HN M

PGS. TS V ANH NH
ThS. NGUYN KINH QUC

MC TIU BI GING
1. Khi nim c bn hn m. M t cc c im
sinh l bnh hc ca hn m.
2. M t qui trnh thm khm tng qut cn thc
hin trn bnh nhn hn m.
3. Phn tch ngha ca cc thm khm thn kinh
hc lin quan n t th thn th, t th mt
u, kiu cch th, c ng mt v c im
ng t.
4. Phn tch cc nguyn l c s ca vic khm v
nh gi hn m.
5. M t thang im Glasgow nh gi hn m, u
im v nhc im ca thang im ny.

MC TIU BI GING
6. Phn tch s khc bit gia hn m vi trng
thi cht no, trng thi thc vt v hi chng
kho trong.
7. Lit k qui trnh x tr mt trng hp hn m
bao gm vic ch nh cc xt nghim v vic
iu tr ban u
8. Lit k cc nguyn nhn thng gp ca hn m
v cc c im lm sng chnh ca tng
nguyn nhn mt: bnh mch mu no, vim
no mng no, khi chon ch ni s, ri lon
chuyn ho, ng c v chn thng s no.

MT S THUT NG HN M

Hn m l hi chng lm sng (khng phi l

bnh), l mt trong nhng tnh hung lm
sng thng gp
Hn m l mc nng ca suy gim thc,
tri gic.
Mt trng thi khc vi ng da vo kch thch.
Cc nguyn nhn ca hn m th nhiu v k
Hn m l mt tnh hung cn c chn on
v x tr khn cp

Cc mc ca thc

Trng thi thc ca con ngi bnh thng gm c hai

mt an quyn li vi nhau l kh nng nhn thc v
tnh trng thc tnh. S nhn thc l kh nng con ngi
ta c th nhn bit c mt cch ton din vi y
ngha v bn thn v v mi trng chung quanh. Hot
ng thn kinh cao cp ny chnh l s tch hp v x tr
mi ngun kch thch hng tm do cm gic v gic quan
em li, v thuc v chc nng lan ta ca v i no.
Tnh trng thc tnh th gm nhng p ng thn kinh s
khai hn v l biu l ca hot ng ca nhng cu trc
thn kinh thn no vn l mt mng li ca cc b si
thn kinh v cc nhn thn kinh. H thng ny c tn gi
l h thng li hot ha hng ln (HTLHH), ko di t
phn thp ca cu no ln trn cho ti phn trung tm
ca i th v ta ra vo mt di trong ca thy trn

Nhng bt thng v mc thc c c trng bi s

suy yu thc tnh hay s tnh ro, v l hu qu tn
thng h thng li hot ha hng ln v
tn thng hai bn cu no. Mc nng nht suy
gim thc l hn m vi khng p ng v khng tnh
Nhng ri lon lm tn hi ni dung thc nhng khng
gy tn thng mc thc: ngn ng, sa st tr tu
hay l ln.
Ba c ch khc nhau c th gy ra nhng ri lon v thc
tri gic gm c
1. suy chc nng v no lan ta c hai bn
2. suy chc nng thn no
3. suy chc nng v no hai bn phi hp vi suy chc nng
thn no.

CC DNG SUY GIM V MT

THC

- Trng thi thc vt

(vegetative state)
- Chng lng thinh.
(mutism akinetic)
Nh cn gi l chng
mt ch (abulie)
- H/c kho trong
(Locked in
syndrome).

TRNG THI THC VT

Trng thi thc vt l hu qu ca tn thng v no

lan ta, c th do thiu oxy mu hoc thiu mu no
hay tn thng cc cu trc no. Bnh nhn c th
tnh to tr li nhng khng c nhn thc.
Sau mt thng (3-4 tun), bnh ny c gi l trng
thi thc vt dai dng.
Nhng bnh nhn ny thc m mt t nhin v c
chu k thc ng(khc hn m khng c chu k thc
ng)
Chc nng thn no v thn kinh t ch cn nguyn
vn.

