..o0o..

X tr chn thng - vt thng lng ngc

X TR CHN THNG LNG NGC

I.

i cng:
1. nh ngha: l mt nhm cc cp cu ngoi khoa thng gp bao gm cc chn thng (vt
thng) ngc h v chn thng ngc kn.
- CTNK: thnh ngc tuy tn thng nhng vn kn, khoang mng phi khng thng thng
vi khng kh bn ngi.
- VTNH: thnh ngc b thng, lm khoang mng phi thng thng vi khng kh bn ngi.
2. c im c bn v thng bng sinh l h hp:
Cc thnh phn gii phu ca lng ngc:
- Thnh ngc: bao gm:
o Khung xng: xng c pha trc, ct sng pha sau, c ni nhau bng cc xng
sn. B mch thn kinh lin sn nm b di cc xng sun. Pha ngi xng
sn c da v c che ph, pha trong l mng phi thnh
o Cc c h hp (c bit l c hnh): c hoanh ngn cch bng ngc. Vm hnh phi cao
hn vm hnh tri t 0,5 1,5 cm. nh vm hnh c th ln n khoang lin sn 5
ng nch gia.
o Mng phi l thnh
- ung h hp:
o T mi, mm, kh ph qun - ph nang (ng hh phi thng thng m bo trao i
kh c tt)
o Trong CTLN ng h hp rt d b cn tr do dch tit tng ln, mu chy or d vt (do
au m hu nh bnh nhn khng th ho khc tng ra ngi c)
- Khoang mng phi
o L khoang o gia l thnh v l tng mang phi. p lc trong khaong thay i t -10 -> -5
cmH2O (tu theo th th ra hay ht vo), khi ho hoc rn p lc thay i nhiu hn.
o KMP kn, khi b thng s mt p lc m bnh thng, phi hkng n ln c na. KMP
thng vi khng kh bn ngi s gy nn nhng ri lon nghim trng v h hp v tun
hn
- Cc c quan trong lng ngc:
o Phi
o Tim
o Cc c quan khc trong trung tht:
MC v cc mch mu ln khc
Kh - ph qun gc
Thc qun
Sinh l h hp:
- 3 thnh phn chnh m bo chc nng sinh l h hp bnh thng l thnh ngc, ng
h hp v khoang mng phi. Khi 3 thnh phn ny bo tn th chc nng h hp s c
duy tr n nh.
- ng tc ht vo - th ra oc bo m nh c cc c h hp, tnh n hi ca ngc - phi
-> lung khng kh s i t ni c p sut cao n ni c p sut thp. p sut trong ph

II.

nang lun gn bng p sut kh quyn. Bnh thng c hnh m bo v 70% dung tch h
hp.
Vic m bo p lc m tnh trong khoang mang phi, s tn ven ca long ngc v thng
thng ca ng h hp ng vai tr ht sc quan trng trong sinh l h hp.
Trong hn cnh bnh thng, khong cso nhng ri lon v h hp v tun hn s c nhng
hng s sinh l sau:
o pH: 7,40 7,42
o pO2: 80 100mmHg
o PCO2: 35 45 mmHg
o BE: 2
o SB: 24 mEq.
Trong chn thng lng ngc, nguyn tc x tr l lp li thng bng sinh l h hp v tun
hn, nhng thng tn gii phu ch ng hang th yu.

Mt s hi chng gp phi trong CTLN

1. HC suy h hp:
- LS:
o C nng: au ngc, kh th.
o Tn thn: mch nhanh, da nim mc tm.
o Thc th: th nhanh nng > 25l/pht, cnh mi php phng, co ko c h hp.
- CLS: xn kh mu ng mch thy tnh trng nhim toan
2. HC TMMP:
- LS thng c hi chng SHH phi hp vi:
o Triu chng tn thn: mch nhanh, da nim mc nht, HA tt, chn tay lnh, v m hi.
o Thc th:
LN bin dng, gim bin h hp.
Km theo du hiu gy xng sn hoc MS di ng.
G c, RRPN gim hoc mt, chc d mng phi ra mu khng ng.
- CLS: hnh nh trn mu mng phi, gy xng sn trn phim XQ; xn thy thiu mu.
3. HC TKMP:
- LS: thng c hi chng suy h hp phi hp vi:
o Thc th ti b my h hp:
LN phng, bin h hp gim.
Thy trn kh di da, gy xng sn hoc MS di ng
G vang, RRPN gim hoc mt, chc d mng phi ra kh.
- CLS: XQ c hnh nh gy xng sn, trn kh mng phi.
4. HC TMTKMP: biu hin ca s phi hp 2 hi chng TKMP v TMMP:
- LS:
o HCSHH
o HC TMMP
o HC TKMP
- CLS: XQ: hnh nh gy xng sn, TMTKMP. XN thy thiu mu.
5. VTNH:
- HC SHH
- Vt thng trn thnh ngc, c th thy ph ph mu kh.
3

- HC trn mu trn kh mng phi.

6. HC chn p tim cp tnh:
- HC SHH: c c im l bnh nhn rt vt v, au ngc v kh th, nhng khng tng
xng vi cc biu hin c trn lng ngc
- HC TMMP: bn phi hoc tri, nu c thng biu hin nng
- Triu chng tn thn: nh th hi chng chn p tim cp tnh
- Ting tim m:
- XQ: hinh nh trn dch mng tim. C th c hnh nh trn mu trn kh mng phi.
- Siu m tim: c dch mng tim
- Chc do mng tim ra mu khng ng

III.

Chn n chn thng lng ngc:

1. Triu chng c nng:

- au ngc: thng xh ngay sau CT vi mc khc nhau, lin tc v tng dn theo thi gian
- Kh th: xut hin ngay sau CT vi cc th nng v mun hn vi cc th nh, tnh cht lin
tc v tng dn.
- Ho khc ra mu sm: t gp nhng c gi tr chn n cao (xh ngay nhng h u sau CT:
thng do CT kh - ph qun gc, nhu m phi ng gip nng -him).
- Hi bnh pht hin c:
o Nguyn nhn, tc nhn, c ch CT
o TS bnh tim, phi (lm nng thm CT ngc, gip phn bit gia suy tim v du hiu chn
p tim cp tnh)
2. Triu chng tn thn: Thay i tu tng th bnh ca CTLN
- Th thng thng:
o M nhanh, HA bnh thng.
o Da nim mc nht v tm nh
- Th c mt mu nhiu:
o M nhanh, HA c th bnh thng hoc tt
o Da nim mc nht r
o Chn tay lnh, v m hi
- Th c suy h hp nng:
o M nhanh, HA c th tt (g mun).
o Da, nim mc tm r.
o C th km theo biu hin ca th mt mu nhiu.
- Th c hi chng chn p tim cp tnh:
o M nhanh, mt mch ngoi vi khi ht su. HA m tt v kt. PVC tng cao (>15cmH2O).
o Gan to, tnh mch c ni, phn hi gan tm c (+)
o C th phi hp biu hin ca th mt mu nhiu hoc suy h hp nng.
Ngi ta c th pht hin, nh gi cc thng tn phi, hp, trong cso cc thng tn nng
lm nn bnh cnh a chn thng: CTSN, CT-VT bng, CT thn, v xng chu, gy xng
i, CTCS...
3. Triu chng thc th
a. Nhn:
- Cc du hiu chung:
o Bin dng LN: c th
Phng ln (trong TKMP)

Xp xung (trong TMMP)

o Vng xy xt - t mu trn thnh ngc
o Ngc bn thng tn gim bin h hp so vi bn lnh
o Php phng cnh mi.
o Co ko cc c h hp ph (vng c - ngc) khi h hp: r khi c SHH nng.
o MSD.
Trong VT ngc:
o C VT trn thnh ngc: 90% VT c l vo t thnh ngc, 1 s c l vo t bng hoc c.
Qua vt thng c 2 kh nng xy ra:
Thy ph ph kh mu qua vt thng: nu c, l du hiu khng nh chc chn trn
LS l VTNH.
Khng cn thy ph ph kh mu qua vt thng na: do c s cu, bng p
hoc khu kn.
o Xc nh v tr, o di, tnh cht VT:
V tr VT gip nh hng thm khm v chn n: VD
VT vng tm gic tim -> nguy c VT tim.
VT di KLS 5 ng nch gia tr xung: nguy c VT ngc bng.
di v tnh cht VT gip nhn nh tc nhn gy thng tch v mc thng
tn.
Trong CTNK:
o Vng xy xt da, t mu trn thnh ngc:
Thng gp, gi c CTLN.
V tr, ln vng xy xt c ngha nh hng cho thm khm v chn n.
o Vng h hp o ngc ca mng sn di ng:
Thng xut hin ngay vng xy xt v t mu thnh ngc.
th ht vo, trong khi lng ngc phng ln th vng ny li tht vo trong v di ng
ngc li trong th th ra.

b. S:
- Th nhanh, nng (> 25l/pht), c khi c suy h hp.
- Du hiu au chi, lc cc ca gy xng sn.
- TK di da quanh vng tn thng: gip khng nh l c CTLN (hu ht c gy xng
sn, rch phi, trn mu trn kh mng phi)
c. G: so snh vi bn lnh thy
- Vang hn cng cao khi c trn kh mng phi.
- c hn vng thp khi c trn dch mng phi hoc xp phi.
d. Nghe:
- RRPN: gim hoc mt bn tn thng.
- Ting tim: m trong hi chng chn p tim.
e. Chc d mng phi: ch nn dng khi khng c iu kin chp XQ ngc, hoc triu chng XQ
khng r rng. Nn chc t th nm:
- Khi tm trn kh: chc ht KLS 2 ng gia n, ht ra kh d dng hc t y piston ca
bm tim ra.
- Khi tm trn mu: chc ht KLS 5-6 ng nch gia, thy ra mu khng ng.

