Phac Do Dieu Tri BV Quan 5

PHC IU TR BNH VIN QUN 5 NM 2014

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NGNG TUN HON - H HP

I/ I CNG: - Ngng tun hon - h hp (NTH-HH) hay cn gi l ngng tim l mt cp cu ht sc khn

cp, c th xy ra bt c ni no trong hoc ngoi bnh vin. - X tr cp cu NTH-HH thng c gi l Hi sinh Tim- Phi (HSTP-CPR). Ty theo

phng tin cp cu c s dng v trnh ca ngi cp cu m chia thnh HSTP c bn (BLS) v HSTP cao cp ( ACLS).

- Mc ch ca HSTP l cung cp tm thi tun hon v h hp nhn to, qua to iu kin phc hi tun hon v h hp t nhin c hiu qu.

II/ CHN ON NGNG TUN HON H HP: - Cn ngh ngay n NTH-HH khi c tnh trng: Mt thc t ngt. Ngng th t ngt. Mt mch bn hoc mch cnh. Hoc c cc du hiu khc gi : da nht nht nu mt mu cp, da tm ti nu c suy h hp cp, ngt th, mu ngng chy khi ang m.

III/ QUY TRNH X L NGNG TUN HON H HP: (theo th t A B C D) A Airway: Kim sot ng th:

- nh gi lu thng: quan st, thi, dng tay, - Lm thng nu c tc: nng cm, ko li; mc ht b d vt - t ng th nhn to: canul, Mask, Kim lun mng gip nhn...

B Breathing: Thng kh c hc - nhn to - Thc hin qua: + Ming ming . + Bng Mask. + Bng - NKQ.

- C gng tng nng Oxy trong kh thi vo BN (tt nht FiO2 = 100 % vi bng gip th c ti d tr).

- Tn s 8 - 10 ln/pht, trnh tng thng kh qu mc. - Phi hp vi p tim nu cha t c NKQ.

C Circulation: Tun hon nhn to - p tim ngoi lng ngc:

+ Bin : 3,8 - 5 cm. + p tim phi hp vi thi hoc bp bng vi t l: 30/2 (30 ln p tim /02 ln thi, bp bng) khi cha c NKQ. + Tn s: 100 ln / pht nu c NKQ, hn ch ti a vic gin on p tim.

- ng dng thuc: + Tnh mch ngoi vi (TMNV): cng ln v c sm cng tt. + Qua ng Ni kh qun: cn tng liu >2 ln v ha long.

- Dng thuc trong hi sinh tim phi: + Adrenalin 1mg: TM 1mg/ln, lp li mi 3 -5 pht. C th dng liu cao 3-5 mg/ln sau liu u tht bi. Trng hp bm thuc qua NKQ liu phi gp i liu IV, pha long v bp bng 2 ln. + Atropin 1mg: TM 1mg/ln, lp li mi 3 - 5 pht, tng liu < 3mg. C th bm qua NKQ.


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+ Dch truyn: ch nn dng NaCl 0,9%. + Lidocain: Khi c rung tht hoc nhanh tht: 1mg/kg bolus, lp li 0,5mg/kg mi 5 n 10 pht; sau 30 50 g / kg / pht IV. D Defibrillation: ph rung

- Pht hin sm rung tht v tin hnh ph rung ngay v rung tht l th thng gp nht (75 - 95%) v iu tr hiu qu rung tht duy nht l kh rung.

- Tin hnh ph rung ngay 1 ln vi 360J nu s dng my ph rung n pha (monophasic defibrillator) hoc 200J nu s dng my ph rung hai pha (biphasic defibrillator).

- Sau khi ph rung, nu khng hiu qu th phi tin hnh hi sinh tim phi (CPR) ngay trong 05 chu k hoc 2 pht, ri li ph rung tip ln th hai vi mc nng lng c.

IV/ PHN CNG NHIM V TRONG NHM CP CU HI SINH TIM PHI:

1. Bc s: - Bc s 1:

+ Trng nhm quyt nh, ch o can thip thuc... + m bo phn h hp: phn A-airway v B- breathing. + m bo phn C Circulation v D Defibrillation (nu cha c BS 2 tng cng). + Ghi h s bnh n: din bin bnh, ch nh thuc, th thut

- Bc s 2(nu c tng cng): + m bo phn C Circulation v D Defibrillation: p tim, ph rung, dng thuc + Thc hin nhim v ca BS 3, nu cha c tng cng.

- Bc s 3 (nu c tng cng). + H tr thc hin cc th thut HSTP theo lnh. + Cm mu bn ngoi, gip thay y phc cho BN.

2. iu dng: - iu dng 1: h tr Bs1

+ Cung cp Oxy, duy tr thng kh, gip t NKQ, ht m. + Ghi h s phn iu dng: din bin, can thip, thuc s dng

- iu dng 2 (khi c tng cng): h tr Bs 2 + t ng truyn TM, tim thuc, t sonde tiu, + Chun b dng c cn thit cho cp cu hi sinh. + Ly v gi mu bnh phm xt nghim (nu c ch nh). + Gip thay y phc, gi ti sn, h tng BN khi di chuyn.

- iu dng 3 (khi c tng cng): + Sp xp, n nh v tr BN v my mc dng c. + H tr cho nhm khi c yu cu, trn an, cch ly thn nhn BN.

Ti liu tham kho: - Hng dn chn on v x l Ngng Tun hon H hp v phc x tr Hi sinh cao cp

ca Bnh vin Cp cu Trng Vng


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Lu : x l Ngng Tun hon H hp

SC IN: 360 J (ln 2) Tip tc 05 chu k CPR /02 pht Lp ng truyn: cho thuc

Epinephrine IV 1mg mi 3-5 pht

NGNG TIM- MT MCH

Hi sc c bn (BLS): CPR, OXY, MONITOR, PH RUNG

KIM TRA NHP

RUNG THT /NHP NHANH THT V TM THU

SC IN: 360 J (ln 1) 05 chu k CPR /02 pht

(05 ln CPR theo t l p tim: thng kh l 30:2 trong 02 pht, kim tra nhanh nhp trn monitor)

TIP TC CPR (05 chu k) LP NG TRUYN TM EPINEPHRINE 1mg IV, lp li mi 3-5 ph ATROPIN 1mg IV, lp li mi 3-5 ph

KIM TRA NHP

KIM TRA NHP NHP NN SC HAY KHNG ?

Nu v tm thu /PEA th tip tc cc bc x l VTT/PEA nh trn .

Nu c nhp th sn sc sau hi sinh

KIM TRA NHP

SC IN: 360 J (ln 3) Tip tc 05 chu k CPR /02 pht Xem xt cc thuc: - Amiodaron 300 mg IV

- Lidocain 1-1,5 mg/kg IV

- MgSO4 1-2 g IV

Tm nhng nguyn nhn c th iu tr

SC IN

NHP KHNG SC

NHP SC I65N

Sc in Khng sc in

Sc in Khng sc in

(Nu RT/NNT cn)

(Nu RT/NT cn)

(Nu RT/NT cn)

Sc in

(Nu RT/NNT cn)

(Nu RT/NT cn)

(Nu RT/NT cn)

Khng sc in


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NG C CP THUC GY NGHIN (NHM OPI, HEROIN V MORPHIN)

I. I CNG: - Thuc gy nghin: thuc phin (Opiates), codein, morphin v heroin rt d gy ng c

cp khi s dng, c bit nhng ngi lm dng thuc v ph thuc thuc. Ng c nhm thuc gy nghin c th t vong do suy h hp cp.

II. CHN ON: 1. Bnh s: - C tip xc vi thuc gy nghin. - C tin cn nghin heroin, c bnh mn tnh thng cn dng thuc gy nghin. - Khai thc bnh s thng phi thng qua thn nhn, bn b hay ngi chng kin tnh

hung ng c. 2. Triu chng lm sng:

xut hin tam chng c in: hn m, suy h hp v co ng t - c ch h hp: th chm, yu, ngng th, tm ti, Sp02 gim, ph phi cp. - c ch thn kinh trung ng: biu hin nhiu mc khc nhau t l m, ng g n

hn m.

- ng t co nh, mt cc phn x. - Ngai ra cn c th : huyt p h, lnh do h thn nhit. 3. Cc xt nghim cn lm sng cn thit: - Xt nghim thng quy: cng thc mu, ng huyt, BUN, Creatinin, SGOT, SGPT,

Ion , Sp02, ECG, X Quang phi. - Test th Morphin/Hroin trong nc tiu dng tnh. 4. Chn on phn bit: - Hn m do ung thuc ng v an thn qu liu. - Hn m do h ng huyt, thng gp ngi tiu ng dng thuc h ng huyt

qu liu. - Tai bin mch mu no. II. IU TR: a) Nguyn tc iu tr: 1. Hi sc tch cc ni khoa: - t ni kh qun nu BN ngng th. - m bo tun han: p tim ngoi lng ngc nu ngng tim, - Chng co git, iu tr ph phi nu c. 2. iu tr c hiu: Naloxone 3. iu tr h tr: - Truyn dch Glucose 5% hoc NaCl 0,9 % m bo huyt p. - Dng thuc vn mch Noradrenaline trong trng hp c tt huyt p. - Th oxy mi 4 l/ph. b) Thuc c hiu: Naloxone - Bt u tc dng nhanh: 1 pht


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- Thi gian bn hy: 20 pht - Thi gian tc dng: 20-60 pht - Rt an tan - Cch dng: c ch thn kinh ch yu: - Tn cng: Liu th 1: Naloxone 0,4mg /1ml TMC

Liu th 2: Naloxone 0,4mg /1ml TMC sau liu 1 02 pht. Tr em: < 20 kg: 0.1 mg/kg/TMC/TB mi 2-3 pht

> 20 kg: ging liu ngi ln - Duy tr: 0.25 mg/gi/6-10 gi

[ 05 ng pha 40 ml Nacl 0.9% (Glucose 5%) TTM 5ml/gi ] c ch h hp ch yu: - Tn cng: 2 mg TMC

Lp li mi 2 pht n tng liu 10mg - Duy tr: 1.2 mg/gi/6-10 gi

[ 15 ng pha 40 ml Nacl 0.9% (Glucose 5%) TTM 8ml/gi ]

Trong trng hp cp cu khng c ng truyn TM, Naxolone c th c cho di li, qua nim mc mi, hay ni kh qun.

c) Theo di: - Nu BN hi phc sau khi s dng liu u m khng c triu chng trong vng 4-6 gi,

BN c th xut vin.

III. TIU CHUN CHUYN VIN:

- Nu sau 4 liu ban u khng kt qu th tm xem bnh nhn c ung thm thuc khc : barbiturate, thuc an thn, ru, hoc chn thng u chuyn tuyn trn.

Ti liu tham kho:

- Ng c thuc gy nghin (nhm OPI, Heroin v morphin) ca PGS.TS Nguyn Th D -Trung tm chng c Bnh vin Bch Mai H Ni.

- Phc x tr ng c Heroin nm 2013 ca Bnh vin Ch Ry. - Phc x tr ng c Heroin nm 2014 ca Bnh vin Nguyn Tri Phng - Phc x tr ng c Heroin nm 2013 ca Bnh vin Nguyn Tri.


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HN M H NG HUYT I. I CNG:

H ng huyt (H) l mt ri lon sinh ha khi vn tc di chuyn ng khi mu vt

qu kh nng b tr ca c th duy tr mt lng ng huyt bnh thng (80-120

mg/dl).

Khi ng huyt gim di 70 mg/dl c gi l h ng huyt. Nhng triu chng lm

sng ch xy ra khi H di mc 45-50 mg/dl.

Chn on h H da vo Tam chng Whipple:

C triu chng lm sng.

Nng Glucose huyt tng thp < 45 -50 mg/dl.

Triu chng gim sau khi ung hoc truyn ng.

II. NGUYN NHN-YU T THUN LI:

1. H ng huyt khi i:

Xy ra 5-6 gi sau ba n cui cng, triu chng thng nng, dn n hn m v t vong.

Cn h H thng xy ra vo ban m, khi thc gic hoc sau khi vn ng nhiu v

thng c Tam chng Whipple.

Thng do thuc iu tr T: Insulin, Sulfonylurea hay h H do ru

Cc yu t thun li: bnh nhn nh tui, ln tui, thiu n, nhn i lu ngy, suy gan, suy

thn

2. H ng huyt sau n:

xy ra sm trong vng 2-3 gi sau khi n, thng c triu chng nh: chng mt, chong

vng, mun xu m khng hn m.

Thng l loi H H chc nng.

H H do phn ng vi thc n: trn nhng bnh nhn ct bao t, hp mn v

Cc yu t thun li: xy ra sau ba n c nhiu carbohydrate c th do tng sn xut

insuline hoc tng nhy cm vi insuline.

III. CHN ON:

Da vo Tam chng Whipple

1. Lm sng:

a) Ri lon thn kinh t ch:

i, v m hi

Tim p nhanh, hi hp

Da ti nht

Run ry, yu c, ni lp

b) Ri lon thn kinh trung ng: h H ko di, nng

Nhn i, m mt, l ln


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Thay i tri gic hoc hnh vi, mt tr nh

Co git, hn m

2. Cn lm sng:

H ng huyt sinh ha: ng huyt < 70mg/dL.

