - Giai on ton pht: c th hn m va hoc nh, c ri lon thc vt mc trung bnh. - Tin trin: nu qua c giai on cp tnh (nht l ngy th 2 n th 10) bnh s phc hi dn nhng hay li di chng. Phi phng cc bin chng do nm lu. Thng c lit na ngi khng ton b, khng thun tu, khng ng u. Nu v tr tn thng bn cu no u th s c thm triu chng mt li ni vn ng kiu Broca. 2.5.3. Th lm sng - Nhng vng ng mch no gia nng: vng tn thng l v no thu trn nh v thi dng. Lit na ngi r ngn chi v mt. Nu bn cu no u
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th, s c mt li. Nu bn cu bn kia s c hi chng Anton - Babinski. Cng c khi c bn manh. Nu ch thiu mu mt khu vc nh: v d np cong - c th thy mt li kiu Wernicke. - Nhn vng ng mch no gia su: vng tn thng khu vc bao trong, mt phn nhn ui v nhn u; lit na ngi ton b, ng u v khng km theo ri lon cm gic. Nu bn cu no u th s b mt li. C th tin trin thnh lit co cng na ngi. - Nhn ton b vng ng mch no gia Hn m su vi nhiu ri lon thc vt. Lit na ngi, ri lon cm gic, mt li, bn manh. - Nhn vng ng mch no trc Lit mt chn hoc lit na ngi, r nht l chn. Tn thng thu trn v th trai. Hay c lit mt. - Nhn vng ng mch no sau. Tn thng mt trong thu thi dng, thu chm v i th. Gim hoc mt cm gic na ngi, hi chng i th, bn manh. - Nhn vng thn no. Hay gp hi chng cung no gia: lit t chi, lit lic dc hoc lit vn nhn ton b. - Nhn khu vc ng mch mc trc Tn thng xm phm bao trong v bi th. Lit na ngi khng km theo ri lon cm gic, c bn manh. - Tc ng mch bn ca hnh tu Hi chng Wallenberg: lit dy V, IX, X, hi chng tin nh. Claude Barnard Horner, hi chng tiu no mt bn. Bn i din mt cm gic au nng lnh chi. 3. CHN ON chn on TBMMN, xc nh v tr khu tr ng mch tn thng v nguyn nhn ca tai bin cn phi hi bnh k, theo di din bin bnh, phn tch c im ca bnh cnh lm sng, s dng nhiu bin php thm d nh in tim, Doppler mch, khm tai mi hng, khm y mt xem c ph n, chy mu khng, khm phn x ng t v vn nhn, o opthalmo - dynamometry nh gi gin tip huyt p ng mch cnh trong, in no nh , siu m no, chp ng mch no, ng mch ch, CT- Scanner, cng hng t ht nhn. Ngoi ra cn th cc xt nghim v ng mu (APTT, prothrombin, tan si huyt. . .) , cc xt nghim v ng mu ri rc trong lng mch, cc xt nghim v glucose, cc lipid mu.
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i vi chc dch no tu, cn thn trng ch nh v c th gy kt no nguy him, tr trng hp c bit cn cho chn on. Khi chc, bnh nhn u thp, dng kim nh, ly t dch. Trong trng hp khng lm c CT Scan v cng hng t th 2 xt nghim chnh vn l chc dch no tu v chp ng mch no. Cc tin trnh ca chn on: 3.1. Phi chng tnh trng l TBMMN? c tnh TBMMN l khi u t ngt v tin trin nhanh n nng (tnh theo giy, pht, gi) . 3.2. Loi tai bin l XH hay nhi mu no (xem bng) . 3.3. V tr tn thng ca no v ca mch mu Da vo lm sng v xt nghim c hiu: CT-Scanner, CHT, chc d DNT, chp ng mch no, Doppler. 3.4. Nguyn nhn g? (Ch cc nguyn nhn ph bin HA cao, d dng mch no, bnh tim, x va mch. . .) Bng 11: So snh tai bin XH v TMCB no
Biu hin lm sng Tam chng xut huyt: - Nhc u - Mt thc Thi gian tin ti ton pht Nhanh hoc tng bc, Nhanh (giy, pht. nng ln lin i nhanh tc trong 1 2 gi u) Triu chng TK khu tr Du hiu mng no Dch no tu R khu vc h cnh hoc Khng r. thng lan to, u th sng nn mt bn Hay gp Mu khng ng tng t trng thun nht, ph n quanh , du hiu chn p. St trong giai on ton pht, bch cu ngoi vi tng TMCB (nhi mu) Xut huyt Khng hoc ri lon y , ph bin v ko di (in thc nh hnh ngi tr XMH-MN)

Khng Trong (him c mu vi th) Chp ct lp vi tnh (CT- Vng gim t trng chp Scanner) sau 48 gi u Du hiu ton thn Khng st

- i vi tuyn c s, ni khng c cc phng tin k thut hin i, chn on TBMMN da vo triu chng lm sng, din bin ca bnh v tm cch chuyn ln tuyn trn ni c iu kin chn on su hn. 4. X TR V PHNG BNH 4.1. X tr Mc du c nhiu th nghim, cho n nay th gii cha c phng php
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no c cng nhn c hiu qu chc chn. Mt s im c nht tr: - Quan trng hng u l x tr t qu, s dng tt c cc k thut hi sc cp cu cha cn chn on k l xut huyt no hay nhn no. Song song vi hi sc cp cu phi ch trng ngay n phc hi chc nng. Ngay c khi bnh qua khi lc him ngho vn phi tip tc phc hi chc nng, hn ch di chng. 4.1.1. Ni khoa - t bnh nhn t th nm nghing an ton. - Lm thng ng th, nu cn t ni kh qun hay m kh qun, ht m di. - Th oxy qua mi lin tc hay ngt qung. - H tr h hp cho bnh nhn bng bp bng Ambu, th my nu c ch nh. - Cn bng nc v in gii, cn bng kim toan. - Nu cn, t ng thng d dy qua mi nui dng v cho thuc vo d dy. - Ch ng thuc iu tr HA khi HA tm thu > 200 mmHg: lm thng 1 nang Adalat 10mg nh 3-5 git vo di li a huyt p xung < 200mmHg, vo khong 170 - 180 mmHg. - i vi chy mu no: Dng Nimotop iu tr cc thiu ht thn kinh v co tht mch sau chy mu mng no do v phnh mch no, dng bm tim in liu bt u lmg/gi (0,25 g/kg/pht) TM. Khng dng khi c tng p lc s no nng, suy tim. Nn truyn song song mt dung dch ng trng qua mt chc ba ngay st ni tim trnh tn thng thnh mch. C th dng thuc vin 30mg cho 2 vin, c 4 gi/1n, trong 3 tun d phng khi c chy mu no do v phnh mch. + Nu chy mu no do dng thuc chng ng th phi ct ngay thuc. - i vi thiu mu no + Cn nhc dng thuc chng ng v thuc tiu huyt khi. + Thuc chng kt tp tiu cu: aspirini60 - 325 mg/ngy, Persantine 150 225 mg/ngy hoc Ticlid 250 mg 2 vin/ngy. . . + Cc thuc ci thin tun hon no: Duxil, Tanakan, Pervincamin, Cavinton, Stugeron, Lucidril hoc Nootropyl Nhng ngy u c th dng dng tim. C th dng Cerebrolysin 5 - 10 ml/ngy TM chm trong 4 tun. + Cc thuc bo v thnh mch nh vitamin C lg/ngy, rutin. + Chng ph no i vi c chy mu v nhi mu no: mannitol 20% truyn TM bt u liu 300 ml trong 30 pht, sau c 4 gi li truyn thm 100ml, tip tc trong 24 gi; Lasix 20 - 40 mg TM. DD glycerin 50% 100 ml/ngy chia lm 2 ln, ung hoc cho vo ng thng d dy va chng ph
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no, va chng c to bn. - Nu mch > 110 - 120 chu k/pht, dng thuc c ch nu khng c chng ch nh. - Nu c lon nhp tim, suy tim x tr theo phc . - Nu c cn ng kinh: carbamazepin hoc phenytoin, Iorazepam, diazepam - Khng sinh chng nhim khun ng h hp, ng tit niu, d phng nhim khun mu t trong chy mu no. - Nu chy mu no do suy gan, thiu ht cc yu t ng mu, dng thuc theo phc . - Nu st cao qu dng Paracetamol. - Khng dng thuc an thn, thuc ng tr khi bnh nhn b kch ng. - Phng chng lot bng cch xoay tr bnh nhn khi cho php, nm m hi, m nc. 4.1.2. Can thip ngoi khoa Cn nhc khi thy c d dng mch mu b v v khi mu t no hay tiu no. giai on n nh cn phi hp thm cc phng php vt l tr liu, y hc c truyn (chm cu) , liu php phn x thn kinh phc hi di chng. * i vi tuyn c s vic x tr ban u TBMMN cn thc hin: - bnh nhn t th nm nghing an ton trnh tt li v tro ngc. - m bo h hp cho bnh nhn: lm thng thong ng th, ht m di, h tr h hp bng bp bng. - Tm cch vn chuyn bnh nhn ln tuyn trn khi iu kin cho php. 4.2. Phng bnh Tai bin mch mu no li di chng tn ph nghim trng nh di chng vn ng, gim hoc mt tr tu, li cho x hi mt gnh nng, do vy phng bnh c ngha rt quan trng 4 2.1. D phng cp 1 - Chin lc cng ng (d phng khi cha xy ra tai bin) Mc tiu chnh l phng chng v hn ch va x mch, mt nguyn nhn ch yu gy tai bin bng cc bin php: - Gi HA mc bnh thng. - Ch n gim cc cht m bo ho, khuyn n cc loi tht trng, hn ch tht c mu . - Cai thuc l. - Dng thuc Aspirin: th nghim trn 22000 thy thuc M khe mnh thy
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tc dng gim t l nhi mu c tim, v t tc dng vi nhi mu no. Gia nhi mu c tim v nhi mu no c lin quan cht ch v vy Aspirin c coi l bin php d phng cp I quan trng trong TBMMN. - Cn thay i np sng phi hp tp luyn th dc u. - Pht hin v iu tr x va ng mch, tng huyt p mt cch cn bn. - Pht hin v x tr nhng d ng mch mu c th l nguyn nhn ca TBMMN. - Cn trnh nhng yu t c th to iu kin xut hin tai bin mch mu no: Stress tm l, gng sc qu nhiu, lnh t ngt, ru, cn tng huyt p. - Khi c nhng du hiu bo trc (nh nhc u qu mc, chng mt, tai, t bun chn tay, om m mt) ngi c tng huyt p, cn x tr kp thi ngay. - Qun l v iu tr bnh nhn TBMMN v nhng ngi c yu t nguy c 4.2.2. D phng cp II (D phng cc tai bin mch mu no) Tin hnh khi xut hin cc biu hin ca thiu mu cc b no hay vng mc, c ngha l khi d phng cp 1 tht bi. giai on ny d phng ch yu nhm: - Pht hin v iu tr cc yu t nguy c (huyt p cao, i tho ng, cc bnh tim) . - Dng thuc chng ng v thuc chng kt dnh tiu cu. - Phng cc tai bin mch mu no ti pht. - Phng chng lot v bi nhim; qun l v iu tr bnh nhn cng ng. * iu tr cc yu t nguy c - Chng tng huyt p: + p dng cc bin php gim trng lng c th (chng bo ph) . + n nht. + Tp th dc. + Dng thuc h huyt p u n. + Trnh dng cc thuc gy tng HA khi c bnh khc phi hp. - Cai thuc l trit Thuc l lm tng Fthrinogen mu, kch thch dnh tiu cu, tng th tch hng cu do lm tng qunh ca mu. - Chng tng cholesterol mu, c bit l tng thnh phn lipoprotein t trng thp (LDL) v gim lipoprolein t trng cao (HDL), l yu t nguy c ca nhi mu c tim v thiu mu cc b no. D phng bng ch n gim m v dng thuc gim cholesterol trong mu (Clorflbral) . - Ch n mui v kali
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n mn lm tng HA. i vi cc nc nhit i, ch nn gim mui va phi do mt mui qua m hi. Ch n t kali lm tng nguy c TBMMN c l do tng HA. B sung kim bng n thm hoa qu v rau ti. - Cai ru: Ru gy tng huyt p, tng triglycerid mu, d gy rung nh tng t. - Tp th dc c tc dng gim huyt p tm thu, tng t l lipoprotein t trng cao (HDL), gim bo ph. Th dc lm gim t l nhi mu c tim do cng lm gim t l TBMMN. - Chng bnh tng th tch hng cu: Tng th tch hng cu gy tng t l TBMMN, nht l ph n. Cn pht hin cc nguyn nhn gy tng th tch hng cu v iu tr. - Chng tng tiu cu: cn phi iu tr khi s lng tiu cu trn 600.000/mm3. - Chn thuc trnh thai c nng Estrogen thp. - iu tr bnh i tho ng - Bnh hng cu lim l bnh d giai on tim tng hay r rt u gy t l cao TBMMN. - Pht hin v iu tr sm cc bnh tim: cc bnh tim l yu t nguy c TBMMN ng hng th hai sau va x mch bao gm: lon nhp (c bit l rung nh hoc bnh tm nh), tn thng van tim (hp van hai l, sa van hai l, vi ha van hai l, vim ni tm mc nhim khun), cc tn thng c tim (c bit l nhi mu mi, nhi mu c c ti phng vch), gim ng tng khc (Akinsie segmentaire) v bnh c tim. - Cc bnh vim mch * Dng thuc - Thuc chng ng mu V c th c bin chng xut huyt nn khi dng thuc chng ng mu phi tun theo cc nguyn tc sau: + Ch dng c cc c s c trang b xt nghim m bo khng chn on nhm vi TBMMN loi XH. + i vi thiu mu cc b no (TMCBN) rng v mi ch dng sau khi b tai bin 72 gi nu c ch nh. + Bit rng cc nhi mu xut huyt hay xy ra sau mt nghn tc mch no do tim, sau trong vng 15 ngy nguy c ti pht xut huyt l 1% mi ngy. Cc thuc nh fraxiparin, khng vitamin K - Cc thuc chng kt dnh tiu cu nh: Aspirin, Ticlopidin, Dipyridamol.
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Kt lun Tai bin mch mu no l mt bnh nng hay gp ngi c tui. C th gy t vong v nu khng cht cng hay li di chng. Cn ch n tng huyt p, va x ng mch v mt s bnh tim mch c bin php phng chng, trnh xy ra tai bin.

