Chung Thy 05 - 11 CHUYN : THOT V BN - I Cu 1: Chn on x v x tr thot v bn nght I.

I CNG ng bn l 1 im yu ca thnh bng trc bn, gii hn bi: o Thnh trc: c cho ln o Thnh trn: gn kt hp o Thnh di: cung i

o Thnh sau: mc ngang, m di PM v PM

Thot v nght l b/c nng v thng gp ca tt c cc loi thot v, trong ch yu l thot v bn v thot v i TV bn nght l mt bc nng ca TV bn, thng gp h bn gia Gp nam gii nhiu hn n gii, thng gp ngi ng tui v ngi gi v thnh bng yu, tuy nhin cng gp thanh nin v tr em iu kin thun li: o Thng xy ra sau 1 ng tc gng sc o TVB gia hay gp

o Tin s b TV nght vi ln nhng sau li tr li bnh thng o Khi TV b d b nght hn khi thot v ln do c ti TV b, vng x l TV chc
Cn chn on tht sm v x tr ngay (< 6h) v nu mun sau 6-12h tng thot v s b hoi t, dn n tnh trng VPM, tc rut..., nhng ri lon ton thn. II. CHN ON XC NH

Ch yu da vo lm sng Hon cnh: o Trn 1 BN c tin s TVB nhiu ln, khi TV t ln c

o Ln ny thng xut hin t ngt sau 1 ng tc mnh, gng sc v khng ln c

nh thng ngy mc d bn nm nga, t xoa nh v y ln

Trc khc nhau ty theo bnh nhn n sm hay mun

1. BN n sm (<6h): au ti ch khi thot v l ch yu a) C nng:

au: l triu chng quan trng nht buc bnh nhn phi ti vin

Xut hin t ngt khi bn lm ng tc mnh. au chi d di lin tc vng bn lan xung bu lm cho BN ku la, lo s THOT V BN - I

Chung Thy 05 - 11 Nu c du hiu nght rut th s xut hin cn au bng.

Nn hoc bun nn: c th c hoc ko B trung i tin: cha c trong G u

b) Ton thn: Nt mt nhn nh, nhng th trng vn tt. Mch u r, c th hi tng mt cht. Huyt p vn gi nguyn. c) Thc th: Thm khm t m cn thn v nhiu khi thot v b nm su d st Nhn:

Mt khi phng trn, kch thc to nh ty trng hp Nm trn ng Malgaigne (ni GCTT vi gai mu) hoc chy di xung bu

S:

C cm gic cng chc, n c im au chi tng ng c bao thot v y ko ln, nn ko nghe thy ting c ch, ko thay i kthc khi ho, rn G vo c. Bng mm khng chng, ko c du hiu rn b, quai rut ni, PTB, CPM 1 s trng hp, ch c 1 phn quai rut b nght, hoc khi TV nh nm su, biu hin ti ch ko r, ch c au bng, nn => quan trng phi pht hin im au chi bn bu 2. Triu chng khi n mun: Ty trng hp m din bin c th nhanh hay chm, nhng thng sau 6-12h nu ko x tr g cc triu chng thay i r rt. Ngoi cc triu chng nh trn th c thm cc triu chng ca cc bin chng: Tc rut, hoi t, vim phc mc. a) C nng:

au bng tng cn, tng dn hoc au lin tc d di, au xon vn v m hi, t ch TV lan ra khp bng Nn nhiu lin tc, cht nn mu nu en B trung i tin r

b) Ton thn: Thay i r Tinh thn: lo lng, ht hong Du hiu mt nc, RL G: mt hc hc, mt trng, da kh, nhn nheo, kht, i t Ko st hoc st nh Mun hn c th shock do gim khi lng tun hon v RL G: BN li b hoc vt v, kch thch, da NM nht, v m hi, mch nhanh nh, HA tt. c) Thc th:

Ti ch: vng bn bu sng n, ty , au chi, cng tc lm cho BN ko cho bc s khm

THOT V BN - I

Chung Thy 05 - 11

Hi chng tc rut: bng chng cng, g vang, quai rut ni r, c dh rn b, ting ro di chuyn ca hi v dch, bng trc trng rng Mun hn c dh ca VPM: PTB, CPM khp bng, thm Douglas au chi i khi quai rut nght, ti TV v ra to apxe phn v m hoc l r tiu ha trn thnh bng

3. Cn lm sng: Ko c gi tr chn on m dng hi sc, tin lng bnh 3.1. Xt nghim c bn: n mun c bin chng

CTM: c c mu (HC, Hct tng). Mun hn: BC tng VSS tng SHM: Ri lon G (Na, K, Cl ban u gim, sau tng)

