i” A = a bs Wwe Te Daan BO y TE BY Aow vor bev pho ae BENH VIEN BACH MAI O95 9®SSXG HOI SUC TICH CUC CO BAN (GIAO TRINH DAO TAO SAU DAI HQC) Ha NGi- 2013LOI GIGI THIEU Trong lich str hon 100 nam xay dyng va phat trién, Bénh vién Bach Mai luén 1a co sé dao tg0 Ién nhat cia Trudng Dai hoo Y Ha N6i va cing Ia dia chi tin ody cia hang trigu ngudi dan Vigt Nam khi ho cdn duge chim séc site khoé. Cling 46, Bénh vién 44 nd hye hé tro cdc bénh vign tuyén trude théng qua céng tac dao tao, chi dao tuyén, ting curdng can bO y té vé co sé va dic biét frien Khai mé hinh bénh vign vé tinh, Song'song vi Dé an “XAy dyng mot sé Bénh vign vé tinh clia Bénh vign Bach Mai” duoc trién khai tir thing 8/2009 theo Quyét dink sé 2741/QD-BYT ngay 30/7/2009, BO trudng BO Y té da giao cho Bénh vién Bach mai nhigm vu Dao tao bac sf chuyén khoa cap |, cdp Il, NGi tra bénh vién voi myc dich nang cao nang lye chuyén mén cho cén b6 y té va ting cudng chat lvong dich va khém chia mot céch bén vitng. Mét trong cdc mye tigu uu tién cia cong téc dao tao 1a chudn héa hoat déng ao tao, chi dao tuyén thong qua 4p dung hé théng quan ly chat long theo tiéu chudn quéc t8 ISO 9001: 2008; dic biét 14 bién soan, chudn héa céc chuong trinb, tai ligu dao tao vé cdc linh vyc lam sing va cAn lm sing. Cc chuong trinh va tai ligu dao tao 46 d& dugc phé duyét bdi Hi déng Khoa hoc cia BO Y Rs dé dp dung rong rai trong céc co sé dao tao y hoc. Dén nay gan 100 khung chwong trinh, tai ligu dao tao di duge bién sogn, chudn héa. Sich “Héi site tich eye co ban” da duge che Gido su, Tién sy, Bac s¥ dang cOng tic tai Khoa H8i stic tich eye - Bénh vign Bach Mai va BG mén Hoi ste cfip iru Dai hgc Y Ha Noi bién soan trén co sé chuong trinh dao tao da duge Héi déng Khoa hgc Bé Y té thim dinh va phé duyét, theo phuong cham: kién thite co ban, hé théng; ndi dung chinh xéc, khoa hoe; cp nhét cae tién b khoa hoc, kf thudt hign dai va thyc ti&n cua Viét Nam. Bénh vign Bach Mai xin chan thinh cém on céc tée gid da dinh nhiéu eéng sire hoan thanh cudn séch; xin cam on céc Gido su, Tién s¥ trong Hgi déng khoa hoc i doc phan bign, nhdn xét va gip nhiéu y kién quy bau cho vige hoan thign cudn sich nay. Chiing t6i mong nhfin duge nhidu y kién déng gép ctia déng nghiép, cdc hoc vien va dOc gia dé cudn sach duc hoan chinh hon trong Lin xuat ban sau. Xin tran trong cdm on ! PGS. TS. NGUYEN QUOC ANH GIAM DOC BENH VIEN BACH MAILOLNOI BAU Theo quy ché Cp ctru, Hi stic tich cye va Chéng déc do BO Y té ban hanh n&im 2008, cdc bénh vign tuyén tinh tré 1én sé thanh lap khoa Hi ste tich cyc va khoa CAp citu. Hién nay hau hét cdc bénh vién tuyén tinh da cé khoa Cap cttu va Héi site tich cue. Do 46 nhu cau vé dao tao céc bac si 06 kién thie vé Hai site tich cyc 1a rét 1én va cp bach, phan lén cdc bac si tré duge tuyén vao cdc bénh vign déu méi 1A bac s¥ da khoa, nén cdn gap nhidu khé khiin trong vige chin doan va xir tri ede bénh nhan ning. Gio trinh nay duge bién sogn véi myc dich cung cdp cho che dng nghiép nhting kién thire co ban va ky nang can thiét nhat cho viée chin doan, xii tri cp ciru céc tinh hudng bénh ly thudng gap trong khoa Hdi site tich eye. Cée gido su, bac si cOng tac tai khoa Hi sic tich cye Bénh vign Bach — Mai va BO mén Héi site cdp citu Dai hoc Y Ha NGi bién soan gido trinh nay dya trén kinh nghiém diéu trj va giang day c6 bd sung mét sé kién thire méi va thie té trong céng téc chi dao tuyén tai cic bénh vién. Viée bién soan tai ligu nay kh6ng thé tanh khéi nhting thiéu sét, do 6 chting t0i xin cém on va mong nhan duge nhiing déng gép cla cdc déng nghiép cho cdc tac gia 8 lan xuAt ban sau duge hoan chinh hon, Xin tran trong cam on! PGS.TS. NGUYEN GIA BINH PGS.TS. DO DOAN LOIBAN BIEN SOAN Chit bien: PGS.TS. NGUYEN GIA BINH Truéng Khoa Héi site tich eye - Bénh vién Bach Mai PGS.TS. BO DOAN LOT Phé Gidm dc Bénh via Bach Mai Vién truéng Vién tim mach Viet nam Cae thanh vién tham gia bién soan: 1, PGS. TS. NGUYEN GIA BINH . PGS. TS. BO DOAN LOI . PGS.TS. BANG QUOC TUAN . TS. BAO XUAN CO . TS. LE TH] DIEM TUYET . TS. NGUYEN CONG TAN . ThS, NGUYEN DANG TUAN . ThS. GIANG THUC ANH . ThS. BUI VAN CUGNG 10,ThS. MAI VAN CUONG 11, ThS. BUI TH] HUONG GIANG 12.ThS. PHAM THE THACH CPA AwWRYWHN Thu ky bién soan: 1. TS. BAO XUAN CO Khoa Héi site tich cye - Bénh vién Bach Mai 2. ThS. VU TRI TIEN Phé Gidm déc Trung tam Dao tao va Chi dao tuyén Bénh vién Bach Mai 3. ThS. VU VAN NHAN Trung tam Dao tao va Chi dao tuyén Bénh vign Bach MaiMUC LUC Suy hé hap cap EEE PGS.TS. Deng Quée Tudn . Con ting huyét ap PGS.TS. Dé Doan Loi; ThS. Giang Thyuc Anh . Pha phdi cdp huyét dong PGS.TS. Dé Doan Loi; ThS. Giang Thuc Anh |. Tai bién mach mau nao PGS.TS. D6 Dodin Loi; ThS: Pham Thé Thach . Trin khi mang phdi : TS. Nguyén Cong Tan Con hen phé quan ning PGS.TS. Dang Quéc Tudn Dot cp ctta bénh phdi tic nghén man tinh PGS.TS. Dang Quée Tudn ._Hén mé nhi&m toan ceton do dai tho dung TAS. Busi Thi Huong Giang . Hon mé ting dp luc thdm thau do dai thao duong 7 ThS. Bui Thi Huong Giang R6i loan thing bing nudc dign giai — Tang kali mau ThS. Bui Van Cuong . Réi loan thing bing nude dién giai — Ha kali mau ThS. Biti Van Cuong . R6i loan thing bing nuéc dign gidi — Tang natri mau TS. Bisi Viin Cuong . Réi loan thing bing nude dign gidi ~ Ha natri mau TAS, Biri Vein Cuong . Réi loan thing bing kiém toan TS. Lé Thi Diém Tuyét . Séc nhiém khuan PGS.TS. Nguyén Gia Binh; ThS. Nguyén Déing Tudn . Séc do tim PGS.TS, Nguyén Gia Binh; ThS. Mai Van Cudng . Séc do gidm thé tich tuan hoan PGS.TS. Nguyén Gia Binh; THS. Mai Van Cuéng . Sée phan vé PGS.TS. Nguyén Gia Binh; ThS. Giang Thuc Anh 34 45 54 69 83 88 96 103 109 117 124 136 146 153 1599. 20. 2 2: S 23. 24. 2: a 26. 27. 23 & 29, 30. 3 32. 33. 34, HOi chiing suy da tang PGS.TS. Nguyén Gia Binh; TS. Dao Xuan Co Viém tuy cp PGS.TS. Nguyén Gia Binh; TS. Déto Xuan Co . Suy than cdp TS. Lé Thi Diém Tuyét . Nguyén ly théng Ichi nhfn tao va cée phuong thite thé thudng gap PGS.TS. Nguyén Gia Binh; ThS, Bui Vein Cuong Chi dinh va chéng chi dinh cia théng khi nhén tao PGS.TS. Nguyén Gia Binh; ThS. Bui Vain Cuong Dat ndi khi quan TRS. Neuydn Ding Tudn . Cac ky thugt khai théng dong thé ThS. Nguyén Dang Tudn At catheter tinh mach trung tim ThS. Pham Thé Thach pat din luu mang phdi : ThS. Pham Thé Thach . Quy trinh Idy khi méu dong mach TAS. Bui Vain Cuong Cp ctu ngimg tuan hoan co ban 6 ngudi lon PGS.TS. Nguyén Gia Binh; ThS. Pham Thé Thach Cp ctu nging tudn hoan nding cao PGS.TS. Nguyén Gia Binh; ThS. Pham Thé Thach . Séc dign cap ctru TAS. Giang Thuc Anh Su dung méy theo doi thong ding trong hdi site cp ciru TS. Nguyén Cong Tan Choc hit qua mang nhin gidp khf quan TS. Nguyén Céng Tan at catheter trén khép vé ThS. Mai Van Cuong 164 172 185 197 207 211 221 229 237 244 249 254 261 267 275 280ALT ALTMTT ALTT ARDS AST BNP BPTNMT CPAP CT scan CVVH DIC EPAP FiO, GGT HA HATB HATT HATIr HPQ IPAP LDH MRI PaCO, PaO, PEEP PPC Pro BNP a0? pO, vic DANH MUC TU VIET TAT Alanine transaminase Ap luc tinh mach trung tim (Central venous pressure - CVP) Ap luc tham thdu Hi ching suy ho hip cdp tién trién (Acute respiratory distress syndrome-ARDS) Aspartate transaminase ‘Yyéu t6 thai natri nto-nigu (Brain natriuretic peptide-BNP) Bénh phdi tic nghén man tinh (Chronic Pulmonary Ostructive Disease-COPD) Ap lye dudng thé durong lién tuc (Continuous positive airway pressure) Chyp eft lép vi tinh (Computed Tomography scanner) Loc mau tinh mac-finh mach lién tue (Continuous Veno-Venous Hemofiltration) Ong mdu rai rdc trong long mach (Disseminated Intravascular Coagulation- DIC) Ap lye duong thi thé ra (Exspiratory positive airway pressure) Nong 46 Oxy khi thé vao (Fraction of inspired oxygen) Gamma-glutamyl Transferase Huyét dp Huyét ap trung binh Huyét dp tam thu Huyét dp tam truong Hen phé quan Ap lye duong thi thé vao (Inspiratory positive airway pressure) Lactic acid dehydrogenase Chup cOng huéng tt hat nhan (Magnetic Resonance Imaging) Ap lye rigng phan CO, trong mau dng mach (Partial pressure of carbon dioxide in arterial blood) Ap luc riéng phan oxy trong mau dong mach (Partial pressure of arterial oxygen) Ap Iue durong cudi thi thé ra (Positive end exspiratory pressure) Phi phdi cp N-terminal pro B-type natriuretic peptide D6 bao hod 6xy mau dGng mach (Saturation of arterial oxygen) D6 bao hoa xy mau ngoai vi (Saturation of Peripheral oxygen) Viém tuy capBail suy HO HAP CAP Mue tigu 