TO BN
M U Thng thng mi ngy i i tin mt ln, lng phn ca ngi ln trong mt ngy m khong 200-300g. Phn mm ng thnh khun. Khi to bn lng phn t v kh lm cho phn rn hn bnh thng 1. S THNG GP V NH HNG CA TO BN VI BN Khong 10% dn s chu u phi s dng thng xuyn thuc nhun trng chng to bn (Hsrrison's 2000). Vit Nam cha c s liu thng k y nhng t l to bn chc chn khng cao nh chu u do s c th ca ch n nhiu x. To bn thng gp tt c mi la tui v c 2 gii nhng c xu hng cao hn ph n, ngi ln v c bit ngi cao tui. N thng khng phi l nguyn nhn gy nhng ri lon trm trng nhng gy rt nhiu phin h cho BN. Lm gim kh nng lao ng lm gim cht lng cuc sng. i khi to bn chc nng cng gp phn cho mt s tai bin tim mch nh tai bin mch mu no, nhi mu c tim. 2. NGUYN NHN TO BN 2.1. o thi phn ngi bnh thng Thc n sau khi tiu ha v hp th rut non, xung i trng. Phn ln nc c hp thu li. Phn tr nn do hn, i xung i trng sigma v c cha . Khi khi lng tng ln khong 200-300g s xung trc trng v kch thch nim mc trc trng gy nn phn x mt, rn. C nng hu mn co li, c vng hu mn m ra, i trng co bp mnh, ng thi c honh v cc c thnh bng cng co bp mnh lm tng p lc trong bng, tng phn ra ngoi. Khi c ch ny b ri lon s sinh ra to bn. 2.2. Nguyn nhn * To bn chc nng: loi ny hay gp nhng khng c tn thng i trc trng v hu mn - To bn thi gian ngn: + Thng do cc bnh ton thn nh st, nhim khun, sau phu thut. + Do dng mt s thuc gim nhu ng rut nh thuc phin, thuc an thn, st
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+ Do phn x: to bn i km cc bnh si thn, si mt, ph + To bn trong nhim c ch - To bn mn tnh + Do thi quen, do ngh nghip ngi nhiu, t hot ng. Phn nhiu do thi quen nhn i ngoi t tui u th hoc lm vic ni khng tin iu kin i ngoi. Lu dn trc trng mt dn phn x v p lc khng tng phn u n na. + Hi chng rut kch thch vo thi k gim nhu ng rut hoc co tht nhiu. + Do ch n ung t, khu phn qu t. + Do suy nhc thn kinh lm gim trng lc c, gim nhu ng rut hoc do ri lon tm thn dn n mt phn x i tin gy nn. * To bn do tn thng thc th - Do lot d dy, hnh t trng, c tng tit acid - Do cn tr ng i ca phn trong cc trng hp u i trc trng hoc u trong bng chn p i trc trng - Do cc bnh bm sinh ca i trng nh i trng di, i trng to gi phn li i trng lu v nhiu, b ti hp thu kit nc gy nn. - Do vim i trng mn tnh - Cc bnh mch mu vng hu mn trc trng nh tr. . . - Cc trng hp dnh tc sau m - Cc u no, vim no mng no, tng p lc ni s, tn thng tu sng cng gy to bn 3. TRIU CHNG 3.1. Lm sng - Hi k v tin s thi quen ngh nghip, ch n ung sinh hot cng cc ri lon tiu ha ca ngi bnh, ch yu ngi bnh i tin kh nhiu ngy mi i ngoi mt ln. Khi i ngoi phi rn nhiu, phn cng, rn, thnh cc, c th dnh theo nhy hoc mu ti - Nu to bn lu ngy c th lm cho bnh nhn cu gt, nhc u, mt ng mt mi, trng ngc - Khm xt k: s nn bng, nn dc khung i trng thy phn rn thnh chui ln nhn. Thm trc trng thy phn cng. - Khm phn: khm phn l mt ng tc cn thit chc chn bnh nhn to bn, khng nhng th cn c th nh gi mc to bn, tnh cht to bn v cc yu t khc c th pht hin trong phn ca bnh nhn nh mu, nhy

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3.2. Xt nghim - Thm trc trng: bao gi cng nn lm v rt c gi tr. Bng trc trng rng hoc c t phn rn. C th thy c cc nguyn nhn thc th vng trc trng nh cht hp, u - Soi trc trng - Soi i trng ng mm gip tm cc nguyn nhn gy to bn cao nh u, K - Chp khung i trng c thuc cn quang - o p lc thnh i trng cng c tc dng pht hin cc l do c nng Ti c s chn on to bn thng cng n gin song khng qun cc ng tc thng thng m c gi tr nh thm trc trng, khm phn nu trn 4. IU TR 4.1. Khng dng thuc - Thy thuc gio dc sc khe cho bnh nhn v chui cc s kin dn n to bn. - C gng thay i m hnh ko di nhiu nm - Tp i i tin hng ngy v ng gi - Tp th dc, i b trc khi c gng i i tin - n nhiu rau v cc cht x ko di v hng nh nht l cc bnh nhn c tui C th ni y l phng php d p dng, thc hin mi ni k c cc c s Thy thuc i hi c hiu bit nhiu v lnh vc ny v t vn tho ng. Khng nn coi y l mt bnh qu n gin, thiu quan tm thch ng. 4.2. Thuc Khi c gng nhng khng t c hiu qu mi dng thuc - Cc thuc nhun trng lm tng khi lng phn nh cht bn cellulo y l phng php ph hp sinh l hn c - Cc cht nhun trng tng nhu ng - Cc nhun trng thm thu - Ch khi lm dng thuc nhun trng c th gy mt kim, lm gim phn x i tin, tng tit nhy - i vi to bn c nguyn nhn thc th cn c iu tr nguyn nhn c hiu qu. 5. D PHNG D phng chung: tuyn truyn, gio dc trong cng ng v vai tr ca cht x trong khu phn n, vic ung nc, nht l i vi ngi lao ng trong mi trng nng nng lin tc. Khng c d phng c hiu cho to bn c nng. i vi cc to bn do
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nguyn nhn thc th th vic thng xuyn dng mt thuc lm mm phn v iu tr nguyn nhn l d phng tch cc nht.

