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

Vt thng mch mu. I. i cng 1. Vt thng mch mu l 1 trong nhng cp cu ngoi khoa thng gp k c trong thi bnh v thi chin. Tuy nhin vic chn on v x tr cn nhiu sai st ng tic, nht l v chn on, v vt kt qu iu tr khng tt. 2. Kt qu iu tr ca tn thng mch mu ph thuc trc ht vo thi gian can thip sm ngay sau khi pht hin, sau l vic hi sc, v cui cng mi l phu thut. Trong trng hp nghi ng cn lm mi cch chn on: Siu m doppler, chp mch, m thm d. 3. Trc y i a s cc tn thng mch mu u l tht, hin nay a s l khu phc hi lu thng mch mu. Kt qu kh quan hn do: k thut m, phu thut vin v phng tin tt, vn chuyn nhanh, s cu tt, khng sinh ph rng ngay sau khi s cu. II. Gii phu bnh: 1) Lp ni mc: trong cng, bao gm cc lin bo lt, c tc dng ngn tiu cu bm vo thnh mch. V cc lin bo lt nn rt d nt v bong ra khi lp gia. 2) Lp gia: l lp c nhn, c ny co theo hai hng: hng chu vi v hng theo trc. 3) Lp v ngoi: l lp m lin kt, c dy thn kinh giao cm. Lp ny kh b thng tn hn. 2. Nhng trng thi tn thng mch mu c th gp: 1) Trong thi bnh: vt thng mch mu phn ln l tn thng do vt sc nhn m vo do thng tn gn, khu tr. Ngoi ra cn do gy xng chc vo, ng dp, thng tn lc ny dp nt rng hn. 2) Trong thi chin ch yu do ho kh (n, mnh). C 2 loi: loi c tc thp (di 1000m/s) nh kiu sng sn, v 1 1. Mch mu (ng mch v tnh mch) bao gm 3 lp:

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

loi c tc cao (trn 1000m/s) nh M16 hay AK 47. Loi c tc cao gy thng tn rng hn ta tng do hin tng l hng ngay sau vin n xuyn qua (cavitation). 3) Vt thng t i v mt on: C chu vi mch b t, 2 u co li theo 2 chiu : u lng mch co li lm cho mu cc d hnh thnh, t cm mu d dng hn, v 2 u mch t xa nhau hn nn kh tm khi m. 4) Vt thng bn hoc xuyn qua: chu vi mch khng bt kn hon ton, lp c co li theo chiu chu vi lm vt thng ming vt thng to rng, kh t cm mu.Trng hp vt thng xuyn qua ng mch v tnh mch to ra 1 dng mu t ng mch sang tnh mch. 5) Tn thng lp ni mc: thng gp trong chn thng kn, ch lp ni mc b dp nt, bong ra gy mu cc bt kn lng mch. Khi mu cc ny ngy cng di ra theo dng mu, c th b t on, tri xung di gy tc mch xa. 6) Co tht mch: ch xy ra trong 1 thi gian ngn, him gp. III. Cc hnh thi lm sng: 1) Thc t khng phi l hay gp, thng ch gp mch mu nm ngay di da v thng do vt sc nhn m vo. 2) Vic chn on d dng, quan trng l s cu cm mu li. 2. Vt thng thm m mu: 1) Do tnh mch b tn thng. 2) Do cc m xung quanh dy v dp nt nn mu khng th chy thnh tia. 1. Vt thng mch mu chy thnh tia:

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

3. Vt thng khng c chy mu: do mu cc hnh thnh, do cc m xung quanh ngn li v do s cu m vt thng mch mu c cm li. C th gp 3 hon cnh: 1) Khi mu t di da: Khi mu t cng cng, do lp cn xung quanh bc li, gy chn p tnh mch lm cho chi pha bn ngoi tm li. Hoc khi mu t p, dn n v to nhanh chng (t gp). 2) Vt thng kh: B ngoi ch l vt thng phn mm, d b st. Nu khm s thy hi chng thiu mu ngoi bin: mch gim hoc mt, da lnh nht, vn ng v cm gic gim, mt. y l mt hi chng rt c gi tr Chn on c hay khng chn thng mch mu. Mt khi pht hin, cn phi ngh ngay n thng tn mch mu v tm mi cch x tr ngay. 3) Chn thng kn: Do cc u xng gy chc vo hoc do chn p, ng dp t ngoi vo. Bn ngoi khng thy c vt thng, cn phi pht hin hi chng thiu mu ngoi bin. c bit l phi pht hin hi chng khoang (cng chn) v thng tn mch mu do gy mm chy. - Hi chng khoang: 4. Tn thng mch mu do cc th thut thm d, can thip gy nn. IV. Din bin ca tn thng mch mu: Nhiu khi bnh nhn n khng ch vi nhng hnh thi lm sng trn m vi nhng triu chng do s cu v x tr khng ng ca tuyn trc. Do vy cn nh gi ng tnh trng ca bnh nhn cng nh tnh trng ca mch mu. 1. Tnh trng nng ca vt thng mch mu ph thuc vo rt nhiu yu t. 1) Nhng tn thng phi hp: Tn thng ti ch: phn mm, thn kinh, xng 3

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

Tn thng ton thn: thng tn cc ni khc. 2) Khi lng mu mt: Kch thc mch mu. V tr mch mu: nng gn da hay trong su. Vic s cu cm mu v hi sc. 3) Thi gian x tr: Quan trng, nh hng ln n kt qu cng nh tnh mng bnh nhn. X tr cng sm, chi tn thng cng d c bo tn, cng t nh hng n tnh mng. Can thip cng sm, chi b thng tn cng d c bo tn, mun th nhiu khi khng nhng khng cu c chi m cn mt c tnh mng. 2. Nhng nguyn nhn gy t vong: 1) Shock mt mu. 2) Nhim khun: nhim khun huyt, hoi t sinh hi. 3) Nhng tai bin khi phc hi dng mu: th garo v th clamp mch sau khi khu ni mch. Nhng ng tc ny lm tt t ngt khi lng tun hon do mu chy xung vng di tn thng, vng ny coi nh rng trong sut thi gian trc khi phc hi, mt khc cc mch vng ny li gin n do thiu oxy, gii phng mt lng ln cc sn phm chuyn ho ym kh vo h tun hon gy ng c, tru tim mch, mt mu do chy mu t ch khu hoc t cc m dp nt. Suy thn cp c th gy v niu do thiu oxy thn v do cc sn phm chuyn ha ym kh gy nn. Cng chnh v vy m cn cn nhc gia bo tn v ct ct chi khi thiu mu trong mt thi gian di. 3. Tn thng ti ch chi tng ng c th c nhng hu qu nghim trng: t hoi t, mt c nng, cho n di chng tn thng. 1) Hoi t chi do thiu mu phi ct ct. C nhiu yu t tc ng:

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

Vng gii phu nguy him: ng mch khoeo c t l Tn thng ti ch phi hp nghim trng: ngoi thng ct ct cao gp 5 ln so vi cc ng mch khc. tn ng mch cn c nhng thng tn khc nh: tnh mch, thn kinh, xng, phn mm. Nhng thng tn ny nhiu khi quyt nh chi bo tn cn kh nng sng na hay khng. Thi gian can thip: cng lu sau khi b tn thng Tnh trng nhim khun: vt thng do ho kh ngc th kh nng ct ct cng ln. ngch d vt nhiu kt qu km hn vt thng do dao m. Hi sc trong thi gian sau khi b tn thng: vt thng mch mu gy chy mu cng lm tng tnh trng thiu mu , thiu O2 gn chi tng ng. 2) Mt c nng chi: Do ng mch thng tn b tc hay hp, chi khng hoi t nhng c nng gim st do thiu mu. Pha tnh mch c th b cn tr gy tr lm cho chi b ph, ri lon dinh dng. 3) Di chng ca vt thng mch mu: Phng ng mch: Lc u l khi mu t thng vi ng mch ri dn dn hnh thnh mt ti phng. y l gi phng v lt ti phng khng phi l ni mc m l lp c ca ng mch. Thng ng mch - tnh mch: c th hnh thnh ngay k u do vt thng m xuyn, hoc do ti phng ng mch v vo tnh mch to thnh dng mu chy t ng mch vo tnh mch gy nn nhng ri lon dinh dng pha ngoi vi ng thi tng gnh tim phi. Tim tri lm b do mt mu sang phi v l thng. V. Cn lm sng: Thng thng lm sng Chn on xc nh c thng tn mch mu hay khng, trong 5

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

trng hp nghi ng, nu c iu kin, trc khi m thm d, cn lm cc xt nghim sau: 1. Siu m doppler: dng u d siu m pht hin nhng thay i v cng dng chy v xc nh v tr tn thng. 2. Chp ng mch: chc kim trc tip hoc lun kim t xa a ng thng t pha trn tn thng, bm thuc cn quang s thy cc hnh nh: thuc cn quang trn ra ngaoif lng mch, lng mch thu nh li cng vi xut hin cc nhnh bn, hnh ct ct, hnh nham nh trong lng mch hay hnh nh thuc sang tnh mch. VI. X tr: 1) Mc ch: cm mu tm thi. 2) Phng php: a. Bng p vng quanh chi. b. Nht mche vo su trong vt thng cm mu. Ch thi gian t cng ngn cng tt (ngha l sm chuyn bnh nhn i iu tr thc th) do nht mche lm tng kh nng nhim khun. c. Garo: Ch nh: + Khi cc bin php trn khng kt qu. + Mm ct. + Chi dp nt khng cn kh nng bo tn. + Ch m, thi gian iu tr thc th sau t khng qu 2 h. Nu c iu kin, c th cm mu tm thi bng cch t 1 sonde Foley vo lng mch, bm cng qu bng. Nu tt hn dng 1 on ng nha lm nng ni gia u trn v u di bo m nui dng chi trong khi ch i iu tr thc th. 6 1. S cu:

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

Trong khi vn chuyn bnh nhn hoc ch m, tt nht l hi sc gi huyt p, khng sinh chng nhim khun, Heparin chng mu cc tip tc hnh thnh. 2. iu tr thc th: a. Cm mu v phc hi lu thng dng mu l mc ch ti a. Ch tht mch khi khng chuyn mn v phng tin. Sau khi tht ng nhin c nguy c hoi t do thiu mu nui dng. C nhiu cch: Khu ni 2 u trc tip sau khi ct lc. Khu ni 2 u c on ghp gia. V vt thng bn, khu vt thng bn: thng dng

tnh mch t thn ghp, t khi dng on mch nhn to. b. Hi sc: tt nht l truyn mu, khi khng c iu kin mi dng cc dch thay th mu, gi c huyt p s bo v tt hn on chi b tn thng. c. Chng nhim khun: Trc ht l ct lc sch vt thng: Ly ht d vt, loi b ht khi mu t, ct lc ht m dp nt, cm mu tt. Phi ct lc cho tt ri mi t vn khu phc hi dng mu, nu khng chc chn s tht bi. Khng sinh ch l gii php h tr. d. X tr cc tn thng phi hp: cc tn thng phi hp s lm nng n v phc tp hn cho vt thng mch mu, nhiu khi chnh nhng tn thng phi hp ny l yu t quyt nh chnh dn n loi b chi. i vi gy xng nn dng np v inh bt ng ngoi gy trnh d vt vng vt thng. i vi thn kinh nn khu ni sau 1 vi thng nu khng c iu kin k thut.Vi vt thng tnh mch ln (khoeo, i, cnh tay, di n) cn phi

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

khu phc hi lu thng mi m bo ming ni ng mch c tt. e. M cn: lm gim tnh trng thiu O2 pha di chi b tn thng. Ch nh m cn th u trong cc trng hp sau: Bnh nhn n mun. Shock, h huyt p ko di. Hi chng khoang: Chi ph n, nht l thy cc c Vt thng vng khoeo. Dp nt phn mm nhiu. Tn thng tnh mch nng n. ng mch c tht.

cng, p lc khoang cao trn 30mmHg.