H ng huyt lm sng: khi H < 45-50 mg/dL. 3. Phn bit:

Hn m nhim ceton axit.

Tai bin mch mu no. IV. X TR:

1. Nguyn tc iu tr: x tr cp cu h H ty thuc:

Tnh trng tri gic.

Nng Glucose huyt.

D on v din tin lm sng. 2. iu tr c th: x tr h ng huyt theo mc lm sng:

Mc Lm sng X tr

I (nh)

Bnh nhn cn tnh to, ch c triu chng thn kinh giao cm:

- Ung ng hp thu nhanh :01 ly nc tri

cy hay 01 tch sa ( cha khong 15-20 g carbohydrates).

- Bm li H mao mch sau 10-15 pht, nu

cn h


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PH PHI CP DO TIM

I/ I CNG:

Ph phi cp do tim l mt tnh trng suy gim chc nng tht tri cp tnh do bnh hp van

2 l, m hu qu l s gia tng r rt p lc nh tri v p lc mao mch phi, gy tp trung

dch vo trong khoang ph nang v m k phi, lm nh hng n s trao i kh v s

oxy ha y .

II/ CHN ON:

a s bnh nhn bit c bnh tim t trc, nhng i khi ph phi cp l biu hin u tin

ca bnh l gc.

1/ Lm sng:

C nng: - Cm gic ngp th tng ln khi nm, do bnh nhn thng phi ngi. - Lo u s hi, ht hong.

Thc th: - Th nhanh, v m hi, co ko c h hp ph, ho khc bt hng, u chi tm ti.

- Mch nhanh, u chi lnh, huyt p tng do cng giao cm. - Ting th n o: phi nhiu ran m, ran rt t y dng ln nh 2 ph trng. Ting tim kh nghe do ran phi. C th nghe ting T3, ting P2 mnh.

2/ Cn lm sng: - Xq KTS phi thng: hnh nh ph m k, ti phn b tun hon phi. Hnh nh dch ph t cc vch ngn gia cc tiu phn thy. Hnh nh mun l ph ph nang, tim to thot dch hnh cnh bm. - in tm : Hnh nh TMCT, NMCT, lon nhp tim, gin nh tri v ph i tht tri, Sng T o ngc, QT ko di. - BNP: gip phn bit gia suy tim v nguyn nhn kh th do phi. Khi BNP


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III/ X TR: Nguyn tc iu tr: - iu tr triu chng. - iu tr cc yu t thc y. - iu tr nguyn nhn.

1/ X tr ban u: - Th oxy m 3 5 lt/pht qua sonde mi hay mt n sao cho SpO2> 60%. - Aminophyline 6mg/kg/20pht tim TM chm, sau truyn TM 0,2 0.,5 mg/kg/gi.

2/ Gim tin ti: - Nitroglycerin: Nitromint aerosol xt 2 nht di li ( BN cha c tt HA hay sc ) hoc Nitrosol TTM 5-10mcg/kg/ph, tng liu 5mcg mi 10ph, dng tng liu khi c hiu qu (khng dng khi HATThu


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SUY THN CP

I/ I CNG:

Suy thn cp l mt hi chng xut hin khi chc nng thn (ch yu l chc nng lc

cu thn) b suy sp nhanh chng, xy ra t ngt bnh nhn khng c suy thn trc

hoc bnh nhn mc suy thn mn.

Mc lc cu thn c th b suy gim nng nhng c th c hi phc hon ton mt

cch t nhin hoc di nh hng ca iu tr nguyn nhn.

Suy thn cp th hin trn lm sng c trng vi v niu, nhng c nhng th bnh vn

c lng nc tiu bo tn.

Gn y chn on suy thn cp da vo s gia tng cratinine mu so vi cratinine

cn bn bit: nhiu hn 50mmol/l i vi cratinine cn bn di 250 mmol/l hoc

nhiu hn 100 mmol/l i vi cratinine mu cn bn trn 250 mmol/l.

II/ NGUYN NHN:

1. Nguyn nhn trc thn (suy thn cp chc nng) Mt nc ngoi bo Mt qua da (m hi, bng)

Mt qua ng tiu ho (nn ma, tiu chy, l d)

Mt qua thn: + iu tr li tiu qu mnh. + a niu thm thu trong i tho ng mt b v trong hi chng ly vt tc nghn. + Vim thn k mn + Suy thng thn

Gim th tch mu tht s Hi chng thn h nng

X gan mt b

Suy tim xung huyt

H huyt p trong cc tnh trng sc: tim, nhim trng, phn v, xut huyt. Suy thn cp huyt ng (do thuc c ch men chuyn, c ch th th angiotensin II,

Khng vim khng stroid) 2. Nguyn nhn ti thn (suy thn cp thc th)

Vim ng thn cp

Vim cu thn cp

Vim thn k cp 3. Nguyn nhn sau thn (Suy thn cp tc nghn)

Si niu qun l hng u Vit Nam

U x, ung th tuyn tin lit

U vng khung chu lnh hay c tnh (u bng quang, ung th t cung, c t cung, trc trng)


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X cng sau phc mc

Di cn sau phc mc (him)

Lao lm teo hai niu qun III/ CHN ON: 1/ Lm sng:

Giai on khi u: L giai on xm nhp, tn cng ca cc tc nhn gy bnh, din tin ty theo tng loi,

bnh nhn ng c th din bin nhanh c th dn n v niu ngay, bnh nhn sc th din bin nhanh hay chm ty theo nguyn nhn sc v k thut hi sc lc u.

Giai on thiu v niu: Thiu niu khi lng nc tiu < 500ml/24 gi (hoc di 20ml / gi), c th bt u t

t hoc ngay vi ngy u khi bnh, trung bnh ko di 1 - 2 tun, khi thiu niu ko di trn 4 tun th cn xem thn b hoi t v, vim cu thn cp th tin trin nhanh, vim quanh tiu ng mch thn, si gy tc niu qun.

V niu khi lng nc tiu < 100ml/24 gi.

Chnh v nguyn nhn thiu v v niu nn lm cho ur, creatinine tng cao nhanh trong mu.

Biu hin trong giai on ny ch yu l hi chng tng ur mu cp gm c cc triu chng: - V tiu ha: chn n, bun nn, nn ma , to bn hoc a chy. - V tim mch: Tng huyt p thng gp cc bnh vim cu thn, cn li l do lm dng dch truyn gy nc, mui, tng huyt p nng, gy ph phi, ph no. - Du thn kinh: c th kch thch vt v, hn m, co git, c khi ri lon tm thn. - V h hp: nhp th toan kiu Kussmaul hoc Cheyne - Stokes, ph phi, nhim khun phi. - Thiu mu: Thng xut hin sm nhng khng nng lm, khi c thiu mu nng th cn ngh n nguyn nhn suy thn cp l do xut huyt nng ko di hoc bnh c suy thn mn trc . - Ph thng do ung nhiu nc hoc truyn dch qu nhiu. - Ri lon in gii: thng gp trong suy thn cp l tng Kali mu, Toan mu l hu qu t tng chuyn ha, d tr kim gim 1 - 2 mmol/ ngy. Nhim trng: trong giai on v niu nhim trng l nguyn nhn hng u gy t vong thng l nhim trng ng h hp, tit niu v ngoi da.

Giai on tiu nhiu: Thng bt u t 300ml/24gi sau bnh nhn tiu nhiu, thng vo ngy th 3 ca

giai on ny lng nc tiu t 1lt/ngy.

Cc ch s v sinh ho trong mu ch bt u gim dn sau vi ngy tiu nhiu. Giai on phc hi: Ur, creatinine mu gim dn, mc c c nc tiu tng dn, lm sng tt ln.

2/ Cn lm sng:

Ure, creatinine tng.

Ion : ri lon in gii, Kali mu tng.

TPTTBMBMT.


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Siu m bng tng qut.

Tng phn tch nc tiu.

IV/ IU TR: Nguyn tc chung l iu tr theo nguyn nhn suy thn cp, rt khc bit ty tng

nguyn nhn trc, ti v sau thn. 1. iu tr suy thn cp chc nng:

Suy thn cp vi mt nc ngoi bo v gim th tch mu.

iu tr cn bn suy thn cp chc nng bng hi phc li nc, th tch mu lu thng bng in gii, mu, huyt tng cho phn ln cc nguyn nhn trc thn

iu tr chnh bng dung dch mui ng trng 0,9%, hoc nhc trng 0,45% bng ng tnh mch. Trong trng hp khng nng cung cp bng ng ung.

Trng hp c bit do thuc c ch men chuyn v thuc khng vim khng phi steroide: Ngng thuc.

Chung cho cc suy thn cp chc nng, nng huyt p, cng nh tc dng li tiu c th s dng cc thuc sau: - Isuprel 0,2 - 0,6mg - 1mg trong 1000ml glucose ng trng truyn tnh mch. - Dopamin 3 5 g/kg/pht cho ngi nng 50 kg truyn vi glucose 5%.

2. iu tr suy thn cp thc th: 2.1. Gim mui v nc

giai on v niu, n lt hon ton, lng nc k c dch truyn v ung mi ngy khng qu 700ml ngi 50kg.

2.2. giai on thiu niu. hoc ngay ngy u v niu, c nc ngoi bo:

Furosemid mi ln 120 - 160mg, tim tnh mch mi 3 - 4 gi, liu ti a c th n 1000mg - 1500 mg/24h nhm chuyn th v niu sang th i nhiu. Furosemid thng thay i lng nc tiu m khng nh hng n chc nng thn. Nu dng liu lng trong ngy m vn khng c lng nc tiu th ngng dng.

2.3. Khi c tng K mu

Dung dch glucose 20% 500ml + 20v Insulin truyn tnh mch nhanh t 60-90 pht.

Clorua calci 10% 5-10ml tim tnh mch chm 3-5 pht, khi cp cu vi in tim c bloc xoang nh, QRS gin rng hoc K+ > 7mEq/l.

2.4. iu tr toan chuyn ho.

Truyn tnh mch Bicarbonat ng trng 1,4 g% hoc trong trng hp cn thit s dng loi m c 4,2%, 8,4%.

V/ TIU CHUN CHUYN VIN:

Suy thn cp sau thn.

Trng hp nng, iu tr nh trn khng hiu qu.

Chuyn vin an ton. Ti liu tham kho :

Phc iu tr Suy thn cp Bnh vin Nhn dn 115.


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RUNG NH I/ I CNG: Phn loi:

- Rung nh cp: 48 gi hoc khng xc nh c thi gian. - Rung nh cn: trn 1 ln rung nh ri t v nhp xoang. - Rung nh khng tr: khng p ng thuc v sc in. - Rung nh trong hi chng WPW.

II/ CHN ON: 1. Lm sng:

- .

- .

- .

-

- .

- Huy .

- .

2. Cn lm sng:

- iu tm : .

< 3mm (c

trng hp nh : rung nh).

< 120l/pht (n 200l/pht).

-

.

III/ X TR: 1/ Loi tr nguyn nhn.

2/ iu tr khng ng:

Phn loi yu t nguy c: - Nguy c thp: N, 65 74 tui, bnh mch vnh, nhim c gip. - Nguy c trung bnh: trn 75 tui, tng huyt p, suy tim, EF


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- C bt k 1 yu t nguy c cao hoc trn 1 yu t nguy c trung bnh: Warfarin gi INR

2-3; Van c hc gi INR > 2,5.

3/ Khng ch nhp tht: - Digoxin 0,0125 0,025 mcg/ngy, hoc

- Verapamine 60 120 mg/ngy, hoc

- Diltiazem 60 120 mg/ngy, hoc

- Bisoprolol 2,5 10 mg/ngy.

IV/ CHUYN VIN:

- C biu hin ri lon huyt ng.

- C yu t nguy c trung bnh hoc cao.

- C ch nh chuyn nhp xoang.

- Chuyn vin an ton.

Ti liu tham kho:

- Phc iu tr Lon nhp nhanh trn tht Bnh vin Nhn dn Gia nh.


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CN TNG HUYT P

I/ I CNG:

Cn tng huyt p l tnh trng tng huyt p t ngt vi huyt p tm trng vt >120mmHg.

Phn loi: Tng huyt p cp cu: l cn tng huyt p km tn thng c quan ch tin

trin cp tnh (VD tn thng tim, no, thn v.v...) i hi phi h huyt p trong vng vi gi bng thuc ng tnh mch.

Tng huyt p khn trng: l cn tng huyt p khng km triu chng tn thng c quan ch tin trin cp tnh, huyt p c th c gim dn trong vng 24-72 gi khi dng thuc bng ng ung.

Tng huyt p c tnh-gia tng: l cn tng huyt p km theo tn thng y mt (ph hay xut huyt) v cc bin chng khc.

II/ CHN ON: 1/ Chn on xc nh :

Huyt p tm trng > 120mmHg.

Km t nht mt trong cc tiu chun sau: Ph gai th. Suy thn gia tng. Bin chng thn kinh cp tnh. Bin chng tim mch cp tnh.

