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1
B Y T
HNG DN CHN ON V IU TR
MT S BNH THNG GP TR EM
(Ban hnh km theo Quyt nh s 3312/Q-BYT ngy 07/8/2015
ca B trng B Y t)
H Ni, 2015
2
CH BIN TP
PGS. TS. Nguyn Th Xuyn
NG CH BIN
PGS.TS. L Thanh Hi
PGS. TS. Lng Ngc Khu
BAN BIN SON
GS.TS. Nguyn Gia Khnh
GS.TS. Trn nh Long
PGS.TS. Phm Nht An
PGS.TS. Nguyn Ph t
PGS.TS. Phan Hu Nguyt Dim
PGS.TS. Trn Minh in
PGS.TS. on Th Ngc Dip
PGS.TS. Khu Th Khnh Dung
PGS.TS. H S H
PGS.TS. L Thanh Hi
PGS.TS. L Th Minh Hng
PGS.TS.Nguyn Th Qunh Hng
PGS.TS. V Minh Phc
PGS.TS. L Tn Sn
PGS.TS. Nguyn Vn Thng
PGS.TS. Phm Vn Thng
PGS.TS. Nguyn Th Diu Thy
PGS.TS.o Minh Tun
PGS.TS.Ninh Th ng
PGS. TS. Bi Vn Vin
TS. BS. Nguyn Th Hng Giang
TS.BS. Nguyn Th Vit H
TS.BS. Nguyn Th Thu H
3
TS.BS. Trn Th Hng H
TS.BS. L Th Hng Hanh
TS.BS. Trn Kim Ho
TS.BS. Phan Th Hin
TS.BS. Nguyn Phm Anh Hoa
TS.BS. Trng Th Mai Hng
TS.BS. Nguyn Thanh Hng
TS.BS. Cao V Hng
TS.BS. Nguyn Th Thanh Hng
TS.BS. Nguyn Thu Hng
TS.BS. Bi Ngc Lan
TS.BS. Phng Tuyt Lan
TS.BS. Hunh Thoi Loan
TS.BS. Trn Th Chi Mai
TS.BS. Nguyn Vn Ngoan
TS.BS. Phan Hu Phc
TS.BS. Bi Phng Tho
TS.BS. Lu Th M Thc
TS.BS. Dng B Trc
TS.BS. H Mnh Tun
TS.BS. T Anh Tun
BSCKII. Nguyn Th Diu
BSCKII. Trnh Quang Dng
BSCKII. L Th Cng Hoa
BSCKII. Nguyn Th Minh Ngc
BSCKII. L T Nh
BSCKII. Phan Huy Thun
BSCKII. Nguyn Minh Tin
BSCKII. Trn Kinh Trang
BSCKII. Trnh Hu Tng
4
Ths.BS. Nguyn Th Vn Anh
Ths.BS. L Qunh Chi
Ths.BS. V Ch Dng
Ths.BS. L Ngc Duy
Ths.BS. L Th H
Ths.BS. L Th Thu H
Ths.BS. Trn Thu H
Ths.BS. Trnh Th Thu H
Ths.BS. Thin Hi
Ths.BS. Nguyn Thy Hng
Ths.BS. o Trung Hiu
Ths.BS. Nguyn Th Mai Hon
Ths.BS. u Vit Hng
Ths.BS. Chu Lan Hng
Ths.BS. Nguyn Mai Hng
Ths.BS. Nguyn Th Mai Hng
Ths.BS. Nguyn Ngc Khnh
Ths.BS. Nguyn Vn Lm
Ths.BS. Nguyn Ngc Qunh L
Ths.BS. Trng B Lu
Ths.BS. Nguyn Kin Mu
Ths.BS. Quch Thy Minh
Ths.BS. Thnh Ngc Minh
Ths.BS. Nguyn Hong Nam
Ths.BS. Nguyn Trn Nam
Ths.BS. Thi Thin Nam
Ths.BS. Cn Th Bch Ngc
Ths.BS. Nguyn Hu Nhn
Ths.BS. Giang Trn Phng
Ths.BS. L Hng Quang
5
Ths.BS. Phm Th Thanh Tm
Ths.BS. Phan Thnh Th
Ths. Tm l Nguyn Th Hng Thy
Ths.BS. V c Tr
Ths.BS. Nguyn Th Ngc T
Ths.BS. H Anh Tun
Ths.BS. Nguyn Minh Tun
Ths.BS. Trn Anh Tun
Ths.BS. Trn Th Hng Vn
Ths.BS. Nguyn Minh Tr Vit
Ths.BS. Chu Vit
ThS.BS. Phng ng Vit
BSCKI. Bi Vn
BSCKI. L Nht Trung
BS. Bch Vn Cam
BS. Ninh Quc t
BS. L Th Thu Hng
BS. Thc Thanh Huyn
BS. Trn Th Bch Huyn
BS. Trng Hu Khanh
BS.Nguyn Thu Vn
T TH K
Ths.BS. Trn Vn Hc
Ths.BS. Nguyn c Tin
Ths.BS. Ng Th Bch H
Ths.BS. Trng L Vn Ngc
Ths.BS. Nguyn c Thng
BSCKI. Bi Th Hng Hoa
6
MC LC
Trang
Danh mc cc t vit tt 10
Chng 1. NHI KHOA I CNG 14
1.Cc thi k pht trin ca tr 14
Chng 2. HI SC CP CU CHNG C 21
1. Nhn bit v x tr cc du hiu e da chc nng sng tr em 21
2. Cp cu c bn 34
3. Tip cn chn on v x tr bnh nhi kh th 50
4. Ngng th ngng tim 56
5. Vn chuyn an ton bnh nhn tr em 67
6. Nguyn tc tip cn v x l ng c cp tr em 73
7. X tr vt thng do ngi v sc vt cn 77
8. X tr ong t tr em 80
9. Rn cn 85
10. Sc tim tr em 93
11. Sc gim th tch tun hon tr em 97
12. Sc phn v tr em 103
13. Sc nhim khun 110
14. Ri lon nc in gii 118
15. Ri lon kim toan tr em 127
16. Ri lon Can xi v Ma gi mu 138
17. Ri lon Natri v Kali mu 143
18. Nui dng tnh mch cho bnh nhn nng hi sc cp cu 150
19. Tng p lc ni s 156
20. Hn m 164
21. Co git 171
22. Vim phi lin quan n th my 176
23. Nhim khun huyt trn bnh nhn t Catheter mch mu 181
Chng 3. S SINH 185
1. H ng huyt s sinh 185
2. Tng ng huyt s sinh 191
3. Hi chng ht phn su 196
4. Tng p lc ng mch phi dai dng tr s sinh 201
5. Vim rut hoi t s sinh 207
6. Bnh phi mn tnh tr s sinh 213
7. Cn ng ng mch tr non 218
8. Vng da tng Bilirubine gin tip 223
7
9. Bnh mng trong tr non 230
10.Bnh no thiu oxy thiu mu cc b 233
11. Suy h hp s sinh 238
12. Dinh dng qua ng tiu ha cho tr sinh non, nh cn 244
13. D on, nh gi, iu tr v tin lng tr s sinh c nguy c cao 250
Chng 4. H HP 258
1. Vim phi do Virus 258
2. Vim phi do vi khun tr em 262
3. Vim phi khng in hnh tr em 266
4. Kh th thanh qun tr em 269
5. Trn kh mng phi 272
6. Vim tiu ph qun cp tr em 275
7. D vt ng th 279
8. Vim m mng phi 283
Chng 5. TIM MCH 286
1. Tn ti ng ng mch 286
2. Vim c tim do virus 290
3. Suy tim huyt 293
4. Vim m mng ngoi tim 297
5. Vim ni tm mc nhim trng 303
6. Chn on v iu tr bnh Kawasaki 311
Chng 6. TIU HA DINH DNG 316
1. Tiu chy cp 316
2. Tiu chy ko di 325
3. To bn 330
4. Nhim k sinh trng ng rut tr em 335
5. au bng chc nng 344
6. Bnh tro ngc d dy thc qun 349
7. Xut huyt tiu ha 354
8. Lot d dy t trng tr em 362
9. Phc iu tr vim lot d dy Helicobacte Pylori ti bnh vin 366
10. Bnh suy dinh dng do thiu Protein Nng lng 370
11. Bnh ci xng do thiu Vitamin D tr em 377
12. Bo ph tr em 384
Chng 7. GAN MT 393
1. Cc nguyn nhn gy vng da mt tr em 393
2. Teo ng mt bm sinh 399
3. Tip cn suy gan cp tr em 403
8
Chng 8. THN TIT NIU 408
1. Tip cn chn on Protein niu 408
2. Tip cn chn on i mu 412
3. Nhim trng ng tiu 417
4. Hi chng thn h tin pht tr em 424
5. Bnh Lupus h thng tr em 430
6. Suy thn cp 437
7. Bnh thn mn 444
Chng 9. THN KINH 449
1. Nhc u tr em 449
2. Co git do st 455
3. ng kinh tr em 459
4. Chy mu trong s tr em 467
Chng 10. TRUYN NHIM 473
1. Bnh Chn Tay Ming 473
2. Vim mng no m 482
3. Vim no 489
4. Bnh cm 496
5. Bnh si 500
6. Chn on, iu tr st xut huyt Dengue 505
7. St rt tr em 517
8. Nhim trng huyt 524
Chng 11. HUYT HC 534
1. Tip cn chn on thiu mu 534
2. Thiu mu thiu st 539
3. Bnh Thalassemia 543
4. iu tr suy ty xng mc phi 551
5. Chn on iu tr xut huyt gim tiu cu nguyn pht tr em 557
6. Hemophilia 560
7. Hi chng thc bo mu 564
8. Thiu mu tn huyt cp 572
9. Thiu mu tn huyt min dch 579
Chng 12. UNG BU 586
1. Bch cu cp dng Lympho 586
2. Tip cn chn on v x tr khi u c thng gp 595
3. U nguyn bo thn kinh 602
4. St gim bch cu ht 612
Chng 13. NI TIT CHUYN HA DI TRUYN Y HC 617
1. Suy thng thn tr em 617
9
2. Tng sn thng thn bm sinh 621
3. H ng mu nng do cng Insulin bm sinh 626
4. Toan Xeton do i tho ng 632
5. i tho nht trung ng 638
6. Suy gip trng bm sinh 641
7. Long xng tr em 644
8. Dy th sm trung ng 648
9. Tip cn tr chm tng trng chiu cao v iu tr tr
chm tng trng do thiu ht hormon tng trng 654
10. Di truyn y hc v chm sc sc khe ban u 660
11. Tip cn chn on v nguyn tc iu tr cp cu cc ri lon
chuyn ha bm sinh 663
12. H ng mu trong cc RLCH bm sinh 668
13. Toan chuyn ha v toan Xeton
trong cc bnh ri lon chuyn ha bm sinh 672
14. Bnh thiu ht Enzym Beta - Ketothiolase 675
15. Tng Amoniac mu 678
16. Tng Lactate mu trong cc ri lon chuyn ha bm sinh 683
Chng 14. MIN DCH D NG KHP 685
1. Hen ph qun tr em 685
2. X tr cn hen ph qun cp tr em 694
3. Nhim trng ti din 700
4. D ng thc n tr em 710
5. D ng thuc 715
6. Vim khp t pht thiu nin 718
Chng 15. TM THN PHC HI CHC NNG 726
1. Ri lon tng hot ng gim ch tr em 726
2. Ri lon t k tr em 731
3. Ri lon TIC 739
4. Cc liu php tm l 743
5. Tm l bnh nhi nm vin 751
6. Ri lon gic ng tr em 756
7. Phc hi chc nng tr bi no 760
PH LC 769
1. T chc v trang b phng cp cu nhi 769
2. Nguyn tc s dng khng sinh trong nhi khoa 777
3. Khong tham chiu cc xt nghim huyt hc 784
4. Gi tr ha sinh bnh thng 790
10
T VIT TT
6MP 6- mercaptopurine
AFP Alpha feto Protein
ALL Bch cu cp dng Lympho
ALNS p lc ni s
ALOB p lc bng
BC Bch cu
BCN Bch cu non
BCTT Bch cu trung tnh
BP Bo ph
BPD Bronchopulmonary dysplasia
BUN Blood Urea Nitrogen
CADO French induction regimen consisting of
cyclophosphamide, adriamycin, vincristine, carboplatin
CCG Children Cancer Group
CLD Chronic lung disease
CMV Cytomegalo Virus
CO Cyclophosphamide, Vincristine
COJEC Rapid, platinum- containing induction schedule (CBDCA,
CDDP, CYC, VCR, VP16)
CPAP Continuous positive airway pressure
CRP C Reactive Protein
CTM Cng thc mu
BCN au bng chc nng
DD Dung dch
11
K ng kinh
M ng mch
MC ng mch ch
MP ng mch phi
T i tho ng
TDTE i tho ng tr em
EBV Epstein- Barr Virus
ELBW Extreme low birth weight
FAB French American British
GCSF Thuc kch bch cu
GIR Glucose influsion rate
HA Huyt p
Hb Hemoglobin
HC Hng cu
HCG Hormone Chorionique gonadotrope
HCTH Hi chng thn h
HI Hemophilus influenza
HPQ Hen ph qun
HSCC Hi sc cp cu
HSV Herpes simplex Virus
HVA Homovanillic acid
IDRF Image Defined Risk Factors
INPC International Neuroblastoma Pathology Classification
INRG International Neuroblastoma Risk Group
INSS International Neuroblastoma Staging System
12
IVC Inferior Vena Cava
LTS Life Threatening Symtoms
MBH M bnh hc
MIBG Meta- iodobenzylguanidine
MRD Bnh tn d ti thiu Minimal Residual disease
MRI Chp cng hng t
NBTK Nguyn bo thn kinh
NEC Necrotizing enterocolitis
NICU Neonate instensive care unit
NKBV Nhim khun bnh vin
NKHH Nhim khun h hp
NKM Nhim khun mu
NKQ Ni kh qun
NTT Nhim trng ng tiu
NTHH Nhim toan h hp
OMA Opsoclonus-myoclonus-ataxia
PCR Polymerase chain reaction
PDA Patent ductus arteriosus
PPHN Persistent pulmonary hypertension of the Newborn
PTNSLN Phu thut ni soi lng ngc
RA 13-cis Retinoic acid
RDS Respiratory dystress syndrom
RLCHBS Ri lon chuyn ha bm sinh
RNA Ribonucleic acid
RSV Respiratory Syncytial Virus
13
SDD Suy dinh dng
SGA Small for gestational age
SGC Suy gan cp
SGTTTH Sc gim th tch tun hon
SHH Suy h hp
SNK Sc nhim khun
SPV Sc phn v
TB Tim bp
TBS Tim bm sinh
TC Tiu cu
TM Tnh mch
TMC Tnh mch ch
TMTT Tnh mch trung tm
TNM Tumor Node Metastase H thng phn loi u hch, di
cn
TSB Total serum bilirubin
TVCH Thot v c honh
TVCHBS Thot v c honh bm sinh
TX Ty xng
VDM Vng da mt
VIP Vasoactive Intestinal Peptide
VMA Vanillyl mandelic acid
VMNM Vim mng no m
VP- Carbo Etoposide, Carboplatin
14
CHNG 1: NHI KHOA I CNG
CC THI K PHT TRIN CA TR
1. C IM CHUNG
Tr em khng phi l ngi ln thu nh m l mt c th ang ln ln v
pht trin. T lc th thai n tui trng thnh tr phi tri qua 2 qu trnh
chnh.
