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

Vt thng s no

i cng:
Vt thng s no l vt thng lm dch no tu v m no thng vi mi trng bn ngoi qua cc thng tch ca mng no, xng s v da u. Nguyn nhn chnh l do cc vt sc nhn va chm mnh hoc do cc tai nn giao thng, tai nn lao ng v tai nn sinh hot. Ngoi ra cn do cc vt thng ho kh nh n bn, mnh bom mn, Vit nam cn do sc vt hc. V nn s lm cho dch no tu chy ra tai hay ra mi cng c th coi l mt vt thng s no, tuy da u khng c tn thng, c trn phim Xquang ch thy 1 ng v xng n gin. Vt thng s no c nguy c nhim khun do vi khun xm nhp vo dch no tu v nhu m no gy vim mng no v p xe no khc vi chn thng s no kn, nguy c chnh l chn p no do mu t. V vy n l nguyn nhn chnh gy t vong v cc di chng nng n. Ch nh m cng sm cng tt (nht l trong 6 gi u) trnh nguy c nhim khun v x tr ng nguyn tc trnh cc bin chng. Phng tin cn thit x tr l dao in v my ht, loi trang b ny kh khn cho bnh vin tuyn c s. V vy nu khng c iu kin th chuyn bnh nhn sm ti ni c kh nng phu thut.

Thng tn gii phu:

Cc hnh thi vt thng:

Vt thng cht: C l vo, khng c l ra.

Thng do ho kh. Vt thng ngoi da nh. Thng tn no khng ln. Lm sng ch yu l dch no tu chy ra ngoi, c th c mu t ni s.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi Vt thng xuyn: C l vo, c l ra.
L vo: Kch thc nh, thng tn gii phu bnh l phc tp, c ng hm no dp, c th c d vt v t chc no. L ra: kch thc rng hn l vo, vng thng tn no t hn l vo. t chc d vt c th bn ra ngoi vt thng.

Vt thng kn o: T xa ( mt, c) i ln.

Thng tn gii phu bnh:
Ly vt thng s no bn cu no lm v d s thy cc thng tn t ngoi vo trong:

Da u:
Rch da gn sch hoc dp nt, nham nh, bn. Kch thc: tu thuocj vo nguyn nhn, c th rt nh ch

gy chy mu, sy xt da u, c th ln qua t chc no n ra.

Xng s (ch yu l vm s):

Vt v ca xng thng rng hn vt rch da. Hnh thi v:
+ V km theo c ng rn nh hnh chn chim. + V vn: c cc mnh su trong no, ci vo phn di xng b sp, rch xoang tnh mch no, c th ko theo c da v tc vo trong t chc no.

Mng no:
Thng, rch gn, rch x hnh chn chim hoc dp nt. Din rch mng cng:
+ Bnh thng: nh hn din xng v v din no b tn thng pha di. + Trng hp m no li ra ngoi vt thng: mng no b x rng thm ra v dnh vo mp vt thng (xng v).

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi Nhu m no:

Dp no tu mc , thng gim dn v pha trong no. C th c d vt (tc, t ct mnh xng ln) l nguyn nhn thun li cho nhim khun sau ny. Tn thng c xu hng hnh phu vi y quay ra ngoi (do lc tc ng gim dn t ngoi vo), y ca tn thng c th ti no tht gy chy mu no tht, hoc lm cho t chc no vo gy tc no tht, dch no tu. Hoc tn thng no kiu ng hm (do ho kh). Tnh cht no dp:
+ Li ngay ra pha ngoi nu vt thng rng. + Hoc dn dn phi ra ngoi khi c hin tng ph no, mu t trong no km theo.

Nu l vt thng do ho kh th c th to 1 ng hm t ngoi vo trong theo ng i ca mnh n. Mch mu:

Thng b thng tn ni va p. Nu vt thng nm trn ng i ca xoang tnh mch th c th c vt thng xoang gy mu t km. Mch mu no thng b t ti ch t chc no b dp nt: t mch nh chy mu khng ng k, t mch ln c th gy t mu km theo.

Nguyn c Thng Y6B7: cng n thi bc s ni tr Ngoi No tht: Nu thng tn su c th thng vi no tht gy chy mu no tht, tin lng nng. Cc hnh thi lm sng:
Vt thng s no vm s:

Nh: Ch c dch no tu chy ra hoc rch da u c mnh xng ln lm rch mng no. Ln: C th thy no li ra ngoi.
Vt thng thu no t nn s ln: thng ch c r dch no tu qua vt thng. Vt thng vo nhng vng c bit:

Vo cc xoang tnh mch (xoang tnh mch dc trn: vt thng trn ng i ca xoang tnh mch t gc trn mi pha trc n chm ngoi pha sau) d c nguy c chy mu d di, dn n t vong ( khi m cn chun b tt v gy m hi sc, phu thut vin v vt liu v xoang). Vt thng s no vng hi lu Hrophilie: chm ngoi, rt nng, t l t vong cao. Vt thng vo xoang hi trn: Thng vt thng s no vng trn trc, pha trong 2 cung lng my, cn ch n trn h mt v nhng thng tn nhn cu v sau nhn cu (v nhn cu, t mu sau nhn cu). Nguy c nhim khun ln.
Vt thng do ho kh:

Vt thng xuyn: l vo nh, l ra rng, nt. C ng hm trong no gy chy mu v tn thng no nng. Vt thng cht: ch c l vo.
Trng hp d vt ln nng c th ly d vt ngay khi m. Trng hp d vt nh:

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

+ n thun: coi nh 1 chn thng s no kn, iu tr khng sinh, theo di, khng nn ly d vt. + Gy mu t ni s: Coi nh 1 cp cu trong chn thng s no kn.

Vit nam cn gp thm vt thng s no do sc vt hc: vt thng s no do tru hc, nga : thng n mun (3 5 ngy), c nm no, vim mng no nng, cn iu tr vim mng no n nh sau mi m. Nu m cn trit (v mng no, che kn da u nu thiu da)

Chn on:
Mt vt thng s no chn on khng kh, nu ta ngh n ngay khi gp 1 vt thng ang chy mu km theo dch no tu v cht no trng l ra ngoi. Nu ch c vt thng da u, d rng hay hp, d chy mu hay khng chy mu vn phi ngh n vt thng s no trnh b st thng tn bn trong trc khi cm mu da u. Cn xc nh vt thng s no gi th my, vt thng gn sch hay dp nt, vng no, bn cu (trn, nh chm) hay h sau.

i vi nhng vt thng s no ln:

Bnh nhn n sm(< 6h):

Ton thn: + Thng tnh to, tri gic nh gi theo thang im Glasgow, + C th ht hong, lo s hoc trong tnh trng chong khi vt thng rng, chy nhiu mu hoc a chn thng. + C th l m, hn m do dp no v mu t n s. + Khng st, c mm. + c th c triu chng thn kinh khu tr: lit na ngi, ri lon ngn ng. Ti ch vt thng: + Vt thng gn sch, khng dp nt , cn ang chy mu hay ngng. Cn xc nh vt thng vng no (bn cu no hay h sau). + Nc no tu hoc t chc no li ra: Long, khng ong, chy lin tc, mu hng, thm gc thy loang nh vt du. Cc du hiu sinh tn khc: thng t c thay i, trong a chn thng c thay i r.

