I HC Y DC THNH PH H CH MINHNIN KHA 2010-2011

NHI KHOA

BNH VIN NHI NG ICopyright by group 17-18 - Y05C

MC LC

NHI C SNHI C S5SUY DINH DNG7CHNG NGA9PHT TRIN TM THN VN NG11

CP CUSHOCK SXH15SHOCK MT MU17SHOCK NHIM TRNG19SHOCK TIM22SUY H HP23RN CN26ONG T29NG C31CCH PHA V S DNG THUC34

TIM MCHTIP CN TIM BM SINH36TIP CN SUY TIM41KAWASAKI44BNH VIM NG MCH TAKAYASU49BNH THP51VIM KHP DANG THP THIU NIN53

HUYT HCHI CHNG XUT HUYT60XUT HUYT GIM TIU CU MIN DCH61HEMOPHILIE63THIU MU65THIU MU THIU ST:67THALASSEMIA69HENOCH SCHONLEIN71

H HPHEN PH QUN73VIM PHI78VIM TIU PH QUN82VIM THANH KH PH QUN CP85

THN NIUHI CHNG THN H90NHIM TRNG TIU (NTT)93VIM CU THN CP HU NHIM LCT97TIP CN TIU MU98SUY THN CP100

S SINHC IM BINH THNG CUA TRE S SINH103VNG DA S SINH108CO GIT TR EM112NHIM TRNG HUYT S SINH115

NHIMSI120THY U122TAY CHN MING124VIM MNG NO M127

TIU HATIU CHY131

NHI C S

4

NHI C S

1. Cn nng:Mi sinh: 3.25kg5th: gp 2 lc sanh12th: gp 3 24th: gp 4>2t: mi nm tng 2 kg6t: 20kg

2. Chiu cao:Mi sinh:50cm3th: 609th: 7012th: 7524th: 853t: 954t: 100>4t: mi nm tng 5cm

3. Vng u:Mi sinh: 35cm1t: 45cm2-5t mi nm tng 2-3cm6t: 55cm

4. Vng cnh tayTr t 1 - 5 tui :14 -15 cmNu s o di 12 cm: SDD nng

5. Thp:Thp sau: 1-3thThp trc: 12-18th

6. Mc rngRng sa: 6-12th: 8 rng ca12-18th: 4 rng tin hm18-24th: 4 rng nanh24-30th: 4 rng hm ln

Rng vnh vin:6-7t4 rng hm6-8t4 rng ca gia8-9t4 rng ca 2 bn9-10t4 rng tin hm I24-14t4 rng hm II16-25t4 rng hm III

7. Nhu cu nng lng: 40ml/kg mu Xem xt ch nh PT cm mu, hi sc song song phu thut.

IV. C phu thut: t mm V tng c: PT khi huyt ng n Khi truyn mu > 50ml/kg m cn shock hay Hct < 30% PT cm mu gp

V. Theo di: M, HA, ti mu da mi 15ph/shock, 1 gi/n Hct sau truyn mu v mi gi ti khi n Nc tiu mi 4-6h Tnh trng chy mu ti vt thng Vng bng/ chn thng bng kn

SHOCK NHIM TRNGI- i cng: Hi chng p ng vim ton thn St > 38.5 hay < 36 Tim nhanh theo tui/ tim chm tr < 1tui Th nhanh theo tui BC tng hc gim theo tui, hay BC non > 10%

Ri lon chc nng c quan1. Tim mch: d truyn 40ml/kg/h dd ng trng: HA vn tt Cn vn mch duy tr HA bt 2/5 tiu chun: CRT > 5sChnh lch nhit ngoi bin v trung tm > 3oCThiu niu: < 0.5ml/kg/hToan CH (BE < - 5 mEq/l) khng gii thch cLactat/M > 2 ln bt2. H hp: PaO2< 300: k c TBM, hay bnh fi trc PaCO2> 65 hoc cao hn bt 20mmHg Cn FiO2> 50% duy tr SaO2 92% Cn th my hay bp bng

3. Thn kinh:Glassgow 11Glassgow gim 3

4. Huyt hc:TC < 80kINR> 2

5. Thn:Cre 2 ln gii hn trn theo tui hay 2 ln bt

6. Gan:Bili 4 mg% (k p dng s sinh)ALT >100 UI hay 2 ln bt

Cc nh ngha: NT huyt: hi chng p ng vim ton thn + nguyn nhn do NT NT nng: NT huyt + RL chc nng tim mch/suy h hp/RL 2 c quan khc Shock NT: NT huyt + RL chc nng tim mch l NT nng Shock m: gim ti mu: thay i tri gic, phc hi da mt nhanh, mch ny vt chm nhanh Shock lnh: gim ti mu: thay i tri gic, phc hi da > 2s, mch gim, chi lnh, m

Hamax bt tr 1-10 tui: 90 + 2n (tui)

Gim HA:TuiHAmax

S sinh thng1-12th> 1 -tui 10 tui< 60< 70< 70 + 2n< 90

II- Chn on: Hi bnh: Tm nhim trng v nh hng tc nhn: Tiu: tiu gt but, lt nht, Tiu chy, tiu mu Nht da, pxe, St, ho

Chng nga: HI, ph cu, no m cu

Tin cn yu t nguy c: Sanh non SDD SGMD, ang iu tr cor Bnh mn tnh: T, bnh tim, gan, thn

Khm: Shock, da ni bng Triu chng p ng vim nhim trng Ban mu, bm mu, hng ban,

III- CLS:CTM, huyt , CRP, cy muIon , H, MTB, chc nng gan thnKMM/RL kim toanCy mu bnh phm nghi ng: m, nc tiu, phnXQS bng tm NT, pxe su

Chn on xc nh: Shock + $ p ng vim TT + cy mu (+)

IV- X tr:1. H tr h hp2. Lp ng truyn TM/ty xng, XN mu, khng sinh TM (xem bi NT huyt)3. LR/NaCl 20ml/kg/15ph hoc CPT c th ti 60ml/kg Theo di mi 5ph: nhp tim, rale, TMC, gan, mu mi, c h hp ftrnh qu ti4. iu tr h H, h Ca nu c5. Dopamin TTM khi u 5g/kg/ph tng mi 2.5g/kg/ph n 10 g/kg/ph, CVP, HA ng mch xm ln, t sonde tiu, duy tr dch 5-10ml/kg sao cho CVP 12-16 mmHg, HAmean 50-60mmHg, ScvO2 70%, Lactat < 4 mmol/L6. Phi hp Dobu khi:Khng Dopa+ nghi gim co bp m p lc y tht btBiu hin gim co bp c tim: gan to, TMC, kh th,ScvO2 < 70%Khi u 5g/kg/ph, tng liu mi 2.5g/kg/ph n hiu qu hay ti 20g/kg/ph (>20 c th lm tng nhp tim, gim HA qua th th 2)7. Norepinephrine khi:Shock m khng dch khng DopaKhi u 0.1g/kg/ph, nng liu mi 0.1, max 28. Epinephrine khi:Shock lnh khng dchShock lnh k p ng Dopa liu 10Shock khng NorepinephrineKhi u 0.05 g/kg/ph, nng mi 0.1, max 0.39. Hydrocortisone 1mg/kg TMC mi 6h

Theo di, h tr h hp, tun hon, in gii, chuyn ha, toan kim, H, ng mu

SHOCK TIM1. Chn on:Hi bnh:TBS, bnh c tim, lon nhp tim ,thp timKhm: du hiu suy tim: Din tim to, gallop, m thi, kh th khi gng sc, gan to, TMC ni Nu nghi ng/BN c gim th tch TH km theo: tiu chy, st, b, ung km,: test: truyn 5-10ml/kg LR sau nh gi li: BN kh th, tm, rale fi gip chn on shock tim

2. CLS:ECG, XQngc, S timIon , H

3. X tr1. H tr h hp2. Shock in/ RL nhp tim3. Tng co bp c tim/gimHA< 70mmHg: Dopa 5-10g/kg/phHA 70: thm Dobu 5-15g/kg/ph4. Nm u cao5. Hn ch dch truyn6. Hi chn chuyn khoa tim

SUY H HPI.nh ngha:SHH l tnh trng h h hp ko duy tr c s oxy ha mu hay s thng kh hay c hai

II. Chn on:*C cc ni dung:Xc nh c SHHMc SHHV tr SHH ( Bi ca BS.Nguyn c ghi nhng Tr thy c th b qua bc ny)Nguyn nhn SHH

1.Xc nh v phn SHH:Lm sng

1 2 3

H hpNhp th tng < 30%Co lm Nhp th tng 30-50%Co lmNhp th tng > 50%Th chm do mt c Ngng th 15-20s

Tim mchNhp tim nhanh (+/-)Nhp tim nhanhNhp tim nhanhNhp tim chm, h HA

Tri gicTnhBt rt, vt v, L m, hn m

p ng oxyHng vi kh triTm vi kh triHng vi oxyOxy FiO2 60% vn tm

CLS:KMMSpO2

2. V tr v nguyn nhn SHHa. Tc nghn h hp trn: D vt, vim thanh thit, apxe thnh sau hng, ph n thanh qun sau phn v hay sau t NKQc im nhn bit:D vt: Hi chng xm nhp, kh th t ngtSt, au hng, khn gingTh chm,ko di th ht voTh rtb. Tc nghn h hp di: Suyn, VTPQc im nhn bit:Ho, kh kh, kh th, ran rt, ran ngyc. Nhu m phi: Vim phi, ph phic im nhn bit:Th nhanh, co lmRan n, ran md. Suy bm:Thn kinh trung ng: vim no, vim mng no, chn thng, ng cC h hp: Nhc cKhung sn: g vo ct sngNgoi ra cn c cc nguyn nhn:Tim mch: Suy tim, trn dch mng tim, vim c tim, TBS tmToan chuyn haThiu mu nng

III. iu tr:Gm:Thng thong ng thCung cp oxyiu tr nguyn nhniu tr h tr1.Thng thong ng th;Ht m nhtLy d vtVim thanh qun cp: Kh dung Adrenaline: Adre 1%o 0,1ml/kg ti a 3ml pha NaCl 0,9% 3ml. C th lp li sau 2-4hHn m: Nga u-nng cm, t ng thng ming huNKQ: Ch nh:Ngng th, th hcGim oxy mu ng mch: PaO2 = 60% Tm ti, l m SpO2 < 90% khi cung cp oxy Tng PaCO2>=60mmHgTc ng th do d vt, apxe hu hng, ph n thanh qunBo v ng th cho bnh nhn m v mt phn x hu hngV tm thu, try mch, nhp tim chm hay nhanh vi gim ti mu

