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S Y T CNG HA X HI CH NGHA VIT NAM BNH VIN KTT c lp T do Hnh phc AN GIANG

PHC IU TR

KHOA HI SC TCH CC (ICU)

DUYT HI NG KHCN TRNG KHOA CH TCH

TS BS NGUYN NGC RNG BSCK2 PHM NGC TRUNG

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MC LC

Trang

CP CU NGNG TUN HON C BN ........................... 4

CP CU NGNG TUN HON NNG CAO ..................... 8

SC PHN V ......................................................................... 13

SC NHIM TRNG ............................................................... 15

NHI MU C TIM CP ....................................................... 18

XUT HUYT NO ................................................................ 20

T QU THIU MU NO CP ....................................... 22

CHN THNG S NO NNG ......................................... 25

CO GIT V NG KINH NGI LN ......................... 27

PH PHI CP ........................................................................ 28

CN HEN NNG V NGUY KCH ...................................... 29

T CP BNH PHI TC NGHN (COPD) .................... 32

VIM PHI ............................................................................... 34

VIM PHI BNH VIN ........................................................ 38

VIM TY CP ....................................................................... 41

XUT HUYT TIU HA TRN .......................................... 43

HN M GAN .......................................................................... 45

NHIM CETON ACID V TNG P LC THM THU . 47

TRN BNH NHN I THO NG ............................ 47

IU TR CN BO GIP TRNG ...................................... 51

SUY THNG THN CP .................................................... 53

SUY THN CP TRONG HI SC ....................................... 55

CC CH NH LC MU LIN LC.................................. 57

H NATRI MU ...................................................................... 58

TNG NATRI MU ................................................................. 60

RI LON KALI MU ........................................................... 61

RI LON THNG BNG KIM TOAN ............................. 63

PHN TCH KT QU KH MU NG MCH ............... 65

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CC BC C KT QU KH MU ................................ 66

NGUYN TC X TR NG C ........................................ 68

NG C PHOSPHO HU C ............................................. 72

NG C OPIUM ................................................................... 74

NG C METHANOL .......................................................... 75

NG C THUC NG ......................................................... 77

NG C THUC DIT CHUT ......................................... 79

NG C PARAQUAT .......................................................... 82

ONG T .................................................................................. 85

RN C CN ........................................................................ 87

IU TR RN LC TRE CN .............................................. 92

NG C C T CA CC ............................................... 94

BNG NGI LN ................................................................. 95

K THUT T NG THNG BLAKEMORE ................... 98

O HUYT P NG MCH XM LN ........................... 99

KHNG SINH TRONG SC NHIM TRNG .................... 102

PHNG CHNG LOT D DY T TRNG ................... 104

DANH MC THUC KHOA HI SC ............................... 105

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CP CU NGNG TUN HON C BN

I) i cng: Hi sinh tim phi cn c bt u ngay lp tc sau bnh nhn ngng tun hon. Kh nng cu sng bnh nhn ngng tim ph thuc ch yu vo kh nng v k nng ca kp cp cu. Sc in cp cu ph rung tht s c hiu qu nht nu c thc hin trong vng 5 pht u sau ngng tim. Hi sinh tim phi kt hp sm vi sc in sm trong vng 3 n 5 pht u tin sau khi ngng tun hon c th t t l cu sng ln n 50% - 75%. II) Chn on: 1) Chn on xc nh: mt thc t ngt, ngng th, mt mch cnh. 2) Chn on phn bit: - Phn bit v tm thu vi rung tht song nh: xem ECG trn t nht 2 chuyn o - Phn bit phn li in c vi sc, try mch: cn bt mch 2 v tr - Phn bit mt mch cnh/mch bn do tc mch: bt mch 2 v tr 3) Chn on nguyn nhn: Song song vi cp cu HSTP c bn, cn nhanh chng tm kim nguyn nhn gy NHT gip cp cu c hiu qu v ngn nga ti pht. Cc nguyn nhn thng gp v c th iu tr nhanh chng:

Bng 1. Nguyn nhn ngng tun hon thng gp 11T trong ting Vit 6H trong ting Anh 12T trong ting Vit 5T trong ting Anh

Thiu th tch tun hon Hypovolemia Trng c cp Toxins

Thiu oxy m Hypoxia Tamponade tim Tamponade (cardiac)

Toan mu Hydrogenion(acidsis) TK mng phi p lc Tension pneumothorax

Tng/tt kali mu Hyper/Hypokalemia Tc mch vnh, tc mch phi

Thrombosis (coronary

and pulmonary)

Tt h ng huyt Hypoglycemia Thng tch Trauma

Thn nhit thp Hypothermia

III) X tr cp cu: - X tr cp cu NTH c khi ng t khi pht hin trng hp nghi ng NTH. Ngi cp cu va tin hnh chn on, gi ngi h tr va bt u cc bin php HSTP c bn ngay. - Cn c 1 ngi ch huy, t chc cp cu ng trnh t v ng b - Cn ghi chp cc thng tin cn thit v cp cu - Khng gian cp cu rng v hn ch ti a cc nhn vin hoc nhng ngi khng tham gia cp cu. 1) Tin hnh ngay HSTP c bn (ABC) ng thi gi h tr khi nghi ng b NTH (khng c ng, khng phn ng khi lay gi). a) Kim sot ng th: t nga u, c n, th thut ko hm di/nng cm.

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Cn t NKQ cng sm cng tt nhng khng c lm chm sc in v khng lm gin on p tim/thi ngt qu 30s. b) Kim sot v h tr h hp: bp bng Nu bnh nhn khng th: bp bng 2 ln lin tip, sau k tra mch: - Nu c mch: tip tc bp bng - Nu khng c mch: thc hin chu k p tim/bp bngtheo t l 30/2 - Nhp th nhn to (bp bng) lm cho lng ngc phng ln nhn thy c vi tn s nhp l 10-12 ln/pht i vi ngi ln. - Sau khi c ng th nhn to (ng NKQ) tn s bp bng l 8-10 ln/pht v p tim 100 ln/pht, khngngng p tim. Ni oxy vi bng ngay khi c oxy c) Kim sot v h tr tun hon: p tim ngoi lng ngc - Kim tra mch cnh (hoc mch bn) trong vng 10 giy. Nu khng thy mch tin hnh p tim ngay. - p tim di xng c, ln 1/3-1/2 ngc (4-5 cm vi ngi ln) s thy mch khi p, tn s 100 ln/pht. Phng chm l p nhanh, p mnh, khng gin on v ngc phng ln ht sau mi ln p. - T l tim/thng kh l 30/2 - Kim tra mch trong vng 10 giy sau mi 5 chu k p tim/bp bng hoc sau mi 2 pht (1 chu k p tim/bp bng l 30/ 2). 2) Ghi in tim sm ngay khi c th v sc in ngay khi c ch nh a) Nhanh chng ghi in tim v theo di in tim trn my theo di Phn loi 3 loi ECG: rung tht/nhp nhanh tht, v tm thu, PL in c b) Tin hnh sc in ngay khi c rung tht My sc in: My sc in 2 pha: 120 200J Tin hnh ngay 5 chu k p tim/bp bngsau mi ln sc in. 3) Cc thuc cp cu NTH (xem bng 2) IV) Phng bnh NTH thng xy ra t ngt, khng d on trc c. Tt c cc nhn vin cp cuphi c tp luyn v chun b sn sng cp cu. Cn trang b phng tin v thuc cp cu cn thit.

Bng 2. Cc thuc cp cu NTH

Thuc Liu tim TM Liu ti a Liu qua NQK

Ch nh chnh

Adrenalin 0,1% 1mg/3-5pht/ln 2-2,5mg Cc loi NTH

Amiodaron 300mg 2,2g/24gi Rung tht tr

Atropin 0,1% 1mg/3-5pht/ln 3mg 3mg Nhp chm. V tm thu

Magiesulfat 15% 1-2g Xon nh

Lidocain 2% 1-1,5mg/kg 3mg/kg 2-4mg/kg Rung tht

Vasopressin 40UI (1 ln duy nht)

Rung tht tr

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Phc HSTP c bn NTH (BIS algorithm)

S thy mch p

Khng s thy mch p

Kim tra nhp tim

Nn nhn nghi ng b NTH (khng c ng hay khng p ng khi lay gi)

Nu bnh nhn khng th, tin hnh TKNT (bp bng) 2 nhp, lm ngc phng ln

Khai thng ng th (A); kim tra bnh nhn c cn nhp th hay khng (B)

Nu khng p ng, kim tra xem bnh nhn cn mch (C) hay khng: thi

gian xc nh mch trong vng 10 giy

Tin hnh 1 nhp bp bng sau mi 5-6 giy. Kim tra li mch

sau mi 2 pht

Tin hnh cc chu k gm 30 ln p tim v 2 ln bp bng, chun b my sc in Ch : p tim mnh v nhanh (100 ln/pht) v nhc tay hon ton khi thnh ngc sau mi

ln p. Hn ch ti mc ti thiu cc thao tc gy gin on quy trnh p tim ngoi lng ngc

Kim tra ECG trn monitor hay trn my sc in

Nhn nh nhp cn sc in hay khng?

Sc in 1 ln tin hnh ngay 5 chu k p tim-bp

bng

Tin hnh ngay 5 chu k p tim-bp bng. Kim tra li mch sau mi chu k p tim-bp bng. Tin hnh

lin tc quy trnh ny ti khi nn nhn c ng tr li.

Gi ngay e kp cp cu

v yu cu thm ngi h tr.Mang my sc in n

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Tm tt k thut hi sinh tim phi c bn (BLS) ABCD Cho tr nh nhi, tr nh, ngi ln (khng gm tr mi )

K thut Ngi ln v tr ln

Tr nh(1 n 8tui)

Tr nh nhi

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CP CU NGNG TUN HON NNG CAO

I) i cng: HSTP c bn (BLS) gip duy tr dng mu tuy nh nhng v cng quan trng cho no v tim. HSTP nng cao (ACLS) nhm kim sot ti mu no v tim tt hn na v nhanh chng ti lp li tun hon v quan trng nht l tin hnh sc in cng sm cng tt. Sc in cp cu ph rung tht s c hiu qu nht nu c thc hin trong vng 5 pht u sau ngng tim. HSTP kt hp vi sc in sm trong vng 3-5 pht u tin sau khi NTH c th t t l cu sng ln n 50%-75%. II) Chn on: 1) Chn on xc nh: Chn on xc nh: mt thc t ngt, ngng th, mt mch cnh 2) Chn on phn bit: - Phn bit v tm thu vi rung tht song nh: xem ECG 2 chuyn o - Phn bit phn li in c vi sc, try mch: cn bt mch 2 v tr - Phn bit mt mch cnh/mch bn do tc mch:bt mch 2 v tr 3) Chn on nguyn nhn: Song song vi cp cu HSTP c bn, cn nhanh chng tm kim nguyn nhn gy NHT gip cp cu c hiu qu v ngn nga ti pht. Lu , 12 nguyn nhn thng gp v c th iu tr nhanh chng (xem quy trnh cp cu c bn NTH). III) X tr cp cu: - X tr cp cu NTH c khi ng ngay t khi pht hin trng hp nghi ng NTH - Cn 1 ngi l ch huy phn cng, t chc cp cu ng trnh t v ng b. - Cn ghi chp cc thng tin cn thit v tin trnh cp cu - Thit lp khng gian cp cu rng v hn ch ti a cc nhn vin hoc nhng ngi khng tham gia cp cu v lm cn tr cng tc cp cu. 1) Tin hnh ngay HSTP c bn (ABC), ng thi gi h tr khi pht hin bnh nhn b nghi ng b NTH (khng c ng, khng phn ng khi lay gi) (xem quy trnh cp cu c bn NTH). 2) Ghi in tim sm ngay khi c th v sc in ngay nu c ch nh a) Nhanh chng ghi in tim v theo di in tim trn my theo di. Nhn nh 3 dng in tim: rung tht/nhp nhanh tht, v tm thu, p li in c. b) Rung tht hoc nhp nhanh tht v mch - Tin hnh ngay HSTP c bn, t NKQ cng sm cng tt v m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo di ECG trn my monitor. Nu c lon nhp dng ngay thuc chng lon nhp. - Tin hnh sc in ngay: 120-200J (my sc in 2 pha). Tin hnh ngay 5 chu k p tim/thi ngt sau mi ln sc in. - Cc thuc dng trong x tr rung tht: adrenalin, amiodaron, magiesulfat, lidocain, vasopressin, procainamid.

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c) X tr v tm thu - V tm thu l tnh trng hnh nh sng in tim l ng thng nhng phi kim tra t nht 2 chuyn o khng nhm vi rung tht sng nh. - Tin hnh ngay HSTP c bn, t NKQ cng sm cng tt v m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo di ECG/ monitor. Nu c lon nhp dng ngay thuc chng lon nhp thch hp. - nh gi v tm kim tnh trng vn cn dng tun hon nhng yu (gi phn li in c) bng siu m tim lm nhanh ti ging - Nhanh chng tm kim cc nguyn nhn gy ra NTH (xem quy trnh cp cu c bn NTH) v x tr theo nguyn nhn. - Nu c th t ngay to nhp ngoi qua da - Cc thuc dng trong x tr phn li in c: adrenalin, atropine d) X tr phn li in c - Phn li in c l hnh nh c sng in tim nhng khng bt c mch cnh - Tin hnh ngay HSTP c bn, t NKQ cng sm cng tt v m bo thng kh c hiu qu. t ngay ng truyn tnh mch ln, theo di in tim trn my monitor nu c. Nu c lon nhp dng ngay thuc chng lon nhp thch hp. nh gi v tm kim tnh trng vn cn dng tun hon nhng yu (gi phn li in c) bng siu m tim lm nhanh ti ging. - Nhanh chng tm kim cc nguyn nhn gy ra NTH (xem quy trnh cp cu c bn NTH) v x tr theo nguyn nhn - Cc thuc dng trong x tr phn li in c: adrenalin, atropin (nu nhp tim chm), natri bicarbonat) truyn tnh mch nu c toan ha mu IV) Phng bnh: NTH thng xy ra t ngt, khng d on trc c. Tt c cc nhn vin cp cu, nhn vin y t cu h phi c tp luyn v chun b sn sng cp cu NTH. Cc xe cp cu, cc c s cp cu cn c phng tin v thuc cp cu cn thit cho cp cu NTH.