Qu trnh tng trng (pht trin v s): do s tng s lng v kch
thc t bo ca cc m.
Qu trnh trng thnh v cht (cu trc v chc nng hon chnh dn): do
s thay i v cu trc ca cc b phn dn n s thay i chc nng t bo.
Qu trnh ln ln v pht trin ca tr c tnh cht ton din c v th
cht, tm thn - vn ng v qua nhiu giai on. Mi giai on c nhng c
im v sinh l v bnh l ring.
T khi hnh thnh n khi trng thnh (15 - 20 tui) tr em tri qua 6
giai on pht trin: giai on bo thai, giai on s sinh; giai on nh nhi; giai
on rng sa; giai on thiu nin; giai on dy th. Cc giai on c c im
pht trin v nhu cu dinh dng khc nhau.
2. C IM CA TR QUA CC THI K
2.1. Thi k bo thai
Tnh t lc th thai n khi ra i (trung bnh 270 15 ngy) tnh t ngy
u tin ca k kinh cui cng. Thi k bo thai chia lm 3 giai on:
- Giai on th thai: ko di khong chng hai tun u ca thai k.
- Giai on pht trin phi: tun l th hai n th tm
- Giai on bo thai: t tun th chn n khi sinh
2.1.1. Giai on th thai v giai on pht trin phi:
- c im sinh l:
Giai on ca s hnh thnh v bit ho cc b phn. Phn ln cc giai
on pht trin cc c quan quan trng din ra trong 12 tun u. Nu c mt
yu t no lm nh hng n giai on pht trin, c bit thuc hay bc x th
cc d tt bm sinh s xy ra.
15
- c im bnh l:
3 thng u ca thai k l thi k hnh thnh thai nhi. Nu c iu g
can thip vo s pht trin ca cc c quan trong giai on ny th chng s
khng sa cha c sau ny
Trong thi k ny, nu m b nhim cc cht c (thuc hay ho cht),
hay b nhim virus nh nhim TORCH (Toxoplasmo, Rubeola, Cytomegalovirus,
Herpes simplex) th tr sinh ra d b d tt.
2.1.2. Giai on bo thai (tun l th chn n khi sinh)
- c im sinh l:
Sau khi phn ln cc c quan c hnh thnh, thi k bo thai dnh
ht hon ton cho s tng trng v hon chnh cc b phn. Rau thai hnh
thnh, m nui tr trc tip qua rau thai.
+ Tun th 13 14 thi k bo thai, gii tnh ca thai nhi c th c xc
nh.
+ Tun th 25 28: Tt c cc c quan b phn ca c th hon chnh v
y l giai on pht trin chiu di, cn nng ca thai nhi. T thng 3 n thng
th 6 tr di c 70% chiu di khi .
+ Tun th 37 41: l thi im thai nhi tng trng v trng lng c
th. Bo thai ln nhanh, c bit ba thng cui thai k t 700g qu II, tng mi
tun 200g trong qu III.
+ tr khe mnh thng minh th m khng c mc bnh v cn tng
10 -12 kg trong sut thi gian mang thai.
S tng cn ca m khi mang thai:
Thai k
Qu I
Qu II
Qu III
S cn m tng (kg)
0-2
3-4
5-6
B khe mnh l b khi sinh ra cn nng trung bnh l 3000gr (2500 -
3500gr), di trung bnh 50cm (48 -52cm) v khng c d tt bm sinh.
- c im bnh l: trong giai on ny, dinh dng ca thai nhi c
cung cp t ngi m qua rau thai. Nu ngi m khng dinh dng hay
tng cn km hoc m c vn v rau thai th tr sinh ra d c cn nng thp
lc sinh v t l t vong cao. non d xy ra trong 3 thng cui do rau thai
khng cn l hng ro vng chc bo v thai na.
16
2.2. Thi k s sinh: t lc ct rn cho n 4 tun l u.
2.2.1. c im sinh l
- S chuyn tip t i sng trong t cung sang ngoi t cung buc tr
phi c s thay i chc nng ca mt s c quan thch nghi vi cuc sng
mi nh hot ng ca b my h hp, b my tun hon. Trong cc c quan th
s thch nghi ca phi l quan trng nht. Nh th tt, h tun hon cng thch
nghi nhanh chng v h thn kinh nht l v no cng c kin ton.
- Ngay sau khi ra i, tr bt u th bng phi v vng tun hon chnh
thc thay cho tun hon rau thai. S thch nghi ca b my tiu ho, gan thn
bt u cng vi ba n u tin ca tr.
- B no tr cn non nt nn tr ng nhiu 20gi/ngy do v no trong
trng thi c ch. Tuy ng nhiu nhng tr bit git mnh khi c ting ng
mnh. Tr khng t ch c mi ng tc v c mt s phn ng t nhin ton
thn nh tng trng lc c nh.
- H tiu ha: nim mc ng tiu ha cha hon thin, cha c men
tiu bt. Thc n duy nht ca b l sa m hoc sa thay th. Tr bit b m
ngay t khi sinh ra. Tr khng thch ung nhng cht ng, chua, cay v rt
thch ngt v vy khng nn cho tr ung nc ng, sa b trc khi b m v
tr s ch sa m. Tr c kh nng ngi mi sa ca m qua nhn c m
v tm c v m.
- Cn nng: tr bnh thng, mi ngy trung bnh tr tng 15gram. Trung
bnh khi 1 thng tr nng t 3500 kg - 4500 kg. Chiu cao: tng khong 2cm.
2.2.2. c im bnh l
- V tr bt u thch nghi vi mi trng bn ngoi nn nhiu yu t c
th cn tr s thch nghi ca tr v gy t vong cao trong 24h u hoc tun u
tin sau sinh.
- Cc bnh l hay gp:
+ Sang chn sn khoa: gy ngt, xut huyt no, gy xng.
+ Glucose mu tr s sinh thp nn cn cho tr b sm sau khi sinh.
+ H thng min dch cn non yu nn tr d b nhim trng nh nhim
trng rn, phi, no, nhim trng huyt. Tuy vy nh c khng th t m chuyn
sang nn tr t b cc bnh nh si, bch hu...
- Cc bnh vng da tng bilirubin t do.
+ Do vy vic sn sc tt nht cho tr s sinh l chm sc tt trong giai
on trc sinh rt quan trng nhm hn ch vic kh, nhim trng nhm h
17
thp t vong s sinh. B m phi c khm thai nh k. V sinh cho tr, tr
sng trong iu kin sch s v sa m.
2.3. Thi k nh nhi (b m): t 2 thng n 12 thng tui
- c im sinh l: trong thi k ny tr ln rt nhanh.
+ Cn nng: trung bnh, 6 thng u tr nng gp i cn nng lc sinh
(khong 5-6kg) v n thng th 12 tr nng gp 3 (trung bnh t 9 kg - 10kg)
so vi lc .
+ Chiu cao: mi thng tng 2 cm. n 12 thng tr cao gp ri lc sinh
(trung bnh tr cao t 74cm - 78cm)
+ Vng u: tng 10cm (34+10= 44cm). T chc no tng nhanh t ti
75% so vi ngi ln (900g).
+ H tiu ha: hon thin dn v khi 4 thng bt u c kh nng tiu
ho c tinh bt v cc thc phm khc ngoi sa. Tr bt u mc rng
sa:
+ Cng thc tnh s rng sa = s thng 4.
Lp m di da pht trin mnh nn trng tr b bm do vy tr cn b
i hi nhu cu nng lng cao hn ngi ln trong khi chc nng ca b
my tiu ho cn yu, cc men tiu ho cn km nn d b ri lon tiu ho v
dn n suy dinh dng nu nui dng khng ng cch. V vy thc n tt
nht l sa m. Tr cn 120 - 130 calo/kg c th/ngy.
Cng vi s pht trin mnh v th cht, tr bt u c s pht trin tinh
thn, tr tu v vn ng.
+ Thn kinh: cng bt u pht trin, tr bt u nhn ra cc vt,
khun mt. Tp ci ni giao tip vi mi ngi xung quanh, 2 thng hng
chuyn, 3 thng ci thnh ting, chm ch nhn vo vt c mu , en, trng.
12 thng bit ch tay vo vt mnh a thch. Phn bit c li khen v cm
on.
+ Vn ng: tr tp b, ng, i. 3 thng bit ly, 8 thng bit b, 9 thng
bit hoan h, 12 thng bit i.
+ Ngn ng: 9 thng bt u pht m b, ba, m.
12 thng pht m c 2 m.
2.3.1. c im bnh l: sau 6 thng tr d mc cc bnh nhim trng.
Tr d b tiu chy cp, tiu chy ko di, nn, chn n do chc nng ca
h tiu ho cha hon chnh nht l tr khng b m. tr c nui bng sa
m cc ri lon d dy-rut t gp v nh hn tr nui nhn to.
18
- Tc pht trin nhanh cng h tiu ho km nn tr d b suy dinh
dng, thiu vitamin, thiu mu. Ngoi ra cc thc n nhn to thng thiu cc
vi cht cn thit, cc vitamin v t l phn b cc cht khng hp l.
- Trung tm iu nhit v da ca tr cng cha pht trin y , qu trnh
c ch v hng phn vn c xu hng lan to nn cc yu t gy bnh u c
th phn ng ton thn do tr d b h thn nhit hoc st cao co git, phn
ng no, mng no.
- Trong 6 thng u tr t b cc bnh nhim trng cp nh si, bch hu...
do khng th t m (IgG) truyn sang qua rau cn tn ti c th tr.
- Cng v sau, min dch t m truyn sang gim dn, trong lc h
thng min dch ca tr hy cn non yu nn tr d mc cc bnh ly nh vim
phi, vim mng no, bch hu, si. Tr hay b chn thng do ng v bt u
tp i.
2.4. Thi k rng sa: (Thi k trc khi i hc)
T 1n 6 tui. C th chia lm 2 thi k nh: Tui nh tr: 1 - 3 tui, tui
mu gio: 4 - 6 tui.
2.4.1. c im sinh l
Trong thi k ny tr tip tc ln v pht trin nhng tc ln chm hn
giai on trc. Chc nng vn ng pht trin nhanh, tr bt u i mt mnh
ri chy, tp v, vit, tr t xc thc n, ra tay, ra mt Tn hiu th hai,
ngn ng pht trin. Tr bt u i hc. Tr la tui mu gio c c im
hiu ng. Cc c pht trin mnh nhng trng lc c dui nh hn c gp
nn tr khng ngi lu c.
- Cn nng: mi thng tng t 100gram - 150gram. T l m trong c th
thp nht so vi cc la tui nn nhn tr c v gy m.
- Chiu cao: mi nm tng 5cm chiu cao. 6 tui tr cao t 105cm -
115 cm.
Cng thc tnh chiu cao cho tr > 1 tui:
X (cm) = 75 + 5 (N -1)
(X= chiu cao; N= s tui tnh theo nm)
Vng u bng ngi ln (55cm), t chc no trng thnh bng 100%
ngi ln.
- H tiu ha: hon thin, tr mc 8 rng hm
- Hot ng: tr t m, hot ng nhiu, ham hc hi, thch t lm vic.
C nhng hot ng giao tip, ham chi hn n.
19
2.4.2. c im bnh l
Xu hng bnh t lan to. la tui ny tr cng rt d b cc ri lon
tiu ho, ci xng, cc bnh v th tng. Trong thi k ny min dch th ng
t m chuyn sang gim nhiu nn tr hay mc cc bnh nh cm, ho g, bch
hu, thng b bnh ly do i sng tp th.
Xut hin cc bnh c tnh cht d ng: hen ph qun, m ay cp, vim
cu thn cp. Tr hot ng nhiu nn hay b cc tai nn, chn thng, ng c,
bng...
2.5.Giai on thiu nin: tui hc ng.
C 2 thi k: tui hc sinh nh: 7 -
20
- Chiu cao cng pht trin nhanh hn trong nhng nm u, cn tranh
th giai on ny tng chiu cao ca tr. Tng t 5-8 cm/nm vi n v 5,5-9
cm/nm vi nam sau chiu cao tng chm dn. Chiu cao ca n dng li khi
19-21 tui v nam l 20-25 tui.