2. Cung cp oxy:a. Sonde 1 mi: Cho FiO2 30% vi lu lng oxy 4-8l/ph, nhng FiO2 ko tng bao nhiu khi >5l/phb. Sonde 2 mi:-Tr > 1 tui: 20+4n-Tr 1/2 chi b cn Sng n sau khi b cn ti ngn chn c bit ti ngn tay Sng n lan rng nhanh Sng n, au hch lympho dc chi b cnCch cho v liu lng Chun b sn Adrenalin HTKNR 2ml/ph TMC Hoc pha 5-10ml/kg dd ng trng TTM trong 1 gi Nn cho sm trong 4 gi u, sau 24h t hiu quTai bin Phn ng phn v sm St cao co git Phn ng mun (bnh huyt thanh)t/d p ng Tng trng kh hn RLM, tr/ch nhim c TK ci thin Huyt ng n Tn huyt v ly gii c vn c th mt trong vng 1 vi gi, nc tiu v mu bnh thng.iu tr h tr KS: c th gp Gr-, Gr+, ym khi RLM:Truyn mu mi ton phn 10-20ml/kg khi Hct20 micro gam/ml nu ko r gi ng c. Nu ko nh c liu acetaminophen mu,liu acetaminophen >150mg/kg or >100mg/kg km tin cn bnh l gan or ko xc nh c lng ung vo C ri lon chc nng gan trong 24h u sau ng c. Liu lng Liu u 150mg/kg pha trong 10ml/kg Dextrose 5% bm tim TM trong 1h Sau 10ml/kg/h pha trong dd Dextrose 5% truyn chm trong 20h,c th cho truyn ko di nhng trng hp nhp vin tr >10 ngy or c tn thng no */ N-acetylcystein ung Liu u 150mg/kg pha vi nc or nc tri cy t l ung.sau 75mg/kg mi 4h 17 liu,nu nn 1h sau khi ung phi ung li or i sang dng chch. 4/ iu tr triu chng: H ng huyt: glucose u trng RL ng mu: vitamin k1*Ghi ch:- Bit dc ca N-acetylcystein: ACC 200,acehasan 100,Acetylcystein 200mg,Acinmuxi 200mg

B/ NG C CHT N MN Gm cc cht acide,baseI/ CHN ON Phng nim mc ng tiu ha: Suy h hp do ph thanh qun or sc vo kh qun Bin chng mun: cht hp thc qun,d thc qun-kh qunII/ IU TR Ko ra d dy v lm tn thng thm nim mc thuucj qun c th gy thng Ko dng cht trung ha Ko dng than hot Sc ming vi tht nhiu nc sch.BN cn ung c c th cho ung nc or sa pha long nng cht n mn. iu tr suy h hp nu c Lp ng truyn tnh mch bi hon nc v in gii. X-quang ngc pht hin thng thc qun. Kham chuyn khoa tai mi hng Ch t sonde d dy nui n sau khm v c kin ca chuyn khoa tai mi hng Khng sinh nu tn thng rng or su

C/ NG C PHOSPHORE HU CI/ CHN ON 1/ Chn on xc nh. a/ Lm sng: HC Muscarinic: au bng,tiu chy,co ng t,tng tit m nht,chm nhp tim,h huyt p. HC Nicotine: Rung git c,yu c,tim nhanh,cao huyt p. HC Thn kinh trung ng:nhc u,hn m,co git. b/ Cn lm sng: Tm phospho hu c trong d dy Acetylcystein esterase trong hng cu v mu: gim >50% bt Ion ,ng huyt,chc nng gan thn,x-quang phi. 2/ Chn on phn bit. Cn chn on phn bit vi ng c Clor hu c v Atropin lm nng thm tnh trng bn.Ng c Clor triu chng chnh l thn kinh,co git.X tr:loi b cht c,chng co git.

II/ IU TR iu tr cc tnh hung cp cu:shh,co git,hn m. Lp ng truyn tnh mch Atropine Atropine phi c tim trc v trong khi ra d dy Liu 0,02-0,05mg/kg(TM) mi 15ph cho n khi co du hiu thm atropine Sau : +Gim liu or tim ngt qung xa hn. + Or tim tnh mch lin tc 0,02-0,08mg/kg/gi Nn chn atropine m c 1mg/1ml trnh ng c nc,h natri mu Ra d dy: Thc hin cng sm cng tt Ra d dy d tin trc ra Ra k n nc trong v ko mi Nu sau 3 gi tnh trang cha ci thin th c th ra li d dy ln 2 Than hot tnh Pralidoxim:+Yu c,run c+Ung lng nhiu or loi thuc c c tnh cao Nn dng sm 12-24h u Bit dc: pampara 500mg,contrathion 200mg,protopam 500mg. Cch dng: 20-50mg/kg/ln ( ti a 1g) pha trong 100ml normalsaline TTM trong 30ph-1h.c th lp li sau 1-2h nu vn cn shh.Liu k tip mi 10-12h cho n khi mt biu hin ca Nicotinic Tc dng ph: C th gy nhc u,bun nn,tim nhanh,co gng c.

CCH PHA V S DNG THUC

Cng thc tng qut

VD = 3PC

P: cn nng kgC: liu thuc g/kg/hV: th tch = tc chy ml/hD: lng thuc cn fa trong 50ml Dextrose 5%mg

i vi liu < 1 g/kg/h p dng cng thcVd: tr 30kg, liu Adre 0.2g/kg/h VD = 3PC = 3 x 30 x 0.2 = 18 Nu dng 1 mg Adre (fa 50ml D) th bm 18ml/h2mg Adre (fa 50ml D) th bm 9ml/h

Liu > 1 g/kg/h: cho C = V D = 3PVd: tr 30kgD = 3P = 3 x 30 = 90mgLiu 3g/kg/h: Dopa fa trong 50ml Dextrose bm tim t ng3 ml/hLiu 5 g/kg/h: 5 ml/h

Quy i ra git:1ml = 20 gits git/ph = s ml/h chia 31ml = 60 git s git/ph =s ml/h

TIM MCH

139

TIP CN TBSA. TR C B TBS KHNG?Du hiuBnh sTin cnKhmCLS

phiTng tun hon phi-Nhim trng h hp di-Mt, kh th bt thng-Vim phi ti pht nhiu ln-th nhanh-co lm ngc-ran m ngy, rtXQ: cung MP phng, rn phi m, mch mu ra 1/3 ngoi ph trng.

Gim tun hon phi-nhim trng h hp trn, rng min-Mt, tm, kh th tng-cn tm ti i ti li-th bt thng-Tm nim, tng gng sc-tay chn di trng-kt mc rc-th nhanh su-phi ko ranXQ: cung MP lm, rn phi nh,Mch mu ch 1/3 trong ph trng.

2. Gim ti mu cc c quan-b km, ngt qung,mt mi,chm pht trin th cht, tm vn.-Da: xanh, lnh, v m hi-Thn: tiu t-Tiu ha: chn n, au bng, i-No: bt rt, kch thch, quy khc-Da nim nht, lng bn tay nht-CRT>2s-mch nhanh, nh, nh-huyt p thp

3. tr tun hon-ph-gan to-Tm c ni-n gan phng cnh (+)

4.Triu chng ti tim-Tim to-Tim p bt thng( v tr, din p, kiu p)-Tim c m thi-XQ: bng tim to-ECG: ln nh, ln tht-Siu m tim

5. d tt khc

II. B B TBS G? Tip cn 5 bc TBS1. Tm: trung ng( tm nim), ngoi bin (ko tm nim)

+ Phn bit c tm trung ng, tm ngoi bin, tm chuyn bit._ Tm trung ng : tm nim, tm da.[ quan st nim mc ming.ging mng tay, mi ,li] + da._ Tm ngoi bin : tm da [ quan st cnh mi, vnh tai, u chi ]_ Tm chuyn bit : o Sp02 t chi, xc nh bnh nhi c tm chuyn bit khng .

+ Phn bit c tm do h hp, tm do tim mch :

H HPTIM MCH

NHP TIMNHANHRT NHANH

NHP THRT NHANHNHANH

TING RN(+)(-)

M THI-/+++++/(-)

MCH BT THNG(-)(+)

P NG VI OXYTTGN NH KHNG P NG,KHNG THAY I TNH TRNG TM,CI THIN S KH TH

+ Xch nh thi gian khi pht tim, hon cnh khi pht tm, chn on phn bit :

_ Tim bm sinh tm_ Cn tm /Tim bm sinh khng tm

+ Chn on phn bit nguyn nhn gy tm trung ng :

Tm trung ngBnh sTin cnKhmCLS

1.Tim

o shunt Ko tmtm /gng sctm thng xuynTm, cn tm thiu O2-Th nhanh su-phi ko ranXQ: $Eisenmenger( rn phi m, 2ph trng sng)KMM: PCO2

ShuntP-TTm t nhXQ:du hiu gim tun hon phi

2.PhiTm cp tnh-Suy h hp-phi c ran-p ng tr O2 100%XQ: phi tn thngKMM: PCO2

3.Bnh Hb

2. Tun hon phi nh th no?tng gim ( trn)

3. Tim no b nh hng?

TimTCCNKhmXQECG

Tim (P)Th nhanh su, kh th.Tm [ do gim tun hon phi ]-du ny trc ngc(+), Hardzer(+)-mm tim ln trn-Bng tim to-gc tm honh nhn-mm tim ra ngoi v ln trn-ln tht (P)

Tim (T)- Kh th khi gng sc (b kh,tiu tiu -c bit khi to bn 0- Khng chu nm, thch c m, quy khc.- Kh th kch pht v m ( ang ng tnh dy khc tht ,tm ,ho )- Ph phi cp.,-mm tim xung di v ra ngoi, din p rng.-bng tim to-gc tm honh t- mm tim xung di v ra ngoi-ln tht (T)

4. C tng p MP? p lc phi= lu lng mu phikhng lc mm

Bnh sKhmCLS

-triu chng ca tng tun hon phi-tm/gng sc, tm thng xuyn-click phun,S/D do dn MP-T2 mnh-thay i m thi -tht (P) tng gnh tm thu-S/S h 3 l-ln nh (P)- tr tmXQ: -$EisenmengerECG: tht (P) tng gnh tm thu.