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

Cn lm sng: Chp s thng thng, nghing nh gi tn thng xng s v d vt. Khng cn chp CT.

n mun (24 48 h): Thng c biu hin nhim khun tu mc :

- Ton thn: + Hi chng nhim khun (vim mng no): st cao > 38,5C, mi kh, li bn. + C th c hi chng nhim c: m sng, gy st. + Tnh trng tri gic km, hn m. + Biu hin hi chng mng no: nn vt, c cng, du hiu Kernig (+). Ti ch: vt thng bn, khng cn chy mu, mi hi, c dch c hoc t chc no n ra ngoi, nu n mun 3 5 ngy c th no li ra vt thng c th gi mc ph bn ngoi (nm no). Triu chng thn kinh: Tu v tr tn thng (vng trn nh, chm, thi dng ) dn n lit 1/2 ngi (nu chn vo b thp) tm phn x gn xng, du hiu Babinski, ri lon ngn ng (vng Broca, Wernik). Ri lon tm thn. ng kinh (cc b, ton th). Cn lm sng: + Cc xt nghim mu, sinh ho, s lng bch cu, tc mu lng + Chc d tu sng: nh gi tnh trng vim mng no, nui cy vi khun lm khng sinh . + Xquang s thng thng nghing: nh gi tn thng xng v d vt (nht l do mnh kim loi). + CT: Rt cn thit nh gi cc thng tn trong s nh km theo mu t, dp no cc vng chc nng, mc chn p no tin hnh phu thut, trnh b st thng tn

i vi nhng vt thng s no nh:

1) n sm (trc 6h):

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

Tnh to. Cn kim tra k: vt thng, nhng thng tn trong no km

theo (mu t..). Theo di nh trong chn thng s no kn. 2) n mun: Hi chng nhim khun. Hi chng mng no. Nu c khong tnh phi ngh ngay ti mu t ni s.

Cn lm sng:
1. Xquang s: T th: thng, nghing (phi, tri), tip tuyn. Mc ch:

+ nh gi thng tn xng s. + Tm d vt. + Xc nh hng i ca d vt, qua nh gi su ca thng tn. 2. CT scanner s: Mc ch: nh gi thng tn ton din ca hp s v nhu Hnh nh: tn thng xng, xng vn trong no, dp no v m no. mu t phi hp, d vt, kh trong s, hnh nh p xe. 3. Cc xt nghim mu, sinh ho, s lng bch cu, tc mu lng 4. Ly dch m vt thng cy lm khng sinh . 5. Chc d tu sng: Ch nh: n mun, c du hiu vim mng no. V tr: khe lin t 4 5. nh gi tnh trng vim mng no: nc no tu c, protein Nui cy vi khun lm khng sinh . Gip cho chn on l vim mng no hay p xe no.

tng, nhiu t bo bch cu.

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

1. Vt thng s no ln: Nu khng c s cu kp thi v iu tr ng nguyn tc t u s gy vim mng no, p xe no, t l t vong cao. 2. i vi vt thng s no nh: Nu d nc no tu lu ngy cng s gy vim mng no, ap Bin chng c th xy ra: xe no. + Cp tnh: mu t ni s. + Lu di: ti phng ng mch no, ti phng thng ng tnh mch.

Nguyn tc iu tr:
1. S cu: 1) Khng nn: Ra trc tip vt thng. Ra vt thng bng thuc st khun. Rc, ra khng sinh trn b mt vt thng (gy ng kinh, Thm d vt thng bng dng c cng. Bng p cht vt thng. Ly d vt (c th lm chy mu th pht do d vt x th Gt b hoc p cht no phi ra vo trong (nguy c nhim Dng thuc gim au ton thn v nguy c gy suy h hp

nc chy vo nhu m no)

ang tn th tbt kn mch thay xoang tnh mch tn thng) khun v chy mu). hoc phng c mu t trong no km theo. 2) Nn: Chng shock. m bo h hp thng sut, chng suy h hp nu c. Ct tc cng rng cng tt (gim nhim khun), c th co St trng quanh mp vt thung t trong ra ngoi. Ra xung

trc. quanh vt thng bng huyt thanh sinh l.

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

Bng v khun vt thng: Bng nh tay, nu c t chc no li ra th dng d vt thch hp (chn, bt) p chp ln vt thng ri bng li vn chuyn Khng sinh ton thn. SAT. Theo di tri gic st. Chuyn bnh nhn i sm n ni phu thut.

2. iu tri thc th: Nn m sm (trong vng 24 h), coi nh cp cu tr hon, khng nh mu t trong chn thng s no kn. 1) i vi vt thng s no n sm: Nguyn tc: + M ngay cng sm cng tt. + Chun b trc m: khng sinh, SAT. + C th gy t tu sng hoc gy m. Rch rng vt thng da u, ch ct lc tit kim. Tch mng xng. Ly xng v nht l cc mnh ri, nu cn gm rng xng M rng mng no, ct lc mng no tit kim Ti vt thng ch yu ht no dp, ly mu t v d vt (x-

n phn xng lnh.

ng, da, tc). i vi mnh ho kh nng nu khng phi tm kim kh khn th ly b, nu kh tm th li. Bm ra vi p lc mnh (t chc no nt b y ra, t chc no lnh cn nguyn). Ht t chc no dp (ht cho ti khi no bt u c chy mu ra l c. Nu st t chc no dp: nhim khun. Nu vo no tht: cho sonde Nlaton vo bm ra nc mui sinh l lm sch no tht cho ti khi trong, lu li sonde (24 48h) theo di tnh trng no tht. Cm mu: t bng dao in, nu khng c th dng clip bc. Nu rch xoang tnh mch: C th dng ngn tay tm thi bt li cm mu tm thi. Sau ct c (thng l c thi dng) gi nhuyn p vo xoang cm mu.