2/ Chn on loi cn tng huyt p: a/ Tng huyt p cp cu:

Bnh no do tng huyt p .

Tng huyt p c tnh (mt s trng hp).

Tng huyt p nng km cc bin chng cp tnh. Mch mu no:

- Xut huyt trong s. - Xut huyt di nhn. - Nhn no nghn mch nng cp tnh.

Thn: suy thn tin trin nhanh. Tim mch:

- Phnh bc tch ng mch ch. - Suy tim tri cp vi ph phi. - Nhi mu c tim. - Cn au tht ngc khng n nh.

Sn git hay tng huyt p nng khi c thai.

Tnh trng tng tit Catecholamin: Cn u ty thng thn Do ngng thuc h huyt p t ngt (Clonidine, Methyldopa).

_ Chn thng u. b/ Tng huyt p khn trng:


16

- Tng huyt p c tnh-gia tng. - Bng nng. - Vim cu thn cp vi tng huyt p nng. - Vim mch mu ton thn cp tnh. - Tng huyt p lin quan phu thut.

+ Tng huyt p sau phu thut. + Tng huyt p nng bnh nhn cn phu thut khn cp.

- Chy mu cam nng. - Do ngng thuc huyt p t ngt.

3/ Cn lm sng: - TPTTBMBMT, creatinin, ng huyt, ion , tng phn tch nc tiu. - o ECG - X quang phi thng. - Ty theo nghi vn tn thng c quan ch no c th ch nh thm cc xt nghim thm d su hn tip theo.

III/ IU TR: 1/ Mc ch v yu cu: i vi tng huyt p cp cu:

- Gim 25% tr s huyt p trung bnh hay gim tr s huyt p tm trng xung


17

Khi pht 15-30 pht, thi gian tc dng 6-8 gi (khi ung) 15-30 pht, thi gian tc dng 2-6 gi (khi ngm di li).

Nifedipine 10 mg ung, lp li nu cn. Thn trng: bnh mch vnh, tai bin mch mu no. Khi pht 15-30 pht.

IV/ CHUYN VIN:

Tng huyt p c km theo tn thng c quan ch.

Chuyn vin an ton: xe cp cu.

Ti liu tham kho:

Phc iu tr Cn tng huyt p - Bnh vin Nhn dn 115.

Phc iu tr Tng huyt p cp cu Bnh vin Cp cu Trng Vng.


18

CHONG PHN V I/ I CNG:

Phn v l phn ng h thng nng, c th gy t vong, xy ra t ngt sau khi tip xc vi cht gy d ng.

y l mt cp cu cn x tr ngay.

II/ CHN ON: Ngay sau khi tip xc vi d nguyn hoc mun hn, xut hin:

Cm gic khc thng: bn chn, ht hong, s hi., tip xut hin triu chng mt hoc nhiu c quan.

Mn nga, ban , m ay, ph Quincke.

Mch nhanh nh kh bt, huyt p tt c khi khng o c.

Kh th kiu hen, thanh qun, nght th.

au qun bng, tiu tiu khng t ch.

au u, chng mt, i khi hn m.

Chong vng, vt v, giy gia, co git.

III/ X TR: 1/ X tr ngay ti ch:

- Ngng ngay ng tip xc vi d nguyn: thuc ang tim, thuc ung, thuc bi, nh

mt, nh mi.

- Cho bnh nhn nm ti ch.

- Thuc: Adrenaline l thuc c bn chng chong phn v.

Adrenaline dung dch 1/1000, ng 1ml = 1mg,

Ngi ln: 0.5 1 ng tim di da.

Tr em: khng qu 0.3 ml (ng 1ml pha 9ml nc ct, tim di da 0.1ml/kg).

Hoc Adrenaline 0.01 mg/kg cho c ngi ln v tr em tim di da.

Tip tc tim di da adrenaline liu nh trn 10 15 pht/ ln cho n khi huyt

p tr li bnh thng.

m, nm u thp chn cao, theo di huyt p 10 15 pht/ln, nm nghing

nu c nn i.

Nu chong qu nng e da t vong, ngoi ng tim di da c th tim

adrenaline dung dch 1/10.000 (pha long 1/10) qua tnh mch, bm qua ng ni

kh qun hoc qua mng nhn gip.

2/ Cc x tr khc: - Suy h hp: ty mc kh th c th s dng cc bin php sau:

Th oxy mi thi ngt.

Bp bng ambu c oxy.

t ni kh qun, thng kh nhn to. M kh qun nu ph thanh mn.

- Thit lp ng truyn tnh mch adrenaline duy tr huyt p, liu 0.1 mcg/kg/pht,

iu chnh liu theo huyt p.

- Cc thuc khc:


19

Hydrocortisone 5mg/kg/gi TMC. Dng liu cao hn nu chong nng.

Natri chlorua 0.9% truyn tnh mch 1 2 lt ngi ln, tr em khng qu

20ml/kg.

Diphenhydramine 1 2 mg tim bp hay tim mch.

- iu tr phi hp:

Ung than hot 1g/kg nu d nguyn qua ng tiu ha.

Bng p chi pha trn cho tim hoc ng vo ca nc c.

- Ch : iu dng c th s dng adrenaline tim di da theo phc khi bc s

khng c mt.

IV/ THEO DI:

- Theo di sinh hiu, triu chng ci thin.

- Cn theo di bnh nhn t nht 24 gi sau khi huyt p n nh.

V/ CHUYN VIN: - Khi khng p ng vi iu tr nh trn.

- Cn chuyn vin an ton n bnh vin gn nht.

Ti liu tham kho: - Phc cp cu sc phn v - BV Bnh nhit i.

- Thng t 08/1999/TT-BYT ngy 04/05/1999 ca B Y t v hng dn x tr sc phn v.


20

BNH TIM THIU MU CC B

I/ I CNG: - Bnh tim thiu mu cc b l mt thut ng ch tnh trng mt cn bng cung cu oxy

cho c tim. N xy ra khi c hp >50% bt c nhnh mch vnh no.

- Phn loi:

- Cn au tht ngc n nh.

- Thiu mu c tim yn lng.

- Bnh c tim thiu mu cc b.

- Ri lon nhp do thiu mu c tim.

II/ CHN ON: - Cn au ngc kiu mch vnh. - in tm : bnh thng n 50%. - Siu m tim: kho st vng gim ng, phn sut tng mu. - Test gng sc, MSCT, MRI tim, chp mch vnh khi c ch nh.

III/ X TR: Mc tiu: ti lp cn bng cung cu oxy cho c tim. C th: 1/ Thay i li sng: ngng thuc l, trnh stress, gng sc. 2/ iu chnh cc yu t nguy c: i tho ng, ri lon chuyn ha m. 3/ iu tr bnh km theo: thiu mu, tng huyt p, hp kht van ng mch ch, cng gip, st. 4/ Thuc s dng: Khng kt tp tiu cu:

- Aspirin 81 300 mg/ngy.

- Clopidogren 75mg/ngy.

c ch beta:

- Atenolol 25 200 mg/ngy.

- Bisoprolol 2,5 10 mg/ngy.

c ch calci: nu c ch beta b chng ch nh.

- Verapamine 60 480 mg/ngy.

- Diltiazem 60 360 mg/ngy.

Nitrat:

- Dinitrat 5 40 mg, 2 ln/ngy.

- Mononitrat 30 120 mg/ngy.

Statin:

- Atorvastatine 10 20 mg/ngy.

Nu bnh nhn c suy tim, ri lon nhp: dng thm thuc tng ng.

5/ iu tr cn au tht ngc n nh: - Th oxy m 3-5 lt/pht.


21

- Nitromint xt : 1-2 nht di li hoc Nitrosol 5 10 mcg/kg/pht TTM, lp li khi cn

thit.

- t monitor theo di du hiu sinh tn, M.HA.

- Aspirin: Aspegic 100-300 mg ung.

- Statin: Atorvastatin 40 60 mg/ngy.

- Thm thuc c ch men chuyn cho bnh nhn c tng huyt p, bnh c tim, hay thuc

c ch th th angiotensin II bnh nhn tng huyt p, i tho ng.

IV/ TIU CHUN NHP VIN:

- Khi bnh nhn p ng km vi iu tr.

- Khi c biu hin ca hi chng vnh cp.

- Khi c biu hin suy tim.

V/ CHUYN VIN:

- Cn au tht ngc n nh: bnh nhn vn au hoc au hn.

- Chuyn vin khi tnh trng tm n nh.

- Chuyn vin an ton.

Ti liu tham kho: - Phc iu tr Bnh tim thiu mu cc b - Bnh vin Cp cu Trng Vng.


22

AU BNG CP

I/ I CNG: - au bng cp l nhng cn au bng t nh n d di, thng xy ra t ngt, c th

l biu hin ca nhiu bnh l ni hay ngoi khoa.

II/ CHN ON: 1/ Bnh s: - c im cn au: Khi pht: t t hay t ngt. V tr. Kiu au; tng cn, m , co tht. Hng lan: khu tr hay lan ta. Yu t gim au: sau khi i tiu, t th chng mng, sau nn i.

- Triu chng i km: Ton thn: st, mt mi. au u, nn i, tiu chy. Ho, th nhanh, au ngc. Tiu lt nhc, tiu gt, tiu kh, tiu mu. au khp.

2/ Tin cn: - Phu thut bng; gi dnh rut. - Chn thng bng. - Bnh ni khoa, tiu ng, hi chng thn h. - Ph khoa: kinh nguyt, huyt trng. - Thuc dng. - Tin cn au bng trc y. 3/ Lm sng:

- Tng trng: Du gim th tch, mt nc: chn thng bng, xon rut, vim phc mc Vng da: bnh l gan, tn huyt.

- Sinh hiu: St: gi nhim trng. Th nhanh: vim phi, toan chuyn ha. Huyt p thp: chn thng bng, xon rut, vim phc mc

- Khm bng: bng chng, nhu ng rut, v tr au, du hiu vim phc mc, thm trc trng.

- Khm tng qut cc c quan khc. 4/ Cn lm sng: - TPTTBM: Bch cu tng gi nhim trng, hng cu gim gi xut huyt. - Sinh ha:

Tng men gan, lipase, amylase gan gi vim gan, vim ti mt, vim ty. ng huyt tng gi nhim toan ceton. Ion , chc nng thn.


23

- TPT nc tiu. - X quang phi thng: vim phi, X quang bng khng sa son: du tc rut, thng tng

rng, d vt. - Siu m bng tng qut: vim rut tha, vim ty. Siu m bnh thng cng cha

loi tr c.

III/ IU TR: - iu tr theo nguyn nhn theo phc iu tr tng bnh. - Trnh dng thuc gim au v khng sinh khi cha loi tr nguyn nhn ngoi

khoa.

- C th chm m bng.

IV/ CHUYN VIN: - Khi khng xc nh c chn on. - Khi tnh trng bnh nng, din tin kh xc nh. - Chuyn vin an ton.

Ti liu tham kho: - Phc iu tr au bng cp tnh Bnh vin Nhi ng 2.


24

BLOCK NH THT 1

I/ I CNG:

Block nh tht l mt trong nhng loi ri lon dn truyn hay gp nht. Do tn thng thc th hay c nng ti nt nh tht hay thn b His hoc c hai nhnh phi v tri lm cho s dn truyn xung ng t tm nh xung tm tht b chm li hay ngng tr.

Blc nh tht 1: L hin tng dn truyn chm tr t tm nh xung tm tht, biu hin bng on PQ (PR) ko di trn in tm > 0,20 giy. Hin tng ny c th gp ngi bnh thng hoc trong mt s bnh l ca tim.

II/ CHN ON: Ph thuc vo mc nhp tim chm v s dung np ca tng bnh nhn.

1/ Triu chng c nng:

Block nh tht 1 c nhp tht chm t, bnh nhn c th khng c triu chng g c.

Nhng nu nhp tim chm nhiu th lng mu t tim n cc c quan, trong c no b gim st. Do , bnh nhn c th thy chong vng thong qua, mt thng bng v c khi b xu hay thm ch b ngt (Hi chng Adams Stokes). Khi xy ra cn ngt, th bnh nhn mt thc, tay chn co qup, si bt mp.

2/ Triu chng thc th:

Block nh tht 1 khng c triu chng thc th g c hiu 3/ Biu hin trn in tm : - Khong PQ (PR) > 0,20 giy. - Mi sng P u c mt phc b QRS i sau. - Khong PQ (PR) thng di t 0,20 n 0,40 giy. - i khi PR di ti 0,60 giy hoc hn lm n c th chng ln sng T ca tht trc.

III/ IU TR:

Block nh tht 1 thng khng cn iu tr g c hiu.

Thuc: Dng trong trng hp cp cu, c bit khi bnh nhn c ngt. Thuc thng ch c tc dng tm thi ch cy my to nhp hoc trong giai on cp ca mt s bnh ch khi hi phc.

Atropine: 0.25 mg 4 ng tim tnh mch chm, nu c tc dng (tn s tim tng) tip tc tim hoc truyn tnh mch.

Dopamine truyn tnh mch vi liu bt u 5mcg/kg/pht nhng bnh nhn c km huyt p thp.