HI CHNG RUT KCH THCH

1. M U Hi chng rut kch thch l bnh tiu ha ph bin nht trn lm sng, tuy n khng phi l bnh e da tnh mng nhng n gy nhiu phin h lo lng cho bnh nhn v l mt vn b tc cho thy thuc. Bnh c th gp c nam v n nhng thng gp n nhiu hn vi t l 4/1. L th bnh ca thanh nin v la tui trung nin Trc y quan nim v HCRKT cha c ng, tt c cc ri lon chc nng i trng, i khi c tiu trng u c gi chung l vim i trng mn. iu khng nhng khng ng m cn gy nn mt tm l cho thy thuc v bnh nhn l cn phi s dng thuc khng vim, khng sinh... nhiu khi chnh cc thuc ny lm cho bnh nng ln. Cn khm xt t m loi tr cc nguyn nhn thc th. Khi khng c cc nguyn nhn thc th vic iu tr s c hiu qu hn - Sinh l to phn trong i trng: Thc n sau khi tiu ha v hp th rut non, xung i trng. Phn ln nc c hp thu li. Phn tr nn do hn i xung i trng sigma c cha . Ti i trng cc nhu ng lun chuyn a phn i xung trc trng. Khi khi lng tng ln khong 200-300g s xung trc trng v kch thch nim mc trc trng gy nn phn x mt, rn. C nng hu mn co li, c vng hu mn m ra, i trng co bp mnh, ng thi c honh v cc c thnh bng cng co bp mnh lm tng p lc trong bng, tng phn ra ngoi. Trong qu trnh vn chuyn trong i trng, phn b ti hp thu nc. Nu v l do no i trng tng cng nhu ng s dn n phn i qua i trng nhanh khng kp ti hp thu nc sinh ra a lng. Nu c nhng ri lon i trng d c nng hay thc th u nh hng n tnh cht phn. 2. TRIU CHNG 2.1. Lm sng Cc triu chng lm sng gin on, mn tnh - au bng di thng l vng h chu tri, au qun hoc au m i khi c cn qun ln. Cn au c th do co tht i trng nhng cng c th do tng nhu ng, do sinh nhiu hi. - Ri lon bi tit phn: phn khi lng, khi to thng th c mt chu k i lng sau phn c dn ri chuyn sang to bn t ngy trc khi chuyn sang mt thi k i lng tip theo. i lng c th xy ra bt cht khi thc n thay i khi thay i iu kin sng hoc khi thay i thi tit.
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- Ri lon tri gic ni tng: bnh nhn lun cm gic bng cng phng, trung tin qu mc. Bnh nhn lc no cng c cm gic mun i ngoi, khi i ngoi c cm gic cha ht phn, khng thoi mi Ri lon tm l: c th thy tnh trng bn chn lo lng mt s bnh nhn, mt s khc li c tnh trng trm cm. i khi cc strees lm trm trng hn cc triu chng trn. - Thm khm thc th: bnh nhn lo lng. Cm gic n au vng i trng sigma. C th s thy thng i trng hoc du hiu co tht i trng. 2. 2. Cn lm sng Ni soi i trc trng khng thy c tn thng thc th. C th thy mch mu ni r di nim mc i trng, i trng co tht, c nhiu nhy, qua ni soi sinh thit loi tr cc nguyn nhn thc th ti rut. - Chp khung i trng vi barit c gi tr khi khng c ni soi - Cc xt nghim vi sinh vt ti rut c gi tr chn on cc nguyn nhn thc th - Test dung np sa gip chn on tnh trng thiu ht men lactose chn on th gi HCRKT. Khm v xt nghim chc nng tuyn gip i khi cn thit phn bit a chy do u nng gip 2.3. Cc th lm sng Lm sng ca HCRKT rt a dng. Thng thng l th tng nhu ng rut vi cc triu chng au bng, a lng, nhiu phn hn bnh thng. Th to bn vi phn kh, khi lng t hn bnh thng v thng c co tht i trng km theo. Th xen k khi lng, khi to khi co tht khi khng, lm cho bnh nhn kh chu. Trong iu tr th phi hp cn theo di cht ch trnh tc dng ph ca thuc khi bnh giai on khng ph hp. 3. IU TR 3.1. Khng dng thuc i hi thy thuc phi kin nhn. iu quan trng l lm bnh nhn yn tm, Bit bnh khng dn n vim rut mn, khng dn n u i trng ung th i trng. Cn t vn, gii thch bnh nhn hiu y l bnh mn tnh, khng th cha khi hn m bnh l thnh cng ln cho c thy thuc ln bnh nhn. Bnh nhn phi thch nghi dn vi bnh "Chung sng ho bnh" c l l thut ng vui nhng ng trong trng hp ny. Thy thuc khng c m ch bnh sinh ra l do tm l bnh nhn ch khng c nguyn nhn thc, iu ny tai hi lm cho bnh nhn phn i v khng tin thy thuc. Nh vy hiu qu t vn v iu tr khng dng thuc s gim nhiu. Ty vy vn phi nhn mnh vai tr ca cc stress tm l, thn kinh c nh hng xu n bnh. Tt c s t vn trn phi c thc hin sau khi tm hiu k khm xt t m
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v lm mt s thm d cn thit. iu ny khng nhng gip loi tr cc nguyn nhn thc th m cn gip bnh nhn tin tng iu tr. 3.2. iu tr thuc Ch yu l iu tr triu chng: to bn c th cho nhun trng tng khi lng, tng nhu ng. a lng c th cho cc thuc khng tit chon, loperamid, dicyclomin. Cc thuc an thn v cc vitamin thng c coi l iu tr h tr. 4. D PHNG D phng chung bng cch ch n hp l, gii thot cc stress. D phng trong cc trng hp c nguyn nhn thc th l iu tr nguyn nhn.

