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Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG

CHN THNG V VT THNG BNG

1-i cng:
1.1-Chn thng bng kn:
Chn thng bng kn thng gp trong thi bnh.
Tai nn lu thng chim 50-75% cc nguyn nhn ca chn thng bng kn. Cc nguyn nhn
khc bao gm: u , ri t trn cao, tai nn trong sinh hot
Tng thng b tn thng, theo th t, l lch, gan, sau phc mc, rut non, thn, bng quang,
rut gi, c honh, tu.
C ch tn thng:
1-S gim tc t ngt: lm cc tng khc nhau di chuyn vi tc khc nhau. Tn
thng thng l rch do b chng ko, c bit ti ni tip gip vi cc v tr c nh.
2-S nghin: cc tng b p gia thnh bng v ct sng hay thnh ngc sau. Tng
c (gan, lch, thn) thng b tn thng nhiu hn c.
3-S tng p lc trong xoang bng t ngt: gy v cc tng rng (tun theo nh lut
Boyle).
Chn on chn thng bng kn thng kh khn v:
B cc tn thng phi hp nh lc hng.
Tri gic BN st gim do chn thng s no, ng c (ru, heroin...).
Gy m v phu thut cc vng khc c th nh hng n vic theo di tnh tng
bng BN b a chn thng.
1.2-Vt thng thu bng:
Vt thng thu bng c nh ngha l vt thng thnh bng trc xm nhp vo xoang bng
(thng phc mc thnh), vt thng ngc xm nhp vo xoang bng (thng c honh), vt
thng vng hng hay lng xm nhp vo khoang sau phc mc.
Vt thng thu bng thng gp trong c thi bnh ln thi chin.
Tc nhn gy vt thng thu bng:
Thi bnh: do cc vt sc nhn (do b m).
Thi chin: do ho kh.
i vi vt thng thu bng do ho kh, tn thng c nng lng truyn dn cao, do kh
tin on c mc tn thng cc tng trong xoang bng (khng th da vo tn thng b
mt nh gi tn thng ni tng).
i vi vt thng thu bng do b m, c th tin on trc mc tn thng cng nh
tng b tn thng.
Cc tng thng b tn thng: rut non (29%), gan (28%), rut gi (23%), d dy (13%).
2-Chn on:
2.1-Chn on lm sng:
Cc du hiu quan trng nht chng t c tn thng ni tng l: au bng (c bit au ngy
cng tng), tt huyt p, cc du hiu ca vim phc mc, tiu mu, xut huyt tiu ho.
2.1.1-Chn thng bng kn:
Khi thm khm lm sng, cn thm khm v x tr theo th t u tin (h hp/ct sng c-tun
hon-thn kinh trung ng-bng-t chi).
Cc du hiu gi chn on:

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Gy cc xng sn cui: c th v gan hay v lch.
Bng chng hi, nhu ng rut gim: c th vim phc mc.
Du bm mu vng hng lng (du hiu Gray Turner): t mu sau phc mc.
m rut c nghe trn thnh ngc: c th v c honh.
Tiu mu: c th chn thng thn.
Tiu kh + tiu mu hay b tiu: c th v bng quang.
V khung chu: c th chn thng niu o.
Cn ch l chn thng cc xng sn cui, xng chu, ng dp thnh bng cng gy ra
cc triu chng tng t nh vim phc mc.
Ch 65% cc trng hp chy mu trong xoang bng c chn on trn lm sng.
2.1.2-Vt thng thu bng:
Khi tip nhn BN, cn ch khai thc:
Tc nhn gy tn thng (hnh dng, kch thc)
Hng tc ng
Lc tc ng
Tnh trng ban u ca BN (nu BN nhp vin trong tnh trng sc, c ch nh m bng
thm st m khng cn lm thm cc chn on cn lm sng).
Cc vt thng nh trn thnh bng thng d b b qua, tuy nhin chng c th l
ng vo ca mt tn thng ni tng.
Vt thng vng trn rn c th l vt thng bng-ngc. Do cn ch n biu hin
au ngc hay kh th, nghe phi v chp phim ngc thng.
2.2-Chn on cn lm sng:
2.2.1-Chc ra xoang phc mc chn on (DPL-Diagnostic peritoneal lavage):
Ch nh: BN nghi ng c chn thng bng kn v:
C chn thng ct sng
Tt HA m khng xc nh r nguyn nhn
L m (chn thng s no, ng c thuc)
c phu thut v cc ch nh khc
Phng php:
M mt l nh trn thnh bng vo xoang phc mc hay lun catheter vo xoang phc
mc.
Truyn vo xoang phc mc 1000 mL NaCl 0,9%, cho dch chy ra theo c ch siphon,
ly dch lm xt nghim.
DPL (+):
Chn thng bng kn: > 10 mL/mu, HC > 100000, BC > 500, dch mt, mu thc n.
Vt thng thu bng: > 10 mL/mu, HC > 10000, BC > 500, dch mt, mu thc n.
2.2.2-FAST (Focused Assessment with Sonography for Trauma):
FAST: mt khm nghim v siu m gii hn trong vic xc nh c dch (trong chn thng,
ng ngha vi mu) hin din trong xoang phc mc hay xoang mng tim hay khng.
FAST c tin hnh ti ging v c ch nh cho tt c cc BN b CTBK.
Lng mu 30-70 mL c th c pht hin bi FAST.
chnh xc ca FAST ph thuc vo ngi lm siu m.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
2.2.3-CT:
CT l tiu chun vng trong chn on tn thng tng c (gan, lch, thn).
CT c th xc nh c mu trong xoang phc mc. Tuy nhin, FAST cng c th xc nh c
vi thi gian nhanh hn. Tuy nhin, CT c th xc nh ngun chy mu (du hiu thuc cn
quang thot mch), iu m siu m v DPL khng lm c.
CT cng c th chn on cc tn thng sau phc mc.
Hn ch ca CT: kh chn on tn thng tu, c honh v tng rng.
2.2.4-X-quang khng chun b:
i vi chn thng bng kn, X-quang c gi tr hn ch. Cc tn thng c th c pht hin
qua X-quang: v c honh (vm honh mt lin tc, trn dch mng phi, d dy hay rut nm
trong lng ngc), v rut non (lim hi di honh), v t trng (hi sau phc mc), v bng
quang (gy xng chu)
i vi vt thng thu bng, X-quang l ch nh bt buc, nht l khi vt thng bng nm
vng trn rn. Cc du hiu bt thng c th gp: trn mu/trn kh mng phi, bng tim to, lim
hi di honh
2.2.5-Ni soi i trng xch-ma:
Ni soi i trng xch-ma c ch nh khi nghi ng c tn thng i trng xch-ma, c th l:
Thm trc trng c mu.
Vt thng nm di ng ngang qua hai gai chu trc trn.
2.2.6-Cc xt nghim:
Cc xt nghim sau y bt buc phi c thc hin trc tt c cc BN b chn thng bng:
Cng thc mu
Glycemia, ur, creatinine huyt tng
Thi gian mu chy, PT, aPTT
Nhm mu
Tng phn tch nc tiu
Test thai (QS)
o nng ru v cc cht khc
3-iu tr:
3.1-Thi chn on v x tr:
3.1.1-Chn thng bng kn:
Can thip phu thut ngay nu BN c:
Vim phc mc ton din
Sc mt mu km theo chng bng
X-quang phi c du hiu v c honh
Nu khng c mt trong ba biu hin trn, thc hin FAST:
Sinh hiu n nh (mch < 110, HAmax 100)
FAST dng tnh: ch nh CT.
FAST m tnh v khng c ch nh khc ca CT: theo di, thc hin li FAST sau 6-12
gi.
Sinh hiu tng i n nh (truyn < 2000 mL dch duy tr sinh hiu n nh): Ch nh CT
(hoc DPL). Nu CT dng tnh: x tr tu tn thng. Nu CT m tnh: cn nhc n tn thng
cc vng khc.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Sinh hiu khng n nh (truyn > 2000 mL dch duy tr sinh hiu n nh): ch nh FAST (hay
DPL). Nu dng tnh: chuyn BN vo phng m. Nu m tnh: phi loi tr cc nguyn nhn
khc.
3.1.2-Vt thng thu bng:
3.1.2.1-Vt thng thu bng thnh bng trc:
Nu c sc, thng d dy c mu, thm trc trng c mu, c du vim phc mc, FAST (+): can
thip phu thut.
Nu khng c cc du hiu trn:
Vt thng do b m: thm st vt thng: gy t ti ch, m rng vt thng, thm st
tng lp thnh bng. Nu c tn thng lp cn sau, ch nh DPL.
Vt thng do ho kh, ch nh DPL.
Nu DPL (+), ch nh phu thut.
3.1.2.2-Vt thng ngc-bng:
Nu c sc, thng d dy c mu, thm trc trng c mu, c du vim phc mc, FAST (+): can
thip phu thut.
Nu khng c cc du hiu trn, ch nh DPL hay ni soi xoang bng chn on.
3.1.2.3-Vt thng vng hng hay lng:
Nu c sc, thng d dy c mu, thm trc trng c mu, c du vim phc mc, FAST (+): can
thip phu thut.
Nu khng c cc du hiu trn: CT (c bm thuc cn quang qua ba ng: tnh mch, d dy,
trc trng), c th kt hp DPL.
Nu (+): x tr tu tn thng.
Nu (-): theo di thm 24 gi loi tr tn thng rut non.
3.2-Chun b trc phu thut:
Mt s nguyn tc chnh cn bit khi chun b phu thut mt BN b chn thng bng:
Thi v thi gian hi sc trc m tu thuc vo tnh trng BN (c bit l sinh hiu)
khi nhp vin.
t mt hay nhiu ng truyn bng catheter c khu knh ln (16-18 Fr) chi trn. C
th t thng tnh mch trung ng.
Hi sc nhanh bng dch truyn. Dung dch la chn l Ringers lactate, NaCl 0,9%, cc
dung dch i phn t.
Nu lng mu mt 20-40% v cha c kt qu nhm mu: truyn trc 2 n v mu
nhm O Rh (-).
Khng sinh lun cn thit.
m bo gi m cho BN trc trong v sau m (si m, mn p, thit b lm m mu
v cc loi dch truyn).
t thng d dy trnh tro ngc trong qu trnh gy m.
t thng tiu nh gi chc nng thn v hiu qu ca vic hi sc.
3.3-nh gi v kim sot cc tn thng:
Nguyn tc nh gi v x tr tn thng khi vo xoang bng:
vo ng mch ch bng ngay di honh nu BN tru mch khi m bng .
Nht bn ming gc bng vo di honh v hai hc chu.
Nht gc p vo cc tng c b tn thng.
Kim tra mc treo rut non, kp cc mch mu ang chy.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Thm st gan, lch.
Thm st ton b ng tiu ho t tm v n trc trng. Kp tm hai u on c tn
thng (hay khu ng bng stapler) trc khi tip tc thm st.
M phc mc sau thm st thn.
3.4-Chn on v x tr tn thng cc tng:
3.4.1-V lch:
Hu ht v lch gp trong chn thng bng kn.
Hnh nh tn thng lch trn CT:
Khi t mu:
m : thp hn, bng hay cao hn m ch m lch (tu thuc vo tui
ca khi t mu- khi t mu cng non, m cng cao).
Khng tng quang.
Rch lch: gim m , khng tng quang, ng b khng u.
Thuc cn quang thot mch: him khi thy.
Phn v lch (theo AAST-American association standard of trauma) (bng 1):