Adrenaline truyn tnh mch liu 1 2 mcg/kg/pht nu bnh nhn trong tnh trng rt trm trng.

IV/ CHUYN VIN: - Block nh tht 1 c ri lon huyt ng. - C ch nh t my to nhp. - Chuyn vin an ton.

Ti liu tham kho: - Phc iu tr Block nh tht 1 Bnh vin Cp cu Trng Vng.


25

CN AU QUN THN

I /I CNG: - Cn au qun thn l hi chng au cp tnh vng lng v bng. - Do s tc nghn v s c xt gy phn ng co tht ng tiu trn, nht l niu qun,

lm thn cng chng cp tnh ko theo s dn p v bc thn. - C 75% - 80% lin quan ti si.

II/ CHN ON: 1/ Tnh cht cn au:

- Thng thng sau mt chuyn ng hay khng c nguyn nhn r rng v v ban m. - Cn au qun thn c th xut hin t ngt hay sau nhng cn au nh vng hng

lng. - au d di, khng c t th gim au hiu qu. - Ko di t vi pht n vi gi. - Lc u khu tr gc sn tht lng, sau lan ra trc vng h chu, vng bn. 2/ Triu chng i km: - Bun nn, nn, chng bng. - Tiu gt, tiu but, thiu niu hay v niu tm thi. 3/ Cn lm sng: - TPTTBM - Siu m bng tng qut. - X quang bng ng khng sa son. - Tng phn tch nc tiu. - Creatinine khi cn.

4/ Chn on phn bit: - Vim rut tha, vim ti mt, lot d dy t trng, thot v bn nght. - Bu bung trng xon, thai ngoi t cung. - T mu quanh thn, nhi mu thn, xon tinh hon, vim mo tinh hon.

III/ IU TR: 1/ Gim au:

- Khng vim khng steroid:

Mobic 15mg hoc Diclofenac 75mg tim bp 1 ln/ngy trong 2 ngy. - Morphine 0,1mg/kg mi 4 gi khi khng gim au vi khng vim khng steroid.

2/ iu tr khc: - Khng sinh:

Khi c du hiu nhim trng.

Chn loi khng sinh khng c cho thn.

iu chnh liu lng theo tui, thanh thi creatinine.

Dng khng sinh ung hoc tim tnh mch.

Thi gian iu tr: 7-14 ngy. Ngng khng sinh khi ht st 3-5 ngy, hoc th trng n nh.


26

- B dch khi c st, nn i. Hn ch truyn dch nhiu trong khi c cn au qun thn. - Chm m bng.

IV/ CHUYN VIN: - Khi iu tr nh trn khng hiu qu, sau khi hi chn. - C bin chng km theo: nhim trng, suy thn. - Chuyn vin an ton.

Ti liu tham kho: - Phc iu tr Cn au qun thn Bnh vin Cp cu Trng Vng.


27

CHONG NHIM TRNG

I/ I CNG: - Chong nhim trng l tnh trng nhim trng huyt c biu hin huyt p thp ko di

mc d c b dch y . - xc nh nguyn nhn cn tin hnh cy mu.

II/ CHN ON: 1/ Nhim trng huyt:

- St cao, lnh run - Mch nhanh. - Th nhanh. - Bch cu tng hoc gim.

2/ Triu chng chong: - Mch nhanh, huyt p tt (huyt p ti a 90%.

3/ Dch truyn: - Natri chloride 0.9% TTM 100 200 git/pht, duy tr huyt p tm thu >80 mmHg.

4/ Vn mch: - Nor adrenaline 0,2 10 mcg/kg/pht. - Hoc Dopamine 3 5 mcg/kg/pht trong 15 30 pht. Tng liu 10 15 mcg/kg/pht

khi cn.


28

- Dobutamine ti a 20 mcg/kg/pht truyn tnh mch khi c suy tim hoc khi huyt p cha nng ln c sau khi dng Nor adrenaline hay Dopamine nh trn.

5/ iu tr khc: - Hydrocortisone khi khng p ng vi dch truyn hay thuc vn mch, khng qu 300

mg/ngy.

- H tr h hp, an thn. - S dng insulin kim sot v gi ng mu mc di 150mg %.

IV/ CHUYN VIN: - Huyt ng tm n nh v cha tm c nguyn nhn. - Chuyn vin an ton n bnh vin gn nht.

Ti liu tham kho: - Phc iu tr Sc nhim trng Bnh vin Bnh nhit i.


29

T CP BNH PHI TC NGHN MN TNH

I/ I CNG:

t cp bnh phi tc nghn mn tnh l mt tnh hung xy ra trong din tin t nhin ca bnh., c trng bi s thay i cc triu chng c bn ca bnh nhn nh kh th, ho m khc vi din bin hng ngy, khi pht cp tnh v yu cu phi x l cp cu.

II/ CHN ON: 1/ Chn on COPD:

- Triu chng ho, khc m, kh th, ran rt, ran ngy phi. - Yu t nguy c: thuc l, ngh nghip, nhim mi trng. - H hp k: FEV1/FVC 90%. 2/ Dn ph qun: - Kt hp Beta 2 ng vn vi anticholinergics phun kh dung:

Salbutamol 2,5 5 mg pha nc ct 5ml, phun kh dung, hoc

Combivent 01 ng pha nc ct 5ml, phun kh dung. Lp li mi 20 30 pht. - Methylxanthin:

Aminophyline: 3 5 mg/kg truyn tnh mch 20 pht. Sau : 0,2 0,6 mg/kg/gi truyn tnh mch.


30

S dng khi Beta 2 ng vn vi anticholinergics phun kh dung khng hiu qu hoc c th phi hp c 2 loi thuc ngay t u.

3/ Corticoids:

Prednison 40 60 mg ung.

Hoc Methylprednisolone 40 120 mg TMC. 4/ Khng sinh:

Khi c du hiu nhim trng.

Chn loi khng sinh khng c cho thn.

iu chnh liu lng theo tui, thanh thi creatinine.

Dng khng sinh ung hoc tim tnh mch.

Thi gian iu tr: 7-14 ngy. Ngng khng sinh khi ht st 3-5 ngy, hoc th trng n nh.

Amox/Acid clavuclanic 625 1000mg/ 12 gi. Cefuroxim 500mg/ 12 gi. Ceftriaxone 1g TMC/ 12 gi.

5/ iu tr khc: - B dch in gii. - Ch dinh dng. - iu tr bnh l i km.

IV/ CHUYN VIN: - Khi c du hiu bnh nng. - Khi bnh nhn khng p ng vi iu tr nh trn. - Khi bnh nhn c ch nh th my. - Chuyn vin an ton.

Ti liu tham kho:

- Phc iu tr t cp bnh phi tc nghn mn tnh Bnh vin Cp cu Trng V


31

SC IN

I/I CNG:

My sc in c pht minh vo nm 1899, c th gip chuyn tnh trng rung tht v nhp xoang.

Sc in l phng php s dng nng lng in khi phc li nhp tim bnh thng. Phng php ny n gin v tc dng nhanh trong iu tr mt s trng hp ri lon nhp nhanh.

Phng thc: - Sc in khng ng b: my phng xung in ngay thi im nhn nt. Ch nh

trong rung tht. - Sc in ng b: my nhn bit c v tr sng R trn ECG trnh phng xung

in vo thi k nguy him (sng T). Ch nh trong cc ri lon nhp khc rung tht.

Cc loi my sc in: - My sc in cm tay. - My sc in bn ngoi t ng. - My sc in chuyn nhp cy di da t ng.

II/ CH NH: - Rung nh: Cn ti thiu l 100J. - Cung nh: T 10J n 50J. - Nhp nhanh trn tht: T 25J 100J. - Nhp nhanh tht: T 25J 50J. Nu bnh nhn mt mch hay tt huyt p: bt u t

200J, tng ln n 360J nu khng p ng. - Rung tht: T 200J, tng ln n 360J nu khng hiu qu.

III/ CHNG CH NH: - Ng c digitalis. - Cn nhp nhanh ngn, ti pht nhiu ln. - Nhp nhanh nh a . - Rung nh vi huyt ng n nh. - Block nh tht hon ton.

IV/ PHNG PHP TIN HNH: Trng hp khn cp: c th b qua nhng bc chun b nhanh chng loi b lon nhp

nguy him. Trng hp khng khn cp: - Gii thch cho bnh nhn. - Khm lm sng, xem xt thuc ang s dng. - t monitor theo di. - Bnh nhn c nm trn mt phng cng. - Diazepam ung. Th oxy qua bng ambu hay qua mt n.


32

- K thut: Kim tra trn monitor ghi nhn s ng b ca sng R. Chn in cc: ngi ln in cc c ng knh 8 10 cm, tr em in cc c

ng knh 5 cm. Bi gel in cc. t in cc: - in cc trc y tim, in cc bn mm tim.

- in cc trc y tim, in cc sau mm xng vai tri.

Tin hnh sc in. Mc nng lng in:

Lon nhp My 1 pha My 2 pha

Cung nh 50 (ng b) 30 (ng b)

Nhp nhanh kch pht trn tht 50 (ng b) 30 (ng b)

Rung nh 100 (ng b) 70 (ng b)

Nhp nhanh tht n dng 100 (ng b) 70 (ng b)

Nhp nhanh tht a dng v rung tht

360

(Khng ng b) 120 200 (Khng ng b)

Theo di st bnh nhn sau sc in.

Ti liu tham kho:

Phc iu tr Sc in Bnh vin Cp cu Trng Vng.


33

SUY GIP

I/ I CNG:

L tnh trng gim hot ngchc nng tuyn gip, lm gim sn xut hormone gip gy ra nhng tn thng m v ri lon chuyn ha.

II/ CHN ON: 1/ Lm sng:

C nhiu triu chng trn lm sng gi : - S lnh - Trm cm

- Tng cn - Gim tr nh

- Da kh - Ph nim

- Ph quanh hc mt - Xanh xao

- Ging ni thay i, khn ging - Bu gip

- Chm chp - Hi u

- Mt mi - au c

- To bn - Nhp tim chm

- Rong kinh - Phn x gn c gim

- V mt v cm - Ri lon chuyn ha m

2/ Cn lm sng: - Suy gip nguyn pht: TSH cao v FT4 thp.

- Suy gip th pht: TSH bnh thng/ thp v FT4 thp.

- Suy gip di lm sng: TSH cao v FT4 bnh thng.

III/ IU TR: 1/ Levothyroxine (T4), L-thyroxine, Thyroxine:

Bnh nhn thng thng:

- Liu khi u: 50 100 mcg/ngy ung 1 ln.

Tng 25 50 mcg mi 3 4 tun cho n khi TSH v bnh thng. - Liu duy tr: 100 200 mcg/ngy ung 1 ln.

Bnh nhn gi, bnh nhn c bnh mch vnh, suy gip lu ngy:

- Liu khi u: 25 50 mcg/ngy.

Tng liu 25 mcg mi 4 tun cho n khi TSH v bnh thng.

Hi chng Sheehan: nn cho hormone thng thn trc trnh suy thng thn cp

khi cho hormone gip.

Bnh nhn c thai: nn cho liu cao hn trnh bu gip thai nhi.

Suy gip di lm sng:

- Liu 25 50mcg/ngy

Tng liu n khi TSH v bnh thng.

Hn m suy gip:

- Liu u: 200 500 mcg tim mch.


34

- Liu duy tr: 100 200 mcg/ngy tim mch hoc qua sonde d dy cho n khi bnh

gip th i qua ung.

Ch :

Cch dng v theo di:

- Ung trc n sng 30 pht.

- Ung cch xa cc loi thuc khc.

- Bnh nhn gi: mc monitor theo di.

- o TSH v FT4 mi 4 tun.

Tc dng ph: khi dng qu liu gm c au ngc, nhp nhanh, hi hp, tiu chy, nn, au u, bun ng.

2/ Liothyronine (T3)

Bnh nhn thng thng:

- Liu khi u: 20 mcg/ngy ung 1 ln.

Tng liu n khi bnh gip hoc TSH v bnh thng.

- Liu duy tr: 60 100 mcg/ngy chia 2 3 ln.

Bnh nhn gi, bnh nhn c bnh mch vnh, suy gan lu ngy: khi u liu thp v

tng dn.

Hn m suy gip: 50 mcg TMC, sau 25 mcg mi 8 gi cho n khi ci thin, sau

25 mcg tim mch mi 12 gi.

Ch : theo di:

- Tng liu da trn p ng lm sng, th TSH, FT4 u n.

- Thn trng bnh nhn ln tui, c bnh mch vnh.

IV/ CHUYN VIN: - Khi iu tr nh trn khng hiu qu.

- Khi bnh nhn c nhiu bnh phi hp hoc c yu t nguy c (bnh nhn ln tui, c

bnh mch vnh)

Ti liu tham kho: - Phc iu tr Suy gip Bnh vin Nhn dn Gia nh.


35

TNG NATRI MU I/ I CNG:

- Khi Natri mu >145 mEq/lt.

- Thng l tai bin iu tr.

II/ CHN ON: - Lm sng:

au u, kch ng, ng g, co git , hn m, t vong.