X TR CP CU NNG CAO I VI RUNG THT V NHP NHANH THT V MCH

BT U CC BC ABCD CA HI SINH TIM PHI C BN

(HSTP c bn + sc in kh rung) - nh gi p ng ca bnh nhn - Khi ng h thng cp cu ngng tim - Gi my kh rung A: ng th (Airway): p dng cc bin php khai thng ng th B: H hp (Breathing): tin hnh 2 nhp bp bng, mi nhp bp bng trong vng 1 giy C: Tun hon (Circulation): p tim ngoi lng ngc 30 ln p tim/2 ln thng kh ti khi chun b xong my sc in. D: Kh rung (Defibrillation): nh gi v tin hnh lm sc in nu c rung tht v nhp nhanh tht

v mch, nh gi 1 ln sc in (150-200J vi my sc in 2 pha).

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Rung tht v nhp nhanh tht vn tn ti hay ti pht?

C nhp trn in tim? Kh rung x 1 ln nh sc in 150250J

V tm thu Phc hi li tun hon t nhin

Tin hnh ngay tr li HSTP c bn x 2

pht (30 ln p tim/2 ln thng kh)

(a) Cp bng chng: - Cp I: iu tr hay can thip lun c chp nhn, vi tnh an ton c chng minh v chc chn c li. - Cp IIa: Chp nhn c, an ton, hiu qu; iu tr chun hoc can thip c la chn - Cp IIb: Chp nhn c, an ton, hiu qu; c coi l iu tr chun, nhng ch l la chn

c xem xt hay canthip c thay th

Cn hot ng in nhng v

mch

- nh gi cc du hiu sinh tn - H tr ng th - H tr h hp - Dng thuc thch hp tr HA, tn s

tim v lon nhp

TIN HNH CC BC ABCD CA HSTP NNG CAO

(Thc hin cc nh gi v iu tr nng cao hn) A: ng th (Airway): t canun ng th, NKQ

B: H hp (Breathing): - m bo canun ng th t ng v tr bng khm lm sng v test khng nh - C nh tt canun, nn s dng cc thit b c nh canun ng th c chng - m bo tnh trng oxy ha v thng kh hiu qu C: Tun hon (Circulation): - t ng truyn tnh mch - Pht hin nhp tim v theo di trn minitor - Dng thuc chng lon nhp thch hp iu tr tnh trng lon nhp (nu c). D: Chn on phn bit (Differential diagnosis):tm kim v x tr nguyn nhn gy ngng tim c thiu tr c (12T).

Th nh li sc in 200-250J trong vng 30-60 giy

Adrenalin: 1mg tim TM nhanh (hoc 2-2,5 mg bm

qua ng NKQ) tim nhc li 3-5pht/ln

Xem xt dng thuc chng lon nhp: (a) - Amiodaron (IIb): 300mg TM nhanh (c th tim TM nhc li vi liu 150mg) - Lidocain (cha c khuyn co r rng): 1-1,5mg/kg TM nhanh hoc 2-4mg/kg bm qua NKQ (c th tim nhc li liu np 0,5-0,75mg/kgx3-5pht/ln ti tng liu 3mg/kg) - Magiesulfat (IIb): nu c gim Mg mu v nhp nhanh tht a dng (xon nh) 1-2g tim TM - Procainamid (IIb): iu tr rung tht v NNT ti pht tng lc: 20-50mg/pht, ti tng liu 17mg/kg

Xem xt dng natribicarbonat: iu tr tng kali mu, toan mu c t trc, mt sng cthuc

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X TR CP CU NNG CAO I VI TNH TRNG C HOT NG IN SONG KHNG C MCH

Tnh trng c hot ng in song v mch (Pulseless Electrical Activity PEA) (C nhp tim trn mn monitor song khng bt c mch)

PEA bao gm cc loi nhp: - Phn li in c (Electromechanical dissociation (EMD)) - Gi phn li in c (Pseudo EMD) - Cc nhp t tht - Cc nhp thot tht - Nhp chm v tm thu (Bradyasystolic rhythms)

- Cc nhp t tht xy ra sau sc in kh rung tim (Postdefibrillation idioventricular rhythms)

Pht hin (v x tr) cc nguyn nhn thng gp gy tnh trng cn hot ng in song v mch (12T)

Thiu th tch tun hon (truyn dch) Tc mch vnh hay nhi mu c tim cp rng

Thiu oxy m (th O2, th my) Trn kh mng phi p lc (Chc gim p mng phi)

Toan mu (Truyn bicarbonat) (b) Trn dch mng ngoi tim gy p tim cp Chc dch

Tng kali mu (CaCl2,) v tt gim kali mu (truyn kali)

Trng c do qu liu thuc hoc do ung nhm cc thuc nh tricyclic, digitalis, chn beta giao cm

Tt h ng huyt Tc mch phi ln (phu thut, thuc tiu huyt khi)

Thn nhit thp Thng tch

Tin hnh cc bc ABCD ca HSTP nng cao (thc hin cc nh gi v iu tr nng cao hn) A: ng th (Airway): t canun ng th (NKQ) cng sm cng tt B: H hp (Breathing): - m bo canun ng th ng v tr bng khm lm sng v test khng nh - C nh tt canun, nn s dng cc thit b c nh canun ng th c chng - m bo tnh trng oxy ha mu v thng kh c hiu qu C: Tun hon (Circulation): - t ng truyn TM - Pht hin nhp tim v theo di trn mn monitor

- Dng thuc chng lon nhp thch hp iu tr tnh trng lon nhp (nu c)

- nh gi v tm kim tnh trng vn cn dng tun hon d yu (tnh trng gi phn li in c) (a)

Bt u cc bc ABCD ca HSTP c bn (HSTP c bn + sc in kh rung) 1) nh gi p ng ca nn nhn 2) Khi ng h thng cp cu ngng tim 3) Gi my sc in A: ng th (Airway): p dng cc bin php khai thng ng th B: H hp (Breathing): tin hnh 2 nhp bp bng, mi nhp bp bng trong vng 1 giy

C: Tun hon (Circulation): p tim ngoi lng ngc, tin hnh 30 ln p tim/2 ln bp bng

D: Kh rung (Defibrillation): nh gi v sc in nu c rung tht v nhp nhanh thtv mch

Adrenalin: 1mg tim TM nhanh, dng nhc li 3-5 pht/ln (c)

Atropin 1mg TM (nu tn s tim chm). Tim nhc li 3-5 pht/ln nu cn, n khi t tng liu 0,04mg/kg

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X TR CP CU NNG CAO I VI V TM THU

Ti liu tham kho: AHA Guideline for CPR and ECC, Circulation 2005

V TM THU

BT U CC BC ABCD CA HSTP C BN (HSTP c bn + sc in kh rung) - nh gi p ng ca bnh nhn - Khi ng h thng cp cu ngng tim - Gi my kh rung A: ng th (Airway): p dng cc bin php khai thng ng th B: H hp (Breathing): tin hnh 2 nhp bp bng, mi nhp bp trong vng 1 giy C: Tun hon (Circulation): p tim ngoi lng ngc: tin hnh 30 ln p tim/2 ln bp bng Khng nh li chc chn bnh nhn c tnh trng v tm thu D: Kh rung (Defibrillation): nh gi v sc in nu c rung tht v nhp nhanh tht v mch Tm kim nhanh ngay ti hin trng bng chng cho quyt nh khng cn tin hnh cp cu (a)

TIN HNH CC BC ABCD CA HSTP NNG CAO (Thc hin cc nh gi v iu tr nng cao hn)

A: ng th (Airway): t canun ng th (vd NKQ) cng sm cng tt B: H hp (Breathing): - m bo canun ng th t ng v tr bng khm lm sng v test khng nh - C nh tt canun, nn s dng cc thit b c nh canun ng th c chng - m bo tnh trng oxy ha mu v thng kh c hiu qu C: Tun hon (Circulation): - t ng truyn TM - Pht hin nhp tim v theo di trn mn monitor - Dng thuc chng lon nhp thch hp iu tr tnh trng lon nhp (nu c) - nh gi v tm kim tnh trng vn cn dng tun hon yu (tnh trng gi phn li in c)

D: Chn on phn bit: tm kim v x tr nguyn nhn gy ngng tim c thiu tr c

To nhp qua da (nu c th thc hin c, cn tin hnh

ngay) (b)

Adrenalin 1mg tim nhanh TM (2-2,5mg bm qua ng NKQ)

Tim nhc li 3-5 pht/ln (c)

Atropin 1mg TM (hoc 2-2,5mg bm qua ng NKQ)

Tim nhc li 3-5 pht/ln n khi t ti tng liu 0,04mg/kg

Tnh trng v tm thu vn tip din

Cn nhc ngng cp cu khi: - Tin hnh cp cu ng nhng khng t kt qu - Khng phi l bnh nhn b ngt nc hoc h thn nhit - Khng tm thy nguyn nhn c th phc hi hoc khng phi l bnh nhn ng c cp

- tiu chun ngng cp cu theo phc cp cu ti c s

Trong : (a): nh gi cc ch s lm sng ch dn khng cn ch nh cp cu (du hiu chng t bnh nhn t vong) (b): t my to nhp khng c khuyn co ch nh thng quy iu tr v tm thu ngoi tr trong cc trng hp c chn lc nh v tm thu xy ra trong qu trnh lm th thut

(c): Adrenalin 1mg TM 3-5 pht/ln. Nu khng c hiu qu, c th dng liu cao hn (ti 0,2mg/kg) nhng khng

c Hi Tim Mch Mkhuyn co.

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SC PHN V

I) TRIU CHNG: Ngay sau khi tip xc vi d nguyn hoc mun hn, xut hin:

Cm gic khc thng (bn chn, ht hong, s hi . . .) tip xut hin triu chng 1 hoc nhiu c quan.

Mn nga, ban , my ay, ph Quincke.

Mch nhanh nh kh bt, huyt p tt c khi khng o c.

Kh th (kiu hen, thanh qun), nght th.

au qun bng, tiu tiu khng t ch.

au u chng mt, i khi hn m.

Chang vng, vt v, giy gia, co git. II) X TR:

A. X tr ngay ti ch:

1) Ngng ngay ng tip xc vi d nguyn (tim, ung, nh mt).

2) Cho bnh nhn nm ti ch.

3) Thuc: Adrenaline l thuc c bn chng sc phn v

Adrenaline dung dich 1/1000 ng 1ml = 1mg, TDD hoc TB ngay sau khi xut hin sc phn v vi liu nh sau:

+ 1/2 - 1 ng ngi ln.

+ Khng qu 0,3ml tr em (ng 1mg/1ml+9ml nc ct=10ml tim 0,1ml/kg)

+ Hoc Adrenaline 0,01mg/kg cho c tr em ln ngi ln.

Nu sau tim adrenalin 1mg/5 pht m khng bt c mch quay th c tim adrenaline 0,3-0,5mg/ln/5 phtcho n khi bt c mch th chuyn sang truyn tnh mch lin tc.

m, u thp chn cao, TD huyt p 10-15pht/ ln (nm nghing nu c nn).

Nu sc nng e da t vong, ngoi ng TDD c th tim Adrenaline dung dch 1/10,000 (pha long 1/10) qua tnh mch, ng NKQ, qua mng nhn gip.

B. Cc x tr khc:

1) X tr suy h hp: ty theo tnh trng bnh nhn

- Th Oxy mi, oxy ti - Bp bng Ambu c oxy

- t ng ni kh qun, thng kh nhn to, m kh qun

2) Tun hon

- t ng truyn TM (ngoi bin, trung tm hoc TM i)

- Natriclorua 0.9% 12 lt truyn TM ngi ln/30-120 pht

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- Adrenalin truyn tnh mch lin tc bt u bng 0.1 g/kg/pht chnh liu sao cho huyt p tm thu > 90mmHg (khong 2mg Adren-aline/gi cho ngi ln 55kg).

2) Cc thuc khc:

- Methylprenisolone 12mg/kg/4gi hoc Hydrocortisone 5mg/kg/gi TTM. Dng liu cao hn nu sc nng (gp 2 5 ln).

- Promethazine (pipolphen) 50mg/2ml 1/2 1 ng TB hay tnh mch.

C th dng:

- Terbutaline 0.5mg, 01 ng tim di da ngi ln v 0.2ml/10kg em. Tim li sau 6 8 gi nu khng kh th.

- Xt hng, kh dungterbutaline, salbutamol nu c kh th hoc phi hp thm aminophylin truyn bolus tnh mch.

3) iu tr phi hp:

- Ung than hat 1g/kg nu d nguyn qua ng tiu ha.

- Bng p chi pha trn ch tim hoc ng vo ca nc c.

Ch : - Theo di bnh nhn t nht 24gi sau khi huyt p n nh.

- Sau khi s cu nn tn dng ng tim tnh mch i (v tnh mch to nm pha trong ng mch i, d tm).

- Nu huyt p vn khng ln sau khi truyn dch v Adrenaline th c th truyn thm huyt tng, Albumin (hoc mu nu mt mu) hoc bt k dung dch cao phn t no c sn.

- iu dng c th s dng Adrenaline TDD, TB theo phc khi bc s khng c mt.

- Hi k tin s d ng v chun b hp thuc cp cu sc phn v trc khi dng thuc l cn thit.

NI DUNG HP THUC CP CU CHNG SC PHN V (Km theo thng t s 08/199- TT BYT, ngy 04 thng 05 nm 1999) Cc khon cn thit trong hp chng sc (tng cng: 07 khon) 1. Adrenaline 1mg 1mL 2 ng 2. Nc ct 10 mL 2 ng 3. Bm tim v khun (dng mt ln): 10mL 2 ng; 1mL 2 ng 4. Hydrocortisone 100mg hoc Methyprednisolon 40mg 02 ng 5. Phng tin kh trng(bng, bng, gc, cn) 6. Dy garo.

7. Phc cp cu sc phn v. Li khuyn cho cc D: -Trc khi cho BN dng thuc phi khai thc tin s d ng ca BN. - Khng nn truyn, pha bt k thuc l nu cha r ngun gc - Truyn v tim chm khng nn vi v kt hp theo di ngi bnh -Th phn ng trc khi dng thuc v lun mang theo hp chng sc bn cnh xe tim truyn.

15

15

SC NHIM TRNG

I. i cng 1. Hi chng p ng vim ton thn (SIRS) khi c 2 hay nhiu yu t: - Nhit c th > 38oC hoc < 360C - Nhp tim > 90l/ph - Th nhanh > 20 l/p hoc PaCO2< 32mmHg - Bch cu trong mu > 12.000/mm3 hoc < 4.000/mm3 hoc c s hin din > 10% bch cu non. 2. Nhim trng huyt: nhim trng + SIRS 3. Nhim trng huyt (NTH)nng Nhim trng huyt + Ri lon chc nng c quan ch (ARDS, hoi t ng thn cp, ri lon tri gic, DIC, vim gan cp, dn d dy, lit rut). 4. Sc nhim trng: NTH + Tt HA (HAMax< 90mmHg hoc gim 40mmHg so vi gi tr bnh thng trc ) mc d b dch, km vi bt thng ti mu (toan mu nhim acid lactic, thiu niu, RL tri gic).

