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CC CNG THC CN NH CC QUY TC TOAN KIM1

NHIM TOAN CP H hpChuyn ho

NHIM KIM [PH] = 0,008 X PACO2 [HCO3-] = -0,2 X PACO2 (THNG KHNG < 18 MEQ/ L) [HCO3-] = - 0,4 x PaCO2 (thng khng < 18 mEq/L) PACO2 = 0,9 X [HCO3-] + 9 ( 2) PACO2 = (0,6 X [HCO3-]

PH = -0,08 X PACO2 [HCO3 ] =0,1 X PACO2 ( 3)-

MN PaCO2 = 2,4 x [HCO3-] 22 [HCO3-] = 0,35 x PaCO2 ( 4) PACO2 = 1,5 X [HCO3-] + 8 ( 2) PACO2 2 S CUI CA PH PACO2 = 1,2 X [HCO3-]

TON TOAN KIM2

CC PHNG TRNH NH GI CHC NNG THN p lc thm th u c tnh ton (mM) = 2 x Na (mM) + Ur (mg/dL)/2,8 + Glucose(mg/dL)/18 + EtOH(mg/dL)/4,6 + Isopropanol(mg/dL)/6 + methanol/3,2 + ethylen glycol/6,2 (bnh thng 275-290 mOsm/kg) Khong trng p lc thm thu = ALTT o - ALTT tnh ton/0,93 (do huyt thanh c 93% th tch nc); (bnh thng < 10 mOsm) Khong trng anion = [Na] - [Cl] - [HCO3] Khong trng anion niu=[Na] + [K] -Cl - HCO3 (c th khng tnh HCO3 nu pH < 6,5) thanh thi Creatinin = Ucr x V/Pcr = [Creatinin niu(mg/dL)]x[th tch nc tiu(mL/ngy)]/creatinin mu (mg/dL) x1440 min/ngy thanh thi Creatinin = (140 - tui(nm)/creatinin mu(mg/dL)x72) x trng lng c th (kg)(x 0,85 nu l n)

Mc lc cu thn (GFR) = 170 x [Cr] x tui(nm)-0,18 x [0,762 nu l n] x [1,18 nu l da en] x [Ur]-0,17 x [Alb]0,32 Lng nc t do thiu ht = 0,4 x trng lng c th x ((Na+ huyt tng/140)-1) Phn s thanh thi natri (FENa) = ([Na niu]x[Cr mu])/([Cr mu]x[Na mu]) Chnh lch K+ qua ng thn (TTKG) = (K niu x ALTT mu)/ (K mu x ALTT niu) Quy tc: Lng protein niu bi tit c tnh trong 24 gi (g/ngy) = T s protein/creatinin niu 0,33 Kali v pH: [K+] tng 0,6 mEq/L cho mi mc gim 0,1 ca pH Natri v glucose: [Na+] gim 1,6 mEq/L cho mi mc tng 100 mg/dL ca glucose Can xi v albumin: [Ca++] gim 0,8 mg/dL cho mi mc gim 1 g/dL ca albumin

CC PHNG TRNH NH GI HUYT NG Huyt p: huyt p trung bnh (MAP) MAP = (HA tm thu + (2x HA tm chng)/3

Cung lng tim (CO) (Tnh theo phng php ca Fick): CO = (lng O2 tiu th)/(lng O2 trong ng mch-tnh mch) = (10 xVO2 (ml/min/m2) /(Hb(gm/dL) x1,39 x ( bo ha O2 ng mch - tnh mch) Ch s tim (CI): CI = CO/din tch da (bnh thng 2,5-4,2 L/min/m2) Th tch nht bp = CO/nhp tim Sc cn mch h thng (SVR) = (80 x [MAP(mmHg) - p lc nh phi(mmHg))/CO (L/ mint) Sc cn mch phi (PVR) = (80 x [p lc ng mch phi tb mmHg) - p lc mao mch phi bt tb (mmHg))/ CO(L/min) Din tch da (BSA) (m2) = chiu cao (cm)0,718 x cn nng(kg)0,43 x 74,5 = .......

CC THNG S HUYT NG3 Thng s p lc Nh phi (RA) Trung bnh Sng "a" Sng "v" Tht phi (RV) Tm thu Tm trng ng mch phi (PA) Tm thu Tm trng Trung bnh Mao mch phi bt Trung bnh Sng "a" Sng "v" Gi tr bnh thng (mmHg) 0-8 2 - 10 2 - 10 Ch s tim 15 - 30 0-8 15 - 30 3 - 12 9 - 16 1 - 10 3 - 15 3 - 12 Sc cn mch h thng (SVR) Sc cn mch phi (PVR) O2 tiu th Chnh lch O2 ng - tnh mch 1130 178 dyn/sec/cm-5 67 23 dyn/sec/cm5

Thng s Cung lng tim

Gi tr bnh thng 4,0 - 6,0 L/min

2,6 - 4,2 L/min/m2

110 - 150 mL/min /m2 3,0 - 4,5 mL/dL

CC PHNG TRNH NH GI CHC NNG H HP Th tch lu thng (Vt): Vt = (Vkhong cht + Vph nang) = VD + VA Thng kh pht (VE): VE = (0,863 x VCO2(mL/min))/PaCO2 x (1 - VD/VT) (bnh thng 4-6 L/min) Khong cht Bohr: VD/VT = (PaCO2 - PCO2 th ra)/PaCO2 gin n tnh = Vt/(P plateau - P cui th th ra) (bnh thng > 60 mL/cmH2O) Sc cng b mt theo nh lut La Place: Sc cng = (2 x lc cng)/bn knh Uc tnh O2 ph nang: PAO2 = FiO2 x [P kh quyn - PH2O] -PCO2/ thng s h hp = FiO2 x [760 - 47 mmHg] - PCO2/0,8 Chnh lch O2 ph nang - ng mch = PAO2 - PaO2 = 2,5 + 0,21 x tui(nm)

PaO2 t th ngi = 104,2 - 0,27 x tui (nm) PaO2 t th nm = 103,5 - 0,42 x tui (nm) PaCO2 = K x (CO2 sn xut/thng kh ph nang) = 0,863 x (VCO2/VA) Phn s shunt: Qs/Qt = ((A-aDO2)x0,0031)/(A-aDO2)x0,031 + CaO2-CvO2) CaO2 = lng O2 trong mu ng mch CvO2 = lng O2 trong mu ng mch phi (ly t catheter ng mch phi) CxO2 = [1,39xHb(g/dL)x(SaO2%)]+[0,0031xPxO2] A-aDO2 = chnh p gia O2 ph nang - ng mch (mmHg)

H S QUY I CC THNG S XT NGHIM4 Thng s n n v v quc t chun Sinh ha U/L kat/L U/L kat/L U/L nkat/L mg/dL mol/ L mg/dL mmol/L mg/dL mg/dL H s quy i 0,0167 0,0167 0,0167 17,1 0,357 Thng s n v chun n v quc t H s quy i

ALT, AST Phos kim Amylase Bilirubin BUN Calcium Cholesterol

mmol/L 0,25 mmol/L 0,0259

Kh mu PaCO2 mmHg kPa 0,133 PaO2 mmHg kPa 0,133 Theo di thuc v c cht Acetaminophen g/m mol/ 6,62 L L Amikacin g/m mol/ 1,71 L L Carbamazepin g/m mol/ 4,23 L L Digoxin ng/mL nmol/L 1,28

Cortisol CK Creatinin Glucose LDH Lipase Mg++ 5'-NT Phos T4 T3 Acid uric

g/d L U/L m/dL mg/dL U/L U/dL

nmol/L kat/L

27,6

Gentamycin

0,0167 Phenytoin

Salicylat mol/ 88,4 L mmol/L 0,0555 Theophyllin kat/L kat/L 0,0167 Tobramycin 0,167 Valproat Vancomycin

g/m L g/m L mg/L

mol/ 2,09 L mol/ 3,96 L mmol/L 0,00724 5,55 2,14 6,93 0,690

mEq/L mmol/L 0,5 U/L mg/dL g/d L g/d L mg/dL

kat/L 0,0167 mmol/L 0,322 Folat nmol/L 12,9 Hemoglobin nmol/L mol/ L 0,0154 St, TIBC 59,5 Vitamin B12

g/m mol/ L L g/m mol/ L L g/m mol/ L L g/m mol/ L L Huyt hc ng/mL nmol/L g/dL mmol/L g/dL pg/mL mol/ L pmol/L

2,27 0,621 0,179 0,738

3

Lambert CR et al. Pressure measurement and determination of vascular resistance. In: Diagnostic and therapeutic Cardiac Catheterization, 3/e. Pepine CJ (ed). Williams & Wilkins 1998, Batimore. 4 NEJM 1998; 339(15): 1063 - 1072. TEST THNG K Y HC Test dng tnh Test m tnh C bnh Dng tnh tht (TP) m tnh gi (FN) Khng c bnh Dng tnh gi (FP) m tnh tht (TN)

Tn sut (Prevalence) (xc sut xut hin) = (TP + FN)/ (tng s) = S c bnh /tng s nhy (Sensitivity) = TP/(TP + FN) = Dng tnh tht/ c bnh c hiu (Specificity) = TN/(FP + TN) = m tnh tht/khng bnh T l dng tnh gi = 1 - c hiu T l m tnh gi = 1 - nhy Gi tr d on dng tnh = TP/(TP + FP) = Dng tnh tht/s dng tnh Gi tr d on m tnh = TN/(FN + TN) = m tnh tht/s m tnh chnh xc (Accuracy) = (TP + TN)/tng s = Kt qu tht/tng s T l kh nng cho kt qu dng tnh = nhy / (1 - c hiu) T l kh nng cho kt qu m tnh = (1- nhy) / c hiu

T s chnh trc test (Pre-test odds ratio) = Xc sut trc test /(1-xc sut trc test) T s chnh sau test (Post-test odds ratio) = T s chnh trc test x t s kh nng Xc sut sau test = T s chnh sau test / (t s chnh sau test + 1) T s kh nng > 10 hoc < 0,1 5-10 hoc 0,1 - 0,2 2 - 5 hoc 0,2 - 0,5 0,5 - 2 Thay i xc sut t trc test n sau test Ln, thng c tnh quyt nh Va phi Nh; i khi quan trng t quan trng

THNG S CHC NNG SNG C BN NHI KHOA Tui Khi sinh (12h, < 1kg) Khi sinh (12h, 3 kg) S sinh (96h) Tr 6 thng Tr 2 tui 3-6 tui 7 - 14 tui Trn 15 tui5

Nhp tim lc thc

Nhp tim lc ng

Nhp th

Huyt p tm thu 39 - 59 50 - 70 60 - 90 87 - 105 95 - 108 96 - 110 97 - 112 112 - 128

100 - 180 100 - 160 80 - 110 70 - 110 65 - 110 60 - 90

80 - 60 75 - 160 60 - 90 60 - 90 60 - 90 50 - 90

30 - 60 24 - 40 22 - 34 18 - 30 12 - 16

Huyt p tm trng 16 36 25 45 20 60 53 66 53 66 55 69 57 71 66 80

Jaeschke R et al. User's guide to the medical literature III. How to use an article about a diagnostic test. B What are the results and will they help me in caring for my patients? JAMA 1994; 271: 703-7. 6 Cummins RO (ed). Textbook of Advanced Cardiac Life Support. Dallas: American Heart Association, 1994, page 1:65.

CC PHC CP CU TIM MCH NGNG TIM 7

Bt u theo trnh t ABCD ban u (cp cu c bn) Xem nn nhn c p ng khng Khi ng h thng cp cu Gi my sc in Tin hnh thi ngt 2 ln nu bnh nhn khng th Tin hnh p tim nu thy bnh nhn khng c mch Ni vi my theo di/my sc in nu c nh gi nhp tim & tip tc cp cu nu khng c mch

Rung tht/nhp nhanh tht: Khng c rung tht hoc sc in (200; 200-300, 360 nhp nhanh tht (v tm thu J nu rung tht vn tn ti) hoc phn ly in c)

Tin hnh cp cu 1 pht

Tin hnh cp cu 3 pht

Tin hnh theo cc bc ABCD cp 2 ng th (Airway): th t NKQ H hp (Breathing): Kim tra li NKQ c nh, thng kh, xy Tun hon (Circulation): t ng truyn tnh mch; thuc vn mch; cn nhc dng thuc chng lon nhp; bicarbonat v t my to nhp nu cn Bnh nhn rung tht/nhp nhanh tht Vasopressin 40 UI tim TM chm trong vng 5-10 pht, hoc Epinephrin 1 mg 3-5 pht/ln. Dng ngay t u hoc sau dng Vasopressin khng c kt qu. C th bm qua NKQ vi liu 2-2,5 ln liu thng thng Bnh nhn khng b rung tht hoc nhp nhanh tht Epinephrin 1 mg tim TM 3-5 pht/ln (hoc 2-2,5 mg qua NKQ) Chn on phn bit: Tm v iu tr cc cn nguyn c th gii quyt c Gim O2 mu (O2, thng kh) Ng c Gim th tch mu (truyn p tim cp dch) Trn kh mng phi p Toan chuyn ha (HCO3, lc thng kh) Tc mch, mch vnh Tng kali mu (CaCl2, vv) Tc mch, mch phi H thn nhit7

Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular Care. Circulation 2000; 102 (Suppl 1) RUNG THT & NHP NHANH THT V MCH (RT/NNT)8 Bt u theo trnh t ABCD ban u (cp cu ngng tun hon c bn v sc in) Xem nn nhn c p ng khng Khi ng h thng cp cu Gi my sc in ng th (Airway): khai thng ng th H hp (Breathing): thng kh p lc dng Tun hon (Circulation): p tim Sc in (Defibrillation): nh gi v tin hnh sc in nu c rung tht & nhp nhanh tht v mch, t 1 n 3 ln (200J, 200-300 J, 360J hoc 2 pha tng ng) nu cn RT/NNT vn tn ti hoc ti pht

Tin hnh theo cc bc ABCD cp 2: nh gi v x tr cao cp hn ng th (Airway): th t NKQ cng sm cng tt H hp (Breathing): m bo NKQ ng v tr bng khm lm sng v test khng nh H hp (Breathing): c nh ng th; nn dng loi c nh ng NKQ c chng H hp (Breathing): m bo xy ha v thng kh mt cch c hiu qu Tun hon (Circulation): t ng truyn tnh mch Tun hon (Circulation): xc nh loi nhp tim theo di Tun hon (Circulation): cho thuc tng ng theo loi nhp tim v tnh trng bnh nhn Chn on phn bit: pht hin v iu tr cc nguyn nhn c th phc hi

Epinephrin 1 mg tim TM (hoc 2-2,5 mg bm qua NKQ), 3-5 pht/ln,

hoc Vasopressin 40 IU tim TM 1 ln; c th chuyn sang dng epinephrine sau 5-10 pht Tip tc sc in 1 ln 360J (hoc hai pha tng ng) trong vng 30-60 giy Xem xt dng thuc chng lon nhp: a Amiodaron (IIb) 300 mg TM nhanh (c th tim TM nhc li vi liu 150 mg) Lidocain (cha c khuyn co r rng) 1-1,5 mg/kg TM nhanh hoc 2-4 mg/kg bm qua NKQ (c th tim nhanh nhc li 0,5-0,75 mg/kg 3-5 pht/ln, ti a 3 mg/kg) Magi (IIb nu c thiu Mg mu) 1-2 g tim TM Procainamid (IIb, dng cho RT/NNT ti pht) 20-50 mg/pht, ti a 17 mg/kg Xem xt dng bicarbonate Tip tc sc in 360J sau khi dng mi thuc trn hoc 1 pht/ln trong khi cp cu a: Cp bng chng: Cp I - iu tr lun c chp nhn, an ton v chc chn c li. Cp IIa - chp nhn c, an ton, hiu qu; iu tr chun hoc l la chn; IIb - chp

nhn c, an ton, hiu qu; thuc v iu tr chun, nhng ch l la chn thay th; Cp III - khng hiu qu v i khi c hi. 8 Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2000; 102 (suppl 1) PHN LY IN C9 (c nhp tim trn T nhng khng c mch) Bt u theo trnh t ABCD ban u (cp cu ngng tun hon c bn v sc in) Xem nn nhn c p ng khng Khi ng h thng cp cu Gi my sc in ng th (Airway): khai thng ng th H hp (Breathing): thng kh p lc dng Tun hon (Circulation): p tim Sc in (Defibrillation): nh gi xem c rung tht & nhp nhanh tht v mch, sc in nu c ch nh