Tn thng

T mu
Tn thng nhu m

II

T mu

M t
Di bao: < 10% din tch b mt.
Su < 1cm.
Di bao: 10-50% din tch b mt.
Trong nhu m: kch thc < 2cm.

Tn thng nhu m
III

T mu

Su: 1-3 cm, ang chy mu nhng khng tn thng

cc mch mu b.
Di bao: > 50% din tch b mt.
Trong nhu m: kch thc > 2cm.

IV

Tn thng nhu m

Su: > 3 cm, tn thng cc mch mu b.

Tn thng nhu m

V khi mu t trong nhu m, ang chy mu.

Tn thng mch mu thu hay rn lch.

Tn thng nhu m

Lch dp nt hay thiu mu, tn thng mch mu rn

lch.

Bng 1- Phn v lch (theo AAST-American association standard of trauma)

Ch nh iu tr ni khoa:
c chn on tn thng bng CT
Sinh hiu n nh
Tri gic: thang im Glassgow > 8
Hb duy tr n nh 12-48 gi
BN nh hn 55 tui, khng mc cc bnh l ni khoa lm c th km chi ng s mt
mu (thiu mu c tim).
Ni dung iu tr ni khoa:
C du hiu thuc cn quang thot mch trn CT: can thip qua chp ng mch hay
phu thut.
Tn thng lch IV-V: lu BN trong phng chm sc c bit.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Ngh ngi, nhn n ung.
Theo di sinh hiu mi gi cho n khi tr v bnh thng.
Xt nghim Hct mi 6 gi/24-48 gi.
Khi Hct n nh:
Chuyn BN v phng chn thng
Xt nghim Hct, Hb mi ngy
Bt u cho n ung
Ch nh can thip phu thut:
Sinh hiu khng n nh
Truyn 2 n v mu tr ln duy tr Hct > 26%
C phn ng phc mc ton din
C tn thng phi hp cn can thip phu thut.
Phng php:
Ct lch l la chn trc tin trong cc trng hp sau:
Tn thng lch phc tp, dp nt hay tn thng cung lch.
C tn tng khc phi hp.
Trong trng hp sinh hiu BN n nh, c th c gng bo tn lch bng cch:
Ct lch bn phn
Khu lch: bng cc mi khu m hay khu trn mt tm mesh tan c.
Di ng lch tht tt (bng cch ct cc dy chng ni lch vi vm honh hay i trng
gc lch, rch mc lch-thn, a lch v ngang mc vt m trn thnh bng) l cha
kho phu thut lch thnh cng, c bit cc phu thut bo tn lch.
Khng cn thit phi dn lu h lch, tr khi nghi ng c tn thng ui tu km theo.
Nu BN c ct lch, sau m cn:
Ch cho ht thng d dy trong vng 48 gi lm xp d dy, trnh nguy c bung ch
buc cc nhnh v ngn, gy chy mu sau m
Chng nga Pneumococcus, Haemophilus v Meningococcus trong vng 24 gi n 2
tun sau m.
Khng sinh d phng (sut i) trc khi thc hin cc th thut/ phu thut (nh rng).
Bin chng phu thut:
Chy mu l bin chng c cn nhc trc tin, c bit sau cc phu thut bo tn
lch.
Cc bin chng khc, him gp hn: tn thng tu, vim tu cp, p-xe di honh,
hoi t b cong ln d dy.
Bin chng xa:
Nhim trng huyt ti cp: l bin chng ng ngi nht (t l xy ra thp: 0,03-0,8%,
nhng t l t vong rt cao: 70%).
Chng tng tiu cu (c th gy lp mch nu TC > 1000000/mm3).
3.4.2-V gan:
3.4.2.1-Phn v gan (theo AAST) (bng 2):

