Bai giang Chng dc

1
Ngo doc cc thuoc v ha chat gay co giat
1. Bi giang: Lam sng
2. thi gian giang: 2 tiet
3. dia diem: Khoa Chong doc BV Bach mai
4. muc tieu hoc tap:
4.2. Chan doan xac dinh co giat do ngo doc thuoc v hoa chat
4.3. Chan doan phan biet co giat do cac nguyen nhan khac
4.4. Dieu tri co giat do ngo doc thuoc hoc hoa chat
5. Noi dung:
Mot vi con so (Dich te): Ty le nhiem doc cua Viet Nam ( theo nien gim
thong ke Bo Y te 2000, trang 158):
Gan 80 benh nhan N/100.000 dan/nam. Hay 800 benh nhan N/1trieu
dan/nam. 64000 trung hop N/ 80 trieu dan/nam
Ty le tu vong do nhiem doc l:
15 benh nhan tu vong/1 trieu dan/nam tc 1200 ngui chet/ 80 trieu dan
Tc nhan gay doc nhieu, phc tap, v nguy hiem
Ha chat bao ve thuc vat: gay co giat , gay roi loan nhip tim, roi loan tr nh v
tam than: Trifluoroacetate, Cyanacetamide, Striazin, Tetramin
Kim loai nang: Ch, Hg, Arsenic, Thallium...
Kh: CS (v kh ha hoc), CO, CN trong cc vu chy nh...
C nc, thit cc, ong dot, ran doc can, l doc , thuoc dan gian (mat c, d
mai...), nhiem doc thuc pham, nam doc, bot ngo...
Rat nhieu cc ha chat cong nghiep, nong nghiep v gia dung.
Ma ty (opiate, cocain, amphetamin...), HIV
Qu lieu v tc dung phu cua duoc pham dong - tay y
V nhieu doc chat cn chua xc dinh duoc
Nhiem doc thnh cum, hng loat, gay lo lang, bc xc cho xa hoi
Mot so vu dien hnh qua bo ch:
Mien Bac:
280 ngui nhiem doc bnh day tai 3 thon An Ph, Xuan Ph, Xuan An (Yen Dng,
Bac Giang) (Bo Lao dong ra ngy 27/6/2002)
87 n cong nhan cua X nghiep giy Lien Dinh v 119 n cong nhan cua cong ty
TNHH Sao Vng (Hai Phng) nhiem doc thc an (Bo Lao dong ra ngy
25/6/2002)
Vu nhiem doc bnh bot ngo o H Giang 2/2002, Cao Bang tu vong cao (19/21 BN)
Cc vu nhiem doc gay chet nhieu ngui o V Tay -Thi Bnh Thng (9-2002),
ong lam - Hiep Ha - Ph Tho (thng 12-2002) gay du luan xau trong nhan dan
v benh la v nhung hien tuong me tn cng bi ...
Mien Nam:
154 hoc sinh trung Duong Minh Chau (TP HCM) nhiem doc do thc an
nhiem vi khuan (Bo Lao dong, ra ngy 16/5/2002)
206 cong nhan cong ty Dong Yang (Long Khnh, ong Nai) nhiem doc thc
an (Bo Nhan dan, ra ngy 04/4/2002)
- Thnh pho Ho ch Minh nam 2002 so vu nhiem doc thuc pham l cao nhat
trong 4 nam qua trong d c 14 vu nhiem doc thuc pham o cc bep an tap the gay
benh cho 1465 ngui. ac biet l ti le nguyen nhan do ha chat chiem hon nua
(57,1%) cng c xu hung tang manh
Bai giang Chng dc
2
1. Chan don xc dinh:
a). Lam sng:
Co giat dot ngot xuat hien o mot ngui khong c tien su dong kinh l mot hoat
dong tu dong, khong mong muon cua co, ket hop vi mat thc tren mot benh nhan
th phai nghi den bi ngo doc mot ho chat, mot loai thuoc hay mot doc to no d. Co
giat l nguyen nhan chu yeu gay benh v tu vong do ngo doc.
Co giat km vi trieu chng c the dinh hung tc nhan gay doc:
- Cc dau hieu song:
Nhip tim nhanh, tang huyet p, tang nhiet do goi l ngo doc cocain,
amphetamin, hoi chng thm ruou, benzodiazepin, cc chat kch thch
khc, chat c che MAO, hoi chng S erotonin, hoi chng than kinh c
tnh.
Tim nhanh, ha huyet p goi ngo doc thuoc chong tram cam 3 vng,
theophilline, quinine hoac chloroquine
Nhip cham, ha huyet p goi thuoc c che beta (propranolone),
photpho hu co, carbamate, noc cc, digoxin
- Cc dau hieu ve mat:
Kho mat, c dn dong tu, goi Atropin Belladon, thuoc khng
histamin, thuoc tram cam 3 vng, ran ho can
ong tu co goi meperidin, photpho hu co v cacbamate,
propoxyphen
Rung giat nhn cau goi carbamazepin (Seduxen, diazepam,...) hoac
thuoc chong co giat khc
- Cc dau hieu ve da:
Da ti lanh, ut goi ngo doc Photpho hu co, hoac hoi chng thieu
benzodiazepin, ruou hoac barbiturates
Da do, kho thung gap trong ngo doc atropin, belladone
- Cc dau hieu ve tim mach:
Tim nhanh, QRS dn >100 rusei, ha huyet p goi ngo doc cc thuoc
chong roi loan nhip tim nhm 1, quirin, chloroquine
Roi loan nhip, Bloc A.V, ngoai tam thu that goi ngo doc aconitin (cu
au tau), nhip cham, QT ko di goi ngo doc noc cc
- Cc dau hieu ve ho hap:
Ph phoi cap, tang tiet dich phoi, goi ngo doc PPHC, Carbamate,
heroin, nicotine, salisylate, nam doc
- Viem gan cap: goi ngo doc nam doc, chlorin hydrocarbon, thuoc khng lao
- Ha Kali mu goi ngo doc Theophylline
- Ha Canxi mu goi ngo doc thuoc chuot tu loai Fluoroacetate
- Than kinh: kch thch roi loan tam than goi ngo docc cocain amphetamines,
thieu oxy do bat ky nguyen nhan no. Tr tre, hon me, l d goi ngo doc thuoc an
than, thuoc ngu, cacbon monoxide, opioids
Bai giang Chng dc
3
- Ha dung huyet goi ngo doc Iusulin, propranolon, cc thuoc uong ha dung
huyet.
b). Xt nghiem
Can kiem tra cc enzym CPK, AST, ALT: chc nang gan, than, dung mu cho
tat ca benh nhan
o corboxyhemoglobin, dinh hung thuoc trong mu
o kh trong mu, dien tim, dien no, CT scaner de kiem tra v theo di
2. Chan don phan biet voi cc trang thi co giat
Viem mng no, viem no, p xe no, u no
Tu mu dui mng cng, tai bien mach no, ph no
Thieu oxy, ha dung huyet, roi loan dien giai, nhip tim cham
ong kinh, hoi chng thm ruou v an than
Uon vn
3. Nguyen nhan gay co giat do doc chat v thuoc
3.1. Cc chat doc thung gap:
Khng histamin, khng cholinergic (atropin)
Cocaine, amphetamines, ergotamine
Kh CO (Carbonmonoxide)
INH (o benh nhan dang dieu tri lao)
Thuoc tr sau: Photpho hu co v cacbamate
Theophylline, Salicylate, thuoc chong tram cam 3 vng
Phenothiazine, Phencyclidine, Meperidin, thuoc gay ha dung mu
Strychnin (m tien), c trong ca thuoc diet chuot tu
Fluoroacetate, cyanoacetate c trong thuoc diet chu ot tu
3. 2. Cc doc chat t gap:
Butyrophenon
Thuoc diet muoi
Chloroquine, Lindane (dieu tri ghe)
Ch, Lithium, Hydrocarbons
4. Tien luong v cch phng:
Co giat ko di, lien tuc l nguyen nhan chnh gay tu vong v benh tat
do suy ho hap cap thieu O
2
, ton thuong no, v suy than cap do tieu co van
5. ieu tri
Muc tieu l bao ve dung ho hap v cat con co giat
5.1. Truoc benh vien:
- Trnh gay non
- Lay rang gia, trnh can phai lui, dat canun mieng
5.2. Trong benh vien:
a). Thuoc cat con giat:
Bai giang Chng dc
4
Diazepam (Seduxen, Valium) 5-10 mg tiem tinh mach trong 2-5 pht,
nhac lai sau 10 pht neu thay can. Tre em: 0,2 - 0,5 mg/kg moi 10 pht
neu can
* at ong noi kh quan neu diazepam khong dp ng, roi cho:
Phenobarbital: lieu 18 mg/kg, tinh mach cho ca ngu i ln v tre em roi
duy tr truyen 60 g/ pht, truyen nhanh c the gay ha huyet p
* Thuoc gin co, tho my vi oxy 40% neu Phenobarbital khong dp ng:
Phenytoin
Pentobarbital 5-6 mg/kg/gi
b) Thong kh, dam bao oxy (NKQ, Tho my)
c) Huy bo chat doc:
- Rua da dy: ong ln o ngui ln (36-42 French)
ong tre con (24-32 Frech)
neu ngo doc trong 3 gi dau, so luong ln
- Uong mot lieu than hoat 1-2g/kg, neu ngo doc mi trong 1-2 gi dau,
sau khi rua da dy hoac khong rua da dy
- Truyen dich dang truong t 2-4lt/ngy.
Trnh suy than cap do tieu co van hau qua cua co giat
d). Chat giai doc (antidote)
Co giat do ngo doc INH: dng Pyridoxine (vitamin B6) 5g t/m. Lieu c the
nhac lai mot lan na sau 30 pht (neu can) song khong vuot qu 10 g.
Bai giang Chng dc
1
Ngo doc thuoc tr sau moi Nereistoxin
PCS.IS. Aguyen Ihi Du
Iruong Khoa Chong doc-B\ Bach Mai
I. ai cuong
T truc ti nay, loai thuoc tr sau duoc ngui ta biet den nh ieu nhat l Photpho hu co v
tc dung diet tr sau hai manh m cua n, song cng chnh n d gay nhieu tu vong do ngo
doc cap v nhieu ngo doc mn lm cho tat ca moi ngui quan tam, nghien cu v xep loai
doc III. o nhieu nuc d c quy dinh nghiem cam sa n xuat v su dung loai ha chat ny.
Nuc ta cng khong nhap nhng loai ha chat Photpho hu co na. Tuy nhien, tren thuc te
lai xuat hien mot loai mi, duoc quang co manh m v dang su dung trong nong nghiep
nham diet sau cho la, hoa mu v hoa qua. l: Shachong Shuang (SCS), Shachong Dan
(SCD) do Trung Quoc san xuat, TmyQsx, hay Netoxin, Vinetox do Cty lien doanh cua
nuc ta san xuat, hoac Dimotrin cua Nhat, Panda cua M. Tat ca deu l loai Nereistoxin.
Nereistoxin trong cc pham thuong mai dng cho nong nghiep o tren duoc nhap vo nuc
ta l o dang hat, bui phun hay bot de tan trong nuc, thong dung v re tien l loai dang bot
gi 20g cua Trung Quoc v cua Si Gn lien doanh san xuat - cc mat hng d quang co
nhieu ve hieu qua tr sau v t doc ch o ngui. Song thuc te lai tri nguoc hon ton. Tong
thi gian 2002-2003, khoa Chong doc chng toi d tiep nhan 6 trung hop ngo doc cap v
3/6 benh nhan d tu vong. Sau day, chng toi xin trch dan ve 6 benh nhan tren.
II. Su benh nhan ngo doc Nereistoxi n tai Khoa Chong doc - BV Bach Mai
1. Benh nhan n, 23 tuoi, Thuan Thnh -Bac Ninh, chuyen den khoa Chong doc 1 gi sau
khi uong 1/3 gi (7g) Shachong Shuang vi muc dch doa tu tu. Khm lc vo: BN tinh,
keu dau thuong vi, buon non, non, da lanh, v mo hoi. BN d duoc rua da dy o tuyen
truc, uong than hoat v giam dau bang Atropin Sulfate. Tho 20lan/pht, M = 100
lan/pht, HA 95/60, sot 37
o
C, dong tu 3mm, HC 4,4, BC 16600, U 1,8 mmol/L, G =
6,4mmol, ChE 7042, Na 135, K 3,5, Cl 105, CK = 105dv, T: 100lan/ pht, xoang
bnh thung, Q
+
/Q
+C
=340/397 ms. Ra vien sau 2 ngy dieu tri.
2. Benh nhan nam, 27 tuoi, Vinh Tuy, H Noi. Ngo doc Netoxin (Si Gn -Viet Nam) v
tu tu, uong 1/2 gi (10g) netoxin cng vi uong ruou. 20 pht sau, non, dau bung, v
mo hoi, xe van chuyen cap cu, dua den khoa Chong doc trong tnh trang l d.
Glasgow 8 diem, da lanh ti, v mo hoi, dong tu 4mm, giam phan xa t chi, tho 30
lan/pht, M = 120lan/pht, HA 80/50 v 70/0, ia long phan mu tuoi, sot 39,5
o
C, CVP
= 1, ChE 10800, Amylase 299/4942. Cc xt nghiem chc nang than, gan bnh thung,
HC = 4,4, BC = 16700. BN duoc dieu tri: RDD, than hoat sau rua, truyen dich +
Stilamin, Transzamin, Dopamin, truyen mu. 3 ngy sau, BN hoi phuc ra vien
3. Benh nhan nam, 19 tuoi, Yen Phong-Bac Ninh, uong 1 gi Shashongdan (20g) vi ruou,
tu tu, duoc gia dnh dua ngay den BV huyen rua da dy, uong than hoat. 1 gi sau, xuat
hien co giat ton than, duoc dat NKQ, cho thuoc an than, chuyen ve khoa Chong doc -
BV Bach Mai trong tnh trang Glasgow 3 diem, do da ton than kieu gin mach, xuat
huyet, M = 150 l/ph, HA = 0, SpO
2
75%, ngng tho, giat co tu nhien, xuat huyet tieu
ha, chay mu mi, nuc tieu do sam. Sau 24gi cap cu (truyen dich, thuoc van mach
Sandostatin, thuoc bao boc da dy, NKQ, tho my), BN tie n trien xau: van tm, chay
mu, toan chuyen ha, HA 60/40, BC 16100, ChE 10380, CK 29950, T: Bloc NT
cap 1, T am nen gia dnh xin ve de chet.
4. Benh nhan n, 14 tuoi, hoc sinh, Que V -Bac Ninh, uong 1 gi Dibazan Nereistoxin tu
tu. 10 pht sau, xuat hien non, dau bung, ti lanh -> BV Que V rua da dy, uong than
Bai giang Chng dc
2
hoat. Ngay lc rua da dy, xuat hien co giat ton than. uoc dat NKQ, chong co giat,
chuyen den BV Bac Ninh, den khoa Chong doc -BV Bach Mai. Sau 9 gi, BN trong tnh
trang dong tu dn, liet co ho hap, hon me sau, HA 50/30, do da ton than dn mach,
phan mu, xuat huyet da dy, chay mu mi, toan chuyen ha, Prothoombri < 10%, Hc
3,73, BC 32900. Tai khoa Chong doc, dieu tri hoi sc rat tch cuc, tho my vi PEEP,
Human Albumine, truyen mu, Dopamin, Dobutamin, Omeprazol nhung bat kha
khng. BN tu vong trong benh canh suy da tang
5. Benh nhan nam, 41 tuoi, Van Lam-Hung Yen, uong 1 gi Apaschuang (Nereistoxin) tu
tu. 10 pht sau, non, dau bung, vat v, keu la. 1 gi sau vo BV Van Lam rua da dy,
uong than hoat, truyen dich. 8 gi sau d, chuyen den khoa Chong doc -BV Bach Mai
trong tnh trang tm ton than, ngng tho, dong tu dn, mach ri rac, da lanh. Khoa
Chong doc d cap cu v hoi sc tch cuc, tim dap lai, HA 110/70, CVP = 5, SpO
2
90%,
my co nguc, toan mu, chuyen ha pH 7,1, PCO
2
64, PaO
2
83, HCO
3
20,7, BE -20, HC
5,6, BC 3400, ChE 10610, Prothombin 21%, phan c mu, dich no tuy c mu hong
khong dong. BN tien trien xau, tu vong sau 10 gi nhap vien
6. Benh nhan n, 26 tuoi, Hung Yen, uong 1/2 gi N etoxin tu tu. 20 ph sau, non, dau
bung, ia chay, duoc dua thang vo khoa Chong doc rua da dy, uong than hoat, truyen
dich, mach, huyet p on dinh
Tren day l 6 BN (3 n + 3 nam) ngo doc Nereistoxin, tuoi t 14 den 41, deu song o vng
nong thon san thuoc tr sau, mot ngui uong t nhat l 1/3 gi, hai ngui uong 1/2 gi v ba
ngui uong ca gi. Ba ngui uong nua gi v 1/3 gi th song, cn ba ngui uong ca gi
deu tu vong, chiem 50%. Nguyen nhan tu vong l suy ho hap, tut HA, chay mu v toan
chuyen ha chi trong vng 2-3 ngy. R rng Nereistoxin l mot ha chat tr sau gay chet
ngui.
III. Nereistoxin l g?
Trong tu nhien, Nereistoxin duoc tm thay trong tuyen nuc bot cua 1 loai oc dac biet v
Nereistoxin c tc dung gay doc cho sau la, hoa qua q ua dung ho hap tieu ha v tiep
xc. Nereistoxin tro thnh thuoc tr sau do nhieu cong ty trong v ngoi nuc san xuat vi
nhieu ten thuong mai khc nhau nhu tren d ni.
Nereistoxin c ten goi khc l Dimehypo, Neretox.
Ten ha hoc cua Nereistoxin l 4-N,N-dimethylamino-1,2 dithiolane.
Phan nhm doc cua WHO: loai II
LD 50: 192mg/kg dung uong vi chuot duc
250mg/kg dung uong vi chuot ci
316mg/kg dung uong vi tho
o khoa Chong doc, lieu tu vong doi vi 3 BN l 400mg/kg
Dang su dung: Bot, nuc, bot dng gi 20g
Sinh benh hoc: Nereistoxin hap thu vo co the qua dung da dy ruot, da v dung ho hap
Nereistoxin tc dung truc tiep tren da dy ruot, gay tang co bp, non, dau bung, ia chay.
Tren he than kinh, Nereistoxin tc dung ngung chen hoat dong than kinh co. Thuc nghiem
dua 1mg/kg Nereistoxin vo tinh mach hau qua c 50% chen than kinh co trong 2 -5pht,
v tiep tuc s gay ra liet co ho hap v tu vong trong vi pht. Quan st mach v huyet p sau
truyen tinh mach Nereistoxin thay tim nhanh v giam huyet p tam thu v tam truong. Tuy
nhien, liet co ho hap gap nhieu hon suy tim - nguyen nhan tu vong neu khong c bien php
dieu tri kip thi
Bai giang Chng dc
3
IV. Chan don v xu tr:
1. Lam sng:
Cc trung hop nhe v trung bnh:
Cc bieu hien da dy ruot rat sm, xuat hien sau khi uong l dau bung, non mua v
ia chay, c the c chay mu tieu ha
Da ti lanh, v mo hoi, kch thch, mach nhanh
Trung hop nang:
Trieu chng da dy ruot nang ne, v mo hoi, gay ra giam the tch tuan hon, co giat
ton than, suy ho hap, tut huyet p, dn mach ton than, roi loan dong mu, toan
chuyen ha v suy da tang. Tu vong do suy ho hap, suy tim cap v chay mu nang
Theo di xt nghiem:
Hong cau giam khi chay mu nhieu, bach cau tang cao
Roi loan dong mu
Giam the tch tuan hon
Roi loan nhip tim
2. Pht hien Nereistoxin bang sac k kh (GC) hay sac k long
3. Xu tr dieu tri :
1. Loai bo chat doc
Rua da dy sau khi cho thuoc chong co giat v dat ong noi kh quan
Cho than hoat 1g/kg + 250ml sach quay deu bom qua xong da dy. Neu
chua dat duoc ong NKQ, BN cn tinh th cho uong than hoat
2. Ho tro v bao ve dung ho hap
at ong NKQ bom bng chn
Tho my khi roi loan thc
Tho O
2
v ht dm
3. at dung truyen tinh mach trung uong
o CVP
Truyen dich phan tu luong cao khi c soc
Truyen mu khi c chay mat mu
Dng thuoc van mach nang huyet p
4. ieu tri toan chuyen ha
Truyen Bicarbonate Natri
Loc mu
5. Thuoc giai doc
Cobal + Chloride c tc dung tot o chuot (Huj Zhang - China)
Bai giang Chng dc
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Neostiguine v 4-aminopyridine c hieu qua o tho (Shopp RT Dechie ZW
USA 1981)
Dimercaptosucimic acid (DMS) (Ding G-S, Liang Y-Y journal of Applied
Toxicology, Vol 11-No 1)
Tm lai, Nereistoxin l thnh phan trong thuoc tr sau Shachong dan, Shachongchuang,
Netoxin, Vinetox, Dimotin, Panda. Nereistoxin l mot c hat c doc tnh cao gay tu vong cho
ngui. Thuoc ny can duoc quan l chat ch, gio duc nang cao nhan thc cho ngui duoc
su dung. Cc nh san xuat can than trong du phng ngo doc khi dua ra thi trung quang co
su dung cc loai thuoc tr sau ny.