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

Khng ng kn mng no. ng kn da, t dn lu ra ngoi (nu da b ct nhiu, khi

ng ai c tnh trng qu cng hoc khng : Rch da vng bn cnh, ko da trt trn cn Galea ng kn vt thng) 1) n mun: Chng nhim khun (khng sinh), hi sc tt, m sau. Thay bang vt thng. Lc m ra hnh thnh ap _ xe : Ly ra d hn ( c M : th t nh n sm : V khun, ct lc t ngoi vo Khng khu kn mng no, khu da che vt thng. Vt thng xoang hi trn: No sch xoang hi trn (do xoang

khi). trong. 2) Th c bit: hi c nim mc ph nn nguy c nhim khun cao). Cm mu thnh xoang bng sp ong. V mng no. C th lp y xoang bng c. Vt thng xoang tnh mch: + Tht (xoang dc trn): 1/3 trc tht khng hi, 1/3 gia tht nng hn, 1/3 sau tht ph no. Khng c tht hi lu Hrophilie. + V: c thi dng gi nhuyn p vo xoang cm mu. Vt thng hc mt: Nu v: b nhn cu. V mng cng. Vt thng xuyn: X l ch yu ng vo quan trng hn

+ L vo nh, tnh to, khng nhim khun: Ch cn theo di: Mu t, ap xe no v cho khng sinh. + M, khong tnh: X tr ly mu t cp cu. + Mnh kim loi chui qua h mt, xoang trn, xoang sng: nn m do nguy c nhim khun. 3. Sau m : Ti vt m: Hn ch thay bng nu vt m kh. Chng nhim khun: khng sinh theo khng sinh . Chng ph no: thng kh tt, O2, Mnnitol, lasix.

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

Rt dn lu sau 24 48h. Nng cao th trng bnh nhn. Nui dng qua sonde v tnh Chng lot nu m. V sinh rng ming, chng nhim khun h hp. Theo di: mu t, vim mng no, p xe no. Phc hi chc nng sm.

mch nu m.

4. Bin chng, di chng: Nhiu hn CTSN kn do tn thng nhu m no: thng ch gp vi vt thng ln v hoc khng c x tr sm, ng. 1) Bin chng: Vim mng no. Ap xe no. Vim xng s. Lit, tht ngn. Ri lon tm thn. i sng thc vt.

2) Di chng:

Mu t trong no
Nguyn nhn: Do cc dp no gy chy mu nhu m no, thng vng bao trong, c khi n thng vi no tht gy chy mu no tht. Lm sng : Bnh nhn m ngay sau tai nn, cc triu chng v huyt ng, v h hp thng nng. Trc tin phi x tr ri lon h hp nh t ni kh qun ht m di, nu cn phi m kh qun. Chn on hnh nh:Chp ct lp vi tnh cho thy hnh nh no dp, t trng khng u, c mu t trong nhu m no, nhiu v tr khc nhau nh thi dng trn, thi dng nn, vng bao trong, vng nhn xm trung ng v. v

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

iu tr : Tin lng nng nn xu hng thng iu tr khng m. Tuy nhin cn theo di v tri gic v chp ct lp vi tnh kim tra, nu tri gic xu i, chp ct lp thy thng tn tin trin cn m sm dn lu mu t, gii to chn p no.

Mu t ngoi mng cng

II. i cng: 1. Mu t ngoi mng cng l loi mu t nm gia xng s v mng cng. 2. Mu t ngoi mng cng l loi mu t ti cp (thng t 6 12 gi sau chn thng), khi mu t nm gia lp xng v mng no. 3. Phn ln c th chn on d dng qua thm khm 4. Tin lng tt nu m sm, x l kp thi. Ngc li bnh nhn c th b t vong nhanh chng nu khng c chn on v x tr kp thi. III. Nguyn nhn: 1. Ch yu do ng v xng s hoc ln xng lm t cc nhnh ca ng mch mng no gia i st vo mt trong xng s, thng hay gp vng thi dng (60%). 2. Do chy mu t lp xng xp hoc thng tn xoang tnh mch do mnh xng v hoc ln cm vo, c th gy mu t c 2 bn. 3. Tn thng xoang tnh mch v cc mch vo xoang. 4. Chy mu ht Pachioni hay hi lu Herophilie. IV. V. VI. VII. Sinh l bnh tng p lc ni s Hu qu tng p lc ni s Chn on: Cc th lm sng c bit: C hnh nh lm sng ging nh hi chng chy mu trong 1. Mu t ngoi mng cng tr em. kh r v lng mu t l ng k so vi lng mu ca c th.

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

1 s trng hp : + Tr gi c bnh n tri gic tri gic trong 1 thi gian. + Tr thng nm nh ng nhng khi tri gic thay i th suy gim rt nhanh. 2. Mu t ngoi mng cng ngi gi: 3. Mu t ngoi mng cng th vm s: Do mu chy trong xoang tnh mch dc Chp ng mch no :

+ thuc cn quang thot ra ngoi mch no. + C bc tch xoang tnh mch khi xng s. 4. Mu t ngoi mng cng vng chm: Chn on khi c ng v xng nghi ng tn thng xoang tnh mch bn, i khi c phi hp mu t di lu. 5. Mu t ngoi mng cng h sau: VIII. D b st. Ngun chy mu: v xng chm, tn thng xoang tnh mch Din bin rt nhanh (ti cp) hoc bn cp vi cc du hiu iu tr:

bn, tn thng hi lu Herophilie. sm ca ri lon thn kinh thc vt trc khi c suy tri gic. 1. Ch nh m cp cu: 1) C khong tnh. 2) Xquang quy c c ng v xng vng thi dng hoc chp ct lp vi tnh thy c hnh thu knh hai mt li. 3) Nu xut hin gin ng t 1 bn v lit na ngi bn i din l giai on mun, tin lng nng. 4) Ch : Nu Glasgow > 8 im c th chuyn v tuyn trung ng, Nu glasgow 8 im, vn chuyn s nguy him, nu cn nu vn chuyn khng qu 3 gi. m ti a phng. 2. Nhng nguyn tc chnh m mu t ngoi mng cng:

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

1) M hp s nu chp ct lp vi tnh hoc khoan thm d nu khng c chp ct lp vi tnh. 2) Ly mu t ngoi mng cng. 3) Kim tra di mng cng xem c t mu hoc dp no di. 4) Dn lu ngoi mng cng. 5) t li xng s v ng vt m 2 lp: lp cn Gala, lp da u. 3. Sau m Chng ph no tch cc. Khng sinh ton thn. Theo di sau m:

+ Theo di dn lu v rt sau 24 - 48 gi + Theo di tri gic v cc du hiu thn kinh khu tr (gin ng t cng bn, lit na ngi bn i din) pht hin mu t ti pht. + Theo di cc bin chng nhim khun. 4. nh gi kt qu sau m: Da vo bng Glasgow Outcome Scale gm 5 im nh sau: + Kt qu tt : Tr li cuc sng gia nh v x hi. + Trung bnh : T ch trong cuc sng, thay i ngh khc hoc b ngh. + Kt qu xu : Sng ph thuc vo ngi khc. + i sng thc vt. + T vong.