TRNG THI THC VT

Bnh nhn khng hiu v khng pht ra

ngn ng v khng p ng vn ng c
mc ch.
Tnh trng ny c th tn ti nhiu nm.
Hi phc thc: him c trng hp hi
phc thc do cc nguyn nhn khng
chn thng sau 3 thng v do cc
nguyn nhn chn thng sau 12 thng.

TRNG THI THC VT

1. Khng c bng chng v kh nng nhn thc v bn thn v v chung

quanh. Vn cn phn x m mt hay m mt t pht.
2. Khng cn biu l v lin lc gia bnh nhn vi ngi khm qua cc
phng thc ni-nghe v vit ch. Khng cn c ng mt nhn ui
theo ngun kch thch th gic, mc d i khi vn c v c biu l ny
thong qua. Khng cn biu l cm xc trc cc kch thch ngn ng.
3. Khng cn pht m hay ni c ngha
4. C th cn phn ng xut hin tht thng i vi mt kch thch no
, di hnh thc mm ci, khc hay nhn mt.
5. Cn chu k thc-ng.
6. Cn mt s phn x thn no v ty gai nh b, nhai, nut, phn x
quang vn ng, phn x mt-u, phn x nm, phn x gn c.
7. Khng cn c ng hu hay biu l hnh vi hu , cho d ch di
dng rt s khai. C th c phn x gng cng hay trnh n i vi
kch thch au.
8. Chc nng h hp v tim mch thng cn hin din bnh thng. Tiu
tiu khng t ch.

CHNG LNG THINH

(mutism akinetic)

Mt s bnh nhn sau hn m hay sau tnh

trng tn thng no cp tnh, sau tnh to
tr li vi trang thi thc lng thinh (mutism akinetic)
Chng lng thinh, bnh nhn thc hon ton
hoc khng, nhng nm bt ng khng tip
xc c. Thng tn vng cun vin hay
thu trn hai bn
Hi chng mt ch (abulie) l th nh ca
chng lng thinh, bnh nhn gim ng, ni
nh yu v ngho nn. Tn thng vng
quanh knh sylvius v gian no thp.
Hi chng lng thinh nh v va c th phc
hi thc trong 3 thng sau hn m.

HI CHNG KHO TRONG

Thnh phn ca h thng li chu trch nhim v

thc hay phn x thc tnh nm cu no cao
tr ln.
Mt tn thng di thn no di mc ny gy
hi chng kha trong.
Nhi mu cu no, xut huyt trung tm cu no,
hy myelin cu no, khi u, vim no..c th lm
gin on ng dn truyn thn kinh ly tm, gy
nn tnh trng bt ng v mt ngn ng, nhng
thc vn bnh thng.
70% trng hp do mch mu . 40 % nguyn nhn
khc

HI CHNG KHA TRONG

Hi chng kha trong hay cn gi l gi hn m.

Khm lm sng c v ging hn m (c th c
mt trc )
Lm sng: mt ngn ng, lit t chi, t th mt
v hay tng trng lc gp hai tay, m mt t
nhin, vn nhn dc cn, phn x hi t mt cn,
mt vi vn ng c th cha mt hn.
Tin lng: c th phc hi mt phn hay ton
phn trong vi tun n vi thng. T vong do
bin chng vim phi hay do tn thng nng
cu no.
Cn phn bit cc trng thi trm cm trong tm
thn hay chng bt ng trong tm thn phn
lit.

CHT NO
1.
2.

3.

4.
5.
6.

Hn m, khng p ng vi cc kch thch c thc hin

ln cc vng pha trn l chm ln.
Vn ngng th sau khi ct my gip th (nhng vn cung
cp oxygen cho ngi bnh qua ng mi hay mt n)
trong 10-20 pht (lc ny PCO2 t 50-60 mm Hg
kch thch trung khu h hp hot ng).
Mt cc phn x ca vng u bao gm phn x ng t,
phn x mt-u, phn x mt tin nh, phn x gic
mc, phn x b v nut, phn x gng cng mt no.
Cc phn x c ngun gc thun tu ti ty gai c th vn
tn ti v gm c phn x gn c, phn x da lng bn
chn, phn x gp chi khi kch thch au.
Thn nhit trn 340.
i tun hon c th cn nguyn vn.
Chn on bnh c xc nh l do tn thng cu trc
hoc do ri lon chuyn ho khng cn o ngc c;
khng c vai tr ca ng c thuc nh ethanol, an thn,

