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Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi

V tng rng I. i cng: 1. Chn thng bng kn l mt cp cu ngoi khoa thng gp v xut hin vi t l ngy cng tng (chim 43% trong tng s cp cu do nguyn nhn chn thng). Chn thng c th gy tn thng t thnh bng vo n cc tng nhng khng c thng phc mc ( bng khng thng vi bn ngoi) do lc trc tip hoc gin tip tc ng. 2. V tng rng l mt thng tn thng gp trong chn thng bng kn, ch ng sau v tng c. 3. C ch gy v tng rng: Tc ng trc tip :nh, tai nn Do chn thng gin tip vo bng.

Lc tc ng cng mnh th tn thng cng nng. 4. Chn thng bng kn gy v tng rng thng xut hin sau mt chn thng mnh vo vng bng nn a phn thng km cc thng tn phi hp ngoi bng, nh chn thng ngc, chn thng s nogy nn bnh cnh lm sng a dng, gy kh khn cho chn on v x tr nn t l t vong cn cao. 5. V tng rng c th l v d dy, t trng, hng hi trng, i trng Hu qu thng gp l vim phc mc ton th/khu tr tc th/th 2 cn c chn on sm v x tr sm. i khi v tng rng km v tng c. 6. ng trc 1 bnh nhn ngh ng v tng rng, 2 vn cn phi t ra l: 1) C cn phi m khng v khi no m. 2) X tr cc tn thng nh th no. II. Lm sng v cn lm sng: 1) Hi bnh: 1. Lm sng:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Hon cnh chn thng: Nguyn nhn, thi gian, tc nhn chn thng: cng , hng v vng tip xc.T th bnh nhn khi b chn thng. Din bin k t khi chn thng cho n khi nhp vin: + Ngt xu khi thay i t th. + Bun nn/ nn, nn ra mu. + au bng, hng lan, tin trin ca au. + i mu, b i. + Mu chy qua hu mn. + T khi b thng x tr g. Tin s v tnh trng bnh nhn trc tai nn + Tin s ni ngoi khoa. + Lc tai nn l lc i hay no. + i ln cui cng trc khi tai nn l bao lu. T ta c th nh hng c v tr tn thng, din bin tn thng gip ch cho vic khm lm sng. C nng: + au bng d di nh dao m (ging nh thng d dy). + B trung i tin. 2) Ton thn: Sau tai nn giai on u khng c g c bit. Shock do nhim c-nhim khun:

+ St cao dao ng 39 - 40C. Mi kh, li bn, hi th hi. + Kht nc, nht, v m hi, chn tay lnh, th nhanh, vt v hoc li b. Mch nhanh nh kh bt > 100l/ph. Huyt p < 90mmHg, 1 s trng hp chy mu trong

bng huyt p khng tt hoc ch tt sau 1 thi gian theo di nhng mch thng xuyn tng cao. Du hiu nhim khun (vim phc mc) : st cao, mi kh , li bn, th hi. 2

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Thc th: Nhn: + Vt xy xc, bm tm trn thnh bng + Bng chng, mc chng. + bng khng di ng theo nhp th. S: pht hin cc du hiu: + Bng cng nh g. + Co cng thnh bng (xut hin mun) v phn ng thnh bng l nhng du hiu hay gp trong chn thng tng rng. Tuy nhin cc du hiu ny kh nh gi khi thnh bng c tn thng. + Cm ng phc mc(+) Nghe: + Bng: im lng, khng c nhu ng rut. + Ngc: c trn mu trn kh mng phi phi hp. + C lc xc trn ngc: v c honh. G: + c vng thp: c dch trong bng. + Mt vng c trc gan: tn thng tng rng. Thm trc trng m o: + Ti cng Douglas phng: c trn mu mng phi v au d di khi c vim phc mc. + Phn c mu/c mu theo tay 4) Khm cc tn thng phi hp: Ngc: + Mng sn di ng + Gy xng sn. + Trn mu trn kh mng phi. Chn thng ngc thng gy ra co cng / phn ng di sn. Chn thng s no : thang im Glasgow. Chn thng thn: t mu h tht lng, i mu. V xng chu: p 2 bn cnh chu au. 3

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Chn thng ct sng: S nn dc theo ct sng tm im au/bin dng. *V xng chu v gy ct sng gy ra t mu sau phc mc lm bng chng au tng t nhng trng hp chy mu trong bng. Nh vy da trn nhng du hiu trn y ta c th s b ngh n chn thng bng kn v tng rng v a ra cc ch nh xt nghim. 2. Cn lm sng: 1) Xt nghim mu (c gi tr xc nh tn thng v cho vic hi sc). Nhm mu. Thi gian mu chy, mu ng. S lng bch cu: Tng > 9000. Xt nghim ny phi

lm i lm li nhiu ln so snh v pht hin nhng thay i. 2) Chp Xquang bng khng chun b: 2 phim thng v nghing t th ng/nm trn 1 phim Hnh nh lim hi: tp trung vo vm honh. + Di c honh: 80% c thng tng rng, v vy khng c lim hi cng khng loi tr c thng tng rng. + Sau phc mc: v t trng. Hnh nh d dy, rut trn lng ngc Cc tn thng ca xng sn cui, xng chu v ct

sng. 3) Chp Xquang lng ngc pht hin cc tn thng phi hp 4) Siu m: Trng hp v tng rng siu m kh nh gi. 5) Chc d bng: V tr: cc ch thp. c m, thc n / bch cu > 500/ml: v tng rng. 4

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Nu bch cu = 1000 500: Lm li sau 2h. Nu bch cu < 100: m tnh. Trng hp chc d nu m tnh vn khng cho php

loi tr v tng rng v kh theo di lm sng sau khi chc d do thnh bng b tn thng, khng nn s dng khi c tin s m bng nhiu ln trnh tai bin thng rut. 6) Chc ra bng: chnh xc cao, thng c s dng khi triu chng lm sng cha r rng, nht l khi bnh nhn c km chn thng s no. lng ngc, a chn thng. Khng nn s dng khi c tin s m bng nhiu ln trnh tai bin thng rut. c m / bch cu > 500/ml: v tng rng. Bch cu = 1000 500: Ra li sau 2h. Bch cu < 100: m tnh. Ch nh khi tnh trng bnh nhn n nh. Cho php nh gi chnh xc v tr, mc tn th-

7) CTscanner:

ng l c s cho vic chn on v x tr. 8) Soi bng: xc nh v tr, mc v c th x tr tn thng trong bng. III. Chn on hi chng v tng rng: 1. C nng: au nh dao m, nn, b trung i tin. 2. Thc th: au, co cng khp bng: mc co cng nh trong Phn ng, cm ng phc mc Mt vng c trc gan. Thm trc trng: ti cng Douglas phng, n au. thng d dy.

3. Ton thn: Trong nhng gi u khng c g thay i. Khi n mun: v mt nhim khun: mi kh, li bn, hi th hi, st 38 39. 5

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Vi cc du hiu trn c s chn on vim phc mc do thng tng rng. Nu bnh nhn shock th phi hi sc ri m. Nu bnh nhn khng c shock th lm thm cc xt nghim: 4. Cn lm sng: Chp bng khng chun b: nu c lim hi l chc chn c, nu khng c th cng khng loi tr thng tng rng. Siu m: dch trong bng. Chc ra:

+ Nc c, dch tiu ho, nc phn: chn on xc nh. + Nc trong, th bch cu > 500/ml: thng tng rng. Xt nghim: bch cu tng. IV. Chn on th lm sng: 1. Vim phc mc khu tr: Dch do tng rng v c cc tng khc v mc ni ln n bao bc li. Thng gp l p xe di c honh. Trong trng hp ny bnh cnh lm sng khng rm r nh vim phc mc ton th: 1) Lm sng: au 1 vng nht nh. St nh hoc khng st. Thnh bng c phn ng hoc co cng ch 1 vng

nht nh (di sn phi, tri, gia bng) cc phn cn li ca bng mm, khng au. Vn c trung tin 2) Cn lm sng: Bch cu tng cao > 10000/ml. Xquang: khng c lim hi, c th thy hnh mc nc Siu m: Thy khi long m (dch) + hi.

hi ca ap xe di c honh. 2. Th theo din bin: 1) Th cp din

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Bnh nhn n vi tnh trng shock nhim cT vong sau 2 3h nu khng c x tr kp thi. V tng rng bt nay l thng b bung ra. Thng tn di thanh mc nay b v ra. Tn thng mc treo rut: rut hoi t dn. nhim khun nng. 2) Th din bin chm (v tng rng th 2):

Sau giai on ban u, cc triu chng lm sng v cn lm sng khng r, sau 1 3 ngy bnh nhn xut hin cc triu chng in hnh ca hi chng vim phc mc (ton th, khu tr). 3. Th phi hp: 1) V tng rng+ chn thng s no: Trong chn thng s no khng c huyt p tt, v vy nu 1 bnh nhn chn thng s no m huyt p tt phi c gng tm cc tn thng bng, ngc. Khi nghi ng: chc ra bng. 2) V tng rng+ chn thng ngc: Thng nhng triu chng ca chn thng ngc che lp nhng triu chng ca chn thng bng. trnh b st nn: Dn lu ngc c h thng. nh gi li huyt ng, siu m pht hin tn th-

ng. 3) V tng rng + a chn thng: Hi sc tch cc sau nh gi li ton b cc tn thng trong c tn thng bng. 4) V tng rng + chn thng ct sng: Lu tn thng tng sau phc mc phi hp ca thn: i mu, siu m, UIV.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


i khi chn thng ct sng n thun gy t mu sau phc mc cng c bnh cnh lm sng tng t chn thng bng. 5) V tng rng + v xng chu: V. Tn thng bng quang, niu o sau. Chn on: khng t i, mu sc nc tiu, t X tr: 1) Chn on sm v x tr sm cc tn thng. Hi sc tch cc phi c tin hnh ngay khi bnh Nu bnh nhn n vi tnh trng shock nhim cnhn ti vin, trc trong v sau khi m. nhim khun sau chn thng vi cc du hiu in hnh ca chn thng tng rng th tin hnh va hi sc va m ngay, cc xt nghim c lm trong nh m. Nu bnh nhn khng shock, tin hnh thm khm t m, nhiu ln chn on sm, khi c chn on xc nh v tng rng l phi m cp cu, va m va hi sc, ch nh khng sinh ton thn ngay t lc khi m. Nu c lm sng v cn lm sng u khng r l v tng rng cho bnh nhn vo vin theo di 3 5 ngy, nu thy cc triu chng: + Nhit tng cao, mch nhanh, h huyt p. + au km co cng thnh bng, cm ng phc mc (+), bng chng dn. + Cc xt nghim hng cu, bch cu, Hematocrit thay i qua nhng l th lin tip. Th phi ngh n v tng rng. Tt nht l gy m ni kh qun + gin c c th thm d v tm ht tn thng.

sonde niu o 1. Nguyn tc:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


M bng rng ri ng gia trn v di rn. Nu c mu th tm ngay vo ch ang chy mu ri n, p hoc kp cm mu tm thi. Thm d 1 cch ton din cc tng trong bng theo 1 trnh t nht nh. Lit k y tn thng, nh du tn thng mi khi tm thy, tip tc tm cho n khi xem ht cc tng. nh gi tng th mc tn thng, sau mi chn phng php iu tr thch hp (tr trng hp chy mu d di phi u tin x tr trc). Tnh trng tn thng cng nng, x tr cng n gin v hp l trc mt l cu sng bnh nhn.Cha cc di chng v sau nu bnh nhn sng. 2. C th 1) Hi sc: t t nht 1 ng truyn : + Bi ph nc in gii, mu + Theo di lng dch b vo thng qua CVP v huyt p ng mch v lng nc tiu theo di sau mi gi. Th O2 hay ni kh qun v h hp h tr. t ng thng d dy ht lm xp bng trnh tro t sonde bng quang theo di s lng, mu sc nKhng sinh nu nghi ng tn thng tng rng.

ngc dch. c tiu. 2) Gy m: ni kh qun + gin c. 3) ng m: gia trn v di rn. 4) Thm d: Ngay sau khi vo bng cn xc nh s lng mu Cm mu. Thm d ton din nh gi y tn thng trong bng v v tr chy mu.

khi x tr. 9

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


5) X tr cc tn thng: D dy: Khu l ch yu. Nu mt trc d dy khng c thng tn phi m hu

cung mc ni thm khm, trnh b st tn thng mt sau d dy. Rut non: + Khu l thng n thun. + Ct on rut v ni th u (bn bn, tn tn). + dn lu l thng ra ngoi trong trng hp ni s bc, khu s hp. T trng: + L chn thng nng, hay on c nh ca t trng, k thut x tr kh. + Khu l thng n thun. + Dn lu t trng qua l thng. + Khu t trng + ct d dy bn phn. + Khu t trng + ct dy X + ct hang v. + Ct khi t tu nu km theo chn thng tu. i trng: Khng khu i trng trong th u. + Ch yu l a ch thng ra ngoi, lm hu mn nhn to tm thi, ni th 2. + i vi phu thut vin c kinh nghim: ni ngay th mt sau khu ch ni vo mp vt m hoc a lun ch ni ra ngoi bng chm sc, sau 3 5 ngy khng bc a i trng tr li. + Ct on i trng cp cu: c bo v bng hu mn nhn to trn Trc trng: + Khu kn. + Lm hu mn nhn to pha trn. + Ni li th 2.

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Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Bng quang: Khu bng quang + m thng bng quang. 3. Theo di bin chng v iu tr sau m: Hi sc tch cc. Khng sinh ton thn. Rt dn lu. Theo di. Ct ch.

V tng c I. i cng 7. Chn thng bng kn l mt cp cu ngoi khoa thng gp v xut hin vi t l ngy cng tng (chim 43% trong tng s cp cu do nguyn nhn chn thng). Chn thng c th gy tn thng t thnh bng vo n cc tng nhng khng c thng phc mc ( bng khng thng vi bn ngoi) do lc trc tip hoc gin tip tc ng. 8. C ch gy chn thng rt a dng, c th: Tc ng trc tip (nh p vo ghi ng): tn thC th b dng t ngt khi ang di chuyn vi tc ng b p gia ct sng v nguyn nhn. cao (phanh gp, ng cao) : mc treo, mc ni b ging x. Lc tip tuyn tc ng xoy vo bng. Lc tc ng cng mnh th tn thng cng nng. 9. Chn thng bng kn thng xy ra sau cc chn thng nng v a s cc trng hp c km theo nhng tn thng phi hp ngoi bng, c bit l chn thng s no, chn thng ngc Bi vy biu hin lm sng rt a dng v phc tp. Vic chn on v x tr cc tn thng trong

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Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


bng cn rt nhiu kh khn, do vy t l t vong cn cao (10 25%). 10. Trong chn thng bng kn tt c cc tng u c nguy c tn thng nhng tng c c t l tn thng nhiu hn tng rng. 11. Trong chn thng tng c th t l gp nh sau: Lch (45%) > Gan (33%) > thn > tu vi cc dng tn thng chung l : t mu di bao, v, rch nhu m, tn thng mch mu. 12. Hu qu ca cc tn thng tng c l hi chng chy mu trong bng, cn c chn on sm v x tr sm.C khi tn thng c tng c ln tng rng. 13. ng trc 1 bnh nhn c nghi v tng c, 2 vn cn phi t ra l: 3) Tn thng c cn phi m khng v khi no m. 4) X tr cc tn thng nh th no. II. Lm sng: 2) Hi bnh: Hon cnh chn thng: + Nguyn nhn v gi xy ra chn thng. + Tc nhn chn thng: cng , hng v vng tip xc. + T th bnh nhn khi b chn thng. Din bin k t khi chn thng cho n khi nhp vin: + Ngt xu khi thay i t th. + Bun nn/ nn, nn ra mu. + au bng, hng lan, tin trin ca au. + i mu, b i. + Mu chy qua hu mn. + T khi b thng x tr g. Tin s v tnh trng bnh nhn trc tai nn. 12 3. Lm sng:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Tin s ni ngoi khoa: gan to, lch to. + Lc tai nn l lc i hay no. + i ln cui cng trc khi tai nn l bao lu. T ta c th nh hng c v tr tn thng, din bin tn thng gip ch cho vic khm lm sng. C nng: + au, nn, b trung i tin. + au v tr tng tn thng. + V lch km au h chu phi do mu chy xung. 5) Ton thn: Phi tr li c cu hi bnh nhn c shock hay Shock: kht nc, nht, v m hi, chn tay lnh, th Mch nhanh nh kh bt > 100l/ph. Huyt p < 90mmHg, 1 s trng hp chy mu trong khng, shock do au hay shock do mt mu/nhim khun. nhanh nng, vt v hoc nm lm i.

bng huyt p khng tt hoc ch tt sau 1 thi gian theo di nhng mch thng xuyn tng cao. Du hiu nhim khun (vim phc mc) : st cao, mi kh , li bn, th hi. 6) Thc th: Nhn: + Vt xy xc, bm tm trn thnh bng: c gi tr gi v tr tng tn thng. + Bng chng, mc chng. + Bng c di ng theo nhp th khng S: pht hin cc du hiu: + Co cng thnh bng (xut hin mun) v phn ng thnh bng l nhng du hiu hay gp trong chn thng tng rng. Tuy nhin cc du hiu ny kh nh gi khi thnh bng c tn thng.

13

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Cm ng phc mc: hay gp trong tn thng tng c. + Thm khm h tht lng bng 2 tay thy h tht lng y au: t mu quanh thn. Nghe: + Bng: im lng, khng c nhu ng rut. + Ngc: c trn mu trn kh mng phi phi hp. + C lc xc trn ngc: v c honh. G: + c vng thp: c dch trong bng. + Mt vng c trc gan: tn thng tng rng. II. Thm trc trng m o: Khi bnh nhn n vi ta sau khi tai nn vi 1 tnh trng shock v c cc du hiu ca v tng c gy hi chng chy mu trong. 1. Shock: Da xanh ti, lnh, u chi lnh. Kht nc, mi kh. Vt v hoc li b. Mch nhanh nh kh bt > 100l/ph. Huyt p c th h < 100mmHg. + Ti cng Douglas phng: n au.

2. au d di vng gan, lch trn rn. 3. B trung i tin. 4. C vt xy st thnh bng vng h sn phi, h sn tri, trn rn. 5. Bng chng. 6. Cm ng phc mc, co cng thnh bng, phn ng thnh bng. 7. G c vng thp. 8. Thm trc trng : Douglas phng au.

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Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


9. Khng c thng tn khc l gii c tnh trng ny (khng a chn thng, khng chn thng ngc). Nhng triu chng trn l chn on c hi chng chy mu trong do v tng c, lc ny cn chuyn bnh nhn vo nh m ngay, va m va hi sc mi mong cu sng c bnh nhn, cc xt nghim lm ti nh m. III. Nu bnh nhn n khng c tnh trng shock, mch nhanh nh (>100 l/ph), nhng huyt p > 100mmHg, ngh n v tng c khi: 4. C vt sy xt vng h sn phi, h sn tri, trn rn. 5. au d di vng gan, lch, trn rn, h sn phi, h sn tri. Th tin hnh cc thm khm cn lm sng sau: IV. Cn lm sng: 1. Xt nghim mu (c gi tr chn on xc nh tn thng, tin lng, theo di v hi sc). Nhm mu. Thi gian mu chy, mu ng. S lng hng cu gim: < 3,5 triu S lng bch cu: Tng > 9000. L du hiu c trng Hematocrite: Gim < 30%. Transaminse tng trong trng hp c tn thng gan. Amylase tng trong trng hp thng tn tu.

khi tn thng tng.

*Cc xt nghim ny phi lm i lm li nhiu ln so snh v pht hin nhng thay i. 2) Chp Xquang bng khng chun b: Chy mu trong bng (v tng c): + bng m. + Cc quai rut dn, thnh rut dy (do dch ng thnh rut). + D dy gin hi ni ln trn nn bng m (bng c dch mu). 15

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ V lch: d dy gin hi b y sang phi, vm honh tri cao, bng m ca lch to. Nu km theo gy xng IX, X, XI tri th cng ngh n v lch. Hnh nh d dy, rut trn lng ngc Cc tn thng ca xng sn cui, xng chu v ct

sng. 3) Chp Xquang lng ngc pht hin cc tn thng phi hp. u: + Khng nguy him, c th tin hnh nhiu ln gip chn on v theo di s tn thng. + chnh xc cao 90 97%. Xc nh hnh tn thng cc tng, dch trong bng. 4) Siu m: L phng php tt chn on, theo di du hiu lm sng do khng nguy him, c th lm li nhiu ln, chnh xc cao. Hnh nh: + T mu di bao/ khi mu t trong nhu m + ng v tng, mnh v tng. + Hnh nh rn gan, rn lch + Dch trong bng: s lng dch o c qua siu m thng t hn s lng dch thc t. Dch trong khoang Morrison, rnh thnh i trng, quanh lch, tu, Douglas. Nhc: kh pht hin thng tn trong trng hp bng chng nhiu, trn kh di da, c km v tng rng, thng tn tu. 5) Chc d bng: V tr: cc ch thp. Nu dch ra: mu / hng cu > 100000/ml: v tng

c. 16

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


C th thy Amylase trong dch tng cao Nu: hng cu = 5000 10000, bch cu = 1000 500: Nu dch trong hoc hng cu < 5000: m tnh. Trng hp chc d nu m tnh vn khng cho php

Lm li sau 2h.

loi tr tn thng tng v kh theo di lm sng sau khi chc d do thnh bng b tn thng: bnh vin Vit c ch c cc I mi c chc d 6) Chc ra bng: chnh xc cao, thng c s dng khi triu chng lm sng cha r rng, nht l khi bnh nhn c km chn thng s no. lng ngc, a chn thng. Khng nn s dng khi c tin s m bng nhiu ln trnh tai bin thng rut. Nu dch ra: mu / hng cu > 100000/ml: v tng C th thy Amylase trong dch tng cao. Nu: hng cu = 5000 10000, bch cu = 1000 500: Nu dch trong hoc hng cu < 5000: m tnh. Ch nh khi tnh trng bnh nhn n nh. Cho php nh gi chnh xc v tr, mc tn thc.

