CHUONG 3 SINH LY TUAN HOAN Chdc nang bom mau cia tim Lan dau duge biét dén nhd cong trinh eda William Harvey, mot thay thudc ngudi Anh o thé ky 17. Ong da ching minh ring tim bom mu di quanh co thé. Khang dinh dé trai vi quan niém duong thdi, Harvey khong duge phép in thanh séch. Cac ban cua Ong bi mat dem ban thao sang luc dia chau Au in, ri bi mat chuyén séch vé Anh phé bién. Sinh ly hoc thuc sy cua tim va cua tu’n hoan mau bat dau tir dé. Vay tuan hoan cé j nghia gi d6i voi su s6ng? O co thé don bao nhu con amip su lay thie an va loai ( thai duge thuc hién qua trao d6i true tiép vGi moi trudng bao quanh, khong cn cé bd méy van chuyén chat. O dong vat cao eSp, cdc té bao két edu thanh m6 va co quan cé khdi lugng tn va c6 chic nang chuyén biét, do dé can {t gidia cac m6, céc co quan. Su van chuyén dé chinh fa tuan hon méu, van chuyén cl thuc hign nho c6 bd may tim mach: - Tim bom day mau di - Mach din mau (i m6, cap cho méi co quan mt lugng m4u hop vai nhu cau ting lic ciia tig co quan. CHUC NANG BOM MAU CUA TIM 1. DAC DIEM CAU TRUC CHUC NANG CUA TIM Trai tim la mOt khéi co réng lam thank hai cai bom riéng biét 6 hai nita trai va phai cia tim, dp sat nhau qua mdt e4i vach doc. Tim phai bom mau lén phéi, con tim tréi bom ra ngoai vi. 1.1, SU PHAN BUONG TIM VA VAN TIM m chic MGi bén tim c6 hai budng. Budng trén goi la nhi cé thanh mong chi yéu nang chéa m4u nhu mot thé tién phong trudc khi vao thét, Budng dudi goi a that c6 176thanh day la khéi co 1én cung céip lye chinh day mau vao dong mach. Gita nhi va that cia mdi bén tim ¢6 van nhi thét cho mau chi di mét chiéu tit nhi xudng that chit khong cho di nguge Jai. Khi mau qua Id van di xuéng that thi van md, la van Ap vao thanh tht. Khi that co, 6 that Lim van nhi that dong lai, mau ra dong mach. Van nhi that 6 tim trai goi la van kbong tn tro hai la, van nhi that 6 tim phai goi [a van ba Ia. O 16 thong tit méi ben tl la van dong mach chi cho mau tu that trai qua déng mach chi ra ng la van dgng mach phdi cho mau tit that phai di Kén phéi tim nghi khéng co b6p, céc thét gidn ra, nhung mau 6 dong mach khOng In vé that (tra dong mach, c6 van dong mach. Bén t i vi nudi co thé. Bén phai dy oxy. © thi tam truong, duge vi cae van déng mach dong Iai, mau van tiép tuc di ra ngoai vi. 1.2. SOL CO TIM Soi co xuong. Cac sgi két lai nhu mot mang Ludi, soi nay tach khdi co tim 1 Joai co van c6 sgi actin va myosin c6 kha nang co ngin rat gidng nhu gi khac, r6i lai dan vao nhau, roi lai chia ra. Co tim 1 mot hop bae. Soi co tim gém nhigu té bao riéng 1é song song, cO nhanh fa t6i chay ngang soi co tim c6 dién trd rat thdp, chi bing 1/400 im. Dign td thép vi mang té bao hoa lin ndi sang nbau. Cac so v6i dign trd qua mang ra ngoai soi co nhau tao thanh nhiing ché ndi té bao no sang té bao kia. Dé 1a nhiing ché ndi c6 tinh thm cao, cho cde ion dé dang khuéch tan qua. Dac diém céu tric nay cho phép ion di chuyén dé dang doc theo soi co tim. Nha d6 dién thé hoat dong chay tir té bao nay sang té bao 'khac, Nhu thé co tim 1a mot hop bao, tde 14 mot tap hop té bao dan vao nhau, khién cho khi mQt tf bao hung phan, thi dién thé hoat dong cia n6 lan toa ra khdp moi té bao cua mang ludi soi co tim dé. Tim c6 hai khdi hop bao. Mét la hop bao nhi lam thanh cac vach cua hai nhi. Cdn hop bao that lam thanh céc véch cua hai that. O mdi bén tim phai hoac trai, nhi va that ngan céch nhau bing mé xo bao quanh [6 van nbi that, Binh thudng dién thé hoat dong duge truyén tir khéi bgp bao nhi xudng khéi hgp bao that, hoan toan chi do mot hé din truyén dac bigt goi la b6 nbi thét, thudng viet gon la bé A-V (do A: atrium [a nhi, con V: ventricle 1a that), 1.3. HE NUT CUA TIM Tim c6 mOt he sgi co dac biét, duge biét héa dé thyc hign chic nang phat sinh hung phan va dan truyén s6ng hung phén, goi 12 hé nat hay he hung phén-din truyén, r1a-suH 177cau trie: (1) Duing Hinh 3-1 trinh bay hé dé, vdi na Pras nit xoang con goi 1a mat xoang-nhi, hay nut S-A (do S sinus 1 xoang), day 1 noi ph dong nhip nhang; (2) dudng lién nét, tru dong tir nit xoang sang nut A-V; (3) nat A-V, con goi 1A nat nbi-that 1 noi xung dong tir nhi ti, ding lai dé mot chat thdi gian ri mdi di xuGng that; (4) b6 A-V con goi la b6 His truyén xung dong tir nhi dén that, va (5) nan trai va nhanh phai cia cae sgi Purkinje (doc 1a pua-ki-ni-¢) din ind: 3-1. WG dln trayén trong, tim xung dong t6a di khap hai that. sinh xung Nab xoang Web he thif Whaich phat a hank pra} 2. NHUNG THUOC TINH SINH LY CUA CO TIM Co tim 14 mot co van, c6 kha nang co ngdn nhu moi co van. Tuy vay chtic nang co tim c6 ché khae co xuong. Co xuong co theo ¥ mudn, khi co nhanh, khi co cham, lai 0 6 mOt tu thé, tay nhu chu ting Kae. Co tim c6 chic nang co xong thi gidn, ri 6 khi git nguyén mic co tu dong (khOng theo ¥ mudn) va co nhip nhang tite lai gian, c6 nhu thé mdi bom mau dugc. Dé hoan thanh chic nang bom. co tim cé b6n thude tinh sinh ly chinb J3 tinh hung phéin, tinh nhip digu, tinh din truytn va tinh tro c6 chu ky. 2.1, TINH HUNG PHAN CUA CO TIM Tinh hung phén 1a kha nang co tim phat sinh dién thé hoat dong, di¢n thé nay lam co co tim, con goi tat 1a dién hoat dong. Dién thé mang lic nghi cia co tim xp xi tit -85 dén -95 milivon (mV), con cua cée sgi din truyén thi ching -90 dén -100 mV. Lic nghi sgi co c6 dién thé am nhu vay goi 1 6 trang thai phan cue. Khi ¢6 dién thé hoat dong thi c6 hign tugng khit cuc te 1a khu b6 trang thai phan g len vé phia khong i phan cuc, dién t phan cuc nia, tiie tang vé phia OmV. C6 diéu la ting thém ching 105 mV, cho nén qua trinh khd cue khong ding lai 6 mite 0 mV, ma dién thé cn lén thém dén mic tr] duong nay goi la dién thé lén qua da (overshoot). ti mac -85 mV cia trang t hoi duong, ching +20mV. Phan D6 la dinh dién thé tac dau. Sau dinh, mV dé trong 0,2 dén 0,3 gidy goi la cao nguyén, sau cao nguyén lai xudng dot ngot danh du lic két thic dién thé hoat dong (cao nguyén 1a plateau ti¢ng Phap, chi mat mat bing cao hon mat dat, tit Phap dia ly nay da rat thinh hanh 6 nhidv aude dé chi iGn thé con duge duy tri 6 muc tri sé +20 178dign thé cao va kéo dai 6 mic trén dién thé sinh hoc co sd). Dién hoat dong co tim khéc co xudng 6 hai diém chinh la c6 kénh cham va c6 giam tham kali, Khde bigt the nhat la c6 kénh calei cham 6 co tim. Dign hoat dong 6 co xuong la do mé kénh natri nhanh dan ion natri at vao nhanh trong soi co, goi la kénh nhanh vi chi mé trong vai 1/10.000 giay, rdi dot ngot déng ngay. Sau dé qua trinh tai phan cyc lai thuc hién rat nhanh cdng chi trong vong vai 1/10.000 gidy. © co tim thi kénh calei cham cing cdn goi 1a kénh calei - dng o6 kénh natri nhanh, ngoai ra con natri. Kénh cham nay mé thoi gian dai ti vai 1/10 gidy, Iie nay long ln ion Ca** va Na’ vao trong soi co tim, duy tri lau dai trang thai khét cuc. Trang thai khu cuc dai nay duge phan nb Ién dating ghi cao nguyén cia dign thé, Khe biét thit hai la su gidm tinh thm kali 6 mang co tim. Trong hic c6 dién thé hoat dong, tinh thém nay giam chi cn 1/5, do dé kali khong ra khdj mang, khong gay hién tuang tdi phan cue dugc. Dac diém giam thém K* nay khong 6 6 co xuong, chi c6 4 co tim. DO 1a yéu t6 gop phan cing 16 khac biét thi nhat (kénh Ca** cham) duy tri cao nguy¢n cia dién thé, Noi cach khac 1a do hai khac biét_ké wen, co tim 6 dién hoat dong dai thé hign 6 cao nguyén, do dé thdi gian co co dai, nho do thuc hién chic nang bom. Ta biét ring dién hoat dong co xuong 1a xung rat ngén khong c6 cao nguyén. 2.2. TINH DAN TRUYEN CUA CO TIM Trong sdi co d ahi cing nhu 6 that, dién thé hoat dong duge dan truyén voi tc do ching 0,3 dén 0,5 mét mot gidy, tue a chi bing 1/10 6 soi co xuong, va 1/250 6 sgi thin kinh to. Téc dé trong hé dan truyén la ti 0,02 dén'4 mét mot giay tay ting phan tim. Dac diém dan truyén cham va khée ahau nhiéu tay phan tim la lién quan vdi chic nang tg0 abip co bép tim bom mau (néi ky 6 doan 3.2 cing bai). 2.3. TINH TRO CO CHU KY CUA CO TIM Co tim c6 tinh tre nhu moi mé c6 tinh hung phan. Tinh tro thé hign Ia sau khi vila ng dién thé hoat dong, hode kich Thoi gian tro 6 that hung phan co co xong thi mét xung dién mdi (mot s thich nhdn (ao) khOng thé kich thich gay hung phén mdi du tir 0,25 dén 0,30 gidy. Sau thoi gian tro tuyét d4i 46, e6 thdi gian tro tuong déi, [a lie kich thich cé gay hung phdn nhung kho hon. Thdi gian tro 6 nhi ngdn hon that, chi ching 0,15 giay. Tinh tro cia co tim gidi thich. hign tuong ngoai tam thu, 2.4. TINH NHIP DIEU CUA CO TIM Tinh nhip digu la kha nang ké tiép phat xung lam tim c6 Lin s6 tim dap: co ri lai 179gidn, d6 1a mot Lin dap, ri lai co gian nia, ctf thé mii... vdi mot nhip tim dap binh thudng ching 70 Fin trong mot phtit (70 lin/phat). Xung déng gay tim dap thudng phat sinh 6 nut xoang rdi truyén di khap tim gay mot Lin tim dap. Ngudi ta gidi thich co ché cua tinh nhip diéu co tim trén co sO su ty hung phan nut xoang do 6 ri ion natri nhu sau. Dé giai thich co ché cia tinh nhip digu co tim, da e6 mhiGu da liGu phang phi ve nhitu mat. Sau day la t6m tat ¥ kiGn chinh. Dién thé nghi ca nuit xoang co gid tri it Sau [in tim dap, ion natei 1 Fi us -60 mV lén t hoang -40 mV, n hoat ding. Nhu vay vé co ban, su r6 ri vao sgi nat xoang m hon sgi co thét, chi chiing -60 mV so vd vao (rong sgi nut xoang Lim ung din dig d6 la mie ngudng tao di lam nt nay ty hung phan, va hung phan theo nhip déu dan. Khong chi nt xoang, ma nhiéu phin khdc cua tim cing 66 kha nang ty hung phan theo nhip, dac biét 1a ndt A-V va che soi Purkinje. Binh thudng ndt xoang phat xung v6i nhip chung 70 in/phit va toan bd tim hung phan theo nhip dé. Ngudi ta goi nut xoang 1 nut din nhip (pacemaker). Khi ndt A-V khdng nhan xung ti nut xoang (bénh ly hode thue nghiém) thi phat xung vi nhip ri¢ng 1a 40 dén 60 Lan/phut. C Purkinje khi khong nhan xung noi khde dén, thi wf phat xung vi nhip tir 15 dén 40 Lan/phat, Cac trudng hop nay goi la din nhip lac ch6. 