Bai giang Chng dc
1
Ngo doc thuoc gay nghien
( Nhm OPI, Heroin v morphin )
PGS. TS Nguyen Thi Du
Khoa Chong doc BV Bach Mai
Thuoc gay nghien: thuoc phien, codein, morphin v heroin rat de gay ngo doc cap khi xu
dung, dac biet o nhng ngui lam dung thuoc v phu thuoc thuoc.
C the tu vong do suy ho hap cap ( ngng tho, ph phoi cap )
Mot so dan chat opi l thuoc giam dau, giam ho ( dac biet l ho ra mu ) v cam ia chay,
dng di ngy c the gay nghien. Ngui benh thm thuoc, tm moi cch de c thuoc dng.
C thuoc lai dng qu lieu s bi ngo doc cap. Tiem chch khong vo khuan gay nhiem
HIV suy giam mien dich, viem noi tam mac.
ieu tri chu yeu dam bao thong kh v thuoc giam doc naloxon ( Narcan ). ieu tri cai
nghien duoc dam bao an ton nhat o cc Trung t am Chong doc.
I. Chan don ngo doc cap:
1) Chan don xc dinh:
Trieu chng ngo doc cap xay ra t 30 - 60 giay sau khi dua thuoc gay nghien tren vo co
the, ngui benh c cam gic ' khoi cam , ' em dem ( di may ve gi ), sau d di vo
hon me.
Cc dau hieu chu yeu:
Tho cham dan roi ngng tho, c the ph phoi cap, tm
Mat thc, dong tu co nho, mat cc phan xa.
Huyet p ha, lanh do ha than nhiet
Tren benh nhan tre, c vet tiem trch hay nghi lam dung thuoc
2) Chan don phan biet:
Hon me do uong thuoc ngu v an tha n qu lieu.
Hon me do ha dung huyet, thung gap o ngui tieu dung dng thuoc ha dung
mu qu lieu.
Tai bien mach no.
II. Xu tr:
1) Tai cho:
Thoi ngat 14 - 16 lan/1pht ( neu ngng tho )
Bai giang Chng dc
2
p tim ngoi long nguc ( neu ngng tim )
Tiem naloxon 0,4mg ( bap hay ti nh mach ). Nhac lai sau moi 5 pht.
Neu benh nhan tinh lai, tho duoc, khong tm, dong tu 3 - 4mm th thoi.
Neu benh nhan tinh, tu tho roi nhanh di vo hon me lai, tho cham, yeu, tm, cho
lai Naloxon v goi xe cap cu.
Thiet lap mot dung truyen tinh mach
2) Tren xe cap cu:
Bp bng ambu 14 - 16l/pht, 30% oxy
Hoac dat ong noi kh quan tho my, neu benh nhan c ph phoi cap, cho Lasix
40mg/TM.
Truyen dich - thuoc van mach neu ha huyet p.
Naloxone truyen TM 0,4mg/gi
III. Tai Khoa Cap cu v Chong doc
1) Neu benh nhan tho duoi 10lan/pht, tm, ha HA, dong tu co:
- Naloxon: 0,4 - 0,8mg TM.
Tre em 0,2 - - 0,4mg TM
Nam pht sau khong tinh lai c the cho tiep lan 2 hay lan th 10 cho den khi c ket qua,
giam dan naloxon.
Naloxon tiep tuc truyen lien tuc, duy tr 0,4mg/g i o ngui ln v 0,01ng/kg 3 pht o
tre em.
em nhip tho, theo di thc, huyet p v dong tu trong 10gi.
Thong kh nhan tao:
+ Bp bng ambu vi FiO
2
50%
+ Tho my khong xam nhap neu cn nhip tu tho.
+ at ong noi kh quan tho my ( dac biet khi ph ph oi cap ) trong khoang t 1
gi den 10gi
+ Truyen dich nang HA ( c the dng them thuoc van mach )
2) Neu benh nhan tho > 10lan/pht:
Naloxon 0,4mg tiem bap hay tinh mach.
Tho O
2
4lt/pht
Truyen dich ( glucose 5% )
Theo di nhip tho, thc v huyet p 15ph/ lan.
Bai giang Chng dc
3
3) Theo doi dau hieu thm thuoc sau dng naloxone.
l: ong tu gin ( v mo hoi ), son gai oc, vat v, run co, soi bung, non, tim nhanh, tho
nhanh . . .
Cho them cc thuoc ngu v an than, dong thi lap ke hoach cai nghien cho benh nhan.
Bai giang Chng dc
1
Ngo doc thuc pham
Ngo doc thuc pham (NTP) l cc hoi chng lam sng xuat hien do:
1. Thuc pham bi nhiem cc vi sinh v Ot hoac cc san pham cua chng (thung gap
nhat),
2. Thuc pham bi nhiem cc ho chat doc, hoac
3. An phai cc thuc vOt hoac dong vOt c doc to.(11)
NTP c the anh huong moi doi tuong, moi quoc gia (8,9,14), c the tc dong
cng mot lc ti nhieu ngui, gay h Ou qua khong nhng ve y te (truc mat v lau
di) m cn ve kinh te, tr Ot tu x hoi.
o nuc ta, trong nhng nam gan day NTP xay ra c xu hu ng nhieu hon. N
khong khong cn chi l van de y te m d can den su tham gia cua nhieu ngnh
chc nang c lien quan.
inh nghia thuc pham :
Thuc pham l nhng do an, thc uong cua con ngui o dang tuoi song hoac d qua so
che, che bien bao gom ca do uong, nhai, ngOm v cc chat duoc su dung trong san xuat,
che bien thuc pham.(2)
Phan loai thuc pham
Theo phan loai Lurocode Main Food Croup Clasijication and Policy, version 99 -2. htm
(16) phan loai ny gom hai phan :
1.1. Phan loai cc nhm thuc pham ch nh :
1.1. Sa v cc san pham t sa
1.2. Trng v cc san pham t trng
1.3. Thit v cc san pham t thit
1.4. C, loi nhuyen the, b st, loi tom cua v cc san pham 1.5.
Dau, m v cc san pham t dau, m.
1.6. Ng coc v cc san pham t ng coc
1.7. Hat dOu, cc loai hat, nhan cua hat v cc san pham.
1.8. Rau v cc san pham t rau.
1.9. Qua v cc san pham t qua.
1.10. ung, cc san pham dung, cc san pham socola v bnh keo.
1.11. o uong (khong phai sa).
Bai giang Chng dc
2
1.12. Cc thuc pham khc, cho, sp, canh, nuc sot, nuc mam, tuong v cc san pham.
1.13. Cc san pham dng cho muc dch dinh dung dac biet. 1.2. Mo ta,
phan loai v m ho cu the tng nhm thuc pham cng vi c c v du.
Phan loai thuc pham Aynrveda (Aynrveda jood classijication)(17): Chia thnh 10 nhm
thuc pham l : Thit, sa, dau, bnh keo, d Ou, rau, qua, rau thom v gia vi, ng coc, hat.
Vi cc dac diem cua tng nhm ve vi, che bien nng hay lanh, tc dung sau khi duoc
tieu ho v tnh chat vOt l.
Tieu chuan ve sinh thuc pham :
Theo danh muc tieu chuan ve sinh doi vi luong thuc, thuc pham cua Bo Y te (3),
xin duoc neu tm tat, gom c :
Muc 1 : Gii han phu gia thuc pham v cc chat o nhiem :
Phu gia thuc pham:
Khi niem chat phu gia thuc pham.
Cc phu gia thuc pham duoc chia lm 16 nhm chat vi chc nang, cong dung, so
luong chat o tng nhm duoc php su dung. Tong so chat duoc su dung o tat ca
cc nhm l 246 chat.
V du : Mononatri L (-) glutamat (monosodium L(-) Glutamate, l my chnh,
thuoc nhm cc chat dieu vi (Flavo enhancers) so luong an vo hng ngy chap
nhOn duoc (ADI : Acceptable daily intake) khong gii han, vi thit cua hop gii
han toi da cho php l 500 mg/kg.
Gioi han cc chat o nhi em :
1.Cioi han nhiem doc to vi nam (Mycotoxin ).
2.Iieu chuan ve sinh an ton vOt lieu thiet bi bao goi chua dung thuc pham.
3.Iieu chuan ve sinh an ton do choi tre em.
4.Iieu chuan ve sinh thuc pham chat tay rua dng rua dung cu chua n v chua dung
thuc pham.
5.Kiem tra gioi han kim loai nng Sb, As, Cd, Pb trong dung cu chua dung, bao quan v
nau n.
6. Hm luong kim loai cho php trong cac loai thuc pham.
7.Cioi han thuoc thu y toi da cho php trong san pham thit
Bai giang Chng dc
3
Muc 2 : Du luong thuoc bao ve thuc vOt trong thuc pham :
Thuoc bao ve thuc vOt l che pham c nguon goc t ho chat, thuc v Ot, dong vOt,
vi sinh vOt dng de phng, tr sinh vOt gay hai ti nguyen thuc vOt.
C 144 thuoc BVTV duoc dng lm chi tieu, v du: Methamidophos (O,S -
Dimethyl Phosphoramidothioate) tren dua chuot, luong ton du toi da l 1 mg/kg.
Muc 3 : Trang thi cam quan v cc ch tieu l ho doi vi mot so mat hng luong
thuc , thuc pham chnh.
Muc 4 : Gii han o nhiem vi sinh vOt trong thuc pham.
Tuy nhien, vi su pht trien cua khoa hoc, nhieu ho chat duoc dua vo su dung
trong di song hng ngy, vi sinh v Ot cng thay doi dien mao do con ngui su
dung nhieu ho chat de tieu diet chng v cng vi nhieu l do khc khien cc
nguyen nhan cua NTP ngy cng tr o nen phc tap v kh kiem sot. V du, trong
linh vuc ho chat bao ve thuc vOt, cho ti nam 2000, o nuc ta c(1)
Trieu chng chung cua NTP
V c rat nhieu cc tc nhan vi sinh v Ot, chat doc v cc ho chat nen khi duoc
vo co the cng vi thc an s gay nhieu tri eu chng khc nhau.
Do dung tieu ho l con dung vo cua cc tc nhan d nen hau het cc benh
canh cua NTP deu c bieu hien mot mc do no d cua viem da dy ruot, c the
noi bOt o dung tieu ho tren hoac dung tieu ho dui. Cc hoi chng khc
thung thay bao gom cc trieu chng ngoi co quan tieu ho, dac biet l ve than
kinh (11).
Viec dnh gi mot trung hop nghi ng NTP khong chi dua vo cc trieu chng
khi benh nhan den vien m cn can quan tam den benh su, tnh chat thuc pham,
thi gian xuat hien cc trieu chng tnh t thi diem an uong, hon canh, ma v
cc trieu chng xuat hien o nhng ngui khc cng an uong loai thuc pham nghi
ng (21).
Tan xuat bi benh o nhng ngui khong cng an loai thuc pham nghi ng cng
gip chan don.
COn lam sng c the gip chan don nguyen nhan v dinh hung dieu tri.
Bai giang Chng dc
4
Trong pham vi de ti ny chng toi s chi xin de c Op ti cc hoi chng NTP c
tnh cap tnh, tc l cc trieu chng thung bat dau xuat hien trong vng 72 gi
(18). Cc trung hop khc bao gom cc hOu qua lau di cua NTP cap, ngo doc
cc thuc pham c cha cc chat doc vi hm luong thap nhung gay tch lu lieu
khi dng lau, cng de lai nhng h Ou qua khong km, chng toi khong c dieu
kien di sau.
Cc trieu chng cu the cua NTP s phu thuoc vo tng nguyen nhan.
Nguyen nhan NTP
Chua day mot nua so vu NTP duoc biet tm thay nguyen nhan(41%) (11). Trong d
do tc nhan vi khuan l 79%: ho chat 14%: virus 4% v k sinh trng 1% (10) v dung
nhu cc trung hop khong thay nguyen nhan l do virus gay ra (15).
Ngo doc thuc pham do vi sinh v Ot (13)
Nguyen nhan:
Vi cc thuc pham l rau qua, ng coc, hat, sa v cc san pham : Cc loi tu cau,
Bacilus cereus, Campylobacter fetus hoac yersinia enterocolitica.
Phu n c thai rat de bi nhiem Lis teria, cc thuc pham thung gap nhat l thit g
khong duoc nau chn hoac cc san pham sa bi nhiem Listeria monocytogenes.
Do nuc hoac dng nuc de rua thuc pham: Cc nguyen nhan l E.coli (ca loi
sinh doc to v xam nhOp), cc loi Shigella, Salmonell a enteritis, Y.
enterocolitica, C.fetus, hoac Vibrio cholera.
Do thit v trng: +Thung l thit d qua qu trnh xu l, thit duoc nau khong
k, bao quan lanh khong day du hoac v On chuyen khong dng, bnh ngot c kem
hoac c sa-trng v cc san pham c trng khc bi nhiem cc vi khuan vi so
luong dat ti mc do c the gay benh.
Cc vi khuan thung l cc tu cau, C.perfringens, B.cereus, cc Salmonella
v Campylobacter jejuni.
Co che:
Theo mot trong hai co che sau:
Viem da dy ruot do xam nhOp:
Vi khuan truc tiep xam nhOp niem mac ruot, gay thoi ho cc vi nhung
mao v phan ng viem manh m, bieu hien bang ia chay phan c mu,
non, dau quan bung v chung bung.
Bai giang Chng dc
5
Vi khuan thung gap nhat l Salmonella v E.coli xam nh Op.
Viem da dy ruot do doc to ruot:
Cc doc to cua vi khuan ph v co che v On chuyen nuc v cc chat ho
tan qua mng te bo dan ti ia chay phan khong c mu, dau quan bung,
chung bung v non.
Cc tc nhan thung gap nhat l cc loi tu cau, E.coli sinh doc to ruot,
Clostridium perfringens, B.cereus v Campylobacter jejuni.
Trieu chng:
Cc trieu chng thuc the khong dac hieu v chu yeu do mat nuc v cc tc dung
tai cho tren dung tieu ho cua doc to.
Dien bien: Hau het cc benh nhan sau vi ngy s hoi phuc hon ton.
Viec hoi ve qu trnh an uong v moi lien quan vi kh oi dau cua trieu chng s
gip hung ti nguyen nhan.
a. Thi gian u benh v bi benh: (*)
Thi gian bi benh Vi khuan
benh
(Trung bnh)
Trung bnh Thay doi
Tu cau 1 - 6 h 1 ngy 8 - 48 h
Gay hoi chng non 1 - 6 h 9h 2 - 10 h Bacillus cereus
Gay benh l ia chay 6 - 14 h 20h 16 - 48 h
Salmonella 8 - 48 h 3 ngy 1-14ngy
Sinh doc to ruot 12 - 72 h 3 ngy 1-14ngy E.coli
Xam nhOp ruot 6 - 36 h 3 ngy 1-14ngy
V. cholera 12 - 72 h 3 ngy 2-14ngy
Shigella 24 - 72 h
(ti 7 ngy)
3 ngy 1-14 ngy
Y. enterocolitica 24 - 72 h
(ti 6 ngy)
7 ngy 2-30 ngy
Campylobacter 2 - 11 ngy 3 ngy 2-30 ngy
C.perfringens 8 - 24 h 24 h 8 - 72 h
Bai giang Chng dc
6
b. Cc dau hieu song:
Sot: Goi benh l xam nhOp, v du nhu salmonella, C.fetus hoac E.coli.
Nhip tim nhanh do sot hoac mat dich.
Huyet p ha thung do mat the tch dng ke (tren 10 % tong the tch)
Nhiem Listeria c trieu chng sot v viem thanh quan.
Cc tc dung cua doc to , dac biet l mat nuc c the noi b Ot o tre em v ngui
cao tuoi.
c. Da: Da kho v do dn hoi km cho thay tnh trang mat nuc.
d. Tieu ho:
au quan khap bung, chung bung, ia chay, bung cang ton bo, co co bung chu
dong: Gap o hau het cc trung hop v khong dac hieu.
Khm truc trng thay niem mac bi viem, mun hoac xt nghiem thay c H em: Goi
tc nhan vi khuan xam nhOp.
e. ThOn: Luong nuc tieu giam cho thay tnh trang thieu dich.
f. Nuc v dien giai:
Non, ia chay v mat nuc dien giai theo con dung khong thay c the gay tang
Natri mu (mat nuc) hoac ha natri (mat natri ton bo co the), ha kali mu, ha clo
mu, ha magie mu, hoac ha phospho mu.
C the c kiem chuyen ho (non) hoac toan chuyen ho (mat bicarbonat do ia
chay).
g. Co xuong:
Thung gap co cng co lan toa v dau co.
Nhiem listeria c trieu chng dau co.
h. Than kinh:
Ngo doc thuc pham don thuan do vi khuan khong c trieu chng than kinh dac
hieu.
Neu c liet vOn nhn hoac liet t tren xuong th can nghi ng nhiem Botulium.
Nhiem Listeria c trieu chng dau dau d roi.
i. Ngui cao tuoi v tre em:
Cc trieu trng nang hon vi tre em v ngui cao tuoi mac d tu vong do soc v mat the
tch dich hiem gap ngay ca o doi tuong ny.
Bai giang Chng dc
7
Xt nghiem:
1. Xt nghiem mu c the thay bach cau da nhan trong mu tang, dac biet vi cc vi
khuan xam nhOp.
2. Soi phan c the thay bach cau, vi khuan gay benh.
3. Cay thc an, chat non hoac phan, dinh type huyet thanh vi khuan, xt nghiem doc
to (tu cau, E.coli sinh doc to ruot, C.perfringens). Cay mu cho thay vi khuan xam
nhOp.
4. re, creatinin v dien giai mu can duoc lm de dnh gi h Ou qua cua mat nuc.
Chan don:
1. Khi c nhieu benh nhan ti vien cng lc t cng mot noi hoac khu vuc cho thay
do cng mot nguon tiep xc.
2. Khai thc benh su ve viec dng cc thuc pham v thi diem trieu chng dau tien
xuat hien s gip pht hien nguyen nhan.
3. Cc co gang qu mc de xc dinh nguyen nhan v nguon benh t c nghia lam
sng.
ieu tri:
a. Nguyen tac chung:
Viec dieu tri nen tOp chung giam cc trieu chng buon non, non v ia chay cng
vi viec ch ti kha nang thieu dich v soc.
Vi cc benh nhan c mat nuc nang v soc, dieu tr i ho tro trong d c boi phu
dich c nghia song cn.
Viec phan biet ia chay do vi khuan xam nh Op hay khong xam nhOp thung du de
dinh hung dieu tri.
Can xc dinh thi gian v qu trnh benh nhan an uong doi vi tat ca cc thc an
duoc dng trong vng 48 gi.