Tn thng

T mu

M t
Di bao: < 10% din tch b mt.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Tn thng nhu m
II

T mu

Su < 1cm
Di bao: 10-50% din tch b mt.
Trong nhu m: kch thc < 10cm.

Tn thng nhu m
III

T mu

Su: 1-3 cm, di: < 10cm.

Di bao: > 50% din tch b mt.
Trong nhu m: kch thc > 10cm.
V khi t mu.

IV

Tn thng nhu m

Su: > 3 cm.

Tn thng nhu m

V 25-75% thu.
V 1-3 tiu thu Couinaud trong mt thu gan.

Tn thng nhu m

V > 75% thu.

V > 3 tiu thu Couinaud trong mt thu gan.

VI

Mch mu

Tn thng mch mu chnh ca gan (tnh mch trn

gan) hay ln cn gan (tnh mch ch di)

Mch mu

Dp nt gan

Bng 2- Phn v gan (theo AAST)

3.4.2.2-iu tr ni khoa:
Ch nh iu tr ni khoa: tn thng gan I-V trn CT v sinh hiu n nh.
Ni dung iu tr ni khoa:
Lu BN trong phng chm sc c bit nu:
Tn thng gan III-V
Hct < 32%
Ngh ngi, nhn n ung.
Theo di sinh hiu mi gi cho n khi sinh hiu tr v bnh thng.
Xt nghim Hct mi 6 gi/24-48 gi.
Khi Hct n nh:
Chuyn BN v phng chn thng
Xt nghim Hct, Hb mi ngy
Xt nghim men gan v bilirubin vo ngy 2
Bt u cho n ung
C th cho BN xut vin vo ngy 5
Dn d khi xut vin:
Ngh ngi ti nh 1 tun.
Khng chi th thao trong 6 tun (tn thng I-III), 3 thng (tn thng IV-V)
Ti khm sau 2 tun
Ti khm ngay khi c cc du hiu sau:
au nhiu hn
Vng da
3.4.2.3-iu tr phu thut:

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
3.4.2.3.1-Ch nh phu thut:
Sinh hiu khng n nh
Bng chng v n au nhiu hn
FAST: nhiu dch trong xoanh bng
CT:
Tn thng gan VI
C du hiu thuc cn quang thot mch (cn nhc n vic can thip qua chp
ng mch)
Vt thng vng trn phi bng do ho kh
C tn thng phi hp cn can thip bng phu thut.
3.4.2.3.2-Ni dung can thip phu thut:
Sau khi c ch nh phu thut, chuyn ngay BN vo phng m. Ch chun b vng m t
cm n gia i.
M bng bng ng rch gia, t mi c n qua rn. Sau khi vo xoang bng, chn gc tm
vo vng trn gan, kim tra lch, mc treo rut. Nu cc tn thng chy mu khc trong xoang
bng c loi tr hay c kim sot, mi tin hnh nh gi v kim sot vic chy mu
t gan.
Nu mu chy nhiu, kp cung gan bng hai ngn tay hay clamp (th thut Pringle) (hnh 1). Sau
khi kp cung gan, mu vn tip tc chy chng t c tn thng tnh mch ch di on sau
gan hay tnh mch gan.

Hnh 1- Mt s th thut nhm tm cm mu trong x tr tn thng gan phc tp p gan bng

tay (a), chn gc (b) v th thut Pringle (c).