3. CHU KY HOAT DONG TIM Mot chu ky hoat dong tim goi tt 1a chu ky tim hay chu chuyén tim la mt vong hoat dong ké tir mot Rin tim dip dén lic lai bat dau dap Fin sau. Tay déi tugng va myc tiéu nghién edu hay khéo sit, c6 thé c6 nhigu cach lay mée luc bat du chu ky. Dudi day mé ta cdc hién tuong theo trinh tu céc hién tugng sinh I phat sinh, ké tit lic c6 sng dién hoat dong 6 nut xoang 1a yéu 16 gay Rin lugt céc hign tuong tigp theo, cho dén khi c6 s6ng dign thé hoat dong ky sau 6 nat xoang 3.1. PHAT SINH BIEN THE HOAT BONG NUT XOANG Nat xoang nim 6 nhi phai, thanh phia trén va bén, noi tinh mach chu trén dé vio nhi (Hinh 3-1). Séng dién thé toa nhanh ra khap ha ALY (te nat nhi that). Dén nut A-V xung dong lan truyén cham lai 1/10 gidy trude khi qua b6 A-V dé xudng that. Su chim lai nay c6 ¥ nghia chit nang 1a doi cho nhi En lugt that co dé nhi, qua dudng lién nhi dén nit thu xong, hoan tit viée chuyén mau tir nhi xudng that, thi moi bom mau ra he dong mach di khip co tné. 180Gait dang sith Fang nae pM ve nhanh ease we ‘Mau vé° chim eae [ ea hie 4207 | Mean | | | 100) “ame Hinh 3-2, Chu kj hoat dong tim (chu chusén tim) 1B thi bibu dién cia: 1 asdm C (4p sult ding mach chi 2. a8 nh (Ap suit tam ni tris 3. as that (@p sult kam that tails 4. thE ich that; 5. ECG (ign Lim dy, 6. PCG (tim thanh 43):11, Ta, Ta: ce ting tim ther mbit, thir hal va whi ba; van NT: van bi ‘Tom Ii, song dién thé phat sinh 6 nut xoang, tir d6 lan ra nbi, roi xudng that, Ln lugt gay ra tai cic phn cia tim, nhing am thanh nhu hinh 3-2. i¢n tugng dién hoc, co hye co ca, ap suat va 3.2, TRINH TU CAC HIEN TUONG TRONG CHU KY HOAT DONG TIM. C6 thé coi la ¢6 ba giai doan chinh la nhi thu, that thu va tam truong toan b6. Nhi thu 1a két qua cua su lan t6a sng dién thé dan nhip ti nét xoang ra toan bo hai ni. Lae may van nbi that van dang mo, nhi co diy nét lwgng mau (ching 1/4) tit nhi xudng that, lim 4p sudt nbi va that ting lén tao s6ng a. Nhi thu kéo dai ching 0,1 gia 181ng dién thé lan khap thét. That thu lam 4p That thu [a két qua cia co that khi sudt that tang vot, diéu dé lam thay déi cc twong quan 4p suat va chia giai doan that thu lam hai thoi ky la tang 4p va téng mau. Thdi ky ting 4p bat dau lie ap sudt that Ot 4p sudt nhi lam dong van nhi that, va két th it vuot Ap sudt dong mach chit lam md van dong mach. Thai ky nay rt ng’n, chi 0,02 dén 0,03 gidy, va con goi 1 co dang thé tich, thudng ndi tat 1a dang tich (isovolumetric contraction), Dang thé tich vi tuy co tim tao sie nén vao mau, nhung Ap sudt 4 that chua vuot Ap sudt dong mach, mau chua ra déng mach, thé tich that van khong ddi. Tiép theo d6 1a thoi ky tng mau dai chimg 0,25 - 0,30 gidy, bat dau Iie md van dong mach, két thite tic dong van déng mach. Van nay déng khi that chom gidn lam 4p suat that sut xudng ich. Nhu vay toan giai doga that thu, gém ca tang 4p lin tng mau, € lie fp suait t thap hon 4 dong dai ching 0,30 gidy. Tam truong toan bé [2 giai doan toan tim nghi ci nhi ln that, khong 6 song dién thé nao lam co co. Giai doan nay dai chimg 0,4 gidy, bat dau lic déng van dong mach va két thiic khi nhi sip bat dau co. Giai doan fom ba thoi ky 1a gidn dang lich, mau vé cham va mau vé nhanh. Thai ky gidn dang tich (tim gid nguyén thé tich, thie mau khong vao) bit dau Iie dng van dong mach khi co that chém gi ft that tut xudng thap hon 6 ahi. Tiép dé la tho lic m6 van nhi that do Ap si tim nhanh. Tiép theo sau nia 1 thoi ky mau vé tim cham. Qué trinh mau vé tim c6 nhigu tén goi nhu "ve day tim" (filling), "mau vao tim" (inflow). Dén day nhi co, coi la bat dau chu ky sau, dui anh hudng cia dign thé hoat dong [an sau phat sinh 6 nit xoang. Trén day 1a trinh bay ba giai doan cia chu ky tim, vi hai dic diém: (1) trinh ty cae hign tuong theo logic thdi gian, hign tugng dién thé 6 xoang e6 dau tién ri mdi lan ra nhi gay co nhi réi xuéng that gay co that; (2) quy tron thdi gian cho dé nhd. ch mo ta Nén biét ring trong thye hanh va trong mén tim hoc, chu ky tim c6 khac, e6 hai dic diém: (1) thdi gian cae giai doan la khong Lam tron s6 va khong cé dinh, ma bién déi theo Lin s6 tim dap, va cin c6 thém ce tri s6 chi tiét vA nhang thong s6 khac cia chu ky tim; (2) thudng chia mOt chu ky tim Kim hai giai doan la tam thu day mau dj va tam truong lay mau vé. Nhiing séch sinh ly gin day, ngoai phiin dign thé 6 xoang c6 trudc va lan xudng m6 ta ba giai dogn theo nguyén nhan két qu: ahi 1A nguyén nhan gay co nhi ri mdi lan xudng that gay co U chu ky tim hai giai doan tam thu, tim truong (Guyton, 1994), C6 thé ndi dé 1a dich bom vita hat ay mau lai c6 phn mo nhin dong hoc cia mau qua trai tim. Dudi gée nhin dé, tim 1a mot visa day, chu ky tim c6 hai giai doan: (1) tam truang (diastole): that gi vao that; roi (2) tam thu (systole): that co, tim bom mau di (xem dogn 7, chiie nang that, 6 dudi). Nhi thu khdng fa m6t giai doan, ma chi la mot phn nh, phan cudi va 182khong thiét yeu cua giai doan tam truong tc giai doan Idy mau vé. Néi 1a khGng thiét yéu vi nhi khong bom toan bo mau vé that ma chi "bom nét" 1/4 lugng mau ve that va trong bénh ly khong c6 nbi thu, chic nang ldy mau vé that vin thyc hign trong thi tam truong, do sie hut cua that. 4. SU SONG HANH HUNG PHAN-CO CO. D6 1a co ché chuyén dién thé hoat dong thanh su co co tim, dién bién nhu sau. Khi dién thé tir hé din truyén chuyén sang mang co tim, n6 toa ra khdp sgi co tim (libers) doe theo mang dng T, rdi tic dung lén dng doc 6 co tuong, Lim gidi phéng n calci tis mang co tuong (sarcoplasmic reticulum) ma vao co tuong. Chi trong vai 1/1600 gidy, ion calei khuéch tén vao to co (myofibrils) xc tae céc phan ing hoa hoe lam sgi actin va sgi myosin trugt Ién nhau, dé Li su co co voi co ché gidng nhaw gia co tim va co xuong. Lai c6 dae diém 6 co tim khae co xudng. Dé 1a ion calci gdm hai phan: mot phan ti mang co tuong vao to co, lai con phan nda la mot lugng [on ion calei tu Sng T cing co xuang khuéch tin vao co tuong. O co tim, mang co tuong kém phat trién so vi nén c6 it calci, ma cin thém calci tir 6ng T 1a loai ng dudng kinh to gap 5 fin dng T co xuong, do d6 thé tich chda ion calci l6n gap 25 Lan, moi di cho nhu cu co tim. Luc co co tim phy thuge phin Idn vao nding dQ ion calci ngoai bap vi Sng T thong voi Khong ke bén ngoai sdi co, Dé 1a diém khdc voi co xuong, phy thuge chu yéu vao ion calci mang co tuong. 5. DIEN TIM TRONG CHU KY TIM Dign tim binh thudng 4 hinh 3-2 ¢6 cdc song P, Q, R, S va T. Dé Ia tim phat ra va ghi tir dign cyc dit G mat ngoai co thé. Song P la do su khit cuc toa ra khap nhi. Tiép sau hién tugng dién (séng P) ld su co nhi lam tang nhe 4p sudt (sng a) 6 nbiva 6 tinh mach gan tim. Ching 0,16 giay sau khi bat dau song P, thi xudt hin phie bé QRS do khit cuc céc that. Khit cuc nay gay hign tugng co hoc co that Kim Lang vot 4p suat trong that, Sy co that bat dau sau mdt chut so vdi lic bat dau phic bd QRS cia dign tim. Cui ing 1a séng T cua tam that, la gi co that bat dau gidn. Hién tuong dién (song T) xay ra true md co hoc khi that bit dau gidn (chi tt vé dién tim, xin xem phan cudi chuong Sinh IY doan tai cuc céc tam that, lac nay cae soi chit so v6i hin tugng tain hoan). 1836. AP SUAT 6 NHI VA TINH MACH DO Dé thi 4p suat nbi 6 hinh 3-2 c6 ba s6ng a, ¢ va v. S6ng a la do nbi thu, 4p suat ting 4 - 6 mm Hg 6 nhi phai va 7 - 8 mm Hg & nhi trai. Séng ¢ chit yéu do van nhi that (van A-V) phong vé phia nhi lam tang nhe 4p suat nhi. Cé ngudi cho ring mOt phiin con do Ivong nh mau Idi ve nhi, Song v 6 cudi thi co that. Trude d6, trong qua trinh co that, van nhi that dng, mau tit h mach ty do chay vao nhi lam p sudt nhi tng tu 1, Chot tam that gi 4p suat trong that sut nhanh, khi xudng thdp bon dp suat nbi thi van nhi that mo, ap sudt nhi bi kéo theo da giam 4p 6, dd thi di xuGng lam ndi go lén song v. © doan tink mach gan vé dén tim, bién dong 4p sudt phan Anh tinh hinh ap suit ahi trai, nén trude day ngudi ta ghi dd thj tinh mach canh 6 c6, voi ba séng a, ¢ va v 7. CHUC NANG CUA TAM THAT: CAI BOM VUA HUT VUA DAY Ngudi ta goi tam that 1a cai bom vita hat via day, vi trong tam truong né hat mau vé thdt, trong tam thu né day mau ra dong mach. 7.1, LAY MAU VE THAT TRONG TAM TRUONG Trong thi tam thu, van nhi that déng nén mu tit tinh mach vé nhi thi dong lai trong nhi, Lam p sudt nbi tir ti tang. Dén khi chat glan, dp sudt that sut, khi xudng dudi mac 6 nhi, thi mé van nbj that, mau ti nhi xuéng nhanh that. Su mau vao that nhanh dé duge phan nh [én dé thj thé tich that tang nhanh 6 hinh 3-2. D6 1a thoi ky mau vé nhanh, Ap suat nbi chi con chénh hon that mot ti chat ( mot phin cua 1 mm Hg) vi 16 van mo rong khdng can dang mau xudng t chiém khoang 1/3 dau cua tam truong. Thoi ky mau Vé nhanh Dén 1/3 gitta cia tam truong, chi c6 mot it mau vio that, méu nay ti tinh mach vé qua nhi khdng ding 6 d6 ma di thang ludn xudng thai, day [a th Dén day da 6 ching 3/4 luong mav vé that. _ 1 Dén 3 that (cha ¥ nhi co la mot b6 phan’ cia tam truong 6 quing 1/3 cudi cua thi tam truong). i ky mau vé cham. . ay nay 4b . cudi tam truong nhi co day nét_ — lwong mau vi 7.2. BAY MAU KHOI THAT TRONG TAM THU Trong thoi ky co dang tich (dang thé tich), co tim trién khai lye co [am tang 4p 184sudt that, nhung van dong mach chua md (0,02 - 0,03 gidy). Trude day ngudi ta goi 1a thdi ky co ding trudng (isometric, khong déi chiéu dai), nhung tit ding trudng chi tuong déi ding vai sy co dai ti day dén dinh tim 1a ngén Iai, chu vi quanh tim thi phinh to ra, cho nén nay chon tit co dang thé tich (isovolumetric) ki hop hon. co xuong git tu thé, cOn déi voi co tim thi cu ly chiéu A that lam m6 van dong mach, mau chay Sang thai ky tng mau (ejection), ap s sang dong mach. Lac dau, mau ra nhanh, chi 1/3 dau cia thoi gian téng mau ma da bom 161 2/3 luong mau cia mot Lin tam thu, Con lai 2/3 thai gian, mau ra cham, dua n6t 1/3 lugng mau con lai. Vi vay, 1/3 thdi gian dau con goi 1a tng mau nhanh, 23 thoi gian cOn lai goi la tng mau chim. O day c6 mot chi tit rat dae bist, la trong tng mau cham, Ap suat 6 that hoi thép hon déi chat so vdi 6 dong mach chi, Mau chuyén (ir noi ap suat thap sang noi ap suat cao khong 1a diéu mau thudn. Gidi thich nhu sau: mau duge t6ng ra khoi thit tao ra mot momen quan tinh, momen d6 c6 dong nang duge chuyén thanh ap suat 4 dong mach chi lam cho ap sudt 6 dong mach hoi cao hon 6 that, 8. CHUC NANG VAN VA TIENG TIM it (van hai la bén trai, van ba la bén phai) ngin mau khoi lon te tv nhi, cdm van dong mach ngan mau khoi ln ti déng mach cha va déng mach it (wong Ging. Co ché van [i thu dong, déng néu mau di nguge chitu, mo f pho khi mau di audi chigu. La van duge gitt khdi In nguge kéo mau doi nguge chiéu, la nho e6 day ching bude mép l4 van vio co tru trong that, Khi co that co thi co try cing co dé niu la van lai, Khoi phing qué vé phfa nhi Kim méu lai qua khe hé! Cac 14 van dong mach cing c6 day ching, 14 van va day ching bén va khoe 6 van nhi that vi phai chiu dung 4p sudt cao hon. Khi ding dng nghe tim, khong nghe thay tiéng m6 van, nhung khi van d6ng gay dot ngot bién dong va khae bigt Ap sudt thi tao nén rung dong cia [4 van va cla éu dé tao thanh tiéng lan di kh&p long ngye. xung quanh, Thoat that co, lam dong céc van nhi that, (a nghe tiéng tram va dai goi Ia tiéng thi nha At [4 T), goi tuong thanh Ja ting "bim". Khi that truong, céc van dong mach déng, ta nghe duge ting thanh va ngan, goi la tiéng tha hai, ghi tét A T,, goi tugng than 1a tigng "a yen King ngéin. , goi la yén lang dai. Thoi gian tir T, dén T, dng xdp xi voi Lam thu, chiing 03 g Thai gian tu T, im truang, chimg 0,5 gi Doi khi c6 thé 6 tigng tha ba, nhung thong thudng t tam thanh dd cha khong nhan biét duge qua tai ngudi nghe. T, sau dng xp xi vo ing dé phan 4nh trén dd thi 1859. LUU LUQNG VA CONG CUA TIM THE TICH TAM THU mau diy ra khdi tim trong mot Thé tich am thu thudng ky higu 1 Qs 1a 6 mi tam thu (con goi li mot nhit bop). Thé tich dé thong thudng {4 60-70ml. Hinh siéu am c6 thé cho ta bit thé Lich mau trong that trude khi that thu 1a khoang 110 ml, goi