TRNG I HC Y KHOA THI NGUYN B MN NI

BNH HC NI KHOA
Tp 1

NH XUT BN Y HC H Ni - 2006

CH BIN: BS. CKII. Doanh Thim Thun

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

TH K: BS. Trng Vit Trng

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

BS. Chu. Doanh Thim Thun

MC LC
Tp 1
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
TNG HUYT P............................................................................................................. 3 HP VAN HAI L ........................................................................................................... 15 H VAN HAI L............................................................................................................. 24 H VAN NG MCH CH ........................................................................................ 29 HP VAN NG MCH CH ...................................................................................... 35 IU TR SUY TIM ........................................................................................................ 40 IN TM NG DNG TRONG LM SNG ..................................................... 44 HEN PH QUN ............................................................................................................. 57 VIM PH QUN CP, MN ....................................................................................... 64 VIM PHI THY .......................................................................................................... 70 P XE PHI..................................................................................................................... 74 LOT D DY T TRNG........................................................................................... 80 XUT HUYT TIU HA CAO.................................................................................... 86 VIM KHP DNG THP ............................................................................................ 91 XUT HUYT GIM TIU CU................................................................................ 100 I THO NG...................................................................................................... 104 BASEDOW..................................................................................................................... 115 BU GIP TRNG N THUN ........................................................................... 126 CHN ON V IU TR THN H TH PHT................................................ 132 TM PH MN............................................................................................................. 138 X GAN ......................................................................................................................... 144 P XE GAN DO AMP.................................................................................................. 150 CP CU NGNG TUN HON............................................................................... 157 IN GIT .................................................................................................................... 163 NGT NC ................................................................................................................. 167 RN C CN ............................................................................................................. 171 NGUYN TC X TR NG C CP .................................................................... 174 NG C BACBITURIC ............................................................................................. 179 NG C LN HU C............................................................................................. 182 NG C THUC CHUT T TRUNG QUC ....................................................... 186

TNG HUYT P
1. I CNG 1.1. nh ngha Theo T chc Y t Th gii, mt ngi ln b tng huyt p thc s khi huyt p tm thu trn hoc bng 160mmHg v huyt p tm trng trn hoc bng 95 mmHg. - Huyt p tng gii hn khi huyt p tm thu t 140 - 160 mmHg v huyt p tm trng 90 - 95 mmHg. nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton n nh v huyt p thay i theo gii, tui... 1.2. Dch t hc Tng huyt p l mt triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th l mt, bnh tng huyt p nu khng tm thy nguyn nhn. 1.2.1. Th gii cc nc chu u - Bc M t l tng huyt p chim 15 - 20% ngi ln. C th: Hoa K 6 - 8% Thi Lan 6,8%; Chi L 19 - 21%. 1.2.2. Vit Nam T l tng huyt p chung l 11% (B Y t Vit Nam, 1989 T l ny gia tng ng quan tm v trc nm 1975 t l ny min Bc Vit Nam ch c 1 - 3% (ng Vn Chung - 1971). 2. NGUYN NHN V CC YU T THUN LI 2.1. Tng huyt p nguyn pht Chim gn 90% trng hp tng huyt p (theo Gifford - Weiss). 2.2. Tng huyt p th pht 2.2.1. Bnh thn Vim cu thn cp, vim cu thn mn, thn a nang, vim i b thn mn do nc, m i b thn, u thn lm tit renin, hp ng 2.2.2. Bnh ni tit - Bnh v thng thn nh: hi chng Conn, hi chng Cushing. - Bnh tu thng thn: u tu thng thn (hi chng Pheochromocytone). 2.2.3. Bnh tim mch - Bnh hp eo ng mch ch, h van ng mch ch. - Vim hp ng mch ch bng ch xut pht ng mch thn. 3

2.2.4. Do thuc Cc hormon nga thai, cam tho, corticoid, ACTH, cht gy chn n, cht chng trm cm vng... 2.2.5. Cc nguyn nhn khc - Ng c thai nghn: hi chng albumin niu. - Bnh cng gip, bnh Beriberi, bnh a hng cu, hi chng carcinoid, toan h hp, tng p lc s... 2.3. Mt s yu t thun li: c lin quan n tng huyt p nguyn pht l: 2.3.1. Yu t di truyn, tnh gia inh 2.3.2. Yu t n ung n nhiu mui, ung nhiu ru, ung nc mm t Ca+, Mg+, K+, n t protid. iu ni bt c tha nhn l s lin quan gia con Nay v tn sut bnh tng huyt p. ton Na+ lm tng huyt p qua trung gian gia tng th tch mu v qua s co thi mch mu. 2.3.3. Yu t tm 1 x hi, tnh trng cng thng stress thng xuyn 3. C CH BNH SINH CA TNG HUYT P NGUYN PHT Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan n h thn kinh giao cm, thn, Renin, angiotensin v c ch huyt ng, th dch khc. 3.1. Bin i v huyt ng 3.1.1. Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn b li mu lu thng t ngoi vi v tim phi. Do sc cn mch mu cng tng dn. Tim c biu hin tng hot ng b tr v dn n dy tht tri, huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm thu gim, cui cng dn n suy tim. 3.1.2. Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm v ton b. - Ti thn, tng sc cn mch thn, gim lu lng mu ti thn. Chc nng thn suy gim. - Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k c tng huyt p r. - Khi huyt p tng, sc cn ngoi vi tng th tch huyt tng c xu hng gim cho n khi thn suy, th tch dch trong mu tng c th dn n ph. 3.2. Bin i v thn kinh 4

 thi k u h giao cm nh hng s tng tn s tim v tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng catecholamin trong huyt tng nh: Adrenalin, No-adrenalin cc cht ny rt thay i trong bnh tng huyt p h thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh no - tu sng v c hai h ny lin h nhau qua trung gian cc th cm p lc. Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao nht. 3.3. Bin i v th dch 3.3.1. H Renin - Angiotensin - Aldosteron (RAA) Hin nay c chng minh c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ng no gy tng huyt p qua cc th th Angiotensin II. Angiotensin II c tng hp t Angiotensinogne gan v di tc dng ca Renin s to thnh Angiotensin I ri chuyn thnh angiotensin II l mt cht co mch rt mnh v lm tng tit Aldosteron. S phng thch Renin c iu khin qua 3 yu t. p lc ti mu thn - lng Na n t ng ln xa v h thn kinh giao cm. S thm d h RAA da vo s nh lng Renin trc tip huyt tng hay gin tip phn ng min dch v Angiotensin II nhng tt nht l tc dng ca cc c ch men chuyn. 3.3.2. Vasopressin (ADH) c vai tr kh r rng trong c ch bnh sinh tng huyt p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung ng i vi phn x t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si adrenergic). 3.3.3. Cht Prostaglandin tc dng trung ng lm tng huyt p, tc dng ngoi vi lm gim huyt p. 3.3.4. Ngoi ra cn c vai tr ca h Kalli - Krein Kinin (K.K.K) trong bnh tng huyt p v mt s h c vai tr cha r nh: H angiotensin trong no v cc encephalin, h cng dopamin bin i hot ng th cm p lc. Mt c ch iu ho lin quan n cc th cm p lc. Mt c ch iu ho lin quan n cc th th Imidazol trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm Imidazole gy gin mch. 3.3.5. C ch sinh bnh ca tng huyt p th pht: Tu thuc vo nguyn nhn gy bnh. 4. TRIU CHNG HC 4.1. Lm sng 4.1.1. C nng a s bnh nhn b tng huyt p khng c triu chng g cho ti khi pht hin ra bnh. 5

- au u vng chm v hai bn thi dng. - Cc triu chng khc c th gp nh: hi hp, mt, kh th, m mt...nhng khng c hiu. - Mt s triu chng khc ca tng huyt p tu thuc vo nguyn nhn tng huyt p hoc bin chng ca tng huyt p. 4.1.2. Thc th, ton thn * o huyt p: l ng tc quan trng nht c ngha chn on xc nh. Khi o cn phi m bo mt s quy nh. - Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun trn khuu tay 2cm. Nu dng my o thu ngn phi iu chnh 6 thng 1 ln. - Khi o cn bt mch trc. t ng nghe ln ng mch cnh tay bm nhanh bao hi n mc 300 mmHg trn p lc ghi, x chm t t vi tc 2 mmHg/l giy. - Huyt p tm trng nn chn lc mt mch. - Phi o huyt p nhiu ln trong 5 ngy lin. o huyt p c chi trn v chi di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun. - Cc du hiu lm sng nh: Bnh nhn c th bo ph, mt trn, c chi trn pht trin hn c chi di trong hp eo ng mch ch. Tm cc biu hin x va ng mch trn da (u vng, u m, cung gic mc...). - Khm tim phi c th pht hin sm dy tht tri hay du hiu suy tim tri. S v nghe ng mch pht hin cc trng hp nghn hay tc ng mch cnh. - Cn lu hin tng huyt p gi nhng ngi gi i ng, suy thn do x cng vch ng mch lm cho tr s huyt p o c cao hn tr s huyt p ni mch. - Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng mch thn, phng ng mch ch hoc pht hin thn to, thn a nang. - Khm thn kinh c th pht hin cc tai bin mch no c hoc nh. 4.2. Cn lm sng Cn n gin, mc ch nh gi nguy c tim mch, tn thng thn v tm nguyn nhn. 4.2.1. Nhng xt nghim ti thiu Mu: ure, creatinin, kali, cholesterol, glucose, acid uric trong mu. Nc tiu: protein, hng cu. 6

Soi y mt, in tim, xquang tim, siu m... 4.2.2. Cc xt nghim hay trc nghim c bit i vi tng huyt p th pht hay tng huyt p kh xc nh V d: bnh mch thn: chp UIV nhanh, thn , trc nghim saralasin. U tu thng thn (Hi chng pheocromocytome) th nh lng catecholamin nc tiu 24h, trc nghim Rgitin. 5. CHN ON 5.1. Chn on xc nh Cn phi chn on sm v ng n bnh tng huyt p. Ch yu bng cch o huyt p theo ng cc quy nh trn. Tuy nhin iu quan trng l nn t chc nhng t khm sc khe khm xt ton din nhm pht hin sm nhng trng hp tim tng hoc cha c triu chng. 5.2. Chn on giai on Theo OMS (1978) chia lm 3 giai on. 5.2.1. Giai on 1 Tng huyt p thc s nhng khng c tn thng thc th cc c quan. 5.2.2. Giai on 2 C t nht mt trong cc bin i c quan sau. - Dy tht tri: pht hin bng lm sng, X quang, in tim, siu m. - Hp lan to hay tng vng cc ng mch vng mc (giai on I v II y mt). - Thn: c protein niu, ure hoc creatinin mu tng nh. 5.2.3. Giai on III * C du hiu chc nng v thc th do tn thng cc c quan sau. - Tim: suy tim tri - No: xut huyt no, tiu no hoc thn no. - y mt: xut huyt vng mc c hay khng c ph gai th (giai on III v IV), cc du hiu ny l c bit ca giai on c tnh (giai on tin trin), cc biu hin khc thng gp giai on II, nhng khng c hiu lm ca tng huyt p nh: - Tim: cn au tht ngc, nhi mu c tim. - No: huyt khi ng mch trong s. - Mch mu: phng tch, bt tc ng mch. - Thn: suy thn * Tng huyt p c tnh hay tin trin nhanh l mt hi chng gm c: 7

- Huyt p ti thiu rt cao trn 130 mmHg. - Tn thng y mt giai on III v IV. - Bin chng thn, tim, no. - Bnh nhn tr di 40 tui. - Tin trin nhanh, t vong trong vng 2 - 3 nm. 5.3. Chn on th 5.3.1. Theo tnh cht - Tng huyt p thng xuyn nh tng huyt p lnh tnh v c tnh. - Tng huyt p dao ng c lc cao c lc bnh thng. 5.3.2. Theo nguyn nhn gm c: Tng huyt p nguyn pht (v cn) v tng huyt p th pht. 5.4. Chn on bin chng 5.4.1. Tim Suy tim v bnh mch vnh l hai bin chng chnh v l nguyn nhn gy t vong cao nht i vi tng huyt p. - Dy tht tri l bin chng sm do dy c tim tri i ph vi sc cn ngoi vi nn gia tng sc co bp lm cng tim tng ln v vch c tim dy ra. Dn dn suy tim tri vi cc triu chng kh th khi gng sc hen tim hoc ph phi cp sau chuyn sang suy tim ton b vi: ph, gan to, tnh mch c ni, X quang v in tim c du hiu dy tht phi. - Suy mch vnh biu hin bng cc cn au tht ngc in hnh, lon nhp tim. in tim c ST chnh xung di ng ng in cc chuyn o tim tri, khi c bin chng nhi mu s xut hin sng Q hoi t. 5.4.2. No Tai bin mch no thng gp nh: nhn no, xut huyt no, tai bin mch no thong qua vi cc triu chng thn kinh khu tr ch ko di khng qu 24 gi hoc bnh no do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc u d di. 5.4.3. Thn - Va x ng mch thn sm v nhanh. - X thn gy tnh trng suy thn dn dn. - Hoi t dng t huyt tiu ng mch thn gy tng huyt p c tnh. - Giai on cui thiu mu cc b nng thn s dn n nng Renin v 8

Angiotensin II trong mu tng gy cng aldosteron th pht. 5.4.4. mch mu - Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh thnh va x ng mch. - Phng ng mch ch, bc tch. 5.4.5. Mt Khm y mt rt quan trng v n l du hiu tt tin lng. Theo Knh Wagener - Barker c 4 giai on tn thng y mt. - Giai on 1 : tiu ng mch cng v bng. - Giai on 2: tiu ng mch hp c du hiu bt cho (gng) - Giai on 3: xut huyt v xut tit vng mc nhng cha c ph gai. - Giai on 4: ph lan to gai th. 6. IU TR 6.1. Nguyn tc: mc tiu nhm - a huyt p tr v tr s sinh l n nh. - Ngn nga cc bin chng. - Ci thin cc bin i bt thng cc ng mch ln. Do phi gii quyt 3 vn l: - iu tr nguyn nhn tng huyt p nh: ct b u tu thng thn, ct b thn teo, thng ng mch b tc... nu tm thy nguyn nhn. - iu tr triu chng tng huyt p: bng phng php ni khoa khng dng hay dng thuc hoc phu thut (ct b mt s dy thn kinh giao cm). - iu tr bin chng ca tng huyt p (nu c) Tn trng huyt p sinh l ca ngi gi. iu tr huyt p tng cn lin tc, n gin, kinh t v phi theo di cht ch. 6.2. Phng php iu tr 6.2.1. n ung v sinh hot - Hn ch Na di 5g NaCl mi ngy. - Hn ch m, cc cht bo ng vt. - Khng ung ru, ht thuc l, ung ch c. - Trnh lao ng tr c cng thng, lo lng qu , nn tp th dc nh, i b th gin, bi li. 9

6.2.2. Thuc Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng huyt p v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc chnh: * Thuc tc dng ln thn kinh trung ng: C nhiu loi nhng hin nay t dng v c nhiu tc dng ph. - Alpha Methyldofa (Aldomet) H huyt p do to ra alpha methylnoadrenalin lm hot ha cc c quan th th giao cm no do c ch trng lc giao cm. Vin 250 m (500mg) liu 500 - 1500 mg/24h. Tc dng ph: h huyt p, thiu mu huyt tn, bt lc, suy gan. - Reserpin vin 0,25 m liu 2 - 6 vin/24h. Tc dng ph gy h huyt p khi ng, thiu mu huyt tn, bt lc, suy gan. - Clonidin vin 0,15mg x 3 - 6 vin/24h. Tc dng ph: trm cm, kh ming, to bn, ri lon sinh dc. - Cc thuc tc dng trung ng khc: Guafacin, Tolonidin, Hyperium... * Thuc li tiu: - Thiazid: c ch ti hp thu Na+ v Cl- trong ng ln xa. Hypothiazid vin 25mg x 2 vin/ngy. Chlorthalidon vin 50mg - 100mg x 1 ln/24h. Tc dng ph: tng acid uric, gim kim mu, tng ng mu, tng LDL cholesterol v gim HDL cholesterol. - Li tiu quai Henle Furosemid (lasix) vin 40mg x 2 vin/24h ch nh khi suy thn nng. Tc dng ph: lm h kim mu, liu cao c tnh ln tai. - Li tiu khng aldosteron gi kali. + Nhm khng aldosteron nh: Aldacton, Spirolacton vin 25 - 50mg x 4 ln/24h. Dng phi hp vi Thiazid. + Nhm c tc dng trc tip nh Amilorid, Teriam, loi ny phi phi hp v tc dng thi Na+ yu. Tc dng ph: v to, bt lc, ri lon kinh nguyt. - Li tiu phi hp: trnh c tnh trng gim kim mu. Loi ny phi hp mt 10

loi aldosteron v mt loi Thiazid. * Thuc chn giao cm Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung ng. - Propranolon (Inderal) vin 40mg x 1 - 6vin/ngy. Tc dng ph: lm chm nhp tim, ri lon dn truyn nh nht, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu ha, mt ng, d ng... * Cc thuc c ch men chuyn: - c ch s to thnh Angiotensin II. - Tng cng hot ng Kali - Krine - Kinin do ngn cn s phn hu bradykinin. - Kch thch s tng hp Prostaglandin. + Ch nh: tng huyt p cc giai on. + Tc dng ph: thm n, nga, ho khan, lu khi phi hp vi li tiu gi kim, thuc chng vim. + Chng ch nh: tng huyt p c hp ng mch thn hai bn, ph n c thai. - C 3 nhm: + Catopril: vin 25 - 50mg liu 50 mg/ngy. + Enalapril (Renitec) vin 5 - 20mg liu 20mg/ngy. + Lisinopril (Prinivill) vin 5 - 20 m liu 20mg/ngy. * Thuc c ch calci. Ngn cn s i vo t bo ca con Ca++, c ch lung Ca++ chm ca knh Ca++ ph thuc in th. C 2 ni tc dng. Trn mch mu: s gim lung calci a n s gin c v lm gin mch. iu ny lm gim sc cn ngoi bin v ci thin gin n cc mch mu ln. Trn tim: lm gim nhp tim, cn bng t nhiu phn x nhp nhanh th pht v gim s co bp c tim. + Nhm 1 - 4 Dihydro pyridime: Nipedipin (Adalat) vin trung, liu 2 vin/ngy. + Diltiazem (Tildiem) 300mg LP x 1 vin/ngy. + Isotin 120 - 240 LP x 1-2 vin/ngy. - Tc dng ph (10 - 20%) cc trng hp: nhc u, ph ngoi bin, h huyt p khi ng, mt, ri lon tiu ha, bun ng, bt lc. N c th gy ri lon dn truyn nh tht, nhp chm. 11

Khng dng khi c suy tim, mc nh tht nng. * Thuc gin mch: - Minipres: tc dng c ch cm th alpha sau tip hp nn c hiu lc tt. Vin ng x 1-2 viningy tng dn 10 vin/ngy nu cn. Tc dng ph: chng mt, ri lon tiu ha, d kch ng, tiu kh, h huyt p. - Dihydralazin vin 25mg x l-4 vin/ngy. Dng khi c suy thn. Tc dng ph: nhp tim nhanh, gi mui nc, vim dy thn kinh ngoi vi. - Minoxidil: tc dng rt mnh, ch dng khi tng huyt p khng cc loi khc. 6.3. iu tr c th * iu tr bc thang p dng cho tng huyt p t nh nng gm 4 bc. - Bc l: dng mt trong hai loi li tiu (gi) chn giao cm Beta (ngi tr). - Bc 2: dng c hai loi trn - Bc 3: dng hai loi trn thm mt loi gin mch. - Bc 4: dng bn loi mt lc bng cch thm vo mt loi h huyt p mnh khc nh c ch thn kinh trung ng. - Phng php tng bc c hiu qu, d thc hin v t tn km. Gn y cc tc gi thng nht iu tr chn lc c nhn ha thch hp vi tng bnh nhn tng huyt p s dng vi mt s thuc t nht, hiu qu nht v t tc dng ph nht. * Phc iu tr c nhn ha: - iu tr khng dng thuc + Gim cn nng + Hot ng th lc + iu chnh cc yu t nguy c - iu tr dng thuc: + Mt loi thuc: - Chn giao cm Beta - Li tiu - c ch calci - c ch men chuyn 12

- Ch nh chn lc thuc theo phng php iu tr c nhn (hi tim mch hc Hoa K 1997). + Li tiu: ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn. + Chn Beta: ngi tr, da trng, nam gii, cng giao cm, hot tnh Renin cao, bnh mch vnh, au na u. + c ch men chuyn: tng huyt p nng, suy tim hay suy thn, ri lon tnh dc, tng lipid mu, i ng, tng acid uric mu. + c ch calci: ngi gi, da en, bnh mch vnh, i ng. + Bo ph, tng huyt p khng kim sot c bng chn Beta th pht sau cng aldosteron nguyn pht, bt lc, tng lipid mu v tng acid uric mu. + Khng adrenergic ngoi bin: bnh nhn tr, trm ut, hen suyn, bnh phi tc nghn, i ng, tng lipid mu. 6.4. iu tr tng huyt p cp tnh (kch pht) Cn phi dng loi h huyt p bng ng tnh mch nh: - Niprid truyn tnh mch liu 0,5 - 2mg/pht (10 mg/gi) c chn trong hu ht cn tng huyt p. Tc dng ph: ng c Thiocyanat. - Nitroglycerin (truyn tnh mch khi c suy vnh cp liu 5 - 10 mg/pht). - Alpha Methyldofa hay Clonidin (truyn tnh mch). - Cc loi c ch men chuyn - Nipedipin 10 - 20mg ngm di li. - Thng phi hp thm lasix (tnh mch). 7. PHNG BNH 7.1. D phng cp I Lu vn sinh hot hng ngy nht l cc thi quen c hi sc khe phi khm nh k pht hin tng huyt p hay cc bnh lin quan. Trong i tng ny cn ch nhng ngi c yu t nguy c mc bnh cao, cho d nhng ln u cha pht hin tng huyt p nhng cn trao i, tuyn truyn phi hp d phng cng nhn vin y t tuyn trc. 7.2. D phng cp II i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung, ngh ngi theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin trin, tc dng ph ca thuc. Cn ch yu t kinh t trong iu tr v y l mt liu trnh lu di tn km. 13

8. TIN LNG Tin lng bnh nhn huyt p ph thuc vo: 8.1. Tr s huyt p: tr s cng cao th t l t vong cng ln. 8.2. Cc bin chng: l yu t tin lng gn rt quan trng nht l khi c bin chng. 8.3. Tin lng xa Cholesterol mu c v tr quan trng v a n va x ng mch vnh, nhi mu c tim sau ny. 8.4. Vn diu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm, ng cch, c theo di lu di Kt lun: Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh nguyn, c ch. Vic iu tr c nhiu tin b nhng khng trnh khi nhng tc dng ph ng k. Bnh nh hng ln n sc khe con ngi. V vy tng huyt p l vn ln ang c nc ta v th gii quan tm.

14

HP VAN HAI L
1. I CNG 1.1. nh ngha Hp van hai l l tnh trng van m ra khng ht trong thi k tm trng. N l tnh trng gim din tch ca l van do hin tng dnh mp van. 1.2. Dch t hc 1.2.1. Tn sut - Tn sut mc bnh thay i tu theo mc pht trin ca cc quc gia tc l bnh hp van hai l gp nhiu nhng nc km pht trin. Cn nhng nc pht trin th t l mc bnh gim i rt nhiu nhng vn cn gp tng lp ngho. - T l mc bnh hp van 2 l ph thuc rt nhiu vo cht lng ca chng trnh phng thp. 1.2.2. Tui, gii - Tui thiu nin d mc hn ngi ln tui. - Gii: n gii mc bnh nhiu hn nam gii (2/3), theo ng Vn Chung 1971: N gii b bnh hp van 2 l chim > 70%. 1.2.3. nc ta Thng k nm 1959 cho bit hp van 2 l chim 40% cc bnh tim ni chung. Trong 99% l hu thp. Tuy nhin c nhiu bnh nhn khng ghi nhn tin s thp khp (khong 30% trng hp v nhiu th bnh khng biu hin khp). - Bnh tim hu pht: hp van 2 l n thun 25%, hp h van 2 l 40%. 2. NGUYN NHN 2.1. Thp tim L nguyn nhn hay gp nht chim 99% trong tng s . 2.1.1. Nhng ngi c tin s thp r. sau nhiu ln b thp tin trin s li di chng hp 2 l. 2.1.2. Tin s thp khng r: khng c chn on sm v khng c iu tr do khi bnh nhn vo vin th b hp van 2 l. 2.2. Bm sinh Gp trong hi chng Lutembacher gm c hp van 2 l + thng lin nh. 2.3. Mng si trong vim ni tm mc bn cp (Osler) 15

2.4. Vi ha van hai l, vng van. 2.5. Lupus ban ri rc: vim khp dng thp. 2.6. Lng t amynoid trn van tim hu pht. 3. GII PHU 3.1. Gii phu van hai l bnh thng - Phc hp van hai l gm: hai l van, vng van, dy chng gi van, cu c, ct c - L van hai l hi hnh bu dc, gm c l trc gia ln v l sau bn. - Din tch van 2 l bnh thng 4 - 6cm2. - Hai l van dnh vo mt vng si c tnh n hi nh c vng thu nh din tch l van khi van 2 l ng li, b di 2 l van c cc dy chng dnh neo vo 2 ct tr thng. Do sut c th tm thu, cc dy chng gn cng thng, cc ct tr co cng nn cc ba van lun p st vo nhau khng b lt ngc ln trn. 3.2. Tn thng van 2 l do thp tim - L van dy do m x hay lng t cht vi (vi ha). - Cc mp van b dnh, ba van dy, cun li lm l van 2 l c hnh phu cng nm su trong lng tht tri. - Dy thng gn dnh li v co rt. - Nhng tn thng trn u tin l do thp, nhng thay i sau c th l mt qu trnh khng c hiu do dng mu b thay i khi chy qua van b bin dng trc gy chn thng l van. S vi ha 2 l gy bt ng l van, lm hp l van. - S to huyt khi v nghn ng mch c th pht sinh t chnh van b vi ha. 4. SINH L BNH L van 2 l bnh thng c din tch 4 - 6cm2. Khi van b hp khong 2cm2 (hp nh) dng mu chy t nh tri xung tht tri ch khi n c y mt p lc bt thng gia nh tri v tht tri. 4.1. Hu qu huyt ng di ch hp - Lng mu tht tri gim do tht tri bnh thng hay hi nh. - Mch ngoi vi nh, huyt p thp. - Bnh van tim tri khng nh hng n tht tri. - Bin chng tc, nghn mch c th xy ra no, gan, lch, thn. 4.2. Hu qu huyt ng trn ch hp 16

* Hp van 2 l gy tng p lc nh tri, dy gin nh tri, tng p lc tiu tun hon, nh tri gin sinh ra cc hu qu: - Lon nhp nh; huyt khi ngay ti bung tm nh tri. - Chn p cc c quan ln cn nh: + Chn p thc qun gy nut nghn + Chn p thn kinh qut ngc gy ni khn + Chn p vng cnh ct sng gy au ngc. * mu trong mao qun phi cn tr s trao i kh ti mng ph nang mao qun gy ph ph nang, ph m k, biu hin kh th, khc ra mu, bt hng. * Tng p lc ng mch phi do: - S lan truyn th ng ngc dng ca hin tng tng p lc nh tri. - Tiu ng mch phi co tht. - Tn thng thc th trong mao ng mch phi. * Tht phi dy, gin: tng p lc ng mch phi khin tht phi phi chu mt gnh nng khi bm mu vo ng mch phi nn tht phi dy, gin gy h van 3 l c nng, suy tim phi. * mu tnh mch ngoi bin nht l chi di gy huyt khi, nghn mch phi. 5. TRIU CHNG LM SNG 5.1. C nng Bnh nhn c th c pht hin bnh hoc v mt biu hin c nng hay tai bin ca bnh nh: 5.1.1. Kh th. khi gng sc, khi nm hay ph phi kt qu ca s gim tnh n hi ca phi. 5.1.2. Ho ra mu: s lng t, dnh vi m. 5.1.3. au ngc (15% trng hp) do tng p lc ng mch phi hoc nhi mu phi. 5.1.4. Hi hp nh trng ngc do ri lon nhp tim 5.1.5. Cc triu chng khc nh: nut nghn, ni khn do nh tri to chn p. 5.2. Thc th 5.2.1. Nhn - Lng ngc bin dng vng trc tim - Tm mi, ngn chi 17

5.2.2. S - Mm tim c rung mu tm trng - B tri xng c: du ny ca tht phi do tng p lc ng mch phi, tht phi ln 5.2.3. G. din c tng i ca tim to v bn phi. 5.2.4. Nghe: l triu chng quan trng nht chn on. * Mm tim: - T1 anh, gn - Rung tm trng (RTTr) - Thi tin tm thu (trm, nh) - Clc m van 2 l: nghe ti mm hay b tri xng c vng thp (khoang lin sn IV, V cnh c tri, c th lan n y tim). * y tim: - T2 vang, tch i nghe r nht van ng mch phi. - Ting Clich phun mu van ng mch phi. - Thi tm trng do h van ng mch phi c nng. * Ngoi ra c th khm thy: gan to, phn hi gan tnh mch c (+), ph chn, trn dch mng bng, mng phi. 6. TRIU CHNG CN LM SNG 6.1. X quang lng ngc 6.1.1. Phim thng - B tri 4 cung - B phi 2 cung ct nhau hoc ng tm - Bng trn m ca nh tri - Rn phi m,ng mch phi ln. 6.1.2. Phim nghing: gc kh ph qun rng, thc qun b chn p 1/3 gia v 1/3 di (ung Baryte). 6.2. in tm Nhp xoang hoc rung nh. Ph i gin nh tri: sng P > O,12s, 2 mi, Vl: p 2 pha -/+ Trc bnh thng hoc lch phi. 18

- Dy tht phi: RVI + SV5 >- tham, R/s ( Vl) 6.3. Tm thanh Xc nh cc ting tim trn lm sng. 6.4. Siu m tim: 2D - TM - Doppler. Phng php ny nhy cm v c hiu nht chn on bnh. - L trc mt hnh M, l sau di chuyn v trc, 2 l van song song th tm trng. - dc EF gim. - L trc m c dng phnh gi. - Dy l van v h dy chng di van. - o c din tch l van 2 l, kch thc cc bung tim. - o p lc mch phi th tm thu. - Pht hin huyt khi trong tm nh tri. 6.5. Thng tim - o p lc bung nh tri tng, p lc mao mch phi, ng mch phi, tht phi, nh phi tng. 7. CHN ON 7.1. Chn on xc nh 7.1.1. Lm sng: cc triu chng in hnh. - Nghe tim: T1 anh, gn, rung tm trng. V mt lm sng tuyn c s c th da vo ting rung tm trng v T1 anh. Khi c hai du hiu ny c th chn on gn nh chc chn hp van 2 l. y l triu chng ph bin, d pht hin. 7.1.2. Cn lm sng: ECG + Xquang + siu m, trong siu m l phng php chn on c gi tr nht. 7.2. Chn on phn bit 7.2.1. U nhy nh tri: lm sng ging hp van 2 l, tuy nhin ting rung tm trng thay i theo t th ngi bnh, khng c T1 anh. Chn on xc nh da vo siu m. 7.2.2. Cung gip: tng trng lc thn kinh vi nhp tim nhanh, cung lng tim tng cao c th lm gi triu chng hp 2 l. Hnh thi lm sng v siu m cho php chn on. 7.2.3. Nh tri 2 bung (nh tri ln) v thng trn nh l ln (lm gin ng mch 19

phi): ging hp van hai l trn X quang: chn on da vo siu m Doppler, thng tim, chp bung tim. 7.2.4. Ting rung Flint trong h van ng mch ch. Khng c T1 anh, nghe rung tm trng ngn hn. 7.3. Chn on mc hp Da vo: 7.3.1. Lm sng: c hay khng c hi chng gng sc. 7.3.2. Siu m: dc tm trng < 15mm/s l hp kht. - Trn siu m 2D cho php o din tch l van 2 l, nu < 1 cm2 l hp kht cn phi can thip phu thut. - Trn Doppler nh gi mc hp da vo chn p thng qua o thi gian na nh (Sm < 1 cm2 nu T1/2 > 220 m/s). - Thm d huyt ng: cho php tnh c p lc mao mch phi, ng mch phi, phn nh c kiu tng p lc ng mch phi. 7.4. Chn on th 7.4.1. Hp 2 l n thun - Th ph phi (hp 2 l kht < 1 cm2). Triu chng ni bt phi: kh th, ho ra mu. - Th hp 2 l nh (din tch > 2cm2): khng c triu chng c nng. - Th hp 2 l cm: khng c triu chng trn lm sng. Chn on bng in tm , siu m tim. 7.4.2. Hp 2 l phi hp - H van 2 l: thm vo triu chng ca hp van 2 l l nghe ting thi tm thu mm cng mnh, lan theo ng nch ra sau lng. Nu h l ch yu th ting thi tm thu nghe to, lan r ra sau lng, c du hiu gin v dy tht tri - nu h l th yu th ting thi tm thu cng nh, t hoc khng lan c T1 anh, rung tm trng ln. - H van ng mch ch: c thm ting thi tm trng ecbotkin, ngoi ra c hi chng ngoi vi. - Hp van ng mch ch: ting thi tm thu van ng mch ch lan sang phi, c rung mu tm thu. T2 m. - H van 3 l c nng: nghe ting thi tm thu sn sn VI cnh mi c hai bn, cng tng khi ht vo, gan p. - Bnh tim bm sinh: hp 2 l + thng lin nh gi l hi chng Lutembacher, c 20

thm ting thi tm thu lin sn II bn tri. 7.5. Chn on giai on hp 7.5.1. Theo phn loi ca M da vo triu chng c nng - Giai on I: khng c kh th - Giai on II: kh th khi gng sc - Giai on III: kh th khi lm vic nh - Giai on IV: kh th khi ngh ngi 7.5.2. Phn loi theo Lin X (c) phn lm 5 giai on da vo c cn lm sng - Giai on I: khng kh th, tim khng to, ECG bnh thng - Giai on II: kh th khi gng sc, ho khc mu, nh tri to, phi m, ECG c dy nh tri. - Giai on III: kh th nhiu hn, ho khc ra mu, gan to, nh tri tht phi to, ECG c dy tht phi. - Giai on IV: suy tim r hn, ph, gan to, tnh mch c ni r, iu tr cn hi phc. - Giai on V: suy tim khng hi phc 7.6. Chn on bin chng 7.6.1. Ri lon nhp nh nh Rung nh, cung ng nh, ngoi tm thu nh. S xut hin ca rung nh gy hu qu xu d hnh thnh cc mu ng trong tim. 7.6.2. Suy tim phi - Hay xy ra cn hen tim, ph phi cp hp van 2 l kht. - Hi chng suy tim phi tin trin khng th trnh khi. 7.6.3. Tc mch - Cc mu ng c hnh thnh nh tri lm tc mch no, thn, chi. - Cc mu ng hnh thnh tnh mch ch di gy tc mch phi. 7.6.4. Nhim trng - Vim ph qun - phi do vi trng, vim phi, p xe phi. - Vim ni tm mc bn cp (Osler). 7.6.5. Mt s th lm sng c bit - Thai sn: ngi bnh hp van hai l c thai s lm nng thm tnh trng huyt ng do tng cung lng tim v th tch mu khi mang thai. Do ngi bnh c 21

nguy c cao b ph phi cp. - Ti hp van: sau khi m tch van hai l kn. Nguyn nhn c th l do dai dng qu trnh thp tim hoc l ti b thp tim. Thng thng km theo h hai l (do phu thut). 8. IU TR 8.1. Ni khoa Trnh lao ng nng, tm ngh thch hp khng i hi hot ng th lc nhiu. 8.1.1. Khi c hi chng gng sc th phi chuyn bnh nhn ln tuyn trn, c th can thip ngoi khoa cho ngi bnh trong lc ch i, tuyn c s c th cho bnh nhn dng li tiu nh: Furosemid 40mg x l-2vin/ngy. Thuc gin mch Nitrat nh Risordan 10 80 mg/ngy. Thuc tr tim hay c dng khi bnh nhn c rung nh vi tn s tht nhanh. 8.1.2. Phng nga thp tim v u tr bin chng nn c Ni chung l trng hp hp khng kht, bnh nhn dung np c, tuy nhin khng loi tr c th xy ra bin chng ri lon nhp. 8.2. Ngoi khoa 8.2.1. Tch van 2 l: m tim kn hoc tch van bng bng. Vit Nam cn thng dng ch nh m kn tch van: tui 20 - 60, hp < l,5cm2, giai on 2 hoc 3, hp n thun hoc kt hp h hai l, h ch nh. - Chng ch nh khi h hai l, h ch nng, hp ng mch ch, t chc di van h bin, van vi ha. - Chng ch nh tng i: khi ang c t thp tin trin, vim ni tm mc hoc tc mch mi xy ra. 8.2.2. Thay van 2 l: bng van sinh hc hoc van c hc trong trng hp h bin t chc di van v calci ha nng. Trong trng hp tn thng phi hp c th phi sa hoc thay c hai van. 9. TIN LNG - Tu thuc mc hp v s hin din hay khng ca cc tn thng phi hp - Tin lng khng tt khi tui tr, c thai, lao ng nng. Vi s tin b ca k thut phu thut cng nh cc phng tin iu tr mi ca y hc tin lng cho bnh nhn b hp van 2 l ngy cng kh quan. 10. PHNG BNH - Hp van 2 l l bnh van tim rt thng gp nc ta, nguyn nhn ch yu l do thp tim. Bnh c th sinh nhiu bin chng nng, do vn chm sc sc khe 22

ban u rt quan trng. - Cn phi gio dc rng ri v y t trong cng ng phng nga vim hng tr em. Khi mc bnh cn c iu tr y . - T chc khm sc khe nh k cc trng hc, v hc sinh l tui d mc bnh thp khp cp. - Khi pht hin bnh thp khp cp, cn c ch iu tr cht ch, ch qun l theo di bnh nhn pht hin di chng van tim ng thi theo di ch khng sinh phng nga n ht thi gian quy nh. - Cn pht hin sm nhng trng hp hp van hai l c k hoch c th, trnh bin chng c th xy ra.

