Qui Trình Kỹ Thuật Răng Hàm Mặt _ Răng Hàm Mặt

19/5/2015 qui trnh k thut rng hm mt | Rng hm mt

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PHC CP CU VIM TY CP

I. Triu chng:

1. C nng:

au t nhin thnh cn, cn au ko di vi pht n hng gi, khong cch gia cccn au ngn. au theo nhp mch p, lan ln na u cng bn, i khi khng xc nhc im au.

au nhiu v m, au tng khi c kch thch.

2. Thc th:

Rng c l su hoc vt rn nt, y nhiu ng mn, c th c im h ty.

G ngang au hn g dc.

Th nghim ty: dng tnh, ngng thp, ko di.

3. Xquang:

Pht hin l su st ty.

Vng cung rng c th c phn ng nh, dy chng hi gin rng.

II. X tr:1. M ty, ly ty: c hai phng php:

1.1. Ly ty sng:

Gy t ti ch quanh chn rng bng xylocain 2 %.

Dng mi khoan m mt l vo trn ty.

Gy t trc tip vo bung ty v ng ty (qua l m trn ty).

Dng chm gai ly ty: xoay vng quay li nhiu ln. Trng hp ng ty rng c thdng lentulo quay ngc chiu ly ty ra.

1.2. t thuc dit ty:

Gy t ti ch bng xylocain 2%.

Lm sch l su bng no ng hoc mi khoan.

t thuc dit ty (ch trnh ra ngoi li gy hoi t).

Hn tm.

Sau 5- 7 ngy m bung ty v ly ty.



2. Chun b ng ty:

Dng da ng ty, cc c t s nh n s ln a t trn xung quay na vng nhnhng khng c cng gy gy dng c.

Nong ng ty t s nh n ln lm nhn thnh ng ty sau khi da.

Bm ra ng ty bng oxy gi 10 th tch hoc dung dch natri hypochlorite 10%.

St trng ng ty bng cn 90o

Lm kh bng bng hoc bc giy.

Ch tm ht ng ty (trnh b st).

3. Hn ng ty:

Dng lentulo nhi pate vo ng ty nh nhng vi tc thp t trn xung nhiu ln.a pate vo s lng cc ng ty trong rng sau lau sch v nhi kim gutta-perchavo cc ng ty cho n khi cht v va n chp rng.

Hn tm.

Chp phim kim tra,nu t yu cu sau vi ngy hn vnh vin.

III. THEO DI V X L TAI BIN:1.Thng sn bung ty: Hn Ca(OH)2 v theo di.

2. Gy dng c trong ng ty: Ly dng c ra.

3.Vim quanh chp rng sau khi hn ng ty: iu tr khng sinh v gim au.

PHC CP CU VIM, ABCESS QUANH CUNG CP

I.Triu chng:

1. Ton thn:

- Vim quanh cung cp: Mt mi, st cao, c th c phn ng hch vng lin quan.

- Abcess quanh cung cp: St cao, sng ty hch vng lin quan.

2. Ti ch:

C nng:

- au rng t nhin, lin tc, lan ln na u, au khi nhai, t p ng vi thuc gim au,

c th xc nh r rng au.



- Cm gic chi rng.

- Trong abcess quanh cung cp, nu m khng c dn lu s lan rng gy vim m

t bo.

Thc th:

- Rng c th i mu.

- Rng lung lay, g dc au.

- Li tng ng vng cung rng sng phng, , n au.

- Th ty: m tnh.

Xquang:

- Vim quanh cung cp: c th m vng cung, gin nh dy chng quanh rng.

- Abcess quanh cung cp: gin rng dy chng quanh cung.

II. X tr:

1. M tho trng:

Dng mi khoan m m mt l vo trn ty.

Dng chm gai ly ty: xoay vng quay li nhiu ln. Trng hp ng ty rng cth dng lentulo quay ngc chiu ly ty ra.

Rch abcess dn lu m trong trng hp abcess quanh cung cp.

Tho trng trong 24 - 48h.

Dng khng sinh, chng vim trong 5 - 7 ngy.

2. Lm sch v to hnh ng ty:

Dng da ng ty, cc c t s nh n s ln a t trn xung quay na vng nhnhng khng c cng gy gy dng c.

Nong ng ty t s nh n ln lm nhn thnh ng ty sau khi da.

Bm ra ng ty bng oxy gi 10 th tch hoc dung dch natri hypochlorite 10%.

Lm kh bng bng hoc bc giy.



Ch tm ht ng ty (trnh b st).

3. t thuc st khun ng ty: Ca(OH)2, Osomol hoc CPC.

4. Hn ng ty:

Dng lentulo nhi pate vo ng ty nh nhng vi tc thp t trn xung nhiu ln.a pate vo s lng cc ng ty trong rng sau lau sch v nhi kim gutta-perchavo cc ng ty cho n khi cht v va n chp rng.

Hn tm.

Chp phim kim tra,nu t yu cu sau vi ngy hn vnh vin.

III. THEO DI V X L TAI BIN:

1.Thng sn bung ty: Hn Ca(OH)2 v theo di.

2. Gy dng c trong ng ty: Ly dng c ra.

3.Vim quanh chp rng sau khi hn ng ty: iu tr khng sinh v gim au.

PHC CP CU VIM, ABCESS QUANH RNG

I. Triu chng:

Vim quanh rng giai on cp tnh c biu hin l au, n li vng rng bnh thy cm chy ra, rng lung lay

p xe quanh rng c biu hin l au, sng ph, , b mt bng.

II. X tr:

1. Vim quanh rng cp:

Mc tiu:

- Lm gim au

- Kim sot s lan rng ca nhim trng

iu tr:

- Thuc khng sinh ton thn: Rodogyl 750UI: ngy ung 4 vin chia 2ln

- Thuc gim au: Efferalgan 500mg: dng ng ung, c 4 n 6 gi khi cn thit,nhng khng qu 4 gam mt ngy

2. Abcess quanh rng cp:



2.1. Mc tiu:

- Lm gim au

- Kim sot s lan rng ca nhim trng

- Dn lu m

2.2. iu tr:

Dn lu m: 2 cch:

Dn lu qua ti li:- T ti ch b mt hoc t thm- Dng thm chm hoc dng c c u nh dt p vo thnh ti li tng ng p xe t

pha trong ti li- Dng cy no nh hoc cy ly cao thm nhp vo t chc v dn lu.

Dn lu qua ng rch bn ngoi:

Khi p xe quanh rng kh dn lu qua ng rch ti li hoc thy r pha ngoi li th dnlu bng ng rch bn ngoi .

- Cch ly, lm kh v st trng- Gy t ti ch- Dng dao rch ng rch ng qua phn di ng nht ca tn thng, ng rch i

t li nim n b li. Nu ch sng phng mt li th ng rch bt u ngay dichsng phng( pha cui rng) v m rng n b li.ng rch phi su v ti c vng c m

- Lm rng nh nhng ng rch dn lu- Bm ra bng nc mui sinh l, betadine pha long- Hng dn bnh nhn xc ming bng nc mui sinh l 0.9%

K n thuc khng sinh, gim au cho bnh nhn.

