_ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com S TAY GIP TR NH CN LM SNG MUC LUC 1.in tm bnh thng 1.1.in bnh l 1.2.Xc nh trc in tim 2.Nghim php gng sc 3.Cc tiu chun o c v siu m kiu tim 3.1.Cc tiu chun o ac v siu m kiu tim 3.2.Cc s o v siu m tim ngi bnh thng 3.3.nh gi chc nng tht tri - tm thu 3.4.nh gi chc nng tht tri - tm trng 3.5.H van 2 l 3.6.Hp van 2 l 3.7.Hp van ng mch ch 3.8.H van ng mch ch 3.9.Tnh p lc ng mch phi 4.Ch s huyt ng hc 5.Mch mu 5.1.ng mch vnh T 5.2.ng mch vnh P 5.3.Phn loi cc on mch vnh theo hip hi tim mch Hoa K 5.4.Phn loi cc tn thng mch vnh theo hip hi tim mch Hoa K 5.5.Phn loi dng mu mch vnh 6.M s cc my to nhp tim 7.Tiu ha 8.Thn hc 9.H hp 10.iu tr bng dch truyn trong tnh trng mt nc 10.1. iu tr bng dch truyn trong tnh trng mt nc 10.2. Nguyn tc bi hon in gii 10.3. Dch truyn v thuc (ng tnh mch) thng c dng 10.4. K thut truyn tnh mch 10.5. Dch truyn tnh mch - nng cht in gii 10.6. S milimol ca mi Ion trong 1g mui 10.7. Thnh phn in gii trong dch tit s dng ng tiu ha 10.8. Lu lng - vn tc/ thi gian truyn 10.9. S truyn mu: cc nhm mu 10.10. S truyn mu: kho st cc xt nghim 11.Huyt hc 11.1. Huyt hc 11.2. Gi tr bnh thng ca mu 12.Test dung np Glucose 13.Dch no ty 14.Ty 15.Prothrombin_ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 1. IN TM BNH THNG PHC QRS BNH THNG Sng P: oThi gian = 1mm trong thi gian 0,08 giy ST chnh ln >= 1mm i vi 1 s tc gi: sng T tng bin hoc T su o ngc Tng bin sng R, gim bin sng Q Sng U m V5 Xut hin bloc nhnh T hon ton hoc bloc phn nhnh T trc TIU CHUN NGNG NGHIM PHP: Nghim php t ti a C cc du hiu in tim dng tnh au ngc Huyt p tm thu > 250 mmHg Tt huyt p Ri lon nhp: Rung nh, nhanh tht, ngoi tm thu tht xut hin nhiu. Ri lon dn truyn: bloc nh tht, bloc phn nhnh T trc trn nn bloc nhnh P sn c Cc du hiu khng dung np v tun hon (xu, l ln, ngt) PHC NGHIM PHP GNG SC 3 Cc tiu chun o c v siu m kiu tim 1.Cc tiu chun o ac v siu m kiu tim 2.Cc s o v siu m tim ngi bnh thng 3.nh gi chc nng tht tri - tm thu 4.nh gi chc nng tht tri - tm trng 5.H van 2 l 6.Hp van 2 l 7.Hp van ng mch ch 8.H van ng mch ch 9.Tnh p lc ng mch phi _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 3.1 CC TIU CHUN O C V SIU M KIU TM: LVd: Kch thc tht tri cui tm trng, o u QRS LVs: Kch thc tht tri cui tm thu, o im vch lin tht co bp nhiu nht v pha sau. IVSd: Chiu dy vch lin tht cui tm trng, o u QRS IVSs: Chiu dy vch lin tht cui tm thu, o ch dy nht PWd: Chiu dy thnh sau t do tht tri cui tm thu, o ch dy nht. Ao: Kch thc gc ng mch ch cui tm trng, o lc bt u QRS LA:Kchthcnhtricuitmthu,ochlnnhttthnhsaungmchchnthnh sau nh tri _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 3.2 CC S O V SIU M TIM NGI BNH THNG MT CT CNH C TRC DC THT TRI: RV: tht phi PW: thnh sau IVS: vch lin thtpillier post: ct sau LV : tht triaml: l ln (l trc) van 2 l LA: nh tri pml: l nh (l sau) van 2 l Ao: ng mch ch KCH THC THT TRI ( LV ) MODE TM LVd: 37 56 mm IVSs: 12 3mm LVs: 27 37 mm IVSd: 6 11mm PWs: 15 3mm PWd: 6 11mm T l: vch lin tht/ thnh sau 0,9 1,2KCH THC THT PHI (RV) MODE TM (NG CT CNH C TRI TRC DC) RVd (tm trng) 9 26mm RVs (tm thu) 24mm KCH THC THT PHI ECHO 2D (MT