23

H VAN HAI L
1. I CNG 1.1. nh ngha H van hai l xy ra khi van 2 l ng khng kn trong th tm thu, cho php dng mu chy ngc t tht tri ln nh tri. 1.2. Dch t hc 1.2.1. Tn sut Mc bnh tu thuc theo mc pht trin ca cc quc gia tc l bnh h van 2 l gp nhiu nhng nc km pht trin. Bnh xy ra vng nng thn, ngoi thnh c kinh t, vn ha thp. - H van hai l hay gp phi hp vi hp van hai l (t l 40% trong tng s bnh tim mc phi) v h van ng mch ch. - T l h van 2 l ph thuc rt nhiu vo cht lng ca chng trnh phng thp. 1.2.2. Tui, gii - Tui thiu nin d mc hn ngi ln tui. - N gii mc bnh nhiu hn nam gii (2/3). 1.2.3. nc ta - Hp, h van 2 l chim 40% bnh tim hu pht. - 99% l do thp tim (ng Vn Chung - 1971). - Bnh gp nhiu nng thn, ngoi thnh. 2. NGUYN NHN 2.1. Thp tim - Chim 1/3 cc trng hp h van 2 l n thun, hay gp nam gii. - Tui 20 - 35. - Lc bnh nhn b thp tim n khi biu hin h van 2 l r khong 20 nm (Braun Wald). 2.2. Cc nguyn nhn khc - Vim ni tm mc c lot v si do vi khun gy thng van hai l. - Nhi mu c tim: tn thng n vch, nh hng n cu - c, ct c. - Bm sinh: x chun ni mc, van 2 l nhy d. 24

- Bnh c tim ph i. - Sa van hai l. - Vi ho vng van 2 l. - Lupus ban ri rc, vim ct sng dnh khp. - Hi chng Marfan: ri lon di truyn m lin kt. - H van hai l c nng do bt k nguyn nhn no lm gin tht tri. 3. GII PHU BNH 3.1. H van 2 l do thp tim mn Gy cng, bin dng, co rt ba van. 3.2. Vim ni tm mc nhim khun Gy thng van, t dy chng, co rt l van. 3.3. Nhi mu c tim Gy t c nh, gin tht tri, phnh vch tht vng y c nh. 3.4. Vi ha vng van 2 l Do l sau dnh vo khi calci gy bt ng l van. 3.5. Sa van hai l L di chng ca thp tim trong bnh c tim, thiu mu c tim. Sa van 2 l lm t dy chng v gin vng van lm h van. 4. SINH L BNH H van 2 l c th l kt qu ca mt qu trnh bnh dn dn gim st chc nng van. Mt dng mu pht ngc vo nh tri, gnh nng v s e da nhm vo, tun hon tnh mch phi v phi dn dn tht tri suy, cung lng tim ti gim giai on mt b. 5. TRIU CHNG LM SNG 5.1. Triu chng c nng - Kh th khi gng sc, dn dn kh th theo t th, c cn kh th v ban m. - Ho ra mu. - au ngc nht l khi c bnh ng mch vnh kt hp. 5.2. Triu chng thc th 5.2.1. Nhn: lng ngc hi g bn tri. 5.2.2. S 25

- Mm tim p mnh, lch xung di. - C rung mu tm thu mm. 5.2.3. Nghe: nghe tim l triu chng chnh chn on. Ta c th nghe c ting thi tm thu mm tim. - Cng rt to 4/6. - m sc th rp ging ting pht hi nc. - Lan ra nch tri hay ra sau lng. - Khng thay i theo t th ngi bnh. - y tim: nghe ting T2 vang, tch i. 6. TRIU CHNG CN LM SNG 6.1. Triu chng X quang - Tht tri to ra. - Bng nh tri ln v gin n nhiu. - Chp nghing: ung Baryte nh tri to s chn p vo thc qun. - Vt ng vi vng van 2 l. 6.2. in tm - Nhp xoang u hay rung nh. - Dy nh tri: P DII 0,12sec. P 2 pha -/+ V1 - Dy tht tri: Sokolow - lyon: RV5 + SV1 35mm. 6.3. Siu m tim: siu m 2D - TM - Doppler. - Xc nh h van 2 l: c dng mu pht ngc. - Xc nh nguyn nhn gy h van. - o kch thc bung tim (nh tri, tht tri). 6.4. Tm thanh Xc nh s xut hin ca ting thi v ting tim. 6.5. Thng tim tri - o p lc bung tht tri, p lc mao mch phi. - Thy c dng cht cn quang pht ngc vo nh tri. - nh gi chc nng tht tri, phn sut phun mu. 26

7. CHN ON 7.1. Chn on xc nh - Nghe ting thi tm thu thc tn mm tim. - T2 tch i y tim. - Cn lm sng 7.2. Chn on nguyn nhn - Thp tim: da vo lm sng - tin s. - Vim ni tm mc nhim khun: cy mu (+) - Nhi mu c tim. - Sa van 2 l. 7.3. Chn on bin chng - Ri lon nhp tim - Suy tim tri - suy tim phi - suy tim ton b. - Ph phi cp. - Tc mch no. - Thp tim tin trin. - Vim ni tm mc. 7.4. Chn on th 7.4.1. Th n thun 7.4.2. Th phi hp - Vi hp van 2 l - (hp h van 2 l). - Vi h van ng mch ch. 8. IU TR 8.1. Ni khoa - V ni khoa khng c thuc cha h thc tn. - tuyn c s: ch yu iu tr bin chng do h van 2 l gy nn nh: 8.1.1. iu tr ri lon nhp tim bng cc thuc chng lon nhp, c bit l rung nh. 8.1.2. iu tr suy tim bng tr tim Digoxin, li tiu Trofurit, an thn seduxen, kali gluconat... 8.1.3. Nu c cn ph phi cp th phi iu tr cn ph phi cp. 8.1.4. iu tr thp tim tin trin bng khng sinh, corticoid. 27

8.2. Ngoi khoa Phu thut lm nh l h hoc thay van 2 l. 9. PHNG BNH - cng ng vic quan trng nht l pht hin ra h van 2 l c phng php phng thp tim kp thi hu hiu. Thy thuc pht hin v x tr ng lc vim hng do lin cu tim Pemcillin chm 1 thng 2.400.000 n v. - Ci thin mi trng sng, vn ha, kinh t. - Sau khi tn thng van, pht hin sm phng bin chng, ko di sc lao ng v tui th.

28

H VAN NG MCH CH
1. I CNG 1.1. nh ngha H van ng mch ch l s ng khng kn van sigma ng mch ch trong thi k tm trng gy tro ngc mu t ng mch vo trong tht tri. 1.2. Dch t hc H van ng mch ch chim 15% trong s cc bnh tim. - L bnh van tim mc phi ng th 2 sau hp van 2 l. - Hai nguyn nhn thng gp nht l thp tim (gp cc nc km pht trin) v lon dng va x ng mch (cc nc pht trin). 2. NGUYN NHN 2.1. H van ng mch ch mn tnh 2.1.1. Thp tim: gp ngi tr, tn thng do thp tim gy dy v co rt cc l van gi l bnh corigan. 2.1.2. Bnh lon dng ng mch ch: gy h hi l van hoc vng van (va x ng mch, gi l bnh Hodgson). 2.1.3. Cc nguyn nhn khc him gp - Giang mai giai on III (gome giang mai). - Vim ct sng dnh khp (bnh Becherew). - Vim khp dng thp. - Lupus ban ri rc, bnh Takayasu. 2.2. H van ng mch ch cp tnh 2.2.1. Vim ni tm mc nhim trng (Osler) 2.2.2. H van ng mch ch sau chn thng 2.2.3. Phnh tch ng mch ch (kiu I hoc II) Cc nguyn nhn ni trn c th gy tn thng h thng van ng mch, ch yu mt ni tm mc (thp tim), mt ni mch mc (va x ng mch, giang mai III) hay vng l van (hi chng Marfan). 3. SINH L BNH 3.1. Tht tri Do b h van ng mch ch nn tht tri phi bp mnh hn tng ht lng 29

mu tro ngc trong thi k tm trng. C ch b tr ny bo m cung lng tim bnh thng trong nhiu nm. Sau phn s tng mu gim, lc u l sau gng sc v sau c lc ngh ngi v ph i ri cui cng dn n suy tim tri. 3.2. Huyt ng S tro ngc mu lm cho ng mch rng, xp, huyt p ti thiu gim thp, th tch mu cui tm trng tht tri tng ln, km theo tht tri bp mnh lm cho ng mch ny mnh, huyt p ti a tng trong k tm thu, hiu p tng gy ra cc triu chng lm sng ngoi vi. 3.2.1. Lng mu pht ngc tht tri tu thuc vo 3 yu t. - ln ca b mt h. - chnh p tm trng gia ng mch ch v tht tri. - di ca k tm trng. 3.2.2. Hin tng suy vnh trong h van ng mch ch nng l do: - Gim p lc ng mch tm trng (ti mu vnh thc hin k tm trng). - Tng p lc cui tm trng ca tht tri. - Tng khi lng c tim. 3.2.3. Trong trng hp h ch cp tnh thi cc du hiu suy tim xut hin sm do cc c ch thch nghi ca tht tri khng c th gian pht ng 4. TRIU CHNG 4.1. Lm sng 4.1.1. Triu chng c nng - Khng c triu chng c nng trong mt thi gian di mt s trng hp h van ng mch ch. - Khi h van ng mch ch nng bnh nhn c cm gic kh chu, tim p mnh c hi hp nh trng ngc hoc c au tht ngc do suy vnh c nng. Triu chng au ngc s ht rt nhanh khi s dng - Khi c suy tim tri th trn lm sng c du hiu tng p lc tiu tun hon: kh th, ho khc ra m ln mu. 4.1.2. Triu trng thc th 4.1.2.1. Ti tim (trung tm) - Nhn mm tim lch sang tri, din p mm tim rng, p mnh. - S: mm tim di mnh vo lng bn tay. - G: din c tng i ca tim to v bn tri. 30

- Nghe: van ng mch ch hay ecbtkin nghe c ting thi tm trng, m sc m du, cng nh, lan xung mi c hoc mm tim. y l triu chng c bn nht chn on h van ng mch ch. - Ngoi ra cn nghe c ting thi tm thu km theo van ng mch ch. - Ting rung Flint mm tim. - y tim: ting T2 vang, ting cch m van sigma. 4.1.2.2. ngoi vi - Mch ny mnh chm su (mch corigan) - Huyt p ti a tng, huyt p ti thiu gim, lm cho hiu s huyt p ti a v huyt p ti thiu tng ln. - C du hiu nhp nhy mng tay. - ng mch i: nghe ting thi i Dieusier. - ng mch p qu mnh gy u gt theo nhp tim (du hiu Musset). - ng mch li g lc hng, lc ti. 4.2. Cn lm sng 4.2.1. in tim - Trc tim lch tri, dy tht tri kiu tng gnh tm trng. 4.2.2. X quang tim Tht tri, quai ng mch ch p mnh cung di tri gin, ng mch ch gin v di ra, c du hiu tr tiu tun hon. - o ch s tim ngc gredel > 50%. 4.2.3. Siu m - Siu m - Doppler c th chn on h van ng mch ch nhy >93%, trong khi lm sng v tm thanh ch c 82%. - Siu m TM v 2D cho thy du hiu gin tip ca h van (l trc van 2 l rung k tm trng) v tnh trng van ng mch ch (si trong vim ni tm mc). - Siu m Doppler c th ghi c dng mu pht ngc t quai ng mch ch tr v tht tri, kch thc bung tht tri gin to. 5. CHN ON 5.1. Chn on xc nh 5.1.1. tuyn c s. chn on tng i d vi th n thun trong ch yu da vo nghe ting thi tm trng v du hiu ngoi vi: huyt p ti a tng cao, huyt p 31

ti thiu gim thp. 5.1.2. Tuyn trn: trong nhng trng hp kh th ta phi da vo siu m Doppler hoc thng tim chp mch. 5.2. Chn on phn bit 5.2.1. H van ng mch phi Nghe khoang lin sn II bn tri xng c c ting thi tm trng Graham Steel km theo c du hiu tng p lc ng mch phi nghe T2 vang mnh tch i, khng bao gi c du hiu ng mch ngoi vi. 5.2.2. Vi hp van hai l phi hp Phi phn bit rung Flint v rung tm trng. 5.3. Chn on nguyn nhn 5.3.1. Da vo tui - S sinh: bm sinh - Tr tui: 7 - 14 tui: do thp tim - Trung nin: do giang mai III - Gi: do x va ng mch 5.3.2. Da vo xt nghim - Cy mu (+) nguyn nhn do Osler - BW (+): nguyn nhn do giang mai III - Yu t thp (+) nguyn nhn do cc bnh t min Becherew, vim a khp dng thp. 5.3.3. Da vo c ch bnh sinh - Nu h van ng mch ch + Hp van 2 l nguyn nhn chc chn do thp tim. - Nu h van ng mch ch + nt phng ng mch - nguyn nhn do giang mai giai on III. - Nu h van ng mch ch + cholesterol mu tng cao nguyn nhn do x va ng mch. 5.4. Chn on th 5.4.1. Th n thun - H van ng mch ch c tnh: t gp, tin trin nhanh trong vi thng suy tim ton b, t vong. - H van ng mch ch do thp tim. 32

- Du hiu ngoi vi r, thng phi hp vi hp van 2 l. - H van ng mch ch do giang mai. Tui kh ln (> 30) do vim ng mch ch gy tc l M vnh hay lm au tht ngc. Xquang ng mch ch gin nhiu, ngon ngoo, phn ng huyt thanh giang mai BW (+); tin trin xu. - H van ng mch ch do Osler: Do vi khun, van b si, tin trin nhanh, nng. - H van ng mch ch c nng: do tng huyt p hoc va x ng mch (Hodgson): ln tui, gin van ng mch ch gin rng mch ch ph i tht tri. Nghe thi tm trng v tng huyt p nh hn, du hiu calci ha ng mch ch hay gp, dung np tt hn. - Do phnh tch ng mch ch: tin s au ngc ging nhi mu c tim nhng khng c du hiu in tim ca nhi mu, au ngc cp d di, d t vong. 5.4.2. Th phi hp: thng gp - Vi hp van hai l: trn in tm dy c 2 tht 4/6 van ng mch ch km theo rung mu tm thu. - Vi h van hai l thc th hay c nng. 5.5. Chn on bin chng Bnh c biu hin triu chng nh trong thi gian kh di nhng mt b t ngt. - Gy vim ni tm mc bn cp Osler. - Thp tim ti pht sau vim hng cp. - Tc mch: no, thn, chi, lch - Suy tim tri biu hin cn hen tim hoc OAP. 6. IU TR 6.1. Ni khoa: c th thc hin tuyn c s. 6.6.1. Th nh: ch c hot ng th lc nh, lm ngh t tn sc, c th dng an thn. 6.1.2. Th va v nng c suy tim: iu tr suy tim nu au tht ngc c th chn thuc gin vnh nh Trinitrin, iu tr suy tim bng thuc tr tim Digoxin, li tiu (Thiazid, Furosemid...) l rt r tin thc hin d dng tuyn c s ngay c thuc gin mch. 6.1.3. Phng bnh vim ni tm mc nhim khun bng iu tr tt mi nhim khun c bit nhim khun ng h hp. 33

6.1.4. iu tr nguyn nhn: thp tim, giang mai, x va ng mch... 6.2. Ngoi khoa 6.2.1. Thay van nhn to: ch c th thc hin trung tm tim mch chyn su. Nu c iu kin nn gi bnh nhn ln tuyn trn khi ngi bnh c triu chng c nng. - Ch nh: + H van ng mch ch cp tnh + H van ng mch ch mn tnh Triu chng c nng 3, siu m c FR (Phn s co hi) < 25% ng knh cui tm trng tht tri > 70mm, ng knh cui tm thu tht tri > 55mm. + Chp bung tim c FE (Phn s tng mu), < 50% X quang c t l tim/1ng ngc >60%. T l t vong 3 - 5%. 7. TIN LNG H van ng mch ch khi c suy tim t l t vong 25% trong 5 nm. Nu suy tim tin trin nng th t vong trc 2 nm. 8. PHNG BNH - Tng t 6 thng phi iu tr d phng Osler k c bnh nhn h ch nh, va v nng. - Phi gim hot ng th lc ngay t khi chn on h van sigma ng mch ch d bnh nhn cha c biu hin cc triu chng c nng trn lm sng. - Phi hn ch mui v cho bnh nhn dng li tiu thi mui. - Dng thuc tr tim Digoxin sm ngay c khi cha c cc triu chng suy tim. - Thuc gin mch dng nhm Nitrat thng xuyn c tc dng chm v ko di nht l khi bnh nhn hay c triu chng au ngc. - Phi iu tr tch cc nguyn nhn gy ra h van ng mch ch v phi phng Osler v rt d xy ra trn mt ngi h ch. - Phi phng thp tim nu nguyn nhn gy h van ng mch ch l do thp.

34

HP VAN NG MCH CH
1. I CNG 1.1. nh ngha Hp van ng mch ch l tnh trng van ng mch ch m ra khng ht nn cn tr dng mu t tht tri ra ngoi vi trong thi k tm thu. 1.2. T l mc bnh L mt bnh t gp hn cc bnh van tim khc nh hp van 2 l hoc h van ng mch ch. Thng gp ngi tr tui do thp tim. T l mc bnh nc ta cng nh cc nc khc thp (ng Vn Chung 1971). 2. NGUYN NHN GY BNH 2.1. Thp tim Gp ngi tr tui. Tn thng van mt ni tm mc, cc van dnh vi nhau gy hp van. 2.2. X va ng mch ch Gp ngi gi, tn thng van t pha ni mch mc ca van. 2.3. Hp van ng mch ch c van calci ha cha r nguyn nhn. 2.4. Bnh bm sinh Khng c 3 l van r rt m ch c mt mng c l nh gia. 3. GII PHU BNH - Bnh thng l van sgma ng mch ch khong 3cm2, 3 l van ring bit nhau v mng. - Khi hp van ng mch ch: + L van nh hn li, khng cho lt c ngn tay. + Cc van sigma b dy, cng, mp van dnh vo nhau ch h gia mt l trn nh: v van b x cng khng c ng c nn l khng th to ra c. Trong thi k tm trng, van cng khng khp cht c nn bao gi cng c h km theo. + Hp van ng mch ch n thun rt t, phn nhiu u phi hp vi h nhng hp l ch yu. + Nu nguyn nhn do thp tim: cc mp van dnh vi nhau. 35

+ Nu do x va ng mch: tn thng t vch ng mch ch lan dn n van lm van phng ra khng khp li c v gy ra tn thng nhim vi rt cng. + Cc tn thng ni trn cng lan n xung quanh l ng mch vnh v lm hp cc l y. 4. SINH L BNH - V hp van ng mch ch nn tht tri phi tng cng sc bp m bo lu lng mu cho c th. Do dy v to. ra. Khi bnh nhn gng sc lu lng mu khng na nn bnh nhn thng b ngt khi gng sc do thiu mu no. - V l ng mch vnh b hp nn mu vo ng mch vnh t hn nn cn au tim xut hin. - p lc tm thu trong tht tri tng cao nhng p lc tm trng trong ng mch ti thp. S chnh lch cng cao nu hp cng kht.

5. TRIU CHNG 5.1. C nng - Ngt khi gng sc (15-20%) hoc thip i rt nhanh trong vi giy ri tnh ngay. - Cn au tim (50%) lc gng sc. - Kh th. 5.2. Thc th * S: khoang lin sn II bn phi xng c ( van ng mch ch) c rung mu tm thu (86%). * Nghe: - Ting thi tm thu van ng mch ch. + Cng 5/6 - 6/6. + Chim ht thi k tm thu. + Lan ln xng n phi, ln vai phi. - Ting thi tm trng: nh hn (l/6) c trong 50% trng hp. - Ting T2 m hoc khng nghe thy (57%). - Nhp tim u, mch nghe yu. - Huyt p: tr s ti a thp hoc bnh thng. - Tr s ti thiu h (nu c h km theo) 36

5.3. Xquang - Tht tri to - ng mch ch to - C th thy van b calci ha khi chp. 5.4. in tm - Ph i tht tri, tng gnh tm thu. - Trc tri, dy tht tri. Ch s RV5 + SV5 35mm R rt cao V5, V6, T m V5, V6 5.5. Tm thanh Ta ghi c ting thi tm thu kiu pht v hnh qu trm. 6. CHN ON 6.1. Chn on phn bit 6.1.1. H van ng mch ch: c t ra khi c km theo ting thi tm trng - Ting thi tm thu nh. - Khng c rung mu. - Huyt p ti a tng cao. 6.1.2. Vim ng mch ch km theo h ng mch ch - C ting thi tm thu nhng khng c rung mu. - Ting T2 vang. 6.1.3. Hp van ng mch phi - Nghe thy ting thi tm thu khoang lin sn III, IV bn tri lan ln trn hoc sang tri. - Huyt p ngoi vi khng thay i. 6.2. Chn on xc nh - Ting thi tm thu rt to khoang lin sn II bn phi xng c lan ln xng n phi. - Rung mu tm thu. - Ting T2 nh hoc mt. - Mch yu, huyt p ti a v ti thiu h. - Thng tim tri c s chnh lch gia p lc tht tri v ng mch ch. 37

6.3. Chn on nguyn nhn 6.3.1. Da vo tui - Tr tui: thp tim - Gi: x va ng mch ch 6.3.2. Nu hp van ng mch ch kt hp vi hp van hai l hoc h van 2 l th chc chn do thp tim 6.3.3. Nu van b nhim vi - 50% cho rng n l mt bnh ring bit khng r nguyn nhn g. - 50% cho rng nhim vi l mt qu trnh khng c g c hiu. 7. IU TR 7.1. iu tr ni khoa Ch iu tr triu chng hoc cha suy tim khi bnh mt b. - tuyn c s vic pht hin sm bnh hp van ng mch ch iu tr sm ngn chn cc bin chng xy ra hoc chuyn bnh nhn ln tuyn trn c iu kin phu thut cho bnh nhn. - iu tr triu chng. + Dng thuc gin mch nhm Nht hoc Lenitral ngy 2V (2,5mg). Nu cn au tim xut hin. + Kt hp vi an thn v thuc chng lon nhp. - iu tr bin chng: + iu tr suy tim tri bng tr tim, li tiu, an thn, kim. + iu tr lon nhp tim bng thuc chng lon nhp. 7.2. iu tr ngoi khoa - M l b hp bng: + ng tht tri. + ng ng mch ch. - Thay van nhn to (Starr). * Ch nh phu thut - Bnh nhn tr di 50 tui. - Hp ng mch ch n thun hoc hp l ch yu. - Hp kht: da vo triu chng c nng nh ngt, au tim, s thay i ca mch v iu tr. 38

* Chng ch nh: - Bnh nhn ln tui > 50 tui. - Cha c ri lon c nng. - Phi hp vi h van ng mch ch r. - Suy tim - Tc ng mch vnh. * Cc trng hp: - Phi hp vi hp van 2 l. - Nhim vi cc van khng phi l nhng trng hp chng ch nh. 8. PHNG BNH - tuyn c s vic quan trng nht t ra l pht hin bnh sm c hng iu tr. - Phng thp tim: c bit ngi tr tui c tin s thp r. Dng Penicillin chm 2.400.000 UI/1 thng. - iu tr trit vim hng lin cu. - Phi c ch n ung, sinh hot, theo di rt st phng cc bin chng nh suy tim tri, Osler...

39

IU TR SUY TIM
1. NHC LI PHN CHN ON Mun chn on c mt bnh nhn suy tim thng thng ngi ta da vo: lm sng - Xquang - in tm - Siu m v mt s thm d ph tr khc, nhng thng thng tuyn c s ch yu da vo lm sng. d dng nh li chng ti nhc li nhng triu chng lm sng v cn lm sng chnh theo cch phn loi m ni phn trc. - Suy tim phi: + Triu chng c nng u tin l kh th vi tnh cht kh th t t tng dn khng c nhng cn kch pht, tu theo giai on m kh th c th nhiu hoc t. + Triu chng c nng tip theo l ph vi tnh cht ph tim ngha l ph chn trc, ph tm n lm, ph bui chiu nhiu hn bui sng, n nht c bt ph. + Triu chng thc th ti tim: din c tng i ca tim to v bn phi, c du hiu Harzer, nghe thy ting thi tm thu do h van ba l c nng. + Triu chng ngoi vi: huyt p ti a bnh thng huyt p ti thiu tng. Gan to vi tnh cht gan tim: b t, mt nhn, phn hi gan - tnh mch c (+). + Triu chng XQ: tim phi to y mm tim ln cao v sang tri, phi huyt. + in tm : trc in tim lch phi, dy tht phi. - Suy tim tri: + Triu chng c nng cng l kh th nhng thng l kh th tng cn xut hin sau gng sc hoc na m v sng. + Triu chng th hai l ho v ho ra mu trong cn hen tim v ph phi cp. + Triu chng thc th ti tim: tim to v bn tri, c th c ting nga phi tri, nghe thy ting thi tm thu do h van hai l c nng. + Ngoi vi: huyt p ti a gim, huyt p ti thiu bnh thng. + Xquang: tim to ch yu bn tri y mm tim chc xung, phi huyt ch yu l vng rn phi. + in tm : trc in tim lch tri - dy tht tri. - Suy tim ton b: c th ni y l bn bnh n tng hp ca c suy tim phi v suy tim tri nhng d nh chng ti tp hp thnh nm triu chng chnh. + Mt l: kh th thng xuyn vi tnh cht kh th ca suy tim. Mc kh th ph thuc vo mc suy tim. 40

+ Hai l: tim to ton b trn c lm sng v X quang. + Ba l: gan to vi tnh cht gan to do mu, mc cng ph thuc vo mc suy tim. + Bn l: ph vi tnh cht ca ph tim. + Nm l: tr tiu tun hon th hin trn lm sng l ran m phi v X quang l phi huyt. Trn y chng ti nhc li nhng triu chng chnh trn lm sng.v cn lm sng gip ch cho chn on iu tr c hiu qu. 2. PHN GII ON SUY TIM THEO NYHA Cho n nay c rt nhiu cch phn giai on suy tim nhng theo chng ti phn loi NYHA l cch n gin d nh d sp xp t s thng nht gip cho cng tc iu tra qun l v iu tr tt hn. NYHA phn suy tim lm 4 giai on. - Giai on 1 l giai on suy tim tim tng ngha l khng r rt, triu chng ch xut hin khi gng sc m triu chng hay c k n nht l kh th, ngha l kh th ch xut hin khi bnh nhn gng sc cho d l suy tim phi hay suy tim tri. - Giai on 2 l giai on suy tim r rt nhng khng ton b, ngha l tc nhn nh vo tim no trc th biu hin ca suy tim r rt cn tm tht kia bnh thng, v d hp van hai l mi ch biu hin suy tim phi. - Giai on 3 l giai on suy tim ton b cho d ch c tc nhn nh vo mt tm tht, v d hp van hai l c suy tim ton b nhng khi iu tr suy tim ng th suy tim hi phc. - Giai on 4: l giai on suy tim ton b iu tr khng hi phc. Vi cch phn giai on nh trn chng ta thy khi ni n giai on no ca suy tim th ta lin hiu ngay ngi bnh ang trong tnh trng nh th no v c thi x tr ng mc. 3. IU TR SUY TIM 3.1. Nhng nguyn tc chung Lm tng cung lng tim bng thuc tr tim hoc nhng thuc c tc dng lm tng cung lng tim. Lm gim tr tun hon bng n nht, li tiu, kim sot lng nc a vo c th. 3.2. Nhng bin php chung L nhng bin php c th p dng cho suy tim do bt c nguyn nhn no, bt c giai on no, c chng khc nhau mc can thip. 41

- Ch n v ung: ni chung ch n ca ngi b suy tim u cn hn ch Na nhng ty tng giai on suy tim m chng ta c th hn ch Na+ nhiu hoc t. Cn lng nc ung th khoa hc nht l da vo lng nc tiu 24 gi ca ngy hm trc + 200 - 300ml nc mt theo ng khc, ng nhin phi cng c lng nc trong thc n. Thng th ch hn ch nc ch p dng cho nhng ngi bnh suy tim giai on 3 tr i.
+

- Ch lm vic v ngh ngi: y ta khng t vn l ch lm vic trong x hi v vn ny khng ph thuc hon ton vo cn b y t. Chng ta ch t vn ngh ngi hp l trong tng giai on ca bnh. Bnh giai on cui th cn ngh ngi tuyt i ti thng v nhng vic lm khi khng suy tim th l nhng cng vic nh nhng nhng khi suy tim nng th li l cng vic cn gng sc. - Thuc li tiu: l thuc rt cn thit nhm lm gim tr tun hon v lm gim tin gnh trong suy tim, thuc li tiu thng c chn l Furocemid nhng tu nguyn nhn gy suy tim m ta c th thay i, v d suy tim trong tm ph mn ta nn chn thuc li tiu c ch men AC hoc suy tim trong tng huyt p ta li chn li tiu thi mui. Tuy nhin da vo lm sng ta iu chnh liu v thi gian dng cho thch hp. - Thuc tr tim: l thuc rt cn thit cho tt c cc loi suy tim nhng cn nm vng tc dng, tc dng ph cng nh chng ch nh ca tng nhm thuc. Suy tim c nhp nhanh khng c ngoi tm thu th tt nht l Digoxin thuc nhm Digitalis liu dng thng bt u bng 1-2 vin 0,25 m ri tu tc dng, thng l da vo nhp tim v tnh trng lm sng m gim dn liu, khng nn qu 10 ngy cho mt t iu tr. Nhng trng hp suy tim cp cn tc dng nhanh hoc suy tim khng c nhp nhanh ta dng nhm Strophantus bit dc hay dng l Ouabain ng 0,25mg tim tnh mch, ngy dng 1-2 ng ty trng hp c th, t iu tr t 5-10 ngy. - Thuc gin mch: l thuc mi c a vo nhm lm gim tin gnh hoc hu gnh nhm ci thin tnh trng huyt ng trong suy tim. Cc thuc gin mch thng khng c ch nh trong nhng trng hp suy tim c huyt p tm thu <90mmHg. Nhng thuc hay c dng l : + Gin tnh mch nhm lm gim tin gnh l Lenitral 2,5mg x 1-2 vin. + Gin ng mch nhm lm gim hu gnh i din hay c dng l nhm chn dng calci: Adalat thuc ny t lm gim sc co bp c tim. + Lm gin c ng mch v tnh mch l thuc c ch men chuyn: hay dng nht l Coversyl 4mg. - S dng cc Amin ging giao cm thng c dng trong nhng trng hp Shock tim hoc tr vi cc thuc khc v thuc ny cng lm tim tng sc co bp. 42

Tt nht l Dobutamin hoc Dopamin. - S dng thuc chng ng: trong suy tim nht l nhng trng hp suy tim mn, mu li cc c quan rt d hnh thnh cc cc mu ng t gy nhng bin chng khng lng c. Thuc chng ng thng c s dng khi c thm lon nhp nht l lon nhp hon ton. ng ra thuc chng ng ch c dng l Heparin nhng do s phc tp ca nhng xt nghim cn theo di khi dng n, nn theo chng ti dng thuc phin phc v nguy him ta nn dng Aspirin bit dc l Aspirin PH8 500mg mi ngy mt vin ko di, iu cn lu l tc dng kch ng nim mc d dy ca PH8. phng bng cch khng dng cho nhng ngi c tin s bnh d dy v hnh t trng. 3.3. iu tr theo nguyn nhn Ngoi nhng bin php chung, nhng ngi bnh suy tim c nguyn nhn r rng c th iu tr c th ta p dng nhng bin php c th cho tng nguyn nhn. - Suy tim trong cng gip trng: phi phi hp iu tr tch cc cng gip trng th ng nhin tnh trng suy tim s c ci thin. - Suy tim trong thiu vitamin Bl th ng nhin phi bi ph vitamin Bl, tt nht l bng ng tim v c nhng ngi khng hp th c vitamin Bl bng ng ung. - Suy tim do ri lon nhp tim nht l nhng trng hp suy tim do Block nh tht, nht l cp 3 s khng c g thay th tt bng my to nhp. - Suy tim trong nhi mu c tim th tt nht l can thip trc tip vo ch ng mch vnh b tc c th l nong hoc lm cu ni. - Suy tim trong cc bnh van tim mc phi hoc bm sinh th ngoi nhng bin php chung ch l tm thi, ta phi can thip thay van hoc sa nhng khuyt tt bm sinh mi hy vng ci thin c tnh trng suy tim mt cch lu di. Tm li: suy tim khng phi l mt bnh nhng n gy ra khng t s nguy him cho i sng v sinh hot ca ngi bnh. Cho n nay khng c bin php no duy nht c th iu tr c nn ta phi phi hp nhiu bin php, da vo tng trng hp c th khng nn b st mt bin php no cho d bin php n gin.

43

IN TM NG DNG TRONG LM SNG

1. NHHG KHI NIM C BN V IN TM 1.1. nh ngha - in tm l mt ng cong ghi li s bin thin ca dng in do tim khi hot ng pht ra. - in th rt nh, ch tnh bng mihvn nn rt kh ghi, n nm 1903 ln u tin Einthoven ghi c n bng mt in k c y mc nhy cm. - Ngy nay, ngi ta sng ch ra rt nhiu loi my ghi in tim. Cc my c b phn khuych i bng n in t hay bn dn ghi in tm trc tip ln giy hay v ln mn hunh quang. Ngoi ra, chng cn c th ghi ng thi c nhiu chuyn o cng mt lc lin tc 24 gi trn bng ca mt my nh gn vo ngi (Cardio Cassette type Holter). 1.2. Phng php ghi in tim Phng php ghi in tim cng ging nh cch ghi cc ng cong bin thin tun hon khc. Ngi ta cho dng in tim tc ng ln mt bt ghi lm bt ny dao ng qua li v v ln mt mt bng giy. N c mt ng c lm chuyn ng u v lin tc theo mt vn tc no nh th ta c mt ng cong tun hon gm nhiu ln sng bin thin theo thi gian: l in tm . in tm c th coi l mt th c honh l thi gian v tung l in th ca dng in tim. Ty theo in th ny cao hay thp, bt ghi s vch ln giy mt ln sng c bin cao hay thp. 1.2.1. Thi gian Ta in sn trn giy nhng ng k dc cch nhau 1 mm. Nh vy khi cho giy chy theo: - Vn tc 25mm/s th mi 1 mm c gi tr 0,04 sec. - Vn tc 50mm/s th mi 1 mm c gi tr 0,02 sec. - Vn tc 12,5mm/s th mi 1 mm c gi tr 0,08 sec. 1.2.2. Bin Ngi ta in sn ln giy nhng ng ngang cch nhau mm. Trc khi cho dng in tim chy vo my, ngi ta phng vo mt dng in 1 milivn (1mv) v vn nt iu chnh sao cho bt ghi dao ng va ng mt bin 10 (10 mm = 1 cm). C 3 cch test bin 1 mV = 10 mm (1N) 44

0,5 mV = 5mm (N/2) 2 mV = 20mm (2N) Thng thng ta hay cho my chy tc 25 mm/s v test bin l 1N (10mm) 2. C CH IN SINH L HC CA C TIM 2.1. Dng in do tim pht ra v u? Ngy nay khoa in sinh l hc hin i cho ta bit r l do s bin i hiu th gia mt trong v mt ngoi ca mng t bo c tim. S bin i hiu th ny bt ngun t s di chuyn ca cc con (K+, Na+...) t ngoi vo trong t bo v t trong t bo ra ngoi khi t bo c tim hot ng, lc ny tnh thm thu ca mng t bo i vi cc loi ln lun lun bin i. Khi t bo bt u hot ng (b kch thch), in th ngoi mng t bo s tr thnh m tnh tng i (b kh mt cc dng) so vi mt trong. l hin tng kh cc (dpolarisalion). Sau , t bo dn dn lp li th thng bng con lc ngh, in th mt ngoi tr li ng tnh tng i (ti lp cc ng) l hin tng ti cc (repolarisalion). 2.2. S hnh thnh in tm - Tim l mt c rng, gm 4 bung dy mng khng u nhau, co bp khc nhau. Cu trc phc tp l lm cho dng in hot ng ca tim (kh cc v ti cc) cng bin thin phc tp. - Tim hot ng c l nh mt xung ng truyn qua h thng thn kinh t ng ca tim. u tin, xung ng i t nt xoang ta ra c nh lm cho nh kh cc trc, nh bp trc y mu xung tht. Sau nt Tawara tip nhn xung ng truyn qua b His xung tht lm tht kh cc. Hin tng nh v tht kh cc ln lt trc sau nh th chnh l duy tr qu trnh hot ng bnh thng ca h thng tun hon. iu lm cho in tim gm c hai phn: mt nh ghi li dng in hot ng ca nh i trc v mt tht , ghi li dng in ca tht i sau. 2.2.1. Nh Xung ng t nt xoang s ta ra lm kh cc c nh t trn xung di t phi sang tri. Nh vy vect kh cc nh s c hng t trn xung di v t phi sang tri lm vi ng ngang mt gc + 49o gi l trc in nh. Lc ny in cc B s dng tnh tng i v my s ghi c mt sng dng gi l sng P. Do trc in nh cn gi l trc sng P gi l AP (PAxis). Khi nh ti cc, n pht ra mt dng in ghi ln my mt sng m nh gi l Ta (auricular T), nhng ngay lc ny cng xut hin kh cc tht (QRS) nn trn in tm khng thy c Ta na. Do nh ch cn li sng P. 2.2.2. Tht 45

* Kh cc tht bt u t phn gia mt tri vch lin tht i xuyn sang mt phi vch ny, my s ghi c mt sng m nh gi l sng Q. - Sau xung ng truyn xung tin hnh kh cc ng thi c 2 tm tht trn my ghi c mt sng dng cao, nhn gi l sng R. - Sau cng kh cc nt vng y tht t tri sang phi, my ghi c mt sng m, nhn gi l sng S. Tm li kh cc tht bao gm 3 sng QRS gi l phc b QRS c thi gian 0,07 sec. Nu ta tng hp 3 vect kh cc QRS trn li ta c mt vect kh cc c hng t trn xung di, t phi sang tri lm vi ng ngang mt gc khong 58o gi l trc in tim (QRS Axis). * Ti cc: tht kh cc xong s qua mt thi k ti cc chm, biu hin trn in tm l mt on ng in gi l on ST. Sau n thi k ti cc nhanh (sng T). Tm li: tht gm c hai giai on. - Giai on kh cc bao gm phc b QRS. - Giai on ti cc gm ST v T (gi l pha cui) thi gian tht gi l QT khong 0,36 sec. 3. CC BC CHUN B GHI IN TM 3.1. Chun b bnh nhn Bnh nhn phi c khm v chn on lm sng trc, nht l tuyn di cng ng c chn on lm sng. - Ngh ngi trc khi ghi in tim 15 pht, khng n ung, khng hot ng. - Nm nga trn ging ghi, u bng. 3.2. Chuyn mn - Cm dy t. - Cm in ngun. - Vn hnh my th, bi past vo in cc. - Mc in cc. Khi ghi cc chuyn o thng dng ngi ta thng t in cc cc chi (c tay, c chn) v trn lng ngc vng trc tim. Theo quy c quc t. - Mu t tay phi. - Mu vng t tay tri. - Mu xanh l cy t chn tri. 46

- Mu en cho in cc (dy t) chn phi. - Cc mu khc: xanh, nu, tm cho in cc lng ngc. * Ghi in tim ln lt t DI n V6 4. CC CHUYN O THNG THNG (12 CHUYN O) 4.1. Cc chuyn o mu - Chuyn o DI. in cc m c tay phi, in cc dng c tay tri. - Chuyn o DII: in cc m t c tay phi, in cc dng t c chn tri. - Chuyn o DIII. in cc m t tay tri v in cc dng chn tri. 4.2. Chuyn o n cc chi Khi in cc thm d c t mt chi th ta gi l chuyn o n cc chi. Thng ngi ta t 3 v tr. - VR: c tay phi n thu c in th m bn phi v y tim. - VL: c tay tri n o c in th pha tht tri. - VF. c chn tri n l chuyn o nhn thy c thnh sau di y tim.

VR, VL, VF gi l chuyn o n cc chi tng thm.

4.3. Cc chuyn o trc tim Ngi ta t ghi ng lot cho bnh nhn 6 chuyn o trc tim, k hiu bng ch V (Voltage) km theo ch s t 1 6. - V1: khoang lin sn 4 bn phi, st b xng c. - V2: khoang lin sn 4 bn tri, st b xng c. - V3: im gia V2 v V4 - V4: mm tim. - V5: giao im ca ng nch trc vi ng ngang qua V4 - V6: giao im ca ng nch gia vi ng ngang i qua V4-V5 V1V2: l chuyn o trc tim phi. V5V6: l chuyn o trc tim tri. V3V4: l chuyn o trung gian. 4.4. Cc chuyn o khc - V3R, V4R, V5R, V6R: in cc m phi lng ngc nghin cu tht phi. - V7, V8, V9: in cc m tri v sau lng ngc thm d tht tri. 47

- Chuyn o thc qun (VOE), chuyn o trong bung tim, in th b His.