Ra li sau 2h. 7) CTscanner:

ng l c s cho vic chn on v x tr. 8) Soi bng: xc nh v tr, mc v c th x tr tn thng trong bng. V. Chn on cc th lm sng: 3) Th cp din Chy mu t thng do v tng c hoc t cc mch Bnh nhn n vi tnh trng shock nng. 17 mu ln cung lch, rn gan, tnh mch trn gan. 1. Th theo din bin:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


T vong sau 2 3h nu khng c x tr kp thi. do t mu di bao ca tng c. Sau giai on chnh ban u, cc triu chng lm sng v cn lm sng khng r, sau 1 3 ngy bnh nhn xut hin cc triu chng in hnh ca hi chng chy mu trong. 2. Th phi hp: 5) Chn thng tng c + chn thng s no: Trong chn thng s no khng c huyt p tt, v vy nu 1 bnh nhn chn thng s no m huyt p tt phi c gng tm cc tn thng tng c. Khi nghi ng: chc ra bng. 6) Chn thng tng c + chn thng ngc: Thng nhng triu chng ca chn thng ngc che lp nhng triu chng ca chn thng bng. trnh b st nn: Dn lu ngc c h thng. nh gi li huyt ng, siu m pht hin tn th4) Th din bin chm (thng tn tng th 2):Chy mu

ng. 3) Chn thng tng c + a chn thng: Hi sc tch cc sau nh gi li ton b cc tn thng trong c tn thng bng. 4) Chn thng tng c + chn thng ct sng: Lu tn thng tng sau phc mc phi hp ca thn: i khi chn thng ct sng n thun gy t mu sau i mu, siu m, UIV. phc mc cng c bnh cnh lm sng tng t chn thng bng. 5) Chn tng c + v xng chu: Tn thng bng quang, niu o sau. Chn on: khng t i, mu sc nc tiu, t

sonde niu o 3. Th theo tn thng tng c: 18

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) V lch: Sau chn thng trc tip vo h sn tri nht l i vi Hay gp, chy mu nhiu: phi can thip ngoi khoa. au h sn tri v h chu tri do mu theo rnh i Xquang. au nhiu h sn phi, lan ln vai phi. Bch cu tng, t l Transaminase mu tng. Mt lc tc ng rt mnh mi gy v tu. Thng km v lch v t trng. C th gy bin chng vim tu cp v nang gi tu. Xt nghim: amylase mu tng. lch bnh l.

trng tri xung h chu. 2) V gan:

3) V tu:

4) V thn: au tht lng, i mu, sng n h tht lng, hi chng sau phc mc (bng chng, b trung i tin, cm ng phc mc na bng bn thng tn). 6) Mu t sau phc mc: VI. au bng, au vng tht lng. Du hiu mt mu. Bng chng hi, phn ng thnh bng, co cng na X tr: 2) Chn on sm v x tr sm cc tn thng. Hi sc tch cc phi c tin hnh ngay khi bnh Nu bnh nhn n vi tnh trng shock sau chn thnhn ti vin, trc trong v sau khi m. ng vi cc du hiu in hnh ca v tng c th tin hnh va hi sc va m ngay, cc xt nghim c lm trong nh m. 19

bng, c khi mu t vng tht lng. 1. Nguyn tc:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Nu bnh nhn khng shock, tin hnh thm khm t m, nhiu ln chn on sm, khi c chn on xc nh tn thng tng c l phi m cp cu, va m va hi sc, ch nh khng sinh ton thn ngay t lc khi m. Nu c lm sng v cn lm sng u khng r l v tng c th cho bnh nhn vo vin theo di 3 5 ngy, nu thy cc triu chng: + H huyt p t ngt khi thay i t th km theo sy sm, chong vng. + au km co cng thnh bng, cm ng phc mc (+), bng chng dn. + Cc xt nghim hng cu, bch cu, Hematocrit thay i qua nhng l th lin tip. Th phi ngh n v tng c. Nu khng c g c bit: chuyn v tuyn trc, cho ra vin. Tt nht l gy m ni kh qun + gin c c th M bng rng ri ng gia trn v di rn. Nu c mu thm d v tm ht tn thng. th tm ngay vo ch ang chy mu ri n, p hoc kp cm mu tm thi. Thm d 1 cch ton din cc tng trong bng theo 1 trnh t nht nh. Lit k y tn thng, nh du tn thng mi khi tm thy, tip tc tm cho n khi xem ht cc tng. nh gi tng th mc tn thng, sau mi chn phng php iu tr thch hp (tr trng hp v tng chy mu d phi u tin x tr trc). Tnh trng tn thng cng nng, x tr cng n gin v hp l trc mt l cu sng bnh nhn.Cha cc di chng v sau nu bnh nhn sng. 2. C th 1) Hi sc: 20

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


t t nht 1 ng truyn : + Bi ph nc in gii, mu + Theo di lng dch b vo thng qua CVP v huyt p ng mch v lng nc tiu theo di sau mi gi. Th O2 hay ni kh qun v h hp h tr. t ng thng d dy ht lm xp bng trnh tro t sonde bng quang theo di s lng, mu sc nKhng sinh nu nghi ng tn thng tng rng.

ngc dch. c tiu. 2) Gy m: ni kh qun + gin c. 3) ng m: gia trn v di rn. 4) Thm d: Ngay sau khi vo bng cn xc nh s lng mu Cm mu. Thm d ton din nh gi y tn thng trong bng v v tr chy mu.

khi x tr. 5) X tr cc tn thng: Gan: Nguyn tc: cm mu, cm mt. C nhiu phng php: + Chn gc n thun + hi sc chuyn ln tuyn trn. + Khu cm mu bng ch cagut to, kim trn. Tt nht l khu tng mp vt thng. + Ct gan khng in hnh: Thc cht l ly b cc phn gan b dp nt, cm mu chc chn, tht cc ng mt b t, dn lu tht tt. + Ct gan theo phng php Tn Tht Tng, sau nn dn lu ng mt lm gim p lc trnh d mt v cn dn lu bng tht tt trnh ng. Lch: + Ct lch ton b: 21

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Ch nh: -Trng hp tn thng rng, tn thng cung lch. - nhng ni khng c iu kin theo di, phu thut vin t kinh nghim th nn ct lch ton b d tn thng mc no. + Bo tn: -Ch nh: nhng ni c iu kin theo di, phu thut vin c kh nng v i vi tr em th ch nh bo tn lc c t ra: -Ct bn phn lch nu tn thng khu tr 1 thu. -Khu / bc lch bng li t tiu. -Cy nhng mnh lch nh vo mc ni ln, dn lu h lch Tu: + Khu cm mu v dn lu bng. + C th ct ui tu + lch / ct u tu t trng. + Chn gc + dn lu. Thn: + Bo tn ti a nu c th c. + Nu t ng bi niu + cung thn: m cp cu ct thn. 6) Vn iu tr bo tn khng m gan lch: C s ca vic bo tn: + Tn thng gan lch khng cn chy mu khi m bng. + nhng trng hp chy mu th pht nng rt him xy ra. + nhng bnh nhn khng m, nhng bin chng nhim khun bng v mc truyn mu t hn. Ch nh: + Tnh trng huyt ng n nh. + Khng c tn thng phi hp phi m. + Nhu cu truyn mu thp < 1l. + Tn thng trn phim chp ct lp 1,2. 22

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Tui < 55. + Phi c theo di st trung tm hi sc ngoi khoa v lm li CTscanner nh gi. 3. Theo di bin chng v iu tr sau m: Hi sc tch cc. Khng sinh ton thn. Rt dn lu. Theo di. Ct ch.

Chn thng bng kn VII. i cng: 1. Chn thng bng kn l mt cp cu ngoi khoa thng gp v xut hin vi t l ngy cng tng (chim 43% trong tng s cp cu do nguyn nhn chn thng). Chn thng c th gy tn thng t thnh bng vo n cc tng nhng khng c thng phc mc ( bng khng thng vi bn ngoi) do lc trc tip hoc gin tip tc ng. 2. C ch gy chn thng rt a dng, c th: Tc ng trc tip (nh p vo ghi ng): tn thC th b dng t ngt khi ang di chuyn vi tc ng b p gia ct sng v nguyn nhn. cao (phanh gp, ng cao) : mc treo, mc ni b ging x. Lc tip tuyn tc ng xoy vo bng. Lc tc ng cng mnh th tn thng cng nng. 3. Chn thng bng kn thng xy ra sau cc chn thng nng v a s cc trng hp c km theo nhng tn thng phi hp ngoi bng, c bit l chn thng s no, chn thng ngc Bi vy biu hin lm sng rt a dng v phc tp. Vic chn on v x tr cc tn thng trong 23

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


bng cn rt nhiu kh khn, do vy t l t vong cn cao (10 25%). 4. Tn thng trong chn thng bng kn rt phc tp v hu qu thng gp l: 1) V tng c (gan, lch,) gy hi chng chy mu trong tc th hoc th 2. 2) V tng rng (d dy, bng quang, rut ) gy nn vim phc mc ton th hoc khu tr tc th hoc trng hp ng dp, v khng hon ton gy thng th pht. 3) C khi tn thng c tng c ln tng rng. *Tt c cc trng hp u i hi phi chn on sm v m sm. Thng th t l v tng c nhiu hn v tng rng. 5. ng trc 1 bnh nhn c chn thng bng kn, 2 vn cn phi t ra l: 5) C tn thng trong bng cn phi m khng v khi no m. 6) X tr cc tn thng trong bng nh th no. VIII. Nguyn nhn, c ch, gii phu bnh. 1. Nguyn nhn + Tai nn giao thng (70%). + Tai ni sinh hot v lao ng. 2. Tui v gii: Hay gp nam gii tui lao ng. 3. C ch: + Chn thng trc tip: cc tng b p gia tc nhn gy chn thng v cc thnh phn khc ca vng bng (ct sng, xng sn ) gy nhng tn thng nng v phc. + Ging x do gia tc khi ang di ng dng li t ngt. 4. Gii phu bnh: 1) Thnh bng: xy st, t / rch cn c. 2) Tn thng tng c: 24

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Gan: + T mu: di bao/ trong nhu m gan. + Rch gan: rch bao v nhu m. + V gan: dp nt tng h phn thu, phn thu, v lm nhiu mnh, t cc mch mu, ng mt, chy mt. + t cc dy chng ca gan, tnh mch trn gan gy chy mu nng (c ch do ging x). Lch: + L tng d b tn thng, c bit l lch bnh l (st rt, x gan). + Hnh thi tn thng ging nh gan + i khi c t ri cung lch. Tu: + Tn thng mnh, tn thng phn tu vt ngang ct sng (rch/v). + t ng Wirsung + Hnh thnh nang gi tu, p xe tu. Thn: + V thn tri hay i km v lch. + T mu di bao. + t ri cung thn. 4) Tn thng tng rng: Cc hnh thi chung ca tn thng tng rng. + Tn thng di thanh mc gy hoi t, vim phc mc. + Vt thng bn + t ri 2 u rut. D dy: + Hay b t ri sau khi n no, phnh v ln hay b b st. + Do c ch n p. T trng: + on c dnh hay b tn thng gy trn kh v hu cung mc ni, sau phc mc. 25

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Dch t trng chy ra to 1 vng ph n, ngm mt vng. Rut non: Gc Treizt gn gc hi manh trng. Rut gi:

+ Gy vim phc mc nng do c phn. + on i trng xch ma hay gp. Mc treo rut: + n c/phi hp cc tng. + C ch ging git gy t mu mc treo: nu t mch mu s gy nguy him v on rut tng ng b hoi t. IX. Bng quang: v, rch gy vim phc mc nc tiu, trn C honh: do p vo bng. Chn on: iu quan trng nht i vi 1 trng hp chn thng bng kn l phi pht hin cc du hiu chng t c tn thng tng c thi x tr kp thi, khng nht thit phi bit tng no tn thng. Trong trng hp in hnh sau 1 chn thng bnh nhn vo vin trong bnh cnh shock nng do mt mu hoc do vim phc mc nng, nhim khun nhim c i hi 1 can thip ngoi khoa cp cu, khng cn thm khm g thm mt thi gian, m va hi sc va m mi hy vng cu sng c bnh nhn. Trong trng hp bnh nhn khng c tnh trng shock nng tin hnh thm khm mt cch cn thn v t m lp i lp li nhiu ln nhm tm ra cc du hiu tn thng tng c hng x tr. 1. Lm sng: 3) Hi bnh: hi trc tip bnh nhn v ngi i theo. Hon cnh chn thng: + Nguyn nhn v gi xy ra chn thng. + Tc nhn chn thng: cng , hng v vng tip xc. 26 vo khoang Reitzius.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ T th bnh nhn khi b chn thng. Din bin k t khi chn thng cho n khi nhp vin: + Ngt xu khi thay i t th. + Bun nn/ nn, nn ra mu. + au bng, hng lan, tin trin ca au. + i mu, b i. + Mu chy qua hu mn. + T khi b thng x tr g. Tin s v tnh trng bnh nhn trc tai nn + Tin s ni ngoi khoa: gan to, lch to. + Lc tai nn l lc i hay no. + i ln cui cng trc khi tai nn l bao lu. T ta c th nh hng c v tr tn thng, din bin tn thng gip ch cho vic khm lm sng. C nng: + au, nn, b trung i tin. + au v tr tng tn thng. + V lch km au h chu phi do mu chy xung. 7) Ton thn: Phi tr li c cu hi bnh nhn c shock hay Shock: kht nc, nht, v m hi, chn tay lnh, th Mch nhanh nh kh bt > 100l/ph. Huyt p < 90mmHg, 1 s trng hp chy mu trong khng, shock do au hay shock do mt mu/nhim khun. nhanh nng, vt v hoc nm lm i.

bng huyt p khng tt hoc ch tt sau 1 thi gian theo di nhng mch thng xuyn tng cao. Du hiu nhim khun (vim phc mc) : st cao, mi kh , li bn, th hi. 8) Thc th: Nhn: 27

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Vt xy xc, bm ftims trn thnh bng: c gi tr gi v tr tng tn thng. + Bng chng, mc chng. + Bng c di ng theo nhp th khng S: pht hin cc du hiu: + Co cng thnh bng (xut hin mun) v phn ng thnh bng l nhng du hiu hay gp trong chn thng tng rng. Tuy nhin cc du hiu ny kh nh gi khi thnh bng c tn thng. + Cm ng phc mc: hay gp trong tn thng tng c. + Thm khm h tht lng bng 2 tay thy h tht lng y au: t mu quanh thn. Nghe: + Bng: im lng, khng c nhu ng rut. + Ngc: c trn mu trn kh mng phi phi hp. + C lc xc trn ngc: v c honh. G: + c vng thp: c dch trong bng. + Mt vng c trc gan: tn thng tng rng. Thm trc trng m o: + Ti cng Douglas phng: c trn mu mng phi v au d di khi c vim phc mc. + Phn c mu/c mu theo tay 9) Khm cc tn thng phi hp: Ngc: + Mng sn di ng + Gy xng sn. + Trn mu trn kh mng phi. Chn thng ngc thng gy ra co cng / phn ng di sn. Chn thng s no : thang im Glasgow. Chn thng thn: t mu h tht lng, i mu. 28

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


V xng chu: p 2 bn cnh chu au. Chn thng ct sng: S nn dc theo ct sng tm

im au/bin dng. *V xng chu v gy ct sng gy ra t mu sau phc mc lm bng chng au tng t nhng trng hp chy mu trong bng. Nh vy da trn nhng du hiu trn y ta c th s b ngh n chn thng bng kn v a ra cc ch nh xt nghim. 2. Cn lm sng: 2) Xt nghim mu (c gi tr xc nh tn thng v cho vic hi sc). Nhm mu. Thi gian mu chy, mu ng. S lng hng cu gim: < 3,5 triu S lng bch cu: Tng > 9000. L du hiu c trng Hematocrite: Gim < 30%. Transaminse tng trong trng hp c tn thng gan. Amylase tng trong trng hp thng tn tu.

khi tn thng tng.

*Cc xt nghim ny phi lm i lm li nhiu ln so snh v pht hin nhng thay i. 9) Chp Xquang bng khng chun b: 2 phim thng v nghing t th ng/nm trn 1 phim Hnh nh lim hi: tp trung vo vm honh. + Di c honh: 80% c thng tng rng, v vy khng c lim hi cng khng loi tr c thng tng rng. + Sau phc mc: v t trng. Chy mu trong bng (v tng c): + bng m.

29

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Cc quai rut dn, thnh rut dy (do dch ng thnh rut). + D dy gin hi ni ln trn nn bng m (bng c dch mu). + V lch: d dy gin hi b y sang phi, vm honh tri cao, bng m ca lch to. Nu km theo gy xng IX, X, XI tri th cng ngh n v lch. Hnh nh d dy, rut trn lng ngc Cc tn thng ca xng sn cui, xng chu v ct Chp Xquang lng ngc pht hin cc tn thng

sng. 10) u: phi hp + Khng nguy him, c th tin hnh nhiu ln gip chn on v theo di s tn thng. + chnh xc cao 90 97%. Xc nh hnh tn thng cc tng, dch trong Trng hp c trn kh di da, bng chng, tn thng Siu m: bng. tng rng, tn thng tu : siu m kh pht hin. 11) L phng php tt chn on, theo di du hiu

lm sng do khng nguy him, c th lm li nhiu ln, chnh xc cao. Cho bit: Hnh nh cc tng v, khi mu t trong nhu m, di bao, hnh nh dch trong bng: s lng dch o c qua siu m thng t hn s lng dch thc t. Trng hp v tng rng, trn kh di da, bng chng, chn Chc d bng: thng tu su siu m kh nh gi. 12) V tr: cc ch thp.

30

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Nu dch ra: mu / hng cu > 100000/ml: v tng c m, thc n / bch cu > 500/ml: v tng rng. C th thy Amylase trong dch tng cao Nu: hng cu = 5000 10000, bch cu = 1000 500: Nu dch trong hoc hng cu < 5000, bch cu < Trng hp chc d nu m tnh vn khng cho php c.

Lm li sau 2h. 100: m tnh. loi tr tn thng tng v kh theo di lm sng sau khi chc d do thnh bng b tn thng: bnh vin Vit c ch c cc I mi c chc d 13) Chc ra bng: chnh xc cao, thng c s dng khi triu chng

lm sng cha r rng, nht l khi bnh nhn c km chn thng s no. lng ngc, a chn thng. Khng nn s dng khi c tin s m bng nhiu ln trnh tai bin thng rut. Nu dch ra: mu / hng cu > 100000/ml: v tng c m / bch cu > 500/ml: v tng rng. C th thy Amylase trong dch tng cao Nu: hng cu = 5000 10000, bch cu = 1000 500: Nu dch trong hoc hng cu < 5000, bch cu < CTscanner: c.

Ra li sau 2h. 100: m tnh. 14) Ch nh khi tnh trng bnh nhn n nh. Cho php nh gi chnh xc v tr, mc tn thSoi bng: xc nh v tr, mc v c th x

ng l c s cho vic chn on v x tr. 15) tr tn thng trong bng. 31

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


X. Chn on cc hi chng ca chn thng bng kn: 1. Hi chng v tng c (hi chng chy mu trong): c tnh trng shock mt mu ngay sau khi vo vin: 1) C nng: au, nn, b trung i tin. 2) Ton thn: da xanh, nim mc nht, chi lnh, mch > 100, huyt p < 90mmHg, CVP gim. Khng thy nguyn nhn no khc ct ngha c tnh trng shock ny (khng c trn dch mng phi), khng c a chn thng. 3) Thc th: Bng chng, n au khp bng. G c vng thp. Thm trc trng: ti cng Douglas phng v au. C vt xy st thnh bng c bit vng gan, lch,

trn rn. Vi nhng trng hp in hnh ny, phi ngh ngay n v tng c, cn nhanh chng chuyn vo nh m, va chuyn va hi sc. Cc th tc th mu, xt nghim cng lm ti nh m, khng c chng chnh ch i, khng nht thit phi chn on chnh xc l v tng no. Vi nhng tn thng khng in hnh, vic chn on v theo di phi theo 1 qui trnh cht ch .. i vi v tng c: Lm xt nghim mu: Thiu mu, bch cu tng, hematocrite gim. C th lm li nhiu ln xt nghim ny so snh, nu cng v sau cng tt : nghi ng hi chng chy mu trong. Chp bng khng chun b: + bng m, khng thy r bng c i chu. + Rut gin, khong cch gia cc quai rut rng v m. + Hnh nh v lch.. Chc ra bng: Ht ra mu, dch ra . 32

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Siu m: du hiu v tng + mu trong bng. CTscanner bng: thy c dch trong bng, thy -

ng v tng. 2. Hi chng v tng rng (hi chng vim phc mc): 5. C nng: au nh dao m, nn, b trung i tin. 6. Thc th: au, co cng khp bng: mc co cng nh trong Phn ng, cm ng phc mc Mt vng c trc gan. Thm trc trng: ti cng Douglas phng, n au. thng d dy.

3) Ton thn: Trong nhng gi u khng c g thay i. Khi n mun: v mt nhim khun: mi kh, li bn, hi th hi, st 38 39. Vi cc du hiu trn c s chn on vim phc mc do thng tng rng. Nu bnh nhn shock th phi hi sc ri m. Nu bnh nhn khng c shock th lm thm cc xt nghim: Chp bng khng chun b: nu c lim hi l chc chn c, nu khng c th cng khng loi tr thng tng rng. Siu m: dch trong bng. Chc ra:

+ Nc c, dch tiu ho, nc phn: chn on xc nh. + Nc trong, th bch cu > 500/ml: thng tng rng. Xt nghim: bch cu tng. 3. Khi cc triu chng v du hiu khng r rng: 1) Triu chng chy mu trong v vim phc mc khng r. Ch c nhng du hiu nghi ng tn thng tng trong bng: au khp bng: au t nhin hoc khi th, ho au tng ln. 33

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Khng c co cng thnh bng. 2) chn on r hn cn lm thm cc xt nghim v theo di st bnh nhn, 30 pht khm li 1 ln, t nh hng chn on. 3) Nu sau khi lm tt c cc bin php thm do trn m vn khng r chn on th cho bnh nhn vo vin theo di vi ba ngy. Nu xut hin cc din bin mi sau y th phi ngh ti tn thng tng trong bng: Huyt p tt t ngt khi ang nm ngi dy, km Xut hin thm cc du hiu lm sng mi: au km co theo chong vng, xy xm mt mi. cng thnh bng, bng chng dn v c cm ng phc mc. Xt nghim hng cu, hematocrite, gim dn qua nhiu ln th lin tip 4. Trng hp c bit: bnh nhn c a n trong tnh trng a chn thng hoc hn m li nghi ng c tn thng tng trong bng: Trc tin hi sc tt, ch huyt p ln v n nh. Lm thm 1 s thm khm h tr khc: Xquang, siu m, Nu tnh trng bnh nhn ti cp cu th va hi sc

chc ra. va chuyn bnh nhn vo phng m, sau va m va kim tra cc tng trong bng. XI. Chn on cc th lm sng ca chn thng bng kn: 1. Th theo din bin: 5) Th cp din Chy mu t thng do v tng c hoc t cc mch Bnh nhn n vi tnh trng shock nng. T vong sau 2 3h nu khng c x tr kp thi. 34 mu ln cung lch, rn gan, tnh mch trn gan.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


6) Th din bin chm (thng tn tng th 2): Chy mu do t mu di bao ca tng c. V tng rng bt nay l thng b bung ra. Thng tn di thanh mc nay b v. Tn thng mc treo rut: rut hoi t dn.