Mc nng ph thuc vo mc v tc tng natri mu.

- Cn lm sng: Natri mu >145 mEq/lt.

III/ IU TR: 1/ Nguyn tc:

B nc, gim Natri mu 0,5-1 mEq/lt/gi v gim


36

TNG KALI MU I/ I CNG:

- Tng Kali mu khi Kali mu >5 mmol/lt.

- Hu qu nghim trng nht l c tnh trn tim, gy ri lon nhp tim. Khng c tng

quan cht ch gia nng Kali mu v mc ri lon nhp tim.

II/ NGUYN NHN:

- Gim bi tit Kali: thng gp nht nh suy thn, bnh Addison, suy Aldosteron, li tiu

gi Kali, dung thuc c ch men chuyn.

- Tng chuyn Kali ra ngoi bo: toan mu, dng thuc c ch Beta.

- Tng to Kali: tn huyt, truyn mu, bng, chn thng, ha tr liu.

- Tng lng Kali a vo c th: dch truyn, thc n.

III/ CHN ON: - Lm sng: co cng c, kch thch, tiu chy, nn i, h p t th.

- Cn lm sng: in tm c sng T cao, nhn, i xng, PR ko di, QRS dn rng,

ST chnh xung, ri lon nhp tht.

IV/ IU TR: 1/ iu tr triu chng: - n nh in th mng t bo: Calcium gluconate, Calci chlorua Truyn tnh mch hoc

tim tnh mch chm.

- a Kali vo t bo: dng dung dch bicarbonate , beta 2 agonist, Insuline+ Glucose.

- Loi b Kali: Kayaxalate, li tiu.

Liu Khi pht tc dng

Thi gian tc dng

Calcium

gluconate

10-20 ml IV trong 2-3 pht Tc thi 30 pht

Insuline 10-15 UI+100 ml Dex 30%

trong 5 pht

15-30 pht 2-6 gi

Ventoline 10-20 mg PKD trong 10 pht 15-30 pht 2-3 gi

Furosemide 20-40 mg IV 15-60 pht 4 gi

2/ iu tr nguyn nhn: suy thn, toan mu.

V/ CHUYN VIN: - Khi iu tr nh trn khng hiu qu.

- Bnh nhn c ch nh chy thn, lc mu.

- Chuyn vin an ton.

Ti liu tham kho:

- Phc iu tr ri lon Kali mu Bnh vin Nguyn Tri Phng.


37

H NATRI MU I/ I CNG:

- H Natri mu khi Natri mu < 135 mEq/lt.

- L ri lon in gii thng gp nht, nht l bnh nhn ln tui.

II/ CHN ON: 1/ Lm sng:

- au u, chn n, bun nn, nn, kch ng, ng g, co git, hn m, t vong.

- Mc nng ca triu chng ph thuc vo mc v tc h Natri.

2/ Cn lm sng: Natri mu < 135 mEq/lt.

III/ IU TR: 1/ Nguyn tc: - Nng Natri mu 0,5-1 mEq/lt/gi v < 8-12 mEq/lt/24 gi u. Mc tiu iu tr nhm

t nng Natri >125 mEq/lt.

- Dng dung dch Natri u tng trong trng hp nng.

2/ Cch b Natri:

- H Natri mu km tng th tch ngoi bo: dng li tiu, hn ch nc.

- H Natri mu km gim th tch ngoi bo: dng dung dch Natri chloride 0,9%, lng

dch b ty mc mt nc.

- H Natri mu km th tch ngoi bo bnh thng: hn ch nc, b Natri u trng 3%

trong trng hp nng.

- Cch b Natri: theo cng thc:

Natri tng khi truyn 1 lt dch = (Nng Natri/dch truyn Nng Natri/pl) (TBW +1)

3/ iu tr nguyn nhn.

IV/ CHUYN VIN: - Khi iu tr nh trn khng hiu qu.

- H Natri mu nng.

- Chuyn vin an ton.

Ti liu tham kho: - Phc iu tr ri lon Natri mu Bnh vin Nguyn Tri Phng.


38

H KALI MU

I/ I CNG: - H Kali mu khi Kali mu < 3 mEq/lt - Gim 1 mEq/lt: c th mt khong 200 400 mEq.

II/ NGUYN NHN:

- Gim cung cp; suy dinh dng, nghin ru, n king mt thng bng. - Di chuyn Kali vo t bo: kim mu, dng insulin, cathecholamin. - Mt Kali ngoi thn: i, tiu chy, d tiu ha. - Mt Kali ti thn: thuc li tiu, li tiu thm thu, cng Aldosterone, h Magie, toan

mu ng thn type 1. III/ CHN ON:

- Mi c, au c, yu c, lit c. - in tm : sng T dt hay o ngc, sng U cao, ST chnh xung, khong QT di,

QRS dn rng, lon nhp tht. IV/ IU TR:

H Kali qu nng Kali < 2 mmol/lt

Nhp khoa HSCC Theo di monitor lin tc. Tim TM 3040 mEq x 2 trong 2-4 gi v Ung 40 mEq (4 vin) x 2 mi 2 gi.

Xt nghim Kali mi 2 gi. Tip tc b cho n khi Kali >2,8 mEq/ lt.

Hi chn chuyn vin.

H Kali nng Kali 2-2,5

mmol/lt

Nhp khoa HSCC Theo di monitor lin tc. Tim TM 13-20 mEq x 2 trong

2-4 gi v Ung 20 meq (4 vin) x 2 mi 2 gi

Tip tc b cho n khi Kali >2,8 mEq/ lt.

Hi chn chuyn vin.

Ha Kali trung bnh

Kali 2,5-3

mmol/lt

Tim TM 10 mEq x 2 trong 2-4

gi v Ung 40 mEq(4 vin) x 2-3 ln/ngy

Xt nghim Kali sau 2 gi.

H Kali trung bnh Kali 3-3,5

mmol/lt

Tim TM 20-40 mEq hoc Ung 20 mEq(4 vin) x 2-3 ln/ngy

Xt nghim Kali sng hm sau

Kali 3,6-4

mmol/lt

Tim TM 20 mEq hoc Ung 20 mEq(4 vin) x 1-2 ln/ngy

Xt nghim Kali sng hm sau.


39

Hng dn dng Kali qua ng truyn tnh mch ngoi bin:(ti HSCC c monitor theo di) Ti HSCC c monitor theo di:

- Nng ti a: KCl 10 mEq/100 ml. - Tc truyn ti a: 10 mEq/gi. Ti khoa phng:

- Nng ti a: KCl 40 mEq/lt. - Tc truyn ti a: 60 mEq/gi.

V/ CHUYN VIN: - H Kali qu nng hoc nng, c bnh l i km. - Chuyn vin an ton.

Ti liu tham kho: Phc iu tr ri lon Kali mu Bnh vin Nguyn Tri Phng.


40

H CALCI MU

I/ I CNG: - H calci mu khi calci ton phn trong mu < 80mg/lt (hoc 2 mmol/lt), hoc calci ion

ha < 1 mmol/lt

II/ CHN ON: 1/ Hi bnh:

- Tin cn c h calci mu. - Co git khng c st, nn i. - Ngt, c hoc khng km theo mt thc. - Du kin b.

2/ Lm sng:

Thn kinh: - Tng kch thch, run c. - Co cng c (bn tay hoc bn chn nga). - Du hiu Chvostek, Trousseau. Lust,. Cc du hiu khc:

- Khng st. - Kh th thanh qun. - Suy tim khng r nguyn nhn. - Ri lon nhp tim. - Ci xng. - i khi khng c triu chng lm sng.

3/ Cn lm sng: - Xt nghim calci mu v magnesium mu khn. - Cc xt nghim tm nguyn nhn: ch tin hnh khi h calci mu nng hoc ti pht. - Phosphatase kim, creatinine mu - X quang c tay v h xng. Cn Tentani:

- Cn tetani xut hin do h canxi mu nng. - Biu hin: d cm u chi, mi, li, bn c chn, au c lan ta, co

cng c vng mt, tay, chn. - Du hiu Chvostek biu hin bng s co c mt t pht sau khi g nh vo dy thn kinh

mt v tr ngay trc ng tai. Du hiu ny gp trong hu ht cc trng hp h canxi mu cp.

- Du hiu Trousseau biu hin bng s co rt cc c vng c tay, bn tay xut hin khi gim lng mu cung cp cho bn tay, du hiu ny cn gp trong h magie, kim ha mu, h kali mu.


41

III/ IU TR: 1/ H calci mu nng (calci ion ha ton phn


42

CHT UI

I/ I CNG: - Cht ui l mt qu trnh tn hi h hp t khi nn nhn b ngp mnh trong nc.

l mt qu trnh lin tc, bt u t khi ng th nn nhn b ngp nc, nu khng a ra khi nc, nn nhn s t vong.

II/ CHN ON: Nhn bit: - T th thng ng. - Cnh tay m rng sang 2 bn. - Tay vy p di nc. - Tr em thng vy p 10 20 giy, ngi ln khong 60 giy trc khi chm xung

nc.

III/ X TR: 1/ Hi sc c bn di nc:

- Nm vt cu h cho nn nhn. - Tip cn v dng phao cu h, gi thng ng th.

2/ Hi sc c bn trn mt t: - Xc nh mc mt thc. - t nn nhn nm nga, u bng, xoay u sang 1 bn. - Nu ngng th: hi sinh c bn: h hi thi ngt v xoa bp tim ngoi lng ngc.

3/ Hi sc ti Bnh vin: a/ Grade 6: ngng tim phi

- Lm m nn nhn, chng gim thn nhit. - H hp: th oxy qua mt n vi lu lng 15 lt/pht. Nhanh chng t ni kh qun v

th my. - Tim mch: monitor theo di v x l cc ri lon nhp. Sc in khi c ch nh. S

dng Adrenaline. Lp ng truyn tnh mch. S dng dung dch Bicarbonate. b/ Grade 5: ngng h hp

- Lm m nn nhn, chng gim thn nhit. - Hi sinh nng cao nh Grade 6.

c/ Grade 4: ph phi cp km gim huyt p - Th mt n c ni oxy 15 lt/pht. Nhanh chng t ni kh qun v th my.

d/ Grade 3: ph phi cp khng tt huyt p - Th oxy qua mt n vi lu lng 15 lt/pht duy tr v nng SpO2.

e/ Grade 2: phi c ran vi ch khi nghe phi - Th oxy qua sonde mi 3 5 lt/pht.

f/ Grade 1: Bnh nhn ho, khm phi bnh thng - Khng cn th oxy. - Theo di v cho xut vin.


43

IV/ CHUYN VIN: - T Grade 4 n grade 6. - Chuyn vin an ton.

Ti liu tham kho: Phc iu tr Cht ui Bnh vin Cp cu Trng Vng.


44

IN GIT

I/ I CNG: - Tai nn in git gy ra nhiu hu qu ton thn v ti ch trn c th, trc mt v lu

di.

- Cp cu in git cn nm vng cc k nng cp cu ni khoa. Tn thng do in git c nhiu dng khc nhau, cn chn on v iu tr ph hp.

- Nhng tn thng do in git: tn thng do in nng, tn thng do dng in i qua, tn thng do n.

- X tr cn nm 2 phng chm: + Hi sinh c bn ti ni in git. + Hi sinh nng cao ti bnh vin.

II/ CHN ON: 1/ Khi b in git: Ton b c ca bnh nhn b co git mnh gy ra 2 tnh hung: - Nn nhn b bn cch xa vi mt, c th km theo chn thng. - Nn nhn nh b dnh cht vo vo ni b truyn in, cn phng bnh nhn ng ra,

gy chn thng thm khi ngt in. 2/ Tai bin tc thi: - Ngng tim ngng th. - Bng do dng in. Vt bng khng au, c ranh gii r, i khi su kh nh gi. - Gy xng, cn ch ct sng v xng sn. 3/ Tai bin mun: - Chong gim th tch. - Ph tng p lc ni s. - Suy thn cp. - Tim: ngoi tm thu nh v tht, lon nhp hon ton, cn au tht ngc. - Thn kinh: lit na ngi, hi chng ngoi thp, bnh thn kinh ngoi bin.

III/ IU TR: 1/ Nguyn tc: - iu tr triu chng - Can thip nhanh khng qu 3 pht. 2/ Cc bc tin hnh: - Cp cu dao in, a nn nhn ra khi dng in. - Hi sinh tim phi: hi sinh c bn: h hp ming ming v xoa bp tim ngoi lng ngc. - Ti Bnh vin: hi sinh nng cao: Mt n c oxy vi bng ambu 15 lt/pht, a SpO2>90%. Xoa bp tim ngoi lng ngc khi c ngng tim ngng th. Sc in nu c rung tht. Chng toan chuyn ha bng dung dch Natribicarbonate truyn tnh mch.

S dng Adrenaline khi c ch nh theo phc x tr ngng tim ngng th.


45

B dch Natri chloride 0.9% TTM 100 200 git/pht. Chng suy thn cp bng Furosemide 20mg 2 - 4 ng TMC. Theo di monitor n khi chuyn vin. o in tm . Tm v x l cc tn thng khc: bng, gy xng, tn thng c quan ni tng.