Cn nng p dng cng thc:
X (kg) = 21 + 4 (N-10)
(X= cn nng; N= s tui tnh theo nm)
2.6.2. c im bnh l
- Trong thi k ny thng xy ra s mt n nh trong cc chc nng ca
h giao cm - ni tit, nn thng thy nhng ri lon chc nng ca nhiu c
quan nh hay hi hp, tng huyt p, nhng ri lon v thn kinh: tnh tnh thay
i, d lc quan nhng cng d bi quan hay c nhng suy ngh bng bt...
- V bnh tt: giai on ny tr thng t bnh tt hn c, tuy nhin t t
v cc bnh tm thn li xut hin nhiu .
Tm li:
- S ln ln v pht trin ca tr em tri qua 2 giai on c bn bao gm 6
thi k. Ranh gii gia cc thi k ny khng r rng m thng xen k nhau.
Ngoi ra cn c mt s yu t tc ng khng nh n qu trnh ln ln v pht
trin ca tr hoc nh hng n dung mo bnh tt ca tr nh ngoi cnh, mi
trng sng ca tr (yu t ngoi sinh).
- Mi mt la tui c c im sinh l v bnh l ring, nu p dng ch
chm sc v nui dng ng, tr s c mt sc kho tt. Tr cn c s chm
sc tt ca gia nh, x hi v cch nui dng ng. xc nh tr cht
dinh dng hay cha cch tt nht l theo di cn nng v khm sc kho ca
tr mi thng can thip kp thi, trnh hu qu lu di.
- Do nhim v ca nhng cn b Nhi khoa l phi nm vng nhng c
im ca cc thi k trn, to iu kin m bo cho s ln ln v pht trin
ca tr c tt.
TI LIU THAM KHO
1.Ti liu ging dy ca b mn nhi Hu (gio trnh ca b mn nhi Hu)
2. Bi ging Nhi Khoa ca B Mn Nhi- Trng i hc y khoa TP HCM
(2000).
3. Bi ging Nhi Khoa tp 1 B Mn Nhi- i hc Y Khoa H Ni (2006).
21
CHNG 2: HI SC CP CU CHNG C
NHN BIT V X TR CC DU HIU E DA
CHC NNG SNG TR EM
T vong bnh vin thng xy ra trong vng 24 gi u nhp vin.
Phn ln cc trng hp t vong ny u c th ngn nga c nu tr b bnh
nng c pht hin sm v x tr ngay sau khi n bnh vin .
Vic nhn bit cc du hiu e da chc nng sng l mt quy trnh sng
lc nhanh tr bnh, c th xp tr vo cc nhm sau:
- Tr c du hiu cp cu cn iu tr cp cu ngay lp tc.
- Tr c du hiu cn u tin cn c khm u tin trong lc i, phi
c nh gi v c iu tr khng chm tr.
- Tr khng cp cu l nhng tr khng nng, c cc du hiu khng
nm trong 2 nhm trn.
1.CC DU HIU E DA TNH MNG bao gm:
* Tc nghn ng th * Suy h hp nng
* Tm ti trung tm * Cc du hiu sc
* Hn m * Co git
Tr c du hiu cp cu cn iu tr ngay lp tc ngn nga t vong.
Tr c du hiu cn u tin l nhng tr c nguy c t vong cao. Nhng
tr ny cn c nh gi ngay, khng chm tr.
2.NHN BIT DU HIU E DA TNH MNG
Vic nhn bit cc du hiu ny phi c thc hin ni tip nhn bnh
nhn trong bnh vin, trc khi lm bt k th tc hnh chnh no nh th tc
ng k khm HOC ngay khi bnh nhn nhp khoa cp cu. Do phi t
chc mt trnh t bnh nhn khi n vin tun theo. Tr phi c phn loi
trc khi b m ngi vo phng i. Cn c mt y t nh gi nhanh tnh trng
tng tr trc khi cn v trc khi lm th tc ng k khm
2.1. nh gi ban u ng th v th
Nhn bit du hiu suy h hp
22
Th gng sc
Khi mc th gng sc tng ln l biu hin nng ca cc bnh h hp.
Cn nh gi cc ch s sau y:
Tn s th
Cn s dng nhp th nh l cng c nhn nh s thay i lm sng
tt ln hay xu i.
Khi c biu hin ri lon nhp th, th nhanh tng thng kh do bnh
ca phi hoc c cn tr ng th, hoc toan mu. Nhp th chm th hin suy
yu sau gng sc, tng p lc ni s hoc giai on gn cui.
Bng 1.Nhp th bnh thng ca bnh nhn theo tui
Tui Nhp th (ln/pht)
12
30 40
25 35
25 30
20 25
15 20
Rt lm lng ngc
Co rt c lin sn, h sn v cc hm c u th hin th gng sc.
Mc rt lm th hin mc kh th. Khi tr th gng sc lu v suy yu
i, th du hiu rt lm lng ngc cng mt i.
Ting n th ht vo, th ra
Ting th rt th ht vo (stridor) l du hiu ca tc nghn ti vng hu
v thanh qun. Kh kh gp nhng tr c tc nghn ng h hp di v
thng nghe thy th th ra.Th th ra ko di cng th hin c tc hp ng
th di. Mc to nh ca ting n khng tng ng vi nng ca bnh.
Th rn
y l du hiu rt nng ca ng th v c trng tr nh b vim
phi hoc ph phi cp. Cng c th gp du hiu ny nhng tr c tng p
lc ni s, chng bng hoc vim phc mc.
S dng c h hp ph
Cng nh ngi ln, khi cn th gng sc nhiu hn c th cn s dng
n c c n chm.
23
Php phng cnh mi
Du hiu php phng cnh mi hay gp tr nh c suy th
Th ht ra
y l du hiu khi thiu oxy nng v c th l du hiu ca giai on
cui.
Hu qu ca suy th ln cc c quan khc
Nhp tim
Thiu oxy dn n nhp tim nhanh tr ln v tr nh. Tr quy khc v
st cng lm tng nhp tim, lm cho du hiu ny khng c hiu. Thiu oxy
mu nng hoc ko di s lm nhp tim chm v l giai on cui.
Mu sc da
Thiu oxy mu (do gii phng catecholamine) gy co mch v da nht.
Tm ti l du hiu nng biu hin giai on cui ca thiu xy mu. Cn phn
bit vi tm do bnh tim.
Tri gic
Tr c thiu oxy hoc tng CO2 mu s kch thch vt v hoc li b. Khi
bnh nng ln trng thi li b s r rt hn v n mc hn m. Nhng du hiu
ny c bit c gi tr nhng thng kh thy tr nh.
nh gi li
Ch theo di nhp th, mc rt lm, vv... l c nhng thng tin quan
trng, nhng cha . Cn thng xuyn nh gi li pht hin xu hng
din tin lm sng ca bnh nhn.
2.2.Bc u nh gi tun hon (Circulation)
Nhn bit nguy c suy tun hon
Tnh trng tim mch
Nhp tim
Nhp tim c th tng ln giai on u ca sc do s gii phng
catecholamin v b li mt dch. Nhp tim, c bit l tr nh, c th rt cao
(n 220 nhp/pht).
Bng 2. Nhp tim v huyt p tm thu theo tui
Tui (nm) Nhp tim (ln/pht) HA tm thu (mmHg)
12
110 160
100 - 150
95 140
80 120
60 - 100
70 90
80 - 95
80 100
90 110
100 120
24
Mch chm bt thng, nhp tim chm, l khi nhp tim t hn 60 ln/pht
hoc gim nhp tim nhanh chng cng vi biu hin suy gim cp mu. y l
du hiu nng giai on cui.
ny ca mch
C th trong sc nng, huyt p vn duy tr c, du hiu ch im l cn
so snh ny ca mch ngoi bin v trung tm. Khi khng bt c mch
ngoi bin v mch trung tm bt yu l du hiu ca sc, v c tt huyt p.
Mch ny mnh c th gp trong c khi tng th tch tun hon (v d, trong
nhim khun huyt), cu ni ng tnh mch trung tm (v d, cn ng ng
mch) hoc khi c tng CO2 mu.
Du hiu y mao mch tr li (refill)
Khi thi gian y mao mch tr li ko di hn th hin gim cp mu
ngoi bin. Khng nn s dng ring l cc du hiu ny nh gi sc hoc
nh gi mc p ng vi iu tr.
Huyt p ng mch
Bng 3. Huyt p tm thu theo tui
H huyt p l du hiu mun ca giai on cui ca suy tun hon. Khi
c h huyt p l sp c nguy c ngng tim. Tng huyt p c th l nguyn
nhn hoc l hu qu ca hn m v tng p lc ni s.
nh hng ca suy tun hon ln cc c quan khc
C quan h hp:
Nhp th nhanh, su nhng khng c co ko lng ngc, l hu qu ca
toan mu do suy tun hon gy ra.
Da
Da m, lnh, nht nht vng ngoi bin l biu hin ca gim cp mu.
Khu vc da lnh c th gn vng trung tm hn nu suy tun hon tip tc
nng ln.
Tui (nm) Huyt p tm thu (mmHg)
12
70 90
80 95
80 - 100
90 110
100 120
25
Tri gic
Tr c th kch thch vt v hoc l m, li b n hn m nu c suy tun
hon. y l hu qu ca gim cp mu no.
Nc tiu
Lng nc tiu t hn 1 ml/kg/gi tr v t hn 2 ml/kg/gi tr nh
nhi l du hiu gim cp mu thn trong sc. Cn khai thc nu c thiu niu
hoc v niu trong bnh s.
Suy tim
Nhng du hiu sau s gi suy th do nguyn nhn tim mch:
Tm, khng p ng vi oxy
Nhp tim nhanh khng tng ng vi mc kh th
Gan to, tnh mch c ni
Ting thi tm thu/ nhp nga phi, khng bt c mch i
2.3. nh gi ban u chc nng thn kinh
Nhn bit nguy c tn thng thn kinh trung ng
Thiu oxy t chc hoc sc u c th gy ri lon thc. V vy, bt c
ri lon no xy ra khi nh gi theo ABC cng phi c xem xt trc khi kt
lun ri lon thc l do nguyn nhn thn kinh.
Chc nng thn kinh
Mc tri gic
C th nh gi nhanh thc ca bnh nhn mt trong 4 mc sau y:
A: Tnh to (ALERT)
V: p ng vi li ni (VOICE)
P: p ng vi au (PAIN)
U: Khng p ng (UNRESPONSIVE)
T th
C nhiu tr mc nhng bnh nng cc c quan c biu hin gim
trng lc c. Nhng t th co cng nh bc v (tay co, chn dui) hoc mt
no (tay dui, chn dui) l biu hin tn thng no tr em. Du hiu c cng
v thp phng tr nh gi v bnh vim mng no.
26
ng t
Nhiu loi thuc v tn thng no c th lm thay i kch thc v
phn x ca ng t. Nhng du hiu ng t quan trng cn tm l: gin ng
t, ng t khng phn x, hoc ng t 2 bn khng cn xng l nhng du
hiu tn thng no nng.
nh hng n h h hp do tn thng thn kinh trung ng
C nhng kiu th bt thng do tng p lc ni s. Nhng kiu th ny
c th thay i t mc tng thng kh cho n kiu th Cheyne Stokes hoc
ngng th. Nhng kiu th bt thng ny bnh nhn hn m chng t c tn
thng no gia v no sau.
nh hng n h tun hon do tn thng thn kinh trung ng
Khi c du hiu chn p hnh no do tt kt thng km theo tng huyt
p v nhp tim chm (p ng kiu Cushing). y l du hiu ca giai on
cui.
2.4. Khm ton thn
Nhit
Khi tr c st thng gi n nguyn nhn bnh l do nhim trng,
nhng cng c th st l do co git hoc rt run ko di.
Pht ban:
Khm ton thn tr c th thy cc dng pht ban, t dng mn gp trong
phn ng d ng; hoc ban xut huyt, t mu trong nhim khun huyt hoc tr
b xm hi, hoc m ay ln c phng nc gp trong phn ng d ng v mt
s dng nhim trng.
3. CCH TIP CN MT TR B BNH NNG
X tr cp cu mt tr cn phi nh gi nhanh v can thip kp thi. Cc
bc tip cn mt tr b bnh nng gm:
1. nh gi bc u
2. Hi sc
3. nh gi bc hai v tm nhng vn mu cht
4. X tr cp cu
5. n nh v vn chuyn bnh nhn n n v iu tr
3.1. nh gi bc u v hi sc
ng th (Airway)
27
nh gi ban u: nh gi s thng thong ng th theo trnh t:
Nhn di ng lng ngc v bng
Nghe thng kh phi
Cm nhn lung kh th ch c hiu qu khi bnh nhn th t nhin.
Nu tr ni c hoc khc c chng t ng th thng thong, h
hp m bo.
Nu tr t th, ch n cc du hiu khc c th gi tc ng h hp
trn nh:
Ting th rt
Cc du hiu co ko
Nu khng c bng chng chc chn v s lu thng ca ng th th
lm k thut n hm v nng cm, sau nh gi li. Nu ng th vn cha
lu thng th c th tin hnh m ming bnh nhn v thi ngt.
Hi sc
Bng cc k thut: nhn, nghe v cm nhn m thy ng th khng
thng thong th c th m thng ng th bng:
K thut nng cm v n hm
iu chnh t th bnh nhn m bo s thng thong
C th t ni kh qun (NKQ) nu thy cn thit.
H hp (Breathing)
nh gi ban u
ng th thng thong cha chc thng kh y . Thng kh ch
t c hiu qu khi c s phi hp ca trung tm h hp, phi, c honh v
cc c lng ngc.
Hi sc
S dng oxy lu lng cao (15lt/pht) cho nhng bnh nhn c ri lon
h hp hoc thiu oxy t chc. Nhng bnh nhn c suy h hp cn c thng
kh vi oxy qua mt n c van v ti hoc t ng NKQ v cho th p lc dng
ngt qung.