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Tu thuc vo tnh trng BN v kinh nghim x tr ca phu thut vin, thi x tr mt trng
hp tn thng mch mu ln (tnh mch gan hay tnh mch ch di on sau gan) trong chn
thng gan c th l chn gc hay can thip trc tip vo tn thng. Nu can thip trc tip vo
tn thng mch mu ln trong v gan, nht thit phi c lp chng trc.
Cc bin php c lp tn thng mch mu ln trong v gan trc khi can thip vo chng c
th l (hnh 2):
To thng ni nh-tnh mch ch di (atrial-caval shunting)
To shunt tnh mch-tnh mch

Hnh 2- Hai phng php c lp mch mu gan trc khi can thip trc tip vo ni tn thng:
shunt tnh mch-tnh mch (a) v to thng ni nh-tnh mch ch di (atrial-caval shunting) (b).
Sau khi mch mu gan c c lp, kp v ct ngang tnh mch ch di trn gan, xoay gan
v tnh mch ch di on sau gan ra trc, tip cn vo vng phi sau ca tnh mch ch di
on sau gan. Tn thng thnh trc ca tnh mch ch di on sau gan s c sa cha
t phi sau, thng qua ng m tnh mch thnh sau (hnh 3).
Nu sau khi kp cung gan, mu bt chy chng t tn thng c th c can thip m khng
cn phi thc hin cc bin php c lp mch mu. Trong trng hp ny cc bin php cm
mu sau y c th c thc hin (sau khi di ng gan bng cch ct dy chng lim, ct dy
chng tam gic hai bn, y gan hng v vng vt m gia bng):
Kim sot chy mu t ch v bng cc mi khu m nm ngang
M rng ch v (hepatotomy) bng u cc ngn tay (finger fracture), tm v kim sot
cc nhnh mch mu ang chy y ch v (hnh 4).
Trong bt c tnh hung no, nu BN c ri lon ng mu, chn phng php cm mu nhanh
nht. Nu mu ngng chy sau khi chn gc, nn kt thc cuc m.
t dn lu (di gan, di honh) nu nghi ng c d mt hay t dch di honh sau m.
Nu c chn gc, cho BN cephazolin 1gm mi 8 gi cho n khi rt gc.
Rt gc chn trong vng 24-48 gi. Trc khi rt cn chun b sn:
Mu
Phng tin truyn mu t thn
My t laser bng Argon

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG

Hnh 3- Sau khi c lp mch mu, kp ct ngang tnh mch ch di trn gan, xoay gan v tnh
mch ch di on sau gan ra pha trc, tn thng tnh mch ch di on sau gan s c
sa cha t phi sau.

Hnh 4- Mt trong cc phng php cm mu

gan: tm v kim sot cc mch mu ang chy
y ch v

Bin chng:
T dch mt (biloma):

10

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Biu hin bng st, vng da.
X tr:
Khng nh bng CT
Chc d qua da
ERCP t stent v/hoc ct c vng Oddi.
Chy mu ng mt:
Thng xy ra 2-4 tun sau chn thng.
X tr:
Khng nh c tn thng nhu m gan phc tp/khi t dch trong nhu
m gan bng CT
X-quang ng mch xc nh v tr chy mu v gy tc mch
(embolization)
Khng can thip bng phu thut
Chy mu ti pht:
HA v Hct gim 7-10 ngy sau.
X tr: X-quang ng mch xc nh v tr chy mu v gy tc mch
(embolization). C gng khng can thip bng phu thut (rt kh xc nh tn
thng).
Tn thng ng mt (trong hoc ngoi gan):
Bng chng v au tng, HA v Hct khng thay i.
Khng nh bng ERCP. Tu tn thng m x tr.
3.4.3-V bng quang:
Nguyn nhn: 60-85% do chn thng kn, 15-40% do vt thng xuyn thu (ch yu l do ho
kh). Cc nguyn nhn khc: v bng quang do th thut/phu thut (phu thut sn ph khoa,
ni soi bng quang), v bng quang t pht
V bng quang do chn thng: 50-70% v trong phc mc, 25-40% v ngoi phc mc, 7-15%
v phi hp trong v ngoi phc mc.
Nghi ng c tn thng bng quang khi:
Tam chng v bng quang:
Tiu mu ton th
au vng h v
Kh khn hay khng th i tiu c
V xng chu c di lch nhiu. BN v xng chu: 10% c tn thng bng quang, 1025% c tn thng niu o. 10-29% BN tn thng niu o sau c tn thng bng
quang kt hp.
Khi nghi ng c tn thng bng quang v loi tr tn thng niu o sau: t Foley chp bng
quang c cn quang xc nh tn thng trong hay ngoi phc mc.
Nguyn tc iu tr:
V bng quang ngoi phc mc, ch v nh: lu thng niu o 7-10 ngy. Sau chp
bng quang kim tra, nu thy lnh tt th rt thng. Thc t tt c cc vt thng nh
ca bng quang u lnh sau 3 tun.
V bng quang trong phc mc, v bng quang ngoi phc mc ch v to: phu thut.
Ni dung phu thut:
M bng quang