CHN ON V IU TR THIU MU
1. NH NGHA Thiu mu c nh ngha l mt s gim st khi lng hng cu trong h thng tun hon, tiu chun thng l Hemoglobin (Hb) < 12g/dl; Hematocrite (Hct) <36% n v Hb < 14g/dl; Hct <41% nam [5]. Tuy nhin, trong mt s trng hp, nhng tr s v mu khng phn nh ng nhng bin i v khi lng hng cu. Th d Hb, Hct tng gi to bnh nhn gim th tch huyt tng cp nh bng rng, mt nc nng. Ngc li cc tr s ny c th thp gi to bnh nhn c tng th tch mu nh khi ph n c thai hay suy tim xung huyt. Nhng tr s bnh thng v mu c s khc nhau theo la tui. Cc tr s mu ph n ni chung thp hn nam gii (cng tui) khong 10%. cc vng ni cao, tr s mu cao hn tng ng vi cao chnh trn mc nc bin. Thiu mu c th c xc nh khi tr s mu thp hn 10% tr s trung bnh ca tng gii. Song v lng Hb bnh thng thay i gn gii hn, nn vic xc nh thiu mu nh c th khng chc chn. 2. C IM DCH T HC THIU MU Thiu mu l mt bnh rt ph bin Vit Nam, nguyn nhn gy thiu mu rt nhiu, Vit Nam c th gp hu ht cc nguyn nhn, ring bnh thiu mu hng cu khng l do thiu vitamin B12 th hu nh cha gp Ni chung thiu mu thng gp hn ph n c bit l ph n c thai v tr em. Theo nghin cu ca Vin dinh dng ti mt s vng min bc Vit Nam (nm 1990) thy t l thiu mu ph n c thai nng thn l l 49% v thnh ph H Ni l 41%. Nm 1995, trong mt iu tra ton quc v thiu mu cho thy:
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T l thiu mu tr 6 thng n 24 thng tui l 60,5%. T l thiu mu tr 24 n 60 thng tui l 29,8%. T l thiu mu ph n khng c thai l 41,2% ' T l thiu mu ph n mang thai l 52,3%. T l thiu mu nam trng thnh l 16,5%. Theo cc vng sinh thi th t l thiu mu cao nht l Ty Nguyn, tng i thp l vng ng bng Bc B [3]. 3. TRIU CHNG THIU MU Triu chng ca thiu mu ph thuc rt nhiu vo nguyn nhn, mc thiu mu, thiu mu xy ra nhanh hay chm v kh nng thch nghi ca c th. Bnh nhn cng ln tui th kh nng thch nghi cng kh khn, thiu mu xy ra trn bnh nhn c sn cc bnh c bit l tim - phi th c th gy cc triu chng trm trng hn. Mc d mc thiu mu nng nhng c th vn c th chu ng c nu nh thiu mu pht trin t t. Nhng ni chung khi Hb < 7g/dl s c cc du hiu thiu oxy t chc (mt mi, hoa mt chng mt, tc ngc, kh th. . .) . C mt s triu chng chung cho mi loi thiu mu, bt k do nguyn nhn no. - Xanh xao da v nim mc: Thng r rt nht lng bn tay, m mng cc ngn, nim mc mt - ming. Mng tay, u ngn c th kh t li, mng tay c kha do s phn phi li mu. - Cc ri lon thn kinh: D b ngt, thong ngt. Thng tai, hoa mt, chng mt nht l khi ang ngi m ng ln. Ngi rt hay mt, kh ng, km tp trung. - Ri lon tun hon:. Cm gic trng ngc p mnh, nht l khi gng sc. Khm thy tim p nhanh, c th nghe thy ting thi tm thu c nng. Tu theo mc v thi gian thiu mu, tim s to ra v c bnh cnh suy tim r rt nhng c im c bit l y t khi thy tm ti do t l Hb thp. - Ri lon tiu ha: Chn n, nn, a chy hoc to bn do nhu ng d dy- rut khng u l hu qu ca lu thng mu ni tng km. - Ph n hay b ri lon kinh nguyt (mt kinh) . Nam g c th b bt lc. - Chuyn ha c bn ha tng v nhiu khi ngi bnh cm thy si nh. - Trong trng hp thiu mu do tan mu thng c vng da v lch to. 4. CC XT NGHIM CN LM 4.1. o Hemoglobin (Hb) v Hematocrite (Hct)
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Xt nghim ny dng nh gi khi lng hng cu gip chn on xc nh thiu mu. Cn lu n tnh trng th tch mu ca bnh nhn. Ngay sau khi mt mu Hb vn c th bnh thng v c ch b tr cha c thi gian lp li th tch huyt tng bnh thng. Trong khi c thai Hb thng thp trong khi khi lng hng cu li bnh thng v tng th tch huyt tng. 4.2. m s lng hng cu li Xt nghim ny phn nh mc sn xut hng cu v l mt ch dn v tnh trng p ng ca tu xng i vi thiu mu. S lng hng cu li thng c tnh bng t l hng cu li/100 hng cu. Ch s hng cu li (Reticulocyte IndexRI) hiu chnh cho mc thiu mu v c nh c s p ng thch hp ca tu xng. RI = [% hng cu li x Hct bnh nhn/ Hct bnh thng]: 2 RI > 2- 3% cho thy mt p ng y , nu thp hn chng t c yu t gim sinh gy thiu mu, ngc li, tng hng cu li gi c tan mu. 4.3. Th tch trung bnh hng cu (MCV: Mnh Corpuscular Volume) MCV l mt tiu chun dng nh gi kch thc trung bnh ca hng cu v thng c dng phn loi thiu mu. Bnh thng MCV 80- 90 fl (m3) Khi MCV < 80 fl: thiu mu hng cu nh Khi MCV > 100 fl: thiu mu hng cu to Thng thng, thiu mu hng cu to thng u sc, thiu mu hng cu trung bnh thng ng sc, thiu mu hng cu nh thng nhc sc. 4.4. Kho st lam mu ngoi bin (Huyt ) y l xt nghim rt quan trng trong vic nh gi bnh nhn thiu mu. C th pht hin s thay i kch thc hng cu (hng cu to nh khng u), thay i hnh dng (hng cu bin dng), nhng thay i ny gip chn on cc loi thiu mu c hiu. Chnh v vy, xt nghim ny c bit quan trng chn on bnh tan mu, hu ht cc thiu mu tan mu u c thay i v hnh thi. Ngoi ra, xt nghim ny cn cho ta bit v tnh trng bch cu v tiu cu. 4.5. Xt nghim tu Xt nghim ny c ch nh trong trng h thiu mu cha r nguyn nhn, cho bit phn ng ca tu xng v s sinh sn hng cu v pht hin cc t bo l. 4.6. Xt nghim phn y l xt nghim n gin, rt c ngha trong sng lc nguyn nhn thiu mu m c th p dng tuyn c s. C th soi phn tm trng k sinh trng ng rut, c bit l giun mc. C th lm phn ng Weber Meyer tm hng cu trong phn. 5. CHN ON
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5.1. Chn on xc nh Chn on xc nh thiu mu thng d, ch yu da vo: - Da xanh xao, nim mc nht nht: y l du hiu khng chc chn, hn na du hiu ny thng ch r rt khi Hb < 10g/dl. - Mng tay kh, c kha, tc d rng: du hiu ny thng gp trong thiu mu mn tnh. - Chc chn nht phi da vo xt nghim Hb, Hct. Ni chung, trong trng hp thiu mu r vic chn on thiu mu c th da vo cc triu chng lm sng, xt nghim mu c gi tr khng nh chn on (nht l nhng trng hp thiu mu nh) ng thi cho ta bit mc thiu mu. 5.2. Chn on mc thiu mu: 3 mc . * Thiu mu mc nh: - Cc triu chng lm sng thng khng r rt. Bnh nhn c th mt, nh trng ngc, kh th nh khi gng sc. - Xt nghim mu: Hb gim nhng vn > 10 g/dl. * Thiu mu mc trung bnh: - Cc triu chng lm sng r rt hn, da xanh, nim mc nht. - Xt nghim mu: Hb t 7- 10 g/dl. * Thiu mu mc nng: - Bnh nhn thng c biu hin triu chng khi ngh ngi v khng chu ng c s gng sc. Bnh nhn thng ku chng mt, tai, au u, hoa mt. . . - Xt nghim mu: Hb < 7 g/dl. 5.3. Chn on bin chng * Suy tim ton b: y l bin chng nng n nht, thng xy ra trong trng hp thiu mu nng v ko di. Khi Hb < 7,5 g/dl, cng tim lc ngh tng r rt c v nhp tim ln cung lng. Nu thiu mu nhiu s xut hin ting thi nghe r mm tim v van ng mch phi. Thiu mu nng v ko di s lm cho tim to ln do tng lin tc lu lng tim. Triu chng suy tim s xut hin nu mc d tr c tim ca bnh nhn b suy gim khng cn kh nng b tr. c im ca suy tim do thiu mu l suy tim ton b v suy tim vi cung lng tim cao. Tt c cc triu chng ny s lui dn khi lng Hb tr v bnh thng. * Cc tc hi khc ca thiu mu: - Thiu mu lm gim kh nng lao ng, khng c kh nng lm vic nng v lm vic ko di. - Thiu mu gy cm gic lun mt mi ko di, mt kh nng tp trung lm vic v hc tp.
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- Tr nh b thiu mu ko di c th dn n chm pht trin th cht v tinh thn. - i vi ph n c thai, thiu mu lm tng nguy c cht m, trong k sinh ngi m thng yu v c th b chy mu nng. Thiu mu cng lm tng nguy c mc bnh v t vong tr, tr sinh ra thng c cn nng thp, tr yu v c nguy c t vong cao. 6. NGUYN NHN THIU MU Thiu mu do nhiu nguyn nhn gy ra, c nhiu cch phn loi thiu mu, sau y phn loi da trn ng hc hng cu. Thiu mu vi ch s hng cu li thp gi c s suy gim sn xut hng cu, ch s hng cu li tng cao thng lin quan n cc nguyn nhn do mt mu hoc ph hu hng cu. Xc nh MCV cng nh xt nghim huyt h tr thm cho vic xc lp chn on. 6.1. Thiu mu do gim sn xut hng cu (Ch s hng cu li thp) 6.1.1. Thiu mu th tch trung bnh hng cu thp * Thiu st: y l ri lon c bit hay gp Vit Nam, i tng thng gp l ph n. Trong trng hp khng c chy mu do kinh nguyt, mt mu d dy- rut c coi nh l nguyn nhn chnh bnh nhn trng thnh. Tnh trng hp thu st (bnh a chy phn m, sau ct on d dy) hay tng nhu cu st (c thai, cho con b, tr em) cng c th dn n thiu st. nc ta nhim giun mc l nguyn nhn rt ph bin khu vc nng thn. * Thalassemia: y l bnh ri lon v s lng huyt sc t, y l bnh di truyn c h hi n kim sot chu trch nhim iu ho s tng hp cc chui Polypeptid ca globin, en kim sot b h hi th t l sn xut cc chui s b thay i. Bnh thng gp vng a Trung Hi, n , Trung Quc v ng Nam . * Thiu mu trong cc bnh mn tnh. * Nhim c ch. 6.1. 2. Thiu mu th tch trung bnh hng cu cao: * Thiu mu hng cu to: - Thiu vitamin B12 - Thiu acid Folic - Do thuc * Nghin ru * Hi chng ri lon tu xng * Thiu nng tuyn gip 6.1.3. Thiu mu th tch trung binh hng cu binh thng:
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- Thiu mu suy tu - Thiu mu trong cc bnh mn tnh - Thiu mu o suy thn mn tnh - Thiu mu lin quan n cc bnh ni tit - Thiu mu do thm nhim tu xng 6.2. Thiu mu do tng hu hoi hng cu (ch s hng cu li tng i bnh thng) 6.2.1. Chy mu 6.2.2. Thiu mu huyt tn di truyn * Bnh huyt sc t. bnh hng cu hnh lim * Thiu men hng cu: thiu G6-PD * Bt thng ca protein cu trc hng cu: bnh hng cu hnh bi 6.2.3. Thiu mu huyt tn mc phi * Do min dch trung gian - Khng th nng - Khng th lnh * Do thuc: hay gp nht l do Methyldopa. * Huyt sc t niu m kch pht * Thiu mu huyt tn do bnh vi mch * Huyt tn do chn thng * Cc bnh gan * Cng lch 7. IU TR 7.1. iu tr triu chng thiu mu Cng nh cc bnh khc, iu tr thiu mu c hiu qu hay khng cn ph thuc vo chn on, khng c l do g cho cc thuc to mu nh st, vitamin B 12 hay acid folic khi cha c bng chng hay bit trc thiu cc cht . Vic s dng khng hp l cc ch phm st trong thi gian di c th gy tnh trng tha st. Nhiu loi thiu mu c th cha khi nu nguyn nhn thc y bnh c pht hin v loi tr. Nu thuc hay c tm nguyn nhn, th khi loi b thuc hay ha cht , bnh s hon ton bnh phc. Truyn mu (truyn hng cu) c ch nh tng kh nng vn chuyn oxy ca mu cho bnh nhn thiu mu khi thiu mu gy tnh trng cung cp oxy cho t chc km. Vic cung cp oxy cho m y thng ch t c khi Hb t mc 7- 8 gii bnh nhn c th tch mu bnh thng. Mt n v hng cu ng ti s lm tng Hb thm 1 g/dl (Hct 3%) ngi trng thnh trung bnh.
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Tnh trng cp tnh v mc nng ca thiu mu quyt nh c iu tr truyn mu hay khng. Vic s dng cc ch phm mu t ngi bnh trc nhng nguy c b mt tc dng c hi, c th e da tnh mng. Li ch v nguy c ca truyn mu cn phi cn nhc k trong tng trng hp. Thiu mu nng xy ra nhanh (v d: xut huyt tiu ha cao lm Hct gim < 25%, km theo gim th tch) l c ch nh truyn mu. Thiu mu mn tnh (v d: thiu st, thiu vitamin B12) k c nng cng khng nht thit phi truyn mu nu nh bnh nhn chu ng c. Tnh trng gim khi lng hng cu ng k c th c chu ng tt, nht l bnh nhn tr hoc t phi i li. t khi phi ch nh truyn mu cho bnh nhn thiu mu mn tnh m Hb > 9g/dl. C th tit kim truyn mu cho bnh nhn c p ng iu tr tt vi cc yu t c hiu nh st, acid hay vitamin B12. Nu thiu mu gy suy tim xung huyt hay thiu mu c tim phi ch nh truyn khi hng cu ngay, song phi thn trng. Ni chung ch truyn mu ton phn cho bnh nhn gim th tch mu. Tui bnh nhn, nguyn nhn v mc nng ca thiu mu, s c mt ca nhng bnh khc nh cc bnh tim phi u cn phi xem xt khi xc nh s cn thit phi truyn mu. Nu nguyn nhn ca thiu mu d iu tr c (nh thiu st hay thiu acid folic) tt nht l trnh truyn mu. Hng cu khng nn c dng lm cht tng th tch kch thch vt thng chng lnh hay tng s d chu hn nu cc triu chng khng c lin quan g n thiu mu. 7.2. iu tr c hiu * Thiu mu thiu st: Phi kt hp iu tr nguyn nhn (ty giun mc, cha lot d dy-t trng) vi bi ph cho d tr st. Ung hoc tim cht st, n ch n bnh thng s p ng s lng mt hng ngy, vi iu tr, s lng hng cu li s t nh cao nht trong 5 - 10 ngy v Hb s tng ln trong vng 1- 2 thng. - iu tr bng ng ung: Tt nht nn dng st sulfat 300 mg, ngy 3 ln trong 3- 6 thng thng s iu chnh c thiu mu v phc hi d tr st. Nn ung thuc trong ba n hn ch tc dng ph d dy- rut. Gluconat v Fumarat st nn dng iu tr xen k. - iu tr bng ng tim: p dng cho nhng bnh nhn hp thu km (vim rut, km hp thu), nhu cu v st ln khng th b bng ng ung hoc khng dung np cc sn phm ng ung. Dextran st (Imferon) thng c dng hn c, thuc c th tim bp hay tim tnh mch. C th c tnh lng st cn dng theo cng thc sau: St (mg) = (Hb bnh thng - Hb bnh nhn) x 2,21 + 1000 S lng ny s phc hi khi lng hng cu v cung cp 1000 m cho d tr st.
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Liu lng thng l 1 ml (50 mg)/ ngy, tim bp. * Thiu acid Folic: Tnh trng ny ph bin ngi nghin ru, km hp thu, dng thuc trnh thai. Ung acid Folic 1 mg/ngy n khi iu chnh c thiu ht. Vi ngi km hp thu thng phi dng liu 5 mt ngy. * Thiu vitamin B12: Nguyn nhn do thiu mu c tnh, ct on d dy, thiu nng tuyn tu, vim hoc ct on hi trng. Cch dng: vitamin B12 tim bp 1000 g/ ngy trong 7 ngy, sau c 1- 2 thng li tim 1 tun. iu tri di hn 1000 g/ thng. * Thiu mu trong suy thn mn: Hin nay thiu mu bnh nhn suy thn c th c iu tr c kt qu tt bng Erythropoietin. iu tr c ch nh cho c bnh nhn trc thm phn v giai on cui ca bnh. iu tr bnh nhn c Hct > 30 % thng t c kt qu. Thuc c th dng ng tnh mch ( bnh nhn thm phn mu) hay di da (Bnh nhn trc thm phn). Liu lng u tin cn tng Hct ln n 30% thng l 50- 150 UI/ kg, 3 ln/ tun. C th dng tim di da 1 ln/ tun. Cn m bo cung cp st y cho bnh nhn. * Thalassemia: Ch yu l truyn mu duy tr Hb > 9 g/dl, b sung acid Folic, ct lch, ghp tu t thn. * Thiu mu huyt tn t min: iu tr c bn bng Glucocorticoid. Ung Prednisolon 1 - 1,5 mg/kg/ ngy cho n khi Hct n nh v cn ko di 3 - 4 thng. Trn 80% bnh nhn c p ng nhng thng ti pht. C th thuc c ch min dch nh Azathioprin, Cyclophophamid c hoc khng kt hp vi Glucocorticoid. Ct lch c ch nh cho nhng bnh nhn khng p ng vi Glucocorticoide. Ngoi ra cn c th lc huyt tng hoc dng globulin min dch. * Thiu mu trong cc bnh mn tnh: iu tr trc tip vo cc nguyn nhn chnh v phng nga cc yu nhm nng thm nh suy dinh dng, cc thuc c ch tu xng. Erythropoietin c th dng trong thiu mu trong cc bnh c tnh v vim nhim. * Bnh thiu mu hng cu hnh lim: Dng Hydroxyurea kt hp vi b sung acid folic, iu tr sm cc nhim khun, c th ghp tu. * Thiu mu bt sn:
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Dng globulin chng t bo tuyn c, ghp tu. * Thiu ht men G 6- PD: Ch yu trnh cc yu t thc y bnh nh nhim khun, thuc Sulfamid, Quinin 8. PHNG BNH THIU MU - Tuyn truyn khuyn khch n thc n giu st v folat nh tht, c, ph tng Cc loi rau qu cha nhiu vitamin C v acid chc gip cho hp thu st tt hn ng thi cha nhiu folat. - Nng cao ch dinh dng ton dn, c bit ch n cc i tng nguy c cao l ph n mang thai v tr em. Nu cn thit th cho ung b sung vin st (Tardyferon B9 probofex. . .) . - Tch cc chng nhim mi trng bng mi bin php, ch trng vo vic xy dng v s dng h x ng quy cch, bo v ngun nc sch v v sinh mi trng phng cc bnh giun sn, st rt. - Thc hin tt k hoch ha gia nh.