5. Tt tim nm u? Da vo 4 cu hi trn + c im ring tt tim

TBSTmTng tun hon phiTim b nh hngTng p phic im

VSDkocTim (T) tng gnh tm trngchaS/S ton tm thu( cha TAP), u tm thu(TAP), dang pht( l nh), dng trn(l va), LS III-IV tri lan hnh nan hoa.

C 2 timTim (P) tng gnh tm thuc

ASDKoCTim(P) tng gnh tm trngCha-tng ng tht (P)-T2 vang mnh, tch i rng v c nh-S/D hp 3 l c nng

Tim (P) tng gnh tm thuc

PDAKocTim (T) tng gnh tm trngcha-tm chuyn bit( o shunt)-mch Corrigan-hm c p(cung MC phng)-hiu p rng-m thi lin tc( cha TAP), u tm thu(TAP),LS II di n (T).

C 2 timTim (P) tng gnh tm thuc

Hp MPkokoTim (P) tng gnh tm thuko-P2 gim-S/S dng pht LS II tri c lan c-click pht u tm thu can MP( phnh sau hp)

4F-C-Th 4F hngkoTim(P) dy, ginko-ngi xm-tim ko to nhng tht (P) tng ng-T2 n nh-S/S hp MP-S/S h 3 l-m thi lin tc ca THBH ch-phi sau lng hay ca PDA di n.

Lu : St / tim bm sinh - Vim ni tm mc nhim trng ; p xe no ; Nhim trng h hp di .TIP CN SUY TIMNH NGHA:Suy tim l mt hi chng ls do ri lon chc nng tim gm nhng du hiu, triu chng ca qu ti th tch trong mch mu, trong m k (kh th, rales phi, ph, gan to) v nhng biu hin ca gim ti mu m (mt, km dung np vi gng sc)

CC BC TIP CN

Nhn din tr c nguy c ST

Chn on x ST

Chn on nguyn nhn v tm yu t thun li

ST cp hay mn

Phn loi ST

Phn tch c ch sinh bnh hc, nh gi h thng tun hon

Hng iu tr

TR C NGUY C SUY TIM: Trong tin cn c ghi nhn bnh tim (TBS, tim mc phi) Tr c triu chng ng h hp (ho, kk, kh th, th mt) nht l khi nhng triu chng ny ko di hoc ti pht nhiu ln Tr c triu chng ng tiu ha cp or mn tnh (i ma, n b km, au h sn Phi) Ph Thiu mu nng, bnh tuyn gip

CHN ON XC NH STBnh s (gi )Thm khm (quyt nh)

Triu chng ng h hp Ho m ko di St nh Kh th Kh khTriu chng ng tiu ha au bng Chn n Bun nn, i maTriu chng ton thn Mt mi Chm pht trin th cht v tm vnTriu chng ca - sung huyt Ph, TMC ni, gan to Th nhanh, rt lm ngc, rales phiTriu chng ti tim Tim to Tim nhanh gallop rt chm Ting tim c th mTriu chng ca gim cung lng tim Mch nhanh, nh, nh Chi mt, lnh, v m hi Da xanh, CRT > 2s Huyt p thp Tiu t

CHN ON NGUYN NHN V YU T THUN LI:NGUYN NHN:C nhiu nguyn nhn dn n ST nhng y6 ch ch trng TBS (ASD, VSD, PDA, TOF)YU T THUN LI: Ko tun th iu tr: tit ch, thuc Nhim trng (vim phi thng gp nht) t thp tim ti pht (thng gp tr > 5 tui, c tin cn thp tim) Thiu mu (nht l tr TBS lung thng T-P) S RLG kim toan: h Na, h K, h Mg mu, toan mu Thi oxy mu RLN: tim nhanh (nhp nhanh trn tht, rung nh, cung nh...)SUY TIM CP HAY MN ST cp gm OAP (chc nng tim (T) gim, tim (P) bnh thng) v sc tim (chc nng tim (T), (P) u gim), ko c nhng triu chng ca OAP v sc tim th l ST mn PHN LOI SUY TIM Tr ln: theo Framingham Tr nh: theo NYHA (xi khi BN c iu tr, chi tit hn v c CLS v bnh nn) v ROSS (ph hp vi cp cu) PHN LOI ST NH NHI CA ROSS 1Ko c triu chng

2Khi n/b tr th hi nhanh v v m hi nhKh th khi gng scKo ln

3Khi n/b hoc gng sc, tr th nhanh v v m hi ng kn/b luKo ln

4Th nhanh, co lm ngc, rn hoc v m hi ngay c khi ngh ngi

PHN TCH C CH SINH BNH HC ST cp hay mn ST cung lng tim thp hay cao ST cung lng thp thng xy ra th pht sau bnh TBS, bnh van tim, bnh c tim v bnh mng ngoi tim ST cung lng cao thng gp BN cng gip, thiu mu mn, c thai, d ng tnh mch, beri beri, bu mu ST (P), (T) hay ton b (T): biu hin u tin l KT khi gng sc (b, khc...) (P): ph, gan to, TMC ni, AGPC (+) tr em, gan c tr lng ln so vi ngi ln, gan phn nh tr mu r nht tr em c bit l nh nhi, s sinh. Nhng bt k nhim trng j u tng sinh gan, lch do phn ng ngoi ty. Da vo siu m: TM trn gan v trong gan gin, or gan to p theo nhp tim gan to do ST (P) ST tng gnh th tch (tng gnh tm trng) hay tng gnh p sut (tng gnh tm thu) Suy chc nng tm thu hay suy chc nng tm trng ST tm thu: tim mt kh nng co bp bnh thng tng mu, biu hin ls lin quan n gim CLT nh yu ui, mt nhc, gim kh nng gng sc v cc triu chng gim ti mu khc. BN c tim va ph i va dn n, tn ti ng thi c suy tm trng v tm thu ST tm trng: mt kh nng dn n y mu bnh thng. Biu hin lin quan ch yu n tng p lc y tht, biu hin ch yu bng cm gic kh th. nh gi h thng tun hon: tin ti, hu ti, sc co bp c tim ST nng hay nh

IU TR:Gim tin tiTr timGim hu ti

iu tr h trNm u caoTit ch mui ncGarot 3 chi (OAP)Trch mu (OAP)Th oxy (ST nng)Dinh dng ttNgh ngi, an thnTrnh: bn, stressH stiu tr cc yu t thun liTrnh b lnhTrnh stress

Thuc c hiuLi tiuThuc dn TMDigitalisDopamin, dobutaminAmrinone, milrinoneDn ng mch

c ch beta: propranolol, metoprolol, carvedilol

KAWASAKII. NH NGHABnh Kawasaki l bnh vim ko c hiu cc mch mu kch thc nh n TB. Bnh thng xy ra tr di 4 tui v gy di chng mch vnh nng n, c th t vong.

II. CHN ON1. Tiu chun chn on: th in hnhTiu chunM t

St5d v c t nht 4 trong 5 triu chng sau

1. vim kt mc2 bn, ko sinh m

2. sng hchHch c>1.5cm

3. hng bana dng, ko bng nc

4. thay i nim mc mi mingMi nt, . Li du hoc hng ban lan ta hu hng

5. thay i chiG u: hng ban v ph bn tay, bn chnG sau: trc da ngn tay

V ko ngh n bnh khc ph hp vi triu chng lm sng hin ti

Th ko in hnh: tr st 5d, ch c 3 trong 5 triu chng trn, km vi dn mch vnh trn siu m tim, tr38.5oC hoc h thn nhit 0.5g/24h hoc >3+, tr t bo)8) Nhng ri lon v thn kinh: co git hoc ri lon tm thn nguyn pht.9) Ri lon v mu: HC, BC, TC , 10) Ri lon min dch: Anti DsDNS(+), hoc Anti Sm(+), hoc Anti phospholipid(+), hoc xt nghim huyt thanh giang mai dng tnh gi.11) Nhng khng th khng nhn (ANA - antinuclear antibody): L marker thng gp trong mu cc bnh t min. ANA tng ln trong mu theo tui chnh v vy chnh xc ca chng gim i nhng bnh nhn ln tui. Xt nghim ANA rt c gi tr khi m tnh, y l yu t c bn loi b chn on bnh lupus ban do c khong trn 98% bnh nhn lupus cho kt qu xt nghim ANA dng tnh RA thiu nin th h thng cn gi l th cp, c biu hin ni tng, bnh Chauffard Still Lm sng : Gp la tui 5 - 7 tui, thc t 1 - 2 tui, khi pht cp tnh- Ton thn : + St cao dao ng ko di+ Mt mi km n, gy st nhanh+ Da xanh, hc hc

- Ti khp :+ Cc khp b vim : c tay, c chn, gi, khyu, khp ngn, t thy vim khp hng v khng c biu hin ct sng.+ Cc khp sng, nng, au, t , da bn ngoi ph n, c th c trn dch khp .

- Biu hin ngoi khp :+ Da : ban , thng gp, c tnh cht c hiu. l nhng nt, chm mu hng trn mt da, khng au, khng nga, xut hin nhiu lc st cao trong ngy ri mt dn sau vi gi, ban thng xut hin thn mnh, t chi nht l lng bn tay, bn chn.+ Gan, lch, hch : Gan hi to, t ri lon chc nng gan . Lch mp m b sn. Hch to, ni nch, bn, to va, khng au. + Vim mng ngoi tim vi au ngc, tim to, lng nc t trn siu m. Din bin a s lnh tnh. Vim c tim him gp v khng vim ni tm mc.+ Vim mng bng, mng phi : c th gp, siu m c lng nc t.

Cn lm sng : - CTM : HC gim nh, BC tng hoc gim.- VSS tng, fibrinogne tng.- Xt nghim min dch m tnh .- X-quang xng khp bnh thng

Tin trin, bin chng, tin lng :Bnh tin trin tng t, mi t vi tun n vi thng, theo ba cch - Sau vi t ri khi khng li di chng.- Ko di vi nm, tha dn ri khi, c th li di chng khp.- Mt s trng hp nng dn ri t vong v cc bin chng (suy tim, thn do nhim tinh bt)

HC Steven JohnsonHi chng S. J thng gp tr em v ngi tr tui nam nhiu hn n, t l 2: 1 Cn nguyn.+ Do thuc: h st, gim, an thn c bit khng sinh nhm Penicillin, Sunfamides.+ Do tim vacin, huyt thanh.+ Nhimvirut: do Herpes.+ Cc bnh nhim khun: vim phi, vim mng no, vim no, nhim khun rng ming + Cc loi bnh k sinh trng, st rt, trng roi, nhim nm.+ Bnh to keo : lupus ban .+ Ri lon ni tit, c thai hoc ri lon kinh nguyt ...

