NHN MT TRNG HP VT THNG VNG C DO VT

SC NHN M XUYN THNG NG MCH CNH TRONG

Nguyn Trit Hin, Nguyn Minh Hi v Nguyn Kim Quang
Khoa CTCH, Bnh vin An Giang

Report one case of neck injury by sharp objects penetrating at the right carotid
Abtracts: The authors presented the first case of neck injury with the right internal carotid
artery was cut by sharp object. This case was diagnosed and treated successfully in An Giang
general hospital.
Materials and Methods: a male patient, 45 years old, was diagnosed: The wound at the right
neck pierced by sharp object with suspected vascular lesions, the vital signs were stable.
Results: The operation time was 90 minutes. Estimated blood loss was 100-200ml.
Postoperative recovery was uneventful. The hospital stay was 7 days.
Conclusion: The technique for treating the damage of blood vessels in the neck (or
at the base of neck) is similar to that for other blood vessels elsewhere. The accurate choice
of the incision determines the success of the operation.
Tm tt: tc gi trnh by mt trng hp u tin vt thng vng c, t ng mch cnh
trong bn phi c chn on v x tr thnh cng ti Bnh vin a khoa trung tm An
giang.
T liu v phng php: Phu thut thc hin trn bnh nhn nam gii, 45 tui, c chn
on: Vt thng vng c bn phi do vt sc nhn m, nghi ng c tn thng mch mu
v bnh nhn c du sinh hiu n nh.
Kt qu: thi gian phu thut 90 pht, lng mu mt lc phu thut khong 100-200 ml,
din bin hu phu thun li, thi gian nm vin 7 ngy.
Kt lun: k thut x l tn thng mch mu vng c-nn c, v c bn ging nh cc tn
thng cc mch mu ni khc. vic la chn ng m i vo ni tn thng nhanh, chnh
xc gp phn quyt nh kt qu cuc m.
T VN :
Vt thng vng c - gy thng gp trong cp cu hng ngy ti cc bnh vin. Vng
ny c nhiu c quan quan trng, lin quan n sinh tn ca bnh nhn nh: ct sng, ty
sng, thanh kh qun, thc qun v c bit l cc mch mu nui no m thng c
K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 106

gi l mch mu vng c - nn c (bao gm: h thng ng mch cnh, tnh mch cnh
trong, ng - tnh mch di n, ng tnh mch v danh, ng mch ct sng)(1). Vt
thng ng mch thng gy mt mu nhiu v cp tnh nn l loi tn thng cn c
x tr ngay.
Trong x tr phi ng thi thc hin 2 vic chnh: lm ngng ngay tnh trng chy mu
v m bo c dng mu tun hon nui dng cho vng t chc do ng mch b tn
thng chi phi.
Vt thng mch mu vng c-nn c, chn on v x tr phc tp hn so vi vt
thng mch mu t chi v c t l t vong cao 30- 40%
do mt mu nng, sc khng hi phc

(2,3)

, nguyn nhn ch yu l

(4,5)

Tc nhn gy thng tch thng gp do dao, vt sc nhn khc hoc do ha kh gy nn.

Trong thi gian trc y khoa Chn thng chnh hnh x tr 2 trng hp tn
thng t ng mch cnh trong, nhng tht bi v c hai u t vong sau 24 gi, chng
ti a ra bo co ny nhm rt kinh nghim cho chn on v iu tr.
Tng quan: Gii phu hc vng c (6):Cc c c cng vi xng hm di v xng n to
nn gii hn cc tam gic c: tam gic c trc v sau. tam gic c trc c chia 3 tam
gic nh:
Tam gic di hm: cha ng tnh mch mt v tuyn di hm
Tam gic cnh: cha ng tnh mch cnh trong, thn kinh lang thang v thn giao cm c
Tam gic c: cha thanh kh qun, thc qun, tuyn gip, mch mu gip di v thn kinh
thanh qun di. Da vo c im trn, ngy nay cc tc gi thng p dng cch phn chia
c-nn c thnh 3 vng ca Saletta.J.D(7) xc nh v tr vt thng lin quan vi cc c
quan trong vng c-nn c.

