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NG C

MC TIU BI GING 1. Bit c cc bin php chn on s b cc trng thi ng c ngoi bnh vin. 2. Bit c cc bin php iu tr c bn cp cu c tnh cht sinh mnh tuyn ngoi bnh vin (mt tri thc, tr ngi chc nng h hp, ri lon tim mch, sc, ngng tun hon). 3. Bit c cc thuc khng iu tr chng c thng hay s dng trong cc trng hp ng c Phospho hu c, thuc phin, hi c, v cch s dng trong cp cu, cng nh cc bin php gy nn, ra d dy. I. I CNG: I.1. Tn sut: Chim 5 10% ca tng s bnh nhn nhp vin 15 20% cc trng hp gi cp cu vn chuyn n bnh vin. 20 40% cc bnh nhn iu tr ti khoa sn sc c bit ni khoa. 35 40% cc bnh nhn hn m khng phi chn thng. I.2. Nguyn nhn: 80 90% cc trng hp ng c do dng cc cht c vi mc ch t st. 10 15% do tai nn. 5% do ngh nghip. I.3. Loi cht c: Thuc chim 80 90% cc trng hp ng c. Trong : thuc ng v hng tm thn l 85%, c bit l cc thuc an thn. Thuc gim au chim 5% cc trng hp. Tuy nhin, cng c trng hp dng phi hp nhiu loi thuc, ch c chuyn khoa c hc mi phn tch c cc thnh phn ch yu. Ng c thuc + ru: thng nghim trng hn nhiu so vi ng c ru n thun. I.4. Phn loi theo gii tnh bnh nhn: T l n gii / nam gii = 2/1 Tui t 20 40 chim a s I.5. Mc ch iu tr ng c ngoi lai: I.2.1. Ch ng v ngn nga cc ri lon e do sinh mnh do tc dng ca cht c trc tip hoc cc bin chng th pht do cht c gy nn. I.2.2. Ngn nga v iu tr cc tn thng thc th do tc dng ca cht c. I.6. Ni dung iu tr gm c: I.3.1. iu tr c bn tng qut. I.3.2. iu tr c bn cp cu v cc bin php sn sc c bit phc hi v duy tr cc chc nng sinh mnh. I.3.3. iu tr c bit chng c: Bin php iu tr cp cu v sn sc c hiu o thi hoc ho gii cht c cn cha c hp th, chng cc tc dng c, v tng tc o thi cht c c th c hp th. II. CHN ON: II.1.Ngoi bnh vin: Kim tra mi trng bnh nhn ang : tm cc bao b thuc s dng, cc chai l ng tim ng cc cht kh nghi. Hi bnh nhn (nu c) v cc ngi thn cn: cht g? Bao gi? Nh th no? Ti sao? Cc biu hin khng mun sng hoc mc ch t st. II.2.Nhng triu chng thng thng ca ng c: II.2.1. Ri lon TKTW: Suy sp TKTW: ri lon tri thc hoc hn m. Kch thch TKTW: mt ng, l ln, kch thch, dy da, run ry, co git. II.2.2. Triu chng d dy, rut: Nn, c gng ma, ma, i lng. 92