f. Chc d mng tim: t p dng (l phng php va c tc dng chn n va c tc dng iu tr

tm thi - ht bt mu gim chn p tim), thng chc d theo ng Marfan hoc Dieulafoix
thy ra mu khng ng
4. Triu chng cn lm sng:
- XQ lng ngc thng:
o Ch nh: nn chp cho mi th bnh nu c iu kin chp cp cu v tn trng bnh nhn
cho php.
o Cc t th chp thng thng:
Chp t th ng:
Chp t th nm nga:
Tiu chun phim XQ:
Thy tn b lng ngc ( kch thc), ht vm hnh 2 bn.
ng t th: ct sng thng, xng b vai ra khi ph trng, chm tia vung gc
vi ngc.
Cng tia : ch thy r 3-4 t sng ngc u tin v kh qun nm gia ct
sng. Nu tia qu cng s thy ht cc t sng ngc, nu qu mm khng thy
kh qun.
o Cc triu chng chnh: in hnh khi chp XQ ngc t th ng:
Hnh nh gy xng sn: ch thy c hnh nh gy cung sau v cung bn, cn
cung trc l sn sn. Pht hin s lng xng gy v mc di lch.
Hnh nh trn kh mng phi:
Ph trng qu sng do mt vn phi pha ngoi vi.
Nhu m phi co v pha rn phi lm xut hin ng vin nhu m phi.
Tim v trung tht b y sang bn i din.
C hnh b y xung di.
Cc khoang lin sn gin rng.
Hnh nh trn mu mng phi:
Ph trng m vng y phi, to thnh hnh nh ng cong Damoiseau.
Tim v trung tht b y sang bn i din.
C hnh b y xung di, KLS gin rng.
Hnh nh trn mu, trn kh mng phi:Thy hnh nh ca TKMP pha trn v
ng thng ngang phn cch vi vng m ca hnh trn mu pha di.
Hnh nh ca:
Dp phi: m m ri rc .
Xp phi: ph trng m, vn phi tng m, KLS xp l, c hnh ko ln trn,
trung tht b ko v bn tn thng.
Trn dch mng tim: bng tim to, mt cung tim, b tim r nt.
Trn kh trung tht:
Tht v hnh:
Chp t th nm: hnhf nh tng t nh trn nhng cht lng km hn. L :
trong TMMP s thy m u tn b ph trng hoc trong TMTKMP s thy hnh
nh thin v trn kh nu l kh chim u th v thin v mu nu trn mu chim u
th, v khng c ng phn cch gia vng trn mu v vng trn kh.

IV.

XN mu thng thng:
o BC thng tng:
o HC, HST v Hematocrit gim nu c mt mu nhiu.
Mt s thm d c bit khc:
o Kh mu ng mch: thm d h hp t bo, ri lon thng bng kim toan (nu c)
o Siu m tim: phthin trn dch mng tim v cc thong tn trong tim khi nghi ngh
c chn thng v vt thng tim.
o Soi kh ph qun: gip xc nh tn thng khi nghi ng c chn thng kh - ph
qun ln, ng thi c th phi hp ht mu, m di lm tc ng h hp chng
xp phi.

Thi x tr chung:

1. Nguyn tc chung:
- S cu ban u phi ng, kp thi.
- Qu trnh iu tr chia lm 2 giai on:
o iu tr cp cu: nhm phc hi sinh l h hp - tun hn:
Hot ng KMP.
Chng h hp o ngc.
Khai thng ng th.
Cung cp oxy.
B khi lng tun hn.
o iu tr tip theo: nhm phc hi gii phu chng nhim khun
- Th thut ph bin lL DL ti thiu KMP ri theo di st.
- M ngc ch gii hn trong 1 s ch nh nht nh.
2. S cu:
- Khai thng ng h hp trn
- Bt ngay l thng thnh ngc:
o Bng p
o Khu tm thi
o Nt Depage
- To ngay van 1 chiu Hemlich khi c TKMP di p lc.
- C nh tm thi mng sn di ng.
- Bt ng bnh nhn - chuyn nhanh ti c s chuyn khoa.
3. iu tr thc th:
- m bo lu thng ng th
o t ni kh qun
o M kh qun: khi c:
CT hm mt:
CT thanh qun:
- Cung cp oxy
- Bi ph mu mt
- Gim au, KS, SAT.
- Gii phng KMP bng dn lu kn:
o ng dn lu:
L mt ng nha, khng qu cng v cng khng qu mm, pha trong c
trng Silicon trnh mu cc hnh thnh.
7

C ng t 28 32 Fr vi ngi ln, tr em dng c nh hn (3Fr = 1 mm).

Di 40 cm, c vi l bn khng i xng phn u trong MP, u ngi hi loe
ra lp ng ni..
1 s c ng c ng ch cn quang ckhi chp ngc bit u ng u.
o TKMP: n lu ti KLS II ng gia n
o TMMP: LS 5 ng nch gia.
o TK-TM MP: t 2 ng 2 vi tr tng ng hoc 1 ng ti KLS 5 ng nch gia
o Nguyn tc:
Kn thng 1 chiu
p lc ht m tnh (-20cm H2O)

Theo di
o L lng mu chy ra hng gi
o Lng kh x ra.
o Chp XQ ngc xem c ng trong KMP khng, phi c n ln khng.
o Cn lun lun vut ng trnh mu cc lm tc. Nu tc cn phi pht hin v thng
ngay hoc thay ng.
Du hiu tc l: mc nc trong ng khng cn ln xng khi th (cn tho ng ra
khi my ht quan st)
o Khi gii phng ht KMP khi mu vkh, phi n ln hn tn th phi rt ngay dn
lu, khng nn lu d bi nhim KMP.
o TKMP:
Tt: kh gim dn, phi n ra, RRPN bnh thng tr li
Phi khng n (tng p lc ht -> ti a n 70cm H2O)
Nu khng c kt qu: m ngc cp cu x tr thng tn
o TMMP:
Tt: mu gim dn, phi n ra.
Nu mu ra trn 300ml/h trong 2 h lin -> m ngc cm mu.
4. Cc ch nh m ngc:
- Ngay sau chn thng:
o VT ngc rng.
o VT tim - mch mu ln.
o VT ph qun ln.
o VT thc qun.
o VT kh qun.
- Cp cu sau khi theo di:
o TKMP khng cm:
o TMMP khng cm:
o Mu cc mng phi
- Ch nh m ngc mun:
o Dy dnh mng phi
o cn mng phi

V.

Cc thng tn thng gp v x tr c th:

1. Gy xng sn:
8

i cng:
- Bn thn gy xng sn n thun l mt tn thng nh, lnh, thng khng li di
chng d khng iu tr g. M ch yu l thng tn km theo mi nng v d gy bin
chng.
- C ch gy:
o Gy trc tip: tc nhn chn thng u th xng sn gy . Loi ny gy vo
trong, tng nm ngay st gy d b tn thng (thng l phi)
o Gy gin tip: l tc nhn gy chn thng p t pha truc ngc, con pha sau lc l mt
vt cn c nh, lng ngc b p li theo chiu trc sau, cung bn xsn gy ra ngi.
Tng trong trung tht d b tn thng (Tim, mch mu ln).

1 s trng hp gy xng c bit cn ch :

o Gy xng sn 1 - 2: Phi mt chn thng c lc tc ng rt ln mi lm gy c 2
xng ny, nu c th b mch thn kinh (M ui n, rtk cnh tay) d b tn thng.
o Gy xng sn 8 9: thng km theo thng tn gan lch
o Gy xng sn ngi gi: gy gy au ngi gi -> gim ho, khc -> d bin chng
tc ph qun, xp phi.
o Gy xng sn tr em: tr em xng mm, kh gy -> cn lc tc ng rt ln -> nu
c th tn thng km theo thung nghim trng.
Chn n:
- C nng:
o au chi vng chn thng sau tai nn, vng au c nh, au thng tng ln khi ho, khi
th su.
o Tc ngc, kh th (do gy xng sn gy au)
- Thc th:
o Th nhanh nng.
o C vng mu t v im au chi trn thnh ngc (1 tay di lng, 1 tay trn xng c ->
p nh -> au chi ti gy), s thy ting lo xo xng.
- Cn lm sng: XQ lng ngc: c th pht hin c gy cung sau v cung troc (kh v vng
ny l sn sn) v c cung bn, i khi cng cn chp phim chch xc nh chnh xc
x tr gy cung bn.
o Khong tun th 3 6 th c hnh can xng, cng thy r gy.
o Gy sn sn, sn sn b tch ri thng khng nhn thy.
- >50% trng hp gy xng sn l c thng tn phi hp km theo v vy cn thm khm
t m, tn din pht hin v x tr kp thi cc thng tn phi hp.
Thng tn phi hp:
- TMMP thng do:
o Tn thng b mch lin sn
o Tn thng mch mu nhu m phi do u xng gy m vo.
o Tn thng c hnh hoc cc tng trong bng, hoc thng tn b mch di n.
- TKMP :
o Thng tn nhu m phi

o VT m t ngi vo to nn VTNH
TM-TKMP:
TKDD

iu tr:
- Gim au (l ch yu):
o Thuc NSAID
o Phong b thn kinh lin sn (phi phong b 1 ls trn v 1 ls di n) ti vng cung sau (4
kht ngn tay t ng gia lng -> gy t gc dy thn kinh ; cng c th gy t ti ch
vt thng = Novocain hoc Xylocain.
o Gy t vng (gy t ngi mng cng vi Morphine)
- C nh xng gy (c tc dng gim au, chng di lch u gy -> thng tn b mch tk
lin sn hoc cc tng trong LN): do tnh cht di ng ca LN nn t khi c nh xng
sn gy :
o Bng vi, bng p quanh ngc : nhng nhiu nhc im gy hn ch h hp.
o Bng dnh dn quanh ngc (tn km) : bnglm nhiu tng, chng ln nhau, vt ln trn
v di gy mt sn, dn 1 na lng ngc.
o Thng khng c ch nh kt hp hoc c nh xng bng KL tr MS di ng
o Vi gy cung sau, c th cho nm t th nga c m gi 2 bn sn, ngi gi cho nm t
th Fowler.
- m bo thng thng ng h hp trn :
o Ch ng ho hoc gy ho, khc m (p tay t vo vng gy c tc dng gim bt au khi
ho)
o Nu khng t ho khc c th phi ht m di qua (mi hoc ming ch khu v
khun v cc bin chng c th gp ca th thut ny)
- Th oxy: mt s ngi CT nng, ngi bnh phi mn tnh, ngi gi (thng nhiu m
ri xut tit, d co tht ph qun).
- Vn ng sm: trnh nhng bin chngkhi nm lu
- Khng sinh: tu trng hp c th c th cho khng sinh.
1 s trng hp gy 1-2 xng sn khng c bin chng, c th ch cn gim au cho bnh
nhn l , khng cn p dng tt c cc bin php trn.
Nu c bin chng th x tr nh cc x tr tn thng c quan trong lng ngc.
2. Mng sn:
2.1 nh ngha: mng sn c nhiu loi:
- Mng sn truc - mng c sn: bao gm xng c v cc sn sn gy ri lon nghim
trng v h hp v tun hn v gy co ko c hnh khi h hp.
- Mng sn bn: l li mng sn hay gp nht di ng khng nhiu nh mng c sn.
- Mng sn sau: t di ng nht v ch cn nm b hn ch di ng, khng cn phi c nh.
- Na mng sn: xng sn ch gy 1 ni, mng sn di ng kiu cnh ca vi bn l,
thng xy ra ngi tr.
2.2 Din bin: tu theo tnh cht di ng sau khi hnh thnh mng sn chia thnh:
- Mng sn di ng: l mt vng no ca lng ngc b mt lin tc v di ng ngc
chiu vi lng ngc khi th. iu kin l xng sn phi b gy 2 ni trn cng 1 xng v
t nht 3 xng sn lin tip nhau.
- Mng sn c nh: do c u xng gy ci vo nhau, tuy c nh nhng mng sn ny c
th di dng th pht di thy i p lc t ngt trong khoang mng phi (ho), thng xy ra