X tr mu t di mng cng
IX. i cng: 1. Mu t di mng cng l khi mu t nm gia mng cng v mng nhn. 2. Gm 3 loi: cp tnh, bn cp v mn tnh. 3. Thng km theo dp no, ph no l cc thng tn nng v kh iu tr.

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

X. Nguyn nhn: 1. Do sang chn lm t cc tnh mch cu ni t v no n mng no hoc ng dp lm chy mu cc tnh mch v no thng km theo cc dp no khu tr hoc lan to. 2. Mu t di mng cng mn tnh do mu lng ng thnh dch mu nu sm c bc trong 1 lp v gy chn p no t t, giai on u thng khng c biu hin lm sng. XI. Chn on: 1. Mu t di mng cng cp tnh xut hin trong 72 gi u. Thng km theo 1 vng no b gip. Nn nhn m su v nhanh sau 1 sang chn nng. C lit na ngi v c gin ng t 1 bn. Cn co cng mt no thng xut hin km theo ri lon nhp th. Loi ny thng phi hp vi nhiu loi tn thng khc no X tr: M ly mu t v ht no dp. Sau m cn iu tr tch cc chng ph no. Do chn thng (dp no, ph no) nn tin lng nng.

no trc tip nn no b ph, ngha l nc, ban u khoang ngoi t bo. Ph no c th l hu qu gin tip, v thm thu cc mao mch no tng thm. Ph no c th khu tr 1 thu, 1 bn cu hay ton b no: iu tr bng dung dch Mannitol. Lasix. Dexamethsone. C th dng my th lm gim ph no. 2. Mu t di mng cng bn cp xut hin t 3 21 ngy: 1) Bnh nhn ku nhc u, bun nn, ngi chm chp, l ln. 2) n khm thy ph n gai mt, lit nh na ngi, chp ng mch no c di lch. 3) Tin lng sau m tt. 3. Mu t di mng cng mn tnh: xut hin t tun l th 3 tr i sau 1 sang chn nh (c khi ngi bnh khng nh r): 1) Chy mu khng nhiu lm bt u t vng thi dng nh, hnh thnh 1 bc gm l thnh dy, c nhiu mch mu tn to, nhiu si huyt v bch cu, l tng mng hn c th

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

bc d dng khi v no di. Bao ny mu vng a trong cha nc mu pha ln nc no tu ng mu v tin trin lu ngy. 2) Trn lm sng thng c hi chng tng p lc ni s sau 1 chn thng: au u, ph n gai mt, lit nh na ngi, ri lon tnh tnh. 3) Chp ng mch no thy c hnh nh c bit l c vng v mch hnh thu knh rt r. 4) Khi m : ch cn khoan 1 l vng nh thi dng dn lu mu t long, khng cn m hp s. Phu thut nh nhng, khng tn mu, khng c t vong. 4. Mu t di mng cng tr s sinh: 1) t khi pht hin c 1 chn thng trong tin s, c th b sang chn s no trong khi hay sau vim mng no, hay thiu vitamin K. 2) Trn lm sng thng gp tr c u to ( thp cha kn, vng u tng ln) km 1 tnh trng thiu mu. 3) X tr : chc ht bng kim nh gc ngoi thp trc XII. X tr: Nguyn nhn: Ch nh ngoi khoa:

+ Tri gic xu dn (khong tnh khng r) + Chp ct lp vi tnh c hnh nh khi mu t hnh lim lan to c bn cu, gim t trng Nguyn tc m: c 1 s im khc vi m mu t ngoi mng cng: + Nn m hp s (Volet) gii to no v tin hnh x tr trit thng tn di mng cng nh ly mu t, cm mu, ht no dp. + Nu ph nh, no p tt c th ng mng no, t li mnh xng s. + Nu ph nng, no p yu, khng nn ng mng no (nu cn ch khu nh hoc nu c iu kin th to hnh no,

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

mnh xng di da bng (h chu tri) hoc gi bo qun ngn hng m. Tin lng: + Thng nng do ph no. + Nu tri gic km nn chp ct lp vi tnh kim tra c thi x tr. i vi mu t di mng cng mn tnh: + Gy t ti ch bng Xylocaine 1%, khoan 1 l vng thi dng nh (bu nh) bn bn cu no c mu t, m mng no, ht nc mu mu nu sm, c khi c qunh. t 1 ng sonde Nlaton, bm ra bng huyt thanh sinh l, rt dn lu sau 48 h. + Tin lng tt, ngi bnh tr li sinh hot bnh thng.

Chn thng s no kn
XIII. i cng: 1. Chn thng s no l nhng thng tch hp s do nhiu nguyn nhn khc nhau nh tai nn giao thng, tai nn sinh hot v tai nn lao ng. Trong hon cnh nc ta hin nay th ch yu do tai nn giao thng ng b(72%, bnh vin Vit c 2003). 2. i vi ngi thy thuc thc hnh cn phn bit 2 loi: chn thng s no v vt thng s no c hng v thi x tr ng. 3. Chn thng s no kn l chn thng s no nhiu khi khng c biu hin bn ngoi, nhiu khi da u b rch, xng s v nhng khng gy rch mng cng, khng c thng thng trc tip dch no tu v m no vi mi trng bn ngoi. 4. T l t vong cao, li nhiu di chng nng n cho gia nh v x hi. 5. Kt qu iu tr chn thng s no ph thuc phn ln vo thi x tr cp cu ban u, nht l i vi chn thng s no nng.