la thé tich cudi am truong. Sau khi thét thu, Iugng mau dé con khoang 40 ml, goi la thé thé tich tam thu 110 - 40 = 70 ml, quy ra phan cudi tam thu, Hiéu hai dai lung dé trim lvong mau o6 ¢rong that, goi la phan sé t6ng mau, 14 70 : 110 = 60 phan tram. i tm truong c6 thé lén toi 150 - 180 ml, thé tich cudi fh tam thu Ién tdi 150 - 180 mf tie la gap 2 - 3 Khi vn co manh, thé tich con 10 - 20 ml, do dé thé in Ide nghi. tam thu cl LUU LUQNG TIM VA CONG CUA TIM Luu luong (im can goi la thé tich phuit, thudng ky higu la Q, la sé lit mau do tim bom di trong mot phdt. Luu lugng bing tich ca thé tich tam thu Qs nhan vdi tin sé tim fe. Ngudi nghi ngoi, lu lugng tim thudng quang 5 lit/phut Q = Osx te = 70 ml x 70 lan/phut = 5 lit/phut. Céng cia tim la ng nang luong tim sit dung trong mt phat. Nang lugng tigu dang dudi hai dang. Dang thi nhét goi la dang ngoai, chiém phiin rat lén, la cong ding dé chuyén mau ti tinh mach c6 4p sudt thip dén dong mach c6 ap suat cao. Dang cong ngoai cdn goi 1a cong thé tich-4p sual. Dang cOng thi hai chiém ti 1¢ nhd, ding dé gia te mau, tiie Li tao We dé chuyén mau qua céc 16 van dong mach, dé 1a nang luong ding hoc cia dong mau, goi la cong dong hoc. Cong thé tich - 4p sudt (cong ngoai) Tri s6 cua cong nay bang tich cua luu lung tim Q nhan v6j chénh iéch ap suat AP. Chénh Iéch 4p suat Ja higu céa dp sudt tam thu trung binh that trai tru Ap sudt tam truong trung binh that trai. Ngudi ta biéu thi bang dyn trén centimet vudng, luu lugng tim bang mililit va nhu vay don vi cia cong 1A erg. Co thé tinh cong cua mot [in tam thu, céng d6 bang thé tich cam thu Qs nhan vdi chénh léch 4p suat AP. Cong thé tich-Ap suat cia that phai thudng bing 1/6 cua that trai Cong dong hoc cia dong mau Dé 1a cong thyc hién dong nang cia dong mu, cong nay ti Ié voi khdi lugng m 186cia mau nhan voi binh phuong van téc v cua dong mau. Dong nang = — gam, van tc mau bang don vi ccntimet Nguoi ta biGu thi luong mau bang don trong mot gidy, vi nhu vay don vi ciia cong 1a erg. Binh thudng cong dé tao dong nang dong mau chi chitng mOt phin iam tng s6 cong do that thuc hién, nén c6 thé b6 qua dai lvong nay, ma chi clin tinh cong Ap sudt -thé lich va lay dé danh gid 16ng sd cOng do co that thyc hién. Trong mot s6 diéu kign bat thading nhu hep van dong mach, mau qua Id van chi An t6c rat cao, tham 86 van te v rat ln, dong nang 16n cé thé 161 mc 50 phan tram ting sé cong cua tim. Trong trung hop nay, tinh cng cia tim phai ké cd cong dong hoe. hep voi 10. DIEU HOA HOAT DONG TIM Mot ngudi lic nghi thi tim bom di khoang 4 dén 6 lit mau mdi phat. Khi van co nang uu lugng ¢6 thé ting gap 4 dén 7 Rin. SO di tim thich nghi vi dép dng duge nhu chu d6 1a ahd hai co ché co ban la; (1) ty digu ha lye co co tim theo Iugng mau vé tim, va (2) diéu hoa do cae yéu t6 ngoai tim, 10.1, TY DIEU HOA TIM THEO CO CHE FRANK-STARLING Luu lugng mau tit cdc tinh mach ngoai vi tro vé Limi Ja yéu (6 phat dong su tu dong thay déi Ive co that, sao cho méu tinh mach vé bao nhiéu, thi that sé day ra dong mach bay abi i tim thich dng vai luang mau ve tim duge goi 1a co ché Frank- Kha nang noi Starling dé ton vinh danh du hi Starling da nghién cau co ché ny (ngudi 12 cdng con ndi 1a tim dip dng theo quy luat Starling). N6i céch khde 1: trong pham vi gidi han sinh ly, mau vé tim bao nhiéu thi nha sinh ly hoc céch day gan mot thé ky fa Frank va tim bom di bay nhidu, khong dé ¢ dong mau qué nhiéu 6 tinh mach. Giai thich co ché Frank-Starling Mau vé that nhiéu thi lugng mau dé lam co tim bj kéo dai thém, Diéu dé lam cho céc sgi actin va myosin g6i nhau voi vi tri thudn loi hon dé tao luc co co. Nhu vay mau cang vé nhicu, co tim cang bom khoe. Kha nang sgi co cang bi kéo dai cang dap ing co ngin manh, li dae tinh chung cia moi co chi khong chi riéng ci co tim. Ngoai 6 tim dap ra mau vé nhigu lim phong cang vich tam obi phai, digu dé 1am tang van tuy phiin dong gop nay cho luu lugng rit it hon phan cua co ché Frank-Starling. Huyét 1874p dong mach cing rat it tac dung én mc bom mau cua tim. Tom co ché Frank-Starling c6 vai tro rat co ban digu hoa Luu lvong tim. 10.2. DIEU HOA DO CAC YEU TO NGOAI TIM Vai trd hé giao cdm pho giao cam (thfin kink) iao cam (day mé tau tric vagus). Tim nhn rat nhiéu soi than kinh giao cém va pho. Thye nghigm kich thich giao cdm fam luu lugng tim ting gap doi, con kich thich day pho giao cam lam Luu lugng giam xudng gan s6 khong. Kich thich giao cm manh 6 ngudi tré tudi lam tn sé tim dap 1én ti 200 Lin/phat, tham chi hon nia, ngoai ra con ting thé tich tam thu, tang dp suai téng mau, uu lugng tim tang gap 2 - 3 lan. Binh thudng, cae sgi giao cam phat xung 16i tim Jam law lugag tim 6 mtic 30 phan tram cao hon so vai khng c6 xung giao cim. Do dé néu ite ché giao cm thi luu lugng Jin Jyc co tim. tim gidm 30 phan tram do gidm ca tin s6 tim Kich thich pho giao cam (day mé tu tue vagus, tie day phd vi, day X) lam tim dap cham, kich thich manh lam nging tim trong vai gidy, tigp dé néu vin ct lién tyc kich thich thi c6 hién tugng “tam thoat" tc [8 phd giao cdm mat higu luc; tim lai dap tro lai vOi tan s6 thap hon, ching 20 - 30 Ran/phdt. Lic nay fuu Ivgng tim chi cOn chimg 50 phan trim. Su tang thn s6 tim dap cd mot mde t6i uu lam tang Iwu lugng tim. Dinh tdi uu dé vao quang 150 - 170 lin/phat. Tan sé tim vi dip qué nbanh, chu ky tim ngan fai, thdi gian tam {ruong qué ngin khong du cho p Ien qué cao nda thi luu lugng tim gidm mau vé tim. Co ché thé Jon kali 6 dich agoai bao am tim dap cham va yéu di, va déng thi dan truyén xung dong ti nhi xudng that bi cham lai. Co ché tac dung 1a do ndng dO cao kali: agogi bao n didn thé aghi mang sgi co tim. Ion calei ngoai bao c6 tac dung nguge lai ion kali, do calei Lim ting co co tim. Thiéu ion calci lam giém hoat dOng tim, binh thugng mde calci huyét co thé duge duy tri kha dn dinh, it khi cé dao dong ti mie anh hudng dén tim. g in sO tim dap khi sét, giam nhip tim 6 than thé, thi dy mudng Nhiét dO c6 anh hudng dén tim, 1am 1 trong ha nhiet nhan tao (ha nhiét nbn tao 1a lam gidm ahié con 30°C hode 25°C, lic nay co thé chiu dung tt su thiéu oxy trong mé tim). Cac hormon tuy thugng than va céc chat thude gidng giao cam lam tang hoat dong 188tim. Ci tang hoat dong tim. chat thude gidng phé giao cam tae dung nguge lai. Hormon tuyén giép lam Cac yéu té khée diéu hoa tim C6 mot s6 phan xa digu hoa tim. Ap sudt cao 6 déng mach chi tao xung dong qua a day thin kinh gidm ap), Ap suat cao 6 dong mach canh day Cyon (day Cyon con goi tao xung dong qua day Hering, céc logi xung dong nay vé hanh nao, chuyén sang day thin kinh phé vi (te day mé tau, day X) de ché hogt dong tim. Dé 1a nhing phan xa 5 V, ciing vé hanh nao, ra day Ep vio nhan clu tao xung dong 6 day than kinh so s phé vi (day s6 X) te ché tim, Day la phan xa mat tim c6 ng dung Lam sang (tham do truong lye day X, lam giam nhip tim). Trung tam ho hap c6 anh hudng dén tim, thé hién 1a sau khi bat dau thi hit vao, thi nhip tim tang nhanh, sang thi tho ra nhip tim chm tai. Hign tuong nay thay 6 ac dung nay bing phan xa tren cho thue nghiém. Ngudi ta giai thich mot phin Bainbridge: khi hit vio, nguc nd, ap sudt quanh tim gidm, nhi va tigu nhi nd to lam Ung nhip tim. Cang c6 ngudi giai thich day {a tae dung lign trung tam: trung tam hit vao hoat dong thi lam ting nbjp tim. O loai ngudi thudng la khong thay ro anh hudng cia h6 hip déi vai nhip tim. Tuy vay 6 mot s6 ngudi tac dung nay rét 16, tao nen hign tugag sinh ly goi l& nhip tim khong déu do ho hap. CO SO VAT LY CUA TUAN HOAN MAU do luu chuyén trong hé mach gdm cae phan kich thudc rat khde p. Su luu chuyén méu tudn theo nhiing quy luat vat ly rat p sudt ddy méu, dén Iuu lugng mau chay, dén sie cin cua tinh thanh mach ( nhau, hinh dang rat phic ién quan dén ai quan vi kich thudc mach, tht mach) va nhiéu yéu t6 khée. Phin dudi day xem xét may vin dé vat ly 1a co sO cia dong hoe mau trong he mach cua co thé. 1. DAC DIEM LY CHUNG CUA SY TUAN HOAN Tuan hoan gdm hai phan la: (1) tuin hoan hé théng con goi 1a dai tu’n hoan hay tun ho’n ngoai vi; (2) tu’n hoan phéi con goi 1a tiéu tuan hoan 189Phan nay sé diém nhing dac tinh chinh cla céc phan khac nhau cua hé mach. 1.1, CAC PHAN CHUC NANG CUA HE MACH Dong mach c6 chic nang van chuyén mau dudi ap suat cao, do dé c6 thanh mach khoe, bén, din mau chay nhanh. Tiéu dong mach la céc nhanh nhé cudi cing cia he dong mach, hoat dong nhu cae van digu hoa lugng mau dén mao mach (uy nhu cau. Dé [i nhd c6 lép co khée cia thanh mach c6 thé déng tit dong mach hodc md rong cho mau qua nhidu. Mao mach c6 chife nang trao déi dich, chat dinh dudng, hormon, v.v. nén thanh mong, tham cée chat phan tit nho. Tiéu tinh mach thu gom mau tt mao mach, hOi ty din thanh tinh mach ngay cing to hon. Tinh mach la 6ng din mau tt m6 quay ve tim, va 1a noi chia méu quan trong. Ap a lap co €6 thé co suat 4 day thép nén thanh mach méng. Tuy vay thanh tinh mach hoac gian dé thay d6i sac chia mau dy tri ty nhu chu. 1.2, LUONG MAU, THIET DIEN VA AP SUAT 0 CAC PHAN CUA CAY MACH Ti Ie luong mae edi fn 1 8 tinh mach, cd (i 64 phan tram mau toan co thé lao tinh mach, 13 4 dong mach, 7 4 tiéu dong mach va mao mach hé théng, 7 6 tim va 9 phan trim 6 cac nhé) nhung cudng d6 trao ddi cao nhd c6 dign tigp xic rit rong. Tong thiét dign (mat c4t) céc ph’in cua cay mach nhy sau: déng mach chi 2,5 cm tinh mach 250, tinh mach chu 8 em’. Cha ¥ tigu dong mach 40, mao mach 2500, tinh mach c6 thiét dién rong hon dong mach chimng gp bén Lan. Van t6c mau ti mm/giay 6 mao mach (1/1000). Nhu vay voi chigu dai mao mach théng thudng tit 0,3 , thai gian dé la dit cho khuéch é nghich vi thiét dign, chimg 33 cm/gidy 6 dong mach chu, 0.3 dén 1 mm, madu fuu trong mao mach tit 1 dén 3 tn moi chit. Ap suat cao nhat 6 dau dong, chiing 100 mm Hg 6 dong mach che véi dao dong qua cac tri sé huyét 4p tam thu (Ps) 110 mm Hg va huyét 4p tam truong (Pd) 70 mm phai thi Hg. Ap sudt gidm dan susi theo cay mach, ti ché tinh mach chi dé vao ni bang khong (bang 4p suat khi quyén). O mao mach hé théng, dau mao dong mach 6 4p sudt 35 mm Hg, dau mao tinh mach 10 mm Hg, nhung "trung binh chic nang" cia dng mao mach chi thap ching 17 mm Hg, nhd dé nude khong rd ri qua 16 mao mach, trong khi chat dinh dudng van khuéch can dé dang. © hé tu’n hoan phéi ap suat thap 190hop so v6i tuan hoan hé théng. O dong mach phéi, Ps 25 mm Hg, Pd 8, trung binh 16 mm Hg. Ap suat mao mach phdi chi 7 mm Hg. 2. LY THUYET CO BAN VE CHUC NANG TUAN HOAN Chiic nang tun hoan co lam chi tit nhigu khi rat phic tap. Tuy vay moi chic nang tuan hoan hau nhu déu dua trén co so ba nguyén ly co ban trinh bay sau day. IH RAT DUNG NHU CAU 2.1. LUU LUONG MAU TOL MGI LOAI MO DEU DUOC DIEU CH Khi mo hoat déng, nhu clu mau c6 thé tang rat cao, 161 gdp 20 dén 30 Lain so voi tic nghi, Thong thudng tim khong thé ting Iuu lugng gap 4 dén 7 Rn so vi muc nghi binh thudng . Nhung céc mao mach c6 kha nang theo ddi nhu clu cia m6 noi cé mao mach