Sau giai on chnh ban u, cc triu chng lm sng v cn lm sng khng r, sau 1 3 ngy bnh nhn xut hin cc triu chng in hnh ca hi chng chy mu trong hoc vim phc mc (ton th, khu tr). 2. Th phi hp: 7) Chn thng bng + chn thng s no: Trong chn thng s no khng c huyt p tt, v vy nu 1 bnh nhn chn thng s no m huyt p tt phi c gng tm cc tn thng bng, ngc. Khi nghi ng: chc ra bng. 8) Chn thng bng + chn thng ngc: Thng nhng triu chng ca chn thng ngc che lp nhng triu chng ca chn thng bng. trnh b st nn: Dn lu ngc c h thng. nh gi li huyt ng, siu m pht hin tn th-

ng. 3) Chn thng bng + a chn thng: Hi sc tch cc sau nh gi li ton b cc tn thng trong c tn thng bng. 4) Chn thng bng + chn thng ct sng: Lu tn thng tng sau phc mc phi hp ca thn: i khi chn thng ct sng n thun gy t mu sau i mu, siu m, UIV. phc mc cng c bnh cnh lm sng tng t chn thng bng. 5) Chn thng bng + v xng chu: Tn thng bng quang, niu o sau. 35

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Chn on: khng t i, mu sc nc tiu, t sonde niu o 3. Th theo tn thng tng: 3) V lch: Sau chn thng trc tip vo h sn tri nht l i vi Hay gp, chy mu nhiu: phi can thip ngoi khoa. au h sn tri v h chu tri do mu theo rnh i Xquang. au nhiu h sn phi, lan ln vai phi. Bch cu tng, t l Transaminase mu tng. Mt lc tc ng rt mnh mi gy v tu. Thng km v lch v t trng. C th gy bin chng vim tu cp v nang gi tu. Xt nghim: amylase mu tng. lch bnh l.

trng tri xung h chu. 4) V gan:

3) V tu:

4) V thn: au tht lng, i mu, sng n h tht lng, hi chng sau phc mc (bng chng, b trung i tin, cm ng phc mc na bng bn thng tn). 5) V d dy: Khi d dy y thc n. Nn mu v ht sode d dy ra dch ln mu. au bng, au vng tht lng. Du hiu mt mu. Bng chng hi, phn ng thnh bng, co cng na

6) Mu t sau phc mc:

bng, c khi mu t vng tht lng. 7) V t trng: kh chn on. XII. X tr: 1. Nguyn tc: 36

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Chn on sm v x tr sm cc tn thng. Hi sc tch cc phi c tin hnh ngay khi bnh Nu bnh nhn n vi tnh trng shock sau chn thnhn ti vin, trc trong v sau khi m. ng vi cc du hiu in hnh ca chn thng bng kn th tin hnh va hi sc va m ngay, cc xt nghim c lm trong nh m. Nu bnh nhn khng shock, tin hnh thm khm t m, nhiu ln chn on sm, khi c chn on xc nh tn thng tng l phi m cp cu, va m va hi sc, ch nh khng sinh ton thn ngay t lc khi m. Nu c lm sng v cn lm sng u khng r l chn thng bng kn th cho bnh nhn vo vin theo di 3 5 ngy, nu thy cc triu chng: + H huyt p t ngt khi thay i t th km theo sy sm, chong vng. + au km co cng thnh bng, cm ng phc mc (+), bng chng dn. + Cc xt nghim hng cu, bch cu, Hematocrit thay i qua nhng l th lin tip. Th phi ngh n chn thng bng kn. Tt nht l gy m ni kh qun + gin c c th M bng rng ri ng gia trn v di rn. Nu c mu thm d v tm ht tn thng. th tm ngay vo ch ang chy mu ri n, p hoc kp cm mu tm thi. Thm d 1 cch ton din cc tng trong bng theo 1 trnh t nht nh. Lit k y tn thng, nh du tn thng mi khi tm thy, tip tc tm cho n khi xem ht cc tng. nh gi tng th mc tn thng, sau mi chn phng php iu tr thch hp (tr trng hp v tng chy mu d phi u tin x tr trc). 37

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Tnh trng tn thng cng nng, x tr cng n gin v hp l trc mt l cu sng bnh nhn.Cha cc di chng v sau nu bnh nhn sng. 2. C th 7) Hi sc: t t nht 1 ng truyn : + Bi ph nc in gii, mu + Theo di lng dch b vo thng qua CVP v huyt p ng mch v lng nc tiu theo di sau mi gi. Th O2 hay ni kh qun v h hp h tr. t ng thng d dy ht lm xp bng trnh tro t sonde bng quang theo di s lng, mu sc nKhng sinh nu nghi ng tn thng tng rng.

ngc dch. c tiu. 8) Gy m: ni kh qun + gin c. 9) ng m: gia trn v di rn. 10) 11) php: + Chn gc n thun + hi sc chuyn ln tuyn trn. + Khu cm mu bng ch cagut to, kim trn. Tt nht l khu tng mp vt thng. + Ct gan khng in hnh: Thc cht l ly b cc phn gan b dp nt, cm mu chc chn, tht cc ng mt b t, dn lu tht tt. 38 Thm d: Ngay sau khi vo bng cn xc nh s lng mu Cm mu. Thm d ton din nh gi y tn thng X tr cc tn thng: Gan: Nguyn tc: cm mu, cm mt. C nhiu phng

trong bng v v tr chy mu.

khi x tr.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Ct gan theo phng php Tn Tht Tng, sau nn dn lu ng mt lm gim p lc trnh d mt v cn dn lu bng tht tt trnh ng. Lch: + Ct lch ton b: Ch nh: -Trng hp tn thng rng, tn thng cung lch. - nhng ni khng c iu kin theo di, phu thut vin t kinh nghim th nn ct lch ton b d tn thng mc no. + Bo tn: -Ch nh: nhng ni c iu kin theo di, phu thut vin c kh nng v i vi tr em th ch nh bo tn lc c t ra: -Ct bn phn lch nu tn thng khu tr 1 thu. -Khu / bc lch bng li t tiu. -Cy nhng mnh lch nh vo mc ni ln, dn lu h lch Tu: + Khu cm mu v dn lu bng. + C th ct ui tu + lch / ct u tu t trng. + Chn gc + dn lu. Thn: + Bo tn ti a nu c th c. + Nu t ng bi niu + cung thn: m cp cu ct thn. D dy: Khu l ch yu, trnh b st tn thng mt Rut non: sau d dy. + Khu l thng n thun. + Ct on rut. T trng: + dn lu t trng qua l thng. 39

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Khu t trng + ct d dy bn phn. + Khu t trng + ct dy X + ct hang v. i trng: Khng khu i trng trong th u. + Ch yu l a ch thng ra ngoi, lm hu mn nhn to tm thi. c th khu ngoi bng. + Ct on i trng cp cu: c bo v bng hu mn nhn to trn Bng quang: Khu bng quang + m thng bng Trc trng: quang. + Khu kn. + Lm hu mn nhn to pha trn. + Ni li th 2. 12) Vn iu tr bo tn khng m gan lch: C s ca vic bo tn:

+ Tn thng gan lch khng cn chy mu khi m bng. + nhng trng hp chy mu th pht nng rt him xy ra. + nhng bnh nhn khng m, nhng bin chng nhim khun bng v mc truyn mu t hn. Ch nh: + Tnh trng huyt ng n nh. + Khng c tn thng phi hp phi m. + Nhu cu truyn mu thp < 1l. + Tn thng trn phim chp ct lp 1,2. + Tui < 55. + Phi c theo di st trung tm hi sc ngoi khoa v lm li CTscanner nh gi. XIII. Theo di bin chng v iu tr sau m: Hi sc tch cc. Khng sinh ton thn. Rt dn lu. 40

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Theo di. Ct ch.

Tc rut do b thc n. I. i cng 1. Tc rut l tnh trng ngng tr lu thng ca dch v hi trong lng rut do 2 nhm nguyn nhn chnh: c nng v c gii. 2. Tc rut mt cp cu ngoi khoa thng gp trong cp cu bng, ch ng sau vim rut tha. C nhiu nguyn nhn gy tc rut thay i ph thuc vo v tr tc, c ch tc. Chn on cn kh khn cho d c nhiu phng tin chn on hin i c p dng. 3. Trong thi gian gn y vi s tin b ca gy m hi sc v phu thut t l t vong v bin chng sau m tc rut ci thin ng k. 4. C nhiu cch phn loi tc rut : 1) Theo din bin: Tc rut hon ton: l tc rut xy ra cp tnh v tc Tc rut khng hon ton (bn tc rut): l tc rut hon ton. khng hon ton, c cn tr lu thng nhng mt phn v hi vn qua c ch tc. 2) Theo sinh l: Tc rut c hc: l tc rut c mt nguyn nhn c th gy tc nghn nhu ng rut. V d: bi giun, khi u, thot v nght Tc rut c nng: Khng c nguyn nhn c th no, rut mt nhu ng, khng c co bp hoc co bp qu mc dn n lit rut. V d : lit rut c nng sau m bng.

41

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


5. Tc rut do b thc n thng gp ngi gi, rng ming km, bnh l tu km, nhng gn y gp c ngi tr (?, c bnh l u) sau khi n thc n kh tiu. 6. Tc rut do b thc n kh chn on do triu chng khng in hnh v thay i. II. Cc ri lon trong tc rut: Khi rut b tc hon ton s dn n nhng bin i phc tp v nghim trng v sinh bnh. Trong iu tr tc rut khng ch ly i nguyn nhn gy tc m cn phi bit cch iu chnh ng n nhng bin i ny. 1. Cc ri lon ti ch: 1) Tng nhu ng rut: Lc u: Rut tng co bp v bp mnh c thng cn tr: biu hin lm sng tng ng l cc triu chng : + au bng tng cn + Nn nhiu. + Nhn thy quai rut ni v chuyn ng t tri sang phi tng t ng vi cn au. + Nghe bng thy ting ro si ca hi v dch rt r v mnh. V sau: Rut ra khng co bp na hoc co bp yu, rut gin chng. + au gim i, cc cn au tha ra. + Nn t hn. + Khng nhnh thy cc quai rut chuyn ng na m phi t tay ln thnh bng mi cm thy c nhng chuyn ng ny. 2) Chng rut: Do hi v dch ng trong lng rut trn ch tc. Hi c ngun gc t: khng kh v hi nut vo khng

thot ra c; hoc tng sinh hi trong lng rut.

42

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Dch trong lng rut c ngun gc t thc n, dch tiu ho khng c hp thu, hoc do tng tit dch vo lng rut v 2 kch thch: rut gin cng v tr tun hon thnh rut. 3) Ri lon tun hon rut mc treo: Nu nguyn nhn gy tc rut l xon, nght rut th c ng mch v tnh mch chi phi on rut nght b chn p, bp nght nn thnh rut khng c mu nui dng dn n hoi t. p lc trong lng rut trn ch tc tng cao gy chn p tnh mch, co tht tiu ng mch, dn n thiu mu rut lm hoi t, thng rut. Tnh trng thiu mu, tr v thiu O2 lm tn thng nim mc rut lm cc cht c tr trong lng rut tro ngc vo mu dn n shock nhim c. 2. Cc ri lon ton thn: C nhiu yu t phi hp vi nhau dn n ri lon ton thn nh: ri lon in gii, tnh trng mt nc, mt thng bng kim toan, nhim khun-nhim c. III. Chn on. 1. Chn on hi chng tc rut: Da ch yu trn lm sng v Xquang. 1) C nng: au bng: + t ngt thnh tng cn, tng nhanh, tng dn v cng au, khong cch gia cc cn ngn dn. + Lc u au v tr b tc, sau lan ra khp bng. + Cm gic au tht, xon vn dn n lo s (trng hp xon rut). Nn: + Tc rut cao: nn sm v lin tc, tc rut thp: nn t hoc khng nn. 43

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Cht nn: nc mt, thc n, nc phn (mun) + Nn xong vn khng mt hon ton cm gic au. B trung i tin: tc cao cn c th i tin (phn cn ng di ch tc). 2) Ton thn: Trong nhng gi u t thay i. Nu dn mun c th c biu hin ca mt nc v

nhng bin chng ca tc rut: hoi t rut, thng rut, tuy nhin i vi tc rut do xon th tnh trng tru mch do shock nhim c l rt sm. 3) Thc th: Bng chng: Tu vo v tr tc rut m c nhng biu hin khc nhau.Thng thy: + Bng chng u: tc rut thp. + Bng chng lch v pha bn tri: xon i trng xch ma, bn phi: xon i trng phi. + Nhng ngi bo hoc c thai th kh nh gi chng bng, nu tc rut cao bng cn xp li ch khng chng. + Bng chng dc theo khung i trng kiu ng khung (tc i trng). Du hiu rn b: + xut hin t nhin km c au hoc khi kch thch vo thnh bng. + Hnh nh cc quai rut ni chuyn ng t tri sang phi tng t (thng trong cn au) c th nhn thy r nu thnh bng mng, t m. + Nhiu khi ta ch thy quai rut ni m khng thy du hiu rn b phi t tay ln thnh bng mi cm nhn r. C khi s thy 1 quai rut di ng di lng bn tay Trng hp mun: phn ng thnh bng, du hiu cm hoc c th s thy bi giun, khi lng, u.. ng phc mc: biu hin hoi t rut, tin lng xu. 44

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


G: vang vng chng, c vng thp (dich bng). Nghe: Ting ro, si trong lng rut rt mnh v r (lc Thm trc trng:

xc tng). + Bng trc trng rng, khng c phn. + Douglas phng; dch bng, quai rut chng. + i khi s thy khi u trc trng l nguyn nhn ca tc rut thp. + Mu theo tay: lng rut. Khm cc l thot v bn i Khm tm so m c. Khm rng ming. Xt nghim c bn:

4) Cn lm sng: + C c mu: hng cu tng, hematocrite tng. + in gii gim. + Ure tng, d tr kim gim. Xquang: + Xquang bng khng chun b: -T th: ng-chp thng mt, nm-chp nghing. -Hnh nh: cc quai rut gin v c mc nc mc hi: tc rut non: chn rng vm thp, tp trung gia bng. Tc i trng: chn hp vm cao, nm dc theo khung i trng trn ch tc. -Du hiu c dch bng: m vng thp, thnh rut dy (dch ng gia cc quai rut). -Nu rut b thng s thy lim hi di vm honh (phi) trong bng. + Chp khung i trng c thuc cn quang: -Ch nh: nghi ng c tc i trng.

45

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


-Thuc cn quang: khng dng baryt m dng thuc cn quang tan trong nc phng thng rut, thuc cn quang vo bng gy bin chng nguy him. -Trng hp tc rut bn cp: theo di s di chuyn ca thuc trn mn hunh quang pht hin u, lng rut, cht hp + Nu hnh nh tc rut khng r th c th chp li sau vi gi: nu thy hnh nh mc nc hi ngy cng nhiu v to: tc rut. Siu m: + Hnh nh gin tip: dch bng, quai rut gin (khng c hiu) + Hnh nh trc tip: khi lng, khi u). 2. Chn on tc rut do b thc n: Trn c s cc triu chng ca tc rut, nhng triu chng sau lm cho ta ngh n nguyn nhn do b thc n: 1) Hon cnh: thng xy ra ngi gi rng rng, rng gim sc nhai hoc vim tu mn, c n thc n nhiu x, b (cam, mng, mt, hng, rau mung). Cng c th gp tr em do n nhiu qu cht: sim, i, gng 2) Triu chng: Thng khng in hnh, trc khi tc thc s thng c du hiu bn tc. Du hiu bn tc ph thuc vo v tr ca b thc n ng tiu ho ch rut b gp gc nh gc Treizt hi manh trng au bng d di hay au va phi ph theo nt thc n Thng khng nn. C th vn trung tin c. Bng chng t hay nhiu ph thuc v tr tc. Bnh tng gim thnh tng t. cht hay lng.

46

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Xquang: thy nhiu mc nc hi rut non nhng i khi thy hi sang i trng v nt thc n bt tc khng hon ton. 3. Chn on phn bit : 1) Tc rut c nng: Hay gp c trong cc bnh ni khoa cng nh ngoi khoa: ri lon K, vim phc mc, si niu qun. Triu chng lm sng: + khng c cn au hoc au t. + bng chng nhng khng c du hiu rn b. c. 2) Tc rut do xon rut: + Sau m, c vt m c. + au bng d di. + Shock: ht hong, mch nhanh, huyt p h, st. + Bng chng lch. + Khng c triu chng rn b v bng im lng khi nghe. + Thm trc trng: Douglas y v au. + Xquang: Xut hin sm1 quai rut gin to, duy nht, cha nhiu dch, t hi, dch v hi c ngn cch bi mt mc ngang. 3) Tc rut do thot v nght: 4) Tc rut do giun. 5) Tc rut do u. 6) Mu t sau phc mc, chn thng ct sng; 7) Cn au qun thn: Khu tr 2 bn h chu, lan n b phn sinh dc. Nc tiu : hng cu(+), bch cu (+) UIV cp cu. Tp trung vng gan 47 Xquang: khng c mc nc mc hi, c du hiu bn

8) Cn au qun gan:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Gan to, hong m. Hi chng tc rut c gii (-). au thng v Nn khng b trung i tin. Ni : ng c thuc, a chy,

9) Vim d dy cp:

10) vim rut

*Da trn khm lm sng + Xquang c th nh hng chn on v tr v c ch tc rut cp , phi m mi bit chnh xc nguyn nhn tc rut cp. IV. X tr 1. Nguyn tc: M cp cu khi c triu chng tc rut cp, m cp cu c tr hon khi c triu chng bn tc. 1) Hi sc trc m. Ht dch d dy t trng (sode d dy) Bi ph nc in gii, thng bng kim toan ng tnh

mch, theo di qua o CVP. 2) V cm: Tt nht l gy m ni kh qun. Mt s trng hp c th gy t tu sng/ ngoi mng

cng. 3) ng m: ng trng gia di rn. 4) Tm v tr tc rut: t v tr rut xp ln ngc ln s thy ch tc. 5) X tr tc rut: Kim tra k trong d dy xem cn cc b thc n no khng. Nu c th phi y ht xung rut non ly ht ra. M rut ly khi b thc n pha di ch gin. Khu phc hi thnh rut. Dn lu hi trng. 48

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


6) Lm xp rut trc khi ng bng: li. Vut dn hi v dch ln d dy ri ht qua sonde mi. y mt sonde d dy xung ch tc, va y va ht. Qua ch m rut (trnh gy bn bng). Tip tc bi ph nc in gii. lu sonde d dy ht lin tc cho ti khi trung tin tr

7) Sn sc sau m:

Tc rut sau m I. i cng 2. Tc rut l tnh trng ngng tr lu thng ca dch v hi trong lng rut do 2 nhm nguyn nhn chnh: c nng v c gii. 3. Tc rut mt cp cu ngoi khoa thng gp trong cp cu bng, ch ng sau vim rut tha. C nhiu nguyn nhn gy tc rut thay i ph thuc vo v tr tc, c ch tc. Chn on cn kh khn cho d c nhiu phng tin chn on hin i c p dng. 4. Trong thi gian gn y vi s tin b ca gm m hi sc v phu thut t l t vong v bin chng sau m tc rut ci thin ng k. 5. C nhiu cch phn loi tc rut : 1) Theo din bin: Tc rut hon ton: l tc rut xy ra cp tnh v tc Tc rut khng hon ton (bn tc rut): l tc rut hon ton. khng hon ton, c cn tr lu thng nhng mt phn v hi vn qua c ch tc. 2) Theo sinh l:

49

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Tc rut c hc: l tc rut c mt nguyn nhn c th gy tc nghn nhu ng rut. V d: bi giun, khi u, thot v nght.. tc rut c nng: Khng c nguyn nhn c th no, rut mt nhu ng, khng c co bp hoc co bp qu mc dn n lit rut. V d : lit rut c nng sau m bng. 6. Tc rut sau m l tc rut gp trn bnh nhn tng m bng xut hin hi chng tc rut c hc m nguyn nhn sau ny c tm thy l do dnh, dy chng lm xon, lm nght rut hoc do d vt cn st li gy dnh rut. 1) Tc rut c th xy ra sm (sau m 7 10 ngy) hoc c th xy ra mun (sau m 10 20 nm). 2) i vi nhng trng hp lit rut c nng tm thi sau m hoc lit rut do vim phc mc, bc ming ni sau m th khng c gi l tc rut sau m. V. Cc ri lon trong tc rut: Khi rut b tc hon ton s dn n nhng bin i phc tp v nghim trng v sinh bnh. Trong iu tr tc rut khng ch ly i nguyn nhn gy tc m cn phi bit cch iu chnh ng n nhng bin i ny 1. Cc ri lon ti ch: 1) Tng nhu ng rut: Lc u: Rut tng co bp v bp mnh c thng cn tr: biu hin lm sng tng ng l cc triu chng : + au bng tng cn + Nn nhiu. + Nhn thy quai rut ni v chuyn ng t tri sang phi tng t ng vi cn au. + Nghe bng thy ting ro si ca hi v dch rt r v mnh.

50

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


V sau: Rut ra khng co bp na hoc co bp yu, rut gin chng. + au gim i, cc cn au tha ra. + Nn t hn. + Khng nhnh thy cc quai rut chuyn ng na m phi t tay ln thnh bng mi cm thy c nhng chuyn ng ny. 4) Chng rut: do hi v dch ng trong lng rut trn ch tc. Hi c ngun gc t: khng kh v hi nut vo khng Dch trong lng rut c ngun gc t thc n, dch tiu

thot ra c; hoc tng sinh hi trong lng rut. ho khng c hp thu, hoc do tng tit dch vo lng rut v 2 kch thch: rut gin cng v tr tun hon thnh rut. 5) Ri lon tun hon rut mc treo: Nu nguyn nhn gy tc rut l xon, nght rut th c ng mch v tnh mch chi phi on rut nght b chn p, bp nght nn thnh rut khng c mu nui dng dn n hoi t. p lc trong lng rut trn ch tc tng cao gy chn p tnh mch, co tht tiu ng mch, dn n thiu mu rut lm hoi t, thng rut. Tnh trng thiu mu, tr v thiu O2 lm tn thng nim mc rut lm cc cht c tr trong lng rut tro ngc vo mu dn n shock nhim c. 2. Cc ri lon ton thn: C nhiu yu t phi hp vi nhau dn n ri lon ton thn nh: ri lon in gii, tnh trng mt nc, mt thng bng kim toan, nhim khun-nhim c. VI. Chn on: Trn 1 bnh nhn m bng c c cc triu chng sau: 51

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) C nng: 1) au bng: t ngt, d di, tng nhanh. Lc u au ti v tr vt m, sau lan ra khp bng. Cm gic au xon vn, au tht gy cm gic lo s. Nn thc n, nc mt, nc phn. Sau khi nn vn khng ht cm gic au. nu l tc rut cao th thi gian u vn c th c Nu l tc i trng th b trung i tin ngay t

1) Nn:

3) B trung i tin trung tin. u. 2. Ton thn: Thi gian u cha c thay i g. Nu n mun c th c du hiu mt nc. Trng hp tc rut do xon c du hiu tru mch sm.