10

trong khong 2-3 ngy u sau chn thng. Nu nh khng c di ng th p lc m trong

khoang mng phi s ngy cng ht mng sn vo su hn, gy ra di chng hn ch h hp.
Cn nh: nhiu khi gy xng sn th nhu m phi bn trong thng b tn thng, gy nn
trn mu, trn kh, xp phi. C khi do nhng tn thng ny m bt buc phi m iu
tr.
2.3 Chn n:
- C nng:
o Kh th v au ngc rt nhiu.
o C th ho khc mu sm (biu hin ca rch ph qun lon hoc dp phi nhiu)
- Tn thn:
o Biu hin ca suy h hp nng thng phi hp vi biu hin ca mt mu.
o C th c shock.
- Thc th: bn cht l du hiu mng sn di ng + TM-TK mng phi nng, bao gm:
o Vng xy xt da - t mu rng trn thnh ngc
o MSD
o Php phng cnh mi, co ho cc c h hp c - ngc
o Bin h hp gim
o Th nhanh nng
o TKDD nhiu
o G vang vng cao, c vng thp.
o RRPN phi gim hoc mt
o Chc d mng phi ra nhiu kh cao, ra mu khng ng v tr thp.
- CLS:
o XQ ngc:
Gy rt nhiu xong sn, gy 2 ni/1 xng, di lch r. Hnh nh khng r nu gy
cung trc/mng sn trc.
Hnh nh TM TK mng phi rt thay i do phn ln cc trng hp c chp t
th nm, thng th tn b ph trng m hn, nhu m phi co li v ng vin nhu
m, c trn kh di da
o XN mu: thy cc du hiu: HC, HST, HCT gim; BC c th tng.
2.4 X tr:
a. S cu:
- Lm thng thng ng th, cung cp oxy
- Nu xc nh l mng sn di ng th hn ch di ng ca mng sn ngay bng:
o Dng 1 cun bng t vo mng sn, ri ly bng khc cun vng quanh ngc lm cho
mng sn lun t th tht vo m khng phng ln c. (tt nhin lm hn ch h
hp).
o Dng tay p ln ngc bnh nhn v n nh vo mng sn.
o n 1 gi mng vo vng MSD ri cho bnh nhn nm nghing ln vng mng sun nul mng sn bn, nga - nu l mng sn sau.
o Dng mt kp c mu di cp vo da gia vng MSD sau khi gy t, ko gi c
nh mng sn ra ngi.
- Hi sc, truyn dch mu (nu pht hin c shock mt mu)
- Gim au (h paracetamol, tt nht l dng tim tnh mch: perfalgan, prodafalgan)
- Chuyn ngay v trung tm iu tr
11

b. iu tr thc th:
- Dn lu ti thiu khoang mng phi:
- C nh:
o C nh ngi:
Np Judet: cn phi chn np sao cho thch hp vi xng sn: np rng th lng,
np b th phi bp nhiu d gy thi h xng sn v sau.
Xuyn inh Kirschner qua gy gi 2 u:
Ko lin tc qua h thng rng rc hnh mng nga, hoc khng vng to quanh
xng sn bng ch perlon to vo cc xng sn thuc mnh sn, c th dng
loi kp cp vi m, tt c si chi buc tm li ri qua rng rc , qu t ko lin
tc. Trng lng ko ph thuc vo tng bnh nhn sao cho mng sn b ko ra
m khong tht vo trong c khi th -> nh vy trong t nht 1 tun ri gim hn
trng lng t xem mng sn c di ng khng ri dn b hn.
Phng php khc: khu c nh mng sn vo khung kim loi t trn ngc, np c
nh mng sn, khu c nh xng sn vo nhau (t p dng).

o C nh trong (c nh sinh l):

t ni kh qun (nu qu lu trn 1 tun th nn m kh qun), dng thuc gin c
ri cho th my.
MS D c c nh do bnh nhn khng t th m th theo my nn p lc m
trong KMP khng thay i -> c nh c mng sn.
Sau 1 tun tp cai my t t.
Bin chng: tc m ri, kh sn sc, TM MP, dinh dng, v sinh c nhn kh
khn, nhim khun h hp) -> kh cai my.
iu tr sau m:
o Sn sc, theo di dnlu mng phi -> rt sau 3- 4 ngy.
o Hng dn bnh nhn tp l liu php h hp sm ngay sau m.
o Tho b h thng khu trao MS D thng vo ngy th 7 sau m.
o Khng sinh liu cao, gim au, ho long m, gim vim
o n ung nng cao th trng.
o B mu nu thiu mu.
Bin chng v tin lng:
o Bin chng: Tc m ri, TMMP, xp phi, nhim khun vt m,...
o Tin lng: kh tt nu iu tr ng v tch cc. V au ngc do gy xng sn cn ko
di nhiu ngy -> gim au, gim vim, tp l liu phap cn ko di nhiu tun sau m.
Thi chung khi x tr vi mng sn:
o i vi mng sn c nh: theo di phng di lch th pht
o i vi mng sn di ng:
Ko lin tc vi mng sn trc v bn.
Np Judet cho mng sn bn.
M xuyn inh trong nhng trng hp c nhng thng tn trong lng ngc cn
gii quyt ng thi.
S dng my th khi c i ng y t tt, thnh tho chm sc.
o B mu y (v lng mu mt trong mng sn l rt ng k).
12

3. Trn mu mng phi:

L mt bin chng hay gp trong chn thng lng ngc. Mu chy vo phi t 3 ngun: phi,
thnh ngc, mch mu trong trung tht.
3.1 Chn n: nh nhng bc trong phn chn n chung, nhng cn c bit ch khi chp XQ
ngc: v bnh nhnh khng ng c m phi chp nm nn hnh nh khng c in hnh, d chn
n sai.
3.2 Din bin:
- Nu t mu c th t tiu m t li di chng
- Nu nhiu, ngi kh nng phi m cp cu, nu khng cn chy tip, c th s gay dy dnh
mng phi -> Nhim trng s thnh m mng phi, i khi thnh mu cc mng phi
khng th dnlu ra ngi c m phi m.
3.3 X tr: tng t nh i vi mt trng hp chn thng ngc kn khc.
- Nguyn tc:
o Ht ht mu trong KMP, ht trit (ht lin tc bng h thng my ht p lc m), khng
gy bi nhim.
o Ch khi khng c iu kin (phng tin v ngi theo di) th mi chc ht khoang mng
phi bng kim.
o Cn theo di lng mu chy ra sau dn lu
- Tin trin:
o Phi n ln, p st mng phi lng tng vo l thnh, bt kn m khng chy mu na ->
iu tr bo tn thnh cng.
o Nu ngc li th phi m ngc cp cu.
- Bin chng hay gp: xp phi, t gp nhim trng vt m.
4. Trn kh mng phi:
Kh vo khoang mng phi t 2 ngun: qua vt thng ngc h hoc qua nhu m phi b tn
thng.
- Chn n: ngi nhng du hiu thng thng ca trn kh mng phi, cn ch ti trn kh
mng phi di p lc:
o Khng kh trn vo khaong mng phi ngy mt nhiu qua mi ln th, p lc khoang
mng phi ngy cng tng, y lch trung tht v bn i din, p phi bn lnh lm cho
bnh nhn kh th d di. Nu khng s cu kp thi th thng BN s cht.
o Du hiu XQ l du hiu y.
- X tr:
o Ht dn lu lin tc qua h thng my ht p lc m -> ht ht kh trong khoang (lu
lng kh ht ra phi ln hn lng kh x vo khoang mng phi)
o Phi n c cn ph thuc vo ng th c thng khng,: nu b tc do m hoc di vt
th d c tng p lc ht th phi vn xp
o Nu phi khng n ln c, bt buc phi m, x tr ch khng khi bx (thng l vng
nhu mi phi dp nt nhiu hoc kh ph qun b v).
o Trong trn kh mng phi di p lc, lc vn chuyn bn cn t van Heimlick, hoc dng
mt kim tim to c buc u gng cao su ct mt ng, chc vo khoang lin sn
2-3 ng gia n.
5. Trn mu trn kh mng phi:
- Chn n:
o C nng: au ngc v kh th.
o Lm sng:
13