Tun hon (Circulation)
nh gi ban u
Cc bc nh gi tun hon c m t.
28
Hi sc
Tt c cc trng hp suy tun hon (sc) nn c cho th oxy qua mt
n, hoc qua ng NKQ (nu cn phi t ng kim sot ng th).
S dng ng truyn tnh mch hoc ng truyn trong xng
truyn ngay dung dch in gii hoc dung dch keo vi lng dch l 20ml/kg
v ly cc mu mu xt nghim ngay thi im ny.
nh gi chc nng thn kinh
nh gi ban u
Thiu oxy t chc hoc sc u c th gy ri lon thc. V vy cn
nh gi theo ABC trc khi xem xt cc ri lon thc l do nguyn nhn thn
kinh. Thm na, cn lm test ng mu trc bt c tr no c suy gim tri
gic hoc co git.
Hi sc
Nu bnh nhn c ri lon thc mc P hoc U (ch p ng vi
au hoc khng p ng), phi cn nhc t ng NKQ kim sot ng th.
iu tr h ng huyt bng dung dch glucoza 10% 2ml/kg. Trc khi truyn
ng, ly mu xt nghim ng v cc xt nghim.
3.2. nh gi bc hai v iu tr cp cu
Ch c thc hin sau khi tin hnh nh gi ban u v iu tr cc
du hiu e do tnh mng. nh gi bc hai gm hi bnh s, thm khm lm
sng v lm cc xt nghim c hiu. Do thi gian c hn nn vic tip cn phi
tp trung vo nhng vn thit yu. Khi nh gi bc hai xong, bc s phi
hiu hn v bnh ca tr v c chn on phn bit. Vic iu tr cp cu giai
on ny l ph hp, c iu tr tnh trng chuyn bit (nh hen ph qun) ln
iu tr hi chng (tng p lc ni s).
H hp nh gi bc hai
Cc triu chng h hp thng gp:
Triu chng
Kh th
S mi
Ho
Th n o (th rn, th rt, kh kh...)
Khn ting
Khng ung c
au bng
Du hiu
Nhp th nhanh
Co rt lng ngc
Th rn
Cnh mi php phng
Th rt
Kh kh
Lp bp thnh ngc
29
Tm ti
Co rt lng ngc
au ngc
Ngng th
Khng n c
Nhp th nhim toan
Kh qun b y lch
Ting g bt thng
Nghe ting ran n
Xt nghim
o lu lng nh nu nghi ng hen, chp XQ phi, kh mu ng mch,
bo ho oxy.
iu tr cp cu
Nu nghe thy ting lc sc do ng th c nhiu dch th phi ht m
di.
Khi c th rt kt hp vi ho ng ng v kh th nng th ngh n vim
tc thanh qun nng, iu tr bng kh dung adrenalin 1 5ml v oxy.
Nu c ting rt nh v tr mt th xem c vim np thanh mn khng, tuy
nhin bnh ny him gp. C th lin h bc s gy m tr gip. Khng nn
c cc can thip th bo vo ng th.
Nu bnh ca tr khi pht t ngt v c tin s sc r th ngh n d
vt thanh qun. Lm cc bin php tng d vt ra ngoi khng thnh cng th
phi soi thanh qun gp d vt. Khng c can thip th bo vo ng th.
Khi cn, lin h vi bc s gy m m kh qun gp.
Ting th rt xy ra sau khi bnh nhn tim hoc n phi d nguyn th
ngh n phn v. Cho adrenalin 1 10g/kg, tim bp.
Nhng tr c tin s hen ph qun, th kh kh, suy h hp nng, lu
lng nh gim hoc thiu oxy t chc th phi c iu tr bng kh dung cc
thuc ch vn 2 v ipratropium vi O2.
i vi tr b nhim toan, cn ly mu lm kh mu v ng mu. iu
tr nhim toan do i ng bng huyt thanh mn 9 v insulin
30
Tun hon (Circulation): nh gi bc hai
Cc du hiu lm sng thng gp:
Triu chng
Kh th
St
Nhp tim nhanh
n ung kh
Tm ti
Xanh xao
Gim trng lc c
Tnh trng ng g
Mt dch
Thiu niu
Du hiu
Nhp tim nhanh
Nhp tim chm
Ri lon nhp v bin mch
Mu sc v ti mu da bt thng
Gim HA
Tng HA
Ri lon nhp th v bin th
Gan to
Phi c ran
Cc ting thi tim
Ph ngoi bin
Tnh mch c ni
Cc xt nghim
Ur, in gii , kh mu, XQ phi, in tm , cng thc mu, cy mu.
iu tr cp cu
Bolus dch nu bnh nhn sc, khng p ng vi ln bm dch th nht.
Cn nhc dng thuc vn mch v t NKQ nu phi bolus dch ln 3.
Cn nhc vic s dng khng sinh TM trong trng hp tr sc nu
khng c du hiu mt nc v c th l nhim khun mu.
Nu bnh nhn c ri lon nhp tim th dng phc lon nhp thch hp.
Nu sc phn v th dng adrenalin TB liu 10mcg/kg v theo phc sc
phn v.
31
Thn kinh (disability)
nh gi bc hai: Cc triu chng thng gp
iu tr cp cu
Nu co git ko di, dng phc x tr trng thi ng kinh
Nu c bng chng ca tng p lc ni s nh mt thc cp tnh, t th
bt thng hoc phn x vn ng nhn cu bt thng, tr cn c t ng
NKQ v thng kh nhn to. Cn nhc dng manitol 0,5g/kg tnh mch.
Nu tri gic gim hoc co git, cn ngh n vim mng no hoc vim
no v cho cefotaxim/acyclovir.
Nu tr l m v th yu, cn kim tra ng mu, kh mu, nh lng
salicylate trong mu. iu tr nhim toan do i ng bng huyt thanh mn
9 v insulin.
Nu tr hn m, ng t co nh th ngh n ng c opiate, c th dng
th naloxone.
Triu chng
au u
Co git
Thay i hnh vi
Ri lon thc
Gim vn ng
Ri lon th gic
St
Du hiu
Ri lon thc
Co git
Kch thc ng t v phn x nh sng
thay i
T th bt thng
Phn x mt no bt thng
Cc du hiu mng no
Ph gai th v xut huyt vng mc
Phn x gn xng thay i
Tng huyt p
Mch chm
Xt nghim
Ur, G, ng mu, cy mu (c chn lc)
32
Khm ton thn (exposure)
nh gi bc hai
Cc triu chng thng gp
Triu chng
Ban d ng
Sng mi, li
St
Du hiu
Ban hoi t
My ay
Ph mch
iu tr cp cu
Nu tr c triu chng ri lon tun hon v thn kinh, c ban xut huyt
th gi c nhim khun huyt hoc vim mng no m, iu tr bng cefotaxim
v cy mu.
Nu tr c triu chng h hp, tun hon, c ban m ay hoc ph mch
th gi c sc phn v, iu tr bng epinephrin 10 mcg/kg tim bp.
Tiu ho
Cp cu tiu ho thng gp l sc do mt dch. iu ny d nhn thy
khi nh gi ban u v tun hon hoc nh gi bc hai v tim mch.V cng
cn tm loi tr cc du hiu ngoi khoa.
Bnh s b sung
Mi trng sng v s pht trin ca tr
c bit l i vi tr nh v tr nh nhi, hiu bit v qu trnh pht trin,
tim chng v hon cnh gia nh ca tr rt hu ch. Ngi nh c th nh cc
bnh mc ca tr.
Thuc v d ng
Nu nghi ng tr b ng c th phi quan tm n tin s dng thuc
nh hoc iu tr trc .
TM TT
Cc bc nhn bit cc du hiu e da chc nng sng cho php thy
thuc chn on v iu tr bnh ca tr trong nhng gi u mt cch thch
hp. nh gi ban u v hi sc nhm duy tr chc nng sng c bn, nh gi
bc hai v iu tr cp cu cho php iu tr c hiu hn. Giai on iu tr
xc nh i hi ngi thy thuc phi lm tng bc, c h thng trnh b
st nhng du hiu thay i trn lm sng.
33
TI LIU THAM KHO
1. Simon Nadal, Nirajan, Suchitra R (2008) Recognition and intial
Management of Shock Roger textbook of PICU 4th edition William & Willkins,
p 372- 380.
2. Advanced Paediatric Life Support: The Practical Approach, Chapter 7
The structured approach to the seriously ill childFifth Edition Australia and
New Zealand 2012. , p 207-218
3. Bebra L, Weinner (2008) Respiratory Distress Texbook of Pediatric
Emergency Medecine, 4th
p 553-564.
34
CP CU C BN
1. GII THIU
Cp cu c bn trong nhi khoa l vic p dng chnh xc cc k thut cp
cu c bn theo kch thc ca tr. Ranh gii gia cc la tui c p dng:
tr nh nhi (di 1 tui) v tr nh (di 8 tui).
tr em, nguyn nhn chnh gy suy h hp - tun hon l do thiu oxy.
V vy, vic cung cp oxy cho tr cn cn thit hn c vic chng rung tht. y
l iu khc bit chnh so vi phc cp cu p dng cho ngi ln.
2. NH GI V IU TR
Sau khi tr c tip cn an ton, nh gi mc tri gic bng
phng php n gin, tin hnh nh gi v x tr tr theo trnh t A - B - C.
Trnh t cp cu c bn chung cho tr b ngng th - ngng tim c tm tt
trong hnh.1.
Ch : Hng dn ny dnh cho mt hoc nhiu ngi cp cu.
35
S cp cu c bn
D Nguy him?
R Hi : Chu c b sao khng
S Gi ngi h tr
A M thng ng th
B
Nhp th bnh thng ?
Thi ngt 2 ln
C
Kim tra mch
Khng qu 10 giy
Bt u CPR
15 p tim : 2 ln thi ngt
D
Kt ni my shock in
Chc chn gip ang n
Tip tc CPR cho n khi tr c p ng
Hoc nhp th bnh thng
Thng 4 2011, Hip hi hi sc c v New Zealand dnh cho o
to cc nhn vin y t.
Xem s gc ti www.resus.org.au
36
Tip cn ban u: Danger, Responsive, Send for help (DRS)
Ngi cp cu khng c mnh tr thnh nn nhn th hai,
a tr phi c thot khi s nguy him cng nhanh cng tt. Nhng
vic ny phi c thc hin trc khi tin hnh nh gi ng th.
Trong trng hp c mt ngi cp cu, nn gi s h tr ngay khi pht
hin nn nhn khng p ng. Cc bc tip cn c tm tt trong hnh 2.
D Nguy him?
R Hi : Chu c b sao khng
S Gi ngi h tr
Hnh 2: Tip cn ban u
Khi c trn 2 ngi tin hnh cp cu th mt ngi s lm cp cu c
bn trong khi ngi th hai gi cp cu.
Tr s sinh hoc tr nh, nhn vin cu h c th b a tr ra ni in
thoi v vn tip tc lm cp cu c bn trn ng.
Gi in thoi trc
Trong mt vi trng hp, trnh t trn b o ngc nh trong ngng tim
do ri lon nhp tim th tin hnh sc in sm c th cu c tnh mng
tr. Trng hp ny, nu c 2 ngi 1 ngi cp cu c bn, 1 ngi gi cp
cu. Nu ch c mt nhn vin th nn tin hnh gi trung tm cp cu trc
v tin hnh cp cu c bn ngay sau .
Khi ng thit b y t trc khi tin hnh cp cu c bn khi ch c
mt ngi cu h trong trng hp:
37
Chng kin mt ngi t ngt ngt xu m khng c du hiu bo trc
g.
Chng kin mt tr t ngt ngt xu m tr ny c bt thng v tim
v khng c nghi ng nguyn nhn do h hp hay tun hon.
Chu c b sao khng?
Hi tr: Chu c b sao khng? v kch thch tr nh gi u v lay tay
tr. Nhng tr nh nhi v tr nh, nu v qu s m khng tr li c, vn c
th p ng bng cch m mt hoc ku ln nhng ting nh.
Hnh 3: Nng cm tr nh nhi: t th trung gian
Hnh 4: Nng cm tr ln
38
ng th (Airway - A)
M thng ng th, tr c th hi phc m khng cn can thip g
thm. Nu tr c li tt v pha sau gy tc nghn hu hng, phi m thng
ng th bng th thut nga u v nng cm. Tr nh nhi, t c t th
trung gian, tr ln th t c hi ng ra sau. Tr t tm c mt t th thch
hp duy tr s thng thong ng th. V vy, khng nn p tr phi
t th khng thoi mi.
nh gi s thng thong ng th bng cch:
NHN di ng ca lng ngc v bng
NGHE ting th
CM NHN hi th
Ngi cp cu nghing u trn mt tr, tai trn mi tr, m trn ming
tr v nhn dc theo lng ngc tr trong vng 10 giy.
Trong trng hp khng thc hin c th thut ny hoc c chng ch
nh do nghi ng chn thng ct sng c, c th dng th thut n hm. Dng
2 - 3 ngn tay t di gc hm 2 bn v y hm ra pha trc. Phng php
ny d thc hin hn nu khuu tay ngi cp cu t trn vng mt phng m
tr ang nm. u tr c th nghing nh v mt bn.
Hnh 5: n hm tr nh nhi v tr ln
39
nh gi s thnh cng hay tht bi ca bin php can thip bng cch
dng k NNG NHN, NGHE v CM NHN.
Ch : trong trng hp c chn thng, bin php an ton nht l n
hm nhng khng nga u.
Th (B)
Nu p dng cc bin php m thng ng th m tr vn khng th
li trong vng 10 giy th nn bt u thi ngt.
Cn thi ngt 2 ln
Trong khi gi thng thong ng th, tin hnh thi ngt theo phng
php ming ming cho tr ln hoc c ming v mi cho tr nh.
