Bi ging Chng c

Ng c cc thuc v ha cht gy co git

1.
2.
3.
4.

Bi ging: Lm sng
thi gian ging: 2 tit
a im: Khoa Chng c BV Bch mai
mc tiu hc tp:
4.2.
Chn on xc nh co git do ng c thuc v ho cht
4.3.
Chn on phn bit co git do cc nguyn nhn khc
4.4.
iu tr co git do ng c thuc hoc ho cht
5. Ni dung:
Mt vi con s (Dch t): T l nhim c ca Vit Nam ( theo nin gim

thng k B Y t 2000, trang 158):

Gn 80 bnh nhn N/100.000 dn/nm. Hay 800 bnh nhn N/1triu

dn/nm. 64000 trng hp N/ 80 triu dn/nm
T l t vong do nhim c l:
15 bnh nhn t vong/1 triu dn/nm tc 1200 ngi cht/ 80 triu dn
Tc nhn gy c nhiu, phc tp, v nguy him
- Ha cht bo v thc vt: gy co git , gy ri lon nhp tim, ri lon tr nh v
tm thn: Trifluoroacetate, Cyanacetamide, Striazin, Tetramin
- Kim loi nng: Ch, Hg, Arsenic, Thallium...
- Kh: CS (v kh ha hc), CO, CN trong cc v chy nh...
- C nc, tht cc, ong t, rn c cn, l c , thuc dn gian (mt c, d
mi...), nhim c thc phm, nm c, bt ng...
- Rt nhiu cc ha cht cng nghip, nng nghip v gia dng.
- Ma ty (opiate, cocain, amphetamin...), HIV
- Qu liu v tc dng ph ca dc phm ng - ty y
V nhiu c cht cn cha xc nh c
Nhim c thnh cm, hng lot, gy lo lng, bc xc cho x hi
Mt s v in hnh qua bo ch:
Min Bc:
- 280 ngi nhim c bnh dy ti 3 thn An Ph, Xun Ph, Xun An (Yn Dng,
Bc Giang) (Bo Lao ng ra ngy 27/6/2002)
- 87 n cng nhn ca X nghip giy Lin Dinh v 119 n cng nhn ca cng ty
TNHH Sao Vng (Hi Phng) nhim c thc n (Bo Lao ng ra ngy
25/6/2002)
- V nhim c bnh bt ng H Giang 2/2002, Cao Bng t vong cao (19/21 BN)
- Cc v nhim c gy cht nhiu ngi V Ty -Thi Bnh Thng (9-2002),
ng lm - Hip Ha - Ph Th (thng 12-2002) gy d lun xu trong nhn dn
v bnh l v nhng hin tng m tn cng bi ...
Min Nam:
- 154 hc sinh trng Dng Minh Chu (TP HCM) nhim c do thc n
nhim vi khun (Bo Lao ng, ra ngy 16/5/2002)
- 206 cng nhn cng ty Dong Yang (Long Khnh, ng Nai) nhim c thc
n (Bo Nhn dn, ra ngy 04/4/2002)
- Thnh ph H ch Minh nm 2002 s v nhim c thc phm l cao nht
trong 4 nm qua trong c 14 v nhim c thc phm cc bp n tp th gy
bnh cho 1465 ngi. c bit l t l nguyn nhn do ha cht chim hn na
(57,1%) cng c xu hng tng mnh

Bi ging Chng c
1. Chn on xc nh:

a). Lm sng:
Co git t ngt xut hin mt ngi khng c tin s ng kinh l mt hot
ng t ng, khng mong mun ca c, kt hp vi mt thc trn mt bnh nhn
th phi ngh n b ng c mt ho cht, mt loi thuc hay mt c t no . Co
git l nguyn nhn ch yu gy bnh v t vong do ng c.
Co git km vi triu chng c th nh hng tc nhn gy c:
- Cc du hiu sng:

Nhp tim nhanh, tng huyt p, tng nhit gi l ng c cocain,

amphetamin, hi chng thm ru, benzodiazepin, cc cht kch thch
khc, cht c ch MAO, hi chng S erotonin, hi chng thn kinh c
tnh.
Tim nhanh, h huyt p gi ng c thuc chng trm cm 3 vng,
theophilline, quinine hoc chloroquine
Nhp chm, h huyt p gi thuc c ch bta (propranolone),
photpho hu c, carbamate, nc cc, digoxin

- Cc du hiu v mt:

Kh mt, c dn ng t, gi Atropin Belladon, thuc khng

histamin, thuc trm cm 3 vng, rn h cn
ng t co gi meperidin, photpho hu c v cacbamate,
propoxyphen
Rung git nhn cu gi carbamazepin (Seduxen, diazepam,...) hoc
thuc chng co git khc
- Cc du hiu v da:
Da ti lnh, t gi ng c Photpho hu c, hoc hi chng thiu
benzodiazepin, ru hoc barbiturates
Da , kh thng gp trong ng c atropin, belladone
- Cc du hiu v tim mch:

Tim nhanh, QRS dn >100 rusei, h huyt p gi ng c cc thuc

chng ri lon nhp tim nhm 1, quirin, chloroquine
Ri lon nhp, Bloc A.V, ngoi tm thu tht gi ng c aconitin (c
u tu), nhp chm, QT ko di gi ng c nc cc

- Cc du hiu v h hp:

Ph phi cp, tng tit dch phi, gi ng c PPHC, Carbamate,

heroin, nicotine, salisylate, nm c

- Vim gan cp: gi ng c nm c, chlorin hydrocarbon, thuc khng lao

- H Kali mu gi ng c Theophylline
- H Canxi mu gi ng c thu c chut tu loi Fluoroacetate
- Thn kinh: kch thch ri lon tm thn gi ng cc cocain amphetamines,
thiu oxy do bt k nguyn nhn no. Tr tr, hn m, l gi ng c thuc an
thn, thuc ng, cacbon monoxide, opioids

Bi ging Chng c
- H ng huyt gi ng c Iusulin, propranolon, cc thuc ung h ng
huyt.
b). Xt nghim
Cn kim tra cc enzym CPK, AST, ALT; chc nng gan, thn, ng mu cho
tt c bnh nhn
o corboxyhemoglobin, nh hng thuc trong mu
o kh trong mu, in tim, in no, CT scaner kim tra v theo di
2. Chn on phn bit vi cc trng thi co git
Vim mng no, vim no, p xe no, u no
T mu di mng cng, tai bin mch no, ph no
Thiu oxy, h ng huyt, ri lon in gii, nhp tim chm
ng kinh, hi chng thm ru v an thn
Un vn
3. Nguyn nhn gy co git do c cht v thuc
3.1. Cc cht c thng gp:

Khng histamin, khng cholinergic (atropin)

Cocaine, amphetamines, ergotamine
Kh CO (Carbonmonoxide)
INH ( bnh nhn ang iu tr lao)
Thuc tr su: Photpho hu c v cacbamate
Theophylline, Salicylate, thuc chng trm cm 3 vng
Phenothiazine, Phencyclidine, Meperidin, thuc gy h ng mu
Strychnin (m tin), c trong c thuc dit chut tu
Fluoroacetate, cyanoacetate c trong thuc dit chu t tu

3. 2. Cc c cht t gp:
Butyrophenon
Thuc dit mui
Chloroquine, Lindane (iu tr gh)
Ch, Lithium, Hydrocarbons
4. Tin lng v cch phng:
Co git ko di, lin tc l nguyn nhn chnh gy t vong v bnh tt
do suy h hp cp thiu O 2, tn thng no, v suy thn cp do tiu c vn
5. iu tr
Mc tiu l bo v ng h hp v ct cn co git
5.1. Trc bnh vin:
- Trnh gy nn
- Ly rng gi, trnh cn phi li, t canun ming
5.2. Trong bnh vin:
a). Thuc ct cn git:

Bi ging Chng c

Diazepam (Seduxen, Valium) 5 -10 mg tim tnh mch trong 2 -5 pht,

nhc li sau 10 pht nu thy cn. Tr em: 0,2 - 0,5 mg/kg mi 10 pht
nu cn

* t ng ni kh qun nu diazepam khng p ng, ri cho:

Phenobarbital: liu 18 mg/kg, tnh mch cho c ng i ln v tr em ri

duy tr truyn 60 g/ pht, truyn nhanh c th gy h huyt p

* Thuc gin c, th my vi oxy 40% nu Phenobarbital khng p ng:

Phenytoin
Pentobarbital 5-6 mg/kg/gi

b) Thng kh, m bo oxy (NKQ, Th my)

c) Hu b cht c:
- Ra d dy: ng ln ngi ln (36 -42 French)
ng tr con (24-32 Frech)
nu ng c trong 3 gi u, s lng ln
- Ung mt liu than hot 1 -2g/kg, nu ng c mi trong 1 -2 gi u,
sau khi ra d dy hoc khng ra d dy
- Truyn dch ng trng t 2-4lt/ngy.
Trnh suy thn cp do tiu c vn hu qu ca co git
d). Cht gii c (antidote)
Co git do ng c INH: dng Pyridoxine (vitamin B6) 5g t/m. Liu c th
nhc li mt ln na sau 30 pht (nu cn) song khng vt qu 10 g.

Bi ging Chng c

Ng c thuc tr su mi Nereistoxin
PGS.TS. Nguyn Th D
Trng Khoa Chng c-BV Bch Mai
I. i cng
T trc ti nay, loi thuc tr su c ngi ta bit n nh iu nht l Photpho hu c v
tc dng dit tr su hi mnh m ca n, song cng chnh n gy nhiu t vong do ng
c cp v nhiu ng c mn lm cho tt c mi ngi quan tm, nghin cu v xp loi
c III. nhiu nc c quy nh nghim cm s n xut v s dng loi ha cht ny.
Nc ta cng khng nhp nhng loi ha cht Photpho hu c na. Tuy nhin, trn thc t
li xut hin mt loi mi, c qung co mnh m v ang s dng trong nng nghip
nhm dit su cho la, hoa mu v hoa qu. l: Shachong Shuang (SCS), Shachong Dan
(SCD) do Trung Quc sn xut, TmyQsx, hay Netoxin, Vinetox do Cty lin doanh ca
nc ta sn xut, hoc Dimotrin ca Nht, Panda ca M. Tt c u l loi Nereistoxin.
Nereistoxin trong cc phm thng mi dng cho nng nghip trn c nhp vo nc
ta l dng ht, bi phun hay bt d tan trong nc, thng dng v r tin l loi dng bt
gi 20g ca Trung Quc v ca Si Gn lin doanh sn xut - cc mt hng qung co
nhiu v hiu qu tr su v t c ch o ngi. Song thc t li tri ngc hon ton. Tong
thi gian 2002-2003, khoa Chng c chng ti tip nhn 6 trng hp ng c cp v
3/6 bnh nhn t vong. Sau y, chng ti xin trch dn v 6 bnh nhn trn.
II. Su bnh nhn ng c Nereistoxi n ti Khoa Chng c - BV Bch Mai
1. Bnh nhn n, 23 tui, Thun Thnh -Bc Ninh, chuyn n khoa Chng c 1 gi sau
khi ung 1/3 gi (7g) Shachong Shuang vi mc ch da t t. Khm lc vo: BN tnh,
ku au thng v, bun nn, nn, da lnh, v m hi. BN c ra d dy tuyn
trc, ung than hot v gim au bng Atropin Sulfate. Th 20ln/pht, M = 100
ln/pht, HA 95/60, st 37 oC, ng t 3mm, HC 4,4, BC 16600, U 1,8 mmol/L, G =
6,4mmol, ChE 7042, Na 135, K 3,5, Cl 105, CK = 105v, T: 100ln/ pht, xoang
bnh thng, Q +/Q+C =340/397 ms. Ra vin sau 2 ngy iu tr.
2. Bnh nhn nam, 27 tui, Vnh Tuy, H Ni. Ng c Netoxin (Si Gn -Vit Nam) v
t t, ung 1/2 gi (10g) netoxin cng vi ung ru. 20 pht sau, nn, au bng, v
m hi, xe vn chuyn cp cu, a n khoa Chng c trong tnh trng l .
Glasgow 8 im, da lnh ti, v m hi, ng t 4mm, gim phn x t chi, th 30
ln/pht, M = 120ln/pht, HA 80/50 v 70/0, a lng phn mu ti, st 39,5 oC, CVP
= 1, ChE 10800, Amylase 299/4 942. Cc xt nghim chc nng thn, gan bnh thng,
HC = 4,4, BC = 16700. BN c iu tr: RDD, than hot sau ra, truyn dch +
Stilamin, Transzamin, Dopamin, truyn mu. 3 ngy sau, BN hi phc ra vin
3. Bnh nhn nam, 19 tui, Yn Phong -Bc Ninh, ung 1 gi Shashongdan (20g) vi ru,
t t, c gia nh a ngay n BV huyn ra d dy, ung than hot. 1 gi sau, xut
hin co git ton thn, c t NKQ, cho thuc an thn, chuyn v khoa Chng c BV Bch Mai trong tnh trng Glasgow 3 im, da ton thn kiu gin mch, xut
huyt, M = 150 l/ph, HA = 0, SpO 2 75%, ngng th, git c t nhin, xut huyt tiu
ha, chy mu mi, nc tiu sm. Sau 24gi cp cu (truyn dch, thuc vn mch
Sandostatin, thuc bao bc d dy, NKQ, th my), BN ti n trin xu: vn tm, chy
mu, toan chuyn ha, HA 60/40, BC 16100, ChE 10380, CK 29950, T: Bloc NT
cp 1, T m nn gia nh xin v cht.
4. Bnh nhn n, 14 tui, hc sinh, Qu V -Bc Ninh, ung 1 gi Dibazan Nereistoxin t
t. 10 pht sau, xut hin n n, au bng, ti lnh -> BV Qu V ra d dy, ung than

Bi ging Chng c
hot. Ngay lc ra d dy, xut hin co git ton thn. c t NKQ, chng co git,
chuyn n BV Bc Ninh, n khoa Chng c -BV Bch Mai. Sau 9 gi, BN trong tnh
trng ng t dn, lit c h h p, hn m su, HA 50/30, da ton thn dn mch,
phn mu, xut huyt d dy, chy mu mi, toan chuyn ha, Prothoombri < 10%, Hc
3,73, BC 32900. Ti khoa Chng c, iu tr hi sc rt tch cc, th my vi PEEP,
Human Albumine, truyn mu, Dopamin, Dobutamin, Omeprazol nhng bt kh
khng. BN t vong trong bnh cnh suy a tng
5. Bnh nhn nam, 41 tui, Vn Lm -Hng Yn, ung 1 gi Apaschuang (Nereistoxin) t
t. 10 pht sau, nn, au bng, vt v, ku la. 1 gi sau vo BV Vn Lm ra d dy,
ung than hot, truyn dch. 8 gi sau , chuyn n khoa Chng c -BV Bch Mai
trong tnh trng tm ton thn, ngng th, ng t dn, mch ri rc, da lnh. Khoa
Chng c cp cu v hi sc tch cc, tim p li, HA 110/70, CVP = 5, SpO 2 90%,
my c ngc, toan mu, chuyn ha pH 7,1, PCO 2 64, PaO2 83, HCO 3 20,7, BE -20, HC
5,6, BC 3400, ChE 10610, Prothombin 21%, phn c mu, dch no ty c mu hng
khng ng. BN tin trin xu, t vong sau 10 gi nhp vin
6. Bnh nhn n, 26 tui, Hng Yn, ung 1/2 gi N etoxin t t. 20 ph sau, nn, au
bng, a chy, c a thng vo khoa Chng c ra d dy, ung than hot, truyn
dch, mch, huyt p n nh
Trn y l 6 BN (3 n + 3 nam) ng c Nereistoxin, tui t 14 n 41, u sng vng
nng thn sn thuc tr su, mt ngi ung t nht l 1/3 gi, hai ngi ung 1/2 gi v ba
ngi ung c gi. Ba ngi ung na gi v 1/3 gi th sng, cn ba ngi ung c gi
u t vong, chim 50%. Nguyn nhn t vong l suy h hp, tt HA, chy mu v toan
chuyn ha ch trong vng 2-3 ngy. R rng Nereistoxin l mt ha cht tr su gy cht
ngi.
III. Nereistoxin l g?
Trong t nhin, Nereistoxin c tm thy trong tuyn nc bt ca 1 loi c c bit v
Nereistoxin c tc dng gy c cho su la, hoa qu q ua ng h hp tiu ha v tip
xc. Nereistoxin tr thnh thuc tr su do nhiu cng ty trong v ngoi nc sn xut vi
nhiu tn thng mi khc nhau nh trn ni.
Nereistoxin c tn gi khc l Dimehypo, Neretox.
Tn ha hc ca Nereistoxin l 4-N,N-dimethylamino-1,2 dithiolane.
Phn nhm c ca WHO: loi II
LD 50: 192mg/kg ng ung vi chut c
250mg/kg ng ung vi chut ci
316mg/kg ng ung vi th
khoa Chng c, liu t vong i vi 3 BN l 400mg/kg
Dng s dng: Bt, nc, bt ng gi 20g
Sinh bnh hc: Nereistoxin hp thu vo c th qua ng d dy rut, da v ng h hp
Nereistoxin tc dng trc tip trn d dy rut, gy tng co bp, nn, au bng, a chy.
Trn h thn kinh, Nereistoxin tc dng ngng chn hot ng thn kinh c. Thc nghim
a 1mg/kg Nereistoxin vo tnh mch hu qu c 50% chn thn kinh c trong 2 -5pht,
v tip tc s gy ra lit c h hp v t vong trong vi pht. Quan st mch v huyt p sau
truyn tnh mch Nereistoxin thy tim nhanh v gim huyt p tm thu v tm trng. Tuy
nhin, lit c h hp gp nhiu hn suy tim - nguyn nhn t vong nu khng c bin php
iu tr kp thi

Bi ging Chng c

IV. Chn on v x tr:

1. Lm sng:
Cc trng hp nh v trung bnh:

Cc biu hin d dy rut rt sm, xut hin sau khi ung l au bng, nn ma v
a chy, c th c chy mu tiu ha

Da ti lnh, v m hi, kch thch, mch nhanh

Trng hp nng:

Triu chng d dy rut nng n, v m hi, gy ra gim th tch tun hon, co git
ton thn, suy h hp, tt huyt p, dn mch ton thn, ri lon ng mu, toan
chuyn ha v suy a tng. T vong do suy h hp, suy tim cp v chy mu nng

Theo di xt nghim:

Hng cu gim khi chy mu nhiu, bch cu tng cao

Ri lon ng mu

Gim th tch tun hon

Ri lon nhp tim

2. Pht hin Nereistoxin bng sc k kh (GC) hay sc k lng

3. X tr iu tr :
1. Loi b cht c

Ra d dy sau khi cho thuc chng co git v t ng ni kh qun

Cho than hot 1g/kg + 250ml sch quy u bm qua xng d dy. Nu
cha t c ng NKQ, BN cn tnh th cho ung than hot

2. H tr v bo v ng h hp
t ng NKQ bm bng chn
Th my khi ri lon thc
Th O2 v ht m
3. t ng truyn tnh mch trung ng
o CVP
Truyn dch phn t lng cao khi c sc
Truyn mu khi c chy mt mu
Dng thuc vn mch nng huyt p
4. iu tr toan chuyn ha
Truyn Bicarbonate Natri
Lc mu
5. Thuc gii c
Cobal + Chloride c tc dng tt chut (Huj Zhang - China)

Bi ging Chng c
Neostiguine v 4-aminopyridine c hiu qu th (Shopp RT Dechie ZW
USA 1981)
Dimercaptosucimic acid (DMS) (Ding G -S, Liang Y-Y journal of Applied
Toxicology, Vol 11-No 1)
Tm li, Nereistoxin l thnh phn trong thuc tr su Shachong dan, Shachongchuang,
Netoxin, Vinetox, Dimtin, Panda. Nereistoxin l mt c ht c c tnh cao gy t vong cho
ngi. Thuc ny cn c qun l cht ch, gio dc nng cao nhn thc cho ngi c
s dng. Cc nh sn xut cn thn trng d phng ng c khi a ra th trng qung co
s dng cc loi thuc tr su ny.