PHC CP CU NT V THN RNG

I. Triu chng:

1.Tn thng men rng:

Rn rng: nhn thy ng nt rn trn mt men rng hay gp mt ngoi nhnghnh th rng khng thay i.Cc du hiu c nng khng c.

Gy v men rng: Hnh th rng thay i do mt phn men rng b mt v li vtgy sc cnh nhng khng th ng mu vng .C th c du hiu but nh khi n ung nnghoc lnh.



2.Gy thn rng khng h ty:

Hnh th rng thay i, trn ng gy c thy ng rng mu vng l nhng khngthy im h ty.

But rng khi n nng lnh.

3.Gy thn rng c h tu:

ng gy nm thn rng c im h ty mu .

Bnh nhn c bit but khi c kch thch, thm ch au nhc rng t nhin.

II. X tr:

1. Tn thng men rng:

Rn men c th khng cn x tr g, hoc ch ph mt lp bonding resin vi kthut etching nhm phng nga vt trn rng sau ny.

V men rng: Phn gy c lm nhn trnh gy tn thng m mm, phc hi rngbng composite hoc dn phn men v c th tr hon hoc lm ngay sau sang chn

2. Tn thng men v ng rng:

Phn ng l c th phc hi bngf composite hoc lt Ca(OH)2, hoc dycal trong trng hpst ty phi chp ty gin tip.

3. Tn thng men, ng v ty rng:

Chp ty trc tip khi im h ty nh v c iu tr trong cng ngy rng b sangchn

Ly ty bung nu l cung rng cha ng v ly ty ton b sau 7-10 ngy nu lcung ng trong trng hp im h tu rng, tn thng h ty qu 24h hay b nhimkhun nng.

Phc hi li hnh th rng bng composite hoc chp, tr rng ty tn thng.

PHC CP CU RNG TRT KHP HON TON

I. Triu chng:

Rng b bt hon ton ra khi xng rng.

II. X tr:

Cm li rng vo huyt rng khi:



Rng ri ra cn nguyn vn chn

T chc xng rng v XOR cn trn 2/3 din tch bnh thng

Khng c bnh l ti ch v ton thn( Bnh vim quanh rng tin trin, lm m ti ch,bnh mu, bnh tiu ng, tim mch, qu cao tui....)

1.X l rng:

Khng c cm tay vo vng chn rng.

Nu rng ngoi di 2h, ra sch bng nc mui sinh l, ko co phn mng nha chubao quanh chn rng, sau t vo rng c chun b. nu c dung dch Hank c thngm rng trong 30 pht, sau ngm trong dung dch khng sinh doxycyline1g/20ml trong 5pht s ti lp mach mu nhanh hn.

Nu rng ngoi qu 2 h khng bo qun tt c th no sch vng dy chng nha churi ngm trong dd NaClO trong 30 pht, sau ngm trong dd acid citric trong 3 pht v rasch bng nc mui sinh l.

Trc khi tin hnh iu tr ni nha ngm rng trong dd ZnF21%trong 5 pht vdoxycylin 1mg/20ml trong 5 pht. Khng sinh gip dit khun, cng vi ZnF2 gim kh nngngoi tiu.Nn hn Ca(OH)2 trc vi rng cha ng cung trnh tiu chn rng

2. X l xng rng:

Ly d vt trong huyt rng, ra bng nc mui si knh l, nu c cc mu ngkhng nn no vt ly i.

Cm li rng c x l theo v tr gii phu, n nh rng vo rng cho ngkhp cn.

C nh rng bng np compospite 2 - 3 tun nu khng gy xng rng, 6 tun nuc gy xng rng.

3. n thuc: Khng sinh, chng ph n v gim au, tim phng un vn.

4. Theo di v nh gi:

Chp xq mi hai tun, 1 thng, 2 thng, 3 thng, 6 thng

Khi rng cha iu tr ni nha cn th ty, khi c du hiu ty cht, hoi t hoc ngoi tiuphi iu tr ngay.

Tin lng: s thnh cng lin quan ti vic bo qun rng, thi gian rng nm ngoi huyt rng, giai on rng ang pht trin v c bit phng php x l rng trc khi cm. (Trong30 pht u cho kt qu tt nht)



PHC CP CU VIM, ABCESS QUANH THN RNG CP

I. Triu trng:

Vim quanh thn rng cp c pht hin bng cch tm cc triu chng vt liph thn rng v t chc ln cn v cc triu chng hch ln cn, triu chng nhim trng tonthn.

Ti ch thng l: au ti ch v c th lan ln tai, ra sn ming, thnh hng, sng n, khcn cht rng, li chy dch hoc m. ngoi mt c th sng gc hm.

Ton thn: c th st, mt mi, c phn ng hch vng lin quan.

II. iu tr:

1. Ti ch:

Bm ra nh nhng bng nc mui sinh l m loi b mn thc n v dch r vim, dungbng thm betadine lau nh mn bm trn li v trn rng.

Sau khi lm sch trn li th a dng c banh nh b li bm ra di li.

Nu c abcess th gy t ri dng li dao 15 chch rch v bm ra.

Ch nh nh rng: Nu rng khn khng ch hoc mc khng ng v tr hay mc lchtrc th ch nh nh rng khi ht vim cp.

2. Ton thn:

Khng sinh: Nu bnh nhn c phn ng hch, st th cho bnh nhn ung Metronidazol500mg hai ln/ngy, kt hp vi khng sinh ph rng khc. Thng dng Rodogyl.

Chng vim.

Gim au.

Sau khi khng cn triu chng cp (au, phn ng hch, st) cn cn nhc nh hay gi li rng khn.Nu iu kin gi li rng khn th thc hin phu thut ct li trm, nguyn tc l bc l ton bmt nhai v mt xa rng khn.

PHC CP CU NGT TRONG NH RNG

I. Xu:



1. Triu chng:

Bt u c th- Hoc t ngt mt tri gic ngay.

- Hoc t t mt tri gic; bt u bng:

Mun ngp

m hi

Mt xanh

C khi mun nn v cui cng

Bnh nhn thu

Tim v phi vn cn m bo chc nng, nhng chm hn bnh thng2. X l:

Lp tc khm:- Theo di mch: c tay, mch cn nhng nh, chm khng u.- Theo di nhp th: c

iu tr cp cu- t bnh nhn nm, u thp, ni thong gi, cng nhanh cng tt.

- Nu c gh loi ng ta lng ra sau c th cng tt, nu khng c, khing ngay bnhnhn n mt ci ging v nm u thp, mu chy vo no d dng. Qut cho thong mt.

- M nt c o, ci tht lng, th d v mu lu thng d c.

- Xoa cn mt, trn, thi dng v hai bn c.

- Chm khn t lnh trn trn.

- Tt nh vo m, git nh tc mai v gi tn bnh nhn.

- Nu khng khi: Tim thuc tr tim:

+ Campho: 1 ng 5 ml di da hoc;

+ Coramin: 1 ng 5 ml di da hoc;

+ Cafein: 1 ng 1 ml di da.