Suy h hp
HC trn mu MP
HC TKMP
HC thiu mu, tu mc chy mu
o CLS:
XQ ngc: thy hnh nh gy xng sn di lch r v TM-TKMP
Xn mu: BC tng cao, co th thiu mu.
Th lm sng: c th gp 2 th lm sang nm 2 cc ca TM-TK mng phi
o Th trn mu >> Trn kh: biu hin lm sang v XQ ging nh mt trn mu mng phi
n thun. Nguyn nhn c th do t 1 mch mu ln ca thnh ngc hoc cc mch
mu nhu m phi
o Th trn kh >> Trn mu: biu hin lm sang v XQ thng nng hn mt trn kh mng
phi n thun. Trn kh di da nhiu, thm ch lan ra tn b ngc - bng - c - mt, i
kh c trn kh mng phi di p lc. Nguyn nhn thng l ng gip nhu m phi
rng, i khi do rch cc ph qun ln.
Ch : mc d biu hin lm sang th nghing v trn mu hoc trn kh mng phi,
nhng khng c quan nim l trn mu hoc trn kh n thun - nht l i vi th
c trn kh nhiu, v thi iu tr ca chng hn tn khc nhau.
X tr: tng t nh i vi mt trng hp CT ngc ni chung (ly trng hp ny lm
mu chung cho cc trng hp thng tn chn thng ngc kn khc: TKMP, TKMP
o S cu sau khi b thng:
Lm thng thng ng h hp, th xy.
Hi sc, truyn dch nu c sc mt mu.
KS gim au, phng un vn nu c xy xt.
Sm chuyn vo phng m hay chuyn n c s c kh nng iu tr thc th.
Ring i vi th c trn kh nhiu (ngc cng phng, trn kh di da nhiu, suy h
hp rt nng) -> chc kim vo KMP + t chc di da gim p -> chuyn ngay i
m.
o iu tr phu thut:
Ch yu l dn lu mng phi ti thiu vi gy t ta ch, v tr dn lu thng l qua
khoang lin sn 5 ng nach gia (TK>>TM), c th t thm 1 dn lu kh quan
KLS 2 (gia n).
Nu dn l ra ngay > 1500ml mu (thi gian b thng ti khi m < 6h) hoc dlu
ra > 200ml/h X 3h -> mi xt ch nh m ngc (tham kho kin BSCK) vi mc
ch chnh l cm mu cc mch mu ln (M lin sn, PQ, phi). Thng m qua
LS 5.
Nu dn lu kh ra nhiu phi khng n - huyt ng khng ci thin (SaO2 thp)
-> mi xt ch nh m ngc khu cc ch rch phi pq qu ln. Khu ph qun
bng ch tiu chm.
Hu ht khng cn can thip g trn cc gy xng sn).
Rt him khi c ch nh m ngc.
o iu tr sau m:
Sn sc dn lu mng phi, thng rt vo 48 -72 h sau m.
Hng dn bnh nhn tp l liu php h hp sm ngay sau m.

14

 KS, gim au, ho, long m, gim vim.

n ung nng cao th trng, b mu nu thiu.
o Theo di bin chng:
Nhim trng vt m: nu c m ngc, ct ch da sm, thay bng, KS theo KS.
Xp phi: tch lm lm l liu php.
Mu cc mng phi: l bin chng him gp sau dn lu mng phi do TM-TKMP,
v c ch chy mu khng t. Tuy nhin iu tr kh khn hn do c gy xng
sn, nn p dng m ni soi.
o Tin lng: nhn chung kh t nu iu tr ng v tch cc. au do gy sn cn ko di
ti c thng -> vic cho gim au, gim vim v tp l liu php cn ko di nhiu tun
sau m.
6. Xp phi: l mt bin chng rt hay gp sau chn thng. Nguyn nhn thng do tit m ri
tng, mu v di vt nm trong ng h hp, nhng ch yu l do phn x ho gim v au qu.
-> xp phi. Nu xp phi trn 2 tun s dn n x h -> phi khng n ra na.
- Chn n: cn phi phn bit vi TKMP (du hiu y)
o Du hiu XQ l du hiu co:
Trung tht b ko sang bn tn thng (Xc nh trn phim bng bong ca kh qun
so vi ct sng).
Co hnh b ko ln.
KLS thu hp
- X tr:
o Gim au sau chn thng l ch yu phng bin chng ny, cn kch thch bnh
nhn ho v th su.
o Khi c xp phi, phi tm cch kch thch ho tng m ri ra ngi: thuc long m,
th dc liu php, kch thch ho, nu khng mi bt buc phi soi ht ph qun.
7. VTNH
- N: l vt thng lm rch l thnh KMP lm KMP thng vi bn ngi.
- Tn thng gii phu:
o Thng tn thnh ngc:
Thng thnh ngc: KMP thng thng vi bn ngi, d km theo t - m xng
sn hay vt thng b mch thn kinh lin sn. Hu qu l khng kh bn ngi +
mu chy t vt thng vo ra KMP, gy trn mu trn kh mng phi -> ri lon
thng kh nng n.
Gy xng sn: t xng sn thng km theo thng tn b mch lin sn,
gy chy mu rt nhiu -> hu qu nghim trng
Thng c hnh: thng c hnh hay gp trong VTNH vi v tr vt thng t KLS 5
ng nch gia tr xung, gy VT ngc - bng.
o Thng tn khoang mng phi: TK + TM MP
o Thng tn cc tng:
Rch nhu m phi
VT ph qun ln:
Xp phi:
Tn thng tim v mng tim:

15

 Thong tn: rch mng tim v tim do vt nhn m., thng th v tr vt thng
nm ngay vng nguy him ca tim (tam gic tim).
Hu qu thng 2 dng:
o Mu chy ra ngi hay vo KMP do VT ln, thng gy t vong do mt mu
nn t gp trn LS
o Mu chy t vo khoang mng ngi tim, khng kp tht ra ngi do VT mng
tim nh, nn mu ng li tm thi bt kn VT -> chn p tim cp tnh (gp
ch yu trn lm sng).
MC ngc:
- Chn n v x tr theo th lm sng:
VTNH n thun:
o VT cn ang h
C nng: tai nn, m chm nhau -> kh th, au ngc d di
Thc th: SHH: th nhanh nng, co ko c h hp ph, v m hi
Mi ln th bt kh v mu bn ra ngi qua VT trn thnh ngc, nghe thy ting ph
ph qua VT
o VT bt kn: nn nhn c th c s cu trc , hoc VT nh t bt kn
C VT thnh ngc
C biu hin ca 2 hi chng TMMP v TDMP kt hp vi nhau.
XQ lng ngc c hnh nh TM-TK MP, c th thy hnh nhgy xng sn (lu
VT b mch thn kinhlin sn)
XN mu: thiu mu, BC tng cao
o iu tr:
Mc ch nhm
Lm sch KMP.
Lp li p lc m trong KMP
Lm cho phi n tt.
S cu sau khi b thng
Nhanh chng bt kn VTNH: bng cch bng p vi 1 lp gc dy, nu VT ln c
th khau da tm thi (nu c iu kin). Nt Depage ch dnh cho VT rt ln.
Lm thng thng ng h hp, th oxy.
Hi sc, truyn dch nu c shock mt mu.
KS, gim au, phng UV
Sm chuyn vo phng m hay c s c kh nng iu tr thc th.
iu tr phu thut
Ch yu gm: dn lu ti thiu KMP, cn mu, khu kn VT, ht sch ng h
hp (mu, m, d vt)
V cm: thng gy t ti ch, phi gy m NKQ, nu VT ln hay cn thm d VT
(nu nghi ng VT ngc bng)
Phu thut:
o DL ti thiu KMP qua KLS 5 ng nch gia.
o Cm mu v khu kn VT thnh ngc theo tng lp.
Ch nh m ngc:

16

o Nu dn lu ra ngay > 1000 ml mu/thi gian t khi b thng ti khi m

di 6h.
o Nu theo di sau dn lu thy ra > 200 ml/h x 2-3 h lin tc.
Mc ch: m ngc ly mu cc KMP, cm mu thng tn mch mu ln
(thng l b mch LS, mch v trong, i khi l mch phi).
iu tr sau m
Sn sc dn lu MP, thng rt vo 48-72h sau m.
Hng dn bnh nhn tp l liu php.
KS (3-5 ngy), gim au, ho long m, gim vim.
n ung nng cao th trng, b mu nu thiu.
Theo di bin chng:
NT vt m v VT thng.
Xp phi: tch cc lm l liu php.
iu tr di chng:
Ly d vt:
o Khi ly d vt, kch thoc d vt trn phim chp ngc > 1cm3
o Khi d vt gy bin chng ho ra mu hoc NT.
cn mng phi:
o Bc mng phi
o p sp sn hay dng c nht vo cn MP (t dng)

VTNH vi cc th bnh khc:

o VT tim
V tr VT: nm trong vng tam gic tim hoc vng nguy him ca tim (tng i v
tuyt i)
2 th LS: VT c hi chng chn p tim cp tnh (thng gp). VT c hi chng mt
mu cp tnh (t gp).
Nguyn tc iu tr: m ngc khu VT tim cng sm cng tt.
o VT mch mu ln:
V tr VT thng l st ct sng, c bit l bn tri.
Chn n: VT ngc + HC mt mu rt cp tnh.
Nguyn tc iu tr: m ngc cm mu cng sm cng tt.
o VT ngc bng:
VT VT: ngang mc KLS 5 ng nch gia tr xung.
Chn n: VT ngc h + du hiu bng (LS + CLS)
Nguyn tc: m c ngc v bng x tr thng tn
o Mu cc mng phi:
C ch hnh thnh: thng do t M lin sn hay cc mch mu ln cat phi,
mu chy ra nhiu v nhanh nn hnh thnh cc mu ng trong khoang mang phi,
sau mch t cm mu, X tr ban u ch dn lu ti thiu MP nn mu cc khng
ra c.

17

Chn n: LS v XQ ngc thy cn du hiu TMMP dai dng (thng y phi),

dn lu ra t mu en thm mu, i khi c c mu cc. Thng xut hin st + HC
nhim trng vo ngy 3 5 sau m.
Nguyn tc: bn cp cu, tt nht trong 10 ngy u sau m: m ngc bn nh hoc
ni soi ly mu cc - ra MP- phng phi. Tp l liu php tt sau m.
8. V ph qun:
- Nguyn nhn: do ti nn xe c tc cao, chn thng kn vo vng ngc v thanh qun li
ng kn. Phn ln l v gn ch chia i kh ph qun.
- Chn n:
o CT kn, mnh vo vng ngc trn
o Gy cc xng sn t 1-3.
o Kh th nhiu, ho ra mu v tkdd.
o TKMP di p lc hoc trn kh c 2 bn, tk trung tht.
o Phi khng cn n ln c d tng p lc ht rt nhiu.
o Kh th nhiu khi ht ng dn luu mng phi.
o Soi ph qun: l mt thm khm c tnh cht xc nh chn n v tr cng nh mc tn
thng -> x tr cho tt. Trong cp cu khng nn chp ph qun, kh n nh c th
chp.
- X tr:
o i vi nhng trng hp rch nh, iu tr bo tn, soi ph qun theo di s lin. M
kh qun thng khng c tc dng.
o M khu ph qun rch (kh): cn t ni kh qun, phu tch k cng, ct b nhng m
dp nt ri mi khu ni (nn dng vicryl 3/0 4/0). Phi ht sch ph qun pha di
ch v trc khi khu kn.