Tin hnh theo cc bc ABCD cp 2: nh gi v x tr cao cp hn ng th (Airway): th t NKQ cng sm cng tt H hp (Breathing): m bo NKQ ng v tr bng khm lm sng v test khng nh H hp (Breathing): c nh ng th; nn dng loi c nh ng NKQ c chng H hp (Breathing): m bo xy ha v thng kh mt cch c hiu qu Tun hon (Circulation): t ng truyn tnh mch Tun hon (Circulation): xc nh loi nhp tim theo di Tun hon (Circulation): cho thuc tng ng theo loi nhp tim v tnh trng bnh nhn Chn on phn bit: pht hin v iu tr cc nguyn nhn c th phc hi Pht hin (v x tr) cc nguyn nhn thng gp nht a Gim th tch tun hon (truyn dch) Ng c (qu liu hoc tai nn) Thiu xy mu (cho th O2, th my) p tim cp Toan mu (HCO3, th my) Trn kh mng phi p lc Tng kali mu (CaCl2, vv) Tc mch vnh H thn nhit Nhi mu phi Epinephrin 1 mg TM, nhc li 3-5 pht/ln b

Atropin 1 mg TM nhanh (nu nhp chm); tim nhc li 3-5 pht/ln nu cn, n khi t tng liu 0,04 mg/kg c a: Ch nh ca Natri bicarbonat 1 mEq/kg (theo cp bng chng): Cp I: c tnh trng tng kali mu t trc ; Cp IIa: bit trc tnh trng toan mu p ng vi bicarbonat; qu liu thuc trm cm 3 vng; gy kim ha nc tiu trong qu liu salicylat hoc thuc khc. Cp IIb: Trn bnh nhn t NKQ th my c thi gian ngng tim di. Cp III (c th c hi) toan h hp. b: Epinephrin 1 mg tim TM 3-5 pht/ln (cp bng chng cha chc chn). Nu vi liu tim nh trn khng c kt qu th c th dng liu 0,2 mg/kg nhng cha c khuyn co. Cha c bng chng no ng h dng vasopressin trong v tm thu hoc phn ly in c. c: Atropin vi khong thi gian tim nhc li liu gn hn (3-5 pht/ln) c th c tc dng i vi ngng tun hon9

Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1) V TM THU10 Bt u theo trnh t ABCD ban u (cp cu ngng tun hon c bn v sc in) a Xem nn nhn c p ng khng Khi ng h thng cp cu Gi my sc in ng th (Airway): khai thng ng th H hp (Breathing): thng kh p lc dng Tun hon (Circulation): p tim Khng nh (Confirm): kim tra xem c phi l v tm thc s khng Sc in (Defibrillation): nh gi c rung tht & nhp nhanh tht v mch, sc in nu c ch nh Quan st lt qua hin trng: c nhng bng chng cho quyt nh khng nn cp cu?

Tin hnh theo cc bc ABCD cp 2: nh gi v x tr cao cp hn ng th (Airway): th t NKQ cng sm cng tt H hp (Breathing): m bo NKQ ng v tr bng khm lm sng v test khng nh H hp (Breathing): c nh ng th; nn dng loi c nh ng NKQ c chng H hp (Breathing): m bo xy ha v thng kh mt cch c hiu qu Khng nh (Confirm): kim tra in cc v dy ni; monitor c mt in khng? Xc nh xem c v tm thu trn cc chuyn o khc khng? Tun hon (Circulation): t ng truyn tnh mch Tun hon (Circulation): xc nh loi nhp tim theo di Tun hon (Circulation): cho thuc tng ng theo loi nhp tim v tnh trng bnh nhn b Chn on phn bit: pht hin v iu tr cc nguyn nhn c th phc hi t to nhp ngoi Ngay lp tc c Epinephrin 1 mg tim TM (2-2,5 mg bm qua NKQ) 3-5 min /ln d

Atropin 1 mg TM (hoc 2-2,5 mg bm qua NKQ) Tim nhc li 3-5 min /ln n khi t n liu 0,04 mg/kg e Nu vn v tm th th cn nhc ngng cp cu khi Cht lng ca cp cu ng nhng khng kt qu Thiu bnh cnh in hnh? Khng phi l bnh nhn ngt nc hoc h thn nhit? Khng phc hi hoc khng phi l ng c thuc? C tiu chun ngng cp cu theo protocol? a: nh gi cc ch s lm sng cho thy khng cn cp cu na, v d c du hiu t vong. b: Natri bicarbonat 1 mEq/kg c ch nh trong qu liu thuc chng trm cm 3 vng; lm kim ha nc tiu trong ng c, t NKQ c thi gian ngng tun hon ko di, hoc sau khi tim p li bnh nhn c thi gian ngng tun hon ko di. Khng c hiu qu thm tr c hi i vi toan h hp. c: t my to nhp ngoi cn c thc hin sm, kt hp vi dng thuc. Khng phi l ch nh thng quy i vi v tm thu. d: Epinephrine 1 mg TM 3-5 min/ln. Nu khng c hiu qu th c th dng liu cao (ti 0,2 mg/kg) nhng khng c khuyn co. Cha c bng chng ng h dng vasopressin trong v tm thu. e: Atropin: khong thi gian dng ngn hn 3-5 min /ln trong v tm thu

10

Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1). NHP TIM CHM11

Nhp tim chm tuyt i (nhp tim < 60 ln/pht) Nhp chm tng i (nhp khng tng ng vi bnhcnh , vd. tt p Khm ban u ln lt theo trnh t ABCD nh gi ABC m bo ng th m bo monitor theo di/ my sc in nh gi cp 2 theo trnh t ABCD nh gi bc 2 ABC (chm sc ng th xm nhp nu c) Th O2 - t ng truyn TM- theo di - truyn dch Du hiu sinh tn, o SpO2, theo di huyt p Lm v c T 12 chuyn o Chp v c kt qu phim XQ phi Hi bnh s v khm lm sng theo nh hng Tm chn on phn bit

C cc du hiu v triu chng nng ca nhp tim chm khng? a,b Khng Block A-V cp II hoc cp III f Cc bc iu tr - Atropine 0,5-1,0 mg c,d - t to nhp qua da nu c th e - Dopamin 5-20 g/kg/pht - Epinephrine 2-10 g/kg/pht C - Chun b t to nhp qua da g - Nu c triu chng, s dng t to nhp qua da cho n khi t c to nhp qua TM

Khng Theo di tip

a: Nu bnh nhn c du hiu v triu chng nng, cn xc nh cc du hiu ny c lin quan n nhp tim chm hay khng. b: Triu chng: au ngc, kh th, ri lon thc Du hiu: tt p, shock, ph phi, suy tim c: Tim ghp khng p ng vi Atropin. t to nhp ngay.

d: Atropin nn tim nhc li 3-5 min /ln n khi t n tng liu 0,03 - 0,04 mg/kg. Nn dng dy hn cc trng hp nng (3 min/ln). e: Nu bnh nhn c triu chng, phi t to nhp qua da ngay ch khng i n khi t xong ng truyn hoc sau khi atropin c tc dng. f: Khng bao gi dng lidocain (hoc bt k thuc no gy c ch nhp thot tht) iu tr block cp 3 v nhp thot tht. g: Kim tra kh nng bt nhp ca my v kh nng dung np ca bnh nhn. S dng gy t v an thn nu cn. 11 Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1).

NHP TIM NHANH12 Khng n nh a Xc nh xem nhp tim nhanh c phi l nguyn nhn ca cc triu chng Nhp tim < 150 him khi gy triu chng Chun b sn sng my sc in n nh Chn on nhp nhanh da vo T

Rung nh hoc flutter nh nh gi 4 im: Lm sng khng n nh? Chc nng tht tri gim? WPW(h/c tin kch thch)? Thi gian 48h ?

Phc b QRS hp

Phc b QRS rng n nh Chn on nhp c hiu 12 chuyn o b Thng tin lm sng Chuyn o thc qun

Chn on nhp c hiu 12 chuyn o Thng tin lm sng Kch thch ph giao cm Adenosin

iu tr Khng n nh iu tr cp Kim sot nhp tim Phc hi php xoang Chng ng iu tr rung nh v flutter nh theo phc

SVT (nhp nhanh kch pht trn tht)

Nhp nhanh c phc b QRS rng khng r loi

VT (nhp nhanh tht)

Sc in ng b, hoc Amiodaron, hoc c Procainamid (nu EF>0,4, khng c suy tim) Phc iu tr nhp nhanh tht (VT) n nh

a: Sc in:

Theo di bo ha O2, ht m, t ng truyn TM, chun bb t NKQ Thuc trc khi tin hnh th thut (nhm benzodiazepam hoc barbituric) Sc in ng b theo trnh t sau: 100, 200-300, 360J hoc 2 pha tng ng b: Xem thm phn nhp nhanh c phc b QRS rng trang 28. c: Cho amiodaron (150 mg TM trong 10 pht, sau 1 mg/kgx 6h, sau 0,5 mg/min ) hoc procainamid (20 mg/min n khi t tng liu 17 mg/kg hoc xut hin tt p hoc QRS gin rng). Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1).12

NHP NHANH THT (NNT) N NH13

n dng hoc a dng?

NNT n dng nh gi chc nng tht phiTm tht bnh thng

Cn nhc sc in tc th

NNT a dng nh gi khong QT trn T c bn?QT nn ko di

QT nn bnh thng

Thuc: bt k thuc no trong: Procainamid Sotalol Cc thuc chp nhn c Amiodaron a Lidocain

QT nn bnh thng iu tr thiu mu cc b iu chnh in gii thuc kch thch Thuc: bt k thuc no trong Chn giao cm hoc Lidocain hoc Amiodaron hoc Procainamid hoc Sotalol

QT nn ko di ( Xon nh ?) c iu chnh ri lon K+, Ca++, Mg++ Thuc: bt k thuc no trong Magi To nhp vt tn s Isoproterenol (cho n khi t c to nhp) Phenytoin Lidocain

Amiodaron 150 mg TM/10 min, hoca Lidocain 0,5-0,75 mg/kg TM Sau sc in ng b b

a: Liu amiodaron: 150 mg TM/10 min. Nhc li 150 mg TM 10-15 min/ln nu cn. Hoc c th truyn 360 mg trong 6h (1 mg/min) sau 540 mg trong 18h. Liu ti a 2,2 g trong 24h k c liu cp cu ban u. b: Liu lidocain trn bnh nhn suy tim: 0,5-0,75 mg/kg TM nhanh. Nhc li 5-10 min/ln sau truyn 1-4 mg/min. Liu ti a 3 mg/kg trong 1h. c: Nu T gi xon nh: dng tt c cc thuc iu tr lm ko di QT. Pht hin v iu tr ri lon in gii.

13

Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1).

RUNG NH/ FLUTTER NH14 Kim sot tn s tim Chc nng tim bnh thng S dng 1 trong cc thuc sau: Chuyn li nhp xoang Nu lon nhp ko di < 48h, cn:

Chn can xi Chc nng tim gim (EF 2,0 mV hoc Sng S V1 hoc V2 > 3,0 mV hoc Sng R V5 hoc V6 > 3,0 mV Bt thng on ST: khng do digitalis Do digitalis Ph i nh tri Trc chuyn tri > -30o

3 im

2 im 1 im 3 im 2 im 1 im 1 im

Phc b QRS > 0,09 giy Nhnh ni in V5 v V6 > 0,05

Tng s im: 4: c kh nng dy tht tri 5: C dy tht tri nhy: 40-50% c hiu: 80-90% Tiu chun Cornell23 - R(aVL) + S(V3) 2,8 mV (nam), 2,0 mV (n) nhy: 42% v c hiu 96% Tiu chun khc: Sng R aVL > 1,1 mV ( c hiu 97%) Ph i tht phi (bt k tiu chun no trong cc tiu chun sau)

Trc phi > 90o m khng c nhi mu c tim trc vch, NMCT thnh sau, blocknhnh phi ( c hiu 99%)

R>S V1 and R V1 > 0,5 mV ( c hiu 90%, nhy cao nht l 44%) S V5 hoc V6 0,7 mV ( c hiu 95%) Dng S1Q3 ( c hiu 93%)

P ph ( c hiu 97%) Ch : nhy v c hiu s cao hn nu nh khng c km thm dy tht tri

Cc nguyn nhn gy sng R ni tri V1 & V224 - Dng bnh thng- Ph i tht phi -NMCT thnh bn hoc thnh sau- WPW- Tng gnh tm trng tht tri- Bnh c tim ph i- Teo c kiu Duchenne.