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Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Quan st hai l niu qun bo m chng cn nguyn vn
Ct lc, khu ch v bng quang 2-3 lp, bng ch tan. Nu ch v gn l niu qun, t
thng niu qun trc khi khu
M thng bng quang ra da
Khu ng li bng quang. Bm nc kim tra bo m cc ch khu u kn
t dn lu ti cng Douglas
Chm sc hu phu:
Dng khng sinh cho n khi cc thng c rt
Rt dn lu xoang bng khi lng dch ra ti thiu
Chp bng quang vo ngy hu phu 10-14. Nu bnh thng, rt thng niu o
Kp thng bng quang trn xng mu, nu BN i tiu bnh thng th rt thng
Bin chng:
D nc tiu qua ch khu
Chy mu trong bng quang
Nhim trng vng chu
Hi chng bng quang nh
3.4.4-Chn thng thn:
Vt thng thn:
Do vt thng thnh bng trc: m bng thm st.
Do vt thng vng hng hay lng: CT kho st tn thng:
Vt thng khu tr trong thn, mu quanh thn t: iu tr ni khoa.
C t nc tiu quanh thn: m bng thm st niu qun.
Chn thng thn:
Nu BN c sinh hiu khng n nh, chp X-quang ng mch thn:
Thuc cn quang thot mch: gy tc mch. Nu tht bi v bn i din thn
bnh thng: phu thut.
Mch mu b bt: iu tr ni khoa.
Nu BN c sinh hiu n nh: iu tr ni khoa.
T nc tiu quanh thn khng phi l ch nh phu thut.
Tn thng cung thn:
Chn on c tn thng cung thn: thn bt thuc ngho nn trn CT hay cm trn
IVU.
Nu BN c sinh hiu n nh, chp quang ng mch:
Thuc cn quang thot mch: gy tc mch. Nu tht bi: can thip phu thut.
Mch mu tn thng b bt, c th do mnh ni mc trc gy bt lng mch:
iu tr ni khoa. C hi sng ca thn (ti ti mu) s cao nu thi gian chn
thng < 6 gi.
BN c sinh hiu khng n nh: can thip phu thut.
Ni dung iu tr ni khoa:
Lu thng Foley cho n khi ht tiu mu i th.
Hct kim tra mi 6 gi. Nu Hct n nh: kim tra mi 3 ngy.

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Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Khng sinh c th khng cn thit khi c t nc tiu trong chn thng thn kn.
Khi xut vin:
Ngh ti nh 1-2 tun
Khng chi th thao trong 3 thng
Nguyn tc phu thut:
Phi khng nh thn bn i din bnh thng trc khi quyt nh ct thn tn thng.
Kim sot c ng, tnh mch thn on ngoi cn Gerota s lm tng c hi bo tn
thn (t l ct thn t 53% gim cn 18%).
Cc phng php phu thut:
Thn dp nt, khng kim sot c chy mu, c tn thng phi hp cn thi gian
x tr: ct b thn.
Tn thng mt cc thn: ct thn bn phn
Cc phng php cm mu khc:
Bao thn bng tm mesh
Thoa cht keo gy cm mu
Nht mc ni ln
Bin chng sau m:
Chy mu
T mu/nc tiu sau phc mc
Cao HA do hp ng mch thn
3.4.5-Chn thng tu:
Chn on chn thng tu:
Trc tin phi ngh n kh nng c chn thng tu.
Chn thng bng kn:
CT l phng tin chn on c chn la trc tin, tuy nhin gi tr chn
on ca CT cn thp.
Khi nghi ng c v ng tu, ERCP c ch nh.
Vt thng thu bng:
Lun c tn thng phi hp (t trng, d dy, i trng ngang) v ch nh
phu thut v cc tn thng phi hp .
Ch thm st tu khi c cc du hiu nghi ng: t mu vng tu, chy dch trong
hay dch mt
Amylase tng trong chn thng bng kn khng l du hiu c hiu cho chn thng tu.
Ch nh iu tr ni khoa: BN b chn thng bng kn, trn CT khng c cc du hiu sau: tu b
t ri, t mu trong tu, t mu sau phc mc, t dch trong hu cung mc ni.
Cc phng php can thip phu thut:
Rch bao tu, dp nhu m tu, t mu nhu m tu: nguyn tn thng, dn lu tt
vng tu bng ng mm.
Tn thng ng tu trong chn thng bng kn:
Thng v tr tn thng gia c v thn tu.
Ct thn v ui tu l phng php phu thut c chn la. Thng phi ct
lch km theo (hnh 5). Khu kn ng tu bng ch khng tan (hoc Vicryl). Mm
ca phn tu cn li c th c khu ng bng tay hay stapler hay nguyn.

13

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Dn lu tt vng tu bng ng mm. Phn u v c tu chim 40-50% khi
lng tu nn t c kh nng dn n suy tu sau ct thn v ui tu.