UNG TH PHI
1. I CNG V DCH T HC Ung th phi l bnh thng gp, trong ung th ph qun thng gp hn c. L ung th thng thy nht nam gii. - Vit Nam: theo thng k ca Trung tm u bu thnh ph H Ch Minh thy ung th phi ng hng th 2 sau ung th gan - nc ngoi: ung th ph qun gia tng cng vi s gia tng ht thuc l t l cht v ung th ph qun ngy cng tng. Nm 1995 c khong 174000 ngi ung th mi M, ung th phi chim 33% s t vong nam v 28% do ung th n. 2. NGUYN NHN, CC YU T NGUY C - Gii: Php thy ung th ph qun gy t vong nam gii ng hng u trong cc loi ung th, t l nam/ n l 6/1. - Tui: thng gp nht l tui 40-60, di 40 tui v trn 70 tui t gp hn. Tuy vy vn c th gp bt k la tui no. - a d: cc nc cng nghip pht trin, ung th phi rt thng gp, thnh th mc gp 5 ln nng thn. - Thuc l: mt s nc trn th gii ung th ph qun tng ln vi lng
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thuc l tiu th, t l ung th ph qun ngi nghin thuc l cao hn rt nhiu. Theo Harrison th 90% trng hp ung th phi l ngi nghin thuc l. Trong khi thuc l c nhng cht c kh nng gy ung th l Hydrocarbure thm a vng nh 3 - 4 Benzopyren, Dthenzanthracen - Kh quyn b nhim: kh thi cng nghip, hi t gia nh - Ngh nghip: cng nhn lm m c cht phng x nh Uranium. Ngi tip xc vi Nikel carbonyl, cromate, Amiante, than, nha, kh t Lp biu m ph qun c din tch 60-90m2, do din tch ln nh vy nn ph qun l ni d b tc ng bi cc nguyn nhn gy bnh v cc yu t nguy c. - Cc yu t khc: di truyn, bnh ph qun phi cha c chng minh. 3. TRIU CHNG LM SNG S pht hin sm ung th ph qun phi rt quan trng cho iu tr v tin lng bnh nhng kh khn v khng th chp Xquang v lm xt nghim t bo hc hng lot, nn vic tuyn truyn gio dc sc khe cng ng l quan trng gp phn cho chn on sm. 3.1. Giai on tim tng - Triu chng ph qun: a s ung th vng rn phi lc u biu hin ho khan hoc khc m, ho ko di, dng cc thuc iu tr triu chng khng , ngi nghin thuc l cng hay ho nn nhiu khi kh chn on. Do vy ngi c tui nghin thuc l m c cc triu chng trn cn c khm bnh v chp phi pht hin bnh sm. - Ho ra mu: 50% bnh nhn c triu chng ny. Ho ra mu rt t ln m, thng ho v bui sng v ko di trong nhiu ngy. C th nghe thy ting rt ph qun (chng t khi u lm tc ph qun khng hon ton) . - Hi chng vim ph qun phi cp hoc bn cp: thng gp trong ung th ph qun ln, c biu hin nh vim phi hoc ph qun ph vim. Cn ngh n ung th khi bnh nhn ht st, khng ho, khng khc m nhng hnh nh Xquang vn cn tn ti trn 1 thng. 3.2. Ung th tim tng Ung th ph qun nhiu khi khng c triu chng g v lm sng, nht l ung th dng biu b do vy c 6 thng nn chp kim tra li phi mt ln. 3.3. Nhng du hiu chng t ung th lan to - au ngc: khng c v tr au r rt, thng au dai dng bn tn thng, c khi au quanh b vai, mt trong cnh tay (hi chng Pancoast- Tobias), l nhng trng hp ung th nh phi. Triu chng ny d b b qua. - Kh th: khi tc ph qun v xp phi hon ton, nu khi u ng ba kh ph qun th kh th kiu thanh qun v c ting c c, c th kh th do lit c honh.
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- Kh ni: ging khn, ging i do thn kinh qut ngc b chn p. - Kh nut: do thc qun b chn p. - Hi chng chn p tnh mch ch trn: ph kiu o khoc, c tun hon bng h ngc v lng, mi tm. - Hi chng trn dch mng phi: ung th di cn vo mng phi. Cn chc dch. mng phi xt nghim t bo, sinh thit mng phi, soi mng phi. - Hi chng Claude-Bernard-Horner: do chn p thn kinh giao cm c: thy na mt , khe mi mt hp, ng t nh, nhn cu tt v pha sau. 3.4. Du hiu ngoi phi - St cn > 5% trng lng c th trong 6 thng, st nh. - Hi chng Pierre- Marie: ngn tay di trng, au khp. - C th c v to mt bn hoc hai bn nam gii. - Hi chng Cushing tin trin nhanh, hoc hi chng Schwartz-Barter (gim natri trong mu, khng c suy thn hoc tuyn thng thn) . 4. TRIU CHNG CN LM SNG - Xquang phi: chp thng, chp nghing, chp chch, chp ct lp. Thy bng m phi, pht trin theo thi gian. Hoc thy hnh nh xp phi mt phn hay ton b. Chp ph qun c bm thuc cn quang thy ph qun b hp, hoc ph qun b ct ct, b y. - Ni soi ph qun: rt cn thit, kt hp sinh thit chn on m hc. - m: tm t bo ung th (cho bnh nhn nh rng xong khc su ly m 3 bui sng lin) . - Mu: tc lng mu tng, bch cu c th tng, hng cu bnh thng hoc gim. - Chc nng h hp: CV gim, VEMS gim, nu ch s Tiffeneau di 50% th khng c ch nh phu thut. 5. CHN ON 5.1. Chn on xc nh Da vo lm sng v cn lm sng. 5.2. Chn on sm Nu nam gii 45 tui tr ln, nghin thuc l, c ho khan v khc m ko di, th c 4 thng 1 ln cho chiu hoc chp phi, v ly dch ph qun, m xt nghim t bo. Do vy vn tuyn truyn gio dc sc khe ti cng ng l rt quan trng. 5.3. Chn on phn bit
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V ung th ph qun phi c biu hin lm sng m h, ko di v a dng, nn hay nhm vi: Lao phi Vim thu phi p xe phi giai on u Trn dch mng phi do lao Nhi mu phi. Cho nn cn khm bnh ton din, theo di din bin ca bnh nhn trnh nhm ln. 5.4. Chn on giai on ung th * p dng cho ung th phi tin pht (T- Tumor) chia 4 giai on: TX: ung th kn o khng c triu chng lm sng v Xquang, ung th ch nim mc cha lan xung mng y, ch c th pht hin c bng cch xt nghim t bo trong dch ra ph qun. T1: khi u c ng knh nh hn 3cm, khng lm tc ph qun. T2: khi u c ng knh ln hn 3cm, c trn dch mng phi. T3: khi u to v lan gn n mng phi, thnh ngc, c honh, trung tht, c trn dch mng phi. * Ngi ta cng quy nh hch lymph ti ch (N- node) NO: khng c hch rn phi v trung tht. N1: c hch rn phi. N2: hch trung tht, c chn p thnh phn trung tht, thn kinh, thc qun, kh qun. * Di cn (M- Mtastase) : MO: khng c di cn. M1: di cn no, gan, xng Kt hp khi u, hch, di cn xp 4 giai on: 1. Giai on tim tng: 2. Giai on I: TX, NO, MO Tl. , NO, MO hoc Tl, Nl, MO hoc T2, NO, MO 3. Giai on II: 4. Giai on III: T2, Nl, MO T3, vi N hoc M bt k, hoc N2 vi T hoc M bt k, hoc M1 vi T hoc N bt k Ch nh phu thut giai on I v II.
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6. IU TR Nhm hai mc ch: - Hn ch khi u pht trin. - iu tr triu chng v bin chng. 6.1. Hn ch khi u pht trin - Phu thut: nu ung th giai on I v II. Nu ung th th pht (ung th tng khc di cn n) th khng c ch nh phu thut. - Tia x: dng Cobalt 60 - Ha tr liu: Dng thuc hu hoi Nucleoprotein nh: Dcgranol, Endoxan, Myleran. Thuc chng phn bo: Aminopterine, Methotrexate, 6 MP. Khng sinh chng ung th: Actinomycin-D, Bleomycine. - Min dch tr liu: Dng BCG. C th phi hp cc bin php iu tr. 6.2. iu tr triu chng v bin chng - Chng nhim khun: dng khng sinh phi hp. - Gim ho: cc dn xut t thuc phin. - Chng au: cc thuc gim au v an thn. - Chng kh th: chc ht dch mng phi, thuc gin ph qun, corticoid 7. PHNG BNH - Pht hin bnh sm, ch cc i tng c nguy c ung th ph qun cao nh nam gii trn 45 tui, nghin thuc l lu nm, lm vic mi trng nhim bng cch: Chp phi hng lot. Tm t bo ung th trong m. - Tuyn truyn rng ri chng ht thuc l, bo v mi trng sng.