1. Trinh bay dueoe dinh nghta va cde nguyen nhdn chinh gay suy hé hap cdp. 2. Trinh bay duge ede triéu ching var chéin dodn etia suy hé hdp cdp. 3. Trinh bay duge cde nguyen téc diéu tri edp ctu suy hé hdp cdp. L. DAL CUONG Suy hé hp cp 1a tinh trang giém cp tinh chite n’ing thong khi hode trao adi khi & phdi, din dén tinh trang giém oxy méu, tir d6 gidm cung cAp oxy cho cdc co quan cita ca thé, 06 thé kém theo hoc khéng kém theo ting CO; mau. Cé hai logi suy hé hap cdp: - Gidm oxy mau don thuan, - Giam oxy mu kém theo ting CO2 mau. 11. SINH LY BENH 1, Co ché gy giam oxy hod mau (giam PaO) - Gidm cung cdp oxy (giam ndng dé oxy trong khi thé vao), - Gidm ap lye khi quyén. - Giam théng khi phé nang. ~ Mat cfn bing théng khi/tuéi mau. ~ Tang shunt déng-tinh mach phéi. - Gidm kha ning khuéch tan cia mang phé nang - mao mech.92 coz on 02 con Hiéu ting shunt Hiéi ting khodng chét Hinh 1.1. Co ché gay giam oxy héa méu 2. Co ché gidm thong khi (ting PaCO,) - Gidm thé tich khf liu théng nhung khéng durgc bi bing ting tin s6 thé. - Gidm tin sé thé nhung khéng duge ba bing ting thé tich khi luu thong. ~ Tang khoang chét khéng duge bi bing ting thong khi. - Tang tao CO2 khéng duge bi bang ting thong khi. UL. TRIEU CHUNG 1. Lam sing ~ Khé thé nhanh > 25 lén/ phut hay chm < 12 lan/ phut. Trudng hop nguy kich hay suy hé hép cfp do nguyén nhan trung wong cé thé cd con ngimg tho. - Co kéo co hé hp. Khéng c6 dau higu nay néu suy hé hdp do nguyén nhan trung wong, do nhuge co hoi ligt co hé hap. - Tim, mite 46 tim tuy thuge mite 4 suy hd hdp. Dau higu nay khong 16 néu bénh nhan cé thiéu mau. ~ Va mé héi. - Réi loan tinh than (suy hd hap cdp mite d6 nang), vat va, 1o 4, hon mé (suy hé hap cAp nguy kich). - Mach nhanh trén 100 Kin/ phit, cd thé ri logn nhip, huyét 4p ting (suy hé hap cdp nang), c6 thé tyt huyét 4p, mach cham (suy hé hip cp nguy kich).- Kham phéi: thy cdc trigu chimg tuy theo nguyén nhén gay suy ho hip cap. - Trigu chimg cla cac bénh ly nguyén nhin hay bénh ly kém theo. - Luu y: héi ky tinh hudng xuét hign 06 thé goi ti nguyén nhin gay suy hd hap. 2. Xét nghigm - Khi méu; PaO, gidm, SaO, gidm, o6 thé cé ting PaCO, (> 45 mmHg), gidm pH Khi cé nhiém toan hé hap. : Binh thudng: PaO, (mmHg) = 102 - 0,33 x tudi (nam) PaCO, = 35 - 45 mmHg - Trén lam sing, SpO. theo doi lién tye o6 thé thay thé SaO, 48 danh gid mite d6 ning cia suy hé hdp (voi didu kign huyét 4p binh thudng, tudi méu dau chi t6t). ~ Xquang phéi: thdy céc binh anh tén thuong tuy theo nguyén nhan: viém phéi, tran dich mang phdi, tran khi mang phdi.... ~ Che xét nghiém khéc tuy thude nguyén nhan gay bénh Iv. CHAN DOAN 1. Chan dodn xéc inh Dya vao: - Tinh trang Ih6 thé -Tim - Hoat dng bat thudng cia co hé hip va co hé hap phy - SpO> gidm, PaO2 gidm 2. Chan dodn phan biét - Suy tim: gay khé thé, giam oxy mau, nhung nguyén nhan do tim, - Thiéu mau ning: khé thé, niém mac nhot, khéng tim. Thiéu mau dp 6 thé co tut huyét dp. = Thé nhanh do céc nguyén nhén khdc: nhiém toan chuyén hod, cudng giao cim, hdi chiing d4p img viém hé théng.3. Chan doan nguyén nhan 3.1, Hé théng thn kinh trung wong ~ Thude: qué lida, ngé dée cdc thudc 06 tae dung tre ché trung tim hé hap (an than, gay nga, gay mé, thudc nhém opiat). ~ R6i loan hoat dong caa trung tam diéu hod hd hap 6 hanh nfo (chén thuong so no, bgnh Iy mach n&o, ting 4p lye ndi so, nhiém tring hé théng than kinh trung wong...). ~ R6i logn ho hép lién quan ti gide ngi: hoi ching nging thé Khi ngi nguyén nhan trung ong, h6i chimg gidm théng khi do béo béu. ~ Hi chitng giam thong khi v6 cin. 3.2. Bénh If than kinh co ~ Bénh ly than kinh-co nguyén phat: hdi chimg Guillain Barré, nhuge co, bai ligt, cac trudng hop viém tuy cé tn thuong ty cé, teo co, xo edt bén teo co, viém da co... ~ Chén thong cét sing (gay tén thuong tuy 8). - Thudc va ngé de: ng6 adc tht (thit hop), thudc trix sau phospho hitu co, cée thudc tte ché than kinh co, aminoglycoside, rin dc fn. ~ Réi loan dign giai: ha K", ting magié, ha phospho mau, 3.3. Thanh ngye - Gy xuong sudn, mang sudn di dong. ~ Gd veo c6t sng, béo bgu: gay suy hé hp man tinh, c6 thé xudt hign dot mit bd cdp va suy hé hdp cdp. + Tang dp lye 6 bung (cd chuéng nhidu, chuéng bung...) anh hudng téi hoat dong co hoanh. 3.4, Mang phéi - Tran khi mang phdi. - Tran djch mang phdi. 3.5. Bénh by mach phéi Tc mach phdi (do huyét khéi, do hoi, te mach 6i. 3.6. Cac tén thong nhu mé phéi khdc ~ Phu phdi cdp:. Phi phdi cdp huyét ddng (pti phdi cp do tim). _ Tén thutong ming mao mach phé nang: héi chimg suy hé hap cdp tién trién (ARDS). - Viém phéi. ~ Bénh phi ké. ~ Hi ching chdy mau phé nang lan tod. - Ung thu phdi: nguyén phat va di cain. - Chin thurong phdi. - Xep phdi. 3.7, Duéng dan khi - Dudng hé hip trén: dém, dj vat, phd, nhiém tring, co that. - Viém tiéu phé quan cdp. ~ Hen phé quan. - Dot cp bénh phdi tic nghén man tinh. 4, Chan doan mire a n§ng Dinh gid mic 49 suy hé hap cp 1a trung binh, ning hay nguy kich cin dya vao cdc trigu ching ciia suy hd hap, mirc 46 ning cia bénh nguyén nhan, ddng thdi xem xét dén co dia, tudi va cdc bénh man tinh kém theo cua bénh nhan. - Theo GS. Vii Van Dinh dinh gid mite d6 ning ca suy hé hép nhur sau: Du higu Suy ho hdp ning —Suy hd hiip nguy kich Xanh tim +t H+ ‘Va méd héi + tHe Khé thé +h bt Huyét ap Tang Tut Réi loan ¥ thie 0 + - Mét s6 déu higu khéc gitp phan mite 46 nang ctia suy hé hip cap: + Nhip tim: suy hé hap ning nhip tim nhanh > 120/phut, trong suy hé hp nguy kich nhip tim cham dan.+ Tan sé thé: suy h6 hap ning bénh nhan thé nhanh > 30 —35 1an/phit; suy ho hap nguy kich cé thé thé cham, c6 con nging thé. + Co kéo co hé hp: suy hé hap ning co hé hap phy co kéo nhidu; suy hé hap nguy kich cé thé c6 h6 hp ngye-bung nghich thudng (ddu hiégu cia kigt sie hé hp). + Tinh than: bgnh nhdn suy hé hip nang hay 66 kich thich, hét hoang, Vat va, cdn r6i loan ¥ thite 1a d4u higu cia suy hé hép nguy kich, + Sa02 < 90%, PaO, < 60 mmHg trong suy hé hAp ning. Trong suy ho hdp nguy kich, PaO, cé thé rét giam nang < 50 mmHg va khéng d4p ting voi ligu phap oxy. V. DIEU TRI ~ Suy hd hp cfip 14 mét edp citu ndi Khoa, trong trudng hop nguy kich phai xi ly cp ctru ngay tai ché, tai nha, trén xe van chuyén cting nhu tai cdc don vj cp citu 6 cdc mite 49 khéc nhau, vi thiéu oxy nang rat nhanh dan dén tt vong hay mit v6, mat nao. - Trong phan 16n trudng hop suy hé hép cp cn phai nhép vién ngay 46 didu trj 06 higu qua. ~ Khi van chuyén mgt bgnh nhan suy hé hAp can chia ¥ bao dam dia tri lién tye, Xe van chuyén phai cé trang bj hd tr hd hdp: binh oxy, dng dit noi kh{ quan, may hut dom, b$ mo khi quan, 06 thé c6é méy thé kém theo. ~ Luén bao dam xtt tri cdp ctu suy hé hp cMp song song véi xir tri nguyén nhén. 1. Cac phwong tign cin thiét LL. Oxy ~ Hé théng oxy (oxy tudng, binh oxy, binh oxy nhé cho van chuyén - chit ¥: binh oxy phai cé van gidm Ap ding tiéu chudn). ~ Dung cu thé oxy (gong kinh oxy, mit na, m&t na c6 tii dy tri, binh Jam dm va Juu wong ké). 1.2. Cite mdy, plucong tign chim séc hé hdp - Bong ambu, may thé.- Ong ndi khi quan, canun mé khi quan va bG mo khi quan, canun Guedel, Mayo, dyng cy mé mang phi. - May hiit dom, may but lién tuc (ding:trong din 1uu mang phéi). 1.3. Cle may theo doi, chin dodn - May chyp X quang tai giudng. - May theo dai lign tye: dign tim, huyét 4p, SpO2. - May xét nghiém khi trong mau (néu c6 diéu kién). 2. Dinh gid ban dau Can xdc dinh ngay: + Mite d6 suy hé hap: trung binh, ning hay nguy kich. + Nguyén nban: cin phai xde djnh bode logi tri ngay cho nguyén nhan sau - Suy hé hép cp do nguyén nhin trung wong. - Suy hé hp cp do bénh ly than kinh-co. - Tran khi mang phdi ning (tran khi mang phéi duéi 4p lye). * Dj vat dudng thé gay kkhé thé thanh quan. 3. Xie tri cp ecru Néu xée djnh mite suy h6 h4p cap nguy hich, hogc suy hd hap cAp do cde nguyén nhdn néu trén, cin xi tri ngay: - Suy hé hp cp nguy kich: thong khi nhiin tao. - Suy hé hap ofp do nguyén nhén trung wong, do bénh ly thin kinh-co: thong khi nhan tao. - Tran khi mang phdi nang: dan hu mang phdi. - Dj vat dudng thé gay khé thé thanh quan: thi thuat Heimlich. Trong céc truéng hop kbéc, xi tri cp ciu tuy theo mite 4) nang va nguyén nhdin cia suy hé hp. Bao gm céc bign phap sau. 3.1. Tw thé bgnh nhin - Khai thong duing hé hip - Tw thé ddu cao (phan than trén cao 300 - 400 so véi mat giudng), hode tu thé ngdi thong chan (trong phi: phdi cép huyét dong). - Khi bénh nhén c6 déu higu tut ludi: nim nghiéng, dat canun Mayo hodc Guedel dé dé Indi.