IN TIM : BLOCK NHNH, BLOCK THN NHNH & NHI MU THNH SAU25 Block nhnh tri QRS > 120 ms

Khng c sng Q phn nh kh cc vch lin tht(hot ho vch lin tht bt thng theo hng t phi tri)

Sng R rng cc chuyn o DI & V6(chm dn truyn t phi qua tri)

Sng R c mc DI v V6 Trc A-P khng tnh c, dng hot ho t di ln trn: o Trc in tim c th bnh thng hoc chuyn tri o C th c hoc khng c sng R trc tim phi Mt sng Q trong block nhnh tri s che lp biu hin so ca nhi mu c tim Vect ca on ST v sng T ngc vi vect ca QRS Block nhnh tri khng hon ton:o QRS 100-120 ms o Mt sng Q vch o QRS rng hoc c mc D1 v V6

Block nhnh tri v nhi mu c tim cp26

- ST chnh ln 1 mm ng hng vi phc b QRS - rt nhy v c hiu cho -

NMCT trong mt s bi cnh lm sng thch hp (vd: c km au ngc) ST chnh xung 1 mm V1, V2 hoc V3 - rt c hiu nhng t nhy cho NMCT (36-78%) ST chnh ln 5 mm tri hng vi QRS - l mt d kin gi NMCT song cn phi da vo cc ch s khc chn on

Block nhnh phi - QRS > 120 ms - Hot ho vch lin tht bnh thng

- Phn tn ca vect QRS hng sang phi v ra trc V1: c dng RSR' trong sng R phn nh s hot ho bnh thng vchlin tht; sng S phn nh s hot ho tht tri v sng R' phn nh s hot ng in ca tht phi xut hin mun sau

D1, V5, V6: c dng QRS trong sng Q phn nh hot ng in bnhthng ca vch lin tht; sng R phn nh hot ng in bnh thng ca tht tri v sng S nng v ko di do hot ng in ca tht phi xut hin mun sau Vect ca sng T tri chiu vi vi phn tn ca QRS Phn sm ca cc hot ng in hc khng b nh hng (do khng che lp sng Q ca so NMCT) Block nhnh phi khng hon ton: QRS 100-120 ms

-

Tiu chun v hnh dng ca blok nhnh phi (dng RsR' V1, sng S nngv ko di cc chuyn o bn)

Block thn nhnh tri trc (fascicular block) - Trn vect tm (VCG): trn mt phng trc sau vect s i ngc chiu kim ng h, khi u t pha sau v kt thc pha trc, do aVL t nh trc aVR. - Trn T: (1) phc b QRS bao gi cng kt thc bng sng R aVR v aVL (2) nh ca sng R tn aVR xut hin mun hn so vi nh sng R tn aVL. - Tiu chun hng vecto kh cc (Scalar criteria):

Trc ca QRS -45o n -90o, QRS < 120 ms,

Sng Q nh D1,

Sng R nh D2, D3, aVF, Thi gian xut hin nhnh ni in mun aVL (>45ms)Block thn nhnh sau tri - Trn vecto tm (VCG): Phc b QR D2, D3, aVF do vect kh cc khi u hng ln pha trn v vect kt thc hng xung pha di - Tiu chun hng vect kh cc (Scalar criteria):

Trc QRS > +90o Bt u bng sng R D1, aVL v sng Q nh D2, D3 v aVF QRS < 120 ms

Thi gian xut hin nhnh ni in mun aVF ( 90%) - Vect tm (VCG): vect kh cc ban u trn mt phng trc sau theo chiu kim ng h v ln trn - Xoay theo chiu kim ng h trn mt phng trc sau (nh D2 trc D3) v

- Sng Q > 30 ms D2 hoc thoi trin ca vect kh cc ban u pha di t D3n D2 (phn u ca QRS D2 m hn so vi D3) Nhi mu c tim thnh sau + Block nhnh trc tri (phi gm c 2) - C aVR v aVL u c sng R cui; sng R aVL kt thc trc aVR; v

- C sng Q d bin no D2 - VCG: khi u t pha trn v i theo chiu kim ng h; kt thc cng trn nhngngc chiu kim ng h25

Warner RA. Recent advances in diagnosis of myocardial infartion. Cardiology Clinics 1987; 5(3): 381; Warner RA ets al. Improved ECG for diagnosis of left anterior hemiblock. Am J Cardiol 1983. 26 Sgarbossa E et al. Electrocardiography diagnosis of evolving acure myocardial infartion in the presense of left bundle branch block. IN TM : NHP TIM NHANH C PHC B QRS GIN RNG27 Nhng c im gi nhp nhanh tht (NNT) - Trc in tim chuyn tri rt mnh

- QRS > 140ms (i vi dng block nhnh phi), > 160 ms (i vi dng block nhnh tri) Cc nht "bt c" (capture) (QRS hp) v nht hn hp (fusion) ( QRS vi dng lai gia phc b QRS rng v QRS hp) Phn din tch pha di ca phc b QRS m r c D1 v D2

Tiu chun Brugada ( nhy 99%, c hiu 97%) c gi l nhp nhanh tht khi c mt trong cc tiu chun sau: - Khng thy dng RS tt c cc chuyn o trc tim (c th di dng QS, QR, hoc R) - Khong R-S > 100 ms (bt u ca sng R n y ca S) bt k chuyn o trc tim no R

- Phn ly nh tht - Tiu chun v hnh thi ca NNT trn c V1-2 v V6

S

+ QRS ging nh dng ca block nhnh phi (ch yu dng V1)

+ QRS ging nh dng ca block nhnh tri (ch yu m V1)

Cc dng kinh in khc khng c trong tiu chun Brugada l: * Block nhnh phi: RSR' vi R>R' ** Block nhnh phi: R/S1 *** Block nhnh tri: QS V1-2 + Nu khng c bt k tiu chun no trn, 99% kh nng l nhp nhanh trn tht Mt s im cn nh - Trn bnh nhn c bnh tim thc th v gim chc nng tht tri, kh nng mt nhp nhanh c phc b QRS rng l nhp nhanh tht ti 95%

- Biu hin lm sng (vd d bnh nhn c triu chng hay huyt ng n nh) l mtch im rt km chn on lon nhp nhanh ny l NNT hay nhp nhanh trn tht - Nu cha chc chn mt lon nhp tim l NNT hay NNTT v bnh nhn cha cn phi sc in cp cu, th nhng thuc chng lon nhp c chn xa lon nhp l amiodaron hoc procainamid TM. Trnh dng verapamil v diltiazem. C th th tim adenosin nhng (1) p ng ca bnh nhn cng cha gip phn bit c lon nhp l NNT hay NNTT v (2) c nguy c b rung tht khi dng thuc, mc d nguy c ny nh (1%). 27 Brugada et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991; 83: 1649-1659. Note: these patients were not taking antiarrhythmic drugs. Diagrams adapted from Tom Evans, MD, with permission.

HI CHNG QT DI & XON NH33 Nguyn nhn mc phi Bnh sinh: Thng "ph thuc thi gian ngh", vd. Khi pht t khong RR t di ngn, vd. Ngoi tm thu tht theo sau l khong ngh b, hoc ngh xoang thng xuyn Nguyn nhn: - Ri lon nhp chm: nhp rt chm, + Suy nt xoang, + Block nh tht

- Chuyn ha: + H kali mu, + H magi mu, + H can xi mu - Dinh dng: + i, + Chn n thn kinh - Thuc: tc dng ph thuc vo liu +Ng c c th l do tng tc thuc, vd.Erthromycin v ketoconazole Nhm thuc Thuc chng lon nhp tim (khng phi l 1C) Tn thuc Nhm 1A: quinidine, procainamide, disopyramide Nhm III: amiodarone, satalol, ibutilide, dofetilide Terfenadine, astemizole Thuc chng trm cm v iu tr tm thn Nhm macrolide (erythro/clarithro/azthomycin), trimethoprim-sulfa, keto/itraconazole, pentamidine, amantidine Cisapride. Li tiu, phospho hu c, cocain

Chng d ng Thuc tm thn Khng sinh

Thuc khc

- Nguyn nhn khc: + Nhim HIV, + Xut huyt di nhn, TBMN v chn thngs no, + Kch thch thn kinh thc vt khi phu thut (ct dy ph v, phu thut mch cnh) iu tr: B cc thuc gy bnh, + Magi sulfat 1-2 g TM nhanh, + iu chnh ri lon in gii, cn nhc b thm kali, + t my to nhp hoc truyn isoproterenol duy tr nhp tim > 80 ln/pht, + Thuc chng lon nhp nhm 1B (lidocain hoc phenytoin) Nguyn nhn bm sinh/ di truyn Bnh sinh: thng "ph thuc cathecholamine", vd. Thng xy ra khi c kch thch h adrenergic; cng c th "ph thuc thi gian ngh" Nguyn nhn: c th l mt phn trong mt hi chng di truyn vd. Bnh Jervell-LangeNielsen (di truyn theo NST tri v gy ic bm sinh) hoc Romano-Ward (di truyn theo NST tri v khng gy ic); hoc b l t. t bin gen c trng cng c m t34 iu tr (mn tnh): chn giao cm, cy my kh rung, t my to nhp, ct hch giao cm 33 WM Jackman et al. Long QT syndromes: a critical review, new clinical observations, and a unfying hypothesis. Prigr Cardiovasc Dis 1988; 31(2): 115-172. 34 Keating MT. The long QT syndrome. A review of resent molecular and physiologic discoveries. Medicine 1996; 75: 1-5. HI CHNG BRUGADA35 M t v dch t hc - L hi chng gy t t hoc NNT/ rung tht vi T khng bnh thng (block nhnh phi v ST chnh ln t V1-V3), QTc bnh thng v khng c bng chng ca bnh tim thc tn - C th chim ti 40-60% ca cc NNT/RT "v cn" ( M chim < 5% cc trng t t) - Gp t l cao cc nc chu (l nguyn nhn gy cht ng u nam gii tr Thi lan) Bnh sinh: do bt thng qu trnh ti cc (do bin i cu trc knh Na+) Lm sng - T l nam:n =10:1; - Phn ln c ngun gc chu ; - Tui xut hin triu chng u tin 22-65 tui, cao nht l la tui 40 - Tin s gia nh c t t, ngt hoc pht hin c NNT/RT ch 20% trng hp

- Thng xut hin khi ng hoc sau ung ruin tim - Dng block nhnh phi mc d khng thy sng S gin rng cc chuyn o bn tri - Tim trc tri

- ST chnh ln mt cch c trng 0,1 mV V1-V3, tuy vy c th thy ST chnh cao hay thp ty theo bnh nhn v thng tr v bnh thng tm thi C th gy ST chnh ln khi dng thuc procainamide hoc flecainide

Cc thm d khc - Siu m tim, MRI hoc sinh thit c tim thng khng thy g c bit

- Thm d in sinh l: Khong (H-V) gia b His-tht ko di (95%), rung tht (66%)hoc NNT (11%) iu tr - Cy my kh rung l mt bin php hiu qu nht

- Thuc chng lon nhp tim nh blocker v amiodarone cng khng trnh c tt 35 Brugada J, Brugada R, Brugada P. Right bundle-branch block and ST segment elevation in leads V1-V3: A marker for sudden dearth in patients without demonstrable tructural heart disease. Circulation 1998; 97: 457-60. Alings M, Wilde A. "Brugada" syndrome. Circulation 1999; 99: 666-73. Website: http://www. Crtia.be

NGT nh ngha: Mt thc t ngt v phc hi hon ton tr cc tnh trng khc nh co git, t qu hoc t t. Ch : mc d l lnh tnh nhng c th l bo hiu ca t t. Mc tiu chnh trong tin trnh chn on l loi tr cc bnh tim thc tn bng hi bnh s v khm lm sng; nh gi chc nng tht tri, T, cn nhc cc thm d chun on NMCT khc. Nguyn nhn31 1) Lnh tnh v khng r nguyn nhn - 40% cc trng hp

2) Cc nguyn nhn c th:Do tim H thng dn truyn: + Block nh tht nhp tim chm; + Suy nt xoang; + My to nhp hng; + Ri lon nhp tht (NNT; xon nh); + Hi chng QT ko di; + NNTT; + WPW (c bit khi c rung nh); + Hi chng Brugada Nguyn nhn c hc: + Hp mch mu (HC; HHL; tc van c hc); + Bnh c tim ph i; + U nhy nh tri; + Tc mch phi; + V ti phnh xoang Valsalva Nguyn nhn ngoi tim Phn x/t ng: + Thn kinh tim (cht gy lit mch gin mch v gim nhp tim mt cch khng tng xng; cht c ch c tim block nh tht); + Tnh hung (nut; tiu tin; i tin; ho vv); + Tng nhy cm xoang cnh; + au thn kinh thit hu Thn kinh: + Co git; + Thiu mu no thong qua (TIA); Hin tng n cp mu ca ng mch di n Phu thut chnh hnh: + Thuc; + Ri lon thn kinh thc vt; + Mt th tch mu Chuyn ha: + H ng mu; + Thiu xy mu Nguyn nhn khc: + Tch ng mch ch; + p tim cp; + Tng p ng mch phi Do thuc: + Lit hch ( blocker; chen knh can xi, digoxin); + QT ko di (thuc chng trm cm ba vng; thuc iu tr tm thn; khng sinh nhm Macrolide); + Thuc chng lon nhp (gy lon nhp) Tip cn chn on32 Tm thn: + Cn hong lon; + Tng thng kh Do thuc: + Thuc gin mch (hydralazine; c ch men chuyn; nifedipine, nitrate; -blocker); + Thuc li tiu; + L-dopa; + Ru; + Thuc h ng huyt ng ung v insulin

- Da vo tin s: Chn on d nu l do cc ri lon nhp tim nu thy bnh nhnt ngt mt thc khng c tin triu v "cm gic" tr v bnh thng ngay sau . Ngt do nguyn nhn thn kinh tim thng xut hin vi cc tin triu sau cm gic bun nn, yu, ti v mt ko di nhiu pht hoc nhiu gi sau ngt. Ri lon nhp tht hoc nhp tim chm c th khi pht ngt do nguyn nhn thn kinh tim. Cc bnh nhn ln tui c th khng nh c cc triu chng ca ngt do thn kinh tim gy ra. Hi bnh s v khm lm sng: Gi tr chn on > 50%

- Xoa xoang cnh: rt c ch nu triu chng ti pht sau > 3 giy v lm sng gi .

Khng c xoa xoang cnh trong trng hp c ting thi ng mch cnh, tin s NNT, TBMN, hoc NMCT gn y. - Nghim php gng sc v siu m tim: khng ng gp cho chn on ngt nhng c vai tr pht hin bnh tim thc th ( nguy c NNT cao, t t, xem xt thng tim/ti ti mu sau khi thm d in sinh l) - Theo di bng Holter trong vng 24-48 gi nu c triu chng t nht 1 ln/ngy. Kt qu thu c rt hu ch nu xut hin lon nhp hoc khng c lon nhp vo thi im xut hin triu chng. - Thm d v thn kinh (chp CT scan s no, in no , thm d ng mch cnh): rt t vai tr tr khi tin s v bnh cnh lm sng gi c nguyn nhn thn kinh. - Test bn nghing (TTT): c ch trong vic pht hin ngt c nguyn nhn thn kinh tim biu hin lm sng khng r. c hiu (vi liu isoproterenol thp) 90%, kh nng chn on 50-80% nhm c ngt. TTT cng c vai tr trong nh gi p ng thuc. Nhng im cn nh - Trn bnh nhn c bnh tim v c ngt th phi loi tr NNT trc khi gn triu chng l do nhp tim chm - Co git, mt thc hoc chn thng khng gip xc nh nguyn nhn

- Khng ngh n kh nng co git tr khi c nhng triu chng in hnh (l m saucn, bt thng khi khm thn kinh, lit Todd vv). Nhng bnh nhn c ri lon nhp tht hoc nhp chm hoc ngt do thuc gy lit mch c th c nhng cn co git trong khi ngt - Thiu mu no thong qua do bnh l ng mch cnh khng gy ngt Tin lng - Bnh nhn ngt c bnh tim thc tn c nguy c t vong rt cao Nguyn nhn T l t vong trong nm u 30% 8% T l t vong sau 5 nm Tt c nguyn nhn 50% 25% t t 30% 5%

Ngt do tim Ngt khng do tim

Ngt v cn

6%

20%

2,5 mm

60-69

85 13

76 18

94 6 38 17 65 16 75 13 81 11 19 11 41 17 53 18 62 17 10 2 26 4 37 5 45 5 5 2 13 4 20 5 26 6

90 9

99 1 76 13 91 6 94 4 96 3 55 18 78 12 86 9 90 7 38 5 64 4 75 3 81 3 21 6 44 8 57 8 65 7

98 2 33 17 63 17 84 9 93 5 16 10 39 18 67 16 83 10 9 3 25 6 50 5 72 4 4 2 12 4 31 7 52 8

100 2

100 3 79 13 93 5 98 2 99 6 59 19 84 10 94 4 98 2 42 9 72 6 98 2 95 1 24 8 53 10 78 6 90 3

ST chnh xung > 2 - 2,5 mm 30-39 40-49 50-59 60-69 18 10 39 17 54 17 61 16 3 2 10 7 27 14 47 17 8 6 24 14 50 18 72 14 96 3 98 1 99 5 100 4

ST chnh xung > 1,5 - 2,0 mm 30-39 40-49 50-59 60-69 8 5 20 11 31 15 37 16 1 1 4 3 12 8 25 13 3 2,5 11 7,2 28 14 49 18 91 6 97 2 98 1 99 1

ST chnh xung > 1,0 - 1,5 mm 30-39 40-49 50-59 60-69 4 1 11 2 19 2, 6 23 3 0,6 0,2 2 0,5 7 1 15 2 2 0,7 62 16 3 33 5 83 3 94 1 96 0, 7 97 0, 5 68 7 86 4 91 3 94 2

ST chnh xung > 0,5 - 1,0 mm 30-39 40-49 50-59 60-69 2 0,6 5 2 9 3 11 3 0,3 0,1 1 0,3 3 1 7 2 0,7 0,4 3 1 8 2 17 5

Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 1979; 300: 1350. Reprinted by permission of The New England Journal of Medicine, copyright 1979, Massachsetts Medical Society.28

TEST GNG SC Mc ch ca test gng sc (1) Chn on v mt chc nng ca bnh mch vnh nh gi kh nng hot ng chc nng ca bnh nhn, vd. cn iu tr ni hay ngoi, cc iu tr trn tho ng cha, hoc c an ton cho bnh nhn lao ng hoc vui chi gii tr khng (3) D kin tin lng i vi cc bnh nhn c chn on c bnh mch vnh vi mc tiu l xc nh c nhng bnh nhn cn iu tr trit hn na Nhng hn ch ca test gng sc trong pht hin bnh mch vnh - Gi tr ca test hn ch trong mt s trng hp sau:

(2)

Ph n: t l dng tnh gi cao (p ng ca on ST khi lm test gngsc); kt qu dng tnh ca test khng ng gp nhiu trong tin lng so vi ch n thun hi bnh s v khm lm sng;

blocker: do tc ng ca iu tr gy hn ch cng ti a ca tim (nhptim x huyt p) gim nhy

Digitalis: lm ST chnh xung thng l 0,1 mV. Nu ST chnh su hn thth nn ngh ti c nguyn thiu mu cc b do cn phi ngng iu tr digitalis t nht 1 tun trc khi lm test.