LEUCMIE CP
1. NH NGHA Leucmine cp l bnh mu c tnh trong ch yu l tng sinh bch cu non loi cha bit ha hoc bit ha rt t do trong tu v huyt c khong trng bch cu. 2. NGUYN NHN Hin nay cha xc nh c nguyn nhn, bnh thng gp tr em v ngi
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tr tui khng phn bit nam v n. Tuy nhin ngi ta cng cng nhn mt s yu t thun li. Nhng ngi thng xuyn tip xc vi tia X hoc cc tia phng x nh nhng ngi lm vic khoa X quang hoc cng nhn m rt him, c bit nhng nn nhn ca cc v tai nn hoc chin tranh ht nhn nh v nm bom nguyn t Nht Bn hoc v r r ca nh my in nguyn t Trec- n-bn. Nhng ngi thng xuyn tip xc vi ha cht c hi nh Toluen, et xng. C tc gi cn cho rng do virus thng, nht l virus cm trong cm c tnh. 3. SINH L BNH Theo nh ngha y l bnh sinh ra do tng sinh bch cu non cha bit ha nhng t bo ny s ln t s sn sinh nhng t bo khc nn dn ti nhng hu qu sau: - Ln t dng hng cu: hng cu c sn sinh ra t, hu qu l thiu mu trn lm sng v xt nghim. - Ln t dng tiu cu: thiu tiu cu nn lm sng c hi chng xut huyt vi tnh cht xut huyt gim tiu cu - xt nghim dng tiu cu cng gim. - Bn thn dng bch cu mc d tng v s lng nhng thiu nhng bch cu trng thnh nn kh nng chng nhim trng b suy gim. - Nhng t bo non cha bit ha rt d thm nhp vo nhng t chc lin vng nh gan, lch, hch lm cho nhng t chc ny to ra. Vi cch gii thch ny ta d dng hiu c ti sao th in hnh biu hin bng nhng hi chng lm sng tng ng m chng ti s trnh by sau y. 4. TRIU CHNG 4.1. Th in hnh Mc d gi l th in hnh nhng triu chng lm sng ch mang tnh cht gi ta ngh n mt bnh v mu cn quyt nh chn on phi da vo huyt v tu . tuyn c s v cng ng khng th chn on c cn chuyn bnh nhn n c s c th xt nghim c chn on. - Triu chng u tin bao gi cng c l st. Thng l st cao lin tc c th dao ng st ko di sut qu trnh tin trin ca bnh cc thuc h st thng thng khng h c st ch ch khi iu tr c lui bnh st mi c ci thin. - Thiu mu: cng ging nh thiu mu khc l gim s lng hng cu v huyt sc t nhng thiu mu y c c im l thiu mu rt nhanh v nhiu, c khi ch trong vng 1 tun hoc 10 ngy ngi bnh thiu mu rt nng. - Xut huyt: Cng vi st v thiu mu xut huyt c th xut hin rt sm mang tnh cht ca xut huyt gim tiu cu ngha l xut huyt t nhin, nhiu ni nu xut huyt di da a hnh thi v nhiu la tui, du hiu dy
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tht (+) . - Gan, lch, hch to: thng l to t ch l mt nhng thng l to nhanh ch trong vi ngy s thy lch, ngi bnh c th au. - Hi chng lot: thng lot ming, li, vng hng hu. Trn lot c th ph mt lp mng trng bn, ng vo d chy mu, nu khng rt d nhm vi gi mc trong bnh bch hu. - Triu chng cn lm sng: vi nhng triu chng lm sng trn bt buc ta phi chuyn bnh nhn ln tuyn trn, ti thiu phi l tuyn bnh vin tnh c th lm tu v huyt chn on xc nh. Huyt : - S lng hng cu gim nng - S lng tiu cu gim tp trung km - S lng bch cu tng nhng ch yu l nhng bch cu u dng cha bit ha hoc bit ha t. Trong bch cu trng thnh rt t xut hin khong trng bch cu. - Tu : tu giu t bo nhng ch yu l t bo dng bch cu m l nhng bch cu non u dng xut hin khong trng bch cu. Trong khi dng hng cu v tiu cu b ln t nng. - Thi gian chy mu ko di (>l0pht) 4.2. Th khng in hnh y l th kh chn on v thng l chn on c nh tnh c hoc l sau khi suy xt v lm nhng xt nghim cn thit. C nhiu cch phn loi th bnh nhng thng phn chia theo. * Lm sng - Th t ngt: bnh tin trin rt nhanh ngi bnh c th cht trong vi gi do xut huyt nht l xut huyt no v xut huyt tiu ha. - Th ch c thiu mu v st: ngi bnh ch thy st ko di v thiu mu dn ch chn on c khi chng ta ngh n v lm huyt v tu . - Th ch c st v xut huyt: ngi bnh st ko di km theo xut huyt vi tnh cht xut huyt gim tiu cu rt d nhm vi st xut huyt do virus Dengue. Chn on phn bit da vo dch t, huyt thanh chn on v huyt , tu . - Th bt u bng nhng khi u xng: thng l xng s, xng hm trn, xng sn khi sinh thit nhng u ny thng c mu xanh (mu ca Porphyrin) ' * Th theo huyt hc: - Th tn: thng gp tr em v ngi tr iu tr thng d t ti lui bnh v
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thi gian lui bnh di. Hnh thi t bo l nhng nguyn bo lympho c nhn to trn li nhn mn, t ht nhn. Nhum ha hc t bo: + Peroxydase (-) + P.A.S (+) - Th tu: thng gp ngi ln tui, iu tr kh lui bnh v nu lui bnh thng c ngn ngy hn th trn. Hnh thi t bo l nhng nguyn bo tu nhn to t nguyn sinh cht, li nhn th v c nhiu ht nhn. Nhum ha hc t bo: - Peroxydase (+) : - P.A.S (-) 5. CHN ON 5.1. Chn on xc nh y l bnh d chn on c nh vo huyt hc. Nhng n v cha iu kin nht thit phi gi bnh nhn n tuyn c iu kin lm huyt v tu . 5.2. Chn on phn bit Trn thc t sau khi c kt qu huyt v tu bnh t khi cn phn bit nhng cn lu vi mt th bnh ca lao cp c th l lao phi cp hoc lao ton th bch cu dng tn cng c th tng lm ta nhm vi bnh Leucose cp dng tn phn bit nn lm huyt v tu nhiu ln nhiu thi im khc nhau phn bit. 6. TIN TRIN Trc y bnh thng gy t vong trong vi tun hoc vi thng. Nay vi s tin b ca iu tr i sng ngi bnh c th ko di n vi nm. Bnh thng tin trin tng t xen k vi thi gian lui bnh nh iu tr. Thng thng cuc sng ngi bnh thng kt thc bng: - Xut huyt t nhiu ni nng nht l xut huyt mng no - no. - Nhim trng: thng nhim trng nhiu ni v nng n nht l nhim trng mu. - Tc mch: thng t xy ra tr khi bch cu tng qu cao. 7. IU TR 7.1. Chng tng sinh bch cu non - a ha hc tr liu thng p dng phng thc tn cng v ti tn cng. - Tn cng thng p dng cng thc V.A.M.P - Vineriltin leng x 1-2 ng/1m2 da/ tun - Alexan loomg x 4-6 vin/ngy - 6 M.P 50mg x 1-2 mg/kg/ngy
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- Prednisolon 5mg x 3mg lkg/ngy - Duy tr: 6M.P x l-2mg lkg/ngy - Ti tn cng: dng nh giai on tn cng thng 2 thng mt ln. Lu : giai on tn cng dng n khi no ht triu chng lm sng. Xt nghim thy t l bch cu non mu ngoi vi <5% 7.2. Min dch tr liu - Min dch ch ng khng c hiu. Ngi ta dng BCG nh thc c quan min dch. Thng dng BCG 75mg ho 2ml nc ct chung cho ngi bnh hng tun trong thng u ri 2 thng 1 ln v 4 thng mt ln. - Min dch th ng c hiu: dng huyt thanh ca ngi b Leucose cp giai on lui bnh truyn cho ngi b Leucose cp giai on cp, thc t phng php ny rt kh thc hin. 7.3. Co ban liu php hoc chiu tia X vo tun hon ngoi c th liu t 3.500 4000 rad chia u trong vng 2 tun 7.4. iu tr triu chng - Xut huyt cn dng mu ti truyn tu mc xut huyt v thiu mu c th 1 tun mt n v mu hoc hn. - Dng khng sinh phng nhim trng thng dng khng sinh c ph rng v t c vi gan v thn. 7.5. Phng bnh - Cn khm bnh c nh k cho nhng cng nhn hoc nhng ngi c tip xc vi nhng yu t thun li k trn. - ng vin bnh nhn v gia nh hp tc iu tr ng v phc iu tr.