Bi ging Chng c

Ng c thuc gy nghin
( Nhm OPI, Heroin v morphin )
PGS. TS Nguyn Th D
Khoa Chng c BV Bch Mai
Thuc gy nghin: thuc phin, codein, morphin v heroin rt d gy ng c cp khi x
dng, c bit nhng ngi lm dng thuc v ph thuc thuc.
C th t vong do suy h hp cp ( ngng th, ph phi cp )
Mt s dn cht opi l thuc gim au, gim ho ( c bit l ho ra mu ) v cm a chy,
dng di ngy c th gy nghin. Ngi bnh thm thuc, tm mi cch c thuc dng.
C thuc li dng qu liu s b ng c cp. Tim chch khng v khun gy nhim
HIV suy gim min dch, vim ni tm mc.
iu tr ch yu m bo thng kh v thuc gim c naloxon ( Narcan ). iu tr cai
nghin c m bo an ton nht cc Trung t m Chng c.
I.

Chn on ng c cp:

1) Chn on xc nh:
Triu chng ng c cp xy ra t 30 - 60 giy sau khi a thuc gy nghin trn vo c
th, ngi bnh c cm gic khoi cm , m m ( i my v gi ), sau i vo
hn m.
Cc du hiu ch yu:
-

Th chm dn ri ngng th, c th ph phi cp, tm

Mt thc, ng t co nh, mt cc phn x.

Huyt p h, lnh do h thn nhit

Trn bnh nhn tr, c vt tim trch hay nghi lm dng thuc
2) Chn on phn bit:
-

Hn m do ung thuc ng v an th n qu liu.

Hn m do h ng huyt, thng gp ngi tiu ng dng thuc h ng

mu qu liu.

II.

Tai bin mch no.

X tr:

1) Ti ch:
-

Thi ngt 14 - 16 ln/1pht ( nu ngng th )

Bi ging Chng c
-

p tim ngoi lng ngc ( nu ngng tim )

Tim naloxon 0,4mg ( bp hay t nh mch ). Nhc li sau mi 5 pht.

Nu bnh nhn tnh li, th c, khng tm, ng t 3 - 4mm th thi.

Nu bnh nhn tnh, t th ri nhanh i vo hn m li, th chm, yu, tm, cho

li Naloxon v gi xe cp cu.

Thit lp mt ng truyn tnh mch

2) Trn xe cp cu:
-

Bp bng ambu 14 - 16l/pht, 30% oxy

Hoc t ng ni kh qun th my, nu bnh nhn c ph phi cp, cho Lasix

40mg/TM.

Truyn dch - thuc vn mch nu h huyt p.

Naloxone truyn TM 0,4mg/gi

III.

Ti Khoa Cp cu v Chng c

1) Nu bnh nhn th di 10ln/pht, tm, h HA, ng t co:

- Naloxon: 0,4 - 0,8mg TM.
Tr em 0,2 - - 0,4mg TM
Nm pht sau khng tnh li c th cho tip ln 2 hay ln th 10 cho n khi c kt qu,
gim dn naloxon.
-

Naloxon tip tc truyn lin tc, duy tr 0,4mg/g i ngi ln v 0,01ng/kg 3 pht
tr em.

m nhp th, theo di thc, huyt p v ng t trong 10gi.

Thng kh nhn to:

+ Bp bng ambu vi FiO 2 50%
+ Th my khng xm nhp nu cn nhp t th.
+ t ng ni kh qun th my ( c bit khi ph ph i cp ) trong khong t 1
gi n 10gi
+ Truyn dch nng HA ( c th dng thm thuc vn mch )

2) Nu bnh nhn th > 10ln/pht:

-

Naloxon 0,4mg tim bp hay tnh mch.

Th O2 4lt/pht

Truyn dch ( glucose 5% )

Theo di nhp th, thc v huyt p 15ph/ ln.

Bi ging Chng c
3) Theo di du hiu thm thuc sau dng naloxone.
l: ng t gin ( v m hi ), sn gai c, vt v, run c, si bng, nn, tim nhanh, th
nhanh . . .
Cho thm cc thuc ng v an thn, ng thi lp k hoch cai nghin cho bnh nhn.

Bi ging Chng c

Ng c thc phm
Ng c thc phm (NTP) l cc hi chng lm sng xut hin do:
1. Thc phm b nhim cc vi sinh v Ot hoc cc sn phm ca chng (thng gp
nht),
2. Thc phm b nhim cc ho cht c, hoc
3. n phi cc thc vOt hoc ng vOt c c t.(11)

NTP c th nh hong mi i tng, mi quc gia (8,9,14), c th tc ng

cng mt lc ti nhiu ngi, gy h Ou qu khng nhng v y t (trc mt v lu
di) m cn v kinh t, tr Ot t x hi.

o nc ta, trong nhng nm gn y NTP xy ra c xu h ng nhiu hn. N

khng khng cn ch l vn y t m cn n s tham gia ca nhiu ngnh
chc nng c lin quan.

nh ngha thc phm :

Thc phm l nhng n, thc ung ca con ngi o dng ti sng hoc qua s
ch, ch bin bao gm c un g, nhai, ngOm v cc cht c s dng trong sn xut,
ch bin thc phm.(2)
Phn loi thc phm
Theo phn loi Eurocode Main Food Group Clasification and Policy, version 99 -2. htm
(16) phn loi ny gm hai phn :
1.1. Phn loi cc nhm thc phm ch nh :
1.1. Sa v cc sn phm t sa
1.2. Trng v cc sn phm t trng
1.3. Tht v cc sn phm t tht
1.4. C, loi nhuyn th, b st, loi tm cua v cc sn phm

1.5.

Du, m v cc sn phm t du, m.

1.6. Ng cc v cc sn phm t ng cc
1.7. Ht Ou, cc loi ht, nhn ca ht v cc sn phm.
1.8. Rau v cc sn phm t rau.
1.9. Qu v cc sn phm t qu.
1.10. ng, cc sn phm ng, cc sn phm socla v bnh ko.
1.11. ung (khng phi sa).

Bi ging Chng c
1.12. Cc thc phm khc, cho, sp, canh, nc st, nc mm, tng v cc sn phm.
1.13. Cc sn phm dng cho mc ch dinh dng c bit. 1.2.

t,

phn loi v m ho c th tng nhm thc phm cng vi c c v d.

Phn loi thc phm Aynrveda (Aynrveda food classification )(17): Chia thnh 10 nhm
thc phm l : Tht, sa, du, bnh ko, Ou, rau, qu, rau thm v gia v, ng cc, ht.
Vi cc c im ca tng nhm v v, ch bin nng hay lnh, tc dng sau khi c
tiu ho v tnh cht vOt l.
Tiu chun v sinh thc phm :
Theo danh mc tiu chun v sinh i vi lng thc, thc phm ca B Y t (3),
xin c nu tm tt, gm c :
Mc 1 : Gii hn ph gia thc phm v cc cht nhim :
Ph gia thc phm:
Khi nim cht ph gia thc phm.
Cc ph gia thc phm c chia lm 16 nhm cht vi chc nng, cng dng, s
lng cht o tng nhm c php s dng. Tng s cht c s dng o tt c
cc nhm l 246 cht.
V d : Mononatri L (-) glutamat (monosodium L(-) Glutamate, l m chnh,
thuc nhm cc cht iu v (Flavo enhancers) s lng n vo hng ngy chp
nhOn c (ADI : Acceptable daily intake) khng gii hn, vi tht cua hp gii
hn ti a cho php l 500 mg/kg.
Gii hn cc cht nhim :
1.Gii hn nhim c t vi nm (Mycotoxin ).
2.Tiu chun v sinh an ton v Ot liu thit b bao gi cha ng thc phm.
3.Tiu chun v sinh an ton chi tr em.
4.Tiu chun v sinh thc phm cht ty ra dng ra dng c cha n v cha ng
thc phm.
5.Kim tra gii hn kim loi nng Sb, As, Cd, Pb trong dng c cha ng, bo qun v
nu n.
6. Hm lng kim loi cho php trong cc loi thc phm.
7.Gii hn thuc th y ti a cho php trong sn phm tht

Bi ging Chng c

Mc 2 : D lng thuc bo v thc vOt trong thc phm :

Thuc bo v thc vOt l ch phm c ngun gc t ho cht, thc v Ot, ng vOt,
vi sinh vOt dng phng, tr sinh v Ot gy hi ti nguyn thc v Ot.
C 144 thuc BVTV c dng lm ch tiu, v d: Methamidophos (O,S
Dimethyl Phosphoramidothioate) trn da chut, lng tn d ti a l 1 mg/kg.
Mc 3 : Trng thi cm quan v cc ch tiu l ho i vi mt s mt hng lng
thc , thc phm chnh .
Mc 4 : Gii hn nhim vi sinh v Ot trong thc phm.
Tuy nhin, vi s pht trin ca khoa hc, nhiu ho cht c a vo s dng
trong i sng hng ngy, vi sinh v Ot cng thay i din mo do con ngi s
dng nhiu ho cht tiu dit chng v cng vi nhiu l do khc khin cc
nguyn nhn ca NTP ngy cng tr o nn phc tp v kh kim sot. V d, trong
lnh vc ho cht bo v thc v Ot, cho ti nm 2000, o nc ta c(1)
Triu chng chung ca NTP
V c rt nhiu cc tc nhn vi sinh v Ot, cht c v cc ho cht nn khi c
vo c th cng vi thc n s gy nhiu tri u chng khc nhau.
Do ng tiu ho l con ng vo ca cc tc nhn nn hu ht cc bnh
cnh ca NTP u c biu hin mt mc no ca vim d dy rut, c th
ni bOt o ng tiu ho trn hoc ng tiu ho di. Cc hi chng khc
thng thy bao gm cc triu chng ngoi c quan tiu ho, c bit l v thn
kinh (11).
Vic nh gi mt trng hp nghi ng NTP khng ch da vo cc triu chng
khi bnh nhn n vin m cn cn quan tm n bnh s, tnh cht thc phm,
thi gian xut hin cc triu chng tnh t thi im n ung, hon cnh, ma v
cc triu chng xut hin o nhng ngi khc cng n ung loi thc phm nghi
ng (21).
Tn xut b bnh o nhng ngi khng cng n loi thc phm nghi ng cng
gip chn on.
COn lm sng c th gip chn on nguyn nhn v nh hng iu tr.

Bi ging Chng c
Trong phm vi ti ny chng ti s ch xin c Op ti cc hi chng NTP c
tnh cp tnh, tc l cc triu chng thng bt u xut hin trong vng 72 gi
(18). Cc trng hp khc bao gm cc hOu qu lu di ca NTP cp, ng c
cc thc phm c cha cc cht c vi hm lng thp nhng gy tch lu liu
khi dng lu, cng li nhng h Ou qu khng km, chng ti khng c iu
kin i su.
Cc triu chng c th ca NTP s ph thuc vo tng nguyn nhn.
Nguyn nhn NTP
Cha y mt na s v NTP c bit tm thy nguyn nhn(41%) (11). Trong
do tc nhn vi khun l 79%; ho cht 14%; virus 4% v k sinh trng 1% (10) v dng
nh cc trng hp khng thy nguyn nhn l do virus gy ra (15).
Ng c thc phm do vi sinh v Ot (13)
Nguyn nhn:
Vi cc thc phm l rau qu, ng cc, ht, sa v cc sn phm : Cc loi t cu,
Bacilus cereus, Campylobacter fetus hoc yersinia enterocolitica.
Ph n c thai rt d b nhim Lis teria, cc thc phm thng gp nht l tht g
khng c nu chn hoc cc sn phm sa b nhim Listeria monocytogenes.
Do nc hoc dng nc ra thc phm : Cc nguyn nhn l E.coli (c loi
sinh c t v xm nh Op), cc loi Shigella, Salmonell a enteritis, Y.
enterocolitica, C.fetus, hoc Vibrio cholera.
Do tht v trng:

+Thng l tht qua qu trnh x l, tht c nu khng

k, bo qun lnh khng y hoc v On chuyn khng ng, bnh ngt c kem
hoc c sa-trng v cc sn phm c trng khc b nhim cc vi khun vi s
lng t ti mc c th gy bnh.
o Cc vi khun thng l cc t cu, C.perfringens, B.cereus, cc Salmonella
v Campylobacter jejuni.
C ch:
Theo mt trong hai c ch sau:
Vim d dy rut do xm nh Op:
o Vi khun trc tip xm nhOp nim mc rut, gy thoi ho cc vi nhung
mao v phn ng vim mnh m, biu hin bng a chy phn c mu,
nn, au qun bng v chng bng.

Bi ging Chng c
o Vi khun thng gp nht l Salmonella v E.coli xm nh Op.
Vim d dy rut do c t rut:
o Cc c t ca vi khun ph v c ch v On chuyn nc v cc cht ho
tan qua mng t bo dn ti a chy phn khng c mu, au qun bng,
chng bng v nn.
o Cc tc nhn thng gp nht l cc loi t cu, E.coli sinh c t rut,
Clostridium perfringens, B.cereus v Campylobacter jejuni.
Triu chng:
Cc triu chng thc th khng c hiu v ch yu do mt nc v cc tc dng
ti ch trn ng tiu ho ca c t.
Din bin: Hu ht cc bnh nhn sau vi ngy s hi phc hon ton.
Vic hi v qu trnh n ung v mi lin quan vi kh oi u ca triu chng s
gip hng ti nguyn nhn.
a. Thi gian bnh v b bnh: (*)
Vi khun

bnh
(Trung bnh)

T cu
Bacillus cereus

1-6h

Thi gian b bnh

Trung bnh

Thay i

1 ngy

8 - 48 h

Gy hi chng nn

1-6h

9h

2 - 10 h

Gy bnh l a chy

6 - 14 h

20h

16 - 48 h

8 - 48 h

3 ngy

1-14ngy

Sinh c t rut

12 - 72 h

3 ngy

1-14ngy

Xm nhOp rut

6 - 36 h

3 ngy

1-14ngy

V. cholera

12 - 72 h

3 ngy

2-14ngy

Shigella

24 - 72 h

3 ngy

1-14 ngy

7 ngy

2-30 ngy

Salmonella
E.coli

(ti 7 ngy)
Y. enterocolitica

24 - 72 h
(ti 6 ngy)

Campylobacter

2 - 11 ngy

3 ngy

2-30 ngy

C.perfringens

8 - 24 h

24 h

8 - 72 h

Bi ging Chng c
b. Cc du hiu sng:
St: Gi bnh l xm nh Op, v d nh salmonella, C.fetus hoc E.coli.
Nhp tim nhanh do st hoc mt dch.
Huyt p h thng do mt th tch ng k (trn 10 % tng th tch)
Nhim Listeria c triu chng st v vim thanh qun.
Cc tc dng ca c t , c bit l mt nc c th ni b Ot o tr em v ngi
cao tui.
c. Da: Da kh v n hi km cho thy tnh trng mt nc.
d. Tiu ho:
au qun khp bng, chng bng, a chy, bng cng ton b, co c bng ch
ng: Gp o hu ht cc trng hp v khng c hiu.
Khm trc trng thy nim mc b vim, mn hoc xt nghim thy c H em: Gi
tc nhn vi khun xm nh Op.
e. ThOn: Lng nc tiu gim cho thy tnh trng thiu dch.
f. Nc v in gii:
Nn, a chy v mt nc in gii theo con ng khng thy c th gy tng
Natri mu (mt nc) hoc h natri (mt natri ton b c th), h kali mu, h clo
mu, h magi mu, hoc h phospho mu.
C th c kim chuyn ho (nn) hoc toan chuyn ho (mt bicarbonat do a
chy).
g. C xng:
Thng gp co cng c lan to v au c.
Nhim listeria c triu chng au c.
h. Thn kinh:
Ng c thc phm n thun do vi khun khng c triu chng thn kinh c
hiu.
Nu c lit vOn nhn hoc lit t trn xung th cn nghi ng nhim Botulium.
Nhim Listeria c triu chng au u d ri.
i. Ngi cao tui v tr em:
Cc triu trng nng hn vi tr em v ngi cao tui mc d t vong do sc v mt th
tch dch him gp ngay c o i tng ny.