Khi c nhieu ca cng xay ra can phai thong bo cho trung tam y hoc du phng.
b. Cu the:
Gay non, rua da dy: Ni chung khong can thiet do benh nhan non nhieu.
Khng sinh:
Trong trung hop nghi ng nhiem trng do vi khuan xam nh Op, cay phan
c the c ty le am tnh gia ti 40%, c the chi dinh dieu tri thuc te nhu sau:
Bai giang Chng dc
8
Ciprofloxacin, 250 mg, 2 lan/ngy, trong 5 -7 ngy, hoac
Trimethoprim/Sulfamethoxazole, vien 160/800 mg, 2 lan/ngy, trong5 -7 ngy.
Khi d xc dinh duoc nguyen nhan, dng khng sinh tuy theo vi khuan.
Do virus : (25)
Viem da dy ruot do virus xuat hien nhieu hon so duoc pht hien, cc nguyen
nhan d duoc xc dinh gom c : Virus Norwalk, Rotavirus, Adenovirus dung
ruot, Calcivirus.
Trong hau het cc ca viem da dy ruot do virus, chan do n xc dinh gap kh khan
do di hoi cc k thuOt chan don tuong doi phc tap.
Virus Norwalk:
uoc coi l nguyen nhan cua t nhat 1/3 cc vu dich viem da dy ruot do virus o
M.
Virus chiu duoc nhiet, gay benh o ruot non l chu yeu: gay giam tieu ho v h ap
thu cng vi viem ruot.
Trieu chng : non v ia chay cap tnh cng vi cc bieu hien giong cm, hiem khi
ko di qu vi ngy.
ieu tri trieu chng
Rotavirus :
Ton thuong : ph huy lp vi nhung mao, lm giam tieu ho v hap thu, thay doi
ny c the ko di ti 8 tuan.
oi tuong de mac : Chu yeu l tre nho, tre b sa me t bi mac hon.
Bieu hien : Non, sau d ia chay phan nuc, ko di trung bnh vi ngy, mat nuc
dien giai.
ieu tri : Boi phu nuc dien giai.
Do k sinh trng :
Do dong vOt don bo : (7)
Nhieu loai dong vOt don bo c the nhiem trong thuc pham v gay benh.
* Amibe :
Benh Amibe do Etamoeba histolytica gay ra
Bai giang Chng dc
9
Thuc pham bi nhiem : rau qua song, nuc l, thc an bi nhiem phan c kn amp, qua bn
tay ban.
Nung benh : 1-14 tuan, thung 2-4 tuan
Benh canh : - ly amp (benh amp dai trng):
+ Hoi chng ly, thung khong sot
+ Chan don : Xt nghiem phan tm amibe gay benh.
Benh amibe ngoi dai trng (p xe gan, viem phoi, trn dich mng phoi): Chan
don : Xquang, sieu am, chan don xc dinh bang cc phan ng huyet thanh mien
dich.
ieu tri : Metronidazol hoac cc che pham.
*Giardia :
ong vOt don bo c long roi Giardia lambia.
Thuc pham bi nhiem : Thuc pham nuc bi nhiem phan ngui v dong v Ot c au
trng Giardia.
Trieu chng : benh 3- 25 ngy: trung bnh 7-10 ngy. Bieu hien : ia chay, c the
phan m, dau quan bung, thung khong c ton thuong ngoi ruot, benh thung tu
gii han, dac biet o ngui sc de khng tot.
Chan don : tm thay nang hoac cc the tu dung trong phan (thuc hien t nhat 3
lan truc khi duoc coi l am tnh, hoac tm thay the tu dung trong dich t trng
hoac trong niem mac sinh thiet ruot non.
ieu tri : Metronidazol, quinacrin, Furazolidol.
Nhiem vi nam : (11)
Clavicep purpurea : c t rong cc loai ng coc, dac biet la mach
+oc to l Ergotamin : co bp co tu cung, co mach, c the dan ti hoai thu.
+ Hien nay hiem gap.
-Aspergillus (loi A. Flavus v A.parasiticus):
C doc to l aflatoxin
Thuc pham nhiem nam : Cc hat, hat dOu (nhu ngo, gao, la m, dOu
tuong, lac, hat bong), thuc pham ny thung duoc de o moi trung am, am.
Aflatoxin : chat gay ung thu manh, dac biet vi gan.
Ngo doc thuc pham do chat doc c san tu nhien trong thuc pham.
Bai giang Chng dc
10
Cay co (21,25,6,19 )
uoc biet rong ri v de dng nhat l cc chat c hoat tnh duoc l duoc thay trong nhieu
phan khc nhau cua cay co.
Cc Glycozide tro tim c t cc cay : c trong cay duong dia hong ( Digitalis purpurea)
v mot so cay khc.
Pyrrolizidine : c trong cay vi voi (Heliotropium) v mot so cay khc.
Cc alkloid Pyrrolizidine c trong cc cay ny c the gay sot, non, dau bung, v cuoi cng
vng da, co chung, dau hieu cua benh l gan tac nghn tinh mach.
* Cc cay ny duoc dng de che ch, gia vi, do uong c ga v cc thuoc dan gian.
Cay dOu thien l:(Lathyrus sativus)
Ou ny duoc bao quan o cc vng c nan di o chau Phi, chau .
Bieu hien : Liet dan 2 chi dui, liet cng, liet ny c the kch thch dan ti xo cot
ben teo co.
oc chat : Ngui ta cho l : - amino proprionitrile.
Cay dOu rang ngua (Vicia faba)
Hoat chat : Hat cha cc dan chat pyrimidine oxy ho, khi ngui an vo dong
thi neu c thieu men G6PD s gay thieu mu tan mu, khong phai tat ca
nhng ngui an deu bi.
cc nuc ia Trung Hai, viec pho bien loai d Ou ny nhu mot loai thuc pham
v su thung gap cua thieu men G6 PD c xu hung dong thi xay ra.
Bieu hien: Sau an vi ngy, thieu mu v sot noi b Ot sau d tu giam v het
trong vi tuan sau, tu vong 5%.
ieu tri : Chu yeu dieu tri trieu chng, ngui ta d de xuat viec lay hong cau
ton thuong ra bang phuong php huyet thanh.
Cc Glycozide c Cyanua.
Cc cay cha Hydro cyanua: San, Cc cay d Ou, bau b, dua chuot, mang, qua
Ake, chuoi chn, nhan hat qua mo.
Trieu trng ngo doc:
Roi loan tieu ho: au bung, buon non, ia chay.
Bai giang Chng dc
11
Than kinh: Chng mat, nhc dau. Nang hon c the co cng, co gi Ot, dong
tu gin sau d hon me.
Ho hap: Ngat tho, xanh tm, suy ho hap cap, gay tu vong nhanh.
Xt nghiem: Mu tinh mach do tuoi.
Chat non v nuc tieu c acid cyanhydric.
Xu tr:
Gay non, rua da dy bang dung dich thuoc tm 2/1000.
Neu nang dat ong noi kh quan, tho my, tang thong kh, Fi02=1.
Dng Hydroxocobalamin tinh mach, Glucose 20%.
Chong soc.
Nam
C hng nghn loi nam, chi dui 5% cc loi l doc. Song phan biet gia nam doc v
khong doc rat kh khan.
* Nam muc (Copriruss atramentarius)
oc to : coprine
Tc dung giong Difulfiram, khi an c uong ruou, sau 30 pht c nhip tim nhanh,
boc hoa, buon non.
* Nam phien dm chuong (Paneolus campanuletus)
oc to : Psylocibin
Tc dung : Sau an 30 - 60 pht, non nhieu, dau quan bung, ao gic, tang hoat
dong. Co the dung nap duoc Psylocibin nen thung lnh tnh .
* Nam mun trang (Amanita pantherina)
oc to : xit Ibotenic v cc dan xuat isoxazole
Tc dung : 20 - 90 pht sau an: gay lan lon, vOt v, roi loan nhn.
* Nam mat tri :(A. Muscaria)
oc to : cc hop chat muscarine
Tc dung : sau an 30 pht, tang tiet dich ngoai tiet, nhip tim ch Om v cc dp ng
cholinergic khc.
* Nam doc xanh den : (A. phalloides).
oc to Amatoxins v Phallotoxins
Bai giang Chng dc
12
Tc dung : Ngo doc kieu 2 pha : dau tien vi dau bung, non, ia chay xuat hien
612h sau khi an v thung het trong 24h. Sau khi benh nhan on dinh 1 -2 ngy,
benh tien trien vi suy gan, suy thOn nang ne, tu vong cao(30-50% ) c the loc
mu hap phu.
ong vOt : (25, 6)
Cc:
oc to: Bufotalin, Bufotenin, Bufotonin, c trong cc tuyen dui da, gan, trng.
Trieu trng: Xuat hien 1-2 gi sau khi an:
Roi loan tieu ho: au bung, buon non, non.
Tim mach: Lc dau c huyet p cao, nhip tim nhanh, c the do Bufotonin.
Sau d roi loan tnh kch thch: ngoai tam thu, con nhip nhanh that, flutter
that, rung that. oi khi c block nhi that, nhip nt, dan den truy mach. C c
roi loan nhip c the do Bufotalin.
Roi loan than kinh v tam than: Bufotenin c the gay ao gic, hoang tu ong,
roi loan nhan cch, lieu cao hon c the c che trung tam ho hap, ngng
tho.
Ton thuong thOn: Viem ong thOn cap.
Xu tr: Thai tr chat doc, dieu tri ho tro v loc mu khi can.
C nc
oc to l Tetradotoxin : ben vng vi nhiet, c nhieu o cc tang v dac biet l gan,
da, trng, so luong thay doi theo ma.
Trieu chng than kinh v tieu ho xuat hien 10 -40 pht sau an, nhung c the
chOm hon gom di cam, te (dac biet quanh mieng v o lui), chng mat, mat dieu
ho, tang tiet nuc bot, gi Ot co, non, kh nuot, dau bung, ia chay , mat tieng, liet,
chu yeu co ho hap. ong tu lc dau co sau gin mat phan xa nh sng, tut huyet
p, loan nhip tim, suy ho hap. Benh nhan van tinh truc khi chet, tu vong 60%.
Chan don : Hoi benh, dien bien lam sng, c the xt nghiem doc chat vi mau c
nghi ng.
ieu tri :
Gay non, rua da dy, than hoat.
ieu tri ho tro: at ong noi kh quan, th o my c liet co ho hap c suy ho
hap, dam bao huyet p, nhip tim.
Bai giang Chng dc
13
C Scombroid
Cc c c m trong thit nhu c ng, c thu, doc to tch lu dan trong thit c do
duoc giai phng dan t qu trnh decacboxy ho histidine cua vi khuan (chu yeu
do Proteus morganii), doc to c lie n quan ti Histamin, ben vng vi nhiet.
Trieu chng : 15 - 45 pht sau an, xuat hien cc trieu chng dac trung cua phan
ng Histamin boc hoa, dau dau, chng mat, dau bung, non, buon non, ia chay. Cc
trieu chng het sau vi gi v khong c tu vong.
ieu tri : Thuoc khng Histamin
Ngo doc ciguatera
Chu yeu do an phai cc c nhu c nhong, c chi vng v cc loi c o tang dy
bien khc. Khi cc loi c to hon an c nho hon cha mot loi tao Lyngbia
majusula th loai tao ny duoc tch ly dan trong thit c v giai phng doc to khi
ngui an phai.
Ban chat l doc to than kinh, khong de bi bat hoat b oi nng hay lanh, gay di cam
(dac biet moi, lui v hong), nga, cc trieu chng tieu ho trong d c non, ia
chay. C the c benh l no, suy ho hap v soc.
Cc trieu chng thung bat dau 12h - 30h sau an, thung l trieu chng tieu ho
truc tien.
Chan don : dua vo lam sng v hon canh, c the xt nghiem nhanh doc to trong
mau c bang 1 test don gian.
ieu tri : ieu tri ho tro
Ngo doc trai, s :
Do an cc dong vOt than mem c 2 manh vo, cc dong v Ot ny c cha tao
Gonyanlax.
Trieu chng : Te o mat, mieng, te cng sau d te o tay v chan, cc bieu hien r
sau an 30 pht, kh nuot, kh ni, chng mat, dau dau vng trn, tu vong (do suy
ho hap), c the km theo nhiem khuan do cc vi khuan c trong s, trai v di ng.
Chan don :
Khi thay benh nhan d an thit hoac uong nuc cua trai, s truc kh i bi
benh.
C the xt nghiem doc chat bang quang pho hoac thu nghiem sinh hoc tren
chuot.
Bai giang Chng dc
14
ieu tri :
Rua da dy, than hoat
ieu tri ho tro
Cc amin hoat mach :
Cc chat : Diamine Histamine v mot so monamine (tyramine, phenylethyl amine
v Serotonin)
Cc thuc pham cha cc chat ny :
* Hm luong tuong doi cao
+ Pho mt (pho mt , pho mt xanh v pho mt Rockopho)
+ Rau (rau bina, c tm)
+ Ruou vang do (vang kianti, Bourgogne)
+ C : C ng, c thu
+ Men ruou, bia.
* Hm luong tuong doi thap
- C chua
- Gan g, bia, xc xch
- Bap cai muoi
- Cc thc an ny lm tang Histamin nieu sau ba an.
- C thc an tuy c hm luong Histamin thap nhung c hm luong dng ke Histidine, khi
vo co the duoc chuyen thnh Histamin.
- Cc thc an c the c cha nhng chat c kha nang kch dong te bo mast giai phng
Histamin : trng, dau tay, socol a, c chua, cc qua ho cam, buoi. - Viec dng dong thi
mot so thuoc c che chuyen ho bnh thung cua Histamin (nhu Izoniazid) gp phan vo
van de ny.
- Cc thuc pham cha Monoamine :
* Tyramine :
Pho mt, men bia, vang do, c trch ngam dam, gan g .
So luong t hon c trong qua bo, chuoi, qua mOn do, c chua v c tm.
* Phenylethylamine :
C trong pho mt, vang do.
* Senotonin :
Bai giang Chng dc
15
C trong chuoi, da, qua chuoi l, qua bo, qua m On, c chua v mot so dong vOt
than mem (dac biet l bach tuoc)
- Cc trieu chng :
Roi loan vi gic, phong rop niem mac mieng, boc hoa, dau dau, co that phe quan, ha
huyet p, non, buon non, dau quan bung, ia chay. Cc trieu chng thung giam di sau vi
gi. o cc benh nhan nhay cam, c the dng cc chat khng H1, H2 d e phng hoac lm
diu di.
- Cc Monoamin hoat mach bi MAO chuyen ho, he men ny t Op trung o ruot. Cc thuoc
c che chuyen ho ny lm tang tc dung cua monoamin. Cc thuoc. :
Iso carboxazid (marplan)
Phenelzine (Nardil)
Tranyl cypromine (Parnate)
L cc thuoc chong tram cam truc day duoc dng.
+ Cc benh nhan dng thuoc ny can trnh cc thc an c monoamine
+ Cc benh nhan c nguy co l benh nhan Migraine v nga man tnh, chu yeu trieu
chng s l dp ng ve co that .
NTP do ho chat trong thuc pham
Cc chat phu gia:(20, 25 )
Chat bao quan :
2 nhm duoc dng rong ri khap the gii l Benzoate v paraben.
* Ben zoate:
Uu dien: Pham vi chong vi sinh v Ot, nam rong ri, rat t hoac khong doc khi dng
dng hm luong, re tien.
Tc dung c hai hiem gap v hau het o ngui hen v nga man tnh. C the do cau
trc tuong tu cua Benzoate vi aspirin.
*Paraben :
Methyl paraben, propyl paraben, heptyl parabens.
uoc dng chu yeu trong do m pham, cc che pham thuoc duoc dng tai cho, c
the duoc dua vo cc thuc pham nung, cc rau qua duoc xu l, m, dau v bot
ngot.
Cc tc dung c hai : hau nhu chi c viem da tiep xc.
Bai giang Chng dc
16
*Sulfite:
Dioxide sulfua, Sulfite natri, Bisulfite natri v kali, Metabisulfite natri v kali, day
l cc chat bao quan v chong oxy ho, d bi cam tren rau qua.
oc tnh: c tu vong do sulfite, c the kch thch con hen, mat thc, soc
phan ve, ia chay, buon non v non.
*Natrinitrit :
Dng trong thit che bien
Tc dung : gin mach, d duoc pht hien l nguyen nhan cua 'Hotdog headache)
Cc chat dieu vi
Tr muoi an, chat thung gap nhat l Glutamat natri.
Tc dung : L mot chat kch thch, bang viec khu cuc, tc dung len cc receptor vi
gic, mot tc dung c lien quan ti tc dung c hai len cc yeu to than kinh ngoai
vi o noi khc ngoi mieng lui.
Tc dung phu thuoc lieu v phu thuoc c the.
Hoi chng 'Nh hng Tu :
uoc mo ta lan dau tien nam 1968 o M.
30% ngui M truong thnh bi anh huong, tre em de bi phan ng hon.
Bieu hien : Trong vng 1 gi tr o lai sau an: dau dau, lang lang, cam gic
nng bong quanh dau v co, that nguc, non, v mo hoi, tu het trong 1 gi
hoac lau hon. An nhieu c the lm kh oi pht con hen o mot so ngui.
Cc chat ngot tong hop:
* Aspartame v saccharin:
Cc chat ny c the gay nhieu roi loan: au dau ( trong d c hoi chng Migraine),
chng mat, co giOt, tram cam, buon non, non, v dau quan bung. C the lien quan ti
tnh trang hoat dong qu mc cua tre em. Phu n c thai can trnh dng cc bot ngot ny
mac d chua chng minh duoc tc dung gay ung thu.
Cc chat mu tong hop:
Cc chat mu c the thay o nhieu thuc pham, tre em v ngui ln c the tiep xc vi cc
chat gay ung thu nhu chat mu do so 8,9,19, v 37, hoac chat mu da cam so 17.
Bai giang Chng dc
17
Cc chat o nhiem:( 20, 23 )
Ihuoc tr sau:
Rau v qua c the cha tren be mat du luong ho chat tr sau v diet co nguy
hiem. Hm luong cc thuoc tr sau trong rau qua tuoi cao ti mc bo dong trong
khi cc thuc pham dng hop c hm luong thap hon nhieu.
Hon 40 % cc thuoc tr sau l phospho hu co, trong d c Malathion, Parathion,
Daizanon, Dursban ngoi tc dung c che Cholinesterase cn gay bat thung cho
bo thai v gay ung thu.
Chat doc mu da cam: Hon hop cua hai thuoc tr co 2,4,5 - T v 2,4- D c the gay ung
thu. Ngui ta cng d thay tc dung gay u no tren chuot cua cc chat ny.
Cac Dioxin: C 75 chat doc trong nhm Dioxin, l cc Clo hu co c doc tnh cao v ton
tai trong moi trung nhieu nam. Ngui ta d thay trong cc dong v Ot, cay co v c, dac
biet rong cc vOt nuoi, cay trong, thOm ch trong sa me. Co che gay doc: Dioxin gan
vi AND cua te bo lm thay doi viec doc m, chi mot thay doi nho c the anh hu ong ln
len di song te bo v cc the he te bo sau.
Cac dong vi phong xa: Bang viec o nhiem dat, nuc, thuc v Ot, dong vOt roi gay benh cho
con ngui. C nhieu chat dong vi phng xa trong d phai ke den mot chat nguy hiem nhat
trong l phan ng hat nhan l Plutonium vi thi gian bn huy l 24.000 nam.
Kim loai nng:
Ch xuat hien trong thuc pham c the qua rau qua v tron g sp duoc nau vi xuong
hoac cc nguon bo sung canxi duoc che t xuong, hoac qua nuc ngam v nuc
vi. oc tnh cua ch c nhieu trong d c gay ch Om pht trien the chat v tinh
than.