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

6. Trong cc loi thng tn do chn thng s no th mu t ngoi mng cng l loi thng tn c tin lng tt, nu c Chn on v x tr kp thi. 7. iu quan trng nht trong chn thng s no kn l pht hin sm khi mu t trong hp s gy chn p no cp tnh, x tr kp thi mi hy vng cu sng c bnh nhn. 8. Theo di pht hin mu t trong chn thng s no kn l 1 cp cu ngoi khoa i hi ngi thy thuc thc hnh no cng phi bit chn on v x tr hoc chuyn ln tuyn trn kp thi mi hy vng gim c t l t vong. 9. Trc y t l t vong do chn thng s no chim 60% cc t vong do tai nn. Ngy nay vic tin b trong chn on hnh nh (CT scanner) v trong gy m hi sc lm cho t l t vong gim i nhiu. 10. Hai trng hp ch nh m cp cu: 1) Mu t trong hp s. 2) Ln xng s. XIV. Sinh bnh hc trong tng p lc ni s do chn thng. Theo nh ngha tng p lc ni s l p lc trung bnh o c trong dch no tu t th nm nghing trn 20 mmHg. Bnh thng p lc ni s l 10mmHg. 1. c im gii phu, sinh l: 1) Hp s c coi nh 1 khoang kn khng gin n. Mi hin tng lm thay i cc thnh phn cha trong hp s u gy nn tnh trng tng p lc ni s. 2) No b c chia thnh 3 khu vc: Nhu m no, dch no tu v mch mu. Vic duy tr c p Th tch mu + Th tch dch no tu + Th tch no = Hng s Nu tng th tch mt trong cc khu vc trn s nh hng n cc khu vc khc. Nhu m no l mt t chc mm v n hi, c th bin dng nhng khng nn p c. Ch c khu vc lc ni s bnh thng da vo cng thc sau:

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

dch no tu v mch mu c th gim th tch nh dch no tu c th dch chuyn xung di tu sng, tnh mch xp li. 3) Ngi ta cho rng mu v dch no tu l h thng gim sc cho php trong mt thi gian nht nh, vic tng th tch 1 trong 3 khu vc trn nh s pht trin ca 1 khi chon ch (mu t) khng gy tng p lc ni s, l giai on b tr. Nu s b tr ny mt i s dn n hin tng tng p lc ni s. l thuyt Monro-Kellie. 2. Nguyn nhn tng p lc ni s l mu t trong s, ph no v ri lon vn mch. Tng p lc ni s l mt bin chng nguy him, e do tnh mng bnh nhn. 3. Hu qu ca tng p lc ni s: 1) Tng p lc ni s lm gim hoc ngng p lc ti mu no, gy thiu mu no. Lu lng dng ti mu no bng 15% lu lng tim (50ml/100g no/pht). S thiu mu no s gy ra phn x khng (phn x Cushing): l s bi tit Catecholamine lm tng huyt p ng mch v ti lp trong thi gian ngn lu lng mu no, nhng trong mt mng li mch mu mt kh nng t iu ho lu lng mu ny s gy tng th tch mu no vi mc cao hn p lc ni s. Mt khc tnh trng toan ho do thiu mu gy gin mch v tng tnh thm thnh mch gy ph no li tng p lc ni s. 2) Do tnh cht n hi ca t chc no khi c s chnh lch p lc trong s, cc cun no c th di chuyn gy hin tng tt kt vo cc khe trong hp s. C 4 loi tt kt: XV. Hi th trai tt di b t do ca lim no. Hi hi m tt vo khe Bichat. Hnh nhn tiu no vo l chm. Tt kt trung tm do no gia b y xung thp. Cc thng tn gii phu:

1. Thng tn nguyn pht: xy ra ngay ti thi im chn thng v do tc nhn chn thng gy ra.

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

1) Da u: Bnh thng hoc bm tm, xy st, t mu di da hoc rch da u rng l xng s. 2) Hp s: a. Vm s: bnh thng hoc rn nt, v, ln. V xng vng thi dng lm t ng mch mng no gia gy mu t ngoi mng cng. Xng s ln su vo trong gy p mng no cng, dp no ni xng ln, rch v xoang tnh mch gy t mu ngoi mng cng. b. Nn s: ng dp mnh mi nt v thng do chn thng trc tip hoc v xng vm s lan xung nn s. Cc du hiu: V tng trc nn s: ng v c th i qua: + Trn hc mt: mu t quanh h mt (du hiu eo knh rm). + ng th gic: lit thn kinh 2. + Xoang hi trn: d nhim khun. + Xoang sng: Chy mu v dch no tu qua mi, + Cnh xng bm: Lit thn kinh vn nhn (on vo khe bm) V tng s gia: v xng : + Chy mu tai. + Lit mt do tn thng dy VII. + ic do tn thng dy VIII. V tng sau nn s: him gp. 3) Thng tn trong hp s: a. Chn ng no: Khng c tn thng thc th: No v h thng no tht b rung ng trong hp s h thng tun hon no thay i vn mchThiu mu tm thi t bo nothiu O2 nom ngay t u~ 10 15 phttnh li hon ton v khng nh s vic xy ra. b. Dp no: Cc triu chng xut hin ngay sau khi ng. Thng bn i din vi tn thng. Nhiu mc : Nh: ng dp bm tm mt ngoi v no hoc dp 1 phn t chc no. Lm sng c th vn tnh to. Bnh nhn c th qua khi nhng thng li di chng (ng kinh, tm thn)

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

Nng: dp nt nhiu t chc no, thng gy thm ph no: t vong. c. Chy mu mng mm, i khi km chy mu no tht. Chy mu khoang gia mng nhn v mng nui. Chy mu mng mm gy co tht mch mu no, hu qu l thiu mu nui v ph no. 2. Thng tn th pht: l nhng thng tn xut hin bt k thi im no sau tai nn. N thng l bin chng ca cc thng tn tin pht. 1) Mu t: Cc triu chng khng xut hin ngay sau khi ng. a. Mu t ngoi mng cng: L khi mu t nm mt trong s v mt ngoi mng Ngun chy mu do: cng. + t ng mch mng no gia (i qua l trn b): l ng mch nm st xng s, c th t bt c lc no do 1 ng v xng i ngang qua vng thi dng. + Tn thng tnh mch: rch xoang tnh mch no hoc tn thng cc ht Pachioni 2 bn xoang tnh mch dc bn. + V lp xng xp hp s. V tr: hay gp vng thi dng nh, t gp hn l vng Mc to nhanh chm ph thuc mc tn thng mch trn, chm v h sau. mu. b. Mu t DMC: L khi mu t nm mt gia mng cng v mng nhn. Ngun mu chy:

+ t tnh mch i t v no v xoang. + V cc tnh mch ca v no (thng c dp no km theo). Tnh cht: thng lan to theo khoang di nhn, chy t t nn c thi gian cho no thch nghi nn t c triu chng thn kinh (au u, ri lon tinh thn). Nu khng m, ph no tng s

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

dn n thot v no do tt hnh nhn tiu no. Mu t l nc mu, t khi ng cc nh mu t ngoi mng cng. Phn loi: + Mu t di mng cng cp tnh: Thng km theo 1 vng no b gip. Bnh nhn m su nhanh, lit na ngi, dn ng t 1 bn, co cng mt no, ri lon nhp th. Tin lng nng. + Mu t di mng cng bn cp: Sau 1 chn thng nh 2 3 tun sau mi biu hin triu chng. Bnh nhn nhc u, bun nn, chm chp l ln, ph gai th, lit nh na ngi. Tin lng sau m tt. + Mu t di mng cng mn tnh: Din bin vi tun n vi thng sau chn thng. Thng l 1 bao gm nhiu mch mu tn to, nhiu t huyt v bch cu bao quanh nc mu pha ln nc no tu ng mu nu do thng tn lu ngy. Trn lm sng c ri lon tinh thn, lit nh na ngi, ph gai th tng dn. + Mu t di mng cng tr s sinh: Do chn thng s no khi , sau vim mng no, hoc do thiu vitamin K. Lm sng: Tr u to (thp cha kn) v thiu mu. X tr: chc ht kim nh trc tip qua da gc ngoi thp trc. c. Mu t trong no: Thng km theo dp no, ph no. Nguyn nhn: no dp lm tn thng cc mch mu trong t C th chy vo no tht nu gn no tht. Chn on kh, tin lng nng, nhiu di chng.

chc no.