Ri lon dn truyn (block nh tht, tin kch thch): do tnh trng ti cc btkhin khng th phn tch c on ST (tr cc chuyn o trc tim vng bn trong block nhnh phi)

Qu ti p lc (ph i tht tri, hp van ng mch ch) gy thiu mudi ni tm mc v ST chnh xung ngay c khi bnh nhn khng c bnh mch vnh thc s (test dng tnh tht i vi tnh trng thiu mu cc b v dng tnh gi cho tc mch vnh phn thng tm mc)

Ri lon chuyn ha: thiu mu, thiu xy, h kali mu v tng thng kh - Bnh nhn khng th thc hin c test gng sc - Khng chc chn l bnh nhn c bt thng v gii phu - ST chnh xung gi c thiu mu cc b c tim nhng khng khu tr c vngb thiu mu cc b Cc bin th ca test gng sc - X hnh tim bng cc ng v phng x (thalium/sestamibi) hoc siu m tim

-

+ nhy v c hiu trong chn on bnh ng mch vnh tng mt cht so vi ghi T n thun + Rt c gi tr nu kh nng b bnh mch vnh l mc va , ngc li khng c nhiu gi tr nu nguy c bnh mch vnh l cao hoc thp + Hay c dng hn so vi test gng sc chun trn cc bnh nhn c bt thng trn T khi ngh vd: block nhnh, ph i tht tri v t my to nhp (nhn chung c c hiu tng t nhng nhy thp hn?) + Khu tr c vng thiu mu cc b (c vai tr nh hng cho th thut can thip mch vnh) Kch thch c tim bng cc thuc nh dobutamin hoc adenosin + Lm tng sc ti ca c tim trn nhng bnh nhn khng th thc hin c test gng sc (vim khp, bnh mch mu ngoi vi). Tng nhy trong pht hin bnh mch vnh do hp ng mch c ngha nhng ngha nh gi chc nng khng tht r rng, hu ch nht l phn loi nguy c cho bnh nhn trc khi m + Tc dng ca dobutamin km hn trn bnh nhn ang dng thuc chn giao cm + Chng ch nh dng adenosin v dipyramidol trn bnh nhn c co tht ph qun hoc block nh tht cp cao; thuc b gim hiu qu khi dng theophyllin v caffein Bng im nh gi tin lng ca Duke29 S im = (thi gian tin hnh test) - (5x ST chnh ln nht tnh bng mm) - (4 x mc au ngc trn bng ti) Ch s au ngc trn bng ti: 0 = khng au; 1 = au ngc nh khng cn phi dng test; 2 = au ngc n mc phi ngng test Nguy c t vong (im) Thp ( +5) Va (-10 n +4) Cao ( 120 mmHg nhng c khi ch l 160/100 nhng bnh nhn c HA bnh thng (vd. Ph n c thai, phn ng thuc ngi tr) - "Cn tng HA": tng HA khng km theo tn thng c quan ch; thng ch cn iu tr bng thuc ung Nguyn nhn THA mn tnh, + Bnh mch thn, + Dng thuc (cocain, amphetamine), + Khng dng thuc y hoc b thuc (vd. Clonidine, blocker), + Pheochromocytoma, + X cng b (hoc cc bnh l to keo khc, + Phu thut ng mch cnh hoc thn kinh trung ng, + Bnh thn (vd. Vim cu thn cp), + Chn thng s no, + Chn thng ty v Guillain Barr Bnh cnh lm sng Bnh no do THA Mc tiu iu tr La chn u tay# Bnh lun Chc nng thn kinh c th xu i. Nn trnh dng clonidine, B (nh hng trn TKT) SNP, FD v NTG c th lm tng ICP. Mc tiu HA t 185/110 nu dng thuc tiu cc mu ng Theo di du hiu chc nng thn kinh ti i khi gim HA Trnh dng SNP, FD v NTG (do lm tng ICP)

Gim HA TB 20SNP, FD, labetanol 25% trong 2-3 gi (nhng gi HATB > 100 mmHg) Duy tr HA khng Nitropaste thp hn 220/120 t Labetanol t trong vng 24 gi

t qu

Xut huyt no

HA tm thu 140-160 SNP, FD, labetanol, mmHg (hoc bng nicardipine HA trc khi tai bin) Nhn chung l khng can thip g nu BN tnh, xem xt iu tr phng nguy c chy mu li37 HA tm trng 100 mmHg hoc ht triu chng Nimodipine 60 mg ung/qua ng thng d dy 4 gi/ln ( phng co tht mch no) + labetanol SNP hoc FD cng NTG cng thuc li tiu

Xut huyt di nhn

Ph phi

Trnh dng cc thuc inotrope (-) trong suy tim tri

NMCT hoc cn au tht ngc khng n nh Phnh tc ng mch ch

HA tm trng 100 mmHg hoc ht triu chng

NTG, -B, thm SNP/FD nu HA tm trng vn cn cao Gim dP/dT. Trnh dng diazoxide, hydralazine Trnh dng -B hoc labetanol n c38 (khng c ch c kch thch giao cm). Dng li clonidine hoc -B nu b thuc ng ung: methyldopa. Trnh dng SNP, thuc c ch men chuyn Gim au, chng qu ti dch, thiu xy mu

HA tm thu 100-120 SNP hoc FD cng hoc HA TB 80 -B hoc labetanol mmHg (theo di V hoc trimethaphan nc tiu) Phentolamine (u tin) sau -B hoc labetanol. Thm benzodiazepine khi c qu liu hoc cai thuc) HA tm trng 90105 hoc HA TB 126 mmHg Hydralazine, labetanol, FD

Cn cng giao cm (cocain, amphetamine, pheochromocytoma, MAOI, b thuc B hoc clonidine) Sn git

Hu phu

SNP, FD, labetanol

t cp ca x cng b

Thuc c ch men chuyn

# V liu dng v cch s dng xin xem trong phn cc thuc thng dng SNP = Natri nitroprusside; FD = fenoldopam; -B = blocker; NTG = nitroglycerine; ICP = p lc ni s 36 Calhoun DA, Oparil S. Treatment of hypertensive crisis. NEJM 1990; 323(17): 11771183. Gifford RW. Management of hypertensive crises. JAMA 1991; 266: 829-835. 37 Van Gijn. Sub-arachnoid hemorrhage. Lancet 1992; 339: 653. 38 Hollander JE. Management of cocain-associated myocardial ischemia. NEJM 1995; 333: 1270-6. NGUY C TIM MCH TRONG KHI M Mc tiu - Xc nh cc bnh nhn c nguy c cao thay i nguy c, chun b cc bin php chm sc c bit khi phu thut, tr hon cc phu thut chn lc, hoc cn nhc cc bin php ti ti mu - Xc nh nhm bnh nhn c nguy c thp tin hnh phu thut

- Bnh nhn c nguy c tc th dng chn sau vi tip tc tm cch phn loicc nguy c bng cc test khng xm nhp khc - Ch nn xem xt bin php nong vnh v ti ti mu (PTCA, CABG) nu ch nh ca chng tch ri vi phu thut Ch s nguy c tim mch ci tin cho cc phu thut ngoi tim39 - Ch s ny c u im r rt so vi cc ch s dng trc y (Goldman, Detsky)

- Cc yu t nguy c: 1) Phu thut c nguy c cao (phu thut mch mu trong lng ngc, bng, tiukhung) 2) Tin s bnh tim thiu mu cc b

3) Tin s suy tim 4) Tin s tai bin mch no 5) iu tr insulin trc khi m 6) Creatinine mu trc m > 2,0 mg/dlNhm nguy c I II III IV # yu t nguy c 0 1 2 3 T l gp cc bin chng ln trong khi m# 0,4-0,5% 0,9-1,3% 4-7% 9-11%

# Cc bin chng ln l: NMCT, ph phi, rung tht hoc ngng tun hon, block nh tht hon ton Cc bin php gp phn lm gim cc bin chng trong khi m - i bnh nhn c nguy c cao, blocker lm gim t l t vong v NMCT trong khi m cng nh t l di chng v t vong nhiu ngy sau 40. Liu php iu tr th: (1) Atenolol 5-10 mg TM trong 5-10 pht vi iu kin nhp tim > 55 v HA tm thu > 100, dng thuc 30 pht trc v ngay sau khi phu thut, sau 50-100 mg/ngy ng ung; hoc (2) Bisoprolol 5-10 mg ung hng ngy, chnh liu khi nhp tim < 60; bt u iu tr trc khi m 1 tun v tip tc sau m 4 tun. - Nitrate v thuc chn knh can xi c hiu qu rt hn ch

- Aspirin l iu tr c chp nhn - Trnh dng cc thuc c tc dng c ch c tim trn bnh nhn suy tim tri nng (vd. Xem xt gy t ty sng hoc cc thuc gc opiat) Theo di huyt ng (t catheter ng mch phi, T 12 chuyn o lin tc?, siu m tim qua thc qun ?) trong (a) NMCT gn y cha c ti ti mu (b) vng nhi mu ln khng c ti ti mu (d) Bnh l van ng mch ch v van hai l nng (e) M cp cu trong khi huyt ng cha hon ton n nh.

- iu tr gim th tch, au, v huyt p.39 Lee TH et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043-49. 40 Mangano DT et al. Effect of atenolol an mortality after cardiovascular morbidity after noncardiac surgery. NEJM 1996; 335(23): 1713-20. Poldermans D et al. the effect of bisoprolol on perioperative cardiac death and myocardial infarction in high risk patients undergoing vascular surgery. NEJM 1999; 341(24): 1789-94. NH GI TIM MCH TRONG M CA CC PHU THUT NGOI TIM41 Cn phu thut Phu thut cp cu Phng m, tip theo l phn loi v x l nguy c hu phu

Phu thut chn lc hoc cp cu Ti ti mu vnh trong vng 5 nm tr li y? Khng nh gi v ng mch vnh gn y (trong vng 2 nm)? C Triu chng lm sng ti pht?

C C Lm test gng sc hoc chp mch vnh gn y? Kt qu tt

Khng Ch s tin lng (xem bng di y) Kt qu khng tt hoc khng thay i triu chng Phng m

Ch s tin lng lm sng chnh

Ch s tin lng lm sng mc va, nh hoc khng

Xem xt tr hon hoc khng m

Xem xt chp mch vnh

Sang trang tip

iu tr ni khoa v can thip vo cc nguy c

iu tr ty theo triu chng lm sng v p ng iu tr

CC YU T TIN LNG LM SNG CA CC NGUY C TIM MCH42 Ln Trung bnh au ngc nh C tin s hoc trn T c du hiu NMCT trc Suy tim trc y hoc cn b i ng Nh

- au tht ngc khng n nh43 - Suy tim mt b - Lon nhp tim44 - Bnh van tim nng -

- Tui cao - T bt thng46 - Khng phi l nhp - Tin s t qu - THA khng khng chxoang Thch nghi km

c Va Nh hoc khng 41 Eagle KA et al. Guideline for perioperative cardiovascular evaluation for noncardiac surgery. Report of ACC/AHA Task force on Practice Guidelines. Circulation 1996; 93: 1278-1317. 42 Increased risk for MI, CHF or death. Km Va - tt Km Va - unstable or severe (class III/IV) angina. 43 Recent MI w/ important ischemic risk; tt (METs) (METs) 44 High grade A-V METs)symptomatic ventricular arrhythmias w/ underlying heart disease, or SVT with uncontrolled ventricular rate. 45 LVH, LBBB, ST-T abmornalities. Ch s tin lng lm sng Phu thut c nguy c thp Kh nng hot ng47 Phu thut c nguy c trung bnh Phu thut c nguy c cao Phu thut c nguy c va/thp

Phng m

Nguy c ca phu thut (xem di)

Test khng xm nhp48

Nguy c cao

Nguy c thp

Phng m

Xem xt chp mch vnh

iu tr theo lm sng v p ng

Phn tng nguy c ca cc phu thut ngoi tim Nguy c cao (>5%) Nguy c TB ( 1

mm Sng T o ngc i xng r rt trn nhiu chuyn o trc tim on ST v sng T thay i cng vi au ngc

ST 0,5-1,0 mm Sng T o ngc

hoc T dt trn cc chuyn o c sng R chim u th T bnh thng

> 90% bnh nhn c

Phn nhm nguy c cao vi t l t vong tng: au ngc kiu thiu Triu chng khng mu cc b & on thuyn gim hoc thiu ST s xut hin mu cc b ti pht sng Q mi hoc cc du ch im Bt thng T lan (marker) ca nhi rng mu c tim (+) Chc nng tht tri Nu thy sng T bin gim i cp th bt buc Suy tim phi ghi li T Troponin v CK (+) Bnh nhn c ST

Nhm khng ng nht: nh gi nhanh chng: T hng lot Theo di tin trin ca on ST Men tim trong huyt tng nh gi nguy c khc gip: Chp scinti ti mu Siu m gng sc

sm cc o trnh trc tim thng gi c nhi tim sau di

Liu php ti ti

mu thrombin (heparin trng lng phn t thp) Aspirin Heparin (nu s dng Chng ngng tp tiu cu: aspirin cc thuc tiu si huyt chn lc) Thuc c ch IIb/IIIa Thuc chn giao Cc nitrat nu c ch cm nh Cc nitrat nu c ch nh15

iu tr thuc khng

Aspirin iu tr khc Men tim (+), T bt thng, hoc chc nng tim gim: iu tr nhm c nguy cao hn

Guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2000; 102 (Suppl 1).