II. Ngt xanh:1. Triu chng:

Bt u c th sau khi b thu, mt tri gic vi pht ri hoc t ngt ngng th (nhtrong lc gy m)

D trong trng hp no cng c- Mt tm ngt


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- Nhp th nhanh, sau chm, cui cng ngng th;

- Song song cng c mch nhanh, sau chm, cui cng khng u (c ngoi tmthu)

- i khi, huyt p cng ln dn, sau tht li v cui cng h thp.

2. X l:

Cn cp cu ngay: trc 5 pht v sau tn thng no khng hi phc c.

Kim tra ng h hp, c th tc do cc mu ng, cht nhn trong ming hoc ngkh qun b di chuyn, b tc. Dng ng thng cao su thng qua hai li mi, ming v hu ht.

Cho th oxy: bng mt n, c bp bng cao su ca my gy m.

Nu khng c bng cao su: h hi thi ngt ming - ming 12 ln/pht.

Tim thuc tr tim v h hp: Campho, coramin, cafein

Nu ng h hp vn b tc:- M kh qun cng sm cng tt, mi cu sng c bnh nhn.- Trong khi ch i, nu c nguy kch, dng phng php chc kim vo kh qun: trn

ng rch dc gia cc sn gip khong 2cm, cm 2 hoc 3 cy kim to (10/10 hoc12/10); nh l kim to, bnh nhn c th th c cht t trong khi ch chun b m kh qun.III. Ngt trng:1. Triu chng:

t ngt: bnh nhn ti mt, bn rn, da xm, ng t gin.

C th c vi du hiu bo trc:

- Du hiu thu, m hi, nn, mt mt phn hoc ton b tri gic.

- Mch khng u, thng l chm.

- Huyt p h

Chn on ngng tim vi nhng du hiu:

- Mch: khng bt c.

- Huyt p: khng ly c.

- Tim: khng nghe c.

2. X l:

H hi thi ngt.



Tim trong tim: khong lin sn 4 v 5, su 4cm vo tm tht tri hoc adrenalin1/1000: 0,2 - 0,3 ml hoc canxi clorua 5%: 10ml hay canxi clorua 10%: 2 - 4ml.

Bp tim ngoi lng ngc (ngang 1/3 di ca xng c).

Phi song song hi phc h hp v kch thch c tim v nu mu chy m khng cmang oxy th v tc dng.

PHC CP CU CHY MU SAU NH RNG

I.Triu chng:

Mu vn tip tc r chy: nh nc bt thy c vt mu.

Cn cht bng hoc gc th bt nhng b gc ra mu li tip tc r chy.

Bnh nhn c cm gic mn v tanh trong ming.II. X tr:

Cn chp thm phim Xquang h tr chn on.

Ty theo nguyn nhn m c hng x tr ph hp.

Khm k: Sc ming, dng bng gc lau sch rng xem k mu chy t rng minh hay li, li, nim mc mi m... Nu mu chy t nim mc: khu li bng ch catgut loi000.

Bm ra, no sch rng, ly b chn rng gy, mnh xng rng gy hoc t chcht, b cc mu ng c, thm kh rng.

Nht gc tht cht trn rng, bo bnh nhn cn gc li 15 - 30 pht.

Nu cn chy mu: no li tht sch rng, thm kh, t vo rng bt thrombin +bt penicillin G, t ln trn bt mt ming gelatin hoc oxycal v trn cng l mt ming gc,cho bnh nhn cn cht gc 15 - 30 pht b gc ra, ming gelatin s t tiu trong vi ngy sau,bt penicillin s gip rng lnh thng tt.

C th dng oxy gi 10V thm gc v t ln rng.

Khng sinh

Tip tc theo di trong 4 - 5 ngy.

Nu vn cn chy mu: cn cho lm thm cc xt nghim mu xc nh nguyn nhnv phi hp vi chuyn khoa huyt hc iu tr.

PHC CP CU KHT HM DO CO THT C

I. Triu chng:



1. C nng:

au vng trc tai, vng c cn mt bn hoc c hai bn.

au t nhin, tng khi vn ng.2. Thc th:

H ming hn ch, c th c ri lon chuyn ng sang bn, lch hm di sang bntn thng hoc khng.

Tng kch thc c nhai mt hoc c hai bn, cn i hoc khng.

Tng trng lc c cn: s b c thy cng cng.

au c khi co c ng b chng li lc cn (c h ming trong khi bc s y ngcli).

Rng: Mn rng, gy thn, chn rng, bnh l ty nhng rng gy tr ngi hoc rngi. Mn rng, m gc, cht ty cc rng cn li. Rng lung lay, di chuyn rng, tt li, tiuxng rng, ti quanh rng.II. X tr:

1. iu tr cp cu:

Mi rng loi b nhng im chm sm hay nhng cn tr nhai nng.

Lm mng nhai s khi iu tr cp cu gip th gin c.

Thuc:- Thuc gin c Coltramyl 4mg ung 2 vin/ln, 2 ln/ngy trong 5 ngy.- Thuc gim au Efferalgan codein ung 1 vin khi au, sau n, cch 4 - 6h/ln.- Tim thuc ti ch thuc t khng cha cht co mch, corticoid (ti a hai mi),

hyaluronate natri, cht gy x.

L liu php: lm gim au (p lnh, p lc liu php, kch thch in bng tip xc hayxuyn qua da), chng vim (nhit, siu m).

Xoa bp v liu php vn ng.

n mm, lng.2. Sau khi bnh nhn ht kht hm:

Nh nhng rng nhim trng, khng th bo tn c, rng khn mc lch.

iu tr ni nha nhng rng vim ty.

Hn nhng rng su.

Hng dn b nhng thi quen xu.

Xc nh t th phc hi khp cn. Mi rng c chn lc iu chnh khp cn, phchi khp cn bng nn chnh rng, phc hnh hoc phu thut nu cn.

iu tr ton thn v iu tr tm l phi hp.

PHC CP CU TRT KHP THI DNG HM



I. Triu chng:

1. Trt khp thi dng hm mt bn:

C nng:- Sau khi h to hoc b chn thng vng hm mt, khng ngm ming c.- au vng khp thi dng hm bn tn thng, au tng khi c ng hm di.- Kh ni hoc n nhai.

Thc th:Ngoi mt:

- C th sng, vng khp thi dng hm bn tn thng.- Hm di a ra trc lch sang bn lnh.- Hm cho rng.- C th s thy li cu pha trc hm cho, mm vt di thn xng g m.- C ng li cu gim.

Trong ming:

- Khng ngm ming c.- Sai khp cn, cn chm vng rng sau bn tn thng.- Trng hp chn thng, c th c tn thng nim mc li, hoc tn

thng gy xng km theo.1.2. Trt khp thi dng hm hai bn:

Triu chng tng t trt khp thi dng hm mt bn nhng hm di a ra trc, saikhp cn, cn chm vng rng sau c 2 bn.

II. X tr:

1. Nguyn tc:

Gim au bng gy t hoc gy m.

Lm mm c v dy chng.

a li cu xung di ra sau.

C nh.

2. Nn:

Trng hp trt khp ln u, bnh nhn n sm, c th nn ti phng mch, khngcn gy m.