9. V ng mch ch do CTNK: khng phi l 1 tn thng him gp, m thng do tai nn c

tc nhanh: tc dng t ngt, thng tn thng xy ra v tr tip gip gia quai ng
mch ch (t do) v on m ch xung (c gi bi cc nhnh ca ng mch lin sn) tng ng chn ng mch di n tri.
Thng cht do mt mu t vo khang mng phi hoc mng tim,
- Gii phu bnh: c 3 loi thng tn:
o V hn tn c 3 lp: him gp, v thng cht
o V di lp o ngi: hay gp nht gy nn ti phng ti ch v d dng lc thnh mch
sang hai pha, c khi ti tn vng van ng mch ch v chc 3 ch chu.
Tin trin ca khi mu t l gy gi phng ng mch ch ngc. Vi tun sau thnh ti
phng c t chuc h v bnh nhn c th sng c vi tun sau khi b chn thng.
Ti phng ngy mt to ln, chn p vo t chc xung quanh v c th v vo mng phi
hoc trung tht.
o V lp ni mc: tuy thng gp nhng do khng c biu hin g nn kh chn n v c
th t thnh so.
o Cc v tr thng tn thng gp:
Vng eo ng mch ch.
ng mch ch ln ngay truc thn cnh tay u.
MC on st trn van gy h van, TMMT -> t vong.

18

Chn n:c 2 tnh hung

V mi: (thng b ng c v phng tin v phu thut vin)
o C nng:
TS: Tai nn xe c vi tc nhanh (dng t ngt)
au ngc, au sau lng
i khi c nut kh, kh th (do chn p, kh qun, thc qun b y lch) - thng
l du hiu mun
o Tn thn: vo vin trong bnh cnh a chn thng hoc c khi khng c du hiu g c
bit
i khi c shock
o Thc th:
Lit hoc gim cm gic 2 chn d thong qua v khng c chn thng ct sng
km theo.
Chnh lch p lc ng mch gia tay v chn,
Ting thi tm thu trc ngc, sau lng hoc gia 2 xng b vai.
Mt hoc gim mch cnh, mch bn hoc cnh tay (khi v vng quai ng mch
ch).
o CLS:
Chp ngc khng chun b: trung tht rng hn 8cm - mt hnh quai ng mch ch,
kh qun y lch k c ph qun tri v thc qun.
Chp cn quang ng mch ch:
Tht cht cn quang khi lng mch
Thy hnh nh gi phng ng mch ch.
Hnh nh mt lin tc ca thnh ng mch ch
Gin vng eo ng mch ch
CT ngc, MRI, siu m (ch khi tn trng bnh nhn cho php)

Ti gi phng eo ng mch ch:

o LS: ngho nn c th c:
au ngc tri.
Du hiu chn p tng xung quanh gy: kh th, kh nut, lit thn kinh qut ngc
tri .
Triu chng gi hp eo ng mch ch ch l ngoi l.
o CLS:
XQ ngc tiu chun:
Hnh nh phng eo ng mch ch.
Kh qun b y lch
Chn p thc qun (khi chp thc qun c ung thuc cn quang).
Chp ng mch ch qua ng tnh mch hoc ng mch ngc dng: -(xc nh
chn n phng eo mc sau chn thng) da:
V tr eo ng mch ch.
BN tr tui c tin s chn thng.
- X tr:

19

V eo ng mch ch do chn thng

o M cp cu khn trng, phi hp vi hi sc tt. (ung m thng theo KLS IV t ct
sng n xng c)
o M tr hoc hoc m vo giai on hnh thnh mt ti phng ng mch ch, c th gi
chun b v c th dng my tim phi h tr khi cp ng mch ch bng cc phng
php sau:
H thn nhit trung bnh b mt xung cn 31 .
Lm cu ni tm thi tm nh tri v ng mch i.
Lm cu ni tm thi ng mch nch v ng mch i bn phi.
o Chy my tim phi tin hnh phu tch ng mch ch. Cp cc mch mu, m khi mu
t, ly ht mu cc, nh gi thng tn sa cha.
o Phc hi lu thng mch mu bng khu ni trc tip hoc qua 1 on ghp.
o Kt thc phu thut:
Ngng my tim phi, rt ng v khu li ng mch tnh mch i.
Trung h Heparin v protamin.
t dn lu i.
Dn lu v ng ngc
Phng eo ng mch ch sau chn thng:
o Nguyn tc iu tr phng eo ng mch ch sau chn thng cng ging nh iu tr v
eo ng mch ch mi. Ch khc 1 vi im.
o Bnh nhn khng trong tnh trng cp cu khn cp.
o Phu tch MC ngc thng d hn so vi v eo MC mi.
o Kp ng mch ch trn v di ch phng phi hp vi tun hn ngi c th, phu tch
ni 2 u qua on mch nhn to, cng c th khu li trc tip ch v hoc v bng
mt ming nhn to (khi v 1 phn chu v ng mch ch tin trin thnh ti phng hnh
ti m c ti phng chnh l ch v ca thnh ng mch ch.)
o Th kp ng mch ch phi t t trnh x rch hoc lc thnh mch
o Ct b 1 phn v ti phng v khu che v ti phng trn on mch ghp cch bit vi
phi tri.
o Khng cn dng heparin sau m
Bin chng:
o Chy mu sau m.
o Phng ming ni sau m.
o Lit tu sau kp ng mch ch.
o Suy thn sau kp ng mch ch.
10. Vt thng ngc bng: bn cht l mt VT ngc h thp, i qua ngc, xuyn qua c hnh
xung bng.
- Gii phu bnh: do c im gii phu l nh vm hnh tng ng mc KLS 5 ng
nch gia v p lc m tnh trong khoang mng phi -> c th sau:
o L vo ca VT hu nh nm di mc KLS 5 ng nch gia.
o Lng dch v mu trong KMP >> VTNH n thun do ht t bng ln. Nu bn phi s
l rt nhiu v c km theo VT gan, nu bn tri thng kem theo dch tiu h, thc n,
phn c th b ht ln KMP tri.
o Tht v hnh him khi xy ra do VT c hnh nh nhng rt d nght.

20

o Mu v dch tiu h trong OB thng t trong nhng h u, tr 1 s trng hp chy mu

d di do VT ln vo gan, lch.
Chn n:
o C nng:
Tai nn m chm nhau -> au ngc kh th d di
o Tn thn:
M nhanh, huyt p tt -> shock do mt mu.
o Thc th:
VTNH vi tr < KLS 5 ng nch gia
Lng ngc:
vi cc du hiu cu TM-TKMP s lng nhiu hay t tuy trng hp.
Gi : VT nh bn phi nhng TMMP nhiu (c th km shock mt mu), hay du
hiu ca tht v hnh bn tri (nghe thy nhu ng rut ngc).
Du hiu bng: cn phn bit vi cc du hiu ca phn ng c hnh - bng trong
CT ngc: au tc, co cng vng di sn bn tng ng vi tn thng, nhng
vng h chu th mm v khng au.
in hnh ci cc du hiu ca VT thu bng: au khp bng hoc bng bn
thng tn, phn ng, co cng thnh bng, cm ng phc mc, ti cng Douglas
phng v au. n mun c th thy tnh trng vim phc mc.
Khng in hnh: bng t au, vn mm. Nu thm khm k vn c th thy au
thc s v phn ng khu tr vng di sn tng ng bn thng tn, r hn c
th thm au v phn ng nh lan xung h chu.
o CLS:
XQ, XN cho du hiu nh trong VTNH.
1 s thy hnh nh tht v hnh.
iu tr:
o Thi x tr:
Bao gi cng cn dl MP ri mi quyt nh x l u troc: sau khi dl MO nu
thng tn trong ngc l khng c ch nh m cp cu th m bng trc.
Bao gi cng phi tm l thng c hnh khu kn li.
Nu khng c ch nh m ngc (ch dn lu mng phi) th trc khi khu kn c
hnh cn ht sch KMP qua ng bng nht l sau khi n no m d dy b thng.
Cc ng dl (ngc, bng) u phi ht v kn, khng c ng dl bng h, khng
kh qua s gy TKMP.
o S cu:
Nhanh chng bt kn VTNH: bng cch bng p vi 1 lp gc dy, nu VT ln c th
khau da tm thi (nu c iu kin). Nt Depage ch dnh cho VT rt ln.
Lm thng thng ng h hp, th oxy.
Hi sc, truyn dch nu c shock mt mu.
KS, gim au, phng UV
Sm chuyn vo phng m hay c s c kh nng iu tr thc th.
o Phu thut:
Nu chn n chc chn VT ngc bng:
Gy t ti ch, dl MP ti thjiu v khu kn VT.
21