K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 107

Bo co trng
III IIhp lm sng
I
Bnh nhn TRNG
VN D tui 49 ngh nghip: lm rung
a ch: p An Bnh, x Hi An ng, huyn Lp V, tnh ng Thp
Vo khoa cp cu lc16 gi 50 pht, ngy 30/8/2011.
L do vo vin: mnh kim loi m vo vng c bn phi.

Bnh s: Bnh nhn quay my n, tay quay my vng vo mnh khn lau my nm cnh
bn, trong khn c cha mnh thic sc nhn. Mnh thic vng ra theo qun tnh quay ca
bnh my, gm vo c bn phi. Thy khng chy mu qua ming vt thng Ngi bnh
dng tay rt mnh thic ra nhng khng c. Chuyn n Bnh vin KTT An giang.
Khm:
Bnh nhn tnh to, tip xc tt, khng st, Da nim hng. khng kh th, khng khn ging,
khng yu lit chi. Mch 90 ln/pht, huyt p 130/80 mmHg, nhit 37 0C, nhp th 20
ln/pht. Vng c phi c mnh kim loi gm su vo bn trong c. To vt thng da ht su
vo trong, kch thc tng ng vi kch thc mnh kim loi, hng i ca mnh kim loi
m thng vo v tr ng i ca b mch cnh bn phi.
S mch cnh phi ni tn thng yu hn so vi bn tri, khng thy chy mu qua ming
vt thng. khi mu t vng c phi tng dn kch thc.
Lng ngc cn i, ting tim v r ro ph nang 2 phi bnh thng
Cng thc mu: HC 3,6 triu/mm3, HCT 31,9%, HbG 10,1g/dl, TC 73.000/mm3, BC
9.900/mm3.
X quang c thng, nghing: u xa mnh kim loi gm su vo thn t sng C4

K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 108

Chn on: Vt thng c bn phi (vng 2) nghi tn thng b mch cnh trong do mnh
kim loi gm vo.
Cc bc tin hnh phu thut v chm sc sau m:
Bnh nhn c gy m ni kh qun, t th nm nga, u thp.
Tin hnh rch da qua ngay trn vt thng song song vi xng n, bc tch bc l dn
n tn u xa ca mnh kim kh. Dng bipolar t nhng mch mu nh trn ng i
ca vt thng. Quan st thy mnh kim kh xuyn thng ngang qua 2 thnh ca ng mch
cnh trong bn phi, gn t ri ng mch, v tr tn thng ng mch ngang mc sn
nhn (C4). Bc tch bc l r ni tn thng ng mch, dng Bulldog kp 2 u mch mu
v khu li vt thng ng mch bng ch Premilene 7.0, mi khu ri. Sau khi khu, thy
mch p tt, khng chy mu, ng vt m tng lp.

Sau m, vt thng kh, khng chy mu qua dn lu, khng hin tng ph n vng c,
ting ni trong, khng yu lit chi.
Thuc: khng sinh, gim au, Levonox 4000UI tim mt ln di da trc m.
Hu phu Bnh nhn n nh, xut vin sau 7 ngy iu tr.
K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 109