d6, cu thé 1a nhu cu vé lay chat dinh dudng, va vé loai bé chat thai dang tich hoa rat tu. Chinh nhu ciiu noi trén la yeu t6 tai chd ditu hda luu luong mau, di chinh xc, vila dung nhu cu. Ngoai ra co ché digu hoa thin kinh cing gép phan lam thay d6i luu luong mau dén mo. 2.2, BIEU HOA LUU LUONG TIM CHU YEU LA DO LUU LUQNG MAU Tat CHO O MO Mau dén mo réi lip tée qua tinh mach ma quay ve tim. Tim 6 dac tinh 1a mau tinh mach quay vé tim bao nhicu thi tim bom ra dong mach ding bay nhiéu hode rat gin ding nhu thé (co ché Frank-Starling), Nhu vay tim I mOt co quan wy dong dép ding ding nhu cau cia m6, Tuy nhién nhigu khi tim clin c6 trg lye thém, d6 i cae tin higu thin kinh gitp tim bom dung lugng mau thco nhu civ. 2.3. NOL CHUNG HUYET AP DONG MACH DUOC DIEU HOA MOT CACH BOC LAP BOT YOr DIEU HOA DONG MAU TA CHO, VA BOL VOI DIEU HOA LUU LUONG TIM. BO may tuan hoan c6 ca hé théng cae co ché ditu hoa huyét 4p dong mach. D6 1a mot log loai phan xa thin kinh, chi trong vai giay dua huyét dp tré ve binh thudng. Thi dy huyét ap sut thi lam tang fue b6p tim, co cée tinh mach lon dé don cay dong mach. ch mau, qua mau dy tra ve tim, co toan bd cae tidu dong mach dé don mau 6 vai trd lau dai do bai tit hormon va do diéu hoa th Negoai ra, than d6 diéu hda huyét ap dong mach. dong tuu lugng mau 4 mot phan Y nghia cua diéu hoa hu: co thé khong x40 dong dén luv lugng mau noi khac. St Ap 1a git sao cho bi 3. MOL LIEN QUAN AP SUAT, LUU LUONG, SUC CAN VA CONG THUC POISEUILLE Luu lugng méu Q chay qua mot 6ng mach mau chiz tac dung chi phdi cua hai yCu 191(6: (1) higu dp.sudt AP gita hai dau dng, do la dong lye déy mau qua 6ng; (2) stic chéng ddi lai dong chay qua dng, goi la s ‘in R (resistance) cla mach. M6i quan-hé dinh tong: gida ba yéu t6 O, AP va R duge xac dinh bling cong thic Poiseuille. Ngudi.ca cing noi ‘quan he dé 12 theo dinh luat Ohm Q = a4PR Dé cho don gian hon, ta coi d cudi Gng mach 4p sudt bang khong (bing ap suat 4p sudt AP tro thanh 4p suat P. khi quyén), nhu vay hi Nhang nam gin day, khoa hoc co ban thim nhap ngay cang nbide va c6 nhitu dng dung thuc hanh trong d0i sng. Trong y hoc, tham do chide nang, cling nhu trong nhiéu it long nhu dich chay trong mat, nudc 16 dong song, linh vue didi s6ng, c6 dong hoe € v.v. Nguoi sinh vién y khoa nén Lim quen voi cae bién thé ca céng thdc Pois c6 nhigu tng dung thyc hanh cin {am sang va 1A can thiét dé tip thu kién thite 6 cae phan sau. Ba bién thé dang nho cua cong thie Poiseuille la: uille vi Q = PIR (dé hiéu luu Iuong mau nudi md) P = QxR (dé hidu huyét dp) R = P/Q (dé hidu va tinh stic can, thi dy ste cin hé mach trong séc, trong tang huyét ap, stic cn dudng tho ‘trong hen). 3.1, LUU LUQNG Ngay nay do luu lugng mau bing phuong phép khong chiy mau da td thanh viée co thé. Don vj lu lugng 1a ml/giay hoa I/phit. kha thong dung. Dung cu do 6 ngoai Huyét liu ké dign tir 1a may do va ghi db thi Iuu Luong méu theo nguyen ly diga tit, D6 1a mOt thanh tit hinh ngo’m, khi dat chi vao ngoam dé thi dong mach trong chi nim theo phuong thang g6c voi dudng site tu ndi hai cue cia thanh tit, Gita hai . Loai may nay ghi duge cye phat sinh dign thé 6 gia tri ti 1é v6i gid tri luu lugng mai bign doi luu vgn nhanh ti 0,01 Huyét lu ké siéu Am Doppler cé mot tinh thé dién. ap (piezoelectric crystal) phat s6ng siéu 4m nhiéu trigu chu ky/giay, phat theo chiéu xudi dong mau chay trong mach. M6t phan 4m duge cac hong clu trong mach phan xa lai, Am phan xa cé tn s6 thap hon am phat di vi hong clu dang di chuyén ra xa din tinh thé. Hién tugng déi tin sé am d6 goi la higu dng Doppler. MOt thiét bi khac x4c dinh mic bién déi Qn s6 va chuyén higu tin s6 thanh dai luong Jit/phdt. May nay ghi duge cac dao dong rat nhank. Ché d6 dong chay trong mach c6 anh hudng dén cdc gid tri tham s6 trong cng ché dO ding chay ta (6p song song (laminar) va xody [6c thtic Poiseuille. Co hi 192(turbulent): (1) dong chdy lép song song 1A dong ém A, céc lép mau gid nguyén khodng cach véi thanh mach, do dé di chuyén song song véi thanh mach va song song véi gan thanh mach nhau. Lép ¢ true tam cia mach di chuyén nhanh nhét, ede lép cang cang chdm din do ma sat. Chénh léch van tée d6 khién cho khéi chat léng trong dan thang cé giao dién phang, sau mot gidy chay kiéu lép song song thi c6 giao dién parabol goi 1a mat nghiéng parabol (parabolic profile). Dong chay 1ép song song thudng c6 @ mach thang, vach nhan, dutng kinh kha déu dan it doi, van toc di chuyén khong cao; (2) dong chay xody Ide 66 cdc 1ép mau di chuyén khée huéng phau, trén dutng di chuyén va vao nhau, tron ln nhau tung toé, kiéu dong chay nay thuting gap khi dng dan quanh co, gp khtie, cé ché ré, ché nghén hep, thanh ong 6 mat gé ghé, cé duéng kinh lén, mau chay nhanh. Khi c6 dong chay xoay lée, Ap suat P va stie cain R tang lén, do d6 ton thém cong etia tim dé bom mau. Trong eo thé binh thuéng, mau chay theo lép song song 6 hau hét cde phan ctia cay mach, cé doi chit xody l6e 6 gée dong mach chi vA nhiing dong mach én (do dudng kinh mach Idn va mau di chuyén nhanh). Trong bénh ly nhiing ton thueng gay dj dang mach cé thé tao dong chay xody léc. Ngudi ta xde dinh dinh lugng xu thé phat sinh dong xody léc bing con sé Reynolds ky hiéu la Re. Gia tri Re ti 1é thudn véi vn tée v (cm/sec) cua dong mau, véi duting kinh d cia mach va ti Ié nghich véi do nhét n (poise) eda mau, do nhét nay chia cho ty trong mau g, theo phuong trinh Khi sé Reynolds vugt quaing 200-400, bit ddu xuat hi Se é vai doan mach mau nhung ¢ ché mach thang va nhén thi khong c6. Nhung néu sé Reynolds lén n xody tdi 2000 thi é doan mach thang va nhan cing 6 xody léc. G ca thé ngudi, sé Reynolds thuéng lén tdi 200-2000 6 g6c déng mach chu va vai nhanh Ién. Noi 46 mau chiy xody Ie 3.2. HUYET AP Ap suat mau do bang don vi milimet thuy ngan (mmHg), dé 1a théi quen tiy nhiéu thé ky. Co khi ding don vi centimet nude khi ap sudt thap, ImmHg = vi ty trong Hg 1a 13,6. Ngay nay don vi do luéng théng nhat quéc systéme international khuyén ding don vi pascal, véi bdi so kilopaseal ky hiéu la Pa va kPa Do huyét ap bing kim choc vac long mach néi véi ap ké thuy ngan 1a phuong php cé dién eo tiv ngay so khai sinh ly hoc.Ap ké thuy ngan cho tri sO ding, dang ras 193tin cay. Nhuge diém thu ngan la quan tinh cao, khong phan ting nhay kip theo dao dong véi chu ky 2 dén 3 gidy. Ngay nay nghién ctu khoa hoc ding ap ké co chuyén dat dién tis (electronic pressure transduce) chuyén Ap suat thanh tin hiéu dién, rat nhay. phan anh cdc bién dong ap suat cue nhanh. 3.3. SUC CAN DOI VOI DONG CHAY (Ky higu R) Stic cain (resistance) 1a lye chéng Jai dong mau chéy trong mach. Don vi site cin tinh bang sé don vi 4p sudt can thiét dé day 1 don vi thé tich mau qua thiét dién mach trong 1 giay. Hé SI khuyén ding don vi kilopascal cho 1 lit/giay Iu lugng, ky hiéu la kPa.1.s. Hién nay cng con mét sé ngudi nghién edu va hang san xuat quen ding don vi ca 1a mm He. , hodc em H2O/lit/sec, hoae dyn.s m/sec ne om Don vi "mmHg cho 1 ml/sec” dugc mot sé tac gid (Guyton) va due hé théng don vi CGS goi tat 1a dan vi ste can ngoai vi PRU (peripheral resistance unit) dung trong sinh ly tuan hoan. Negudi ta con ding khai niém d6 dan thong conductance thudng ky hiéu la G, la nghich dao cda stic can R, tue lA G = UR. 3.4. CONG THUC POISEUILLE Cong thie Poiseuille xae inh méi quan hé gitta cdc dai lugng Q, P, Rd cae phan trén, trong 46 stie can R ti 16 véi chiéu dai 1 cia mach véi 46 nhét 9 ciia mau, va ti 1é nghich véi luy thira bac bon cia ban kinh r cla mach. Cong thtic nhu sau: ¢ P art =Px a 8Ln . 8L Nhu thé la stie cn R= ——! >” 1 art DO dan thong G = Bin Mot digu dang chi y la kha nang vin chuyén mau cua mach mau chiu anh huéng rat manh cua ban kinh mach mau thé hién bing luy thifa bae 4 ciia ban kinh r. Cu thé bn kinh mach bién dong 2 lan thi dé din mau bien dong 2° = 16 lan Cong thu Poiseuille cho kha m co ban vé déng hoc chat long trong co thé, 6 nhiéu ting dung trong sinh ly tuan hoan va hé hap. 1944. TINH GIAN NO CUA MACH Hé mach dan mau trong co thé, nhung thanh mach khong cting dé nhu éng din nude trong thanh pho. Nguge lai cée mach mau ¢6 tinh gian nd tic 14 khi c6 ap suat bén trong long mach, thi mach gian phinh ra theo mtic ap suat do. 4.1. ¥Y NGHIA CHUC NANG CUA TINH GIAN NO ‘Tinh gian né 1a co sé vat ly dé hé mach hoan thanh ba chic nang sinh ly quan trong la gidm stic can, tao dong mau ém va chifa mau. Site can R ea Sng dan ty 1é nghich vi ban kinh dng dan. Noi cdch kha la ban kinh nhé thi site can cao, phai tén nhiéu cong ciia tim méi bom duge mau. Ban kinh to (6ng to) thi ste cdn thap, miu dé qua, tim do ton cong. Méi khi mot doan mach co bién déi tang dp suat, 4p suat dé lam gian phinh mach ra, do dé gidm sie can, Ap suat cing gidm xudng, do cong cia tim trong bom mau. Tao dong mau ém é déng mach Ia nhé tinh gidn né, chii yéu cia ddng mach. O dong mach chu, tim dap tao dong mau ngat quang theo mdi lan tam thu. Nang lugng tim d4p mt phan day mau di chuyén trong déng mach chi, mét phan lam gian nd thanh dng mach. Lic tam truong, tim khdng day mau, nhung thanh dong mach dan héi lai co trd lai, dén mau tiép tue lau chuyén ra ngoai vi. Do d6 tinh gidn nd cia ddng mach chuyén ché do dong mach chit thanh dong mau cang ra ngoai vi cang ém a déu dan hon. Ché d dong mau ém 6 cuéi cdc tiéu dong mach 1A phd hgp véi viéc cung cp mau nudi duéng mo 6 ngoai vi Chita mau 1A chife nang chii yéu cia hé tinh mach vi tinh mach e6 kha nang gian né cao. Hé tinh mach 1a noi chtfa lugng mau du dé dy tri. Khi cén dén, thi du dot ngot mat mau, thi tinh mach co, dua mau dy trif ra dong tuan hoan duy tri Ap suat can cho su song. C6 hai théng sd adng gid dinh lugng tinh gian né cia mach mau 1a: (1) hé sé nd compliance thudng ky hiéu la C, va (2) hé sé né tuong doi (HSNTD, distensibility). 