CHT NO
7. i

vi bnh nhn ngi ln c bit l c tn thng cu trc v

khng b ng c thuc hay ethanol, cn phi theo di t nht trong 6
gi tnh trng mt cc chc nng no b nu trn trc khi quyt
nh chn on cht no; i vi cc trng hp khc, bao gm c cc
trng hp b thiu oxy no, phi theo di t nht l 24 gi v phi loi
tr tnh trng ng c thuc bng xt nghim tm sot trc khi quyt
nh chn on cht no.
8. Chn on cht no khng ph hp i vi tr nh hn 7 ngy tui.
i vi tr t 7 ngy tui n 2 thng tui, phi theo di t nht l 48
gi; i vi tr t 2 thng tui n 1 nm tui, phi theo di t nht 24
gi; i vi tr t 1 nm tui n 5 nm tui, phi theo di t nht l
12 gi (theo di trong 24 gi nu l tn thng no do thiu ti mu
v thiu oxygen); i vi tr gi hn na, p dng tiu chun ca
ngi ln.
9. Cc thm d khc c th c p dng ty hon cnh b sung xc
nh chn on: EEG ng in ko di t 30 pht tr ln; khng c
p ng in th gi thn no; chp hnh nh ng v phng x, hnh
nh cng hng t mch mu chng minh tun hon no khng cn
tn ti.

SINH BNH HC HN M

Hn m l do tn thng hai bn cu no hay

thn no.
Tn thng 1 bn cu no t gy hn m. Trong
trng hp tn thng 1 bn cu do t mu,
nhi mu din rng, u no, ph no c th gy
hn m do chn p no i bn hay ph no
th pht.
Hn m tn thng thn no, tiu no do nh
hng cu trc li.
Hn m do ri lon chuyn ho nh hng trn
h thng li v chc nng hai bn cu.
C th mt c ch hn hp cc yu t trn.

C CH BNH SINH HN M

1. Suy gin chc nng

v no hai bn.
2. Suy gim chc
nng thn no.
3. Hoc kt hp c hai
THEO NGUYN
NHN:
- Nguyn pht
- Th pht

TN THNG THN KINH

TRN LU: 3 v tr gy
tt no
- Chn p y lch
ng gia.
- Tt no.
DI LU: 1 v tr
- Chn p
- Tt kt no.
- Hy cu trc thn
no.

YU T CHUYN HO LIN QUAN

HN M

Oxy ho no b cung cp nng lng cho 3

chc nng chnh
Duy tr hot ng in th mng.
Tng hp cc cht dn truyn, hot ng ca
no: Acetylcholine, dopamine, cc cht khc.
Thay th cc enzyme d ho v yu t cu trc
t bo.
p ng nhu cu trn, no cn nhanh v lin
tc tng hp ATP. Nu s cung cp dng cht v
lu lng mu gim, qu trnh oxy ho ngng th
no b hoi t.

S chuyn ho glucose:

calo

Glucose + 6O2 = 6CO 2 +6H2O + 888,000

v 38ATP.
Glucose + khng c O2 = 2 Pyrovic v 2
lacticacid + 54,000 calo + 2ATP.
Khong 2gr glucose d tr di dng glucogen.
Hn m h ng huyt c th ko di 90 pht,
nu qu no khng phc hi.
ng huyt gim: nh hng v no v cu trc
hot ho no b.

S chuyn ho oxy

Oxy d tr trong no ch hot ng 10 giy.

Nhu cu no cn 3.3ml oxy/100gr/pht. Trong
mi thi gian. No chim khong 2% trong
lng c th. Nhng cn 15-20% oxy c th.
Nu oxy <2,5 ml/100gr/pht thay i chc
nng no b.
Nu oxy < 2 ml/100gr/pht hn m.
Phn ng thiu oxy no l tc khc.