II. Chn on 1. Lm sng

- TT sc: HAMax

16

16

1. iu tr tnh trng sc - Mc ch cn t l: + Phi nhanh chng khi phc tnh trng huyt ng n nh + iu chnh ri lon chc nng c quan do tnh trng sc gy ra + Yu t thi gian quan trng, phi a HA v CVP ln trong gi u -Mc tiu iu tr chong trong 6 gi u l: + CVP 8-12 mmHg (10-16cmH20) + HATB> 65 mmHg

+ Nc tiu >0,5ml/kg/gi + SvO2> 70% + Hb >8-10g/dl + Nhp tim, nhp th gim + pH tr v bnh thng, lactate mu gim - Cc bin php chung + t bnh nhn nm t th u thp + Th oxy mi hoc oxy ti + t hai ng truyn tnh mch ln vi kim 16-18 ( truyn nhanh) + t catheter TM trung tm, giCVP mc 10-16cmH2O. + Theo di nc tiu mi gi + TD lin tc M, HA, SpO2. Nn o HAMXL sm khi dng vn mch

2. Bi hon th tch dch - Truyn nhanh Natrichlorua 0,9% 20-30ml/kg (1-2lt)/1-2gi duy tr huyt p hoc truyn nhanh 500ml dung dch cao phn t (Haes-steril6%) trong 20 pht. Nu HA cn thp cn t CVC, b dch theo CVP.

3. Thuc vn mch Khi CVP 10-16 cmH20 m HAMax 90mmHg (hoc HATB< 65mmHg) - Noradrenaline: 5-20g/p, tng mi 5 pht,mi ln 0,5-1g/pht - Dopamin: 5-20g/kg/p, tng mi 5 pht, mi tng ln 2,5-5g/kg/pht - Nu Bn khng p ng phi hp thm Dobutamin: 5-20g/kg/pht * Nu phi hp 3 thuc vn mch trn m HA vn thp hay khng n nh c th dng Adrenaline: 0,1-20g/pht, tng mi ln 0,5-1g/pht.

Theo di huyt ng ngng can thipHuyt ng n nh 4gi Huyt p ng mch trung bnh (HATB) >70mmHgS thay i p lc mch p (VPP) 70%

Khng c du hiu gim ti mu mi

HATB 70 mm Hg

S thay i p lc mch p+ (Siu m tim)

VPP 13%

Ngng can thipTr li giai on trc

Th nghim truyn dch250 mL gelatines/15 ph

VPP >13%

HATB > 70 mm Hg

Ngng Noradrenaline Gim 0,1 mg/gi mi 15 pht

Kipnis E et al. Reanimation 2010:19;146-53

17

17

4. T nhim trng bng khng sinh thch hp v phu thut (nu cn) - La chn khng sinh da vo + ng vo ca nhim trng + Kt qu nhum gram bnh phm + TT min dch ca bnh nhn + S dng thuc khng sinh

Ngun nhim khun Khng sinh la chn Khng sinh thay th

Khng r ngun gc Meropenem 1g IV/8g x 2w Hoc imipenam 0,5g/6g

Cipro 0,4g/12g x2w

hoc Levo 0,5/24g x 2w kt hp Metro 0,5g/12g

Vimphi cng ng

VP bnh vin

Levo 0,75g/24g x 2w

Hoc ceftriaxon 1g/24g x2w Xem vim phi bnh vin

Cefepim 2g/12g x2w

Nhim trng ng truyn tm trung tm Nghi ng MRSA

Meronem 1g/8gx2w

Hoc cefepim 2g/12gx2w Vanco 1g/12g x 2w

Ceftriaxon 1-2g/24gx2w

Hoc levo 0,75g/24gx2w

Nhim trng bng Meropenem 0,5g/8g x2w Hoc imipenam 0,5g/6g

Ceftriaxon or Levo x 2w

kt hp Metro 0,5g/12g

NT niu dc Cipro hoc levofloxacin Hoc imipenam x1-2w

Cefepim 2g/12gx1-2w

nh gi li sau 48-72gi sau khi bt u iu tr S dng khng sinh liu cao, ng tnh mch ngay trong gi u.

- Gii quyt nhim trng: p xe, si mtCh catheter, thng tiu 5. Corticoid: S dng Steroid bnh nhn p ng km mcd phi dng vn mch v b dch, hoc bnh nhn ph thuc corticoid, liu Hydrocortison 50mg mi 6 gi trong 5-7ngy. 6. Kim sot ng mu: Duy tr ng mu 7-9mmol/l V. Theo di:

- TD Monitoring (M, HA, To, SpO2/15-30pht 1gi trong 24gi u)

- Lng nc tiu, CVP/1-3gi/24gi u - Nc tiu, tri gic, du hiu xut huyt/3gi theo tnh trng bnh - KMM, Ure, Creatinin, Ion , lactate, ECG/ngy theo tnh trng bnh

18

18

NHI MU C TIM CP

I. Chn on: 1. Tiu chun: Khi c t nht 2 trong 3 tiu chun:

1.au ngc kiu mch vnh 2. Bin i ng hc ECG 3. Tng men tim: - Troponin T: tng sau 3-12 gi, t nh 24-48 gi, sau 5-14 ngy.

- CK-MB: tng sau au ngc 3-12 gi, t nh 24 gi, bt sau 48-72 gi 2. Phn Killip:

3. im nguy c TIMI cho hi chng mch vnh cp

1 Tui > 65

2 Tin s hp MV >50%

3 C 3 YTNC ca bnh MV: THA, tng cholesterol mu, tin s gia nh c bnh MV, ang ht thuc l, T

4 dng aspirin trong vng 7 ngy qua

5 ST chnh xung trn ECG

6 Tng men tim

7 C 2 cn au tht ngc xy ra lc ngh trong vng 24 gi qua

- Nu 2 YTNC: Bnh nhn thuc loi nguy c thp - Nu 3-4 YTNC: Bnh nhn thuc nhm nguy c trung bnh - Nu >4 YTNC: Bnh nhn thuc nhm nguy c cao

II. iu tr 1. Cc bin php chung iu tr ban u: a. Bnh nhn phi c bt ng ti ging b. Th oxy mi 2-4l/pht c. Gim au: - Morphin sulfat 0,5-1 ng TM mi 5-10 pht cho ti khi kim sat c cn au hoc xut hin tc dng ph (tut HA, bun nn, nn; cng i giao cm) - Nitroglycerin: BT khi u 10/pht (1ml/gi) (3ng Nitroglycerin 10mg/10ml pha 20ml NaCl 0,9%) tng dn mi 5 pht ln 16-30g/pht hoc khi kim sat c cn au (phi theo di st mch v huyt p). ** Chng ch nh:+ HA max110l/ph hoc chm

19

19

f. Thuc c ch Bta - S dng Metoprolol 25-50mg mi 6-12 gi, hoc Atenolol, Bisoprolol ** Chng ch nh: + Suy tim nng + HA tm thu < 90mmHg + Nhp tim < 60 l/ph+ Block A-V + Bnh co tht ph qun nng g. Cc thuc khc

- Thuc c ch men chuyn, c ch AT II: C th cho trong 24 gi u + Captopril 25mg -1 vin 2-3 ln/ngy; - Lisinopril 5mg 1-2 vin/ngy + Atovastatin, rosuvastatin 10mg: liu u 4 vin, ngy sau 1 vin/ngy h. Cc thuc chng lan nhp (nu c), thuc vn mch (Dopamin, Dobutamin, Noradrenalin) nu cn. 2. tr ti ti mu mch vnh bng tiu si huyt (NMCT STchnh ln) - Dng thuc tiu si huyt, dng trc 6 gi t lc au ngc. - Streptokinase 1,5MUI / 1 l pha trong 100ml NaCl 0.9% TTM xxx git/pht. ** Lu + Phn ng d ng: ni mn da v st+ Tt HA Do phn ng sn xut khng th chng Streptokinase sau khi dng, BN dng th ch c dng li sau 10 nm. * Chng ch nh tuyt i: - Tin cn XH no - D dng ng tnh mch, phnh mch no - U no - t qu thiu mu < 3 thng, ngoi tr 3 gi u - Tng HA khng kim sot c: HA tthu > 180 mmHg, HA ttrng > 110 - Bc tch ng mch ch - Chn thng u, mt nng trong vng 3 thng - Vim mng ngoi tim cp- Chy mu tng - Mang thai * Chng ch nh tng i: - Tin cn d ng vi Streptokinase hoc anistreplase - Lot d dy - Chy mu trong 2-4 tun - t qu thiu mu > 3 thng - i phu < 3 tun- Chy mu kinh nguyt nhiu - Tc chy mu ni nhn

3. iu tr h tr: - S dng thuc chng nn nu c - Khng khuyn co s dng thuc c ch knh Canxi - S dng pantoprazol, c ch th th H2/bnh nhn c nguy c XHTH cao - Dinh dng: n long, m, nhiu ln trong ngy; khng BN b bn. - S dng an thn nu cn III. Theo di:

- Mc monitoring theo di M, HA, SpO2, ECG, nhp tim . TD au ngc - Men tim v ECG mi 6 gi trong 24 gi u, sau mi ngy - Theo di cc bin chng. Ti liu tham kho:

1.V Thnh Nhn, iu tr nhi mu c tim cp, iu tr hc ni khoa trng ai hc y dc tp HCM, Nh xut bn y hc 2009, trang 73-85. 3. Angela L. Brow, Acute coronary syndrome-Unstable angina and Myocardi-

al infarction,The Washington Manual of Medical Therapeutics, 33nd

Edition,

p112-154.

3. Chritopher P. Cannon, Eugene Brauwald; Elliott M. Antman, Unsta-

ble angina and ST-Elevation_Non-Elevation Myocardial infarctionHarrison's

Principles of Internal Medicine, 17th

Edition, p1527-1544.

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20

XUT HUYT NO

I. Nguyn nhn:

- Do tng huyt p - XH no sau nhi mu no - Chn thng u - U no di cn - Bnh l RL ng cm mu hoc do gim s lng tiu cu, do thuc khng ng, thuc chng kt tp tiu cu. - Thuc gy nghin- Dn mao mch - D dng, v ti phnh, u mch TM hang, d ng-tnh mch mng cng. - Bnh mch mu no: thoi ha dng bt, vim ng mch no

II. Chn on: 1. Lm sng: - Xut hin t ngt vi giy n vi pht - C th c tin triu: au u d di, nn i - Ri lon thc t ngt v nhanh chng i vo hn m - Du hiu thn kinh khu tr, hi chng mng no nu c xut huyt no-

mng no, ph no, ri lon thn kinh thc vt. - Soi y mt c th c xut huyt vng mc, ph gai th.

- Ch cc yu t nguy c: THA, T, tng Lipid mu, bnh c tim,

bnh van tim, NMCT, lon nhp tim, RL ng mu, bnh l tc mch

mu ngoi bin...Giy ra vin trc y, cc thuc ang dng (nu c).

2. Cn lm sng: - CT-scan, MRI u c gi tr chn on quyt nh - XN chung: CTM, glycemie, ure, creatinin, ion , Bilan lipid mu, TQ,

TCK, KMM, X-quang tim phi, ECG, TPTNT, chc d DNT (nu nghi ng xut huyt di nhn m CT m tnh).

III. iu tr chung: 1. Chm sc ng th: gi thng ng h hp - Nm u cao 300 - Th oxy 2-5 l/ph

- Duy tr PaCO2 30 35 mmHg- Xt ch nh t NKQ

2. iu tr tng thn nhit: duy tr T0 < 380 C - Lau mt tch cc - Paracetamol 0.5 0.65g / 6h ung hoc truyn 1g mi 6 gi khi st

3. Kim sot ng huyt: theo phc - Khi glycemie > 200 mg% (11.2 mmol/L) cn iu chnh bng insulin - Duy tr glycemie 120 150 mg% ( 7 8 mmol/L)

4. D phng XHTH: thuc c ch bm proton hoc khng H2 (khi cn) 5. Nc in gii, nui dng v chm sc:

- Truyn 1- 2l NaCl0,9% trong 24 gi, nhng ngy sau ty theo lng nc tiu (khng dng dung dch nhc trng v dung dch c ng).

- iu chnh in gii theo ion , ch h kali mu (b 20-40mmol/d)

- Quan trng l nui n qua ng d dy(1300-1500 kalo/ngy) - Xoay tr, v lng, chng lot, v sinh rng ming. Trnh to bn.

6. n nh huyt p

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21

Duy tr HA tthu 160-180mmHg hay duy tr HA MTB 200mmHg hoc HA mtb > 150mmHg: + Nicardipin 5-10mg/gi (pha1 ng 50ml NaCl 0.9%, BT 25 50ml/gi) + Hoc thuc ung: c ch men chuyn hoc c ch th th Angiotensin, c ch , c ch Canxi (khng dng Nifedipin nh di li).

7. iu tr ph no v tng p lc ni s - Nng cao u ging 300 - An thn (Midazolam, Diazepam, Barbituric ) khi bnh kch thch, vt v. - Duy tr PaCO2 # 30-35 mmHg.

- Mannitol 20% liu 0.5 g/kg trong 20-30 pht, mi 4-6 gi 8. Bo v v dinh dng t bo thn kinh - Cerebrolysin 10ml: 10-60ml/24 gi (pha trong 50-100ml dd mui ng

trng v truyn chm ti thiu trong 20-50 pht). S dng trong 10-20 ngy. - Choline alfoscerate (Gliatilin, Atelin) 1-2g TMC/ngy x 4 tun.

IV. IU TR PHU THUT:

a.Khng ch nh phu thut:

-Xut huyt nh hay thiu st thn kinh nh.

- Bnh nhn c tnh trng hn m su (Glasgow 75

- Xut huyt su (hch nn, i th).

b.C th c ch nh phu thut:

- Nhng tn thng c triu chng, vi hiu ng chon ch, ph hay di lch

ln (>1cm) ng gia trn hnh nh hc.

- Khi mu t kch thc va 30 cc bn cu, 10cc bn cu tiu no.

- Biu hin tng p lc ni s mc d iu tr (iu tr ni khoa tht bi)

- Tnh trng bnh xu i- Bnh nhn cn tr

- V tr P thut thun li: thy no, tiu no, bao ngoi, bn cu khng tri

Ch nh phu thut cho xut huyt di lu: khi mu t tiu no> 3cm ng

knh (khng nn tr hon v lm lm sng xu i nhanh chng).

V. Yu t tin lng t vong: - Tui > 60 - Glasgow < 9 im (lc nhp vin ) - xut huyt > 80ml - Xut huyt no tht lng nhiu - Huyt p cao kh kim sot - Ri lon h hp- Ri lon thn nhit.

