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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:
+ 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
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
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
+ 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.
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.
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
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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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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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.
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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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*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
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
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.
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:
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
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
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
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
+ 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.
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
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.
*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.
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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.
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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
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
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
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.
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
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
bng, c khi mu t vng tht lng. 7) V t trng: kh chn on. XII. X tr: 1. Nguyn tc: 36
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
khi x tr.
+ 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
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.
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42
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
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.
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46
8) Cn au qun gan:
9) Vim d dy cp:
*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
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:
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50
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
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.
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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
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.
+ 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
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
56
57
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
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61
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
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
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.
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(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
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).
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+ 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
* tr em cn chn on phn bit vi: khi m rut tha phi kim tra hi trng tm ti tha.
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
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
2) p xe rut tha (vim phc mc khu tr): chc xung quanh nh mc ni, cc quai rut dnh li. 77
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
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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
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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
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
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
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:
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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
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
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
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
2) Vim tu cp:
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
1. Nguyn tc:
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
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
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
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
9) Ton thn:
94
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
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
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.
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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
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
6) V hnh thi: rut tha hnh phu. 7) V s lng : Hai rut tha. Rut tha chung gc. 100
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
(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
103
+ 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
107
108
111
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
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
115
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
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
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
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
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
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
+ 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.
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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:
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
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da ngay, cho khng sinh. 5) Khu phc hi thnh bng: c bao thot v lm cho tng bng khng sa xung c na.
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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
+ 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 (?):
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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
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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
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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
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
tt ln bng.
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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:
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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
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
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.
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