CT T MM, 4 BUNG) Trc di tht phi tm trng (RVd): 80mm Trc ngn tht phi tm trng: 33mm Din tch tht phi tm thu (RVs): 10.9 cm2 Din tch tht phi tm trng (RVd): 20,1 cm2 T l tht phi / tht tri: 1/3 KCHTHCNHTRI(LA)MODETM (MT CT CNH C TRC DC) Nh tri: 25 45mm (20 tui) Nh tri: 30 45mm (80 tui) T l nh tri/ng mch ch: 1,1 KCH THC GC NG MCH CH (AO) V M VAN SIGMA (OS) Ao < 42 mm nam Ao < 35 mm n Os: 19mm 3.3 NH GI CHC NNG THT TRI CHC NNG TM THU Phn sut rt ngn tm thu ca tht tri (FS) Dtd: ng knh cui tm trng Dts: ng knh cui tm thu Bnh thng = 36 6% Tc rt ngn trung bnh theo chu vi ca c tim (VCF) ET: Thi gian tng mu (thi gian m van ng mch ch) BT = 1,2 0,1 circonf/giy nh gi th tch tm tht (cng thc Teicholz) V= 7D3/2,4 + D Vtd = 70 10 ml/m2 (th tch cui tm trng) Vts = 25 5 ml/m2 (th tch cui tm thu) VES = Vtd Vts (th tch tng mu tm thu) Phn sut tng mu tht tri (EF) BT 60% Vtd: th tch cui tm trng Vts: th tch cui tm thu KHI LNG THT TRI: LVM (DEVEREUX) Bnh thng (Devereux):LVM = 176 45g (nam) LVM = 121 40g (n) Ph i tht LVMI > 134g/m2 (nam) LVMI > 110g/m2 (n) LVMI: ch s khi lng c tht tri _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com Dtd: ng knh cui tm trng 3.4 NH GI CHC NNG THT TRI: CHC NNG TM TRNG PHN LOI THEO APPLETON Cc dng khc nhau ca ph Doppler dng chy qua van 2 l AoC: ng van ng mch ch IVR: th gin ng th tch Tahoma'>OM: m van 2 l E: vn tc ti a y nhanh A: vn tc ti a nh thu MC: ng van 2 l Type 1: E/A < 1 + trin xung sng E chm li Thi gian th gin ng th tch ko di (lm gia tng s ng gp ca nh trong giai on y tm trng) = Ri lon th gin tht tri Type 2: E/A > 1 + trin xung sng E rt ngn Thi gian th gin ng th tch rt ngn: dng siu bnh thng = bnh c tim hn ch Ri lon s n hi tht tri Type 3: (bnh thng) E/A > 1 + trin xung sng E bnh thng Thi gian th gin ng th tch bnh thng (khong 95ms)LVM (Penn) = 1,04 x lang=VI [ (td + IVS + PW)3 (Dtd)3] 13,6 LVM (ASE) = 0,8 x 1,04 x [(Dtd +IVS + PW)3 (Dtd)3] + 0,6 _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 3.5 H VAN 2 L KHO ST DNG 2 L (DOPPLER XUNG) Vn tc u tm trng (sng E) ln hn 1,5m/s gi h van 2 l nng T L VTI (Velocity Time Infegral) VTI=dintchphadingbiudinvn tc dng mu qua van 2 l. m: van 2 l Ao: van ng mch ch T l > 1,3: H lang=VI hai l nng KHO ST LUNG MU TRO NGC Doppler xung: Kho st chnh xc tan ca dng h bng cch o in tch dng h trong nh tri 1: H hai l nh 2: H hai l va 3: H hai l trung bnh 4: H hai l nhiu SIU M QUA THC QUN ng knh dng pht ngc ti gc (D) 1: D < 6mm 2 v 3: D = 6 8mm 4: D > 8 10mm Din tch dng pht ngc 1: 1,5 4cm2

2 v 3: 4 7cm2 4: > 7 cm2 3.6 HP VAN 2 L NH GI HP 2 L BNG CCH TNH CHNH P TRUNG BNH S bin dng 4 cnh ca ng biu din vn tc qua van 2 l (my t tnh sau khi v dc theo cc cnh ca dng qua van 2 l) NH GI HP 2 L BNG CNG THC HATLE PHT (Pressure Half Time): thi gian gim chnh p NH GI HP VAN 2 L BNG PHNG TRNH LIN TC SAo: din tch gc ng mch ch MVA: din tch van 2 l VTI: tng din tch di ng biu din vn tc MVA < 1cm2: Hp rt kht MVA: 1 1,5cm2: Hp kht MVA> 1,5cm2: Hp va _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 3.7 HP VAN NG MCH CH CHNH P TRUNG BNH THT TRI NG MCH CH (DOPPLER LIN TC) nh gi chnh lch qua van ng mch ch bng nh lut Bermouilli P2-P1 = 4 x V2 G > 50 mmHg: Hp kht van ng mch ch