4.2. HE SO NG MACH Hé sé nd mach (compliance, C) cing ed ngudi goi la hé s6 chifa cia mach (capacitance) 1a sé mililit mau chifa thém duge vao mét doan ciia cay mach dudi tde dung ctia tang m6t don vi 4p suat. Tang thé tich Hé sé nd mach = - Tang ap suat C = AV/AP 1954.3. H8. SO NO TUONG BOI CUA MACH He don vi 5 nd tuong déi ciia mach la phan trim thé tich no thém dudi tac dung mot p suat, Tang thé tich HSNTD Tang ap suat x thé tich ban dau av AP x Vi Thi du mot doan mach chia 10 ml mau, nay tang Ap sudt thém 1 mm Hg lim doan d6 phinh to thém, chia duge 11 ml mau (thém 1 ml), nhu vay hé s6 nd tuong déi la HSNTD = (11 - 10)/10 = 0,1 cho 1 mm Hg, con ndi 1a 10 p.100 cho 1 mm Hg. Cie dong mach c6 thanh mach rat khé d6i cia tinh mach cao hon dOng mach gi tinh mach c6 chite nang quan {rong 1a noi chia mau. hon tinh mach, do dé hé s6 no tuong Hé 6 n6 tuong déi (distensibility) va hé sé nd (compliance, C) la hai khai ni¢m khac nhau. So sanh mét doan déng mach va m6t doan tinh mach tuong ng, tinh mach 1 mach, nhung thé tich c6 hé s6 nd tuong déi (quy ra % thé tich ban dau) gip 8 tinh mach binh thudng gap 3 dong mach tuong tng, do dé hé sé nd compliance cia doan tinh mach gap 8 x 3 = 24 lan doan dong mach tuong ting. Chinh dac tinh nay lam cho hg s6 nd compliance 1a co s6 vat ly cia chic nang chia mau cia tinh mach. 4.4, DO THI THE TICH-AP SUAT CUA MACH D6 thi thé tich-4p sudt la mét dudng cong biéu dién ign déi Ap suat P (truc tung) theo thé tich V (tryc hoanh) cia mach. Dong mach cé hé sé né thap nén ting thé tich mau doi chit thi ap suat da tang cao, dd thj déc ding. Tinh mach c6 tinh nd cao nén ting nhiéu thé tich mau dy trad ma dp sudt chi tang doi chit, dd thi thoai thoai. Thue nghiém cho thay kich thich giao cam lam d6 thi cia dong mach chuyén trai, de ché giao cam lm chuyén phai, c6 nghia IA xung dong giao cam gidp cho vGi mot thé lich mau nhat dink, ma c6 duge 4p suat (huy. khi lugng mau 6 qué nhiéu, thé tich Jon, U bét, git duge hing tinh cua Ap suat nOi moi (huyét 4p). Khi mat méu mang, thi du mat ti 25 phan tram (dng thé tich m4u, thi xung dong giao cam [am tang truong Ive mach, p) cao thém theo nhu clu. Ngugc lai jc ché giao cim gidp cho dp sudt giam Thuc nghiém trén mt doan tinh mach bude’kin hai du, trong cé mau dudi 4p suat 1965mmHg (d6 1a mde dp sudt thudng gap d tinh mach trong diéu kién sinh ly). Dot nhién tiém thém mét lugng mu vao tii kin d6, dé dp suat tt § tang lén 12 mmHg. Sau 1-2 phuit, 4p suat trong tai tif tir gidm xudng con 9mmHg. Nhu vay c6 nghia la sau 1-2 phuit chiu dung sy cng phinh ra, thi thanh tinh mach bat dau thay déi thudc tinh co gian cua minh. Cy thé lA tinh mach ty nd ra thém dé thich nghi véi hoan canh mdi phai chia lugng mau Idn hon, ma van khong tgo 4p sudt qua cao, réi dua dan tri sé ap sudt tinh mach vé diéu kién inh iy nhat. Hign tugng nay goi la snd mach mun (delayed compliance), hoe con goi 1a sy gian thanh mach sau khi bj cang ra (stress relaxation). Day la m@t khia canh cia sy thich nghi vdi diéu kién méi, trong thyc nghiém nay diéu kién mdi la phai chia lugng mau nhiéu hon truéc, ma lugng mau 6 khong gay xdo dong cdc chi tiéu sinh ly binh thudng, trudng hgp nay 1a khong gay qué cao 4p suat tinh mach. Néu tiép dé lai dot ngot rut ding thé tich mau truée da tiém vao, thi 4p suat sut chi cn mmHg, nhung sau 2-3 phut lai tir tir lén muc dau tién 5mmHg. Day Ja hign tugng nguge chiéu véi phan trén, cing 1a sy né mach mugn nhung theo dau am. ‘Trén day la cg ché ty diéu chinh thuge tinh mach mau trong cdc trudng hgp thay doi dét ngét thé tich mau nhu mat mau nang, hoac bi truyén mau hoi qué nhiéu. SINH LY TUAN HOAN DONG MACH 1. HIEN TUGNG MACH DAP ' T biét tham do hién tugng mach dap 6 cé tay nhu ngay nay ta bat mach 6 déng mach quay dé ti dé rit ra thong tin khong nhang vé tim ma nhat 1a con vé trang thai suc khoé toan than nia. Lich sti lau dai dé da dé lai dau vét trong ngon nga dan gian ta c6 noi goi phOng khdm bénh 1a "phdng mach". Phan nay chi néi vé mach dap: (1) hién tugng dao dOng cita 4p suat dong mach trong chu ky tim, va (2) hién tugng séng rung dong thanh mach ¢ cé tay (dong mach quay) ma ngén tay thay thuée dat vao cé thé cam nhan thay duge. rat lau truée khi cé nén y hoe phuong Tay hién dai, cae nén van héa cé da 1.2. DO THI DAO DONG AP SUAT Hinh 3-3 trinh bay dé thi dao déng ap suat (pressure contours) dién hinh tie [4 suat dong mach trong chu ky tim, ghi tai doan géc dong mach g nhu dudng ghi dong 1 é hinh dé thi bién dong a chu. D6 thi nay 197\ cx tg mach chi 1 ' J : ' Uf : ! D3ay nach a7 [Yt mach ger Thdigen Gey) Hinh 3-3. Su tat dan dao dong ap suat Giua ap suat tam thu tam truong ¢6 chénh léch, mie chénh Iéch nay cao é gan tim, ma gidm dan khi ra ngoai vi O ngu@i binh thug tré tudi, ap suat hic lén cao nhat 1A 120mmHg, goi la huyét dp tam thu Ps (P: pressure, s: systolics, trudc day goi la huyét ap téi da). dp suat luc xudéng thap nhat la 80mmHg, goi 1a huyét ap'tam truong Pd (d: diastolic). Chénh léch gitta hai tri sé dé 1a 40mmHg, goi la dp suat higu hay huyét ap hiéu 5 (pulse pressure, pression differentielle) Do thi ap suat c6 hai lan séng, song th’ nhat dang cao d mic 120mmHg, do la i 6 thi bat dau xuéng thi lai nhé lén mét chut, goi lA song thir hai tue séng dicrote (c6 ngudi goi 1a cai méc incisura vi gén méc rang eva). Gyn séng tht hai 1A do déng van déng mach dot ngdt, mau ddi vao 1A van gay gon séng Ap sudt. Sau dé dudng di xuéng, Ap sudt gidm dan tdi mic 80mmHg IA tri sé do stic co dan héi thanh dong mach Ap vao ma tao lén. Dé la dp sudt tam truong Pd. tri 4p suat tam thu Ps do that tong mau. Cudi tam thu 1.2, MACH QUAY Mach quay 1a cam gide mach ny nhan thay 6 hai dau ngén tay néu ta dat nhe lén ranh quay goi la bat mach. Cam gide mach nay khéng do bién ding dp sudt 198méiu, ma do lan s6ng rung dong thanh déng mach (hode goi 1a rung chuyén). lau bat mach la dong tac quen thudc cua thay thudc tiép xc bénh nhan, giup biét tan sé tim, dac diém cua mach nay gop phan chan dodn bénh va cé tac dung tam ly tét. Ngay nay c6 thiét bi ghi 46 thi lan séng mach nay, goi la déng mach dé. Dé thi nay c6 hinh thai ede sdng lén xudng, véi hai song gidng nhu dién bién song Ap sudt, nhung ban chat séng nay khac. Vé thai gian thi giéng nhu song 4p suat mau ttc la song th nhat do that thu téng mau d6t ngot gay rung dong, song thit hai do ct mau déng mach bi lé van déng mach chan gay rung dong thanh mach. Vé ban chat, hai séng déu la chan dong rung chuyén, sy rung chuyén nay cia thanh mach lan doc theo thanh mach thanh lan séng vdi van téc nhanh hon nhiéu so vdi van tée di chuyén dong mau trong long mach. Van téc lan truyén séng thanh mach tang la dau hiéu phan anh trang thai xo cing dong mach. 1,3. LAN TRUYEN AP SUAT RA NGOAI VI Trong thi tam thu, khi tam that tong mau vao dong mach cht, chi doan dau cua thanh d6ng mach chu bi phinh ra dudi tac dung ap suat. Sau d6 dp sudt d géc dong mach thing quan tinh c6t mau, va cé mét lan séng cia sy phinh thanh dong mach do ap suat tang doc suét dong mach chu. Hién tugng do goi la sy lan truyén ap suat (chi y: lan truyén ap sudt la su lan truyén trang thai cé ap sudt cao néi 6 diém 1.1.. kha vdi lan truyén lan song chan déng rung thanh mach néi 6 diém 1.2 va cing khae véi di chuyén tic la sy chuyén ché cia khéi mau chay trong long mach) Van téc lan truyén dp suat ¢ dong mach chi binh thuéng tir 3 dén 5 mét mot gidy, déng mach Idn 7 dén 10 mét mét gidy, dng mach nhé 15 dén 35 mét mot éi chung doan mach cé hé sé né compliance cang cao thi van téc truyén ap sudt cang thap (cang truyén cham). Nhu vay 6 dong mach chi, van téc lan truyén Ap suat gap 15 lan cao hon (truyén nhanh hon) van t6e di chuyén khéi mau. Chi ¥ phan biét ranh mach, ché nén lon ba thi van tée 6 dong mach: (1) van tée lan truyén ap suat thap ¢ dong mach chu, cng ra ngoai vi cang cao hon tee 1a cang lan nhanh hon do hé sé né compliance cua déng mach cang ra ngoai vi cang nhé hon; (2) van tée chuyén ché khéi mau chay trong long mach cao 6 déng mach chi, cing ra ngoai vi cang thap hon, tite 1A chay eang cham hon do thiét dién cay mach cang lén hon; (3) van tée lan truyén séng chan dng thanh mach tic la séng cua su rung thanh mach, thi kh6ng déi vi chi phy thugc ban chat thanh mach, & ngudi mach xo cting thi va t0¢ 46 cao hon (s6ng lan di nhanh hon). Sy phan biét ba loai hién tugng d dong mach, vdi van tée truyén khde nhau, chua ¢6 nhiéu ung dung thuc hanh ¢ ta. 199Su tét dan séng dao dong dp suat khi ra ngoai vi Hinh 3-3 cho thay cang di ra ngoai vi (di xa tim, vé phia mao mach) thi dao dong dp suat tat dan (damping) cé nghia la bién d6 dao dong tri sé dp suat lic tam thu so véi tam trugng, cang gidm dan. Noi cach khae 1a mau do tim day ra ting dgt theo nhip tam thu, cing xa tim thi cang giam dan tinh chat ting dot, tinh chat ngdt quéng, cang tang dan tinh lién tue, tinh ém a cua dong nude lang lé tréi déu. Hién tugng nay cé y nghia sinh ly: cg tim chi day mau luc tam thu, réi lay mau lic tam truong, khong thé day mau lién tuc va déu dan nhu bom eg khi c6 caénh quat. Sie can va tinh gian né cia cdy ddng mach da lam chic nang chuyén dong mau tiing dot hic dau, thanh dong lién tue hop diéu kién nudi cdc md. Di vao chi tiét, cing cd ché nhu déng mach dui, song dgi lai lam tang bién d6 dao dng ap suat va bién dang adi chit dé thi ¢ dong 2 cla hinh 3-3. Tuy nhién, nhin ghung toan co thé thi thay la dao dong Ap suat tat dan. 2. DO HUYET AP G LAM SANG Nhitng di liéu 6 phan trén day cho ta kién thie ly thuyét, va do la két qua cua nghién cau vdi thiét bj tinh xdo, phic tap, nhiéu khi phai choc kim vao cdc dong mach trong sau. O lam sang cing nhu thuc hanh sn séc ste khoé & eng déng, c6 phuong phap don gidn do huyét Ap tic 1A do tri sé cia Ap sudt dong mach, khéng can phai choc kim qua da. 2.1. DO HUYET AP BANG PHUONG PHAP NGHE ' Nguyén ly cia phugng phap la dang mét bao hai qu@n quanh canh tay. Bom hoi cho ap suat trong bao cao hon han trong déng mach, thi du trén 160 mmHg. Si hoi cho ap suat trong bao xudng tit ty, chiing ap sudt 6 con cao hon 6 dong mach (cao hon 110mmHg [a tri sé huyét ap tam thu 6 ngudi binh thudng) thi Ong nghe dat ché mép dudi bao khong nghe tiéng gi. Khi 4p sudt bao gidm tx mife huyét Ap tam thu, xuéng dan dén mic huyét dp tam truong, thi suét thai gian do nghe thay tiéng dap theo nhip tim. Ngudi ta cho rang tiéng dap la do su rung déng cua thanh dng mach dan héi dang ndm gid hai ché dQ Ap suat bang nhau (dp sudt trong bao va dp suat trong déng mach) C6 nguti gidi thich tiéng dap bang co ché khac. Di sao tiéng dap bao hiéu ap suat bao bang Ap suat trong déng mach, nén ngudi ta quy dink khi nghe tiéng dap dau tién thi tri sé dp suat 6 bao 1a huyét ap tam thu, tiéng dap cudi cing cho ta huyét Ap tam truong. Doi khi cé nguéi nghe thay tiéng dap suét dén tan khi ap suat d bao xuéng tdi sé khong. Trudng hgp nay lay tri s6 Ap sudt vao luc tiéng dap déi am sac ro rét 2601a huyét 4p tam truong. C6 thé két hop thém bat mach quay. Do huyét 4p nhu vita ta trén, khi xudt hién mach quay, lay tri s6 ap sudt & bao Itc dé 1a huyét ap tam trucng. 