3. thc th: 1) Bng chng: tu v tr tc rut: tc rut non: bng chng u. tc rut cao: bng khng chng. tc i trng xch ma: bng chng lch sang tri . ph n c thai hoc ngi bo tc rut kh nh gi

bng c chng hay khng. 2) du hiu rn b. 4. Xquang : 1) Xquang bng khng chun b : hnh nh mc nc mc hi: + tc rut cao (rut non): chn rng vm thp, tp trung gia bng hoc xp thnh hnh bc thang t h chu tri n h sn phi.

52

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Tc i trng: chn hp vm cao, nm dc theo khung i trng trn ch tc. du hiu c dch bng: m vng thp, thnh rut dy Nu rut b thng do hoi t s thy lim hi di vm (dch ng gia cc quai rut). honh (phi) trong bng. 2) Chp khung i trng c thuc cn quang: Ch nh: nghi ng c tc i trng. Thuc cn quang: khng dng baryt m dng thuc cn

quang tan trong nc phng thng rut, thuc cn quang vo bng gy bin chng nguy him. Trng hp tc rut bn cp: theo di s di chuyn ca thuc trn mn hunh quang pht hin u, lng rut, cht hp Nu hnh nh tc rut khng r th c th chp li sau vi gi: nu thy hnh nh mc nc hi ngy cng nhiu v to: tc rut. *Tm li chn on l tc rut sau m c th t ra khi: trn 1 bnh nhn c tin s m bng c, trn lm sng c hi chng tc rut c hc: nn, au bng, b trung i tin, bng chng, du hiu rn b, trn Xquang c mc nc mc hi. VII. Chn on phn bit 1. Vim tu cp hoi t chy mu: xt nghim amylase mu v amylase niu. 2. Nhi mu mc treo rut: chn on trong m. VIII. X tr: 1. Nhng trng hp c ch nh m ngay (va hi sc va m): 1) tc rut sau m do xon hoc nght rut do dy chng. au d di khc thng. 53

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Cn au lin nhau 1 2 pht mt cn. Tnh trng shock km theo: v m hi, mch tng, huyt n au chi ti 1 im c nh.

p h. 1) Tc rut n mun c bin chng hoi t gy thng rut vim phc mc: v mt nhim khun nhim c: b ph, hc hc, da n au khp bng, cm ng phc mc r. Cn au tha nh Tnh trng ton thn n nh, khng c shock. Bng mm, khng c cm ng phc mc. Nhp vin Ht dch d dy lin tc. Cho n ng tnh mch. Khng sinh. Lp bng theo di: xanh, v m hi, shock 2. Nhng trng hp c th theo di.

1) Ni dung theo di:

+ Thi gian gia cc cn au. + Mc au: tng, gim, nh c. + Bng chng: tng, gim, nh c. + Cm ng phc mc: c hay khng. + Ton thn: kh ln, nh c, suy sp i. Xquang bng khng chun b: chp li sau mi 6h, nh gi so snh. 1) din bin v thi x tr: ch nh m cp cu khi xut hin cc yu t mi: + au tng ln, cn au mau hn so vi lc mi vo. + Tt huyt p. + Bng n au, cm ng phc mc (+). + Xquang: mc nc hi nhiu ln 54

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Tnh trng chung khng thay i kh ln so vi lc vo sau 24 h theo di. c coi l ht tc rut khi: + au nh dn ri ht hn. + Cn au tha dn ri ht hn. + C trung tin. + ton thn tnh to, d chu. 3. X tr c th khi m: 1) Gy m: ni kh qun + gin c. 2) ng m: i li ng m c. Trng hp l ng Mac Burney th i li ng trng gia di rn. Ch khi m phc mc d gy thng rut do rut thng dnh ngay st vt m c. 3) Cc bin php x tr rut tc: Dy chng: ct dy chng. Dnh: g dnh, nu khng c: ni tt. Xon: tho xon, ct on rut. M thng rut non nu khng lm c g hn

4) Xp li rut trc khi ng bng, c th huyt thanh ln bng trc khi ng trnh tc li. 5) Sn sc sau m: Ht d dy lin tc trc khi c trung tin. truyn dch, bi ph nc in gii. khng sinh ton thn. Tc rut cp I. i cng 3. Tc rut l tnh trng ngng tr lu thng ca dch v hi trong lng rut do 2 nhm nguyn nhn chnh: c nng v c gii. 4. Tc rut mt cp cu ngoi khoa thng gp trong cp cu bng, ch ng sau vim rut tha. C nhiu nguyn 55

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


nhn gy tc rut thay i ph thuc vo v tr tc, c ch tc. Chn on cn kh khn cho d c nhiu phng tin chn on hin i c p dng. 5. Trong thi gian gn y vi s tin b ca gm m hi sc v phu thut t l t vong v bin chng sau m tc rut ci thin ng k. 6. C nhiu cch phn loi tc rut : 1) Theo din bin: Tc rut hon ton: l tc rut xy ra cp tnh v tc Tc rut khng hon ton (bn tc rut): l tc rut hon ton. khng hon ton, c cn tr lu thng nhng mt phn v hi vn qua c ch tc. 2) Theo sinh l: Tc rut c hc: l tc rut c mt nguyn nhn c th gy tc nghn nhu ng rut. V d: bi giun, khi u, thot v nght.. Tc rut c nng: Khng c nguyn nhn c th no, rut mt nhu ng, khng c co bp hoc co bp qu mc dn n lit rut. V d : lit rut c nng sau m bng. 7. Tc rut cp l s ngng tr t ngt ca dch v hi trong lng rut vi mt nguyn nhn c th gy tc nghn nhu ng rut. 8. Nguyn nhn tc rut cp: 6) Tc rut do bt: lng rut b bt hp li hoc tc hon ton do: Trong lng rut: bi giun, b thc n. Ti thnh rut: u lnh, ung th gy hp lng rut Ngoi rut: u hch mc treo gy chn p gp khc rut.

2) Tc rut do tht nghn:

56

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


b. L loi tc rut m thnh rut v mc treo rut u b bp nght bi nguyn nhn gy tc. mch mu nui quai rut b tc nghn dn n hoi t rut nhanh chng. c. C 3 loi: + Tc rut do dy chng: Thng hay gp trong trng hp tc rut sau m.Dy chng x cng li chn ngang qua rut gy tnh mch cp ti ch v nhanh chng dn n hoi t. + Tc rut do xon rut: Thng hay gp rut non chui ln rut gi.Mt hoc mt vi quai rut b xon vn quanh trc ng ca mc treo rut kiu vc v . Mch mu nm ngay trong mc treo cng b xon nght rt nhanh dn n hoi t rut. + Tc rut do thot v nght: Thot v i nght. Thot v bn nght. Thot v trong. Quai rut chui vo 1 hc c to ra sau 1 phu thut bng (v d: ni v trng). 3) Tc rut do dnh v gp:Thanh mc rut mt trn, nhn dn n dnh gp tng on rut vi nhau gy cn tr lu thng rut. Hay gp trong tc rut sau m, do lao 4) Tc rut do lng rut: d. Cc quai rut chui lng vo nhau v b bp nght. C thnh rut v mc treo rut u b nght. e. Tu theo on rut b lng vo nhau m c cc tn gi khc nhau: lng hi hi trng, lng hi - i trng. f. tr nh nhi lng rut thng do ri lon nhu ng rut g. ngi ln lng rut thng do c 1 tn thng nm trong thnh rut (polype, u). II. Cc ri lon trong tc rut:

57

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Khi rut b tc hon ton s dn n nhng bin i phc tp v nghim trng v sinh bnh. Trong iu tr tc rut khng ch ly i nguyn nhn gy tc m cn phi bit cch iu chnh ng n nhng bin i ny 1. Cc ri lon ti ch: 1) Tng nhu ng rut: Lc u: Rut tng co bp v bp mnh c thng cn tr: biu hin lm sng tng ng l cc triu chng : + au bng tng cn + Nn nhiu. + Nhn thy quai rut ni v chuyn ng t tri sang phi tng t ng vi cn au. + Nghe bng thy ting ro si ca hi v dch rt r v mnh. V sau: Rut ra khng co bp na hoc co bp yu, rut gin chng. + au gim i, cc cn au tha ra. + Nn t hn. + Khng nhnh thy cc quai rut chuyn ng na m phi t tay ln thnh bng mi cm thy c nhng chuyn ng ny. 7) Chng rut: do hi v dch ng trong lng rut trn ch tc. Hi c ngun gc t: khng kh v hi nut vo khng Dch trong lng rut c ngun gc t thc n, dch tiu

thot ra c; hoc tng sinh hi trong lng rut. ho khng c hp thu, hoc do tng tit dch vo lng rut v 2 kch thch: rut gin cng v tr tun hon thnh rut. 8) Ri lon tun hon rut mc treo: Nu nguyn nhn gy tc rut l xon, nght rut th c ng mch v tnh mch chi phi on rut nght 58

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


b chn p, bp nght nn thnh rut khng c mu nui dng dn n hoi t. p lc trong lng rut trn ch tc tng cao gy chn p tnh mch, co tht tiu ng mch, dn n thiu mu rut lm hoi t, thng rut. Tnh trng thiu mu, tr v thiu O2 lm tn thng nim mc rut lm cc cht c tr trong lng rut tro ngc vo mu dn n shock nhim c. 2. Cc ri lon ton thn: C nhiu yu t phi hp vi nhau dn n ri lon ton thn nh: ri lon in gii, tnh trng mt nc, mt thng bng kim toan, nhim khun-nhim c. III. Chn on. 1. Chn on hi chng tc rut: Da ch yu trn lm sng v Xquang. C nng: b. au bng: + t ngt thnh tng cn, tng nhanh, tng dn v cng au, khong cch gia cc cn ngn dn. + Lc u au v tr b tc, sau lan ra khp bng. + cm gic au tht, xon vn dn n lo s (trng hp xon rut). c. Nn: + Tc rut cao: nn sm v lin tc, tc rut thp: nn t hoc khng nn. + Cht nn: nc mt, thc n, nc phn (mun) + Nn xong vn khng mt hon ton cm gic au. d. B trung i tin: tc cao cn c th i tin (phn cn ng di ch tc). 11) Ton thn: e. Trong nhng gi u t thay i.

59

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


f. nu dn mun c th c biu hin ca mt nc v nhng bin chng ca tc rut: hoi t rut, thng rut, tuy nhin i vi tc rut do xon th tnh trng tru mch do shock nhim c l rt sm. g. hi chng vim phc mc: do nhim khun. 12) Thc th: h. Bng chng: Tu vo v tr tc rut m c nhng biu hin khc nhau.Thng thy: + Bng chng u: tc rut thp. + Bng chng lch v pha bn tri: xon i trng xch ma, bn phi: xon i trng phi. + nhng ngi bo hoc c thai th kh nh gi chng bng, nu tc rut cao bng cn xp li ch khng chng. + Bng chng dc theo khung i trng kiu ng khung (tc i trng). i. du hiu rn b: + xut hin t nhin km c au hoc khi kch thch vo thnh bng. + Hnh nh cc quai rut ni chuyn ng t tri sang phi tng t (thng trong cn au) c th nhn thy r nu thnh bng mng, t m. + Nhiu khi ta ch thy quai rut ni m khng thy du hiu rn b phi t tay ln thnh bng mi cm nhn r. j. Khi s thy 1 quai rut di ng di lng bn tay hoc c th s thy bi giun, khi lng, u.. k. Trng hp mun: phn ng thnh bng, du hiu cm ng phc mc: biu hin hoi t rut, tin lng xu. l. G: vang vng chng, c vng thp (dich bng). m. Nghe: Ting ro, si trong lng rut rt mnh v r (lc xc tng). n. Thm trc trng: + Bng trc trng rng, khng c phn. 60

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Douglas phng; dch bng, quai rut chng. + i khi s thy khi u trc trng l nguyn nhn ca tc rut thp. + Mu theo tay: lng rut. o. Khm cc l thot v bn i p. Khm tm so m c. q. Khm rng ming. 13) Cn lm sng: r. xt nghim c bn: + c mu: hng cu tng, hematocrite tng + in gii gim + ure tng, d tr kim gim. s. Xquang: + Xquang bng khng chun b: T th: ng-chp thng mt, nm-chp nghing. Hnh nh: cc quai rut gin v c mc nc mc hi: Tc rut non: chn rng vm thp, tp trung gia bng. Tc i trng: chn hp vm cao, nm dc theo khung i trng trn ch tc. du hiu c dch bng: m vng thp, thnh rut dy (dch ng gia cc quai rut). Nu rut b thng s thy lim hi di vm honh (phi) trong bng. + Chp khung i trng c thuc cn quang: Ch nh: nghi ng c tc i trng. Thuc cn quang: khng dng baryt m dng thuc cn quang tan trong nc phng thng rut, thuc cn quang vo bng gy bin chng nguy him. Trng hp tc rut bn cp: theo di s di chuyn ca thuc trn mn hunh quang pht hin u, lng rut, cht hp

61

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Nu hnh nh tc rut khng r th c th chp li sau vi gi: nu thy hnh nh mc nc hi ngy cng nhiu v to: tc rut. t. Siu m: + hnh nh gin tip: dch bng, quai rut gin (khng c hiu) + Hnh nh trc tip: khi lng, khi u). 2. Chn on phn bit : 1) Tc rut c nng: u. Hay gp c trong cc bnh ni khoa cng nh ngoi khoa: ri lon K, vim phc mc, si niu qun. v. Triu chng lm sng: + khng c cn au hoc au t. + bng chng nhng khng c du hiu rn b. w. Xquang: khng c mc nc mc hi, c du hiu bn c. 2) Lit gin d dy cp: x. Gp trong trng hp ng c thc n. y. Bng chng, dn ch yu trn rn. z. Nu thnh bng mng c th thy hnh d dy ni trn thnh bng (di da bng. 3) Lit gin i trng cp: Gp trong nhng t vim cp ca 1 bnh vn c sn i trng. v d vim i trc trng chy mu, bnh Crohn. 4) Vim tu cp: aa. bb. 14) dd. ee. 15) Bng chng, lit rut. Amylase mu, nc tiu tng. Tc mt do si: Bilirubin mu tng cao. Siu m: si mt Vim phc mc (km tc rut c nng): 62

cc.tin s vng da st nhiu ln.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


ff. du hiu rn b (-). gg. 16) 17) hh. Xquang: gin ton b rut. mu t sau phc mc, chn thng ct sng; Cn au qun thn: Khu tr 2 bn h chu, lan n b phn sinh dc.

ii. Nc tiu : hng cu(+), bch cu (+) jj. UIV cp cu. 18) Cn au qun gan: kk.Tp trung vng gan ll. Gan to, hong m. mm. Hi chng tc rut c gii (-). 19) nn. oo. pp. 20) Vim d dy cp: au thng v Nn khng b trung i tin. Ni : ng c thuc, a chy, vim rut

*Da trn khm lm sng + Xquang c th nh hng chn on v tr v c ch tc rut cp , phi m mi bit chnh xc nguyn nhn tc rut cp. 3. Chn on v tr tc rut. 1) Tc rut non: qq. Khi u t ngt: + au d di vng quanh rn hoc khp bng. + Nn sm v nhiu ln, cht nn nhanh chng c mi phn. + Thi gian u vn c th trung tin (nh phn cn li di ch b tc) + Bng chng tp trung ch yu quanh rn, nu tc cao bng c th khng chng. rr. Xquang:hnh nh mc nc hi: chn rng vm thp nm tp trung gia bng hoc xp thnh hnh bc thanh t h sn tri n h chu phi. 63

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2) Tc i trng: ss. Khi u t t: + lc u ch bun nn, nn xut hin mun hn. + b trung tin ngay t u. + Bng chng: chng u khp hoc chng dc theo khung i trng. tt. chn on nguyn nhn theo la tui: + s sinh: khng c hu mn, teo rut bm sinh. + 4 12 thng tui: lng rut. + 4 12 tui: bi giun, b thc n, thot v nght + thanh nin: xon rut, thot v. + ngi gi: u i trng, tc rut do phn, b thc n, xon i trng xch ma. uu. phi: i trng phi tri nn, au va chng t nhiu s u (+) thy u ton thn:t bin i nhiu Xquang:mc nc hikhng dc trng vv. Bt au cn tc bng chng rn b (+) nhiu mc nc hi 64 bng chng lch rn b (-) 1 mc nc hi Xon au d di lin c trng chn on phn bit tc rut do xon v bt ri lon khng s tc cp chng i trng chn on phn bit tc i trng tri v i trng

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


tin trin chm mch: m ngay 4. chn on nguyn nhn: Mt s trng hp tc rut c th chn on c nguyn nhn trc m: 1) Xon rut: au d di khc thng km theo tru mch. 2) Thot v bn, i nght: khm vng bn i. 3) Lng rut tr nh nhi: ww. xx. yy. Tr b bm < 12 thng tui. t ngt khc tht, b b. a mu d shock tru

zz. S thy bi lng. 4) Tc rut sau m (do dnh, dy chng): c so m trn thnh bng. 5) Tc rut do ung th, trc trng. aaa. hi chng tc rut thp. bbb. S / thm trc trng thy u. ccc. Chp khung i trng cp cu: hnh khuyt hay cht hp i trng. 5. chn on th lm sng: Tc rut cp: lm sng r, xut hin sm, tin trin Tc rut bn cp: triu chng khng thng xuyn, mt nhanh, thng do tc cao, xon rut. i khi trung tin c, khng suy sp nhanh. thng do tc rut thp, bi giun, u chn p. Tc rut th khng in hnh: au nh khng thnh cn, bng xp. Phi dng cc xt nghim cn lm sng chn on. IV. X tr 1. Nguyn tc: Khi chn on xc nh l tc rut cp th ch nh m cp cu. 1) Hi sc trc m. 65

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


ddd. ht dch d dy t trng (sode d dy) eee. Bi ph nc in gii, thng bng kim toan ng tnh mch, theo di qua o CVP. fff. s dng khng sinh ton thn ph rng chng vi khun ng mt v vi khun khc. Thng dng cephalosporin th h III 1- 2 g, metrronidazole tim bp. ggg. trng hp nghi ng xon rut, nght rut do dy chng th va hi sc va m ngay v lu c nguy c hoi t rut. 9) V cm: b. Tt nht l gy m ni kh qun. c. Mt s trng hp c th gy t tu sng/ ngoi mng cng. 3) ng m d. Nu l tc rut sau m thng i li ng m c l tt nht (tr trng hp ng m c l ng Macburney th nn i bng ng trng gia di rn). e. Ch khi m vo oob rt d b thng rut v rut thng b dnh ngay thnh bng pha di vt m. f. Cc trng hp khc th i ng trng gia di rn. 3) Tm v tr tc rut g. t v tr rut xp ln ngc ln s thy ch tc. h. Trong trng hp xon rut, hoi t rut m bng ra thy ngay nc mu, quai rut gin en. 4) X tr tc rut: Tu theo nguyn nhn v v tr tc rut: i. tc rut non: + G dnh, ct dy chng. + M rut ly giun, b thc n. + Ct on rut non sau ni bn bn. + Ni tt. + Dn lu hi trng. 66

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


j. Tc i trng: + Ung th i trng gy tc: ct on i trng, lm hu mn nhn to. + Lng rut: Tho lng. + Xon i trng xich ma: tho xon, ct i trng xich ma. 5) Lm xp rut trc khi ng bng: k. Vut dn hi v dch ln d dy ri ht qua sonde mi l. y mt sonde d dy xung ch tc, va y va ht. m. Qua ch m rut (trnh gy bn bng). 6) Sn sc sau m: n. Tip tc bi ph nc in gii. o. lu sonde d dy ht lin tc cho ti khi trung tin tr li. Chn on v x tr vim rut tha th khng in hnh I. i cng: 1. Vim rut tha l cp cu ngoi khoa thng gp nht trong cp cu bng (60 65%) vi cc biu hin lm sng a dng. 2. Vim rut tha c th gp mi la tui, mi gii, ni c iu kin pht trin nhng vim rut tha him gp tr em < 3 tui, tng dn v hay gp la tui thanh thiu nin. 3. Cc th vim rut tha in hnh (cc th thng thng) thng d chn on v x tr n gin, nu m sm thng c kt qu tt, khng li di chng g c bit. 4. Vim rut tha th khng in hnh kh chn on v triu chng lm sng a dng tu theo tng bnh nhn nn c th nhm vi nhiu loi bnh khc hoc b st m khng x tr kp thi c th gy ra nhng bin chng nguy him. 67

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


5. Ngy nay tuy c nhiu phng tin hin i chn on vim rut tha khi nghi ng nh siu m, ni soi song vic chn on vim rut tha vn phi da ch yu vo thm khm v theo di lm sng t m, nhiu ln, c bit l vi cc th khng in hnh. Tt c cc phng php cn lm sng ch c tnh cht tham kho hoc loi tr cc bnh khc. 6. Cn ngh n vim rut tha trc bt c bnh nhn no n khm do au bng. Khng c cch no d phng v d on tin trin ca vim rut tha nht l cc th khng in hnh. Cch tt nht h thp bin chng v trnh t vong l chn on sm v m ct b rut tha trc khi n v hay hoi t. Vim rut tha l mt cp cu ngoi khoa cn c chn on sm v m sm (trc 6h). II. V tr gii phu ca rut tha: Rut tha nm y manh trng, ni hi t ca 3 di 1. Bnh thng: c dc, di gc hi manh trng 2 3cm v thng nm trong phc mc. Rut tha thng vi y manh trng v c cu to bi 3 lp t ngoi vo trong l thanh mc, c nim v nim mc. Nim mc rut tha ngoi cc tuyn cn c nhiu nang lympho. 2. Bt thng: 1) V v tr : Rut tha sau manh trng. + Trong thanh mc. + Trong phc mc. Rut tha sau hi trng. Rut tha trong thnh i trng. Rut tha trong tiu khung. Rut tha di gan. 68

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Rut tha h sn tri. Rut tha trong bao thot v. Rut tha ph n c thai. Rut tha gia bng.

2) V hnh thi: rut tha hnh phu. 3) V s lng: Hai rut tha mt manh trng: + Rut tha chung gc. + Rut tha tch gc. III. 2 manh trng. Nguyn nhn vim rut tha:

1. Nguyn nhn gy tc rut tha: Do qu sn t chc lympho thnh rut tha hoc d vt (si, phn ) gy tc lng rut tha (gc) lm tr dch tit, tr tun hon lm tng p lc lng rut tha, cng vi s pht trin ca vi khun gy vim rut tha. 2. Do nhim khun huyt (t cc m tai, mi, hng ) cng c th gy vim rut tha. IV. Gii phu bnh ca vim rut tha: 1) Rut tha: Lp thanh mc mt bng. Mch mu xung huyt gin to trn thnh rut tha. Rut tha di hn bnh thng. Vi th: ngm cc t bo vim thnh rut tha nhng 1. Vim rut tha th xut tit (6 12h u).

khng c p xe. 2) bng: Khng c dch hoc ch c mt t dch trong xut tit c vi khun. 2. Vim rut tha m: 1) Rut tha: Sng to, mng, c dnh gi mc bao bc u t v di.

