THNG KH TRONG CHN

THNG S NO
BC S DANH QUNH
ICU BENH VIEN VIET UC

I CNG
Chn thng s no l nhng thng tn
ca s hoc no hoc c s v no do
cc chn thng gy nn
Bc m; 300 per 100,000 per year (0.3%
dn s ) v t l TV l 25 per 100,000
Vit nam ;

SINH L -GII PHU

Ba thnh phn trong hp s
- No
- Mch mu nui no
- Dch no tu

HUYT NG HC NO
p lc ti mu no ( Cerebral Perfusion
Pressure -CPP);
CPP = MAP -ICP (p lc ni s ; 5-15)
= 73-10
Dng mu no ( Cerebral blood flow-CBF)
CBF = CPP/ CVR
= 750 mls/min or 15% lu lng tim

DNG MU NO (CBF)
50-54ml/100g/pht
Ph thuc vo CPP v CVR( Cerebral vascular
resistance-Sc cn MM no)
CVR ph thuc vo;
Pressure autoregulation
Chemical control (by arterial pCO2 and pO2
Metabolic control
Neural control

DNG MU NO (CBF)
55-60 ml/100g/pht ; mu no , tng
p lc trong s ( ICP )
18-20 ml/100g/pht ; Thiu mu no
8-10 ml/100g/pht ; T bo no cht

Pressure autoregulation
T IU CHNH P LC
S lin quan gia CBF & CPP
Phm vi t iu chnh ca CBF
50-150 mm Hg ca CPP

CHN THN S NO

Chn thng s no kn

Vt thng s no h

CHN THN S NO KN
Chn ng no
Ln s ( Skull depressed Fracture )
Mu t trong s-TT chon ch
Mu t ngoi mng cng
Mu t di mng cng
Mu t trong no

CHN THN S NO KN
Tn thng trc lan to
- Xut huyt di mng nhn
- ng dp no ri rc

CTSN- TN THNG
Tn thng tin pht;
do chn thng gy nn ; MTNMC ..
Tn thng th pht;
pht sinh sau khi BN b CTSN , Lm
nng TT tin pht , gy t vong nhiu
CTSN trong vin

TN THNG TH PHT
Phng thch cc cht trung gian vim, gc t
do.tn thng hng ro mu no ,suy gim
chc nng ty lp th
Thiu mu no( dng mu no khng )
Thiu oxy no (oxy no khng )
H huyt p
Ph no
Tng p lc ni s
Thot v no , tt hnh nhn tiu no..

PH NO (CEREBRAL EDEMA)
Vasogenic cerebral edema ; Do tn thng
hng ro mu no ( lm rng khp gia
cc t bo ni mc) v chn thng
Cytotoxic cerebral edema ;do suy gim
chc nng bm natri v kali trong mng t
bo Glial; Gy mui v nc trong TB.
Gp trong thiu oxy , thiu mu no

MU T NGOI MNG CNG

Ch nh m
- Khi mu t 30 cm

MU T NGOI MNG CNG

Ch nh m
- Khi mu t
- ng gia b y

30 cm
5mm

- dy ca khi mu t 15mm

MU T DI MNG CNG
Ch nh m;
- Mu t dy
10mm
- ng gia b y 5mm

Theo di ICP ;
- Tt c cc BN c GCS 9

MU T DI MNG CNG
C GCS 9 , dy mu t 10mm ,v
y ng gia 5mm ; Nn m nu
- GCS tt 2 trong T tai nn-nhp vin
- ng t dn 1 bn
- ICP tng 20 mmHg

HI SC SAU M

m bo huyt ng
Kim sot h hp
Theo di tri gic
Gim au , an thn
Nui dng
Chng nhim khun
Kim sot ng huyt, in gii.

M BO HUYT NG
Duy tr CPP ti thiu 60 mmHg
Trnh tt huyt p (HA 90 mm Hg )
Duy tr Hematocrite 25-30 %
Dch truyn; Nacl 0.9% , keo

M BO HUYT NG
Tr tim nu sc thn kinh;
- Dopamin
- Noradrenalin
- Adrenalin

M BO H HP
H hp nhn to ng thn;

PaCO2 ; 35-40 mmHg

; 100mmHg Gin mch ti a
20mmHg LL gim 40%
= 10mmHg LL co ti a

M BO H HP
Trnh thiu oxy
PaO2 > 50mmHg LLMN khng i
< 50mmHg LLMN tng nh
< 30mmHg LLMN tng gp i
> 350mmHg LLMN bt u gim

M BO H HP
SjO2 l bo ho oxy mu tnh mch cnh
SjO2 = SaO2 - (Oxygen Consumption /
Cardiac Output x Hb x 1.39) = 50-75%
SjO2 gim trnh tng thng kh
SjO2 tng c th tng thng kh