2) Ph no: l hu qu ca nhiu loi thng tn, do nhiu c ch khc nhau. Thng tn ban u

V hng ro mu no

Thiu mu, Thiu oxy

Chy mu

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

Gii phng hormon

Ri lon vi tun hon

Thng tn t bo

Lit mch, co tht, huyt khi

Ph vn mch (ngoi t bo)

Ph nhim c (trong t bo)

Mun khc phc tnh trng ph nhim c t bo phi chuyn c nc tch t qu nhiu bn trong t bo a ra ngoi khong k ri vo trong cc mao mch, t o thi ra ngoi c th. i. Lm sng: Thng tn sau chn thng s no l thng tn phi hp, lm sng phc tp, chn on kh khn. Chn on ch yu da vo din bin ca triu chng qua vic theo di st bnh nhn, vi mc ch chnh l pht hin mu t trong hp s, biu hin trn lm sng l: cc du hiu thn kinh thc vt, tri gic v thn kinh khu tr. 3. Hi bnh: 1) C ch ng: u c nh: vt cng p vo u: tn thng trc tip u di ng: u p vo vt cng: tn thng i din vi ni b chn thng. bn chn thng. 2) Din bin tri gic ngay sau chn thng l quan trng nht. Chn ng no: khm hin ti tnh hon ton, qun ht din Khong tnh: sau chn thng bnh nhn tnh, sau li M ngay t u. bin tai nn. hn m: gi mu t ni s.

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

3) Khai thc tin s ng kinh, cao huyt p, x tr trc vo vin, ung bia ru 4. Khm cc du hiu sinh tn hay thn kinh thc vt: Cc du hiu sinh tn hay thn kinh thc vt c gi tr tin lng: Mch gim( 50), huyt p tng, h hp tng, nhit tng. Nu c cc du hiu ny: tin lng xu. 5. Khm tri gic: 1) nh gi mc ri lon tri gic theo 4 kinh in: 1: Ri lon tri gic hiu bit, cn tri gic t ng v bn 2: Ri lon tri gic hiu bit v tri gic t ng v bn 3: Co cng mt no. 4: Cht no, mt ht cc phn x. nng. nng.

2) nh gi tri gic theo thang im Glasgow: Da vo 3 du hiu sau cho im: Mt: ti a 4 im. + M t nhin: 4 im + Gi m: 3 im + Cu m: 2 im. + Khng m: 1 im. Tr li: Ti a 5 im. + Tr li ng: 5 im. + Tr li ln ln: 4 im. + Khng r ni g: 3 im. + Ku rn: 2 im. + Khng ni: 1 im. Vn ng: Ti a 6 im: + Bo lm ng: 6 im. + Cu gt ng: 5 im. + Cu gt khng ng: 4 im. + Gp cng chi trn: 3 im. + Dui cng chi trn, chi di: 2 im.

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

+ Khng p ng: 1 im. Thang im Glasgow ti a l 15 im, ti thiu l 3 im. im Glasgow cng cao th tin lng cng tt, cng thp th tin lng cng xu. im Glasgow < 13 c th coi l c tn thng no, > 8 im tin lng tt hn, < 8 im l tin lng nng. Thang im Glasgow khng p dng cho ngi say ru, ri lon im Glasgow h t 2 im tr ln th coi l c tri gic xu tm thn, dng thuc an thn v tr em < 5 tui. i. 3) Pht hin khong tnh: L du hiu lm sng in hnh nht ca mu t ni s, nht l mu t ngoi mng cng. Sau tai nn bnh nhn vn tnh hoc mt tri gic tm thi (15 20 pht) ri tnh li, nhng sau mt thi gian theo di bnh nhn m i, khong thi gian tri gic xu i gi l khong tnh. Khong tnh cng di th tin lng cng tt, khong tnh cng ngn th tin lng cng xu. Khi pht hin c khong tnh th c ch nh m. 4) Nh vy quan trng nht khi khm tri gic l nh gi mu t ni s thng qua mc suy i tri gic, khong tnh kt hp vi cc du hiu au u, nn ngy cng tng (nu bnh nhn tnh). 6. Khm da u v nn s: 1) Da u: Sy st, bm tm, mu t di da u, dp nt, rch. Qua vt rch c th thy:

+ Nc no tu, cht no chy ra: vt thng s no h. + ng v, mnh xng ln (thm khm bng gng v khun). 2) V nn s: Pht hin nhng ng v, ln qua cc du hiu trc tip v gin tip sau: S thy khi mu t di da u. Chy mu mi, bm tm h mt, nn nhiu mu: v tng trc

nn s (ng v thng xung mi hng).

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

Nc no tu chy qua mi, tai: v tng gia nn s (vng xoang Trng hp v xng s vng thi dng cn theo di mu t sng, xng , c rch mng no cng). ngoi mng cng do c kh nng lm t ng mch mng no gia. 7. Khm thn kinh khu tr: Khi c tri gic gim dn, c khong tnh (c mu t trong hp s) th du hiu thn kinh khu tr l du hiu ch im v tr khi chon ch trong hp s. ng t dn cng bn c thng tn: + Do khi mu t p no, dy 3. + Gin t t tng dn. + Mc gin tng dn t l thun vi khi mu t. Lit na ngi i bn vi khi mu t: yu na ngi n lit Du hiu b thp: Babinski (+). i vi mu t di mng cng: na ngi i bn, 1 s trng hp cng bn.

+ Du hiu mng no v v no: au u d di, vt v, dy da, cng gy, co cng, dui cng na ngi. + Trng hp c dp no, mu t n thun: ng kinh cc b. Cc du hiu thn kinh khu tr trn xut hin t t mi c gi tr, nu xut hin ngay th t gi tr. 8. Khm pht hin cc thng tn phi hp v cc bnh l sn c: V. Gy xng tay chn. Chn thng bng. Chn thng lng ngc. Chn thng ct sng. V xng chu Cn lm sng: 1) Loi phim: Thng (trn, chm). Nghing (phi, tri).