Thuy ngan: C o tang dy bien gan noi o nhiem c the bi nhiem thuy nga n. Nhng
ngui an phai thc an ny c the bi m, liet, v ch Om pht trien, dac biet o tre em
Bai giang Chng dc

Ng o do c r uo u
(Bi giang cho nhan vien y te co so)
BS \ Ihe Hong
BS Dng Quoc Iuan
Bo mon Hoi suc cap cuu
Irung Dai hoc khoa H noi
1. ai cuong
1.1. Ruou uong (Ethanol) l chat c tc dung c che than kinh trung uong, sau k hi uong
nong do ruou tang dan trong mu. Tc dong cua ruou thay doi ty tng ngui v luong
ruou d uong. Khi uong nhieu ruou, bieu hien say ruo truc het l tnh trang kch thch,
roi loan hnh vi, tc phong, sau d benh nhan di vo tnh trang c che, li b. Khi nong do
ruou trong mu cao qu benh nhan s bi ngo doc ruou.
1.2. Ruou methanol duoc su dung trong cong nghiep, c the gay cc ton thuong nang
tham ch tu vong.
1.3. Mot so loai ruou luu hnh tren thi trung cn c the cha nhieu chat gay nguy hi em
khc nhu aldehyt, tham ch cn c thuoc sau.
2. Dau hieu lam sng
Bi ny chi mo ta ngo doc ruou thuc su, l ngo doc alcool ethylic (ethanol).
+ Hon me : goi hoi khong dp ng, hoac dp ng khi goi roi lai nam yen
Giai doan sm : tho sau, mat do ut, mach dap manh
Giai doan muon : tho nhanh nong, mat kho, mach nhanh yeu, huyet p tut,
dong tu gin.
+ Non. C the sac chat non vo phoi gay ra suy ho hap : kh tho, tho nhanh, tm
moi, tho kh kh, loc soc.
+ Ha dung mu : thung kh pht hien tren lam sng, v cc dau hieu cua ha
dung mu bi hon me do ruou che lap. Neu nang c the c co giat.
+ Ha than nhiet : c the anh huong den than kinh trung uong, dac biet l ve ma
lanh.
+ Can ch l mot ngui say ruou c the bi ng, v c cc ton thuong do ng
(chan thuong, sac nuc, sac bn,...)
3. Xu tr
3.1. Say ruou
Sangs Chng dc

Chua phai l ngo doc ruou : benh nhan khong c hon me, goi van biet, tra li
duoc, khong c roi loan nhip tho.
+ Theo di that tot, neu di vo hon me phai dua di benh vien ngay.
+ Cho nam nghieng an ton de trnh tro nguoc chat non vo phoi.
+ u am, trnh cho c gi la.
+ Cho uong nuc dung neu cn tinh.
+ Neu cn tinh, di lai duoc : khong cho dieu khien cc phuong tien giao thong,
khong cho di mot mnh. Tho nhanh, manh, ni nhieu c the lm cho tinh ruou nhanh hon.
3.2. Ngo doc ruou
Khi nghi ng, hoac xc dinh mot ngui l ngo doc ruou can phai chuyen that sm
den benh vien.
Van chuyen : phai cho benh nhan nam tu the nghieng an ton de trnh benh nhan
ht phai chat non vo phoi gay suy ho hap nang.
Neu c the duoc :
- Truyen cho benh nhan dung dich dung Glucoza.
- Tiem bap 1 ong vitamin B1.
Viec dieu tri benh nhan ngo doc ruou o benh vien bao gom : cho tho my, truyen
dung dich dung uu truong, b nuc v dien g iai, rua da dy v cho than hoat. Neu benh
vien khong thuc hien duoc cc k thuat tren th phai so cu roi chuyen ngay den tuyen
chuyen khoa.
Bai giang Chng dc
1
Ngo doc cap quinine
Quinine l mot alkaloid cua vo cay canh -ki-na. N l dong phan ta tuyen cua quinidine.
Ngy nay, Quinine chi duoc dng de dieu tri sot rt khi k sinh trng khng vo cc
thuoc khc.
1. Chan don:
1.1. Chan don duong tnh;
a. Lam sng:
Hoi benh : dang dieu tri sot rt bang quinine, hoac c muon ph thai, hoac c l
do de tu tu, c vo thuoc hoac thuoc roi vi.
Trieu chng: tai, hoa mat, chng mat, non mua, roi loan thc, giam hoac mat
thi luc, diec mot phan hoac hon ton, nang th d a tm, lanh, ha than nhiet, di ra
huyet sac to, loan nhip tim, tut huyet p, hon me, chet do ngng tho sau vi gi
den vi ngy.
b. Can lam sng:
Xt nghiem tm quinine trong nuc tieu dng vai tr quyet dinh
ien tim: QT ko di, T det hoac dao nguoc, QR S dn rong, bloc nhi that cap 1,
khoang PR ko di.
1.2.Chan don phan biet:
Vi ngo doc quinidine hoac chloroquine: trieu chng tim mach nang hon, chan
don bang xt nghiem doc chat.
2. Nguyen nhan:
Ngo doc thung xay ra do qu lieu dieu tri sot rt, do tu t u hoac do uong lieu cao
vi muc dch ph thai.
3.Tien luong:
Lieu dieu tri v lieu doc cua Quinine rat gan nhau( lieu dieu tri: 1800 mg chia lm
3 lan trong khi lieu gay tu vong l 1800 mg den 8g). Mat khc, ngay vi lieu dieu tri cng
c the gay ra nhng roi loan dan truyen co tim. V vay trong qu trnh dieu tri sot rt bang
quinine can theo di dien tim de pht hien kip thi cc roi loan dien tim.
Du phng: quan l thuoc: giai quyet cc nguyen nhan dan den tu tu.
Bai giang Chng dc
2
4. ieu tri
1. Tuyen co so: Gay non neu benh nhan chua non, chua roi loan thc.
Than hoat: 1g/1kg can nang uong km sorbitol 2g/kg can nang (neu c).
Truyen dich: Glucose 5%, Natri clorua 0,9%.
Chuyen benh nhan den khoa cap cu gan nhat.
2. Tuyen Huyen:
- on dinh cc chc nang song: theo di cc dau hieu song(mach, huyet p, ho hap,
dien tim), tho oxy, truyen dich glucose 5% v natri clorua 0,9%, natri bicarbonate
1,4%.
- neu c suy ho hap: thong kh nhan tao bang tho my vi phuong thc CMV, Vt
10 ml/ kg, tan so: 16-20lan/pht,
- Neu tut huyet p: Dopamin 200mg 1 ong, pha vo 500 ml glucose 5% truyen tinh
mach 15 giot/ pht( khoang 8 g/kg/pht), dieu chinh toc do truyen de duy tr
huyet p mong muon ( huyet p tam thu > 90 mmHg )
- Theo di dien tim, pht hien v xu tr loan nhip. Truyen kiem de dat duoc pH
mu t 7,45 den 7,50 c the ngan nga roi loan dan truyen nang len v phng
duoc cc loan nhip gay tu vong. Khong su dung cc thuoc chong loan nhip nhm
1A v 1C...
- Han che hap thu doc chat: gay non neu khong roi loan thc, rua da dy 2-3lit
nuc(den khi nuc trong).
Than hoat 60g km sorbitol 120 g ho trong 100ml nuc, uong chia lm 3 lan cch
nhau 1-2 gi 1 lan.
- Tang do thai doc chat: Truyen nhieu dich(4 -5l/ngy) glucose 5% v natri clorua
0,9%, lasix 20mg tiem tinh mach , duy tr luong nuc tieu 4 -5 lt/ngy. Neu di t
hoac vo nieu can nhac chi dinh than nhan tao hoac loc mng bung.
-ieu tri ho tro: ch dieu chinh can bang nuc dien giai, dinh dung, cham sc
ton dien.
Chuyen tuyen tinh neu suy ho hap m khong c my tho, suy than m khong c
than nhan tao, hoac loan nhip phc tap m khong c my tao nhip.
3. Tuyen tnh:
ieu tri nhu tuyen huyen, neu suy ho hap cho tho my, chay than nhan tao neu c
chi dinh v dat my tao nhip neu c loan nhip ph c tap
Bai giang Chng dc
1
Ngo doc cap phospho huu co
I. ai cuong
Thuoc tr sau phospho hu co (PPHC) l mot trong hai loai thuoc tr sau thuoc nhm
c che cholinesterse dang duoc su dung rong ri trong nong nghiep. Cc ha chat tr
sau nhm clo hu co doc hon nhu DDT d bi cam hoac han che su dung. Do bi thuy
phan nhanh thnh cc hop chat vo hai v khong tch tu chat doc lau di trong moi
trung nen PPHC ngy cng duoc su dung rong ri trong nong nghiep(tr sau) cng
nhu trong nh( tr gin,muoi...).Cng v su dung rong ri nhu vay nen ngo doc cap
phospho hu co (NC PPHC) l mot benh canh cap cu rat thung gap, chiem khoang
80% trung hop ngo doc cap thuoc tr sau phai vo vien.
Phospho huu co (Organophosphate - O.P) l cc hop chat bao gom carbon v goc
cua axt phosphoric.Chat dau tien duoc su dung de diet con trng l Tetraetyl
pyrophosphate (TEPP). Ngy nay c hng ngn hop chat phospho hu co ra di nhung
van tren co so mot cong thc ho hoc chung:
C2H5O hoac CH3O O ( hoac S )
P
C2H5O hoac CH3O O
R
II. Chuyen ha:
Cc hop chat phospho hu co duoc hap thu rat tot qua dung da v niem mac, dung
tieu ha v dung ho hap. Nguyen nhan nhiem doc c the l s u dung khong dng
trong nong nghiep, tai nan, tu tu, v hiem khi l bi dau doc. Tu tu thung dan den
nhng nhiem doc nang nhat, sau d l tai nan trong nong nghiep v cong nghiep, roi
den tre em nhiem doc tai nh.C the gap ngo doc hng loat do thuc pham nhiem
doc.Cc dau hieu v trieu chng nhiem doc rat thay doi ty theo dung nhiem v mc
do nhiem doc: tuy nhien khoang thi gian t lc bi nhiem den lc xay ra trieu chng
thung dui 12 gi. Nhiem doc kh dan den trieu chng xay ra trong vng vi giay.
Nhung cng can biet rang mot so ha chat mi nhu diclofenthion v fenthion ha tan
trong m nhieu hon nen c the gay ra cung cholinecgic muon (sau vi ngy) v trieu
chng c the ton tai vi tuan den hng thng. Hien tuong ny c the l do thuoc tr sau
lc dau duoc gi lai trong cc mo m v sau d duoc ti phan bo vo mu. Ngoi ra,
ngo doc dung uong neu khong duoc tay rua dung tieu ha tot v khong duoc dng
Bai giang Chng dc
2
than hoat th thuoc tr sau dong trong ruot s tiep tuc duoc hap thu vo mu trong
nhng ngy sau v ko di qu trnh benh l.
Phospho hu co duoc chuyen ha v khu doc o gan boi cc enzyme mono -
oxygenase.Tuy nhien, mot so phospho hu co nhu parathion v malathion khi chuyen
thnh oxon lai c doc tnh manh hon chat me nhieu lan.
III. Co che tc dung v doc tnh
Acetylcholin l chat trung gian ho hoc tai cc synapes than kinh truc hach cua he
than kinh tu dong ( bao gom ca giao cam v ph giao cam) , cng nhu tai cc synapes
hau hach cua than kinh ph giao cam v day than kinh giao cam chi ph oi cc tuyen
mo hoi, o cc cc tan cng cua cc day than kinh van dong chi phoi cc co van, o cc
diem noi te bo than kinh trong no. Sau khi tc dong len cc receptor dac hieu o
mng te bo hau synap, Acetylcholin s bi thuy phan boi acetylcholinesterse( AChE).
Phospho huu co khi vo co the se gan voi AChE dan den phosphoryl ho v lm
mat hoat tnh cua ChE. Hau qua l su tch tu Acetylcholin tai cc synap than kinh.Su
tch tu ny gay len su kch thch lien tuc qu mc cc receptor o hau synap(lc
dau),sau d l giai doan kiet synap o ca he than kinh trung uong v than kinh ngoai
bien. Su kch thch dan ti hoi chng cung cholin cap v su kiet synap dan den
nhng thay doi bieu hien ra ngoi thnh cc trieu chng benh canh NC PPHC. C
hai loai receptor chiu tc dong cua acetylcholin: muscarin( o hau hach ph giao
cam)v nicotin ( o hach than kinh thuc vat v o cc diem noi than kinh co van -cc ban
van dong). V vay cc trieu chng lam sng rat phc tap v tap trung thnh cc hoi
chng benh l khc nhau.
oc tnh : lieu gay chet cho ngui ln khc nhau ty hop chat : 25g doi vi
diadinon,60g vi malathion trong khi d chi t 10 den 300mg vi parathion. LD50
cua cc OP cuc doc thay doi t 1,3 mg/kg(Tebupirimfos), 7mg/kg(Phosphamidon v
chlomephos) den 15mg vi Fenamiphos, 13mg/kg vi Parathion. Mot so loai PPHC
c doc tnh cao thung gap o Viet nam l: Methamidophos(Monitor) - LD50 = 30
mg/kg, Methidathion- LD50 = 25 mg/kg, Monocrotophos - LD50 = 14mg/kg...
IV. Trieu chng ngo doc cap:
Cc trieu chng cua ngo doc phospho hu co t nhe den nang bao gom mat ngu v roi
loan dinh hung, dau dau, chng mat nhn m, yeu co, mat dong van, my co, run co,
Bai giang Chng dc
3
liet co, ia chay, dau bung, chen nguc, tho rt v ho c dm. Co giat, roi loan thc, ia
di khong tu chu, hon me sau v truy mach l cc bieu hien cua tnh trang nhiem doc
nang. Cc dau hieu v trieu chng cua ngo doc phospho hu co s day du v de hieu
de nh hon khi xep chng vo cc hoi chng:
Hoi chng cung cholin cap:
Bao gom trong 3 hoi chng thnh phan: hoi chng muscarin, hoi chng nicotin v hoi
chng than kinh trung uong.
1.Hoi chung Muscarin: do tc dong cua acetylcholin kch thch hau hach ph giao
cam, tc dung chu yeu len cc co tron gay co that ruot, phe quan, v co tron bng
quang, co dong tu v giam phan xa dong tu /nh sng, kch thch cc tuyen ngoai tiet:
tang tiet nuc bot, dich ruot, mo hoi, nuc mat, dich phe quan... Benh nhan bi tc
nguc, cam gic chen nguc, kh tho, dau bung, buon non, non, ia chay, ia di khong tu
chu. Khm thay tnh t rang suy ho hap, long nguc cang km di dong, phoi nghe r ro
phe nang giam, c nhieu ran am, doi khi c ran rt. Tren tim mach c the thay nhip
cham xoang, giam dan truyen nhi that, roi loan nhip that.
2.Hoi chung Aicotin: do su tch tu cua acetylcholin o cc ban van dong dan den roi
loan su khu cuc cua cc co van gay giat co, my co, co cng co, liet co bao gom ca cc
co ho hap: kch thch he than kinh giao cam gay ra: da lanh, xanh ti (do co mach),
mach nhanh, huyet p tang, v mo hoi, dn dong tu.
3.Hoi chung than kinh trung uong :
Lo lang, bon chon, roi loan thc, ni kh, that dieu, nhuoc co ton than, hon
me mat cc phan xa.
Ngo doc nang: c che trung tam ho hapv tuan hon dan den suy ho hap ,truy
mach, co giat, hon me sau.
Hoi chng Muscarin vi bieu hien chnh l co that v tang tiet phe quan l hoi chng
xay ra sm nhat v o tat ca benh nhan NC PPHC. Cc hoi chng Nicotin(vi liet co )
v hoi chng TKTW thung chi gap trong cc trung hop nhiem doc nang.
Hoi chng trung gian :
L hoi chng liet co type II do tc gia ngui Srilanca dat ten nam 1987 vi cc dac
diem sau:Bat dau t 24-96 h sau nhiem doc, khi cc trieu chng cung cholin d duoc
giai quyet. H/c bao gom: liet cc co goc chi, co gap co, cc co ho hap v cc co do cc
Bai giang Chng dc
4
day than kinh so chi phoi, liet mem, giam phan xa gan xuong. Liet khong dp ng vi
diu tri atropin v PAM, di hoi thong kh nhan tao khi c suy ho hap. Hoi chng ny
c the chnh l hau qua cua su kch thch qu mc ko di cc receptor nicotin dan
den pha " kiet"cua h/c nicotin trong khi dieu tri tot h/c muscarin bang atropin.
Hoi chng benh l than kinh ngoai vi muon :
Xay ra 8-14 ngy hay muon hon sau NC PPHC. Benh canh bao gom: yeu co, liet co,
chng met moi, chuot rt, km vi cc roi loan cam gic ki eu te b kien b , thung
bat dau o dau chi, c the tien trien den liet ton than v cc co ho hap gay suy ho hap
v tu vong. Benh thoi trien sau vi thng den vi nam, teo co nhieu, phuc hoi cham v
khong hon ton. Co che sinh benh l do chet cc soi tr uc than kinh. Hoi chng ny
rat hiem xay ra.
Tien trien:
Trong NC PPHC, hoi chng cung cholin xay ra rat sm nhn chung thung l
truc 12 gi sau nhiem doc, c the vi giay sau nhiem dung ho hap, vi pht den vi
gi sau nhiem doc dung tieu ha: nhi em doc dung da mc do nhe c the den muon
hon. Trong hoi chng cung cholin th hoi chng muscarin thung den sm nhat v
l hoi chng trung thnh nhat, nghia l luon luon xay ra. Hoi chng nicotin v hoi
chng than kinh trung uong thung chi xay ra khi nhiem doc trung bnh hoac nang.
Tu vong thung xay ra sm trong ngy dau tien nhung cng c the xay ra trong
nhng ngy sau. Khoang 50% tu vong c nguyen nhan truc tiep l suy ho hap. C
nhieu nguyen nhan dan den suy ho hap: tang tiet v co that phe quan, liet co ho hap,
c che trung tam ho hap, boi nhiem phoi trong d nguyen nhan co that v tang tiet
phe quan chiem hng dau nhung lai c the khac phuc duoc nhanh chng vi lieu
atropin thch hop.
Hoi chng cung cholin c the ton tai hng tuan hoac lau hon . Vi dieu tri lieu PAM
thch hop hoi chng ny s rt ngan thi gian ton tai trong vng vi ngy(1 -4 ngy).
Hoi chng trung gian xay ra vo ngy th 2 -6 sau nhiem doc, khong dp ng vi
PAM v atropin, dieu tri can thiet duy nhat l tho my neu liet co dan den suy ho hap.
Thung khong c tu vong neu duoc bao dam ho hap v hoi phuc hon ton sau 1 -2
tuan.
Xt nghiem:
Bai giang Chng dc
5
Tm doc chat trong nuc tieu, trong dich da dy, trong mu bang phuong php
sac k lp mong v sac k kh.
XN enzymcholinesteraza hng ngy de theo di tien trien cua benh, phan loai
do nang lm can c dieu chinh lieu PAM dng cho benh nhan. C hai loai
enzym cholinesterase: acetyl cholinesterase ( cholinesterase hong cau) , Butyryl
cholinesterase (cholinesterase huyet tuong). Acetyl cholinesterase c trong
hong cau, to chc than kinh, phoi, lch v chat xm cua no: duoc nhieu tc
gia cho rang phan nh trung thuc mc do ngo doc hon: nhung toc do phuc hoi
cham (2-3 thng): k thuat xt nghiem cng c nhng kh khan nhat dinh lm
cho kh p dung lam sng.
Cholinesterase huyet tuong (butyro choliesterase) c trong huyet
tuong, do gan san xuat, nhung cng tm thay o to chc than kinh, tuy,
tim v chat trang cua no. Thay doi hng ngy ln, v bi anh huong boi
benh gan, viem mn, suy dinh dung, mocphin, codein, succinylcholin
v phan ng qu man. Giam nhanh trong nhiem doc cap v phuc hoi
khoang 10% -20% moi ngy khi benh nhan duoc dieu tri Pralidoxime
(PAM) day du. ac diem ny cng vi k thuat xt nghiem don gian
hon cholinesterase hong cau nen duoc dng de theo di tien trien trong
qua trnh dieu tri v l co so de dieu chinh lieu PAM.
ien tim: ghi dien tim v theo di tren monitor de pht hien roi loan nhip.