Bi ging Chng c
Xt nghim:
1. Xt nghim mu c th thy bch cu a nhn trong mu tng, c bit vi cc vi
khun xm nhOp.
2. Soi phn c th thy bch cu, vi khun gy bnh.
3. Cy thc n, cht nn hoc phn, nh type huyt thanh vi khun, xt nghim c
t (t cu, E.coli sinh c t rut, C.perfringens). Cy mu cho thy vi khun xm
nhOp.
4. ur, creatinin v in gii mu cn c lm nh gi h Ou qu ca mt nc.
Chn on:
1. Khi c nhiu bnh nhn ti vin cng lc t cng mt ni hoc khu vc cho thy
do cng mt ngun tip xc.
2. Khai thc bnh s v vic dng cc thc phm v thi im triu chng u tin
xut hin s gip pht hin nguyn nhn.
3. Cc c gng qu mc xc n h nguyn nhn v ngun bnh t c ngha lm
sng.
iu tr:
a. Nguyn tc chung:
Vic iu tr nn tOp chung gim cc triu chng bun nn, nn v a chy cng
vi vic ch ti kh nng thiu dch v sc.
Vi cc bnh nhn c mt nc nng v sc, iu tr h tr trong c bi ph
dch c ngha sng cn.
Vic phn bit a chy do vi khun xm nh Op hay khng xm nhOp thng
nh hng iu tr.
Cn xc nh thi gian v qu trnh bnh nhn n ung i vi tt c cc thc n
c dng trong vng 48 gi.
Khi c nhiu ca cng xy ra cn phi thng bo cho trung tm y hc d phng.
b. C th:
Gy nn, ra d dy: Ni chung khng cn thit do bnh nhn nn nhiu.
Khng sinh:
o Trong trng hp nghi ng nhim trng do vi khun xm nh Op, cy phn
c th c t l m tnh gi ti 40%, c th ch nh iu tr thc t nh sau:

Bi ging Chng c
Ciprofloxacin, 250 mg, 2 ln/ngy, trong 5 -7 ngy, hoc
Trimethoprim/Sulfamethoxazole, vin 160/800 mg, 2 ln/ngy, trong5 -7 ngy.
o Khi xc nh c nguyn nhn, dng khng sinh tu theo vi khun.
Do virus : (25)
Vim d dy rut do virus xut hin nhiu hn s c pht hin, cc nguyn
nhn c xc nh gm c : Virus Norwalk, Rotavirus, Adenovirus ng
rut, Calcivirus.
Trong hu ht cc ca vim d dy rut do virus, chn o n xc nh gp kh khn
do i hi cc k thuOt chn on tng i phc tp.
Virus Norwalk:
c coi l nguyn nhn ca t nht 1/3 cc v dch vim d dy rut do virus o
M.
Virus chu c nhit, gy bnh o rut non l ch yu; gy gim tiu ho v h p
thu cng vi vim rut.
Triu chng : nn v a chy cp tnh cng vi cc biu hin ging cm, him khi
ko di qu vi ngy.
iu tr triu chng
Rotavirus :
Tn thng : ph hu lp vi nhung mao, lm gim tiu ho v hp thu, thay i
ny c th ko di ti 8 tun.
i tng d mc : Ch yu l tr nh, tr b sa m t b mc hn.
Biu hin : Nn, sau a chy phn nc, ko di trung bnh vi ngy, mt nc
in gii.
iu tr : Bi ph nc in gii.
Do k sinh trng :
Do ng vOt n bo : (7)
Nhiu loi ng vOt n bo c th nhim trong thc phm v gy bnh.
* Amibe :
Bnh Amibe do Etamoeba histolytica gy ra

Bi ging Chng c
Thc phm b nhim : rau qu sng, nc l, thc n b nhim phn c kn amp, qua bn
tay bn.
Nung bnh : 1-14 tun, thng 2-4 tun
Bnh cnh : - l amp (bnh amp i trng):
+ Hi chng l, thng khng st
+ Chn on : Xt nghim phn tm amibe gy bnh.
Bnh amibe ngoi i trng (p xe gan, vim phi, trn dch mng phi): Chn
on : Xquang, siu m, chn on xc nh bng cc phn ng huyt thanh min
dch.
iu tr : Metronidazol hoc cc ch phm.
*Giardia :
ng vOt n bo c lng roi Giardia lambia.
Thc phm b nhim : Thc phm nc b nhim phn ngi v ng v Ot c u
trng Giardia.
Triu chng : bnh 3- 25 ngy; trung bnh 7-10 ngy. Biu hin : a chy, c th
phn m, au qun bng, thng khng c tn thng ngoi rut, bnh thng t
gii hn, c bit o ngi sc khng tt.
Chn on : tm thy nang hoc cc th t dng trong phn (thc hin t nht 3
ln trc khi c coi l m tnh, hoc tm thy th t dng trong dch t trng
hoc trong nim mc sinh thit rut non.
iu tr : Metronidazol, quinacrin, Furazolidol.
Nhim vi nm : (11)
Clavicep purpurea : c trong cc loi ng cc, c bit la mch
+c t l Ergotamin : co bp c t cung, co mch, c th dn ti hoi th.
+ Hin nay him gp.
-Aspergillus (loi A. Flavus v A.parasiticus):
C c t l aflatoxin
Thc phm nhim nm : Cc ht, ht Ou (nh ng, go, la m, Ou
tng, lc, ht bng), thc phm ny thng c o mi trng m, m.
Aflatoxin : cht gy ung th mnh, c bit vi gan.
Ng c thc phm do cht c c sn t nhin trong thc phm.

Bi ging Chng c
Cy c (21,25,6,19 ):
c bit rng ri v d dng nht l cc cht c hot tnh dc l c thy trong nhiu
phn khc nhau ca cy c.
Cc Glycozide tr tim c t cc cy : c trong cy dng a hong ( Digitalis purpurea)
v mt s cy khc.
Pyrrolizidine : c trong cy vi voi (Heliotropium) v mt s cy khc.
Cc alkloid Pyrrolizidine c trong cc cy ny c th gy st, nn, au bng, v cui cng
vng da, c chng, du hiu ca bnh l gan tc nghn tnh mch.
* Cc cy ny c dng ch ch, gia v, ung c ga v cc thuc dn gian .
Cy Ou thin l:(Lathyrus sativus)
Ou ny c bo qun o cc vng c nn i o chu Phi, chu .
Biu hin : Lit dn 2 chi di, lit cng, lit ny c th kch thch dn ti x ct
bn teo c.
c cht : Ngi ta cho l : - amino proprionitrile.
Cy Ou rng nga (Vicia faba)

Hot cht ; Ht cha cc dn cht pyrimidine xy ho, khi ngi n vo ng

thi nu c thiu men G6PD s gy thiu mu tan mu, khng phi tt c
nhng ngi n u b.

cc nc a Trung Hi, vic ph bin loi Ou ny nh mt loi thc phm

v s thng gp ca thiu men G6 PD c xu hng ng thi xy ra.

Biu hin: Sau n vi ngy, thiu mu v st ni b Ot sau t gim v ht

trong vi tun sau, t vong 5%.

iu tr : Ch yu iu tr triu chng, ngi ta xut vic ly hng cu

tn thng ra bng phng php huyt thanh.

Cc Glycozide c Cyanua.

Cc cy cha Hydro cyanua: Sn, Cc cy Ou, bu b, da chut, mng, qu

Ak, chui chn, nhn ht qu m.

Triu trng ng c:
o Ri lon tiu ho: au bng, bun nn, a chy.

10

Bi ging Chng c
o Thn kinh: Chng mt, nhc u. Nng hn c th co cng, co gi Ot, ng
t gin sau hn m.
o H hp: Ngt tho, xanh tm, suy h hp cp, gy t vong nhanh.
Xt nghim: Mu tnh mch ti.
Cht nn v nc tiu c acid cyanhydric.
X tr:
o Gy nn, ra d dy bng dung dch thuc tm 2/1000.

o Nu nng t ng ni kh qun, th o my, tng thng kh, Fi02=1.

o Dng Hydroxocobalamin tnh mch, Glucose 20%.
o Chng sc.
Nm
C hng nghn loi nm, ch di 5% cc loi l c. Song phn bit gia nm c v
khng c rt kh khn.
* Nm mc (Copriruss atramentarius)
c t : coprine
Tc dng ging Difulfiram, khi n c ung ru, sau 30 pht c nhp tim nhanh,
bc ho, bun nn.
* Nm phin m chung (Paneolus campanuletus)
c t : Psylocibin
Tc dng : Sau n 30 60 pht, nn nhiu, au qun bng, o gic, tng hot
ng. C th dung np c Psylocibin nn thng lnh tnh .
* Nm mn trng (Amanita pantherina)
c t : axit Ibotenic v cc dn xut isoxazole
Tc dng : 20 90 pht sau n; gy ln ln, v Ot v, ri lon nhn.
* Nm mt tri :(A. Muscaria)
c t : cc hp cht muscarine
Tc dng : sau n 30 pht, tng tit dch ngoi tit, nhp tim ch Om v cc p ng
cholinergic khc.
* Nm c xanh en : (A. phalloides).
c t Amatoxins v Phallotoxins

11

Bi ging Chng c
Tc dng : Ng c kiu 2 pha : u tin vi au bng, nn, a chy xut hin
612h sau khi n v thng ht trong 24h. Sau khi bnh nhn n nh 1 -2 ngy,
bnh tin trin vi suy gan, suy th On nng n, t vong cao(30 -50% ) c th lc
mu hp ph.
ng vOt : (25, 6)
Cc:
c t: Bufotalin, Bufotenin, Bufotonin, c trong cc tuyn di da, gan, trng.
Triu trng: Xut hin 1 -2 gi sau khi n:
o Ri lon tiu ho: au bng, bun nn, nn.

o Tim mch: Lc u c huyt p cao, nhp tim nhanh, c th do Bufotonin.

Sau ri lon tnh kch thch: ngoi tm thu, cn nhp nhanh tht, flutter
tht, rung tht. i khi c block nh tht, nhp nt, dn n tru mch. C c
ri lon nhp c th do Bufotalin.
o Ri lon thn kinh v tm thn: Bufotenin c th gy o gic, hoang t ong,
ri lon nhn cch, liu cao hn c th c ch trung tm h hp, ngng
tho.
o Tn thng thOn: Vim ng thOn cp.
X tr: Thi tr cht c, i u tr h tr v lc mu khi cn.
C nc
c t l Tetradotoxin : bn vng vi nhit, c nhiu o cc tng v c bit l gan,
da, trng, s lng thay i theo ma.
Triu chng thn kinh v tiu ho xut hin 10 -40 pht sau n, nhng c th
chOm hn gm d cm, t (c bit quanh ming v o li), chng mt, mt iu
ho, tng tit nc bt, gi Ot c, nn, kh nut, au bng, a chy , mt ting, lit,
ch yu c h hp. ng t lc u co sau gin mt phn x nh sng, tt huyt
p, lon nhp tim, suy h hp. Bnh nhn vn tnh trc khi cht, t vong 60%.
Chn on : Hi bnh, din bin lm sng, c th xt nghim c cht vi mu c
nghi ng.
iu tr :
o Gy nn, ra d dy, than hot.

o iu tr h tr: t ng ni kh qun, th o my c lit c h hp c suy h

hp, m bo huyt p, nhp tim.

12

Bi ging Chng c
C Scombroid
Cc c c m trong tht nh c ng, c thu, c t tch lu dn trong tht c do
c gii phng dn t qu trnh decacboxy ho histidine ca vi khun (ch yu
do Proteus morganii), c t c li n quan ti Histamin, bn vng vi nhit.
Triu chng : 15 45 pht sau n, xut hin cc triu chng c trng ca phn
ng Histamin bc ho, au u, chng mt, au bng, nn, bun nn, a chy. Cc
triu chng ht sau vi gi v khng c t vong.
iu tr : Thuc khng Histamin
Ng c ciguatera
Ch yu do n phi cc c nh c nhng, c ch vng v cc loi c o tng y
bin khc. Khi cc loi c to hn n c nh hn cha mt loi to Lyngbia
majusula th loi to ny c tch ly dn trong tht c v gii phng c t khi
ngi n phi.
Bn cht l c t thn kinh, khng d b bt hot b oi nng hay lnh, gy d cm
(c bit mi, li v hng), nga, cc triu chng tiu ho trong c nn, a
chy. C th c bnh l no, suy h hp v sc.
Cc triu chng thng bt u 12h 30h sau n, thng l triu chng tiu ho
trc tin.
Chn on : da vo lm sng v hon cnh, c th xt nghim nhanh c t trong
mu c bng 1 test n gin.
iu tr : iu tr h tr
Ng c trai, s :
Do n cc ng vOt thn mm c 2 mnh v, cc ng v Ot ny c cha

to

Gonyanlax.
Triu chng : T o mt, ming, t cng sau t o tay v chn, cc biu hin r
sau n 30 pht, kh nut, kh ni, chng mt, au u vng trn, t vong (do suy
h hp), c th km theo nhim khun do cc vi khun c trong s, trai v d ng.
Chn on :
o Khi thy bnh nhn n tht hoc ung nc ca trai, s trc kh i b
bnh.
o C th xt nghim c cht bng quang ph hoc th nghim sinh hc trn
chut.

13

Bi ging Chng c
iu tr :
o Ra d dy, than hot
o iu tr h tr
Cc amin hot mch :
Cc cht : Diamine Histamine v mt s monamine (tyramine, phenylethyl amine
v Serotonin)
Cc thc phm cha cc cht ny :
* Hm lng tng i cao
+ Pho mt (pho mt , pho mt xanh v pho mt Rockpho)
+ Rau (rau bina, c tm)
+ Ru vang (vang kianti, Bourgogne)
+ C : C ng, c thu
+ Men ru, bia.
* Hm lng tng i thp
- C chua
- Gan g, bia, xc xch
- Bp ci mui
- Cc thc n ny lm tng Histamin niu sau ba n.
- C thc n tuy c hm lng Histamin thp nhng c hm lng ng k Histidine, khi
vo c th c chuyn thnh Histamin.
- Cc thc n c th c cha nhng cht c kh nng kch ng t bo mast gii phng
Histamin : trng, du ty, scl a, c chua, cc qu h cam, b oi.

- Vic dng ng thi

mt s thuc c ch chuyn ho bnh thng ca Histamin (nh Izoniazid) gp phn vo

vn ny.
- Cc thc phm cha Monoamine :
* Tyramine :
Pho mt, men bia, vang , c trch ngm dm, gan g .
S lng t hn c trong qu b, chui, qu m On , c chua v c tm.
* Phenylethylamine :
C trong pho mt, vang .
* Senotonin :

14

Bi ging Chng c
C trong chui, da, qu chui l, qu b, qu m On, c chua v mt s ng v Ot
thn mm (c bit l bch tuc)
- Cc triu chng :
Ri lon v gic, phng rp nim mc ming, bc ho, au u, co tht ph qun, h
huyt p, nn, bun nn, au qun bng, a chy. Cc triu chng thng gim i sau vi
gi. o cc bnh nhn nhy cm, c th dng cc cht khng H1, H2 phng hoc lm
du i.
- Cc Monoamin hot mch b MAO chuyn ho, h men ny t Op trung o rut. Cc thuc
c ch chuyn ho ny lm tng tc dng ca monoamin. Cc thuc. :
Iso carboxazid (marplan)
Phenelzine (Nardil)
Tranyl cypromine (Parnate)
L cc thuc chng trm cm trc y c dng.
+ Cc bnh nhn dng thuc ny cn trnh cc thc n c monoamine
+ Cc bnh nhn c nguy c l bnh nhn Migraine v nga mn tnh, ch yu triu
chng s l p ng v co tht .
NTP do ho cht trong thc phm
Cc cht ph gia:(20, 25 )
Cht bo qun :
2 nhm c dng rng ri khp th gii l Benzoate v paraben.
* Ben zoate:
u in: Phm vi chng vi sinh v Ot, nm rng ri, rt t hoc khng c khi dng
ng hm lng, r tin.
Tc dng c hi him gp v hu ht o ngi hen v nga mn tnh. C th do cu
trc tng t ca Benzoate vi aspirin.
*Paraben :
Methyl paraben, propyl paraben, heptyl parabens.
c dng ch yu trong m phm, cc ch phm thuc c dng ti ch, c
th c a vo cc thc phm nng, cc rau qu c x l, m, du v bt
ngt.
Cc tc dng c hi : hu nh ch c vim da tip xc.

15

Bi ging Chng c
*Sulfite:
Dioxide sulfua, Sulfite natri, Bisulfite natri v kali, Metabisulfite natri v kali, y
l cc cht bo qun v c hng xy ho, b cm trn rau qu.
c tnh: c t vong do sulfite, c th kch thch cn hen, mt thc, sc
phn v, a chy, bun nn v nn.
*Natrinitrit :
Dng trong tht ch bin
Tc dng : gin mch, c pht hin l nguyn nhn ca Hotdog headache)
Cc cht iu v
Tr mui n, cht thng gp nht l Glutamat natri.
Tc dng : L mt cht kch thch, bng vic kh cc, tc dng ln cc receptor v
gic, mt tc dng c lin quan ti tc dng c hi ln cc yu t thn kinh ngoi
vi o ni khc ngoi ming li.
Tc dng ph thuc liu v ph thuc c th.
Hi chng Nh hng Tu :
o c m t ln u tin nm 1968 o M.

o 30% ngi M trong thnh b nh hong, tr em d b phn ng hn.

o Biu hin : Trong vng 1 gi tr o li sau n; au u, lng lng, cm gic

nng bng quanh u v c, tht ngc, nn, v m hi, t ht trong 1 gi
hoc lu hn. n nhiu c th lm kh oi pht cn hen o mt s ngi.
Cc cht ngt tng hp:
* Aspartame v saccharin:
Cc cht ny c th gy nhiu ri lon: au u ( trong c hi chng Migraine),
chng mt, co giOt, trm cm, bun nn, nn, v au qun bng. C th lin quan ti
tnh trng hot ng qu mc ca tr em. Ph n c thai cn trnh dng cc bt ngt ny
mc d cha chng minh c tc dng gy ung th.
Cc cht mu tng hp:
Cc cht mu c th thy o nhiu thc phm, tr em v ngi ln c th tip xc vi cc
cht gy ung th nh cht mu s 8,9,19, v 37, hoc cht mu da cam s 17.