2.2, BO HUYET AP BANG PHUONG PHAP DAO BONG Huy¢t dp ké do bang phuong php dao dong cing cing nguyén Jy cdu tric nhu via {4 Uén. Chi c6 thay vi cho nghe ting dap thi c6 mot thigt bi thé hign su rung cua thanh dong mach bing sy dao dong cia mot kim chi trén vach khéc ngin. Duong in, thi giée 1 gide quan khoa hoe nhin kim (rén vach cho phép danh gid dong tt hon nghe, nén huyét 4p ké dao déng cia Pachon da cé mot thdi kha ndi danh. 2.3. HUYET AP KE TU DONG DIEN TE Tign bd cua cOng nghigp dién tu da gidp ché tao ra huyét 4p ké tu dong dign ti. Thuyc ra nguyén ly may nay khong khdc may do hu 6 mot diém khde fa thay vi cho vi nghe tiéng dap hode nhin kim dao dé Tdi nhin Ap ké lay but ghi két qua, thi may c6 mt _bO phan theo doi su rung thanh cho két qua lén dong mach, chuyén thanh tin higu dua vio bd vi xu ly nho xiv, man hién s6, ca céc thong s6 huyét Ap Jdn tan sé tim dap. 2.4. CAC THONG SO CUA HUYET AP C6 bén thong sé la huyét 4p tim thu (Ps), huyét 4p tam truong (Pd), huyét 4p trung binh (Pm) va huyét 4p hi¢u s6 (pulse pressure, pression différenticlle). Ps va Pd trude day go? Iyyhuyét ap t6i da va huyét dp t6i thiéu. Huyét dp tdm thu [a tri sé huyét 4p dong mach lic cao nbat trong chu ky tim, Ging véi lic tam thu. Théng sé nay phan Anh lye co ciia tam that 1a chinh. $6 binh thudng 12 110 mm Hg. Gidi han 12 90 va 140 mm Hg, cé nghia 1a Ps dudi 90 mm Hg la huyét ap thap, trén 140 mm Hg la huyét 4p 1én cao bat thudng. O ta mic Ps tu 160 mm Hg tré (én [a tiGu chun bénh tang huyét ap. Huyét 4p tam truong [a tri s6 huyét 4p lic thip nhat trong chu ky tim, tng vdi tam truong. Théng sé nay phan nh trang thai truong luc ctia mach, thi du khi 6 mdi ap tam truong truGng rat néng, mat dé di du higu cia gidin cdc ma gidm. Khi hé van dong mach, 6 thi tam truong c6 mot phn mau dong mach chi lai vé tim, huyét p Lam truong cing giim. SO binh thudng {4 70 mm Hyg, gidi han {a 50 va 90 mm Hg, dé {a cdc moc inh gid huyét ap thdp hay tang huyét dp. Trong bénh tang huyét 4p, nu chi huyét 4p tam thu 201tng cao thi chua IA ning, néu ca huyét 4p tam truong céing cao thi ganh nang déi voi im rat lon, SO dT nhu vay vi sudt toan 69 thoi gian thét hoat dong déu phai vugt qua mac cao ca huyét dp tam truong dé, méi c6 higu Ive bom mau duge. Trong diéu kién ganh ngng nhu vay, tam that dé phi dai va di dén suy tim Huyét 4p trung binh [a tri sé ap sudt ma néu git nguyén gid tri khong doi nhu vay trong sudt thoi gian mot chu ky tim, thi cd higu lye bom mau bang ding mot chu ky hién thuc v6i 4p suat bién dong én cao luc tam thu, xu6ng th&p lic tam treong. dong trong Nguoi ta tinh huyét 4p trung binh qua tich phan cac tr] s6 huyét ap bi mot chu ky tim. Trong thyc hanh do huyét ap, s6 trung binh la 4p suat lic tiéng dap nghe 16 hat hoac hic kim dao dong manh nhat. Huyét 4p trung binh khong nim 6 i sO huyCt ap tam thu va huyét 4p tim truong, ma gin sO am truong hon vi binh thudng huyét gitta t thoi gian tam truong dai hon tam thu (0,5 so vdi 0,3 gidy). Ngua 4p tam thu 110 mm Hg, huyét dp tam truong 70 mm Hg (thudng viét tat la HA 110/70) thi huyé ap trung binh ching 85 mm Hg. Huyét ap higu sola d9 chénh binh thudng fa 110 - 70 = 40 mm Hg. Thong s6 nay phan 4nh higu luc mot Rin tng éch gid huyét 4p tam thu va huyét ap tam truong, méu cua tim, thi du trong van co, can dua nhiéu méu dén co, huyét 4p higu sé tang ip cau hi , huyét ap sut thudng iy ap ket". Huyét 4p lén trén mic 40, c6 thé tdi 60 - 70 mm Hg. Trong a mOt nguy co, nbung néu huyét ap higu s6 rat thaip, thi rat im trong, do t huyét 4p tam thu rat gin tri s6 huyét 4p tam truong, goi 1a "huyét ket (huyét 4p higu sé rét thép) la dau higu cia tim dang c6 rat it higu lye bom mau. 2.5. HUYET AP NGUOI VIET NAM THEO TUGL Tri s6 110/70 mm Hg la huyét 4p ngudi Viet Nam tré tudi ip so voi ngudi chau Au vi sé huyét 4p }20/80 mm Hg theo cae sé tigu nude ngoai. Voi moi dan tc, huyét 4p tang dan theo tudi cho dén gia. 3. DIEU HOA TUAN HOAN DONG MACH 3.1. CO CHE THAN KINH, HE THAN KINH THUC VAT Co ché than kinh tac dung chu yéu In cdc hoat dong twain hoan toan co thé nhu lam ting bom méu, phan phdi lai mic cung c&p mau giita céc khu vue, va dac biét 1a diéu hoa nhanh huyét 4p dong mach (HA) tro vé mic binh thudng. Tac dung cua hé than kinh b’x nhu hoan toan thong qua hé than kinh thue vat trong d6 phan rat quan trong 1a hé thin kinh giao cém. 2023.1.1. Hé than kinh giao cam soi van mach giao cim tir ty sGng dén day giao cim ri qua hai dudng dén he 1) qua cdc day thin kinh giao cam dén cdc mach (ang va dén tim; (2) qua twin hoan: cac day thin kinh tuy dén céc mach 3 ngoai vi. Cac svi giao cim di dén hau hét cde mach mau, trit mao mach va co vong trude mao mach. Kich thich giao cim lam co ede dong mach nhé va cdc tiéu dong mach, lam ting mach tuong ting, do dé bién déi luu lugng méu di ti cic m6. Giao cam cc tinh mach co nhé lai do dé dén mau ve tim, dé sie can cing lam cae mach ln, dac la mot khau diéu hoa quan trong. . Cang c6 nhing soi giao cam di dén tim c6 téc dung tang tin s6 tim dap va phan diéu hoa tim, luc co tim abu da ni 3.1.2. H@ than kinh pho giao cam quan trong déi voi cae chic nang thue vat kI tr khOng ldn. Cac syi phd giao cm dén tim qua day ic nhu tiGu hoa, He c6n d6i v6i twin hoan thi c6 va mé tau (vagus) chit yéu 1a tac dung gidm in s6 tim dap va giam nhe lye co co tim. ph6 giao cam ri 3.1.3. Hé giao cam gay co mach duéi sy kiém soat cia hé thn kinh trung wong soi co mach, nhung chi c6 rat it soi gian c bigt cd Lae dung Cée day than kinh giao cam chia +h di t6i hau hét cdc phan cua hé tuan hoan, di "tae dung khong manh bing. mac! . Cac gi co cia hanh nao va phn ba dudi cia C6 trung tam vin mack nim 6 hai clu nao. Trung Gim nay phat xung dong di xudng tay roi tit dé qua cae sgi giao cam co mach di dén hau hét céc mach mau than thé. Van dé t6 chite cia mOt trung tam van mach hoan chinh chua duge sing 16, dit sao fy 6 may ving chinh nhu sau (Hinh 3-4): (1) ving co mach 6 phan trén cua hanh nao, cdc noron 6 dé tiét noradrenalin va kich thich céc si co mach cia in mach 6 nda dudi cia hanh nao, cae sgi thin kinh tir dé thye nghiém cho t hé giao cim; (2) ving chay lén tic ché mt ving 6 trén, qua d6 gay gin mach; (3) ving cam gide nim 6 tractus solitarius 6 hanh ndo va nia dudi clu nao, céc noron ving nay nhan tin hig cam giée cha yéu tit day mé tau (vagus), day thit hu rdi phat tin hiGu di gop phan diéu hoa ca ving co mach lin ving gidn mach, nhu vay ving nay thuc hién m6t co hoa nhiv ché phan xa chiic nang twin hoan, thf dy phan x@ cam thy dp. 203Hinh 3-4, ‘Trang tim van mach va hé gao cém diéu hea tuiin hoan. Tneong luc co mach giao cém 1a trang thai hoi co mach mOt chit nhung co lién tyc. dudi t xung dong thua thot nhung duy tn lién tyc cia cae thude he sgi nay thudng xuyén nhan tin higu cda trung tam Xung d6ng giao cim duy tri truong Iyc chi thua thét 1 - 2 lia mot gidy. Chang minh truong lye bling thyc nghiém phong ngoai vi. Nhu vay lam huyét 4p cua con vat giam tir 100 xuéng con 50 mm Hg. Néu ba noradrenalin (la chat trung gian, binh thudng do day giao cim tiét ra) vao moi xung dOng tir hé thin kinh trung uong ra tid tinh mach thi huyét 4p Iai lén. Trung tam van mach khéng chi kiém soat mic do co mach, ma cdn kiém soat hoat dong tim. Phin lung cia trung tam gui xung dong qua cdc sgi giao cam dén tim lam tang tin s6 tim va luc co tim, con phan gitta thi gi xung dong dén nhan lung cua day mé tau (vagus) lam gidm tn sé tim. 204Cée trung tam thiin kinh cao cp kiém soat trung tim vin mach: Chit ludi chiém vang rong cua cau nao, nao gitta, nao trung gian, © vai tro kiém sodt,phin bén va trén cia nd thudng tie dung kich thi ch trung tam van mach con phin gida vi dudi thi ie che. Vang dudi ddi 6 vai tro kiém soat, phan sau bén thi chu yéu kich thich, con phan trude thi c6 diém kich thich nhe, c6 diém te ché. Nhiéu ving rong Jén cia vo nao nhu thay thai duong, thay tran, hanh han, hai 5 te dung kich thich hoge de ché tay tiing diém nhé duge kich thich dign, dic tay cuding dé kich thich. ma ho wy. 3.1.4. Cde catecholamin adrenalin va noradrenalin c6 cau tric hoa thiét Catecholamin 1a ten chung chi hai ch gidng nhau (noradrenalin chi kém mot gée -CH,) va lién quan nhau ma hoe rat vé chuyén héa va vé tée dung sinh ly, Noradrenalin duge day thin kinh co mach tiét ra, tae dung Ién cae cém thy alpha co tron thinh mach, gay co mach. Xung dong giao cm t6i cac mach mau lam co mach, dong thoi ti tuyén tuy thuong than Lm Lit cdc catecholamin 1a adrenalin va noradrenalin, hai hormon nay theo dong mau dén tac dung truc tiép Itn mach, chi yéu la gay co mach (d6i khi adrenalin gay in mach do tae dung kich thich cam thy béta). g Hé giao cam gin mach va su kiém sodt cia hé than kinh trung uong ico mach Lin sgi gid ma ay thin kinh giao cm di ti co xuong mang GO dong vat bac thap nhu mao, soi gidn mach tig acetylcholin, cdn & dong vat bac cao nhu linh treéng (g6m khi va ngudi) thi tiét adrenalin kich thich cc cim thy beta cla mach co gay gidin mach. Phan trudc cia ving dudi déi 18 noi ch yéu kiém soat he giao cdm gian mach. Ngudi ta cho ling khi bat dau van co, hé giao cim gidn mach co lam tang luu lugng mau tdi co sin sang cung cp thém chit dinh dudng cho co. Khi xe cim qué manh dén ngat di, la do trung tam day mé (iu (vagus) phat tin higu manh Lim tim cham lai, ddng thdi hé gidin mach bi kich thich gay gidm huyét dp va gidm luu lugng mau Ién nao, dua dén bat tinh. Hign tuong goi la ngait tu (vasovagal syncope). Trude lic ngit da bi rdi logn tu duy 6 v6 nao. Con dudng than kinh e6 Ie dén trung tim mé a di ti trung tam gin mach eda phan trudc ving dudi doi, roi ti dé iu (vagus) 6 hanh nao, ri qua tly s6ng dén cae day thin kinh gidn mach cua e4c co. 2053.2. CO CHE DIEU HOA NHANH HUYET AP DO VAI TRO HE THAN KINH 3.2.1. Nguyén ly cia co ché dam bao diéu hoa nhanh kip théi M6t chuc nang quan trong cua hé than kinh trong digu hoa tuan hoan la kha nang rit nhanh chéng nang cao huyét 4p dong mach khi cin thiét. Mudn vay can cing hic Kich thich h¢ giao cam véi chac nang co mach, tang higu luc tim, dong thisi we ché cde tin higu cla day X-mé téu (vagus) — pho giao cam t6i tim. Do d6 cn cé ba loai bién ddi 1dn di song song va twong tac tang cudng lin nhau. Ba bién déi nhu sau: M6t Ia toan bo ticu dong mach phai co lam tang sc cin ngoai vi R dé git mau 6 do dé lam tang huyé ving dong mac Nai la céc tinh mach va ca cée mach 16n déu phai co manh dé chuyén mau vé tim, nhd dé tim mdi dap manh (co ché Starling) lam ting huyét ap. ang tin s6é tim, tang lyc co Ba Ia tim cin duge hé giao cam kich thich «ruc tip dé tam that, qua dé tam tng higu lye bom mau, tang huyét ap. Co ché than kinh c6 téc dung nang huyét 4p nhanh nhat trong mai co ché, c6 khi chi ti 5 dén 15 giay da nang tri sé huyét 4p én cao gap hai roi. 3.2.2. Tang huyét 4p trong van co va trong cdc stress khéc Van co la mot trang thai stress te 1a trang thai cing thang do tang chuy€n héa 6 ting luu lugng mau dén co. Mot phan nbu cx mau duge dip 1 bao co, ddi hoi ph ting do sin phém chuyén héa da lam giéa mach tai ché. Dong (hoi tang huyét 4p gop thém phan lam tang luu luong mau tdi co; huyét dp tang ching 30 dén 40 phan tram thi lm tang g4p doi ‘lugng mau tdi co. Co ché than kinh tang nhanh huyét 4p nhu sau. Vang van dong ciia vo ndo hung phan gay van co thi dng thdi hé ludi than nao hung phan gay kich thich ving co mach va ving tng nhip tim cua trung tm van mach. Khi rat hoang so, chi trong vai giay huyét 4p da tang gap di mic binh thudng. Dé la phan ting béo déng gitip co thé sin sang c6 muic cung cép mau cho co hoat dong chay trén khdi ché nguy, hode cd ting pho khac. 3.2.3, Céc co ché phan xa cém thy 4p duy tri mite huyét 4p binh thuong Trong dai s6ng thudng ngay, moi dao dong huyét 4p déu duge nhanh chéng diéu chinh vé mic binh thudng hoge gin binh thudng . Dap tng dé 1a do céc co ché thin kinh tiém thdc ma hau hét 1a phan xa ditu khién ngugc (feedback) am, tte Ia mie 4p thap gay phan xa nang huyét 