69

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Trong lng rut tha c nhng m thi, lot nh nim mc, lp c b ph hu, thanh mc cha v. 2) bng c dch c khng thi, cy khng c vi khun. 3. m qunh rut tha: Trong trng hp rut tha vim cha v phn ng cc quai rut, mc ni ln n quy li khu tr vim, c nhiu mch mu tn to xung quanh mang cc t bo, cc cht chng vim n. 4. Vim rut tha hoi t: 1) Rut tha: C mu c a, en hoi t tng mng trn thanh mc c l thng c gi mc, mc ni n dnh vo. Trong trng hp m c khu tr li bi cc t chc xung (hu qu ca tc mch). 2) bng: c nhiu dch m thi, cy c vi khun. quanh gm rut, mc ni, phc mc dnh li s to thnh p xe rut tha. Trong trng hp m chy v khu tr trong h chu phi, tiu khung c gi l vim phc mc khu tr, nu trng hp m chy ra khp bng c gi l vim phc mc ton th. V. Chn on th in hnh: Da ch yu vo lm sng. 1. C nng: 1) au bng: T nhin, xut hin dt ngt. v tr: h chu phi, c lc au nhng v tr khc

(quanh rn, thng v ) nhng sau khu tr li h chu phi. Tnh cht: Thng au m , bnh nhn c cm gic nng h chu phi, au tng dn, khng thnh cn, au tng khi ho, vn ng. 70

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2) Bun nn, t khi nn. 3) B trung i tin. 4) Cc du hiu ri lon tiu ho khc: chn n, to bn, a chy t thy. 2. Ton thn: Th trng nhn chung tt. C biu hin ca tnh trng nhim khun nh: st nh

37,5 38C, hi th hi, li bn, mi kh. 3. Thc th (cha c vim phc mc): Bng mm, khng chng. n au cc im:

+ im Mac Burney l im gia ng ni gai chu trc trn bn phi vi rn. + im Clado l im nm trn ng ct gia ng ni hai gai chu trc trn v b ngoi c thng to bn phi. + im Lanz: l im ni 1/3 bn ngoi phi vi 2/3 bn tri ca ca ng ni 2 gai chu trc trn. du hiu phn ng thnh bng thnh bng h chu du hiu co cng thnh bng vng h chu phi thng phi. l vim rut tha giai on mun: khi c nh n sau bn tay trn thnh bng th bnh nhn ku au bn tay cm nhn sc cng ca thnh bng, n su na c co cng thc s. 2) Cc du hiu phn nh tnh trng phn ng ti ch ca mng bng khi vim rut tha cp: au h chu phi xut hin khi khi ngi thy thuc au h chu phi khi n 2 tay lin tip vo h chu rt nhanh tay tay ln (du hiu Blumberg) tri dn hi sang i trng phi (du hiu Rowsing).

71

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Thm trc trng / thm m o 1 s ph n: bnh nhn au thnh phi trc trng (hay thnh phi ti cng Douglas). 4. cn lm sng: 1) xt nghim mu: bch cu > 9000/ml, bch cu a nhn > 75%. 2) Xquang bng khng chun b: Khng c g c hiu cho vim rut tha. Mc ch: chn on phn bit:

+ tm du hiu ca cc bnh khc :Lim hi, si tit niu. + C th thy si phn vng h chu phi 3) Chp khung i trng c baryt: Thuc khng ngm vo lng rut tha vim 4) Siu m:hnh nh rut tha to, c dch xung quanh. Ct ngang rut tha: nhng vng trn ng tm. 5) Ni soi chn on va chn on, va iu tr. VI. Chn on cc th khng in hnh ca vim rut tha: Ngoi cc triu chng lm sng cn phi da thm vo cc xt nghim cn lm sng phn bit vi cc bnh khc. 1. Cc th lm sng theo tui, c a: 1) Vim rut tha tr nh nhi: Tr quy khc + st. Kh khm do tr cha bit ni, thng ch chn on khi

vim phc mc. Tin trin ca vim rut tha khng bao gi pht trin thnh p xe rut tha v mc ni ln cha pht trin. Xquang bng khng chun b: nhiu mc nc hi tp trung h chu phi. 2) Vim rut tha tr 2 5 tui: Khai thc bnh s kh khn 72

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


r. Bnh cnh lm sng ging tc rut, bn tc rut. Khm h chu phi thy khi u ging nh u mang trng, n au. Tin trin chm. Cn lm sng: bch cu tng t hoc khng tng. Tc rut. U manh trng. St, quy khc, trn trc. Hay c nn, a chy. Bng chng. Co chn bn phi gp vo bng. *Tm li nhm < 5 tui (th vim rut tha hoi t, Kh hi bnh v thm khm. Nhim khun r (st cao), c nhim c (nn nhiu). Du hiu ti ch khng r rng. Din bin nhanh, t l v t 50 100% tu tui. Vim ti tha Meckel: kh chn on nn 1 nguyn tc Lng rut cp. Vim hch mc treo. Vim rut. Vim phi. St virt gy au h chu phi. Du hiu nhim khun khng r: C th khng st. au bng t, c khi ch hi nng nng hoc tng tc,

vim rut tha nhim c) thng c nhng biu hin sau:

* tr em cn chn on phn bit vi: khi m rut tha phi kim tra hi trng tm ti tha.

3) Vim rut tha ngi gi:

chm khu tr vo h chu phi, thnh bng co cng khng

* ngi gi chn on phn bit vi:

4) Vim rut tha ph n c thai: 73

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Vim rut tha ph n c thai trong 6 thng u ca thai k triu chng khng c s khc bit so vi ph n bnh thng. Trong 3 thng cui do t cung to y manh trng ln cao v xoay ra ngoi nn im au dng cao v lch ra pha ngoi (tht lng), co cng thnh bng khng r. Khm: + bnh nhn nm nghing tri t cung sang tri, rut tha v v tr c. + Bnh nhn nm nga, y vo t cung t bn tri: au h chu phi. Ch : + Vim rut tha ph n c thai tin trin nhanh chng n hoi th. V vy cn chn on sm v ch nh m sm trc khi hoi th l iu cn thit bo m cho tnh mng ca m v thai nhi. + M vim rut tha ph n c thai trong 3 thng u ca thai d xy thai. * ph n chn on phn bit vi: Cha ngoi t cung v / do v: + Chm kinh, ri lon kinh nguyt, au bng di t ngt, d di. + V m hi, mch nhanh, huyt p h, ra mu m o, hi chng thiu mu. + Thm m o: ti cng Douglas rt au. + Siu m, HCG(+). U nang bung trng xon: + Cn au qun d di. + S thy 1 khi u vng di rn kch thc tng dn. + Thm trc trng v thm m o. + Siu m. Vim m vi t cung v: 74

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ St rt cao 39 40, rt run, 2 g m . + Siu m. Vim phn ph: + au 2 bn h chu. + Ra kh h. + St cao dao ng. + Siu m: Douglas c dch, 2 phn ph rt to. 2. Cc th theo v tr: 1) Vim rut tha sau manh trng: au lch v lan ra pha sau, i khi au h tht lng H chu phi chng nh, phn ng khng r rt. C cc du hiu mn ca vim c i chu: chn phi phi, n au im trn mo chu phi.

co li do kch thch c i chu, bnh nhn khng th dui chn ra c v au. Siu m khng thy m c i chu. Thng d b b st v dn n p xe rut tha. au vng h chu phi. Du hiu kch thch c i chu: chn phi co gp Siu m: m c i chu. Do rut tha cha quay ht, manh trng v rut tha Bnh cnh ging bnh cnh ca vim ti mt cp: au *Chn on phn bit: Vim c i chu:

vo bng, bnh nhn khng th dui chn ra v au. 2) Vim rut tha di gan: nm ngay di gan. h sn phi, st, n co cng vng ti mt (nht l ngi cao tui) nhng khng vng da, vng mt. *Chn on phn bit: Vim ti mt cp: + au vng h sn phi km theo strt run, vng da vng mt. 75

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ H sn phi n au, cm ng phc mc, c th s thy ti mt cng to. + Siu m: hnh nh ti mt vim, thnh dy. Vim gan B: HbSAg (+). au vng di rn, c du hiu gi tc rut im au xung phn thp h chu phi. C cc du hiu v tit niu: au rt, i but (d 3) Vim rut tha trong tiu khung:

nhm l vim bng quang). *Chn on phn bit: Cn au qun thn, vim ng tit niu: + au tht lng phi, c th sau vn ng. + Ri lon tiu tin: i but, i dt, nc tiu c c mu. + Siu m, UIV, xt nghim nc tiu. Si niu qun phi: + Ri lon tiu tin: i but, i dt, i mu. + au tng cn dc theo ng i ca niu qun. + Siu m, Xquang, UIV h tit niu. 4) Vim rut tha nm gia bng: im au nm gia bng, quanh rn. Du hiu thn kinh.(?) Thng d v gy vim phc mc hoc dnh gy tc

rut. 5) Vim rut tha bn tri (o ngc ph tng): Triu chng nh vim rut tha in hnh nhng l cc Khm tim gan pht hin c o ph tng hay triu chng h chu tri. khng. 6) Vim rut tha trong bao thot v: Ti thot v au ging nh thot v bn nght. 3. Cc th vim rut tha cp mun: 76

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) Vim phc mc: Cc hnh thi din bin: + Vim phc mc tc th: thng sau 24h. + Vim phc mc th 2: v p xe vo bng. + Vim phc mc th 3: m qunh p xe v p xe. Triu chng: bnh cnh lm sng l mt vim phc mc in hnh: + au khp bng. + Bng chng, co cng thnh bng, n au khp bng (cm ng phc mc ton b). + Ton thn: st cao, mi kh, li bn, hi th hi. + Ure huyt, bch cu tng cao > 10000/ml, i t. + Chp bng khng chun b: chng hi (lit rut c nng), khng c lim hi. ( vim phc mc th 2, th 3 thng l th vim phc mc nng do bnh tin trin lu trn c th suy kit v nhim khun). *Chn on phn bit: Thng lot d dy t trng: Do dch tiu ho chy theo rnh i trng phi xung h Trng hp ny do thng d dy khng pht hin sm, Khi u thy cn au t ngt, d di vng trn rn chu phi gy au. mun khi c nhim khun ton thn. bng cng nh g, sau c th au do co cng na bng bn phi. Vn thy co cng vng trn rn. Vng c trc gan mt. Thm trc trng: ti vng bn phi phng au. Xquang bng khng chun b: lim hi. Do m ca vim rut tha c bao bc bi cc t

2) p xe rut tha (vim phc mc khu tr): chc xung quanh nh mc ni, cc quai rut dnh li. 77

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Cc tnh cht ca vim rut tha gim bt i, sau 3 5 ngy bnh nhn thy au tng ln, st dao ng, bch cu tng (do nhim khun) H chu phi c khi cng, lin vi gai chu, ranh gii r, C khi da vng ny ty ln do khi m sp v ra ngoi. C th gp p xe trong bng. Khi khm thy 1 n au chi.

khi au chi, c th di ng, nm cch vi gai chu, lch vo pha trong. 3) m qunh rut tha: L trng hp rut tha giai on vim c cc t chc Thng xut hin t ngy th 3 tr i, c khi mun hn. Tnh trng nhim khun nh, st nh 37,5 38,5. S thy mng cng h chu phi, ranh gii khng r, y l trng hp vim rut tha duy nht khng nn m xunh quanh bao bc li.

khng au, au t. ngay m nn cho khng sinh v theo di. Qu trnh vim c th t thoi tro, khu tr li thnh p xe rut tha. 4) Vim rut tha mn tnh: Cha c cng nhn rng ri. Triu chng khng r rng, sau vi 3 ngy t khi v ti

pht sau 1 thi gian. 4. Vim rut tha trn bnh nhn iu tr: 1) Vim rut tha trn bnh nhn iu tr khng sinh: Vi bnh nhn ny cn c theo di k, thm khm nhiu ln khi cc triu chng lm sng sau tin trin nng hn ln trc th nn m sm. 2) Vim rut tha trn bnh nhn m ct vim rut tha: bnh nhn 2 rut tha him gp. Thng c 1 s bnh nhn ct b b st 1 on rut tha, nay on ny

78

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


vim, cc du hiu ging nh vim rut tha th in hnh. 5. Cc th khc: 1) Vim rut tha do giun chui vo: au d di tng cn vng h chu phi. Khm bng vn mm, khng st, bch cu. 2) Vim rut tha do lao: VII. Bnh nhn din bin chm, au v phn ng h chu M thy rut tha sng to, ri rc c nhng ht trng Cn iu tr lao tch cc. C nguy c d v bc mm rut tha iu tr: Khi chn on l vim rut tha cp, ch phi, khng r rt. n, nhiu hch mc treo v bng c dch vng chanh.

3) Vim rut tha do thng hn: him. nh m tuyt i. 1. Nguyn tc: 1) Vi trng hp cha r vim rut tha: Khi mt bnh nhn nghi vim rut tha cp m cha chc chn th nn lu 24 48h: + Thm khm bng sau 1h, t m. + Ly mu, o nhit , th bch cu 3h/ln. + Khng s dng thuc gim au c Morphin, khng s dng khng sinh. + Theo di v so snh sau mi ln khm. i vi trng hp r vim rut tha: m (tr m qunh rut tha). 2) Chun b bnh nhn: Bnh nhn nm nga. V cm: gy t vng (cha c bin chng), gy m ton

thn (c bin chng)

79

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Bnh nhn nm nghing sang tri v u hi thp ng m: tu theo tin trin ca vim rut tha m c dn cc quai rut non sang tri d bc l rut tha. v tr khc nhau: + ng Mac Burney vi vim rut tha in hnh. + ng dc b ngoi c thng to trong trng hp vim phc mc khu tr. + ng gia di rn trong trng hp p xe rut tha / vim phc mc cha r nguyn nhn. Thm d bng: nh gi tn thng rut tha so vi tn thng, dch trong bng v thi gian din bin kim tra cc tng v trnh tn thng. i vi ph n: kim tra mt cch h thng phn ph 2 Ct rut tha xui dng, ngc dng (trng hp rut tha bn kp thi x tr ng thi cc nguyn nhn khc. su trong manh trng): bc l manh trng, tht v ct rut tha, tht ct gc rut tha trc. Khu vi mm rut tha nu t chc manh trng xung quanh rut tha mn v ph n. nguyn nu t chc manh trng xung quanh rut tha mn v ph n. Kim tra c h thng ~ 80 cm hi trng t gc hi manh trng tm ti tha Meckel. Trng hp rut tha khng r vim / vim giai on u th ct ti tha Meckel. Trng hp vim phc mc: ch ct rut tha khi n l Dn lu hay khng tu th. ng bng. nguyn nhn gy vim.

2. C th: 1) Vim rut tha cp th in hnh. M cng sm cng tt (trc 6h). V cm: m ni kh qun, t tu sng, t ti ch. 80

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Ct rut tha vi khng dn lu. ng bng theo cc lp gii phu. Trnh khong

trng gia cc lp nu khng s gy nn vim nhim thnh bng. Khng sinh d phng trong m Ct ch: sau 5 7 ngy, ct ch sm khi c du hiu Theo di sau m:

nhim khun vt m: st, au, ty . + Chy mu trong bng: do tut ch tht mc treo rut tha: m li. + Nhim khun vt m + Toc vt m + li tng. + Tc rut sm sau m. 2) Vim rut tha tiu khung / gia bng: ng m gia di rn. Ct rut tha. Lau sch, ng bng, khng cn dn lu Douglas (ra k

bng bng huyt thanh, betadine) 3) Vim rut tha di gan: ng rch ngoi c thng to bn tri. Ct rut tha, ng bng 1 lp, da khu tha. p xe rut tha thnh ho, khi m bit lp hon

4) p xe rut tha: ton vi phc mc v dnh vo thnh bng trc: + Chn im au chi nht, thng khong 1cm pha trong gai chu trc trn bn phi. + Dng 1 kim chc d, nu c m s rch rng theo chn kim, tch qua cc lp vo dn lu m ngoi phc mc. + Ct rut tha sau 6 thng. p xe rut tha trong bng: + L loi p xe tin trin t nhin s v vo bng, gy vim phc mc:ch nh m l bt buc. 81

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ ng m: ng cnh bn bn phi. + Ct b rut tha + mc ni ln bc quanh m. 5) Vim phc mc rut tha: Gy m ni kh qun. Khng sinh trong m. ng m: ng trng gia di rn hoc ng cnh Ct rut tha vi, khng vi (khi m bng ra nu vim

gia bn phi. phc mc khng do vim rut tha th khng ct rut tha). Lau ra bng, thm sch, xp li quai rut. Dn lu 3 ngy. ng bng 1 lp da h. Ct ch di nt buc ngy th 15. Khu da th 2 sau 1 thng (khi t chc ht mc p) L trng hp vim rut tha duy nht khng m ngay. Khng sinh, gim au, theo di. X tr rut tha: nu tn thng thnh p xe rut tha

6) m qunh rut tha:

th x tr nh p xe. Nu m qunh rut tha gim dn ri ht: m ct rut tha sau 3 4 thng. 3. Vn s dng khng sinh trong vim rut tha: 1) Ch dng khng sinh khi chn on xc nh l vim rut tha v iu tr cho bnh nhn trong v sau m. 2) Dng khng sinh ngay khi khi m : c theo di lm gim t l nhim khun r rt nht l nhim khun vt m. 3) Thuc: Flagyl hoc dng Flagyl phi hp vi khng sinh ph rng (cepha3) 4. Bin chng sau m vim rut tha:

82

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) Chy mu: do tut ch tht mch mc treo rut tha. Gy: Hi chng chy mu trong: m li cm mu. Mu t sau m rut tha, nht l rut tha sau manh

trng dn lu qua vt m / qua ng rch thp pha bn. 2) Vim phc mc sau m: bc mm rut tha, v p xe trong bng sau m, vim thn rut tha ct khng ht :hi chng vim phc mc. 3) D manh trng: Trng hp c hoi t gc rut tha: Khng sinh + sn sc p xe ti cng Douglas: ti ch. 4) Nhim khun ton thn + kch thch trc trng (mt rn, a nhy mi). Thm trc trng thy ti cng Douglas au chi. iu tr: dn lu qua ng trc trng khi p xe khu tr. 5) Tc rut sau m: Sm: do p xe tn d/d vt b qun. + Hi chng tc rut + hi chng nung m su. + Xquang + Siu m. Mun: do dy chng: nght, xon rut: chn on sm v m sm. Vim phc mc rut tha. I. i cng: 5. Cc th vim rut tha in hnh (cc th thng thng) thng d chn on v x tr n gin, nu m sm thng c kt qu tt, khng li di chng g c bit. 6. Vim rut tha th khng in hnh kh chn on v triu chng lm sng a dng thay i theo la tui, tu theo tng bnh nhn nn c th nhm vi nhiu loi bnh 83

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


khc hoc b st m khng x tr kp thi c th gy ra nhng bin chng nguy him. 7. Vim rut tha c th gp mi la tui, mi gii, ni c iu kin pht trin nhng vim rut tha him gp tr em < 3 tui, tng dn v hay gp la tui thanh thiu nin. 8. Ngy nay tuy c nhiu phng tin hin i chn on vim rut tha khi nghi ng nh siu m, ni soi song vic chn on vim rut tha vn phi da ch yu vo thm khm v theo di lm sng t m, nhiu ln, tt c cc phng php cn lm sng ch c tnh cht tham kho. 9. Cn ngh n vim rut tha trc bt c bnh nhn no n khm do au bng. Khng c cch no d phng v d on tin trin ca vim rut tha. Cch tt nht h thp bin chng v trnh t vong l chn on sm v m ct b rut tha trc khi n v hay hoi t. 10. Vim rut tha cp l mt cp cu ngoi khoa cn c chn on sm (trc 6h) v m sm. Chn on da ch yu v lm sng nhng hnh thi lm sng a dng nn chn on khng d. 11. Vim phc mc rut tha l tnh trng vim phc mc do vim rut tha cp v m gy ra. y l mt bin chng nng ca vim rut tha cp c th dn n thot v hoc li hu qu nng n sau ny. Vim rut tha l cp cu ngoi khoa thng gp nht trong cp cu bng (60 65%) vi cc biu hin lm sng a dng. C 2 loi vim phc mc rut tha l vim phc mc rut tha ton th v vim phc mc rut tha khu tr. 12. c im ca phc mc: Phc mc gm 2 l: l thnh v l tng bao bc cc Tit din gn bng tit din c th. 84

khoang mng bng (?).