16

Bi ging Chng c
Cc cht nhim:( 20, 23 )
Thuc tr su:
Rau v qu c th cha trn b mt d lng ho cht tr su v dit c nguy
him. Hm lng cc thuc tr su trong rau qu ti cao ti mc bo ng trong
khi cc thc phm ng hp c hm lng thp hn nhiu.
Hn 40 % cc thuc tr su l pho spho hu c, trong c Malathion, Parathion,
Daizanon, Dursban ngoi tc dng c ch Cholinesterase cn gy bt thng cho
bo thai v gy ung th.
Cht c mu da cam: Hn hp ca hai thuc tr c 2,4,5 - T v 2,4- D c th gy ung
th. Ngi ta cng thy tc dng gy u no trn chut ca cc cht ny.
Cc Dioxin: C 75 cht c trong nhm Dioxin, l cc Clo hu c c c tnh cao v tn
ti trong mi trng nhiu nm. Ngi ta thy trong cc ng v Ot, cy c v c, c
bit rong cc vOt nui, cy trng, thOm ch trong sa m. C ch gy c: Dioxin gn
vi AND ca t bo lm thay i vic c m, ch mt thay i nh c th nh h ong ln
ln i sng t bo v cc th h t bo sau.
Cc ng v phng x: Bng vic nhim t, nc, thc v Ot, ng vOt ri gy bnh cho
con ngi. C nhiu cht ng v phng x trong phi k n mt cht nguy him nht
trong l phn ng ht nhn l Plutonium vi thi gian bn hu l 24.000 nm.
Kim loi nng:
Ch xut hin trong thc phm c th qua rau qu v tron g sp c nu vi xng
hoc cc ngun b sung canxi c ch t xng, hoc qua nc ngm v nc
vi. c tnh ca ch c nhiu trong c gy ch Om pht trin th cht v tinh
thn.
Thu ngn: C o tng y bin gn ni nhim c th b nhim thu ng n. Nhng
ngi n phi thc n ny c th b m, lit, v ch Om pht trin, c bit o tr em

17

Bi ging Chng c

Ng c ru
(Bi ging cho nhn vin y t c s)
BS V Th Hng
BS ng Quc Tun
B mn Hi sc cp cu
Trng i hc Y khoa H ni

1. i cng
1.1. Ru ung (Ethanol) l cht c tc dng c ch thn kinh trung ng, sau k hi ung
nng ru tng dn trong mu. Tc ng ca ru thay i ty tng ngi v lng
ru ung. Khi ung nhiu ru, biu hin say r trc ht l tnh trng kch thch,
ri lon hnh vi, tc phong, sau bnh nhn i vo tnh trng c ch, li b. Khi nng
ru trong mu cao qu bnh nhn s b ng c ru.
1.2. Ru methanol c s dng trong cng nghip, c th gy cc tn thng nng
thm ch t vong.
1.3. Mt s loi ru lu hnh trn th trng cn c th cha nhiu cht gy nguy hi m
khc nh aldehyt, thm ch cn c thuc su.
2. Du hiu lm sng
Bi ny ch m t ng c ru thc s, l ng c alcool ethylic (ethanol).
+ Hn m : gi hi khng p ng, hoc p ng khi gi ri li nm yn
Giai on sm : th su, mt t, mch p mnh
Giai on mun : th nhanh nng, mt kh, mch nhanh yu, huyt p tt,
ng t gin.
+ Nn. C th sc cht nn vo phi gy ra suy h hp : kh th, th nhanh, tm
mi, th kh kh, lc sc.
+ H ng mu : thng kh pht hin trn lm sng, v cc du hiu ca h
ng mu b hn m do ru che lp. Nu nng c th c co git.
+ H thn nhit : c th nh hng n thn kinh trung ng, c bit l v ma
lnh.
+ Cn ch l mt ngi say ru c th b ng, v c cc tn thng do ng
(chn thng, sc nc, sc bn,...)
3. X tr
3.1. Say ru
1

Sangs Chng c
Cha phi l ng c ru : bnh nhn khng c hn m, gi vn bit, tr li
c, khng c ri lon nhp th.
+ Theo di tht tt, nu i vo hn m phi a i bnh vin ngay.
+ Cho nm nghing an ton trnh tro ngc cht nn vo phi.
+ m, trnh ch c gi la.
+ Cho ung nc ng nu cn tnh.
+ Nu cn tnh, i li c : khng cho iu khin cc phng tin giao thng,
khng cho i mt mnh. Th nhanh, mnh, ni nhiu c th lm cho tnh ru nhanh hn.
3.2. Ng c ru
Khi nghi ng, hoc xc nh mt ngi l ng c ru cn phi chuyn tht sm
n bnh vin.
Vn chuyn : phi cho bnh nhn nm t th nghing an ton trnh bnh nhn
ht phi cht nn vo phi gy suy h hp nng.
Nu c th c :
- Truyn cho bnh nhn dung dch ng Glucoza.
- Tim bp 1 ng vitamin B1.
Vic iu tr bnh nhn ng c ru bnh vin bao gm : cho th my, truyn
dung dch ng u trng, b nc v in g ii, ra d dy v cho than hot. Nu bnh
vin khng thc hin c cc k thut trn th phi s cu ri chuyn ngay n tuyn
chuyn khoa.

Bi ging Chng c

Ng c cp quinine
Quinine l mt alkaloid ca v cy canh -ki-na. N l ng phn t tuyn ca quinidine.
Ngy nay, Quinine ch c dng iu tr st rt khi k sinh trng khng v cc
thuc khc.
1. Chn on:
1.1. Chn on dng tnh;
a. Lm sng:
Hi bnh : ang iu tr st rt bng quinine, hoc c mun ph thai, hoc c l
do t t, c v thuc hoc thuc ri vi.
Triu chng: tai, hoa mt, chng mt, nn ma, ri lon thc, gim hoc mt
th lc, ic mt phn hoc hon ton, nng th d a tm, lnh, h thn nhit, i ra
huyt sc t, lon nhp tim, tt huyt p, hn m, cht do ngng th sau vi gi
n vi ngy.
b. Cn lm sng:
Xt nghim tm quinine trong nc tiu ng vai tr quyt nh
in tim: QT ko di, T dt hoc o ngc, QR S dn rng, blc nh tht cp 1,
khong PR ko di.
1.2.Chn on phn bit:
Vi ng c quinidine hoc chloroquine: triu chng tim mch nng hn, chn
on bng xt nghim c cht.
2. Nguyn nhn:
Ng c thng xy ra do qu liu iu tr st rt, do t t hoc do ung liu cao
vi mc ch ph thai.
3.Tin lng:
Liu iu tr v liu c ca Quinine rt gn nhau( liu iu tr: 1800 mg chia lm
3 ln trong khi liu gy t vong l 1800 mg n 8g). Mt khc, ngay vi liu iu tr cng
c th gy ra nhng ri lon dn truyn c tim. V vy trong qu trnh iu tr st rt bng
quinine cn theo di in tim pht hin kp thi cc ri lon in tim.
D phng: qun l thuc; gii quyt cc nguyn nhn dn n t t.

Bi ging Chng c
4. iu tr
1. Tuyn c s: Gy nn nu bnh nhn cha nn, cha ri lon thc.
Than hot: 1g/1kg cn nng ung km sorbitol 2g/kg cn nng (nu c).
Truyn dch: Glucose 5%, Natri clorua 0,9%.
Chuyn bnh nhn n khoa cp cu gn nht.
2. Tuyn Huyn:
- n nh cc chc nng sng: theo di cc du hiu sng(mch, huyt p, h hp,
in tim), th oxy, truyn dch glucose 5% v natri clorua 0,9%, natri bicarbonate
1,4%.
- nu c suy h hp: thng kh nhn to bng th my vi phng thc CMV, Vt
10 ml/ kg, tn s: 16-20ln/pht,
- Nu tt huyt p: Dopamin 200mg 1 ng, pha vo 500 ml glucose 5% truyn tnh
mch 15 git/ pht( khong 8 g/kg/pht), iu chnh tc truyn duy tr
huyt p mong mun ( huyt p tm thu > 90 mmHg )
- Theo di in tim, pht hin v x tr lon nhp. Truyn kim t c pH
mu t 7,45 n 7,50 c th ngn nga ri lon dn truyn nng ln v phng
c cc lon nhp gy t vong. Khng s dng cc thuc chng lon nhp nhm
1A v 1C...
- Hn ch hp thu c cht: gy nn nu khng ri lon thc, ra d dy 2 -3lit
nc(n khi nc trong).
Than hot 60g km sorbitol 120 g ho trong 100ml nc, ung chia lm 3 ln cch
nhau 1-2 gi 1 ln.
- Tng o thi c cht: Truyn nhiu dch(4 -5l/ngy) glucose 5% v natri clorua
0,9%, lasix 20mg tim tnh mch , duy tr lng nc tiu 4 -5 lt/ngy. Nu i t
hoc v niu cn nhc ch nh thn nhn to hoc lc mng bng.
-iu tr h tr: ch iu chnh cn bng nc in gii, dinh dng, chm sc
ton din.
Chuyn tuyn tnh nu suy h hp m khng c my th, suy thn m khng c
thn nhn to, hoc lon nhp phc tp m khng c my to nhp.
3. Tuyn tnh:
iu tr nh tuyn huyn, nu suy h hp cho th my, chy thn nhn to nu c
ch nh v t my to nhp nu c lon nhp ph c tp

Bi ging Chng c

Ng c cp phospho hu c
I. cng
Thuc tr su phospho hu c (PPHC) l mt trong hai loi thuc tr su thuc nhm
c ch cholinesterse ang c s dng rng ri trong nng nghip. Cc ha cht tr
su nhm clo hu c c hn nh DDT b cm hoc hn ch s dng. Do b thy
phn nhanh thnh cc hp cht v hi v khng tch t cht c lu di trong mi
trng nn PPHC ngy cng c s dng rng ri trong nng nghip(tr su) cng
nh trong nh( tr gin,mui...).Cng v s dng rng ri nh vy nn ng c cp
phospho hu c (NC PPHC) l mt bnh cnh cp cu rt thng gp, chim khong
80% trng hp ng c cp thuc tr su phi vo vin.
Phospho hu c (Organophosphate - O.P) l cc hp cht bao gm carbon v gc
ca axt phosphoric.Cht u tin c s dng dit cn trng l Tetraetyl
pyrophosphate (TEPP). Ngy nay c hng ngn hp cht phospho hu c ra i nhng
vn trn c s mt cng thc ho hc chung:
C2H5O hoc CH3O

O ( hoc S )

P
C2H5O hoc CH3O

O
R

II. Chuyn ha:

Cc hp cht phospho hu c c hp th rt tt qua ng da v nim mc, ng
tiu ha v ng h hp. Nguyn nhn nhim c c th l s dng khng ng
trong nng nghip, tai nn, t t, v him khi l b u c. T t thng dn n
nhng nhim c nng nht, sau l tai nn trong nng nghip v cng nghip, ri
n tr em nhim c ti nh.C th gp ng c hng lot do thc phm nhim
c.Cc du hiu v triu chng nhim c rt thay i ty theo ng nhim v mc
nhim c; tuy nhin khong thi gian t lc b nhim n lc xy ra triu chng
thng di 12 gi. Nhim c kh dn n triu chng xy ra trong vng vi giy.
Nhng cng cn bit rng mt s ha cht mi nh diclofenthion v fenthion ha tan
trong m nhiu hn nn c th gy ra cng cholinecgic mun (sau vi ngy) v triu
chng c th tn ti vi tun n hng thng. Hin tng ny c th l do thuc tr su
lc u c gi li trong cc m m v sau c ti phn b vo mu. Ngoi ra,
ng c ng ung nu khng c ty ra ng tiu ha tt v khng c dng

Bi ging Chng c
than hot th thuc tr su ng trong rut s tip tc c hp thu vo mu trong
nhng ngy sau v ko di qu trnh bnh l.
Phospho hu c c chuyn ha v kh c gan bi cc enzyme mono oxygenase.Tuy nhin, mt s phospho hu c nh parathion v malathion khi chuyn
thnh oxon li c c tnh mnh hn cht m nhiu ln.
III. C ch tc dng v c tnh
Acetylcholin l cht trung gian ho hc ti cc synapes thn kinh trc hch ca h
thn kinh t ng ( bao gm c giao cm v ph giao cm) , cng nh ti cc synapes
hu hch ca thn kinh ph giao cm v dy thn kinh giao cm chi ph i cc tuyn
m hi, cc cc tn cng ca cc dy thn kinh vn ng chi phi cc c vn, cc
im ni t bo thn kinh trong no. Sau khi tc ng ln cc receptor c hiu
mng t bo hu synap, Acetylcholin s b thu phn bi acetylcholinesterse( AChE).
Phospho hu c khi vo c th s gn vi AChE dn n phosphoryl ho v lm
mt hot tnh ca ChE. Hu qu l s tch t Acetylcholin ti cc synap thn kinh.S
tch t ny gy ln s kch thch lin tc qu mc cc receptor hu synap(lc
u),sau l giai on kit synap c h thn kinh trung ng v thn kinh ngoi
bin. S kch thch dn ti hi chng cng cholin cp v s kit synap dn n
nhng thay i biu hin ra ngoi thnh cc triu chng bnh cnh NC PPHC. C
hai loi receptor chu tc ng ca acetylcholin: muscarin( hu hch ph giao
cm)v nicotin ( hch thn kinh thc vt v cc im ni thn kinh c vn -cc bn
vn ng). V vy cc triu chng lm sng rt phc tp v tp trung thnh cc hi
chng bnh l khc nhau.
c tnh : liu gy cht cho ngi ln khc nhau ty hp cht : 25g i vi
diadinon,60g vi malathion trong khi ch t 10 n 300mg vi parathion. LD50
ca cc OP cc c thay i t 1,3 mg/kg(Tebupirimfos), 7mg/kg(Phosphamidon v
chlomephos) n 15mg vi Fenamiphos, 13mg/kg vi Parathion. Mt s loi PPHC
c c tnh cao thng gp Vit nam l: Methamidophos(Monitor) - LD50 = 30
mg/kg, Methidathion- LD50 = 25 mg/kg, Monocrotophos - LD50 = 14mg/kg...
IV. Triu chng ng c cp:
Cc triu chng ca ng c phospho hu c t nh n nng bao gm mt ng v ri
lon nh hng, au u, chng mt nhn m, yu c, mt ng vn, my c, run c,

Bi ging Chng c
lit c, a chy, au bng, chn ngc, th rt v ho c m. Co git, ri lon thc, a
i khng t ch, hn m su v try mch l cc biu hin ca tnh trng nhim c
nng. Cc du hiu v triu chng ca ng c phospho hu c s y v d hiu
d nh hn khi xp chng vo cc hi chng:
Hi chng cng cholin cp :
Bao gm trong 3 hi chng thnh phn: hi chng muscarin, hi chng nicotin v hi
chng thn kinh trung ng.
1.Hi chng Muscarin: do tc ng ca acetylcholin kch thch hu hch ph giao
cm, tc dng ch yu ln cc c trn gy co tht rut, ph qun, v c trn bng
quang, co ng t v gim phn x ng t /nh sng, kch thch cc tuyn ngoi tit:
tng tit nc bt, dch rut, m hi, nc mt, dch ph qun... Bnh nhn b tc
ngc, cm gic chn ngc, kh th, au bng, bun nn, nn, a chy, a i khng t
ch. Khm thy tnh trng suy h hp, lng ngc cng km di ng, phi nghe r ro
ph nang gim, c nhiu ran m, i khi c ran rt. Trn tim mch c th thy nhp
chm xoang, gim dn truyn nh tht, ri lon nhp tht.
2.Hi chng Nicotin: do s tch t ca acetylcholin cc bn vn ng dn n ri
lon s kh cc ca cc c vn gy git c, my c, co cng c, lit c bao gm c cc
c h hp; kch thch h thn kinh giao cm gy ra: da lnh, xanh ti (do co mch),
mch nhanh, huyt p tng, v m hi, dn ng t.
3.Hi chng thn kinh trung ng :
Lo lng, bn chn, ri lon thc, ni kh, tht iu, nhc c ton thn, hn
m mt cc phn x.
Ng c nng: c ch trung tm h hpv tun hon dn n suy h hp ,try
mch, co git, hn m su.
Hi chng Muscarin vi biu hin chnh l co tht v tng tit ph qun l hi chng
xy ra sm nht v tt c bnh nhn NC PPHC. Cc hi chng Nicotin (vi lit c )
v hi chng TKTW thng ch gp trong cc trng hp nhim c nng.
Hi chng trung gian :
L hi chng lit c type II do tc gi ngi Srilanca t tn nm 1987 vi cc c
im sau:Bt u t 24-96 h sau nhim c, khi cc triu chng cng cholin c
gii quyt. H/c bao gm: lit cc c gc chi, c gp c, cc c h hp v cc c do cc

Bi ging Chng c
dy thn kinh s chi phi, lit mm, gim phn x gn xng. Lit khng p ng vi
iu tr atropin v PAM, i hi thng kh nhn to khi c suy h hp. Hi chng ny
c th chnh l hu qa ca s kch thch qu mc ko di cc receptor nicotin dn
n pha " kit"ca h/c nicotin trong khi iu tr tt h/c muscarin bng atropin.
Hi chng bnh l thn kinh ngoi vi mun :
Xy ra 8-14 ngy hay mun hn sau NC PPHC. Bnh cnh bao gm: yu c, lit c,
chng mt mi, chut rt, km vi cc ri lon cm gic ki u t b kin b , thng
bt u u chi, c th tin trin n lit ton thn v cc c h hp gy suy h hp
v t vong. Bnh thoi trin sau vi thng n vi nm, teo c nhiu, phc hi chm v
khng hon ton. C ch sinh bnh l do cht cc si tr c thn kinh. Hi chng ny
rt him xy ra.
Tin trin:
Trong NC PPHC, hi chng cng cholin xy ra rt sm nhn chung thng l
trc 12 gi sau nhim c, c th vi giy sau nhim ng h hp, vi pht n vi
gi sau nhim c ng tiu ha; nhi m c ng da mc nh c th n mun
hn. Trong hi chng cng cholin th hi chng muscarin thng n sm nht v
l hi chng trung thnh nht, ngha l lun lun xy ra. Hi chng nicotin v hi
chng thn kinh trung ng thng ch xy ra khi nhim c trung bnh hoc nng.
T vong thng xy ra sm trong ngy u tin nhng cng c th xy ra trong
nhng ngy sau. Khong 50% t vong c nguyn nhn trc tip l suy h hp. C
nhiu nguyn nhn dn n suy h hp: tng tit v co tht ph qun, lit c h hp,
c ch trung tm h hp, bi nhim phi trong nguyn nhn co tht v tng tit
ph qun chim hng u nhng li c th khc phc c nhanh chng vi liu
atropin thch hp.
Hi chng cng cholin c th tn ti hng tun hoc lu hn . Vi iu tr liu PAM
thch hp hi chng ny s rt ngn thi gian tn ti trong vng vi ngy(1 -4 ngy).
Hi chng trung gian xy ra vo ngy th 2 -6 sau nhim c, khng p ng vi
PAM v atropin, iu tr cn thit duy nht l th my nu lit c dn n suy h hp.
Thng khng c t vong nu c bo m h hp v hi phc hon ton sau 1 -2
tun.
Xt nghim:

Bi ging Chng c
Tm c cht trong nc tiu, trong dch d dy, trong mu bng phng php
sc k lp mng v sc k kh.
XN enzymcholinesteraza hng ngy theo di tin trin ca bnh, phn loi
nng lm cn c iu chnh liu PAM dng cho bnh nhn. C hai loi
enzym cholinesterase: acetyl cholinesterase ( cholinesterase hng cu) , Butyryl
cholinesterase (cholinesterase huyt tng).

Acetyl cholinesterase c trong

hng cu, t chc thn kinh, phi, lch v cht xm ca no; c nhiu tc
gi cho rng phn nh trung thc mc ng c hn; nhng tc phc hi
chm (2-3 thng); k thut xt nghim cng c nhng kh khn nht nh lm
cho kh p dng lm sng.
o Cholinesterase huyt tng (butyro choliesterase) c trong huyt
tng, do gan sn xut, nhng cng tm thy t chc thn kinh, ty,
tim v cht trng ca no. Thay i hng ngy ln, v b nh hng bi
bnh gan, vim mn, suy dinh dng, mocphin, codein, succinylcholin
v phn ng qu mn. Gim nhanh trong nhim c cp v phc hi
khong 10% -20% mi ngy khi bnh nhn c iu tr Pralidoxime
(PAM) y . c im ny cng vi k thut xt nghim n gin
hn cholinesterase hng cu n n c dng theo di tin trin trong
qu trnh iu tr v l c s iu chnh liu PAM.
in tim: ghi in tim v theo di trn monitor pht hin ri lon nhp.
Cc xt nghim khc : cng thc mu - ur - in gii mu Transaminase

mu,

Amylase mu, protin niu t bo niu.

chn on
* Chn on xc nh ng c cp PPHC :
Bnh s tip xc thuc tr su trong vng 12 gi trc khi vo vin
Hi chng cng cholin cp(+)
Xt nghim ChE :gim <50% gi tr bnh thng (gi tr trc nhim),
thc t c thay bng gi tr ti thiu ca hng s sinh hc
Xt nghim c cht nc tiu hoc trong mu, dch d dy (+)
Chn on mc nng nh theo cc hi chng bnh l lm sng :
NC PPHC nh

: Khi ch c h/c Muscarin ( M )

NC PPHC trung bnh : Khi c h/c M+h/c Nicotin ( N )

hoc M+ TKTW

Bi ging Chng c
NC PPHC nng

: Khi c h/c M+h/c N+ri lon thc

NC PPHC nguy kch : Khi c 3 h /c trn cng vi suy h hp cp

(PaO2 < 60 mmHg

PaCO2 > 40mmHg) v / hoc tru mch.