Hnh 6: Thi ngt ming - ming v mi tr nh nhi
Thi chm 1-1.5 giy v lm cho lng ngc di ng nh mc bnh
thng, nu thi qu mnh s gy bng chng v tng nguy c tro ngc
dch d dy vo phi. Gia 2 ln thi, ngi cp cu ht th cung cp c
nhiu oxy cho nn nhn hn.
Do cc tr em c kch thc ln nh khc nhau nn ch c th a ra
mt hng dn chung lin quan n th tch v p lc thi ngt nh sau :
Ch dn chung v thi ngt
Lng ngc di ng theo nhp thi ngt.
p lc thi ngt c th cao hn bnh thng v ng th nh.
Nhp thi ngt chm vi p lc thp nht mc c th c lm
gim chng bng (do hi i thng vo d dy).
n nh vo sn gip lm gim kh vo d dy.
40
Nu lng ngc vn khng n thng do khng p dng chnh xc cc k
thut m thng ng th. Do , t li t th u tr v tip tc thc hin thi
ngt. Nu vn khng c kt qu th nn n hm. Mt ngi cp cu c th va
n hm, va thi ngt. Nu c hai ngi cp cu mt ngi s m thng ng
th, mt ngi tin hnh thi ngt. Thc hin 2 ln thi ngt, ch xem tr c
ho hay c p ng li hnh ng ca bn hay khng. S p ng l mt phn
ca nh gi du hiu sinh tn c m t di.
Khi t li t th u tr v n hm m vn khng c kt qu th phi
nghi ng c d vt lm tc nghn ng th. Cn tin hnh cc phng php
ph hp khc.
Tun hon (C)
Ngay khi ang tin hnh phng php thi ngt phi ch n tun
hon.
nh gi:
Tun hon khng y c xc nh khi khng c mch trong vng 10
giy hoc khi c mch nhng mch chm. ngi ln v tr em c th bt
mch cnh nh gi, tuy nhin bt mch trong vng 10 giy l vn kh.
V vy khi vng mt ca cc du hiu sinh tn (c ng, ho hoc nhp th bnh
thng) l ch nh u tin ca p tim.
tr nh c th bt mch cnh hoc mch bn cn tr nh nhi, do c
ngn v bo nn bt ng mch cnh tay v ng mch i (hnh 7).
Hnh 7. Bt mch cnh tay
41
Bt u p tim ngoi lng ngc khi:
Khng c du hiu ca s sng.
Khng c mch.
Mch chm (t hn 60 nhp/pht vi du hiu ti mu km)
Trong trng hp khng c du hiu ca s sng p tim c th c tin
hnh ngay, nu trong trng hp bn khng chc chn l nhp tim trn 60
nhp/pht trong 10 giy th vic p tim khng cn thit cng khng gy tn
thng.
Nu c mch vi tn s v du hiu ti mu tt m tr vn ngng th
th phi tip tc thi ngt cho n khi tr th li.
p tim ngoi lng ngc
t tr nm nga trn mt phng cng t c kt qu tt nht. tr
nh nhi c th s dng bn tay ngi cp cu to mt phng ny.
Do kch thc tr khc nhau nn thng thng tr nh nhi (8 tui) c th s dng k thut dng cho ngi
ln v iu chnh cho ph hp vi kch thc ca tr. p tim su xung khong
1/3 b dy lng ngc ca tr.
V tr p tim thng nht cho mi la tui l : Mt phn hai di xng
c
Tr nh nhi
Vi tr nh nhi: p tim c hiu qu hn khi s dng k thut 2 tay m
vng quanh ngc (hnh 8). Phng php ny ch c th p dng khi c 2 ngi
cp cu v cn phi c thi gian t li t th m thng ng th.
Hnh 8 : p tim tr nh nhi - k thut 2 tay vng quanh ngc
42
Mt ngi cp cu c th s dng phng php 2 ngn tay. Mt tay cn
li gi thng ng th (Hnh 9).
Hnh 9: p tim tr nh nhi : K thut 2 ngn tay
Tr nh:
Dng gt bn tay ca mt tay p ln xng c na di xng c,
nng cc ngn tay chc chn khng n vo xng sn tr, v tr ca bn
thng trc vi ngc a tr v cnh tay thng.
Tr ln:
Dng c hai tay vi cc ngn tay kho li vi nhau v p su t nht 1/3 b
dy lng ngc (Hnh 11).
Hnh 10: p tim tr nhi Hnh 11: p tim tr ln
43
Hi sc tim phi lin tc
Tn s p tim cho tt c cc la tui l 100 ln/pht, t l 15 ln
p tim : 2 ln thi ngt. Nu khng c s gip , phi lin lc vi trung
tm cp cu sau CPR 1 pht.
Phi cp cu c bn khng ngng cho n khi tr c c ng v th c.
p tim nn thc hin ng tc nhanh v mnh, su t nht 1/3
b dy lng ngc vi t l p tim 100 chu k/pht v hn ch ngng p
tim.
Khng cn kim tra li v tr p tim sau mi ln thng kh.
K thut hi sc tim phi cho tr nh nhi v tr nh c tm tt
trong Bng 1.
Bng 1: Tm tt cc k thut cp cu c bn tr em
Tr nh nhi v tr nh Tr ln
ng th
T th u nga Trung gian Nga u
Nhp th
Nhp th ban u 2 2
Tun hon
Bt mch Mch cnh tay hoc mch i ng mch cnh hoc
mch i
V tr p tim Na di xng c Na di xng c
K thut 2 ngn tay hoc 2 ngn ci
15/2
Mt hoc hai tay
T l p tim/thi ngt
S dng my chng rung t ng bn ngoi tr em
Trong 1 s trng hp c th dng my chng rung t ng bn ngoi
trong ngng tim tin pht v cng vi vic nhn vin c hun luyn c th
d dng s dng nhng ni cng cng nh sn bay, t hp thng mi.
44
T th hi phc
Tr nn c t t th m bo duy tr c thng thong ng th,
c th theo di v tip cn c v m bo an ton, lu cc im d b p.
Xc nh tui
Ch cn xc nh nhm tr nh (< 1 tui) v tr ln hn (t 1 tui tr ln).
T l p tim thng kh
Nu thi gian p tim di hn trong lc tin hnh cp cu th p lc ti
mu vnh s tng hn. T l p tim / thi ngt 15:2 l ph hp cho mi la tui .
Cc mc nhn vin cu h
Nhng ngi chng kin thng khng mun thc hin cp cu c bn
v h s lm sai v v lo lng khi phi tin hnh hi sc ming - ming vi
ngi l. Khi s dng ngi cu h trc tip, t l p tim/thng kh 30/2 c
khuyn dng c ngi ln v tr em. Khi c mt nhn vin y t cng c th
tin hnh vi t l ln 30 ln p 2 ln thi ngt cho tr em, nu h gp kh khn
khi chuyn t p tim sang thi ngt. Trong trng hp ngi cp cu khng th
tin hnh h hp nhn to ming ming h phi tin hnh p tim.
3. CP CU C BN V NGUY C NHIM TRNG
C t thng bo v bnh truyn nhim do thi ngt ming ming, nu
nhim no m cu, nn s dng khng sinh d phng cho ngi cp cu,
lao cng c th ly qua CPR v vy phi c bin php phng h. HIV, vim gan
B khng c thng bo ly truyn qua ng ming ming.
Cn thn trng khi tip xc vi cc cht nh mu, dch tit m o, dch
no tu, dch mng phi, dch mng bng v dch i, vi c nhng dch c th
cha mu. Gc hoc cc vt liu c l t trn ming nn nhn thng khng
c hiu qu trong trng hp ny.
D bp b dng thc hnh cha c biu hin l ngun ly nhim, v
sinh thng xuyn vn phi c tin hnh theo ch dn ca Nh sn xut. T
l nhim khun khc nhau tu theo tng nc nn ngi cp cu phi nhn
thc c nguy c ly nhim a phng mnh.
4. TR B D VT NG TH
Thng gp la tui tin hc ng, chn on him khi r rng, nghi
ng khi tr khi pht vi cc du hiu suy h hp t ngt, ho, nn o v th
rt. Phn bit vi vim np thanh mn v vim thanh qun.
45
Nhng tr b tc nghn ng th do nhim khun hoc nghi ng
nhim khun v nhng tr tc nghn khng r nguyn nhn nhng vn t th
cn c a ngay ti bnh vin.
Nhng phng php vt l lm thng ng th c m t sau y ch
nn tin hnh nu:
1. D vt ng th c chn on r (c chng kin hoc nghi ng
nhiu), tr khng ho c v kh th tng dn, mt thc hoc xut hin
ngng th.
2. T th nga u/nng cm v n hm lm thng ng th khng
c kt qu tr ngng th.
Nu tr ho c th nn khuyn khch tr ho. Khng nn can thip, tr
khi ho khng c hiu qu (ho yu) hoc a tr mt thc. Ho c hiu qu
c nhn ra bi cc du hiu : tr c th ni, khc hoc th gia nhng ln ho.
Tr vn tip tc c nh gi v khng nn tr mt mnh. Cc can thip ch
tin hnh khi tr ho khng hiu qu, tr khng th khc, ni, th hoc nu tr
tm v dn mt thc. Hy gi h tr v bt u cc can thip cho tr.
Hnh 12. Trnh t x tr mt tr sc
nh gi
Ho khng hiu qu Ho c hiu qu
Tnh Bt tnh
V lng 5 ln M thng
ng th
p ngc hoc
bng 5 ln
2 nhp thi
ngt
nh gi v tip
tc th thut
CPR 15 : 2
Kim tra d vt
Khuyn khch ho
H tr v tip tc
nh gi
46
Tr nh nhi
n bng tr nh nhi c th gy chn thng ni tng. V vy, la tui
ny nn phi hp ng tc v lng v n ngc loi b d vt.
t tr dc theo cnh tay ngi cp cu, u thp, ngi cp cu t tay
dc ln i mnh, bn tay gi vo cm tr gip cho ng th c m ra v
t tr t th trung gian v dng gt bn tay cn li v ln lng tr 5 ln.
Nu d vt khng bt ra, lt ngc tr li, t nm dc trn i vn t
th u thp. n ngc 5 ln ti v tr p tim vi tn sut 1 ln/giy. Nu tr qu
ln khng s dng c k thut 1 tay nh m t trn th t tr nm
ngang trn i ngi ngi cp cu v lm cng bin php. K thut ny c
m t Hnh 13 v Hnh 14.
Hnh 13: V lng tr nh nhi
Hnh 14 : n ngc tr nh nhi
47
Tr ln
S dng k thut v lng v n ngc nh tr nh nhi loi b d vt,
n bng c th gy ra chn thng bng.
Hnh 15: V lng tr nh
t tr nm nga, v tr n ngc tng t v tr p tim nhng t l mt ln
trong mt giy, tin hnh p tim
5 ln nu d vt vn khng ra c. Nu d vt ra c, nh gi cc du
hiu lm sng, c th vn c mt phn ca d vt cn li trong ng th. Mi
ln th nhn vo ming tr xem cn d vt hay khng v loi b d vt nu nhn
thy. Ch khng y d vt xung v trnh lm tn thng m mm. Nu d
vt c loi b , nhng nn nhn khng th vn tip tc thng kh h tr
hoc c thng kh v n ngc nu tr khng c du hiu ca s sng.
Nu tr th c hiu qu t tr t th hi phc v tip tc theo di nn
nhn.
Tr nh b hn m hoc tr ln c d vt ng th gy chn p
Ku h tr
t tr nm nga trn nn cng.
M ming a tr v th ly nhng d vt nhn thy c ra.
M thng ng th v th h hi thi ngt 2 ln, m thng li ng
th nu lng ngc khng di ng sau khi thi ngt.
Bt u p tim k c khi thi ngt khng c tc dng.
Tip tc tin hnh cp cu c bn trong 1 pht, sau gi h tr li
nu cha thy ai n.
48
H hi thi ngt li, xem li trong ming tr c d vt g nhn thy c
khng v ly d vt ra ngoi, cn cn trng khng y d vt vo su hn v
trnh lm tn thng m mm.
Khi gii thot c tc nghn d vt, nn nhn vn cn c thng
kh tip tc nu cha t th c hoc cn tin hnh ng thi c thng kh
v p tim nu cha thy du hiu hi phc ca tun hon.
Nu tr t th c, cho tr nm t th hi phc v tip tc theo di
tr.
49
5. TNG HP
D Nguy him?
R Hi : Chu c b sao khng
S Gi ngi h tr
A M thng ng th
B
Nhp th bnh thng ?
Thi ngt 2 ln
C
Kim tra mch
Khng qu 10 giy
Bt u CPR
15 p tim : 2 ln thi ngt
D
Kt ni my shock in
Chc chn gip ang n
Tip tc CPR cho n khi tr c p ng
Hoc nhp th bnh thng
Hnh 18. Ton cnh th t tin hnh cp cu c bn khi c ngng tim phi
50
TIP CN CHN ON V X TR BNH NHI KH TH
Kh th l biu hin thng gp trong cp cu nhi khoa, nguyn nhn gy
ra kh th gm 3 loi chnh: Kh th do tc nghn ng th, kh th do bnh
tim phi v kh th do bnh l ngoi tim phi (thn kinh, chuyn ho.). Cch
tip cn v x l chung trc mt bnh nhn kh th gm:
1.NH GI V CP CU BAN U
Vic nh gi v x l u tin theo th t A, B, C, D, E:
1.1.ng th: (A)
1.1.1. nh gi
S dng k nng: Nhn - Nghe - Cm nhn nh gi s thng thong
ng th: (Nhn: S di ng ca lng ngc, bng. Nghe: ting th v cm
nhn: hi th ca bnh nhn).
Nu tr cn c th ni c, khc c r, th ng th thng.
Nu lng ngc di ng km, khng c khng kh lu thng chng t ng
th tc hoc tr suy th nng.
Nu c ting rt thanh qun (Stridor) ngh n tc ng h hp trn.