Ti liu tham kho 1. Nguyn Thi Hng (2008), Chy mu no t pht, Hng dn v x tr TMMMN, Nh xut bn y hc, trang 241-249.

2.V Anh Nh (2001), Thn Kinh Hc Lm Sng v iu tr, Tai Bin Mch Mu No.p 99 118.

3. Wade S. Smith, Yoey D. English, S. Claiborne Johnston,

Cerebrovascular Diseases, Harrisons Principles of Internal Medicine,17th Edition. p2513-2535.

22

22

T QU THIU MU NO CP

A. KHM THN KINH

- Khm thn kinh nhanh chng: Glasgow, NIHSS

-Bnh s: thi gian khi bnh, th t cc triu chng xut hin u tin, nhng than phin chnh, nhng ln t qu trc c v iu tr trc y.

-Cc YTNC: THA, T, tng Lipid mu, bnh c tim, bnh van tim, NMCT, lon nhp tim, ri lon ng mu, bnh l tc mch mu ngoi bin...

- Giy ra vin trc y, cc thuc ang dng (nu c)

-nh gi nhn thc, ngn ng, cc dy s, vn ng, cm gic.

B. DU THN KINH KHU TR

C. CN LM SNG

- CT scan (khng cn quang) hoc MRI ( ln 2 sau 24 gi)

- XN khc: in tm , cng thc mu, Ion , Glycemie, chc nng thn, gan, kh mu ng mch, m tiu cu, PT, aPTT, INR

D. IU TR

I. IU TR TNG QUT (khn cp) 1. H Hp: Bo m thng ng th - Th Oxy qua mi t 2-4 lt/pht, mc tiu SpO2 95-100%

- Xem xt t ni kh qun: - PO2 50-60 mmHg

Du hiu shh cp: Th nhanh >30 nhp/pht, s dng c h hp ph

Thay i thc quan trng -Nguy c ht sc - Mt duy tr n nh kh o.

2. St: Tin lng xu., dng thuc h st: Acetaminophen, lau mt 3. Nhp tim:NMCT v lon nhp tim c kh nng l bin chng ca t qu thiu

mu cp. LN thng gp nht l rung nh, c th c t t. Cn theo di st.

4. Huyt p: a. iu tr tng huyt p bnh nhn t qu chia thnh 2 giai on: Giai on cp cu: Cn bng gia gim HA gim nguy c tim mch lu di

v gim t vong vi kh nng gim HA qu mc s gy thiu mu no. iu tr lu di: Mun iu tr HA ti u phi da vo: Bn cht ca loi t

qu, bnh l km theo (tn thng tim, gan, thn) v NN gy ra t qu. - Theo di HA v ECG lin tc: Mi 15 pht: HA ttrng >140 mmHg, mi 30

pht, khi HA ttrng >110 mmHg v 1-3 gi khi HA tm trng 120 mmHg c km theo tn thng c

quan ch tin trin. Loi ny cn h HA ngay trong 1-2 gi u.

- THA cp cu: HA tm trng >120 mmHg khng km tn thng c quan ch. C th h HA trong vng 24 gi v bng ng ung.

c. Cc thuc h HA: - ng tnh mch: Nicardipine: 1-5 mg/30 pht, IV 1-10 mg/gi - ng ung: .Captopril 25 mg, lp li khi cn (lu : Tt HA, suy thn). Lisinopril, Enalapril: 5-10 mg, lp li khi cn hoc c ch ATII

23

23

d. Mc tiu h HA: (Bnh nhn khng dng thuc tiu si huyt) HA tthu 140 mmHg: Nicardipine liu khi u: 5mg/gi truyn tnh mch, tng 2,5 mg/5 pht cho n liu ti a 15 mg/gi vi mc tiu gim t 10-15% mc HA ban u.

Sau 24 gi, nhng bnh nhn ang dng thuc HA th bt u ung li thuc ang dng hay thay thuc chng tng HA ng ung khc.

- iu tr lu di: Sau giai on cp (khong 7 ngy) iu tr lu di. + Hu ht bnh nhn dung np tt vi gim HA t t xung 140/85 mmHg

+ Tng HA tm thu cn gim HA xung

24

24

-Thuyn tc phi: 1-3% thng vo tun2, ngn nga bng vt l tr liu, v p, chn chn on bng CT phi, dng Heparine trng lng phn t thp: Enoxaparin (Lovenox), Fraxiparine.

5. Tiu ho:Xut huyt tiu ho do stress: Sucralfate, khng H2, PPI

6. Thuyn tc tnh mch su: Phng nga bng vn ng sm, vi nhng bnh nhn nm lu, c NC cao dng d phng Enoxaparine (Lovenox)30mg/tdd/12gi trong 7-14 ngy.

7. Nhim trng tiu: C khong 16-44% bnh nhn b nhim trng tiu. -Phng nga t dn lu tm thi, ch t lu khi cn, theo di st tnh trng

nhim trng tiu, xt nghim TPTNT, cy v iu tr theo khng sinh . 8. Lot, cng khp: Xoay tr/mi 2 gi, chm sc v sinh da. Tp vn ng sm.

9. iu tr ng huyt: Duy tr ng huyt 120-150mg/dl (7-8mmol/l)/Insulin

10. iu tr cc ri lon nc v in gii: - t Catheter tnh mch trung tm

B nc lm gim qunh ca mu, trnh nhng dung dch nhc trng

Hn ch dch khong 1.5-2 lt/ngy bng Nacl0,9% hay Ringer Lactat.

- Na: Gim Na hay gp trong tng thi mui hay tng tit ADH khng thch hp

-Kali: khi dng li tiu, thm thu gy h Kali mu, cn theo di v b Kali.

10. Dinh dng:

- nh gi kh nng nut (test 3 tha nc), cung cp 1300-1500 kcalo/ngy. - t sonde d dy nui n bnh nhn c RL nut hay c suy gim thc. - Trnh to bn.

III. IU TR C HIU - IU TR TIU SI HUYT (rTPA) - Thuc khng ng: - Khng kt tp tiu cu: Cho sm 24-48 gi / bnh nhn t qu cp

Aspirin: Liu dng 325 mg/ngy u, nhng ngy tip theo t 81- 325 mg.

Clopidogrel: liu ti: 300 mg/ngy, nhng ngy sau 75 mg/ngy.

E. IU TR PHNG NGA TI PHT - Khuyn khch bnh nhn thay i li sng, b thuc l, gim cn nng, bt mui,

n tri cy v nhng sn phm t cht bo, hot ng th lc. -Dng thuc h p: c ch Can xi, UCMC, chn Beta, li tiu duy tr HA <

140/90mmHg. Vi bnh nhn stim, suy thn, T duy tr HA

25

25

CHN THNG S NO NNG

I.VN : Chn thng s no nng: GCS 8 C th kt hp vi a chn thng: ct sng, hm mt, ngc, bng, gy

xng chi, mch mu. Quan trng nht trong hi sc v h hp, thiu mu nui no, ph no.

CTSNMU T

DP NO

ST CAO PH NOTALNSHN M

RL THNG KH ( CO2)

* Phn loi nng CTSN 2.1. Theo thang im hn m Glasgow: - Nhm nh: Thang im Glasgow: 13- 15. - Nhm trung bnh: Thang im Glasgow: 9- 12 - Nhm nng Thang im Glasgow: 300ml/gi, t CVP

II. IU TR : 1. Nguyn tc iu tr:

T th u cao 300, c thng, CVP: duy tr t 7-14 cmH2O Huyt p tm thu 90-120 mmHg(HA trung bnh >90 mmHg) Nc tiu: 0,5-1 mL/kg/gi (30-60mL/gi) ALTT: 290 mOsmol/L(trnh 320 mmol/L) in gii: ch natri(135-145 mmol/L), Kali (3,5-5mmol/L) Nh t sonde tiu cho bnh nhn m, a chn thng.

2. Hi sc chng ph no: 2.1 .V h hp:

t NKQ khi c ch nh Th my: tn s: 12l/pht, Vt = 8-10mL/kg. Ch A/C Trong trng hp c tn thng phi (dp phi, vim phi), c

th s dng my th vi ch PEEP ( ci thin Oxy, nhng khng lm tng p lc ni s). Duy tr SpO2 >88%.

2.2 . V tun hon:Duy tr HA tm thu 90-120mmHg Lun duy tr huyt p n nh (HA trung bnh >90mmHg).

trnh nguy c thiu mu nui no, nht l khi c km tng ALNS.

26

26

C th dng vn mch (Dopamin,Norepinephrin) nng huyt p ln cao hn, khi p lc trong s tng cao, m bo ti mu no.

2.3 . Manitol: Liu ban u 1g (5mL dd manitol 20%)/kg Duy tr: 0,25-0,5g (1,25-2,5mL dd manitol 20%)/kg mi 6 gi. Ngng khi osmolarity >320 mOsmol/L

Natri Clorua u trng 3%c p lc thm thu l 2533 mOsm/kg, c tc dng ging Mannitol 20%; liu dng 2,5ml/kg truyn TM nhanh trong 15-20 pht, Natri u trng khng gy li tiu nh Mannitol nn t gy mt nc in gii v thi gian li trong mu cng lu hn 500 pht. Natri u trng c ch nh u tin trong bnh nhn a chn thng, c h huyt p.

2.4 . Furosemide: Liu: 10-20 mg mi 6 gi Ngng khi osmolarity >320 mOsmol/L

2.5 . H st: Laumt,qut Acetaminophen(nht hu mn,qua sonde,TTM)

2.6 . Gim au,an thn,gin c: Mc ch BN nm yn,khng vt v,th chng my Morphine(10mg mi 4 gi),Midazolam(0,03-0,2 mg/kg/gi),

Seduxen 10mg/ng TB, TMC/4-6 gi. * Ch CC:1. Khng kim sot c h hp v ng th

2. Khng kim sot c nguy c ht cht nn, i.

2.7 .T th u: Gi t th u cao 300 Gi c thng trnh chn p tnh mch cnh hai bn.

1.8. Bo v v dinh dng t bo thn kinh Cerebrolysin 10ml: 10-60ml/24 gi (pha trong dd mui, ng

ng trng) v truyn > 20-50 pht or TMC S dng trong 10-20 ngy. Choline alfoscerate (Gliatilin, Atelin) 1-2g TMC/ngy x 4 tun.

1.9. Cn Bng Nc in Gii: Duy tr huyt p trung bnh >90mmHg, CVP t 7-14cmH2O Lng nc tiu t 0,5-1mL/kg/gi (khong 30-60mL/gi). Nu

>300mL/gi,kim tra t trng nc tiu. Cn bng lng dch xut nhp, Ch ri lon natri v kali.

Ti liu tham kho 1. L xun Trung et al (1997),Chn thng v vt thng s no tr em v

ngi ln, Bnh hc Ngoi Thn Kinh, Trng HYD tp HCM,Vol I, trang 137-173.

2. Guha A (2004). Management of traumatic brain injury. Postgraduate Medi-cal Journal; 80: 650-53.

3. Kelly DF, Becker DP (1997), Diagnosis and treatment of moderate and se-vere head injuries in adults, Neurological Surgery ed., 4

th ed., USA: W.B.

Saunders company.

27

27

CO GIT V NG KINH NGI LN

I. nh ngha Co git l l mt t ri lon chc nng thn kinh gy nn bi s phng in bt thng ca t bo thn kinh no

II. c im LS - Co git ton thn gm c co git cn ln (co git) v cn vng thc (cn nh). Bnh b co git biu hin bng t gng cng thn th ngi n v tay chn dui ra, mt thc v trng lc t th. BN thng ngng th, tm nng v c th tiu tiu ra qun. Khi giai on gng cng chm dt (tng trng lc), BN c cc run git u 2 bn (git) ca thn v t chi ko di 60-90 giy. thc t t tr li nhng c th c giai on l ln sau cn ko di vi gi. - ng kinh cc b c chia thnh cc b n thun, trong thc vn ton vn, v cc b phc tp; trong thc b nh hng. Co git cc b phc tp thng bt ngun t thy thi dng v km theo kh chu thng v, c ng t , ri lon tr nh, RL tri gic v cc ri lon cm xc.

III. Chm sc v b tr ti khoa Cp Cu: . Gi thng ng th v cc du hiu sinh tn. BN ang co git cn c

bo v chng li chn thng v t nm nghing nga ht. . t ng truyn TM v test ng huyt .Cho th oxyv mc monitor theo di M, HA, SpO2, ECG . t NKQ nhng ngi co git ko di . BN cn c nh gi v mt chn thng v cc bt thng chuyn ha.

Sau khi n nh, cn tm nguyn nhn thc y v tin hnh iu tr thch hp. IV. Bng hng dn x tr ng kinh:

X tr Thi gian

Thit lp /Duy tr ng th

t ng truyn TM, th oxy, mcmonitor theo di

Glucose30% 25 50g TM nu c ch nh 0 5 pht

Thiamine 100mg TM v Magiesium 1 2 g TM cho ngi nghin ru hoc suy dinh dng

Diazepam 5mg TM mi 5 pht cho n 20mg 10 20pht

Phenobarbital n 20mg/kg TM, truyn 50 70 mg/pht TM

Thm phenobarbital 5 10 mg/kg TM 30 pht

Gy m ton thn vi Midazolam 0,2 mg/kg truyn TM chm v sau 0,1 mg/kg/gi hoc Propofol 1 2mg/kg TM v sau 1 15 mg/kg/gi

Magiesiumsulfate: iu tr ng kinh trong sn git, khi u vi liu ti 2g 6g, tip theo l truyn TM 1 2g/gi. Tr liu cho n khi ra tri.

- Thuc ung: Valproic acid(Depakin chrono): 1-3 vin/ngy, tng dn.

Phenobarbital: Ngi ln 30 -60mg/ngy, Duy tr 60 240mg/ngy

28

28

PH PHI CP (OAP)

I. CHN ON 1. Lm sng:

- Triu chng c nng + Cm gic ngp th nhiu, tng ln khi nm nn bnh nhn phi ngi + Lo lng, ht hong v cm gic sp cht ngp + Vt v

- Triu chng thc th + Nhn: . Th nhanh, v m hi, co ko c h hp ph

. Ho khc bt hng, u chi tm ti. + S: Mch nhanh, u chi lnh + Nghe: Phi crt ngy, ran m, t y dng nhanh ln nh, trn ngp

hai ph trng. Tim kh nghe do ran phi, c th c ting T3 ca tht P, ting P2 mnh

2. Xt nghim: - KMM: PaO2 gim, PaCO2 bnh thng hoc gim. - X quang phi thng: Rn phi m, phi m hnh cnh bm 3. Chn an phn bit: Ph phi cp tn thng (din bin, ng nhn) II. IU TR: 1. iu tr h tr ban u

- Th oxy qua ng thng mi 4-6l/p, oxy ti 8-12 l/ph. Ht m di SHH nng th NCPAP-PSV vi PEEP khi u5 v PSV10 cmH2O tng

dn hoc th my xm ln, ty tnh trng bnh nhn. - T th: nu khng c tt HA t th ngi, 2 chn thng hoc Fowler. - Ga r 3 chi lun phin, hn ch dch truyn.