3. Ch nh ct ct th u: Cn pah nhn nh cho ng trc khi quyt nh khu phc hi lu thng dng mu, nu khng s lm nghim trng hn n tnh mng bnh nhn hoc cui cng vn l ct ct chi. Trong nhng trng hp sau cn ch nh ct ct th u: 1) Shock nng d dn n khng hi phc nu ko di cuc m. 2) Vt thng phi hp nng: s no, ngc, bng 3) Vt thng ti ch nng: vt thng tnh mch, thn kinh, xng, phn mm (c dp nt nhiu), mt da ln. 4) Garo qu 5h: thng thng garo qu 2 h gy nhng bt thng ca chi. 5) Thiu mu khng hi phc: xut hin cc nt phng da, c cng au, gim (mt) vn ng, cm gic. VII. Theo di sau m: Trong khong 24 48h gi u: do sai st v k thut: 1. Chy mu: c th c 2 thi gian khc nhau: ming ni qu cng, c nh xng khng tt, chy mu ming ni. 8

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

Chy mu th pht sau hn 7 ngy: Nguyn nhn ch yu l do nhim khun gy ming ni. 2. Thiu mu: do ming ni b tc 1 phn hay hon ton: thng l cc mu ng hnh thnh ngay ti ming ni. Do k thut ni khng tt, khng ct b ht tn thng ca thnh mch trc khi khu ni. Cn pht hin sm trnh bin chng hoi t. 3. Ph: Sau khi phc hi lu thng, chi b ph. C 2 yu t gy ra: Tn thng tnh mch km theo khng c x tr (tht) Thi gian can thip mun, tnh trng thiu O2 nng, hoc khu ni li nhng tc. shock ko di. Vt thng ngc h I. i cng 1. Vt thng ngc h l nhng vt thng lm thng l thnh mng phi, lm cho khoang mng phi thng vi mi trng bn ngoi. 2. Vt thng ngc h l loi vt thng thng gp trong cp cu c thi bnh v thi chin v l vt thng c nguy c nhim khun cao. 3. Vt thng ngc h l 1 cp cu nng i hi phi x tr kp thi mi mong cu sng c bnh nhn, trong s cu ng vai tr quan trng. 4. Cn phc hi nhanh chng thng bng sinh l h hp v tun hon sau mi t vn phc hi gii phu. Ch nh m ngc l rt hn ch v cn phi c iu kin v kinh nghim nht nh. 5. Phn loi: 1) Theo nguyn nhn: Vt thng do ho kh. 9

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

Vt thng do vt sc nhn m vo. Ti thnh ngc. T bng, c, nch ln. 2) Theo v tr:

3) Vt thng cht, vt thng xuyn. 4) Vt thng bt, vt thng cn ang h. 6. Trong vt thng ngc h, phi l tng hay b tn thng nht, ngoi ra cn tn thng cc mch mu ln, tim, thc qun. II. Cc hnh thi lm sng ca vt thng ngc h: 1. Vt thng ngc h n thun (vt thng phi mng phi). 1) Vt thng cn ang h: Khoang mng phi cn thng vi mi trng bn ngoi. y l loi vt thng rng, mt nhiu t chc v thng do ho kh. Thng bnh nhn n ngay, cha kp s cu. a. Lm sng: Ni bt ln l nhng triu chng kh th v shock (do ri lon h hp, mt mu, au phn x) c th t vong nu khng kp cp cu. Ton thn: + Tm ti, ht hong, th nhanh nng, cnh mi php phng, co ko c h hp ph, kh th d di. + V m hi, chi lnh, mch nhanh nh, huyt p tt. C nng: + au chi ngc. + Ho khc m ln mu. Thc th: + L vt thng toc rng, c ting ph ph, bt kh mu bn ra mi khi th. c bnh, trn kh di da. + Nghe phi: r ro ph nang gim, mt, rung thanh gim, g vang. du hiu ng: kh kh, ral m, n. 10

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

C th c bin chng: + Tc nghn h hp do h hp o ngc v trung tht lc l dn n suy h hp cp, tru mch, thiu O2, t vong. + M mng phi: 39%. b. Sinh l bnh: Vt thng ngc h Mt p lc m trong khoang mng phi H hp o ngc v trung tht lc l. Khi th ra, khng kh mt phn ra ngoi, mt phn sang bn phi b thng, trung tht sang bn b thng lm cho khng kh t khoang mng phi qua vt thng ra ngoi. Lc th vo, hin tng ngc li. Hai hi chng ny gy thiu oxy nghim trng v khng kh ht vo li c mt phn l khng kh cn ca ln th trc t phi bn b thng sang, phi ng l phi n ln th do trung tht b ht sang lm cho n km, qu tim lc l lm cho mu t tnh mch ch kh v tim. Do thiu oxy m bnh nhn th nhanh hn, cng nhanh th ri lon cng nhiu. V th nu khng s cu kp thi, bnh nhn rt d cht. c. Cn lm sng sau khi s cu: Xquang: hnh nh trn kh mng phi, trn mu mng phi: Nhu m phi co rm li, trn sng mt vn phi, di m do c mu. i khi c th thy d vt (vt thng ho kh). Xt nghim: Hng cu, hematocrit, hemoglobin, pO2, pCO2, pH. 2) Vt thng c bt kn: Do: vt thng nh + thnh ngc dy, hoc do bnh Lm sng: nhn c s cu. + Ton thn: nhn chung nh hn th trn. bnh nhn thng khng chng nng v cc du hiu cng t cp cu hn. Bnh nhn c 2 hi chng trn kh mng phi v trn mu mng phi, c th c thiu mu. 11

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

+ C nng: au ngc, kh th, ho ra mu, trn kh di da. + Thc th: vt thng c bt kn (khu kn), khng thy ph ph. C hi chng trn kh mng phi,trn mu mng phi. Cn lm sng: Xquang, Xt nghim Bin chng:

+ Tc nghn ng h hp, gy suy h hp cp, thiu O2 mu. + Mu mng phi ng lm hnh thnh cn mng phi, dy dnh mng phi, m mng phi, phi m tch lp v mng phi. 3) Vt thng trn kh mng phi van: trn kh mng phi di p lc. y l 1 trng hp ti cp phi x tr kp thi mi trnh c im ca loi ny l c hin tng to van ti vt thc t vong. ng, khng kh vo mng phi c m khng ra c. V vy khng kh vo khoang mng phi ngy cng nhiu lm cho phi co rm li khng n ln c, trung tht b y sang bn i din gy nguy c xp phi cho c bn lnh, suy h hp rt nhanh. Lm sng: + Tnh trng rt nng, du hiu ni bt l tnh trng kh th d di ngy cng tng ln nhanh chng. + Tm ti, chong, cnh mi php phng. + Ngc cng to, g vang, tim b lch hn sang bn i din, r ro ph nang gim, mt. + C th: trn kh di da, trn kh trung tht: tnh mch c ni to, s lp bp mm trn xng c. Cn lm sng: sau s cu: Xquang: thng trn kh mng phi ton b, trung tht b y sang bn i din, c th trn kh mng phi trung tht. 12

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

Hu qu: t vong nhanh do suy h hp. 2. Vt thng ngc h km vt thng tim, mng tim. 1) Chn on: Vt thng c th trc tim hoc xa. Hi chng mt mu cp: do mu t vt thng tim c

th chy vo khoang mng phi, qua vt thng ngc chy ra ngoi. Hi chng chn p tim cp do vt thng ngc h Xquang: Bng tim m, b tim nt. Siu m: Dch khoang mng phi. in tm : in th ngoi bin gim. c bt li.