IU TR TCH CC CATHETER M PHI SWANS GANS49 Tc dng: (1) Xc nh nguyn nhn ca ph phi cp (do tim hoc khng do tim), tt huyt p (chc nng tim hay do thiu dch hoc gim trng lc thnh mch) hoc thiu niu (Suy tim hay thiu dch hay bnh thn) (2) L bin php h tr iu tr bnh nhn ( NMCT, suy tim hoc nhim khun huyt) Hiu qu: Cha c th nghim lm sng ngu nhin (RCT) chng minh c s ci thin t l bnh v t l t vong nh vic theo di bng catheter ng mch phi. Mt nghin cu quan st cn cho thy tng t l t vong50 Chng ch nh tng i51: Toan nng cha iu tr (pH 7,20) hoc thiu oxy mu (PaO2 < 60 mmHg) - nguy c rung tht cao Ca++ cha hiu chnh < 8 mEq/l) cha iu tr, h K (K+ 3,5 mEq/l) cha iu tr Bloc nhnh tri - c nguy c 5% b block tim hon ton Bnh l ng mu XC NH V TR NG CA SWANS GANS Nhng dng sng c trng khi bng xp

PCWP < PADP, PCWP TB < PAP TB Dng sng u nu u catheter khng tc Mu u catheter bo ho 100% nu khng c bnh phi hoc shunt (Mu mu "bo ho bt" khi bng bm ln v loi b 5 mL u tin) o p lc bt ti cui th th ra, thn trng khi din gii p lc bt khi c u catheter su hoc h hp thay i nhiu Din gii p lc mao mch phi bt ( PCWP) PCWP phi tng quan vi LVEDP xem nhng trng hp ngoi l di LVEDP cao c th do: + Tng tr tun hon (tha dch) ca tht khi gin n bnh thng + Tm tht khng dn tt (suy chc nng tm trng) + Tng p lc ngoi tim (mng tim, mng phi, lng ngc) LVEDP "sinh l" thay i theo tn s tim: + Nhp tim chm tng LVEDP + Nhp tim nhanh gim LVEDP LVEDP cao khng c ngha l ph phi + Tc nghn mn tnh h bch huyt v gim tnh thm thnh mch + Tn thng ni m (vd ARDS) gy ph khi LVEDP bnh thng Nu ALMP lc tm trng > PCWP & LVEDP t 5-7 mmHg c th do: + Tng sc cn mch phi (vd huyt khi tc mch, co tht mch do thiu oxy hoc tng p MP) + Tn thng nhu m phi + Nhp tim nhanh PCWP phn nh sai LVEDV (tin gnh) khi: + p lc trong lng ngc v trong mng ngoi tim cao (vd bnh phi tc nghn, PEEP cao hay bnh MNT). Ch : LVEDV t l thun vi chnh p trong tim v trong MNT. PCWP t l vi chnh p trong tim v kh quyn + Tc nh tri v tc TM phi + Dao ng do trng lc ng mch phi (gim th tch, dopamine)

+ Nhp nhanh (Rt ngn thi gian tm trng) + Bnh van tim ( hp hai l, h hai l, h ch v van 2 l ng sm) + Catheter khng trong vng "Zone III" (vd sng vt qu bt, dch chuyn bng ra pha trc khi bnh nhn nm nga. -> PCWP > PAD gim th tch thay i Zone III thnh Zone I/II + Xon catheter c bit trong trng hp tng ng + Tc u catheter (x trung tht, u nhy, u khc) NHNG TRNG HP C BIT PEEP: Hiu chnh PCWP theo PEEP bng cch tr 1/2 PEEP (nhn cmH2O vi 0,8 ra mmHg). Nu gin n phi km (vd ARDS) th PEEP t nh hng hn v ngc li vi gin n ca phi cao (vd kh ph thng) H 2 l: o QRS ng thi (sng V nhn in hnh khong T-P). X bng: sng tm thu ng mch phi ch i v sng V h . Bm bng (sng V khng l, di chuyn chm hn tng i so vi phc hp QRS. Sng A tc. Mu c oxy ho c th tro ngc v ng mch phi

49. OQuin. PAOP: Clinical physiology, measurement and interpretation. Am Rev Respir Dis 1983; 128 : 319; Sarkey. Beyond the wedge: Clinical physiology and the Swan-Gans catheter. Am I Med 1987; 83:111; Connors. Hemodynamic status in critically ill patients with or without acute heart disease. Chest 1990; 98:1200. Leathman JW. Marini JJ. Clinical use of the pulmonary artery catheter. In: Hall ed. Principles of Critical Care, 2/e, New York: McGraw-Hill; 1988. Figures copyright 1987 Lawrence Martin MD, with permission 50. Connors. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996; 276(11): 889. 51. Sprung C. Advanced ventricular arrhythmias during bedside pulmonary artery catheterization. Am J Med 1982; 72: 203 S DNG MY TH52 Bnh nhn c c hc phi v trao i kh bnh thng Ch nh: - Mt kim sot ca trung tm h hp (vd ng c thuc, tn thng TKTW) - Bnh l thn kinh c

- iu tr sc - Tng thng kh sau tn thng no (ch l tm thi c th lm nng thm tnh trng thiu mu no) Ci t: - Mode: A/C hoc SIMV vi trigger thp nht (- 2 cmH2O), c th dng PS nu bnh nhn lit c cn c th khi ng c my (nu khng th rt nguy him) - FiO2 0,21- 0,4 - Vt 8-12 ml/kg - Tn s: 8-12ln/pht (18-24/pht nu cn tng thng kh, cao ngt s t th ca bnh nhn trong sc) - Tc dng (40l/pht) iu chnh theo d chu bnh nhn Nhng iu cn xem xt: - Mc tiu PaCO2 25 cmH2O nu cn gim p lc ni s - Trong sc cn tng thng kh pht hoc an thn gin c tuyt i - Chng xp phi: dn lu 3 t th, v rung, th sigh, PEEP thp - p lc ng th nh nn < 30 cmH2O

TC NGHN NG TH NNG Ch nh: - Cn hen ph qun nng - Bng ng h hp trn - Khi chn p ng th - Hp kh qun Ci t: - Mode: H tr h hp hon ton (hoc AC/SIMV vi tn s kim sot cao), FiO2 duy tr PaO2 60 mmHg (FiO2 > 50% c th tn thng ph nang. - Vt 8 ml/kg. - Tn s 8 ln/pht trnh auto-PEEP. - Tc dng th ra: 60-80 l/pht (lm gim thi gian th vo v ko di thi gian th ra) Nhng iu cn xem xt: - Tng thn kh "cho php c th chp nhn c nu pH 7,20 trong chin lc bo v phi. iu ny lm tng by kh, PEEP ni sinh v tng p lc ng th - Gim lng mu v tim thng hay gp lc mi th my, thng p ng tt vi liu php truyn dch v ngng th my - An thn v gin c sm s lm gim p lc ng th, gim tiu th oxy, chng my. - PEEP ni sinh (auto-PEEP) l tnh trng tng p lc ph nang cui th th ra trong trng hp tc nghn nng n. o autoPEEP ti l th ra cui k th ra trong nghim php ngng th (exh hold manuever). PEEP ni sinh tng do rt ngn thi k th ra. N gy tng mc p lc cn khi ng my th, tng cng th v mt c. Gi PEEP ni sinh < 15 cmH2O bng cch lm gim tn s th v ko di thi k th ra - PEEP ngoi v th sigh khng cn thit v p lc qu tng t cp ca suy h hp mn Ch nh: Mt c tin trin, toan h hp nng ln

Ci t: xem phn tc nghn ng th nng Cn xem xt: - Ngh ngi hon ton trong 36h-72h - Tt huyt p hay gp sau khi th my (xem trn) - Kim h hp sau t ng hay gp nu c toan h hp mn, thng kh lm PaCO2 thp hn nn c th nh hng n cai my - Nu bnh nhn khi ng my m c PEEP ni sinh c th lm tng mt c (xem trn), nu ci PEEP ngoi c th lm gim cng th - PEEP hoc CPAP c th c li khi bnh nhn bt u tp dng c h hp khi cai bng h tr p lc

SUY H HP GIM OXY MU CP Ch nh: - Khng m bo c PaO2 sau khi th xy hoc thng kh khng xm nhp - Th nhanh v ri lon nhp th l du hiu e da ca mt c h hp Nguyn nhn thiu oxy mu: - Ri lon thng kh ti mu. - Shunt. - FiO2 khng . - Gim thng kh (gi nu chnh ph nang mao mch bnh thng). - Gim khuych tn xy Mt s tnh hung lm sng hay gp: Vim phi; ARDS; suy tim; X phi; ung gip phi; Sc phi Ci t: Mode: + SIMV hoc AC vi trigger ti thiu (- 2 cmH2O). + FiO2 khi u 1,0. + Vt 6 ml/kg. + Nhp th 10-20 /pht, hiu chnh PaCO2 (xem tng thn kh cho php di y). + PEEP iu chnh nh di y Cn xem xt: - Nn iu chnh tn s trnh auto-PEEP, m c th xy ra nu TS > 20-22 pht. - p lc plateau l ch s khng xm nhp phn nh p lc xuyn phi. p lc plateau khng nn vt qu 32-35 cmH2O trnh chn thng th tch m c th gy tn thng phi. Tng thn kh v toan h hp (tng thn kh cho php) l mt phn trong chin lc thng kh bo v phi nu PaCO2 khng th bnh thng trong iu kin p lc ng th nh trn53. pH > 7,20 thng dung np tt nhng cn phi an thn tt bnh nhn th theo my - PEEP gy ti phn b dch ph nang vo khong k, v huy ng ph nang xp hay c dch bn trong. Trong ARDS, mc PEEP nn t 12-20 nhm trnh ti xp ph nang v m ph nang dn n ci thin oxy ho mu v c th phng chng tn thng phi cp54. + Xc nh PEEP ti u: (1) t PEEP ban u 5 cmH2O, sau tng dn 5 cmH2O/ln (2) Hiu chnh PEEP cho ti khi nhu cu FiO2 khng qu 0,6 hoc p lc plateau > 35 cmH2O hoc gin n gim [(Compliance = Vt/(p lc tnhPEEP)] + PEEP c th nh hng n s y nh tri v nh phi, gy tt huyt p v mch nhanh + nhm bnh phi tn thng khng ng nht (vd vim phi thu) PEEP khng ci thin oxy ho mu m c th cn gy tng shunt phi + t ngt b PEEP thm ch trong thi gian ngn (vd bp bng khi vn chuyn) c th nguy him bnh nhn c oxy mu ang mc ranh gii

- Gim ph phi cp bng cch chnh PCWP xung mc ti thiu m bo cung lng tim y . - Tc dng/ Dng sng: lm chm tn s th (vd 40 L/pht) v/hoc dng dng sng gim dn s tng thi gian th vo v c th tng oxy ho mu - Nu trong trng hp thiu oxy ho mu tr nn cn nhc: + Th nghim t th nm xp trong 20-40 pht (vd 40l/pht); nu oxy ho mu ci thin th tin hnh th nghim thng xuyn 2-3h, 2-3 ln ngy + Kim sot p lc vi I/E o ngc (1:1 hoc ln hn-s tng thi gian th vo v tng oxy ho mu). Cn phi an thn v lit c hon ton

BNH PHI HN CH Ch nh: - Bnh phi hn ch tin trin (vd x phi) hoc bnh thnh ngc (vd vim ct sng dnh khp) - Him gp hn, tng p lc trong bng, mi phu thut bng Ci t: Mode: SIMV hoc AC, FiO2: 30-50%. Vt 6-7ml/kg. Tn s 18-24l/pht Cn xem xt: - Loi b nhng yu t gy hn ch nu c (vd chc mng bng, rch so) - T th u cao c th gim hn ch do nguyn nhn bng - S chn p gy tng nguy c: (1) Gim mu v tim v gim cung lng tim (2) Tng khong cht sinh l do tng thng kh v PEEP, c bit nu c gim th tch mu (m rng vng Zone I) CH NH CHO DNG AN THN V GIN C Bnh nhn c nguy c cao b tn thng phi do th my: - Bnh ng th c tng AL ng th v auto PEEP (vd cn hen ph qun nng) - Suy h hp gim oxy mu hoc ng c oxy mc d dng PEEP cao - Suy h hp gim oxy mu auto PEEP cao v gng sc - D ph qun mng phi bnh nhn c dn lu mng phi Kim sot tng thng kh do nguyn nhn thn kinh Phng thc th lm bnh nhn kh chu, vd PC/IE o ngc, tng thn kh cho php THNG KH KHNG XM NHP55 Ch nh: Rt hiu qu trong suy h hp cp do COPD, ARDS, suy tim mn tnh, bin chng ca ghp tu xng, hen, c th gim t l t ng NKQ, gim t l t vong v gim ngy nm vin Chng ch nh:

Bnh nhn khng hp tc, ri lon thc, huyt ng khng n nh, mt kh nng bo v ng th, tc nghn ng h hp trn, nhiu m ri, d dng mt, khng c k thut vin h hp c k nng Cch dng: Thng s dng di dng h tr hai mc p lc dng qua mt n mi hoc ming mi. My th chuyn dng trong HSCC cung cp oxy nng cao hn v chnh xc hn, tc dng cao hn (thch nghi vi bnh nhn hn v c chc nng theo di v bo ng Ci t thng s: Bt u vi tn s 10, risetime 0,4 giy, IPAP 8-10 cmH2O v EPAP 2-4 cmH2O, chnh tn s v IPAP, EPAP duy tr SaO2 v thng thong ng th Bin chng: Kch thch ti ch do mt n Chng bng (him tr khi p lc d trn 20 mmHg)

52 Hall JB, Wood LDH. Management of the patient on a ventilator. In: Hall(ed). Principles of Critical Care, 2/e. NY: McGraw-Hill, 1998. Hubmayer RD. Setting the ventilator. In: Tobin MS(ed). Principles and Practice of Mechanical Ventilation. NY: McGraw Hill, 1994. 53 ARDS network. Ventilation with lower tidal volume as compared to traditional tidal volume for acute lung injury and the adult respiratory distress syndrome. NEJM 2000, 342: 1301-8. 54 Amato M et al. Am J Resp Crit care 1995; 152: 1835-46. Amato M et al. NEJM 1998; 338: 347-54. 55 Hillberg RE, Johnson DC. Noninvasive ventilation. NEJM 1997; 337(24): 1746-52. Hess DR, Kacmarek RM. Essentials of Mechanical Ventilation. McGraw-Hill, New York, 1996. CP CU MY TH p lc cao Nu SpO2 80% hoc huyt ng khng n nh, tho my th bp bng oxy 100%, kim tra tm nguyn nhn di y Nu oxy v huyt ng n nh, kim tra my th v p lc plateau: p lc nh tng v p lc p lc nh v p lc plateau u tng (> 35 cmH2O) plateau thp ( 35 cmH2O) Tc m Cn ng NKQ Tc kh qun Co tht ph qun - Suy tim cp - Trn kh mng phi - ng NKQ nm trong ph qun gc

p lc thp Nu SpO2 80% hoc huyt ng khng n nh, tho my th v bp bng O2 100% Cc nguyn nhn: - Tut ng

- D cuff - D kh qun thc qun - D trong my th CAI TH MY Cc phng thc cai th my56 PSV v th nghim T pieces hiu qu gn nh nhau IMV t hiu qu hn 2 phng php trn Cc yu t tin lng cai my thnh cng57 Th my < 8 ngy Th my 8 ngy nhy c hiu nhy c hiu 0,79 0,75 0,75 0,08 Thng kh pht 15 l/pht 1,0 0,63 0,88 0,67 TS th/Vt 105 l/ml 0,75 0,69 0,63 0,25 Compliance ng 22 ml/cmH2O 0,82 0,56 0,50 0,08 Compliance tnh 33 ml/cmH2O 1,0 0,50 0,88 0,58 Vt 325 ml 0,96 0,38 0,88 0,42 Vt 4ml/kg 0,79 0,38 0,88 0,17 PaO2/PAO2 0,35 0,89 0,31 1,0 0,42 Tn s th 38 l/pht 1,0 0,00 1,0 0,25 MIP -15 cmH2O TS th/Vt 105 tin lng cai my thnh cng cao, ch s cao hn vn c gi tr tin on thnh cng c bit ph n nh v ln tui58 Thng s TI U HA TRC KHI CAI MY - t bnh nhn t th u cao ht m hu hng - Ngng dng thuc an thn - Ngh ngi - Gii thch tm l bnh nhn - Dinh dng y - Dng li tiu gim ph phi - Chng co tht ph qun - iu chnh ri lon in gii m c nh hng n c h hp vd PO4, Mg, Ca - H st - iu tr n nh bnh h thng (vd nhim khun) - Dng thuc chng au ngc - Ngng dng cc thuc chn thn kinh c (aminoglycosid) 56 Esteban A et al. A comparison of four methods of weaning patients from mechnical ventilation. NEJM 1995; 332(6): 345-50. Esteban A et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Am J Rep Crit Care 1997; 156: 459-65. Brochard. Am J Resp Crit Care Med 1994; 150: 896-903. 57 Yang KL. A prospective study of indexes predicting the outcame of trials of weaning from mechanical ventilation. NEJM 1991; 324(21): 1445-50.