 Gy m NKQ.
M bng: tm v x l cc thng tn bng.
o Nu khong c thng cc tng rng -> khu kn c hnh 2 lp.
o Nu c thng tng rng -> cn trnh nguy c nhim trng gy m MP bng
cch:
Phu thut vin c kn m ngc: m rng l thng c hnh, bm ra tht
sch KMP nhiu ln bng HT pha betadine, m bo ly ht d vt ng
TH trong KMP.
Phu thut vin khc: sau khi ng OB, tin hnh m ngc theo 1 ng
ring (thng m ng bn qua LS 5), c th nhn r v ra sch
KMP.
o t DL bng (nu c) th cn m bo nguyn tc nh dn lu MP (kn, 1
chiu), trnh TKMP.
Nu cha chc chn VT ngc bng:
Gy t, dn lu MP ti thiu.
Gy m NKQ (khng nn gy t)
M rng VTNH thm d xem c thu bng khng:
o Nu thu bng: khu kn c hnh qua ng ngc, x tr thng tn phi v
ng ngc. M bng x tr tn thng nh trn.
o Nu khng thu bng: x tr thng tn phi (nu ln), ng ngc.
o iu tr sau m:
V LN: nh i vi VTNH, tuy nhin cn ht sc lu bin chng xp phi, v c
can thip bng gy cn tr h hp v nh hng n tp l liu php -> dn lu MO
thng lu hn v c gng vn ng bnh nhn kin tr tp l liu php.
V OB: sn sc nh sau PT bng.
Theo di bin chng:
Nhim trng MP: gy m hoc cn MP (do lm sch cha tt): HC nhim trng,
dn l hoc chc ht MP ra dch c -> cy -> m li sm lm sch v bc
MP.
Nhim trng vt m.
Xp phi gy TDMP ti pht.
Cc bin chng v bng, lu l rt d st thng tn trong ln m u v thm
d cha k.
o Tin lng: nhn chung l tt nu khng c bin chng g c bit. Ph thc vo: x tr tt
thng tn bng, lm sch MP, sn sc l liu php tt.
11. Vt thong thc qun: VT thc qun thng do bch kh v ho kh t gp c. VT thc qun
thng phi hp vi nhng VT mch mu ln vng c hoc kh ph qun vi biu hin lm sng
l chy mu ln hac TKDD c hoc trung tht.
Him gp v thc qun do CTB hoc CTNK v ch yu nhng bnh nhn CT. S tng p
lc t ngt trong thc qun thng gy v thc qun. V on thc qun 1/3 trn thng km
theo v phn mng kh qun. Mt s trng hp v do ht vo ng hi c p lc cao, ng v
thc qun thng rt ln.
a. Gii phu bnh:

22

V thc qun do chn thng: thng gp 1/3 trn ca thc qun ngc do chn thng
mnh vo lng ngc. Tn thng thc qun thng km theo tn thng mng sau ca kh
ph qun v cc tng trong lng ngc.
- Vt thng thc qun: t gp v t khi l tn thng thc qun n c. c, VT thc qun
thng km theo tn thng cc mch mu ln c v kh qun nn triu chng lm sng
thng b che lp bi hi chng chy mu hoc kh th.
b. Chn n: thng chn n kh v mun v cc triu chng c trng thng t gp hoc
xut hin mun. Trong CT v VT thc qun, triu chg thng b che lp bi bnh cnh a
chn thng hoc hi chng chy mu, kh th do tn thng cc mch mu ln hoc kh
ph qun:
- C nng:
o au: sau xng c hoc trn rn (thng thc qun t pht), au co vng c i vi
thng thc qun c vi c im au d di, lin tc, tng ln khi nut lm cho bnh
nhn khng dm nut m thng phi nh nc bt
o Kh th: c th km u hoc thay i ging ni, thng gp nht sl trong thg thc qun
ngc vo mng phi.
o Nn mu: l du hiu rt c gi tr nhng him gp.
o Ho, sc khi nut: do ng v thc qun thng vi kh qun trong trng hp thng thc
qun 1/3 trn klm theo v rch mng sau kh qun
- Tn thn: tnh trng shock c th xut hin sm vi biu hin: M nhanh, HA tt.
- Thc th:
o TKDD vng c xut hin sm: c phng to ln, s thy mm v lp bp kh di da.
o Cm lc nh sn gip sang 2 bn lm bnh nhn rt au (trong trng hp thng thc qun
on c.
o Du hiu co cng hoc phn ng thnh bng trn rn (trong tn thng thc qun on
bng)
Khi c s phi hp 3triu chng (au khi nut, kh th v trn kh di da c), cn ngh ti
tn thng thng thc qun v phi ngng cho n qua ming, lm cc thm khm CLS
xc nh chn n sm v iu tr sm. Nu khng c iu tr sm, sau vi h s dn ti
tnh trng Vim trung tht nhim khun rt nng. BN st cao: 39 40 , v mt hc hc,
tng tit m ri, kh th, tm ti.
- CLS:
o XQ ngc: cc t th (thng, nghing, ly c vng c):
TKDD vng c
Hnh nh trn kh trung tht (75 80%), c khi thy hnh nh hi hnh ch V trn c
hnh (du hiu Nacle Rio).
Du hiu hi sau thc qun - du hiu Minigerode (trn phim chp nghing), khoang
sau thc qun rng ra, y thc qun, kh qun ra trc.
lu:
Trung tht gin rng (do t dch, bces trung tht).
TD TK mng phi (do thng vo mng phi, hoc phn ng mng phi).
o XQ bng khng chun b:
Hi t do trong bng (lim hi di hnh trn phim chp ng)
Hi sau phc mc (trong cc trng hp thng thc qun bng on sau phc mc)

23

o Chp thc qun c cn quang: (xc nh c 80% thng thc qun, v tr v bn thnh
thc qun tn thng chn ng m ph hp), khng nh thng thc qun khi c
cc du hiu sau:
Hnh khc thc qun trong thng hp tn thng mi ch c thnh thc qun.
Hnh m thuc cn quang trn c hnh tri trong thng hp c thc qun t pht.
ng r thuc cn quang ra ngi thc qun vo trung tht, mng phi trong cc tn
thng lm thng hn tn thnh thc qun ngc hoc c thp.
o Chc d mng phi:
Thy dch mng phi c mu xanh nht cu dch d dy.
pH dch mng phi < 6.
Dch mng phi c mu xanh sau khi cho bnh nhn ung xanh Methyln chng t c
thng thng tiu h v mng phi.
o CT: c 2 li ch cn bn l chn n v nh gi chnhn xc, tn din cc nhim khun,
abces trung tht trong cc thng hp thng mun, gip la chn ng dn lu abces
qua da; cn l phng tin tt nht chn n tn thng t mu thnh thc qun. Du
hiu thng thc qun trn phim chp CT c thuc cnquang dng nc l:
Hnh nh r thuc cn quang ra ngi thc qun vo trung tht.
Du hiu trn kh trung tht v t chc phn mm c.
Abces trung tht: biu hin dng dch c hi gia
o Ni soi: ch p dng khi chp XQ khng khng nh c chn n v ni si phi thc
hin trong phng m ngay trc kh m
c. iu tr:
- Nguyn tc:
o Thi x tr ph thuc vo loi tn thng, thi gian pht hin sm hay mun, tnh trng
tn thn, tnh trng NK trung tht, thng trn thc qun lnh hay bnh l.
o Xc nh chn n cn cho ngng n ung qua ming ngay v chuyn sm v c s iu tr
ngoi khoa.
o Hi sc tch cc trc, trong, sau m:
iu tr d phng v chng shock.
m bo chc nng h hp tt bng: ht m ri, ht kh ph qun, th oxy, h hp
h tr nu cn thit, dn lu trn dch mng phi nu c.
m bao nui dng y (2500 3000 calo/ngy) bng ng tnh mch, tt nht
l qua ng m thng hng trng, qua m thng d dy hoc ng thng d dy (tuy
nhin 2 cch sau c th c bin chng tro ngc dch d dy ln thc qun vo trung
tht.)
Chng NK bng KS:mnh, ph rng, phi hp hiu qu iu tr c Gr (+) v GR (-).
Tt nht l theo KS.
o Thi x tr tn thng thc qun ph thuc 3 yu t chnh:

Tnh trng ca thc qun:

Thng trn thc qun lnh, nn p dng bo tn thc qun, m bo thi gian
nhanh nht v t nguy c nht
Thng trn thc qun bnh l cn tnh tn gia bo tn chc nng thc qun v tin
lng chung va bnh nhn v bnh c trc thc qun.
Thi gian t khi thng thc qun n kh c chn n:

24

Thng sau 12 18 gi, do c NK trung tht nn l thng thc qun rt kh c th

khu chc chn, nguy c r rt cao.
Pht hin mun, tnh trng tn thn nng hoc hnh thnh abces trung tht thc
s th iu tr bng khng m m dn lu qua da.
Nguyn nhn, hn cnh tn thng thc qun v thnh trng ca trung tht bnh
thng hay c vim dnh t trc :
Thng thc qun khi trung tht bnh thng th nguy c NK trng tht xy ra rt
sm v lang rng, cn phi m cp cu sm x tr tn thng.
Thng thc qun nh qua ni soi, c pht hin ngay trn mt trung tht c
vim dnh t trc do di chng ca so bng thc qun, hay vim thc qun tro
ngc th c th iu tr bo tn, khng m.
iu tr phu thut:
o ng m:
ng m qua b trc c c n chm tri: thng dng khi tn thng thc qun
on c.
ng m sau bn phi qua KLS IV, V: thng thc qun 1/3 trn hoc gia
ng m ngc tri trc bn, KLS VI, VII: thng thc qun 1/3 di
ng m gia trn rn: thng thc qun on bng
o Cc phng php phu thut:
Khu thng:
Loi tr thc qun:
To ng r ch huy:
t stent nng thc qun:
Ct thc qun:
iu tr khng phu thut: iu tr bo tn c p dng cho cc trng hp thng thc qun
khi c cc iu kin sau:
o Thng thc qun c pht hin sm hoc thng mun nhng khng do du hiu NK lan
to.
o ng r vo trung tht nh trn phim chp cn quang thc qun v c dn lu tt vo
nng thc qun, khng c r vo mng phi.
o BN khng n k t khi b thng ti khi chn n.
o V tr thng thng nm thc qun bng, thc qun khng c u hoc hp pha di.
o HC nhim trng nh.
o Ch nh iu tr bo tn khng m gm:
Thng thc qun do dng c lm th thut, trc ht l thng c, thng trong cc
trng hp ly d vt thc qun.
Thng thc qun nh trong lng ngc sau nong thc qun iu tr hp do vim
thc qun tro ngc, nong iu tr co tht tm v, hp do bng thc qun c.
Trng hp n mun, m khu tr, du hiu NT tn thn nh v m c th dn
lu qua da di s hng dn ca CT.
o iu tr bao gm:
t BN u cao.
Nhn n tuyt di, nui dng tt v hn tn bng ng tnh mch.
KS mnh v hiu qu vi cc VK Gr (+) v Gr (-).
25