Chn on mc nng nh theo gi tr nng ChE huyt tng :

NC PPHC nng khi nng ChE < 10% gi tr bnh thng, trung bnh khi ChE =
10 - 20%, nh khi ChE = 20 -50% gi tr bnh thng. Tuy nhin v thng khng c
c gi tr bnh thng nn c th s dng gi tr bnh thng ti thiu ca hng s
sinh hc.
iu tr :
1. Cp cu:
Nu bnh nhn n sm , cha c triu chng: u tin cc bin php chng c : Ra
d dy, tm ra, gi u..., P
Nu n mun, c triu chng ng c hoc bin chng: u tin hng u l s
dng atropin (xem phn s dng atropin)v cc bin php hi sc h hp, tun
hon(xem phn hi sc).
2. Hi sc:
-Hi sc h hp l quan trng hng u v phi song song vi vic dng atro pin, v
nguyn nhn chnh gy t vong l suy h hp. Tu tnh trng suy h hp m p dng
cc bin php hi sc h hp.Ti thiu nht cng phi cho bnh nhn th oxy qua
sonde mi. Nu cn th t ni kh qun ht m v bp bng hoc th my bo
m thng kh.
-Hi sc tun hon: - truyn dch bo m khi lng tun hon: bnh nhn ng c
PPHC d b mt nc do nn, a chy, khng c n ung trong qu trnh iu tr
...Ng c atropin cng gy nng thm tnh trng mt nc. Nu c tt huyt p t h
nn t catheter tnh mch trung tm truyn dch theo p lc tnh mch trung tm.
Nu truyn dch m vn tt huyt p th mi cho dopamin 5 -10 Mg/kg/pht.
-Cc bin php hi sc tng hp: trong cn ch ti dinh dng cho bnh nhn.
Cn bo m nng lng 2000 Kcalo tr ln. Trong 24 gi u c th dinh dng n
thun bng ng truyn tnh mch v phi cho bnh nhn ung than hot v thuc
ty.King m v sa trong vng 1tun n 10 ngy trnh tng hp th phospho hu
c tan trong m.

Bi ging Chng c
3.Cc bin php chng c c hiu:
3.1 Hn ch hp thu: Ra d dy l bin php gim hp thu hiu qu khi ng c
PPHC ng ung.Nc ra d dy phi c pha 5 -9 g mui n cho mi lt Vi than
hot pha vo 2-3 lt nc ra u tin, lng nc ra d d y ch cn khong 10lt tr
xung. C th cn ra li ln 2 sau khi trng thi bnh nhn n nh.
Nu nhim c ng h hp: nhanh chng a bnh nhn ra khi vng c kh c
n ni thong mt.Ci b qun o nhim c. Nu cn c th thng kh nhn t o
tng thng kh.
Nhim c qua da: tm ra v gi u cho bnh nhn bng x phng.
3.2.Thuc gii c c hiu :
Atropin l thuc i khng tc dng Muscarin v tc dng ln h thn kinh trung
ng ca O.P. N lm gim cc tnh trng: tng tit ph qun, nc bt, m hi, lm
mt au bng, bun nn, nhp chm v cm gic chn ngc, lm gin ng t. Atropin
khng c tc dng trn lit c v suy h hp bnh nhn ng c nng.
Mc ch s dng Atropin l to ra mt tnh trng thm Atropin nhm xo h t cc
triu chng ca h/c Muscarin song ch yu l lm tit v ht co tht ph qun. Gin
ng t, mch nhanh, da hng m c s dng nh nhng yu t tham kho ca tnh
trng ngm thuc hn l mc ch iu tr. V cng cn nh rng mch nhanh, gin
ng t c th l triu chng ca hi chng nicotin. ng dng Atropin thng l
tim tnh mch chm, liu thp c th tim di da v liu cao c th c truyn tnh
mch lin tc.
Liu lng Atropin rt thay i t vi chc mg ti 20g trong c t i u tr, ph
thuc liu O.P v p ng ca bnh nhn vi Atropin . : bt u bng tim 2-5 mg tnh
mch nhc li sau 5, 10 pht mi ln n khi t c tnh trng thm Atropin. Tm
dng cho n khi ht du thm th tnh thi gian v liu atropin dng t suy ra
liu cn thit duy tr du thm.
V thi gian: tnh trng thm Atropin phi c duy tr cho n khi tt c O.P hp
th c chuyn ho ht thng t vi ngy n hng tun. Gim liu dn theo
nguyn tc dng liu thp nht duy tr c du thm . Ngng atropin khi liu duy
tr gim ti 2mg/24 gi.
Tc dng ph ca Atropin: Qu liu Atropin gy st, da nng, th rt, kch thch
(sng nh), ng t gin v mt phn x, kh cht tit gy tc m.
Ng c Atropin a li nhiu nguy hi m :

Bi ging Chng c
+ Lm bnh nhn ri lon thc, gi lit c lm nhm vi triu chng NC PPHC
nng ln.
+ Lm kh qunh m dn n tc m, xp phi gy suy h hp .
+ Tng nhp tim, tng nhu cu oxy c tim dn n nguy c lon nhp, tru mch.
+ Lit rut gy chng bng cn tr h hp lm nng thm SHH.
Tt c lm cho tnh trng bnh nhn nng ln v li c chn on l NC PPHC
nng do tng liu Atropin v PAM v c th dn n lon nhp, ngng tim do ng
c Atropin .
trnh ng c atropin c t h p dng bng im atropin theo di phn bit gia
ng c v thm atropin nh sau:
Triu chng

Thm atropin

im

Ng c atropin

im

Co tht v tng tit

khng nhng cn

m kh c khng ht

ph qun

m long

ng t

3-4 mm

> =5 mm

Da

hng m

nng

Mch

80 - 100

.> 100

tinh thn

tnh bnh thng

kch thch hoc li b

bng

mm bnh thng

chng hi, g trong

Cu bng quang

khng

Cng tng s im; Thm atropin: 4 -6 im; Ng c atropin: > 6 i m

Pralidoxime l mt thuc gii c c hiu theo c ch trung ho c cht.
T nm 1951 Wilson (tc gi ngi M) cho rng cholinesteraes b c ch c kh
nng c ti hot nh cc hp cht c kh nng nucleophile cao. Ngy nay tng
hp c mt s hp cht nh Oximes hoc acide hydroxamine. Trong s chng 2 PAM (2 pyridine aldoxime methyl iodure hoc clorua) ( dn cht ca Pralidoxime
)c nhiu tc gi a dng
PAM s gn vng bn vi PPHC, gn lng lo vi ChE to thnh phc hp b
3, sau enzym tch ra li phn phosphoryl -oxime s tip tc thu phn
cho cc sn phm thoi ho ca PPHC v axit phosphoric .Nh vy PAM
kh phosphoryl v ti hot ho ChE.
PAM cn tc dng phng c bng cch gn vo v kh c cc phn t PPHC
cn li trong mu.

Bi ging Chng c
Hu ht cc tc gi u cho rng Pralidoxime l thuc c hiu cn c s dng
trong iu tr NC PPHC .Tuy nhin cch s dng v liu lng c khc nhau:
Namba v CS 1971, Borowitz 1988, de Kort v CS 1988 : PAM c th hiu qu hn
khi oc dng trong 24-48h u, song n vn c hiu qu 2 -6 ngy sau nhim c ,
nht l nhng bnh nhn nhim c nng .
Mt s tc gi tim TM 1g trong 10 pht, nhc li mi 6 -8h trong 24-48h. Mt s
dng liu 1-2g tim TM hoc truyn TM vi 250ml NaCl 0.9% tr ong 30 pht, nhc
li sau 1h v sau 6-12 h nu vn c lit c v hn m .
Thompson cho rng truyn TM lin tc 500mg/h tt hn l tim TM .
Farrar 1990 truyn duy tr 9 -19mg/kg/h ngay sau liu u 25 -50mg/kg pha trong
dung dch NaCl 0.9%.
Thi gian dng: nhiu tc gi cho l phi dng sm v PAM ch c hiu qu trong 24 48h u sau nhim c.
Tuy nhin mt s khc li cho rng cn phi dng ko di v:
Mt s thuc tr su (parathion) gy s gi ho chm (slow aging) ca ChE
Khi ung mt liu ln th PPHC ng trong rut cn c hp thu dn
trong nhng ngy sau
Mt s OP tan trong m nhiu --> gii phng dn trong nhng ngy sau.
Wadia v Amin cho rng c th cn truyn PAM trong 4 -6 ngy v ti 22 ngy c
bit l cc trng hp nh im O.P tan nhiu trong m nh Fenthion.
Thomson (1987): Truyn TM 0,5g/h duy tr c nng > 4mg/L trong huyt tng,
l nng c coi l ti thiu c tc dng bo v chng li c tnh ca O.P. Nng
Pralidoxime gim xung nhanh chng <4mg/L tr ong vng 1,5-2h sau tim TM
1g bolus.
Ti A9, t 1996 p dng 1 phc s dng PAM liu cao thch hp trong PAM
c chnh liu theo nng ChE v cc h/c lm sng. phc em li hiu qu
cao: gim t l t vong ca ng c PPHC t 10% (1995 ) xung cn 2%(19992000).Phc c trnh by di y.
Nguyn tc s dng PAM :
- Dng cng sm cng tt, liu cao ng lot ngay t u.
- Truyn TM lin tc.
- Liu dng, thi gian s dng s c iu chnh theo p ng ca tng
bnh nhn: triu chng lm sng, liu atrropin, s thay i hot tnh ChE.
- Gim liu khi kim sot c h/c cng cholin
phc s dng PAM

Bi ging Chng c
* Ngay khi c chn on xc nh v phn loi lm sng :
+ Nng ( v nguy kch ) : Tim TM 1g trong 10 pht ri truyn TM
0.5-1g/h cho n khi thm Atropin hoc c kt qu ChE
+ Trung bnh : Tim TM 1g trong 10 pht ri truyn tnh mch 0,5g/h
cho n khi thm Atropin hoc c kt qu ChE
+ Nh : Tim TM 0,5g trong 5 pht ri truyn TM hoc tim TM 0,5g/2h
* iu chnh PAM theo kt qu ChE hoc theo liu lng Atropin nh di y:
(ly kt qu ChE lm cn c chnh).
+ Nu Atropin > 5mg/h v/hoc ChE < 10% gi tr bnh thng ti thiu ( gtbt tt):
tip tc truyn 0,5g/h
+ Nu Atropin 2-5 mg/h v/hoc ChE 10-20% gtbt tt tip tc truyn 0,5g/mi 2h
+ Nu Atropin 0,5-2mg v/hoc ChE = 20-50 tip tc truyn 0,5g/mi 4h
+ Ngng PAM khi Atropin < 4 mg/ 24h v ChE > 50%
Chn an qu liu PAM khi:

ang truyn vi tc >= 0,5g/h

Thm Atropin tt vi liu Atropin t hp.

Xut hin lit c ( mi ) hoc lit nng thm.

Tng huyt p hoc tru mch.

ChE ang c khuynh hng tng li gim.

c tnh ca PAM :
- PAM c t c tnh, liu 40,5g trong 7 ngy hay 26g trong 54h c dng m
khng c tc dng ph xy ra (Namba v CS 1971).
- Tim nhanh qu 500mg/1pht c th gy ra nhp nhanh, co tht ph qun, tru mch,
nhn m, chng mt, au u, nn, cng c v lit c thong qua .
-

nng cao PAM c th c ch hot tnh ChE (th nghim trn ng vt). Tuy
nhin, tc dng ph ny trong nhng liu iu tr rt t hoc khng gp ngi.
Nhng nghin cu ngi cho thy PAM c mt ch s iu tr cao. Nhng liu
ln ( truyn TM lin tc 0,5g/gi) dng cho nhng ngi tnh nguyn trong thi k
di khng thy gy c.

10

Bi ging Chng c

Ng c ma ty nhm Opioid
I. i cng
Ma ty l mt vn nhc nhi ca xh trong nhiu nm qua.
Ma ty th/dng l pi, trong ph/bin nht l morphin v heroin. D
Cc kh/nim c bn
-

Opiat: Cc cht ng/gc t nha cy th/phin ( opium poppy).

Opioid: Cc hp cht m tt c cc t/dng tr/tip u b Naloxone i khng.

Bng 1: So snh cc thuc gim au gy ng thng dng

Liu v ng dng

t/2 (gi)

TD (gi)

=10mg MSO 4

2-10mg,TB/TM
60mg, ung

1,5 2

4-5

60mg, ung

2,9

4-6

120 mg

3mg, TB/TM

1,5 2

3-4

3 mg

65-100mg, U

3,5

2-4

240mg

5mg, ung

12-14

6-8

240mg

0,05mg, TB/TM

2-4

50-60ph TM
1-2 gi TB

0,125mg

Meperidine

50-100mg, TB/TM

3,5

2-4

80-100mg

Methadone

5-15mg, TB/TM

15

36-48

80-100mg

2-3

Thuc
T nhin:
MSO4
Codein (Methylmorphine)
Bn tng hp:
Heroin (Diacetylmorphine)
Tng hp:
Propoxyphene
Diphenoxylate
Fentanyl

Kch thchc ch
Pentazocine

30mg, TB/TM
50mg, ung

Nghin opioid l hin tng phi lin tc tng liu t c cng mt p ng sinh l.
Nu t ngt ngng dng opiat, lng enkephalin ni sinh khng gy kch thch thn kinh,
tnh trng kch ng vi cc triu chng thiu thuc.
II. Biu hin lm sng
C th sau chch, ht, ht hoc do ng qua da.
Do i dng thuc sang ngi bn khc.
Do tng liu t khoi cm.

Bi ging Chng c
Do t st hoc b mu hi.
Tr em c th b tai nn
Nhng ngi khng nghin ma ty c th ng c ng ung do c tnh (t t) hoc do
tai nn iu tr.
1. c ch thn kinh trung ng
-

L mt trong 3 tiu chun ca ng c opiat.

Him gp co git do qu liu opioid tinh ch ngoi tr tr em hoc ng c propoxyphene

v meperidine.

Trng lc c thng khng thay i nhng c th tng nu do qu liu meperidine hay

fentanyl.

2. ng t co nh
-

L du hiu lm sng kinh in th hai

3. c ch h hp c th gy t vong
-

L c im th ba ca ng c opioid.

Th nhanh nng c th thy bnh nhn ph phi cp tn thng

Do tc dng c ch TKTW ca opioid, phi xt chn on vim phi do sc

4. Tc dng trn h tim mch

- Sc, try tim mch: bnh nhn ng c heroin do tim chch c th vo vin trong tnh
trng sc. Sc c th l do suy tim ton b cp, hoc do tim c cht vo tun hon (hi chng
sc do c t - toxic shock syndrome).
Cc bin chng tim mch khc l lon nhp chm v lon n hp nhanh do quinine, rung nh
kch pht, QT ko di, vim ni tm mc, ngng tim do tng kali mu, tm trng ko di, phnh
mch dng nm.
5. Cc tc dng trn h tiu ha
Bun nn v nn; dng cc liu tip theo li c tc dng c ch vng ny v sau r t kh
gy nn.

Bi ging Chng c
Nhu ng rut gim trong khi trng lc cc c tht tng dn n hp thu thuc rt chm v
lm cho thi tr thuc qua ng tiu ha c th chm ti 27 gi sau khi ung.
6. Cc bin chng khc ca NC opioid
Tiu c vn, h ng mu, tng t hn nhit...
III. Xt nghim
Nng heroin trong mu khng c gi tr nhiu v lm sng nhng c th pht hin c
trong vng 36 gi. 6-MAM c thi gian bn thi trong mu ngn (38 pht) nhng c th pht hin
trong nc tiu bng phng sc k v l bng chng s dng heroin.
iu tr
1. Hi sc tim mch:
Dng vn mch cho cc bnh nhn tt HA. Theo di st tng gnh th tch, ch nh gi
lng dch vo v ra. Sau khi bnh nhn n nh c th chp phim X quang ngc.
2. Hi sc h hp:
t NKQ nu c ch nh. Naloxone TM 0,8 -1,2mg, tim li cch mi 5 pht cho ti khi
bnh nhn tnh, th li tt. Tt HA iu tr bng vn mch. Khng truyn nhiu dch bnh nhn
ph phi. Nu tnh trng bnh nhn n nh chp X quang phi v lm kh mu theo di. Theo
di lin tc in tim. Dng xy v c th phi th PEEP. Digitalis v li tiu khng c nhiu tc
dng v l ph phi cp tn thng.
3. Naloxone
Naloxone l cht gii c c hiu c tc dng c ch c 4 loi receptor pi (mu, kappa,
sigma, delta). Nhanh chng dng naloxone thng cu c bnh nhn ng c pi.
Liu dng
1) Liu thng c hiu qu trong iu tr cp cu l 1 n 5 ng (0,4 -2mg) tnh mch. nh
gi im Glasgow hoc thang im hn m khc. Nu khng c tc dng, dng thm 1
liu 2mg tnh mch (dng cch 2-3 pht cho ti tng liu 10mg). Nu c p ng 1 phn,
tim TM cch 15 pht cho ti khi bnh nhn tnh, th c hoc khng c ci thin thm.
Nu c p ng, bt u truyn tnh mch naloxone.

Bi ging Chng c
2) Phc liu truyn tnh mch lin tc h i phc tc dng gim au gy ng c
Goldfrank v cng s xut. Truyn tnh mch 4 mg naloxone/lt vi tc 400 g/gi
(0,4mg/gi). ngi ln, dng 4 mg/1000m l Glucose 5% truyn 100 ml/gi

Phc iu tr cp cu
ng c cp pi
Hn m
Th chm, ngng th, SHH cp
ng t co nh
Tt HA
Vt tim chch
Bp bng xy 100%
Naloxone 0,4 mg tnh mch

Bn tnh, t th c:
-Theo di
-naloxone
0,4 mg mi 20-60 pht
theo lm sng
- xy 4 l/ph
-Truyn dch g5%,
nacl 0,9%, m bo
HA

Bn khng tnh v/hoc th <10 ln/pht

Sau 3 pht:
- naloxone 0,4 mg tm 2-3 pht/ln
- tng liu 2 mg (5 ln)

p ng 1 phn:
-bp bng
hoc th
myliu
qua mt
Qu
ma n
tu
-truyn dch: g5%,
nacl0,9%
-naloxone 0,4 mg tm/30
pht.