TI MU NO(cerebral blood flow)

Bnh thng lu lung mu no l

55ml/100gr/pht. Mu cung cp glucose, oxy,
vitamine B v pyridoxine. Thiu mu <35 ml th
gy ri lon in th mng. Nu < 10-20 gy
hoi t no.
Khi lu lng mu no gim nh hng ch yu
ln t bo thn kinh l s gim oxy trong mu,
nhng s tr mu cng din ra gy tch t cc
thnh phn c t nh nhim Acid lactic ti ch
gy ph no.

Cc ri lon khc gy hn m
ngoi c ch oxy ho.
1.
2.

3.

Gy tr ngi n s tng hp hoc tan v cc

cht dn truyn thn kinh.
Bin dng hoc c ch cc enzyme tham gia
qu trnh trao i lipid v qu trnh trao i
cacbonhydrate sn sinh nng lng.
Hn m do chuyn ho do nhiu yu t, khng
mt c ch no hon ho cho mt trng hp
hn m ngay c do nguyn nhn thn kinh.

PHNG PHP KHM LM SNG

BNH S :

HI NGI THN
Chn thng s no?
Tin s bnh trc ?
ang iu tr thuc?
KIU XUT HIN HN M:
Chm tng dn: khi u
L ln : chuyn ha. Lan ta
t ngt: stroke
C khong tnh (mu t)
chn thng.

KHM TON THN PHT HIN CC

BNH LIN QUAN
HN M DO SUY GIM CHC NNG:
- Suy h hp mn
- Suy thn
- Suy chc nng gan
- Suy tim nng
HN M CHUYN HA V NI TIT:
- i tho ng
- Ri lan nc in gii
- Suy cn gip
- Tuyn thng thn
- Nhim c ni ngai sinh,

nh gi mc thc

Mc thc c ghi nhn di dng ca

trng thi biu hin ca bnh nhn v s tnh
to v p ng cc kch thch.
Cc kch thch c hiu:
- Thi gian
- Khng gian
- Bn thn
Khng dng cc thut ng thiu chun xc:
n, l m, sng s, bn hn m..

Mc thc

thc bnh thng: tnh to v cnh tnh vi mt

m v ng yn trong khun mt (t lay chuyn
nhn cu). p ng li ni thch hp.
Suy gim nhn thc:
- Mc nh: gn ging ngi ng, bnh nhn d
tnh li khi gi hi, cn gi l ng g
- Mc nng hn th cng kch thch
cho tnh li phi gia tng, thi gian tnh li chm
i. BN p ng thch hp tr nn him hoi hoc
khng c.

KHM THN KINH

NH GI TNH TRNG THC:
thc hay thc tnh : v no
+ Hi v tr li
+ Ni dung hay t duy
+ vn ng
Cc phn x khng c hiu thng qua cc phn x
di v:
+ Phn x nghe- nhn
+ Phn x au.
Mt dn chnh xc l tn thng
Nng dn theo kiu u cui

nh gi cc nhn thc khc

S ch hay kh nng tp trung
Ngn ng v li ni
Tnh cch v hnh vi
Ni dung t duy
Tr nh
- Ghi nhn tr nh
- Ghi nh
- Nh li

NH GI CHC NNG H HP

Nhng nh hng chuyn bit

ln h hp ca cc bnh chuyn
ha
Loi thng kh

c im sinh
ha- lm sng

Nguyn nhn thng gp

Tng thng kh
HH nhim toan

pH<7,30
CO 2 < 5mEq/l

Tng ure, tng ng

huyt,
Toan acid lactic, ng c
thc n

Tng thng kh
HH nhim kim

pH >7,45
Nhim salicylate, Gan, bnh
phi, th nhanh do tm l
CO 2 bnh
thng hay gim
nh

Gim thng kh
Toan h hp

Toan chuyn ha n nhiu thc n kim hoc

mt nhiu acid qua ng
tiu ha v thn.