1. Xquang thng:

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

Worm-Breton: pht hin v xng chm v tr mai chm, l Nu c xng ln th c th cho bnh nhn chp thm phim chm. tip tuyn. 2) Mc ch: Pht hin ng v xng v hng i ca ng v, c bit xMnh xng ln. ng thi dng v c th gy rch ng mch mng no gia. 2. Chp ng mch no qua ng mch cnh gc: 1) Ch nh: Khi trn lm sng cha r, cn nghi ng mu t: C khong tnh, khng c du hiu nh khu. Tri gic suy i nhng tnh trng m cha qu mc. Ti cc c s xa trung tm, cha c iu kin chp CT.

(Trng hp lm sng r, c th ch nh m ngay ti y t c s, khng cn dng phng php ny cho d khng c CT). 2) V tr chp: C du hiu thn kinh khu tr: Chp bn ng t gin, i Khng c du hiu thn kinh khu tr: da vo tc nhn gy din vi bn lit. chn thng: + u c nh: chp bn c chn thng. + u di ng: chp bn i din bn chn thng. Chp bn c ng v xng. 3) K thut: Bm thuc cn quang qua ng mch cnh chung, st ch chia i cnh trong, cnh ngoi. 4) nh gi kt qu: Hnh nh ng mch no: + Mu t ngoi mng cng, di mng cng: c vng v mch st xng s, y ng mch no gia vo trong v y ng mch no trc sang bn i din (di lch > 5mm). Hoc y ng mch no gia vo trong v khng thay i v tr ng mch no gia (mu t 2 bn).

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

+ Mu t trong no: y cc mch ra xung quanh: ng mch no gia b y st xng s, ng mch no trc b y lch sang bn i din qua ng gia. Hoc y ng mch mng no gia vo trong v khng thay i v tr ng mch no trc (mu t 2 bn). Hnh nh khi mu t: trong lng khi mu t thng khng c mch nhng i khi c ng thuc cn quang trong lng khi mu t do c mch mu b v. Nh vy chp ng mch ch cho bit gin tip thay i ng mch no v khng phn bit c mu t NMC vi mu t DMC. 3. CT scanner s: 1) y l phng php chn on c sm, chnh xc, cho bit c v tr, kch thc, hnh nh tng loi mu t ngay c khi cha c triu chng lm sng in hnh, cho php ch nh phu thut sm cho bnh nhn. 2) Chun b bnh nhn trc chp: Nu bnh nhn c vt v, ri lon h hp: t ni kh qun, an thn chp t kt qu tt. 3) Ch nh: Ngi gi, tr em (do kh nh gi c im Glasgow). Xquang c ng rn xng s. C du hiu thn kinh khu tr. Tri gic xu dn. au u ngy cng tng (vi mu t mn tnh: sau khi ng

bnh nhn c th ch c au u nh tng dn trong mt khong thi gian vi tun ti vi thng). L tng nht l mi bnh nhn sau khi b chn thng s no. Bnh nhn hn m su. Bnh nhn khng cn cc phn x. Khng t th. 4) Chng ch nh:

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

5) Thi im chp l rt quan trng, c th phi chp nhiu ln, sau chp phi theo di bnh nhn cn thn v cho bnh nhn chp li bt c khi no c triu chng nghi ng. 6) Kt qu: Du hiu trc tip: + Tn thng hp s. + Mu t ngoi mng cng: khi tng t trng hnh thu knh 2 mt li st xng s, gii hn r. + Mu t di mng cng: khi tng t trng hnh li lim, ngoi t chc no, nm st xng s (c hnh rng ca ranh gii gia nhu m no lnh v khi mu t l do khi mu t chn p vo cc cun no). + Mu t trong no: khi tng t trng nm trong nhu m no, b khng u. + Dp no: hnh t mu ri rc, quanh t chc no dp c hin tng ph n. Hnh nh gin tip: + H thng no tht: B y lch sang bn i din. Khng i xng. Khng ng dng. + ng gia: y lch sang bn i din. + Ph no. Cc thng tn phi hp: cc thng tn mt, rng hm mt 4. o p lc trong s: c th o ngoi mng cng, di mng cng, trong no tht. Chnh xc nht l o p lc trong no tht, cho php theo di din bin ca p lc ni s c ch nh iu tr (m, khng m). 5. Chp cng hng t: cho kt qu chnh xc nht nhng t tin, cha c p dng Vit nam. VI. Chn on: 1) Chn on mu t trong s: trc 1 bnh nhn chn thng s no phi nhanh chng chn on chnh xc c mu t ni s hay khng, da vo triu chng lm sng:

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

Khong tnh. Lit na ngi bn i din tn thng. Dn ng t cng bn tn thng. Tri gic suy i. Trng hp khng triu chng th theo di st bnh nhn

v ch nh chp CT s. 2. Chn on tn thng xng s: 1) Vm s: Khng c triu chng r rng trn lm sng. Chn on da vo cn lm sng: Xquang s. Khi c ng v vng thi dng, cn theo di st mu t ngoi

mng cng. 2) Nn s: ch yu da vo lm sng: V tng trc nn s: + Chy mu mi, chy nc no tu qua mi (c rch mng no cng). + Mu t phn mm di da quanh hc mt (mt eo knh rm). V tng gia nn s (xng ): + Chy mu tai, chy nc no tu qua tai (km rch mng no cng). + T mu di da vng xng chm km theo lit mt ngoi bin. 3) Chn on no dp: Dp no nh: + Bnh nhn tnh. + C du hiu thn kinh ni no dp. + Lit na ngi ngay khi ng. + Ri lon ngn ng. + ng kinh. Dp no nng: Hn m ngay sau chn thng, m ngy cng Trn CT s: nhiu, t vong. + Trong t chc no dp: c mu t nh ri rc.