3. Vt thng kh, ph qun gc (thng km theo vt thng mch mu): phn chn thng ngc. 4. Vt thng thc qun (thng km vt thng tim, mch mu, ct sng): rt nng: phn chn thng ngc. 5. Vt thng mch mu: phn chn thng ngc. 6. Vt thng ngc bng: 1) L loi vt thng xuyn t ngc xung bng (hoc ngc li lm rch c honh). 2) Tu v tr ca vt thng m ta c nhng ch sau: Vt thng c c l vo v l ra:d chn on. Vt thng ngc t xng sn 4 tr xung: cn lu xem Vt thng t bng km triu chng ngc hoc ngc li c im: c honh b thng lm thng thng gia

c vt thng ngc bng khng. cn lu vt thng ngc bng. lng ngc v bng: tng trong bng b tn thng , mu v dch trong bng b huyts ln khoang mng phi. Nu rch to cc tng trong bng c th chui ln ngc: tn thng v nhng ri lon gy ra phc tp hn: m ngc cp cu. 13

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

3) Lm sng: Ngoi cc triu chng ca vt thng ngc cn c cc du hiu ca bng tu theo tn thng: Hi chng chy mu trong: Do tn thng tng c (gan, lch, tu), mch mu (mch mc treo, tnh mch gan). + Nht, mch nhanh nh, huyt p tt. + Bng chng, cm ng phc mc, g c vng thp. Hi chng vim phc mc: Do tn thng tng rng: d dy, rut non, i trng. + au bng, bng chng, cm ng thnh bng (+). + Xquang: lim hi. Hi chng tc rut: thot v (d dy, rut) qua c honh: Nc, nn. Kh th, cng bng. Si bng trn ngc. Xquang ngc thy mc nc hi. III. i khi ch c vt thng c honh m khng c tn X tr: 1) Phc hi sm nhng ri lon h hp v tun hon. 2) Hi sc ng vai tr quan trng, c khi l quyt nh. Ch yu l bo m h hp, bi ph tun hon. 3) Phu thut ng vai tr th yu. Phn ln cc ch nh m ngc cp cu l sau khi theo di din bin 1 thi gian. 2. C th: 1) S cu: Bt kn vt thng ang h bng bng, khu hoc nt Chc khoang mng phi tho hi ngay nu trn kh Depage. mng phi di p lc bng van Heimlick t to. Chc ht khoang mng phi dn lu n thun. Lm lu thng ng h hp nu b tc. thng cc tng trong bng: d b st dn n thot v. 1. Nguyn tc:

14

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

Chng shock: truyn mu hoc cht thay th, tr tim, lp ng truyn tnh mch trung ng theo di kt qu hi sc. Chng nhim khun, un vn. Gim au: thuc gim au nh, phong b dy thn

kinh lin sn, giao cm c bnh nhn d th, d ho, khc c m. Vn chuyn sm ti ni iu tr thc th.. Mc ch : 2) iu tr thc th: + Gii phng khoang mng phi. + Lp li p lc m khoang mng phi. + Lm cho phi n tt. C th: + Vt thng h: m ngay, ct lc, khu kn vt thng. Chc ht dn lu khoang mng phi. + Vt thng kn: phn ln bo tn: chc ht dn lu khoang mng phi. + Vt thng c van: m ct lc v khu kn, dn lu. khoang mng phi. Van trong: dn lu khoang mng phi ht lin tc. + Cc thng tn khc i km: x tr nh chn thng ngc kn. Tn thng cc tng trong chn thng ngc. I. Thng tn khoang mng phi: 1) L bin chng hay gp trong chn thng ngc. Mu chy vo khoang mng phi t 3 ngun: phi, thnh ngc, mch mu trung tht. 1. Trn mu mng phi:

15

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

2) Xquang t th ng: m y phi. Nu bnh nhn chp t th nm, hnh nh trn mu khng cn in hnh na nn rt d b st hoc chn on sai. 3) Din bin: Nu trn mu t th lng mu ny s t tiu, t li di chng. Nu trn mu nhiu s gy dy dnh mng phi, m mng phi, mu cc mng phi nu mu t cm, c th t vong nu mu khng cm. 4) X tr: Trn nguyn tc, ngay sau khi Chn on l trn mu mng phi, phi ht trit v khng c gy bi nhim. Ht trit l ht ht v lin tc. Do tt nht l t ng dn lu mng phi ri lp vo h thng ht lin tc. Chc ht khoang mng phi bng kim ch khi khng c iu kin v phng tin v ngi theo di. Do ht trit m khoang mng phi c lp li nh sinh l bnh thng, ngha l khoang tr thnh o, p lc m. Phi n ln, p st mng phi l tng vi l thnh, ni nhu m phi b thng tn s dnh vi l thnh, bt kn m khng chy mu na. Sau khi t ng dn lu, theo di nu lng mu ngy cng gim, phi n ln th iu tr bo tn thnh cng. Theo di nu lng mu khng gim, phi khng n: m ngc cp cu. 2. Trn kh mng phi: 1) Ngun: T vt thng ngc h hoc t nhu m phi x vo. 2) Lm sng: R ro ph nang gim. Rung thanh tng. G trong.

3) Din bin: Nu trn kh mng phi t th t khi sau vi ngy. Nu trn kh mng phi di p lc: khng kh 16

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

trn vo khoang mng phi ngy cng nhiu sau mi ln th, p lc trong khoang mng phi ngy mt tng, y trung tht sang bn i din, p phi bn lnh gy kh th d di dn n ngng th, t vong nu khng s cu kp thi. 4) Xquang: Phi sng. Bng m mng phi. Du hiu y: trung tht b y sang bn i din. Khoang lin sn gin rng, c honh b y xung thp. 5) X tr: S cu: + Ht m di, m bo lu thng ng h hp. + Trn kh mng phi di p lc: Dng van Heimlick lc vn chuyn hay dng 1 kim tim to u buc gng cao su ct 1 ng, chc vo khoang lin sn 2, 3 ng gia xng n. Ht trit , ht lm sao cho ht kh trong khoang mng phi, ngha l lu lng ht ra phi ln hn lu lng khng kh x vo, nn phi n ra, 2 l mng phi dn vo nhau bt kn ch khng kh x vo. Phi n ln cn ph thuc vo ng th c thng khng: nu b tc do m di th phi xp d c tng p lc ht dn lu. V vy phi lun lun m bo lu thng dng h hp bng cch ht m di. II. Trng hp phi khng n ln c: thng do nhu m Thng tn nhu m phi: 1) L 1 bin chng hay gp sau chn thng. L tnh trng ng ph qun tng ng b tc do nhiu nguyn nhn: tng tit m di, mu v d vt ng trong ng h hp, nhng ch yu l do phn x ho ca bnh nhn phi b dp nt nhiu th phi m ngc cp cu. 1. Xp phi:

17

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

gim do au qu. V vy gim au ng vai tr quan trng. 2) Xquang: du hiu co: trung tht b ko sang (nh gi trn bng kh qun so vi ct sng), c honh b ko ln, cc khoang lin sn nh li, cc xng sn xui hn. Cn chn on phn bit vi trn kh mng phi: du hiu y: trung tht b y sang bn i din, c honh b y xung di, cc khoang lin sn gin rng, nhn r ng ranh ri trong khoang mng phi. 3) X tr: Gim au sau chn thng lng ngc l ch yu Khi xp phi: Phi tm mi cch kch thch ho d phng bin chng ny. tng m di ra ngoi: thuc long m, th dc liu php, kch thch ho. Nu khng mi bt buc phi soi ht ph qun. 2. V phi: 1) V nng: trn kh mng phi , trn mu mng phi t, c th t khi. 2) V su: trn mu mng phi nng, trn kh mng phi di p lc: x tr ct b thu phi tn thng. 3. Chy mu nhu m phi: 1) Lan to, nhiu mch b tn thng , c th 2 bn phi. 2) Thnh khi ln t tiu so nh nang gi, ap xe ho III. V ph qun. Nguyn nhn thng do tai nn xe c vi tc cao, Vt thng: . Phn ln cc trng hp l v gn ch phn 1. i cng: chn thng kn vo vng ngc v thanh qun ng kn chia kh ph qun, thng tn c th l v 1 phn (phn mng) hay t hon ton ph qun: 18

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

+ V kh ph qun gc. + V ph qun thu, phn thu. Khong 30% cc trng hp cht trc khi vo vin. Vic Chn on thng tn ny cng rt kh do nh hng ln n kt qu iu tr do di chng hp ph qun vi xp phi tng ng. 4. Triu chng lm sng: Chn thng kn mnh vng trn lng ngc. Gy xng sn 13. Kh th nhiu, ngay c khi ht ng dn lu khoang mng Ho ra mu. au ti ch tn thng. Trn kh mng phi, trn mu mng phi, trn kh di Shock. Trn kh mng phi di p lc, trn kh mng phi c V ph qun gc: trn kh trung tht gy ri lon huyt V ph qun thu, phn thu gy trn kh mng phi Phi khng n ln c cho d tng p lc ht.

phi.

da nn c.

2 bn. ng v suy h hp cp d dn n t vong. nng. 5. Chn on xc nh: Soi ph qun l mt thm khm quan trng xc nh v tr, mc tn thng. Trong lc cp cu khng nn chp ph qun, khi n nh c th chp. 6. X tr: Rch ph qun nh: x tr bo tn, soi ph qun theo di s lin. M kt qu thng khng c tc dng.

19

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

Rch ph qun ln: m ngc khu ph qun , ph kn bng t chc xung quanh, nu ph khng c th ct phn phi tng ng. M khu ph qun l mt phu thut kh. Ngay t lc gy m ni kh qun phi rt ch , nu khng s gy suy h hp cp. Phi phu tch k cng, ct b nhng nhu m dp nt ri mi khu ni. Nn dng ch Vicryl 3/0 hay 4/0. IV. V ng mch ch. 1) Tai nn giao thng vi gia tc mnh, tc nhanh, dng t ngt, on ng mch ch xung c cc ng mch lin sn gi li, cn on quai ng mch ch theo qun tnh vng ra trc, do vng v ng mch ch l vng ni tip ca 2 on ny l pha chn ng mch di n tri. 2) Khong 80% l cht do chy mu d di vo khoang mng phi, ch nhng trng hp lp v ngoi ca ng mch ch v mng phi trung tht ngn khng cho mu chy o t mi sng st. 3) Cc trng hp n vi tnh trng n nh th c cc du hiu sau: Lit hay gim cm gic 2 chn c th thong qua trn Chnh lch huyt p gia tay v chn. Gim hoc mt mch c, tay hoc mch tay chn Thi tm thu vng trc tim hay sa lng gia 2 xng b Trn mu trung tht rng. 1 bnh nhn khng c tn thng ct sng. 1. Lm sng:

bt i xng. vai. 2. Cn lm sng:

20

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

Xquang ngc: trung tht rng hn 8cm, mt hnh quai ng mch ch, kh qun, ph qun tri v thc qun b y. Xquang ng mch ch c bm thuc cn quang. CTscan ngc. M cp cu i hi phi khn trng c v phu thut M tr hon hoc m vo giai on thnh mt ti

3. X tr: ln hi sc. phng ng mch ch: c th gi chun b v c th dng my tim phi h tr trong khi cp ng mch ch. V. Khu ni trc tip hoc qua 1 on ghp. Tim v mng ngoi tim: do dp v, l thng tn nng nht. 1. Tn thng tim: Du hiu gi : vt thng vo vng tam gic tim, c gy Triu chng lm sng: biu hin 2 hi chng l hi xng c. chng mt mu v hi chng chn p tim cp: + Tru mch km theo mch khng gii thch c bng suy h hp v tun hon. + Ting thi km tim to hay suy tim, lon nhp. + Trn dch, trn kh mng ngoi tim. + Nghi ng th chc d mng ngoi tim. Khi chn on xc nh th m cp cu ngay khu li. 2. Tn thng mng ngoi tim: VI. Thng nh v khng chy mu. Trng hp rch mng ngoi tim rng: tim thot v gy Thng tn cc thnh phn trong trung tht:

ri lon nhp, suy tim, ngng tim.

21

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

1. Trn mutrung tht: mu t cc mch mu ln, km trn mu mng phi 2. Trn kh trung tht: Ngun: mng phi, kh qun. Lm sng: trn kh di da c, kh nut, ging mi.