Lm sng.Bnh khi u t ngt st cao 39- 40o, nhc u, mt mi, vim hng ming v sau ton trng ngy cng nng.+ Vim mingl mt du hiu xut hin sm, biu hin mn nc mi, li v nim mc ming hoc xung quanh ming v sau gy vim ming nng km theo gi mng xut huyt, chy nc bt, lot ming n ung rt kh khn.+ Mt: vim kt mc hai bn, lot gic mc.+ Mi: vim mi, xung huyt, chy mu mi.+ Da: xut hin mn, bng nc hoc ban xut huyt mt tay, chn sau xut hin tn thng ban hnh huy hiu ton thn km theo vim mt hoc tt c cc l t nhin (ming, mi, kt mc, niu o, m o, hu mn).+ C quan ni tng khc: vim ph qun, ri lon tiu ha.

3. nh gi nguy c theo tiu chun Harada BC>12k/mm3 TC3+ Hct4 khp): chim 35%; n>nam.2.1.1.Nhom RF(+): Chim 20-25%,khi phat tr.Tn thng vim khp thng nng,thng kem ban thp,nt thp,vim mach mau,HC Sjogren Tin trin thng dn n pha huy khp,mt chc nng vn ng tan ph.2..1.2.Nhom RF(-): Chim 5-10%,khi phat bt ky la tui.Tin lng thng nhe.

Th a khp dang thpTh it khpTh h thng

Ti l thng gp30-40%50%10-20%

S khp vim>=5=nam; khi phat n: khi phat > 8t;RF,ANA(-); 75% HLA-B27;10-20% co VMMTM.Tn thng thng khp ln 2 chn,co th kem vim gn bam got,ban chn.Mt s trng hp co th din tin thanh vim ct sng dinh khp thiu nin v sau.

5.3.Th h thng (bnh Still-Chauffard) Chim 20%.y la biu hin tn thng ni tang cua bnh VDKTTN,vi st cao c trng cua bnh,kem biu hin lan toa ngoai khp (da,mach mau,tim,phi,gan ,lach,hach).Th nay tn thng khp thng thoang qua,nhng cac tn thng ngoai khp thng nng va keo dai co th gy t vong cho tre.Cn chu y chn oan phn bit vi cac bnh co biu hin toan thn khac nh nhim trung huyt,vim da c,vim a c,bnh kawasaki,Lupus ban o h thng,bnh Behcet,bach huyt cp

3.Cn lm sang:3.1.Phan ng vim & min dich CTM,m tiu cu,tc gia tng lng mau; CRP; in di protein huyt tng ; ANA; RF; ASO.3.2.Xet nghim anh gia tn thng xng3.2.1.X quang xng khp quy cKhng th thiu trong chn oan va anh gia tn thng xng!!! XQ khp thng thng tuy khng giup phat hin sm tn thng xng bnh VKDTTN nhng cho n nay vn co gia tri giup chn oan tn thng xng g 1.Tn thng CS tht lng,xng cung,khp cung chu kho thy hn ch khac,oi hoi ky thut chup thich hp.Phn xa cua xng ban t gn bi rng ra,co th la du hiu duy nht cua bnh va tn tai ngay ca khi bnh khng dang hoat ng.Xng banh che or mt s xng khac cung co th bi rng ra.XQ giup phat hin tn thng khac khp thai dng ham,vi tre em tn thng khp nay thng kin ao va dng nh s pha huy cua khp nay din ra sm va nhanh hn cac khp khac trong VKDTTN.Vim khp hang thng him gp g khi phat cua VKDTTN th it khp.Triu chng vim khp hang tre nho i khi khng ro rang,do o XQ khp hang la chi inh bt buc nu nghi ng co tn thng tai khp nay.y la vi tri tn thng khp cn c iu tri tich cc tranh s pha huy khp,bao tn chc nng vn ng va han ch s tan ph cho tre.Cassidy.JT cn c vao nhng thay i cua xng trong bnh VKDTTN a ra cach phn loai tn thng xng khp nh sau: Nhng thay i sm:-Sng m mm hay loang xng-Tao xng mi di mang xng-Loang hanh xng. Nhng tn thng nng hn:-Pha huy sun.-Huy xng.-Dinh xng.-Ban trt cac khp ln-Gay u xng-Chen ep ct sng. Bt thng tng trng:dai chi or ngn chi,lem cm,tng ct hoa sm Vim ct sng: c,ban trt t sng i Atlas; lng-tht lng; xng cung. Phn loai CNV khp theo Steinbrocker.O,kt hp vi mc tn thng xng:Giai oanXQ khpTeo cDinh bin dang khpKha nng vn ng khp

1-smBinh thng hoc loang xng nhe u xng

(-) (-)Gn binh thng

2-vaMt vi u xng ro + (-)Han ch mt phn

3-nngMt vi nng,khuyt xng,pha huy u xng,dinh khp mt phn.

++

+

Han ch nhiu

4-cuiDinh khp va bin dang khp +++ ++Tan ph

3.2.2.Siu m khp: kim tra mang hoat dich,tran dich khp,bao gn,bao c,phn mm cac khp,c bit cac khp ln su.3.2.3.Choc dich khp: chi inh trng hp co vim khp cp cn loai tr vim khp nhim trung.Con c dung iu tri rut bt dich trong bao khp.Co th iu tri bng chich tai ch Triamcinolone hoc Dexamethasone vao khp hoc cac gn va c quanh khp,tuy nhin it c ap dung.3.2.4.Sinh thit mang hoat dich.3.3.XN cn thit loai tr: tuy tng bnh canh cu th.3.3.1.Tuy .3.3.2.Cac ki thut hinh anh khac: xa hinh,chup ct lp,MRI.4.Chn oan:4.1.Tiu chun chn oan:Tiu chun chn oan bnh VKDTTN (JRA),theo Hip hi Thp khp My (ACR) 1982: Vim khp man tre di 16t; co thi gian au khp keo dai hn 6 tun l.Chn oan VKDTTN chi c t ra sau khi a loai tr cac bnh khac tre emTheo tiu chun nay.bnh VKDTTN co 3 dang lm sang chinh:-Th h thng (bnh Still-Chauffard)-Th khp (huyt thanh dng tinh va m tinh)-Th it khp(tip 1 va 2)Tiu chun chn oan bnh VKDTTN(JRA),theo Hip hi chng Thp chu u (EULAR):Theo tiu chun nay tre mc bnh co tui khi phat 3thang.Typ khi phat bnh vim khp man tinh thiu nin gm:-Th a khp:vim> 4 khp vi yt t thp m tinh.-Th it khp:vim4 khp.-Th h thng:vim khp vi st c trng.-VKDTTN:vim>4 khp vi yu t thp (+)-Vim ct sng dinh khp thiu nin.4.2.Chn oan loai tr:- Nhim trung (virus,vi trung)- Hu nhim trung (vim khp sau tiu chay,hi chng reiter,thp khp cp)- Loan san mau (bach huyt cp,hemophilie,Von Willerbrand)- Neoplasm (neuroblastome,bu xng nguyn phat)- Khng vim (au chi lanh tinh,bnh xng khp di truyn,coi xng)- Bnh m lin kt (Lupus o,Kawasaki,Behcet,vim mach mau,vim da c)- Vim khp th phat sau vim rut,vy nn- Bnh ly khac: giam gamma globulin mau,sarcoidosis4.3.Chn oan phu hp tng tuyn:Nu vim khp cp (30kg),ung bui sang.Methy prednisolone (Solumedrol): chi inh trong trng hp phan ng vim tin trin nng khng khng ch c bng corticoid ung tn cng hoc nhng trng hp co tn thng phu tang nng e doa sinh mang tre.Liu 3-5mg/kg/ngay (trng hp nng co th dung liu 10-20mg/kg/ngay)TTM trong 3-5 ngay,sau o i qua Prednisone ung.Thi gian iu tri:Trong t cp,Corticoid c dung vi liu tn cng cho ti khi phan ng vim giam (ht st,ht au khp va tc lng mau gi u giam < 50mm).Thi gian tn cng tuy ap ng cua phan ng vim trn lm sang va cn lm sang,nhng khng nn keo dai> 4 tun. Sau t cp,Corticoid c giam liu dn: T 60-20mg/ngay,giam 2,5-5mg/tun. T 20-10mg/ngay,giam 1-2,5mg/tun. Di 10mg/ngay,giam 0,5-1mg/2-4 tun.NSAIDs c thay th dn sau o gian oan corticoid. Thuc iu tri c ban:Nhom thuc thay i din tin bnh: chi inh khi phan ng vim tin trin manh,ap ng kem vi thuc khang vim tac dung nhanh ,gy nguy c huy xng sm do vim; hoc VKDTTN a co tn thng xng.Sulfasalazine(SZP): Thi gian co tac dung t 1-3 thang,do o thuc cn c phi hp vi khang vim tac dung nhanh trong giai oan vim cp.Hiu qua iu tri tt khi tn thng xng nhe( 10-11g/dl Ch phm : hng cu lng ( 1n v 125ml) , mu ti ton phn Liu : 10-20ml/kg HCL truyn chm trong 4h Nu c suy tim truyn 3 tui Ferritin > 1000 ng/ml Truyn mu c khong 10 12 ln Liu: 30 40 mg/kg /m , 8-12h, 5m Ung vitamin C 3mg/kg 1h sau thi st( v vit C gip lm chm qu trnh bin i Ferritin thnh Hemosiderin) Cch dng: TB, TDD ,TTM( desferal 0,5g/l pha vi Destrose 5% ) c tnh thi Fe : cc tn thng c th hi phc sau ngng thi Fe. Kim tra tai v mt mi 6 thng ic do dng liu cao 50mg/kg/ngy , gp tr < 3 tui Th gicc. Ct lch: Ch nh: Tr > 6 tui Lch to qu rn Truyn HCL 250ml/kg/nm hay thi gian truyn mu gia 2 ln < 3 tun hay khi lng mu truyn gp i phng nhim trng: Tc nhn thng gp l Steptococcus pneumonia, no m cu, Haemophilus influenzae. Chng nga 3 loi trn trc ct lch 2 thng, lp li mi 5 nm Khng sinh TM ngay khi tr nhim trng, st iu tr d phng st rt /tr sng vng dch t Ung Phenoxylmethylpenicilline 250mg/vin ung 2 ln ngy hay Erythromycine 250mg mi ngy n 16 tui

TRUYN MU

1.Hng cu lng :+ Truyn 1ml/1kg nng ln 1% Hct.+ Truyn 3ml/kg nng ln 1g/dl.Tc truyn 3ml/kg/h.1 n v mu tr em 125 ml.Ch nh Thiu Mu : + Thiu mu thiu Fe # Hb < 4g/dl.+ Thalasemia : Hct < 25%, Hb < 8 g/dl.2. Tiu cu m c :Truyn 1dv/10kg nng ln c 50.000Tc truyn : 60 ml/h4. Kt ta lnh :1 v nng yu t ng mu tng them 8 %-12%.Ty theo mc xut huyt m ch nh khc nhau, khng da vo nh lng yu t 8 .Trong 1 ti 50ml c 75 n v.Truyn : 20 v/1kg, Tc truyn : 30 v/h.5. Huyt tng ng lnh :Truyn 10-15 ml/kg/12h.