5. HNG DN C MT IN TM 5.1. Trc khi c ta phi nm vng tui, gii tnh, chn on lm sng ca bnh nhn - Bnh nhn gy, bo, cao, thp: v n nh hng rt nhiu n t th tim, bin sng, chn on dy tht. - C ang dng thuc tr tim hay thuc chng lon nhp di ngy khng. 5.2. Kim tra k thut ghi in tim Pht hin ghi sai, nh hng tp, milivon ly ng 1 cm khng? Tc ghi bao nhiu. 5.3. Nhp tim 5.3.1. C cn nhp xoang hay khng xoang? Khng xoang l ri lon nhp g. Tiu chun 1 nhp xoang. - y 5 sng PQ RST. - PQ 0,20s. - P ng trc QRS. 5.3.2. Tnh tn s tim Tn s/tht (R) - Dng thc tnh tn s (nhanh v thun tin). - Theo cng thc

Tn s nh (f) trong nhng trng hp rung nh th o 10 khong (f) sau t vo thc tnh. 5.4. Trc in tim Gc , c hai cch tnh gc . 5.4.1. Cch 1 Nhn trn 6 chuyn o ngoi vi xem chuyn o no trit tiu nht th ta ly chuyn o lm mc, ri ly chuyn o vung gc vi n v suy ra gc . Ta c: + 90o DI aVF 0o 48

- 30o DII aVL + 60o + 30o DIII aVR + 120o 5.4.2. Cch 2 Phng php h khong DI v DIII 5.4.3. Trc n tim bnh thng Bnh thng gc = + 58 + 65o gi l trc bnh thng hay trc trung gian. 5.4.4. Trc n tim bnh l - Trc phi: gc : + 90o -150o tim ng - Trc tri: gc : 0o - 90o do tng gnh tht tri. 5.5. T th in hc ca tim 5.5.1. ngi bnh thng - T th tim trung gian: gp ngi c chiu cao trung bnh. - Tim ng: ngi cao, lng ngc hp (nam gii) - Tim nm: ngi thp, lng ngc rng (n gii). 5.5.2. ngi bnh - Dy tht phi do tim bm sinh hay c t th tim ng hoc na ng. - Dy tht tri hay c t th tim nm hay na nm. 5.5.3. Xc nh t th n hc ca tim da vo Chuyn o aVL v aVF ta s c 5 t th in hc ca tim. 5.6. Phn tch hnh dng cc sng 5.6.1. Sng P Biu th cho thi gian kh cc nh. P bnh thng l mt sng dng t u: DI, DII, aVF, V5,V6 - Thi gian: 0,05 - 0,08 sec. - Bin : 0,5 - 2mm. - Hnh dng sng P khi bnh l. 5.6.2. Khong PQ (PR) Biu th cho thi gian dn truyn xung ng t nh xung tht. - Bnh thng PQ = 0,11 0,20 sec. - PQ di 0,20 s Blck A/V cp I. 49

- PQ ngn < 0,11 sec Hi chng PQ ngn L.G.L. 5.6.3. Phc b QRS Biu th cho thi gian kh cc tht, bnh thng QRS = 0,07 sec. 5.6.4. on ST - ST ng in (ST bnh thng). - ST chnh ln cn gi l ST dng (ST+, ST) - ST chnh xung di ng ng in l ST m (ST (-), ST) - ST i ngang (un ngang). on ST bnh l + ST chnh ln hay chnh xung nh th thng l do nhp nhanh hay cng thn kinh. + ST chnh xung qu 0,5mm nhng i ngang hay dc xung nht l V5, V6 thiu nng vnh. + ST chnh ln v un cong th ngh ti nhi mu c tim cp. + ST chnh v un cong tri chiu vi QRS l tc dng ca glucozid tr tim. + ST chnh cng chiu vi T v tri chiu vi QRS ngh n dy tht, luc nhnh, hi chng W.P.W. + ST chnh hay ng in do tc dng ca nhiu bnh phi hp vi nhau gi l ST hn hp. 5.6.5. Sng T - Bnh thng T l mt sng dng khng i xng sn ln thoai thoi, sn xung dc. - Sng T bnh l: + T cao nhn, i xng: thiu mu c tim, bnh mch vnh. + T m: ri lon ti cc tht, ni chung T cng m su th cng bnh l hn. + T 2 pha kiu -/+ v kiu +/-. + T c dng qu trn trnh th nn ngh n ri lon in gii. + T dt hu ht cc chuyn o th phn ln l do phi hp vi gim bin ca QRS to nn hnh nh in th thp. 5.6.6. Khong QT. Khong QT bnh thng - Nu tn s tim 60 - 70 chu k/pht th QT: 0,36- 0,42 sec. n gii, QT hi 50

di hn. - Nu tn s tim nhanh QT ngn li. Ngc li nu tn s tim chm QT di ra. QT bnh l: - QT di phi ngh n cc bnh ni tit, ri lon th dch: h Ca++ mu, gim kali mu, thiu nng tuyn gip, m huyt cao, nhim c kim. - Cc bnh v tim: dy tht, luc nhnh, thiu nng vnh, thp tim, bch hu bin chng tim... - Tc dng ca thuc Quinidin v Procainamid. - QT ngn: tng kim mu, calci huyt tng trong cng cn gip, tc dng ca Digital. 6. MT S HI CHNG V BNH THNG GP 6.1. Tng gnh nh 6.1.1. Tng gnh nh tri Cn gi l dy nh tri hay gp trong hp van 2 l, h van 2 l, h van ng mch ch, tng huyt p. Triu chng trn in tm l: - P rng ra 0,12s: y l triu chng quan trng. - P 2 nh hay c mc. 6.1.2. Tng gnh nh phi Gi l dy nh phi hay gp nht trong bnh tm ph mn (P ph) ri n cc bnh tim bm sinh: bnh Fallot, hp ng mch phi, thng lin nh, hp h van 3 l... cc triu chng l: - P cao 3mm, nh nhn v i xng, gi l P ph. 6.1.3. Tng gnh hai nh Dy hai nh hay gp trong bnh hai l - ba l, bao gm cc triu chng ca dy nh tri v dy nh phi phi hp vo nhau rt nhiu hnh thi. P (tiu biu) va rng 0,12s, va cao ( 3mm) v c 2 nh hay c mc. - V1 thy P hai pha +/- hay m su. Phc b tht bao gi cng c du hiu dy tht phi hp vo. 6.2. Tng gnh tht 6.2.1. Tng gnh tht tri Nguyn nhn do tng huyt p, h hp van ng mch ch, hp eo ng mch ch, h van 2 l, thiu nng vnh... 51

Hnh nh trc tip V5V6: R cao ln. Gin tip V1 V2: S Su Cc ch S Sokolow - Lyon RV5 + SV1 35mm RV5 25mm; RV6 RV5 6.2.2. Tng gnh tht phi Nguyn nhn: hp van 2 l, tm ph mn, bnh tim bm sinh c tm (Fallot, thng lin nh, thng lin tht, thn ng mch chng...). Hnh nh trc tip chuyn o trc tim V1 V2: R cao. Gin tip V5 V6: S Su Vng chuyn tip dch sang tri. Ch s. RV1 + SV5 > 1mm RV1 7mm; V1 dng R/s 5.2.3. Tng gnh hai tht Nguyn nhn: bnh hai l - ng mch ch, tm ph mn, tng huyt p. Triu chng: tng gnh hai tht gm triu chng ca dy tht phi v dy tht tri phi hp. - R cao v STT m c V1 ln V5 V6 - Hoc R cao v STT m V5 V6 nhng li c trc phi mnh > + 100o - Hoc c dng hai pha RS vi bin cao V3 V4 6.3. Block nhnh: l ri lon dn truyn trong tht. 6.3.1. Block nhnh tri khng hon ton V5 V6: sng R gin rng c mc nh, c th c sng Q nh hay khng, nhnh ni in (0,04 - 0,055s), STT c th dng. V1 V2: dng rS c mc i khi l dng QS l hnh nh gin tip. 6.3.2. Block nhnh tri hon ton Triu chng quan trng nht khng th thiu l QRS, gin rng 0,12S. - V5 - V6: sng R gin rng, c mc nh, sng Q v S bin mt. + Nhnh ni in mun qu 0,055s. - V1 V2: dng rs c mc i khi QS (hnh nh gin tip). - V3V4: dng trung gian (RS). 6.3.3. Blc nhnh phi khng hon ton 52

- V3R, V1 c dng rsR vi R rng v nhnh ni in mun qu 0,03s, QRS: 0,08 - 0,10 sec. - V5 V6 c S rng. 6.3.4. Blc nhnh phi hon ton Triu chng quan trng nht l QRS gin rng 0,11s. - V3R, V1: + Dng rsR vi R gin rng, trt m hay c mc. + Nhnh ni in mun qu 0,055s, c khi qu 0,10s, hai du hiu trn gp li l hnh nh trc tip. -V5, V6, V7: dng QRS vi S gin rng, c mc gi l hnh nh gin tip. 6.4. Hi chng Wolf - Parkinson - White (W.P.W). 6.4.1. Nguyn nhn Bnh nhim khun, d ng, thoi ha, bnh mch vnh, thp tim, tim bm sinh, bnh Ebstein. 6.4.2. Triu chng - PQ ngn li < 0,12s. - Xut hin sng en ta, n l on trt m phn u ca phc b QRS. - QRS (bao gm c sng en ta, c thi gian qu di 0,10s - 0,12s, b tr cho PQ b rt ngn). - on STT bin i th pht ngha l tri chiu vi sng en ta. C 2 kiu: + Kiu A: sng en ta (+) tt c cc chuyn o trc tim khi cu Kent bn tri. + Kiu B: sng en ta (-) cc chuyn o trc tim phi v dng cc chuyn o trc tim tri khi cu Kent bn phi. 6.5. Hi chng Lown - Ganong - Levin (L.G.L) - Khong PQ ngn li < 0,12s. - QRS c hnh dng, thi gian bnh thng khng c sng en ta. 6.6. Bnh mch vnh in tm c mt gi tr rt ln trong vic chn on cc bnh mch vnh. 6.6.1. Thiu mu - T m, nhn, i xng nu thiu mu di thng tm mc. 53

- T dng, cao, nhn i xng nu thiu mu di ni tm mc. 6.6.2. Tn thng - ST chnh ln v cong nh ci vm gp c sng T gi l mt pha. - ST chnh xung, thng un: y l tn thng di ni tm mc. 6.6.3. Hoi t Xut hin mt sng Q su rng, c mc, trt m. 6.7. Nhi mu c tim 6.7.1. Giai on 1 (cp): 1, 2 ngy u. Sng cong vm, xut hin sng Q bnh l, QT di ra. 6.7.2. Giai on 2 (bn cp): t vi ngy n vi tun. - ST chnh ln thp hn, T (-) su nhn, i xng to thnh sng vnh Pardee. Sng Q bnh l r rt v QT di ra. 6.7.3. Giai on 3 (mn tnh): t vi thng n vi nm. ST ng in, T c th dng hay vn m, cn Q bnh l th thng tn ti vnh vin. - Nu 6 - 8 tun nu ST cn chnh ln th thng c phng thnh tim ch nhi mu. 7. CC RI LON NHP TIM in tm c mt gi tr rt ln trong vic chn on cc ri lon nhp tim cc tuyn c s, trn lm sng bng phng php nghe tim chng ta c th pht hin c mt s ri lon nhp tim thng gp sau kt hp vi ghi in tm c chn on chnh xc. 7.1. Ngoi tm thu L mt nht bp ngoi lai gy ra bi mt xung ng pht ra t xut v sm hn bnh thng t mt no ca c tim b kch thch. 7.1.1. Ngoi tm thu tht - Tht QRS gin rng 0,13s, trt m, c mc STT tri chiu khc hn vi nhp c s. Tht phi sm ngha l RR < RR, khong RR gi l khong ghp ca ngoi tm thu. Nu khong ghp ca tt c cc ngoi tm thu bng nhau mt , cn khong ghp khc nhau ngoi tm thu a , tin lng xu. - Ngoi tm thu ngh b, i km vo tht ngoi tm thu c mt sng P c th ri bt k trc, trong hay sau tht . 54

7.1.2. Ngoi tm thu trn tht - Tht QRST rt ging cc tht ca nhp c s. - Mt tht c km mt sng P sm (PP < PP). - Sng P thng bin dng (c mc, dt, m) khc vi P c s. 7.2. Cn nhp nhanh kch pht trn tht (Bouveret). - Nhp tim rt nhanh 140 - 220 chu k/pht, rt u. - Tht QRS c hnh dng bnh thng. - Sng P ln vo tht . 7.3. Cn nhp nhanh kch pht tht (nhp nhanh tht) - Tn s tim 160 - 170 chu k/pht. - QRS gin rng, trt m, c mc, ST v T tri chiu vi QRS. - P khng thy r. - Khng u. 7.4. Rung tht Khng cn hnh nh cc sng bnh thng na m thay bng mt dao ng ngon ngoo vi hnh dng, bin v tn s khng u. 7.5. Rung nh - Sng P v ng ng in u bin mt v c thay th bi nhng sng f l nhng sng ngon ngoo mo m, to nh di ngn khng u vi tn s (f) 400 chu k/pht. - R nht V1, V2, V3R. - Cc khong RR rt khng u nhau l hnh nh lon nhp hon ton. Tn s QRS c th nhanh 100 - 160 chu k/pht. - Hnh dng cc phc b QRST trn cng mt chuyn o c chi tit khc nhau. 7.6. Cung ng nh (Flutter nh) Sng P v ng ng in u bin mt v c thay th bi mt chui nhim sng f rt u nhau v ni ui nhau lin tc v tn ging nh rng ca hay sng nc dao ng. - Cc sng f c tn s (f) = 300 chu k/pht v bin ln hn sng P bnh thng. - Phc b QRST ni chung khng b bin dng, gin rng nhng v chng ln sng f nn trng c v mo m i. 55

- C cc loi cung ng nh 3/1, 4/1, 5/1... - Tn s QRS cn hay thay i (chuyn t loi 2/1 sang 3/1, 4/1 hay ngc li, nht l khi n nhn cu, tn s c th gim hn xung. - C trng hp trn mt on in tm c c rung nh v cung ng nh ta gi l rung cung ng nh.

56

HEN PH QUN
1. I CNG Hen ph qun l bnh bit n t rt lu. T hng ngn nm trc cng nguyn, ngi Trung Quc bit dng ma hong cha cn kh th, n th k XII Areteus m t cn hen ph qun v m. Dn dn ngi ta hiu bit c phn no c ch gy kh th, v mt lot cc thuc c sn xut iu tr v d phng. Hen ph qun l bnh rt ph bin, gp mi ni trn th gii, hin c khong 150 triu bnh nhn hen (theo T chc Y t Th gii). M c khong 6-8 triu ngi hen ph qun (B.Weiss). Anh nm 1992 - 1993 c 12% dn s mc hen ph qun, Australia l 11,9%. Vit Nam c khongl% dn s sng nng thn, 2% dn s sng thnh th mc hen ph qun, gp mi la tui ; chim 18,7% trong cc bnh phi (Chu Vn ), 25 - 30% (L Vn Tri - 1984). S ph bin ca bnh ph thuc vo kh hu v thin nhin vng bnh nhn sinh sng, t l mc bnh cc nc pht trin gp nhiu hn cc nc chm pht trin. Ngi ta ni nhiu n nguyn nhn ch yu l do s gia tng cc bnh d ng, s th ha, nhim mi trng, s dng rng ri ha cht, thuc, vacxin... C bnh nhn khng c cn hen ph qun trong thi gian ny, nhng c ngi li lin tc, sinh c th lm bnh hoc nng nn. Cui cng thng l tm ph mn tnh. Trong iu tr cn ch trng iu tr cn hen v iu tr d phng. nh ngha: hen ph qun l trng thi lm sng ca s phn ng cao ph qun do nhiu kch thch khc nhau, biu hin c trng l cn kh th vi ting c c do hu qu co tht c trn ph qun, ph n nim mc ph qun v tng tit dch nhy ph qun. Cn kh th c th hi phc (t khi hoc do iu tr). Hen ph qun l mt hi chng ch khng phi l mt bnh. 2. TN THNG GII PHU BNH Tu theo tng mc , c nhng biu hin sau: - i th: Nhng mng nhy, qunh dnh lp lng ph qun, nht l ph qun nh. C nhng vng ph nang b xp xen ln vng ph nang b gin. - Vi th: Trong lng ph qun c bch cu i toan, bch cu a nhn trung tnh, tinh th Charcot - Leyden, mng y nim mc dy v c thoi ha nhy, ph i c nim ph qun v cc tuyn, ph i mch mu. 57

3. TRIU CHNG 3.1. Triu chng lm sng Biu hin cn hen ph qun thng xy ra v m, khi thay i thi tit hoc khi tip xc vi d nguyn. - Giai on tin triu (triu chng bo trc): ht hi, s mi, nga mt hoc mt (do vim mng tip hp d ng), ho khan. - Giai on kh th cao : bnh nhn kh th chm, kh th ra, c ting c c, kh th tng dn, phi t tay vo thnh ging, i m ca th, mt, tot m hi, ting ni t qung, cn kh th ko di 5 - 10 pht hoc hng gi hoc hng ngy. - Giai on hi phc: cn kh th gim dn, kt thc l trn ho v khc m di trong qunh v dnh, cng khc nhiu cng cm thy d chu. Ht cn hen th bnh nhn ng c. Khm thc th trong cn hen thy: + G lng ngc: trong. + Nghe phi: r ro ph nang gim, c vng phi th b, c ting ran ngy v ran rt khp hai phi. Ngoi cn hen khng c g c bit. + Tim mch: nhp tim thng nhanh, huyt p tng, c khi lon nhp ngoi tm thu. 3.2. Cn lm sng - Xt nghim mu: t l bch cu i toan tng, bch cu a nhn trung tnh tng. - Xt nghim m: c bch cu i toan, tinh th Charcot - Leyden, bch cu a nhn trung tnh, i thc bo, vi khun. - Chn on hnh nh: chiu phi trong cn hen thy phi sng, rn phi m, khoang lin sn nm ngang v gin rng. - Chc nng h hp: (Ch lm sau cn hen) VEMS gim, dung tch sng bnh thng, ch s Tiffeneau gim. o lu lng nh thy thay i. - Phn tch kh mu (bng my Astrup): Hay lm, nht l trong cn hen nng. + PaO2 gim di 70 mmHg. + SaO2 gim trong cn hen nng. + pH mu gim khi toan h hp. - Soi ph qun: nim mc xung huyt, ph n, tng tit dch, ph qun co tht. - Prick test vi d nguyn nghi ng thy dng tnh. 58

- IgE trong mu tng. 4. PHN LOI HEN PH QUN 4.1. Hen ngoi sinh (hen d ng) c c im - Bnh xy ra tr em v ngi tr. - C tin s gia nh. - Tin s bn thn c mc bnh d ng (chm...). - Cn hen c lin quan vi d nguyn c hiu. - Test da: dng tnh. - IgE trong mu tng. - iu tr bng gii mn cm c hiu qu. - Tin lng tt, t t vong. 4.2. Hen ni sinh (hen nhim khun) c c im - Bnh xy ra ngi ln thng trn 35 tui. - Khng c tin s gia nh. - Tin s bn thn khng mc bnh d ng. - Cn hen lin quan n nhim khun h hp. - Test da: m tnh. - iu tr bng gii mn cm khng kt qu. - Tin lng khng tt hay c bin chng. 4.3. Phi hp gia hen d ng v nhim khun Bnh nhn ho ko di, khc m c. 4.4. Hen c tnh c c im Cn hen ko di hn 24 gi, c suy h hp nng, dng cc thuc thng thng khng c kt qu, c th t vong. 4.5. Cc th hen khc - Vim ph qun mn th hen: va vim ph qun mn, va c cn hen. - Hen do gng sc. 5. CHN ON 5.1. Chn on xc nh. Da vo: - Cn hen ph qun. - Cn hen xy ra trong nhng iu kin ging nhau: ban m, khi thay i thi 59

tit. - Chng kin c cn hen. - Thi gian: c cc cn hen xut hin trong 2 nm. Nh vy c th chn on xc nh c cn hen ph qun t tuyn c s. 5.2. Chn on phn bit - Hen tim: bnh nhn c cn kh th kch pht, kh th hai th, kh th nhanh, nghe phi c ran m nh ht y phi lan nhanh ln nh phi. Chiu hoc chp phi thy phi m do huyt. C th xy ra ngi b bnh hp van 2 l, tng huyt p. - Vim ph qun mn t cp: thng ngi ln tui, ngi gi, ngi c vim ph qun nng, c cn kh th ging nh hen, c biu hin nhim khun ng h hp. - Khi u v polyp kh ph qun: bnh nhn kh th lin tc, c c. Cn soi ph qun xc nh. - D vt ph qun: cn khai thc tin s kt hp soi ph qun xc nh. - Hch trung tht v khi u trung tht: chn p vo kh ph qun gy kh th, nghe phi c ran rt. Cn chp phi, chp ph qun xc nh. - Cn kh th do gng sc: ngh ngi s ht. 5.3. Chn on mc 5.3.1. Trc y - Cn hen mc nh: bnh nhn kh th nh, nghe phi thy c ran rt lan to. - Cn hen mc trung bnh: bnh nhn kh th nhanh, nghe phi c ran rt r, c biu hin suy h hp nh. PaO2 gim, PaCO2 tng. - Cn hen mc nng: biu hin suy h hp r, r ro ph nang mt. Tinh thn l ln, mch o ngc. PaO2 gim nhiu, PaCO2 tng nhiu, pH mu gim.

60

5.3.2. Hin nay (theo T chc Y t th gii)

Bc Triu chng Triu chng Lu lng Dao ng lu v m nh lng nh

1. Nh < 2 ln/ tun. cch - Khng triu chng v bnh thng cc < 2 ln/ thng 80% qung cn t pht. - Cc cn t pht ngn. 2. Nh 2 ln/ tun. dai dng - Cc cn t pht c th nh hng n 2 ln/ thng 80% sinh hot 3. Trung - Triu chng xy ra hng ngy. bnh dai - S dng thuc ct cn hng ngy. dng - Cc cn t pht nh hng n sinh > 1 ln 1 tun > 60-80% hot. - Cn t pht > 2 ln/ tun v ko di c ngy. 4. Nng - Triu chng xy ra lin tc. dai dng - Gii hn hot ng hng ngy. - Cc cn t pht xy ra thng xuyn. Thng xuyn 60%

< 20%

20 - 30%

> 30%

> 30%

5.4. Chn on nguyn nhn C nhiu nguyn nhn gy hen ph qun nhng hay gp l do d ng v do nhim khun. 5.4.1. D ng: (chim 50 - 60%). - Ht phi nhng cht v mi gy kch thch nh: phn hoa, bi nh, lng da cm, bi bng, bi g, bi kim loi, xng du, khi thuc l, ha cht, nm mc, vi khun... - Thc n: tm, cua, c, trng... - Thuc: Aspirin, penicillin, vacxin... cn gi hen d ng v hen ngoi sinh (Atopi). 5.4.2. Nhim khun Nguyn nhn nhim khun lm khi pht cn hen c ni n nhiu mc d c ch cn cha r gm virus, vi khun, cc nhim khun mn tnh nh: vim xoang, vim amydal, t nhim khun ng h hp lm bnh nng thm. 5.4.3. Do yu t vt l Thay i thi tit, nhit , gi ma, m... 5.4.4. Do gng sc 61

Sau gng sc (chy...) xut hin cn hen, hay c tr em, ngi tr tui. C ch cha r rng, cho rng khi gng sc s lm thay i nhit v p sut ca kh th vo gy kch thch nim mc ph qun. 5.4.5. Stress tinh thn Yu t tinh thn rt quan trng, nhng Stress tinh thn lm khi pht cn hen, c th lm bnh nng ln hoc gim nh. Ngi ta cho rng do ri lon cn bng thn kinh - th dch. 5.4.6. Cc yu t khc nh: c a di truyn (trong gia nh c ngi mc hen ph qun). 5.5. Chn on bin chng - Nhim khun phi do tp khun hoc lao phi. - Gin ph nang. - Trn kh mng phi. - Tm ph mn tnh (c th 5 - 10 nm sau). 6. IU TR V D PHNG 6.1. iu tr trong cn Nguyn tc: - Tng kh nng thng kh. - Gin c trn ph qun. - iu ho nc v in gii. C th: - Vi cn hen nh: + Theophyllin 0,1g x 4 - 6 vim 24h (hin nay t dng). + Kh dung Ventolin. + Seduxen 2,5 mg - 5mg /24h. + C th chm cu hoc bm huyt. - Vi cn hen trung bnh: + Nm u cao, ht m di. + Th oxy qua bnh nc, th hn hp oxy 70 - 75% qua ng thng. + Aminophyllin 0,24g x 1 ng (tim tnh mch chm 5 - 10 pht). + Hoc Adrenalin 1mg x 1 ng (tim bp hoc tim di da). 62

+ Nu khng , sau mt gi tim nhc li. + Kh dung Ventolin. + Khi iu tr cn hen nh v trung bnh, phng thc iu tr ny l ph hp vi tuyn c s. - Vi cn hen nng: + Nm u cao, ht m di, th oxy. Nu c suy h hp nng phi t ni kh qun, th my. + Corticosteroid: Depersolon hoc Solumedrol truyn tnh mch, c th kt hp Aminophyllin. + iu ho nc v in gii: qua ng ung v truyn dch: dung dch Glucose 5%, dung dch Natribicarbonat 14 + Nu khng , phi chuyn tuyn trn iu tr trnh suy h hp v nguy c t vong. 6.2. iu tr ngoi cn (d phng) - Hn ch v loi b tip xc vi d nguyn: thuc l, thuc lo, bi... - Gii mn cm bng d nguyn c hiu. - Khng vim Corticoid dng ht. - iu t cc nhim trng mi, hng, xoang... - Thay i ni lm vic v sinh sng, lm sch mi trng sng. - Trnh mi sang chn tinh thn. - Tp th dc liu php. - Bo v s bn vng ca mng t bo Mastocyte: Coromolyn ntal, Zaditen). - iu tr ngoi khoa: ct hch giao cm ngc (kt qu khng r). Kt lun: hen ph qun rt ph bin, gp mi la tui, nguyn nhn phc tp, c ch cha tht r rng, cha c thuc iu tr khi bnh. iu tr HPQ thng lu di, i hi cn c s hp tc cht ch gia thy thuc v bnh nhn d phng xut hin cn kh th, nhn bit sm cn hen, bit theo di tnh trng bnh n bnh vin kp thi. Cn phi phi hp nhiu phng php, gio dc sc khe qun l bnh nhn hn ch bin chng ca bnh v tai bin do iu tr.

63

VIM PH QUN CP, MN

Vim ph qun cp l tnh trng vim nhim nim mc ca ph qun ln v ph qun trung bnh. Bnh c th xy ra bt k tui no, nhng gp nhiu tr em v ngi gi, thng vo ma lnh v u ma xun. Biu hin lm sng chnh l ho v khc m nhy m, khi khi khng li di chng, nhng cng c th lm khi pht cn hen ph qun nhim khun. Vim ph qun mn l bnh thng gp, chim 5% dn s (Php), khong 47% ngi tui 55 (Anh). Cn gi l bnh phi tc nghn mn tnh, v c nh ngha nh sau: Vim ph qun mn tnh l tnh trng tng tit dch nhy ca nim mc ph qun, gy ho v khc m lin tc hay ti pht t nht l 3 thng trong 1 nm v t nht l 2 nm lin. 1. NGUYN NHN 1.1. Vim ph qun cp - Nhim khun ng h hp trn do vi khun v virus: vim mi, vim xoang, vim amydal. Thng do Staphylococus, hoc do Streptococus pneumonia (68,5% theo Nguyn Vn Thnh). Adenovirus, Hemophylus... - Do bnh truyn nhim: cm, si, ho g... - Ht phi hi c: Chlore, amoniac, khi thuc l, dung mi cng nghip... - Yu t d ng: c a d ng. - Yu t thun li: c th suy yu, suy tim, m, lnh, khi bi... 1.2. Vim ph qun mn - Thuc l, thuc lo. - Bi trong khng kh, kh hu m t. - Ngh nghip: cng nhn m than, luyn kim, dt, nha... - Nhim khun, d ng. - Tui, gii: thng trn 40 tui, nam gp nhiu hn n. - Yu t x hi: sinh hot thiu thn. 2. TRIU CHNG 2.1. Triu chng ca vim ph qun cp 2.1.1. Triu chng lm sng Bnh bt u bng vim long ng h hp trn, s mi, ht hi, rt hng, ho khan. Khi vim nhim lan xung ng h hp di l bnh ton pht, gm 2 giai 64

on: * Giai on kh: Bnh nhn cm thy cm gic rt bng sau xng c, tng khi ho. Ho khan hoc ng ng, ho tng cn, khn ting. Triu chng ton thn: st c th st cao 39-40oC, nhc u, mt mi, bing n. Khm phi c ri rc ran rt v ran m to hoc va ht. * Giai on t: Cm gic rt bng sau xng c gim v ht, kh th nh, ho khc m nhy, m vng m. Nghe phi c ran rt, ran ngy, ran m to v va ht. Din bin 4 - 10 ngy th khi hn. C trng hp ho khan ko di vi tun. C th bnh bt u rm r biu hin st cao, ho nhiu, ho ra mu... 2.1.2. Triu chng cn lm sng - Xquang phi: rn phi m. - Xt nghim mu: s lng bch cu tng, tc mu lng tng. 2.2. Triu chng ca vim ph qun mn 2.2.1. Triu chng lm sng a s gp tui 50, nam gii, nghin thuc l, thuc lo. Bnh thng din bin m thm, sau biu hin cc triu chng sau: Ho v khc m vo bui sng, m nhy, trong, dnh hoc xanh vng, c m. Lng m khong 200ml. Mi t ko di 3 tun vo nhng thng ng - xun. - t cp ca vim ph qun mn thng c cc biu hin sau: + Ho, khc m c m. + Kh th nh cn hen. + Phi c ran rt, ran ngy, ran m, r ro ph nang gim. + St hoc khng. + C th c suy h hp. 2.2.2. Triu chng cn lm sng - Xquang: rn phi m, c th thy cung ng mch phi phnh ra. Nu c gin ph nang cn thy hnh nh kh, hnh tim di v b. Nu chp ph qun c cht cn quang (Lipiodol) thy vch ph qun khng u c ch tc. Chp ng mch ph qun thy gin. - Soi ph qun: vch ph qun dy, nim mc nht mu, xung huyt v vim nhim tng vng. Kt hp ht dch tm t bo, sinh thit nu nghi ng khi u. 65

- Thm d chc nng h hp: + VEMS gim. + VC gim. + Tiffeneau gim. + RV (th tch cn) tng khi gin ph nang. - Xt nghim: + m: tm vi khun, lm khng sinh . Nn tm trc khun BK nhiu ln. + Mu: thy hng cu tng, hematocrit tng, bch cu tng, tc lng mu tng (khi c t bi nhim). 3. CHN ON 3.1. Chn on xc nh * Vim ph qun cp da vo: - Triu chng ca vim ng h hp trn: + Nh: vim hng , chy nc mi. + Nng: vim mi m, vim xoang, vim amydal, vim tai gia. - Triu chng ca vim ng h hp di: + Nh: ho, khn ting, th kh kh v du hiu ca vim ng h hp trn, nghe phi c ran rt. + Nng: ngoi nhng triu chng trn, kh th r rt, co ko lng ngc, tm, nhp th nhanh trn 50 ln/ pht. Nghe phi thy c ran rt, ran m vng y phi pha sau lng. * Vim ph qun mn da vo: - Nam gii, tui 40-50, tin s nghin thuc l thuc lo, ho v khc m v bui sng tng t 3 tun, 3 thng trong nm v trong 2 nm lin. - C t kch pht. - Xquang: rn phi m hai bn. Ti tuyn c s thng chn on xc nh c ngay l vim ph qun cp. i vi vim ph qun mn phi hi k tin s gip chn on. 3.2. Chn on phn bit 3.2.1. Cn phn bit vim ph qun cp vi - Hen ph qun tng tit dch: sau cn hen th ht cc triu chng. - ng phi trong suy tim: c biu hin suy tim. 66

- Mt s bnh phi c biu hin vim ph qun: lao phi, bnh bi phi, ung th phi... khng ngh n vim ph qun nu triu chng nghe phi ch mt bn. 3.2.2. Cn phn bit vim ph qun mn vi - Gin ph nang: c th vim ph qun mn tnh m khng c hoc cha c gin ph nang, hoc gin ph nang m khng c triu chng ca vim ph qun mn tnh, phn bit nn da vo mt s c im sau: Xem bng 3.1. Bng 3.1.
Gin ph nang - Kh th: nng - Ho: xut hin sau kh th - Vim ng h hp t - Suy h hp: vo giai on cui - Xquang: lng ngc cng, phi qu sng - R (sc cn ng th) tng nh - Khuch tn kh ca phi: gim nhiu - Va - Xut hin nc kh th - Rt thng gp - Tng t cp - Cc nhnh ph huyt qun tng m - Tng nhiu - Gim t Vim ph qun mn tnh

- Lao phi: tm BK (+), c tn thng trn phim chp phi. - Hen ph qun: cn hi k tin s hen, hoc chng kin c cn hen ph quan. - Ung th ph qun: iu tr khng sinh khng , cn phi chp phi, soi ph qun phn bit. - Gin ph qun: chp ph qun thy gin hnh ng, hnh ti. 3.3. Chn on giai on vim ph qun mn tnh * Giai on O: - Khng kh th - Khng c ri lon chc nng h hp. * Giai on l: - Ho dai dng 3 tun. - Khc m dai dng 3 tun. - Kh th 2 (khi leo tng 2- theo Sadoul) * Giai on 2: ging giai on 1 v - Ho, khc m trn 3 tun trong nm. - Kh th 3 (khi i bnh thng) - Phi c ran rt, ran ngy. 67

- Kh th ging hen. - Thay i thng kh phi. * Giai on 3: ging giai on 2 v - Ri lon chc nng h hp. - Kh th nhiu. * Giai on 4: bnh phi tc nghn mn tnh nng. * Giai on 5: bnh phi tc nghn mn tnh nng, ri lon chc nng thng kh nng. Bnh tin trin 5-10-20 nm, thnh tng t, trong qu trnh tin trin ca bnh, c th c nhng bin chng sau: - Bi nhim phi - Gin ph nang, suy h hp. - Suy tim phi. 4. IU TR V PHNG BNH 4.1. iu tr v phng bnh vim ph qun cp * Th nh: ngh ngi ti ging. Ung nc Cho Codein Khng cn dng khng sinh * Th nng: c vim mi m, vim amydal, vim VA, vim tai gia, vim ph qun: - Cho khng sinh: c th dng Erythromycin 1- 2 gam/ ngy cho 10 ngy. - Nn cho khng histamin khi c du hiu co tht ph qun. - H st, gim au. - Long m: Natri Benzoat - iu tr nguyn nhn. - Phng bnh: + Loi b cc yu t kch thch: trnh khi bi, mi trng nhim. + Gi gn sc khe, gi m trong ma lnh. + Tim vacxin chng virus, vi khun. + Dng khng sinh tng t, nht l nhng ngi c vim ng h hp mn 68

tnh. 4.2. iu tr v phng bnh i vi vim ph qun mn tnh 4.2.1. Trong t cp - Dn lu m theo t th, kt hp v rung lng ngc. - Dng thuc long m: Natri Benzoat, Mucomyst. - Nu c suy h hp: th oxy ngt qung. - Nu c tc nghn, co tht ph qun: cho Aminophyllin tim tnh mch, Ventolin kh dung... - Corticoid: Depersolon, hoc Prednisolon 30mg/24 gi. - Khng sinh: dng nhm Cyclin, hoc Erythromycin 1-2 gam/ ngy. .2.2. Ngoi t cp - Tim vacxin phng cm ma thu- ng. Vacxm chng vi khun. - iu tr nhim khun ng h hp. - Tp th bng. - B thuc l, thuc lo. 4.2.3. Phng bnh - B, hn ch cc yu t kch thch: thuc l, thuc lo. - Bo h lao ng cho nhng ngi tip xc vi mi trng c nhiu bi nh cng nhn lm vic hm m... - Xy dng cc x nghip xa vng dn c v ngc chiu gi. - Tim phng cm vo ma thu - ng. - iu tr tt cc nhim trng ng h hp trn. Dng khng sinh vo nhng thng lnh mi t 10 ngy (c th dng nhm cyclin, hoc Erythromycin) - Tuyn truyn, gio dc sc khe cho cng ng, qun l bnh nhn tt.

69

VIM PHI THY

1. I CNG nh ngha: vim phi l hin tng vim nhim ca nhu m phi, bao gm vim ph nang, ti ph nang, ng ph nang, t chc lin kt khe k v vim tiu ph qun tn cng. Nguyn nhn do vi khun, virus, k sinh vt. * c trng ca thng tn l khi ng c nhu m phi. Vit Nam vim phi chim 12% cc bnh phi. Bnh gp c nam v n. * Tn thng gii phu bnh: Thng gp thy di phi phi hn, t khi b c hai bn. Theo Laennec, c ba giai on: - Giai on xung huyt: vng phi b tn thng xung huyt mnh, gin mch mu, thot hng cu, bch cu vo ph nang, nu cy dch vim ny thy c nhiu vi khun. - Giai on gan ha : sau b bnh 1 - 2 ngy, vng phi c mu chc nh gan, ct mnh phi b vo nc thy chm. Trong ph nang cha nhiu hng cu, bch cu. Nu cy dch ph nang c nhiu ph cu. - Giai on gan ha xm: vng tn thng chc nh gan, mu xm, trn mt c m, trong ph nang c nhiu hng cu, bch cu, i thc bo. 2. NGUYN NHN - Do ph cu Gr(+) c phn lp t 1883 (Talamon). Hin nay c > 75 chng loi, typ 1, 2, 3 gy bnh ngi ln, typ 4 gy bnh tr em. - iu kin thun li: + Lnh. + C th suy yu, ci xng, gi yu. + Nghin ru. + Chn thng s no, hn m. + Mc bnh phi nm iu tr lu. + Bin dng lng ngc, g, vo ct sng. + TMH: vim xoang, vim amydal. + Bnh tc nghn ng h hp. - ng vo: thng do 70

+ Ht phi vi khun mi trng, khng kh. + Ht phi vi khun do nhim khun ng h hp trn. + Vi khun theo ng mu t nhim khun xa. 3. TRIU CHNG * C nng: bnh thng xy ra t ngt ngi tr tui. - Bt u bng cn rt run khong 30 pht, nhit 39 40oC, mch nhanh, mt , sau vi gi thy kh th, tot m hi, mi tm, c mn herpet mi, mp. - ngi gi, ngi nghin ru c l ln, tr em c co git. - au ngc bn tn thng. - Ho: lc u ho khan, sau c m hoc mu g st. - C khi nn ma, trng bng. * Thc th. - Lc u thy r ro ph nang gim bn tn thng, g v s bnh thng. C th c ting c mng phi v ran n cui th th vo. - Thi k ton pht: c hi chng ng c r, c ting thi ng. * Cn lm sng: - X quang: thy mt m m ca mt thy hay mt phn thu hnh tam gic, y quay ra ngoi, nh quay vo trong. - Xt nghim mu: BC tng 15.000 - 25.000/mm, 80 - 90% l BC a nhn trung tnh. Tc lng mu tng. Cy mu c khi c ph cu. - Nc tiu: c protein thong qua. * Tin trin: thng st khong mt tun, sau gim st, ra nhiu m hi, i c nhiu, bnh nhn d chu v khi bnh. Khm phi vn cn hi chng ng c, hnh nh X quang tn ti vi tun na. Nu c bin chng th triu chng nng ln. 4. CHN ON 4.1. Chn on xc nh Da vo: - Khi pht t ngt ngi tr. - Cn rt run, st cao 39 40oC. - Hi chng nhim khun: mi kh, li bn, bch cu tng, i t. - au ngc bn tn thng. 71

- Ho, khc m mu g st. - Hi chng ng c phi. - X quang phi c m m u hnh tam gic y quay ra ngoi. Ti c s chn on thng da vo hai biu hin : + Hi chng nhim khun + Hi chng ng c. Do vy vic thm khm lm sng l rt quan trng. 4.2. Chn on phn bit - Xp phi: trung tht b ko v bn xp, c honh ln cao. - Trn dch mng phi: va vim va trn dch (chc d chn on). - Nhi mu phi: au ngc d di, sc, st, ho ra mu. Thng xy ra ngi c bnh tim, hoc phu thut vng h chu. - p xe phi giai on u: da vo din bin ca bnh. - Ung th phi: sau iu tr ht nhim khun m tn thng cn tn ti > 1 thng nht l ngi c tui, nghin thuc l. - Gin ph qun bi nhim: ho, khc m ko di, nn chp ph qun c cn quang chn on. 5. BIN CHNG 5.1. Bin chng ti phi - Bnh lan rng hai hoc nhiu thu phi: kh th tng ln, tm mi, mch nhanh, c th cht. - Xp mt thu phi: do cc m gy tc ph qun mt thu. - p xe phi: st dai dng, m nhiu m, X quang c mt hoc nhiu hnh hang c mc nc mc hi. - Vim phi mn tnh: bnh tin trin ko di, thy phi b tn thng x ha. 5.2. Bin chng ngoi phi - Trn dch mng phi: thng nh, chng khi. - Trn m mng phi: st dai dng, chc d mng phi c m. - Vim mng ngoi tim: au vng trc tim, c ting c mng ngoi tim. - Vim ni tm mc cp tnh do ph cu: (t gp): st rt run, lch to. - Vim khp do ph cu: khp sng , nng, au. - Vim mng no do ph cu t gp. - Vim phc mc: hay gp tr em. 72

- Vim tai xng chm. - Lon nhp ngoi tm thu, suy tim. - Sc 6. IU TR * Chng nhim khun. - Nn dng khng sinh sm. - Penicillin 2 - 3 triu n v/24h tim bp tht 3 - 4 ln. - Kt hp vi Gentamycin 80 - 120 mg/24 h. n khi ht st 4 - 5 ngy hoc dng Ampicillin 2 - 3 g/24h. * iu tr triu chng. - Gim au ngc: cho Codein 2 - 4v/24h. au qu c th dng Morphin 0,01g x 1 ng (tim di da). - Nu c trng bng. Prostigmin 1ml dung dch 0,05%, 1 - 2 ln/24h (tim di da). - Nu c mt nc: cho n lng, bi ph nc v in gii bng dung dch ng trng (Ringer Lactat, dung dch Glucose 5%). * Vi th nng (kh th nhiu, tm, mch nhanh...) - Th oxy. - Khng sinh liu cao: Penicillin 5 triu n v/24 h kt hp Gentamycin 80 - 120mg/24h. - Nu c tru mch. Truyn dch. Prednisolon (Depersolon). Dopamin. - Chuyn tuyn trn nu iu tr khng hoc c bin chng. 7. PHNG BNH - iu tr tt nhim khun vng tai mi hng, nht l vim xoang c m, vim amydal c m vim hng: bng khng sinh hoc kh dung - iu tr tt t cp ca vim ph qun mn tnh: bng khng sinh ung mi thng 10 ngy trong 5 thng ma ng. - Loi b yu t kch thch c hi: b thuc l, thuc lo. - Gi m c, ngc trong ma lnh. - Tim vacxin phng bnh. (Vacxin ph cu a gi). 73

P XE PHI
1. NH NGHA V DCH T HC - nh ngha: p xe phi l m trong nhu m phi, sau khi c m ra ngoi th to thnh hang mi, qu trnh hoi t do vim nhim cp tnh phi (do vi khun, k sinh vt, nm khng do lao). - Dch t hc: trc y bnh gp nhiu hn do c t khng sinh, hin nay p xe phi l bnh gp t hn so vi cc bnh phi khc do c chn on sm v iu tr tch cc. 2. NGUYN NHN * Vim nhim hoi t. - Do vi khun lm m: t cu vng, Klebsiella, lin cu khun nhm A v nhng Cocci ym kh khc. - Mycobacteria: Mycobacterium, tuberculosis... - K sinh vt: amp, sn l phi. * nhi mu phi do: - Tc mch. - Tc mch nhim khun. - Vim mch mu (vim nt quanh ng mch). * Ung th nguyn pht ph qun. * Nguyn nhn khc. - Kn hi nhim khun. - Tn thng hoi t trong bnh bi phi. - Vit Nam p xe phi thng do t cu vng, lin cu, ph cu, trc khun m xanh, amp (p xe gan v ln phi). * Cc iu kin thun li: - Chn thng lng ngc c mnh n nm trong phi. - Sau gy m t ni kh qun, th my. - Sau phu thut vng TMH, RHM. - B bnh khc: i ng, suy mn. - C bnh phi mn tnh: gin ph qun. - Nghin ru, nghin thuc l. 74

