BS CKII PHAN TH XUAN KHOA HSCC BV CH RAY BO MON HOI SC-CAP CU-CHONG OC AI HOC Y DC TPHCM

TIEP CAN BENH NHAN CHAN THNG

ABC
A: AIRWAY B: BREATHING C: CIRCULATION

Con th khong ?

Con th khong ?
anh gia trong 5 giay
Nhn

c ong len xuong cua long ngc

Neu a c up mat na co hi nc ong tren mat na hoac khong?

Nghe Cam

kh thoat ra t mui, mieng. giac chuyen ong cua luong kh.

Con th khong ? KHONG

Lay sach chat oi, d vat trong hong

Benh nhan ngng th

Mot ngi

Hai ngi

Benh nhan ngng th

An vao sun nhan e ngan s trao ngc

Thyroid Cartilage

Cricoid

13

TIM CON AP? KHONG

CAC BC ANH GIA S TOAN VEN NG TH

Tm cac dau hieu cua suy ho hap: moi tm, phap phong canh

mui, co keo c ho hap Co can at noi kh quan ngay hay khong? Co can th may khong? Neu benh nhan noi bnh thng la mot dau hieu chng to ng th toan ven.

CAC BC ANH GIA S TOAN VEN NG TH

Nhn trong mieng benh nhan xem co mau, chat oi, manh xng gay, rang gay, rang gia va vat la khong. Lang nghe benh nhan th co tieng rt hay kho khe khong. Tm cac dau hieu cua ton thng ng th: chan thng au, mat, co, ngc, bung...

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG: Rang gay, vat la, dch tiet, Gay tac nghen ng th, co the chat oi lot vao kh quan

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG: Li Tut li la nguyen nhan gay tac nghen ng th thng gap nhat benh nhan hon me Gap benh nhan beo ph, gay tac nghen ng th vung ha hong va tren nap thanh quan

Mo tren nap thanh quan

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:

Chan thng vung ham mat

Gay xng ham di co the gay tac nghen mot phan hoac hoan toan ng th, lam cho benh nhan th kho khe

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:

Phu ne ng th Bu mau vung co chen vao ng th

Gap benh nhan bong, ht khoi trong am chay Gap benh nhan chan thng kn hoac h vung co

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:

Chan thng thanh quan

Chan thng kn vung co co the gay chan thng thanh quan, gay tac nghen mot phan hoac hoan toan ng th t ri thanh Chan thng kn hoac h vung co co quan kh the gay t ri thanh quan kh quan quan mot phan hoac hoan toan. Thng phai at noi kh quan qua may noi soi phe quan.

CAC NGUYEN NHAN GAY TAC NGHEN NG TH BENH NHAN CHAN THNG:

Ht mau va Gay tac nghen hoan toan chat oi vao ng th. ng th Ht lng nho chat oi co o acid cao gay bong hoa chat va ARDS. Noi soi phe quan e lam sach chat oi.

CAC BIEN PHAP KIEM SOAT NG TH

Lay vat la va hut sach dch trong mieng, hau hong. Cac thao tac m thong ng th: nga co, an ham.

at cac dung cu ho tr ng th: ong mui /mieng hau (oral/nasal airway).

Kiem soat ng th chac chan: at ong noi kh quan, m kh quan.

CAC BIEN PHAP KIEM SOAT NG TH M thong ng th khi benh nhan khong chan thng cot song co Thao tac nga co (Head tiltchin lift)

T the "sniffing"

Truc ng th
Mouth A A
B C B

Pharynx

Trachea

Extend-the-head-on-neck (look up): aligns axis A relative to B Flex-the-neck-on-shoulders (look down): aligns axis B relative to C
26

CAC BIEN PHAP KIEM SOAT NG TH M thong ng th khi nghi ng chan thng cot song co Thao tac an ham (Jaw thrust)

Ong mieng hau va ong mui hau

Ong mieng hau (Oral airway, oropharyngeal airway)

29

Ong mieng hau (Oral airway, oropharyngeal airway)

30

at ong mieng hau sai v tr

Ngan qua

31

Ong mui hau (Nasal airway, Nasopharyngeal airway)

32

CAC BIEN PHAP KIEM SOAT NG TH

AT ONG NOI KH QUAN

Ch nh at ong noi kh quan: e kiem soat ng th e th may.

CAC BIEN PHAP KIEM SOAT NG TH

AT ONG NOI KH QUAN

Ch nh at ong noi kh quan e kiem soat ng th:

Benh nhan hon me, iem Glasgow 8. Gay nang xng ham mat.