~ Néu 66 tr dong dom: vén dong tr] ligu, tp cho bénh nhan ho khge, hit dm 6 hong hodc dat ndi khi quan dé hit dom néu can, - Dit dng nGi khi quin hose mé khi quan dé kiém soat duéng hd hap néu cé chi dinh, 3.2, Tho oxy ~ Thé oxy hru tugng thép (1 - 2 Itt/phuit) trong dgt cdp cia suy hé hap man tinh, ~ Thé oxy Iuu hrgng cao trong suy hé hép cp - hu hygng oxy tuy theo nguyén nh&n va mite dé suy hé hdp. 7 ~ Thé oxy dudi 4p lye dong lign tue (CPAP, CPAP Boussignac) - Chi dinh khi thé oxy don thudn khéng ning duge oxy méu, tinh trang bénh nhan khéng qué nang, co hé hap va trung tim ho hap binh thudng. . Mite CPAP thuong duge ding: + 5 cmHI,0. 3.3. Thé may Thong khi duge chi dinh khi thé oxy kh6ng gidi quyét duge tinh trang thiéu oxy mau va/hode ting CO, mau. C6 thé chi dinh thd may khéng xAm nhap hoc thé may xém nhép tuy tinh trang cy thé cha bénh nhén, 3.3.1. Tho mdy khong xm nhdp ~ Qua mit na mili hoc mat na mit. ~ Chi dinh trong suy h6 hdp cép mite 46 trung binh hodc nang, khi khong c6 chéng chi dinh cia thé may khéng xim nh§p. Phuong thi nay Khéng cin dit dng nOi khi quan nén trinh duge nhing bién chiing lién quan t6i éng ndi khi quan, ~ Chéng chi din, phuong thite: xem thém bai Nguyén Iy thong khf nhan tao. 3.3.2. Tha may xdm nhdp - Qua éng ngi khi quan hoe mé khi quan. ~ Chi dinh trong suy hé hép cAp nguy kich, cdc trrang hop 06 chéng chi dinh voi thong kh{ khong x4m nhgp hoe khi thong khi khong x4m nhap kh6ng higu qua.= Chong chi dinh, phuong thie: xem thém bai Nguyén ly thong khi nhan tao. 4, Xir tri nguyén nbéin - Mét s6 trudng hop, khi suy hé hip cAp khong ning, chi can xir tri tét nguyén niin bénh nan cting c6 thé hét suy hd hdp (vi dy: con hen phé quan mite 46 trung binh, tran dich mang phéi,...) - Tuy vay, trong phan 1én céc suy hé hép can xit tri nguyén nhan song song véi hdi stte hé hp. 5. Cac bign phap didu tri phéi hop - Didu tri cdc bénh 1y phdi hop khdc néu c6 (suy tim, tyt huyét 4p, tinh trang sdc, s6t cao, dau, co giat,...) - Bao dam thing bing nuéc - dign gidi, kiém - toan. - Bao dam dinh duéng. ~ Chim séc tich oye. 6. Theo di = Tan s6 thé, tinh trang da - niém mac (cé6 tim khéng? mite 467), hoat dong cia co hé hp (co lién swim, co hodnh), co kéo co hé hép phu. - Mach, nhip tim, huyét 4p, tinh trang y théte, cm gide cha bénh nhan. - Sp02. - Thé tich hru théng ty thé, dung tich séng, Iva Iugng dinh thé ra (chi inh khi can thiét). - X quang phéi. - Xét nghiém khf trong méu dng mach. ~ Din bién cia bgnh nguyén nhéin.TAL LIEU THAM KHAO : -Ng6 Quy Chiu va cs (2011): Sup hé hdp. Trong: Bénh ho hap, Nxb Gido dyc Viét Nam, 638-647. - Va Van Binh (2004): Suy hd hap céip. Trong: Hi site cdp citu toan t4p, Nxb Y hoe, 82-94, -Chelluri L., Pousman R. (2011): Acute Respiratory Failure. In: Textbook of critical care (Editors: Vincent J-L., Abraham E., Kochanek P., Moore F.A., Fink M.P.), Elsevier Saunders, 6" edition, 33-35. Isakow W. (2012): An approach to respiratory failure. In: ‘The Washington Manual of Critical Care (2ditors: Kollef M. and Isakow W.). Ban dich tiéng Viét “Hai site cp ctu - Tiép can theo phic dd”, Nxb Khoa hoc ky thuat, 59-66. . Vineent J-L, (2009): Classification. Approche de Uinsuffisance respiratoire aigue @ VUSI. Dans: Le manuel de réanimation, soins intensifs et médecine d'urgence, Springer-Verlag France, Paris, 3° édition, 67-75, n wo > w TY LUQNG GIA 1. Trong cée nguyén nhan gay syy,hé hdp cdp sau day, nguyén nhén nio Khéng cé dau higu thé nhanh va co kéo co h6 hap (chon 1 d4p An): A- Kho thé thanh quin B- Viém phdi thiy c4p C- Bénh ly than kinh trung uong D- Chan thuong ling ngyc 2. 6 bénh nan suy hé hap cp, déu higu xanh tim khéng gap khi (chon 2 dap an): A- Bénh nhén 06 thiéu mu ning B- Bénh nhan tran khi mang phéi C- Bénh nhan phi phdi cdp D- Bénh nhan ng@ déc khi CO3. Trong nhiing trudng hop nao sau day, suy h6 hap c6 gidm oxy kém theo ting CO, mau (chon 2 dap én) A- Liét co hé hép B- Viém phi thay c&p C- Dot cap bénh phdi te nghén man tinh D- Dung.dép phdi 4, Nhiing trudng hgp nao sau day c6 tinh trang higu tmg shunt gdy suy ho hap (chon 2 dap An): A- Xep phéi B- Viém phéi thiy C- Tic mach phéi lén D- Hen phé quan 5. Onan nhan cia dam chay, suy hé hp 6 thé xay ra do (chon nhidu dap dn): A- Ngat khéi B- Ng6 dec cp khi déc C- Bong dung hd hap D- Phu phdi huyét dong 6. Trude mot bénh nhéin cd suy hé hap cap mirc 46 ning, trudng hgp nao phai tién hanh théng khi nhan tao ngay: A- Con hen phé quan nang B- Viém ph6i thay nang C- Bénh ly than kinh-co D- Tran khi mang phéi 7. Trude mét bénh nhan suy hé hip dp mite 46 nguy kich, viée dau tién cin 1am 1a gi: A- Cho bénh nhan thé oxy uu ugng cao qua mit na B- Cho bénh nhfn thé may khong x4m nh§p C- Dat ngi khi quan ngay va cho thé may D- Bép bong qua mat na cé oxy, sau dé dat ngi khi quan va cho tho may8. Trude mét bénh nhan suy hé hap cp, nhiing nguyén nhan nao khéng thé xir tri theo trinh ty thong thudng va can duge xée dinh hoc loai trit ngay: 9. Muc dich cia dat éng ndi khi quan la gi: A- Khai théng dudng thé B- Bao vé dudng thé khdi sy tro nguge dich da day C- Dé thong khi han tao D- Tat ca cdc y trén déu ding 10, Thu thugt Heim lich duoc tién hanh trong trong hop nao sau day: A- Sic thite tn khi dang an B- U dong dom nhiéu C- Sac dich da day vao phdi D- Hit phai khi dgc 12Bai2 CON TANG HUYET AP Muc tiéu 1. Trinh bey duge cde nguyén nhén, tiéu chuan chén dodn con ting huyét dp. 2. Nik tri duge bénh nhan bj con tang huyét dp. L DAI CUONG Con ting huyét 4p (THA) Ja sy ting cp tinh con sé buyét ap giiy tén thuong hoic de doa tén thong céc co quan dich nhu tim, néio, day mit, than, cé thé xay ra & bénh nhan c6 THA dé cé tir trude, hofie khong 6 ting huyét Sp trude dé. “Dinh nghia con sé HA trong con THA: khi HA tim truong tang trén 120mmHg vi/ho%e HA tém thu ting cao hon con sb HA nén cia bénh nhén trén 30 mmHg. Cac yéu t6 Lam ning thém con THA: - Thc d6 gia ting HA: Sy gia ting con sé HA cang nhanh, t6n thurong cang nang. HA nén ciia bénh nhfn cé cao hay khéng? bénh nhén cé bj ting HA man tinh khong? Con s6 HA tam thu c6 ¥ nghia tién Ivgng tong ty nhu con s6 HA tam truong. Khi con s6 HA tim thu ting trén 220 mmHg 14 rit nguy hiém. Dya trén mite d6 nguy hiém trén co quan dich, thugt ngé con ting HA ‘bao gdm 2 tinh trang sau: ~ Con THA cAp ctu (Hypertensive emergencyy: khi 06 dau higu ton thurong cp tinh trye tiép trén co quan dich (tén thong méi), ddi hdi phai ha HA nhanh (thuéc ha 4p dung tinh mach) ~ Con THA don thuan (Hypertensive urgency): khi chi c6 con tang HA, khong cé tén thuong cép tinh cla co quan dich, e6 thé ha din con sb HA bing thudc ubng.Il. CAC TON THUONG Co QUAN DICH CUA CON TANG HUYET AP Biéu hign tim mach: + Phinh téch thanh dgng mach chi. + Suy tim tri + Phi phdi cA + Nhdi méu co tim + Con dau that ngyc khéng én dinh, Biéu hién than kinh: + Bénh nao do ting huyét dp. + Xudt huyét nfo. + Thiéu mau cue b6 nao. + Tai bién mach nfio thoang qua + Tén thuong day mit: phd gai thi, xudt huyét, xudt tiét, mach co nhd. + Tén thuong thn cp: d4i mau, suy thfin, protein nigu. + Bénh dong mach ngogi vi: the dng mach chi, tie déng mach canh, + Tién sin gidt hodc sin git 6 thai ky. II. SINH BENH HQC VA CO Cui DIEU HOA HUYET AP Khi cé tinh trang THA, co thé dap img Iai tinh trang nay thong qua cdc co ché thin kinh va thé dich 48 didu hoa hu luong méu dim bio yéu cdu cho sw tuéi mau. Co ché nay thé hign 16 nhét trén tan hoan nfo, khi 6 tinh trang THA kéo dai do khéng kiém soat duge con sé HA, co thé da didu hoa lai ru Tugng tuéi mu nao Lim cho nfo “dung nap” véi tinh trang huyét 4p cao. Do dé khi diéu tri, néu ha HA qué nhanh lam thay déi lu lugng mau nfo din t6i khong di bru Iwong tuoi mau ndio va lam xudt hign thigu mdu nao. Vi vay, trong con ting HA ngudi ta cho rang chi nén ha 20 - 25% con sé huyét 4p trung binh dé trénh Jam nang thém céc tén thuong thin kinh, Sy lién quan gitta dong mau nao va dp lye tui mu n&o duge bigu dién theo phuong trinh sau: ALTMN = HATB - ALNS‘Trong 46: ALTMN : dp lye tuoi mau ndo. ALNS —: dp luc ngi so. HATB : Auyét dp trung binh HATB chinh la bién sé ctta phucong trinh. Binh thudng ALNS tuong d6i bing dinh, vi-vay,sy thay di ALIMN phy thude chi yéu vao sy thay di cha HATB. Khi HATB ting tim ALTMN ting, cdc dong mach & nao co lai Jam dong mau 1én nfo khOng tng, nguge Iai khi HATB gidm, ALTMN gidim