- t ng thng tnh mch di ngy. Cc nguyn nhn v cc yu t thun li ny c th gy p xe phi theo ng ph qun (do ht vo), hoc theo ng mu, theo ng k cn (p xe di c honh...). 3. GII PHU BNH V tr tn thng 3/4 thy di phi, 1/4 l thu trn. C th b c hai phi. - i th: + p xe cp: vng tn thng l mt khi c, mu hi vng, khi ct ngang mt trong thng cc lp m, c ph qun thng ra ngoi. + p xe m thi: tn thng rng, lan to, ct ngang mt ct c mu xm, mt khng u, m rt thi. - Vi th: + p xe cp: vch p xe c cc lp m, thanh t, ph nang vim ph, thnh p xe c t chc ht, vim ni mc, c huyt khi mch mu ln cn. + p xe mn: thnh p xe c t chc x dy c khi 2 cm, x phi, ph nang, vim m cha nhiu t huyt v bch cu, ph nang thnh dy v x ha. 4. TRIU CHNG LM SNG p xe phi din bin qua ba giai on: 4.1. Giai on vim * Hi chng nhim khun: a s l bt u nh vim phi nng, st cao 39-40oC, mi kh, li bn, i t v nc tiu sm mu. Mt s trng hp biu hin ging tnh trng cm. * Triu chng phi: ho v khc m c, c khi c mu. au ngc bn bnh, c th kh th, khm phi c hi chng ng c mt vng, c ran n mt vng, c khi c hi chng ba gim. 4.2. Giai on c m Triu chng c m c khi xut hin sm 5 - 6 ngy, sau khi bnh bt u, c khi xut hin mun 50 - 60 ngy sau. M c th c ra nhiu mt lc 300 - 500ml/24h, hoc m khc ra t mt nhng ko di. Tnh cht m tu theo nguyn nhn: nu do vi khun ym kh th hi thi, do amp th c mu chocolate, do p xe ng mt thng ln phi th c mu vng. Cn phi cy m xc nh vi khun v lm khng sinh . Sau khi c m s gim st, bnh nhn thy d chu hn nhng vn tip tc khc m. Nu m ra t, hoc cn p xe khc cha v th bnh nhn vn st cao. 75

Khm phi thy c c ran n mt vng, c hi chng ng c hoc ba gim, triu chng hang khng r. 4.3. Giai on thnh hang Bnh nhn vn khc m nhng t hn, c th nhit tng cao (khi m cn nhiu trong phi). Trng hp in hnh c th thy hi chng hang: nghe thy ting thi hang r. Cng c th ch thy hi chng ng c hoc hi chng trn dch (do hang su hoc cn cha nhiu m). 5. TRIU CHNG CN LM SNG - Xt nghim mu: s lng bch cu tng, t l bch cu a nhn trung tnh tng, tc lng mu tng. - Xt nghim m, cy m tm thy vi khun, k sinh trng gy bnh. - X quang phi: + Giai on vim: thy m m nh vim phi. + Giai on thnh hang: thy hnh hang trn, hoc bu dc, c mc nc v hi. Cn chp nghing bit hang pha trc hay sau, su hay nng so vi thnh ngc, nu cn thit th cho chp ct lp. 6. CHN ON XC NH Da vo lm sng v cn lm sng, ch yu thy: - Hi chng nhim khun. - Triu chng c m. - X quang phi c mc nc, mc hi. Nh vy cn ch nhng triu chng ban u chn on sm p xe phi l: mt mi, chn n, au ngc, hi th thi, khm phi c hi chng ng c hoc hi chng 3 gim, hnh nh X quang phi thy m m, ko di mt tun cn nghi ng p xe phi v nu ch n triu chng c m l mun. 7. CHN ON PHN BIT * Giai on vim: chn on phn bit vi vim phi nhng nhiu khi kh khn, do vy nu nghi ng l p xe phi th dng khng sinh mnh thch hp ngay. * Giai on c m: phn bit vi. - Gin ph qun bi nhim: l bnh rt hay gp thng c biu hin: + C hi chng nhim khun. + Khc m ko di, c th ho ra mu. 76

+ C tin s ho v khc m lu ngy. + X quang: hnh m khng u. + Chn on xc nh bng chp ph qun c cn quang thy gin ph qun hnh ng hoc ti. - Kn hi phi b bi nhim: + Thng l kn hi bm sinh, nhiu kn v hai bn phi. + C hi chng nhim khun. + C khc m. + X quang c hnh mc nc, mc hi, sau iu tr ht nhim khun hnh nh kn hi vn gi nguyn. Cn hi k tin s bnh nhn v tm nhng d dng bm sinh khc. - Ung th phi (khi u b hoi t bi nhim): chn on thng da vo cc biu hin nh ngi ln tui 45-55 tui, nghin thuc l, c ho khan, ho ra mu trong tin s, triu chng lm sng v X quang ging p xe phi, iu tr ht nhim khun nhng triu chng X quang vn cn tn ti. - Lao hang: da vo tin s, c hi chng nhim khun mn tnh, X quang c hnh hang hoc m m h n, cn tm BK trong m nhiu ln xc nh. - p xe thc qun: nguyn nhn do hc xng gy p xe thc qun c th gy l r vi kh ph qun, chn on xc nh cn hi tin s hc xng, chp thc qun c cn quang hoc soi ph qun, thc qun. - R mng phi- ph qun: cn chc d mng phi chn on. - p xe di c honh: gy l r c honh - ph qun. - Nang t mu do chn thng lng ngc. - Kn sn ch: X quang thy m m, c th tm u sn trong bnh phm. Trn thc t: giai on u thng chn on phn bit vi vim phi, ung th phi. Giai on sau thng chn on phn bit vi hang lao, kn hi phi. 8. CHN ON BIN CHNG Mc d hin nay c nhiu khng sinh ph rng iu tr nhng nu khng c chn on sm, iu tr kp thi, tch cc vn c th c nhng bin chng sau: - Trn m mng phi (do p xe thy di thng vi mng phi), c khi km theo trn kh, trn dch. - Ho ra mu nhiu do v mch mu ln. 77

- Nhim trng mu. - Vim m trung tht, vim mng ngoi tim c m. - Gin ph qun v x phi. - p xe no, thn nhim bt. - Bi nhim lao, suy mn. - T vong. 9. IU TR 9.1. Nguyn tc - Dng khng sinh liu cao phi hp, da vo khng sinh , iu tr theo nguyn nhn. - iu tr triu chng v bin chng (nu c). 9.2. C th 9.2.1. iu tr ni khoa - Dng khng sinh liu cao phi hp theo khng sinh , nu khng lm c khng sinh th chn: Penicillin 5 - 10 triu n v/24h tim bp, truyn tnh mch. Hoc Cephalosporin th h mi nh Cefotaxim 2-4g/24h kt hp vi Gentainycin 160mg/24h. Thi gian dng thuc n khi ht triu chng lm sng, hnh nh X quang ch cn nhng di m nh. - Dn lu t th. cho bnh nhn nm t th thch hp (v d: p xe nh phi phi th cho bnh nhn nm nghing sang tri, u cao, p xe thy y th cho bnh nhn nm u dc xung, bng gp vo thnh ging). Kt hp g, lc, rung lng ngc. - Thuc long m: Acemuc 4-6 gi/24h. Natribenzoat: 4-6g/24h. - Soi ht ph qun ch lm khi c tc ph qun do d vt hoc m khng thot ra c. - Chc ht m qua thnh ngc nu p xe gn thnh ngc. - iu tr c hiu: cho Emetyl, Flagyl trong p xe do amp. - Nu p xe phi do tc mch nhim khun: cn trch rch nhim khun bn ngoi. 78

- iu tr triu chng: gim au, h st bng Paracetamol 0,5 - lg/24h. Nu iu tr khng thy th cn phi chuyn tuyn trn kp thi. 9.2.2. iu tr ngoi khoa C th ct thy phi, l phi. Ch nh: - p xe phi mn tnh. - Ho ra mu ti pht nhiu ln v nng. - p xe phi phi hp vi gin ph qun. - Ung th phi p xe ha. Thc t rt him khi phi iu tr phu thut do c iu tr ni khoa sm v hiu qu. 9.3. Phng bnh - Tuyn truyn gio dc sc khe, v sinh rng ming tt, phng tc d vt tr em, khng ht xng du bng ming. - iu tr nhim khun vng tai mi hng, rng hm mt. - Khi phu thut vng tai mi hng, rng hm mt cn ch phng p xe phi. - Bnh nhn hn m, ng kinh, nhc c... khi nui dng bng ng thng phi cn thn trnh sc.

79

LOT D DY T TRNG
1 C IM DCH T HC Lot d dy t trng l mt bnh ph bin trong cc bnh ng tiu ha. T l mc bnh ti M: 1,9%, Nga 3-4%. Vit Nam cha c thng k chnh xc song mt nghin cu s b trc y ti Bnh vin Bch Mai thy khong 5% dn s c triu chng ca bnh lot d dy hnh t trng. Mi la tui u c th gp nhng gp nhiu hn 20- 40 tui. Thng nam mc nhiu hn n vi t l 3:l. Lao ng cng thng, thnh ph mc nhiu hn nng thn, thi chin nhiu hn thi bnh. Lot hnh t trng gp nhiu hn lot d dy. Lot d dy hnh t trng nh hng nhiu n sc khe ca bnh nhn, lm gim kh nng lao ng v quan trng hn c mt s bin chng c th nguy him n tnh mng. 2. C CH BNH SINH, BNH NGUYN C nhiu thuyt gii thch s hnh thnh v tn ti lot. Thuyt huyt qun ca Wirchov, thuyt n mn ca Claude Bernard, thuyt c gii ca Aschoff. Thuyt vim, thuyt ri lon chuyn ha, thuyt ri lon thn kinh thc vt... Cc thuyt ny cui cng u dn n gii thch l do mt cn bng gia hai yu t bo v v hu hoi: tng tit HCl, pepsin - Gim tit cht nhy bo v. - Mt s yu t c coi l yu t thun li hoc nguy c nh: s cng thng thn kinh qu mc v ko di, stress tinh thn [Curling], cc tn thng thc th nh bng nng, chn thng, cc bnh l cp tnh khc [Cushing], yu t gia nh, thiu dinh dng, n khng ng ba, thc n cng, la tui: 20- 40 tui, nam d mc bnh hn n, cc thuc h st gim au chng vim khng steroid, thuc chn giao cm... Gn y vi khun Helicobacter pylori (HP) c nh gi l nguyn nhn gy vim, lot d dy, hnh t trng. HP l tht xon khun c kch thc 0,5 x 3m, u c 46 roi, giam (-). Xon khun lm thoi ha lp nhy do sn xut ra men urease to NH4+ khi nim mc d dy mt cht nhy, acid HCl tc ng ln vng khng cn cht nhy gy lot [Marshal.1983]. Vi khun HP c th ly truyn theo ng tiu ha nn trong gia nh thng c nhiu thnh vin cng mang HP trong d dy, tuy nhin khng phi tt c cc thnh vin ny u mc bnh lot. 3. TRIU CHNG 3.1. Lm sng Triu chng thng a dng, din bin theo chu k. - au: l triu chng chnh, au m , c tnh cht chu k, tng t. Thng au theo ma nht nh, hay au vo ma rt, mi t au thng ko di 1 n 2 tun. V tr au thay i tu v tr lot. 80

+ Lot tm v, mt sau d dy c th au khu tr thng v, lan ln ngc tri, d chn on nhm. au ngay sau khi n + Lot b cong ln - hang v: au sau khi n 2-3 gi + Lot mn v: thng khng lin quan n thi gian n v thng au qun. + Lot hnh t trng: au lc i, hi lch sang phi, ra sau lng, cm gic au bng rt + C lot d dy- hnh t trng c th lm sng khng au gi l lot cm. y l mt th lm sng kh c bit ca lot d dy hnh t trng thng khng pht hin triu chng g, ch thc s pht hin khi c cc bin chng nh thng hoc chy mu lot. - Ri lon dinh dng d dy: hi, chua, nc, nn, bun nn. - Ri lon thn kinh thc vt: trng hi, to bn, t gp hn lot t trng. - Thm khm: Phn ng nh khi khm vng thng v, n tc hoc cm gic au tng ln. Ngoi cn au khm khng thy g c bit. Nu c hp mn v nn ra thc n ca ngy hm trc, lc c ch lc i. Trong cn au khm thy co cng thng v hi lch phi. i khi bnh nhn c th xc nh c mt im au khu tr vng thng v khong 3 cm2. 3.2. Cn lm sng - Chp X quang d dy, hnh t trng c ung cn quang: thy ng thuc d dy, hnh t trng bin dng. Hnh nh rt phong ph ty theo hnh thi lot. Tuy nhin c nhiu hn ch - Soi d dy bng ng soi mm rt c gi tr chn on xc nh v sinh thit chn on phn bit. Cn ch cc c s tuyn huyn th Xquang l phng tin kh hu hiu khng nh cc chn on lm sng. Ti cc bnh vin ln c iu kin, ni soi l mt thm khm cn lm sng c gi tr hn. - BAO (Basal acid output): ht dch v lc i tnh lu lng toan c bn, ngoi ra cn o hot lc ca pepsin, xt nghim t bo: hng cu, bch cu, t bo khc. - nh gi tnh trng bi tit khi kch thch: nghim php Histamin, nghim php Insulin. y l hai nghim php thm d kh nng bi tit khi kch thch th dch hoc kch thch thn kinh nht l thm d trong ch nh phu thut ct dy X. Ngy nay thm d chc nng t lm v c ni soi pht trin v ni soi c u vit hn hn. Thm d chc nng ch lm trong nghin cu v khi nghi ng c thiu toan d dy. 81

4. CHN ON XC NH V CHN ON PHN BIT 4.1. Chn on xc nh - au thng v c tnh cht chu k. - X quang hoc ni soi c kt lun lot d dy hay hnh t trng. - Thm d chc nng ca d dy c ri lon. - Trong vic chn on cng ng cn ch hi bnh k nhm pht hin tnh chu k ca au. y l triu chng quan trng v c th chn on c bnh, khng nht thit bt buc phi c y cc xt nghim nh trong phn triu chng cn lm sng nu. Ch nh ni soi hoc Xquang cn tu thuc hon cnh ca c s v l xt nghim tham kho. 4.2. Chn on phn bit - Vim d dy mn: lm sng c au thng v, tnh chu k khng r; soi chp khng c lot. - Vim ti mt: thng c st hoc chn on nh siu m. - Ung th d dy: da vo soi v sinh thit. - Vim i trng, nht l i trng ngang: chn on da vo tnh cht i ngoi, tnh cht phn v chn on da vo ni soi d dy, i trng. 5. CC BIN CHNG C 5 bin chng hay gp - Chy mu d dy hnh t trng: hay gp nht, trong hay gp chy mu hnh t trng v mt trc nhiu hn mt sau. Nu lot d dy km chy mu phi xem kh nng ung th. Lm sng c thm triu chng nn ra mu hoc/v a phn en. Tu mc mt mu m c nh hng huyt ng nhiu hay t. y l mt bin chng nguy him d gy t vong nu khng pht hin sm. - Thng lot: gy vim phc mc ton th, thng bt gy vim phc mc khu tr, lm sng c au d di vng thng v, bng cng nh g Xquang bng c lim hi di c honh. - Hp mn v: nn nhiu, nn ra thc n ngy hm trc, n khng tiu, lc c ch lc i. Chp Xquang hoc ni soi thy hnh nh d dy gin hoc thy l mn v hp. - Ung th ha: vn ang cn tranh ci. Lot hnh t trng khng c ung th ha. Lot d dy c th ung th ha. Ung th c trc hay lot c trc kh xc nh c. Thc n cng l mt tc nhn gy ung th ha, nht l cc thc n cha nhiu nht. - Vim quanh d dy- t trng: c mng cng vng thng v, hi chng nhim 82

trng. Ni soi khng tn thng d dy, hnh t trng. 6. IU TR 6.1. Ch nh ni khoa Phn ln cc trng hp lot d dy, hnh t trng ngy nay c ch nh iu tr ni khoa nhm bo tn chc nng ca d dy, trnh nhng ri lon sau ny. Cc thuc iu tr v phc : - Thuc tc ng ln h thn kinh trung ng v thn kinh thc vt + Ct kch thch t v no: Sulpint (Dogmatil), Diazepam, Meprobamat. + Ct s dn truyn qua synap thn kinh ph v: Atropin, Pirenzepin 100 150mg (c ch M1) - Thuc chng acid: Ch yu trung ho acid tc dng t t: Hydroxit nhm, Hydroxit magi, Calci carbonat, Trixilicat magn. Khng dng NaHCO3 gy vim d dy, tng pa qu nhanh v gy tng HCl pha 2. - Cc thuc bo v nim mc, bng nim mc Alumin Sacharo sulfat (Surcralfate). Khi gp HCl tr nn dnh qunh, c tc dng bng nim mc. Liu: 4 g / 24 gi. - Bismuth: trc y l dng v c, nay khng dng v hi chng no- Bismuth hin nay dng dng hu c liu nh l mui citrate. Bit dc Trymo, De non... ngoi tc dng bng nim mc cn c tc dng dit HP. + Laze Heli-neon chiu vo lot. + Cc vitamin PP, B1, B6 c tc dng iu ho acid bo v nim mc d dy. + Prostaglandin PGE2 (Cytotex, Selbex) kch thch lin so nim mc. - Cc thuc chng bi tit + c ch cm th H2 (t bo vin): Cimetidin, Ranitidin, Famotidin, Nizatidin, th h sau c nhiu u vit hn th h trc liu nh hn, t tc dng ph hn. + c ch bm Proton K+ H+ ATPase ti t bo vin: Omeprazol, Lanzoprazol Pantoprazol, Oesomeprazol... - Chng nhim khun Mt s khng sinh c s dng chng HP nh Amoxicilin, Clarithromyxin, Metronidazol, Tetracyclin. Hin tng HP khng thuc xut hin v ngy cng tng ln i hi phi phi hp cc thuc khng sinh vi nhau. Tu theo s nhy cm ca HP m phi hp khng sinh, tuy nhin cn tun th nguyn tc phi hp chung v ch cc tc dng ph khi dng khng sinh (d ng, nhn thuc...). 83

Khi pH ca d dy tng ln lm cho HP nhy cm hn vi khng sinh, Bismuth cng c tc dng dit HP. Chnh v vy ngy nay trong iu tr bnh lot thng phi hp khng sinh vi cc thuc c ch bi tit HCI v thuc bng nim mc c Bismuth. iu tr tn cng t 4-8 tun tu v tr lot. Sau cn soi li nh gi hiu qu v quyt nh iu tr tip hoc ngng. C th phi hp nhiu loi thuc trong iu tr song ch khng phi hp cc thuc trong cng mt nhm. Tu theo nguyn nhn hoc yu t nguy c, mc lot quyt nh phi hp thuc iu tr - Cc thuc y hc dn tc: c rt nhiu bi thuc Nam c s dng iu tr lot d dy hnh t trng v cho hiu qu ng k nh ch dy, cao d cm, l khi... cc thuc ny ang c tip tc nghin cu. nhng c s vng su vng xa nn tn dng ngun thuc ti ch ny tng cng hiu qu iu tr. Vic la chn thuc iu tr cho bnh nhn phi cn c vo tnh hnh ca tng bnh nhn, kh nng ti chnh ca c s, ca bnh nhn m bo bnh nhn c th dng liu, m bo tnh thch hp v tnh chp nhn ca cng ng. Cc thuc mi thng t tin, hiu qu cao hn nhng nu kh nng khng liu th khng nn dng v d lm khng thuc hoc ti pht nhanh. - Ch sinh hot: n ung ngh ngi, th gin tinh thn s gip ci thin iu tr. 6.2. Ch nh ngoi khoa Khi iu tr ni khoa ng phc , thi gian khng hoc c nhng bin chng nguy him nh thng d dy, hnh t trng, chy mu khng cm, ung th... cn c pht hin sm v phu thut. C nhiu phng php phu thut song cn ch theo di sau phu thut, pht hin sm cc bin chng ca phu thut nh hi chng ri lon hp thu, lot ming ni, ung th ha... x l kp thi. 7. D PHNG 7.1. D phng chung - Lm vic iu , trnh mi kch thch qu mc, ngh ngi sau khi n. - Khng n qu nhiu mt s thc n c th lm bng nim mc nh gng, ht tiu... khng ung qu nhiu ru. - iu tr cc bnh vim nhim lin quan vng tai mi hng. 7.2. D phng bin chng v tai bin ca thuc - iu tr sm bnh lot, iu tr trit , trnh cc bin chng xy ra. - Mt s thuc c kh nng lm tng nguy c bin chng hoc tng nguy c mc bnh nh cc thuc gim au chng vim, cc steroid phi c ch c bit khi 84

dng cho nhng bnh nhn c tin s lot. Tt nht khng dng nu c ch nh tht cn thit th khi dng phi theo di cht ch, khi c cc biu hin tai bin ca thuc phi ngng ngay. - Cc thuc iu tr d dy, hnh t trng hin nay cha thy c tai bin ng k. Vi cc khng sinh phi tun th nguyn tc s dng khng sinh. - iu tr dit HP d phng hin nay cha c ti liu no cp.

85

XUT HUYT TIU HA CAO

Xut huyt tiu ha cao l mu chy ra t phn trn ca ng tiu ha t thc qun, d dy, hnh t trng v na trn hng trng. y l mt cp cu ni khoa cn theo di st x tr kp thi v nguy c t vong rt cao. C nhiu nguyn nhn gy xut huyt tiu ha cao, song trn lm sng hay gp lot d dy hnh t trng v v tnh mch thc qun. 1. NH NGHA, DCH T HC Xut huyt tiu ha (XHTH) l tnh trng mu chy ra khi thnh mch vo trong ng tiu ha. Trn lm sng c biu hin nn ra mu, a phn en. XHTH gp c nam v n, mi la tui nhng thng gp nam nhiu hn. Cc yu t thun li thng gp l tui 20-50 tui, khi chuyn ma t xun sang h, t thu sang ng, sau nhng chn thng tinh thn gy stress hoc sau khi dng mt s thuc gim au chng vim, sau cm cm... 2. TRIU CHNG 2.1. Triu chng lm sng - C th c tin triu: au bng, mt l, hoa mt, tanh ming, i khi xut hin t ngt khng c tin triu hoc bnh nhn khng cm thy c. - Nn mu: nhiu hoc t, mu ng hoc ti, tm sm, c th ln thc n. Cn c vo tnh cht ca mu nn ra c th chn on c v tr ca chy mu nhng khng phi lc no cng chnh xc. - a mu: phn en nh b c ph, thi khn. Chy mu nhiu phn long, c dch . Chy mu t phn en, thnh khun hoc do nh nha ng. - Sc do gim th tch mu t ngt. Xut hin sau khi nn, i ngoi. Triu chng mt ti hoc trng, ng vt ra, chn tay lnh, v m hi, huyt p gim, mch nhanh, nh. C th i t hoc v niu... - nh gi khi lng mu mt kh, ch thy phn ra ngoi, khng bit phn cn li. - Khm c quan tiu ha v cc c quan khc s b chn on v tr chy mu. 2.2. Cn lm sng - Cng thc mu gim. - Huyt sc t gim. - Hematocrit gim. - Thm d chc nng gan nu nghi chy mu ng mt. 86

- Chp d dy k c t th u thp pht hin tn thng nhng khng khng nh c chy mu hay khng. - Soi thc qun d dy: rt c gi tr trong chn on v iu tr. - Chp ng mch thn tng nu nghi chy mu ng mt. 3. NH GI MC MT MU - Da vo khi lng mu thi ra (nn, a) + Nh: < 200ml + Va: 200- 500 ml + Nng: 500- 1000m1 + Rt nng: > 1000ml Cha nh gi chnh xc c v thng c chng v cn s mu ng trong ng tiu ha, nhng nu s lng mu nn, i ngoi nhiu th nh gi mc nng. - Nn da vo cc triu chng khc Nh Mch Huyt p ti a Hng cu Hb Hematocrit < 100 ln/ pht > 110 mmHg > 3 triu/ ml 9-13 g/l > 31% Va 100- 120 ln/ pht 90- 100 mmHg 2-3 triu/ ml 6-9 g/l 20-30% Nng > 120 ln/ pht < 80 mmHg < 2 triu/ ml < 6g/l < 20%

Ch s mch huyt p c gi tr cao v n nh hng n chc nng sng ca c th, cng thc mu nhiu khi thay i chm hn. Nh vy ch s mch huyt p v tnh trng ton thn ca ngi bnh c gi tr chn on sm mc mt mu. 4. NGUYN NHN 4.1. Cc nguyn nhn trc tip lm tn thng nim mc d dy- hnh t trng - Lot d dy- hnh t trng. - Ung th d dy. - Vim d dy cp chy mu sau khi ung mt s thuc: NSAID, Corticoid, thuc chng ng. - Vim trt d dy- hnh t trng. - Polyp. 87

- Thot v honh, u thn kinh, lao. 4.2. Nguyn nhn xut huyt do bnh l ngoi ng tiu ha - Tng p lc tnh mch ca: chy mu do v bi gin TM thc qun hoc chy mu do bnh d dy xung huyt trong TALTMC (Gastropathie congestive). - Chy mu ng mt do si, vim ng mt. - Bnh mu. - Mch mu hnh t trng m vo lng rut (chy mu Dieulafoire). - Bnh ton thn: huyt p cao, nh mu cao, chn thng, bng, hi chng Mallory- Weiss. C th chia hai loi tn thng: - Thng vo thnh mch. - Chy mu mao mch. 5. CHN ON 5.1. Chn on xc nh Da vo triu chng lm sng, cn lm sng ch du hiu nn mu, a phn en l cc du hiu cho php chn on c bnh ngay tuyn c s. Ni soi ch c gi tr chn on chc chn, chn on v tr v x l cm mu nu c th. 5.2. Chn on phn bit - Nn ra mu: cn phn bit vi ho ra mu, n tit canh hoc thc n c mu . - i ngoi phn en cn phn bit vi: n gan, lng, tit, ung mt s thuc c mu nh cam tho, Rifampixin... 6. BIN CHNG Xut huyt tiu ha (XHTH) gy ra ri lon huyt ng trc tip nh hng ln tnh mng ngi bnh. Ngoi ra c th gy nn nhng tnh trng nng n khc nh v niu- suy thn chc nng dn ti suy thn thc tn, thiu oxy no... c bit gy thiu mu c tim bnh nhn c tui hoc c tin s suy mch vnh. C th coi nhng ri lon ny l bin chng ca 7. X TR 7.1. Nguyn tc - Bi ph lng mu mt v hi sc. - Cm mu. - X tr nguyn nhn trnh ti pht. 7.2. Hi sc chng sc 88

- Nm bt ng, u thp. - Kh th: th oxy. - t ng thng tnh mch nn hoc ng thng tnh mch cnh trong truyn dch cao phn t, truyn mu. Khng dng cht co mch hoc glucose 30% nng huyt p v d gy hoi t ng thn. - Tr tim. - n nh, lng. - Cho an thn, cho Atropin, ch mch nhanh. i vi tuyn c s: ch cn bt ng, nm u thp truyn dch ng trng hoc dch cao phn t nu c. Sau chuyn bnh nhn ln tuyn trn, ch khi vn chuyn khng cho bnh nhn vn ng hoc ngi dy. 7.3. Cm mu v x tr nguyn nhn (p dng cho tuyn trn c trang b tt hn) 7.3.1. Xut huyt tiu ha nguyn nhn do d dy t trng - Lm lnh d dy bng truyn nc lnh qua ng thng hoc chm lnh bng. - Ni soi d dy cp cu chn on v iu tr. Qua ni soi tim cm mu, tim cht gy x hoc cht keo sinh hc. - iu tr lot (nu c) bng cc thuc khng H2 khng proton H+ dng tim, bng nim mc d dy. - Nu khng kt qu chy mu ti pht nhiu ln hoc chy mu ko di, e da tnh mng bnh nhn khi cn phi phu thut. 7.3.2. Chy mu do tng p lc tnh mch ca - Thng gp trong x gan. Khi tng p lc tnh mch ca thng c gin tnh mch thc qun, bi gin c th v bt c lc no gy chy mu t. - Mu ng ti rut, cc sn phm thoi ha trung gian c hi c hp thu li gy hn m gan. X tr: - Tinh cht hu yn Vasopressin 5-20UI truyn TM. Tuy nhin thuc hay gy cc tai bin nh tng huyt p, thiu mu c tim... chng li tc dng ph ny ngi ta phi hp vi thuc gin mch Nitroglycerin. Ngy nay c mt dn cht ca Vasopressin l Glypressin c tc dng tt hn, khng gy co mch v tc dng ko di hn. - t ng thng Blackemore thc qun. - Somatostatin 50- 100mcg tim TM, sau truyn TM 250 mcg/4 gi, trong 5 ngy lin tip. Thuc ny c tc dng gim p lc TMC, gim tit v ngng chy mu. Octreotid l cht tng hp c thi gian bn hu di hn gi r hn. -Propranolon l mt thuc chn bta giao cm khng chn lc. c s dng trong d phng chy mu do TALTMC t nm 1980. Mc ch ca propranolon l 89

lm gim p lc TMC, gim lu lng dng mu n TMC, t gim p lc ti tnh mch thc qun. Liu c gi tr iu tr l liu ti thiu lm gim nhp tim 20-25% tn s ban u, cn ch tc dng ph v chng ch nh ca thuc. - Tht tho gii phng phn hoc cho khng sinh ng rut nh Neomyxin, Biseptol. C tc gi ch trng cho ng Lactulose 40- 100g/24h gy a lng thm thu nh, bnh nhn chu c. Mc ch gim to NH3 trong lng rut. - Chng tng NH3 mu bng truyn cc acid vn chuyn quan nh glutamic, aspartic, ornithin, arginin. Khng n m. - Phu thut ni ca ch hoc cc th thut ti ch (th thut Crile). Ngoi ra cn c cc bin php lm gim p lc tnh mch thc qun khc nh TIPS hoc can thip trc tip vo ch gin thc qun nh tim x, tht... 7.4. Ch n ung v chm sc Nm bt ng khi c ri lon huyt ng, n lng v lnh nhng cam Chm sc ch h l cp 1 Theo di: + nh gi tnh trng chy mu (24 gi u v nhng ngy tip theo) bng cc du hiu lm sng v cng thc mu. + Theo di v nh gi kt qu khi ra vin: bnh nhn khng i ngoi phn en, huyt ng n nh. Tu theo nguyn nhn m nh gi kh nng khi hay ch . 7.5. Ch nh ngoi khoa - Nu khng kt qu chy mu ti pht nhiu ln hoc chy mu ko di, e da tnh mng bnh nhn khi cn phi chuyn ngoi khoa iu tr. 8. PHNG BNH - Phng ti pht: tt nht l iu tr nguyn nhn vi cc nguyn nhn c th iu tr nh lot d dy hnh t trng, polyp hoc iu tr gim p lc TMC trong x gan. - Phng nguyn nhn chy mu: ch tin s ca ngi bnh, trnh cc yu t nguy c, yu t thun li, yu t c a...

90

VIM KHP DNG THP

1. I CNG 1.1. M u Vim khp dng thp l bnh hay gp nht trong cc bnh khp mn tnh. L bnh mang tnh cht x hi v s din bin ko di v hu qu dn n tn ph, nh hng n lao ng, sinh hot ca bnh nhn v gia nh. Nn rt cn c tuyn truyn gio dc sc khe, phng bnh, chn on sm, qun l tt ti cng ng, c bin php iu tr thch hp vi iu kin hon cnh ca tng tuyn gp phn iu tr hiu qu hn ch tn ph. 1683 Sydenham m t v gi l thp khp teo t. 1853 Charcot gi l bnh khp Charcot. 1890 Garrod gi l vim khp dng thp. Bnh gp khp ni trn th gii, chim 0,5 - 3% dn s ngi ln, 6% ph n Anh. Vit Nam c 0,5% trong nhn dn v 20% s bnh nhn mc bnh khp iu tr ti bnh vin. Bnh hay gp n (70-80%), tui trung nin (60-70%). Mt s trng hp bnh c tnh cht gia nh. 1.2. Nguyn nhn v c ch sinh bnh 1.2.1. Nguyn nhn Ngi ta coi vim khp dng thp l bnh t min, c s tham gia ca nhiu yu t. - Yu t tc nhn gy bnh (cha chc chn): virus. - Yu t c a: v c lin quan HLA DR 4. V bnh lin quan n tui, gii. - Yu t di truyn: vim khp dng thp c yu t gia nh. - Yu t thun li: chn thng, c th suy yu, mt mi, lnh m ko di... 1.2.2. C ch bnh sinh Tc nhn gy bnh (virus ?) tc ng vo mt c th c sn c a thun li v c nhng yu t di truyn d tip nhn bnh, c th sinh ra khng th chng li tc nhn gy bnh, khng th ny li tr thnh tc nhn kch thch c th sinh ra khng th chng li n (t khng th). Khng th lc u v t khng th vi s c mt ca b th, kt hp vi nhau trong dch khp thnh phc hp khng nguyn - khng th. 91

Nhng phc hp ny c mt s t bo n thc bo (bch cu a nhn trung tnh, i thc bo), sau t bo ny b ph hu bi chnh cc men tiu th m chng gii phng ra tiu cc phc hp khng nguyn - khng th trn. S ph hu cc t bo thc bo gii phng nhiu men tiu th, men ny s kch thch v hu hoi mng hot dch khp gy ra qu trnh vim khng c hiu ko di, t khp ny sang khp khc. 2. TRIU CHNG 2.1. Lm sng 2.1. Vim khp * Giai on bt u (khi pht). - V tr: c th bt u bng vim mt khp, thng l khp gi, khuu, bn tay... - Tnh cht: sng au r, ngn tay thng c hnh thoi. C du hiu cng khp bui sng. - Din bin vi tun, vi thng ri chuyn sang giai on r rt. * Giai on r rt: - V tr: bn tay, c tay, khp ngn gn, khp bn ngn, khp gi, bn chn, c chn, khp khuu. - Tnh cht vim: + i xng (95%), ngn tay hnh thoi. + Sng phn mu tay hn phn lng bn tay. + au tng v m, gn sng. C du hiu cng khp bui sng (90%). + Sng au, hn ch vn ng, t nng , c th c nc khp gi. - Din bin: cc khp vim tng dn v nng dn sang cc khp khc, dn n dnh khp v bin dng t th na co v lch trc v pha xng tr (bn tay gi thi, ngn tay hnh c c), khp gi t th na co. 2.1.2. Triu chng ton thn v ngoi kh * Ton thn: gy st, mt mi, n ng km, da xanh, nim mc nht, ri lon thn kinh thc vt... * Da: - Ht di da (5%): l ht, cc ni ln khi mt da, mt chc, khng au, khng di ng, khng r, ng knh khong 0,5 - 2cm. S lng mt vi ht. - Da kh, x, teo. - Gan bn tay v chn gin mch, hng. - Ri lon dinh dng v vn mch: lot v khun chn, ph mt on chi 92

di. * C, gn, dy chng, bao khp: - Teo c r rt vng quanh khp tn thng. - Vim gn: Achille... - Dy chng: vim co ko, c th gin dy chng. - Bao khp: phnh thnh kn (kyste) hot dch chn (kn Baker). * Ni tng: him khi b tn thng, c th: - Tim: tn thng c tim kn o, vim mng ngoi tim... - H hp: vim mng phi nh, x ph nang. - Hch to, lch to. - Xng mt vi, gy xng t nhin. * Mt, thn kinh, chuyn ha: - Mt: vim gic mc, vim mng mt th mi. - Thn kinh: do vim v x dnh phn mm quanh khp c th chn p dy thn kinh ngoi bin. - Thiu mu nhc sc (cha r nguyn nhn). - Ri lon thn kinh thc vt. - Nhim amyloid, thng l mun. 2.2. Cn lm sng 2.2.1. Xt nghim chung - Cng thc mu: hng cu gim, nhc sc. - Tc mu lng tng, si huyt tng. - in di protein: albumin gim, globulin tng. 2.2.2. Xt nghim min dch - Waaler - Rose v Latex: nhm pht hin yu t dng thp (t khng th) trong huyt thanh, do IgM ngng kt vi IgG. Nu dng hng cu ngi hoc hng cu cu tin hnh phn ng gi l phn ng Waaler - Rose, nu dng ht nha latex gi l test latex. Nu ngng kt pha long huyt thanh < 1/32 l phn ng dng tnh. - T bo Hargraves (+) 5 - 10%. 2.2.3. Dch khp 93

- Lng mucin gim, test mucin (+ + +) dch khp lng, vng nht, gim nht. - Bch cu a nhn trung tnh tng s thc bo phc hp khng nguyn - khng th dn ti xut hin t bo hnh nho, nu c hn 10% (so vi t bo dch khp) c gi tr chn on. - Waaler - Rose (+). 2.2.4. Sinh thit * Mng hot dch: thy 5 tn thng c bn: - S tng sinh cc hnh lng mng hot dch. - Tng sinh lp t bo ph hnh lng. - m hoi t dng t huyt. - Tng sinh nhiu mch mu tn to. - Thm nhp nhiu t bo vim quanh mch mu (lymphocyt, plasmocyte). * Ht di da: - Gia ht l m ln hoi t dng t huyt. - Xung quanh c nhiu lymphocyt v tng bo. 2.2.5. X quang - Giai on u: mt vi u xng v cn quang phn mm quanh khp. - Sau thy hnh khuyt nh phn tip gip sn khp v u xng, hp khe khp. - Cui cng hu hoi sn khp, dnh khp v bin dng. 3. TIN TRIN, BIN CHNG, TIN LNG 3.1. Tin trin Ko di nhiu nm, 25% tin trin tng t, c giai on lui bnh, c khi nng ln o bi nhim, chn thng... Da vo chc nng vn ng v tn thng X quang chia 4 giai on (theo Stein brocker): - Giai on I: tn thng khu tr mng hot dch, sng au phn mm, vn ng gn nh bnh thng. - Giai on II: tn thng nh hng n u xng v sn khp, vn ng hn ch nhng cn cm nm c, i li bng gy v nng. X quang: c hnh khuyt, hp khe khp. 94

- Giai on III: tn thng nhiu u xng sn khp, dnh khp mt phn. Kh nng vn ng cn t, cn t phc v sinh hot c nhn, khng i li c. - Giai on IV: dnh khp v bin dng trm trng, mt ht chc nng vn ng, tn ph. Thi gian t giai on I n giai on IV khong 10 - 15 nm. 3.2. Bin chng v tin lng - Bin chng: + Nhim khun: lao... + Chn p thn kinh gy lit. + Tai bin do dng thuc. - Tin lng: nng nu tn thng nhiu khp, c tn thng ni tng. 4. TH LM SNG 4.1. Th bnh theo triu chng - Th mt khp: thng khp gi, cn sinh thit mng hot dch. - Th c lch to (hi chng Felty): lch to, gim bch cu, c th gan to, hch to, sm da. - Th c km hi chng Sjogren Gougerot: vim khp dng thp km x teo tuyn l v tuyn nc bt. - Th xut hin sau bnh bi phi (Caplan) thng nhim bi than v bi Silic. 4.2. Th bnh theo tin trin - Lnh tnh: tin trin chm. - Nng: tn thng nhiu khp, st, tn thng ni tng, tin trin nhanh. - c tnh: st cao, trn dch khp, tin trin nhanh chng, dnh khp v bin dng. 4.3. Th theo c a - Nam gii: nh, khng in hnh. - Ngi gi: nh. - Waaler - Rose (-): nng, kh iu tr. 5. CHN ON 5.1. Chn on xc nh Nu triu chng thng chn on d, nhng mun. 5.1.1. Tiu chun chn on ARA (American Rheumatism Association) 1958 gm 11 95

tiu chun (Ngy nay thng khng c s dng) - Cng khp bui sng. - au mt khp tr ln (khi khm, khi vn ng). - Sng mt khp tr ln. - Sng khp trc cch khp sau - 3 thng. - Sng c tnh cht i xng hai bn. - C ht di da. - X quang: mt vi u xng, hp khe khp. - Waaler - Rose, test Latex (+). - Dch khp: gim mucin r. - Sinh thit mng hot dch c > 3 tn thng. - Sinh thit ht di da c tn thng in hnh. Chn on xc nh nu c trn 7 tiu chun thi gian trn 6 tun. Nghi ng nu c 4 tiu chun, thi gian 4 tun. 5.1.2. Tiu chun ARA 1987 (ang p dng): gm 7 tiu chun - C du hiu cng khp bui sng trn 1 gi. - Sng au ti thiu 3 khp chi (khp ngn tay gn, bn ngn, c tay, khuu, gi, c chn, bn ngn chn) i xng, ko di trn 6 tun. - Sng au ti thiu 1 khp trong 3 v tr: khp ngn tay gn, bn ngn tay, c tay, ko di trn 6 tun. - Sng au i xng. - Waaler - Rose (+). - X quang in hnh. - C ht di da in hnh. Chn on xc nh nu c trn 4 tiu chun. 5.1.3. Vit Nam Do mt s ni xt nghim cn lm sng cha lm c y nn da vo cc yu t sau (Theo Trn Ngc n): - N, tui trung nin. - Vim cc khp nh hai bn tay v khp gi, khuu, c chn. - i xng. 96

- Cng khp bui sng. - Din bin trn 2 thng. Da vo cc yu t ny chn on rt ph hp vi iu kin v thc t Vit Nam. 5.2. Chn on phn bit 5.2.1. Giai on u cn phn bit vi - Thp tim: au c tnh cht di chuyn, thng gp tui tr. - Thp khp phn ng: xut hin sau nhim khun, khng c di chng. - Hi chng Reiter: vim khp, vim niu o v kt mc mt. 5.2.2. Giai on sau cn phn bit vi - Hi chng Pierre - Marie: vim nhiu khp, ngn tay di trng. Do u ph qun. - Biu hin khp trong cc bnh to keo: x xng b, Lupus ban . - Bnh gt: vim nhiu khp, ni u cc quanh khp, acid uric mu tng. - Vim ct sng dnh khp: vim khp ln v ct sng thng gp nam gii, tr tui. - Thoi khp: au, mi nhiu. - Thp khp vy nn: vim khp v c vy nn ngoi da... 6. IU TR 6.1. Nguyn tc chung - u tr kin tr, lin tc, sut i. - Kt hp iu tr ni khoa, vt l tr liu phc hi chc nng, ngoi khoa, chnh hnh, ti gio dc. - Chia iu tr ra nhiu giai on: ni tr, ngoi tr, iu dng. - Qun l bnh nhn. 6.2. C th * i vi th nh, giai on I: - Aspirin l-2g/24h chia nhiu ln, ung sau khi n. - Chloroquin (Delagyl) 0,2 - 0,4g/24h ung lin tc. - Tim Hydrocortison acetat vo vi khp vim nhiu. - Tng cng vn ng, luyn tp, trnh lnh, m v lao ng nng. - iu tr vt l tr liu. 97

- Thuc nam: l lt, cy xu h, hy thim... * i vi th trung bnh, giai on II: iu tr ni tr n khi ht t tin trin: - Aspirin: - Delagyl: 1 - 2g/24h 0,2 - 0,4g/24h.