Ure, creatinin mu tng Men gan tng dy) 3.3. S bng: ko lm v vng hi. C th thy dch bng Nh vy, CX TVBN da vo trc LS v CLS ni trn, trong da vo LS l ch yeus vi tin s TV nhiu ln, au vng bn bi, khi phng TV au chi. Cn vic C loi TV trn LS l kh khn, phi cn c vo phu thut. III. CC TH LM SNG 1. Th theo din bin a) Th nght ko hon ton Thng c khi TV ln Thnh thong c xut hin dh ca TV nght Thng BN n trc 6h Biu hin: RL M (PT gim) Kh mu: pH gim, toan mu Nhm mu, HIV: phc v cho phu thut

3.2. X quang bng KCB: hnh nh tc rut (quai rut gin, mc nc hi, bng m, thnh rut

Khi TV cng, au Nu cho nm ngh, gim au, gin c, ngm nc nng, khi TV c th t ln Sau 1 thi gian li ti pht b) Th nght hon ton Thng gp khi TV nh

THOT V BN - I

Chung Thy 05 - 11 BN n mun > 12h Biu hin

au chi vng bn bu, lan nhanh khp bng Dh CN v ton thn nng, nhanh chng dn n b/c, tin lng xu c) Th TVB nght c b/c Ngoi dh ca TVB nght hon ton, cn c cc biu hin ca TR Nu c hoi t rut, c biu hin VPM: HC NT N nng, PTB, CPM khp bng Him gp: khi TV v ra to ra l d thnh bng

2. Th theo tng TV a) Mt quai rut non Thng gp nht L TV cng b, cng x chc, cng d nght, dn ti nhng b/c TR cp, hoi t, VPM b) Mc ni ln: din bin chm, ko c biu hin TR cp c) RT: chui v dnh vo ti TV => au chi khi TV, HCNT xy ra sm d) Manh trng, i trng sigma: trc TR ko r rng, xut hin mun e) BQ: c RL tiu tin 3. Cc th LS c bit a) TV Richter (TV hp bn) Ch 1 phn thnh rut b kt vo l TV v b bp nght au chi d di vng bn bu, ko thay i nhiu Nn, bun nn Trng hp ny thng kh C, quan trng phi tm dh au chi vng bn bu Ko ch 1 m nhiu quai rut, ko ch quai rut trong ti TV m c quai rut trong bng cng b hoi t Hoi t quai rut bng din bin nhanh Kh C, thng biu hin : BN > 60t, tin s TV nhiu ln C HC TR, PTB, CPM Khi m lu phi ko c quai rut bng kim tra IV. CHN ON PHN BIT 1. Nu BN n sm: cn phn bit khi TV vi a) TV ko nght au t Khi TV to, ko cng, t ln c

b) Thot v W (TV ngc dng)

THOT V BN - I

Chung Thy 05 - 11 b) Hch bn vim C nguyn nhn gy vim gn y Vng bn bu sng au, ty HCNT Di ng au chi

c) Vim mo tinh hon

L bn nng, rng S mo tinh hon rt au 1 or 2 bn bu to ra Ko s thy mo tinh hon Dh kp mng tinh hon (-) Soi tinh hon trong bung ti thy dch trong mu hng Nm song song vi thng tinh Khi nm trong ng bn ko thay i kch thc, ko di ng khi ho, rn Ko tinh hon khi u ny cng di chuyn theo cng hng Ko c cm gic p vo u ngn tay khi lun vo l bn nng khi BN ho

d) Trn dch mng tinh hon

e) Nang nc thng tinh

f) Tinh hon lc ch Ch s thy 1 tinh hon hoc ko c tinh hon no C th s thy tinh hon trong ng bn S or CT-Scanner: trng hp tinh hon trong bng

g) Gin TM thng tinh

S nn vng khi phng thy r tnh mch gin nh bi giun, au tc dc thng tinh lan ln vng tht lng cng bn. U m/ hch vng bn Hch bn di ng Thng tinh, l bn bnh thng Rung miu khi BN ho Khi phng mt i khi BN nm L bn nng, rng