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Di phc mc c nhiu mch mu v thn kinh do vy khi phc mc vim s gy phn ng nhanh v rm r gy ra cc hin tng phu n v xung huyt. 13. Gii phu bnh: 1) Rut tha: Cng to, ty , mt bng, c gi mc bao quanh, l thng thng thy u rut tha (tc mch nui ca rut tha do vim). 2) Cc tng ln cn: Mc ni ln: ph n, mt bng. n bc ly rut tha, sun Rut non v manh trng: Vim , dy, mt bng, c Mc treo rut: ph n, hch to mm. Phc mc l thnh: ph n, cng bng nh bm li thnh cc. Tch ra gia c m thi mu trng. gi mc bm.

novocaine. 3) M: Trng c v c mi thi (vi khun k kh). Lan ra khp bng nhng tp trung nhiu nht h M nm rnh thnh i trng, Douglas, gia cc quai

chu phi. rut. 4) Vi khun:E.Coli, T cu, Vi khun ym kh, Proteus. VIII. Cc hnh thi lm sng ca vim rut tha. din bin nhanh Hay gp tr em (th nhim c). Nu khng m kp thi: vng da, v niu, nn mu Nu ngi gi v ph n c thai (?): Khi u c cc triu chng ca vim rut tha :au 1. Th ti cp:

en: t vong. 2. Vim phc mc rut tha 2 th (th 2): m h chu phi, st nh, nn. 85

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Bnh din bin sau 24 48h thy : gim, ht st, au, sau t ngt au d di h chu phi. Ton thn suy sp nhanh vi cc du hiu vim phc mc ton th r. 3. Vim phc mc th 3: Khi u au h chu phi vi cc triu chng ca Sau hnh thnh m qunh rut tha : m qunh rut tha tin trin thnh p xe rut tha. Khi p xe v vo phc mc do khng c iu tr: vim rut tha.

bnh nhn t ngt au bng tng ln vng h chu phi, tip theo xut hin cc triu chng ca vim phc mc ton th. u l th vim phc mc nng do bnh tin trin lu trn c th suy kit v nhim khun. 4. Ngoi ra c th coi p xe rut tha l hnh thi vim phc mc rut tha khu tr. IX. Chn on vim phc mc rut tha (th vim phc mc ton th) 1. chn on xc nh: Da ch yu vo lm sng: 1) C nng: au bng: au khp bng, au tng khi s, thm khm bng. Trc vi ngy bnh nhn au bng m vng h chu phi du i ri au li t ngt h chu phi ri lan ra khp bng, l khi rut tha v. Nn, bun nn. B trung i tin. Tnh trng nhim khun r: st cao 39 40, mi kh, li Nu mun c th c cc du hiu ca nhim c:

2) Ton thn: bn, hi th hi. L m, suy sp, hc hc, mt nc, thiu niu, v niu, ure huyt tng, th nhanh nng. 86

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Thc th: Bng chng u, cm ng phc mc ton b, khm k Phn ng thnh bng r, h chu phi co cng. Trng hp mun: thnh bng n (du hiu lm ngn Thm trc trng: Ti cng Douglas cng, au. thy r nht vng h chu phi.

tay). *Trng hp vim phc mc rut tha ngi gi thng biu hin bi bnh cnh tc rut, xy ra 3 5 ngy sau khi bt u au. Lm sng c du hiu cm ng phc mc + tc rut c gii do gi mc dnh vo cc quai rut gy ra. 4) cn lm sng: xt nghim: bch cu > 10000/ml (ch yu a nhn trung tnh), ure, creatinin mu tng. in gii gim (Na, K, Cl ) do mt nc (nn, st). Xquang: du hiu lit rut c nng: Cc quai rut gin Siu m: c dch trong bng , trong khoang hi, thnh dy, khng c lim hi. Morrison, ti cng Douglas. *Tm li ng trc mt bnh nhn: C bnh cnh lm sng ca vim phc mc. Cc du hiu thc th ni tri h chu phi. tin s c au h chu phi. Xquang khng c lim hi.

l bnh cnh tng i r ca vim phc mc rut tha c th ch nh m. 2. Chn on p xe rut tha (vim phc mc khu tr): 3. Chn on phn bit: 1) Vim phc mc do thng d dy mun: Khi u au trn rn, t ngt, d di nh dao m, au lin tc cho ti khi vo vin, ln bn m. 87

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Mc co cng thnh bng mnh hn, r hn. Xquang c lim hi. Thng km theo tnh trng tru mch. Amylase mu, niu tng. Siu m c th thy hnh nh vim tu. Du hiu vng da, vng mt. au, co cng nhiu nht h sn phi. Siu m: thnh ti mt vim dy. L m, st ko di trc vi ngy. nhim khun nhim c. Phn ng huyt thanh (+)

2) Vim tu cp:

3) Vim ti mt hoi t / vim phc mc mt:

4) Thng rut do thng hn:

5) Vim ti tha Meckel: i ngoi phn en, triu chng ca tc rut. 6) Vim vi t cung v: X. au nhiu nht di rn. Kh h nhiu, hi. Thm m o: ti cng au. Siu m: phn ph c ti m. Chm kinh, au bng t ngt, d di. Mch nhanh, huyt p h, nht nht. Thm m o: mu theo tay, Douglas rt au. X tr vim phc mc rut tha (ton th): 1) Ch nh m tuyt i. 2) Hi sc tch cc trc m nhm: chng shock nhim khun nhim c, chng suy a tng (tun hon, h hp, gan, thn). 2. C th; 88

7) Cha ngoi t cung v:

1. Nguyn tc:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) Hi sc trc m: t ngay ng truyn: 1 ngoi vi, 1 trung tm, ly Sonde d dy ht lin tc. t h thng theo di mch, huyt p, in tm . Khng sinh :cephaIII + metronidazole. Gy m ni kh qun + gin c. S dng khng sinh ton thn ngay t lc tim m: ng m: ng trng gia di rn. i khi c th i Ct rut tha: mu lm bilan.

2) Phu thut:

Flagyl + Cephalexin. ng cnh bn phi. + Xui dng: ct ng mch trc sau ct rut tha. + Ngc dng: ct rut tha trc sau tht v ct mch (trng hp rut tha su, rut tha sau manh trng). Khu vi mm ct. i khi khng khu vi nu manh Lau ra bng: s dng huyt thanh m + betadine. trng mn nt v hoi t. Tuyt i khng dng bt khng sinh vo bng. Sau thm sch. Xp li cc quai rut trc khi ng bng. t dn lu ng bng 1 lp da h, ct ch di nt buc sau 15 dn lu 3 ngy. khng sinh ton thn (7 ngy). Bi ph, cn bng nc in gii. Nui dng ng tnh mch. Theo di cc bin chng: h hp, thn, tim mch, nhim thnh bng v tr thp. ngy, khu da th 2 sau 1 thng (khi t chc ht ln tt). 3) Theo di sau m:

khun. 89

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


V. X tr p xe rut tha. 1. p xe rut tha thnh ho, khi m bit lp hon ton vi phc mc v dnh vo thnh bng trc. + Chn im au chi nht, thng khong 1cm pha trong gai chu trc trn bn phi. + Dng 1 kim chc d, nu c m s rch rng theo chn kim, tch qua cc lp vo dn lu m ngoi phc mc. + Ct rut tha sau 6 thng. 2. p xe rut tha trong bng: + L loi p xe tin trin t nhin s v vo bng, gy vim phc mc:ch nh m l bt buc. + ng m: ng cnh bn bn phi. + Ct b rut tha + mc ni ln bc quanh m.

Bin chng ca vim rut tha cp mun. I. i cng: 3. Vim rut tha l cp cu ngoi khoa thng gp nht trong cp cu bng (60 65%) vi cc biu hin lm sng a dng. 4. Cc th vim rut tha in hnh (cc th thng thng) thng d chn on v x tr n gin, nu m sm thng c kt qu tt, khng li di chng g c bit. 5. Vim rut tha th khng in hnh kh chn on v triu chng lm sng a dng thay i theo la tui, tu theo tng bnh nhn nn c th nhm vi nhiu loi bnh khc hoc b st m khng x tr kp thi c th gy ra nhng bin chng nguy him, c bit l vim rut tha cp mun. 6. Vim rut tha c th gp mi la tui, mi gii, ni c iu kin pht trin nhng vim rut tha him gp tr

90

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


em < 3 tui, tng dn v hay gp la tui thanh thiu nin. 7. Ngy nay tuy c nhiu phng tin hin i chn on vim rut tha khi nghi ng nh siu m, ni soi song vic chn on vim rut tha vn phi da ch yu vo thm khm v theo di lm sng t m, nhiu ln, tt c cc phng php cn lm sng ch c tnh cht tham kho. 8. Vim rut tha cp l mt cp cu ngoi khoa cn c chn on sm (trc 6h) v m sm. Khng c cch no d phng v d on tin trin ca vim rut tha. Cch tt nht h thp bin chng v trnh t vong l chn on sm v m ct b rut tha trc khi n v hay hoi t. 9. Vim rut tha cp khng c iu tr kp thi s dn n cc bin chng. Ba bin chng hay gp nht ca vim rut tha l vim phc mc rut tha, p xe rut tha v m qunh rut tha. Tr trng hp m qunh rut tha khng cn m ngay v iu tr v theo di ni khoa cn 2 bin chng u cn c chn on sm v x tr sm. 10. Trong cc trng hp bnh nhn n khi c bin chng ca vim rut tha nu hi k bc s s khai thc c cc triu chng m u ca vim rut tha cp trc vi ngy: au bng vng h chu phi, nn, bun nn v ngy ngy st. Cc triu chng c th thuyn gim cht t hoc ht hn nu c iu tr khng sinh theo hng 1 bnh khc ri t ngt au tr li v cm thy nng hn trc. thng l nhng biu hin ca 1 trong nhng bin chng ca vim rut tha. XI. V tr gii phu ca rut tha: Rut tha nm y manh trng, ni hi t ca 3 di 1. Bnh thng: c dc, di gc hi manh trng 2 3cm v thng nm trong phc mc. 91

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Rut tha thng vi y manh trng v c cu to bi 3 lp t ngoi vo trong l thanh mc, c nim v nim mc. Nim mc rut tha ngoi cc tuyn cn c nhiu nang lympho. 2. Bt thng: 1) V v tr : Rut tha sau manh trng + Trong thanh mc. + Trong phc mc. Rut tha sau hi trng. Rut tha trong thnh i trng. Rut tha trong tiu khung. Rut tha di gan Rut tha h sn tri. Rut tha trong bao thot v Rut tha ph n c thai. Rut tha gia bng.

4) V hnh thi: rut tha hnh phu. 5) V S T: XII. Hai rut tha. Rut tha chung gc. Rut tha tch gc. 2 manh trng. Nguyn nhn vim rut tha:

1. Nguyn nhn gy tc rut tha: Do qu sn t chc lympho thnh rut tha hoc d vt (si, phn ) gy tc lng rut tha (gc) lm tr dch tit, tr tun hon lm tng p lc lng rut tha, cng vi s pht trin ca vi khun gy vim rut tha. 2. Do nhim khun huyt (t cc m tai, mi, hng ) cng c th gy vim rut tha. XIII. Gii phu bnh ca vim rut tha: 92

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1. Vim rut tha th xut tit (6 12h u) 1) Rut tha: Lp thanh mc mt bng. Mch mu xung huyt gin to trn thnh rut tha. Rut tha di hn bnh thng. Vi th: ngm cc t bo vim thnh rut tha nhng

khng c ap xe. 7) bng: Khng c dch hoc ch c mt t dch trong xut tit c vi khun. 2. Vim rut tha m: 1) Rut tha: Sng to, mng, c dnh gi mc bao bc u t v di. Trong lng rut tha c nhng m thi, lot nh

nim mc, lp c b ph hu, thanh mc cha v. 2) bng c dch c khng thi, cy khng c vi khun. 3. m qunh rut tha: Trong trng hp rut tha vim cha vm phn ng cc quai rut, mc ni ln n quy li khu tr vim, c nhiu mch mu tn to xung quanh mang cc t bo, cc cht chng vim n. 4. Vim rut tha hoi t: 1) Rut tha: c mu c a, en hoi t tng mng trn thanh mc c l thng c gi mc, mc ni n dnh vo. (hu qu ca tc mch). 6) bng c nhiu dch m thi, cy c vi khun. 7) Trong trng hp m c khu tr li bi cc t chc xung quanh gm rut, mc ni, phc mc dnh li s to thnh p xe rut tha. 5. Trong trng hp m chy v khu tr trong h chu phi, tiu khung c gi l vim phc mc khu tr, nu trng hp

93

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


m chyar ra khp bng c gi l vim phc mc ton th. XIV. Vim phc mc rut tha. 1. L tnh trng m v vo bng gy nn bnh cnh nhim khun nhim c nng: vim phc mc ton th nu chy ra khp bng, nu c khu tr li vng tiu khung, h chu phi: vim phc mc khu tr. 2. Vim phc mc rut tha c nhiu loi nh: Vim phc mc tc th: Trng hp vim rut tha khng c x tr kp thi din bin sau 24 48h v ra gy vim phc mc. Vim phc mc th 2: vim rut tha tin trin sau 24 48h thy : ht st, ht au sau t ngt au d di vng h chu phi, ton thn suy sp nhanh vi du hiu vim phc mc ton th r. Vim phc mc th 3: + Khi p xe rut tha khng c x tr: v vo phc mc. + y l 1 th vim phc mc nng do bnh tin trin lu trn c th nhim khun. Nhn chung c 3 loi trn u c nhng triu chng sau (nu khng k trng hp vim phc mc khu tr l p xe rut tha): 3. Triu chng lm sng: 8) C nng: au bng: au khp bng, au tng khi s, thm khm bng. Trc vi ngy bnh nhn au bng m vng h chu phi du i ri au li t ngt, l khi rut tha v. Nn, bun nn. B trung i tin.

9) Ton thn:

94

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Tnh trng nhim khun r: st cao 39 40, mi kh, li Nu mun c th c cc du hiu ca nhim c: bn, hi th hi. L m, suy sp, hc hc, mt nc, thiu niu, v niu, ure huyt tng, th nhanh nng. 10) Thc th: Bng chng, cm ng phc mc ton b, khm k thy Phn ng thnh bng r, h chu phi co cng. Trng hp mun: thnh bng n (du hiu lm ngn Thm trc trng: Ti cng Douglas cng, au.

r nht vng h chu phi.

tay). *Trng hp vim phc mc rut tha ngi gi thng biu hin bi bnh cnh tc rut, xy ra 3 5 ngy sau khi bt u au. Lm sng c du hiu cm ng phc mc + tc rut c gii do gi mc dnh vo cc quai rut gy ra. 11) cn lm sng: xt nghim: bch cu > 10000/ml (ch yu a nhn Xquang: du hiu lit rut c nng: Cc quai rut gin

trung tnh), ure, creatinin mu tng. hi, thnh dy, khng c lim hi. 5. X tr: 1) Ch nh m tuyt i, hi sc trc m hoc va m va hi sc: 2) Gy m ni kh qun + gin c. 3) S dng khng sinh ton thn ngay t lc tim m: Flagyl + Cephalexin. 4) ng m: ng trng gia di rn. i khi c th i ng cnh bn phi. 12) Ct rut tha: Xui dng: ct ng mch trc sau ct rut tha. 95

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Ngc dng: ct rut tha trc sau tht v ct mch Khu vi mm ct. i khi khng khu vi nu manh Lau ra bng: s dng huyt thanh m + (trng hp rut tha su, rut tha sau manh trng). 13) 14) trng mn nt v hoi t. betadine. Tuyt i khng dng bt khng sinh vo bng. Sau thm sch. 15) 16) 17) XV. Xp li cc quai rut trc khi ng bng. t dn lu ng bng 1 lp da h, ct ch di nt buc sau 15 Dn lu 3 ngy. thnh bng v tr thp. ngy, khu da th 2 (khi t chc ht ln tt). p xe rut tha:

1. L hnh thi c bit ca vim phc mc rut tha , y l th vim phc mc khu tr do m ca rut tha v c mc ni ln v rut n bao bc li thnh 1 bc m cch ly vi bng cn li. 2. C 2 hnh thi p xe rut tha: Vim rut tha v m vo bng: p xe rut tha. Vim rut tha m qunh rut tha p xe rut

tha. 3. Lm sng: Tip sau cc triu chng do vim rut tha (), cc triu chng du bt i, sau 3 5 ngy bnh nhn thy au tng tr li, st dao ng. 1) C nng: au bng vng h chu phi. Nn, bun nn. t thay i. St nh 38 hoc khng st.

2) Ton thn:

3) Thc th: Vng h chu phi c khi cng, nn au chi, lin vi gai chu. C khi thy da vng ny ty ln 96

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


do m sp v ra ngoi. C th gp p xe trong bng khi khm thy 1 khi au chi, c th di ng, nm cch vi gai chu trc trn bn phi, lch vo trong. 4. Cn lm sng: Xt nghim: bch cu tng (ch yu a nhn trung Siu m: khi tng m h chu phi tng ng vi Chc d bng kim (i vi p xe rut tha thnh tnh khi u s thy. ho): ht ra c m mu trng hi. 5. Chn on phn bit: p xe quanh ung th manh trng: Siu m, ni soi, chp Vim c i chu: T th nm, siu m. Vim c thnh bng, c cho ln. khung i trng c thuc cn quang phn bit.

6. X tr: 1) i vi trng hp p xe rut tha thnh ho, khi m bit lp vi phc mc v dnh vo thnh bng: Cch 1: + Chn im au chi nht, thng khong 1 cm pha trong gai chu trc trn bn phi, dng 1 kim chc d, nu c m s rch rng theo chn kim, tch qua cc lp vo dn lu m ngoi phc mc. + t 1 ng dn lu cao su vo m dn lu ti khi ht m. + Ct rut tha sau 6 thng. + Theo di v sn sc sau m (?) Cch 2: M dn lu p xe ngoi phc mc: + Gy m/ t tu sng / t ti ch. + ng rch song song vi cung i phi v st vi mo chu.

97

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Khi ti phc mc, khng m phc mc m vn phc mc vo trong, lun ngn tay ra sau ti khi m trng thi ra. Cng c th dng kim chc d trc, sau rch theo kim. + Ht sch m, t ng dn lu, 3 5ngy th rt. + Hn m ct rut tha sau 2 3 thng, m phin. 2) i vi trng hp p xe rut tha trong bng. Chn on xc nh nh siu m + lm sng. Gy m / t vng. ng m cnh bn phi, vo bng dng gc ln che

xung quanh trnh m chy vo bng khi thao tc. Mc ni ln bc quanh m phi c ct b cng vi rut tha. XVI. m qunh rut tha: 1. m qunh rut tha l trng hp vim rut tha cp c mc ni ln v rut n bm quanh to thnh 1 mng cng, s thy trn lm sng. 2. Lm sng: Thng th bnh nhn n vin trong tnh trng 4 5 ngy sau khi c cn au u tin vng h chu phi, c cc biu hin sau: 1) C nng: au h chu phi nh, nn v bun nn. 2) Ton thn: du hiu nhim khun nh. 3) Thc th: khm thy vng h chu phi c mt mng cng, chc, ranh gii khng r, n au t. 3. Cn lm sng: bch cu tng (ch yu bch cu a nhn trung tnh). Siu m khng thy khi long m, c th thy hnh bia hoc hnh ng ray xe la (rut tha vim mi thy). 4. Chn on phn bit: U manh trng: chp, soi i trng. 5. X tr: 1) y l trng hp vim rut tha duy nht khng m ngay. 98

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2) Khng sinh, gim au, theo di. 3) Nu cc triu chng ht dn : m ct rut tha sau 2 3 thng (m phin). 4) Nu tin trin thnh p xe rut tha: x tr nh p xe rut tha.

Chn on v x tr vim rut tha XVII. i cng: 1. Vim rut tha l cp cu ngoi khoa thng gp nht trong cp cu bng (60 65%) vi cc biu hin lm sng a dng. 2. Cc th vim rut tha in hnh (cc th thng thng) thng d chn on v x tr n gin, nu m sm thng c kt qu tt, khng li di chng g c bit. 3. Vim rut tha th khng in hnh kh chn on v triu chng lm sng a dng thay i theo la tui, tu theo tng bnh nhn nn c th nhm vi nhiu loi bnh khc hoc b st m khng x tr kp thi c th gy ra nhng bin chng nguy him. 4. Vim rut tha c th gp mi la tui, mi gii, ni c iu kin pht trin nhng vim rut tha him gp tr em < 3 tui, tng dn v hay gp la tui thanh thiu nin. 5. Ngy nay tuy c nhiu phng tin hin i chn on vim rut tha khi nghi ng nh siu m, ni soi song vic chn on vim rut tha vn phi da ch yu vo thm khm v theo di lm sng t m, nhiu ln, tt c cc phng php cn lm sng ch c tnh cht tham kho. 6. Cn ngh n vim rut tha trc bt c bnh nhn no n khm do au bng. Khng c cch no d phng v d 99

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


on tin trin ca vim rut tha. Cch tt nht h thp bin chng v trnh t vong l chn on sm v m ct b rut tha trc khi n v hay hoi t. 7. Vim rut tha cp l mt cp cu ngoi khoa cn c chn on sm (trc 6h) v m sm. Chn on da ch yu v lm sng nhng hnh thi lm sng a dng nn chn on khng d. XVIII. V tr gii phu ca rut tha: 1. Bnh thng: Rut tha nm y manh trng, ni hi t ca 3 di c dc, di gc hi manh trng 2 3cm v thng nm trong phc mc. Rut tha thng vi y manh trng v c cu to bi 3 lp t ngoi vo trong l thanh mc, c nim v nim mc. Nim mc rut tha ngoi cc tuyn cn c nhiu nang lympho. 2. Bt thng: 1) V v tr : Rut tha sau manh trng. + Trong thanh mc. + Trong phc mc. Rut tha sau hi trng. Rut tha trong thnh i trng. Rut tha trong tiu khung. Rut tha di gan. Rut tha h sn tri. Rut tha trong bao thot v. Rut tha ph n c thai. Rut tha gia bng.

6) V hnh thi: rut tha hnh phu. 7) V s lng : Hai rut tha. Rut tha chung gc. 100

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


XIX. Rut tha tch gc. 2 manh trng. Nguyn nhn vim rut tha:

1. Nguyn nhn gy tc rut tha: Do qu sn t chc lympho thnh rut tha hoc d vt (si, phn ) gy tc lng rut tha (gc) lm tr dch tit, tr tun hon lm tng p lc lng rut tha, cng vi s pht trin ca vi khun gy vim rut tha. 2. Do nhim khun huyt (t cc m tai, mi, hng ) cng c th gy vim rut tha. XX. Gii phu bnh ca vim rut tha: 1. Vim rut tha th xut tit (6 12h u). 1) Rut tha: Lp thanh mc mt bng. Mch mu xung huyt gin to trn thnh rut tha. Rut tha di hn bnh thng. Vi th: ngm cc t bo vim thnh rut tha nhng

khng c ap xe. 8) bng: Khng c dch hoc ch c mt t dch trong xut tit c vi khun. 2. Vim rut tha m: 1) Rut tha: Sng to, mng, c dnh gi mc bao bc u t v di. Trong lng rut tha c nhng m thi, lot nh

nim mc, lp c b ph hu, thanh mc cha v. 2) bng c dch c khng thi, cy khng c vi khun. 3. m qunh rut tha: Trong trng hp rut tha vim cha vm phn ng cc quai rut, mc ni ln n quy li khu tr vim, c nhiu mch mu tn to xung quanh mang cc t bo, cc cht chng vim n. 4. Vim rut tha hoi t: 101

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) Rut tha: C mu c a, en hoi t tng mng trn thanh mc c l thng c gi mc, mc ni n dnh vo. (hu qu ca tc mch). 8) bng c nhiu dch m thi, cy c vi khun. 9) Trong trng hp m c khu tr li bi cc t chc xung quanh gm rut, mc ni, phc mc dnh li s to thnh p xe rut tha. 10) Trong trng hp m chy v khu tr trong h chu phi, tiu khung c gi l vim phc mc khu tr, nu trng hp m chyar ra khp bng c gi l vim phc mc ton th XXI. Lm sng: 1. C nng: 1) au bng: L triu chng thng gp bnh nhn vim rut tha tr trng hp bnh nhn b lit tu ct ngang hoc ngi c ri lon tm thn khng nh gi c. T nhin, xut hin dt ngt. v tr: h chu pahir, c lc au nhng v tr khc Tnh cht: Thng au m , bnh nhn c cm gic

(quanh rn, thng v ) sau khu tr li h chu phi. nng h chu phi, au tng dn, khng thnh cn, au tang khi ho, vn ng. Cng c trng hp au d di h chu phi khi bnh nhn vo vin, l khi rut tha cng sp v hoc vim rut tha do c d vt lt vo trong rut tha. 5) Nn, bun nn: tr em thng hay nn. 6) B trung i tin. 7) Cc du hiu ri lon tiu ho khc: chn n, to bn, a chy. 2. Ton thn: 102

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Th trng nhn chung tt. tuy nhin c biu hin ca St nh 37,5 38, c th st cao tr em (thng gp tnh trng nhim khun nh: hi th hi, li bn, mi kh. th vim rut tha hoi t). Mch, huyt p bnh thng. Trng hp st cao hn cn phi ngh ti v tm cc nguyn nhn khc. 3. Thc th: 1) Giai on cha c vim phc mc, bng mm nhng vng h chu phi au c phn ng thm khm: n au cc im: + im Mac Burney l im gia ng ni gai chu trc trn bn phi vi rn. + im Clado l im nm trn ng ct gia ng ni hai gai chu trc trn v b ngoi c thng to bn phi. + im Lanz: l im ni 1/3 bn ngoi phi vi 2/3 bn tri ca ca ng ni 2 gai chu trc trn. + im au trn mo chu phi: vim rut tha sau manh trng. du hiu phn ng thnh bng thnh bng h chu du hiu co cng thnh bng vng h chu phi thng phi. l vim rut tha giai on mun: khi c nh n sau bn tay trn thnh bng th bnh nhn ku au bn tay cm nhn sc cng ca thnh bng, n su na c co cng thc s. 2) Cc du hiu phn nh tnh trng phn ng ti ch ca mng bng khi vim rut tha cp: au h chu phi xut hin khi khi ngi thy thuc au h chu phi khi n 2 tay lin tip vo h chu rt nhanh tay tay ln (du hiu Blumberg) tri dn hi sang i trng phi (du hiu Rowsing).