DL abces qua da nu c.
t ng thng thc qun quan mi vo cnh l thng ti ra lin tc vi huyt
thanh mnh ng trng, c th pha thm KS vo dung dch ra.
Theo di lin tc nh gi hiu qu iu tr.
Nu iu tr bo tn tht bi cn chuyn sang iu tr phu thut sm trc 24h.
12. Chn thng tim: l nhng thng tn ti tim gy ra do sang chn trc tip hoc gin tip,
nhng thng tn ny khng thng vi mi trng ngi v hu ht chn thng tim gp sau tai
nn giao thng do tng p lc t ngt trong lng ngc.
d. Nguyn nhn v c ch tn thng:
- Nguyn nhn:
o TNGT: t, xe my vi tc ln...
o TN th thao, tru b hc.
o CT tim do p tim ngi lng ngc.
- C ch:
o Lc tc ng trc tip vo lng ngc (CT trc tip vo xng c).
o Lc p t 2 pha ca lng ngc.
o Tng p lc trong bung tim do chn p bng t ngt.
o Gim tc t ngt.
o Sc p do n ln.
o Lc chuyn ng mnh lm thay i nhp tim d khng gy ra tn thng gii phu.
e. Gii phu bnh: trong CT tim c th gp thong tn bt k thnh phn no ca tim, t ng
gip n v tim.
- Mng tim:
o Chy mu mng tim.
o V hay rch mng tim.
o Vim mng tim t huyt hay vim m mng tim
o Vim mng tim co tht.
o Vim mng tim ti din c trn dch mng tim.
- C tim:
o ng gip c tim.
o Rch c tim.
o V tim v cc vch ngn trong tim.
- Mch vnh:
o Rch ng mch vnh, c hay khng c nhi mu c tim.
o Huyt khi tc mch.
o R ng tnh mch vnh.
- Van tim:
o Rch van tim, ng gip van tim.
o t dy chng, ct c.
- Ri lon nhp tim hoc ri lon dn truyn:
f. Chn n v iu tr cc th lm sng:
- Thng tn mng tim.
o LS v CLS:

26

Biu hin l cc bin chng nh: TMMT, CET: bnh nhn vt v, tm ti, tt HA,
tnh mch c ni, ting tim m...
T: in th thp.
XQ ngc: bng tim to, mt ng vin bnh thng.
SA tim: dch mng tim.
o iu tr v tin lng:
M cp cu khi c du hiu CET, tu theo thng tn thnh ngc m quyt nh
chn ng m ngc hay m xng c.
TDMT ti pht, km theo st, au ngc: khng sinh, gim au.
Vim mng tim co tht rt him gp nhng khi c th cn m ct mng tim.
V nguyn tc, vim mng tim n thun, khng c bin chng c th t khi.
Thng tn c tim:
o ng gip c tim: thng gy ra nhng du hiu khng c hiu v thng khng pht
hin c (hay gp tn thong ng gip nh trc tht phi). -> bt k trng hp no,
khi c tn thng thnh ngc nng cn ngh n c thng tn ng gip c tim.
LS v CLS:
au vng trc tim :au nh nhi mu c tim, xut hin mun vi gi hoc vi
ngy sau chn thng.
T: phng tin hu ch nht pht hin ng gip c tim:
o Thay i bt thng sng T, on ST v sng Q.
o Du hiu c in ca vim mng tim.
o Ri lon dn truyn nh tht.
H sinh: SGOT, LDH, CPK tng trong CT ni chung nhng tng nhiu khi c ng
gip c tim, c hoi t c tim.
SA Tim: bung tim gin, di ng bt thng ca thnh tim.
iu tr:
Ngh ngi ti ging trong 4-6 tun, gn ging iu tr nhi mu c tim, nhng
khng dng chng ng v nguy c chy mu trong c tim, mng tim.
TMMT, khng c chn p tim: chc ht khng sinh v gim au.
Rung nh: thng quay li nhp xoang t nhin hoc c th dng tr tim lm
gim nhp tht v c th tr v nhp xoang.
Tin lng:
ng gip c tim nh: tin lng ni chung l tt, phc hi 1 hoc tn phn. Cn
theo di cht ch v c th xut hin cc bin chng nh: ri lon nhp tht, tc
mch vnh, phnh tht, v tim...
Hoi t c tim c th xy ra sau ng gip c tim nhng tn thng ch khu tr
mt vng d vy tin lng lu di cng rt tt.
o V tim: c th xy ra ngay sau chn thng hoc vi ngy sau do ng gip, chy mu dn
n hoi t c tim. Thng gp cc thng tn: v tiu nh, v nh v v bung tht
LS v CLS: ch yu gp l hi chng chn p tim, km theo c xy st vng trc
ngc.
Kh th, vt v, tm ti,
Mch nhanh, huyt p tt.

27

g.
-

Tnh mch c ni.

Ting tim m.
SA tim: thy dch mng tim, mu cc mng tim.
XQ it dng v tnh trng bnh nhn nng, nu khng c siu m tim c th: chc d
mng tim, ct sn sn tri khng nh chn n (phng php hay dng).
iu tr:
M cp cu cng sm cng tt
o Chc d mng tim truc gy m v gy t t ni kh qun.
o M dc xng c.
o Khu phc hi thng tn.
Tin lng: tt nu thng tn khu tr tiu nh v c chn n, iu tr kp thi.
Thng tn van tim v t chc di van:
o LS v CLS:
Ting thi bt thng, mi xut hin sau chn thng v km theo au ngc.
Tn thng van 2 l gy h van: thi tm thu mm tim lan ra nch.
Tn thng van ng mch ch, van 3 l t gp hn.
Triu chng LS thay i t mt mi, kh t, ph, gan to tu theo mc tn thng
v nh hng ca huyt ng.
SA tim: siu m 2D, Doppler chop php xc nh v nh gi mc thng tn.
o iu tr:
Ch nh iu tr t ra khi: tn thng van tim gy ri lon huyt ng v c bi
hn triu chng lm sng.
Thay van hoc sa va tu thng tn gii phu khi m ra.
Tn thng van tim khng c ri lon huyt ng cn c iu tr ni v theo di
nh k bng siu m Doppler.
o Tin lng:
Tu thuc vo mc thng tn van tim
Ty thuc van tim b tn thng: 3 l tin lng tt hn 2 l, van MC.
Thng tn mch vnh:
o Cc dng thng tn gp trong CT tim: Nhi mu c tim xuyn thnh, bong ni mc ln ->
huyt khi NMCT, CT nhng ngi c bnh tim trc .
o Thng ng tnh mch vnh (thng gp vi MV phi). Ting thi lin tc lan rng
vng trc tim, bng tim to trn phim chp ngc, v du hiu nhi mu c tim trn in
tm -> gi cho tn thng ny.
o Chp mnh vnh l phng php tt nht xc nh chn n v a ra ch nh iu tr.
o Tin lng: tt nhng bnh nhn m trc khng c tn thng mch vnh, nhng
bnh nhn tn thng mch vnh trn tn thng tn c cn c can thip sm.
Bin chng:
Bin chng do chn thng tim:
o V cc bung tim -> t vong.
o Lon nhp tim, suy tim, t mu thnh c tim, phnh hoc gi phnh tht, phnh vch lin
tht, thng ng tnh mch vnh
Bin chng sau m:
o BC thng thng sau m tim mch ni chung: chy mu, xp phi
28

o Vim xng c sau m v tim do chn thng.

o T vong sau m.
13. Chn ptim:
a. i cng:
- CET tim cp tnh l 1 bnh cnh i hi x tr kp thi mi c th cu c bnh nhn.
- Mng tim l mt bao x, bc tim v cc cung mch ln. Bnh thng, p lc trong khonag
mng tim ging nh p lc trong khoang mng phit v c s chnh lch p lc vi mmHg
gia th th ra v ht vo. C tc dng:
o Trnh lm tim gin qu mc.
o Trnh xon cc cung mch ln.
o Gi nguyn v tr ca tim v cc mch ln khi thay i t th
- Nguyn nhn:
o Thng gp:
VT hoc CT tim: gin tip hoc trc tip.
Nhim trng: do Virus hoc Vi khun.
Bnh l c tnh: ti tim hoc di cn K.
Bnh t chc lin kt.
Ur mu cao suy thn.
o Cc nguyn nhn khc:
Trn mu mng tim do
V tim sau NMCT.
Lc MC.
ang iu tr chng ng.
Di chng sau PT tim.
Bin chng cu cc th thut thm d tim.
Sau iu tr tia.
b. Chn n:
- LS:
o Kh th, tm ti: BN th nhanh, nng.
o V mt lo lng, kch ng.
o Tim p nhanh, mch nghc thng (Pouls paradoxal).
o PVC tng cao.
o Ting tim m.
o Gan to tnh mch c ni.
o St cao gp trong vim m mng tim.
o Tru tim c th gp trong trng hp nng.
- CLS:
o XQ: khng nn lm khi tn trng v huyt ng khng n nh, nh hng tnh mng BN.
Trong trng hp chp c, cc du hiu thu c ph thuc vo s lng dch trong
khoang mng tim:
Trn dch mng tim s lng t: bong tim bnh thng.
TDMT s lng nhiu: bong tim to, mt hnh dng bnh thng ca cc cung tim,
c th km theo trn dch mng phi.
29

 Phi sang.
o T: ch yu theo di trong iu tr, in hnh c cc biu hin
Gim in th cc chuyn o: song T v QRS.
Thay i khng c hiu ca song T v ST.
Sng P bnh thng.
o SA tim: kt hp SA TM v 2D cho gi tr chn n cao. Cng c gi tr theo di cao, chc
d hng dn trong iu tr, xc nh chc nng ca tim.
SA (TM) cho hnh nh gin tip ca trn dch mng tim, chn p tim vi nhng
khong trung siu m gia mng tim v cc thnh tim.
SA 2D: nhn c trc tip tnh trng tim, mng tim, tnh cht dch trong khoang
mng ngi tim, xc nh c hay khng c chn p tim, trn dch khu tr.
CET vi s lng dch mng tim nhiu: khong trng siu m gia mng tim v
thng tm mc tn ti c 2 th tm trong v tm thu. Tin lng nng nu
khong trng siu m c c mt truc v sau tim.
c. iu tr:
- iu tr ni khoa:
o Chc ht mng tim c p dung cho tt c cc trng hp chn p tim do vim mng tim
- TDMT n thun.
o Khi tnh trng trn dch mng tim thuyn gim cn tip tc iu tr xc nh nguyn
nhn chn p phng nga ti pht.
- iu tr ngoi khoa:
o c p dng cho cc trng hp:
Trn dch mng tim gy chn p tim ti din nhiu ln.
Chn p tim do chn thng hoc VT tim.
Trn m mng tim gy chn p tim.
Chn p tim nhng chc ht mng ngi tim khng c hiu qu.
o M ngc tri KLS V trc bn.
o M mng tim v x tr cc thung tn ti tim.
o DL mng phi trong chn p tim do chn thng hoc VT tim.
o Vi trn m mng tim hoc chn p tim ti dinct b mng tim rng ri cn c p
dng, gii phng trit chn p tim v phng nguy c vim mng ngi tim co tht.
o M ca s mng tim khng cn c p dng cc trung tm PTTM.
14. Vt thng tim: VT l mt tn thng tim cn phi chn n, x tr tht nhanh v chnh xc
mi c th cu sng c bnh nhn. Nguyn nhn thng do ho kh v bch kh, mnh gy
xng sn (t gp), ngi ra cn c nhng nguyn nhn khc do thy thuc gy ra: chp bung
tim, thng tim, chp mch vnh, can thip mch vnh.
a. Gii phu bnh v sinh l bnh:
- Tn thng gii phu c th gp trong vt thng tim: (ging nh phn chn thng tim):
trong LS thng gp cc thng tn theo th t sau: VT tht phi, tht tri, nh phi, nh tri.
- Nhng thay i sinh bnh hc: tnh trng ri lon huyt ng trong VT tim cn tu thuc vo
v tr, kch thc, tnh cht ca VT, tnh trng ca mng tim. Hu qu lm sng thng gp
l:
o Chp p tim cp tnh.
o Sc gim th tch:
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o Vim mng tim.