2. Thuc + Li tiu: Furosemid ng 20 mg: liu 20 - 40 mg TM, c th lp li mi 15-30

pht nu tnh trng bnh nhn cha gim. + Morphin: ng 10 mg, liu 2 - 5 mg pha long TMC trong 3 pht, lp li mi 10-25 pht sau nu ph phi cha gim. Ch CC v tc dng ph. + H p: Nitroglycerin (10 mg/10ml) TTM khi u 5g/ph (3 ng + 20 ml NaCl 0.9%) B 5 ml/h, sau tng dn 5 g/ph mi 5-10 ph n khi ph phi gim hoc HA tm thu 100 mmHg (ch CC). +Kh dung: Ventoline 5mg 1ng x 3 mi 20 pht khi c co tht ph qun. + Thuc tng sc co bp c tim: Dopamin, Dobutamin s dng trong nhng trng hp OAP c h HA hoc sc, khi u 2-10 g/kg/ph sau tng dn n khi t hiu qu. S dng digoxin 0,25mg trong trng hp suy tim tri gy OAP - iu tr nguyn nhn: Tng HA, NMCT, RL nhp tim - Theo di lin tc / lm sng (HA, nhp tim, nhp th, ran phi), SpO2 Ti liu tham kho: 1. V Thnh Nhn, Ph phi cp, iu tr hc ni khoa, Trng i hc

Y Dc tp H Ch Minh, Nh xut bn y hc 2009, trang 57-70. 2. Judith S. Hochman, David H. Ingbar, Pulmonary Edema, Principles of

Internal Medicine, McGraw-Hill, 17th

edition, Vol 2, p1706-1707.

29

29

CN HEN NNG V NGUY KCH

I. Khi nim:l cn hen c tnh trng tc nghn ph qun rt nng v p ng km vi cc thuc dn ph qun gy suy h hp cp e da tnh mng cn theo di v iu tr ti ICU. II. Cc yu t thun li cho s xut hin cn hen nng: - C TS vo vin cp cu v/hoc phi t NKQ v cn hen. - C bnh khc km hoc tin trin n COPD. - S dng thuc khng ng.

III. Chn an: 1. Xc nh cn hen nng: - Kh th, th nhanh > 30 l/ph, co ko c h hp ph v hm c lin tc, phi ngi ci v pha trc. Phi c ran rt, khng c ran ngy. - Ni kh khn (ni c tng t) - Kch ng, ht hang, v m hi - Nhp tim > 120 l/ph - PaO2 < 60 mmHg, SaO2< 90% v hoc PaCO2 > 45 mmHg. - Khng gim vi iu tr thuc kch thch 2. 2. Xc nh cn HPQ nguy kch: khi c 1 trong cc du hiu sau: - Phi yn lng, th chm < 8 l/ph hoc ngng th. - Ri lan thc. - Nhp tim chm v/hoc HA tt - V m hi, tm ti.

III. CLS:

1. KMM: - PaCO2 tng nhanh - Toan mu 2. X quang phi: - Tng sng 2 ph trng - C th c bin chng: TKMP, trn kh trung tht, xp phi, vim phi. 3. ECG:

Trc lch phi, tng gnh tht phi, P ph, nhp nhanh xoang, block nhnh P, ri lan nhp tht.

IV. PHC IU TR CN HEN NNG A. Gi u tin 1.Th oxy qua mt n hoc gng knh oxy, duy tr SpO2 > 90% 2. Thuc gin ph qun: Thuc kch thch 2 - Salbutamol (Ventolin: 5mg/2ml): 5mg KD mi 20ph x3 ln lin tip 3.Corticosteroids:

- Methyl prenisolon: 125 mg TMC, sau 40- 80 mg mi 6h (TM) Hoc Hydrocortison: 200 mg TMC, sau 100-200 mg mi 4-6h (TM) nh gi sau 1 gi, nu cha ct c cn hen nng: B. Gi tip theo

Tip tc iu tr nh trn Thm:

- Ipratropium bromide KD 0,5mg mi 20 ph x 3 ln lin tip - Magnesium sulfate: 2g pha lang TMC trong 20-30 ph (13 ml MgSO4

15% + 100 ml NaCl 0.9% TTM LX g/ph).

Nu cc du hiu nng cha mt i, tip tc iu tr: C. 6-12 gi tip theo

1.Th oxy qua mt n hoc gng knh oxy, duy tr SpO2 > 90%

30

30

2. Thuc gin ph qun: - Salbutamol (Ventolin: 5mg/2ml): KD lin tc 5mg/ln (10-15mg/gi) - hoc thuc cng 2 truyn tnh mch lin tc . Tc khi u 0,1-0,15g/kg/pht . Tng tc truyn 5 pht/ln (ty theo p ng ngi bnh), mi ln 0,1-0,15g/kg/pht (c th ln n 4mg/gi)

- Kt hp vi: Ipratropium 0,5mg kh dung 4 gi/ln

Xem xt ch nh: - Theophylin (diaphylin) 0,24g pha lang TTM chm trong 20 pht - Thng kh nhn to: Nu sau 6-12 gi cha c p ng tt - Tip tc duy tr iu tr thuc nh trn, v: D.Xem xt ch nh thng kh nhn to Nn bt u vo thng kh khng xm nhp (nu cha c TK xm nhp) Thng kh khng xm nhp p lc dng (c sm khi NB mt c h hp)

Ci t ban u: PEEP 4 cmH20, PS 6 cmH20, Fio2 100% chnh theo Spo2. Thng khi nhn to xm nhp(TKXN): Ch nh: Ch nh TKXN ngay khi c xut hin bt k du hiu no sau y:

- Xut hin ri lon thc - PaO2< 60mmHg khi th oxy qua mt n c ti d tr - pH < 7,30, PaCO2> 50 mmHg - Tnh trng lm sng xu i nhanh - Ngi bnh mt, kit sc c h hp - Th my khng xm nhp khng c hiu qu. t thng s: Thng kh nhn to phng thc h tr / iu khin: t thng s ban u: - Vt: 8ml/kg PF: 60l/p (hoc I/E = 1/3) - Trigger -1 n -2 cmH2O (nu dng trigger p lc)

hoc 3-4 lt/pht (nu dng trigger dng) - FiO2 = 100% (t lc u), sau iu chnh duy tr SpO2> 92%. - PEEP

iu chnh thng s: - iu chnh PF v Vt ngi bnh hon ton th ng nhp vi my. - iu chnh Vt gi Pplat

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31

- pH > 7,20; PaCO2< 70 mmHg. Thi th my: - Ch nh thi th my khi ngi bnh ct c cn hen, xt nghim

pH, PaCO2 v PaO2 bnh thng. - Lm th nghim CPAP (cho ngi bnh th CPAP 5cmH2O qua ng

NKQ) trong 2 gi. Thi th my v rt ng NKQ nu nghim php CPAP thnh cng.

VI. PHC IU TR CN HEN NGUY KCH - Bp bng qua mt n vi oxy 100%. - Adrenalin 0,3 0,5 mg tim di da, c th nhc li sau 5-10 pht - t ng NKQ qua ming (ch : phi cho thuc an thn v/hoc thuc

gin c ngn m bo t ng NKQ thnh cng). - Thng kh nhn to qua ng NKQ Truyn tnh mch lin tc thuc gin ph qun: - Adrenalin truyn tc khi u 0,1g/kg/pht, tng tc truyn gp

i ln sau 2-3pht n khi c p ng. - Hoc thuc cng beta -2 giao cm truyn tc khi u 0,1 0,15 g /kg/pht, tng tc gp i sau 2 -3 pht n khi c p ng. - Cc thuc khc: nh pht iu tr cn hen nng. * Cai my ngay sau khi tiu chun. Sau 4 6h c th rt NKQ nu BN tnh, hp tc tt. III. LU : - Khng nht thit phi thc hin ng th t A-B-C-D nh trong pht

. Nu trc ngi bnh c x tr ng pht th p dng lun bc tip theo.

- Adrenalin c ch nh khi c cn hen nguy kch e da ngng tun hon, hoc khi ngi bnh khng p ng vi iu tr thuc v thng kh nhn to.

- Khi dng thuc cng beta -2 liu cao cn ch b kali cho ngi bnh trnh bin chng h kali mu.

* Theo di: - Mc monitor TD ECG lin tc. - KMM, SpO2,M, HA, nhp tim, nhp th, tri gic

Ti liu tham kho 1. Phc iu tr cn hen nng v nguy kch, Hng dn chn an v iu tr hen 2010, B y t, Nh xut bn y hc, trang 40-43.

2. Lee Demertzis, Robert M. , Luke Caristrom, Mario Castro, Tonya

Russell, Meena M, Murali Chakanila, Devin Sherman, Alexander Chen, Ara

Chrssian, Raksha Jain, and Daniel B, Asthma, The Washington Manual of

Medical Therapeutics-33RD

Edition p283-303.

32

32

T CP BNH PHI TC NGHN (COPD)

I.nh ngha: COPD l bnh l c c trng bi s tc nghn dng kh do vim ph qun mn, kh ph thng. S tc nghn ny tin trin dn dn, c th kt hp vi tng phn ng ng th v c th o ngc c mt phn.

t cp COPD l s khi pht cp tnh, nng ln ca cc triu chng v cn thit c s thay i trong iu tr so vi thng ngy bn COPD n nh. II. Chn on: Bnh nhn c COPD nay: 1.LS:

- Kh th tng ln km theo kh kh, co ko c h hp ph, thng kh km, th bng. Tm ti mi hay ngoi bin.

- Nhp tim nhanh. - Ni ngt qung v khng thnh cu. - Ri lon tri gic

2. CLS: Xq phi, KMM, cy m, Xn thng qui, CRP III. iu tr

1.Th oxy mi: gi Spo290-92%(SaO2 90%; PaO2>55mmHg) 2.Thng kh c hc:

a. Th my khng xm ln: c xem l bin php u tay - Ch nh: Ch nh sm cho tt c bn SHH (PaCO2 >45mmHg) - CC: ch cn 1 tiu chun + Tim mch khng n nh. + RL tri gic hoc bn khng hp tc. + Tng tit nhiu hay khng ho khc c. + Bo ph qu mc. + Bt thng hay chn thng u mt . + Ngng th. b. Th my xm ln:

+ Ngng th hoc suy h hp nng. +Gim Oxy mu e da tnh mng (PaO260mmHg), toan mu nng pH

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33

NaCl 0.9% BT 100ml/gi, sau pha 1ng vo 500ml NaCl 0,9% TTM XX g/ph, sau chuyn sang ung.

1. Glucocorticoide: Methylprednisolone (solumedrol 40mg/l) 1l x 3TMC/8h x 3ngy, sau Prednisone 40-60mg/ngy hoc Medrol 30-50mg/ngy trong vi ngy ri gim liu. 2. Khng sinh: ty nng, c a BN, mm bnh d on

Thng dng: Augmentin, Azithromycine, Cephalosporine th h 3, Fluoroquinolone (Levofloxacine) . C3 + sulbactam (sulperazone).

Trng hp nhim trng nng hoc nhim trng bnh vin: imipenam, Timentin, Cefepim, Fluoroquinolone (Levofloxacine), c th phi hp Aminoglycoside.

Lu BN th my nn s dng khng sinh ph c P. aeruginosa (Ceftazidim, Cefepim, Ciprofloxacine, Levofloxacine).

3. iu tr h tr: - Dinh dng: 1500-2000 Kcalo/ngy - Cung cp nc v in gii - Chng thuyn tc mch: Enoxaparin 0,5mg/kg/ngy - Tng khc m: vt l tr liu, dn lu t th - Mc monitor theo di lin tc.

Ti liu tham kho l. L Hu Thin Bin (2004), t cp bnh phi tc nghn mn tnh, Hi sc cp cu ni khoa, i hc Y dc tp H Ch Minh. p231-217. 2. Peter Barnes, Lionel Mandel, Chronic Obtruction Pulmonary Disease,

Principles of internal medicine, McGraw-Hill, 17th

edition.

3. Lee Demertzis, Robert M. , Luke Caristrom, Mario Castro, Tonya Rus-

sell, Meena M, Murali Chakanila, Devin Sherman, Alexander C, Ara

Chrssian, Raksha J, and Daniel B, Chronic obstructive pulmonary desease,

The Washington manual of medical therapeutic, 33RD

Edition, p 272-282.

34

34

VIM PHI

1. nh ngha: Vim phi l tnh trng nhim trng nhu m phi

2. Nguyn nhn:

BN ni tr

BN ngoi tr Non-ICU ICU

Streppneumoniae S. pneumoniae S. pneumoniae

Mycoplasma pneumoniae M. pneumoniae Stap aureus

Haemophilus influenzae Chlamydophila pneumoniae Legionella spp.

C. pneumoniae H. influenzae, Legionella spp. Trc khun G(-)

Virus ng h hp Virus ng h hp H. influenzae

Yu t dch t gi kh nng nguyn nhn gy VP MP C

Yu t Tc nhn

Nghin ru Strep pneumoniae, vkk kh, Klebsiella pneumoniae, Acinetobacter spp, lao

COPD v hoc ht thuc H influenzae, P aeruginosa, Legionella spp., S. pneumoniae, Moraxella catarrhalis,

Chlamydophila pneumoniae

Bnh l (dn ph qun,..) P. aeruginosa, Burkholderia cepacia, Stap aureus

Mt tr, t qu, gim nhn thc

Vk k kh, trc khn G(-)

Abscess phi T cu khng Methicillin mc phi trong cng ng, vkk kh, Nm, Lao, vk khng in hnh

KS hoc i bin, my bay trong vng 2 tun

Legionella spp.