103

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Tng cm gic da vng h chu phi: bnh nhn rt au khi mi chm vo vng ny (gp 1 s bnh nhn). 3) Thm trc trng / thm m o 1 s ph n: bnh nhn au thnh phi trc trng (hay thnh phi ti cng Douglas). XXII. cn lm sng: 1. xt nghim mu: 1) bch cu > 9000/ml, bch cu a nhn > 75%. 2) bch cu khng tng song song vi mc tn thng. 3) ngi gi s lng bch cu c th bnh thng. 2. Xquang: 1) Xquang bng khng chun b: chn on phn bit: Khng c g c hiu cho vim rut tha. Mc ch:

+ tm cc du hiu (-):Lim hi + C th thy si phn vng h chu phi. + Phn bit vi cn au si niu qun. chn on xc nh: mt s trng hp tr em (nh nhi) du hiu vim rut tha c th pht hin qua phim chp bng khng chun b vi nhiu hnh nh mc nc hi ca cc quai rut non tp trung h chu phi. Chp khung i trng c baryt: Thuc khng ngm vo lng rut tha vim. 3. Siu m: 1) Cha c tnh cht chn on r rng: hnh nh rut tha to, c dch xung quanh. Ct ngang rut tha: nhng vng trn ng tm. 2) Dng chn on phn bit hoc pht hin p xe rut tha/m qunh rut tha. 4. Ni soi chn on:

104

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Trng hp kh, nghi ng, loi tr vim rut tha nht l nhng ph n ang tui sinh . Hin nay tin hnh nhiu ca ct rut tha ni soi. XXIII. Cc th lm sng ca vim rut tha: Cc triu chng v du hiu trn y c th thay i theo cc hnh thi lm sng khc nhau ca vim rut tha. 1. Cc th lm sng theo la tui: Vim rut tha tr nh nhi: 1) Him gp nhng nu gp th kh chn on do tr cha bit ni, khi pht hin d dn n vim phc mc. 2) Khi tr c quy khc + st: nn ngh ti vim rut tha. 3) Chp Xquang bng khng chun b: nhiu mc nc hi tp trung h chu phi. 4) Tin trin ca vim rut tha khng bao gi pht trin thnh p xe rut tha v mc ni ln cha pht trin. Vim rut tha tr 2 5 tui: 1) Khai thc bnh s kh khn, cc triu chng lm sng khng y cn c thm khm k. 2) st, quy khc, trn trc. 3) nn, a chy. 4) Bng chng. 5) Co chn bn phi gp vo bng. 6) Thm trc trng mt cch nh nhng. Tm li nhm < 5 tui khi b vim rut tha thng c nhng biu hin sau: 7) st cao, nhim khun, nhim c, nn nhiu. 8) Khc nhiu, kh khm. 9) du hiu ti ch khng r rng, 10) tui. Vim rut tha ngi gi: 1) chn on kh khn, du hiu nhim khun khng r. 105 din bin nhanhm t l v t 50 100% tu

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2) st khng cao, khng st. 3) au bng t, c khi ch hi nng nng hoc tng tc, chm khu tr vo h chu phi, thnh bng co cng khng r. 4) Chn n, bun nn. 5) Bnh cnh lm sng ging tc rut, bn tc rut. Khm h chu phi thy khi u ging nh u mang trng, n au. 6) Tin trin chm. 7) cn lm sng: bch cu tng t hoc khng tng. 2. cc th theo v tr: Vim rut tha sau manh trng: 1) H chu phi chng nh, phn ng khng r rt. 2) au lch v lan ra pha sau, i khi au h tht lng phi, n au nhi. 3) C cc du hiu mn ca vim c i chu: chn phi co li do kch thch c i chu, bnh nhn khng th dui chn ra c v au. Siu m khng thy m c i chu. 4) Thng d b st v d dn n ap xe rut tha. Vim rut tha di gan: 1) Do rut tha cha quay ht, manh trng nm ngay di gan. 2) Bnh cnh ging bnh cnh ca vim ti mt cp: au h sn phi, st, n co cng vng ti mt (nht l ngi cao tui). 3) chn on phn bit: siu m: ti mt, ng mt chnh bnh thng. Vim rut tha trong tiu khung: 1) st. 2) au vng di rn, c du hiu gi tc rut hoc im au xung di thp h chu phi. 106

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) C cc du hiu v tit niu: au rt, i but (d nhm l vim bng quang). 4) chn on phn bit: siu m, thm trc trng. Vim rut tha nm gia bng: 1) St. 2) im au nm gia bng, quanh rn. 3) du hiu thn kinh. 4) Thng d v gy vim phc mc hoc dnh gy tc rut. Vim rut tha bn tri (o ngc ph tng): 1) Ging nh vim rut tha in hnh nhng l cc triu chng nm h chu tri. 2) Khm tim gan pht hin c o ph tng hay khng. Vim rut tha trong bao thot v: 1) Ti thot v au ging nh thot v bn nght. 2) St, bch cu cao. 3. Cc th vim rut tha. Vim rut tha ph n c thai: 1) Vim rut tha ph n c thai trong 6 thng u ca thai k triu chng khng c s khc bit so vi ph n bnh thng. 2) Trong 3 thng cui do t cung to y manh trng ln cao v xoay ra ngoi nn im au dng cao v lch ra pha ngoi (tht lng), co cng thnh bng khng r. 3) Khm: + bnh nhn nm nghing tri t cung sang tri, rut tha v v tr c. + bnh nhn nm nga, y vo t cung t bn tri: au h chu phi. 4) ch :

107

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ vim rut tha ph n c thai tin trin nhanh chng n hoi th. V vy cn chn on sm v ch nh m sm trc khi hoi th l iu cn thit bo m cho tnh mng ca m v thai nhi. + M vim rut tha ph n c thai trong 3 thng u ca thai d xy thai. Vim rut tha do giun chui vo: au d di tng cn vng h chu phi. Khm bng vn mm, khng st, bch cu. Vim rut tha do lao: 1) bnh nhn din bin chm, au v phn ng h chu phi, khng r rt. 2) M thy sng to ri rc c nhng ht trng n, nhiu hch mc treo v bng c dch vng chanh. 3) Cn iu tr lao tch cc. 4) C nguy c d v bc mm rut tha. Vim rut tha do thng hn: him. XXIV. Chn on vim rut tha: 1. chn on xc nh: 1) Da ch yu vo lm sng + xt nghim mu thy bch cu tng cao, bch cu a nhn tng. 2) au bng vng h chu phi. 3) Tnh trng nhim khun. 4) Khm phn ng h chu phi. 5) xt nghim: bch cu tng cao. 6) Nghi ng: siu m 2. chn on phn bit: Phn bit vi cc nguyn nhn khc trong bng: 1) Thng lot d dy t trng: + do dch tiu ho chy theo rnh i trng phi xung h chu phi gy au.

108

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Trng hp ny do thng d dy khng pht hin sm, mun khi c nhim khun ton thn. + Khi u thy cn au t ngt, d di vng trn roonsm bng cng nh g, sau c th au do co cng na bng bn phi. + Vn thy co cng vng trn rn, + Vng c trc gan mt. + Thm trc trng: ti vng bn phi phng au. + Xquang bng khng chun b: lim hi. 2) Vim ti mt cp: + D nhm vi vim rut tha di gan. + au vng h sn phi km theo rt run + h sn phi n au, cm ng phc mc, c th s thy ti mt cng to. + Siu m: hnh nh ti mt vim, thnh dy. 3) tr em: + Vim ti tha Meckel kh chn on nn 1 nguyn tc khi m rut tha phi kim tra hi trng tm ti tha. + Lng rut cp. + Vim hch mc treo. + Vim rut. 4) ph n: + Cha ngoi t cung v / do v: Chm kinh, ri lon kinh nguyt, au bng di t ngt, d di. V m hi, mch nhanh, huyt p h, ra mu m o, hi chng thiu mu (+) Thm m o: ti cng Douglas rt au. chn on phn bit: siu m, HCG(+). + U nang bung trng xon: Cn au qun d di. S thy 1 khi u vng di rn kch thc tng dn. 109

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Thm trc trng v thm m o. Siu m. + Vim m vi t cung v: St rt cao 39 40, rt run, 2 g m . Siu m. + Vim phn ph: au 2 bn h chu. Ra kh h. St cao dao ng. Siu m: Douglas c dch, 2 phn ph rt to. 5) ngi gi: + tc rut. + U manh trng. Vi cc bnh l ng tit niu: 1) Cn au qun thn, vim ng tit niu: + d nhm vi vim rut tha sau manh trng. + au tht lng phi, c th sau vn ng. + Ri lon tiu tin: i but, i dt, nc tiu c c mu. + Siu m, UIV, xt nghim nc tiu. 2) Si niu qun phi: + Ri lon tiu tin: i but, i dt, i mu. + au tng cn dc theo ng i ca niu qun. + Siu m, Xquang, UIV h tit niu. Vim c i chu: 1) au vng h chu phi. 2) du hiu kch thch c i chu: chn phi co gp vo bng, bnh nhn khng th dui chn ra v au. 3) Siu m: m c i chu. Vi cc bnh ni khoa: 1) Vim phi, nht l tr em. 2) Ng c thc n. 110

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Vim gan B. 4) St vir gy au h chu phi tr em. 5) Vim tai mi hng. XXV. Chn on vim rut tha cp mun: Vim rut tha mun dn n cc bin chng: 1. Vim phc mc Cc hnh thi din bin: 1) Vim phc mc tc th: thng sau 24h. 2) Vim phc mc th 2: v p xe vo bng. 3) Vim phc mc th 3: m qunh p xe v p xe. triu chng: bnh cnh lm sng l mt vim phc mc in hnh: 1) au khp bng. 2) Bng chng, co cng thnh bng, n au khp bng (cm ng phc mc ton b). 3) Ton thn: st cao, mi kh, li bn, hi th hi. 4) Ure huyt, bch cu tng cao > 10000/ml, i t. Chp bng khng chun b: chng hi (lit rut c nng), khng c lim hi. ( vim phc mc th 2, th 3 thng l th vim phc mc nng do bnh tin trin lu trn c th suy kit v nhim khun). 2. p xe rut tha (vim phc mc khu tr): Do m ca vim rut tha c bao bc bi cc t Cc tnh cht ca vim rut tha gim bt i, sau 3 5 chc xung quanh nh mc ni, cc quai rut dnh li. ngy bnh nhn thy au tng ln, st dao ng, bch cu tng (do nhim khun). H chu phi c khi cng, lin vi gai chu, ranh gii r, n au chi. + C khi da vng ny ty ln do khi m sp v ra ngoi.

111

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ C th gp p xe trong bng. Khi khm thy 1 khi au chi, c th di ng, nm cch vi gai chu, lch vo pha trong. 3. m qunh rut tha: L trng hp rut tha giai on vim c cc t chc thng xut hin t ngy th 3 tr i, c khi mun hn. Tnh trng nhim khun nh, st nh 37,5 38,5. S thy mng cng h chu phi, ranh gii khng r, xunh quanh bao bc li.

khng au, au t. *y l trng hp vim rut tha duy nht khng nn m ngay m nn cho khng sinh v theo di. Qu trnh vim c th t thoi tro, khu tr li thnh p xe rut tha. 4. Vim rut tha mn tnh: Cha c cng nhn rng ri. triu chng khng r rng, sau vi 3 ngy t khi v ti

pht sau 1 thi gian. XXVI. iu tr: Khi chn on l vim rut tha cp, ch nh m tuyt i. 1. Nguyn tc: 1) Vi trng hp cha r vim rut tha: Khi mt bnh nhn nghi vim rut tha cp m cha chc chn th nn lu 24 48h: + Thm khm bng sau 1h, t m. + Ly mu, o nhit , th bch cu 3h/ln. + Khng s dng thuc gim au c Morphin, khng s dng khng sinh. + Theo di v so snh sau mi ln khm. i vi trng hp r vim rut tha: m (tr m qunh rut tha). 2) Chun b bnh nhn: 112

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


bnh nhn nm nga. V cm: gy t vng (cha c bin chng), gy m ton bnh nhn nm nghing sang tri v u hi thp

thn (c bin chng) dn cc quai rut non sang tri d bc l rut tha. 3) ng m: tu theo tin trin ca vim rut tha m c v tr khc nhau: ng Mac Burney vi vim rut tha sm cha. ng dc b ngoi c thng to trong trng hp vim ng gia di rn trong trng hp p xe rut tha / vim

phc mc khu tr. phc mc cha r nguyn nhn. 4) Thm d bng: nh gi tn thng rut tha so vi tn thng, dch trong bng v thi gian din bin kim tra cc tng v trnh tn thng. i vi ph n: kim tra mt cch h thng phn ph 2 bn kp thi x tr ng thi cc nguyn nhn khc. 5) Ct rut tha xui dng, ngc dng (trng hp rut tha su trong manh trng): bc l manh trng, tht v ct rut tha, tht ct gc rut tha trc. 6) Khu vi mm rut tha nu t chc manh trng xung quanh rut tha mn v ph n. nguyn nu t chc manh trng xung quanh rut tha mn v ph n. 7) kim tra c h thng ~ 80 cm hi trng t gc hi manh trng tm ti tha Meckel. Trng hp rut tha khng r vim / vieem giai on u th ct ti tha Meckel 8) Vi ct rut tha, trng hp c vim phc mc: ch ct khi n l nguyn nhn gy vim. Khng dn lu. ng bng. 113

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2. C th: Vim rut tha cp cha c bin chng. 1) M cng sm cng tt (trc 6h). 2) V cm: m ni kh qun, t tu sng, t ti ch. 3) Ct rut tha vi khng dn lu. 4) ng bng theo cc lp gii phu. Trnh khong trng gia cc lp nu khng s gy nn vim nhim thnh bng. 5) Khng sinh d phng trong m. 6) Ct ch: sau 5 7 ngy, ct ch sm khi c du hiu nhim khun vt m: st, au, ty . 7) theo di sau m: + Chy mu trong bng: do tut ch tht mc treo rut tha: m li. + nhim khun vt m + Toc vt m + li tng. + Tc rut sm sau m. Vim rut tha tiu khung / gia bng: 1) ng m gia di rn. 2) Ct rut tha. 3) Lau sch, ng bng, khng cn dn lu Douglas (ra k bng bng huyt thanh, betadine) Vim rut tha di gan: 1) ng rch ngoi c thng to bn tri. 2) Ct rut tha, ng bng 1 lp, da khu tha. p xe rut tha: 1) p xe rut tha thnh ho, khi m bit lp hon ton vi phc mc v dnh vo thnh bng trc. + Chn im au chi nht, thng khong 1cm pha trong gai chu trc trn bn phi. + Dng 1 kim chc d, nu c m s rch rng theo chn kim, tch qua cc lp vo dn lu m ngoi phc mc. 114

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Ct rut tha sau 6 thng. 2) p xe rut tha trong bng: + L loi p xe tin trin t nhin s v vo bng, gy vim phc mc:ch nh m l bt buc. + ng m: ng cnh bn bn phi. + Ct b rut tha + mc ni ln bc quanh m. Vim phc mc rut tha: 1) Gy m ni kh qun. 2) Khng sinh trong m. 3) ng m: ng trng gia di rn hoc ng cnh gia bn phi. 4) Ct rut tha vi, khng vi. 5) Lau ra bng, thm sch, xp li quai rut. 6) dn lu 3 ngy. 7) ng bng 1 lp da h. 8) Ct ch di nt buc ngy th 15. 9) Khu da th 2 sau 1 thng (khi t chc ht mc p) m qunh rut tha: 1) L trng hp vim rut tha duy nht khng m ngay. 2) Khng sinh, gim au, theo di. 3) X tr: nu tn thng thnh p xe rut tha th x tr nh p xe. Nu m qunh rut tha gim dn ri ht: m ct rut tha sau 3 4 thng. 3. S dng khng sinh trong vim rut tha: 1) Dng khng sinh ngay khi khi m : c theo di lm gim t l nhim khun r rt nht l nhim khun vt m. 2) Thuc : khi rut tha cha v m: Flagyl hoc dng Flagyl phi hp vi khng sinh ph rng (cepha3) 4. bin chng sau m vim rut tha:

115

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Chy mu: do tut ch tht mch mc treo rut tha. Gy: 1) hi chng chy mu trong: m li cm mu. 2) Mu t sau m rut tha, nht l rut tha sau manh trng dn lu qua vt m / qua ng rch thp pha bn. Vim phc mc sau m: bc mm rut tha, v p xe trong bng sau m, vim thn rut tha ct khng ht :hi chng vim phc mc. D manh trng: 1) Trng hp c hoi t gc rut tha. 2) Khng sinh + sn sc ti ch. p xe ti cng Douglas: 1) nhim khun ton thn + kch thch trc trng (mt rn, a nhy mi). Thm trc trng thy ti cng Douglas au chi. 2) iu tr: dn lu qua ng trc trng khi p xe khu tr. 5. Tc rut sau m: 1) Sm: p xe tn d/d vt b qun. + Hi chng tc rut + hi chng nung m su. + Xquang + Siu m. - Mun: do dy chng: nght, xon rut: chn on sm v m sm.

Thot v i nght I. i cng 1. Thnh bng vng bn i c nhng im yu t nhin m qua c th hnh thnh cc ti phnh cha rut v 116

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


mc ni ln c gi l ti thot v. C 2 loi thot v hay gp vng ny l thot v bn v thot v i. C th pht hin cc bnh ny bng cch khm lm sng t m v c phng php. 2. Thot v nght l khi rut chui xung bao thot v v b c bao thot v bp nght li khng tr ln c bng. y l 1 bin chng nng v thng gp ca tt c cc loi thot v. Trong thot v i t gp hn thot v bn nhng li c t l nght cao hn, i hi phi chn on sm v x tr ngay nu khng ch sau 6 12 h tng thot v s b hoi t do tr tun hon hoc gy nn bnh cnh ca tc rut cp, tin lng s nng hn rt nhiu. Do vy tin lng bnh ph thuc vo thi gian can thip sm hay mun. 3. Trong nhng nm gn ay, do nhng tin b v gii phu hc dn n c nhiu phng php m ci tin nh phng php Shouldice v m ni soi lm gim t l ti pht sau m ch cn khng qu 1%. II. Dch t: 1. Tui: Gp mi la tui, hay gp nht trung nin v ngi gi, sau mi n thanh nin v tr em. 2. tr em do cc cn c cn mm mi, vng c ti khng chc lm nn thng b tht nh. 3. Gii : nam < n. 4. iu kin thun li: Sau mt ng tc gng sc mnh: vc nng, y xe, ho nn hay gp ngi lao ng chn tay v i li nhiu. Tin s thot v t nh. V tr thot v:

+ Thot v bn nght + Thot v rn nght + Thot v i nght 117

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


+ Thot v bt nght + Thot v ng trng nght Thot v nght gp nhiu nht l thot v bn. Thot v i t gp hn thot v bn nhng t l b nght cao hn thot v bn. III. Khi thot v: ti thot v b d nght hn ti thot v C s gii phu ca thot v i: gia l c thng bng. bn ngoi t trong ra ngoi gm: C ngang bng, c ln. 1. Thnh bng mi bn c cu to bi (?):

cho bng trong v c cho bng ngoi. 2. Cc thnh phn di phc mc i phc mc ln thnh 3 hm phc mc hay hm bn: Hm bn ngoi nm ngoi ng mch thng v di. Hm bn gia nm gia ng mch thng v di v Hm bn trong nm gia ng mch rn v dy treo

ng mch rn. bng quang. Tr hm bn trong c cn, c thng bng che chn cn hm bn gia v hm bn ngoi l nhng din yu v l im xut pht ca cc thot v bn i. 3. Thot v i l 1 dng ca thot v bn trc tip, l thot v l c lc. Thot v nm pha di dy chng bn (ng Malgaine), vng tam gic Scarpa. 4. Ti thot v i qua 1 khe hp (gi l vng i) c gii hn bi: Pha trc l dy chng bn, pha sau l dy chng Gimbernart, pha trong l dy chng Cooper, pha ngoi l b mch thn kinh i. Dy chng bn v dy chng Cooper c nh cht trn xng mu, hn na ng i thng hp nn d gy nght. Thot v i t gp hn thot v bn nhng li hay gy nght hn thot v bn. 118

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


IV. Triu chng lm sng ca thot v bn - i nght: Khi bnh nhn n khm vi tnh trng au, tc rut do thot v th l du hiu ca thot v nght. l khi rut chui xung bao thot v v b c bao thot v bp nght li gy hi chng tc rut cp tnh v c nguy c hoi t rut. Mi loi thot v u c nguy c gy nght nhng nhiu nht l thot v i nght v thot v bn nght. Triu chng thng gp l triu chng ca 1 thot v nght m tng thot v l mt quai rut non. Triu chng lm sng khc nhau tu theo bnh nhn n sm hay n mun. 1. Khi bnh nhn n sm: Trn 1 bnh nhn thot v c chn on t trc khi thot v t nhin to ra hoc t nhin thy ni 1 khi phng vng bn i. 1) C nng: au khi thot v: thot v i t khi c biu hin r rt, ngay c khi nght hay tc rut, bnh nhn vn c cm gic kh chu vng bng hn vng i: thng c km cn au bng. Nn, bun nn. Giai on u khng c thay i g c bit, mch Khng st. Thy 1 khi phng nm trn ng Malgaine, phn 2) Ton thn: c th hi nhanh nhng u r, huyt p bnh thng. 2) Thc th: trn tam gic Scarpa, pha trc b mch i, trn, kch thc to hay nh tu trng hp. S c cm gic cng, chc hn xung quanh. n au, Khi thot v cng, y khng ln, bp khng thu nh nht l pha c ti (au chi). li c, khng thay i th tch khi ho, rn. 119