Nguy c ht mau va chat oi vao phoi.

Tac nghen hoac nguy c tac nghen ng th: bu mau ln vung co, chan thng thanh quan, kh quan, bong nang, th

rt, th kho khe.

anh gia at noi kh quan kho

I Mallampati Score II

III

IV

Class I: Uvula/tonsillar pillars visible Class II: Tip of uvula/pillars hidden by tongue Class III: Only soft palate visible Class IV: Only hard palate visible
Den Herder, et al. Laryngoscope. 2005;115(4):735-739.

anh gia at noi kh quan kho

Ngoai ra co the d oan kho at noi kh quan qua ng mieng khi: Benh nhan ngi ln khong the ha mieng hn 4 cm. Khoang cach t loi thanh quan en xng ham di < 6,5 cm Benh nhan co khau cai uon vong cung cao.
Pham vi duoi gap cua co giam 80 o

anh gia at noi kh quan kho

37

at noi kh quan qua ng mieng

at noi kh quan qua ng mui

Mat na thanh quan (Laryngeal Mask Airway LMA)

40

Mat na thanh quan

41

Mat na thanh quan

42

Mat na thanh quan

Bop bong qua mat na thanh quan

43

at noi kh quan qua ong noi soi mem

CAC BIEN PHAP KIEM SOAT NG TH

M KH QUAN M kh quan c thc hien khi at noi kh quan that bai, trng hp khan cap choc kim to vao mang nhan giap e thong kh trong khi ch m kh quan.

THONG KH TRONG TRNG HP CAP CU

Choc kim to vao mang nhan giap: chu yeu cung cap oxy, khong thai CO2

THONG KH TRONG TRNG HP CAP CU

Horizontal Cricothyrotomy Incision

SHH-OXY THERAPY.pdf 47

Nguyen nhan gay giam oxy mau benh nhan chan thng

Moi trng (nong o FiO2 thap)

Ap lc kh quyen thap (o cao). Nong o FiO2 thap (chay nha, gieng sau) KMM: PaCO2 bnh thng
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy

Nguyen nhan gay giam oxy mau benh nhan chan thng
Giam thong kh Mang sn di ong Ngo oc heroin Chan thng cot song
KMM: PaCO2 ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy roi tang thong kh phe nang

Nguyen nhan gay giam oxy mau benh nhan chan thng
Bat tng hp thong kh / ti mau Giam the tch mau Vt cao qua PEEP cao qua KMM: PaCO2 bnh thng

ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, bu ap the tch tuan hoan, ieu chnh thong kh

Nguyen nhan gay giam oxy mau benh nhan chan thng
Shunt tai phoi Tran kh mang phoi Tran mau mang phoi. KMM: PaCO2 bnh thng

ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, dan lu mang phoi

Nguyen nhan gay giam oxy mau benh nhan chan thng
Shunt tai phoi Xep phoi Viem phoi ht. Dap phoi. Thuyen tac m. ARDS. Qua tai tuan hoan KMM: PaCO2 bnh thng
ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, th may co cai PEEP

Them li tieu trong trng hp co qua tai tuan hoan

Nguyen nhan gay giam oxy mau benh nhan chan thng
Mat mau Xuat huyet KMM: PaCO2 bnh thng

ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, truyen HC.

Nguyen nhan gay giam oxy mau benh nhan chan thng
Giam cung lng tim Giam the tch mau. Chen ep tim. Tran kh, tran mau mang phoi.

KMM: PaCO2 bnh thng, khi co toan chuyen hoa ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, sau o ieu tr nguyen nhan

Nguyen nhan gay giam oxy mau benh nhan chan thng
c che ho hap te bao Ngo oc cyanide Ngo oc kh CO

KMM: Luc au sau o

ap ng vi oxy 100%: PaO2 X tr: Cung cap oxy, sau o dung Nitrit - thiosulfate oi vi ngo

oc cyanide va oxy cao ap oi vi ngo oc kh CO

Nhng ton thng long ngc gay suy ho hap co the dan en t vong nhanh chong neu khong chan oan va x tr kp thi
Tran kh mang phoi ap lc Tran mau mang phoi lng ln

Vet thng ngc h

Mang sn di ong

Tran mau mang tim

TH MAY BENH NHAN CHAN THNG

Ch nh th may benh nhan chan thng

Th cham, th hc, ngng th.
Th nhanh tren 35 lan/phut. SpO2 < 90% (PaO2 < 60 mmHg) du ang th oxy qua mat na co

tui d tr (FiO2 > 60%). PaCO2 > 45 mmHg va kh mau ong mach co toan ho hap.