LEUCMIE KINH DNG HT

1. C IM DCH T y l bnh mu c tnh c hin tng qu sn dng bch cu bit ha nhiu nhng cht lng bch cu khng bnh thng. S lng bch cu tng cao trong mu ngoi vi cng nh tu xng. Trong cng thc bch cu gp mi la tui t non n gi nn khng c khong trng bch cu. S thng gp: - Tui thng gp t 30 - 50 tui. - Rt t gp tr em v ngi > 70 tui. - Khng phn bit nam n. - Nguyn nhn gy bnh khng r nhng ngi ta thy bnh c lin quan n
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phng x, ha cht. c bit l st rt, 10% bnh nhn c tin s st rt. 2. TRIU CHNG LM SNG V XT NGHIM Cc tiu chun tng qut chn on xc nh v s tin trin ca bnh Leucose kinh dng ht c chia ra lm hai giai on r rt. + Giai on mn tnh ko di t 20 - 40 thng c bit cn di hn tip l giai on chuyn dng cp vi biu hin lm sng rt t ging nh Leucose cp ko di 2 - 4 thng kt thc ging nh Leucose cp, c bit nu iu tr tch cc c th t c lui bnh hon ton. Bnh Leucose kinh dng ht c th biu th bng cc tiu chun chn on nh sau: 2.1. Lm sng - Lch to: thng l lch rt to > III, mt chc b c rng ca t c bnh no lch to n nh vy (95%) . - Da xanh, nim mc nht biu hin thiu mu nh (75%) . - St thng l st nh tng t khng r nguyn nhn (74%) . - Gan to thng l to t l-2cm di b sn, mt mm b sc (62%) . - Gy st thng gy st t nht l trong thi k c st, triu chng ny khng c hiu nhng hay gp (61%) . - Nghe tim c ting thi tm thu do thiu mu (90%) . - Hch to: thng l nhng vng c hch to sn nh vng trc c, bn ch to t, mt chc di ng d (36%) . - Xut huyt di da: giai on mn th khng c xut huyt di da, ch xut hin giai on chuyn dng cp. - Tc mch: do bch cu tng qu cao trong mu c th tc mch chi di gy au v ph tm, tc mch dng vt gy du hiu Priapison hoc tc mch no gy lit na ngi. 2.2. Xt nghim - Tng sinh dng bch cu ht trong mu ngoi vi thng l trn 80.000 bch cu/1mm3 c khi ti vi trm nghn bch cu, ngi ta thy t c loi bnh no gy tng bch cu n nh vy. - Cng thc bch cu ngi ta khng thy khong trng bch cu giai on mn tnh. Khi chuyn dng cp mi xut hin khong trng bch cu. - Hm lng vitamin B12 trong mu tng cao (bnh thng t 4.500 - 8.500 lt) - Men Phosphatase kim bch cu gim nng (bnh thng t 30 - 80%) . - Hm lng acid c tng cao (bnh thng t 4-5 mg%) - Tm c nhim sc th Philladelphy trong mu. - Tng s lng t bo tu trong tu m ch yu l ca dng bch cu, t non
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n trng thnh. - Thiu mu ng sc hng cu bnh thng. Trn y l nhng triu chng lm sng v xt nghim m chng ti sp xp theo th t da theo s thng gp v tnh cht quan trng ca n gip cho chn on. 3. CHN ON 3.1. Chn on phn bit Ni chung bnh Leucose kinh dng ht nm trong hi chng tng sinh tu c tnh. Ta ch cn phn bit vi mt bnh cng c lch to v bch cu cng tng cao l bnh lch to sinh tu. Trong bnh lch to sinh tu lch thng khng to bng Leucose kinh dng tu. Bch cu cng tng nhng t khi qu 50.000 bch cu trong mt ml trong : - Ch yu l tn cu cn bch cu ht ch cn chim 20% tu xng b x cng (Xc nh c khi ta chc tu lm tu ) v men Phosphatase kim bch cu bnh thng, vitamin B12 trong mu bnh thng, acid c mu bnh thng. + Chn on xc nh: da vo lm sng triu chng ch yu l lch to. Xt nghim: s lng bch cu tng cao khng c khong trng bch cu C nhim sc th Philladelphy trong mu. 3.2. Chn on giai on - Giai on mn tnh: bnh c chn on giai on ny d dng da vo lm sng l lch to, xt nghim bch cu tng cao, giai on ny iu tr thng p ng rt tt c th lch nh li, cng thc mu bch cu v bnh thng, men Phosphatase kim bch cu dn c tng ln. Trn lm sng khng cn triu chng ngi bnh c th sinh hot v lm vic bnh thng thi gian lui bnh c the ko di t 30 40 thng nu iu tr v theo di cn thn c th di hn. Cuc sng ngi bnh ch kt thc khi bnh chuyn dng cp. - Giai on chuyn dng cp: y l giai on cui cng ca bnh Leucose kinh dng tu n c nhng c im sau: - Mt s nhy cm vi iu tr. - Tnh trng lm sng nng ln: lch to nhiu xut hin thm st cao, xut huyt di da. . . - Mt kh nng bit ha t bo tu. Thi gian ny c th ko di 2 thng k t lc pht hin chuyn dng cp n khi t vong. Tuy nhin c bit cng c bnh nhn p ng vi iu tr (tt nhin l iu tr nh Leucose cp) c th t c lui bnh. giai on ny bch cu non tng ln thng chim >30% xut hin khong trng bch cu. Trn lm sng xut hin thm cc triu chng khc ging nh bnh bch cu cp thng giai on ny xut hin cc bin chng. 3.3. Chn on bin chng
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Cc bin chng sau y c th l nguyn nhn gy t vong cho ngi bnh: - Tc mch nhiu ni do bch cu tng qu cao thng tc mch no, chi, phi, dng vt. . . . - V lch t nhin do lch qu to nn d c va chm nh hoc khng va chm gy chy mu t dn n t vong. - Nhim khun: thng xut hin giai on chuyn dng cp. - Xut huyt: do tiu cu b ln t nn giai on ca ngi bnh c xut huyt mang y tnh cht xun huyt do gim tiu cu. 4. IU TR BNH LEUCOSE KINH DNG TY - iu tr Leucose kinh dng tu giai on mn tnh: + Ha hc tr liu thng dng Bisulfan vi cc bit dc: Misulban, Myleran, Myelosan. y l mt cht tng hp chng phn bo nhim sc th kiu Alkylant. Liu dng 4-5 mg/ngy ung hng ngy, sau 1 thng iu tr theo di cng thc mu thng xuyn duy tr s lng bch cu khong 10.000 - 15.000 bch cu / 1mm 3 mu. - C th dng Dibromomanntol cng l mt Alkylant nhng khng bn vng bng liu dng 200 - 300mg/ngy ung 7 ngy ngh 3 ngy. Tc dng ph d gy tc mch v gim bch cu. - Cyclophosphamid (Endoxan, Cytoxan) tc dng kiu Alkylant liu dng 100 200mg/ngy tc dng ph: bun nn v rng tc. + Gn bt bch cu trong mu ngoi vi ngi ta ly mu ngi bnh ra ri gn bt bch cu sau truyn li. + Ct b lch: khi lch qu to d gy v lch t nhin th c ch nh ct lch ng nhin, phi kim tra k s lng tiu cu v thi gian mu chy mu ng. - Min dch tr liu thng p dng min dch th ng c hiu tc l ly huyt thanh ngi bnh b Leucose kinh ng ht giai on lui bnh truyn cho ngi cha lui bnh. - Ngoi ra cn c phng php ghp tu nhng t hiu qu v tn km. - giai on chuyn dng cp th iu tr nh Leucose cp ngha l dng V.A.M.P truyn mu ti, tia x. . . Tm li: Leucose kinh th tu l mt bnh mu c tnh thuc nhm bnh tng sinh tu c tnh nguyn nhn gy bnh cha r, thng gp ngi ln khng phn bit gii tin trin t t so vi cc bnh mu c tnh khc iu tr d t c lui bnh, thuc c hiu nht l Bisulfan. Cn c chn on sm giai on mn tnh ko di cuc sng ngi bnh.
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C IM BNH L V NGUYN TC IU TR NGI C TUI