tiéu d6ng mach niio gian ra 4 dim bio dong mau Ién nfo khong gidm. Nhw vay, mie di) HA thay d6i dong méu Ién n&o vin duge duy tri én dinh. Tuy vay, kha nang digu boa chia mach nio cfing chi 6 gidi han, Gidi han nay rit khée nhau gitta bénh nhén 6 hofe khOng 6 THA, G ngudi khong co THA sy didu hda tu6i mau n&o duge duy tri trong khodng ti 50-150 mmHg cla HATB. O ngudi THA, gidi:han may 12 110-180 mmHg. Khi HA ting cao vwot qué gidi han digu hoa sé dan dén tinh trang ting dng méu lén ndo gay ting ALNS, lam thodt dich vao 16 chtre quanh mach, dan dén phi naio ma bigu hign kam sing la bénb nao do ting) HA. HA ting cao c6 thé gay tén thuong cho cée co quan dich khdc, c6 thé xudt hién suy than cp dai ft, thiéu mau huyét;t4n vi mach, ting renin buyét twong do tén thuong thigu méu thn fan ta, din dén eudng aldosteron thit phat va thudng biéu hign ha kali mau, Téng renin va aldosterone tht phat lai 6 nguy co Lm nang thém tién trién tén thuong ca THA. Khi HA th4p hon gidi han digu hod Lim giam déng miu lén no, néu khéng digu chinh kip thoi c6 thé gay bgah cénh thiéy mau cyc bé nao. IV. TRIEU CHUNG 1. Lam sang Chan don con THA phai dya vao s6 do, HA va phai di tim kiém cac daw higu tn thong hoje de doa tén thong cée co quan dich 48 c6 dink huéng chan dodn va xtr tri ding. VeBénh nhén can duge hoi k¥ va tién sit THA, cdc thuéc ha HA da ding, céc thude dang ding, cach ding thube ha HA cia bénh nhin, HA hang ngay cia bénh nhan (HA nén).va céc thuée khéc. ‘M6t sé diém hvu ¥ khi thim khdm lam sang: Tim cdc déu higu tn theong thdn kinh : + ¥ thitc: tinh, tinh than cham chap, lo mo, vat va, kfch thich, lo ling, bon chén, hén mé,.. + Dau dau, budn nén hodc nén. + Ligt khu tri, r6i loan cém gide (t@ bi .:.), oimg gay. + R6i loan thj gidc nhw nhin mé, gidm hay mat thj lye. + Déng tir 2 bén ddu hay khdng dau, co nbd, gin to. Cac ddu higu tim - mach : + Do huyét dp 2 tay, 2 chan 48 khing dinh con s6 HA va phat hién chénh HA gitta 2 tay, chénh HA gitta tay va chan. + Khém dong mach cdnh, dong mach ben 2 bén va so sénh, phat hién tiéng thdi hay giam cuong 49 mach + Nghe tim phat hién nhimng tiéng tim moi bat thudng nhu tiéng thdi, tiéng ngya phi, loan nhip. + Nghe phéi phét hign cde déu higu bét thudng nhw ran Am, ran ngdy, ran tit... + Dau ngye: tinh chat, ewdng 46, hudng lan,.. + Kho thé. Khém dy mét: + Soi day mit tim kiém cdc tén thong nhw phi gai, xudt huyét vong mac, déu higu Gunn... M6t s6 vin dé khae : + Nuc tiéu: tinh chit, mau sic, luu lugng nude tiéu + Thai nghén, pho, protein nigu, + Cc bénh ndi khoa kém theo nhu déi thao duéng, suy than, suy tim, cdc bénh phdi man tinh,.. 162. Xét nghigm Tuy theo két qua khdm lm sang 48 chi dinh cdc xét nghi¢m phi hop, mye dich lA Iugng héa duge cdc tin thuong cp tinh vA man tinh tai cé¢ co quan dich do THA va con THA gay sa. Cae xét nghiém tim kiém tn thwong cho hé tim mach: + Dign tam dd, chyp X quang tim phdi. + Sign 4m tim, siéu 4m doppler mach, xét nghi¢m men tim,.. Cae xét nghiém tim kiém t6n theong than kinh trung uong: + Chup cit lop so nfio, cong hwéng tir hat nhan so no + Siéu am Doppler xuyén so. Cae xét nghiém khée: + Céc xét nghiém dénh gid tén thuong than: uré mau, creatinin mau, dign gidi dd, ting phan tich nu6c tiéu,.. + Soi ddy mit. Vv. CHAN DOAN 1. Chan dodn xdc dinh Bénh nhan d6t nhién xudt hign HA tim truong ting trén 120 mmHg vi/hokc HA tim thu ting cao hon con sé HA nén cia bénh nhan trén 30 mmHg va cé 1 trong 3 nhém trigu ching sau: ~ Phi gai, xudt huyét vong mac - Bién chimg than kinh - Bién chimg than Luu ¥: do HA ca 2 tay, do ft nhdt 2 lan, bénh nhén nim ngita, sau khi d& nghi ngoi it nbdt 10 phit, 2, Chan don phan biét 21. Con ting HA don thudn: HA ting d6t ng6t, 06 thé xudt hign céc dau higu co ning: nhite dau, hoa mit, chong m&t, ma mat nhumg céc déu higu nay chi i thodng qua, khéng kéo dai va khéng cé biéu hign tn thong co quan dich.2.2. Ting HA niing man tinh chun cé bién ching 6 mit, than, than kinh: chi can ha HA trong vai ngay, khong dugc ha ngay HA trong vai gid vi cé thé gay nhdi mau nao. 2.3. Bénh Ij thin kink trung wong: u nao, xudt huyét nao, nhdi miu nfio, chay mau dudi mang nhén,,con dong kinh, viém mang nfo. ~ Chan doin phan bigt thudng khé, phai cha y dén yéu 16 thai gian, trinh ty xudt hign céc trigu ching, két hop véi cdc xét nghiém c§n lam sang, 2.4, Réi logn than kinh tw dong ~ Biéu hign bing céc trigu chimg ting HA, nhip tim cham, mit 46, vai md hoi ~ C6 thé gip trong céc trudng hgp: bing quang cng to, soi nigu quan, khdi u tién ligt tuyén, nhiém Khudn tiét nigu, hoi ching Guillain — Barre, hodc khi tién hanh lam m6t sé thi thuat. ~ Xtt tr: digu ty trigu ching (gidm dau...), gay t6 tt khi lam thi thudt, 2.5. Ting HA do suy nghi cing thing: khong c6 cdc trigu ching & mit, than, than kinh. C6 thé didu tr] bling thudc an than ofing da 06 két qua. 3. Ch4n doan nguyén nhan 3.1. Nguyén nhan 3.1.1. Thuang gdp nhdt- +; «, ~ Ting HA man tinh khong dugc digu tri; ho%e didu tr] khong ding - Viém cau thén va viém than bé thén man tinh - Soi th§n, & nude bé than, thin da nang 3.1.2. Cée nguyén nhan it gap hon - Hep dng mech than - Bénh td chic tao keo - U thuong thin (tay, vd) - H6i ching Cohn 3.1.3. Cae bénh bj cp tinh - Nhiém dc thai nghén - Viém cau than cdp - Te déng mach than3.2. Cac yéu t6 thudin Igi phat dong con ting huyét dp , Bo didu tr ting huyét ap, dac bigt 14 bd dot ngét clonidin. Truyén TM qué nhanh cae thudc co mach Lam dung m6t sé loai thuéc nbu cocain, phencyclidin, amphetamin. ‘Tac dung khéng mong mudn cia mét sé thude diéu tri nhu thudc 66 phenylpropanolamin (chtta cm cim,..), nhd mdi qué nhiéu va nhiéu lan thudc c6 chita naphazolin. Ding IMAO cing lic véi cac thude cudng giao cam Tinh trang stress. Sau phau thuat. VL XU TRE CON TANG HUYET AP 1. Nguyén tie chung Con THA don thuan khéng cé tin thuong cp tinh cla co quan dich nén khéng cn thidt phai ha huyét dp khén cp, c6 thé sir dyng thuédc udng dé ha din huyét 4p. Con THA cép ctu chi nén ha nhanh 20 - 25% con s6 HA trung binh 48 tranh gay ra tinh trang thiéu mau nao: L.1. Déi voi con THA cé biéu hign than kinh Nén hg huyét 4p trong vong 1 dén vai gid, sau d6 dua dan HA vé mife an toan trong vong 24 — 48 gid, c6 thé bat dau cho thudc ha HA udng sau 12 - 24gid. Khéng cdn didu tri ha HA cp ctu khi HA dudi 180/105 mmHg. idu tri ha HA bing thuéc uéng khi huyét 4p tam thu ti 180 - 220 mmHg va HA tam trong tir 105 - 120 mmHg. Didu tri ha HA bing thudc truyén tinh mach khi HA tam thu > 220 mmHg va HA tam truong > 120 mmHg. 1.2. Déi véi con THA cé biéu hign tim mach Can ha huyét 4p nhanh hon, dic biét khi cd phinh tach déng mach chi cin dua con sé HA xuéng mite thap nhat c6 thé.~ C6 thé cho nitroglycerin va natrinitroprussid 1a cdc loai thudc duge uu tién Iya chon. 2. Lya chon thude hg HA xi tri con ting huyét ép 2.1. Con THA cép citu: chn ha HA ngay bing cac thudc ha 4p duéng tinh mach (TM): ¢ Lya chon thuéc ha HA truyén TM tuy theo trudng hop cy thé: ¥ Natrinitroprusside: trayén TM 0,3 - 10 Me/kg/phut, digu chink theo tinh trang HA. Chi dinh uu tién theo tén throng co quan dich: phinh tach quai dng mach cha, tai bién mach mau nao, phd phéi suy that trai, Thude gay gitin dGng mach va tinh mach manh v6i thdi gian bat dau cé tac dung va hét tic dyng nhanh. Khi sir dung thude cin chi ¥ céc trigu chimg nhiém Adc thiocyanat va cyanid (dc bigt khi bGnh nbn suy gan, suy than), Y Nicardipine: truyén TM liéu 5 - 15 mg/h, sau 46 duy tri ligu 3 - 5 mg/h. Chi dinh cho sau ph&u thugt mach méu, phinh tach quai d6ng mach chi. Chéng chi dinh trong hep van d6ng mach chi. ¥ Nitroglycerin: trayén TM lid 5 - 100 jig/phitt. Chi dinh wu tien cho con dau thét ngyc khéng én dinh, nhdi méu co tim, suy thét tréi, phd phdi cp, sau phéu thudt mach méu. Chéng chi dinh cho viém mang ngoai tim co that, Y Labetalol: tiém tinh mach 1 mg/kg trong 10 phiit, sau a6 0,1 mg/kg/h truyén finh mach. Chi dinh cho ting qué mic catecholamin, tai bién mach no. Chéng chi dinh cho hen, bénh phéi the nghén man tinh, bloc nhi thét, nhip cham, Y Hydralazin: tiém TM 5 - 20 mg, sau dé truydn tinh mach 0,5 - 1 mg/phit. Chi dinh cho san giat, tién san gidt. Chéng chi dinh cho con dau thit ngyc, hep hai l4, nhdi méu co tim cp. © Lya chon thudc Igi tiéu: ¥ Furosemid : ligu tiém tinh mach 1 mg/kg, tiém ngét quang ho%c truyén TM . Chi dinh wu tin khi cé ting génh thé tich, suy thét trai, phd phdi cép. 20VY Mannitol: truyén TM 