58 Krieger B et al. Chest 1997; 112: 1029-34. TNG THN KH Phng trnh kh ph nang L gii c cc chn on phn bit ca tng thn kh. PaCO2 tng khi c tng sn xut CO2 hoc khi c gim thng kh ph nang: VA = VE VD PaCO2 = VCO2/VA VD/VT = PaCO2-PeCO2/PaCO2 Trong : VCO2 = lng CO2 c th sn xut ra, VA = thng kh ph nang, VE = thng kh pht, VD = thng kh khong cht, Vt = th tch kh lu thng, PeCO2 = p lc ring phn CO2 lc th ra Sn xut CO2 qu mc: Kim chuyn ho, tnh trng tng chuyn ho GIM THNG KH PHT Gim thng kh trung ng: Ngng th khi ng v gim thng kh do bo ph; Gim thng kh do thuc; Suy gip ; Bnh l thn no Mt c v bnh l thn kinh c: Mt c trong t cp ca suy h hp mn tnh, do thuc (vd chn thn kinh c, aminoglycoside), bnh thnh ngc (vd vim ct sng dnh khp, to hnh lng ngc, ngc dt), bnh thn kinh c tin pht (vd nhc c, ALS, teo c, hi chng sau bi lit, chn thng c cao) TNG THNG KH KHONG CHT Tc cc ph nang chc nng: kh ph thng, x phi, nang Mt cp mu cho ph nang: tc mch phi, thiu th tch (West Zone II-III Zone I), thng kh p lc dng v PEEP (n cp mu t ph nang bnh thng cho ph nang tn thng) VAI TR CA OXY Oxy gy tng tng thn kh do: gim kch thch trung tm h hp bnh nhn tng CO2 mn tnh. Tng khong cht do gin ph qun nh vai tr ca O2 S dng oxy thn trng bnh nhn tng thn kh nhng cng nn nh rng thiu oxy mu nguy him hn tng thn kh bnh nhn tnh SHUNT PHI PHI QUA TRI59 Loi shunt Nguyn nhn Shunt tuyt i "Ging nh " shunt Shunt sinh l qua TM Gim khuych tn kh kh qun, trung tht, tnh Ri lon thng kh ti mch Thebesian mu nng Shunt gii phu vd fistule ng tnh mch phi Shunt trong tim vd VSD, PDA, ASD Xp ph nang, vd xp

p ng vi Oxy 100%

phi, ng c phi Rt t hoc khng thay i PaO2

Tng PaO2

T s Shunt (Qs/Qt): Qs/Qt = [(A-aDO2).0,0031]/[(A-aDO2).0,0031 + CaO2-CvO2] Trong : CaO2 = Oxy ng mch CvO2 = Oxy TM trn (ly t catheter ng mch phi) CxO2 = [1,39 . Hb(g/dl) . SaO2(%)] + [0.0031.PxO2(mmHg)] Bnh thng CaO2-CvO2 = 5 nhng c th cao hn bnh nhn rt nng A-aDO2 = chnh lch oxy ph nang ng mch = [FiO2 x (Patm-PH2O)] - [PaCO2/t s h hp] - PaO2 Vi FiO2 = 1, t s h hp = 1,0 A-aDO2 = 713-PaCO2-PaO2 DIN DI T L QS/QT 30% Bnh thng Tng i bt thng, thng t m bo oxy ho mu vi kh tri Shunt nng. Thng cn oxy h tr hoc PEEP; c th e do bnh nhn c ri lon TKTW v tim phi Rt nng n

59 Marini JJ, Wheeler AP. Critical Care Medicine - The essentials. Boston: Williams & Wilkins; 1989.

NI TIT HC HN M DO SUY GIP71 Nguyn nhn Bnh tuyn gip nn: + Bnh t min, + Phu thut ct b tuyn gip (khm c xem c vt so m c hoc tin s dng I131), + i khi do suy gip th pht ( TSH) hoc do thuc (amiodarone, lithium) Cc yu t khi pht cp tnh: + H thn nhit (phn ln din ra vo ma ng), + t qu, + Suy tim huyt, + Nhim khun, + Thuc: thuc gy m, an thn, gy ng, narcotic, + Chn thng, + Xut huyt tiu ho, + Ri lon chuyn ho ti din ( ng mu, Na mu, CO2, toan mu) Biu hin H thn nhit: t l t vong tng nu c h thn nhit Du hiu thn kinh: Mt l l hn m v suy h hp (c th nng hn nu c thm vai tr ca thuc), + Ri lon thc thng bo hiu kh nng tng t l t vong, + "myxedema madness": trm cm, lon thn, hoang tng, + Gim phn x Triu chng h hp: + Gim kh nng thch ng ca trung tm h hp gim thng kh, + Trn dch mng phi, + Tc nghn ng h hp do ph i sn np v thm nhim ph nim Triu chng tim mch: + Nhp tim chm, + Tt huyt p, + TDMT thng gp (nhng him khi c p tim), + Ri lon chc nng tm thu/ tm trng, + T: block, in th, QT

Triu chng thn: + H Na+ mu, + Gim th tch trong lng mch cng vi tng lng Na+ v nc ton th Xt nghim: Glucose, Na+, K+, cortisol, cholesterol, Hct, bch cu, Creatinine >2, PCO2, PO2 iu tr Liu php thay th hormon. Khi u dng ng tnh mch (gim hp thu qua ng ung khi c ph nim rut), cn gim liu ngi c bnh mch vnh v ngi cao tui. Cha c nghin cu kim chng ngu nhin no xc nh c liu v ch phm ti u. Cc phng thc sau: (1) Thyroxine (T4) - t1/2 ~ 7 ngy, phi chuyn thnh T3 c hot tnh. Liu tn cng l 300-600 g TM sau l 50-100 g/ngy; (2) Liothyronine (T3) - dng hormone c hot tnh, t1/2 ~ 1 ngy. Cch dng cn gy nhiu tranh ci; dng liu cao c th gy tng t l t vong. C s dng thuc l tc dng chm nu ch dng n ho tr liu bng T4 v tnh trng c ch chuyn t T4 T3 trn bnh nhn c bnh l ngoi tuyn gip km theo. Liu tn cng 10-20 g ung/ TM, sau 10 g 4-6 gi/ln cho n khi lm sng ci thin. Liu thp ti 2,5 g c tc dng phc hi cc ri lon chuyn ho; (3) iu tr kt hp - dng T4 vi liu hi gim (4 g/kg) + T3 nh phn trn Suy thng thn phi hp l thng gp (5-10%) ban u dng glucocorticoid (ly mu mu nh lng cortisol trc khi dng hoc dng dexamethasone) Tin hnh thng kh nhn to cho nhng trng hp suy h hp (SHH tin trin nhanh, vi nguy c sc cao). Nu c tt huyt p th cn b dch trc khi cho thuc vn mch (dopamine c a dng hn so vi cc thuc ch c tc dng n thun). Nu tt p tr vi iu tr th cn ngh n p tim cp hoc suy thng thn cp iu tr h ng mu (ng cn cho phn ng chuyn t T4 T3) iu tr h thn nhit: m th ng cho bnh nhn bng chn v tng nhit phng; m ch ng c th lm cho tnh trng sc b ti i iu tr h Na+ mu bng cch hn ch nc; dng mui u trng nu bnh nhn c co git Pht hin v x l cc yu t khi bnh, xem xt iu tr khng sinh d phng iu chnh liu cc thuc khng ph hp vi tnh trng gim chuyn ho 71 Wartowsky L. Myxedema coma. In: Wemer and Ingbar's Thyroid: a Fundamental and clinical Text, 7/e. Braveman LE, Utiger RD (eds). Philadelphia: Lippincott, 1996; Emerson CH: Myxedema coma. In: Intensive Care Medicine, 4/e. Irwin RS, Cerra FB & Rippe JM (eds). Philadelphia: Lippcott-Raven, 1999. MacKerrow SD et al. Myxedemsassociated cardiogenic shock treated with intravenous triidothyronine. Ann Intern Med 1992; 117(12): 1014-5. CN BO GIP TRNG72 Nguyn nhn Cng gip nn: + Thng l do bnh Grave, + Nguyn nhn khc: vim tuyn gip cp, bu c, bnh basedow do iod, gi (ung thyroxine)

Cc yu t khi pht: + Nhim trng, + Phu thut hoc chn thng, + Qu liu iod (dng I131, thuc cn quang, kelp, amiodarone), + H ng huyt, + Sinh , + Phu thut hoc can thip lin quan n tuyn gip, + Cc sang chn tm l, + T b thuc khng gip trng, + Toan x tn do T, + Nhi mu phi, + t qu, + Dng cc thuc kch thch giao cm (gi ephedrine) Triu chng Triu chng ton thn: st, nhp nhanh, v m hi (khng tng xng vi tnh trng nhim trng) Triu chng tim-phi: nhu cu chuyn ho, tiu th xy, cung lng tim, + Tnh trng tng ng suy tim cung lng cao, + Thiu mu cc b c tim, + Lon nhp tim (thng gp cn nhp nhanh trn tht, c bit l rung nh), + Tng p tm thu vi khong chnh huyt p Triu chng thn kinh: + Sng, l ln hoc hn m, co git, + Bnh c > 50%, + Li mt, + Bin chng him gp: cn nhc c hoc lit chu k do h kali mu do ng c gip (nam gii chu ) Triu chng tiu ho: + Nn, a chy, ri lon hp thu, + Gastrin lot d dy t trng, + Bt thng v men gan Xt nghim: T4, FT4, T3, TSH, glucose, bch cu v chuyn tri, thiu mu, tiu cu, K+, Ca++ (c th rt nng), ALT & AST, cortisol iu tr 1) iu tr khng gip trng - c hiu qu cho nhng tuyn cng nng (vd. bnh Grave) nhng khng c hiu qu trong vim tuyn gip hoc do hormon gip trng ngoi sinh c ch tng hp hormon bng PTU (250 mg ung/hoc qua sonde d dy 4 gi/ln) hoc methimazole (20 mg ung hoc bm qua sonde d dy 4 gi/ln). PTU c a dng hn v c tc dng i vi qu trnh chuyn t T4 T3 t chc ngoi bin. Dng tim TM cha c M c ch bi tit hormon bng iodine: dng dung dch Lugol hoc SSKI (8 git ung 6 gi/ln) hoc Na iodide 0,5-1,0 g TM 12 gi/ln. Thn trng: cho t nht 1 gi sau khi dng methimazole hoc PTU (dng n c c th lm nng thm tnh trng ng c gip. Trng hp d ng iod: dng lithium carbonate 300 mg ung 6 gi/ln duy tr nng ~ 1 mEq/L 2) c ch tc dng ca hormon v phn ng chuyn i ti ngoi vi 1. c ch giao cm, vd. propanalol (1 mg TM/pht n khi t tng liu 2-10 mg, iu chnh liu theo nhp tim; sau 20-80 mg ung 4-6 gi/ln - c th cn liu cao hn bnh thng) 2. c ch qu trnh chuyn T4 T3 ngoi vi bng cc thuc cn quang c cha iod vd. iopanoate (Telepaque3 g ung ban u sau 1 g ung hng ngy) v/hoc glucocorticoid vd. dexamethasone (2 g TM/ung 6 gi/ln). blocker & PTU cng c tc dng c ch qu trnh chuyn T4 T3. 3. Nu triu chng khng ci thin cn nhc lc mu hoc gn huyt tng; hoc do hormon gn cholesteramine ti rut (4 g ung 6 gi/ln) 3) iu tr cc bnh l nn, vd. nhim trng tim tng, suy tim, toan x tn, vv 4) iu tr h tr iu tr h nhit bng acetaminophen, chn lnh

Truyn dch + detrose nu bnh nhn c v m hi nhiu, nn, a chy, h ng huyt B vitamin TM (vd. B-complex) Cn nhc dng glucocorticoid nu nghi suy thng thn

72 Wartowky L, Thyrotoxic storm. In: Werner and Ingbar's Thyroid: a Fundamental and clinical Text, 7/e. Braverman LE, Utiger RD (eds). Philadelphia: Lippincott, 1996; Abend SL, Braverman LE. Thyroid storm. In: Intensive Care Medicine, 4/e. Irwin RS, Cerra FB & Rippe JM (eds). Philladelphia: Lippincott-Raven, 1999. SUY THNG THN CP73 Hon cnh xut hin Tiu hu thng thn lan rng t ngt (vd. chy mu hoc do nhi mu) hoc Sang chn sinh hc chnh (v nh. Phu thut, nhim trng, chn thng) trn nhng bnh nhn c suy thng thn nguyn pht tim tng hoc Liu corticoid khng trn bnh nhn c suy hoc nghi ng suy thng thn (vd. dng corticoid di ngy k c vi liu thp) t gp do suy thng thn th pht do c th vn m bo cn bng ni mi i vi corticoid chuyn ho mui nc. Tuy nhin nu c suy tuyn yn t ngt/nng (do chy mu) c th gy tt huyt p do thiu glucocorticoid (corticoid chuyn ho mui nc th tch lng mch; glucocorticoid trng lc mch mu) Chnh sc nhim khun c th gy suy thng thn tng i (c hi phc) Cc nguyn nhn ca suy thng thn Tn thng c hai tuyn thng thn: + Xut huyt (thng b che lp): chng ng, ri lon ng mu, sau m, + Huyt khi: huyt khi tnh mch thng thn sau chn thng, bnh l huyt khi vi mch (DIC, HIT), + Ung th di cn Nhim khun: NKH do no m cu (Waterhouse-Friderichsen), Pseudomonas Vim tuyn thng thn t min: v cn hoc nm trong bnh cnh ca suy nhiu tuyn ni tit Nhim khun sinh u ht: lao, histoplasmosis, v cc loi nm khc HIV: do chnh HIV, CMV, MAC Do thuc: thuc gy c ch thng thn (corticosteroid, megestrol, medroxyprogesterone acetate), + c ch tng hp cortisol (ketoconazole, etomidate), + Tng ging ho cortisol (phenytoin, rifampin, barbiturate) Suy tuyn yn: suy thng thn th pht (vd. ch c glucocorticoid) Triu chng Sc: va l sc gim th tch (thiu corticoid chuyn ho mui nc) v sc phn b (glucocorticoid). Thng khng tng xng vi mc nng ca mt bnh cp v khng p ng vi b dch v thuc vn mch cho n khi c iu tr hormon thay th Triu chng tiu ho: nn/ bun nn, chn n, au bng (c th ging nh cn au bng cp) St: thng do cortisol mu thp nhng thng do nhim khun th n TKT: l , l ln, hn m