1.1.2. X l
- Lm th thut m thng ng th: Nga u- nng cm hoc n- nng
gc hm.
- t canuyn ming - hng hoc mi hng.
- t ng ni kh qun (NKQ) nu cc x tr trn tht bi.
- Trong mt s trng hp cn thit c th phi chc catheter qua sn
nhn gip hoc m kh qun.
1.2. Th: (B)
1.2.1. nh gi: nh gi xem bnh nhn th c m bo khng da vo:
a. Th gng sc
- S co rt: y l du hiu thng gp trong kh th, khi c biu hin s
rt lm trn xng c th thng c tc nghn ca ng h hp trn.
- Tn s th: tng khi c kh th, nhng khi tn s th gim xung ri
chm li l du hiu nng ln.
51
- Ting th rt trong th th vo (Stridor) biu hin tc nghn ng h
hp trn, ting kh kh trong th th ra biu hin trong tc nghn ng h hp
di (hen, vin tiu ph qun).
- Th rn: thng gp trong kh th tr s sinh.
- S dng c h hp ph mi ln th.
- Cnh mi php phng.
- T th ca tr: khi b kh th tr thng tm mt t th thch hp lm
gim s kh th - nht l trong khi kh th do tc nghn (d tt, vim thanh
qun, hen, vim np thanh mn).
- Khi bnh nhn c biu hin kit sc, (gim s gng sc, tn s th gim,
gim thng kh hai phi) bo hiu bnh nhi ang trong tnh trng nguy kch.
a. Hiu qu ca th
- Nghe ting th: nh gi thng kh ca hai bn phi v ng th.
- S dn n ca lng ngc v di ng ca bng (nht l tr nh).
- bo ho oxy mch mu (s dng pulse oximeter)
- Biu hin phi cm (gim, mt r ro ph nang, di ng lng ngc gim
hoc khng di ng). bo ho oxy
52
- ny ca mch
- Thi gian tr v ca mu mao mch.
- Huyt p.
Khi huyt p h l du hiu nguy kch.
d. nh hng ca tun hon ln c quan khc
Nhp th v kiu th.
Mu sc da v thn nhit: Biu hin tm ti trung ng khng ci thin khi
cho bnh nhn th oxy lu lng cao l gi bnh nhn mc bnh tim bm sinh
c shunt phi tri.
Tnh trng tinh thn kinh
Lng bi niu
e. Du hiu suy tim: bnh nhn c th kh th do bnh ca tim c suy tim.
Tn s tim nhanh, c th c: nhp nga phi, nghe tim c ting thi.
Tnh mch c ni (t thy tr b m)
Nghe phi c ran m
Gan to
1.3.2 X tr
Tt c cc bnh nhn c biu hin suy tun hon (sc), cn phi c
cung cp oxy lu lng cao: (mi, mt n, ng ni kh qun).
Truyn dch hi phc khi lng tun hon (dung dch in gii hoc
dung dch cao phn t: 20ml/kg), tr trng hp bnh nhn c du hiu suy tim.
Ly mu lm mt s xt nghim cn thit: cng thc mu, in gii ,
ur, creatinin, nhm mu, kh mu, cy mu
1.4. Tinh, thn kinh: (D)
1.4.1. nh gi
nh gi tri gic ca bnh nhn da vo thang im AVPU (tnh - p
ng vi li ni - ch p ng vi au - khng p ng). Khi bnh nhn ch
p ng vi kch thch au, th cn thit phi c nhng bin php tr gip v
h hp.
Khm ng t: kch thc phn x.
Co git t th nm ca tr (khi b suy th tr thng t th gim trng
lc).
53
Khi bnh nhn c gim tri gic hoc c co git th bt buc phi nh
lng glucose mu.
1.4.2. X l
Bnh nhn b gim tri gic, khng hoc ch p ng vi kch thch au
cn phi t ng ni kh qun m bo s thng sut ca ng th.
Bnh nhn nghi ng gim glucose mu cn tim dung dch glucose 10%
hoc 20% vi liu lng 0,5g/kg (trc phi ly mu nh lng ng
mu).
S dng lorazepam tim tnh mch hoc diazepam bm, tht hu mn khi
bnh nhn b co git.
1.5 Khm ton thn: (E)
Ch ly nhit c th: nu st th gi tr c th b nhim khun (tuy
vy khi khng b st cng cha loi tr c nguyn nhn ny).
Pht hin ban trn da: nu l ban sn m ay phi nghi ng tr b
phn v.
2. CHN ON NGUYN NHN
ng thi vi vic nh gi v cp cu ban u cn phi hi bnh s ca
tr, t nht l trong 24 gi trc khi tr c cp cu. Kt hp vi kt qu cc
xt nghim c c, vic chn on nguyn nhn kh th c th da vo cc
triu chng dn ng theo s di y:
54
S 1. Chn on nguyn nhn kh th
Kh th do tc nghn
ng th
(Kh th chm)
Kh th th th vo km
ting rt (Stridor)
Kh th th th ra km
theo th kh kh
Kh th c hai th
Kh th + Hi chng xm
nhp
Kh th thanh qun
Kh th do ph qun (hen
ph qun)
Kh th kh qun
Kh th d vt ng th
Kh th do
Tim , phi
(Kh th
nhanh)
C suy
tim
Nhp tim nhanh Khng bt c
mch bn
Hp eo ng
mch ch
Tnh mch c ni Nhp tim rt
nhanh
Nhp nhanh
kch pht trn
tht Gan to Tim c ting phi,
tng gnh phi
Tim bm sinh c
shunt phi - tri
Tim to
(XQ)
Bnh cnh
nhim trng
Vim c tim
Khng c suy
tim, c biu hin
thng tn phi
v mng phi
Th kh kh ran lan
ta th th ra lng
ngc cng
Vim tiu
ph qun
Ran m nh
ht + st ()
Vim phi
G c vng thp, g
vang mt bn phi
Trn dch, trn
kh mng phi
Khng c du hiu tn
thng tim phi (tr
ng ng th )
C du hiu thn kinh
km theo
Lit h hp
Lng ngc bin dng D dng lng ngc
Kh th do
ngoi Tim ,
phi (khng
c du hiu
gng sc)
Tng thng kh
Try mch
Thiu mu
Chy mu Thiu mu cp
St cao Du hiu
nhim trng
Nhim khun mu
Nhim khun nng
Mt nc a chy
cp Vim d dy rut
i nhiu,
tng ng
huyt
i tho ng,
nhim toan
Nhim toan
n thun
Ng c cp (Salicylat)
Bnh chuyn ha (t gp)
Gim thng
kh
Ri lon
tri gic
Du hiu
thn kinh
Nguyn nhn
trung ng
Chn thng s
no Trng thi ng kinh
Tn thng h thn
kinh TW
Ng c
Ngt th, du hiu kit sc
55
3. NH GI LI V IU TR CP CU THEO NGUYN NHN
Sau bc cp cu v nh gi ban u, tnh trng bnh nhn tm n nh,
nguyn nhn kh th c xc nh (da vo cc triu chng dn ng xem
s 1). Bnh nhn cn phi c khm, nh gi li t m hn. Lc ny mt s
xt nghim mu, cn lm sng (X- quang, in tm , kh mu) cn c
lm thm gip cho vic chn on, iu tr v theo di bnh nhn theo
nguyn nhn.Tuy vy, trong giai on ny bnh nhi vn lun c gim st cc
chc nng sng (h hp, tun hon, tinh thn kinh, thn nhit) nu c ri lon
no th phi tin hnh nh gi v iu tr cp cu ban u li.
3.1 iu tr cp cu
- Nu nghe thy c lc xc trong ming bnh nhn: ng th c
nhiu cht dch tit, i hi phi ht sch.
- Nu bnh nhn c th rt thanh qun (Stridor) km vi ting ho ng
ng v biu hin suy th nng th chng t ng h hp trn b tc nghn c
th do vim thanh qun nng, cn phi cho bnh nhn th kh dung adrenalin
(5ml adrenalin 1:1000 ).
- Nu bnh nhn c ting th rt thanh qun nh nhng tnh trng chung
ca tr rt nng (st, suy th, tit nhiu nc bt) c kh nng tr b vim np
thanh qun cn: cho khng sinh, corticoid v mi ngi c kinh nghim t ng
ni kh qun cp cu. Tn trng t th thch nghi ca tr, khng lm cho tr s
hi.
- Din bin bnh t ngt, c tin s ca hi chng xm nhp phi ngh
n nguyn nhn d vt thanh qun. Nu s dng quy trnh x l i vi tr b
sc khng thnh cng th phi tnh n vic ni soi thanh qun cp cu.
- Th rt thanh qun xy ra ngay sau ung hoc tim thuc phi ngh n
nguyn nhn phn v. Tim bp adrenalin 10g/kg.
Bnh nhn c tin s hen ph qun hoc th kh kh c suy th nng -
lu lng nh gim v/hoc thiu oxy th cho kh dung ventolin v Ipratropium
vi oxy. tr b m c th do vim tiu ph qun th ch cn th oxy.
3.2. iu tr n nh tnh trng v vn chuyn an ton bnh nhn
Sau bc iu tr cp cu, tnh trng bnh nhn tm n nh vn phi
thng xuyn gim st nh gi bnh nhn, vic quyt nh tip theo (chuyn
hi sc tch cc, chuyn iu tr chuyn khoa hay chuyn vin) ph thuc vo
56
tnh trng bnh nhn v iu kin ca c s y t tip nhn bnh nhn ban u.
Trn nguyn tc khi chuyn bnh nhn phi an ton, m bo ba yu t an ton
ca bnh nhn: bnh nhn phi c n nh chc nng sng (ng th, th,
tun hon), lin h cht ch vi ni bnh nhn s chuyn n, tip tc duy tr
chc nng sng ca bnh nhn trong sut qu trnh vn chuyn (Xem bi vn
chuyn an ton bnh nhn).
NGNG TH NGNG TIM
1. I CNG
tr em ngng th thng l hu qu ca tnh trng suy h hp cp.
Ngng tim thng sau ngng th.
No s b tn thng khi ngng th ngng tim trn 4 pht v nu trn 10
pht thng t vong, nu sng s li di chng no nng n. V th khi ngng
th ngng tim cn nhanh chng cung cp oxy v mu cho no.
C 2 loi hi sc:
Hi sc c bn: hi sc ti hin trng, khng c dng c
Hi sc tin b: hi sc thc hin ti c s y t hoc trn xe cu thng
vi dng c, thuc cp cu
2. HI SC C BN
2.1 Chn on ngng th ngng tim
- Hn m: lay gi khng tnh
- Lng ngc khng di ng
- Khng c mch trung tm
2.2 Hi sc c bn
Thc hin ti ni xy ra tai nn ngoi bnh vin
Nguyn tc: nhanh v theo th t A, B, C
Thng ng th (Airway)
Thi ngt (Breathing)
n tim ngoi lng ngc (Circulation)
Cc bc thc hin theo th t u tin:
57
a. Lay gi, ku gip
- Lay gi bnh nhn
- Nu khng p ng l hn m, nghi ng ngng th ngng tim khi hn m
v ku gi ngi gip
b. Thng ng th
- Nga u nng cm, nu nghi chn thng ct sng c th dng phng
php n hm v c nh c trnh di lch ct sng c
Trong trng hp hn m th cc c vng c mt trng lc gy chn p
tc ng th
- Ly d vt nu c:
+ Th thut v lng n ngc: s sinh, nh nhi
+ Th thut v lng: tr ln
Khng dng tay mc m d vt v c th y d vt vo su hn v lm
tn thng nim mc ming hu
c. Quan st di ng lng ngc v nghe cm nhn hi th
- Lng ngc khng di ng
- Khng cm nhn c hi th BN
d. Thi ngt
- Thi ngt 5 ln t c 2 nhp c hiu qu
Thi c hiu qu khi thy lng ngc nh ln khi thi
e. Bt mch trung tm
- S sinh, tr nh: mch cnh tay, mch bn
- Tr ln: mch c, mch bn
Nu c mch trung tm th tip tc thi ngt
Khng c mch trung tm trong vng 10 giy Ngng tim n tim
ngoi lng ngc.
f. n tim ngoi lng ngc
- V tr n tim cho mi la tui: di xng c
- n su 1/3 b dy lng ngc
- Tr s sinh nh nhi (di 1 tui):
- K thut: 2 ngn ci hoc 2 ngn tay
Ngng th
58
Hnh 1: n tim 2 ngn tay
- Tr ln (Trn 1 tui):
- K thut: 1 bn tay ( 1- 8 tui)
2 bn tay (> 8 tui)
Hnh 2: n tim 1 bn tay
Tn s n tim cho tt c cc la tui: 100 ln/pht
n tim ng: mch trung tm c khi n
- Ngng th ngng tim:
T l n tim/ thi ngt: 15/2 cho 2 cp cu vin, 30/2 cho 1 cp cu vin
3. HI SC NNG CAO
Thc hin ti c s y t, bnh vin c y dng c v thuc cp cu
3.1. Lay gi, ku gip
- Lay gi bnh nhn
- Nu khng p ng, hn m, ku gi BS, D gip
3.2. Thng ng th:
- Nga u nng cm (nghi chn thng ct sng c: n hm, c nh c )
- Ht m
- Ly d vt nu c:
+ Th thut v lng n ngc: s sinh, nh nhi
+ Th thut v lng: tr ln
- t ng thng ming hu khi tht bi vi nga u, ht m
59
3.3. Quan st di ng lng ngc v cm nhn hi th
- Lng ngc khng di ng
- Khng cm nhn c hi th BN
3.4. Bp bng qua mask
- Bp bng qua mask 2 nhp c hiu qu vi FiO2 100%
Bp bng c hiu qu: lng ngc nh khi bp
- Bp bng m lng ngc khng nh:
+ ng th cha thng: kim tra nga u
+ Mt n khng kn
+ C bng nh so vi tr
+ Bp bng nh tay
- n nh sn nhn (th thut Sellick): trnh hi vo d dy, gim chng
bng v nguy c ht sc
3.5. Bt mch trung tm
Khng c mch trung tm trong vng 10 giy Ngng tim
3.6. n tim ngoi lng ngc
K thut n tim: xem phn hi sc c bn
T l n tim/ bp bng
- S sinh : 3/1
- Tr ngoi tui s sinh : 15/2
Nu c 2 ngi: ngi n tim m ln ngi bp bng nghe phi hp
Tip tc bp bng v n tim trong vng 2 pht, sau nh gi li
Trng hp khng t th li sau bp bng qua mask (1 - 5 pht): t ni
kh qun ng ming v bp bng qua NKQ
3.7. Thuc
Thit lp ng tnh mch. Nu sau 2 ln ly ven ngoi bin tht bi phi
tin hnh tim trong xng (dng kim 18 vi trocha, bm tim 5ml, tim vo
mt trc, 2-3 cm di mo xng chy).