Khng p ng
-t nkq
-th my
ippv Peep

Bi ging Chng c

Ng c kh CO
BS. B Hng Thu
Khoa chng c :BV Bch Mai

I.i cng v CO
1. T l mc:

Ng c cp CO rt thng gp Php (10000 cas/nm, 500 ngi cht) v rt

thng gp ng c nhiu ngi tr ong mt gia nh.

Ng c cp CO l nguyn nhn gy t vong hng u ti M ( 5613 trng hp

trong nm 1979 1988 ).

T l di chng: 10.000 ngi phi mt t nht mt ngy ngh. Di chng 4 40 %

bnh nhn xut vin.
2. c im l ho:
CO l mt cht kh khng mu,khng mi,khng v, khuch tn mnh,khng gy kch
thch.
CO c t trng gn bng t trng khng kh ( 0,968 )
Trng lng phn t: 28,01 Dalton.
3. Ngun CO:
CO l sn phm chy khng hon ton ca cc cht c cha carbon: nh khi ca c c v
ng t, nhim khi cng nghip, cht kh ng lu hm l, tng hm, khi thuc l,
khi cc l si, ..
4. C ch ng c CO
Khi vo c th: CO c nh vo Hemoglobine (Hb) 85%, n c i lc gn vi Hb cao gp
200 250 n so vi xy. Mt ph n cn li kh CO ho tan vo plasma v c nh vo
myoglobine v vo cc cytocrome.
T l HbCO ( Carboxyhemoglobine ) c hnh thnh ph thuc vo lng HbCO ban
u ( c bit ngi ht thuc ), vo thi gian nhim, lng kh CO v thng kh ca
bnh nhn.
T l HbCO: + Ngi khng ht thuc l: 1 2%
+ Ht thuc l: 5 10 %
+ Nng c: > 10%z
Ng c oxyt carbon gy thiu oxy t bo do lm gim t l HbO2, lm gim gii phng
oxy t HbO 2, lm gim s dng oxy ca t bo.
CO c th thm qua hng ro rau thai v c nh vo Hb ca thai nhi.
CO c o thi qua ng h hp di dng khng thay i. Thi gian bn thi l 4
gi. Khi thng kh vi oxy ng p th thi gian bn thi cn 80 pht v di oxy cao p
th thi gian bn thi cn 23 pht.
CO gy ra thiu oxy ch yu h thn kinh trung ng, i vi c tim v thai nhi trong
thi gian c mang. Tnh trng thiu oxy s nguy him c bit i vi ngi ln tui,
ngi thiu mu, suy h hp v suy tim.

Bi ging Chng c
5.Pht hin v nh lng:
Trong giai on ng c cp, HbCO c n h lng bng my quang ph k
(spectrophometri ).
Chn on xc nh ng c CO da vo t l HbCO > 10%. Nhng ngi ht thuc c t
l HbCO cao t 3 - 8%, thm ch n 15 % ngay sa u khi ht thuc. nhy ca HbCO
rt cao nhng c hiu thp.
nh lng CO cho kt qu ng tin cy, n c nh lng bng s hp ph tia cc tm,
kt qu c o bng mmol/100ml hoc ml/100ml. chuyn n v mmol% thnh
ml%, ta c cng thc sau:
CO ml% = mmol% x 2.24
bo ho HbCO c tnh theo cng thc sau:
HbCO% = T l ca CO ( ml% )/ 1,39 x nng Hb(g%)
Khi c kt qu phi ch n thi im ly mu so vi thi gian b ng c v thi
im ht thuc cui cng ngi ht thuc l trc khi b ng c.
Khi HbCO > 10% khng nh chn on ng c CO.
II. Triu chng ca ng c cp
1. Ng c cp c th gp trong cc m chy ln v gy t vong nhanh chng.
Khi u biu hin bng au u, mt m i, chng mt, bun nn, nhn m, ri lon hnh
vi km theo cm gic sng khoi, nng hn c th dn n hn m. Chn on da vo:
Hi bnh: hi bnh nhn v nhng ngi xung quanh: ng c thng xy ra vi
nhiu ngi sng trong cng mt nh, v c th c nhng du hiu nh t nhng ngy
trc nhng khng c pht hin. Nhng vt nui trong nh l nn nhn ca ng
c CO, c th b cht nh ch, mo. Cn hi trong nh c dng l si khng, bp
than, hoc sa cha tng hm? Mt hon cnh khc c th g y ng c nh l ht
khi ca ng c t, xe my (i khi l mt hnh thc t t).
nh lng CO hoc HbCO khi bnh nhn n bnh vin hoc sau khi th oxy th
t l HbCO v CO c th bnh thng.
Dng nng hoc hn m:
o
thng gp khi b nhim c lu hoc ngi gi b suy tim hoc suy h
hp. N thng gy tn thng no, c tim v h c.
Tn thng thn kinh trung ng :
c biu hin bng hn m tng trng lc c, thi gian v mc hn m rt thay i.
C cc du hiu ngoi thp.Mt s bnh nhn hn m c th hi phc nhanh chng,
mt s khc c ci thin thong qua v khng hon ton, tin trin nng ln tun
th 2 ( Hi chng khong - syndrome postinterval) dn n di chng thn kinh hoc
tm thn. C ch do tn thng cht trng c a no vng hi m theo kiu mt
myeline v c pht hin bng chp ct lp no. Di chng lm sng thng gp l
nhng vn ng bt thng, tng trng lc, tn thng h thn kinh cao cp, cm v
m v.
Tn thng c tim: ph thuc vo nhu cu oxy v c tim chim 75% lng oxy mu
lu hnh trong khi cc c quan khc ch chim 25% lng oxy.Tn thng c tim
c biu hin trn ECG bng thiu mu c tim, lon nhp ( chim 5 6 %) . Nhng
ri lon ch yu l ri lon ti cc, thay i ca sng T v o n ST . N c th gy ra
thiu mu di ni tm mc hoc thiu mu di thng tm mc, hoc on ST
2

Bi ging Chng c
chnh ln hoc chnh xung di ng ng in n thun. Nng hn biu hin
bng tru mch v ph phi cp. Ph phi cp l phi hp c ph phi cp tn thng
v ph phi huyt ng. nhng bnh nhn b bnh mch vnh trc c th gy ra
nhi mu c tim.
Tn thng c c biu hin di dng tiu c vn (rhabdomyolyse). C ch do p
vo mch mu v thn kinh. Nn tm mt cch h thng nhng du hiu ca tiu c
vn nh: c cng, tng th tch, mt mt hay nhiu mch ngoi vi. Xt nghim thy
CPK, transaminasse, amylase tng. i khi kh c th phn bit c l do thiu oxy,
do t th nm sau hn m hoc do ng c CO gy ra.
Bng 1. Triu chng theo nng CO
% CO trong
khng kh
35 ppm
50 - 100
100
100 - 200

Thi gian
tip xc
Khng x
Khng x
Khng x
Khng x

% COHb
3,5
5
10
10 - 20

200 -300

5-6

20 - 30

400- 600
700-1000
1100 - 1500
1600 - 3000
> 4000

4-5
3-4
1,5 - 3
1 - 1,5
Vi pht

30 - 40
40- 50
50 - 60
60- 70

Triu chng
Khng
au u nh, gim kh nng lm vic
au u nh, kh th khi gng sc nng
Kh th khi gng sc va, hi hp, au u vng
thi dng
au u nhiu, ngt, chng mt, nhn m, bun
nn v nn
Chng mt, tht iu, l ln, mt thc
L ln, tim nhanh, th nhanh, hn m, co git
Cheyne stokes, hn m, co git, shock, ngng th
Hn m co git, suy h hp, tru tim mch
T vong

Bng 2. Theo mc lm sng

Mc
Nh
Va

Nng

Triu chng
au u
Bun nn
Chng mt
au ngc
Kh tp chung
Nhn m
Kh th khi gng sc nh
au ngc
Hi hp
Mt nh hng

Du hiu
Nn
Mch nhanh
Th nhanh
Hoi t c
Tht iu
Co git
Hn m
Ri lon nhp tim
Tt HA
Thiu mu c tim
Phng da

Bi ging Chng c
2. Sinh ho:

Tng ng huyt

Tng bch cu, ch yu l bch cu a nhn trung tnh.

Toan h hp do ph phi. Toan chuyn ho do suy tun hon phi hp vi tiu c

vn c th gy ra suy thn cp.
Ngoi ra c th gp vim tu cp trong ng c nng.
3. Cc dng lm sng
Mt vi bnh nhn c biu hin ng c di cc dng khng thng gp ph thuc vo
cc triu chngs hoc c a hoc l tin trin.
Dng thn kinh- tm thn: Khi u i long chong, kh tp trung t tng, hnh ng
khng ph hp v ri lon th gic.

Tr em c th c pht hin bng co git. i khi ngi ln, khi u cng

biu hin bng co git.

Ngi gi: c th khi u bng tnh trng ln ln, i khi c du hiu thn kinh
khu tr lm nhm chn on.
ph n c thai: Khng c s tn ti song song gia mc nng ca m vi mc
nng ca thai nhi. Trong thi k u, thiu oxy ca thai c th gy ra thai cht lu hoc
gy ra d dng bm sinh. giai on cui ca thi k c thai, ng c CO gy ra thai cht
lu hoc bnh no cho thai. Tuy nhin , ngi ta c th gp thai nhi pht trin bnh
thng nhng trng hp ng c nhe hoc trung bnh.
Mt nguyn nhn ng c c bit cn ch l ng c kh chlore mthylene v kh
dichloromethane. Nhng dung mi ny s c chuyn ho mt phn trong c th th nh
CO. Hai loi kh trn c s dng trong cng nghip v trong hi ho ( ty tranh ), n
thng c s dng trong nhng ni km thng kh v c th gy ra ng c kh CO
nng.
III.Chn on
1. Chn on xc nh
- Khai thc bnh s
- Khm thc th
- HbCO mu. Ch nng COHb khng tng quan vi lm sng v di chng thn
kinh
2. Chn on phn bit
- Ng c nh: d lm vi cm cm nht l v ma ng. Sau 4 gi tip xc CO
200ppm COHb 15 - 20% au u. CO 500 ppm bun nn
- Ng c va: d nhm vi ng c thc n (bun nn, nn); au tht ngc khng n
nh
- Ng c nng cn phn bit vi cc nguyn nhn gy hn m v co git khc.
- Mu anh o xut hin khi tip xc qu nhiu (2 -3%). y l du hiu t nhy
IV.Di chng ca CO
- Sa st tr tu
- Tm thn
- Parkinson
4

Bi ging Chng c
- Lit
- Ma vn
- M v
- Bnh l thn kinh ngoi vi
- Bt lc
Tn thng thn kinh xut hin 2 - 40 ngy sau nhim CO
+ 1 thng k trn BN ng c c th oxy 100% trong ICU 14% sng st c tn thng
thn kinh khng hi phc
+ 1 nghin cu 2360 BN ng c CO thy 3% sa st tr tu v Parkinson sau 1 nm
+ 1 nghin cu trn 63 BN b ng c nng 43% gim tr nh, 33% thay i v tnh cch
sau 3 nm theo di.
V. iu tr:
Chin lc iu tr khng da vo nng HbCO, m da vo tnh trng c b mt thc
lc u hay khng?, tnh trng hn m, cc yu t tin lng nng, v vo cc di chng
thn kinh.
1.
Nhanh chng a nn nhn ra khi ni ng c:
cho php HbCO phn ly nhanh chng. Trong khi ko nn nhn ra khi vng b ng c:
ngi cu nn phi lu mang mt n phng c hoc eo khu trang m, phi phng
kh nng n ca khng kh giu CO.
2.Th oxy :
S phn ly ca HbCO c thc y di oxy liu php, v vy cn cho th oxy cng
sm cng tt, cho th oxy ngay sau khi ly mu nh lng HbCO.
- Th oxy 100% n khi COHb < 2%, i vi BN c thai th duy tr 2 gi sau khi
COHb v 0 nhm ko di thi gian thi tr CO t thai nhi
iu tr oxy ng p( ONB ) l bin php u tin. oxy c s dng di dng masque
hoc lu oxy tr em. Liu php oxy cao p ( OHB ) ch nh cho ph n c thai, hn m
( c tc dng lm tng p lc ring phn ca oxy, lm tng s phn ly HbCO, lm tng s
khuch tn ca oxy trong mu v lm cho t chc s dng oxy d dng hn.
3. iu tr triu chng:
- Nu c suy h hp cn t ni kh qun, th my.
- iu tr HA tt, t catheter, dng thuc vn mch tu theo mc ca ri lon huyt
ng.
- Theo di chc nng sng c bn,
- lm kh mu
- iu tr toan chuyn ho ch khi pH < 7,1. Tnh trng toan gip ng phn ly xy
dch chuyn v pha bn phi thun li cho gii phng xy cho t chc
- 4. Phng ti pht:
gio dc bnh nhn. V sinh ni v mi trng lao ng
VII. xy cao p trong ng c CO
1. C s ca iu tr
- Gim thi gian na i sng: Nu th O2 100% thi gian trong vng 40 pht nu
HBO 2,5 atm th thi gian ch cn 20 pht (4 -86 pht). Tng O2 ho tan ln 10 ln
- Cung cp O2 cho t chc di dng ho tan trong plasma

Bi ging Chng c
- Gy co mch no tc th trong khi vn duy tr c O2 cho t chc no
- Ngn chn s tng hp cc gc t do t hin tng peroxidation ca m trong t bo
no do ng c CO.
2. Ch nh:
- Ngt
- Hn m
- Co git
- GCS < 15 im
- C du hiu thn kinh kh tr hoc COHb > 25% (mt s >40% v > 25% nu km
theo: co git, lon nhp tim,di chng) hoc COHb > 15% ph n c thai
- Thiu mu c tim
- Lon nhp tht
- Sau khi iu tr ban u n nh sau 2 -4 gi m triu chng thn kinh khng phc hi
(au u, tht iu, l ln)

Bi ging Chng c

Ng c cp Barbituric
BS. ng Th Xun

I. i cng

Ng c cp barbituric l ng c rt thng gp trong cc khoa Hi sc cp cu.

Nhiu bnh nhn ung vi mc ch t t v vy ung vi s lng nhiu, nhiu loi thuc,
bnh cnh lm sng thng ph c tp v nng. Trn thc t, hay gp ng c nhng bnh
nhn b ri lon tm thn, ng kinh, nghin ma tu.
Ng c cp barbituric l mt vn cn phi quan tm v t vong cn cao do nhiu
bin chng. Vit Nam barbituric c dng nhiu nht l ph enobarbital (luminal, gardenal).
Bn cnh ng c cp cn c ng c mn do lm dng thuc.
II. tnh cht - chuyn ho - c tnh
1. Cu trc v tnh cht l ho
-

Barbiturat c dng ch cc dn xut ca acid barbituric v ure vng ca acid malonic.

O=C
Ure

NH - H

HO - C - C

NH - H

HO - C - C

Acid Malonic

CH 2

-2H2O

NH - CO

O=C
NH - CO

Malonylure (acid Barbituric)

Bn thn acid barbituric khng c dng trong y hc, nhng cc dn cht th v tr C 5

(i khi 1, 3) cho mt lot cc dn cht c tc dng gy ng, chng co git c gi l
thuc ng barbituric. Nu thay ure bng Thio ure s c Thio-barbituric, khi thay H 5
bng cc nhm th khc nhau s cho mt dn cht gy ng mnh v nhanh dng lm thuc
gy m.

Ni chung barbiturat l nhng tinh th trng, v thay i, t tan trong nc v te du ho,

tan nhiu trong dung mi h u c (alcol, te, clorofoc). D thng hoa trong chn khng
170 - 180oC. im nng chy thay i t 100 - 190oC. Barbiturat thng b than, silicagen
hp ph.

Axit barbituric c tnh axit mnh (nht l pKa=4.04). Do tnh axit nn to mui khng tan
vi mt s kim loi nng, d tan trong dung dch kim v carbonat kim.
Barbiturat d to phc hn hp vi mt s ion kim loi do d tan trong dung mi, b
phn hu khi c nc, c mu c trnghoc tinh th c hiu nn c dng khi kim
nghim.

Hu ht cc barbiturat c ph hp th UV c trng, quang ph ph thuc vo pH ca

dung dch.

2. Chuyn ho barbituric trong c th

-

Barbituric d dng hp th qua nim mc khi pH ca mi trng nh hn pKa ca

barbituric , do vy thm nhanh qua nim mc d d y.
Barbituric c chuyn ho gan do tc dng ca cc men c trong gan. V vy ngi
quen dng barbituric , liu ng c cao hn ngi cha dng barbituric . Ngc li, ngi
suy gan d b ng c. Thuc c hp thu nhanh, phn b nhiu trong t chc .
Cc barbituric chm (gardenal, barbital...) c th thi tr nhiu nht qua nc tiu di
dng nguyn vn (65 - 80%), v vy gy li tiu l mt phng php o thi tt. Cc
barbituric chm c lc qua cu thn v ti hp thu ng ln gn. Nc ti u kim lm
gim ti hp th barbituric, v vy kim ho huyt thanh l mt bin php tt thi tr
barbituric qua thn.

3. c tnh sinh bnh hc

-

Da theo thi gian gy ng, ngi ta chia barbituric ra lm 4 loi:

+ Tc dng chm (6 gi) : barbital, gardenal
+ Tc dng trung bnh (3 - 6 gi) : allobarbital, amobarbital, aprobarbital,
butobarbital.
+ Tc dng ngn (3 gi) : xyclobarbital, secobarbital, pentobarbital
+ Tc dng cc ngn gy m: thiopental

Barbituric tc dng ln cc ty l p th ca cc t bo lm gim tiu th oxy, gim pht sinh

ra nhit lng v acid lactic. Vi liu cao, barbituric c ch thn kinh trung ng, tc
dng c ch h thng li ARAS v vng no trung gian lm cho bnh nhn hn m.

Barbituric c ch cc trung tm vn mch, h hp, cc th th pH, PCO 2/PO2, lm mt

phn x ho.
Tc dng ca barbituric cn ph thuc vo c im ca ngi dng thuc : s nhy cm,
tui, chc nng gan thn, nghin ru, c dng thuc thng xuyn hay khng.
Tc dng ca barbituric tng ln khi c mt ca cc thuc c ch thn kinh khc : morphin
v ch phm, clopromarin, bromua... Tc dng kt hp gia barbituric v ru c th gy
t vong d nng barbituric mu khng cao.