Nu trn kh trung tht di p lc (kh t ph qun): m cp cu . Cn lm sng: Xquang: mng phi trung tht b tch ra bng 1 ng vin nh. 3. Tn thng ng ngc: Chc thm d khoang mng phi thy dng chp. X tr:

+ Ht khoang mng phi. + Dinh dng tnh mch, king m. + Sau 10 ngy khng khi th m . 4. Thc qun: nng 1) Lm sng: Thc n, dch tiu ho b ht ln ngc gy hoi t mng au d di, nht l khi nut, khng n c. Kh th. Tru tim mch. Trn kh c v trung tht. Trn kh mng phi , trn mu mng phi . Xquang: phi nhanh, tru tim mch, t vong.

2) Cn lm sng: + Phi m do trn dch. + Ung thuc cn quang tan trong nc s thy ch d. + Soi thc qun. Chc d khoang mng phi: dch c ln dch d dy, thc n hoc xanhmethylen cho bnh nhn ung trc chc. 22

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

3) X tr: do d b nhim khun nhim c cho nn: VII. Khu ch v, dn lu trung tht khoang mng phi. Chng nhim khun, st, suy h hp . n qua sonde d dy v hng trng. Chn thng ngc bng:

1. L vt thng xuyn t ngc xung bng qua c honh, hoc theo chiu ngc li. y khng bao gm loi c vt thng ngc v bng ring bit, ngha l c honh khng b thng. 2. V c honh b thng nn 2 ngc v bng thng vi nhau, p lc trong khoang mng phi ht ln mu, dch trong lng ng tiu ho, hay c cc tng trong bng. 3. Chn on: V mt chn on, cn phi ch khi b st thng tn bn kia: i vi vt thng bng xuyn ln ngc, d st thng tn trong ngc v ngc li. Ngoi vic nh hng m xuyn, v tr vt thng, mt s du hiu sau y cn phi ngh n: + Vt thng vo ngc nhng bng c du hiu vim phc mc v chy mu trong bng: i khi cc du hiu ny kh khm v mu hoc dch tiu ho b ht ln phi, hoc ch c vt thng ngc m lm na bng co cng. + Vt thng ngc nhng c lim hi trong bng khi chp Xquang . + Vt thng bng c kh th, Xquang c trn kh mng phi , trn mu mng phi mng phi, thot v bn ngc. + vt thng bng hoc vt thng ngc nhng khng c du hiu thot v bn ngc. 4. X tr: Bao gi cng dn lu khoang mng phi, sau quyt nh x tr u tu vo tn thng u tin: sau khi dn 23

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

lu mng phi nu thng tn trong ngc l khng c Ch nh m cp cu, th m bng trc. Bao gi cng phi tm l thng c honh khu Nu khng c ch nh m ngc (ch dn lu mng kn li. phi) th trc khi khu kn c honh cn ht sch khoang mng phi qua ng bng, nht l sau khi n no m d dy b thng. Cc ng dn lu (ngc, bng) u phi kn v ht lin tc vi p lc - 20cm H2O , khng c ng dn lu bng h, khng kh qua s ln khoang mng phi. VIII. Vt thng ngc h. 1. Vt thng lm thng mng phi l thnh lm cho khoang mng phi thng vi mi trng bn ngoi. 2. Lm sng: trng hp c l thng nh c bt li trn kh mng phi , trn mu mng phi . Trng hp l thng to h hp o ngc v trung tht di ng gy thiu O2 trm trng. 3. X tr: IX. Bt kn li ngay vt thng ngc h. X tr nh trn kh mng phi , trn mu mng phi Ch nh m ngc cp cu:

(sau khi bt kn). 1. Trn mu mng phi khng cm: sau khi dn lu mng phi, lng mu chy ra > 300ml/h trong 3h lin tc, hoc chy mu d di qua vt thng. Tuy nhin khng th my mc da vo con s ny m quyt nh. Th d: do mu cc lm tc dn lu, tr nh. Cn phi da c vo triu chng ton thn, Xquang ngc. 2. Trn kh mng phi khng cm: d tng p lc ht m phi vn khng n ln c, lng kh x qua ng dn lu li tng ln, i khi tng p lc ht li lm cho bnh nhn kh 24

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

th hn (c kh nng v ph qun hoc dp nt nhu m phi nhiu). 3. Vt thng thc qun: Rt him gp. Soi thc qun s xc nh Chn on. M ngc khu thc qun cn phi km vi m thng d dy nui dng. 4. Chn thng tim (v tim hoc vt thng tim) v chn thng mch mu ln (bnh nhn trng: hi chng mt mu cp do mu t tim trn vo khoang mng phi, bnh nhn tm: hi chng chn p tim cp do mu chy ra t tim b li trong mng ngoi tim). Ton thn huyt mch huyt p p Mt mu cp Nm yn Nht ng Tt tnh Tt Chn p tim cp Dy da Tm Kp Cao

mch i vi vt thng tim: du hiu gi l v tr vt thng vo tam gic tim. i vi chn thng kn: du hiu gi l gy xng c. 5. Vt thng ngc rng, mt nhiu thnh ngc. 6. Mu cc mng phi. 7. D vt ln. X. Dn lu mng phi: 1. dn lu mng phi l mt th thut rt thng lm trong chn thng cng nh vt thng ngc. y l mt th thut c bn trong iu tr. Cn phi thc hin ng nhng nguyn tc nu khng tai bin em li cn tc hi hn l khng lm. Trong thc t thng thy nhng dn lu mng phi sai quy cch. 2. ng dn lu: L ng nha, khngc cng qu nhng cng khng mm qu s b bp, pha trong trng silicon trnh mu cc hnh thnh. C ng l 18 32 Fr i vi ngi ln, tr em dng c nh hn (1Fr = 1/3mm) . ng di khong 40cm, 25

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

c mt vi l bn khng i xng phn t trong khoang mng phi, u ngoi hi loe ra lp ng ni. Nu tt hn c mt ng ch cn quang khi chp x ngc c th bit u ng u. 3. v tr: i vi dn lu mu: t ng dn lu qua khoang lin sn 5 6 ng nch gia, i vi dn lu kh, t qua khoang lin sn 2 3 ng v (c th ch t 1 ng dn lu mu cho c kh cng c). 4. Ht lin tc: Sau khi t cn ht ng dn lu ngay. Ht phi c tiu chun: lin tc 24/24 v p lc iu khin khong 20cmH20. Cn c bnh iu chnh p lc gia my ht v v ng dn lu ngc m bo chc chn t c p lc theo mun. Ton b h thng ht phi kn 5. Sau khi t cn theo di ng dn lu: Lu lng mu chy ra hng gi. Lng kh ph ra. Chp Xquang ngc xem cn ng trong khoang mng

phi khng, phi n ln khng. 6. Cn lun vut ng dn lu trnh mu cc lm tc. Nu ng dn lu tc cn pht hin ngay thng li hoc thay ng. Du hiu tc l: mc nc trong ng khng cn ln xung khi th (cn tho khi mu quan st). 7. Khi gii phng ht khoang mng phi khi mu v kh, phi n ln hon ton th phi rt ngay dn lu, khng nn lu s bi nhim khoang mng phi. Nhng thng tn thnh ngc ca chn thng ngc kn. I. Gy xng sn: 1) Xng sn b gy l 1 trong nhng thng tn thng gp trong chn thng ngc kn. Bn thn gy xng sn l mt tn thng nh, t li di chng cho d c iu 26 1. i cng.