Cc xt nghiem khc : cong thc mu - ure - dien giai mu Transaminase mu,
Amylase mu, protein nieu te bo nieu.
chan don
* Chan don xc dinh ngo doc cap PPHC :
Benh su tiep xc thuoc tr sau trong vng 12 gi truc khi vo vien
Hoi chng cung cholin cap(+)
Xt nghiem ChE :giam <50% gi tri bnh thung (gi tri truc nhiem),
thuc te duoc thay bang gi tri toi thieu cua hang so sinh hoc
Xt nghiem doc chat nuc tieu hoac trong mu, dich da dy (+)
Chan don mc do nang nhe theo cc hoi chng benh l lam sng :
NC PPHC nhe : Khi chi c h/c Muscarin ( M )
NC PPHC trung bnh : Khi c h/c M+h/c Nicotin ( N )
hoac M+ TKTW
Bai giang Chng dc
6
NC PPHC nang : Khi c h/c M+h/c N+roi loan thc
NC PPHC nguy kich : Khi c 3 h /c tren cong vi suy ho hap cap
(PaO2 < 60 mmHg PaCO2 > 40mmHg) v / hoac truy mach.
Chan don mc do nang nhe theo gi tri nong do ChE huyet tuong :
NC PPHC nang khi nong do ChE < 10% gi tri bnh thung, trung bnh khi ChE =
10 - 20%, nhe khi ChE = 20 -50% gi tri bnh thung. Tuy nhien v thung khong c
duoc gi tri bnh thung nen c the su dung gi tri bnh thung toi thieu cua hang so
sinh hoc.
dieu tri :
1. Cap cu:
Neu benh nhan den sm , chua c trieu chng: Uu tien cc bien php chong doc : Rua
da dy, tam rua, goi dau..., P
Neu den muon, d c trieu chng ngo doc hoac bien chng: Uu tien hng dau l su
dung atropin (xem phan su dung atropin)v cc bien php hoi sc ho hap, tuan
hon(xem phan hoi sc).
2. Hoi sc:
-Hi sc ho hap l quan trong hng dau v phai song song vi viec dng atro pin, v
nguyen nhan chnh gay tu vong l suy ho hap. Tuy tnh trang suy ho hap m p dung
cc bien php hoi sc ho hap.Toi thieu nhat cng phai cho benh nhan tho oxy qua
sonde mi. Neu can th dat noi kh quan de ht dm v bp bng hoac tho my de bao
dam thong kh.
-Hi sc tuan hon: - truyen dich bao dam khoi luong tuan hon: benh nhan ngo doc
PPHC de bi mat nuc do non, ia chay, khong duoc an uong trong qu trnh dieu tri
...Ngo doc atropin cng gay nang them tnh trang mat nuc. Neu c tut huyet p t h
nen dat catheter tinh mach trung tam de truyen dich theo p luc tinh mach trung tam.
Neu d truyen du dich m van tut huyet p th mi cho dopamin 5 -10 Mg/kg/pht.
-Cc bien php hoi sc tong hop: trong d can ch ti dinh dung cho benh nhan.
Can bao dam nang luong 2000 Kcalo tro len. Trong 24 gi dau c the dinh dung don
thuan bang dung truyen tinh mach v phai cho benh nhan uong than hoat v thuoc
tay.Kieng m v sa trong vng 1tuan den 10 ngy de trnh tang hap thu phospho hu
co tan trong m.
Bai giang Chng dc
7
3.Cc bien php chong doc dac hieu:
3.1 Han che hap thu: Rua da dy l bien php giam hap thu hieu qua khi ngo doc
PPHC dung uong.Nuc rua da dy phai duoc pha 5 -9 g muoi an cho moi lt Vi than
hoat pha vo 2-3 lt nuc rua dau tien, luong nuc rua da d y chi can khoang 10lt tro
xuong. C the can rua lai lan 2 sau khi trang thi benh nhan d on dinh.
Neu nhiem doc dung ho hap: nhanh chng dua benh nhan ra khoi vng c kh doc
den noi thong mt.Coi bo quan o nhiem doc. Neu can c the thong kh nhan t ao de
tang thong kh.
Nhiem doc qua da: tam rua v goi dau cho benh nhan bang x phng.
3.2.Thuoc giai doc dac hieu :
Atropin l thuoc doi khng tc dung Muscarin v tc dung len he than kinh trung
uong cua O.P. N lm giam cc tnh trang: tang tiet phe quan, nuc bot, mo hoi, lm
mat dau bung, buon non, nhip cham v cam gic chen nguc, lm gin dong tu. Atropin
khong c tc dung tren liet co v suy ho hap o benh nhan ngo doc nang.
Muc dch su dung Atropin l tao ra mot tnh trang tham Atropin nham xo h et cc
trieu chng cua h/c Muscarin song chu yeu l lm tiet v het co that phe quan. Gin
dong tu, mach nhanh, da hong am duoc su dung nhu nhng yeu to tham khao cua tnh
trang ngam thuoc hon l muc dch dieu tri. V cng can nh rang mach nhanh, gin
dong tu c the l trieu chng cua hoi chng nicotin. ung dng Atropin thung l
tiem tinh mach cham, lieu thap c the tiem dui da v lieu cao c the duoc truyen tinh
mach lien tuc.
Lieu luong Atropin rat thay doi t vi chuc mg ti 20g trong ca dot die u tri, phu
thuoc lieu O.P v dp ng cua benh nhan vi Atropin . : bat dau bang tiem 2-5 mg tinh
mach nhac lai sau 5, 10 pht moi lan den khi dat duoc tnh trang tham Atropin. Tam
dng cho den khi het dau tham th tnh thi gian v lieu atropin d dng t d suy ra
lieu can thiet de duy tr dau tham.
Ve thi gian: tnh trang tham Atropin phai duoc duy tr cho den khi tat ca O.P d hap
thu duoc chuyen ho het thung t vi ngy den hng tuan. Giam lieu dan theo
nguyen tac dng lieu thap nhat de duy tr du oc dau tham . Ngng atropin khi lieu duy
tr giam ti 2mg/24 gi.
Tc dung phu cua Atropin: Qu lieu Atropin gay sot, da nng, tho rt, kch thch
(sang nhe), dong tu gin v mat phan xa, kho chat tiet gay tac dm.
Ngo doc Atropin dua lai nhieu nguy hi em :
Bai giang Chng dc
8
+ Lm benh nhan roi loan thc, gia liet co lm nham vi trieu chng NC PPHC
nang len.
+ Lm kho qunh dm dan den tac dm, xep phoi gay suy ho hap .
+ Tang nhip tim, tang nhu cau oxy co tim dan den nguy co loan nhip, truy mach.
+ Liet ruot gay chung bung can tro ho hap lm nang them SHH.
Tat ca lm cho tnh trang benh nhan nang len v lai duoc chan don l NC PPHC
nang do d tang lieu Atropin v PAM v c the dan den loan nhip, ngng tim do ngo
doc Atropin .
e trnh ngo doc atropin c t he p dung bang diem atropin de theo di phan biet gia
ngo doc v tham atropin nhu sau:
Trieu chng Tham atropin iem Ngo doc atropin iem
Co that v tang tiet
phe quan
khong nhung cn
dm long
2 m kho dac khong ht
duoc
4
ong tu 3-4 mm 1 > =5 mm 2
Da hong am 1 nng do 2
Mach 80 - 100 1 .> 100 2
tinh than tinh bnh thung 1 kch thch hoac li b 2
bung mem bnh thung 0 chung hoi, g trong 2
Cau bng quang khong 0 C 2
Cong tong so diem: Tham atropin: 4 -6 diem: Ngo doc atropin: > 6 diem
Pralidoxime l mot thuoc giai doc dac hieu theo co che trung ho doc chat.
T nam 1951 Wilson (tc gia ngui M) d cho rang cholinesteraes bi c che c kha
nang duoc ti hoat nh cc hop chat c kha nang nucleophile cao. Ngy nay d tong
hop duoc mot so hop chat nhu Oximes hoac acide hydroxamine. Trong so chng 2 -
PAM (2 pyridine aldoxime methyl iodure hoac clorua) ( dan chat cua Pralidoxime
)duoc nhieu tc gia ua dng
PAM s gan vng ben vi PPHC, gan long leo vi ChE tao thnh phc hop bo
3, sau d enzym tch ra de lai phan phosphoryl -oxime s tiep tuc thuy phan de
cho cc san pham thoi ho cua PPHC v axit phosphoric .Ahu vay PAM d
khu phosphoryl v tai hoat hoa ChL.
PAM cn tc dung phng doc bang cch gan vo v khu doc cc phan tu PPHC
cn lai trong mu.
Bai giang Chng dc
9
Hau het cc tc gia deu cho rang Pralidoxime l thuoc dac hieu can duoc su dung
trong dieu tri NC PPHC .Tuy nhien cch su dung v lieu luong c khc nhau:
Namba v CS 1971, Borowitz 1988, de Kort v CS 1988 : PAM c the hieu qua hon
khi duoc dng trong 24-48h dau, song n van c hieu qua 2 -6 ngy sau nhiem doc ,
nhat l o nhng benh nhan nhiem doc nang .
Mot so tc gia tiem TM 1g trong 10 pht, nhac lai moi 6 -8h trong 24-48h. Mot so
dng lieu 1-2g tiem TM hoac truyen TM vi 250ml NaCl 0.9% tr ong 30 pht, nhac
lai sau 1h v sau 6-12 h neu van c liet co v hon me .
Thompson cho rang truyen TM lien tuc 500mg/h tot hon l tiem TM .
Farrar 1990 d truyen duy tr 9-19mg/kg/h ngay sau lieu dau 25-50mg/kg pha trong
dung dich NaCl 0.9%.
Thi gian dng: nhieu tc gia cho l phai dng sm v PAM chi c hieu qua trong 24 -
48h dau sau nhiem doc.
Tuy nhien mot so khc lai cho rang can phai dng ko di v:
Mot so thuoc tr sau (parathion) gay su gi ho cham (slow aging) cua ChE
Khi uong mot lieu ln th PPHC dong trong ruot cn duoc hap thu dan
trong nhng ngy sau
Mot so OP tan trong m nhieu--> giai phng dan trong nhng ngy sau.
Wadia v Amin cho rang c the can truyen PAM trong 4 -6 ngy v ti 22 ngy dac
biet l o cc trung hop nhiem O.P tan nhieu trong m nhu Fenthion.
Thomson (1987): Truyen TM 0,5g/h duy tr duoc nong do > 4mg/L trong huyet tuong,
l nong do duoc coi l toi thieu c tc dung bao ve chong lai doc tnh cua O.P. Nong
do Pralidoxime giam xuong nhanh chng <4mg/L tr ong vng 1,5-2h sau tiem TM
1g bolus.
Tai A9, t 1996 d p dung 1 phc do su dung PAM lieu cao thch hop trong d PAM
duoc chinh lieu theo nong do ChE v cc h/c lam sng. phc do d dem lai hieu qua
cao: giam ti le tu vong cua ngo doc PPHC t 10% (1995 ) xuong cn 2%(1999-
2000).Phc do duoc trnh by dui day.
Nguyen tac su dung PAM :
- Dng cng sm cng tot, lieu cao dong loat ngay t dau.
- Truyen TM lien tuc.
- Lieu dng, thi gian su dung s duoc dieu chinh theo dp ng cua tng
benh nhan: trieu chng lam sng, lieu atrropin, su thay doi hoat tnh ChE.
- Giam lieu khi d kiem sot duoc h/c cung cholin
phc do su dung PAM
Bai giang Chng dc
10
* Ngay khi c chan don xc dinh v phan loai lam sng :
+ Nang ( v nguy kich ) : Tiem TM 1g trong 10 pht roi truyen TM
0.5-1g/h cho den khi tham Atropin hoac c ket qua ChE
+ Trung bnh : Tiem TM 1g trong 10 pht roi truyen tinh mach 0,5g/h
cho den khi tham Atropin hoac c ket qua ChE
+ Nhe : Tiem TM 0,5g trong 5 pht roi truyen TM hoac tiem TM 0,5g/2h
* ieu chinh PAM theo ket qua ChE hoac theo lieu luong Atropin nhu dui day:
(lay ket qua ChE lm can c chnh).
+ Neu Atropin > 5mg/h v/hoac ChE < 10% gi tri bnh thung toi thieu ( gtbt tt):
tiep tuc truyen 0,5g/h
+ Neu Atropin 2-5 mg/h v/hoac ChE 10-20% gtbt tt tiep tuc truyen 0,5g/moi 2h
+ Neu Atropin 0,5-2mg v/hoac ChE = 20-50 tiep tuc truyen 0,5g/moi 4h
+ Ngng PAM khi Atropin < 4 mg/ 24h v ChE > 50%
Chan dan qu lieu PAM khi:
ang truyen vi toc do >= 0,5g/h
Tham Atropin tot vi lieu Atropin t hap.
Xuat hien liet co ( mi ) hoac liet nang them.
Tang huyet p hoac truy mach.
ChE dang c khuynh hung tang lai giam.
oc tnh cua PAM :
- PAM c t doc tnh, lieu 40,5g trong 7 ngy hay 26g trong 54h d duoc dng m
khong c tc dung phu xay ra (Namba v CS 1971).
- Tiem nhanh qu 500mg/1pht c the gay ra nhip nhanh, co that phe quan, truy mach,
nhn m, chng mat, dau dau, non, cng co v liet co thong qua .
o nong do cao PAM c the c che hoat tnh ChE (th nghiem tren dong vat). Tuy
nhien, tc dung phu ny trong nhng lieu dieu tri rat t hoac khong gap o ngui.
Nhng nghien cu o ngui cho thay PAM c mot chi so dieu tri cao. Nhng lieu
ln ( truyen TM lien tuc 0,5g/gi) dng cho nhng ngui tnh nguyen trong thi ky
di khong thay gay doc.
Bai giang Chng dc
1
Ngo doc ma ty nhm Opioid
I. ai cuong
Ma ty l mot van de nhc nhoi cua xh trong nhieu nam qua.
Ma ty th/dng l opi, trong d ph/bien nhat l morphin v heroin. D
Cc kh/niem co ban
Opiat: Cc chat ng/goc t nhua cay th/phien ( ).
Opioid: Cc hop chat m tat ca cc t/dung tr/tiep deu bi Naloxone doi khng.
Bang 1: So snh cc thuoc giam dau gay ngu thung dng
Thuoc
Lieu v dung dng t/2 (gi) TD (gi) =10mg MSO
4
Tu nhien:
MSO
4
2-10mg,TB/TM
60mg, uong
1,5 - 2 4-5
Codein (Methylmorphine) 60mg, uong 2,9 4-6 120 mg
Bn tong hop:
Heroin (Diacetylmorphine) 3mg, TB/TM 1,5 - 2 3-4 3 mg
Tong hop:
Propoxyphene 65-100mg, U 3,5 2-4 240mg
Diphenoxylate 5mg, uong 12-14 6-8 240mg
Fentanyl 0,05mg, TB/TM 2-4 50-60ph TM
1-2 gi TB
0,125mg
Meperidine 50-100mg, TB/TM 3,5 2-4 80-100mg
Methadone 5-15mg, TB/TM 15 36-48 80-100mg
lch thch-c che
Pentazocine
30mg, TB/TM
50mg, uong
2-3 _
Nghien opioid l hien tuong phai lien tuc tang lieu de dat duoc cng mot dp ng sinh l.
Neu dot ngot ngng dng opiat, luong enkephalin noi sinh khong du gay kch thch than kinh,
tnh trang kch dong vi cc trieu chng thieu thuoc.
II. Bieu hien lam sng
C the sau chch, ht, ht hoac do dung qua da.
Do doi dng thuoc sang ngui bn khc.
Do tang lieu de dat khoi cam.
Bai giang Chng dc
2
Do tu st hoac bi muu hai.
Tre em c the bi tai nan
Nhng ngui khong nghien ma ty c the ngo doc dung uong do co tnh (tu tu) hoac do
tai nan dieu tri.
c che than kinh trung uong
L mot trong 3 tieu chuan cua ngo doc opiat.
Hiem gap co giat do qu lieu opioid tinh che ngoai tr o tre em hoac ngo doc propoxyphene
v meperidine.
Truong luc co thung khong thay doi nhung c the tang neu do qu lieu meperidine hay
fentanyl.
ng tu co nho
L dau hieu lam sng kinh dien th hai
c che ho hap c the gay tu vong
L dac diem th ba cua ngo doc opioid.
Tho nhanh nong c the thay o benh nhan ph phoi cap ton thuong
Do tc dung c che TlTW cua opioid, phai xt chan don viem phoi do sac
Tc dung tren he tim mach
Soc, truy tim mach: benh nhan ngo doc heroin do tiem chch c the vo vien trong tnh
trang soc. Soc c the l do suy tim ton bo cap, hoac do tiem doc chat vo tuan hon (hoi chng
soc do doc to - toxic shock syndrome).
Cc bien chng tim mach khc l loan nhip cham v loan n hip nhanh do quinine, rung nhi
kich pht, QT ko di, viem noi tam mac, ngng tim do tang kali mu, tam truong ko di, phnh
mach dang nam.
Cc tc dung tren he tieu ha
Buon non v non: dng cc lieu tiep theo lai c tc dung c che vng ny v sau d ra t kh
gay non.
Bai giang Chng dc
3
Nhu dong ruot giam trong khi truong luc cc co that tang dan den hap thu thuoc rat cham v
lm cho thai tr thuoc qua dung tieu ha c the cham ti 27 gi sau khi uong.
Cc bien chng khc cua NC opioid
Tieu co van, ha dung mu, tang t han nhiet...
III. Xt nghiem
Nong do heroin trong mu khong c gi tri nhieu ve lam sng nhung c the pht hien duoc
trong vng 36 gi. 6-MAM c thi gian bn thai trong mu ngan (38 pht) nhung c the pht hien
trong nuc tieu bang phuong sac k v l bang chng su dung heroin.
ieu tri
1. Hoi sc tim mach:
Dng van mach cho cc benh nhan tut HA. Theo di st tang gnh the tch, ch dnh gi
luong dich vo v ra. Sau khi benh nhan on dinh c the chup phim X quang nguc.
2. Hoi sc ho hap:
at NlQ neu c chi dinh. Naloxone TM 0,8-1,2mg, tiem lai cch moi 5 pht cho ti khi
benh nhan tinh, tho lai tot. Tut HA dieu tri bang van mach. lhong truyen nhieu dich o benh nhan
ph phoi. Neu tnh trang benh nhan on dinh chup X quang phoi v lm kh mu theo di. Theo
di lien tuc dien tim. Dng oxy v c the phai tho PEEP. Digitalis v loi tieu khong c nhieu tc
dung v l ph phoi cap ton thuong.
3. Naloxone
Naloxone l chat giai doc dac hieu c tc dung c che o ca 4 loai receptor opi (mu, kappa,
sigma, delta). Nhanh chng dng naloxone thung cu duoc benh nhan ngo doc opi.
Lieu dng
1) Lieu thung c hieu qua trong dieu tri cap cu l 1 den 5 ong (0,4 -2mg) tinh mach. nh
gi diem Glasgow hoac thang diem hon me khc. Neu khong c tc dung, dng them 1
lieu 2mg tinh mach (dng cch 2-3 pht cho ti tong lieu 10mg). Neu c dp ng 1 phan,
tiem TM cch 15 pht cho ti khi benh nhan tinh, tho duoc hoac khong c cai thien them.
Neu c dp ng, bat dau truyen tinh mach naloxone.
Bai giang Chng dc
4
2) Phc do lieu truyen tinh mach lien tuc de h oi phuc tc dung giam dau gay ngu d duoc
Goldfrank v cong su de xuat. Truyen tinh mach 4 mg naloxone/lt vi toc do 400 g/gi
(0,4mg/gi). o ngui ln, dng 4 mg/1000ml Glucose 5% truyen 100 ml/gi
Phc do dieu tri cap cu
ngo doc cap opi
Hon me
Tho cham, ngng tho, SHH cap
ong tu co nho
Tut HA
Vet tiem chch
Bp bng oxy 100%
Naloxone 0,4 mg tinh mach
Qu lieu ma tu
Bn tnh, tu tho duoc:
-Theo di
-naloxone
0,4 mg moi 20-60 pht
theo lam sng
- oxy 4 l/ph
-Truyen dich g5%,
nacl 0,9%, dam bao
HA
Bn khong tnh v/hoac tho <10 lan/pht
Sau 3 pht:
- naloxone 0,4 mg tm 2-3 pht/lan
- tong lieu 2 mg (5 lan)
dp ng 1 phan:
-bp bng
hoac tho my qua mat na
-truyen dich: g5%,
nacl0,9%
-naloxone 0,4 mg tm/30
pht.