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

+ Quanh t chc no dp: no ph n. 4) Chn on ph no: Tt c nhng tn thng trn u c th gy ph no. Ph no c th xut hin cng lc hay sau khi c cc thng tn trn do cn c thi gian huyt tng thot ra ngoi lng mch: cn chng ph no sm. C th ph khu tr hay lan to ton b no, gy hi chng Din bin thng phc tp. Trn lm sng sau chn thng s tng p lc ni s, hn m v t vong. no nu tri gic gim dn, hi chng tng p lc ni s tng dn, loi tr mu t ni s, ngh n ph no. VII. iu tr: 1) X tr ban u tuyn tnh hay khu vc: X tr ban u tt s gip hn ch cc thng tn th pht ca no v lm gim nguy c t vong. Mc ch chnh l d phng thiu mu no. 1) Trng hp bnh nhn tnh: Xquang s thng nghing pht hin ng v xng. Chuyn phng theo di mu t ni s nu nghi ng. Chng ph no:

2) Bnh nhn hn m: + m bo lu thng ng th: ht m di, t bnh nhn t th nm nghing trnh tt li ra sau v trnh sc m di. t ni kh qun, m kh qun, th O2, th my h tr khi cn. + m bo tun hon, duy tr lng mu ln no tt: Truyn dch nc v in gii qua ng tnh mch ngay t u. Gi huyt p mc y v trnh tt huyt p xung. Khu cm mu vt thng da u. t bnh nhn t th u cao 20, c thng (d nm nghing hay nga) gim cn tr mu v tnh mch cnh 2 bn (hn ch ph no do tr tnh mch no). Truyn Mannitol 20% vo tnh mch vi liu 1g/kg trong 20 Dng Lasix khi huyt p tt. 30 pht.

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

t sonde bng quang theo di nc tiu, sonde d dy qua Dng thuc gim au, khng dng thuc an thn khi cn theo C th dng: mi. di. + Thiopental nh git tnh mch bnh nhn nm yn v gim nhu cu tiu th O2 ca no. + Khng dng ng u trng, ch dng mn u trng liu nh nhm: Nng khi lng tun hon, khng gy ph no, gim p lc ni s, tng p lc thm thu. Pht hin kp thi cc du hiu c mu t trong hp s. 2. iu tr thc th: 1) Ch nh phu thut cp cu: i. Mu t ni s. Ln xng s M cp cu khng tr hon. Nhanh chng ly khi mu t. Cm mu ngun chy mu. Trnh mu t ti pht bng khu treo mng cng vo cn K thut m: Khi chn on mu t ni s th m cp cu. Khong tnh r, khng iu kin m: khoan s no gii Sau m, phu thut vin phi t thay bng pht hin mu t

2) i vi mu t ni s:

Gala. 1. Nguyn tc chung:

phng chn p trc khi chuyn ln tuyn trn. ti pht. 3) i vi mu t ngoi mng cng: M hp s nu chp ct lp vi tnh hoc khoan thm d Ly mu t ngoi mng cng. Tm ngun mu chy cm mu. nu khng c chp ct lp vi tnh.

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

Kim tra di mng cng xem c t mu hoc dp no di. Khu treo mng cng vo cn Gala trnh mu t ti pht. Dn lu ngoi mng cng rt sau 24 gi. t li xng s v ng vt m 2 lp: lp cn Gala, lp da

u. 4) i vi mu t di mng cng: a. Th cp tnh(< 72 h) v bn cp (72h 2 tun): Thng km dp no. Ch nh m v k thut nh vi mu t ngoi mng cng, c

1 s dim khc: + Nn m hp s (Volet) gii to no v tin hnh x tr trit thng tn di mng cng nh ly mu t, cm mu, ht no dp. + Nu ph nh, no p tt c th ng mng no, t li mnh xng s. + Nu ph nng, no p yu, khng nn ng mng no (nu cn ch khu nh hoc nu c iu kin th to hnh no, mnh xng di da bng (h chu tri) hoc gi bo qun ngn hng m. 2) K thut m: Khi chn on r trn lm sng l c mu t trong hp s: + Co nhn u. + Gy m ni kh qun. + m np s nu c phim chp CT. Nu cha c CT m phi m: Rch da vng thi dng ngay trc tai (bn ng t gin). Ct dc c thi dng bng dao in. Khoan 1 l xng s cch l tai ngoi 2 cm trn vnh tai 2cm (73% mu t ngoi mng cng y). Nu khng thy mu t th c th khoan thm 1 l s 2 (nh), l s 3 (chm-nh), l s 4 (chm) v cc l v tr i din. + Nu c mu t ngoi mng cng th sau khi khoan thng xng, c mu c ngay y l khoan. Nu ch thy mng cng

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

thm tm: mu t di mng cng . Nu thy mng cng trng hng: mu t trong no. + qua l khoan dng km bm u xng m rng l khoan ly mu t v kim sot cm mu ch chy mu. + Ly mu t: T mu di mng cng : M mng cng ly mu t. T mu trong no: Sau khi m mng cng s thy t chc no t t li ra khi mng cng (do khi mu t chim ch bn trong no). Dng troca chc thm d tm mu t trong no sau ct vn t chc no vo ly mu t v cm mu ch chy mu. + Cm mu : Mch mu nh: t in; mch mu ln: kp ch chy mu bng clip bc; rch xoang tnh mch: ly c thi dng, nghin nt p vo; chy mu t xng: dng sp xng, sp ong mit cht. + Trnh chy mu ti pht: Mu t ngoi mng cng: khu treo mng cng vi cn Gala. Mu t di mng cng v mu t trong no: Khng ng kn mng cng, c th b volet xng s (cy xung di da bng hoc gi ngn hng m ri y li np s vi thng sau khi bnh nhn n nh). + Dn lu : V tr dn lu tu vo v tr mu t. L t dn lu ra ngoi trnh xa vt m, 24 48h. + Khu da u 2 lp: Lp Gala, lp da. X tr xng ln: = mnh xng ln t vo mng cng, chn p no, lu ngy to dnh, hnh thnh so v no v ng kinh. + Ch nh m: khi ln ca mnh xng v 2/3 chiu dy cu xng s. + Rch da ngay trn xng ln, dng kp banh rng vt rch da l xut ton b din xng ln. + Khoan 1 l xng s phn s lnh st b xng ln, mnh xng ln c u no nng hn th khoan.

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

+ Dng km bm rng l khoan va nhc mnh xng ln ra nh nhng, + Kim tra mng cng: nu c mu t th x tr nh trng hp c mu t. + khu treo mng cng vi cn Gala. Khu kn da u. i vi tr em: Ln xng theo hnh lm do xng s mm: rch da 1 vt nh trn b xng ln, khoan 1 l nh thng xng. Qua l khoan dng 1 dng c nh c chiu cong u lun nh vo khe gia mng cng v y ch xng ln by t t. 5) Chng ph no. VIII. Di chng 1) Thn kinh: 6. Lit na ngi, ri lon ngn ng, ng kinh (dp no). 7. Lit dy VII ( nu v xng ). 8. Nghe km, ic (tn thng dy VIII). 2) Tm thn : 6. Gim tr nh, chm chp, au u, trm cm 7. Sng i sng thc vt.