IV/ CHUYN VIN: - Chuyn vin khi tnh trng bnh nhn tm n nh. - Chuyn vin an ton.

Ti liu tham kho: Phc iu tr in git Bnh vin Cp cu Trng Vng.


46

NHI MU C TIM C ST CHNH LN I.I CNG

- Nhi mu c tim c ST chnh ln (STEMI) thng do huyt khi gy tc ng mch vnh thng mc: V hoc bo mn v x si ca mng x va d b tn thng c th dn n hot

ha tiu cu, hnh thnh thrombin, v to huyt khi, dn n tc mch mu v thiu mu cc b c tim/ nhi mu c tim. Bng chng huyt khi ng mch vnh trn hnh nh chp ng mch vnh hin din > 90% bnh nhn nhi mu c tim c ST chnh ln.

Do tnh cht t ngt v tc ca huyt khi ng mch vnh bnh nhn nhi mu c tim c ST chnh ln, hoi t c tim thng khng gii hn lp ni mc m cn lan rng xuyn thnh tht.

II. CHN ON 1. LM SNG

- in hnh: bnh nhn STEMI thng nhp vin vi biu hin cn au tht ngc lc ngh ngi.

- Khng in hnh: kh th, v m hi, bun nn v chng mt c th xy ra trng hp khng c au ngc, c bit l ph n, bnh nhn i tho ng v ngi gi.

- Cung lng thp: nhi mu mt phn ng k tht tri c th dn n cung lng tim thp (h huyt p, nhanh xoang, v m hi, da lnh, suy gim nhn thc) v gia tng p lc y [p lc tnh mch cnh tng, ran phi].

- Lon nhp: nhp nhanh tht v rung tht. - Nhi mu tht phi [tc ng mch vnh phi]:

+ Lon nhp: nhp chm xoang v / hoc block nh tht. + Suy tht phi: nhi mu tht phi lin quan n tc on gn ng mch vnh phi c th biu hin bng tt huyt p .

2. CN LM SNG - Xt nghim c bn: TPTTBM, glucose, creatinin, ion - Xt nghim du n sinh hc: CK-MB, Troponin I - in tm

ST chnh ln > 1 mm (0,1 mV) t nht hai chuyn o tip gip Block nhnh tri mi (LBBB) trong bi cnh lm sng nghi ng cao

Phn vng trn in tm : + Trc rng: V1 - V6 + Trc vch: V1 - V3 + Thnh bn: V4 - V6, I, aVL

+ Thnh di: II, III, aVF + Thnh sau: V7 - V9, sng R cao v ST chnh xung V1 - V2 + Tht phi: V4R, V5R, V6R

- Chn on phn bit v vn ST chnh ln trn in tm : + Vim mng ngoi tim cp + Ti cc sm + Ph i tm tht tri + Bnh c tim ph i


47

+ Hi chng Wolff - Parkinson - White + Hi chng Brugada + Hi chng Tako - Tsubo (bnh c tim do stress)

+ Co tht mch vnh cng c th dn n ST chnh ln, mc d thay i trn in tm thng thong qua. + Bc tch ng mch ch cng vi che lp ng mch vnh c th dn n ST chnh ln

III. IU TR Thi gian l vng - Nguyn tc c bn trong iu tr STEMI l chn on v iu tr ti ti mu kp thi.

Ti thng mch mu nhanh chng lin quan vi ci thin kt cc ngn hn v di hn. - Mc tiu: tng thi gian thiu mu cc b tnh t khi khi pht triu chng: 120 pht. X tr: 1. Bnh nhn nm ngh, gii thch cho bnh nhn trnh lo lng 2. Th Oxy 2 5l/pht qua mi, 0xy 6l/pht khi bo ha oxy


48

AU THT NGC N NH

I.I CNG - au tht ngc n nh l hi chng lm sng c trng bi kh chu ngc, quai hm,

vai, cnh tay, hoc lng, thng khi pht khi gng sc v ci thin khi ngh ngi hoc ngm di li Nitroglycerin (NTG). au tht ngc n nh l hu qu ca tc nghn ng mch vnh. Chin lc iu tr hin nay tp trung vo iu tr ni khoa ci thin sng cn v ngn nga nhi mu c tim, v iu tr ni khoa km hoc khng km ti thng ng mch vnh nhm iu tr triu chng au tht ngc.

- Nguyn nhn: Thiu mu cc b vng c tim, thng do mng x va gy tc nghn mt hoc nhiu nhnh ng mch vnh thng mc. t gp hn l do bnh c tim ph i, hp ng mch ch, co mch, vim ng mch vnh, cu c, ma ty, ng mch vnh xut pht bt thng (ln n 6,6%) hoc cc bnh l him gp khc. Do gia tng nhu cu oxy c tim ("au tht ngc do tng cu") hoc gim cung cp oxy thong qua ("au tht ngc do gim cung").

II.CHN ON

1. Bnh s: - Cc yu t nguy c gy bnh ng mch vnh (tui, thuc l, tng cholesterol mu, i

tho ng, tng huyt p, tin s gia nh b bnh mch vnh sm, tai bin mch mu no hoc bnh ng mch ngoi bin)

- Da vo c im bnh s c th phn loi nh sau: au tht ngc in hnh:

+ Kh chu c c im ph hp tnh cht v thi gian (Bng 1) + Khi pht khi gng sc hoc do cm xc + Gim khi ngh ngi hoc NTG

au tht ngc khng in hnh: + Kh chu khng p ng tiu chun ca au tht ngc in hnh

Khng do tim: + Bao gm co tht thc qun, bnh l lng ngc v phi

au tht ngc khng n nh Bng 1: Triu chng au tht ngc

in hnh Khng in hnh, khng do tim

Kh chu m t nh bp cht, tht nght, nng trc ngc Hng lan ra vai, c, hm, mt trong cnh tay (thng bn tri), hoc vng thng v (t gp) Khi pht c th tin on c, thng lin quan vi gng sc, xy ra vo bui sng, sau ba n giu carbohydrate, lnh Ko di 3-15 pht

Gim khi ngh ngi hoc NTG

Kh chu m t kiu mng phi, au but, kim chch, dao m, mch p, nght th Lin quan n thnh ngc; c v tr, s nn au; hng lan thay i Khi pht ngu nhin

Ko di vi giy, vi gi, hoc c ngy. p ng vi NTG thay i


49

2. Khm lm sng: Ting T3, T4 (do tht tri suy, cng v ph i thnh tht tri), hoc c mng tim (do vim mng ngoi tim)

H van hai l hoc ting thi tm thu mm tim (h van 2 l c th l do thiu mu cc b c nh)

Ting T2 tch i nghch thng (bng chng ca block nhnh tri) Ran phi (suy tim do bnh l mch vnh) Bng chng bnh l mch mu (m thi ng mch cnh, phnh ng mch ch bng) au khi s n thnh ngc (au ngc khng do tim)

3. Cn lm sng: TPTTBM, creatinin, ng huyt lc i, ion Xem xt CRP, BNP, Troponin. ECG lc ngh (bnh thng > 50%): C th o trong ln thm khm u tin v bt k khi c cn au tht ngc Theo di in tm lin tc nu nghi ng au tht ngc do co tht mch vnh

Chp X quang ngc thng: Khi nghi ng suy tim, bnh van tim, bnh mng ngoi tim Khi nghi ng bnh phi.

Siu m tim:

Nu nghi ng do bnh l van tim hoc ri lon chc nng tm tht tri. nh gi bt thng vn ng vng.

III.IU TR 1. Ci thin tin lng:

- iu tr ni khoa: + Thuc chng kt tp tiu cu: Aspirin (ASA) 75-325 mg l chn la u tay, Clopidogrel (liu np 300 600 mg sau 75 mg/ngy) nu ASA khng dung np. iu tr khng tiu cu kp c th hu ch i vi phng nga th pht (trnh s dng COX-2, nu cn s dng NSAID) + Statin cho tt c cc bnh nhn bnh ng mch vnh vi mc tiu LDL


50

+ Nitrat tc dng ko di (30 240 mg/ ngy) + c ch beta (ngoi tr au tht ngc do co tht) + c ch canxi + Trimetazidine, Ranolazine.

+ C th phi hp nhiu loi thuc khc nhau.

IV. CHUYN VIN - Khi c ch nh ti thng mch mu. Cc trng hp ch nh Ti thng mch mu:

+ Hp ng mch vnh tri chnh c ngha + Bnh 3 nhnh ng mch vnh v c mt trong nhng iu sau y: bng chng khch quan vng thiu mu cc b ln, ri lon chc nng tht tri, hp nng on gn ng mch lin tht trc

TI LIU THAM KHO - Hng dn chn on v iu tr bnh ni tr nm 2013 Bnh vin cp cu Trng

Vng.


51

CN AU THT NGC KHNG N NH V NHI MU C TIM KHNG ST CHNH LN

I. I CNG - Hi chng mch vnh cp bao gm tt c cc biu hin lm sng ph hp vi thiu mu

cc b c tim. au tht ngc khng n nh / nhi mu c tim khng ST chnh (CTNKO / NSTEMI) bao gm nhm con nguy c cao ca nhm hi chng mch vnh cp, vi thiu mu cc b c tim ang xy ra. CTNKO: triu chng thiu mu cc b c tim mi xy ra hoc din bin xu i, c hoc khng c thay i in tm (ECG) nhng men tim khng tng. NSTEMI: men tim tng (troponin hoc CK - MB), triu chng thiu mu cc b, thay i in tm (hai trong ba tiu chun ca WHO v nhi mu c tim).

- Nguyn nhn: Huyt khi ng mch vnh khng gy tc (hoc tc tng lc) v /hoc v mng x va Thuyn tc ng mch vnh Tc nghn ng hc ng mch vnh (co tht, tng nhu cu trn nn hp c nh) Bc tch ng mch vnh (VD hi chng mch vnh cp xy ra giai on chu sinh) Mng x va ng mch gy hp nng nhng khng c huyt khi

CTNKO th pht (cc bnh l lm gia tng nhu cu): + Cng gip + Hemoglobin (thp) + Tng huyt p + Nhit cao + Bnh c tim ph i II. CHN ON (Bng 1) 1 . Lm sng

- au tht ngc lc ngh ngi - au tht ngc khi gng sc (CCS III) mi xy ra (< 2 thng) - Gia tng au tht ngc khi gng sc (cng , thi gian, v/hoc tn s) - Bnh s:

Tnh cht ca triu chng: + in hnh: au ngc, lan ti hm, c, cnh tay, vai, lng, vng thng v, kh th khng r nguyn nhn, au ko di trn 20 pht

+ Khng in hnh cho thiu mu cc b c tim + Mng phi, khu tr bng, khu tr u ngn tay, au khi s nn, thi gian ngn (giy), lan ra nhiu chi + Nam gii (pertest bnh ng mch vnh cao) Tin cn NMCT hoc tc nghn ng mch vnh c chn on Hin din ca cc yu t nguy c bnh ng mch vnh khc [thuc l, tng huyt p, ri lon lipid mu, i tho ng, bnh ng mch ngoi bin]

- Khm thc th: Loi tr cc nguyn nhn au ngc khng do tim (v d nh trn kh mng phi, c xng khp,lin quan ti h tiu ha)


52

Du hiu suy tim (ran, p lc tnh mch cnh tng, T3, ph) H van hai l mi xy ra hoc xu i (c th l do thiu mu cc b c nh)

Nu xut hin m thi tm trng mi, xem xt chn on thay th bc tch ng mch ch

2. Cn lm sng:

- ECG: ST chnh xung 0,5 mV thong qua xy ra khi au khng lin quan ti gng sc Sng T o ngc, c bit > 2 mV ST chnh ln thong qua

ECG bnh thng khng qui kt nguy c thp thp (CTNKO 4%, NSTEMI 1-6%)

Nu khng chn on c, in tm hng lot gip gia tng nhy (15 - 30 pht): Xem xt chuyn o V7 - V9 in tm khng chn on c xc nh ST chnh ln do tc nhnh m

Bng 1 Kh nng c biu hin ca hi chng mch vnh cp (bt k du hiu no di y) c im KH NNG CAO KH NNG TRUNG

BNH

KH NNG THP

Bnh s v tin s

-C au hoc kh chu ngc hoc tay tri l triu chng chnh trc khi c au thc ngc c xc nh. -C tin s bnh MV bao gm c NMCT

-C au hoc kh chu ngc hoc tay tri l triu chng chnh. -Tui trn 70. -Nam.

-i tho ng.

- c triu chng thiu mu c tim cc b m khng c c im nh nhm kh nng trung bnh.

-Mi dng cocaine gn y.

Khm lm

sng

H 2 l thong qua, h p, v m hi, ph phi cp hoc c ran phi.

Bnh mch mu ngoi tim. Cm gic kh chu ngc nh hi hp nh trng ngc.

ECG Thay i on ST thong qua, mi ( 0,05 mV ) hoc sng T o chiu ( 0,2 mV) cng vi triu chng lm sng.

Sng Q c nh. ST hoc T bt thng nhng khng phi l mi.