Khong dp ng
-dat nkq
-tho my
ippv Peep
Bai giang Chng dc

Ngo doc kh CO
BS. Be Hong Ihu
Khoa chong doc :B\ Bach Mai
I.ai cuong ve CO
1. T le mac:
Ngo doc cap CO rat thung gap o Php (10000 cas/nam, 500 ngui chet) v rat
thung gap ngo doc nhieu ngui tr ong mot gia dnh.
Ngo doc cap CO l nguyen nhan gay tu vong hng dau tai M ( 5613 trung hop
trong nam 1979 - 1988 ).
Ti le di chng: 10.000 ngui phai mat t nhat mot ngy nghi. Di chng 4 - 40 %
benh nhan xuat vien.
2. ac diem l ho:
CO l mot chat kh khong mu,khong mi,khong vi, khuech tn manh,khong gay kch
thch.
CO c ti trong gan bang ti trong khong kh ( 0,968 )
Trong luong phan tu: 28,01 Dalton.
3. Nguon CO:
CO l san pham chy khong hon ton cua cc chat c cha carbon: nhu khi cua c c vu
dong dat, o nhiem khi cong nghiep, chat kh dong lau o ham l, tang ham, khi thuoc l,
khi cc l suoi, ..
4. Co che ngo doc CO
Khi vo co the: CO co dinh vo Hemoglobine (Hb) 85%, n c i luc gan vi Hb cao gap
200 - 250 an so vi oxy. Mot phan cn lai kh CO ho tan vo plasma v co dinh vo
myoglobine v vo cc cytocrome.
Ti le HbCO ( Carboxyhemoglobine ) duoc hnh thnh phu thuoc vo luong HbCO ban
dau ( dac biet o ngui ht thuoc ), vo thi gian nhiem, luong kh CO v thong kh cua
benh nhan.
Ti le HbCO: + Ngui khong ht thuoc l: 1 - 2%
+ Ht thuoc l: 5 - 10 %
+ Nong do doc: > 10%z
Ngo doc oxyt carbon gay thieu oxy te bo do lm giam ti le HbO2, lm giam giai phng
oxy t HbO
2
, lm giam su dung oxy cua te bo.
CO c the tham qua hng ro rau thai v co dinh vo Hb cua thai nhi.
CO duoc do thai qua dung ho hap dui dang khong thay doi. Thi gian bn thai l 4
gi. Khi thong kh vi oxy dang p th thi gian bn thai cn 80 pht v dui oxy cao p
th thi gian bn thai cn 23 pht.
CO gay ra thieu oxy chu yeu o he than kinh trung uong, doi vi co tim v thai nhi trong
thi gian c mang. Tnh trang thieu oxy s nguy hiem dac biet doi vi ngui ln tuoi,
ngui thieu mu, suy ho hap v suy tim.
Bai giang Chng dc

5.Pht hien v dinh luong:

Trong giai doan ngo doc cap, HbCO duoc din h luong bang my quang pho ke
(spectrophometri ).
Chan don xc dinh ngo doc CO dua vo ti le HbCO > 10%. Nhng ngui ht thuoc c ti
le HbCO cao t 3 - 8%, tham ch den 15 % ngay sau khi ht thuoc. o nhay cua HbCO
rat cao nhung do dac hieu thap.
inh luong CO cho ket qua dng tin cay, n duoc dinh luong bang su hap phu tia cuc tm,
ket qua duoc do bang mmol/100ml hoac ml/100ml. e chuyen don vi mmol% thnh
ml%, ta c cong thc sau:
CO ml% = mmol% x 2.24
o bo ho HbCO duoc tnh theo cong thc sau:
HbCO% = Ti le cua CO ( ml% )/ 1,39 x nong do Hb(g%)
Khi doc ket qua phai ch den thi diem lay mu so vi thi gian bi ngo doc v thi
diem ht thuoc cuoi cng o ngui ht thuoc l truc khi bi ngo doc.
Khi HbCO > 10% khang dinh chan don ngo doc CO.
II. Trieu chng cua ngo doc cap
1. Ngo doc cap c the gap trong cc dm chy lon v gay tu vong nhanh chng.
Khoi dau bieu hien bang dau dau, met moi, chng mat, buon non, nhn m, roi loan hnh
vi km theo cam gic sang khoi, nang hon c the dan den hon me. Chan don dua vo:
Hoi benh: hoi benh nhan v nhng ngui xung quanh: ngo doc thung xay ra vi
nhieu ngui song trong cng mot nh, v c the c nhng dau hieu nhe t nhng ngy
truc nhung khong duoc pht hien. Nhng vat nuoi trong nh l nan nhan cua ngo
doc CO, c the bi chet nhu ch, mo. Can hoi trong nh c dng l suoi khong, bep
than, hoac sua cha tang ham?Mot hon canh khc c the gay ngo doc nhu l ht
khi cua dong co o to, xe my (doi khi l mot hnh thc tu tu).
inh luong CO hoac HbCO khi benh nhan den benh vien hoac sau khi d tho oxy th
ti le HbCO v CO c the bnh thung.
Dang nang hoac hon me:
thung gap khi bi nhiem doc d lau hoac o ngui gi d bi suy tim hoac suy ho
hap. N thung gay ton thuong no, co tim v he co.
Ton thuong than kinh trung uong :
duoc bieu hien bang hon me tang truong luc co, thi gian v mc do hon me rat thay doi.
C cc dau hieu ngoai thp.Mot so benh nhan hon me c the hoi phuc nhanh chng,
mot so khc c cai thien thong qua v khong hon ton, tien trien nang len o tuan
th 2 ( Hoi chng khoang- syndrome postinterval) dan den di chng than kinh hoac
tam than. Co che do ton thuong chat trang cu a no o vng hai m theo kieu mat
myeline v duoc pht hien bang chup cat lp no. Di chng lam sng thung gap l
nhng van dong bat thung, tang truong luc, ton thuong he than kinh cao cap, cam v
m vo.
Ton thuong co tim: phu thuoc vo nhu cau oxy v co tim chiem 75% luong oxy mu
luu hnh trong khi d cc co quan khc chi chiem 25% luong oxy.Ton thuong co tim
duoc bieu hien tren ECG bang thieu mu co tim, loan nhip ( chiem 5 - 6 %) . Nhng
roi loan chu yeu l roi loan ti cuc, thay doi cua sng T v doa n ST . N c the gay ra
thieu mu dui noi tam mac hoac thieu mu dui thuong tam mac, hoac doan ST
Bai giang Chng dc

chenh len hoac chenh xuong dui dung dang dien don thuan. Nang hon bieu hien
bang truy mach v ph phoi cap. Ph phoi cap l phoi hop ca ph phoi cap ton thuong
v ph phoi huyet dong. o nhng benh nhan bi benh mach vnh truc d c the gay ra
nhoi mu co tim.
Ton thuong co duoc bieu hien dui dang tieu co van (rhabdomyolyse). Co che do p
vo mach mu v than kinh. Nen tm mot cch he thong nhng dau hieu cua tieu co
van nhu: co cang, tang the tch, mat mot hay nhieu mach ngoai vi. Xt nghiem thay
CPK, transaminasse, amylase tang. oi khi kh c the phan biet duoc l do thieu oxy,
do tu the nam sau hon me hoac do ngo doc CO gay ra.
Bang 1. Trieu chng theo nong do CO
% CO trong
khong kh
Thi gian
tiep xc
% COHb Trieu chng
35 ppm Khong xd 3,5 Khong
50 - 100 Khong xd 5 au dau nhe, giam kha nang lm viec
100 Khong xd 10 au dau nhe, kh tho khi gang sc nang
100 - 200 Khong xd 10 - 20 Kh tho khi gang sc va, hoi hop, dau dau vng
thi duong
200 -300 5 - 6 20 - 30 au dau nhieu, ngat, chng mat, nhn m, buon
non v non
400- 600 4 - 5 30 - 40 Chng mat, that dieu, l lan, mat thc
700-1000 3 - 4 40- 50 L lan, tim nhanh, tho nhanh, hon me, co giat
1100 - 1500 1,5 - 3 50 - 60 Cheyne stokes, hon me, co giat, shock, ngng tho
1600 - 3000 1 - 1,5 60- 70 Hon me co giat, suy ho hap, truy tim mach
> 4000 Vi pht Tu vong
Bang 2. Theo mc do lam sng
Mc do Trieu chng Dau hieu
Nhe au dau
Buon non
Chng mat
Non
Va au nguc
Kh tap chung
Nhn m
Kh tho khi gang sc nhe
Mach nhanh
Tho nhanh
Hoai tu co
That dieu
Nang au nguc
Hoi hop
Mat dinh hung
Co giat
Hon me
Roi loan nhip tim
Tut HA
Thieu mu co tim
Phong da
Bai giang Chng dc

2. Sinh ho:
Tang dung huyet
Tang bach cau, chu yeu l bach cau da nhan trung tnh.
Toan ho hap do ph phoi. Toan chuyen ho do suy tuan hon phoi hop vi tieu co
van c the gay ra suy than cap.
Ngoi ra c the gap viem tuy cap trong ngo doc nang.
3. Cc dang lam sng
Mot vi benh nhan c bieu hien ngo doc dui cc dang khong thung gap phu thuoc vo
cc trieu chungs hoac co dia hoac l tien trien.
Dang than kinh- tam than: Khoi dau di loang choang, kh tap trung tu tuong, hnh dong
khong ph hop v roi loan thi gic.
Tre em c the duoc pht hien bang co giat. oi khi o ngui ln, khoi dau cng
bieu hien bang co giat.
Ngui gi: c the khoi dau bang tnh trang lan lon, doi khi c dau hieu than kinh
khu tr lm nham chan don.
o phu n c thai: Khong c su ton tai song song gia mc do nang cua me vi mc do
nang cua thai nhi. Trong thi k dau, thieu oxy cua thai c the gay ra thai chet luu hoac
gay ra di dang bam sinh. o giai doan cuoi cua thi k c thai, ngo doc CO gay ra thai chet
luu hoac benh no cho thai. Tuy nhien , ngui ta c the gap thai nhi pht trien bnh
thung o nhng trung hop ngo doc nhe hoac trung bnh.
Mot nguyen nhan ngo doc dac biet can ch l ngo doc kh chlore mthylene v kh
dichloromethane. Nhng dung moi ny s duoc chuyen ho mot phan trong co the th nh
CO. Hai loai kh tren duoc su dung trong cong nghiep v trong hoi hoa ( de tay tranh ), n
thung duoc su dung trong nhng noi km thong kh v c the gay ra ngo doc kh CO
nang.
III.Chan don
1. Chan don xc dinh
Khai thc benh su
Khm thuc the
HbCO mu. Ch nong do COHb khong tuong quan vi lam sng v di chng than
kinh
2. Chan don phan biet
Ngo doc nhe: de lam vi cam cm nhat l ve ma dong. Sau 4 gi tiep xc CO
200ppm COHb 15 - 20% dau dau. CO 500 ppm buon non
Ngo doc va: de nham vi ngo doc thc an (buon non, non): dau that nguc khong on
dinh
Ngo doc nang can phan biet vi cc nguyen nhan gay hon me v co giat khc.
Mau do anh do xuat hien khi tiep xc qu nhieu (2 -3%). ay l dau hieu t nhay
IV.Di chng cua CO
Sa st tr tue
Tam than
Parkinson
Bai giang Chng dc

Liet
Ma vn
M vo
Benh l than kinh ngoai vi
Bat luc
Ton thuong than kinh xuat hien 2 - 40 ngy sau nhiem CO
+ 1 thong ke tren BN ngo doc duoc tho oxy 100% trong ICU 14% song st c ton thuong
than kinh khong hoi phuc
+ 1 nghien cu 2360 BN ngo doc CO thay 3% sa st tr tue v Parkinson sau 1 nam
+ 1 nghien cu tren 63 BN bi ngo doc nang 43% giam tr nh, 33% thay doi ve tnh cch
sau 3 nam theo di.
V. ieu tri:
Chien luoc dieu tri khong dua vo nong do HbCO, m dua vo tnh trang c bi mat thc
lc dau hay khong?, tnh trang hon me, cc yeu to tien luong nang, v vo cc di chng
than kinh.
1. Nhanh chng dua nan nhan ra khoi noi ngo doc:
cho php HbCO phan ly nhanh chng. Trong khi ko nan nhan ra khoi vng bi ngo doc:
ngui cu nan phai luu mang mat na phng doc hoac deo khau trang am, phai de phng
kha nang no cua khong kh giau CO.
2.Tho oxy :
Su phan ly cua HbCO duoc thc day dui oxy lieu php, v vay can cho tho oxy cng
sm cng tot, cho tho oxy ngay sau khi lay mu dinh luong HbCO.
Tho oxy 100% den khi COHb < 2%, doi vi BN c thai th duy tr 2 gi sau khi
COHb ve 0 nham ko di thi gian thai tr CO t thai nhi
ieu tri oxy dang p( ONB ) l bien php dau tien. oxy duoc su dung dui dang masque
hoac leu oxy o tre em. Lieu php oxy cao p ( OHB ) chi dinh cho phu n c thai, hon me
( c tc dung lm tang p luc rieng phan cua oxy, lm tang su phan ly HbCO, lm tang su
khuech tn cua oxy trong mu v lm cho to chc su dung oxy de dng hon.
3. ieu tri trieu chng:
Neu c suy ho hap can dat noi kh quan, tho my.
ieu tri HA tut, dat catheter, dng thuoc van mach tuy theo mc do cua roi loan huyet
dong.
Theo di chc nang song co ban,
lm kh mu
ieu tri toan chuyen ho chi khi pH < 7,1. Tnh trang toan gip dung phan ly oxy
dich chuyen ve pha ben phai thuan loi cho giai phng oxy cho to chc
4. Phng ti pht:
gio duc benh nhan. Ve sinh noi o v moi trung lao dong
VII. Oxy cao p trong ngo doc CO
1. Co so cua dieu tri
Giam thi gian nua di song: Neu tho O2 100% thi gian trong vng 40 pht neu
HBO 2,5 atm th thi gian chi cn 20 pht (4 -86 pht). Tang O2 ho tan len 10 lan
Cung cap O2 cho to chc dui dang ho tan trong plasma
Bai giang Chng dc

Gay co mach no tc th trong khi van duy tr duoc O2 cho to chc no

Ngan chan su tong hop cc goc tu do t hien tuong peroxidation cua m trong te bo
no do ngo doc CO.
2. Ch dinh:
Ngat
Hon me
Co giat
GCS < 15 diem
C dau hieu than kinh khu tr hoac COHb > 25% (mot so >40% v > 25% neu km
theo: co giat, loan nhip tim,di chng) hoac COHb > 15% o ph u n c thai
Thieu mu co tim
Loan nhip that
Sau khi dieu tri ban dau on dinh sau 2 -4 gi m trieu chng than kinh khong phuc hoi
(dau dau, that dieu, l lan)
Bai giang Chng dc
1
Ngo doc cap Barbituric
BS. Dng Ihi Xuan
I. ai cuong
Ngo doc cap barbituric l ngo doc rat thung gap trong cc khoa Hoi sc cap cu.
Nhieu benh nhan uong vi muc dch tu tu v vay uong vi so luong nhieu, nhieu loai thuoc,
benh canh lam sng thung phc tap v nang. Tren thuc te, hay gap ngo doc o nhng benh
nhan bi roi loan tam than, dong kinh, nghien ma tu.
Ngo doc cap barbituric l mot van de can phai quan tam v tu vong cn cao do nhieu
bien chng. o Viet Nam barbituric duoc dng nhieu nhat l ph enobarbital (luminal, gardenal).
Ben canh ngo doc cap cn c ngo doc mn do lam dung thuoc.
II. tnh chat - chuyen ho - doc tnh
1. Cau trc v tnh chat l ho
Barbiturat duoc dng de chi cc dan xuat cua acid barbituric v ure vng cua acid malonic.
NH - H HO - C - C -2H
2
O NH - CO H
O = C CH
2
O=C C
NH - H HO - C - C NH - CO H
Ure Acid Malonic Malonylure (acid Barbituric)
Ban than acid barbituric khong duoc dng trong y hoc, nhung cc dan chat the o vi tr C
5
(doi khi o 1, 3) cho mot loat cc dan chat c tc dung gay ngu, chong co giat duoc goi l
thuoc ngu barbituric. Neu thay ure bang Thio ure s duoc Thio-barbituric, khi thay H
5
bang cc nhm the khc nhau s cho mot dan chat gay ngu manh v nhanh dng lm thuoc
gay me.
Ni chung barbiturat l nhng tinh the trang, vi thay doi, t tan trong nuc v ete dau hoa,
tan nhieu trong dung moi hu co (alcol, ete, clorofoc). De thang hoa trong chan khong o
170 - 180
o
C. iem nng chay thay doi t 100 - 190
o
C. Barbiturat thung bi than, silicagen
hap phu.
Axit barbituric c tnh axit manh (nhat l pKa=4.04). Do tnh axit nen tao muoi khong tan
vi mot so kim loai nang, de tan trong dung dich kiem v carbonat kiem.
Barbiturat de tao phc hon hop vi mot so ion kim loai do d de tan trong dung moi, bi
phan huy khi c nuc, c mu dac trunghoac tinh the dac hieu nen duoc dng khi kiem
nghiem.
Hau het cc barbiturat c pho hap thu UV dac trung, quang pho phu thuoc vo pH cua
dung dich.
2
2. Chuyen ho barbituric trong co the
Barbituric de dng hap thu qua niem mac khi pH cua moi trung nho hon pKa cua
barbituric , do vay tham nhanh qua niem mac da d y.
Barbituric duoc chuyen ho o gan do tc dung cua cc men c trong gan. V vay o ngui
quen dng barbituric , lieu ngo doc cao hon ngui chua dng barbituric . Nguoc lai, ngui
suy gan de bi ngo doc. Thuoc duoc hap thu nhanh, phan bo nhieu trong to chc .
Cc barbituric cham (gardenal, barbital...) c the thai tr nhieu nhat qua nuc tieu dui
dang nguyen ven (65 - 80%), v vay gay loi tieu l mot phuong php do thai tot. Cc
barbituric cham duoc loc qua cau than v ti hap thu o ong luon gan. Nuc ti eu kiem lm
giam ti hap thu barbituric, v vay kiem ho huyet thanh l mot bien php tot de thai tr
barbituric qua than.
3. oc tnh sinh benh hoc
Dua theo thi gian gay ngu, ngui ta chia barbituric ra lm 4 loai:
+ Tc dung cham (6 gi) : barbital, gardenal
+ Tc dung trung bnh (3 - 6 gi) : allobarbital, amobarbital, aprobarbital,
butobarbital.
+ Tc dung ngan (3 gi) : xyclobarbital, secobarbital, pentobarbital
+ Tc dung cuc ngan de gay me: thiopental
Barbituric tc dung len cc ty la p the cua cc te bo lm giam tieu thu oxy, giam pht sinh
ra nhiet luong v acid lactic. Vi lieu cao, barbituric c che than kinh trung uong, tc
dung c che he thong lui ARAS v vng no trung gian lm cho benh nhan hon me.
Barbituric c che cc trung tam van mach, ho hap, cc thu the pH, PCO
2
/PO
2
, lm mat
phan xa ho.
Tc dung cua barbituric cn phu thuoc vo dac diem cua ngui dng thuoc : su nhay cam,
tuoi, chc nang gan than, nghien ruou, c dng thuoc thung xuyen hay khong.
Tc dung cua barbituric tang len khi c mat cua cc thuoc c che than kinh khc : morphin
v che pham, clopromarin, bromua... Tc dung ket hop gia barbituric v ruou c the gay
tu vong d nong do barbituric mu khong cao.