0,5 g/kg/lin 4 dén 6 lin/ 24 gid. Chi dinh uu tién cho phi nao. 2.2. Con THA don thudn © Can ha HA xuéng mic an toan trong 24 gid. Dang thuéc udng, nén phéi hop céc nhom: - Chen Ca: Nifedipin,..... = Thudc tte ché men chuyén - Thuédc Igi tiéu. - Thudc chen beta 2.3. Ché d@ in trong con ting HA - Kiéng mudi (dic biét 18 mi chinh). = Kiéng mé va céc loai chat béo dong vat. 2.4. Chuyén tie kiém sodt con THA bang thubc ha HA truyén TM sang thuéc ubng ~ KhiHA cia BN a dat duge HA mye tiéu cn didu chinh ligu thuée truyén TM va bat dau cho cée thuée dang uéng thich hgp, giam dan Jidu thude truyén TM, oft thude truyén hi thudc udng 43 dat duge higu qua kiém sodt HA, khéng dimg thudc truyén TM d6t ngot. - Tip tye gidm sat con s6 HA, digu tri cde tén thuong co quan dich. - Tiép tue didu tri THA nhw thudng quy khi BN da thodt khoi con THA, kiém soat dug cae tén thuong cia oo quan dich. 21TAI LIEU THAM KHAO 1. VG Viin Dinh. (2000). Con tang huyét dp. Chm nang cdp citu. Ha N6i: Nha xudt ban y hoc; 99 - 101, 2. Va Viin Dinh, (2004). Con tang huyét dp. Hi site cp oizu toan tap. Ha N6i: Nha xudt ban y hoc 2004; 126 — 137, 3. Hi Tim mach hge Vigt Nam (2008). Khuyén céo vé chan dodn, didu tri ting huyét dp 6 ngwdi I6n. 4. Derrick R. Fansler and Daniel H. Cooper. (2012). Approach to Hypertensive Emergencies. The Washington Manual of Critical Cate 2nd. Philadelphia, USA; 171 - 177. 5. Carl J Vaughan, Norman Delanty. (2000). Hypertensive Emergencies, Lancet. 356; 411 - 417. 6. Susan E. Andrade, ScD; Jerry H. Guer Witz, MD; et Al (2004). Hypertension Management : The care gap between clinical guidelines and clinical practice. The American Journal of managed care — July. Vol. 10, No 7; 481 - 486. 7. Joseph Varonl and Paul E Marik. (2003). The management of hypertensive crises. Critical Care, 7; 374-384, 22TU LUQNG GIA ‘A. Cau béi tri Wi ng&n (din nhiing tir con thiéu): 1, Con ting huyét 4p cp citu: 1a con ting huyét 4p c6 kém theo ...(1)... ich, ddi hoi khi xir tri nén ...(2)... a6 ...(3)... 2. Con ting huyét ap don thuan: 1a con ting huyét dp khong cé...(4)... C. Chu hai tra Iai ding hoge sai: xir tri con ting huyét dp NOi dung 3, Trong xi tri con tng huyét 4p don thudn: ‘nén ha nhanh 20-25% con s6 huyét 4p trung binh 4. Trong xir i con tang huyét 4p cép cau: nén ha nhanh 20-25% con s6 huyét dp t6i da F-Khi cb phinh tich @ng meh chi: cha hq huyét &p ahah hon (xuéng mitc thdp nhdt cé thé) (6, Furosemid 1a thude Iya chon dau tay 7, Go thé sir dung thude udng a6 ha dan huyét 4p trong con ting huyét 4p don thuan 23,Bai3 PHU PHOI CAP HUYET DONG Myce tigu 4. ‘Trinh bay duoc cde nguyén nhdn, tiéu chudn chdn dodn Phi phéi cdp huyét dong. 2. Xté tri dug bénh nhan bj phir phéi cdp huyét dong. 1 DAI CUONG Phi phdi cp (PPC) Ia bidu hién lam sang cia suy tim trai cdp, do tinh trang ting tich tu nude va céc thanh phan hou hinh cita huyét tuong trong khodng ké gay thoat thanh dich vo trong long phé nang, din dén r6i loan trao 446i Ki phé nang — mao mach phdi va gy nén tinh trang suy hd hép cdp trén Jam sang. PPC huyét dng [A hau qua cia nhidu bénh tim mach: tting huyét 4p, hep hai 14, nhdi méu co tim, ede r6i loan nhjp nhanh... Day 1a mét cp ctu ndi Khoa d0i béi phai duge phat hign sém va xi ly nhanh chéng, chink xéc, hop 'Y, vi tinh trang suy h6 hip ep dé gay nging tuin hoan do giém ning oxy héa mau, va nguy co tix vong rit cao. TI. NHAC LAI GIAI PHAU, SINHLY BINH THUONG VA SINILLY BENH 1. Binh thudng 1.1, Mang phé nang mao mgch (MPNMM): la ving trao d4i cia phé nang vd mao mach. Mang phé nang mao mach day 0,1 jum bao gdm cdc lop: - Té bao ngi m6 mao mach: cho Phép loc née, cée chit dign gidi va cdc chat hoa tan ¢é trong hrgng phan tir nhé (< 10.000). ~ Mang day: déng vai trd mang nang do va it anh huéng dén qua trinh trao i qua MPNMM. - Biéu m6 phé nang véi hai loai té bao: © Té bao I: 1a nhiing é bao det phi long céc phé nang.© Té bao Il: 1a nhiing té bao cé hat, bai tit surfactant gip 1am gidm site ofing b8 mit va ngin cho phdi khOng bj xep. 1.2. Trao déi nuéc qua mang phé nang mao mgch Phuong trinh Starling quyét dinh tinh trang trao adi nuéc gitta mao mach va t6 chit ké duge biéu dign nhw sau: Q=Kef( Pe P if) ~ o(7 1 - %i)] ~ Qiym ‘Trong dé: K: Ja 46 dan truyén thuy tinh o: H@s6 thim cia mang Pe: 1a Ap lyre thuy tinh (4p lyre mao mach phéi) tpt : 1 Ap lye keo huyét tuong mg: ld dp Iyc keo khoang ké Quym? 1a dong chay cia bach huyét Cac théng sé quyét djnh trao di nuéc qua MPNMM 6 thé quy vé 3 yéu +6 chinh: tinh thdm mang phé sang mao mach va cae 4p lye 6 hai phia ca mang, die biét IA dp lye mao mach phdi (binh thudng 8-10mmHg) va dp lye keo do protein huyét trong quyét dinh (binh thydng 25 mmHg). Trong didu kign binh thudng, Iyc c6 xu hudng gitt nude trong long mach cao hon so véi luc cé xu huéng dy nude ra khoi ong mach. Thém vao 1a kha nang diéu hoa rng cla tuan hoan bach mach cho phép hp thu nude duge loc tty phé nang vao khoang ke va lép lai can bing trao di made gitta huyét trong va khoang ké dé ngan cho nudc khéng tran vao cée phé nang. 2. Truong hyp bégnh ly Sy xudt hign dich trong céc phé nang 1a hau qua cha céc bién adi quan trong cia mét trong hai co ché sau va cing 1a bigu hién cia 2 kidu phd phéi cap gap trén lam sang: ~ Phi phdi cdp ngudn géc do tim (PPC huyét dong): do mat can bang 4p luc & 2 phia cita mang phé nang mao mach gay ting I9e nude vao khoang ké 16i tran vao phé nang. = Phi phi cp khéng do tim (PPC tn thuong): do r6i loan tinh thdm eta mang phé nang mao mach, hau qua la cling gay ting loc nuée qua mang mao mach phé nang bj tn thuong. 25Trén lam sang thudng c6 sy phéi hop hai co ché nay, phan logi nay od tinh chat cy thé hoa. 3. Tién trign ciia PPC theo ede giai dogn trén gidi phdu bénh ~ Giai doan 1: phi trong té bao ~ Giai doan 2: phi 6 khoang ké (gay gidm oxy hod mau) ~ Giai doan 3: phi phé nang, PPC thé hign trén lam sang 4, Hau qua trén hé hap ~ Suy hé hp véi gidm oxy hod méu: tinh trang gidm oxy méu c6 lién quan véi mite 49 ning eta phi phdi, Co ché gay gidm oxy hod miu cht yéu do tac dung shunt trong phéi. O giai doan tién tridn, the nghén cdc tidu phé quan va phé quan gay gidm théng khi phé nang gay ting CO, méu. ~ Phi phdi cdp lam gidm sttc cing cia phdi lam gidm thé tich phdi va ting 4p Ic bé mat phé nang. Hau qua gay ting site can dudng thé va Lam ting céng h6 hdp va nguy co gay mét co hé hdp. I. TRIEU CHUNG 7 1..Lam sang ~ Déu higu co ning: , + Budn nén, ngét ngat, tite ngye, lo du, sy sét 7 + Khé thé nhanh, co kéo co hé hap + Tim, diu chi lanh, va mé héi, ho khac bot hong + Tinh trang khé thé xuat hién va ting lén rt nhanh Dau higu thye thé: + Mach nhanh + Huyét 4p thudng ting, khi suy hé hdp qué ning bénh nhén c6 thé 6 tut huyét dp + Nghe phdi ran Am tang nhanh tir day phéi dang Iga inh phéi + Nghe tim c6 thé thay cdc déu higu suy tim trai ep: ngya phi trai va cdc bénh tim nguyén nhan (hep hai l4,)...). 2. Can Kim sang - Dién tim: 26+ C6 thé thay hinh anh bénh nguyén nhén: nhdi mau co’ tim, loan nhip nhanh + ‘Thudng gip déu higu thir phét: nhip nhanb thir phat do gidm oxy mau hay do suy tim, r6i logn tai cuc thir phat sau ting huy & dp, hode déu higu phi dgi nb va that ti 6 cdc bgnh nha 06 ting HA ci ~ X quang tim phéi |} Hinh anh nhidu dam mo 6 hai phdi, nhidu hai rén va day phdi, 46i khi hai phdi chi mé nhe néu chyp phéi sém. + Phéi mé hinh cénh buém. + Phéi tring hay g&p trong phit phdi cdp tén thong. _ Kh{ méu Ong mach: giai doan s6m PaO, va PaCO> chi gid nhe, giat doan ning giam oxy nang va ting COz, toan hoa. _ Sigu am tim: 6 thé th4y hinh anh bgnh nguyén nhan: giém van dong thanh tim trong NMCT, cdc bénh van tim, bénh co tim gian. - Tham do huyét dng bing Catheter Swan-Ganz thdy ving 4p luc dong mach phéi va dp lye mao mach phéi bit trong PPC huyét d6ng, binh thudng trong PPC tin thuong. Cung hong tim gidm trong PPC huyét déng. Do ap wc tinh mgch trung tm ting trong PPC huyét dng, binh thudng hoe giém trong PPC tén thuong. ~ Cée xét nghiém khéc: trong PPC tén thuong protid méu ha va giém 4p lyc keo huyét tuong. Iv. CHAN DOAN 1, Chan doan xée dinh ~ Dya vio lam sang [a chit yéu: 4. Khé tho nhanh, phai ngdi day 48 thé, xanh tim, va md hdi. + Khdi ddu ho khan, sau ho khac bot héng. + Phdinhidu ran 4m hai day phdi, sau lan ti dinh. + Khém tim mech: nhip tim nhanb, ¢6 thé phat hién thy cdc tiéng tim bénh ly (rung nhi, rung tam truong néu c6 hep van hai 14, 27tiéng ngya phi néu