T dt hoc o chiu chuyn o c song R cao. ECG bnh thng.

Cc men

tim

Tng men: TnI, TnT, CKMB

Bnh thng Bnh thng

- Sinh ha: Troponin (Tn) nhy cm v c hiu hn CK - MB o cch nhau 6-8 gi 2 - 3 ln

La chn thay th c th bao gm delta CK - MB v Tn thi im 0 v 2 gi hoc myoglobin + CK - MB / Tn thi im 0 v 90 pht

- Cc xt nghim khc: + TPTTBM, ng huyt, creatinin (suy thn tin lng xu hn), ion , BNP + Chp X quang phi nu c ph phi hoc huyt ng khng n nh + Bilan lipid mu.


53

III. IU TR X tr :

1. Bnh nhn nm ngh, gii thch cho bnh nhn trnh lo lng 2. Th Oxy 2 5l/pht qua mi, 0xy 6l/p khi bo ha oxy


54

HEN PH QUN CP NGI LN

I. I CNG - Hen ph qun l mt bnh vim mn tnh ng th dn n tng phn ng v tc nghn

ng th, th hin bng cc t kh kh, ho, kh th lp i lp li. - Qu trnh vim ny do nhiu lai t bo v thnh phn t bo tham gia. - Tc nghn ng th lan ta, bin i theo thi gian v thng hi phc. - Yu t nguy c v con ngi (lm cho c nhn d b hen ph qun hay bo v h khng

b hen): di truyn, c a, tng p ng ng th, phi, bo ph. - Yu t nguy c v mi trng (nh hng trn bnh nhn c sn c a, gy nhng t

kch pht hen, c th lm cho triu chng ko di): cc di nguyn, cht nhy cm trong ngh nghip, khi thuc l, nhim mi trng, nhim trng h hp, thay i thi tit, ..

II. CHN ON 1. Phn cn hen:

Thng s Nh Trung bnh Nng Da ngng th

Kh th Khi i, c th

lc nm Lc ni, khi ngi Khi ngh

Ni Trn cu Cn ngn Tng ting

Tinh thn C th bt rt Thng bt rt Thng bt rt L hay bun

ng

Nhp th Tng Tng Thng >30

l/p

Co ko c h hp

ph Khng C Thng c

C ng ngc

bng nghch

thng

Kh kh Va, cui k

th ra Ln Thng ln Khng nghe

Mch < 100 100 120 >120 Chm

PaO2 Bnh thng >60 mmHg


55

2. Lm sng - Triu chng thay i v m hay sng sm, ho, kh kh,kh th. - C tin s d ng, vim mi. - C tin s gia nh. - TC thc th: ran rt, ran ngy, tng thi gian th ra, cng phnh lng ngc.

3. Cn lm sng - o d bo ha oxy qua da (SpO2). - Ion . - CTMTP : dnh gi c nhim trng (BC tng,BCNTT tng) - o din tm : nh gi tnh trng tim mch, ch dnh cho nhng bnh nhn > 60 tui

hay nghi c bnh mch vnh. - Chup Xquang phi thng: khng cn thit, ngoi tr:

Khi chn on lm sng khng chc chn.

Khi c triu chng khng gii thch l do hen.

Nghi ng c bin chng : xp phi, trn kh mng phi.

Khi tht bi vi iu tr.

V. IU TR X tr ban u: 1.Ht 2 ng vn tc dng nhanh: thng bng my phun kh dung, 1 liu mi 20 pht trong 1 gi - t cp nh: Albuterol 4-8 puffs MDI hoc 2,5-5mg phun kh dung

- t cp nng: 2 ng vn v anticholinergic liu cao: Ipratropium bromide 4-6 puffs MDI hoc 0,5mg (2ml) phun kh dung

2.Th Oxy duy tr SaO2 90% 3.Dng Corticoid ton thn: nu khng thy p ng ngay hay bnh nhn thng xuyn dng Corticoid hoc cn nng trm trng: - Corticoid ung: Prednisone 40-80mg/ngy - Corticoid tnh mch: Methylprednisolone 120-180mg/ngy chia 3-4 ln

4.Cp cu h hp, tun hon, thng kh h tr: nu bnh nhn suy h hp. iu tr khc: - Khng sinh: ung hay tnh mch: khi c du hiu nhim trng - Cn bng nc, in gii, dinh dng, ...

Pht hin v iu tr bnh l i km

nh gi ban u

Bnh s, khm lm sng(nghe phi, co ko c h hp, nhp tim, nhp th, SpO2).

iu tr ban u *Th oxygen t SpO2 90% *Ch vn B2 tc dng ngn ng kh dung lin tc trong 1 gi (Ventolin


56

Nebules,Bricanyl).

*Glucocorticosteroids ton thn (nu khng c p ng tc th hoc gn y BN ung hoc ang c cn nng). *Chng ch nh s dng thuc an thn trong iu tr cn HPQ cp.

nh gi li sau 1 gi

Khm, LS, SpO2 v cc xt nghim khc nu cn thit.

Tiu chun cn nng *Bnh s nguy c cao hen nng. *Khm LS : triu chng nng kh ngh, co keo lng ngc. *Khng ci thin sau iu tr ban u. iu tr: *Oxygen.

*Ch vn 2 v khng cholinergic (Berodual, Combivent) dng ht hng gi hoc lin tc. *Glucocorticosteroids ng ton thn.

nh gi li sau 1 2 gi

Tiu chun cn va Khm LS : triu chng va.

iu tr: *Oxygen.

*Ch vn 2 v khng cholinergic (Berodual, Combivent) mi 60 pht. *Glucocorticosteroids ng ung. *Tip tc iu tr 1 3 gi khi c ci thin.

p ng tt trong 1 -2 gi -p ng ko di 60 sau ln iu tr cui. -Khm LS bnh thngkhng SHH

-SpO2 > 90%.

Khng p ng trong 1- 2

gi -C yu t nguy c cao hen nng. LS : triu chng nng, ng g, l ln.

p ng khng hon ton trong 1

2 gi -C yu t nguy c cao hen nng. -Khm LS : triu chng t nh n trung bnh.

-SpO2 khng ci thin.

Chuyn vin

C p ng: xut vin

iu tr nh: *Tip tc ht 2 ch vn. *Cn nhc cho Glucocorticosteroids

ng ung. *Cn nhc cho thuc hit dng phi hp (Berodual). *Gio dc bnh nhn: -Dng thuc ng. -Tip tc theo di st ti nh


57

VI. NH GI LI

- p ng km chuyn vin - p ng khng hon ton: xem xt chuyn vin nu khng ci thin 6-12gi

VII. CHUYN VIN - Cn hen ph qun cp trung bnh hoc nng khng p ng iu tr ban u. - Phi m bo an ton chuyn vin.

TI LIU THAM KHO - Hng dn chn on v iu tr bnh ni tr nm 2013 Bnh vin cp cu Trng

Vng.


58

NHI MU NO I. i cng: - Nhi mu no l tnh trng tn thng 1 vng ca no xy ra khi 1 mch mu b tc do

huyt khi hay b lp mch do tim. Khu vc no do ng mch d cp mu b thiu mu v hoi t.

- Nhi mu no c c im l s khi pht cp tnh cc du hiu thn kinh khu tr tng ng vi tn thng tc nghn ca M chi phi 1 vng no.

- K thut CT Scan gip chn on phn bit gia nhi mu no v chy mu no giai on cp.

- Cn phn bit cn thiu mu no thong qua (TIA) khi cc triu chng thn kinh thoi lui trong 1,3 tun l.

II. Chn on: 1. Chn on lm sng:

- Khi pht t ngt, c th nhc u lc khi pht - Yu hay lit na ngi, gim phn x gn c, c du Babinski - Lit mt trung ng - Mt ngn ng nu lit bn phi - Tn thng thn no: chng mt, mt thng bng, lit vn nhn - thc c th gim nu nhi mu no din rng, hai bn cu hoc thn no Hnh nh hc: Hnh nh gim m ph hp lm sng trn CT Scanner hoc MRI, loi tr xut huyt no, loi tr tn thng c tng ng trn lm sng 2. Chn on nguyn nhn:

- X va cc mch mu ln v trung bnh: Tng lipid mu, tng huyt p, tiu ng, tng homocystein mu, x tr. Bc tch ng mch, lon sn si c, bnh moyamoya, sarcoidois, vim mch do nm v lao, vim mch do varicella zoster, hi chng vim mch h thng, vim mch h thn kinh trung ng cng bn.

- Bnh mch mu nh: Lipohyalinosis, x va ng mch, nhim trng (giang mai, lao, cryptococcus), vim mch.

- Thuyn tc t tim: Tng huyt p, bnh c tim, rung nh, bnh van tim, huyt khi nh tri, huyt khi thnh tht sau nhi mu c tim, vim ni tm mc nhim trng, khng do vi trng (ung th, hi chng antiphospholipid), u nhy nh tri.

- Tnh trng tng ng: Thuc nga thai, thai k v hu sn, hi chng antiphospholipid, bnh hng cu lim, ung th, a hng cu thc s, TTP, DIC, tng ng di truyn.

- Do thuc: Cht gy co mch, vim mch, lon nhp tim, vim ni tm mc, phnh mch dng nm, tim truyn cc cht gy nhim hoc to huyt khi.

- CADASIL (bnh mch mu no di truyn tri nhim sc th) thng vi nhi mu di v v bnh no cht trng, bnh Fabry, hi chng Sneddon, MELAS (bnh no ty th vi nhim acid lactic mu v t qu tng t).

3. Chn on phn bit: Cc dng bnh mch mu no khc: - Xut huyt no, xut huyt di nhn, huyt khi tnh mch ni s. - Lit sau cn ng kinh (lit Todd) - Lit trong migraine - H ng huyt - Khi chon ch ni s


59

- Ri lon chuyn dng. III. iu tr: 1. Nguyn tc iu tr: - Ti thng mch mu phc hi ti mu no - m bo ti mu no hn ch lan rng tn thng - Chng bin chng, chng ti pht sm - Phc hi chc nng v phng nga ti pht

2. X tr ban u: Lng gi mc trm trng ca nhi mu no da trn lm sng. - X tr THA c bin chng t qu trong giai on cp : *t qu cp: khi pht trong vng 72 gi: iu tr THA nng (>220/120 mmHg): h khong 15-25% trong 24 gi u v h p dn dn sau . Trnh h p qu mc v c th lm nng thm tnh trng thiu mu. *Huyt p tm thu 185 220 mmHg hay huyt p tm trng 105 120 mmHg (trong 2 ln o cch nhau 60 pht), iu tr cp cu tng huyt p nn hon li tr khi c du hiu suy tim tri, phnh bc tch M ch hay thiu mu c tim cp. * giai on cp ca TBMMN, khi HA tm thu


60

- Khng sinh: Da vo khng sinh , khi cha c kt qu khng sinh -> iu tr khng sinh theo kinh nghim. Cc khng sinh:

-

+ Betalactam /c ch Betalactamase:Ampicilline/Sulbactam (Trifamox 1.5g), 3 l/ngy. Cefoperazone/sulbactam (Cefosul 3-6g/ngy)

+ Quinolones: Lefloinfusion 750mg-1000mg/ngy

-

- Khng kt tp tiu cu: Aspirin 160mg-325mg/ngy, Clopidogrel 75mg/ngy + Statin iu chnh lipid mu v bo v thnh mch: Atorvastatin (Ator 10mg), Rosuvastatin (Rosvas 10mg)

+ iu tr d phng lot ng xut ng tiu ha: Omezprazone 20mg, Pantoprazone 40mg

+ iu chnh li sng, iu chnh cc yu t nguy c, c bit l tng huyt p v i tho ng.

IV. CHUYN VIN: - Khi c ch nh dng thuc tiu si huyt trong vng 3- 4 gi sau khi pht. m bo

chuyn vin sm cng sm cng tt (thi gian vng


61

XUT HUYT NO

I.I CNG - Xut huyt no (XHN) l tnh trng chy mu vo trong nhu m no hoc no tht do v

ng mch, tnh mch hoc cu trc mch mu khc. Cn phn bit XHN tin pht (v mch mu) v nhi mu no (NMN) chuyn dng xut huyt (bt u t tc nghn mch mu) v nguyn nhn v iu tr hon ton khc nhau.

- Cn chp CT. SCAN chn on phn bit gia chy mu no v nhi mu no giai on cp. Nguyn nhn thng gp l THA. Cc nguyn nhn t gp khc l: chn thng s no, liu php khng ng, phnh ng mch no, u no

II.CHN ON 1. Chn on lm sng

- Bnh cnh lm sng hng t qu no. - Biu hin lm sng cp tnh vi du hiu thn kinh khu tr gi kch thc v v tr

chy mu no, nhc u, i ma, ri lon thc do chy mu lan rng v c tng p lc ni s.

- Hi bnh s v khm; tm cc du hiu chn thng. nh gi GCS v phn x thn no (nu hn m) hoc im NIHSS nu BN cn tnh. Kim tra huyt p, bo ha oxy, tnh trng thng kh.