NH GI DIN TCH L VAN NG MCH CH Dng phng trnh lin tc p dng cho hnh tr, lu lng chy vo bng vi lu lng chy ra Q1 = S1 x V1 = S2 x V2 = Q2 S1: Din tch bung tng tht tri (din tch di van ng mch ch) V1: Vn tc trong bung tng tht tri (Vmax hoc VTI) S2: Din tch van ng mch ch cn tnh V2: Vn tc dng mu ti ch hp ng mch ch Hp kht van ng mch ch:din tch < 0,75cm2 3.8 H VAN NG MCH CH O NG KNH DNG H TI GC o ng knh h ch bng TM mu (cnh c trc dc) 1: ng knh < 8mm 2: ng knh 8 11mm 3: ng knh 12 15mm 4: ng knh > 15mm

O BNG PH DOPPLER LIN TC o bng PHT (thi gian gim chnh p) ca dng h ch PHT > 400 ms => I hay II PHT < 400 ms => III hay IV Theo Scheubi I: 470 90 ms II: 370 70ms III: 250 80ms IV: 140 30ms DNG TI EO NG MCH CH t Doppler xung ti ng mch ch xung on di eo Vtd= vn tc cui tm trng Vs= vn tc tm thu Vs > 0,2 m/s: h ch 3 hay 4 Vtd/VsVTId/VTIs I020%>60% _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 3.9 TNH P LC NG MCH PHI PAPs= p lc ng mch phi tm thu PAPd= p lc ng mch phi tm trng O P LC NG MCH PHI (PAP) BNG DNG H 3 L PAPs = (4 x V2) + PRA V= Vn tc ti a dng h 3 l PRA= p lc nh phi: trung bnh 10 mmHg (nhng thay i theo bnh cnh lm sng: c th 20 mmHg trong trng hp h 3 l nng) O P LC NG MCH PHI BNG DNG H PHI PAPs = (3 xPAPm) (2 x PAPd) PAPm = p lc ng mch phi trung bnh = (4 x V proto2) + 10mmHg PAPd = p lc ng mch phi tm trng = (4 x V tl2) + 10 mmHg 4 CH S HUYT NG HC P LC Bnh thng Nh phi (mmHg)5/0 Tht phi (mmHg)30/5 ng mch phi (mmHg) 10 Cung lng tim (l/pht) 5 6 CH S V KHNG LC Bnh thngC.I.: ch s tim (l/pht/m2)3 5 S.I.: ch s tm thu (ml/m2)50 Khng lc mch mu h thng(dynes/sec/cm-5) 960 1300 Khng lc ng mch phi (dynes/sec/cm-5)200 300 BO HO O2 Tnh mch ch trn74%Tnh mch ch di 78%Tht tri nh tri 97%Tht phi ng mch phi76%5 Mch mu 1.ng mch vnh T 2.ng mch vnh P 3.Phn loi cc on mch vnh theo hip hi tim mch Hoa K 4.Phn loi cc tn thng mch vnh theo hip hi tim mch Hoa K _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 5.Phn loi dng mu mch vnh 5.1 NG MCH VNH T Theo nhm cc thm d chc nng v chp mch mu ca SFC 1978 01. Thn chung ng mch vnh T 07. Nhnh cho th 1 02. Nhnh lin tht trc on gn 08. Nhnh cho th 2 03. Nhnh lin tht trc on gia 09. Nhnh vch th lang=VI 1 04. Nhnh lin tht trc on xa010. Cc nhnh vch 05. Nhnh ng mch vnh m011. Cc nhnh tm nh ca ng mch ch 06. Nhnh ng mch b T012. Nhnh ng mch b th 2

T th chp chch sau T th chp chch trc T 55o T th chp chch trc P 30o T th chp ngang T th chp ch _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 5.2 NG MCH VNH P 1. on u (nm ngang) ca ng mch vnh P 7. ng mch nt xoang 2. on 2 (nm dc) ca ng mch vnh P8. ng mch b P 3. on 3 (nm ngang) ca ng mch vnh P9. ng mch tht P 4. ng mch lin tht sau10. ng mch nt nh tht5. ng mch qut ngc tht11. ng mch c honh 6. ng mch chp12. Cc nhnh vch di T thchch trc P 45o T th chch trc T 45o 5.3 PHN LOI CC ON MCH VNH THEO HIP HI TIM MCH HOA K

ng mch vnh P T th chch trc T 45o