- T th bnh nhn: ngi trn gh rng thp, hm di ngang mc khuu tay bc s, tau chc.

- T th bc s: ng pha trc bnh nhn.- Lm mm c v dy chng.



- Hai ngn ci ca bc s t ln trn mt nhai cc rng hm ln (c th ph mt lp gcln mt nhai cc rng hm ln bo v tay). Cc ngn tay cn li ca bc s m b dixng hm di ca bnh nhn, hai c tay quay vo i din nhau.

- n xng hm xung di ng thi y ra sau, ng tc phi nhanh, dt khot, chngli c lc co rt ca cc c hm.

- i vi sai khp hai bn c th vo khp tng bn mt hoc c hai bn mt th.

- C nh bng bng cm u trong 24 48h. K thuc gim au nu cn.

- Hng dn bnh nhn ch n mm, hn ch h ming qu rng. Nu bnh nhn n mun, khng th nn khp ti phng khm, c th gy m nn

chnh li khp.

PHU THUT P XE HM MT CC LOI

I. i cng:1. nh ngha:L p xe cc vng nng, nguyn nhn do rng, rng ci hm trn v hm di, nht l rngkhn m phn ln l do vim ty rng hoi t, nhim khun qua xng vo phn mm gyvim, p xe cc vng lin quan. p xe gy au nhc, c th gy bin chng xa vo cc phtng quan trng hoc nhim khun mu, cn c phu thut sm, m m dn lu.p xe c th nng di nim mc, hoc su di mng xng vo phn mm gy sng to,bin dng mt.2. Phn loi: Ty theo nguyn nhn p xe c th hnh thnh cc vng:- p xe di li: Sng li pha tin nh hay pha trong (li)- p xe quanh thn rng: thng gp do rng mc ngm nhim khun, nht l rng khn di:Li chm vim m, sng n quanh thn rng 8, vng di hm, kht hm, hch.- p xe m: Sng vng m, trn b nn xng hm di, rnh mi m, tin nh m.- p xe mi trn v mi di, cm:

+ Mi trn: Sng, m t trn hoc di c sim, mi y ra trc, rnh mi-mi b y.+ Mi di sng n

- p xe tin nh trn hoc di: M t di nim mc tin nh rng nguyn nhn- p xe vm ming: Sng di nim mc vm ming, k cn rng nguyn nhn- p xe vng di hm: Thng gp do bin chng rng khn, rng ci, vim nhim snming. Triu chng: Sng vng di hm, gc hm, sn ming vng sau, kht hm.- p xe vng cm: Thng do rng ca, rng nanh.Lm sng: Sng vng cm, da cng bng.- p xe di li-di nim mc: p xe nng ngay chn rng nguyn nhn.- p xe h mt: Thng do nhim khun rng nanh, hay lan t vng ln cn n. Lm sng: Nmi trn v di , n kt mc, li mt nh, lch mt s nhn cu rt au.- p xe li: Do nhim khun li hoc d vt, hay vt thng trc tip, lao, giang mai Lmsng: Li sng n, n c du hiu chuyn song, sn ming c th b xm nhim, nhai, nut,ni kh.



II. CH NH:- M cc p xe khi c du hiu lm m, chuyn song khi thm khm.- p xe iu tr khng sinh, chng vim khng khi, lm m, thng thng t ngy th 6-7.III. CHUN B:1. Cn b chuyn khoa: L bc s chuyn khoa rng hm mt, bc s gy m, t lm ctrung th thut.2.Phng tin: C phng m, c phng tin gy m, oxy.3. Ngi bnh:- Khng c bnh v tim mch, h hp, khng c chng ch nh gy m.- H s bnh n: C xt nghim c bn v mu, sinh ha ch nh gy m.IV. CC BC TIN HNH:1. V cm: Gy t ti ch khi p xe nng v c th gy m ngn i vi p xe su.2. K thut:a. p xe nng: Gy t, rch m p xe i vi p xe nng di nim mc, di da ch rchva t nim mc hay da. Lun kp cm mu m rng p xe dn lu ht m. C thdn lu m bng mnh cao su. Thay sau 48 gi, bm ra cho n khi ht m.b.p xe su: Ty mc p xe, tui, c th chn gy t hay gy m. i vi p xe su, lanrng nn gy m ngn d m p xe.- Rch ni c th trnh so xu, l ra ngoi (di b nn xng hm, np rnh t nhin )trnh cc thng tn mch, thn kinh. - p xe m: Rch rnh mi m, hay di b nn xng hm di, lun kp Kocher vo m, m rng,dn lu.- p xe mi: Rch mt trong nim mc.- p xe tin nh: Rch nim mc tin nh, cha hoc nh rng nguyn nhn.- p xe vm ming: Rch dc cung rng, tch nim mc, dn lu m.- p xe vng di hm: Rch di v cch b nn 2cm, lun kp Kocher hng mt trongxng hm dn lu m.- p xe h mt: Ty ni t m c th rch b trn hay b di h mt, lun kp Kocher stthanh xng dn lu m.- p xe vng cm: Rch da sau cung cm dng kp Kocher dn lu m.- p xe di li, di nim mc: Rch t nim mc pha st mt trong xng hm di, trnh tn thng ng Wharton hay thn kinh di li, lun kp Kocher m m.V. THEO DI V X L TAI BIN:1.Theo di:a. Thay bng, bm ra m thay dn lu sau mi 48 gi, hoc hng ngy nu nhiu m.b. Mch, nhit gim v tr li bnh thng khi dn lu ht m v x l rng nguynnhn.c. Nh rng nguyn nhn nu l rng ci ln, nht l rng khn.d. Cha cc rng nguyn nhn.e. Khng sinh, chng vim, nng th trng.2. X l:a. M khng vo ng p xe do sai ng vo, do khng chuyn khoa hoc chn on sai:



Cn hi chn chuyn khoa.b. Ko di nhim khun m do cha m rng v dn lu ht m: m rng p xe, bm rasch m, dn lu.c. Tai bin gy m: Cn c bc s gy m chuyn kha, kim tra ngi bnh k trc khi gym, ch nh ng.d. p xe ti pht: Do cha dn lu ht m hay cha x l rng nguyn nhn: X l li trit .

PHU THUT P XE VNG SU HM MT

I.I CNG

1. nh ngha: Cc vng su l nhng vng gii phu nm gia xng, c, v cc lp ca cnc su. Cc vng su cha nhiu mch mu, thn kinh quan trong. Cc vng ny d thng vinhau; khi 1 vng b nhim khun, t c th lan ln nn s hay vo trung tht. Cc vng sauy c xp vo vng su: p xe vng c cn, p xe vng mang tai, p xe khoang chnbm hm, h thi dng.

2. Ngun nhim khun phn ln do rng ci, rng khn, sang chn.

3. Phn loi:

a. p xe vng c cn:

- Vng c cn i t cung tip n b di xng hm di, t b trc c cn pha trcn b sau cnh ln xng hm di. Vng c cn c ng mch ngang mch, cc nhnh cathn kinh mt v phn ko di ca tuyn mang tai, ng Stenon i qua, cn v c cn.