III.

Cc tc dng ny c tnh cht tm thi v mt i khng li di chng sau khi thuc

c thi tr ht.
Ng c trn 2g c th gy hn m su v t vong, trn 6g s gy t vong nhanh chng
nu khng kp thi cu cha.
Triu chng lm sng ng c nng

Trong bi ny chng ti ch cp n ng c cp barbituric tc dng chm :

phenobarbital (gardenal)
1. Hn m su

Hn m khng c lit chi, bnh nhn nm yn, cc chi mm nhn, mt ht phn x gn

xng, k c phn x gic mc, nhng phn x ng t vi nh sng vn cn v ch mt
nu bnh nhn ngt th do tt li hoc suy h hp.
Nu c tnh trng co cng kiu mt no phi coi chng c thiu oxy t chc (tt li,
ng m di)
Ri lon thc t l vi mc ng c, c a ng kinh chu ng liu cao hn.
Hn m: nh gi mc hn m theo bng im Glasgow (tuy nhin bng im
Glasgow khng c gi tr tin lng bnh nhn ng c barbituric)
in no gip cho nh gi mc hn m v theo di tin trin ca bnh
Nhiu tc gi kho st s lin quan gia nng barbiturat trong mu v mc lm
sng. Nng ny thay i tng loi.
Nng barbiturat (mg%) v giai on lm sng
(theo Bi ging kim nghim c cht - Trng i hc Dc H Ni)
Mc ng c
Phenobarbital
Amobarbital
Pentaobarbital
Secobarbital

1.0
0.7
0.4
0.3

3.4
1.5
0.6
0.5

5.5
3.0
1.5
1.0

8.0
5.2
2.0
1.5

15.0
6.6
3.0
2.0

Tuy nhin nng barbituric cn ph thuc vo phng php xt nghim v nng

ca ng c cp barbituric ph thuc vo cc du hiu lm sng, chc nng sng , bin
chng hn l nng barbituric mu. C bnh nhn nng barbituric mu khng cao
nhng li t vong do tt li, sc, nhim trng bnh vin.. .
-

C th h thn nhit hay st cao.

Nhn cu thng c nh.

2. Ri lon h hp

Rt thng c, l nguyn nhn ch yu gy t vong

C ch: gim thng kh ph nang:
Tc ng h hp do tt li, m di, mt phn x ho, ht phi dch v (hi chng
Mendelson), l nguyn nhn chnh gy t vong. Trc khi bnh nhn c t ng ni kh
qun, nn bnh nhn t th nm nghing an ton.
Bi nhim phi nhng bnh nhn nm lu, t ng ni kh qun th my

3. Ri lon tun hon

- T lit thn kinh trung ng dn n gim thc tnh thnh mch gy ra h huyt p. Tnh
trng h huyt p nhng ngi gi c th gy nh ng bin chng nng n, c bnh nhn
sau khi iu tr n nh ng c cp li pht hin ra nhn no do b tt huyt p ko di.
- Thng km theo mt nc, mt mui, tc mch phi.

4. Bi nhim
- L bin chng rt thng gp, nhim trng bnh vin thng do vi khun gram m hoc
trc khun m xanh khng thuc, iu tr kh.
- Vim phi, vim ph qun phi: do ht phi, do ng m di, do cng tc chm sc, ht
m. a s cc bnh nhn th my b nhim trng phi, thng l nguyn nhn ko di
thi gian th my, thi gian iu tr, thm ch gy t vong cho bnh nhn .
- Nhim khun tit niu, c bit nhng bnh nhn t ng thng bng quang, nm lu, i
tho ng.
- Lot mc
5. Suy thn cp
- Thng l chc nng
- Nhng c th l thc tn do bnh nhn c tn thn g tim tng thn, hoc do nm bt
ng p vo chi gy tiu c vn (rhabdomyolyse): i t, sm mu, men CPK tng cao.
6. Bnh phi hp
IV.

Bnh nhn nm lu c th c bin chng: tai bin mch mu no , huyt khi tnh mch
chi di, tc mch phi, nhi mu c tim.
Tin lng xa: c th thy vim nhiu dy thn kinh.
Xt nghim c cht
Mu bnh phm:
Dch c th: mu, nc tiu, dch d dy
Ph tng

1. nh tnh barbiturat:
1.1.
Phn ng chung ca cc barbiturat: phn ng Parris
- Phn ng to phc hp hn hp c mu hng vi Coban Nitrat hoc Coban Acetat trong
mi trng Metanol.
- Phn ng ny k nc, c th pht hin n 0.03mg barbiturat trong mu th, nhng
khng c hiu. Tt c cc nhm c CO NH CO u cho phn ng ny.
- Phn ng trn c th thc hin trn sc k lp mng.
1.2. Phn ng c hiu tm Gardenal
- Phng php sc k lp mng so snh vi mu gardenal chun ( chm 5 -10mcg mu
chun)
- Dung mi trin khai: Clorofoc/Aceton 9/1
- Thuc th: Millon hoc orthotoludin 1% hoc 3 dung dch KaliIodu a 1% trong nc vi
Benzidin bo ho trong acid Acetic 1%.
- Dng tnh khi thy vt mu trng xm trn nn trng (Rf trng vi Rf gardenal ca mu
so snh).
- Phn ng ny c th dng bn nh lng gardenal
1.3. Phn ng soi tinh th trn knh hin vi phng i 8 10 ln

2. nh lng barbiturat
- Phn ng to phc mu ri o quang (hin nay t dng)
- Phng php o ph UV (ph hp thu t ngoi)
o trong dung dch NaOH 0.1N o hp ph bc sng 240nm
pH = 10 cho max = 244 nm
pH = 13 cho max = 249 nm
(c th dng nh lng gardenal trong dch sinh l)
- Sc k kh
V. X tr
X tr cp cu ph thuc vo mc nng khi bnh nhn vo vin: loi b cht c trc
hay hi sc trc.
1.
-

Bo m thng kh trc
t ng ni kh qun, ht m.
H hp nhn to vi phng thc IPPV
M kh qun nu c ph thit hu, thanh mn.
Nu c xp phi: soi ht ph qun

2. Hn ch ng c
- Khng gy nn
- Ra d dy:
+ Bnh nhn tnh: t ng thng d dy nh qua ng mi, ra d dy. Cn phi tin
lng trc tnh trng b nh nhn v c th hn m v din bin nng ln rt nhanh.
+ Bnh nhn m: t ni kh qun c bng chn (cuff) v thng kh nhn to trc khi ra
d dy.
+ K thut ra d dy: bnh nhn nm nghing tri, mi ln a vo 100 200ml dung
dch mui 0.9%. S lng dch ra: 3- 5 lt, ma lnh dch ra phi c lm m. Ly dch
ra d dy ln u xt nghim c cht.
- Cho bnh nhn ung than hot 100g (20g/2 gi), thuc ty sorbitol 1 - 2g/kg chia u theo
cc liu than hot.
3. Tng o thi
-

Gy bi niu cng bc: truyn 4 6 lt/ngy (theo di CVP), cho li tiu tng thi
barbituric. Vi cc bnh nhn khng c suy tim, suy thn, khi truyn dch nhiu, cha cn
cho li tiu s lng nc tiu c th tng. Nhng bnh nhn c suy tim, suy thn ph i
theo di cht tc truyn dch v CVP , cho li tiu.
Kim ho huyt tng: truyn bicarbonat
Cc bin php trn c th tin hnh c mi tuyn, trong a s cc trng hp ng
c ch cn hi sc tt, ra d dy, cho than hot v thuc ty l c th cu sng bnh
nhn.
Lc ngoi thn: L bin php thi tr cht c rt c hiu qu nhng khng phi tuyn
no cng c th lm c, gi thnh cao.
+ Thn nhn to: ch nh vi nhng bnh nhn ng c nng: hn m su, v niu, tru
mch, nng barbituric trong mu cao. Tuy nhin, trong iu kin ca nc ta hin nay,

ch nh lc ngoi thn ch yu da vo cc du hiu lm sng. Khi chy thn nhn to

phi m bo huyt p bng truyn dch, dopamin hay noradrenalin.
V thuc tch lu nhiu trong t chc, cn ch hin tng ti phn b li barbituric
trong c th, trong hoc ngay sau khi chy thn nhn to bnh nhn c th tnh ra sau
li hn m tr li.
+ Lc mng bng ngi c tt huyt p c ch nh tt hn thn nhn to, hoc nh ng
bnh nhn c thm suy vnh, cao huyt p, suy tim. m bo huyt p ri lc mng bng.
Ngi ta thy rng c 6 gi lc mng bng th c hiu qu bng 1 gi chy thn nhn to,
hay c ngha l chy thn nhn to 6 gi th bng lc mng bng 24 gi.
4. m bo tun hon
- Hi phc nc in gii, thng bng toan kim.
- t catheter tnh mch truyn dch ngy 4 6 lt, trong natriclorua 0.9%, glucose,
bicarbonat, ch cn dng bicarbonat 1.4% 500ml/ngy. Theo di CVP, nc tiu iu
chnh lng dch truyn.
- Nu tru mch: chng sc, truyn noradrenalin, aramin, plasma, mu.
- t ng thng bng quang theo di nc tiu
5. Chng bi nhim
- S dng khng sinh theo khng sinh
- Phi hp hai khng sinh: cephalosporin v aminoglycosid.
6. Chng ng
Heparin 1ml 5000 UI mi 8 gi, tim di da
Hoc fraxiparin 7500 UI 15 000 UI /ngy, tim di da
7. iu tr ph phi cp tn thng nu c
8.
-

Khi nghi ng c hi chng tro ngc phi:

Soi ht ph qun
M kh qun t canun c bng chn, th my c PEEP.
Steroid liu cao: methylpresnisolon 30mg/4 gi.
Gim bt lng dch truyn (theo di k CVP) v dng furosemid.

9. H l v chm sc
- m bo dinh dng: 1500 2000 Kcalo/ngy, bnh nhn hn m cho n qua ng thng
d dy.
- Nm m chng lot, vt l tr liu, thay i t th bnh nhn trnh t gy tiu c hoc
lot.
- Gi m cho bnh nhn, nu st cao: chm mt, cho thuc h nhit
- Chm sc mt: bng mt, nh cloroxit 0.4%
- V sinh thn th: ming, b phn sinh dc
- Vi tamin B1, vitamin C

Bi ging Chng c

iu tr ng c cp v qu liu ma tu
PGS.PTS.Nguyn Th D
Ng c cp opioids l mt cp cu nguy kch, c th iu tr khi nhanh qua
thuc khng c (antidote) ca n l naloxone. Naloxone l mt thuc c t 20
nm, thuc i khng cho tt c cc opioids, c dng nhiu ng : di da,
tnh mch, tim bp. Thuc hu nh khng c tc dng ph, k c a mt liu
ln.
A. Nhng im cn ch :
Khi dng naloxone cn ch 2 im sau :
1. Thuc c tc dng nhanh sau 2 -3 pht, thi gian tc dng rt ngn 60 -90 pht,
n ngn hn tc dng ca tt c opioids, loi tr fentanyl. V vy cn a nhc
li hay truyn lin tc naloxone mt bnh nhn ng c opioids nng.
2. Naloxone c th gy ra hi chng thiu t huc sm ngi ph thuc
opioids, tuy nhin dng liu cao s ngn chn c triu chng suy h hp trong
hi chng ny.
B. Triu chng v du hiu ng c, qu liu ma tu
1. Suy gim h hp, th chm, ngng th, cht nhanh trong vi pht sau tim,
hoc 1-4 gi sau ung.
2. Co ng t
3. Mt thc, hn m
4. H huyt p
5. Ph phi cp
6. H nhit
7. Nu hn m ko di c th cht v vim phi
8. Tm vt tim 2 cng tay, tnh mch c, i.
9. Xt nghim nc tiu : c morphine v 6MM (6 monoacetyl morphine) nn
tm thm barbiturate, benzodiazepine, quinin trong nc tiu ngi nghin.

C. iu tr cp cu ng c v qu liu ma tu

Bi ging Chng c

1. Bnh nhn th yu, ngp c, ngng th (<10ln/pht)

- m bo thng kh, bp bng ambu + oxy 1 00%, h hp h tr
- m bo tun hon : p tim ngoi lng ngc nu ngng tim, truyn dch
- T th an ton khi hn m, m, theo di th
Bt u bng :
- Naloxone 1ml=0,4mg tim TM (ngi ln v tr em). C th cho liu ban
u2mg c ngi ln v tr em nu rt nng.
+ Sau 2-3 pht khng tnh : cho li 0,4mg (c th ti 4 liu) nu th li, c th
cho naloxone qua ng tim bp, di li. Tng liu naloxone c th 10 20mg/24 gi.
+ Nu liu ban u ca naloxone hiu qu (bnh nhn tnh, th li) th tim
nhc li sau mi 20-60 pht hoc duy tr bng ng truyn tnh mch lin tc.
+ Nu sau 4 liu ban u khng kt qu th tm xem bnh nhn c ung thm
thuc khc : barbiturate, thuc an thn, ru..., hoc chn thng u, c th c ho
thm than hot vi nhun trng nu bnh nhn ng c qua ng tiu ho.
- Truyn dch nng huyt p, thng bng in gii.
+ Glucose v d c h ng huyt
2. Bnh nhn th > 15ln/pht
- Liu u : naloxone 0,4mg tim bp.
Nu p ng mt phn c th cho tip ln 2 sau 20 -60 pht
- Th oxy mi 4L/pht
- Truyn dch, Glucose 5%, NaCl 0.9% m bo huyt p.
* Pha truyn lin tc naloxone :
Cho bt k loi opioids no, c bit loi tc dng ko di nh methadone
(30-36 gi). Truyn lin tc da vo nhp th v mch, huyt p bnh nhn p
ng sau liu u. Truyn lin tc s d phng suy h hp li v naloxone c thi
gian bn hu ngn hn opioids.
Truyn dch + 0,4-0,8mg/gi ngi ln v 0,01mg/kg tr em, nh gi
sau mi gi ngi ln v mi 5 pht tr em. Truyn lin tc c th tng ln
nu thc cn gim. Nhiu tc gi cho thy truyn naloxone lin tc trong 10
gi mt n v hi sc tch cc l an ton bo m v nh gi li tnh trng
suy h hp ca bnh nhn sau 1 gi tip xem tc dng naloxone cn hay ng
c opioids cn hoc ng c loi khc. Naloxone s khng c p ng nu
xut hin hi chng thiu thuc.
Th my nu bnh nhn hn m, phng thc iu k hin th tch (CMV)
hoc h ttr p lc, vi FiO 2 = 50%, dng PEEP nu bnh nhn c ph phi cp
hay hi chng ARDS.
Chm sc nui dng calo.

Bi ging Chng c

phc iu tr ng c ma ty
Ng c ma tu (mt thc, th yu, ng t
co,HA)
m bo :
- Thng kh
- Tun hon
- T th an ton
Naloxone
Nhp th < 10ln/pht

Nhp th > 15ln/pht

1. 0,4mg-0,8mg/TM

(c ngi ln + tr em)
0,4mg tim
bp
3 pht sau khng tnh li : cho li (c
- C p ng mt phn cho nhc li ln
th n 10 ln n khi c kt qu)
2,3
2. Truyn naloxone lin tc sau khi c kt
qu.
0,4mg/gi cho ngi ln
0,01mg/kg/3 pht cho tr em
m nhp th v o HA trong10 gi.

- Oxy : 4L/ph
- Truyn dch, glucose, m bo tun hon
- Theo di th, HA, mch 20pht/ln

3. Thng kh nhn to (bp bng ambu th my)

T FiO 2 100% 50%
(1 gi 24 gi)
4. Truyn dch nng HA

Ch :
1. Cho than hot v sorbitol nu bnh nhn dng thuc ung
2. Cn tm cc ng c khc km theo barbiturate, an thn v ru, quinin v cc
bin chng.
3. Nu c tn thng no th rt nng
4. Liu naloxone truyn lin tc 2mg (5 ng) + 500ml Glucose 5% cho
0,4mg/100ml/gi.
3

Bi ging Chng c

iu chnh liu truyn naloxone ph hp mi bnh nhn

1. Nu liu u thnh cng (0,4 -0,8mg tnh mch) a 2/3 liu ny bng ng
truyn lin tc.
2. Nu sau liu u tht bi :
- NKQ, bp bng, oxy
- Tim nhc li sau 2,3 pht a ln ti 10mg trc khi truyn
3. Nu sau liu u, bnh nhn c du hiu thiu thuc
- Gim bt liu u
- Nu xut hin gim thc li, nhc li 1/2 liu b an u cho ti lc c hiu qu.
- Tnh liu ban u thch hp sau cho truyn lin tc
4. Nu bnh nhn xut hin du hiu thiu thuc khi ang truyn :
- Dng truyn cho ti khi du hiu ny
- Bt u truyn li = 1/2 tc ban u, theo di
- Tm nguyn nhn khc gy thiu thuc
5. Nu bnh nhn gim thc trong lc truyn :
- a 1/2 liu u v nhc li cho ti khi tt
- Tng truyn lin tc = 1/2 tc ban u
- Tm ng vo mu li ca opioids hay nguyn nhn khc gy gim thc.

Bi ging Chng c

Ng c c nc
I. Tiu chun chn on
1. Chn on xc nh
a). Lm sng:
Sau khi n c nc (cn gi l Puffer fish, Balloon fish, Fugu -tn gi Nht Bn)
hay c kh, ruc c lm bng c nc, triu chng xut hin sau 10 -30 pht: T ming,
li, hai mi, au u, nn, ni kh, t ngn, bn tay chn, yu v mt, t vong do
lit c h hp hoc suy tun hon cp.
Cc du hiu khc: Tim chm, ri lon nhp, h huyt p, h nhit , tng tit
nc bt, tm, ngng th, mt phn x gn xng v trng lc c .
Cc du hiu lm sng c th mt i sau 24 gi nu bnh nhn c cu sng.
b). Xt nghim:
- Mu: in gii, ure, ng, creatinin, thng bng toan kim
- in tm : nhp chm, ri lon nhp
- Theo di SpO 2 v EtCO 2 (nu c iu kin) hoc chc nng phi ( Vt, p lc m
th vo)
Pht hin c cht Tetrodotoxin (TTX) trong dch c th hoc trong mu bnh
phm: ch thc hin c nhng c s xt nghim hin i
2. Chn on phn bit:

Cc cht c khc thc phm (vi khun, ho cht tr su, cht bo qun, c
c loi Scombroid, Ciguatera, Shellfish cng gy nn, bun nn)
Cc nguyn nhn khng do c: Vim d dy cp, co tht i trng

II. Nguyn nhn gy bnh:

Cht c trong c nc c gi l Tetrodotoxin (TTX) l cht c khng
protein, tan trong nc v khng b ph hy nhit si hay lm kh, cht c b
bt hot trong mi trng acid v kim mnh.
TTX tp trung trng c, rut gan, v tinh hon ca c. Cht c ny cn tm
thy trong mt s loi vt khc nh: bch tuc c vng xanh tua (d ln vi con
mc), con sa-ging (Newts) v k nhng (Salamanders)
Cht c TTX tc dng la chn chn dng natri trong c ch bm Kali -Natri
v knh Natrium tm vn ng, do TTX gy ra lit c, lit h hp, ng th TTX
cn pht ng vng nhn cm ho hc gy nn, nn lin tc.
II. Tin lng & Cch phng:
nng ca ng c c nc tu thuc vo lng c t v thi gian c cp cu:

Nu bnh nhn c triu chng nh c th theo di v khi

Nu c triu chng r, cha b tm, iu tr cp cu ban u v h i sc,

s cu c trong vng 24 gi.