ng mch vnh T T th chch trc P 45o _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 5.4 PHN LOI CC TN THNG MCH VNH THEO HIP HI TIM MCH HOA K TYPE C: Di > TN THNG TYPE A: oNgn < 10mm ong tm oD i ti c tn thng oTn thng khng gp gc (< 45o) oB trn lng ot hoc khng vi ho. oKhng tc hon ton oTn thng xa l xut pht oKhng c nhnh bng h quan trng ch ng mch b hp oKhng c huyt khi TN THNG TYPE B: oDi 10 - 20 mm oLch tm oon mch mu trc tn thng ch ngon ngoo va phi oTn thng khng gp gc trung bnh (>45o v 90o) oTc hon ton > 3 thng oKhng th bo v cc nhnh bng h chnh oTn thng trn ming ghp tnh mch vi tn thng d v. 5.5PHN LOI DNG MU MCH VNH (TIU SI HUYT TRONG TH NGHIM NMTC)TIMI 0khng h c dng mu ngang qua ch b tc TIMI Ic cht cn quang ngang ch hp nhng khng ngm thuc hon ton vng h lu TIMI IIcht cn quang i qua c ch hp, ngm thuc hon ton h lu, tc tho lu thuc chm TIMI IIIcht cn quang qua ch hp tt, ngm thuc hon ton h lu, tc tho lu thuc khng b chm 6 M S CC MY TO NHP TIM M s chung NASPE/BPEG (NBG) Ch th 1bung tim c kch thch 0: khng c bung tim no A: tm nh V: tm tht D: 2 bung (tm nh & tm tht) Ch th 2bung tim c nhn cm 0: khng c bung tim no A: tm nh V: tm tht D: 2 bung (tm nh & tm tht) Ch th 3Cch p ng 0: khng c T: khi pht I: c ch D: c 2 (va khi pht + c ch) _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com Ch th 4chng trnh thch ng nhp 0: khng c P: chng trnh n gin M: nhiu chng trnh C: o t xa R: thch ng nhp Ch th 5chc nng chng nhp nhanh B: hng lot (BURST) N: tn s bnh thng S: r sot E: kim sot t bn ngoi 7. TIU HO GI TR BNH THNG CA CC XT NGHIM CHC NNG GAN Xt nghimGii hn bnh thng Bt thng Nguyn nhn gy bt thng Bilirubin ton phn/ huyt thanh (hth) 5 17 mol/lTngTng bilirubin khng lin hp (ester ton phn). do tng to (vd: tn huyt) hoc do gim kh nng lin hp. Bilirubin ester/hth< 6 mol/l Tng bilirubin ester do bnh nhu m gan hoc tc mt ngoi gan Bilirubin niu(-)(-) hoc tng Kt qu (-): tng bilirubin khng lin hp trong mu Kt qu (+): hu ht cc nguyn nhn khc gy vng da Aspartatet aminotransferase/hth (AST) 5 40 IU/L (37oC) Tng Nhiu loi bnh gan, nhi mu c tim, bnh c Alnine amino transferase/hth (ALT) 5 40 IU/lTngBnh gan Alkaline phosphatase/hth 30 110 IU/l tui tr con v tui dy th th cc tr s ny s cao hn TngBnh gan c bit l c tc nghn ng mt Bnh xng bnh Pagets, nhuyn xng, mt s tn thng xng th pht hoc cng tuyt cn gipPh n c thai 5 nucleotidase/hth1 15 IU/l (37oC) TngBnh gan c bit l c tc mt. Thng c dng xc nhn tnh trng phosphatase kim cao l c ngun gc t gan (khng cn nu c alkaline phosphatase isoenzyme). g - glutamyl transferase/hth Nam :065IU/L N: 0-40 IU/L Tng (37oC) Hu ht cc loi bnh gan Nghin ru lu ngy, vim tu cp, nhi mu c tim, tiu ng, cc thuc to ra enzyme Albumin/hth35 50 g/lGimTn thng gan lan rng, hi chng thn h, bnh l ng tiu ho, tnh trng dch (c th l bin chng ca bnh gan). Caeruloplasmin/hth270 370 mg/lGimBnh Wilson Mt s ri lon khc v gan ng ton phn/ hth13 -21 mol/lGimBnh Wilson ng/nc tiu 24h0 0,4 mol/24hTngBnh Wilson Thi gian prothrombin (PT) PT: 10 14 giyTngBnh gan Thi gian Thromboplastin tng phn (PTT) PTT: 32 42 giyTngThiu vitamin K c iu chnh sau 3 ngy iu tr tr khi s tng hp b gim v tn thng t bo gan Ri lon di truyn v c ch ng mu Cc gii hn ca tr s c th thay i cc phng xt nghim khc nhau. _ebook oc xy dng bi CLB195_ Ngun ti liu t YKhoanet.com 8. THN HC TNG PHN TCH NC TIU Cht c phn tchGii hnn vKt quYu cuCht bo qun Albumin (vi th)