o Chn p tim cp + shock mt mu.
o VT tim khng c biu hin LS.
o VT c km theo cc tn thng phi hp:
b. Chn n xc nh:
- C nng:
o Vt ngc (c bit trong tam gic tim) hoc na trn bng do nh nhau hoc tai nn
- Tn thn: 2 hi chng c th gp:
o Hi chng shock mt mu cp:
Kh th nhanh, nng.
Nht nht, ht hong, kht nc.
Mch nhanh, nh, kh bt.
Huyt p tt, kh o.
o Hi chng chn p tim:
Kh th, tt huyt p ng mch.
Tnh mch c ni.
Mch nghch thng, nhanh, nh.
PVC > 20 cm H2O.
- Thc th:
o Vt vng tam gic tim hoc cc vng khc.
o Ting tim m: ch thy khi c TDMNT nhiu, nu t khng thy du hiu ny.
- CLS
o XQ ngc thng: ch c tin hnh khi tn trng n nh, khng c suy h hp, huyt p ti
a trn 90 mmHg.
Mt cc cung tim, c bit b tri thnh 1 ng thng.
C hi trong mng tim.
Trung tht rng: khi cc mch mu ln b tn thng. (cn nh VT vung tam gic
tim, khng c thay i v huyt ng, XQ ngc bnh thng vn phi xc nh c hay
khng c vt thng tim. Khng theo di lu hoc khng cho bnh nhn v.
o Siu m tim: c gi tr cao trong chn n VT tim, du hiu thng gp gm:
Dch mng tim: s lng dich t hoc nhiu tu thuc VT tim, c th km theo mu
cc mng tim.
Chn p tim: hay gp du hiu p tim phi:
tht phi b p nh li trong th tm trng
Vch lin tht di ng nghch thng.
Tnh mch ch di, tm trn gan gin.
Ngi ra c th thy c tn thng tim, dy chng, ct c
o Chc d mng tim v ct sn sn V tri:
Chc d mng tim: theo ng Marfan hay Dieulefoie c p dng trong chn n
xc nh VT tim thi k cha c siu m 2D hoc c s khng c SA.
VT ngc + chc d mng tim c mu khng ng -> VT tim.
Ngi vai tr chn n chc d mng tim cn lm gim bt p lc trong khaong
mng tim, gii phng chn p tim tm thi ci thin tnh trng huyt ng

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trong s cu, vn chuyn, ch m (khi VT tim, c chn p tim c, tt HA, kh th

d di); trnh ngng tim do p lc lng ngc tng lc khi m.
Ct sn sn tri: c th xcnh chnh xc c hay khng c vt thng tim
VT ngc + Ct sn sn V bn tri thy mng tim c mu -> VT tim.
y cng l mt th thut gip cho cuc m an tn ngi mc ch chn n ra.
c. Chn n phn bit:
- VT ngc c tt HA: VT ngc c biu hin shock mt mu, trong trng hp c tn thng
ng mch lin sn, ng mch v trong, tn thng nhu m phi rng... siu m 2D c gi
tr chn n
- VT mch mu ln trong ngc:
o Shock mt mu:
o Khng c bnh cnh chn p tim.
o XQ ngc thng c hnh nh trung tht gin rng, trn mu MP.
o SA tim khng c dch mng ngi tim.
d. Ch nh m:
- Cp cu:
o VT tim c biu hin chn p tim cp.
o VT tim c biu hin shock mt mu.
o VT vng trc tim cn c thm d sm trong nh m
- M c tr hn:
o VT n mun: thng tn mng tim n thun hoc tn thng thnh tim khng thng vi
bung tim, VT tim nh c mu cc bt li... trn LS khng c biu hin chn p tim,
tnh trng bnh nhn n nh.
o D vt c tim: d vt nh thnh tht phi hoc sau tht tri, khng thong vi bung tim,
khng gy chn p tim c th thao di bn v m tr hn.
o Bin chng ca VT tim: TMMT tn thng van tim, dy chng, ct c, d ng mch ch
- bung tim, mv - bung tim, thong ng tnh mch vnh, thong lin tht.
e. iu tr:
- Nguyn tc:
o VT tim cn c chn n v u tin m sm.
o Chuyn ngay bnh nhn vo nh m khi tnh trng shock nng, chn p tim cp c suy h
hp, mi thm khm, xt nghim, chn n nn tin hnh trong nh m.
o DL mng ph hoc gp chn p tim tm thi nhm cu sng bnh nhn, cuc m tin
hnh an tn.
o Nghi ng VT tim: cn chuyn BN vo nh m chun b phng tin gy m, hi sc, d
tr mu, dng c phu thut v phu thut vin chuyn khoa.
- iu tr thc th:
o T th BN:
Nghing 45 sang bn i din khi c ch nh m ngc.
Nm nga, n 1 gi ngang qua xng b vai 2 bn khi m dc xng c.
o ng m: nguyn tc chugn l: VT ngc bn no h m ngc bn v c th ko di
ng m sang bn i din khi cn thit. Chn ng m th no tu thuc: v tr VT,
thi quen v kinh nghim ca PTV.
M ngc tri trc bn qua KLS V.
M ngc phi trc bn qua KLS V.
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M dc xng c.
M ngang xng c (ch p dng khi ng m ngc khng rng x tr VT tim
phc tp nh VT xuyn, 2 VT khc nhau...)
o Gy m hi sc:
Ti thiu 2 ng truyn tnh mch.
Theo di HA ng mch, PVC, bo h Oxy, nhp tim trong tn b cuc m.
Gy t ti ch t NKQ, ch khi m v gy m tn thn khi kp m ra tay, mc
o, i gng, chun b y dng c cho cuc m.
Chun b y dch truyn hoc mu, cho KS trc khi rch da.
o Khu VT tim:
M dc mng tim song song TK hnh, c th m ngang mng tim ra trc khi cn.
Ht sch mu trong mng tim, dung ngn tay tr tm thi cht ni chy mu.
Dng ch khng tiu, si n 3 4/0 khu VT tim, khu mi ri hoc ch U c mnh
n bng mng ngi tim hoc Teflon, mi khu c chc, khng x rch c tim,
trnh thng tn tim nng thm.
Ch khi c cc thng tn sau:
VT tim st ng mch vnh: khu mi ch U, lun kim pha di ng mch vnh
sang bn i din khng gy tn thng hoc buc vo M vnh.
VT mt sau tim: VT tht tri, mt sau mm tim. Cn ch bin chng xon tnh
mch ch gy ngng tim do nng mm tim qu cao, qu lu trong khi khu VT.
Theo di T lin tc v bo cho BS gy m hi sc bit mi ln nng mm tim
khu VT. Dng tayu hoc gc nh nng nh mm tim v chn gc vo mt sau,
hoc khu tm 1 mi ch 5/0 vo mm tim, nng nh mm tim tng t khi t
cc mi khu.
VT ng mch vnh: cn c ch nh dung tun hn ngi c th, khu VT tim, phc
hi l thng mch vnh bnh cu ng mch ch - ng mch vnh bng on
ghp t thn. Tn thng ng mch vnh nhng nhnh nh, u ngoi vi
khng gy thiu mu c tim c th khu, tht c.
o Ra sch mng tim:
o Cm mu thnh ngc: DL ngc cn ni h thng ht lin tc ngay sau dn l, ch ng
mng tim, ng ngc khi huyt p ti a trn 90 mmHg.
f. Bin chng:
- Do VT tim:
o T vong:
Shock mt mu cp tnh.
Chn p tim cp, nng.
o Thng tn trong bung tim: tn thng van tim, ct c, vch lin tht, lin nh... c th
gp trong VT tim. Cn ch nh m di tun hn ngi c th khi c biu hin ls, nh
hng chc nng tim.
- Khc: chy mu, xp phi do tc m ri, trn dch mng tim.

VI.

Cc ch nh m ngc cp cu:

o TKMP khng cm: d tng p lc ht m phi khng n ln, lng kh x ra qua dn lu

tng ln, hoc tng lc ht lm bnh nhn kh th hn. (thng l ph qun v, hoc nhu m
phi b ng gip nhiu)

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o TMMP khng cm: sau khi dn lu MP, lng mu chy ra vi lu lng 300ml/h trong 3
h lin. Tuy nhin khng th cn c ch vo con s ny m cn phi da vo tnh trng tn
thn, XQ ngc. (v c th tr em, mu cc c th lm tc dn lu)
o Vt thng thc qun: Soi thc qun gip xc nh chn n. M ngc khu thc qun cn
lm km vi m thng d dy nui dng.
o Chn thng hoc vt thng tim: khi c tn thng tim s th hin bng 2 hi chng: Hi
chng mt mu (VT tim nht) v Hi chng chn p tim (VT tim tm)
Vi VT tim: rt gi v VT vo tam gic tim
CT tim: du hiu gi l gy xng c.
o VT thnh ngc rng:
o Mu cc mng phi:
o Di vt ln:

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