h) Gin TM hin

THOT V BN - I

Chung Thy 05 - 11 i) Thot v i Gp n TV nm di dy chng bn

2. Nu BN n mun: PB vi TR do nhng nguyn nhn khc

V. IU TR 1. Nguyn tc: Tt c cc loi TVB nght khi c C phi x tr ngay cng sm cng tt 2. iu tr c th: 2.1. iu tr bo tn: C:

BN n sm trc 6h au t Cha c b/c: tc rut, VPM, hoi t rut K thut

Cho nm yn, dng thuc gim au, gim co tht Th y nh khi TV ln

o Nu ln c th theo di, c th c nh bng bng hoc qun chun, mang

prothese trnh ti pht sm. Sau m theo k hoch

o Nu ko ln, ko c y do c th y mt on rut b hoi t vo bng hoc gy

ra v rut => chuyn m sm Vi tr em: Cho gim au, gin c, ngm nc m 10-15 hi vng khi thot v t ln. 2.2. iu tr phu thut: a) Ch nh iu tr bo tn tht bi Trng hp nght hon ton, c ko hay ko c b/c

b) Nguyn tc:

M cng sm cng tt, tt nht l trong vng 6h u Mc ch:

Gii phng tng b nght

THOT V BN - I

Chung Thy 05 - 11 nh gi y cc tng thng tn X l cc b/c hoc cc tn thng Phc hi thnh bng theo cc phng php ph hp i vi tr em < 1 tui: nn m c tr hon v ng phc tinh mc c kh nng tip tc x ha bt kn ng TV, TV t khi. Thi gian ch i c th tr eo bng p ti ch d phng tai bin nght. c) K thut x l V cm:

Gy t ty sng l tt nht, thng dng nht, trnh c nhng b/c ca gy m, nht l trn ngi gi

Tr em, ngi d xc ng: gy m NKQ n mun c bin chng: Gy m NKQ ng rch:

ng phn gic gia np bn v b ngoi c thng to, bt u t l bn ngoi ko ln trn, di t 8 -12cm. Ri m theo tng lp gii phu i vo bao thot v

Tr em: Rch theo ng ngang trn l bn ngoi, di 3-4cm Trng hp c bin chng: ng gia trn di rn. Bc l v rch ti thot v:

Phu tch thn trng t nng vo su, trnh lm tn thng cc tng thot v bn trong Khi vo ti thot v, m rng ti v pha c Ngi ph nm gi quai rut ( rut ko b ko tt vo trong bng), PTV ct t c ti, gii phng.tng TV

X tr tng thot v:

Quan st tnh trng rut b TV Ko thm quai rut xung nh gi y , x tr khc nhau ty thng tn:

o Nu quai rut di ch tht c ti vn hng, bng, co bp bnh thng, mch

mc treo p tt: y li vo bng

o Quai rut c vi nt nghi ng hoi t, ch khc vn bnh thng: khu vi ni li o Nu quai rut b hoi t, tm en: cp ngay ch li, ct b rng ri on rut TV,
c th phc hi lu thng ngay bng ming ni tn tn hoc tn bn nu iu kin. Trong trng hp BN gi yu hoc tng thot v l 1 on i trng th a 2 u ra ngoi bng (kiu Mickulicz), khu phc hi lu thng th 2 o Trng hp nghi ng: THOT V BN - I

Chung Thy 05 - 11 p gc c huyt thanh m. Phong b novocain 0.5% vo gc mc treo v ch 10-15p Nu rut hng tr li: bo tn, nu ko th ct rut v phc hi lu thng ngay

o Nu l RT b nght: ct RT, vi gc. o Nu l mc ni b nght: ct b mc ni o Nu ti thot v l apxe, m: rch rng, dn lu, iu tr KS, m li sau
Khu phc hi thnh bng trnh ti pht: c nhiu phng php ty vo loi thot v v kinh nghim PTV Phng php Bassini o Phng php hay lm hin nay

o Khu 2 bnh din nng su, thng tinh nm gia bng ch ko tiu
Lp nng khu 2 mp c cho ln Lp su khu gn kt hp vi cung i sau thng tinh.

Pp Forgue: khu 2 lp nng su trc, thng tinh nm sau Pp Halsteat: khu 2 bnh din nng su sau, thng tinh nm trc Pp Schouldice: khu phc hi theo 3 lp: lp mc ngang, lp nng, lp su bng ng khu vt, ch ko tiu, khu i khu li=>m bo phc hi tt, t l ti pht thp Pp Macvey: ct rch c thng bng c th ko di thp gn kt hp xung khu vi cung i Pp dng vt liu tng hp phc hi thnh bng: tm dt Vicryl hoc Marcelence. Dng pp ni soi hoc m m t tm dt

Trng hp TR mun, VPM do hoi t:

M bng rng ri: ng trng gia trn v di rn nh gi y tn thng Phc hi thnh bng c th t bn trong hoc rch thm ng m thot v bn