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

tr hay khng. Tuy nhin nhng thng tn km theo do gy xng sn gy nn thng nng hn, gy ra nhiu bin chng. Do vy x tr gy xng sn ch yu l gim au cn x tr nhng thng tn km theo mi l quan trng. 2) Vic tm kim nhng thng tn gy xng sn ch yu da trn c ch gy xng sn v khm t m. 3) C 2 c ch gy xng sn: Gy trc tip: gy t ngoi vo trong, tc nhn gy chn thng u, gy xng sn . Cc c quan ngay pha di gy hay b tn thng nht thng l phi. Gy gin tip: gy t trong ra, tc nhn gy chn thng p t pha trc ngc, cn pha sau lng l mt vt cn c nh, lng ngc b p dp li theo chiu trc sau, nn cung bn xng sn hay b gy nht v hay gy tn thng nht cho cc tng trong trung tht l tim v cc mch mu ln. 2. Lm sng: 1) C nng: Tc ngc, kh th, th nhanh nng. au nhi ti ch tn thng, im au c nh, au

tng khi ht th su. 2) Ti ch tn thng: im lo xo xng, im au chi: + n dc xng sn tn thng. + p nh lng xng c. + p tay ln ngc, yu cu bnh nhn ho s thy lo xo. Trng hp c trn mu, trn kh: + Bnh nhn kh th, au tc ngc nhiu. + Trn mu mng phi = hi chng ng c. + Trn kh mng phi = hi chng 3 gim. 3) Cc thng tn phi hp khc do gy xng sn: 27

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

Trn mu mng phi, trn kh mng phi: thng nng Trn kh di da. Tn thng cc tng bng (gan, lch) (gy xng sn Tn thng mch thn kinh (ng mch, tnh mch di gy suy h hp, tun hon.

8,9). n, m ri thn kinh cnh tay): gy xng sn1, 2: Cc xng sn ny c che ph pha trc bi xng n, pha sau l xng b vai nn him khi gy. Tro qua b trn xng sn 1 t trong ngc ra l ng mch di n, i km l tnh mch di n t ngoi vo v b dy thn kinh cnh tay. Phi c mt lc rt mnh mi c th lm gy 2 xng sn ny, do cc thnh phn trn d b tn thng. 4) Cn lm sng: Xquang lng ngc: T th: thng, nghing tri , phi, chch 3/4 (nh gi Hnh nh: cung bn). + gy xng sn: n gin, phc tp + cc thng tn phi hp: trn kh mng phi , trn mu mng phi. + tn thng cc sn sn: kh thy. 5) Siu m: (?) bng: tn thng phi hp. 3. x tr: 1) Nguyn tc: Khng t kt hp li xng sn nu khng l mng sn Gim au ti ch l ch yu. m bo h hp thng sut. chng nhim khun. 28 di ng. Lng ngc: trn mu mng phi, trn kh mng phi

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

x tr cc tn thng phi hp. gim au: 2) c th: + Mc ch: cho bnh nhn t th tt do bnh nhn khi au khng dm th. Nh vy s ci thin tnh trng thiu O2 cho bnh nhn. + c 2 cch: *Gim au ti ch: phong b dy thn kinh lin sn: tim vo gy hoc gc dy thn kinh Xylocain hoc gy t vng ngoi mng cng bng Morphin. *Gim au ton thn: t dng phng php ny do nu dng thuc gim au nh s t c tc dng, cn nu dng thuc gim au mnh gy c ch h hp. C nh bng bng dnh: y l phng php n gin nhm c nh xng gy. Tuy nhin do tnh cht ca lng ngc phi di ng cho nn s gy hn ch h hp. Phng php ny hin hu nh khng cn dng. m bo h hp thng sut, trnh ng m di: + Tp th. + Tp ho khc mnh 1- 2 ln/24h. + Kh dung: khng sinh, long m, gin ng th. Nu khng kt qu th phi soi ht kh ph qun hoc m kh qun. + Vn ng sm trnh vim phi. Chng nhim khun: + Khng sinh: nht l khi c sn vim ng h hp t trc. + t th nm hp l. V d : gy cung sau: nm gia gi chn 2 bn. X tr thng tn phi hp. Ch : + Ngi gi: xng rn d gy, li gy au nn khng dm ho, ng m di, d vim phi, xp phi.

29

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

+ Tr em xng cn mm rt kh gy, v vy khi c gy xng sn c ngha l chn thng rt mnh nn thng tn km theo l nghim trng. II. Mng sn: Khi gy xng sn gy c hai u t 3 xng sn lin tip tr ln. 1. Phn loi: 1) Mng sn trc (mng c sn): bao gm xng c v cc sn sn. L loi mng sn gy ri lon nghim trng v h hp v tun hon do c honh co ko khi h hp. 2) Mng sn bn: hay gp nht nhng t gy ri lon h hp hn mng c sn. 3) Mng sn sau: l loi mng sn t di ng nht, khng cn c nh do khi nm mng sn b hn ch di ng ri. 4) Mng sn trc bn: cn c nh, c khi ch l na mng sn: nng? 5) Na mng sn: xng sn ch gy 1 u, mng sn di ng kiu cnh ca vi bn l l cc sn sn. Xy ra ngi tr. 2. Chn on: 1) Quan st s cn i ca lng ngc 2 bn, pht hin s di ng ngc chiu mng sn lng ngc (d thy khi th su, ho). 2) Phi xc nh: V tr mng sn. Tnh cht di ng:

+ mng sn di ng gy nn 2 hi chng l h hp o ngc v trung tht di ng, gy thiu O2, toan mu. + mng sn c nh: thng do cc u xng gy ci vo nhau. V vy c th gy di ng th pht do thay i p lc th pht khoang mng phi (ho), thng xy ra trong 2 3 ngy u. Cng c th lm dn vo trong do p lc 30