Gim thng kh

Kim chuyn
ha

Bnh phi hay bnh thn

kinh c

H hp

Khng sm th mun bnh no do chuyn ha

gn nh lun lun gy nhng ri lon v chiu
su hay nhp h hp.
Nhng bnh nhn hn m hoc gn cht thng
th nh v nhanh.
Nhng bnh nhn hn m nh, chuyn ha
thng th Cheynes-Stokes.
Trong trng hp c ch thn no, tng thng
kh do thn kinh c tnh nht thi do kch thch
trung tm h hp hnh no
H ng huyt v thiu oxy c th gy th
nhanh ngn

KHM NG T
1. Dn 1 bn + PXS () tt
no.
2.Dn 2 bn + PXAS( ).
3.Dn 2 bn + PXAS (+)
hn m chuyn ha.
4.Co 2 bn: tn thng gian no,
cu no.
5.Dn + ng trng mt: thn
no
6.Horner syndrome: Di i,
thn no, M cnh.
7.Nh v c PXAS do opiates

KHM VN NHN
1. V tr u v mt
Bn cu & cu no
2. Lic mt:
Ra ngai: h sau
Xung di: i th
Ln trn: bn cu
3. Px mt bp b
4. C ng mt lo ling
5. Hi chng Foville
6. Lit tk s :III, IV, VI

KHM VN NG, PHN X

1.
2.
3.
4.
5.
6.
7.

Vn ng
Phn x
Du mng no
Ri lan vn ng t pht
Hi chng lit na ngi
T th mt v
T th mt no

XC NH MC HN M
1. nh gi hn m theo
Theo mc : I, II, III
2. nh gi theo thang im Glasgow
- M mt (4 )
- p ng li ni (5 )
- p ng vn ng (6)
3. nh gi hn m theo tng thn kinh
- Trn lu (v no, di v).
- Di lu : cung, cu, hnh no.

Thang im Glasgow

Thang im Lige

M mt
4- T pht
3- Theo li yu cu
2- Khi b kch thch au
1- Khng
Ni
5- Ni, nh hng tt
4- Ni, nh hng sai lm
3- Dng t khng ph hp
2- Pht m v ngha
1- Khng
Vn ng
6- Theo lnh
5- Khu tr ng im kch thch au
4- C ng co khi b kch thch au
3- Gng cng mt v
2- Gng cng mt no
1- Khng

M mt
4- T pht
3- Theo li yu cu
2- Khi b kch thch au
1- Khng
Ni
5- Ni, nh hng tt
4- Ni, nh hng sai lm
3- Dng t khng ph hp
2- Pht m v ngha
1- Khng
Vn ng
6- Theo lnh
5- Khu tr ng im kch thch au
4- C ng co khi b kch thch au
3- Gng cng mt v
2- Gng cng mt no
1- Khng
Phn x thn no
5- Trn - C vng mi
4- Mt bp b
3- Quang vn ng
2- Mt bp b ngang
1- Mt-tim

CH NH XT NGHIM
BNH NHN HN M

C DU TK CC B
TK
TRN LU
HA

DI LU

CT
CH KT QU
HA

KHNG C DU

LAN TA.
VIEM
K
XHDN

C.

MRI
SINH

LM SNG HN M DO THN
KINH
- Khi pht t ngt.
- Tri gic mt ton b.
- Ri lan h hp, th Cheynes stokes,
tng thng kh tk.
- Dui cng mt v no.
- Du TK cc b (lit ngi).
* Trn lu
* Di lu

HN M DO CHUYN HO

Xut hin t t
Mt tr nh gn duy tr tr nh xa.
Ri lon vn ng t pht.
ng t: dn, pxas +
H hp c th Cheynes-Stokes
Him gp du TK cc b

S SUY GIM NHN THC

Nhng thay i v trng thi tm l v nhn thc

l triu chng bo hiu sm nht hn m chuyn
ha. Bao gi cng c trc hn m.
- S tnh to: kh nng nhn bit thay i.
- Suy gim nh hng v nhn bit.
- Tri gic v s ch gim mt tr.
- Mt tr nh v ri lon cm xc.