- c im p xe vng c cn l kht hm nhiu, au v sng mt bn mt, da v nim mcsng n , sung huyt v n lm, c th sng lan n thnh bn hu amydal, di li. aud di, kh nut, nhim khun ton thn.

b. p xe vng mang tai:

Sng t b sau cnh ln xng hm n b trc c c n chum. Da tm cng, n lm,m c th chy qua ng Stenon, nu p xe v vo tuyn mang tai. au, kht hm, kh hming, n mi di.

c.p xe khoang chn bm hm v h thi dng:

- Khoang chn bm hm v h thi dng nm chung trong vng sau hm, thng b vimnhim do rng nn v bnh l c m t chung l p xe h chn bm hm, khu tr mt vngsu gia:

+ Pha ngoi l mt trong cnh ln xng hm di

+ Pha trong l chn bm, thnh bn hu



+ Trn l nn s

+ Trc l li c xng hm trn

+Di v sau l khoang bn hu, vng di hm, vng mang tai

-Trong vng c ng mch hm trong, dy thn kinh hm trn, hm di v m ri tnhmch chn bm. H chn bm thng vi h thi dng, h mt.

-Nguyn nhn p xe thng do rng ci, rng khn trn v di, chn thng hm trn, vimxoang hm, vim xng hm trn gy ra.

-Du hiu p xe

+Sng vng h thi dng, n mi nht l mi di, li mt, sng au cnh ln, gc hm.Kht hm nhiu, nhai, nut, ni kh khn. Ton thn th trng nhim khun nng, au na mt.

+Sng v xung huyt nim mc m, b trc cnh ln, mng hu, n b trc cnh lnrt au.

II.CH NH:

p xe cc vng su c nguy c lan n cc c quan quan trng nh nn s, trung tht, hu,h mtDo khi c du hiu nhim khun ton thn v p xe ti ch cn x l sm:khng sinh, chng vim ng mch mu, m dn lu, trit cc p xe.

III.CHUN B:

1.Cn b chuyn khoa: Bc s chuyn khoa RHM, chuyn v phu thut hm mt

2.Phng tin: Bung phu thut, gy m hi sc, c my gy m, oxy, dng c phu thut

3. Ngi bnh: c kim tra ton thn, xt nghim ha sinh, huyt hc tiu chun, cxc nh chn on vng b p xe

IV. CC BC TIN HNH

1.p xe vng c cn: Rach vng di hm, lun kp Kocher vo c cn gia da v c, haygia c v mt ngoi xng cnh ln (p xe su), m rng dn lu qua ng rch di hm.

2.p xe vng mang tai: Rach di gc hm hoc rch dc trc np tai, lun kp Kocherqua ng rch vo vng mang tai, dn lu m bng ng hay mnh cao su.

3.p xe khoang chn bm hm: M p xe theo ng trong ming, ngoi ming, hay hnhp, lun kp Kocher vo su tn pha sau li c xng hm trn m m.

- ng trong ming sau xng hm trn i vi p xe sau li c hm trn. ng rch vngquanh rng khn v b sau ngoi li c xng hm trn.

- i vi p xe chn bm hm di: rch nim mc dc b trc cnh ln, lun kp



Kocher theo ng gy t gai Spix vo gia mt trong cnh ln v c chn bm trong, banhrng, dn lu bng mnh cao su.

- ng ngoi ming: ch nh i vi p xe h chn bm hm v cc vng ln cn nhkhoang bn hu, vng thi dng, vng di hmDn lu tt c cc p xe

4.Cc ng rch c th p dng nh sau:

a. ng di gc hm: ch dng vi p xe vng sau hm, khoang bn hu. Nu p xekhoang bn hu th ko di ng rch ti b trc c c n chum. Qua ng rch, lunkp m cc vng tng ng.

- M vng di hm: Lun kp vo mt trong cnh ngang

- M vng sau hm: y kp i ln trn, ra trc v vo trong cnh ln

- M chn bm hm di cn chc thng, tch th c chn bm trong

- Nu m khoang bn hu th lun kp hng vo trong, ra sau, dn lu bng mnh cao su

b. ng cung tip: ch nh i vi p xe h thi dng v m; rch 2-3 cm dc b trncung tip, lun kp xung di, vo trong v hi ra trc cho ti khi chm vo li c hm trn

c. ng hn hp ngoi da-trong ming:

-Ch nh p xe lan ra nhiu vng cn dn rng

-Rch ng cung tip: dng kp xuyn qua cn, qua ng rch nim mc b trc cnh ln.Dn lu ngoi v trong ming

5. Nguyn tc chung l m rng v dn lu nhanh tt c cc m.

V.THEO DI V X L TAI BIN

1. Khi lm phu thut vo vng su d chm vo mch mu ln (khoang bn hu, sau hm) :ch rch t da, tch v lun kp cm mu t t cho n khi m, khi c m chy ra th dngli.

2. Theo di nhim khun: cy mu, cy m, lm khng sinh . Khng sinh theo khng sinh.

3. Bm ra hng ngy dn lu m v thay dn lu

4. Bnh tin trin tt khi dn lu ht m, nh rng nguyn nhn, khng sinh

PHU THUT VIM TY TA LAN MING HM MT



I. i cng:

1. nh ngha:

Vim m t bo ta lan( phlegmon diffuse) l th vim cp c c im an ta rt nhanh, hoit t chc khng gii hn, khng gy p xe t m r rt trong thi k u. Do c t mnhca vi khun tc ng trn mt c th v t chc ti ch km khng.

Vim ty ta lan ngay t u ngy nguy him n tnh mng bnh nhn trong vng vai ngy.

2. Bnh sinh: Do rng, nht l rng ci di, rng khn, vim quanh chp rng, quanh thnrng, nhim khun sau nh rng, gy xng hm, vim xng ty

3. Yu t thun li: Bnh d bt pht trn c th km khng nh mt, yu, i thong

4. Vng b vim: L sn ming, h thi dng, vng di hm hay vng su ca mt, trong th vim ty sn ming hay cn gi l vim Ludwig-Gensoul, hay gp nht v nguy him.

5. Vi khun: a dng c k kh v i kh.

6. Triu chng:

- Khi u l vim ty ta lan vng sn ming, ngy th 2-4 hnh thnh nhng hoi t.

- Ngy 5-6 hnh thnh dch thi, hoi t, mu nu sm dc cc mch mu v cn,c th hnhthnh nhng m nh ri rc trong c, cn, sng to dn sn ming v di cm, di hm haibn, da v nim mc cng, xm nht,cng dn (nh g). Sng lan xung c trn xng n.

- Ming khng ngm c, lun h, chy nc bt hi thi, li b y ln trn, ra sau.

- Nhai, nut, ni kh,ri lon chc nng.Kh th do n thanh mn,nhim c hnh ty.

-Ton thn c du hiu nhim c nhim khun. Nht nht, st cao, lc u 39-400 C, mchnhanh nh 120-140 ln /pht, c th mch nhit phn l( mch nhanh, nhit khng tng),protein, tr niu.