Cc du hiu thc th/in quang: xm nim mc, cc np gp v cc vng da tip xc nhiu vi nh sng mt tri (ch gp trong suy thng thn tin pht) + Bng tim nh trn phim XQ ngc, + Hnh can xi ho v tuyn thng thn to trn phim CT Xt nghim: Na+, K+ ( aldo), BUN/cre, glucose, Ca++, tng BC i toan Suy thng thn th pht khc ch: + Khng c tng ACTH v POMC (khng c xm da), + Hot tnh ca corticoid chuyn ho mui nc c bo tn (khng c tng Kali mu), + H Na+ mu do ADH trung ng, + Thng gp h ng mu Chn on nh lng nng cortisol ngu nhin: < 5 g/dL trong iu kin c stress sinh l ( c hiu ~ 100%)74 Test kch thch ACTH liu cao (cosyntropin): Tim 250 g (40 v) TB/TM. Chc nng thng thn c coi l bnh thng khi cortisol mu tng 20 g/dL so vi mc nn hoc sau khi tim trong vng 60 pht (Tiu chun cortisol mu tng gp i hoc tng mc ti thiu khng c ngha). Test c c hiu cao nhng c th b st cc trng hp suy bn phn. Test kch thch ACTH liu thp (cosyntropin)75: Tim TM 1 g (0,16 v)76. Cortisol 18 g/dL so vi gi tr nn hoc trong vng 30 pht c nhy 95% v c hiu 96% trong suy thng thn; cortisol 22 g/dL c nhy 100% v c hiu 83%. Nng ca ACTH: dng phn bit suy thng thn tin pht (ACTH >> bnh thng) v th pht (ACTH thp hoc bnh thng). Cn nh lng mt test ngu nhin trc khi cho corticoid iu tr 1. Bi ph nhanh chng th tch tun hon (30-50% th tch trong mch bnh thng, thng 2-3 L mui sinh l). iu chnh tc truyn theo ALTMTT hoc ph phi. B kali v glucose nu cn 2. Dexamethasone (5 mg TM) nhm phc hi li trng lc thnh mch (khng nh hng n kt qu ca test kch thch ACTH) 3. Ly mu lm xt nghim cortisol v ACTH nn, sau tin hnh test kch thch ACTH 4. Khi u dng hydrocortisone 100 mg TM 6-8 gi/ln. Gim liu dn dn (vd 50% hng ngy) khi lm sng n nh. Khng cn dng ngay corticoid chuyn ho mui nc trong giai on cp 5. Pht hin v iu tr cc yu t khi pht 6. Nu suy thng thn tin pht cn b hydrocortisone di ngy (20 mg vo bui sng, 10 mg vo bui chiu) v fludrocortisone (0,1 mg hng ngy) 73 Orth DN et al. The adrenal cortex. In: Wilson JD, Foster DW (eds). Williams Textbook of Endocrinology, 9/e. Philadelphia: Saunders 1998. Longcope DN. Hypoadrenal crisis. In: Intensive Care Medicine, 4/e. Irwin RS, Cerra FB & Rippe JM (eds). Philladelphia: Lippincotts-Raven, 1999. Lamberts SW et al. Corticosteroid therapy in severe illness. NEJM 1997; 337 (18): 1285-92 74 "If it ain't high, it's low": typical sage advice from Dr. David Aron, Case Western Reverse University School of Medicine

75 Abdu TAM et al. Comparison of the low dose short synacthen test(1 g), the conventional dose short synacthen test (250 g), and the insulin tolerance test for assessment of the hypothalamic-pituitary adrenal axis in patients with pituitary disease. J Clin Endocrinol Metab 1999; 84: 2973 76 Mix one vial (250 g) cosyntropin in 1 mL diluent. Withdraw 0,2 mL and dilute to 25 mL in NS to produce 2 g/mL solution (0,5 mL = 1 g required for low dose ACTH test) SUY TUYN YN77 Hon cnh xut hin Nhi mu xut huyt tuyn yn (thng trong khi u) iu kin thun li l dng chng ng, tia x, hi chng Sheehan (nhi mu tuyn yn do co mch trong khi , thng km theo tt p), iu tr bng hormon (estrogen, c ch tin lit tuyn), phu thut, chn thng Biu hin lm sng Chy mu ni s: c du hiu kch thch mng no, au u, v dch no tu nh vng Khi u lan rng trong h yn: au u, nhn i, mt th trng thi dng hai bn, lit c vn nhn, thay i thc v hn m, suy h hp, h Na+ mu (SIADH) Suy tuyn yn ton b cp tnh: tt HA (suy thng thn), tng Na+ mu (T nht). < 50% c triu chng r rng, nhng phn nhiu c thay i v mt xt nghim iu tr Bi ph nc v in gii Liu php thay th hormon (hydrrocortisone 100 mg TM 6-8 gi/ln) Xt nghim c tnh chn on xc nh (MRI nhy hn CT) 77 Aron DC. Metabolic and endocrine emergencies. In: Current Emergency Diagnosis anf Treatment, 4/e. Saunders CE, Ho MT (eds). Norwalk, CT: Appleton & Lange, 1992. Randeva HS et al. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinology 1999; 51(2): 181-88. H CAN XI MU Nguyn nhn H can xi mu gi To xng Ca++ 0,8 mg/dL mi khi albumin mu 1 g/dL Dng Ca++ khng b nh hng PO4 (suy thn, tiu c vn, hoi t khi u) Vim tu Di cn xng lan rng Hi chng "xng i" sau iu tr cng cn gip trng, cng gip hoc toan chuyn ho ko di Gn trong mch: citrate (mu d tr), lactate hoc toan a xt lactic, foscamet, EDTA, kim h hp ( gn vi albumin)

bi tit PTH

hot tnh ca PTH (suy cp gip trng gi) 25-OH vitamin D

1,25-OH vitamin D Cc nguyn nhn khc

Hu phu (ct b tuyn cn gip, ct b tuyn gip, hoc ct v no vt hch vng c) hoc tia x Bnh t min Mg++ (< 0,8 mEq/L) hoc Mg++ nng (> 5mEq/L) - HIV Bnh l thm nhim (hemachromatosis, di cn ung th) Di truyn Mg++ (ru, a chy, li tiu, aminoglycoside) n km hoc ri lon hp thu Khng tip xc nh sng Bnh gan Thuc chng co git Bnh thn Nhim khun hoc hi chng sc c t Hu phu Fruoride

Biu hin lm sng Bnh thn kinh c: kch ng ton thn (cn xon vn, t b) tin trin dn thnh cn tetani (carpopendal, co tht thanh qun); du hiu Trousseau v Chvostek. Cn tetany r rt hn khi bnh nhn c kim mu, Mg++, K+. Triu chng thn kinh trung ng: mt l, ri lon cm xc, co git ton th, ph gai th Biu hin tim mch: thi gian QT ko di (vi sng T hp); block tim, tt huyt p, ri lon chc nng tim mch. iu tr h canxi cp c triu chng 4. Khng nh chn on bng kim tra li Ca++ hoc hiu chnh theo albumin mu 5. Nu khng r cn nguyn, ly xt nghim nh lng creatinine, PO4, albumin, PTH, 25-OH vitamin D (khng cn 1,25- OH vitamin D tr khi c bnh thn) 6. Dng ~ 4 mg/kg canxi nguyn t di dng Ca gluconate 10% (93 mg canxi nguyn t / 10mL) hoc CaCl 10% (272 mg canxi nguyn t Ca++/10 mL) pha trong 50-100 mL dung dch ng 5% tim trong - pht, sau truyn 1 2 mg canxi nguyn t/kg/gi cho n khi Ca++ > 4,5 mg/dl (1,1 mmol/L) 7. Tim bolus magnesium sulfate (2 gram TM) tr khi nng Mg mu tng cao, vd trong suy thn 8. Nu nghi ng thiu vitamin D hoc PTH th cho ung 0,25 g calcitrol/ngy. TNG CANXI MU78 Nguyn nhn: Bnh c tnh (gp ch yu nhm bnh nhn ni tr) v cng cn gip trng tin pht (ch yu nhm ngoi tr) chim ti 90% cc trng hp

Bnh c tnh

Cng cn gip trng tin pht vitamin D Bt ng xng

Do thuc Cc nguyn nhn khc

Thng gp cc khi u nguyn pht (thng gp nht l u ty, u v, phi, u/c, thn, bng quang) 3 c ch chnh: (1) di cn lan ta vo xng; (2) sn xut ra protein tng t PTH (PTH-rP); (3) tng chuyn ha ca vitamin D (u lympho) Nguyn pht (adenoma, hi chng MEN) PTH th pht (vd. suy thn, thng c canxi thp hoc bnh thng tr khi c b sung thm Ca++ v Vitanmin D) 25-OH vitamin D: ch n 1,25-OH vitamin D: bnh u ht (sarcoid, lao); lymphoma; ch n Hi chng sa-kim (thuc bc d dy) Bt ng xng lu ngy Gy nhiu xng HCTZ +lithium + ng c Vit A Pheochromocytoma Suy thng thn Ng c gip Tiu c vn c suy thn Tng canxi mu gi (canxi ion bnh thng nhng tng phn gn vi albumin hoc paraprotein)

Biu hin lm sng Thn kinh trung ng: l ln, mt, ri lon tm thn, hn m Tiu ha: to bn, chn n, vim ty Tim: QT, PR v QRS, in th QRS, sng T dt v rng, QRS c mc, block nh tht, ngng tim (Ca++ > 15 mEq/L) Thn: mt nc, suy thn, si thn, toan ha ng thn on ng ln xa iu tr tng canxi mu cp c triu chng79 1) Xt nghim chn on: canxi ion, PO4, creatinine, PTH, 1,25-OH v 25-OH vitamin D 2) Tng cng bi tit canxi qua nc tiu bng truyn dung dch mui sinh l (NaCl 250 ml/h); khi tnh trng mt nc c gii quyt th bt u thuc li tiu quai (vd. furosemide 20-40 mg TM 2-4 gi/ln) duy tr tnh trng ng tch. Bt u c hiu qu trong vng 2-4 gi. Ch nh chy thn nu bnh nhn c chng ch nh truyn dch nh trong suy thn hoc suy tim. 3) c ch hy xng bng pamidronate 60-90 mg truyn TM trong vng 4 gi; thuc bt u c tc dng sau 1-2 ngy v tc dng ti a trong 4-6 ngy. 4) Trong trng hp tng canxi mu nng, cho calcitonin 4 n v/kg TM 12 gi/ln x 4 liu. C tc dng sau 4-6 gi nhng thng xut hin tr tc dng sau 2-3 ngy. 5) Glucocorticoid TM (vd. prednisone 20-40 mg/ngy) c hiu qu i vi tng canxi mu do u lympho hoc bnh u ht; cng c th c ch hp thu canxi qua ng tiu ha bng ung PO4 500 mg 4 ln/ngy

6) Bin php iu tr i vi tng canxi mu tr: mithramycin, nitrat gali, PO4 TM (c hiu qu nhng d b ng c) 78 Bilezekian JP. Management of acute hypercalcemia. NEJM 1992; 326: 1196-12 79 Gucalp R et al. Treatment of cancer-associated hypercalcemia. Arch Int Med 1994; 154(17): 1935-44.

BNH TIU HA NHIM KHUN DO HELICOBACTER PYLORI80 Xt nghim chn on v ch nh iu tr: Ch nh chc chn: bnh lot d dy t trng tin trin (PUD) + Tin s lot d dy t trng nhng cha c iu tr Helicobacter pylori (HP) + U lympho d dy MALT Ch nh ang tranh ci: vim d dy mn tin trin Khng c ch nh: khng c triu chng + Bnh tro ngc d dy thc qun Xt nghim chn on: Xt nghim Tin s Test urease mnh sinh thit Test urea hi th ELISA mu hoc huyt nhy 93-96% a 88-95% b 90-96% b 86-94% c hiu 98-99% 95-99% 88-98% 78-95% c Nhn xt Cn soi d dy Cn soi d dy S lng hn ch Khng tin cy nu

tng Antigen trong phn81

90-94%

b

86-95%

bnh nhn c iu tr Test mi, cha c s dng rng ri

a: nhy gim nu dng c ch H2 (H2B) hoc bm proton (PPI) b: nhy gim nu dng H2B, PPI, bismuth hoc khng sinh; nhy cng gim khi c lot ng chy mu hoc chy gn y c: c hiu gim nu bnh nhn c x gan iu tr Ch iu tr PPI (omeprazole 20 mg hoc lanzoprazole 30 mg) hai ln/ngy cng metronidazol 500 mg 2ln/ngy cng clarithromycin 500 mg 2ln/ngy PPI (omeprazole 20 mg hoc lanzoprazole 30 mg) 2 ln/ngy cng amoxicilline 1000 mg 2 ln/ngy hoc clarithromycin 500 mg 2ln/ngy (PrevPac) Ranitidine bismuth subsalicylate (RBC) 400 2 ln/ngy cng Clarithromycin 500 2 ln/ngy cng amoxicillin 1000 mg hoc metronidazol 500 mg hoc tetracycline 500 mg 2 ln/ngy PPI (omeprazole 20 mg hoc lanzoprazole 30 mg) 2 ln/ngy cng bismuth subsalicylate (Pepto Bismol) 525 mg 4 ln/ngy cng metronidazole 500 mg 4 ln/ngy cng tetracycline 500 mg 3 ln/ngy Bismuth subsalicylate (Pepto Bismol) 525 mg 4 ln/ngy cng metronidazole 250 mg 4 ln/ngy cng tetracycline 500 mg 3 ln/ngy cng c ch H2 f (x 4 tun) Thi gian 2 tun d 2 tun d 2 tun T l lnh bnh 90-95% 86-94% 82-94%

2 tun

94-98%

2 tun d

84-94%

d: liu php ko di trong 10 ngy vi PPI c th chp nhn c e: Amoxicillin c a chung hn so vi metronidazole nu c khng metronidazole f: famotidine 40 mg 1 ln/ngy/20 mg 2 ln/ngy hoc ranitidine/nizatidine 300 mg 1 ln/ngy/150 mg 2 ln/ngy 80 Howden CW, Hunt RH. Guidelines for the management of Helicobacter pylori infection. Am J Gastroenterology 1998; 93(12) 2330-2338. 81 Vaira D et al. Diagnosis of Helicobacter pylori infection with a new non-invasive antigen-based assay. Lancet 1999; 354 (9172): 30-3. IU TR VIM I TRNG DO C. DIFFICILE82 iu tr ban u:

iu tr u tay: Dng tt c cc khng sinh ang dng v theo di bnh nhn nu triu chng lm sng khng nng + Trng hp c triu chng nng th dng metronidazole 500 mg ung 3 ln/ngy iu tr thay th: vancomycine 125 mg ung 4 ln/ngy + Cha c nghin cu no cho thy c hiu qu hn so vi metronidazole; ch nh trong trng hp nhim khun nng khng p ng vi metronidazole ng tnh mch : metronidazole 500 mg TM 8 gi/ln nu bnh nhn khng c ch nh nui dng qua ng tiu ha; cho thm vancomycin ung nu c nhim khun nng Thi gian iu tr: 10-14 ngy (iu tr di ngy khi c ngun nhim khun ch khc) Nhim khun ti pht (10-25% cc trng hp)83: t ti pht u tin: dng cc thuc khng sinh nu c th c; + Xem li chn on, + Nhc li iu tr bng metronidazole hoc vancomycin trong 10-14 ngy Ti pht nhiu t: gim dn liu vancomycin ung: o Tun 1: 125 mg 4 ln/ngy o Tun 2: 125 mg 2 ln/ngy o Tun 3: 125 mg 1 ln/ngy o Tun 4: 125 mg 2 ngy/ln o Tun 5-6: 125 mg 3 ngy/ln o Tun 7-10: cholestyramine 4 gram ung 4 ln/ngy Liu php thay th: Colestipol (5 g 2 ln/ngy) hoc cholestyramine ( 4g 3-4 ln/ngy) hoc vancomycin ung (cch nhau 2-3 gi) + Vancomycin (125 mg ung 4 ln/ngy) cng rifampin (600 mg ung 2 ln/ngy) + Phc hi li vi khun ch rut bng Saccharomyces boulardii, lactobacillus Ch nh ngoi khoa (1-3% bnh nhn): Thng i trng Tc rut gy hi chng nhim c phn Nhim khun huyt Khng p ng vi iu tr 82 Fekety R. Guidelines for the diagnosis and management of C. difficile-associated diarrhea and colitis. Am J Gastroenterology 1997: 92: 739-50. Kelly CP et al. C. difficile colitis. NEJM 1994; 330(4): 257-62 83 Tedesco FJ et al. Approach to patients with multiple relapses of antibiotic-associated pseudomenbranuos colitis. Am J Gastroenterology 1985; 80: 867-8. CHNH LCH ALBUMIN MU-DCH C TRNG84 Chnh lch albumin mu dch c trng (SAAG) = albumin mu albumin dch c trng SAAG 1,1 mg/dl gp trong tng p tnh mch ca

chnh xc trong phn loi nguyn nhn ti 97% (cao hn khi s dng khi nim dch thm-dch tit) SAAG < 1,1 (khng c tng p TM ca) Ung th phc mc Vim phc mc khng c c trng (vi khun, lao) Hi chng thn h C trng do ty hoc do mt C trng dng chp c tnh Nhi mu rut hoc tc rut