- Epinephrine (Adrenaline) 1 TM
Ch nh: ngng tim
Cch pha dd Epinephrine 1: dng ng tim 10 ml rt 1ml dd Epinephrine
1 + 9 ml nc ct.
Ngng th
60
Liu: 0,1 ml/kg dung dch 1%oo TM. Sau khi bm Epinephrine, bm 2 5
ml nc mui sinh l y thuc.
Sau 3 - 5 pht tim cha p li: lp li liu hai nh trn hoc gp 10 ln,
nhc li mi 3 5 pht.
- Epinephrine (Adrenaline) 1 bm qua NKQ, dng trong trng hp
khng c ng tnh mch
Liu: 0,1 ml/kg dung dch Epinephrine 1 pha NaCl 9 cho 1-2 ml.
Sau bm NKQ: bp bng thuc phn tn v hp thu vo h tun hon -
Bicarbonate u trng:
- Khng thng quy v nguy c CO2 gy nng thm tnh trng toan h hp.
- Ch nh:
Toan chuyn ha nng,
Nu khng th kh mu c : c th xem xt ch nh Bicarbonate sau 10
pht bp bng gip th v tim Epinephrine bnh nhn vn cn ngng th
ngng tim.
- Liu: dung dch bicarbonate 8,4% 1ml/kg/ln hay dung dch 4,2% 2
ml/kg/ln TMC, khng c dng chung vi ng TM ang truyn canxi.
- Atropine
Ch nh: nhp tim chm (nhp chm xoang).
Liu: 0,02 mg/kg TMC, liu ti thiu 0,1 mg, ti a 0,5 mg/liu hoc tng
liu khng qu 1mg.
- Amiodarone
Ch nh: y l thuc c la chn trong trng hp nhp nhanh trn
tht, rung tht, nhp nhanh tht mt mch.
Liu 5 mg/kg bm TM nhanh hay qua tu xng trong 20 - 60 pht.
C th nhc li liu trn. Liu ti a 15 mg/kg/ngy. Theo di huyt p
trong qu trnh iu tr v thuc gy tt huyt p nu tim nhanh.
Thuc thay th: Lidocain 2% (0,04g / 2ml), liu 1mg/kg TM, duy tr 20-
50 g/kg/pht qua bm tim t ng.
- Canxi: khng dng thng qui, ch dng trong trng hp c bng
chng h can xi huyt hoc ng c thuc c ch canxi.
Calcium chloride 10% 0,2ml/kg TM chm
Calcium gluconate 10% 1ml/kg TM chm
- Glucose:
61
Ch nh: h ng huyt (Dextrostix)
Tr ln: dung dch glucose 30% 2ml/kg TMC
Tr s sinh : dung dch glucose 10% 2ml/kg TMC
- Truyn dch:
Nu nguyn nhn ngng th ngng tim l hu qu ca sc gim th tch:
truyn nhanh Lactate Ringer 20 ml/kg/15 pht, nu tht bi dng dung dch cao
phn t.
Trong trng hp cp cu khng th cn bnh nhn c c th c
lng cn nng theo tui:
- Tr 0-12 thng : Cn nng(kg) = (0,5 x tui tnh theo thng) + 4
- Tr 1-5 tui : Cn nng(kg) = (2 x tui tnh theo nm) + 8
- Tr 6-12 tui : Cn nng(kg) = (3 x tui tnh theo nm) + 7
3.8. Sc in (xem lu x tr ngng th ngng tim sau bp bng n tim)
Ch nh:
- Sc in khng ng b: Rung tht, ngng tim, nhp nhanh tht mt
mch.
- Sc in ng b: nhp nhanh tht c mch, nhp nhanh kch pht trn
tht, sau khi iu tr thuc tht bi hay c ri lon huyt ng.
tr nh, dng bn in c tr em 4 5 cm. Nu khng c bn nh, c
th dng bn ln t trc v sau ngc.
Sau mi ln sc in, phi nghe tim v theo di nhp tim qua monitor
c hng x tr tip
3.9. Theo di sau hi sc
- Nhp th, mu da, nim mc, mch, HA, tri gic, ng t mi 15 pht
- SaO2 ( bo ha oxygen)
- Nhp tim bng ECG monitoring,
- Kh mu, ion , Dextrostix, XQ tim phi
- Din tin tt: hng ho, t th, tim p li, mch r, tnh to.
- Khi no ngng hi sc ?
Quyt nh thi im no ngng hi sc trng hp ngng th ngng tim
ko di th kh khn. Tuy nhin c th xem xt vic ngng hi sc nu sau 30 -
60 pht m tim khng p li, khng th li, ng t dn v sau khi gii thch
thn nhn.
62
CC BC TIN HNH CP CU NGNG TIM
nh gi
nhp
Sc in: Rung tht,
nhanh tht mt mch
Khng sc: ngng
tim, mt mch cn
in tim
Nguy him ?
Hi: "Chu c b sao khng"
Gi ngi h tr
M thng ng th
Nhp th bnh thng? Thi ngt 2 ln
Kim tra mch
Khng qu 10 giy
Bt u CPR
15 p tim: 2 ln thi ngt
Kt ni my shock in
Chc chn gip ang n
63
LU IU TR RUNG THT V NHP NHANH THT
MT MCH
Trong qu trnh CPR
Dng c ng th (LMA/ETT)
Oxy
Dng c o CO2
Thit lp tun hon
K hoch hnh ng trc khi
ngng n tim (sc my sc 4J/kg)
Tm nguyn nhn:
Thiu Oxy
Gim th tch
Tng/h kali, ri lon chuyn ho
Tng gim nhit
Trn kh mng phi
Chn p tim cp
Ng c
Huyt khi ( phi/mch vnh)
Chm sc sau hi sc: nh gi li ABCDE
Lm in tm 12 chuyn o
iu tr nguyn nhn
nh gi li Oxy v thng kh
Kim sot nhit
nh gi
nhp tim
Sc in
VF/VT mt
mch
Khng sc in
PEA/v tm
thu
Tun
hon
tr li ?
Chm sc sau hi sc
Bt u CPR
Kt ni my sc in/my theo di
Sc in (4J/kg)
khng ng b
Adrenaline
10mcg/kg
Sau ln sc th 2
(sau mi 2 chu k)
Amiodarone
5mg/kg
Sau ln sc th 3
CPR
Trong 2 pht
CPR
Trong 2 pht
Adrenaline
10mcg/kg (sau
mi 2 chu k)
64
LU X TR NHP TIM CHM
v
C sc?
iu tr thiu Oxy
v sc
Adrenalin
10mcg/kg
Khng
C sc?
Mi hi chn
Atropin 20mcg/kg
kch thch
ph v?
Khng
m
Cn nhc Adrenaline TM
hoc t my to nhp
Khng
C
C
sc?
Khng C
65
LU X TR NHP NHANH KCH PHT TRN THT
*Liu ti a 12mg(s sinh 300mcg/kg)
C sc?
Nghim php kch
thch TK ph v (nu
iu kin cho php)
Nghim php kch
thch TK ph v
Thit lp ng
truyn nhanh
hn sc in?
Khng C
Adenosine
100mcg/kg
Adenosine
200mcg/kg
Cn nhc
Adenosine 400-500 mcg/kg*
Sc in ng th
Hoc Amidarone
Hoc thuc chng lon nhp
khc (xem ch dn)
Adenosine
300mcg/kg
Sc in ng th
liu 2J/kg
Sc in ng th
liu 1J/kg
Khng
Cn nhc Amiodarone
C
66
LU IU TR NHP NHANH THT
C mch? iu tr theo phc
rung tht
Amiodarone 5mg/kg trn
30 pht
C
C sc?
Sc in 2J/kg
Sc in 1J/kg
ng b
Cn nhc sc in ng b.
Mi hi chn
Amiodarone
C Khng
67
VN CHUYN AN TON BNH NHN TR EM
Vic vn chuyn bnh nhn t khoa ny n khoa khc trong cng mt
bnh vin hoc t bnh vin ny n cc bnh vin khc khng c tnh
trng ca bnh nhn nng thm ln, v vy vn chuyn bnh nhn i hi c ch
nh ng, vic chun b v thc hin theo ng mt quy trnh nh sn v do
nhng ngi c kinh nghim thc hin. Mc tiu l m bo ti u s an ton
ca bnh nhn trong sut qu trnh vn chuyn vi vic theo di st tnh trng
bnh v c nhng bin pht x tr thch hp.
1.CH NH
Vic chuyn bnh nhn c thc hin khi tnh trng bnh nhn i hi
phi chuyn n ni c iu kin chm sc, iu tr, theo di c tt hn hoc
n ni lm cc thm d, xt nghim phc v cho vic chn on v iu tr
bnh nhn.
2. T CHC
- Ngi c kinh nghim v c o to vn chuyn bnh nhn.
+ Gii thch cho b m, ngi nh bnh nhn l do chuyn bnh nhn.
+ Khm, nh gi nhanh tnh trng bnh nhn.
- Lin h bng in thoi trc tip vi ngi c trch nhim (chuyn mn)
ni m bnh nhn s c chuyn n.
m bo an ton bnh nhn cn:
- Khng nh li ch nh chuyn bnh nhn.
- Xc nh ni bnh nhn s chuyn n.
- Quyt nh nhng can thip cn thit trong khi ch i.
- D kin phng tin vn chuyn, dng c cp cu cn thit v ngi
trc tip vn chuyn bnh nhn cng nh thi gian xut pht v n ni.
- Trong qu trnh vn chuyn trn ng cn c s lin h cht ch vi
ni xut pht v ni s n qua in thoi.
3. PHNG TIN VN CHUYN BNH NHN
- Xe vn chuyn bnh nhn chuyn dng (c cng vn chuyn, c lng
m vi tr s sinh).
- Trang b ti khoa Cp cu v c s dng c, thuc men y theo
di v iu tr cho bnh nhn trong khi c vn chuyn (tt c nhng nhn vin
h tng phi nm r).
68
3.1. Phng tin cp cu bnh nhi
3.1.1. ng th
- Canuyn ng th cc c: 000, 00, 0, 1, 2, 3.
- ng ni kh qun cc c t: 2,5 7,5mm (ng 7,5mm c bng chn
cuffed).
- n t ng NKQ
+ Li thng: cho s sinh, tr nh.
+ Li cong: cho tr ln.
- Km gp Magill
- My ht xch tay (Yankauer).
- ng ht mm.
- Kim chc d qua sn nhn gip.
3.1.2. Th
- My th.
- Bnh cha oxy (mini) c van iu chnh p lc. Bnh nn c E, cha
600l, c th cho th trong 150 pht vi lu lng 4l/pht.
- Mt n th oxy c ti d tr.
- Bng bp t phng c ti d tr vi cc kch thc (240ml cho tr b
m, 500ml cho tr nh/1600ml cho tr ln).
- Mt n cc c:
+ Cho tr b m : 0, 1, 2
+ Cho tr nh : 2, 3
+ Cho tr ln : 4, 5
- ng ht thng ming v b phn ni.
- Bng bp (ayrs T - piece).
- B dn lu mng phi.
3.1.3. Tun hon
- My kh rung (sc in) c gn gim st in tim cho tr em.
- My o huyt p (cc c bng cho tr em).
- My o nng oxy mch mu (pules oximeter).
- Dng c thit lp ng truyn.
69
+ ng thng tnh mch.
+ Kim truyn trong xng (c 16- 18).
- Dy truyn c bu m.
- Bm tim: 1- 50ml.
- My m git.
- My tim (rt cn cho bnh nhn vn chuyn ng xa).
- Dng c bc l tnh mch.
3.1.4. Dch truyn
- Dung dch mui ng trng NaCl 0,9%.
- Dung dch ringerlactat.
- Dung dch glucose 5%, 10%.
- Dung dch hn hp: (Glucose 4% v natriclorua 0,18%).
- Dung dch keo.
- Dung dch albumin 4,5%.
3.1.5. Thuc
- Epinephrin (Adrenaline) 1:10.000, 1:1000
- Atropin sulfat 0,25mg
- Natribicarbonate 8,4%, 4,2%
- Dopamin 40 mg/ml
- Dobutamin
- Lignocain 1%
- Amiodaron
- Calcium clorid 10%, calcium gluconat
- Furosemid 20mg/ml
- Manitol 10%, 20%
- Valium 5mg, 10mg
- Khng sinh: cefotaxim, gentamicin, penicillin, ampicillin
3.2. Phng tin khc
- My glucose k
70
Vi phng tin trang b nht thit trn ng vn chuyn phi gim
st:
- in tim, tn s tim
- bo ha oxy
- Huyt p
- Nhit (trung tm / ngoi vi)
- CO2 ca kh th cui th th ra ( End tidal CO2)
- Tn s th
Cc trang thit b c trang b ni d ly v thng xuyn phi c
kim tra, b sung sau mi ln vn chuyn bnh nhn. Ngun in cho my (pin,
c quy) cng phi c sc b sung thng xuyn.