Cc tc dung ny c tnh chat tam thi v mat d i khong de lai di chng sau khi thuoc d
duoc thai tr het.
Ngo doc tren 2g c the gay hon me sau v tu vong, tren 6g s gay tu vong nhanh chng
neu khong kip thi cu cha.
III. Trieu chng lam sng ngo doc nang
Trong bi ny chng toi chi de cap den ngo doc cap barbituric tc dung cham :
phenobarbital (gardenal)
1. Hon me sau
3
Hon me khong c liet chi, benh nhan nam yen, cc chi mem nhn, mat het phan xa gan
xuong, ke ca phan xa gic mac, nhung phan xa dong tu vi nh sng van cn v chi mat
neu benh nhan ngat tho do tut lui hoac suy ho hap.
Neu c tnh trang co cng kieu mat no phai coi chng c thieu oxy to chc (tut lui,
dong dm di)
Roi loan thc ty le vi mc do ngo doc, co dia dong kinh chiu dung lieu cao hon.
Hon me: nh gi mc do hon me theo bang diem Glasgow (tuy nhien bang diem
Glasgow khong c gi tri de tien luong benh nhan ngo doc barbituric)
ien no do gip cho dnh gi mc do hon me v theo di tien trien cua benh
Nhieu tc gia d khao st su lien quan gia nong do barbiturat trong mu v mc do lam
sng. Nong do ny thay doi tng loai.
Nong do barbiturat (mg%) v giai doan lam sng
(theo Bi giang kiem nghiem doc chat - Trung ai hoc Duoc H Noi)
Mc do ngo doc 0 1 2 3 4
Phenobarbital 1.0 3.4 5.5 8.0 15.0
Amobarbital 0.7 1.5 3.0 5.2 6.6
Pentaobarbital 0.4 0.6 1.5 2.0 3.0
Secobarbital 0.3 0.5 1.0 1.5 2.0
Tuy nhien nong do barbituric cn phu thuoc vo phuong php xt nghiem v do nang
cua ngo doc cap barbituric phu thuoc vo cc dau hieu lam sng, chc nang song , bien
chng hon l nong do barbituric mu. C benh nhan nong do barbituric mu khong cao
nhung lai tu vong do tut lui, sac, nhiem trng benh vien.. .
C the ha than nhiet hay sot cao.
Nhn cau thung co dinh.
2. Roi loan ho hap
Rat thung c, l nguyen nhan chu yeu gay tu vong
Co che: giam thong kh phe nang:
Tac dung ho hap do tut lui, dm di, mat phan xa ho, ht phai dich vi (hoi chng
Mendelson), l nguyen nhan chnh gay tu vong. Truc khi benh nhan duoc dat ong noi kh
quan, nen de benh nhan o t u the nam nghieng an ton.
Boi nhiem phoi o nhng benh nhan nam lau, dat ong noi kh quan tho my
3. Roi loan tuan hon
Te liet than kinh trung uong dan den giam thc tnh thnh mach gay ra ha huyet p. Tnh
trang ha huyet p o nhng ngui gi c the gay nh ng bien chng nang ne, c benh nhan
sau khi dieu tri on dinh ngo doc cap lai pht hien ra nhn no do bi tut huyet p ko di.
Thung km theo mat nuc, mat muoi, tac mach phoi.
4
4. Boi nhiem
L bien chng rat thung gap, nhiem trng benh vien thung do vi khuan gram am hoac
truc khuan mu xanh khng thuoc, dieu tri kh.
Viem phoi, viem phe quan phoi: do ht phai, do dong dm di, do cong tc cham sc, ht
dm. a so cc benh nhan tho my bi nhiem trng phoi, thung l nguyen nhan ko di
thi gian tho my, thi gian dieu tri, tham ch gay tu vong cho benh nhan .
Nhiem khuan tiet nieu, dac biet o nhng benh nhan dat ong thong bng quang, nam lau, di
tho dung.
Lot muc
5. Suy than cap
Thung l chc nang
Nhung c the l thuc ton do benh nhan c ton thuon g tiem tng o than, hoac do nam bat
dong d p vo chi gay tieu co van (rhabdomyolyse): di t, sam mu, men CPK tang cao.
6. Benh phoi hop
Benh nhan nam lau c the c bien chng: tai bien mach mu no , huyet khoi tinh mach
chi dui, tac mach phoi, nhoi mu co tim.
Tien luong xa: c the thay viem nhieu day than kinh.
IV. Xt nghiem doc chat
Mau benh pham:
Dich co the: mu, nuc tieu, dich da dy
Phu tang
1. inh tnh barbiturat:
1.1. Phan ng chung cua cc barbiturat: phan ng Parris
Phan ng tao phc hop hon hop c mu hong vi Coban Nitrat hoac Coban Acetat trong
moi trung Metanol.
Phan ng ny ky nuc, c the pht hien den 0.03mg barbiturat trong mau thu, nhung
khong dac hieu. Tat ca cc nhm c CO - NH - CO deu cho phan ng ny.
Phan ng tren c the thuc hien tren sac k lp mong.
1.2. Phan ng dac hieu tm Gardenal
Phuong php sac k lp mong so snh vi mau gardenal chuan ( cham 5 -10mcg mau
chuan)
Dung moi trien khai: Clorofoc/Aceton 9/1
Thuoc thu: Millon hoac orthotoludin 1% hoac 3 dung dich KaliIodu a 1% trong nuc vi
Benzidin bo ho trong acid Acetic 1%.
Duong tnh khi thay vet mu trang xm tren nen trang (Rf trng vi Rf gardenal cua mau
so snh).
Phan ng ny c the dng de bn dinh luong gardenal
1.3. Phan ng soi tinh the tren knh hien vi do phng dai 8 -10 lan
5
2. inh luong barbiturat
Phan ng tao phc mu roi do quang (hien nay t dng)
Phuong php do pho UV (pho hap thu tu ngoai)
o trong dung dich NaOH 0.1N do hap phu o buc sng 240nm
o pH = 10 cho max = 244 nm
o pH = 13 cho max = 249 nm
(c the dng dinh luong gardenal trong dich sinh l)
- Sac k kh
V. Xu tr
Xu tr cap cu phu thuoc vo mc do nang khi benh nhan vo vien: loai bo chat doc truc
hay hoi sc truc.
1. Bao dam thong khi truoc
at ong noi kh quan, ht dm.
Ho hap nhan tao vi phuong thc IPPV
Mo kh quan neu c ph thiet hau, thanh mon.
Neu c xep phoi: soi ht phe quan
2. Han che ngo doc
Khong gay non
Rua da dy:
+ Benh nhan tinh: dat ong thong da dy nho qua dung mi, rua da dy. Can phai tien
luong truc tnh trang benh nhan v c the hon me v dien bien nang len rat nhanh.
+ Benh nhan me: dat noi kh quan c bng chn (cuff) v thong kh nhan tao truc khi rua
da dy.
+ K thuat rua da dy: benh nhan nam nghieng tri, moi lan dua vo 100 - 200ml dung
dich muoi 0.9%. So luong dich rua: 3- 5 lt, ma lanh dich rua phai duoc lm am. Lay dich
rua da dy o lan dau de xt nghiem doc chat.
Cho benh nhan uong than hoat 100g (20g/2 gi), thuoc tay sorbitol 1 - 2g/kg chia deu theo
cc lieu than hoat.
3. Tang do thai
Gay bi nieu cung bc: truyen 4 - 6 lt/ngy (theo di CVP), cho loi tieu de tang thai
barbituric. Vi cc benh nhan khong c suy tim, suy than, khi truyen dich nhieu, chua can
cho loi tieu so luong nuc tieu c the d tang. Nhng benh nhan c suy tim, suy than pha i
theo di chat toc do truyen dich v CVP , cho loi tieu.
Kiem ho huyet tuong: truyen bicarbonat
Cc bien php tren c the tien hnh duoc o moi tuyen, trong da so cc trung hop ngo
doc chi can hoi sc tot, rua da dy, cho than hoat v thuoc tay l d c the cu song benh
nhan.
Loc ngoi than: L bien php thai tr chat doc rat c hieu qua nhung khong phai o tuyen
no cng c the lm duoc, gi thnh cao.
+ Than nhan tao: chi dinh vi nhng benh nhan ngo doc nang: hon me sau, vo nieu, truy
mach, nong do barbituric trong mu cao. Tuy nhien, trong dieu kien cua nuc ta hien nay,
6
chi dinh loc ngoi than chu yeu dua vo cc dau hieu lam sng. Khi chay than nhan tao
phai dam bao huyet p bang truyen dich, dopamin hay noradrenalin.
V thuoc tch lu nhieu t rong to chc, can ch hien tuong ti phan bo lai barbituric
trong co the, trong hoac ngay sau khi chay than nhan tao benh nhan c the tinh ra sau d
lai hon me tro lai.
+ Loc mng bung o ngui c tut huyet p c chi dinh tot hon than nhan tao, hoac o nh ng
benh nhan c them suy vnh, cao huyet p, suy tim. am bao huyet p roi loc mng bung.
Ngui ta thay rang c 6 gi loc mng bung th c hieu qua bang 1 gi chay than nhan tao,
hay c nghia l chay than nhan tao 6 gi th bang loc mng bung 24 gi.
4. Dam bao tuan hon
Hoi phuc nuc dien giai, thang bang toan kiem.
at catheter tinh mach truyen dich ngy 4 - 6 lt, trong d natriclorua 0.9%, glucose,
bicarbonat, chi can dng bicarbonat 1.4% 500ml/ngy. Theo di CVP, nuc tieu de dieu
chinh luong dich truyen.
Neu truy mach: chong soc, truyen noradrenalin, aramin, plasma, mu.
at ong thong bng quang theo di nuc tieu
5. Chong boi nhiem
Su dung khng sinh theo khng sinh do
Phoi hop hai khng sinh: cephalosporin v aminoglycosid.
6. Chong dong
Heparin 1ml 5000 UI moi 8 gi, tiem dui da
Hoac fraxiparin 7500 UI - 15 000 UI /ngy, tiem dui da
7. Dieu tri ph phoi cap ton thuong neu co
8. Khi nghi ng co hoi chung tro nguoc phai:
Soi ht phe quan
Mo kh quan dat canun c bng chn, tho my c PEEP.
Steroid lieu cao: methylpresnisolon 30mg/4 gi.
Giam bt luong dich truyen (theo di k CVP) v dng furosemid.
9. Ho ly v chm soc
am bao dinh dung: 1500 - 2000 Kcalo/ngy, benh nhan hon me cho an qua ong thong
da dy.
Nam dem chong lot, vat l tri lieu, thay doi tu the benh nhan trnh ty d gay tieu co hoac
lot.
Gi am cho benh nhan, neu sot cao: chum mt, cho thuoc ha nhiet do
Cham sc mat: bang mat, nho cloroxit 0.4%
Ve sinh than the: mieng, bo phan sinh duc
Vi tamin B1, vitamin C
Bai giang Chng dc
1
ieu tri ngo doc cap v qu lieu ma tu
PCS.PIS.Aguyen Ihi Du
Ngo doc cap opioids l mot cap cu nguy kich, c the dieu tri khoi nhanh qua
thuoc khng doc (antidote) cua n l naloxone. Naloxone l mot thuoc c t 20
nam, thuoc doi khng cho tat ca cc opioids, c dng nhieu dung : dui da,
tinh mach, tiem bap. Thuoc hau nhu khong c tc dung phu, ke ca dua mot lieu
ln.
A. Nhng diem can ch :
Khi dng naloxone can ch 2 diem sau :
1. Thuoc c tc dung nhanh sau 2-3 pht, thi gian tc dung rat ngan 60 -90 pht,
n ngan hon tc dung cua tat ca opioids, loai tr fentanyl. V vay can dua nhac
lai hay truyen lien tuc naloxone o mot benh nhan ngo doc opioids nang.
2. Naloxone c the gay ra hoi chng thieu t huoc sm o ngui phu thuoc
opioids, tuy nhien dng lieu cao s ngan chan duoc trieu chng suy ho hap trong
hoi chng ny.
B. Trieu chng v dau hieu ngo doc, qu lieu ma tu
1. Suy giam ho hap, tho cham, ngng tho, chet nhanh trong vi pht sau tiem,
hoac 1-4 gi sau uong.
2. Co dong tu
3. Mat thc, hon me
4. Ha huyet p
5. Ph phoi cap
6. Ha nhiet do
7. Neu hon me ko di c the chet v viem phoi
8. Tm vet tiem o 2 cang tay, tinh mach co, di.
9. Xt nghiem nuc tieu : c morphine v 6MM (6 monoacetyl morphine) nen
tm them barbiturate, benzodiazepine, quinin trong nuc tieu ngui nghien.
C. dieu tri cap cu ngo doc v qu lieu ma tu
Bai giang Chng dc
2
1. Benh nhan tho yeu, ngp c, ngng tho (<10lan/pht)
- am bao thong kh, bp bng ambu + oxy 1 00%, ho hap ho tro
- am bao tuan hon : p tim ngoi long nguc neu ngng tim, truyen dich
- Tu the an ton khi hon me, u am, theo di tho
Bat dau bang :
- Naloxone 1ml=0,4mg tiem TM (ngui ln v tre em). C the cho lieu ban
dau2mg ca ngui ln v tre em neu rat nang.
+ Sau 2-3 pht khong tinh : cho lai 0,4mg (c the ti 4 lieu) neu tho lai, c the
cho naloxone qua dung tiem bap, dui lui. Tong lieu naloxone c the 10 -
20mg/24 gi.
+ Neu lieu ban dau cua naloxone hieu qua (benh nhan tinh, tho lai) th tiem
nhac lai sau moi 20-60 pht hoac duy tr bang dung truyen tinh mach lien tuc.
+ Neu sau 4 lieu ban dau khong ket qua th tm xem benh nhan c uong them
thuoc khc : barbiturate, thuoc an than, ruou..., hoac chan thuong dau, c the c ho
them than hoat vi nhuan trng neu benh nhan ngo doc qua dung tieu ho.
- Truyen dich nang huyet p, thang bang dien giai.
+ Glucose v de c ha dung huyet
2. Benh nhan tho > 15lan/pht
- Lieu dau : naloxone 0,4mg tiem bap.
Neu dp ng mot phan c the cho tiep lan 2 sau 20-60 pht
- Tho oxy mi 4L/pht
- Truyen dich, Glucose 5%, NaCl 0.9% dam bao huyet p.
* Pha truyen lien tuc naloxone :
Cho bat ky loai opioids no, dac biet loai tc dung ko di nhu methadone
(30-36 gi). Truyen lien tuc dua vo nhip tho v mach, huyet p benh nhan dp
ng sau lieu dau. Truyen lien tuc s du phng suy ho hap lai v naloxone c thi
gian bn huy ngan hon opioids.
Truyen dich + 0,4-0,8mg/gi o ngui ln v 0,01mg/kg o tre em, dnh gi
sau moi gi o ngui ln v moi 5 pht o tre em. Truyen lien tuc c the tang len
neu thc cn giam. Nhieu tc gia cho thay truyen naloxone lien tuc trong 10
gi o mot don vi hoi sc tch cuc l an ton bao dam v dnh gi lai tnh trang
suy ho hap cua benh nhan sau 1 gi tiep de xem tc dung naloxone cn hay ngo
doc opioids cn hoac ngo doc loai khc. Naloxone s khong c dp ng neu
xuat hien hoi chng thieu thuoc.
Tho my neu benh nhan hon me, phuong thc dieu k hien the tch (CMV)
hoac ho ttro p luc, vi FiO
2
= 50%, dng PEEP neu benh nhan c ph phoi cap
hay hoi chng ARDS.
Cham sc nuoi dung du calo.
Bai giang Chng dc
3
phc do dieu tri ngo doc ma ty
Ngo doc ma tu (mat thc, tho yeu, dong tu
co,HA)
am bao :
- Thong kh
- Tuan hon
- Tu the an ton
Naloxone
Nhip tho < 10lan/pht Nhip tho > 15lan/pht
1. 0,4mg-0,8mg/TM (ca ngui ln + tre em) 0,4mg tiem
bap
3 pht sau khong tinh lai : cho lai (c
the den 10 lan den khi c ket qua)
2. Truyen naloxone lien tuc sau khi c ket
qua.
0,4mg/gi cho ngui ln
0,01mg/kg/3 pht cho tre em
em nhip tho v do HA trong10 gi.
3. Thong kh nhan tao (bp bng ambu -
tho my)
T FiO
2
100% 50%
(1 gi 24 gi)
4. Truyen dich nang HA
- C dp ng mot phan cho nhac lai lan
2,3
- Oxy : 4L/ph
- Truyen dich, glucose, dam bao tuan hon
- Theo di tho, HA, mach 20pht/lan
Chu y :
1. Cho than hoat v sorbitol neu benh nhan dng thuoc uong
2. Can tm cc ngo doc khc km theo barbiturate, an than v ruou, quinin v cc
bien chng.
3. Neu c ton thuong no th rat nang
4. Lieu naloxone truyen lien tuc 2mg (5 ong) + 500ml Glucose 5% cho
0,4mg/100ml/gi.
Bai giang Chng dc
4
ieu chinh lieu truyen naloxone ph hop moi benh nhan
1. Neu lieu dau thnh cong (0,4-0,8mg tinh mach) dua 2/3 lieu ny bang dung
truyen lien tuc.
2. Neu sau lieu dau that bai :
- NKQ, bp bng, oxy
- Tiem nhac lai sau 2,3 pht dua len ti 10mg truc khi truyen
3. Neu sau lieu dau, benh nhan c dau hieu thieu thuoc
- Giam bt lieu dau
- Neu xuat hien giam thc lai, nhac lai 1/2 lieu b an dau cho ti lc c hieu qua.
- Tnh lieu ban dau thch hop sau d cho truyen lien tuc
4. Neu benh nhan xuat hien dau hieu thieu thuoc khi dang truyen :
- Dng truyen cho ti khi dau hieu ny d
- Bat dau truyen lai = 1/2 toc do ban dau, theo di
- Tm nguyen nhan khc gay thieu thuoc
5. Neu benh nhan giam thc trong lc truyen :
- ua 1/2 lieu dau v nhac lai cho ti khi tot
- Tang truyen lien tuc = 1/2 toc do ban dau
- Tm dung vo mu lai cua opioids hay nguyen nhan khc gay giam thc.
Bai giang Chng dc
1
Ngo doc c nc
I. Tieu chuan chan don
1. Chan don xc dinh
a). Lam sng:
Sau khi an c nc (cn goi l Puffer fish, Balloon fish, Fugu -ten goi o Nhat Ban)
hay c kho, ruoc c lm bang c nc, trieu chng xuat hien sau 10 -30 pht: Te mieng,
lui, hai moi, dau dau, non, ni kh, te o ngn, bn tay chan, yeu v met, tu vong do
liet co ho hap hoac suy tuan hon cap.
Cc dau hieu khc: Tim cham, roi loan nhip, ha huyet p, ha nhiet do, tang tiet
nuc bot, tm, ngng tho, mat phan xa gan xuong v truong luc c o.
Cc dau hieu lam sng c the mat di sau 24 gi neu benh nhan duoc cu song.
b). Xt nghiem:
Mu: dien giai, ure, dung, creatinin, thang bang toan kiem
ien tam do: nhip cham, roi loan nhip
Theo di SpO
2
v EtCO
2
(neu c dieu kien) hoac chc nang phoi ( Vt, p luc am
tho vo)
Pht hien doc chat Tetrodotoxin (TTX) trong dich co the hoac trong mau benh
pham: chi thuc hien duoc o nhng co so xt nghiem hien dai
2. Chan don phan biet:
Cc chat doc khc o thuc pham (vi khuan, ho chat tr sau, chat bao quan, c
doc loai Scombroid, Ciguatera, Shellfish cng gay non, buon non)
Cc nguyen nhan khong do doc: Viem da dy cap, co that dai trng
II. Nguyen nhan gay benh:
Chat doc trong c nc duoc goi l Tetrodotoxin (TTX) l chat doc khong
protein, tan trong nuc v khong bi ph huy o nhiet do soi hay lm kho, chat doc bi
bat hoat trong moi trung acid v kiem manh.
