B Y T

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CNG HO X HI CH NGHA VIT NAM c lp - T do - Hnh phc

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S: 1732 /Q-BYT

H Ni, ngy 16 thng 5 nm 2008

QUYT NH V vic ban hnh Hng dn chn on, iu tr bnh tay-chn-ming ______________ B TRNG B Y T Cn c Ngh nh s 188/2007/N-CP ngy 27 thng 12 nm 2007 ca Chnh ph quy nh chc nng, nhim v, quyn hn v c cu t chc B Y t; Xt bin bn hp Hi ng chuyn mn nghim thu Hng dn chn on, iu tr bnh taychn-ming ngy 13/5/2008 v ngy 16/5/2008; Theo ngh ca Cc trng Cc Qun l khm, cha bnh- B Y t, QUYT NH iu 1. Ban hnh km theo Quyt nh ny Hng dn chn on, iu tr bnh tay-chn-ming. iu 2. Hng dn chn on, iu tr bnh tay-chn-ming p dng cho tt c cc c s khm bnh, cha bnh. iu 3. Quyt nh ny c hiu lc k t ngy k, ban hnh. iu 4. Cc ng, b: Chnh Vn phng B; Chnh Thanh tra; V trng cc v, Cc trng cc cc thuc B Y t; Gim c cc Bnh vin, Vin c ging bnh trc thuc B Y t; Gim c S Y t cc tnh, thnh ph trc thuc trung ng; Th trng y t cc ngnh; Th trng cc n v c lin quan chu trch nhim thi hnh Quyt nh ny. KT. B TRNG TH TRNG ( k) Nguyn Th Xuyn

HNG DN Chn on, iu tr bnh tay-chn-ming (Ban hnh km theo Quyt nh s: 1732 /Q-BYT ngy 16 thng 5 nm 2008 ca B trng B Y t) I. I CNG - Bnh tay-chn-ming l bnh truyn nhim ly t ngi sang ngi, d gy thnh dch do vi rt ng rut gy ra. Hai nhm tc nhn gy bnh thng gp l Coxsackie virus A16 v Enterovirus

71 (EV71). Biu hin chnh l tn thng da, nim mc di dng phng nc cc v tr c bit nh nim mc ming, lng bn tay, lng bn chn, mng, gi. Bnh c th gy nhiu bin chng nguy him nh vim no-mng no, vim c tim, ph phi cp dn n t vong nu khng c pht hin sm v x tr kp thi. Cc trng hp bin chng nng thng do EV71. - Bnh ly ch yu theo ng tiu ho. Ngun ly chnh t nc bt, phng nc v phn ca tr nhim bnh. - Bnh tay-chn-ming gp ri rc quanh nm hu ht cc a phng. Ti cc tnh pha Nam, bnh c xu hng tng cao vo hai thi im t thng 3 n thng 5 v t thng 9 n thng 12 hng nm. - Bnh thng gp tr di 5 tui, c bit tp trung nhm tui di 3 tui. Cc yu t sinh hot tp th nh tr i hc ti nh tr, mu gio l cc yu t nguy c ly truyn bnh, c bit l trong cc t bng pht. II. CHN ON 1. Lm sng: 1.1. Triu chng lm sng: a) Giai on bnh: 3-7 ngy. b) Giai on khi pht: T 1-2 ngy vi cc triu chng nh st nh, mt mi, au hng, bing n, tiu chy vi ln trong ngy. c) Giai on ton pht: C th ko di 3-10 ngy vi cc triu chng in hnh ca bnh: - Lot ming: vt lot hay phng nc ng knh 2-3 mm nim mc ming, li, li. - Pht ban dng phng nc: lng bn tay, lng bn chn, gi, mng; tn ti trong thi gian ngn (di 7 ngy) sau li vt thm. - St nh. - Nn. - Nu tr st cao v nn nhiu d c nguy c bin chng. - Bin chng thn kinh, tim mch, h hp thng xut hin sm t ngy 2 n ngy 5 ca bnh. d) Giai on lui bnh: Thng t 3-5 ngy sau, tr hi phc hon ton nu khng c bin chng. 1.2. Cc th lm sng: - Th ti cp: Bnh din tin rt nhanh c cc bin chng nng nh suy tun hon, suy h hp, hn m co git dn n t vong trong vng 48 gi. - Th cp tnh vi bn giai on in hnh nh trn. - Th khng in hnh: Du hiu pht ban khng r rng hoc ch c lot ming hoc ch c triu chng thn kinh, tim mch, h hp m khng pht ban v lot ming. 2. Cn lm sng: 2.1. Cc xt nghim c bn: - Cng thc mu: Bch cu thng trong gii hn bnh thng. - Protein C phn ng (CRP) (nu c iu kin) trong gii hn bnh thng (< 10 mg/L). 2.2. Cc xt nghim theo di pht hin bin chng: - ng huyt, in gii , X quang phi. - Kh mu khi c suy h hp - Troponin I, siu m tim khi nhp tim nhanh 150 ln/pht, nghi ng vim c tim hoc sc. - Dch no ty: + Ch nh chc d ty sng khi c bin chng thn kinh.