4. VN CHUYN
Lun m bo ng th v th trong qu trnh vn chuyn.
Vi bnh nhn chn thng hoc bnh nng cn phi m bo ng th
v thng kh h tr:
- t ng ni kh qun (NKQ)
- Bp bng qua ng NKQ vi oxy hoc th my (nu c iu kin).
- Ch an thn tt cho bnh nhn v c nh chc ng NKQ (tt nht l
t ng qua ng mi khi bnh nhn c ri lon ng mu hoc tn thng nn
s).
4.1.m bo chc nng tun hon
m bo c hai ng truyn tt trong qu trnh vn chuyn nht l i
vi bnh nhi c nguy c ri lon tun hon (sc) qua y c th truyn cc
dch keo, dung dch gy kch ng mch mnh (bicarbonat, kali, calcium,
adrenalin) vo tun hon trung ng (tt nht l c c mt ng truyn
vo tnh mch trung tm).
4.2. Tinh thn kinh
Vn chuyn bnh nhn hn m i hi phi cn nhc c bit vi nhng
bnh nhn b chn thng, trnh tai bin th pht ca h thn kinh trung ng.
4.3. Thn nhit
Bnh nhi d b nhim lnh nht l tr nh, tr s sinh cho nn trong khi
vn chuyn khng c tr b h thn nhit (c th s dng chn, bnh nc
lm m, h thng iu ha m trn xe) lm m bnh nhn. Nn s dng
71
phng php Kangaroo m cho tr nh. Dch truyn cn phi c m
trc khi truyn cho tr.
Trong qu trnh vn chuyn nu pht hin ra bt c biu hin nng no
u phi c x l kp thi.
4.4. Ghi chp h s bnh n
- Tt c cc th thut, thuc, dch truyn cho bnh nhn phi ghi chp .
- Cc du hiu lm sng, cc xt nghim, X quang, nhm muphi
thng bo cho ni bnh nhn s chuyn ti (nu c iu kin thng bo trc
qua in thoi).
4.5. Chun b bnh nhn trc khi vn chuyn
- Ch thc hin vn chuyn bnh nhn khi cc chc nng sng phi m
bo v duy tr tt (ng th - tun hon thn nhit pH, ng mu).
- Cc vic sau y cn lm chun b tt, an ton cho vic chuyn bnh
nhn:
1. Xem ng th v th m bo cha? (kh mu ng mch nu c
th).
2. c nh c, tay, chn ca bnh nhi tt cha?
3. Oxy mang i theo cha?
4. ng truyn tnh mch cho bnh nhn tt cha?
5. cc loi dch cho bnh nhn trong khi vn chuyn cha?
6. Cc phng tin gim st bnh nhn.
7. Liu bnh nhn c m trong qu trnh vn chuyn hay khng?
8. H s, bnh n cha?
- H tn bnh nhn
- Tui
- Cn nng
- Phim chp X quang nu c
- Triu chng lm sng
- Thuc s dng (liu, ng dng, thi gian)
- Theo di dch truyn
- Ch s h hp (nhp th, kiu th ca bnh nhn, ca my th).
- Cc kt qu xt nghim
72
9. trao i vi ni nhn bnh nhn cha?
10. trao i vi b m, ngi nh ca bnh nhn cha?
4.6. Mt s trng hp c bit
- Bnh nhn s sinh b teo thc qun: cn tr t th ngi u nghing
phi t ng thng vo khoang ti cng ht nhiu ln (ch trnh lm tn
thng). C th ch ng t ng ni kh qun ht thng ni kh qun, trnh
bp bng h hp nhn to.
- Thot v c honh: cn t ng NKQ (khng c bp bng qua mt n)
h hp h tr qua ng NKQ vi tn s nhanh v p lc thp hn bnh thng,
t ng thng d dy ht cht dch ng.
- Bnh nhn s sinh b thot v rn hoc thot v qua khe h thnh bng
th bc cc quai rut v ph tng trong mt tm gc v khun bnh nhn
nghing v mt bn. Trong qu trnh vn chuyn phi lin tc lm m v lm m
khi thot v.
- Nhng trng hp: tr s sinh b thot v mng no ty th tr nm
sp trong khi khi thot v v vng b thng tn c che ph mt tm
gch v khun v c lm m, m trong qu trnh vn chuyn.
- Tt c tr s sinh c chuyn n ni can thip ngoi khoa u phi
c tim bp 5mg vitamin K1.
- Tr s sinh ca nhng b m b i tho ng, phi c truyn dung
dch glucose 10% trong sut qu trnh vn chuyn.
- i vi tr b vim np thanh qun hoc tc nghn ng h hp, khi
vn chuyn phi t th ngi hoc nm nghing sang mt bn.
- Vi bnh nhn sc nhim khun, c bit nhim khun do mng no cu
c ban xut huyt hoi t lan ta th khng c vn chuyn khi tr cn b sc
v nhit >39oC.
73
NGUYN TC TIP CN V X L NG C CP TR EM
tr em, ng c xy ra nh l 1 tai nn khng c , c bit tr em
di 12 tui, ch yu xy ra qua ng tiu ho (do n ung phi cht c).
1. CHN ON
1.1. Trc mt tr nghi ng c cp cn xc nh.
- Tr c b ng c tht s hay do mt nguyn nhn bnh l khc
- Mc nng ca ng c.
- Cht c l g.
- Thi gian b ng c, lng cht c m tr n ung phi.
1.2 Trong thc t cc tnh hung c th xy ra l.
- D chn on: gia nh a tr n vi li khai r rng cc tang chng
a theo c th (thuc, chai l ng thuc, c, qu)
- Kh chn on: phi da vo nhiu yu t (hi bnh, khm lm sng v
xt nghim c cht), c th nghi ngh tr b ng c khi:
+ Cc triu chng bt thng xy ra t ngt (hn m, co git, nn, tiu
chy, tm ti) tr trc hon ton kho mnh hoc ch nhng bnh nh
thng thng (st nh, ht hi, s mi)
+ Thng khng st cao (ngoi tr mt s cht c nht nh).
+ Hi nhng ngi xung quanh (i theo) v cc cht c (thuc dit
chut, thuc tr su) hoc thuc iu tr m gia nh hin ang dng.
1.3. Khm lm sng ton din:
xc nh tnh trng ca tr, c bit phi ch xc nh c: tui,
cn nng, cc chc nng sng nh h hp, tun hon, tinh thn kinh, thn nhit).
ng thi pht hin cc du hiu ch im c hiu, v d:
- Hn m, khng c du hiu thn kinh khu tr km theo: ng c thuc
ng (barbituric) hoc cc loi an thn khc.
- Co git: Ng c strychnine, atropin, theophylin, long no
- Co ng t: Ng c atropin, imipramin, thuc m, ru
- Mch chm: Ng c digitalis, quinine, muscarin
- Mch nhanh: Ng c atropine, xanthin, theophylin
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- St cao: Ng c nhm xanthin, theophylin
- H thn nhit: Ng c barbituric,phenothiazin
- Tng thng kh: Ng c salicylat (aspirin)
- Xut huyt: Ng c cht chng vitamin K
1.4. Xt nghim c cht:
Phi ly cc cht nn, dch d dy, phn, nc tiu, mu ca bnh nhn v
cc cht vt phm nghi ng m gia nh a n xc nh c cht.
1.5. Tu theo mc nng nh v cc ri lon m mt s xt nghim sau y
cn phi lm gip cho vic theo di v iu tr:
Cng thc mu, ur, creatinin mu, in gii , ng mu, kh mu,
chc nng gan, in tm
2. X L
2.1. m bo v duy tr cc chc nng sng
- Phi m bo bnh nhn th tt: lm thng ng th, th oxy, t ng
ni kh qun, h hp h tr nu cn.
- m bo chc nng tun hon: cp cu ngng tim (nu c). Nu bnh
nhn c biu hin sc th phi truyn nhanh dung dch c in gii, dung dch
keo hoc mu (tu theo trng hp c th, khng c dng ngay thuc vn
mch nu cha c truyn dch tha ng.
- iu tr v ngn nga co git hay ri lon thn nhit.
2.2. Loi tr cht c
2.2.1. Nhng cht c qua da, nim mc
- Ci b qun o.
- Ra sch c th bng nc hoc dung mi thch hp.
2.2.2. Nhng cht c qua ng ung: Cc bin php loi b cht c l:
Gy nn, ra d dy, ty rut, bi niu mnh, lc mu ngoi thn (thm
phn phc mc, thn nhn to), h hp h tr.
a. Gy nn, ra d dy
- Gy nn: Ch nh khi cht c dng thc n, l, thuc vin, thc hin
trong vng mt gi u sau khi tr n ung phi cht c m vn cn tnh to.
+ C th lm tc khc bng cch cho ngn tay vo hng kch thch
nn.
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+ Ung sir Ipeca 7- 10%: tr em 6 - 12 thng ung 1 ln 10ml, 1-10 tui
ung 15ml, trn 10 tui ung 30ml. Sau khi ung xong cho tr ung nhiu nc,
nu sau 20 pht tr khng nn th ung liu th hai.
+ Tim apomorphin liu 0.07mg/kg sau 2 n 5 pht tr s t nn (nu c
du hiu suy th th tim naloxon (Narcan) liu 0.01mg/kg.
- Ra d dy
+ Ch thc hin trong 6 gi u sau khi ung phi cht c v tr vn
cn tnh to hoc c t ng ni kh qun nu tr b hn m.
+ t ng thng vo d dy, cho bnh nhn nm u hi thp nghing v
mt bn. Dng nc m thm natriclorua (1 lt nc thm 4g natriclorua) hoc
dng lun dung dch huyt thanh mn ng trng 0.9% ra v lm sch d
dy. Phi ch cht dch chy ra xem c cc mu thuc, thc n, mu. V
nguyn tc l ra cho n bao gi nc ly ra trong (thc t l lng dch ra
d dy khong 100ml/kg cn nng tr em. Cht dch thu c cn gi i xt
nghim c cht. Sau khi ra xong nn bm than hot vo d dy.
- Chng ch nh gy nn v ra d dy:
Khng gy nn v ra d dy khi bnh nhn ang co git v hn m.
Cht c l cht n mn (acid, kim, thuc ty), cht bay hi (xng, du
ho, nc hoa), cht du khng tan (cht bi trn, cht lm bong).
b. Than hot:
Ly khong 30gam than hot pha vi nc thnh 1 th h, liu dng
1g/kg cn nng cho 1 ln. Cho bnh nhn ung trc tip hoc bm vo d dy
sau khi ra d dy, c hiu qu tt nht mt gi u sau khi bnh nhn n, ung
phi cht c. Than hot khng c hiu qu i vi cc cht c l: ru, acid
boric, st, alcan, thilium, mui acid, cyanid, cc cht c hydrocarbon.
c. Thuc ty rut:
S dng mag sulphat 250mg/kg cn nng hoc du paraphin 5ml/kg cn
nng, Khi dng thuc ty phi theo di tnh trng mt nc, in gii. Khng
dng thuc ty c magi cho ngi c suy thn.
d. Tanin:
Lm bin tnh mt s alcaloid v c th kt hp vi mui kim loi nng,
ngn cn s hp thu ca chng. Liu dng 2-4g/ mt ln.
e. Bi niu mnh:
Ch nh khi cht c c o thi qua thn.
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f. Kim ho mu: ng c thuc ng Barbiturate
g. Lc mu ngoi thn:
Ch nh trong nhng trng hp ng c nng vi lng ln cc cht
c c kh nng qua c mng lc.
h. o thi cht c qua ng h hp:
- Ch nh trong nhng trng hp ng c cht bay hi (Ru, benzene,
ether,ceton, oxydcarbon, xylem)
- K thut: t ng ni kh qun, h hp h tr.
2.3. Gii c
- Gii c khng c hiu:
+ Hp th: than hot, tanin, sa.
+ Trung ho ho hc: dng oxyd magi trung ho acid, dng dm pha
long, chanh trung ho cht kim
- Gii c c hiu:
- Ch dng khi bit chc chn cht gy c v ch pht huy ht tc dng
khi cht c cn lu thng trong h tun hon.
V d: Methemoglobin Dng xanh methylen
Opi Narcan
Phospho hu c Conthrathiol + Atropin
Paracetamol N. Acetyl systein
Heparin Protamin
Dicoumarin Vitamin K1,PPSB
77
X TR VT THNG DO NGI V SC VT CN
Cc vt thng do ngi v sc vt cn chim khong 1% s cc trng
hp n khoa cp cu, trong ch yu do ch cn (80-90%) sau y do mo,
kh chut v ngi. Tr trai thng b cn nhiu hn tr gi v ch yu xy ra
vo ma h. Do tnh thng gp v nhng bin chng tim n ca nhng vt
thng loi ny, ngi thy thuc cc c s cp cu cn phi nm vng cch
tip cn v x l chng.
1.TIP CN CHN ON
1.1 Hi bnh s bit c
- Loi sc vt no hay ngi cn, trong hon cnh no.
- Thi gian b cn.
- Tin s bnh ca tr trc (i tho ng, bnh mch mu ngoi vi,
bnh nhim khun, bnh mn tnh ang s dng steroid hoc cc bnh gy suy
gim min dch khc).
1.2 Khm ni khoa ton din
- Khm ton din xc nh tnh trng chung ca tr (ng th, th,
tun hon, tinh thn kinh)
- Khm k vt thng bit: V tr, kiu tn thng (vt rch, bm dp
do day nghin, vt cn ngp su do rng), tr em vt cn vng u c
th gy tn thng xng s, nhng tn thng vng khp d nh hng n
hot ng ca khp .
Ch n cc du hiu nhim khun: ban xut huyt, sng ty, cht dch,
m chy ra t vt thng, phn ng hch, au cc chi lin quan khi th ng.
1.3. Cc xt ng