- Thuc chng vim khng Steroid. - Indomethacin 25mg: - Voltaren 25mg: - Naprosyn 300mg: - Prednisolon: 2-6 vin/24h 2-6 vin/24h 2vin/ 24h. 40mg/24h gim n liu.

- Cc bin php khc p dng ging th nh. Khi n nh cho bnh nhn iu tr ngoi tr c theo di, hng dn iu tr. * i vi th nng, tin trin nhiu (giai on III - IV). - Steroid liu cao: - Prednisolon: - Hemisuccinat hydrocortison: - Gim liu dn v duy tr l,5mg/kg/24h hoc 100 - 200mg (tnh mch). 5mg/24h.

- Tim mui vng (Selsdor) mi tun 1 ln tng dn. - Tng liu - Hoc: Auranofin 3 mg: - Salazopyzin 500mg: - Endoxan: 1500 - 2000mg. 2 vin/24h dng 3 thng. 2-4 vin/24h dng ko di. l-2mg/kg/24h.

Methotrexat: 7 - 10mg/24h (mi tun ung 1 ln dng 3 thng). Cn ch cc tc dng ph ca thuc v kh nng chi tr ca ngi bnh la chn phng php v thuc thch hp. - Lc huyt tng: nhm loi b phc hp khng nguyn - khng th lu hnh. - Tip tc iu tr ging giai on I, II. * Ngoi khoa, vt l tr liu - phc hi chc nng. - iu tr vt l tr liu - phc hi chc nng l yu cu. bt buc nhm hn ch bt di chng, gm iu tr bng in, bng tay, sui khong, vn ng. - iu tr ngoi khoa: c th ct b mng hot dch, phu thut chnh hnh (ghp 98

khp kim loi hoc cht do). * Phng bnh: - Loi tr cc yu t thun li bng cch tuyn truyn gio dc sc khe. - Theo di, pht hin sm v iu tr kp thi, trnh tn ph. - Ch trnh tai bin do iu tr thuc ko di. Tm li: v y l bnh khp mn tnh thng gp, gy hu qu tn ph nn cn c chn on sm v iu tr kp thi, tch cc ng phng php, thch hp vi tng bnh nhn v tng tuyn.

99

XUT HUYT GIM TIU CU

1. NH NGHA y l bnh xut huyt do tiu cu b ph hu qu nhiu mu ngoi vi trong khi tu xng bnh thng. 2. SINH L BNH Trong bnh ny tu xng sn xut tiu cu bnh thng, biu hin mu tiu cu tng sinh, trong khi i sng tiu cu ngn do ph hu ngoi vi v l do min dch, c th l cc khng th khng tiu cu. Ngi ta xc nh c l mt IgG do c th t sinh ra chng li chnh tiu cu ca mnh nn c th xp bnh ny l mt bnh t min dch. 3. S THNG GP Bnh gp ngi tr tui t 10 - 40 nhiu nht l la tui t 16 - 30 (72%), sau l 31 - 80 (20%), > 50 tui ch chim 0,7% (khoa huyt hc Bnh vin Bch Mai nay l Bnh vin Huyt hc truyn mu), gii n mc nhiu hn nam th 87% - nam 13%). 4. TRIU CHNG LM SNG Triu chng lm sng ch yu l xut huyt mang y tnh cht xut huyt gim tiu cu ngha l : - Xut huyt t nhin khng sau va chm, nhng a phn c pht hin sau k kinh nguyt u tin, biu hin kinh nguyt ko di hn bnh thng, c ngi rong kinh (56%). - C khi xut huyt di da di dng chm, nt, mng. Cc nt ny khng xut hin cng mt lc nn c nhiu mu khc nhau, thng l , tm, xanh, vng (90%). - Nhiu khi li xut hin ln u l chy mu chn rng (65%), hoc mi, cn biu hin i mu v ng tiu ha rt t gp (l v 9%). iu nguy him l c nhng biu hin rt t gp nhng li nguy hi cho tnh mng ngi bnh l chy mu no v mng no, nu y l biu hin u tin th thy thuc t ngh ti bnh ca dng tiu cu. - Ngoi ra do xut huyt nn ngi bnh c biu hin thiu mu nhiu mc khc nhau tu theo s ln v s lng mu b mt. - Trong khi gan - lch - hch khng to. - Ngi bnh c th st nh khi b xut huyt nhiu. Khi ht xut huyt th tnh trng st v thiu mu c hi phc rt nhanh, ngi bnh th li sinh hot bnh thng. 100

5. TRIU CHNG CN LM SNG - S lng tiu cu thng gim di 80.000/1ml, thm ch cn di 50.000/1ml. S lng ny gim thp nht khi gn c t xut huyt v tng ln bnh thng sau khi ht xut huyt. - S lng hng cu bnh thng, tr khi xut huyt qu nhiu c th gy thiu hng cu. - S lng bch cu bnh thng, cng thc bch cu khng c g thay i - tu xng: t bo tu bnh thng, ring mu tiu cu tng, nht l nhng mu tiu cu ang sinh tiu cu (nguyn tiu cu, mu tiu cu kim, mu tiu cu c ht), iu ny ni ln tiu cu b ph hu qu nhiu ngoi vi. - Du hiu dy tht (+). - Thi gian mu chy ko di: thng c s lin quan gia thi gian mu chy vi s lng tiu cu trong mu. Do vy, thi gian mu chy tr li bnh thng khi ht xut huyt, ng ngha s lng tiu cu tng, tuy nhin cng c khi thi gian mu chy khng tng xng vi mc xut huyt. - Thi gian co hi cc mu ko di, bnh thng sau 2 gi nhng bnh nhn ny sau 4 gi cc mu vn cha co hon ton, xt nghim ny rt c gi tr v t l gp cao (92%). - Mc tiu th Prothrombin gim, thng gim <60 giy (bnh thng 60 giy) - o n hi cc mu (TEG), ch yu l bin m hp (bnh thng l 54mm), thng l di 54mm - Thi gian Quick v phc h Prothrombin bnh thng (12 giy v 100%). - Khng th khng tiu cu: bng phng php c bit ngi ta pht hin c khng th khng tiu cu. Nu pht hin c khng th ny cng chc chn l xut huyt tiu cu t min. 6. CHN ON 6.1. Chn on phn bit Ni chung xut huyt gim tiu cu v c im u ging cc xut huyt c gim tiu cu khc nn cn phn bit vi : - Bnh bch cu cp: xut huyt trong bnh bch cu cp cng ging nh xut huyt gim tiu cu t min nhng ngoi xut huyt ra cc triu chng nh st, gan to, lch, hch to u nng n hn rt nhiu, ng nhin khi xt nghim mu cng nh tu u thy s thay i c trng. 101

- Bnh bch cu kinh th tu: trn lm sng ngoi xut huyt ra ta thy lch rt to v xt nghim thy bch cu tng rt cao v tng tt c cc giai on tng trng ca dng bch cu. Cn thit lm thm cc xt nghim khc nh P.A.L v nhim sc th Philladelphie. - Suy tu xng: y l bnh kh phn nh nht. Ta phi da vo tu . Lu trong suy tu khng c s tng mu tiu cu ang sinh tiu cu. 6.2. Chn on xc nh Da vo c tnh xut huyt, cch tin trin v c bit l huyt thy gim tiu cu nhng tu li tng sinh mu tiu cu ang sinh tiu cu. Chc chn hn ta i tm khng th khng tiu cu 6.3. Chn on th C nhiu cch phn loi th bnh da vo cch tin trin ta c th phn ra mt s th sau y: - Th c tnh: biu hin xut huyt rm r nhiu ni cng mt lc c bit l xut huyt no, mng no gy t vong trong vi tun mc d c iu tr. - Th cp tnh: bnh xut hin ln u v c th khi t nhin trong vng 1 thng. Bnh thng gp tr em, thng xy ra sau khi ung mt loi thuc g thng l Sulfamid nn ngi ta thng ngh n xut huyt do thuc. - Th bn cp: bnh thng tin trin trong vng 3 thng - Th mn tnh: y l th hay gp nht bnh tin trin tng t trong vng 6 thng hoc nhiu nm. - Th xut hin tng lc: bnh xut hin tng t thi gian cch nhau ngn hay di tu nhng gia hai t s lng tiu cu v cht lng tr li hon ton bnh thng. 6.4. Chn on bin chng Thng th bnh tin trin rt phc tp kh lng trc nhng thng c hai bin chng dn n t vong l: - Xut huyt no, mng no: ang iu tr xut huyt gim tiu cu m t ngt c lit na ngi hoc hi chng mng no th nn ngh n bin chng ny. - Xut huyt mng ngoi tim hoc c tim: xut huyt mng ngoi tim c th dn n p tim cp. Biu hin xut huyt c tim ging nh nhi mu c tim. 7. TIN TRIN V TIN LNG Nh trn ni bnh tin trin rt phc tp kh on trc nhng cho d th no y cng l bnh khng nn ni trc iu g. - Bnh tin trin tng t ngt qung gia cc t bnh thng c lm sng v 102

xt nghim. - Bnh tin trin nng ngay t u c th dn ti t vong ngay do xut huyt no v mng no - cn xut huyt di da t khi gy t vong. - Bnh gi nguyn tnh trng ban u khng cng khng nng ln mc d vn c iu tr ng cch. - Bnh nh dn khi tui cng ln thng l > 25 tui. - Thai nghn thng lm bnh nng ln hoc gim i, i lc gy xut huyt t khi . - n tui mn kinh c khi li lm bnh nng ln. - Mt s c bit bnh tin trin trong nhiu nm nh dn ri khi hn. 8. IU TR Cho n nay ngi ta thng dng. 8.1. Corticoid - Mc xut huyt nng s lng tiu cu < 50.000/ml c nguy c chy mu no mng no th dng Prednisolon liu 2-5mg/lkg/24 gi dng lin tc trong 2 tun ri gim dn liu trong 2 tun tip theo. - Mc nh tiu cu > 50.000/ ml th dng Prednisolon liu 1- 2mg/kg/24 gi trong 2 tun sau gim dn liu trong 2 tun tip. 8.2. Truyn mu ti y l bin php cn thit hi phc nhanh chng s lng tiu cu, nht l nhng trng hp tiu cu di 80.000/ml, truyn lin tc trong 3 ngy mi ngy t 12 n v mu ti. 8.3. Ct lch y l phng php iu tr tch cc mang li hiu qu cao nhng c ch nh khi dng corticoid v truyn mu ba t khng c kt qu, theo thng k ch nh ng bnh khi n 87%. 8.4. Cc thuc gim min dch c ch nh sau khi dng corticoid + truyn mu + ct lch m bnh vn tin trin. Thuc thng dng: - Cyclophosphamid 200mg/ngy hoc 6MP 200mg/ngy, trong hng ngy, sau 2 tun lm li cng thc mu iu chnh liu lng.

103

I THO NG
1. I CNG 1.1. nh ngha i tho ng (T) l nhm ca cc bnh chuyn ha, c c im tng ng huyt do thiu ht v tit insulin, v tc ng ca insulin hoc c hai. Tng ng huyt ko di ko theo nhng tn thng, ri lon chc nng cc c quan trong c th, c bit l mt, thn, thn kinh, tim v mch mu. 1.2. Dch t i tho ng chim khong 60-70% cc bnh ni tit. T l mc bnh n nhiu hn nam. Theo s liu ca vin nghin cu T quc t, nm 1994 s bnh nhn b bnh T typ 2 trn th gii vo khong 98,9 triu ngi, d bo s tng ln 215 triu ngi vo nm 2010. T l mc bnh thay i theo tng nc c nn cng nghip pht trin hay ang pht trin, thay i theo tng dn tc, tng vng a l khc nhau. Tui cng ln, t l mc bnh T cng cao, 65 tui tr ln, t l mc bnh ti 16% t l mc bnh T cao nhng ngi bnh b bo. Nh vy tui gi v bnh bo lin quan n nhng yu t nguy c pht trin bnh T nhng ngi c t bm i vi bnh ny. Theo ti liu nghin cu tnh cht dch t bnh T, th t l bnh tng ln hng nm, c 15 nm th t l bnh tng ln 2 ln, T c xp vo mt trong ba bnh thng gy tn ph v t vong nht (x va ng mch, ung th, T). Vit Nam, theo ti liu nghin cu thng k ca 3 nhm tc gi nghin cu trn 3 vng khc nhau ca t nc cho thy t l mc bnh T t 15 tui tr ln: H Ni 1,1% (L Huy Liu v cng s, 1991). Thnh ph H Ch Minh 2,52% (Mai Th Trch v cng s, 1993), Hu 0,96% (Trn Hu Dng,1996). V t l bnh ngy cng tng, nht l nhng ngi ang tham gia lao ng sn xut, c bit hin nay bnh i tho ng cha th cha khi c, cho nn phng chng bnh T ang tr thnh vn y hc ca x hi. 1.3. Phn loi, c ch bnh sinh Theo ADA (American Diabete Association) (Hi i tho ng M) th bnh i tho ng c chia thnh 4 nhm ch yu sau: - i tho ng typ 1: do tn thng hoc suy gim chc nng t bo nguyn pht, a n thiu insulin hon ton. 104

+ Xy ra ngi tr, phn ln t 10 - 20 tui. + T l mi mc cao cc gia nh c ngi b i ng typ 1, c xu hng hn m toan huyt. + Thng ngi c HLA - DR3 v DR4 + C khng th khng tiu o Langerhans. + S bi tit insulin c th cn giai on u chn on, sau dn n cn kit t nm sau. - i tho ng typ 2: + Thng xy ra ngi trn 35 tui. + ng huyt thng tng cao nhiu nm trc khi c chn on. + Thng ngi c triu chng nh, pht hin tnh c. + a s bnh nhn thuc loi bo (90% cc bnh nhn cc nc pht trin), nhng Vit Nam t l ngi bo rt thp. + S tit insulin thp tng i, c s khng tc dng insulin t chc ngoi bin v gan. + Cc yu t di truyn loi ny rt quan trng, thng thy tr sinh i ng hp t (100% tp 2, trong khi ch c 50% tp l). i ng tp 2 c th chia ra 3 tp: i ng tp 2 khng bo. i ng tp 2 bo Th MODY (Maturity onset Diabetes of youth), i ng khi pht ngi tr tui. - i tho ng thai nghn + i ng thai nghn thng gp ph n c thai c ng huyt tng hoc gim dung np glucose, gp khi c thai ln u v thng mt i sau . + i tho ng ngi mang thai thng khi pht t tun l th 24 ca thai k, i khi xut hin sm hn. + Mt s ph n c xp vo nhm c nguy c cao l: bo ph, tin s gia nh c ngi mc bnh i tho ng, tin s sinh con trn 4 kg, tin s b sy thai hoc thai cht lu khng tm c nguyn nhn, ph n trn 30 tui. pht hin sm, tt c ph n c thai nn c kim tra ng huyt pht hin i tho ng vo tun l th 24 v th 28 ca thi k mang thai. Nhng trng hp ph n c thai b i tho ng hoc ri lon dung np glucose c th c nhiu 105

kh nng mc phi cc bin chng nguy him nh: nhim c thai nghn, a i, thai cht lu. V vy, cc trng hp ny phi theo di v kim sot ng huyt thng xuyn. Nu kim sot tt ng huyt, nhng bin chng nguy him trn s rt t xy ra. - Ri lon dung np glucose Ri lon dung np glucose ch c php kt lun sau khi tin hnh nghim php tng ng huyt bng ng ung. Nhng trng hp c chn on b ri lon dung np glucose thng c nguy c cao v bnh l tim mch, tng huyt p, ri lon m mu v tng cn hn l cc trng hp khng b ri lon dung np glucose. Nh vy sau khi c chn on ri lon dung np glucose, chng ta cn can thip tch cc bng ch n, luyn tp th dc th thao hp l, gim cn khi bo, theo di ng huyt nh k c th ngn cn s xut hin ca i tho ng thc s hoc lm chm s xut hin bnh. 2. NGUYN NHN * Nguyn nhn do ty: - Vim ty. - Ung th ty. - Si ty - Bnh thit huyt t (Hmochromatosse). * Nguyn nhn ngoi ty: - Cng thu trc tuyn yn. - Cng v thng thn. - U tu thng thn. - Cng gip trng. * Mt s nguyn nhn khc; - Do di truyn. - Do t min. - Do nhim khun, virus. - Do thuc: Corticoid, Thiazid. - Do ru: c ch AMPC dn ti gim sn xut insulin. - Tn thng no. 3. TRIU CHNG 3.1. Lm sng * Khi pht: - Thng khng c biu hin g c bit, ch pht hin c khi lm xt nghim 106

mu v nc tiu. - Bnh c th xut hin sau khi bnh nhn b cm, cm. * Ton pht: - i nhiu: bnh nhn i 6 - 7 lt / 24h. - Ung nhiu: i nhiu nn bnh nhn mt nc, kht v bnh nhn s ung nhiu. - n nhiu, nhanh i. - Gy nhiu: + Do gim ng ha, tng d ha protid, lipid lm teo c v t chc m di da. + Do mt nc. - Nc tiu c rui u, kin bu. - Bnh nhn mt mi, kh mm, kh da. - C khi bnh nhn c cc biu hin do bin chng: tc mch chi, nhi mu c tim, vim a dy thn kinh, nhim trng, rng rng sm, nga ngoi da, mn nht lu khi, hn m. 3.2. Cn lm sng - Glucose mu lc i tng cao. - Glucose niu (+). C mt cch th nc tiu l dng mt loi giy th c bit, nu cc mnh giy ny i mu khi nhng vo trong nc tiu l nc tiu c ng. - Nghim php tng ng mu (+). + Ly mu nh lng glucose lc i. + Cho bnh nhn ung 75g glucose pha trong 250ml nc si ngui, ung trong thi gian 5 pht. + 2 gi sau khi ung, ly mu nh lng glucose. Chn on ri lon dung np glucose khi ng huyt sau 2 gi l 7,8- 11 mmol/l. Nu kt qu > 11, 1 mmol/l th chn on xc nh l i tho ng. - Nghim php Conn (+) (nghim php vi Cortison), nhng hin nay t lm. - Th xeton niu (+). - HbA1c tng cao so vi bnh thng. Xt nghim ny ch c gi tr nh gi kt qu iu tr, n phn nh mc kim sot ng huyt trong 4-8 tun qua, m t c gi tr chn on xc nh i tho ng. - nh lng insulin huyt thanh. 107

- nh lng C-peptid. - nh lng cc t khng th: khng th khng insulin, khng t bo ty: GAD (acid glutamic decarboxylase). - Ri lon chuyn ha lipid km theo. Ch yu thy tng cholesterol, triglycend, LDL-c v gim HDL-c 4. CHN ON 4.1. Chn on bnh da vo: (C th chn on c tuyn c s) * Cc triu chng kinh in: n nhiu, ung nhiu, i nhiu, gy nhiu. * Cc bin chng thng gp: thn kinh, mt, bnh l mch mu, nhim trng. * Mt s yu t nguy c gi : - Bo. - Tin s gia nh c ngi b bnh T. - Ph n c T lc thai nghn. - Tin s con nng trn 4 kg. * Xt nghim: - ng huyt lc i hay xt nghim ng huyt bt k trong thi gian no. - Nghim php tng ng huyt. - nh lng HbA1c. - ng niu. 4.2. Tiu chun chn on (c WHO cng nhn nm 1998): Da vo mt trong ba tiu chun - Mt mu ng huyt tng bt k 200 mg/ dl (11,l mmol/l), kt hp vi cc triu chng tng ng huyt. - ng huyt tng lc i 126 mg/ dl (7 mmol / l). - ng huyt tng 2 gi sau ung 75 g glucose 200mg/dl (11,l mmol/l). Chn on chc chn khi kt qu c lp li 12 ln trong nhng ngy sau . 4.3. Chn on phn bit - i nht: ung nhiu, i nhiu, xt nghim ng mu bnh thng, ng niu (-), t trng nc tiu thp. - i ng phi hp vi i nht: - ng huyt cao khng tng xng vi ng niu. 108

- Sau iu tr, ng huyt v bnh thng m bnh nhn vn i nhiu. - i ng do thn: do ngng ng thn gim. 4.4. Chn on giai on (4 giai on) * Giai on 1 (tin i ng, i ng n). - Thng gp cc i tng: + Con ca hai ngi i tho ng. + Sinh i cng trng, mt b i tho ng. + Nhng ngi c khng nguyn HLA - DR3 hoc DR4 - Xt nghim sinh ha bnh thng, sinh thit thn thy mng y cu thn dy. * Giai on 2 (i ng tim tng): Nghim php Conn (+), tn thng vi mch nng hn. * Giai on 3 (i ng sinh ha): Cc nghim php sinh ha (+), tn thng vi mch nng. * Giai on 4 (i ng lm sng). C y triu chng lm sng v sinh ha, bin chng nhiu. 4.5. Chn on nguyn nhn * Nguyn nhn ngoi ty Da vo lm sng v cn lm sng: thy c cng cc tuyn khc. * Do ty: - Cn chp Xquang, siu m ty, CT- Scanner pht hin u, si ty. - Xc nh cc t khng th, khng t bo ty. 5. BIN CHNG 5.1. Bin chng cc c quan * Tim mch: - Cn au tht ngc. - Nhi mu c tim. - Vim tc ng mch chi di. * Ngoi da: - Nga khng tm thy nguyn nhn. - Mn nht lu khi. 109

- Lot bn chn. * Mt: - c thu tinh th. - Vim mng mt. - Thoi ha vng mc. * Hoi th do i tho ng: - L bin chng mun, tin trin t t. * Bin chng thn kinh: Vim a dy thn kinh (ta, tr, ri lon cm gic su). * Bin chng thn: Do x ha tiu cu thn, xut hin Microalbumin niu, gy hi chng Kimmelstiel - Wilson. * Rng li: rng rng, vim m li ko di. * Phi: d gy nhim khun phi: - p xe phi. - Lao phi. * Tiu ha: gan to v thoi ha m, a chy ko di. * C xng khp: teo c, au xng khp, thoi khp. * Sn khoa: v sinh, sy thai, thai to. 5.2. Bin chng hn m do i tho ng * Hn m toan mu do i tho ng: - Thng gp bnh nhn T typ 1. - ng mu tng rt cao. - ng niu tng. - Xeton niu (+). - D tr kim gim nhiu. * Hn m do tng p lc thm thu: - Thng gp bnh nhn T typ 2. - ng huyt v ng niu tng rt cao. - Khng c th xeton niu. - p lc thm thu mu tng rt cao. 110

* Hn m do tng a. lactic: - Tng a. lactic mu. - pH mu gim. - Xeton niu (-). - Km theo c bnh gan, thn. * Hn m do h ng mu: Cn phi ngh ti h ng mu khi bnh nhn c cc biu hin nh mt mi, nhc u, v m hi, bn rn chn tay...Thng xut hin nhng bnh nhn i tho ng ang c iu tr ti nh bng thuc h ng huyt nhng n king qu mc, hoc dng thuc khng ng. 6. IU TR Nu thy r nguyn nhn th phi iu tr nguyn nhn, nu khng phi xc nh v iu tr theo typ 1 hoc typ 2. 6.1. iu tr i tho ng Typ 1 * Ch n: Ch n l vn quan trng nht trong iu tr i tho ng vi mc ch nhm bo m cung cp dinh dng, cn bng y c v s lng v cht lng c th iu chnh tt ng huyt, duy tr cn nng theo mong mun, m bo cho ngi bnh c sc khe hot ng v cng tc ph hp vi tng c nhn. Trong i tho ng khng c mt cng thc tnh ch n chung cho tt c cc bnh nhn, v cn ph thuc vo nhiu yu t nh: ngi bo hay gy, lao ng th lc hoc khng lao ng, c bin chng hay khng v cn ph thuc vo iu kin kinh t ca tng bnh nhn. Ch n ca ngi bnh phi c chn sao cho n cung cp cho c th ngi bnh mt lng ng tng i n nh v quan trng nht l phi tnh iu v hp l v gi gic, tc l chia s thc phm c s dng trong ngy ra cc ba n chnh v ph hp l. Nu bnh nhn c tim insulin, phi tnh thi im lng ng huyt tng cao sau ba n ph hp vi thi im insulin c tc dng mnh nht. Thng thng ngi bnh i tho ng cn thc hin ch n: - Hn ch glucid, m bo 30-35 Kcalo/kg/24h. Protid 16% - 20%, lipid 20% 30%, glucid 50% - 60%. - Chia ra nhiu ba n trong ngy theo t l 1- 1- 3 - 1-3 - 1. Trong ba sng 10%, ba ph bui sng 10%, ba tra 30 %, ba ph chiu 10% ba ti 30%, ba ph ti 10%. - n tng cc loi thc n c nhiu x, hn ch m ng vt. 111

- Trnh cc loi thc phm c lng ng cao. * Insulin: dng l bt buc v dng sut i, v insulin cn cho tt c bnh nhn i tho ng type1, mc ch iu tr insulin l thay th mt cch sinh l lng insulin bnh thng do ty to ra. - Cc loi insulin: hin nay c cc loi insulin thng, insulin chm v insulin na chm. - Cch dng: insulin c th c s dng mt cch linh ng. + Trong cp cu dng loi nhanh, cn li th dng loi chm hoc na chm. + Loi insulin nhanh c th tim di da, tim bp, truyn tnh mch. - Cc loi insulin khc ch tim di da. + Thng cho 20 - 40 n v/ngy (liu 0,6 - 0,7 UI/kg/ngy), tng liu khng qu 80UI/ngy, tim di da chia 3 phn: 2/3 dng trc ba n tra, cn 1/3 ng trc ba n ti. + Trong khi iu tr phi da vo kt qu xt nghim ng mu, ng niu v tu loi insulin c th tng hoc gim liu, mi ln 5 - 10 n v kim sot ng huyt. + Liu iu tr s c xc nh sau 2 - 3 ngy iu tr. + C th xy ra d ng ngay sau khi dng insulin vi biu hin my ay hoc ph quinck, nhng rt him. + Nu qu liu insulin xy ra h ng huyt nh: ung mt cc nc ng hoc glucose, nu nng cn tim 20 - 40. m dung dch glucose 20%, nu khng phi a bnh nhn vo bnh vin. 6.2. iu tr i tho ng typ 2 * Ch n: - p dng nh i tho ng typ 1. - Ch n nn c p dng u tin cho mi bnh nhn. - Nu khng , phi dng thm thuc iu chnh ng huyt. - Hu ht bnh nhn i tho ng typ 2 cn iu tr bng thuc h ng huyt ung, nhng thuc ny c chia thnh cc nhm chnh: * Thuc: - Sulfamid h ng huyt (Sulfonylurea). + Cc loi:

Tolbutamid 0,5g (th h 1) x 4 vin/24h.

112

Glthenclamid (Daonil, Maninil): 5mg (th h 2) x 2 - 4 vin/24h. Gliclazid (Diamicron, Predian): 80mg (th h 2) x 1 - 4 vin/24h.

+ C ch tc dng:

Kch thch t bo ty sn xut insulin. Tng hiu lc tc dng ca insulin ni v ngoi sinh:

- c ch enzym insulinase ca gan. - c ch kt hp insulin vi khng th v vi protein huyt tng. + Bin insulin khng hot ng thnh insulin hot ng. + Lm tng s lng Receptor tip nhn insulin mng t chc c v gan ca sinh vt. + Lm tng hp thu glucose t chc. + Sulfonylurea th h 2: lm gim kh nng kt dnh v ngng tp tiu cu, chng li s hnh thnh vi huyt khi, gim tn thng vi mch (lm chm qu trnh tin trin ca bnh l vng mc, bo tn c chc nng thn, gim prrotein niu). - Biguanid (thuc chng cao ng huyt): + Metformine, glucophage 500mg x 2 - 3 vin/24h. Ung trong hoc sau ba n. Tc dng ph trn ng tiu ha thng gp 20% bnh nhn (nghin cu UKPDS 1998) + Tc dng:

Tng tnh thm mng t bo i vi glucose,tng s dng glucose t chc ngoi vi, ch yu l c. C th lm tng t l insulin t do/ insulin kt hp vi protein huyt tng. Gim t l cc tin cht insulin. c ch s tn to glucose gan m vn ci thin nhy cm ca t bo c i vi insulin.. Lm chm hp thu glucose rut non. Khng c tc dng kch thch t bo tit insulin nn khng gy tng insulin mu. C tc dng lm gim hin tng khng insulin.

- Loi khc: + Acarbose: (glucobay) (l mt Tetrasaccharid gi): 50mg, 100 mg x 1 - 2 vin x 2 - 3 ln/ ngy, ung ngay khi bt u n. C tc dng c ch disacharide b bn chi rut non, do lm chm s hp thu carbohydrate v khng lm tng ng 113

huyt sau n. Ri lon tiu ha l mt tc dng ph hay gp trong khi bnh nhn c iu tr bng glucobay. + Mediator (Bennuorex): 150 mg C tc dng ln s khng insulin, iu chnh ri lon chuyn ha lipid, gim triglycerid, lm tng HDL- c. - Tun l: 1 vin / 24 gi, ba n ti. - Tun 2: 2 vin /24 gi, lc n tra v ti. - Tun 3: 3 vin /24 gi, vo cc ba n sng, tra, ti. + Amaryl (Glimepiride) 1 mg, 2 mg, 3 mg. Ung nguyn vin 1 ln / ngy. + Vitamin E v C. * Ch : - Nu cc bin php iu tr nh tit ch, thay i li sng, thuc h ng huyt ung (c th phi hp) m khng kim sot c ng huyt bnh nhn i tho ng typ 2, nn t vn iu tr bng insulin, thng tip tc phi hp vi thuc h ng huyt ung. - iu tr bnh km theo v bin chng (nu c). c bit ch bin chng tim mch, hn m v bnh l bn chn bnh nhn i tho ng. - Trch nhim qun l, theo di ngi bnh, hng dn bnh nhn thc hin ch n, ch luyn tp, ch thuc men l rt quan trng i vi cc thy thuc cng ng. - Khi pht hin cc bin chng bnh nhn i tho ng, cn x tr bc u sau tm cch chuyn bnh nhn ln tuyn trn x tr. 7. PHNG BNH Tuyn truyn, gio dc sc khe cho bnh nhn, ngi nh bnh nhn v cho cng ng v vic thc hin ch n king, luyn tp, hn ch yu t nguy c, c bit l vic qun l bnh nhn ngoi tr nhm hn ch bin chng do bnh i tho ng gy ra. Cho n nay c 3 cp phng bnh l: - Phng bnh cp l: ngn nga hoc lm chm s pht bnh cng ng v c nhn ngi c yu t nguy c mc bnh i tho ng. - Phng bnh cp 2: ngn nga hoc lm chm s tin trin cc bin chng ca bnh. - Phng bnh cp 3: tng cng kh nng ca h thng sc khe quc gia phc v c hiu qu cho vic ngn nga v chm sc ngi bnh i tho ng. 114

BASEDOW
1. I CNG 1.1. c im dch t Bnh Basedow cn c gi l bnh Parry hay bnh Graves, bnh bu c c li mt hay bnh tng nng gip t min. Bnh gp mi la tui, nhng tp trung nhiu tui 20 - 40, trong Vit Nam thng gp nhiu la tui 20 - 30 (31,8%), n chim nhiu hn nam, tu theo thng k c th chim t l 4/1 - 7/1 (Williams, L Huy Liu). y l mt bnh ni tit thng gp nc ta, him gp tr nh v ngi gi > 50 tui, chim 45,8% cc bnh ni tit v 2,6% cc bnh ni khoa iu tr ti Bnh vin Bch Mai (L Huy Liu v cng s -1991). M, t l mc bnh Basedow chim 0,02 - 0,4% dn s, trong khi theo thng bo ca Tunbridge v cng s th Bc Anh t l mc bnh Basedow l khong 1%. 1.2. nh ngha Bnh Basedow l bnh cng chc nng tuyn gip, kt hp vi ph i bu lan to. Nhng bin i bnh l trong c quan v t chc l do tc dng ca hormon gip tit qu nhiu vo trong mu. 2. NGUYN NHN V C CH BNH SINH 2.1. Quan nim trc y Cc tc gi cp ti cc yu t khi bnh nh: + Chn thng tinh thn (stress): yu t chn thng tinh thn lm ri lon qu trnh min dch v ng mt vai tr quan trng trong s khi pht bnh Basedow. + Nhim khun: di tc ng ca virus, cc t bo lympho T phng thch Interferon - (IFN - ) v gy bc l khng nguyn HLA - DR v - DQ ca t bo gip, nhng t bo gip ny ng vai tr duy tr v tng p ng t min. + Yu t c a di truyn: bnh c tnh gia nh r rt, thng trong gia nh c ngi c biu hin bnh l tuyn gip nh bu gip n thun, vim tuyn gip hoc Basedow. Bnh cng thng xy ra c a nhng ngi c ri lon thn kinh thc vt thuc loi cng giao cm. Cc tc gi cho thy t l ph n b mc bnh Basedow nhiu hn so vi nam gii, bnh Basedow cn lin quan ti h HLA.. + Ung thuc c nhiu iod: thng gp mt s bnh nhn b bu c a phng, c bit l bu gip th nhn, sau mt thi gian iu tr ko di vi cc ch phm c iod, c th dn ti cng chc nng tuyn gip gi l bnh iod Basedow. Dng thyroxin v cc chit sut gip gy tng nng gip bn vng hn. 115

- C ch bnh sinh: do ri lon iu ha trc di i - tuyn yn - tuyn gip. 2.2. Quan nim hin nay Basedow c chng minh l mt bnh t min dch. - Nm 1956 Adams v Purves pht hin thy trong huyt thanh bnh nhn Basedow c mt cht vi hot tnh kch thch tuyn gip nhng khc vi TSH ca tuyn yn ch chng hot ng chm, v sau (1960) ngi ta a thut ng cht kch thch tuyn gip hot ng ko di LATS ch cht ny. - Kriss v cng s (1964) xc nh LATS l mt globulin min dch thuc lp IgG do t bo lympho B to ra. - 10 nm sau, Manley (1974) v Mehdi (1975) pht hin ra cc phn t IgG ny c ch s gn TSH vo th th tng ng trn mng Plasma t bo tuyn gip. Tu theo k thut s dng m c tn gi khc nhau: TSAb, TSI, TBII v c gi chung l a. TSH. ReAb (khng th khng th th dnh cho TSH). - Cc khng th ny khi gn vi th th TSH th va c ch gn TSH vo th th, va bt chc hot ng ca TSH v gy kch thch tuyn gip. 3. TRIU CHNG M t bnh Basedow in hnh. 3.1. Triu chng lm sng * Bu gip trng: C th c trng hp tuyn gip khng to, nhng rt him (l,5% cc trng hp). - Thng l bu gip mch: bu to lan to, thu phi thng to hn thu tri. S c rung mu, nghe c ting thi tm thu hoc ting thi lin tc ti tuyn. - Qua nghin cu khng thy c s lin quan gia mc nng, nh ca bnh vi to ca bu tuyn gip. * Tim mch: y l triu chng quan trng, vi biu hin: - Nhp tim nhanh: nhp nhanh xoang thng xuyn, tng ln khi gng sc hoc xc ng, km theo c hi hp nh trng ngc, i khi kh th, c khi c lon nhp hon ton hoc lon nhp ngoi tm thu. - Kch ng tim mch: bao gi cng c, vi biu hin cc mch mu ln p mnh nh ng mch cnh, ng mch i, ng mch ch bng. - Cung lng tim tng, tc tun hon nhanh. - Huyt p ti a c th tng, T1 p mnh. - C th c suy tim, thng l suy tim ton b. * Gy st: 116

Bnh nhn gy st, mc d n vn ngon ming, c khi gy st nhanh (khong 10 kg/thng). * Cc biu hin mt: - Mt li, sng long lanh. + Thng li mt c hai bn. + li ca mt c xc nh bng li k Hertel (bnh thng li ca mt: 12 1,75 mm). + C th c li mt c tnh. - Mt s du hiu v mt: + Graefe (+): mt s phi hp gia nhn cu v mi trn khi nhn xung di. + Mbius (+): mt s hi t nhn cu. + Dalrymple (+): khe mt m rng. - Run nh, nhanh cc u ngn. - Tng ln khi xc ng. * Mt s biu hin khc: - Bnh nhn nng bc, s nng, c nhng cn bc ho. Ra m hi, nht l hai lng bn tay. - Thay i tnh tnh: bnh nhn bn chn khng yn, hay cu gt, d xc ng. Bnh nhn lo lng nhiu v bnh tt. - Ri lon tiu ha: thng i ngoi phn lng nhng khng c mu, mi. - Mi c: thng gp th trung bnh v nng, pht hin bng du hiu gh u, khi iu tr bng thuc khng gip tng hp, bnh Basedow th triu chng mi c cng gim dn. - Ri lon sinh dc: + Ri lon kinh nguyt n. + Lit dng nam. 3.2. Triu chng cn lm sng - Chuyn ha c s tng: > + 20% mi c ngha. Chuyn ha c s phi o ng k thut v bnh nhn phi c chun b trc kh o cn thn th kt qu mi ng tin cy. Trong thc t lm sng, nu nhng ni khng c phng tin o, th c th tnh c lng CHCS theo cng thc Gic: CHCS % = {tn s tim + (HA max - HA min) - 111}. - Phn x gn gt rt ngn: (bnh thng 0,24 - 0,26s). Nhng hin nay t 117

c lm. - Cholesterol mu gim. - ng huyt bnh thng hoc tng nh. - nh lng PBI (Protein Bound Iodine) thy tng, (bnh thng 9-12 mg). - tp trung inh ti tuyn gip thi im 2 gi v 24 gi thy tng cao v c gc chy in hnh. + Nghim php Wermer (-), ch s hm gim. + nh lng T3, T4 v FT4 trong huyt thanh thy tng cao (theo phng php RIA: bnh thng T4: 50 - 150 nmol/l; T3: 1 - 3 nmol/l). + nh lng TSH huyt thanh theo phng php IRMA (Immuno Radio Metrie Assay) thy gim thp (bnh thng TSH: 0,3 - 3,5 mU/l). + Ghi x hnh v siu m tuyn gip: xc nh hnh th v kch thc tuyn gip. + Gii phu bnh vi th: (ch nn tin hnh vi t chc tuyn gip c ct b sau phu thut) thy hnh nh Basedow. 4. CHN ON 4.1. Chn on xc nh * Lm sng: - Hi chng nhim c gip. + Nhp tim nhanh. + Gy st + Run tay + Thay i tnh tnh + Nng bc, da nng m, nhiu m hi. - Bu gip mch. - Mt c th li. * Cn lm sng - CHCS tng: + 20%. - nh lng T3, T4 ton phn, FT4 trong huyt thanh thy tng cao. - TSH trong huyt thanh gim thp. - Trong lm sng, trc mt ngi bnh c bu gip to, mt li, km theo c nhp tim nhanh l c th cho php ngh ti bnh nhn b bnh Basedow. 4.2. Chn on phn bit 118