3. iu tr ni kt hp: Tin hnh c trc, trong v sau m. Nu n sm th hi sc ni khoa n gin: truyn dch, nng cao th trng n mun phi HSTC:

t ng truyn TM : bi ph khi lng tun hon, b nc v in gii

THOT V BN - I

Chung Thy 05 - 11 Th oxy t sonde d dy ht lin tc t sonde tiu theo di lng nc tiu KS ton thn liu cao

Trng hp khi thot v c y ln: theo di ti vin, phng b/c mun Quan trng nht chm sc vt m tt, ko nhim trng vt m

4. Chm sc v theo di sau m Chm sc : Tip tc hi sc: truyn dch, sonde d dy ht lin tc KS ton thn Chm sc vt m tt, trnh nhim trng

Theo di b/c : Chy mu Rch thng bng quang Sng teo tinh hon Nhim trng vt m Khu vo rut.

Cu 2: Chn on xc nh v x tr thot v i nght I. I CNG ng i l im yu ca thnh bng trc bn, gii hn bi Pha trc l cung i (dc bn) Pha sau ngoi l dy chng Cooper Pha trong l dy chng Gimbernat Pha ngoi l b mch thn kinh i

Thot v i l TV l c lc, trong ti TV chui trong ng i di cung i. Do l TV hp, x chc => rt d b nght Hay gp n, thng ngi bo bu v cha nhiu. Cn phi C v x tr sm (< 6h) v x tr ngay trnh bin c/c: hoi t, tc rut, VPM.

II. CHN ON XC NH Da vo lm sng l ch yu.

THOT V BN - I

Chung Thy 05 - 11

Nhng C TV i nght thng kh khn v ti thot v ko to v au t, cc du hiu c nng v ton thn ko r rng nn cn phi thm khm t m. Tin s c th c TV trc hoc ko Triu chng khc nhau ty vo bnh nhn n sm hay mun

1. BN n sm (trc 6h): a) C nng: au vng bn i Xut hin t ngt sau khi BN lm ng tc mnh.

au nh, tc gc i, gim khi dui chn. C th c cn au bng i km nu bt u c dh nght rut.

Ch : TV t khi c biu hin r rt ngay c khi b nght hay tc rut, bn vn c cm gic kh chu vng bng hn l vng i C th i km nn hoc c cm gic bun nn.

b) Ton thn: t thay i, huyt ng bnh thng c) Thc th:

Thm khm t m cn thn, c bn i din v nhiu khi thot b b, su d b b qua Bnh nhn nm nga, i dng v chn dui Thy 1 khi phng c c im:

Khi phng trn, kch thc to nh ty trng hp Nm di np bn, hay chy di xung i (phn trn tam gic Scarpa) S c cm gic cng, chc, n rt au, nht l pha c ti (im au chi ng vi c bao TV) y ko ln, nn ko nghe thy ting c ch, ko thay i th tch khi ho rn G c

Bng mm ko chng. Ko c cc dh quai rut ni, rn b, PTB, CPM Ch : 1 s trng hp ch 1 phn quai rut b tht nght hoc ti TV nh, su, biu hin ti ch ko r, ch au bng v bun nn => quan trng phi tm c im au chi vng bn bu

2. BN n mun : Tu trng hp m din bin c th nhanh hay chm nhng thng sau 6-12 gi nu ko x tr g th cc triu chng thay i r rt. Ngoi cc trc nh G sm, cn c thm trc ca b/c: Tc rut, hoi t, VPM. a) C nng: THOT V BN - I

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Chung Thy 05 - 11

au bng tng cn, tng dn hoc lin tc, d di, xon vn. Nn nhiu lin tc, cht nn nu en B trung i tin. Tinh thn: lo lng, ht hong Du hiu mt nc, RL G: mt hc hc, mt trng, da kh, nhn nheo, kht, i t Ko st hoc st nh Mun hn c th shock do gim khi lng tun hon v RL G: BN li b hoc vt v, kch thch, da NM nht, v m hi, mch nhanh nh, HA tt.

b) Ton thn: Thay i r

c) Thc th:

Ti ch: vng bn bu sng n, ty , au chi, cng tc lm cho BN ko cho bc s khm Hi chng tc rut: bng chng cng, g vang, quai rut ni r, c dh rn b, ting ro di chuyn ca hi v dch, bng trc trng rng Mun hn c dh ca VPM: PTB, CPM khp bng, thm Douglas au chi i khi quai rut nght, ti TV v ra to apxe phn v m hoc l r tiu ha trn thnh bng

3. Th khng in hnh: Nght c th xy ra ph n bo bu, khi TV nh au pha trn, trong tam gic Scarpa au bng cn Nn nhiu B trung i tin