+ Xt nghim protein bnh thng hoc tng nh, s lng t bo trong gii hn bnh thng hoc tng nh bch cu n nhn. Trong giai on sm c th tng bch cu t 100-1000 bch cu/mm3, vi t l a nhn chim u th. - Chp cng hng t no: Tn thng tp trung thn no. Ch thc hin khi c iu kin v khi cn chn on phn bit vi cc bnh l ngoi thn kinh. 2.3. Xt nghim pht hin vi rt: Ly bnh phm hu hng, phng nc, trc trng, dch no tu thc hin xt nghim RT-PCR hoc phn lp vi rt chn on xc nh nguyn nhn do EV71 hay Coxsackievirus A16. 3. Chn on xc nh: Ch yu da vo triu chng lm sng v dch t hc. - Yu t dch t: Cn c vo tui, ma, vng lu hnh bnh, s tr mc bnh trong cng mt thi gian. - Lm sng: St km theo phng nc in hnh ming, lng bn tay, lng bn chn, gi, mng. - Xt nghim xc nh c vi rt gy bnh. 4. Chn on phn bit: 4.1. Cc bnh c biu hin lot ming: Vim lot ming (p-t): Vt lot su, c dch tit, hay ti pht. 4.2. Cc bnh c pht ban da: - St pht ban: hng ban xen k t dng sn, thng c hch sau tai. - D ng: hng ban a dng, khng c phng nc. - Vim da m: , au, c m. - Thu u: Phng nc nhiu la tui, ri rc ton thn. - Nhim khun huyt do no m cu: mng xut huyt hoi t trung tm - St xut huyt Dengue: Chm xut huyt, bm mu, xut huyt nim mc. 4.3. Vim no-mng no: - Vim mng no do vi khun - Vim no-mng no do vi rt khc 5. Bin chng: 5.1. Bin chng thn kinh: Vim no, vim thn no, vim no ty, vim mng no. - Rung git c (myoclonic jerk): Tng cn ngn 1-2 giy, ch yu tay v chn, trong cn tr vn cn thc. - Ng g, bt rt, chi vi, i long chong, run chi, mt nhn ngc. - Yu lit chi (lit mm cp). - Lit dy thn kinh s no. - Co git, hn m l du hiu nng, thng i km vi suy h hp, tun hon. 5.2. Bin chng tim mch, h hp: Vim c tim, ph phi cp, tng huyt p, suy tim, try mch. - Mch nhanh > 150 ln/pht. - Thi gian y mao mch chm trn 3 giy. - Da ni vn tm, v m hi, chi lnh. - Giai on u c huyt p tng (HA tm thu: tr di 2 tui 115 mmHg, tr trn 2 tui 120 mmHg), giai on sau mch, huyt p khng o c. - Kh th: Th nhanh, rt lm ngc, th rt thanh qun, th khng u. - Ph phi cp: Si bt hng, kh th, tm ti, phi nhiu ran m. 6. Phn lm sng:

6.1. 1: Ch lot ming v/hoc tn thng da. 6.2. 2: Bin chng thn kinh hoc tim mch mc trung bnh. Rung git c: Km theo 1 trong cc du hiu sau: - i long chong. - Ng g. - Yu lit chi. - Mch nhanh >150 ln/pht (khi tr nm yn v khng st). - St cao 39o5C (nhit hu mn). 6.3. 3: Bin chng nng v thn kinh, h hp, tim mch. - Co git, hn m (Glasgow < 10 im). - Kh th: Th nhanh, rt lm ngc, SpO2 < 92% (khng oxy h tr). - Mch nhanh >170 ln/pht hoc tng huyt p. 6.4. 4: Bin chng rt nng, kh hi phc - Ph phi cp. - Sc, tru mch. - SpO2 < 92% vi oxy qua gng mi 6 lt/pht. - Ngng th. III. IU TR 1. Nguyn tc iu tr: - Hin nay cha c thuc iu tr c hiu, ch iu tr h tr (khng dng khng sinh khi khng c bi nhim). - Theo di st, pht hin sm v iu tr bin chng. - Bo m dinh dng y , nng cao th trng. 2. iu tr c th: 2.1. 1: iu tr ngoi tr v theo di ti y t c s. - Dinh dng y theo tui. Tr cn b cn tip tc cho n sa m. - H st khi st cao bng Paracetamol liu 10 mg/kg/ln (ung) mi 6 gi hoc lau mt. - V sinh rng ming. - Ngh ngi, trnh kch thch. - Ti khm mi 1-2 ngy trong 5-10 ngy u ca bnh - Dn d du hiu nng cn ti khm ngay: + St cao 39oC. + Th nhanh, kh th. + Rung git c, chi vi, run chi, quy khc, bt rt kh ng. + Co git, hn m. + Yu lit chi. + Da ni vn tm. - Ch nh nhp vin: + Bin chng thn kinh, tim mch, h hp (t 2). + St cao 39oC. + Nn nhiu.

+ Nh xa: khng c kh nng theo di, ti khm. 2.2. 2: iu tr ni tr ti bnh vin huyn hoc tnh - iu tr nh 1. - Nm u cao 30, c thng. - Th oxy qua mi 3-6 lt/pht khi c th nhanh. - Chng co git: Phenobarbital 10 mg/kg/ln tim bp hay truyn tnh mch. Lp li sau 6-8 gi khi cn. - Immunoglobulin (nu c). - Theo di mch, nhit , huyt p, nhp th, tri gic, ran phi, mch mi 4- 6 gi. - o bo ha oxy SpO2 v theo di mch lin tc (nu c my). 2.3. 3: iu tr ni tr ti bnh vin tnh hoc bnh vin huyn nu iu kin. - Th oxy qua mi 3-6 lt/pht. t ni kh qun gip th sm khi tht bi vi th oxy. - Chng ph no (xem iu tr bin chng). - Chng co git: Phenobarbital 10-20mg/kg pha trong Glucose 5% truyn tnh mch trong 30- 60 pht. Lp li 8-12 gi nu cn. - H ng huyt: Glucose 30% 2 ml/kg/ln, lp li khi cn. - iu chnh ri lon nc, in gii, toan kim. - Dobutamin c ch nh khi suy tim mch > 170 ln/pht, liu khi u 5g/kg/pht truyn tnh mch, tng dn 1-2,5g/kg/pht mi 15 pht cho n khi c ci thin lm sng; liu ti a 10g/kg/pht. - Immunoglobulin (nu c). - Theo di mch, nhit , huyt p, nhp th, tri gic, ran phi, SpO2, mi 1- 2 gi. 2.4. 4: iu tr ni tr ti bnh vin trung ng, hoc bnh vin tnh, huyn nu iu kin. - X tr tng t 3. - iu tr bin chng (xem phn iu tr cc bin chng). 3. iu tr cc bin chng: 3.1. Ph no: - Nm u cao 30, c thng. - Th oxy qua mi 1- 4 lt/pht. t ni kh qun sm gip th khi SpO2 < 92% hay PaCO2 > 50 mmHg. - Th my: Tng thng kh gi PaCO2 t 25-35 mmHg v duy tr PaO2 t 90-100 mmHg. - Hn ch dch: tng dch bng 1/2-3/4 nhu cu bnh thng. 3.2. Sc: Sc do vim c tim hoc tn thng trung tm vn mch thn no. - Th oxy qua mi 3-6 lt/pht. - o v theo di p lc tnh mch trung ng. - Truyn dch Natri clorid 0,9% hoc Ringer lactat: 5 ml/kg/15 pht, iu chnh tc theo hng dn CVP v p ng lm sng. Trng hp khng c CVP cn theo di st du hiu qu ti, ph phi cp. - Dopamin l thuc c chn la, liu khi u 5g/kg/pht, tng dn 1- 2,5g/kg/pht mi 15 pht cho n khi c hiu qu, liu ti a 10 g/kg/pht. Trng hp khng p ng vi Dopamin phi hp Dobutamin liu khi u 5g/kg/pht, tng dn 1- 2,5g/kg/pht mi 15 pht cho n khi c hiu qu, liu ti a 20 g/kg/pht. 3.3. Suy h hp: Suy h hp do ph phi cp, hoc vim no.