- C th ch p dy thn kinh III, IV, VI, kch thch mng no, nhim khun mu, nhim cton thn.

II. Ch nh:

Vim ty lan ta ming hm mt : Khng sinh mnh, nng th trng. Phu thut khn cpm rng cc nhim khun, bm ra bng dung dch st khun ;loi b t chc, dch hoi tcng nhanh cng tt.

III. Chun b:

1.Cn b chuyn khoa: bc s chuyn khoa rng hm mt, chuyn v phu thut hm mt.



C khoa gy m hi sc v bc s gy m.

2. Phng tin: oxy, dng c m kh qun khi cn, my ht.

3. Ngi bnh: th trng v cc xt nghim p ng c gy m ngn.

IV. Cc bc tin hnh:

1. V cm: Gy t hoc gy m ngn nu th trng tt.

Chun b m kh qun nu cn phng bin chng.

2. K thut:

a. Rch dc ng gia cm hoc rch cong hnh mng nga vng cm, t vng di hmbn ny sang hm bn kia. Rch da, c bm da, cn c nng.Lun kp cm mu tch cc thc hm mng, c nh thn vo vng di li, ch khng lm thng nim mc sn ming.

Banh rng kp m nhim khun, thng l nhiu dch c, xm ln nhn t chc hoi tthi.

b. M rng cc vng b nhim khun.

- M vng di hm bng cch hng kp i ra sau v vo trong.

- M vng bn hu bng cch hng kp i ln trn v vo trong.

- Qua ng rch, bm ra k bng huyt thanh, oxy gi, dn lu tt c cc vng b nhimkhun. t mi vng 1-2 ming cao su dn lu: Vng cm, vng di hm 2 bn, vng dili v bn hu.

V. Theo di v x l tai bin:

1. Theo di:

a. Ti ch qua ng dn lu, bm ra bng cc dung dch st khun, oxy gi, cloramin,dakin 3 gi/ln hay 1-2 ln/ngy cho n khi ht dch.

b. Phun ozon vo vt m.

c. Ton thn cho khng sinh mnh, ph rng. Truyn dch NaCl, Glucoso, tr tim, chngvim, corticoid.

d. Tin trin tt nu sau m v iu tr khng sinh 2-3 ngy, ton thn tt hn, khng cnmch nhit phn li, ti ch: gim sng n, d nut, ni c.

2. X l:

Ngng th khi t ni kh qun do th trng suy yu, nhim c hnh ty: m kh qun gym, iu tr oxy. C th gy t m p xe.



PHC HI VT THNG VNG HM MT

I. i cng:

Vt thng phn mm khng tn thng xng.

II. Ch nh:

- ng gip n gin.

- Xc gia nng.

- Vt thng thng hoc dp nt.

- Vt thng x nt, git t hay mt t chc.

III. Chng ch nh:

Khng khu k u:

-Vt thng mun sau 24-36 gi

- Vt thng bn.

- Vt thng mt nhiu t chc v cng khi khu.

IV. Chun b:

1. Cn b chuyn khoa: Bc s phu thut rng hm mt.

2. Phng tin:

Cc phng tin gy t, gy m, thuc ra, st khun, khng sinh, oxy, ch tiu, khng tiu3/0, 4/0

3. Ngi bnh: Khng c du hiu chn thng s no.

- c s cu ban u: Chng chong, chng ngt th, cm mu

- Khu k u trc tip cho vt thng n trc 24-36 gi sau sang chn, nu vt thngkhng bn, khng mt nhiu t chc, cng, bn (phi ra v st khun vt thng trc khikhu).

- H s bnh n: theo quy nh, m t vt thng, hng x l phu thut

V. Cc bc tin hnh:

1. V cm: Gy t ti ch hay gy m ni kh qun.



2. K thut:

a. M rng vt thng, bm ra sch bng dung dch NaCl 0,9%, nc oxy gi 3-5 th tch,ly ht d vt.

b. Ct xn mp vt thng, khu trc tip kn hai mp bng ch nh, mi ri.

c. Khu nh hng: Vt thng gip nt t chc nghim trng, tch nim mc v da, khu ko2 mp gn kht iu khin lin so v v tr bnh thng. Khu tng cng bng phngphp Donati gim cng.

d. Nhng vt da hon ton t ri, c th s dng li nh ghp da ri t thn.

e. Khu mun:

- Vt thng n mun sau 24h, bn nhim khun, mt nhiu t chc. Sau khi lm sch vtthng (bm ra, kh khun) vi ngy, ct b t chc gip nt, hoi t, ct lc mp vtthng, sau khu bng mi ch ri.

- Vt thng su: X l qua cc bc nu trn.

- Cn khp li tht ng v tr cc vt da hay nim mc quanh cc l t nhin (mi, m mt, lmi, ming ). ng kn sn ming.

VI. Theo di v x l cc tai bin:

Nhim khun: Dn lu m, lm sch nhim khun, ly ht d vt, cho khng sinh, chngvim. C th ng vt m k hai.

PHU THUT GY XNG HM TRN

I. i cng:

1. nh ngha:

iu tr gy xng hm trn l nn v c nh hoc kt hp xng cc on gy ng v trgii phu nhm gip cho qu trnh lin xng tt, ng vi v tr ban u v phc hi chcnng n nhai v thm m.

2. Phn loi:

a. Lefort I (gy ngang): ng gy t h l di gai mi i ngang qua trn apex rng, chydi ng ni Zygoma hm trn, ra sau ct ngang phn di chn bm.

b. Lefort II (gy hnh thp): ng gy i t ng ni trn-mi qua xoang l ri i xung vngang ra phn trc nht ca h mt-b di h mt, ri i xung qua thnh trc xoanghm, chy di xng m, ra li c hm trn v ct ngang phn trn cao ca chn bm.



Bn trong: ng gy qua 1/3 trn vch mi, qua mnh thng xng sng v phn gia vm.

c. Lefort III (Gy xuyn ngang): Hon ton tch ri s, mt. ng gy bt u t ng nitrn-mi, trn hm trn chy ngang phn trn nht ca rnh l, ra sau dc xng sng,l thgic, xung ng di mt, ra bm khu ci, ri ct ngang chn bm.

II. Ch nh:

- Gy mt phn xng hm trn

- Gy ngang: gy Lefort I, gy Lefort II, gy Lefort III.

- Gy tch ri gia hai xng hm trn.

K thut c tin hnh khi khng cn cc triu chng nguy c e da tnh mng.

III. Chng ch nh:

-Khng c chng ch nh tuyt i

- K thut c th tr hon, sau khi ngi bnh khng cn cc triu chng e da tnh mng.

IV. Chun b:

1. Cn b y t: Bc s chuyn khoa s b, chuyn khoa I tr ln

2. Phng tin:

- Khoan xng (my v mi khoan), ch thp khu kt hp xng

- Cung Tigguersted

- Dng c phu thut xng.

3. Ngi bnh: c gii thch v k thut

- C nh hai hm trong 6-8 tun, ngi bnh cn bit c ch nui dn hp l.

- H s bnh n: Hon chnh h s bnh n theo quy nh ca chuyn khoa, X-quang chpphim Blondeau, Hirtz, panaroma, nu cn thit c th chp thm ct lp vi tnh.