* Bnh nhn b bu c n thun c cng thn kinh giao cm: - Thng khng c hi chng nhim c gip. - iu tr ch yu bng thuc an thn thy cc triu chng lm sng thuyn gim. * Cc bnh cng gip trng (hyperthyroid) khng phi Ba8edow: - Bnh iod Basedow: + Cng gip xy ra ngi c bu c (thng l bu nhn) c iu tr bng iod (lipiodol) liu cao, ko di. + Bnh nhn thng khng c li mt. + Ghi x hnh tuyn gip thy x hnh trng. - U c gip trng (bnh Plummer). + Bu nhn gip trng. + C triu chng cng gip. + Khng c li mt. + Chn on xc nh nh ghi x hnh tuyn gip v nghim php Qurido. - Cng gip trng cn ung th: + Xy ra bnh nhn ung th sinh dc, ung th phi. + Hay gp nam > 50 tui. + Mt khng li + Do t chc ung th tit ra mt cht tng t nh TSH (TSH like). 4.3. Chn on mc Theo Baranov V.G (1977) v Potemkin (19S6) chia ra lm 3 mc nhim c hormon gip nh sau:
Triu chng Thn kinh, tinh thn Nhp tim (ln/pht) Cn nng gim CHCS T4 (nmol/l) Mc nhim c hormon gip Nh Trung bnh Nng + ++ +++ < 100 100 - 120 > 120 < 10% 10 - 20% > 20 % < 5kg 5 - 10kg > 10kg +20% +30% +30% +60% > +60% 150 250 251 3 00 > 300

4.4. Tin trin v bin chng Nu c chn on sm, iu tr ng cch din tin thng kh quan. Tuy nhin vn c nhng trng hp ti pht. Din bin xu,nhiu bin chng thng xy 119

ra nhng trng hp chn on. v iu tr qu mun. * Cn cng gip cp: D xy ra bnh nhn cng gip nng, bnh nhn c phu thut trong khi cha t bnh gip hoc khng c chun b ni khoa tt. Nhn dp b mt bnh nhim trng thm vo, c khi cn xut hin do ct t ngt thuc khng gip tng hp. Cn cng gip thng c biu hin: - St 38 - 39oC hoc Cao hn, v m hi, vt v, kch ng, i khi mt l. - Nhp tim rt nhanh, lon nhp, suy tim c khi try mch. - Bnh nhn au bng, vng da, a chy, nn ma, gy st cn nhanh. - Ban u bao gi cng c triu chng run, mt ng, i khi m sng, hoc ri lon tm thn, vt v lo u. Tin lng rt nng, t l t vong cao 30-60%. * Bin chng tim mch: Thng gp nht bnh nhn c sn bnh tim, bnh ng mch vnh. V vy ngi c tui d b bin chng ny. C 3 biu hin chnh: - Cc ri lon nhp tim: cn nhp nhanh xoang, nhp nhanh trn tht, lon nhp hon ton... - Suy tim: kh th, tm, ph ngoi vi, i t. - au tht ngc: o suy vnh c nng. * Bnh c do nhim c gip. D xy ra hn trong trng hp nhim c gip nng, thng lit gc chi, i li kh khn, phn x gn xng ni chung bnh thng, khng c du hiu b thp. * Bin chng ti mt: - Li mt c tnh: lc u bnh nhn b chy nc mt, s nh sng, li mt nng ln nhanh, mt , cng t gic mc, d b lot gic mc, thng nhn cu, c th m lo. - Lot gic mc. - Lit c vn nhn. 5. TH LM SNG 5.1. Th theo triu chng - Th vi triu chng cng gip ni bt: bu to, mch nhanh, gy st... - Th mt li. 5.2. Th theo c a 120

* Theo tr em: - S pht dc thng nhanh. - Bnh nhn gy st - Nhp tim nhanh - t li mt * Theo ngi gi: - Triu chng lm sng kn o. - Biu hin v tim mch r: lon nhp hon ton. * Theo nam gii: - Bu gip to t. - Triu chng lm sng r rng. - iu tr kh khn, kt qu chm. * Basedow ph n c thai: - Bnh thng nng 3 thng cui ca thi k c thai. - Cn ch trong iu tr: m bo duy tr bnh gip nhng phi m bo an ton cho m v thai nhi. 5.3. Mt s th lm sng c bit - Th bin chng tim: - Th u tuyn c: y l th rt c bit, cn gi l bnh Plummer. - Bu a nhn hn hp c: nhim c gip xy ra bnh nhn c bu c lu nm v c nhiu nhn. - Bu c Basedow ha: Basedow xut hin trn mt bu c t trc. - Cng gip do iod: cng gip gp nhiu nam gii tui trn 40. Trong vic phng bu c do thiu ht iod, cng gip c th xy ra sau khi dng ch phm c iod, nht l tim lipiodol. Bnh d xut hin trn nhng ngi c bu nhn. Bnh nhn thng khng c li mt, tuyn gip bo ho iod v x hnh trng. 6. IU TR Cho n nay, trong iu tr bnh Basedow c 3 phng php iu tr t bn: - iu tr ni khoa - iu tr bng iod phng x - iu tr bng phu thut. 6.1. iu tr ni khoa 121

Ch yu l iu tr bng thuc khng gip tng hp, cn cc thuc khc gip cho iu tr ni khoa t kt qu tt hn. 6.1.1. Ch nh - Bnh mi khi pht - Th nh v trung bnh - Bu to t, lan to - Bnh nhn c iu kin iu tr ko di 1 - 2 nm. 6.1.2. iu tr c th * Ch ngh ngi n ung: - Ngh ngi tng i, trnh lao ng nng, trnh stress. - n ung m bo y cc cht dinh dng, vitamin. * Thuc: - Khng gip tng hp: hin nay c cc loi thuc ch yu sau: MTU (Methylthiouracil), PTU (Propylthiouracil), BTU (Benzylthiourracil) (Basden), Mercasolin, Thiamazol, Carbimazol... iu tr theo giai on: + Giai on tn cng: thuc khng gip c cho theo mc nhim c gip. Thi gian iu tr t 4 - 6 tun. C th chn mt trong cc loi thuc sau:
Tn thuc MTU (25mg; 100mg) PTU (50mg) Methimazol (5mg) Mercasolin (5mg) Liu lng thuc theo mc nhim c gip Nng Trung bnh Nh 300 - 400 30 - 40 200 - 300 20 - 30 100 - 200 10 - 20

+ Giai on cng c. liu bng 1/2 liu tn cng, dng ko di 1 - 3 thng. + Giai on duy tr: liu bng 1/2 liu cng c, dng ko di 1 - 2 nm. C th dng lin tc hoc cch nht. Ch :

Liu lng thuc KGTH cho theo mc nhim c gip. Gim dn liu theo mc nhim c gip gim dn. Hng ngy theo di CTM: nu s lng bch cu < 4000/mm3 th ngng thuc. Mt bch cu ht l bin chng t gp nhng rt nng, gp 0,1% bnh nhn iu tr bng Methimazol v 0,4 % cc bnh nhn iu tr bng PTU. Mt s tc dng ph khc c th gp l nga, vim da d ng, bun

122

nn v chn n. - Ch phm c iod (dung dch lum): iod ngn cn chuyn t iod v c sang iod hu c, c ch s xut hormon ra khi tuyn gip v pht huy tc dng nhanh hn so vi cc hp cht c ch tng hp hormon. + Ch nh:

Cng gip trng mc nh. Chun b bnh nhn trc m. . Dng phi hp vi thuc KGTH.

+ Cch dng: Dung dch lum (l%, 5%), 40 - 50 git/24h (loi l%). Ch liu lng phi mnh, ngy no cng ung, t nht l 6 thng, trc khi ngng thuc vi tun phi gim dn liu. - Thuc khng giao cm: y l thuc c ch bta giao cm, t tc dng ph, khng gy h huyt p. Propranolol 40mg x 1 -2 vin/24h, dng cho n khi nhp tim tr v bnh thng. Tc dng ca thuc l lm gim cc triu chng do cng gip gy nn nh nhp tim nhanh, run, ra m hi v lo u. N c th l thuc c chn la u tin trong x tr cn cng gip trng cp. - Thuc an thn: Seduxen 5mg x 1-2 vin/24h, dng 7-10 ngy. - Vitamin B1, C. Hin nay c quan im iu tr theo c ch bnh sinh bng cch phi hp thuc c ch min dch nh prednisolon 5mg x 4-6 vin/ 24 h, Cyclophosphamid 50mg x 1-2 vin/ 24 h vi thuc khng gip tng hp trong phc iu tr. Tuy vy ch nn p dng v ch nh trong cc trng hp: - Basedow nhim c hormon gip mc nng. - Li mt. - Thi gian mc bnh trn 6 thng. - Bnh hay ti pht. * Tiu chun nh gi bnh gip (euthyroid): - Nhp tim tr v bnh thng. - Tng cn v cn tr v bnh thng. - Ht triu chng ri lon thn kinh thc vt. 123

- CHCS, T3, T4 v bnh thng. 6.2. iu tr bng iod phng x (I131) y l phng php iu tr tng i n gin, c hiu qu v kinh t. C th xem y nh l mt phng php phu thut chn lc, tc dng vo cc t bo kht iod ca tuyn gip, ph hu cc t bo ny bng cc tia bta. * Ch nh: - Bnh nhn > 40 tui, bu to va. - Ti pht sau m - Mc bnh tim, khng phu thut c. - Bnh nhn khng th theo di cht ch khi iu tr bng ni khoa. - Tht bi khi iu tr ni khoa. * Chng ch nh: - Ph n c thai hoc thi k ang cho con b. - Bnh tr em, thiu nin. - Bu nhiu nhn, bu rt to, bu chm. - H bch cu thng xuyn. * Tai bin: - Cn cng gip trng cp. - Ung th gip. - Suy gip: y l bin chng hay gp. 6.3. iu tr bng phu thut Ch yu l phng php ct b gn hon ton tuyn gip. * Ch nh: - Cc th nng bnh nhn tr < 40 tui, tr em v thiu nin iu tr ni khoa khng kt qu. - Bu nhn. - Bu rt to. - Basedow khng iu tr bng I131 c, v bu bo ho iod. - iu tr ni khoa tch cc 5 - 6 thng nhng khng c kt qu r rt. - Bnh nhn khng c iu kin iu tr ni khoa, c nguyn vng mun m. * Chng ch nh: 124

- Basedow c nhng ri lon bnh l c quan ni tng (suy tim, ph, c trng...). - Chng ch nh tm thi: bnh nhn Basedow ang b cm, vim hng, bnh phi, ph qun. * Bin chng sau phu thut: - Chy mu, tc ng th. - Ni khn, cn tetani. - Nhim khun vt m gy so xu. - Cng gip trng cp. - Suy gip - Bnh ti pht. Tm li: - Bnh Basedow l mt bnh ni tit hay gp Vit Nam cng nh trn th gii. Ngy nay, cc tc gi u tha nhn y l bnh t min dch c hiu c quan. Trong iu tr, d la chn phng php no th phng php iu tr ni khoa bng thuc khng gip tng hp vn l phng php c p dng u tin, trc khi p dng phng php iu tr bng I131 hoc bng phu thut ct b gn hon ton tuyn gip. Mc tiu cui cng ca iu tr l nhm a bnh nhn v trng thi bnh gip (euthyroid). - Phng bnh: Trn c a nhng ngi d mc bnh Basedow cn trnh cc sang chn tm l, trnh dng cc ch phm c iod liu cao ko di. c bit cn tuyn truyn gio dc cho cc bnh nhn Basedow thc hin tt liu trnh iu tr ni khoa, duy tr bnh gip, trnh ti pht, trnh cc bin chng c th xy ra.

125

BU GIP TRNG N THUN

1. I CNG 1.1. nh ngha Bnh bu gip trng n thun l tnh trng ph i v qu sn ca tuyn gip, mt phn ng thch nghi ca tuyn gip trc nhiu yu t khc nhau, trong ch yu l thiu iod tuyn gip. Theo nh ngha ca T chc Y t Th gii th c bu c khi thu bn ca tuyn gip ln hn t cng ca ngn tay ci ngi c khm. 1.2. Dch t Bnh bu gip trng n thun l mt bnh ph bin c xp vo loi bnh c tnh cht x hi. Bnh c th gp mi ni nhng nhiu nht l vng min ni, giao thng kh khn, kinh t km pht trin. Bnh bu gip trng n thun gp cc dn tc, la tui. Ph n mc bnh nhiu hn nam gii, nht l la tui dy th, cho con b, mn kinh. Theo ti liu ca T chc Y t Th gii cho ti nay c khong 655 triu ngi mc bnh bu c, ch yu tp trung cc nc ang pht trin. Theo Brodow Retal (1989) t l bu c a phng mt s nc chu Phi nh cng ho Zaire, Tn ghi n ln ti 42,4%. ng Nam c ti 100 triu ngi mc bnh bu c. Vit Nam, theo ti liu cng b ca L M (1990) - Vin Ni tit Trung ng, t l bnh bu c chung cho dn s tt c cc vng c nghin cu l 34,2%, trong c nhng vng t l bu c cao nh Sn La, Vinh Ph, Ho Bnh, Lai Chu, Sn La, c Lc. Tnh hnh thiu ht iod l nghim trng trn ton lnh th Vit Nam, i hi mt chin lc phng chng cc ri lon do thiu iod lu di v ton din. B sung iod vo ch n d phng c hiu qu bnh bu c v chng n n do thiu iod. T nm 1995, thc hin ngh quyt 481/TTg ca Th tng Chnh ph v vic t chc v vn ng ton dn n mui iod thay cho mui thng, chng trnh quc gia phng chng cc ri lon thiu ht iod tp trung ch o v iu hnh ch tiu, k hoch, phi hp vi cc b ngnh trung ng v cc a phng trin khai tt cc mc tiu k hoch ra. 1.3. Phn loi bu c: gm hai loi - Bu c l t (bu c do phn ng): 126

+ Thng xy ra n: thi k dy th, mang thai, cho con b, tin mn kinh. + Vng khng c thiu ht iod. + Bnh chim t l thp < 10% dn s. - Bu c a phng: + Gp vng c thiu ht iod. + T l mc bnh cao > 10% dn s, c ni 50-60%; hoc t 5% tr em la tui 8 - 12 b mc bu c 2. BNH NGUYN - BNH SINH Nhu cu v iod ph thuc vo la tui, tnh trng sinh l nh thi k tr nh, dy th, cha v ch lao ng. Khi b thiu iod c th c nhng c ch thch nghi tu theo mc thiu iod nh hay nng. Bu c a phng l loi bu c gy nn bi cc thay i bt thng can thip vo s sinh tng hp ca thyroxin. S thiu tng i hay tuyt i ni tit t ny s gy ra tnh trng cng kch t hng gip trng ca tuyn yn (TSH) v a ti hu qu l ph i v qu sn t bo gip trng, do sinh ra bu. Trong bnh bu c n thun c nhiu yu t c th lm nh hng ti s sinh tng hp hormon gip. - Do gim iod trong thc n: y l nguyn nhn chnh gy ra bnh bu c n thun. - Do n phi thc n c cht sinh bu: + Cht thiocarbamid c nhiu trong su ho, bp ci c tc dng c ch tng hp thyroxin (tc dng tng t thuc khng gip tng hp). + Thiocyanat cn tr men chuyn ch iod nn c rt t iod trong tuyn gip. - Do thiu men peroxydase dn ti iod v c khng c chuyn thnh iod hu c, do dn ti thiu ht hormon gip. - Do mt sion v c: ton Ca+, K+, Zn++ c th nh hng ti bnh bu c. - Do tnh trng thiu v sinh, thiu vitamin nn d sinh bu. 3. TRIU CHNG 3.1. Lm sng * C nng - Triu chng c nng thng ngho nn v khng c g c bit. - Nu bu qu to c th chn p gy kh nut, nut vng, kh th nh. * Thc th 127

- Nhn: thy bu to t hoc nhiu. Khi khm, xc nh to ca bu theo T chc Y t Th gii: O: khng nhn thy, khng s thy tuyn gip. Ia: nn thy tuyn gip t th thng, nga c ra sau khng nhn thy, thy bn tuyn gip nh hn u ngn tay ci bnh nhn. Ib: nn thy tuyn gip t th thng, nga c ra sau nhn thy mi thy to bng u ngn tay ci bnh nhn tr ln. II: nhn r bu t th thng. III: bu to r, nhn thy t cch xa khong 10m. - S: c th xc nh c mt s c im. + Bu nm di sn nhn, ranh gii r, khng dnh vo t chc xung quanh. + Di ng theo nhp trut. + Khng nng, khng c rung mu. + Khi thm khm, c th xc nh c 3 loi bu:

Bu lan to: bu to u, ton th Bu nhn: nhn mt chc, di ng theo nhp trut. Bu hn hp: trn nn bu lan to c mt vi nhn....

- Nghe: khng thy ting thi ti tuyn. - o: theo di v nh gi kt qu iu tr. 3.2. Cn lm sng Cc xt nghim ch thay i nhiu khi c bin chng. - Chuyn ha c s: trong gii hn bnh thng (-10% - +10%). - tp trung I131 ti tuyn gip: hi tng, nhng khng to gc chy (y l tnh trng ho iod). - nh lng T3, T4 huyt thanh thy bnh thng, c th gim nh T4 (bnh thng theo phng php ELISA: T3: 0,8 - 1,8 g/l; T4: 4,5 - 11,7 g/dl; theo phng php RIA: T3: 1 - 3 nmol/l, T4: 50 - 150 nmol/l). - TSH huyt thanh: bnh thng hoc tng nh - Ghi x hnh v siu m tuyn gip: cho bit kch thc, hnh th, v tr v pht hin nhn tuyn gip. - Iod niu: thy gim cc bnh nhn nm trong vng c thiu ht iod (< 10g/dl) 128

4. CHN ON 4.1. Chn on xc nh Thng l d, bnh nhn c bu c nhng t c s thay i chc nng v lm sng v cn lm sng. Xc nh to ca bu (theo WHO). 4.2. Chn on phn bit * Bnh Basedow - Bu gip mch - Nhp tim nhanh - Mt li - Xt nghim mu thy T3, T4, FT4 tng; TSH gim. * Hch quanh bu - Hch thng cng, chc, ranh gii r. - Khng di ng theo nhp nut. * Lp m di da Thng gp ngi bo, mt mm, ranh gii khng r v khng di ng theo nhp nut. 4.3. Chn on bin chng * Chn p kh ph qun - Bu to, gy kh th, kh nut - Bu ngm, c th gy chn p trung tht * Chn p dy thn kinh qut ngc C th gy ni khn, ging i * Ri lon chc nng - Cng gip trng - Suy gip trng * Vim tuyn gip cp hoc bn cp - St - au vng tuyn gip - C sng, nng, r * Ung th gip trng 129

- Thng xy ra trn nhng bu nhn. - Tuyn gip to, cng, ln nhn. - Bnh tin trin chm. - Chn on da vo xt nghim gii phu bnh vi th. 5. PHNG BNH V IU TR 5.1. Phng bnh bu c a phng * Nguyn tc: - Cc ri lon do thiu iod c th phng c bng b sung iod cho c th. - Mi cng ng sng trong vng thiu iod u phi c b sung iod. i tng u tin l ph n c thai, ph n trong la tui sinh v tr em. - Bng mi cch a lng iod cn thit theo nhu cu hng ngy cho ton dn vng bu c a phng. Liu iod b sung ph hp vi nhu cu sinh l v khng gy tai bin. - Phng bnh bng b sung iod phi m bo an ton, lu di v lin tc. - K c sau khi thanh ton c cc ri lon do thiu iod. * C th: c th dng mt trong cc bin php sau: - Vim IK (Kali Iodua) 5mg, 1 tun ng 1 vin. Tuy vy cng kh p dng v t tin hn so vi mui iod. Mt khc, cng d qun ung, c th dng nhng ni kh a mui n. - ng Lipiodol, tim bp su, mi ln 1 ml (l-2 nm tim 1 ln). C tc dng ti ch nh phn ng au, i khi gy p xe ti ch. C th tng nguy c cng gip, nht l nhng ngi c bu nhn. Hin nay c mui iod nn t dng. Ch s dng khi vng c t l mc la tui hc sinh 8 - 12 t 30% tr ln v c nng iod niu < 2g/dl. - Vin nang Lipiodol, mi ln ung 1 nang (6 - 12 thng ung 1 ln). - Tt nht l trn iod vo mui n v cc loi thc phm khc nhau cho ton dn s dng, thc hin theo chng trnh quc gia phng chng cc ri lon thiu ht iod. + n mui iod va t hiu qu phng bnh tt va kinh t nht. + Vic hng dn s dng mui iod trong ba n l rt quan trng, v n am bo cht lng iod c b sung hng ngy cho c th. + Khi nu thc n cn ch bc ni, cho thc n ra khi bp mi cho mui iod vo trnh b mt i khi nu. Dng mui iod chm thc n l rt tt. 5.2. iu tr bu c l t v bu c a phng 130

* Ni khoa - Bu c I: tt nht l dng hormon gip vi liu sinh l. T4 (Thyroxin) 100 g x 1 virl/ngy. T3 (Triiodothyronin) 20 g x 1 vin/ngy. Thi gian ko di 2 - 3 thng, c th dng ring r hoc phi hp. Ch l khi iu ta c th gy tng nng gip do tng hormon, cn loi tr trc khi kt lun bnh nhn b bnh Basedow. - Bu c II, III hoc bu nhn: iu tr ni khoa t kt qu. * Ngoi khoa: ct b gn hon ton tuyn gip. Trong thc hnh iu tr, cn ch nh phu thut theo ng ch nh v khng c lm dng v c th xy ra nhiu bin chng. - Ch nh: + Bu qu to gy chn p + Bu nhn, iu tr ni khoa khng kt qu. + Bu nghi chuyn c tnh. - Bin chng + Ct phi dy thn kinh qut ngc: gy ni khn, ging i. + Ct phi tuyn cn gip gy h calci mu. + Ct qu nhiu t chc tuyn gy suy gip. + Chy mu. Tm li: bu gip trng n thun l mt bnh ni tit thng gp nc ta, bnh mang tnh cht x hi, nguyn nhn gy bnh ch yu l do thiu ht iod. Trong cc bin php phng bnh th b sung iod bng cch trn iod vo mui n v ton dn dng mui iod l bnh php phng bnh c hiu qu v d thc hin nht. nc ta, phi hp cc ngnh thc hin tt chng trnh quc gia phng chng cc ri lon thiu ht iod nhm thc hin mc tiu thanh ton bnh bu c a phng vo nm 2005.

131

CHN ON V IU TR THN H TH PHT

1. I CNG 1.1. nh ngha Hi chng thn h l mt hi chng ca bnh cu thn xy ra mt cch t ngt do tn thng cu thn c c trng bi: - i mu - i t - Tng huyt p - Protein niu - Ph 1.2. c im dch t Hi chng thn h th pht gp ch yu ngi ln tui. Theo thng k ca Trn Vn Cht v Trn Th Thnh t nm 1991 - 1995 ti khoa thn tit niu Bnh vin Bch Mai c 31,5% s bnh nhn nm ti trong khoa vi s tui trung bnh t 36 - 54 tui chim 98,32%, bnh khng lin quan v gii v a d, nh vy bnh gp nhiu la tui lao ng trong c bin chng suy thn mn chim 26%. Vic iu tr chn on ng c ngha rt quan trng trnh bin chng ca hi chng thn h th pht gnh nng cho gia nh v x hi. 2. NGUYN NHN V C CH BNH SINH 2.1. Nguyn nhn 2.1.1. Bnh h thng v chuyn ha - Lupus ban h thng - Hi chng ban xut huyt dng thp - i ng - Thn nhim bt 2.1.2. Thuc v c cht - Phenindion, tridion - Captopril - Li tiu thu ngn - Ong t - Heroin. 132

2.1.3. Tim mch - Vim ngoi tm mc - Tng huyt p c tnh - Hp ng mch thn 2.1.4. Nhim khun - k sinh vt - St rt - Giang mai - AIDS - Vim gan B 2.1.5. Ung th (v, ph qun, i trng) 2.1.6. Sau tim (Bismut, vacxin bi lit) 1.2. C ch bnh sinh - Bnh sinh ca hi chng thn h cha c hiu bit y . V gii phu bnh hc, th tn thng mng y cu thn l ch yu. Bnh thng mng y khng cho cc phn t ln nh protein i qua. Khi c mt nguyn nhn no lm mng y bi tn thng in th ca mng y b thay i th protein lt qua c. Protein niu cng nhiu th Protein mu cng gim, albumin ra nhiu nht (80%) lm gim p lc keo ca huyt tng. Nc thot ra ngoi lng mch hu qu l gy ph v gim th tch tun hon hiu dng. T mt mt trc tip gy ti hp thu nc v nan ng ln gn, mt khc gin tip qua h thng iu ho ni tit lm tng ADH v aldosteron. - ADH tng s ti hp thu nc ng gp. - Aldosteron tng s ti hp thu Na+ v nc ng ln xa v ng gp. - Kt qu ca qu trnh trn l qu trnh gi Na+, gi nc, do s i t v dn n ph ton thn ko theo cc ri lon nc v in gii (xem s c ch gy ph). 3. TRIU CHNG LM SNG V CN LM SNG 3.1. Ph th in hnh th triu chng lm sng ch yu l ph - Ph to ton thn, ph mt - c bit l mi mt, ri xung chi di v b phn sinh dc - C trng, trn dch mng phi mt hoc hai bn - Trng hp nng c th ph no 133

3.2. i t Nc tiu thng di 500ml/24h 3.3. Mt mi, n km 3.4. Thiu mu nh 3.5. Protein niu cao Protein niu thng ln hn hoc bng 3,5g/24h, thnh phn ch yu l albumin, ngoi ra nc tiu cn c th m, lng chit quang, tr m tr ht, hng cu niu v 134

bch cu niu. 3.6. Protein mu gim Do mt lng ln albumin b mt qua nc tiu, kt qu dn n albumin huyt tng gim. - Trng hp nng albumin gim di 30 g/l. - Alpha 2 globulin thng tng - Ga ma globulin bnh thng hoc gim trong hi chng thn h sau vim cu thn lipid thng tng cao. 3.7. Lipid mu tng Tng lipid mu c xem nh l mt c trng c bn ca hi chng thn h. C th tng >9g/l. Trong cholesterol > 2,5mg/l. 3.8. Na+ trong mu thng thp 3.9. Na+ niu thng thp 3.10. Mu Mu lng thng tng, s lng hng cu, hemoglobin v hematorit gim nh. 3.11. Mc lc cu thn Bnh thng khi suy thn th gim 3.12. Sinh thit thn Thy tn thng cu thn Nh vy triu chng lm sng quan trng l ph vi tnh cht ph rt to v nhanh c th c trn dch cc mng. cng ng c th ngh n hi chng thn h. Nu trn mt bnh nhn c cc bnh khc hoc ph ti pht nhiu ln th ngh n hi chng thn h th pht. 4. CHN ON 4.1. Chn on xc nh: da vo tiu chun chn on - Protein niu >3,5g/24h - Protein mu <60g/l, albumin <30g/l - Lpid mu >900mg%, cholesterol mu >250mg%. - Trong nc tiu c ht m, tr m, th lng chit quang. Tiu chun 2 v 3 l tiu chun bt buc, cc tiu chun khc cng c th khng y cng c coi l hi chng thn h. 4.2. Chn on bin chng 135

- Nhim khun + Cp tnh: vim t chc t bo, vim phc mc tin pht, vim phi, vim c... + Mn tnh: lao phi, lao phc mc... - Tc mch + Tc tnh mch thn + Tc tnh mch ngoi vi + Tc ng mch ngoi vi - Suy thn cp: do gim th tch tun hon hiu dng t c th gy nn suy thn cp trc thn hoc hoi t ng thn cp. - Thiu dinh dng: do mt nhiu protein qua ng nc tiu km theo chn n v n km do c c trng. 5. IU TR 5.1 Chng ph - Li tiu: phi theo di in gii v rt hay gy gim kim mu. - B protein cho c th: + Tng protein trong khu phn thc n (l,5 - 2g/kg cn nng) tng cam, hn ch mui v nc. + Truyn cc dung dch m nh Plasma, Moriamin... 5.2. Liu php corticoid - Liu tn cng l-1,5mg/kg/24h, ko di 1-2 thng. - Liu cng c bng 1/2 liu tn cng, ko di 4-6 thng. - Liu duy tr 10 mg/24h, ko di hng nm. - Cn theo di cc bin chng do dng corticoid ko di 5.3. Thuc gim min dch khc - Dng khi khng p ng vi corticoid: Cyclophosphamid 2 - 2,5mg/kg/24h ko di 1-2 thng. Khi protein niu m tnh th duy tr 50mg/24h, ko di 1-2 thng. Ch . Mt s bin chng do dng thuc gim min dch nh: + Nhim khun + Rng tc, vim bng quang xut huyt. 136

+ Gim bch cu, nu bch cu di 3000 bch cu/mm3 mu th phi ngng thuc. 5.4. iu tr cc triu chng v cc bin chng khc - iu tr nhim trng tt nht da vo khng sinh . - iu tr tng huyt p - iu tr phng tc mch: nn cho thuc chng ng cho tt c cc bnh nhn hi chng thn h. - iu tr suy thn cp (nu c): b nc, in gii, truyn Plasma 5.5. iu tr bnh chnh dn n hi chng thn h th pht Cn iu tr theo nguyn nhn. Hi chng thn h th pht do cc bnh khc tn thng gii phu bnh hc ch yu cu thn. Chn on ch yu da vo: - Ph, Protein niu cao, protid mu gim - iu tr ch yu bng corticoid v thuc gim min dch, bnh thng ti pht nhiu ln cui cng dn n suy thn trong khong 10 - 15 nm, thi gian di hay ngn tu thuc vo vic chn on v iu tr hi chng thn h v bnh chnh gy nn hi chng thn h.

137

TM PH MN
1. NH NGHA Tm ph mn l ton b c ch thch ng ca tim ch yu l ph i tm tht phi do tng p lc ng mch phi bi nguyn nhn ti phi hoc lin quan n phi gy nn. 2. DCH T HC - T l mc bnh nam > n (3/1) - Tui t 40 - 60 tui - Gp cc nc cng nghip v x lnh. - Vit Nam 1959-1964 ti khoa Ni Bnh vin Bch Mai c 200 trng hp tm ph mn. Bnh tm ph mn chim 7% bnh phi ti Khoa H hp Bnh vin Bch Mai (Bnh hc Ni khoa tp 14 - nm 1994). 3. CC NGUYN NHN GY TM PH MN 3.1. Bnh phi tc nghn mn tnh - Vim ph qun mn tnh. - Hen ph qun - Gin ph nang. - Gin ph nang tc nghn. 3.2. Cc bnh phi hn ch - X phi - Vim dy dnh mng phi. - Bnh bi phi - Bnh Mucoviscidose (suy tuyn tu - vim nhim phi mn tnh). 3.3. Bnh thuc v ng mch phi * Bnh thnh mch: - Tng p lc ng mch phi tin pht. - Vim nt quanh ng mch. - Vim ng mch khc. * Vim tc mch. - Tc mch phi tin pht. 138

- Tc mch phi trong bnh thiu mu hnh li lim. * Nghn mch: - Nghn mch do cc mu ng ngoi phi. - Nghn mch do sn mng. * Tng p lc ng mch phi. - Do chn p bi khi u trung tht, phng quai ng mch ch. 3.4. Bnh lng ngc - G vo ct sng. - Ct nhiu xng sn. 3.5. Nguyn nhn khc - Bnh thn kinh c mn tnh - Bnh bo bu gim thng kh ph nang - Bnh gim thng kh ph nang khng r nguyn nhn. - Vit Nam nhng nguyn nhn thng gp: - Vim ph qun mn tnh - hen ph qun: - Lao x phi - Gin ph nang - Vim ph qun mn tnh n thun - Vim mng phi - D dng lng ngc 4. C CH BNH SINH C ch tng p lc ng mch phi * C Ch co tht mch mu phi: Theo Daum suy h hp tng phn gy thiu xy mu, thiu xy t chc, dn n toan chuyn ha. Suy h hp ton phn lm tr CO2 gy toan h hp. Thiu xy t chc gy co tht ng mch phi, toan mu gy co tht tnh mch phi. S co tht ng mch phi v tnh mch phi lm tng p lc ng mch phi dn n ph i tm tht phi v cui cng suy tim phi. S co tht tnh mch phi gy shunt phi v tim tri cui cng gp phn gy suy tht phi. 5. TRIU CHNG 5.1. Triu chng ca bnh phi mn tnh * Bnh phi tc nghn: 139 76,5% 15,5% 13% 12% 7% 4%

- ng u l bnh ca ph qun: vim ph qun mn tnh, hen ph qun, gin ph nang. Trong giai on ny ch ti t kch pht. + Bnh nhn ho nhiu, khc m mu vng, khc m. + C cn kh th nh hen. + Thnh thong c t kch pht bnh li nng thm. + Chc nng phi: VEMS gim, RV tng. * Bnh phi hn ch. - Tn thng chc nng h hp c hiu CV gim. - S khuch tn kh phi gim chng t c tn thng gia mng mao mch ph nang. - Ri lon t l phn b kh v mu trong phi. * C th phi hp triu chng ca hai nhm bnh phi mn tnh trn. 5.2. Giai on tng p lc ng mch phi - Biu hin l suy h hp mn tnh: kh th khi gng sc, mng tay khum, PaO2 gim khong 70 mmHg nht l sau lm nghim php gng sc. - X quang: hnh tim di v thng xung xng cng, ng mch phi ni v p mnh. - Thng tim phi p lc ng mch phi tng t 25-30 mmHg. 5.3. Giai on suy tim phi * Triu chng c nng: - Kh th: lc u kh th khi gng sc sau kh th c lc ngh. - C th c cn ph phi cp do tng tnh thm mao mch phi do nhiu xy v tr CO2 - au vng gan: bnh nhn c cm gic nng hoc cng vng gan, nu gng sc th au hn, ngh ngi li ht. * Triu chng ngoi bin: - Gan to v au: mt hi trc, mt nhn, c khi thy gan to trong thi k tm thu. - Tnh mch cnh p, phn hi gan TMC (+). - Ph 2 chi di, ph ton thn, ph trn dch cc mng. - Tm: tm mi, tm xut hin khi Hemoglobin kh > 5g% - Mt li: do tng mch mu mng gip hp. 140

- i t: lng nc tiu khong 200 ml/ 24h - o p lc tnh mch tng > 25cm H2O - Ngn tay di trng. * Triu chng tim mch: - Nhp tim nhanh, c khi lon nhp hon ton. - Mm tim p mi c (du hiu Hastzer) - T2 vang mch van ng mch phi. - C ting nga phi phi. - Ting thi tm thu do h van 3 l c nng. * Cn lm sng: - X quang: + Cung ng mch phi ni r. + Giai on cui tim to ton b. - in tm : + Trc phi, dy tht phi. + P ph chuyn o DII, DIII, AVF. + Blc nhnh phi khng hon ton. - Huyt ng hc: thm d huyt ng l phng php duy nht nh gi tng p lc ng mch phi. Giai on u p lc ng mch phi tng t 25-30 mmHg. Giai on suy tht phi p lc ng mch phi tng ln 45 mmHg hoc cao hn. - o hng s kh mu: + PaO2 gim n 70 mmHg + SaO2 gim c khi < 75% + pH mu gim < 7,2 - Xt nghim mu: + S lng hng cu tng + Hematocrit tng 6. CHN ON 6.1. Chn on xc nh * cng ng chn on tm ph mn da vo: - Hi bnh c bnh phi mn tnh. 141

- C du hiu suy tim phi trn lm sng: ph, gan to, tnh mch c ni, xut hin ting thi tm thu van 3 l. * bnh vin chn on xc nh: - C hi chng suy tim phi - X quang: cung ng mch phi ni r. - Thm d huyt ng: p lc ng mch phi tng. - in tm : P ph, dy tht phi trc phi. - Hng s kh mu: PaO2 gim, PaCO2 tng, SaO2 gim, pH mu gim. 6.2. Chn on phn bit - Suy tim ton b do bnh van tim mc phi, bnh tim tin thin, bnh c tim. - H/c Pick: c tin s trn dch, trn m mng ngoi tim. - Suy tim do suy mch vnh v nhi mu c tim cn hi k tin s cn au tht ngc. - Suy tim ngi gi: xy ra ngi gi c x tim, x mch mu ln, khng c tin s bnh phi mn tnh. 6.3. Chn on nguyn nhn - Nhm bnh phi tc nghn ch yu l bnh ph qun, tiu biu l VEMS gim. - Nhm bnh phi hn ch. rt phc tp bao gm bnh ph nang, bnh mch mu phi, xng lng ngc. Tiu biu l CV gim. 6.4. Chn on giai on - Giai on sm: rt quan trng v giai on bnh phi mn tnh, c nhng t kch pht cn pht hin sm phng. - Giai on tng p lc ng mch phi: trn lm sng khng th pht hin c m phi thng tim phi o p lc ng mch phi. - Giai on suy tim ton b iu tr khng c kt qu. 7. IU TR * Ti cng ng: Cn phi khng sinh thng thng nh Tetraxylin cho nhng t kch pht ca bnh phi mn tnh. Thuc gin ph qun Ephedrin, thuc long m. * Ti bnh vin: - Ch ngh ngi, n ung: bnh nhn b bnh phi mn tnh khi xut hin kh th, nn ngh ngi lm vic nh, khi c du hiu suy tim phi cn ngh hon ton. 142

- n t mui - Khng sinh: trong t bi nhim phi iu tr khng sinh liu cao ko di. - Corticoid: c tc dng chng vim chng d ng, gim xut tit Prednisolon, hydrocortison kh dung. - Thuc gin ph qun: Theophylin, Aminophylin. - xy liu php: th xy qua ng thng mi trong t tin trin ca bnh. - Tr tim v li tiu. + Uabain. + Digoxin phi ht sc thn trng c th gy lon nhp, ch nn s dng khi suy tim cn b. + Li tiu: dng nhm c ch men AC, Diamox 0,025 x 2-4v/ ngy, Fonurit 0,5 x 1 ng (tim TM) - Chch huyt: ch nh khi hematorit > 65 - 70%. - Khng dng cc thuc: Morphin, Gacdenal. - Thuc gin mch mu phi: Hydrabazin. - Tp th: th bng - Loi b cc yu t kch thch. 8. D PHNG - iu tr tch cc cc bnh ng h hp ti cng ng. - Loi b cc cht kch thch. - Khi b bnh phi mn tnh phi tp th kiu th bng.