II.2.3. Tn thng da: Ni mn, km nt phng hoi t trung tm, c th xut hin bnh nhn mt tri thc, ko di 6 8 gi, sau khi ng c thuc ng hay hng tm thn, cc nt phng (gi l nt phng do thuc ng phlyctenes barbituriques) nhn thy mt c chn u gi hng vai. Bng ho hc sau khi dy phi cc cht n mn gy tn thng da ging nh cc vt bng sau khi tip xc vi cc dung mi ho tan v cc hp cht ho hc khc. II.2.4. Mi hi: mi hi h hp hoc cht nn c th khu gi kiu ng c II.3.Khi vo vin: II.3.1. Tin hnh cc bin php pht hin cht c: LOI CHT C NGHIM PHP PHN NG - Thuc ng - Chit xut chloroforme - Chuyn mu xanh dng + Acetate de cobalt - Phnolthiazine + Hydroxyde de - Chuyn sang mu tm cam lithium - Paraquat - Cht phn ng (ractif) - Chuyn mu xanh l cy Meunier (FPN) - Dn xut hu c - Kim hobng Thionate de - c ch hot ng sodium - Cholinestrase Xc nh (bng dng c) cc kh hi, c bit trong kh th ra hoc cc cht nn. Chp bng khng chun b tm xem c cc vin thuc ng (bromure) trong d dy. Nghim php pht hin ng c do thuc: nh lng men, min dch, hunh quang, sc k (chromatographie) tng lp mng. II.3.2. Xt nghim: Tng hot ng men Cratinine Kinase (CK) trong huyt thanh, cc bnh nhn mt tri thc, khng c cc triu chng chn thng hoc chy mu trong ni s. Xc nh cc cht c c trong d dy, nc tiu hoc mu (huyt thanh). III. IU TR CP CU: III.1. Cc ng tc cp cu chung c tnh cht sinh mnh: III.1.1. Nguyn tc c bn cho tt c cc trng hp cp cu ng c: bnh nhn trong t th nm nghing. m bo lu thng ng th (gii thot cc d vt). Thng kh nhn to nu c suy th hoc ngng th. Hi sc tun hon h hp nu c ngng tun hon h hp. Truyn tnh mch, y mch mu nu c sc. III.1.2. Ri lon sinh mnh thng thng trong cc trng hp ng c: Mt tri thc. Tr ngi chc nng h hp (lit h hp, tc cc ng th, hi chng ht). Tc h thng ph qun. Ri lon vn chuyn oxy. Ri lon tim mch (sc, ngng tim tun hon, suy tim, ti lon nhp tim). III.2. Cp cu c th: III.2.1. a ngay nn nhn ra khi mi trng nhim: Trng hp b ng c do kh, khi c. III.2.2. Ci b qun o, lau ra da: nu cht c c kh nng thm nhp qua da. III.2.3.Gy nn: 1.Ch nh: Nu chc chn nn nhn ung phi cht c hoc xc minh c cht c (qua du vt cn li hoc bnh nhn cn tnh v hp tc, t khai bo). 2.Chng ch nh: Ri lon, mt tri thc (kh nng b hi chng ht) Bin php gii quyt: ra d dy. 93

Ung phi cc cht n mn, c kh nng gy tn thng thc qun v hu hng Bin php gii quyt: cho bnh nhn ung nhiu nc. Ung phi cc cht si bt: c kh nng gy ri lon h hp Bin php gii quyt: s dng cc cht chng si bt. Ung phi cc dung mi hu c c kh nng gy tn thng phi nghim trng Bin php gii quyt: ung than hot tnh. 3.Gy nn bng cc dung dch mn: 1 2 ly dung dch mui u trng nng (2 tha canh mui cho mi ly) ung nhanh. Trng hp c gng nn nhng cha nn c: bnh nhn cn ung nhiu nc trng hoc nhiu nc tri cy nn c nhiu. Kch thch phn x nn bng kch thch c vng hu bng. Ch c th p dng cho ngi ln hoc tr em > 10 tui. Khng c qun: Nu dung dch mn khng gy c nn, cn phi ht hoc ra d dy trnh ng c mui do hp thu mt lng ln mui. 4.K thut gy nn bng thuc Ipca: Sirop Ipca: s dng cho tr em < 1,5 tui : 10ml 1,5 12 tui: 15ml > 12 tui : 30ml Km theo: nc (nc tri cy, nc ch, nc trng) qua ng ming. Phi gy c nn trong 20 pht. Trng hp khng thun li: kch thch vng hu hng gy nn hoc kch thch nn. Chng ch nh: tr em < 8 thng tui. III.2.4.Ho gii cc cht c: 1.Khi ung phi cc cht n mn: Pha long mc c hiu qu bng cch cho bnh nhn ung nhiu nc (nc tri cy, nc ch, nc trng). S dng cc thuc chng acides trong trng hp ng c acides. Ung gim pha long (1%: 3 tha canh gim trong 1 ly nc) hoc nc tri cy trong trng hp ng c bi cc cht kim. 2.Ung phi cc cht gy si bt: S dng cc cht chng si bt. V d: Simthicome. 3.Ung phi cc dung dch du hoc cc dung mi hu c: Than hot trong cc trng hp ng c nghim trng: 30g bng ng thng d dy. Than hot bao gi cng thch hp, ngoi tr cc trng hp ung phi cc cht acides hoc kim. Liu lng nhiu nht c th, di dng dung dch qua ng thng d dy: 30g trong cc trng hp nghim trng. III.2.5.Cc thuc i khng: L bin php cp cu c th thc hin ngoi bnh vin trong cc trng hp nghim trng, khi cc bin php thng thng khng tc dng. 1.Ng c cc cht hu c: Atropine: 1 2 mg lc ban u, tip theo t 0,5 2 mg ty theo mc dch tit ph qun v tng tit nc bt. 2.Ng c thy ngn: Nitrite damyle: 1 ng, do bnh nhn t ht ly (nu Nitrite sodium khng c sn). Nitrite sodium: 6,6 mg/kg lc ban u, v tip theo 50 ml/kg dung dch 25% Thiosulfate sodium, tnh mch chm ( to thun li cho s hnh thnh Ferrihmoglobine v t tc dng th pht hn l Nitrite). Thiosufate sodium: sau khi iu tr DMAP (4-dimethyl amiphnol): 50-100mg TMC. 3.Ng c Mthanol: Ethamol (acool thylique) qua ng ung (vo khong 100ml dung dch ru 50%, thng thng l ru Whisky). Alcool thylique, nh git tnh mch chm, t c nng ru trong mu vo khong 0,001 mg/dl. 4.Ng c thuc m: 94