Khng c du hiu nhi mu no trn phim CT Scanner

BN LUN:
Lm sng: Sc mt mu l biu hin quan trng lc mi vo vin. Theo Demetriades- D v
Skalkides- J(4) sc mt mu chim 81%. Mch b mt v yu hn bn khng b thng l
triu chng khch quan c gi tr. Mt s tc gi(3,8,9) ngh mch p yu i hay mt mch
bn c vt thng cng l mt ch nh m thm st.
Biu hin lm sng ni bt v chim phn ln l triu chng chy mu, nht l c tn thng
mch- mu, mu ang chy qua ming vt thng. Khi mu t p ny cho bit c tn
thng lin quan mch mu v mu cc bt ming vt thng t gp hn. Theo Lundy- LJ v
Mandal AK(9), trong 100 vt thng mch mu c c chy mu ti vt thng l 44 trng
hp, khi mu t 32 trng hp v vt thng c mu cc bt 24 trng hp. Belinkie SAv
Russell- JC(10) bo co 44 trng hp vt thng mch mu vng c, hai triu chng thng
gp nht l chy mu t vt thng v khi mu t.
X tr: Phu thut cp cu l phng php tt nht va xc nh thng tn va ly i d
vt. mt s tc gi c ch nh m thm st khi c thng da c(11). Theo Wood. J(12) m thm
st mi bnh nhn c vt thng vng II do t l tn thng nng vng ny cao.
Tc nhn gy thng tch m vo ng i ca mch mu v d vt gi nguyn v tr cho
n lc nhp vin. D cn d vt hay khng, mt vt thng nm ngay trn ng i ca
ng mch cng l mt ch nh m cp cu(13,14).
Qua trng hp trn nhn thy trc mt bnh nhn, c khi mu t p tng dn kch
thc, mt mch sau ni b thng, d vt m thng vo v tr ng i ca mch mu l c

K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 110

ch nh m cp cu. Phng tin cn lm sng thc hin khi sinh hiu n nh, ch nh m
cha r rng, nht l cc vt thng vng I hoc III.
Chp X quang ngc thng c th lm ti ging mt cch nhanh chng nn ch nh tng
i rng ri nht l khi bnh nhn c vt thng vng nn c. Do cc tc nhn gy thng
tch c th xuyn thu vo lng ngc gy ra cc triu chng nh trn mu / trn kh mng
phi cp tnh. Chp X quang ngc thng cn cho bit c t mu trung tht trn hoc m m
khng ng nht nh phi(15). Theo Wisner DH(16), trn phim X quang ngc thng nu
trung tht trn c chiu ngang t 8 cm tr ln gi l gin rng, thng gp trong cc tn
thng quai ng mch ch gy t mu.
Siu m mch mu c kh nng pht hin tn thng mch mu tng i chnh xc(2),
khng gy au n, khng bin chng, khng mt nhiu thi gian nh chp ng mch.
Nhng cn trang b my siu m mch mu v c bit l chuyn vin c kinh nghim.
Cho n nay, chp ng mch vn l phng tin kho st thng tn ng mch chnh xc
nht, c th chn on loi tr vt thng ng mch vng c - nn c khi c nghi ng(11).
Tuy nhin cn cn nhc k, chn lc bnh nhn nhm tit kim thi gian qu bu m kp
thi. Theo Synder WH(17), mt tn thng mch mu thng c biu hin bng nhng bt
thng rt nh trn hnh nh, phi ht sc thn trng i vi nhng biu hin rt nh .
Wisner- DH (16) chp ng mch l th thut gy au n, c th gp bin chng v t l
dng tnh khng cao nn cc tc gi ngh khi c trung tht gin rng trn X quang ngc
cho chp CT- scan trc. Nu c khi mu t trung tht th chp X quang ng mch.
ng thi theo Demetriades D v Skalkides J(4), lm sng quyt nh m, chp ng
mch khng phi l ch nh tuyt i trc m. Ngy nay, nhng trung tm ln c trang b
CT scan hoc chp ng mch in ton - xa- nn (DSA) c gi tr chn on cao c th p
dng trn nhng bnh nhn lm sng tng i n nh, c bit khi c vt thng c vng
I hoc III. Theo Fisher RG & Chasen M H(18), vai tr ca CT scan so vi chp X quang ng
mch trong chn on tn thng ng mch ch ngc v cc nhnh ln cn ang tranh lun.
Theo Wood J(12) nhng- bnh nhn c vt thng vng I v III, chp ng mch khi lm
sng n nh. Theo Elerding SC Moore- EE v Manart FD(8) ch nh m thm st trong vt
thng mch mu vng c - nn c l chy mu lin tc vt thng, khi mu t rng hoc
tin trin, gim hoc mt mch c.
Kt lun: Vt thng mch mu vng c - nn c l loi vt thng nng, kh chn on v
x tr. Bng cc du hiu lm sng c th quyt nh m c bit l cc vt thng vng II.