V. Cc bc tin hnh:

1. V cm: Gy m ni kh qun.

2. K thut:

a. Ly ht mu ng, d vt trong ming

b. Nn xng ng v tr

- Nn kn trong trng hp gy xng sm v ng gy khng phc tp



- Nn h: Rch bc l gy qua ng ngoi da v trong ming

- Khu kt hp xng hai bn ng gy vo ng v tr

- Kim tra thy khp cn theo khp cn trung tm, mt cn i, khng bin dng.

c. Treo hm trn ln g m cung tip trong trng hp gy Lefort I v II.

d. Khoan v treo hm trn ln mu ngoi xng trn trong trng hp gy Lefort III.

e. Khoan c nh hai hm ng khp cn.

g. Khu phc hi phn mm

VI. Theo di v x l cc tai bin:

1. Theo di:

a. Chy mu

b. Kim tra cc u xng vo ng v tr cha.

c. Kh th.

d. Khp cn.

e. Nhim khun

g. Qu trnh lin xng.

2. X l:

a. Chy mu t xng chnh mi-trn: t bc mi trc v bc mi sau

b. Chy mu nhiu do xng hm trn gy phc tp, c bit l gy Lefort IIII. Nu cc binphp ti ch khng kt qu: Phi buc tht ng mch cnh ngoi 1 bn hoc c 2 bn.

c. Kh th do nn: Ngi bnh ang c nh 2 hm, nu nn gy tro ngc: Cn tho cnh hai hm ngay lp tc v ht k.

d. Lng ch thp c nh: Xon li

e. Sai khp cn: Theo di v nn chnh li ngay.

g. Nhim khun ct ty vim do mnh xng cht, d vt : Loi b xng cht, ch thp,iu tr khi nhim khun mi c nh li.

PHU THUT GY XNG HM DI



I. i cng:

iu tr trng hp gy xng hm di l nn chnh, c nh hoc kt hp xng hm nhmphc hi hnh th gii phu, gip cho qu trnh lin xng tt, m bo chc nng n nhai vthm m.

II. Ch nh:

- Gy gia hai rng ca gia

- Gy cnh bn gia rng ca bn v rng nanh

- Gy bn t rng nanh n rng ci nh v ln

- Gy gc hm, gy cnh ln, gy mm vt, gy li cu, gy gip nt

III. Chng ch nh:

Khng tuyt i, th thut c th tr hon sau khi tnh trng ton thn n nh.

IV. Chun b:

1. Cn b chuyn khoa: Bc s chuyn khoa rng hm mt, phu thut hm mt chuyn khoaI tr ln.

2. Phng tin: Khoan xng, ch thp, cung Tiguersted. B dng c phu thut xng.

3. Ngi bnh:

- c gii thch trc l phu thut cn gy m, sau phu thut c th s c nh 2 hm trong6 tun l, ch n lng trong sut thi gian .

- H s bnh n: bnh nh phi chi tit v khm ti ch v an ton thn.- Cc xt nghim c bn v huyt hc, ha sinh.- X-quang quan trng nht l Panorama hay hm ch, thng v v V. Cc bc tin hnh:

1. V cm: gy t ni kh qun.

2. K thut:

Ch tui: ngi gi mt rng s dng hm gi gip cho s nn chnh c d dng. Tr emc gng c gngs c nh bo tn bng mng, nu kt hp xng trnh tn thng mm rng.

a. iu tr nn chnh hnh:- C nh hai hm: cung Tiguested c buc mt ngoi c rng hm trn v hm di. sau cnh hai cung rng bng mc cao su vo cc mc c sn, hoc c nh bng buc ch thp (cnh cng).



- Buc ch thp quanh xng hm v mng nha i vi gy rng tr em v ngi gi mt rngton b.b. iu tr phu thut:- Ly b ton b mu ng v d vt trong ming.- Nn, xp xng ng v tr gii phu.- Dng khoan xng v ch thp c nh xng hai bn ng gy. (C iu kin th c nhxng bng b thp c vt).- C nh hai hm trong 6 tun xng lin.- Chm sc ti ch, khng sinh chng vim, nng cao th trng.- Nu kt hp xng bng np vt th khng cn c nh hai hm.VI. Theo di v x l tai bin:

1. Theo di:- Nng th- Chy mu- Ph n thanh qun gy kh th- Tt li do tt mnh gy ra sau- ng th b nght do rng ri vo ng th hay do tt li.2. X tra. Chy mu him gp:C th do tn thng ng rng di v ng mch mt: cm mu, buc ng mch mt hay cnhngoi.b. t dy thn kinh rng di hoc dy mtc. Nn:V c nh hai hm nn phi sn ko ct ch thp trong trng hp bnh nhn nn. Ch cnh hai hm khi bnh nhn tnh.d. Vim xng, ct ty vim, vim m t bo quanh hm:Thng do rng nhim khun.Ly rng nm trong ng gy m p xe, ly xng mc, iu tr nh ct ty vim.e. Ri lon lin xng:- Chm lin xng.- Khp gi ( khng lin sau 6 thng)- Lin lch do c nh khng ng v tr, khng kht: cn c nh li.f. au khp thi dng hm do mi c nh:Gii thch cho ngi bnh, s khi sau khi tho c nh.

PHU THUT GY C LI CU XNG HM DI

I. i cng:1. nh ngha:Gy c li cu xng hm di thng hay gp, do chn thng, vt thng ha kh. Gy c



li cu c iu tr ton din, phi phc hi chc nng n nhai cho ngi bnh. Nu iu trkhng ng phng php s gy ra hu qu: dnh khp, sai lch khp cn, au vng khpmn tnh.2. Phn loi:a. V lm sng:- Gy khng di lch mt bn hoc hai bn on xng.- Li cu c th chng ln nhau nhng c li cu vn trong khp.- Gy di lch: bt khi hm khp.- C li cu bt khi v tr hm khp (dislocation).- Bao khp dy chng, a sn c th thng tn.b. Theo v tr:- Gy chm cu.- Gy li cu.- Gy di li cu.3. Chn on:a. Lm sng:- au hay chy mu vng khp thi dng hm, c th khp cn sai, cn khp khng kht.- Khp cn h vng ca chm rng sm. khp cn hai hm khng chm.b. X-quang:- Chp phim t th mt thng. chp hm ch. Chp Pannorama. Chp Schuller. II. Ch nh:1. Khng can thip phu thut:a. Gy 1 bn hoc hai bn khp cn dng, khng di lch. C th c nh hai hm trong thi

gian 1-2 tun. sau cho tp vn ng khp.b. Trng hp gy t di lch, c th ko on gy v v tr c, dng ming cao su hay ming

nha chun b t trc t vo 2 mt rng hm ln nng cao khp cn, c nh hai hmcho ng v tr trong thi gian 3 4 tun. cn theo di st, nu thy khp di lch , khngng v tr th phi t li kch thc ca ming cao su.