AN THN GIM AU

Mocphin ; 4mg/h iu chnh nu cn

Midazolam ; 2-4mg/h
Fentanyl ; 2-5mcg/kg/h
Sulfentanyl ; 0.05-2 mcg/kg
Propofol ; 20-75mcg/kg/m

MANITOL, MUI U TRNG

Manitol ; 0,25-1g/kg
Kim sot tng ICP
Mui u trng; cha c li khuyn

D PHNG NHIM KHUN

Khng sinh lc t NKQ phng m
Cephalosporin th h 1 or 2
T 3-5 ngy
Chc d TS or t catheter theo di ICP
trong K v trng

D PHNG TC MCH
D phng tc mch su;
Qun p hi (intermittent pneumatic
compression stockings)
Heparin trng lng phn t thp;
D dt nguy c xut huyt

THEO DI P LC TRONG S
ICP ; 0-10mmHg ( 20-25)
CTSN ; Glasgow coma scale; 3-8
CT scan bt thng (ng dp)
Hng dn iu tr

TNG ICP
2540 mmHg vi HA bnh thng; Tnh
4050 mmHg ; M
50mmHg Nhi mu no , cht no
Tr em thch ng vi tng ICP tt hn

TNG ICP-NGUYN NHN

Mass effect ;

Mu t , ng gip , ph , u

increased CSF production ; Vim mng

no , xut huyt di mng mm
generalized brain swelling ;
obstruction to CSF flow and/or absorption ;

TNG ICP-IU TR

Khi ICP 25 mmHg

Ly b mu t
m bo h hp , trnh thiu oxy
C th tng thng kh kim sot
Manitol , Mui u trng
An thn ( Thiopental..), dn c nu cn
Trnh tt huyt p

TNG ICP-IU TR

u cao 30 c kim sot

u thng
Chc dch no tu ( CSF )
M b xng s
Ly b mt phn t chc no

NUI DNG
Nui dng ng rut sm
Sau 5-7 ngy sau m cho n calo
Qua sonde DD hoc m thng hng trng
Kim sot ng huyt; 5-7 mmol/l

NC IN GII
Natri thng thp ; c th do CSW v
SIADH . Duy tr Na 140-150
Mg cng thng thp , gim ngng git
Na cao v i nht ( Diabete insipide )

LOT DD- TT DO STRESS

40 % BN CTSN
n sm
Bao bc nim mc DD; Maalox ,
Phosphalugel..
Khng H2
c ch bm proton; Pantoprazole..
Ch nguy c tng pH dd , tng NT h hp

KHNG DNG
Corticoids
Glucose trong 72h u
Tng thng kh tr khi c tng p lc ni
s

CTSN-CC BAN U
L giai on quan trng nht LQ ti hu
qu sau chn thng
50 % CTSN thiu oxy ngay sau tai nn
Tng t l t vong

CTSN-CC BAN U
Lm thng ng th
t NKQ cho cc BN c Glasgow 8
H hp h tr
Bt ng c, tht lng
Truyn dch nu c HA tt

TBI TRN ALI V ARDS

oxy no
Bo v phi;
- Vt thp
- Peep cao
- FiO2 < 60%
- PaCO2 ng or cao

TBI TRN ALI V ARDS

OXY
-Thiu oxy no;
+Tn thng th pht
+ Hu qu xu
- Evidence ;

IMPACT 9000 bn

TBI TRN ALI V ARDS

Gim phn phi oxy no ;

- Gin mch no
- Tng ICP
- Gim CPP

TBI TRN ALI V ARDS

im un gin mch no - Oxy
- ng vt
; 50 mmHg
- Ngi kho ; 58 mmHg
SpO2
90%
ARDSnet PaO2 ; 55-58 mmHg
SpO2 ; 88-95 mmHg

TBI TRN ALI V ARDS

BTF

; PaO2 > 60mmHg

UK Transfer Guideline; PaO2 > 97,5mmHg

Addenbrooke NCU

; PaO2 > 82,5mmHg

Tc gi

; Normoxia bt c lc
no v bt c u

TBI TRN ALI V ARDS

Vt v PaCO2
ARDSnet Protocol
Vt thp 6ml/kg-PaCO2 44 mmHg day 7
Vt bnh thng PaCO2 40 mmHg-day7
TBI c Compliance s thp
PaCO2 31-34 mmHg
Tng thng kh vi Vt cao- ALI & ARDS
Cn duy tr cn bng; Kim sot CO2 v Bo
v phi

TBI TRN ALI V ARDS

PEEP

PEEP < ICP

Luu duy tr MAP

( Mc Guire et al )

TBI TRN ALI V ARDS

Prone Ventilation

High Frequency Ventilation