1. I CNG Tui th cng cao, s ngi c tui ngy cng nhiu. Mt mn hc mi ra i nhm gii quyt cc vn lin quan n la tui ny. Lo khoa ngy nay pht trin theo 3 hng. - Lo khoa c bn - Lo khoa lm sng - Lo khoa x hi 2. C IM C TH NGI GI Qu trnh xy ra 5 mc: mc phn t, t bo, t chc, c quan, h thng v ton c th. Do c tnh chung nht ca qu trnh ny l khng ng th v khng ng tc c ngha l mi b phn trong c th khng gi cng mt lc v vi tc nh nhau. C b phn gi trc, c b phn gi sau, c b phn gi nhanh, c b phn gi chm. 2.1. S ha gi ca h thn kinh - V mt gii phu: khi lng no gim dn trong qu trnh ha gi cn khong 1180g nam, l060g n vo lc 85 tui. Lc 25 tui nam 1400g; n 1260g. - V mt sinh l: bin i thng gp nht l gim kh nng th cm + Gim th lc + Gim sinh lc + Gim khu gic + Gim v gic + Gim xc gic Hot ng thn kinh cao cp gim c ch sau l gim hng phn. Ph bin nht l gim tnh linh hot trong s dn truyn xung ng thn kinh. Gp ri lon gic ng. - V mt tm l c s gim tc v gim tnh linh hot ca mi hot ng vn tru tng thng gim. 2.2. S ha gi ca h tim mch - Tun hon nui tim gim, nh hng n dinh dng c tim. - Hay c suy tim tim tng, gim dn truyn trong tim - Cc ng mch b x ha, tnh mch gim trng lc, mao mch km hiu lc
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- Huyt p ng mch thng tng cao theo tui. 2.3. S ha gi ca thn - V phng din hnh thi hc, bt u t 20 tui c nhng bin i cc ng mch nh v trung bnh ca thn - Vo lc 70 - 80 tui s nephron hot ng gim i khong 1/3 hoc 1/2 so vi lc mi sinh. - V phng din chc nng mc lc cu thn gim dn. 2.4. S ha gi ca h tiu ha - ng tiu ha gim trng lng, c hin tng thu teo, suy yu cc c thnh bng v cc dy chng dn n tnh trng sa ni tng. - Gim hot lc ca cc h tit dch tiu ha. - Gan gim trng lng, trong nhu m gan c ch teo, v lin kt dy ln, mt gan chc hn. - Ti mt: tui t 40 c s gim n hi thnh ti mt v ng dn mt do x ha c vng oddi hay c ri lon iu ho dn mt. 2.5. S ha gi ca h h hp - Hnh dng ca lng ngc bin i nhiu do sn sn b ri lon, khp sn ct sng x cng, t sng a m b thoi ha, c lng di teo, hn ch c ng. T bo biu m tr ph qun dy, t bo biu m tit dch lon dng, cht nhy gim lng, c c. - V chc nng: dung tch sng (CV) gim ch s Tiffeneau gim, kh nng hp th oxy v mu ng mch gim dn n tnh trng thiu oxy t chc. 2.6. S to ha ca h ni tit - Tuyn ni tit trong qu trnh ha gi khng ng th cng khng ng tc. - Bt u thoi ha sm nht l thoi ha tuyn c, sau tuyn sinh dc, ri n tuyn gip trng, cui cng l tuyn yn v thng thn. Nhng bin i chc nng ca tuyn ni tit, lm thay i tnh cht cc phn ng thch nghi ca c th i vi cc Stress. 3. DCH T HC BNH NGI C TUI 3.1. c im chung - Gi khng phi l bnh nhng gi to iu kin cho bnh pht sinh v pht trin. - Ngi gi t khi ch mc mt bnh m thng c nhiu bnh ng thi nht l cc bnh mn tnh. - Cc triu chng ca bnh tui gi thng t khi in hnh do d b qua hoc lm sai lch chn on. - Bnh ngi gi thng km kh nng hi phc v vy cha bnh ngi gi
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phi ht sc ch n phc hi chc nng. 3.2. Tnh hnh bnh tt ngi c tui C th tm hiu bnh tt ca tui gi 3 khu vc: trong nhn dn qua iu tra c bn, ti cc c s iu tr qua m t thi. Mi nc c hon cnh sinh sng ring cho nn c cu bnh tt cng khc nhau, c bit gia cc nc pht trin v nc ang pht trin - Trong nhn dn; 13.392 ngi t 60 tui tr ln c khm ti cc vng dn c, dn tc khc nhau. Cc bnh ni khoa thng gp l: + Bnh h hp: 19,63% + Bnh tiu ha: 18,25% + Bnh tim mch: 13,32% + Thn - Tit niu: 1,64% + Bnh mu v c quan to mu: 2,29% + C xng khp: 47,69% Ni chung bnh tng t l thun vi tui. Phn loi sc khe thy a s sc khe km 62,71% loi trung bnh t 36,52%, loi kh chim 0,75%. - Ti cc c s iu tr: + Ti khoa ni Bnh vin Bch Mai bnh gp nhiu nht l bnh tim mch 59,3%, bnh tiu ha 39%, h hp 35,6%, tit niu sinh dc 10,8%, thn kinh 4,6%, c quan to mu 4,1%, ni tit 1,38%, bnh khc 15,6%. + Ti tri dng lo Th Chu (Thanh Ha) gp 15% l suy kit tui gi, 9% l tng huyt p; 9% c thu tinh th, 7% rng rng hon ton, 8% lao phi n nh, 7, 5% bnh xng khp, 6% lit na ngi, 5% g vo ct sng, 3% thin u thng, 2% vim i trng mn (BH ni khoa tp II - 1996) . - Qua m t thi: V Cng Ho 1480 trng hp bnh nhn c tui c m t thi ti Bnh vin Bch Mai thy nhiu nht l nhm VII tim mch 21,2%. Sau bnh nhm II ung th 17,5% ri bnh nhm I nhim khun 16%, cn li nhm IX tiu ha 14,3% nhm VI thn kinh 11,6% v nhm VIII h hp 8, % 3.3. Tnh hnh t vong ngi c tui Theo ti liu nc ngoi 1,4% ngi gi cht ti nh cn li t vong ti tri dng lo. Nguyn nhn t vong l tim mch 51,7% h hp 28,6%; tiu ha 7%, ni tit chuyn ha 1,5% nhim khun 5,7%, bnh mu v c quan to mu 1,7% nguyn nhn khc 3,8% Ti cc khoa ni Bnh vin Bch Mai thy tui cht trung bnh ngi gi 67
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tui; 69, 5% cht vo ma lnh, 72,7% cht v ban m. Xt v thi gian t lc vo vin n khi cht 34,6% cht xy ra vo ngy u, 64% cht trong 10 ngy u. (Bi ging BH Ni khoa 1996) 4. CHN ON C MT S BNH THNG GP V VN PHC HI CHC NNG Mt s bnh thng gp ngi cao tui 4.1. Bnh tim mch - Cn au tht ngc nhi mu c tim ri lon nhp tim v dn truyn, tai bin mch mu no, suy tnh mch, nghn ng mch, ti phnh ng mch. 4.2. Bnh h hp - Vim ph qun mn, gin ph nang, K phi, gin ph qun, x phi, lao phi mng phi, ph qun ph vim. 4.3. Bnh tiu ha - Lot d dy t trng, vim i trng mn, ung th d dy, ung th gan, x gan, tr. 4.4. Bnh thn tit niu - Vim b thn mn, vim cu thn mn, x mch thn, si thn, u x tin lit tuyn. 4.5. Bnh ni tit chuyn ha - i tho ng, tng cholesterol mu, suy gip trng, suy sinh dc, ri lon mn kinh. 4.6. Bnh mu v c quan to mu - Thiu mu do thiu st, thiu acid folic, thiu kh nng tu xng, a u tu xng, ung th mch. 4.7. Bnh t min - T khng th lipoprotein, khng insulin, khng nim mc d dy, khng gip. 4.8. Bnh tm thn - Lon tm thn trc tui gi v lon tm thn tui gi. - Bnh tm thn tui gi, thng gp sa st tr tu kiu Alzheimer. 4.9. Bnh thn kinh - Ri lon tun hon no, hi chng ngoi php nht l bnh Parkinson, vim a dy thn kinh. 4.10. V ng quan - Glaucome, c thu tinh th, teo dy thn kinh th gic. - Gim thnh lc, ri lon tin nh. - Nga tui gi, ung th hc t.
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- Mt nhiu rng. * Vn phc hi chc nng. - Phc hi chc nng nhm m bo hot ng th lc, tm l, t duy quan h gia nh x hi, kh nng lao ng. - Ngi c tui nu luyn tp phc hi chc nng suy gim do tui tc iu m ring thuc men khng gii quyt c. - Mun t c yu cu phi : + Bt u phc hi chc nng cng sm cng tt + Tin hnh iu tr phc hi mt cch t gic. + Kt hp rn luyn vi h tr ca chuyn mn + Vn ng tu theo iu kin c th. Ti bnh vin, ti cc c s iu dng, tri dng lo, cu lc b ngi c tui. 5. C IM IU TR HC V BNH TUI GI 5.1. Nguyn tc chung iu tr phi ton din, iu tr nguyn nhn, triu chng cn ch n vic nng c th to iu kin cho vic cha bnh, c bit v dinh dng h tr v tinh thn, t tng. 5.2. S dng thuc ca ngi gi - Do c im c th ngi gi, tc dng thuc khng hon ton ging ngi tr, vic hp th thuc km v tc cng nh mc chuyn ha, nhy cm ca c th c nhiu bin chng c th xy ra, do vy cn ch + Nu c mt phng php iu tr cha bnh no c hiu nghim m khng cn dng thuc th khng dng. + Nu nht thit phi dng thuc th dng cng t loi thuc cng tt. + Cn chn liu lng thch hp nht t hiu qu cao nht khng gy tai bin. Nn bt u bng liu thp + Nu chn thuc c c tnh cao, cn ch dng cc bin php hn ch c tnh. + D thuc khng c cng phi phng tai bin d ng. + Khi dng thuc trong thi gian di phi theo di st, kim tra, s kt tng t.
6. HNG DN CNG NG V CHM SC SC KHE NGI CAO TUI

- Hng dn cng ng bit pht hin sm bnh tt ngi c tui. - Bit khai thc nhng triu chng c nng v thm khm thc th. - C bin php iu tr sm, tch cc.

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TI LIU THAM KHO

1. Bch khoa th bnh hc, 1996. 2. Bi ging bnh hc ni khoa, Nh xut bn Y hc, H Ni 1996. 3. Bnh hc ni khoa tp I, II - 1996. 4. Bnh hc ni tiu ha - Hc vin Qun y- 1998 5. Bnh thp khp PGS - TS. Trn Ngc n - Nh xut bn y hc 1995. 6. Bnh tuyn gip v cc ri lon do thiu iod, Nh xut bn Y hc, H Ni, 1996
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7. Cc bnh v mu, NXB Y hc, 1996. 8. Cc nhim c cp thng gp. NXB Y hc 1985. 9. Cp cu ni khoa - 2001. 10. C p cu ng c NXBYH 2001. 11. Chn on v iu tr hc hin i - NXB Y hc 2001. 12. ng Trn Du (1996) , Bnh tuyn gip v cc ri lon do thiu iod, NXB Y hc. 13. Trung Qun (1998) , Bnh i tho ng, Nh xut bn Y hc H Ni. 14. iu tr hc ni khoa. tp 1, 2 NXB Y hc 2002. 15. Hi sc cp cu - ai hc Y khoa Thi Nguyn 2001. 16. Hi sc cp cu NXB Y hc 1998. 17. Hng dn c in tm , Nh xut bn Y hc, H Ni, 2001. 18. Hng dn qun l v kim sot HQP - WHO 1998. 19. Huyt hc trong lm sng, 1996. 20. K sinh trng -NXB Y hc. 21. Lm sng tim mch, Nh xut bn Y hc, H Ni, 2001. 22. Nhim trng tit niu PGS. Trn Vn Cht. 23. Phm Mnh Hng. Cc biu hin t min dch trong cc bnh ca tuyn gip. 24. Tnh hnh bnh thn, tit niu iu tr ni tr ti Bnh vin Bch Mai (1991 - 1995) PGS. Trn Vn Cht - BS. Trn Th Thnh. 25. Ti liu i hi hen ton cu ln III (7/2001) . 26. Ti liu tp hun HSCC - 2000 - B mn HSCC H Y H Ni 27. Thi Hng Quang (2001), Bnh ni tit, Nh xut bn Y hc H Ni. 28. Triu chng hc ni khoa, Nh xut bn Y hc, H Ni, 2000.

NH XUT BN Y HC

BNH HC NI KHOA
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TP 2

Chu trch nhim xut bn HONG TRNG QUANG

Bin tp: Sa bn in: Trnh by ba: KT vi tnh:

BS. V TH BNH V TH BNH CHU HNG BI TH THNG

In 1.000 cun, kh 19 x 27cm ti Xng in Nh xut bn Y hc. S ng k k hoch xut bn: 23 - 2006/CXB/675 - 271/YH In xong v np lu chiu qu I nm 2006.
Gi: 17000

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