143

X GAN
1. I CNG X gan l mt bnh cn tng i ph bin Vit Nam v th gii theo thng k trc y BV Bch Mai x gan chim 3,4% cc bnh ni khoa v 37% trong cc bnh gan mt. X gan gp c 2 gii nhng nam c phn nhiu hn n. Mt s nghin cu gn y nc ta thy t l Nam/ n gn bng 3/1, tui trung bnh ca bnh nhn t 40-50, sm hn cc nc chu u (55-59) T nm 1819 Laenec m t x gan l bnh mn tnh tin trin vi du hiu suy chc nng gan v tng p lc tnh mch ca (TALTMC). Ngy nay gii phu bnh gan x cho thy r gan teo nh, mt chc, mt gan mt tnh nhn bng m ln sn vi cc cc u. V vi th thy cc t bo lin kt ca khong ca b x cng, lan rng bp cht cc h thng mch v ng mt. T bo nhu m mi gan sinh sn ra t bo mi to thnh khm nh, xung quanh l t chc x lm o ngc cu trc bnh thng ca gan. T hin tng cc di x tng sinh trong khong ca, bp nght h thng mch trong ch yu l cc nhnh ca TMC lm cho mu li h thng ca v lm tng p lc h thng ca. Mt khc trong x gan c s tng ln ca mt s cht trung gian ha hc nh l monxyt nh (No), endotheline 1, prostaglandine...cc cht ny tng cng gin mch ni tng lm cho mu n vng xut pht ca TMC nhiu ln gi l tng lu lng ca. C hai yu t dn n tng p lc TMC. C trng trong x gan mt phn do tng p lc TMC nhng mt phn khc do gim p lc keo huyt tng ch yu do gim tng hp albumin ti gan. 2. TRIU CHNG 2.1. Lm sng Triu chng c nng khng c hiu bao gm mt mi gy st, mau mt, km n, s m... thng thy trong cc bnh mn tnh khc. Giai on mt b biu hin hai hi chng ln l tng p lc tnh mch ca v suy chc nng gan 2.1.1. Tng p lc tnh mch ca (TAL TMC) - C trng t do dch thm. Lng albumin thp di 30g/l - Lch to do mu, t c th gy gim t bo mu, nht l gim s lng v tp trung tiu cu - Gin cc tnh mch vng ni ca ch, tun hon bng h kiu gnh ch. c bit gy gin TM thc qun, rt nguy him do c th v, gy chy mu t d dn n hn m gan. 2.1.2. Suy chc nng gan - Ri lon tiu ha, chn n, so m, phn to hoc lng. 144

- Ph 2 chi hoc ph ton thn km theo c trng. - Xut huyt di da, nim mc. - Gin cc mao mch di da (sao mch, bn tay son). - Vng da do chn p ng mt v bilirubin t do khng lin hp c. - Khi c vng da thng th hin t tin trin nng ca bnh. - Ri lon chuyn ha gluxid, hpid, protid biu hin: + Chng mt mi, c cn h ng huyt + Da kh, bong vy, lng tc mng d rng, gy. - Tr nh gim, mt ng m. - Gim tnh dc - Giai on mun: tin hn m, hn m gan. 2.1.3. Khm gan - Gan teo nh hoc to ra nhng thng teo nh. - Mt chc. - B sc, khng u. - Mt g gh do tng sinh cc cc u. 2.2. Cn lm sng * Suy gan - Cng thc mu: gim 3 dng t bo mu, khi c lch to cng r. - Albumin gim, t s A/G < 1. - Prothrombin mu gim < 75%. - Cholesterol este gim < 65% cholesterol ton phn. - Bilirubin mu tng - Phosphatase kim tng - BSP v Galactose niu (+). - NH3 tng, ur c th tng hoc gim. * Do vim t chc lin kt - Gross < l,7ml dung dch Hayem. Maclagan > 10 n v - Globulin tng > 20%. * Do hoi t t bo gan 145

- ALT, AST tng va (men SGOT, SGPT c) * Siu m gan: Trn mt gan c nhiu nt m, c hnh nh gin tnh mch ca, tnh mch lch. T l ng knh thy phi gan vi ng knh thy ui gim c khi nh hn 1, cn lu hnh nh siu m ch l xt nghim b sung ch khng phi l xt nghim c hiu. * Sinh thit gan Chn on c th da vo soi bng v sinh thit gan lm xt nghin m bnh hc. Soi bng thy gan teo, mu nht, loang l, b mng v vnh ln, mt g gh c cc, tun hon bng h, dy chng trn xung huyt. Lch to, c dch c trng. Sinh thit gan lm xt nghim m bnh h(thy hnh nh ca x gan l tiu chun vng trong chn on, tuy nhin khng phi lc no cng cn sinh thit gan v khng phi lc no cng lm c. Sinh thit gan ch t ra khi cha c chn on chnh xc v hoc cn chn on phn bit x gan vi K gan hoc vim gan mn tnh. 3. NH GI MC X GAN THEO PHN LOI CA CHILD- PUGH nh gi mc nng nh ca tnh trng suy chc nng gan (bnh nhn x gan, vo nm 1964 Cho v Turcotte a ra mt bng nh gi gm 5 ch tiu l bilirubin albumin, dch c trng, tnh trng thu thn v tnh trng nui dng. Theo bng ny x gan c chia 3 mc i A, B, C theo th t t nh n nng. Mc ch lc u ca tc gi ch phn loi bnh nhn trc phu thut v nh gi kh nng chu ng phu thut BN x gan. Nm 1973 Pugh v cng s thay i mt s tiu ch nh gi mc x gan v thy c gi tr hn. T phn to. nh gi ny mang tn Chim- Pugh Bng nh gi mc s gan theo Child - Pugh
im Hi chng gan no C trng Bilirubin (mol/l) Albumin (g/l) T l prothrombin(%) 1 Khng c Khng c <26 >35 >65 2 Nh t 26- 51 28-35 40-65 3 Hn m Trung bnh >51 <28 <40

Theo phn loi ny nu bnh nhn c nh gi t 5-6 im s thuc Child A, 7-9 im thuc Child B v 10 -15 im thuc Child C. Hin nhin Child A nh hn, tin lng tt hn chim B v Child B nh hn, tt hn Child C. Child - Pugh khuyn khng nn phu thut cho bnh nhn Child C. 4. NGUYN NHN X GAN 146

C mt s nguyn nhn x gan c xc nh. Mt s vn cha r hoc cn ang tranh ci. - X gan do vim gan virus: ngy nay bit 6 loi virus gy vim gan trong virus B, virus C c coi l tc nhn gy x gan nhiu nht - X gan do mt ko di: + Thut th pht: si, giun gy tc, cht hp. + Thut nguyn pht: hi chng Hanot - X gan do ru. - X gan do ng mu ko di: + Suy tim, vim mng ngoi tim dy dnh + Vim tc tnh mch trn gan (hi chng Budd-chiari). + Bnh huyt sc t (hng cu hnh lim). - X gan do k sinh trng: sn mng, sn l gan. - X gan do nhim c ha cht v thuc. - X gan do ri lon chuyn ha: nhim st, nhim ng, ri lon chuyn ha porphyrin. - X gan do di truyn. - X gan lch to kiu Banti. 5. CHN ON XC NH 5.1. X gan tim tng Triu chng ngho nn, ch c mt vi triu chng c nng nh au nh h sn phi, ri lon tiu ha, trng hi, chy mu cam, gin mao mch vng c, ngc. Gan c th to, mm. Chn on kh, da vo sinh thit gan. 5.2. X gan mt b: biu hin hai hi chng Hi chng tng p lc tnh mch ca, hi chng suy t bo gan cng mt s xt nghim cn lm sng khc nh nu trn. 6. CHN ON PHN BIT 6.1. Vi x gan to - Gan to do suy tim, do huyt, c cc triu chng ti tim, phn hi gan - TM c (+). - Ung th gan: gan to cng, suy kit nhanh, AFP (+) - Gan to ca vim gan mn: tin s vim gan, Transaminase tng, c th c 147

HBsAg(+). 6.2. C trng cn chn on phn bit vi - Lao mng bng: chc d c trng dch tit, hi chng nhim lao. - U nang nc bung trng: siu m hoc X quang thy hnh nh u nang - Ung th cc tng trong bng: thng dch c trng c mu, ton thn suy sp nhanh. 7. BIN CHNG - TIN LNG X gan l bnh nng, nu c theo di, iu tr v loi b nguyn nhn c th ko di cuc sng c 10- 15 nm. X gan to tt hn x gan teo. Nu c c trng, vng da ko di l nhng du hiu xu. C 4 bin chng - Chy mu do v tnh mch thc qun: nguy him v mt mu, NH3 tng, hn m, t vong - Tin hn m, hn m: thng bnh nhn c th c tin hn m, nu khng iu tr tt s i vo hn m. Tin hn m l do cc sn phm c trong mu khng c gan lin hp, c nh v thi tr. Hn m xy ra sau cc yu t nh xut huyt tiu ha, nhim trng, a chy, chc tho nhiu dch c trng, dng li tiu mnh.... - Nhim khun: vim phi, lao, nhim trng dch c trng. - Ung th ha. 8. IU TR - Ch ngh ngi tuyt i trong t tin trin. - n tng ng, m, n nht nu c ph. - Thuc: + Ci thin chuyn ha t bo gan: cc vitamin. + Glucocorticoid 20- 25 mt ngy trong 2 tun. + Tng cng ng ha m: Testosteron 100 mg/ 2 tun. + Ung, truyn glucose + Truyn mu, m, plasma, albumin. Nn lu cc dung dch acid quan ch c tc dng khi chc nng gan cn hot ng tng i tt, khi gan suy nng ch truyn albumin mi c tc dng C trng: + Chc tho khng qu 2 lt, tc chm + Li tiu khng thi kim, khng aldosteron; - X tr cc bin chng. 148

- Ghp gan 9. D PHNG d phng cn pht hin nhng trng hp c nguy c x gan, l cc vim gan mn, nghin ru, cc bnh nhim trng gan cp v mn. Bin php d phng chung l khng lm cho gan nhim c, iu tr cc bnh gan c sn i vi cc bnh nhn cha c vim gan mn iu tr d phng trnh mc cc bnh dn n vim gan mn nh tim vacxin phng vim gan B, khng ung nhiu ru. Khi dng cc thuc iu tr bnh mn tnh khc phi ch chc nng gan c b nh hng khng. i vi cc bnh nhn vim gan mn hoc c bnh gan khc: d phng l phng php iu tr bo tn khng lm cho vim gan nng ln khng tip tc nhim thm cc tc nhn c hi cho gan D phng cn c t ra t ngay tuyn c s bng cc bin php tuyn truyn tc hi ca nghin ru, bnh vim gan B, vim gan C, cc tc nhn khc... v d phng vacxin vim gan B.

149

P XE GAN DO AMP
I CNG p Xe (abcs) gan do Amp (amibe) l bnh thng gp ca cc nc nhit i. Tuy nhin gn y t l mc cng c phn thay i gia cc a phng. Nu 10 nm trc y p xe gan do amp cn l mt bnh ph bin nc ta cng nh cc nc nhit i khc th ngy nay n ang dn dn tr thnh mt bnh t gp. Hng nm trong khoa ni ca bnh vin a khoa trung ng Thi Nguyn ch c vi ba trng hp p xe gan do amp c pht hin. C l s gim t l mc bnh ny c lin quan n vic s dng rng ri thuc iu tr amp l metronidazol trong cng ng. Mc d vy b mt lm sng ca p xe gan do amp ngy cng thay i, cng i hi chn on sm iu tr c hiu. 1. TC NHN GY BNH V SINH BNH HC - Amp c hai loi: + Entamoeba Vegetative hystolytica: th ny n hng cu v gy bnh + Entamoeba Vegetative minuta: th ny n vi khun, cn thc n, khng gy bnh. - Chu k pht trin: c hai chu k + Chu k khng gy bnh: khi bo nang t ngoi mi trng vo rut bin thnh th Minuta, th ny khng n hng cu, khng gy bnh, sng trong lng rut bin thnh bo nang. Bo nang ny c o thi ra ngoi sng trong mi trng t nhin khong 20 ngy. + Chu k gy bnh: bo nang ny li c lt vo trong c th v bin thnh th Hystolytica, th ny n hng cu v c kh nng gy bnh. Amp gy tnh trng vim ti gan sau t chc vim b hoi t v to m. M ca p xe bao gm t chc gan, xc amp, dch mt, cc bch cu v mu. Chnh v vy n c mu chocolate v thng khng thi. M ch thi khi c bi nhim cc vi khun k kh. Ngi l ngun ly nhim duy nht mc d ngi ta cn thy amp k sinh loi mo. 2. TRIU CHNG LM SNG 2.1. Th in hnh L th hay gp chim 60- 70%. C 3 triu chng ch yu hp thnh tam chng Fontan gm st, au h sn phi v gan to. - St: in hnh thng st cao thnh cn, nhit 39 40oC, c th rt run, song c th st nh. 150

- au vng h sn phi: mc au khc nhau tu tng trng hp: Nh: tc nng h sn phi. Nng: au nhiu vng h sn phi, bnh nhn khng dm c ng. au tng khi c ng hoc khi ho. au lin min sut ngy m khng thnh cn, au xuyn ln vai phi. - Gan to: gan to khng nhiu, mt nhn, mt mm, n k sn (+), rung gan (+). y l nhng du hiu c gi tr chn on p xe gan. Ngoi tam chng Fontan cn thy mt s du hiu khc: - Da vng h sn phi c th nng hn bnh thng, ph n, . (y l triu chng him gp nhng c hiu ca p xe gan). - Ri lon tiu ha: a lng, a nhy mi (ging ly). - n km, n khng ngon ming, bng trng. - Gy: trng hp nng gy nhanh d nhm vi ung th gan. - Ph: nu bnh ko di (do gim protid mu). - C trng: thng km theo ph (hu qu ca suy dinh dng). - Trn dch mng phi: nht l p xe phn trn ca gan, thng gy phn ng tit dch mng phi. - Lch to: him gp, lch to t 1-2 cm. * Mt s triu chng m tnh: bnh nhn thng khng c vng da, nu c vng da rt kh phn bit vi p xe gan ng mt. 2.2. Th lm sng: ngoi th in hnh cn c: - Th khng st: bnh nhn c th st nh vi 3 ngy u ri sau ht hn. Th ny gp khong 10% cc trng hp. - Th st ko di: Bnh nhn c th st lin tc ko di hng thng, c th st ngt qung. - Th c vng da: Thng do p xe ln chn p ng mt gy tc mt. Th ny thng nng, d nhm vi p xe ng mt, ung th gan, ung th ng mt. - Th khng au: Thng do p xe nm trong su nhu m v kch thc p xe nh. - Th c suy gan: Thng do p xe qu to, khi chng ph hu trn 50% t chc gan. 151

Th ny ngoi cc triu chng nh ph, c trng, thm d chc nng gan b ri lon v c th cht do suy gan. - Th theo kch thc gan: Gan c th khng to do p xe nh song gan c th rt to nu p xe ln. - Th p xe gan tri: Him gp, chim 3-5% cc trng hp. Th ny d v vo mng tim gy trn m mng ngoi tim. - Th phi- mng phi: Do vim nhim gy tng tit dch mng phi hoc v vo mng phi gy trn m mng phi. Th ny triu chng ch yu l ca phi v mng phi, triu chng ti gan b lu m. - Th c trn dch mng ngoi tim Trn dch mng ngoi tim km theo p xe gan do amp ch khng phi trn m t p xe - Th gi ung th gan: Gan to, cng, bnh nhn gy nhiu v nhanh. Th ny chim khong 15- 16%. 3. BIN CHNG 3.1. Bin chng v p xe L bin chng hay gp nht v nguy him nht. C th v t nhin hoc do va chm, chn thng hoc o thm khm th bo. 3.1.1. V vo phi p xe v trc tip vo nhu m phi, c th thng vi mt ph qun, bnh nhn ho khc m hoc c m. Mc d vy y l mt bin chng may mn cho bnh nhn v cng l mt hnh thc dn lu m. 3.1.2. V vo mng phi Gy trn m mng phi (thng mng phi phi) gy kh th t ngt, cn chc d mng phi ht dch v dn lu mng phi. 3.1.3. V mng ngoi tim Gy trn m mng ngoi tim. Thng gp p xe phn thu 7-8 hoc gan tri. Bnh nhn t nhin kh th nhiu, tm ti. Thm khm tim thy c du hiu ca trn dch mng ngoi tim v du hiu p tim cp. Cn chc ht mng ngoi tim khn cp. 3.1.4. V vo bng gy vim phc mc ton th 152

- L bin chng hay gp. Phi m cp cu. - t nhin au bng d di cp tnh - Bng trng cng, bng co cng, phn ng thnh bng. - St tng - Chc d dch bng c m. 3.1.5. V vo bng gy vim phc mc khu tr p xe v vo bng nhng b mc ni v cc tng bao bc nn m khu tr. 3.1.6. V vo ng tiu ha Gy nn ra m hoc i ngoi ra m. 3.1.7. p xe di c honh 3.1.8. Vm thnh bng gy p xe thnh bng 3.2. Bin chng nung m su Dn n suy kit v amylose ha (gan nhim bt) 3.3. Bin chng bi nhim p xe p xe gan do amp thng v khun, lu c th b bi nhim thng l vi khun ym kh. 4. TRIU CHNG CN LM SNG - Huyt hc: bch cu tng, mu lng tng. - Xquang: c honh phi y ln cao, di ng c honh km, trn dch mng phi. - Soi bng: l phng php chn on p xe gan nhanh chng. - C th thy hnh nh trc tip: p xe li ln mt gan vi nhng biu hin vim nhim nh xung huyt, ph n, dy dnh, ht fibrin. Hoc c th thy du hiu gin tip nh: ch thy gan to, mt gan vng ln. Hn ch. ch thy mt phn mt trn v mt di gan cn phn gan trn cao khng nhn thy c. - Siu m gan: l phng php rt tt chn on p xe gan + p xe giai on sm: thy mt vng gim m, nhu m gan khc bnh thng. + Nu to m: p xe gim m, khng ng nht, c th thy vng trng m, c th c v x bao bc xung quanh p xe - Chp mch mu: ngy nay t dng, hnh nh c th thy l s y ln ng i ca mch mu v nu chp th mao mch th thy mt vng khuyt mao mch. 153

- Phn ng huyt thanh: nh phn ng min dch hunh quang vi amp hoc phn ng min dch hp th gn men (ELISA). Phn ng c coi l dng tnh khi du hiu khng th l 1/160 i vi phn ng min ch hunh quang v 1/200 i vi ELISA. Tuy nhin phn ng ny khng cho bit l amp trong p xe gan hay amp trong ng tiu ha 5. CHN ON 5.1. Chn on xc nh - Da vo tam chng Fontan - C th da vo cc xt nghim nh siu m, X quang, mu lng, cng thc bch cu, soi bng. Chn on chc chn nht khi ht c m mu chocolate. Vi c s ch cn thy thuc pht hin tam chng c in, ngh ti bnh p xe gan l c th chn on ng. Trn lm sng c th s dng iu tr th khi khng c kh nng lm cc xt nghim nh siu m, X quang... 5.2. Chn on nguyn nhn do amp - Tt nht tm thy amp trong m p xe. Song thng l khng c v amp ch c ra p xe - Hoc da vo cc phn ng huyt thanh: min ch hunh quang hoc ELISA vi hiu gi khng th cao. C th da vo lm sng nu: - Khng vng da - M khng mi, mu chocolate, nui cy vi khun m tnh. - iu tr th bng thuc c hiu bnh nhn khi. 5.3. Chn on phn bit 5.3.1. Ung th gan Bnh nhn ung th gan thy thay i da v nim mc: a sm, gin mch hnh sao, lng bn tay son. Cn lm sng: - Ri lon chc nng gan - AFP tng cao bnh nhn ung th gan. - Hnh nh siu m: ung th gan thng l khi u c, p xe gan thng c hnh nh ca t chc lng. - Chc ht di hng dn ca siu m - iu tr th bng thuc chng amp. 154

5.3.2. p xe gan ang mt do si hoc do giun - Lm sng: + Thng c vng da + Trong tin s ca p xe gan ng mt c nhiu ln au h sn phi. - Cn lm sng: p xe gan ng mt m mu sa, c nh vng ln mt, mi rt thi, nui cy c vi khun. - Siu m thng thy nhiu p xe nh, thnh mng, nhn, kch thc thng khng qu to. 5.3.3. Vim ti mt - Bnh xut hin t ngt, au d di, st cao hn p xe. au c tnh cht au qun. - C th thy ti mt to - Nu kh phn bit c th cho siu m thy ti mt to, thnh dy. 5.3.4. Trn dch mng phi do trong phi 5.3.5. Trn dch mng ngoi tim 6. IU TR 6.1. Dng thuc chng amp * Ch nh: - Th nh, va - p xe khng qu ln (<= 6cm). - Bnh nhn n sm di 1 thng * Cc thuc: - Dehydro Emetin: liu 1-2 mt kn ngy dng t 8- 10 ngy. - 5 Metronidazol (Klion, Flagyl) liu 1,5- 2g/ ngy dng t 8- 10 ngy. - Cloroquin (Delagyl) 0,4g/ ngy dng t 8- 10 ngy. Tu th bnh c th dng kt hp c 3 loi thuc trn hoc dng 2 loi thuc u, sau kt thc bng loi th 3. Sau khi dit amp gan, dng thuc dit amp rut Cc dn cht iode Direxiod 0,22g mi ln ung 3 vin, dng 3 ln trong ngy trong 20 ngy. Metronidazol c kh nng dit amp th hot ng v th kn, dit amp c trong gan v trong rut. 155

6.2. Chc ht m p xe kt hp vi thuc chng amp * Ch nh - p xe qu to (trn 6cm) - Bnh nhn n mun (trn 1 thng) * Tin hnh va chc ht m p xe di hng dn ca siu m, bm ra p xe kt hp vi ng thuc. 6.3. M phi hp vi dng thuc * Ch nh: - C bin chng nguy him. - Da c bin chng (Nu khng chc c th mi m). - Bnh nhn n mun (trn 4 thng) - Dng thuc ng, liu kt hp vi chc ht p xe m khng khi. 7. PHNG BNH Phng bnh chung l cc nguyn tc v sinh thng thng nh n chn, ung si, v sinh chn tay sch s. Ch kim tra sc khe cho cc nhn vin bn hng n ung nht l nhng ngi lnh mang amp l ngun ly nguy him trong cng ng Khi mc bnh iu tr trit trnh ti pht v iu tr phi hp ni, ngoi khoa nu cn trnh cc bin chng v vo cc c quan khc. Trong iu tr lu mt s thuc c th gy c tnh khi dng qu liu nh emtin hoc c giao thoa thuc nh hi chng disulfriam khi dng metronidazol vi ru.

156

CP CU NGNG TUN HON

1. I CNG - Ngng tun hon c th xy ra bt c ni no trn ng ph, trong bnh vin ti cc khoa phng. Nguyn nhn ngng tun hon rt nhiu, thm ch c trng hp khng r nguyn nhn. V vy bt c bc s no cng phi bit tham gia cp cu ngng tun hon. - Cht lm sng l tnh trng xy ra bnh nhn k t khi ngng hot ng ca tun hon cho ti khi nhng tn thng c th khng hi phc ca no. Thi gian ny ko di khong 5 pht. Qu thi gian ny no s xut hin nhng tn thng khng hi phc, giai on ny c gi l cht sinh vt. Cc bin php hi sinh khng mang li kt qu. 2. NGUYN NHN NGNG TUN HON 2.1. Ngoi khoa - Ngng tun hon xy ra lc ang phu thut do tai bin gy m, do mt mu nhiu dn n thiu oxy t chc. - a chn thng gy chn thng s no v sc. 2.2. Do ni khoa - Do tim: + Ri lon nhp (Blc nh tht nh Blc xoang nh) + Kch thch trc tip vo tim lun catheter hoc dy in cc vo tim. + Tc ng mch vnh: do kh, do cc mu, chp ng mch vnh bng thuc cn quang. - Do dng qu liu cc thuc cha lon nhp tim khng ng quy cch: ung li tiu, v dng Digital khng b kim. - Do tai bin mch mu no: gy tng p lc ni s, tt no gy ngng th, ngng tim. - Do tai nn nhim c. + in git, st nh gy rung tht. + Ng c Aconitin, nc cc lm chm nhp tim hoc rung tht. + Tnh trng nhim toan trong cc bnh nh i ng do tu, suy thn hoc tun hon ngoi c th khng m bo k thut. - Do suy h hp cp: y l nguyn nhn thng gp nht trong lm sng, cng 157

nh khoa hi sc cp cu. Mt bnh nhn hn m, ri lon nhp th mt phn x ho c th ngng tun hon v tt li sc gy suy h hp cp. 3. SINH BNH HC - Hot ng ca no ph thuc vo cung lng mu ln no v s cung cp oxy v glucose cho c th. - Mi pht long no cn 3,5ml oxy, 5 m glucose. D tr glucose v oxy tip tc cung cp cho t bo no 2 pht sau khi ngng tun hon. Khi cung lng mu ln no gim xung cn 25ml, bnh thng l 75ml, tn thng no s khng hi phc sau 4-5 pht ngng tun hon, cn tim vn tip tc p trong 2 - 3h trong tnh trng thiu oxy. - Hu qu ca ngng tun hon dn ti toan chuyn ha, tng acid lactic tng kim mu. 4. PHN LOI NGNG TUN HON 4.1. Ngng tim (v tm thu) - th tm trng: tim gin nho, tm nu thiu oxy gy ngng tim, nht mu nu thiu mu cp. - th tm thu: him hn nh trong ng c cc thuc co mch. 4.2. Rung tht - Rung tht bin ln: ln hn l,5mm gp cc bnh nhn mi ngng tun hon cha thiu oxy nhiu. - Rung tht sng nh: bin di l,5mm. 4.3. Tim khng hiu qu Trn lm sng c ngng tun hon, tim vn hot ng nhng co bp khng hiu qu. - Khng cn mu tng ra ngoi bin nh trong thiu mu cp. - Ri lon nhp tim: nhp t tht. - Phn ly in c: in tm gn nh bnh thng hoc gn nh bnh thng nhng tm tht khng co bp ch cn vi nhm c hot ng trn mt ngoi ca tim. Hu qu ca ngng tun hon gy thiu oxy t chc. Cc t chc mun c hot ng tr li phi c cung cp oxy y . iu ny ni ln tm quan trng ca vic thng kh nhn to trong hi sinh tim - phi - no. Khi c rung tht d sng to, sng nh th vic thng kh nhn to vn rt cn thit 4.4. Nu can thip sm Tim c th p tr li, no c th khng hi phc hoc hi phc chm. 158

Hi sinh no tip tc ngng sau khi gii quyt tnh trng cp cu l mt cng vic rt phc tp. 5. TRIU CHNG V CHN ON NGNG TUN HON - Hn m t ngt. - Khng bt c mch cc ng mch ln nh ng mch bn ng mch cnh. - Ngng th hoc th ngp v ngng th hn thng xy ta sau ngng tun hon khong 45 -60 giy. - Da xm, tm ti. - ng t gin to, du hiu ny xy ra sau khi ngng tun hon khong 30-40 chng t no bt u b tn thng. - Thy mu khng chy khi ang phu thut. + Da nht nht nu thiu mu cp. + Da tm ngt nu c suy h hp cp. - Hai triu chng c bn xc nh c ngng tun hon l: + Hn m t ngt. + Khng s thy mch p cc ng mch ln. 6. X TR NGNG TUN HON - Mc ch hi sinh l nhanh chng phc hi li tun hon v h hp hu hiu chng li qu trnh bnh l c bn thiu oxy bo v no, ng thi pht hin v gii quyt nguyn nhn c bn gy ra ngng tun hon. - Nguyn tc: nhanh chng, khn trng tranh th tng pht cu bnh nhn v no ch chu ng qu trnh thiu oxy ti a trong vng 4-5 pht. 6.1. Ti y t c s - Bnh nhn nm trn mt mt phng cng, c nga ti a. - p tim ngoi lng ngc. - H hp nhn to: h hi thi ngt, ming ming, ming mi - Nu p tim c hiu qu: mi bnh nhn hng tr li, bt c mch bn. 6.2. Ti bnh vin Cp cu ngng tun hon c ba giai on: - Giai on 1: hi phc chc nng sng c bn gm cc ABC ca cng thc ban u. 159

* Kim sot ng th (Airway control = A) - Lm lu thng ng h hp, y l vic lm rt quan trng, c ngha ln ti kt qu hi sc, nu khng thc hin c tt th mi bin php tip theo s khng c kt qu. Thi gian hon thnh vic ny cng nhanh th kh nng thnh cng cng ln. - C nhiu nguyn nhn lm cn tr lu thng ng h hp, tt li ra sau, m di, cht nn, cc d vt ri vo ng th, co tht thanh qun, co tht ph qun. Lm lu thng ng th tht nhanh. + t bnh nhn trn nn cng. + Nga u ra pha sau, y hm di bnh nhn ra pha trc, m mm lau sch m di. + Nghim php Heimlich nu c d vt ng th. * H hp h tr (Berathing Support) - H hp ming ming, ming mi thi 3-5 ci bt mch bn, mch cnh nu cn mch bn tip tc thi 12 ln/ pht. - Bp bng Ambu, thng kh nhn to bng my sau khi t ng ni kh quan. * H tr tun hon (Circulation Suport = C) - Dng nm m vo vng gia xng c kch thch tim p tr li. - Trong mt s trng hp ch vi ng tc n gin ny tim p li. - p tim ngoi lng ngc: phng php ny c Kowenhoven, Jude v Knicherbocket p dng c hiu qu trn lm sng t nm 1960. K thut: mt ln thi/5 ln p tim. Nu p tim ng k thut ch m bo 20-40% mc bnh thng ca dng mu. Ch khi p tim cnh tay phi t trc tip thng gc vi xng c, khng nhng ch dng lc cnh tay m phi dng lc ton thn. - Tai bin ca p tim ngoi lng ngc: + Gy xng sn. + Tn thng c quan bn trong + Rch mng phi, trn kh, trn mu mng phi. + Tn thng c tim. + Gy xng m i vo tun hon gy tc mch. + Dp gan. - Vi tr em 10 - 12 tui p tim ngoi lng ngc ch cn mt tay, tr cn b ch cn 2 ngn tay. - Du hiu chng t p tim c tc dng: s thy ng mch bn, ng mch cnh 160

p thy c xung ng mi khi p tim v ng t dn dn co li. - Giai on II. T D n F h tr chc nng sng mc cao. * t kim tnh mch truyn dch, tim thuc (Drugs and fluids = D). - Adrenalin 0,5 1mg tnh mch. - Natrthicarbonat lmEq/kg tnh mch nu ngng tun hon trn 2 pht. - Tim li 10 pht/ ln n khi mch tr li. + Theo di bng Monitor. + Truyn mu v truyn dch nu cn. * Ghi in em (EKG = E) C 3 hnh thi: rung tht, v tm thu hoc nhp t tht. * Chng rung tht (Fibrilation = F) - Sc in ngoi lng ngc 100 - 400w/s c th sc lin 2 ci. - Xylocain 1-2 mg/kg trng lng c th tim tnh mch, nu cn tip tc truyn xylocain. - Nu v tm thu: + Tim calciclorua 0,5 - l (tnh mch) + Isuprel 1-2 ng (tim mch) + Tip tc hi sc cho ti khi mch ny tt. + t my to nhp ngoi c th kch thch qua catheter bung tim. - Giai on III. T G - I tip tc h tr cc chc nng sng (Hi sinh no) * Ganging: suy ngh tm nguyn nhn iu tr nguyn nhn. nh gi kh nng hi sinh. * Human mentation: hi sinh no. + Tip tc thng kh nhn to. + Chng ph no. * Intnsive care. iu tr tch cc, h tr cc chc nng sng ngay sau khi hi phc tun hon, khi bnh nhn cn hn m phi c gng ci thin no do thiu oxy t chc chm sc tch cc, theo di mch, HA, CVP, t ng thng bng quang, in tim duy tr huyt p, thng kh nhn to, ht m, iu ho thn nhit, bi ph nc in gii, chng tng 161

p lc ni s. 7. KHI NO NGNG CP CU Thi gian cp cu ph thuc vo. - Tnh trng bnh, nguyn nhn gy ngng tun hon. - Din bin trong cp cu c ba tnh hung xy ra. + Tim p tr li, h hp t nhin tr li cn phi s dng cc bin php theo di iu tr tch cc hi phc chc nng h hp, tun hon v ri lon khc. + Mt no:

Tim p nhng bnh nhn hn m su ng t gin to, tru mch, khng th t nhin. Co cng kiu mt no: hai tay v hai chn dui cng. Sau 24 gi c th ngng cp cu. Nu in no l ng thng c th ngng hi sc sau 8 gi.

+ Tim khng p tr li, mc d x l ng cch, c th ngng cp cu sau 60 pht. 8. D PHNG - Phi iu tr tch cc cc bnh v tim. - Khi s dng cc thuc iu tr lon nhp phi theo di st v c bit bi ph y in gii. - phng ngn nga cc tai nn bt thng. - Gio dc cng ng bit chn on xc nh v cp cu ti ch ca ngng tun hon.

162

IN GIT
1. DCH T HC - Cng vi s pht trin ca cng nghip in c s gia tng song song s ngi b in git v t vong. - M: + 1000 ca t vong/l nm l nguyn nhn t vong ng hng th 5 trong bnh ngh nghip. + 0,54% dn s/ nm t vong do in git + > 60% ca t vong l nam gii, cao nht tui 20-34. + 3-14% nn nhn in git do in th cao t vong sau khi nhp vin. - Dng in th cao: 1/3 trng hp l th in, 1/3 l cng nhn xy dng. 2. SINH L BNH 2.1. Cc yu nhin quan n mc nng - in tr ca c th: + Tng loi m c th c sc cn khc nhau vi dng in. Dng in s dng li ch c in tr cao. - a im tip xc da: cn tu vo m, dy v sch ca da. Lp thng b khng c mch mu nn in tr cao. Khi da m m hi in tr gim. - Trong c th: in tr gim theo th t xng, m, gn, c, nim mc, thn kinh - Thi gian tip xc in. - Cng lu, in nng bin thnh nhit nng. - Dng in xoay chiu nguy him hn dng in 1 chiu. - Dng xoay chiu 60HZ vi Voltage thp c an ton rt hp ; v d 1-5 mA ch thy t t, nhng vi 10-20 mA c th xy ra kch thch cc si c lm co c kiu tetanie v cn phng nn nhn b tr cht tay vo ngun in nh th s ko di thi gian tip xc vi ngun in. Ngc li dng in 1 chiu v xoay chiu c Voltage cao thng gy ra au co c xng t ng v y nn nhn khi ngun in. - T chc ni tng nm trn ng trc dng in s tng yu t nguy c tn thng v bin chng mc d khong cch ca cc tng nm xa ngun in. 2.2. Tn thng t bo - Thay i tnh thm mng. 163

- V t bo. c chng minh t bo c xng v t bo thn kinh cng nh t bo c tim dn n tng kim v men tim, calci trong t bo tng ln ng gp yu t d pht trin thnh rung tht v ri lon chc nng tim, 2.3. Ph hu t chc do dng nhit in gy ra c ni dn nhit ln chn thng khng dn in - Ni tip xc l ni nng lng in ln nht. - Vng trc dng in i qua. - T chc c sc cn in nh nht, (thn kinh, mch mu, c) th mt in v nhit in s ln nht. T chc c v thn kinh b ph hu (mng t bo v), gy ra ph, hoi t ng vn v thiu mu, thnh mch b ph hu gy ng mu trong mch, chy mu, t chc c ph hu phng thch ra cc men myoglobin. nng ca dng in qua cc trc gy ra bng vi nhit c khi 5000oC. 2.4. Ngng tim - Cht t ngt do Shock in gy co cng c tim nh trong t nhin gy ngng tim ngay tc khc hoc do ri lon nhp cht ngi do tn thng c tim. - Dng in c th thay i vn chuyn mng t bo c tim phng thch ra cc catecholamin thn kinh ngng h hp v c ngc dn n ngt v thiu xy t chc. Rung tht s xut hin vi dng nh 50-100mA. 2.5. H thn kinh Thn kinh trung ng, no. Tu sng b trc tip ca dng in, hoc th pht sau h h hp v tun hon, thiu mu v thiu xy no, co git ko di, sc ngng h hp, ngng tim, tc mch. 2.6. Suy thn Thng l bin chng sau tn thng c do in myoglobin, Nng globin gy hoi t tc ng thn, tan mu, gim th tch mu ko di s dn n gim mc lc cu thn, thiu mu v thn. 3. TRIU CHNG - Cht t ngt thng do ngng tim, ngng th, dng in xoay chiu 50 - 100 mA gy rung tht v v tm thu cng dng in 10A: gy: + V tm thu. + Nhp nhanh tht + Ngoi tm thu tht. + Nhp chm, rung nh luc nhnh 164

+ ST - T chnh. - Da: + Bng da: nht trng xm v trng gia. + Bng ni bn cnh. - Thn kinh: + Mt thc tm thi. + Ln ln hay kch thch n ng su, hn m. + au u, ng vt, cm khu, ic. + Vim dy thn kinh ngoi bin. - Mch: gy co tht ng mch th pht, vim tc mch, v mch, chy mu. - Chn thng th pht: gy ct sng lng ngc, bng. - Bng mm. - Khi c thai: v i, non, thai cht lu - Bin chng khc + D dy rut: lot, chy mu. + Mt: bng, chy mu. + Tai: ic 4. TRIU CHNG CN LM SNG - Ur mu tng, creatinin tng - Toan chuyn ha, h kim mu. - Hemoglobin, myoglobin niu. - CK - MB tng - CT - Scanner nh gi tn thng - in tim ST - T chnh 5. IU TR 5.1. Cp cu tc thi ti ni xy ta tai nn - Tch nn nhn ta khi ngun in: ct in, ngi cu khng c chm tay trn vo nn nhn, ng trn vn kh v dng cy kh y dy in khi nn nhn. - p tim ngoi lng ngc, thi ming - ming. - Bt ng, c nh tt chi v ct sng. - Sau khi tim p tr li- ht th t nhin c chuyn n bnh vin. 165

5.2. Hi sc ti bnh vin - Phng nga suy thn: iu chnh nc, in gii, kim toan. - Ch yu theo di lng nc tiu: duy tr lng nc tiu 1-1,5 ml/kg/gi nu c hemoglobin v myoglobin - Theo di in tm t nht 24 - 72h theo di ri lon nhp tim. - m bo thng kh th oxy, thng kh nhn to. - Truyn dch 10 - 12 ml/kg/ gi m bo n nh tun hon (natriclorua 0,9%, natribicarbonat 1,4%) - o CVP, khng ch truyn ch nhanh nhiu. - Theo di XN mu, nc tiu, CPK, LDH, SGOT, in gii, hemoglobin triu - Phng nga nhim trng: nu c tn thng nng tim SAT, khng sinh liu cao. - Chng ph no nu hn m ko di. 6. PHNG NGA - Lp t ng cch cc gia dng bng in c dy t. - Giy dp kh ro khi tip xc vi in. - Bt cc in, cc u dy in - bnh vin cn kim tra nh k cc thit b in v c th gy rung tht do dng in nh qua Pacemaker.

166

NGT NC
1. I CNG Hng nm nht l v ma h c nhiu ngi b cht ui khng cu c hoc cu khng ng cch. Hon cnh xy ra cht ui c th gp trong 4 trng hp sau: - Do ngt nc: l trng hp nhng ngi khng bit bi ng xung nc. - Do ngt t ngt khi tip xc vi nc. - Ln qu su di nc ri ngt. - Do bi qu mt, c th gi l ui nc ri ngt i. 2. C CH BNH SINH 2.1. Thc nghim - Trn ch cht ui qua 4 giai on: + ng thit hu mt cch t ngt. + Ht phi nc. + Ngng th + Ngng tim 2.2. Tnh trng nc git hay sc nc - L mt ri lon huyt ng t ngt do s chnh lch gia nhit da v nc. - Ngi bi ang c tnh trng gin mch do phi nng, ang tiu ha (sau ba n) ang vn ng nhiu. - Khi xung nc, ngi t nhin b co mnh d di lm tun hon tr v tng mnh, gy ra ngt v bnh nhn chm lun. l ngt trng mt tai bin do khng thch ng. Ngt trng ging tnh trng sc nng khng gy ngng tim ngay. Nu may mn bnh nhn lc ny c vt ngay v c cp cu ngay th d kh nng hi phc v phi cha b sc nc. Lartigue cho rng trong ngt trng cn c vai tr ca sc thanh qun. Sc ny gy ra mt tnh trng ngt v phn x Sinlera do tip xc t ngt vi nc v dy thn kinh X. Gii phu bnh cng cho thy tim phi gin, tim tri co cng. 2.3. Hi chng sau ngt nc - Sau ngt nc c hai ri lon chnh e da tnh mng nn nhn. 167

- Gim xy mu do nhiu yu t. + Nc vo ph nang gy ra mt mng nc ngn cch s khuch tn xy qua mng ph nang vo mch. + Co tht ph qun, co tht ng mch phi. + Tng sc cn phi. - Ph phi cp c cc yu t tham gia: + Yu t thm thu: nc mn hay nc ngt khi vo phi u c th gy ra PPC. + Tng gnh t ngt tht phi, tng gnh tun hon mu, tng th tch mu tr v. + Gim xy t chc nh hng n thn kinh trung ng v c tim. Ri lon thc, ri lon dn truyn, kch thch c tim. + Nim mc ph qun, ph nang b kch thch do nc bn, do nc c nhiu clo. 3. TRIU CHNG 3.1. Lm sng - Sau ngt nc: 3-4 pht vng vy nn nhn ht phi nc vo ng th s b ngng th, sau ngng tim. - Nn nhn xanh tm (ngt xu) bt hng y mi mm v tro ra. - Sc do ngt nc: xut hin di 3 hnh thc. + Trng hp nh:

Cm gic n lnh, kh chu Cm gic co tht bng v ngc Bun nn, chng mt, nhc u, mch nhanh, ni my ay kiu d ng.

+ Bnh c th chuyn t nh sang nng:

Tru mch, ni my ay, ngt.

+ Ngt t ngt trong khi bi

Ngt trng kiu c ch thn kinh, nn nhn chm xung khng giy gia.