TTX tap trung o trng c, ruot gan, v tinh hon cua c. Chat doc ny cn tm
thay trong mot so loi vat khc nhu: bach tuoc c vng xanh o tua (de lan vi con
muc), con sa-giong (Newts) v ky nhong (Salamanders)
Chat doc TTX tc dung lua chon chen dng natri trong co che bom Kali -Natri
v kenh Natrium tam van dong, do d TTX gay ra liet co, liet ho hap, dong th TTX
cn pht dong vng nhan cam ho hoc gay non, non lien tuc.
II. Tien luong & Cch phng:
o nang cua ngo doc c nc tuy thuoc vo luong doc to v thi gian duoc cap cu:
Neu benh nhan c trieu chng nhe c the theo di v khoi
Neu c trieu chng r, chua bi tm, dieu tri cap cu ban dau v ho i sc,
s cu duoc trong vng 24 gi.
Neu thieu oxy lau, khong duoc cap cu ban dau c the gay bien chng
hoac tu vong
Bai giang Chng dc
2
* Cch phng nga: Tot nhat l khong an c nc, chuan bi ti cap cu khi can
thiet
III. ieu tri:
* Truoc khi vo benh vien:
- Neu benh nhan cn tinh vi trieu chng nhe: cho uong than hoat 1 -2g/kg v
Sorbitol 1g/kg cho ca ngui ln v tre em tren 2 tuoi
- Neu benh nhan c tm, roi loan thc: Thoi ngat, bp bng ambu, roi dua
den co so benh vien gan nhat
* Trong benh vien:
Neu da xuat hien trieu chng tm, roi loan thc
1. Khong gay non
2. at ong Noi kh quan, c bom bng chn de dam bao dung dan kh, ho
tro ho hap bang bng ambu, tho my
3. at xong rua da dy neu mi an c trong 1 gi dau, sau rua cho than hoat
1-2g/kg
4. Truyen dich G 5% v NaCl 9% de duy tr huyet p
iu tri cc trieu chng nang (neu c):
- Ha huyet p
+ Truyen dich 10-20 ml dd NaCl 9% qua dung TM v dat benh nhan
tu the nghieng tri, dau thap. Can theo di p luc tinh mach trung tam
(CVP). Trnh truyen dich qu mc.
+ Neu truyen dich khong lm tang huyet p can cho:
Dopamin 2-5 g/kg/pht lieu cho ca benh nhan ngui ln lan
tre em, dieu chinh tang lieu de dat hieu qua, song khong qu 15
g/kg/pht, c the them:
Noradrenalin 0,1 - 0,2 g/kg/pht, dieu chinh lieu de c ket
qua, lieu cao qu khong c loi gay thieu mu to chc
- Co giat: l trieu chng hiem gap, dieu tri co giat bang Seduxen, (Valium) 10
mg tiem tinh mach, neu khong dp ng c the cho Phenobacbitan hay
Phenyltoin sau khi d dat ong noi kh quan, thong kh ho tro (Xem bi "ieu
tri co giat").
Bai giang Chng dc
1
Rua da dy trong ngo doc cap.
I. ai cuong:
Rua da dy l mot trong cc bien php han che hap thu, loai bo doc chat qua
dung tieu ho trong cap cu ngo doc cap dung uong. Neu duoc thuc hien sm, dng k
thuat th day l phuong php rat hieu qua de han che hap thu doc chat: neu duoc thuc hien
sm trong vng mot gi sau khi uong c the loai bo duoc ti 80% luong doc chat uong
vo. neu rua muon hon s km hieu qua, loai bo duoc t doc chat, tuy nhien van c the giam nhe
mc do ngo doc xuong dui lieu tu vong, hoac ch t cng giam nhe mc do ngo doc.
Ngoi ra, rua da dy cn gip lay dich de xt nghiem doc chat gip cho chan don
nguyen nhan.
Rua da dy thung duoc ket hop vi cc bien php nhu: cho than hoat truc trong
v sau khi rua da dy de hp phu doc chat trong lng ong tieu ho, sau d dng thuoc tay
de nhanh chng dua doc chat ra ngoi co the.
Tuy nhien rua da dy khong dng chi dinh, sai k thuat th khong nhng khong c loi m
cn c the dan ti cc bien chng vi nhng hau qua nang ne, tham ch tu vong. Chnh v vay
can phai can nhac khi chi dinh rua da dy, dac biet l doi vi tre em, neu loi ch khong r rng m
nguy co bien chng ln th khong nen rua.
Da dy l doan phnh to cua ong tieu ho o gia thuc quan v ruot non.T cung
rang tren den tam vi di khoang 40- 45 cm. Da dy c hnh ch J rong 12cm, di 22 -
25 cm, dung tch cha khoang 1200 ml, tren thong vi t trng qua lo tam vi, dui thong
vi t trng qua lo mon vi. oan mot t trng thong vi da dy qua mon vi, nam ngang,
hoi chech nen tren, ra sau v sang phai. l l do khi rua da dy chng ta phai dat benh
nhan nam nghieng sang tri, chnh l de trnh day doc chat trong da dy qua mon vi
xuong ruot.
II. Ch dinh v chong ch dinh:
1. Ch dinh:
Tat ca trung hop ngo doc dung uon g den truc 6 gi, khong c chong chi dinh
rua da dy v khong the gay non duoc( roi loan thc, giam hoac mat phan xa non...).
Tuy nhien c mot so diem can ch :
Trong thuc te, thung kh xc dinh chnh xc thi diem uong v vay gii han 6
gi tro thnh tuong doi.
Bai giang Chng dc
2
Ngo doc mot so loai thuoc trong d c cc thuoc an than v thuoc ngu gay
giam nhu dong dung tieu ho, v vay sau 6 gi van c the cn mot luong ln
doc chat nam trong da dy, nhat l trong cc trung hop ngo doc nang. Thuc te
tai A9 d c benh nhan ngo doc nhieu loai thuoc ngu v thuoc an than phoi
hop duoc rua da dy sau gi th su m noc tho ra van dam dac, thuoc lm
duc trang nuc rua. V vay nen dat ong thong da dy tham d cho nhng
benh nhan duoc cho l den muon, rua vi chuc mililt nuc neu duc ta s rua
tiep.
Trong cc trung hop duoc cho l nhe, hoac benh nhan l tre em khong hop
tc, loi ch cua rua da dy khong r rng m nguy co bien chng cao th nen
thay the rua da dy bang cho uong than hoat.
2. Chong ch dinh:
2.1. Chong ch dinh tuyet doi
Uong cc chat gay an mn: a xt, kiem manh.
Cc chat khi gap nuc tao ra cc phan ng lm tang tc dung doc hai: kim loai
natri, kali, phosphua km...
Xang, dau hoa, cc chat tao bot.
C ton thuong niem m ac dung tieu ho : lot nang. chay mu, phnh mach
thuc quan...
Benh nhan c roi loan thc, c nguy co sac m chua dat noi kh quan c
bng chn de bao ve dung tho.
2.2. Chong ch dinh tuong doi:
Ton thuong niem mac mieng: dat ong thong nho dung ni.
Tre em uong vi vien thuoc loai t nguy hiem, khong c dau hieu ngo doc.
Phu n c thai: can can nhac loi hai v de gay con co tu cung khi dat ong thong
rua da dy.
III. Chuan bi:
3.1. Dung cu:
Bo dung cu rua da dy he thong kn: gom cc bo phan dong bo nhu sau:
ong thong Fauchet bang chat deo, dau t, c nhieu lo o canh, dng de dat dung
mieng, c cc c sau:
+ So 10 dung knh trong 4 cm.
Bai giang Chng dc
3
+ So 12 dung knh trong 5 cm.
+ So 14 dung knh trong 6 cm.
ong thong cho an thung dng cho benh nhan uong t doc chat, chua an, dau hieu
ngo doc hau nhu khong c, uong d lau qu 6 gi,hoac khong c chi dinh rua
nhung c chi dinh dat ong thong de lay dich xt nghiem.
Day noi ch "Y" v cc van dieu chinh dng mo dung ra dung vo.
Hai ti dung dich c chia vach do moi 50 ml. Ti tren treo cao > 1m so vi mat
giung c dung tch 3000 ml (dung nuc muoi 0,5 -0,9 % ). Ti dui treo dui mat
giung t nhat 30cm.
Xo dung nuc sach (khoang 5-10 lt nuc) c pha muoi vi ty le 5 -9 gam/lit nuc
v xo hoac chau dung nuc dich sau khi rua.
Dung cu mo mieng.
Canun Guedel.
Seringe 50 ml
ong nghe, bom cho an hoac bng ambu: Dng de kiem tra xem xong d vo da
dy chua.
Lo dung dich da dy de xt nghiem doc chat: Dung tch khoang 200ml.
Dau paraffin: e boi tron dau ong xong, han che duoc chan thuong do dau ong
xong gay ra.
Muoi an: khoang 50 gam
Than hoat: e hap phu chat doc, thung dng sau khi rua da dy.
Trong trung hop ngo doc thuoc tr sau th pha luon vo nuc rua da dy sau khi
d lay dich da dy lm xt nghiem doc chat.
Thoc tay: Sorbitol hoac magne sulpht c tc dung tang do thai chat doc v than
hoat qua dung phan. Thung bom cng than hoat sau khi rua da dy.
Thuoc an than: Valium 10mg (ong tiem) dng cho benh nhan kch thch vat v
nhieu, ngo doc chat gay co giat.
3.2. Benh nhan:
Neu benh nhan tinh: phai giai thch de benh nhan hop tc
Neu benh nhan c roi loan thc, giam hoac mat phan xa nuot phai dat noi kh
quan c bng chn truc khi tien hnh rua da dy.
Bai giang Chng dc
4
Khi benh nhan uong thuoc gay co giat (Thuoc chuot Trung Quoc, m tien, ...) phai
dng valium de trnh co giat truc khi rua da dy.
Neu benh nhan c suy ho hap, truy tim mach phai uu tien tien hnh cap cu ho
hap v tuan hon. en khi tnh trang benh nhan on dinh mi tien hnh rua da dy.
C the va rua da dy va bp bng hoac tho my.
Trai mot tam nilon o dau giung de trnh dich dy chay ra ga.
Tu the benh nhan: Nam nghieng tri, dau thap.
3.3. Nhan vien lm thu thuat:
Phai l nhng ngui d duoc do tao k thuat rua da dy, can phai doi m, deo
khau trang, di gang tay sach.
Can c 2 ngui: mot ngui dat xong da dy v co dinh xong, xoa bung trong qu
trnh rua. Mot ngui dieu chinh luong nuc vo ra.
Khi benh nhan can phai bp bng th phai c them ngui th ba.
V. Ky thuat:
Buc 1: ua ong xong vo da dy.
Chon lua ong xong: dat dung mieng dng on g xong to, dat dung mi dng ong
xong nho (loai xong dng mot lan)
o do di ong xong can dua vo: Bat dau t cung rang hm tren ko vng ra sau
tai roi ko thang xuong mi c. nh dau do di ong xong can dua vo. Thong
thung t 40-50 cm.
Boi tron dau ong xong da dy bang gac tham paraffin.
at dung mieng:
Bao benh nhan h mieng neu benh nhan tinh, hop tc. Neu can thiet dng dung
cu mo mieng, sau d luon canun Guedel vo roi rt dung cu mo mieng, sau d
luon canun Guedel vo roi rt dung cu mo mieng ra .
ua ong thong vo mieng benh nhan tng t mot, t t, khi vo den hau va
dua vo va bao benh nhan nuot. Neu kh khan th de dau benh nhan gap cam
vo thnh nguc roi va day va bao benh nhan nuot. Khi dau xong vo den da
dy thay c dich v thc an chay ra trong lng ong xong. ieu chinh trong qu
trnh rua da dy de dau ong xong luon luon o vi tr thap nhat trong dich da
dy.
Tien hnh co dinh dau ngoi ong xong o vi tr d dnh dau.
Bai giang Chng dc
5
at dung mi: Luon ong xong cho an vo lo mi khong c dat noi kh q uan dong
thi de dau benh nhan gap vo thnh nguc. Khi qua lo mi sau vo den hau th bao
benh nhan nuot dong thi day vo.Cc thao tc tiep theo cng giong nhu dat
dung mieng.
Khi dat neu khong vo duoc thuc quan phai dng dn noi kh quan de xc dinh vi
tr thuc quan sau d dng panh Magil de gap dau ong xong dua vo thc quan
dong thi mot ngui khc day phan ngoi ong xong vo.
Khi c noi kh quan can tho bng chn truc khi dat xong, sau d bom bng chn
truc khi rua da dy.
Buc 2: Noi he thong rua da dy vi dau ngoi ong xong.
Noi ch 'Y hoac kho ba chac vo dau ngoi ong xong.
Noi hai ti vo hai dau cn lai cua ch 'Y hoac kho ba chac.
Ti dung dich vo treo len cot truyen cch mat giung 0,8 -1m.
Ti dung dich ra dat thap hon mat giung (t heo nguyen tac bnh thong nhau)
Buc 3: Tien hnh rua da dy
ua dich vo: ng dung dich ra lai, mo kho dung dich vo de cho dich
chay vo nhanh khoang 200 ml, sau d kho dung dich vo lai. Dng tay lac v
p vng thuong vi de can thuoc v thc an du oc tho ra theo dich.
Mo kho dung dich ra de cho dich chay ra ti dung den khi het so luong dich
dua vo, dong thi vi lac v p bung de dich chay ra nhanh v du hon. Sau d
lay dich cho vo chai de lm xt nghiem doc chat (khoang 200ml).
Lm nhu vay cho den khi het so luong can rua (3-5 lt) hoac dich da dy d
trong khong cn van thuoc v thc an (neu <3 lt). Trong trung hop ngo doc
thuoc tr sau luong dich c the rua toi da l 10 lt.
Ch :
Theo di can bang luong dich vo ra. Neu thay luong dich c hay ra < 150ml
nghi ng tac xong, kiem tra lai dau xong.
Dich dua vo can phai pha muo vi nong do 0,5 -0,9% de trnh tnh trang
ngo doc nuc do pha long mau.
Thi tietlanh nen dng nuc am 37
0
c trnh tnh trang benh nhan rt v gay
ha nhiet do.
Bai giang Chng dc
6
Benh nhan ngo doc thuoc tr sau phai rua nuc c pha them than hoat de
hieu qua loai bo chat doc dduoc tot hon, sau khi d lay dich da dy lm xt
nghiem doc chat. Thung pha 20-30 gam/lit, pha trong 3-5 lt dau.
Sau khi rua xong, ho than hoat v sorbitol vi ty l e 1:1 vo 50ml bom vo dad
y roi rt xong neu khong c chi dinh luu xong rua lan 2. Lieu luong than hoat
v Sorbitol cho vo da dy sau khu rua 1 -2 gam./kg benh nhan, c the chia lm
nhieu lan cc nhau moi 2 gi. e dam bao p luc tham thau trong lng ru ot cao
sau khi rua trnh tnh trang to bn hoac tac ruoot do than hoat lieu luong
Sorbitol c the cao gap 1,5-2 lan so vi than hoat, c the cho lm 2 -3 lan sau khi
rua da dy.
Trung hop khong c ti dung dich chia vach v chac ba c the dng pheu de
hng dich do vo, doi den khi luong dich trong pheu xuong gan het ta ha dau
xong xuong thap hon mat giung (theo nguyen tac bnh thong nhau) de cho dich
chay ra dong thi lac v p bung benh nhan de han che can thuoc v thc an
bm vo be mat da dy v dich c hay ra duoc nhanh hon. Tot nhat van phai dng
bo rua da dy kn.
VI. Bien chng:
Non: hay gap do khi dua dau xong vo den hong benh nhan c phan xa buon
non v non nhat l tre em, benh nhan lo so. V vay can phai giai thch cho benh
nhan de benh nhan duoc hop tc trong qu trnh lm thu thuat, v qu trnh dat
phai nhe nhng dng k thuat
Viem phoi do sac: l mot bien chng nang ne, de tien trien thnh ARDS gay
tu vong neu khong pht hien v xu tr kip thi.
Gap o benh nhan c roi loan thc m khong duoc dat noi kh quan c bng chn
truc khi lm thu thuat hoac qu trnh dat khong de benh nhan dng tu the, dat
nham vo kh quan m khong kiem tra truc khi tien hnh rua da dy, hoac moi
lan cho dich vo qu nhieu, hoac khong ht het truc khi ngng thu thu at.
Bieu hien: benh nhan kh tho tm moi v dau chi, nhip tho nhanh, nghe phoi c
ran am hai ben thung o ben phai, Xquang phoi c dm m thung o ben phoi
phai.
Phng: at noi kh quan cho benh nhan c roi loan thc, nam nghieng tri dau
thap trong qu trnh lm thu that, kiem tra lai vi tr xong truc khi rua da dy, moi
Bai giang Chng dc
7
lan dua dich vo nho hon hoac bang 200ml, ht het dich da dy khi ngng thu
thuat .
ieu tri: tuy theo tnh trang benh nhan m c the theo di v dieu tru khng sinh
hoac ket hop vi dat noi kh quan, soi ht v bom rua phe quan.
Chan thuong vng thanh mon gay ph ne thanh mon, hoac phan xa gay
co that thanh mon do dau xong di vo dung kh quan, dat tho bao .
Bieu hien: benh nhan c cam gic dau vng hong, ni kh, khn tieng. Nang c
kh tho thanh quan c the gay ngat tho cap. Neu khong xu tr kip thi benh nhan
c the tu vong.
ieu tri:
Nhe: Cho benh nhan kh dung corticoid.
Nang: at noi kh quan, neu khong duoc phai mo kh quan mot th
Chay mu:
Hay gap chay mu mi khi dat xong dun g mi do niem mac mi nhieu mach
mu nong, xong to, khong boi tron dau paraffin, dat tho bao. Chay mu mieng t gap
hon chu yeu chay mu chan rang khi kh mo mieng benh nhan, benh nhan dy giua
khi dat ong xong. Chay mu thuc quan da dy gap khi dng xong c dau cng, dua
vo qu sau.
Phng: Phai giai thch de benh nhan hop tc, lm dng dong tc, nhe nhng
dau xong khong vt canh v cng.
ieu tri: Chay mu nhe thung tu cam neu benh nhan khong c roi loan dong
mu. Nang c the dng adrrenalin pha nong do 1/10.000 roi nho vo cho chay
mu khi benh nhan khong c chong chi dinh dng adrrenalin. Neu khong d
c the phai dat nt gac lo mi? Tot nhat nen mi chuyen khoa Tai Mi Hong
de cam mu. Trong trung hop chay mu da dy nang phai soi da dy de cam
mu, c khi phai truyen mu khi c tnh trang mat mu nang.
Ha than nhiet:
Bieu hien: Benh nhan rt run, da tm v noi da g, nhiet do trung tam ha <36
do
Phng: thi tietlanh phai rua da dy bang nuc am, ni kn gi, dng my suoi
trong qu trnh rua
Bai giang Chng dc
8
ieu tri: lau kho, u am cho benh nhan, dng my suoi, cho benh nhan uong
nuoc gng-dung nng (khong dng gng cho benh nhan c huyet p)
Roi loan nuoc-dien giai: thung gap ngo doc nuc do rua nhieu nuc, khong
pha muoi.
Bieu hien: Nhe: ha Natri, Kali mu. Nang: ph phoi, hon me, c khi co giat de
gay sac phoi neu benh nhan khong x noi kh quan.
Phng: Dng lasix tinh mach, bo sung muoi sau khi benh nhan d tieu nhieu
(Natriclorua ong tiem TM v cho uong).
Neu hon me, co giat phai dng thuoc chong co giat, dat noi kh quan, tho my,
dng manitol truyen tinh mach.
Roi loan nhip tim: Thung l do phan xa, c khi cng do roi loan nuc dien
giai nang gay ra nhat l ha Kali mu. dac biet ngo doc mot so thuoc tc dong len
tim (digitalis, chloroquin, cacabamat...)
C the gap: Nhip cham xoang do kch thch day X: NTT that do ha kali mu
ieu tri: Nhip cham <40 lan/pht tiem atropin 0,5mg TM.
NTT that khi c ha kali phai b kali bang pha truyen TM.