 Duy tr KMM trong gii han bnh thng

Muc tieu cua th may

(pH 7,35 - 7,45, PaO2 80 - 100 mmHg, PaCO2 35 - 45 mmHg). Vi t bien chng nhat, bao gom on nh huyet ong va han che ton thng phoi do th may. e han che ton thng phoi do th may FiO2 60%. Ap lc bnh nguyen cua ng th (P plateau) < 30 cmH2O. Cai PEEP mc thch hp.

Cai at ban au
Mode th: A/C.

Vt: 8 ml/kg.

Tan so th: 14 16 lan/phut. PEEP: 5 cmH2O.

FiO2: 100% sau o giam dan theo SpO2

Sau 30 phut th may, th KMM e ieu chnh cac thong so may th

 Duy tr kh mau ong mach trong gii han bnh thng (pH 7,35 -

Muc tieu cua th may

7,45, PaO2 80 - 100 mmHg, PaCO2 35 - 45 mmHg), Vi t bien chng nhat, bao gom on nh huyet ong va han che ton thng phoi do th may. e han che ton thng phoi do th may
FiO2 60% Ap lc bnh nguyen cua ng th (P plateau) < 30 cmH2O Cai PEEP mc thch hp.

ieu chnh cac thong so may th

oi sang mode th SIMV hoac PSV khi tnh trang benh nhan tng oi on nh, co khi phat nhp th t nhien tot.
Giam Vt xuong 6 - 7 ml/kg neu ap lc bnh nguyen ng th > 30 cmH2O, hoac KMM co PaCO2 < 35 mmHg.

ieu chnh cac thong so may th

Tang tan so th neu KMM co PaCO2 > 45 mmHg, sau khi a

kiem tra xem bong chen noi kh quan co b thung khong, day may th co b thung hoac cac cho noi a kn cha. Giam dan FiO2 tuy theo SpO2, duy tr SpO2 95 - 98%. PEEP: tang mc PEEP khi benh nhan co bien chng ARDS.

Hoi chng suy ho hap cap nguy kch (Acute respiratory distress syndrome ARDS)
ARDS la phan ng viem tai phoi, gay ra tang tnh tham cua hang rao phe nang mao mach Nguyen nhan thng gap nhat benh nhan chan thng la dap phoi.

X quang ngc thang benh nhan ARDS

CT scan ngc benh nhan ARDS

Chan oan ARDS

Chan oan ARDS (theo AECC 1994) Tnh trang suy ho hap cap co u 3 tieu chuan:
1. 2. 3.

PaO2 / FiO2 200 bat ke mc PEEP X quang phoi co ton thng dang phu mo ke phe nang 2 ben Ap lc mao mach phoi bt 18 mmHg hoac khong co bang chng lam sang va X quang cua gia tang ap lc nh trai (Loai tr phu phoi do tim).

(AECC: American-European consensus conference)

Nguyen nhan ARDS

1. Benh ly gay ton thng phoi trc tiep:
Viem phoi
Ht dch v vao phoi Ht khoi Dap phoi Thuyen tac m Ngat nc Sau ghep phoi hoac lay huyet khoi M phoi.

Nguyen nhan ARDS

2. Benh ly gay ton thng phoi gian tiep:
Nhiem trung huyet. Chan thng nang co soc va truyen nhieu mau. Thi gian tien hanh tim phoi nhan tao keo dai. Ngo oc thuoc (thuoc phien, thuoc ray P hu c, paraquat, salicylate...) Viem tuy cap. Tang hoac ha than nhiet.

Bong.
Truyen mau va cac che pham cua mau.

Th may benh nhan ARDS

Ap dung chien lc thong kh bao ve phoi:
1. S dung PEEP e cai thien oxy mau, vi muc tieu oxy

PaO2 = 55 - 80mmHg hoac SpO2 = 88 - 95%.

2. Cai Vt = 5 6 ml/kg can nang ly tng. 3. Duy tr ap lc bnh nguyen 30 cmH2O. 4. Chap nhan tang CO2 e duy tr ap lc bnh nguyen.