Trng hp e do lit h hp, nhng khng c kh nng t ng NKQ: Naloxone 0,01 mg/kg (nu cn c th 0,1 mg/kg), tim lp li n 8 ln . 5.Ht phi khi c: Stroides di dng bnh xt c van nh liu cho mi ln ht vo: u tin 2 4 ln ht Dexamthsone, tip theo 2 ln ht sau mi 10 pht, cho n khi bnh xt cn thuc. CC THUC I KHNG (ANTIDOT) IU TR NG C Ch nh Phospho hu c Baryum Plomb (ch) Cyanure Digitaline Thuc i khng Atropine Sulfate de soude EDTA calcique Edetate de calcium disodique Thiosulfate de sodium Khng th chng Digitaline c hiu (FBA): (Digibind, Burroughs-wellcome) Naloxone Dfroxamine Dimercaprol (BAL) Sinh t B6 Naloxone Bipridine Diphnyldramine Naloxone N-actyl-cystine Dimercaprol (BAL) Dexamthasone Sulfate de physostigmine Liu lng Bt u 1-2mg trong 15 pht. Tip theo, nh git TM 0,5-2mg/gi 15g (ung): 2g cho mi gram Cl2Ba Bt u: nh git TM 15-20mg/kg trong 2 gi. iu tr ko di cho n 50mg/kg/ngy Bt u vi Nitrite sodium vi liu lng 6,6mg/kg, ri 50mg/kg dung dch 25% Liu lng thch hp vi nng huyt thanh: 80mg Antitoxine inactivera/ 1mg Digitaline. 0,01mg/kg TM, ti a 8 ln; 0,1mg/kg khi cn cho ng c nghim trng. 1-2g (ung) 1-4g (ung)/ngy 20mg/100mg tim bp hoc ung 0,01mg/kg TM (n 0,1mg/kg) tim lp li 8 ln 0,04mg/kg TM chm hoc TB, lp li 4 ln. 50mg TM chm hoc TB 0,01mg/kg (n 0,1mg/kg khi ng c nng), tim lp li n 8 ln. Bt u 140mg/kg, ri 70mg/ 4 gi, cho n 17 ln tim (68 gi) 5mg/kg TB Bt u: 2-4 ln phun sng. Ri tip theo 2 ln phun cho mi 10 pht cho n khi ht bnh xt Liu u tin 3mg c tc dng trong 5-10 pht. Tc dng ko di t 20 pht n nhiu gi. Lp li khi cn.

Dextropropoxyphene St Vng Isoniazide (INH) Methadone Thuc lit TK (neuroleptiques) Thuc phin (Opices) Actominophne Thy ngn (v c) Hi c Hi chng khng cholinergique

GII C
I. GII C S KHI: loi b cc cht c trc khi chng c hp th I.1. Ra da hon ton I.2. Gy nn II.1. t ng thng d dy: Ra d dy I.3.1. Ch nh: Bt tnh, hoc tri thc ti tm trong trng hp ng c qua ng ung (xc nh hoc nghi ng). Lun c ch nh sau khi ung phi cc cht rt c, v d phospho hu c-Paraquat hay Deiquat, kim loi nng, ngay c khi bnh nhn c nn. Nu th gy nn bng huyt thanh mn u trng nhng tht bi. I.3.2. Cn tm hiu trc khi t ng thng d dy: 95