HENOCH SCHONLEINI. N: henoch scholein la th vim mch mu thng gp nht tr em, nh hng ti cc mch mu nh cc c quan c bit l da, khp, ng tiu ha v thn.

II. LM SNG: chn on ch yu da vo lm sng1. DA: dt hng bansn m ayban xut huyt. i xng, gp nhiu 2 cng chn, 2 cng tayC th ph nh.2. KHP: au km ph quanh khp ln( gi, c chn, khuu , c chn), thong qua, di chuyn, ko li di chng.C th trn dch thanh dch nhng ko xut huyt.3. TIU HA:au qun bng km nn i, tiu mu. Khm ko c im au c th, ko c phn ng thnh bng.

4. THN:Lm sngSinh thit thnNguy c suy thn

Tiu mu vi th hay i th, tiu m ti thiu hoc ko c 1-2, him 350%

5. CC C QUAN KHC:Thn kinh: au u, ri lon tm thn, co git, lit, xh ni so,Nhi mu c timBnh phi m k, xh phi,

III. CLS: ko dng chn on x-CTM, TS, TC-tng IgA, C3-TPTNT, m niu 24h, Ur, Creatinin, sinh thit thn( khi tiu m >30mg/kh/ngy)-siu m bng-sinh thit da khi cn

IV. IU TR:1. Nguyn tc: ch tr triu chng, ko c iu tr c hiu2. Corticoid ch dng khi c triu chng tiu ha v thn nng3. Theo di v ti khm mi 1-3 thng pht hin bin chng v din tin tn thng thn.

H HP

HEN PH QUNL tnh trng vim mn tnh ca ng h hp1. Chn on Hi bnh:Kh kh:Tnh cht: lin tc hay c giai on khng kh khYu t tng: sau n, khi nm, khi gng sc, v m, gn sngTriu chng i km: ho, s mi, stKhai thc yu t khi ft: cm lnh, siu vi, gng sc, d nguyn h hp, thi tit Triu chng phn kim sot v nguy c: cn ngy m? m c thc gic? Gii hn hot ng? c ang iu tr thuc g, ung hay xt, bao lu ht 1 l, NV v cn kch pht bao nhiu ln? c t NKQ

Tin cn:Bn thn: Chm, m ay, d ng thc n, d nguyn h hp, vim mi d ngKh kh ln myC phun kh dung ln no cha, c p ng kGia nh: 4 bnh d ng, ht thuc l, lao

Triu chng: hi chng tc nghn h hp di: ho, kh kh, th nhanh, kh th th th ra, ran ngy rt, au ngc/tr ln

Chn on: 5 tiu chun Ho, kh kh ta i ti li C yu t nguy c suyn Khm LS v test p ng thuc DPQ Loi c cc nguyn nhn khcCLS:CTM: khi stXQIon , HKMM: da ngng th, LS xunh lng theophylline: k thy lm

Chn on: suyn cn nh/TB/nng, mc kim sot, bin chng

Phn cn: Nh: Khng suy h hpTrung bnh: SHH INng: SHH IIDa ngng th: SHH III

c imKS ttKS 1 fnkhng KS

1.Hn ch hot ngKhngBt k 3 cn trongbt k tun no

2.Tr/ch ban m/thc gicKhngBt k

3.Tr/ch ban ngyKhng( 2ln/tun)> 2 ln/tun

4.Cn thuc ct cn/cp cuKhng( 2ln/tun)> 2 ln/tun

5.FEV1 hay PFBnh thng< 80%

6.Cn kch phtKhng 1 ln/nmLn trong bt k tun

Yu t nguy c: Nhp cc v suyn trong nm trc t NKQ v suyn Mi ung cor hay ung thi gian ngn K dng ICS Dng hn 1 l ct cn/1 thng Khng tun th iu tr C vn tm l

Kh kh sm tm thi v khng km theo suyn thng gp nh nhi v tr nh: B trai Khi ft kh kh: siu vi Nh cn lc sanh B m HTL

Tr kh kh < 3t nguy c cao thnh suyn: thang im API (Asthma predictive index)1 TC chnh: Cha m suynVim da d ngD ng d nguyn h hp2 TC f: Vim mi d ngD ng thc nKh kh k lq cm lnhEos > 4%(+): nguy c suyn t 6-14t tng 4-10 ln(-): 95% k suyn 2. C phn bit: VTPQ D vt ng th Tro ngc TQ

3. iu tr: Nguyn tc H tr HH Ct cn Phng nga Qun l BN

Ct cnCn TB: PKD2x 3 / 20ph, cor ung nh gi p ng tt: PKD mi 4-6h/24h p ng k hon ton: PKD 2 + Ipra mi 1h x 3 ln, sau mi 4-6h Khng p ng: nh cn nng

Cn nng:PKD2 + Ipra x 3 mi 20ph qua oxy 6-8l/ph, cor TM nh gi p ng tt: PKD Kh dung 2 Ipra mi 4-6h/24h, chuyn cor ung Khng p ng: khoa hi sc: PKD 2 + Ipra mi 1h x 3 ln, sau mi 4-6h ti khi ct cn + cor TM + MgSO4M nu 1t hay aminophylline TM nu 90% VP do VK3. VS, CRPVS tng trong VP mn, ko di hoc c b/cCRP20mg/l trong VP cp gi do VK4. XN m Cch ly m Ho khc: tr 10t, d ngoi nhim VK thng tr h hp trn Ht dch kh qun (NTA nasaltracheal aspiration) tr nh, cht lng m tt khi cha>25 Neu v 70l/ph Co lm ngc nng Th rn u gt g theo nhp th Th CPAP: vn cn tm vi th oxy FiO = 40% Th nhanh>70l/ph d ang th oxy C hnh nh xp phi trn Xq Th my: cn ngng th, kit sc, tng PaCO, gim nng PaO2

b. Khng sinh: St> 38.5, ho, v mt nhim trng Phi c ran n Xquang c tn thng nhu m Bnh cnh nngThng gp l do Haemophilus influenzaeTuy nhin theo WHO: cc nc ang pht trin, t l t vong cao, VTPQ nhp vin c s dng khng sinh nh vim phi( nhiu yu t nguy c nhim trng kt hp VK, ko c du hiu c hiu phn bit SV va VK, kh nng cch ly hn ch)c. Dn ph qun:S dng khi bnh nhi kh th, kh kh nhiu, PKD 2 ln cch nhau 20ph sau nh gi li nu p ng th s dng tip.Cc loi: Salbutamol. Nacl 9, Adrenalin, Nacl 3%( hiu qu nht v l dd u trng rt nc gim ph n PQ v ct phn t m d thi ra ngoi nhng thn trng trn bn suyn).d. Corticod:Ch nh khi ko loi tr c suyn v bnh cnh nng n.e. Dinh dng:Tip tc cho n, bCh nh nui n qua sonde: th nhanh>70l/ph Nn i lin tc Tr b m SpO2103 khm cu trng gram dng99%

t sonde105104 - 105103 104104Nhim trng

Gi:3 mu > 1052 mu 1051 mu 1055x104-105104-5x104

5HC/QT 402. Nguyn nhn cu thn hay ngoi cu thnTriu chngTiu mu cu thnTiu mu ngoi cu thn

LSTM ton dngKo cc mu ngKo au, ko RL i tiuKm ph, THA, tiu tu dng hay cui dngC th c cc mu ngTiu au, gt, but, tiu rnC th km st

CLSTr HC/nc tiu (+)HC bin dng (dysmorohic) >80%MCV/HC niu < 72flKo c tr HCHC ng dngTiu m t < 1g/24gMCV/HC niu > 72fl

3. Nguyn nhn tiu mu l j?a. Bnh s hon cnh xy ra tiu mu: t nhin, sau vn ng mnh, ang hnh kinh, sau dng thuc, chn thng... c im tiu mu: ton dng, u dng hay cui dng, c cc mu ng ko triu chng i km: st, au h v, ai lng, au c, khp, triu chng xut huyt ni khc, TM km cn au qun thn, tiu rn, tiu gt, tiu lt nht..b. Tin s: Bn thn: c TM trc y ko, NTT nhiu ln, bnh thn, bnh tit niu, vim hng, vim da trc 1-2 tun Gia nh: Bnh thn mn (CKD), TM, ic, THA, si niu,, bnh l Hb, RLMc. LS: cc du hiu quan trng nh THA, ph, st, ni hng ban, t ban, au khp, khi u bng, n au im sn sngd. CLSTM u dng gi tn thng niu o, cui dng km vi RL i tiu v au h v gi tn thng bng quangTM ko di km vi tiu m nghim trng, suy thn cn tin hnh sinh thit thn xc nh sang thng thn TM cu thn: C3, C4, ASO, ure, cre, m niu 24g (hay m, cre niu), XN nc tiu cha m, o thnh lc khi nghi ng hi chng Alport, sinh thit thn khi TM i km HCTH, suy thn, TM ti pht TM ngoi cu thn: cy nc tiu, siu m h niu, Ca niu/24 gi hay Ca niu/cre niu ti mt thi im, tm sot bnh l HC hnh cu, CT h niu. Khi nghi ng bt thng ti ng tiu di: u mch BQ, bu BQ, u niu o...c th hi chn ngoi niu soi BQ. Soi BQ khi ang TM cn gi tr xc nh TM t l niu qun no t s c thm khm tip tc

CU HI THI:1. B tiu ton dnga. Hi thm nhng jb. Chn on j ngh nhiu nht? ngh XN?2. t HCTH nguyn pht ln u tr em3. t HCTH sang thng ti thiu

SUY THN CP

I/ NH NGHA: L mt tnh trng suy gim lc cu thn trong vi gi n vi ngy m c th phc hi li c.