Vng influenza hot ng Influenza virus, S. pneumoniae, S. aureus

Tip xc vi di v chim H. capsulatum

Tip xc vi chim Chlamydophila psittaci

Tip xc vi Th Francisella tularensis

Tip xc vi cu, d, mo Coxiella burnetii

3. Chn on - Ton thn: mt mi, n lnh hoc st, chn n, sa st tri gic mi xut hin - C nng h hp: nng ngc, kh th, ho, khc m c - Khm phi: ting th bt thng, ran n.- X-Quang: h nh thm nhim mi

35

35

- Nhum gram mu dch ph qun - Cy mu - XN mu: CTM, CRP, Procalcitonin. 4. iu tr vim phi cng ng - Ni chm sc bnh nhn: Tiu chun CURB-65 + Confusion: Gim tri gic mi xut hin (l m, tiu khng t ch + Ure > 7 mmol/L+ Nhp th > 30 ln/pht hoc Spo2< 90% (Fio2: 21%) + Huyt p tm thu < 90 mmHg hc HA tm trng < 60 mmHg + Tui > 65 * 0-1 im: Tin lng t vong 30 ngy 1,5%, iu tr ngai tr * 2 im: Tin lng t vong 30 ngy 9,2%, nn nhp vin * 3 im: Tin lng t vong 30 ngy 22%, nhp ICU - X tr thuc khng sinh

Bnh nhn ICU

- -lactame [ceftriaxone (2 g IV/24h), ampicillin-sulbactam (2 g IV q8h)] +

- Azithromycin hocFluoroquinolone (moxifloxacin (400 mg PO or IV/24h), levofloxacin (750 mg PO or IV/24h)

Quan tm c bit

Nu trc khun m xanh c xem xt

- Piperacillin/tazobactam (4.5 g IV q6h), cefepime (12 g IV q12h), hoc imipenem (500 mg IV/6h)/ meropenem (1 g IV/8h)] kt hpCiprofloxacin (400 mg IV/12h) hocLevofloxacin (750 mg IV/24h).

- -lactams +Aminoglycoside [amikacin (15 mg/kg od) hocTobramycin (1.7 mg/kg/24h ) v Azithromycin].

- -lactamsf+Aminoglycoside +Fluoroquinolone

Nu t cu vng khng Methicillin mc phi cng ng c xem xt

Thm linezolid (600 mg IV q12h) hoc vancomycin (1g IV q12h)

Note: CA-MRSA, t cu trng mc phi cng ng khng methicillin .aDoxycycline (100 mg ung 2 ln mi ngy) thay th cho nhm macrolide.

cKhng sing fluoroquinolone h hp nn s dng cho bnh nhn d ng penicillin.

dDoxycycline (100 mg IV q12h) thay th cho nhm macrolide.

eBnh nhn d ng penicillin, s dng fluoroquinolone h hp v aztreonam (2 g IV q8h).

fCho bnh nhn d ng penicillin, th aztreonam.

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36

Vim phi do my th 1. Nguyn nhn:

Non-MDR Pathogens MDR Pathogens

Streptococcus pneumoniae Pseudomonas aeruginosa

Other Streptococcus spp. MRSA

Haemophilus influenzae Acinetobacter spp.

MSSA Antibiotic-resistant

Enterobacteriaceae

Antibioticsensitive

Enterobacteriaceae

Enterobacter spp.

Escherichia coli ESBL-positive strains

Klebsiella pneumoniae Klebsiella spp.

Proteus spp. Legionella pneumophila

Enterobacter spp. Burkholderia cepacia

Serratia marcescens Aspergillus spp.

Note: ESBL, extended-spectrum - lactamase; MDR, multidrug-resistant; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-

sensitive S. aureus.

NN t ph bin hn l Nm v vius, thng nhng bnh nhn ny rt nng.

2. Chn on: - Khng c tiu chun chuyn bit sn c chn on vim phi do th my - Xem xt 3 du hiu ph bin nhng bnh nhn c nguy c: + S xm nhp ca VK ng kh qun + X-Quang phi thm nhim + St 3. iu tr

iu tr KS kinh nghim

BN khng c YTNC a khng thuc

Ceftriaxone (2 g IV q24h) hoc

Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q 12h), or

levofloxacin (750 mg IV q24h) HOC

Ampicillin/sulbactam (3 g IV q6h) HOC

Ertapenem (1 g IV q24h)

BN c YTNC a khng thuc

1. A lactam:

Ceftazidime (2 g IV q8h) or cefepime (2 g IV q812h) HOC

Piperacillin/tazobactam (4.5 g IV q6h), imipenem (500 mg IV q6h or 1 g IV

q8h), or meropenem (1 g IV q8h) +

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37

2. A second agent active against gram-negative bacterial pathogens:

Gentamicin or tobramycin (7 mg/kg TB q24h) or amikacin (20 mg/kg TB

q24h chia 2 ln) HOC

Ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV q24h) +

3. An agent active against gram-positive bacterial pathogens:

Linezolid (600 mg IV q12h) HOC

Vancomycin (15 mg/kg, up to 1 g IV, q12h)

Note: MDR, multidrug-resistant (a khng thuc) Ti liu tham kho

1. Trn Vn Ngc, Vim phi, Hng dn thc hnh ni khoa bnh phi, NXB Y Hc 2009, trang 24-32.

2. Lionel A. Mandell, Richard Wunderink, Pneumonia, Harrison's Principles of Internal Medicine, 17

th Edition, Volume 2, p1619-1628.

3. Burke A. Cunha, Empiric Therapy Of Lower Tract Infection, Antibi-otic Essentials, Ninth Edition, p 48-68.

38

38

VIM PHI BNH VIN

I) NH NGHA: Vim phi bnh vin (VPBV) l tnh trng vim phi xut hin sau nhp

vin 48 gi. Trong khi nim ny cng cp n VP th my, VP trn ngi suy gim min dch, VP ht v VP trn nhng ngi c chm sc y t ko di. Vim phi ny do cc tc nhn vi sinh c ngun gc BV v a khng thuc. II) CHN ON:

Chn on VPBV: XQuang ngc thng c hnh nh thm nhim mi hoc tin trin. Km theo bnh nhn cn phi c t nht 1 trong cc tiu chun sau:

- Cc nhim trng ng h hp: lm sng (st, au ngc, khc m c, kh th, ran n hay HC ng c, gim tri gic hay tt HA t ngt khng gii thch c) v CLS (gim oxy mu t ngt, bch cu mu tng, CRP tng).

- Chn on vi trng hc: Cy m hay dch ht PQ qua ng NKQ (+), cy mu hay dch mng phi

- Chn on vim phi bng m bnh hc 3) Chn on phn loi mc nng v phn nhm bnh nhn:

Bng 1. Cc tiu chun nh gi mc nng VPBV

Tiu chun nh gi (*) Nh Trung bnh Nng

Cch nh gi

Cc tiu chun

C t nht 5 tiu chun

Khng nm trong nhm nh hoc

nng

C t nht 5 tiu chun

1.Mc lan rng ca tn thng thm nhim trn Xquang phi

Di 1/3 din tch mt trng phi

Khng nm trong nhm nh hoc nng

Trn 2/3 din tch mt trng phi

2. Nhit < 37.5oC >38.5oC

3. Mch < 100 ln/pht 120 ln/pht

4. Nhp th < 20 ln/pht 30 ln/pht

5. Tnh trang mt nc (-) (-) hoc (+) (+)

6. Bch cu mu < 10000/mm

3

20000/mm3 or < 4000/mm

3

7. C-reactive protein (CRP) < 10 mg/dl

Khng nm trong nhm nh hoc nng

20 mg/dl

8. PaO2 > 60 mmHg < 60 mmHg hoc

SpO2< 90%

(*) Ngoi cc tiu chun k trn, bnh nhn s c xp vo tnh trng nng khi c mt trong cc tiu chun sau: xanh tm, gim tri gic, sc (HAmax 90 mmHg), bnh nhn cn th Oxy 3 lt/pht duy tr SaO2> 90%, thiu niu ( 65 tui - Ung th - Suy gim min dch

5. Phn nhm bnh nhn: - Nhm I: Cc trng hp nh hoc trung bnh khng c YTNC nng

39

39

- Nhm II: Cc trng hp nh nhng c t nht mt YTNC - Nhm III: TB nhng c t nht mt YT nng hoc cc trng hp nng - Nhm IV: Trng hp c bit (suy gim MD, th my, nguy c VP ht).

III) IU TR KHNG SINH (KS): Mt s lu : - iu tr KS kinh nghim phi thc hin ngay sau khi c chn on VPBV - Cn nhc n chi ph iu tr, c tnh VK v khng thuc ti c s - Thi gian iu tr 7-10 ngy/trng hp nh, khng c YTNC nng (nhm

I) v t 14-21 ngy/trng hp TB, nng c YTNC nng (nhm II, III, IV). - p ng iu tr sau 48-72 gi. nh gi bng LS, CLS (CRP, PCT,

CTM, KMM, XQ ngc v c bit l cy nh lng dch PQ kim tra). - Liu php xung thang c thc hin khi bnh c biu hin p ng tt

bng vic la chn KS ph hp da theo kt qu VT hc v KS. - Nhng trng hp khng p ng T: cc bnh khng NT, VK gy bnh

him hoc VK khng thuc, NT ngoi phi v cc bin chng ca vim phi.

Bng 2. Phc iu tr khng sinh kinh nghim

Nhm BN c im Phc Thuc

Nhm I VP nh hoc TB nhng khng c

YTNC nng

A 1) Cephalosporine II (Cefuroxim)

hoc Cephalosporine III (Ceftriaxone) 2) Ciprofloxacin, Levofloxacin

Nhm II Vim phi nh c YTNC nng

B A,C ty theo nh gi: 1) Cephalosporine III dit Pseudomonas (Ceftazidime)

2) Cephalosporine IV (Cefepime)

3) Carbapenem (Imipenem +

Cilastatin Na: Tienam, Pythynam)

Nhm III Vim phi trung bnh c YTNC

nng hoc vim phi nng

C 1) Cephalosporine III dit Pseudomonas (Ceftazidime), Cepha

IV (Cefepime), Carbapenem

(Imipenem + Cilastatin Na),

Piperracillin + Tazobactam (Tazocin)

Ciprofloxacin, Levofloxacin (hoc Aminoglycoside (Amikacin)

2) Khi khng loi tr c Staphyloccus khng Methicilline: nh thm Vancomycin hoc Linezolide

Nhm IV: Vim phi c cc tnh hung c bit

IV 1: Vim phi c suy gim min dch

IV-1a

Gim bch cu a nhn trung tnh

D 1) Cephalosporine III dit Pseudomonas (Ceftazidime), Cepha IV (Cefepime),

Carbapenem (Imipenem + Cilastatin Na)

Aminoglycoside (Amikacin)

2) Levofloxacin TM Clindamycin

IV-1b E La chn thuc C, thm nhm Macrolide,

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40

Suy gim min dch t bo

Fluoroquinolone hoc thuc khc nu phn lp c vi sinh gy bnh (Cotrimoxazole-trimethoprime vi P.cariniii)

IV-1c Suy gim min dch dch th

F Cephalosporine III (Ceftriaxone), IV

(Cefepime) hoc Carbapenem

IV-2

Vim phi th my G - Vim phi sm (1-4 ngy): Betalactam /

khng betalactamase (Timentin) hoc

Ertapenem or Cepha II-III Fluoroquinolone

- Vim phi mun (5 ngy): Betalactam dit Pseudomonas (Ceftazidime, Cefepime, Fluoroquinolone dit Pseudomonas (Ciprofloxacin, Levofloxacin, Carbapenem

(Imipenem + Cilastatin ) + Aminoglycoside

(Amikacin) Vancomycin

IV-3

Vim phi ht H Betalactam dit Pseudomonas (Ceftazidime,

Cefepime), Carbapenem (Imipenem +

Cilastatin) + Clindamycin

Bng 3. Liu lng khi u cc thuc dng tnh mch i vi cc vim phi bnh vin ngi ln xut hin mun hoc c nguy c khng thuc.

Nhm khng sinh Khng sinh Liu dng

Cephalosporine khng

Pseudomonas

Cefepim 1-2 g mi 8-12 gi

Ceftazidime 2 g mi 8 gi

Carbapenem Imipenem 500mg mi 6 gi hoc 1g mi 8 gi

Meropenem 1 g mi 8 gi

Betalactam/khng betalactamase Piperacillin/Tazobactam 4.5 g mi 6 gi

Aminoglycosides Amikacin 20 mg/kg ngy

Quinolonse khng Pseudomonas Levofloxacin 750 mg ngy

Ciprofloxacin 400 mg mi gi

Glycopeptide Vancomycin 15 mg/kg mi 12 gi

Oxazolidine Linezolid 600 mg mi 12 gi

Clindamycin 15-40mg/kg/d chia 2-4lan

Ti liu tham kho 1. Nguyn Vn Thnh, Vim phi bnh vin, Hng dn thc hnh ni khoa bnh phi, NXB Y Hc 2009, trang 33-40. 2. Jean-Yves fagon; jean chastre (2005), Nosocomial pneumonia, Text-

book of Critical Care 5th

edition, p663-678.

41

41

VIM TY CP

I. nh ngha: Vim ty cp l s vim cp m ty v m xung quanh ty do kh nng hot ha ca men ty ln tuyn ty, c bit l trypsin. II. Nguyn nhn:

- a s do ru v bnh si mt (40-70%) - Ru (5-7%) - Nhm nguyn nhn khc: chn thng bng, tng canxi mu, tng triglycerit mu, do thuc, vim ty do ERCP, nhim siu vi - Khng th xc nh nguyn nhn (20-25%). III. Chn on: l chn on loi tr cc nguyn nhn khc ca au bng cp 1. Lm sng:

- au bng, bun nn, nn - Du Mayo-Robson: im au sn lng tri - Du Mallet Guy- Tn Tht Tng: im chiu sn lng tri thnh trc. - Du Cullen: mng bm di da vng quanh rn (XH trong xoang phc mc) - Du Turner-Grey: mng bm tm di da vng lng tri v hng tri - Triu chng khc: st, vng da, ri lon vn chuyn rut (to bn hoc tiu chy), tit dch trong xoang bng. 2. Cn lm sng: + Men ty tng rt sm t nhng gi u, v bnh thng sau 2-3 ngy (Amylase nc tiu v bnh thng mun hn: sau 7-10 ngy). - Amylase, Lipase mu tng trn 3 ln tr bnh thng (Amylase mu > 500 UI) - Amylase dch mng bng>5000U/dL-Amylase nc tiu >1000 UI/L + X-Quang: du quai rut canh gc, i trng ct cc, si ng mt, TDMPT + Siu m bng: hnh nh ty to, ph n, hoi t ty, abces ty, nang gi ty, t dch quanh ty, bnh l ng mt (si, giun).