cd bénh co tim hay nhdi méu co tim. .); bidu hign tang huyét 4p. + Ap lye tinh mach trung tam ting cao (> 15 mmfg). ~ X quang tim phdi: rén phdi dg, phdi mo theo hudng tiv trung tam ra ngoai bién (mé hinh cénh buém). ~ Khiméu d6ng mach: thay di PaO, va PaCO, tity theo giai dogn bénh. 2. Chan don phan biét 2.1. Phan bigt gitta PPC huyét dong va PPC tén thuong Deic diém Ton thuong Huyét dng | 'Tén thuong tién phat mang PNMM i Ap lye mao mach phdi (mmEig) Bj ton thuong Binh thudng cvP 12-14 >30 Protein trong dich phi bt Tang Hng cau trong dich pha >30 <30 ‘Vj tri phi tic khoi dau 0 + Thé tich méu toan bo vach phé nang | Phé quan, mach méu |X quang. binh thudng Tang Di chimg phéi tring.xo | Mé hinh cénh buém phdi 0 4 2.2, Con hen phé quan dc tinh 2.3. Con hen tim 2.4, Bot cdp ctia bénh phéi tée nghén man tinh 2.5. Tran khi mang phéi 2.6. Nhoi méu phoi, viém phéi thup. 3. Chan doan nguyén nhan Tang 4p Ive mao mach phdi hay ting ap lye dong mach phdi: do 2 ngudn goc: - Do tim: suy that tri va bénh van hai 1é 1a hai c&in nguyén thudng gip nhat 284 Suy that tri: Tang ap luc cudi tam truong that tai do cée nguyén nhfin: - Bénh tim do thiéu mau cue 4, dc biét 1a nhdi mau co tim - Tang huyét ap, nbdt 1a con ting huyét dp. = Hep van déng mach chi + Hep khit van hai ld 4+ Con loan nhjp nhanh ~ Nguyén nhén ngoai tim gay ting 4p lye dgng mach phi + Nhdi mau phdi + Phu phdi do 46 cao: gap & 49 cao 3500m, trong ving 3 ngay dau, véi yéu 16 thudn loi la ging site. — Gidm 4p lye keo huyét tuong: gidm albumin mau 1a yéu té than Ioi gay phd phdi, dic bigt nhan mét can thiép phdu thugt 16n, mAt méu, truyén qué nhiéu dich ding truong. - Suy tuin hoan bach mach. — Tang 4p lye am khoang ké: lim né phdi qué nhanh trong trudng hop hiit tran dich hay tran khi mang phdi cé thé gay phis phdi mot bén. Co ché 1a do ting ap lye 4m cita khoang ké hoc gidm surfactant. = Phi phdi do ting génh thé tich do ting tién ganh dot ng6t. Trong 46 mét s6 cin nguyén thudng gap nhat 1a: — Tim mach: ting huyét 4p, hep bai 14, viém co tim, nhdi mau co tim ~ Truydn qué nhidu dich, tbc 46 truyén qué nhanh — Ng6 d6c cép meprobamat,cocaine v. x0 TRI 1. Nguyén tie didu tri — Nhanh chong, khin truong (14 mOt cdp ctru ndi khoa). - V6i suy hé h4p nguy kich de doa tinh mang cAn can thigp thi thudt truéc, thude sau. Véi suy hé hdp ning sir dung thudc truée can thigp thi thuat sau. = piu tr} nguyén nhan gay phi phdi cdp va cée digu tri hd try khdc. 202, Bidu trj cu thé theo tuyén 2.1. Clip citu ban déu ~ Dit bénh nhan 6 tu thé ngdi, hai chan thong giip gidi phéng co hoanh va lam gidm hdi hru tinh mach. ~ Trinitrin (hoge Risordan) ngém dudi Iuéi hay Lenitral spay xit duéi lu0i 2-4 nhat. ~ Furosemide 20 mg x 02 dng (c6 téc dung gin tinh mach tru6c khi loi nigu) C6 thé nhic Iai cdc thudc trén sau 15 phit. 2.2. Trén 6 6 cdp cu - Thé oxy 4-10 I/phiit (kinh mati ho&c mat na). Theo doi SpO2 ~ Tiép tye sir dung céc thudc trén néu cdn thiét. 2.3. Ti bénh vign : 2.3.1. Te thé bénh nhén: Néu khong cé tut HA, dit bénh nbén 6 tu thé ngdi thong chén hode it nhdt ¢ tw thé Fowler (ita niim nita ngdi), myc tigu lam gidm t6i da lugng méu vé phdi. 2.3.2. Diéu tr} triéu ching ~ Digu tr tinh trang gidm oxy mau: : + Tho oxy mit na, lum lung 6 - 10 lit/phut, myc dich phai dua bao hda oxy mau >90%, + Néu tinh trang thiéu oxy khéng duge cai thign: cho bénh nhan thé kh6ng x4m nh§p (ngoai tac dung hé tro tng trao déi khi 6 phdi, con gitp 1am gidm tién génh va hgu ginh that tréi) voi phuong thite 4p luc dudng thé duong lién tuc - CPAP. Cai dit mite CPAP bit dau 14 4 - 5 cmH,O, ting dan 2 cmH,O/lAn cho t6i khi tim duge mite CPAP thich hop. + Chi djnh théng khi khong x4m nhdp hai mite 4p hye duong (phuong thie BiPAP hoc PSV) néu van thiéu oxy mau nang. + Dat éng n9i khi quan, thong khi nhén tgo xAm nhap néu tinh trang van khéng cai thign (bénh nhan suy hd hap nang, c6 r6i loan y thite).- Gidm hau ganb: Thude nhém nitrat ( trinitrin, nitroglycerin) truyén tinh mach 10-100 uag/ phit, hay d&t duéi Indi, & cde bgnh nhdn c6 HA tam thu > 100 mmHg, ‘Thudc chi yéu lam gidin tinh mach lam gidm tidn ganh, ngoai ra con lam gifin cdc tigu d6rig mach lam ha HA. va gidn dong mach vanh nén rt pho hop véi céc bénh nhén nhdi mau co tim. Clin theo doi sat HA a8 didn chinh tigu, duy tri HA tam thu > 90 mmHg. ~Chérig lai tinh trang xuat dich mao mach 4+ Morphin: tiém nh mch chim 0,05 - 0,1 mg, ne Iai sau 20 - 30 plxit néu tinh trang bénh nhan chua cai thign, chi dinh véi céc benh nhan c6 vat va kich thich nhiéu, d&c biét phi phdi cfip 6 ngudi bj nhdi méu co tim. Tée dung kim git dau, giim kich thch lo ling, gim Kich thich adrenergic, gidin tinh mach nhe lam gidm tién ganh, giam tigu thy oxy co’ tim.. Morphin c6 thé géy tre ché ho hdp nén sir dyng than trong cho bénh nhfn suy hé hap ning chua duge thong khf nhén tao, bénh nhdn mic bénh phdi tic nghén man tinh, hoje tut HA. + Loi tiéu: thude Lim gidm thé tich tudn hoan nén gidm t tre phdi, khi ding dudng tinh mach, thude cdn c6 tée dung kim gitin nh mach, lam gidm tién gaénh nén giam phi phéi, téc dung nay cdn xut hign truéc cd tac dung loi tiu. Cach diing: furosemid 20mg tiém tinh mach 2 4 éng/lin, 6 thé nhc Iai sau 20 - 30 phiit cho én khi bénh nhan 46 khé thé hode tiéu duge = 300ml. + Thuéc gitin phé quan : Aminophyllin 240 mg tiém tinh mach cham. ‘Thudc c6 the dung lam gidm co that phé quan, ting dbng méu qua than, bai xudt natri qua than va lim ting co bép co tim. + Han ché dich vao co thé bénh nhan. 2.2.3. Didu tri nguyén nhdn: tuy theo nguyén nhan ma tya chon bién phép didu tri thich hop. — Pidu tri ha huyét dp néu pha phdi cdp la do con ting huyét ap. — Phu thudt v6i cdc bénh van tim: hep hai {4, hep van dng mach ch. I~ Nhdi mau co tim eAp: tiéu soi huyét, chup mach vanh can thiép, hay bic cau ndi cha vanh. — Diéu trj cdc loan nhip nhanh. 2.3.4. M6t s6 bién phdp héi site khde ~ Str dung cée digitalis tro tim: digoxin 0,25 mg tiém tinh mach trong truéng hop suy tim tréi gay pho phdi cp, dic biét trudng hyp suy tim 6 nhip nhanb, rung nhi. - Néu 6 tut huyét Ap: sir dung thude 1am ting strc co bép co tim (obutamin), chinh ligu ting din 48 dat myc tidu mong muén (trénh diing noradrenalin va adrenalin do lam ting hgu génh that trdi va ting 4p luc cudi tam truong). TAL LIEU THAM KHAO 1, Nguyén Dat Anh, Va Vin Dinh. (2012). Phi phéi cdp. Bénh hoc néi Khoa Tap 2. Ha NGi: Nha xudt ban Y hoc; 498 — 506, 2. Nguyén Quée Anh, Ngé Quy Chéiu, (2011). Phir phi cdp huyét dong. Hudng dan chin dodn va didu trj bénh ngi khoa, Ha Néi: Nha xudt ban Y hoe; 230-232. 3. Nguyén Gia Binh. (2011). Phi phdi cdp huyét dong. K¥ thuat tho may va hdi site hé hép co bain. Ha Noi: Nha xudt ban Y hoo; 116 — 124. 4. Ware LB et al, (2005), Acute pulmonary edema. New England Journal of Medicine, 353: 2788 — 2796.TY LUQNG GIA A, Cau hoi tra Idi ding hoie sai: Noi dung io 1, Dida ti ndi Khoa bing thude [a bign php duge wu tién khi xir tr{ phd phdi-cdp huyét dong 3, Te thé ngudi bénh duge wa tién (khi xir tri phd phdi cp huyét déng): ngdi thong chan, ho%c it nhAt mira nim nika ngdi (tu thé Fowler) 3, Xu tri ngudi bénh pha phdi cap huyét déng cé suy h6 hap nhe va trung binh: chi dinh oxy ligu phap 4. ‘Trong xir tri phu phoi cdp huyét déng: muc tiéu dua SpO, > 95% B. Chon mt y dung nhat: 5, Ba A, duge ch4n dodn phir phdi cp huyét dong voi mie 46 suy hd hap ning, Bac s¥ di chi dinh oxy ligu phap va cde didu tr] ndi khoa theo phac dd. 30 phuit sau dénh gid Ii: ba A. vin trong tinh trang thiéu oxy mau, nhung con tinh, khong tut huyét 4p. Thai 46 xit tri tiép theo: a. Chi djnh dat ndi khi quan thong khi nhén tao b. Tiép tuc digu tr nhu trén va theo doi tiép c. Chi dinh thong khi nhan tgo khéng xém nhap 4 . Tiép tye didu tri nhu trén (thude + oxy ligu phép), ddng thdi nhanh chong chi dinh chuyén tuyén trén va bép bong c6 oxy trén dudng van chuyén. 