2. Ch nh phu thut:- Cc trng hp gy c li cu b di lch.- Gy hai ln hay 1 bn di lch.- Gy bt khi hm khp.III. Chun b:1. Cn b chuyn khoa:- Phu thut vin chuyn khoa I rng hm mt tr ln, c kinh nghim, trnh lm tn thngdy thn kinh VII gy lit mt, chy mu do tn thng ng mch hm trong.2. Phng tin:- Phng tin gy m.- B dng c phu thut Rng Hm Mt, my khoan xng, mi khoan xng, ch thp(0,3mm), cung tiguersted (Miniplate neus c).3. Ngi bnh:



- Nu gy li cu xng hm n thun, khng chy mu (Mt s trng hp gy li cu vgy LeFort chy mu c th phi cp cu), ngi bnh phi c phm khm y , nhgi ht tn thng.- H s bnh n theo quy nh, m t tn thng ngoi ming, trong ming (tnh trng khpcn khsr nng n nhai).- Chp X-quang khp li cu: Panorama, Schuller.- Xt nghim c bn (mu, nc tiu).

IV. Cc bc tin hnh:1. V cm: Gy m ni kh qun.2. K thut:a. Gy c li cu c di lch nhng li cu trong khp:- Rch ng trc np tai hay gc hm (ngoi gia), bc tch da, c bm gia, vo ongy.- Dng mc xng t vo hm gy ko hm di xung, mc v ko on gy vo ng vtr.- Khoan hai u xng gy, lun ch thp c nh hai u gy.- C nh hai hm 4-6 tun bng cung np ch U hoc c nh hai u gy bng np vt.- V sinh rng ming hng ngy bng thuc sc ming.- n ung cht du dinh dng: sp, cho.- S dng thuc ks trong 5-7 ngy. Thuc gim au, chng ph n.- An thn 3-4 ngy.b. Gy c li cung rch nh trn.- M rng, tm ly cc mnh vn nt ca li cu.- Cm mu lm nhn li cu.- Buc c nh 2 hm gy v tr ng, 3-4 tun.

V. Theo di v x l tai bin:1. au ti ch: thuc chng vim gim au.2. Chy mu khi phu thut, tn thng ng mch hm trong:Phu thut li cm mu hoc buc ng mch cnh ngoi.3. Nhim khun:Abcess do mnh gy b loi b, phi ly mnh gy, dn lu m.

NH RNG KHN MC LCH C BIN CHNG

I. i cng:- Phu thut nh rng khn lch c bin chng chim v tr quan trng trong phu thut ming,bi v tr n chim t l cao nht trong s cc loi rng hm gay bin chng: vim nhim, p xehm mt.



- Khi phu thut nh rng khn lch c bin chng, cn nm vng ch nh chng ch nh,cc bc chun b trnh chuyn mn ca cn b y t, phng tin, dng c, ngi bnh,h s, cc bc lm th tc, theo di ngi bnh nh bit c cc tai bin v cch x trtrong v sau khi lm phu thut.II. Ch nh:1. Nh rng phng bnh:Ni chung tt c cc rng khn mc lch c nguy c bin chng (m vo rng 7, kt xnghm khng mc ln c) coi nh bin php phng bnh. Trnh c bin chng do rngsau nayftuy nhin phi c s ng ca bnh nhn.2. Rng khn lch v ang gy ra bin chng:

- Su mt xa rng s 7, tiu vch xng mt xa r7.- Vim quanh thn rng (vim li trm rng khn).- Chn p cc rng k cn gy lch cung rng.- Vim m t bo hoc vim xng ty hm.III. Chng ch nh: (khng tuyt i)- Ngi bnh c bnh ton thn: a chy mu, mu chm ng, thiu mu nng, tng bchcu, tng huyt p, i tho ng, bnh tim, thai nghn- Ngi bnh cao tui, sc khe khng cho php phu thut.IV. Chun b:1. Cn b chuyn khoa: bt buc phi l bc s chuyn khoa rng hm mt.2. Phng tin:

y phng tin nh rng kh.- Dng c:

+ Phn mm gm: dao, ko con, cy bc tch vt nim mc.

+ Phn xng: ct xng bng khoan cao tc vi mi khoan kim cng. Km gm xng bm xng rng, cy da xng.

+ Kim ch khu catgut.

+ Km kp kim, kp t chc, kp cm mu, mc, by v km thch hp vi tng loi rng.

- Dng c gy t: (ch dng mt ln)+ Bm tim gy t vng vi mi kim di 4-5 cm.

+ Bm tim gy t ti ch vi thuc v kim tim t ring.

- Thuc st khun:+ Bng gc hp tit khun.

+Dung dch NaCl 0,9%, H2O2 5 th tch, cn Iod 4%.

- Thuc cm mu: c Iodofoc, Geslaspon vvv..,..3. Ngi bnh:- Hi k tin s gi nh, bn thn, khm ton thn ti ch, nu cn thit phi hi chn vphi hp iu tr vi khoa khc, sau mi nh rng.



- H s bnh n phi r rng, t m, phi c xt nghim mu phim x-quang ti ch sau rnghay Panorama.

V. Cc bc tin hnh:1. St khun ti ch bng cn.2. V cm bng t ti ch vi thuc t c adrenslin1/100.000.3. K thut:- Rch to vt nim mc theo nguyn tc m rng phu trng hnh ch Z hoc ch T.- M xng bc ln rng bng my tc cao, m bc l chiu cao thn rng (nmngang), hoc ct thn, ct chn- Ly rng bng by hoc km.- Khu phc hi bng ch Catgut.VI. Theo di v x tr tai bin:1. Theo di.- Ton thn: Nu c chong do qu s, nh hng h thn kinh giao cm, hoc d ng thuct, hoc sang chn gy au, mt mu t u thp mu lu thng ln no c d dng,ni bt tht lng, c cao p m, thuc tr tim.- Chy mu: Gi bnh nhn 15-30p theo di , dng gc v khun cn cht trn rng nhmto sc p, bo v cc mu ng, nht Gelaspon hay gc cm mu, thuc cm mu, snngi baanhj trnh mt chp ming v n nhai mnh trn huyt rng mi.- Sng n: chm lnh, khng sinh chng vim, nng cao sc khe ton thn v thuc an thn.2. X tr.- Gy chn rng: c gng ly bng by hoc m xng .- Gy ra xng rng: tch nt mng xng gy v lm nhn.- Gy xng hm di nhng ngi gi b long xng: c nh xng hm bng mng haykt hp xng.- Chy mu phi xc nh r nguyn nhn:

+ Ti ch rng: bm ra tht sch rng, cho cn gc cht.

+ Ti nim mc khu kn bng ch catgut.

+ Ti pht nhiu ln, ko di 2-3 ngy: no sch cc mu ng, dng Geslaspon hay gccm mu nht cht huyt rng. Dng khng sinh chng nhim khun.,

- Vim rng: ra sch rng bng H2O2 5v, dt bc c tm khng sinh chng vim rng.- Vim xng ty hm, vim m t bo, vim hch c mt dn n nhim khun huyt: btbuc dng khng sinh liu cao, phi hp vi nng cao th trng, m dn lu m hay lyxng mc hi sc, chng nhim khun nhim c.

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