II/ NGUYN NHN: Trc thn: Gim ti mu thn: sc,mt nc,mt mu,thiu oxy,tt nghn mch mu thn,thuc. Ti thn: Hoi t ng thn cp,vim cu thn cp,HC tn huyt ure huyt cao, ng t,thuc. Sau thn: Tc nghn ng niu*Thng gp l suy thn cp trc thn do mt nc,sc nhim trng or vim cu thn cp

III/ CHN ON XC NH 1/ Lm sng: Ph THA Tiu t: 37:t chi co tt

Vi tri u-28-30:cm tip xuc mon cung vai cua xng ba vai.-30-34:cm nm trc mon cung vai va di chuyn v gia xng on.->34-37:cm gia xng on di chuyn v xng c>37:cm tip xuc xng c.

Nghim phap co tay-2 giy>37:tay co trong 1-2s

Du khn quang37: (-)cui cho khng qua c ng gia.

Goc nhng chn120 34-37:90-120 >37:90

Goc ban chn30 34-37:10-30 >37:0-10

Nghim phap got tai90-120 >37: 90

Phan xa nguyn phat:c tinhTre thiu thang(tun)Tre u thang(tun)

Bu nut-28-30:phan xa yu-30-34:manh hn-34:ng b>37:hoan chinh

-Dung ngon tay ut sach cho tip xuc mi di,li sau o xoay nga ngon tay ln tip xuc vi vom khu cai cng.-ng tac bu xut hin,be mut ngon tay va keo ngon tay vao su.-anh gia co xut hin ng tac nut khi thy sun giap nhp nh.

Bn im(tim kim)-28-30: yu-30-34:manh hn.-34:3 im,cha co im di.-36: 4 im.->37:hoan chinh(co im th 5-lao u ra trc)

-Dung ngon tay tro sach cho tip xuc vi im giau74 mi trn,im gia mi di,hai bn khoe ming,nu tre oi,tre se xoay mt v hng ngon tay tip xuc.-im tip xuc mi di lam tre cui u la im co sau cung.

c tinhTre thiu thangTre u thang(tun)

moro-28-30:yu-30-32: manh hn nhng chi co thi mt-32-43:Thi 1 ro,thi 2 yu.-36:thi 1 va thi 2 ro.>37:hoan chinh

-Nm 2 ban tay be nng vai be ln khoi mt ging,u mng vn con cham ging.t ngt bung 2 tay be ra 2 vai ri xung ging.Khi vai cham ging thi moro xut hin.-Thi 1: Dang vai,dui tay,xoe ngon,khoc.-Thi 2: Ap vai,khep 2 canh tay lai trong ting khoc.

Nm-28:ngon tay nm.-30:c tay gp.-32-34:canh tay co.-36:nhc vai ln c>37:hoan chinh

-Ngi kham t ngon tro vao long ban tay be,kich thich trn cac go ngon lin tuc cho n khi be nm tay lai.-Khi be nm cht,nng be ln va keo be ngi dy.Quan sat kha nng nm cua be va s phi hp cac phn cua tay.

Dui cheo-28-30:yu->30-32:manh hn nhng chi co thi 1-34:thi 1 ro,thi 2 bt u-36:thi 1,2 ro,thi 3 bt u.>37:hoan chinh

-Ngi kham ng 1 bn tre.-Dung 1 tay gi gi thng.Tay kia kich thich long ban chn bi gi.Xem phan ng chn i din (chn bi gi xoe dui ngon lin tuc).Chn t do co 3 ng tac:1.Co chn 2.Dui chn 3.Ap va dang.

T ng bcBc trn ngon chnBc trn ca ban chn

Gi cho tre ng thng ngi trn ca i chn,sau o nghing ngi tre v phia trc bng cach y tun t tng vai ra phia trc.T th nay se tao ra nhng ng tac bc xem ke nhau 1 cach chm rai.

MC TRNG THANH THC THDuHiuimim

-1012345

DaTrong sut,m tTrong sut,o, nhyHng min, thy mach mauDa d bong, hng ban, thy it mach mauDa xanh xao, nt da,him thy mach mauBong da day, khng thy mach mauDa dy, bong da np gp

Lng tKhng coThaNhiuMong minCo nhng vung hoiHoi hu ht

Long ban chnGot=>ngon:40-50(mm)(-1)50mm khng co np nhnNp nhn o, m nhatNp nhn nm ngang & phn trnNp nhn 2/3 trnNp nhn chim toan b long ban chn

VuKhng nhn thyKho nhn thyQung vu det, khng chi vuQung vu t 1-2mm co chi vuQung vu 3-4mm, co chi vuQung vu 5-10mmCo chi vu

Mt/taiMi mt: khep h (-1),Khep cht(-2)M mt,Vanh tai det& d bin dangVanh tai mm, an hi kemVanh tai mm, an hi tta inh dang, chc, an hi roSun vanh tai dy,tai cng

C quan sinh duc nL m vt & 2 mi mongL m vt & mi be nhoL m vt & mi be lnMi ln va mi be bng nhauMi ln ln hn mi beMi ln che kin mi be va m vt

C quan sinh duc namBiu dai phng, khng co np nhnBiu dai rng,np nhn m nhatTinh hoan ng ben trn,np rt itTinh hoan a xung, vai np nhnTinh hoan xung,nhiu np nhnTinh hoan a xung hn,np nhn nhiu va su

IM ANH GIA TC TRNG THANH CUA TREim-10-505101520253035404550

Tun20222426283032343638404244

VNG DA S SINH

1. i cngVD ko di: >14d ( thng)>21d (non thng)VD tng bili TT: bili TT >1mg% (vi bili TP 5mg%)bili TT >20% (vi bili TP >5mg%)

2. Phn bit VD tng bili GT v TTTnh chtTng bili GTTng bili TT

Thi im xut hin1w

Mu daVng camVng chanh

Tiu Vng trongVng sm, vt vng trn t hay tm tri vi trng sau tiu

PhnVngBc mu

GanThng ko to to, chc

VD tng bili TT chc chc l bnh lVD tng bili GT c th sinh l hoc bnh l

3. 8 nguyn nhn gy vng da thng gp :+ Bt ng nhm mu.+ Do nhim trng.+ Vng da sinh l .+ Vng da do sa m.+ Do thiu G6PD.+ Do khi mu t.+ M T.+ a HC.4. VD sinh l Tr khe: b, c ng v tip xc bnh thng VD xut hin sau 24h, thng vo N2-3 sau sanh Thi im ht vng: N5-7 Mc VD ko vt qu ngng chiu n: trn rn hoc Kramer 1,2,3 VD ko di 5mg%/24h hay >0.2mg%/h6. Bnh no cp do bili (BIND): biu hin G1 (1-2d): b km, l m, TLC, phn x, khc tht tng ting G2 (gia w1): TLC, gng n ngi, co git, c ng mt bt thng, ri lon thn nhit (/). Thng t vong g ny G 3 (sau w1): TLC TLCYu t thc y BIND: Tn huyt Toan mu Ngt Tc ng ln hng ro mu no: non thng, tng ALTT, chn thng Tc ng ln lin kt bili-Alb: gim alb 4/1, ceftriaxone, chrothiazide.7. Nguyn nhn: gi da vo ngy khi pht VDNgyNguyn nhn

1Bnh l tn huyt do bt ng Rh, NTH

2-4Tn huyt, sinh l, non thng, NTH, h/c VD do sa m, HC thot mch, a HC, h/c Crigler-Najjar, h/c Gilbert, HC hnh cu

5-10NTH, h/c VD do nui bng sa m, thiu men G6PD, galactosemia, suy gip, hp mn v

>10NTH, NT tit niu

H/c VD do sa m: do chnh sa m gy ra, N2-4, nu ngng sa m bili nhanh trong 24h H/c VD do nui bng sa m: do calori nhp thp, N5-10, 20-30% VD ko di hn 2-3w, n 3m Galactosemia: tun u, gan to, b km, i, XH do RLM, suy gan, l m, h H, NTH Gr (-). Thi gian sau b c T3 gy m, x gan.8. iu trNguyn tc:Nhn ra sm v iu tr cc n/n VD ko sinh liu chnh cc yu t thc y bnh no cpm bo cung lng nc tiu, phn v nng lngTheo di cht ch din tin VD tr VD nngHng dn ti khm VD khi tr x/vThay mu va chiu n ng lcC th:3 nhm YT nguy c:Nguy c thp: 38w + kheNguy c va: 38w + YTT35-37w 6d + kheNguy c cao:35-37w 6d + YTTThay mu: tiu ch Thay mu khn nu c biu hin BIND hay TSB trn ngng 5mg% Tr thng, khe mnh: >30mg%>25mg% + tht bi chiu n (ko 1mg% sau 4h) Tr non thng: TSB (mg%) > 1% CN (g) Cn nhc ngng thp hn 3-5mg% tr c YT nguy cMu dng cho thay mu: Mu mi 13mg% Tr non thng: TSB (mg%) > 1% CN (g) /2Ch : Che mt, bu Theo di than nhit Thay i t th Tng nhu cu nc 20% CC tr tng bili TT Bc l da cng nhiu cng tt, chiu lin tc trong 24-48h, ch ngh khi b, sau chiu ngt qung, trung bnh ko di 4-5dTDP: Phn lng, tng than nhit gy mt nc, ng cn tm thi Tn thng vng mc H/c em b da ng: da sm nu + tiu sm gn nh en9. Theo diNu bili >75th percentile cn dinh dng, nc, v xem xt cc n/n: NT Tn huyt Thiu men G6PD (dn s nguy c)o bili theo ng cong Bhutani: >75th: o bili mu 24-48h >40th + c YT nguy c: o bili mu 24-48h =15

S ln co git trong t bnh ny : khng

>=2 cn git

2.Yu t tng nguy c ti pht1. 160l/ph CRT > 3 giy Huyt p h > 2SD di mc trung bnh theo tui Bt thng ti mu: Thiu niu( < 0,5ml/kg/h) Toan huyt nhim axit lactic ( tng lactate huyt v/hoc pH mu < 7,25) Ri lon tri gic

II . 13 Du hiu nhim khun :1. Co git, b b.2. Th nhanh .3. Rt lm ngc nng.4. Cnh mi php phng.5. Th rn.6. Thp phng.7. Chy m tai.8. Ty quanh rn9. St hoc st.10. Nhiu mn hay mn m nhim khun nng da, su v rng.11. Ng li b hoc kh nh thc.12. C ng t hn bnh thng.