33Bai4 ‘TAI BIEN MACH MAU NAO Muc tiéu 1. Trinh bay duge cdc déu higu lam sang cia tai bién mach mdu ndo 2. Trinh bay duge cde nguyén nhdn ctia tai bién mach mdu néo 3. Trinh bay dugc cde bign phdp cdp ctu bénh nhén tai bién mach mau néio I, DAL CUONG Tai bién mach méu nao (TBMN) Ia tinh trang tén thuong chite ning thin kinh xdy ra d6t ngét do tdn thuong mach mau nfo (thudng tic hay do vé dong mach nfo). Cac tén thuong thin kinh thwong khu tra hon 1a Jan téa, tn tai qué 24 gid, dién bién 6 thé din dén tit vong hoc dé lai di chtmg Ganh nang cia TBMN rit 16n va la nguyén nhdn gay ti vong ding thir ba sau bénh ung thu va tim mach, 14 mét trong nhiing nguyén nhan hang diu gfy tan phé & céc nude phat trién va 1A génh nang 16n cho nén kinh té va xa AGi. Do 46, vige dy phong cé vai trd rét quan trong gitip gidm ty 16 mic, ty 16 tir vong va ty 1é tan phé cla TBMN. nudéc ta, TBMN Jai 14 nguyén nhan gay tir vong dmg hang dau, Gin day, ty 1¢ mac trong dan cu mién Bac 14 75/100.000 dan, ty 1 méi mic hang nam 1a 53/100.000dén. II. MOT SO DAC DIEM GIAI PHAU SINH LY MACH MAU NAO Nao dug nudi dudng bang hé théng cdc dong mach nio, ching dugc hinh thanh tir bén cudng mach chinh: Hai déng mach canh trong va hai dong mach dét sng (hinh 1.1). Tae gid Lazorthe phin chia tuain hoan no thanh hai khu vue tui mau c6 ché 46 huyét dp khdc nhau: 1. Tuan hoan ngoai vi Do cdc nhanh néng cia cde mach no tsi méu cho vé nao va 6p chit tring duéi vd, tgo thanh mét hé néi rit phong phi, Qua méi lin phan nhénh, dp luc tai d6 giam xudng, do dé c6 Ap luc thp, khi huyét ap ha d6t ngét d8 bi aatén thong nhdi mau nao. 2. Tuan hoan trung tim Gdm céc nhdnh sfu cla mach méu nao tuéi mau cho ving nhan xém trang vong, sau dé di ra nOng va tin cing 6 6p chat tring du6i v6. Cae nbénh nay 1a nhiing nhanh tin, do dé chju ap lye cao. Khi c6 dot ting huyét dp d6t ng6t thudng gay chay méu nao. Gitta khu vue ngoai vi va trung tim hinh thank mét duéng vién ranh gi6i, khdng c6 céc mach n6i quan trong gitta hai khu ve néng va su va durge goi Ia ving “16i han” rat dB xay ra cf t6n thuomg sihdi mau lan tod hoge nhdi mau chay mau no. 3. Co ché ty didu hoa cung lrgng méu nao Nao 1a co quan tigu thy nhigu glucose va Oxy nhat ca co thé nhung 1 noi khong 6 dy tit glycogen va phai cln mt lua fuong 1 50-55ml méw/100gam nfio/phut dé cung cp di glucose va Oxy cho nfo hoat dng binh thudng, Khi gidm uu lung méu no xudng 25ml/100gam nfo thi s8 géy thiéu mau nfo va xudt hign céc trigu chimg thin kinh khu trd. Cung lugng méu nao bling khodng 15% cung long tim (khong 750ml/phiit) va khéng 06 bién 46i theo cung lngng tim nh vao sy co gin cita co tron thinh mach. Khi cé ting huyét 4p, méu Ién niio nhidu, cdc co tron thanh mach co nhé Iai va khi huyét 4p ha cae mach méu Iai gidin ra 48 mau [én nao nhiéu hon, goi 1a higu tng Bayliss. Ngoai ra, sy didu hod cung lugng mau nao cn chju anh huéng cila cac nang 4} CO2, H’, O2 trong mau va su diéu hoa thin kinh giao cdm cla mach méu, Khi PaO» giém va PaCO, ting, cde dng mgch nhé 6 nfo sé gidn ra va nguge lai. TL. TRIEU CHUNG LAM SANG 1. Lam sang — Hi bénh: Tidn str tai bién thigy méu thodng qua, eo dia, cde yéu t6 nguy co. ~ Tinh chAt xudt hién dt ngot cilia cdc trigu chting thn kinh (ti vai phat, vai gid, t6i da cé thé vai ngay).~ Céc trigu ching thn kinh khu tré (ty theo déng mach bj tén thuong): Ligt nia ngudi, kém réi loan cdm gidc cae thé, that ngén, ban manh (déng bén, hay bén manh géc), ligt cdc day than kinh so nfo, héi ching giao bén v.v... ~ Céc trigu ching khéc ntur r6i logn ¥ thite (thudng khéng e6 hoke thoang qua), con dong kinh cyc b6 hay toan b6 (5% cdc trudng hop). ~ Réi loan ¥ thitc thudng gp trong nhdi mau nao dign rong va cdc trigu ching réi loan tim than trong vong 3 ngdy dau sau tai bién cting hay thay & ngudi trén 65 tudi. ~ Cae trigu chimg toan than khéc, d&c bigt 1a tim mach, tién théi dong mac canh, sét vv... 2. Cae yéu t6 nguy eo ~ Tang huyét dp, R4i loan lipid, dai thao dudng — M6t sé bénh tim mach (dac biét rung nhi) ~ Céc con thiéa mau nao cye 66 thoding qua, hep the dng mach cinh c6 hodc khéng cé trigu chimg ~ Hut thude 14, lam dung rugu 3. Trén lim sang, TBMN duge chia thanh cc thé sau — TBMN nhéi mau ndo (chiém 80%) + Tai bién nhdi mau nao thoang qua + Tai bién nhdi méu nao thyc sy — Chéy mau thiry no = Chay mau dudi nhén IV. CHAN DOAN 1. Nhdi mau nao 1.1. Dinh nghia Su xuit hign tai bién thiéu mau nao (nhdi mau nao, nhiin nao) [a hu qua ciia sy gidm d6t ng6t luu lugng tudin hoan nao do tic mét phan hay toan bo mot d9ng mach néo biéu hign lm sing bing sy xudt hién dot ngot clia cde triéu chimmg than kinh Ichu tri ma hay gap nhat 1a ligt niza ngudi, 361.2. Chin dodn nhéi mau nao Chup cit lép vi tinh (CLVT) sp nao — Chup (CLVT) so nfo (khéng tiém thuée cén quang) phai duge thye hign nhanh chéng vi n6 gitip phan biét mot cach chinh xAc nhdi mau nfio va chily mau néo ~ Tén thyong nhdi mau nio: + Hinh anh-ving gidm ty trong & nhu mé nio thude khu vue cua d6ng mach bi tén thuong chi phéi. + Ngoai ra cé thé thy hinh anh phd n&o (mat cdc rfinh vé nfo, higu ting dé day). = Hinh 4.1. Hinh anh chup CLVT sém ngay khi vao vign (A) va sau 2 ngay (B) Chup c6ng hudng te (MRD Chup céng huéng tir mach no: cb 49 nhay cim cao han so voi chup cit lop. — Chi dinh: + CLVT so nao binh thueng + Tai bién mac hé séng-nén 4+ Nghi ngé béc tich dgng mach canh ho%e déng mach aét séng hoje nghi ng’ viém tac finh mach nao. — Hinh anh tén thuong nhdi méu nao thay rét s6m sau tai bién thé hign bing hinh anh ting tin higu 6 thi T2. 37Hinh 4.2. Hinh anh cong huong tie nhdi mdu néio ving than nao, bén cdu néio trdi, tée dong mach 2. Chay mau no 2.1. Dinh nghia Chay méu niio 1a su xudt hign cla méu & trong nhu mé nfo, cé thé k&m theo méu @ trong Khoang duéi nhén va cde nfo thét. Ty 18 chay mau nao chiém 10% téng sé cdc TBMN. 2.2. Chén doin Chup c&t lép vi tinh so nfo: Hinh anh ting ty trong cia miu trong nhu mé nfo, c6 thé trong nao thét, trong khoang duéi nhén; xudt hign phi néo xung quanh, c6 thé c6 higu ting dé dy 1én nao thét, duong gitta, Hinh 4.3. Hinh anh chay méu dudi nhén, nao thdt va tiéu nao wen chyp CLVT 38Chan dodn vj tri xuat chay mau: — Chay mau bein odu (chiém 85% che trudng hop TBMN) + Thé chay mau [dn: Méu ty W6n gdy ngdp néo that, bénh nbn hon mé sdu, tir vong nhanh chong. 4+ Chay méu vig bao trong - nhdn ddu: Benh nhan 6 1igt mia ngudi abi bén, quay mit quay du vé bén tén thuong, that van ngén Khi tén thurong nao ban chu un thé, thudng kém 16i loan ¥ thite 6 céc mite d6. + Chay mau thity no: Vi th thudng & ving chat tring du6i vo nfo 6 mét thiy hod lan réng hon. Vj tri mau ty c6 thé 6 thiy tran, dinb, thai duong hoi thity cham. Chay méu than nao: Chiém 5% céc trudng hop chiy mau nao, ty theo vi tri tn thuong mach méu nhung hay gip 6 ving edu nfo, — Chay mau tiéu nao: Chiém 10% cde benh nhan TBMN, bién hign lam sang nhite dau, nén, chéng mit, r6i logn thang bing va kham thay cdc triéu chimg tidu no. ~ Chay mau duéi nhén: 80% la vo che thi phinh mach 2.3, Cite xét nghigm e@n lam sing khde cin thiét — C&c xét nghiém sinh hoc duge thyc hién mét cach hé théng — Chup Xquang tim-phdi, ghi dign tam 45, sigu Am tim, — ECHO - Doppler cc mach mau & ving c6: Bay 1a tham do v6 hai, 6 thé Lam cho moi bénh nhan, gitip phat hién hep, the, cfc mang xo vita cita cdc dng mach 6 ¢5. — Chup dong mach nao: Duge chi dinh trong trudng hop hep khit dong mach c6 thé cn phai phdu thudt hoge tai bién thiéu méu 6 ngudi tré chua 16 nguyén nhén. 2.4. Chan dodn phan bigt ~ Chan dodn phan bigt nhdi mau no va xudt huyét no: rét kh6 chdn dodn dya vao lam sing — Chin dodn phan biét nhdi mau n&o voi: undo 2.5, Chén dodn nguyén nhan 2.5.1. Nguyén nhan nhoi méu ndo 39~ Xo vita cée dong mach néo:Xo vita cac ding mach cénh & trong va ngoai nao 1d nguyén nhan phé bién nbat gay ra nhdi méu ndo, dic biét 1A 6 nhting ngudi cé tudi, ~ Mang xo vita: Mang xo vita 18 thuong tén co ban Iép 40 trong cia Ong mach. Né duge hinh thanh do sy tng sinh cha céc sgi co tron, cde soi chun va sw ling dong cia lipid, din dén am hep long mgch va gay ra the mach tai chd ~ Cte huyét khdi dén tie tim: Chiém khodig 20% eée nguyén nhéin nhdi mau ndo, hay gip 6 ngudi tré va thudng kém theo céc bgnh tim gay huyét ki + Céc bién ching cia thép tim: Bénh van tim dic biét LA hep hé van hai ld Rung nhi: La nguyén nhdn rét quan trong gay nhdi mau nao, Cac nguyén nhén tim mach khac: Nhdi mdu co tim, viém n6i tim mac do vi khudn c&p hoe ban cp, bénh co tim, u nbdy tiéu nht, van nhan tao — Cée nguyén nhan khée + + + + + + + Cée thudc uéng chéng thy thai Boc tach déng mach nao Loan san xo - co thanh mach Viém dong mach Cac bénh mau: Ba hénig cau, r6i loan déng méu... Céc bénh r6i loan chuyén héa Ty 1¢ tai bién nbdi méu nfo khong r nguyén nhan chiém 18-40% cdc trudng hop . 