2. Chn on nguyn nhn:Tng huyt p l nguyn nhn thng gp nht: - Thng ngi ln tui (>65), v tr XHN gi do tng huyt p (hch nn, i th, cu

no, tiu no, thy), hoc nhiu XHN v no. - Do thuc (heparin hoc coumadin; Cocaine). - Do d dng mch mu no (phnh mch, d dng tnh mch, cavernous angioma). - Do huyt khi tnh mch no. - U no. - Chn thng u. - Cc bnh l ng cm mu.

III.IU TR 1. Nguyn tc diu tr

- Hn ch lan rng tn thng. - m bo ti mu no. - Phng nga bin chng. - Phc hi chc nng. - Phng nga ti pht. - Kim sot sm huyt p: HA tm thu < 160mmHg BN khng c TANLS/lm sng v

HA tm thu < 180mmHg nu nghi ng c TANLS/lm sng. 2. X tr cp cu ban u trc khi chuyn vin

- t bnh nhn ni yn tnh. - Theo di tnh trng lm sng thn kinh (Theo thang dim GLASGOW) - Nm u 300. - Truyn dch NaCl 0,9% duy tr khi lng tun hon n nh ( hay Hct >38% v < 42

%).

- X tr THA c bin chng t qu trong giai on cp :


62

*t qu cp: khi pht trong vng 72 gi: iu tr THA nng (>220/120 mmHg): h khong 15-25% trong 24 gi u v h p dn dn sau . Trnh h p qu mc v c th lm nng thm tnh trng thiu mu. *Huyt p tm thu 185 220 mmHg hay huyt p tm trng 105 120 mmHg (trong 2 ln o cch nhau 60 pht), iu tr cp cu tng huyt p nn hon li tr khi c du hiu suy tim tri, phnh bc tch M ch hay thiu mu c tim cp. * giai on cp ca TBMMN, khi HA tm thu


63

NHP NHANH KCH PHT TRN THT

I. I CNG: - Cn nhp nhanh kch pht trn tht ( gi tt l tim nhanh trn tht - TNTT ) l mt thut

ng rng bao hm nhiu loi ri lon nhp nhanh c c ch v ngun gc khc nhau. Trc y mt cn tim nhanh QRS hp, u, xut hin t ngt mt ngi khng c bnh tim thc tn c gi l bnh Bouveret. Ngy nay vi nhng tin b ca thm d in sinh l hc ngi ta hiu c cc c ch gy ra cc cn nhp nhanh v t a ra cc cch phn loi cn nhp nhanh trn tht cng nh phng php iu tr hiu qu nht.

II. CHN ON ECG: - Tn s 150-250 l/p. - Nhp u, QRS hp c khi dn rng qua dn truyn qua ng ph. - Sng P kh xc nh thng ln vo QRS. III. IU TR: 1. Trng hp NNTT c huyt ng khng n nh: BN c tt HA, co git, au tht ngc,

ph phi cp: tin hnh sc in cp cu ct cn nhp nhanh ngay. 2. Trng hp NNTT c huyt ng n nh: vic iu tr cp cu c thc hin theo cc

bc: Cc th thut cng ph v: a) n nhn cu:

- Khng dng th thut ny nu BN c tin s bnh vng mc, tng nhn p, - BN nhm mt, t 2 ngn tay ci hoc 3 u ngn tay ch, gia, nhn ln h mt, mi bn n t t tng dn. Trong khi n theo di trn monitoring T hoc nghe tim, nu cn tim nhanh ngng th cng dng n nhn cu ngay. Khi cn tim nhanh ngng s c on ngng tim ngn sau c thot b ni hoc nhp xoang tr li.

b) Xoa xoang cnh: - Khng thc hin nu bnh nhn c ngt xoang cnh, c tin s TBMMN thong qua. - BN nm nga xoa nh nhng tng bn t 10-20 giy, sau chuyn sang bn kia. - Khng nn tin hnh xoa ng thi 2 bn. - Cn theo di T hoc nghe tn s tim lin tc nu khng c monitoring v khi cn tim nhanh ngng li th cn dng ngay xoa xoang cnh nu khng nhp chm qu mc s dn n ngt. - Tc dng ca xoa xoang cnh, n nhn cu s tng ln nu BN c dng digitalis trc .

c) ng tc Valsalva: nut ming thc n to, ung ming nc lnh ln, ci gp ngi thp, u kp gia 2 u gi, p mt vo chu nc lnh. Cc thuc ct cn:

a) Adenosin: l mt thuc c tc dng gy cng ph v mnh, lm chm dn truyn, gy bloc nt nh tht ph v c vng vo li ct c cn nhanh trn tht. + Thuc c half-life rt ngn


64

+ Liu lng: Tim TM 1 ng 6mg. Nu khng c kt qu sau 2-3 pht tim liu th 2 hoc th 3 l 12mg. + Nn chun b Atropin (0,5-1mg tim TM) phng khi nhp qu chm). + Chng ch nh: Nhng ca c hi chng suy yu nt xoang. Nhng ca dng cc thuc c ch nt xoang. CC tuyt i BN hen ph qun.

+ Nu sau khi tim BN mt tri gic cn m mnh vo vng trc xng c BN c th tnh li. b) Digitalis: l thuc c hiu qu v an ton nhng cn mt vi gi c tc dng. + Liu lng: Digoxin 0,5mg tim TM, sau 4-6 gi c th cho li nu cn hoc sau 0,25 0,125 mg c 2-4 gi /ln. Tng liu 1 1,25mg / ngy. + Nn dng Digitalis trong TH cn tim nhanh c km suy tim.

IV.CHUYN VIN - Cn NNKPTT khng p ng iu tr ban u. - Phi m bo an ton chuyn vin.

TI LIU THAM KHO - Phc hng dn chn on v iu tr Bnh vin Nguyn Tri. - Bnh hc ni khoa Bnh vin Bch Mai


65

HN M NHIM CETON ACID

I. I CNG: - Nhim ceton acid l 1 triu chng thng gp bnh nhn i tho ng do tnh trng

thiu ht insulin cp.

II. CHN ON 1. Bnh s:

- Hi chng tng ng mu : ung nhiu, tiu nhiu, st cn. - Tin cn tiu ng, t ngng s dng insulin.

2. Lm sng: - RL tri gic: l m n hn m,thng khng c du TK nh v. - Du mt nc. - Nn i, hi th c mi ceton,th kiu Kussmaul. - Yu t thc y, c bit ch nhim trng.

3. Cn lm sng - ng mu >16.6 mmol/l,thng 5mg/l) hoc ceton niu (+) - Ion mu, ECG, xt nghim tm sot nhim trng.

III. IU TR - X tr c bn trc khi chuyn vin: nhm m bo h hp tun hon, a ng

mu 155 166mmol/l

- Theo di M,HA,TM c, ran phi 2. Insulin thng : (Ordinaire,Regular, Actrapid)

- Bt u bolus TM 0,3 v/kg (10 - 20 v) - Duy tr 0,1v/kg/gi (5v/gi) - Khng nn

+ H ng huyt qu nhanh. + Ngng insulin t ngt. + B qu 7000ml dch trong 24h u.

IV.CHUYN VIN - X tr c bn v chuyn vin sm. - m bo chuyn vin an ton.

TI LIU THAM KHO - Phc iu tr Bnh vin Nguyn Tri Phng.


66

HN M TNG P LC THM THU DO TNG NG MU

I. I CNG - Hn m tng ng huyt tng p lc thm thu l tnh trng cp cu ni khoa, c

trng bi ng huyt tng cao trn 600 mg/dl, p lc thm mu >340 mosm/l, pH mu > 7.2 v khng c nhim ceton mu.

- y l bin chng ch yu gp T tp 2, n nhiu hn nam, thng gp tui gi gp kh khn trong vic duy tr y dch c th.

- Cc yu t thun li a n hn m bao gm cc tnh trng nhim trng (vim phi, nhim trng ng tiu), nhi mu c tim, tai bin mch mu no, vim ty, phng, say nng v mt s ri lon ni tit nh hi chng cushing,

II. CHN ON 1. Bnh s

- Hi chng tng ng mu : tiu nhiu, ung nhiu, st cn - Tin cn tiu ng

2. Lm sng - Ri lon chi gic : l m n hn m, co git - Khng th kiu Kussmaul - Du mt nc nng - Yu t thc y c bit, ch nhim trng

3. Cn lm sng - ng mu > 33mmol/l - p lc thm thu mu 320 mosmol/l - ALTT : 2 (Na+ + K+)mEq/l + H(mmol/l) +BUN (mmol/l) - Ceton mu < 5mg/l, ceton niu (-) hoc ch (+) nh

III. IU TR X tr c bn trc khi chuyn vin: m bo h hp tun hon, a ng mu 11

14 mmol/l, gim p lc thm thu mu 1. Dch truyn

- NaCl 0,9 % : loi dch truyn chon la - Lng v tc dch truyn ph thuc vo mc mt nc, c chong hay khng,

trung bnh: 1000 2000 ml trong 1 2gi u - NaCl 0,45 % khi Na+ mu> 160mmol/l, iu chnh theo ion mu

2. Insulin thng - ng mu 33mmol/l bolus TM 10-20 UI, duy tr : 3-10 UI/gi - ng mu < 33mmol/l bolus TM 0,3 v/kg, duy tr : 0,1 v/kg/gi

Ch + Khng nn h ng mu qu nhanh. + Tc d dch truyn bnh nhn gi, nhi mu c tim, suy thn, suy tim.


67

IV. CHUYN VIN - X tr c bn v chuyn vin sm. - m bo chuyn vin an ton.



68

XUT HUYT TIU HA TRN I. I CNG

- Xut huyt tiu ha trn (XHTH trn) l tnh trng chy mu ra khi mch mu vo trong ng tiu ha. Vic chy mu ny c th hin trn lm sng vi du hiu nn ra mu v i tiu phn en. Xut huyt tiu ha trn l mt bnh l cp cu ni v ngoi khoa.

II. CHN ON 1. Bnh s: - S dng steroids, aspirin, khng vim NSAIDs, ru - i mu, tiu phn en. 2. Lm sng:

- Du mt mu : chi lnh, nim nht, h p t th. - au thng v. - Triu chng bnh c bn: XGCC, RLM. - Tube levin c mu. - Thm trc trng phn en . 3. Cn lm sng - TPTTBM, nhm mu, phn ng cho, TS,TQ,TCK, Creatinin mu, ion mu. - Hct mi 4gi trong ngy u. - Ni soi d dy ghi nhn tn thng xut huyt thc qun, d dy hoc t trng. - ECG, siu m bng.

nh gi mc mt mu NH TRUNG BNH NNG

Lng mu mt 1000

Mch (1/pht) 120

Huyt p Bnh thng H p t th H HA

Hct >30% 20 30 %


69

III. IU TR 1. iu tr ban u trc khi chuyn vin: m bo h hp tun hon cm mu - Th oxy lu lng cao i vi trng hp c chong, t NKQ & thng kh nhn to

i vi trng hp xut huyt nng v ri lon tri gic. ( Phi x tr c bn trc khi chuyn vin).

- Xc lp ng truyn TM ln ngoi vi. - i vi trng hp ri lon huyt ng: khi u Normal Salin 1000- 2000 ml trong 20

30 pht, sau diu chnh theo p ng huyt ng. Hon tt h s chuyn vin sm. - Thuc cm mu: Transamin. - Thuc c ch bm proton: Omeprazol liu 80mg bolus TM trong 30 pht, sau truyn

80 mg mi gi.

2. iu tr ni khoa ti BV mc XHTH nh v trung bnh: Do lot d dy t trng: - Cc thuc bng nim mc d dy. - Khng H2 : Ranitidin. - Ranitidin : 50mg TB/4 6 gi. - c ch bm proton : Omeprazol : 40 - 80 mg TMC sau 40mg/24gi, chuyn dng

ung 40mg/ngy khi tnh trng xut huyt n. - Truyn mu khi c ch nh.

IV. CHUYN VIN - XHTH trn trung bnh, nng km chong RLHH, ri lon tri gic. - XHTH trn do gin v TM thc qun. - Phi m bo chuyn vin an ton.



70

XUT HUYT TIU HA DI I. I CNG

- . -

(vascular

.

-

.

II. CHN ON 1. Bnh s - i cu mu ti ln phn, hoc sau phn. - i cu phn en ln mu . - Mu chy r r tn ng trong rut s c biu hin phn en st c mi tanh.

2.Lm sng

- DHST: mch, huyt p thay i ty tnh trng mu chy v s lng mu mt. - Thiu mu: da xanh, nim nht. - Th nhanh nng nu mt mu nhiu. - Ri lon tri gic: l m , hn m nu thiu mu nng v sc nu khng x tr kp. Mc chy mu - Chy mu nh: mu mt 250ml, khng nh hng ton trng, du sinh hiu khng i,

cc ch s v mu bnh thng. - Chy mu trung bnh: mu mt 250-500ml, c nh hng ton trng, M-HA thay i. - Chy mu nng: mu mt trn 1000ml, ton trng thay i, da xanh, nim nht, vt v,

ri lon tri gic. + M > 120l/p, HA

PHC IU T

Phac Do Dieu Tri BV Quan 5

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