K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 111

Nhng bnh nhn c lm sng n nh v nht l vt thng vng I hoc III nn lm siu
m mch mu hoc chp X quang ng mch c k hoch iu tr thch hp(19,20).
Do thng b mt mu nhiu, nguyn nhn t vong ch yu l sc mt mu nn hi sc tch
cc, chn on v x tr nhanh l phng hng quan trng gip h thp t l t vong trong
vt thng mch mu.
Khi gp mt bnh nhn c vt thng vng c-nn c, phi ngh n kh nng c tn
thng mch mu vng ny. Bng cc du hiu lm sng c th quyt nh m thm st,
nhng cc ch nh m ny l c chn lc.

Ti liu tham kho

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

14.
15.

16.
17.
18.
19.
20.

L Ngc Thnh & Tn Tht Bch (1993):Thi x tr vt thng mch mu vng c - nn c. Ngoi
khoa, 4:1 - 6.
Davis JM, Holbbook TL. Blunt carotid artery dissection: Incidence, associated injury, screening and
treatment. J. Trauma, 1990,12:1514 - 17.
Golueke PJ, Golstein AS & Sklafini SJA. Routine versus selective exploration of penetrating neck
injuries: A rando-mized prospective study. J Trauma, 1984, 12:1010.
Demetriades D & Skalkidae J. Carotid artery injury. [Carotid artery injuries: experience with 124
cases.] J Trauma, 1989,1: 91 - 94.
Reul GJ & Mattox RL. The early operative management of injuries to the great vessels. Surgery,
1973,7:868 - 887. .
Nguyn Quang Quyn. Bi ging Gii phu hc. Nh xut bn y hc 1990, tp 1: 177- 261
Saletta JD, Lowe RJ, Lim LT, Thornton J, Delk S, Moss GS Penetrating trauma of the neck. J Trauma
1976 Jul; 16(7):579-87.
Elerding SC, Mananrt FD, Moore EE. A reappraisal of penetrating neck injury management. J Trauma,
1980, 8:695 - 698.
Lundy LJ, Mandal AK. Experience in selective operations in the manangement of penetrating wounds
of the neck. Surg Gynec & Obstetrics, 1978, 147:845 - 848..
Belinkie SA, Russell JS, Becker DR. Management of penetrating neck injury. J Trauma, 1983, 3: 235
237.
Sclafini SJA, Cavaliere G. The role of angiography in penetrating neck trauma. J Trauma, 1991, 4:557
- 561.
Wood J, Fabian TC &- Mangiante EC. Penetrating neck injuries: Recommendations- for selective
management. J.Trauma, 1989, 5: 602 - 605.
Nguyn Khnh D. ng m vo phn trung tm ca ng mch cnh gc v ng mch di n
tri.Tng kt kinh nghim x tr vt thng chin tranh: Vt thng lng ngc v mch mu. Cc
Qun Y, 1984,176 178.
Trn Quyt Tin (1997): Ch nh m ngc cp cu. Lun n Ph tin s. X tr cp cu ngoi khoa vt
thng phi - mng phi. Trng HYD Tp HCM, 109 - 116.
Woodring- JH, King JG. Determination of normal transverse mediastinal width and mediastinal - width
to chest ratio in control subjects: Implications for subjects with aortic or brachiocephalic arterial injury.
J Trauma, 1989,9:1268-72.
Wisner DH:Trauma to the chest. Sabiston DC: Surgery of the chest. 1995, WB Saunders company,
Vol I, 456 - 493. .
Synder WH, Thal ER. The valadity of normal arteriography in penetrating trauma. Arch Surg,
1978,113: 424 - 428.
Fisher RG. Diagnosis of injuries of the aorta and Brachiocephalic Arteries caused by blunt chest
trauma: CT vs Aortography. AJ R 1994,162: 1047 - 52.
Burrows PA, Tubman DE: Mutiple extracranial arterial lesions following closed cranio-cervical
trauma. J Trauma, 1981,6: 498 - 9.
Welling RE, Saul JS. Management of blunt injury to the internal carotid artery. J Trauma,
1987,11:1221 - 6.

K yu Hi ngh Khoa hc bnh vin An Giang S thng 10/2011

Trang: 112