4. Cn lm sng Ko c gi tr chn on m dng hi sc, tin lng bnh 3.1. Xt nghim c bn: n mun c bin chng CTM: c c mu (HC, Hct tng). Mun hn: BC tng VSS tng SHM: Ri lon G (Na, K, Cl ban u gim, sau tng)

Ure, creatinin mu tng Men gan tng RL M (PT gim) Kh mu: pH gim, toan mu Nhm mu, HIV: phc v cho phu thut

THOT V BN - I

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Chung Thy 05 - 11 3.2. X quang bng KCB: hnh nh tc rut (quai rut gin, mc nc hi, bng m, thnh rut dy) 3.3. S bng: ko lm v vng hi. C th thy dch bng III. IU TR 1. Nguyn tc:

Khi chn on x phi x tr ngay cng sm cng tt (<6h). Thot v i nght ch c phu thut, khng dng bng gi nh thot v bn Mc ch:

Gii phng tng b nght nh gi y cc tng thng tn X l cc b/c hoc cc tn thng Phc hi thnh bng theo cc phng php ph hp

Ct b thot b cao: Vng i trong su, trong mt lp m, dy cung i cn tr c thot v => mun thot b ti thot v phi ct cung i hoc i t pha trn bng xung. Do c th dng ng rch thp i hoc ng rch cao bn.

Phc hi li thnh bng: khu dy chng Cooper dnh mo lc vi cc c cho nh, c ngang v cn ca c cho ln.

2. K thut: V cm: Gy t ty sng l tt nht, thng dng nht, trnh c nhng b/c ca gy m, nht l trn ngi gi Tr em, ngi d xc ng: gy m NKQ n mun c bin chng: Gy m NKQ ng rch:

Kinh in: ng vung gc qua cung i ngay trn khi phng thot v.

C th dng ng rch da ngay trn np bn, ta s thy cung i di v cn c cho ln trn

Trng hp c bin chng: ng gia trn di rn.

Bc tch ti thot v: Thn trng t t, ti thot v nm di cc lp x v m, bc tch cho n tn c ti TV Ct cung i: Cung i pha trc c TV, khi ct cung i c ti thot v s l ra, gii phng tng b nght. X l tng thot v:

THOT V BN - I

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Chung Thy 05 - 11 Quan st tnh trng rut b TV Ko thm quai rut xung nh gi y , x tr khc nhau ty thng tn:

o Nu quai rut di ch tht c ti vn hng, bng, co bp bnh thng, mch

mc treo p tt: y li vo bng. Dng kim xuyn qua v buc c ti li, ct ti di ch buc v nh vo thnh bng. o Quai rut c vi nt nghi ng hoi t, ch khc vn bnh thng: khu vi ni li

o Nu quai rut b hoi t, tm en: cp ngay ch li, ct b rng ri on rut TV,

c th phc hi lu thng ngay bng ming ni tn tn hoc tn bn nu iu kin. Trong trng hp BN gi yu hoc tng thot v l 1 on i trng th a 2 u ra ngoi bng (kiu Mickulicz), khu phc hi lu thng th 2. o Trng hp nghi ng: p gc c huyt thanh m. Phong b novocain 0.5% vo gc mc treo v ch 10-15p Nu rut hng tr li: bo tn, nu ko th ct rut v phc hi lu thng ngay o Nu l RT b nght: ct RT, vi gc. o Nu l mc ni b nght: ct b mc ni o Nu ti thot v l apxe, m: rch rng, dn lu, iu tr KS, m li sau o Trng hp hoi t, vim ty gc i: m bng ng trng gia di rn, ct on rut, khu ni li. on rut hoi t nguyn, dn lu hoi t. Khi no n nh th m li

Phc hi thnh bng: th quan trng nht

Khu dy chng Cooper vi c ngang, c cho b v cn c cho ln bng ch ko tiu mi ri bt kn vng i li. Ch : Khng chm vo cc mch mu cnh nh b mch TK i, M thng v.

Sau : khu bt l i (phng php c in) hoc khu bt l bn ln l i (pp Macvey) Khu da v lp m di da.

Trng hp TR mun, VPM do hoi t:

M bng rng ri: ng trng gia trn v di rn nh gi y tn thng Phc hi thnh bng c th t bn trong hoc rch thm ng m thot v bn

3. iu tr ni phi hp: (nt) 4. Chm sc v theo di sau m: THOT V BN - I

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Chung Thy 05 - 11 Quan trng nht ko nhim trng vt m, y l nguyn nhn gy tht bi cuc m.

THOT V BN - I

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