Khm xt cc ch nh t ng NKQ v kh nng t ng NKQ trc khi ra d dy. Phn x hu hng (sc, nut, ho l nhng phn x bo v): km hoc mt. Suy th. Ty ra a ra khi d dy cc dung mi hu c hoc dn xut du m ung phi. I.3.3. Chng ch nh: Ng c cc cht acide hoc cht kim vo giai on mun do c nguy c tai bin thng hoc lm nng hm mt tai bin thng xy ra. Khng c chng ch nh nu cn trong giai on sm I.3.4. K thut: Nm nga, nghing u sang mt bn, u thp (150) Quyt nh nn t ng NKQ qua ng no cho thun tin (trong cp cu ng ming thch hp hn ng mi). Chn ng thng d dy c khu knh ln (to bng ngn tay cho ngi ln). Ong thng c bi trn (vi nc, du, phun sng m). Kim tra v tr u ng thng bng bm hi v nghe vng thng v Lm sch d dy bng dn lu v ht. Gi li cc cht cha trong d dy. Ra d dy: nh ghi s lng dch cho vo v ht ra ( ngi ln, mi ln ra phi dng mt lng nc t 200 300ml c nhit bng thn nhit, lng dch tng th phi t nht bng 20 lt). Khi ra xong d dy, trc khi cp v rt ng thng ra d dy, phi t mt ng thng d dy qua ng mi lu ti ch. Qua ng thng d dy, bm than hot tnh (dng dung dch treo) hp thu (ngi ln: 30g). iu tr bng Sorbitol to i lng. II. GII C TH PHT TNG TC O THI CC CHT C KHI CHNG C HP THU: II.1.Cc loi cht c ra khi c th bng cc phng php: II.1.1. Thm phn mu (thn nhn to) II.1.2. Hmofiltration (lc mu): loi cht c ra khi mu. ng lc ca s trao i cc cht c qua mng lc l p lc xuyn mng. II.1.3. Hmoperfusion (ti mu): l bin php gii c ngoi c th. Cc ht than hot hoc ht nha c tc dng trao i ions c ti mu. Trong qu trnh ny, cc kh hoc cc cht ho tan c hp thu trn b mt cc vt th rn. II.1.4. Plasmaphrse (filtration plasmatique: lc huyt tng) Mc ch loi b protine ca huyt tng v cc cht c gn vi huyt tng. Huyt tng c ly i v thay th (chanephasmatique) Phng php: lc mu bng cc mng lc c l (spores) rng II.1.5. Ch nh: nu hi hai ch tiu: Khi c cc triu chng lm sng nghim trng: try tim mch tin trin, ko di, hn m su hn v h thn nhit ko di. in no dt lin tc hoc cch qung. Nng cht c trong mu cao, c kh nng gy cht. II.2.Tng thng kh iu tr cc trng hp ng c bng Hydro-carbures: II.2.1. Ch nh: 1.Xc nh Hydro-carbures chlora trong kh th ra (mc d c hoc khng c cc du hiu ng c in hnh) 2.Nu bnh nhn cn th t nhin y : cho th vo 2 3 lt CO2/ pht qua mt ng thng mi (c gn embout iu chnh chnh xc). Nu PaCO 2 > 50 mmHg, cn ngng ngay phng php. 3.Nu bnh nhn th my: iu chnh th tch thng kh/ pht: 20 30 lt. Cho CO2 b sung (7 10%) vo ton b lng kh th vo, ngn nga trng thi gim CO 2. Phng php tng thng kh phi ngng nu nhn thy khng cn du vt Hydrocarbures trong kh th ra, hoc khi cc men chuyn amines h cn 50 n v / ml, hoc t hn bnh nhn m men chuyn amines trc tng cao. 96

II.3. Tng li niu qu mc (diurse force): ch c ch nh vi cc cht c o thi ch yu bng ng thn, v d nh: Salicylate Bartital Phnobarbital Mui lithium Thalium Mprobamate Isoniazide Khng c qun: tng li niu qu mc c chng ch nh nu nghi ng c b ng c v trong cc trng hp hn m khng r nguyn nhn chc chn.

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