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

m tnh khoang mng phi, gy di chng hn ch h hp. Din tch mng sn. Tnh trng h hp: nhp th, mi, u chi, kh mu tn thng phi hp: trn kh mng phi , xp phi:

bng Xquang, siu m. 3. X tr: 1) Nguyn tc: Chn on sm, khi pht hin mng sn c nh cn X tr s cu ngay khi chn on mng sn di ng theo di st phng di ng th pht. nhm khng cho mng sn ny di ng trc khi chuyn vin hoc x tr tip theo. Duy tr h hp thng sut. Dn lu mu, kh khoang mng phi. Hi sc tch cc: b mu mt, iu chnh cc ri lon Phu thut c nh mng sn. Khi nhiu xng sn gy, nhu m phi thng b tn th-

khc.

ng, gy trn mu, trn kh mng phi. Nhiu khi do nhng tn thng ny m bt buc phi m iu tr. 2) C th: S cu: khng cho mng sn di ng bng cch t 1 cun bng vng mng sn ri ly bng khc vng quanh ngc sao cho mng sn lun t th tht vo khng phng ln c. Cch lm ny s trnh c nhng ri lon v tun hon v h hp nhng tt nhin l hn ch h hp. iu tr thc th: + Duy tr ng th thng sut (duy tr kh mu n nh). Ht mu kh trong khoang mng phi. 31

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

Gii phng ng h hp: ht m di, gy ho, m kh qun. Gim tit dch: atropin, li niu Gim au. Truyn mu. Ht d dy: bng bt chng, d th. Th O2. Khng sinh. + C nh mng sn di ng khng m ngc. *C nh trong (c nh gin tip, c nh sinh l): t ni kh qun, m kh qun + gin c+ th my: c nh mng sn, cai my th t t sau 1 tun, th li sau 3 tun. Nhc im : chm sc theo di phc tp d nhim khun , ph thuc myV vy ch tin hnh khi c i ng y t tt, chm sc tt. *C nh bn ngoi ( c nh trc tip, c nh gii phu): -Np Judet xuyn inh qua gy gi 2 u. Phng php ny tt nht vi mng c sn. -Ko lin tc: Dng ch perlon to vng quanh xng sn thuc mng sn ri buc li thnh tm ri qua h rng rc qu t ko lin tc. -M xuyn inh Kirchner qua gy gi 2 u : ch nh -khi loi tr c hon ton h hp o ngc. -d nhim khun ti ch. -kt hp vi m ngc x tr tn thng khc. -ko lin tc khng kt qu. Cn nh l trong mng sn, lng mu mt t cc gy l Ni chung thi x tr l: vi mng sn c nh cn ng k. theo di phng di lch th pht, mng sn di ng 32

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

th ko lin tc vi mng sn trc bn, np Judet cho mng sn bn, mng sn sau khng cn c nh. M xuyn inh khi c nhng tn thng trong ngc cn x l ng thi. Dng my th khi c i ng iu dng tt. III. Tn thng sn sn: 1. au ti ch, bin dng lng ngc. 2. Khng thy tn thng trn Xquang do sn sn khng cn quang (tr ngi gi). 3. x tr ging nh gy xng sn. Khi sn tch ri khp th m c nh. IV. Gy xng c: 1. t gp. 2. Lm sng: au xng c, tng khi th su, ho. Nu gy xng c di lch th ng g ni ln mt trc Nn thy di ng khc thng.

xng c. 3. Xquang: chp xng c nghing. 4. X tr: 1) Khng di lch: Bt ng, gim au, phong b ti ch. K cao b vai 1 ti ct nh trn gy 2 3 tun.

2) Di lch: Gi tay ln u, n ngc ra trc n nh ch gy. Nu khng kt qu th m buc ch kim loi. Chn thng lng ngc. I. i cng: 1. Chn thng ngc v vt thng ngc l cc thng tn thng gp trong cp cu hng ngy. Nguyn nhn thng gp l do tai nn giao thng, tai nn lao ng, tai nn sinh hot, dao m. Cn trong chin tranh phn ln l do n, bom.

33

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

2. Chn thng ngc kn l mt trong nhng thng tn nng v nh hng 2 c quan quan trng l h hp v tun hon nn bnh nhn rt d t vong m nhng t vong ny phn ln ngay sau khi b thng. 3. Vic s cu ban u l rt quan trng nhm cu bnh nhn thot khi nhng ri lon nng v h hp v tun hon, to iu kin thi gian chuyn bnh nhn v tuyn iu tr thc th. 4. Nguyn tc iu tr l nhm phc hi thng bng sinh l h hp v tun hon, phc hi thng tn gii phu ng hng th yu, tr tn thng qu nng khng th phc hi c thng bng sinh l, lc mi bt buc phi can thip phu thut, ngha l c ch nh m ngc cp cu. Nh vy, phn ln cc chn thng ngc v vt thng ngc khng cn m ngc cp cu x tr cc thng tn bn trong. II. Sinh l thng bng h hp da vo 3 yu t chnh: 1) Bao gm khung xng, c h hp, c honh, l thnh mng phi. Thnh ngc ny va vng chc li va di ng trong khi th. 2) C honh ng vai tr ht sc quan trng, nht l tr em. Khi bng chng gy chn p d dn n suy h hp. 2. ng h hp: 1) T mi, ming, qua kh ph qun vo n ph nang. ng h hp phi thng thong bo m trao i kh c tt. 2) Trong chn thng ngc, ng h hp ny d b cn tr do dch tit tng ln, mu chy vo hoc do d vt v 1 iu quan trng hn l do au m bnh nhn khng ho khc tng ra ngoi. 3. Khoang mng phi: L khoang gia 2 mng phi l thnh v l tng. Bnh thng do 2 l st vo nhau nn thc 34 1. Thnh ngc:

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

t n l mt khoang kn v o, duy tr p lc m so vi p lc kh quyn: - 10 - 5 cmH2O lm cho phi n ra. Khi khoang ny b thng, c trn kh hoc dch mu vo, p lc m ny s mt, phi khng n ln c na gy nhng ri lon quan trng trong khi th. Ba yu t trn lin quan trc tip vi nhau. Bnh thng nhng thng s v h hp l: pH = 7,4 7,42; pO2 = 80 100mmHg; pCO2 = 35 40 mmHg; BE = 2; SB = 24 mEq. Trong chn thng ngc, nguyn tc x tr l lp li thng bng sinh l h hp, do cn phi nm vng cc yu t trn t kt qu trong iu tr.

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