- CT scan bng c gi tr chn on xc nh, nn tr han 48 gi nu c

IV. Phn loi + Cc yu t tin lng nng ca bnh:

- Phi hp vi suy c quan v/hoc bin chng khu tr nh hoi t ty - Biu hin lm sng: BMI > 30, Hct > 44%, Tui > 70 - Suy c quan: Sc, PO2 8

+ Tiu chun Ranson: Lc nhp vin: Qua 48h theo di: - Tui >55t - Ure huyt >3mmol - Bch cu >16000/mm3 - PaO2 10mmol/l - Calci mugim 350 UI/L - Hct gim >10% - SGOT >250 UI/L - Thot dch m k >6l + Nu c t 3 yu t tr ln l VTC nng. IV. iu tr:

1. Cc nguyn tc chung: - iu tr kt hp ni ngoi khoa: hi sc ni khoa v theo di din tin VTC ch nh can thip ngoi khoa thch hp

42

42

- tuyn ty ngh ngi trnh kch thch ty bng thuc v cho n - iu tr nng - iu tr cc bin chng 2. iu tr ni: nhm gim au, gim tit ty, chng sc, nui n, dung khng sinh khi bi nhim, iu tr h tr khc. a. Gim au: - Meperidine (Dolargan) ng 0,1g/2ml. 50-100mg mi 4-6 gi IM, IV - Nospa

b. Gim tit dch ty: - t ng thng d dy khi bng chng - Thuc chng tit dch v: Omeprazol, pantoprazol 40mg 1-2 l / ngy, IV - Octreotide 100mcg x 3 ln / ngy TDD - Metoclopramide (Primperan) 10mg 2 3 ng IM / ngy, khi NB nn i c. Nui n: - ng TM trong 1-2ngy u, 30 calo/kg/ngy tng dn 50-60 calo/kg/ngy. - Khi bnh nhn ht au bng th chuyn dn sang nui n ng ming theo trnh t: nc ng, cho ng, cm nho ri cm bnh thng. - King sa, m, bo. d. Phng v iu tr sc: - Truyn dch lng nhiu (4-6l/ngy) trong nhng ngy u - iu chnh ri lon nc in gii, kim toan (lu h Canxi mu) - Khi c sc iu tr theo nguyn nhn (xut huyt, nhim trng, nhim c) - t catheter o CVP, s dng vn mch nu cn (khi c sc) e. iu tr cc bin chng khc - Suy h hp: h tr h hp tng bc - Suy thn: lc thn khi c ch nh, lc mu lin tc nu l VTC nng - Vn s dng khng sinh (KS): Li ch ca KS cn ang tranh ci: Trong vim ty cp hoi t c th dng Imipenem 0.5g TTM, 3 ln / ngy x 7 ngy hoc Cefuroxim 1,5g TM, 3 ln/ ngy x 7 ngy. C th s dng Quinolone + Metronidazol.

f. iu tr VTC do tng triglycerit mu: ngoi cc iu tr nh trn, b sung thm:

- Heparine trng lng phn t thp Lovenox 40mg 01 ng TDD/ngy (ch CC , theo di tnh trng xut huyt) - Insuline R truyn vi tc t 1 - 4UI/gi kim sot cht ng huyt trnh h ng huyt. - Thay huyt tng. - Dng nhm Fibrate kt hp nhm statine s lm tng tc dng gim triglycerid mu (dng sau 48 gi).

3. Ch nh can thip ngoi khoa: - Khi c nghi ng trong chn on,khng loi c bnh ngoi khoa khc. - C bin chng ngoi khoa nh xut huyt ni, vim phc mc, p xe ty, hoi t nhim trng. - C bnh ng mt kt hp ch nh can thip ngoi gii ta, dn lu ng mt. K thut ly si qua ni soi lm gim ng k ch nh ny. - Khi iu tr ni tch cc m khng ci thin tnh trng bnh.

43

43

XUT HUYT TIU HA TRN

I. nh ngha: l hin tng mu chy vo ng tiu ha t trn gc Treitz v c thi ra ngoi bng nn ra mu v/hoc tiu ra mu.

II. Nguyn nhn xut huyt: - Lot d dy t trng (31-59%) - Tng p tnh mch ca (7-20%)

- Rch Mallory-Weiss (4-8%) - D dng mch mu (0-6%) - Vim trt d dy (2-7%) - U c d dy (2-7%)- Vim thc qun - Khng r nguyn nhn: 8-14%

III.Chn on:

1. Xc nh XHTH trn cp: - Nn ra mu v/hoc tiu phn en - t sonde d dy c mu - Sc mt mu - Ni soi gip xc nh chn on

2. Mc mt mu cp:

Mc Nh Trung bnh Nng

1. Lng mu mt < 15% V mu c th (750ml)

15-30% (750-

1500ml

> 30% ( > 1500ml)

2.Triu chng ton thn

Tnh, lo u nh, hi mt.

Lo u va, mt mi, nim nht, da xanh, chng

mt, v m hi, tiu t.

RL tri gic, ht hong, li b, vt v, th nhanh, v niu, kht nc, chi lnh nim nht.

3. Mch (l/pht) 90 100 100 120 > 120

4. HA (mmHg) > 90 80 90 < 80

5. Hct (%) > 30 20 - 30 < 20

6. S lngHC 3 x 10 12 /L 2 3 x 1012 /L < 2 x 10 12 /L

7.Loi dch Dung dch tth Dd tinh th mu DD tinh th v mu

X tr: 1. Hi sc chung: cho bnh nhn nm u thp

- Hi phc th tch tun hon: theo mc mt mu + Thit lp hai ng truyn kim ln (16-18G), nu cn t CVP + Truyn dung dch mui ng trng 20ml/kg. Khi truyn mui ng trng ti 50ml/kg m bnh vn cn sc, cn truyn dung dch keo 500-1000ml (voluven 6%), albumin; khng dng dung dch Glucose u trng. + Plasma ti ng lnh khi bnh nhn XHTH cp c RL ng mu, truyn tiu cu cho bnh nhn ang b XHTH v tiu cu < 50.000/mm3. + Truyn mu khi Hb< 8 g/dL hoc

44

44

A. iu tr xut huyt tiu ha do lot d dy- t trng: - Cm mu qua ni soi ch nh vi Forrest Ia, Ib, IIa v cn nhc IIb - Thuc:c ch bm proton: Liu cao: (Esomoprazol, pantoprazole, omeprazoleliu u 80mg (2 l)+50ml Nacl 0,9% BT 100ml/gi, sau BT 8mg/h (1l pha va 50 mL dung dch ng trng B 10 mL/h) trong 72h, nu n nh duy tr bng thuc vin, ung 40mg/ngy trong 28 ngy). Liu thp: Omeprazol, pantoprazol 40mg 1 l x 2-3lnTMC/ngy. - Ch nh hi chn ngoi khoa: 1. Chy mu t e da tnh mng 2. Truyn > 5v mu/ 24h m huyt ng khng n nh 3. Tn thng qu ln (>2cm) hoc v tr kh cm mu bng NS 4. Chy mu ti pht iu tr ni soi ln 2 tht bi 5. iu tr ni khoa tch cc tht bi

B. iu tr xut huyt tiu ha do v gin tnh mch thc qun: - Cm mu trc tip:* Sonde Blakemore * Chch x, tht thun * Cm mu bng thuc:

+ Octreotid 0,1 mg:TM 1 ng, sau BT lin tc 25-50g/gi (3 ng octreotid 0.1mg + NaCl 0.9% va 50ml BT4-8ml/ h trong 3-5 ngy). + Somatostatin 3mg 1 l + NaCl 0.9% va 50 ml: 4 ml TMC sau BT 3- 4mL/ gi.

- Nga hn m gan: + Lactulose: 10-30ml x 3l/ngy bnh nhn i tiu ngy 2-3 ln + Acid amin khng phn nhnh (aminoplasmahepa, aminoleban)

+ Khng sinh: . Metronidazol 0,25g 1 vin x 3-4 ln/ngy . Quinolone (norloxacin hoc ciprofloxacin) . Ceftriaxon 1g 1-2l/ngy x 5 ngy * Nga ti pht sau khi qua cn cp: Thuc: propanolol 40mg (liu 10-20 mg x2l/ngy sao cho gim khong 25% tn s tim) hoc Betaloc + ISMN.

III. X tr khc: - XN: CTM, ure, creatinin, glucose, ion , TQ, TCK, nhm mu, chc

nng gan (khi cn) ECG, Xq phi, NTTP. - Theo di:M, HA, nhp th/30 ph, 1gi, 3 gi/1 ln (ty theo bnh)

Nc tiu mi 4 gi, Hb 3-6,12,24 gi/ln hoc sau truyn mu - Ung sa ngui khi huyt ng n nh hoc sau ni soi 6 gi.

Ti liu tham kho: 1. Trn Th Kiu Min, iu tr xut huyt tiu ha, iu tr hc ni khoa, i hc y dc tp H Ch Minh, NXB y hc 2009, trang 163-174. 2. Khuyn co x tr xut huyt tiu ha trn cp tnh khng do tng p tnh mch ca (2010), Hi khoa hc tiu ha Vit Nam. 3. Loren Laine, Gastrointestinal Bleeding, Harrisons Internal Medicine 17th, p257-260.

4. C. Prakash and Ahmad Manasra,Gastrointestinal bleeding, Washington

Manual of Medical Therapeutics33ND

Edition, p 577- 583.

45

45

HN M GAN

I. nh ngha - Gm cc triu chng tm thn kinh - Xy ra bnh nhn c bnh gan cp, mn tnh - Khng c ri lon thn kinh khc

II. CC YU T THC Y 1- Qua din tin t nhin: XHTH, ch n nhiu m, nhim trng, suy

thn, to bn, ri lon nc in gii, h ng huyt. 2- Do can thip: Thuc li tiu, thuc an thn,gy m, chc tho dch bng

III.LM SNG 1. Ri lon tri gic: Km tr nh, kh tp trung t tng,thay i hnh vi,thi . Mt nh

hng khng gian v thi gian,hn m gan t nh n su. 2. Du chng thn kinh: Run ry, phn x gn xng tng, co git, gng cng

kiu mt no, Banbinski 2 bn. 3. Du chng t bit: Hi th mi gan, th nhanh v su.

IV. CN LM SNG: 1. NH3 mu:

- Tng trong 90% cc trng hp, khng t l vi t l hn m - C hin tng i chm - Bnh thng: 0.4-0.7mg/L

+ NH3 1mg/L c gi tr chn on + NH3 1.5mg/L c triu chng r + NH3 2mg/L hn m

2. Cc CLS khc cn lm thm Glucose, Ion , Chc nng gan, Chc nng thn, Albumin, Protein, TQ,

TCK,VGSV B-C, AFP, ECG, ECHO bng, X- Quang phi.

IV. CHN ON 1. Lm sng

- Ri lon tri gic- Cc triu chng ca suy t bao gan - Cc triu chng ca tng p lc tnh mch ca - Cc du chng thn kinh v cc du chng c bit

2. Cc cn lm sng quang trng - o nng NH3 l rt quan trng c ngha chn on nht - o in no k: ch s hin din ca sng

3. Phi hp cc cn lm sng - Echo, Chc nng gan, dch bng - Cc xt nghim nhn dng siu vi vim gan, AFP

V. CHN ON NGUYN NHN 1. Bnh gan cp

- Vim gan do VGSV, vim gan do thuc - p xe gan do vi trng - Sc rt c tnh th gan mn- Nhim xon khun

2. Bnh gan mn: Vim gan do VGSV B-C. X gan, gan a nang, K gan

B. PHN : chia hn m gan lm 4 I: Sng khoi, c ch III: Ng g, ng gt

46

46

Li ni ln xn khng r rng Li ni ri rc khng mch lc Run ry () Run ry (+) EEG: bnh thng EEG: bt thng II: L IV:Hn m ban u cn p ng Ln ln va phi vi cc kch ng th khng Run ry (+) Run ry (-) EEG: bt thng EEG: bt thng

Phn loi Child-Pugh im 1 2 3

Bnh l no gan khng 1-2 3-4

Dch bng khng Nh, p ng thuc li tiu

Nhiu, khng p ng thuc

Bilirubin(mg/dl)

+ Bnh gan khng mt + Bnh gan mt

2 4

2-3

4-10

> 3

>10

Albumin (g/L) > 3,5 2,8-3,5 < 2,8

Thi gian Prothrombin (s) 1-3 4-6 > 6

INR < 1,7 1,8-2,3 > 2,3

INR= International Normalized Ratio

Thang im theo Child-Pugh: A: 5-6 im; B: 7-8 im; C: 10-15 im

IV. IU TR 1. T cn nguyn: nhim trng, st rt 2. T yu t thc y: XHTH, nhim trng, h ng huyt, h kali

3. T hn m gan - Ch n: m bo nng lng 2000-2500 Kcal/ngy + n gim m: 0,5-0,75g/ngy c th 10-20g/ngy. Sau tng ln 10g/ngy mi 3-5 ngy. C th tryn m (Aminoplasmal-Hepa, aminoleban).

+ Truyn ng u trng: Glucose 30% - Gim NH3

+ L-Ornithine, L-Arnigine (Hepamez, Helotec) ng 5g, 2-4ng pha Glucose 5% 500ml TTM xxxg/p x 2ln/ngy + Lactulose (Duphalac gi 10ml) Ung: 1-5gi/gi n khi tiu chy

ri gim 15-30ml x 2-4ln/ngy (cho BN i tiu 2-3 ln/ngy).

- Dit vi khun . Metronidazol 250mg x3 ln/ngy . Ceftriaxon 1-2g/ngy x 5 ngy

V. THEO DI - Tri gic, DHST/2-4gi- Lng nc xut nhp/ngy - Ion , Hb, Ure, Creatinin, Glucose/ngy Ti liu tham kho 1.V Th M Dung, Bnh no gan, iu tr hc ni khoa, i hc y dc

tp H Ch Minh, NXB y hc 2009, trang 242-253. 2. Anil B. S and Mauricio Lisker-Melman, Hepatic encephalopathy,

Washington Manual of Medical Therapeutics33ND

Edition, p 577- 583.

47

47

NHIM CETON ACID V TNG P LC THM THU TRN BNH NHN I THO NG

I.TRIU CHNG LM SNG 1.1. Nhim ceton acid:

- n nhiu, ung nhiu, tiu nhiu, gy st gia tng r rt - Mt mi, chn n, bun nn, nn i, au bng - Th nhanh su kiu Kussmaul v mi ceton trong hi th - C du mt nc: da nim kh, mch nhanh, HA h, TM c xp, lng nc tiu gim, nhn cu xp. - Tri gic: l ln, hn m su, hoc gn nh bnh thng - Hn m khng c du thn kinh nh v.