Hnh 5- Phu thut ct thn v ui tu (a-bo tn lch, b-lch c ct b km thn v ui tu)

Tn thng ng tu trong vt thng thu bng:
Thng kt hp tn thng cc mch mu ln ln cn (tnh mch ch di, tnh
mch ca, tnh mch mc treo trng trn). T l t vong cao (40-50%), ch yu do
xut huyt khng cm c hn l do tn thng tu.
X tr cc tn thng mch mu l chnh. Nu BN n nh: x tr tn thng tu
trong ln phu thut k tip.
Ct b vng u tu-t trng l phu thut c chn la cho tn thng phc
tp vng u tu, hay tn thng t-tu phi hp.
Bin chng phu thut:
D tu
Nang gi tu
Vim tu
Phnh ng mch lch (nu lch cn c gi li)
3.4.6-Chn thng mch mu ln:
Chn on da vo cc du hiu: sc mt mu, bng chng, c du hiu tn thng vng bng
(vt thng hay du try xt).
Thng phi can thip phu thut ngay m khng cn phi thc hin cc phng tin chn on
hnh nh.

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Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
C bn vng tn thng mch mu da vo v tr ca khi mu t:
Khi mu t ng gia, trn mc treo i trng ngang:
Mch mu b tn thng: ng mch ch trn thn, ng mch thn tng, ngtnh mch mc treo trng trn, ng-tnh mch thn.
X tr:
Kp ng mch ch bng di tm v.
Lm th thut Kocher m rng tip cn trc tip tn thng.
Thng phi ct ngang c tu tip cn tn thng ng-tnh
mch mc treo trng trn.
ng mch thn tng c th c tht an ton.
Khu ni tn thng ng v tnh mch mc treo trng trn l u
tin s mt. Tuy nhin, c th tht tnh mch mc treo trng trn.
Khi mu t ng gia, di mc treo i trng ngang:
Mch mu b tn thng: ng mch ch bng di thn, tnh mch ch di.
X tr:
Rch phc mc sau cnh tri chn mc treo rut non, lt rut non
ra ngoi thnh bng, lt mc treo i trng ngang ln trn.
Kp ng mch ch bng ngay di tnh mch thn tri v ch
phn i.
Khu li tn thng ng mch ch bng.
Nu ng mch ch bng cn nguyn vn, tn thng tnh
mch ch di.
Tip cn tn thng tnh mch ch di bng cch di ng i
trng phi v t trng.
Tn thng ln tnh mch ch di c th c khu v bng
mt mnh phc mc.
Khi mu t quanh thn hai bn:
Mch mu b tn thng: thn, ng tnh mch thn.
X tr (xem phn chn thng thn): nu c CT, quang ng mch, IVU trc
m cho kt qu m tnh th khng cn thit phi m khi mu t.
Khi mu t vng hc chu hai bn:
Mch mu b tn thng: ng tnh mch chu chung, ng tnh mch chu
ngoi, ng tnh mch chu trong.
X tr:
Kp ng mch ch bng ni phn i v kp ng mch i pha di
dy chng bn.
nh gi tn thng tnh mch chu, c th phi ct ng mch chu
phi trn.
quan st ng mch chu trong, c th nng ng mch chu chung
v chu ngoi ln.
Tn thng ng mch chu chung, ng mch chu ngoi: khu ni li
tn thng.
Tn thng tnh mch chu chung, tnh mch chu ngoi: tht tnh mch.
Tn thng ng-tnh mch chu trong: tht b mch.
3.4.7-Vt thng d dy:

15

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Chn on trc m da vo:
Chn thng/ vt thng vng trn rn
Nn ra mu/thng d dy c mu
X-quang: lim hi di honh
Ch cc tn thng phi hp, c bit l tn thng tu v t trng.
Hu ht cc vt thng d dy c th khu k u.
Ch m mc ni v-i trng ngang thm st c mt sau d dy.
Vt thng phc tp vng mn v: ct hang v, ni v-t trng hay v-hng trng.
Vt thng vng tm v: khu li vt thng, khu che ph bng y v.
3.4.8-Vt thng t trng:
CT (vi thuc cn quang trong lng rut v qua ng tnh mch) l phng tin c chn la
chn on tn thng t trng. Cc hnh nh tn thng t trng trn CT:
Thnh t trng gim m v khng tng quang
Thuc cn quang thot khi t trng
thm st tn thng t trng, cn h i trng gc gan v lm th thut Kocher di
ng ton b khung t trng.
X tr:
Vt thng n gin, vt thng t ngang t trng: nu loi tr tn thng nh Vater,
khu ng li t trng (2 lp) theo chiu ngang (hnh 6).
Vt thng toc rng: mt quai hng trng c th c a ln (phng php Roux-enY) khu che ln tn thng.
Vt thng ng mt ch hay nh Vater: c th phi ct b khi t tu (phu thut
Whipple).