- Thng ng th: ht sch m ri. - Th oxy 3- 6 lt/pht, duy tr SpO2 > 92%. - t ni kh qun nu c cn ngng th hoc tht bi vi th oxy. - Th my: Tng thng kh gi PaCO2 t 25- 35 mmHg v duy tr PaO2 t 90- 100 mmHg. 3.4. Ph phi cp: - Ngng ngay dch truyn nu ang truyn dch. - Dng Dobutamin liu 5-20 g/kg/pht. - Furosemide 1-2 mg/kg/ln tim tnh mch ch nh khi qu ti dch. 4. Immunoglobulin (nu c): - Ch nh t 2 v 3. - Liu: 1g/kg/ngy truyn tnh mch trong 6- 8 gi x 2 ngy lin tip. - Ring 2 cn nh gi li lm sng trc ch nh liu th 2. Khng dng liu 2 nu lm sng ci thin tt. 5. Khng sinh: - Khng sinh khng c ch nh trong bnh tay-chn-ming. - Ch dng khng sinh khi c bi nhim. - C th dng cc khng sinh sau y: + Amoxicillin + Cephalosporin th h 3: Cefotaxim 200 mg/kg/ngy chia 4 ln (tnh mch) Hoc Ceftriaxon 100 mg/kg/ngy chia 1-2 ln (tnh mch) IV. PHNG BNH 1. Nguyn tc phng bnh: - Hin cha c vc xin phng bnh c hiu. - p dng cc bin php phng bnh i vi bnh ly qua ng tiu ho, c bit ch tip xc trc tip vi ngun ly. 2. Phng bnh ti cc c s y t: - Cch ly theo nhm bnh. - Nhn vin y t: Mang khu trang, ra, st khun tay trc v sau khi chm sc. - Kh khun b mt, ging bnh, bung bnh bng Cloramin B 2%. - X l cht thi theo quy trnh phng bnh ly qua ng tiu ho. 3. Phng bnh cng ng: - V sinh c nhn, ra tay bng x phng (c bit sau khi thay qun o, t, sau khi tip xc vi phn, nc bt). - Ra sch chi, vt dng, sn nh. - Lau sn nh bng dung dch kh khun Cloramin B 2%. - Cch ly tr bnh ti nh. Khng n nh tr, trng hc trong tun u tin ca bnh.