SAAG 1,1 mg/dl (c tng p TM ca) X gan ( nhim khun phi hp hoc ung th) C trng do suy tim (suy tim huyt, h 3 l, vim mng ngoi co tht hoc p tim) Di cn gan lan ta Huyt khi TM ca Hi chng Budd-Chiari Suy gan ti cp Ung th t bo gan Vim gan cp (do virt hoc do ru) trn nn x gan

84 Runyon BA et al. The serum-ascites albumin gradient is superior to the exudatetransudate concept in the classifiction of ascites. Ann Int Med 1992; 117: 215-220. NHIM KHUN DCH C TRNG (AF)85 Hi chng lm sng Lng BCN trong AF 250 TB/mm3 Nhum gram hoc cy Dng tnh (1 loi vi khun) m tnh Nhn xt Chim 2/3 s bnh nhn nhim khun c trng iu tr nh SBP. Chn on phn bit vi: lao, ung th phc mc, vim ty cp iu tr nh SBP nu c triu chng (st, au bng); theo di nu khng c triu chng Kh phn bit vi SBP, nhng nu in hnh th thy phc mc c kh hoc dch c trng c 2 trong 3 tiu chun sau: 1) Protein > 1 g/dL 2) Glucose < 50 mg/dL 3) LDH > 225 (hoc gii hn cao ) Thng do chc phi rut trong khi ht ; theo

Vim phc mc tin pht (SBP) Dch c trng tng bch 250 TB/mm3 cu cy m tnh (CNNA) C trng khng tng bch cu cy dng tnh vi 1 loi vi khun (MNB) Vim phc mc th pht < 250 TB/mm3

Dng tnh (1 loi vi khun) Dng tnh (nhiu loi vi khun)

250 TB/mm3

C trng nhim nhiu loi vi khun

< 250 TB/mm3

Dng tnh (nhiu loi vi

khun)

di tr khi c triu chng

Nguyn nhn v biu hin lm sng ca SBP Hu ht xut hin trn bnh nhn x gan tin trin, nhng c th thy trn suy tim huyt hoc hi chng thn h Yu t nguy c: + Bnh gan nng (70% BN c Child-Pugh C hoc bilirubin > 2,5 mg/dl); + Protein ton phn trong dch bng < 1 g/dl; + C xut huyt tiu ha phi hp; + Nhim khun tit niu; + Lon khun ch; + ang lu catheter; + C vim phc mc tin pht trc (70% ti pht sau 1 nm) Vi khun ch: + 60% vi khun gram (-) (E. coli v Klebsiella); + 25% cu khun gram dng (phn ln l ph cu hoc lin cu khc); + Enterococci, ph cu v k kh < 5% (tr trng hp vim phc mc tin pht) Du hiu v triu chng: thng gp nht l st (69%) v au bng (59%); + Cc triu chng khc gm bnh no (54%), cng bng (59%); a chy (32%); tc rut (30%); sc (21%); h thn nhit (17%); + 10% khng c triu chng Chn on: xem bng tiu chun + Thng s quan trng l bch cu trong dch c trng86- chn on nu 250 TB/mm3; + Cy mu dng tnh trong 30-60%; + Cy dch c trng dng tnh trong 32-44% (vd. CNNA); + Kt qu cy s cao hn nu dch c trng c bo qun trong chai dng cy mu iu tr, tin lng v phng SBP iu tr: Cephalosporine th h 3 (vd. cefotaxime) c hiu qu r rt hn ampicillin/aminoglycoside87; + La chn thay th: aztreonam, ampicillin-sulbactam, ticarcillin-clavulanate, fluoroquinolone; + Thi gian iu tr: hiu qu tng t nhau nu dng 5 ngy so vi 10 ngy (nu c p ng lm sng); + T l thnh cng 8085%; + Fluoroquinolone c hiu qu v an ton trn nhng bnh nhn c nguy c thp Tin lng: lin quan n c bnh l gan hay khng (t l sng 30% sau 1 nm v 20% sau 2 nm) D phng88: Cn nhc iu tr khng sinh ng ung (vd. norfloxacin 400 mg/ngy hoc Bactrim DS ung 1 ln/ngy) cho nhng bnh nhn x gan c xut huyt tiu ha (trong vng 7 ngy), protein dch c trng < 1 g/dl (trong khi nm vin) hoc c vim phc mc tin pht trc 85 Such J, Runyon B. Spontaneous bacterial peritonitis. Clin Inf Dis 1998; 27: 669-676 86 Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastro Clinic North Am 1992; 21: 257-75 87 Felisart J et al. Cefotaxime is more effective than ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985; 5: 457. 88 Soriano G et al. Selective intertinal decontamination prevents spontaneous bacterial peritonitis recurrance in cirrhosis. Hepatology 1990; 12(4Pt1): 716-24 NGUY C TRONG PHU THUT CA BNH GAN89 Bng im Child-Pugh ci tin90

Biu hin 1 im 2 im 3 im Bnh no do gan # Khng I - II III - IV C trng Khng Khng nhiu Nhiu Bilirubin (mg/dl) - Khng c tc mt 3 - C tc mt* 10 Albumin (g/dl) > 3,5 2,8 - 3,5 < 2,8 INR < 1,7 1,7 2,3 > 2,3 # Bnh no do gan: (I) tip xc chm; khng c run tay; (II) ln ln; c run tay; (III) l ln, m sng; c run; (IV) khng p ng hoc ch p ng vi kch thch au; khng run tay * vd. x gan mt tin pht Phn Child-Pugh ci tin im T l t vong trong phu thut91 A 5-6 10% B C 7-9 10 31% 76% M t p ng bnh thng vi tt c cc loi phu thut; kh nng ti to li bnh thng Chc nng gan b tn thng va. Ch chu ng c phu thut nu c chun b tt. Kh nng ti to ca gan km, chng ch nh ct mt phn gan ln p ng km vi phu thut bt k chun b tt hay khng. Chng ch nh ct gan d nh

89 Patel T. Surgery in the patient with liver disease. Mayo Clin Proc 1999; 74: 593-9 90 Pugh RN et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973; 60: 646-9 91 Garrison RN. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984; 199: 648-55

VIM TY92 Chn on Amylase v lipase: C gi tr h tr cho chn on khi > 3 ln so vi bnh thng; + Gi tr < 3 ln bnh thng khng c hiu (chn on loi tr bao gm thng lot d dy, nhi mu mc treo, suy thn); + Lipase c gi tr hn; + Gi tr tuyt i khng tng xng vi tnh trng nng ca bnh hoc tin lng bnh; + Xt nghim seri khng tin on c p ng lm sng hoc tin lng ALT: > 80 u/mL c c hiu cao cho nhng vim ty do nguyn nhn ng mt

Siu m bng: pht hin c si ti mt hoc gin ng mt Chp ct lp vi tnh c tim thuc cn quang: tin hnh trong vng 72 gi trn bnh nhn vim ty nng cho php nh gi mc ca hoi t

Tin lng Suy tng: L ch s quan trng nht nh gi mc nng. Suy tng khi c mt trong cc du hiu sau: HA tm thu 2 mg/dl, hoc xut huyt tiu ha > 500 mL/24 gi. C c mu: Ht > 44% tin lng hoi t ty im APACHE II: phc tp nhng c nhy/ c hiu cao nht nh gi mc nng Bng im Ranson93 Khi vo vin Sau khi nhp vin 48 gi Tui > 55 Ht < 30% hoc tt > 10% Bch cu > 16000 Canxi mu < 8 mg/dL ng mu > 200 mg/dL Ur mu tng > 5 mg/dL LDH mu > 2 ln bnh thng PaO2 < 60 mmHg AST mu > 6 ln bnh thng Kim mt > 4 mEq/L Lng dch mt c tnh > 6 lt Bi ph mt lng dch rt ln im Ranson 0-2 3-4 5-6 7-8 T l t vong (%) 0,9% 16% 40% 100% % cht hoc > 7 ngy trong ICU 3,7% 40% 93% 100%

Ch s mc nng nh gi theo CT scanner (CTSI)94 Mc A Tuy bnh thng B Ty to kh tr hoc lan ta C Ty bt thng km theo c vim nh quanh ty D Thy t dch mt pha (thng l mt sau ty) E T dch 2 pha ca ty; c kh trong ty hoc xung quanh phn ty b vim Hoi t < 33% 33 50% > 50% Tng im ( + hoi t) 03 46 T l bin chng 8% 35%

im CTSI 0 1 2 3 4 im CTSI 2 4 6 T l t vong < 3% 6%

7 - 10

92%

17%

iu tr iu tr h tr: truyn dch, gim au, dinh dng tnh mch nu thi gian nhn n > 1 tun Ni soi mt ty ngc dng cp cu (ERCP): ch nh khi vim ty cp do si mt nng; tin hnh m c oddi nu phi ly si95 Khng sinh ph rng d phng: ch nh khi c vim ty hoi t phi hp vi suy tng96 Chc ht qua da: ch nh loi tr bi nhim trn bnh nhn vim ty hoi t lm sng khng ci thin Phu thut: + Si ti mt (ch nh ct b ti mt sau khi ht t cp; t l t vong tng nu phu thut trong vng 48 gi u); + p xe hoc hoi t bi nhim; + Hoi t v khun nhng c suy tng ko di (vd. 4-6 tun); + Nang gi ty c triu chng khng gii quyt c bng iu tr bo tn hoc th dn lu c qua ni soi hoc qua da 92 Banks P. Practice guidelines in acute pacreatitis. Am J Gastroenterology 1996; 92(3): 377-386 93 JHC Ranson et al. Surg Gynecol Obstet 1976; 143: 209. Ranson JHC, Spencer FC. Ann Surg 1978; 187: 565 94 Balthazar EJ et al. Imaging and intervention in acute pacreatitis. Radiology 1994; 193: 297-306 95 Fan S-T et al. Early treatment of acute biliary pacreatitis by endoscopic papilotomy. NEJM 1993; 328:228-232 96 Sainio V. Early antibiotic treatment in the acute necrotising pancreatitis. Lancet 1995; 346: 663-667. XUT HUYT TIU HA CAO97 Chn on Mu phn98: 14% XHTH cao c mu trong phn (mu ti hoc phn nu); + Nhng bnh nhn i tin phn mu thng do mt mu rt nng cn phi truyn mu nhiu hn, nguy c phi phu thut v t l t vong cao hn (14% so vi 8%) nhm ch c phn en hoc nu Dch d dy: c nhy l 90% i vi cc chy mu kh tr (gi tr tin on m tnh cao nu dch d dy c mu mt v khng c mu); + Khng c gi tr nu ra d dy bng mt lng ln dch; + T l t vong: dch trong (6%) < mu c ph (10%) < mu (18%) Tin lng Yu t nguy c trc ni soi99: 1) Tin s c x gan hoc c dch c trng khi khm 2) Nn ra mu 3) Dch d dy c mu

4) Huyt p tm thu < 100 mmHg 5) Ht ban u < 30% # yu t nguy c % bnh nhn Nguy c chy mu li 0 23% 9% 1 38% 13% 2 21% 34% 3 12% 62% 4 5% 71% 5 < 1% 100% - Cc pht hin trn ni soi100 Nguy c thp Nguy c trung Nguy c cao Nguy c rt cao bnh PUD khng PUD-im PUD-khng XHTH cao SRH en hoc c thy chy tin trin cc mu ng mu t mch Gin tnh M-W, khng mu chy mu Bnh lot trt mch thc c SRH PUD-SRH qun Bnh lot trt khc Tn thng Bnh thng D sn mch mu c tnh M-W= Hi chng Mallory-Weiss; PUD=Bnh lot d dy; SRH=c XHTH gn y H thng cho im sau khi soi (theo tiu chun ca Anh)101 Yu t im 0 1 2 3 Tui (nm) < 60 60 - 79 80 Mch < 100 Mch 100 HA tm thu Shock < 100 HA tm thu HA tm thu 100 100 Bnh km Khng IHD, suy Suy thn, theo tim, cc bnh suy gan, ung l nng khc th di cn Chn on Tn thng M- C tt c cc Tn thng ni soi W khng c tn thng c tnh ca tn UGIT thng/khng SRH

SRH

Mu trong UGIT, hnh cc mu ng, nhn thy mch ang chy mu IHD= bnh tim thiu mu cc b; UGIT= ng tiu ha trn

Khng c hoc c cc im en trn nn lot

im % T l T l T l t vong trn theo tiu bnh chy t bnh nhn chy chun nhn mu li vong mu li Anh 0-2 29% 4,3% 0,1% ... 3-4 34% 13% 3% 12% 5 15% 17% 8% 21% 6 9% 29% 15% 29% 7 8% 40% 20% 35% 5% 48% 40% 53% 8 Chy mu do v bi gin tnh mch thc qun102: + 35-80% bnh nhn tng p tnh mch ca c gin tnh mch thc qun; + 25-35% bnh nhn gin TM thc qun c chy mu trong vng 1 nm u sau khi chn on; + 30-50% t vong trong ln xut huyt u tin; + 70% thot cht sau ln chy mu u tin s b chy mu li, hu ht l trong vng 6 thng sau ; + T l t vong cho mi ln chy mu ti pht l 30-35%; + Nguy c chy mu ti pht gim ng k nu bnh nhn c iu tr chn khng chn lc hoc tht bi gin bng vng cao su d phng; + Cng nn xt xt dng chn trc ln chy mu u tin trn bnh nhn c gin tnh mch bit t trc; + Nn xem xt tin hnh th thut ni thng ca ch trong gan qua da (TIPS) cho bnh nhn c chy mu nhiu ln tr vi iu tr ni khoa; + Ch nn ch nh phu thut ni thng cho nhng bnh nhn khng c ghp gan iu tr iu tr h tr: 70-85% bnh nhn t cm mu m khng c iu tr g c hiu c ch tit a xt: c ch H2 khng lm thay i tin trin v tin lng ca bnh; + c ch bm proton c th ci thin tin lng nhng bnh nhn c nguy c trung bnh khng c ni soi v gim c chy mu ti pht sau ni soi103 iu tr ni soi: cung cp cc thng s gip tin lng nhng khng cn thit phn ln bnh nhn; + nhm c nguy