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Nn khng thy ting c ch. G c do c dch trong ti thot v.

i khi trong trng hp ch c 1 phn rut b kt vo l thot v v b bp nght hoc khi thot v b nm su th lm sng ch c triu chng au d di, nn nhng vng bn bu khng c thay i g. Trng hp ny phi khm t m tm im au chi ng bn hoc vng i. 2. Khi bnh nhn n mun: Tu tng trng hp v tng loi thot v m din bin nhanh hay chm, nhng trung bnh sau 6 12h thot v nght khng c x tr th cc triu chng lm sng thay i r rt. Ngoi cc triu chng m t trn cn c triu chng ca tc rut v quai rut b hoi t: 1) C nng: au bng tng cn. Nn nhiu v lin tc. B trung i tin. Mt hc hc, mt trng, mi kh, li bn. Mch nhanh nh. Khng st/st nh i t Vng bn bu: khng c thay i g lm so vi giai Bng: chng cng, g vang, cc quai rut ni r, c nhu

2) Ton thn: Thay i rt r rt:

3) Thc th: on sm. ng kiu rn b. Giai on ny nn lm cc xt nghim cn lm sng nh gi tin lng v lm cn c cho vic hi sc: hematocrite tng do mt nc, ure huyt tng, in gii thp. 120

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


V. Cc th lm sng: 1) Th cp tnh: Gp nhng khi thot v nh: thng khng tht hon ton c quai rut m ch mt phn thnh rut, ni b t do. Cc triu chng ton thn v c nng nng, din bin nhanh chng: + Nn v a chy lin tc + Ton thn thay i nhanh: mt xanh xm, mch nhanh nh, huyt p tt, nhit gim, c cc triu chng ri lon thn kinh: ni nhm, chut rt, co git Tin lng nng, nu khng x tr sm, t vong sau 36 48h. 2) Th bn cp: Gp nhng khi thot v ln. Thnh thong c cc triu chng nght, nu nm 1. Theo din bin:

ngh/ngm nng c th khi. Tnh trng ny ti i ti li nhiu ln. 3) Th tim tng: Gp nhng ngi gi yu, din bin chm, cc triu chng c nng khng r rng, tng thot v thng l mc ni ln, rut + To bn, nn t/bun nn. + au t Chn on mun khi rut hoi t. 2. Theo tng thot v: 1) Rut non: hay gp. 2) Mc ni ln: thng khng c triu chng tc rut. 3) Manh trng, i trng xch ma. 4) Rut tha. 5) Bng quang (1 phn): triu chng tit niu. 121

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3. Theo c a: 1) Nh nhi: hay gp thot v nght nhng mc nght nh hn. 2) Thot v li: M nhiu ln, iu tr kh v cc lp gii phu thay i. Hay gp ngi gi. 4. Theo phn ca tng b nght: 1) Thot v Richter: Thot v b, khng c cung, kh thy. Nght 1 phn thnh rut. au nhiu + a chy + nn + st, chn on phi tm Khng gy tc rut m gy vim ty lan rng do hoi

im au chi vng bn i. t trong ti thot v. 2) Thot v Mayld (hnh W- Thng hay thot v bn hn). VI. VII. Hoi t quai rut trong bng, tin trin nhanh. Kh chn on trn lm sng: thng bnh nhn gi C hi chng tc rut, cm ng thnh bng, phn ng Khi m: phi ko di thm rut ra ngoi kim tra. Din bin ca thot v nght: T tt ln. Ri lon tc rut Vim phc mc ton th do quai rut nght, hoi t v V ti thot v v quai rut nght dn n hnh thnh Chn on thot v nght: Tin s thot v. Lm sng au + khi thot v. 122

> 50 tui, tin s thot v. thnh bng.

tt ln bng. p xe phn m, to ra 1 l r ng tiu ho. 1. Chn on xc nh:

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2. Chn on phn bit: 1) n sm: Thot v bn: khi thot v nm trn ng Malgaine. Vim hch bn:

+ L bn v ng bn trng rng. + St, au. + C th thy tn thng chi di. Gin tnh mch hin trong: s thy rung miu khi bnh nhn ho v khi thot v t bin mt khi bnh nhn nm. Ung th hch di cn: + Rt au ti ch sng. + au lan theo ct sng. + St cao, nhim khun r. Vi thot v kt(?): chn on phn bit nh phu thut. 2) n mun: Cn phi khm k vng bn i khi bnh nhn n vi triu chng tc rut nhm phn bit tc rut do thot v nght vi tc rut do cc nguyn nhn khc, nht l khi khi thot v b, nm su ngi bo, m dy. VIII. iu tr: 1. Nguyn tc: 1) Thot v i nght khi c chn on cn phi c iu tr ngay, cng sm cng tt bng phu thut. 2) Ct b thot v cao: vng i su, trong mt lp m dy cung i cn tr ch c thot v. Mun ct b ti thot v, phi ct b cung i hoc i t pha trn bng xung mi ct c, do c th dng ng rch thp i hoc trn cao bn.

123

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


3) Phc hi thnh bng: khu dy chng Cooper dnh mo lc vi cc c cho nh, c ngang bng v cn c cho ln. 2. iu tr phu thut. 1) Mc ch: Gii phng tng b nght X tr tn thng tng nu cn. Phc hi thnh bng, gii quyt nguyn nhn gy

thot v. 2) Chun b trc m: Chng shock: Truyn dch tnh mch, tr tim mch. Thng tiu: gim p lc, xp bng quang, trnh rch Thng d dy t trng. Gy t i vi ngi gi, ngi c bnh tim mch. Gy m khi d kin phu thut phi ct rut. ng rch:

thng bng quang khi phu tch bao thot v. 3) V cm:

4) Nguyn tc x tr: + Kinh in hay dng ng vung gc qua cung i ngay trn khi phng thot v. + C th dng ng rch da ngay trn np bn ta s thy cung i di v cn c cho ln trn. Bc tch ti thot v: ti thot v nm di cc lp x v Ct cung i: cung i pha trc c thot v, ct cung m, rch m ti thot v bc tch cho n c. i c thot v s hin ra (khng ct rch cung i trc khi rch m ti thot v v d tut quai rut b thot v vo bng). Bc l v rch ti thot v phi thn trng t t, t nng n su trnh tn thng tng. Khi vo ti thot

124

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


v, m rng ti v pha c v ct c ti. Khi c ti b ct t, tng thot v c gii phng. Khi nghi hoi t rut phi ko rut kim tra t u ti X tr tng thot v da vo dch trong ti thot v, cui, nu kh phi m bng (ch thot v hnh W) tnh cht quai rut (ko thm rut ra kim tra). + Nu ch rut b tht, ni c thot v v quai rut di vn hng, bng, co bp bnh thng, cc mch mu mc treo rut vn p tt: khng cn x tr g. + Quai rut c mt vi nt nghi ng hoi t, cc ni khc tt: Khu vi cc nt li. + Rut b hoi t mt on: Ct b rng ri ni li ngay bng ming ni bn bn/tn tn (ch trng hp ngi gi yu/tng thot v l mt on rut gi mi nn lm hu mn nhn to, m th 2 ni). + Trng hp nghi ng hoi t: p gc c huyt thanh m v phong b Novocain (khng c Adrenalin vo mc treo v ch, nu khng hi ph phi ct rut. + Nu ti thot v thnh 1 ap xe phn m: Rch rng dn lu. + Nu thnh l r: m phin Khu phc hi thnh bng trnh ti pht. Cm mu k trc khi ng bng. dn lu bng drain Redon v bng p, rt sau 24h. Theo di vt m nu thy ty , n: ct ch khu Dng ch khng tiu loi monfi/ nhim khun. Nguyn tc: phu tch c bao thot v v khu kn

da ngay, cho khng sinh. 5) Khu phc hi thnh bng: c bao thot v lm cho tng bng khng sa xung c na.

125

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Khu dy chng Cooper vi c ngang bng, c cho b v cn c cho ln bng ch khng tiu bt kn vng i li. Khu bt l i ( phng php c in) hoc bt c l bn ln l i (phng php Mac Vay). Khu da v lp m di da. 3. iu tr ni khoa phi hp trc trong v sau m: 1) Trng hp n sm: iu tr nhim khun n gi. 2) Trng hp n mun: IX. Bi ph nc in gii. Ht d dy lin tc. Khng sinh. Bin chng sau m: 1) Chy mu do thng tn mch mu. 2) Rch thng bng quang. 3) Khu vo rut, thng rut. 4) Tai bin khi ct t thn kinh. 5) Nhim khun vt m.

Thot v bn nght X. i cng 1. Thnh bng vng bn i c nhng im yu t nhin m qua c th hnh thnh cc ti phnh cha rut v mc ni ln c gi l ti thot v. C 2 loi thot v hay gp vng ny l thot v bn v thot v i. C th pht hin cc bnh ny bng cch khm lm sng t m v c phng php. 2. Thot v nght l khi rut chui xung bao thot v v b c bao thot v bp nght li khng tr ln c bng. y l 1 bin chng nng v thng gp ca tt c cc loi thot v. Trong thot v bn hay gp nht i hi phi chn on sm v x tr ngay nu khng ch sau 6 12 h tng 126

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


thot v s b hoi t do tr tun hon hoc gy nn bnh cnh ca tc rut cp, tin lng s nng hn rt nhiu. Do vy tin lng bnh ph thuc vo thi gian can thip sm hay mun. 3. Trong nhng nm gn ay, do nhng tin b v gii phu hc dn n c nhiu phng php m ci tin nh phng php Shouldice v m ni soi lm gim t l ti pht sau m ch cn khng qu 1%. XI. Dch t: 1. Tui: Gp mi la tui, hay gp nht trung nin v ngi gi, sau mi n thanh nin v tr em. 2. tr em do cc cn c cn mm mi, vng c ti khng chc lm nn thng b tht nh. 3. Gii : nam > n, n thng gp thot v i ngt. 4. iu kin thun li: Sau mt ng tc gng sc mnh: vc nng, y xe, ho nn hay gp ngi lao ng chn tay v i li nhiu. Tin s thot v t nh. V tr thot v:

+ Thot v bn nght + Thot v rn nght + Thot v i nght + Thot v bt nght + Thot v ng trng nght Thot v nght gp nhiu nht l thot v bn. XII. Kch thc khi thot v: ti thot v b d nght hn C s gii phu ca thot v bn: gia l c thng bng. ti thot v ln. 1. Thnh bng mi bn c cu to bi (?):

127

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


bn ngoi t trong ra ngoi gm: C ngang bng, c cho bng trong v c cho bng ngoi. 2. Cc thnh phn di phc mc i phc mc ln thnh 3 hm phc mc hay hm bn: Hm bn ngoi nm ngoi ng mch thng v di. Hm bn gia nm gia ng mch thng v di v Hm bn trong nm gia ng mch rn v dy treo

ng mch rn. bng quang. Tr hm bn trong c cn, c thng bng che chn cn hm bn gia v hm bn ngoi l nhng din yu v l im xut pht ca cc thot v bn. 3. Phn loi thot v bn: 1) Thot v bn: Thot v bn gin tip: T h bn ngoi chui qua l bn su vo ng bn ri chui qua l bn nng xung bu. C 2 th: + Bm sinh: Do ng phc tinh mc cn tn ti sau khi sinh ( n c thot v mi ln do cn ng Nuck). Ti thot v v thng tinh nm trong 1 bao x chung. V vy ti thot v c th dnh vi cc thnh phn ca thng tinh s kh khn hn khi tch bao thot v. + Mc phi: Ti thot v v thng tinh khng nm trong bao x chung. Thot v bn trc tip: + Thot v xy ra t h bn gia. Ni xy ra thot v l din yu nht ca thnh bng trc bn, l tam gic Hesselback c cu to bi 3 cnh: cnh trn ngoi l ng mch thng v di, cnh trong l b ngoi c thng bng, cnh di l dy chng bn. + c im: Hay gp ngi gi do thnh bng yu. Ti thot v khng i qua l bn su v ng bn. C v y 128

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


ti thot v rng gn bng nhau (thot v gin tip: c nh m ti rng) nn t b nght. Him khi sa xung bu. Thot v chch trong: Tng chui qua h bn trong, pha trong ng mch rn. Loi ny t gp v cng t khi b nght do thnh bng vng ny dy v chc. XIII. Triu chng lm sng ca thot v bn: Khi bnh nhn n khm vi tnh trng au, tc rut do thot v th l du hiu ca thot v nght. l khi rut chui xung bao thot v v b c bao thot v bp nght li gy hi chng tc rut cp tnh v c nguy c hoi t rut. Mi loi thot v u c nguy c gy nght nhng nhiu nht l thot v bn nght. Triu chng thng gp l triu chng ca 1 thot v nght m tng thot v l mt quai rut non. Triu chng lm sng khc nhau tu theo bnh nhn n sm hay n mun. 1. Khi bnh nhn n sm: Trn 1 bnh nhn thot v c chn on t trc khi thot v t nhin to ra hoc t nhin thy ni 1 khi phng vng bn i. 1) C nng: au vng thot v: l triu chng u tin v ch o. + Xut hin t ngt khi bnh nhn ang lm ng tc mnh. + au chi, d di, lin tc: bnh nhn ku la. + au lan xung bu. C th c km cn au bng. Nn, bun nn. Giai on u khng c thay i g c bit, mch Khng st. 2) Ton thn: c th hi nhanh nhng u r, huyt p bnh thng. 6) Thc th:

129

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Thy 1 khi phng nm vng bn bu ,kch thc to S c cm gic cng, chc hn xung quanh. n au, Khi thot v cng, y khng ln, bp khng thu nh Nn khng thy ting c ch. G c do c dch trong ti thot v. hay nh tu trng hp. nht l pha c ti (au chi). li c, khng thay i th tch khi ho, rn.

i khi trong trng hp ch c 1 phn rut b kt vo l thot v v b bp nght th lm sng ch c triu chng au d di, nn nhng vng bn bu khng c thay i g. Trng hp ny phi tm im au chi ng bn hoc vng i. 2. Khi bnh nhn n mun: Tu tng trng hp v tng loi thot v m din bin nhanh hay chm, nhng trung bnh sau 6 12h thot v nght khng c x tr th cc triu chng lm sng thay i r rt. Ngoi cc triu chng m t trn cn c triu chng ca tc rut v quai rut b hoi t: 1) C nng: au bng tng cn. Nn nhiu v lin tc. B trung i tin. Mt hc hc, mt trng, mi kh, li bn. Mch nhanh nh. Khng st/st nh i t Vng bn bu: khng c thay i g lm so vi giai

2) Ton thn: Thay i rt r rt:

7) Thc th: on sm.

130

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Bng: chng cng, g vang, cc quai rut ni r, c nhu ng kiu rn b. Giai on ny nn lm cc xt nghim cn lm sng nh gi tin lng v lm cn c cho vic hi sc: hematocrite tng do mt nc, ure huyt tng, in gii thp. XIV. Cc th lm sng: 1. Theo din bin: 1) Th cp tnh: Gp nhng khi thot v nh (thng l thot v i): khng tht hon ton c quai rut m ch mt phn thnh rut, ni b t do. Cc triu chng ton thn v c nng nng, din bin nhanh chng: + Nn v a chy lin tc + Ton thn thay i nhanh: mt xanh xm, mch nhanh nh, huyt p tt, nhit gim, c cc triu chng ri lon thn kinh: ni nhm, chut rt, co git Tin lng nng, nu khng x tr sm, t vong sau 36 48h. 2) Th bn cp: Gp nhng khi thot v ln. Thnh thong c cc triu chng nght, nu nm

ngh/ngm nng c th khi. Tnh trng ny ti i ti li nhiu ln. 3) Th tim tng: Gp nhng ngi gi yu, din bin chm, cc triu chng c nng khng r rng, tng thot v thng l mc ni ln, rut + To bn, nn t/bun nn. + au t Chn on mun khi rut hoi t. 131

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


2. Theo tng thot v: 1) Rut non: hay gp. 2) Mc ni ln: thng khng c triu chng tc rut. 3) Manh trng, i trng xch ma. 4) Rut tha. 5) Bng quang (1 phn): triu chng tit niu. 3. Theo c a: 1) Nh nhi: hay gp thot v nght nhng mc nght nh hn. 2) Thot v li: M nhiu ln, iu tr kh v cc lp gii phu thay i. Hay gp ngi gi. 4. Theo phn ca tng b nght: 1) Thot v Richter: Thot v b, khng c cung, kh thy. Nght 1 phn thnh rut. au nhiu + a chy + nn + st, chn on phi tm Khng gy tc rut m gy vim ty lan rng do hoi

im au chi vng bn i. t trong ti thot v. 2) Thot v Mayld (hnh W) XV. Hoi t quai rut trong bng, tin trin nhanh. Kh chn on trn lm sng: thng bnh nhn gi C hi chng tc rut, cm ng thnh bng, phn ng Khi m: phi ko di thm rut ra ngoi kim tra. Din bin ca thot v nght: T tt ln. Ri lon tc rut Vim phc mc ton th do quai rut nght, hoi t v

> 50 tui, tin s thot v. thnh bng.

tt ln bng.

132

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


XVI. V ti thot v v quai rut nght dn n hnh thnh Chn on thot v nght: Tin s thot v. Lm sng au + khi thot v. p xe phn m, to ra 1 l r ng tiu ho. 1. Chn on xc nh:

2. Chn on loi thot v: Cn c vo v tr khi thot v. 3. Chn on phn bit: 1) n sm: Vim thng tinh: Ko thng tinh rt au, s vo mo Vim mng tinh hon: tinh au. + Tinh hon to au. + S vo mo tinh hon : au chi + L bn khng to. Vim hch bn (hch Cloquet): + L bn v ng bn trng rng. + St, au. + C th thy tn thng chi di. Ung th hch di cn: + Rt au ti ch sng. + au lan theo ct sng. + St cao, nhim khun r. Vi thot v kt(?): chn on phn bit nh phu thut. 2) n mun: Cn phi khm k vng bn i khi bnh nhn n vi triu chng tc rut nhm phn bit tc rut do thot v nght vi tc rut do cc nguyn nhn khc, nht l khi khi thot v b, nm su ngi bo, m dy. XVII. iu tr:

133

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Tt c cc loi thot v bn nght khi c chn on cn phi c iu tr ngay, cng sm cng tt. 1. iu tr khng m: 1) Ch nh: i vi thot v nght tr nh. n trc 6h, au t, cha c bin chng. Cho thuc gim au, nm yn, khng rn. t chu b nm trong 1 chu nc m khong 10 15 Khng c nn bp c y khi thot v ln v c

1) Phng php:

pht hy vng khi thot v t ln. th lm v rut hoc y ln bng 1 on rut b hoi t. Nu khng c kt qu th phi m. Nu khi thot v ln c th eo bng p ti ch cho bnh nhn d phng tai bin tht nght, ch 1 thi gian ng phc tinh mc x ho v bt kn. 2. iu tr phu thut. 1) Khi khi thot v nght khng y ln c, thot v gy tc rut phi m cp cu cng sm cng tt. Tt nht phi m trong 6 gi u, khng c c y tng nght vo bng. 2) Mc ch: Gii phng tng b nght X tr tn thng tng nu cn. Phc hi thnh bng, gii quyt nguyn nhn gy

thot v. 3) Chun b trc m: Chng shock: Truyn dch tnh mch, tr tim mch. Thng tiu: gim p lc, xp bng quang, trnh rch Thng d dy t trng. 134

thng bng quang khi phu tch bao thot v.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


4) V cm: Gy t i vi ngi gi, ngi c bnh tim mch. Gy m khi d kin phu thut phi ct rut. ng rch: Thay i tu loi thot v, khi rch phi che Khng ct rch vng c ti thot v trc khi rch m ti Bc l v rch ti thot v phi thn trng t t, t nng

8) Nguyn tc x tr: ph cn thn. thot v v tut quai rut b thot v vo bng. n su trnh tn thng tng. Khi vo ti thot v, m rng ti v pha c v ct c ti. Khi c ti b ct t, tng thot v c gii phng. Khi nghi hoi t rut phi ko rut kim tra t u ti X tr tng thot v da vo dch trong ti thot v, cui, nu kh phi m bng (ch thot v hnh W) tnh cht quai rut (ko thm rut ra kim tra). + Nu ch rut b tht, ni c thot v v quai rut di vn hng, bng, co bp bnh thng, cc mch mu mc treo rut vn p tt: khng cn x tr g. + Quai rut c mt vi nt nghi ng hoi t, cc ni khc tt: Khu vi cc nt li. + Rut b hoi t mt on: Ct b rng ri ni li ngay bng ming ni bn bn/tn tn (ch trng hp ngi gi yu/tng thot v l mt on rut gi mi nn lm hu mn nhn to, m th 2 ni). + Trng hp nghi ng hoi t: p gc c huyt thanh m v phong b Novocain (khng c Adrenalin vo mc treo v ch, nu khng hi ph phi ct rut. + Nu ti thot v thnh 1 ap xe phn m: Rch rng dn lu. + Nu thnh l r: m phin Khu phc hi thnh bng trnh ti pht. 135

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


Cm mu k trc khi ng bng. dn lu bng drain Redon v bng p, rt sau 24h. Theo di vt m nu thy ty , n: ct ch khu Dng ch khng tiu loi monfi/ nhim khun. Nu rut tha b nght th ct vi gc. Cc mc ni b

da ngay, cho khng sinh.

nght th cn ct i. 9) Khu phc hi thnh bng: Nguyn tc: phu tch c bao thot v v khu kn c bao thot v lm cho tng bng khng sa xung c na. Cc phng php khu phc hi thnh bng: + Phng php Bassini: khu 2 bnh din bng ch khng tiu: Lp su: khu gn kt hp vi cung i Lp nng: Khu 2 mp cn c cho bng ngoi trc thng tinh. + Phng php Shaudice: tng s t trong ra ngoi bao gm 5 lp khu vt trong 2 lp u tin pha su nht khp hp va l bn trong v khu nh mc ngang vi cung i. + Phng php dng vt liu tng hp phc hi thnh bng (tm dt Vicryl): t di phc mc v m ly l bn nng. M c in/m ni soi. 3. iu tr ni khoa phi hp trc trong v sau m: 1) Trng hp n sm: iu tr ni khoa n gin. 2) Trng hp n mun: Bi ph nc in gii. Ht d dy lin tc. Khng sinh.

XVIII. Bin chng sau m: 136

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi


1) Chy mu. 2) Rch thng bng quang. 3) Sng teo tinh hon. 4) Khu vo rut, thng rut. 5) Tai bin khi ct t thn kinh. 6) Nhim khun vt m.

137

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