Th may benh nhan chan thng so nao Tac ong cua th may len bn CTSN: giam ap lc ti mau nao do giam cung lng tim, giam huyet ap ong mach trung bnh tang ap lc tnh mach trung tam lam cho lng mau t nao ve tim giam, lam tang ap lc noi so. V the bn CTSN co th may can c duy tr cung lng tim va huyet ap bnh thng.

Th may benh nhan chan thng so nao Muc tieu th may benh nhan chan thng so nao la duy tr: - PaO2 bnh thng (80 100 mmHg) - PaCO2 bnh thng 35 40 mmHg neu khong co tang ap lc noi so, 30 - 35 mmHg neu co tang ap lc noi so.

Th may benh nhan chan thng so nao

Neu can phai dung PEEP e cai thien oxy mau nen cai PEEP

mc toi a10 cmH2O. Neu can phai dung mc PEEP cao hn can nhac th may tan so cao.

Th may benh nhan chan thng so nao Tang thong kh: c s dung e giam ap lc noi so trong phu nao Tang tan so th hoac Vt e PaCO2 t 25 30 mmHg trong 30 phut c s dung sau khi a dung an than, dan lu dch nao tuy va dung mannitol nhng cha giam c ALNS. Khong s dung bien phap nay keo dai, v tang thong kh gay giam ALNS thong qua c che co that mach mau nao gay giam lu lng mau ti nao, lam nang hn tnh trang thieu mau nao.

S dung thuoc an than, giam au benh nhan th may

Muc ch giam tnh trang kch ong, chong may th gay ra do au, cam giac kho chu, bat an, lo lang, hot hoang, tnh trang thieu oxy mau.

Thuoc thng c s dung la giam au nhom a phien (opioid) va an than nhom benzodiazepin. Co the phoi hp ca hai loai thuoc tren.

Bai giang tai t trang web HYDTPHCM www.yds.edu.vn Bo mon HOI SC-CAP CU-CHONG OC
phan Tai nguyen hoc tap

Curved Blade Laryngoscope Inserted Against Epiglottis

80

Straight-Blade Laryngoscope

81

Straight-Blade Laryngoscope Inserted Past Epiglottis

82

Aligning Axes of Upper Airway

Mouth

A
A
B C B

Pharynx

Trachea

Extend-the-head-on-neck (look up): aligns axis A relative to B Flex-the-neck-on-shoulders (look down): aligns axis B relative to C
83

Visualization of Vocal Cords

Anatomy
Vallecula Vocal cord Tongue

Epiglottis

Glottic opening

Arytenoid cartilage
84

Tracheal Intubation
Indications
Inability to ventilate the unconscious patient After insertion of pharyngeal airway

Inability of patient to protect own airway (coma,

areflexia, or cardiac arrest) Need for prolonged mechanical ventilation

85

Tracheal Intubation
Recommendations
Intubate as soon as possible after ventilation

and oxygenation in cardiac arrest Intubation should be done by most experienced person Do not take longer than 30 seconds per attempt Auscultate the thorax and epigastrium after intubation
86

Tracheal Intubation
Complications
Traumateeth, lips, tongue, mucosa,

vocal cords, trachea Esophageal intubation Vomiting and aspiration Hypertension and arrhythmias

87

Esophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B

E
Distal End

C = tracheal tube; ventilation through open end if proximal end inserted in trachea D = pharyngeal cuff; inflated through catheter = E F = esophageal cuff; inflated through catheter = G

H = teeth marker; blindly insert Combitube until marker is at level of teeth

H D B

Proximal End

G
88

Esophageal-Tracheal Combitube Inserted in Esophagus

D
A = esophageal obturator; ventilation into trachea through side openings = B D = pharyngeal cuff (inflated) F = inflated esophageal/tracheal cuff H = teeth markers; insert until marker lines at level of teeth

89

Esophageal Detector Device

(Bulb-Type)

90

Confirmation: Tracheal Tube Placement

End-tidal colorimetric CO2 indicators

91

CAC BIEN PHAP KIEM SOAT NG TH

M KH QUAN M kh quan c thc hien khi at noi kh quan that bai, trng hp khan cap choc kim to vao mang nhan giap e thong kh trong khi ch m kh quan.

Airway: Surgical

Tracheostomy: Not usually for emergencies, need experience, knife and a tube Percutaneous Tracheostomy: Not for emergency situations

Hemothorax
Massive Hemothorax
Can be result of lines or

thoracentesis Limited diagnostic use of thoracentesis Chest tube is intial management Larger size tube 40FR If large quantity or persistent then surgery