III. YU T NGUY C:1. Yu t nguy c t m: M st > 38oC lc sanh M b nhim trng ko st Vim mng i i v sm > 18h Chuyn d sanh non C huyt tng hi/tun cui +h eo t cung2. Yu t t con: Nh cn, non thng Phi nam Sanh i D tt bm sinh Sang thng ngoi da APGAR thp < 5 im( 5ph) Tim thai > 160/ph ko di3. Yu t nguy c t mi trng: Nm vin > 3ngy Th thut xm ln Khoa s sinh qu ti T l bnh nhi /diu dng cao Thiu ng tc ra tay Liu php khng sinh ko di Phu thut

III. TC NHN:1. ng ly truyn:Nhim trng trong t cungNhim vi trng ngc dng: thng gp trong giai on chuyn dNhim trng mun sau sinh: ngun ly bnh quan trng nht cho tr nm vin l bn tay nhn vin y t2. Tc nhn:Bnh l bo thai: TORCH, un vn, lu cu, VGSV B. st rt, HIV, ChlamydiaVi trng thng gp nht giai don s sinh: streptococcus nhm B, E. Coli, Listeria monocytogenes.

IV. CC TH LM SNG:c imKhi pht smKhi pht mun

Khi pht rt mun

Lc khi phtLc sanh 7 ngy, thng < 72h7 30 ngy> 30 ngy

b/c sn khoaThng gpKo thng gpThay i

Sanh nonTn sut caoThay iHay c

Ngun gy nhimng sinh dc mng sinh dc m/ mi trngmi trng/ cng ng

Biu hina h thnga h thng khu tra h thng khu tr

V trPhng cho b thng/ nm vi mNICU, cng ngNICU, cng ng

Th LSNT Bo ThaiNTHNTH ; VMN , NT tiu ; cc NT khu tr khcTt c th ls khu tr.

Nhim trng bnh vin: nhim trng sau 3 ngy tui m ko c ngun gc t m.

V. CHN ON:Phi hp 3 yu t: lm sng, cn lm sng v yu t nguy c1. Yu t nguy c: PHN TRN2. 3. Lm sng:1. Tr ko khe mnh2. Triu chng h hp:Xanh tmRn rRi lon nhp thTh nhanh > 60l/ph + co koNgng th > 15 giy3. Triu chng tim mach:Xanh tmXanh tm, da ni bngCRT > 3 giyHuyt p h4. Triu chng tiu ha:B km, b bNn iTiu chyChng bngDch d dy > 1/3 th tch c n trc5. Thn kinh: Tng trng lc/ kch thch Co gitThp phngGim trng lcGim phn xHn m6. Huyt hc: Xut huyt nhiu ni T banGan lch to7. Da nim: Hng banVng da sm trc 24hNt mPh nCng b8. Ri lon thc th: ng cn/ st cnRi lon thn nhit(h, tng thn nhit)

4. Cn lm sng:a. CTM v pht mu ngoi bin: Thiu mu Tiu cu gim Bch cu < 5000 hay > 20000/mm T l Band Neutrophil/neutrophil 0,2 Bch cu c ht c, ko bo, th Dohl T l t bo non > 10%b. CRP hay PCT( procalcitonin)c. Cy mu hay cy dch c thd. Chc d ty sng: khi Biu hin nghi ng NTHSS C triu chng nhim trng, nht l th khi pht mun Triu chng TKTW nghi do nhim trng Cy mu dng tnh /bnh cnh NTHSSe. Xt nghim khc: KMM: khi c suy h hp, nhim trng huyt nng Ion , ng huyt, billirubin khi c vng da ng mu ton b khi co biu hin xut huyt Chc nng gan thn Xquang phiA. Chn on xc nh: lm sng + cy mu(+)B. Chn on c th: khi cha c kt qu cy muLm sng: triu chng nhiu c quan+ nhim trng + CLS gi nhim trng.CTM: phi c t nht 3 tiu chun sau: Bch cu < 5000 hay > 20000/mm T l Band Neutrophil/Neutrophil 0,2 C ko bo, ht c, th Dohl Tiu cu < 150000/mm CRP > 10mg/l

VI. IU TR:1. Nguyn tc:Pht hin v iu tr bin chng: suy h hp, sciu tr khng sinhPhi hp diu tr nng v iu tr cc bin chng khc2. Chin lc iu tr: C cc yu t gi nhiu kh nng NTHSS: M st > 38 khi chuyn d C huyt trng hi/tun cui + h eo t cung Sang thng i th trn nhau dng p xe( nhim Listeria) Triu chng da nim xut hin < 12h tui Suy h hp + Xquang phi ko ng nht Suy tun hon cp tnh Gan lch to Tr st > 38 ko r nghuyn nhn Toan chuyn ha ti din ko do nghuyn nhn tim phi BC < 6000/H24 hay < 5000 > h24

Cho khng sinh ngay , hiu chnh theo lm sng v cn lm sng. C yu t gi NTHSS: tr c lm sng n m M v i sm > 24h M b nhim trng tiu 1 thng trc khi sanh m ko chc chn iu tr ht Dch i d, c mu sc bt thng, c phn su nhng ko do sanh kh v tr ko ngt khi sinhKhm lm sng 2 ln/ngy, xt nghim mi 12 24h .3. Khng sinh:a. khng sinh ban u: Ampicilline + Gentamycine Hoc Ampicilline + Cefotaxim Hoc Ampicilline + Gentamycine + Cefotaxim khi c 1 trong cc du hiu sau: Nhim trng huyt trc 7 ngy tui Bnh c du hiu nng nguy kch ngay t u Nhim trng huyt + vim mng no m Nu nghi ng t cu ( nhim trng da hay rn): oxacillin + Gentamycin Cefotaxim Thi gian iu tr: Trung bnh 7 10 ngy Khi c vim mng no m i km : 21 28 ngy4. Trng hp nng: H tr h hp n nh huyt ng Kim tra yu t ng mu Thay mu khi c ch nh Vitamin K1 1mg (TB) mi 15 ngy khi iu tr khng sinh ko di

NHIM

SII. nh ngha: Si l bnh truyn nhim do siu vi si (Polinosa morbillarum) gy ra.La tui d mc bnh nht l tr em t 2 6 tui.II. Chn on: da vo dch t, lm sng v cn lm sng1. Dch t: la tui, ang c dch bnh xy ra, c tip xc vi bnh nhn si2. Lm sng: Hi chng nhim c: st, mt mi, u oi ton thn, n ung km, nn i, Hi chng vim long (vim xut tit): chy nc mt, nc mi gy ht hi, ho; vim kt mc mt gy chy nc mt, nhiu ghn, ph n mi mt, mt . Vim long ng tiu ha gy tiu chy. Nt Koplik thng xy ra trc hay ngy u ra ban (ngy th 2 ca st), bin mt sau 24 48 gi sau pht ban (tn ti 12 14 gi): nt trng c kch thc bng u kim, nim mc m vng rng hm. Hng ban ton thn: Pht ban vo ngy th 4 6 ca bnh, hng ban khng tm nhun, dng dt, sn, kch thc nh, gia cc nt ban l khong da lnh. Ban mc ri rc hay dnh lin nhau thnh mng trn 3 6 mm, s pht ban din ra theo trnh t: Ngy u: mc sau tai ri lan dn ra hai bn m, c Ngy 2: ban lan xung ngc, bng v 2 tay Ngy 3: ban lan ra sau lng, hng v 2 chn Ban tn ti n ngy th 6 k t ngy bt u pht ban, k s dn dn bin mt theo trnh t xut hin, t mt n thn mnh v chi, li cc nt thm c trc da mng, mn ging bi phn hay vy cm.3. Cn lm sng: Xt nghim huyt thanh tm IgM anti virus si (thng dng tnh ngy th 3 sau khi pht ban).III. Chn on phn bit:1. Bnh rubella: st nh, vim long nh, du hiu nhim c ton thn khng r, ban dt sn dng si nhng nh hn, mc tha hn v mc sm ngay t ngy 1 2. Khng c du Koplik. Hch sau tai, chm sng au.2. Ban do siu vi khc: Ban khng xut hin ton thn, khng vim long Ban xut hin nhanh v bin mt nhanh3. Ban nhit (rm sy): xut hin vng np gp, ban km mn m4. Tinh hng nhit: ban thng bm ton thn, khi ban bay gy trc vy, trc da u ngn tay. Xt nghim ASO huyt thanh tng5. Ban d ng: t ngt sau tip xc d nguyn, thng ni mn nga ton thn, khng vim long6. KawasakiIV. ngh xt nghim: CTM Huyt thanh tm IgM X-quang phi nu c nghi ng vim phiV. iu tr:1. Nguyn tc: B sung vitamine A Pht hin v iu tr bin chng Tt c tr si bin chng nng cn c nhp vinA. B sung vitamine A:a. Ch nh: tt c tr b si, tr nhng tr ung liu trong mt thng.b. Cch dng: Cho 2 liu: liu u ngay khi chn on, liu th 2 ngy hm sau Liu lng: Tr < 6 thng: 50.000 v/liu Tr 6 11 thng: 100.000 v/liu Tr 12 thng 5 tui: 200.000 v/liu Nu tr c tn thng mt do thiu vitamine A hoc suy dinh dng nng th cho thm liu th 3 sau liu th 2 t 2 4 tun.B. iu tr triu chng v nng :a. St: paracetamol 10 15 mg/kg x 4 ln/ngy khi st trn 38.5 0CCn st sau pht ban 3 4 ngy: bi nhim hoc st do nguyn nhn khc.b. Gim ho: Pectolc. Dinh dngd. V sinh: thong mt, kh ro, nga bi nhim.C. iu tr bin chng:a. Vim phi, vim tai gia: Khng sinh vim phi Chy m tai: bc su knb. Tiu chy:c. Vim thanh qund. Vim kt mc mt, tn thng gic mc, vng mc: vitamine A, v sinh, bng mt nga bi nhim, pommade Tetracyclin tra mt 3 ln/ ngy, 7 ngy, khng c dng cc loi thuc c steroid.e. Lot ming: Sc ming bng nc mui sinh l t nht ngy 4 ln Thoa tm Gentian 0.25% Lot nng v c hi: Benzyl penicilline 50.000 v/kg mi 6 gi hoc Metronidazol ung 7.5 mg/kg x 3 ln/ngy trong 5 ngy Khng n ung c nn nui n qua thng d dyf. Bin chng thn kinhg. Suy dinh dng nng