- Hi chng sau khi ngt nc: + Gim thn nhit. + Ri lon thn kinh do thiu oxy no, hn m, hi chng b thp. + Ph phi cp. + Hi chng suy h hp cp tin trin ARDS. 168

3.2. Xt nghim - Mu: hematocrit tng, hng cu tng. - Thay i cc cht kh v kim toan: SaSO2 gim, PaCO2 tng, pH mu gim. - Ri lon nc, in gii: biu hin mt nc ngoi t bo. - Tan mu (t gp) - ng huyt tng. 4. X TR 4.1. Hng x tr - Hai phng chm c bn: + S cu ti ch, tch cc, ng phng php. + Kin tr cp cu trong nhiu gi. - Cc bin php ch yu x tr nhm: + Gii phng khai thng ng h hp. + em li xy cho nn nhn. + Chng li nhng ri lon tim, phi v chuyn ha. 4.2. X tr c th Cc giai on cp cu - X tr ti ch: + L quan trng nht quyt nh tin lng. - Cp cu ngt nc: phi cp cu ngay khi cn di nc. + Nm tc nn nhn nh u ln khi mt nc. + Tt 3-4 ci tht mnh vo m nn nhn gy phn ng hi tnh v nhp th tr li. + Qung tay qua nch ri li ln b. - Khi a nn nhn ln b: + Vn quan trng vn l gii phng h hp em li xy cho bnh nhn. + nn nhn nm n c, ly khn lau sch mi, hng, ming. + Tin hnh h hp ming ming. + m mnh vo vng trc tim 5-6 ci. + ng tc dc ngc nn nhn c tc dng khai thng vng bng v nc trong phi chy ra. 169

+ Cn h hp ming ming v p tim ngoi lng ngc cho n khi tim p, h hp hot ng tr li. - Khi kp cp cu n. + H hp nhn to bng bng Ambu + t canun Guedel hay Mayo v ht m di, ht nc trong d dy. + Nu tnh trng thiu xy bt th c th t ni kh qun, bp bng. + Chch mu ti ch: c tc dng gy phn x kch thch h hp v gii quyt vn huyt ng. Vn chuyn bnh nhn: - Vn chuyn n n v hi sc c trang b y c t ra khi: + Nn nhn th tr li, giy gia, ku la. + Nn nhn vn hn m, nhng c mch v nhp th. - Ti trung tm cp cu: c nhiu tnh hung. + Nu bnh nhn vn cha hi tnh hn phi bp bng Ambu cho th xy ri tin hnh t ni kh qun h hp nhn to bng my. + Chng rung tht, try mch v ph phi cp. + iu chnh nc in gii thng bng kim toan. + Cn ch n tnh trng mt nc ngoi t bo mu c c sau ngt nc phi truyn nhiu dch v da vo p lc tnh mch trung tm. + Chp phi theo di bi nhim. + Nu bnh nhn khng tm, bt u tnh: ch cn ht m di, th xy qua mi theo di 48h. + Nu tnh trng suy h hp nng ln, xanh tm phi t ni kh qun, ht m di, th my c PEEP. 5. D PHNG - Cn c s phi hp gia gia nh, nh trng v cc on th trong vic tuyn truyn gio dc, qun l tr em v vn bi li, tm ao h, sng sui - T chc cc lp dy bi ph hp cho tng la tui. - T chc cc lp tp hun x tr ban u ngi ngt nc.

170

RN C CN
1. I CNG Cc loi rn c thuc hai h: - H c mc c nh, gm cc loi: Elapidae v Hyrophidae - H c mc di ng gm cc loi: Crotalidae v Viperidae. Cc loi rn c chnh: 1.1. H rn bin Hydrophidae (u trn, ui dt Vit Nam c Hydrophis cyanocinctus). 1.2. H rn h Elapidae (u trn, vy u rt to, khng c vy mc trung gian vy mi v vy trc mt). Vit Nam c rn cp nong, cp nia, rn h cha thy c 3 min. 1.3. H rn lc Crotalidae: u nhn, ui c b phn rn nh sng khi quy c th ku thnh ting. 1.4. H rn lc Viperidae: u nhn, khng c hm nh, ng t di v ng dc, vy u nh. Rn Vit Nam c khong 135 loi trong 25% l rn c. 2. C TNH Thnh phn ca nc rn rt phc tp gm cc enzym, mt s protein, mui v c v mt s cht hu c. c t protein: + Neurotoxin (c t thn kinh) tc dng ln synap thn kinh c v cc dy thn kinh. c t ny c rt nhiu loi rn h. + Cardiotoxin (c t c vi tim) + Hemolysin (gy tan huyt) + Hemorragin (gy chy mu) + Coagulin (gy ng mu) Cc c t gy ri lon ng mu c nhiu rn lc. Cc protein ca nc rn cn c kh nng gy d ng, sc phn v. 171

c t ca nc rn cn ph thuc vo nhiu yu t, loi rn, ni cn, rn non hay rn gi, tnh trng nc c ca rn, sc khe v tui ca nn nhn. 3. TRIU CHNG 3.1. Lm sng * i vi rn Elapidae v Hydrophidae. - Du hiu ti ch rt t. - Du hiu ton thn st nng n trong vi gi u, bnh nhn kh chu, bun nn, v m hi, kh th do lit h hp, lit dy thn kinh s no, ri lon c trn cui cng gy ngng th, ngng tim. * i vi Viperidae v Crotalidae. - Du hiu ti ch ca rn d di mc d vt cn nh, ph to, ph cng, chy thnh dch . Sau 6 gi ton chi sng to, tm. Sau 12 gi chi b hoi t, da phng rp ln cha y dch . Tn thng nng dn ln, 2-3 ngy sau c th dn n hoi th, nhim khun, lot mc. - Du hiu ton thn: chng mt, lo lng tnh trng sc. - Ri lon ng mu, ng mu ri rc trong lng mch, tan mu, xut huyt khp mi ni. - Ri lon tiu ha. - Ri lon thn nhit. - Suy gan, suy thn: v niu 3.2. Xt nghim Cng thc mu - T l prothrombin gim, flbrinogen gim, mu chy mu ng ko di, s lng tiu cu gim. - in tim: ri lon nhp tim. - Ur mu tng, creatinin tng - SGOT, SGPT tng 4. BIU HIN NHNG DU HIU NGUY KCH - Bnh nhn hn m, tn thng dy thn kinh s no (sp mi). - Kh th do lit h hp. - Tnh trng sc: mch nhanh, HA h chn tay lnh, bnh nhn vt v, i t, v niu. - Cui cng ngng th, ngng tim 172

5. X TR Khng bnh nhn t i, khng c ung ru hoc cht kch thch. 5.1. Ti ch Loi tr nc ra khi c th, cn c tin hnh cng sm cng tt, c th tin hnh ngay ti ch, ti y t c s. - t garo: phi t ngay sau khi b cn v sau mt vi gi c th b ra. t gia qu chm sau 30 khng cn kt qu na. V vy khi b rn cn vo chn nn nhn khng nn chy v nc d khuch tn vo c th. - Chm vo ch cn, ra vt thng bng nc javel 1/10 hay thuc tm 1 rch ch cn bng dao sch kh khun su 5mm, di khm ri ht mu bng bm tim 20ml. 5.2. Tim huyt thanh chng nc rn c hiu Thng c tin hnh chuyn khoa chng c. - Phi tim ngay sau khi b cn. Tim tnh mch 80 - 200ml. Mi gi tim lon cho n khi c tc dng. Nu nghi ng c a qu mn, phi tim tnh mch 40mg Solumedrol sau truyn tnh mch 160mg. - Phi ch n phn ng min dch c th xy ra nu nn nhn c tim 1 ln trc loi huyt thanh tr liu no t trc. Lc phi dng phng php gim nhy cm Besredka liu u l/10 ml, liu th hai: 3 pht sau 1/4 ml, liu th ba 5 pht sau: ton b huyt thanh. 5.3. iu tr triu chng v hi sc Cn c s phi kt hp ca cc tuyn. - St khun ti ch tim SAT, cho khng sinh c th tin hnh ti y t c s - Chng ph: corticoid ti ch, chy tia hng ngoi. - Chng lot mc: bng dung dch dakin pha long 1/3 nh git vo vt thng. - Chng sc bng corticoid tnh mch, truyn dch, truyn mu. - Huyt tn: thay mu, truyn mu, li tiu dung dch Mannitol, Furosemid. - Hn m, lit h hp: t ni kh qun, m kh qun, th my. - Chng ri lon nhp tim: Isuprel, t my to nhp. - Nu c sc phn v tim Adrenalin

173

NGUYN TC X TR NG C CP
1. M U Ng c cp l khi c mt lng nh hoc rt nh cht c xm nhp vo c th gy nn nhng hi chng lm sng v tn thng cc c quan, e da t vong. Cht c bao gm ha cht, thuc, c t vi khun, nc c ca ng vt, c t c sn trong cy c, mi trng. Cht c vo c th qua ng tiu ha, da, nim mc hay ht th. Thi gian t khi tip xc vi cht c n khi c triu chng ng c tu thuc vo loi c t, tc hp thu cng nh cc phng php loi b cht c. S chng ca c th vi cht c tu thuc vo tnh trng chc nng gan, thn ca c th cn tt hay khng cng nh tnh trng hi sc ng, kp thi khng. Khi vn chuyn bnh nhn cn lu thi gian tim tng v thi gian tc dng ca c cht 2. CC BIU HIN LM SNG CA NG C CP 2.1. Cc biu hin c nng - Bnh nhn t ngt hn m, co git au bng, nn ma, a chy cp. - C th c suy h hp, suy tun hon, suy thn, suy gan cp, ri lon thn nhit, i t, v niu.... Cc triu chng trn xy ra trn mt bnh nhn trc gn nh bnh thng. - Pht hin cc du hiu nghi ng thm vo nh bnh nhn tr tui, c bng chng ng c cp, c mu thun gia nh, chn thng tnh cm, nghin ht, ung ru, sng mt mnh, c tin s tm thn, c bnh mn tnh hoc bnh c tnh. 2.2. Thm khm * Hi chng thn kinh giao cm: mch nhanh, huyt p tng, thn nhit tng, th nhanh, ng t gin, da m, nim mc kh, kch thch vt v, hoang tng. Thng gp trong ng c cc cht kch thch, cc cht ma tu nh amphetamin, cocain, ephedrin, phencyclidin... * Hi chng thn kinh ph giao cm: h huyt p, thn nhit gim, mch chm, ng t co, gim vn ng co bp, phn x gn, xng, c gim, bnh nhn l m v hn m. Cc triu chng trn thng gp trong ng c cc thuc an thn, thuc ng: Seduxen, bacbiturat hoc cc thuc h p nh clonidin, cc alcohol, opium... * Hi chng cholinergic (khng men cholinesterase) - Du hiu muscarine: gin mch, huyt p thay i, ng t co nh, tng tit dch tiu ha, dch ph qun, dch ph nang, m hi. - Du hiu nicotin: yu c, rung c, sau cng lit c dn n lit h hp. Ri lon nhp tim, rung thy ngng tim 174

- Du hiu thn kinh trung ng: hn m, c ch h hp. c ch trung tm vn mch gy suy tun hon. Co git d dn n t vong Hi chng ny thng gp trong ng c ln hu c, carbamate, physosticmine, nicotin * Hi chng anh cholinergic: huyt p tng, thn nhit tng, ng t gin. da nng , kh, gim co bp, vt v kch thch, gim co bp, phn x gn xng tng. Thng gp ng c c c dc, atropin... 3. CC XT NGHIM 3.1. Cc xt nghim thng thng - Mu: ng, in gii, ur, creatinin, toan, kim Cng thc mu, CPK, hemoglobin - Nc tiu: ng, protein, in gii - Xquang: bng, ngc, xng... 3.2. Cc xt nghim tm c cht - Ly bnh phm l cc dch nghi c c cht nh dch ra d dy, ch nn (50ml), ly nc tiu (50ml), mu (10ml) - Cc k thut nh tnh, sc k lp mng - Cc k thut nh tnh, nh lng: sc k lng quang ph khi, quang ph hp th, min dch phng x - Cc k thut nh tnh thng thng dng, r tin d s dng nhng tnh chnh xc thp. Cc xt nghim nh lng thng c chnh xc cao nhng t tin hn. - Ti cc tuyn c s ch yu da vo cc xt nghim thng thng v tnh cht cc triu chng lm sng chn on. Khi chn on l ng c cp cn c tin hnh cp cu ngay. Vi cc xt nghim c hiu c th gi bnh phm nu c thc mc hoc nghi ng. Tuyt i khng ch xt nghim chnh xc mi x tr v nh vy s lng ph thi gian 4. CC NGUYN TC X TR NG C CP 4.1. Loi tr cht c ra khi c th 4.1.1. Cht c qua ng tiu ha - Phng php ny ph thuc nhiu vo thi gian bnh nhn ung c cht v bn cht ca cht c * Bnh nhn tnh - Gy nn Bng cch kch thch hng nh ngoy hng bng bt lng g, bng ngn tay c eo gng 175

Ung bt Ipeca 1-2 g trong mt cc nc m Tim apomorphine 0,005g di da Ti c s nu khng c cc thuc gy nn di tay c th cho ung 1,5 -2 lt nc tr m ri kch thch hng cho nn ht. Nh vy cc cht c ung c th ho tan trong nc ch v c nn ra - Ra d dy + Lun ng thng Faucher n d dy. Bnh nhn nm nghing an ton bn tri, u hi thp. Ly 200 ml dch d dy ban u hoc dch ra ln u gi i xt nghim c cht. Ra bng nc m c pha mui 5-9 hoc natribicarbonat hoc thuc tm 1/5000. S lng nc ra d dy khng c nh c th 10-30 lt. Thng ra n khi dch ra ra khng cn mi c cht, mu sc trong + Khng ra d dy trong cc trng hp ng c acid hoc kim mnh. - Cho than hot 120g/24 gi mc ch hp ph hu ht cc cht c cn trong d dy, rut. Than hot ngn cn cht c ngm vo mu. Cho cc thuc nhun trng: tng cng tc o thi cc cht c cn trong ng tiu ha, hoc ngm vo than hot * Bnh nhn hn m t ni kh qun c bng chn ri mi tin hnh ra d dy, ra t mt ht ht dch mi bm dch ln sau. Cng ra n khi trong mi thi 4.1.2. Cht c thi tr qua ng thn - Tng cng li tiu o thi c cht bng dung dch Mannitol 10% truyn tnh mch hoc thuc li tiu trofurit tim tnh mch. - Truyn natribicarbonate 14 hoc dung dch THAM 0,3 M nhm kim ha mu, kim ha nc tiu to iu kin thun li cho c cht thot ra ngoi theo ng niu (trong ng c bacbituric) 4.1.3. Lc ngoi thn - Lc mng bng hoc thn nhn to khi nhim c qu nng thn khng sc thi cc cht c nhanh chng - Lc mng bng thng n gin hn khng cn c cc trang thit b t tin, d thc hin, ch nh rng ri hn. Tuy nhin khng phi cht c no cng qua mng bng c 4.1.4. Cht c thi tr qua phi - Mt s cht bay hi nh benzen, ru, aceton c thi tr qua phi. - bnh nhn th my, tng thng kh vi tn s cao v th tch lu thng ln 176

c th tng thi tr cht c. Ti cc tuyn c s khng c iu kin ra d dy, nn p dng bin php gy nn hoc cho ung nc ch sau gy nn l bin php hu hiu nht trong loi tr cht c ra khi c th... Sau cho nhun trng tng o thi cht c. Nhanh chng chuyn bnh nhn ln tuyn trn. Vi cc trng hp nh gi ng c cht c th dng ngay cc cht i khng tranh th thi gian. 4.2. Trung ho hoc ph hu cc cht c bng cc cht i khng - Kt hp vi cht c thnh cht khng c v c o thi ra ngoi BAL gp AS, Hg. EDTA gp ch. PAM trung ho ln hu c... - Tc dng sinh l ngc vi cht c, cn gi l thuc gii c triu chng Atropin vi ln hu c, atropin vi Digoxin.... Mt s thuc gii c ch yu
Cht c Acetaminophen (paracetamol) Antidepressants Arsenic, mercury Benzodiazepin Beta blocker Cyanide Heparine Ch Methemoglobine Narfarine Nacortics Metanol, etanol Nhiu cht khc Thuc gii c N- acetycystein Bicarbonat Dimercaprol (BAL) Anexat Glucagon Lilly cyanite kit Protamin EDTA Methylene bieu Vitamin K Naloxon 4 methylpyrazol Than hot

4.3. Duy tr cc chc nng sng ca c th - Duy tr h hp: m bo thng kh tt phng tt li, ht m di thng xuyn, bnh nhn nm nghing an ton. Nu cn thit t ni kh qun, m kh qun th my p lc cao, p lc th ra dng tnh. - Duy tr tun hon + m bo b dch 3-5 lt / ngy + Thuc vn mch khi dch m c tt huyt p Noradrenalin: 2-4mg pha vi glucose 5% 500ml truyn tnh mch hoc Dopamin 200mg trong 500ml glucose 5% truyn tnh mch 177

+ Hi sinh tim phi nu c ngng tim - Duy tr bi tit thn + Bi ph lng dch, thuc vn mch m bo huyt p trn 90mmHg + Theo di lng nc tiu cho li tiu khi cn - Duy tr thng bng kim toan + Theo di pH mu + Theo di d tr kim + PaCO2 + iu chnh toan kim bng thng kh hoc truyn dung dch kim 4.5. iu tra v nguyn nhn gy ng c - iu tra ti ch - Hi ngi xung quanh - Gi bnh phm nghi ng i gim nh c cht - Bo co c quan c trch nhim - iu tra tnh trng tm thn ca bnh nhn 5. D PHNG 5.1. D phng chung - Qun l tt cc loi c cht, khng ri vo tay nhng ngi km hiu bit nhng ngi c th nng tm thn gim st - Phng h lao ng tt khng tip xc vi c cht, sng trong mi trng c c cht - Khi c triu chng nhim c cn c xem xt cn thn v a ngay ti c s y t gn nht xc nh v s cp cu kp thi 5.2. D phng bin chng nng ln ca cc nhim c - Khn trng p dng cc bin php cp cu hi sc - Thn trng trong dng thuc, qun l thuc ti bnh vin, cc khoa phng iu tr - Trong cp cu ng c cp cc thuc i khng cht c cng c th gy c. Cn xem k tn thuc hm lng, ng dng trc khi dng cho bnh nhn. - Dng liu ngy trong cp cu ng c.

178

NG C BACBITURIC
1. M U Trc y ng c bacbituric l ng c thng gp nht trong ng c cc thuc an thn, ngy nay t gp hn song n vn l mt vn thi s v tnh cht nghim trng ca triu chng lm sng. Bn cnh ng c mn tnh do s dng ko di thuc, chng ti cp n y l ng c cp in hnh ca phenobacbital 2. CHUYN HA BACBITURIC TRONG C TH Bacbituric d dng hp thu trong mi trng toan nn thm nhanh qua nim mc d dy. Bacbituric c chuyn ha gan do tc dng ca cc men c trong gan. V vy ngi quen dng thuc liu ng c cao hn liu thng rt nhiu, tri li ngi suy gan kh nng chng c rt km nn d b ng c. Sau khi hp thu cc bacbituric c thi tr qua thn di dng gn nh nguyn vn, n c lc qua cu thn v ti hp thu ng ln gn. Nc tiu kim lm gim ti hp thu bacbituric do lm kim ha nc tiu l bin php tt gim ti hp thu v dng li tiu nhiu l bin php thch hp o thi bacbitunc. 3. C TNH SINH HC Bacbituric tc ng ln cc ty lp th ca cc t bo lm gim tiu th xy, gim pht sinh nhit lng v acid lactic. Vi liu cao bacbituric c ch thn kinh trung ng, c ch h thng li ARAS v vng no trung gian lm cho bnh nhn b hn m. Bacbituric c ch cc trung tm vn mch, h hp, cc th th pH, pCO2, pO2 lm mt phn x ho. Cc tc dng ny c tnh cht tm thi v khi mt i khng li di chng sau khi o thi ht bacbituric 4. TRIU CHNG 4.1. Lm sng - Hn m su hoc ng g tu theo lng bacbituric ung. Cc chi mm nhn, mt ht phn x gn xng, k c phn x gic mc nhng phn x ng t vi nh sng vn cn v ch mt nu bnh nhn ngt th do tt li ra sau trong hn m hoc suy h hp qu nng. Trong cp cu nu thy co cng mt no th khng phi do ng c bacbituric m chnh l tnh trng thiu oxy t chc do m di, tt li Ri lon thn nhit c th st cao hoc gim thn nhit. Nhn cu n nh khng c hin tng rung, git nhn cu - Ri lon h hp: biu hin gim thng kh ph nang, tc ng h hp do tt li, do mt phn x ho, do ht phi dch v... y l nguyn nhn chnh dn n t vong. 179

- Ri lon tun hon: t lit thn kinh trung ng dn n gim trng lc thnh mch gy h huyt p, thng km theo mt nc, mt mui tc mch phi - Suy thn cp: thng suy thn cp chc nng nhng c khi v thc tn do bnh nhn c bnh thn t trc - Bi nhim do vim phi, ph qun ph vim, lot hoi t do t - Cc bnh phi hp nh tai bin mch mu no, tc mch phi, vim a dy thn kinh, nhi mu c tim... 4.2. Cn lm sng - Tm c cht trong dch d dy, nc tiu - nh lng gacdenal mu tin lng v ch nh lc mng bng - nh lng men CK nh gi tnh trng tiu c vn - Xt nghim pH mu, pH niu, in gii mu 4.3. Chn on xc nh Ti c s khng cn c cc xt nghim c cht vn c th chn on cn c vo lm sng - Hi bnh: c tin s iu tr bng bacbituric, c thuc ri vi trong nh, quanh ging. Ch ng tc nh lc hng ca bnh nhn - Khm thy bnh nhn hn m su hoc ng g - Th nng, suy h hp, huyt p thp, thn nhit gim - Ngi mm nhn, phn x gn xng mt, nhu ng rut mt - C th c cc phng rp phn t . 5. X TR CP CU 5.1. Ti ch - Mi ung, cn tnh: gy nn bng ngoy hng, cho ung mn tht, ung nhiu nc... - Hn m: khng gy nn v d gy tro ngc, khi vn chuyn bnh nhn n tuyn trn phi t t th nm nghing an ton - Ngng th, ngng tim phi hi sinh tim phi, p tim ngoi lng ngc, h hp nhn to kiu ming- ming 5.2. Trong khi vn chuyn - T th bnh nhn: nm nghing an ton - Theo di h hp st sao nu ngng th cn h hp h tr kp thi 5.3. Ti khoa cp cu hi sc 180

- Bnh nhn tnh: gy nn sau cho ung than hot, thuc ty - Bnh nhn c suy h hp, hn m cn t ni kh qun thng kh nhn to tch cc. Ra d dy sau khi t ni kh qun - Gim huyt p cn truyn dch, truyn dopamin 15 g/kg/pht duy tr huyt p. - Cho than hot 20g /2h cho 120 g - Thuc nhun trng sothitol 5-20g/24 h chia nh 5-6 ln cng ung vi than hot - Li tiu, kim ha nc tiu: natriclorua 0,9% 1000-2000ml truyn tnh mch natribicacbonate 0,14% 500ml-1000ml, li tiu furosemid - Lc ngoi thn khi c suy thn, ng c nng hn m su, bnh gan, bnh thn c t trc. Lc mng bng hoc chy thn nhn to. - Chm sc v dinh dng m bo 6. D PHNG 6.1. D phng chung - Qun l tt thuc nht l cc thuc iu tr ng kinh, tm thn - Nm c tm l ca ngi bnh ng kinh tm thn thng hay chn cuc sng, coi mnh l gnh nng cho gia nh. - Khi c triu chng nhim c cn c xem xt cn thn v a ngay ti c s y t gn nht xc nh v s cp cu kp thi. 6.2. D phng bin chng nng ln - Khn trng p dng cc bin php cp cu hi sc - Trong cp cu ng c bacbituric ch theo di st tnh trng lit c h hp, truyn dch nhiu cn nh gi bun nc trnh tnh trng tha nc gy ph no, ph phi. Cn xem k tn thuc, hm lng, ng dng trc khi dng cho bnh nhn - Dng thuc liu ngy trong cp cu.

181

NG C LN HU C
1. M U Thuc tr su phospho hu c (cn gi l ln hu c) c s dng rt rng ri trong sn xut nng nghip nc ta. Thuc c tc dng tt trong phng tr su bnh gp phn nng cao nng xut cy trng. Song hng nm mt s lng ln cc bnh nhn phi nhp vin v ng c ln hu c Nguyn nhn ng c thng l c tnh t t. Bnh nhn ung mt lng ln ln hu c. Song hu ht cc ng c ny thng nh. Chnh v vy khi n vin thng mun. Cc triu chng thng rm r, c nhiu biu hin e da tnh mng ca bnh nhn. Cng c trng hp ng c do tip xc trong lao ng nh phun thuc, bn thuc v.v... Trong x tr cn khn trng thnh thc trong ch vic hiu v dng atropin sm v ng liu. 2. C TNH V CHUYN HA LN HU C

- Ln hu c c cu to mt phn t phospho ha tr 5 vi 2 gc carbuthydro (R1, R2), mt nhm chc X cha S hoc N v mt nguyn t oxy ni i. Khi thay th cc gc R1, R2 hoc nhm chc ta c mt cht mi c c tnh khc vi cht ban u, v vy ngy nay tng hp c hn 400 cc ln hu c khc nhau - C ch ng c ln hu c: Acetylcholin l cht trung gian ha hc hu hch ph giao cm v hu hch giao cm, chi phi tuyn ngoi tit, chi phi h ph giao cm mt s nhnh giao cm v tn cng thn kinh vn ng chi phi c vn. Sau khi tc ng ln mng sau synap acetylcholin b hu bi men cholinesterase (ChE). Ln hu c khi vo c th c chuyn thnh paraoxon gn vi ChE lm mt hot tnh ca ChE, t acetylcholin khng b thu phn na m tch t li cc synap gy nn cng chon cp. chnh l bnh cnh ng c ln hu c Ln hu c c o thi qua nc tiu di dng chuyn ha para- nitrophenol khng c v c th nh lng c. nh lng para- nitroophenol cho php chn on chc chn c ng c ln hu c hay khng. 3. TRIU CHNG NG C Ng c ln hu c c biu hin di ba hi chng - Hi chng Muscarin: y l hi chng cng giao cm bao gm + Tng tit dch tiu ha, nc bt, m hi 182

+ au bng, nn ma, a chy + Mch chm, huyt p h, c ri lon dn truyn trong tim + ng t co, mng tip hp , chy nc mt, gim th lc, c lc nhn i + Co thanh qun t ngt, tng tit m di rt mnh - Hi chng nicotin: + Thng xut hin trong ng c nng + Yu c, rung c, sau cng lit c dn n lit h hp + Ri lon nhp tim, rung tht, ngng tim - Hi chng thn kinh trung ng + Hn m, c ch h hp + Co git + c ch trung tm vn mch gy suy tun hon dn n t vong 4. CHN ON - Hi bnh s: c tip xc vi thuc tr su, nhim c qua da qua ng h hp hay ung - nh hng thi gian, loi thuc s lng - Lm sng thy bnh cnh cng chon cp: nh ch thy hi chng muscann nng hn c th thy hai hi chng hoc y c ba hi chng. - Lm test atropin: tim tnh mch 2mg atropin khng thy mch nhanh, da , ng t gin chng t c ng c ln hu c - i vi tuyn c s ch cn khm lm sng t m nh vy cng chn on. Trng hp cc c s hin i c th lm thm cc xt nghim tm c cht trong dch d dy, tm cht chuyn ha trong nc tiu... 5. BIN CHNG Trong cp cu ng c ln hu c nu khng kp thi, khng theo di st c th xy ra nhiu bin chng: - Co git ton thn - Ph phi cp tn thng - Kh th chm kiu Cheyne- Stockes 6. IU TR 6.1. Loi tr cht c ra khi c th - Gy nn hoc ra d dy i vi cc trng hp ung ln hu c. Ra d dy 183

bng nc chn c pha mui nng 0,9%, c th pha thm than hot cho 20g mi 10 lt, nhng cng c th khng cho than hot vo nc ra m bm sau khi ra xong. Ra khong 20-30 lt nc tu tnh trng ung nhiu hay t. Ra n khi nc ra trong, khng cn mi. Ba ngy sau nn ra li vi t nc hn nhm loi b lng ln hu c ngoi rut ngm tr li rut. Sau khi ra xong bm 200ml du parafin vo d dy hoc 12g than hot. Nu bnh nhn hn m phi t ni kh qun c bng chn. Cho bnh nhn ung sorbitol 5- 10g/ ngy tng o thi ln hu c qua ng rut. Du parafin c tc dng trung ho thuc c v thi tr nhanh hn - Tm ra sch bng x phng, thay qun o vi cc trng hp ng c do tip xc - Dng thuc li tiu tng cng o thi thuc theo ng thn. Chy thn nhn to nu c v niu, thiu niu 6.2. Duy tr cc chc nng sng ca c th - Th oxy qua ng thng mi hoc h hp h tr nu khng t th c. - Cc c s c iu kin cho th my, t ni kh qun hoc m kh qun khi cn - Truyn dch ng trng duy tr huyt p, mc lc cu thn - Nui dng qua ng tnh mch 6.3. Dng cc thuc i khng c hiu - PAM: bn cht l mt o xim (2-pyridin aldoxim methylcloride) cn c nhiu loi khc trn th trng nh pralioxim, contrathion, obioxim... Dng tim tnh mch 200 - 500mg trong vng 10 pht. Khng tim trong vng 5 pht v c th khng chu ni d gy tru mch. Th nng phi tim nhiu ln, sau liu u 1 gi mi tim nhc li liu th hai v sau c th tim 30 pht mt ln. Th nh v trung bnh 2 gi 1 ln. Vi bnh nhn nng phi thng kh trc, tim atropin trc ri mi tim PAM. - Atropin tim tnh mch t l-5mg trong vng 5-10 pht. Tim lin tc cho n khi no c du hiu ngm atropin: da kh nng , mch nhanh 120 ln/1 pht, thn kinh hi vt v giy gia. Nu tim 5-10 mg trong 10 pht vi ln m khng thy du hiu ngm th phi tng liu atropin hoc rt ngn thi gian dng thuc xung cn 5 pht. Phi duy tr tnh trng thm atropin sut trong qu trnh thng kh, sau khi ngng thng kh nhn to, c khi n ngy th 10. Mun duy tr tnh trng ny phi thm d lng atropin cn thit. Khi c PAM lng atropin gim i rt nhiu c khi ch cn vi chc mg hoc vi trm mg. - Khi c du hiu ngm atropin th gim liu PAM. Ngng PAM sau 2-4 ngy iu tr. 6.4. Cc s cu ban u c s - Gy nn, ngoy hng. Ch lm sau 1-2 pht mi b ng c hoc tm ra nu 184

nhim c qua da - Tim atropin 0,5 mg tnh mch 2-4 ng/ ln nhc li cho n khi da hng, m, ht kh th, ht tng tit. - Bng mi cch a bnh nhn n vin cng nhanh cng tt trn ng i vn phi tim duy tr atropin v h tr h hp nu cn. - Sau khi ti tuyn trn cc bc tip theo mi c p dng. 7. D PHNG 7.1. D phng chung - D phng ngay t c s, d phng ngay t khi cha ng c - D phng ng c thuc tr su ln hu c bin php tt nht l qun l tt ngun thuc khng thuc trong tay tr em hoc nhng ngi km hiu bit - Tuyn truyn cho nhn dn nm c tc hi ca thuc khi b ng c hu qu s dng khng ng mc ch - C bin php phng h khi tip xc vi thuc tr su nh i gng, i ng... 7.2. D phng cc bin chng trong iu tr - Thy thuc phi thnh thc trong vic s cu, ra d dy... dng thuc ng, liu lng, thi gian - nh gi ng du hiu ngm atropin cho thuc kp thi - Theo di st bnh nhn nht l trong ngy th 3 th 4 khi cc triu chng tm n phng ng c li - Atropin v PAM l cc thuc c gi tr cao trong iu tr ng c ln hu c nhng cng l thuc c cn theo di st dng ng liu Trong iu tr ng c ln hu c phi dng atropin ng ng l-5mg hoc dung dch atropin 1% tim tnh mch. Khng dng atropin thng thng 0,25mg v nh vy khi dng liu cao phi a vo c th qu nhiu dung dch nhc trng s dn n ph t bo. Ch khi dng dung dch m c cn xc nh r mi mi c bao nhiu m trnh nhm ln v nng .

185

NG C THUC CHUT T TRUNG QUC

1. M U Ng c thuc chut Tu l mt cp cu thng gp trong nhng nm gn y. Nu trc y l ng c ln hu c th ngy nay a s ng c thuc chut Tu, do vic s dng qu rng ri, qun l qu lng lo loi c dc ny. Khi mi xut hin Vit Nam ng c thuc chut tu cn nhiu b n v l ni m nh ca cc thy thuc cp cu hi sc. Ngy nay bn cht ca thuc c lm sng t, song trong cng tc cp cu khng v th m ht nhng kh khn. Cc cp cu hu ht l iu tr triu chng ch khng c thuc i khng. 2. BN CHT CA THUC CHUT TU Loi thuc trong ng thu tinh hoc tm vo cc ht go c mu c bn cht l Trinuoroacetamid v mt s mui ca flour. N gy c t bo do c ch chu trnh Krebs lm gim chuyn ha glucose gim hp thu t bo v rng d tr nng lng. 3. CC BIU HIN LM SNG Sau khi ung xong chng 5-10 pht cc biu hin xut hin. Khi u l cc du hiu au bng, bun nn v nn, tip sau l cc du hiu lo lng, kch ng, cng cc c vn. Co git v hn m l cc biu hin mun ca ng c thuc chut Tu. Ngoi cn co git bnh nhn c biu hin co cng c kiu nh un vn, phn x gn xng tng. Cc triu chng lm sng din ra nhanh v rm r nu khng x l nhanh bnh nhn s i vo hn m v t vong. Khm tim mch thy nhp tim nhanh, huyt p tt, mc nh tht. Nng hn c th rung tht, ngng tim. Thng kh km do co cng cc c h hp. i t, nc tiu sm mu v c th suy thn sau 3- 4 ngy. 4. CC XT NGHIM CN LM Ging nh cc ng c khc cn xc nh li loi c cht m bnh nhn s dng bng cch ly bnh phm l cht nn, dch d dy i xt nghim. Trong nhng trng hp c th ly c mu thuc cn st li nh bao b, ng thuc, ht go m BN n lm xt nghim tm c cht. Xt nghim mu nh gi tnh trng gan, thn, men CK, ur, creatinin, nh gi in gii . in tm theo di tnh trng ri lon nhp. C th thy thay i sng T hoc 186

ST, Block nh tht cp 1, block nhnh, ngoi tm thu tht, nhp nhanh tht, rung tht... Cc xt nghim trn c lm trong iu kin c c s vt cht. Mc ch ca cc xt nghim cn lm sng l gip cho chn on thm chnh xc. Tuy nhin khng coi y l nhng xt nghim hon ton bt buc vi tt c bnh nhn v trong cp cu cn tranh th thi gian v ch cn thy cc triu chng lm sng cn x tr bnh nhn mt cch tch cc. 5. CHN ON 5.1. Ti c s Cn xc nh bnh nhn c tin s s dng hoc c tip xc vi thuc chut Tu, hin ti trong tnh trng co cng, co git. Lu bnh nhn c th ung thuc chut tu mt cch khng c thc (tr em v tnh tng l go khng c) nhng cng c th c du bn cht thuc nh khi bnh nhn c t t. Vic pht hin phi nh vo gia nh, nhng ngi chng kin. Quan trng hn c thy thuc tm thy cc du hiu ng c nh nn, co git hn m 5.2. Ti cc trung tm C iu kin lm xt nghim tm c cht, cc xt nghim khc nh gi tnh trng ca ngi bnh v khng nh thm chn on ca c s 6. X TR CP CU 6.1. Cc trang b cp cu Cn c mt s trang thit b thit yu nh - Diazepam (seduxen) ng 10 mg - Thiopental l 1g (dng tim tnh mch) - Than hot v thuc ty - B m kh qun, bng Ambu, oxy, my th nu c - Dobutamin l 250mg - Xylocain ng 100 mg - Dopamin ng 200mg - Thuc gii c c hiu + Acetamid 10% + Glycerol monoacetate. Hai thuc gii c va nu cng cha phi c chp nhn mt cch rng ri v cng ang trong giai on th nghim nn nhiu c s cha h c. Cc trang b v thuc men c th trang b cho tn cc tuyn c s. Cc trang b v phng tin nh my th, b m kh qun... ch c th p ng cc tuyn trn, khng cu k i trin 187

khai mi tin hnh cp cu. 6.2. Cc bc x tr * Cha c co git: - Loi cht c ra khi c th bng: - Ra d dy bng nc sch pha mui 0,9% cho n khi nc sch (3-5 l) + Than hot: cho ung 20g than hot mi 2 gi sau khi ra d dy, tng liu t 120g + Sorbitol: 1 -2g/ kg cn nng - iu tr h tr cc chc nng sng + Tim bp Diazepam trung nu c phn x gn xng tng + Gacdenal vin 0,1g ngy 1-3 vin + Truyn cc dch ng trng m bo lng nc tiu 100ml/h * Nu c co git hoc co cng ton thn - iu tr h tr cc chc nng sng + Tim ngay Diazepam trung ng tnh mch nu cha c hiu qu c th nhc li cho n 30mg. Nu vn khng c kt qu cn tim thiopental 200mg tnh mch sau truyn duy tr l-2mg/kg/gi trong 24 gi u + t ng ni kh qun, th my vi p lc FiO2 = 1 trong 1 gi, sau vi p lc FiO2 = 0,4 - 0,6. Ch ngng th my khi ht cng ton thn v ngng thuc an thn. - Loi cht c ra khi c th + t ng thng d dy, ra d dy, bm than hot sau khi khng ch co git + Truyn dch ng trng c nc tiu 100 ml/ gi + Theo di th tch nc tiu nu thy di 1 50ml/3h th cn t catheter TMTT theo di ALTMTT nu p lc ny trn 10 cmH2O th Cho ng li tiu trofurid 2040mg tnh mch. - Dng thuc gii c c hiu v tip tc h tr cc chc nng sng + Acetamit 10% truyn tnh mch trong 30 pht / mi 4 gi hoc + Glycerol monoacetat 0,1-0,5 mg/kg cn nng/30 pht + Nu c tt huyt p cho Dopamin phi hp dobutamin: Dopamin: 5-20g/kg/pht Dobutamin: 5 - 10 g/kg/pht. Duy tr liu dng cho ti khi huyt p ti a t 188

c trn 90 mmHg + Nu c ngoi tm thu tht trn 10% tn s tim: Xylocain 50-100mg tim tnh mch nhc li sau 15 pht nu khng hiu qu th dng truyn lin tc TM 2mg/kg + Suy thn cp nu c s c tin hnh lc mng bng, lc thn nhn to * i vi tuyn c s: Quan trng nht l ct cn git. Nu c xanh tm, suy h hp khi ang co git th vn u tin ct cn git trc bng thuc tim tnh mch ri thng kh nhn to bng bp bng. Nu khng trong cn co git c thng kh nhn to cng khng hiu qu. phng suy thn cp do tiu c vn cc bnh nhn c co git v co cng nhiu cn truyn dch, li tiu c nc tiu trn 2000ml/24.

6. D PHNG 6.1. D phng chung - Qun l tt thuc dit chut. Nn chng c s tham gia ca chnh quyn trong vic qun l nhp lu thuc ny trn th trng - Tuyn truyn, gio dc nhn dn mc nguy him ca thuc chut Tu. Tuyn truyn cch qun l an ton s dng thuc chut - Trang b kin thc s cu ng c thuc chut tu cho cn b y t tuyn c s c th x tr ban u cc trng hp xy ra ti a phng, chuyn tuyn ng v kp thi cho bnh nhn 6.2. Phng c hiu Phng cc bin chng nng nh suy h hp, suy thn, ngng tim... ca bnh nhn bng cch theo di din bin st. Ch ng cho thuc trc khi c nhng bin chng xy ra.

189

TI LIU THAM KHO

1. Bch khoa th bnh hc, 1996. 2. Bi ging bnh hc ni khoa, Nh xut bn Y hc, H Ni 1996. 3. Bnh hc ni khoa tp I, II - 1996. 4. Bnh hc ni tiu ha - Hc vin Qun y- 1998 5. Bnh thp khp Trn Ngc n - Nh xut bny hc 1995. 6. Bnh tuyn gip v cc ri lon do thiu iod, Nh xut bn Y hc, H Ni, 1996. 7. Cc bnh v mu, NXB Y hc, 1996. 8. Cc nhim c cp thng gp. NXB Y hc 1985. 9. Cp cu ni khoa - 2001. 10. Cp cu ng c NXBYH 2001. 11. Chn on v iu tr hc hin i - NXB Y hc 2001. 12. ng Trn Du (1996), Bnh tuyn gip v cc ri lon do thiu iod, NXB Y hc. 13. Trung Qun (1998), Bnh i tho ng, Nh xut bn Y hc H Ni. 14. iu tr hc ni khoa. tp 1, 2 NXB Y hc 2002. 15. Hi sc cp cu - i hc y khoa Thi Nguyn 2001. 16. Hi sc cp cu NXB Y hc 1998. 17. Hng dn c in tm , Nh xut bn Y hc, H Ni, 2001. 18. Hng dn qun l v kim sot HQP - WHO 1998. 19. Huyt hc trong lm sng, 1996. 20. K sinh trng -NXB Y hc. 21. Lm sng tim mch, Nh xut bn Y hc, H Ni, 2001. 22. Nhim trng tit niu PGS Trn Vn Cht. 23. Phm Mnh Hng. Cc biu hin t min dch trong cc bnh ca tuyn gip. 24. Tnh hnh bnh thn, tit niu iu tr ni tr ti Bnh vin Bch Mai (1991 - 1995) 25. PGS. Trn Vn Cht - BS. Trn Th Thnh. 26. Ti liu i hi hen ton cu ln III (7/2001). 27. Ti liu tp hun HSCC - 2000 - B mn HSCC H Y H Ni 28. Thi Hng Quang (2001), Bnh ni tit, Nh xut bn Y hc H Ni. 29. Triu chng hc ni khoa, Nh xut bn Y hc, H Ni, 2000.

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NH XUT BN Y HC

BNH HC NI KHOA
Tp 1

Chu trch nhim xut bn HONG TRNG QUANG

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

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

In 1000 cun, kh 19 x 27cm ti Xng in Nh xut bn Y hc. S ng k k hoch xut bn: 23 - 2006/CXB/675 - 271/YH In xong v np lu chiu qu I nm 2006.