Hnh 6- Vt thng t trng t

trng, nu loi tr tn thng
nh Vater, c khu ng hai
lp theo chiu ngang

Vt thng t-tu phi hp:

Sau khi x tr vt thng t trng, tin hnh th thut loi tr mn v (ct hang v, ng
mm t trng v ni v trng hay khu ng mn v v ni v trng (hnh 7).
Sau m ht thng d dy cho n khi BN c trung tin v cho BN n long (7-10 ngy).
Nu xt thy c nguy c d tu, d t trng:
M d dy ra ra
t thng hng trng nui n

16

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Dn lu ng mt ch bng thng T
Dn lu tt tu.

Hnh 7- X tr vt
thng t tu phi hp:
khu cc vt thng,
khu ng mn v v
ni v trng.

3.4.9-Vt thng rut non:

Rut non l tng d b tn thng, c trong chn thng bng kn v vt thng thu bng.
Tn thng rut non c th kt hp tn thng mc treo rut non.
Nhiu tn thng nh ca rut non, nu ch da vo lm sng, thng b b st.
CT (vi thuc cn quang trong lng rut v qua ng tnh mch) l phng tin c chn la
chn on tn thng rut non v mc treo rut (bng 3)
Du hiu trc tip

Du hiu gin tip

Tn thng rut
non

Thnh rut gin on

Hi/dch trong xoang phc mc

Thuc cn quang thot khi rut non

Thnh rut gim m khu tr (ph

n khu tr) v tng quang (thiu
mu, thuc cn quang)

Tn thng mc
treo rut

Thuc cn quang thot mch.

Thnh rut gim m lan to.

T mu mc treo rut non

Khi phu thut ch thm st sut chiu di rut non, t gc Treitz n gc hi manh trng.
Thi x tr cc tn thng rut non:
Khu rut non, nu vt thng < 50% chu vi rut non.
Ct on rut non ni tn tn khi:
Vt thng > 50% chu vi rut non
Vt thng dp nt
Rut non b thiu mu do tn thng mch mu mc treo rut
Vt thng mc treo rut non:
on rut non tng ng b thiu mu: ct on rut non v ni tn-tn.
on rut non tng ng hng tt: tm v buc cc mch mu hai mp vt
thng, khu ng vt thng trnh thot v ni.
3.4.10-Vt thng i trng:
Nu BN khng c cc yu t nguy c:

17

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Vt thng < 50% chu vi i trng: khu vt thng, bt k vt thng on i trng
no (hnh 8).
Vt thng > 50% chu vi i trng, vt thng dp nt, i trng b thiu mu do tn
thng mch mu mc treo:

Hnh 8- X tr vt thng i
trng n gin: khu vt
thng, bt k vt thng
on i trng no

Nu i trng phi: ct i trng phi, ni hi-i trng ngang (hnh 9).

Hnh 9- X tr vt thng i trng phi phc tp: ct i trng phi, ni hi-i trng ngang
Nu i trng tri: ct on i trng, a c hai u ra ngoi lm hu mn nhn to kiu hai
nng sng (hnh 10).
Nu BN c cc yu t nguy c (c tn thng phi hp, sc ko di trc m, truyn mu khi
lng ln, BN n sau 4-6 gi): a on i trng c vt thng ra ngoi lm hu mn nhn
to.
3.4.11-Vt thng trc trng:
Vt thng trc trng on trong phc mc: x tr nh vt thng i trng.
Vt thng trc trng on di phc mc:
Lm hu mn nhn to trn dng kiu chuyn lu phn hon ton (hnh 11)
Tho ra ht phn trong bng trc trng

18

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
Dn lu trc xng cng (hnh 12)

Hnh 10- X tr vt thng i trng tri phc tp: ct on i trng, a c hai u ra ngoi lm
hu mn nhn to

Hnh 11- X tr vt thng trc

trng on di phc mc: lm
hu mn nhn to trn dng v
dn lu trc xng cng.

Hnh 12- K thut dn lu trc xng cng:

rch da gia hu mn v nh xng cng, bc
tch t (bng ngn tay) vo khoang gia h
xng cng v trc trng, t mt Penrose dn
lu, c nh Penrose vo da.

19

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi

S TAY NGOI KHOA LM SNG
3.5-Chm sc sau m ;
Mt s nguyn tc chnh ca chm sc sau m BN chn thng bng:
Tip tc hi sc bng dch truyn v mu.
Ch pht hin sm cc ri lon ng mu.
Truyn b xung 6 n v tiu cu v 2 n v huyt tng ti cho mi 5 n v mu ton
phn.
nh gi s lng v tnh cht dch qua cc ng dn lu.
X-quang ngc kim tra ngay sau m.
Siu m bng kim tra 3-5 ngy sau m.
Cc bin chng c th xy ra sau m:
Chy mu tip tc
Suy h hp
Ri lon ng mu
Nhim trng (p-xe tn lu trong xoang bng, nhim trng vt m, nhim trng tiu)
Hi chng ngn bng kn (abdominal compartment syndrome)
D tiu ho.

20