2.5.2. Nguyén nhan chay méu néio ~ Tang huyét dp dong mach: Chiém 70 dén 80% nguyén nhan xudt huyét nao, dic bigt cao & ngudi 06 tudi — Di dang mach méu nao ‘+ Tai phdng dng mach n&o: Thudng gay chay méu dudi nhén, trong 6 20% cac trréng hyp dj dang c6 kém theo chay méu nao. 404: U mach mau kigu thong dng tinh mach: Cfing hay gay xudt huyét dui nhén nhung trong 50% cdc trrdng hop kém theo chay mau nao. 4 Céc r6i loan déng mau: Do cde bénh miu, do ding thudc chéng déng hoac xo gan. y. DIEU TRE TAI BIEN MACH MAU NAO 1. Nguyén the didu tr] LL. Diéu trj trigu chitng _ Pam bao sy théng suét cia dudng hé hap trén: Hit dim di, thé oxy, hole Git noi khi quan néu cin. _. Bao dam su thing bing nude - dign gidi va thing bing kiém toan, pH miu. _ pam bao dinh dubng cho bénh nhan t6t nhat bang dudng migng. Dat x6ng da day néu c6 r6i loan nudt hodc r6i loan ¥ thie, ~ Dy phong va didu tri boi nbi&m dudng ho hap, tiét nigu viv... — Pibu trj céic con déng kinh (néu 06) bang diazepam, ho’c clonazepam. _ Dam bao tt chite niing tim mach: Chng loan nhip, chéng suy tim,... — Duy trl huyét dp déng mach én dinh. — Chéng phi nao: 4 Tw thé ddu cao 30°, khai théng dung h6 hap, tang thong khi,... + Manitol: Ig/kg, sau mdi 6 ~ 8 gid nhdc lai libu 0,25 - 0,5g /kg + Corticoid: Khéng cé tac dung. _. Cham séc: Nim dém chéng loét, thay d4i tu thé, vé sinh cé nhan. — CAn theo dai sét tinh trang bénh nbfin nhdt 1a trong tudin 18 dau nhiim phat bign va didu tri kip thdi cdc bién chimg. — Phuc hdi chic ning: Vén déng thy dong hay chit dong sém 4é trénh co citng co, cing khép. Phuc hdi chite ning ngdn ngit cho bénh nhan — Cée thuée gin mach: Khéng cé tac dyng diéu tri, 1.2, Diéu tri nguyén nhan: tai bién mach nao thodng qua, nhdi mau nao, xuat huyét nao. 41.3. Diédu tri nhéi mau néo 1.3.1. Diéu tr} tai bién thiéu méu ndo thodng qua ~ Kiém soat céc yéu t5 nguy co nhat la ting huyét ap déng mach. - Ding thuéc chéng ngung tap tiéu cdu: aspirin (100-300mg/ngay), ticlopidin (500mg/ngay), clopidogrel (75mg/ngay) v.v.. 1.3.2. Nguyén tée diéu tri nhdi mdu nao ~ Didu tr] thudc tiéu soi huyét: khuyén céo str dung alteplase cho cac trudng hop nhdi méu nao mdi trong vong 3gi¢r Diéu trj thuéc tre ché tidu cdu trong giai doan ofip nhdi mau nfio — Cée nghién cimu gin day thdy ring chi duy nhdt Aspirine voi liga 300mg/ngay ding trong giai doan cdp da lam gidm dang ké ty 18 tir 1 vong va ty 1é tai phat cia nhdi mau nao. Diéu trj chéng dong ~ Vige sit dung heparin duge chi dinh sém trong céc truéng hop huyét khdi do nguyén nhan tir tim, béc tach d6ng mach nao, viém tke tinh mach nao. Didu trj dy phong tai phat ~ Kiém soat céc yéu 16 nguy co: Didu trj ting huyét 4p, d4i théo dudng, réi loan mé mau... ~ Ding thude.chéng ngung tp tiéu ciu: Aspirin, Ticlopidin, Clopidogrel... Phau thugt béc tach Idp do trong déng mach. Déi vOi cée huyét khdi ti tim: Didu tri bénh tim, ding thude chéng d6ng lau dai v6i sy theo doi chat ché va déng mau. 1.4, Diéu 7 chay méu nao: Bouh nhin phai duoc theo doi va didu tri tai eo 80 phiu thugt than kinh, 1.4.1. Diéu trj néi khoa ~ Nghi ngoi tuyét d6i trén giwdng, gidm t6i da cdc kich thich 4nh sng, tiéng dong. ~ Cée phuong phap diéu trj cp ctu, hdi sti. - Du phong co thit mach nao bing Nimodipine (Nimotop) véi liéu 360mg/ngay. 42- Duy tri huyét ap tém thu khoang 1 50mmHg. - Chéng d9ng kinh. - Chéng dau bing cc thude khong anh hudng én chite ning ctia tik 4 cd - Chéng tao bon. - Ding thude an than khi 6 kich thich, ting déng. 1.4.2, Diéu tri phau thudt - Phau thuat digu tri nguyén nhén nén dure thyc bign sém dé trénh chay méu tai phat va co thit mach: 4+ Phau thudt din lua khdi mau ty duge chi djnh trong hai trudng hop: “Ty méu 6 tidu ntio khi 06 kich thude 1én, de doa gay tut ket hanh nhan tidu nao hot di cé trigu ching ép vao thin ndo hay gay ra nfo Gng thay. Ty mau thiy néu diéu tri ndi khoa khong két qua, bénh nang lén. + Phu thuat didn tri nguyén nhén di dang mach mu n&o néu c6 thé, - Khéng phdu thuft néu bénh nhan trén 70 tudi hode thé trang qua nang. ~ Néu khéng thé phdu thudt sém duge, tién hanh chyp dong mach xdc inh 48 tim nguyén nhén va c6 the phfu thuat di dang mach sau giai doan cp cia xudt huyét duéi nhén. VI. DI CHUNG TBMN 1. Dong kinh: Gap 6 10% céc bénh nhan TBMN, thudng lé dng kinh eye bo toan thé, 2, R6i logn gidc ng sau TBMN: Biéu hign bing cdc ching nga ri, ting ngi kém theo tinh trang réi loan y thitc. 3, Ligt van dng: Ligt niva ngudi, ligt mat, ligt hu hong, TAL LIEU THAM KHAO 1, Lé Dite Hinh va es (2009): Tai bién mach ndo, huong dan chan dodn va xtt irl, NXB Y hoc. 2, Mahnaz Fatahcadeh, Michael Glick, Newark, NJ. Stroke (2006): epidemiology, classification, risk factors, complications, diagnosis, 433. Tv prevention, and medical and dental management, Oral Sure Oral Med Oral Pathol Oral Radiol Endod 102:180-91, American Heart Association. Heart disease and stroke statistics, 2005 update. Dallas: American Heart Association. LUQNG GIA Phan A. Chon cau héi ding Cau 1. TBMN duge chia thanh céc thé lim sang sau: A. Nhdi méu niio (chiém 80%) B, Chay mau thity nfio C. Chay mau duéi nhén D. Ca3 y trén Cau 2, Nguyén nhan nhdi mau nao A. Xo vita cic déng mach n&o B. Mang xo vita C. Cae huyét khdi d&n tt tim, D. Cée thudc udng chéng thy thai E, Tat cd cde ¥ trén Cfu 3. Nguy4n nhan chay mau n&o A. Tang huyét 4p déng mach. B, Dj dang mach mu nao C, Réi loan déng mau D.Ca3 y trén Phan B. Chon cAu héi ding sai SIT NOi dung p|S 4 | ¥éut6 nguy co TBMN: Ting huyét 4p, Réi loan lipid, dai théo dudng, mét sé bénh Ii tim mach 5 | Yéu tb nguy co TBMN: Hit thude 1a, lam dyng regu 6 | Digu te tu soi huy&t cd thé ap dung cho cde nhdi mau nao > 9h [- 44,Bais ‘TRAN KHi MANG PHOL Mye tigu 1. Trinh bay duoc cdc nguyén nhdn tran khi mang, ‘phi 2. Chén doan dugo bénh nhan bj tran khi mang phéi. 3. Xie tri dugc tinh trang tran khi mang, phéi. 1. DAL CUONG - Tran khi mang phdi 1a mét tinh trang bénh ly nang, cdn phai duge chan don va xi tri kip thai. TY 1¢ tir vong phy thuge vao thai a6 xir tri vA mite 49 tran khi mang phdi. - Tran Kchi mang phdi tién phat xay ra 6 bénh nbn khong c6 ben ly & phdi hod tac dong trade d6, Tran khi mang phdi thir phat nhu la bién ching cia bénh nhan c6 bénh phdi true dé hoc sau the dong nao dd. ~ Ty Ié tran khi ming ph6i thir phat: COPD chiém 60-70%, xo phdi chiém 3-4%, ung thu phdi 16%, lao phdi, viém phdi do vi khuan, bgnh poi ké. II. CO CHE BENH SINH - Binh thudng khoang mang phdi khéng cb khf, chi e6 mot l6p dich mong 6 gitta 14 thanh va la tang gitp cho nhu mo phdi dich chuyén trong thi hé hap duge dé dang. ~ Hign tuong tran khf mang phéi xay ra 1A do rich 14 tang ctia t6 chite phi dan dén khi ti trong nhu md phéi di vio khoang mang phdi. Toy theo lvgng khi vao khoang mang phéi nhiéu hay it mA cé mito 46 biéu hign lam sing khac nhau. = C62 Jogi tran khi mang phdir + Tran khi mang phdi tién phat: xay ra 6 ngudi khong 6 bénh ly 6 phdi va khong cé tée déng nao tham gia vio qué trink gay tran khi mang phdi. 4 Tran Kkhi mang phéi thir phat: xay ra 6 ngudi c6 bénh ly 6 phdi nh trong lao phdi, COPD, hen phé quan, viém phéi...va c6 thé do nguyén nhan 45,gay tran khj mang phdi nhu bénh nhan dang thé méy, cde thi thuat lién quan... - Tran khi ming phdi thir phat thudng nang hon train khi mang phdi tién phat, die biét & bénh nhan dang thé may, dgt cdp COPD, con hen phé quan, UL TRIEU CHUNG 1. Lam sang ~ Tran Kkhi mang phdi tién phat thuong xay ra Ite bénh nhdn dang nghi, hiém khi xay ra 6 ngudi trén 40 tudi. ~ Khé thé, dau ngyc bén tran khi, mic a9 khé thé lién quan dén mite 46 khi tran vao khoang mang phéi, trigu ching kh6 the ndi bat néu tran khi mang phéi sé Irong nhigu. ~ Tran khi mang phdi thir phat thudng c6 biéu hién lim sang nang hon néu bénh nhan c6 bénh ly 6 phdi trade khi d6. ~ Di déng ciia ling ngye ben bj tran khi mang phdi gidm, ri rao phé nang gidm, g6 vang, cé thé c6 tran khi dui da di kem, - Tho nhanh, ging site. - Khi 6 r6i loan huyét dng (nhip tim nhanh, ha huyét 4p) goi ¥ tran khi ‘mang phdi ap lye (khi tiép tuc vao khoang mang phdi lam cho 4p lye trong Khoang mang phdi bén bj tran khi ngay cing ting). Cin duge giam 4p lye khoang mang phdi cp citu, Tran khi mang phdi dp lye chiém 1-2% bénh nhén tran khf mang phdi tién phat. ~ Gidm PaO, va Sa0, méu thudng gip do xep nhu mé phéi. ~ Ting PaCO, mau kh6ng phai thudng xuyén gap do chite ning phdi tanh thong khi bi. Kiém ho hap cdp 06 thé xay ra khi bénh nhén dau, lo ling va/hode giam PaO, mau dang ké. ~ Bénh nhan bj tran khi mang phdi thir phat 6 thé kém theo cé ho, sdt, gai rét, mét mdi, 46