4p va ngugc lai mic huyét 4p cao gay phan xa huyé gidm Ap. 206Cac phan xa cdm thu dp: Phan xa cam thu 4p (baroreceptor reflex) cing goi tat 1a phan xa cém Ap la phan xa xuat phat tit cae cdm thy cing gin (stretch receptor) 6 thanh céc dong mach Idn 6 hé théng tuc 6 dai tuan hoan. Tang huyét 4p lam no dong cae cém thy nay phét tin higu vé hé thin mach, kéo cing gidn cac cam thy 4p khici kinh trung uong, ri tit dé lai c6 tin higu diéu khién ngugc (tin higa feedback) tic 1a logi tin higu di nguge tro Ve gée ci. N6 von xudt phat tit hé twin hoan noi c6 huyét Ap cao, nay théng qua hé than kinh thuc vat, IOn nguge tr ve tuan hoan, lam huyét 4p tro xuéng mic binh thudng . Cam thy Ap (baroreceptor) li loai cim thy gém cac tan cing soi than kinh toa trén céc thanh dong mach lin. Logi cam thy 4p c6 rat nhiéu 6 hai noi la: (1) cung dong mach chu va (2) dong mach canh trong, trén ché chia nhéah it dong mach canh géc, noi goi la xoang canh. Tin higu tit xoang canh vé qua day Hering, day thigt hau, dén tractus solitarius 6 m gic cua day mé téu (vagus), . Tin higu tis cung dong mach chi, cing vé tractus solitarius ciia hanh Khi huyét 4p 6 mac tir 0 dén 60 mm Hg, cac cam thy ap 6 xoang canh khong phat i phat xung Lin s6 ving dan dén ti da 6 180 xung. Khi huyét mm Hg. Cam thy ap dong mach cha cing dap ung nhu vay, nhung 6 mac huyét ap Nhu vay co ché digu khién ngugc cm thy Ap 6 higu lye 2 dinh, p tren 60 mm Hg t cao hon ching 30 mm H, cao nhat 6 chinh pham vi dp suat clin duge diéu hoa duy ur Dap ting cam thy dp a loai dap dng nhay bén dén mie vin sé xung tang trong tim thu, gidm trong tam truong. Déi voi huyét ap bién dong, dép dng manh mé hon so voi huyét dp 6n dinh di Ia 6n dinh 6 tri sé cao hoc thdp, Con duong phin xa cdm the dp: Huyét ap cao tao tin higu cam thy Ap vé t6i tractus sofitarius 6 hanb nao, rdi c6 tin higu tiép theo gay te ché trung Lam van mach hanh iu (day vagus). Két qua la: (1) gidn toan bd tinh ein sd tim nao va kich thich trung tam day m mach va tiGu dong mach ngoai vi, qua d6 gidm sie cin he mach; (2) va luc co tim, qua dé giim Iuu lugng tim. Mac huyét dp thdp gay loat dap dng nhu trén, nhung theo chigu nguge lai. it do Khi dang nim dot ngot ngdi day ding day, thi huyét ap 6 dau xu thé s trong luc cot méu, lam (6i xam mat (thi€u mau n&o) tham chj c6 thé bat tinh. Lic nay muc huyét 4p thap phat dong phan xa phat xung giao cam nang huyét 4p, dic biét nang ap sudt mau 6 du Chitc nding dém huyét dp cia hé cm thu dp: Cac phan xa cim thu Ap gitt cho dao dong cia huyCt 4p trong ngay 6 mic thap chi bang 1/2 hoae 1/3 bién do dao dong 6 dong vat h cha va xoang canh, Tae thue nghiém déi ching da loai bé cae cm thu ap dong 207dung dn dinh huyét 4p d6 goi 1a chic ning dém huyét ap. Hé cam thu dp trong diéu hoa huyét dp dai ngay. Dat lai diém chudn céc cdm thu Gp: He dong huyét ap tiép tuc duy tri t thoi gian m thy dp la co ché digu hda nhanh déi vi bign dong huyét ap. Néu bién s6 mdi, di cao hon trude, hay thap hon truéc, trong cae cém thy 4p thich ting vdi diéu kién ap sudt moi, diéu chinh huyét ap nita. Su thich dng voi tri sé huyét mot hai ngay, t khong phat xung gay phan x Ap méi goi la "dat lai diém chudin" (resetting) cdc cdm thu Ap. 3.2.4. Co ché cam thu héa hoc diéu hoa huyét 4p H¢ dap ting cam thu héa cing 66 co sé giai phdu vi co ché hoat dong Luong ty hé cim thu 4p. Diém khie [a cdc cam thy (receptor) 6 day 1a cée 1 bao nhay cam héa hoc, cm thu su thidu oxy, su du thifa carbon dioxid hoae du ion hydro. Cac cam thy ha (chemoreceptor) nim trong cae tiéu thé ¢6 kich thude 1 dén 2 milimet. Cé mot tigu thé dong mach canh nim 6 méi bén dong mach cinh chung noi chia nhanh dong ng mach chii nim 6 cung dong mach chi. C6 thé ding canh (carotidian bodies) va tiéu thé cha (aortic bodies). mach canh, va ahiéu tiéu th tén tat goi chang 1a ti€u thé Cae tigu thé phat xung theo céc soi cim thy héa, di song song cing cdc soi cam thu (vagus) ma vé trung tam van mach. Ap trong day Hering va day mé Cac tiéu thé duge cap mau du dit, nén ludn tiép xte voi mau mang tinh dong mach (mau giau oxy). Khi huyét 4p sut, tiéu thé nhan it mau nén nban dugc it oxy, con CO, va ion hydro thi du vi mau cham lay di, Cac cm thy hda bon phat xung vé trung tam van mach Lim nang huyét ap lén mic binh thudng. Vai tro céc cém thy hoa chi quan trong khi huyét 4p (am thu sut xudng dudi 80 mm Hg. ' 3.2.5. Phan xa tam nhi va dong mach phdi khi thé tich mau tang cao Cac cam thu ving dp thdp: Dong mach phéi va hai tam nhi la noi chéa mau 66 4p ch nhi va vach dong mach phéi suat thip so vi 6 tim that va dong mach cha. Trén v: 6 cae cim thy cang gian (stretch receptor) ttc 1A cde cm thy nhay cam vdi trang thai cing gidn cua cae co quan bi cang phdng to. Chang thudng duge goi la cae cam thy ving dp thap. Khi mau dn vé tim nhiéu, la lic co thé cO nguy co ting thé tich mau gay tang a dng mach phéi phng cing, cdc cim thy cang gin ben phat huyét 4p. Luc nay nht xung ngan chan sy tang cao huyét 4p do tang thé tich mau. Nguoi ta thc nghiém truyén 300 ml mau cho ché nguyén ven, huyét ap chi tang 15 mm Hg. Néu truyén cho ché da bj khit cdc cdm thy 4p dong mach, huyst dp tang 20850 mm Hg. Néu truyén cho ché da khis n6t ci dm thu cing gin 6 tam nhi va dong mach ph6i (cim thu ving ap thap) thi huyét ap ting thém (61 120 mm Hg. Nhu vay m thy ving dp théip (6 nhi va d.m. phdi) tuy khong phat hién duoc tinh hinh Ap sual 6 dong mach hé thdng (tic 6 lac i tun hon), nhung ching phat hién su ting 4p 6 ving dp thip do ting thé tich mau, va chang phéi hop vai ic phan xa tir vang Ap cao cia twin hoan hé théng,tao thanh mot tng thé hé théng phan xa c6 hiéu lye cao kiém soat huyét ap. Phan xa nhi-thdn wée phén xa thé tich: Tang lugng mau vé tim lam cing phong abi, 6 téc dung phan xa tang thai nude qua hai dudng nhu sau: (1) mot [a cing phong nhi gay gidn tiéu dong mach dén than, lam ting ap sual mao mach cdu thin do dé tang loc ciu than, tang thai nude; (2) ducdng tde dung dué hai 1a tin higu ti nbi len vang dudi d3i lam gidm bai tiét hormon chéng niéu, do dé cing ting thai nude dudng thé Hai tac dung nay lam gidm thé tich mau, qua dé ngan cin sy ting huyét ap. Phan xa Bainbridge: Tang 4p suat nhi lam ting nhip tim, mot phan do cang gidn nut xoang din nhip tim, phan nda do phan xa Bainbridge: tin ra, qua day nut xoang, kich thi higu vé qua day mé tau (day vagus soi vi mé tau (sgi ra) va day giao cém lam tng nhip tim va ting lye co tim chéng lai a mau nhi, 3.2.6. Tae dung cia thiéu mau nao Phin trén ndi dén vai tro cée cdm thy 4p, cdm thy hoa, cdm thu ving 4p thép déu 6 tuin hon ngoai vi. Ngoai ra chinh trung tam van mach a 6 than nao au thiéu ma Nguai ta cho [a mau dén id lactic va cae acid khac tich ty da kich thich trung tam van mach. Phan ing co quan cim thu dén nudi dudng, cing phat xung lam ting huyét ap hé thdng. m thai CO,, Ia y€u t6 kich thich giao cam manh. Cang 6d thin kinh trung uong (central nervous system su dap dng do thiéu m: Day IA mOt co ché dap dng giao p tam thu thadp dén mde nguy hiém 1A 60 mm Hg, tham chi dén 15 - nay goi ischemic respon: khai khi huyét 20 mm Hg. Déi khi ngudi ta goi phan dng nay 1a chién hao bao ve cudi cing. am rat manh, nhung chi trién 3.2.7. Cae khia canh khdc cia vai trd thén kinh diéu hoa huyét 4p Co xuong: Cac phan xa cam thy 4p va cam thy hoa khéng nhing chi kich thich he giao cam co mach ma cOn thong qua trung tam vn mach va chat ludi gui xung ding dén co va day thin kinh co xuong. Dae bigt co bung tang truong luc, diy mau chia trong cée mach bung vé tim. Dap Gng d6 goi 1a phan xa ép bung. Nhing agudi ligt co bung thudng bi nhing con ha ap. risus 209Khi van co manh, co co, chén ép manh cac mach mau, téc dung din mau vé tim. Song h6 hap cia huyét dp: Tri s6 huyét ap c6 dao dong theo chu ky thd do nhigu 1) xung dng lién trung 1am, tir trung tam thd sang trung tam van mach; (2) 4p suat trong nguc am thém trong thi hit vao lam Uing long mau vé that trai; (3) kich thich cdc cém thy cing gin 6 nhi. Cac tac dung trén day 1a da dang, nhiéu mat, 6 thé cing hudng hode nguge hudng tuy loai dong vat, tay cé thé va tay lic, téc dung: Cée song dai han khéc cia huyét dp: Nhitu tac gia d4 mo ta nhitu loai song dao Co thé ké s6ng truong lye van mach (séng dong cua nén huyét 4p trong chu ky da Mayer, s6ng y), séng phan xa cim thy 4p, cam h6a, song dap dag thiéu mau nao, v.v. 3.3. CO CHE DAI HAN DIEU HOA HUYET AP DO VAI TRO THAN Khi huyét 4p dong mach cé biGn déi cham va kéo dai nhiéu gid, nhiGu ngay, co ché thin kinh mat dan higu lye diéu hoa tri sé huyét 4p. Thay thé vao d6, than sé phat trién din vai tro chi yéu kiém soat huyé p dai han hang twin, hang thang. 3.3.1. Hé than-thé djch diéu hoa huyét 4p dong mach Hé than-dich than thé, goi tit la hé than-thé dich, 1a mOt hé théng rat don gian trong ditu h6a huyct ap. Khi co thé c6 dich ngoai bao nhidu qua thi huyét 4p tang. bai xuat lugng dich thisa, huy€t 4p lai tro Huyét Ap cao tée dung true tiép Lam thé vé binh thudng. Huyét 4p chi cin tang vai milimet thay ngan thi lugng nude bai xudt qua than co thé da tang gp d6i dé diéu chinh lai. D6 1a hicn tugng bai iu do dp sudt. Dong thoi ing bai xuat theo, goi ld bai xud¢ nazz do dp sudt (pressure diures © loai ngudi, hé than-thé dich kiém soat huy€t 4p la mot co ché co ban cua qua inh diéu hoa huyét 4p dai han. Bai niéu do dp sudt la hién tong co ban trong diéu hoa huyét dp: Hinh 3-5 biéu két qua thyc nghiém cho thay sy bai ni¢u do Ap suat 1a mot co ché ri co ban ). goi i dB thj bai nigu, hode d digu hoa huyét 4p. Dé thi cé dang hinh mo (exponent d6 thi chic nang than, cho thay 6 huyét 4p 50 mm Hg khéng baj nié Hg 1a huyét 4p binh thudng va thé tich bai nigu binh thudng, voi huyét 4p 200 mm Hg bai nigu nhiéu g&p 6 dén 8 lan. Vide bai xuat natri cing tuong ty. Thye nghiém khac trén cho da kh cae co ché thin kinh phan xa diéu hoa huyét ap, cho thay truyén lung dich lai gy tang huyét Ap, song song vai Ling bai nigu, tang luu lugng tim. Sau thdi gian thai lugng nude Ion ba thong $6 trén lai déu tré ve binh thudng. Thue nghiém wén da ching minh vai tro co ban cia thin ditu hoa huyét ap. Néu luong dich thu nhép, cing xlue chute nang than déu van git mite binh thuong, 210thi dit tang siée can ngoai vi cing khong lam ting huyét dp dai han: C6 mot phuong trinh co ban ciia huyét 4p: huyét 4p P bing Iuu luong tim Q nhan voi sé can R. D6 J& mot thie Poise P=QxR ign thé cia cong le va viét nhu sau: Duong ahi sc edn ngoai vi toan than Uing edp tinh thi huyét 4p ting ngay. Nhung sau d6, néu than vin hoat dong binh thudng thi ma ngoai vi toan than 4p dai han lai quay ve tri s6 binh thudng trong khoang mot ngay. dau sic can huyét ih thating ) nh bai 21 bin The 56 lin ( 0 20 40 40 60 to ito 140 Go 10 to Ab suit ding mach (mm Hy) Hinh 3-5. MO 4 thy dién hinh biBu din sy bal nigu do dp suit (nuyét dp dng mach), 9 thi dang hinh md, xay dung tir 6 eu thu nghigm v6r than tach rot Khoi cor th’, durge tip mau dent 4p suit