THY UI. nh ngha: Thy u l bnh nhim trng cp tnh do siu vi Varicella zoster.Bnh xy ra hu ht tr em, 90% tr di 3 tui, c bit tui mu gio v cp 1 2, nam v n mc bnh nh nhau.II. Chn on: da vo dch t, lm sng, cn lm sng.1. Dch t: cha chng nga thy u, cha mc bnh thy u, c tip xc vi bnh nhn thy u 2 3 tun trc.2. Lm sng: St, hng ban khong vi mm nhanh chng chuyn thnh bng nc sau 24 gi. Bng nc da t 3 10 mm, lc u cha dch trong, sau 24 gi ha c, nhiu la tui: dng pht ban, dng bng nc trong, dng bng nc c v bng nc gi nht l dng ng my, mt s trng hp c bng nc dng xut huyt. Bng nc c th mc nim mc ming, ng tiu ha, h hp, tit niu, sinh dc hay mt.3. Cn lm sng: CTM: BC c th bnh thng hay tng nh Phn lp siu vi, PCR Phng php min dch hc (phng php c nh b th, min dch hunh quang trc tip hoc ELISA) t c s dngIII. Chn on phn bit:1. Imptigo (chc l bng nc): do Streptococcus beta hemolytic nhm A, xy ra sau khi da b try xt, g my thy c vt trt khng lot c qung bao quanh.2. Nhim trng da3. Bng nc do Herpes simplex, da vo phn lp siu vi.4. Bnh tay chn ming do virus Coxsackie nhm AIV. iu tr:1. Nguyn tc iu tr: iu tr c hiu iu tr triu chng Pht hin v iu tr bin chng2. iu tr c hiu: Acyclovir 200, 400, 800mg Hiu qu cao nu s dng sm trong 24 gi sau khi khi pht 80mg/kg/ngy chia 4 ln (ti a 800mg/ln) ung iu tr 5 ngy hoc n khi khng xut hin thm bng nc mi Trng hp nng hoc bn SGMD nn tim tnh mch liu: 10 mg/kg mi 8 gi trong 7 ngy3. iu tr triu chng: Chng nga: khng histamin, Gim au, h st: Paracetamol Khng dng Aspirin v c th gy hi chng Reye Hi chng Reye: L bnh l gan no gp giai on u mc nu tr ung Aspirin gim au, h st Lo u, bn chn, kch thch, nng hn s hn m, co git do ph no, c th vng da, gan to, xut huyt ni tng Cls amoniac mu tng cao, H gim, tng ALT, AST v LDH. Dch no ty thay i khng c hiu ca vim mng no.4. iu tr bin chng: Bi nhim: Bristopen (Oxacilline 500mg, 1g/l): 100mg/kg ung hay tim mch nu nng Vim no

TAY CHN MINGNH NGHA:Bnh TCM l bnh truyn nhim di siu vi trng ng rut thuc nhm Cooxsakie Virus v Enterovirus EV71 gy ra. Biu hin chnh l sang thng da nim di dng bng nc cc v tr c bit nh ming, lng bn tay, lng bn chn, mng, gi. Bnh c th gy nhiu bin chng nguy him nh vim no, vim c tim, ph phi cp dn n t vong nu ko c pht hin sm v x tr kp thi. Bnh thng gp tr di 5 tui, nht l di 3 tui. Bnh xy ra hng nm, nht la thng 2 n 4 v thng 9 dn 12CHN ON XC NHBng nc ming, lng bn tay, lng bn chn, gi, mngPhn 2: rung git c, bt rt, chi vi, i long chong2a: git mnh t, ko ghi nhn khi khm, quy2b: git mnh nhiu 2 ln/30 pht, ghi nhn khi khm, hay git mnh km 1 trong cc du hiu sau Chi vi Run chi i long chong Ng g Mch > 150 ln/pht St cao ko h Yu lit chi 3: v m hi lnh, mch nhanh > 170 ln/pht, th nhanh, THA, co git, hn m (GCS < 10) 4: SHH, try mchCHN ON PHN BIT1. Bnh l c sang thng da St pht ban: sang thng ch yu la hng ban xen k t dng sn, thng c hch sau tai D ng da: sang thng dng hng ban a dng nhiu hn bng nc Vim da m: sang thng au , c m Thy u: sang thng bng nc nhiu la tui, ri rc tan thn, ko ch tp trung tay, chn ,ming2. Bnh l nhim trng Nhim trng huyt: sang thng da ko in hnh, bm mu vt chch, xut huyt di da, CRP mu tng VMN vi trng: sang thng da ko in hnh, thp phng, CRP mu tng, DNT m tng, ng gimCLS CTM KSTSR Trng hp nghi ng bin chng: H, CRP, ion , X quang phi KMM khi c SHH: th nhanh, rt lm ngc hay SpO2 < 92% Troponin I khi nhp tim trn 160 ln/pht Chc d ty sng C: khi c bin chng tkinh (t IIB). Trng hp BN SHH, try mch, ang co git hay kch thch qu mc s th hin khi tnh trng n nh Nu cha thc hin cn chc d sau khi th my hay khi BN t vong DNT c th bnh thng hay thay i theo huoesng bch cu tng nh, c th a nhn u th, m tng nh < 1g/l, ng ko gim Xn tm tc nhn gy bnh Pht hng, pht trc trng thc hin PCR (EV71, Coxsakie virus): t Iib Cy, phn lp virus t phn, bng nc, pht hngIU TRNguyn tc: t triu chng Theo di st, pht hin sm v t tch c bin chng Sd thuc an thn sm gim kch thischm trnh gy tng p lc ni sX tr 1 c th t ngoi tr, 2 phi nhp vin t 1: t ngoi tr H st, gim au bng Para V sinh rng ming Ngh ngi, trnh kch thch, Ti khm mi 1-2 ngy trong 7 ngy u ca bnh Dn d nhng du hiu cn ti khm ngay St cao 39 Th mt Git mnh, rung chi, chi vi, quy khc, bt rt Co git, hn m Yu chi Da ni bng 2:2a Phenobarbital 5-7mg/kg ung hay TB Ngh ngi, trnh kch thch Theo di M, N, HA, tri gic, ran n, SpO2 mxi 6-8 g Theo di st pht hin t bin chng2b An thn Phenobarbital 10mg/kg TB hay TTM Ngh ngi, trnh kch thch Th oxy, nm u cao 30 , c thng Theo di M, N, HA, tri gic, ran n, SpO2 mi 4-6 g Dng Immunoglobulin Ngy 1: 1g/kg TTM trong 6-8g Ngy 2: nh gi li nu tr v 2a hay ko dng, nu cn 2b hay 3 tip tc dng 1g/kg TTM trong 6-8g 3: Phenobarbital: nu c kch thch 10-20 mg/kg pha trong Glucose 5% TTm trong 30-60 pht Chng ph no Nm u cao 30 , c thng Th oxy, nu ko hiu qu nn t NKQ sm v th my khi SpO2 < 92% hay PaCO2 50 mmHg Khi th my cn tng thng kh. Gi PaO2 90-100 mmHg va PaCO2 25-35 mmHg (PaCO2 thp lm co mch no, gim lu lng mu ln no gy gim p lc ni s Hn ch dch: tng dch bng -3/4 nhu cu bnh thng iu chnh ri lon nc, in gii, toan kim v ng huyt, lu h Na mu v h ng huyt IGIV 1g/kg/ngy TTM trong 6-8g x 2 ngy Dng Dobutamin khi mch 170 ln/pht, bt u 5g/kg/ph, tng dn mi 15 pht cho n khi hiu qu Theo di M, N, HA, tri gic, ran phi, SpO2 mi 1-2 gi 4: x tr tng t 3, ko dng IGIV iu tr sc Th oxy Truyn dd in gii (NaCl 0.9% hoc LR) 5ml/kg/15 ph, nu ko c CVP theo di st du hiu ph phi (du hiu SHH, si bt hng, ran phi) Khi c CVP, iu chnh dch theo hng dn CVP v theo p ng lm sng Sd vn mch: Dopamin TTM bt u 5g/kg/ph, tng dn mi 15 pht cho n khi hiu qu, ti a 10 g/kg/ph Phi hp thm Dobutamin 5g/kg/ph, tng dn mi 15 pht cho n khi hiu qu, ti a 20 g/kg/ph iu tr SHH Thng ng th, ht sch m di\ Th oxy nu kh th hoc hn m, duy tr SpO2 trn 92% t NKQ sm, cho th my nu c cn nhng th hoc tht bi vi oxy, trnh thiu oxy mu ko di lm tng tnh trng ph no v tn thng a c quan dn n t vongKhng sinh: khi ko loi tr nhim trng huyt, VMNM hoc c bi nhimPHNG NGA V sinh c nhn, ra tay bng x phng (c bit sau khi thay qun o, t, sau khi tip xc vi phn, nc tiu, nc bt) Ra sch chi, vt dng, sn nh Cch ly tr bnh trong tun u tin

VIM MNG NO MI.TC NHNThng gp : Hib, PC, NMCTheo tui NM, Hib

Co git phc tp v ko diSau 72h KS thch hp

ng DNT 2 ln trong 24hPhn lng l fn c hnh ca vt cha

14. Tc nhn gy bnh:Vius:Rotavirus: tc nhn chnh tr