1.2.Tng p lc thm thu: - Ri lon tri gic lun lun c- C th c du thn kinh nh v - Tnh trng mt nc nng- To thng tng, d khng nhim trng - C th th nhanh su kiu Kussmaul

II. CHN ON:

NHIM CETON ACID TNG ALTTM ng huyt (mmol/L) > 14 > 34

pH mu M 7.3 > 7.3

D tr kim (mmol/L) 15 > 15

Ceton nc tiu dng t

Ceton huyt thanh dng t

ALTT huyt thanh 320(mosmol/kg) > 320(mosmol/kg)

Khong trng ion > 12 thay i

Tri gic thay i m mt, hn m

Na+ huyt thanh thay i thay i, thng tng

K+ huyt thanh thng gim, c th tng gi thay i

HCT, ur, creatinin mu tng Tng

Bnh s T type 1 BN tr, gy Trc hon ton khe Din tin bnh 155 mmol/L, dung dd NaCl 0.45%, Glucose 5% + insulin - Khi H gim n ~14 mmol/L phi phi hp Glucose 5% hoc 10% 2) iu chnh ri lon in gii: - Natri

48

48

- Kali: B Kali l 1 phn c bn trong iu tr, TD kali mu/1-4 gi Nu BN c nc tiu, K mu bnh thng hoc gim, b K khi bt u insulin Khi c kt qu ion : (01 ng KCl 10% 10 ml c khong 13 mmol kali)

Kali huyt thanh (mmol/L) Kali cn b sung (mmol/L)

5.5, v niu Khng truyn

Khi c suy thn gim liu 20 50% - Dung dch kim: DD bicarbonate c ch nh khi: + Toan mu nng pH < 7.0 hoc HCO3

-< 5 mmol/L

+ pH < 7.2 km chong hoc bnh nhn hn m (Khng truyn NaHCO3 qu sm) 3) Insulin:

Khi mi chn on: TM 10 15 n v insulin tc dng nhanh Sau TTM insulin tc dng nhanh 5-10 n v/gi (0.1 n v/kg/gi). [50 v insulin + NaCl 0.9% va 50ml (1ml = 1v) bm in 0.1*CN ml/h] Theo di: iu tr ng, H s gim 3-5 mmol/gi. Nu nghi ng c khng insulin, c th tng liu insulin 50 100%/gi. [Khng iu chnh h H qu nhanh (>6mmol/L/gi) v gy ph no] Khi H gim n 14 mmol/L, gim liu insulin 2 4 n v TTM/gi cng vi glucose 5% hay 10% khi ht toan v n ung c chuyn insulin TDD. 4) Tm v iu tr cc yu t thun li: nhim trng, bnh cp mi xut hin, b chch insulin, cng gip nng,

IV. THEO DI: - M,HA, nhp th, lng nc tiu/gi - Test H /1 hoc 2 gi trong 24 gi - in gii / 2 gi n khi n nh, sau theo di /4 - 6 gi - Theo di toan mu / 2 4 gi cho n khi pH > 7.2, c th theo di bng khong trng anion. Khng theo di bng th ceton. V. CH CHM SC: - Chm sc bnh nhn hn m: xoay tr, v lng, ht m nht - Ch n ung ca ngi T - Tim insulin ng gi, ng liu - Theo di du hiu h ng huyt - V sinh thn th, trnh try xt

Ti liu tham kho 1. Nguyn t Anh, Nguyn Anh Tun2007, Hn m nhim ceton acid v tng p lc thm thu do i tho ng, Cp cu hi sc v chng c, trang 251-272.

2. Janet B. McGill, Diabetes Mellitus and Related Disoders, The Washington

Manual of Medical Therapeutics, 33nd

Edition, p802-815 .

49

49

Phc iu tr hn m nhim ceton acid do T theo Umpierrez v khuyn co ca Hi T M

Sau khi hi bnh v khm thc th, tin hnh XN c bn, Cc XN sinh ha nh hng v XN kh mu, tin hnh iu tr ti phng cp cu

Dch truyn TM

INSULIN iu tr bng BICARBONAT

E

pH7.0

0

KALI

pH < 7.0

Sau 1h truyndch

NaCl 0.9% 500-1000

ml/h trong 2h

Thm G 5% khi nng H5.5 mEq/L

khng dung K, cn kim tra K2h/2ln

Dng li NaHCO3 mi 2h ti khi pH >7. Theo dinng K

Ha long 40

mmol NaHCO3

vo 200 ml

NaCl0.9% .

Truyn vi tc

200ml/h

Khng

dng

50

50

Phc iu tr hn m do tng p lc thm thu trong T

nh gi ban u hon chnh. Bt u truyn dch TM: 1 lt NaCl 0.9%/h lc khi u

DCH TRUYN

TM

INSULIN KALI

Nu K huyt thanh 16 mmol/L.

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51

IU TR CN BO GIP TRNG

I. TRIU CHNG LM SNG - Cc triu chng sm ca cn bo gip gm st, tim p nhanh, ri lon cm xc, tng hot tnh h thn kinh trung ng. Nu khng iu tr c th a n suy tim, ph phi, try mch, hn m, t vong trong vng 72 gi. - Cc triu chng thng gp ca cn bo gip gm c: + St t 38 n 41 + Thn kinh: lo lng kch ng, l ln, m sng, RL tri gic, hn m + Tim mch: tim p nhanh, lon nhp nh rung nh, ngoi tm thu tht, suy tim huyt. Bnh nhn c th cht v suy tim, ph phi cp, try tim mch. + Tiu ha: i, bun i, au bng, tiu chy. i khi bnh nhn c vng da, gan ln nh do xung huyt hoc hoi t t bo gan. + Triu chng nhc c cng ni bt, ch yu c gc thn mnh. trng hp nng c th nhc c u chi, c thn mnh, c mt. + Cc triu chng khc nh da mn m, m hi, nh mt sc, co ko c mi trn. Tuyn gip ln, c m thi, hoc khng. i khi c th bnh v cm, bnh nhn b yu lit, hn m, nhit ca c th ch hi tng, th ny hay gp bnh nhn ln tui b bu tuyn gip a nhn ha c.

II. CN LM SNG - T3, T4, FT4 tng, TSH gim - Chc nng gan: bilirubin tng, thi gian Prothrobin ko di, AST ALT tng - C th tng calci huyt, tng ng huyt (h ng huyt l mt d hiu xu). III. X TR Truyn dch:mn ngt ng trng, in gii, sinh t nhm B. - H nhit bng Paracetamol - iu tr suy tim (nu c) bng digitalin v li tiu, iu tr lon nhp tim. - Cho th oxy m. - Thuc an thn phi c s dng rt thn trng

2. c ch s tng hp v phng thch HormonThuc khng gip tng hp + Liu u 300mg ung / 6 gi hoc dng ngay 100mg/2 gi trong ngy u, sau 300-600mg/ngy trong 3-6 tun n khi kim sot c HC cng gip. + Nu khng c PTU c th dng Methimazole ung, liu u 30-40mg, sau 20-30mg ung/ 8 gi trong ngy u v 30-60mg/ ngy trong nhng ngy sau Ch cho 1-2 gi sau khi dng khng gip tng hp. + Dung dch Iod bo ha (SSKI) 6-8 git ung mi 6 gi. - Corticoid: C th dng Dexamethason 2mg mi 6 gi ung hay tim mch hoc Hydrocortison 50-100mg tim mch mi 6-8 gi hoc methyl prednisolon

- Thuc c ch giao cm + Thuc c s dng nhiu nht l propranolol 40-80mg ung mi 4-6 gi

3. Tm v iu tr cc yu t thun li iu tr khng sinh nu nghi c nhim trng...Tuy nhin phi bt u iu tr c hiu cn bo gip trc. Khng nn i c y kt qu xt nghim mi iu tr 4. Din tin vi iu tr - Sau khi phi hp iu tr bng PTU (propylthyouracil), dung dch iod v FT4 c XN mi 4-6 ngy. Khi FT4 t gii hn bnh thng, liu PTU v iodine

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52

c gim dn. - Sau khi LS n nh c th gim dn liu Dexamethasone, Iod. PTU s c dng tip tc cho n khi chuyn ha v gn bnh thng, khi s ngng Iod. - Cn bo gip c th ko di 1-8 ngy, trung bnh l 3 ngy. V. GIO DC SC KHE V PHNG NGA - Bnh nhn b cng gip do nguyn nhn ti tuyn phi c iu tr y - T bng phu thut hoc x tr phi a v bnh gip trc khi thc hin.

Ti liu tham kho: 1. Nguyn Thy Kh, Chn on v iu tr cn bo gip trng, Ni tit hc i cng 2007- trang 627-631. 2. William E. Clutter, Hyperthyroidism, Disoders of Thyroid Gland, The

Washington Manual of Medical Therapeutics, 33nd

Edition, p832-8837 .

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53

SUY THNG THN CP

I. CHN ON A. LM SNG

Tnh trng ton thn rt nng, v cm, ri lon tri gic, m sng, st Ting tim m, h HA, chong nng, mch nhanh, yu. Chn n,bun nn, nn, au bng, tiu chy, Truyn dch y

m vn try mch, tnh trng toan rt nng, CVP lun m. ang dng thuc corticoid di ngy, nhng ngng thuc t ngt ang b nhim khun nng, NK huyt, cm c tnh, st xut huyt. Gim d tr thng thn do: rifampicin, barbiturat, ketoconazol

- Addison: sm da,so sm mu - Dng corticoid lu ngy: Biu hin Cushing, khng sm da.

B. CN LM SNG Natri mu h, kali mu tng rt gi chn on Dh c c mu: Hct tng, protid mu tng, toan mu nh BUN tng, h dng huyt, tng calci mu trong vi ca Thiu mu, tng a nhn i toan, tng lympho Cy mu, m, nc tiu (+) nu nguyn nhn l NK Cortisol mu gim.

C. CHN ON Ch yu da vo LS H HA khng tm ra nguyn nhn, nht l km bun nn, nn

i hoc st. Tin s bnh l tuyn thng thn, tuyn yn. Tin s dng Corticoid liu cao trong vi tun. Da vo nng Cortisol:Bt k:< 15 mcg/dL

Sau test kch thch: < 20 mcg/dL

II. X TR 1.Nguyn tc: iu tr ngay,trc khi c kt qu xt nghim

Nhanh chng nng lng corticoid lu hnh trong mu iu tr: h HA, h ng mu, h kali mu iu tr nguyn nhn thc y.

2. C th

- Corticoid:

Ngay khi chn on: Hydrocortison 100mg TM hoc TTM mi 4-6 gi trong 24 gi u (c

th dng methylprednison 40mg TM). Sau : tim hoc TTM 50-100mg / 6-8 gi trong 1- 3 ngy ri gim

liu trong 1-3 ngy nu c th. Khi n nh: gim liu dn v chuyn sang dng ung (sau 7-10 ngy) - Truyn nhanhNaCl0,9%, Glucose 5%, 10%, 30% (2 ng truyn kim

ln, c th 5-6 lt trong 24 gi, truyn nhanh trong 3-4 gi u), t CVP. - Dng vn mch khi b dch v corticoid y .

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54

III.THEO DI

Lng dch b hon da vo p lc TMTT (CVP), huyt p, mch, in gii , th tch nc xut nhp v chc nng thn.

Khng cho an thn iu tr yu t thun li: nhim trng, phu thut Theo di M, T

0, HA/gi sau mi 3-4gi XN ng mu, ion , cortison mu chc nng thn mi 4-6 gi

sau 1-2 ln/ngy n khi n. IV. D PHNG (trong suy tuyn thng thn mn) a. Khu phn n mui bnh thng b. Glucocorticoid liu thay th - Hydrorcortison: l thuc iu tr tt nht. Liu 10-30mg/ngy chia 2 ln hoc prednison 5-7,5mg mt ln/ngy c. Khi bnh hoc phu thut - iu chnh in gii, huyt p, b dch - Hydrocortison 50-100mg mi 6-8gi. Gim liu trong 1-3 ngy v chuyn dn thnh liu ung. Duy tr hoc tng liu hydrocortison 200-400mg/ngy nu c st, h huyt p hay bin chng khc xy ra d. Phng nga suy thng thn mt b - Gio dc bnh nhn l do iu tr sut i, ch n mui bnh thng. Bit tng liu thuc 2-3 ln hoc tim hydrocortison khi bnh. - Vi cc bnh nhn phi dng corticoid ko di hoc liu cao iu tr mt s bnh mn tnh cn trnh gim hay ngng t ngt trnh suy TT cp

Ti liu tham kho 1. Dip Thanh Bnh, Suy thng thn mn v cp, Ni tit hc, i hc Y Dc tp H Ch Minh, 2006, trang 81-87. 2. Suy thng thn, Hng dn chn on v iu tr bnh ni khoa, Nh xut bn y hoc 2011, trang 473-476. 2. Mark Thoelke and Christopher J . Gutjahr 2010, Adenal Insufficiency

and Corticosteroid Management, The Washington Manual of Medical

Therapeutics, 33nd

Edition, p42-43.

3. Paul A. Fitzgeraldn 2011, Acute adenocortical insufficiency (adrenal Cri-

sis), Current Medical Diagnosis and Treatment, p1106-1108.

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55

SUY THN CP TRONG HI SC

I . nh ngha Suy thn cp (STC) l tnh trng gim lc cu thn nhanh chng (t vi gi n vi ngy) biu hin bng s tng nhanh ure v creatinin mu,ri lon cn bng nc,in gii v kim toan,lng nc tiu thng gim < 400ml/24gi nhng cng c th bnh thng. II . Chn on 1 . Lm sng

- Thiu niu (nc tiu 100 - 400ml/ngy) - V niu (nc tiu < 100ml/ngy) thng do nguyn nhn tc nghn - STC khng thiu niu (nc tiu >400ml/ngy) thng do thuc gy

c thn bnh nhn ang nm vin. - Hi chng ure huyt cao: Nn i, XHTH,RL tri gic, hn m,co git,ph

phi,ph no;c th c ting c mng tim, trn dch mng tim,suy tim huyt, THA v ri lon nhp tim.

2 . Cn lm sng - Tng BUN v Creatinin mu: tc tngtng ng nhau: BUN

tng10-20mg%/ngy,Crea tng 0,5-1mg%/ngy, t l BUN/Crea:10-20/1. - Tng BUN > tng Creatinin: STC trc thn,STC sau thn, bnh nhn c

tng d ha protein. - Creatinin tng nhanh hn trong ly gii c vn c th tng > 2mg%/ngy. - Tng Bun v Creatinin khng triu chng l biu hin thng gp nht

ca STC ca bnh nhn ang nm vin do thuc gy c thn.

III . Phn loi 1 . STC trc thn . - Lm sng: Gim th tch tun hon,h huyt p,suy tim,suy gan,nhim

trng,dng thuc khng vim nonsteroid hoc thuc c ch men chuyn. - Phn tch nc tiu: khng c t bo,t tr hyaline,t trng NT > 1,018 - STC phc hi nhanh nu phc hi ti mu thn. 2 . STC ti thn .

- Hu ht STC ti thn l hoi t ng thn cp,do STC trc thnkhng c chn on v iu tr ng hoc do cc cht c thn.

- Phn bit STC trc thn v STC ti thn da vo bnh sLS v cc XN

Xt nghim STC trc thn STC ti thn

-