cao trén mize binh thudng. Khi dp saat ti 200 mm Hg, Nhu thé la vi thin da dép dng the tich bai nigu gp 7-8 Hin me binh thurdng, va bai natri do ap svat" cho dén khi huyét ap tro vé binh thudng. "tang bai ni h ngoai , mi Ting thé tich dich lam ting huyét dp. Co ché te diéu hoa: Tang thé tich bao Lim tang huyét 4p qua co ché trinh bay 6 hinh 3-6. Co ché gdm cé 6 bud bude trudc 1a nguyén nhan gay nén bude sau thanh qué trinh 6 bude sau day: (1) tang thé tich dich ngoai bao; (2) Lang thé tich mau; (3) ing 4p sudt mau tinh mach vé tim; (4) ing lung mau tinh mach vé tim; (5) tang luu lugng tim, yéu t6 nay cudi cing lam (6) tang huyét ap. Chi ¥ la sy tang luu lugng tim gay Ling huyét 4p qua hai dudng truc tiép va gian tiép. Dudng gia tiép 14 qua su diéu hda luu lugng mau tai ché 6 mo. Tac dung gian (ip duge giai thich nhu sau Ta da biét ring khi c6 dang mau qua m6, néu du thita méu thi mach 6 m6 d6 co nhé lai dé 1am gidm luu lugng (rd vé mdc binh thudng. Dé [a hin tuong ty diéu hoa, 1u d6 don gian nghia la mo ty minh diéu hda luu lugng mau audi minh. Khi thé tich mau tang lam tang lugng mau dén méi logi md, thi co ché ty diéu hda gay co mach 6 toan than thé, do dé tang sife can ngoai vi toan than, cudi cing ting huyét Ap. ¥ nghia ctia mudi trong so dd than-thé dich diéu hoa huyét dp: Khong chi c6 thé thai tich dich diéu hoa huyét ap nbu trén da ndi, ma mudi cdng rat quan trong vi tha nude dé va nhanh, con mudi thudng tich tu trong than thé khé thai ra hon, Mudi gién tigp Kim tang thé tich dich ngoai bao vi hai Ié: (1) khi co thé du mudi, ndng ¢6 osmol auBing thé tith obch ngow bao 2. Tang thé tith maw | 4. Ting ludng mais tizh mach ve tim | | | 3. Ting a suit mai vet | | 5. mi Tw vi HO; Hox @ | \e0 sab ooh | inane | ee ace cae a ROTO Hinh 3.6, Siu buce cba qué tinh ting the tich dich ngoai to fam tang huyét dp. : Jar ¥ Bi tang law Jong tim 6 tie dung gay Wing buye Sp do had during: (1) true tigp, 2) plan up qua tang sie cén ngoai vi ton thin (osmolality) ciia thé dich tang, kich thich trung tim khat, gay udng nhidu lam tang thé tich dich ngogi bao; (2) tang ndng dO osmol dich ngoai bao kich thich co ché dudi di hau yén lam tiét hormon chéng nigu gitt nude lai co thé (tang tai hdp thu Sag than). Két qua cudi ciing 1a mudi lam Wing huyét dp. Bénh wing huyét dp do ung thé tich dich ngoai bdo: Benh nay cdn goi la “ting huyét mo hinh rat tt dé hiéu vai trd sinh ly ap ganh nang thé tich" tich dich trong diéu hda huyét 4p. Bénh tang huyét 4p génh ni bénh tang huyét 4p do tich ty qué nhiéu dich ngoai bao trong co thé. Ngudi ta thuc nghiém trén ché cat bé 70 phan tram khéi than lam gidm kha nang thai mudi, huyct 4p chi ting 6 mm Hg. Cho ché udng nudc mudi, ché thay khat phai udng gap 4 lugng binh thudng, huyét 4p tang ching 40.mm Hg. Sau 2 twin lai cho udng nude trang 2 fg thé tich nghia fa 212ngay thi huyét 4p lai binh thudng. Cudi cing lai cho uéng nude mudi thi Iai ting huyét 4p. Thyc nghiém da chting minh co ché ganh nang thé tich. Nhigu loai thuc nghiém da ching minh néu gay bénh tang huyét 4p ganh ning thé tich kéo dai thi bénh cing thay déi ¢6 nhiéu chi tiét phic tap chi yéu do "co ché tu diéu hoa dai ngay". Sau thdi gian dai thi mét s6 co quan cdm thu (receptor) thich nghi va “dat lai diém chudn" (reset) nén 6 nhiing giai dogn sau cua bénh cé vai thong sé tré lai binh thudng. Bénh aldosteron, tiie bénh u v6 thugng than tiét nhieu aldosteron gay & mudi nudc, la mt loai bénh tang huyét ap génh nang thé tich. 3.3.2. Hé renin-angiotensin diéu hda huyét 4p Ngoai co ché diéu ha thong qua thé tich dich ngoai bao via ndi 6 phan trén, than con cé mot co ché nita rat manh diéu hoa huyét 4p, dé 1a hé renin-angiotensin. Renin a mét protein men phan tit nh6 duge th4n giai phong ra khi huyét ap rat thap. Renin tac dung nhiéu mat nang huyét 4p tit mic thap tro vé binh thudng. Thanh phiin hé renin-angiotensin va céc bude diéu hoa huyét dp: Renin duge téng hop tai té bao canh cau than nim 6 vich tiéu déng mach dén (afferent) ngay sat cau in pham téng hop duge dy trit dudi dang khong hoat dong 1a prorenin. Khi phong than. huyét 4p sut, cdc phan tng trong than lam tach m6t s6 phan tit prorenin, gi renin. Lugng 16n renin rai thén vao mau tun hoan, mét lugng nhé renin 6 Iai trong dich ca than va c6 nhiéu chic nang trong thin. Renin li mOt men, khéng c6 tc dung 1am co gin mach. Hinh 3-7 cho thay renin tac dung nhu m6t men 46i vi mét protein huyét tuong c6 ban chat globulin gai la co chat renin hay Ia angiotensinogen. Tac dung men-co chit dé giai phéng ra mot peptid C6 10 géc acid amin goi 1a angiotensin I. Angiotensin I c6 téc dung co mach nhe nhung khong c6 ¥ nghia chife nang dang ké d6i vai tuan hoan. Renin tn tai trong mau 30 phat dén m6t pid dé tao angiotensin I. Chi vai giay sau khi hinh thanh, phan tit angiotensin I da tach bé hai acid amin dé {go thanh angiotensin II 1a peptid c6 8 géc acid amin, Phan dng nay xay ra 4 céc mach ho cia phéi dudi sy xic tac cia men chuyén (converting enzyme) c6 6 m6 mach phéi Angiotensin II téc dung co mach cyc manh va cOn c6 tac dung khac lén tuan hoan. trong mau ching mét hai phat vi bj khis hoat nhanh chéng do Nhung n6 chi tn ta nhitu loai men cia m4u va cia mé goi tén chung 1a angiotensinase. © mau, angiotensin It c6 hai téc dung chinh lam tang huyét 4p: (1) tut nhdt 1a gay co mach nhanh chéng vi manh mé céc tiéu dong mach, va co tinh mach c6 rate 46. Co mach lam tang sic cdn ngoa: vi va dua huyét p vé mic binh thudng. Ng tinh mach thie day mau v8 tim Lim ing site bom cua tim; (2) tdc dung thit hai 1a lam ai ra, co 213Gar HA ’ Renin (othr) | Cachit renin ———______, Angiotensin 1 (protein huyét tuang ) a Men chiyén, (hat) Angiotensin 1 LN & musi ve (Khe boat) mute 8° thin © mach a N\ a Ting HA Hinh 3-7, Cor ch renin-angiotensin gly co mach diéu hoa dp sult déng mach (HA). gidm bai xudt mudi nude, d6 1 tac dung qua than. NhO vay tang thé tich dieu ngoai bao, lam huyét 4p tang din-tir tis hang gid hang ngay. Téc dung dai han d6 qua thé a tr vé binh thudng. ngoai bao, {a manh hon tac dung co mach c4p tinh trong viée nang huyét 4p Hé renin-angiotensin tac dung manh dua huyét 4p vé binh thudng sau khi mat mau nang, do d6 cé thé cu séng, dac biét trong sée tan hoan. Luu ¥ 1a hé nay c&n ching 20 phot dé phat huy hét tac dung tic 1a rét chm hon phan xa than kinb va hé giao cim. Angiotensin lam than gitt mudi va nde. Co ché dai han quan trong diéu hoa huyét 4p: Angiotensin tac dung lam than git’ mudi va nude do hai cach: (1) truc tiép lén than gay giti mudi va nudc; (2) 1am vo thugng thAn tiét aldosteron, a hormon lam tang t4i hp thu mudi nude 6 Ong than. 214‘Trén day 1a hai tae dung git mudi, nuée eda angiotensin. Co thé mudn duy tri can bing thi phai t&ng dao thai mudi va nuéc bing each tang huyét 4p. Do d6 khi c6 nhiéu angiotensin trong mau thi co ché dai han than - thé dich phai tu déng “dat lai diém chudn" cua huyét dp lén mic cao hon binh thudng. Ca ché angiotensin téc dung lén than git? muéi vd nuéc: angiotensin cé nhiéu mat tac dung lén than. Tac dung quan trong nhét cé 1é la gay co mach than do a6 gidm luu lugng mdu qua than, gidm lugng dich loc, tang tai hap thu dich 6 ong than. Kich thich bai tiét aidosteron gdy git nude va mudi do thdn: angiotensin la mot chat manh diéu hda bai tiét aldosteron, chat nay lam dng than tdi hap thu natri. Ca tac dung truc tiép lan tac dung gidn tip cia angiotensin déi vdi than déu la quan trong trong diéu hoa dai han doi voi huyét 4p. Tuy nhién c6 lé tae dung tryc tiép manh hon gap ba bén lan. Tém Iai, he Renin - angiotensin 14 mot co ché diéu hoa dai han di voi huyét Ap do nhiéu mat tac dung: truc tiép co mach than thé, cing nhu tac dung gidn Ién than. Tac dung than 1a qua con dudng gidm loc edu than, lai c6 con dudng aldosteron lam tang tdi hap thu 6ng than git muéi va nude. Hé renin - angiotensin gii? huyét ap binh thuang mde dau mic thu nhén mudi dao déng manh: Cé 1é chte nang quan trong nhdt cia hé renin-angiotensin la duy tri én dinh thé tich dich ngoai bao va huyét dp, mac dau tay hoan cdnh con ngudi c6 luc An rat it mudi, c6 lic rat nhiéu. C6 thé an lugng mudi nhiéu gap 50 lan binh thugng ma huyét 4p chi tang khong qué 4 dén 6 mmHg. Nhung néu hé renin - angiotensin bi phong bé thi lugng mudi néi trén 1am huyét 4p tang thém 50 dén 60 mmHg. Co ché “diéu khién ngugc’ (tiie feedback) ty dong duy tri huyét 4p nhu sau. Mudi lam tang dich ngoai bao, réi tang huyét dp, diéu dé Jam tang lau lugng mau qua thn, do dé gidm bai tiét renin khién cho than gidm git mudi nude, dich ngoai bao gidm dan vé binh thuéng, huyét dp trd vé gan binh thudng. 3.4. CAC YEU TO THE DICH KHAC ANH HUONG DEN HUYET AP Khi huyét 4p gidm, ving dui déi tang bai tiét vasopressin cdn c6 tén goi 1A hormon chéng bai niéu (ADH, antidiuretic hormone). Goi la hormon chéng bai nié vi n6 tae dung tang tai hap thu 6 éng than, qua dé 1am gidm bai nigu. Con goi la vasopressin vi cé tac dung tryc tiép gay co mach lam tang stfc can, tang Ap sudt trung binh (vaso nghia 14 mach, pressin 1a tang 4p). Trong cac y€u té thé dich gay gian mach c6 bradykinin 1a peptid cé trong mau va ich. Né duge kallikrein (¢6 sdn trong mau) hoat héa gay gian mach va tang tinh thém mao mach dan téi gidm 4p. Histamin cé 6 hau hét cdc mé trong co thé va 2156 téc dung gidn mach, tang tinh th4m mao mach, gay giém 4p. Cac prostaglandin cé 6 hau hét cdc mé, ndi chung cé téc dung gian mach tang tinh tham mao mach, mot 86 logi c6 téc dung co mach, ndng dd ion Ca** gay co mach, céc ion K*, Mg** gay gin mach. Nong dé oxy thap va carbon dioxid cao gay gién mach. 3.5. CACH NHIN TONG HOP VE MOT HE THONG NHIEU CO CHE DIEU HOA HUYET AP Ditu hoa huyét 4p khong don gidn chi la tac dung lén 4p sudt mau dong mach ma la su tich hop (integration) cée tac dung da dang, nhiéu mat, nhiéu co ché tién quan dén céc chtic nang nhiéu co quan, céc tac dung khong riéng ré ma tuong tac lén nhau, phéi hop ln nhau, dé duy tri huyét 4p, ing ph voi nhing bién dong tic thdi cing nhu thich nghi voi bién di lau dai cia tuan hoan. Xt Hinh 3-8 1a so dd tam co ché diéu hoa huyét 4p do Guyton téng hop (1980) va chia lam ba nhém 1a: nhom kiém soat nhanh, nh6m trung gian va nhom diéu hoa dai han. ean Hits lie feedback hi HA 188 ww ” a é 4% g8: ops ee! pldesteror als oy Ba zZ Chuyér obit 2) -{ dich as qua thank o Oemi tab wuias dias big, \M40 mach Chis tasbiryamiss is | Gy Phd Gib Ngay Tibi gran sau lui HA bid dong der ngst Hinh 3.8. Sor &® bitu din glin diing cdc cor ché diéu hoa huyét dp vao ec Kaodng thot glan Kkivic nhau sau khi r6i loan huyét ap. Laru ¥ higu ie rit cao cba cor ché thénh® dich bit du phat huy sau vai ngly (Ur liu tng hop cia Guyton, xast bin 1980): +: c0 mach do renin-angitensin. Nh6m cdc co ché kiém sodt huyét 4p nhanh trong giay phit D6 Ia ba co ché: (1) diéu khién agugc (feedback) cdm thy 4p; (2) thiéu mau thin kinh trung uong, va (3) cdm thu héa. Ba co ché nay dap tng chi trong vai gidy, dua 216