S SUY GIM DN L DU HIU QUAN

TRNG.

NG T

Hn m bin dng, trng thi ng t

tr thnh tiu chun quan trng phn
bit HM do CH hay HM thn kinh:
Phn x nh sng cn cho d:
Suy h hp
Phn ng nhit tin nh mt
Gim hot ng chc nng v no
Suy yu vn ng. Vn ngh n HM do
chuyn ha.

VN NG

Bnh no do chuyn ho c hai loi bt

thng:
Ri lon vn ng khng c hiu : lon
trng lc c, phn x b, phn x cm
nm, gm du mt v, du mt no c
i xng hoc khng i xng.
Ri lon bt thng vn ng c trng:
Run, lon ng (Asterixis), git c nhiu
.

NGUYN NHN HN M
BNH NO DO CHUYN HO :
1. Bnh Jakob Creutfeldt. Bnh thoi ho
no tin trin ngi ln.
2. Bnh Marchiafava Bignami (thoi ho th
chai). Thng gp ngi Chu u , nghin
ru vang.
3. Bnh ca Schilder (x cng lan rng)
bnh ri lon cht trng bn cp. Bnh
hu myelin hai bn cu tr em.

NGUYN NHN HN M
Bnh no do chuyn ho th pht

1. Thiu mu no v thiu oxy.

- Thiu oxy lan to cp (suy h hp).
- Thiu mu cp (tru tim mch)
2. Bnh no do tng huyt p.
3. Di chng do thiu oxy (7-21 ngy sau)
4. H ng huyt
5. Thiu cc yu t bin dng (cofactor): B1,
B6,PP, B12.
6. Tng p lc thm thu : Tng NaCl, tng ng
huyt

Bnh ni khoa thng gp

1.
2.
3.
4.
5.
6.
7.

Bnh gan: suy chc nng gan, tng NH3.

Bnh thn: bnh no do tng ure huyt.
Bnh phi: lin quan pH, PaCO2, PaO2.
Bnh ni tit: bnh Addison, nhc gip.
K di cn, bnh no do cc u t xa.
Bnh ng c ngoi sinh.
Ri lon nc in gii (gim p lc thm
thu, tng p lc thm thu (T).

HN M CHUYN HO LIN
QUAN BNH THN KINH.
1. Nhim trng h thn kinh trung ng: vim
mng no, cc ri lon hu nhim.
2. Xut huyt di nhn: (thiu mu no do
co tht v chn p no).
3. ng kinh thiu oxy no trm trng.
4. Chn ng no (khi cha c bng chng
tn thng no.

NGUYN NHN THN KINH

THNG GP.

Chn ng no, t mu sau chn thng.

Tai bin mch mu no.
Giai on cui ca U no.
Cc nhim trng h thn kinh trung ng
Vim mng no m, p xe no, Huyt khi TM
ni s. Vim no : vim no Herpes
Trng thi ng kinh, ph no,
Do cc nguyn nhn khc.

THI THC HNH TRC HN

M

Lu thng h hp v iu chnh kh mu.

t ng truyn gi vein vi NaCl 0,9%.
Glucose 5%.
t sonde nui n
Theo di : Mch, in tim, xt nghim
sinh ho mu.

Din tin ca hn m

Phc hi hon ton

Phc hi mt phn
Trng thi i sng thc vt
Cht no

TAI LIEU THAM KHAO

1. Adams D R, Victor M, Ropper H.A Principles of Neurology: Coma

and Related Disorder of Consciousness p313-344) International
Edition.
2. Aminoff.J.A & Greenberg A.D, Simon P.R. Clinical Neurology.
Coma, International Edition (ti liu c dch ti Vit Nam)
3. V Anh Nh. Lm sng thn kinh :Ri lon thc v l ln
NXBHQG. 2010 tr32-39.
4. L Minh, Hn m, Thn kinh hc, NXBYH. 2003-2010. 183-207.
5. V Anh Nh. Lm sng thn kinh Hn m tr 41-54. NXB
HQG.2010.
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