Nu thiu oxy lu, khng c cp cu ban u c th gy bin chng

hoc t vong

Bi ging Chng c
* Cch phng nga: Tt nht l khng n c nc, chun b ti cp cu khi cn
thit
III. iu tr:
* Trc khi vo bnh vin:
- Nu bnh nhn cn tnh vi triu chng nh: cho ung than hot 1 -2g/kg v
Sorbitol 1g/kg cho c ngi ln v tr em trn 2 tui
- Nu bnh nhn c tm, ri lon thc: Thi ngt, bp bng ambu, ri a
n c s bnh vin gn nht
* Trong bnh vin:
Nu xut hin triu chng tm, ri lon thc
1. Khng gy nn
2. t ng Ni kh qun, c bm bng chn m bo ng dn kh, h
tr h hp bng bng ambu, th my
3. t xng ra d dy nu mi n c trong 1 gi u, sau ra cho than hot
1-2g/kg
4. Truyn dch G 5% v NaCl 9% duy tr huyt p
iu tr cc triu chng nng (nu c):
- H huyt p
+ Truyn dch 10-20 ml dd NaCl 9% qua ng TM v t bnh nhn
t th nghing tri, u thp. Cn theo di p lc tnh mch trung tm
(CVP). Trnh truyn dch qu mc.
+ Nu truyn dch khng lm tng huyt p cn cho:
-

Dopamin 2-5 g/kg/pht liu cho c bnh nhn ngi ln ln

tr em, iu chnh tng liu t hiu qu, song khng qu 15
g/kg/pht, c th thm:

Noradrenalin 0,1 - 0,2 g/kg/pht, iu chnh liu c kt

qu, liu cao qu khng c li gy thiu mu t chc

- Co git: l triu chng him gp, iu tr co git bng Seduxen, (Valium) 10

mg tim tnh mch, nu khng p ng c th cho Phenobacbitan hay
Phenyltoin sau khi t ng ni kh qun, thng kh h tr (Xem bi "iu
tr co git").

Bi ging Chng c

Ra d dy trong ng c cp.
I. i cng:
Ra d dy l mt trong cc bin php hn ch hp thu, loi b c cht qua
ng tiu ho trong cp cu ng c cp ng ung. Nu c thc hin sm, ng k
thut th y l phng php rt hiu qu hn ch hp thu c cht: nu c thc hin
sm trong vng mt gi sau khi ung c th loi b c ti 80% lng c cht ung
vo. nu ra mun hn s km hiu qu, loi b c t c cht, tuy nhin vn c th gim nh
mc ng c xung di liu t vong, hoc ch t cng gim nh mc ng c.
Ngoi ra, ra d dy cn gip ly dch xt nghim c cht gip cho chn on
nguyn nhn.
Ra d dy thng c kt hp vi cc bin php nh: cho than hot trc trong
v sau khi ra d dy hp ph c cht trong lng ng tiu ho, sau dng thuc ty
nhanh chng a c cht ra ngoi c th.
Tuy nhin ra d dy khng ng ch nh, sai k thut th khng nhng khng c li m
cn c th dn ti cc bin chng vi nhng hu qu nng n, thm ch t vong. Chnh v vy
cn phi cn nhc khi ch nh ra d dy, c bit l i vi tr em, nu li ch khng r rng m
nguy c bin chng ln th khng nn ra.
D dy l on phnh to ca ng tiu ho gia thc qun v rut non.T cung
rng trn n tm v di khong 40- 45 cm. D dy c hnh ch J rng 12cm, di 22
25 cm, dung tch cha khong 1200 ml, trn thng vi t trng qua l tm v, di thng
vi t trng qua l mn v. on mt t trng thng vi d dy qua mn v, nm ngang,
hi chch nn trn, ra sau v sang phi. l l do khi ra d dy chng ta phi t bnh
nhn nm nghing sang tri, chnh l trnh y c cht trong d dy qua mn v
xung rut.
II. Ch nh v chng ch nh:
1. Ch nh:
Tt c trng hp ng c ng un g n trc 6 gi, khng c chng ch nh
ra d dy v khng th gy nn c( ri lon thc, gim hoc mt phn x nn...).
Tuy nhin c mt s im cn ch :
-

Trong thc t, thng kh xc nh chnh xc thi im ung v vy gii hn 6

gi tr thnh tng i.

Bi ging Chng c
-

Ng c mt s loi thuc trong c cc thuc an thn v thuc ng gy

gim nhu ng ng tiu ho, v vy sau 6 gi vn c th cn mt lng ln
c cht nm trong d dy, nht l trong cc trng hp ng c nng. Thc t
ti A9 c bnh nhn ng c nhiu loi thuc ng v thuc an thn phi
hp c ra d dy sau gi th su m nc tho ra vn m c, thuc lm
c trng nc ra. V vy

nn t ng thng d dy thm d cho nhng

bnh nhn c cho l n mun, ra vi chc mililt nc nu c ta s ra

tip.
-

Trong cc trng hp c cho l nh, hoc bnh nhn l tr em khng hp

tc, li ch ca ra d dy khng r rng m nguy c bin chng cao th nn
thay th ra d dy bng cho ung than hot.

2. Chng ch nh:
2.1. Chng ch nh tuyt i:
-

Ung cc cht gy n mn: a xt, kim mnh.

Cc cht khi gp nc to ra cc phn ng lm tng tc dng c hi: kim loi

natri, kali, phosphua km...

Xng, du ho, cc cht to bt.

C tn thng nim m c ng tiu ho : lot nng. chy mu, phnh mch

thc qun...

Bnh nhn c ri lon thc, c nguy c sc m cha t ni kh qun c

bng chn bo v ng th.

2.2.

Chng ch nh tng i:
-

Tn thng nim mc ming: t ng thng nh ng ni.

Tr em ung vi vin thuc loi t nguy him, khng c du hiu ng c.

Ph n c thai: cn cn nhc li hi v d gy cn co t cung khi t ng thng

ra d dy.

III. Chun b:
3.1.

Dng c:
B dng c ra d dy h thng kn: gm cc b phn ng b nh sau:
-

ng thng Fauchet bng cht do , u t, c nhiu l cnh, dng t ng

ming, c cc c sau:
+ S 10 ng knh trong 4 cm.

Bi ging Chng c
+ S 12 ng knh trong 5 cm.
+ S 14 ng knh trong 6 cm.
-

ng thng cho n thng dng cho bnh nhn ung t c cht, cha n, du hiu
ng c hu nh khng c, ung lu qu 6 gi,hoc khng c ch nh ra
nhng c ch nh t ng thng ly dch xt nghim.

Dy ni ch "Y" v cc van iu chnh ng m ng ra ng vo.

Hai ti ng dch c chia vch o mi 50 ml. Ti trn treo cao > 1m so vi mt

ging c dung tch 3000 ml (ng nc mui 0,5 -0,9 % ). Ti di treo di mt
ging t nht 30cm.

X ng nc sch (khong 5 -10 lt nc) c pha mui vi t l 5 -9 gam/lit nc

v x hoc chu ng nc dch sau khi ra.

Dng c m ming.

Canun Guedel.

Seringe 50 ml

ng nghe, bm cho n hoc bng ambu: Dng kim tra xem xng vo d
dy cha.

L ng dch d dy xt nghim c cht: Dung tch khong 200ml.

Du paraffin: bi trn u ng xng, hn ch c chn thng do u ng

xng gy ra.

Mui n: khong 50 gam

Than hot: hp ph cht c, thng dng sau khi ra d dy.

Trong trng hp ng c thuc tr su th pha lun vo nc ra d dy sau khi

ly dch d dy lm xt nghim c cht.

Thc ty: Sorbitol hoc magne su lpht c tc dng tng o thi cht c v than
hot qua ng phn. Thng bm cng than hot sau khi ra d dy.

Thuc an thn: Valium 10mg (ng tim) dng cho bnh nhn kch thch vt v
nhiu, ng c cht gy co git.

3.2.

Bnh nhn:
-

Nu bnh nhn tnh: phi gii thch bnh nhn hp tc

Nu bnh nhn c ri lon thc, gim hoc mt phn x nut phi t ni kh

qun c bng chn trc khi tin hnh ra d dy.

Bi ging Chng c
-

Khi bnh nhn ung thuc gy co git (Thuc chut Trung Quc, m tin, ...) phi
dng valium trnh co git trc khi ra d dy.

Nu bnh nhn c suy h hp, tru tim mch phi u tin tin hnh cp cu h
hp v tun hon. n khi tnh trng bnh nhn n nh mi tin hnh ra d dy.
C th va ra d dy va bp bng hoc th my.

Tri mt tm nilon u ging trnh dch dy chy ra ga.

T th bnh nhn: Nm nghing tri, u thp.

3.3.

Nhn vin lm th thut:

-

Phi l nhng ngi c o to k thut ra d dy, cn phi i m, eo

khu trang, i gng tay sch.

Cn c 2 ngi: mt ng i t xng d dy v c nh xng, xoa bng trong qu

trnh ra. Mt ngi iu chnh lng nc vo ra.

Khi bnh nhn cn phi bp bng th phi c thm ngi th ba.

V. K thut:
Bc 1: a ng xng vo d dy.
-

Chn la ng xng: t ng ming dng n g xng to, t ng mi dng ng

xng nh (loi xng dng mt ln)

o di ng xng cn a vo: Bt u t cung rng hm trn ko vng ra sau

tai ri ko thng xung mi c. nh du di ng xng cn a vo. Thng
thng t 40-50 cm.

Bi trn u ng xng d dy bng gc thm paraffin.

t ng ming:
Bo bnh nhn h ming nu bnh nhn tnh, hp tc. Nu cn thit dng dng
c m ming, sau lun canun Guedel vo ri rt dng c m ming, sau
lun canun Guedel vo ri rt dng c m ming ra .
a ng thng vo ming bnh nhn tng t mt, t t, khi vo n hu va
a vo va bo bnh nhn nut. Nu kh khn th u bnh nhn gp cm
vo thnh ngc ri va y va bo bnh nhn nut. Khi u xng vo n d
dy thy c dch v thc n ch y ra trong lng ng xng. iu chnh trong qu
trnh ra d dy u ng xng lun lun v tr thp nht trong dch d
dy.
Tin hnh c nh u ngoi ng xng v tr nh du.

Bi ging Chng c
-

t ng mi: Lun ng xng cho n vo l mi khng c t ni kh q un ng

thi u bnh nhn gp vo thnh ngc. Khi qua l mi sau vo n hu th bo
bnh nhn nut ng thi y vo.Cc thao tc tip theo cng ging nh t
ng ming.

Khi t nu khng vo c thc qun phi dng n ni kh qun xc nh v

tr thc qun sau dng panh Magil gp u ng xng a vo thc qun
ng thi mt ngi khc y phn ngoi ng xng vo.

Khi c ni kh qun cn tho bng chn trc khi t xng, sau bm bng chn
trc khi ra d dy.

Bc 2: Ni h thng ra d dy vi u ngoi ng xng.

-

Ni ch Y hoc kho ba chc vo u ngoi ng xng.

Ni hai ti vo hai u cn li ca ch Y hoc kho ba chc.

Ti ng dch vo treo ln ct truyn cch mt ging 0,8 -1m.
Ti ng dch ra t thp hn mt ging (t heo nguyn tc bnh thng nhau)

Bc 3: Tin hnh ra d dy

a dch vo: ng ng dch ra li, m kho ng dch vo cho dch

chy vo nhanh khong 200 ml, sau kho ng dch vo li. Dng tay lc v
p vng thng v cn thuc v thc n c tho ra theo dch.

M kho ng dch ra cho dch chy ra ti ng n khi ht s lng dch

a vo, ng thi vi lc v p bng dch chy ra nhanh v hn. Sau
ly dch cho vo chai lm xt nghim c cht (khong 200ml).

Lm nh vy cho n khi ht s lng cn ra (3 -5 lt) hoc dch d dy

trong khng cn vn thuc v thc n (nu <3 lt). Trong trng hp ng c
thuc tr su lng dch c th ra ti a l 10 lt.

Ch :
Theo di cn bng lng dch vo ra. Nu thy lng dch c hy ra < 150ml
nghi ng tc xng, kim tra li u xng.
Dch a vo cn phi pha mu vi nng 0,5 -0,9% trnh tnh trng
ng c nc do pha long mau.
Thi titlnh nn dng nc m 37 0c trnh tnh trng bnh nhn rt v gy
h nhit .

Bi ging Chng c
Bnh nhn ng c thuc tr su phi ra nc c pha thm than hot
hiu qu loi b cht c ddc tt hn, sau khi ly dch d dy lm xt
nghim c cht. Thng pha 20-30 gam/lit, pha trong 3-5 lt u.

Sau khi ra xong, ho than hot v sorbitol vi t l 1:1 vo 50ml bm vo dd

y ri rt xng nu khng c ch nh lu xng ra ln 2. Liu lng than hot
v Sorbitol cho vo d dy sau khu ra 1 -2 gam./kg bnh nhn, c th chia lm
nhiu ln cc nhau mi 2 gi. m bo p lc thm thu trong lng ru t cao
sau khi ra trnh tnh trng to bn hoc tc ruot do than hot liu lng
Sorbitol c th cao gp 1,5 -2 ln so vi than hot, c th cho lm 2 -3 ln sau khi
ra d dy.

Trng hp khng c ti ng dch chia vch v chc ba c th dng phu

hng dch vo, i n khi lng dch trong phu xung gn ht ta h u
xng xung thp hn mt ging (theo nguyn tc bnh thng nhau) cho dch
chy ra ng thi lc v p bng bnh nhn hn ch cn thuc v thc n
bm vo b mt d dy v dch c hy ra c nhanh hn. Tt nht vn phi dng
b ra d dy kn.

VI. Bin chng:

-

Nn: hay gp do khi a u xng vo n hng bnh nhn c phn x bun

nn v nn nht l tr em, bnh nhn lo s. V vy cn phi gii thch cho bnh
nhn bnh nhn c hp tc trong qu trnh lm th thut, v qu trnh t
phi nh nhng ng k thut

Vim phi do sc: l mt bin chng nng n, d tin trin thnh ARDS gy
t vong nu khng pht hin v x tr kp thi.

Gp bnh nhn c ri lon thc m khng c t ni kh qun c bng chn

trc khi lm th thut hoc qu trnh t khng bnh nhn ng t th, t
nhm vo kh qun m khng kim tra trc khi tin hnh ra d dy, hoc mi
ln cho dch vo qu nhiu, hoc khng ht ht trc khi ngng th thu t.
Biu hin: bnh nhn kh th tm mi v u chi, nhp th nhanh, nghe phi c
ran m hai bn thng bn phi, Xquang phi c m m thng bn phi
phi.
Phng: t ni kh qun cho bnh nhn c ri lon thc, nm nghing tri u
thp trong qu trnh lm th tht, kim tra li v tr xng trc khi ra d dy, mi

Bi ging Chng c
ln a dch vo nh hn hoc bng 200ml, ht ht dch d dy khi ngng th
thut .
iu tr: tu theo tnh trng bnh nhn m c th theo di v iu tru khng sinh
hoc kt hp vi t ni kh qun, soi ht v bm ra ph qun.
-

Chn thng vng thanh mn gy ph n thanh mn, hoc phn x gy

co tht thanh mn do u xng i vo ng kh qun, t th bo .

Biu hin: bnh nhn c cm gic au vng hng, ni kh, khn ting. Nng c
kh th thanh qun c th gy ngt th cp. Nu khng x tr kp thi bnh nhn
c th t vong.
iu tr:
Nh: Cho bnh nhn kh dung corticoid.
Nng: t ni kh qun, nu khng c phi m kh qun mt th
-

Chy mu:
Hay gp chy mu mi khi t xng n g mi do nim mc mi nhiu mch

mu nng, xng to, khng bi trn du paraffin, t th bo. Chy mu ming t gp

hn ch yu chy mu chn rng khi kh m ming bnh nhn, bnh nhn dy gia
khi t ng xng. Chy mu thc qun d dy gp khi dng xng c u cng, a
vo qu su.
Phng: Phi gii thch bnh nhn hp tc, lm ng ng tc, nh nhng
u xng khng vt cnh v cng.
iu tr: Chy mu nh thng t cm nu bnh nhn khng c ri lon ng
mu. Nng c th dng adrrenalin pha nng 1/10.000 ri nh vo ch chy
mu khi bnh nhn khng c chng ch nh dng adrrenalin. Nu khng
c th phi t nt gc l mi? Tt nht nn mi chuyn khoa Tai Mi Hng
cm mu. Trong trng hp chy mu d dy nng phi soi d dy cm
mu, c khi phi truyn mu khi c tnh trng mt mu nng.
-

H thn nhit:
Biu hin: Bnh nhn rt run, da tm v ni da g, nhit trung tm h <36

Phng: thi titlnh phi ra d dy bng nc m, ni kn gi, dng my si

trong qu trnh ra

Bi ging Chng c
iu tr: lau kh, m cho bnh nhn, dng my si, cho bnh nhn ung
nc gng-ng nng (khng dng gng cho bnh nhn c huyt p)
-

Ri lon nc-in gii: thng gp ng c nc do ra nhiu nc, khng

pha mui.
Biu hin: Nh: h Natri, Kali mu. Nng: ph phi, hn m, c khi co git d
gy sc phi nu bnh nhn khng x ni kh qun.
Phng: Dng lasix tnh mch, b sung mui sau khi bnh nhn tiu nhiu
(Natriclorua ng tim TM v cho ung).
Nu hn m, co git phi dng thuc chng co git, t ni kh qun, th my,
dng manitol truyn tnh mch.

Ri lon nhp tim: Thng l do phn x, c khi cng do ri lon nc in

gii nng gy ra nht l h Kali mu. c bit ng c mt s thuc tc ng ln
tim (digitalis, chloroquin, cacabamat...)
C th gp: Nhp chm xoang do kch thch dy X; NTT tht do h kali mu
iu tr: Nhp chm <40 ln/pht tim atropin 0,5mg TM.
NTT tht khi c h kali phi b kali bng pha truyn TM.